Vignette 1

Bipolar I- severe with psychotic features; Alcohol Abuse and Anxiety Disorder. Clearly cycling into manic phase with rapid pressured speech, disorganized and tangential thinking, free association, inappropriate affect including labile mood occurrence.  Highly distractible with limited attention span. Describes manic and depressive episodes with paranoia and psychotic features including some command hallucinations. No evidence of current self-harm or suicidal ideation. Presence of significant alcohol abuse and potential of dependence.  At risk behaviors including promiscuousness. Engages in addictive gambling with significant financial loss. Expresses anxiety and panic with potential agoraphobic tendencies. Poor insight and medication non- compliance.

Status- Isabella has been diagnosed with Bipolar I- severe with psychotic features; Alcohol Abuse and Anxiety Disorder related to Hyperthyroidism. She initially has difficultly tracking and responding to assessor's questions and cries and smiles & laughs within 1-2 minute span, talking rapidly with quick hand movements. Isabella experiences both manic and depressive symptoms in increased frequency. She described her manic phases as initially being "upbeat" and "energizing" in which she accomplishes a great deal, does not need to sleep and engages in numerous social activities such as meeting friends, dancing, drinking and playing cards and slot machines at local casinos. Isabella states that at these times she spends money she "does not have" and does "stupid things" such as buying clothes for self and others and having relationships with several partners. Isabella's drinking, spending and gambling increase as she becomes more "upbeat". As her mania progresses Isabella feels more and more "outta control" and becomes increasingly anxious and fearful. These result in her inability to leave the apartment and care for herself and see her son. Her anxiety has increased with recent reoccurring hallucinations in which she describes seeing and hearing an American soldier from the Viet Nam era tell her to do things- none of which are directed to self harm or harm of others. Isabella describes her depression as "being down". As her depression worsens she experiences limited energy and sleeps 15-18 hours a day, does not bathe or clean the house and does not engage with her son or in any other social activities. Isabella has difficulty maintaining her prescribed medication regime when she experiences severe mania, depression and anxiety. Isabella's drinking is worrisome to her family and friends but she feels she can control and limit it at will.