Bipolar disorders According to ICD-11

1. Bipolar Disorders
Prof. Dr.S.Balachandar. PhD
Vice Principal
SCPM college of nursing and
paramedical science. Gonda

2. Prevalence of Bipolar Disorders
 Prevalence of BPD-I is 0.6%.
 prevalence of BPD-II is 0.3%.
 Prevalence of cyclothymic disorder is approximately 0.4%–1%.
 Age at onset of BPD-I is approximately 18 years, BPD-II is
approximately 25 years, Cyclothymic disorder usually begins in
adolescence
 Male-to-female ratio of is approximately 1:1.
 Females are more likely to experience rapid cycling
 90% who had a single manic episode may led to recurrent mood
episodes
 60% of manic episodes occur immediately before a major depressive
episode
 More common in developed countries
 Separated, divorced, widowed individuals have higher rates
 Attempted suicide in BPD I is 36.3% and BPD II is 32.4%
 Risk of suicide is 15 times more that general population

3. ICD-11 CLASSIFICATION OF BIPOLAR DISORDERS
Bipolar or related disorders
6A60 Bipolar type I disorder
6A61 Bipolar type II disorder
6A62 Cyclothymic disorder
6A6Y Other specified bipolar or related disorders
6A6Z Bipolar or related disorders, unspecified

4. What is BPD-I
 Bipolar I disorder is an episodic mood disorder
defined by the occurrence of one or more manic
or mixed episodes

5. Diagnostic Criteria for Bipolar I
Disorder
 For a diagnosis of bipolar I disorder, it is
necessary to meet the following criteria for a
manic episode. The manic episode may be
followed by hypomanic or major depressive
episodes.

6. Manic Episode
◦ A. Elevated or irritable mood and increased goal-
directed activity or energy, for at least one week
◦ B. During the period three (or more) of the following
symptoms are present
 1.Inflated self-esteem or grandiosity.
 2.Decreased need for sleep
 3.More talkative than usual or pressure to keep talking.
 4.Flight of ideas or subjective experience that thoughts are
racing.
 5.Distractibility
 6.Increase in goal-directed activity or psychomotor agitation
 7.Excessive involvement in activities that have a high potential for
painful consequences.
◦ C. The mood disturbance cause impairment in social or
occupational functioning
◦ D. The episode is not attributable to the physiological

7. Hypomanic Episode
A. Elevated or irritable mood and increased activity or energy, for at least 4
days
B. During the period three (or more) of the following symptoms are
present
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility.
6. Increase in goal-directed or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for
painful consequences.
C. The disturbance in mood and the change in functioning are observable
by others.
D. The episode is not cause marked impairment in social or occupational
functioning
E. The episode is not attributable to the physiological effects of a
substance

8. Major Depressive Episode
A. Five (or more) of the following symptoms have been present
during the same 2-week period
1. Depressed mood
2. Decreased interest in all activities
3. Significant weight loss when not dieting
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation
6. Loss of energy.
7. Feelings of worthlessness or guilt
8. Decreased ability to think or concentrate,
9. Recurrent thoughts of death, recurrent suicidal ideation
B. The symptoms cause impairment in social, occupational, or other
important areas of functioning.
C. The episode is not due to substance use or another medical
condition.

9. 6A60 Bipolar type I disorder
6A60.0 Bipolar type I disorder, current episode manic, without psychotic symptoms
6A60.1 Bipolar type I disorder, current episode manic, with psychotic symptoms
6A60.2 Bipolar type I disorder, current episode hypomanic
6A60.3 Bipolar type I disorder, current episode depressive, mild
6A60.4 Bipolar type I disorder, current episode depressive, moderate without psychotic symptoms
6A60.5 Bipolar type I disorder, current episode depressive, moderate with psychotic symptoms
6A60.6 Bipolar type I disorder, current episode depressive, severe without psychotic symptoms
6A60.7 Bipolar type I disorder, current episode depressive, severe with psychotic symptoms
6A60.8 Bipolar type I disorder, current episode depressive, unspecified severity
6A60.9 Bipolar type I disorder, current episode mixed, without psychotic symptoms
6A60.A Bipolar type I disorder, current episode mixed, with psychotic symptoms
6A60.B Bipolar type I disorder, currently in partial remission, most recent episode manic or
hypomanic
6A60.C Bipolar type I disorder, currently in partial remission, most recent episode depressive
6A60.D Bipolar type I disorder, currently in partial remission, most recent episode mixed
6A60.E Bipolar type I disorder, currently in partial remission, most recent episode unspecified
6A60.F Bipolar type I disorder, currently in full remission
6A60.Y Other specified bipolar type I disorder
6A60.Z Bipolar type I disorder, unspecified

10. What is BPD-II
 Bipolar II disorder is an episodic mood disorder
defined by the occurrence of one or more
hypomanic episodes and at least one depressive
episode.

11. Diagnostic Criteria for Bipolar II Disorder
For a diagnosis of bipolar II disorder, it is
necessary to meet the criteria for hypomanic
episode and criteria for major depressive
episode

12. Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode
and at least one major depressive episode.
B. There has never been a manic episode.
C. The occurrence of the hypomanic episode and major
depressive episode is not alike schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional
disorder, or other psychotic disorder.
D. The symptoms causes impairment in social, occupational, or
other important areas of functioning

13. 6A61 Bipolar type II disorder
6A61.0 Bipolar type II disorder, current episode hypomanic
6A61.1 Bipolar type II disorder, current episode depressive, mild
6A61.2 Bipolar type II disorder, current episode depressive, moderate without
psychotic symptoms
6A61.3 Bipolar type II disorder, current episode depressive, moderate with
psychotic symptoms
6A61.4 Bipolar type II disorder, current episode depressive, severe without
psychotic symptoms
6A61.5 Bipolar type II disorder, current episode depressive, severe with
psychotic symptoms
6A61.6 Bipolar type II disorder, current episode depressive, unspecified severity
6A61.7 Bipolar type II disorder, currently in partial remission, most recent
episode hypomanic
6A61.8 Bipolar type II disorder, currently in partial remission, most recent
episode depressive
6A61.9 Bipolar type II disorder, currently in partial remission, most recent
episode unspecified
6A61.A Bipolar type II disorder, currently in full remission
6A61.Y Other specified bipolar type II disorder
6A61.Z Bipolar type II disorder, unspecified

14. Diagnostic Criteria for Cyclothymic Disorder
 Cyclothymic disorder is characterized by a
continuous instability of mood for a period of at
least 2 years, involving numerous periods of
hypomanic and depressive

15. Cyclothymic Disorder
A. For at least 2 years there have been numerous periods with
hypomanic symptoms that do not meet criteria for a
hypomanic episode and numerous periods with depressive
symptoms that do not meet criteria for a major depressive
episode.
B. During the period of 2 years the hypomanic and depressive
periods present for at least half the time and the symptom-
free intervals last no longer than 2 months .
C. Criteria for a major depressive, manic, or hypomanic episode
have never been met.
D. The symptoms are not due to schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder
or other psychotic disorder.
E. The symptoms are not due to substance use or another
medical condition
F. The symptoms cause impairment in social, occupational, or
other important areas of functioning.

16. ETIOLOGY
 Biologic Theories
 Genetic Theories
◦ First-degree relatives of people with bipolar
disorder have a 3% to 8% risk compared
with a 1% risk in the general population.
◦ monozygotic twins have a higher rate (2 to
4 times) than dizygotic twins

17. ETIOLOGY
 Neuroanatomical factors.
◦ Right-sided lesions in the limbic system,
temporo basal areas, basal ganglia, and
thalamus have been shown to induce
secondary manic episode
◦ Enlarged third ventricles and subcortical
white matter and periventricular
hyperintensities in clients with bipolar
disorder

18. ETIOLOGY
 NEUROCHEMICAL THEORIES
◦ Decrease in serotonin is found in the blood
or cerebrospinal fluid of people with
depression
◦ Nor epinephrine levels decreased in
depression and increased in mania
◦ Dysregulation of acetylcholine and
dopamine also are cause mood disorders.

19. ETIOLOGY
 NEUROENDOCRINE INFLUENCES
◦ Bipolar disorders have been found in people
with endocrine disorders such as those of
the thyroid, adrenal, parathyroid, and
pituitary.
◦ About 5% to 10% of people with depression
have thyroid dysfunction, notably an elevated
TSH
◦ Increased cortisol secretion is present in
40% of depression cases

20. ETIOLOGY
 Psychodynamic Theories
◦ Sigmund Freud viewed mania as a “defense”
against underlying depression.
◦ Meyer viewed depression as a reaction to a
distressing life experience.
◦ Horney believed that children raised by
rejecting or unloving parents were risk for
depression.
◦ Beck saw depression as resulting from
specific cognitive distortions.

21. Test Methods
 Self-reported scales:
◦ Young Mania Rating Scale (YMRS)
◦ Beck scale (depression)
◦ Zung scale (depression)
 Interview with physician:
◦ Hamilton scale (HAMD)
◦ Montgomery and Asberg scale (MADRS)

22. Treatment during Manic
Episode
 Mood stabilizers:
◦ Lithium carbonate (0.6 - 1.2 mEq/L)
◦ Carbamazepine (6 - 12 mg/L)
◦ Sodium valproate (50 - 125 mg/L)
 Anticonvulsants:
◦ Lamotrigine
◦ Gabapentine
◦ Topiramate
 Psychotic patient
◦ Antipsychotics (olanzapine, risperidone)
◦ Benzodiazepines (lorazepam, clonazepam)
 ECT

23. Treatment during Depressive
episode
 Antidepressants
◦ Overall effectiveness: 65-70%
◦ Mild to moderate depressive episode: SSRIs.
◦ Severe depression: Antidepressants with broader spectrum of
effects, like SNRI or TCA.
◦ Patients with lethargy, hypersomnia, weight gain and anxiety
may prefer the less sedating medications such as bupropion,
Reboxetin.
◦ MAOIs should be beneficial in refractory patients.
◦ Patients with insomnia or anorexia may do better with more
sedating medication (mirtazapine, Trazodon)
• Psychotic patient - adding on neuroleptics.
• Electroconvulsive therapy (ECT) is the treatment of choice for
patients with very severe depression, with high risk for suicide or self-
destroying behaviour and for pregnant women.

24. Psychological treatment
 Cognitive behaviour therapy
 Interpersonal therapy
 Psychoanalytical therapy
 Behaviour therapy
 Group therapy
 Family and marital therapy

25. Common Nursing Diagnoses and Interventions for BPD
RISK FOR INJURY (Manic Episode)
 Reduce environmental stimuli. Assign a private room, if
possible, with soft lighting, low noise level, and simple
room decoration
 Limit group activities. Help client try to establish one or
two close relationships. Assign to a quiet unit, if possible
 Remove hazardous objects and substances from client’s
environment
 Stay with the client to offer support
 Provide physical activities as a substitution for
purposeless hyperactivity (examples: brisk walks,
housekeeping, dance therapy, aerobics).
 Administer tranquilizing medication, as ordered by
physician.
 Observe for effectiveness and side effects of medication

26. RISK FOR SELF-DIRECTED OR OTHER-DIRECTED
VIOLENCE (Manic Episode)
 Maintain low level of stimuli in client’s environment (low lighting, few
people, low noise level.
 Observe client’s behavior frequently (every 15 minutes).
 Remove all dangerous objects from client’s environment
 Try to redirect the violent behavior with physical activity (e.g.,
punching bag).
 Staff should maintain and convey a calm attitude toward client.
 Have adequate staff available to show your strength to client if
necessary.
 Administer tranquilizing medications as per physician order.
 If client is not calmed by medication, use of restraints may be
necessary.
 Observe the client in restraints every 15 minutes. Ensure that
circulation to extremities. Assist client with needs related to
nutrition, hydration, and elimination.
 When the agitation decreases, Remove one restraint at a time while
assessing client’s response

27. RISK FOR SUICIDE (Depressive Episode)
 Create a safe environment for the client. Remove all potentially harmful
objects from client’s access (sharp objects, straps, belts, ties, glass
items).
 Supervise closely during meals and medication administration.
 Perform room searches when necessary
 Formulate a short-term verbal or written contract with the client that he
or she will not harm self during specific time period.
 Get promise from client that he will seek out a staff member if thoughts
of suicide comes.
 Maintain close observation of client.
 Provide one-to-one contact, constant visual observation, or every-15-
minute checks.
 Place client in room close to nurse’s station; do not keep in separate
room. Accompany client to bathroom.
 Make rounds at frequent, irregular intervals (especially at night, early
morning, at change of shift, or busy times).
 Encourage verbalizations of honest feelings.
 Encourage patient to express angry feelings.
 Orient patient to reality, as required.

28. LOW SELF-ESTEEM (Depressive Episode)
 Be accepting of patient and his negativism.
 Spend time with patient
 Help patient to recognize and focus on strengths.
Minimize attention given to past failures
 Encourage participation in group activities
 Ensure that patient is not becoming increasingly
dependent.
 Ensure that therapy groups offer client simple methods
of achievement.
 Teach effective communication techniques,
 Assist patient in self-care when required.
 Offer positive feedback for tasks performed
independently.

29. POWERLESSNESS (Depressive Episode)
 Encourage patient to take as much
responsibility as possible for own self-care.
 Help client set realistic goals.
 Help client identify areas of life situation which
he can control and which he cannot control
 Encourage verbalization of feelings related to
inability
 Identify ways in which client can achieve.
Encourage participation in these activities, and
provide positive reinforcement for participation,
as well as for achievement.

30. IMBALANCED NUTRITION, LESS THAN BODY REQUIREMENTS
(Depressive Episode)
 In collaboration with dietician, decide number of calories
required to provide adequate nutrition.
 Provide fibre rich diet to prevent constipation .
 Encourage patient to take more fluid and physical exercise to
promote normal bowel functioning.
 Keep strict documentation of intake, output, and calorie count.
 Check weigh daily.
 Assess patient’s likes and dislikes.
 Provide small and frequent diet
 Administer vitamin and mineral supplements as ordered by
physician.
 If possible, ask family members to bring special foods that
patient likes.
 Stay with client during meals
 Monitor laboratory values, and report any changes to physician

31.  IMPAIRED VERBAL COMMUNICATION
 Use the techniques of validation and
clarification to decode communication
patterns.
 Maintain consistency of staff assignment
over time
 In a nonthreatening manner, explain to
patient that how his behavior is viewed by
others.
 If client is unable or unwilling to speak, use
use of the technique of verbalizing.

32.  SELF-CARE DEFICIT
 Encourage client to perform normal ADLs to his level
level of ability
 Encourage independence, but assist when client is
unable to perform
 Provide positive reinforcement if he do independently

33.  INSOMNIA
 Keep strict records of sleeping patterns
 Discourage sleep during the day
 Assist with measures that promote sleep, such as
warm, non stimulating drinks; light snacks; warm
baths; and back rubs.
 Performing relaxation exercises with soft music may
may be helpful
 Limit intake of caffeinated drinks such as tea,
coffee, and colas.
 Administer antipsychotic medication at bedtime

34.  DISTURBED SENSORY PERCEPTION:
(AUDITORY/VISUAL)
 Observe client for signs of hallucinations.
 Avoid touching the client before warning him.
 Encourage the client to share the content of the
hallucination with you.
 Do not reinforce the hallucination. Use words such
such as “the voices” instead of “they” when referring
referring to the hallucination.
 Try to distract the client away from the
hallucination.
 Listening to the radio or watching television helps
helps distract some clients from hallucination.

35.  DISTURBED THOUGHT PROCESSES
 Convey your acceptance of client’s false belief, but
but make him understand that you do not share the
the belief.
 Do not argue the belief
 Help client try to connect the false beliefs to times of
times of increased anxiety.
 Teach the techniques used to control anxiety
 Reinforce and focus on reality.
 Talk about real events and real people.
 Assist the client to verbalize feelings of anxiety, fear,
fear, or insecurity