Key Fundamentals of Bipolar Disorder

Bipolar disorder is a mental health condition characterized by alternating episodes of emotional highs and lows. The occurrence of these extreme mood swings is variable. Some individuals experience them multiple times per year while others have rare occurrences. Though a lifelong condition with no cure, bipolar disorder can be managed with proper treatment. 

The exact cause of bipolar disorder is not known, but it is thought to be a consequence of genetics, environment, altered brain chemistry, and/or altered brain structure. Additionally, some studies suggest that bipolar disorder may be linked to dysregulation of the immune system as serum inflammation markers are increased in individuals with the disorder.

Individuals most at risk for bipolar disorder are those with a family history. A child born to a parent with bipolar disorder has a 10-25% risk of also having the condition. Additionally, highly stressful events such as trauma or death of a family member can increase the risk of bipolar disorder as can drug/alcohol abuse. Interestingly, advanced paternal age (45 years and older) is shown to be related to higher incidences of bipolar disorder in their offspring. There is an equal risk between males and females, with the average age of onset being 18 years of age. In addition to bipolar disorder, many individuals also have anxiety disorder, substance use disorder or ADHD as well.

Key terms

Major depressive episode – A period of at least two weeks where the individual experiences at least five symptoms of depression such as sleeping more than usual, difficulty concentrating, loss of interest in things they once found enjoyable, and recurrent thoughts of death or suicide (more details provided further on).

Manic episode – A period of at least seven days characterized by feelings of euphoria or irritability for most of the day each day, feelings of having more energy than usual and at least three characteristics of mania such as increased activity, decreased need for sleep and racing thoughts (more details provided further on).

Hypomanic episode – This is a less severe form of a manic episode that is shorter in duration (about four days) and does not disrupt daily functioning in the way a manic episode does.

Types of bipolar disorder

There are two types of bipolar disorder (BD). 

• Bipolar I Disorder (BDI) is present when there is a history of one or more manic episodes with or without any episodes of depression.
• Bipolar II Disorder (BDII) is present when the individual has recent episodes of major depression along with at least one hypomanic episode. This individual has never experienced a full manic episode.

Bipolar disorder is frequently misdiagnosed

Bipolar disorder is often misdiagnosed as depression, cyclothymic disorder or borderline personality disorder due to similarities between these conditions. This can lead to a delay in starting the appropriate treatment. Some key differences to note are: 

• BD vs depression – Because more than half of patients with BD initially experience a depressive episode, this leads to a high incidence of individuals being misdiagnosed with depression. The individual with BD will have a manic or hypomanic episode at some point, whereas an individual with depression will not.
• BD vs cyclothymic disorder – Cyclothymic disorder involves elevated mood episodes that don’t meet the criteria for hypomania as well as depressive episodes that don’t meet the criteria for a major depressive episode.
• BD vs borderline personality disorder (BPD) – BD patients experience varying episodes of depression and elation or mania while BPD patients experience varying episodes of depression and rage. Additionally, BPD mood shifts tend to be more rapid (hours to days) while BD episodes are of longer duration.

What are the complications of bipolar disorder? 

The greatest risk to individuals with bipolar disorder is the higher risk of suicide. In fact, suicide risk is 20-30% greater in BD patients compared to the standard population, and a study by Wang & Yu showed it to be the higher than any other mental disorder. Other risks include: 

• Risk for injury during manic episodes due to decreased inhibition 
• Significant insomnia
• Poor nutrition
• Weight loss or obesity 
• Increased risk of cardiovascular disease and hypertension
• Increased risk of diabetes and metabolic syndrome 
• More likely to be involved in violence

Now that you have a basic understanding of bipolar disorder, let’s go through it using the Straight A Nursing LATTE method. 

L: How does the patient with bipolar disorder LOOK?

Patients with bipolar disorder will typically display extreme mood swings, though how quickly they shift from highs to lows will vary based on each individual. 

The signs/symptoms of mania and hypomania are similar with mania being more severe, lasting longer, and causing disruption to daily life. These include at least three of the common signs which include: 

• Talking more than usual or talking faster than usual
• Increased physical activity or working on multiple projects/tasks simultaneously
• Decreased need for sleep
• Reckless behavior such as overspending, risky sexual encounters, or driving dangerously
• Racing thoughts or changing topics when speaking
• Being easily distracted
• Feelings of increased self esteem
• Exaggerated sense of well-being
• Increased libido, increased flirtation

Manic episodes are further characterized by severely increased grandiosity and self-confidence and can include psychotic features such as disorganized thinking, hallucinations and false beliefs.

The patient will show at least five signs of major depressive episode, which includes:

• Difficulty focusing or concentrating, indecisiveness
• More or less sleep than usual
• More or less appetite than usual (weight gain and weight loss can also occur)
• Restlessness
• Slowed speech
• Slower movement than usual
• Increased fatigue
• Loss of interest in things they once enjoyed
• Significant feelings of sadness, hopelessness and even despair
• Feeling guilt or worthlessness
• Poor hygiene
• Disorganized thinking, hallucinations and/or false beliefs
• Recurrent thoughts of death or suicide

Note that individuals with bipolar disorder may also exhibit manipulative behavior. This may help them feel more secure as the manipulation provides a sense of control in unfamiliar situations.

A: How do you ASSESS the patient with bipolar disorder?

• One of the most important things you can assess is suicidal ideation. If present, this patient is at high risk for self harm and requires a higher level of monitoring and intervention.
• Assess frequency and intensity of manic/hypomanic symptoms as well as depressive symptoms.
• Assess the patient and surroundings for safety issues. Patients are at risk for injury to self and others during manic episodes and at risk for self harm during depressive episodes. Many everyday items in the patient’s environment can be utilized as weapons against self or others.
• Weigh the patient and assess nutritional status as loss of appetite and weight loss are common.
• Ask the patient about drug and alcohol use.
• Assess the caregiver/family members for caregiver burnout. Caring for a BD patient may involve considerable burdens and stressors.
• Assess the patient for comorbid health or psychiatric issues – recall that many patients with BD have anxiety disorder, substance use disorder and/or ADHD.

T: What TESTS will be ordered for a patient with bipolar disorder?

The MD may conduct or order specific assessments/diagnostics for the patient to rule out other medical conditions that could be causing the symptoms and will vary based on each individual. 

The  main diagnostic tool for bipolar disorder is psychiatric evaluation. This will include observation of the patient, discussion with the patient regarding their feelings, behaviors and thoughts. A commonly used tool is the Mood Disorder Questionnaire (MDQ) which is a 13-item questionnaire that has shown to have reliable sensitivity and specificity for a diagnosis of BD when utilized with psychiatric evaluation. 

The patient may be asked to record their mood and sleep patterns as part of their initial evaluation and throughout treatment.

T: What TREATMENTS will be provided?

Your key nursing interventions are to promote an environment of safety for your patient and to avoid escalating behavior. In addition to maintaining a low-stimulus environment you’ll also want to ensure there are no dangerous objects in the room. This includes anything your patient could use to harm you or themselves. 

Other important nursing interventions are to: 

• Use therapeutic communication to validate the patient’s feelings if they become anxious, aggressive or agitated. You should also remain calm when speaking.
• Anxious patients may benefit from physical activity such as going for a walk through the halls.
• Offer restless patients easy-to-consume snacks such as finger foods.
• Set limits for patients who display manipulative behavior by explaining limits and consequences. Do not engage in bargaining as this validates the manipulating behavior. Conversely, give positive reinforcement when the patient exhibits non-manipulative behavior. Some patients will require the use of behavior contracts, which are signed documents outlining the specific behaviors to avoid and consequences of noncompliance.

Patients with bipolar disorder will likely receive therapy from a psychiatrist. This can include:

Cognitive behavioral therapy – This form of therapy teaches strategies for coping with stress, helps patients identify their negative beliefs and behaviors, and teaches them to recognize their triggers and replace negative beliefs/behaviors with positive ones.

Interpersonal and social rhythm therapy (IPSRT) – This form of therapy helps the individual recognize and regulate daily routines and social rhythms and includes interpersonal therapy to help the individual improve their relationships.  It also uses sleep/wake regulation as a way to treat disruption of the circadian rhythm that can be common in BD.

Group therapy – Support groups and group counseling help patients gain perspective and form positive connections with others. 

Family therapy – Addressing the complex issues families face when dealing with BD has shown to reduce relapse rate.

Substance abuse treatment – BD may be more difficult to treat in patients with concurrent substance abuse disorder.

Electroconvulsive therapy may be utilized in cases where the disorder is resistant to pharmacologic treatment or the patient is unable to take the medication (such as in pregnancy or high suicide risk). This treatment involves passing low levels of electricity through the brain to induce brief seizures that can change brain chemistry to reduce or reverse BD symptoms. Want to learn more about ECT? I’ve got you covered right here.

Hospitalization may be required for patients who are suicidal or exhibiting dangerous behaviors.

Medications

Pharmacologic treatment often requires at least two medications and will typically involve trial and error to find the right combination with side effects that are tolerable for the patient.

Mood stabilizers – Lithium is considered the most effective medication for BD, but does have a narrow therapeutic window with high toxicity risk. Signs of lithium toxicity include ringing in the ears, diarrhea, ataxia and vomiting. The patient will require periodic blood draws to assess their lithium level and may also have renal and thyroid function monitored as lithium can adversely affect both. Other mood stabilizers commonly used for bipolar disorder are lamotrigine and carbamazepine. 

Second generation atypical antipsychotics such as olanzapine (Zyprexa) and quetiapine (Seroquel) may also be used. Common adverse effects of these medications are weight gain, hyperglycemia, dyslipidemia, sedation and extrapyramidal symptoms such as tardive dyskinesia. A key benefit of these medications is that some have a long-acting injectable form, which makes adherence more likely in some individuals.

Antidepressants such as sertraline (Zoloft) and fluoxetine (Prozac) are also commonly used in combination with a mood stabilizer or atypical antipsychotic. Note that antidepressants are not approved for monotherapy as their use in patients with BD can lead to rapid cycling between manic and depressive states. Additionally, antidepressants can cause increased suicidal ideation (especially in children and adolescents) so patients must be closely monitored until the prescribing physician is aware of how they are affected by the medication.

Benzodiazepines such as lorazepam (Ativan) may be used for short-term treatment of insomnia associated with bipolar disorder and are highly addictive. 

Anticonvulsants may be utilized during manic episodes by calming hyperactivity in the brain. Commonly used anticonvulsants are valproic acid (Depakote) and topiramate (Topamax).

Barriers to pharmacologic treatment

Some key barriers to effective pharmacologic treatment of bipolar disorder are non-adherence to the regimen, side effects (real or imagined), stigma of being on psych medications, fear of dependence, financial issues, and even denial about their diagnosis. 

Additionally, when patients with BD have a comorbid disorder such as another psych disorder or substance abuse disorder, compliance with medications may be more challenging. In some cases, long-term medications such as once-monthly IM injections of aripiprazole (Abilify) may prove to be especially beneficial.

E: How do you EDUCATE the patient/family?

Some key teaching points for bipolar disorder are:

• Some medications need weeks or months to take full effect.
• The specific drug regimen may need to be tweaked until the best combination of medications for that patient can be determined. 
• Teach patients to continue with their medications, even when their BD symptoms improve.
• Teach your patient to eat meals at regular times, avoid caffeine, and keep to a consistent sleep schedule.
• Teach patients to monitor for weight loss or gain and that medications may cause weight gain.
• Teach patients to self-monitor for BD symptoms. Teach family members to monitor the patient for BD symptoms as well, and to know when to seek medical/psychiatric help.
• Provide support resources such as The Depression and Bipolar Support Alliance (DBSA).
• Specific medication teaching:
  • Lithium – teach the patient to monitor for signs of toxicity and to maintain adequate hydration as well as dietary sodium intake. Additionally, they should notify their MD immediately if they become pregnant or are trying to become pregnant.
  • Anticonvulsants – teach the patient to report a rash, bleeding, bruising, fever, dark urine or yellowing skin/eyes as these are signs of anticonvulsant hypersensitivity syndrome.
  • Antipsychotics – teach the patient their skin will be more sensitive to the sun, so they should wear sunscreen and protective clothing to avoid burns. They should  know to report signs of liver damage such as bleeding/bruising, dark urine, pale stools, and yellowing of the skin/eyes. Sipping water or chewing sugar free gum can help with dry mouth symptoms and they should stand up slowly to prevent orthostatic hypotension. Patients taking antipsychotics should immediately notify their physician/psychiatrist if they become pregnant.

Did you find this review of bipolar disorder helpful? If so, you’ll love our other mental health topics here.

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REFERENCES:

American Psychiatric Association. (n.d.). Psychiatry.org—What Are Bipolar Disorders? https://psychiatry.org:443/patients-families/bipolar-disorders/what-are-bipolar-disorders

Calabrese, J. R., Jin, N., Johnson, B., Such, P., Baker, R. A., Madera, J., Hertel, P., Ottinger, J., Amatniek, J., & Kawasaki, H. (2018). Aripiprazole once-monthly as maintenance treatment for bipolar I disorder: A 52-week, multicenter, open-label study. International Journal of Bipolar Disorders, 6(1), 14. https://doi.org/10.1186/s40345-018-0122-z

Handrup, C. T. (2020, November 3). Understanding bipolar disorder. American Nurse. https://www.myamericannurse.com/understanding-bipolar-disorder/

Mayo Clinic. (n.d.-a). Bipolar disorder—Diagnosis and treatment—Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/diagnosis-treatment/drc-20355961

Mayo Clinic. (n.d.-b). Bipolar disorder—Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955

McIntyre, R. S., & Calabrese, J. R. (2019). Bipolar depression: The clinical characteristics and unmet needs of a complex disorder. Current Medical Research and Opinion, 35(11), 1993–2005. https://doi.org/10.1080/03007995.2019.1636017

Stovall, J. (2021, August 9). Bipolar disorder in adults: Epidemiology and pathogenesis—UpToDate. https://www.uptodate.com/contents/bipolar-disorder-in-adults-epidemiology-and-pathogenesis?search=bipolar&source=search_result&selectedTitle=13~150&usage_type=default&display_rank=13

Suppes, T. (2020, January 16). Bipolar disorder in adults: Clinical features—UpToDate. https://www.uptodate.com/contents/bipolar-disorder-in-adults-clinical-features

Townsend, M. C., & Morgan, K. I. (2018). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (9th ed.). F.A. Davis Company.

Wang, X., & Yu, Y. (2021). Application of systematic nursing in patients with maniac access of bipolar disorder and its impact on treatment compliance and quality of life. American Journal of Translational Research, 13(6), 6929–6936.