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Psychiatric-Mental Health Nursing

16.4 Bipolar Disorders

Psychiatric-Mental Health Nursing16.4 Bipolar Disorders

Learning Objectives

By the end of this section, you will be able to:

  • Define bipolar disorder
  • Describe the symptoms of bipolar disorder
  • Outline the approaches used to treat bipolar disorder

Bipolar disorder is a chronic mental health condition characterized by fluctuating periods of intense mood states, often categorized as manic, hypomanic, and depressive episodes (American Psychiatric Association, 2022). During a manic episode, an individual may exhibit heightened energy, delusions (often of grandeur), decreased need for sleep, racing thoughts, rapid speech, and impulsive or reckless behavior. Hypomanic episodes are similar but less severe and disruptive. Conversely, depressive episodes involve symptoms, such as feelings of intense sadness, hopelessness, lack of energy, difficulty concentrating, and changes in sleep and appetite. These mood shifts can occur over weeks to months and are often interspersed with periods of relatively normal mood (American Psychiatric Association, 2022).

Bipolar disorder treatment involves medication management alongside psychotherapy. Health-care providers should be aware that these individuals may also be at risk for co-occurring conditions, including substance use disorders, anxiety disorders, and suicidal ideation (American Psychiatric Association, 2022). Health-care professionals must develop skills for working with individuals with bipolar disorder, including communication strategies, empathy, and a comprehensive understanding of this condition and its treatment options.

Definition of Bipolar Disorder

Defined, bipolar disorder is a serious mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression). When a person becomes depressed, they may feel sad or hopeless and lose interest or pleasure in most activities. When their mood shifts to mania or hypomania, they may feel euphoric, full of energy, or unusually irritable. These mood swings can affect sleep, energy, social and occupational activity, judgment, behavior, and the ability to think clearly. Episodes of mood swings may occur rarely or multiple times a year. While most people experience some emotional symptoms between episodes, some may not experience any (American Psychiatric Association, 2022).

Mania Versus Hypomania

Mania and hypomania are both mood states associated with bipolar disorder characterized by elevated or irritable mood, increased energy, and other specific symptoms, but they differ in their severity and impact on functioning. Mania is a severe form of elevated mood most of the time for seven days that may result in psychosis or necessitate hospitalization. Individuals experiencing mania often exhibit poor judgment, impulsivity, excessive spending, gambling, hypersexuality, and may engage in risky behaviors leading to inadvertent self-harm. On the other hand, hypomania is a milder form that typically does not impair social or occupational functioning to the extent that mania does and does not progress to psychosis (Jain & Mitra, 2023). While clients experiencing hypomania may show increased productivity or creativity, they are at risk for progressing to a manic episode or experiencing depressive episodes. For health-care professionals, recognizing the symptoms of mania and hypomania is crucial for timely intervention and treatment, which usually involves pharmacotherapy with mood stabilizers, such as lithium and antipsychotic medications, and may include psychotherapy (Jain & Mitra, 2023).

Causes of Bipolar Disorder

The exact causes of bipolar disorder are not understood fully, but it appears to be a complex interplay of genetic, neurochemical, and environmental factors. Research reveals that bipolar disorder tends to run in families, which indicates a genetic predisposition to the disorder. Neurochemically, there may be imbalances in certain neurotransmitters in the brain that contribute to the mood instability seen in bipolar disorder. Environmental factors, such as high stress levels, traumatic events, or major life changes can also play a significant role in the onset of bipolar disorder (McIntyre et al., 2022). Note, however, that not everyone with these risk factors develops the disorder, and many people without these risk factors do develop bipolar disorder, which points to the complex nature of its causes.

Types of Bipolar Disorder

There are several types of bipolar disorder, each differentiated by the severity and pattern of mood fluctuations. Bipolar I disorder is characterized by manic episodes that last for at least seven days or by manic symptoms so severe that hospitalization is required, and usually includes depressive episodes as well (American Psychiatric Association, 2022). By contrast, bipolar II disorder involves a pattern of depressive and hypomanic episodes but not the full-blown manic episodes observed in bipolar I disorder (American Psychiatric Association, 2022). Cyclothymic disorder, or cyclothymia, is a milder form of bipolar disorder that involves periods of hypomanic symptoms and periods of depressive symptoms lasting for at least two years (one year in children and adolescents) (American Psychiatric Association, 2022). There is also bipolar disorder “other specified” and “unspecified,” which include bipolar-like symptoms but do not meet the specific criteria for the other types (American Psychiatric Association, 2022).

Cultural Context

Cultural Differences Relating to Elation

Elation is a universal human emotion characterized by a sense of joy, exhilaration, and high spirits. How this emotion is experienced, expressed, and interpreted differs greatly when accounting for cultural and age-related factors. Understanding these differences is key to fostering effective cross-cultural and intergenerational communication (Lim, 2016).

Many individuals of East Asian cultures, such as Chinese, Japanese, and Korean people, experience and express elation in a subdued, controlled manner. These cultures tend to be collectivist and therefore value harmony, adjusting, and conformity. Demonstrating excessive emotion, even positive emotions like elation, can be seen as a disruption of harmony or a lack of self-control. This tends to be true across all age groups (Ip et al., 2021).

In contrast, many Western cultures (such as American and some European) tend to express elation and other emotions more openly. People in these cultures prefer emotions they can express more exuberantly than those emotions that are generally not expressed as enthusiastically (Lim, 2016). There is generally less stigma around showing strong emotions; such expressions are often associated with individualism and influencing others (Lim, 2016). Other cultures may express elation in other ways. In general, a culture’s expression and feeling of elation varies according to what they value, such as communal activities or celebration.

Younger generations, who are generally more connected globally through technology and social media, may share and express their elation differently than older generations. For example, this could be through posts, pictures, or videos on social media platforms. On the other hand, older generations might prefer to express elation more personally or directly, such as sharing their joy with close friends or family members in person.

Symptoms of Bipolar Disorder

Bipolar disorder is typified by extreme shifts in mood, energy, and activity levels that interfere with day-to-day functioning. Symptoms vary across the manic and depressive phases. Manic episodes can be characterized by: feeling overly happy, energized, and restless; rapid pressured speech; impulsive behavior; experiencing delusions and a decreased need for sleep. During depressive episodes, symptoms may include feeling intensely sad or hopeless; loss of energy; difficulty concentrating; changes in eating, sleeping, or other habitual behaviors; and in severe cases, suicidal thoughts or attempts. Mixed episodes, characterized by symptoms of both mania and depression, can also occur (NIMH, 2023). It is important to note that these symptoms can be severe and differ from the normal ups and downs most people experience.

A state of extreme happiness or exhilaration called elation can present as a symptom in certain mood disorders, such as bipolar disorder and cyclothymic disorder. A prolonged period of elation, as described previously, is considered mania. The types of elation in these contexts can be categorized as hypomanic elation and manic elation. Hypomanic elation is a characteristic symptom of hypomania, a mood state one step down from full-blown mania. Individuals experiencing hypomanic elation may feel extremely energetic, talkative, and overly confident. Despite these intense feelings, hypomanic individuals can typically carry on with their daily activities, though they may engage in risky or impulsive behaviors due to the elevated mood.

On the other hand, manic elation is a symptom of a manic episode, as seen in bipolar I disorder. This form of elation is more severe and disruptive than hypomanic elation. Individuals experiencing manic elation may feel invincible or omnipotent and often engage in reckless activities without considering the consequences. This intense level of elation can impair one’s ability to function normally and may necessitate hospitalization to ensure the safety of the individual and others (American Psychiatric Association, 2022).

Treatment of Bipolar Disorder

The treatment of bipolar disorder generally includes a combination of medication and psychotherapy to manage and mitigate symptoms (Mayo Clinic, 2022). Mood stabilizers, antidepressants, and atypical antipsychotics often play a role in treatment (NIMH, 2023). Psychotherapy, including CBT, family-focused therapy, and interpersonal and social rhythm therapy (IPSRT), can also be an essential part of treatment (Mayo Clinic, 2021). In some cases, ECT or other brain stimulation therapies may work when other treatments are ineffective or if the person’s symptoms are severe (NIMH, 2023). Importantly, treatment plans should be tailored to the individual because what works best may differ from person to person.


Medication is a crucial part of treatment for bipolar disorder, aiming to stabilize moods and help control symptoms (NIMH, 2023). Mood stabilizers, such as lithium and valproate, are often the first line of treatment, particularly for managing manic episodes. Antidepressants can manage depressive episodes, though they are typically prescribed alongside a mood stabilizer like lithium to prevent the onset of a manic episode. Antipsychotic medications, such as olanzapine or quetiapine olanzapine, may work if other drugs fail to control the symptoms of mania or depression (Mayo Clinic, 2022). In some instances, benzodiazepines, a type of antianxiety medication, may temporarily relieve acute symptoms, such as restlessness or insomnia (NIMH, 2023). It is important to note that medication needs can change over time, so it is vital to monitor medications continually (Mayo Clinic, 2022).

Lithium, a mood stabilizer commonly used to treat bipolar disorder, comes with a number of safety concerns:

  • Therapeutic range: Lithium has a narrow therapeutic range, meaning the difference between a therapeutic dose and a toxic dose is small. The therapeutic range for lithium is very narrow, typically 0.8 and 1.2 mEq/L for acute goals and 0.8 and 1.0 mEq/L for maintenance goals, with the toxicity levels beginning at 2.0 mEq/L. Regular monitoring of blood levels is required to ensure safety (Chokhawala et al., 2024).
  • Kidney damage: Long-term use of lithium can lead to kidney damage or even chronic kidney disease. Regular monitoring of kidney function is essential.
  • Thyroid issues: Lithium can interfere with the function of the thyroid gland, causing hypothyroidism, requiring regular thyroid function tests.
  • Side effects: Common side effects of lithium can be disruptive and include thirst, frequent urination, weight gain, memory problems, hand tremors, and gastrointestinal problems.
  • Drug interactions: Lithium can interact with other drugs, such as diuretics, NSAIDs, and certain antihypertensive medications, leading to increased lithium levels and potential toxicity.
  • Overdose risk: Overdosing on lithium can be life-threatening. Signs of lithium overdose can include diarrhea, vomiting, drowsiness, muscle weakness, and tremor. If not treated promptly, overdose can lead to seizures, coma, or even death.

While lithium is a very effective medication, its use requires careful monitoring due to its inverse relationship with sodium, to ensure client safety. There is a need for dietary education. It is also important that clients understand the effects of dehydration with lithium knowing that increased sodium will deplete lithium, causing increased sodium presentation. It is essential to understand the signs and symptoms of lithium toxicity; early recognition and intervention can be lifesaving. Early signs of lithium toxicity include the following:

  • Gastrointestinal symptoms: Nausea, metallic taste in mouth, vomiting, and diarrhea are among the early signs.
  • Fine hand tremors: An increase in the tremors that many clients experience when initially starting lithium.
  • Generalized weakness: Clients may complain of feeling weak or fatigued.
  • Thirst and polyuria: Increased thirst and frequent urination can be indicative of beginning toxicity.

Signs of moderate lithium toxicity include the following:

  • Coarse tremors: The tremors may become more severe and noticeable.
  • Confusion: The client may start to become mentally disoriented.
  • Muscle hyperirritability: Symptoms like twitching or hypertonia.
  • Unsteady gait: Trouble with balance and coordination.

Signs of severe toxicity include the following:

  • Seizures: Uncontrolled electrical activity in the brain
  • Coma: Loss of consciousness
  • Oliguria or Anuria: Reduced or absent urine output, potentially leading to kidney failure
  • Arrhythmias: Irregularities in heart rate and rhythm

Nursing interventions for suspected lithium toxicity include immediate notification of health-care providers, cessation of lithium administration, and close monitoring of vital signs and lithium blood levels. Depending on the severity of the symptoms, hemodialysis may be required (Hedya et al., 2022).

Nurses should review all of the medications being taken by each client on lithium to ensure no contraindications and provide client education on taking lithium and the side effects and safety concerns. Adherence to the medication may be a concern, particularly with the occurrence of side effects, such as weight gain, and because clients who are entering a manic phase may deny the presence of the disorder and need for medication.

Psychotherapeutic Approaches to Dealing with Bipolar Disorder

Psychotherapeutic interventions are important in managing bipolar disorder alongside medication. CBT can help individuals understand the patterns of their thoughts and behaviors and develop strategies to manage symptoms and prevent relapses (Özdel et al., 2021). Interpersonal and social rhythm therapy (IPSRT) aims to stabilize daily rhythms, such as sleep, wake, and mealtimes, which can be particularly beneficial for individuals with bipolar disorder; disruptions in these areas can precipitate manic or depressive episodes (Mayo Clinic, 2021). Family-focused therapy involves family members and concentrates on enhancing family communication, problem-solving, and coping skills, which can be crucial for managing the disorder (Miklowitz & Chung, 2016). Psychoeducation, which involves teaching individuals with bipolar disorder and their families about the disorder, is another key psychosocial intervention. It helps improve treatment compliance and decreases the likelihood of relapses (Miklowitz & Chung, 2016). Each of these approaches can be tailored to the individual’s unique needs and circumstances to optimize the management of the disorder.

Planning Nursing Care for a Client with Bipolar Disorder

Planning nursing care for a client with bipolar disorder requires an individualized, holistic approach that considers the person’s unique symptoms, triggers, and needs (Hernández-Gómez et al., 2021). The first step is typically a comprehensive assessment of the client’s physical and mental health and their personal and social situation to identify specific areas of need. Next, developing a care plan should include elements of psychoeducation, helping the client understand their condition, treatment options, and strategies for self-management. Nursing care also involves monitoring the client’s mood, behavior, and response to medication and communicating this information to the health-care team.

In acute phases, the focus may be on maintaining safety, providing support, managing symptoms, and stabilizing mood. In the maintenance phase, nursing care should emphasize recovery and the prevention of future episodes, which can include lifestyle counseling, promoting medication adherence, encouraging participation in therapy, and coordinating care with other health-care providers (Hernández-Gómez et al., 2021). Throughout this process, it is essential to involve the client in decision-making, support their autonomy, and respect their dignity.

Interacting with clients who have a bipolar disorder can be both rewarding and challenging. These individuals often go through phases of manic and depressive episodes, and knowing how to effectively communicate during these different stages is crucial (SAMHSA, 2016). During manic phases, the client may exhibit elevated mood, increased activity, hostility, and grandiose thoughts. It is essential for the nurse to maintain a calm demeanor, provide concise and clear directions, and avoid challenging the client’s grandiosity to prevent escalation. In contrast, during depressive phases, the client may be withdrawn, exhibit low energy, and may even have suicidal thoughts. It is vital to employ empathetic and active listening, and to consult the mental health team for additional evaluation and treatment, if necessary (SAMHSA, 2020b). Understanding the specific needs and symptoms of clients’ bipolar disorder can lead to more effective nursing care and better outcomes (Novick & Swartz, 2019).

Real RN Stories

Nurse: Joan, RN
Years in Practice: Four
Clinical Setting: Crisis intervention unit in a regional hospital
Geographic Location: Oregon

Joan is looking after Sarah who is a thirty-five-year-old client diagnosed with bipolar disorder. She was in a manic phase upon admission, extremely talkative and agitated. Her medical chart indicated a history of medication noncompliance, which often exacerbated her symptoms. The challenge was to keep her safe while her medication was adjusted. She was so full of energy and grandiose plans that she wanted to leave the hospital immediately to “change the world.” By using a calm, clear, and firm approach, health-care providers managed to convince her to stay for observation. During the manic phase, clients like Sarah often feel invincible, which can lead to risky behaviors. It is crucial for health-care providers to ensure a safe environment and encourage medication compliance to stabilize their mood (SAMHSA, 2023a).

A week later, Sarah began displaying depressive behaviors. She became withdrawn and started expressing feelings of worthlessness. She also began to discuss suicidal thoughts. The nurse’s role transitioned from setting firm boundaries to providing emotional support and vigilant monitoring for suicidal ideation (Twivy et al., 2023).

With medication adjustments and a multidisciplinary approach involving psychiatrists, social workers, and mental health nurses, Sarah began to stabilize. With proper care she was able to transition from extreme behaviors to a more balanced state. This transition emphasizes the importance of holistic care and teamwork in managing complex conditions like bipolar disorder (Skjærpe et al., 2022).


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