BIPOLAR 1 AND

BIPOLAR 2
By: Marissa Wiesen
Epidemiology of Bipolar Disorder

■ Bipolar effects approximately 5.7 million American adults. Which is about 2.6% of the
US population 18 years or older, each year.
– 82.9% are considered severe
■ The incidence of bipolar is almost equal in women to men, which is about 1.2:1
■ The average onset is 25 years old.
■ Bipolar disorder tends to occur more in people of higher socioeconomic class.
■ In people who respond to lithium treatment (about 33%), bipolar is completely
treatable, with no further episodes.
Bipolar Disorder
■ Bipolar disorder refers to as extreme mood swings from episodes of mania to episodes of depression with
periods of normal behavior
– In the past, it was referred to as manic-depressive illness
– Each mood can last for weeks or months
■ Manic phase
– A patient’s mood is abnormally and persistently elevated.
– They are euphoric, energetic, sleepless, or irritable.
– Usually lasts about 1 week.
– Patients have poor judgement and rapid thoughts, actions, and speech
■ Depressive phase
– Slow body movements, slow cognition processing, and slow verbal interaction
– View themselves as hopeless, helpless, down or anxious
– May experience anhedonia (losing pleasure in activities formally enjoyed or apathetic (not caring about
themselves, activities)
– Patients have impaired judgement due to slowed cognitive ability, low self-esteem, difficulty fulfilling
roles, responsibilities, and relationships
Bipolar 1 and 2 Defined

■ Bipolar 1
– Manic episodes with at least one
depressive episode
■ Bipolar 2
– Recurrent depression with at least one
hypomanic episode (less extreme than
mania), but you have never had a full-
blown manic episode.
Risk Factors
■ Having a first degree relative with bipolar disorder
– Like a parent or sibling
■ Periods of high stress
– Death of loved one or other traumatic events
■ Drug or alcohol abuse
■ Effects both men and women equally
Physiology of Disease
■ Biological differences
– Studies show that the brain of someone with bipolar disorder and without the disorder are different.
■ Neurotransmitters
– Mania is associated with elevated dopamine and norepinephrine
– Serotonin is believed to be low in both mania and depression, but exact mechanism of action is not
yet understood.
– Acetylcholine is believed to be related to symptoms on bipolar
– Glutamate is an excitatory neurotransmitter and elevated levels is associated with bipolar
■ Genetic
– Some research suggests that people with certain genes are more likely to develop bipolar disorder.
– Many genes are involved but no one gene causes bipolar disorder
– You are more likely to develop bipolar disorder if you have a parent of sibling with the disorder
■ Neuroanatomical changes
– Dysfunction of the prefrontal cortex, basal ganglia, temporal and frontal lobes.
– Dysfunction of the limbic system including the amygdala, thalamus, and striatum.
Signs and Symptoms of Mania/Hypomania Episode

■ Abnormally upbeat, jumpy or wired

■ Increased activity, energy, or agitation
■ Exaggerated sense of well being and self-confidence (euphoria)
■ Unusual talkativeness
■ Racing thoughts
■ Distractibility
■ Poor decision making
■ Major depressive episode
Signs and Symptoms of a Depressive Episode
■ Depressed mood
– Feeling sad, empty, hopeless or tearful
■ Loss of interest or feeling no please in activities
■ Significant weight loss when not dieting or weight gain
■ Decreased or increased appetite
■ Insomnia or sleeping too much
■ Restlessness or slowed behavior
■ Fatigue or loss of energy
■ Feelings of worthlessness or excessive inappropriate guilt
■ Decreased ability to think or concentrate, or indecisiveness
■ Thinking about, planning or attempting suicide
Related Disorders/Common Comorbidities
■ Anxiety disorders
■ Eating disorders
■ Attention-deficit/hyperactivity disorder
■ Personality disorders
■ Alcohol or drug problems
■ Suicide
■ Physical health problems
– Heart disease
– Thyroid problems
– Headaches
– Obesity
– Metabolic and endocrine disorders
Other Issues Related to Bipolar Disorder

■ Problems related to drug and alcohol use

■ Suicide or suicide attempts
■ Legal or financial problems
■ Damaged relationships
■ Poor work or school performance
Medication – Lithium
■ Class – psychotherapeutic agent, mood stabilizer
■ Side effects
– Headache, lethargy, fatigue,
– recent memory loss, nephrogenic diabetes insipidus
– N/V/D, anorexia, ab pain, dry mouth, metallic taste in mouth
– Fine hand tremors, muscle weakness,
– *leukocytosis and thrombocytopenia (low platelet)
■ Labs to monitor and why
– Serum lithium level
■ Assess if level is in a therapeutic range and prevent toxicity
– BUN and creatinine
■ Lithium forces the kidneys to excrete sodium. Lithium is contraindicated in kidney disease
– Thyroid function tests
■ Lithium is known to effect the function of the thyroid
Medications – Lithium
■ Therapeutic range of lithium
– 0.6 – 1.2 mEq/L
■ Lithium toxicity
– Levels 1.5-2 mEq/L:
■ Vomiting, diarrhea, lack of coordination, drowsiness, muscular weakness, slurred speech
– Levels >2 mEq/L:
■ Ataxia, blurred vision, giddiness, tinnitus, muscle twitching, coarse tremors, polyuria
■ Patient education
– Monitor for lithium toxicity. Make sure to get levels drawn regularly
– Report signs and symptoms of hypothyroidism
– Drink plenty of water (1-2L a day), and report increased urine output or dilute urine and if
diarrhea or fever develops.
– Avoid low salt diet
– Lithium is toxic in pregnancy. use contraceptive and inform physician if you become pregnant
Medications – Depakote
■ Class – anticonvulsant, GABA inhibitor
■ Side effects
– Sedations, drowsiness, dizziness, visual disturbances, hallucinations, aggression
– N/V/D/C, indigestion, heartburn, rash
– Hypotension, hypertension
– Liver failure, pancreatitis, prolonged bleeding time
– Deep coma, death (with overdose)
■ Labs to monitor and why
– Serum Depakote level
■ To make sure level is within therapeutic range
– Baseline and periodic platelet, and bleeding time
■ Depakote can cause low platelet count and slowed bleeding time
– Liver function – ALT, AST, bilirubin, ammonia
■ Liver function is disturbed with Depakote, High ammonia levels can lead to hepatic encephalopathy
Medications - Depakote
■ Therapeutic range
– 50 – 125 g/mL
■ Patient education
– Monitor effectiveness and patient alertness. Monitor patient carefully during dose
adjustments and to report any adverse effects.
– Drug can give a false positive test for urine ketones
– Do not discontinue drug abruptly
– Report spontaneous bleeding or bruising
– Withhold dose and notify physician for following symptoms: visual disturbances,
rash, jaundice, light-colored stools, protracted vomiting, diarrhea. Fatal liver
failure has occurred in patients receiving this drug.
– Avoid alcohol and self-medicating. Consult physician when taking OTC medications
– Avoid driving and hazardous activities until response to drug is known.
Medications – Clorzaril
■ Class – psychotherapeutic agent, antipsychotic
■ Side effects
– Orthostatic hypotension, tachycardia, agranulocytosis
– Drowsiness or insomnia, weakness, fatigue, edema, tremors, blurred vision
– Respiratory depression, coma, hypertensive crisis, circulatory collapse,
– Constipations, dry mouth, nausea, vomiting anorexia weight gain
■ Labs to monitor and why
– Baseline and periodic CBC and absolute neutrophil levels
■ Drug can cause agranulocytosis
– Monitor blood glucose in patients with diabetes for hypoglycemia
Medication – Clorzaril
■ Therapeutic level
– Medium range: 200 – 300 nd/mL
– High range: 350 – 450 ng/mL
■ Patient education
– Evaluate BP and pulse before starting treatment and throughout treatment
– Monitor effectiveness of drug. Improvement in sleep pattern, appetite, physical activity, anxiety.
– Takes 2-6 weeks to see and effect.
– Avoid OTC medications
– Report headache and palpitation, prodromal symptoms of hypertensive crisis.
– Report jaundice.
– Do not consume foods and beverages containing tyramine or tryptophan or drugs containing
pressor agent. These can cause severe hypertensive reactions.
– Avoid excess caffeine and chocolate beverages.
– Check weight 2-3 times a week and report unusual weight gain.
Laboratory values to monitor
■ Therapeutic levels to medications a patient is on
– To prevent toxicity of medications and monitor effectiveness
■ Kidney function – BUN and creatinine
– Medication are excreted through the kidney. Proper function is important
■ Thyroid function
– Hypothyroidism can mimic depression symptoms and medication can effect thyroid
function
– Hyperthyroidism can mimic manic symptoms
■ Liver function - ALT, AST, bilirubin, ammonia
– Medications effect the liver.
– If liver is not functioning, ammonia will build up, which is toxic to the brain
 Other treatments and therapies
■ Individual psychotherapy
– This is useful in mild depressive phase but not during acute mania because the patient’s
attention is very short
– Overall, it is helpful in combination with medications to decrease the risk of injury and provide
support to the patient and family.
■ Cognitive or behavioral therapy
■ Transient magnetic stimulation
– Uses magnetic waves to stimulate the brain while the patient is awake. Preformed almost daily
for 1 month
■ Electroconvulsive therapy
– A short-term treatment when patient does not respond to other treatments. Involves short
electrical impulses to the brain while under anesthesia
■ Education and support
■ Lifestyles management
Nursing diagnosis – Ineffective Health Maintenance
■ Goals
– Meet goals for agreed upon health maintenance plan
– Discuss problems that interfere with current health maintenance
■ Interventions
– Assess the patient’s thoughts, feelings, values, and reasons for not following the
treatment plan. Patients are more compliant when they are involved in their plan of
care.
– Help encourage and assist the patient to develop confidence in their health
maintenance.
– Consider a written or verbal contract for the patient to follow their health
maintenance plan.
Nursing Diagnosis – Adult Failure to Thrive
■ Goals
– Participate in ADLs and social interaction
– Express feelings and resume highest level of functioning
■ Interventions
– Instill hope. Help patient manage bipolar disorder through education and social
support
– Help patient find activities that they enjoy and make them feel useful.
– Assess cause of adult failure to thrive and help resolve and treat any other
underlying problems.
Nursing Diagnosis – Chronic Low Self-esteem
■ Goals
– Improved ability to interact with others.
– Improve independent decision-making and problem-solving skills.
■ Interventions
– Assess patient’s strengths and coping ability. Provide opportunities for their
growth, expression and recognition.
– Encourage journal writing as a safe way to express their feelings.
– Encourage the patient’s family to provide positive support and feedback to the
patient when necessary.
Nursing Diagnosis – Ineffective coping
■ Goals
– Partake in behaviors that decrease stress and use effective coping strategies
– Stop destructive behaviors toward self and others
■ Interventions
– Assess for other factors that effect coping such as poor self-concept, grief, lack of
problem-solving skills, lack of support, recent change in life situation,
maturational or situational crisis
– Use therapeutic communication techniques (both verbal and nonverbal) such as
empathy, active listening to encourage the patient to express thoughts and feelings
– Allow the client to talk about previous coping mechanism used on response to
stress and help guide the patient problem solve.
Nursing diagnosis – Anxiety
■ Goals
– Identify, verbalize and show techniques to control anxiety
– Demonstrate a return of basic problem-solving skills
■ Interventions
– Assess for suicidal ideation and have an emergency plan in place.
– Assess the patient’s level of anxiety and physical reaction to it.
– Encourage the patient to use positive self-talk and intervene when possible to help
relieve anxiety
National Institute of Mental Health
Article on Bipolar Disorder summarized
■ https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
■ This article explains bipolar 1 and 2 where they involve changes in mood, energy and
activity levels. This is explained as manic and depressive episodes. Bipolar is typically
diagnoses in early adulthood. Sometimes it can develop during pregnancy or shortly
after childbirth. This article explain the signs and symptoms, risk factors, and treatments
for bipolar disorder. It is a life-long adherence to the treatment and lifestyle
modifications.
Springer Link on Treatment for Bipolar Disorder
■ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536930/
■ This study researches treatments to be used with medications to improve outcomes for
patients with bipolar disorder. Specifically, it looks at the data for psychotherapy,
individual psychoeducation, group psychoeducation, individual cognitive-behaviors
therapy, group therapy, family therapy, and interpersonal therapy. 35 reports of 28
randomized trails from 1995 to 2013 was analyzed. In most cases, psychotherapy and
pharmacotherapy improves outcomes for patients with bipolar disorder. Patients who
has psychoeducation had a decrease number of manic episode's.
National Institute of Mental Health
Article on Bipolar 1 and 2 Summarized
■ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4915933/
■ This study looks at bipolar 1 and 2 by researching the abnormalities in cortical volume,
thickness, and surface area of the brain. It helps further examine the disease and signs
and symptoms. 225 participants underwent MRI to look at the brain which was assess
for abnormalities before continuing on with the study. 81 patients with bipolar 1 and 59
with bipolar 2. This study also included 85 healthy controls with matching sec and age.
Conclusions show that the brain of bipolar 1 and 2 have similarities and distinct
differences. This shows different symptoms of each type and can provide potential
targets for treatment and intervention.
 References
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Heights, Missouri. Elsevier
■ Abe, C., Ekman, C., Sellgren, C., Petrovic, P., Ingvar, M., Landen, M. (2015). Cortical thicknes, volume and surface
area in patients with bipolar disorder types I and II. Journal of Psychiatry & Neuroscience Dio: 10.1503/jpn.150093
■ Bipolar disorder. (2018, January 31). Retrieved September 14, 2020, from
https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955
■ Maletic, v., Raison, C. (2014). Integrated neurobiology of bipolar disorder. Frontiers in psychiatry.
■ Swartz, H., Swanson, J. (2015). Psychotherapy for bipolar disorder in adults: a review of evidence. US National
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■ (2007). Bipolar disorder. Harvard health publishing: Harvard medical school.
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