Bipolar

Bipolar Disorder and Anticonvulsant Therapy

Tiffany Pipitone MSN, RN, PMH-BC

Objectives

  • Discuss the role of mania and mood lability in mental disorders.

  • Delineate the clinical symptoms and course of bipolar disorder.

  • Develop strategies to establish a patient-centered, recovery-oriented therapeutic relationship with a person with bipolar disorder.

  • Apply a person-centered, recovery-oriented nursing process for persons with bipolar disorder.

  • Identify medications used to treat people with bipolar disorder and evaluate their effectiveness.

  • Develop wellness strategies for persons with bipolar disorder.

Understanding Bipolar Disorder

Emotional Experience

  • Individuals with bipolar disorder experience emotional highs (mania) and lows (depression).

  • Mood swings may be better described as an emotional roller coaster rather than abrupt changes.

Overview of Bipolar Disorder

  • Characterized by alternating periods of mania or hypomania and depression.

  • Classifications:

    • Bipolar I: Involves at least one full manic episode.

    • Bipolar II: Hypomanic episodes alternate with major depression.

    • Cyclothymic disorder: Hypomanic episodes alternate with depressive episodes that do not meet criteria for major depression.

Mania Characteristics

Symptoms of Mania

  • Elevated, expansive, or irritable mood.

  • Grandiosity: inflated self-esteem, may include grandiose delusions.

  • Pressured speech: more talkative than usual, difficult to interrupt.

  • Flight of ideas or racing thoughts, increased distractibility.

  • Decreased need for sleep, increased energy.

Impacts of Mania

  • Goal-directed activity may deteriorate into hyperactivity and disorganized behavior.

  • Impairment of social, occupational, and interpersonal functions.

  • High involvement in pleasurable activities with disregard for painful consequences.

Causes of Mania

  • Can be associated with medical disorders, certain medications, and metabolic abnormalities.

  • Mood lability refers to rapid swings between moods with little external cause.

Epidemiology and Etiology

Prevalence and Onset

  • Estimated prevalence of bipolar disorder: 1% to 4%.

  • Onset typically between ages 14 to 21, fewer cases after age 40.

  • Higher occurrence in females, who may have rapid cycling and higher lifetime prevalence of depression.

Etiological Factors

  • Biologic, chronobiologic, and genetic theories.

  • Psychological, social factors, and stress-related theories influence recovery-oriented interventions.

Comorbidity and Associated Conditions

Common Comorbidities

  • Anxiety disorders (panic disorder, social phobia).

  • Substance use disorders complicate the illness and treatment compliance.

  • Other associations include IBS, asthma, and migraines.

Clinical Features of Bipolar I

Diagnostic Criteria for Manic Episodes

  • Must present 3 out of the following 7 symptoms:

    • Inflated self-esteem/grandiosity

    • Decreased need for sleep

    • Increased talkativeness

    • Distractibility

    • Flight of ideas

    • Increased goal-directed activities

    • Excessive involvement in risky behaviors.

  • Symptoms must cause marked impairment or not be attributable to physiological effects.

Family and Social Impact

Effects on Families

  • Bipolar disorder can lead to significant family distress: emotional instability due to erratic behavior, impulsive spending, and relationship strain.

Recovery-Oriented Care

Goals of Treatment

  • To minimize or prevent manic and depressive episodes.

  • Treat with a collaborative interdisciplinary team: nurses, physicians, social workers.

  • Focus on therapies: medications, psychotherapy, education, and support.

Safety Concerns

Suicide Risk

  • Elevated risk during both depressive (may feel life is not worth living) and manic (due to impulsivity) episodes.

  • Recovery stage may be accompanied by feelings of devastation about past behaviors.

Nursing Assessments and Interventions

Nursing Assessment

  • Conduct thorough physical, psychosocial, and mental health assessments.

  • Evaluate risks for relapse and monitor overall wellbeing.

Nursing Interventions

  • Establish recovery and wellness goals, focusing on sleep, nutrition, and hydration.

  • Educate about medications and the importance of adherence.

Pharmacological Treatment

Mood Stabilizers

  • Lithium Carbonate: Monitor levels closely, side effects include nausea, weight gain, and tremors.

  • Divalproex Sodium: Anticonvulsant side effects include sedation and liver toxicity.

  • Carbamazepine: Risk of aplastic anemia, requiring regular CBC checks.

  • Lamotrigine: Warning of serious skin rashes, monitoring for CNS side effects.

Psychoeducation

Teaching Strategies

  • Educate about the illness, medication adherence, and warning signs of relapse.

  • Involve family members in the education to enhance supportive care.

Evaluation

Treatment Outcomes

  • Desired outcomes include mood stabilization and improved quality of life.

  • Utilize nursing observations and patient self-report for ongoing evaluation.