Bipolar Disorder
The Diagnostic Interview
The police took her to Central Lockup at the Orleans Parish Prison. The next day, she was transferred to Charity Hospital by the sheriff on a coroner’s order for protective custody. At Charity Hospital, she was seen by Dr. Rodriguez, a psychiatrist, who conducted the intake interview. Within her first hour there, Sally was alternately excitable, irritable, and upset. She talked excitedly of her many business ideas, suddenly began pacing around the small interview room, and then became agitated when Dr. Rodriguez suggested she sit back down.
When he asked her why the police brought her to the hospital, her eyes teared up. She sat down hard in the chair and began to sob. Dr. Rodriguez coaxed out of Sally the story of the last 7 weeks, including suddenly leaving home, her excitement at arriving in New Orleans, and the many ups and downs that she experienced over the 7-week period. He noted in particular that Sally reported sleeping very little and eating only sporadically.
Dr. Rodriguez conducted a mental status exam as described in the cases of Ricky and Barbara. As with Barbara, the psychiatrist was particularly interested in Sally’s risk of suicide and other violent tendencies, and her current and lifetime history of substance use. Given her behavior as noted by the police, he asked Sally about her business plan, and asked open-ended questions that revealed a variety of other examples of risky behavior, including financial excesses, sexual promis-cuity, and general recklessness. Her symptoms strongly suggested some form of bipolar mood disorder, but Dr. Rodriguez needed to distinguish this disorder from substance abuse and various personality disorders (e.g., Hilty, Brady, &
Hales, 1999).
Dr. Rodriguez decided that Sally’s behavior indicated both mania and depres-sion, and it was important that she had described the past several days of this kind of pattern as typical for her. Further assessment entailed both current symptoms and other details, and also past history and features of the disorder over time.
Dr. Rodriguez concluded, based on her present symptoms and history over the preceding weeks, that Sally’s disturbance met the criteria for Bipolar I disorder (most recent episode mixed), which is severe but without psychotic features. In particular, he was struck by her rapidly alternating moods and occasional suicidal thinking, her impaired social functioning, and her apparent need for hospital-ization. He was also confident that her symptoms were not directly attributable to a general medical condition, intoxication with a substance, or reaction to a treatment for mood disorder, such as antidepressant medication, ECT, or light therapy.
Given Sally’s instability, the possibility she would do something self-destructive was a serious concern. Suicide risk is lower during the manic phase of Bipolar Disorder than the depressive phase, but is still above average. Suicide risk increases if, as in Sally’s case, the individual experiences rapid shifts from one mood to another. The presence of substance abuse increases the risk here,
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and Sally acknowledged having used alcohol to excess in the past. Dr. Rodriguez understood that use of substances can ref lect efforts at self-medication and can mislead the clinician by masking the underlying Bipolar Disorder. He also asked for a complete account of prescription and nonprescription medications Sally had taken.
Satisfied that he had enough evidence for a tentative diagnosis, Dr. Rodri-guez turned his attention to Sally’s ability to care for herself, whether she was pregnant or might become pregnant (see the Medications section later in this chapter), and her readily available support system and other resources (family, friends, finances, living situation, work situation). His immediate consideration was whether Sally should be hospitalized. Persons in the throes of a manic epi-sode usually benefit from a calm, stable environment.
Sally’s labile moods, risky conduct, and poor judgment were such that Dr. Rodriguez doubted she was presently in a position to care for herself. He wanted to be sure Sally did not abuse substances and considered there to be some risk of intentional or unintentional self-harm. Dr. Rodriguez realized that 72 hours was probably not going to be long enough to get Sally’s situation turned around. The way Sally was strenuously objecting to remaining in the hospital caused him to fear that she would not be willing to stay after the 72-hour order had run out. At that point, he would have to struggle with a decision about the possibility of getting an involuntary commitment.
A CRITICAL THINKING AND QUESTIONING PAUSE Based on what you have read about this case so far, do you think Dr. Rodri-guez should try to have Sally hospitalized against her will? What are the reasons why you believe he should? What are arguments against doing so?
Try to generate at least three reasons for and three reasons against hospital-izing her against her will. Once you have generated your list, which side do you find most convincing and why?
Sally’s History
Bipolar Disorder has a more variable course over time than most other mental disorders. Dr. Rodriguez was also interested in how effective Sally’s “nor-mal” functioning (e.g., social, work-related) was between episodes and what previous treatments she had received. He was interested in finding out how many manic episodes Sally has had, how long they lasted on average, and how much time typically elapsed between episodes. He also wanted information about Sally’s family history of mental illness, in particular mood disorders (most particularly manic and other bipolar illnesses). She consented to having
medical records from her previous hospitalizations faxed to him. From these he obtained the following history.
Sally was 27 years of age and was trained as a recreation therapist. From birth until the age of 15, Sally was a quiet child but had lots of friends and fit in very well in school. She took gymnastics lessons, horseback riding, ballet lessons, was on sports teams, and was active in Brownies and Girl Scouts. At about the age of 15, she was sick with a respiratory tract infection for about a week. When Sally returned to school, she was unable to think clearly at school and had no energy or ability to tackle her homework. She could not even start dealing with mate-rial, and seemed to have lost some of her ability to think. She developed what she referred to as a “short fuse” and lost much of her ability to cope with stress and the added work of making up what she had missed. She began making a series of
“bad choices,” such as skipping school and taking off in the afternoon. Her par-ents took her to a child psychologist, thinking that something might be wrong.
The psychologist concluded that there was nothing wrong with Sally other than a rebellious cycle that some teenage children go through. He did suggest that they learn more effective parenting skills.
The following year, Sally had more problems with school and her grades were worse than ever. Her parents thought that perhaps she was having an off year and things would get better when she went on to high school, but in the spring of that year, her behavior became quite bizarre. One morning at about 4:00 a.m.
her mother discovered Sally coming in from outside the house. She told a very bizarre story about seeing a camel run through the neighbor’s yard. She went outside to get closer to it. Her mother was concerned about this behavior and kept Sally home from school that day. Sally, however, kept trying to leave, and finally disappeared entirely at about 2:00 in the afternoon. Her family called the police, then drove all over looking for her. At about 6:00 that night, the police called to say that they had picked her up after she wandered into someone’s house. Sally spent that night in the local hospital. The psychiatrist did not have a firm diagnosis for Sally, but mentioned the possibilities of problems with family dynamics.
Although Sally continued to be very depressed the following year, over the summer she improved a little, found a part-time job, and did a little dating.
Within just a few days of starting school, her bizarre behavior recurred. She started picking up small items that did not belong to her, such as watches and rings. She came home with them and then lost them all as she wandered about the neighborhood. After several days of this, her parents contacted their doctor and had her admitted to the Children’s Hospital psychiatric unit. She stayed there for 3 weeks, at which point the psychiatrist said he didn’t want to label her as having a mental illness, but put her on Lithium.
Taking Lithium, Sally went back to school for her senior year, and by the time she graduated had made plans to attend college and study recreational therapy.
She had observed recreational therapists while in various psychiatric hospitals, so
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she took the appropriate tests and applied and was accepted at the state university.
Sally got along very well there, but her parents suspected that she was drinking too much at times. She certainly was acting immature, but did not have a recurrence of the earlier bizarre behavior. Her grades were only average, but she did well enough to graduate and was accepted for an internship in recreational therapy.
Toward the end of her senior year, Sally reported that her psychiatrist had told her that when the stress of college was over, she could stop taking Lithium. He was concerned about long-term health risks since Sally began Lithium treatment at a relatively young age. As her internship ended, Sally decided on her own to stop taking the Lithium. The hospital where she did the internship hired Sally for a full-time job. She did well at first, but within a year, the cycle resumed with another bout of bizarre behavior. She lost her job, which made her very depressed.
Given that keeping an individual with Bipolar Disorder taking her medication is a primary concern during the treatment process, we should consider why Sally would stop taking her medication when it had apparently helped her so much.
Prior to taking Lithium, Sally had always described herself as, “energetic, cre-ative, high-strung, and up on life.” With the medication, however, Sally felt her
“highs” were diminished and she was less creative. Writing poetry had always been an outlet for her, but she found herself unable to “create” while taking Lithium. In addition, Sally was truly feeling better. Her moods were more stable, people were responding more positively to her, and even the psychiatrist said that she appeared to be “much improved.” (“Maybe I am better now and don’t need the medication anymore,” she thought.) Finally, Sally had to acknowledge that the long-term prospects of being on the medication frightened her. Although the side effects she had experienced so far were mild in comparison to the symptoms of the disorder, she couldn’t help but wonder if the side effects and risks to her health would get worse the longer she took the medication. All in all, these issues seemed to Sally to add up to pretty convincing reasons to stop taking Lithium.
The summer after stopping the Lithium treatment, Sally got a job in the horse stable at the local state park. While working there, she met and fell in love with a young man who also worked with the horses. Sally was extremely happy, and by the end of the summer, they talked of getting married. Sally considered herself engaged. The job was only for the summer, and after returning home to live with her parents, Sally found a job there and moved to her own apartment.
Before long, she became unhappy that her fiancé was not coming to visit her, and then she was unhappy with her job. A few months later, her fiancé broke off their relationship; soon after, Sally was let go from her job. She found another job, but soon began to show up at her parents’ house every weekend, depressed, crying, and upset. Her mother spent many hours talking with her, trying to cheer her up. Sally was supposed to be taking Lithium, but her parents began to doubt she was doing this. They also began to suspect that she was abusing alcohol and perhaps also smoking marijuana.
Eventually Sally lost her most recent job and stopped taking care of her apart-ment. Her parents refused to let her move back with them because she would not take her medicine and was abusive to them. Sally would not attend therapy sessions, and at times, would leave town for days on end, such that her parents did not know where she was. She acquired a new boyfriend and left her apartment to move in with him, but he kicked her out within 2 weeks. She tried to live with a girlfriend but the girlfriend soon kicked her out as well. She told her parents that the only choice left was to do herself in. In desperation, they contacted the courts and filed a request stating that Sally was mentally incompetent. The psychiatrist cooperated with them and Sally was admitted to the psychiatric unit of a general hospital. However, when she saw the psychiatrist, Sally claimed that nothing was really wrong with her. The psychiatrist got a separate history from Sally’s par-ents, and after he confronted Sally with the discrepancies between her story and theirs, Sally abruptly went AWOL from the hospital. The next her parents heard, she had been picked up in New Orleans.
An Interview with Dr. Chapman
I am really surprised that Sally gave you my name as someone you could talk to about her. I met her when she first came to New Orleans. I’m a psychiatrist and she made an appointment with me. I realized after we had talked for 10 or 15 minutes that she is bipolar, but she never said that to me. I also realized that I was not going to be able to keep her as a patient.
It is the first time it has happened to me in my five years of practice, but I could not ignore the strong attraction that I felt for her. At the end of the session, I suggested that I would refer her to a psychiatrist who would be more appro-priate. I had my receptionist give her Steve Owens’ office number, but I called Steve myself to ask if he could see Sally right away, because I realized how shaky things were for her right then. Steve owed me a favor, so I didn’t hesitate to ask.
As it turns out, Sally never went to see Steve, which explains how she ended up in lockup at Orleans Parish Prison. Many times the police do not know what else to do with someone in the state Sally must have been in. I guess it worked out for the best, though, because she ended up with Dr. Rodriguez. According to what I have heard, Rodriguez is one of the best when it comes to helping people with bipolar illness.
Wouldn’t you guess, I saw Sally again that weekend in my favorite spot in the Quarter. A friend of mine since I was a kid plays there. Jones can play every wind instrument known to humankind and then some. Well, Sally was there by herself and we started talking and have been seeing each other since then. Never, since she left my office that first, day, has either of us mentioned her health or her illness.
That’s one of the reasons that I am so surprised that she gave you my name.
Come to think of it, she probably doesn’t have that many friends here in New Orleans who know that she is ill. I know that Randy, one of the guys who plays
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with Jones, has schizophrenia. He wasn’t doing well at all until he got a chance at Clozapine, and that has turned things around for him. I know he has kept an eye out for Sally and for a couple of days she stayed with Miss Lillian.
Lord, that woman is a saint!
Jones told me that Randy calls her home a “safe place” for people who are ill and just need a quiet place to be for a few days. She’s not a professional. She doesn’t give meds. She’s just there for them. She’ll feed them and remind them when it’s time to take their meds if they need that. She doesn’t see gender, color, age, poverty, or wealth. She just sees hurt and does her bit to make it better. Jones told me that Randy wouldn’t have made it through the years before Clozapine without Miss Lillian and her “safe place.”
To my knowledge, that’s all the people in New Orleans who know anything about Sally’s illness. I know that she is from Baton Rouge, but I’m not certain that there is anyone in her family she speaks to. From the little she told me, I’d put money on a hunch that her father and probably a grandmother, an aunt, and uncle have bipolar illness also. She didn’t say that, but just listening to her on the rare occasions that she mentions her family at all, I got that picture. She told me once that both of her parents and her brother Alexander (Sandy) are all patholo-gists, but I don’t know any more than that.
So, when you asked for people to talk to, I guess that explains why me. Well, I’m not sure how helpful I can be. There’s no way I can be objective about Sally.
I’ve never felt this way about anyone before, and it isn’t an easy one to figure out.
Even when she’s not doing well and off on one of those hare-brained money making schemes of hers, she has a way about her that I can’t turn away from. She isn’t a “knockout” at all. I’ve dated a lot of those, but Sally has a kind of haunt-ing, subtle beauty. She’s bright, but certainly not intellectual. Frankly, she’s not
“my type,” or at least that’s what I would have said before that day in my office.
“Creative” describes her without a doubt. She wrote a song, and the melody is haunting. Jones plays it all the time. She wrote words to it and sang it for me one night when there were only a few people there. Jones talked her into singing it while he played. It was just that one night that she sang it, for me at least. I think she and Jones had gone over it quite a bit, because they sure had it down pat. The words weren’t as haunting as the music, but they were so revealing. Something like, “Touch me and hold on as we f ly, f ly past the moon and toward the sun.
The sky goes on forever and I don’t want to go alone.” There was a middle part and then something like, “Touch me and hold on. Here we go deeper than the grave, beyond the river where we see Charon wink and wave. Hold on. Don’t let me down. I cannot go alone.”
Well, I’m holding on because I can’t let go of her. I have no idea what will happen. I know she has sex with other men when she’s on a high that is out of control. That scares me for both of us, but I can’t let go of her.
It isn’t rational. I know that. Before I met Sally, I would have predicted that the other factors—rich or poor background, religion or color differences—would