Bipolar Disorders

Mania

an abnormally and persistently elevated mood, expansive mood, or irritable mood 

Elevated mood 

Euphoria or elation 

Expansive mood

Lack of restraints in expression;

Overvalued self importance

Irritable mood

Easily annoyed and provoked to anger

Manic episode

Distinct period of mania

Mood lability 

Rapid shifts in mood with little or no change in external events 

Bipolar disorders

Group of mood disorders characterized by
• Manic episodes (mania)
• Hypomanic episodes
• Depressive episodes

Cyclothymic disorder

Related disorder
• Emotional highs and lows less intense
• Symptoms not severe enough to meet criteria for Bipolar
disorders

Bipolar patho

• No definitive cause of specific pathophysiology identified
• Complex combination of genetic, physiologic, psychosocial factors
• Immunologic abnormalities may contribute
• Mitochondrial dysfunction, oxidative stress may be involved
• Children of parents with bipolar disorders have increased risk
• Shares biological susceptibility, inheritance patterns with
schizophrenia, major depressive disorder (MDD)

Bipolar etio

• Bipolar disorders tend to be recurrent
• Increase with frequency as the individual ages
• Patients may return to normal functioning during
remission but ~30% will have functional impairment at work
• Typically appear between the ages of 15 and 30

Bipolar risk factors

• Family history of bipolar disorders
• Alcohol/substance use
• Periods of very high stress
• Major life-altering event
• Women and men at equal risk
• No identifiable methods of prevention

Bipolar 1 key diagnostic criteria

• DSM-5 criteria for a manic episode
• Abnormally elevated mood or very irritable
• Lasts most of the day, every day, for at least 1 week
• Any duration if …
• Cannot be attributed to…
• At least one manic episode necessary to
diagnose…
• Some combinations of symptoms and
behaviors such that the person’s changes
in behavior are noticeable, impair social ,
academic, or occupational functioning

Bipolar 2 key diagnostic criteria

History or current presentation of at least one major depressive episode, accompanied by …
• No history or current presentation of …
• Symptoms not attributable to …
• Patient may lack awareness of…

Depressive episode key diagnostic criteria

• Depressive phase of bipolar disorder includes same symptoms as …
• In assessing patients who present with depression, important to determine whether…
• Antidepressant medications should be used with care

Cyclothymic disorder

• ≥2 years of chronic, fluctuating mood disturbance
involving periods of …
• Symptoms do not meet criteria for …
• Patient often considered moody, unpredictable
• Begins early, usually adolescence or early adulthood
• Thought to predispose to other mood disorders
• May go on to develop symptoms of manic intensity or major depression
• Roughly equal incidence in men and women

Bipolar collaborative care

• Multidisciplinary
• Nurse
• Primary care provider
• Mental health specialist
• Case manager
• Pharmacist
• Encourage patient to track feelings, behaviors, response to medication
• Especially in first few days as medication is started

Bipolar diagnostic tests

• No test to determine bipolar disorders
• Diagnosis made on basis of clinical manifestations, patient history
• Physical examination
• Laboratory tests
• Screening tools

Pharmacological therapy

Ayptical antipsychotics

Lithium

Anticonvulsants 

Atypical antipsychotics nursing interventions

• Monitoring patient for side effects
• Reassure patient, explain what is happening

Lithium carbonate 

• Alters neurotransmission in central nervous system (CNS)
• Not recommended in …
• Administered orally
• Onset of action 1–3 weeks
• Dosage gradually increased until at therapeutic blood level of
0.8 – 1.2 mEq/L
• Maintenance dose requires blood level of 0.6 – 1.2 mEq/L

Lithium carbonate high risk for toxicity

• Difference between harmful and therapeutic lithium levels is very small
• Determine patient’s serum lithium levels before starting therapy
• Carefully monitor once therapy is begun
• Individual response to specific doses must be carefully documented, monitored
• Toxic symptoms at blood levels >1.5 mEq/L
• Narrow margin of safety → monitor serum levels closely

1.5 mEq/L or less (Lithium)

Metallic taste
Fine hand tremor
Nausea
Polyuria
Polydipsia
Loose stools
Muscle weakness
Weight gain
Edema
Memory impairments

1.5-2.5 mEq/L (Lithium) 

Dry mouth
Blurred vision
Ataxia
Incoordination
Muscle twitching
Tinnitus
Slurred speech
Nausea and vomiting
Severe diarrhea
Increasing tremor

2.5 mEq/L or above

Arrhythmias
Impaired consciousness
Nystagmus
Course tremor
Seizures
Confusion
Oliguria
Anuria
Myocardial infarction
Cardiovascular collapse
Coma
Death

Atypical antipsychotics

• Hyperactive, agitated behavior responds rapidly to

• aripiprazole
• risperidone
• olanzapine
• quetiapine

Anticonvulsant medications 

valproic acid
lamotrigine
carbamazepine

Anticonvulsants

• Often prescribed in combination with lithium or antipsychotic
medications
• Mood stabilizers
• Common side effects include …
• Blood levels
• Cannot be discontinued abruptly, must be tapered off
• Adverse effects/black box warnings

Children and adolescents

• Younger children may demonstrate mood and behavioral changes that are unusual for the child
• Older children may take on multiple tasks, develop grandiosity
• Adolescents commonly show mood changes and changes in sleep and eating.
• Diagnosis made after other possibilities ruled out
• Treatment
• Medications to reduce severity of symptoms
• Fewest possible medications
• Psychotherapy

Pregnancy 

• Women diagnosed with bipolar disorder are very likely to
experience episode during pregnancy
• Some women may experience first episode while pregnant
• Stopping medications can worsen symptoms
• Some providers slowly taper woman off medications,
decrease dosage, change medication
• If lithium is continued
• Serum lithium levels must be monitored frequently
• Close monitoring necessary during pregnancy, postpartum
period

Older adults

• Onset of bipolar disorder can occur as late as 60s, 70s
• First episodes of manic symptoms indicate need for medical testing
to rule out medical or substance-related etiology
• Treatment same as for younger adults
• Medication doses may be lower
• Prone to more side effects, toxicity
• Lithium
• Contraindications

Nursing process

• Nurses must
• recognize clinical manifestations
• understand how patients respond
• provide patient and family teaching
• Nursing care for patients with depressive symptoms is the same
whether diagnosis is…
• For all patients, assess personal history of cyclical patterns,
triggers
• Early identification of triggers can assist in identifying helpful
interventions, improving patient outcomes
• Hospitalization

Observation and patient interview 

• Past manic or depressive episodes or behaviors
• Family history of mood disorder
• Signs and symptoms of mood disorders and their severity
• Speed of onset of any symptoms (gradual or dramatic)
• Manic behaviors
• Cognitive alterations
• Impairments in adaptive functioning

Physical examination

• Hallmark of mania: constant motor activity
• Disordered sleep patterns
• Bruises and other injuries from constant activity
• Patients in manic state usually unable to cooperate in assessment process

Mania mood 

Euphoric and elated mood
On a continuous high
Subject to frequent variation,
easily changing to irritability and
anger or even to sadness and
crying

Mania cognition and perception

Rapid thinking progressing to racing thoughts and disjointed thinking (flight of ideas) which may be manifested by a
Continuous flow of accelerated
pressured speech with abrupt changes from topic to topic
Grandiose or paranoid delusions
Poor attention span, distractibility
Disorganized speech (tangential, circumstantial)

Mania activity and behavior

Excessive psychomotor activity
Increased sexual interest
Poor impulse control
Excessive spending
Manipulative; projecting blame on
others and splitting
Poor sleep and nutrition
Flamboyant or bizarre dress
Excessive make-up or jewelry

Analysis/Diagnosis

• Risk for Injury
• Risk for Suicide
• Risk for Harm to Others
• Altered Thought Processes
• Impaired Social Interaction
• Ineffective Impulse Control
• Impaired Mood Regulation
• Imbalanced Nutrition: Less Than Body Requirements
• Self-Care Deficit, Bathing, Dressing, and Feeding
• Sleep Deprivation

Planning 

• Remain free of injury
• Not harm self or others
• Adhere to treatment plan including medication
• Recognize thoughts that are not reality-based
• Be able to make choices between two or more alternatives
• Use appropriate behaviors in variety of social settings
• Meet daily allowances of nutrients
• Complete ADLs with minimal supervision
• Report improved and greater sleep duration

Implementation: Promote patient safety

• Provide patient with community support by supplying names, phone numbers or resources such as crisis hotline
• Assist patient in scheduling appointments with mental health
professionals
• Provide safe environment by reducing environmental stimuli
• Monitor for safety hazards
• Offer activity to channel anger and anxiety
• Set, enforce limits

Implementation: Promote reality-based thinking

• Present reality by spending time with patient, orienting to
time and day, location, other information as needed
• Establish consistency by following schedule, assigning
same caregivers to work with patient when possible
• Refrain from arguing or trying to reason with patient
experiencing delusions
• When patient communicates perceptions of altered reality,
reflect their statements back to them for validation

Implementation: Enhance socialization 

• Set limits
• All staff must agree on established limits, enforce them
consistently
• Patients must know what behaviors are expected, what
consequences will result if they exceed limits
• Expect manipulative responses to limits but don’t be
disarmed by them
• Consistent application of consequences essential to
promote adaptive behaviors

Implementation: Promote improved self-care

• Promote improved self-care
• Ensure adequate nourishment, fluids
• Assist patient with personal hygiene, toileting
• For patient who gets minimal or no sleep
• Incontinence occasionally seen in severely regressed
patients

Implementation: Enhance rest and sleep

• Design nursing activities to facilitate regular sleep–wake cycles
• Monitor patients closely for signs of fatigue
• Promote nighttime sleeping by limiting daytime naps
• Sleep may promote rapid resolution of first episodes of mania
• When patients can sleep, avoid waking them for nonessential care or activities

Evaluation 

• Outcomes that indicate the patient has improved include
• Patient remains free from injury
• Patient is performing adequate self-care
• Patient can sleep through the night
• Patient behaves appropriately in social settings

If goals are not met

• Time frame may need to be extended
• Combination pharmacologic therapy may need to be implemented
• Clozapine or electroconvulsive therapy (ECT) when first-line therapies unsuccessful
• Important for patient to understand that finding effective medication regimen is a process that often requires adjustments