1. BIPOLAR DISORDERS
Presented by:
Eric F. Pazziuagan, RN, MAN

4. BIPOLAR DISORDERS
• Bipolar disorders are those in which individuals
experience the extremes of mood polarity.
• Persons may feel euphoric or very depressed.
• A recurrent mood disorder featuring one or
more episodes of mania or mixed episodes of
mania and depression. (DSM- IV- TR)
• Bipolar disorders differ from major depression
in that there is a history of manic or hypomanic
(milder and not psychotic) episodes.
• Manic- depressive: diagnostic equivalent; less
precise.

5. • Mood disturbances range from pure euphoria, or
elation, to irritability to a labile admixture that
also includes dysphoria (unpleasant mood).
• Kinds of mood episodes:
▫ Mania
▫ Hypomania
▫ Depression
▫ Mixed episodes (symptoms of both mania and
depression at the same time or alternating
frequently during the day).

7. Symptoms occurring during manic
episodes:
▫ Common Symptoms
 Elevated mood
 Grandiosity
 Irritability
 Anger
 Insomnia
 Anorexia
 Flight of ideas
 Distractibility
 Hyperactivity
 Involvement in pleasurable activities
 Loud, rapid speech

8. ▫ Other symptoms
 Lack of awareness of illness.
 Resistance to treatment
 Labile mood
 Depression
 Delusions
 Hallucinations

9. DSM- IV CRITERIA FOR BIPOLAR
DISORDERS
• Manic episode:
▫ A distinct period of abnormal and persistent
elevated, expansive, or irritable mood that lasts at least 1 week
(or less if hospitalization is required).
▫ At least three of the following symptoms must occur during
the episode (or four if the patient is only irritable).
 Inflated self- esteem or grandiosity.
 Decreased need for sleep.
 Very talkative.
 Flight of ideas or subjective feeling that thoughts are racing.
 Distractibility.
 Increase in goal- oriented activity
(social, occupational, educational, or sexual) or psychomotor
agitation.
 Excessive involvement in pleasurable activities that have a higher
potential for personal problems (e.g., sexual promiscuity, spending
sprees, bad business investments).

10. ▫ Mood disturbances severe enough to cause
problems socially, interpersonally, or at
work, or the person has to be hospitalized to
prevent harm to self and others.
▫ Not due to a substance.

11. • Hypomanic episode:
▫ The person experiencing a hypomanic episode
meets most of the criteria for manic
episode, with two major exceptions: the
symptoms must be at least four days and the
person must manifest an unequivocal change
in functioning that is observable by others. A
hypomanic episode is not severe enough to
result in significant impairment or to require
hospitalization.

12. • Bipolar disorders
▫ Bipolar episodes are divided into Bipolar I and
Bipolar II.In Bipolar I, the patient must have a
history of manic episodes.
▫ Bipolar II: The patient has experienced a
major depression and hypomanic episodes
(but not a manic episode).
• Cyclothymic disorder
▫ For a period of two years, the patient has had
numerous periods of hypomanic symptoms and
numerous periods of depressed mood. The patient
is never symptom- free for more than two months
at a time. The patient has never experience major
depression.

14. BIPOLAR I
• Six separate criteria sets:
▫ Single manic episode
▫ Most recent episode hypomanic
▫ Most recent episode manic
▫ Most recent episode mixed
▫ Most recent episode depressed
▫ Most recent episode unspecified.

15. BIPOLAR II
• Similar to bipolar I, with major exception
that the person has never experienced a
manic episode.
• Requires the presence of a full hypomanic
and a major depressive episode.
• Remains underused because hypomania is
frequently not recognized, especially when
occurring in the context of atypical
depression.

16. CYCLOTHYMIA
• Sometimes categorized as Bipolar III
• Marked by Manic and depressive states, yet
neither is of sufficient intensity nor duration to
merit a diagnosis of bipolar disorder or major
depressive disorder.
• There is a history of hypomania but no prior
episodes of mania or major depression.
• Characterized by mood swings that have
occurred for at least 2 years without symptom
remission for more than 2 months.

17. EPIDEMIOLOGY
• Bipolar disorder I affects 1 to 1.5% of the general
population
• Bipolar II: 0.5 to 0.6% of the population, females
more affected than males
• Economic cost in US: 45 billion dollars
• Males display more
hyperactivity, grandiosity, and risky
behavior, and females more often display racing
thoughts and distractibility.
• Sixth leading cause of disability
• 19% die from suicide

18. BEHAVIOR

19. Objective behavior
• Manic episode appears enthusiastic and euphoric;
recognized as excessive by others.
• Disturbances of speech
▫ Loud in a rapid- fire fashion
▫ Monopolizes the dialogue and deflect by others to
contribute
▫ Filled with jokes and puns
▫ Sarcastic and biting remarks
▫ Tendency to complain often and loudly
▫ Speech is dramatic
▫ Ability to engage staff in members in debate and place
them on the defensive
▫ Flight of ideas

20. Altered social, interpersonal, and
occupational relationships
• Manipulation of the self-esteem of others.
▫ Patients use coercive techniques to increase or
decrease another’s self esteem
• Ability to find vulnerability of others.
▫ Can exploit weakness in others or create
conflicts among staff members.
• Ability to shift responsibility.
• Limit testing
▫ Patients keep pushing the limits on the
psychiatric unit.
• Alienation of family.

21. Alterations in activity and
appearance
• Hyperactive and agitated
• Pacing, flamboyant gestures, colorful
dress, singing, and excessive use of make- up
• May dress sloppily and omit personal grooming
• May not need sleep, or perhaps need only a few
hours per night
• May drop form exhaustion
• May suffer from poor nutrition.

22. SUBJECTIVE BEHAVIOR

23. Alterations of affect
• Euphoria and high regard to self (may
reach levels of grandiosity)
• Elevated mood, a feeling of joy, and
greatness.
• Sense of invincibility.
• Labile or quick changing affect.

24. Alterations of perception
• Delusions and hallucinations may
occur, and their content is typically
consistent with their mood.

25. CAUSATIVE FACTORS:
THEORIES AND PERSPECTIVES

26. Psychodynamic, Existential, Cognitiv
e- Behavioral, and Development
Theories
• Biological and genetic factors may be the most significant
etiological factors.
• Psychosocial stressors can precipitate the onset of illness
episodes (when biologic or genetic factors are present).
• Family Dynamics
▫ Faulty family dynamics during early life are responsible
for manic behaviors in later life.
▫ May be related to an alternating identification with
parents: depression with the mother and mania with the
father figure.
• Mania as a Defense
▫ Manic episodes as defense against massive denial of
depression.

27. Biological Theories
• Neurochemical and Neuroendocrine Factors
• Biogenic Amine Theory of depression essentially implies
that an imbalance of relative deficiency exists in relation
to certain neurotransmitters or biogenic amines such as
norepinephrine and serotonin.
• Deficiencies in the substances mentioned above results
in neurochemical imbalance.
• Depression is related to increased cholinergic activity
and mania is related to increased noradrenergic activity.
• Neuroanatomical Factors
• Lesions in the white matter of the brain that tend to
concentrate in areas that are responsible for emotional
processing.

28. Genetic Factors
• The risk to relatives of those individuals
with bipolar disorder is significantly
greater than the risk for those individuals
without bipolar disorder in family history.
• Greatest risk when disorder is present in
first- degree family members.

29. Other Factors
• Chronobiology: circadian rhythm or sleep- wake
cycle of the body
▫ Involved in the pathogenesis of Bipolar
disorder.
▫ Sleep deprivation and the development of
manic symptoms suggest disruption of
circadian rhythm may precipitate affective
relapse.
▫ Seasonal variations in circadian rhythm may
precipitate affective episodes.

30. • Kindling theory
▫ Analogous to the use of kindling to build a fire.
▫ Bipolar disorders develop as a result of
biologic and genetic predisposition in addition
to environmental factors.
▫ This process often results in less severe
episodes of mood disturbances that initially
occur infrequently and escalate overtime.
▫ As this repetitive cycle occurs, the mood
disturbance becomes more severe at more
frequent intervals, finally resulting in full-
blown bipolar disorder.

31. BIPOLAR DISORDERS
ACROSS THE LIFE SPAN

32. Childhood and Adolescence
• Once thought to be rare in children.
• Researchers are discovering that not only it can
begin very early in life, it is much more common
than previously believed.
• Parents describe their children as being different
from early infancy.
• Infants: sleeping erratically; not sleeping long; being
irritable, fussy, and difficult to settle;
temperamental; and extremely anxious, often
experiencing great difficulty with separation from
the mother.
• Night terrors, rages, fear of death, and behaviors
that fit into the diagnostic criteria of oppositional
defiant disorder are often aspect of bipolar disorder.

33. Older Adulthood
• Bipolar is frequently missed or misdiagnosed.
• Depression is more readily diagnosed.
• Mood elevation, increase in energy, and other
subtle manifestations are often left
unrecognized.
• Increases the risk of suicide.
• Complicating the assessment and diagnosis is
that the client may present with various medical
conditions such as dementia.

34. COMORBIDITY
• 87% have a comorbid mental health
disorder
• Other 50% of patients have
borderline personality
disorder, ADHD, generalized anxiety
disorder, panic disorder, social
phobias, OCD, PTSD

35. TREATMENT GOALS:
• Getting acute mania under control.
• Preventing relapse once remission
occurs.
• Returning to prior level of
functioning
(social, occupational, interpersonal)

36. TREATMENT MODALITIES

37. Mood Stabilizers
• Two properties:
▫ Provide relief from acute episodes of mania or
depression or prevent them from occurring
▫ Do not worsen depression or mania or lead to
increase in cycling.
• Before administering, check the basic laboratory
studies (electrolytes, CBC, chemistries, and
pregnancy test in women of childbearing age).

38. • Lithium carbonate: first psychotropic agent
shown to prevent recurrent episodes of illness.
▫ Major indications: prevention and treatment
of mania
▫ Maintain blood levels between 0.6 to 1.2
mEq/L.
▫ Dosage: 900 to 1200mg/ day.
• Anticonvulsants:
▫ valproic acid (Depakene), divalproex
(Depakote), and carbamazepine (Tegretol)
▫ newer agents: lamotrigine (Lamictal) and
topiramate (Topamax)

39. Benzodiazepines
• Antianxiety agents often used in the acute
phase of mania or to treat the
accompanying symptoms of overwhelming
anxiety and panic in patients experiencing
Bipolar symptoms.
• Lorazepam (Ativan), clonazepam
(Klonopin), and alprazolam (Xanax)

40. Calcium Channel
Blockers
• For treatment- resistant mania as
well as for clients who cannot tolerate
lithium(preganant women, brain
injury, etc.)
• Verapamil (Calan) and nifedepine
(Procardia)

41. Antipsychotics
• Adjunct to antidepressant therapy to treat
psychotic symptoms of either acute mania or
depression.
• Current Atypical Antipsychotics:
▫ Olanzapine (Zyprexal)
▫ Quetiapine (Seroquel)
▫ Risperidone (Risperdal)
▫ Clozapine (Clozaril)
▫ Zeprasidone (Geodon)

42. Electroconvulsive Therapy
• Effective and often lifesaving
treatment for mania or depression if
pharmacologic interventions fail or if
symptom severity requires immediate
relief.

43. PSYCHOSOCIAL AND
BEHAVIORAL INTERVENTIONS

44. Treatment Considerations
• Most important consideration: SAFETY
• Important issues: confidentiality and supportive
resources for the individual and family.
• Learning to live with Bipolar Disorder requires
that the client be educated about the disorder
and receive specific instructions.
▫ Maintain a stable sleep pattern.
▫ Maintain a regular pattern of activity.
▫ Do not use alcohol or other substances.

45. ▫ Ask for and use the support of family and
friends.
▫ Reduce stress at home and at work.
▫ Be aware of own early warning signs
(often the first clue is change in sleep
needs).
▫ Develop a repertoire or problem- solving
skills.
▫ Develop awareness of automatic negative
thinking and approaches to combat
them.

46. Milieu Management in the Acute
Setting
GOALS:
• Provide a SAFE environment.
• Decrease environmental stimuli.
• Eliminate danger to self and others.
• Stabilization and medication compliance.
• Thought processes intact.

47. • Elimination of perceptual
disturbances.
• Improved social interaction/
decreased isolation.
• Improved self- esteem.
• Improved sleeping and eating
patterns.
• Psychoeducation regarding
medications and psychotherapy.

48. MILIEU MANAGEMENT
• Safety.
▫ Prevent patients from hurting themselves or
others.
▫ Consistency among staff.
 Nursing and other staff should meet often to diffuse
conflict and clarify communication.
▫ Reduction of environmental stimuli.
 Helpful environmental modifications: limited
activities with others, gross motor activities
(walking, sweeping, aerobics)
 Free public room form TV or stereo.

49. ▫ Dealing with patients who are escalating.
 Deal in a calm, confident manner.
 Administer Haloperidol.
▫ Reinforcement of appropriate hygiene and dress.
▫ Nutrition and sleep issue.
 Patients too busy to eat.
 Provide patients with foods that can be eaten on the
run (finger foods) because some patients cannot sit
long enough to eat.
 Provide high- protein, high calorie snacks for
patients. A vitamin supplement might be indicated.
 Weigh patients regularly (sometimes weighing daily
is needed).

50.  Patients who cannot sleep.
 Provide a quiet place to sleep.
 Structure patient’s days so that there are
fewer stimulating activities toward bedtime.
 Do not allow caffeinated drinks before
bedtime.
 Assess the amount of rest that patients are
receiving. Manic patients are not capable of
judging the need for rest, and exhaustion
and death have resulted from lack of rest.

51. Community Setting
• Focus: maintenance and monitoring of
medications, moods, and behaviors.
• Client and nurse must develop a healthy plan of
daily living.
• Assist the patient in understanding the
importance of continuing to take prescribed
medications and participating in any prescribed
psychotherapy.
• Psychotherapy: individual, family, or group
therapy.

52. Family Focused
• Affective lability, financial extravagance, fluctuations
in level of sociability, sexual indiscretions, and violent
behaviors- source of turmoil, conflict and concern to
the SOs.
• Education of the FAMILY is paramount during acute
periods.
▫ Functions:
 Helps family cope with their pain and suffering and
prepares them for difficult times.
 Encourages them to become active partners in the
treatment process.
 Tailor the involvement of SO to the special needs of the
individual.

53. NURSE- PATIENT RELATIONSHIP
• Matter of fact tone.
▫ Minimizes need for the patient to respond
defensively and avoids power struggles.
▫ Nurse conveys control of the situation and
empathy.
• Clear, concise directions and comments.
▫ The nurse can raise hand and say “Wait, just a
minute. I do not want to be rude, but I would
like to say something.”

54. ▫ Work out a nonverbal signal to indicate
need for the patient to stop and let
someone else speak.
▫ Keep remarks brief and simple.
▫ Limit setting.
▫ Reinforcement of reality.
▫ Respond to legitimate complaints.
 To diffuse irritability and develop trust.
▫ Redirect patients into more healthy
activity.