copyright © 2014. f.a. davis company bipolar and related disorders chapter 26

Copyright © 2014. F.A. Davis Company

Bipolar and Related DisordersBipolar and Related DisordersChapter 26Chapter 26


IntroductionIntroduction

• 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.


• 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.

Introduction Introduction (cont.)(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.

Introduction Introduction (cont.)(cont.)


Historical PerspectiveHistorical 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.”


• 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.

Historical Perspective Historical Perspective (cont.)(cont.)


EpidemiologyEpidemiology

• 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.


Types of Bipolar Disorders 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.


• Bipolar II Disorder

– Characterized by bouts of major depression with episodic occurrence of hypomania

– Has never met criteria for full manic episode

Types of Bipolar Disorders Types of Bipolar Disorders (cont.)(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



• 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).



• 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.



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.



• 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.



Predisposing FactorsPredisposing Factors

• Biological Theories – Genetics

• Twin and family studies• Other genetic studies

– Biochemical influences• Possible excess of norepinephrine and dopamine


• Biological Theories (cont.)– Physiological Influences

• Brain lesions• Enlarged ventricles• Medication side effects

Predisposing Factors Predisposing Factors (cont.)(cont.)


• Psychosocial Theories– Credibility of psychosocial theories has

declined in recent years.– Bipolar disorder is viewed as a disease of the

brain.



• The Transactional ModelBipolar disorder most likely results from an interaction between genetic, biological, and psychosocial determinants.



Developmental ImplicationsDevelopmental 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).


• 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.

Developmental Implications Developmental Implications (cont.)(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.



• 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.



• 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.



• 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.



• Childhood and Adolescence (cont.)– Treatment strategies

• Psychopharmacology– Lithium– Divalproex– Carbamazepine– Atypical antipsychotics



• 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.



• Childhood and Adolescence (cont.)– Treatment strategies (cont.)

• Family Interventions– Psychoeducation about bipolar disorder– Communication training– Problem-solving skills training



Nursing Process/AssessmentNursing 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


– 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

Nursing Process/Assessment Nursing Process/Assessment (cont.)(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

Nursing Process/Assessment Nursing Process/Assessment (cont.)(cont.)


Nursing DiagnosisNursing Diagnosis

• Risk for Injury related to:– Extreme hyperactivity, increased agitation,

and lack of control over purposeless and potentially injurious movements


• Risk for Violence: Self-directed or other-directed related to:– Manic excitement– Delusional thinking– Hallucinations– Impulsivity

Nursing Diagnosis Nursing Diagnosis (cont.)(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



• Disturbed thought processes related to:– Biochemical alterations in the brain,

evidenced by delusions of grandeur and persecution and inaccurate interpretation of the environment



• Disturbed sensory perception related to:– Biochemical alterations in the brain and to

possible sleep deprivation, evidenced by auditory and visual hallucinations



• Impaired Social Interaction related to:– Egocentric and narcissistic behavior

• Insomnia related to:– Excessive hyperactivity and agitation



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 hyperactivityB. Disturbed sleep pattern related to manic

hyperactivityC. Imbalanced nutrition, less than body

requirements related to inadequate intakeD. Situational low self-esteem related to

embarrassment secondary to high-risk behaviors



• 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.



Criteria for Measuring OutcomesCriteria 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


• 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

Criteria for Measuring Outcomes Criteria for Measuring Outcomes (cont.)(cont.)


Planning/ImplementationPlanning/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


Client/Family EducationClient/Family Education

• Nature of the Illness– Causes of bipolar disorder– Cyclic nature of the illness– Symptoms of depression– Symptoms of mania


• Management of the Illness– Medication management– Assertive techniques– Anger management

Client/Family Education Client/Family Education (cont.)(cont.)


• Support Services– Crisis hotline– Support groups– Individual psychotherapy– Legal/financial assistance



EvaluationEvaluation

• Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria.


Evaluation Evaluation (cont.)(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?


• 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?

Evaluation Evaluation (cont.)(cont.)


Treatment Modalities for Bipolar Treatment Modalities for Bipolar DisorderDisorder

• Individual Psychotherapy • Group Therapy• Family Therapy• Cognitive Therapy


• 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.

Treatment Modalities for Bipolar Treatment Modalities for Bipolar Disorder Disorder (cont.)(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.



• 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.



• 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.



PsychopharmacologyPsychopharmacology

• For mania:– Lithium carbonate– Anticonvulsants– Verapamil– Antipsychotics

• For depressive phase:– Use antidepressants with care (may trigger

mania).


• 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

Psychopharmacology Psychopharmacology (cont.)(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.



– 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



– 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



– 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)



– Side effects (cont.)• Monitor for side effects of verapamil:

– Drowsiness, dizziness– Hypotension, bradycardia– Nausea– Constipation



– 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



Client/Family EducationClient/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.


• 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



• 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.



• 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



• 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.



• 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



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.



• 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 bipolar and related disorders chapter 26

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