Bipolar Disorder

Bipolar disorder, also known as manic-depressive illness, is a mental health condition characterized by extreme shifts in mood, energy levels, and activity patterns. Individuals with bipolar disorder experience episodes of intense highs, known as manic or hypomanic episodes, where they might feel overly energetic, euphoric, or impulsive. These episodes alternate with periods of deep lows, or depressive episodes, during which they might feel extremely sad, hopeless, and lethargic. The disorder can disrupt daily life, relationships, and decision-making.

Understanding its varied manifestations, potential causes, nursing interventions, and available treatments is important in supporting those affected by this challenging condition.

What is Bipolar Disorder?

Bipolar disorders are mood disorders characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy.

• These disorders are linked to early death, primarily due to cardiovascular disease-related fatalities being the prevailing reason.
• Bipolar disorders stand apart from other affective disorders due to recurring manic or hypomanic episodes alternating with depressive episodes. Bipolar I involves overt manic episodes with symptoms like grandiosity and decreased need for sleep, often accompanied by psychotic features. Bipolar II is marked by depression alternating with hypomania.

Types of Bipolar Disorder

• Bipolar I disorder is the diagnosis given to an individual who is experiencing, or has experienced, a full syndrome of manic or mixed symptoms; the client may also have experienced periods of depression.
• Bipolar II disorder. Bipolar II disorder is characterized by recurrent bouts of major depression with the episodic occurrence of hypomania; this individual has never experienced a full syndrome of manic or mixed symptoms.
• Cyclothymic disorder. The essential feature is a chronic mood disturbance of at least 2 years duration, involving numerous periods of depression and hypomania, but not of sufficient severity and duration to meet the criteria for either bipolar I or bipolar II disorder.
• Bipolar disorder due to general medical condition. This disorder is characterized by a prominent and persistent disturbance in mood (bipolar symptomatology) that is judged to be the direct result of the physiological effects of a general medical condition (APA, 2000).
• Substance-induced bipolar disorder. The bipolar symptoms associated with this disorder are considered to be the direct result of the physiological effects of a substance (e.g., use or abuse of a drug or medication, or toxin exposure).

Pathophysiology

The pathophysiology of bipolar disorder, or manic-depressive illness (MDI), has not been determined, and no objective biologic markers correspond definitively with the disease state.

• The genetic component of bipolar disorder appears to be complex; the condition is likely to be caused by multiple different common disease alleles, each of which contributes a relatively low degree of risk on its own.
• Many loci are now known to be associated with the development of bipolar disorder.
• These loci are grouped as major affective disorder (MAFD) loci and numbered in the order of their discovery.

Statistics and Incidences

Globally, the life-long prevalence rate of bipolar disorder is 0.3 to 1.5%.

• The life-long prevalence of bipolar disorder in the United States has been noted to range from 0.9 to 2.1%.
• For both bipolar I and bipolar II, the age range is from childhood to 50 years, with a mean age of approximately 21 years.
• BPI occurs equally in both sexes; however, rapid-cycling bipolar disorder is more common in women than in men.

Causes

Predisposing factors to bipolar disorder include:

• Biological. Twin studies have indicated a concordance rate for bipolar disorder among monozygotic twins at 60% to 80% compared to 10% to 20% in dizygotic twins.
• Biochemical. Just as there is an indication of lowered levels of norepinephrine and dopamine during an episode of depression, the opposite appears to be true of an individual experiencing a manic episode.
• Physiological. Right-sided lesions in the limbic system, temporobasal areas, basal ganglia, and thalamus have been shown to induce secondary mania.
• Medication side effects. Certain medications used to treat somatic illnesses have been known to trigger a manic response; the most common of these are the steroids frequently used to treat chronic illnesses such as multiple sclerosis and systemic lupus erythematosus.

Clinical Manifestations

These are the symptoms of bipolar disorder:

• Heightened, grandiose, or agitated mood. The affect of a manic individual is one of elation and euphoria- a continuous “high”.
• Exaggerated self-esteem. Usual inhibitions are discarded in favor of sexual and behavioral indiscretions.
• Sleeplessness. Sleep patterns are disturbed; the client becomes oblivious to feelings of fatigue, and rest and sleep are abandoned for days or weeks.
• Pressured speech. Loquaciousness, or pressured speech, is so forceful and strong that it is difficult to interrupt maladaptive thought processes.
• Flight of ideas. There is a continuous, rapid shift from one topic to another.
• Reduced ability to filter out extraneous stimuli; easily distractible. There is inability to concentrate because of a limited attention span; the individual is easily distracted by even the slightest stimulus in the environment.
• Increased number of activities with increased energy. Motor activity is constant; the individual is literally moving at all times.
• Multiple, grandiose, high risk activities, using poor judgement; with severe consequences.

Assessment and Diagnostic Findings

A number of reasons exist for obtaining selected laboratory studies in patients with bipolar disorder; an extensive range of tests is indicated, because bipolar disorder encompasses both depression and mania and because a significant number of medical causes for each state exist.

• Complete blood count. A complete blood count with differential is used to rule out anemia as a cause of depression in bipolar disorder.
• Erythrocyte sedimentation rate. The erythrocyte sedimentation rate (ESR) is determined to look for underlying disease processes such as lupus or an infection; an elevated ESR often indicates an underlying disease process.
• Fasting glucose. In some cases, a fasting glucose level is indicated to rule out diabetes.
• Electrolytes. Serum electrolyte concentrations are measured to help diagnose electrolyte problems, especially with sodium, that are related to depression.
• Proteins. Low serum protein levels found in patients who are depressed may be a result of not eating.
• Thyroid hormones. Thyroid tests are performed to rule out hyperthyroidism (mania) and hypothyroidism (depression).
• Creatinine and blood urea nitrogen. Kidney failure can present as depression; treatment with lithium can affect urinary clearances, and serum creatinine and blood urea nitrogen (BUN) levels can increase.
• Substance and alcohol screening. Alcohol abuse and abuse of a wide variety of drugs can present as either mania or depression.
• MRI. The total value of performing an MRI in a patient with bipolar disorder remains unclear; however, a couple of reasons do exist for performing an imaging study.
• Electrocardiography. Many of the antidepressants, especially the tricyclic agents and some of the antipsychotics can affect the heart and cause conduction problems.

Medical Management of Bipolar Disorder

The treatment of bipolar disorder is directly related to the phase of the episode (i.e. depression or mania) and the severity of that phase.

• Psychotherapy. Psychotherapy helps patients with bipolar disorder but does not cure the disorder itself; when Schottle and colleagues looked at psychotherapy for patients, family, and caregivers, they found that although results were heterogeneous, most studies demonstrated relevant positive results in regard to decreased relapse rates, improved quality of life, increased functioning, or more favorable symptom improvement.
• Electroconvulsive therapy. Electroconvulsive therapy (ECT) is useful in a number of instances in patients with bipolar disorder, such as when rapid, definitive medical/psychiatric treatment is needed; when the risks of ECT are less than that of other treatments; when the bipolar disorder is refractory to an adequate trial with other treatment strategies; and when the patient prefers this treatment modality.
• Diet. Patients should be advised not to make significant changes in their salt intake, because increased salt intake may lead to reduced serum lithium levels and reduced efficacy, and reduced intake may lead to increased levels and toxicity.
• Activity. Patients in a depressed state are encouraged to exercise; these individuals should try to develop a regular daily schedule of major activities, especially times of going to bed and waking up.

Pharmacological Management

Appropriate medication for managing bipolar disorder depends on the stage the patient is experiencing.

• Anxiolytics, benzodiazepines. By binding to specific receptor sites, benzodiazepines appear to potentiate the effects of gamma-aminobutyric acid (GABA) and facilitate inhibitory GABA neurotransmission and the action of other inhibitory neurotransmitters.
• Mood stabilizers. Lithium is the drug commonly used for prophylaxis and treatment of manic episodes.
• Anticonvulsants. Anticonvulsants have been effective in preventing mood swings associated with bipolar disorder, especially in those patients known as rapid cyclers.
• Antipsychotics, 2nd generation. Second-generation, or atypical, antipsychotics are increasingly being used for the treatment of both acute mania and mood stabilization in patients with bipolar I disease.
• Antipsychotics, 1st generation. First-generation antipsychotics, also known as conventional or typical antipsychotics, are efficacious in treating both psychotic and nonpsychotic manic and mixed episodes, as well as hypomania.
• Antipsychotics, phenothiazine. Phenothiazine antipsychotics, which are classified as first-generation antipsychotics, are efficacious in treating both psychotic and nonpsychotic manic and mixed episodes, as well as hypomania.
• Antiparkinsons agents, dopamine agonists. Dopamine agonists are non-errgot agents that bind to D2 and D3 dopamine receptors in the striatum and substantia nigra.

Nursing Management for Bipolar Disorder

Nursing management of a patient with bipolar disorder includes the following:

Nursing Assessment

Assessment of a patient with bipolar disorder includes:

• History. Taking a history with a client in a manic phase often proves difficult; obtaining data in several short sessions, as well as talking to family members, may be necessary.
• General appearance and motor behavior. Clients with mania experience psychomotor agitation and seem to be in perpetual motion; sitting still is difficult; this continual movement has many ramifications; clients can be exhausted or injure themselves.
• Mood and affect. Mania is reflected in periods of euphoria, exuberant activity, grandiosity, and a false sense of well-being.
• Thought process and content. Cognitive ability or thinking is confused and jumbled with thoughts racing one after another, which is often referred to as a flight of ideas; clients cannot connect concepts, and they jump from one subject to another.

Nursing Diagnosis for Bipolar Disorder

Nursing diagnoses commonly established for clients in the manic phase are as follows:

• Risk for other-directed violence related to manic excitement, suspicion of others, paranoid ideation.
• Risk for injury related to extreme hyperactivity, destructive behaviors.
• Imbalanced nutrition: less than body requirements related to refusal or inability to sit still long enough to eat meals.
• Disturbed thought processes related to psychotic process.
• Disturbed sensory perception related to sleep deprivation, psychotic process.

Nursing Care Planning and Goals

Main Article: 6 Bipolar Disorders Nursing Care Plans

Nursing care planning goals for bipolar disorders are:

• Client will no longer exhibit potentially injurious movements after 24 hours with administration of tranquilizing medications.
• Client will experience no physical injury.
• Client’s agitation will be maintained at a manageable level with the administration of tranquilizing medications during first week of treatment.
• Client will not harm self or others.
• Client will consume sufficient finger foods and between-meal snacks to meet recommended daily allowances of nutrients.
• Within one week, client will be able to recognize and verbalize when thinking is non-reality based.
• Client will be able to recognize and verbalize when he or she is interpreting the environment inaccurately.

Nursing Interventions

Nursing interventions for bipolar disorder clients are:

• Providing for safety. A primary nursing responsibility is to provide a safe environment for clients and others; for clients who feel out of control, the nurse must establish external controls emphatically and non judgementally.
• Meeting physiologic needs. Decreasing environmental stimulation may assist clients to relax; the nurse must provide a quiet environment without noise, television, and other distractions; finger foods or things a client can eat while moving around are the best options to improve nutrition.
• Providing therapeutic communication. Clients with mania have short attention spans, so the nurse uses simple, clear sentences when communicating; they may not be able to handle a lot of information at once, so the nurse breaks information into many small segments.
• Promoting appropriate behavior. The nurse can direct their need for movement into socially acceptable, large motor activities such as arranging chairs for a community meeting or walking.
• Managing medications. Periodic serum lithium levels are used to monitor the client’s safety and to ensure that the dose given has increased the serum lithium level to a treatment level or reduced it to a maintenance level.

Evaluation

The goals are met as evidenced by:

• Client is able to differentiate between reality and unrealistic events or situations.
• Client is able to recognize thoughts that are not based in reality and intervene to stop their progression.
• Client has gained or maintained weight during hospitalization.
• There is no evidence of violent behavior to self and others.
• Client is no longer exhibiting signs of physical agitation.

Documentation Guidelines

Documentation in a patient with bipolar disorder include:

• Individual findings include factors affecting, interactions, the nature of social exchanges, and specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

References and Sources

Interesting resources for further reading about bipolar disorder:

• Bartels, S. J., Mueser, K. T., & Miles, K. M. (1997). A comparative study of elderly patients with schizophrenia and bipolar disorder in nursing homes and the community. Schizophrenia Research, 27(2-3), 181-190. [Link]
• Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,.
• Boyd, M. A. (Ed.). (2008). Psychiatric nursing: Contemporary practice. lippincott Williams & wilkins.
• Keltner, N. L. (2013). Psychiatric nursing. Elsevier Health Sciences.
• Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.