Bipolar Disorders

1. Bipolar Disorders

2. Diagnostic Terminology Bipolar Disorder Bipolar I Bipolar II Old terminology Manic-Depressive Bipolar Affective Disorder (BAD)

3. Some Facts About Bipolar Illness Usually chronic with remissions and exacerbations Suicide rate in clients with Bipolar disorder is 15% 60% experience chronic interpersonal and occupational difficulties Age of onset: early 20’s 90% will have recurrent symptoms 30-40% of Bipolar have chemical dependency

4. Types of Bipolar Disorder Bipolar I (many subtypes) Must be a history of a manic episode There is a history of Major Depression More severe Bipolar II There is a history of a hypomanic episode but NOT Mania There is a history of Major Depression Cyclothymic Disorder Episodes of hypomania and numerous periods of depressed mood Chronic: Never symptom free

5. Symptoms of HYPOMANIASimilar to Mania But to a Lesser Degree Energetic and driven Increased goal-directed behavior: may be highly productive Mood: elevated or irritable Lowered inhibitions No delusions or hallucinations

6. Signs/Symptoms of MANIA Mood/affect: euphoric, labile, hostile Hyperactive Too busy to eat or sleep Disorganized activity Disturbed thought process: Unable to concentrate, flight of ideas, tangential Psychotic Thinking Delusions of grandeur or paranoid Hallucinations

7. Signs/Symptoms MANIA, cont’d • Pressured speech; hyperverbal • Poor judgment and impulse control: with money, sex, any pleasure • Loud clothing, excessive make-up

8. http://www.youtube.com/watch?v=TiGRi0kGg_s&feature=related Megan hypomania 4 min. http://www.youtube.com/watch?v=dwWalEE0Yus&feature=related Debra coping with mania 3 minutes http://www.youtube.com/watch?v=F_YPZt7CuNY&feature=related (Pressured speech, flight of ideas Psychiatry teacher)

9. Bipolar I: Mixed Episode Meets criteria for both Mania and Major Depression symptoms Severely disturbed, rapidly alternating moods Not caused by other drugs or alcohol May be induced by antidepressant Client is miserable, may be highly suicidal and/or may be violent

10. Manic Behaviors that Result in Altered Relationships Manipulation Find vulnerability in others Exploit weaknesses and create conflict Shift responsibility Limit testing Alienation of family--may be aggressive and abusive

11. Biologic Theories • Ion dysregulation:causesoversensitivity of neuron to stimuli • Alteration in transcription of messengers in nerve cell nucleus Neurotransmitters involved in mania/bipolar: • Excessive Dopamine and Norepinephrine •  availability of GABA and Serotonin

12. Diagnoses (At end of your outline) • NURSING DIAGNOSES FOR MANIA • Risk for Violence (Directed toward self, others) • Insomnia or Sleep Deprivation • Altered Nutrition: Less than Body Requirements • Acute Confusion • Disturbed Thought Processes • Impaired Social Interaction

13. Psychotherapeutic Management (Focus of presentation is primarily on management of mania except where otherwise noted)

14. Nurse-Client Relationship and Milieu Management Matter-of-fact tone Clear, concise directions Limit setting De-escalating the client     Maintaining safety Consistency among staff Reduction of environmental stimuli

15. Milieu Management, cont’d Reinforcing appropriate hygiene and dress Supporting adequate Nutrition and Sleep Providing activities for excessive energy

16. Psychotherapeutic Management: Medications A Common Diagnostic Mistake Diagnosing Major Depressive Disorder when the client is in the Depressive Aspect of Bipolar Disorder Giving an antidepressant can push the client into Mania

17. Antipsychotics • All Atypicals: olanzepine: Zyprexa, quetiapine: Seroquel,ziprasidone: Geodon, risperidone: Risperdal and Risperdal Consta, aripiprazole: Abilify are FDA approved mood stabilizing agents. • Used alone or with other mood stabilizing agents • Other antipsychotics: used prn for agitation

18. Lithium Mechanism of action unknown: similarity to action of Na /replaces Na in the body Slow onset: 2 weeks Narrow range of therapeutic level 0.6 to 1.2 mEq/L; the optimum maintenance level is 0.8 mEq/L Toxic over 1.5 mEq/L “Normal side effects”- weight gain, fine hand tremor, nausea, metal taste

19. Lithium Toxicity Narrow therapeutic range: therapeutic dose is close to a toxic dose. Mild to Moderate toxic reactions: 1.5 to 2 mEq/L Diarrhea Vomiting Drowsiness Muscular weakness Lack of coordination Dry mouth

20. Lithium Toxicity Moderate to Severe reactions 2 to 3 mEq/L All previous symptoms & Ataxia Tinnitus Blurred vision High urinary output (osmotic diuresis) Delirium Nystagmus

21. Lithium Toxicity Severe reactions:  than 3 mEq/L All previous symptoms Seizures Organ failure Renal failure Coma Death

22. Mood Stabilizing Medications: Anticonvulsants • valproic acid/divalproex: Depakote and Depakene • carbamazepine: Tegretol Side effects: many drug interactions; CNS effects; blood disorders ( RBC, bone marrow, WBC’s), liver failure; toxic reactions common Monitoring of serum levels is necessary

23. Other Anticonvulsants • topiramate: Topamax • gabapentin: Neurontin • oxcarbazepine: Trileptal • lamotrigine: Lamictal-best for bipolar depression. May cause severe rash.

24. Benzodiazepines (Add to your outline) • Good for acute mania and psychomotor agitation in mania • Used in acute care settings; not for long term tx. • clonazepam (Klonopin) • lorazepam (Ativan)