Mood Disorders: Bipolar Disorder Chapter 17 Mood Disorders: Bipolar Disorder

Bipolar Disorders Characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy Delusions or hallucinations may or may not be part of clinical picture Onset of symptoms may reflect seasonal pattern

Types of Bipolar Disorders Bipolar I disorder Bipolar II disorder Cyclothymic disorder

Bipolar I Disorder Individual is experiencing, or has experienced, a full syndrome of manic or mixed symptoms May also have experienced episodes of depression

Bipolar II Disorder Recurrent bouts of major depression Episodic occurrences of hypomania Has not experienced an episode that meets the full criteria for mania or mixed symptomatology

Cyclothymic Disorder Chronic mood disturbance At least 2-year duration Numerous episodes of hypomania and depressed mood

Epidemiology Gender prevalence Incidence of bipolar disorder is roughly equal

Epidemiology (cont.) Age Average age at onset for a first manic episode is the early 20s

Epidemiology (cont.) Social class: there is more bipolar disorder reported in the higher social classes than lower social classes Marital status: more common in unmarried than in married persons

Bipolar Disorder (Mania) Etiological implications Biological theories Strong hereditary implications Biochemical influences Possible excess of norepinephrine, serotonin, and/or dopamine

Bipolar Disorder (Mania) (cont.) Physiological influences Brain lesions Medication side effects

Bipolar Disorders (Mania) (cont.) Psychosocial theories Credibility of psychosocial theories has declined in recent years Bipolar disorder viewed as brain disorder Theoretical integration Bipolar disorder likely results from an interaction between genetic, biological, and psychosocial determinants

Bipolar Disorder: Developmental Implications Childhood and adolescence Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1% Diagnosis is difficult Guidelines for diagnosis and treatment have been developed by the Child and Adolescent Bipolar Foundation (CABF)

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) The Child and Adolescent Bipolar Foundation (CABF) recommends the use of FIND (Frequency, Intensity, Number, and Duration) in making a diagnosis of bipolar disorder in children and adolescents

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) FIND Frequency: symptoms occur most days in a week Intensity: symptoms are severe enough to cause extreme disturbance Number: symptoms occur 3 or 4 times a day Duration: symptoms occur 4 or more hours a day

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Symptoms include Euphoric/expansive mood: extremely happy, silly, or giddy Irritable mood: hostility and rage, often over trivial matters Grandiosity: believes abilities to be better than everyone else’s Decreased need for sleep: may only sleep 4 or 5 hours per night and wake up feeling rested

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Symptoms include (cont.) Pressured speech: loud, intrusive, difficult to interrupt Racing thoughts: rapid change of topics Distractibility: unable to focus on school lessons Increase in goal-directed activity/psychomotor agitation: activities become obsessive; increased psychomotor agitation

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Symptoms include (cont.) Excessive involvement in pleasurable or risky activities: exhibits behavior that has an erotic, pleasure-seeking quality about it Psychosis: may experience hallucinations and delusions Suicidality: may exhibit suicidal behavior during a depressed or mixed episode or when psychotic

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Treatment strategies Psychopharmacology Lithium Divalproex Carbamazepine Atypical antipsychotics

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Treatment strategies (cont.) ADHD is most common comorbid condition ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled

Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Treatment strategies (cont.) Family interventions Psychoeducation about bipolar disorder Communication training Problem-solving skills training

Nursing Process/Assessment Symptoms may be categorized by degree of severity Stage I—Hypomania: symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization Mood: cheerful and expansive Cognition and perception: self- exultation; easily distracted Activity and behavior: increased motor activity; extroverted; superficial

Assessment Stage II—Acute mania: intensification of hypomanic symptoms; requires hospitalization Mood: euphoria and elation Cognition and perception: fragmented, disjointed thinking; pressured speech; flight of ideas; hallucinations and delusions Activity and behavior: excessive psychomotor behavior; increased sexual interest; inexhaustible energy; goes without sleep; bizarre dress and make-up

Assessment (cont.) Stage III—Delirious mania: a grave form of the disorder, characterized by severe clouding of consciousness and representing an intensification of the symptoms associated with acute mania Has become relatively rare since the availability of antipsychotic medication

Nursing Diagnosis Risk for Injury related to Extreme hyperactivity Evidenced by Increased agitation and lack of control over purposeless and potentially injurious movements

Nursing Diagnosis (cont.) Risk for Violence: self-directed or other-directed related to Manic excitement Delusional thinking Hallucinations

Nursing Diagnosis (cont.) Imbalanced Nutrition less than body requirements related to Refusal or inability to sit still long enough to eat Evidenced by Loss of weight, amenorrhea

Nursing Diagnosis (cont.) Disturbed Thought Processes related to Biochemical alterations in the brain Evidenced by Delusions of grandeur and persecution

Nursing Diagnosis (cont.) Disturbed Sensory Perception related to Biochemical alterations in the brain and to possible sleep deprivation Evidenced by Auditory and visual hallucinations

Nursing Diagnosis (cont.) Impaired Social Interaction related to Egocentric and narcissistic behavior Insomnia related to Excessive hyperactivity and agitation

Criteria for Measuring Outcomes The client Exhibits no evidence of physical injury Has not harmed self or others Is no longer exhibiting signs of physical agitation

Criteria for Measuring Outcomes (cont.) The client (cont.) Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status Verbalizes an accurate interpretation of the environment Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations

Criteria for Measuring Outcomes (cont.) The client (cont.) Accepts responsibility for own behaviors Does not manipulate others for gratification of own needs Interacts appropriately with others

Planning/Implementation Nursing interventions are aimed at Maintaining safety of client and others Restoring client nutritional status Encouraging appropriate client interaction with others Assisting client to define and test reality Meeting client’s self-care needs

Client/Family Education Nature of illness Causes of bipolar disorder Cyclic nature of the illness Symptoms of depression Symptoms of mania

Client/Family Education (cont.) Management of illness Medication management Assertive techniques Anger management

Client/Family Education (cont.) Support services Crisis hotline Support groups Individual psychotherapy Legal/financial assistance

Evaluation Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria

Evaluation (cont.) Has the client avoided personal injury? Has violence to client or others been prevented? Has agitation subsided?

Evaluation (cont.) Have nutritional status and weight been stabilized? Have delusions and hallucinations ceased?

Treatment Modalities for Bipolar Mood Disorders Psychological treatment Individual psychotherapy Group therapy Family therapy Cognitive therapy

Treatment Modalities for Bipolar Mood Disorders (cont.) Psychopharmacology For mania Lithium carbonate Anticonvulsants Verapamil Atypical antipsychotics For depressive phase Use antidepressants with care (may trigger mania)

Mood-Stabilizing Agents Background assessment data Indications: prevention and treatment of manic episodes associated with bipolar disorder Examples: lithium carbonate, clonazepam (Klonopin), carbamazepine (Tegretol), valproic acid (Depakote), lamotrigine (Lamictal), gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), verapamil, atypical antipsychotics

Mood-Stabilizing Agents (cont.) Background assessment data (cont.) Action: lithium may modulate the effects of certain neurotransmitters, such as norepinephrine, serotonin, dopamine, glutamate, and GABA, thereby stabilizing symptoms associated with bipolar disorder. Action of anticonvulsants, verapamil, and atypical antipsychotics in the treatment of bipolar disorder is not fully understood. Interactions Contraindications/precautions

Mood-Stabilizing Agents (cont.) Monitor for side effects of lithium Drowsiness, dizziness, headache Dry mouth; thirst; GI upset; nausea/vomiting Fine hand tremors Hypotension; arrhythmias, pulse irregularities Polyuria; dehydration Weight gain Potential for toxicity

Mood-Stabilizing Agents (cont.) Lithium toxicity Therapeutic range 1.0 to 1.5 mEq/L (acute mania) 0.6 to 1.2 mEq/L (maintenance) Initial symptoms of toxicity include Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea Ensure that client consumes adequate sodium and fluid in diet

Mood-Stabilizing Agents (cont.) Monitor for side effects of anticonvulsants Nausea and vomiting Drowsiness; dizziness Blood dyscrasias Prolonged bleeding time (with valproic acid) Risk of severe rash (with lamotrigine) Decreased efficacy of oral contraceptives (with topiramate)

Mood-Stabilizing Agents (cont.) Monitor for side effects of verapamil Drowsiness; dizziness Hypotension; bradycardia Nausea Constipation

Mood-Stabilizing Agents (cont.) Monitor for side effects of antipsychotics Drowsiness; dizziness Dry mouth; constipation Increased appetite; weight gain ECG changes Extrapyramidal symptoms Hyperglycemia and diabetes

Treatment Modalities for Bipolar Mood Disorders (cont.) Electroconvulsive therapy (ECT) Episodes of mania may be treated with ECT when Client does not tolerate medication Fails to respond to medication Life is threatened by dangerous behavior or exhaustion

Treatment Modalities for Bipolar Mood Disorders (cont.) Electroconvulsive therapy For mania Mechanism of action: thought to increase levels of biogenic amines Side effects: temporary memory loss and confusion Risks: mortality; permanent memory loss; brain damage Medications: pretreatment medication; muscle relaxant; short-acting anesthetic