Understanding bipolar disorder
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helping families & friends find better ways Understanding bipolar disorder What is bipolar disorder? What causes bipolar Therapy Bipolar disorder is a mental illness disorder? Verbal therapies are a very useful that was previously referred to as The causes are not fully understood, but a adjunct to medication for the manic depression. It affects the normal genetic predisposition to the development management of bipolar disorder. functioning of the brain so that the of the illness has been clearly established. The therapy of choice for bipolar is person experiences extreme moods – Cognitive Behavioural Therapy (CBT), mania and depression. Treatment and recovery but family therapy and other therapies People may also experience psychosis from bipolar disorder can also be helpful. Improving coping mechanisms and identifying triggers to in the manic and/or depressed phase. While there is no cure for this illness it is highly treatable and manageable episodes can be achieved in this context. A variety of types of bipolar disorder and 80–90 percent of people recover. The development of and adherence exists. According to the Diagnostic to a Wellness Recovery Action Plan can and Statistical Manual of Mental Acute episodes be a very useful strategy for prevention Disorders (DSM IV), the following of relapse for people experiencing are the distinct types: Community management of acute bipolar disorder. episodes of mania or depression depends • Bipolar 1 disorder – characterised on the degree of risk associated with the by one or more major manic or Social behaviours and mood. People will be mixed episodes, usually accompanied People with bipolar disorder have a hospitalised if their mania causes them by major depressive episodes great need to maintain a healthy and to engage in life threatening, risk-taking • Bipolar 2 disorder – characterised behaviours and if their depression causes balanced lifestyle to reduce stresses that by one or more major depressive suicidal ideation or similar. may trigger episodes. Social support and episodes accompanied by at least meaningful occupation all support the A biopsychosocial approach that includes one hypomanic episode recovery process from bipolar disorder. attending to the biological need (chemical • Cyclothymic disorder – characterised imbalance), as well as the psychological Helpful interventions by at least two years of numerous and social aspects of life is the most Recognising that someone is displaying periods of hypomanic symptoms effective method in the treatment of, symptoms of bipolar disorder is the first (that do not meet criteria for a manic and recovery from, bipolar disorder. step to offering helpful interventions. episode) and numerous periods of Medication Overleaf are behaviours common to depressive symptoms (that do not meet the experiences of depression and criteria for a major depressive episode) Medication helps the brain to restore mania, with suggestions for helpful its usual chemical balance. Medications • Bipolar disorder not otherwise specified interventions. commonly used for bipolar include: – where bipolar features exist but do not meet any of the criteria for any • Antipsychotic medication, used of the specific diagnoses above. DSM to control psychotic symptoms (IV) further divides these distinct and severe agitation types into many subcategories. • Mood stabilisers, which are the mainstay of maintenance therapy How common is bipolar and improve symptoms during disorder? acute manic episodes 1.6 percent of the population will • Lithium is the most commonly develop bipolar disorder at some time used mood stabiliser. in their lives.
Understanding bipolar disorder continued... Insight into the experience of depression Symptom Associated behaviour Helpful interventions Remember, these behaviours are out of keeping with the person’s normal value system • Depressed mood, loss of interest • Characterised by expressions of • Be aware you cannot jolly or pleasure in nearly all activities helplessness and hopelessness the person out of this state • Depressed most of the day • Connect with the emotion of the • Loss of interest or pleasure in activities, experience rather than try to change the person may not move much or may someone’s mind eg. ‘It must be very just stare into space hard to feel so low’ • Skin may become coarse and dry, and • Reinforce your love for the person hair lank and greasy or sparse • Try to sit beside and be in the person’s • Sometimes a person can articulate having space – often people who are depressed no feelings, but a depressed mood do not like to make demands on others can be inferred from the person’s facial but they appreciate company. Likewise, expression or demeanour you will need to do the talking rather than expecting the person to do so • Sometimes, depressive mood can be exhibited in irritability rather than • Keep up good levels of communication sadness, including persistent anger, even when not reciprocated eg Let the overreaction to events, angry outbursts person know where you are going even and blaming others if there is no response • Social withdrawal • Sometimes a significant reduction from previous levels of sexual interest or desire • Inability to concentrate • Poor concentration and poverty of thought, • Attend to safety issues that poor where the person has difficulty putting concentration can cause eg if someone sentences and thoughts together, may works with knives or drives a vehicle give monosyllabic responses, and need • Set realistic tasks prompting • Have realistic expectations • May appear easily distracted or complain of memory difficulties • A reduction in ability to achieve intellectually demanding tasks • Suicidal ideation • Recurrent thoughts of death • Always treat talk of suicide seriously • May talk about death or suicide • Be aware of suicide risk. Ask the • May attempt suicide appropriate questions and communicate with treating team about this issue. This issue may be a reason for hospitalisation • If the person expresses unexpected happiness and begins to give possessions away, seek assistance immediately 2
Symptom Associated behaviour Helpful interventions Remember, these behaviours are out of keeping with the person’s normal value system • Decreased energy, • A person may report sustained fatigue • Avoid placing unrealistic demands tiredness and fatigue without physical exertion on the person • Smallest tasks seem to require • Be patient substantial effort • Affirm small achievements • May take twice as long as usual to do things eg washing and dressing in the morning • Sense of worthlessness or guilt • May translate into belief that the • Connect with the emotion of the person has done something terrible experience rather than try to change and needs to be punished for it someone’s mind eg ‘It must be very • May include unrealistic negative hard to feel so low’ evaluation or self worth • Affirm small achievements • Guilty about preoccupations over • Avoid too much attempt at minor past failings problem-solving. The person • Misinterprets neutral or trivial day-to-day probably will not be ready events as evidence of personal defects • Avoid long self-effacing, self-defeating • Exaggerated sense of responsibility for talk from the person untoward events • Changes in appetite • Most commonly, reduced appetite • Be aware of hydration and nutrition • Sometimes an increase in appetite issues. Again, these issues may need but usually cravings for particular to be attended to in hospital foods, eg sweets or carbohydrates • Significant loss or gain in weight • Changes in sleep patterns • Most commonly insomnia • Try to do some exercise like walking • Not sleeping at all or waking early in around the block the morning, (usually between 2am and • Medications can certainly assist 4am) when normally the person does not have trouble sleeping • Less frequently, over-sleeping 3
Insight into the experience of mania Symptom Associated behaviour Helpful interventions Remember, these behaviours are out of keeping with the person’s normal value system Elevation in affect • Increased confidence • Be calm (mood) • Inflated self esteem • Do not participate in the escalation of excitement • Distractibility • Use simple, clear communications, and make sure • May be described as euphoric, unusually good, the message has been understood. You may need cheerful or high to repeat, but do not push • May also alternate between euphoria and irritability. • Make sure that you move away from potential Note: It is important to remember that the person’s conflictual situations. Use their distractibility to mood is very infectious. They can get everyone come back again contributing. However, when others participate in • When the person is able to take feedback, provide the fun it can escalate the situation. Others can be something like ‘You are a little high at the moment, presumed to be able to control their excitement. The what about listening to some music’, person in this state cannot, and the situation can get in a gentle way out of hand, which may result in some combativeness and conflict. Thoughts racing • Flight of ideas shown by continuous flow of • Do not make too many demands accelerated speech, with sudden changes from • Reduce stimulation and loud noises one topic to another • When this is severe, speech may become disorganized and incoherent Inflated self-esteem • Uncritical self-confidence or, sometimes, marked • Avoid conflict grandiosity. These can be delusional • Keep the person’s real level of expertise in mind • May give advice on matters about which they Do not allow yourself to be overly influenced by have no special knowledge their persuasive presentation of advice • Despite lack of any particular experience • Remember that this is the illness speaking or talent, person may embark on writing a novel or composing a symphony Manic speech • Typically, manic speech is pressured, loud, • This is very tiring so make sure that you get some rapid and difficult to interrupt space, which you will need to regulate for yourself – • May talk non-stop sometimes for hours on end and the other person will not recognize your need without regard for others’ wishes to communicate • When you want space, try to manage your • Sometimes joking, punning and emotional state as the individual will pick up amusing irrelevancies on your distress and you may have to defend yourself, as the person will not see themselves as • Person may become theatrical, with dramatic unreasonable mannerisms and singing • Be genuine, try not to turn off. When something • Sounds rather than meaningful sentences may is funny enjoy it govern word choice 4
Understanding bipolar disorder continued... Symptom Associated behaviour Helpful interventions Remember, these behaviours are out of keeping with the person’s normal value system. Increased physical • Restlessness • Be conscious of the safety factor. The danger of mobility and • Can set out on tasks that take great physical physical complications may be one of the trigger energy exertion eg walking a long way factors to indicate the need for hospitalisation • Unaware of thirst, hunger, heat or cold • If you can, help the person to use some of their energy on a walk or helping in the garden • Increase in goal-directed activity, often excessive planning, and participation in multiple activities • Remember it is very easy for this person to end up with disturbed sleep patterns, sleep late and spend • Increased sexual drive, fantasies and behaviour half the evening ringing people. You may need to • May simultaneously take on new business ventures seek advice about medication for sleep without regard for risk or satisfactory outcomes • In hot weather, fluid replacement is important, • Increased sociability – renewing old particularly when the person is on lithium acquaintances, ringing friends (or even People can become so dehydrated that the blood strangers) any time of day or night with no concentration of lithium increases to such an extent regard to the intrusive, domineering and that the person can go into a hepatic coma. Lithium demanding character of the interactions also increases sensitivity to sun • May write a torrent of letters/emails on many topics • Encourage the person to drink small amounts to friends, public figures or media regularly. Consider what the person likes to drink and make it easily available. Address nutrition in the same way, thinking of high-energy food Decreased need • Person can be most active at night when • Encourage the person to have a bath or a shower for sleep every one else is sleeping • Some people suggest warm drinks, but not coffee • Increasing stimulation – radio, television or tea. This helps the person feel looked after • Person awakens earlier than usual, feeling full of energy • Person may go for days without sleep and yet not feel tired Expansiveness • Unceasing and indiscriminate enthusiasm for • Be assertive about your own boundaries and recklessness interpersonal, sexual, or occupational interactions in a friendly manner • May start extensive conversations with • Take action to protect assets where necessary complete strangers • Reduce access to dangerous situations • Intrusive behaviour eg overly enquiring eg put car keys in a safe spot • Crosses personal boundaries • Try to support the person in managing their sexual • Spending sprees urges. If a young girl (in particular), try to organise a friend to accompany her on her outings • Risk taking eg driving fast, walking on roads, jumping distances • Remember, in partner relationships intimacy demands may increase substantially. You will • Increase in goal directed activity eg composing need to work out your own limits a musical, solving a technical problem • Imprudent involvement in pleasurable activities such as buying sprees, foolish business investments, indiscriminate sexual encounters with strangers, or sexual infidelity when this is not characteristic Delusions and • Delusions of grandeur eg ‘I am Jesus Christ’ • Do not argue about the reality hallucinations, • Hallucinations • Connect with the emotion of the delusion or especially of a hallucination eg ‘It must be frightening to believe grandiose nature that you are Jesus Christ’ Risk taking behaviour is often related to manic episodes and can alert families and individuals to the onset of such an episode. Mania may begin as pleasurable so that people will be reluctant to give it up, and develop into a state that is out of control and frightening. 5
What can family and Useful references friends do to help? Ask an expert – receive answers to In addition to the specific interventions questions about bipolar disorder from previously mentioned, there are many consultants and professionals: SFNSW things friends and family can do to help. www.sfnsw.org.au/questions/discussion.htm • Always remember that bipolar disorder Mental Illness Fellowship Victoria is a medical condition that requires www.mifellowship.org medical treatment. Just as you cannot stop a person’s leg bleeding by talking Mental Health Services Website (Vic) to them, you cannot stop bipolar www.health.vic.gov.au/mentalhealth disorder without medical intervention. National Alliance of the Mentally Ill Treatment is effective. (NAMI) (USA) www.nami.org MIFV2013/01 • Find out as much about the illness as you can. Knowledge is power and gives Mental Health Council of Australia you a much better chance of developing www.mhca.com.au good coping strategies. SANE Australia • Be patient. People experiencing bipolar www.sane.org disorder need to come to some insight Beyond Blue regarding their illness. This is not always www.beyondblue.org.au easy and takes time. • Know what to expect of the mental Mental Illness Fellowship health system and be prepared to be Victoria fact sheets assertive in seeking appropriate care. Understanding psychosis • Link in with community organisations that offer supports and services that Family and carer supports and services complement the mental health system. Psychiatric medications They often provide educational Suicide and mental illness programs, counselling and local support groups. What can family and friends do to help a person experiencing mental illness? • Remember to stay healthy yourself. ©Mental Illness Fellowship Victoria 2013(ACN 093357165) Do not underestimate the impact Stress-vulnerability-coping model of the illness on you. Acute episodes Bipolar disorder and drugs and alcohol of depression or mania often involve trauma and grief and have an impact Collaborating with professionals on whole families. Be prepared to seek support to develop strategies that keep you well. PUBLISHED BY: Mental Illness Fellowship Victoria for people with mental illness, their families and friends 276 Heidelberg Road Fairfield Victoria 3078 T: 03 8486 4200 F: 03 8486 4265 W: www.mifellowship.org ACN 093 357 165
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