Bipolar disorders(BD) are characterized by symptoms of hypomanic, manic and depressive episodes which leads to impairment in the ability to function. These symptoms are unpredictable and reoccurring; usually first noted in adolescence or early adulthood. Type of BD includes bipolar I, bipolar II disorder, and cyclothymic disorder (American Psychiatric Association, 2013). Due to the dynamic, chronic, and fluctuating nature of BD, it is can sometimes challenges for the practitioner in managing the disease process. The purpose of this paper is to explore bipolar disorders in adult clients. This paper will discuss a case and recommend treatment modalities, referrals, follow-up plan and collaboration needed to effectively manage the client with BD. Bipolar Disorders
History of Present Illness (HPI) and Clinical Impression
Patient is a 38-years-old African- American male who presented with suspected symptoms of hypomania; accompanied by younger brother. Patient was referred for outpatient visit following discharge from impatient stay at a psychiatric hospital. Patient diagnosis during hospitalization as noted on discharge paperwork is Bipolar disorder, manic state. Client is alert and oriented x4, appropriately dressed and pleasant. Speech was clear but pressured and overly inclusive. Aspect of grandiosity noted in speech. Client noted to be easily distracted and jumped from one irrelevant topic to the other. Patient reported being able to function for days with just about three to four hours of sleep per night. Patient’s brother reported patient has been extremely happy, sociable and full of himself lately since the past five days, which is unlike him because he is usually shy and reserved. Client is currently staying with his brother in an apartment, but client is in of housing as the apartment does not belong to the brother. Client’s brother stated client was living with his girlfriend but she kicked him out after she caught client frolicking with different females in the apartment they shared on different occasions. Client laughed at this statement, verbalizing it is not his fault females out here finds him so irresistible and then stated with conviction that girlfriend will be back begging soon. Client’s brother reported that client quit his job few days ago, because he absolutely believes he will win the jackpot. Client denies feeling down and thoughts of suicide. Client also denies abuse of alcohol and drugs Bipolar Disorders
The presentation of the signs and symptoms noted in the HPI are indicative of hypomania state in Bipolar I disorder. Patient’s mood is elevated and expansive with energy lasting more than four consecutive days. Within the period of increased energy or activity, patient exhibited flight of ideas and distractibility; inflated self-esteem, pressured speech and sexual indiscretion. Patient’s change in mood was observed by brother who accompanied him to the appointment. Patient does not exhibit a state of severe impairment in social functioning or need for hospitalization. The signs and symptoms are all synonymous with the diagnostic criteria outlined by the American Psychiatric Association (2013) in DSM-5.
Despite the difference in the symptom presentation of mania and hypomania (shorter in duration), medication treatment is the same in both cases (Wong, 2011). According to the author, hypomania may lead to a full-blown mania episode depending on the individual but it does not warrant a new initiation of treatment (Wong, 2011). During prior hospitalization for acute mania, patient was started on Lithium but patient stated he has not been taking it because he ran out, so I will resume patient on lithium to maintain treatment. Lithium has been empirically studied and supported as an effective first-line treatment in the maintenance phase of BD. As stated by Connolly and Thase (2011), lithium use will regulate mood and prevent reoccurrence of manic episodes or occurrence of depressive episodes, as well as preventing suicide. These are therapeutic endpoints hoped to achieve with lithium for this client. Bipolar Disorders
In the absence of psychosis or agitation, client can function well both in group or individual therapy. Family-focused therapy will be appropriate in this case. This approach focuses on enhancing family support and knowledge through sessions of psychoeducation, communication skills training, and problem-solving skills training (Geddes & Miklowitz, 2013). The authors stated that patients whose family members attended psychoeducational sessions had longer intervals before manic and hypomanic episodes.
Another effective psychotherapy approach is interpersonal and social rhythm therapy. The approach is used address areas of distress and social disruption caused by BD. Specifically to client, the approach will be used to manage grandiosity and regulate patient’s social rhythm, level of stimulation and emotions (Wheeler, 2014). According to Geddes, and Miklowitz (2013), this approach believes the circadian rhythm leads to mood instability, thus uses problem-solving strategies to encourage patients to maintain regular daily routines, sleep and wake rhythms to stabilize mood. Bipolar Disorders
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According to Jann (2014), clients with bipolar disorder are afflicted with comorbid medical conditions such as diabetes, cardiovascular disease, obesity, migraine, and hepatitis C virus (HCV) infection which needs requires screening, management and continued evaluation by the primary care team. There is also need for the primary care team to be involved to ascertain when patients are developing complications from psychiatric medication regimen, such as lithium which has been linked to progressive renal insufficiency and hypothyroidism. Lithium and the antiepileptic medications are known to carry teratogenic risks, which warrants referral to the primary care team before starting any woman of child bearing age on antiepileptic drugs and lithium (Jann, 2014). Suicide risk is increased in these patients, the primary care team as the first contact for these patient plays a major role in identifying and making appropriate referral for these clients.
Some clients with bipolar disorder experience impairment in social and occupational functioning. Employment can be difficult to maintain due to erratic mood and behaviors. Financial hardship is not uncommon, thus the need for community resources referral. This patient can benefit from the medicare program which offers community resources such as residential care communities. Most patients I see with BD function well in a personal care home or group home which is a type of residential care communities. This environment promotes patient’s autonomy while helping patients maintain compliance with appointments and medications. Organizations such as the National Alliance on Mental Illness, Depression and Bipolar Support Alliance, provides free information about the disorder, medication and support groups for the client and family of clients with BD. These organization also provide access to hotline numbers for crisis management and suicide prevention. Bipolar Disorders
Follow -up Plan and Collaboration
Clients diagnosed with BD requires that a follow up plan be made every visit. Follow plan is to monitor for signs of psychosis, mood swings, violence and self-harmful behaviors. Each of the mood stabilizers or antipsychotic used in treatment presents significant safety issues which requires close monitoring. Due to the narrow therapeutic window of lithium, regular follow up to monitor serum levels essential. There is a need for monthly blood work for serum level of lithium, depakote, tegretol levels, BUN, creatinine, electrolytes etc. to be drawn to prevent occurrence of toxicity. With antipsychotic treatment, it is essential to closely monitor white blood count for immunosuppression.
Collaboration with the primary care team is needed to identify drug to drug interaction, and monitor adverse effects and to reinforce teachings. Laboratory tests such as pregnancy tests, thyroid function tests, blood glucose test and diagnostic test such as electrocardiograms completed by the primary care team provides helpful information when initiating or titrating doses. Collaboration with case managers and social workers is essential in helping identify free or reduced cost resources for the bipolar client in the form of insurance, housing, support groups or medications. Lithium can lead to weight gain and a consistent diet in sodium and adequate water intake is needed. Collaboration with a nutritionist can be beneficial for the patient to plan a healthy diet with a consistent sodium and water intake. Sometimes bipolar clients are poor historians, family members and caregivers when in collaboration can provide helpful collateral information on patient’s symptoms/behaviors, treatment adherence and medication effectiveness/tolerability Bipolar Disorders
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