Bipolar Disorder

Bipolar 1

client experiences at least one manic episode or a mixed episode (mania and depression symptoms together) and a depressive episode

Bipolar 11

bouts of depression with episodic occurrence of hypomania

cyclothymic

chronic mood disturbance involving many episodes of hypomania symptoms and depressed mood

hypomania

A mild manic state in which the individual seems infectiously merry, extremely talkative, charming, and tireless.

mania

a mood disorder marked by a hyperactive, wildly optimistic state

rapid cycling

client experiences four or more episodes of acute mania within a year

mood lability

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

Euthymic

normal, non-depressed, reasonably positive mood

when was the term manic depressive first coined

1913

when was the term bipolar disorder adopted by the American Psychiatric Association

1980

what were other common names for bipolar before the term was coined

circular insanity, dual form insanity

what percent of American adults has bipolar

4.4%

what percent of bipolar cases in America are considered severe

82.9%

does bipolar occur more in men or women

about the same

what does bipolar pose a high risk for, and in what stages

suicide, during both depression and mania

what is the 6th leading cause of disability in the middle age group

bipolar disoder

what is the exact etiology of bipolar disorder

it is unknown

what does scientific evidence support as the etiology for bipolar disorder

a chemical imbalance in the brain (the cause of the imbalance is unknown)

what theories appear to be the most credible about bipolar disorder

the ones that consider both hereditary factors and environmental triggers

pruning

When applied to brain development, the process by which unused connections in the brain atrophy and die.

what are the two main biological theories surrounding bipolar disorder

- genetics

- biochemical

what does genetics tell us about bipolar disorder

- one parent with bipolar risk for child is between 10-25%

- both parents increase risk by 2-3 times

- FAMIIAL RISK

which protein enzymes are being studied to determine role they play in bipolar

- ANK3

- CACNA1C

what does a biochemical theory explain to us about mania

excess of norepinephrine and dopamine

what does a biochemical theory explain to us about depression

deficiency of norepinephrine and dopamine

what neurotransmitter appears low in both states according to biochemical theories

serotonin

what has been known to trigger manic episodes according to biochemical thoeries

medications like steroids and SSRI's

psychosocial theories of bipolar

Credibility of psychosocial theories has declined in recent years.

Bipolar disorder is viewed as a disease of the brain.

theoretical integration

the combining of two or more theories to present a more comprehensive explanation of disease

what does bipolar disorder likely result from on an interaction between

genetic, biological and psychosocial factors

psychological

- emotions and attitudes

- learning

- beliefs

- stress management

social

- family

- peer relationships

- culture

- socioeconomics

biological

- physiological

- medications

- neurochemistry

- genetics

types of bipolar disorder

- bipolar 1

- bipolar 2

- cyclothymia

are the symptoms more dramatic in bipolar 1 or bipolar 2

bipolar 1

is bipolar 1 or bipolar 2 hospitalized more often

bipolar 1

manic symptoms associated with bipolar disease

- onset between 18-30

- mood can be elevated, expansive or irritable

- speech can be loud, punning, poor judgement, clanging or vulgar

- maybe weight loss

- gradiose delusions

- distracted

- hyperactive

- decreased need for sleep

- inappropriate dress

- flight of ideas

depressive symptoms associated with depression

- previous manic episodes

- feelings of worthlessness, guilt or hopelessness

- increased anger and irritability

- decrease interest in pleasure

- negative views

- fatigue and low energy

- decreased appetite

- constipation

- insomnia

- decreased libido

- suicidal precoupation

- may be agitated or have movement retardation

does bipolar 1 or bipolar 2 have a less impact on functioning

bipolar 2

what is judgement like with bipolar 2

normal judgement

what will someone with bipolar 2 never experience

an episode that meets the full criteria of mania or mixed symptomatology

what will a patient with cyclothymia never experiences

lack of hypomania or depression symptoms

how long must the symptoms be present for to be diagnosed with cyclothymia

at least 2 years

where does cyclothymia cause significant distress

in social, occupational or other areas of functioning

are children and adolescents easy to diagnose with bipolar

no, often very challenging

what is the lifetime prevalence for adolescent bipolar

1%

is bipolar common in children

no it is rare

what is true bipolar considered

a chronic illness

what do studies say about the development of bipolar disorder in youth

connection between ADHD: inattention, distractibility, impulsivity are overlapping symptoms

What is the diagnostic criteria for mania

abnormally and persistently elevated, expansive, or irritable mood

how long must the symptoms last to be diagnosed as mania

1 week

during the period of mood disturbances, the client must exhibit 3 or more of the following symptoms

- inflated self-esteem -grandiosity

- decreased need for sleep

- more talkative or pressure to keep talking

- flight of ideas, racing thoughts

- distractibility

- psychomotor agitation

- excessive involvement in pleasurable activities (sexual, spending money, foolish business investments, gambling)

what is stage 1 of mania called

hypomania

is hospitalization need for hypomania

might not be

what is mood like during hypomania

cheerful and expansive, underlying irritability

what is cognition/perception like during hypomania

ideas of great self-worth and ability

what is activity/behavior like during hypomania

increased motor activity, loud, talking and laughing a lot

is disturbance in functioning severe during hypomania

no

what is stage 2 of mania called

acute mania

is hospitalization needed for acute mania

might be

what is mood like during acute mania

euphoria and elation, labile, cry

what is cognition/perception like during acute mania

fragmented, psychotic (paranoid and grandiose thoughts)

what is activity/behavior like during acute mania

poor impulse control, days without sleeping, dress - flamboyant/bizarre, excessive make-up or jewelry

is disturbance in functioning severe during acute mania

yes

what are the goals of the nurse when a patient is in the acute mania phase

maintain safety, limit setting, and stabilization

what is stage 3 of mania called

delirious mania (grave form)

what is delirious mania

severe clouding of consciousness, rare with availability of antipsychotic meds

what is mood like during delirious mania

very labile, panic level of anxiety

what is cognition and perception like during delirious mania

confusion, disoriented, extremely distractible and incoherent

what is activity/behavior like during delirious mania

agitated, purposeless movements

what nursing assessment and clues should we recognize with a patient

- safety issues (risky behavior)

- "tell me what brought you here" (perception, situation)

- mood state

- speech pattern

- sleep pattern

- appetite - height/weight

- activity/behaviors

- thoughts/perceptions (deliriums, hallucinations)

- energy

- labs

- medications reconciliation (include vitamins, herbs, OTC) - adherence

- substance use

- collateral sources, if indicated

what are some nursing diagnoses we might find in patients suffering from bipolar

- potential for self-harm

- disturbed thought-process

- sleep disturbance

- imbalanced nutrition (less than body requirements)

what is a prioritized hypothesis for a patient that is diagnosed with potential for self-harm

patient will not harm self while hospitalized

what is a prioritized hypothesis for a patient that is diagnosed with disturbed thought process

patient verbalizes an accurate interpretation of environment

what is a prioritized hypothesis for a patient that is diagnosed with sleep disturbances

patient will sleep 6 hours a night and self report restful sleep before discharge

what is a prioritized hypothesis for a patient that is diagnosed with imbalanced nutrition (less than body requirements)

patient will eat a well-balanced diet with snacks to prevent weight loss

nursing interventions to take when caring for a person diagnosed with bipolar

- monitor safety, assess risk for harm to self/others

- decrease stimulation, assess eating habits, assess sleeping patterns

- contain symptoms of mania

- milieu management - controls the amount of stimulation (patient may not be appropriate for groups)

- do not argue, use therapeutic communication

- address behaviors in a timely manner, set limits

- provide psycho-education to client and family

- medication management, assess sx/response to tx (often antipsychotics used initially)

what topics may the nurse educated the patient and the family on

- medications/symptom management to client and family

- causes, cyclic nature of illness, symptoms of depression and mania ... usually life long

- importance of regular sleep pattern

- maintain a regular pattern of actvity

- support groups, crisis hotline, legal services, treatment

- helps to increase insight about the illness

what are the different treatment modalities a nurse may recommend to a patient diagnosed with bipolar disorder

- psychopharmacology

- individual therapy

- group therapy

- family therapy

- cognitive therapy

- ECT

psychopharmacology

the study of the effects of drugs on mind and behavior

individual therapy

treatment modality in which the client and clinician meet one-on-one

group therapy

therapy conducted with groups rather than individuals, permitting therapeutic benefits from group interaction

family therapy

therapy that treats the family as a system. Views an individual's unwanted behaviors as influenced by, or directed at, other family members

cognitive therapy

only when patient is ready. assist in identifying dysfunctional patterns of thinking, connect thoughts feelings and behaviors

ECT

when one fails to response to drug treatment, this may be used to treat depression and acute mania

what should we remember about recovery from bipolar disorder

- there is no cure for bipolar disorder

- recovery is possible in the sense of learning to prevent and minimize symptoms and to successfully cope with effects of the illness on mood, career, and social life

in bipolar disorder, what is recovery known as

a continuous process

what must the patient do to be in recovery from bipolar disorder:

- identify goals

- develop a treatment plan

- work on strategies to help the individual manage the bipolar illness

- clinician will serve as support person to help the individual achieve the previously identified goals

common anti-manic drug

lithium carbonate

common anti-convulsant drug

- valproic acid, divalproex (Depakote)

- OFF LABEL USE

what labs should be checked prior to use of mood stabilizers

CBC, LFT, TSH, chemistries, PREGNANCY TEST IN WOMEN OF CHILD-BEARINIG AGE

what was the first drug approved for treatment of mania by FDA

lithium

what is lithium carbonate

eskalith

what is lithium citrate

liquid

what is the chemical structure of lithium similar to and what must we inform our patients about

- similar to sodium

- if body is lacking sodium, lithium is reabsorbed into kidneys (ineffective)

is the lithium a PRN med

NO

what should we be sure about when our patients take lithium

- drinks fluid

- sufficient salt intake

what percent of lithium is excreted by kidneys and why is this important

- 95% excreted by kidneys

- assess renal function

Action of Lithiumu

- many unknowns

- alters sodium transport across cell membranes in nerve and muscle fibers

- alters metabolism of neurotransmitters

usual dosage of lithium

- 1800mg/day in divided doses (acute)

- 900-1200 mg/day (maintenance)