Bipolar

Patient-Centered Care in Acute Mania

  • Key focus: Safety

    • Safety is paramount, especially as patients in manic episodes are prone to impulsive behaviors.

    • Patients may exhibit argumentative tendencies and heightened energy, increasing the likelihood of escalating behavior.

  • Assessment needs:

    • Always assess for suicidal thoughts.

    • Monitor for escalating behaviors.

    • Strive to decrease stimulation in the environment without resorting to isolation, as patients often desire social interaction.

  • Environment management:

    • Pay close attention to background noise (music, TV, etc.) that may increase patient agitation.

    • In certain situations, isolation might be necessary, but typically, patients in a manic phase resist isolation.

  • Activities & Engagement:

    • Engage patients in short, focused physical activities rather than longer, detailed games (e.g., Monopoly).

    • Protect patients from poor judgments and impulsive actions for their safety.

    • Limit the amount of clothing a patient can have access to, as manic patients often change clothes frequently.

    • Provide portable food options that patients can consume while on the move (e.g., granola bars, chicken fingers).

  • Communication strategies:

    • Use calm, matter-of-fact, and specific language to convey instructions.

    • Avoid engaging in power struggles; acknowledge their feelings without reinforcing delusions of grandeur.

    • Emphasize and reinforce good behavior, which is often overlooked in mental health care.

    • Utilize therapeutic communication techniques consistently.

Medications for Bipolar Disorder

  • Gold standard treatment: Lithium

    • Known for being a mood stabilizer.

  • Other medications:

    • Tegretol (Carbamazepine)

    • Lamictal (Lamotrigine)

    • Antipsychotic medications like Risperidone and Seroquel.

    • Antidepressants and benzodiazepines (e.g., Xanax, Ativan) may also be prescribed.

  • Monitoring Lithium therapy:

    • Risk of lithium toxicity necessitates regular blood tests.

    • Initial testing is typically weekly until stable levels are established, followed by checks every three months (usually 12 hours post last dose).

    • Patients must:

    • Avoid excessive caffeine.

    • Maintain a consistent sodium intake.

    • Consume between 2500-3000 ml of fluids daily.

  • Symptoms of lithium toxicity:

    • Muscle weakness and poor coordination.

    • Severe gastrointestinal symptoms (diarrhea, vomiting) and elevated temperature.

    • Monitor for these symptoms as indicators of potential toxicity.

Psychotic Disorders Overview

  • Definition:

    • Not all bipolar cases qualify as psychotic disorders.

    • Features of mania can align with psychotic symptoms, primarily in their manic forms.

  • Most recognized psychotic disorder: Schizophrenia

    • Typical onset is late teens to early 20s, but can appear in childhood and later adulthood.

    • Stressors contributing to onset include increased responsibilities and possible substance use.

  • Classification of psychotic disorders:

    • Delusional Disorder: Stable false beliefs without bizarre behavior and minor hallucinations.

    • Brief Psychotic Disorder: Symptoms last from one day to one month.

    • Schizophreniform: Symptoms last from one month to less than six months, resembling schizophrenia.

    • Schizoaffective Disorder: Combination of mood disorder symptoms and schizophrenia symptoms. Can manifest as bipolar or depressive types.

    • Catatonic Features: Exhibiting abnormal motor behavior and possibly impaired reality.

Characteristics of Schizophrenia

  • Psychotic features:

    • Delusions: False beliefs generally categorized into types:

    • Ideas of Reference: Believing events or comments are relevant to oneself.

    • Persecutory Delusions: Feeling targeted by others for harm.

    • Grandiosity: Believing one has exceptional power or influence.

    • Somatic Delusions: Believing one's body is changing in an unusual manner.

    • Jealous Delusions: Unfounded beliefs about infidelity.

    • Religious Delusions: Preoccupations with religious subjects or beliefs.

    • Magical Thinking: Perceived influence over events or other individuals through actions or thoughts.

    • Hallucinations:

    • Perceptual experiences that occur without any sensory input. Common types include:

      • Auditory: Hearing voices or sounds.

      • Visual: Seeing things or flashes.

      • Olfactory: Smelling things that aren’t present.

      • Gustatory: Altered taste perceptions.

      • Tactile: Feeling sensations that are not there (e.g., presence of bugs).

  • Speech alterations:

    • Associative Looseness: Inability to maintain a single thought leading to fragmented speech patterns.

    • Echolalia: Repetition of words spoken by others.

    • Neologisms: Creating new words that only have meaning for the patient.

    • Clang Associations: Rhyming or rhythm-based speech lacking meaning.

    • Word Salad: Jumbled words devoid of coherence.

Negative and Cognitive Symptoms

  • Negative Symptoms:

    • Diminished emotional expression.

    • Lack of motivation or drive.

    • Withdrawal from social interactions.

  • Cognitive Impairments:

    • Difficulty with attention, memory, and decision-making skills.

Management of Patients with Psychotic Disorders

  • Establishing a safety-focused environment is critical.

  • Building a trusting relationship without arguing or agreeing with the patient's distorted beliefs is essential.

  • Teach patients to recognize their symptoms and the importance of maintaining medication adherence for recovery.

Medications for Schizophrenia

  • Awareness of first-generation (older) versus second-generation (newer) antipsychotics is essential.

  • New treatments may include injectables that alleviate the need for daily dosing.

Extrapyramidal Symptoms (EPS)

  • Early symptoms associated with antipsychotic medication use include EPS; they are treatable with medications like Cogentin (benztropine).

  • Tardive Dyskinesia: A late-onset syndrome characterized by involuntary movements, typically developing after long-term use of antipsychotics, with no effective treatment available once established.

  • Regular assessments are necessary, with evaluations scheduled at twelve months and every three months thereafter, especially when using first-generation antipsychotics.

Conclusion

  • Emphasizing early recognition of EPS and transitioning to newer medications can help mitigate late-onset symptoms in patients receiving antipsychotic treatment.

Final Thoughts

  • Always prioritize patient safety and build a trusting rapport. Routine follow-ups and symptom management education enhance treatment effectiveness.