Bipolar Disorders
Diagnostic Terminology
 Bipolar
Disorder
Bipolar I
 Bipolar II


Old terminology
 Manic-Depressive
 Bipolar Affective Disorder (BAD)
Some Facts
About Bipolar Illness
Usually chronic with remissions and
exacerbations
 Suicide rate in clients with Bipolar disorder is
15%
 60% experience chronic interpersonal and
occupational difficulties
 Age of onset: early 20’s
 90% will have recurrent symptoms
 30-40% of Bipolar have chemical dependency

Types of Bipolar Disorder

Bipolar I (many subtypes)
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
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
Bipolar II



Must be a history of a manic episode
There is a history of Major Depression
More severe
There is a history of a hypomanic episode but
NOT Mania
There is a history of Major Depression
Cyclothymic Disorder


Episodes of hypomania and numerous periods
of depressed mood
Chronic: Never symptom free
Symptoms of HYPOMANIA
Similar to Mania But to a Lesser
Degree
Energetic and driven
 Increased goal-directed behavior: may be
highly productive
 Mood: elevated or irritable
 Lowered inhibitions
 No delusions or hallucinations

Signs/Symptoms of MANIA
Mood/affect: euphoric, labile, hostile
 Hyperactive


Too busy to eat or sleep
Disorganized activity
 Disturbed thought process: Unable to
concentrate, flight of ideas, tangential
 Psychotic Thinking

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
Delusions of grandeur or paranoid
Hallucinations
Signs/Symptoms MANIA, cont’d
Pressured speech; hyperverbal
 Poor judgment and impulse control: with money,
sex, any pleasure
 Loud clothing, excessive make-up

http://www.youtube.com/watch?v=TiGRi0kGg_s&feature=related
Megan hypomania 4 min.
http://www.youtube.com/watch?v=dwWalEE0Yus&feature=related
Debra coping with mania 3 minutes
http://www.youtube.com/watch?v=F_YPZt7CuNY&feature=related
(Pressured speech, flight of ideas Psychiatry teacher)
Bipolar I: Mixed Episode
Meets criteria for both Mania and Major
Depression symptoms
 Severely disturbed, rapidly alternating moods
 Not caused by other drugs or alcohol
 May be induced by antidepressant
 Client is miserable, may be highly suicidal
and/or may be violent

Manic Behaviors that Result in
Altered Relationships

Manipulation

Find vulnerability in others
 Exploit weaknesses and create conflict

Shift responsibility

Limit testing

Alienation of family--may be aggressive
and abusive
Biologic Theories
Ion dysregulation: causes oversensitivity of
neuron to stimuli
 Alteration in transcription of messengers in
nerve cell nucleus

Neurotransmitters involved in mania/bipolar:
 Excessive Dopamine and Norepinephrine
  availability of GABA and Serotonin
Diagnoses (At end of your outline)
NURSING DIAGNOSES FOR MANIA
 Risk for Violence (Directed toward self,
others)
 Insomnia or Sleep Deprivation
 Altered Nutrition: Less than Body
Requirements
 Acute Confusion
 Disturbed Thought Processes
 Impaired Social Interaction

Psychotherapeutic
Management
(Focus of presentation is
primarily on management of
mania except where otherwise
noted)
Nurse-Client Relationship and
Milieu Management
Matter-of-fact tone
 Clear, concise directions
 Limit setting
 De-escalating the client


Maintaining safety
 Consistency among staff
 Reduction of environmental stimuli

Milieu Management, cont’d

Reinforcing appropriate hygiene and dress

Supporting adequate Nutrition and Sleep

Providing activities for excessive energy
Psychotherapeutic Management:
Medications
A Common Diagnostic Mistake
 Diagnosing Major Depressive Disorder
when the client is in the Depressive Aspect
of Bipolar Disorder
 Giving an antidepressant can push the
client into Mania
Antipsychotics
 All Atypicals:
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
 Other
antipsychotics: used prn for agitation
Lithium
Mechanism of action unknown: similarity to
action of Na /replaces Na in the body
 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
 “Normal side effects”- weight gain, fine hand
tremor, nausea, metal taste

Lithium Toxicity
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
Lithium Toxicity

Moderate to Severe reactions

2 to 3 mEq/L
 All
previous symptoms &
 Ataxia
 Tinnitus
 Blurred vision
 High urinary output (osmotic diuresis)
 Delirium
 Nystagmus
Lithium Toxicity
 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
topiramate: Topamax
 gabapentin: Neurontin
 oxcarbazepine: Trileptal
 lamotrigine: Lamictal-best for
bipolar depression. May cause
severe rash.

Benzodiazepines
(Add to your outline)
Good for acute mania and psychomotor
agitation in mania
 Used in acute care settings; not for long
term tx.

clonazepam (Klonopin)
 lorazepam (Ativan)
