1. Bipolar and Related Disorders
Chapter 13
Bipolar and Related Disorders
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2. Objectives
Describe the signs and symptoms of bipolar I, bipolar II, and cyclothymic disorder.
Distinguish between mania and hypomania.
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3. Clinical Picture Bipolar I disorder Bipolar II disorder
Cyclothymic disorder (cyclothymia)

4. Bipolar Disorder – DSM V
A distinct period of abnormally & persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day
Or any duration if hospitalization is required in bipolar disorder, type 1

5. Bipolar Disorder – DSM V (continued)
During the period of mood disturbance, 3 or more of the following have persisted (4 if the mood is only irritable):
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative or pressured speech
Flight of ideas or subjective feeling of racing thoughts
Distractibility
Increased goal-directed activity or psychomotor agitation
Excessive involvement in pleasurable activities that have a high potential for painful consequences

6. DIG FAST Distractible (poorly focused)
Indiscretion (excessive pleasurable activities)
Grandiosity (unrealistic belief in one’s ability or inflated self- esteem)
Flight of Ideas
Activities (increased, hyperactivity)
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)
Need 3/7 in addition to expansive mood
Need 4/7 if primary mood is irritability

7. Case Study/ Audience Response Question
Ms. A, 53, has just been admitted to your unit with bipolar disorder I and is in the manic state. What symptoms might you expect to see?
Catatonia
Expression of racing thoughts
Low self esteem and tearfulness
Lack of interest in her environment
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8. Hypomania
Unequivocal change uncharacteristic of person when not symptomatic
Observable by those who know the person
May be seen as unusual to people who do not know the person but not necessarily recognized as a mental illness
Absence of marked impairment in social or occupational functioning
Hospitalization not indicated
Not due to substance abuse, medication, or other medical condition

9. Mania
Behavior severe enough to cause marked impairment in occupational activities, usual social activities, or relationships
Necessitates hospitalization to prevent harm to self or others, or there are psychotic features
Symptoms not due to substance abuse, medications or other medical condition

10. Endless energy
Decreased need for sleep
Omnipotent feelings
Substance Abuse
Increased sexual interest
Poor judgment
Euphoric mood
Can’t sit still
Irritable, impulsive, intrusive
Nothing is wrong (denial)
Active: Aggressive
Mood Swings

12. Epidemiology
Up to 21% of patients with major depression may actually have undiagnosed bipolar disorder
Bipolar I—more common in males
Bipolar II—more common in females
Cyclothymia—usually begins in adolescence or early adulthood
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13. Co-morbidities >50% Anxiety Panic attacks Substance abuse
Social Phobia
Specific Phobia
Borderline Personality disorder
Seasonal Affective disorder

14. Case Study
An assessment interview reveals that Ms. A is an adjunct college English professor who has published two novels and is working on a third. “It was almost inevitable,” she says, “because I grew up in a family of five anxious girls with competitive, ego-driven professional parents. It was hellish. I found escape in writing stories and putting on plays with my sisters. When I got a scholarship later, I practically ran away to college, where I absolutely lived on coffee, books, and the drama department!”
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15. Case Study (Cont.)
Ms. A further describes her childhood, a part of her life she finds particularly troubling. “We all had to compete if we wanted attention. Dad played favorites, depending on our grades and talents. I was his favorite, but I hated it because it made my mother hate me. How could she compete with her own daughters? Sometimes in high school I scared myself with how much I just wanted to hurt them both. I decided I would never marry and have kids.”
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16. Etiology
Biological factors
Genetic
Neurobiological
Neuroendocrine

17. Psychosocial & Environmental Factors
Stress
Education
Occupation
Economic status
Creativity

18. Audience Response Question
Based on her history, which factors can you identify that may have an influence on Ms. A’s condition?
Biological factors
Psychological factors
Environmental factors
All of the above.
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19. Objectives
Formulate three nursing diagnoses appropriate for a patient with mania.
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20. Assessment Mood Behavior Thought processes Cognitive functioning
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21. Assessment (Cont.) Speech patterns Thought content Pressured speech
Circumstantial speech
Tangential speech
Loose associations
Flight of ideas
Clang associations
Thought content
Grandiose delusions
Persecutory delusions
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22. Case Study Discussion
What are some problems that can be avoided if your manic patient gets proper treatment?
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23. Self-Assessment Manic patient Staff member actions Manipulative
Demanding
Splitting
Staff member actions
Frequent staff meetings to deal with patient behavior and staff response
Set limits consistently
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24. 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
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25. Nursing Diagnosis Risk for injury Risk for violence Ineffective coping
Other-directed
Self-directed
Ineffective coping
Disturbed sensory perception
Imbalanced nutrition
Disturbed sleep pattern
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26. Outcomes Identification
Acute phase
Prevent injury
Continuation phase
Relapse prevention
Maintenance phase
Limit severity and duration of future episodes
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27. Planning Acute phase Continuation phase Maintenance phase
Medical stabilization
Maintaining safety
Self-care needs
Continuation phase
Maintain medication adherence
Psychoeducational teaching
Referrals
Maintenance phase
Prevent relapse

28. Nursing Care for Acute Mania (Hospitalization)
Managing medications
Decreasing physical activity
Increasing food and fluid intake
Ensuring at least 4 to 6 hours of sleep per night
Intervening so that self-care needs are met
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29. Communication With Patient Experiencing Mania
Use firm, calm approach
Use short and concise explanations
Remain neutral: avoid power struggles
Be consistent in approach and expectations
Firmly redirect energy into more appropriate areas
Act on legitimate complaints
Convey limits, consequences

30. Structure - Milieu Low level of stimuli
Structured solitary activities or with staff
Redirect violent behavior
Minimize physical harm – medication, seclusion, restraints
Observe for medication side effects/toxicity
Protect from consequences of behavior
Such as giving away possessions, spending all money, disrobing

31. Interventions: Physiologic Safety/ Self-Care Needs
Monitor vital signs, I & O if indicated
Nutrition
Offer frequent mobile high calorie foods or protein drinks
Elimination
Sleep
Avoid caffeine, reduce stimulation, encourage rest, other sleep-inducing interventions
Hygiene
May need supervision, step by step reminders
Minimize choices

32. Pharmacological Interventions
Mood stabilizers
Antipsychotics
Anxiolytics
Antidepressants
Two main foci
Agitation
Mood stabilization
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33. Pharmacological Interventions
Lithium carbonate
First-line agent
Therapeutic and toxic levels
Therapeutic blood level: 0.8 to 1.4 mEq/L
Maintenance blood level: 0.4 to 1.3 mEq/L
Toxic blood level: 1.5 mEq/L and above
Takes 7 to 14 days to reach therapeutic levels in blood

34. Initial Treatment of Acute Mania Until Lithium Takes Effect
Antipsychotics
Slow speech
Inhibit aggression
Decrease psychomotor activity
Antipsychotic or benzodiazepine to prevent:
Exhaustion
Coronary collapse
Death

35. Lithium: Expected Side Effects
Blood level: <0.4 to 1.0 mEq/L
Signs
Fine hand tremor
Polyuria
Mild thirst
Mild nausea
General discomfort
Weight gain

36. Lithium: Expected Side Effects
Blood level: <0.4 to 1.0 mEq/L
Signs
Fine hand tremor
Polyuria
Mild thirst
Mild nausea
General discomfort
Weight gain

37. Lithium: Early Signs of Toxicity
Blood level: 1.5 mEq/L
Signs
Nausea
Vomiting
Diarrhea
Thirst
Polyuria
Slurred speech
Muscle weakness

38. Lithium: Advanced Signs of Toxicity
Blood level: 1.5 to 2.0 mEq/L
Signs
Coarse hand tremor
Persistent gastrointestinal upset
Mental confusion
Muscle hyperirritability
Incoordination

39. Lithium: Severe Toxicity
Blood level: 2.0 to 2.5 mEq/L
Signs
Ataxia
Blurred vision
Clonic movements
Large output of dilute urine
Seizures
Stupor
Severe hypotension
Coma
Death

40. Lithium: Severe Toxicity - Continued
Blood level: >2.5 mEq/L
Signs
Confusion
Incontinence of urine or feces
Coma
Cardiac arrhythmias
Peripheral circulatory collapse
Abdominal pain
Proteinuria
Oliguria
Death

41. Lithium: Common SE and Major Long-Term Risks
Other common SE
Drowsiness
Weakness
Blurred vision, dry mouth
Fatigue
Acne
Weight gain
Major Long-Term Risks
Hypothyroidism
Impairment of kidneys’ ability to concentrate urine

42. Contraindications to Lithium
Cardiovascular disease
Brain damage
Renal disease
Thyroid disease
Myasthenia gravis
Pregnancy
Breastfeeding mothers
Children younger than 12 years

43. Patient and Family Teaching for Lithium Therapy
Effects of treatment
Need to monitor lithium blood levels
Side effects and toxic effects
Effects of dietary salt and dehydration
Caffeine effects
Check with physician before taking OTC medications
Take with food to decrease stomach irritation
High fat helps-spoonful of peanut butter

44. Anticonvulsant Mood Stabilizers
Valproate (Depakote)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
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45. Second-Generation Antipsychotics
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Aripiprazole (Abilify)
Asenaprine (Saphris)
Cariprazine (Vraylar)
Lurasidone (Latuda)
Quetiapine (Seroquel, Seroquel XR)
Ziprasidone (Geodon)
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46. First-Generation Antipsychotics
Chlorpromazine (Thorazine)
Loxapine (Adasuve) inhaled
Antianxiety Drugs
Clonazepam (Klonopin)
Lorazepam (Ativan)
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47. Milieu Therapy: Seclusion Room or Restraints
Used in an emergency for patient when:
Clear risk of harm to patient or others
Patient's behavior has continued despite use of less restrictive methods to keep patient and others safe

48. Objectives
Evaluate specific indications for the use of seclusion for a patient experiencing mania.
Discuss the use of ECT for a patient in specific situations.
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49. Other Treatments ECT Teamwork and safety Seclusion and restraints
Support groups
Health teaching and health promotion
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50. Advanced Practice Interventions
Cognitive-behavioral therapy (CBT)
Interpersonal and social rhythm therapy
Family-focused therapy
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51. Evaluation Evaluate outcome criteria Reassess care plan
Revise care plan if indicated
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52. Quality Improvement Standards for Bipolar Excellence Project
15 evidence-based performance measures regarding screening, assessment, treatment, and monitoring bipolar disorder and its care
Provides tools for research, teaching, and quality improvement
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53. Audience Response Questions
Which anticonvulsant medication might be prescribed for a patient with bipolar disorder?
Divalproex sodium (Depakote)
Clonazepam (Klonopin)
Olanzapine (Zyprexa)
Lithium (Lithobid)
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54. Audience Response Questions
Lithium toxicity may result in which one of the following?
Neuroleptic malignant syndrome
Dystonia
Blurred vision
Akathisia

55. Case Study Discussion
Ms. A is started on lithium. Discuss what patient teaching about this medication the nurse should provide before the patient is discharged.
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