1. Mood Disorders: Bipolar Disorder
Chapter 17
Mood Disorders:
Bipolar Disorder

2. Bipolar Disorders
Characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy
Delusions or hallucinations may or may not be part of clinical picture
Onset of symptoms may reflect seasonal pattern

3. Types of Bipolar Disorders
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder

4. Bipolar I Disorder
Individual is experiencing, or has experienced, a full syndrome of manic or mixed symptoms
May also have experienced episodes of depression

5. Bipolar II Disorder Recurrent bouts of major depression
Episodic occurrences of hypomania
Has not experienced an episode that meets the full criteria for mania or mixed symptomatology

6. Cyclothymic Disorder Chronic mood disturbance At least 2-year duration
Numerous episodes of hypomania and depressed mood

7. Epidemiology Gender prevalence
Incidence of bipolar disorder is roughly equal

8. Epidemiology (cont.) Age
Average age at onset for a first manic episode is the early 20s

9. Epidemiology (cont.)
Social class: there is more bipolar disorder reported in the higher social classes than lower social classes
Marital status: more common in unmarried than in married persons

10. Bipolar Disorder (Mania)
Etiological implications
Biological theories
Strong hereditary implications
Biochemical influences
Possible excess of norepinephrine, serotonin, and/or dopamine

11. Bipolar Disorder (Mania) (cont.)
Physiological influences
Brain lesions
Medication side effects

12. Bipolar Disorders (Mania) (cont.)
Psychosocial theories
Credibility of psychosocial theories has declined in recent years
Bipolar disorder viewed as brain disorder
Theoretical integration
Bipolar disorder likely results from an interaction between genetic, biological, and psychosocial determinants

13. Bipolar Disorder: Developmental Implications
Childhood and adolescence
Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1%
Diagnosis is difficult
Guidelines for diagnosis and treatment have been developed by the Child and Adolescent Bipolar Foundation (CABF)

14. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
The Child and Adolescent Bipolar Foundation (CABF) recommends the use of FIND (Frequency, Intensity, Number, and Duration) in making a diagnosis of bipolar disorder in children and adolescents

15. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
FIND
Frequency: symptoms occur most days in a week
Intensity: symptoms are severe enough to cause extreme disturbance
Number: symptoms occur 3 or 4 times a day
Duration: symptoms occur 4 or more hours a day

16. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
Symptoms include
Euphoric/expansive mood: extremely happy, silly, or giddy
Irritable mood: hostility and rage, often over trivial matters
Grandiosity: believes abilities to be better than everyone else’s
Decreased need for sleep: may only sleep 4 or 5 hours per night and wake up feeling rested

17. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
Symptoms include (cont.)
Pressured speech: loud, intrusive, difficult to interrupt
Racing thoughts: rapid change of topics
Distractibility: unable to focus on school lessons
Increase in goal-directed activity/psychomotor agitation: activities become obsessive; increased psychomotor agitation

18. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
Symptoms include (cont.)
Excessive involvement in pleasurable or risky activities: exhibits behavior that has an erotic, pleasure-seeking quality about it
Psychosis: may experience hallucinations and delusions
Suicidality: may exhibit suicidal behavior during a depressed or mixed episode or when psychotic

19. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
Treatment strategies
Psychopharmacology
Lithium
Divalproex
Carbamazepine
Atypical antipsychotics

20. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
Treatment strategies (cont.)
ADHD is most common comorbid condition
ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled

21. Bipolar Disorder: Developmental Implications (cont.)
Childhood and adolescence (cont.)
Treatment strategies (cont.)
Family interventions
Psychoeducation about bipolar disorder
Communication training
Problem-solving skills training

22. Nursing Process/Assessment
Symptoms may be categorized by degree of severity
Stage I—Hypomania: symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization
Mood: cheerful and expansive
Cognition and perception: self exultation; easily distracted
Activity and behavior: increased motor activity; extroverted; superficial

23. Assessment
Stage II—Acute mania: intensification of hypomanic symptoms; requires hospitalization
Mood: euphoria and elation
Cognition and perception: fragmented, disjointed thinking; pressured speech; flight of ideas; hallucinations and delusions
Activity and behavior: excessive psychomotor behavior; increased sexual interest; inexhaustible energy;
goes without sleep; bizarre dress and make-up

24. Assessment (cont.)
Stage III—Delirious mania: a grave form of the disorder, characterized by severe clouding of consciousness and representing an intensification of the symptoms associated with acute mania
Has become relatively rare since the availability of antipsychotic medication

25. Nursing Diagnosis Risk for Injury related to Extreme hyperactivity
Evidenced by
Increased agitation and lack of control over purposeless and potentially injurious movements

26. Nursing Diagnosis (cont.)
Risk for Violence: self-directed or other-directed related to
Manic excitement
Delusional thinking
Hallucinations

27. Nursing Diagnosis (cont.)
Imbalanced Nutrition less than body requirements related to
Refusal or inability to sit still long enough to eat
Evidenced by
Loss of weight, amenorrhea

28. Nursing Diagnosis (cont.)
Disturbed Thought Processes related to
Biochemical alterations in the brain
Evidenced by
Delusions of grandeur and persecution

29. Nursing Diagnosis (cont.)
Disturbed Sensory Perception related to
Biochemical alterations in the brain and to possible sleep deprivation
Evidenced by
Auditory and visual hallucinations

30. Nursing Diagnosis (cont.)
Impaired Social Interaction related to
Egocentric and narcissistic behavior
Insomnia related to
Excessive hyperactivity and agitation

31. 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

32. Criteria for Measuring Outcomes (cont.)
The client (cont.)
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

33. Criteria for Measuring Outcomes (cont.)
The client (cont.)
Accepts responsibility for own behaviors
Does not manipulate others for gratification of own needs
Interacts appropriately with others

34. Planning/Implementation
Nursing interventions are aimed at
Maintaining safety of client and others
Restoring client nutritional status
Encouraging appropriate client interaction with others
Assisting client to define and test reality
Meeting client’s self-care needs

35. Client/Family Education
Nature of illness
Causes of bipolar disorder
Cyclic nature of the illness
Symptoms of depression
Symptoms of mania

36. Client/Family Education (cont.)
Management of illness
Medication management
Assertive techniques
Anger management

37. Client/Family Education (cont.)
Support services
Crisis hotline
Support groups
Individual psychotherapy
Legal/financial assistance

38. Evaluation
Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria

39. Evaluation (cont.) Has the client avoided personal injury?
Has violence to client or others been prevented?
Has agitation subsided?

40. Evaluation (cont.) Have nutritional status and weight been stabilized?
Have delusions and hallucinations ceased?

41. Treatment Modalities for Bipolar Mood Disorders
Psychological treatment
Individual psychotherapy
Group therapy
Family therapy
Cognitive therapy

42. Treatment Modalities for Bipolar Mood Disorders (cont.)
Psychopharmacology
For mania
Lithium carbonate
Anticonvulsants
Verapamil
Atypical antipsychotics
For depressive phase
Use antidepressants with care (may trigger mania)

43. Mood-Stabilizing Agents
Background assessment data
Indications: prevention and treatment of manic episodes associated with bipolar disorder
Examples: lithium carbonate, clonazepam (Klonopin), carbamazepine (Tegretol), valproic acid (Depakote), lamotrigine (Lamictal), gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), verapamil, atypical antipsychotics

44. Mood-Stabilizing Agents (cont.)
Background assessment data (cont.)
Action: lithium may modulate the effects of certain neurotransmitters, such as norepinephrine, serotonin, dopamine, glutamate, and GABA, thereby stabilizing symptoms associated with bipolar disorder. Action of anticonvulsants, verapamil, and atypical antipsychotics in the treatment of bipolar disorder is not fully understood.
Interactions
Contraindications/precautions

45. Mood-Stabilizing Agents (cont.)
Monitor for side effects of lithium
Drowsiness, dizziness, headache
Dry mouth; thirst; GI upset; nausea/vomiting
Fine hand tremors
Hypotension; arrhythmias, pulse irregularities
Polyuria; dehydration
Weight gain
Potential for toxicity

46. Mood-Stabilizing Agents (cont.)
Lithium toxicity
Therapeutic range
1.0 to 1.5 mEq/L (acute mania)
0.6 to 1.2 mEq/L (maintenance)
Initial symptoms of toxicity include
Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea
Ensure that client consumes adequate sodium and fluid in diet

47. Mood-Stabilizing Agents (cont.)
Monitor for side effects of anticonvulsants
Nausea and vomiting
Drowsiness; dizziness
Blood dyscrasias
Prolonged bleeding time (with valproic acid)
Risk of severe rash (with lamotrigine)
Decreased efficacy of oral contraceptives (with topiramate)

48. Mood-Stabilizing Agents (cont.)
Monitor for side effects of verapamil
Drowsiness; dizziness
Hypotension; bradycardia
Nausea
Constipation

49. Mood-Stabilizing Agents (cont.)
Monitor for side effects of antipsychotics
Drowsiness; dizziness
Dry mouth; constipation
Increased appetite; weight gain
ECG changes
Extrapyramidal symptoms
Hyperglycemia and diabetes

50. Treatment Modalities for Bipolar Mood Disorders (cont.)
Electroconvulsive therapy (ECT)
Episodes of mania may be treated with ECT when
Client does not tolerate medication
Fails to respond to medication
Life is threatened by dangerous behavior or exhaustion

51. Treatment Modalities for Bipolar Mood Disorders (cont.)
Electroconvulsive therapy
For mania
Mechanism of action: thought to
increase levels of biogenic amines
Side effects: temporary memory loss and confusion
Risks: mortality; permanent memory loss; brain damage
Medications: pretreatment medication; muscle relaxant; short-acting anesthetic