Bipolar Affective Disorder, previously known as manic-depressive illness (MDI), is a significant and enduring mental health condition. It presents a considerable, lifelong challenge for individuals affected by it.

Bipolar affective disorder is defined as a mental health condition distinguished by notable shifts in mood. These mood alterations range from periods of profoundly low and sustained sadness (major depression) to episodes of extreme elation and elevated mood (mania), with periods of relatively stable mood occurring in between.

The frequency of these mood episodes can vary significantly, occurring infrequently for some individuals or multiple times within a single year for others. While some individuals may experience residual emotional symptoms between distinct episodes, others might return to a baseline mood state without any noticeable lingering symptoms.

Bipolar disorder can be categorized into three primary types:

• Mixed Bipolar Disorder: Characterized by the simultaneous or rapid alternation of both manic and depressive episodes. Individuals may experience symptoms of both poles of the disorder concurrently.

• Manic Bipolar Disorder: Marked by a predominant elevation in mood, which can manifest as intense elation or heightened irritability. This type often includes excessive physical activity and may involve overt psychotic features, such as delusions or hallucinations.

• Depressed Bipolar Disorder: The primary symptoms are those characteristic of major depression. A crucial diagnostic criterion is a documented history of at least one prior manic episode, distinguishing it from unipolar depression.

Symptoms of Bipolar Affective Disorder

The specific symptoms of bipolar disorder can be diverse, varying significantly from person to person and fluctuating over time depending on the current mood phase of the individual.

Manic Episode

A manic episode is characterized by a distinct period of at least one week during which there is a significantly elevated, expansive, or irritable mood, accompanied by markedly increased activity or energy. To meet the diagnostic criteria for mania, at least three of the following symptoms must be persistently present and represent a noticeable change from usual behavior:

• Grandiosity: An inflated sense of self-esteem or exaggerated beliefs about one’s abilities, importance, power, or knowledge.

• Increased Energy and Activity (Boundless Energy): A marked increase in goal-directed activity or psychomotor agitation. Individuals may exhibit relentless energy and drive, often beyond what is typical for them.

• Exaggerated Sense of Well-being and Self-Confidence (Euphoria): A feeling of intense happiness, excitement, and optimism that is disproportionate to the circumstances.

• Decreased Need for Sleep: A reduced need for sleep without feeling tired. Individuals may feel rested after only a few hours of sleep or even go without sleep for extended periods.

• Unusual Talkativeness (Pressured Speech): Speaking more than usual or feeling compelled to keep talking. Speech may be rapid, loud, and difficult to interrupt.

• Racing Thoughts or Flight of Ideas: Subjective experience that thoughts are racing, or abruptly jumping from one topic to another.

• Distractibility: Attention is easily diverted to unimportant or irrelevant external stimuli.

• Poor Decision Making: Engaging in activities that have a high potential for painful consequences, such as impulsive spending sprees, risky sexual encounters, or unwise business investments, without considering the potential negative outcomes.

Hypomanic Episode

A hypomanic episode is distinguished by an elevated, expansive, or irritable mood lasting for at least four consecutive days. Similar to mania, the diagnosis of hypomania requires the presence of at least three of the symptoms listed for mania. The key difference is that in hypomania, the symptoms, while noticeable and representing a clear change in functioning, are not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. Psychotic features are also absent in hypomania.

Depressive Episode

A major depressive episode is characterized by experiencing five or more of the following symptoms during the same 2-week period, with at least one of the symptoms being either depressed mood or loss of interest or pleasure. These symptoms represent a significant change from previous functioning:

• Depressed Mood: Persistent feelings of sadness, emptiness, hopelessness, or tearfulness. In children and adolescents, this may manifest more as persistent irritability than overt sadness.

• Marked Loss of Interest or Pleasure (Anhedonia): Significantly reduced interest or feeling of no pleasure in almost all activities that were previously enjoyed.

• Significant Weight Loss or Weight Gain: Noticeable change in weight (typically weight loss) when not dieting, or decrease or increase in appetite.

• Psychomotor Retardation or Agitation: Observable slowing down of thought and physical movement (retardation) or restlessness and an inability to sit still (agitation).

• Insomnia or Hypersomnia: Disturbed sleep patterns, either difficulty falling asleep or staying asleep (insomnia) or excessive sleepiness (hypersomnia).

• Fatigue or Loss of Energy: Persistent feelings of tiredness or lack of energy.

• Feelings of Worthlessness or Excessive or Inappropriate Guilt: Feelings of low self-worth, hopelessness, or excessive or inappropriate guilt, which may be delusional.

• Decreased Ability to Think or Concentrate: Diminished ability to think clearly, concentrate, or make decisions.

• Recurrent Thoughts of Death or Suicide: Recurrent thoughts of death (not just fear of dying), suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Melancholia

Melancholia is a subtype specifier for depression, often used to describe a particularly severe form of depression that is not triggered by an identifiable stressful life event. It is characterized by a distinct set of symptoms, including profound sadness, anhedonia, early morning awakening, and significant weight loss.

Management of Bipolar Affective Disorder

The approach to managing bipolar affective disorder is highly dependent on the current phase of the illness (mania, depression, or mixed state) and the severity of the symptoms being experienced. Treatment strategies are tailored to address the specific mood episode and to prevent future episodes.

MANIA

Mania is a clinical state characterized by an abnormally elevated or irritable mood, often accompanied by increased energy levels and activity. It represents a distinct phase within bipolar disorder, marked by a range of behavioral and psychological changes.

Mania is often described as a state of mind characterized by:

• Cheerfulness, and an exaggerated sense of well-being (euphoria).

• A mood that can rapidly shift to irritability, particularly when the individual’s wishes are not immediately met or when faced with limitations.

Types of Mania

Mania can be categorized based on severity and presentation:

• Hypomania: A milder form of mania, characterized by elevated mood and increased energy, but without significant impairment in functioning or psychotic features.

• Acute Mania: Represents a more severe and pronounced form of mania, often requiring intensive intervention and potentially hospitalization due to the intensity of symptoms and potential for risky behaviors.

• Delirious Mania: A severe and less common form of mania characterized by significant confusion, disorientation, and impaired cognitive function, often seen in the context of organic psychoses or underlying medical conditions.

• Chronic Mania: Refers to a persistent manic state that has been present for an extended period and has proven resistant to various treatment approaches. This form is more commonly observed in individuals over 40 and may represent treatment-resistant bipolar disorder.

CAUSES OF MANIA

The precise causes of mania, like bipolar disorder itself, are multifactorial and not fully understood. However, several factors are believed to contribute to its development:

1. Genetic Factors: There is a strong genetic component to bipolar disorder, and mania is considered to have a hereditary element, often running in families.

2. Neurochemical Imbalances:

   • Increased Noradrenaline Metabolites: Elevated levels of metabolites of noradrenaline (norepinephrine) in the brain are implicated in manic states.

   • Serotonin Imbalances: Dysregulation or imbalances in serotonin neurotransmitter levels in the brain are also believed to play a role in mania.

   • Increased Dopamine Levels: Elevated dopamine neurotransmitter activity is another neurochemical factor associated with manic episodes.

3. Cyclothymic Personality Traits: Individuals with a cyclothymic personality, characterized by naturally occurring mood swings, may have an increased predisposition to developing manic illness.

4. Body Physique (Less Supported): Historically, some theories linked body physique to mental illness, but this is not a current or widely accepted etiological factor for mania.

5. Psychosocial Factors: Stressful life events and psychosocial stressors, such as divorce, bereavement, job loss, or significant life changes, can act as triggers for manic episodes in susceptible individuals.

Clinical Features of Mania

The clinical presentation of mania encompasses a range of characteristic symptoms:

• Elevated Mood (Euphoria or Irritability): A persistently elevated, expansive, or irritable mood is a core feature. While euphoria (intense happiness) is common, irritability, particularly when demands are not met, is equally characteristic.

• Greatly Increased Energy (Boundless Energy): Individuals experience a significant surge in energy levels, feeling tireless and driven, often engaging in excessive activity without fatigue.

• Restlessness and Overactivity: Marked psychomotor agitation, with an inability to sit still, constant movement, pacing, and restlessness.

• Poor Concentration and Distractibility: Difficulty focusing attention and easily diverted by irrelevant stimuli, leading to impaired concentration and task completion.

• Increased Appetite but Neglect of Eating: Paradoxically, while appetite for food and drinks may be increased, individuals often neglect eating due to hyperactivity and lack of focus, potentially leading to weight loss and nutritional deficits.

• Increased Sexual Urge (High Libido): Elevated libido and increased interest in sexual activity are common.

• Excessive Involvement in Pleasurable Activities: Engaging in activities that are inherently pleasurable but have a high potential for negative consequences, such as excessive spending, reckless driving, or risky sexual behaviors.

• Inappropriate and Theatrical Dressing: Clothing choices may be unusual, flamboyant, and socially inappropriate, often involving bright, clashing colors, excessive makeup, and jewelry.

• Delusions of Grandeur: Exaggerated beliefs about one’s own importance, abilities, or identity, often reaching delusional proportions.

• Over-talkativeness and Pressured Speech: Speech is rapid, loud, and incessant, with an inability to be interrupted. In acute mania, this pressured speech is particularly pronounced.

• Racing Thoughts (Accelerated Thinking): Subjective experience of thoughts racing through the mind at an accelerated pace, often described as “racing thoughts.” Speech reflects this accelerated thinking pattern.

• Loss of Insight: Impaired awareness of the illness and its symptoms. Individuals often lack insight into their abnormal behavior and may deny they are ill or need treatment.

• Disturbed Sleep or Insomnia: Sleep patterns are significantly disrupted, ranging from reduced need for sleep to complete insomnia (total inability to sleep).

• Auditory Hallucinations: Hearing voices or other sounds in the absence of external stimuli is a common psychotic symptom in mania.

• Ideas of Reference: The false belief that irrelevant occurrences or remarks in the external world have direct personal meaning or significance, often of a negative or persecutory nature (e.g., feeling that people are talking about them specifically).

Diagnosis of Mania

The diagnosis of mania is based on a constellation of clinical features. Key diagnostic criteria include:

1. Abnormally Elevated Mood and Irritability: A sustained period of elevated, expansive, or predominantly irritable mood, representing a clear departure from the person’s typical mood state.

2. Grandiosity (Overrating One’s Self): Inflated self-esteem or grandiose ideation, which may range from inflated self-confidence to frankly delusional beliefs of superiority.

3. Boundless Energy: Markedly increased energy and activity levels, often exceeding what is normal for the individual.

4. Overactivity: Psychomotor agitation, restlessness, and excessive involvement in goal-directed activities.

5. Over-talkativeness (Pressured Speech): Rapid, pressured, and excessive speech that is difficult to interrupt.

6. Racing Thoughts: Subjective experience of racing thoughts, or flight of ideas, where thoughts jump rapidly from topic to topic.

7. Poor Concentration and Distractibility: Easily distracted by extraneous or irrelevant stimuli, with impaired ability to focus or sustain attention.

Management of Mania

Management strategies for mania depend on the severity of symptoms and the individual’s overall clinical presentation.

Hypomania, if symptoms are mild and the individual is cooperative, may sometimes be managed in an outpatient setting, particularly if there is reliable support at home to ensure medication adherence.

1. Hospitalization: In cases of acute mania, hospitalization in a psychiatric facility is often essential, particularly if the patient is:

   • Severely agitated or exhibiting uncontrolled excitement.

   • Engaging in publicly disruptive or inappropriate behavior.

   • Neglecting self-care needs, including nutrition and hygiene.

   • At risk of harming themselves or others.

2. Establishment of Therapeutic Relationship: Developing a strong and trusting therapeutic relationship with the patient is paramount. This relationship forms the foundation for effective nursing care and all other interventions.

3. Pharmacological Intervention for Agitation: If the patient is acutely agitated, restless, and cannot be calmed through verbal de-escalation techniques, rapid tranquilization may be necessary. Injectable antipsychotics or sedatives, such as chlorpromazine (100-200mg IM) or haloperidol (5-10mg IM), may be administered to rapidly reduce agitation and promote calmness.

4. Dosage Adjustment: As the manic symptoms begin to subside, the dosage and frequency of medication administration should be gradually reduced under medical supervision to minimize side effects and promote stabilization.

5. Clear and Concise Communication: When interacting with a manic patient, communication should be clear, simple, and direct. When answering questions, provide short, straightforward responses, avoiding lengthy or complex explanations.

6. Stimulus Reduction: Create a low-stimulus environment for the patient. Minimize environmental stimulation, such as excessive noise, bright lights, and crowded spaces, to reduce agitation and promote calmness.

7. Safety Measures – Environmental Hazard Removal: Ensure a safe environment by removing any potentially dangerous objects from the patient’s surroundings. This includes items that could be used for self-harm or to harm others, such as sharp objects, heavy or easily portable objects, and items that could be used to create ligatures.

8. Hygiene Supervision and Assistance: Closely supervise and assist the patient with maintaining personal hygiene. Due to hyperactivity and distractibility, manic individuals may neglect basic hygiene practices. Provide reminders and assistance with bathing, dressing, and oral hygiene.

9. Nutritional Support: Pay special attention to the patient’s nutritional needs. Manic individuals are often too active and distractible to eat adequately, leading to weight loss and potential dehydration. Encourage and supervise food and fluid intake. Offer a diet rich in carbohydrates and proteins, along with ample fluids, to meet increased metabolic demands. Supervise meal times to ensure adequate intake.

10. Behavioral Monitoring: Closely observe and document the patient’s behavior patterns, including toilet habits, eating patterns, sleep-wake cycles, and any changes in mood or activity levels. This ongoing observation is crucial for assessing treatment progress and identifying any emerging needs or complications.

DRUG TREATMENT

Pharmacological interventions are central to managing manic symptoms and stabilizing mood in bipolar disorder.

• Antipsychotics: To rapidly control acute manic symptoms, antipsychotic medications are often used. Examples include:

  • Chlorpromazine (CPZ): Dosages typically range from 100-1200mg daily, administered in divided doses. As the patient’s condition improves, the dosage is gradually reduced.

  • Thioridazine: Effective at dosages of 100-600mg daily in divided doses. Thioridazine may also have a libido-reducing effect, which can be beneficial in managing hypersexuality sometimes seen in mania.

  • Haloperidol: Often used in dosages of 5-15mg, usually administered at night (nocte), primarily for short-term management of acute agitation.

• Mood Stabilizers:

  • Lithium Carbonate: Lithium is considered the gold standard mood stabilizer and is often the drug of choice for long-term management of bipolar disorder, particularly the manic phase. Typical dosages range from 250-550mg, with careful monitoring of serum lithium levels to maintain therapeutic efficacy and avoid toxicity.

• Benzodiazepines: While primarily anxiolytics, certain benzodiazepines may be used adjunctively in mania to manage agitation and promote sleep in the acute phase. Benzhexol (Artane) mentioned in the original text is not typically used for mania; it is an anticholinergic medication used to treat extrapyramidal side effects of antipsychotics.

• Anticonvulsants with Mood-Stabilizing Properties: Certain anticonvulsant medications are also effective mood stabilizers and are used in bipolar disorder management:

  • Carbamazepine: Dosages range from 100-400mg daily, administered in divided doses.

  • Sodium Valproate (Valproic Acid): Dosages typically range from 100-1500mg daily, often given as divalproex sodium or sodium valproate formulations.

ELECTROCONVULSIVE THERAPY (ECT)

Electroconvulsive therapy (ECT) is a highly effective treatment option, particularly for severe manic excitement or when rapid symptom control is needed. It is often considered in cases of treatment-resistant mania or when medication is contraindicated. Typically, a course of ECT involves 1 or 2 treatments per week for a total of 6-9 weeks. ECT is often most effective when used in combination with pharmacological agents.

OCCUPATIONAL THERAPY (OT)

Occupational therapy plays a vital role in the rehabilitation and recovery process for individuals with bipolar disorder, particularly after a manic episode. The specific occupational therapy interventions are tailored to the individual patient’s needs and capabilities. Occupational therapy aims to help patients regain functional skills, re-establish daily routines, and reintegrate into social and occupational roles.

PSYCHOTHERAPY

Family-focused psychotherapy is highly beneficial for families affected by bipolar disorder. Psychoeducation for families can improve understanding of the illness, enhance communication, and promote effective coping strategies within the family system.

RESETTLEMENT AND FOLLOW-UP

A structured resettlement plan and a robust follow-up system are crucial components of comprehensive care. These elements help ensure continuity of care, medication adherence, early detection of relapse, and ongoing support for the individual’s long-term recovery and well-being in the community.

Nursing Care of Manic Patients

Nursing care for manic patients is multifaceted and focuses on safety, symptom management, and support:

• Dietary Management: Special attention must be given to the patient’s diet. Manic patients are often too preoccupied with activity to eat adequately, which can lead to weight loss and dehydration.

  • Meals and fluids should be offered and encouraged under supervision.

  • Provide extra nourishment and snacks to compensate for increased energy expenditure due to hyperactivity.

  • Ensure adequate hydration to prevent dehydration.

• Hygiene and Self-Care: Manic patients may neglect personal hygiene.

  • Ensure the patient dresses appropriately for the setting and weather.

  • Provide supervision and direction to maintain personal hygiene, including assistance with bathing and oral hygiene, as needed.

• Therapeutic Nurse-Patient Relationship:

  • Assign one consistent nurse to care for the overactive patient. This helps build trust and rapport, which is crucial for effective therapeutic interventions.

  • A consistent nurse can provide a stable and predictable presence in the patient’s often chaotic experience.

• Environmental Stimulus Control:

  • Maintain a low level of environmental stimuli.

  • Minimize noise levels and avoid overly bright colors in the ward environment.

  • Create a quiet and pleasant ward atmosphere to promote calmness and reduce agitation.

• Behavioral Observation:

  • Frequently observe and monitor the patient’s behavior.

  • Report any changes in behavior, mood, activity levels, or symptom presentation to the healthcare team promptly.

• Safety and Hazard Removal:

  • Remove any dangerous objects from the patient’s environment to prevent self-harm or harm to others during periods of agitation or impulsivity.

• Injury Management:

  • Attend to any injuries the patient may sustain as a result of hyperactivity or impulsive actions. Provide appropriate first aid and medical care for injuries.

Prognosis

• With effective treatment, most manic episodes typically resolve within a period of three months and rarely persist for more than six months.

• The risk of recurrence of bipolar episodes is higher if the disorder begins before the age of 30.

• Research suggests that a significant proportion (10-20%) of individuals who develop mania have experienced several (typically 3 or more) depressive episodes prior to the onset of mania.

• In general, the long-term prognosis for mania is considered more favorable compared to that of schizophrenia, with many individuals achieving significant symptom remission and functional recovery with appropriate ongoing management.