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The purpose of this activity is to enable the learner to understand how to assess, diagnose, and treat bipolar disorders using evidence-based practice. This course reflects the latest diagnostic criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th Editions (DSM-5).
Describe the etiology and pathogenesis of bipolar disorders including the role of genetics, biochemistry, and psychodynamics.
Bipolar disorders are a group of disorders classified by their extremes in mood [1]. Historically, they were referred to as bipolar affective disorders or manic-depression. They consist of excessive swings in mood very different from the normal ups and downs of daily life. The shifts in mood, energy, and the ability to function in life that spring from bipolar disease can manifest in several forms ranging from periods of hyper-energy to intervals of deeply morbid depression [1]. There are seven types of bipolar disorders classified in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5):
Often the presence of bipolar disease goes unrecognized and untreated [1]. When diagnosed, treatment for bipolar disorder differs from that conventionally used for unipolar depression [3]. The ability of health professionals to recognize signs of bipolar mood disturbances is an important skill, as is the understanding of current treatment and management of this potentially life crippling disorder.
Bipolar disorders are a lifelong disease [4]. The onset of significant symptoms may occur at any age from early childhood to late in the 50’s and even beyond [4]. For many, the age range between 15 and 24 seems to be the time when significant, disruptive swings in mood and functioning manifest clearly [4].
Genetics are a factor in bipolar disorder with first-degree relatives seven times more likely to also experience bipolar symptoms than a person chosen from the population at random [5]. However, no direct “bipolar gene” has been identified. Neither race nor sex play favorites in bipolar disorder as prevalence is distributed equally although certain subtypes of bipolar tend to be slightly more common in one sex or the other [2].
Biochemistry changes in the brain accompany bipolar disorder. Several neurotransmitter systems show alteration in bipolar brain disease, making it difficult to determine exactly what is going on. Glutamate increases in the brain appear consistent in both bipolar and major depression, while poor regulation of serotonin has been associated with mania [5]. Hormonal imbalances along with disruptions of the hypothalamic-pituitary-adrenal axis involved in homeostasis and the stress response have also been implicated as biochemical contributors to the clinical picture of bipolar disorder [5].
Psychodynamic factors that influence cognitive processing also play roles in bipolar disorder [6]. The efforts of the brain to cope with difficult to reconcile feelings of loss, or acute and chronic stresses are all implicated as contributors to the disease process we refer to as bipolar [6].
In 2013, the American Psychiatric Association (APA) published the DSM-5, an update of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) [7]. The APA made four major changes to bipolar disorders in order to enhance accuracy and specificity of their diagnosis in the clinical setting [8].
First, the criteria for manic and hypomanic mood episodes now emphasize a change in activity and energy in addition to changes in mood. Second, the diagnosis of bipolar I disorder, mixed episode has been removed and replaced with the diagnostic specifier, “with mixed features.” Third, the APA added a new diagnosis called other specified bipolar disorder, which encompasses patients who meet all the symptomatic criteria but who do not meet the duration criterion. Lastly, a new specifier called “with anxious distress” was added to more accurately classify patients with prominent anxiety symptoms [8].
To fully understand a bipolar disorder diagnosis, nurses and nurse practitioners must learn to differentiate mood episodes. Mood refers to a sustained emotion that paints the way a person interprets their life [9]. Nearly 20% of women and 10% of men experience a mood disturbance at some point in their lives [9].
The DSM-5 outlines three different types of bipolar mood episodes: (1) manic, (2) hypomanic, and (3) major depressive episode [2]. While both manic episodes and major depressive episodes must present with symptoms severe enough to impair the patient’s social and occupational functioning, a hypomanic episode does not. Prior to the diagnosis of any mood disturbance, the physiological effects of a substance or medical condition must be ruled out.
Mania is described as a period of elevated, expansive, or irritable mood that is often associated with goal-directed activity or energy. During periods of mania, patient’s might find themselves involved in uncontrollable shopping sprees, unsafe sexual encounters with many partners, or foolish business investments [9]. Patient’s often report feeling rested after only three hours of sleep and may present with pressured speech [4]. The mood disturbances caused by a manic episode must be considered sufficiently severe, leading to marked impairment in either social or occupational function [9].
The DSM-5 diagnostic criteria for a manic episode is as follows [2].
Hypomanic episodes consist of the same symptoms as manic episodes except they have a shorter duration and do not include psychosis [9]. The mood disturbances caused by a hypomanic episode must not be severe enough to impair the patient’s social or occupational functioning [9].
The DSM-5 diagnostic criteria for a hypomanic episode is as follows [2].
The presenting symptoms of a depressive episode vary widely from patient to patient. Some patients may appear slowed down and flat while others may sob uncontrollably [9]. Others may even deny subjective feelings of sadness but instead report a debilitating loss of interest in their hobbies [4]. Often times, patients struggle to recognize or accurately describe their symptoms. They may report vague feelings of unhappiness and hopelessness [9].
The DSM-5 diagnostic criteria for a major depressive episode is as follows [2].
The DSM-5 includes 10 different specifiers that clinicians can append to the bipolar diagnosis in order to include more information about the current or most recent mood episode [2]. The 10 specifiers and their definition are included in below.
For a patient to be diagnosed with bipolar I disorder, they must meet the criteria for having experienced at least one manic episode. It is not necessary for the patient to have experienced a major depressive episode. At the time the diagnosis is made, the current mood episode should be listed and classified as either mild, moderate, or severe. The diagnosis may also include a specifier to provide further information about the patient’s current state [9].
In addition to traditional manic episode symptoms, patients may also report a sharper sense of sight, smell, and hearing. They may dress more flamboyantly, wearing extra makeup or gaudy costumes [4]. Gambling, sexual indiscretions, and reckless driving may emerge as well. Some patients will become hostile, delusional, and verbally threatening [9].
The average age of bipolar I disorder onset is 18 years old. Manic symptoms that begin after the age of 40 should prompt a thorough medical work-up to rule out an underlying physical condition such as frontotemporal neurocognitive disorder. The prevalence of bipolar I disorder in the United states is 0.6%. In other countries, the prevalence ranged from 0% to 0.6%. The male to female ratio is 1.1:1. As many as 90% of those who experience one manic episode will go on to have additional mood episodes [2].
Very little scientific research exists on cultural differences in the expression of bipolar I disorder. Men are less likely to experience rapid cycling or mixed states. Women are more likely to have co-morbid eating disorders and alcohol use disorders [2].
The differential diagnosis of bipolar I disorder should always include major depressive disorder, other bipolar disorders, anxiety disorders, attention-deficit/hyperactivity disorders (ADHD), and personality disorders [2].
Anxiety disorders and substance abuse commonly co-occur with bipolar I disorder. Approximately 75% of individuals suffering from bipolar I disorder are also diagnosed with either panic disorder, social anxiety disorder, or a specific phobia. More than 50% of those with bipolar disorder also have an alcohol use disorder. Metabolic syndrome and migraines also affect those with bipolar I disorder more than the general population [2].
Melissa is a 39 y/o female client admitted with multiple traumas following a single car accident at high speed. Her clothing is expensive in appearance though soiled and disheveled. During the intake interview, she continually shifts position and frequently breaks into laughter despite the seriousness of her injuries and the situation. Her speech is rapid and somewhat rambling. Early laboratory screening fails to show the presence of alcohol, and the use of intoxicant drugs does not appear to be a factor.
On questioning, Melissa reveals that she has not slept more than two hours a night for the past week, and currently feels neither fatigue nor need for sleep.
When asked concerning circumstances that led up to her accident she laughs while tears begin to stream down her face and replies, “Life sucks except when it doesn’t. I hate the bumps that bring me low, I want to live fast and burn out while my flame is bright”.
A diagnosis of bipolar II disorder requires both a current or past hypomanic and major depressive episode [9]. At the time of diagnosis, the clinician should decide which type of episode the patient is experiencing, and whether this episode is mild, moderate, or severe. Individuals with bipolar II disorder usually present to treatment during a major depressive episode. The most common feature of bipolar II disorder is impulsivity, which can sometimes lead to suicide attempts and substance abuse disorders [4]. Increased levels of creativity are sometimes noted during hypomanic episodes as well [4].
Bipolar II disorder emerges in late adolescence and early adulthood. The mean age of onset is 25. The disorder usually begins with a major depressive episode and is not recognized as bipolar II disorder until a hypomanic episode occurs later on. Mood episodes that follow a rapid cycling pattern have a poorer long-term prognosis. The prevalence of bipolar II disorder in the United States is 0.8% compared with 0.3% internationally [2].
Women are more likely to report hypomania with mixed features that follow a rapid-cycling course compared with men. About 10-20% of women with bipolar II disorder experience hypomanic symptoms following childbirth, and about 50% of those women go on to develop a postpartum depressive episode [2].
The differential diagnosis of bipolar II disorder should include major depressive disorder, cyclothymic disorder, psychotic disorders, anxiety disorders, ADHD, personality disorders, and bipolar I disorder [2, 9].
Nearly 60% of individuals with bipolar II disorder have three or more comorbid psychiatric conditions. About 75% of those with bipolar II disorder also have an anxiety disorder and 37% also have a substance use disorder. Furthermore, 14% of these individuals suffer from an eating disorder at some point in their life, with binge eating disorder being the most common. These co-occurring conditions seem to worsen during the mood episodes associated with the bipolar II disorder [2].
Cyclothymic disorder is a type of bipolar disorder characterized by both hypomanic and depressive episodes that do not meet the full criteria for severity or duration [9]. Furthermore, in the previous two years, the cyclothymic symptoms must have been present for at least half the time. The key feature of this disorder is the chronic fluctuating mood episodes with symptom-free intervals lasting less than 2 months [9].
The prevalence of cyclothymic disorder is 0.4% to 1%, and the prevalence in mental health clinics ranges from 3% to 5%. This condition affects males and females equally; however, women are more likely to seek treatment than men. Cyclothymic disorder begins in late adolescence and early adulthood. It tends to have an insidious onset and persistent course. About 15% to 50% of those diagnosed with cyclothymic disorder later develop bipolar I or bipolar II disorder. If cyclothymic-like symptoms arise in mid-to-late adulthood, multiple sclerosis should be ruled out [2].
The differential diagnosis for cyclothymic disorder should include bipolar disorder due to another medical condition, substance/medication-induced bipolar disorder, bipolar I and II with rapid cycling, and borderline personality disorder [2, 9].
Sleep disorders and substance abuse disorders often co-occur with cyclothymic disorder [2].
The DSM-5 includes two bipolar disorder categories for situations where patient’s do not fit neatly into the other diagnostic categories: other specified bipolar disorder and unspecified bipolar disorder [2].
Other specified bipolar disorder describes a situation where a patient does not meet full criteria for bipolar I, bipolar II, or cyclothymic disorder, but they are experiencing significant social or occupational impairment. The “other specified” diagnosis must include one of four designations:
Unspecified bipolar disorder refers to a patient who does not meet full criteria for bipolar I, bipolar II, or cyclothymic disorder, but they are experiencing significant social and occupational impairment. The different between unspecified and other specified is that clinicians do not have to include one of the four designations listed above. Instead, clinicians do not specify a specific reason why the criteria are not met [2].
Physical conditions can create or extend mental health conditions. If nurses and nurse practitioners forget to evaluate for underlying medical conditions, they jeopardize both the accuracy of the diagnosis and their patient’s health.
Medical conditions that imitate symptoms of bipolar disorder include:
Clinicians should pay close attention to signs, symptoms, and historical information in order to rule out an underlying medical condition. A mental status exam in addition to diagnostic imaging and laboratory work can help rule out medical conditions. A physical cause for mental symptoms is more likely if the patient is experiencing their first mood disturbance or if their patient is 40 years or older [10].
Those suffering from a bipolar disorder are at an increased risk of committing suicide. Recent literature reveals that 15 percent of bipolar sufferers successfully complete suicide, with between 25 to 50 percent of bipolar disorder clients attempting suicide at least once during the course of this life-long illness [4].
To help put this into perspective, more clients experiencing bipolar symptoms attempt suicide than in any other psychiatric diagnosis, including that of unipolar depression. On average, 29.2% of patients diagnosed with bipolar disorder attempt suicide, compared with 15.9% of those with unipolar depression and 4.2% of those with any other psychiatric condition [4].
The emotional roller coaster of bipolar disorder places clients at a heightened risk for suicide not only during depressed episodes but also during the manic swings when the executive decision-making process and the ability to make good judgment is impaired. While suicide is a major risk for all bipolar clients, certain factors tend to affect the potential for suicidal thoughts or acts. Early diagnosis and treatment decreases a patient’s risk of suicide; however, the following factors increase the risk of suicide or self-injurious behavior:
Geraldo is a 29 y/o Hispanic male admitted after being found unconscious in a parked car outside of his ex-spouse’s apartment complex. Empty prescription medication containers were found in the passenger seat next to him by the deputy sheriff who had been called to investigate a suspicious vehicle.
Medications involved are:
Also found with Geraldo was a small spiral bound notebook of the type commonly issued during counseling for the purpose of journaling thoughts and feelings. The handwriting on the last few pages of the notebook are difficult to decipher, yet mention the loss of friends, spouse, and job due to recurrent bouts of deep depression. No suicide note is present.
Geraldo’s former wife reports that she has been without contact with him for several months; however, she had heard recently from former friends that he was without a job or a place to live. She reports Geraldo has a longstanding history of “laziness” where he would just lay around the house without bathing or even talking to her, and that he put very little effort into relationships or into maintaining employment.
Geraldo’s former wife also reports that his underlying inattentiveness was interrupted by occasional periods of high energy that lasted a few weeks at a time but which occurred infrequently. She further reports that she had pressed Geraldo to seek treatment for depression after losing several jobs, however even after treatment nothing seemed to change so she had decided that the lack of interest he showed in their relationship and in seeking work must be a choice. She adds that someday he will wake up, make a decision, and grow out of it.
Acute treatment of bipolar disorders focuses on which phase of the disease the client is currently experiencing and the severity of symptoms experienced [3]. Clients in an acute manic episode may display such poor judgment that they pose a serious risk to themselves and even those around them, and, therefore, require the safety provided by inpatient treatment [3].
Whenever suicidal behaviors are present, inpatient treatment is required. Severe depression also warrants inpatient treatment, while moderate depression or behaviors without risk of injury to the client or others around them may be handled in day treatment clinics or outpatient settings [11].
Clients in the grip of a manic episode must be assessed for risk of suicide, risk of violence or harm to others, and for their level of ability to adhere to treatment. Any antidepressants currently being taken should be stopped, and the use of alcohol or other substances of abuse evaluated and treated. This includes addressing how much caffeine and nicotine are being used to support or maintain the feelings of mania.
Medication used to shift the client’s biochemistry back towards the state of remission in mania or hypomania include:
Other treatments found particularly useful in acute mania or hypomania are:
Electroconvulsive Therapy (ECT). ECT remains a reliable and effective treatment for both severe manic and severe depressive episodes. Treatment with ECT followed by maintenance lithium therapy has shown greater benefit than lithium alone for refractory mania [3].
Depressive episodes occur more frequently and tend to last longer than manic shifts. The treatment for bipolar depression differs from unipolar depression as mixed symptomatology and the underlying cycling tendency of brain biochemistry play an elusive role in treatment [3].
Medications used for bipolar depression include:
Other treatments found particularly useful in acute bipolar depressive episodes include:
Bipolar disorders are a life-long illness. Maintaining clients in a state of disease remission, close to their euthymic or normal level of mood is an ongoing challenge. In addition to medication, psychotherapy has proven effective in minimizing relapse and maintaining a high level of functioning [11].
Maintenance therapy for clients suffering from any of the bipolar spectrum disorders should consist of both regular medication checkups and psychotherapy. Psychotherapy interventions may include:
Bipolar disorders are a life-long ride of hyper-energetic mood highs and deeply depressive lows. Many of those afflicted by this brain disease contemplate, attempt, and succeed in suicide as a means of coping with the intense turmoil bipolar disorder creates in their life. More people have bipolar disorder than are currently diagnosed. The spectrum of illness created by bipolar swings can vary widely, yet share the characteristics of significant shifts in mood and ability to function effectively in life. Often bipolar disease goes undiagnosed and untreated. Effective treatment consists of medication, psychotherapy, and ongoing support to minimize the aversive effects of bipolar symptoms while keeping this ever-present disorder in remission.
[1] Black, D. W. & Anderson, N. C. (2014). Introductory textbook of psychiatry. Washington, DC: American Psychiatric Publishing.
[2] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association
[3] Gabbard, G. O. (2014). Gabbard’s treatments of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Association.
[4] Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Synopsis of psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
[5] Maletic, V. & Raison, C. (2014). Integrated neurobiology of bipolar disorder. Frontiers in Psychiatry. 5(98): 1-24. doi: 10.3389/fpsyt.2014.00098
[6] Sharf, R. S. (2012). Theories of psychotherapy and counseling (5th ed.). Belmont, CA: Brooks/Cole.
[7] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association
[8] American Psychiatric Association. (2013). Highlights of changes from DFSM-IV-TR to DSM-5. Arlington, VA: American Psychiatric Association.
[9] Morrison, J. (2014). DSM-5 made easy: The clinicians guide to diagnosis. New York, NY: The Guileford Press.
[10] Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians (2nd ed.). New York, NY: The Guilford Press.
[11] Connolly, K.R. & Thase, M. E. (2011). The clinical management of bipolar disorder: A review of evidence-based guidelines. The Primary Care Companion Journal of Clinical Psychiatry. 13(4). doi: 10.4088/PCC.10r01097
