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Chapter 13. Bipolar and Related Disorders. Clinical Picture. Bipolar I disorder Bipolar II disorder Cyclothymia. Bipolar Disorder – DSM V.
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Chapter 13 Bipolar and Related Disorders
Clinical Picture • Bipolar I disorder • Bipolar II disorder • Cyclothymia
Bipolar Disorder – DSM V • A distinct period of abnormally & persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day • Or any duration if hospitalization is required in bipolar disorder, type 1
Bipolar Disorder – DSM V (continued) • During the period of mood disturbance, 3 or more of the following have persisted (4 if the mood is only irritable): • Inflated self-esteem or grandiosity • Decreased need for sleep • More talkative or pressured speech • Flight of ideas or subjective feeling of racing thoughts • Distractibility • Increased goal-directed activity or psychomotor agitation • Excessive involvement in pleasurable activities that have a high potential for painful consequences
DIG FAST • Distractible (poorly focused) • Indiscretion (excessive pleasurable activities) • Grandiosity (unrealistic belief in one’s ability or inflated self-esteem) • Flight of Ideas • Activities (increased, hyperactivity) • Sleep deficit (decreased need for sleep) • Talkativeness (pressured speech) • Need 3/7 in addition to expansive mood • Need 4/7 if primary mood is irritability
Hypomania • Unequivocal change uncharacteristic of person when not symptomatic • Observable by others known to patient • Absence of marked impairment in social or occupational functioning • Hospitalization not indicated • Not due to substance abuse, medication, or other medical condition
Mania • Behavior severe enough to cause marked impairment in occupational activities, usual social activities, or relationships • Necessitates hospitalization to prevent harm to self or others, or there are psychotic features • Symptoms not due to substance abuse, medications or other medical condition
Endless energy Decreased need for sleep Omnipotent feelings Substance Abuse Increased sexual interest Poor judgment Euphoric mood Can’t sit still Irritable, impulsive, intrusive Nothing is wrong (denial) Active: Aggressive Mood Swings
Case Study • A patient was just admitted to your unit with bipolar disorder I and is in the manic state. • What symptoms might you expect to see?
Epidemiology • Lifetime prevalence of bipolar disorder in the United States is 5.1% • Bipolar I – more common in males • Bipolar II – more common in females • Cyclothymia – usually begins in adolescence or early adulthood
50% have co-morbidities • Panic attacks • Substance abuse • Social Phobia • Specific Phobia • Borderline Personality disorder • Seasonal Affective disorder
Etiology • Biological factors • Genetic • Neurobiological • Neuroendocrine
Psychosocial & Environmental Factors • Stress • Education • Occupation • Economic status • Creativity
Assessment • Mood • Behavior • Appearance • Speech • Thought processes • Flight of ideas • Clang associations • Grandiosity • Cognitive functioning
Case Study (Cont.) • What are some problems that can be avoided if your manic patient gets proper treatment?
Self-Assessment • Manic patient • Manipulative • Aggressively demanding • Splitting • Staff member actions • Frequent staff meetings to deal with patient behavior and staff response • Set limits consistently
Assessment Guidelines Bipolar Disorder • Danger to self or others • Need for protection from uninhibited behaviors • Need for hospitalization • Medical status • Coexisting medical conditions • Family’s understanding
Nursing Diagnosis • Risk for suicide • Risk for violence • Other-directed • Self-directed • Risk for injury • Defensive / Ineffective coping • Disturbed thought process • Situational Low Self-esteem
Outcomes Identification • Acute phase • Prevent injury • Continuation phase • Relapse prevention • Maintenance phase • Limit severity and duration of future episodes • Continuation of relapse prevention • Education for interpersonal strategies to improve relationships and quality of life
Planning • Acute phase • Medical stabilization • Maintaining safety • Self-care needs • Continuation phase • Maintain medication adherence • Psychoeducational teaching • Referrals • Maintenance phase • Prevent relapse
Implementation • Acute phase • Depressive episodes • Manic episodes • Continuation phase • Prevent relapse with follow-up care • Maintenance phase • Prevent recurrence
Intervention: Acute Phase • Communication • Structure in a safe milieu • Physiological safety • Self-care needs
Communication with Manic Patient • Use firm, calm approach • Use short and concise explanations • Remain neutral: avoid power struggles • Be consistent in approach and expectations • Firmly redirect energy into more appropriate areas • Act on legitimate complaints • Convey limits, consequences
Structure - Milieu • Low level of stimuli • Structured solitary activities or with staff • Redirect violent behavior • Minimize physical harm – medication, seclusion, restraints • Observe for medication side effects/toxicity • Protect from consequences of behavior • Such as giving away possessions, spending all money, disrobing
Interventions: Physiologic Safety/ Self-Care Needs • Monitor vital signs, I & O if indicated • Nutrition • Offer frequent mobile high calorie foods or protein drinks • Elimination • Sleep • Avoid caffeine, reduce stimulation, encourage rest, other sleep-inducing interventions • Hygiene • May need supervision, step by step reminders • Minimize choices
Bipolar Disorder Psychopharmacology • Mood stabilizers • Antipsychotics • Anxiolytics • Antidepressants
Pharmacological Interventions • Lithium carbonate • First-line agent • Therapeutic and toxic levels • Therapeutic blood level: 0.8 to 1.4 mEq/L • Maintenance blood level: 0.4 to 1.3 mEq/L • Toxic blood level: 1.5 mEq/L and above • Takes 7 to 14 days to reach therapeutic levels in blood
Initial Treatment of Acute Mania Until Lithium Takes Effect • Antipsychotics • Slow speech • Inhibit aggression • Decrease psychomotor activity • Antipsychotic or benzodiazepine to prevent: • Exhaustion • Coronary collapse • Death
Lithium: Expected Side Effects • Blood level: <0.4 to 1.0 mEq/L • Signs • Fine hand tremor • Polyuria • Mild thirst • Mild nausea • General discomfort • Weight gain
Lithium: Expected Side Effects • Blood level: <0.4 to 1.0 mEq/L • Signs • Fine hand tremor • Polyuria • Mild thirst • Mild nausea • General discomfort • Weight gain
Lithium: Early Signs of Toxicity • Blood level: 1.5 mEq/L • Signs • Nausea • Vomiting • Diarrhea • Thirst • Polyuria • Slurred speech • Muscle weakness
Lithium: Advanced Signs of Toxicity • Blood level: 1.5 to 2.0 mEq/L • Signs • Coarse hand tremor • Persistent gastrointestinal upset • Mental confusion • Muscle hyperirritability • Incoordination
Lithium: Severe Toxicity • Blood level: 2.0 to 2.5 mEq/L • Signs • Ataxia • Blurred vision • Clonic movements • Large output of dilute urine • Seizures • Stupor • Severe hypotension • Coma • Death
Lithium: Severe Toxicity - Continued • Blood level: >2.5 mEq/L • Signs • Confusion • Incontinence of urine or feces • Coma • Cardiac arrhythmias • Peripheral circulatory collapse • Abdominal pain • Proteinuria • Oliguria • Death
Lithium: Common SE and Major Long-Term Risks • Other common SE • Drowsiness • Weakness • Blurred vision, dry mouth • Fatigue • Acne • Weight gain • Major Long-Term Risks • Hypothyroidism • Impairment of kidneys’ ability to concentrate urine
Contraindications to Lithium • Cardiovascular disease • Brain damage • Renal disease • Thyroid disease • Myasthenia gravis • Pregnancy • Breastfeeding mothers • Children younger than 12 years
Patient and Family Teaching for Lithium Therapy • Effects of treatment • Need to monitor lithium blood levels • Side effects and toxic effects • Effects of dietary salt and dehydration • Caffeine effects • Check with physician before taking OTC medications • Take with food to decrease stomach irritation • High fat helps-spoonful of peanut butter
Anticonvulsant Drugs • Valproate (Depakote, Depakene) • Carbamazepine (Tegretol) • Lamotrigine (Lamictal) • Gabapentin (Neurontin) • Topiramate (Topamax) • Oxcarbazepine (Trileptal)
Antianxiety Drugs • Clonazepam (Klonopin) • Lorazepam (Ativan) • Atypical antipsychotics • Olanzapine (Zyprexa) • Risperidone (Risperdal)
Other Treatments • Electroconvulsive therapy (ECT) • Severe manic behavior • Rapid cycling (four or more cycles/yr) • Paranoid, catatonic, destructive features • Acutely suicidal behavior
Milieu Therapy: Seclusion Room or Restraints • Used in an emergency for patient when: • Clear risk of harm to patient or others • Patient's behavior has continued despite use of less restrictive methods to keep patient and others safe
Advanced Practice Interventions • Psychotherapy • Cognitive-behavioral therapy (CBT) • Interpersonal and social rhythm therapy
Evaluation • Evaluate outcome criteria • Reassess care plan • Revise care plan if indicated
Audience Response Questions • Which anticonvulsant medication might be prescribed for a patient with bipolar disorder? • Divalproex sodium (Depakote) • Clonazepam (Klonopin) • Olanzapine (Zyprexa) • Lithium (Lithobid)
Audience Response Questions 2. Lithium toxicity may result in which one of the following? • Neuroleptic malignant syndrome • Dystonia • Blurred vision • Akathisia
Case Study (Cont.) • Your patient with mania has been started on lithium. • What patient teaching about this medication should the nurse provide before the patient is discharged?