BIPOLAR DISORDER

OBJECTIVES
1. Assess a patient with mania for (a) mood, (b) behavior, and (c)
thought processes, and be alert to possible dysfunction.
2. Formulate nursing diagnoses appropriate for a patient with
mania, and include supporting data.
3. Explain the rationales behind five methods of communication
that may be used with a patient experiencing mania.
4. Teach at least four expected side effects of lithium therapy.
5. Distinguish between signs of early and severe lithium toxicity.
6. Write a medication care plan specifying five areas of patient
teaching regarding lithium carbonate.
 OBJECTIVES
7. Compare and contrast basic clinical conditions that may respond
better to anticonvulsant therapy with those that may respond better to
lithium therapy.
8. Evaluate specific indications for the use of seclusion for a patient
experiencing mania.
9. Defend the use of electroconvulsive therapy for a patient in specific
situations.
10. Review at least three of the items presented in the patient and family
teaching plan (see Box 13-2) for a patient with bipolar disorder.
11. Distinguish the focus of treatment for a person in the acute manic
phase from the focus of treatment for a person in the continuation or
maintenance phase.
 INTRODUCTION

Once commonly known as manic-depression, bipolar disorder is a

chronic,recurrent illness that must be carefully managed through
out a person’s life. Bipolar disorder frequently goes unrecognized,
and people suffer for years before receiving a proper diagnosis
and treatment. Up to 21% of patients with major depression in primary car
may actually have an undiagnosed bipolar disorder;
lack of specific treatment for the bipolar disorder is associated
with worse outcomes (Smith et al., 2011).
 BIPOLAR DISORDER

Bipolar disorder is marked by shifts in mood, energy, and abil-

ity to function. The course of the illness is variable, and symp
toms range from severe mania—an exaggerated euphoria or
irritability—to severe depression.
 TYPES OF BIPOLAR

BIPOLAR I DISORDER

Is a mood disorder that is characterized by at least one

week-long manic episode that results in
excessive activity and energy.
 Additionally, the presence of three of the
following behaviors constitutes mania

• Extreme drive and energy

• Inflated sense of self-importance
• Drastically reduced sleep requirements
• Excessive talking combined with pressured speech
• Personal feeling of racing thoughts
• Distraction by environmental events
• Unusually obsessed with and overfocused on goals
• Purposeless arousal and movement
• Dangerous activities such as indiscriminate spending, reck-
• less sexual encounters, or risky investments
Mania can be euphoric or dysphoric. Euphoric mania feels
wonderful in the beginning, but it turns scary and dark as
it progresses toward loss of control and confusion. Dysphoric
mania is also referred to as a mixed state or agitated depression,
with depressive symptoms along with mania. A person with
dysphoric mania may be irritable, angry,suicidal, or hypersexual
and may experience panic attacks, pressured speech, agitation,
severe insomnia or grandiosity as well as persecutory delusions
and confusion.
BIPOLAR II DISORDER
In bipolar II disorder, low-level mania
alter-nates with profound depression. We
call this low-level symptomatology
hypomania.
 Cyclothymic disorder

Symptoms of hypomania alternate with symptoms of mild to

moderate depression for at least two years in adults and one year
in children.
• rapid cycling and may have at least
four mood episodes in a 12-month period.
 EPIDEMIOLOGY

Among children and teens bipolar disorder has a rate of about 1%

(American Academy of Child and Adolescent Psychiatry, 2010). The
lifetime risk, or the percentage of the population that will have a bipolar
disorder by age 75, is 5.1% (Kessler, 2005). The median age of onset for
bipolar I is 18 years; for bipolar II, the median age of onset is 20 years
(Merikangas, 2007).
Bipolar I tends to begin with a depressive episode—in women
75% of the time and in men 67% of the time (Sadock & Sadock,
2008). The episodes tend to increase in number and severity
during the course of the illness.

Women who experience a severe postpartum psychosis

within two weeks of giving birth have a four times greater
chance of subsequent conversion to bipolar disorder (Munk?
Olsen et al., 2011).
• Bipolar I disorder seems to be somewhat more common among males, but
bipolar II disorder (characterized by the milder form of mania—hypomania—
and increased depression), rapid cycling, mixed states, and depressive
episodes are more common among females.

• Among adults, bipolar II disorder is believed to be underdiagnosed and

is often mistaken for major depression or person?ality disorders, when
it actually may be the most common form of bipolar disorder (Vieta &
Suppes, 2008).

• Cyclothymic disorder usually begins in adolescence or early adulthood. There

is a 15% to 50% risk that an individual with this disorder will subsequently
develop bipolar I or bipolar II disorder.
 ETIOLOGIC FACTORS
Biological Factors
GENETIC
The bipolar disorders have a strong heritability (i.e., the influence of genetic factors is much greater than the
influence of external factors). Bipolar disorders are 80% to greater than 90% heritable whereas Parkinson’s
disease, for example, is only 13% to 30% heritable (Burmeister, McInnis, & Zollner, 2008).

The scientific community has been increasingly drawn to the concept of bipolar disorders and
schizophrenia having similar genetic origins and pathology (Ivleva, 2010). Both disorders exhibit
irregularities on chromosomes 13 and 15.
 NEUROBIOLOGICAL

Neurotransmitters (norepinephrine, dopamine, and

serotonin) have been studied since the 1960s as
causal factors in mania and depression.
Receptor site insensitivity could also be at the root of
the problem; even if there is enough of a certain
neurotransmitter, it is not going where it needs to
go.
 PSYCHOLOGICAL FACTORS

Although there is increasing evidence for genetic and biological

vulnerabilities in the etiology of the mood disorders, psychological
factors may play a role in precipitating manic episodes for many
individuals.
 ENVIRONMENTAL FACTOR

Bipolar disorder is a worldwide problem that generally affects all races and ethnic groups
equally, but some evidence suggests that bipolar disorders may be more prevalent in upper
socio?economic classes.

For children who have a genetic and biological risk of developing bipolar disorder, stressful
family environments and adverse life events may result in increased vulnerability and more
severe course of illness (Miklowitz & Chang, 2008).
 Signs and Symptoms
• Hyperactivity, locomotion into unauthorized spacing, poor judgement
• Loud, profane, hostile, combative, aggressive, demanding behaviors anxiety, agitation,
inability to concentrate, restlessness, prolonged periods of time without sleep
• Poor reality testing, gradiosity, denial of problems, difficulty organizing and attending to
information, poor concentration, inability to meet basic needs
• Minimal nutritional intake, poor hygiene, clothing unclean
• Giving away of valuables, neglect of family, impulsive major life changes, stress and
frustration of family members
• Pressured speech, flight of ideas, going from one person or event to another, annoyance or
taunting of others, Loud and crass speech, provocative behaviors
 THERAPEUTIC MANAGEMENT
1. Lithium Maintenance Therapy - Some clinicians suggest that patients with bipolar
disorder need to be given lithium for 9 to 12 months, and some patients may need
lifelong lithium maintenance to prevent further relapses. Many patients respond well
to lower dosages during maintenance or prophylactic lithium therapy.

• The patient and family therefore should be given careful instructions about:
1. the purpose and requirements of lithium therapy.
2. Its adverse effects,
3. its toxic effects and complications, and
4. situations in which the physician should be contacted.
• Patients need to know that two major long-term risks of lithium therapy are
"hypothyroidism and impairment of the kidneys ability to concentrate urine".

2. Integrative Therapy
- A few generations ago, children actively resisted a nightly dose of cod liver oil
that mothers swore by as a method to prevent constipation
3. Electroconvulsive therapy (ECT)
- is used to subdue severe mania behavior, especially in
patients with treatment-resistant mania ane patients with
rapid cycling (i.e.,thosewho experience four or more
episodes of illness a year).
4. Support Groups- Patients with bipolar disorder, as well as
their friends and families, benefit from forming mutual support
groups, such as those sponsored by the Depression and Bipolar
Support Alliance (DBSA), the National Alliance for the Mentally Ill
(NAMI), the National Mental Health Association, and the Manic-
Depressive Association.
5. Pharmacotherapy and psychiatric management are
essential in the treatment of acute manic attacks and
during the continuation and maintenance phases of
bipolar disorder. Individuals with bipolar disorder must
deal with the psychosocial consequences of their past
episodes and their vulnerability to experiencing future
episodes.
 6. Cognitive-behavioral therapy (CBT)
-is typically used as an adjunct to pharmacotherapy in many psychiatric disorders
- It is also used for bipolar disorder in children.

• A formalized psychotherapy called "interpersonal and social rhythm therapy" has been
tested in combination with pharmacotherapy in randomized clinical trials as
treatment for patients during the maintenance phase of bipolar illness.

- This therapy addresses the variables that relate to recurrence of symptoms,

especially nonadherence with medication, stress management, and maintenance of
social supports.
LABORATORY EVALUATION/LABORATORY TEST OF
BIPOLAR DISORDER
What tests will the doctor use to make a bipolar
diagnosis?
A doctor may have fill out a mood questionnaire or checklist to help guide
the clinical interview when they assesses mood symptoms. In addition, doctor
may order blood and urine tests to ruleout other causes of your symptoms. In
a toxicology screening, blood, urine, or hair are examined for the presence of
drugs. Blood tests also include a check of thyroid stimulating hormone (TSH)
level, since depression is sometimes linked to thyroid function.
ASSESSMENT
Individuals with bipolar disorder are often misdiagnosed or
underdiagnosed. Early diagnosis and proper treatment can help people
avoid:

suicide attempts
alcohol or substance abuse
martial or work problems
developmental of medical
comorbidity
GENERAL ASSESSMENT
The characteristics of mania discussed in the following sections are (1) mood, (2)
behavior, (3) thought processes and speech patterns, and (4) cognitive function.

MOOD
The euphoric mood associated with mania is unstable, the patient may state that
he or she is experiencing intense feeling of well being, is "cheerful in a beautiful
world" os is becoming "one with God".
People experiencing a manic state may laugh, joke, and talk in a continuous stream,
with uninhibited familiarity.
 BEHAVIOR
When persons experience hypomania, they have various appetites for social engagement,
spending, and activity, even indiscriminate sex

THOUGHTS PROCESSES AND SPEECH PATTERNS

FLIGHT OF IDEAS is a nearly continuous flow of accelerated speech with abrupt changes
from topic to topic that are usually based on understable assciations or plays on words. the
incessant talking often includes joking, puns, and teasing.
CLANG ASSOCIATIONS are stringing together of words because of their rhyming
sounds, without regard to their meaning.
GRANDIOSITY (inflated self-regard) is apparent in both the ideas expressed and the
person's behavior. people with mania may exaggerate their achievements or importance,
state that they know famous people, or believe they have great powers.
COGNITIVE FUNCTION

The onset of bipolar disorder if often preceded by comparatively high

cognitive function; however, there is growing evidence that about one
third of patients with bipolar disorder display significant and persistent
cognitive problems and difficulties in psychosocial ares
 CASE SCENARIO
Jasmine is brought to the emergency department after being found on
the high way shortly after her car broke down. She is dressed in a long
red dress, a blue and orange scarf, many long chains, and a yellow and
green turban. The police report that when they came to her aid, she told
them she was “driving to fame and fortune.” She appeared overly
cheerful and was constantly talking, laughing, and making jokes. At the
same time, she paced up and down beside the car, sometimes tweaking
the cheek of one of the policemen. She was coy and flirtatious with the
police officers, saying at one point, “Boys in blue are fun to do.”
When she reached into the car and started drinking from an open bottle of bourbon, the
police decided that her behavior and general condition might result in harm to herself or
others. When they explained to Jasmine that they wanted to take her to the hospital for a
general checkup, her jovial mood turned to anger and rage, yet minutes after getting into
the police car, she was singing “Rolling in the Deep.”

In the emergency department a psychiatrist sees Jasmine, and her sister is called. The sister
states that Jasmine stopped taking her lithium about five weeks ago and has become more
and more agitated and out of control. She reports that Jasmine has not eaten in days, has
stayed up all night calling friends and strangers all over the country, and finally fled the
house when the sister called an ambulance to take her to the hospital. The psychiatrist
contacts Jasmine’s physician, and her previous history and medical management are
discussed. She is hospitalized, and lithium therapy is restarted. It is hoped that medications
and a controlled environment will prevent further escalation of the manic state and prevent
possible exhaustion and cardiac collapse.
 CHIEF
COMPLAINT
According to the sister of the patient, the patient has become more and more agitated
and out of control, the patient has not eaten in days and has stayed up all nights calling
friends and strangers all over the country.
 PATIENTS DEMOGRAPHIC PROFILE
Name: Jasmine klein
Sex: Female
Age: 32 years old
Religion: Roman Catholic
Civil status: Single
Address: City of toronto, Ontario, Canada
Occupation: Business Woman
Nationality: American
Date of birth: 1990
Date of admission: August 17, 2022
Time: 20:51pm
 NURSING HISTORY
REASON FOR ADMISSION NURSING
OBSERVATION
•Patient become more and • Constantly talking, laughing and
more agitated and out of making jokes
control • Coy and flirtatious
• Has not eating and stayed • Extrememood swings
up all night calling friends
and strangers
• Constantly talking, laughing
and making jokes
HISTORY OF PRESENT ILLNESS

A female patient is brought to the emergency department after being found on the highway
shortly after her car broke down and fled to their house. The police reported that when
they came to aid the patient, the patient told them " she was driving to fame and fortune"
The patient appeared overly cheerful and was constantly talking, laughing and making
jokes . The patient was Coy and flirtatious as she paced up and down beside the car and
tweaking the cheek of one policeman. When the police explained to the patient that they
wanted to take her to the hospital for general check-up, her Jovial mood turned to anger
and rage, yet minutes after getting into the police car she started singing.
 FAMILY AND PERSONAL
HEALTH HISTORY

According to the patient's sister, Ms. Klein has a history of mental health
issues; she also mentioned that her parents passed away in a car accident.
Due to Ms. Klein's psychological disorder, their relationship deteriorated,
and eventually ended in divorce. Ms. Klein was identified as having bipolar
disorder due to her conflicting feelings
 HISTORY OF PAST
ILLNESS
The patient was taking lithium for the mental illness, but discontinued. The
sister of the patient states that about 5 weeks ago after the patient stops
taking lithium, the patient has become more and more agitated and out of
control, the patient has not eaten in days and has stayed up all nights
calling friends and strangers all over the country.
GORDON'S
GORDON'S

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GORDON'S

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 DEVELOPMENTAL
TASK
The Role of the Behavioral Approach System (BAS) in Bipolar Spectrum Disorders
There are highs and lows in a person's mood, energy, motivation, cognition, and level
of activity with bipolar spectrum disorders. An integrated model for comprehending
the psychosocial and biological aspects of bipolar illnesses is provided by the
behavioral approach system (BAS) dysregulation theory. The idea places a strong
emphasis on the part that reward sensitivity and goal sensitivity play in bipolar
disorder.
Bipolar disorder patients can display euphoria, and obsessive goal-setting, but other
times they are depressed, lethargic, and hopeless.
 PHYSICAL
ASSESSMENT
 MENTAL STATUS EXAMINATION
Appearance and Behavior
The patient is a female 32 years old,
stands at 5’5 in height, and dressed not
appropiate in the occasion, wearing a
long red dress, blue and orange scarf,
many long chains and green turban.
Speech and Language
She speaks continuosly telling jokes,
laughing and keeps talking to the
officers. the patient also have a flight of
ideas. that is why the patient takes so
long to interview.
Mood
the patient moods range from
happy to angry. she becomes
angry when the officers says
they will take her to hospital.

Thoughts
The patients shows sign of delusion of
Insight Judgement
grandeur. the patient’s believed that she does The patient is not capable
context: the patient says she was not need to go to hospital and she on basic judgment
driving into fame and fortune. is not sick.

Alertness and orientation

The patient attention is partially impaired, because
she constantly making sexual comments during
interview. patient is oriented in terms of time,
people and location.
Anatomy
And
Physiology
 Limbic System
The limbic system (also known as the paleomammalian brain)
is a collection of brain structures located in the middle of the
brain. The limbic system is not a discrete system itself but
rather a collection of structures—anatomically related but
varying greatly in function. The limbic system as the centre for
emotional responsiveness, motivation, memory formation and
integration, olfaction, and the mechanisms to keep ourselves
safe.
ANATOMY AND PHYSIOLOGY
The prefrontal cortex (PFC) is the
cerebral cortex covering the front
part of the frontal lobe. This brain
region has been implicated in
planning complex cognitive
behavior, personality expression,
decision making, and moderating
social behaviour.
 Frontal lobes

The frontal lobes are probably of most

interest to psychotherapy interventions
such as CBT because they are home to the
PFC,
 Prefrontal Cortex
The PFC is the part of the cerebrum that lies directly behind the eyes and the
forehead. More than any other part of the brain, this area dictates our
personality, our goals, and our values.
Dorsolateral prefrontal cortex (DLPFC). The DLPFC is the topmost
part of the PFC and is considered to have overall management of
cognitive processes such as planning, cognitive flexibility, and
working memory.
Orbitofrontal cortex (OFC). The OFC, like the DLPFC, is
involved in the cognitive processing of decision making;
however, because of its close connection with the limbic system,
it is particularly associated with our ability to make decisions
based on emotional information.
Ventromedial prefrontal cortex (vmPFC). This part of the PFC helps us make
decisions based on the bigger picture gathered from connections to the amygdala,
temporal lobe, ventral segmental area, olfactory system, and the thalamus. It is very
well connected, receiving and sending a lot of information that influences many brain
regions, including the amygdala.
 The medial temporal lobe consists of the
hippocampal formation (blue-green) superiorly
and the parahippocampal gyrus inferiorly. The
entorhinal (brown) and perirhinal (yellow)
cortices form the medial and lateral components,
respectively, of the anterior portion of the
parahippocampal gyrus, while the
parahippocampal cortex (off-white) forms the
posterior portion.
PSYCHOPATHOLOG
Y
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another file
DRUG STUDY
DRUG STUDY
 DISCHARGE
1. HEALTH TEACHING PLAN
*Take Medicine as prescribe
to keep your mood stable or to help you sleep. Changes in medicine are
often needed as your bipolar disorder change
*Take note the expected side effects of the prescribe medication as well as
whom to call and where to go in case of toxic reaction
2.CONTACT YOUR HEALTH CARE PROVIDER OR PSYCHIATRIST IF:
*You are having trouble in managing your bipolar dis order.
*You cannot sleep Or sleeping all the time
*You have a question or concerns about your cindition
*You think your medicine is not helping or if you have side effects. Tell to
your respective healthcare provider if you are allergic to any medicine.

3. PATIENTS WITH BIPOLAR DISORDER AND THEIR FAMILY NEED TO KNOW:

*The chronic and episode nature of bipolar dis order.
*The Signs and Symptoms of relapse that “COME OUT OF THE BLUE”
*The role of family members and others in preventing a full relapse.
*The phone numbers of emergency contact person which should kept in an easily accessed
phase.
4.The use of alcohol, drugs of abuse, even small amount of caffeine
and over the counter medication can produce a relapse.

5. Psychosocial strategies is important for dealing with work

interpersonal and family problems: Like for lowering stress, for
enhancing a sense of personal control and for increasing community
functioning.

6. Groups and individual psychotheraphy are invaluable for gaining

insight and skill in relapse prevention, providing social support,
increasing coping skills in interpersonal relations, improving to the
medication regimen, reducing morbidity and decreasing
rehospilalization.