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 26 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 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 Malaysia. 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 10 prestigious
companies in the period of 8 years. She has been married for almost 5 years to a man who is 4
years her junior and she is currently 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
Bipolar disorder is the o 6
th
leading cause of disability in the world according 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 the study conducted has different
methodology and definition. In 2011 , the National Institute of 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 with bipolar disorder in the adolescent
years. Furthermore, it is found that 75% of the bipolar patients inclined to have at least 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 of Occupational Safety and Health Malaysia,
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 refuse to seek professional help due the social shame when
someone consult the shrink, that person will be label as insane. Mohamad (2006) stressed there
were enough information given by the media about the mental illness being the silent
killer.Based on Malaysian health ministry statistic in 2009, 319 death 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 of the Malaysian
Psychiatrist Association. He also mentioned although the percent of bipolar disorders patients in
Malaysia is not so significant but bipolar 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 literature review regarding bipolar. The literature review will be
divided into several sub-topics history of bipolar disorders, definition of bipolar disorder, the
symptoms of bipolar disorder according to DSM-IV and the causes of bipolar disorders.
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 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
to be possessed by demon by strict religious dogma. Later in early 19
th
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 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 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 Associations 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. 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 Manual of Mental Disorder (DSM-5,
2013), bipolar is different than depressive disorder and psychotic disorders. There are two types
of bipolar disorders which are bipolar I and bipolar II. Bipolar I characteristics are exhibiting the
modern day concept of class manic depression that has been described in the 19
th
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 episode as ,A distincitive period of abnormally and persistently
elevated, expensive, irritatable mood and abnormally and persistently increased goal-directed
activity or energy , lasting at least 1 week and present most of the day , nearly every. Whereas
the hypomanic episode is A distinct period of abnormally and persistently elevated, expansive
or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4
consecutive days and present most of the day, nearly everyday day. According to DSM-IV
during the period of mood disturbance and increase energy or activity, three (or more) of the
following symptoms( four if the mood is only irritable) are present to a significant 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 such
as engaging in unrestrained buying sprees, sexual indiscretion or foolish business
engagement. (DSM-IV, 2013)
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 to be hospitalized.
DSM-IV demarcated major depressives as five 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 subjective report
such as feels sad, 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, nearly every day as
indicated by either subjective account or observation
3. Significant weight loss when not diet or weigh gain such a change of more that 5% of body
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 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. (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. (Zubin & Spring, 1997).
The bipolar patient may have born with biochemical disturbances such as brain over or
underproduction of neurotransmitters such as dopamine or serotonin and it 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 examined the impact of the bipolar
of the disorder on her and her family members . Each interview lasted for about 30 minutes to
an hour. This method was suitable because the researcher was able to gain information about the
disorder and to have different insight on how her family 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 understanding 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 conducted were transcribed by the researcher. 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, the
treatment received by bipolar patients, the challenges faced by bipolar patient and her family
members.

Finding
This chapter will discuss about the background Mariams 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 health 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
school ,she scored excellent academic grades and obtained scholarship to enter College Tunku
Kurshah ,one of the most prominent elite girl 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 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, based 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 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 to access to night clubs, her friends and her loved going there to
dance and socialize with people 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 grief over the death of her former boyfriends brother
and emotional stress due to quarrels between her and her two best friends. She was under 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 cant 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 Kuala Lumpur and stayed at the ward 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 At hospital Kuala Lumpur the doctor
interviewed Mariam and her mother about her background and her lifestyle. Rosnah*, Mariams
mother informed me in Malaysia bipolar diagnoses are based 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
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 in the
meantime her parents were finding other alternatives to cure her daughter illness. Mariams
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 Mariams mind. The Islamic
spiritual healing works for a while until Mariams manic bipolar episode relapse. The second
episode occurred when her other ex-boyfriend Michael* took her to steel fence 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 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 Mariams* bipolar was genetic because one of her sister who is
60 years old now has scziporneia since she was in her mid 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 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 medications regularly,they make her dizzy, 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 peoples behaviours and it made her very temperamental and stressful. She
also mentioned was unable to get pregnant when she was 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 Mariams story it shows 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 the DSM-IV and the DSM has been revised
five times by the board members of American 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 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 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 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 cant to
tolerate them. According Milklowitz (2002), most professionals believe that bipolar response a
intricate interaction between biological agents, psychological agents and stress agents. In
addition, Milklowitz(2002) mentioned bipolar suffers are born with biochemical disturbances or
vulnerabilities, these disturbances include brains over or under producing of 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 persons expectation and 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 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 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 stay 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 psychiatrys disease 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 the chemical status of living persons
brain. Hence, none of the psychiatrists have conducted any physical tests on the bipolar patients
brain. Therefore, psychiatrists have no evidence there are chemical imbalances in the bipolar
disorder patients 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 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 that used by the bipolar disorders patients to control their
depressive moods and high moods. Moreover, 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 all, 2000) The comprehensive treatment plan
include taking the correct mood stabilizers that are prescribed by the doctor in order to help
reduce the highs and lows of bipolar disorder. Next, it is psychotherapy treatment that would
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 need to their
emotional support and motivation from their family members, friends and bipolar disorders
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.








Reflection