DEPARTMENT OF PSYCHIATRY AND MENTAL

HEALTH

EBM CASE WRITE UP

BIPOLAR DISORDER WITH

MANIC PHASE

NAME: NUR SYAZWANI BT MOHD NAZIR

MATRIC NO: 1310-4231

GROUP: 5/ SUBGROUP D

SUPERVISOR: DR RAFIDAH BT BAHARI

CASE SUMMARY

Miss A, a 29 year old Malay lady, single and unemployed with underlying Schizophrenia for
3years, previously follow up under Hospital Taiping and Hospital Kelantan, was brought to
emergency department by his sister due to abnormal behaviour, easily irritable and reduce
oral intake for the past one month prior to admission. The symptoms started one year ago but
getting worse for the past one month after the patient had lost her job as promoter at AEON
Wangsa Maju. She was noted by her sister to be talking and mumbling to herself, talking
irrelevantly and had imaginary friend. She always scolded her housemates and had an attempt
to harm them. She also had not eaten properly and only took biscuits and drinks. The sister
also noted obvious weight loss and poor sleeping. She only took 2 hours to sleep.
The patient claimed that she doesn’t need to sleep like others because she’s very energetic.
Keep saying that she is talking fast like cartoon and don’t know why. She also had
persecutory delusion towards her housemate and her family. She claimed all her housemates
are bad and trying to harm her. She said that her sister and her friends just want to make her
looked sick. No auditory or visual hallucination and she deny any substance usage. The
patient admits for defaulting her follow up and her medication since one year ago due to
feeling headache and busy working. Apart from that, the sister did mention that her late
mother had sleeping problem and always taking sleeping pills. Unsure about the diagnosis.
No abnormal behaviour noted on her late mother. Her bmi is 16.1 kgm2 indicate that she’s
underweight.
Regarding mental state examination, the patient looked appropriate to her age and has thin
body built. She has fair hygiene. She wore ‘tudung’ with green hospital attire. She was
cooperative and had good eye contact. Her behaviour and movement were normal. She was
very talkative and the speech was pressured. Sometimes there was flight of ideas. It was
monotonous, coherent and relevant. The mood was mildly elated and the affect was
appropriate and congruent to the thought content. There was increase in goal directed activity.
She’s feeling energetic and said that she has a lot of plans, she want to redo her SPM, want to
enter Kolej Komuniti again, get OKU cards and get her job back. She still had persecutory
delusion toward her sister, her housemates and also towards the doctors. She feels that
doctors in here wrote many bad things about her in the report. She had poor insight and
judgement. She said that she was brought to the hospital because of her sore throat and
cough. She feels that she has no psychiatric illness and she was supposed to be admitted to
different ward. Felt very upset that she’s admitted to this ward. For perception, she denies any
auditory or visual hallucination. Regarding cognition, she scored 21/30 indicate mild
impairment. She was alert and oriented to time, place and person. She was unable to do
spelling of ‘DUNIA’ in backward manner and cannot recall the names of the 3objects learned
earlier. She can name the objects and she was able to repeat “Dulu, kini dan selamanya”. She
was unable to do calculation. However, she was able to draw clock-face, and manage to copy
intersecting pentagon. She understood the meaning of “bagai aur dengan tebing” and able to
tell the meaning of the proverb. She able to state the similarities of orange and apple. She also
able to do action of wave goodbye and comb hair.
Some investigations were done to this patient. They were full blood count to look for any
general medical condition causes and the result was normal. Renal profile and serum
electrolyte to look for dehydration and electrolyte imbalance and showed the patient is mildly
dehydrated. Urine toxicology, UFEME, and thyroid function test were showed normal results.
Upon arrival to A& E department, she was sedated with IM Midazolam 5mg and IM
Haloperidol 5mg and was given IV Drip Normal Saline. She was admitted to the ward 2
Hospital Kuala Lumpur under Form 3 and Form 4. At first she was started with T.
Risperidone 1mg BD and T.Lorazepam 1mg BD. After further clerking, monitoring, meeting
with the family and revised the diagnosis, the doctor change the medication into T.Olanzapine
15mg ON, T.Epilim Chrono 500mg ON and T.Clonazepam 0.5 mg ON.

DISCUSSION

1. Coping strategies and different ways of psychotherapy in bipolar disorder.

Psychotherapy in conjunction with antimanic drugs is more effective rather than the
pharmacotherapy alone. It can be beneficial in the recovery and stabilization of manic patient
if the patient is capable of having good coping strategies. These psychotherapy is for the
family and the patient herself. Regarding my patient, the problem is that she often moving to
different places as she had 3 sisters who are living in different places. Her first sister stays in
Taiping, second one in Shah Alam and the third one in Setapak Kuala Lumpur. This might be
one of the causes of follow up and medication default. The sister also mentioned about unable
to control the patient at home. Thus, what are coping strategies that are able to improve the
mood problem in patients with Bipolar Disorder (BD) and also help to reduce the burdens
having by the family members.

There is an evidence of many modes of lifestyle interventions targeting diet, physical

activity, self-motivation, and beliefs surrounding wellbeing are feasible and efficacious in
individuals with BD. (Depp et al., 2008). Besides that, we also can challenge patient’s
negative view towards their health and improve their knowledge about lifestyle modification.
In relation to that, participants shows improvement of quality of life such as less depressive
symptoms as well as weight loss after having good nutrition plan, exercises and wellness
treatments within 6minutes for 14weeks (Sylvia et al., 2011). A study done by Ng et al., 2007
support the effects of exercise on mood where they invited bipolar inpatients to participate
voluntarily in a walking group during admissions. The walking group had lower scores in
Depression Anxiety Stress Scales – DASS (p¼0.005)and all its subscales (Depression -
p¼0.048, Anxiety -p¼0.002, Stress -p¼0.01).

Some family might not be able to cope with the level of burden and do not want to be
responsible towards the patient because they think that they had no control over the patient's
illness-related behavior due to low knowledge of the illness. However, in the study done by
Scott et al., (2012) proves that these factors are potentially modifiable through the use of
family interventions that help the family understand the illness and its treatment, correct their
attributions regarding the controllability of patients' behaviors, and teach the family strategies
to cope with stress and reduce negative patterns of interaction.
 Apart from that, there are studies showed that psychological intervention also can be
delivered through internet either web or mobile phone. The advantage is that it allowed users
to self-design and track their own recovery plan with the support of trained-peers and
exchanging information between participants to accomplish their goals. Proudfoot et al.,
(2007) reported increase in adherence rate of approximately 70% after implementing the
web-platform “Bipolar education program” which offers non interactive psychoeducation
sessions by sequential modules with audio and visual contents, targeting several
psychoeducative topics related to bipolar disorder. It also included behavioral tasks to
practice between sessions, alongside mood monitoring tools. This is also supported by Todd
et al., (2014) who developed a web-based platform named “Living with Bipolar” showed that
participant who undergone these intervention had quality of life improvement.

Meanwhile Zyto S et al., 2016 reported the efficacy of using combined group and
individual functional remediation program for bipolar disorder, including both patients and
their caregivers in term of getting opportunity to share experience and learn strategies on how
to cope with cognitive problems in everyday life. The result of the study shows increase in
psychosocial functioning after the program and improvement in the area of occupational
functioning. There is one patient (9% of the sample) had enrolled in to a paid job and two
other participants had made major improvement in the domain of occupation. Other strategies
including giving support to the relatives to encourage the patient self care, psychoeducation
about llness and its management, and training in communication and problem solving skills
(Reinares et al., 2014).

Fiorillo et al, (2014) reported that there are significant improvements in patients′
social functioning and in relatives′ burden were found in the psychoeducational family group
compared to treatment alone. The intervention given is 90-minute sessions of adjunctive
psychoeducational family intervention for patients and relatives by using Fallon model.

CONCLUSION

As a conclusion, all these evidence shows that many coping strategies can be used in
psychotherapy to guide the patient and their family in dealing with individual with BD.
Besides that, by encouraging the patient to live healthy lifestyle will also improve the course
of illness and prevent recurrence of symptoms. As in my patient, family involvement and
psychoeducation to both patient and her relative is very crucial for the success of
psychotherapy. Moreover the family members of those with BD also should go through
family counseling, to be able to understand the situation and to learn more helpful strategies.
I believe that every individual needs a support system.
REFERENCES

1. Depp, C.A., Moore, D.J., Patterson, T.L., Lebowitz, B.D., Jeste, D.V. (2008).
Psychosocial interventions and medication adherence in bipolar disorder. Dialogues Clin.
Neurosci. 10, 239.

2. Fiorillo A, V. Del, M. V, Luciano, G.Sampogna, R.C. De, C. Malangone, et al. (2014).

Efficacy of psychoeducational family intervention for bipolar I disorder: A controlled,
multicentric, real-world study. Journal of Affective Disorders, 172C (2014), pp. 291-299

3. Ng, F.,Dodd,S.,Berk,M. (2007). The effects of physical activity in the acute treatment of
bipolar disorder:apilotstudy.J.Affect.Disord.101,259–262.

4. Proudfoot,J.,Parker,G.,Hyett,M.,Manicavasagar,V.,Smith,M.,Grdovic,S., Greenfield, L.
(2007). Next generation of self-management education: web- based bipolar disorder
program. Aust.N.Z.J.Psychiatry 41,903–909.

5. Reinares, M., Sanchez-Moreno, J., & Fountoulakis, K. N. (2014). Psychosocial

interventions in bipolar disorder: What, for whom, and when. Journal of Affective
Disorders, 156,46–55.

6. Scott, J., Colom, F., Pope, M., Reinares, M., & Vieta, E. (2012). The prognostic role of
perceived criticism, medication adherence and family knowledge in bipolar disorders.
Journal of Affective Disorders, 142, 72–76.

7. Sylvia, L.G., Nierenberg, A.A., Stange, J.P., Peckham, A.D., Deckersbach, T.(2011).
Development of an integrated psychosocial treatment to address the medical burden
associated with bipolar disorder. J. Psychiatric Pract. 17, 224.

8. Todd,N.J.,Jones,S.H.,Hart,A.,Lobban,F.A. (2014). Aweb-based self-management

intervention for bipolar disorder “Living withBipolar”: a feasibility randomised
controlled trial.J.Affect.Disord.169,21–29.

9. Zyto S, Jabben N, Schulte PF, Regeer BJ, Kupka RW. (2016) A pilot study of a combined
group and individual functional remediation program for patients with bipolar I disorder.
J Affect Disord. 194:9-15. doi: 10.1016/j.jad.2016.01.029.