This slide contains information regarding Bipolar and affective disorder. Bipolar disorder, formerly called manic depression, causes extreme mood shifts ranging from mania to depression. Here information regarding "mania" is only included. You can find about depression in my next upload with the title "Mood disorder and depression". This can be helpful for proficiency level and bachelor level nursing students. Your feedback is highly appreciated.

1. Bipolar and Affective Disorder
Nabina Paneru

2. Bipolar Disorder
• Bipolar disorder, also known as manic depressive illness, is a
brain disorder that causes unusual shifts in mood, energy,
activity levels, and the ability to carry out day – to – day tasks.

3. Types
• Bipolar I: Is defined as having a clinical course of one or more manic
episodes and sometimes, major depressive episodes (a complete set of
mania symptoms occurs during the course of the disorder).
• Bipolar II: Bipolar disorder characterized by episodes of major depression
and hypomania rather than mania is known as bipolar II disorder ( the
episodes of manic like symptoms do not quite meet the diagnostic criteria
for a full manic syndrome).

4. Mania
• Mania is an alteration in mood that is expressed by feelings of
elation, inflated self – esteem, grandiosity, hyperactivity,
agitation, and accelerated thinking and speaking.
• Mania can occur as a biological (organic) or psychological
disorder, or as a response to substance use or a general medical
condition.

5. Classification of Mania (ICD 10)
• Hypomania
• Mania without psychotic symptoms
• Mania with psychotic symptoms

6. Epidemiology of Mania
• The lifetime risk of manic episode is about 0.8% - 1%. This
disorder occurs in episodes lasting usually 3 to 4 months
followed by complete recovery.

7. • Etiology same as discussed previously in mood disorder.

8. Diagnosis
• 1st step: exclude a disorder with known organic cause, e.g. organic (especially-drug induced)
mood disorders and dementia
• 2nd step: to rule out a possibility of acute and transient psychotic disorders, schizo-affective
disorder and schizophrenia
• 3rd step: exclude possibility of other non-organic psychoses such as delusional disorders
• 4th step: exclude possibility of adjustment disorder with depressed mood, gen. anxiety
disorder, normal grief reaction, obsessive compulsive disorder (with or without secondary
reaction)
• Important to look for comorbid medical and/or psychiatric disorders (anxiety, alcohol or drug
misuse, personality disorder)

9. Diagnostic Criteria for Acute Mania: lasting at least 1
week (or any duration if hospitalization is necessary)
Symptoms of Mania DSM-IV ICD-10
1A Elevated Mood + +
1B Irritable Mood + +
2 Grandiosity or increased self – esteem + +
3 Decreased need for sleep + +
4 Increased talkativeness + +
5 Flight of ideas + +

10. Contd.
Symptoms of Mania DSM-IV ICD-10
6 Distractibility + +
7A Increased social activities or contacts + +
7B Psychomotor agitation + +
8 Risk taking behavior + +
9 Increased sexual activities +
+ indicates that the symptom is included

11. Clinical Features
• Mood: is elevated, expansive and irritable: the patient seems
cheerful and optimistic, feeling full of energy

12. Stages of Elevated Mood

13. Clinical Features Contd.
• Psychomotor activity: Hyperactivity, psychomotor agitation,
hostility
• Appearance and behavior: untidy and disheveled, starts many
activities but leave them unfinished, increased libido
• Sleep: is often reduced (<3hrs), wake early

14. Contd.
• Speech and thought:
Flight of ideas, delusions of grandiosity, inflated self esteem or
delusion of persecution are common.
Religious prophet.

15. Contd.
• Perceptual disturbances: Hallucination occurs: taking the
form of voices, speaking to the patient about his special powers
or occasionally of visions with a religious content.
• Goal directed activity: Alert tries to do many activities at at
time, planning of various activities at one time so distractible
and decrease in functioning, marked increased in sociability.

16. Contd.
• Other features:
Decreased food intake due to over activity
Poor judgement
Involvement in high risk activities (reckless driving, foolish
business, investment, distributing money or articles to unknown
person)

17. Other features contd.
 Mood disturbance is so severe it impairs occupational functioning
relationships, or social activities.
 Laughing inappropriately, inappropriate humor
 Disorientation
 Weight loss
 Dress is often inappropriate with bright colors that do not match, excessive
makeup and jewelry

18. Contd.
• Mania with psychotic symptoms
Emotionally labile, can be very angry, very intrusive,
Uncooperative, severely agitated, no sleep, very talkative, loud:
flight of ideas, grandiosity, religious delusions “hearing god”,
sexually very preoccupied.

19. Management
• Pharmacological Treatment
• Non Pharmacological Treatment
• Nursing Management

20. Pharmacological Management
• Antipsychotics: Typical antipsychotics: Chorpromazine
75 to 400mg, Atypical antipsychotics: Olanzapine 10 to 20
mg, Resperidone 1 to 6 mg
• Mood stabilizers: Lithium: Acute mania: 1,800 to 2400
mg, maintenance: 900 to 1200 mg, Carbamazepine: 200 to
1600 mg, Sodium valproate: 5mg/kg to 60mg/kg
• Other drugs: Clonazepam, calcium channel blockers

21. Non Pharmacological management
• Milieu Therapy
• ECT
• Psychotherapy:
- Individual psychotherapy
- Group therapy
- Occupational therapy

22. Nursing Management
• Nursing Assessment
- History taking
- MSE
- Observe for sign and symptoms like rapid mood swings, sleep disturbances,
delusion and hallucinations, excitement and destructive activities, Intake of
food: special attention is given to the patient’s diet because he/she is
usually too body to eat, hence may lose weight and dehydration may occur.
Meals and foods are given under supervision.

23. Nursing Diagnosis
1. Risk for injury related to extreme hyperactivity and impulsive behavior as evidenced by
lack of control over purposeless and potentially injurious movements.
2. Risk for self directed or other directed violence related to manic excitement, delusional
thinking and hallucinations.
Interventions
- Approach the patient in calm/ unhurried and consistent manner.
- Reduce environmental stimuli. Assign single room, soft lightning, and low noise level, and
simple room décor, limit group activities.

24. Interventions Contd.
- Remove all dangerous objects from client’s environment (sharp objects, glass or
mirrored items, belts, ties, smoking materials etc).
- Provide structured schedule of activities. Provide physical activities as a
substitution for purposeless hyperactivity (example: brisk walking, housekeeping
chores, dance therapy, aerobics.)
- Stay with client as hyperactivity increases.
- Redirect the violent behavior with physical outlets for the client’s hostility (eg.
Punching bag)

25. Interventions Contd.
- Encourage verbal expression of feelings.
- Always speak quietly, tactfully and patiently.
- Avoid arguments, discussion or situation that is stimulating and irritating.
- Administer medications as prescribed.
- Use restrain in case of refusal of medicine. Observe patient every 15
minutes.

26. Nursing diagnosis contd.
3. Imbalanced nutrition less than body requirements related to refusal or
inability to sit still long enough to eat meals, evidenced by loss of weight.
Interventions
- Provide client with high protein, high calorie nutritious foods and drinks
that can be consumed “on the run”.
- Find out patients likes and dislikes, and collaborate with dietician to
provide favorite foods.

27. Interventions contd.
- Provide 6-8 glasses of fluids per day. Have juice and snacks on at all times.
- Maintain accurate record of intake, output and calorie count. Weight the
patient regularly.
- Administer vitamin and mineral supplements.
- Pace or walk with client as finger foods are taken, sit with client during
meals.

28. Nursing Diagnosis contd.
4. Disturbed thought process related to psychotic process or sleep deprivation (Delusion).
Interventions
- Do not argue or deny the belief, while letting him or her know that you do not share the delusion.
- Use the techniques of validation and clarification.
- Reinforce and focus on reality.
- Give positive reinforcement as client is able to differentiate between reality-based and non-reality-
based thinking.
- Teach client to intervene, using thought stopping techniques, when irrational thought prevails.
- Use touch cautiously, particularly if thoughts reveal ideas or persecution.

29. Contd.
5. Disturbed sensory perception related to psychotic process (Hallucinations)
Interventions
- Observe client for signs of hallucinations.
- Avoid touching the clients before warning him/her.
- Show acceptance.
- Do not reinforce the hallucinations.
- Try to connect the times of the misperceptions to times of increased anxiety. Help client to
understand this connection.
- Try to distract the client away from the misperception.

30. Contd.
6. Insomnia related to excessive hypersensitivity
Interventions
- Provide a quiet environment, with a low level of stimulation.
- Monitor sleep patterns.
- Provide structured schedule of activities that includes established times for naps and rests.
- Before bedtime, provide nursing measures that promote sleep.
- Prohibit intake of caffeinated drinks, such as tea, coffee, and colas.
- Administer sedative medications as prescribed.

31. # Another feature seen in bipolar disorder is depression.