Bipolar I disorder: Bipolar I is a mood disorder that is characterized by at least one week-long manic episode that results in excessive activity and energy (Angst et al., 2012). Manic episodes may alternate with depression or a mixed state of agitation and depression. Though people with bipolar I disorder may have periods of time when they may be symptom-free, it is such a severe disorder that the person experiencing it tends to have difficulty in maintaining social connections and employment. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. Additionally, the presence of three of the following behaviors constitutes mania:

Extreme drive and energy

Inflated sense of self-importance

Drastically reduced sleep requirements

Excessive talking combined with pressured speech

Personal feeling of racing thoughts

Distraction by environmental events

Unusually obsessed with and overfocused on goals

Purposeless arousal and movement

Dangerous activities such as indiscriminate spending, reckless sexual encounters, or risky investments

Mania can be euphoric or dysphoric. Euphoric mania feels wonderful in the beginning, but it turns scary and dark as it progresses toward loss of control and confusion. Dysphoric mania is also referred to as a mixed state or agitated depression, with depressive symptoms along with mania. A person with dysphoric mania may be irritable, angry, suicidal, or hypersexual and may experience panic attacks, pressured speech, agitation, severe insomnia or grandiosity as well as persecutory delusions and confusion.

Bipolar II disorder: In bipolar II disorder, low-level mania alternates with profound depression. We call this low-level symptomatology hypomania. The hypomania of bipolar II disorder tends to be euphoric and often increases functioning. Like mania, hypomania is accompanied by excessive activity and energy for at least four days and involves at least three of the behaviors listed under mania. Unlike mania, psychosis is never present in hypomania although it may be present in the depressive side of the disorder (Mazzarini et al., 2010). The disorder is not usually severe enough to cause serious impairment in occupational or social functioning, and hospitalization is rare; however, the depressive symptoms tend to put those who suffer from it at particular risk for suicide.

Cyclothymic disorder: Symptoms of hypomania alternate with symptoms of mild to moderate depression for at least two years in adults and one year in children. Neither set of symptoms constitutes an actual diagnosis of either disorder, yet the symptoms are disturbing enough to cause social and occupational impairment. As part of the spectrum of bipolar disorders, cyclothymic disorder may be difficult to distinguish from bipolar II disorder (Baldessarini et al., 2011). Individuals with cyclothymic disorder tend to have irritable hypomanic episodes. In children, cyclothymic disorder is marked by irritability and sleep disturbance (VanMeter et al., 2011).

Some persons experience rapid cycling and may have at least four mood episodes in a 12-month period. The cycling can also occur within the course of a month or even a 24-hour period. Rapid cycling is associated with more severe symptoms, such as poorer global functioning, high recurrence risk, and resistance to conventional somatic treatments. It is estimated to be present in 12% to 24% of patients who go to specialized clinics for mood disorders (Bauer, 2008).

Epidemiology

Among children and teens bipolar disorder has a rate of about 1% (American Academy of Child and Adolescent Psychiatry, 2010). The lifetime risk, or the percentage of the population that will have a bipolar disorder by age 75, is 5.1% (Kessler, 2005).

The median age of onset for bipolar I is 18 years; for bipolar II, the median age of onset is 20 years (Merikangas, 2007). Bipolar I tends to begin with a depressive episode—in women 75% of the time and in men 67% of the time (Sadock & Sadock, 2008). The episodes tend to increase in number and severity during the course of the illness.

Women who experience a severe postpartum psychosis within two weeks of giving birth have a four times greater chance of subsequent conversion to bipolar disorder (Munk-Olsen et al., 2011). Researchers believe that giving birth may act as a trigger for the first symptoms of bipolar disorder, although few are diagnosed with this disorder during that episode. Hormone changes and sleep deprivation may be causative.

Bipolar I disorder seems to be somewhat more common among males, but bipolar II disorder (characterized by the milder form of mania—hypomania—and increased depression), rapid cycling, mixed states, and depressive episodes are more common among females (Ketter, 2010). Women with bipolar disorders are more likely to abuse alcohol, commit suicide, and develop thyroid disease; men with bipolar disorder are more likely to have legal problems and commit acts of violence.

Among children, researchers are actively studying the difference between attention deficit/hyperactivity disorder (ADHD) and bipolar disorder. Symptoms present in both ADHD and bipolar disorder include impulsivity, inattention, and hyperactivity. It may be that ADHD is overdiagnosed and bipolar disorder is underdiagnosed. This difference in diagnosis may be due to our uncertainty of how bipolar disorder looks or manifests itself in childhood since it does not tend to be diagnosed until adolescence or early adulthood.

Among adults, bipolar II disorder is believed to be underdiagnosed and is often mistaken for major depression or personality disorders, when it actually may be the most common form of bipolar disorder (Vieta & Suppes, 2008). Clinicians may downplay bipolar II and consider it to simply be the milder version of bipolar disorders; however, it is a source of significant morbidity and mortality, particularly due to the occurrence of severe depression. Anyone with major depression should be assessed for symptoms of hypomania since these symptoms are frequently associated with a progression to bipolar disorder (Fiedorowicz et al., 2011).

Cyclothymic disorder usually begins in adolescence or early adulthood. There is a 15% to 50% risk that an individual with this disorder will subsequently develop bipolar I or bipolar II disorder.

Comorbidity

One large-scale study with 9,282 participants revealed that more than half of people with bipolar disorder have another psychiatric disorder (Merikangas, 2007). Within a lifetime, the most commonly co-occurring disorders for all bipolar disorders were panic attacks (62%), alcohol abuse (39%), social phobia (38%), oppositional defiant disorder (37%), specific phobia (35%), and seasonal affective disorder (35%). Substance use disorders were much higher in bipolar I than in bipolar II disorders. Substance abuse and bipolar disorder should be treated at the same time whenever possible.

The incidence of borderline personality disorder occurring along with bipolar disorder is high. Patients who have borderline personality disorder have a 19.4% higher rate of bipolar disorder than do people with other personality disorders (Gunderson, 2006). An important consideration is that this combination may result in higher levels of impulsiveness and aggressiveness and may be a risk factor for suicidality (Carpiniello et al., 2011).

With advances in a global scientific database, trends are emerging that were previously unknown. One such trend is the relationship between psychiatric illnesses and physically based illnesses. In a study of nearly 37,000 people, several physical disorders were found to be associated with bipolar I (McIntyre, 2006). The rates of the following disorders were significantly higher: chronic fatigue syndrome, asthma, migraine, chemical sensitivity, hypertension, bronchitis, and gastric ulcers. The presence of these diseases further complicates the lives of persons with bipolar I by impairing their ability to work, increasing their dependence on others, and increasing their need for health care.

Etiology

Bipolar disorders are thought to be distinctly different from one another; for example, bipolar I disorder, bipolar II disorder, and cyclothymic disorder have different characteristics. Other variants of bipolar disease, including a number of other diseases whose end result is bipolar symptomatology, are currently being evaluated (Baum, 2008).

When the disorder starts in childhood or during the teen years, it is called early-onset bipolar disorder and is more severe than the forms that first appear in older teens and adults (Birmaher et al., 2006). Young persons with bipolar disorder have more frequent mood switches, have more mixed episodes, are sick more often, and are at a greater risk of suicide attempts.

Episodes of depression in bipolar disorders are different from unipolar depression (i.e., depression without episodes of mania—refer to Chapter 14). Depressive episodes in bipolar disorder affect younger people, produce more episodes of illness, and require more frequent hospitalization. They are also characterized by higher rates of divorce and marital conflict.

Theories of the development of bipolar disorders focus on biological, psychological, and environmental factors. Most likely, multiple independent variables contribute to the occurrence of bipolar disorder. For this reason, a biopsychosocial approach will likely be the most successful approach to treatment.

Biological factors

Genetic

The bipolar disorders have a strong heritability (i.e., the influence of genetic factors is much greater than the influence of external factors). Bipolar disorders are 80% to greater than 90% heritable whereas Parkinson’s disease, for example, is only 13% to 30% heritable (Burmeister, McInnis, & Zollner, 2008). The rate of bipolar disorders may be as much as 5 to 10 times higher for people who have a relative with bipolar disorder than the rates found in the general population.

It is likely that bipolar disorder is a polygenic disease, which means that a number of genes contribute to its expression. In a landmark study at the National Institute of Mental Health (NIMH), researchers found a connection between bipolar disorder and a genome that encodes an enzyme called diacylglycerol kinase eta (DGKH). Lithium is the first-line therapy for bipolar disorder, and DGKH is a crucial part of a lithium-sensitive pathway (Baum, 2008). Other research has focused on abnormal circadian genes that may result in a superfast biological clock, which manifests itself in extreme insomnia (McClung, 2007). Genetically, rapid cyclers tend to look a bit different. The circadian clock gene CRY2 is associated with rapid cycling in bipolar disorder (Sjöholm et al., 2010).

The scientific community has been increasingly drawn to the concept of bipolar disorders and schizophrenia having similar genetic origins and pathology (Ivleva, 2010). Both disorders exhibit irregularities on chromosomes 13 and 15. It may be that the genotype has more to do with the specific expression of psychoses (altered thought, delusions, and hallucinations) than is reflected in traditional classification systems. Current psychiatric diagnostic systems will undoubtedly be modified as advances are made in molecular genetics, which will revolutionize our understanding and treatment of many psychotic disorders.

Application of the nursing process

Assessment

Individuals with bipolar disorder are often misdiagnosed or underdiagnosed. Early diagnosis and proper treatment can help people avoid:

• Suicide attempts

• Alcohol or substance abuse

• Marital or work problems

• Development of medical comorbidity

Figure 13-1 presents the Mood Disorder Questionnaire (MDQ). This is not a definitive diagnostic test; however, it is a helpful initial screening device.

FIG 13-1 The Mood Disorder Questionnaire (MDQ). (From Hirschfeld, R., Williams, J., Spitzer, R., Calabrese, J., Flynn, L., Keck, P., …. Zajecka, J. [2000]. Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. *American Journal of Psychiatry,* 157[11], 1873-1875. Copyright © 2004 by Eli Lilly and Company.)

General assessment

The characteristics of mania discussed in the following sections are (1) mood, (2) behavior, (3) thought processes and speech patterns, and (4) cognitive function.

Mood

The euphoric mood associated with mania is unstable. During euphoria, the patient may state that he or she is experiencing an intense feeling of well-being, is “cheerful in a beautiful world,” or is becoming “one with God.” The overly joyous mood may seem out of proportion to what is going on, and cheerfulness may be inappropriate for the circumstances. This mood may change quickly to irritation and anger when the person is thwarted. The irritability and belligerence may be short-lived, or it may become the prominent feature of the manic phase of bipolar disorder.

People experiencing a manic state may laugh, joke, and talk in a continuous stream, with uninhibited familiarity. They often demonstrate boundless enthusiasm, treat others with confidential friendliness, and incorporate everyone into their plans and activities. They know no strangers, and energy and self-confidence seem boundless.

Elaborate schemes to get rich and famous and acquire unlimited power may be frantically pursued, despite objections and realistic constraints. Excessive phone calls and e-mails are made, often to famous and influential people all over the world. Persons in the manic phase are busy during all hours of the day and night, furthering their grandiose plans and wild schemes. To the person experiencing mania, no aspirations are too high, and no distances are too far. No boundaries exist to curtail the elaborate schemes.

In the manic state, a person often gives away money, prized possessions, and expensive gifts. The person experiencing a manic episode may throw lavish parties, frequent expensive nightclubs and restaurants, and spend money freely on friends and strangers alike. This excessive spending, use of credit cards, and high living continue even in the face of bankruptcy. Intervention is often needed to prevent financial ruin.

As the clinical course progresses from hypomania to mania, sociability and euphoria are replaced by a stage of hostility, irritability, and paranoia. The following is a patient’s description of the painful transition from hypomania to mania (Jamison, 1995b):

At first when I’m high, it’s tremendous …. ideas are fast …. like shooting stars you follow until brighter ones appear …. all shyness disappears, the right words and gestures are suddenly there …. uninteresting people, things become intensely interesting. Sensuality is pervasive; the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria …. you can do anything …. but somewhere this changes ….

The fast ideas become too fast and there are far too many …. overwhelming confusion replaces clarity …. you stop keeping up with it—memory goes. Infectious humor ceases to amuse—your friends become frightened …. everything now is against the grain …. you are irritable, angry, frightened, uncontrollable, and trapped in the blackest caves of the mind—caves you never knew were there. It will never end. Madness carves its own reality.

Behavior

When persons experience hypomania, they have voracious appetites for social engagement, spending, and activity, even indiscriminate sex. Constant activity and a reduced need for sleep prevent proper rest. Although short periods of sleep are possible, some patients may not sleep for several days in a row. This nonstop physical activity and the lack of sleep and food can lead to physical exhaustion and even death if not treated; it therefore constitutes an emergency.

EVIDENCE-BASED PRACTICE

Sleep Disruption in the Manic Phase of Bipolar Disorder

Roybal, K., Theobold, D., Graham, A., DiNieri, J., Russo, S., Krishnan, V., …. McClung, C. (2007). Mania-like behavior induced by disruption of CLOCK. Proceedings of the National Academy of Sciences, USA, 104, 6406-6411.

Problem

One of the most dramatic symptoms of bipolar disorder in the manic phase is sleep disruption. If you have ever stayed awake all night and tried to function the next day, you may have a partial appreciation for the thought impairment, decreased judgment, and emotional dysregulation experienced by people who have been awake for 3 nights. Researchers believe that a faulty circadian rhythm, the natural 24- to 25-hour sleep/wake cycle monitored by a body clock in the hypothalamus, may be to blame. This connection is strengthened by our knowledge that normal sleep/wake cycles are essential to mood stabilization and that sleep disruptions can trigger mania.

Purpose of study

The purpose of this study was to examine the role of a specific gene in the disruption of circadian rhythms. This gene is the central transcriptional activator of molecular rhythms, or Clock gene.

Methods

Researchers mutated the Clock gene in mice that served in the study. Next, they implanted electrodes in the medial forebrain bundle of their brains, the area that allowed mice to give themselves pleasurable sensations. They then measured the degree of current, or reward, that the mice gave themselves.

Key findings

• Clock mutant mice are similar to bipolar patients in a manic state in their increased preference for stimuli that are rewarding, including brain stimulation and cocaine.

• The experimental mice displayed other behaviors associated with mania, including less depressive behavior and decreased anxiety.

• Lithium treatment reverses manic-like behavior in Clock mutant mice.

• Once Clock mutant mice had their functional CLOCK restored, their abnormal behavior ceased.

Implications for nursing

The study of molecular genetics holds great promise for how people are diagnosed and treated. At a personal level, understanding the mechanics of mania may lessen professional stigma (negative attitudes of health care workers) and even our own attitudes toward people experiencing mania. When you are dealing with someone who is hypertalkative, hypersexual, and constantly making requests, it is fairly easy to become irritated and even resentful. An increased understanding of the physiology behind the disorder can go a long way.

At a hands-on level, the importance of promoting an adaptive sleep/wake cycle in people with mood disorders, particularly people with mania, is highlighted by this study. Teaching aimed at understanding the importance of not “burning the midnight oil” (staying awake all night) is important for everyone but imperative for people with bipolar disorder. Furthermore, recognizing disturbed sleep patterns may aid patients in recognizing symptoms of impending mania.

When in full-blown mania, a person constantly goes from one activity, place, or project to another. Many projects may be started, but few if any are completed. Inactivity is impossible, even for the shortest period of time. Hyperactivity may range from mild, constant motion to frenetic, wild activity. Flowery and lengthy letters are written, and excessive phone calls are made. Individuals become involved in pleasurable activities that can have painful consequences. For example, spending large sums of money on frivolous items, giving money away indiscriminately, or making foolish business investments can leave an individual or family penniless. Sexual indiscretion can dissolve relationships and marriages and lead to sexually transmitted diseases. Religious preoccupation is a common symptom of mania.

Individuals experiencing mania may be manipulative, profane, fault finding, and adept at exploiting others’ vulnerabilities. They constantly push limits. These behaviors often alienate family, friends, employers, health care providers, and others.

Modes of dress often reflect the person’s grandiose yet tenuous grasp of reality. Dress may be described as outlandish, bizarre, colorful, and noticeably inappropriate. Makeup may be garish and overdone. People with mania are highly distractible. Concentration is poor, and individuals with mania go from one activity to another without completing anything. Judgment is poor. Impulsive marriages and divorces can take place.

People often emerge from a manic state startled and confused by the shambles of their lives. The following description conveys one patient’s experience (Jamison, 1995b):

Now there are only others’ recollections of your behavior—your bizarre, frenetic, aimless behavior—at least mania has the grace to dim memories of itself …. now it’s over, but is it? …. Incredible feelings to sort through …. Who is being too polite? Who knows what? What did I do? Why? And most hauntingly, will it, when will it, happen again? Medication to take, to resist, to resent, to forget …. but always to take. Credit cards revoked …. explanations at work …. bad checks and apologies overdue …. memory flashes of vague men (what did I do?) …. friendships gone, a marriage ruined.

Thought processes and speech patterns

Flight of ideas is a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words. At times, the attentive listener can keep up with the flow of words, even though direction changes from moment to moment. Speech is rapid, verbose, and circumstantial (including minute and unnecessary details). When the condition is severe, speech may be disorganized and incoherent. The incessant talking often includes joking, puns, and teasing:

How are you doing, kid, no kidding around, I’m going home …. home sweet home …. home is where the heart is, the heart of the matter is I want out and that ain’t hay …. hey, Doc …. get me out of this place.

The content of speech is often sexually explicit and ranges from grossly inappropriate to vulgar. Themes in the communication of the individual with mania may revolve around extraordinary sexual prowess, brilliant business ability, or unparalleled artistic talents (e.g., writing, painting, and dancing). The person may actually have only average ability in these areas.

Speech is not only profuse but also loud, bellowing, or even screaming. One can hear the force and energy behind the rapid words. As mania escalates, the flight of ideas may give way to clang associations. Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning:

Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.

Grandiosity (inflated self-regard) is apparent in both the ideas expressed and the person’s behavior. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers. The boast of exceptional powers and status can take delusional proportions during mania. Grandiose persecutory delusions are common. For example, people may think that God is speaking to them or that the FBI is out to stop them from saving the world. Sensory perceptions may become altered as the mania escalates, and hallucinations may occur; however, delusions and hallucinations are not present during hypomania.

Cognitive function

The onset of bipolar disorder is often preceded by comparatively high cognitive function; however, there is growing evidence that about one third of patients with bipolar disorder display significant and persistent cognitive problems and difficulties in psychosocial areas. Cognitive deficits in bipolar disorder are milder but similar to those in patients with schizophrenia. Cognitive impairments are greater in bipolar I but are also present in bipolar II (Torrent, 2006).

The potential cognitive dysfunction among many people with bipolar disorder has specific clinical implications (Robinson, 2006):

• Cognitive function affects overall function.

• Cognitive deficits correlate with a greater number of manic episodes, history of psychosis, chronicity of illness, and poor functional outcome.

• Early diagnosis and treatment are crucial to prevent illness progression, cognitive deficits, and poor outcome.

• Medication selection should consider not only the efficacy of the drug in reducing mood symptoms but also the cognitive impact of the drug on the patient.

Self-assessment

Witnessing mania can elicit numerous intense emotions in a nurse. The patient may use humor, manipulation, power struggles, or demanding behavior to prevent or minimize the staff’s ability to set limits on and control dangerous behavior. People with mania have the ability to staff split, or divide the staff into either the good guys or the bad guys. “The nurse on the day shift is always late with my medication and never talks with me. You are the only one who seems to care.” This divisive tactic may pit one staff member or group against another, undermining a unified front and consistent plan of care. Frequent staff meetings to deal with the behaviors of the patient and the nurses’ responses to these behaviors can help minimize staff splitting and feelings of anger and isolation. Limit setting (e.g., lights out after 11 pm) is the main theme in treating a person in mania. Consistency among staff is imperative if the limit setting is to be carried out effectively.

The patient can become aggressively demanding, which often triggers frustration, worry, and exasperation in health care professionals. The behavior of a patient experiencing mania is often aimed at decreasing the effectiveness of staff control, which could be accomplished by getting involved in power plays. For example, the patient might taunt the staff by pointing out faults or oversights and drawing negative attention to one or more staff members. Usually, this is done in a loud and disruptive manner, which provokes staff to become defensive and thereby escalates the environmental tension and the patient’s degree of mania.

If you are working with a patient experiencing mania, you may find yourself feeling helplessness, confusion, or even anger. Understanding, acknowledging, and sharing these responses and countertransference reactions will enhance your professional ability to care for the patient and perhaps promote your personal development as well. Collaborating with the multidisciplinary team, accessing supervision with your nursing faculty member, and sharing your experience with peers in post conference may be helpful, perhaps essential.

ASSESSMENT GUIDELINES

Bipolar Disorder

1. Assess whether the patient is a danger to self and others:

• Patients experiencing mania can exhaust themselves to the point of death.

• Patients may not eat or sleep, often for days at a time.

• Poor impulse control may result in harm to others or self.

• Uncontrolled spending may occur.

2. Assess the need for protection from uninhibited behaviors. External control may be needed to protect the patient from such consequences as bankruptcy, because patients experiencing mania may give away all of their money or possessions.

3. Assess the need for hospitalization to safeguard and stabilize the patient.

4. Assess medical status. A thorough medical examination helps to determine whether mania is primary (a mood disorder—bipolar disorder or cyclothymic disorder) or secondary to another condition.

• Mania may be secondary to a general medical condition.

• Mania may be substance-induced (caused by use or abuse of a drug or substance or by toxin exposure).

5. Assess for any coexisting medical condition or other situation that warrants special intervention (e.g., substance abuse, anxiety disorder, legal or financial crises).

6. Assess the patient’s and family’s understanding of bipolar disorder, knowledge of medications, and knowledge of support groups and organizations that provide information on bipolar disorder.

Diagnosis

A primary consideration for a patient in acute mania is the prevention of exhaustion and death from cardiac collapse. Because of the patient’s poor judgment, excessive and constant motor activity, probable dehydration, and difficulty evaluating reality, risk for injury is a likely and appropriate diagnosis. Table 13-1 lists potential nursing diagnoses for bipolar disorders.

TABLE 13-1

SIGNS AND SYMPTOMS, NURSING DIAGNOSES, AND OUTCOMES FOR BIPOLAR DISORDERS

SIGNS AND SYMPTOMS	NURSING DIAGNOSES	OUTCOMES
Hyperactivity, locomotion into unauthorized spaces, pacing, poor judgment	Wandering Risk for injury	Remains in secure area when unaccompanied, can be redirected from unsafe activities, free from injury
Loud, profane, hostile, combative, aggressive, demanding behaviors	Risk for other-directed violence	Refrains from harming others, controls impulses, avoids violating others’ space
Anxiety, agitation, inability to concentrate, restlessness, prolonged periods of time without sleep	Sleep deprivation	Sleeps 5-8 hours a night, reports feeling rejuvenated after sleep
Poor reality testing, gradiosity, denial of problems, difficulty organizing and attending to information, poor concentration, inability to meet basic needs	Defensive coping Ineffective coping	Reports an increase in concentration, refrains from manipulative behavior, uses effective coping strategies
Minimal nutritional intake, poor hygiene, clothing unclean	Self-care deficit (feeding, bathing, dressing)	Returns to precrisis level of care: Completes meals, tends to hygiene, dresses in clean clothing
Giving away of valuables, neglect of family, impulsive major life changes (divorce, career changes), stress and frustration of family members	Interrupted family processes Caregiver role strain	Family obtains adequate resources to meet the needs of members; family routine is reestablished
Pressured speech, flight of ideas, going from one person or event to another, annoyance or taunting of others, loud and crass speech, provocative behaviors	Impaired verbal communication Impaired social interaction	Initiates and maintains goal-directed and mutually satisfying verbal exchanges

Outcomes identification

Table 13-1 lists associated outcomes for bipolar disorders. Specific outcome criteria will be based on which of the three phases of the illness the patient is experiencing.