Bipolar Disorder 1

Running Head: Bipolar Disorder

Bipolar Affective Disorder

Bipolar Affective Disorder

Bipolar disorder is a chronic, recurring illness that must be carefully managed

throughout a person’s life (Varcarolis, 2006). Bipolar disorder is the third most common
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mood disorder after major depression and dysthymic disorder. The disorder affects

approximately one out of every seven people. The onset of this disorder usually occurs

between twenty and thirty years of age. The majority of patients with bipolar disorder

will experience significant symptoms before the age of twenty-five years. Without

effective treatment, it leads to suicide in nearly 20% of cases, which is 30 times higher

than the general population.

Etiology

Bipolar disorder is defined as “an affective disorder characterized by extreme

changes in mood ranging from mania to depression” ("Exploring bipolar," 2007). This

disorder can best be compared to a mountain range, with high peaks of euphoria and low

valleys of depression. A person with Bipolar disorder has mood swings ranging from

mania to deep depression, with periods of normal behavior in between. Mania is “a mood

characterized by an unstable expansive emotional state, extreme excitement, excessive

elation, hyperactivity, agitation, over talkativeness, flight of ideas, increased psychomotor

activity, fleeting attention, and sometimes violent, destructive, and self-destructive

behavior” (Anderson, 2007). Depression, on the other hand, is “characterized by feelings

of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness that are

inappropriate and out of proportion to reality” (Anderson, 2007). It is not unusual for the

periods of normality to last longer than the mania or the depression.

Bipolar disorder was first clinically described near the end of the 19th century by

psychiatrist Emil Kraepelin, who published his account of the disease in his Textbook of

Psychiatry. Bipolar Disorder is also commonly (and wrongly) called "manic depression"
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by laymen (and by some psychiatrists in the twentieth century) although this usage is now

unpopular with psychiatrists, who have standardized on Kraepelin's usage of the term to

describe the whole bipolar spectrum (“Bipolar Disorder,” 2007).

DSM-IV-TR Criteria

“Bipolar disorder takes two principal forms, neither of which requires plural

"cycles". According to the DSM-IV-TR (p. 345), the two principal forms of Bipolar

disorder are: Bipolar I disorder, the diagnosis of which requires over the entire course of

the patient's life at least one manic (or mixed state) episode which is usually (though not

always) accompanied by episodes of Major Depressive disorder. Bipolar II disorder,

which over the course of the patient's life must involve at least one Major Depressive

episode and must be accompanied by at least one hypomanic episode; i.e. there need be

no full manic episodes at all” (“Bipolar Disorder,” 2007).

Epidemiology

Current estimates suggest that approximately two million Americans suffer from

Bipolar disorder. Affecting males and females equally, the illness is found more

frequently in first degree relatives of people known to have it. “It has had notable

incidence among creative individuals, affecting such artists as Hector Berlioz, Gustav

Mahler, Ernest Hemingway, and Virginia Woolf” (“Manic-depressive,” 2007).

The illness normally begins in early adulthood or adolescence (in few instances it

has been diagnosed in children) and continues throughout life. About a half of all people

afflicted show the first signs of the disorder in their teenage years. Often people suffer
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needlessly for years or even decades without even recognizing that they have the

disorder.

Biological Theory

“The causes of the disorder are multiple and complex, often involving biological,

psychological, interpersonal, and social and cultural factors” (Anderson, 2007). Intensive

effort is currently being put into identifying the genes involved in Bipolar disorder. “One

candidate gene which might cause Bipolar codes for the serotonin transporter. Serotonin

(a neurotransmitter) is involved in a variety of behaviors including sleep, moods, and

activity, all of which are affected to some degree in Bipolar disorder” (Ketcham, 2007).

Characteristics of Mania

Bipolar disorder can be recognized by many signs and symptoms. There are many

signs of the manic stage of bipolar disorder. Some of these are apparent and, on the other

hand, many are discreet. An increased energy, activity and restlessness occur, along with

racing thoughts and rapid talking. A person experiencing mania has an excessive “high”

or euphoric outlook on life, and an unrealistic belief in their own abilities and powers.

This person may also have a decreased need for sleep. Many times a person in the manic

stage is extremely irritable and easily distracted. This person shows poor judgment and a

period of behavior that is different from their usual self. This clearly can cause serious

problems. For example, a person might spend all of their money at any sporadic moment

just because they have the urge to buy. A manic person may also experience an increased

sexual drive, abuse of drugs, aggressive behavior, and a denial that anything is wrong
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(Varcarolis, 2006). It is not uncommon for manic patients to get involved in reckless

behavior, and to start abusing alcohol. These can all be signs of a serious problem and

could potentially be life threatening.

Characteristics of Depression

Symptoms of depression include periods of: persistent sad, anxious, or empty

mood with hopelessness and feelings of guilt, worthlessness, or helplessness. Patients’

may also experience a loss of interest or pleasure in ordinary activities, including sex. A

depressed person may also show signs of decreased energy, a feeling of fatigue or of

being "slowed down." Difficulty concentrating, remembering, or making decisions are

also prevalent. The depressed person may also show signs of restlessness or irritability

with sleep disturbances. They may also experience a loss of appetite and weight loss

along with chronic pain or other persistent bodily symptoms that are not caused by

physical disease (Varcarolis, 2006). Thoughts of death or suicide; suicide attempts are

also prevalent (“Rates of Bipolar,” 2007). People with this disorder do not recognize how

impaired they may be. They sometimes blame their problems on some other cause other

than a mental illness. For this reason awareness is the key to treatment.

Studies show that bipolar depression (and not mania) predicts greater illness

burden and chronicity. Depressive symptoms are more frequent than manic symptoms

and are more likely to disrupt work as well as social and family life functioning than

manic symptoms. Markedly diminished interest or pleasure in nearly all activities,

significant weight loss when not dieting or weight gain, insomnia or hypersomnia,

psychomotor agitation or retardation, and diminished ability to think or concentrate.

 Bipolar Disorder 6

These symptoms affect the physical, emotional, and social functioning of an individual

and can have a significant effect on the overall quality of life (Robert, 2005). People with

bipolar disorder need encouragement and support from their family and friends to seek

treatment.

Medical and pharmacologic treatment

Treatments such as medications, group therapy, and electroconvulsive therapy can

improve the mental state of those with this disorder. If a person experiencing bipolar

disorder does not receive treatment, the disorder can become worse. It could even break

out into mania and a clinical diagnosis of depression. Thoughts of death and suicidal

tendencies are common among those with bipolar disorder. A sense of hopelessness and

failure can make suicide seem like a favorable way out. Most patients’ with bipolar

disorder can be treated successfully. There are drugs available that can help stabilize

moods swings brought on by this disorder. One such medication is lithium. This drug is

very effective at controlling the mania and preventing the recurrence of both the manic

and depressive episodes (Varcarolis, 2006).

Carbamazepine and valproate are mood stabilizing anticonlvulsants that have

been found to treat some clients with treatment resistant bipolar disorder. Many times

these drugs are combined with lithium for a maximum effect. These are used on both

children and adults alike. For depression, lithium is often prescribed and can be used in

conjunction with anticonvulsants and anxiolytics (Varcarolis, 2006).

Pharmacological effectiveness
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Medication non-adherence is a recurring problem that is high among patients with

bipolar disorder, and may lead to poor clinical outcomes, decreased quality of life, and

increased resource utilization. Patients’ socioeconomic characteristics can affect

medication adherence. Non-adherent individuals were more likely to be younger,

unmarried, nonwhite, or homeless (Sajatovic, 2007). Being white and having more

education has a significant positive effect on adherence. Medication outcome attributes,

especially severity of depressive episodes, strongly influence patients' stated adherence to

treatment. Weight gain and cognitive effects of a medication most significantly affected

patients' likely adherence to medications for bipolar disorder (Johnson, 2007). The

effectiveness of bipolar medication treatments is highly reduced by rates of non-

adherence in clinical settings.

Psychosocial Therapy

Given the recurring problems of medication non-adherence, other treatment

alternatives are clearly needed. Psychotherapies provide treatment options that will not

induce mania. Patient’s who receive standard pharmacotherapies along with intensive

psychotherapy demonstrated better total functioning, relationship functioning, and life

satisfaction compared to those receiving only collaborative care (Strakowski, 2007).

Psychotherapy helps to provide support, education, and guidance to the patient and their

family. Because bipolar disorder is a recurrent illness, a long-term treatment plan is often

recommended. An additional form of treatment that does not involve

psychopharmacology, or can be used in conjunction with it, is ECT, or electroconvulsive

therapy. Electroconvulsive therapy is effective in the treatment of acute mania and

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depression in bipolar disorder. ECT should be used for persons who have an immediate

and serious risk of suicide, followed by long-term psychotherapy. Lastly, many patients’

with bipolar disorder find that the adoption of self management techniques such as

keeping a daily mood diary, or striving to maintain regular patterns of activity and

employing a range of relaxation and stress management techniques such as yoga or tai chi

can make a real difference to their condition (Wellman, 2007).

Psychoeducation

Psychoeducation and intensive psychosocial treatment can also enhance

relationship functioning and life satisfaction among patients with bipolar disorder.

Alternate interventions focused on the specific cognitive deficits of individuals with

bipolar disorder may be necessary to enhance vocational functioning after a depressive

episode (Miklowitz, 2007).

Psychoeducation is based on the premise that individuals have a fundamental

right to have information regarding their illness, and individuals who are informed are

more likely to take a more active role in managing their illness, which results in better

health outcomes.

Psychoeducation strategies for bipolar disorder that have contributed to positive

outcomes have ranged from simple one-site, education-only interventions that improve

lithium adherence and attitudes about medications to a more complex, multi-site,

collaborative care system intervention that yielded shorter durations of affective episodes
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for patients, improved functioning and quality of life, and treatment satisfaction

(Miklowitz, 2007).

Nursing Care

Mental Health nurses use critical thinking skills to analyze, and evaluate

information gathered by observation, experience, reflection, reasoning, and

communication as a guide to make many important decisions regarding their patients care

(Kozier et al., 2004). Nursing diagnosis vary for the manic-depressive client. It is

important for mental health nurses to approach clients with kindness, compassion, and

concern. The nurse must also assess the client’s level of mood, behavior, and thought

processes and should be alert to cognitive dysfunction. Analyzing the objective and

subjective data helps the nurse to formulate appropriate nursing diagnosis (Varcarolis,

2006).

Nursing Diagnosis & Interventions

Some of the nursing diagnoses appropriate for bipolar patients are: Risk for injury

related to dehydration and faulty judgment, as evidenced by inability to meet own

physiological needs and set limits on own behavior. A short term goal for this diagnosis

is to keep client well hydrated, as evidenced by good skin turgor and normal urinary

output and specific gravity, within 24 hours. With this diagnosis it is important to: 1)

Give Haloperidol intramuscularly immediately as ordered. Continuous physical activity

and lack of fluids can eventually lead to cardiac collapse and death. 2) Check vital signs

frequently. Cardiac status must be monitored on a regular basis. 3) Whenever possible

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place client in a private or quiet room. Environmental stimuli are reduced-escalation of

mania and distractibility is minimized. 4) Maintain record of intake and output. Such a

record allows staff to make accurate nutritional assessment for clients’ safety

(Varcarolis, 2006).

Defensive coping related to biochemical changes, as evidenced by change in usual

communication patterns. A short term goal for this diagnosis is to allow the client to rest

or sleep for 3 hours during the first hospitalization night with the aid of medication and

nursing interventions. With this diagnosis it is important: 1) When possible try to direct

energy into productive and calming activities. Directing client to paced, non-stimulating

activities can help to minimize excitability. 2) Encourage short rest periods throughout the

day. Client may be unaware of feelings of fatigue and can collapse from exhaustion if

hyperactivity continues without periods of rest. 3) Client should drink decaffeinated

drinks only. Caffeine is a central nervous system stimulant that inhibits needed rest or

sleep. 4) Provide nursing measures at bedtime that promote sleep-warm milk or soft

music. Such measures promote non-stimulating and relaxing mood (Varcarolis, 2006).

Imbalanced Nutrition: less than body requirements related to failure to eat, as

evidenced by client has been distracted, agitated, and has not eaten for days. A short term

goal for this diagnosis is after 3 hours, client will start drinking small amounts of fluid (2-

4 oz per hour). With this diagnosis it is important: 1) Check vital signs frequently (every

1-2 hours). Cardiac status is monitored. 2) Offer high calories, high protein drink every

hour in a quiet area. Proper hydration is mandatory for maintenance of cardiac status. 3)

Frequently remind client to drink. Client’s concentration is poor; they are easily
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distracted. 4) Maintain record of intake and output. Such a record allows staff to make

accurate nutritional assessment for client’s safety (Varcarolis, 2006).

Conclusion

In summary, patients are the final health care decision makers; their satisfaction

with a medication is likely to affect whether or not they will adhere to the medication

prescribed by their physician (Johnson, 2007). By understanding the factors that improve

adherence, health care providers can optimize prescribing patterns, which may ultimately

lead to more effective management and improvement in the patient's condition. Many

individuals with bipolar disorder remain relatively uninformed regarding their illness,

creating potential barriers to optimal treatment adherence, and limiting self-management

skills.

Primary care providers play a vital role in the recognition and management of

bipolar disorder and in caring for both the physical and mental health needs of people

with this condition. Early recognition and effective treatment maximizes the likelihood of

achieving good control of mood swings and minimizing interruptions to education, work,

and family life (Wellman, 2007).

References

Anderson, K.N. (1998). Mosby’s Medical, Nursing, & Allied Health Dictionary. (5th ed.).

Philadelphia: Mosby.
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Bipolar Disorder. (n.d.). Retrieved November 7, 2007, from http://www.wikipedia.com

Exploring Bipolar Disorder. (n.d.). Retrieved November 7, 2007, from

http://www.seroquel.com

Johnson, F.R., Ozdemir, S., Manjunath, R., Hauber, A.B., Burch, S.P., & Thompson,

T.R. (2007). Factors that affect adherence to bipolar disorder treatments: a stated-
preference approach. Medical Care (Med Care), 45 (6), 545-52.

Manic-depressive disorder. (n.d.). Retrieved November 7, 2007, from

http://www.encylopedia.com

Ketcham, Sandra. Bphoenix – The Causes of Bipolar Disorder. Retrieved November 7,

2007, from http://www.angelfire.com

Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004).

Fundamentals of nursing: Concepts, process, and
practice (7th ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.

Miklowitz, D.J., Otto, M.W., Frank, E., Reilly-Harrington, N.A., Kogan, J.N., Sachs,

G.S., Thase, M.E., Calabrese, J.R., Marangell, L.B., Ostacher, M.J., Thomas,
M.R., Araga, M., Gonzalez, J.M., & Wisniewski, S.R. (2007). Intensive
psychosocial intervention enhances functioning in patients with bipolar
depression: results from a 9-month randomized controlled trial. American Journal
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Olfson, M., & Laje, G. (2007). Rates of Bipolar Diagnosis in Youth Rapidly Climbing,

Treatment Patterns Similar to Adults. Retrieved November 7, 2007, from

http://www.nih.gov
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Robert M.A., Hirschfeld, M.D., & Vornik, L.A. (2005). Bipolar Disorder—Costs and
Comorbidity. American Journal of Managed Care, 11, 275-8

Sajatovic, M., Valenstein, M., Blow, F., Ganoczy, D., & Ignacio, R. (2007). Treatment
adherence with lithium and anticonvulsant medications among patients with
bipolar disorder. Psychiatric Services, 58 (6), 855-63.

Strakowski, S.M. (2007). Approaching the challenge of bipolar depression: results from

Step-BD. American Journal of Psychiatry, 164 (9), 1301-3.

Varcarolis, E.M., Carson, V.B., & Shoemaker, N.C. (2006). Foundations of psychiatric

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