Topic 6: Bipolar Disorders (Ch 13)

bipolar disorders

chronic, recurring mental disorder which primarily involves unusual and unpredictable fluctuations of low (depressive states) and elevated moods (manic/hypomanic states)

DSM criteria for bipolar I

• a period of abnormally/persistently elevated, expansive, or irritable mood and abnormally/persistently increased goal directed activity or energy, lasting at least 1 week and present most of the day, nearly every day, or any duration if hospitalization is ne-cessary

• 3-4 of these S/S

  • inflated self esteem or gradiosity

  • decreased need for sleep

  • more talkative than usual or pressure to keep talking

  • flight of ideas or subjective experience where thoughts are racing

  • distractibility

  • increase in goal-directed activity or psychomotor agitation

    • excessive involvement in activities that have a high potential for painful conseuences

• mood disturbance causes marked impairment in social/occupation functioning or requires hospitalization to prevent harm to self or others

• the episodes are not attributed to the physiological effects of a substance or to another medical condition

bipolar I

the most severe form of BPD that has the highest mortality rates and characterized by shifts in mood, energy, and ability to function and complete ADLs in which periods of normal functioning may alternate with periods of illness and consists of at least 1 manic episode; frequently requires hospitalization

bipolar II

less acute BPD that is often treated outpatient and characterized by cycles of hypomania or less severe mania, lasting at least 4 days and major depression; may seem more talkative/distractible than usual but don’t experience serious impairment in social or occupational functioning

cyclothymic disorder

hypomania that alternates with symptoms of mild to moderate depression for at least 2 years (adults) and rapid cycling is possible

hypomania

low-level, less dramatic mania characterized by euphoria, increased functioning, and excessive activity and energy levels

substance/medicaiton induced bipolar

BPD is directly related to specific substances which cause significant distress and can induce mania in clients without prior manic episodes due to intoxication, withdrawal, toxicity, etc.

causes: levodopa, corticosteroids, anabolic androgenic steroids, TCAs, MAOIs

bipolar related to another medical conditon

BPD directly related to a specific condition and the condition has been verified through medication records or exam which causes significant distress

mania

a period of intense mood disturbances with persistent euphoria, elevation, and/or expansiveness lasting for at least one week, for most of the day, nearly every day; a psychiatric emergency that requires hospitalization

• highly goal-directed in targeted activities/goals

• in perpetual motion

• eat and sleep very little

• may talk non-stop

• may engage in agitatned and aggressive behavior

• feel very powerful (elevated) and important

• frequently engage in high-risk behaviors

• may be a DTS or DTO

• may experience psychotic s/s

what are the characteristics of clients in a manic episode

• auditory hallucinations

• agitation

• impulsivity

• poor judgement

a client is at risk for injury if they experience what s/s during a manic episode

• alteration in cognitive functioning

• impulsiveness

• sexual advances

• threatening violence

• agitation

a client is at risk for violence if they experience what s/s during a manic episode

• agitation

• anxiety

• confusion

• perceptual disorders

• restlessness

a client is at risk for sleep injury if they experience what s/s during a manic episode

deficits in verbal communication, working memory, executive functioning, reasoning, and problem solving

a client is at risk for impaired cognition and concentration if they experience what s/s during a manic episode

• minimal calorie intake

• poor hygiene

• unclean clothing

a client is at risk for self care deficit if they experience what s/s during a manic episode

beginning lithium or other mood stabilizing meds

what is the highest priority for a client in acute mania

• highest priority: beginning lithium or other mood stabilizing meds

• hospitalization/inpatient psychiatric treatment due to risk for harm to self or others

• medication management and frequent labs

• therapeutic communication

• structure in a safe milieu

• set limits to prevent injury and monitor physiological needs

• offer finger foods that can be eaten “on the run” by clients who are not likely to sit down to eat a meal

• encourage sleep and rest

• give safe outlets for client to express their high levels of energy

what are the nursing interventions for a patient in acute mania

• discharge planning once the client is stable

• medication adherence and education

• support groups

• outpatient therapy

• education about relapse prevention for the client and their families

what are the nursing interventions for a patient in the maintenance phase of mania

rapid cycling

experiencing at least 4 mood episodes in 12 months, that may occur in one week or 24 hours; seen in BPD I or II and associated with severe symptoms, has a high recurrence rate, and is resistant to conventional somatic treatments

• more likely in men than women

• men with BPD are more likely to have legal problems and commit acts of violence

• women with BPD are more likely to misuse alcohol, commit suicide, and develop thyroid disease

• women who experience severe postpartum psychosis within 2 week of giving birth have four times the risk for developing subsequent conversion to bipolar disorders with birth as the first trigger sand then sleep loss and hormonal changes trigger mania and psychosis

what is the epidemiology of BPD

• 75% have anxiety disorders

• 50% have substance abuse disorders

• ADHD

  • Challenging because stimulants to treat can trigger the onset of a manic episode

• Impulse control

• Conduct disorders

• Migraines

• Metabolic syndrome

what are the common comorbidities with bipolar I

anxiety and eating disorders

what are the common comorbidities with bipolar II

• genetics: if a twin has BPD, there is a 60% other twin will develop BPD

• prevalent in adults who had high IQs and was particularly verbal as a child

• appear to achieve higher levels of education and higher occupational status that individuals with unipolar depression

• NTs have difficulty being transported to where they need to go and how rapidly/slowly

• Hypothyroidism

• Peripheral inflammation is seen in both manic and depressive states and seems to decrease in between episodes

what are the biological RF for BPD

• childhood and emotional abuse in the form of physical, sexual, and emotional abuse/neglect

• childhood mistreatment is associated with poor clinical outcomes including more frequent and severe episodes, earlier onset, risk of suicide, and substance misuse

• stressful family life and adverse life events

  • stress is a common trigger for mania and depression

what are the environmental RF for BPD

• assess for suicide attempts, substance use disorders, relationship or work problems, and medical problems

• MSE

• assess whether the patient is a DTS or DTO

• assess the need for protection from uninhibited behaviors

• assess the need for hospitalization to safeguard and stabilize the patient

• assess medical status to determine if mania is primary or secondary to another medical condition

• assess the patient’s and family’s understanding of BPD, knowledge of meds, knowledge of support groups, and organizations that provide information on BPD

• Altman Self Rating Mania Scale (ASRM)

what does assessment for BPD include

euphoria, irritability, anger

When doing the MSE, what does assessment of mood for the client with BPD often present as

very self-confident, talkative, overly friendly, shopping sprees, hypersexuality, goal-focused

when doing the MSE what does assessment of behavior for the client with BPD often present as

loose associations, flight of ideas, clang associations, pressured speech, circumstantial, tangenital

when doing the MSE what does assessment of thought process/speech pattern for the client with BPD often present as

pressured speech

fast, ranging from rapid to frenetic, conveying an inappropriate sense of urgency like a stream from a fire hose, is loud, rapid, and incoherent; may talk nonstop and usually has no interest in feedback or conversation

circumstantial speech

adding unnecessary details when communicating with others, but the person eventually gets to the point

tangential speech

similar to circumstantial but they lost the point they were trying to make and never found it again

loose associations

represent the disordered way that a person is processing information; thoughts are only loosely connected in the person’s conversation

ie. “The sky’s the limit now that I have money. I took a flight, you know, from Kennedy. Drinking beer is a belly full of bags”

flight of ideas

a continuous flow of accelerated speech with abrupt changes from topic to topic, that is usually based on understandable associations or plays on words; speech is rapid, verbose, and circumstantial and may be disorganized/incoherent if severe

Often includes joking, puns, teasing

clang associations

the stringing together of words because of their rhyming sounds, without regard to their meaning

• delusions are grandiose, persecutory

• ie. exaggerated ideas about their own abilities in school, work, intelligence, society, money, or sexual activity

when doing the MSE what does assessment of thought content for the client with BPD often present as

grandiose delusions

manifested by highly inflated self-regard that is apparent in both the ideas expressed and the person’s behavior

persecutory delusions

believe that people are out ot get them, such as God is punishing them, the FBI is spying on them, or the mayor is harassing them

• high functioning prior to onset

• deficits affect functioning, such as impaired long-term and short-term memory, and the ability to concentrate and problem solve

when doing the MSE what does assessment of cognitive function for the client with BPD often present as

Altman Self-Rating Mania Scale (ASRM)

BPD assessment tool that is useful in capturing a picture of the patient’s placement on the depression to mania continuum; scores of 6+ suggest mania or hypomania and the need for further assessment/treatment

maintain safety

what is the goal for the acute phase of mania

• Hospitalization is usually required

• decrease activity

• increase food and fluids

• seclusion, restraint, and ECT if needed

what does planning consist of for the acute phase of mania/BPD

• patients are outpatient and focused on lifelong recovery

• avoid relapse

• continue to manage meds

what are the goals for the maintenance phase of mania/BPD

• problem solving

• relationships and work recovery

• support systems

what does planning consist of for the maintenance phase of mania/BPD

continuation phase

sometimes identified between the acute and maintenance phase; usually seen as starting at the point of initial response to meds and treatment, and lasting for 6-12 months of what may be termed early recovery

• the chronic and episodic nature of the disease

• how to identify and prevent relapses

• medication education, how to cope with med SE, and med adherence

  • med will need to be taken for a long time

• importance of maintaining a stable sleep schedule, good hygiene, eating, exercising, and finding ways to improve quality of life

• use of alcohol, drugs, caffeine, and OTC meds can cause relapse

• coping strategies to deal with work, interpersonal, and family problems to lower stress, enhance a sense of personal control, and increase community functioning

• Group and individual therapy are valuable for gaining insight and skills in relapse prevention, providing social support, increasing coping skills in interpersonal relationships, improving adherence to the med regimen, reducing functional morbidity, and decreasing the need for hospitalization

what does health teaching and promotion for BPD include

• prevent self-harm during depression

• set limits during mania and limit the setting

• have frequent team meetings

• minimize staff splitting

what does teamwork and safety for BPD clients include

• A substantial risk of harm to others or oneself is clear

• unable to control actions

• other measures have failed

what warrants the use of seclusions/restraints

seclusions/restraints

may be necessary when a patient is dangerously out of control, requires consent when it is an emergency, must have a written order authorized by a care provider that includes the type of restraint to use, or can be placed by a charge nurse, but they must obtain an order within a specific time frame

has strict protocols of how often to observe/document the behavior, offer the patient food and fluids, offer the bathroom, and measure vital signs

communication with one is secular is concrete, direct, and empathetic; gives reassurance that it is only temporary

should never be used for punishment or the convenience of the staff

• stable vital signs

• client is well hydrated

• adequate sleep and rest

• medication adherence

• improved coping

• stabilized role functioning

• should have decreasing energy and activity level, be eating and sleeping more, and communicating in more coherent ways

what does evaluation for BPD include

• lithium

• divalproex

• olanzapine

• Risperidone

• clonazepam

• lorazepam

what are the meds used for agitation associated with BPD

• lithium

• valproate

• carbamazepine

• lamotrigine

  • not very effective for the manic phase, but very helpful for the depressive phase

what are the first line treatments for BPD

lithium

what is the gold standard for treating mania and often the most effective for many clients, but requires frequent monitoring of labs for toxicity and therapeutic levels and SE

10-21 days

what is the onset for lithium

• reduces elation, grandiosity, expansiveness, flight of ideas, irritability, manipulation, anxiety, and self-injurious behavior

• controls insomnia, psychomotor agitation, threatening or assaultive behavior, distractibility, hypersexuality, and paranoia

what are the effects of lithium

0.6-1.2 mEq/L

what are the therapeutic levels of lithium

• N/V

• diarrhea

• thirst

• polyuria

• lethargy

• sedation

• fine hand tremor

• renal toxicity, goiter, and hypothyroidism with long term use

• monitor kidney function and thyroid levels

what side effects may a patient experience if their lithium levels are less that 1.5 mEq/L

• GI upset

• coarse hand tremor

• confusion

• hyper irritability of muscles

• electroencephalographic changes

• sedation

• incoordination

• withhold med, measure blood lithium levels, reevaluate dosage

what side effects may a patient experience if their lithium levels are 1.5-2.0 mEq/L

• ataxia

• giddiness

• serious electroencephalographic changes

• blurred vision

• clonic movements

• large output of diluted urine

• seizures

• stupor

• severe hypotension

• coma

• death usually secondary or due to pulmonary complications

• hospitalization is indicated, drug is stopped, excretion is hastened, whole bowel irrigation may be done to prevent further absorption

what side effects may a patient experience if their lithium levels are 2.0-2.5 mEq/L

• convulsions

• oliguria

• death

• hospitalization, stop the drug, excretion is hastened, whole bowel irrigation may be done to prevent further absorption, and hemodialysis may be used in severe cases

what side effects may a patient experience if their lithium levels are > 2.5 mEq/L

cardiac, renal, and thyroid disease, pregnancy

what are the contraindications of lithium

• take labs often

• monitor thyroid and kidney function

• stay well hydrated

• maintain a stable sodium levle

• contact HCP if at risk for dehydration due to N/V or diarrhea, which can all affect the levels of lithium in the blood and lead to toxic levels

what should patient education for lithium include

• valproate

• carbamazepine (Equetro)

• lamotrigine (Lamictal)

what anticonvulsants are used to treat BPD

valproate

medication used for acute mania and prevention of future manic episodes

• N/V

• weakness

• somnolence

• indigestion

• diarrhea

• dizziness

what are the SE of valproate

• liver function and hepatotoxicity

• platelets and coagulation studies for thrombocytopenia

what should the nurse monitor for the client taking valproate

pregancy

what is the one contraindication of valproate

carbamazepine (Equetro)

2nd line anticonvulsant used to treat acute mania and mixed states

• dizziness

• somnolence

• N/V

• ataxia

• constipation

• pruritus

• dry mouth

• weakness

• blurred vision

• speech problems

• toxic epidermal necrolysis and S-J syndrome

what are the side effects of carbamazepine (Equetro)

• liver enzymes for the first 8 weeks

• watch for bone marrow suppression and liver inflammation

• CBC to monitor for leukopenia and aplastic anemia

What should the nurse monitor for the client taking carbamazepine (Equetro)

• dizziness

• HA

• diplopia

• ataxia

• blurred vision

• measure

• somnolence

• rhinitis

• pharyngitis

what are the side effects of lamotrigine (Lamictal)

• rash, toxic epidermal necrolysis, and S-J syndrome

  • more common with co-admin of valproate, rapid dose increases, and doses exceeding the recommended upper limit

  • discontinue if rash appears

what should the nurse monitor for in the patient taking lamotrigine (Lamictal)

anticonvulsants

class of meds that is superior for continuously cycling patients, more effective when there is no family history of BPD, effective in diminishing impulsive and aggressive behavior in some nonpsychotic patients, helpful in cases of alcohol and benzo withdrawal, beneficial in controlling mania within 2 weeks and depression within 3 weeks or longer

second generation (SGNs) antipsychotics

class of meds approved for mania, augment mood stabilizers, and have sedative effects

• weight gain

• insulin resistance

• DM

• dyslipidemia

• CV impairment

what are the side effects of SGNs

• Olanzapine

• Ziprasidone

• Risperidone

• Quetiapine

• Lurasidone

• Quetiapine

• Symbax

• Cariprazine

what are the SGNs used to treat BPD

• ECT

• rTMS

what brain stimulation therapies are used to manage BPD

ECT

• brief seizures induced by low electrical current in the brain

• approved for depression, mania, and psychosis

• works more quickly than meds to improve depressive s/s (usually within the week)

• requires IV sedation and monitoring for short-term memory loss or disorientation in the hours/day following treatment

• 80% effective in adults

rTMS

• non-intrusive, magnetic pulses stimulate targeted brain areas taht results in changes in brain activity to address mood and improve cognitive function in patient with BPD

• Has fewer SE and the client is not sedated

• CBT to identify obstacles to med adherence, triggers to relapse, decrease stress, support a recovery lifestyle, and resolve relationship difficulties

• Interpersonal and rhythm therapy to regulate social and sleep routines, improve relationships, recognize symptoms, med compliance, and maintain a sleep schedule

• family-focused therapy to help improve communication among family members, especially during depressive and manic episodes

what are the psychological therapies used to treat BPD