Marla is a 42-year-old Hispanic female who comes to the mental health clinic complaining of trouble sleeping, feeling “jumpy all of the time,” and an inability to concentrate. These symptoms are causing problems for her at work, where she is an accountant.
Marla’s symptoms are consistent with a diagnosis of bipolar disorder, specifically bipolar II disorder. The bipolar I disorder diagnosis is not necessary because there is a lack of data supporting a full manic episode. Furthermore, her symptoms are more in line with hypomania, a milder type of manic episode (Pinel, 2007). This diagnosis is predicated on the assumption that Marla has experienced at least one major depressive episode in conjunction with the aforementioned hypomanic symptoms. One of the main focal points of a clinical interview with Marla would be to gather evidence of an episode of major depression. If evidence for a major depressive episode cannot be found a diagnosis of cyclothymic disorder might be more suitable. However, under the assumption that a major depressive episode has occurred, her symptoms are consistent with a diagnosis of bipolar II disorder, which can be caused by persistent illogical thinking processes and over-generalization and be sufficiently treated through cognitive therapy and drug therapy.
A little more than two million, or 1 percent, of Americans, suffer from bipolar disorder in the adult population (Faces of Abnormal Psychology, 2007). The disorder is characterized by mood shifts between a manic state and a depressive state. The manic state usually entails restlessness, racing thoughts, and/or a decreased need for sleep. Marla’s symptoms appear to be hypomanic in that they do not include delusions, hallucinations, or a significant loss of daily functioning. Conversely, the depressive state usually accompanied by trouble concentrating, irritability, loss of energy, and loss of interest in once satisfying activities. In most cases, the manic state and depressive state reinforce each other over time, and if left untreated can become more and more acute. The causes of bipolar disorder seem to be largely genetic/biological; nevertheless, these factors may only be part of the story. As with most disorders, a complex interaction between nature and nurture are at the heart of the onset of bipolar disorder. Even though inherited traits or brain abnormalities might predispose someone to manic/depressive episodes it is usually life events that actually mark the beginning of the disorder. Therefore, the underlying cognitions involved with Marla’s hypomanic symptoms are of great importance for both the explanation and treatment of her disorder. It is important to note that it is almost impossible for researchers to ascertain whether the biological abnormalities observed in those that suffer from bipolar disorder are a cause or effect of the disorder. With that in mind, the cognitive underpinnings of the development of bipolar disorder are even more important.
The main point of the cognitive approach to the treatment of bipolar disorder is to understand the type of thinking patterns that lead to the manic and depressive episodes. Such patterns of thinking can include over-generalization, the application of broad negative conclusions to seemingly insignificant events. These patterns can be overcome by confronting the errors in logic that are produced by such over-generalizations. Once confronted, a patient can then reassess the reality of dysfunctional thinking. Furthermore, another cognitive approach to the treatment of bipolar disorder is to encourage the patient to make a chart of their moods, life events, and sleep patterns. This chart can reveal patterns and habits that lead to hypomanic behavior or major depressive behavior. Lastly, one of the most successful approaches to bipolar disorder is drug therapy, particularly the use of lithium as a mood stabilizer. Between 30% and 40% of client’s exhibit significant improvements in mood while taking this type of drug (Faces of Abnormal Psychology, 2007). Even though this type of treatment falls squarely in the biological category for the treatment of bipolar disorder, it is still necessary to mention that the chances of improvement are greatly increased with the addition of lithium to the abovementioned cognitive therapy.
In conclusion, Marla exhibits many symptoms of a hypomanic episode consistent with a diagnosis of bipolar II disorder. There is no direct evidence that major depressive episodes are present, but such a fact could be easily determined during a clinical interview. The causes of Marla’s hypomanic behavior could range from performance anxiety associated with insomnia to over-generalizations and unproductive thought patterns to biological abnormalities in her brain. At any rate, treatment for her hypomanic symptoms will most likely include lithium and some type of therapy. In particular, the cognitive approach to the treatment of bipolar disorder entails isolating and confronting illogical, self-defeating thoughts and patterns of behavior that lead to both depressive and hypomanic behavior.
Clinical Interview Questions
- Let me put you in a situation. You are in high school. It is time for the S.A.T.’s. You have studied intensively for several weeks in preparation for the test, and now it is the night before the test. What is going through your head as you get in bed to go to sleep?
I wrote this question to try and look into some underlying behaviorist/cognitive causes of involuntary sleep deprivation/restriction. For instance, performance anxiety has been linked to insomnia as a direct causal factor (Pinel, 2007). This question could elucidate any such performance anxiety on the part of the patient if his/her thoughts are centered on the anxiety related to insomnia rather than some other thought. In the case of Marla, there is not enough data to come to any logical conclusion about her insomnia. Some possible causes could be stress related to her accounting career, such as job performance suffering from a hypomanic state, or anxiety related to loss of sleep.
- Do you have any phobias or what are you most afraid of?
I think it is important to rule out any excessive fears before moving on to other possible causes. Phobias can cause significant stress in a person’s life and therefore must be dealt with before other causal factors can be considered. In the case of Marla, no such phobias are apparent; however, possible phobias could be agoraphobia (fear of panic attack), ochlophobia (fear of crowds), or xenophobia (fear of strangers).
- What are your expectations for this interview and what are your expectations of me?
I think it is important to have reasonable expectations for a clinical interview. It would be a setback for performance anxiety, on the part of the clinician or the client, to get in the way of real progress.
- What is the single most embarrassing experience of your childhood, how did you react, and how has the experience affected the rest of your life?
This seems to be a very insightful question, but it is important not to read into or over-generalize the answer. The answer though could illuminate deep-seated resentments or regret that could be contributing to the patient’s dysfunction.
- Let me put you in another situation. You are at work and the day is almost over. Your supervisor walks up and asks if you can work that weekend. Please explain to me the thought process that you would go through when deciding to say yes or no. In particular, could you explain to me the feelings you would be having about your supervisor and the company at that exact moment?
This question is related to questions number one and ten. The point of the question is to extrapolate whether her insomnia is based on performance anxiety or work-related stress. This question will also help a clinician understand a clients relationship with their company and their boss, both of which could potentially be significant sources of stress.
- In the course of a normal weekday, from the time you wake up until the time you go to sleep, what is your single most common thought(s)?
The point of this question is to bring to light any irrational thinking, persistent negative thinking, or learned helplessness. Of particular interest to Marla is learned helplessness. The hypomanic state might be the result of a coping mechanism meant to help her deal with the stresses of her job and potential family. Recurring, helpless thoughts such as “I can’t do anything right ever” or “No one ever likes me” could potentially be a source of stress in her life. These global, absolute statements could possibly lead to her lack of concentration or lack of sleep.
- On average how many times do you wake up during the night or fall asleep during the day?
This question is meant to differentiate between insomnia and hypersomnia (narcolepsy). Marla could be suffering from some type of R.E.M. related disorder which could be making what sleep she does get unproductive (Pinel, 2007). Also, this question could lead to sleep apnea tests if she is waking up at regular intervals.
- Let me put you in just one more situation. You have just made CEO of a Fortune 500 company. (I know, just give yourself a little pat on the back.) You are going to sleep the night before your first day as CEO. Are you A) Sure of yourself because the company would not have appointed you to the position unless they thought you able and capable to fulfill the responsibilities B) Not quite sure of yourself, but certain that you can figure it out C) Stressed because you have no idea how to run a company D) So overwhelmed that you can’t sleep? Also please explain the thinking behind your response.
Self-confidence and self-esteem are at the heart of many causal symptoms that could lead to bipolar disorder. As in the case of Bernie, his self-esteem was based on his grades and athletic performance, and as a result when those reinforcers were no longer present his self-esteem suffered.
- When you come home from work what are the first three things you normally do when you walk into the door?
This question is meant to isolate any work-related stress or family-related stress that might be present.
- When you wake up what are the first three things that you normally do?
As with question number 1 and 5, this question is meant to get a general understanding of the daily activities of the person in order to better comprehend the underlying causes of their dysfunction.
Faces of abnormal psychology interactive: Bipolar disorder. (2007). Retrieved September 23, 2008, from Mcgraw-Hill Higher Education Web site: http://www.mhhe.com/socscience/psychology/faces/bigvid.swf
Nevid, J.S., & Rathus, S.A. (2005). Psychology and the challenges of life: Adjustment in the new millennium (9th ed.). Hoboken, NJ: John Wiley & Sons.
Pinel, J.J. (2007). Basics of biopsychology. Boston, MA: Allyn & Bacon.