1. SARA SHEIKH STUDENT FINAL YEARB.S OCCUPATIONAL THERAPY 21st MARCH, 2013

2. Name: ----- Age: 18 years Gender: Male Marital status: Single Occupation: Engineering Student Diagnosis: Bipolar Disorder (Relapse of manic behavior) Admitted at: Psychiatry ward; Aga Khan University Hospital 3. The patient has been admitted three times to thehospital to date:1. February 20122. June 20123. October 2012 4. Theclient underwent a meningeal repair surgery because of an RTA. Hewas put on ventilator and had massive bleeding. Afterrecovery he became stable physically, but manic symptoms started to appear a year later. Healso started smoking heavily. His pre-morbid personality was reported to be an aggressive one and he used to mistreat his bed bound (late) father. 5. Accordingto the family, he used to suspect his mothers character. He used to beat his sisters on minor events. Hewarned his mother not to leave any of his sisters alone with him, as he might molest them. He used to throw tantrums at unfounded accusations against his sisters (e.g.: he said that one of them took his car and had an accident; that did not happen). 6. Cooperative and alert Fluency: His speech was coherent and goal directed, without any loosening of association. Orientation: He was oriented 3X. Memory:His memory was intact and he seemed to be of average intelligence.He admitted that he had a problem and Insight: became angry which was a bad thing. 7. Affectiveproblems: over confidence; self-dramatization; high socialization; feelings ofgrandiosity; aggressive behavior Difficulty in maintaining attention Self-organization: fair judgment; lack of time androutine management; self concept varying from highto low; projection of blame Behavior: independent; was conscious of social normsbut had poor self-control 8. ADLs: His grooming and sleeping routine was affected bylack of routine management. He did not feel hungry due to his manic episode.Often he skipped his breakfast and demanded it laterin the day, getting irritated when he was refused. He did not bathe often, saying that he was not feelingup to it. His communication abilities were impaired; he triedto be frank with everyone but got angry with peoplevery quickly on minor events. 9. Work:He was a first year engineering student but his education was discontinued after his illness. He wanted to continue his studies but also admitted that he could not concentrate on his studies properly. Leisure Activities:He did not engage in any of his previous leisure which were; watching English movies and keeping himself informed about cars. Instead he roamed around listlessly or kept watching random TV programs, saying that he did not feel up to them. 10. Short term Goals: Increase attention span Develop time management Develop routine management Increase toleranceLong term goals: Decrease grandiosity Eliminate abusive behavior Enhance ability to make correct decisions Develop realization of importance of takingadvice To decrease relapse rate 11. Interpersonal Social Rhythm Therapy: To develop routine management; To stabilize sleep/wake episodes in order tocontrol mood disorders; To develop tolerant behavior; To increase attention span.Cognitive Behavioral Therapy: To decrease grandiosity; To decrease flight of ideas; To increase reality contact To decrease aggressive and abusive behavior. 12. Group Therapy: To increase tolerance and control aggression; To increase attention span; To develop time management; To develop the concept of discussion.Family Focused Therapy: To assist the client and his family in recognizingthe nature of the disorder; To assist in re-establishing and maintainingequilibrium in the family after the episode; To assist the family to recognize and act quicklyon the signs of relapse. 13. Teaching about how to detect signs andsymptoms of relapse: To decrease relapse rate; To help family by obtaining early treatment; To develop and maintain medicationcompliance. 14. Notto get frightened at the clients manic episodes. Not to adopt submissive behavior or to comply to his each and every demand. Tokeep in touch with the therapist and psychiatrist even after the episode has passed. Keep check and balance on him by inquiring about his outings and friends etc. If he gets angry, gently remind him of his responsibilities. 15. The client was seen in occupational therapy day care almost daily. He was involved in sports and gym activities and participated in time oriented group tasks.Task Completion:He needed constant supervision in completion of a taskdue to his short attention span and distractibility. Hewas always confident of his success and refused tocarry on a task if he wasnt able to do in first attempt. 16. Decision making:He was independent in decision making and problem solving but often made wrong decisions due to over confidence.Level of Group Participation: At first he was a passive participant and refused to doanything. But he became familiar quickly and startedparticipating and even initiating activities sometimes. He did not involve in sharing in group and always tried toforce his opinions on everyone during group discussions.After sometime, he started to listen (not agreeing) to othersopinions. If he lost during a round of game or completed a task out ofa set time limit, he got irritated and left the therapy room. 17. Realization:He admitted that: His behavior towards his relatives was bad; One cannot win every time and one should acceptdefeat.But this concept was short lived and he reverted to hisprevious state often.Sports and Gym:Initially he enjoyed playing and exercising but preferredto play alone (basketball) when he missed the basketwhile playing in a team. After sometime he startedplaying a few games in couples or triplets. 18. Discharge was sudden and unsatisfactory.Upon discharge, Mr. Mussab had made slight changes. His attention span was a little longer and he had started to pay heed to therapists instruction regarding task completion. No other change was observed.There were high chances of relapse. Therefore the client was recommended to attend the occupational therapy day care as an outpatient. 19. Frank and Swartz conducted a comparative study on 125patients with BPD, manic episode to compare the effects ofInterpersonal and social rhythm therapy with Intensiveclinical management in acute and then a maintenance of 2years. They yielded better results from IPSRT in acutetreatment than ICM; thus favoring IPSRT for patients withbipolar disorder.(The Role of Interpersonal and Social Rhythm Therapy inImproving Occupational Functioning in Patients WithBipolar I Disorder by Ellen Frank, Ph.D., Isabella Soreca,M.D., Holly A. Swartz, M.D., Andrea M. Fagiolini, M.D. atWestern Psychiatric Institute and Clinic, University ofPittsburgh Medical Center, Pittsburgh) 20. Otto, Harrington and Sachs conducted a review to determine the efficacy of CBT on patients with bipolar disorder with manic, depressive or mixed episodes. They found sufficient evidence in favor of CBT decreasing the symptoms of patients with either mixed or manic or depressive episodes.(Review: Psycho educational and cognitive-behavioralstrategies in the management of bipolar disorder byMichael W. Otto, Noreen Reilly-Harrington, Gary S.Sachs at Massachusetts General Hospital and HarvardMedical School, Boston, MA, USA) 21. Weiss and Griffin conducted an empirical cohort study regarding group therapy on 45 bipolar, manic patients with substance abuse for 20 weekly hour-long group sessions with a 3- month follow-up. They found out that the mood and medical compliance component had significantly improved, thus supporting group therapy for bipolar patients.(Group therapy for patients with bipolar disorderand substance abuse: A pilot study by Roger D.Weiss, M.D; Margaret L. Griffin, PhD) 22. Ozerdem and Miklowitz carried out Family focused therapy in Turkey to observe its efficacy in the Eastern culture. 10 patients with bipolar disorder volunteered for the treatment and underwent a 9 month therapy with 1-1.5 years follow-up. The study reported that the patients and the family benefitted a great deal, thus supporting the use of FFT for bipolar patients.(Family focused treatment for patients with bipolardisorder in turkey: A case series byOzerdem, Oguz, Miklowitz, Cimilli) 23. Perry and Tarrier conducted a randomized controlled trialon 69 patients with BPD having had at least 1 relapse in12 months, to determine the efficacy of teachingpatients with bipolar disorder to identify earlysymptoms of relapse. They found out that the relapserate of the experimental group from baseline was 65weeks compared to 17 weeks in control group; henceconfirming the efficacy of the objective.(Randomized controlled trial of efficacy of teachingpatients with bipolar disorder to identify earlysymptoms of relapse and obtain treatment by AlisonPerry, Nicholas Tarrier, Richard Morriss, EilisMcCarthy, Kate Limb)