Bipolar

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Introduction Mariam is self-confessed bipolar patient. She was diagnosed with bipolar disorders in the Hospital Kuala Lumpur in 2005 after she had her first episode. She was 2 26 6 years old that time. She had more 10 manic episodes since 2005. Mariam came from upper middle family and she was born and raised in Subang Jaya. She has 2 siblings and she is the eldest he family ..Her Her father worked as aircraft engineer for Malaysian Airlines while her mother owned a travel agency. Her  parents were constantly busy and her maid had to look after her when she was growing up. She was a bright student and she studied in top all girl secondary in Mala Malaysia. ysia. Then later she managed to obtain a scholarship to further her tertiary education in Dublin, Ireland in accountancy. She was also very sociable person and she enjoyed the night life and went to clubs and bars with her friends. Upon her return from Dublin she had work with 1 10 0 prestigious companies in the period of 8 years. years. She has been married married for almost 5 years to a man who is 4 years her junior and she is currently cu rrently eight months pregnant. She is unemployed at the moment; she quitted her job few months ago whereas her husband owned a photocopy shop at Gombak area.

Context

 

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Bipolar disorder is the o 6  leading cause of disability in the world according accordin g National Institute of Mental Health (2001). The impression and the severity of bipolar disorder like indicators are the same across international boundaries. However, each of o f the study conducted has different methodology and definition. In 2011 , the National National Institute of Mental Mental conducted bipolar studies in Americas, Europe , Asian, Middle East New Zealand by applying the prevalence diagnostic definition for mental disorder that are established in the Diagnostic and statistical manual for mental (DSM-V). The result of the study found that prevalence rate bipolar I is 0.4% whereas  bipolar II is 1.4% . Moreover, the result found that United State of America had the highest  prevalence rate of bipolar spectrum which is 4.4% whereas India had the lowest rate. In addition, the bipolar patients worldwide that the were diagnosed diagn osed with bipolar disorder in the adolescent years. Furthermore, it is found that 75% of the bipolar b ipolar patients inclined to have at le least ast one or other disorder such anxiety disorder, behaviour disorders and substance use disorders. The study also found that less than half of the patients with bipolar disorder received mental treatment whereas only 25% patients in low income countries obtained professional help.

 

Rationale There is an increase in the number of children aged 15 and below with the mental in Malaysia according to the chairman of National Institute Institute of Occupational Safety and Health M Malaysia, alaysia, Tan Sri Lee Lam Thype. Furthermore, the statistics from Malaysian Health Ministry showed that 13 percent increased among the group in 1996, 19.4 percent in 2006 and 20 percent in 2011. Tan Sri Lee Lam Type mentioned the caused the rose of mental health problems was due to increase stress level in schools.He mentioned many young mental illness patients in Malaysia have committed suicide. Therefore, he noted that it is important for the mental illness patients, families members and society members to be aware of the problems and seek professional treatments. (The Star Online, 2013) In addition, 21 percent of adult aged 30 and 50 are affected  by these problems.Malaysian psychologist clinical Mahadir Mohamad (2006), who worked at the health ministry emphasized many of the mental illness sufferers are not conscious that they suffer from mental illness but they ref refuse use to seek professional help due the social shame when someone consult the shrink, that person will be label label as insane. Mohamad (2006) stre stressed ssed there were enough information given by b y the media about the mental illness being the silent killer.Based on Malaysian health ministry ministry statistic statistic in 2009, 319 death was was caused by mental illness problems. In Malaysia,out of 21% percent adults who have mental illness 3% of them are  bipolar disorders sufferers according to Dr Kadir Abu Bakar,president Bakar,president of the Malaysian Psychiatrist Association. He also mentioned although the percent of bipolar disorders patients in Malaysia is not so significant but bipolar disorder disorder has been listed in The world Health Organization as the top disorder that have impaired the life of working age adults.(The Star Online, 2013) The study is conducted to learn about the bipolar disorder phenomenon in

 

Malaysia by interviewing the bipolar disorders patients.   Moreover, this case study is about the  journey Mariam has to go through living with bipolar disorders. This chapter shall focus on the the literature review regarding bipolar. The literature review will be divided into several sub-topics history history of bipolar disor disorders, ders, definition of bipolar disorder, the symptoms of bipolar disorder according to DSM-IV and the causes of bipolar disorder disorders. s. History of bipolar The history of bipolar disorder can be traced back to the ancient Mesopotamian era, ancient Greece times and Roman times. The early Greek used the term melancholia or mania to refer to the individual who show depressive and manic behaviours. The ancient Greek believed that melancholia was caused body fluid know as bile while mania was caused by another fluid known as yellow bile. In the first century A.D, Greek physician p hysician and philosopher Arataeus of Cappadious who diagnosed patients who show eccentric behaviours. Arateous found the relationship between mania and depression however the main stream medical failed to acknowledge the relationship for many centuries. People who have mental illnesses were executed because they were believed th

to be possessed by demon by strict religious dogma. Later in early 19  century modern concept of bipolar emerged. In 1854 Jules Bailanger and Jean Pierre Falret described bipolar disorders as dual-form insanity and circular insanity in Academic de Medicine Paris. Then in early 1900s , a  prominent German psychiatrist Emil Kraeplin studied the natural courses of the untreated mental illness and he discovered the different between manic related illness and schizophrenia. He also assembled mental illness according to classification of common patterns and symptoms and he coined the term manic-depression (Ebert et all, 2010) to differentiate from schizopernia. (Bp magazine, 2014) Then early ea rly in 1950s, German psychiatrist Karl Leonhard and his colleagues

 

grouped the mental illness and introduced the term bipolar to differentiate between unipolar and  bipolar depression in order to have a better understanding of the persons who were suffering with the mental illnesses and to give them better b etter treatment. Later in 1980s , Dr.Spitzer and his team included the changed the term manic depression to bipolar disorders in DSM-III, the American Psychiatrist Association’s Diagnostic and Statistical Manual of Mental Disorders. Currently ,there is the fifth version of DSM which was published in 2013. (Psychology today,2013) Clinical psychologists and psychiatrist are using the information listed in DSM to diagnose  patients with mental illness disorders. disorders. DSM is considered as the bible for the clinical  profeessionals. Definition of bipolar in DSM- 5 According to the fifth edition of Diagnostic And Statistical S tatistical Manual of Mental Disorder (DSM-5, 2013), bipolar is different than depressive disorder and psychotic ps ychotic disorders. There are two types of bipolar disorders which are bipolar I and bipolar II. II. Bipolar I characteristics characteristics are exhibiting the th

modern day concept of class manic depression that has been described in the 19  century. The  patients of bipolar I disorders normally experience manic episode which maybe led by or followed by hypomanic and major depressive episode. The bipolar I patients will experience manic episode, hypomanic episode and major depressive episode. However bipolar I patients will not experience manic episode but will experience hypomanic and major depressive episode. DSM-5 explained manic manic episode as ,“A ,“A distincitive period of abnormally and persistently elevated, expensive, irritatable mood and abnormally abno rmally and persistently increased goal-directed activity or energy , lasting at least 1 week and present most of the day , nearly nea rly every.” Whereas the hypomanic episode is “A distinct distinct period of abnormally and persistently elevated, expansive

 

or irritable mood and abnormally and persistently increased activity or energy, en ergy, lasting at least 4 consecutive days and present most of the day, nearly everyday day. According to DSM-IV “during “during the period of mood disturbance and increase energy or activity, three (or more) of the th e following symptoms( four if the mood is only irritable) are present to a significant sig nificant degree and represent a noticeable change from usual behavior. 1.  Inflated self-esteem 2.  Decreased need for sleep (eg. Feels rested after only 3 hours of sleep) 3.  More talkative than usual or pressure to keep talking 4.  Flight of ideas or subjective experience that thoughts are racing 5.  Distractibility 6.  Increase in goal-directed either socially, at work or school or sexually 7.  Excessive involvement in activities that high potential for painful consequences consequ ences such as engaging in unrestrained buying sprees, sexual sexu al indiscretion or foolish business engagement.”” (DSM-IV, 2013) engagement. The bipolar I patient experience mood disturbance gets very severe which can impair their abilities to function socially and occupationally. Hence, the patients may need to be hospitalized in order to stop them harming others or themselves. However bipolar II patients experience mood disturbance that will not impair their abilities to function socially and occupationally. Hence, the bipolar II patients are not necessary ne cessary to be hospitalized. DSM-IV demarcated major depressives as “ f ive ive or more of the following symptoms have been  present during the same 2-week period and represent a change from previous functioning: at

 

least one of the symptoms is either depressed mood or loss of interest of pleasure” The symptoms are: “1. Depressed mood most of the day, nearly every day, as indicated by either e ither subjective report such as feels sad, empty empty or hopeless or observation made by other such as appear tearful such appear tearful. 2. Loss interest or pleasure all, or almost all, activities most of the day, d ay, nearly every day as indicated by either subjective account or observation 3. Significant weight loss when not diet or weigh gain such a ch change ange of more that 5% of bod body y weigh in a month or decrease or increase in appetite nearly everyday. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day observed by others. 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt which may ma y be delusional nearly every day. 8. Diminished ability to think or concentrate or indecisiveness, nearly every day either 9. Recurrent thoughts of death not just fear of dying, recurrent suicidal ideation with out of a specific plan, or a suicide attempt.” attempt. ” (DSM-IV,2013) (DSM-IV,2013) The symptoms mentioned above will result to major distress or impairment in social, occupational or other significance capacities functioning for bipolar I and bipolar II patients.

 

Furthermore, above symptoms are not the result of physiological effects of a substance or another medical condition.

Causes of bipolar Most of the professionals believes` that the bipolar cycles result from the complex interplay  between biological agents such as the decrease of the activity of dopamine in brain,  psychological agents such as the person expectation about his or her life and stress agents that  bring changes in his or her life and it could be positive and negative such as changes in his or her  job or living situation , financial conflicts or new romantic relationships. relationships. (Zubin & Spring, 1997). The bipolar patient may have born b orn with biochemical disturbances such as brain over or underproduction of neurotransmitters such as dopamine or serotonin and iitt may caused abnormality in the structure or function of the bipolar patients’ nerve cell receptors. Most of the time the biochemical disturbances are inactive and do not affect the patients’ daily activities. But they are prone for the bipolar patients to experience bipolar episodes.

Approaches The researcher conducted in-depth, open-ended, face-to-face, confidential qualitative interview to the bipolar patient *Mariam, her husband and her mother in order to have a better understanding of bipolar disorder. Moreover, the researcher researcher examined the impact of the bipolar

 

of the disorder on her and her family members . Each interview interview lasted for for about 30 minutes to an hour. This method was suitable because b ecause the researcher was able to gain iinformation nformation about the disorder and to have different insight insight on how her family members members understand her condition and cope with it. In this type of research the respondents were able to respond to the questions asked in interview based on his/her experiences, opinions, beliefs and emotion openly.

The data analysis was done to find the theme experience by the bipolar patient and her family members. The main objective of the data analysis is to have a better und understanding erstanding bipolar disorder of the challenges faced by the bipolar patient and her family members and the way they choose to cope with them. The interviews interviews conducted were transcribed by the researc researcher. her. The interviews were analyzed using the open coding approach in order to determine the main theme of challenges faced by the bipolar patient. Straus and Corbin mentioned (1990) this type of approach allowed the research to breakdown the data, compare and conceptualize it. In addition, from the result of open coding the researcher developed a selective coding in order to understand  bipolar disorders , the causes of bipolar disorder , the symptoms of bipolar disorders, disorders, the treatment received by bipolar patients, the challenges ch allenges faced by bipolar patient and her family members.

Finding

 

This chapter will discuss discuss about the background Mariam’s family background, her childhood to adulthood lives,careers her manic bipolar episodes, the diagnosis conducted by the psychiatrist, the cause of manic episodes, the treatment that she is receiving from the medical he health alth and alternative medicine, challenges faced by her and family members.

Mariam childhood to adulthood In the interviewed Mariam* revealed that her parents were busy working from 9 am until 5 pm when she was little and she had to stay with the maid. Her dad was working as aircraft engineer and her mother was a travel agent. Hence, she only saw her parents in the evening . Furthermore, she explained when she was underage the age of 10 she used to hear voices calling her names whenever she was alone, she told her parents about it and her parents gave her a tangkal, a spiritual protection pendant that her parents obtained from an Ustaz. After she finished primary primary school ,she scored excellent academic grades and obtained scholarship to enter College Tunku Kurshah ,one of the most prominent prominent elite girl secondary secondary school in Malaysia. While she was in Tunku Kurshah she experiences severe migraines and numerous times she had to be taken governmental clinic. She stressed she started having migraines when she was in form 1 at age a ge of 13 until form 5, at the age of 17. Besides that she also had to remove a lump that grew one her left breast when she was in form 3. Although, she does not mentioned, b based ased on her story it showed that she was going through a lot of stressful events in her life. She graduated from secondary school as a top five student and she further her tertiary education in accountancy in Dublin Business School linked with University of Liverpool. Upon her returned she secured accountancy job with Shells. However, she does not like to stay working in one company for so

 

long because she explained her dislike in office politics and people envied of her higher paid salaries. Hence, she has been working in 7 companies in the period of 9 years Growing up and currently Mariam has 3 best friends friends are the girls that she met when she was in her secondary school and like her they were top students in school and they were very sociable. As they reach the legal age a ge to access to night clubs, h her er friends and her loved going there to dance and socialize with people peop le in order to release tension in fact Mariam met most of her former partners in the night clubs. Her first manic episode Her first episode occurred in 2006 when she was working as an accountant at Shell Malaysia. She expressed at that time she felt very depressed and exhausted because she was given too many works at her office and she had too many deadlines. She had to work under team leaders in comparison with other accountants in the company who only worked under one team leader. Hence, she had to do triple much of workloads compare to other accountants. Besides stress at her workplace, she was also experiencing experiencing grief over the death of her former boyfriend’s brother and emotional stress due to quarrels between her he r and her two best friends. She was u under nder severe emotional and mental break down. She cried a lot and threw tantrums at her team leaders at work  place and her family members. She messed up her whole bedroom by taking clothes out of the closets, breaking the vases and light bulbs and smashing household items. She can’t recall the incident because she was unconscious when it happened, her family members and her maid told her what happened.

 

 

Post first manic episode, hospitalization and diagnosis After her first manic episode, she was taken to Hospital Ho spital Kuala Lumpur and stayed at the wa ward rd for one week. When she was there she was trying to smash items around her and escaped from the ward. Therefore, the nurses had to let her wear a straitjacket in order to make sure that her arm are kept close to her chest so she can move as much muc h At hospital Kuala Lumpur the doctor interviewed Mariam and her mother about her background and her lifestyle. Rosnah*, Rosnah*, Mariam’s mother informed me in Malaysia bipolar diagnoses are based b ased on the Malaysian recognition of the symptoms and the psychiatrist who was responsible to diagnose Mariam,informed that Mariam condition was at the level that it was interfere with her ability to function in the society in term te rm her relationship with the people around her and her occupational Rosnah* explained the doctor gave her medications called olanzanpine to prevent relapse of bipolar and seroquel to help her sleep at night. Medications help to stablise Mariam*’s mood according to her  but  but in the meantime her parents were finding other alternatives to cure her daughter illness. Mariam’s recommended her to seek Islamic spiritual healing treatment that was conducted by an Ustaz in Kelantan. The Islamic spiritual healing uses the knowledge from the Quran and Sunnah. The Quran recitation was used to exorcise the jinn believed to disturb in Mariam’s mind. mind. The Islamic spiritual healing works for a while until Mariam’s manic bipolar episode relapse. The relapse.  The second episode occurred when her other ex-boyfriend Michael* took her to steel fen fence ce factory to accompany him to smoke marijuana with friends. Her ex-boyfriend and his friends were getting

 

high and seemed silly and giggly . Then , Mariam* started to panic and then she went to unconscious state and started to break things in the factory. Her ex-boyfriend had to call her father and her father took her to Hospital University Kebangsaan Malaysia. She was going in and out of the ward for the duration du ration of 3 months. According to her husband Michael* and her mother *Rohani, she has been admitted to the hospital every year due to her manic episodes. Every year since 2005, she would have manic episodes. The causes of manic episodes Rosnah* believes the cause of Mariam’s* bipolar was genetic because one of o f her sister who is 60 years old now has scziporneia since she was in her mi mid d 20s. She also believe jinn are disturbing her daughter. Furthermore, Rosnah* mentioned the doctor said Mariam has some chemical imbalance in her which has affected her psychological and emotional reaction when she is under stress. Whereas her husband believes her previous lifestyle was very unhealthy and stressful. Mariam enjoyed excessive clubbing and meeting with people who are sociable and dated guys who were not emotionally committed to her. She had many series of broken heart and due to that she has developed suspicious feeling toward her husband, she worried her husband might be cheating on. her with other women. He added he believes she had lack of her parents’ attention parents’ attention growing up may have been one of the cause.

 

 

The symptoms of Mariam* bipolar disorders Rosnah* said Mariam* would go for a shopping sprees and spent thousands ringgit in a day. Her husband said she would get so suspicious with him and would start to talk non-sense. Sometimes, she would isolate herself from others and start to scream and shout for no reasons. The challenges faced by Mariam and her family members Mariam said she when she takes her he r medications regularly,they make her dizz dizzy, y, drowsy and sleep which unable her to function well at her workplace and she has changed jobs many times  because she is unable to deal with people who were envious of the better salaries she received. She cannot tolerate people’s behaviours and it made her ver very y temperamental and stressful. She stressful. She also mentioned was unable to get pregnant when she w was as on the medications. She stopped taking meditation for a while and she became pregnant. Michael* stated he has to quit his day job and open his own business because he wants to be close to Mariam in order for her to stop accusing him of seeing other women or cheating on her.

 

 

Discussion Based on Mariam’s story it shows sho ws that she has bipolar disorder I because she had depressive episodes, hypomania episodes and manic episodes. Moreover, she had to be taken to hospital immediately because she was endangering her life and the lives of people around her. Most  psychiatrists diagnosed the bipolar disorders using using the DSM-IV and the DSM has been revised five times by the board members of American Ame rican Psychiatrist Association. The information found in DSM can impact and have impacted million lives. The information used by psychiatrists may help patients to get the right diagnosed and treatment. However, the misinterpretation of information may cause the psychiatrists to misdiagnosed the patients and provide prov ide patients with the wrong medication which could be detrimental. (Psychology today, 2012) Therefore,  producing DSM should be the public trust of the highest order.

Although, Mariam did not expressed of being bein g stress or depress when she was growing up but it is obvious she was under a lot of pressure at young age. Her parents were constantly busy and her husband expressed that he thinks her parents are not emotional available for since she was young until now. Besides not receiving her parents’ attention, she also had to work  hard  hard to excel in school, she went to the top elite secondary in Malaysia and managed to be to 5 student. The researcher believes she suppressed her stress level until it reached to a state that she can’t to

 

tolerate them. According Milklowitz (2002), most professionals believe that bipolar response a intricate interaction between biological agents, psychological agents a gents and stress agents. In addition, Milklowitz(2002) mentioned bipolar suffers are born with biochemical disturbances or vulnerabilities, these disturbances include brain’s over or under producing of o f neurotransmitters neurotransmitters such as norepinephrine, dopamine or serotonin. The biochemical disturbances could be in the state of inactive during the bipolar disorder patients’ childhood years until the psychological agents such as the person’s expectation and a nd stressors such stressors such as transition the person job or living condition, financial problems, family conflicts or new romantic relationship reach a certain level the biochemical disturbances get expressed as symptoms such as irritable mood, racing thoughts,  paralyzing sadness or sleep disturbances. In a nutshell, biochemical disturbances disturb disturb the  psychological and emotional reaction of the persons with bipolar disorders. However, if the  persons with the bipolar disorders learn to control to his or her stress stress level, the biochemical disturbances could become inactive again. Mariam* is taking olanzapine and epilin to control her stress level. Therefore, her mood can be stabilized and she would sta stay y calm. Besides that, based on the interview it showed that her husband and mother understand her condition well and give her the emotional support that she needs. Emotional supports that she received from helps her to feel calm and stay positive. Hence, it reduces her stress level. The theory of the bipolar disorders patients are having chemical imbalance in their brains have  been a debatable issue for decades. Most psychiatrists like to explain to the bipolar patients that they have chemical imbalances in their brains using the psychiatry’s disease model. model. Dr. Mark Graff, Chair of Public Affairs of the American Psychiatrists Association mentioned that theory was “probably drug industry derived” ( as cited in Drummond,2000) Moreover according to Valesnsten (1998), there is no test available to examine ex amine the chemical chemical status of living person’s

 

 brain. Hence, none of the psychiatrists have conducted any physical ph ysical tests on the bipolar patients’ patients’    brain. Therefore, psychiatrists have no evidence there are chemical imbalances in the bipolar disorder patients’ brain.  brain. 

Most psychiatrists prescribe medication to the bipolar patients in order to suppress or to control the emotion of the bipolar disorders patients. Marian* is prescribed olanzapine and epilim by her  psychiatrist at Selayang hospital. Olanzapine is the generic form medication of zyprexa which is antipsychotic medication that are prescribed by psychiatrists to bipolar disorder patients to treat manic episodes and it comes in form of tablets or injections.(RxList, 2014). Moreover, olanzapine is believes to alter some chemical in the brain in order to stabilize the mood of the  bipolar disorders patients. However, the side effects of olanzapine are drowsiness and dizziness that reduce mental alertness and weakened motor skills, stomach upset, constipation, increased in appetite and weigh gain. Besides that, the olanzapine may increase the natural substance called  proclatin that may cause the female patients to miss their menstruation menstruation or unable to become  pregnant. (Encyclopedia of Mental Disorder, 2014) This information related to the finding, Mariam explained when she stopped taking her medication, she became pregnant. Mariam is also taking epilim , a mood stabilizer stabilizer that used by the bipolar disorders disorders patients to control their their depressive moods and high moods. Moreover, Moreov er, epilim is believes to increase the activity of neurotransmitter known as GABA in the brain. GABA functions as the nerve calming agents in the brain. However, the side effects of epilim are drowsiness, affect the ability to drive or operate machinery, lack of appetite or energy, severe abdominal pain, swelling ankle, jaundice, unusual  bruising or bleeding, rashes , blister and many more. (NHS, 2013) The information revealed linked to the finding, Mariam mentioned she cannot drive and focus in her job because she feels drowsy.

 

In order for bipolar disorder patients bipolar to get better , it is important for the patients to receive a comprehensive treatment plan. (Sachs et e t all, 2000) The comprehensive treatment plan include taking the correct mood stabilizers that are prescribed by the doctor in o order rder to help reduce the highs and lows of bipolar disorder. Next, it is psychotherapy treatment that would wou ld assist the bipolar disorder patients to learn to cope with their uncomfortable feeling and manage their mood and stress and modify their lifestyle such as regular sleep schedule , avoid alcohol and drugs. Moreover, the family members and friends of the bipolar disorder patient need to be educated about the knowledge of the illness in order for them to understand and handle the situation that they will encounter. Most importantly , the bipolar disorder patients p atients need to their emotional support and motivation from their family members, friends and bipolar disorders d isorders group. In case of Mariam* it illustrates that she is receiving support from her family members  but not so much from her friends and the society. The solid support that Mariam* is receiving enable her to life a comfortable and happy life even though there are many setbacks.

 

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