Bipolar disorder

Bipolar Disorder Overview

Objectives

  • Identify bipolar I and bipolar II disorders, and cyclothymic disorder
  • Identify nursing interventions that focus on developing an effective nurse–patient relationship
  • Identify medications used to treat people with bipolar disorder

Definition of Bipolar Disorder

  • Mood Fluctuation
    • Mood fluctuates between mania and depression.
    • Typically, patients experience 1-2 episodes per year.
    • Mood Lability - refers to rapid shifts in mood.
  • Gender Impact
    • Bipolar disorder affects men and women equally.
  • Age of Onset
    • First diagnosed typically in the teenage years, twenties, or thirties.

Types of Bipolar Disorder

Bipolar I
  • Characterized by at least one manic episode lasting at least one week.
  • May or may not include depressive episodes.
  • Mania
    • Can last over 1 week and may require hospitalization.
    • Psychosis may occur.
Bipolar II
  • Involves recurrent major depressive episodes mixed with hypomania.
Cyclothymic Disorder
  • Defined by chronic fluctuating mood for at least 2 years (1 year in children).
  • Includes periods of hypomanic symptoms and depressive symptoms that do not meet the full criteria for bipolar disorder.
  • Usually, functioning is not severely impaired.

Mania

  • Symptoms
    • Inflated self-esteem and grandiosity.
    • Decreased need for sleep and food.
    • Pressured, rapid speech and flight of ideas.
    • Psychomotor agitation and involvement in risky behaviors (such as excessive spending, promiscuity, reckless driving).
    • Possible hallucinatory experiences and delusions.
    • Poor judgment and insight.

Hypomania

  • Characteristics
    • Elevated or irritable mood.
    • Increased energy and activity; presence of no psychosis.
    • Functioning may be intact or mildly improved.

Depression in Bipolar Disorder

  • Symptoms
    • Low mood and anhedonia.
    • Changes in sleep and appetite patterns.
    • Presence of suicidal ideation.
    • Psychomotor changes may be observed.

Etiology & Risk Factors

  • Genetics
    • Family history of mood disorders is a significant risk factor.
  • Substance Use
    • Increased likelihood of developing bipolar disorders.
  • Stressors and Social Support
    • Presence of stressors and lack of social support.
  • Neuro-biologic Theory
    • Decreased serotonin levels.
    • Excess of dopamine and norepinephrine.
  • Medications Triggering Manic Episodes
    • SSRIs might lead to mania.
    • Steroids can also induce manic episodes.

Clinical Manifestations Across the Lifespan

  • Children & Adolescents
    • Intense rage episodes are common.
    • Often comorbid with ADHD, ODD (Oppositional Defiant Disorder), and anxiety disorders.
    • Rapid cycling occurs more frequently in this demographic.
  • Older Adults
    • More cognitive changes such as confusion and disorientation occur.
    • Episodes of mania appear to decrease with age.

Rapid Cycling

  • Defined as having 4 or more mood episodes within a 12-month period.
  • Intense and rapid shifts in both energy and mood.
  • More prevalent in women and often associated with the use of antidepressants.

Treatment

Lithium
  • Purpose
    • Reduces the frequency and severity of manic episodes.
  • Monitoring
    • Serum lithium levels must be monitored closely.
    • Hydration and consistent sodium intake should be maintained.
  • Contraindications
    • Not suitable for patients with renal failure, those on diuretics, and pregnant individuals.
Lithium Side Effects
  • Excessive thirst and a metallic taste.
  • Fine tremors and mild diarrhea.
  • Weight gain and nausea.
Therapeutic and Toxic Levels of Lithium
  • Therapeutic Range:
    • 0.6-1.2 mEq/L for therapeutic levels.
    • 0.4-1.0 mEq/L for maintenance doses.
    • 0.8-1.4 mEq/L during acute mania.
  • Toxicity Levels
    • 1.5-2.5 mEq/L indicates mild toxicity.
    • >2.5 mEq/L indicates severe toxicity.
Lithium Toxicity Symptoms
  • Moderate Symptoms
    • Severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination.
  • Severe Symptoms
    • Symptoms can escalate to renal failure, confusion, seizures, and can lead to coma or death.
  • Action Steps:
    • Hold the next dose, notify the provider, and obtain serum lithium levels.
Teaching Points for Lithium
  • Maintaining adequate sodium intake is crucial.
  • Avoid excessive caffeine and diuretics.
  • Prevent dehydration, especially during sweating; replenish fluids.
  • Notify the provider if persistent vomiting or diarrhea occurs.
  • Be aware that medication can increase lithium levels (i.e., NSAIDs, diuretics, ACE inhibitors).
Lithium and Thyroid Function
  • Lithium may alter thyroid function, usually after approximately 6 months of treatment and is more common in women.
  • TSH levels may require monitoring.
  • Monitor for signs of hypothyroidism, including dry skin, constipation, bradycardia, hair loss, and cold intolerance.
Anticonvulsant Treatments
  • Carbamazepine:
    • Risk for agranulocytosis; therefore, monitor white blood cell (WBC) count.
    • Side effects include dizziness, hypotension, and blurred vision.
  • Valproic Acid:
    • Monitor liver function; side effects can include drowsiness, weakness, nausea/vomiting (N/V), and sedation.
Antipsychotic Use for Depressive Symptoms
  • Medications include Quetiapine, Olanzapine, and Aripiprazole.
  • Educate clients about anticholinergic effects of antipsychotics:
    • Small sips of water, lozenges to relieve dry mouth, change positions slowly to prevent orthostatic hypotension, and potential for weight gain.
Treatment: Psychotherapy
  • Most effective during depressive phases.
  • Psychotherapy reduces suicide risk and supports treatment adherence.
  • Helps families comprehend the illness better.

Nursing Assessment: Mental Status Exam

General Appearance
  • Observe for psychomotor agitation.
  • Clothing may reflect an elevated mood.
Mood and Affect
  • Mood may be labile, grandiose, or irritable; may appear elevated.
Thought Process
  • Exhibit flight of ideas and impulsivity.
  • Possible presence of delusions and hallucinations.
Cognition
  • Disorientation and poor concentration can be noted.
Judgment and Insight
  • Insight is often poor during manic episodes, with clients believing they are well.
  • Judgment is impaired, leading to impulsive actions such as shopping sprees, gambling, or reckless driving.
Self-Concept
  • Displays exaggerated self-esteem and a false sense of well-being.
Roles and Relationships
  • Clients may struggle to fulfill responsibilities, leading to impaired work functioning.
  • There may be a great need for socialization, characterized by an overpowering presence.

Nursing Priorities During Acute Mania

  • Safety Concerns
  • Hydration and nutrition must be prioritized.
  • Promote sleep and address potential sleep disturbances.
  • Limit setting is vital for managing behavior.
  • Ensure medication adherence.

Nursing Interventions

  • Safety Measures
    • Assess for suicidal ideation (SI) and the risk of harming others.
  • Disturbed Sleep Pattern
    • Promote rest periods and reduce stimulation.
  • Deficient Knowledge
    • Provide simple and direct instructions and monitor for side effects.
Nutrition Interventions
  • Offer small, high-nutrient snacks that can be consumed on the go.
  • Example:
    • Mixed Berry Vanilla Chobani has 20g protein, 0g added sugar, and specified volume (10 fl oz / 296 mL).
Behavioral Interventions
  • Set clear boundaries for inappropriate behavior.
    • Example phrases:
    • "Please step back, you are too close to my face."
    • "Please do not touch other clients; you may speak to them but do not touch them."
Therapeutic Communication Techniques
  • Utilize short, simple sentences.
  • Employ a firm, calm tone to communicate effectively.
  • Avoid engaging in power struggles; redirect energy appropriately.
  • Present reality without arguing to facilitate understanding.
Milieu Management Strategies
  • Maintain a low-stimulus environment to help reduce agitation.
  • Establish structured schedules and limit group activities during manic episodes.
  • Protect other patients from potential intrusive behavior caused by the manic patient.

Client Outcomes

  • Aim for no self-injury or harm to others.
  • Achieve balanced sleep, rest, and activity.
  • Ensure adequate nutrition and hydration levels.
  • Improve self-care practices.
  • Encourage socially appropriate behavior.
  • Client verbalizes understanding of their illness and treatment plan.