Bipolar Disorder and Crisis Intervention

Filed in Gather Health Essential by on March 23, 2007 0 Comments

According to Mayo Clinic, doctors do not really know what causes this disorder in people.  It has been discovered that the disorder could be triggered by biological factors, environmental factors, as well as through genetics.

            Research shows that people with bipolar show differences in their chemical messengers between the nerve cells of the brain (neurotransmitters).  Many cases indicate this is brought on with genetics, with abnormalities in their genes that controls these specific neurotransmitters.  Other factors that could trigger or bring on these episodes can include drug or alcohol abuse or traumatic events that occur in one’s life.

            Some research suggests that a genetic component in Bipolar type I or BPI are that families with BPI develop 7 times more than people in the general population.  Offspring within family members is 50% of bearing bipolar disorder.  Pertaining to twin studies research shows approximately 33-90% of BPI within identical twins.  In adoption research common environmental factors is not the only factor involved.  Adopted children can still be affected by this illness even though the adoptive parents are not bipolar.  No genes have definitively been identified with BPI, but through technology and statistical advancements researchers pray for a breakthrough in the next decade.

            Biochemical pathways do or likely contribute to bipolar disorder, but detecting it is complicated.  Many neurotransmitters play a part in this disorder.  Dopamine and serotonin levels are implicated, and tend to be low in the brain.  Another cause may be disruptions of hypothalamic, pituitary, and the adrenal axis involving homeostasis.

            One method to treat severe depression in bipolar patients is the use of ECT treatments, which has been very effective with these types of symptoms; usually after all medications have been tried.  Clinical improvement out of 400 patients, 313 showed significant improvement with this type of treatment (Soreff, p.13).  ECT affects brain metabolism and it is unknown how that eases depression, but it is often highly effective (MayoClinic). 

            For outpatient care patients need careful monitoring with both psychotherapy and medications from a psychiatrist.  Education is another form of needed information.  Surgery is not suggested for bipolar disorder; although years ago they attempted psychosurgery using prefrontal lobotomies which are no longer allowed in today’s society.

            Drugs that can be used are mood stabilizers, anti-convulsants, antipsychotics, etc.  Lithium carbonate is one of the most common drugs used today, especially for classical bipolar disorder.  Others include Depakote, Neurontin, Lamictal, and Geodon.

            Clinical studies have shown that people with bipolar are treated best with mood stabilizers that will reduce the rapid cycling periods.  According to some research mood stabilizers and antidepressants can alter moods by stimulation of cell survival pathways and by improving cellular resiliency and they will increase levels of neurotrophic factors.  Another class of drugs, the SSRIs, specifically block presynaptic reuptake of serotonin.  This increases levels of serotonin at the receptor site.  The best known drug in this class is Prozac.

            Crisis intervention strategies for Bipolar patients can be challenging.  These patients can have violent mood swings that range from a superhuman ideation (manic phase) to a deep depressive stage.  They can become aggressive if their plans are disrupted.  Their depressive outlook can place them at risk for suicidal behaviors.  Slowing down or pacing these patients while they are in their manic phase is difficult, but important so that there is some control on their runaway behavior.  Confrontation about any grand ideas they may have alienates them.  In their depressive stage suicide intervention is a primary priority (James, 2005, pg. 64). 

            The crisis worker can do several things to help these patients.  Focusing on here-and-now issues that are concrete and reality oriented brings the client/patient back into reality by slowing emotions down.  They should never participate in a delusion.  Grandiose thinking, however, shouldn’t be denied.  Changing, forgetting, or disregarding meds is the most common reason people become psychotic, so workers should try to get the client/patient to their prescribing physician to have medications adjusted or reinstated.  Some people with suicidal intentions feel a need to “prove” their need for help by threatening lethal behavior.  Crisis workers should disrupt that chain of irrational thinking.  Suicidal clues such as verbal, behavioral, situational, and syndromatic clues are all cries for help and should aid the worker in identifying clients/patients who are in need of intervention immediately (James, 2005).

            Early warning signs can develop into a crisis and relapse of symptoms can occur if crisis-prevention is not used or isn’t effective.  The goal is to avoid an emergency.  Common crisis situations for people with Bipolar Disorder include: staying up all night, spending money recklessly, acting hostile, irritable, or aggressively, experiences anxiety or panic, expresses feelings of worthlessness, talks about suicide or shows signs of suicidal behavior.  Eli Lilly explains that people doing crisis interventions should let the client/patient know that they have an ally – express concern, listen, discuss, and compromise.  Encourage the client/patient to take time to unwind and calm down.  Suggest reasonable time limits instead of threatening.  Do not escalate the problem.  Don’t take things personally but be objective about the situation (Eli Lilly, 2006).

           

            Bipolar clients/patients are at a substantial risk for recurrence of symptoms regardless of medication regimentation.  The National Institute of Mental Health recommended that research in Bipolar Disorder be conducted on development of adjuvant psychosocial interventions.

Patients were randomized; some received family-focused therapy with pharmacotherapy, others received crisis management intervention and pharmacotherapy.  The crisis management intervention consisted of two one-hour sessions that were home-based (within the first two months), followed by the availability to receive an as-needed crisis intervention.  This continued for two years.  The family-focused therapy with pharmacotherapy patients fared better in the testing, but authors concluded that psychosocial interventions may augment therapy with mood stabilizers (Miller, 2004).

            Yeager shares with us the story of Tom, a 44-year-old with Bipolar Disorder and alcohol issues.  Tom reports in that he has had a terrible argument with his wife.  He is aware that his disorder causes problems in his life but that his ability to work long hours and see projects to their end is helpful to his career.  He has used alcohol, marijuana and cocaine to self-medicate his bipolar disorder.  He admittedly cheats on his wife.  He is feeling as though he needs to learn to deal with his disorder at this time or he will lose everything important to him.  He has no suicidal ideation but doesn’t feel he can function on an outpatient basis (Yeager, 2002).

            Tom’s case is not uncommon.  Bipolar disorder occurs in approximately 1.3% of the population.  Individuals who abuse substances like alcohol and cocaine often experience earlier onset of the disorder.  Roberts’ model of crisis intervention can be used to help Tom and others in his position with a combination along with strengths perspective and solution-focused therapy.

            In the process of crisis intervention social workers should be aware of the bipolar client’s unique issues, active defense structures, cravings, traps, trigger issues, vertical splits, and potential for self harm.  These are all remarkable barriers to treatment.  Roberts’ initial seven-stage model placed establishment of rapport as the first stage but later publications recommended shifting lethality assessment to the first item in the mentally ill.  Bipolar patients have the potential of experiencing extremely intense crisis within a short period of time.  After assessing lethality the social worker can apply Roberts’ second stage of crisis intervention by establishing rapport and by establishing a working relationship with the patient.  This is done by having a genuine interest and concern for the problems the patient brings to the session.  That brings the patient and the therapist to the third step which is “identifying major problems, including the last straw or crisis precipitants”.  Closer examination of issues transitions into the fourth stage of dealing with feelings and emotions.  The fifth stage is assessing past coping mechanisms.  The sixth stage is to develop and put into action a plan or strategy.  The seventh stage is development of a follow-up plan and agreement (Yeager, 2002).

            Bipolar Disorder can be a challenging illness and one in which crisis intervention becomes necessary.  Using skills discussed the client/patient who has the disorder can hopefully maintain and manage their disorder with help from family members, therapists and physicians.

 

References

Eli Lilly, (2006). Managing Emergencies. Retrieved March 9, 2007, from Zyprexa Olanzapine

 

            Web site: http://www.zyprexa.com/bipolar/caregiver/emergencies/stage3_crisis.jsp

 

Gavin, K (October 9, 2000). U Research Team finds signs of brain chemistry abnormalities in             bipolar disorder.  The University Record, 26, Retrieved Dec 6, 2006, from             http://www.umich.edu/~urecord/0001/Oct09_00/26.htm

Haines, C (July 2005). Mental Health: The Brain and Mental Illness. Your Guide to Your Brain, Retrieved Dec 4, 2006, from http://www.webmd.com/content/Article/60/67112.htm

James, R., Gilliland, B. (2005).  “Crisis Intervention Strategies”.  Belmont, CA.  Thomson-            Brooks/Cole.

Liebenluft, E. (1996 May). Circadian Rhythms Factor in Rapid-Cycling Bipolar Disorder.             Psychiatric Times, Vol. XIII Issue 5, Retrieved Dec 6, 2006, from             http://www.psychiatrictimes.com/p960533.html

Mayo Clinic (2006, Nov 17).  Bipolar disorder.  Retrieved December 4, 2006, from Bipolar             disorder and manic depression information: treatment Mayo Clinic.com  Web site             http://www.mayoclinic.com/print/bipolar-disorder/DS00356/DSECTION=8

McManamy, John (Oct 13, 2003). Bipolar Disorder – Part II. McMan’s Depression and Bipolar            Web, Retrieved Dec 4, 2006, from http://www.mcmanweb.com/article-5.htm

Miller, Karl E. (2004). Family-focused therapy program for bipolar disorder. American Family  

            Physician, June 1, 2004, Retrieved March 9, 2007, from

 

            Http://findarticles.com/p/articles/mi_m3225/is_11_69/ai_n6076530/print

 

Soreff, MD, S (October 30, 2006).  Bipolar Affective Disorder. eMedicine – Bipolar Affective          Disorder, 229, Retrieved Dec 6, 2006, from             http://www.emedicine.com/med/topic229.htm

Yeager, PhD, LISW, Kenneth R. (2002). Crisis Intervention With Mentally Ill Chemical

             Abusers: Application of Brief Solution Focused Therapy and Strengths Perspective. Ohio               

            State University Medical Center Dept. of Psychiatry.

Reprinted with the permission of Van Cleave, Denise M. (2007).

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