Russell and his Grand Plans
A fictional short story that's More Than True
The case study depicted below the dividing line is a WORK OF FICTION.
P.S. That line will eventually be a paywall.
Quick introduction-
I recently reviewed a past assignment for my graduate school Psychopathology* class and I thought it would be worth posting for yall here. For educational purposes only. Well actually, we call the following psychoeducation in the biz, don’t fret it’s explained in the psudeo-study.
I told a new friend (from online gaming) just the other day about my bipolar 1 (sometimes typed in the Roman numeral {bipolar I} style) diagnosis because she asked what my excuse was for not at least being divorced yet. When I told her bipolar I think she said…
“Oh, so you’re like happy sometimes and sad sometimes?”
No sweetheart, I’ll send you my substack.
I got the privilege to make up the following case study for this assignment. So the “More Than True” part makes me Russell to a large extent. Russell could have been me in another life; was my frame of mind when writing this work of fiction. If you enjoyed reading this while learning something real about bipolar 1 disorder, then please like, subscribe, and share with friends. Help me get to those good things on the horizon.
-Cheers! Manic Mike
^This^ line means the below is not a real case study. Russell is from my imagination.
Benchmark Case Presentation: Bipolar I Disorder
School of Behavioral Sciences, Ladida University ;)
Basic Case Summary
Date of initial assessment: 07-07-2023 Age: 22
Client Name: Russell Gender: Male
Employment Status: Unemployed Race/Ethnicity: Caucasian
School Status: Batchlors Undergrad on leave of absence Marital Status: Single
Reasons for Referral/Presenting Concern
Russell first entered treatment after being arrested during a drug-induced manic episode three weeks before our initial clinical interview. Taken into police custody for assault, but his criminal charges were eventually dropped due to the nature of the physical altercation. Without legal recourse, Russell’s parents endeavored to formally correct his newly established maladaptive behaviors that might have otherwise gone unpunished. The night of his arrest was not an isolated incident and was seen by both Russell’s family and friends as an escalation of negative unmanageable behavior. As explained by Russell “I’ve just been overtaking my Adderall because of exams at school! Mixing that study state of mind with alcohol is the problem, lesson learned, I don't need therapy.” Russell had not been sleeping well the week before his arrest, reportedly getting only 2-3 hours of sleep per night and completely without sleep the two nights before his police incident. “I’ve lost weight during the past semester due to dieting which is why I don't need much sleep anymore; I’ve evolved past that need.” When forced into inpatient treatment Russell was diagnosed with Bipolar I disorder but now refuses to take his prescribed medication because he says, “they make him a miserable person.”
Russell had found “a new kind of energy, the stuff winners are made of.” Full of new creative insight, the college junior had “genius ideas” and simply wanted to share them with the world, or anyone willing to listen. Peers stated, “he’s become something unrecognizable as if he was actively trying to be someone else entirely, someone whose boisterous opinions made most others within earshot uncomfortable.”
History
Family and Home/Religious Background
Russell is the oldest of three siblings of whom are both still in high school. His parents are still married, and their relationship is viewed as both loving and admirable. Russell’s father tends to lean into his tyrant persona when inner turmoil arises within the family, a factor that has gotten Russell into a lot of trouble throughout his past. He was raised in church and started attending vacation bible school as both a child participant and later as an adolescent volunteer. No known family history regarding diagnosed mental illness, but Russell’s nuclear family tree has several extended branches that have been excommunicated for various familial strife-related reasons.
Educational History
Russel was always a good student but received most of his social validation from the sports teams he competed amongst during his high school tenure. Wrestling in the winter and captaining the football team during the fall rounded out his remaining academic free time during his teenage years. His grades got him into a small community college after high school. After completing his first three college semesters Russell’s grand plan had come to fruition, and he was able to transfer with credit to his dream college; The University of Georgia. Russell now has a year left of course credit to graduate with his BA in business development after he is accepted back into UGA following his related academic probation.
Mental Health
Russell is very upset due to his current predicament, forced back home from college and living again with his parents and younger siblings. He scored a 33 using the Beck Depression Inventory, but he states that the day of our BDI assessment “happened to be a particularly bad day for him.” He is very embarrassed by the social fallout directly attributed to the many foolish, impulsive decisions he made during the week preceding his hospitalization. Upon our initial assessment, Russell can’t seem to perceive a path forward that may reconcile his previous social standing once he can return to UGA. For the past two weeks, Russell has been averaging 9-11 hours of sleep per night and feels pathetically lethargic throughout his day. The provocation of his worried parents is what got him out of bed this morning.
Clients Physical Health
The client appears to be in fit physical health. He passed his last physical and blood screening during his stay at the inpatient hospital and has gained fifteen of the twenty pounds lost during the previous months.
Occupational History
Besides the occasional temporary work during past summers, Russell has a limited vocational history and doesn’t appear to have put much thought into a career after graduating from college.
Sexual Adjustment
Russell is recently single after getting dumped by his girlfriend of five months the week before his hospitalization. “It’s not like we were going to get married.” However, Russell has stated that he now regrets his previous positive regard for promiscuity which caused the abrupt termination of his last notable romantic relationship. “I’ve always been a girlfriend kind of guy, at the time I just felt like I deserved to have it all. I’m such an idiot.” Russell has never been married and has no children.
Substance Use History
Dramatic weight loss of twenty pounds was documented during the few weeks leading to Russell’s arrest incident, a physiological response attributed to his now admitted cocaine and Adderall abuse. Russell has been clean of recreational drugs and alcohol for the past three weeks post-hospitalization detox and under the careful supervision of his parents. He says regarding the uppers “I just like the way they help me feel and think, and I don’t think I can get by day to day without the Adderall which they won’t let me have now!”
Spiritual Assessment
Russell is saved as a Christian and posits his life on the personal relationship he has with Jesus Christ. Weeks before his hospitalization “I fell into a YouTube rabbit hole with some dark interpretations of Revelations. “I just knew I was living during the end of times.”
Multicultural/Social Justice Factors
Currently, I have no cause to believe that Russell’s symptoms of sadness are related to discrimination, marginalization, or oppression.
Barriers to Treatment/Success
Russell’s framing of his behavioral issues will be his greatest barrier to success concerning the ongoing treatment he has ahead of him. His mother reports his obstinance to taking the prescribed mood stabilizer and antipsychotic medication. “There is no way that what happened to me is something that can only be solved by taking pills for the rest of my life!”
Other Pertinent Data
During the assessment, Russell reflected on just how highly he thought of himself not that long ago and now worries that he will never be able to feel that sort of “purposeful confidence” again. “I was exactly who I always knew I could be. Now I’m just a loser with no future.”
Mental Status Exam
Russell showed up fifteen minutes late to our first booked clinical interview session wearing a sweatshirt and pants despite our meeting taking place mid-summer. His facial hair was scraggly but hygienically he seemed to be bathing regularly. “I probably spend too much time bathing these days, sometimes I just sit in the shower playing sad music and weep.” His speech was slow and monotone at first impression, yet his voice distinguished itself with notable shifts in tempo and tonal sharpness once the many injustices that now plague him were brought up in conversation.
He oriented himself well to my office, finding himself comfortable laying down on the couch (which he preferred to the armchair), making eye contact mostly with the ceiling as he tediously restated the events that transpired during his past several weeks. He would only turn to face me and make eye contact if I had reflected a feeling or situation wrong about his story. The Language expressed while describing his symptoms was largely dismissive, minimizing personal responsibility. Not yet able to connect his choices that were “made freely” with their consequential destructive nature.
His thought process seemed dulled, and emotionally blunted affect. His attention waned if topics shifted down an avenue he deemed uninteresting. Intellectually he seemed capable of comprehending some of the decision-making that led him to my counseling practice. Forced into treatment he quotes as “a personal defeat.” When the topic of suicide risk was brought up Russell declared that he has not and will not make a plan to take his own life. “But I do lie in bed most nights now hoping that my next dream will be endless. I’d rather wake up in heaven than back here in hell.”
Russell stated that his potential for the type of violence that got him in trouble only culminates if he has been drinking hard liquor, a behavior he now promises to abstain from. “I’m convinced that the depression I’m feeling isn’t about a chemical imbalance in my brain and instead is due to my life completely falling apart. Something has got to give.”
Treatment Recommendations
We will need to help Russell lift himself out of his newly conceived depression cycle before we may be able to hammer home the acceptance of his recently received diagnosis of bipolar I. Using Cognitive Behavioral Therapy, we can begin reframing the way he currently views his life and perhaps give that view a better perspective. CBT is associated with greater stabilization of residual symptoms of depression compared with (TAU) treatment as usual (Miklowitz et al., 2021). Knowing this, I may remind Russell of his previous success in attaining long-term goals (the eventual acceptance to his college of choice). By restructuring his new chronic chaotic diagnosis with the same structures he used to plan his acceptance into UGA. Setting a new order, establishing new rules, and suggesting personalized guardrails will be the basis of his personalized approach to psychoeducation. Focusing on the regulation of his daily rhythms, we set up a consistent daily routine of waking up and going to bed at the same time each day and building the necessary resilience required to prevent relapse. Psychoeducation, with a focus on active skill training (e.g., monitoring of prodromal symptoms) is associated with a lower likelihood of relapse.
Gratitude, conceptualized as a positive feeling state in response to another person’s kindness is associated with increased prosocial behavior (Painter et al.,2019). Positive Emotional Regulation (PER) I.e., practicing gratitude, projecting personal strengths, demonstrating acts of kindness, and imagining the best possible self are therapeutic techniques that require low activation per positive emotion (LAP).
Medication considerations:
Russell did not complain of depression while subject to inpatient treatment following his first manic episode. Due to his negligent self-disclosure statement recorded while first entering inpatient treatment, he was not prescribed an antidepressant (AD) that could be used as adjunctive therapy to his mood stabilizer (MSs) and antipsychotic medications. Expert consensus and treatment guidelines often recommend caution when prescribing ADs for individuals with bipolar disorder primarily due to the counterintuitive possibility of “mood switches” triggering a manic or hypomanic episode out of the period of depression (Dell’Osso et al., 2021). Given Russell’s new willingness to discuss the depth of his sadness and his newfound voluntary acceptance of his depression, I would refer him to a partnered psychiatrist who may add to or reevaluate his current medication regimen to include an appropriate antidepressant.
Thank you for reading! If you would be so kind to pass this along to Kanye :)
Answer Key
DSM-5 Diagnostic Criteria: Bipolar I Disorder (F31.5)
Client’s Reported Symptoms:
Criterion A: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any during if hospitalization is necessary.)
One week before being arrested and hospitalized Russell reported finding a “new kind of energy.” A quality noted by peers as uncharacteristic and unprovoked. Peers stated he had become a different person who others now actively avoided.
Criterion B: Inflated self-esteem or grandiosity
Found a new “purposeful confidence”
Criterion C: Decreased need for sleep.
Russell approximates that he slept a total of 7-9 hours the week leading to hospitalization. “I had evolved past the need to sleep like regular people.”
Criterion D: Depressed mood most of the day, nearly every day, as indicated by either subjective reports or observations made by others.
He scored 33 on the Beck Depression Inventory.
Criterion E: Fatigue or loss of energy nearly every day.
Russell has been averaging 9-11 hours of sleep per night and is only rousted from bed by his worried parents.
Criterion F: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan.
“I lie in bed most nights these days hoping that my next dream will be endless. I’d rather wake up in heaven than back here in hell.”
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Dell'Osso, B., Arici, C., Cafaro, R., Vismara, M., Cremaschi, L., Benatti, B., ... & Ketter, T. A. (2021). Antidepressants in bipolar disorder: Analysis of correlates overall, and in BD-I and BD-II subsamples. Journal of Affective Disorders, 292, 352-358.
Miklowitz, D. J., Efthimiou, O., Furukawa, T. A., Scott, J., McLaren, R., Geddes, J. R., & Cipriani, A. (2021). Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. JAMA psychiatry, 78(2), 141-150.
Painter, J. M., Mote, J., Peckham, A. D., Lee, E. H., Campellone, T. R., Pearlstein, J. G., ... & Moskowitz, J. T. (2019). A positive emotion regulation intervention for bipolar I disorder: Treatment development and initial outcomes. General hospital psychiatry, 61, 96-103.
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