Patients with Bipolar Disorder
We are not so concerned about the diagnosis rather with what the person is experiencing and how we can help. However, there are times when it is helpful to understand more about bipolar, for example a patient may appear calm and lovely pre-operatively but post-operatively miss their medication for a while, then become irritable and won’t listen to you and refuse care saying this hospital isn’t good enough for them. When you know that the patient has a diagnosis of bi-polar it helps you to understand their behaviour and know what to do (stay calm, don’t argue, be polite and helpful and provide their bi-polar medication as soon as possible).
Stephen Fry (who everyone now knows has a diagnosis of bi-polar disorder) has done a fabulous job in de-stigmatising this disorder, but in spite of being hugely successful as well as a great person he has let it be known that at times he struggles with it.
The main symptoms are being high or low and clinically depressed (if you in the main have high episodes you are Bipolar 1, if mainly depressive episodes Bipolar 2). Being high sounds great and can be at first. A good friend of mine described an experience she had on becoming high: ‘It was autumn I was walking along the street and the trees were an unbelievably intense colour and were dripping gold onto the pavement’. Sounds fabulous, but then she couldn’t sleep, was overactive and was driven to keep going not for hours but days with no sleep.
The Royal College of Psychiatrists provides a list of typical symptoms of manic phases:
- very happy and excited
- irritated with other people who don’t share your optimistic outlook
- feeling more important than usual.
- full of new and exciting ideas
- moving quickly from one idea to another
- hearing voices that other people can’t hear.
- full of energy
- unable or unwilling to sleep
- more interested in sex.
- making plans that are grandiose and unrealistic
- very active, moving around very quickly
- behaving unusually
- talking very quickly – other people may find it hard to understand what you are talking about
- making odd decisions on the spur of the moment, sometimes with disastrous consequences
- recklessly spending your money
- over-familiar or recklessly critical with other people
- less inhibited in general.
These perhaps don’t sound too life disrupting however they have consequences. For example you have a high flying job but start to become ill at work and don’t recognise it, you become irritable with one of your best clients. The client complains to your boss and you, thinking you are so good your boss won’t want to lose you, tell him he’s a rubbish leader and should resign right now and let you do the job. He then dismisses you.
You start to become ill and tell your very caring parents that it’s all their fault that you have this diagnosis, why weren’t they better parents, yet you actually care deeply for your parents. This was just an impulsive thought that you voiced – and then couldn’t take back. Your sexual urges are really high, you’re away at a conference and forgot your medication. You think ‘My partner won’t know that I’ve cheated, and I’ve always really fancied my colleague’. Unfortunately you don’t think of the consequences and have unprotected sex and acquire a sexually transmitted illness. If in the depressive phase you can become actively suicidal and at real risk to yourself.
As far as is known, which isn’t particularly far, Bipolar Disorder is caused by:
- genetics – it tends to run in families
- problems with the areas of the brain which control mood
- times of high stress or physical illness can trigger episodes.
- causes of psychosis can be relevant e.g neglect, abuse.
How to help
The correct medication for that patient can be very critical. It can be trial and error getting the right combination, which can understandably be very frustrating and demoralising for the patient. But once the patient feels things are right we need to ensure that medication is correctly given and importantly not missed out.
Once the person starts to get high the only thing that will stop this escalating into hypomania (the beginnings of mania) is medication. The patient is often great fun at this stage and very amusing to be with. Don’t respond by getting a bit high and giggly yourself, stay cool and go with the flow of what the patient’s saying, don’t argue or correct them. We need to try and persuade the patient that it is important and worthwhile to take their medication. There are a few things that can help here:
- Friends and family who can remind the patient how well they have been on their medication (obviously only if this is true).
- The patient may have completed a WRAP (Wellness Recovery Action Plan – try Googling it or speak to the mental health liaison nurse if your hospital has one.) This document is developed with the person when they are well and includes what the person is like when they’re well and also describes the signs that they’re becoming unwell. You can show the person this and it may help them recognise that they need help. The WRAP also says who the person wants informed when they are becoming ill and which medication they would choose to take.
- Routine is very helpful, including eating regularly and getting enough sleep. Many people keep a daily mood chart which helps them track their mood so they can anticipate problems and start helpful practices early. Self-help and mood monitoring are very important aspects of treatment.
- As much as is possible provide a low stimulus environment, this means low soothing music not rave, if the patient asks you to tell jokes with them gently refuse and suggest they read (obviously not the Hannibal Lector novels) or do something else non stimulating – this can be difficult as they may become very irritable but remind yourself how important this low-key care is for their recovery.
A person may be admitted for a routine problem and have a diagnosis of bipolar which we don’t need to address as they are currently well. It’s very stigmatising to be treated as the person with bipolar first not considering their physical problem which is usually paramount for them while in an acute hospital.
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