Diagnosis

Provide the full DSM-5 diagnosis for the client. For any diagnosis that you choose, be sure to concisely explain
how the client fits that diagnostic criteria. Remember, a full diagnosis should include the name of the disorder,
ICD-10-CM code, specifiers, severity, medical needs, and the Z codes (other conditions that may be a focus of
clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
Bipolar I Disorder – Moderate 296.42 (F31.12), with mixed features
V15.49 (Z91.49) Other Personal History of Psychological Trauma
V61.10 (Z63.0) Relationship Distress With Spouse or Intimate Partner
V61.8 (Z63.8) High Expressed Emotion Level Within Family
Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
The DSM-5 states that only one manic episode in a lifetime is necessary to meet the criteria for Bipolar I
Disorder. In the Case of Angel, his first girlfriend reported that Angel was a fast talker and it was difficult for her
to get a word in. This is consistent with the DSM criteria that the individual is more talkative than normal. In

addition, Angel was known to buy his girlfriend various things on his credit card and became irritable when his
bill came in. One of the criteria for this disorder is engaging in unrestrained buying sprees. Last, Angel was
able to function on only a few hours of sleep, indicating mania. Regarding depressive symptoms, Angel reports
being tired and has trouble falling asleep, which meets the diagnostic criteria of insomnia and fatigue.
Furthermore, Angel has tried to commit suicide after his first wife left him.
Recommend a specific evidence-based measurement instrument to validate the diagnosis and assess
outcomes of treatment.
The evidence-based measurement instrument I might use with Angel is the Mood Disorder Questionnaire. This
tool is comprised of 13 questions that measure the severity of both hypomania and mania as well as the level
of impairment that the symptoms cause for the client (Stanton & Watson, 2017). Some of the symptoms that it
assesses are “increased energy, risky behavior, distractibility, and racing thoughts” (Stanton & Watson, 2017,
p. 72).
Describe your treatment recommendations, including the type of treatment modality and whether or not you
would refer the client to a medical provider for psychotropic medications.
One treatment modality for clients with Bipolar Disorder is interpersonal and social rhythm therapy. This
method focuses on identifying stressors and helping the client find ways they can adjust their circadian rhythm.
In addition, this modality serves to identify coping mechanisms the client can use when there is an onset of an
episode (Steardo et al., 2020).
Before referring the client to a medical provider for psychotropic medications, I would make sure to evaluate
the client to ensure that there were no other psychiatric conditions, comorbidities, or factors that might be
contributing to their symptoms (Jain, Maletic, & McIntyre, 2017). If the diagnosis of Bipolar Disorder was
confirmed, I would likely send the client to be evaluated by a psychiatrist for psychotropic medications if the
symptoms were not mitigated by the aforementioned treatment modalities, but this would not be my first step in
the intervention process.

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