66 Bipolar II Disorder

Name: Casey Roberts

Source: Mad Love (Movie, 1995)

Background Information

Casey Roberts is a female high school student in her late teens. Upon arriving at a new high school, she appears to be fairly normal in behavior. However, it is apparent from early on that she has almost no social relationships, or even more, a desire to have any. Aside from a relationship with her parents, who appear supportive and loving, she only has one other relationship which consumes her throughout the movie: her relationship with her boyfriend Matt. This relationship is what drives many of her actions throughout the movie. Her parents say there is no past mental health history in their families. However, they are in denial of her having an actual mental illness and attribute it to her trying to get back at them for controlling her, so the real history may not be reported. No major drug or alcohol use is apparent although casual drinking is seen throughout the movie and nicotine use, especially while in her depressed episode, is also shown. There are no outward health problems visible in Casey. She is a very intelligent girl with a very strong willed personality. However, she does not seem to care too much about asserting that intelligence towards any goals. School is in no way important to her.

Description of the Problem

Although Casey is at some points able of living and functioning normally, she has a past of suicidal behavior. As stated in the Background Information, she has little to no social relationships. However, she does appear to be a fairly friendly person. Probably the largest hindrance on her functioning is her impulsivity. She seems to think that she should do and be able to do whatever she wants when she pleases. Towards the end she also has a tendency towards thoughts that are very sporadic in nature. Casey displays much risk taking behavior without seeing any important consequences that could occur from them. She is also temperamental and very easy to irritate. Delinquent behavior is also presented in her behaviors in the form of truancy and the case of her pulling a fire alarm in the school. She also has very strong thoughts of guilt and states that as punishment for the things she has done to Matt, he should leave her. When the onset of her illness begins to be very apparent, she shows much distractibility and tends to not behave correctly in social situations. Insomnia also is presented along with strange ideas. These ideas could possibly also be symptoms of Schizophrenia such as thinking people are always watching her and out to get her. She believes that she must put cut outs of eyes up around their apartment to protect them.

Diagnosis

The diagnosis for Casey is Bipolar II Disorder (296.89). To reach that diagnosis the following must be true:

1. Presence (or history) of one or more Major Depressive Episodes.
   • Within the movie there is a Major Depressive Episode. Her parents also referred back to the fact that Casey had experienced episodes before as well.
2. Presence (or history) of at least one Hypomanic Episode.
   • A Hypomanic Episode was also included in the movie. Evidence on whether or not she had been through more than one episode of this before was not provided.
3. There has never been a Manic Episode or a Mixed Episode.
   • Casey’s symptoms were not severe enough to classify as a Manic or Mixed Episode.
4. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
   • Although Casey had some odd behaviors that seemed almost similar to ones that would be presented in Schizophrenia or a very similar disorder, they would not be classified as actual delusions. The inconsistencies in her behaviors seem to classify more into Bipolar Disorder.
5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
   • Casey’s ability to form relationships was greatly affected by her symptoms. Also, distress was definitely seen within social situations. Casey was found in a bathroom with her dress off and hitting the walls and crying.

A diagnosis of a Major Depressive Episode was found by the following:

1. Must include five or more of the following over a 2-week period:
   1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). NOTE: In children and adolescents, can be irritable mood.
   2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
   3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NOTE: In children, consider failure to make expected weight gains.
   4. Insomnia or hypersomnia nearly every day
   5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
   6. Fatigue or loss of energy nearly every day
   7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
   8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
   9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
      • Casey presented symptoms a, d, g, and i.
2. The symptoms do not meet criteria for a Mixed Episode.
   • Her symptoms were not presented as both Manic and Depressive on a nearly daily basis.
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
   • Distress and impairment were definitely apparent in social situations. The example of the bathroom scene previously mentioned demonstrated this.
4. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
   • No drugs were being used besides nicotine and no other stated medical condition was present.
5. The symptoms are not better accounted for by Bereavement, i.d., after the loss of a loved one; the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness suicidal ideation, psychotic symptoms, or psychomotor retardation.
   • No loved ones were lost; the symptoms had been reported for over 2 months and she had attempted suicide numerous times.

A diagnosis of a Hypomanic Episode was found according to the following:

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood. It is characterized as a period of increased energy that is not sufficient or severe enough to qualify as a Manic Episode.
   • Casey’s mood was elevated while they were traveling and she was in her Hypomanic Episode. The severity of it would not classify as a Manic Episode however.
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
   1. inflated self-esteem or grandiosity
   2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
   3. more talkative than usual or pressure to keep talking
   4. flight of ideas or subjective experience that thoughts are racing
   5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
   6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
      • Casey presents symptoms b, c, e, and g within her Hypomanic Episode.
3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
   • She seemed to function almost normally when the episode was not happening. When she started presenting symptoms, her level of functioning obviously decreased.
4. The disturbance in mood and the change in functioning are observable by others.
   • Like previously stated, her changes were observable.
5. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
   • Her Hypomanic Episode did not strike Matt as “scary” or needing help immediately like her Depressive Episode. No hospitalization was seen as necessary.
6. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
   • No drugs were being used besides nicotine and no other stated medical condition was present.

Accuracy of Portrayal

Watching the portrayal of Casey would give a person a fairly good look into Bipolar Disorder. Most people label someone as “bipolar” when really they are just having mood swings or maybe suffering from Cyclothymic Disorder. This idea of such rapid switching is not accurate. Although Casey did have her moments of sudden anger or happiness, that can be accounted for by simply an experience she had or something that was said. Simple reactions like this are very common. However, her episodes as portrayed were seen as changing over periods of time, not just in an instant, giving the watchers a pretty good insight on the disorder. In the film, Casey’s mother stated that Casey suffered from depression. This may have influenced watchers to disregard her Hypomanic symptoms. Overall, the audience would get a fairly good look into the actual life of a person with Bipolar Disorder.

Treatment

When Casey arrived for treatment, a medical work up would occur to make sure the disorder was accurately diagnosed. This would also allow knowledge of the current episode, suicidal thoughts, and hopefully more family history. Casey would probably then be prescribed lithium carbonate. Because of the potency of this drug, her dosage would need to be very closely monitored. Therapy would also be a very useful tool for Casey’s treatment. Cognitive behavioral therapy would be a good start to help her deal with her emotions and stress. Therapy would also help Casey to fully understand Bipolar Disorder and to know in the future when an episode may happen. Likewise, education would be essential for her parents. Helping them understand what exactly is happening with Casey and to recognize her episodes would be very beneficial.