Bipolar disorders “are characterized by fluctuations in mood, with episodes of both mania and depression” (Bonder, pg156).
There are 3 types of bipolar disorders: bipolar I, bipolar II, and cyclothymia. “Bipolar I is characterized by intermittent manic and major depressive episodes” (Bonder, pg156). In order to be diagnosed with bipolar I, the individual must either have a manic episode that lasts for a minimum of 7 days or the symptoms must be so intense that they cause the person to need immediate hospitalization. They must also have a major depressive episode that can last for up to 2 weeks. A person with bipolar I disorder additionally can experience a mixed episode where they have a manic and depressive episode at the same time (National Institute of Mental Health, 2016).
The cause of bipolar is undetermined, but there is evidence that genetics may contribute to this mental illness.
Compelling evidence for a substantial genetic contribution to risk, together with the availability of research devices that enable detection of susceptibility genes for common familial disorders, has provided psychiatry with an unprecedented opportunity to identify the biological systems that are involved in illness (Craddock, pg1654).
To expand on this, when it comes to genetics, it has been seen that “bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition” (Mayo Clinic). Bipolar disorders can occur in childhood, adolescence, and early adulthood with the average age of onset being around 25. It can equally affect both males and females. (National Alliance of Mental Illness, 2017)
According to the Diagnostic and Statistical Manual of Mental Disorders a person with bipolar I must have a minimum of 3 of the following symptoms of mania:
Inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual or pressure to keep talking, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal-directed activity, and excessive involvement in activities that have a high potential for painful consequences (American Psychiatric Association, p124).
It also states that they must have 5 or more of the following symptoms for depression almost daily and throughout most of the day: feelings of depression, lack of interest in enjoyable activities, weight loss/weight gain or an increase/decrease in appetite, the inability to sleep, experience fatigue, have feelings of worthlessness or guilt, the inability to concentrate or make decisions and continuously having suicidal thoughts. (American Psychiatric Association)
Occupational therapists can address many areas and play important roles in treatment for individuals with bipolar I disorder. When a person is experiencing a manic episode, “an important role for the occupational therapist is monitoring behavior changes and providing a structured environment in which behavior can be managed” (Bonder, p154). A main role for an OT practitioner in a hospital setting would be to help the patient with reducing their symptoms (Early, 2009). “In community settings, the OT and OTA emphasize a return to function in desired occupational roles, with compensations and environmental modifications to reduce stress and improve attention and focus” (Early, pg168).
Individuals diagnosed with bipolar I experience manic episodes that result in risk-taking and reckless behavior. One of the main areas of concern due to this behavior is overspending. Evidence states that “uncontrolled spending is amongst the most frequent risk-taking behavior in BD” (Cheema, pg425). This takes place by impulsive purchases, gambling, or poor investment decisions. Often the individual will feel guilt and remorse after they have come out of the manic episode and realize what they have done. Overspending in individuals with bipolar I can be the result of poor money management and can lead to financial instability and other relating future problems. “Both impulsivity and financial management influence quality of life for patients” (Cheema, pg434). In a recent study that analyzed the correlating link between impulsivity and poor financial management skills it was brought to light “the importance of equipping patients with the necessary skills of managing their personal finances” (Cheema, pg433).
An OT practitioner can address the area of money management by providing an intervention program to individuals struggling with managing their finances. This can be done by educating individuals in ways to save money, creating and following a budget, and differentiating between expense needs and expense wants. An example of teaching the difference between expense needs and wants would be to inform individuals that if they purchase a desired item before they have first paid their bills, that it could result in severe consequences such as going into debt. A study was completed using a financial management intervention called $teps for Achieving Financial Empowerment($AFE). This intervention is “an individualized, psychoeducational intervention that teaches consumers with psychiatric disabilities how to save money, create a budget, avoid scams, access community resources, and work while receiving disability payments” (Elbogen, pg99). The purpose of this study was to see the benefits from using this intervention and how successful educating individuals with mental disorders, such a bipolar I, would be. The results of the study showed that almost all the participants benefited from being educated on financial management. They followed up with the participants six months later and found that the learned skills that were put to use the most were: going out to eat less, incorporating the use of a coin jar, managing a budget, using coupons and saving on utilities. The study results also showed an increase in the likelihood of them being employed and having an increase in self-efficacy. Overall the “study findings suggest that interventions focusing on improving financial management skills can assist individuals with psychiatric disabilities better meet the basic needs and improve their global functioning” (Elbogen, pg99). An OT practitioner could take the key points from this study and incorporate them into a treatment plan to benefit individuals with bipolar I disorder and help them over come their poor money management skills. (Elbogen, 2013)
The assessment I would use to address financial problems with individuals who have bipolar I disorder would be the Kohlman Evaluation of Living Skills (KELS). The reason I would choose this assessment is because it measures the skills the individual has that allows them to be independent at home and in a community setting. It assesses 17 task groups that are put into 5 different categories with one of the categories being money management. Performing this assessment would allow the OT practitioner to see what the level of the individual’s ability in the money management category would be. (Vroman, 2014)
Bipolar I disorder can prevent an individual from functioning properly in their workplace and from also being able to return to their place of employment. Due to their mental state the individual may “experience disproportionately higher unemployment and underemployment rates despite evidence that suggests they express a desire and preference to work and engage in productive occupations” (Egan, pg1). When an individual is having a manic episode, they display a lack of judgement and self-control that could result in the individual ceasing to take their medication. During a manic episode the individuals functional abilities are impaired and may interfere with their ability to complete vocational tasks. Due to this an individual with bipolar I disorder could lose their job due to their manic states that hinder them from performing well at work. (Bonder 2010)
There are multiple ways in which an OT practitioner can provide treatment for an individual with bipolar I who desires to maintain the functional abilities needed in order to return to work. Treatment can consist of ways to reduce stress, structuring their environment, and helping them maintain focus. It is also important for clients “to learn how to avoid or manage these difficulties by altering lifestyle, monitoring symptoms, and getting family members involved” (Bonder, pg154). When in a manic state an individual may jump from task to task doing only a couple parts of one task then leave it uncompleted and move on to another task. “Helping the individual focus and setting limits to contain manic impulses are both important elements of initial interventions” (Bonder, pg154). It is also important to teach stress management skills and evaluate all work tasks to determine if certain ones are too stressful for the individual to handle and ways that they can be adapted. An OT practitioner can recommend simple accommodations for the individuals work setting and adapt the environment to allow them to be able to perform successfully in their job. This can be done by teaming up with the individual’s employer and discussing different areas where changes can be made to ensure the individual would be able to complete their job roles well. An additional way an OT practitioner can help is by monitoring the individual’s behavioral changes due to medication intake. All of these methods of treatment are valuable and can help improve an individual in returning to their place of employment. (Bonder 2010)
An assessment that would be beneficial for an individual with bipolar I who is wanting to return to work would be the Worker Role Interview (WRI). This assessment analyzes psychosocial and environmental factors associated with the individual returning to their place of employment. It is administered in an interview format that addresses multiple areas such as the individual’s interests, values and roles. Using this assessment could be a helpful tool in guiding an OT practitioner to the treatments that could be the most beneficial for the individual. (Vroman, 2014).
Bipolar I can also affect an individual’s leisure and social life. Due to their frequent manic episodes they can find themselves losing important relationships with family and friends. “One of the most disturbing qualities of persons in manic states is their attitude toward and effect on other people” (Early pg296). When in their manic state they have a tendency to be very manipulative and constantly flatter others in order to get their way. At first family and friends may not be aware of what the individual is doing, but after awhile they are able to see the manipulative manner the individual is partaking in and begin to draw away from the relationship. (Early 2009)
A form of treatment that OT practitioners can provide to an individual who is have social and relationship problems due to bipolar 1 would be social skills training. This could be done one on one with the individual or with their family or a group. It is also important that social skills training is taken place in real life settings. “Researchstudies show that social skills training improves social adjustment and equips patients with means of coping with stressors, thereby reducing relapse rates by up to 50 percent” (The Center for Reintegration). In addition to this communication training can be beneficial for the individual as well, providing ways to improve conversational skills for different everyday settings the individual may be apart of. Individuals can benefit from different techniques such as, “instruction, modeling, role-playing, shaping, feedback, and reinforcement” (Encyclopedia of Mental Disorders). These forms of treatments and techniques provide different ways an individual can grow in their social and communication skills to improve the areas of their leisure and social life. (The Center for Reintegration, n.d.) (Encyclopedia of Mental Disorders, n.d.)
One assessment that could be chosen to address areas of leisure and socialization would be the Leisure Satisfaction Scale (LSS). It focuses on finding if the client is satisfied with their leisure activities. It is divided into 6 subscales with social being 1 of the 6. It can allow the OT practitioner to find the areas that will make the individual become more satisfied about their leisure needs including their social life. (Vroman, 2014)
Overall, individuals with bipolar I can benefit greatly from occupational therapy services. There are many areas and ways that we as OT practitioners can help individuals with bipolar I to learn to overcome their daily challenges. It is our goal as OT practitioners to let these individuals see that they can live a full and meaningful life despite their mental illness.
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