• Bipolar disorder I (BPI): The person has had at least one manic episode, with or without an episode of depression.
• Bipolar disorder II (BPII): The person has had at least one episode of depression and at least one hypomanic episode. Hypomania is a milder form of mania that does not interfere with the person’s daily functioning.
• Cyclothymia: Cyclothymia is a mild form of bipolar disorder in which the person’s highs and lows are not as extreme as in the first two types.
People with bipolar disorder alternate between periods of high energy or irritability in which they may have difficulty sleeping, act impulsively, and make ambitious plans alternating with periods of depression in which they may feel guilty and hopeless, feel unable to accomplish anything, and consider suicide. Some patients have a mixed state, in which the high energy of the manic phase of the disorder is combined with the blue mood of the depressed phase. The mixed state is more common in children or adolescents with the disorder than in adults.
A person who has four or more episodes of alternating between manic and depressive phases
within a twelve-month period is said to have rapid cycling bipolar disorder. Rapid cycling is more likely to develop later in the disorder. Some people with rapid cycling have several episodes of mood changes within a week or even within a single day.
Bipolar disorder takes a heavy toll on a young person’s educational development, employment, and relationships. In fact, it is often misdiagnosed because people tend to attribute the person’s depression and other mood changes to failed relationships or trouble in school rather than seeing the mood disturbances as the cause of these problems. In some cases, the person with bipolar disorder may be misdiagnosed as having a drug or alcohol problem. Most people with bipolar disorder are able to function normally between episodes once they get treatment. A small minority, however, have chronic symptoms that do not improve in spite of treatment.
The National Institute of Mental Health (NIMH) estimates that about two million Americans over the age of eighteen have bipolar disorder and that the disorder costs the country about $15.5 billion every year. About 0.8 percent of the general adult population has BPI and 0.5 percent has BPII. Most people develop symptoms of the disorder in the late teen years or early twenties, but some begin to show signs of the disorder in childhood and others may develop symptoms in their later years. In general, however, a person who has their first manic episode after age fifty should be examined for a medical disorder first before being diagnosed with bipolar disorder. Men and women are at equal risk of developing BPI, although women are more likely than men to have rapid cycling. Women are at greater risk than men of developing BPII. Bipolar disorder occurs with equal frequency in all races and ethnic groups, as far as is known.
Nursing Care Plan Signs and SymptomsThe causes of bipolar disorder are not completely understood, although the disorder is known to run in families. The disorder is not caused by one gene, however, because identical twins of patients diagnosed with the disorder do not always develop it. Some doctors think that patients with bipolar disorder may have chemical imbalances in the brain that affect moods and emotions, while others think that there may be structural differences in these patients’ brains as well. Still other researchers think that bipolar disorder may be triggered by a combination of genetic factors and life experiences, as episodes of mania in some patients are known to be triggered by changes in medications, by thyroid disorders, or by inadequate sleep.
The symptoms of the manic phase of bipolar disorder may include:
• Unusually high levels of energy
• Euphoria (exaggerated sense of well-being), unrealistically high self-esteem, poor judgment
• Rapid speech, racing thoughts, insomnia
• Risky or aggressive behavior, spending sprees, increased sexual drive, drug or alcohol abuse
• Easily distracted, unable to concentrate
• Generally jumpy or agitated
The symptoms of the depressive phase may include:
• Thoughts of suicide
• Feelings of sadness or hopelessness
• Anxiety and guilt
• Loss of appetite
• Loss of interest in friends or normally pleasurable activities
• Chronic pain without an obvious physical cause
Some patients with bipolar disorder have psychotic episodes, which means that they have hallucinations and other signs of losing contact with reality. These patients are frequently misdiagnosed as having schizophrenia, another severe mental illness.
Nursing Care Plan DiagnosisThere is no way to diagnose bipolar disorder through a blood test or through imaging studies of the brain. The diagnosis is made on the basis of the patient’s symptoms and their history, including a family history. The doctor will give the patient a complete physical examination to rule out such physical disorders as diabetes or anemia, and a blood test to rule out thyroid disease. The patient will also be given several psychological tests to help the doctor evaluate their feelings and behaviors. Family members and friends may also be asked about the patient’s recent symptoms and behavior.
Nursing Care Plan TreatmentTreatment of bipolar disorder is a complicated and lifelong process. It is important for patients to have regular appointments with a psychiatrist, a doctor who is licensed to prescribe medications for mental disorders as well as provide psychotherapy. Patients must see the psychiatrist even when they are feeling better between episodes in order to prevent relapses. In addition, psychiatrists are knowledgeable about the many different drugs that can be used to treat bipolar disorder and can replace a drug that is not working well for a particular patient with one that may be more helpful or has fewer side effects. Sometimes patients may have one set of drugs to take during a manic episode and a different set to take during the depressive phase of the illness. The groups of drugs most commonly prescribed for patients with bipolar disorder are mood stabilizers, antidepressants, anti-seizure drugs, tranquilizers, and drugs to treat psychotic episodes. In addition to medications, patients with bipolar disorder usually work with a social worker or a psychotherapist because the disorder affects so many areas of life. Learning about the illness and how to cope with it is a crucial part of treatment; patients may be taught stress management techniques or relaxation techniques in order to help them cope more effectively with mood swings.
In some cases family therapy may be recommended so that the patient’s family members can better understand the illness and not blame themselves for causing it. In addition, families are often angry at the patient because they may have to deal with the consequences of the patient’s behavior, such as wild spending sprees or arrests for drug abuse, and the family members may need help in managing their anger.
Patients with bipolar disorder may be hospitalized for treatment if they are judged to be a danger to themselves or others. They can be treated with electroconvulsive therapy (ECT) in the hospital if they are having a severe episode of depression. Most treatments for bipolar disorder can be given on an outpatient basis, however.
Nursing Care Plan Prognosis
The prognosis for patients with bipolar disorder is generally good as long as they keep in regular contact with their psychiatrist and follow all treatment recommendations. Men, however, appear to have a somewhat worse prognosis than women, as do patients with a history of alcohol and drug abuse. Patients with either BPI or BPII should report all changes in mood to their doctor at once so that their treatment plan can be adjusted. Keeping a daily chart of moods and feelings that can be shared with the doctor is often helpful. Most patients are able to maintain a good quality of life in spite of the disorder; however, about 11 percent will eventually succeed in committing suicide.
Nursing Care Plan PreventionThere is no known way to prevent bipolar disorder, because the causes of it are not yet fully understood.
The NIMH is presently conducting several clinical trials of new medications and treatment strategies for bipolar disorder. Some of these are known as “real-world” clinical trials, because they enroll patients who are not hospitalized and are living productive lives. The newest large-scale study sponsored by the NIMH is called the Systematic Treatment Enhancement Program for Bipolar Disorder, or STEP-BD.