CHAPTER 6 :MOOD DISORDERS - BIPOLAR
INTRODUCATION

Bipolar disorder is a chronic, recurrent illness that needs a lifelong management

Bipolar disorder is characterized by mood swings from profound depression to
extreme euphoria (mania), with intervening periods of normalcy

It is marked by shifts in the individual's mood, energy, activities, and functions

Alternating mood episodes are characterized by mania, hypomania, depression, and
concurrent mania and depression (mixed episodes in which depressive symptoms
occur during a manic attack)

The lifetime prevalence of Bipolar Disorder in the USA is 1.2% - 1.6% but research
indicates that it could reach 3%

The disorder emerges between the ages of 18 and 30 and can go for years without
diagnosis

The first episode of the disorder in males is likely to be a manic episode and a
depressive episode in females

During the course of the illness, the episodes increase in number and severity as the
person gets older

Periods of normal functioning may alternate with periods of illness (highs, lows, or
mixed highs and lows)

Studies indicate that 30-60% of Bipolar sufferers fail to regain full occupational and
social functioning

Many of the Bipolar sufferers experience chronic interpersonal or occupational
difficulties during remission

It has both high mortality and high morbidity rates compared to Unipolar Disorders

It is associated with the highest lifetime rate of suicide of any psychiatric illness

Delusions or hallucinations may or may not be a part of the clinical picture

Onset of symptoms may reflect a seasonal pattern

During a manic episode, the mood is elevated, expansive, or irritable

The disturbance is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others or to require
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hospitalization to prevent harm to self or others.

Motor activity is excessive and frenzied (furious)

Psychotic features may be present

A milder representation of this clinical symptom picture is called hypomania

Hypomania is not severe enough to cause marked impairment in social or
occupational functioning or to require hospitalization, and it does not include
psychotic features
TYPES OF BIPOLAR DISORDERS:
1. Bipolar I Disorder

At least one episode of mania alternating with Major Depression

Bipolar I disorder is the diagnosis given to an individual who is experiencing, or has
experienced, a full syndrome of manic or mixed symptoms

Bipolar I Disorder is found to be more common among males than females

The client may also have experienced episodes of depression

This diagnosis is further specified by the current or most recent behavioral episode
experienced:
a) The specifier might be single manic episode (to describe individuals having a
first episode of mania)
b) Current episode manic, hypomanic, mixed, or depressed (to describe
individuals who have had recurrent mood episodes).
2. Bipolar II Disorder

Hypomanic episode(s) alternating with Major Depression

This diagnostic category is characterized by recurrent bouts of major depression
with episodic occurrence of hypomania

The individual who is assigned this diagnosis may present with symptoms (or
history) of depression or hypomania

Bipolar II Disorder is more common among Females
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
The client has never experienced an episode that meets the full criteria for mania or
mixed symptomatology

Patients with Bipolar II Disorder are more likely to become depressed in winter than
in summer, and are more likely to make suicidal attempt
3. Cyclothymia Disorder

Hypomanic episodes alternating with minor depressive episodes (for at least two
years in duration)

The essential feature of cyclothymic disorder is a chronic mood disturbance of at
least 2-year duration, involving numerous episodes of hypomania and depressed
mood of insufficient severity or duration to meet the criteria for bipolar I or bipolar
II disorders

The individual is never without hypomanic or depressive symptoms for more than 2
months

There is a 15% - 50% risk that an individual with Cyclothymia will subsequently
develop Bipolar I or Bipolar II Disorder

Cyclothymia usually begins in adolescence or early adulthood

Rapid Cycling refers to the patient who has four or more mood episodes in a 12month period. It is used to indicate more severe symptoms such as poorer global
functioning, high recurrent risk, and resistance to conventional somatic treatments
DSM-IV-TR Criteria for Bipolar Disorder
A. A distinct period of abnormality and persistently elevated, expansive, or irritable
mood for at least:

4 days for hypomania

1 week for mania
B. During the period of mood disturbance, three or more of the following symptoms
have persisted (four if the mood is only irritable) and have been present to a
significant degree:
1. Inflated self-esteem or grandiosity
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2. Decreased need for sleep (the person feels rested after only 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (the person's attention is too easily drawn to unimportant or
irrelevant external stimuli)
6. Increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for
painful consequences (the person engages in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
MANIA
Definition
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

Severe enough to cause marked impairment in occupational activities, usual social
activities, or relationships.

OR

Necessitate hospitalization to prevent harm to self or others, or there are psychotic
features

Symptoms are not due to direct physiological effects of substance (drug abuse,
medication) or general medical condition (hyperthyroidism)
HYPOMANIA

The episode is associated with an unequivocal (unmistakable) change in functioning
that is uncharacteristic of the person when not symptomatic
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
The disturbance in mood and the change in functioning are observed by others

Absence of marked impairment in social or occupational functioning

Hospitalization in not indicated

Symptoms are not due to direct physiological effects of substance (drug abuse,
medication or general medical condition)
TREATMENT OF BIPOLAR DISORDERS
MOOD-STABILIZING AGENTS

Most commonly used Mood Stabilizers:
1. Lithium carbonate: has been for many years the drug of choice for treatment and
management of the mania phase of bipolar disorder
2. Anticonvulsants: Valporic Acid, Carbamazepine, Lamotrigine
3. Calcium channel blockers: Verapamil
4. Alpha-2 adrenergics (Colidine)
5. Beta adrenergics (Propranolol)
Diagnosis
The following nursing diagnoses may be considered for clients receiving therapy with
mood-stabilizing agents:

Risk for injury related to manic hyperactivity.

Risk for self-directed or other-directed violence related to unresolved anger turned
inward on the self or outward on the environment.

Risk for injury related to lithium toxicity.

Risk for activity intolerance related to side effects of drowsiness and dizziness.
Planning/Implementation

The plan of care should include monitoring for side effects of therapy with moodstabilizing agents and intervening when required to prevent the occurrence of
adverse events related to medication administration.
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
Be aware of the side effects:
1) Drowsiness, dizziness, and headache: Ensure that client does not participate in
activities that require alertness, or operate dangerous machinery.
2) Dry mouth; thirst: Provide sugarless candy, ice, frequent sips of water. Ensure
that strict oral hygiene is maintained.
3) GI upset; nausea/vomiting: Administer medications with meals to minimize GI
upset.
4) Fine hand tremors: Report to physician, who may decrease dosage. Some
physicians prescribe a small dose of beta blocker propranolol to counteract this
effect.
5) Hypotension; arrhythmias; pulse irregularities: Monitor vital signs two or three
times a day. Physician may decrease dose of medication.
6) Polyuria; dehydration: May subside after initial week or two. Monitor daily
intake and output and weight. Monitor skin turgor daily.
7) Weight gain: Provide instructions for reduced calorie diet. Emphasize
importance of maintaining adequate intake of sodium
Lithium Toxicity

The margin between the therapeutic and toxic levels of lithium carbonate is very
narrow.

The usual ranges of therapeutic serum concentrations are:
o For acute mania: 1.0 to 1.5 mEq/L
o For maintenance: 0.6 to 1.2 mEq/l

Serum lithium levels should be monitored once or twice a week after initial
treatment until dosage and serum levels are stable, then monthly during
maintenance therapy. Blood samples should be drawn 12 hours after the last dose.

Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L
and are dosage determinate. Symptoms include:
1) At serum levels of 1.5 to 2.0 mEq/L: Blurred vision, ataxia, tinnitus, persistent
nausea and vomiting, severe diarrhea.
2) At serum levels of 2.0 to 3.5 mEq/L: Excessive output of dilute urine,
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increasing tremors, muscular irritability, psychomotor retardation, mental
confusion, giddiness.
3) At serum levels above 3.5 mEq/L: Impaired consciousness, nystagmus,
seizures, coma, oliguria/ anuria, arrhythmias, myocardial infarction,
cardiovascular collapse.

Lithium levels should be monitored prior to medication administration.

The dosage should be withheld and the physician notified if the level reaches 1.5
mEq/L or at the earliest observation or report by the client of even the mildest
symptom.

If left untreated, lithium toxicity can be life threatening.

Lithium is similar in chemical structure to sodium, behaving in the body in much the
same manner and competing at various sites in the body with sodium.

If sodium intake is reduced or the body is depleted of its normal sodium (e.g., due to
excessive sweating, fever, or diuresis), lithium is reabsorbed by the kidneys,
increasing the possibility of toxicity.

Therefore, the client must consume a diet adequate in sodium as well as 2500 to
3000 ml of fluid per day.

Accurate records of intake, output, and client’s weight should be kept on a daily
basis.
Client/Family Education (for Lithium)

Take medication on a regular basis, even when feeling well. Discontinuation can
result in return of symptoms.

Not drive or operate dangerous machinery until lithium levels are stabilized.
Drowsiness and dizziness can occur.

Not skimp on dietary sodium intake. He or she should choose foods from the food
pyramid and avoid “junk” foods. The client should drink six to eight large glasses of
water each day and avoid excessive use of beverages containing caffeine (coffee, tea,
colas), which promote increased urine output.

Notify the physician if vomiting or diarrhea occurs. These symptoms can result in
sodium loss and an increased risk of toxicity.
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
Carry a card or other identification noting that he or she is taking lithium.

Be aware of appropriate diet should weight gain become a problem. Include
adequate sodium and other nutrients while decreasing the number of calories.

Be aware of risks of becoming pregnant while receiving lithium therapy. Use
information furnished by health care providers regarding methods of contraception.
Notify the physician as soon as possible if pregnancy is suspected or planned.

Be aware of side effects and symptoms associated with toxicity. Notify the physician
if any of the following symptoms occur: persistent nausea and vomiting, severe
diarrhea, ataxia, blurred vision, tinnitus, excessive output of urine, increasing
tremors, or mental confusion.

Refer to written materials furnished by health care providers while receiving selfadministered maintenance therapy. Keep appointments for outpatient follow-up;
have serum lithium level checked every 1 to 2 months, or as advised by physician.
Outcome Criteria/Evaluation
The following criteria may be used for evaluating the effectiveness of therapy with
mood-stabilizing agents:

Patient Is maintaining stability of mood.

Has not harmed self or others.

Has experienced no injury from hyperactivity.

Is able to participate in activities without excessive sedation or dizziness.

Is maintaining appropriate weight.

Exhibits no signs of lithium toxicity.
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