The case study associated with this week is Case 14 is titled “Cheryl”.
Case 17 Cheryl R. is a twenty-eight-year-old married woman with two children under three years of age. She has been referred by her family doctor, who has been treating her depression for nine months with fluoxetine, 20 mg daily. Her physician states that medication adjustment is not indicated and thinks “talking therapy” will be beneficial. Her psychiatric history is negative for hospitalizations, and she has never been in therapy. She describes a “lifetime of sadness” with periodic episodes of suicidal ideation during late adolescence. Cheryl reports moderate improvement in her depression since starting the medication and wants to continue taking it. However, she says that some of her initial symptoms of irritability, tearfulness, and tiredness have never really improved. She reports continued initial insomnia and describes lying awake worrying about things. Her major concern is that she is not the “best mother” she can be. On particularly “bad days,” she places the children in front of the television and retreats to her room. She wishes she had more “good days,” which occur about every three months and last about a week. During these periods she begins sewing and craft projects for the house, socializes with neighbors, exercises, and “feels on top of the world.” She appears slightly nervous and describes her mood as “pretty bad.” She describes her marriage as “average” and her children as the “center of her life.” She is moderately impatient with the interview questions relative to history taking, since she wants to “get on with things.” You are encouraged by Cheryl’s motivation for treatment. However, you internally question whether she may fit the profile for bipolar II. In the process of the diagnostic interview, you elicit enough information indicative of hypomanic periods that predated the initiation of fluoxetine to warrant further consultation with her original prescriber or a psychiatrist. Listed below are important diagnostic specifiers for bipolar I and bipolar II. The reader should refer to DSM-5 for a full explanation of coding and recording proce dures for these specifiers. Episode severity Remission status With anxious distress With mixed features With rapid cycling With melancholic features With atypical features With mood-congruent psychotic features 106 Handbook of Clinical Psychopharmacology for Therapists With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern The mixed episode was recognized in DSM-IV-TR as a discrete clinical entity, requiring that full diagnostic criteria be met simultaneously for bipolar I and major depression. In DSM-5 a specifier has been added, termed mixed features, applicable to a current manic, hypomanic, or depressive episode in bipolar I or bipolar II disorder. Mixed features would apply to mania or hypomania with depressive features, and to depressive episodes with features of mania or hypomania