Chapter 26
Bipolar and Related Disorders
Copyright © 2014. F.A. Davis Company
Introduction
• Mood is defined as a pervasive and sustained
emotion that may have a major influence on a
person’s perception of the world.
• Examples of mood: depression, joy, elation,
anger, anxiety
• Affect is described as the emotional reaction
associated with an experience.
Copyright © 2014. F.A. Davis Company
Introduction (cont.)
• Mania is an alteration in mood that is
expressed by feelings of elation, inflated selfesteem, grandiosity, hyperactivity, agitation,
and accelerated thinking and speaking.
• Mania can occur as a biological (organic) or
psychological disorder or as a response to
substance use or a general medical condition.
Copyright © 2014. F.A. Davis Company
Introduction (cont.)
• Bipolar disorder is characterized by mood
swings from profound depression to
extreme euphoria (mania) with intervening
periods of normalcy.
• Delusions or hallucinations may or may not
be part of clinical picture.
• Onset of symptoms may reflect seasonal
pattern.
• A somewhat milder form of mania is called
hypomania.
Copyright © 2014. F.A. Davis Company
Historical Perspective
• Documentation of the symptoms associated
with bipolar disorder dates back to the
second century in Greece.
• In early writings, mania was categorized with
all forms of “severe madness.”
Copyright © 2014. F.A. Davis Company
Historical Perspective (cont.)
• The modern concept of manic-depressive
illness began to emerge in the 19th century
with terms such as “dual-form insanity” and
“circular insanity.”
• The term manic depressive was first coined in
1913, and the American Psychiatric
Association adopted the term bipolar disorder
in 1980.
Copyright © 2014. F.A. Davis Company
Epidemiology
• Bipolar disorder affects approximately 5.7 million
American adults.
• Gender incidence is roughly equal: The ratio of
women to men is about 1.2 to 1.
• The average age at onset is the early 20s.
• It is more common in single than in married persons.
• It occurs more often in the higher socioeconomic
classes.
• It is the sixth leading cause of disability in the
middle-age group.
Copyright © 2014. F.A. Davis Company
Types of Bipolar Disorders
• Bipolar I Disorder
– Client is experiencing, or has
experienced, a full syndrome of manic or
mixed symptoms.
– Client may also have experienced
episodes of depression.
Copyright © 2014. F.A. Davis Company
Types of Bipolar Disorders (cont.)
• Bipolar II Disorder
– Characterized by bouts of major depression
with episodic occurrence of hypomania
– Has never met criteria for full manic episode
Copyright © 2014. F.A. Davis Company
Types of Bipolar Disorders (cont.)
• Cyclothymic Disorder
– Chronic mood disturbance
– At least 2-year duration
– Numerous episodes of hypomania and depressed
mood of insufficient severity to meet the criteria
for either bipolar I or II disorder
Copyright © 2014. F.A. Davis Company
Types of Bipolar Disorders (cont.)
• Substance-Induced Bipolar Disorder
– A disturbance of mood (depression or mania)
that is considered to be the direct result of
the physiological effects of a substance (e.g.,
ingestion of or withdrawal from a drug of
abuse or a medication or other treatment).
Copyright © 2014. F.A. Davis Company
Types of Bipolar Disorders (cont.)
• Bipolar Disorder Associated with Another
Medical Condition
– Characterized by an abnormally and
persistently elevated, expansive, or irritable
mood and excessive activity or energy that is
judged to be the result of direct physiological
effects of another medical condition.
Copyright © 2014. F.A. Davis Company
Types of Bipolar Disorders (cont.)
1. A suicidal client, with a history of manic behavior, is
admitted to the ED. The client’s diagnosis is
documented as bipolar I disorder: current episode
depressed. What is the rationale for this diagnosis
instead of a diagnosis of major depressive disorder?
A. The physician does not believe the client is suffering
from major depression.
B. The client has experienced a manic episode in the
past.
C. The client does not exhibit psychotic symptoms.
D. There is no history of major depression in the client's
family.
Copyright © 2014. F.A. Davis Company
Types of Bipolar Disorders (cont.)
• Correct answer: B
– The client’s past history of mania and current
suicide attempt support the diagnosis of bipolar I
disorder: current episode depressed. According to
the DSM-5 criteria, a manic episode rules out the
diagnosis of major depressive disorder.
Copyright © 2014. F.A. Davis Company
Predisposing Factors
• Biological Theories
– Genetics
• Twin and family studies
• Other genetic studies
– Biochemical influences
• Possible excess of norepinephrine and dopamine
Copyright © 2014. F.A. Davis Company
Predisposing Factors (cont.)
• Biological Theories (cont.)
– Physiological Influences
• Brain lesions
• Enlarged ventricles
• Medication side effects
Copyright © 2014. F.A. Davis Company
Predisposing Factors (cont.)
• Psychosocial Theories
– Credibility of psychosocial theories has
declined in recent years.
– Bipolar disorder is viewed as a disease of the
brain.
Copyright © 2014. F.A. Davis Company
Predisposing Factors (cont.)
• The Transactional Model
Bipolar disorder most likely results from an
interaction between genetic, biological, and
psychosocial determinants.
Copyright © 2014. F.A. Davis Company
Developmental Implications
• Childhood and Adolescence
– Lifetime prevalence of pediatric and adolescent
bipolar disorders is estimated at about 1 percent.
– Diagnosis is difficult.
– Guidelines for diagnosis and treatment have been
developed by the Child and Adolescent Bipolar
Foundation (CABF).
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– The CABF recommends the use of FIND
(frequency, intensity, number, and duration) in
making a diagnosis of bipolar disorder in children
and adolescents.
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– FIND:
• Frequency: Symptoms occur most days in a week.
• Intensity: Symptoms are severe enough to cause
extreme disturbance.
• Number: Symptoms occur 3 or 4 times a day.
• Duration: Symptoms last for 4 or more hours a
day.
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– Symptoms include:
• Euphoric/expansive mood: extremely happy, silly, or
giddy
• Irritable mood: hostility and rage, often over trivial
matters
• Grandiosity: Believes abilities to be better than
everyone else’s.
• Decreased need for sleep: May sleep for only 4 or 5
hours per night and wake up feeling rested.
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– Symptoms (cont.):
•
•
•
•
Pressured speech: loud, intrusive, difficult to interrupt
Racing thoughts: Rapid change of topics.
Distractibility: Unable to focus on school lessons.
Increase in goal-directed activity/psychomotor
agitation: Activities become obsessive. Increased
psychomotor agitation.
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– Symptoms (cont.):
• Excessive involvement in pleasurable or risky activities:
Exhibits behavior that has an erotic, pleasure-seeking
quality about it.
• Psychosis: May experience hallucinations and
delusions.
• Suicidality: May exhibit suicidal behavior during a
depressed or mixed episode or when psychotic.
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– Treatment strategies
• Psychopharmacology
– Lithium
– Divalproex
– Carbamazepine
– Atypical antipsychotics
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– Treatment strategies (cont.)
• ADHD is most common comorbid condition.
• ADHD agents may exacerbate mania and should be
administered only after bipolar symptoms have been
controlled.
Copyright © 2014. F.A. Davis Company
Developmental Implications (cont.)
• Childhood and Adolescence (cont.)
– Treatment strategies (cont.)
• Family Interventions
– Psychoeducation about bipolar disorder
– Communication training
– Problem-solving skills training
Copyright © 2014. F.A. Davis Company
Nursing Process/Assessment
• Symptoms may be categorized by degree of
severity.
– Stage I: Hypomania
Symptoms not sufficiently severe to cause marked
impairment in social or occupational functioning
or to require hospitalization
• Cheerful mood
• Rapid flow of ideas, heightened perception
• Increased motor activity
Copyright © 2014. F.A. Davis Company
Nursing Process/Assessment (cont.)
– Stage II: Acute mania
Marked impairment in functioning; usually
requires hospitalization
•
•
•
•
•
•
Elation and euphoria, a continuous “high”
Flight of ideas, accelerated, pressured speech
Hallucinations and delusions
Excessive psychomotor activity
Social and sexual inhibition
Little need for sleep
Copyright © 2014. F.A. Davis Company
Nursing Process/Assessment (cont.)
– Stage III: Delirious mania
A grave form of the disorder characterized by an
intensification of the symptoms associated with
acute mania. The condition is rare since the
advent of antipsychotic medication.
•
•
•
•
Labile mood, panic anxiety
Clouding of consciousness, disorientation
Frenzied psychomotor activity
Exhaustion and possibly death without intervention
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis
• Risk for Injury related to:
– Extreme hyperactivity, increased agitation,
and lack of control over purposeless and
potentially injurious movements
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis (cont.)
• Risk for Violence: Self-directed or otherdirected related to:
– Manic excitement
– Delusional thinking
– Hallucinations
– Impulsivity
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis (cont.)
• Imbalanced Nutrition less than body
requirements related to:
– Refusal or inability to sit still long enough to
eat, evidenced by loss of weight,
amenorrhea
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis (cont.)
• Disturbed thought processes related to:
– Biochemical alterations in the brain,
evidenced by delusions of grandeur and
persecution and inaccurate interpretation of
the environment
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis (cont.)
• Disturbed sensory perception related
to:
– Biochemical alterations in the brain and to
possible sleep deprivation, evidenced by
auditory and visual hallucinations
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis (cont.)
• Impaired Social Interaction related to:
– Egocentric and narcissistic behavior
• Insomnia related to:
– Excessive hyperactivity and agitation
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis (cont.)
2. In the initial stages of caring for a client
experiencing an acute manic episode, what
should the nurse consider to be the priority
nursing diagnosis?
A. Risk for injury related to excessive hyperactivity
B. Disturbed sleep pattern related to manic
hyperactivity
C. Imbalanced nutrition, less than body
requirements related to inadequate intake
D. Situational low self-esteem related to
embarrassment secondary to high-risk behaviors
Copyright © 2014. F.A. Davis Company
Nursing Diagnosis (cont.)
• Correct answer: A
– According to Maslow’s hierarchy of needs,
maintaining client safety is always a priority. The
impulsiveness and hyperactivity seen in clients
diagnosed with acute mania puts them at risk for
injury.
Copyright © 2014. F.A. Davis Company
Criteria for Measuring Outcomes
• The Client:
– Exhibits no evidence of physical injury
– Has not harmed self or others
– Is no longer exhibiting signs of physical agitation
– Eats a well-balanced diet with snacks to prevent
weight loss and maintain nutritional status
– Verbalizes an accurate interpretation of the
environment
– Verbalizes that hallucinatory activity has ceased
and demonstrates no outward behavior
indicating hallucinations
Copyright © 2014. F.A. Davis Company
Criteria for Measuring Outcomes
(cont.)
• The Client (cont.):
– Accepts responsibility for own behaviors
– Does not manipulate others for gratification of
own needs
– Interacts appropriately with others
– Is able to fall asleep within 30 minutes of retiring
– Is able to sleep 6 to 8 hours per night
Copyright © 2014. F.A. Davis Company
Planning/Implementation
• Nursing interventions are aimed at:
– Protection from injury due to hyperactivity
– Protection from harm to self or others
– Restoration of nutritional status
– Progression toward resolution of the grief process
– Improvement in interactions with others
– Acquiring sufficient rest and sleep
Copyright © 2014. F.A. Davis Company
Client/Family Education
• Nature of the Illness
–
–
–
–
Causes of bipolar disorder
Cyclic nature of the illness
Symptoms of depression
Symptoms of mania
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Management of the Illness
– Medication management
– Assertive techniques
– Anger management
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Support Services
– Crisis hotline
– Support groups
– Individual psychotherapy
– Legal/financial assistance
Copyright © 2014. F.A. Davis Company
Evaluation
• Evaluation of the effectiveness of the
nursing interventions is measured by
fulfillment of the outcome criteria.
Copyright © 2014. F.A. Davis Company
Evaluation (cont.)
• Has the client avoided personal injury?
• Has violence to client or others been
prevented?
• Has agitation subsided?
• Have nutritional status and weight been
stabilized?
• Have delusions and hallucinations ceased?
Copyright © 2014. F.A. Davis Company
Evaluation (cont.)
• Is the client able to make decisions about own
self-care?
• Is behavior socially acceptable?
• Is the client able to sleep 6 to 8 hours per
night and awaken feeling rested?
• Does the client understand the importance of
maintenance medication therapy?
Copyright © 2014. F.A. Davis Company
Treatment Modalities for Bipolar
Disorder
•
•
•
•
Individual Psychotherapy
Group Therapy
Family Therapy
Cognitive Therapy
Copyright © 2014. F.A. Davis Company
Treatment Modalities for Bipolar
Disorder (cont.)
• The Recovery Model
– Learning how to live a safe, dignified, full,
and self-determined life in the face of the
enduring disability which may, at times, be
associated with serious mental illness.
Copyright © 2014. F.A. Davis Company
Treatment Modalities for Bipolar
Disorder (cont.)
• The Recovery Model (cont.)
– In bipolar disorder, recovery is a continuous
process.
• Client identifies goals.
• Client and clinician develop a treatment plan.
• Client and clinician work on strategies to help the
individual manage the bipolar illness.
• Clinician serves as support person to help the
individual achieve the previously identified goals.
Copyright © 2014. F.A. Davis Company
Treatment Modalities for Bipolar
Disorder (cont.)
• The Recovery Model (cont.)
– Although there is no cure for bipolar disorder,
recovery is possible in the sense of learning to
prevent and minimize symptoms, and to
successfully cope with the effects of the illness
on mood, career, and social life.
Copyright © 2014. F.A. Davis Company
Treatment Modalities for Bipolar
Disorder (cont.)
• Electroconvulsive Therapy
– Episodes of mania may be treated with ECT when:
• Client does not tolerate medication.
• Client fails to respond to medication.
• Client’s life is threatened by dangerous behavior or
exhaustion.
Copyright © 2014. F.A. Davis Company
Psychopharmacology
• For mania:
– Lithium carbonate
– Anticonvulsants
– Verapamil
– Antipsychotics
• For depressive phase:
– Use antidepressants with care (may trigger
mania).
Copyright © 2014. F.A. Davis Company
Psychopharmacology (cont.)
• Mood-Stabilizing Agents
– Indications: prevention and treatment
of manic episodes associated with
bipolar disorder
– Examples: lithium carbonate, clonazepam,
carbamazepine, valproic acid, lamotrigine,
topiramate, oxcarbazepine, verapamil,
antipsychotics
Copyright © 2014. F.A. Davis Company
Psychopharmacology (cont.)
• Mood-Stabilizing Agents (cont.)
– Action:
• Lithium
– May modulate the effects of certain
neurotransmitters such as norepinephrine,
serotonin, dopamine, glutamate, and GABA,
thereby stabilizing symptoms associated with
bipolar disorder
– The action of anticonvulsants, verapamil, and
atypical antipsychotics in the treatment of
bipolar disorder is not fully understood.
Copyright © 2014. F.A. Davis Company
Psychopharmacology (cont.)
– Side effects
• Monitor for side effects of lithium:
– Drowsiness, dizziness, headache
– Dry mouth, thirst, GI upset, nausea/vomiting
– Fine hand tremors
– Hypotension, arrhythmias, pulse irregularities
– Polyuria, dehydration
– Weight gain
– Potential for toxicity
Copyright © 2014. F.A. Davis Company
Psychopharmacology (cont.)
– Lithium toxicity
• Therapeutic range
– 1.0 to 1.5 mEq/L (acute mania)
– 0.6 to 1.2 mEq/L (maintenance)
• Initial symptoms of toxicity include
– Blurred vision, ataxia, tinnitus, persistent nausea
and vomiting, and severe diarrhea
• Ensure that client consumes adequate sodium and
fluid in diet
Copyright © 2014. F.A. Davis Company
Psychopharmacology (cont.)
– Side effects (cont.)
• Monitor for side effects of anticonvulsants:
– Nausea and vomiting
– Drowsiness, dizziness
– Blood dyscrasias
– Prolonged bleeding time (with valproic acid)
– Risk of severe rash (with lamotrigine)
– Decreased efficacy of oral contraceptives (with
topiramate)
– Risk of suicide with all antiepileptic drugs (FDA
warning, December 2008)
Copyright © 2014. F.A. Davis Company
Psychopharmacology (cont.)
– Side effects (cont.)
• Monitor for side effects of verapamil:
– Drowsiness, dizziness
– Hypotension, bradycardia
– Nausea
– Constipation
Copyright © 2014. F.A. Davis Company
Psychopharmacology (cont.)
– Side effects (cont.)
• Monitor for side effects of antipsychotics:
– Drowsiness, dizziness
– Dry mouth, constipation
– Increased appetite, weight gain
– ECG changes
– Extrapyramidal symptoms
– Hyperglycemia and diabetes
Copyright © 2014. F.A. Davis Company
Client/Family Education
• Lithium
– Take the medication regularly.
– Do not skimp on dietary sodium.
– Drink 6 to 8 glasses of water each day.
– Notify physician if vomiting or diarrhea occur.
– Have serum lithium level checked every 1 to 2
months or as advised by physician.
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Lithium (cont.)
– Notify physician if any of the following symptoms
occur:
•
•
•
•
•
•
•
•
Persistent nausea and vomiting
Severe diarrhea
Ataxia
Blurred vision
Tinnitus
Excessive output of urine
Increasing tremors
Mental confusion
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Anticonvulsants
– Refrain from discontinuing the drug abruptly.
– Report the following symptoms to the physician
immediately: skin rash, unusual bleeding,
spontaneous bruising, sore throat, fever, malaise,
dark urine, and yellow skin or eyes.
– Avoid using alcohol and over-the-counter
medications without approval from physician.
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Verapamil
– Do not discontinue the drug abruptly.
– Rise slowly from sitting or lying position to
prevent sudden drop in blood pressure.
– Report the following symptoms to physician:
•
•
•
•
•
Irregular heart beat, chest pain
Shortness of breath, pronounced dizziness
Swelling of hands and feet
Profound mood swings
Severe and persistent headache
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Antipsychotics
– Do not discontinue drug abruptly.
– Use sunblock lotion when outdoors.
– Rise slowly from a sitting or lying position.
– Avoid alcohol and over-the-counter medications.
– Continue to take the medication, even if feeling
well and as though it is not needed. Symptoms
may return if medication is discontinued.
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Antipsychotics (cont.)
– Report the following symptoms to physician:
• Sore throat, fever, malaise
• Unusual bleeding, easy bruising, skin rash
• Persistent nausea and vomiting
• Severe headache, rapid heart rate
• Difficulty urinating or excessive urination
• Muscle twitching, tremors
• Darkly colored urine, pale stools
• Yellow skin or eyes
• Excessive thirst or hunger
• Muscular incoordination or weakness
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
3. A client, who is prescribed lithium
carbonate, is being discharged from
inpatient care. Which medication
information should the nurse teach this
client?
A. Do not skimp on dietary sodium intake.
B. Have serum lithium levels checked every six
months.
C. Limit fluid intake to 1000 ml of fluid per day.
D. Adjust the dose if you feel out of control.
Copyright © 2014. F.A. Davis Company
Client/Family Education (cont.)
• Correct answer: A
– Clients taking lithium should consume a diet
adequate in sodium and drink 2500 to 3000 ml of
fluid per day. Lithium is a salt and competes in the
body with sodium. If sodium is lost, the body will
retain lithium with resulting toxicity. Maintaining
normal sodium and fluid levels is critical to
maintaining therapeutic levels of lithium and
preventing toxicity.
Copyright © 2014. F.A. Davis Company