Bipolar and Related Disorders Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.

 Assess a patient with mania for (a) mood, (b) behavior, and (c) thought processes, and be alert to possible dysfunction.  Explain the rationales behind five methods of communication that may be used with a patient experiencing mania.  Distinguish between signs of early and severe lithium toxicity  Compare and contrast basic clinical conditions that may respond better to anticonvulsant therapy with those that may respond better to lithium therapy.  Evaluate specific indications for the use of seclusion for a patient experiencing mania Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 2

 Acute Phase – page 234  Bipolar disorder, p. 228  Clang Associations, p. 233  Cyclothymic disorder, p. 228  Euphoric Mania, p. 228  Dysphoric Mania, p. 228  Flight of ideas, p. 233  Grandiosity, p. 233  Hypomania, p.228  Lithium Carbonate, p. 239  Maintenance Phase, p. 234  Mania, p. 245  Rapid Cycling, p. 228 Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3

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 These are mood disorders with recurrent episodes of depression and mania.  They are usually emerge in late adolescence or early adulthood but have been diagnosed in school-age children.  The clinical manifestations of bipolar disorder can mimic the expected finings of attention deficit hyperactivity disorder (ADHD), children are more difficult to assess and diagnose. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5

 There are periods of normal functioning which alternate with periods of illness.  Psychotic, paranoid and/or bizarre behavior may be seen during periods of mania.  Care will depend on the state the patient is experiencing at the time when seen. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6

 Biological factors ◦ Genetic ◦ Neurobiological ◦ Neuroendocrine  Psychological factors  Environmental factors Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.7

 Bipolar I disorder  Bipolar II disorder  Cyclothymia Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.8

 Lifetime prevalence of bipolar disorder in the United States is 5.1%  Bipolar I – more common in males  Bipolar II – more common in females  Cyclothymia – usually begins in adolescence or early adulthood Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.9

 Mood  Behavior  Thought processes and speech patterns  Cognitive functioning Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.10

 Flight of ideas - A continuous flow of speech in which the person jumps rapidly from one topic to another.  Example: How are you doing, kid, no kidding around, I’m going home….home sweet home…where the heart is. ◦ Clang associations - The meaningless rhyming of words, often in a forceful manner.  Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. ◦ Grandiosity - Exaggerated belief in or claims about one’s importance or identity  Glad to meet you, I am the President of Leadville, glad to have you visit my country. Be careful with the FBI may shoot you while you’re here. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11

 Manic patient ◦ Manipulative ◦ Demanding ◦ Splitting  Staff member actions ◦ Frequent staff meetings to deal with patient behavior and staff response ◦ Set limits consistently Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.12

 Danger to self or others  Need for protection from uninhibited behaviors  Need for hospitalization  Medical status  Coexisting medical conditions  Family’s understanding Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.13

 Risk for injury  Risk for violence ◦ Other-directed ◦ Self-directed  Ineffective coping Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.14

 Acute phase ◦ Prevent injury ◦ Hospitalization may be required ◦ Risk of harm to self or others is determined ◦ One to one supervision may be indicated.  Continuation phase ◦ Relapse prevention ◦ Treatment is generally 4 to 9 months in duration  Maintenance phase ◦ Limit severity and duration of future episodes ◦ Requires lifetime treatment Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.15

 Acute phase ◦ Medical stabilization ◦ Maintaining safety ◦ Self-care needs  Continuation phase ◦ Maintain medication adherence ◦ Psychoeducational teaching ◦ Referrals  Maintenance phase ◦ Prevent relapse Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.16

 Acute phase ◦ Depressive episodes ◦ Manic episodes  Continuation phase ◦ Prevent relapse with follow-up care  Maintenance phase ◦ Prevent recurrence Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.17

 Lithium carbonate ◦ Indications ◦ Therapeutic and toxic 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 mEq/L and above ◦ Maintenance therapy ◦ Side/Adverse Effects ◦ Contraindication – Pregnancy Risk Category D – teratogenic during the first trimester. If breastfeeding it should be discouraged and if they have renal dysfunction, heart disease, dehydration it should not be used. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.18

 Valproate (Depakote)  Carbamazepine (Tegretol)  Lamotrigine (Lamictal)  Contraindications which are important: ◦ They are Pregnancy Risk Category D and can result in birth defects ◦ Carbamazepine cannot be used in clients with bone marrow suppression or bleeding disorders. ◦ Valproic acid cannot be used in clients with liver disorders. Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.19

 Clonazepam (Klonopin)  Lorazepam (Ativan)  Atypical antipsychotics  Olanzapine (Zyprexa)  Risperidone (Risperdal) Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.20

 Electroconvulsive therapy (ECT)  Teamwork and safety  Support groups  Health teaching and health promotion Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.21

 Physical exhaustion and possible death ◦ A client in a true manic state usually will not stop moving and does not eat, drink or sleep. This can become a medical emergency ◦ Nursing Actions:  Prevent self-harm  Decrease client’s physical activity  Ensure adequate fluid and food intake  Promote adequate sleep each night  Assist the client with self-care needs  Management medications Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22

 Evaluate outcome criteria  Reassess care plan  Revise care plan if indicated Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.23

1.Which anticonvulsant medication might be prescribed for a patient with bipolar disorder? A.Divalproex sodium (Depakote) B.Clonazepam (Klonopin) C.Olanzapine (Zyprexa) D.Lithium (Lithobid) Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 24