Transcript Bipolar Disorder

Chapter 19
Mood Disorders:
Bipolar
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Bipolar Disorders
• Bipolar I disorder
– At least one manic
episode & depression
• Bipolar II disorder
– At least one
hypomanic episode &
depression
• Cyclothymia
– At least 2 years of
hypomania and mild
depression
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Prevalence and Comorbidity
• 1.2% to 3% lifetime
prevalence
• Highest lifetime rate of
suicide of any
psychiatric disorder
• Comorbidity
– Substance use disorders
– Personality disorders
– Anxiety disorder
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Theories
• “Most likely, multiple independent
variables contribute to the occurrence
of bipolar disorder. For this reason, a
biopsychosocial approach will likely be
the most successful approach to
treatment” (text, p.361).
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Biological Theories
• Strong genetic component
• Neurobiological factors
– Interaction between neurotransmitters and
hormones
– Norepinephrine, epinephrine, dopamine,
serotonin
• Neuroendocrine factors
– Hypothalamic-pituitary-thyroid-adrenal axis
• Neuroanatomical factors
– Dysregulation in prefrontal cortex and medial
temporal lobe
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Sociological Findings: Higher
Prevalence
• Higher levels of
education
• Higher
occupational status
• Upper
socioeconomic
status
• Creative and
professional people
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Psychological Influences
• Role in precipitation of
manic episode
• High expressed emotions
in the family and relapse
• Childhood abuse and
earlier onset, faster
cycling, and more
psychiatric comorbidity
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Early Diagnosis and Treatment
• On average, people spend eight years
seeking treatment before an accurate
diagnosis
• Early treatment can prevent:
– Suicide
– Substance abuse
– Marital and work problems
– Medical comorbidity
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Assessment:
Characteristics of Mania
• Mood
– Mood instability
• From sociability and euphoria to
hostility, irritability, paranoia
• Behavior
– Hyperactivity, no sleep
– Bizarre and colorful dress
– Highly distractible
– Impulsive
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Assessment:
Characteristics of Mania
• Thought processes
– Flight of ideas
– Grandiosity
– Poor judgment
• Cognitive function
– Significant and persistent problems
with psychosocial functioning
– Cognitive impairment a core feature
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Assessment Guidelines
• Danger to self or
others
• Need for external
controls
• Need for
hospitalization
• Medical status
– Rule out medical cause
for mania
• Medical condition
requiring intervention
– Substance abuse
• Client and family
understanding of
diagnosis and
treatment
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Self-Assessment of the Nurse
• Manic patient: Challenging staff
control
– Manipulative
– Splitting
– Aggressively demanding
• Staff member actions
– Set limits consistently
– Frequent staff meetings to deal with
patient behavior and staff response
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Assessment for
Danger to Self or Others
• Assess for suicidal thoughts or plans
• May exhaust themselves to the point
of death
– May not eat or sleep for days at a time
• Poor impulse control
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Nursing Diagnoses
• Risk for violence
• Risk for injury
• Impaired social interaction
• Ineffective coping
• Disturbed thought processes
• Situational low self-esteem
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Outcome Criteria
• Phase I: Acute Phase ( acute mania)
– Prevent injury
• Phase II: Continuation of treatment
– Relapse prevention
• Phase III: Maintenance treatment
– Relapse prevention
– Limit severity & duration of future episodes
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Planning
• Acute phase
– Maintain safety
– Medication stabilization
– Self-care needs
• Continuation phase
– Maintain medication compliance
– Psychoeducation teaching
– Counseling
• Maintenance phase
– Therapy, periodic evaluations
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Intervention: Acute Phase
• Communication
– Firm, calm, consistent
• Structure in a safe milieu
– Low level of stimulation
• Physiological safety
– Nutrition, sleep, hygiene,
elimination
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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.
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Lithium Carbonate (LiCO3)
• Mood stabilizer
• First-line agent
• Takes 7 to 14 days to reach
therapeutic levels in blood
– Therapeutic blood level
0.8 to 1.4 mEq/L
– Maintenance blood level
0.4 to 1.3 mEq/L
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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
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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
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Lithium: Early Signs of Toxicity
• Blood level: <1.5
mEq/L
• Signs
– Nausea
– Vomiting
–
–
–
–
Diarrhea
Thirst
Polyuria
Slurred speech
– Muscle weakness
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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
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Lithium: Severe Toxicity
• Blood level: 2.0 to 2.5 mEq/L
• Signs
–
–
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–
–
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Ataxia
Blurred vision
Clonic movements
Large output of dilute urine
Seizures
Stupor
Severe hypotension
Coma
Death
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Lithium: Severe Toxicity
• Blood level: >2.5 mEq/L
• Signs
–
–
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–
–
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–
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Confusion
Incontinence of urine or feces
Coma
Cardiac arrhythmias
Peripheral circulatory collapse
Abdominal pain
Proteinuria
Oliguria
Death
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Lithium: Major Long-Term Risks
• Hypothyroidism
• Impairment of kidneys’ ability to
concentrate urine
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Lithium: Contraindications
• Cardiovascular disease
• Brain damage
• Renal disease
• Thyroid disease
• Myasthenia gravis
• Pregnancy
• Breastfeeding mothers
• Children younger than 12 years
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Client and Family Teaching
for Lithium Therapy
• Effects of treatment: Prevent relapse
• Need to monitor lithium blood levels
• Side effects and toxic effects
• Effects of food and over-the-counter
medications
– Normal salt and fluid intake
• When to call the physician
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Antiepileptic Medications
• Carbamazepine (Tegretol)
• Divalproex (Depakote)
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topamax)
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Anxiolytics: Acute Mania
• Clonazepam (Klonopin)
• Lorazepam (Ativan)
Antipsychotics:
Acute Mania and
Mood stabilization
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
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Electroconvulsive Therapy (ECT)
• Severe manic behavior
• Rapid cycling
• Paranoid, destructive features
• Acutely suicidal behavior
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Milieu Therapy: Seclusion
• Used in an emergency for client when:
– Clear risk of harm to client or others
– Client's behavior has continued despite
use of less restrictive methods to keep
client and others safe
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Use of Seclusion or Restraints
• Associated with issues
related to
– Therapeutic benefit
– Ethics
– State and federal laws
– Hospital protocols
• Precise documentation
essential
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Intervention: Continuation Phase
• Outcome: Relapse prevention
– Medication compliance
– Day hospitals/programs
– Home visits
– Health teaching to client and family
• Prodromal signs/symptoms of relapse
– Reduced sleep
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Intervention: Maintenance Phase
• Outcome: Relapse prevention
– Cognitive-behavioral therapy with
pharmacotherapy
• Results in better compliance with medication
– Family therapy
– Support groups
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Evaluation
• Frequent evaluation of short-term and
intermediate indicators
• Long-term outcomes include:
– Medication compliance
– Improved psychosocial functioning
– Better coping skills
– Family and work stability
– Mood stability
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