7.12 Bipolar Disorder
Bipolar disorders include shifts in mood from abnormal highs (called manic episodes) to abnormal lows (i.e., depressive episodes). The word bipolar refers to these two seemingly opposite effects at either end of the mood and behavior spectrum. A manic episode is a persistently elevated or irritable mood with abnormally increased activity or energy present most of the day lasting at least one week. The mood disturbance is severe and causes marked impairment in social or occupational function. Severe episodes often require hospitalization to prevent harm to self or others. As the manic episode intensifies, the individual may become psychotic with hallucinations, delusions, and disturbed thoughts. The episode is not caused by the physiological effects of a substance (such as drug abuse, prescribed medication, or other treatment) or by another medical condition.[1]
Hypomanic episodes have similar symptoms to a manic episode but are less severe and do not cause significant impairment in social or occupational functioning or require hospitalization.
Bipolar disorder is further delineated into types I, II, and cyclothymia. In Bipolar I the client experiences mania and depression, while in Bipolar II, clients experience hypomania and depression. Cyclothymia symptoms are similar but not severe enough to be diagnosed as bipolar disorder. Clients may also have other coexisting conditions such as anxiety, attention deficit hyperactivity disorder, binge eating disorder, psychotic symptoms of hallucinations or delusions, and/or misuse of substances.
See the “Depression” section for symptoms of depression that also occur in bipolar disorders. Depressive episodes associated with bipolar disorder can lead to suicide. The mortality ratio due to suicide for people with bipolar disorder is 20 times above the general population rate and exceeds rates for other mental health disorders.
The following are symptoms of mania that occur in bipolar disorder[2]:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (i.e., feels rested after only three hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas (where client jumps from talking about one topic to another) or reports a subjective experience of racing thoughts
- Distractibility (i.e., attention is too easily drawn to unimportant or irrelevant stimuli)
- Increase in goal-directed activity socially, at work or school, or sexually, or psychomotor agitation
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
People experiencing a manic episode may become physically exhausted because of psychomotor agitation and decreased need for sleep.
Assessment (Recognizing Cues)
Nurses assess and document signs and symptoms of mania and depression and also screen for suicidal ideation. Review information about suicide ideation and safety interventions in the “Suicide Screening and Safety Interventions” section. Nurses also assess for potential physiological effects of mania, including poor nutritional and fluid intake, poor sleep, and poor hygiene.
Bipolar Disorder in Children and Adolescents
Bipolar disorder is often diagnosed during late adolescence (teen years) or early adulthood, and sometimes, bipolar symptoms can appear in children. Although the symptoms may vary over time, bipolar disorder usually requires lifelong treatment. Mood changes that occur in bipolar disorder are often extreme and unprovoked and are typically accompanied by changes in sleep, energy level, and the ability to think clearly. Signs and symptoms of bipolar disorder may overlap with symptoms of other disorders that are common in children and adolescents, such as attention-deficit/hyperactivity disorder (ADHD), conduct problems, depression, and anxiety. A health care provider who specializes in working with children and adolescents can carefully evaluate a child’s symptoms to provide an accurate diagnosis. Health care providers usually try to prescribe the fewest number of medications and the smallest doses possible to help treat a child’s symptoms. Bipolar disorder can make it difficult to perform well in school or get along with friends and family members. Early diagnosis and treatment can lead to better functioning and long-term outcomes.[3],[4]
Caring for a child or adolescent with bipolar disorder can be stressful for parents and families. Coping with a child’s mood episodes and other symptoms (such as short tempers and risky behaviors) can be challenging. Nurses assess for caregiver role strain and encourage caregivers to care for themselves, find support groups, and use positive coping strategies for managing stress of caring for a child or adolescent with bipolar disorder.[5]
Treatment
Effective treatment for bipolar disorder includes a combination of medications and psychotherapy and is typically lifelong. Continuous therapy helps clients manage symptoms and prevent relapse (a recurrence of symptoms).[6] Nursing interventions focus on the physiological effects of mania and depression, as well as health teaching.
Medications
Health care providers typically prescribe mood stabilizers (such as lithium) and atypical antipsychotics to manage bipolar disorder. Lithium can also decrease the risk of suicide. Valproate, an anticonvulsant, may be used to help prevent mood episodes or reduce their severity. Medications may also be prescribed to manage sleep disruptions or anxiety as part of the treatment plan.[7]
Read additional information about lithium, antidepressants, antipsychotics, and anti-anxiety medications in the “Psychotropic Medications” section of this chapter.
Read additional information about anticonvulsant medications in the “Anticonvulsant” section of the “Central Nervous System” chapter of Open RN Nursing Pharmacology, 2e.
Psychotherapy and Other Medical Treatments
In addition to medications, clients may participate in psychotherapy, ECT, and self-care journaling as part of their treatment plan. Self-care journaling involves keeping a life chart that records daily mood symptoms, treatments, sleep patterns, and life events to track and treat symptoms of bipolar disorder over time. Read more about psychotherapy in the “Psychotherapy” section of this chapter. Review information about ECT in the “General Treatments for Mental Health Conditions” section of this chapter.
Nursing Interventions
When a client receives inpatient care during an acute manic episode, treatment focuses on stabilizing the client while maintaining safety. Nurses also implement interventions that address the physiological effects related to mania such as nutrition, sleep and rest, elimination, and self care deficits. See common nursing interventions related to these physiological effects in Table 7.12.
Table 7.12. Nursing Interventions Targeting Physiological Effects of Mania
| Problem/ Intervention | Rationale |
|---|---|
Nutrition
|
Ensure adequate nutritional and fluid intake and minimize the risk of dehydration. “Finger foods” allow for “eating on the run.” Clients are often unaware of bodily needs and become easily distracted. |
Sleep/Rest
|
Lack of sleep can lead to exhaustion and increased mania. Relaxation techniques induce sleep. Encouraging bedtime routines and decreasing caffeine intake increases the possibility of sleep. |
Elimination (Constipation)
|
Fluids and fiber stimulate peristalsis and soft stools. The client experiencing acute mania is easily distracted and not aware of bodily needs. Bowel management programs may be needed to avoid fecal impaction. |
Self-Care Deficits
|
Distractibility and poor concentration are addressed with simple, concrete instructions for completing expected hygiene tasks. Good hygiene helps the client maintain dignity and avoid potential ridicule that can lower self-esteem. |
When a client is experiencing acute mania, nurses must use a firm and calm approach with concise communication. See communication tips in the following box.
Effective Communication Tips With Rationale for Clients Experiencing Mania
- Use a firm and matter-of-fact tone and calm approach. (The client needs structure.)
- Use simple, concise, very short explanations. (The client often has a short attention span and difficulty focusing.)
- Reinforce verbal limit setting on behaviors with personal boundaries. (The client is impulsive and distractible with limited insight and inappropriate behaviors towards others.)
- Utilize therapeutic communication techniques, such as redirecting, active listening, distraction, clarification, or restating. Avoid exploring. (The client’s thought processes are expansive and may require focusing and redirection.)
- Avoid the use of jingles, jokes, proverbs, or cliches. (The client is already overstimulated.)
- Remain neutral with a careful choice of words to avoid “power struggles.” (A client experiencing a severe manic episode can be manipulative and lack personal boundaries.)
- If a client demonstrates agitation with escalation of manic behavior, review interventions described in the “Crisis and Crisis Intervention” subsection of the “Mental Health Concepts” chapter. Additional de-escalation techniques to maintain safety are described in the “Workplace Violence” section of the “Maladaptive Coping Behaviors” chapter.
When working with a client in the maintenance phase of bipolar disorder, nursing interventions focus on preventing relapse, as well as limiting the severity and duration of future episodes. During this period, individuals with bipolar disorders often face multiple hardships resulting from their behaviors during previous acute manic episodes. Interpersonal, occupational, educational, and financial consequences may occur. Clients need support as they recover from acute illness and repair their lives.
Individuals with bipolar disorder are often ambivalent about treatment, but medications must typically be taken over long periods of time or for a lifetime to prevent relapse. Clients taking lithium must adhere to routine blood tests to prevent lithium toxicity. Additionally, individuals with bipolar disorder may self-medicate with alcohol or other substances, which can complicate recovery and treatment. Nurses must establish a therapeutic nurse-client relationship to support continued treatment. Nurses also refer clients to community resources and outpatient mental health care settings that can help provide structure and decrease social isolation.
Health Teaching
In addition to teaching clients about the symptoms of bipolar disorder, prescribed medications, routine lab testing, and other treatments, nurses teach clients about healthy coping strategies to manage their moods and emotional responses. Emotion-focused coping refers to strategies used to manage one’s emotional responses, such as participating in mindfulness, meditation, or yoga; using humor and jokes; seeking spiritual or religious pursuits; breathing exercises; and seeking social support.[8] Review additional information in the “Applying the Nursing Process to Promote Healthy Coping” in the “Mental Health Concepts” chapter.
- Ernstmeyer, K., & Christman, E. (Eds.). (2022). Nursing: Mental Health and Community Concepts. Access for free at https://wtcs.pressbooks.pub/nursingmhcc/ ↵
- American Psychiatric Association. (2022). Desk reference to the diagnostic criteria from DSM-5-TR (5th ed.). American Psychiatric Association Publishing ↵
- National Institute of Mental Health. (2023). Bipolar disorder in children and teens. https://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens ↵
- U.S. Department of Health and Human Services. (n.d.-a). Bipolar disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder ↵
- National Institute of Mental Health. (2023). Bipolar disorder in children and teens. https://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens ↵
- U.S. Department of Health and Human Services. (n.d.-a). Bipolar disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder ↵
- U.S. Department of Health and Human Services. (n.d.-a). Bipolar disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2022). Nursing: Mental Health and Community Concepts. Access for free at https://wtcs.pressbooks.pub/nursingmhcc/ ↵
A persistently elevated or irritable mood with abnormally increased activity or energy present most of the day lasting at least one week.
Similar symptoms to a manic episode but are less severe and do not cause significant impairment in social or occupational functioning or require hospitalization.
A mental disorder that causes a person to experience a period of abnormally elevated energy, arousal, and affect.
Where client jumps from talking about one topic to another.
Attention is too easily drawn to unimportant or irrelevant stimuli.
Occurs when an individual returns to the former problematic behavior, such as smoking, drinking excessively, or misusing other substances.