Module 4 Bipolar Disorders: Note Taking Outline
Diagnostic Terminology
Current DSM Terminology:
Bipolar Disorder : Type I, Type II
Cyclothymic Disorder
Older terminology you might see:
Manic-Depressive illness
Bipolar Affective Disorder (BAD)
Incidence, Prevalence and Comorbidities
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Usually chronic with remissions and exacerbations
Age of onset: early 20’s
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90% will have recurrent symptoms
Suicide rate in clients with Bipolar disorder is 15%
60% experience chronic interpersonal and occupational difficulties
30-40% of Bipolar have chemical dependency
Types of Bipolar Disorders (see Keltner, p. 291)
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Bipolar I (many subtypes)
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Must be a history of a manic episode
There is a history of Major Depression
A more severe illness
Bipolar II
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There is a history of a hypomanic episode but NOT Mania
There is a history of Major Depression
FYI: The Harvard Bipolarity Index and “Bipolar Spectrum Disorder”
Comparison of Mania and Hypomania
MANIA
A Manic Episode
may happen suddenly, with little warning.
or, may be preceded by a longer period of hypomania
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Mood/affect:
 Euphoric and/or
 Hostile, may be argumentative, aggressive
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Rapidly changing or alternating = labile
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Activity:
 Hyperactive: too busy to eat or sleep
 Disorganized activity
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Speech: pressured, hyperverbal, loud
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Cognition:
 Poor judgment and impulse control: esp. with rewarding activity
AEB: Loud clothing, excessive make-up, promiscuity, excessive spending
 Flight of ideas, tangential, loosening of associations
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Delusions of grandeur, persecution
HYPOMANIA
Similar to Mania But to a Lesser Degree
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Energetic; less need for sleep
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Meets criteria for both Mania and Major Depression
Increased goal-directed behavior: may be highly productive
Mood: elevated or irritable
Lowered inhibitions
No delusions or hallucinations
Bipolar I: Mixed Episode
Rapidly alternating moods
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Not caused by drugs or alcohol
Client is miserable, may be highly suicidal and/or may be violent
CYCLOTHYMIC DISORDER
(aka Cyclothymia)
 Frequent episodes of hypomania and numerous periods of
depressed mood
 Chronic: Never symptom free
Manic Behaviors that Result in Altered Relationships
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Manipulation
Find vulnerability in others
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Exploit weaknesses and create conflict
Shift responsibility
Limit testing
Denial of illness
Abusiveness
Biologic Theories of Mania and Bipolar Illness
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Ion dysregulation: oversensitivity of neuron to stimuli
Alteration in transcription of messengers in nerve cell nucleus
Neurotransmitters involved in mania/bipolar disorders:
 Excessive Dopamine and Norepinephrine
 availability of GABA and Serotonin
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NURSING DIAGNOSES FOR MANIA
Risk for Violence (Directed toward self, others)
Insomnia or Sleep Deprivation
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Altered Nutrition: Less than Body Requirements
Acute Confusion
Disturbed Thought Processes
Impaired Social Interaction
Ineffective family coping
INTERVENTIONS: Psychotherapeutic Management
(Focus of presentation is primarily on management of mania except
where otherwise noted)
Nurse-Patient Relationship and Communication
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Matter-of-fact tone
Clear, concise directions
Set firm limits
Avoid power struggles
De-escalate the client
Communication techniques
 Focusing and redirecting
Milieu Management
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Maintain safe environment
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Issue: milieu balance
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Reinforce appropriate hygiene and dress
Consistency among staff
Reduce environmental stimuli
Support adequate Nutrition and Sleep
Provide outlets for excessive energy level
Psychotherapeutic Management:
Medications
A Common Diagnostic Mistake
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Diagnosing Major Depressive Disorder when the client is in the
Depressive Aspect of Bipolar Disorder
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Giving an antidepressant can push the client into Mania
Medications for Mania: Antipsychotics
Atypicals*: e.g. olanzepine: Zyprexa, quetiapine: Seroquel,
ziprasidone: Geodon,
risperidone: Risperdal and Risperdal Consta,
aripiprazole: Abilify
are FDA approved mood stabilizing agents.
Used alone or with other mood-stabilizing agents
(*Excluding clozapine/Clozaril)
Lithium: Drug of Choice
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Mechanism of action unknown: similarity to action of Na /replaces cellular Na
Slow onset: 2 weeks
Narrow range of therapeutic level 0.6 to 1.2 mEq/L; the optimum maintenance level
is 0.8 mEq/L
Toxic over 1.5 mEq/L
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“Usual side effects”- weight gain, fine hand tremor, nausea, metal taste
Lithium Toxicity
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Narrow therapeutic range: therapeutic dose is close to a toxic dose.
Mild to Moderate toxic reactions: 1.5 to 2 mEq/L
 Diarrhea
 Vomiting
 Drowsiness
 Muscular weakness
 Lack of coordination
 Dry mouth
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Moderate to Severe reactions: 2 to 3 mEq/L
 All previous symptoms &
 Ataxia
 Tinnitus
 Blurred vision
 High urinary output (osmotic diuresis)
 Delirium
 Nystagmus
 Severe reactions:  than 3 mEq/L
 All previous symptoms
 Seizures
 Organ failure
 Renal failure
 Coma
 Death
Mood Stabilizing Medications: Anticonvulsants
valproic acid/divalproex: Depakote and Depakene
carbamazepine: Tegretol
Side effects: many drug interactions; CNS effects; blood disorders ( RBC,
bone marrow, WBC’s), liver failure; toxic reactions common
Monitoring of serum levels is necessary
Other Anticonvulsants
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topiramate: Topamax
gabapentin: Neurontin
oxcarbazepine: Trileptal
lamotrigine: Lamictal-best for bipolar depression. May cause
severe rash.
PRN and Emergency Medications
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Treatment of Acute Agitation or Aggression/Violence
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Sedating antipsychotic agent and/or
Benzodiazepine: lorazepam (Ativan), clonazepam (Klonipin)
May also use “cocktail” with addition of Benadryl
Patient and Family Teaching
Manage lifestyle factors and stress: Regular sleep/activity
schedules
Early recognition of changes in mood; seeking help
Meds: Regular blood draws, Non-adherence issues
Referrals, Resources
Self-help groups: e.g. Depression and Bipolar Support Group
Family: NAMI, family support groups
Comorbid Disorders: Treat substance abuse