Bipolar Disorders

Clinical Judgment Model

1. Recognize cues (what matters most here?)

2. Analyze cues (What could it mean?)

3. Prioritize Hypothesis (Where do I start?)

4. Generate solutions (What do I want to happen?)

5. Take actions (What will I do?)

6. Evaluate outcomes (Did it work?)

Bipolar Disorder at a Glance

• 4.4% of US adults lifetime prevalence, and about 83% of those cases are considered severe

• 25 average age of onset (young adults)

• 1:1 men and women are affected about equally

• High risk for suicide, in both depression and mania

• Sixth leading cause of disability in the middle-age group world wide

You Do Not Need a Psych Unit to Meet this Client

• Med surge floor, admitted with gastroenteritis, and takes lithium. Vomiting and diarrhea can push lithium levels up

• After surgery or an ED visit: started steroids, now sleepless, talkative and agitated. Some medications can trigger mania.

• Primary care: treated for “depression” with an antidepressant. Nobody asked about a past manic episode

• Women’s health: Pregnant, or planning to be, and taking lithium or an anticonvulsant mood stabilizer

A Brain-Based Illness, Not a Character Flaw

1. Cause: the exact cause is unknown. Heredity and environmental triggers together are the most credible explanation.

2. Genetics: one parent with bipolar disease raises a child’s risk to 10 to 25%. With both parents the risk is 2 to 3 times higher.

3. Genes under study: ANK3 (whether a neuron fires) and CACNA1C (calcium flow in cells)

4. Pruning: the brain trims connections it no longer needs between childhood and adulthood. In bipolar disorder this may be disrupted.

Neurochemistry and the Transactoinal Model

• Mania: Too much norepinephrine and dopamine

• Depression: Too little norepinephrine and dopamine

• Serotonin appears in both states

• Some medications can trigger mania, including steroids and antidepressants such as SSRIs

• Genes, biology and lift context interact

Three Patterns of Mood Over Time

• Bipolar I: At least one full manic episode

• Bipolar II: Hypomania plus major depression, never full mania

• Cyclothymia: Many mild highs and lows for 2 or more years

Telling the Types Apart

Rapid cycling: 4 or more mood episodes (mania, hypomania or depression) in 12 months

Children and Adolescents: Harder to See

• Hard to diagnose: Symptoms in young people look different and overlap with other conditions. Bipolar disorder is rare in children, with about 1% lifetime prevalence in adolescents.

• Looks like ADHD: Inattention, distractibility and impulsivity overlap. Research does not show that ADHD causes bipolar disorder

• Family history matters: A family history of bipolar disorder is an important clue. True bipolar disorder is a chronic illness.

Mania: The Cues to Recognize

• Criteria: Abnormally and persistently elevated, expansive or irritable mood plus increased energy, lasting 1 week (any length if hospitalized)

• 3 or more symptoms (4 if the mood is only irritable)

• Distractibility

• Indiscretion: spending, sex, gambling, foolish investments

• Grandiosity: inflated self-esteem

• Flight of ideas: racing thoughts

• Activity increase: psychomotor agitation

• Sleep decrease: decreased need for sleep

• Talkativeness: pressured speech

Three Stages of Mania

• Stage I: Hypomania (hospital may not be needed)

  • Mood; cheerful, expansive, underlying irritability

  • Thinking: ideas of great self-worth and ability

  • Behavior: more motor activity, loud, talking and laughing a lot

  • Function: not severely disturbed

• Stage II: Acute mania (Hospital may be needed)

  • Mood: euphoria and elation, labile, tearful

  • Thinking: fragmented, psychotic (paranoid, grandiose)

  • Behavior: poor impulse control, days without sleep, flamboyant or bizarre dress

  • Function: severely disturbed. Goals: safety, limits, stabilization

• Stage III: Delirious mania (grave form, now rare)

  • Mood: very labile, panic level of anxiety

  • Thinking: confused, disoriented, extremely distractible, incoherent

  • Behavior: agitated, purposeless movements

  • Severe clouding of consciousness

Do Not Forget the Other Pole: Bipolar Depression

• Cues of a major depressive episode (2 weeks or more)

• Mood: depressed mood or loss of interest in usual activities

• Body: sleep and appetite changes, fatigue, slowed movement

• Thinking: guilt, worthlessness, trouble concentrating

• Hopelessness: thoughts of death or suicide

• Mixed features: manic and depressive symptoms together

Gathering Cues: The Bipolar Assessment

• Safety First

  • Risky behaviors

  • Risk of harm to self or others

  • Suicide screening

  • “Tell me what brought you here?”

• Mental Status

  • Mood state

  • Speech pattern

  • Thoughts and perceptions: delusions, hallucinations

  • Activity and behavior

• Body

  • Sleep pattern

  • Appetite, height and weight

  • Energy 

  • Labs

• Medications and context

  • Medication reconciliation (vitamins, herbs, OTC) and adherence

  • Substance use

  • Collateral sources, if indicated

Analyze Cues: What Could They Mean?

• Slept 2 hours and says they feel amazing → Decreased need for sleep: a manic cue, not insomnia. Exhaustion is a risk.

• Buys new convertible and does not pay rent → Impulsivity and impaired judgment: financial and safety risk.

• Fine hand tremor and metallic taste on lithium → Expected side effects. Watch for them to get worse.

• Started steroids last week, now sleepless and pressured → Possible medication- induced mania. Report it.

• Past manic episode, now hopeless and suicidal → Bipolar I, current episode depressed. Not major depressive disorder.

Prioritize: What Needs Attention First?

• Which needs are immediate?

• Which are most serious?

• Are there signs of a deteriorating condition?

• What are the risks of intaction?

1. Safety: risk of harm to self or others

2. Thinking: Disorganized thoughts, impaired reality testing

3. Sleep: days without sleep, not restful sleep

4. Nutrition: Not eating or drinking enough

Solutions on the Menu: Treatment Modalities

• Psychopharmacology: The foundation. Stabilize first.

• Individual Therapy: One-to-one work once stable. 

• Group therapy: Not for a client who is acutely manic.

• Family therapy: Builds understanding and support

• Cognitive Therapy: When ready→ link thoughts, feelings, and behaviors, and change dysfunctional patterns.

• ECT: Depression and acute mania when drugs fail. A generalized seizure is induced under anesthesia.

Mood-Stablizing Medications at a Glance

Before starting: CBC, LFTs, TSH, chemistries, and a pregnancy test in people who become pregnant.

Stevens- Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis

• The rash in SJS/TEN consists of painful pink to dark-red spots that may blister and usually involves the skin, lips, mouth, eyes,and genitals. 

• Flat or slightly raised pink spots with dark-red centers

• Blistering, peeling skin

• Redness, blisters, and erosions of the lips, and inside the mouth

• Redness, irritation, pain, and erosions of the eyelids and eye

Take Action: Caring for a client in Mania

• Do

  • Monitor safety and risk of harm to self and others

  • Lower stimulation: quiet room, fewer groups and visitors

  • Use short, calm, direct statements

  • Set limits early, kindly and consistently

  • Offer finger foods and fluids she can eat on the move

  • Protect sleep

  • Give medications and watch the response

  • Teach the client and family

• Avoid

  • Arguing or debating delusions

  • Power struggles and bargaining

  • Overstimulating groups

  • Taking insults personally

  • Waiting to address escalating behavior

  • Joking along with grandiose plans

Lithium: Sodium, Water, and a Narrow Window

• Sodium goes DOWN (vomiting, diarrhea, dehydration, low-salt diet, sweating) → Kidneys hold on to lithium (lithium is reabsorbed like sodium) → Lithium level goes UP (risk of toxicity)

• Not a PRN medication. Treats and prevents mania.

• Narrow therapeutic window. Levels are monitored closely

• 95% leaves through the kidneys, so check renal function

• Raises lithium levels: thiazide diuretics, NSAIDs, ACE inhibitors

• Never stop abruptly. Taper gradually.

Lithium Levels: Know the Ladder

1.5 is the max lithium level before you get into a toxic range

RED FLAGS: DO NOT MISS THESE

• Lithium Toxicity: Coarse tremor, vomiting, and diarrhea, ataxia, blurred vision. A level above 1.5 mEq/L with symptoms is an emergency.

• Severe rash: Any new rash on carbamazepine or lamotrigine could be Stevens-Johnson syndrome. Report it right away.

• Pregnancy: Lithium, valproate and carbamazepine can cause birth defects. Ask about pregnancy before starting. 

Teach it back: medication education. Ask pt’s to explain in own words

• Lithium

  • Take it regularly, even when feeling well

  • Keep salt intake steady. Do not cut back

  • Drink 6 to 8 glasses of water a day and limit caffeine

  • Call the provider for vomiting and diarrhea

  • Know the signs of toxicity

• Antipsychotics

  • Use caution driving: drowsiness and dizziness

  • Do not stop suddenly

  • Use sunblock: skin burns more easily

  • Rise slowly from sitting to standing

  • Sip water or use hard candy for dry mouth

  • Avoid alcohol 

Teaching The Client and Family

• Medications and symptoms: What each drug does, side effects, and how to manage symptoms

• The cycle of the illness: mania and depression come in cycles. Usually lifelong

• Regular sleep: a steady sleep pattern is protective

• Regular activity: Keep a steady daily routine

• Support and resources: support groups, crisis hotline (988), legal services, treatment

• Building insight: Help the client understand the illness

Recovery: A continuous Process

• No cure but recovery is possible: preventing and minimizing symptoms, and coping with the effects on mood, career and social life.

1. The client identifies goals

2. Client and clinician build the treatment plan

3. Together they work on strategies to manage the illness

4. The clinician is a support person for the client’s goals