Bipolar

Bipolar Disorder Theories

Genetics: Identical twins have 80% heritability; 1st degree relatives-7-10 times more likely to develop bipolar disorder

Neurobiological: influence of norepinephrine, serotonin, and dopamine; also thought that an increase in neurotransmitters in certain areas of the brain, as well as neuroreceptors sensitivity, may play a role

Psychological: Stressful life events can precipitate symptoms

Neuroendocrine factors: hormonal fluctuations, as well as alterations in the hypothalamic-pituitary-adrenal HPA axis may be a factor

Neuroanatomical: Ventricular enlargement, cortical atrophy, and sulcal widening

Mania

Persistently elevated expansive or irritable mood, coupled with extreme goal-directed activity or energy. The Manic episode lasts at least a week, most of the day. every day.

Hypomania

lower-level mood elevation,, less dramatic. Associated more with bipolar 2 disorder, tends to be more euphoric and may increase functioning

Depressive Episode

2+ weeks of depressed mood and/or loss of interest or pleasure in everyday activities. Typically also experience poor concentration/decision making.

May see emptiness, hopelessness, anxiety, worthlessness, guilt, or irritability

Rapid Cycling

2 or more episodes of mania and depression EACH so 4 episodes total

Mixed features

: a patient in an episode of mania or hypomania also shows depressive symptoms at the same time

Cyclothymia

chronic mood disturbance; lasts 2+ years. Hypomania alternates with depression, but symptoms do not meet full criteria for MDD or hypomania

Bipolar I

1+ episodes of mania. Episode must last at least 1 week. May

experience hypomania or major depressive episode either before or after manic episode

Bipolar 2

dx requires at least one hypomanic episode and a major depressive episode. Psychosis not present in hypomanic episode but could be present during depressive episode. Hypomania must last at least 4 days; depressive episode must last 2+ weeks.

Bipolar Disorder Unspeceficed

Disorders with bipolar features that do not meet criteria for any of the above

Phases of Bipolar Disorder: Acute phase

Acute Phase: Hospitalization to prevent harm(poor judgement, reckless decisions and allow time for medications to take effect)

Continuation Phase

Usually 4-9 months, goal is to prevent relapse

MAINTENANCE PHASE

• Prevent recurrence of illness episode

Assessment of Bipolar Patients

• Hyperactivity

• Overconfidence, heightened sense of own abilities

• Decreased need for sleep; not tired (may sleep small amounts

with hypomania)

• Increased energy

• Poor judgment/risk taking

• Rapid, pressured speech, loud

• Easily distracted, flight of ideas

• Expansive, irritable, or paranoid behaviors

• Impatient, uncooperative, abusive, obscene, manipulative

• Dress, makeup, or behavior may be inappropriate

• Grandiosity, and even delusions or hallucinations (but not with

Bipolar II)

• **Mania may begin gradually, but typically onset is more abrupt

DIG FAST primary symptoms of a maic attack

Distractibility

Indiscretion

Grandiosity

Flight of Ideas

Activity Increase

Sleep Deficit

Talkativeness

What are Nursing assessment priorities?

• Danger to self or othres (suicidal or homicidal ideation)

• Other dangers to self: exhaustion, lack of food or sleep, poor impulse control

• Consider sexual behaviors

• Uncontrolled spending that has far consequences may require assistance/controls

• Determine need for hospitalization

• Medical status

• Determine educational needs for patient and family

Bipolar Disorder: Treatment

• Pharmacological treatment(mood stabilizers)

• Electroconvulsive therapy

• Psychotherapy

Pharmacological Treatment Litium

• A salt

• Acute mania treatment and bipolar maintenance

• Effect can take 7 to 14 days, may need Second generation antipsychotic to stabilize concurrently

Narrow therapeutic range of Lithium

0.8-1.2 mEq/L (Acute Mania)

0.6-1.2 mEq (maintenance)

Lithium Toxicity

1.5 mEq L or greater

How often Lithium Blood levels checked

• Initially every 3-7 days

• Then every 1 to 3 months

Lithium Safety Concerns

• Renal Function

• Thyroid

• Pregnancy/breast feeding

• Toxicity

Side effects of Lithium (<.4 to 1 mEq/L)

Nausea

Vomiting

Diarrhea

Thirst

Polyuria

Lethargy/sedation

Fine hand tremor

Goiter and hypothyroidism

Early Lithium Toxicity (equal to or greater than 1.5-2)

• GI Upset

• Coarse Hand tremor

• Confusion

• EEG Changes

• Sedation

• Incoordination

Advanced/Severe signs (2.0 and above)

• ataxia

• blurred visions

• giddiness

• more eeg changes

• dilute, large output urine

• hypotension

• coma

• convulsions

Lithium: Patient Teaching

• Fluid balance of salt intake, fluid intake, importat

Bipolar Pharmacological Anticonvulsant Treatment

• ANTICONVULSANTS Good for those who have cyclic symptoms

• Help decrease impulsive and aggressive behavior

• Anticonvulsants can work to diminish both mania and depression

Anticonvulsant Bipolar Therapy

• Depakote or Valproic acid

• Carbamazepine/oxecarbazepine

• lamotrigine

• topiramate

Depakote Safety Monitoring

• Liver function

• Platelet count

• Risk for PCOS

Tegretol/Trileptal

• Liver function

• Monitor Blood Levels (4-12 mcg/mL)

Lamictal

• Monitor for rash(Stevens-Johnson syndrome)

• Monitor for aseptic meningitis

Other Pharmacological Bipolar Treatment

• Second-generation antipsychotics

• Benzodiazepines; short-term, generally used with other medications

• Antidepressants (not commonly advised; can bring about symptoms of mania, particularly if used without a mood stabilizer should be prescribed with caution.