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MH Ch. 13- Bipolar - Varcarolis' Foundations. of Psychiatric Mental Health Nursing 8th Edition
Mental Health Nursing (RNSG 2213 )
Lone Star College System
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Mental Health Chapter 13- Bipolar & Mood Disorders
BIPOLAR & MOOD DISORDERS -Commonly known as manic-depression
● CLINICAL PICTURE ○ Bipolar 1 Disorder (most severe) ■ Marked by shifts in mood, energy, and ability to function ■ Have experienced at least ONE manic episode for at least 1 week ■ Mania: abnormal intense mood disturbance with persistent elevation, expansiveness, irritability, extreme activity or energy (psychiatric emergency!) ■ Equally seen in males and females. ■ Initially happiest, most excited, and most optimistic ■ Energetic, don’t sleep or eat, in perpetual motion ■ Take horrific chances and engage in hazardous activities ■ Sees no problem with behaviors and resists treatment ■ Later psychotic and hallucinating, delusions, and disturbed thoughts ● Hallucinations tend to be auditory ■ Agitation, irritability & hostility ■ Later collapse in depression ■ Can result in suicide ○ Bipolar 2 Disorder ■ Experienced at least one hypomanic and one major depressive episode ■ Hypomania: low-level and less dramatic mania ● Not usually severe enough to cause serious impairment in occupational or social functioning ● Does not have psychosis ● At least 4 days of hypomania ■ At least 3 of the behaviors listed under in the DSM- ■ Depressive symptoms put patient at risk for suicide ■ Happens more in females than males. ■ Hypomania not severe enough for hospitalization (rare) ■ *Psychosis is never present with hypomania ■ Depressive symptoms may lead to suicide
■ Believed to be underdiagnosed & mistaken for major depression or personality disorders
○ Cyclothymia ■ Hypomania alternate with mild to moderate depression ● At least 2 years in adults & 1 in children ■ Symptoms do NOT meet the criteria for either bipolar 2 or major depression ■ Symptoms are disturbing enough to cause social and occupational impairment ■ Rapid cycling: at least FOUR mood episodes in a 12-month period. ■ Individuals tend to have irritable hypomanic episodes; children experience irritability & sleep disturbances ■ Starts in adolescence or early adulthood ○ Other Bipolar Disorders ■ Substance/Medication-Induced Bipolar and Related Disorder ■ Bipolar and Related Disorder Due to Another Medical Condition ■ Other Specified Bipolar and Related Disorder ■ Unspecified Bipolar and Related Disorder ● EPIDEMIOLOGY ○ Bipolar 1 & 2 Disorders ■ 4% of population that will have Bipolar 1 or 2 ■ Men & women equal rates, just respond differently ● Men: legal problems, acts of violence ● Women: abuse alcohol, suicide, develop thyroid disease (hyperthyroidism), postpartum psychosis/depression. ○ Children & Adolescents ■ Given to young people who had chronic irritability and anger along with frequent verbal or behavioral outbursts that were an overreaction ■ Issue: did not have as adults ■ In late adolescence: a serious problem ○ Cyclothymic Disorder ■ Begins in adolescence or early adulthood ■ 15-50% risk will develop bipolar 1 or 2 disorder ■ MAJOR risk factor: first degree relative (parent, sibling, child) with bipolar 1
● COMORBIDITY ○ Bipolar 1 Disorder ■ Nearly all anxiety disorders are associated with Bipolar 1 ● Panic attacks, social anxiety disorder, and specific phobias
■ Children most vulnerable in bad environments ■ Stressful family life & adverse life events may result in more severe course ■ Stress- common trigger for mania & depression in adults ○ Psychological Factors ■ Mania once thought to be a defense against underlying anxiety & depression ● Also thought to help individuals tolerate loss or tragedy ● APPLICATION OF THE NURSING PROCESS ○ Assessment ■ Early diagnosis and proper treatment can help people avoid: ● Suicide attempts ● Alcohol or substance abuse ● Martial or work problems ● Development of medical comorbidity ■ General Assessment ● Individuals with BPD tend to spend more time in depressed state than in a manic state ● Characteristics of mania: ○ 1. Mood ○ 2. Behavior ○ 3. Thought processes and speech patterns, thought content ○ 4. Cognitive function ■ Mood: ● Euphoria: unstable state ○ Associated with mania is unstable because mood may change quickly to irritation and anger when the person is thwarted ● Expansive mood- elevated and unrestrained emotional expressiveness ■ Behavior ● Voracious appetites for social engagement, spending, and activity, indiscriminate sex ● Hypomania: voracious appetites for social engagements, spending, and activity ● Constantly active; minimal sleep; exhaustion & worsening of mania ● Excessive phone calls and emails (we want to monitor) ○ May pursue elaborate schemes to get rich, famous and powerful ● Gives away money, prized possessions & expensive gifts
● Distractibility: lose their focus and go from one activity to the other ● Constantly push limits ● Makeup may be gaudy and overdone ■ Thought Processes/Speech Patterns ● Flight of ideas: accelerated speech with abrupt changes from topic to topic ● Clang associations ● Grandiosity (may also be persecutory-thinking God is punishing them) ● Speech: pressured speech, tangential speech, circumstantial speech (too much details), loose associations ● Thought content: grandiose/persecutory delusions ■ Cognitive Function ● Onset of bipolar disorder is often preceded by comparatively high cognitive function ● Mostly correlated with manic episodes. ● ⅓ of patients display significant and persistent cognitive problems and difficulties in psychosocial areas ● Cognitive deficits are milder but similar to those in schizophrenia; greater in Bipolar 1 than Bipolar 2. ● Clinical Implications: ○ Cognitive function affects overall function ○ Cognitive deficits correlate with a greater number of manic episode, history of psychosis, chronicity of illness, and poor functional outcome ○ Early diagnosis and treatment are crucial to prevent illness progression, cognitive deficits and poor outcome ○ Medication selection should consider not only the efficacy of the drug in reducing mood symptoms but also cognitive impact on patient
○ Self- Assessment/Symptomatology ■ Poor boundary may create fear in nurses ● (mood assessment questionnaire) ■ Expansive mood (out of proportion overly joyous mood) ■ Boundless enthusiasm, treat others with confidential friendliness, no strangers ■ Mood may change quickly to irritation and anger ■ Manic patient ● Manipulative
○ Maintenance phase ■ Prevent relapse (compliance)
● INTERVENTIONS:
- Agitation: Lithium OR Valproate + SGA (Olanzapine or Risperidone); Benzodiazepine for anxiety (short term use)
- Mood Stabilizers: all effective in treating mania but some aren’t as effective in treating depression. a. LITHIUM: for acute mania and maintenance treatment; onset of 10-21 days; supplemented with other medications. ● Reduces elation, grandiosity, expansiveness, flight of ideas, irritability & manipulation, anxiety, self-injurious behaviors. ● Controls insomnia, psychomotor agitation, threatening/assaultive behavior. Distractibility, hypersexyality, and paranoia. ● therapeutic/toxic levels: a. Start at 600-1200 mg/day in 2-3 divided doses: increase every few days by 300 mg/day, max dose is 1800 mg/day; lower doses during maintenance/prophylactic lithium treatment. b. Must reach therapeutic blood levels in 7-14 days; measure lithium levels at least 5 days after beginning treatment and after any dosage change until therapeutic level is reached. 1. Check blood levels every month for 6 months to 1 year of stability, then check every 3 months. 2. Draw blood in the morning, 10-12 hours after last lithium dose; START LOW AND GO SLOW. 3. Therapeutic: 0.8-1 mEq/L 4. Maintenance: 0.4-1 mEq/L 5. Toxic: +1 mEq/L ● Contraindications: a. Complete baseline assessment of renal function and thyroid status (thyroxine and TSH levels); do EKG. b. Contraindicated in patients with Cardiovascular disease, brain damage, renal disease, thyroid disease, and myasthenia gravis. c. DO NOT give to pregnant/breastfeeding women and children under 12 years old.
- Anticonvulsants:
a. Valproate (Depakote): better than lithium, prevents future manic episodes; monitor LFTs & platelets count b. Carbamazepine (Tegretol): alt to lithium, valproate, or SGA; more effective in dysphoric pts, rapid cycling pts, & severely paranoid angry pts; monitor liver enzymes weekly for first 8 weeks of tx → bone marrow suppression & liver inflammation; draw CBC → leukopenia & aplastic anemia c. Lamotrigine: maintenance therapy med; potentially life threatening rash → seek immediate med attention 4. FGAs: for acute mania, agitation; chlorpromazine & loxapine 5. SGAs: for acute mania, has mood-stabilizing properties; Olanzapine and Risperidone a. Side effects: weight gain, insulin resistance, diabetes, dyslipidemia, and cardiovascular impairment. 6. Bipolar Depression: antidepressant alone increases risk of manic episodes. COMBINE with mood stabilizer a. Lurasidone, Quetiapine, Symbyax (SGA) → Olanzapine (SGA) + Fluoxetine (SSRI)
OTHER INTERVENTIONS:
● Integrative therapy = cod liver oil → 2 omega-3 fatty acids (EPA & DHA) important in cognitive functioning ● ELECTROCONVULSIVE THERAPY (ECT)= used to subdue severe manic behavior esp in pts with tx-resistant mania/depression & rapid-cycling (when nothing works & they’re not responding to treatment) ● Teamwork & safety= frequent team meetings, training/ support groups ● Health teaching & health promotion= establish regular sleep pattern, meals, exercise, activities ○ Teach weight reduction & management; recovery concepts; coping strategies ● Seclusion & restraint= requires pt consent unless an emergency; never for punishment/staff control ○ Substantial risk of harm to others/self ○ Pt unable to control actions ○ Other measures have failed ○ NEED written order= review and rewrite every 4 hours ○ Observe & document pt behavior= every 15 mins ○ Offer food and fluid = every 30-60 mins ○ Use restroom and measure VS frequently= every 1-2 hours ADVANCED PRACTICE INTERVENTIONS ● CBT, interpersonal & social rhythm therapy, family-focused therapy
MH Ch. 13- Bipolar - Varcarolis' Foundations. of Psychiatric Mental Health Nursing 8th Edition
Course: Mental Health Nursing (RNSG 2213 )
University: Lone Star College System
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