UNIT TWO
SEVERE MENTAL DISORDERS
CHAPTER TWO
MOOD (AFFECTIVE DISORDERS)
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B. BIPOLAR DISORDERS
 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
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 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
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 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
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 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
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 The disturbance is sufficiently severe to cause
marked impairment in occupational functioning
or in usual social activities or relationships with
others or to require 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
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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
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 The client may also have experienced episodes
of depression
 This diagnosis is further specified by the current
or most recent behavioral episode experienced:
 The specifier might be single manic episode
(to describe individuals having a first episode of
mania)
 Current episode manic, hypomanic, mixed,
or depressed (to describe individuals who have
had recurrent mood episodes).
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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
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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
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 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 12-month period. It
is used to indicate more severe symptoms such
as poorer global functioning, high recurrent risk,
and resistance to conventional somatic
treatments
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DSM-IV-TR Criteria for Bipolar Disorder
not in exam
 A distinct period of abnormality and persistently
elevated, expansive, or irritable mood for at
least:
 4 days for hypomania
 1 week for mania
 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:
 Inflated self-esteem or grandiosity
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 Decreased need for sleep (the person feels
rested after only 3 hours of sleep)
 More talkative than usual or pressure to keep
talking
 Flight of ideas or subjective experience that
thoughts are racing
 Distractibility (the person's attention is too easily
drawn to unimportant or irrelevant external
stimuli)
 Increase in goal-directed activity (either socially,
at work or school, or sexually) or psychomotor
agitation
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 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)
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MANIA
Definition
 Mania is an alteration in mood that is expressed
by feelings of elation, inflated self-esteem,
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
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 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
 The disturbance in mood and the change in
functioning are observed by others
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 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)
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TREATMENT OF BIPOLAR DISORDERS
MOOD-STABILIZING AGENTS
 Most commonly used Mood Stabilizers:
 Lithium carbonate: has been for many years the
drug of choice for treatment and management of
the mania phase of bipolar disorder
 Anticonvulsants: Valporic Acid, Carbamazepine,
Lamotrigine
 Calcium channel blockers: Verapamil
 Alpha-2 adrenergics (Colidine)
 Beta adrenergics (Propranolol)
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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.
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Planning/Implementation
 The plan of care should include monitoring for
side effects of therapy with mood-stabilizing
agents and intervening when required to prevent
the occurrence of adverse events related to
medication administration.
 Be aware of the side effects:
 Drowsiness, dizziness, and headache: Ensure
that client does not participate in activities that
require alertness, or operate dangerous
machinery.
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 Dry mouth; thirst: Provide sugarless candy, ice,
frequent sips of water. Ensure that strict oral
hygiene is maintained.
 GI upset; nausea/vomiting: Administer
medications with meals to minimize GI upset.
 Fine hand tremors: Report to physician, who
may decrease dosage. Some physicians
prescribe a small dose of beta blocker
Propranolol to counteract this effect.
 Hypotension; arrhythmias; pulse irregularities:
Monitor vital signs two or three times a day.
Physician may decrease dose of medication.
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 Polyuria; dehydration: May subside after initial
week or two. Monitor daily intake and output and
weight. Monitor skin turgor daily.
 Weight gain: Provide instructions for reduced
calorie diet. Emphasize importance of
maintaining adequate intake of sodium
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Lithium Toxicity
 The margin between the therapeutic and toxic
levels of lithium carbonate is very narrow.
 The usual ranges of therapeutic serum
concentrations are:
 For acute mania: 1.0 to 1.5 mEq/L
 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.
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 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, increasing
tremors, muscular irritability, psychomotor
retardation, mental confusion, giddiness.
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1. 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.
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 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.
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 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.
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 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.
 Carry a card or other identification noting that he
or she is taking lithium.
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 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.
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 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 self-administered
maintenance therapy. Keep appointments for
outpatient follow-up; have serum lithium level
checked every 1 to 2 months, or as advised by
physician.
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Outcome Criteria/Evaluation
 The following criteria may be used for evaluating
the effectiveness of therapy with moodstabilizing 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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