UNM COC:  Your Healthcare Primer for Long Term Care

 
Bipolar Disorder

(Much of this information was gathered from the NIMH pamphlet on Bipolar Disorder written by Melissa Spearing) 

Definition

Bipolar Disorder is a disorder that causes unusual shifts in a person’s mood, energy, and ability to function. The symptoms of bipolar disorder are severe and are much weightier than the normal ups and downs that everyone experiences.

Introduction

Bipolar disorder, also known as manic-depressive illness, affects more than two million American adults, or approximately 1% of the population. Usually, the disorder develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some late in life.

In the general population, it is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. People with developmental disabilities are even more likely to have the condition misdiagnosed as "behaviors" that are part of their disability, rather than as bipolar disorder.

The good news is that bipolar disorder can be successfully treated. However, it is a long-term condition that must be carefully managed throughout a person’s life.

Diagnosis

Bipolar disorder causes dramatic mood swings---from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.

Signs and symptoms of mania:

• Increased energy, activity, and restlessness

• Excessively "high" overly good, euphoric mood

• Extreme irritability

• Talking very fast, jumping from one idea to another

• Can’t concentrate as well as before

• Little sleep needed

• Unrealistic beliefs in one’s abilities and powers

• Poor judgment

• Spending sprees

• A period of behavior that is different from usual

• Increased sexual drive

• Provocative, intrusive, or aggressive behavior

• Denial that anything is wrong

Signs and symptoms of depression:

• Lasting sad, anxious, or empty mood

• Feelings of hopelessness

• Feelings of guilt, worthlessness, or helplessness

• Loss of interest or pleasure in activities once enjoyed.

• Decreased energy, a feeling of fatigue or of being "slowed down"

• Difficulty concentrating, remembering, making decisions

• Restlessness or irritability

• Sleeping too much or can’t sleep

• Change in appetite and/or unintended weight gain or loss

• Chronic pain or other bodily symptoms that are not caused by physical illness or injury

• Thoughts of death or suicide, or suicide attempts

Sometimes, severe episodes of mania or depression include symptoms of psychosis. Common psychotic symptoms are hallucinations (seeing, hearing, or sensing the presence of things not actually there) and delusions(false beliefs that are not influenced by logical reasoning or explained by a person’s cultural beliefs.)

The diagnosis of bipolar disorder is made on the basis of symptoms, course of illness, and when available, family history. Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.

Prevention and Treatment

Prevention: Although bipolar illness itself may not be preventable, it is important to be on the lookout for signs and symptoms that can be treated early on, thus avoiding the progression to psychosis or more severe mania or depression. For example, it is important to pay attention to sleep patterns, changes in behavior, energy, irritability, particularly if people can’t express themselves easily.

Perhaps the most important constituent of bipolar illness to prevent is suicide.

Treatment: Most people with bipolar disorder can achieve substantial help with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended. Most experts recommend a strategy that combines medication and psychosocial treatment.

In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your health care provider.

Keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder, their family, and care-givers better understand the illness.

Medications: Medications known as "Mood stabilizers" usually are prescribed to help control bipolar disorder. The most commonly prescribed mood stabilizers include lithium, anticonvulsant medications, such as valproate (Depakote) or carbamazepine (Tegretol) and newer anticonvulsants which are being studied such as lamotrigine (Lamictal), gabapentin(Neurontin) and topiramate(Topamax).

People with bipolar disorder who develop depression may need anti-depressant treatment; however, people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling during treatment with antidepressant medication. Therefore, mood-stabilizing medications are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch.

Atypical antipsychotic medications, including clozapine(Clozaril), olanzapine(Zyprexa), risperidone(Risperdal), and ziprasidone(Zeldox), are being studied as possible treatments for bipolar disorder.

Emergency Situations – What can go wrong?

Extremes of mood, either mania or depression can be emergencies. If someone’s behavioral changes appear to be escalating to a hazardous degree, be sure to get help immediately. Days and days without sleep or with psychotic thinking can be dangerous. Suicidal thoughts or behavior requires immediate attention.

Lithium, while usually safe, can be very dangerous if blood levels become too high. IF patients become dehydrated, they are at particular risk for developing lithium toxicity. If patients become confused or stuporous, or there is a change in their level of alertness, call your provider and take them to the emergency room right away.

What can go wrong: Medication side effects can be troublesome, but are usually not dangerous. However, they need to be brought to your provider’s attention quickly. Side effects such as tremor, nausea, weight gain, reduced sexual drive can be very discouraging and may contribute to the client’s nonadherence to treatment

In order to avoid escalation of mania or depression, it is important to get help right away if someone’s behavior, mood, or energy level appears to be changing.

Conclusion

Bipolar disorder is a psychiatric disorder that is treatable! It requires careful observation of your clients and careful use of medication. Clients with developmental disabilities who develop bipolar disorder may show more of the physical signs of this disorder: behavior changes, lack of need for sleep, lack of interest in surroundings, irritability, intrusiveness, suicide attempts, than those who are more verbally expressive.

It is very important to get family history and a "mood" and "sleep" timeline to help make the diagnosis. Never assume that "behaviors" are part of developmental disabilities without looking into other causes.

References

National Institute of Mental Health
Office of Communications and Public Liaison, 
Information Resources and Inquiries Branch
6001 Executive Blvd. Rm. 8184, MSC 9663
Bethesda, MD 20892-9663

Goodwin FK, Jamison KR, Manic-depressive illness. New York: Oxford University Press, 1990

American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, fourth edition. Washington, DC American Psychiatric Press, 1994