a case presentation

1. SARA SHEIKH
STUDENT FINAL YEAR
B.S OCCUPATIONAL THERAPY
21st MARCH, 2013

2.  Name: -----
 Age: 18 years
 Gender: Male
 Marital status: Single
 Occupation: Engineering Student
 Diagnosis: Bipolar Disorder (Relapse of manic behavior)
 Admitted at: Psychiatry ward; Aga Khan University Hospital

3. The patient has been admitted three times to the
hospital to date:
1. February 2012
2. June 2012
3. October 2012

4.  Theclient underwent a meningeal repair surgery
because of an RTA.
 He was put on ventilator and had massive bleeding.
 After
recovery he became stable physically, but manic
symptoms started to appear a year later.
 He also started smoking heavily.
 His pre-morbid personality was reported to be an
aggressive one and he used to mistreat his bed bound
(late) father.

5.  Accordingto the family, he used to suspect his
mother’s character.
 He used to beat his sisters on minor events.
 Hewarned his mother not to leave any of his sisters
alone with him, as he might molest them.
 He used to throw tantrums at unfounded accusations
against his sisters (e.g.: he said that one of them took
his car and had an accident; that did not happen).

6. Cooperative and alert
 Fluency: His speech was coherent and goal
directed, without any loosening of association.
 Orientation: He was oriented 3X.
 Memory: His memory was intact and he seemed to
be of average intelligence.
He admitted that he “had a problem and
 Insight:
became angry which was a bad thing”.

7.  Affectiveproblems: over confidence; self-
dramatization; high socialization; feelings of
grandiosity; aggressive behavior
 Difficulty in maintaining attention
 Self-organization: fair judgment; lack of time and
routine management; self concept varying from high
to low; projection of blame
 Behavior: independent; was conscious of social norms
but had poor self-control

8.  ADLs:
• His grooming and sleeping routine was affected by
lack of routine management.
• He did not feel hungry due to his manic episode.
Often he skipped his breakfast and demanded it later
in the day, getting irritated when he was refused.
• He did not bathe often, saying that he was not feeling
up to it.
• His communication abilities were impaired; he tried
to be frank with everyone but got angry with people
very quickly on minor events.

9.  Work:
He was a first year engineering student but his
education was discontinued after his illness. He
wanted to continue his studies but also admitted that
he could not concentrate on his studies properly.
 Leisure Activities:
He did not engage in any of his previous leisure which
were; watching English movies and keeping himself
informed about cars. Instead he roamed around
listlessly or kept watching random TV
programs, saying that he did not feel up to them.

10. Short term Goals:
 Increase attention span
 Develop time management
 Develop routine management
 Increase tolerance
Long term goals:
 Decrease grandiosity
 Eliminate abusive behavior
 Enhance ability to make correct decisions
 Develop realization of importance of taking
advice
 To decrease relapse rate

11. Interpersonal Social Rhythm Therapy:
• To develop routine management;
• To stabilize sleep/wake episodes in order to
control mood disorders;
• To develop tolerant behavior;
• To increase attention span.
Cognitive Behavioral Therapy:
• To decrease grandiosity;
• To decrease flight of ideas;
• To increase reality contact
• To decrease aggressive and abusive behavior.

12. Group Therapy:
• To increase tolerance and control aggression;
• To increase attention span;
• To develop time management;
• To develop the concept of discussion.
Family Focused Therapy:
• To assist the client and his family in recognizing
the nature of the disorder;
• To assist in re-establishing and maintaining
equilibrium in the family after the episode;
• To assist the family to recognize and act quickly
on the signs of relapse.

13. Teaching about how to detect signs and
symptoms of relapse:
• To decrease relapse rate;
• To help family by obtaining early treatment;
• To develop and maintain medication
compliance.

14.  Notto get frightened at the client’s manic
episodes.
 Not to adopt submissive behavior or to comply to
his each and every demand.
 Tokeep in touch with the therapist and
psychiatrist even after the episode has passed.
 Keep check and balance on him by inquiring
about his outings and friends etc. If he gets
angry, gently remind him of his responsibilities.

15. The client was seen in occupational therapy day care
almost daily. He was involved in sports and gym
activities and participated in time oriented group
tasks.
Task Completion:
He needed constant supervision in completion of a task
due to his short attention span and distractibility. He
was always confident of his success and refused to
carry on a task if he wasn't able to do in first attempt.

16. Decision making:
He was independent in decision making and problem solving
but often made wrong decisions due to over confidence.
Level of Group Participation:
 At first he was a passive participant and refused to do
anything. But he became familiar quickly and started
participating and even initiating activities sometimes.
 He did not involve in sharing in group and always tried to
force his opinions on everyone during group discussions.
After sometime, he started to listen (not agreeing) to others’
opinions.
 If he lost during a round of game or completed a task out of
a set time limit, he got irritated and left the therapy room.

17. Realization:
He admitted that:
 His behavior towards his relatives was bad;
 One cannot win every time and one should accept
defeat.
But this concept was short lived and he reverted to his
previous state often.
Sports and Gym:
Initially he enjoyed playing and exercising but preferred
to play alone (basketball) when he missed the basket
while playing in a team. After sometime he started
playing a few games in couples or triplets.

18. Discharge was sudden and unsatisfactory.
Upon discharge, Mr. Mussab had made slight
changes. His attention span was a little longer
and he had started to pay heed to therapist’s
instruction regarding task completion. No other
change was observed.
There were high chances of relapse. Therefore
the client was recommended to attend the
occupational therapy day care as an outpatient.

20. Frank and Swartz conducted a comparative study on 125
patients with BPD, manic episode to compare the effects of
Interpersonal and social rhythm therapy with Intensive
clinical management in acute and then a maintenance of 2
years. They yielded better results from IPSRT in acute
treatment than ICM; thus favoring IPSRT for patients with
bipolar disorder.
(The Role of Interpersonal and Social Rhythm Therapy in
Improving Occupational Functioning in Patients With
Bipolar I Disorder by Ellen Frank, Ph.D., Isabella Soreca,
M.D., Holly A. Swartz, M.D., Andrea M. Fagiolini, M.D. at
Western Psychiatric Institute and Clinic, University of
Pittsburgh Medical Center, Pittsburgh)

21. Otto, Harrington and Sachs conducted a review to
determine the efficacy of CBT on patients with bipolar
disorder with manic, depressive or mixed episodes.
They found sufficient evidence in favor of CBT
decreasing the symptoms of patients with either mixed
or manic or depressive episodes.
(Review: Psycho educational and cognitive-behavioral
strategies in the management of bipolar disorder by
Michael W. Otto, Noreen Reilly-Harrington, Gary S.
Sachs at Massachusetts General Hospital and Harvard
Medical School, Boston, MA, USA)

22. Weiss and Griffin conducted an empirical cohort
study regarding group therapy on 45
bipolar, manic patients with substance abuse for
20 weekly hour-long group sessions with a 3-
month follow-up. They found out that the mood
and medical compliance component had
significantly improved, thus supporting group
therapy for bipolar patients.
(Group therapy for patients with bipolar disorder
and substance abuse: A pilot study by Roger D.
Weiss, M.D; Margaret L. Griffin, PhD)

23. Ozerdem and Miklowitz carried out Family focused
therapy in Turkey to observe its efficacy in the
Eastern culture. 10 patients with bipolar disorder
volunteered for the treatment and underwent a 9
month therapy with 1-1.5 years follow-up. The
study reported that the patients and the family
benefitted a great deal, thus supporting the use of
FFT for bipolar patients.
(Family focused treatment for patients with bipolar
disorder in turkey: A case series by
Ozerdem, Oguz, Miklowitz, Cimilli)

24. Perry and Tarrier conducted a randomized controlled trial
on 69 patients with BPD having had at least 1 relapse in
12 months, to determine the efficacy of teaching
patients with bipolar disorder to identify early
symptoms of relapse. They found out that the relapse
rate of the experimental group from baseline was 65
weeks compared to 17 weeks in control group; hence
confirming the efficacy of the objective.
(Randomized controlled trial of efficacy of teaching
patients with bipolar disorder to identify early
symptoms of relapse and obtain treatment by Alison
Perry, Nicholas Tarrier, Richard Morriss, Eilis
McCarthy, Kate Limb)