Chapter 13

1. Chapter 13 Bipolar and Related Disorders

2. Clinical Picture • Bipolar I disorder • Bipolar II disorder • Cyclothymia

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

10. 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?

11. 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

12. 50% have co-morbidities • Panic attacks • Substance abuse • Social Phobia • Specific Phobia • Borderline Personality disorder • Seasonal Affective disorder

13. Etiology • Biological factors • Genetic • Neurobiological • Neuroendocrine

14. Psychosocial & Environmental Factors • Stress • Education • Occupation • Economic status • Creativity

15. Assessment • Mood • Behavior • Appearance • Speech • Thought processes • Flight of ideas • Clang associations • Grandiosity • Cognitive functioning

16. Case Study (Cont.) • What are some problems that can be avoided if your manic patient gets proper treatment?

17. 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

18. 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

19. 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

20. 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

21. Planning • Acute phase • Medical stabilization • Maintaining safety • Self-care needs • Continuation phase • Maintain medication adherence • Psychoeducational teaching • Referrals • Maintenance phase • Prevent relapse

22. Implementation • Acute phase • Depressive episodes • Manic episodes • Continuation phase • Prevent relapse with follow-up care • Maintenance phase • Prevent recurrence

23. Intervention: Acute Phase • Communication • Structure in a safe milieu • Physiological safety • Self-care needs

24. 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

25. 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

26. 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

27. Bipolar Disorder Psychopharmacology • Mood stabilizers • Antipsychotics • Anxiolytics • Antidepressants

28. 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

29. 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

30. 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

31. 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

32. Lithium: Early Signs of Toxicity • Blood level: 1.5 mEq/L • Signs • Nausea • Vomiting • Diarrhea • Thirst • Polyuria • Slurred speech • Muscle weakness

33. 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

34. 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

35. 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

36. 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

37. Contraindications to Lithium • Cardiovascular disease • Brain damage • Renal disease • Thyroid disease • Myasthenia gravis • Pregnancy • Breastfeeding mothers • Children younger than 12 years

38. 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

39. Anticonvulsant Drugs • Valproate (Depakote, Depakene) • Carbamazepine (Tegretol) • Lamotrigine (Lamictal) • Gabapentin (Neurontin) • Topiramate (Topamax) • Oxcarbazepine (Trileptal)

40. Antianxiety Drugs • Clonazepam (Klonopin) • Lorazepam (Ativan) • Atypical antipsychotics • Olanzapine (Zyprexa) • Risperidone (Risperdal)

41. Other Treatments • Electroconvulsive therapy (ECT) • Severe manic behavior • Rapid cycling (four or more cycles/yr) • Paranoid, catatonic, destructive features • Acutely suicidal behavior

42. 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

43. Advanced Practice Interventions • Psychotherapy • Cognitive-behavioral therapy (CBT) • Interpersonal and social rhythm therapy

44. Evaluation • Evaluate outcome criteria • Reassess care plan • Revise care plan if indicated

45. Audience Response Questions • Which anticonvulsant medication might be prescribed for a patient with bipolar disorder? • Divalproex sodium (Depakote) • Clonazepam (Klonopin) • Olanzapine (Zyprexa) • Lithium (Lithobid)

46. Audience Response Questions 2. Lithium toxicity may result in which one of the following? • Neuroleptic malignant syndrome • Dystonia • Blurred vision • Akathisia

47. 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?