the manic phase of bipolar disorder: calming the storm

by Michael C. Desjardins, MSN, APRN

Ludwig van Beethoven, Theodore Roosevelt, and Mark Twain are all believed to have had bipolar disorder. It may first appear during a manic phase, demonstrated through excessive amounts of energy and impulsivity. A mood disorder stemming from distinct brain abnormalities, bipolar disorder is treated with medications and therapy – and through the nurse’s therapeutic alliance with the patient.

A first-year college student recently started behaving in a bizarre manner at school. Her roommate and her friends are concerned about her actions. She stays out all night and goes to class the next day without sleep. At times her speech is rapid, and she seems to ramble. She often laughs uncontrollably and says she is “on top of the world.” Police bring her to an emergency department (ED) after they find her wandering around campus at 2 p.m. barefoot, disheveled, and confused.

Complete blood count, chemistry and liver- function panels, thyroid-stimulating hormone level, and urine drug screen are all within normal limits, except for evidence of mild anemia. A computed tomography (CT) scan of the brain shows no abnormalities. On assessment, the crisis worker (a licensed clinical social worker) finds that the patient has significantly altered perceptions of reality and demonstrates behavior indicating an inability to care for herself. The crisis worker and the ED physician recommend an inpatient psychiatric admission based on the severity of her behavioral symptoms and the potential for self-harm due to her altered perceptions and wandering. The preliminary diagnosis is psychosis, not otherwise specified. However, she is later diagnosed with bipolar disorder and begins psychopharmacologic and other therapeutic interventions to manage her symptoms and to enhance her quality of life.

The patient is at high risk for self-directed violence due to disorientation and expansive mood. The nurses caring for her assess her throughout hospitalization for harm to self or others. After the patient displays explosive behavior early in her hospital stay, techniques such as speaking in a calm voice and a “time-out” intervention are implemented.

The nurses identify a nursing diagnosis of altered nutrition: less than body requirements related to hyperactivity.1 Because the patient is anemic and underweight with a body mass index of 18, a registered dietician assesses
her eating patterns. The interdisciplinary treatment plan prescribes several small meals throughout the day. During the early stages of mania while the patient is hospitalized for inpatient care, her dietary plan provides portable foods she can ingest while she is mobile. Dietary and fluid intake is measured daily to ensure that she is receiving appropriate nutrition and hydration.

The patient is started on lithium carbonate, with the dosage titrated up quickly to facilitate resolution of her bipolar symptoms. She is discharged from the psychiatric unit after 10 days. Her speech is of normal rate, rhythm, and volume. Her form of thought is logical and goal-directed, and she describes her mood as “grateful.” Her affect is euthymic, and she says she is excited about returning to school, seeing her friends, and continuing her studies. The nurses complete her discharge from the hospital by teaching her about her medications and warning signs of relapse. She is given follow-up appointments with outpatient providers for medication management and therapy. She eventually graduates from college and starts working for a publishing company.

The manic side of the bipolar story

Bipolar disorder is classified as a mood disorder. Mood disorders have a lifetime prevalence rate of approximately 25%.2 Bipolar disorder has a prevalence rate around 1% in the general population, although several recent studies have demonstrated higher rates, especially among teenagers and young adults.

Women have historically demonstrated higher rates for depression, but the rates for bipolar disorder are about the same for both genders.4 The condition does not discriminate based on socioeconomic status, but there is some evidence that it is more common among high-socioeconomic status groups.

Familial links

Bipolar disorder is 18 times more prevalent in first-degree relatives, thus indicating a genetic predisposition.4 Approximately 50% of all bipolar patients have a family member with some type of mood disorder.

Chromosomes 5, 11, and X alterations are postulated to be involved in the development of bipolar disorder. The gene coding for dopamine is on chromosome 5 and the area in question on chromosome X contains the genes for color blindness.

Modulating the mood

Bipolar disorder is a psychoneurobiologic illness that, in intensity and severity, varies with the characteristics of the person affected. Today’s diagnostic and genetic studies have pointed to an imbalance of neurotransmitters in the brain. This imbalance manifests through the specific actions of neurotransmitters, such as serotonin, dopamine, and norepinephrine, located in specific areas of the brain.

Bipolar disorder is also believed to result from an imbalance between the actions of the two most abundant neurotransmitters of the nervous system, the amino acids glutamate and gamma aminobutyric acid (GABA). Glutamate and GABA act together to regulate the “firing” of neurons in the brain through modulating ion channels and also through action in the second-messenger systems of the nervous system. The second-messenger system is believed to facilitate the overall function of neurotransmitters and their actions in binding to specific receptors. This results in modulation of mood and cognition and leads to behavioral expression of mood and thought processing.

Kindling the flames

Bipolar illness involves a phenomenon known as kindling, similar to throwing pieces of kindling wood into a small fire and causing the fire to blaze out of control. Kindling is believed to occur in the temporal lobes of the brain. Glutamate and GABA are sometimes described as the yin and yang of the nervous system. The action of GABA allows or inhibits the excitatory action of glutamate. Repeated stimulation of neurons below the threshold needed to stimulate an action potential in the brain results in seizure activity, hence the relationship between bipolar and seizure disorders. Medications that affect the action of GABA and glutamate, such as the anticonvulsants valproic acid and carbamazepine, are effective psychopharmacologic interventions for the treatment of bipolar disorder.

A look inside the bipolar brain

CT scans have demonstrated some abnormalities in individuals with bipolar disorder. Enlarged ventricles similar to those seen with other mental illnesses have been observed in some studies.7 Magnetic resonance spectroscopy has revealed data indicating abnormalities of membrane phospholipid metabolism.

The importance of the role of the neural cells’ membrane in the regulation of the electrochemical charge of the neuron cannot be understated. The membrane is lined with channels that are activated by specific ions and the membrane voltage is affected by the activation of the ion channels. Depolarization occurs when the threshold is reached and the neuron is thus allowed to exhibit its actions. Metabolic abnormalities can affect the rate, rhythm, and strength of the neural impulses. This is believed be the neurochemical basis for bipolar illness.

Mania from the outside in

Bipolar disorder is characterized by a unique set of symptoms that distinguish it from other disease processes. Typically, bipolar patients have experienced a manic episode at some point in their lives. The hallmark of mania is an elevated, expansive, and grandiose mood along with a decreased need for sleep. The nurse may notice grandiosity or exaggerated outward behavior, such as increased talkativeness, distractibility, tangential speech, or an inability to relax. It is important to differentiate the manic phase of bipolar disorder from any other condition that might mimic mania, such as stimulant abuse or hyperthyroidism.

The inability to relax may be expressed through attempts to be involved in various goal-directed activities. Patients in the manic phase may stay up all night working intensely on a project. They may not perceive a need for sleep the next day and appear to have abnormally large amounts of energy. Characteristically, those with bipolar disorder might be increasingly involved in risky activities without consideration of the consequences. Patients with bipolar disorder may begin excessive and indiscriminate spending of money, have multiple sexual encounters within a short period of time, or make false claims of importance. Such behavior is usually significant enough to cause social or occupational dysfunction and greatly increase the risk to personal safety.

Mania from the inside out

Stress can trigger an episode of bipolar disorder. Specifically, the effect of stress on the brain combined with a genetic predisposition may lead to the expression of the bipolar trait.4 Long-lasting changes in the brain’s biochemistry stemming from stress can produce alterations in the production or release of neurotransmitters and in brain structures.

Stress triggers the stimulation of the pituitary and hypothalamic glands, resulting in the release of the hormone cortisol, a glucocorticoid that supports the “fight or flight” response and helps the brain and organs gear up for action as a result of the stressful circumstance. Cortisol triggers long-lasting changes in the brain, including the limbic system structures involved in emotional regulation. This pathophysiologic response increases the risk of subsequent episodes. Life-altering events or circumstances, such as entry into college, major illness, family change, or significant relational conflict, can trigger mood-disorder symptoms. Some women develop a mood disorder during pregnancy or postpartum.

The best approach to care

Interdisciplinary collaboration in the care of patients is considered current best practice.10 Inpatient psychiatric nursing care involves interdisciplinary collaboration with social workers, psychologists, recreation therapists, music therapists, nutritionists, pharmacists, psychiatrists, and many others (depending on the degree of specialization of the healthcare facility). Each discipline contributes to the care plan during treatment team meetings. This brings each discipline’s area of expertise to the table and results in higher quality and more comprehensive care.

Management of patients with bipolar illness in the manic phase requires formulation of a care plan tailored to their specific needs. Nursing diagnoses such as risk for violence: self-directed or directed at others related to manic state excitement1 highlight the level of risk while treating a patient with bipolar disorder.

It is important to remember that the destructive and negative behavior associated with bipolar disorder is a result of specific brain alterations and learned coping mechanisms. It takes careful self-assessment for nurses to examine their own personal attitudes and remain nonjudgmental. Openness and objectivity are essential for building a therapeutic alliance despite a patient’s aversive, aggressive, or grandiose behavior.

Therapeutic relationships

The therapeutic alliance is the key ingredient for effective nursing interventions across the continuum of mental health disorders. Therapeutic relationships are the living expression of the “art of nursing.” Nurses most skilled in therapeutic alliance building will be the first to admit that learning this skill is a lifelong process.

Therapeutic relationships help patients reach specific goals, including self-acceptance, improved self-esteem, better social relationships, and coping mechanisms. Nurses provide learning opportunities for patients through role modeling and maintaining open lines of communication. Communication with patients is facilitated by observing nonverbal signals and using specific techniques to improve the communication process, such as clarification and open-ended questions. Responsiveness to patients involves being genuine and demonstrating empathy. Bipolar patients, particularly during the manic phase, benefit most from clear and concrete expectations.

Impasses must be crossed in order to continue to build therapeutic alliances. Patients may exhibit defense mechanisms, such as transference reactions (where nurses remind them of people in their lives who provoke certain emotional reactions). It is essential to remember that patients’ behavior is a manifestation of their mental illness and not a personal attack. A therapeutic response often requires nurses to put individual feelings aside while remaining objective and reacting to patients’ ever-changing needs.

The psychopharmacologic artillery

Lithium carbonate, the classic anti-manic medication, acts by modulating intracellular signaling through the second-messenger system and by directly influencing intermembrane ions such as sodium.11 Since lithium is a salt and is excreted via the kidneys, before taking it patients must have adequate renal function confirmed. Patients older than 65 years may require reduced doses.
Lithium also requires careful monitoring due to its narrow therapeutic index of 0.5 to 1.5 mEq/L.11 Serum lithium levels higher than 1.5 mEq/L are considered toxic. Complications such as confusion, muscle hyperirritability, ECG changes, and muscle incoordination can develop at levels above 1.8 mEq/L. If the level continues to rise, the patient may experience seizures, arrhythmias, circulatory collapse, and death.

Even with these and other adverse effects at therapeutic levels, such as gastrointestinal upset, tremors, thirst, and weight gain, the lithium salt is
still the gold standard for treating bipolar disorder. Lithium treatment should be discontinued only when absolutely necessary and, even then, must be done gradually. A gradual reduction causes a much lower risk of relapse than abrupt discontinuation does. After discontinuation, the risk of suicide increases substantially, however, even possibly to the level it was before treatment began. This risk plus the drug’s narrow range of therapeutic dosing has led to the use of other types of medications for treating bipolar disorder.

The anticonvulsant class of medications is used because of the effect on ion channels. This action ultimately facilitates the inhibitory effects of GABA or decreases the excitatory effects of glutamate. One of the most commonly used drugs in this class is valproic acid. Therapeutic ranges (50 to 100 mcg/mL) must be maintained in order to maximize the effectiveness of the medication and minimize its potential for adverse effects. Adverse effects most often include weight gain, hair loss, elevated liver transaminases, cognitive dulling, and menstrual problems. Valproic acid can cause neural tube disorders in the developing fetus and is therefore contraindicated for use during pregnancy.

Atypical antipsychotic medications, such as olanzapine, quetiapine, and risperidone, demonstrate efficacy in treating the manic phase of bipolar disorder and are increasingly used in the manic and psychotic phases but also for maintenance regimens or as an adjunct to other medications. Atypical antipsychotic medications selectively block specific dopamine receptors and exert action at select serotonin receptors. Mood-stabilizing properties account for the positive results obtained in treating bipolar illness. When behavioral symptoms are not effectively controlled, antipsychotic medications are used in conjunction with other classes of medicines such as lithium or the anticonvulsants.11 Antipsychotic medicines produce side effects such as sedation and weight gain. Due to blockage of receptors in the dopamine tracts in the basal ganglia region of the brain, movement disorders, also called extrapyramidal symptoms, may develop. These include a flattened affect, akathisia (feeling of “inner restlessness;” a constant urge to be moving), or the most severe and relatively uncommon movement disorder, tardive dyskinesia (random movements in the tongue, lips, or jaw; facial grimacing; movements of arms, legs, fingers and toes; or even swaying movements of the trunk or hips). Neuroleptic malignant syndrome is an adverse reaction to antipsychotic medications and is a medical emergency due to the risk for brain damage and cardiovascular collapse.1

Where do we go from here?

The goal of inpatient nursing care for patients with bipolar disorder is primarily to restore pre-illness functioning. Outpatient psychotherapy and medication management with a psychiatric nurse practitioner can facilitate longer-term gains by teaching patients and families about expected results and potential adverse effects of prescribed medications. Patients taking lithium must have blood levels measured quarterly to make sure they remain within the therapeutic range. Over time when the levels remain stable, laboratory sampling can become less frequent.

Because lithium is a salt, patients must drink adequate amounts of non-caffeinated fluids to ensure that lithium levels do not rise due to fluid imbalance or hydration issues. Lithium can actually increase salt losses. Therefore, patients should eat a normal diet that includes salt and not use a salt substitute. They should prevent overheating during strenuous exercise, the use of sauna or hot tubs, and hot weather.1

In addition, nurses instruct patients with bipolar disorder to:

1. Take lithium extended-release tablets by mouth and follow the directions on the prescription label.
2. Swallow the tablets whole with water; do not break, crush or chew them.
3. Take lithium after a meal or snack to avoid stomach upset.
4. Take doses at regular intervals.
5. Avoid taking lithium more often than directed.
6. Avoid discontinuing the medicine unless the prescriber advises otherwise.
7. Notify the prescribing healthcare professional if surgery is scheduled.
8. Take a missed dose as soon as possible. If it is almost time for the next dose (less than 4 hours), take only that dose and do not take double or extra doses.

Living with mania

Patient education involves teaching about cognitive distortions and ways to reprogram the brain with positive internal messages.12 This cognitive-based approach has a high rate of success with mood disorders. Cognitive approaches work by empowering patients to gain a better understanding of how their errors in thinking affect their feelings and actions. Cognitive distortion assignments provided for patients help identify patterns in thinking that may cause personal and social distress. Patients can complete these assignments while they are in the hospital and review them with the nurse. This evidence-based treatment has been shown to improve outcomes for these patients.

Untreated bipolar illness can result in fatality rates as high as 50%. This is due to high-risk behavior that can result in unintentional death. The severity of the mood symptoms can also create the impetus for patients to commit suicide. Psychiatric nurse practitioners (APRNs) have the experience and training to prescribe medications that stabilize manic patients psychobiologically.13 APRNs also provide consistent psychotherapy and medication management. Psychotherapy that includes prodrome detection and relapse prevention strategies provide bipolar patients with greater chances of long-term success in managing their illness.