Comprehensive Report: Biopsychosocial Assessment of Bipolar Disorder

This report offers a comprehensive biopsychosocial assessment of bipolar disorder, examining genetic, brain, neurotransmitter, and psychosocial factors contributing to the condition. It explores life events, social support, and substance use as significant influences, providing insights into the complexities of the disorder. The report details treatment approaches, including pharmacotherapy with antidepressants, mood stabilizers, and atypical antipsychotics, as well as psychotherapy like CBT, FFT, and interpersonal/social rhythm therapy. Nursing diagnoses and interventions for mania, such as risk for injury, violence, imbalanced nutrition, disturbed thought processes, impaired social interaction, and insomnia, are thoroughly discussed. Finally, the report addresses ethical implications, focusing on autonomy, beneficence, and coercive measures in the management of bipolar disorder, emphasizing the need for effective and multidisciplinary interventions to reduce relapse rates.

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BIOPSYCHOSOCIAL ASSESSMENT OF BIPOLAR DISORDER
Bipolar is a mental health disorder that is characterised by episodes of depression and mania
or hypomania (Royal College of Psychiatrists, 2015). A survey by AMPS revealed that 2.0%
of the population screened positive for bipolar disorder (McManus, Bebbington, Jenkins, &
Brugha, 2016). Bipolar disorders have long episodes and close to 60% of the patients relapse
in the first two years, and about 75% in over five years following the initial diagnosis (Najafi-
Vosough, Ghaleiha, Faradmal, & Mahjub, 2016). Due to the above statistics, there is need for
effective bipolar management. This has led to the need of evaluation of biopsychosocial
factors that help to inform the appropriate management interventions.
Genetic Factors
Bipolar disorder has been strongly to genetic factors even though the specific genetic
abnormalities that contribute to bipolar disorder are unknown (Nolen-Hoeksema, 2011).
First-degree relatives of people with bipolar disorder are 5 to 10 times more prone to both
bipolar disorder and depressive disorders than relatives of people without bipolar (Farmer,
Elkin, & McGuffin, 2007). This can be a factor on Susan’s case as there is family history of
bipolar since the brother was diagnosed with bipolar.
Brain Abnormalities
Brain imaging techniques like have brought great advancement in the study of bipolar
disorder. Through them, it has been identified that people with bipolar disorder have enlarged
ventricle spaces. Enlarged ventricles are an indication of less brain tissue in the brain which
suggests that there has been loss of cells in the brain or that brains of people with bipolar
develop differently than normal brain (Nemade & Dombeck, Brain Imaging and Bipolar
Disorder, 2009). It has been observed that there is also a reduction in the glial cells in bipolar
brains. This has led to inefficient communication within the brain. Abnormalities in the
structure and functioning of the amygdala and prefrontal cortex have been implicated in

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bipolar. The amygdala processes emotions and the prefrontal cortex controls emotion,
planning, and judgment (Konarski, et al., 2008).
Neurotransmitter Factors
Neurotransmitters are widely used in the brain for facilitating communication within the
brain. The neurotransmitters implicated in bipolar illness include dopamine, serotonin,
GABA, glutamate, acetylcholine and neuropeptides. An imbalance in these chemicals is
believed to cause bipolar. High reward seeking behaviours are thought to be associated with
high levels of dopamine while low levels are associated with insensitivity to reward.
During manic phase this dysregulation in the dopamine system leads to excessive reward
seeking and a lack of reward seeking in the depressed phase (Berk, et al., 2007).
Psychosocial Factors
Life Events
Life events are believed to play a major role in the development and course of bipolar
disorder. This has led to studies to be geared to three types of life events namely negative,
social rhythm disrupting, and goal-attainment (Miklowitz & Johnson, 2009).
Negative life events
Studies have found that increased stressful events are experienced among bipolar individuals
prior to the first onset and relapse. Negative life events are found to be associated with
depressive symptoms rather than mania. Throughout Susan’s life, she has experienced great
losses of the mother and brother that may have triggered her episodes.
Life Events that Disrupt Social Rhythms
Poor regulation of sleep and circadian rhythms influence symptoms (Miklowitz & Johnson,
2009). Decrease in the time the person sleeps can contribute to hypomanic or manic
symptoms, and increase in sleep or bed rest may be followed by depressive symptoms (Brill,

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Penagaluri, Roberts, Gao, & El-Mallakh, 2011). In our case study it is clear that Susan faced
sleep deprivation as there is reduced duration of sleep in the past week.
According to Social Rhythm Stability Hypothesis (SRSH) the core problem in BMD is
instability of regular daily activities. Research states that life events associated with
disruption of social rhythms are better predictors of manic phases (Haynes, Gengler, & Kelly,
2016).
Goal-Attainment Life Events
Bipolar Disorder is associated with elevated activity in areas of the brain associated with
reward sensitivity. These areas include: the basal ganglia and ventral tegmental area.
During mania episodes there is elevation in basal ganglia activity which leads to positive
affect, approach motivation and behaviour which leads to an increase in the probability of
incentive acquisition (Miklowitz & Johnson, 2009). This is evident in Susan’s case as she
would make calls to her friends at midnight and animatedly discuss trips and outings.
Social Support
Social support is an important feature as it affects the course of BMD. Support from family
and friends has benefits on both treatment adherence and the functionality of the individual.
Lack of social support serves as a risk factor for symptom recurrence and results in poor
prognoses (Studart, Filho, Studart, Almeida, & Miranda-Scippa, 2015). In our case study,
Susan lacked social support as she lives alone. This led her to non-adhering to medication
which may have caused her relapses.
Drug and alcohol use
It has been suggested that cormobidity between bipolar disorder and substance use disorder
are marked by severe symptoms, frequent mood episodes, lower functioning and lower
satisfaction (Ostacher, et al., 2010). This can be clearly seen in our case study as Susan has

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started smoking after abstaining for one year. This may have been the reason for the recent
episode or a predisposing factor for it.
Treatment and Medication Non-adherence
Non-adherence in bipolar disorder is associated with several adverse consequences like poor
outcomes, increased risk of relapse, rehospitalisation and suicide. Increased utilization of
health-care services and increased mental health expenditures has also been observed
(Chakrabarti, 2016). Susan in our case has a history of non-adhering to her medications
which may explain the readmissions to the facility and the recent episode.
Management of bipolar disorder
Pharmacotherapy
The two types of bipolar medication widely used are antidepressants and mood stabilizers.
Antidepressants help alleviate depressive symptoms. The most commonly used classes of
antidepressants are SSRIs like fluoxetine and sertaline and SNRIs like buproprion and
venlafaxine. The other classes used include tricyclic antidepressants and monoamine oxidase
inhibitors. For the management of mania, mood stabilizers like lithium and sodium valproate
are used. Lithium has been proven to be not only effective at reducing the frequency but also
the intensity of mood swings (Nemade & Dombeck, 2009). Despite this advancement,
lithium requires regular monitoring as the margin between the therapeutic dose and the toxic
dose is narrow.
Atypical antipsychotics are used in bipolar management as they are efficient mood stabilizers
and produce less cognitive and extrapyramidal effects. The most commonly used
antipsychotics include clozapine, risperidone and olanzapine (Nemade & Dombeck, 2009)..
Psychotherapy
Psychotherapy is used as an adjunctive bipolar treatment alongside medication treatment.
Three varieties of psychotherapies have been found to be efficient in the management of

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bipolar. They include cognitive behavioural therapy (CBT), Family-Focused Therapy (FFT)
and interpersonal/ social rhythm therapy. CBT focuses on one’s cognition and it aims at
identifying maladaptive thoughts and changing them so as to have adaptive behaviour. FFT is
a hybrid of psychoeducation and family therapy. It aims at educating the patient and family
members on the nature of the illness and helping deal with family dynamics and relationships
(Nemade & Dombeck, 2009).
Nursing diagnoses and interventions for mania
Risk for injury
This is related to high levels of hyperactivity which is exhibited during a manic episode. This
is seen by increased agitation and lack of control potentially harzadous movements
(Townsend, Essentials of Psychiatric Mental Health Nursing, 2011). Interventions carried out
include reducing environmental stimuli, removing harmful objects, provide structured
schedule of activities and physical activities so as to keep them engaged and involved in other
activities and administer tranquilizing medication like antipsychotics drugs that offer rapid
relief of agitation and hyperactivity (Townsend, 2015).
Risk for violence
This is mainly seen during episodes characterized by manic excitement, delusional thinking
and hallucinations. The nursing interventions employed to avoid harm of self and others
include; maintenance of low levels of environmental stimuli, removing hazardous objects and
maintaining a calm attitude towards the client (Townsend, Essentials of Psychiatric Mental
Health Nursing, 2011).
Imbalanced nutrition
This is caused by the client’s refusal or inability to eat resulting to weight loss and
amenorrhea. In such cases, the nurse in collaboration with the dietician provide high protein
and calorie nutritious foods and drinks, record food and drink intake and output, calorie

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count and weight, and supplement diet with vitamins and minerals (Townsend, Essentials of
Psychiatric Mental Health Nursing, 2011). Poor nutrition may affect the course of bipolar and
increase chances of relapse.
Disturbed thought processes
This feature is related to abnormalities to biochemical and electrolyte levels in the body,
psychotic process and sleep deprivation. This is evidenced by incorrect interpretation of
environmental stimuli, hypervigilance, distractibility and delusional thinking. In such cases,
the nurse is meant to avoiding arguing or denying the beliefs but show acceptance of the
Client’s false belief. The nurse can also use consensual validation and seeking clarification
techniques when communicating with the client so as to better understand him/ her
(Townsend, 2015).
Impaired social interaction
This comes to be due to delusional thought processes and hallucinations that make it difficult
to develop satisfying relationships. The nurse will actively engage with the patient so as to
bring out any feelings of insecurity and need for manipulation of others and provide positive
reinforcements for acceptable behaviours (Townsend, Essentials of Psychiatric Mental Health
Nursing, 2011).
Insomnia
This is brought about by high levels of hyperactivity, agitation and biochemical
abnormalities. It is reflected by difficulty falling asleep, sleeping for short periods of time and
awakening extremely early in the morning. The interventions applied here include; provision
of a quiet environment with low stimulation, monitoring of sleep patterns, assessing the
client’s activity level and administration of sedative medication as ordered (Townsend,
2015).
Ethical implications of Bipolar disorder

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Management of bipolar has been faced by a variety of ethical issues over time. One of the
acts that face many challenges is the Compulsory Mental Health Care Act that identified
values such as respect for autonomy, integrity, beneficence, justice and sanctity of life as
important in mental health care. This has faced many challenges as in the management of
bipolar, the autonomy of the client is lost. In the management of bipolar, it is possible to
make decisions on behalf of the patient if he has serious impairment. This has led to many
patients despite not being seriously impaired to not being consulted with regards to their
treatment.
Coercive care is a challenging ethical situation as it talks about involuntary admissions,
forced medications and tube feeding just to name a few scenarios. This goes contrary to the
ethic of autonomy as the patient is not consulted for the admission. This is seen in Susan’s
case as she was admitted to the mental facility despite not being for it. This can however be
argued that it was for the benefit of the patient as she will get help which goes in line with the
ethic of beneficence that states that all treatment interventions carried out should be for the
benefit of the patient. Another ethical implication in the management of bipolar is on
coercive measures used. It is evident that in the management of bipolar and other mental
conditions those forceful measures are needed as the patient’s health can deteriorate while
he/she is refusing treatment.
The main question that is asked is how can it be determined if one is being coerced to
treatment for his/her own good and one’s right of sanctity to life is being undermining?
Conclusion
Bipolar is a lifelong mental condition that needs appropriate and effective management
interventions so as to reduce the rate of relapse and readmissions. In the process of
management it is clear that biological, psychological and social factors affect the
development and course of Bipolar. These factors have led to a multidisciplinary approach in

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the management of bipolar by the application of pharmacotherapy and non-pharmacological
strategies. The nurse plays a big role in the management of some of the presentations of
bipolar like risk of injury, risk of violence, insomnia just to name a few. This has made them
to be a crucial part in the management team as they deal with medical, psychological and
social aspects of the patient.

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