Assignment task: Case of Trisha
Trisha is a 45-year-old, unemployed European American woman. She is no stranger to therapy, having seen counselors for most of her teen and adult years. Her friends would describe her as a "wild woman" who takes no crap from anyone. She has held various part-time jobs years because she usually gets angry at her boss or coworkers and quits. Trisha has no children. While she has had a string of boyfriends over the years, she has been seeing one man for the last year or so. He too is unemployed and has both an alcohol and methamphetamine problem. She describes the relationship as "addictive and dysfunctional, yet exciting and hot." Trisha is back in treatment at the urging of her parents, who describe her behavior as erratic and unpredictable. They also claim that she has periods where she "sleeps little and parties lots." There were also several occasions in the last five years when she was so depressed she didn't eat or want to leave the house. Her father also admits to periods of depression, and Trisha's grandfather was diagnosed with manic depression, resulting in numerous hospitalizations. Trisha's only brother died in a car accident several years ago. He was drunk at the time, but she claims he had a long history of depression. Recently Trisha was arrested for disorderly conduct at a friend's party. She had not slept for nearly 24 hours and was drunk and combative. When she was first approached by police, she solicited them for sex. They report that she was rather hyperverbal and hyperactive. They later had to investigate a complaint from local storeowners for bad checks she wrote in excess of $7,000.
POSTCASE DISCUSSION AND DIAGNOSIS: Trisha has Bipolar Disorder Type I, Most Recent Episode Manic (F30.13). She appeared to have boundless energy with little need to rest and was engaging in dangerous, promiscuous and irresponsible behavior. She also meets criteria for recent episodes of major depression. According to Trisha and her parents, she uses alcohol only when she is feeling "high on life" or when she is so depressed she can't get out of bed. There is also a positive family history for both unipolar and bipolar depression.
PSYCHOPHARMACOLOGICAL TREATMENT Upon consultation with a psychiatrist, Trisha was placed on valproate and titrated to a dose of 750 mg daily. In addition, her psychiatrist added quetiapine 300 mg q.h.s. to assist with sleeping and restlessness at night. Trisha's mood has stabilized, and she has been attending therapy twice weekly and group once weekly. She has also been able to return to a part-time job as a waitress and is no longer dating her boyfriend, who was recently arrested for methamphetamine use. She hopes to attend college next year if she is able to save enough money for her own apartment. She has gained much insight into her illness and now helps other young women in a local support group.
Q1. In addition to the diagnosis suggested by the text authors, are there additional disorders that may apply or should be ruled-out?
Q2. Do you agree with the medication suggestions made by the text authors?
Q3. Any other medications that might be considered...and what is the rationale?
Q4. Are the suggested medications, or any other considered medications, agonists or antagonists?
Q5. If you were asked to follow-up on this case as the treating therapist, what would your treatment plan be? Include collaboration and consultation.