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Introduction
Bipolar disorder, previously termed manic depressive psychosis, is a serious mental illness characterized by mood swings with episodes of both elevated and depressed moods (Bipolar Disorder, 2005).
Stressful conditions and functional disturbances are the triggers of mood swings. Effective therapy being available, the positive approach by the families and patient could reduce its impact. Patients may lead a fairly normal life without episodes with the assistance of a multidisciplinary team and the support of family and friends.
The occupation for a Bipolar Disorder patient
Maintaining a steady occupation appears an impossible proposition by virtue of the symptoms of the illness and the difficulty to maintain social relationships. The mood swings that the patient experiences would present a picture of an odd person in his workplace and in his community. Even his family members may not realize his illness and react improperly to his ‘crazy’ behavior. This may aggravate his symptoms and show him up in a bad light. If in a manic episode, he will exhibit an increased energy level. Though in a highly euphoric mood, he may be easily irritable. Talking fast, he will not allow another person to intervene. Jumping from one subject to another, he has enough matter to talk upon. Lacking concentration, he has poor judgment of matters. Unrealistic belief in his own powers, he indulges in spending sprees. Increased sexual drive may provoke him to involve himself in indiscrete affairs which embarrass his friends and family. If somebody were to point out his behavior, he would deny things as he has not realized his mistakes and oddness. These symptoms would interfere with his work and his relationships at work. Similarly if he is in hypomania, he will actually be doing well in work and be productive. His friends and family may notice the difference in behavior but he would be denying the suggestive symptoms. Severe mania may present like psychosis with hallucinations and delusions. Depressive episodes also change his behavior which again makes him stand out among his colleagues at work. Prolonged sadness or emptiness, hopelessness, feelings of guilt and shame, decreased energy, lack of sexual drive, sleep disturbances, memory disturbances, difficulty in concentration are symptoms that definitely hinder the smooth functioning at work.
Change in appetite and suicidal thoughts are other features that can create problems at work.
Even when in therapy, he may need the support of friends and family and the administration at the workplace. Sometimes it may not be possible for all to go along smoothly.
Too many people may need to support him and this may not be possible at work. They cannot always take responsibility for his deviant behavior.
The social stigma attached to the illness would make his colleagues avoid him if they are not close friends. They may even ridicule him if they are not humane and do not understand the seriousness of their ragging. Therapy now includes family and friends and some people are aware of the illness.
When therapy has been started, the patients tend to stay away from work for a long time. They feel inadequate and tired and may feel they cannot make it. Their performance would be poor.
Diagnostic features
Like all mental illnesses, bipolar disorder cannot be diagnosed using a blood test or a brain scan. Symptoms, course of the illness and family history by the DSM-IV (Diagnostic and Statistical Manual for Mental Disorders, fourth edition) criteria clinch the diagnosis (Bipolar Disorder, 2007).
Biological basis
This disorder is a genetically determined condition and the heritability is very high at 80% (Johnson, 2004). The risk of close relatives to persons with bipolar disorder is 10% for developing a similar disorder or depression. The genes have not been discovered yet and researchers suggest that more than one gene may be involved (Bipolar Disorder, 2007).
Dysregulation of neurotransmitters is the probable reason for genetic vulnerability. Functional changes are known to occur in the dopamine and serotonin. Previously it was thought that these neurotransmitters normalize between episodes but currently this idea has changed and now it is said that homeostasis is maintained with difficulty. Attention is now focused on g-proteins and GABA.
Recent research is focusing on how symptoms develop in the face of deprivation of sleep and similar neurobiological changes (Johnson, 2004). The density of neurons does not seem to have any role. However post-mortem studies have shown a reduction in the glial cells. Focus is now on the different brain regions during episodes. Changes have been identified in the activation levels of the amygdale, pre-frontal cortex and the anterior cingulated during the performance of emotion-related tasks. Biological assays have not proved anything so far.
Management of Bipolar Disorder
Diagnosing the symptoms is essential before starting the treatment. Initial clinical assessment followed by a more comprehensive assessment is done (Bipolar Disorder, 2005). Organic causes are excluded by routine hematological investigations and brain scans. A combined long-term treatment with drugs and psychosocial therapy constitutes the management.
Deinstitutionalisation
People with even the most serious of mental illnesses are treated within the community (Pollio et al, 2006). The days of the asylum are over: deinstitutionalization is the dictum. The community and the family have been given the responsibility of the care for these patients. Inadequate knowledge, lack of training and little professional support have all contributed to the struggle of the families. Families need to be trained to care for a person with serious mental illness otherwise the risk of physical and psychological problems in the family members rises.
Though a serious illness, bipolar disorder is also treated within the precincts of the community.
Pharmacological approaches
Pharmacological treatment has a role due to genetic vulnerability and the changes in the neurotransmitters (Johnson, 2004). Lithium is the drug of choice. It reduces the suicidal rates and the risk of re-hospitalization. 75% of people however have side-effects like excessive thirst, frequency of micturition, memory problems and weight gain. Anti-seizure medications can be used instead. For the depressive episode, these are not effective.
Psychotherapy
Residual depressive symptoms may be reduced with psychotherapy. It is “always used as an adjunct to medication approaches” (Johnson, 2004). Psychosocial interventions are used for the improvement of adherence, as a relief for secondary outcomes of the illness and reducing relapses. An increased rate of non-adherence occurs because of side effects.
Psychological outcomes
Accepting the illness is the main problem of individuals. They face the difficulty of letting others know and cannot withstand the social stigma of being rejected by others for having a mental illness. One-third of patients refrain from going to work for about a year. Impaired functioning continues even after the acute episodes. The patients are also unable to maintain close relationships with others. Occupational stability is another problem (Johnson, 2004). Attitudes towards the mentally ill have changed over the years, yet, family members, relatives, friends, employers and their own religious houses are finding difficulty in accepting the ill. Consumer support groups could help overcome the loneliness that results from all the rejections. The feelings of dejection can be handled with psychotherapy.
Predictors of the disorder
The biological variables that throw light on the course of the illness have not been identified even though we know it is a genetic vulnerability that is involved (Johnson, 2004). However psychosocial variables can be identified. Hence it has been understood that family conflict, life stress and social rejection tend to trigger the illness. Protection against the illness is possible by reducing these.
Reasons for combining the pharmacological treatment with psychosocial approaches.
Symptoms are better understood by the patients through this approach (Johnson, 2004). Adherence to medication regimens is promoted. Co-morbid illnesses are also identified and managed. The social stigma involved would be played down and the self-esteem of the patient enhanced. Social adjustment would be advocated and patients are taught to manage good relationships and adjust at work. The risk of suicide is diminished due to appropriate counseling. The patient is taught to identify triggers that increase the risk for relapse and how to prevent relapses.
Coping strategies
The patient is educated on how to identify early signs and symptoms (Bipolar Disorder, 2005). Friends and families are also taught to look out for them. The necessity to remain in therapy is insisted upon. Patient and family are to avoid any reason for stopping treatment consistently. The illness is never allowed to dominate. A mood diary is kept by the patient to keep track of progress. Family and friends are to participate in the extended care (Bipolar Disorder, 2005).
Psychosocial treatment
Three approaches are seen: psychoeducation, cognitive behavior therapy and interpersonal and social rhythm treatment. The main role of this treatment is to help the patient cope with his illness: he is helped with coping strategies. Good outcomes are seen.
Psychoeducation
Psychoeducation and family treatment are related to the relapse rates of the illness. Psychoeducation is believed to improve the social adjustment of the patient (Pollio et al, 2006).
However a family may have difficulty in committing to participate in the psychoeducation to treat the patient as it may be a long-term treatment. Brief workshops would be better accepted by the families. Evaluation following the workshop would elicit information
The Life Goals Program is a group-based psycho-educational program that helps the patient to understand his illness well and use his knowledge to identify possible triggers and methods to prevent the illness (Baeur, 2004). He learns to live with his illness. The program has three parts to it: skills for self-management (Life goals structured group program), providing support as per National Guidelines) and using primary nurse providers and psychiatrists to deliver improved access and continuity of care.
Cognitive behavior therapy
Cognitive behavior therapy is advised for bipolar disorder patients. Their therapy would need “flexibility, strategic planning, awareness of comorbidity and the ability to handle crises” (Leahy, 2004).
Interpersonal and social rhythm
Interpersonal psychotherapy helps to improve the interpersonal relationships around the patient (Frank and Swartz, 2004). Daily and weekly social interactions help the patient to be comfortable in his dealings. Social rhythm therapy helps the patient regularize his social rhythms. Direct monitoring and changing his routines would help him to go through life with ease and no anxiety on a daily basis (Frank and Swartz, 2004).
References
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Bauer, M.S. (2004). in “Psychological treatment of Bipolar Disorder” (Eds) Johnson, S.L. and Leahy, R.L. (2004). Guilford Press
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Bipolar Disorder: Australian treatment guide for consumers and carers, (2005).
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Bipolar Disorder, (2007).
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Frank, E.and Swartz, H.A., (2004) in) in “Psychological treatment of Bipolar Disorder” (Eds) Johnson, S.L. and Leahy, R.L. (2004). Guilford Press
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Johnson, S.L. (2004) in “Psychological treatment of Bipolar Disorder” (Eds) Johnson, S.L. and Leahy, R.L. (2004). Guilford Press
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Leahy, R.L. (2004) in “Psychological treatment of Bipolar Disorder” (Eds) Johnson, S.L. and Leahy, R.L. (2004). Guilford Press
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Pollio, D.E. et al, (2006). “Living with severe mental illness- what families and friends must know: Evaluation of a one-day psychoeducation workshop”. Social Work, Vol. 51 (1). p.31-38
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