NURS 340: UNIT 15 - BIPOLAR / PERSONALITY DISORDERS

What pattern does bipolar disorder follow in a patient who alternates between elevated mood and depressed mood?

Chronic, recurrent shifts from highs (mania/hypomania) to lows (depressive symptoms).

How long do patients with bipolar disorder typically suffer before receiving the correct diagnosis and treatment?

An average of 6 years; the disorder is frequently unrecognized.

Which brain areas show dysfunction on imaging in bipolar disorder?

Prefrontal cortex (executive decision making, personality, social behavior), hippocampus (memory), amygdala (memory, decision making, emotion).

What other body systems and risk are involved in the pathophysiology of bipolar disorder?

HPA axis & thyroid involvement (hypothyroidism, inflammation) + a strong genetic component.

What neurotransmitter imbalances do lithium and anticonvulsant mechanisms suggest in bipolar disorder?

Excess glutamate (mania) & low serotonin (depression).

A patient with bipolar disorder has a history of child abuse. Which type of abuse is linked to worse outcomes?

Emotional abuse.

A patient has had at least one manic episode lasting about a week, psychosis, and major depressive episodes, and needs hospitalization. Which type of bipolar disorder is this?

Bipolar I: the most severe type, with 1 or more manic episodes preceded or followed by major depressive episodes (hypomania may also occur).

A patient has hypomania plus major depression but has never had full mania. Which type of bipolar disorder is this?

Bipolar II: hypomania + major depression, with functioning impact noticeable to others.

How does hypomania present in a patient with bipolar II disorder?

Able to function with little or no sleep, lasting at least 4 days.

• They can hallucinate during depression.

A patient has had hypomania and mild depressive symptoms for over 2 years but never a major depressive episode, and is not hospitalized. What is the diagnosis?

Cyclothymic disorder: hypomania + mild depression, NO major depressive episode, for at least 2 years.

A patient has 4 or more mood episodes in 1 year, with swings lasting weeks to minutes. What is this pattern, and which drugs work better?

Rapid cycling bipolar disorder: worse outcomes, resistant to treatment.

• Valproate/anticonvulsants work better.

What mood and duration criteria define a DSM-5 manic episode in bipolar disorder?

Abnormally elevated, expansive, or irritable mood + increased goal-directed activity/energy for at least 1 week, most of the day nearly every day.

How many symptoms are required for a DSM-5 manic episode, and what are they?

3 or more: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity/psychomotor agitation, risky activities with painful consequences (buying sprees, sexual indiscretions, foolish investments).

How does hypomania differ from a manic episode in bipolar disorder?

Same symptom list, but at least 4 days, no marked impairment, no hospitalization, no psychosis.

Which conditions commonly co-occur with bipolar disorder?

High anxiety, ADHD, conduct disorder, substance use disorder (self-medicating), binge-eating disorder.

A patient with bipolar disorder also uses substances. What does the nurse's history need to clarify?

Whether substance use or mania started first; take a thorough history.

How is bipolar disorder diagnosed?

DSM-5 criteria with a mental status exam; rule out substance/medical causes (e.g., hyperthyroidism).

What tool screens a patient for mania, and what score is concerning?

Altman Self-Rating Mania Scale (ASRM): 5 items scored 1-5 each; a score above 6 is concerning & it classifies severity.

What treatments are used for bipolar disorder, and how is acute mania managed?

Mood stabilizers (lithium, anticonvulsants), second-generation antipsychotics, psychotherapy, ECT/rTMS, family education.

• Acute mania is a psychiatric emergency requiring hospital admission.

What complications can bipolar disorder lead to?

Suicide (more attempts with youth onset), psychosis, legal problems, cognitive deficits (milder than schizophrenia; greater in bipolar I than II), poor outcomes if not recognized early.

How do complications of bipolar disorder differ between men and women?

• Men: legal problems and violence.

• Women: alcohol abuse, suicide, thyroid disease.

What are the risk factors for bipolar disorder?

• Immediate family history

• Early (youth) onset

• Hx of child abuse

• Stress

• Substance use (alcohol, cocaine, caffeine)

• Neuroendocrine disorders

Which groups are linked to bipolar disorder?

High IQ & artistic persons.

A manic patient says, "I can't be sick because I feel better than I've ever been." What is this called?

Anosognosia: the patient cannot see that they are sick.

What is the typical course of a manic episode?

Initial euphoria → agitation & irritability → exhaustion → depression (crash).

How does the mood of a manic patient present, and why is it unstable?

Expansive, euphoric, overly joyous, but it can change quickly to irritation & anger.

What behaviors does a manic patient show?

• Get-rich schemes

• Excessive phone calls/emails (e.g., 5 per hour)

• Busy all hours of day & night

• Grandiose plans

• Gives away money & possessions

A manic patient pushes limits and challenges other patients. What else is expected, and what does the nurse do?

Hyperactivity, alienates others, hypersexuality; the nurse redirects.

How does a manic patient typically dress and groom?

Outlandish, bizarre, colorful, inappropriate clothing (fur coat in summer); gaudy, half-done makeup.

Which manic symptom is very common, and which is the hallmark?

• Grandiosity is very common.

• Distractibility is the hallmark.

Which cardinal manic symptoms involve sleep, speech, and thoughts?

Decreased need for sleep, pressured speech ("talk, talk, talk"), flight of ideas.

Which manic symptom should the nurse watch closely, and why?

Psychomotor agitation, along with painful-consequence activities, as safety risks.

What thought content occurs in mania?

Grandiose delusions (famous, special powers, ending wars, religious themes), supernatural/science-fiction themes, persecutory delusions (FBI spying); can progress to auditory hallucinations (voice of God).

What speech and thought process patterns appear in mania?

Pressured, circumstantial, tangential, loose associations, flight of ideas, clang associations.

How is cognition affected in a manic patient?

Intelligent, but with distractibility & decreased concentration.

How does functioning look in a patient with hypomania?

Euphoric with INCREASED functioning: productive & focused (but not for long), with excessive activity & energy.

What nursing diagnoses apply to a manic patient?

• Altered thought processes

• Self-care deficit (feeding, bathing, dressing)

• Nutrition concerns

• Impaired social interaction

• Risk for injury

• Risk for other-directed violence

What are the priorities for a manic patient?

Sleep deprivation & protecting them from harming others.

What outcomes are expected for a manic patient?

• Improved impulse control

• Sleeps 4-6 hours/night

• Completes a set % of meals

• Attends to hygiene & wears clean clothes

• Improved verbal interactions & respects others' space

• Adheres to medication

What can a manic episode lead to?

• Exhaustion

• Dehydration

• Cardiac collapse (poor intake & constant activity)

• Injury

• Violence

• Financial/legal/sexual consequences

• Suicide (depressive crash)

What triggers relapse into mania?

• Missed mood-stabilizer doses (major cause)

• Sleep loss

• Caffeine/alcohol/drugs

• Stress

A patient with bipolar disorder reports one night of unexplained sleep loss. What does this signal, and what are the priorities?

It can signal the start of mania.

• Priorities: sleep, safety, fluids/nutrition.

A patient says, "I hear the voice of God telling me I'm going to end wars" and has not slept in 3 days. What is the problem and the nursing action?

Manic episode with grandiose delusions & hallucinations; admit & protect.

What causes the depressive episode in bipolar disorder, and what is the proposed mechanism?

Exhaustion after mania crashes into depression.

• Low serotonin is the proposed mechanism (lithium increases serotonin).

What mood and physical symptoms occur in bipolar depression?

• Dysphoric, despairing mood

• Decreased interest in pleasure

• Negative views

• Fatigue

• Decreased appetite

• Constipation

• Insomnia

• Decreased libido

• Suicidal preoccupation

• Agitation or psychomotor retardation

A bipolar patient will not get out of bed for days and is very low and suicidal. What are these signs called?

Vegetative signs.

A depressed bipolar patient hears voices telling them to harm themselves. What does this show?

Psychosis can be present in bipolar depression (it is not present in hypomania).

How is bipolar depression distinguished from unipolar depression, and what must the nurse assess?

By a history of previous manic/hypomanic episodes.

• Suicide risk assessment is essential.

A provider orders only fluoxetine for a patient with bipolar depression. What should the nurse do?

Question it: an antidepressant ALONE can trigger mania.

• Use an antidepressant only with a mood stabilizer.

Which medications are approved for bipolar depression?

• Lurasidone

• Quetiapine (Seroquel)

• Cariprazine (Vraylar)

• Symbyax (olanzapine + fluoxetine)

• Lamotrigine (maintenance, depressive side)

• Omega-3

What nonpharmacologic treatments are used for bipolar depression?

ECT & rTMS, CBT, interpersonal therapy, family-focused therapy.

What can bipolar depression lead to, and what are the risk factors?

Suicide, vegetative state, functional decline.

• Risk: previous manic episodes, antidepressant monotherapy, child abuse history.

What is the major cause of relapse in a manic patient, and what does it increase?

Not adhering to mood-stabilizing medications.

• Mania increases the risk of restraints because of non-compliance.

What are the nursing priorities for a manic patient?

Safety & sleep.

How should the nurse approach a manic patient who refuses to eat (e.g., "John, come with me. Eat this sandwich.")?

A firm, CALM approach with short, concise statements; this gives structure/control to someone out of control.

Why must the nurse be consistent with a manic patient?

Consistency limits manipulation & the short attention span needs simple structure.

How should the nurse state expectations to a manic patient?

In simple, concrete terms with consequences.

How should the nurse respond to a manic patient's complaints and energy?

Hear & ACT on legitimate complaints, & firmly redirect energy to constructive channels (reduces helplessness).

What is the most effective communication tool with a manic patient?

Distractibility (distraction/redirection).

What environment is best for a manic patient?

LOW stimulation (away from bright lights, noise, crowds) with structured solitary activities; reduces escalation & prevents exhaustion.

A manic patient becomes aggressive. What does the nurse do?

Redirect aggression (physical exercise); PRN medication, seclusion, or restraint in acute mania per policy.

What safety measures protect a manic patient who gives away money?

Store valuables in the hospital safe & remove dangerous items.

What must the nurse observe in a manic patient on lithium, and why?

Lithium toxicity; the margin between therapeutic & toxic levels is small.

How does the nurse manage nutrition for a manic patient who cannot sit still?

High-calorie protein drinks & FINGER FOODS (sandwiches, fruit, milkshakes) to eat "on the run"; monitor intake, output, vital signs; remind to eat.

• This prevents dehydration & cardiac collapse.

What interventions promote sleep in a manic patient?

Frequent rest periods, low-stimulation areas, warm baths, soothing music, medication when indicated; AVOID caffeine.

• Lack of sleep leads to exhaustion & increases mania.

How does the nurse help a manic patient with hygiene?

Encourage appropriate clothing; give step-by-step reminders ("Here is your razor. Shave the left side...").

• This maintains dignity & counters distractibility.

What elimination interventions does a manic patient need?

Fluids, high-fiber foods, evaluate need for laxative, encourage bathroom use to prevent fecal impaction.

What should the nurse avoid when a manic patient is demanding?

Do NOT argue, bargain, or give long explanations; distraction & redirection work better than confrontation.

What is lithium's role in treating bipolar disorder?

Gold standard, used for acute mania (with an antipsychotic) & maintenance; many side effects.

How does lithium work?

Exact mechanism unknown.

• Acts like Na, stabilizes membrane electrical activity, DECREASES glutamate (mania) & INCREASES serotonin (depression).

How long does lithium take to work for a bipolar patient, and what covers acute mania meanwhile?

7-14 days to reach a therapeutic level; 10-21 days for full effect.

• Second-generation antipsychotics, anticonvulsants, & antianxiety agents provide short-term coverage.

Which bipolar symptoms improve with lithium?

• Elation

• Grandiosity

• Flight of ideas

• Irritability

• Manipulation

• Anxiety

• Self-injury

• Insomnia

• Psychomotor agitation

• Threatening behavior

• Distractibility

• Hypersexuality

• Paranoia

What are the side effects of lithium?

• Skin issues

• N/V/D

• HYPOTHYROIDISM

• WEIGHT GAIN (water weight at first)

• Edema

• Polydipsia

• Polyuria

• Sedation

• Fine tremor

• Ataxia

Which drugs and conditions INCREASE lithium levels?

• HCTZ & other diuretics

• ACE inhibitors

• NSAIDs

• Kidney disease

• Dehydration

What decreases lithium levels?

Caffeine (energy drinks).

Why do renal function and sodium affect lithium levels?

The kidneys cannot tell lithium from salt.

Which conditions are contraindications or precautions for lithium?

• Cardiovascular disease

• Brain damage

• Renal disease

• Thyroid disease

• Myasthenia gravis

• Hypovolemia

• Schizophrenia

• Children under 12

• Teratogenic (birth defects)

• Avoid breastfeeding

Which labs does the nurse check before and during lithium therapy?

Renal & thyroid (& parathyroid) function.

Why is lithium monitored closely?

It has a LOW therapeutic index: the toxic level is not far above the therapeutic level.

• Teach signs of toxicity.

When is lithium level first drawn, and how often after that?

First 2-3 days after starting or changing the dose, then every 3-6 months.

Which type of lithium level is drawn, and what must the patient do?

TROUGH levels (before the next dose); patients must comply with lab draws.

What is the therapeutic lithium level, and what mild effects are common?

0.6-1.2 mEq/L (maintenance).

• Mild effects:

  • fine hand tremor

  • polyuria

  • thirst

  • mild GI upset

  • weight gain

Above which lithium level is toxicity present?

Greater than 1.5 mEq/L (levels should NOT exceed 1.5).

A patient on lithium has a level of 1.5-2.0 with N/V/D, coarse tremors, ataxia, confusion, and sedation. What does the nurse do?

Early/mild-moderate toxicity: HOLD the dose, notify provider, give fluids, teach consistent water & sodium intake.

A patient on lithium has a level of 2.0-2.5 with sinus node dysfunction, seizures, hyperthermia, blurred vision, tinnitus, and stupor. What stage is this?

Advanced (moderate-severe) toxicity; urea/mannitol may be used to increase excretion.

A patient on lithium has a level above 2.5 with coma and respiratory complications. What is the treatment?

Severe, life-threatening toxicity: immediate HEMODIALYSIS.

A patient on lithium has new vomiting, diarrhea, coarse tremor, and ataxia. What should the nurse do?

Obtain a lithium level, hold the dose, & hydrate.

A patient on lithium starts ibuprofen, a diuretic, or a low-salt diet. What is the risk?

Lithium levels rise → toxicity risk.

What should the nurse teach about the timing of lithium effects and missed doses?

• It needs several weeks for full effect; stay on schedule.

• Missed dose: take as soon as possible unless close to next dose; NEVER double.

What should the nurse teach a lithium patient about salt and water?

Do not increase or decrease regular salt intake; keep consistent water intake 1500-3000 mL/day.

When must a patient on lithium notify the prescriber?

If taking a diuretic or having excessive diarrhea, vomiting, or sweating; use care in hot weather.

What monitoring and side effect should the nurse tell a lithium patient to expect?

Weight gain is common; thyroid, parathyroid, & renal function will be monitored.

How do anticonvulsant mood stabilizers work in bipolar disorder?

GABA agonist (stops signals), glutamate antagonist, reduces electrical activity of the membrane.

When are anticonvulsants preferred for a bipolar patient?

Rapid cycling, no family history of bipolar, need to decrease impulsive/aggressive behavior, or need alcohol/benzodiazepine withdrawal coverage.

How long do anticonvulsants take to work in bipolar disorder?

About 2 weeks for mania & 3 weeks for depression.

When are anticonvulsant blood levels drawn, and what organ is affected?

About 12 hours after the last dose; many affect liver function.

For which bipolar presentations is valproate (Depakote) used?

Mixed episodes & rapid cycling; acute mania, prevents future mania, decreases agitation/aggression.

• NOT FDA approved for maintenance.

What are common side effects of valproate in a bipolar patient?

Tremor, weight gain, sedation, N/V, weakness, somnolence, dyspepsia, diarrhea, dizziness.

What serious adverse effects can valproate cause?

Thrombocytopenia, pancreatitis, LIVER FAILURE, HYPERAMMONEMIA.

Which labs does the nurse monitor for a patient on valproate?

LFTs & CBC before & during therapy; therapeutic blood level (also platelets & ammonia).