Chapter 26 - Bipolar Disorder

Mania

An abnormally and persistently

- elevated mood: euphoria or elation

- expansive mood: lack of restraints in expressions; overvalued self-importance

- irritable mood: easily annoyed and provoked to anger

Manic episode

distinct period of mania

mood liability

rapid shifts in mood with little or no change in external events

Bipolar Disorders

Bipolar 1 (MDD, manic, or mixed episode)

- classic manic-depressive disorder with mood swings alternating from depressed to manic

- Mania: a distinct period (at least 1 week or less)

Bipolar II (MDD and hypomania)

Cyclothymic Disorder (hypomania and depressive episodes not meeting full criteria for depressive episode)

Clinical Course: Bipolar 1

- Chronic multisystemic cyclic disorder

- Earlier onset results in more frequent epsiodes than persons who develop the illness later in life

- Progressive condition with prodromal, symptomatic and residual states

- An early onset and a family history of illness are associated with multiple episodes or continuous symptoms

- Symptoms can be unpredictable and variable

- Lead to severe functional impairment, alienation of family, friends, and coworkers

- Prescence of mood liability and rapid cycling

- Dx reliant upon the occurance of at least one manic episode or mixed and depressive episode

Bipolar 1 across life

Children

- depression occur first, marked by intense rage of 2-3 hours

- symptoms reflexive of developmental level of the child

Older adults

- greater neurologic abnormalities and cognitive disturbances

- incidence of mania deecreased with age

Epidemiology and Risk Factors

Lifetime prevalence: 1-4%

Onset: ages 14-21; fewer after 40

No gender differences

Females at greater risk for depression and rapid cycling

Male at greater risk for manic episodes

Common comorbid conditions: anxiety, panic, social phobia and SUD

Etiology

Biologic Theories

- chronobiologic theories

- genetic factors

- chronic stress, inflammation, and kindling

Psychological and Social Theories

- focus on reducing environmental stress and trauma in genetically vulnerable individuals

Recovery-Oriented Care for Bipolar

Goals:

- minimize and prevent either manic or depressive episodes

- manage stress; med adherence; maintaining social rhythms

- help educate the patient and family learn the disorder

Primary treatment:

- medications, psychotherapy, education, support

Priority Care Issues:

- Safety (suicide, injury, poor judgement, impulsivity)

Evidence Based Nursing Care

Mental Health Nursing Assessment

Physical Health

- changes in activity, eating, and sleep patterns

- diet and body weight

- lab testing: thyroid function

- sex practice changes

- pharmacologic assessment

Psychological Assessment

Mental status and Appearance:

- mood, cognition, thought distrubances, behavior response, stress and coping

- social network and support systems

- risk assessment

- social and occupational functioning

- quality of life

Therapeutic Relationship

Both interesting and exhausting

- provide refocusing

- remain calm and avoid power struggles

- avoid confrontations

- respect personal space

- meet with client "where they are"

PREVENT RELAPSE

Mental Health Nursing Interventions

Recovery and wellness goals:

- periods of stable mental health are perfect times to focus on: stress reduction, illness management, relapse prevention

Physical Care and Rest

- adequate hydration

- encourage regular exercise

Wellness challenges

Medication Interventions

Goals:

- rapid control of symptoms and prevention of future episodes or at least reduction in their severity and frequency

Mood Stabilizers:

- Lithium

- Divalproex Sodium

- Carbamazepine

- Lamotrigine

Antipsychotics

Administrating and monitoriing - during acute mania where patient does not believe they have problem

Promoting adherence - empower and patient centered care

Teaching points: change in dietary salt can affect lithium levels (weight gains)

Other somatic therapies

ECT - effective if patient are taking anti-psychotics

Transcranial magnetic stimulation

Psychosocial Interventions

Therapeutic interactions - reduce self stigma

Enhancing cognitive and behavioral functioning

- individual cognitive

- individual interpersonal therapy

- adjunctive therapies

Psychoeducationteach: safety measures, meds, prevent relapse

Teaching about symptoms

Continuum of Care

Efforts to reduce hospitalization

- emergency care, inpatient focused care, intensive outpatient programs, community care, virtual mental health care

Integration with primary care

Other bipolar and related disorders

Bipolar II

- primarily depressed with brief periods of elevated expansive or irritable moods

- hypomania is characteristic of bipolar II disorder

Cyclothymic Disorder

- less severe hypomanic symptoms alternating with numerous periods of depression

- can be triggered by illicit drug us, presribed meds, and some medical conditons