Bipolar Disorders
Diagnostic Terminology
 Bipolar
Disorder
Bipolar I
 Bipolar II
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Old terminology
 Manic-Depressive
 Bipolar Affective Disorder
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
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Types of Bipolar Disorder
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Bipolar I (many subtypes)
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Bipolar II
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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
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Episodes of hypomania and numerous periods
of depressed mood
Chronic: Never symptom free
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Symptoms of HYPOMANIA
Similar to Mania But to a Lesser
Degree
Energetic and driven
Excitable
Overbearing
Highly sociable
Intense and volatile emotions
Seductive
Overspends
Motivates others
May be highly productive
No delusions or hallucinations
Hypomania Article NY Times 9/19/10
http://www.nytimes.com/2010/09/19/business/19entre.html?_r=1&scp=1&sq=just%20manic%20Enough&st=Search
Signs/Symptoms of MANIA
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Mood/affect: Euphoric, Labile, Hostile
Activity: Hyperactive
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Thought Processes: Disturbed
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Unable to concentrate, flight of ideas, tangential
Psychotic thought content
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Too busy to eat or sleep
Disorganized activity
Delusions: of grandeur or paranoid
Hallucinations
Pressured speech; hyperverbal
Poor judgment and impulse control: with money, sex,
any pleasure
Loud clothing, excessive make-up
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
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FYI: The Harvard Bipolarity Index
and “Bipolar Spectrum Disorder”
www.psycheducation.org
Manic Behaviors that Result in
Altered Relationships
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Manipulation
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Ability to find vulnerability in others
 Exploit weaknesses and create conflict
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Ability to shift responsibility
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Limit testing
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Alienation of family--may be aggressive
and abusive
Etiology: Biologic Theories
Ion dysregulation: causes oversensitivity of
neuron to stimuli
 Alteration in transcription of messengers in
nerve cell nucleus
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Neurotransmitters involved in mania/bipolar:
 Excessive Dopamine and Norepinephrine
  availability of GABA and Serotonin
Nursing Diagnoses (for Mania)
Risk for Violence (Directed toward self,
others)
 Insomnia
 Altered Nutrition: Less than Body
Requirements
 Acute Confusion
 Disturbed Thought Processes
 Impaired Social Interaction
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Psychotherapeutic
Management
(Focus of presentation is
primarily on management of
mania except where otherwise
noted)
Nurse-Client Relationship and
Milieu Management
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Matter-of-Fact Tone
Clear, concise directions
Limit Setting
De-escalating the client
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Maintaining Safety
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Consistency among staff
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Reduction of environmental stimuli
Milieu Management, cont’d
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Reinforcing appropriate hygiene and dress
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Supporting adequate Nutrition and Sleep
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Providing activities for excessive energy
PSYCHOTHERAPEUTIC
MANAGEMENT:
MEDICATIONS
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
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Lithium Toxicity
Narrow therapeutic range: therapeutic
dose is close to a toxic dose.
 Mild to Moderate toxic reactions:
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1.5 to 2 mEq/L
 Diarrhea
 Vomiting
 Drowsiness
 Muscular weakness
 Lack of coordination
 Dry mouth
Lithium Toxicity
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Moderate to Severe reactions
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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
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Side effects: many drug interactions; CNS effects;
blood disorders ( RBC, bone marrow, WBC’s), liver
failure; toxic reactions common
Other Anticonvulsants
topiramate: Topamax
 gabapentin: Neurontin
 oxcarbazepine: Trileptal
 lamotrigine: Lamictal-best for bipolar
depression. May cause severe rash.
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Benzodiazepines
Good for acute mania and psychomotor
agitation in mania
 Used in acute care settings; not for long
term tx.
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clonazepam (Klonopin)
 lorazepam (Ativan)
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Nursing Implications: Lithium
What will the nurse do if a patient shows
behaviors/symptoms of what looks like
lithium toxicity?
A. Stop/hold the medication
B. Draw a lithium level, then hold the
medication
C. Stop/hold med., then draw a lithium level
D. Draw a lithium level, keep giving the
med. until results are in.
Nursing Implications: Mood
Stabilizing Medications
What are nursing interventions for the client
a) starting on, or b) being maintained on
Lithium?
-Labs
-Other testing
-Ongoing assessments
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What client teaching would the nurse
perform for the client, family?