Bipolar Disorder

1. People at Increased risk of suicide and suicide
attempts
Clients with
schizophrenia
Substance use
disorders
Borderline
personality
disorders
Panic disorders
Antisocial
disorders

2. BIPOLAR DISORDER
Fluctuation of mood to extremes of
mania or depression.
Mania is a distinct period during which
mood is abnormally and persistently
elevated, expansive, or irritable.

3. BIPOLAR DISORDER
Manic Episode
● Inflated self-esteem or grandiosity
● Decreased sleep
● Excessive and pressured speech
● Flight of ideas
● Distractibility
● Increased activity or psychomotor agitation
● Excessive involvement in pleasure-seeking

4. BIPOLAR DISORDER
Hypomania is a period of abnormally
and persistently elevated, expansive, or
irritable mood and some other milder
symptoms of mania.
● Do not impair ability to function
● No psychotic features
Mixed episode also called as Rapid Cycling
Experiences both mania and depression.

5. BIPOLAR DISORDERS
BIPOLAR I BIPOLAR II
one or more major
depressive episodes
accompanied by at least
one hypomanic episode
one or more manic or
mixed episodes usually
accompanied by major
depressive episodes
BIPOLAR MIXED
Cycles alternate between
periods of mania, normal
mood, depression, normal
mood, mania & so forth

6. Biologic
A. Genetic
B. Neurochemical
C. Neuroendocrine
01
Psychodynamic
02

7. Genetic Theories
❑ first-degree relatives are:
(a) 2x at risk for developing major
depression
(b) 7x at risk for developing bipolar disorder
❑ Monozygotic (identical) twins have 2-4x at
risk higher than dizygotic (fraternal) twins
❑ genetic overlap between early-onset bipolar
disorder and early-onset alcoholism
Biologic:

8. ❑ Serotonin for mood, activity, aggressiveness and irritability,
cognition, pain, biorhythms, and neuroendocrine processes.
• insufficient serotonin => tryptophan or 5-hydroxyindole
acetic acid in the blood or CSF in people with depression
• reduced metabolism in the prefrontal cortex, which may
promote depression
❑ Norepinephrine levels may be deficient in depression and
increased in mania
• energizes the body to mobilize during stress and inhibits
kindling
• Anticonvulsants inhibit kindling thus treat bipolar disorder.
Neurochemical Theories
Biologic:

9. ❑ Acetylcholine and Dopamine dysregulation
are related to mood disorders
• Cholinergic drugs change mood, sleep, neuroendocrine
function, and the electroencephalographic pattern thus
acetylcholine is linked to depression and mania.
Neurochemical Theories
Biologic:

10. Neuroendocrine Influences
❑ People with endocrine disorders have been
linked to mood disturbances
❑ Elevated glucocorticoid activity is
associated with the stress response
❑ Approx. 5% to 10% of people with depression
have thyroid dysfunction (high TSH)
Biologic:

11. 1. The self-depreciation of people with depression
becomes self-reproach and “anger turned inward”
related to either a real or perceived loss.
2. A person’s ego aspires to be ideal, and that to be
loved and worthy, must achieve these high
standards.
3. The state of depression is like a situation in which the
ego is a powerless, helpless child who is victimized
by the superego, much like a powerful and
sadistic parent who takes delight in torturing the
child.
Psychodynamic

12. 4. Manic episodes as a “defense” against
underlying depression, with the ID taking over the
ego and acting as an undisciplined hedonistic being
(child).
5. Depression is a reaction to a distressing life
experience.
6. Children raised by rejecting or unloving parents
are prone to feelings of insecurity and loneliness.
7. Depression is a result of specific cognitive
distortions in susceptible people.
Psychodynamic

13. PREPARED BY: BILL MANUZON | BSN3A
BIPOLAR
DISORDER

14. Mania Depression
Andehonia, and changes in
weight, sleep, energy,
concentration, decision-
making, self-esteem, and
goals.
Clients are euphoric,
restless, grandiose,
energetic, and sleepless.

15. Bipolar Type
Manic episodes with at
least 1 depressive episode.
I

16. Bipolar Type
Recurrent depressive
episodes with at least 1
hypomanic episode.
II

18. Onset and Clinical Course
1. Average age of onset is teens, early 20s or 30s for both men
and women.
2. The diagnosis of a manic episode or mania requires at least 1
week of unusual and incessantly heightened mood.
3. Clients often do not understand how their illness affects
others.

19. Psychopharmacology
1. Lithium- stabilizes bipolar disorder by reducing the degree
and frequency of cycling or eliminating manic or depressive
episodes.
2. Anticonvulsant drugs- calms hyperactivity in the brain. These
drugs may raise the brain’s threshold for dealing with
stimulation.

22. DSM5-TR DIAGNOSTIC CRITERIA
Manic Episode

23. DSM5-TR DIAGNOSTIC CRITERIA
Manic Episode

24. DSM5-TR DIAGNOSTIC CRITERIA
Manic Episode

25. DSM5-TR DIAGNOSTIC CRITERIA
Manic Episode
Note: A full manic episode that emerges during antidepressant
treatment (e.g., medication, ECT) but persists at a fully
syndromal level beyond the physiological effect of that
treatment is sufficient evidence for a manic episode and therefore a
bipolar I diagnosis.
Note: Criteria A to D constitute a manic episode. At least one
lifetime manic episode is required for the diagnosis of bipolar I
disorder.

26. Assessment
Data Analysis
Outcome
Identification
01 NCP: Mania
02
03 04
WHAT ARE WE DISCUSSING?

27. Intervention
05 Evaluation
06
WHAT ARE WE DISCUSSING?

28. ASSESSMENT
HISTORY TAKING
Obtaining data in several short
sessions as well as talking to family
members may be necessary

29. ASSESSMENT
GENERAL APPEARANCE
& MOTOR BEHAVIOR
• Clients with mania experience psychomotor
agitation and seem to be in perpetual
motion; sitting still is difficult.
• Manic phase, client may wear cloths that
reflect the elevated mood
• Clients experiencing a manic episode think,
move, and talk fast.

30. ASSESSMENT
MOOD AFFECT
Mania is reflected in periods of
euphoria, exuberant activity,
grandiosity, and false sense of
well-being.

31. ASSESSMENT
THOUGHT PROCESS
& CONTENT
• Cognitive ability or thinking is confused and
jumbled with thoughts racing one after
another, which is often referred to as flight of
ideas.
• These clients start many projects at one time,
but cannot carry any to completion.

32. ASSESSMENT
SENSORIUM AND
INTELLECTUAL PROCESSES
Clients may be oriented to person
and place but rarely to time.

33. ASSESSMENT
JUDGMENT AND INSIGHT
• People in the manic phase are easily
angered and irritated and strike back at
what they perceive as censorship by others

34. ASSESSMENT
SELF-CONCEPT
Clients with mania often have
exaggerated self-esteem

35. ASSESSMENT
ROLES AND RELATIONSHIPS
• Clients in the manic phase can rarely fulfill
role responsibilities.
• Usual mood of manic people is elation,
emotions are unstable and can fluctuate
(labile emotions) readily between euphoria
and hostility.

36. ASSESSMENT
PHYSIOLOGICAL AND SELF-CARE
CONSIDERATIONS
Clients with mania can go days
without sleep or food and not even
realize they are hungry or tired.

37. NURSING DIAGNOSIS
Disturbed Thought Processes: Disruption in cognitive operations and activities

38. ASSESSMENT
• Disorientation
• Decreased concentration, short attention span
• Loose associations (loosely and poorly associated ideas)
• Push of speech (rapid, forced speech)
• Tangentiality of ideas and speech
• Hallucinations
• Delusions

39. EXPECTED OUTCOMES
• Demonstrate orientation to person, place,
and time within 24 hours.
• Demonstrate decreased hallucinations or
delusions within 24 to 48 hours.
• Talk with others about present reality within
2 to 3 days.

40. NURSING INTERVENTIONS
1. Set and maintain limits on behavior that is destructive or
adversely affects others.
2. Initially, assign the client to the same staff members when
possible.
3. Reorient the client to person, place, and time as indicated.
4. Provide a consistent, structured environment.
5. Spend time with the client.
6. Use a firm yet calm, relaxed approach.
7. Make only promises you can realistically keep.
8. Avoid highly competitive activities.

41. DATA ANALYSIS
Nurse analyzes assessment data to determine
priorities and to establish a plan of care.
• Risk for other-directed violence
• Risk for injury
• Imbalanced nutrition: Less than body requirements
• Ineffective coping
• Noncompliance
• Ineffective role performance
• Self-care deficit
• Chronic low self-esteem
• Disturbed sleep pattern

42. OUTCOME IDENTIFICATION
Examples of outcomes appropriate to mania are:
• The client will not injure self or others.
• The client will establish a balance of rest, sleep, and activity.
• The client will establish adequate nutrition, hydration, and elimination.
• The client will participate in self-care activities.
• The client will evaluate personal qualities realistically.
• The client will engage in socially appropriate, reality-based interactions.
• The client will verbalize knowledge of his or her illness and treatment.

43. INTERVENTIONS
PROVIDING SAFETY
• A primary nursing responsibility is to provide a safe
environment for clients and others.
• It is important to monitor the clients’ whereabouts and
behaviors frequently.

44. INTERVENTIONS
PROVIDING THERAPEUTIC COMMUNICATION
• Clients with mania have short attention spans, so the
nurse uses clear, simple sentences when
communicating.

45. INTERVENTIONS
PROVIDING THERAPEUTIC COMMUNICATION
• Clients are agitatedly talking, they are usually thinking
and moving just as quickly, so it is a challenge for the
nurse to follow a coherent story.

46. INTERVENTIONS
PROMOTING APPROPRIATE BEHAVIORS
• Clients need to be protected from their pursuit of socially
unacceptable and risky behaviors.

47. INTERVENTIONS
MANAGING MEDICATIONS
• It is important to assess for signs of toxicity and to ensure
that clients and their families have this information before
discharge
• Lithium Carbonate Therapeutic Range is 0.5 – 1.6 mEq/L

48. INTERVENTIONS
Symptoms and Interventions of Lithium Toxicity
• 1.5 – 2 mEq/L ; Nausea and vomiting, diarrhea,
reduced coordination, drowsiness, slurred
speech, and muscle weakness.

49. INTERVENTIONS
Symptoms and Interventions of Lithium Toxicity
• 2 – 3 mEq/L ; Ataxia, agitation, blurred vision, tinnitus,
giddiness, choreoathetoid movements, confusion, muscle
fasciculation, hyperreflexia, hypertonic muscles, myoclonic
twitches, pruritus, maculopapular rash, movement of limbs,
slurred speech, large output of dilute urine, incontinence of
bladder or bowel, and vertigo

50. INTERVENTIONS
Symptoms and Interventions of Lithium Toxicity
• 3 mEq/L & Above; Cardiac arrhythmia, hypotension,
peripheral vascular collapse, focal or generalized seizures,
reduced levels of consciousness from stupor to coma,
myoclonic jerks of muscle groups, and spasticity of muscles

51. INTERVENTIONS
PROVIDING CLIENT & FAMILY TEACHING
• Education about the cause of bipolar disorder,
medication management, ways to deal with behaviors,
and potential problems that manic people can
encounter is important for family members.

52. EVALUATION
Evaluation of the treatment of bipolar disorder
includes, but is not limited to:
• Safety issues
• Comparison of mood and affect between start of treatment and present
• Adherence to treatment regimen of medication and psychotherapy
• Changes in client’s perception of quality of life
• Achievement of specific goals of treatment, including new coping methods

53. Serotonin Syndrome
01 Serotonin syndrome
occurs when there is an
inadequate washout
period between taking
MAOIs and SSRIs or
when MAOIs are
combined with
meperidine
02
DRUG ALERT !!!
Overdose of MAOI and
Cyclic Antidepressants
02
03
MAOI Drug
Interactions
Amphetamines, Ephedrine, Fenfluramine, Isoproterenol,
Meperidine, Phenylephrine, Phenylpropanolamine,
Pseudoephedrine, SSRI antidepressants, Tricyclic
antidepressants, Tyramine

54. OTHER MEDICAL TREATMENTS
ELECTROCONVULSIVE
THERAPY
Transcranial Magnetic
Stimulation (TMS);
Magnetic Seizure Therapy;
Deep Brain Stimulation ;Vagal
Nerve Stimulation
It involves application of electrodes to
the head of the client to deliver an
electrical impulse to the brain; this
causes a seizure. It is believed that the
shock stimulates brain chemistry to
correct the chemical imbalance of
depression

55. PSYCHOTHERAPY
Interpersonal therapy
It focuses on difficulties in relationships, such as
grief reactions, role disputes, and role
transitions.
Behavior Therapy
It seeks to increase the frequency of the client’s
positively reinforcing interactions with the
environment and to decrease negative interactions.
Cognitive Therapy
It seeks to increase the frequency of the client’s
positively reinforcing interactions with the
environment and to decrease negative interactions.
It focuses on how the person thinks about the self,
others, and the future and interprets his or her
experiences.

56. MENTAL HEALTH PROMOTION
The nurse must monitor his or her feelings
and closely when dealing with clients
wireactionsth depression to be sure that he
or she fulfills the responsibility to establish
a therapeutic nurse–client relationship

57. Points to Consider When Working with
Clients with Mood Disorders
• Remember that clients with mania may seem happy, but they are suffering
inside.
• For clients with mania, delay client teaching until the acute manic phase
is resolving.
• Schedule specific, short periods with depressed or agitated clients to
eliminate unconscious avoidance of them.
• Do not try to fix a client’s problems. Use therapeutic techniques to help
him or her find solutions.
• Use a journal to deal with frustration, anger, or personal needs.
• If a particular client’s care is troubling, talk with another professional
about the plan of care, how it is being carried out, and how it is working.