Managing Bipolar Disorders: Comprehensive Approach for Lifelong Wellness

1. Chapter 25: Bipolar Disorders: Management of Mood Lability

2. Key Terms • Mania: an abnormally and persistently • Elevated mood: euphoria or elation • Expansive mood: lack of restraints in expression; overvalued self-importance • Irritable mood: easily annoyed and provoked to anger • Manic episode: distinct period of mania • Mood lability: rapid shifts in mood with little or no change in external events

3. Bipolar Disorders • Mania or hypomania alternating with depression (refer to Key Diagnostic Characteristic 25.1) • Bipolar I (major depressive, manic, or mixed episodes) • Bipolar II (major depression and hypomania) • Cyclothymic disorder (hypomania and depressive episodes not meeting full criteria for major depressive episode)

4. Bipolar Disorders Across the Lifespan • Children and adolescents • Depression usually occurring first; marked by intense rage • Symptoms reflective of developmental level of the child • Older adults • Greater neurologic abnormalities and cognitive disturbances • Incidence of mania decreased with age

5. Epidemiology • Lifetime prevalence: 1.0% bipolar I; 1.1.% bipolar II; 2.4% subthreshhold bipolar disorder • Symptoms before age 25 years • No gender differences in incidence • Female patients at greater risk for depression and rapid cycling than male patients • Male patients at greater risk for manic episodes • Common comorbid conditions: anxiety disorders (most prevalent: panic disorder and social phobia) and substance use)

6. Etiology • Biologic theories • Chronobiologic theories • Genetic factors • Kindling theory • Psychological and social theories • Focus on reducing environmental stress and trauma in genetically vulnerable individuals

7. Interdisciplinary Treatment and Recovery • Goals of treatment • Minimize and prevent either manic or depressive episodes • Help the patient and family learn about the disorder and manage it throughout a lifetime • Priority care issues • Safety

8. Question Is the following statement true or false? • An expansive mood is characterized by euphoria.

9. Answer False. • An elevated mood is characterized as euphoria. An expansive mood is one involving a lack of restraints in expression and overvalued self-importance.

10. Nursing Assessment for the Biologic Domain • Changes in activity, eating, and sleep patterns • Diet and body weight • Laboratory testing: thyroid function • Changes in sexual practices • Pharmacologic assessment • Previous use of antidepressants • Discontinuation of mood stabilizers

11. Manic phase: Disturbed Sleep Pattern Sleep Deprivation Imbalanced Nutrition Hypothermia Deficient Fluid Volume Nonadherence Depressive phase: Disturbed Sleep Pattern Imbalanced Nutrition Fatigue; Nausea Self-Care Deficit Disturbed Thought Processes Sexual Dysfunction Nursing Diagnoses for the Biologic Domain

12. Nursing Interventions for the Biologic Domain • Education about physical care • Mood stabilizers • Lithium (refer to Tables 25.1 to Table 25.3 and Box 25.4) • Divalproex sodium (refer to Box 25.5) • Carbamazepine (refer to Table 25.4) • Lamotrigine (refer to Box 25.6) • Antipsychotics (adjunct or monotherapy)

13. Nursing Interventions for the Biologic Domain (cont’d) • Administering and monitoring medication • Monitoring and managing side effects • Monitoring for drug interactions • Promoting adherence • Teaching points • Other somatic interventions: electroconvulsive therapy

14. Nursing Assessment for the Psychological Domain • Mood • Cognition • Thought disturbances • Stress and coping • Risk assessment

15. Question Which agent would most commonly be prescribed for a patient with bipolar I disorder? • Lamotrigine • Lithium • Carbamazepine • Divalproex

16. Answer B. Lithium • Although divalproex, carbamazepine, and lamotrigine may be used as mood stabilizers, lithium is the most widely used mood stabilizer.

17. Nursing Diagnoses for the Psychological Domain • Disturbed Sensory Perception • Disturbed Thought Processes • Defensive Coping • Risk for Suicide • Risk for Violence • Ineffective Coping • Nonadherence

18. Nursing Interventions for the Psychological Domain • Psychoeducation (refer to Boxes 25.8 and 25.9) • Individual cognitive behavioral therapy • Individual interpersonal therapy • Adjunctive therapies • Psychotherapy

19. Nursing Assessment for the Social Domain • Cultural views of mental illness • Social and occupational changes • Any changes resulting from a manic or depressive episode

20. Nursing Diagnoses for the Social Domain • Ineffective Role Performance • Interrupted Family Processes • Impaired Social Interaction • Impaired Parenting • Compromised Family Coping • Delayed Growth and Development (children and adolescents) • Caregiver Role Strain

21. Nursing Interventions for the Social Domain • Protection from self-harm, as well as harm from other patients • Support groups • Family interventions • Parenting skills • Counseling sessions • Intensive family therapy • Family psychoeducation

22. Continuum of Care • Inpatient management • Intensive outpatient programs • Partial hospitalization • Day hospitalization • Spectrum of care • Extended and continued follow-up

23. Question Is the following statement true or false? • Protecting the patient from self-harm is crucial during a manic phase.

24. Answer True. • During mania, patients usually violate others’ boundaries, and they may miss the cues indicating anger and aggression from others. Thus, protecting the patient from self-harm as well as harm from others is important.

25. Mental Health Promotion • During remission periods: • Teach stress management • Practice relaxation techniques • Develop a plan for managing emerging symptoms