Bipolar Disorder

Bipolar disorder (BD; also called manic depressive illness) is a chronic psychiatric disorder characterized by recurrent, alternating episodes of depression and mania which is described as excessively elevated or irritable mood. Bipolar disorder can result in severe functional impairment that effects relationships and performance at work and school and is associated with a high risk of suicide. Although the condition is treatable, patients frequently experience relapses that lead to a poor quality of life.

The cause of Bipolar disorder is unknown, although many factors are believed to contribute, including genetics, biochemical and environmental factors. Recent research in neuroimaging studies of patients with Bipolar disorder have revealed changes in the brain that regulate emotional responses, such as, the hippocampus; part of the limbic system located in the temporal lobe. Patients with Bipolar disorder present with alternate episodes of mood disturbances ranging from depression to manic or hypomanic episodes that vary in severity and duration.

Manic episodes are characterized by euphoric or irritable mood, hyperactivity, decreased need for sleep, and a sense of grandiosity that if severe could result in the patient engaging in delusional fantasies about his or her abilities or achievements. Many manic episodes also manifest as impulsiveness and poor judgement that drives the patient to risky behaviors and reckless activities without considering the consequences, such as, spending sprees and extramarital affairs.

Bipolar disorder has been classified as BD1, which includes recurrent manic episodes or mixed manic-depressive episodes. BD11, which includes recurrent depressive episodes that alternate with hypomania (less severe mania) episodes. Episodes of mania and depression usually last for about a week or more. Most episodes of Bipolar depression are misdiagnosed as major depression and in some cases it can take years for bipolar disorder to be accurately diagnosed.

Substance abuse is extremely frequent among patients with Bipolar disorder who may suffer from comorbid personality disorders; attention deficit hyperactivity disorders (ADHD) should be ruled out in children and adolescents, or treated if it is comorbid. Treatment depends on both the type and severity of the episode (depression or mania). Pharmacology of patients with Bipolar disorder during the acute manic episodes include lithium carbonate, a mood stabilizer, the anticonvulsants divalproex and carbamazepine, and antipsychotic medications such as olanzapine, quetiapine, risperidone, and aripiprazole.

Monotherapy is the first line treatment for Bipolar acute depression and includes use of quetiapine, lithium, or the anticonvulsant lamotrigine. Any of these can be used in combination with olanzapine and fluoxetine as a second line treatment. Patients with Bipolar disorder may require psychotherapy, education, family intervention and in rare cases, electroconvulsive therapy (ECT). Treatment regimen compliance is indispensable to allow patients to be high-functioning and lead normal lives.

The clinical presentation of Bipolar disorder include racing thoughts, poor judgement, risk-taking behavior such as; drug use, reckless driving, promiscuity and could have symptoms of distractibility, decreased need for sleep, psychomotor agitation and pressured speech which could be loud, rapid, disorganized, or incoherent in nature. The symptoms evidenced by a depressive presentation would include sadness, anxiety, guilt, restlessness, irritability, poor appetite, fatigue, hopelessness, lack of interest in previously pleasurable activities, poor concentration and suicidal ideation.

To assess for Bipolar disorder you need to obtain a personal and family history that would include medical and mental health conditions, substance abuse, current medications, sleep patterns and current or past reckless behaviors. Observe for signs and symptoms of abnormalities in mood, appearance, physical status, affect, speech,thought process and judgement; assess for impulsivity, irritability and agitation. Assessing lab values such as thyroid function test to assess for hypothyroidism which could be a cause for depression and hyperthyroidism which could be a cause for mania.

Monitoring CBC for abnormalities. Urinalysis and urine toxicology may be ordered to assess for substance abuse. Pregnancy test for women of childbearing age may be appropriate if pregnancy is suspected as a Bipolar disorder trigger. Risk for Bipolar disorder is increased with a family history of Bipolar disorder. First degree relatives of persons with Bipolar disorder are 7 times more likely to develop Bipolar disorder than the general population. Stress, lack of sleep, hypothyroidism, and antidepressant use can trigger depressive or manic episodes.

Nursing considerations for caring for a patient with Bipolar disorder would include monitoring vital signs, assess all physiologic systems and review laboratory and diagnostic study results. Immediately report abnormalities and treat as ordered. Administered prescribed medications and monitor for treatment for effectiveness and or adverse reactions. Nurses are able to build rapport and counsel that bipolar patient on effective techniques for managing the disorder and maintaining a good state of physical health.

Interventions for the patient experiencing mania include encouraging patients to eat high-calorie finger foods to help maintain nutrition during states where the patient may not want to sit down to consume a meal. It is also important to encourage and provide a quiet non-stimulating environment and quiet activities for the patient to do. During periods of depression, patients should be encouraged to participate in group therapy. It is also helpful to encourage patients to use a journal to write down their feelings when they are having difficulties talking about them.

RESOURCES: Karch, A. M. (2011). Focus on nursing pharmacology. (5thed. ). Philadelphia, PA: Wolters Kluwer l Lippincott, Williams & Wilkins. Pinto S, Schub T. Bipolar Disorder. [serial online]. September 7, 2012;Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 10, 2012. Sansone, R. A. , & Sansone, L. A. (2011). Managing Bipolar Disorder in the Primary Care Setting: A Perspective for Mental Health Professionals. Innovations In Clinical Neuroscience, 8(10), 10-13.

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