Chapter 17

Bipolar and Related Disorders

Copyright ©2019 F.A. Davis Company

Clinical Picture
• Bipolar I disorder
• Most severe form
• Highest mortality rate of the three
• At least 1 manic episode
• Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms.
• May also have experienced episodes of depression

• Bipolar II disorder
• At least 1 hypomanic episode
• At least 1 major depressive episode
• Characterized by bouts of major depression with episodic occurrence of hypomania
• Has never met criteria for full manic episode

• Cyclothymic disorder
• Altermate with symptoms of mile to moderate depression for at least 2 years (adults)
• Rapid cycling possible
• Chronic mood disturbance
• At least 2-year duration
• Numerous episodes of hypomania and depressed mood of insufficient severity to meet the
criteria for either bipolar 1 or 2 disorder
Clinical Picture
• Hypomania
• A low-level and less dramatic mania
• Tends to be euphoric and often increases
functioning
• Usually accompanied by excessive activity and
energy
• Bipolar II disorder must have at least 1
hypomanic episode
 Other Bipolar Disorders

• Substance/medication-induced bipolar and related disorder

• A disturbance of mood (depression or mania) that is considered to be
the direct result of the physiological effects of a substance (for
example, ingestion of or withdrawal from a drug of abuse or a
medication or other treatment)

• Bipolar and related disorder due to another medical condition

• Characterized by an abnormally and persistently elevated, expansive,
or irritable mood and excessive activity or energy that is judged to be
the result of direct physiological effects of another medical condition
Epidemiology
• Lifetime risk for overall: nearly 4%
• Men & women: nearly equal rates
• Severe postpartum psychosis = 4X greater risk
• Children & adolescents
• Disruptive mood dysregulation disorder
• Cyclothymic disorder
• Adolescence/early adulthood
• 50% risk of subsequent bipolar I or II
Comorbidity: Bipolar I Disorder
• Nearly all anxiety disorders are associated with
bipolar I, affecting about 75% with this disorder
• Panic attacks, social anxiety disorder, phobias
• Other disorders may complicate clinical
presentation/management of bipolar I
• Attention-deficit/hyperactivity
• All disruptive, impulse-control or conduct disorders
• Substance use disorder present in over half of those
with bipolar I
• Serious medical conditions
Comorbidity: Bipolar II Disorder

• 75% of individuals with bipolar II have comorbid

anxiety disorders
• Eating disorders, particularly binge-eating disorder
• Substance use disorders
Comorbidity: Cyclothymic Disorder

• Substance use disorders common

• Sleep disorders
• Attention-deficit/hyperactivity disorder more
common among children with cyclothymic disorder
than with other mental health conditions
Risk Factors
• Biological factors
• Genetic
• Neurobiological
• Neuroendocrine
• Peripheral inflammation
• Environmental factors
• Cognitive factors
 Childhood and Adolescence
• Treatment strategies
• Psychopharmacology
• Lithium
• Divalproex
• Carbamazepine
• Atypical antipsychotics
• Attention deficit/hyperactivity disorder (A D H D) is the most common comorbid condition.
• A D H D agents may exacerbate mania and should be administered only after bipolar symptoms have
been controlled.
• Family interventions
• Psychoeducation about bipolar disorder
• Communication training
• Problem-solving skills training
Stage 1 Assessment
• Symptoms may be categorized by degree of severity.
• Stage 1. Hypomania: Symptoms not sufficiently severe
to cause marked impairment in social or occupational
functioning or to require hospitalization
• Cheerful mood
• Rapid flow of ideas; heightened perception
• Increased motor activity
 Stage 2 Assessment
• Stage 2. Acute mania: Marked impairment in functioning; usually
requires hospitalization
• Elation and euphoria; a continuous “high”
• Flight of ideas; accelerated, pressured speech
• Hallucinations and delusions
• Excessive motor activity
• Social and sexual inhibition
• Little need for sleep
Stage 3 Assessment
• Stage 3. Delirious mania: A grave form of the disorder
characterized by an intensification of the symptoms
associated with acute mania. The condition is rare
because the advent of antipsychotic medication.
• Labile mood; panic anxiety
• Clouding of consciousness; disorientation
• Frenzied psychomotor activity
• Exhaustion and possibly death without intervention
 Assessment
• Mood • Thought processes and
• Altman’s Self-Rating Mania Scale speech patterns
• Behavior • Pressured speech
• Can be manipulative and • Circumstantial speech
demanding • Tangential speech
• Splitting: a need for staff unity
• Loose associations
• Thought processes and speech
• Flight of ideas
patterns
• Clang associations
• Thought content
• Cognitive function • Thought content
• Grandiose delusions
• Persecutory delusions
Assessment (Cont.)
• Cognitive dysfunction: clinical
implications
• Affects overall function
• Cognitive deficits correlate with:
• manic episodes
• history of psychosis
• chronicity of illness
• poor functional outcome
Self Assessment:
Discomfort is common
Enhance your professional ability by—
Sharing/acknowledging
uncomfortable feelings with staff
or nursing faculty member
Collaborating with staff and
nursing faculty member
Sharing your experience with
peers in post conference
Assessment Guidelines
Bipolar Disorder
• Danger to self or others
• Need for protection from uninhibited behaviors
• Need for hospitalization
• Medical status
• Coexisting medical conditions
• Family’s understanding
 Nursing Diagnosis
• Risk for injury related to
• Extreme hyperactivity, increased agitation, and lack of control over purposeless and
potentially injurious movements
• Risk for violence: self-directed or other-directed related to
• Manic excitement
• Delusional thinking
• Hallucinations
• Impulsivity
• Imbalanced nutrition less than body requirements related to
• Refusal or inability to sit still long enough to eat, evidenced by loss of weight,
amenorrhea
• Disturbed thought processes related to
• Biochemical alterations in the brain, evidenced by delusions of grandeur and
persecution, as well as inaccurate interpretation of the environment
 Nursing Diagnosis
• Disturbed sensory perception related to
• Biochemical alterations in the brain and to possible sleep deprivation,
evidenced by auditory and visual hallucinations
• Impaired social interaction related to
• Egocentric and narcissistic behavior
• Insomnia related to
• Excessive hyperactivity and agitation
Criteria for Measuring Outcomes: The Client
• Exhibits no evidence of physical injury
• Has not harmed self or others
• Is no longer exhibiting signs of physical agitation
• Eats a well-balanced diet with snacks to prevent weight loss and
maintain nutritional status
• Verbalizes an accurate interpretation of the environment
Verbalizes that hallucinatory activity has ceased and demonstrates no
outward behavior indicating hallucinations
• Accepts responsibility for own behaviors
• Does not manipulate others for gratification of own needs
• Interacts appropriately with others
• Is able to fall asleep within 30 minutes of retiring
• Is able to sleep 6 to 8 hours per night
Outcomes Identification
• Acute phase
• Prevent injury
• Maintain stable cardiac status
• Maintain hydration/tissue integrity
• Get sufficient sleep & rest
• Demonstrate thought self-control
• Attempt no self-harm
 Outcomes Identification (Cont.)

• Maintenance phase
• Obtain knowledge of the disorder, management, and medication
• E.g., Identify three risk factors for the development of acute mania; identify preventive
strategies
• Identify sources of support
• E.g., Attend group therapy on a daily basis
• Problem-solve
• E.g., Identify new coping skills
Planning: Acute Phase

• Medical stabilization
• Maintaining safety
• In-hospital nursing care
• Seclusion, restraint, or ECT may be considered during
the acute phase
Planning: Maintenance Phase
• Preventing relapse
• Limiting severity and duration of future episodes
• Patients with bipolar disorders require medications
over long periods of time/over entire lifetime
• Support patients in repairing their lives from the
hardships that came out of the acute phase of illness
Implementation:
Depressive vs. Manic Episodes
• Depressive episodes
• Hospitalization for suicidal, psychotic, or catatonic signs
• Medication concerns about bringing on a manic phase
• Manic episodes
• Hospitalization for acute mania (bipolar I disorder)
• Communicating challenges and strategies
Implementation: Acute Mania
(Hospitalization)

• Provides safety for a person experiencing acute mania

• Imposes external control on destructive behaviors
• Provides medication for stabilization
Communication Techniques
• Use firm and calm approach
• Provides structure & control
• Use short, concise explanations
• Minimizes potential for manipulative behaviors
• Identify expectations in simple, concrete terms
• Offers safety as patient experiences outside controls while
understanding reasons for treatment choices
• Hear and act on legitimate complaints
• Reduces helpless feelings; minimizes acting out
• Firmly redirect energy into more appropriate channels
• Distractibility is the most effective tool for a patient experiencing
mania
Implementation: Maintenance Phase
• Focus on preventing relapse
• Medication adherence is essential
• Regular and adequate sleep
• Healthy nutrition
• Community support
• Engagement with community resources
• Use of outpatient facilities
Health Teaching & Health Promotion
• Information on bipolar illness
• Understanding its recurrent nature
• Warning signs of impending episodes
• Importance of regularity
• Sleep patterns
• Meals
• Exercise
• Other activities
• Group and individual therapy
 Patient and Family Education
• Nature of the illness
• Causes of bipolar disorder
• Cyclic nature of the illness
• Symptoms of depression
• Symptoms of mania
• Management of the illness
• Medication management
• Assertive techniques
• Anger management
• Support services
• Crisis hotline
• Support groups
• Individual psychotherapy
• Legal/financial assistance
Evaluation
• Evaluate outcome criteria
• Reassess outcomes and care plan
• Revise care plan if indicated
• Long-term outcomes to be added in time:
• Adherence to medication regimen
• Resumption of functioning in the community
• Achievement of stability in family, work, relationships and
mood
• Improved coping skills for reducing stress
Brain Stimulation Therapies
Electroconvulsive Therapy (ECT)
Passes an electric current through the brain
Most commonly used with patients who have bipolar
disorder with severe levels of depression
Repetitive Transcranial Magnetic Stimulation (rTMS)
FDA approval for treatment-resistant major depressive
disorder, but has not been approved for bipolar depression
Psychological Therapies
• Cognitive-Behavioral Therapy (CBT)
• Usually an adjunct to pharmacotherapy
• Interpersonal and Social Rhythm Therapy
• Aims to regulate social routines and stabilize interpersonal
relationships to improve depression and prevent relapse
• Family-Focused Therapy
• Helps improve communication among family members
 Treatment Modalities for Bipolar Disorder

 Individual psychotherapy
 Group therapy
 Family therapy
 Cognitive therapy
Biological: Pharmacotherapy

• Two main foci

• Agitation
• Mood stabilization
 Psychopharmacology
• For mania
• Lithium carbonate
• Anticonvulsants
• Verapamil
• Antipsychotics
• For depressive phase
• Use antidepressants with care (may trigger mania).
 Client/Family Education
• Lithium
• Take the medication regularly.
• Do not skimp on dietary sodium.
• Drink six to eight glasses of water each day.
• Notify physician if vomiting or diarrhea occur.
• Have serum lithium level checked every 1 to 2 months, or as advised by physician.
• Notify physician if any of the following symptoms occur:
• Persistent nausea and vomiting
• Severe diarrhea
• Ataxia
• Blurred vision
• Tinnitus
• Excessive output of urine
• Increasing tremors
• Mental confusion
 Anticonvulsants
• Anticonvulsants
• Refrain from discontinuing the drug abruptly.
• Report the following symptoms to the physician immediately: skin rash, unusual
bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin
or eyes.
• Avoid using alcohol and over-the-counter medications without approval from physician.

• Valproate (Depakote)
• Carbamazepine (Equetro)
• Lamotrigine (Lamictal)
Verapamil
• Verapamil
• Do not discontinue the drug abruptly.
• Rise slowly from sitting or lying position to prevent
sudden drop in blood pressure.
• Report the following symptoms to physician:
• Irregular heartbeat; chest pain
• Shortness of breath; pronounced dizziness
• Swelling of hands and feet
• Profound mood swings
• Severe and persistent headache
 Antipsychotics
• Antipsychotics
• Do not discontinue drug abruptly.
• Use sunblock when outdoors.
• Rise slowly from a sitting or lying position.
• Avoid alcohol and over-the-counter medications.
• Continue to take the medication, even if feeling well and as though it is not needed;
symptoms may return if medication is discontinued.
• Report the following symptoms to physician:
• Sore throat; fever; malaise, unusual bleeding; easy bruising; skin rash, persistent nausea
and vomiting
• Severe headache; rapid heart rate, difficulty urinating or excessive urination, muscle
twitching, tremors
• Darkly colored urine; pale stools
• Yellow skin or eyes
• Excessive thirst or hunger
• Muscular incoordination or weakness
Second-Generation Antipsychotics
• Examples
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Cariprazine (Vraylar)
Integrative Therapy

• Omega-3 Fatty Acids

• Cod liver oil
• Fish oil
• No evidence to support use in treating mania
• Strong evidence they may improve depressive
symptoms
QUICK QUIZ
A suicidal client with a history of
manic behavior is admitted to
the emergency department. The
client’s diagnosis is documented
as bipolar 1 disorder: current
episode depressed. What is the
rationale for this diagnosis
instead of a diagnosis of major
depressive disorder?
A. The physician does not believe the client
is suffering from major depression.
B. The client has experienced a manic
episode in the past.
C. The client does not exhibit psychotic
symptoms.
D. There is no history of major depression
in the client’s family.
In the initial stages of caring for
a client experiencing an acute
manic episode, what should
the nurse consider to be the
priority nursing diagnosis?
A. Risk for injury related to
excessive hyperactivity
B. Disturbed sleep pattern related
to manic hyperactivity
C. Imbalanced nutrition, less than
body requirements, related to
inadequate intake
D. Situational low self-esteem
related to embarrassment
secondary to high-risk
behaviors
 QUICK QUIZ
A suicidal client with a history of
manic behavior is admitted to In the initial stages of caring for
the emergency department. The a client experiencing an acute
client’s diagnosis is documented
as bipolar 1 disorder: current manic episode, what should
episode depressed. What is the the nurse consider to be the
rationale for this diagnosis priority nursing diagnosis?
instead of a diagnosis of major
depressive disorder?
A.Risk for injury related to excessive
hyperactivity
A. The physician does not believe the client is suffering According to Maslow’s hierarchy of needs,
from major depression. maintaining client safety is always a priority. The
impulsiveness and hyperactivity seen in clients
B. The client has experienced a manic episode in the past. diagnosed with acute mania puts them at risk for
The client’s past history of mania and current suicide attempt injury.
support the diagnosis of Bipolar 1 Disorder: Current
Episode Depressed. According to the D S M-5 criteria, a
manic episode rules out the diagnosis of major depressive B. Disturbed sleep pattern related to manic
hyperactivity
disorder.
C. Imbalanced nutrition, less than body
C. The client does not exhibit psychotic symptoms.
requirements, related to inadequate intake
D. There is no history of major depression in the client’s
D. Situational low self-esteem related to
family. embarrassment secondary to high-risk
behaviors
QUICK QUIZ
A client who is prescribed lithium carbonate is being
discharged from inpatient care. Which medication
information should the nurse teach this client?

A. Do not skimp on dietary sodium intake.

B. Have serum lithium levels checked every 6 months.
C. Limit fluid intake to 1000 milliliter of fluid per day.
D. Adjust the dose if you feel out of control.
QUICK QUIZ
A client who is prescribed lithium carbonate is being
discharged from inpatient care. Which medication
information should the nurse teach this client?
A.Do not skimp on dietary sodium intake.
Clients taking lithium should consume a diet adequate in sodium and drink
2,500 to 3,000 milliliter of fluid per day. Lithium is a salt and competes in
the body with sodium. If sodium is lost, the body will retain lithium with
resulting toxicity. Maintaining normal sodium and fluid levels is critical to
maintaining therapeutic levels of lithium and preventing toxicity.
B. Have serum lithium levels checked every 6 months.
C. Limit fluid intake to 1000 milliliter of fluid per day.
D. Adjust the dose if you feel out of control.