Bipolar Affective Disorder

Bipolar Affective Disorder

Bipolar Affective Disorder

Bipolar Affective Disorder is formerly called manic-depressive illness (MDI). B.A.D is severe and persistent condition that causes serious lifelong struggle and challenge.

Bipolar affective disorder is a mental health condition characterized by mood swings, from deep and prolonged low mood (profound depression) to extreme euphoria (mania), with intervening normal periods.

Episodes of mood swings may occur rarely or multiple times a year. While some people will experience some emotional symptoms between episodes, some may not experience any.

They are of three kinds i.e.

  • Mixed bipolar disorder that is both manic and depressive episodes intermixed
  • Manic bipolar disorder; here there is predominant elation of mood, irritability, excessive motor activity and evident psychotic features
  • Depressed bipolar disorder; symptoms are characteristic of major depression with a history of at least one manic episode.

Symptoms of bipolar affective disorder

Symptoms of bipolar vary from person to person and from time to time depending on the phase the patient is in.

Manic episode

Manic episodes have at least 1 week of profound mood disturbance characterized by elation and irritability at least 3 of the following;

  • grandiosity
  • Increased energy, activity (boundless energy)
  • Exaggerated sense of well-being and self-confidence (euphoria)
  • Decreased need for sleep
  • Unusual talkativeness
  • Racing thoughts or flight of ideas
  • Distractibility
  • Poor decision making for example taking sexual risks or making foolish investments
Hypomanic episode

This is characterized by elated or irritable mood of at least 4 consecutive days duration. The diagnosis of hypomania requires at least 3 of the above symptoms the difference being that here the symptoms are not severe enough to cause marked impairment in social or occupational functioning

Depressive episode

In a major depressive episode, for the same 2 weeks a person may experience 5 or more of these symptoms with at least one of the symptoms being either depressed mood or loss of pleasure or interest.

  • Depressed mood, such as feeling sad, hopeless, tearfulness and irritability in children and teens
  • Marked loss of interest or feeling of no pleasure in almost all activities
  • Significant weight loss when not dieting
  • Psychomotor retardation or agitation
  • Either insomnia or sleeping too much (hypersomnia)
  • Either restlessness or slowed behaviour
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Decreased activity to think or concentrate
  • Thinking about, planning or attempting suicide
  • Melancholia; this refers to depression not triggered by a stressor

Management of bipolar affective disorder

The treatment of bipolar affective disorder is directly related to the phase of episode (i.e. depression or mania and the severity of that phase.

MANIA

Mania is condition characterized by excessive or extreme elation of mood and increased activity.

It is a state of mind manifesting with cheerfulness, euphoria, and rapidly changes to irritability.

Types of mania

Hypomania: This is a mild form of mania

Acute mania: Acute, severe and heavy form of mania

Delirious mania: Excitation characterized by confusion mainly found in organic psychoses.

Chronic mania: Mania that has occurred in the patient, it could be simple form but has failed to respond to various forms of treatment. It usually occurs in people 40 years and above.

CAUSES OF MANIA
  1. Genetic factors; mania is said to run in families
  2. Increase in levels of noradrenaline metabolites
  3. Imbalances in serotonin levels in blood
  4. Increase in dopamine levels
  5. Cyclothymic type of personality (mood swings) plays a big role in the causation of manic illness occurrence.
  6. Body physic;
  7. Psychosocial factors like those resulting from stresses e.g. Divorce, bereavement etc.
 Clinical features of mania
  • Elation of mood
  • Great deals of energy (boundless energy)
  • Usually restless and over active
  • Poor concentration and easily destructed by other activities
  • Patients have high appetite for food and drinks but usually have no time to eat since they lack concentration
  • Increased urge for sex (high libido)
  • Excessive involvement in pleasurable activities e.g. excessive spending habits
  • Dressing is usually inappropriate with bright colours that do not match, excessive make-up and jewelery.
  • Delusions of grandeur are more pronounced
  • Over talkativeness and pressure of speech in acute forms of mania
  • Racing thoughts i.e. accelerated thinking (the speech is very fast and continuous)
  • Insight is lost
  • Sleep is disturbed and a patient may have total insomnia
  • Auditory hallucinations are very common
  • Ideas of reference are very common (when the patient feels that people are conversing about him)
Diagnosis of mania

The following features are diagnostic of mania;

  1. Abnormally elevated mood and irritability
  2. Grandiosity (over rating one’s self)
  3. Boundless energy
  4. Over activity
  5. Over talkativeness
  6. Racing of thoughts
  7. Poor concentration and easily destructed.

Management

Hypomanic can be managed at home if there is someone to assist them take their medications

  1. Hospitalization:  If the patient is too excited, is a public nonsense, not taking care of himself e.t.c. then  admission to mental health hospital is very essential.
  1. Establishment of therapeutic relationship is very important because, it`s the key to the nursing care.
  2. If the patient is very excited, restless and unable to be calm down by the verbal instruction of the care team, a tranquilizer or a sedative such as chlorpromazine 100-200mg or Haldol 5-10mg by injection are administered
  3. Reduce the dosage and frequency as the symptom subsides.
  4. Short simple direct answers should be given when a patient asks questions.
  5. Ensure a low stimuli of the patient`s environment.
  6. Remove all the dangerous particles like iron bars, sharp instruments, easily portable stone etc that the patient can use to harm himself and others.
  7. Supervise and maintain personal hygiene.
  8. Special attention must be given to patient’s diet because a patient is usually too busy to eat because of hyperactivity and restlessness. diet rich in carbohydrates,  proteins with a lot of fluids is recommended.
  9. Observe the patient behaviors, toilet habits, eating habits, steep etc

DRUG TREATMENT

To control the manic symptoms antipsychotic like Haldol or chlorpromazine  can be used.

CPZ (chlorpromazine) 100-1200mg in divided doses which may be reduced when the patient improves

  • Thioridazine 100-600mg in divide doses (it can also help to lower the patient libido)
  • Haloperidol: 5-15mg nocte for not more than to work
  • Lithium carbonates: 250-550mg doses (it is the drug of of choice in manic patients)
  • Benzelhexol (artane)

Other drug used in manic illness in

  • Carbamazepine: 100-400mg in divided doses
  • Sodium volporate: 100-1500mg in divided doses (but are usually given given in carbonates).

ELECTRO COMVULSIVE THERAPY

  • This is very good especially in manic excitement. 1 or 2 shocks a week for 6-9 weeks. ECT is very effective when given in combination with drugs.

OCCUPATIONAL THERAPY

  • Occupational therapy is very important for recovering patient and the type of occupation varies from individual patient to another.
  • Psychotherapy to the family is very helpful
  • Resettlement and good follow up system should be put in place for individual patient.
Nursing care of manic patients
  • Diet; special attention has to be given to patients diet because he is usually too busy to eat and hence may lose weight and also dehydration may occur.
  • Meals and fluids have to be given under supervision and extra nourishment may be required to compensate for extra activity.
  • Care has to be taken to ensure that the patient dresses well
  • Supervision and directions to maintain personal hygiene like bathing, oral hygiene is essential.
  • one nurse has to be assigned to the over active patient so as to improve his confidence in her
  • Maintain a low level of stimuli to the patient environment i.e. Factors like noise and bright colours should be avoided in the ward otherwise the ward should be quiet and pleasant.
  • observe patients behaviour frequently and report any changes
  • remove any dangerous objects from the patients environment that can be used to harm self or others during times of agitation
  • Injuries attained by the patient because of his hyperactivity have to be attended to.

Prognosis

  • If well treated, most episodes resolve within three months and rarely last for more than 6months
  • There is risk of reoccurrence if the disorder begins before 30years of age
  • Studies have revealed that 10-20% of the sufferers have had 3 episodes of depression before developing mania
  • The prognosis of mania is far better than that of schizophrenia
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