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«Case Study: Acute Mixed Manic Episode in a 27 Year Old Male Celebrity with Bipolar I Disorder Michael Brush Capilano University Case Study: Acute ...»

Case Study: Acute Mixed Manic Episode 1

Case Study: Acute Mixed Manic Episode in a 27 Year Old Male

Celebrity with Bipolar I Disorder

Michael Brush

Capilano University

Case Study: Acute Mixed Manic Episode 2

To accommodate the case study format, I am writing this essay from the perspective of a

hypothetical mental health professional who spoke to Kurt Cobain sometime between April1,

1994 when he jumped the wall to leave the Exodus Recovery Center and his death on April 5, 1994 (Cross, 2001, p.343).

Background K.C. is a 27 year old Caucasian male who reports having left a drug and alcohol rehabilitation center without being discharged. He additionally reports previous diagnoses of ADHD, depression, bipolar disorder and a history of drug abuse (Cross, 2001, p. 20, 78).

When K.C. was 7, his doctor prescribed Ritalin which he took for a period of three months. K.C.'s parents and teachers suspected that his endless energy had a medical reason and after a change in diet did not yield any change, the Ritalin was then prescribed. Several of K.C.'s relatives suspect K.C. had attention deficit hyperactivity disorder (ADHD), but as these accounts are anecdotal we will obtain medical records to corroborate (Cross, 2001, p. 20).

When K.C. was 9 his parents divorced which he has states had a profound effect on his life. K.C. began to exhibit defiant and withdrawn behaviours. A great deal of his current agitation seems to stem from the fear of a second divorce, between him and his wife (Azerrad, 1993, p. 17).

K.C. is a musician in a very successful band and it would be fair to consider him a celebrity. While he started the band in 1985, commercial success has been a recent development (Cross, 2001, p. 27).

Case Study: Acute Mixed Manic Episode 3 K.C. suffers from severe stomach pain. He recalls a 5 year history of this pain with no known diagnose to date. K.C. sites pain management as the reason he uses heroin (Azerrad, 1993, p. 76).

With the success of his musical career launching him into celebrity status, K.C., an often withdrawn individual, has found difficulty in adjusting to his exposed persona. After a show in Seattle in September 1991, K.C. reports feeling bewildered by how big the band had become (Cross, 2001, p. 202).

K.C. reports that his relationship with wife Courtney Love has been stressful. Courtney also has a history of mental health disorders and drug and alcohol abuse. When K.C. and Courtney had their first child, The Los Angeles County Department of Children's Services took the couple to court, claiming that the couple's drug use made them unfit parents (Azerrad, 1993, p. 270).

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K.C. appears to be suffering an acute mixed manic episode in the context of a history of bipolar I disorder (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association, 2000).

Distal complications include current comorbidity of heroin abuse (Grau & Vaccaro, 2002, p.

197) and history of multi-drug abuse, suicide attempts, and possible childhood ADHD (Cross, 2001, p. 20, 78, 324). Proximal complications include acute emotional stressors within his

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Bipolar I Disorder (BD-I) Expansive and irritable mood swings. K.C. does exhibit expansive and irritable mood (DSM) as demonstrated by accounts from his band mates (Cross, 2001, p. 138), professional

peers and friends (Cross, 2001, p. 147). K.C.'s producer Butch noted:

[K] was charming and witty, but he would go through these mood swings. He would be totally engaged, then all of a sudden a light switch would go off and he'd go sit in the corner and completely disappear into himself. I didn't really know how to deal with that.

(Vozick-Levinson, 2011) Additional diagnostic symptoms. K.C. does not exhibit any of the following symptoms to indicate a manic episode commonly found in individuals with BD-I: more talkative than usual or pressure to keep talking, distractibility, increased self-esteem or grandiosity (DSM). While grandiosity might be expected from a celebrity rock-star, it was not evident in K.C. His selfesteem is also not elevated as one might expect, in fact collateral information from his journals indicate that he possesses low self-esteem. A journal entry from 1993 reads "I'm not like them, but I can pretend. The sun is gone but I have a light. The day is done but I'm having fun. I think I'm dumb but I think I'm lonely" (Grau & Vaccaro, 2002, p. 193).

Decreased need for sleep. I am not sure K.C. is exhibiting this symptom. He reports a history of difficulty sleeping. He attributes this to stomach pain and recurrent nightmares of people seeking to hurt/kill him. (Cross, 2001, p.149) While this may indicate a decreased need

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Racing thoughts. K.C. has kept thousands of pages of thoughts and ideas within his many journals. His daily routine includes the conversion of his thoughts into his music, art and journals. These were largely composed with thoughts about human bodily functions such as birth, urination, defecation and sexuality (Cross, 2001, p. 94).

Agitation. K.C. is visibly agitated. While it would take more than one session to determine what level of agitation is usual for him, we can site his recent departure from the Exodus Recovery Center. He chose to leave surreptitiously over the garden wall, leaving his belongings behind, despite the fact that Exodus Recovery Center is voluntary and he could have left through the front door at any time (Cross, 2001, p. 343).

Excessive involvement in risky activities. In addition to the previously stated drug abuse, K.C. reveals instances of stereotypical unrestrained buying sprees associated with BD-I (Cross, 2001, p. 174).

Significant functional impairment. The only thing keeping K.C. from complete functional impairment currently is the high level of financial security that exists from his musical success. However, even that is threatened as we learned from a collateral interview that his record label is planning to sever their contract if his erratic behavior and substance abuse does not cease (Cross, 2001, p. 333).

Differential Diagnoses. There is no evidence that present symptoms are the result of a different psychological disorder. While we feel it is unlikely that these symptoms are caused by another medical condition we will order blood tests and MRI to rule out thyroid conditions or

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Depressive Episode Symptoms. K.C. is also exhibiting symptoms of Major Depressive Disorder. This is demonstrated by symptoms of depressed mood, anhedonia, restlessness, feelings of worthlessness and recurrent thoughts of death or suicide (DSM). On March 3, 1994 K.C. attempted to commit suicide by means of ingesting 60 aspirin size tablets of Rohypnol. He had written a suicide note which included "like Hamlet, I have to choose between life and death.

I'm choosing death." In the suicide note K.C. also expressed frustration and fatigue from touring as well as the aforementioned marital stresses. (Cross, 2001, p. 324). K.C. is currently experiencing a mixed manic episode as it contains a combination of symptoms from BP-1 and major depression (DSM). These episodes have persisted for longer than two weeks and cause marked impairment in functioning. Other diagnoses have been ruled out.

Etiology. The etiology of BD-I is known to be multi-factorial with environmental, genetic and other biological factors (Nurnberger & Foroud, 2000). BD-I is highly heritable with first-degree relatives having 4-6 times higher risk of developing BD-I than the 1% population risk (Nurnberger & Foroud, 2000). Family history of other mood disorders and substance abuse also increases the risk of BD-1 for first-degree relatives (Serretti et al, 2013). Examination of K.C.'s family pedigree (Appendix figure 1) is inconclusive with regard to genetic factors. While there are two instances of suicide in the family tree, both are in distant relatives, indicating very little genetic sharing between those individuals and K.C. Additional family history information was difficult to assess as K.C. remained fixated on the specific suicide history in his family, and he had little knowledge (or desire to share) information on other familial conditions/illnesses. I believe environmental factors are likely to have contributed much more to BD-I in this case

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Assessment Tools. We used the Structured Clinical Interview for DSM-IV (SCID) as it is recommended as an initial assessment tool, (Goldberg, 2010). The SCID provides interview probes, symptom thresholds, and information about exclusion criteria designed to help assess diagnoses according to the DSM-IV (Miller, Johnson, & Eisner, 2009). The SCID-I was used as it was apparent early in the interview that an axis-I assessment tool was most appropriate (Miller, Johnson, & Eisner, 2009).

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As the situation stands now, K.C.'s prognosis is poor. If his BP-I continues to go unmanaged as is currently the case, the acute mixed manic episode K.C. is experiencing may be of extended duration. Given the patient's suicide history and markedly impaired social function he is at high risk to harm himself, either intentionally or accidentally. While his recent admission to a drug and alcohol treatment facility does indicate some insight into the severity of his problem, the fact of his unauthorized departure from the treatment facility indicates that this insight may be transient. In the event that K.C. recovers from this particular manic episode unaided, if his BP-I continues to go unmanaged, he is at increased risk for future episodes.

Additionally, if K.C's BP-I continues to be unmanaged, his commitment to/ability to bringing his substance abuse under control is unlikely.

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another overdose. I introduced the prospect of being admitted to hospital in a scenario where discharge would be at the discretion of a mental health professional rather than his own.

Unsurprisingly, he was not open to the idea at this time; however, K.C. has consented to certain member of his family being contacted for this assessment and I will attempt to illicit family support for the idea of temporary hospital admission.

Long-term Idiopathic Stomach Pain. K.C. repeatedly references the high level of pain he experiences as the reason for his heroin use; therefore, additional effort should be made to properly diagnosis the source of this pain. Failing that I believe it is imperative to have K.C.

admitted to a pain clinic where he can find alternatives to heroin for managing his pain.

Medications. K.C. would likely benefit from the use of mood stabilizers. I would like to further consult with K.C.'s physician to develop the best strategy in this regard.

Mindfulness-based Cognitive Therapy (MBCT). Evidence suggests that MBCT improves anxiety and depressive symptoms in bipolar patients and that this improvement is maintained over 3 years follow-up (Williams et al., 2008).

Music Therapy. K.C. appears to have previously found a great deal of catharsis in his music and his writing. Sadly, as a result of his band's success, his current relationship with music has created situations which K.C. finds overwhelming and as his journals (Grau & Vaccaro,

2002) and family/friend interviews (Smith, de Grundwald, & Smeaton, 2005) suggest, is causing him to lose the connection with his primary source of expression. In less than three years, the

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addiction, marriage and fatherhood. Re-establishing a relationship with music would help to ground him. The relationship should exist outside of the pressures associated with his job and

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349.

Azzerad, M. (1993). Come As You Are. The Story of Nirvana. New York, NY. Three Rivers

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Goldberg, J.F. (2010). Differential Diagnosis of Bipolar Disorder. Primary Psychiatry, 2 (suppl 3), 4-7.

Grau, J., & Vaccaro, C. (Eds.). (2002.) Kurt Cobain Journals. New York, NY. Riverhead Books.

Miller, C.J., Johnson, S.L. & Eisner, L. (2009). Assessment Tools for Adult Bipolar Disorder.

Clin Psychol 16(2), 188-201.

Moise, D., & Madhusoodanan, S. (2006). Psychiatric symptoms associated with brain tumors: a clinical enigma. CSN Spectr 11(1), 28-31.

Nurnberger, J.I., & Foroud, T. (2000). Genetics of bipolar affective disorder. Current Psychiatry

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Serretti, A., Chiesa, A., Calati, R., Linotte, S., Sentissi, O., Papageorgiou, K., Kasper, S., Zohar, J., De Ronchi, D., Mendlewicz, J., Amital, D., Montgomery, S., & Souery, D. (2013).

Influence of family history of major depression, bipolar disorder, and suicide on clinical features in patients with major depression and bipolar disorder. Eur Arch Psychiatry Clin

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Smith, M.R. (Producer), de Grundwald, N. (Producer) & Smeaton, B. (Director). (2005).

Nirvana - Nevermind - Classic Albums. [Video]. London, UK; Eagle Vision. Retrieved from http://www.youtube.com/watch?v=pxUq64x3uA4.

Vozick-Levinson, S. (2011, August 23). Inside the 20th-Anniversary Reissue of 'Nevermind'.

Rolling Stone, (1138). Retrieved from http://www.rollingstone.com/music/news/insidethe-20th-anniversary-reissue-of-nevermind-20110823.

Williams, J.M.G., Alatiq, Y., Crane, C., Barnhofer, T., Fennell, M.J.V., Duggan, D.S., Hepburn, S., & Goodwin, G.M. (2008). Mindfulness-based Cognitive Therapy (MBCT) in bipolar disorder: Preliminary evaluation of immediate effects on between-episode functioning. J

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Figure 1. Pedigree for K.

C. tracking suicide, bipolar I disorder (BD-I) and substance abuse

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