Mood Disorders: Bipolar Disorders

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By Persis Mary Hamilton, RN, CNS, MS, EdD

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Explain the characteristics of mood disorders.
• Discuss risks, causal factors, and symptoms of bipolar disorders.
• Apply the caregiving process to individuals with bipolar disorders.
• Communicate effectively with individuals with bipolar disorders.

OVERVIEW OF MOOD DISORDERS

Almost everyone has days when they feel discouraged, disheartened, and a bit grouchy. Usually, such times of reduced energy and irritability last but a short time, and before long, a person’s vitality and joy return and they go on living. During these low periods folks may say they feel “depressed” or “down in the dumps,” but only rarely are they clinically depressed or grieving a significant loss.

At other times, individuals feel energetic, good about themselves, hopeful about the future, and successful in their endeavors and relationships. After a few days, these feelings of elation tapper off and they return to a less euphoric but balanced frame of mind. Such variations in mood are normal ups and downs of daily life and do not interfere with the way folks feel about themselves, their relationships, or their ability to function in the world (Hamilton, 2011).

Mood disorders, on the other hand, are pervasive alterations in temperament, marked by periods of profound depression, exaggerated elation, or both. Such variations in mood interfere with every aspect of the lives of afflicted individuals. The self-doubt, guilt, and anger that result from a mood disorder disrupt interpersonal relationships, lower self-esteem, and interfere with the livelihood of these individuals. It comes as no surprise to learn that mood disorders are the most common psychiatric diagnoses associated with suicide (Sudak, 2009).

Brief summaries of the characteristics of the various mood disorders identified by the American Psychiatric Association are listed in the table below.

MOOD DISORDERS

Disorder	Characteristics
Source: Adapted from APA, 2000.
Bipolar disorders	Unusual shifts in mood, energy, activity levels, and ability to function; occur in distinct episodes lasting at least 1 week, with or without psychosis; during hypomanic episodes, people can function
Major depression	At least 2 weeks of deeply depressed mood, thoughts of death, insomnia or hypersomnia, weight loss or gain, fatigue, psychomotor agitation or retardation, and occasional psychotic, catatonic, or atypical features
Dysthymic disorder	At least 2 years of depressed mood for more days than not, with less severe symptoms which do not meet criteria for major depression
Cyclothymic disorder	At least 2 years of numerous periods of hypomanic symptoms which do not meet bipolar disorder criteria
Mood disorder due to a general medical condition	A depressed or elevated mood judged to be the direct physiologic result of a medical condition, such as metabolic or endocrine disorders, cancer, neurologic conditions, cerebrovascular disease, and autoimmune disorders
Substance-induced mood disorder	Prominent and persistent disturbance in mood that is a direct physiologic result of substances such as alcohol, marijuana, or other drugs or toxins
Seasonal affective disorder (SAD)	Depressed mood, increased or decreased sleep, interpersonal conflict, and weight gain or loss caused by decrease in environmental light
Postpartum blues	Labile mood, sadness, insomnia, and anxiety that begin soon after delivery, peak in 3 to 7 days, and subside without medical treatment
Postpartum depression	Meets all the criteria of a major depressive episode with the onset within 4 weeks of delivery
Postpartum psychosis	Psychotic episode within 4 weeks of delivery; begins with labile mood, fatigue, poor memory, insight, and judgment, then goes on to psychotic delusions, hallucinations, and loss of contact with reality; is considered a medical emergency

The two principal mood disorders are depressive disorders and bipolar disorders, formerly called manic-depressive illness. The focus of this course is bipolar disorders.

BIPOLAR DISORDERS

Bipolar disorders are brain disorders manifested as unusual shifts in mood, energy, activity levels, and an ability to carry out the tasks of daily living. The symptoms of bipolar disorder are severe and differ from the normal ups and downs of everyday life. They lead to poor school and work performance, damaged relationships, and suicide. Fortunately, these disorders can be treated, and afflicted individuals can lead full and productive lives.

Bipolar disorders usually develop in the late teens or early adulthood, and more than half of all cases start before a person is 25 years of age. Debate exists about whether or not children diagnosed with attention deficit hyperactivity disorder (ADHD) actually have early onset bipolar disorder. Regardless of the age at which symptoms first appear, bipolar disorder is a long-term illness that calls for careful management throughout a lifetime (NIMH, 2011).

Symptomatic Mood Episodes

People with bipolar disorder experience intense emotional episodes of depression and mania that occur sporadically for varying periods of time.

Depressive episodes are characterized by feelings of emptiness, hopelessness, sadness, powerlessness, and low energy that last for two or more months and are not caused by bereavement. During these periods, afflicted individuals have difficulty concentrating, making decisions, and remembering past events. They may think about death and seriously consider committing suicide.

Manic episodes are characterized by feelings of elation, enthusiasm, expansiveness, euphoria, impatience, and irritability. Afflicted persons feel “wired,” have racing thoughts and high energy, are easily distracted, and feel restless. Typically, manic episodes last a week or somewhat longer. During these times, the individual exhibits at least three of the following seven symptoms identified by the American Psychiatric Association (2000):

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep, feeling rested after only three hours of sleep
3. Pressured speech that is rapid, relentless, and often loud without pauses
4. Flight of ideas which are disconnected and racing
5. Distractibility with attention easily drawn to irrelevant external stimuli
6. Psychomotor agitation in which there is increased goal-directed activity
7. Risky activities with a high potential for serious consequences, such as sexual indiscretion, buying sprees, and foolish business investments

Hypomanic episodes (or hypomania) are periods of abnormal and persistent elevated energy and expansive or irritable mood, lasting at least four days, during which individuals exhibit three or four of the symptoms of mania listed above. The difference between mania and hypomania is that during hypomanic episodes, the ability to function is not impaired and individuals do not exhibit the psychotic features of hallucinations and delusions. In fact, during hypomanic episodes, folks may be exceptionally productive, quick-witted, and creative, as demonstrated by the many successful comedians, inventors, and teachers known to exhibit this condition.

Mixed episodes (or rapid cycling) are periods when individuals experience four or more episodes of major depression, mania, hypomania, or a mixture of these symptoms within a year. During these episodes individuals cycle between depression and normal behavior or mania and depression, interspersed with periods of normal behavior. Sometimes these individuals experience more than one rapid cycling episode in a week or even within a day (Schneck, 2008).

Euthymia is a normal, moderate mood experienced by individuals between depressed and manic episodes of bipolar disorder, however, these periods vary considerably. Some individuals go directly from mania to depression with no euthymic period between. Others have but one manic episode and continue on in depression or euthymia for months or even years.

Psychotic delusions (false ideas), hallucinations (false perceptions), and illusions (false interpretations of perceptions) occur in some individuals during severe episodes of mania and depression. For example, during a manic episode, people may have delusions of grandeur and believe they are famous, powerful, and wealthy. During a depressive episode, they may have auditory hallucinations and hear voices telling them they are guilty, stupid, and worthless. They may have visual illusions such as misinterpreting a shadow as the ghost of a dead relative.

Risk and Causal Factors

Bipolar disorders rank second only to major depression as a cause of disability in the world. Of the general population, there is a 1.2% lifetime risk of developing the disorder, and of these, a 15% risk of completed suicide. The highest risk of suicide is in young men with a history of alcohol abuse, prior suicide attempts, and recent discharge from a hospital (Rihmer & Angst, 2009).

At this time, no single cause for bipolar disorders has been identified, however many issues seem to increase the risk, including age and coexisting conditions as well as genetic, biologic, environmental, and neurochemical factors.

AGE AND COEXISTING CONDITIONS

People between 15 and 30 years of age are at highest risk for bipolar disorder, though symptoms may begin at any age. Individuals who suffer from anxiety, attention deficit hyperactivity disorder (ADHD), substance abuse, heart disorders, obesity, and thyroid disease have a higher risk of developing the disorder. Even though these conditions coexist with bipolar disorder, they are not necessarily its cause. However, they do complicate its treatment.

GENETIC FACTORS

Bipolar disorder is more common in people who have a blood relative with the condition, such as a sibling or parent. Compared with a 1.2% risk in the general population, these folk have a 3% to 8% risk of developing bipolar disorder (Bressert, 2007). Because of these statistics, in 2007 scientists established the Bipolar Disorder Phenome Database, where genetic data of people with visible signs of bipolar disorder is stored. With this database, researchers hope to find a genetic marker of the disorder (Potash et al., 2007).

Genes, however, are not the only cause of bipolar disorders, as demonstrated by studies of twins where one twin developed the condition and one did not. Since identical twins share all the same genes, this evidence supports the hypothesis that other factors must be at work (Kelsoe, 2009).

BIOLOGIC FACTORS

People with bipolar disorder appear to have physical alterations in their brains. The significance of these variants is still uncertain, but scientists believe they may lead to an understanding of the cause. Brain imaging studies using functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) allow researchers to take pictures of the living brain at work. Some of these studies show that the brains of people with bipolar disorders are similar to those with other mental disorders such as schizophrenia and multi-dimensional impairment, suggesting that brain development may be linked to general risk for unstable moods (NIMH, 2011).

The powerful secretions of endocrine glands—specifically the adrenal, thyroid, parathyroid, pituitary, and reproductive glands—are a source of many mood disturbances. Gotlib and Hammen found that 40% of depressed patients have an increase in adrenal cortisol secretion, with the highest rates found among the elderly (2009). Thase found that 5% to 10% of folk with major depression have thyroid dysfunction (2009). Levels of progesterone and estrogen in women have long been associated with postpartum depression and psychoses (Mayo Clinic, 2011).

ENVIRONMENTAL FACTORS

The symptoms of bipolar disorder, during both depressive and manic episodes, involve energy levels, emotional responses, cognitive abilities, and sleep. It is not surprising, then, to learn that all of these symptoms are affected by stress, grief, traumatic experiences, and physical and emotional abuse. Studies have not yet defined the exact mechanism by which these issues affect mood, but researchers agree that they play a role in the development of the disorder (Mayo Clinic, 2011).

NEUROCHEMICAL FACTORS

Neurotransmitters are powerful chemicals manufactured in neurons that transmit signals across the synapse from one neuron to another. They may excite an action in cells (excitatory), inhibit an action (inhibitory), or modify an action (neuromodulative). Neurotransmitters are contained in synaptic vesicles clustered beneath the membrane on the axon end of neurons and are released in the synaptic cleft, where they bind to receptors in the membrane of the dendrite. After doing so, they are either transported back to the axon to be stored for later use in what is called reuptake, or they are metabolized and inactivated by enzymes such as monoamine oxidase (MAO).

Neurotransmitters are necessary in just the right proportion to relay messages across the synapses between neurons. Studies show that individuals with symptoms of mental disorders have different amounts of various neurotransmitters than individuals without symptoms. Though dozens of neurotransmitters have been discovered, certain ones have been found to play significant roles in mental illness. For this reason, they have become major actors in the treatment of psychiatric disorders. The table below lists some of the most important neurotransmitters, their actions, and effects.

MAJOR NEUROTRANSMITTERS

Type	Action	Effects
Source: Adapted from Videbeck, 2011; Boeree, 2009.
Acetylcholine	Excitatory or inhibitory	Controls sleep and wakefulness cycle; signals muscles to become alert
Dopamine	Excitatory	Controls complex movements, motivation, and cognition; regulates emotional response
Epinephrine (adrenaline)	Excitatory	Controls fight-or-flight response
Gamma-aminobutyric acid (GABA)	Inhibitory	Modulates other neurotransmitters
Glutamate	Excitatory	Results in neurotoxicity if levels are too high
Histamine	Neuromodulation	Controls alertness, gastric secretions, cardiac stimulation, and peripheral allergic responses
Neuropeptides	Neuromodulation	Enhance, prolong, inhibit, or limit effects of principal neurotransmitters
Norepinephrine (noradrenaline)	Excitatory	Causes changes in attention, learning, memory, wakefulness, sleep, and mood
Serotonin	Inhibitory	Controls food intake, wakefulness and sleep, sexual behavior, and pain; regulates temperature and emotions

ASSESSING INDIVIDUALS WITH BIPOLAR DISORDERS

Because the symptoms of bipolar disorder vary dramatically from the highs of mania to the lows of depression, under-diagnoses or misdiagnosis are common. Therefore, assessment should include a broad view of the client’s life, including the personal and family history; general appearance and motor behavior; mood and affect; thought processes and content; abnormal perceptions, ideas, and experience; judgment and insight; self-concept, roles, and relationships; and self-care.

Gathering such information from individuals in the manic phase may be challenging because they find it difficult to sit still, let alone concentrate or remember details of times and places. It may be better to gather data in short sessions or to simply listen and observe these folk over a period of time. Also, family members (such as Marsha’s husband from the case study above) may be valuable sources of specific information (Videbeck, 2011).

Personal and Family History

Because bipolar disorder typically commences between 15 and 30 years of age, learning the age when manic symptoms first appeared is an important diagnostic indicator. So, too, is gaining an understanding the cultural heritage of clients. Such data helps caregivers differentiate between true pathology and ethnic beliefs. For example, some societies believe that good or evil spirits reside in certain trees, animals, statues, and rock formations.

Facts about physical disorders inform caregivers of treatment options; data about mental capacity and educational level help predict the ability of clients to follow treatment plans; a history of suicide attempts alerts caregivers to the need for special precautions and close observation; and learning the support system of clients helps caregivers plan more effective interventions.

General Appearance and Behavior

The general appearance of individuals, whether depressed or manic, reveals their emotional state. Commonly, depressed individuals appear unkempt; wear ill-matched, ill-fitting clothing; and speak slowly, without expression or not at all.

By contrast, manic folk such as Marsha choose flamboyant, colorful, and sexually suggestive clothing. They may cut or dye their hair in bizarre styles and colors, wear lots of jewelry, paint their faces with gaudy makeup, and expose tattoos and other physical attributes. Their behavior is exaggerated and hyperactive, and their speech is loud and rapid, without logical pauses. Often, they talk endlessly, in unintelligible chatter, to anyone or to no one at all, in what is called pressured speech.

Substance use and abuse is common in individuals with bipolar disease. Thus, in the initial assessment, it is important to explore the use of alcohol, cannabis, caffeine, and other drugs and to address such abuse in the treatment plan.

Mood and Affect

People with bipolar disorders experience wide swings of mood. During manic episodes, they may tell you they feel fabulous, on top of the world, gifted, important, and famous. Sometimes those exaggerated positive feelings turn ugly, and they become impatient, irritable, and belligerent, as Marsha did when her husband asked her to tone down her behavior. During depressive episodes, they may tell you they feel empty, frightened, hopeless, angry, and suicidal.

Although individuals in the manic state appear elated and joyful, it is important to remember that those symptoms may last but a short time and that before long, such clients sink back into an underlying state of depression. Thus, it is vital to address self-harm directly.

For example, if a client says, “I just can’t take it anymore,” the caregiver responds, “What is it that you cannot take anymore? How do you see an end to this?” If a client says, “Everyone would be better off without me,” the caregiver responds, “Who would be better off without you? How would you eliminate yourself?” By so doing, suicidal ideation is brought into the open, where it can be addressed openly and honestly.

Thought Processes and Content

Thinking is seriously affected during both manic and depressive phases. Thought processes refer to the way people think and manage information. Thought content refers to what people are thinking and saying. To better understand how and what clients are saying, caregivers listen closely and describe what they hear using the following terms:

TYPES OF THINKING IN BIPOLAR PEOPLE

Circumstantial thinking	Giving all manner of extraneous detail when answering a simple question
Delusion	False ideas or beliefs not based on reality, such as a delusion of grandeur, when a person believes he or she is famous or wealthy
Flight of ideas	Speech composed of fragments of unrelated ideas, delivered rapidly and excessively
Ideas of reference	Inaccurate interpretation of a general event as personally directed to a specific person, such as when a person hears something on the news and believes it is a coded message just for them
Loose association	Disorganized thought that jumps from one idea to another with little or no relationship between the content
Suicidal ideation	Thoughts of death and suicide
Tangential thinking	Wandering off the topic and never getting back to the original topic
Thought blocking	Stopping abruptly in the middle of a sentence or thought, unable to continue
Thought broadcasting	A delusional belief that others can hear or know what one is thinking
Thought insertion	A delusional belief that others are putting ideas or thought into one’s mind
Thought withdrawal	A delusional belief that someone else is taking one’s thoughts away and that one is powerless to stop the other
Word salad	Flow of disconnected words that have no meaning to the listener

Abnormal Ideas and Perceptions

People experiencing a manic episode may exhibit the psychotic symptoms of delusions (false ideas), hallucinations (false perceptions), and illusions (false interpretations of real perceptions). Delusions of grandeur are especially common, such as believing one is famous and wealthy. Hallucinations are less common and include such things as hearing voices no one else hears or smelling odors no one else smells. Illusions include such things as interpreting the voice of another person as God.

When clients experience these symptoms, it is vital for caregivers to report them to the physician because they indicate a more complex disorder for which antipsychotic medications may be prescribed.

Judgment and Insight

In a manic episode, judgment and insight are seriously affected. Excessive energy leads individuals to all manner of impulsive and destructive behaviors. They may start projects they cannot finish, go on shopping sprees they cannot afford, behave inappropriately, have promiscuous sex, take expensive trips, gamble compulsively, and engage in all kinds of extreme behaviors that have serious consequences. For instance, when Marsha offered to teach the staff in a busy emergency department how to dance the hula, her behavior was inappropriate. All such lapses in judgment or insight should be accurately described and recorded.

Self-Esteem, Roles, and Relationships

Though people in a manic phase may have an inflated sense of personal power and entitlement, rarely do they understand the relationship of exaggerated behavior to their chronic low self-esteem. Although mania builds them up for a time, the depression that follows confirms their sense of worthlessness and failure.

People in the mania phase seldom fulfill role responsibilities expected of them. They may be too distracted to attend to the duties of student, employee, spouse, or parent. Thus, they may drop out of school, fail to perform job expectations, leave personal relationships, and neglect their children.

Often, these individuals have a great need to socialize and be accepted by others, but they do not recognize their own inappropriate interpersonal interactions, violate conventional boundaries, and invade the intimate space of others. The need for acceptance may lead to sexual promiscuity, with all the attendant problems that may follow. In our case study, Marsha invited all of her neighbors to the party, even though she did not know them. Then, she flirted shamelessly with the men who came.

Although elation is the usual mood of people in the manic phase, any delay of gratification may trigger a hostile outburst toward anything or anyone who blocks their desire or criticizes them, as Marsha did when she attacked her husband and became foul-mouthed and combative. Evidence of low self-esteem, role failure, and inappropriate relationships should be described and addressed in treatment plans.

Physiologic Responses and Self-Care

Individuals in the manic phase seem to be in constant motion. They are unable to stay still long enough to eat, drink, or sleep adequately, and they may become exhausted, dehydrated, and malnourished. Often, they neglect personal hygiene, injuries, and other health needs because the energy of mania drives them on and on. Thus, ongoing assessment of how well patients attend to physical and personal needs provides critical information about patients in both manic and depressive phases of bipolar disorder.

CARING FOR THOSE WITH BIPOLAR DISORDERS

After healthcare professionals perform a comprehensive assessment, they analyze the findings, identify diagnoses, state realistic treatment goals, and plan appropriate interventions.

During the acute phase of bipolar I, interventions focus on stabilizing the mental state of individuals and maintaining their safety. In order to do this, it may be necessary to hospitalize patients, as it was with Marsha in our case study. Intervention begins in the emergency department and moves to an inpatient unit where there is assessment, stabilization of symptoms, and discharge planning. Only patients with severe and persistent mental illness continue to stay in the hospital.

During hospitalization, interventions focus on safety, physical needs for rest, hydration/nutrition, personal hygiene, therapeutic communication, behavior modification, medication management, possible electroconvulsive therapy, interpersonal support, and planning for the future.

Nowadays, case management plays an important role in the acute and maintenance phases of the disorder. Inpatient case managers follow the client from admission to discharge and serve as liaisons between the client and community resources, home care, and third-party payers (Varcarolis & Halter, 2010).

During the ongoing maintenance phase, the goal is to prevent relapses and regularize life, social relationships, personal pursuits, and employment. Interventions are based on assessment of interpersonal skills, cognitive functioning, and available resources. They include providing emotional and social support, meeting physical needs, and insuring compliance with the medication regimen. To meet these needs, clients and their families may need education; referral to support groups; psychotherapy; and programs for substance abuse, legal issues, and financial crises. These resources are especially important because bipolar disorders may last a lifetime (Varcarolis & Halter, 2010).

Medical Diagnosis

Using the pattern and severity of symptoms, the American Psychiatric Association (2000) has identified four major diagnostic categories of bipolar disorders as follows:

• Bipolar I disorder: Manic or mixed (rapid cycling) episodes lasting at least 7 days and depressed episodes lasting 14 or more days. Symptoms are significantly different from normal human behavior and may be so severe the person needs immediate hospital care. APA identifies six sets of criteria. The first of the six describes the initial manic episode, and the others describe the most recent subsequent episode.
• Bipolar II disorder: At least one hypomanic episode but no full-blown manic or mixed rapid cycling episodes. A pattern of depressive episodes shifts back and forth between hypomanic and depressive episodes. APA identifies only one set of symptoms in this category.
• Bipolar disorder not otherwise specified (BP-NOS): Symptoms are clearly out of the normal range of behavior but do not last long enough to meet the criteria for either bipolar I or II.
• Cyclothymic disorder (cyclothymia): A mild form of bipolar disorder. The episodes of hypomania and mild depression shift back and forth for at least 2 years, however the symptoms do not meet the diagnostic criteria for bipolar I or bipolar II disorders.

Caregiver Diagnoses and Interventions

Some typical caregiver diagnoses, outcome goals, and interventions for individuals in a manic phase of bipolar disorder are listed in the table below.

CAREGIVER DIAGNOSES

Diagnosis	Outcome Goals	Interventions
Source: Adapted from NANDA-1 Approved Nursing Diagnoses. (2009). North American Nursing Diagnosis Association.
Nutrition and hydration, risk for imbalance	Client will maintain adequate hydration and nutrition behavior	Plan and provide a diet of food and fluids with the aid of dietitian and client
Sleep pattern, disturbed	Client will sleep at least 6 hours per day	Plan a daily schedule to provide balance of rest, sleep, and activity
Self-esteem, chronic low	Client will demonstrate assertive behaviors	See that client identifies at least one positive self-attribute each day and shares it with others
Coping, ineffective	Client will engage in socially appropriate, reality- based interactions	Encourage client to participate in daily group therapy; keep records of interactions with others
Role performance, ineffective	Client will fulfill duties of at least one role, such as a responsible patient	Refer client to home health services for follow-up care
Non-compliance with treatment plan	Client will comply with treatment plan	Provide personal and/or group counseling; give prescribed medications
Violence, risk for other-directed	Client will not attack or injure others	Observe client closely; teach assertive rather than aggressive behaviors
Violence, risk for self-directed	Client will not injure self.	Take suicide precautions: observe closely and often; address the issue openly, compassionately

SAFETY

During the acute phase of the illness, the most important responsibilities of caregivers are to provide a safe environment and to guide patients toward socially appropriate behavior and increased self-esteem.

An ever-present concern for bipolar clients is suicide. Although individuals in the manic phase are temporarily energized and elated, their underlying depression makes them vulnerable for self-injury. For this reason, caregivers need to take the following suicide precautions:

• Observe patients frequently throughout the day and night
• Remove all injury-producing sharps, drugs, or ropes and cords
• Make sure patients take medications and do not horde them
• Discuss suicide ideation with patients openly and regularly

Patients in the manic phase have little understanding of how their agitation and anger affect others. They must be monitored continuously and informed that staff members will help them control their behavior. Such external controls reassure patients that even though they may be angry and feel like striking others, staff members will help them respect others by identifying unacceptable behavior and clearly stating appropriate behavior.

PHYSIOLOGICAL NEEDS

Even though they are on the brink of exhaustion, patients in the manic phase may get little rest and sleep. Sedatives may be prescribed; however, other measures can provide a sense of peace and control. These include:

• A calming environment without television or noisy distractions
• Bedtime routine including such measures as a nonstimulating beverage, warm bath, or soothing massage
• Scheduled “quiet times” with soft, gentle music or just silence

Adequate hydration and nutrition are essential. Manic patients may be too agitated to sit down and eat. Depressed individuals may be too despondent. One option for hyperactive folk is to provide food that can be eaten while moving around, such as snack foods, sandwiches, and beverages they can hold in their hands. These foods should be high in protein and calories and available throughout the day, not just at mealtimes.

Personal hygiene affects the physical and mental health of both depressed and manic patients. For this reason, patients may need assistance to do the things that promote health and provide physical comfort, such as brushing teeth, combing hair, washing hands, bathing, and keeping track of elimination.

THERAPEUTIC COMMUNICATION

Clients with mania have short attention spans and may not be able to comprehend complex instructions. For this reason, caregivers need to communicate in clear, simple language and to ask patients to repeat important messages back to them. Many treatment facilities find it helpful to post daily schedules, staff names, visitor rules, civil rights, and other such information on a large chalk boards for all to see.

Patients may use pronouns to refer to others, making it difficult to understand who is being discussed and when the conversation has moved to a new topic. To overcome this problem, caregivers ask patients to identify each person, place, or thing being discussed.

When speech includes flight of ideas, caregivers ask patients to explain the relationship between topics.

Patients with pressured speech may just keep talking, ignoring nonverbal and verbal signals that others want to speak. To overcome this problem, leaders may introduce group-rules, whereby people in the group take turns speaking and listening. By so doing caregivers create an environment of order, support the concept of delayed gratification, and modify patient behavior.

INTERPERSONAL SUPPORT AND INTERACTIONS

In order to give supportive care to individuals in a manic phase, caregivers:

• Establish a connection with clients. Introduce yourself. Reach out with steadiness and kindness. No matter how distracted patients may be, they will know you are there, that there is order and stability, and that they can trust someone.
• Demonstrate your sincere concern. You may not be able to “do anything,” and you may feel quite useless or even frustrated. Yet, by simply “being there,” you convey a message of genuine interest and concern, giving manic patients the recognition they crave and depressed individuals the nurturance they need.
• By your behavior, affirm that individuals in a manic or depressive episode are valuable and that there is hope—the very opposite of the confusion, worthlessness, helplessness, and hopelessness they feel. These messages can be offered in simple ways, such as giving clients choices, affirming their value, and mentioning future events. If clients begin to communicate, allow them to lead the conversation.
• Set reasonable limits for patients in a manic episode and clearly define expectations for severely depressed individuals at the same time as you convey respect.
• Demonstrate genuineness, accurate empathy, unconditional positive regard, and non-possessive warmth. These attributes are the very essence of therapeutic communications.
• Seek to provide the basic human needs identified by Maslow (1968): life/survival, safety/security, belonging/affection, respect/self-respect, and self-actualization.

BEHAVIOR MODIFICATION

Patients are hospitalized for their protection and care. Such care involves treating them with dignity and respect, even as their inappropriate behaviors are addressed. Behavior modification uses positive feedback to reward, encourage, and leave unchanged certain behaviors. It uses negative feedback to discourage and change inappropriate behaviors. Thus, negative feedback makes for change.

A common inappropriate behavior in manic clients is violation of the personal space of others.

Such a suggestion may not only stop inappropriate behavior, but may also reward Jeff for doing something for the good of the community.

Manic clients often display inappropriate sexual behavior, exposing themselves, talking graphically about sex acts, and even asking for sex from staff members and other patients. Caregivers need to handle such behavior in a nonjudgmental yet matter of fact way. They clearly state what specific behavior is not acceptable and what behavior is acceptable.

Later on, when Sally comes to group meetings properly clothed, the leader acknowledges her appropriate dress and conduct.

Medication

Because of the diverse nature of bipolar disorders’ symptoms, a variety of drugs are used in its treatment. These include mood stabilizers (notably, lithium) and anticonvulsant, antidepressant, anxiolytic, and antipsychotic medications. Of these, the mood stabilizers are first-line (preferred) drugs. Other medications may be prescribed for symptoms of anxiety, depression, and psychosis.

MOOD STABILIZERS

Mood stabilizers are chemicals that moderate mood swings by altering the flow of electrical current in the brain in an action that is not fully understood. These include lithium and various anticonvulsant drugs.

Lithium

Lithium carbonate is effective for the prevention and treatment of bipolar disorders in about 75% of individuals with acute mania and a somewhat smaller percent with mixed mania, rapid cycling, and atypical features (Woodrow et al., 2010). When taken as prescribed, lithium reduces the elation, expansiveness, grandiosity, flight of ideas, irritability, and anxiety of mania.

However, the side effects of lithium are many and significant, including fine hand tremor, weight gain, mild nausea and diarrhea, a metallic taste in the mouth, thirst, polydipsia, polyuria, acne, and cognitive slowing. Consequently, patients may not follow the prescribed directions. As a result, their non-compliance reduces the effectiveness of the drug.

When initially ingested, the effects of lithium occur in 5 to 14 days. Until the lithium takes effect, antipsychotic and antidepressant agents may be prescribed to reduce the symptoms of acute mania and depression.

Although lithium has many neurobiological effects, the mechanism of action in bipolar disorder is poorly understood. It is thought to work in nerve synapses to hasten destruction of catecholamines (norepinephrine, dopamine), inhibit neurotransmitter release, and decrease the sensitivity of postsynaptic receptors (Facts and Comparisons, 2009).

The toxic effects of lithium are severe diarrhea, muscle weakness, renal failure, coma, and death. Lithium is not metabolized. Instead, it is reabsorbed by the proximal tubules of the kidneys and excreted in the urine. Thus, baseline and periodic assessment of renal function is essential. Lithium is contraindicated in people with compromised renal function, urinary retention, and in pregnant women because it can cause first-trimester fetal abnormalities.

Since there is only a small difference between a therapeutic dose and a toxic dose of lithium, periodic serum levels are measured with these criteria:

• Treatment serum levels during acute mania (0.8 to1.5 mEq/L)
• Ongoing maintenance serum levels (0.5 to 1.5 mEq/L)
• Toxic serum levels (1.5 mEq/L and above)

When first prescribed, serum levels are measured weekly or biweekly until a therapeutic level is attained. After that, they are determined every month. After a year of stability, serum lithium levels are measured every 3 months.

Anticonvulsants

About 20% to 40 % of bipolar clients have difficulty taking lithium because of side effects, drug interactions, medical conditions such as renal disease, and pregnancy. Fortunately, many drugs used to control seizure disorders also stabilize mood disorders. The exact mechanism of their action is not known. It is surmised that they prevent or reduce mania by raising the brain’s threshold for stimulation and, as a result, block the bombardment of external and internal stimuli (Videbeck, 2011).

Antidepressants

Typically, individuals with bipolar disorder suffer far longer periods of depression than mania. Thus, antidepressant drugs and treatments are commonly prescribed after a manic episode. They are classified as first-line (preferred) and second-line (back-up, when first-line cannot be used), as follows:

First-line antidepressant drugs

• Selective serotonin reuptake inhibitors (SSRI)
• Atypical antidepressant drugs
• Cyclic antidepressants such as tricyclic drugs

Second-line antidepressant drugs and treatment

• Monoamine oxidase inhibitors (MAOI)
• Electroconvulsive therapy (ECT)

Anxiolytics (Antianxiety Drugs)

During manic episodes some patients experience extreme psychomotor agitation. For these individuals, anxiolytics (anxiety drugs) such as clonazepam (Klonopin) and lorazepam (Ativan) may be effective. The most common side effects of these drugs are drowsiness, dizziness, blurred vision, orthostatic hypotension, and a potential for physical dependency. It is important to note that anxiolytics are not recommended for individuals with a history of substance abuse because physical dependency is a common complication (Skidmore-Roth, 2010).

Antipsychotics

Individuals with bipolar disorder may exhibit the psychotic symptoms of hallucinations, illusions, and delusions, especially during a manic episode. When this occurs, antipsychotic drugs may be prescribed, especially the newer atypical antipsychotics because these drugs have mood-stabilizing effects as well as sedative effects.

DRUGS USED IN THE TREATMENT OF BIPOLAR DISORDER

Generic (Trade) Name and Daily Dose	Side Effects	Caregiving Implications
Source: Skidmore-Roth, 2010.
LITHIUM
Lithium 600–1800 mg/day	Nausea/vomiting, fine tremors, diarrhea, polyuria, polydipsia, weight gain, acne, metallic taste in mouth	Report side effects and non-compliance; measure serum levels at up to 3-month intervals; monitor kidney function
ANTICONVULSANTS
Carbamazepine (Tegretol) 800–1000 mg/day	Sedation, dizziness, nausea, cognitive impairment, dyspepsia, ataxia, agranulocytosis, anemia	Assist client to rise slowly from sitting position; monitor gait and assist as needed
Divalproex (Depakote) 1000–1500 mg/day in divided doses	Nausea/vomiting, sedation, weight gain, hair loss	Monitor gait, assist as needed; provide rest periods; give drug with food
Gabapentin (Neurontin) 900–1800 mg/day in divided doses	Sedation, dizziness, ataxia, nystagmus (rhythmic eye movement)	Monitor gait; assist as needed; provide rest periods, give drug with food
Lamotrigine (Lamictal) 100–500 mg/day, beginning at 50 mg	Dizziness, hypotension, ataxia, nausea/vomiting, sedation, headache, fatigue, nystagmus	Assist client to rise slowly from sitting position; monitor gait; provide rest periods; give drug with food; report skin rashes
Topiramate (Topamax) 400 mg/day in divided doses	Dizziness, hypotension, anxiety, ataxia, confusion, sedation, slurred speech, tremor, weakness, blurred vision, nausea/vomiting, anorexia	Assist client to rise slowly from sitting position; monitor gait; orient client; give drug with food
Oxcarbazepine (Trileptal) 600–2400 mg, dosed bid or tid	Dizziness, fatigue, ataxia, nausea/vomiting, anorexia, headache, tremor, confusion rashes	Assist client to rise slowly from sitting position; monitor gait; give med with food; report skin rashes
ANTIDEPRESSANTS
Sertraline (Zoloft) (selective serotonin reuptake inhibitor [SSRI]) 25–150 mg/day	Insomnia, sedation, diarrhea	Monitor sleep cycle, elimination, and fluid intake
Tranylcypromine (Parnate) (monoamine oxidase inhibitor [MAOI]) 20–60m/day	Dizziness, drowsiness, anxiety, tremors, weight gain, dry mouth, diarrhea, flushing, nausea and vomiting	Suicide precautions; monitor gait, food and fluid intake, and weight gain; give drug with food; report skin rash
Amitriptyline (Elavil) (Tricyclic [TRI]) 75–300 mg	Tremors, insomnia, anxiety, dry mouth, tachycardia, suicide from overdose	Suicide precautions; increase fluid intake; monitor for drug dependency
Venlafaxine (Effexor) (atypical antidepressant) 75–225 mg qd	Nausea, dry mouth, constipation, dizziness, anorexia	Increase fluid intake; monitor elimination, food intake, weight loss and gait
ANTIANXIETY (Anxiolytics)
Clonazepam (Klonopin) (long-acting benzodiazepine) 0.5–10 mg qd	Sedation, decreased coordination, weight gain, skin reactions, headache, tolerance, dependency	Monitor dosage and tolerance, weight gain, skin rashes, and mental acuity
Lorazepam (Ativan) (intermediate-acting benzodiazepine) 2–6 mg qd	Sedation, weight gain, skin rash, tolerance, dependency	Monitor dosage and tolerance, weight gain, skin rash, and mental acuity
ANTIPSYCHOTICS
Olanzapine (Zyprexa) 6–20 mg qd	Pseudoparkinsonism, dry mouth, nausea, weight gain, urinary frequency	Monitor weight gain, mental status, psychotic symptoms, elimination; check for hording
Aripiprazole (Abilify) 10–15 mg qd	Akathisia (agitation), nausea, constipation, anxiety, rash, headache, insomnia, lightheadedness, weight gain	Monitor weight gain, constipation, mental status and other side effects
Benzisoxazole (Risperidone) 2–8 mg qd	Restlessness, dystonia, insomnia, anxiety, headache, dizziness, orthostatic hypotension, weight gain	Monitor restlessness, dizziness, orthostatic hypotension, weight gain

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is one of the most effective yet most stigmatized remedies for mood disorders. It is especially useful for individuals who cannot take or do not respond to antidepressant drugs and are at a high risk for suicide. In addition, it is safe for pregnant women and the fetus they carry. Research has found that within 1 to 2 weeks of beginning electroconvulsive treatment, depression is reduced in 90% of clients (NIMH, 2011).

ECT involves applying electrodes to the head and delivering an electric impulse to the brain. It is believed the shock works by causing a massive neurochemical release in the brain in response to the controlled seizure (Mayo Clinic, 2010).

Historically, clients did not receive sedation or anesthetic before ECT. They were placed on a narrow table, electrodes were attached to the head, and attendants held them down as the electric current produced a grand mal seizure. After a long, deep sleep, they gradually awoke, confused and disoriented with significant memory loss and sometimes fractured bones.

Nowadays ECT is administered in hospitals to anesthetized patients who have received muscle relaxants. Carefully calculated current, monitored by an electroencephalogram, is passed through one or both sides of the brain. It causes a carefully controlled seizure that lasts 20 to 90 seconds. Patients awaken in 5 to 10 minutes, and though they may have short-term amnesia, memory returns quickly. Commonly, a course of treatment is 3 times a week for 2 to 5 weeks. After an initial course of treatment, ECT may be given on an outpatient basis.

Psychotherapy

Psychotherapy is the use of various psychological approaches to treat emotional and mental disorders. It is especially valuable for clients in the maintenance phase of bipolar disorder because it helps prevent relapses. Psychotherapy is supplied by healthcare providers with advanced education, such as psychologists, psychiatrists, advanced practice nurses, marriage and family therapists, and social workers.

The goal of psychotherapy is to help clients:

• Gain an understanding of the emotions and ideas that contribute to exaggerated mood swings
• Identify and understand life problems or events
• Learn coping techniques and problem-solving skills
• Regain a sense of control and pleasure in life

Psychotherapy is provided by means of:

• Individual therapy: Clients meet with the therapist in private sessions to discuss issues that are troubling them.
• Couples therapy: Partners meet with the therapist in private sessions to address troublesome issues in their life together and learn new behaviors.
• Family therapy: Family members meet with the therapist in private sessions to discuss the interaction of individuals within the group.
• Group therapy: Two or more persons who are not necessarily related meet with the therapist, share their experiences, and learn from one another

Psychotherapists employ a variety of theoretical approaches.

PSYCHODYNAMIC THERAPY

This system is based on the assumption that a person is mentally ill because of unresolved, generally unconscious conflicts, often stemming from childhood. The goal of this therapy is for clients to understand the emotions they experience and to learn how to manage them more effectively. Such therapy may last many months or even years.

INTERPERSONAL THERAPY

This modality focuses on the behaviors and interactions a client has with other individuals and family members. The goal of this approach is to improve communication skills and increase self-esteem within a short period of time. This therapy is especially effective for depression caused by grief, major life changes such as marriage or divorce, relationship conflicts, and social isolation. Such therapy usually lasts 3 to 4 months, depending on the problem.

COGNITIVE-BEHAVIOR THERAPY

This form of therapy helps people identify and change inaccurate perceptions they have of themselves and the environment. The therapist helps clients learn new ways of viewing both accurate and inaccurate assumptions of themselves and others. This therapy is especially helpful for folks who think and behave in ways that trigger and perpetuate interpersonal conflict.

MEDITATION AND MINDFULNESS THERAPY

These modalities focus on inner peace, relaxation, and awareness of the spiritual aspects of life. Often this type of therapy is conducted in groups when individuals gather together to share life experiences. There is no timeline, and the therapy may continue through life.

Client and Family Education

Whether clients are hospitalized in a psychiatric unit during the rather brief acute phase of bipolar disorders or during the long-term maintenance phase of these disorders, they and their family need to learn about the illness and the many elements of the treatment plan. Specific learning objectives for clients and their families include the following:

• Identify the early signs of relapse of mania and depression
• Discuss the importance of support groups and how to find them
• State the need for and benefits of follow-up appointments
• Participate in support groups and personally satisfying activities
• Discuss the issue of alcohol and substance use and abuse
• Identify the actions, side effects, and special instructions of prescribed drugs
• Describe ways to manage the side effects of medication, such as weight gain, sleep, and drop in blood pressure

CONCLUSION

Bipolar disorder is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out the day-to-day tasks (NIMH, 2011). Often the condition develops in the late teens and continues for a lifetime. The great variation of symptoms obscures the diagnosis, and the likelihood of substance abuse complicates its treatment. Care of bipolar individuals includes providing a safe environment, meeting physical and emotional needs, communicating effectively, administering medications and treatments, providing psychotherapy, and educating clients and their families.