1. Bipolar and Related Disorders
Chapter 17
Bipolar and Related Disorders

2. Introduction
Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world.
Examples of mood: depression, joy, elation, anger, anxiety.
Affect is described as the emotional reaction associated with an experience.

3. Introduction (cont’d)
Mania is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.
Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.

4. Introduction (cont’d)
Bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy
Delusions or hallucinations may or may not be part of clinical picture
Onset of symptoms may reflect seasonal pattern
A somewhat milder form of mania is called hypomania

5. Historical Perspective
Documentation of the symptoms associated with bipolar disorder dates back to the 2nd century in Greece.
In early writings, mania was categorized with all forms of “severe madness.”

6. Historical Perspective (cont’d)
The modern concept of manic-depressive illness began to emerge in the 19th century, with terms such as “dual-form insanity” and “circular insanity.”
The term manic-depressive was first coined in 1913, and the American Psychiatric Association adopted the term bipolar disorder in 1980.

7. Epidemiology
Bipolar disorder affects approximately 5.7 million American adults
Gender incidence is roughly equal: ratio of women to men is about 1.2 to 1
Average age at onset is the early 20s
More common in single than in married persons
Occurs more often in the higher socioeconomic classes
Sixth leading cause of disability in the middle age group

8. Types of Bipolar Disorders
Bipolar I Disorder
Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms
May also have experienced episodes of depression

9. Types of Bipolar Disorders (cont’d)
Bipolar II Disorder
Characterized by bouts of major depression with episodic occurrence of hypomania
Has never met criteria for full manic episode

10. Types of Bipolar Disorders (cont’d)
Cyclothymic Disorder
Chronic mood disturbance
At least 2-year duration
Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either Bipolar I or II disorder

11. Types of Bipolar Disorders (cont’d)
Substance-Induced Bipolar Disorder
A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication or other treatment).

12. Types of Bipolar Disorders (cont’d)
Bipolar Disorder Associated With Another Medical Condition
Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological effects of another medical condition.

13. Types of Bipolar Disorders (cont’d)
1. A suicidal client with a history of manic behavior is admitted to the ED. The client’s diagnosis is documented as Bipolar I Disorder: Current Episode Depressed. What is the rationale for this diagnosis instead of a diagnosis of Major Depressive Disorder?
a) The physician does not believe the client is suffering from major depression.
b) The client has experienced a manic episode in the past.
c) The client does not exhibit psychotic symptoms.
d) There is no history of major depression in the client's family.

14. Types of Bipolar Disorders (cont’d)
Correct answer: B
The client’s past history of mania and current suicide attempt support the diagnosis of Bipolar I Disorder: Current Episode Depressed. According to the DSM-5 criteria, a manic episode rules out the diagnosis of Major Depressive Disorder.

15. Predisposing Factors Biological theories Genetics
Twin and family studies
Other genetic studies
Biochemical influences
Possible excess of norepinephrine and dopamine

16. Predisposing Factors (cont’d)
Biological theories (cont’d)
Physiological influences
Brain lesions
Enlarged ventricles
Medication side effects

17. Predisposing Factors (cont’d)
Psychosocial theories
Credibility of psychosocial theories has declined in recent years
Bipolar disorder is viewed as a disease of the brain

18. Developmental Implications
Childhood and adolescence
Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1 percent
Diagnosis is difficult
Guidelines for diagnosis and treatment have been developed by the Child and Adolescent Bipolar Foundation (CABF)

19. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
The CABF recommends the use of FIND (frequency, intensity, number, and duration) in making a diagnosis of bipolar disorder in children and adolescents

20. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
FIND
Frequency: symptoms occur most days in a week
Intensity: symptoms are severe enough to cause extreme disturbance
Number: symptoms occur 3 or 4 times a day
Duration: symptoms occur 4 or more hours a day

21. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
Symptoms include
Euphoric/expansive mood: extremely happy, silly, or giddy
Irritable mood: hostility and rage, often over trivial matters
Grandiosity: believes abilities to be better than everyone else’s
Decreased need for sleep: may sleep for only 4 or 5 hours per night and wake up feeling rested

22. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
Symptoms (cont’d)
Pressured speech: loud, intrusive, difficult to interrupt
Racing thoughts: rapid change of topics
Distractibility: unable to focus on school lessons
Increase in goal-directed activity/psychomotor agitation: activities become obsessive; increased psychomotor agitation

23. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
Symptoms (cont’d)
Excessive involvement in pleasurable or risky activities: exhibits behavior that has an erotic, pleasure-seeking quality about it
Psychosis: may experience hallucinations and delusions
Suicidality: may exhibit suicidal behavior during a depressed or mixed episode or when psychotic

24. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
Treatment strategies
Psychopharmacology
Lithium
Divalproex
Carbamazepine
Atypical antipsychotics

25. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
Treatment strategies (cont’d)
ADHD is most common comorbid condition
ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled

26. Developmental Implications (cont’d)
Childhood and adolescence (cont’d)
Treatment strategies (cont’d)
Family interventions
Psychoeducation about bipolar disorder
Communication training
Problem-solving skills training

27. Nursing Process/Assessment
Symptoms may be categorized by degree of severity
Stage I—Hypomania: symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization
Cheerful mood
Rapid flow of ideas; heightened perception
Increased motor activity

28. Nursing Process/Assessment (cont’d)
Stage II—Acute mania: marked impairment in functioning; usually requires hospitalization
Elation and euphoria; a continuous “high”
Flight of ideas; accelerated, pressured speech
Hallucinations and delusions
Excessive motor activity
Social and sexual inhibition
Little need for sleep

29. Nursing Process/Assessment (cont’d)
Stage III—Delirious mania: a grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare since the advent of antipsychotic medication.
Labile mood; panic anxiety
Clouding of consciousness; disorientation
Frenzied psychomotor activity
Exhaustion and possibly death without intervention

30. Nursing Diagnosis Risk for injury related to
Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements

31. Nursing Diagnosis (cont’d)
Risk for violence: self-directed or other-directed related to
Manic excitement
Delusional thinking
Hallucinations
Impulsivity

32. Nursing Diagnosis (cont’d)
Imbalanced nutrition less than body requirements related to
Refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea

33. Nursing Diagnosis (cont’d)
Disturbed thought processes related to
Biochemical alterations in the brain, evidenced by delusions of grandeur and persecution and inaccurate interpretation of the environment

34. Nursing Diagnosis (cont’d)
Disturbed sensory perception related to
Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations

35. Nursing Diagnosis (cont’d)
Impaired social interaction related to
Egocentric and narcissistic behavior
Insomnia related to
Excessive hyperactivity and agitation

36. Nursing Diagnosis (cont’d)
2. In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis?
a) Risk for injury related to excessive hyperactivity
b) Disturbed sleep pattern related to manic hyperactivity
c) Imbalanced nutrition, less than body requirements, related to inadequate intake
d) Situational low self-esteem related to embarrassment secondary to high-risk behaviors

37. Nursing Diagnosis (cont’d)
Correct answer: A
According to Maslow’s hierarchy of needs, maintaining client safety is always a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury.

38. Criteria for Measuring Outcomes
The client
Exhibits no evidence of physical injury
Has not harmed self or others
Is no longer exhibiting signs of physical agitation
Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status
Verbalizes an accurate interpretation of the environment
Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations

39. Criteria for Measuring Outcomes (cont’d)
The client (cont’d)
Accepts responsibility for own behaviors
Does not manipulate others for gratification of own needs
Interacts appropriately with others
Is able to fall asleep within 30 minutes of retiring
Is able to sleep 6 to 8 hours per night

40. Planning/Implementation
Nursing interventions are aimed at
Protection from injury due to hyperactivity
Protection from harm to self or others
Restoration of nutritional status
Progression toward resolution of the grief process
Improvement in interactions with others
Acquiring sufficient rest and sleep

41. Client/Family Education
Nature of the illness
Causes of bipolar disorder
Cyclic nature of the illness
Symptoms of depression
Symptoms of mania

42. Client/Family Education (cont’d)
Management of the illness
Medication management
Assertive techniques
Anger management

43. Client/Family Education (cont’d)
Support services
Crisis hotline
Support groups
Individual psychotherapy
Legal/financial assistance

44. Evaluation
Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria.

45. Evaluation (cont’d) Has the client avoided personal injury?
Has violence to client or others been prevented?
Has agitation subsided?
Have nutritional status and weight been stabilized?
Have delusions and hallucinations ceased?

46. Evaluation (cont’d)
Is the client able to make decisions about own self-care?
Is behavior socially acceptable?
Is the client able to sleep 6 to 8 hours per night and awaken feeling rested?
Does the client understand the importance of maintenance medication therapy?

47. Treatment Modalities for Bipolar Disorder
Individual psychotherapy
Group therapy
Family therapy
Cognitive therapy

48. Treatment Modalities for Bipolar Disorder (cont’d)
The Recovery Model
Learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with serious mental illness.

49. Treatment Modalities for Bipolar Disorder (cont’d)
The Recovery Model (cont’d)
In bipolar disorder, recovery is a continuous process
Client identifies goals
Client and clinician develop a treatment plan
Client and clinician work on strategies to help the individual manage the bipolar illness
Clinician serves as support person to help the individual achieve the previously identified goals

50. Treatment Modalities for Bipolar Disorder (cont’d)
The Recovery Model (cont’d)
Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and social life.

51. Treatment Modalities for Bipolar Disorder (cont’d)
Electroconvulsive therapy (ECT)
Episodes of mania may be treated with ECT when
Client does not tolerate medication
Client fails to respond to medication
Client’s life is threatened by dangerous behavior or exhaustion

52. Psychopharmacology For mania For depressive phase Lithium carbonate
Anticonvulsants
Verapamil
Antipsychotics
For depressive phase
Use antidepressants with care (may trigger mania)

53. Psychopharmacology (cont’d)
Mood-stabilizing agents
Indications: prevention and treatment of manic episodes associated with bipolar disorder
Examples: lithium carbonate, clonazepam, carbamazepine, valproic acid, lamotrigine, gabapentin, topiramate, oxcarbazepine, verapamil, antipsychotics

54. Psychopharmacology (cont’d)
Mood-stabilizing agents (cont’d)
Action
Lithium
May modulate the effects of certain neurotransmitters, such as norepinephrine, serotonin, dopamine, glutamate, and GABA, thereby stabilizing symptoms associated with bipolar disorder.
The action of anticonvulsants, verapamil, and atypical antipsychotics in the treatment of bipolar disorder is not fully understood.

55. Psychopharmacology (cont’d)
Side effects
Monitor for side effects of lithium
Drowsiness, dizziness, headache
Dry mouth; thirst; GI upset; nausea/vomiting
Fine hand tremors
Hypotension; arrhythmias, pulse irregularities
Polyuria; dehydration
Weight gain
Potential for toxicity

56. Psychopharmacology (cont’d)
Side effects (cont’d)
Lithium toxicity
Therapeutic range
1.0 to 1.5 mEq/L (acute mania)
0.6 to 1.2 mEq/L (maintenance)
Initial symptoms of toxicity include
Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea
Ensure that client consumes adequate sodium and fluid in diet

57. Psychopharmacology (cont’d)
Side effects (cont’d)
Monitor for side effects of anticonvulsants
Nausea and vomiting
Drowsiness; dizziness
Blood dyscrasias
Prolonged bleeding time (with valproic acid)
Risk of severe rash (with lamotrigine)
Decreased efficacy of oral contraceptives (with topiramate)
Risk of suicide with all antiepileptic drugs (FDA warning, December 2008)

58. Psychopharmacology (cont’d)
Side effects (cont’d)
Monitor for side effects of verapamil
Drowsiness; dizziness
Hypotension; bradycardia
Nausea
Constipation

59. Psychopharmacology (cont’d)
Side effects (cont’d)
Monitor for side effects of antipsychotics
Drowsiness; dizziness
Dry mouth; constipation
Increased appetite; weight gain
ECG changes
Extrapyramidal symptoms
Hyperglycemia and diabetes

60. Client/Family Education
Lithium
Take the medication regularly
Do not skimp on dietary sodium
Drink 6 to 8 glasses of water each day
Notify physician if vomiting or diarrhea occur
Have serum lithium level checked every 1 to 2 months, or as advised by physician

61. Client/Family Education (cont’d)
Lithium (cont’d)
Notify physician if any of the following symptoms occur
Persistent nausea and vomiting
Severe diarrhea
Ataxia
Blurred vision
Tinnitus
Excessive output of urine
Increasing tremors
Mental confusion

62. Client/Family Education (cont’d)
Anticonvulsants
Refrain from discontinuing the drug abruptly
Report the following symptoms to the physician immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes
Avoid using alcohol and over-the-counter medications without approval from physician

63. Client/Family Education (cont’d)
Verapamil
Do not discontinue the drug abruptly
Rise slowly from sitting or lying position to prevent sudden drop in blood pressure
Report following symptoms to physician
Irregular heart beat; chest pain
Shortness of breath; pronounced dizziness
Swelling of hands and feet
Profound mood swings
Severe and persistent headache

64. Client/Family Education (cont’d)
Antipsychotics
Do not discontinue drug abruptly
Use sunblock lotion when outdoors
Rise slowly from a sitting or lying position
Avoid alcohol and over-the-counter medications
Continue to take the medication, even if feeling well and as though it is not needed; symptoms may return if medication is discontinued.

65. Client/Family Education (cont’d)
Antipsychotics (cont’d)
Report the following symptoms to physician
Sore throat; fever; malaise
Unusual bleeding; easy bruising; skin rash
Persistent nausea and vomiting
Severe headache; rapid heart rate
Difficulty urinating or excessive urination
Muscle twitching, tremors
Darkly colored urine; pale stools
Yellow skin or eyes
Excessive thirst or hunger
Muscular incoordination or weakness

66. Client/Family Education (cont’d)
3. A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client?
a) Do not skimp on dietary sodium intake
b) Have serum lithium levels checked every 6 months
c) Limit fluid intake to 1,000 ml of fluid per day
d) Adjust the dose if you feel out of control

67. Client/Family Education (cont’d)
Correct answer: A
Clients taking lithium should consume a diet adequate in sodium and drink 2,500 to 3,000 ml of fluid per day. Lithium is a salt and competes in the body with sodium. If sodium is lost, the body will retain lithium with resulting toxicity. Maintaining normal sodium and fluid levels is critical to maintaining therapeutic levels of lithium and preventing toxicity.