Bipolar Disorder I & II

• Bipolar disorders were once known as manic depression.
• The condition is chronic and recurrent, requiring careful management.
• Bipolar disorder often goes unrecognized for years, leading people to suffer before diagnosis.
• The course of the illness is variable.
• Symptoms range from mania to depression.
• Bipolar disorder is marked by shifts in mood, energy, and ability to function.

Bipolar I Disorder

• Bipolar I disorder involves experiencing at least one manic episode.
• Mania includes intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy.
• Manic periods last at least 1 week for most of the day, every day.
• Symptoms of mania are so severe that this is a state of psychiatric emergency.
• As mania intensifies, individuals may become psychotic, experiencing hallucinations, delusions, and dramatically disturbed thoughts.

Bipolar II Disorder

• Bipolar II disorder involves experiencing at least one hypomanic episode.
• Hypomania refers to a lower-level and less dramatic mania.
• It still can cause significant issues in relationships and occupational functioning.
• Excessive activity and energy lasts for at least 4 days during hypomania.
• Psychosis is never present in hypomania.
• Hospitalization is rare for Bipolar II disorder.
• Bipolar II disorder is often underdiagnosed.
• Often mistaken for major depression or personality disorders.

Cyclothymic Disorder

• Symptoms of hypomania alternate with symptoms of mild to moderate depression for 2 years in adults, or 1 year in children.
• Hypomanic and depressive symptoms do not meet the criteria of Bipolar II disorder or major depression.
• It is disturbing enough to cause social and occupational impairment.
• Symptoms include irritable hypomanic episodes and rapid cycling.

Other Bipolar Disorders Types

• Substance/medication-induced bipolar and related disorder
• Bipolar and related disorder due to another medical condition
• Other specified bipolar and related disorder
• Unspecified bipolar and related disorder

Symptoms of a Manic State

• Extreme drive and energy
• Inflated sense of self-importance
• Drastically reduced sleep requirements
• Excessive talking combined with pressured speech
• Racing thoughts
• Distraction by environmental events
• Obsession with and overfocusing on goals
• Purposeless arousal and movement
• Dangerous activities such as indiscriminate spending, reckless sexual encounters, or risky investments

Epidemiology

• Lifetime risk of bipolar disorder is 4%.
• Age of onset for Bipolar I is 18 years, and for Bipolar II, 20 years.
• Men and women are affected at nearly equal rates.
• Men are more likely to have legal problems and commit acts of violence.
• Women are more likely to misuse alcohol, commit suicide, and develop thyroid disease.
• Women who experience severe postpartum psychosis within 2 weeks of birth are 4 times more likely to develop bipolar disorder.

Comorbidity

• For Bipolar I Disorder, 75% also experience anxiety disorder.
• Individuals with Bipolar I Disorder may also have Attention-deficit/hyperactivity disorder.
• More than 50% of those with Bipolar I Disorder may have substance use disorder, migraines, metabolic syndrome, high blood pressure, or high blood glucose.
• For Bipolar II Disorder, 75% also experience anxiety disorder.
• 37% have substance use disorder.
• Anxiety and eating disorder symptoms arise with depressive symptoms.
• Substance use disorder arises with hypomanic symptoms.
• Cyclothymic Disorder may include substance use disorders as a form of self-medication.
• Sleep disorders are common.
• Attention-deficit/hyperactivity disorder is more common in children.

Etiology

• Biological factors are a key part of the cause.
• Genetics play a strong role in heritability.
• Neurobiological factors include norepinephrine, dopamine, and serotonin.
• Brain structure and function may play a role.
• Neuroendocrine/hormonal factors could be a cause.
• Psychological and environmental factors are also believed to contribute.

Nursing Process: Assessment

• Risk assessment (e.g., suicide risk)
• Mood
• Behavior
• Thought processes and speech patterns, Flight of ideas and Clang associations
• Grandiosity
• Cognitive functioning

Self-Assessment

• Patients experiencing mania can elicit humor, manipulation, power struggles, demanding behavior, and "Staff Split"
• Staff actions include frequent staff meetings to deal with patient behavior and setting limits consistently.

Assessment Guidelines for Bipolar Disorder

• Danger to self or others
• Need for protection from uninhibited behaviors
• Need for hospitalization
• Medical status
• Coexisting medical conditions
• Family's understanding

Nursing Process: Nursing Diagnosis

• Risk for injury
• Risk for violence (other-directed or self-directed)
• Ineffective coping

Nursing Process: Outcomes Identification

• Acute phase: prevent injury
• Continuation phase: relapse prevention
• Maintenance phase: limit severity and duration of future episodes

Nursing Process: Planning

• Acute phase: medical stabilization, maintaining safety, self-care needs
• Continuation phase: maintain medication adherence, psychoeducational teaching, referrals
• Maintenance phase: prevent relapse

Nursing Process: Implementation

• Acute phase: address depressive episodes and manic episodes
• Continuation phase: prevent relapse with follow-up care
• Maintenance phase: prevent recurrence

Nursing Process: Implementation on Pharmacological Interventions

• Mood stabilization and Lithium carbonate
• Indications:
  • Therapeutic and toxic levels
  • Therapeutic blood level: 0.6 to 1.2 mEq/L
  • Toxic blood level: 1.5 mEq/L and above
• Maintenance therapy
• Contraindications
• Adverse effects and toxicity

Implementation on Pharmacological Interventions

• Anticonvulsant drugs:
  • Divalproex sodium (Epival)
  • Carbamazepine (Tegretol)
  • Lamotrigine (Lamictal)
• Antianxiety drugs:
  • Clonazepam (Rivotril)
  • Lorazepam (Ativan)
• Atypical antipsychotics:
  • Olanzapine (Zyprexa)
  • Risperidone (Risperdal)

Other Treatments

• Electroconvulsive therapy (ECT)
• Milieu management:
  • Seclusion protocol
  • Observation levels
• Support groups
• Health teaching and health promotion

Advanced Practice Interventions

• Psychotherapy
• Cognitive behavioral therapy (CBT)
• Interpersonal and social rhythm therapy

Nursing Process: Evaluation

• Evaluation of outcome criteria
• Reassessment of care plan
• Revision of care plan if indicated