Bipolar and related disorders

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  1. mania
    exaggerated euphoria or irritability
  2. Bipolar I disorder
    • - mood disorder that is characterized by at least one week-long manic episode that results in excessive activity and energy
    • - may have difficulty maintaining social connections and employment
    • - psychosis may occur during manic episodes
    • - usual onset age in 18 years
    • - tends to begin with a depressive episode (in women) 
    • - more common in males. everything else for females
  3. mania must of three of the following
    • - extreme drive and energy
    • - inflated sense of self-importance
    • - drastically reduced sleep requirements
    • excessive talking combined with pressured speech
    • - personal feeling of racing thoughts 
    • - distraction by environmental events
    • - unusually obsessed with and overfocused on goals
    • - purposeless arousal and movement
    • - dangerous activities such as indiscriminate spending, reckless sexual encounters, or risky investments
  4. euphoric mania
    - feels wonderful in the beginning but progresses towards loss of control and confusion
  5. dysphoric mania
    • a mixed state or agitated depression.with depressive symptoms along with mania 
    • - irritable
    • - angry
    • - suicidal 
    • - hypersexual 
    • may experience: panic attacks, pressure speech, agitation, severe insomnia or grandiosity as well as persecutory delusions and confusion
  6. Bipolar II disorder
    • low-level mania (hypomania) alternates with profound depression 
    • it tends to be euphoric and often increases functioning
    • - accompanied by excessive activity and energy for at least four days and involves at least 3 of the characteristics listed under mania
    • - feature of psychosis do not occur in mania portion but it can occur during the depressive side of the disorder
    • - risk for suicide but hospitalization is rare
    • - usual onset is 20 years
    • - more common in females
  7. Cyclothymic disorder
    • symptoms of hypomania alternate with symptoms of mild to moderate depression for at least two years in adults and one year in children 
    • - tend to have irritable hypomanic episodes 
    • - not severe enough to disturb socially and occupationally
  8. rapid cycling
    • - experience 4 mood episoides in a 12 month period 
    • - can occur within the course of a month, even within 24 hours 
    • - associated with more severe s/s: poor global functioning, high recurrence risk, resistance to conventional somatic treatments
  9. biology theories
    • Genetic
    • - twin studies and family studies support genetic vulnerability

    • Neurobiological
    • – early studies show association with excess of norepinephrine and dopamine with mania; more recently studies have expanded to include acetylcholine implications

    • Neuroendocrine
    • – hypothyroidism is knows to be associated with depression and client’s experiencing rapid cycling
  10. Psychological Factors
    —Bipolar disorder and schizophrenia are being viewed as diseases of the brain based on research and psychosocial theories, although valid, are declining in credibility

    —The diathesis-stress model does support the psychological factors: genetic predisposition alone does not mean the disease will occur
  11. Environmental Factors
    —Bipolar is a worldwide problem that generally affects all races and ethnic groups equally

    —Some research is showing this disorder is more prevalent in upper socioeconomic classes although exact reason is unclear
  12. s/s of mania
    Image Upload 1
  13. Mood
    • typically euphoric associated with mania
    • that is unstable
    • - mood is cheerful and expansive
    • - irritability and anger when frustrated
    • - perceptions of self are elated
    • - may laugh, joke and talk in continuous stream
  14. general assessment includes
    • - mood
    • - behavior
    • - thought process and speech patterns
    • - cognition function
  15. outcome: acute phase
    injury prevention, reflect both physiological and psychological issues
  16. outcome: continuation phase
    last 4-9 months. overall goal is relapse prevention 

    • pseudoeducational classes for patient and family related to 
    • - knowledge of dx process
    • - knowledge of medication 
    • - consequences of substance abuse addiction for predicting future relapse
    • - knowledge of early s/s of relapse

    support group therapy 

    communication and problem-solving skills training
  17. outcome maintenance phase
    • continues focus on prevention of relapse and limitation on thr severity and duration of future episodes 
    • - leaning interpersonal strategies 
    • - psychotherpay, group, etc.
  18. acute phase
    • - focus on medical stabilization 
    • - maintaining safety
    • - self-care needs
  19. continuation phase
    • - maintain medication adherence and prevention of relapse 
    • - psychoeducational teaching
    • - referrals
  20. maintenance phase
    - preventing relapse and limiting severity of future episodes
  21. acute phase: depressive episoides
    • - same s/s and risk as major depression 
    • - hospitalization may be required
    • - lithium and lamictal are first line of tx
    • - second generation drugs may be added if psychotic features begin to occur
  22. nursing interventions: hypomania to mania
    - Reduce environmental stimuli

    - Assign private room

    - Keep lighting low and noise level low

    - Provide structured schedule activities as tolerated

    - Remove hazardous objects

    - Stay with client who is hyperactive and agitated

    - Administer tranquilizers as ordered

    - Maintain and convey a calm attitude

    - Respond in a  matter-of fact manner
  23. treatment modlaities
    - —Individual psychotherapy

    —- Group therapy

    —- Family therapy

    - —Cognitive therapy

    —- Electroconvulsive therapy

    —- Psychopharmacology
  24. mood stablizers

    • anticonvulsants
    • -Valproate (Depakote, Depakene)

    - Carbamazepine (Tegretol)

    - Lamotrigine (Lamictal)

    - Gabapentin (Neurontin)

    - Topiramate (Topamax)

    - Oxcarbazepine (Trileptal)
  25. Lithium
    • [mood stabilizer]treatment of acute mania, and hypomania.  Maintenance treatment of Bipolar I and II.  Not very effective for mixed mania, substance induced mania, and rapid cycling
    • - requires blood monitoring of med levels and kidney function every 3 months
    • - can cause hypothyroidism 
    • - toxic affects in heat, with inc. sweating, poor water intake or excessive caffeine intake
    • - toxic effect can mimic alcohol intoxication
    • - can cause weight gain, excessive thirst, and lethargy
  26. lithium carbonate
    • effective in reducing
    • - elation, grandiosity, and expansiveness
    • - flights of ideas
    • - irritability and manipulation 
    • - anxiety
    • to a lesser exten
    • - insomnia
    • - psychomotor agitation
    • - threatening or abusive behavior
    • - distractibility
    • - hypersexuality
    • - paranoia
  27. lithium carbonate therapeutic levels
    • –Therapeutic
    • blood level 0.8 to 1.4 mEq/L

    • –Maintenance
    • blood level 0.4 to 1.3 mEq/L

    • –Toxic
    • blood level: 1.5 to 2.0 mEq/L
    • - blurred vision, n/v, severe diarrhea, tinnitus, ataxia

    for older adults, start low go slow
  28. lithium SE
    - —Drowsiness, dizziness, headache

    —- Dry mouth

    —- GI upset: nausea, vomiting

    —- Fine hand tremors

    - —Hypotension, arrhythmias, pulse irregularities

    - —Polyuria, dehydration

    —- Weight gain
  29. Anticonvulsant drugs/ Mood stabilizer
    Produces normalizing effect by stabilizing mood and thought process, and improving sleep.
  30. two long term risks of lithium?
    • - hypothyroidism
    • - impairment of kidneys to concentrate urine
  31. three anti-convolsant drugs approved for mood disorders
    • - Valproate (depokote)
    • - carbamazepine (tegretol)
    • - lamotrigine (lamictal)
  32. Valproate (depokote)
    • First line treatment for mania, agent of choice with rapid cyclers and mixed mania. Excellent for treating rage reactions and extreme mood instability.
    • - . Has high link to lethargic effect and high risk for weight gain.
    • - . Can cause constipation, dizziness, diarrhea, hair loss, nausea /vomiting, headaches, abdominal pain, tremors, rash, nervousness, insomnia.
    • - . Requires blood work for medication levels and liver function every 3 months. Fatal risks with the liver.
    • - . Severe risks for congenital abnormalities in the fetus.
    • - . Now linked in young women to polycystic ovarian syndrome.
  33. Lamictal
    excellent for rapid cyclers, and particularly useful in atypical depression. Less effective for mania however, targets the depressive end of mood swings very well..

    Watch for skin rash which is an early onset symptom of a serious adverse reaction.Stevens-Johnson Syndrome is a rare rash with toxic epidermal necrolysis, and rash related deaths. If untreated this could affect multiple body systems.

    • - Blood cell counts can be lowered, and liver function may be affected. Watch for increasing sadness or irritability.
    • - . Abrupt withdrawal can induce seizures.
    • - Common side effects: dizziness, headaches, blurred vision, nausea/vomiting, gait disturbance, diarrhea, fever, abdominal pain, nervousness, tremors, decreased WBC, photosensitivity, dysmenorrhea.
  34. Mood Stabilizers
    • - Trileptal
    • - Topamax
    • - Tegretol
  35. Trileptal
    was adjunct therapy, now approved for first line mood stabilizing. Good response with impulsivity, and mood swings with anger. Risks are similar to Lamictal however rash is not as common.
  36. Topamax
    Nickname “dopamax.” Utilized often with mood swings associated with drug dependence and onset of recovery. Also, approved for compulsive stress eating and overeating.
  37. Tegretol
    Useful with rapid cyclers and poor response to depakote and lithium.  Affordable medication with good response rate but higher interactions with other medication. Also, need to watch blood counts more carefully
  38. Mood stabilizers: side effects
    • - Nausea/vomiting
    • - Drowsiness dizziness
    • - Blood dyscrasias
    • - Prolonged bleeding with valproic acid
    • - Risk of severe rash (lamictal)
    • - Risk of suicide
  39. Antianxiety Drugs
    • - Clonazepam (Klonopin)
    • - Lorazepam (Ativan)
    • - useful for tx in acute mania in some pts who are resistant to other tx
    • - used for psychomotor agitations 
    • - avoid in pt with hx of substance abuse

    • Atypical Antipsychotics
    • - Olanzapine (Zyprexa)
    • - Risperidone (Risperdal)
  40. ECT
    • - used to subdue severe manic behavior (resistant mania and rapid cycling)
    • - acutely suicidal patients
  41. mood stabilizer risks
    • - weight gain
    • - DM
    • - HTN
    • - dyslipidemia 
    • - cardiac problems 
    • - metabolic syndrome
  42. cognitive behavioral therapy
    involves identifying maladaptative thoughts ("in always going to be a loser") and behaviors ("i might as well drink") that may be a barrier to a persons recovery
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Bipolar and related disorders
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