SARA SHEIKH STUDENT FINAL YEARB.S OCCUPATIONAL THERAPY 21st MARCH, 2013
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
The patient has been admitted three times to the hospital to date:1. February 20122. June 20123. October 2012
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.
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).
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”.
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
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.
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.
Short term Goals: Increase attention span Develop time management Develop routine management Increase toleranceLong term goals: Decrease grandiosity Eliminate abusive behavior Enhance ability to make correct decisions Develop realization of importance of taking advice To decrease relapse rate
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.
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.
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.
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.
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 wasnt able to do in first attempt.
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.
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.
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.
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)
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)
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)
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)
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)