Discuss about the Biopsychosocial Assessment of Bipolar Disorder.
Bipolar is a mental health disorder that is characterised by episodes of depression and mania or hypomania (Royal College of Psychiatrists, 2015). A survey by AMPS revealed that 2.0% of the population screened positive for bipolar disorder (McManus, Bebbington, Jenkins, & Brugha, 2016). Bipolar disorders have long episodes and close to 60% of the patients relapse in the first two years, and about 75% in over five years following the initial diagnosis (Najafi-Vosough, Ghaleiha, Faradmal, & Mahjub, 2016). Due to the above statistics, there is need for effective bipolar management. This has led to the need of evaluation of biopsychosocial factors that help to inform the appropriate management interventions.
Bipolar disorder has been strongly to genetic factors even though the specific genetic abnormalities that contribute to bipolar disorder are unknown (Nolen-Hoeksema, 2011). First-degree relatives of people with bipolar disorder are 5 to 10 times more prone to both bipolar disorder and depressive disorders than relatives of people without bipolar (Farmer, Elkin, & McGuffin, 2007). This can be a factor on Susan’s case as there is family history of bipolar since the brother was diagnosed with bipolar.
Brain imaging techniques like have brought great advancement in the study of bipolar disorder. Through them, it has been identified that people with bipolar disorder have enlarged ventricle spaces. Enlarged ventricles are an indication of less brain tissue in the brain which suggests that there has been loss of cells in the brain or that brains of people with bipolar develop differently than normal brain (Nemade & Dombeck, Brain Imaging and Bipolar Disorder, 2009). It has been observed that there is also a reduction in the glial cells in bipolar brains. This has led to inefficient communication within the brain. Abnormalities in the structure and functioning of the amygdala and prefrontal cortex have been implicated in bipolar. The amygdala processes emotions and the prefrontal cortex controls emotion, planning, and judgment (Konarski, et al., 2008).
Neurotransmitters are widely used in the brain for facilitating communication within the brain. The neurotransmitters implicated in bipolar illness include dopamine, serotonin, GABA, glutamate, acetylcholine and neuropeptides. An imbalance in these chemicals is believed to cause bipolar. High reward seeking behaviours are thought to be associated with high levels of dopamine while low levels are associated with insensitivity to reward.
During manic phase this dysregulation in the dopamine system leads to excessive reward seeking and a lack of reward seeking in the depressed phase (Berk, et al., 2007).
Life events are believed to play a major role in the development and course of bipolar disorder. This has led to studies to be geared to three types of life events namely negative, social rhythm disrupting, and goal-attainment (Miklowitz & Johnson, 2009).
Negative life events
Studies have found that increased stressful events are experienced among bipolar individuals prior to the first onset and relapse. Negative life events are found to be associated with depressive symptoms rather than mania. Throughout Susan’s life, she has experienced great losses of the mother and brother that may have triggered her episodes.
Life Events that Disrupt Social Rhythms
Poor regulation of sleep and circadian rhythms influence symptoms (Miklowitz & Johnson, 2009). Decrease in the time the person sleeps can contribute to hypomanic or manic symptoms, and increase in sleep or bed rest may be followed by depressive symptoms (Brill, Penagaluri, Roberts, Gao, & El-Mallakh, 2011). In our case study it is clear that Susan faced sleep deprivation as there is reduced duration of sleep in the past week.
According to Social Rhythm Stability Hypothesis (SRSH) the core problem in BMD is instability of regular daily activities. Research states that life events associated with disruption of social rhythms are better predictors of manic phases (Haynes, Gengler, & Kelly, 2016).
Goal-Attainment Life Events
Bipolar Disorder is associated with elevated activity in areas of the brain associated with reward sensitivity. These areas include: the basal ganglia and ventral tegmental area. During mania episodes there is elevation in basal ganglia activity which leads to positive affect, approach motivation and behaviour which leads to an increase in the probability of incentive acquisition (Miklowitz & Johnson, 2009). This is evident in Susan’s case as she would make calls to her friends at midnight and animatedly discuss trips and outings.
Social support is an important feature as it affects the course of BMD. Support from family and friends has benefits on both treatment adherence and the functionality of the individual. Lack of social support serves as a risk factor for symptom recurrence and results in poor prognoses (Studart, Filho, Studart, Almeida, & Miranda-Scippa, 2015). In our case study, Susan lacked social support as she lives alone. This led her to non-adhering to medication which may have caused her relapses.
Drug and alcohol use
It has been suggested that cormobidity between bipolar disorder and substance use disorder are marked by severe symptoms, frequent mood episodes, lower functioning and lower satisfaction (Ostacher, et al., 2010). This can be clearly seen in our case study as Susan has started smoking after abstaining for one year. This may have been the reason for the recent episode or a predisposing factor for it.
Treatment and Medication Non-adherence
Non-adherence in bipolar disorder is associated with several adverse consequences like poor outcomes, increased risk of relapse, rehospitalisation and suicide. Increased utilization of health-care services and increased mental health expenditures has also been observed (Chakrabarti, 2016). Susan in our case has a history of non-adhering to her medications which may explain the readmissions to the facility and the recent episode.
Management of bipolar disorder
The two types of bipolar medication widely used are antidepressants and mood stabilizers. Antidepressants help alleviate depressive symptoms. The most commonly used classes of antidepressants are SSRIs like fluoxetine and sertaline and SNRIs like buproprion and venlafaxine. The other classes used include tricyclic antidepressants and monoamine oxidase inhibitors. For the management of mania, mood stabilizers like lithium and sodium valproate are used. Lithium has been proven to be not only effective at reducing the frequency but also the intensity of mood swings (Nemade & Dombeck, 2009). Despite this advancement, lithium requires regular monitoring as the margin between the therapeutic dose and the toxic dose is narrow.
Atypical antipsychotics are used in bipolar management as they are efficient mood stabilizers and produce less cognitive and extrapyramidal effects. The most commonly used antipsychotics include clozapine, risperidone and olanzapine (Nemade & Dombeck, 2009)..
Psychotherapy is used as an adjunctive bipolar treatment alongside medication treatment. Three varieties of psychotherapies have been found to be efficient in the management of bipolar. They include cognitive behavioural therapy (CBT), Family-Focused Therapy (FFT) and interpersonal/ social rhythm therapy. CBT focuses on one’s cognition and it aims at identifying maladaptive thoughts and changing them so as to have adaptive behaviour. FFT is a hybrid of psychoeducation and family therapy. It aims at educating the patient and family members on the nature of the illness and helping deal with family dynamics and relationships (Nemade & Dombeck, 2009).
Nursing diagnoses and interventions for mania
Risk for injury
This is related to high levels of hyperactivity which is exhibited during a manic episode. This is seen by increased agitation and lack of control potentially harzadous movements (Townsend, Essentials of Psychiatric Mental Health Nursing, 2011). Interventions carried out include reducing environmental stimuli, removing harmful objects, provide structured schedule of activities and physical activities so as to keep them engaged and involved in other activities and administer tranquilizing medication like antipsychotics drugs that offer rapid relief of agitation and hyperactivity (Townsend, 2015).
Risk for violence
This is mainly seen during episodes characterized by manic excitement, delusional thinking and hallucinations. The nursing interventions employed to avoid harm of self and others include; maintenance of low levels of environmental stimuli, removing hazardous objects and maintaining a calm attitude towards the client (Townsend, Essentials of Psychiatric Mental Health Nursing, 2011).
This is caused by the client’s refusal or inability to eat resulting to weight loss and amenorrhea. In such cases, the nurse in collaboration with the dietician provide high protein and calorie nutritious foods and drinks, record food and drink intake and output, calorie count and weight, and supplement diet with vitamins and minerals (Townsend, Essentials of Psychiatric Mental Health Nursing, 2011). Poor nutrition may affect the course of bipolar and increase chances of relapse.
Disturbed thought processes
This feature is related to abnormalities to biochemical and electrolyte levels in the body, psychotic process and sleep deprivation. This is evidenced by incorrect interpretation of environmental stimuli, hypervigilance, distractibility and delusional thinking. In such cases, the nurse is meant to avoiding arguing or denying the beliefs but show acceptance of the Client’s false belief. The nurse can also use consensual validation and seeking clarification techniques when communicating with the client so as to better understand him/ her (Townsend, 2015).
Impaired social interaction
This comes to be due to delusional thought processes and hallucinations that make it difficult to develop satisfying relationships. The nurse will actively engage with the patient so as to bring out any feelings of insecurity and need for manipulation of others and provide positive reinforcements for acceptable behaviours (Townsend, Essentials of Psychiatric Mental Health Nursing, 2011).
This is brought about by high levels of hyperactivity, agitation and biochemical abnormalities. It is reflected by difficulty falling asleep, sleeping for short periods of time and awakening extremely early in the morning. The interventions applied here include; provision of a quiet environment with low stimulation, monitoring of sleep patterns, assessing the client’s activity level and administration of sedative medication as ordered (Townsend, 2015).
Ethical implications of Bipolar disorder
Management of bipolar has been faced by a variety of ethical issues over time. One of the acts that face many challenges is the Compulsory Mental Health Care Act that identified values such as respect for autonomy, integrity, beneficence, justice and sanctity of life as important in mental health care. This has faced many challenges as in the management of bipolar, the autonomy of the client is lost. In the management of bipolar, it is possible to make decisions on behalf of the patient if he has serious impairment. This has led to many patients despite not being seriously impaired to not being consulted with regards to their treatment.
Coercive care is a challenging ethical situation as it talks about involuntary admissions, forced medications and tube feeding just to name a few scenarios. This goes contrary to the ethic of autonomy as the patient is not consulted for the admission. This is seen in Susan’s case as she was admitted to the mental facility despite not being for it. This can however be argued that it was for the benefit of the patient as she will get help which goes in line with the ethic of beneficence that states that all treatment interventions carried out should be for the benefit of the patient. Another ethical implication in the management of bipolar is on coercive measures used. It is evident that in the management of bipolar and other mental conditions those forceful measures are needed as the patient’s health can deteriorate while he/she is refusing treatment.
The main question that is asked is how can it be determined if one is being coerced to treatment for his/her own good and one’s right of sanctity to life is being undermining?
Bipolar is a lifelong mental condition that needs appropriate and effective management interventions so as to reduce the rate of relapse and readmissions. In the process of management it is clear that biological, psychological and social factors affect the development and course of Bipolar. These factors have led to a multidisciplinary approach in the management of bipolar by the application of pharmacotherapy and non-pharmacological strategies. The nurse plays a big role in the management of some of the presentations of bipolar like risk of injury, risk of violence, insomnia just to name a few. This has made them to be a crucial part in the management team as they deal with medical, psychological and social aspects of the patient.
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