Mood disorder: Mania and Bipolar disorder

Course outline

Introduction

Continuum of emotional responses

ICD-10 classification of mood disorders

Bipolar disorder

ICD classification

Predisposing factors

Clinical features

Diagnosis

Treatment strategies

Nursing management

Prognosis

References

Mood can be defined as a pervasive and sustained emotion that may have a major influence on a
person’s perception of the world. It refers to an internal emotional state of individual. Examples of mood
include depression, joy, elation, anger, anxiety, sad, empty, melancholic, distressed, irritable,
disconsolate, elated, euphoric, manic, gleeful, and many others, all descriptive in nature.

Affect is described as the emotional reaction associated with an experience. It is the external expression
of internal emotional content.

Like other aspects of the personality, emotions or moods serve an adaptive role.

The four adaptive functions of emotions are social communication, physiological arousal, subjective
awareness, and psychodynamic defense.

Continuum of emotional responses

Emotions such as fear, joy, anxiety, love, anger, sadness, and surprise are all normal parts of the human
experience. The problem arises in trying to evaluate when a person’s mood or emotional state is
maladaptive, abnormal, or unhealthy.

At the adaptive end is emotional responsiveness. It implies an openness to and awareness of feelings. In
this way, feelings provide valuable learning experiences.

• Also adaptive in the face of stress is an uncomplicated grief reaction. Such a reaction implies that the
person is facing the reality of the loss and is immersed in the work of grieving.

• A maladaptive response is the suppression of emotions. This may be a denial of one’s feelings or a
detachment from them. A temporary suppression of feelings may at times be necessary to cope, as in an
initial response to a death or tragedy.

• Delayed grief reaction also is maladaptive. It involves a prolonged suppression of emotion that
interferes with effective functioning.

• The most maladaptive emotional responses are depression and mania seen in bipolar disorder. Severe
mood disturbances are recognized by their intensity, pervasiveness, persistence, and interference with
social and physiological functioning.

Mood disorders are called so because one of their main feature is abnormality of mood. This term
groups together a number of clinical conditions whose common and essential feature is a disturbance of
mood, accompanied by related cognitive, psychomotor, psychophysiological and interpersonal

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difficulties. It is characterized by a disturbance of mood, accompanied by a full or partial manic or
depressive syndrome, which is not due to any other physical or mental disorder.

According to the ICD-10, the mood disorders are classified as follows:

F30-F39 : Mood (affective disorders)

F30 : Manic episode

F31 : Bipolar (affective) disorder

F32 : Depressive episode

F33 : Recurrent depressive disorder

F34 :Persistent mood disorder (including cyclothymia and dysthymia)

F38 :Other mood disorders (mixed affective episode and recurrent brief depressive disorder).

F39 :Unspecified mood disorder.

Patients with only major depressive episodes are said to have major depressive disorder or unipolar
depression. Patients with both manic and depressive episodes or patients with manic episodes alone
are said to have bipolar disorder. The terms “unipolar mania” and “pure mania” are sometimes used
for patients who are bipolar but who do not have depressive episodes.

BIPOLAR DISORDER
Bipolar disorders are a group of mood disorders that include manic episodes, hypomanic episodes,
mixed episodes, depressed episodes, and cyclothymic disorder. Bipolar disorders are characterized by
mania or hypomania alternating with depression.
Mood lability is the term used for the rapid shifts in moods that often occur in bipolar disorder. One
month a person is happy and the next s/he is in the depth of depression. These mood shifts leave
everyone confused and interfere with social interaction. It is alterations in moods with little or no change
in external events. Bipolar disorders tend to be recurrent and have the unusual tendency to increase in
frequency as the individual ages.
Major groups of bipolar disorder are:
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
The majority of bipolar I disorder clients do not have the chance to experience a baseline mood called
euthymic mood because a major depressive episode may quickly follow. Many clients return to normal
functioning during remissions, but approximately 20% to 30% have residual mood symptoms and as
many as 60% have continuing interpersonal and occupational difficulties. Of clients with bipolar II

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disorder, 5% to 10% have four or more mood episodes in a given year, and approximately 15%
experience continuing mood lability and interpersonal and occupational difficulties (APA, 2000).
The average age of onset for bipolar disorder is the early 20s.
As with depression, bipolar disorder appears to be more common in unmarried than in married persons
(Joska & Stein, 2008).
Unlike depressive disorders, bipolar disorder appears to occur more frequently among higher
socioeconomic classes (Sadock & Sadock, 2007).
Bipolar disorder is the sixth leading cause of disability in the middle age group, and the loss of
earnings and productivity attributable to mood disorders (depression and bipolar disorder) may amount
to about $33 billion per year in the United States (Joska & Stein, 2008).
Prevalence is 1.5% and it is uniform throughout the world.

Etiology
a) Biological factors
The biogenic amines include 3 catecholamines—dopamine, norepinephrine & epinephrine—as well as
serotonin and acetylcholine.
Dopamine: several studies have suggested that overactivity of dopamine pathways may play an
important role in the pathogenesis of mania.
Norephinephrine and epinephrine: there is diminished level with depression.
Serotonin: it has been hypothesized that there may be an underlying deficiency in serotonin activity in
both mania and depression.
Acetylcholine: according to research high levels of acetylcholine in the brain cells can cause
depression.
Endocrine system Current study of neuroendocrine factors in mood disorders emphasizes the
disinhibition of hypothalamic-pituitary-adrenal (HPA) axis and hypothalamic-pituitary-thyroid (HPT)
axis.
Cortisol: Many depressed patients exhibit hypersecretion of cortisol.
Biochemistry. There is decreased 5-HT availability in patients with depression. Too little 5-HT, its
precursor (tryptophan), or its major metabolite (5-HIAA) is found in the cerebrospinal fluid or blood
of people with depression and in the postmortem brains of depressed people who died of other causes
or who committed suicide.
Immunological Disturbance: Depressive disorders are associated with several immunological
abnormalities, including decreased lymphocyte proliferation in response to mitogens and other forms
of impaired cellular immunity.
Brain imaging. Computed tomography (CT) and magnetic resonance imaging (MRI) studies find
various abnormalities in the structure of brains in people with mood disorders.

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 • MRI studies of depressed patients show a decrease in the size of the hippocampus. This supports the
hypothesis that increased levels of stress hormones are associated with damage to the hippocampus (a
limbic structure involved in learning and memory).
• MRI studies of bipolar patients show that brain structures responsible for human mood are larger.
Specifically, the amygdala (the limbic structure responsible for modulating feelings of aggression,
anger, love, and shyness) is especially large, perhaps accounting for some of the heightened
emotionality and problematic behaviors seen in manic patients. Positron emission tomography (PET)
studies of mood disorders show decreased frontal lobe brain metabolism (hypometabolism), which is
more pronounced on the left hemisphere in depression and on the right hemisphere in mania. This
means that the frontal lobes, which have an important role in intellectual and emotional activities, are
not using as much glucose as they should.
Alterations of Sleep Neurophysiology: Depression is associated with a premature loss of deep (slow-
wave) sleep and an increase in nocturnal arousal. The latter is reflected by four types of disturbance:
(1) an increase in nocturnal awakenings, (2) a reduction in total sleep time, (3) increased phasic rapid
eye movement (REM) sleep, and (4) increased core body temperature.

b) Genetic factors
The lifetime risk is 20% for relatives of people with depression and 24% for relatives of people with
bipolar disorder. The lifetime risk for mood disorders in the general population is 6%. A person who
has an identical (monozygotic) twin with an affective disorder has a two to four times greater risk for
the disorder than if the sibling were a fraternal (dizygotic) twin or non-twin.
First degree relative: 5-10% chance
Identical twin with bipolar disorders: about 50-70% chance.
studies find a concordance rate for mood disorder in the monozygotic (MZ) twins of 70 to 90%
compared with the same-sex dizygotic (DZ) twins of 16 to 35%
Adoption Studies. Adoption studies provide an alternative approach to separating genetic and
environmental factors in familial transmission. Only a limited number of such studies have been
reported, and their results have been mixed. One large study found a threefold increase in the rate of
bipolar disorder and a twofold increase in unipolar disorder in the biological relatives of bipolar
probands. Similarly, in a Danish sample, a threefold increase in the rate of unipolar disorder and a
sixfold increase in the rate of completed suicide in the biological relatives of affectively ill probands
were reported. Other studies, however, have been less convincing and have found no difference in the
rates of mood disorders.
Psychodynamic theories: developmental theorists have hypothesized that faulty family dynamics
during early life are responsible for manic behaviors in later life. Another psychodynamic hypothesis
explains manic episodes as a defense against or denial of depression.
Psychoanalytical theory: According to Freud (1957) depression results due to loss of a loved object
and fixation in the oral sadistic phase of development. In this model, mania is viewed as a denial of
depression.
Behavioral theory: this theory of depression connects depressive phenomena to the experience of
uncontrollable events. According to this model depression is controlled by repeated losses in the past.

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Cognitive theory: depression is due to negative cognitions which includes – negative expectations of
the environment, self and the future. These cognitive distortions arise out of a defect in cognitive
development and cause the individual to feel inadequate, worthless and rejected by others.
Sociological theory: stressful life events e.g. death, marriage, financial loss before the onset of the
disease or a relapse probably have a formative effect.
Transactional model or stress/adaptation: depression occurs as a combination of predisposing factors
(family history and biochemical alterations), past experiences (object loss in infancy, defect in
cognitive development) and existing conditions (lack of adequate support system, inadequate coping
skills, other physiological conditions). Because of weak ego strength, patient is unable to use coping
mechanisms effectively. Maladaptive coping mechanisms used are denial, regression, repression,
suppression, displacement and isolation. All these factors lead to clinical depression.
c) Psychosocial Factors
 Life events and environmental stress: A long-standing clinical observation is that stressful life
events more often precede first, rather than subsequent, episodes of mood disorders. This
association has been reported for both patients with major depressive disorder and patients with
bipolar I disorder. One theory proposed to explain this observation is that the stress accompanying
the first episode results in long-lasting changes in the brain’s biology. These long-lasting changes
may alter the functional states of various neurotransmitter and intraneuronal signaling systems,
changes that may even include the loss of neurons and an excessive reduction in synaptic contacts.
As a result, a person has a high risk of undergoing subsequent episodes of a mood disorder, even
without an external stressor. Some clinicians believe that life events play the primary or principal
role in depression; others suggest that life events have only a limited role in the onset and timing of
depression. The most compelling data indicate that the life event most often associated with
development of depression is losing a parent before age 11 years. The environmental stressor most
often associated with the onset of an episode of depression is the loss of a spouse. Another risk
factor is unemployment; persons out of work are three times more likely to report symptoms of an
episode of major depression than those who are employed. Guilt may also play a role.
 Personality factors: No single personality trait or type uniquely predisposes a person to depression;
all humans, of whatever personality pattern, can and do become depressed under appropriate
circumstances. Persons with certain personality disorders— OCD, histrionic, and borderline—may
be at greater risk for depression than persons with antisocial or paranoid personality disorder. The
latter can use projection and other externalizing defense mechanisms to protect themselves from
their inner rage. No evidence indicates that any particular personality disorder is associated with
later development of bipolar I disorder; however, patients with dysthymic disorder and
cyclothymic disorder are at risk of later developing major depression or bipolar I disorder. Recent
stressful events are the most powerful predictors of the onset of a depressive episode. From a
psychodynamic perspective, the clinician is always interested in the meaning of the stressor.
Research has demonstrated that stressors that the patient experiences as reflecting negatively on his
or her self-esteem are more likely to produce depression. Moreover, what may seem to be a
relatively mild stressor to outsiders may be devastating to the patient because of particular
idiosyncratic meanings attached to the event.
 Psychodynamic factors: The psychodynamic understanding of depression defined by Sigmund
Freud and expanded by Karl Abraham is known as the classic view of depression. That theory
involves four key points: (1) disturbances in the infant–mother relationship during the oral phase

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 (the first 10 to 18 months of life) predispose to subsequent vulnerability to depression; (2)
depression can be linked to real or imagined object loss; (3) introjection of the departed objects is a
defense mechanism invoked to deal with the distress connected with the object’s loss; and (4)
because the lost object is regarded with a mixture of love and hate, feelings of anger are directed
inward at the self.
Melanie Klein understood depression as involving the expression of aggression toward loved ones,
much as Freud did. Edward Bibring regarded depression as a phenomenon that sets in when a
person becomes aware of the discrepancy between extraordinarily high ideals and the inability to
meet those goals. Edith Jacobson saw the state of depression as similar to a powerless, helpless
child victimized by a tormenting parent. Silvano Arieti observed that many depressed people have
lived their lives for someone else rather than for themselves. He referred to the person for whom
depressed patients live as the dominant other, which may be a principle, an ideal, or an institution,
as well as an individual. Depression sets in when patients realize that the person or ideal for which
they have been living is never going to respond in a manner that will meet their expectations.
Heinz Kohut’s conceptualization of depression, derived from his selfpsychological theory, rests on
the assumption that the developing self has specic needs that must be met by parents to give the
child a positive sense of self-esteem and self
cohesion. When others do not meet these needs, there is a massive loss of self-esteem that presents
as depression. John Bowlby believed that damaged early attachments and traumatic separation in
childhood predispose to depression. Adult losses are said to revive the traumatic childhood loss
and so precipitate adult depressive episodes. Psychodynamic Factors in Mania. Most theories of
mania view manic episodes as a defense against underlying depression. Abraham, for example,
believed that the manic episodes may reflect an inability to tolerate a developmental tragedy, such
as the loss of a parent. The manic state may also result from a tyrannical superego, which produces
intolerable self-criticism that is then replaced by euphoric self-satisfaction. Bertram Lewin
regarded the manic patient’s ego as overwhelmed by pleasurable impulses, such as sex, or by
feared impulses, such as aggression. Klein also viewed mania as a defensive reaction to
depression, using manic defenses such as omnipotence, in which the person develops delusions of
grandeur.

 Cognitive Model
The cognitive model proposes that people experience depression because their thinking is disturbed.
Depression arises from a person’s negative view of self, the world, and the future. The depression-
prone person, according to this theory, is likely to explain an adverse event as a personal
shortcoming.
 Learned Helplessness-Hopelessness Model.
Helplessness is a “belief that no one will do anything to aid you.”
Hopelessness is a “belief that neither you nor anyone else can do anything.”
This theory proposes that it is not trauma that produces depression but the belief that one has no
control over important outcomes in life. Learned helplessness is both a behavioral state and a
personality trait of one who believes that control over reinforcers in the environment has been lost.
These negative expectations lead to hopelessness, passivity, and an inability to assert oneself.

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 People who are resistant to depression have high self efficacy and have experienced mastery in life.
Their childhood experiences proved to them that their actions were effective in producing
gratification and removing annoyances.
People who are susceptible to depression have low self efficacy and have had lives without mastery.
Their experiences caused them to believe that they were helpless and incapable of influencing their
sources of suffering, and they developed no coping responses against failure.
 Behavioral Model.
People are capable of exercising control over their own behavior. They do not merely react to
external influences; they select, organize, and transform incoming stimuli. Thus people are not
viewed as powerless objects controlled by their environments; nor are they absolutely free to do
whatever they choose. Rather, people and their environments affect each other.
d) Physiological Changes
Mood states are affected by a wide variety of physical illnesses and medications
Depression Bipolar disorder
Physical illness
Tuberculosis Influenza
Viral hepatitis General paresis
Hypothyroisdism Hyperthyroidism
Diabetes mellitus St. louis encephalitis
Systemic lupus erythematosus Systemic lupus erythematosus
Chronic fatigue syndrome
Medications
Alcohol Amphetamines
Benzodiazepines Methylphenidate
Neuroleptics Thyroid hormone
Levodopa Levodopa
Alpha-methyldopa Cocaine

Bipolar I Disorder: It is the diagnosis given to an individual who is experiencing a manic episode or
has a history of one or more manic episodes. The client may also have experienced episodes of
depression. The DSM-5 criteria for a bipolar I disorder requires the presence of a distinct period of
abnormal mood lasting at least 1 week and includes separate bipolar I disorder diagnoses for a single
manic episode and a recurrent episode based on the symptoms of the most recent episode. The lifetime
prevalence rate is 0-2.4%.
 Bipolar I Disorder, Single Manic Episode. According to DSM-5, patients must be experiencing their
first manic episode to meet the diagnostic criteria for bipolar I disorder, single manic episode. This
requirement rests on the fact that patients who are having their first episode of bipolar I disorder
depression cannot be distinguished from patients with major depressive disorder.
 Bipolar I Disorder, Recurrent. The issues about defining the end of an episode of depression also
apply to defining the end of an episode of mania. Manic episodes are considered distinct when they are
separated by at least 2 months without significant symptoms of mania or hypomania.

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 DSM 5 Diagnostic criteria for Bipolar 1 disorder
Manic Episode

A. A distinct period of abnormally & persistently elevated, expansive or irritable mood and abnormally
and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of
the day, nearly every day (or any duration if hospitalization is necessary).

 B. During the period of mood disturbances and increased energy or activity, three (or more) of the
following symptoms (four if the mood is only irritable) are present to a significant degree and represent
a noticeable change from usual behavior:

1. Inflated self esteem or grandiosity.

2. Decreased need for sleep (e.g. feels rested after only 3 hours of sleep) or persistent difficulty
falling asleep.

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli).

6. Increase in goal directed activity (socially, at worker school or sexually) or psychomotor agitation.

7. Excessive involvement in activities that have high potential for painful consequences (engaging in
unrestricted buying sprees, sexual indiscretions, or foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational
functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic
features.

D. The episode is not attributable to the physiological effects of substance (e.g. a drug of abuse, a
medication, or there are psychotic features).

Note: A full manic episode that emerges during antidepressant treatment (e.g. medication, ECT) but
persists at a fully syndromal level beyond the physiological effects of treatment is sufficient evidence for
manic episode and therefore a bipolar I disorder.

Note: Criteria A to D constitute a manic episode. At least one lifetime manic episode is required for the
diagnosis of bipolar I disorder.

Bipolar 1 disorder

A. Criteria have been met for at least one manic episode (criteria A to D under Manic Episode above).

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B. The occurrence of the manic and depressive episode(s) is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder.

ICD-10 classification F30 MANIC EPISODE

F30.0 Hypomania

A. The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned
and sustained for at least four consecutive days.

B. At least three of the following must be present, leading to some interference with personal
functioning in daily living: (1) increased activity or physical restlessness;

(2) increased talkativeness;

(3) difficulty in concentration or distractibility;

(4) decreased need for sleep;

(5) increased sexual energy;

(6) mild spending sprees, or other types of reckless or irresponsible behaviour;

(7) increased sociability or over-familiarity.

C. The episode does not meet the criteria for mania (F30.1 and F30.2), bipolar affective disorder (F31.-),
depressive episode (F32.-), cyclothymia (F34.0) or anorexia nervosa (F50.0).

D. Most commonly used exclusion criteria: the episode is not attributable to psychoactive substance use
(F1) or any organic mental disorder, in the sense of F0.

F30.1 Mania without psychotic symptoms

A. A mood which is predominantly elevated, expansive or irritable and definitely abnormal for the
individual concerned. This mood change must be prominent and sustained for at least a week (unless it
is severe enough to require hospital admission).

B. At least three of the following must be present (four if the mood is merely irritable), leading to severe
interference with personal functioning in daily living:

(1) Increased activity or physical restlessness;

(2) Increased talkativeness ('pressure of speech');

(3) Flight of ideas or the subjective experience of thoughts racing;

(4) Loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances;

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(5) Decreased need for sleep;

(6) Inflated self-esteem or grandiosity;

(7) Distractibility or constant changes in activity or plans;

(8) Behaviour which is foolhardy or reckless and whose risks the subject does not recognize e.g.
spending sprees, foolish enterprises, reckless driving;

(9) Marked sexual energy or sexual indiscretions.

C. The absence of hallucinations or delusions, although perceptual disorders may occur (e.g. subjective
hyperacusis, appreciation of colours as specially vivid, etc.).

D. Mot commonly used exclusion criteria: the episode is not attributable to psychoactive substance use
(F1) or any organic mental disorder, in the sense of F0.

F30.2 Mania with psychotic symptoms

A. The episode meets the criteria for mania without psychotic symptoms (F30.1) with exception of
criterion C.

B. The episode does not simultaneously meet the criteria for schizophrenia (F20) or schizo-affective
disorder, manic type (F25.0).

C. Delusions or hallucinations are present, other than those listed as typical schizophrenic in F20 G1.1b,
c and d (i.e. delusions other than those that are completely impossible or culturally inappropriate and
hallucinations, that are not in the third person or giving a running commentary). The commonest
examples are those with grandiose, self-referential, erotic or persecutory content.

D. Mot commonly used exclusion criteria: the episode is not attributable to psychoactive substance use
(F1) or any organic mental disorder, in the sense of F0.

A fifth character may be used to specify whether the hallucinations or delusions are congruent or
incongruent with the mood:

F30.20 mania with mood congruent psychotic symptoms (such as grandiose delusions or voices telling
the subject that he has superhuman powers) F30.21 mania with mood incongruent psychotic symptoms
(such as voices speaking to the subject about affectively neutral topics, or delusions of reference or
persecution).

F30.8 Other manic episodes

F30.9 Manic episode, unspecified

Clinical features of Mania

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 Clinical features
A manic episode is typically characterized by the following features (which should last for at least one
week and cause disruption in occupational and social activities).
a) Elevated, Expansive or Irritable Mood
The elevated mood can pass through following four stages, depending on the severity of manic episode:
 Euphoria (mild elevation of mood): An increased sense of psychological well-being and happiness, not
in keeping with ongoing events. This is usually seen in hypomania (Stage I).
 Elation (moderate elevation of mood): A feeling of confidence and enjoyment, along with an increased
psychomotor activity. Elation is classically seen in mania (Stage II).
 Exaltation (severe elevation of mood): Intense elation with delusions of grandeur; seen in severe mania
(Stage III).
 Ecstasy (very severe elevation of mood): Intense sense of rapture or blissfulness; typically seen in
delirious or stuporous mania (Stage IV).
Along with these variations in elevation of mood, expansive mood may also be present, which is an
unceasing and unselective enthusiasm for inter acting with people and surrounding environment. At
times, elevated mood may not be apparent and instead an irritable mood may be predominant, especially
when the person is stopped from doing what he wants. There may be rapid, short lasting shifts from
euphoria to depression or irritability.
b) Psychomotor Activity
There is an increased psychomotor activity, ranging from overactiveness and restlessness, to manic
excitement where the person is ‘on-the-toe-on-the-go’, (i.e. involved in ceaseless activity). The activity
is usually goal-oriented and is based on external environmental cues. Rarely, a manic patient can go in
to a stuporous state (manic stupor).
c) Speech and Thought
The person is more talkative than usual; describes thoughts racing in his mind; develops pressure of
speech; uses playful language with punning, rhyming, joking and teasing; and speaks loudly. Later, there
is ‘flight of ideas’ (rapidly produced speech with abrupt shifts from topic to topic, using external
environmental cues. Typically the connections between the shifts are apparent). When the ‘flight’
becomes severe, incoherence may occur. A less severe and a more ordered ‘flight’, in the absence of
pressure of speech called ‘prolixity’. There can be delusions (or ideas) of grandeur (grandiosity), with
markedly inflated self-esteem. Delusions of persecution may sometimes develop secondary to the
delusions of grandeur (e.g. I am so great that people are against me). Hallucinations (both auditory and
visual), often with religious content, can occur (e.g. God appeared before me and spoke to me). Since
these psychotic symptoms are in keeping with the elevated mood state, these are called mood congruent
psychotic features. Distractibility is a common feature and results in rapid changes in speech and
activity, in response to even irrelevant external stimuli.
d) Goal-directed Activity
The person is unusually alert, trying to do many things at one time. In hypomania, the ability to function
becomes much better and there is a marked increase in productivity and creativity. Many artists and
writers have contributed significantly in such periods. As past history of hypomania and mild forms of

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mania is often difficult to elicit, it is really important to take additional historical information from
reliable informants (e.g. family members). In mania, there is marked increase in activity with excessive
planning and, at times, execution of multiple activities. Due to being involved in so many activities and
distractibility, there is often a decrease in the functioning ability in later stages. There is marked increase
in sociability even with previously unknown people. Gradually this sociability leads to an interfering
behaviour though the person does not recognize it as abnormal at that time. The person becomes
impulsive and disinhibited, with sexual indiscretions, and can later become hypersexual and
promiscuous.
Due to grandiose ideation, increased sociability, over activity and poor judgment, the manic person is
often involved in the high-risk activities such as buying sprees, reckless driving, foolish business
investments, and distributing money and/or personal articles to unknown persons. He is usually dressed
up in gaudy and flamboyant clothes, although in severe mania there may be poor self-care.
e) Other Features
Increased sociabilities
Impulsive behavior
Disinhibition
Hypersexual and promiscuous behavior
Poor judgment
High-risk activities (buying sprees, reckless driving, foolish business investments, distributing money or
articles to unknown persons)
Dressed up in gaudy and flamboyant clothes although in severe mania there may be poor self-care
Decreased need for sleep (<3 hours)
Decreased food intake due to over-activity
Decreased attention and concentration
Poor judgment
Absent insight

Bipolar II Disorder: it is characterized by episodes of hypomania (not requiring hospitalization) and

major depression. Few studies indicate that more marital disruption and with onset at an earlier age than
bipolar I disorder. Evidence also indicates that patients with bipolar II disorder are at greater risk of both
attempting and completing suicide than patients with bipolar I disorder and major disorder. The lifetime
prevalence rate is 0.3-4.8%.

According to DSM-5

Hypomanic episode

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A. Distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally
and persistently increased activity or energy, lasting at least four consecutive days and present most of
the day, nearly everyday.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the
following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change
from usual behavior and have been present to significant degree:

1. Inflated self esteem or grandiosity.

2. Decreased need for sleep (feels rested only after 3 hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thought are racing.

5.Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.

6. Increase in goal oriented activity (either socially, at work or school, or sexually) or psychomotor
agitation.

7. Excessive involvement in activities that have high potential for painful consequences (e.g. engaging
in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the
individual when not symptomatic.

D. The disturbance in mood and change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning
or to necessitate hospitalization. If there are psychotic features, the episode is, by definition manic.

F. The episode is not attributable to the physiological effects of substance (e.g. a drug of abuse,
medication, other treatment).

Note: A full hypomanic episode that emerges during antidepressant treatment (e.g. medication, ECT)
but persists a fully syndromal level beyond a physiological effect of that treatment is sufficient evidence
for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms
(particularly increased irritability, edginess or agitation following antidepressant use) are not taken as
sufficient for diagnosis of hypomanic episode, nor necessarily indicative of bipolar diathesis.

Note: Criteria A to F constitute a hypomanic episode. Hypomanic episodes are common in bipolar 1
disorder but are not required for the diagnosis of bipolar 1 disorder.

According to ICD-10 F30.0 Hypomania

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 A. The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned
and sustained for at least four consecutive days.

B. At least three of the following must be present, leading to some interference with personal
functioning in daily living:

(1) increased activity or physical restlessness;

(2) increased talkativeness;

(3) difficulty in concentration or distractibility;

(4) decreased need for sleep;

(5) increased sexual energy;

(6) mild spending sprees, or other types of reckless or irresponsible behaviour;

(7) increased sociability or over-familiarity.

C. The episode does not meet the criteria for mania (F30.1 and F30.2), bipolar affective disorder (F31.-),
depressive episode (F32.-), cyclothymia (F34.0) or anorexia nervosa (F50.0).

D. Most commonly used exclusion criteria: the episode is not attributable to psychoactive substance use
(F1) or any organic mental disorder, in the sense of F0.

The lifetime prevalence rate of hypomania is 2.6-7.8%.

Major depressive episode

According to DSM-5

A. Five (or more) of the following symptoms have been present during the same 2-week period and
represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood
or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly everyday, as indicated by either subjective report
(e.g. feels sad, empty or hopeless) or observation made by others (e.g. appears tearful). (Note: in
children and adolescents, can be irritable mood.)

2. Marked diminished interest or pleasure in all, or almost all, activities most of the day,
nearly everyday (as indicated by either subjective account or observation).

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 3. Significant weight loss when not dieting or weight gain (a change of more than 5% of the
body weight in a month) or decrease or increase in appetite nearly everyday. (Note In children,
consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly everyday.

5. Psychomotor agitation or retardation nearly everyday (observable by others; not merely

subjective feelings or restlessness or being slowed down).

6. Fatigue or nearly loss of energy nearly everyday.

7. Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional)

nearly everyday (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate or indecisiveness, nearly everyday (either by

subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with without
the specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational or other
important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or other medical condition.

Note: Criteria A to C constitute a major depressive episode. Major depressive episodes are common in
bipolar 1 disorder but are not required for the diagnosis of bipolar 1 disorder.

Note: Response to significant loss (e.g. bereavement, financial ruin, losses from a natural disaster,
serious medical illness or disability) may include the feelings of intense sadness, rumination about the
loss, insomnia, poor appetite and weight loss noted in criterion A, which may resemble a depressive
episode. Although such symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a significant loss should
also be carefully considered. The decision inevitably requires the exercise of clinical judgment based on
the individual’s history and the cultural norms for the expression of distress in the context of loss.

According to ICD-10

F32 Depressive episode

G1. The depressive episode should last for at least 2 weeks.

G2. There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or
manic episode (F30.-) at any time in the individual's life.

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G3. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance
use (F10F19) or to any organic mental disorder (in the sense of F00-F09).

Somatic syndrome: Some depressive symptoms are widely regarded as having special clinical
significance and are here called "somatic". (Terms such as biological, vital, melancholic, or
endogenomorphic are used for this syndrome in other classification.)

A fifth character (as indicated in F31.3; F32.0 and F32.1; F33.0 and F33.1) may be used to specify the
presence or absence of the somatic syndrome. To qualify for the somatic syndrome, four of the
following symptoms should be present:

(1) marked loss of interest or pleasure in activities that are normally pleasurable;

(2) lack of emotional reactions to events or activities that normally produce an emotional response;

(3) waking in the morning 2 hours or more before the usual time;

(4) depression worse in the morning;

(5) objective evidence of marked psychomotor retardation or agitation (remarked on or reported by

other people);

(6) marked loss of appetite;

(7) weight loss (5% or more of body weight in the past month);

(8) marked loss of libido.

In The ICD-10 Classification of Mental and Behavioral Disorders: Clinical descriptions and diagnostic
guidelines, the presence or absence of the somatic syndrome is not specified for severe depressive
episode, since it is presumed to be present in most cases. For research purposes, however, it may be
advisable to allow for the coding of the absence of the somatic syndrome in severe depressive episode.

Cyclothymic Disorder: it is symptomatically a mild form of bipolar disorder. It is characterized by

episodes of hypomania and episodes of mild depression. It is a disorder resembling bipolar disorder but
with less severe symptoms, characterized by repeated periods of nonpsychotic depression and
hypomania for at least 2 years. The individual is never without the symptoms for more than 2 months.
The lifetime prevalence rate is 0.5-6.3%.

DSM 5 criteria for cyclothymia

A. “For at least 2 years (at least 1 year in children and adolescents) 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.

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B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive
periods have been present for at least half the time and the individual has not been without the symptoms
for more than 2 months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met. [Note: If such
episodes appear later, the diagnosis would be changed to bipolar I or bipolar II disorder, as appropriate.]
D. The symptoms aren’t better explained by another mental disorder.
E. The symptoms aren’t caused by a substance (e.g. medication or drug of abuse) or another medical
condition.
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

EPIDEMIOLOGY
Sex
Major depressive disorder twice in woman than in man.
Bipolar I disorder has an equal prevalence among men and women.
Manic episodes are more common in men, and depressive episodes are more common in women.
Age
The age of onset for bipolar I disorder ranges from childhood 5/6 years to 50 years or even older in
rare cases, with a mean age of 30 years.
The mean age of onset for major depressive disorder is about 40 years, with 50 percent of all patients
having an onset between 20-50 years of age.
Major depressive disorder can also begin in childhood or in old age.
Race
The prevalence of mood disorder does not differ form race to race. However, there is a tendency
among the clinician to underdiagnose mood disorder and overdiagnose schizophrenia in patients who
belong to a different racio-cultural background.
Marital Status
Major depressive disorder occurs most often in persons without close interpersonal relationships and
in widowed, divorced or separated.
Bipolar I disorder is more common in divorced and single persons.
Socioeconomic and Cultural Factors
Bipolar I disorder is found among the upper socioeconomic groups and more common in persons who
did not graduate from college than in college graduates.
Unipolar depression is more common in rural areas than in urban areas.
In general, mood disorder is equally common in urban and rural areas.

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 Religion
Bipolar disorder is more common in religious communities (e.g. the old order Amish), but there
appears to be no correlation between religion and unipolar depression.
Family history
Patients with bipolar disorders have a significantly higher risk of having first degree relatives with
mood disorders than those with major depression.
Life events
In unipolar depression, negative life events are often present before the onset but in bipolar disorder
the relationship with life events is unknown.
Comorbidity
Individuals with major mood disorders are at an increased risk of having one or more additional
comorbid disorders. The most frequent disorders are:
Alcohol abuse or dependence
Panic disorder
Obsessive-compulsive disorder (OCD)
Social anxiety disorder

Diagnosis
History taking
Physical examination
Primary Care Evaluation of Mental Disorders (PRIME-MD):
Patient Health Questionnaire (PHQ-9)
Mood Disorder Questionnaire (MDQ)
Composite International Diagnostic Interview (CIDI)
Fasting lipid profile, fasting glucose
MRI brain
ICD/DSM classification

Treatment Strategies
 Pharmacotherapy
 Mood stabilizers -
Lithium: 900-2100 mg/day
Carbamazepine: 600-1800 mg/day
Sodium valproate: 600-2600mg/day

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 Lamotringine: 25-200 mg/day
Other drugs: clozapine, calcium channel blockers, thyroid hormones, etc. or
atypical antipsychotics (e.g., olanzapine, quetiapine, risperidone, aripiprazole) was determined to be
the first-line treatment (Kowatch et al., 2005).
Nonstimulant medications indicated for ADHD (e.g., atomoxetine, bupropion, the tricyclic
antidepressants) may also induce switches to mania or hypomania.
 Electroconvulsive therapy
ECT can also be used for acute manic excitement if not adequately responding to antipsychotics and
lithium, or when life is threatened by dangerous behavior or exhaustion. In acute mania, ECT is
rapidly effective in up to 80% of patients. Recommended frequency is 3 treatments per week.
 Individual Psychotherapy
It seeks to uncover the origin of a psychiatric disorder in early life experiences, and seeks for
unconscious factors that account for abnormal thinking, emotions and behavior, in its usual form it
aims to produce limited but worthwhile changes through weekly sessions for 6-9 months.
The treatment is focused upon specific problems (focus of treatment).
Patients are encouraged to:
Give specific examples of the selected problems and consider how they thought, felt and acted at that
time (talk freely about emotionally painful subjects).
Consider alternative ways of thinking and behaving in the situations that cause difficulties.
Try out new and more adaptive ways of behaving and responding to emotions.
Some reports have indicated that psychotherapy (in conjunction with medication maintenance
treatment) and counseling may indeed be useful in clients with mania.
It is alone effective in reducing the depressive symptoms in the acute phase of non-melancholic major
depressive episode of less severity. It is especially effective in ameliorating vocational and social
aspects of the patient’s dysfunction.
 Family therapy
Family and marital therapy is used to decrease interfamilial and interpersonal difficulties, reduce or
modify stressors, and also the risk of relapse in patients with marital and family problems. The main
purpose is to ensure continuity of treatment and adequate drug compliance. The ultimate objectives in
working with families of clients with mood disorders are to resolve the symptoms and initiate or
restore adaptive family functioning (communication, autonomy for members, reduce conflict and
distress). As with group therapy, the most effective approach appears to be with a combination of
psychotherapeutic and pharmaco-therapeutic treatments.
 Group Therapy
Once an acute phase of the illness is passed, groups can provide an atmosphere in which individuals
may discuss issues in their lives that cause, maintain, or arise out of having a serious affective
disorder. The element of peer support may provide a feeling of security, as troublesome or
embarrassing issues are discussed and resolved. Some groups have other specific purposes, such as
helping to monitor medication related issues or serving as an avenue for promoting education related

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 to the affective disorder and its treatment. Support groups help members gain a sense of perspective on
their condition and tangibly encourage them to link up with others who have common problems. A
sense of hope is conveyed when the individual is able to see that he or she is not alone or unique in
experiencing affective illness. Self-help groups offer another avenue of support for the individual with
bipolar disorder.
 Cognitive Therapy
In cognitive therapy, the individual is taught to control thought distortions that are considered to be a
factor in the development and maintenance of mood disorders. The general goals in cognitive therapy
are to obtain symptom relief as quickly as possible, to assist client in identifying dysfunctional patterns
of thinking and behaving and to guide the client to evidence and logic that effectively tests the validity
of the dysfunctional thinking.
Cognitive therapy for depressive disorders:
 Reviewing evidence: depressed patients are particularly prone to focus on evidence that supports their
negative ideas and overlook evidence that contradicts them. The therapist should help patients give
appropriate weight to the positive evidence.
 Considering alternatives: depressed patients often reject positive alternatives to their thoughts and
beliefs. The therapist can help the patient consider alternatives by asking questions such as- What do
you think that another person would think about this situation?, What is your evidence for this belief?,
Are you focusing on what you felt rather than on what happened?, What is the worst that could happen
and how bad would it be?
 Considering consequences: patients should be helped to see the consequences of thinking negative
thoughts – e.g. the thought that everything is hopeless may prevent them from attempting even small
changes that could accumulate beneficially.
 Considering errors of logic: the patient should be helped to by asking himself questions such as ‘Am I
thinking in black and white terms?’, ‘Am I drawing too wide conclusions form this single event?’,
‘Am I blaming myself for something for which I am not responsible?’. These beliefs are asked in
relation to specific ideas, beliefs and situations.
 Considering beliefs: as depression improves, more attention is given to the patients beliefs since
abnormal beliefs can lead to relapse. The technique of laddering can be used to uncover these beliefs.
‘In what ways is this idea helpful?’, ‘In what ways is it unhelpful?’, ‘What alternatives are there?’
 Mindfulness: Teasdale has suggested that people who are prone to depression have a cognitive set
whereby thoughts and feelings are experienced as events rather than as aspects of the self and that
modifying this set reduces the risk of relapse. At the time of writing, the evidence for this idea is
incomplete.
Finally, the use of cognitive therapy does not preclude the value of administering medication.
Cognitive therapy is effective in relieving depression. Particularly in the treatment of bipolar mania,
cognitive therapy should be considered a secondary treatment to pharmacological treatment.
 The Recovery Model
The recovery model is a holistic, person-centered approach to mental health care. This model is based
on two simple premises:

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 It is possible to recover from a mental health condition
 The most effective recovery is patient-directed
Davidson (2007) has stated: Recovery from refers to eradicating the symptoms and ameliorating the
deficits caused by serious mental illnesses. Recovery in refers to learning how to live a safe, dignified,
full, and self-determined life in the face of the enduring disability which may, at times, be associated
with serious mental illness.
In bipolar disorder, recovery is a continuous process. The individual identifies goals based on personal
values or what s/he defines as giving meaning and purpose to life. The clinician and client work
together to develop a treatment plan that is in alignment with the goals set forth by the client. In the
recovery process, the individual may still be experiencing symptoms.
In the process of recovery, the client and clinician work on strategies to help the individual with
bipolar disorder take control of and manage his/her illness. Some of these strategies include the
following (National Alliance on Mental Illness [NAMI], 2008):
■ Become an expert on the disorder ■ Take medications regularly
■ Become aware of earliest symptoms ■ Develop a plan for emergencies
■ Identify and reduce sources of stress: Know when to seek help
■ Develop a personal support system
Powell (2006) states: People with bipolar disorder have the power to create the lives they want for
themselves. When they work on recovery and are able to look beyond their illness, the possibilities are
limitless.
Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent
and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and
social life (Kiume, 2007).

Nursing management of patient with mood disorder

Assessment: assess severity of the disorder, forming an opinion about the causes, assessing patient’s
resources and judging the effects of patient’s behavior on other people. Assess mood and affect for
congruency, thinking and perceptual ability, sleep disturbances, changes in energy level and character
of speech pattern, tone, patterns, pace, rate. Also sleeping, eating patterns, energy level and weight
changes should also be assessed.
Nursing diagnosis
 Risk for physical trauma related to extreme hyperactivity and impulsive behavior, evidenced by lack
of control over purposeless and potentially injurious movements.
 Risk for self-directed or directed violence at others related to manic excitement, delusional thinking
and hallucinations.
 Imbalanced nutrition, less than body requirement related to refusal or inability to sit still long enough
to eat, evidenced by weight loss.
 Insomnia related to excitement as evidenced by sleeping only short periods.

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 Risk for chronic low self-esteem related to unmet dependent needs, lack of positive feedback,
unrealistic self-expectations.
 Interrupted family processes related to euphoric-mood and grandiose ideas, manipulative behavior,
refusal to accept responsibility for own actions.
Interventions
Risk for physical trauma/ Risk for violence
 Maintain a low level of stimuli in the client’s environment (low lighting, few people, simple decor,
low noise level). Anxiety level rises in a stimulating environment. A suspicious, agitated client may
perceive individuals as threatening.
 Observe the client’s behavior frequently. Do it while carrying out routine activities so as to avoid
creating suspiciousness in the individual. Close observation is necessary so that intervention can occur
if required to ensure client (and others’) safety.
 Remove all dangerous objects from the client’s environment so that in his or her agitated, confused
state the client may not use them to harm self or others.
 Intervene at the first sign of increased anxiety, agitation, or verbal or behavioral aggression. Offer
empathetic response to client’s feelings: “You seem anxious (or frustrated, or angry) about this
situation. How can I help?” Validation of the client’s feelings conveys a caring attitude and offering
assistance reinforces trust.
 Maintain calm attitude toward the client. As the client’s anxiety increases, offer some alternatives:
participating in a physical activity (e.g., punching bag, physical exercise), talking about the situation,
taking some anti-anxiety medication. Offering alternatives to the client gives him or her feeling of
some control over the situation.
 Have sufficient staff available to indicate a show of strength to the client if it becomes necessary. This
shows the client evidence of control over the situation and provides some physical security for staff.
 If the client is not calmed by “talking down” or by medication
 If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow protocol
established by the institution. The Joint Commission (formerly the Joint Commission on Accreditation
of Healthcare Organizations [JCAHO]) requires that an in-person evaluation by a physician or other
licensed independent practitioner (LIP) be conducted within 1 hour of the initiation of the restraint or
seclusion (The Joint Commission, 2010). The physician or LIP must reissue a new order for restraints
every 4 hours for adults and every 1 to 2 hours for children and adolescents.
 The Joint Commission requires that the client in restraints be observed at least every 15 minutes to
ensure that circulation to extremities is not compromised (check temperature, color, pulses); to assist
the client with needs related to nutrition, hydration, and elimination; and to position the client so that
comfort is facilitated and aspiration can be prevented. Some institutions may require
Imbalanced nutrition
 In collaboration with the dietitian, determine the number of calories required to provide adequate
nutrition for maintenance or realistic (according to body structure and height) weight gain. Determine
client’s likes and dislikes, and try to provide favorite foods, if possible. The client is more likely to eat
foods that he or she particularly enjoys.

23
 Provide the client with high-protein, high-calorie, nutritious finger foods and drinks that can be
consumed “on the run.” Because of the hyperactive state, the client has difficulty sitting still long
enough to eat a meal. The likelihood is greater that he or she will consume food and drinks that can be
carried around and eaten with little effort. Have juice and snacks available on the unit at all times.
Nutritious intake is required on a regular basis to compensate for increased caloric requirements due to
the hyperactivity.
 Maintain an accurate record of intake, output, and calorie count. Weigh the client daily. Administer
vitamin and mineral supplements, as ordered by the physician. Monitor laboratory values, and report
significant changes to the physician. It is important to carefully monitor the data that provide an
objective assessment of the client’s nutritional status.
Insomnia
 Assess the client’s activity level. He or she may ignore or be unaware of feelings of fatigue. Observe
for signs such as increasing restlessness; fine tremors; slurred speech; and puffy, dark circles under
eyes. The client could collapse from exhaustion if hyperactivity is uninterrupted and rest is not
achieved.
 Monitor sleep patterns. Provide a structured schedule of activities that includes established times for
naps or rest. Accurate baseline data are important in planning care to help the client with this problem.
A structured schedule, including time for short naps, will help the hyperactive client achieve much-
needed rest.
 Client should avoid intake of caffeinated drinks, such as tea, coffee, and colas. Caffeine is a CNS
stimulant and may interfere with the client’s achievement of rest and sleep.
 Before bedtime, provide nursing measures that promote sleep, such as back rub; warm bath; warm,
nonstimulating drinks; soft music; and relaxation exercises.
 Administer sedative medications, as ordered, to assist client achieve sleep until normal sleep pattern is
restored.
Impaired Social Interaction
 Recognize the purpose these behaviors serve for the client: to reduce feelings of insecurity by
increasing feelings of power and control. Understanding the motivation behind the manipulation may
help to facilitate acceptance of the individual and his or her behavior.
 Set limits on manipulative behaviors. Explain to the client what is expected and what the
consequences are if the limits are violated. Terms of the limitations must be agreed on by all staff who
will be working with the client. The client is unable to establish own limits, so this must be done for
him or her. Unless administration of consequences for violation of limits is consistent, manipulative
behavior will not be eliminated.
 Do not argue, bargain, or try to reason with the client. Merely state the limits and expectations.
Individuals with mania can be very charming in their efforts to fulfill their own desires. Confront the
client as soon as possible when interactions with others are manipulative or exploitative. Follow
through with established consequences for unacceptable behavior. Because of the strong id influence
on the client’s behavior, he or she should receive immediate feedback when behavior is unacceptable.
Consistency in enforcing the consequences is essential if positive outcomes are to be achieved.
Inconsistency creates confusion and encourages testing of limits.

24
 Provide positive reinforcement for non-manipulative behaviors. Explore feelings, and help the client
seek more appropriate ways of dealing with them.
 Help the client recognize that he or she must accept the consequences of own behaviors and
 refrain from attributing them to others. The client must accept responsibility for own behaviors before
adaptive change can occur.
 Help the client identify positive aspects about self, recognize accomplishments, and feel good about
them. As self-esteem is increased, the client will feel less need to manipulate others for own
gratification.
Risk for chronic low self-esteem
 Act as a role model for the patient or significant others in healthy expression of feelings or concerns.
Assume responsibility for own thoughts and actions.
 Present an environment favorable to the expression of feelings: Spend time with the patient; set aside
enough time so that the encounter is calm and deliberate
 Provide privacy: apply active listening and open-ended questions.
 Consider the normal impact of change on self-esteem. Reassure the patient that such modifications
often occur in a variety of emotional or behavioral responses
 Support the patient in his/her attempts to secure autonomy, reality, positive self-esteem, sense of
capability and problem-solving.
 Give anticipatory direction to reduce anxiety and fear if interference in self-esteem is an expected part
of the process of adjustment to changes in health status.
 Educate the patient about the harmful effects of negative self-talk.
Interrupted family processes
 During the first day of hospitalization, spend time with family identifying their needs during this time.
 Provide information about the disease
 Provide information about lithium or other anti-manic medications (need for adherence, side effects,
toxic effects)
 Knowledge about bipolar support groups in the family’s community and how they can help families
going through crises.

Evaluation of the nursing actions for the client experiencing a manic episode may be facilitated by
gathering information using the following types of questions.
Has the individual avoided personal injury?
Has violence to client or others been prevented?
Has agitation subsided?
Have nutritional status and weight been stabilized? Is the client able to select foods to maintain
adequate nutrition?

25
Have delusions and hallucinations ceased? Is the client able to interpret the environment correctly?
Is the client able to make decisions about own self-care? Has hygiene and grooming improved?
Is behavior socially acceptable? Is client able to interact with others in a satisfactory manner? Has the
client stopped manipulating others to fulfill own desires?
Is the client able to sleep 6 to 8 hours per night and awaken feeling rested?
Does the client understand the importance of maintenance medication therapy? Does he or she
understand that symptoms may return if medication is discontinued?
Can the client taking lithium verbalize early signs of lithium toxicity? Does s/he understand the
necessity for monthly blood level checks?
Lithium Toxicity: normal, acute mania - 1.0 to 1.5 mEq/L, maintenance - 0.6 to 1.2 mEq/L
Serum lithium levels should be monitored once or twice a week after initial treatment until dosage and
serum levels are stable, then monthly during maintenance therapy. Blood samples should be drawn 12
hours after the last dose. Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5
mEq/L and are dosage determinate. Symptoms include the following:
At serum levels of 1.5 to 2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent nausea and vomiting,
severe diarrhea.
At serum levels of 2.0 to 3.5 mEq/L: excessive output of dilute urine, increasing tremors, muscular
irritability, psychomotor retardation, mental confusion, giddiness.
At serum levels above 3.5 mEq/L: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria,
arrhythmias, myocardial infarction, cardiovascular collapse.
The dosage should be withheld and the physician notified if the level reaches 1.5 mEq/L or at the
earliest observation or report by the client of even the mildest symptom. If left untreated, lithium
toxicity can be life threatening. Lithium is similar in chemical structure to sodium, behaving in the
body in much the same manner and competing at various sites in the body with sodium. If sodium
intake is reduced or the body is depleted of its normal sodium (e.g., due to excessive sweating, fever,
or diuresis), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity. Therefore, the
client must consume a diet adequate in sodium as well as 2,500 to 3,000 ml of fluid per day.
Client/Family Education for Lithium
Take medication on a regular basis, even when feeling well. Discontinuation can result in return of
symptoms.
Not drive or operate dangerous machinery until lithium levels are stabilized. Drowsiness and dizziness
can occur.
Not skimp on dietary sodium intake. He or she should eat a variety of healthy foods and avoid “junk”
foods. The client should drink 6 to 8 large glasses of water each day and avoid excessive use of
beverages containing caffeine (coffee, tea, colas), which promote increased urine output.
Notify the physician if vomiting or diarrhea occurs. These symptoms can result in sodium loss and an
increased risk of lithium toxicity.
Carry card or other identification noting that s/he is taking lithium.

26
Course and Prognosis
Mood disorders tend to have long courses and that patients tend to have relapses. Although mood
disorders are often considered benign in contrast to schizophrenia, they exact a profound toll on
affected patients.
Bipolar I disorders have a poorer prognosis than do patients with major depressive disorder. About 40
to 50 percent of patients with bipolar I disorder may have a second manic episode within 2 years of the
first episode. Although lithium prophylaxis improves the course and prognosis of bipolar I disorder,
probably only 50 to 60 percent of patients achieve significant control of their symptoms with lithium.
Bipolar II Disorder The course and prognosis of bipolar II disorder indicate that the diagnosis is
stable because there is a high likelihood that patients with bipolar II disorder will have the same
diagnosis up to 5 years later. Bipolar II disorder is a chronic disease that warrants long-term treatment
strategies.
Cyclothymia Patients with adaptive coping strategy have better outcomes. About 33% of cyclothymic
patients go on to have a major mood disorder, most often bipolar II disorder.

References
1) Saddock BJ, Saddock VA, Ruiz P. Mood disorders. Synopsis of Psychiatric behavioral
sciences/clinical psychiatry. 11th ed. New Delhi: Wolters Kluwer (India) Pvt Ltd. 2015.
2) Townsend MC. Bipolar and related disorders. Psychiatric mental health nursing concept
of care in evidence-based practice. 8th ed. Philadelphia: F.A davis company. 2015
3) Stuart GW. Emotional responses and mood disorders. Principles and practice of
psychiatric nursing. 10th ed. New Delhi: Reed Elsevier India Private Limited. 2013.
4) Sreevani R. Nursing management of patient with mood disorders. A guide to mental
health and psychiatric nursing. 4th ed. New Delhi: Jaypee brothers medical publishers (P) Ltd. 2018.
5) Boyd MA. Bipolar disorders management of mood lability. Psychiatric nursing
contemporary practice. 5th ed. China: Wolters Kluwer Health. 2012
6) Kneisl CR, Trigoboff E. Mood disorders. Contemporary psychiatric-mental health
nursing. 3rd ed. New Jersey: Pearson Education, Inc. 2013.
7) Lyon S. The recovery model. [Internet]. Verywellmind. 2019 [cited 7 December 2019].
Available from: https://www.verywellmind.com/what-is-the-recovery-model-2509979
8) Adhikari BR, Mishra S, Nepal S, Sapkota N. Psychotic symptoms in bipolar disorder:
two years’ retrospective study. NepJOL [journal on the Internet]. 2017 [cited 11th December
2019];13(1):49-7. Available from: https://www.nepjol.info/index.php/HREN/article/view/17947
9) Purse M. Diagnostic criteria for cyclothymic disorder. verywellmind [Internet]. 2019
[cited 12th December 2019]. Available from: https://www.verywellmind.com/cyclothymia-
cyclothymic-disorder-379812

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