Bipolar I Disorder - Anatomy of Psych

What is bipolar I disorder?

Bipolar I disorder is characterized by episodes of highly elevated mood or irritability, known as mania.

At least one manic episode in a person's lifetime is required for the diagnosis of bipolar I disorder. This manic episode can be preceded by and followed by hypomanic or major depressive episodes.

The lifetime prevalence for bipolar I disorder is roughly 0.6%. Men and women are equally affected, but men are likely to have more manic episodes, while women are likely to have more depressive or rapid cycling episodes. Interestingly, bipolar disorder tends to affect those of higher socioeconomic class, and those living in higher income countries. The average age of onset in the United States is 20 years.

See bipolar II disorder, a less severe form of bipolar disorder that involves hypomanic episodes rather than manic episodes.

What does bipolar I disorder look like?

Signs & Symptoms

At least one manic episode that may be preceded or followed by hypomanic or major depressive episodes. Signs of mania include:
- Abnormally upbeat, jumpy or wired
- Increased activity, energy or agitation
- Exaggerated sense of well-being and self-confidence (euphoria)
- Decreased need for sleep
- Unusual talkativeness
- Racing thoughts
- Distractibility
- Poor decision-making — for example, going on buying sprees, taking sexual risks or making foolish investments

DSM-5 Criteria

Bipolar I Disorder Criteria

Criterion A. Criteria have been met for at least 1 manic episode (see Manic Episode Criteria below).

Criterion B. The occurrence of the manic and major 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.

Manic Episode Criteria

Criterion A. A distinct period of abnormally and 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).

Criterion B. During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree, and represent a noticeable change from usual behavior:

Grandiosity or inflated self-esteem.
Sleep decreases (e.g. feels rested after only 3 hours of sleep).
More talkative than usual or pressure to keep talking.
Flight of ideas or subjective experience that thoughts are racing.
Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e. purposeless non-goal-directed activity).
Indiscretion; excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

Criterion 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.

Criterion D. The episode is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g. medication, electroconvulsive therapy), but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

Specifiers

Specifiers:

With anxious distress
With mixed features
With rapid cycling
With melancholic features
With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern
Episode specifier:
- Current or most recent episode manic
- Current or most recent episode hypomanic
- Current or most recent episode depressed
- Current or most recent episode unspecified
Severity specifier:
- Mild
- Moderate
- Severe
Remission specifier:
- In partial remission
- In full remission

Risk Factors

History of anxiety disorder during childhood
First-degree relative with bipolar disorder (9% heritability)
Identical twin with bipolar disorder (40-45% heritability)
Mixed features associated with a major depressive episode
- Less likely to reach full recovery
- More likely to have treatment-emergent mania when exposed to conventional antidepressants
Adverse childhood experiences, especially physical and sexual abuse

Prognosis

Factors associated with good prognosis: treatment adherence, lack of early childhood adversity, higher age of onset, good social supports, absence of rapid cycling, and absence of personality disorders
Factors associated with poor prognosis: male gender, mixed episodes/features, rapid cycling, comorbid anxiety disorder, substance abuse, personality disorder, and/or obesity

Differential Diagnosis

Major depressive disorder
Persistent depressive disorder
Other bipolar disorders, e.g. bipolar II
Substance- or medication-induced mood disorder
Cyclothymic disorder
Disruptive mood dysregulation disorder
Psychotic disorders
Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders
Attention-deficit/hyperactivity disorder
Personality disorders: borderline personality disorder, narcissistic personality disorder, antisocial personality disorder
Obstructive sleep apnea
Vitamin B12 deficiency
Endocrine dysfunction: hypo- or hyperthyroidism, hypercortisolemia
Infectious etiologies

What is rapid cycling?

The occurrence of at least 4 mood episodes during the past 12 months
Episodes can occur in any combination and order, and must each meet their respective DSM-5 criteria
In between episodes, there must be either a 2-month period of partial/full remission, or a switch to an episode of opposite polarity (mania/hypomania vs depression)

Pathophysiology of bipolar I disorder:

Genetics: ANK3 and CACNA1C genes are implicated
Neuroimaging: abnormalities in the fronto-limbic network
- MRI findings: smaller hippocampus, amygdala, thalamus, anterior cingulate regions; larger ventricles; increased white matter hyperintensities; widespread cortical thinning; cortical thickening in individuals taking lithium and thinning in individuals taking anticonvulsants
- fMRI findings: hyperconnectivity in the default mode network, salience network, and central executive network

How is bipolar I disorder investigated?

Labwork: CBC fasting glucose, fasting lipid profile, platelets, electrolytes and extended electrolytes, liver enzymes, serum bilirubin, prothrombin time and partial thromboplastin time, serum creatinine, eGFR, TSH
Urinalysis, urine drug screen
Electrocardiogram (ECG) if age 40+ or if indicated
Pregnancy test and prolactin if woman in childbearing age
Neuroimaging for neurological findings, abrupt or late onset, or if the presentation is different from typical episodes of mania (for individuals who have had previous episodes of mania)

Young Mania Rating Scale (YMRS)

Clinician rater
11-item scale on the patient's subjective report over the last 48 hours plus clinical observations
Takes 15-30 minutes to complete

Mood Disorder Questionnaire (MDQ)

Client rater
13 questions to screen for bipolar spectrum disorder
55% positive predictive value

How is bipolar I disorder treated?

Lithium is the gold-standard treatment for bipolar I disorder. However, medication adherence for individuals affected by bipolar I disorder is typically challenging, with about 1/3 of individuals unable to sustain treatment long-term. Antidepressants or stimulants should be discontinued during a manic episode to reduce to risk of lengthening the episode.

Mood Stabilizers

Lithium
- Used for:
  - Classical euphoric and grandiose mania
  - Classical mania-depression-euthymia course
  - Fewer prior episodes of illness
  - Family history of bipolar disorder and/or lithium response
- Adverse effects:
  - Kidney impairment
  - Thyroid dysfunction
  - Worsening of psoriasis
Valproate
- Used for:
  - Classical mania and dysphoric mania (mixed features)
  - Predominant irritable or dysphoric mood
  - Comorbid substance use
  - History of traumatic brain injury
- Adverse effects:
  - Teratogen
  - Polycystic ovary syndrome (PCOS)
Carbamazepine
- Used for:
  - History of traumatic brain injury
  - Comorbid anxiety and substance use
  - Schizoaffective disorder with mood-incongruent delusions
  - No family history of bipolar disorder
- Adverse effects:
  - Teratogen
  - Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)
  - Hepatic CYP enzyme autoinduction
Lamotrigine
- Used for:
  - Predominant depressive symptoms (does not treat mania)
  - Comorbid anxiety
- Adverse effects:
  - Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)

Special Considerations

Children & Teenagers

Lifetime prevalence is 1%, but difficult to diagnose due to developmental courses and different presentation than in adults
Individuals who do not meet the criteria for pediatric bipolar disorder but experience significant and chronic irritability with behavioral outbursts may qualify for a diagnosis of disruptive mood dysregulation disorder

Older Adults

Late onset bipolar disorder is less associated with family history. Older adults with bipolar disorder are more likely to experience psychotic features, specifically higher severity of delusions. Common comorbidities include diabetes mellitus, hypertension, hypothyroidism, and neurological disorders.

Nursing Management

Risk for injury

Causes & Behaviors:

Affective, cognitive, and psychomotor factors
Biochemical/neurologic imbalances
Exhaustion and dehydration
Extreme hyperactivity/physical agitation
Rage reaction
Abrasions, bruises, cuts from running/falling into objects
Extreme hyperactivity
Impaired judgment (reality-testing, risk behavior)
Lack of fluid ingestion
Lack of control over purposeless and potentially injurious movements

Interventions:

Provide structured solitary activities for focus and security
Provide frequent rest periods to prevent exhaustion
Provide frequent high-calorie fluids to prevent the risk of serious hydration
Observe for signs of lithium toxicity: nausea, vomiting, diarrhea, drowsiness, muscle weakness, tremor, lack of coordination, blurred vision, ringing in ears
Decrease stimuli in the environment to minimize escalation of anxiety and potentially harmful behavior

Risk for violence

Causes & Behaviors:

Impulsivity
Euphoria, elation
Psychotic symptoms
Rage reaction
Restlessness
Agitated behavior, such as slamming doors, increased muscle tension, throwing things over
Loud, threatening, profane speech
Poor impulse control
Provocative behavior, such as being argumentative
Verbal threats against others or self

Interventions:

Frequently assess for signs of hyperactivity and increased agitation in order to address escalation early
Use a calm and firm approach to provide structure and control for a client who is out of control
Use short, simple, and brief explanations or statement, as the client may have a short attention span
Maintain a consistent approach to avoid staff manipulation by the client
Ensure a safe environment by removing any objects that could be used to harm the self or others
Redirect agitation to healthier and safer coping means

Self-care deficit

Causes & Behaviors:

Inability to concentrate on one thing at a time
Perceptual or cognitive impairment
Racing thoughts and poor attention span
Observation or valid report of inability to eat, bathe, toilet, dress, and/or groom self independently

Interventions:

Reduce stimulation to promote relaxation
Encourage frequent rest periods throughout the day to prevent exhaustion
Encourage sleep hygiene practices such as soothing music, low lights, avoiding caffeine, and using as-needed medications if indicated
Encourage frequent high-calorie protein drinks and finger foods to meet the higher caloric need during a manic episode, and to ensure that the client can eat if they are unable to sit down for meals
Frequently remind the client to eat, as the client may be easily distracted during meal times or be unaware of their bodily needs
Provide simple and step-by-step reminders for hygiene and self-grooming

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] McIntyre, R. S., Alda, M., Baldessarini, R. J., Bauer, M., Berk, M., Correll, C. U., Fagiolini, A., Fountoulakis, K., Frye, M. A., Grunze, H., Kessing, L. V., Miklowitz, D. J., Parker, G., Post, R. M., Swann, A. C., Suppes, T., Vieta, E., Young, A., & Maj, M. (2022). The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management. World Psychiatry, 21(3), 364-387.

[4] Mohapatra, D. (2022). Phenomenology and comorbidity in late onset bipolar disorder A comparative study. European Psychiatry, 65(Suppl 1), S157.

[4] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.