Course:RSOT513/2009W2/mood disorder
Bipolar Disorder and Occupational Therapy
1.1 Introduction
Bipolar disorder is a type of mood disorder that is described as having various levels and cycles of manic and depressive episodes. It is a relapsing and recurring illness that can have serious affects on all areas of an individual’s life. This paper will discuss the etiology, prevalence, and signs and symptoms of bipolar disorder as well as the implications for occupation and how occupational therapy can help to address occupational performance issues.
1.2 Etiology
While the exact cause of bipolar disorder is not known, it is generally believed that the illness is influenced by many factors that interact with one another. No one person, event, or experience makes this disorder occur (1). The influencing factors include a variety of biological and psychological causes such as genetics, chemical imbalances, and environmental stress.
It has been recognized that there is a strong link between bipolar disorder and genetics. Many individuals that are diagnosed with bipolar disorder have other family members with the condition. More specifically, about 9 percent will have a first-degree relative with bipolar and about 50 percent will have a parent with some type of mood disorder (2). Studies performed on both identical and fraternal sets of twins have shown that there is a higher number of occurrences of bipolar disorders found in identical twins, indicating that the illness is strongly influenced by genetic factors (3). Further research has determined that not just one but several genes contribute to the risk for bipolar disorder, suggesting that it is a polygenic disease (4).
Other than genetics, it is believed that biological and environmental factors may contribute to the cause of bipolar disorder. For example, people may have an imbalance of the chemicals that send messages to the brain which can contribute to the development of the disorder (2). Environmental factors can include traumatic experiences or stressful situations that occur in one’s life that could help trigger the onset of the disease (2). In some cases, higher levels of stress are also thought to be the main cause of reoccurring episodes of the illness throughout an individual’s life (5). Some other factors that have been suggested to have an influence on triggering the condition include elevated levels of alcohol and drug use, changes in interpersonal relationships, and lack of sleep.
1.3 Prevalence
The reported percentage of the population that has bipolar disorder varies greatly depending on how it is defined and what part of the world the data is from. Generally, the occurrence is reported to be about 1.0% for bipolar I disorder, 1.1% for bipolar II disorder, and 4% for the spectrum of bipolar disorders (1). In comparison, a recent study found that the lifetime prevalence rate in Canada was 2.4% (6). Bipolar disorder usually occurs equally in both men and woman with the average age of onset ranging from 18 to 22 years of age (7), however people may develop the illness at any time (5).
1.4 Signs and Symptoms
Bipolar disorder is a clinical disorder and is defined as the occurrence of one or more episodes of mania, hypomania, or mixed mood states (8). Bipolar disorder is classified into two types. Bipolar I disorder involves recurrent major depressive episodes with manic episodes. Bipolar II disorder is characterized by recurring major depressive episodes with the occurrence of hypomanic episodes (9). However, when an individual previously diagnosed with bipolar II disorder develops a manic or mixed episode, the diagnosis is changed to bipolar I disorder (10). In order for a person to be classified as having bipolar disorder, they must display the symptoms listed below. These symptoms cannot be caused by a substance (for example, alcohol or narcotics) or from a general medical condition, during the period of at least one week (8,9).
1.4.1 Mania
Mania is classified as a persistently elevated, expansive, or irritable mood lasting at least one week (8). In order for an individual to be diagnosed as manic, they must display the following symptoms:
a) A minimum of three of the following: 1. Grandiosity or inflated self-esteem. 2. A decreased need or desire for sleep. 3. More talkative than usual or a need to speak continuously. 4. Feel as though thoughts are racing and ideas are ‘flying’ through ones’ brain. 5. Easily distracted. 6. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. spending sprees or sexual indiscretions) b) The symptoms do not meet the criteria for a mixed episode. c) The mood disturbance is severe enough to, cause marked impairment in: occupational functioning, usual social activities, or relationships with others; necessitate hospitalization to prevent harm to self or others; have psychotic features. d) The symptoms are not because of the direct effects of a substance (e.g. drugs/medication or other treatment) or a general medical condition (e.g. hyperthyroidism) (8). In earlier stages of a manic episode, the affected person may actually seem quite productive and creative at work, school or in social situations. However, if an episode of mania persists, the cumulative effects of pressured expansiveness, sleep deprivation, and the negative reactions of others take their toll, and the affected individual no longer feels elated (8,9).
1.4.2 Hypomania
Hypomania is a milder degree of mania, which often follows a manic episode. Symptoms of hypomania can include elevated mood, increased activity, a decreased need for sleep, grandiosity, and/or racing thoughts. Although less severe than mania, hypomania symptoms still significantly interfere with a person’s daily life. Also note that hypomania usually does not cause severe enough social or occupational functioning impairment to require hospitalizations. Furthermore, there are no associated psychotic features (8) . Hypomania can be hard to diagnose since the patient may feel happy and energetic without having the negative effects often associated with manic episodes. Therefore, there are often no red flags to catch the problem (8).
1.4.3 Mixed Episode
Criteria for a mixed episode include both mania and major depression, experienced simultaneously over a period of at least one week (8).
1.4.4 Rapid-Cycling
Rapid-cycling is a symptom present in both type I and II of bipolar disorder when there are at least 4 episodes of mood disturbances during a 12 month period. The presence of rapid-cycling is usually an indicator of illness that is severe and possibly less responsive to treatment. The affected individual may feel as though they are on a never ending roller coaster ride (8,10).
1.4.5 Dysthymic Disorder & Cyclothymic Disorder
Dysthymic disorder & cyclothymic disorders are both milder but still chronic disorders of depressive and bipolar mood disturbances. Cyclothymic disorder differs from bipolar I disorder by the presence of one or more mixed episodes (10). Cyclothymic disorder is often characterized by many hypomania episodes that do not fall under the criteria regarding other mood disorders (10).
1.5 Implications for Occupations
Bipolar disorder can have major effects on an individual’s life. There can be disruptions in all areas of occupation (from self-care to productivity to leisure) as well as changes in self-identity and recognized ability. Individuals living with bipolar disorder may view themselves as unstable, as there tends to be drastic changes in their mood and thoughts based on which polar state an individual is in (mania, hypomania, or depression). Since changes in mood can occur quite frequently, individuals with bipolar disorder often feel isolated and have a negative sense of self. Many fear failure, as changes in mood can cause separation from friends and family, or even the loss of a job (11). Bipolar disorder is an illness that affects all areas of an individual’s life.
1.5.1 Self-Care
Self-Care can be defined as “occupations for looking after the self” (12). Such occupations can include personal care (hygiene, nutrition, and sleep), responsibilities, and organization of time. One of the major effects of bipolar disorder can be an extreme change in a persons sleeping patterns. While in a manic state, an individual can go for days without sleep or with only an hour or two per night. In contrast, when a person is in a state of depression, they often oversleep and take naps throughout the day. As sleep affects energy levels, which in turn affects the ability to carry out every day activities, self-care is often neglected when a person has bipolar disorder (8).
In addition to difficulties with sleep, nutrition can be affected which can also have effects on a person’s energy level and mood. While in a depressed state, people often have little to no drive to cook for themselves, let alone eat a healthy meal. It is often easier just to grab something available or to not eat altogether. In comparison, when a person is in a manic state, they are often constantly on the go and as a result do not take the time to eat balanced meals. Either way, it is clear that individuals living with bipolar disorder run the risk of having poor nutrition, unbalanced sleep patterns, and a lack of proper self-care.
1.5.2 Productivity (Work and School)
Productivity is defined as “occupations that make a social or economic contribution, or that provide for economic sustenance” (12). Examples of productive occupations for adults include: work, school and volunteering. Working is more than just a person’s ability to obtain and hold onto a paying job, rather it should be looked at in regards to a person's engagement and satisfaction in the job as well as the meaning taken from that occupation. In addition, if a job's demands have things in common with past education, work skills, and expectations, it is often more meaningful (13).
For a person who has bipolar disorder, paid work, volunteer work or school participation (including homework) can often be affected by both manic and depressive episodes. At first glance, a person who is in a state of mania or hypomania may experience positive effects. They may have more enthusiasm and confidence, which could allow them to better interact with staff, customers or teachers. There may be an increase in creativity, allowing them to problem solve. A person in a manic state often displays goal-oriented behaviours and has a better ability to multi-task, which could result in them getting more work done in a day (13). In contrast, mania can increase a person’s anxiety or fear, causing them to act out against co-workers and customers or to remain absent from work. Having extra energy can therefore be seen as a negative effect. For example, an individual may change career paths for no reason or they may aim their extra energy in the wrong direction with the risk of becoming completely off task (13).
When an individual with bipolar disorder is in a depressed state, there can be many negative side effects when looking at productivity. The person often has little or no energy or confidence, and may withdraw from the workplace and the people within it (13). For many people in a depressed state, not showing up for work is a common behaviour. Another negative effect of depression is "‘negative self-talk’" which can be described as voices inside one's head telling the them they cannot do something, or in this case, that they cannot manage their work.
As for school and volunteering, the same or similar as the already mentioned is true. Depending on if the person is in a manic or depressed state, there is often negative interactions with the public (this could include teachers, peers, and other volunteers). The individual may have either too much energy, causing them to spin out of control, or they may have almost no energy, harming their ability to carry on with their daily life (8).
1.5.3 Leisure
Leisure is defined as “occupations for enjoyment” (12), with leisure activities including anything from sports, games, art, social outings and events, to any activity that the individual enjoys. When a person is in a manic state, as mentioned above, they often do not get enough sleep. This means that even though they may feel wide awake and full of energy, their body may actually be sleep deprived, or tired, which can affect the way in which the person performs their leisure activities. Social withdrawal, as mentioned previously, is often seen in a depressed state of bipolar disorder. When a person is depressed, it is very difficult for them to do or enjoy any sort of social activity. This can often lead to low self-esteem and increased negative self-talk, which further decreases the desire to participate (14). In contrast, one study reported that based on self-report, the amount of physical activity done by people with bipolar disorder as compared to the general population is the same (14). This is just an initial study therefore more research is needed.
1.6 Occupational Therapy Interventions
Occupational therapists can assist individuals with bipolar disorder by helping them improve their ability to function and perform their meaningful daily activities. Occupational therapy interventions focus on client's strengths, using them as a platform to identify goals that are achievable, functional and most importantly, meaningful. Occupational therapy services can be carried out in both individual and group settings. Common occupational therapy interventions for bipolar disorder treatment include client-centered education, changing the environment (adaptation), compensatory strategies (ways to make things easier), and resource and skill development (15).
1.6.1 Education
When working with clients living with bipolar disorder and various other mood disorders, occupational therapists play a big role in providing education to clients, their families, other health care professionals, and the general public (16). By providing more knowledge about the disorder and the side effects, education acts to help stay on treatment and medication (17). Education also helps in recognizing symptoms that appear in the early stages of episodes as they occur. Developing management skills that work including; controlling stress and coping skills, identifying things that cause episodes, and creating a relapse plan can help identify signs of bipolar disorder (18). Research shows that many available relapse plans tend to focus on four main areas. These include illness awareness, continuing treatment, noticing early when symptoms re-occur, and regular activity scheduling (19).
Educating family members about bipolar disorder has been shown to improve overall well-being (20). Families are taught to decrease family disagreements by, learning communication skills and problem solving skills (18). Often, family education also includes discussing the importance of creating and improving social support networks for individuals living with bipolar disorder. This will lead to long-term benefits including social support, involvement in meaningful leisure and productivity, and family attitudes towards bipolar disorder (21).
1.6.2 Skill Development
A manic or depressive episode can impair the skills needed to function in everyday activities. The goal of an occupational therapist is to enable the client to function to the best of their abilities. This can be accomplished by teaching new skills or re-establishing old ones in order for the client to participate in meaningful tasks. Skills are developed through learning or re-learning within the environment that the client wishes to participate in. In general, occupational therapy focuses on skill development within the areas of self-care, productivity, and leisure (22).
1.6.2.1 Common Techniques & Concepts
Grading: Grading is a key concept and widely used technique used in occupational therapy intervention. Grading involves creating a gradual change in an activity by increasing the demands needed in small increments. Grading allows the client an individual to re-learn or acquire new skills needed to reach their goals. Some ways that grading can be applied is by increasing the difficulty of the activity, or breaking down the activity into component parts (22).
Chaining: Rooted in behavioural therapy, chaining is widely used in skill development training. Forward chaining is one type of chaining method where tasks are broken down into small steps, starting from the beginning of the task. Once an individual learns the first step of the task, they continue to learn each sequential step until they can complete the entire task independently. The opposite occurs in backward chaining where individual is shown an entire task except for the last step, which they have to perform independently. Preceding steps of the task are performed by the individual until they can complete the entire sequence on their own (23).
Just-Right Challenge: This is a concept central to skill development in occupational therapy. This challenge refers to creating treatment activities that are neither too difficult or too easy to perform. By doing so, the individual will experience small successes in their chosen occupation, while still being challenged and improving on the necessary skills required.
Role Play: Role play is mostly used in specific skill training in occupational therapy. It focuses on in areas such as assertiveness training and anxiety management to help gain a better understanding of certain problems experienced by the a client. When dealing with bipolar disorders, role play gives an individual a chance to view their situations more critically and objectively (22).
Cognitive Behavioural Therapy (CBT): Using a goal-orientated system, Cognitive Behavioural Therapy (CBT) techniques are often used by occupational therapists to address the dysfunctional relationship between a client's thoughts, emotions, and resulting behaviours (20). Some approaches used when working with individuals with bipolar disorder include teaching self-monitoring and regulation techniques, as well as coping skills for manic and depressive episodes (24).
1.6.3 Environment Adaptation and Resource Development
After experiencing a period of depression or mania, a person may feel they no longer have the skills or resources to suit the environments where they complete daily activities. An individual may choose to use a resource or adapt their environment to take on a meaningful role without learning new skills. An occupational therapist connects clients to people, places or things that will help them in their communities. This could include help with applying for government financial assistance, or providing an object like a simplified bus schedule which allows an individual to move around their community independently (15). The therapist helps a person re-build their support network, which may have been disrupted during an acute episode. This support network then acts to help the individual monitor their mood to prevent relapse. Mentorship or peer support programs can allow the client to share their successes and struggles with someone who has learned to live with bipolar disorder (25).
1.6.4 Occupational Intervention Strategies
Occupational intervention strategies can be seperated into three catergories: self-care, productivity, and leisure.
1.6.4.1 Self-Care Intervention Strategies
Some common self-care goals for people living with bipolar disorder include re-establishing sleep routines, acquiring coping skills, and improving medication compliance, healthy eating and exercise habits. Some key intervention strategies used by occupational therapists for these goals include:
Activity scheduling: Occupational therapists act to help individuals create in- depth weekly logs and schedules for their daily lives. Thus, when an individual is in a depressive state and suffering from inactivity and lack of motivation, the goal is to incorporate more meaningful activities in their lives (23). On the other hand, while an individual is in a manic episode, adjustments would be made to the schedule to reduce the amount of activity.
Sleep Routines: During depressive episodes, an individual will often increase the amount of time spent sleeping. To counteract this occurrence, a strict sleeping schedule is encouraged to eliminate daytime sleeping, and control wake-up times. During manic episodes, an individual will often have little or no sleep due to increased agitation and irritability. As a result, an occupational therapist would help an individual create target times for sleeping, as well as making sure that caffeine intake and late working hours, were eliminated in the early evening (17).
Healthy Eating and Exercise Habits: Occupational therapists collaborate with the clients to formulate meal and exercise schedules. A common goal is to help people to commit to eating at regular periods three times a day. Increasing regularity in food intake and physical activity will be graded by the occupational therapists depending on what level the client is currently at and what their overall goals are (17).
Education: Occupational therapists play an important role in educating clients with bipolar disorder about increasing their self-awareness and knowledge about how certain signs and symptoms of the illness and how they may impact their basic activities of daily living. Occupational therapists also teaches clients about compensatory strategies and environmental adaptations that may help them achieve their self-care related goals. For instance, when a client is having a difficult time falling asleep, an occupational therapist may advocate the regular use of of relaxation techniques to help create a more regular sleep pattern (20).
1.6.4.2 Productivity Intervention Strategies
People who have recently experienced an acute episode of depression or mania are likely to experience a disruption in their activities as students, volunteers, and employees. Research has found that paid work is highly valued by people receiving mental health services. Tse and Walsh (26) outline the most important roles for occupational therapists as: help clients maintain hope in their ability to return to work, help increase self awareness, provide support at the workplace, and help the client find meaningful employment.
Workplace support: Occupational therapists may provide support to a client by: advocating for changes at the worksite, coordinating transportation for work, teaching cues for specific tasks and safety, and promoting social interactions with co-workers (26).
Advocating: Collaborating and advocating with employers and schools helps to ensure a safe, stigma free environment willing to accommodate to individual needs. Occupational therapists may also play a role in advocating for policy changes to decrease discrimination against people with bipolar disorders (26).
1.6.4.3 Leisure Intervention Strategies
Research shows that leisure provides a path to self-determination, skill acquisition, improved self-esteem, social connections, and overall life satisfaction (27). Some common leisure goals in bipolar disorder include: individual or group involvement in sports, arts, music, reading, computers, and socializing with friends. Regardless of what type of bipolar disorder an individual has, they will likely lack the confidence to be involved in leisure activities. Occupational therapists help their clients change their thinking to gain confidence and choose leisure activities that are meaningful and motivating to them. Occupational therapists organize and run groups to improve interpersonal skills as well as to connect clients to groups already existing in the community (27).
OT Run Groups: Occupational therapists organize and run a wide range of leisure groups. Some may take place within a clinical setting or in the community. Often the activity chosen for the groups are selected by the participants and might include activities such as badminton, walking, cooking, painting, pottery, music, movie nights, and outdoor outings. Groups run by the therapist may also focus on learning social, communication, and problem solving skills that the participants can then apply in leisure pursuits.
Linking to Community Groups: Many leisure groups already likely exist within a person's community. The occupational therapist will help connect their client to these organizations and may help support them in their involvement. This may involve the occupational therapist attending the first few sessions with the client and providing less and less support from the therapist over time. Many communities have mentorship or peer support groups where the therapist can help link clients to a volunteer who also has bipolar disorder and can act as support within the community (25).
References
1. Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld MA, Petukhova M, et al. Lifetime and 12-Month Prevalence of Bipolar Spectrum Disorder in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2007 May;64(5):543-52.
2. Miklowitz, DJ. Bipolar disorder: a family-focused treatment approach. New York: The Guilford Press; 2008. p. 132,138.
3. Edvardsen J, Torgersen S, Røysamb E, Lygren S, Skre I, Onstad S, et al. Heritability of bipolar spectrum disorders. Unity or heterogeneity? J Affect Disord 2008 Mar;106(3):229-40.
4. Baum AE, Akula N, Cabanero M, Cardona I, Corona W, Klemens B, et al. A genome-wide association study implicates diacylglycerol eta (DGKH) and several other genes in the etiology of bipolar disorder. Mol Psychiatry 2008 May;13:197-207.
5. Hansen RA, Atchison B. Conditions in occupational therapy: effect on occupational performance. 2nd ed. Baltimore: Lippincott Williams and Wilkins; 2000. p. 92.
6. Schaffer A, Cairney J, Cheung A, Veldhuizen S, Levitt A. Community survey of bipolar disorder in Canada: lifetime prevalence and illness characteristics. Can J Psychiatry 2006 Jan;51(1):9-16.
7. Milller K. Bipolar disorder: Etiology, diagnosis, and management. J Am Acad Nurse Pract 2006 March;18:368–73.
8. Atchison BJ, Dirette DK, editors. Conditions in occupational therapy: effect on occupational performance. 3rd ed. Baltimore (MD). Lippincott Williams & Wilkins. 2007. p. 91-109.
9. Ebert MH, Loosen PT, Nurcombe B, editors. Current diagnosis & treatment in psychiatry. New York (NY). McGraw-Hill. 2000.
10. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed. Washington (DC). 2000.
11. Jönsson PD, Wiljk H, Skärsäter I, Danielson E. Persons living with bipolar disorder - their view of the illness and the future. Issues in Mental Health Nursing 2008 Nov; 29(11): 1217-1236.
12. Townsend E, Stanton S, Law M, Polatajko H, Baptiste S, Thompson-Franson T, et al. Enabling occupation: an occupational therapy perspective. Ottawa (ON). CAOT Publications ACE; 2002. p.37
13. Michalak EE, Yatham LN, Maxwell V, Hale S, Lam RW. The impact of bipolar disorder upon work functioning: a qualitative analysis. Bipolar Disord 2007;9:126-143.
14. Cairney J, Veldhuizen S, Faulkner G, Schaffer A, Rodriquez MC. Bipolar disorder and leisure-time physical activity: results from a national survey of Canadians. Mental Health and Physical Activity 2009 Sept; 2:65-70.
15. Pratt CW, Gill KJ, Barrett NM, Roberts NM. Psychiatric Rehabilitation. 2nd ed. Sandiego (CA). Academic Press. 2007. p. 109-161.16.
16. Brintnell S, Anderson D, Calsaferri K, McGovern TJ, Marazzani M, Schultz P, Stern M, Townsend E, Woodside H. Occupational therapy guidelines for client-centred mental health practice. Canada. Canadian Association of Occupational Therapists. 1993.
17. Lam D, Jones S, Hayward P, Bright J, editors. Cognitive therapy for bipolar disorder. West Sussex (England): John Wiley & Sons Limited; 1999.
18. Reiser R, Thompson L, editors. Bipolar disorder. Cambridge (MA): Hogrefe & Huber Publishers. 2005.
19. Colom F, Vieta E, Martinez-Aran A, Reinares M, Goikolea J, Benabarre A. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch of Gen Psychiatry 2003 ;60(4):402-7.
20. Frank E, editor. Treating bipolar disorder. New York (NY): The Guildford Press. 2005.
21. Parikh S, Kusumakar V, Haslam D, Matte R, Sharma V, Yatham L. Psychosocial interventions as an adjunct to pharmacotherapy in bipolar disorder. Can J Psychi 1997;42(2):74-7. 22. Creek J, Lougher, L, editors. Occupational therapy and mental health. 3rd ed. Philadelphia (PA): Elsevier; 2008.
23. Radomski MV, Latham CAT, editors. Occupational therapy for physical dysfunction. 6th ed. Baltimore (MD): Lippincott, Williams & Wilkins. 2008.
24. Scott J, Garland A, Moorhead S. A pilot study of cognitive therapy in bipolar disorders. Psych Med 2001;31(3):459-67.
25. Canadian Mental Health Association. Getting support [online]. 2009 [cited March 26, 2010]; Available from URL:http://www.cmha.bc.ca/localhelp/gettingsupport#groups
26. Tse SS, Walsh AES. How does work work for people with bipolar affective disorder? Occupational Therapy International 2001;8(3):210-25.
27. Lylod C, King R, McCarthy M, Scanlan M. The association between leisure motivation and recovery: a pilot study. Australian Occupational Therapy Journal 2007; 54:33-41.