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Mental Health
Chapter 13 Bipolar and Related Disorders
| Term | Definition |
|---|---|
| Bipolar I disorder | Depression & Mania = 1 each -Depression that last more than 2 weeks then Mania that last more that 1 week. -The Depression usually comes right after or right before the Mania. Most severe form The highest mortality rate of the three (The highest rate of individuals that die by suicide) At least 1 manic episode -Comorbidity: Nearly all anxiety disorders are associated with bipolar I, Attention-deficit/hyperactivity, all disruptive, impulse-control, or conduct disorders, Substance use diso |
| Bipolar II disorder | Depression & Hypomania -The Hypomania has to last for at least 4 days At least 1 hypomanic episode At least 1 major depressive episode ** Higher risk of suicide attempts *** -Have comorbid anxiety disorders, Eating disorders, particularly binge-eating disorder |
| Cyclothymic disorder | Have milder lows and milder high or hypomania; cycle back and forth for 2 years. Alternate with symptoms of mild to moderate depression for at least 2 years (adults) Rapid cycling possible ***Mood swings are milder but occur frequently*** -Cycling of mild to moderate depressive symptoms and then hypomania. Comorbis: Substance use disorders, Sleep disorders , ADHD |
| Mood | Is an emotional state -The patient tells you |
| Affect | -The patient shows you what that mood is -How the patient is responding to the environment that conveys what they are feeling. |
| Congruent | Mood & Affect are equal |
| Incongruent | Mood & Affect are not equal |
| Bipolar Disorder | Dramatic shifts in emotions, mood and energy |
| Extreme lows sign and symptoms | Are the same as Major Depressive Disorders (MDD): Hopeless & Discourages Lack of energy & Focus Physical Symptoms: Eating or Sleeping too much or too little |
| Hypomania sign and symptoms | Hypomania A low-level and less dramatic mania Tends to be euphoric and often increases functioning Usually accompanied by excessive activity and energy Bipolar II disorder must have at least 1 hypomanic episode **Tends to go undiagnosed** DO NOT SEE PSYCHOSIS Energetic Overly happy/Optimistic Euphoric High Self Esteem |
| Extreme High | Mania -Seems like positive characteristics but when people are in a full manic episode it can be dangerous: Behave recklessly Delusion of Grandeur Make poor decision |
| Difference between Bipolar and MDD | *** You cannot have a diagnosis of major depressive disorder if you also have a diagnosis of bipolar disorder because if you have an episode of mania or hypomania, you no longer meet the criteria of major depressive disorder. You will be shifted into one of the categories; Bipolar type I, Bipolar type II, or Cyclothymic disorder.*** |
| Nursing Assessment: | Mood: Altman’s Self-Rating Mania Scale Behavior: Can be manipulative and demanding Splitting: a need for staff unity Thought processes and speech patterns Thought content Cognitive function |
| Nursing Assessment cont: | Thought processes and speech patterns: Pressured speech (Talking faster than normal) Circumstantial speech (Extra detail that is not relevant but will get to the main point) Tangential speech(Not accelerated but is off topic) Loose associations(Derailment) (No Association) Flight of ideas(Accelerated thinking not on topic) Clang associations(Rhyming, does not make sense) Thought content: Grandiose delusions Persecutory delusions |
| Nursing Assessment Guidelines Bipolar Disorder: | Danger to self or others Need for protection from uninhibited behaviors Need for hospitalization Medical status Coexisting medical conditions Family’s understanding |
| Nursing Diagnosis | Risk for injury Risk for violence Sleep deprivation Impaired cognition Impaired concentration Self-care deficit (feeding, bathing, dressing) Impaired socialization |
| Nursing Outcomes: Acute Phase | Acute phase ( Focus on safety and stabilization) Prevent injury Maintain stable cardiac status Maintain hydration/tissue integrity Get sufficient sleep & rest Demonstrate thought self-control Attempt no self-harm |
| Nursing Outcomes Maintenance Phase | Maintenance phase Obtain knowledge of the disorder, management, and medication •Identify three risk factors for the development of acute mania; identify preventive strategies Identify sources of support •Attend group therapy on a daily basis Problem-solve •Identify new coping skills |
| Nursing Planning: Acute Phase | Medical stabilization Maintaining safety In-hospital nursing care Seclusion, restraint, or ECT may be considered during the acute phase |
| Nursing Planning: Maintenance Phase | • Preventing relapse • Limiting severity and duration of future episodes • Patients with bipolar disorders require medications over long periods of time/over entire lifetime • Support patients in repairing their lives from the hardships that came out of the acute phase of illness |
| Nursing Implementation: Depressive vs. Manic Episodes | Depressive episodes: Hospitalization for suicidal, psychotic, or catatonic signs Medication concerns about bringing on a manic phase Manic episodes: Hospitalization for acute mania (bipolar I disorder) Communicating challenges and strategies |
| Nursing Implementation: Acute Mania | (Hospitalization) Provides safety for a person experiencing acute mania Imposes external control on destructive behaviors Provides medication for stabilization |
| Communication Techniques | Use a firm and calm approach: Provides structure & control Use short, concise explanations{ Minimizes the potential for manipulative behaviors Identify expectations in simple, concrete terms: Offers safety as patient experiences outside controls while understanding reasons for treatment choices Hear and act on legitimate complaints: Reduces helpless feelings; minimizes acting out Firmly redirect energy into more appropriate channels: Distractibility is the most effective tool for a patient exper |
| Nursing Implementation: Maintenance Phase | Focus on preventing relapse Medication adherence is essential Regular and adequate sleep Healthy nutrition Community support Engagement with community resources Use of outpatient facilities |
| Treatment Modalities: Pharmacotherapy used to treat | Agitation Mood stabilization |
| Pharmacotherapy : Mood stabilization: Lithium carbonate : | Lithium carbonate (Gold standard for Acute Mania) ** Issues with Lithium – must have therapeutic lithium levels – do not want the patient to have a toxic level in their system. Lithium has a narrow therapeutic window. *** Indications: Contraindicated in pregnancy. |
| Lithium | -Treats both acute mania and maintenance treatment. Onset of action is usually within 10 to 21 days. -Because the onset of action is so slow, it is usually supplemented in the early phases of treatment by second-generation antipsychotics, anticonvulsants, or antianxiety medications. |
| Lithium levels | The first lithium level should be drawn every 2 to 3 days after beginning lithium therapy and after any dosage change until the therapeutic level has been reached. Blood levels are then checked every 3 to 6 months. For older adult patients, the principle of start low and go slow applies. -No antidote, if there is toxicity the patient might need hemodialysis. |
| Therapeutic and toxic levels | A target range for a 12-hour serum trough level is 0.8–1.2 mEq/L. A greater clinical benefit for acute mania may be found in a level of 1.0–1.2 mEq/L -The target serum lithium level for maintenance is 0.6 to 0.8 mEq/L. Even lower levels of lithium—0.4 to 0.6 mEq/L—may be considered in some cases, |
| Signs of Lithium Toxicity | <1.5 mEq/L Nausea, vomiting, diarrhea, thirst, polyuria (producing too much urine), lethargy, sedation, and fine hand tremor Renal toxicity, goiter, and hypothyroidism may occur with long-term use. Electrolyte imbalance Interventions: Symptoms often subside during treatment. Doses should be kept low. Kidney function and thyroid levels should be assessed before treatment and then on an annual basis. |
| Early Signs of Lithium Toxicity | 1.5–2.0 mEq/L Gastrointestinal upset, coarse hand tremor, confusion, hyperirritability of muscles, electroencephalographic changes, sedation, incoordination Interventions: Medication should be withheld, blood lithium levels measured, and dosage reevaluated |
| Advanced Signs of Lithium Toxicity | 2.0–2.5 mEq/L Ataxia(Poor muscle control), giddiness, serious electroencephalographic changes, blurred vision, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, coma. Death is usually secondary to pulmonary complications. Interventions: Hospitalization is indicated. The drug is stopped, and excretion is hastened. Whole bowel irrigation may be done to prevent further absorption of lithium. |
| Severe Signs of Lithium Toxicity | Convulsions, oliguria (producing none or small amounts of urine), and death can occur. Interventions: In addition to the interventions above, hemodialysis may be used in severe cases. |
| Pharmacotherapy: Anticonvulsant drugs | Anticonvulsant drugs (also known as antiepileptics) were developed to treat seizures associated with epilepsy. -The FDA approves them for use in acute mania, acute bipolar depression, and/or bipolar maintenance. Valproate (Depakote) Carbamazepine (Equetro) Lamotrigine (Lamictal) Tegretol |
| Pharmacotherapy: Anticonvulsant drugs are used | • Superior for continuously cycling patients • More effective when there is no family history of bipolar disease • Effective at diminishing impulsive and aggressive behavior in some nonpsychotic patients • Helpful in cases of alcohol and benzodiazepine withdrawal • Beneficial in controlling mania (within 2 weeks) and depression (within 3 weeks or longer) |
| Anticonvulsant Drug: Lamotrigine (Lamictal) causes | Steven Johnson Syndrome – serious side effects: -The risk is greater in children aged 2 to 16 years. -These skin conditions are more common with co-administration of valproate, rapid dose increases, and doses exceeding the recommended upper limit. -Since it is impossible to tell if a benign rash will become dangerous, it is essential to discontinue this drug if a rash appears. |
| Pharmacotherapy: Second-generation antipsychotics | ** Commonly prescribes for bipolar disorders*** Examples: Olanzapine (Zyprexa) Risperidone (Risperdal) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify) Asenapine (Saphris) Cariprazine (Vraylar |
| Brain Stimulation Therapies | Electroconvulsive Therapy (ECT) Passes an electric current through the brain Most commonly used with patients who have bipolar disorder with severe levels of depression |
| Psychological Therapies | Cognitive-Behavioral Therapy (CBT)" Usually an adjunct to pharmacotherapy Interpersonal and Social Rhythm Therapy: Aims to regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse Family-Focused Therapy: Helps improve communication among family members |
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