^{<h3>Introduction</h3>}

<br/>Bipolar affective disorder (BD) is one of the most frequently diagnosed [1] and, at the same time, one of the most severe mental disorders within the group of mood disorders. It is characterized by alternating episodes of depression, mania, or hypomania, as well as mixed episodes in which depressive and manic symptoms appear simultaneously. The disorder follows a chronic and recurrent course, most often beginning in late adolescence or early adulthood. According to epidemiological data from the World Health Organization, the prevalence of BD in the general population is 1-2% [2, 3], meaning that millions of people worldwide struggle with this condition. It is estimated that in Poland, several hundred thousand patients are affected. These rates may be higher, as many individuals remain undiagnosed, and in numerous cases, the first depressive episode is mistakenly classified as unipolar depression [4].

<br/>The health and social consequences of BD are substantial. The disorder is associated with significant impairment in quality of life, difficulties in family and occupational functioning, increased work absenteeism, and loss of employability. For many patients, it leads to disability and dependence on social support. BD is also one of the main risk factors for suicide: studies indicate that 15-20% of patients attempt suicide, and approximately 10% die as a result. The economic burden of the illness is considerable, both for patients and their families as well as for the healthcare system, encompassing hospitalization costs, outpatient treatment, pharmacotherapy, and loss of occupational productivity.

<br/>The etiology of BD is complex and involves an interaction of genetic, biological, and psychosocial factors. Family, adoption, and twin studies demonstrate that heredity plays a crucial role: the risk of illness in first-degree relatives is up to ten times higher than in the general population. From a neurobiological perspective, disturbances in neurotransmission [5], particularly of serotonin, dopamine, and norepinephrine, are significant. There is also evidence of dysfunction in the hypothalamic-pituitary-adrenal axis and circadian rhythm disturbances, which explain patients’ difficulties with sleep and daily activity regulation. Psychosocial factors are also important: chronic stress, traumatic life experiences, family conflicts, and addictions may initiate and exacerbate the course of the disorder.

<br/>Diagnosing BD can be challenging. According to DSM-5 and ICD-10/ICD-11 classifications [6, 7], diagnosis requires the occurrence of at least one manic or hypomanic episode, in addition to depressive episodes. However, in clinical practice, many patients experience an initial depressive episode, leading to misdiagnosis as unipolar depression and a delay in initiating appropriate mood-stabilizing treatment. Differentiation from other affective disorders and personality disorders requires detailed observation and clinical experience [8-11].

<br/>A particular diagnostic and therapeutic challenge is the coexistence of BD with other mental disorders. The most common comorbidities include anxiety disorders, alcohol and other substance use disorders, as well as obsessive-compulsive disorder (OCD). It is estimated that obsessive-compulsive symptoms occur in 15-20% of BD patients. Obsessions may mask affective symptoms, while compulsions significantly reduce the ability to function socially and within the family. The presence of OCD in BD patients increases anxiety, prolongs hospital stays, worsens prognosis, and complicates pharmacological treatment, as some medications effective in OCD may exacerbate affective symptoms. Such patients are also more likely to experience social isolation, feelings of shame, and stigmatization [12, 13].

<br/>The treatment of BD requires a comprehensive approach. The foundation of pharmacotherapy includes mood stabilizers [14] such as lithium, valproate, or lamotrigine, as well as atypical antipsychotics. Antidepressants are used in selected cases but must be prescribed with caution to avoid inducing a manic episode. Complementary to pharmacotherapy are psychotherapy, psychoeducation, and psychosocial support. Psychoeducation of patients and their families is particularly important, as it enables better understanding of the disorder, adherence to therapeutic recommendations, and more effective coping with relapses. The coexistence of OCD requires individualized therapy and close collaboration within the therapeutic team, which includes a psychiatrist, psychologist, occupational therapist, and psychiatric nurse [15].

<br/>The role of the psychiatric nurse in the care of patients with BD is fundamental [16]. Their responsibilities include not only observing the patient and monitoring symptoms but also ensuring safety in crisis situations, providing emotional support, motivating activity, and conducting psychoeducation. The nurse constitutes a key link in communication between the patient and the therapeutic team. Daily contact enables rapid response to deterioration in the patient’s mental state, strengthening the sense of security, and supporting the patient in coping with limitations caused by the illness. Moreover, nurses play an educational role for the patient’s family, helping them to better understand the nature of the disorder and participate in the treatment process.

<br/>A holistic approach to the care of patients with BD, especially when OCD is comorbid, is essential for improving quality of life, reducing hospitalizations, and increasing treatment effectiveness. Modern psychiatric nursing, based on models such as the International Classification for Nursing Practice (ICNP), allows for systematic identification of patient problems, planning of interventions, and evaluation of their effectiveness, which is a crucial element of interdisciplinary psychiatric care [17].

<br/>The aim of this paper was to present in detail the case of a female patient hospitalized due to BD coexisting with OCD. The intention was not only to illustrate the clinical picture of the disorder and its impact on the patient’s psychological, somatic, and social functioning, but also to analyze the diagnostic and therapeutic challenges resulting from the presence of comorbidity.

<br/>Another important objective of the study was to present the specific nursing problems identified in the patient, as well as the developed nursing care plan based on the ICNP. This approach aimed to emphasize the practical significance of a systematic and structured method in the nursing process.

<br/>Another goal was to highlight the importance of interdisciplinary collaboration within the therapeutic team – psychiatrist, psychologist, psychiatric nurse, occupational therapist, and social worker – in the comprehensive treatment of BD patients. The case analysis was intended to demonstrate how integrated actions can improve patient safety, therapeutic effectiveness, quality of life, and prognosis.

<br/>The study also had an educational dimension – its purpose was to draw attention to the role of the psychiatric nurse in the treatment process, including responsibilities related to patient observation, emotional support, psychoeducation for both the patient and family, and prevention of relapse. Furthermore, the paper represents an attempt to contribute to the development of nursing literature by demonstrating the potential for practical application of the ICNP in psychiatric nursing care.

<h3>Methods</h3>

<br/>The study was based on the case of a 48-year-old female patient, A.O., hospitalized in the affective disorders ward due to intensification of depressive symptoms and coexisting OCD. The analysis included the patient’s complete medical records, covering medical history, laboratory and imaging results, and hospitalization course notes. Additionally, sources of data included systematic nursing observations conducted during the patient’s hospital stay, a detailed interview with the patient, as well as conversations with family members that provided information regarding social and family background, treatment history, and the patient’s functioning in the home environment.

<br/>The applied research method was a case study, enabling a detailed, multifaceted analysis of an individual clinical situation. This method allows for a deep understanding of the disease course, identification of health and nursing problems, and evaluation of the effectiveness of interventions undertaken. In this paper, the case study was used not only as a tool for presenting a specific patient but also as a form of reflection on nursing practice and interdisciplinary therapeutic collaboration.

<br/>The collected data were subjected to qualitative analysis, considering current diagnostic and therapeutic guidelines as well as established standards of nursing care in psychiatry. The development of the nursing care plan was carried out using the ICNP, which allowed for the systematization of identified problems and precise formulation of objectives and interventions.

<br/>All ethical principles were respected: the patient’s full anonymity was ensured, and personal data or details enabling identification were omitted or modified. Informed consent was obtained from the patient for the use of clinical information for scientific and educational purposes, with particular attention given to protecting her dignity and privacy.

<h3>Case report</h3>

<br/>The patient, a 48-year-old woman, was admitted to the affective disorders ward due to severe depressive and obsessive-compulsive symptoms. The first symptoms of affective disorder had appeared at the age of 25, initially in the form of a depressive episode. In the course of her illness, she had undergone more than a dozen psychiatric hospitalizations, including for manic and mixed episodes. The patient lives alone, is supported by a disability pension, has secondary education, and is not in a permanent relationship. Family contacts are limited.

<br/>According to the interview, the patient had been experiencing deterioration of her mental well-being for several months – she reported low mood, anhedonia, lack of energy, concentration difficulties, and a sense of meaninglessness of life. Additionally, severe obsessive–compulsive symptoms emerged in the form of intrusive thoughts concerning contamination and repetitive compulsions, such as frequent hand washing and avoidance of meals due to fear of poisoning. These symptoms led to a significant reduction in body weight – with a height of 166 cm, she weighed 40.5 kg (BMI ≈ 14). Somatic examination revealed irritation and redness of the skin on her hands, caused by frequent use of detergents. The patient admitted to having experienced passive resignation thoughts as well as suicidal ideation, though without current plans.

<br/>Her medical records indicated previous pharmacological treatment including mood stabilizers and atypical antipsychotics. During the present hospitalization, olanzapine was introduced at a dose of 10 mg/day. Due to underweight and exhaustion, dietary care and internal medicine consultation were also implemented.

<br/>At admission, the patient was in moderate general condition, conscious, and oriented to place and time; however, her mood was clearly depressed. She complained of sleep difficulties, frequent night awakenings, and a sense of anxiety worsening in the evenings. In the suicide risk assessment, she was classified as high risk, justifying the need for close safety monitoring.

<br/>During the first days of hospitalization, observation of mental status was conducted, and psychoeducation was initiated regarding symptoms of the disorder and the importance of pharmacotherapy. The psychiatric nurse provided emotional support, encouraged the patient to undertake basic self-care activities, and organized assistance in maintaining personal hygiene. Due to significant self-care deficits, the patient was accompanied during meals and supported in maintaining a circadian rhythm.

<br/>In the following days, activation exercises in the form of simple group activities were initiated, which the patient was initially reluctant to participate in. With the support of the staff and gradual motivation, she attempted to join therapeutic activities, which had a positive effect on her mood. The patient’s family was also educated regarding the necessity of supporting her after discharge, with particular emphasis on monitoring medication intake and responding early to signs of relapse.

<br/>After approximately three weeks of hospitalization, partial improvement in mental status was observed: decreased severity of obsessive-compulsive symptoms, better sleep regulation, weight gain of 1.5 kg, and increased motivation to cooperate with the staff. The patient still required emotional support, but her daily functioning had significantly improved.

<br/>Before discharge, the patient was provided with education on further pharmacological treatment, the importance of regular medication adherence, sleep hygiene, stress management strategies, and the necessity of maintaining contact with a mental health outpatient clinic. She also received educational materials to reinforce the knowledge acquired.

<h3>Nursing care plan</h3>

<br/>The individualized nursing care plan was developed based on the ICNP, which enabled the systematization of nursing diagnoses and interventions and ensured a holistic approach to the patient. The use of ICNP allows not only for the precise identification of health problems but also for the standardization of terminology, which is crucial for medical documentation and interdisciplinary team collaboration.

<br/>The plan was created based on a multifaceted analysis, including the patient’s medical records, systematic nursing observations, interviews with the patient, and conversations with her family. The collected information allowed for the identification of the most important nursing problems, such as depressed mood, increased anxiety, deficits in self-care, sleep disturbances, and risk of self-harm. Particular attention was paid to the presence of obsessive-compulsive symptoms, which significantly influenced the patient’s behavior and hindered the performance of daily activities.

<br/>Additionally, the nursing process was enriched with elements of the International Classification of Functioning, Disability and Health (ICF), which enabled a comprehensive assessment of the patient’s functioning in the context of daily activities, social participation, and limitations resulting from the illness. The integration of the ICNP with the ICF made it possible not only to identify health problems but also to assess their impact on the patient’s ability to function in different life roles.

<br/>The patient’s ability for self-care was assessed using the Activities of Daily Living (ADL) scale. This tool made it possible to identify areas requiring support, such as personal hygiene, eating, dressing, and mobility (Table 1). The results of the assessment revealed the patient’s moderate dependence on staff assistance, which served as the starting point for the development of individualized interventions.

<br/>At the same time, due to the presence of severe anxiety and depressive symptoms, a subjective scale for assessing the severity of somatic and psychological symptoms was applied (Table 2). This 11-point scale (0-10), adapted to psychiatric care conditions, makes it possible to continuously monitor the severity of anxiety, depressed mood, sleep disturbances, somatic discomfort, and obsessive-compulsive symptoms. The obtained results indicated predominance of psychological difficulties, with very severe depressed mood (9/10), severe anxiety (8/10), and severe obsessive-compulsive symptoms (8/10). Sleep disturbances were assessed as significant (7/10), while somatic discomfort such as pain and fatigue reached only a moderate level (5/10). Such results demonstrate that emotional and cognitive symptoms were more burdensome for the patient than physical ones, with sleep disorders playing an important role in sustaining and aggravating the overall clinical picture. The assessment outcomes formed the basis for targeted nursing and therapeutic interventions, including psychoeducation on sleep hygiene, emotional support, relaxation training, and activation exercises adjusted to the patient’s functional capacity.

<br/>Because of the above analyses, a care plan was prepared that included a set of nursing diagnoses and interventions using ICNP terminology (Table 3). These included interventions such as safety monitoring, supporting the patient in self-care, building a therapeutic relationship, and psychoeducational activities aimed at both the patient and her family.

<br/>In addition, the plan was supplemented with ICF-based diagnoses (Table 4), which allowed for consideration of the patient’s functioning in a broader context – both in terms of self-care and coping with stress. As a result, the care plan acquired a comprehensive character, covering not only current nursing needs but also long-term therapeutic goals related to improving quality of life, increasing independence, and supporting the process of social reintegration.

<h3>Discussion</h3>

<br/>The presented case illustrates the complexity of the clinical picture of BD coexisting with OCD. The literature emphasizes that the comorbidity of BD and OCD occurs in approximately 15-20% of patients, which significantly complicates both diagnosis and treatment. The presence of obsessive–compulsive symptoms leads to prolonged depressive episodes, greater resistance to pharmacological treatment, and more frequent hospitalizations. Patients with comorbid OCD also demonstrate higher levels of anxiety, which markedly affects their social, family, and occupational functioning. Consequently, the risk of social isolation, stigmatization, and non-adherence to therapeutic recommendations increases [3, 6].

<br/>In the present case, obsessive-compulsive symptoms further intensified anxiety and low mood, which consequently reduced the patient’s motivation to engage in activity and self-care. The literature indicates that BD comorbid with OCD may result in a more severe course of illness, greater risk of self-harm, and poorer prognosis. Therefore, early recognition and implementation of a comprehensive therapeutic plan are of crucial importance [13, 18].

<br/>Care for a patient with bipolar affective disorder coexisting with obsessive–compulsive symptoms required close and well-coordinated collaboration of the entire therapeutic team.

<br/>The psychiatrist played a central role, being responsible for diagnostics, selection and adjustment of pharmacotherapy, and monitoring the safety of treatment. The clinical psychologist conducted psychotherapeutic interventions, including elements of cognitive-behavioral therapy, psychoeducation, and training in anxiety management skills, thereby supporting the patient in the process of adapting to the illness [15].

<br/>The psychiatric nurse remained in daily, direct contact with the patient, observing her psychological and somatic condition, aiding with self-care, educating her on sleep hygiene and adherence to therapeutic recommendations, and motivating her to participate in activating activities. The nurse’s role as an intermediary between the patient and the physician was particularly important in ensuring a rapid response to changes in the patient’s health status. Research indicates that nursing interventions focused on psychoeducation and social skills training contribute to reducing the risk of relapse, improving overall functioning, and enhancing patients’ quality of life [19].

<br/>The nurse’s actions were complemented by the occupational therapist, who, through individually tailored activities, supported the restoration of daily rhythm and reduction of social isolation. Equally important was the involvement of the social worker, who assessed the patient’s family and socioeconomic situation, provided support in organizing community-based assistance, and educated relatives about possibilities for continuing care after hospital discharge. The treatment process also included a dietitian, who addressed the patient’s significant malnutrition and developed dietary recommendations subsequently implemented by the nursing staff and family.

<br/>Such an interdisciplinary and complementary approach ensured comprehensive care for the patient, encompassing pharmacological treatment, psychotherapy, nursing interventions, as well as social and nutritional support. The literature emphasizes that integrated teamwork is an essential prerequisite for the effective treatment of individuals with BD, particularly in cases complicated by coexisting obsessive-compulsive symptoms [19, 20].

<br/>Another important element of care is the education of the patient’s family, since the support of relatives increases the effectiveness of treatment, improves adherence to therapeutic recommendations, and reduces the risk of relapse of manic or depressive episodes. Patients who receive support within the family environment are more likely to participate in therapy and show higher motivation for cooperation.

<br/>In the present case, the nursing interventions implemented allowed for gradual improvement in the patient’s functioning, reduction in the severity of depressive and anxiety symptoms, and increased motivation for further treatment. Particularly valuable was the combination of monitoring mental status with psychoeducation and support in self-care. The interdisciplinary approach enabled not only the stabilization of the patient’s condition during hospitalization but also her preparation for further therapy and functioning within the family environment.

<h3>Conclusions</h3>

<br/>Bipolar affective disorder coexisting with obsessive-compulsive symptoms represent a significant diagnostic and therapeutic challenge. Effective patient care requires a comprehensive approach in which the psychiatric nurse plays a key role through constant observation, psychoeducation, emotional support, and activation activities. The described case confirms that interdisciplinary collaboration within the therapeutic team is essential to ensure optimal treatment outcomes for the patient. A holistic, patient-centered approach contributes to an improved quality of life, reduced severity of symptoms, and increased sense of safety and motivation for further therapy.

<h3>Disclosures</h3>

<br/>This research received no external funding.

<br/>Institutional review board statement: Not applicable.

<br/>The authors declare no conflict of interest.

<h3>References</h3>