Chapter 13: Bipolar & Related Disorders

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Welcome to the Deep Dive.

Today we're really digging into bipolar and related disorders.

We'll be drawing heavily from a core psychiatric nursing text to break down

and the treatment.

This is, well, it's a tough one.

Chronic, complex, comes back again and again.

Used to be called manic depression, right?

And here's something really sobering.

The average person with bipolar disorder waits about six years between symptoms starting and actually getting diagnosed and treated.

Six years, that delay, it's huge.

It's absolutely massive.

And, you know, understanding the spectrum is probably the first step to fixing that.

The DSM -5 very intentionally puts these disorders right between schizophrenia spectrum stuff and major depressive disorders.

Okay.

Why there specifically?

Well, it reflects the overlap.

There's genetic overlap, neurobiological links, and bipolar eye especially can involve psychosis, which, you know, can sometimes look a bit like schizophrenia.

But they are distinct conditions.

Oh, absolutely.

Biologically distinct.

Sharing features doesn't mean they're the same thing.

Got it.

So thinking about that spectrum,

we need to pull apart the main types.

We've got bipolar one, bipolar two,

and cyclothemic disorder.

Exactly.

Those are the big three we need to understand.

All right.

Let's unpack the differences.

Starting with bipolar one, that's the most severe.

Generally, yes.

It's defined by having at least one manic episode.

And when we say manic, we mean it.

What does that look like clinically?

Think persistent high energy, feeling expansive, or maybe intensely irritable.

This isn't just a good mood.

It lasts at least a week and causes real marked impairment in their life.

It's often a psychiatric emergency.

So behaviorally, what are the signs?

Extreme energy focused on goals, but often scattered, like they're in perpetual motion.

They need very little sleep, sometimes little food.

And all this hyperactivity and grandiosity, it leads straight to really risky behaviors.

Right.

And clinically there are a couple of major hurdles with bipolar eye, aren't there?

Two big ones.

First is anasognosia.

It's a tricky concept.

That's the lack of insight.

Exactly.

They literally can't recognize they're ill because the illness affects that part of their brain.

They might feel absolutely fantastic on top of the world, so why would they need help?

Makes treatment incredibly difficult.

It does.

And the second hurdle is the risk of psychosis.

Ballusions are pretty common,

often grandiose, thinking they're royalty or have special powers, or immense wealth.

Sometimes And the worst outcome.

Yeah, we have to talk about suicide risk.

The mortality rate is stark.

About 5 % of deaths in women with bipolar and 10 % in men.

It's serious.

Okay, so that severity really highlights the contrast with bipolar too.

How does that differ?

Bipolar too requires at least one hypomanic episode.

Think of hypomania as a lower level mania, less dramatic.

How long does that last?

At least four days.

And here's the absolute key difference.

Hypomania never involve psychosis.

Never psychosis.

That's the dividing line.

That's the main one.

Hypomania might even feel good, make someone more productive, more creative.

It rarely leads to hospitalization on its own.

But there's another component to bipolar too, right?

It's not just hypomania.

Crucially, no.

You must also have at least one major depressive episode.

And often, that's the only reason they seek help.

The hypomania feels fine, even good, but the depression is crushing.

Which leads to misdiagnosis.

Very often.

It gets mistaken for just major depressive disorder.

And because that depression can be so profound,

the suicide risk in bipolar too is also extremely high.

Maybe even higher sometimes because it's missed.

Okay, so bipolar one mania, possible psychosis, bipolar two hypomania plus major depression, no psychosis.

What about cyclothymic disorder?

Cyclothymia is sort of a milder, more chronic version.

You get symptoms of hypomania alternating with symptoms of mild or moderate depression.

But not full episodes.

Not meeting the full criteria for hypomania or major depression.

But this pattern has to go on for at least two years.

And it still causes significant problems in their life, in functioning.

Is it like a precursor sometimes?

It can be.

It's definitely not benign.

There's a pretty significant risk, somewhere between 15 % and maybe even 50%,

that someone with cyclothymia will eventually develop full bipolar or bipolar two.

Wow, okay.

And one more term we need to define here, rapid cycling.

That sounds intense.

It is.

Rapid cycling isn't a separate diagnosis, but it's a core specifier.

It means the person has at least four distinct mood episodes, could be manic, hypomanic, or depressive, all within a single 12 -month period.

Four or more in a year.

Yeah, and that pattern usually means more severe symptoms overall.

And unfortunately, it often makes the condition harder to treat, more resistant to standard therapies.

Okay, this paints a complex picture.

So what's actually going on underneath?

What are the biological roots?

Well, genetics definitely plays a big role.

If you look at identical twins, if one has bipolar disorder, the chance of the other having it is really high, around 60%.

60%, that's huge.

It is.

And what's really fascinating, tying back to that spectrum idea,

large genetic studies show bipolar eye, the one with more psychosis risk, seems genetically closer to schizophrenia.

Whereas bipolar two, which is dominated by those depressive episodes, shows stronger genetic links to major depressive disorder itself.

Why does knowing that genetic split matter for, say, a clinician?

Well, it helps frame expectations.

It suggests different underlying pathways, maybe different co -occurring issues to watch for.

And it really drives home that this isn't just mood swings.

It's a fundamental brain disorder.

So beyond genetics,

neurobiology.

Yeah, the thinking here has evolved.

The older idea was simple.

Too much norepinephrine or dopamine causes mania.

Now, it's seen as more complex.

Maybe it's about the proportions of neurotransmitters, or how sensitive the receptor sites are.

And brain imaging shows changes.

Functional MRI and other scans show clear dysfunction, sometimes even loss of gray matter in really important brain areas.

The prefrontal cortex, which handles our executive functions, planning, decision making, that's evicted.

Explain some of the impulsivity and poor judgment in mania.

Absolutely.

Also the hippocampus, crucial for memory, and the amygdala, the emotion center.

Damage or dysfunction there really helps explain the mood swings, the emotional ability, and even sort of the cognitive problems people experience.

So biology sets the stage, but environment pulls the trigger.

That seems to be the model.

Having the genetic risk doesn't guarantee you'll get sick.

Yeah.

But put that genetic vulnerability into a stressful environment that increases the risk significantly.

What kind of environmental factors?

Stress is a big one.

Major life stressors can often trigger episodes.

And sadly, childhood adversity,

especially things like emotional abuse or neglect, is strongly associated with developing bipolar disorder and often predicts a tougher course, more episodes.

Given all that complexity and the risk, early assessment is obviously critical.

You mentioned that six -year delay.

Getting that down is key to preventing downstream problems like substance use, relationship issues, job loss.

Absolutely.

And there are tools to help screen.

The source material mentions the Altman Self -Retting Mania Scale, It's a simple, quick screening tool.

Just five questions the patient answers themselves about their mood and energy levels over the past week.

A score of six or more suggests mania or hypomania might be present and flags the knee before a proper clinical evaluation.

Useful in primary care, maybe?

Exactly.

Or even for patients to monitor themselves between appointments.

But for a full assessment, especially in acute mania, you're looking for a distinct cluster of symptoms.

Of the mood?

The mood is key.

Often starts as euphoria, feeling amazing, but it's unstable.

It can flip really quickly to intense irritation or anger, especially if they're frustrated or denied something.

Just this boundless, uninhibited enthusiasm that feels off.

And the behavior we talked about earlier,

that hyperactivity.

Nonstop motion, frenetic.

A really core feature is extreme distractibility.

Their attention just flits constantly, can't stay on task.

And that leads to?

Poor judgment,

risky behaviors, huge spending sprees they can't afford, impulsive travel, sexual indiscretions, suddenly giving away valuable possessions.

They can also be quite manipulative, testing limits constantly.

And there's a real physical risk exhaustion, dehydration, because they just won't stop to eat or sleep.

Let's talk about how they communicate.

The speech patterns are often really telling, right?

They reflect that brain dysfunction.

Oh, definitely.

You often hear pressured speech.

It's rapid, almost nonstop talking.

It feels urgent, like they can't get the words out fast enough.

It's hard to interrupt.

Think fire hose versus garden hose for the flow of words.

And does that connect to their thoughts racing?

Yes, it often reflects underlying racing thoughts, which can manifest as flight of ideas.

Describe that.

It's this continuous accelerated stream of talk where the topic shifts abruptly.

They jump from one idea to the next based on maybe a random association, a distraction in the room, or even just a pun or a word sound.

The links are there, but they're very loose, very fast.

That's if it gets really severe.

It can break down further into clying associations.

That's where the word choices are based purely on rhyming or sound, not logical connection or meaning.

I need a pen, Ben.

Ten hands, the end.

It loses coherence.

Okay.

What about circumstantial versus tangential speech?

I hear those terms, too.

Right.

Circumstantial speech is when someone includes excessive,

unnecessary details in their answer, goes off on little side stories, but eventually they do circle back and answer the original question.

It takes a long time to get there.

And tangential.

Tangential speech is different.

They start answering, get sidetracked by an association, and then just lose the original point completely.

They never come back to it.

They go off on a tangent and stay there.

So these communication issues, the distractibility, it points to cognitive problems.

Is that just during an episode?

That's the really concerning part.

While these are acute symptoms, research shows a significant number of people with bipolar disorder have persistent cognitive issues, problems with attention, memory, executive function, even when they're in remission, between episodes.

Even when their mood is stable.

Yes.

And the more manic episodes someone has had, the worse these cognitive deficits tend to be and the poorer their overall long -term functioning.

That really changes things, doesn't it?

If mania itself can damage cognitive function long -term.

It absolutely raises the stakes.

It makes early diagnosis and consistent effective treatment even more critical.

It's not just about stopping the current episode.

It's about preventing future episodes to protect long -term brain health and function.

Okay.

So let's shift to treatment planning.

We talk about phases.

Acute, continuation, maintenance.

In that acute phase, when someone is floridly manic, what's the absolute number one priority for a nursing pair?

Safety.

Safety and physiological stabilization.

That manic energy can lead to dangerous impulsivity, but also sheer physical exhaustion.

So how do you manage that?

They're not likely to cooperate easily.

No, they're not.

The immediate focus is preventing that physical collapse.

Aggressive hydration is key, monitoring their cardiac status because of the strain.

Trying to ensure they get some sleep, even just four, six hours a night, is a huge win.

How do you even get them to rest or eat?

Communication approach is vital.

Firm, calm, neutral tone.

Short, concise sentences, they can't process complexity, set clear, consistent limits.

For nutrition, since they won't sit for a meal, you offer frequent high -calorie fluids and finger foods they can eat on the move.

Things they can grab and go.

Exactly.

And you need to constantly redirect that intense energy.

Try to channel it into safe, low -stimulus activities.

Pacing may be simple repetitive tasks, but away from other people if they're agitated.

What about when redirection and meds aren't enough?

Seclusion or restraint?

Those are always, always last resorts.

They're only justified if the patient is in immediate, substantial danger to themselves or others, and everything else.

Verbal de -escalation, offering PRN meds, reducing stimuli has failed.

And there are strict rules.

Extremely strict protocols, requires a doctor's order, constant monitoring, usually visual checks every 15 minutes, or even one -to -one observation, and regular attention to their physical needs like fluids, toileting, range of motion.

It's about safety, not punishment.

Okay, let's talk meds.

Pharmacotherapy is central.

Mood stabilizers are the go -to, right?

And the classic one is lithium.

Lithium carbonate, yeah.

It's effective for both treating acute mythia and preventing future episodes, the maintenance phase.

What are the challenges with lithium?

Two main ones.

First, it's slow.

You can take 10, maybe 21 days to really reach full effect for mania.

So early on, you often need something else alongside it, like an anti -psychotic to manage acute symptoms quickly.

And the second challenge?

The big one.

It has a very narrow therapeutic window.

The difference between a dose that works and a dose that's toxic is really small.

Which means blood level monitoring is crucial.

Absolutely essential.

We monitor levels very closely, especially early on.

For acute mania, the target range is usually 0 .8 to 1 .2 mEqL.

For long -term maintenance, it's a bit lower, maybe 0 .6 to 0 .8 mEqL.

So patient education must be intensive.

What do they absolutely need to know?

Consistency is the key word.

They need to maintain consistent fluid intake, usually about 1 .5 to 3 liters a day, and consistent salt intake.

Changes in hydration or salt levels can drastically affect lithium levels.

What happens if levels get too high?

What are the signs of toxicity?

It's a progression.

First, they might just have expected side effects, like increased thirst, needed to pee more, maybe a fine hand tremor, early toxicity, maybe around 1 .5 mEqL or slightly higher, brings things like a coarse hand tremor, nausea, vomiting, diarrhea, confusion, and advanced toxicity.

That's a medical emergency?

Yeah.

You see ataxia problems with coordination, like stumbling, blurred vision, maybe seizures, severe low blood pressure.

So the critical instruction for patients is?

If you have excessive diarrhea, vomiting, or you're sweating heavily, like during intense exercise or a fever, you need to stop taking a lithium and call your doctor immediately.

Dehydration concentrates the drug and can push levels into the toxic range very quickly.

What if lithium isn't suitable or doesn't work?

What are the main alternatives?

We rely a lot on certain anticonvulsant medications.

Valproat or Depakote is a common one.

Carbamazepine, brand name Equetro, is another.

These can be especially helpful for people who experience that rapid cycling pattern.

And antipsychotics.

Yes, particularly the second generation antipsychotics or SGA.

Drugs like Alanzapine, Ciprexa, or Equetipine, Seroquel are often used.

They work well as mood stabilizers.

Plus, they often have immediate sedating effects, which can be really helpful in acute mania.

Any major downsides to the SGA?

The main concern is metabolic side effects.

Significant weight gain is common.

And there's an increased risk of developing diabetes and high cholesterol, impacting cardiovascular health.

So it requires regular monitoring of weight, blood sugar, lipids.

Okay, one last medication point.

Treating bipolar depression.

You mentioned earlier it's often misdiagnosed.

Why is treating it pharmacologically tricky?

The big danger is that using a standard antidepressant alone can actually trigger a switch into mania or hypomania in someone with bipolar disorder.

It can destabilize them.

So you can't just give them an SSRI like you might for regular depression.

Generally not on its own, no.

The standard approach usually involves using a mood stabilizer with an antidepressant or using specific medications approved for bipolar depression.

Often that means certain second generation antipsychotics like loracidone, latuta, or there's Symbiax, which is actually a combination pill of olanzapine and fluoxetine, Prozac.

So always needs careful consideration of the mood stabilizer backbone.

Always.

Protecting against that switch to mania is paramount.

Beyond pills, what about other biological treatments?

Brain stimulation.

Yes,

electroconvulsive therapy, ECT, is actually still considered one of the fastest and most effective treatments, particularly for severe bipolar depression or treatment resistant mania.

It can work much faster than medications sometimes.

Often gets results within a week or two.

It can, yes.

Especially for severe depression where suicide risk is high, ECT can be lifesaving.

And then there is the psychological therapies.

Meds are necessary, but usually not sufficient on their own, right?

Exactly.

They work best in combination.

Several therapies are helpful as adjuncts.

Like CBT.

Cognitive behavioral therapy, yes.

It helps patients identify those negative or maladaptive thought patterns that can fuel depression or trigger relapse.

It's also really good for improving problem solving skills and crucially, medication adherence.

What else?

Interpersonal and social rhythm therapy, or IPSRT, is really interesting.

It focuses specifically on regulating daily routines, sleep -wake cycles, meal times, social interactions.

The idea is that stabilizing these social rhythms helps stabilize the underlying biological rhythms, which helps mood stability.

Makes sense given the sleep connection you mentioned.

It does.

And finally, family -focused therapy is often vital.

Bipolar disorder hugely impacts families, and family stress can trigger episodes.

This therapy helps improve communication, reduce conflict, and educate the family on how to support the patient effectively.

So wrapping this all together, thinking long -term, the maintenance phase is all about preventing relapse.

What are the absolute keys for you the listener to remember for that?

Medication adherence is non -negotiable.

Taking meds consistently, even when feeling well, is the bedrock.

And closely related is lifestyle regularity, especially sleep hygiene.

Why sleep specifically?

Because changes in sleep patterns, sleeping much less or much more, are very often the earliest warning sign that a mood episode, either manic or depressive, might be starting.

Catching it early based on sleep changes can allow for intervention before it becomes a full -blown crisis.

Recognizing those personal warning signs is key.

Okay, so let's recap the big takeaways from this deep dive.

Sure.

First, really grasp the difference.

Bipolar I means at least one manic episode, high -risk psychosis.

Bipolar II means hypomania plus major depression, no psychosis, of very high depression -related risks.

Got it.

Mania versus hypomania depression.

Second, acute mania is a physiological emergency as much as a psychiatric one.

Nursing care must prioritize safety, preventing exhaustion, monitoring physical health.

Physical needs first and acute mania.

And third, if using lithium, remember that narrow therapeutic window,

it demands careful blood -level monitoring and relentless patient education about consistency and toxicity signs.

Lithium needs respect.

Okay.

And a final thought for everyone listening.

We talked about those persistent cognitive deficits, problems with thinking, memory, focus, that often remain even when mood is stable and seem linked to the number of manic episodes someone has.

Think about what that means.

It underscores just how vital early diagnosis and really consistent proactive treatment are.

It's not just about managing mood swings in the moment.

It's about protecting the brain, preserving cognitive function, and ultimately ensuring a better quality of life for the person across their entire lifespan.

That's the long game.

Thank you so much for joining us for this deep dive into bipolar and related disorders.

We hope breaking down these concepts helps in your learning and your practice.