Mary Bittle, PhD, RN, LMFTA

• Recognize characteristics of bipolar disorders.
• Differentiate DSM-IV-TR and DSM-V characteristics, effective 1/1/14.
• Differentiate between mania and hypomania
• Recognize contributing factors of genetics and brain chemistry.
• Recognize common treatments
• Recognize challenges of managing
• Recognize famous people who have/had
• Acknowledge people with successful management can lead successful lives

• Disturbances of mood that significantly interfere with the daily functioning of an individual. DSM IV-TR mood DO. DSM V places in separate category
• Two types: Bipolar I and Bipolar II
• 19 th century called manic-depressive, no longer a correct term.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th
American Psychiatric Publishing.
ed. ). Washington D.C.:

• Prevalence: 2.6%
• Classified Severe: 82.9% (2.6%) = 2.2%
National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults.
Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
• Some 10 million people
National Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf

A. Must have at least one manic episode lasting at least 1 week
B. During manic episode must have 3 or more out of 7 behavioral manifestations of mania(next slide)
C. Major impairment in life functioning
D. Cannot be explained by medications or drugs for another medical condition
May also be followed or preceded by hypomania and/or major depression. Hypomania/MD not necessary for BPI DO.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American
Psychiatric Publishing.

1. Grandiosity, increased self esteem
2. Insomnia
3. Pressured or continuous talking
4. Expresses that thoughts are racing or expressed thoughts jump rapidly from one topic to another, called flight of ideas
5. Distractibility
6. Increase in goal-directed or non-goal-directed activity, called psychomotor activity
7. Activities are of increased risk: pain, excessive spending, hypersexuality…
May include psychotic behavior
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric
Publishing.

Same as for mania except:
A. Lasts at least 4 days
B. Uncharacteristic for usual behaviors of the person
C. Others notice the increased/expansive behaviors
D. Not severe enough for major impairment in life functioning
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

• Typical age of onset ~18 years old
• Prevalence:
– US 0.6%
– 11 other countries 0.0% - 0.6%
• Male to female occurrence 1.1:1
• More common in countries with higher incomes
• Higher rates in separated, widowed
• Suicide risk 15 X that of general population
• 36.3% Lifetime risk
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ).
Washington D.C.: American Psychiatric Publishing.

Same as Bipolar I EXCEPT:
A. Elevated mood of at least 4 days.
B. Not characteristic of person
C. Observable by others
D. Does not significantly interfere with functioning nor require hospitalization
Must include at least one major depressive episode, present or past
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

• Common impulsive behaviors troublesome.
• Suicide ideation and risk increased
– 1/3 have suicide attempt in lifetime, 32.4 %
– Use more lethal means , so success greater
• Substance abuse
• Value of increased creativity leads to denial and aversion to treatment
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

• Prevalence
– 0.8% US
– 0.3% Internationally
• Typical age for development mid 20s
• Usually begins with a depressive episode
• Once there is ever a hypomanic episode, DX = BP II and not MDD
• More lifetime episodes than BP I
• May be rapid cycling, females more likely, poorer prognosis
• Once there is a manic episode, DX changes to BP I
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.


Mania _____________________________________
Hypomania _____________________________________
Normal Mood -
Eupnea
_____________________________________
Dysthymic
Cyclothymic
_____________________________________
Depressed _____________________________________

Bipolar I
1 week elevated mood
3/7 characteristics (4 if mood irritable)
Marked impairment ADLs
Psychosis when present defines BP I
May have major depression
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders. (5 th
American Psychiatric Publishing. ed. ). Washington D.C.:
Bipolar II
4 days elevated mood
3/7 Characteristics (4 if mood irritable)
ADLs NOT markedly affected.
Hospitalization not necessary.
Behaviors noted by others
Must include Major
Depression

• 296. for Bipolar I
• Codes following decimal:
– Mild, Moderate, Severe
– Most current episode Mania, Hypomania,
Depressed
– Psychotic feature present
– Partial or Full Remission
• 296.89 for Bipolar II
– Further modifiers are written in words
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

A. For at least a period of 2 weeks, 5 of 9 symptoms (next slide) have occurred.
Depressed mood or anhedonia (loss of pleasure)
Represents change from usual.
The symptoms are not due to another medical condition.
B. Major impairment in life functioning/distress
C. Not due to another medical condition or effects of a substance
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

1. Depressed mood (sadness, emptiness, hopelessness, crying) most all day, most every day.
2. No or nearly no interest in pleasure or activities, most all day, most every day. (Anhedonia)
3. Significant loss of appetite with unplanned weight loss (=/>5%)
4. Too much or too little sleep, insomnia or hypersomnia
5. Significant activity slowing or irritability
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

6. Continuous low energy and/or fatigue
7. Feeling of excessive guilt (may be delusional) or worthlessness.
8. Less ability to concentrate or make decisions most all day, most every day.
9. Thoughts of death: suicidal ideation with or without a plan
The above may be subjective or observed by others. The above may not be normal reactions to significant loss
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

Major depressive SX are the most common first presentation for which people with BP II disorder seek medical attention, particularly hospitalization.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

• Thoughts of
– Death
– Wanting relief
– The world will be better off w/o me
– Significant others will be better off w/o me
• Contemplation
– Plan
– Means and lethality
– Energy with which to carry out

• Verbalizing the future w/o oneself
• Giving things away
• Threats
ALWAYS take any clue to suicide seriously.
• ADDRESS person openly
• Do want to harm yourself?
• Do you have a plan?
• What is you plan?
• Notify significant others and /or authorities
• Offer HOPE.
• Things NOT to say: guilt, shame, false reassurance, can
“snap out of it.”

• Research does not support effectiveness of
“Suicide Contracts.”
American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors . American Journal of Psychiatry, 160(11Suppl.),
1-60.
• Use written “Plan for Life” (positive approach)
– When I feel______________ (describe)
– I will ___________________ (activities)
– I will call ________________ (support persons)
– I will call ________________ (Suicide Contact ph. #s, 911)

BPI may have psychotic features
Psychoses of BPD are usually of the type of
Delusions – strongly held/fixed beliefs that defy evidence or reality
Examples: grandiosity, persecutory, referential, erotomanic, somatic, nihilistic….
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington
D.C.: American Psychiatric Publishing.

• People who have mania or hypomania frequently do not recognize/deny that their behaviors are abnormal.
• They may enjoy their elevated moods.
• They may value ability to accomplish goals.
• If behaviors are serious enough, persons may have to be hospitalized. Usually they are resistant to hospitalization resulting in involuntary admission.
• Behaviors, particularly delusional, may result in illegal transgressions.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.

• Drug and Substance use, abuse, and addictions are common
– Alcohol
– Marijuana
• Persons desperately want to relieve symptoms

• Familial
– Relatives of those with Bipolar Disorders are more likely to have. 10X the risk.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ). Washington D.C.: American Psychiatric Publishing.
-Both parents: 50-75% chance for children; one parent 27%
-Identical Twins 78-80% concordance
-Familial Twins 17-19% Concordance
Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
- White matter reduction
Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J Psychiatry 2013;170:1317-1325
• Multiple genes involved
– Polymorphisms at the G72/G30 gene locus, on L13q33
Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder in two independent pedigree series. American Journal of Human
Genetics, 72(5), 1131-1140.
•
– Corticotropin receptor and subunit of G protein genes on C-18
Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
• Environmental

• Brain areas: prefrontal cortex (executive function),medial temporal lobe (memory functions), via PET & MRI evidence
• Neurotransmitters: norepinephrine, dopamine, serotonin
- decreased availability associated with mood lowering
• Endocrine – thyroid:
– Low thyroid– risk for depression , and rapid cycling
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis, MO. Saunders. 359-393.

• Medications
• Talk or Psychotherapy
• Electroconvulsive Therapy (ECT)
Every person is different with presentation of
BPD. Since multiple causal and environmental factors are involved, the management is challenging and often takes much trial and error and readjustment.

• ~48.8% receive
• ~38.8% minimally adequate
National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults. Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
Parody of psychiatric and medical treatment access could increase these

Mood Stabilizers
• Lithium is classic (Eskalith or Lithobid)
– Long term necessary
– Therapeutic and toxic levels are close
– Lab tests closely monitor levels
– Acts like salt, so balance /w table salt important
– Decreased levels of salt can raise levels of lithium
– Can cause dry mouth, sensitivity to cold, muscle/joint pain, brittle nails/hair, acne, indigestion, restlessness
– Need monitoring of kidney and thyroid function
National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical Approach. St. Louis,
MO. Saunders. 359-393.

Mood Stabilizers
Anticonvulsants - FDA approved
• Valproic acid or divalproex sodium (Depakote)
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topamax)
• Oxcarbazepine (Trileptal)
National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical
Approach. St. Louis, MO. Saunders. 359-393.

Mood Stabilizers
Side and/or Untoward Effects
• Warnings of increased risk for suicide
• GI: Diarrhea/constipation/heartburn
• Nasal: Stuffy/runny nose
• Neuro: Headache, drowsiness/dizziness
• Potentially fatal skin rash from
Lamotrigine (Stevens-Johnson syndrome)
• Young women & Valproic acid, risk for polycystic ovaries/birth defects
National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A
Clinical Approach. St. Louis, MO. Saunders. 359-393.

Having Bipolar Disorders are serious life altering challenges to individuals who have them and to their families.
Can be managed successfully to have productive life.
Requires tremendous insight in individual and supportive understanding by those closest to them .

• Vivien Leigh
• Carrie Fisher
• Jean-Claude Van
Damme
• Linda Hamilton
• Sinéad O'Connor
• Vincent van Gogh
• Virginia Woolf
• Jane Pauley
• Mariette Hartley
• Catherine Zeta-Jones
Bhatia, J. (2011). 10 Famous people with bipolar disorder: The price of fame? Retrieved 11/14/13 from http://www.everydayhealth.com/bipolardisorder-pictures/famous-people-with-bipolardisorder.aspx#/slide-1

A • Jack Nicholson • Macy Gray
• Jim Carey • Jimi Hendrix
• Rowan Atkinson • Madonna
• Robert Pattinson • Buzz Aldrin
• Ben Stiller • Abraham Lincoln
• Hugh Laurie • Charley Pride
• Craig Manning • Kristy McNichol
• Rapper "DMX'“ • Connie Francis
• Kurt Cobain • Ozzie Osbourne
• Alfred Hitchcock • Sir Isaac Newton
• Salvador Dali‘ • Ludwig Van Beethoven
• Kim Novak • John Forbes Nash Jr.
• Richard Dreyfuss • Rita Lee
• Margot Kidder • Pete Wentz
• Demi Lovato • Patti Duke
• Sir Winston Churchil • Pablo Picasso

• Skywriting: A Life Out of the Blue, a book by
Jane Pauley
• National Alliance on Mental Illness http://www.nami.org
• National Institute for Mental Health. National
Institutes for Health www.nimh.nih.gov
• www.mayoclinic.com/health/bipolar-disorder

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5 th ed. ).
Washington D.C.: American Psychiatric Publishing.
• American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(11Suppl.), 1-60.
• Author. (2012). Famous people with bipolar disorder. Retrieved 11/13/13 from http://famouspeoplewithbipolardisorder.blogspot.com/2012/12/bipolar-famous-people.html
• Bhatia, J. (2011). 10 Famous people with bipolar disorder: The price of fame? Retrieved 11/14/13 from http://www.everydayhealth.com/bipolar-disorder-pictures/famous-people-with-bipolar-disorder.aspx#/slide-1
• Hattori, E. et al. (2003). Polymorphisms at the G72/G30 gene locus, on L13q33, are associated with bipolar disorder in two independent pedigree series. American Journal of Human Genetics, 72(5), 1131-1140.
• National Alliance on Mental Illnesses. Bipolar Disorder FACT SHEET. Retrieved 11/13/13 from http://www.nami.org/factsheets/bipolardisorder_factsheet.pdf
• National Institute for Mental Health. National Institutes for Health. (2005). Bipolar disorder among adults.
Retrieved 11/13/13 from http://www.nimh.nih.gov/statistics/1bipolar_adult.shtml
• National Institute for Mental Health. National Institutes for Health. (2006). Retrieved 11/8/13 from http://www.nimh.nih.gov/news/science-news/2006/early-findings-from-largest-nimh-funded-research-programon-bipolar-disorder-begin-to-build-evidence-base-on-best-treatment-options.shtml
• National Institute for Mental Health. National Institutes for Health. Retrieved 11/8/13 from http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
• Snow, D. (2009). Bipolar lecture. University of Texas at Arlington College of Nursing.
• Sprooten, E. et al. (2013). Reduced white matter integrity in sibling pairs discordant for bipolar disorder. Am J
Psychiatry 2013;170:1317-1325.
• Varcarolis, E. (2006). Mood disorders: Bipolar. In Foundation of Psychiatric Mental Health Nursing : A Clinical
Approach. St. Louis, MO. Saunders. 359-393.