Bipolar disorders

What is flight of ideas?

Abrupt change; rapid skipping from topic to topic

What are clang associations?

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

What is mania?

periods of great excitement,

euphoria,

delusions, and

overactivity.

What is a mixed episode?

A mood episode including symptoms of both depression and mania occurring simultaneously

Depressive Mixed Episode - mostly depressive with a couple of manic symptoms

Mixed Manic Episode- mostly manic with a couple of depressed symptoms

DSM V reflects the above more closely than just saying 'mixed'

What is the gold standard of treatment for those with bipolar

Lithium

What kind of fluids should a person avoid while taking Lithium?

They should avoid bevarages that are contain caffeine

How should a person manage their sodium intake while taking lithium?

Maintain normal intake.

How much fluids should a person take while on lithium?

At least 2,500 to 3,000ml per day

Why is developing lithium toxicity high?

Due to the narrow margin between therapeutic doses and toxic levels

What is the difference between Bipolar I and Bipolar II?

Bipolar I has episodes primarily manic with at least 1 depressive episode; Bipolar II has episodes primarily of depression with at least 1 episode of hypomania

What is the criteria for a manic episode?

> 1 week of >3 DIG FAST symptoms

Distractibility

Impulsivity

Grandiosity

Flight of Ideas

Agitation

Sleep (low)

Talkativeness (pressured speech)

What is the criteria for a hypomanic episode?

Less severe mania >4 days. Does not cause marked social impairment or hospitalization

What is cyclothymic disorder?

Chronic mood disturbance that has a least a 2 year duration.

Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either bipolar I or bipolar II disorder

What are the atypical antipsychotic medication approved by the FDA for the treatment of mania or bipolar disorder?

olanzapine (Zyprexa)

risperidone (Risperdal)

quetiapine (Seroquel)

What are the side effects of lithium?

fine hand tremors, polyuria, thirst, mild nausea, weight gain, cognitive problems

What are some early signs of lithium toxicity?

increased nausea, vomiting, diarrhea, thirst, polyuria, slurred speech, muscle weakness,

What are some signs of advanced lithium toxicity?

coarse hand tremor, persistent G.I upset, mental confusion, muscle hyperirritability, EEG changes, incoordination

What are some signs of severe lithium toxicity?

ataxia, convulsions and oliguria, blurred vision, clonic movements, large output of diluted urine, tinnitus, seizures, severe hypotension, stupor, coma

What are some contraindications of lithium?

All individuals with cardiovascular disease, brain damage, renal disease, thyroid disease, or myasthenia gravis.

What are some emergency measures that can be taken when lithium toxicity is present?

gastric lavage

administration of mannitol, urea, aminophylline

extreme cases require hemodialysis

What is the work up required prior to starting a patient on lithium?

Thyroid panel ( T3, T4, TSH, CBC, BUN, Creatine and electrolytes)

UA

ECG

Pregnancy test

What are some dieuretics that raise lithium levels?

Thiazides,

Ethacrynic Acid,

Spironolactone,

Triamterene

What are some NSAIDS that raise lithium levels?

Indomeththacin (Indocin),

Ibuprofen,

Naproxen,

Sulindac (Clinoril),

Piroxicam (Feldene),

mefenamic acid (Ponstel)

What are some antibiotics that raise lithium levels?

Metronidazole (Flagyl) and Tetracyclines

What are some medications that lower lithium levels?

Theophylline/Aminophylline

caffeine

Acetazolamide

Osmotic Diuretics (Mannitol)

What are some medications that can cause serious potential interactions (nuerological toxicity or death) with lithium?

Verapamil and nueroleptics

How long before lithium starts to take effect for patients?

1-3 weeks for therapeutic effects to become noticeable

What is the sodium diet of a patient on Lithium?

Should consume normal (adequate) amounts of sodium along with 2500 to 3000ml of water per day

What are some foods one can give to a patient on lithium to keep caloric intake up?

High calorie/High Protein: protein shakes, smoothies, granola bars

Easy to eat foods: Cheese sticks, sandwiches, chicken strips

Nutrious and Calorie Dense: Nuts, yogurt, dried fruits

Why is it important for a patient to keep hydrated while on lithium?

drinking water or electrolytes will help compensate for increased urination

What are some anticonvulsants that treat bipolar disorders?

Valoporic Acid (Depakote)

Carbamazepine (Tegretol)

lamotrigine (Lamictal)

What can treat patients experiencing acute mania or psychomotor agitation?

antianxiety meds like Clonazapam and lorazepam

What kind of medications can help those who are continuously cycling or having no family history of bipolar disorder?

anticonvulsants like

valproate

carbamazepine

lamotrigine

Which medications are known to have sedative effects during early phase treatment which have mood stablizing properties?

atypical meds like olanzapine or risperdone

What is the acute phase of treatment for bipolar disorder?

Maintain safety and medically stabalize the patient

What is the continuation phase of treatment for bipolar disorder?

Address patient education needs and maintain medication regime

What is the maintenance phase of treatment for bipolar disorder?

prevent relapse

What kind of foods are recommended during a manic episode?

high calorie snacks

What is the therapeutic blood level of lithium?

0.8-1.4 mEq/L

What is the maintenance blood level for lithium?

0.4-1.3 mEq/L

What is the toxic blood level for lithium?

1.5 mEq/L and above

What is likely to occur when a patient taking lithium carbonate has low sodium levels?

lithium toxicity

What are some communication strategies that are effective with patients in acute mania

Display a firm, calm approach

Express short concise explanations or statements

remain neutral

maintain consistency

conduct frequent staff meetings

hear and act upon legitimate compplaints

firmly redirect energy

What are some outcomes expected during acute mania?

-Be well hydrated

-Maintain stable cardiac status

-Get sufficient sleep

-Demonstrate self control with the aid of staff and medications

-make no attempt of self-harm

What are some outcomes expected during continuation and maintainence phase?

-patient and family will attend psychoeducational classes

-knowledge of disease

-recognition of importance of medication

-recognition of other risk factors for relapse and early signs

-support groups

-therapy groups

-communication and problem soolving skills

What are some plans for a patient during acute mania?

-decreasing excessive physical activity

-maintaining adequate food and fluid intake-ensuring at least 4-6 hours of sleep

-alleviating any bowel or bladder problems

-intervening to ensure self-care needs are met

-providing careful medication management

what are some plans for a patient during the continuation and maintenance phase?

-patient's interpersonal skills

-patient's stress-reduction skills

-cognitive functioning that is associated with nonadherence to medication

-employment status and any legal issues

-social support systems

-individualized relapse prevention plan

What is a priority during the acute manic phase?

safety

How should one talk to a patient during a manic episode?

Set limits in a firm, non-threatening, and neutral manner

What are some examples of milieu therapy?

-environments with decreased stimuli

-spaces for writing, drawing or pacing/walking

What should you do if you notice a patient with bipolar starts to get agitated?

redirect them to their room

When should seclusin be used for a patient with bipolar disorder?

When all other de-escalation techniques have been used and failed

What is the range for early lithium toxicity?

<1.5 mEq/L

What is the range for advanced lithium toxicity?

1.5-2.0 mEq/L

What is the range for severe lithium toxicity?

2.0-2.5 mEq/L

What is likely to occur when a patient taking lithium carbonate has low sodium levels?

Lithium toxicity

What medications can help with treatment resistent mania and psychomotor agitation?

Anxiolytics like clonazepam (Klonopin) and lorazepam (Ativan)

What medications have sedative properties for those who have bipolar disorder?

Atypical antipsychotics:

olanzapine (Zyprexa)

risperidone (Risperdol)

ariprazole (Abilify)

ziprasidone (Geodon)

quetiapine (Seoquel)