Bipolar Disorder and PTSD: A Case Study

Andrea Reeder

Abstract

This case study explores the admit of a 36 year old woman diagnosed with Bipolar disorder NOS (not
other-wise specified), Post-Traumatic Stress Disorder, Generalized Anxiety Disorder, Borderline
Personality Disorder, and a history of substance abuse to an acute inpatient behavioral health unit at a
Salt Lake City hospital. Recreation Therapy played an important role for the patient to learn new ways to
cope with her PTSD, anxiety, and sobriety. This case study demonstrates the role of recreation therapy
within the hospital and the direct interaction with the patient.

Key Words: Discharge planning, coping skills, Post-Traumatic Stress Disorder, Bipolar Disorder,
Substance abuse

Biographical and Demographic Information

Ms. M is a 36 year old, Caucasian, Bi-sexual, single, female transferred from Pioneer Valley ED to St.
Marks Hospital, to the acute behavioral health unit, a for profit hospital in Salt Lake City, Utah for 4 days
after an overdose in a suicide attempt. The primary diagnosis upon admission is Bipolar Affective
Disorder presently mixed, Post-Traumatic Stress Disorder, and General Anxiety Disorder and has a
Cluster B diagnosis of Borderline Personality Disorder. Her medications at time of admission include:
Lamictal, Cymbalta, Wellbutrin, Prazosin, Neurontin, and Seroquel. Ms. M also has PRN medications that
include: Klonopin, Ambien, and Seroquel. Ms. M reported that she thinks her medications were working
well until there was a recent adjustment to her Cymbalta by her provider. Ms. M is on various mood
stabilizers to treat bipolar disorder, and some medications to help with her anxiety, PTSD, insomnia,
migraines and low back pain.

Prior to hospitalization, Ms. M lives with her sister and brother in law, whom Ms. M reported getting in
an argument with and started feeling suicidal. Ms. M reported to overdosing on her psych medications
as well as her other medications. Ms. M reports that she has a history of overdoses and five other
suicide attempts, and has various hospitalizations prior to this one. Ms. M has four brothers and four
sisters, her parents are alive and divorced. Her psychiatric history in the family is positive for two of her
sisters, uncle and an aunt. Ms. M was diagnosed with Bipolar Affective Disorder when she was 19 years
old and admits to having manic episodes that will have her in an elevated mood and wants to clean her
house and also notes that she will lose time and become lost, confused and disoriented and not know
where she is or how she got there. Ms. M has a sexual and emotional abuse history from ages 2 to 9
from a child in her nursery school her mother ran, her mother was told but it was never reported. She
has some PTSD of physical and emotional abuse from her ex-husband as well. Ms. M has a trouble with
sleep onset and has some nightmares about her abuse issues, and wakes up in a panic. She admits to
having high anxiety levels and auditory hallucinations. Ms. M has a high appetite and has gained 10
pounds in two months. Ms. M does not presently exercise regularly. Ms. M is not presently working and
is on disability. Ms. Ms employment history most recently, a bartender for 3 months, she has frequent
job changes. Ms. M claims it is because she blacks out and doesnt know where shes at (dissociating).
Ms. M graduated early from high school at age 16. She had some speech therapy during her school years
and she spent a lot of time in the school counselors office avoiding peers. Ms. M stated that her family
isnt supportive of her and that they do not want to be around her. Ms. M stated that her sister likes to
put her down, and that her mother is fed up with her. Ms. Ms current hobbies and interests are being
around others, a typical day for her is sitting in the basement watching Netflix and YouTube.

St. Marks Hospital acute inpatient behavioral health unit, is a voluntary locked down unit with 16 beds
which serves adults 18 years and older with mental health disorders that need acute short term care to
stabilize medications to manage their emotional well-being to be a functioning member of society.
Patients discharge with 3-5 days depending on the patient needs to a long term inpatient behavioral
health care program or to intensive outpatient programs. Ms. M was admitted to the St. Marks
Behavioral Health treatment team that includes: Physicians, nurses, social workers, spiritual care
providers, recreational therapists and if applicable dieticians, and respiratory therapists.

Case Content

Within 72 hours of admission to the inpatient unit the recreation leisure assessment was presented with
a one to one interview. Questions include types of activities the patient likes, what
leisure/hobbies/interests they currently do, what they want to accomplish with this hospitalization, their
strengths, what their recreational plans are after discharge, how they cope with their stress, if they have
quit or decreased participation in leisure activities they used to enjoy, barriers to participation and how
the recreation therapy team can be beneficial to them. Ms. Ms leisure interests include socializing,
cooking, dancing, crafts, watching movies/TV, Music. Ms. M belongs to NAMI, the National Alliance on
Mental Illness a non-profit support group within the community of West Valley City, Utah.

Through assessment Recreation Therapy could identify Ms. Ms barriers to participation in leisure
activity which include: Physical limitations, financial problems from unemployment, poor memory, and
her living situation with her sister in which she wants to live in her own place.

Ms. Ms team goals for hospitalization were to reduce anxiety, control drug abuse with the use of
positive ways to reduce stress and identify positive recreational activities, and teach safety planning for
self-harm urges. Ms. Ms personal goal was to learn new ways to communicate her needs.

The recreation therapy objectives were to Ms. M to identify positive recreation activities to promote
sobriety and to use as a coping skill for depression and anxiety. The unit has an exercise group in the
mornings that Ms. M would attend and actively participate; she really enjoyed the stretching exercises
vs. the more heart elevating exercises or the Wii video games that are more active. The exercise group
primarily focuses on using exercise to reduce anxiety.

The recreation therapist did a communication group in which the intervention was a team building
exercise of creating a country. Ms. M had to be prompted occasionally to keep her comments
appropriate in group; Ms. M was semi-engaged and was more focused on the social aspect of group
rather than the communication task at hand.

The second recreation therapy group Ms. M attended had the purpose of discharge planning using The
Four Agreements by Don Miguel Ruiz; Be impeccable with your word, dont take anything personally,
dont make assumptions and do your best. And engaging in the game Sorry The group participants
discussed what they liked and didnt like about the game and making plans for discharge and how it can
be challenging, but creating a plan can be helpful in maintaining emotional well-being. Ms. M came to
group late and stated she didnt want to engage in the game of sorry. Ms. M and a peer engaged in
conversation and the facilitator had to prompt them to keep their voices down. Ms. M started engaging
in group when the facilitator talked about The Four Agreements; Ms. M stated two of them by memory
and then talked about her experience of utilizing the four agreements in her life and what a difference it
made for her.

The third recreation therapy group Ms. M attended was Coping Skills Bingo, beginning with identifying
and defining healthy and unhealthy coping skills. When engaging in the Bingo task, Ms. M reported
feeling anxious and needing her PTSD pills because of other patients on the unit. Ms. M used the
group initiative as a coping skill for her anxiety at the present time. Ms. M stated following group that
she really liked that the group incorporated positive coping skills and negative coping skills, making the
coping skills more of a realistic feel rather than just focusing on positive coping skills.

When Ms. M was admitted, she was more interested in the social aspects of treatment and not so much
on learning the skills needed to cope with lifes stressors. Ms. M disclosed that she would have suicidal
ideation when she would talk to her mom, but over the course of the four days of hospitalization she
started denying suicidal ideation. In the discharge interview of Ms. M she reported that exercise and the
Four Agreement groups were really beneficial. Ms. M stated I never exercise, and you got me to
exercise! Ms. M stated that she learned new coping skills and now knows that she cannot be around
her friends that party and use drugs. When she needs help she reported needing to reach out to people
that are clean when she needs help.

By discharge, Ms. M was diagnosed with Bipolar 1 disorder, PTSD, and GAD with Cluster B diagnoses of
Borderline Personality Disorder. Ms. M had her medication adjusted for stabilization with her mania and
depression. Ms. M still has dissociative episodes that were present before admission. The discharge
prognosis is that Ms. M has chronic mental illness and will need outpatient care. Social workers on the
treatment team set up Ms. M with outpatient appointments for ongoing care.

Author Notes

When Ms. M was admitted, she was very tangential in her stories and hyper-verbal and a poor historian,
she told a variety of stories about being violent with staff in hospitals and EDs. Throughout Ms. Ms
stay, Ms. M made progress in gaining insight to what she needs to do when she needs help, and what
coping skills she needs to use. Ms. M didnt disclose specific coping skills except for reaching out to
persons who are clean. She did mention that exercise was really beneficial for her but did not report
using exercise as a means to cope or to maintain emotional well-being. Upon discharge, Ms. M seemed
to be happy to leave the unit and in a more stable condition than she was when admitted. At times the
author had a hard time relating to the patients history of abuse and understanding what the PTSD of
sexual and emotional abuse are. Ms. M disclosed her PTSD triggers and that they are really bad, I look
down when Im walking, I dont look at anyone. When they were trying to restrain me in the ED, I was
freaking out because of my rape in the past.

This case study provided a lot of experience for the author and the internship with St. Marks Hospital. It
is often hard to see the impact of the interventions with the clients. In this case the Ms. M did reach her
goals and objectives and learned new skills to help her with her sobriety and anxiety. Since her goals and
objectives were measurable and achievable for Ms. M, the treatment in the unit helped Ms. M learn
new skills to manage her emotional well-being for the future to be successful. Ms. M will continue
outpatient therapy to keep her stabilized with her medications and provide support.

References:

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Krueger, Vicki and Kanary, Gayle. Prader Willi Syndrome: A Case Study. Therapeutic Recreation Journal.
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Lane, Suzie W.L. Montgomery, Diane. Schmid, William. Understanding Difference to Maximize
Treatment Interventions: A Case Study. Therapeutic Recreation Journal. 1995.

Voelkl, Judith E. and Robertson, Terrance P. Guest Editors Case Histories in Therapeutic Recreation.
Therapeutic Recreation Jounal. 1995.