Introduction Bipolar disorder or manicdepressive disorder, also referred to as bipolar affective disorder or manic depression, is a psychiatric diagnosis that

describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or more depressive episodes. The elevated moods are clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes, or symptoms, or a mixed state in which features of both mania and depression are present at the same time. These events are usually separated by periods of "normal" mood; but, in some individuals, depression and mania may rapidly alternate, which is known as rapid cycling. Extreme manic episodes can sometimes lead to such psychotic symptoms as delusions and hallucinations. Definition Recurrent attack of both mania and depression, in the same patient at different time or this disorders characterized by mood distribution( in appropriate depression or elation) it is usually accompanied by the abnormalities in thinking and perception arising out of mood disturbances. Bipolar disorder is a condition in which people go back and forth between periods of a very good or irritable mood and depression. The "mood swings" between mania and depression can be very quick

Types of Bipolar Disorder:

Bipolar I disorder- People with bipolar disorder type I have

had at least one manic episode and periods of major depression. In the past, bipolar disorder type I was called manic depression.

Bipolar II disorder-People with bipolar disorder type II have

never had full mania. Instead they experience periods of high energy levels and impulsiveness that are not as extreme as mania (called hypomania). These periods alternate with episodes of depression.

Cyclothymic disorder- A mild form of bipolar disorder called

cyclothymia involves less severe mood swings. People with this form alternate between hypomania and mild depression. People with bipolar disorder type II or cyclothymia may be wrongly diagnosed as having depression. In most people with bipolar disorder, there is no clear cause for the manic or depressive episodes. The following may trigger a manic episode in people with bipolar disorder:

Life changes such as childbirth Medications such as antidepressants or steroids Periods of sleeplessness Recreational drug use

Mania It is a mood disturbance, which causes the person to have a severely abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression. Episodes of mania are generally associated with bipolar disorder, where episodes of mania may alternate with episodes of major depression. Gelder, Mayou and Geddes (2005) suggests that it is vital that mania is predicted in the early stages because the patient becomes reluctant to comply to the treatment. The criteria for bipolar do not include depressive episodes and the presence of mania in the absence of depressive episodes is sufficient for a diagnosis. Regardless, even those who never experience depression experience cyclical changes in mood. These cycles are often affected by changes in sleep cycle (too much or too little), diurnal rhythms and environmental stressors. Classification of Mania
o o o o o

Hypomania Mania Mania with psychotic symptoms Mania without psychotic symptoms Mania Associated disorders

Etiological factors Biological Neurotransmitters Endocrine system Family and genetics Sleep

Dysfunction

Woman & mood disorders Psychological Stressful life events

Behavioral factors Cognitive factors Psychodynamic

Social Support system Woman & mood disorders

PSYCHOPATHOLOGY 1. Biological Cause A. Neurotransmitter Alteration A.1 Increase Dopamine - Overproduction of dopamine causes the nerve circuits to misfire and create a split state in the mind where delusions and hallucinations make the reality of the outside world easier to accept A.2 Increase Serotonin level - An increase in serotonin levels indicates Mania / Manic in Bipolar Disorder. Because he has the three signs of mania which are Auditory Hallucinations, delusions and paranoia A.3 Decrease Serotonin Level - A decrease in serotonin levels indicates depression. He has the symptoms of depression like social withdrawal, low selfesteem and persistent sadness B. Genetic Predisposition B.1 Being Shy - He has the presence of the type A personality, which is inherently acquired thus he has poor IPR to others 2. Psychosocial Causes A. Development of Mistrust - It is according to Freuds Psycho-social theory. Presented by poor IPR to other people, unable to express feelings, lack of close friends, isolates self, social withdrawal B. Cultural Norms Because they have a close-knit family

C. Traumatic Experience C.1 Separation from family member - Being alone and independent in an area that is unfamiliar C.2 Death of his Sister - As presented by Long term depression C.3 Living alone for several years - As manifested by anxiety and fear D. Use of Defense Mechanism -Ineffective use of Denial as manifested by unrealistic perception of the situation

Symptoms The manic phase may last from days to months. It can include the following symptoms:

Easily distracted Little need for sleep Poor judgment Poor temper control Reckless behavior and lack of self-control

Binge eating, drinking, and/or drug use Poor judgment Sex with many partners (promiscuity) Spending sprees Excess activity (hyperactivity) Increased energy Racing thoughts Talking a lot Very high self-esteem (false beliefs about self or

Very elevated mood

abilities)

Very involved in activities Very upset (agitated or irritated)

These symptoms of mania occur with bipolar disorder I. In people with bipolar disorder II, the symptoms of mania are similar but less intense.

Symptoms of mania or a manic episode include: According to Book Mood Changes A long period of feeling "high," or an overly happy or outgoing mood Extremely irritable mood, agitation, feeling "jumpy" or "wired." Behavioral Changes

According to Patient Irritable mood Headache Body ache Chest pain Insomnia Hyperactivity

Talking very fast, jumping from one idea to another, having racing thoughts Being easily distracted Increasing goal-directed activities, such as taking on new projects Being restless Sleeping little Having an unrealistic belief in one's abilities Behaving impulsively and taking part in a lot of pleasurable, high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments.

Diagnostic Finding According to Patient History taking o Mental status examination Hematological test o WBCs-5,900 mm3 o Hb-11.5gm/dl o Platelets- 60,000 o Differential Count Neutrophil- 60% Lymphocyte-40% Monocytes- 0%

According to Book History taking Radiological examination o Skull X-Ray

o o

Computed Tomography (CT) Scan Magnetic (MRI) Resonance Imaging

Electroencephalography (EEG) Psychological Assessment Physical Investigation o Routine TC DC

Esinophil-0%

Basophil 0%

Hemoglobin,

Urine analysis, liver function test o Non- Routine Thyroid Function Test

Medical Management According to Book 1) Pharmacological Management Mood Stabilizing Agents e.g. Lithium, Valproic Acid, Carbamazepine, Antipsychotic Medications 1st Generation Medications Chlorpromazine, Thioridazine, Haloperidol, Fluphenazine 2nd Generation Medications Clozapine, Risperidone, Olanzapine, Quetiapine, Ziprasidone 3rd Generation Medications Aripiprazole
2)
3)

According to Patient 1) Pharmacological Management a. Tab. Sodium Valporate 500mg- BD b. Haloparidol 5mg-TDS c. Olanzapine-5mg-SOS d. Atenolol 5mg-TDS 2) Psychosocial Therapy
a.

Individual Family Psychotherapy Group Psychotherapy

Psychotherapy b.
c.

Electroconvulsive Therapy Psychosocial Therapy

Cognitive behavior therapy Interpersonal therapy Psychoanalytic psychotherapy Behavior therapy Group therapy Family and maternal therapy

Nursing Intervention Assess clients perception of self and situation. Note use of defense mechanism. Observe/ listen for early clues of distress/ increasing anxiety. Ask directly if the person is thinking of acting on thoughts/ feelings. Develop and maintain therapeutic nurse-client relationship. Make time to listen to expressions of feelings. Acknowledge reality of clients feelings. Approach in positive manner, acting as if the client has control and is responsible for own behavior. Give positive reinforcement for clients efforts. Maintain calm, matter- of-fact, non- judgemental attitude. Provide a safe/ quiet environment and remove items from the clients environment that could be use to inflict harm to others. Encourage walking or exercise as activities that may diffuse aggression Note concomitant medical and psychological problem that may be factors for care. Identify degree of individual impairment or functional level. Perform/ assist with meeting clients needs when she is unable to meet own needs. Develop plan of care appropriate to individual situation. Plan time for listening to the clients concerns.

 Provide for communication among those who are involved in caring. Provide privacy and equipment within easy reach during personal care activities. Support client in making health related decisions and assist in developing self- care practices that promote health. Impart health teachings about self-care and emphasize the importance of it.

Symptom chart S.N. DATE/SYMPTOM 2068/03/13 1 PSYCHOLOGICAL Agitation Amotivation Insomnia Poor attention, concentration, Drowsiness, 2 Dizziness PHYSICAL Headache Dry mouth Muscle cramping Burning sensation Chest pain Abdominal pain 2068/03/14 2068/03/15

Mood chart DATES AND DAY/ MOOD 2068/03/13 OF THE PATIENT 2068/03/13 2068/03/13

DEPRESSED

EUTHYMIC

EUPHORIC