BIPOLAR DISORDER

1. INTRODUCTION
Bipolar disorder, formerly called manic depression, is a mental health
condition that causes extreme mood swings that include emotional highs
(mania or hypomania) and lows (depression).When you become
depressed, you may feel sad or hopeless and lose interest or pleasure in
most activities. When your mood shifts to mania or hypomania (less
extreme than mania), you may feel euphoric, full of energy or unusually
irritable. These mood swings can affect sleep, energy, activity, judgment,
behavior and the ability to think clearly.

Episodes of mood swings may occur rarely or multiple times a year. While
most people will experience some emotional symptoms between
episodes, some may not experience any.Although bipolar disorder is a
lifelong condition, you can manage your mood swings and other
symptoms by following a treatment plan. In most cases, bipolar disorder is
treated with medications and psychological counseling (psychotherapy).

The most common identified disorders according to DSM - 5 (APA, 2013)

 Bipolar I Disorder

 Bipolar II Disorder

 Cyclothymic Disorder

 Bipolar Disorder Unspecified

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2. DEFINITION
Bipolar disorders are described by the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a group
of brain disorders that cause extreme fluctuation in a person’s mood,
energy, and ability to function.

Bipolar disorder is a category that includes three different condition--

bipolar I, bipolar II, and cyclothymic disorder.

 Bipolar I disorder is a manic-depressive disorder that can exist

both with and without psychotic episodes

 Bipolar II disorder consists of depressive and manic episodes

which alternate and are typically less severe and do not inhibit
function

 Cyclothymic disorder is a cyclic disorder that causes brief episodes

of hypomania and depression

Bipolar and related disorders are given a chapter of their own in the DSM-
5, between depressive disorders and schizophrenia spectrum disorders.
People who live with bipolar disorder experience periods of great
excitement, overactivity, delusions, and euphoria (known as mania) and
other periods of feeling sad and hopeless (known as depression). As
such, the use of the word bipolar reflects this fluctuation between extreme
highs and extreme lows. The diagnosis is frequently assigned to young
patients presenting with a (first) major depressive episode. In these cases,
diagnosis is exclusively based on psychiatric history provided by family and
caregivers, not on the current psychopathological assessment by the
psychiatrist.

Bipolar disorder occurs in up to 2.5% of the population, but the

prevalence is much higher among first-degree relatives of individuals with
bipolar or schizophrenia disorder. Individuals with bipolar disorder
experience mood swings that are less severe in intensity. During what is
known as a hypomanic episode, a person may experience elevated
mood, increased self-esteem, and a decreased need for sleep. Unlike a

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manic episode, these symptoms are not so severe as to impact daily
functioning or cause psychotic symptoms.

3. SIGN AND SYMPTOMS

Every human will experience highs and lows of life, but some people
experience more than the proverbial mood swing. For people with bipolar
disorder, highs and/or lows can interfere with daily life. Work becomes
harder, decisions are tougher, and relationships can suffer.

Knowing the symptoms of mood episodes of bipolar disorder, which

include mania and depression, can be an important first step in getting
treatment and support for yourself or a loved one. Most people associated
bipolar disorder with the highs and lows in mood, but the disorder affects
much more than that. Symptoms also can include changes in sleeping,
eating, energy level, attention, and other behaviors. The average age of
symptom onset is roughly 25 years old, although children and teenagers
can also exhibit signs.

 MANIA

Mania is a term used to describe a high-energy or elevated mood state. A

person with mania may feel on top the world or cranky for no reason. They
don’t need as much sleep, and they might talk quickly as they struggle to
keep up with their racing thoughts and stay focused on a single task. They
also might feel they are capable of great feats, even to the point of having
superpowers or being a celebrity. Because of this elevated sense of self-
worth, they might be in danger of making risky decisions that can be
damaging to their health or their future.

A manic episode must include at least three of the following symptoms:

 increased talkativeness
 increased self-esteem or grandiosity
 decreased need for sleep
 increase in goal-direct activity, energy level, or irritability
 racing thoughts

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  poor attention
 increased risk-taking (spending money, risky sexual behaviors, etc.)

Mania often results in problems in work, school, and relationships, and in

some cases, it may require hospitalization. A less severe form of mania is
known as hypomania, where a person exhibits high-energy symptoms but is
able to continue with day-to-day responsibilities and may even see an
increase in job performance. However, a hypomanic episode can easily
lead to depression or a full episode of mania and should be treated.

 DEPRESSIONS

Depression is a low-energy or decreased mood state commonly

experienced by people with bipolar disorder. A person who is depressed
can almost seem as if they’re moving in slow motion. They have trouble
making decisions and feel discouraged when fun activities which lifted their
mood no longer work. A person who has experienced 5 or more of the
following symptoms may be experiencing a depressive episode:⁴

 depressed mood
 changes in sleep
 changes in eating
 fatigue or lack of energy
 loss of pleasure in activities once enjoyed
 restlessness or slowing down
 feelings of guilt or worthlessness
 indecision or difficulty concentrating
 thoughts of suicide

Not everyone who has bipolar disorder experiences depression, but if you
have experienced manic symptoms, you may also be at risk of developing
depression. It’s also important to remember that a low mood can sometimes
take the form of anger or irritability, so you don’t necessarily have to
experience stereotypical sadness to have depression.

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4. CLINICAL CRITERIA OF BIPOLAR DISORDER BY DSM 5

Talking with a doctor or mental health professional is the first step in

identifying bipolar disorder. Firstly, a doctor may perform a physical
evaluation to rule out any other conditions that may be causing
symptoms. If no other illnesses are present, the doctor will conduct a
comprehensive mental health evaluation to assess the patient’s
symptoms in accordance with the specific criteria from the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders (DSM-5). To be diagnosed with bipolar disorder, a person must
have experienced at least one episode of mania or hypomania.

To be considered mania, the elevated, expansive, or irritable mood must

last for at least one week and be present most of the day, nearly every
day. To be considered hypomania, the mood must last at least four
consecutive days and be present most of the day, almost every day.

During this period, three or more of the following symptoms must be

present and represent a significant change from usual behavior:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep

3. Increased talkativeness

4. Racing thoughts

5. Distracted easily

6. Increase in goal-directed activity or psychomotor agitation

7. Engaging in activities that hold the potential for painful

consequences, e.g., unrestrained buying sprees

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The depressive side of bipolar disorder is characterized by a major
depressive episode resulting in depressed mood or loss of interest or
pleasure in life. The DSM-5 states that a person must experience five or
more of the following symptoms in two weeks to be diagnosed with a
major depressive episode:

1. Depressed mood most of the day, nearly every day

2. Loss of interest or pleasure in all, or almost all, activities

3. Significant weight loss or decrease or increase in appetite

4. Engaging in purposeless movements, such as pacing the room

5. Fatigue or loss of energy

6. Feelings of worthlessness or guilt

7. Diminished ability to think or concentrate, or indecisiveness

8. Recurrent thoughts of death, recurrent suicidal ideation without a

specific plan, or a suicide attempt

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5. TREATMENT
Typically, treatment for bipolar disorder involves a combination of
psychotherapy and medication. Here's a look at recommended
medications, therapy, and other ways to treat the symptoms of bipolar
disorder.

5.1. Medications for Bipolar Disorder

Medication is an essential component of treatment for anyone with bipolar

disorder. Because people with bipolar disorder often experience rapid or
extreme changes in mood, energy level, attention, and behavior,
medication can help stabilize mood changes and reduce symptoms.
Medication can also prevent future manic or depressive episodes from
occurring and reduce their overall intensity.

Bipolar disorder medication is most effective when taken in combination

with therapy and daily, healthy choices. If you’ve been diagnosed with
bipolar disorder, here are some common types of medication you may be
prescribed. Be aware that it may take several tries before you find the
best combination that works for you.Medications may include:

 Mood stabilizers. Used to control manic or hypomanic episodes,

these include lithium (Lithobid), valproic acid (Depakene),
divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro,
others), and lamotrigine (Lamictal)).

 Antipsychotics. Adding an antipsychotic may help relieve

depressive or manic symptoms that persist despite treatment with
other drugs. Taking these alone or with a mood stabilizer may help.
Such drugs include: olanzapine (Zyprexa), risperidone
(Risperdal), quetiapine (Seroquel), aripiprazole (Abilify),
ziprasidone (Geodon), lurasidone (Latuda), asenapine (Saphris),
and lumateperone (Caplyta).

 Antidepressants. Employed to manage depression,

antidepressants are usually prescribed with a mood stabilizer or

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 antipsychotic, since an antidepressant alone can sometimes trigger
a manic episode.

 Antidepressant-antipsychotic. The medication Symbyax

combines the antidepressant fluoxetine and the antipsychotic
olanzapine. It works as a depression treatment and a mood
stabilizer.

 Anti-anxiety medications. Benzodiazepines may help with

anxiety and improve sleep but are usually used on a short-term.⁸

In addition, cariprazine (Vraylar), has been approved by the FDA for

patients with both manic and depressive episodes in bipolar I disorder.

Finding the right medications that can sometimes be a trial-and-error

affair that takes patience since some medications require weeks or
months to reach their full effect. Health providers usually change only a
single medication at a time to make it easier to identify which medications
work to relieve symptoms with the fewest bothersome side effects. And
even if you’ve arrived at the perfect mix, aging and changing symptoms
may send require adjustments.

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5.2. Psychotherapy

Several types of therapy may be helpful in treating bipolar issues. These

include: ¹⁰

 Interpersonal and social rhythm therapy (IPSRT). IPSRT

focuses on stabilizing daily rhythms, since following a consistent
routine in sleeping, eating, and exercising may help you to manage
your moods.

 Cognitive behavioral therapy (CBT). By identifying unhealthy,

negative beliefs and behaviors and replacing them with healthy,
positive ones, CBT can help identify what triggers your bipolar
episodes. You also learn effective strategies to manage stress and
to cope with upsetting situations.

 Dialectical Behavior Therapy: Including both individual and group

therapy, DBT teaches mindfulness and acceptance skills such as
“the ability to experience moment-to-moment thoughts, emotions
and their accompanying physical sensations from an observer’s
stance, without negative judgment.”

 Psychoeducation. Learning about bipolar disorder can help you

and your loved ones understand the condition. Knowing what's
going on can help you get the best support, identify issues, make a
plan to prevent relapse, and stick with treatment.

 Family-focused therapy. Family support and communication can

help you stick with your treatment plan and help you and your
loved ones recognize and manage warning signs of mood swings.

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5.3. ALTERNATIVE AND FUTURE TREATMENTS

“Treatment for bipolar disorder most often requires a multiprong

approach,” Dr. Samuel says. Along with taking your medications and
attending regular therapy sessions, things like establishing a healthy
sleep schedule and cutting down or eliminating drug and/or alcohol use
can help.

 Natural Supplements

Some people treat their symptoms with herbs (St. John's Wort),
dietary supplements (vitamin D), hormones (DHEA), and/or omega-3
fatty acids but research is inconclusive. However, a large meta-
analysis conducted in 2013 found that some evidence is emerging in
support of complementary-alternative treatments (CAM) for people
who do not respond well to traditional medications or have intolerable
side effects.¹¹ However, a 2018 review of reports on drug-induced
bipolar disorder found a causal link between mania and herbal
supplements other than cannabis.¹²

If you are thinking of going the natural route, it’s important to speak
with your doctor as bipolar disorder is a progressive illness and
symptoms can seriously worsen if they aren’t treated with FDA-
approved medications or therapies.

 Cannabis and Bipolar Disorder

Many people with bipolar disorder report that cannabis relieves both
depressive and manic symptoms, that it works better than
conventional medications, and that it helps relieve bothersome side
effects from those drugs.¹³ Despite these anecdotal claims, a 2020
review that examined research on the therapeutic use of cannabis in
bipolar disorder presented a more nuanced picture. ¹⁴

While researchers found that the use of medical cannabis offered

short-term partial alleviation of clinical symptoms,¹⁵ another case study
showed that treating two bipolar type I patients with CBD had no
impact on manic symptoms.¹⁶ Yet another study cited evidence that

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cannabis use might actually worsen manic symptoms and increase the
risk of new manic episodes.¹⁷

With these mixed results, additional clinical trials are needed to better
clarify the role that marijuana might play in treating bipolar disorder.
Upcoming trials include:

 A randomized clinical trial has been registered to examine CBD

as an adjunctive treatment for bipolar disorder

 Another trial aimed to evaluate the cognitive and

psychophysiological effects of THC (administered through a
vaporizer at doses of 2 and 4 mg) in bipolar disorder has been
registered but is not yet recruiting.

 A trial that examines the effects of dronabinol as well as of CBD

on cognitive domains relevant to bipolar disorder, i.e., arousal,
decision making, cognitive control, inhibition, and temporal
perception (sense of timing) will be evaluated in adult patients
and is currently recruiting participants.

 Electroconvulsive Therapy (ECT) and Transcranial Magnetic

Stimulation (TMS)
 In electroconvulsive therapy (ECT), electrical currents are
passed through the brain to trigger a brief seizure in the
hopes of creating changes in brain chemistry that will
reverse symptoms of certain mental illnesses. ECT may be
an option for bipolar treatments in cases where medications
don’t work, antidepressants may not be indicated (such as
pregnancy)or where the is a high risk of suicide.
 Transcranial magnetic stimulation (TMS) is being
investigated as an option for those who haven't responded
to antidepressants. A study in 2018 of TMS in bipolar
disorder concluded that the treatment did not cause
cognitive deficits, and in 2019 a small, sham-controlled
study in bipolar patients not currently in a manic or

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 depressive mood found that TMS improved cognitive
measure.

6. PSYCHIATIRC EMERGENCIES

Psychiatric emergencies usually involve some combination of agitation,

aggression, impulsivity, psychosis, and risk of destructive behavior,
including suicide and homicide. The psychiatrist must ensure the safety of
the patient and others while identifying to treating immediate medical and
psychiatric problems in developing and initiating a strategy for continuing
the management of less immediate problems. In the diagnosis of acute
behavioral disturbances, it is necessary to determine the role of the
patient's primary psychiatric illnesses and any complications or
treatments of those primary psychiatric illnesses, as well as the role of
other medical or toxic disturbances that may be interacting with the
patient's psychiatric illnesses or treatments.

6.1. Management
 De-escalation Technique
De-escalation often is the first-line approach to managing the
violent patient. De-escalation refers to non-coercive verbal
intervention with the patient to modify their behaviour. Very little
literature exists on the best techniques to be used for de-
escalation in this population. What literature does exist reinforces
the importance of consistency among staff, empowering the
patient to regain control of their behaviour, and avoiding physical
restriction, as this often reinforces violence as a solution. It is
important for the provider to consider the patient care
environment for the safety of the patient, the staff, and
himself/herself. Respect the patient’s personal space. An “open”
stance reflects the willingness to interact with the patient and
looks less defensive.

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 Physical Restraint

It’s used manually, material or equipment. Example tightening a

bed sheet to limit movement, raising side rails, applying wrist or
waist restraint or positioning a wheelchair to restrict movement. It
has been used for emergency situation when there is a threat to
the safety of the resident or others. It should have a written
consent and the healthcare responsible for the patient safety.

 Pharmacotherapy
Occasionally de-escalation fails or is not implemented early
enough in the encounter with a violent patient. This may result in
voluntary or involuntary administration of medication to the
agitated patient. If the patient is compliant, oral (PO) routes such
as benzodiazepines category T. Lorazepam 2mg BD, T.
Midazolam 10mg TDS, T. Diazepam 10 mg TDS can be
considered as a less invasive means of chemical restraint. If the
patient is not cooperative, intramuscular (IM) or intravenous (IV)
routes may be necessary. IV Lorazepam 1mg BD, IM.Midazolam
10mg TDS, IV. Diazepam 10 mg TDS), antipsychotics (T.
Haloperidol 5mg stat, T. Risperidone 2mg ON) and IM Ketamine
1 mg BD.

 Seclusion

Patient is dangerously out of control and all other management

and approaches not successful. Its provide comfort and relief to
patient who can’t control their behaviour.

 One To One Nursing

Patient aggressive will observe closely under one to one nursing

as patient given sedation. Observation done every 15 minutes to
document behaviour in behaviour chart. Patient will be given

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compassionate care, where needs of the individual, comfort,
respect and dignity will be consider. This care includes support for
psychological wellbeing, nutrition, personal hygiene, continence,
mobilisation and activity scheduling. One to one nursing
(specialling) is used to reduce the risk and incidence of harm to
the patient where patient keep within sight at all times of day and
night. Monitoring activity which can be intrusive is meant to be a
therapeutic intervention. It provides a great opportunity to carry
out patient-centred care.

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7. NURSING CARE PLAN

NURSING DIAGNOSIS

 The potential for aggression related to delusions by evidenced

changes in argumentative behavior

Objective

 Patient will not hurt others or damage property.

Intervention

1. Access patient according to mental state to gather the early symptoms

of aggressive such as monitor patient’s expression such as anger face
so that intevention can be plan.
2. Build rapport with patient such as call patient by his name to get trust
from patient.
3. Use simple words that can be understand for any order so that patient
understand well and to prevent from patient to be aggressive.
4. Involve patient in diversional therapy such as listen to music to divert
patient’s mind towards symptoms of aggressive.
5. Create condusif environment such as dim light, open window widely
and switch on the fan to keep patient calm.
6. Involve patient with activities such as karaoke or punch punching bag
to help patient reduce their anger.
7. Keep sharp equipment’s in safe place to avoid patient use as weapon
which can injured his self or the healthcare once become aggressive.
8. Give time to patient to express their feelings so that patient can be
calm.
9. Avoid from provoking patient so that patient didn’t feel challenged and
anger.
10. Involve patient in relaxation therapy like deep breathing exercise,
massage to let patient calm.

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 11. Encourage patient to sleep at least 6 to 8 hours at night so that patient
can be calm and reduce anger.
12. Educate patient in coping skill management like anger management
so that patient understand and able to handle anger.
13. Put patient near to nurse counter in case there’s sign and symptoms
of aggressive to give immediate treatment to reduce anger.
14. Close monitoring like 1 to 1 nursing in case patient has potential of
aggressive to apply treatment.
15. Help out in giving medication under doctor’s prescription such as
Benzodiazepine – T. Lorazepam 1mg ON to prevent from worsening
of illness.
16. Document behaviour patient in behaviour chart to observe the effects
of the treatment.
17. Re-evaluation before shift work to inform the patient's progress so that
care can continue to be provided by the staff who continue the task of
continuing to monitor the patient's safety

Evaluation

 Patient display nonviolent behaviour toward others in the hospital.

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8. STRATEGIES FOR BIPOLAR DISORDER

1. Increase The Number Of Support Group Of Bipolar Disorder In

Malaysia

There is no cure for bipolar disorder, but through behavior therapy and the
right combination of mood stabilizers with other bipolar medicines, most
people with bipolar disorder can live normal, productive lives. In addition,
there are support groups available for patients and their family members to
help them talk openly with outcome learning how to support someone with
bipolar disorder. Ongoing encouragement and support are needed after a
person starts treatment. In fact, the findings showing that the availability of
social support systems increases the chances of employment in patients
with bipolar disorder compared with those patients without support.

There are not many support groups for Bipolar Disorder in Malaysia. Bipolar
disorder can make you feel isolated. Although friends and family members
care about you, they may not understand what you're going through. Some
of them may be more critical than supportive.

That's one reason to think about joining a support group for people who have
the disorder. It feels better to meet people who are in your position -- living
with the same symptoms, frustrations, and worries. They might also have
good suggestions for living with bipolar disorder, such as ways to manage
side effects or talk to others about the condition. (Goldberg, 2018)

2. World Bipolar Day

Bipolar disorder is life-threatening, and support is important. An estimated

1 in 5 people diagnosed with bipolar disorder dies by suicide. World
Bipolar Day is an opportunity to show those living with the day-to-day
challenges of this condition they are not alone, they have your support,
and there is always hope.

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Living with bipolar disorder may not be easy, but as van Gogh himself
once said: “The beginning is perhaps more difficult than anything else, but
keep heart, it will turn out all right.”

To initiative World Bipolar Day in Health Department by encouraging

patient with Bipolar to involve in the day to share knowledge, experience
and their feeling in being as bipolar patient. This will avoid the stigma
among the community where they understand well about the illness ad
how to handle patient with bipolar. The Asian Network of Bipolar Disorder,
and the International Society for Bipolar Disorders celebrates World
Bipolar Day on 30th March every year. The vision of World Bipolar Day is
to bring world awareness to bipolar disorders and eliminate social stigma.
Through international collaboration, the goal of World Bipolar Day is to
educate the world population about bipolar disorders that will help
improve sensitivity toward the illness. (Daversa, 2019)

3. Smartphone Apps to Monitor Bipolar Disorder Symptom

Nowadays, everybody have smart phone. Smart phones can do almost

everything that beyond our mind. Such as relapse prevention in bipolar
disorder can be improved by monitoring symptoms in patients' daily life.
Smartphone apps are easy-to-use, low-cost tools that can be used to
assess this information. It can track daily mood, physical activity, and
social communication. This will make it easier for patients to identify the
changes of symptom they have.

According to a study titled ‘Using Smartphones to Monitor Bipolar

Disorder Symptoms: A Pilot Study’, these researchers agree that Clinical
symptoms were related to some objective and subjective smartphone
measurements, and smartphones have the potential to monitor bipolar
disorder symptoms in patients’ daily life. (Beiwinkel, Kindermann, Maie, &
Kerl, 2016)

so it is important to incorporate the technology elements in the treatment

of bipolar patients in order for patients to adjust and not feel isolated when
diagnosed as suffering from mental illness.

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REFERENCE

MAYO CLINIC . (2021, Feb. 16) Bipolar disorder . Retrieved from

https://www.mayoclinic.org/diseases-conditions/bipolar-
disorder/symptoms-causes/syc-20355955

Jessica Truschel. (Sep 29, 2020) Bipolar Definition and DSM-5

Diagnostic Criteria. Retrieved from PSYCOM:
https://www.psycom.net/bipolar-definition-dsm-5

Alan C. Swann, MD (2007,July 1) Psychiatric Emergencies in Bipolar

and Related Disorder, Psychiatric Times, Retrieved from
Psychiatric Times Vol 24 No 6, Volume 24, Issue 6
https://www.psychiatrictimes.com/view/psychiatric-
emergencies-bipolar-and-related-disorders

Kathleen Smith, PhD, LPC. (2021,May 14) Bipolar Disorder

Symptoms. Retrieved from PSYCOM:
https://www.psycom.net/bipolar-disorder-symptoms

Kathleen Smith, PhD, LPC. (2021,May 14) Bipolar Disorder

Medications . Retrieved from PSYCOM:
https://www.psycom.net/bipolar-disorder-medications

Ilene Raymond Rush. (2021,April 21) Bipolar Disorder Treatment:

What to Know to Manage Your Symptoms Retrieved from
PSYCOM: https://www.psycom.net/bipolar-disorder-
treatment#standard-treatment

Beiwinkel, T., Kindermann, S., Maie, A., & Kerl, C. (2016, January 6).
Using Smartphones to Monitor Bipolar Disorder Symptoms: A
Pilot Study. Retrieved from JMIR Publication:
https://mental.jmir.org/2016/1/e2/

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Daversa, C. (2019, mei 5). World Bipolar Day. Retrieved from
Strength for today, hope for tomorrow:
http://www.worldbipolarday.org/about-wbd.html

Goldberg, J. (2018, April 6). WebMD. Retrieved from Bipolar

Disorder Treatment and Support-Support Groups for Bipolar
Disorder: https://www.webmd.com/bipolar-disorder/bipolar-
disorder-treatment-support#2

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