Bipolar Disorders

Mood Disorders: Bipolar

Types:

Mania or hypomania
alternating with depression
Bipolar I (major depressive, manic, or
mixed episodes)
Bipolar II (major depression and
hypomania)
Cyclothymic disorder (hypomania and
depressive episodes not meeting full
criteria for major depressive episode)

BPD Definitions
Mood

swings from profound

depression to mania w/periods of
normalcy in between
Recurrent episodes of depression
w/episodes of mania characterized by
lack of impulse control, excess energy,
delusions or grandiose thinking,
elation, irritability, inappropriate
behavior, pressured speech,
hyperactivity & decreased need for
sleep
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Incidence and
Prevalence of BPD
Lifetime

prevalence: 1.1% bipolar I; 1.4%

bipolar II
Symptoms before age 25 years
No gender differences in incidence
Female patients at greater risk for depression
and rapid cycling than male patients
Male patients at greater risk for manic
episodes
Common comorbid conditions: anxiety
disorders (most prevalent: panic disorder and
social phobia) and substance use

Incidence and Prevalence of

Bipolar Disorders
Hx

of BPD increases risk of PP

psychosis 25%
Annual cost to rx: $45 billion-$7 billion
direct; more expensive than DM to rx
1 manic episode costs average of
$12,000
The

average age of clients

experiencing their first manic episode
is 18 to 20 years

Earlier

age of onset is associated with

worse outcomes, including rapid

Prevalence of Bipolar Disorder

Rates

of morbidity and mortality,

particularly for bipolar depression, are
associated with:

Cardiovascular, cerebrovascular, and

respiratory diseases and other
psychiatric illnesses and substance
use disorders
The associated risk of completed suicide
and bipolar illness is 15%

Bipolar I Disorder
Classic

manic-depressive disorder with mood

swings alternating from depressed to manic
A chronic cyclic disorder
An early onset and a family history of illness
are associated with multiple episodes or
continuous symptoms
Can lead to severe functional impairment such
as alienation from family, friends, and
coworkers; indebtedness; job loss; divorce;
and other problems of living
Diagnosis is dependent upon at least one
manic episode or mixed episode and a
depressive episode

BPD vs Unipolar
BPD:

younger, more episodes of

illness, more hospitalizations;
psychomotor retardation,
hypersomnia, fewer somatic c/o
Unipolar: increased motor
activity, insomnia, somatic c/o

DSM: 3 or >
Inflated

self esteem or grandiosity

Decreased need for sleep
More talkative that usual, pressured speech
Flight of ideas or racing thoughts
Distractability
Increased goal-direct activities or
psychomotor agitation
Excessive involvement in pleasurable
activities that have hi potential for painful
consequences (buying sprees, sexual
indescretions, foolish investments)

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Bipolar, manic: sy
Euphoria

& elation
Labile mood; flight of ideas
Paranoid & grandiose delusions
Sexually uninhibited; inexhaustable
energy
Disorganized, flamboyant or bizarre
dress
Excessive psychomotor activity
Diminished sleep
3 most common sy @ onset: elated
mood, increased activity, reduced sleep
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Behaviors associated
w/BPD
Distractability
Insomnia
Grandiosity
Flight

of ideas
Activities
Speech
Thoughtlessness

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Question

Is the following statement true or false?

An expansive mood is characterized by

euphoria.

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Answer
False.

An expansive mood is one involving a

lack of restraint in expression and
overvalued self-importance. An
elevated mood is characterized as
euphoria.

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Mania theories: biologic

Genetic:

gene location for BPD

found in various regions of
chromosomes
(4, 12, 18, 21, 22, X )
Biogenic amines-may be
increased norepinephrine &
dopamine
Lytes-maybe increased
intracellular NA+ & CA++
Meds-steroids, TCAs,
amphetamines

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Understanding Biologic
Foundations

Physical Findings on Dx
studies
Brain

imaging: lesions in white matter

w/BPD concentrated in area involved
w/emotions
PET scan: abnl activity in prefrontal
cortex, basal ganglia & temporal lobes
during mania & depression
Decreased volume of gray matter &
decreased blood flow to prefrontal
cortex (emotions)

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Kids & BPD

1/3

of 3.4 mil kids w/depression go on

to manifest BPD
Often start w/ADHD @ 4-5 y/o
Sy overlap: distractability,
hyperactive, talkative
Comorbidities: anxiety, conduct
disorder, oppositional defiant disorder,
ED, chemical dependency
May take 10 yrs to dx
By 4th grade may see outburst in
school
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Mania theories:
psychosocial
Psychoanalytic-mania

is denial
of depression, reactivation of
infantile state
Family-early life-loving,
nurturing--as gets older
increasing independence and
nurturing is withdrawn before the
child has object constancy--cant
incorporate good/bad19
ambivalence

Family theories: mania

Family-striving

for prestige, pressure

on child to succeed becomes prestige
carrier; not who you are, but what you
are; restricted psychosocial life,
disrupted ego development, unfulfilled
needs for approval
Loss at some time--> depr or mania, dsuperego punitive, anger turned in; mdepression lifts, ego too weak and id
dominates-->excessiveness
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Nursing DXs
Risk

for violence
Risk for Other-Directed Violence
Ineffective coping
Disturbed thought processes
Disturbed self-esteem
Impaired social interaction
SCD
Disturbed Sleep Pattern
Altered family processes
Imbalanced nutrition; FVD

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Bipolar Disorder Interventions

Psychopharmacology
ECT
Health

Ed Support Groups
Cognitive therapy
Nursing interventions

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Rapid Cycling

Clients have four or more manic episodes

for at least 2 weeks in a single year

Episodes marked by either partial or full

remission for at least 2 months or a
switch to an episode of opposite type

Associated with high risk of recurrence

and resistance to conventional drug
treatments

Greater severity of illness and prominent

depressive symptoms

BPD: Chemo
Mood

stabilizers
lithium or depakote-1st line for acute mania,
Anticonvulsants used as mood stabilizers:
carbamazepine (tegretol)gabapentin (neurontin),
lamotrigine(lamictal)
Antidepressants: SSRIs, bupropion(wellbutrin),
venlafaxine(effexor), mirtazapine(remeron),
nefazodone(serzone)
Antipsychotics: atypical-olanzapine(zyprexa),
quetiapine(seroquel), risperidone(risperdol),
ziprasidone (geodan)clozapine(clozaril)-mood
stabilizing properties; most common side effectsdrowsiness & wt gain; clozaril not 1st choice
because of agranulocytosis
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Mood stabilizer: Lithium

carbonate
Drug

of choice; especially good for elation,

grandiosity, flight of ideas, anxiety, irritability
& manipulativeness
7-14 days for maintenance level 0.6-1.2 mEq/l
Monitoring-wk/bi wk-->rx, then q mos x 6 mos,
then q 3 mos, draw 8-12 hr after last dose
may also have a neuroprotective role.
associated with an increased risk of reduced
urinary concentrating ability, hypothyroidism,
hyperparathyroidism, and weight gain. high
prevalence of hyperparathyroidism should
prompt physicians to check client calcium
concentrations before and during treatment.
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Lithium: indications
1st

choice for BPD

Modify chronic depression or episodic
irritability.
Maintenance to avoid
Enhance antidepressant
Schizoaffective disorder
Schizophrenia
Impulse control

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Lithium therapy
Contraindications-

pregnancy/breast-feeding,
cardiac, renal, thyroid disease,
myasthenia gravis, (kids under
12 y/o)
Baseline- thyroid function, T3, T4,
TSH, renal-bun/cret, EKG

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Lithium
Expected

side effects-mild hand

tremors, polyuria, mild thirst, wt
gain, mild nausea discomfort--goes
away
Major long term riskshypothyroidism, impairment of
kidneys ability to concentrate
urine
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Lithium: toxicity
Levels

should not exceed 1.5

mEq/L;
Early-n/v/d, thirst, polyuria, slurred
speech, muscle weakness (above 1.5
mEq/L)
Advan.-Coarse hand tremors,
confusion, gi upset, muscle
hyperirritability, EEG changes
incoordination (1.5-2.0 mEq/L)
Severe-ataxia, seizures, coma,
hypotension, arrhythmias (2.0-2.5

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Client/family ed: lithium

Must

monitor blood levels

Not addictive
Keep normal diet
Withhold if d/d/n/diaphoresis & contact
HCP
Diuretics contraindicated
Take w/meals
Check renal/thyroid function
Avoid OTCs
If wt up check w/HCP
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Additional &/or alternative

med rx: mania
Neuroleptics-initially

slow
speech, inhibit aggression,
decrease psychomotor activity,
exhaustion & death; risperidone,
flupenthixol
Anticonvulsants-control mania,
pvn mania, relieve psychotic s/s,
dampen mood swings, decrease
impulsive & aggressive behavior
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Anxiolytics, Benzodiazepines
Lorazepam:

short acting
Clonazepam: long-acting
Class Summary: By binding to
specific receptor sites,
benzodiazepines appear to potentiate
the effects of gamma-aminobutyric
acid (GABA) and facilitate inhibitory
GABA neurotransmission and the
action of other inhibitory transmitters.
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Anticonvulsants
Carbamazepin

-(CBZ) used for acute

mania, mixed states; +/- used w/rapid
cycling, weak antidepressant
Onset-7-14 days
Therapeutic level-4-15 mcg/ml
Side effects-aplastic anemia,
agranulocytosis(check CBC), check
blood levels, sedation, diplopia,
incoordination, rash

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Anticonvulsants
Carbamazepine

effective in clients who have

not had a clinical response to lithium therapy
Valproate sodium, valproic acid, divalproex
sodium used to treat aggressive or behavioral
disorders. A combination of valproic acid and
valproate has been effective in treating persons
in manic phase, with a success rate of 49%.
Lamotrigine: anticonvulsant effective in the
treatment of the depressed phase in bipolar
disorders.
Topiramate: an off-label indication for the
treatment of bipolar disease. efficacy occurs
only as adjunctive treatment. not associated
with weight gain.
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BPD: Hospitalization
Acute

mania affects insight &

judgment-often hospitalized against
will
When safety is issue: suicidal,
homicidal or aggressive
When severe distress or dysfunction
requires round the clock care &
support
Where there is ongoing substance
abuse, to prevent access to drugs
When client has unstable medical
condition
When close observation of clients
reaction to medication is required

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Desired Outcomes for

Clients with Mania

Impulse self-control

Aggression self-control

Self-care status

Social interaction skills

Concentration

Compliance behavior

 Mood

management

Nursing Intervention
Self-esteem
Classification (NIC)
(R/T Mania)
enhancement
Active

listening

Behavior

management:
overactivity

Behavior

management: sexual

Cognitive

restructuring

Coping

enhancement

Guilt

work facilitation

Limit

setting

Simple

guided
imagery

Simple

relaxation
therapy

Socialization

enhancement
Spiritual

support

Teaching:

process

disease

Indicators of Effective Rx:

The Client...

refrains from acting aggressively toward others & reports

reduced anxiety and agitation

ingests adequate calories & fluids, maintains a balance

between rest & activity, & independently manages ADL

participates appropriately in milieu activities and social

interactions

expresses a positive sense of self-worth without delusions of

grandeur

demonstrates logical thought processes

adheres to the therapeutic regimen and discusses the

importance of doing so after discharge

Client Ed: BPD

Become

an expert on condition-read
Maintain stable sleep pattern
Maintain regular exercise program
Do not use ETOH or illicit drugs
Enlist support of family & friends
Try to reduce stress at work
Learn to recognize warning signs of new
mood episode

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Client Ed: BDP-Call HCP

Suicidal

or violent feelings
Changes in mood, sleep or energy
Changes in medication side effects
A need to use over-the-counter
medications such as cold meds or pain
meds
Acute general medical illness or need
for surgery, extensive dental care, or
changes in meds

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cyclothymic vs dysthymic
Cyclothymia-chronic

mood
disturbance of 2 or >yrs; alternating
hypomania & depression, no
psychosis or dysthymia &
hypomania; not severe enough to be
bpd
Dysthymia- depressive neurosis,
milder than mdd, no psychosis,
**chronic depressed mood most
days & >2 yrs, w/kids irritable mood
1yr or>
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Question
Which agent would most commonly be
prescribed for a patient with bipolar I
disorder?
A.

Lamotrigine

B.

Lithium

C.

Carbamazepine

D.

Divalproex

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Answer
B. Lithium

Although divalproex, carbamazepine,

and lamotrigine may be used as mood
stabilizers, lithium is the most widely
used mood stabilizer.

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Question
Is the following statement true or false?

Protecting the patient from self-harm is

crucial during a manic phase.

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Answer
True.

During mania, patients usually violate

others boundaries, and they may miss
the cues indicating anger and
aggression from others. Thus,
protecting the patient from self-harm
as well as harm from others is
important.

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WEB Sites
National

Institute of Mental

Health
www.nimh.nih.gov
National Alliance on Mental
Illness
www.nami.org
Bipolar Support Alliance
dbsalliance.org
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