AL-barrak 2008
King Saud University
Faculty of nursing
Master program
Subject \
Course No. 520
Supervised by \ Prof. Dr. Elham Fayad
Prepared by \ Mofida AL-barrak
2008
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Objectives
At the end of this session the students will be able to
1. Define bipolar disorder
2. Discuss causes of bipolar disorder
3. Camper & contrast types of bipolar disorder
4. Identify sings & symptoms of bipolar disorder
5. Explain medication of bipolar disorder
6. Apply nursing process to care of a person with bipolar
disorder
Out line
1. Define bipolar disorder
2. Causes bipolar disorder
3. Types of bipolar disorder
4. Symptoms of bipolar disorder
5. Explain medication of bipolar disorder
6. Apply nursing process to care of a person with bipolar
disorder
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Introduction
Bipolar disorder, also known as manic depressive illness, is a brain
disorder that causes unusual shifts in a person’s mood, energy, & ability
to function.
Different from the normal ups and downs that everyone goes through,
the symptoms of bipolar disorder are severe.
They can result in damaged relationships, poor job or school
performance, and even suicide.
Bipolar disorder typically develops in late adolescence or early
adulthood. However, some people have their first symptoms during
Childhood and some develop them late in life. It is often not recognized
as an illness, and people may suffer for years before it is properly
diagnosed treated.
Like diabetes or heart disease, bipolar disorder is a long-term illness that
must be carefully managed throughout a person s life.
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Definition
Bipolar disorder is not a single disorder, but a category of mood
disorders defined by the presence of one or more episodes of
abnormally elevated mood, clinically referred to as mania.
Individuals who experience manic episodes also commonly experience
depressive episodes or symptoms, or mixed episodes in which features
of both mania and depression are present.
These episodes are normally separated by periods of normal mood, but
in some patients, depression and mania may rapidly alternate, known
as rapid cycling.
Extreme manic episodes can sometimes lead to psychotic symptoms
such as delusions and hallucinations.
The disorder has been subdivided into bipolar I, bipolar II, Bipolar not
otherwise specified (NOS), Cyclothymia & Dysthymia based on the type
and severity of mood episodes experienced.
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Causes
According National Institute of Mental Health (NIMH), "There is no single
cause for bipolar disorder — rather, many factors act together to produce the
illness."
Genetic factors
There is increasing evidence for a genetic component in the causation of
bipolar disorder, provided by a number of twin studies and gene linkage
studies.
The monozygotic concordance rate for the disorder is 70%. This means that if
a person has the disorder, an identical twin has a 70% likelihood of having the
disorder as well. Dizygotic twins have a 23% concordance rate. Bipolar
disorder may be a polygenic disease.
Close relatives of people suffering from bipolar illness are 10 to 20 times more
likely to develop either depression or manic-depressive illness than the general
population.
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Chemical changes
Other studies suggest that imbalances in the biochemistry controlling a
person's mood could contribute to manic-depressive illness.
Two distinct areas of the brain control mood regulation.
A dysfunction of nerves in these regions is associated with bipolar disorder.
Neurotransmitters are chemical messengers that enable nerves
to pass signals to each other and are also found to be involved in
bipolar disease
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Psychological factors
Psychological factors also play a strong role in both the psychopathology of
the disorder and the When faced with a very stressful, negative major life
event, such as a failure in an important area, an individual may have his first
major depression.
Conversely, when an individual accomplishes a major achievement he may
experience his first hypomanic or manic episode.
Individuals with bipolar disorder tend to experience episode triggers involving
either interpersonal or achievement-related life events.
An example of interpersonal-life events include falling in love or, conversely,
the death of a close friend. Achievement-related life events include acceptance
into an elite graduate school or by contrast, being fired from work
Childbirth can also trigger a postpartum psychosis for bipolar women, which
can lead in the worst cases to infanticide.
Psychoanalytic studies suggest that such environmental factors as difficult
Family relationships may aggravate manic-depressive illness.
Environmental factors
Bipolar disorder is not either environmental or physiological, it is multi
factorial; that is, many genes and environmental factors conspire to create the
disorder
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Onset
Onset of symptoms generally occurs in young
adulthood.
Episodes of illness are associated with distress and
disruption, and a relatively high risk of suicide episodes
with dangerous behavior or depressive episodes with
suicidal ideation. Hospital stays are less frequent and for
shorter periods than they were in previous years.
Prevalence
Bipolar I Disorder affects both sexes equally in all age groups
and its worldwide prevalence is approximately 3-5%.
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It can even present in preschoolers. There are no significant
differences among racial groups in the prevalence of this
disorder.
Diagnostic criteria
The following is a short synopsis according to the DSMIV-TR; “Criteria for Bipolar Disorder” includes a distinct
period of abnormality and persistently elevated,
expansive, or irritable mood for at least:
- 4 days for hypomania
- week for mania
During the period of mood disturbance, at least three or
more of the following symptoms:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
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- More talkative than usual or pressure to keep talking
- Excessive involvement in pleasurable activities that
have a high potential for painful consequences.”
Diagnostic criteria and classification(Types)
Classification of Mood Disorders
Mood Disorders
A. Depressive Disorders
1. Major Depressive Disorder, Single Episode
2. Major Depressive Disorder, Recurrent
3. Dysthymic Disorder
4. Depressive Disorder, Not Otherwise
Specified
B. Bipolar Disorders
1. Bipolar I Disorder
2. Bipolar II Disorder
3. Cyclothymic Disorder
4. Bipolar Disorder, Not Otherwise Specified
C. Secondary Mood Disorder Due to a General
Medical Condition
D. Substance-Induced Mood Disorder
E. Mood Disorder, Not Otherwise Specified
Adapted from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth ed. (DSM-IV),
Washington, DC, American Psychiatric
Association, 1994
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There is no clear consensus as to how many types of bipolar
disorder exist.
In DSM-IV-TR and ICD-10 (International classification of mental disorders),
bipolar disorder is conceptualized as a spectrum of disorders
occurring on a continuum.
The DSM-IV-TR lists four types of mood disorders which fit into the
bipolar categories: Bipolar I, Bipolar II, Cyclothymia, & Dysthymia
Bipolar Disorder NOS (Not Otherwise Specified).
Bipolar I
For a diagnosis of Bipolar I disorder according to the DSM-IV-TR,
there requires one or more manic or mixed episodes. A depressive
episode is not required for the diagnosis of Bipolar I disorder but it
frequently occurs.
Bipolar II
Bipolar II disorder is characterized by hypomanic episodes as well as
at least one major depressive episode.
Hypomanic episodes do not go to the extremes of mania (i.e. do not
cause social or occupational impairment, and without psychosis), &
this can make Bipolar II more difficult to diagnose, since the
hypomanic episodes may simply appear as a period of successful high
productivity and is reported less frequently than a distressing
depression.
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For both disorders, there are a number of specifiers that indicate the
presentation and course of the disorder, including "chronic", "rapid
cycling", "catatonic" and "melancholic".
Cyclothymia
Cyclothymia involves a presence or history of hypomanic episodes
with periods of depression that do not meet criteria for major
depressive episodes.
A diagnosis of Cyclothymic Disorder requires the presence of
numerous hypomanic episodes, intermingled with depressive episodes
that do not meet full criteria for major depressive episodes which
interfere with functioning.
Dysthymia
Also called:
Depressive Neurosis,
Dysthymic Episode,
Chronic Depression,
Depressive Personality Disorder,
Dysthymic Disorder
Dysthymia is a mood disorder characterized by chronic depression that
lasts for at least two years, but is not as severe as major depression.
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Causes
 Significant distress or
 Some impairment in function of school or work performance,
socially or otherwise, it is not as severe as the impairment caused
by major depression.
Dysthymia typically begins gradually during early adulthood, and
patients usually have trouble pointing out precisely when they first
became depressed.
It is common for patients to consider their depression normal.
Dysthymia may be associated with other mental illnesses (e.g., anxiety
disorders, substance abuse).
Improper levels of certain brain chemicals seem to be linked to
Dysthymia.
The disorder is more common in adult women and seems to have a
genetic component, making it more common in people closely related
to patients with depression.
Stressful life situations (e.g., discrimination, poverty, chronic illness)
may also be associated with the condition.
The symptoms of Dysthymia include:
 Sadness,
 Hopelessness,
 Despair or pessimism (believing everything will turn out badly),
 Fatigue or loss of energy, and
 Substantial changes in appetite.
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Bipolar-NOS
Bipolar Disorder not otherwise specified is a catch-all diagnosis
that is used to indicate bipolar illness that does not fit into the other
diagnostic categories.
If an individual clearly seems to be suffering from some type of
bipolar disorder but does not meet the criteria for one of the subtypes
above, he or she receives a diagnosis of Bipolar Disorder NOS (Not
Otherwise Specified).
Although a patient will most likely be depressed when they first
seek help.
It is important to find out from the patient or the patient's family or
friends if a manic or hypomanic episode has ever occurred. This will
prevent misdiagnosis of Depressive Disorder and avoids the use of an
antidepressant which may trigger a "switch" to hypomania or mania
or induce rapid cycling. .
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Symptoms of Bipolar Disorder
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Target Symptoms of Manic Patients
Mood
Irritable*
Expansive
Euphoric*
Manipulative
Appearance
Labile with
depression*
*also reported in
children
Hyperactivity
Sleep disturbance*
Pressured speech*
Flight of ideas*
Motor*
Distractibility*
Assaultive/threatening*
Delusional
Sexual
Persecutory*
Religious
Grandiose
Schizophreniform
Tangential
association
Ideas of reference
Catatonia
Hallucinations
(auditory &
visual)
Symptoms of the manic phase are:
Mood
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
Euphoric, the patient feels "on top of the world," &
nothing--bad news, horrifying event or tragedy--will
change his happiness.

Euphoria can quickly change into irritability or anger.
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
In either case, the mood is way out of bounds, given the
situation and the individual's personality.
Thought



Expressions of unwarranted optimism & lack of judgment.
Grandiose delusions in which the person thinks he has a special
connection with God, celebrities, or political leaders.
Flight of ideas. The person's thoughts race uncontrollably like a car
without brakes careening down a mountain.
When the person pressure talks,
Her words come out in a nonstop rush of ideas that abruptly change from
topic to topic.
In its severe form, the loud, rapid speech becomes hard to interpret because
the patient's thought processes become so totally disorganized and
incoherent.

Distractibility in which the patient's attention is easily diverted to
inconsequential or unimportant details.
Behavior
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Foolish business investments
Sexual behavior unusual for the person
spending sprees
reckless driving
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Activity

Increased energy, activity, and restlessness

Hyperactivity and excessive plans or participation in numerous activities
that have a good chance for painful results.

Patients become so enthusiastic about activities or involvements that they
fail to recognize they haven't enough time in the day for all of them.
For example, a person with bipolar illness may book several meetings,
parties, deadlines and other activities in a single day, thinking he or she can
make all of them on time.

Decreased need for sleep, allowing the patient to go with little or no sleep
for days without feeling tired.

Sudden irritability, rage or paranoia when the person's grandiose plans
are thwarted or his excessive social overtures are refused.
The manic phase can last as long as three months. As it abates, the patient may
have a period of normal mood and behavior. But eventually the depressive
phase of the illness will set in.
Depression occurs immediately or within the next few months. But with other
patients there is a long interval before the next manic or depressive episode.
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The symptoms of depressive phase are
Mood
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Feelings of worthlessness
Hopelessness
Helplessness
Total indifference and/or inappropriate guilt
Prolonged sadness
Irritability
Thought
Difficulty concentrating, remembering, making decisions

Thoughts of death or suicide attempts.
Behavior
Persistent fatigue and lethargy, insomnia or noticeable increase in the amount
of sleep needed or con not sleep
 Unexplained crying spells

Withdrawal from formerly enjoyable activities, social contacts, work or
sex.
Physical symptoms


Loss of appetite or noticeable increase in appetite
Aches and pains, constipation, or other physical ailments that cannot be
otherwise explained
Suicide
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Some people with bipolar disorder become suicidal. Anyone who
is thinking about committing suicide needs immediate attention,
Risk for suicide appears to be higher earlier in the course of the
illness. Therefore, recognizing bipolar disorder early and learning how
best to manage it may decrease the risk of death by suicide.
Signs and symptoms that may accompany suicidal feelings
Include (suicidal cues)
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Talking about feeling suicidal or wanting to die
Feeling hopeless, that nothing will ever change or get better
Feeling helpless, that nothing one does makes any difference
Feeling like a burden to family and friends
Putting affairs in order (e.g., organizing finances or giving away
possessions to prepare for one” s death)
Writing a suicide note
Putting oneself in harm way, or in situations where there is a danger
of being killed
Previous attempt of suicidal
Collected medication
Cause
 Untreated depression is the number one cause for suicide.
 Untreated mental illness (including depression, bipolar disorder,
schizophrenia, and others) is the cause for the vast majority of
suicides.
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Other causes
 Failure in exam, live story, death of lived one
Female attempts suicidal more than male but male success in suicide
Modes of suicide






Hanging
Cutting vein
Drawing
Fire
Drugs
Falling from high place
Medication
Modern evidence based psychotherapies designed specifically for bipolar
disorder when used in combination with standard medication treatment
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increase the time the individual stays well significantly longer than
medications alone
Psychotherapeutic factors aimed at
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Alleviating core symptoms.
Recognizing episode triggers.
Reducing negative expressed emotion in relationships.
Recognizing prodromal symptoms before full-blown recurrence, and,
Practicing the factors that lead to maintenance of remission
TREATMENT
Depressive Episode
Manic Episode
Treatments for Bipolar
Depression
Treatments for Mania
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
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Lithium and
anticonvulsants prevent
suicide
Lithium (for prevention of
future depression and
suicide)
Carbamazepine (for
prevention of future
depression)
Lamotrigine (for
depression)
Olanzapine (for suicidal
ideation in bipolar I manic
or mixed-episode patients)
Quetiapine (for
depression)
Fluoxetine (for
depression)
Imipramine (for
depression but not
prevention of future
depression)
Tranylcypromine (for
depression)
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Lithium (for mania &
prevention of future
mania (59% success
rate), but increases risk of
diabetes insipidus and
hypothyroidism)
Carbamazepine (for
mania & prevention of
future mania)
Divalproex sodium (for
mania but not prevention
of future mania, but
increases risk of
polycystic ovaries and
hyperinsulinemia)
No difference between in
generic valproic acid and
divalproex sodium in
hospitalization
Olanzapine (for mania
but increases risk of
weight gain & diabetes)
Olanzapine (for suicidal
ideation in bipolar I
manic or mixed episodes)
Quetiapine (for mania)
Risperidone (for mania)
Haloperidol (for mania)
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
Caution: is the increased
use of atypical
antipsychotic medication
(e.g., olanzapine) causing
an increased risk of
stroke, heart disease and
hypertension?
Promising (But Unproven) Promising (But Unproven)
Treatments for Bipolar
Treatments for Mania
Depression
 Clozapine (but increases
risk of diabetes and
 Amitriptyline (with moodagranulocytosis)
stabilizer)
 Electroconvulsive
 Cognitive Therapy (with
Therapy
mood-stabilizer)
 Lamotrigine (for
 Electroconvulsive
prevention of future
Therapy (no placeborapid-cycling)
controlled trials)
 Phenytoin (with
 Family Psychoeducation
neuroleptic for mania}
(with mood-stabilizer)
 Topiramate (but has
 Group Psychoeducation
serious side-effects)
(with mood-stabilizer)
 L-Sulpiride (with moodstabilizer)
 Moclobemide (with
mood-stabilizer)
 Paroxetine (with mood24
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

stabilizer)
Psychotherapy (with
mood-stabilizer)
Venlafaxine (with moodstabilizer)
when giving lithium the nurse must do the following
1. Complete Blood Count with Differential
Lithium causes leukocytosis, which could be later confused with
an infection.
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2. Multichannel Chemistry
Serum creatinine (SCr) & blood urea nitrogen (BUN)
Lithium is eliminated by the kidney, and adequate renal function
must be present to prevent toxicity.
3. Electrolytes
Hyponatremia may result in rapid intoxication with lithium since
the kidney will increase reabsorption of lithium in the proximal
tubule in place of the missing sodium.
4. Urinalysis (Specific Gravity)
Lithium inhibits anti-diuretic hormone (ADH or vasopressin) by
uncoupling the cell surface receptor from the intracellular
adenylate cyclase. This clinically results in a decreased specific
gravity (<1.010).
5. Thyroid Function Tests (T3, T4, TSH)
During long-term lithium treatment, TSH determinations are
recommended every 6 to 12 months, as well as monitoring for
signs and symptoms of hypothyroidism. Fatigue, vague somatic
complaints, coarsening of skin, brittle hair, cold intolerance,
decreased interest in activities, and depression are common
symptoms of hypothyroidism.
6. ECG
Lithium can cause many cardiac dysrhythmias as well as
exacerbate pre-existing ones. Frequently, lithium will decrease
the area-under-the-curve of the S-T segment similar to
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hypokalemia.
7. b-HCG Pregnancy Test (All Females not Known to be
Sterile)
Lithium is a known teratogen (Epstein’s anomaly) during the
period of organogenesis (1st trimester).
Application of the nursing process to the client with a mood
disorder
Assessment
Nursing assessment of depressive and manic behaviors involves systematic,
thorough consideration of the client’s safety, psychological functioning or
mental status (including affect, thought processes, and intellectual processes),
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physiological, psychobiological, psychomotor activity, behavioral and social
activity.
Nursing diagnosis
Common diagnoses for clients with mood disorders are as
follows:
* Risk for suicide related to impaired judgment and distorted
thinking (client with depressive or bipolar disorder) or
impulsivity (client with bipolar disorder).
* Risk for violence toward others related to impulsivity &
impaired judgment (client with bipolar disorder) or agitation
and low tolerance level (client with agitated depression).
*Ineffective health maintenance related to lack of attention,
lack of concern for self, and low self – esteem (client with
depressive disorder) or low attention threshold, hyperactivity,
and lack of attention to self – care needs (client with bipolar
disorders).
* Impaired social interaction related to distorted thinking,
feelings of low self – esteem, disorientation, or restlessness.
* Disturbed thought processes related to bio – chemical
imbalances or psychological stress.
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* Ineffective therapeutic regimen management related to
lack of knowledge about medications and lack of incentive to
maintain medication regime – men upon discharge.
Planning
Goals for clients with mood disorders include the
following:
 The client will remain safe throughout the hospitalization
,without harming self or others
 The client will demonstrate self control in milieu activities
and interactions with others including maintaining
appropriate boundaries and refraining from aggressive or
risky behaviors.
 The client will have adequate food and fluid intake will
maintain balanced rest sleep and activity and will maintain
personal care.
 The client will engage in appropriate social behavior.
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 The client will demonstrate logical reality based thought
processes.
 The client will consistently maintain the medication
regimen, including taking medications as ordered and
following up with his or her care provider for appropriate
post discharge visits and laboratory work.
Nursing care plan
The client with depression
Nursing diagnosis
Risk for suicide related to depression & feelings of self-blame
& worthlessness as evidenced by the comment, “I’m really no
good to anyone anymore. I just wish I were not here to bother
everyone.”
Goal
She will not harm herself
Interventions
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 Perform a suicide assessment & determine client’s level of
risk
 Repeat assessment frequently over the next 2 months
 Develop a contract with the client in whom the client
agrees to not harm herself & to immediately contact the
therapist if she has suicidal thoughts.
Evaluation
The effectiveness of the plan to prevent self-harm through
frequent assessment & a contract is determined by she
adhering to the contract & not harming.
Nursing diagnosis
Disturbed sleep pattern related to depression as evidenced by
nighttime inability to sleep & daytime lethargy
Goal
She will reestablish a natural pattern of sleep
Interventions
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 Encourage the client to establish normal sleep wake
routines by refraining from napping during the day.
 Suggest establishing nighttime routines that induce sleep,
such as taking a hot bath or reading a book.
 Instruct client about medications & the sleep wake
schedule.
The client with bipolar disorder in the manic phase.
Nursing diagnosis
Risk for other directed violence related to psychiatric
illness as evidenced by poor impulse control when angry
Goal
Danielle will mange her anger appropriately & nor harm
or threaten others.
Interventions
 Perform a violence assessment & determine client’s
level of risk
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 Discuss anger management with client & determine
what behaviors are appropriate when angry.
 Role model appropriate anger management & give the
client feedback on her behavior.
 Limit the client’s environment & remove dangerous
objects.
 Use sedative medication as needed & physical restraint
or seclusion as a last resort.
Evaluation
Anger management strategies for Danielle can be
considered effective if the following outcomes are met:
 Danielle refrains from harming others
 Angry outbursts diminish
 Danielle uses strategies for coping with anger &
frustration.
Nursing diagnosis
Disturbed thought process related to psychiatric illness as
evidenced by unrealistic, grandiose comments; pressured
speech; flight of ideas; & incongruent affect
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Goal
Danielle will exhibit reality based thinking, appropriate
thought content & appropriate social activity.
Intervention
 Use a calm forthright approach with the client & provide
clear directions for the client establish firm expectations
for behavior and communicate these limits clearly to the
client have
 All staff members enforce limits consistently avoid getting
in to power struggles or trying to dissuade the client from
her grandiose delusional ideas.
 Accept acting out behavior neutrally do not respond with
irritation or anger avoid feeding in to client jokiness and
maintain a professional demeanor redirect client in to
productive or more appropriate activities
Evaluation
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It may take 1 to 2 weeks for Danielle’s medication to begin
effectively stabilizing her mood which will correct the
delusional grandiose thinking during this time the effectiveness
of the interventions can be evaluated by noting if danielle
maintains an affect consistent with her mood and maintains
limits set by staff members.
Summary
Bipolar I Disorder is one of the most severe forms of mental illness & is
characterized by recurrent episodes of mania and (more often) depression.
The condition has a high rate of recurrence and if untreated, it has an
approximately 15% risk of death by suicide.
It is the third leading cause of death among people aged 15-24 years, and is the
6th leading cause of disability (lost years of healthy life) for people aged 1544 years in the developed world
References
1. Jamison, Kay Redfield. 1995. An Unquiet Mind: A Memoir of
Moods and Madness. New York: Knopf.
2. Simon, Lizzie. 2002. Detour: My Bipolar Road Trip in 4-D. New
York: Simon and Schuster.
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3. Behrman, Andy. 2002. Electroboy: A Memoir of Mania. New York:
Random House..
4. Kelly, Madeleine Bipolar and the Art of Roller-coaster Riding.
Strathbogie: Two Trees Media 2005
5. Joseph, J. 2006. The Missing Gene: Psychiatry, Heredity, and the
Fruitless Search for Genes. New York: Algora.
6. Earley, Pete. Crazy. 2006. New York: G. P. Putnam's Sons.
7. About Pediatric Bipolar Disorder:
Examples of typical and atypical antipsychotic
Traditonal Antipsychotic medications include:


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Haldol (Haloperidol)
Mellaril (Thioridazine)
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

Stelazine (Trifluoperazine)
Thorazine (Chlorpromazine)
The new atypical antipsychotic medications used for treatmentrefractory (those not responding to traditional drugs)
consumers are:


Clozaril (Clozapine)
Risperidol (Risperidone)
(These medications also have fewer extrapyramidal effects)
.
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