Bipolar, Schizophrenia, and Substance-Related Disorders

Bipolar and Related Disorders: Epidemiology and Characteristics

• Epidemiology and Statistics:

  • Prevalence: Bipolar disorder affects approximately $4.4\%$ of American adults.

  • Gender Distribution: The prevalence is equal between men and women.

  • Age of Onset: The average age of onset is $25$ years old.

  • Course of Illness: After the first manic episode, the disorder tends to be recurrent.

  • Mortality: There is an increased mortality rate in general, with a particularly high risk for suicide.

  • Socioeconomic Factors: The disorder is observed more frequently in higher socioeconomic classes.

  • Disability: It ranks as the $6^{th}$ leading cause of disability in the middle-aged group.

  • Treatment Response: It is considered treatable in approximately $33\%$ of cases, specifically for those who respond well to Lithium treatment.

• General Clinical Picture:

  • Characterized by mood swings ranging from profound depression to extreme euphoria (mania), separated by intervening periods of normalcy.

  • Psychotic Features: Delusions or hallucinations may or may not be present.

  • Seasonal Pattern: The onset of symptoms may reflect a seasonal pattern.

  • Depression Phase Symptoms: Low mood, low energy, low motivation, and high risk for suicide.

  • Acute Mania Phase Symptoms: High energy, hyperactivity, elevated mood, aggression with violence, and irritability.

  • Hypomania: A less severe form of mania that does not involve psychotic behaviors or marked impairment in functioning.

Classifications of Bipolar Disorders

• Bipolar I Disorder:

  • Definition: Characterized by a history of one or more manic episodes. The patient may also experience episodes of depression.

  • Specification: The diagnosis is specified by the current or most recent behavioral episode experienced.

  • Manic Episode Criteria: Symptoms must last at least $1$ week and be present most of the day, nearly every day (or any duration if hospitalization is deemed necessary).

• Bipolar II Disorder:

  • Definition: Characterized by recurrent bouts of major depression with the episodic occurrence of hypomania.

  • Hypomania Criteria: Symptoms must last at least $4$ consecutive days and be present most of the day, nearly every day.

  • Differentiating Factor: The client has never experienced a full manic episode. Symptoms are not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization.

• Cyclothymic Disorder:

  • Definition: A chronic mood disturbance lasting at least $2$ years in duration.

  • Criteria: Involves numerous periods of elevated mood that do not meet the full criteria for a hypomanic episode, alongside numerous periods of depressed mood of insufficient severity or duration to meet the criteria for a major depressive episode.

  • Stability: The individual is never without the symptoms for more than $2$ months.

• Rapid Cycling:

  • Definition: Characterized by $4$ episodes of depression and mania within a $12$-month period.

• Substance/Medication-Induced and Medical Condition-Induced Bipolar:

  • Antidepressant Trigger: A full hypomanic episode emerging during antidepressant treatment (medication or electroconvulsive therapy) that persists at a fully syndromal level beyond the physiological effect of the treatment is sufficient for a diagnosis.

  • Substances: Can result from either intoxication or withdrawal.

  • Medical Conditions: Associated conditions include thyroid disorders, stroke, traumatic brain injury (TBI), multiple sclerosis (MS), systemic lupus erythematosus (SLE), and AIDS.

Predisposing Factors and Biological Theories of Bipolar Disorder

• Etiology: The exact cause is unknown. The most credible theories suggest a combination of hereditary factors and environmental triggers, such as stressful life events.

• Comorbidities:

  • ADHD: The most common comorbidity in children and adolescents, with studies reporting comorbidity rates between $9\%$ and $94\%$.

• Biological Theories:

  • Genetics: If one parent has a mood disorder, the risk of the child developing a mood disorder is between $10\%$ and $25\%$.

  • Biochemical Influences: Mania is associated with a functional excess of norepinephrine and dopamine. Other involved neurotransmitters include Acetylcholine and Glutamate (an excitatory neurotransmitter found in excessive levels).

• Physiological Influences:

  • Depression: Associated with decreased anterior brain function on the left side.

  • Mania: Associated with greater right-side reductions in brain activity.

Stages of Mania

• Stage I: Hypomania:

  • Severity: Not severe enough to cause marked impairment or hospitalization.

  • Mood: Cheerful, expansive, with an underlying irritability that surfaces if desires are unfulfilled; volatile and fluctuating.

  • Cognition: Ideas of great worth and ability; rapid flow of ideas; easily distracted; difficulté with goal-directed activities.

  • Activity/Behavior: Increased motor activity; sociable but lacks depth; loud talk/laughing at inappropriate times; increased libido; possible anorexia; inappropriate behaviors.

• Stage II: Acute Mania:

  • Severity: Most individuals require hospitalization due to marked impairment.

  • Mood: Euphoria, elation, a continuous "high"; shifts rapidly to irritability, anger, or sadness.

  • Cognition: Fragmented and psychotic; racing thoughts; pressured speech (loquaciousness); hallucinations and delusions (paranoid or grandiose) are common.

  • Activity/Behavior: Excessive psychomotor activity; poor impulse control; excessive spending; unreliable reporting; denial of problems; diminished need for sleep; neglected hygiene; bizarre clothing choice (excessive makeup/jewelry).

• Stage III: Delirious Mania:

  • Severity: Rare due to modern medication; severe clouding of consciousness.

  • Mood: Very labile; despair converting to unrestrained ecstasy or indifference; potential for panic-level anxiety.

  • Cognition: Confusion, disorientation, stupor; religiosity; delusions of grandeur or persecution; auditory/visual hallucinations; incoherent.

  • Activity/Behavior: Frenzied, agitated, purposeless movements; high risk for exhaustion, self-injury, or death without intervention.

Nursing Assessment and Interventions for Bipolar Disorder

• Clinical Manifestations:

  • Clang Association: Speech pattern based on sound or rhymes.

  • General Findings: Labile mood, agitation, restlessness, impulsivity, grandiosity, demanding/manipulative behavior, poor judgment, attention-seeking.

• Nursing Diagnoses:

  • Risk for Violence: Self-Directed or Other-Directed.

  • Impaired Social Interaction.

  • Imbalanced Nutrition: Less Than Body Requirements.

  • Insomnia.

• Interventions:

  • Environment: Reduce stimuli, provide a private room, and ensure adequate staff.

  • Safety: Observe patient every $15$ minutes; maintain a calm attitude.

  • Nutrition: Provide high-calorie/high-protein finger foods; daily weighs; measure I&O (Input and Output); sit with them during meals.

Treatment Modalities for Bipolar Disorder

• Individual Psychotherapy: Interpersonal and Social Rhythm Therapy (IPSRT) is specifically designed for bipolar patients.

• Group and Cognitive Therapy: Employed for stability.

• Family Therapy: Reduces relapses and increases medication adherence.

• Electroconvulsive Therapy (ECT): Used primarily when patients do not tolerate or respond to Lithium. Succinylcholine (a muscle relaxant) is administered during the procedure.

Pharmacological Management of Bipolar Disorder

• Acute Mania in Children/Adolescents: Treatment includes Lithium, Risperidone, Aripiprazole, Quetiapine, Olanzapine, and Asenapine.

• Bipolar Depression Medications: Only three are approved: Olanzapine/Fluoxetine combination, Quetiapine, and Lurasidone.

• Lithium:

  • Indication: First-line treatment for Bipolar I.

  • Therapeutic Index: Narrow index of $0.4 - 1.2$.

  • Precautions: Avoid NSAIDs, diuretics, and laxatives due to toxicity risk.

• Anticonvulsants:

  • Carbamazepine: Can make oral contraceptives ineffective; report fever/sore throat (agranulocytosis risk); monitor for bleeding/edema; give before bed.

  • Valproic Acid (Depakote): Therapeutic level is $50 - 120\,mcg/mL$; monitor liver function (ALT/AST); teratogenic (causes birth defects); take with food.

  • Lamotrigine: Used for the depression phase; watch for Stevens-Johnson Syndrome (SJS), a painful, blistering rash.

• Other Agents:

  • Calcium Channel Blockers: Verapamil.

  • Atypical Antipsychotics: Olanzapine (watch WBCs), Ziprasidone (monitor for hypotension and widened QT intervals).

  • Common Side Effects: Hormonal changes, Agranulocytosis, Neuroleptic Malignant Syndrome (NMS), and Extrapyramidal Symptoms (EPS).

  • Anticholinergics: Benztropine, Diphenhydramine, and Trihexyphenidyl are used to treat EPS.

  • Antidepressants: Used with caution; Fluoxetine (SSRI) can cause sexual dysfunction (anorgasmia/impotence).

Schizophrenia and Thought Disorders: Statistics and Phases

• Overview: Schizophrenia causes longer hospitalizations and more fear than other mental illnesses.

• Life Expectancy: Individuals with Severe Mental Illness (SMI) like schizophrenia have a life span approximately $25$ years shorter than the general population.

• Suicide Risk: $20\% - 40\%$ attempt suicide; approximately $5\%$ die from it.

• Etymology: Derived from Greek skhizo (split) and phren (mind).

• The Four Phases of Schizophrenia:

  • Phase 1: Premorbid: Onset of personality changes; shyness, withdrawal, asocial/introverted behavior; few childhood friends.

  • Phase 2: Prodromal: Significant deterioration in function; worsening symptoms.

  • Phase 3: Active Psychotic: Prominent psychotic symptoms; requires hospitalization.

  • Phase 4: Residual: Psychotic symptoms are managed or absent, but other social/emotional symptoms remain.

Schizophrenia Spectrum and Other Psychotic Disorders

• Schizoaffective Disorder: Schizophrenic symptoms combined with strong elements of mania or depression. Hallucinations/delusions must occur for at least $2$ weeks in the absence of a major mood episode.

• Schizophreniform Disorder: Same symptoms as schizophrenia but lasting at least $1$ month and less than $6$ months. If symptoms persist beyond $6$ months, the diagnosis changes to Schizophrenia.

• Brief Psychotic Disorder: Sudden onset of symptoms lasting more than $1$ day but less than $1$ month; return to full normalcy.

• Delusional Disorder: Presence of delusions for at least $1$ month without prominent hallucinations.

  • Subtypes: Erotomanic (famous person in love with them), Grandiose (irrational ideas of worth/power), Jealous (infidelity belief), Persecutory (belief of being followed/poisoned—most common), Somatic (belief of medical condition), Mixed.

Clinical Assessment: Positive and Negative Symptoms

• Positive Symptoms (Excess/Distortion):

  • Delusions: Fixed false beliefs (Persecutory, Referential, Grandiose, Somatic, Erotomanic, Control/Influence, Nihilistic, Jealous).

  • Hallucinations: Auditory (most common), Visual ($27\%$ prevalence), Tactile (formication), Olfactory, Gustatory.

  • Speech Patterns: Loose association, Neologisms, Clang Association, Word Salad, Echolalia, Perseveration, Circumstantiality, Tangentiality.

  • Behavior: Echopraxia (imitating movements).

• Negative Symptoms (Deficit):

  • Affect: Flat or inappropriate.

  • Behavior: Waxy flexibility (limbs stay in placed positions), bizarre postures, pacing, rocking.

  • Anosognosia: Lack of awareness of the illness; a key predictor of nonadherence and relapse.

Comprehensive Treatment and Management of Schizophrenia

• Multidisciplinary Effort: Includes pharmacotherapy, living skills training, social skills training, and family therapy.

• PACT (Program of Assertive Community Treatment): A team-based, proactive approach providing community-based treatment and basic living skills.

• Pharmacology:

  • Haloperidol (1st Gen/Typical): High risk for EPS; watch for Neuroleptic Malignant Syndrome (NMS: high fever, rigidity, mental status change).

  • Clozapine & Risperidone (2nd Gen/Atypical): Indicated for treatment-resistant patients; high risk for infection; monitor CBC/WBC and absolute neutrophil counts. Normal side effects include weight gain and drooling.

• Nursing Actions: Establish trust, use a passive approach, avoid touching without warning, and do not reinforce hallucinations/delusions. Ask the patient to describe hallucinations and listen to music for distraction.

Substance-Related and Addictive Disorders

• Core Definitions:

  • Addiction: Compulsive requirement generating distress if unfulfilled; interferes with life role obligations.

  • Intoxication: Disturbance in cognition, perception, and level of consciousness directly attributable to a psychoactive drug.

  • Withdrawal: Physiological/psychological symptoms occurring upon abrupt reduction of a long-term substance.

• Predisposing Factors:

  • Genetics: Accounting for $40\% - 60\%$ of vulnerability to alcoholism.

  • Psychological: Personality and cognitive factors.

  • Sociocultural: Social learning and cultural influences.

Alcohol Use Disorder: Progression and Effects

• Statistics: Legal intoxication is $0.08\%$ BAC. Alcohol is metabolized at $0.5\,oz/hr$. It is the $3^{rd}$ leading preventable cause of death in the US ($88,000$ deaths annually).

• Metabolism: Metabolized in the liver to acetaldehyde, a CNS depressant.

• Jellinek’s Four Phases of Alcoholism:

  • Phase I: Prealcoholic: Use to relieve stress; tolerance develops.

  • Phase II: Early Alcoholic: Begins with blackouts; sneaking drinks; excessive denial/rationalization.

  • Phase III: Crucial: Physiological addiction; loss of control; binge drinking ($BAC \ge 0.08\,g/dL$); loss of jobs/relationships.

  • Phase IV: Chronic: Emotional/physical disintegration; intoxicated more than sober; life-threatening manifestations.

• Physical Effects:

  • Peripheral Neuropathy and Myopathy: From thiamine deficiency.

  • Wernicke's Encephalopathy: Most serious thiamine ($Vitamin\,B_1$) deficiency; symptoms include ocular muscle paralysis, diplopia, and ataxia.

  • Korsakoff’s Psychosis: Confusion and memory loss following Wernicke's.

  • Liver Problems: Cirrhosis, portal hypertension, ascites, and hepatic encephalopathy.

  • Fetal Alcohol Syndrome (FAS): Leading cause of mental retardation in the US.

Management of Substance Withdrawal

• Alcohol Withdrawal: Starts within $4-12$ hours of cessation. Intoxication levels are $100 - 200\,mg/dL$.

  • Tools: CIWA scale.

  • Medications: Librium (Chlordiazepoxide) or Ativan (Benzodiazepines).

  • Precautions: Seizure precautions and prevention of delirium.

• Opioid Withdrawal:

  • Tools: C.O.W.S scale. (Clinical Opioid withdrawal scale)

  • Symptoms: Dysphoria, muscle aches, lacrimation, pupil dilation, fever, insomnia.

  • Treatment: Methadone for withdrawal; stress oral hygiene for "meth mouth."

• Stimulants and Other Classes:

  • Stimulants: Withdrawal involves "crashing," fatigue, and nightmares.

  • Caffeine: Withdrawal causes HA (headache), N&V (nausea and vomiting).

  • Nicotine: Withdrawal includes decreased HR and weight gain.

  • Inhalants: Readily available/legal; causes neurological and PNS damage.

Nursing Process for Substance Disorders

• Assessment Tools: CAGE questionnaire, AUDIT, toxicology screening, CMP.

• Interventions: CBT (Cognitive Behavioral Therapy), group therapy, hydration, and safety.

• Support Systems: NA (Narcotics Anonymous), AA (Alcoholics Anonymous), AL-ANON.

• Deterrent Therapy: Disulfiram (Antabuse). Must not be given within $2$ weeks of alcohol consumption; ingestion causes extreme discomfort or death.

Comprehensive Glossary of Terms

• Anhedonia: Inability to experience pleasure.

• Ascites: Fluid accumulation in the abdomen from liver failure.

• Catatonia: Motor disturbance (stupor to agitation).

• Codependency: Patterns within families harboring secrets of abuse or pathological conditions.

• Dual Diagnosis: Coexisting mental illness and substance disorder.

• Esophageal Varices: Distended veins in the esophagus from liver cirrhosis.

• Extrapyramidal Symptoms (EPS): Dyskinesia, dystonia, and Parkinsonism resulting from dopamine blockade.

• Magical Thinking: Belief that thoughts control situations or people.

• Neuroleptic Malignant Syndrome (NMS): Life-threatening emergency with fever, rigidity, and mental status changes.

• Social Skills Training: Management of interpersonal communication and response perception.

• Waxy Flexibility: Body parts remain in bizarre positions where they are placed.

• Assessment:
  
  

  • Clinical evaluation is crucial to differentiate schizoaffective disorder from schizophrenia and mood disorders.

  • Key Symptoms:

  • Hallucinations (auditory or visual)

  • Delusions (fixed false beliefs)

  • Mood disturbances (depression or mania)

  • Duration: Psychotic symptoms must occur for at least 2 weeks without a major mood episode.

  • Diagnostic Criteria:

  • Must meet criteria for a mood episode (depressive or manic) that overlaps with the psychotic symptoms.

  • Assessment tools may include clinical interviews, psychological testing, and collateral information from family or prior medical records.
    
    

• Treatment Modalities:
  
  

  • Pharmacotherapy:

  • Atypical antipsychotics are commonly used (e.g., Risperidone, Olanzapine, Quetiapine).

  • Mood stabilizers may be prescribed for mood symptoms (e.g., Lithium, Valproic Acid).

  • Antidepressants can be considered for depressive episodes, used cautiously and with monitoring.
    
    

  • Psychotherapy:

  • Individual therapy to provide support and coping strategies.

  • Family therapy may improve support systems and treatment adherence.

  • Cognitive Behavioral Therapy (CBT) to address distortions in thought and improve function.

  • Electroconvulsive Therapy (ECT):

  • Considered for severe cases, especially if there is a risk of suicide or illness severity where other treatments have failed.