Bipolar and Related Disorders Chapter 13 Bipolar and Related Disorders Copyright © 2018, Elsevier Inc. All rights reserved.

Objectives Describe the signs and symptoms of bipolar I, bipolar II, and cyclothymic disorder. Distinguish between mania and hypomania. Copyright © 2018, Elsevier Inc. All rights reserved.

Clinical Picture Bipolar I disorder Bipolar II disorder Cyclothymic disorder (cyclothymia)

Bipolar Disorder – DSM V A distinct period of abnormally & persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day Or any duration if hospitalization is required in bipolar disorder, type 1

Bipolar Disorder – DSM V (continued) During the period of mood disturbance, 3 or more of the following have persisted (4 if the mood is only irritable): Inflated self-esteem or grandiosity Decreased need for sleep More talkative or pressured speech Flight of ideas or subjective feeling of racing thoughts Distractibility Increased goal-directed activity or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences

DIG FAST Distractible (poorly focused) Indiscretion (excessive pleasurable activities) Grandiosity (unrealistic belief in one’s ability or inflated self- esteem) Flight of Ideas Activities (increased, hyperactivity) Sleep deficit (decreased need for sleep) Talkativeness (pressured speech) Need 3/7 in addition to expansive mood Need 4/7 if primary mood is irritability

Case Study/ Audience Response Question Ms. A, 53, has just been admitted to your unit with bipolar disorder I and is in the manic state. What symptoms might you expect to see? Catatonia Expression of racing thoughts Low self esteem and tearfulness Lack of interest in her environment Copyright © 2018, Elsevier Inc. All rights reserved.

Hypomania Unequivocal change uncharacteristic of person when not symptomatic Observable by those who know the person May be seen as unusual to people who do not know the person but not necessarily recognized as a mental illness Absence of marked impairment in social or occupational functioning Hospitalization not indicated Not due to substance abuse, medication, or other medical condition

Mania Behavior severe enough to cause marked impairment in occupational activities, usual social activities, or relationships Necessitates hospitalization to prevent harm to self or others, or there are psychotic features Symptoms not due to substance abuse, medications or other medical condition

Endless energy Decreased need for sleep Omnipotent feelings Substance Abuse Increased sexual interest Poor judgment Euphoric mood Can’t sit still Irritable, impulsive, intrusive Nothing is wrong (denial) Active: Aggressive Mood Swings

Epidemiology Up to 21% of patients with major depression may actually have undiagnosed bipolar disorder Bipolar I—more common in males Bipolar II—more common in females Cyclothymia—usually begins in adolescence or early adulthood Copyright © 2018, Elsevier Inc. All rights reserved.

Co-morbidities >50% Anxiety Panic attacks Substance abuse Social Phobia Specific Phobia Borderline Personality disorder Seasonal Affective disorder

Case Study An assessment interview reveals that Ms. A is an adjunct college English professor who has published two novels and is working on a third. “It was almost inevitable,” she says, “because I grew up in a family of five anxious girls with competitive, ego-driven professional parents. It was hellish. I found escape in writing stories and putting on plays with my sisters. When I got a scholarship later, I practically ran away to college, where I absolutely lived on coffee, books, and the drama department!” Copyright © 2018, Elsevier Inc. All rights reserved.

Case Study (Cont.) Ms. A further describes her childhood, a part of her life she finds particularly troubling. “We all had to compete if we wanted attention. Dad played favorites, depending on our grades and talents. I was his favorite, but I hated it because it made my mother hate me. How could she compete with her own daughters? Sometimes in high school I scared myself with how much I just wanted to hurt them both. I decided I would never marry and have kids.” Copyright © 2018, Elsevier Inc. All rights reserved.

Etiology Biological factors Genetic Neurobiological Neuroendocrine

Psychosocial & Environmental Factors Stress Education Occupation Economic status Creativity

Audience Response Question Based on her history, which factors can you identify that may have an influence on Ms. A’s condition? Biological factors Psychological factors Environmental factors All of the above. Copyright © 2018, Elsevier Inc. All rights reserved.

Objectives Formulate three nursing diagnoses appropriate for a patient with mania. Copyright © 2018, Elsevier Inc. All rights reserved.

Assessment Mood Behavior Thought processes Cognitive functioning Copyright © 2018, Elsevier Inc. All rights reserved.

Assessment (Cont.) Speech patterns Thought content Pressured speech Circumstantial speech Tangential speech Loose associations Flight of ideas Clang associations Thought content Grandiose delusions Persecutory delusions Copyright © 2018, Elsevier Inc. All rights reserved.

Case Study Discussion What are some problems that can be avoided if your manic patient gets proper treatment? Copyright © 2018, Elsevier Inc. All rights reserved.

Self-Assessment Manic patient Staff member actions Manipulative Demanding Splitting Staff member actions Frequent staff meetings to deal with patient behavior and staff response Set limits consistently Copyright © 2018, Elsevier Inc. All rights reserved.

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 Copyright © 2018, Elsevier Inc. All rights reserved.

Nursing Diagnosis Risk for injury Risk for violence Ineffective coping Other-directed Self-directed Ineffective coping Disturbed sensory perception Imbalanced nutrition Disturbed sleep pattern Copyright © 2018, Elsevier Inc. All rights reserved.

Outcomes Identification Acute phase Prevent injury Continuation phase Relapse prevention Maintenance phase Limit severity and duration of future episodes Copyright © 2018, Elsevier Inc. All rights reserved.

Planning Acute phase Continuation phase Maintenance phase Medical stabilization Maintaining safety Self-care needs Continuation phase Maintain medication adherence Psychoeducational teaching Referrals Maintenance phase Prevent relapse

Nursing Care for Acute Mania (Hospitalization) Managing medications Decreasing physical activity Increasing food and fluid intake Ensuring at least 4 to 6 hours of sleep per night Intervening so that self-care needs are met Copyright © 2018, Elsevier Inc. All rights reserved.

Communication With Patient Experiencing Mania Use firm, calm approach Use short and concise explanations Remain neutral: avoid power struggles Be consistent in approach and expectations Firmly redirect energy into more appropriate areas Act on legitimate complaints Convey limits, consequences

Structure - Milieu Low level of stimuli Structured solitary activities or with staff Redirect violent behavior Minimize physical harm – medication, seclusion, restraints Observe for medication side effects/toxicity Protect from consequences of behavior Such as giving away possessions, spending all money, disrobing

Interventions: Physiologic Safety/ Self-Care Needs Monitor vital signs, I & O if indicated Nutrition Offer frequent mobile high calorie foods or protein drinks Elimination Sleep Avoid caffeine, reduce stimulation, encourage rest, other sleep-inducing interventions Hygiene May need supervision, step by step reminders Minimize choices

Pharmacological Interventions Mood stabilizers Antipsychotics Anxiolytics Antidepressants Two main foci Agitation Mood stabilization Copyright © 2018, Elsevier Inc. All rights reserved.

Pharmacological Interventions Lithium carbonate First-line agent 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 Takes 7 to 14 days to reach therapeutic levels in blood

Initial Treatment of Acute Mania Until Lithium Takes Effect Antipsychotics Slow speech Inhibit aggression Decrease psychomotor activity Antipsychotic or benzodiazepine to prevent: Exhaustion Coronary collapse Death

Lithium: Expected Side Effects Blood level: <0.4 to 1.0 mEq/L Signs Fine hand tremor Polyuria Mild thirst Mild nausea General discomfort Weight gain

Lithium: Expected Side Effects Blood level: <0.4 to 1.0 mEq/L Signs Fine hand tremor Polyuria Mild thirst Mild nausea General discomfort Weight gain

Lithium: Early Signs of Toxicity Blood level: 1.5 mEq/L Signs Nausea Vomiting Diarrhea Thirst Polyuria Slurred speech Muscle weakness

Lithium: Advanced Signs of Toxicity Blood level: 1.5 to 2.0 mEq/L Signs Coarse hand tremor Persistent gastrointestinal upset Mental confusion Muscle hyperirritability Incoordination

Lithium: Severe Toxicity Blood level: 2.0 to 2.5 mEq/L Signs Ataxia Blurred vision Clonic movements Large output of dilute urine Seizures Stupor Severe hypotension Coma Death

Lithium: Severe Toxicity - Continued Blood level: >2.5 mEq/L Signs Confusion Incontinence of urine or feces Coma Cardiac arrhythmias Peripheral circulatory collapse Abdominal pain Proteinuria Oliguria Death

Lithium: Common SE and Major Long-Term Risks Other common SE Drowsiness Weakness Blurred vision, dry mouth Fatigue Acne Weight gain Major Long-Term Risks Hypothyroidism Impairment of kidneys’ ability to concentrate urine

Contraindications to Lithium Cardiovascular disease Brain damage Renal disease Thyroid disease Myasthenia gravis Pregnancy Breastfeeding mothers Children younger than 12 years

Patient and Family Teaching for Lithium Therapy Effects of treatment Need to monitor lithium blood levels Side effects and toxic effects Effects of dietary salt and dehydration Caffeine effects Check with physician before taking OTC medications Take with food to decrease stomach irritation High fat helps-spoonful of peanut butter

Anticonvulsant Mood Stabilizers Valproate (Depakote) Carbamazepine (Tegretol) Lamotrigine (Lamictal) Copyright © 2018, Elsevier Inc. All rights reserved.

Second-Generation Antipsychotics Olanzapine (Zyprexa) Risperidone (Risperdal) Aripiprazole (Abilify) Asenaprine (Saphris) Cariprazine (Vraylar) Lurasidone (Latuda) Quetiapine (Seroquel, Seroquel XR) Ziprasidone (Geodon) Copyright © 2018, Elsevier Inc. All rights reserved.

First-Generation Antipsychotics Chlorpromazine (Thorazine) Loxapine (Adasuve) inhaled Antianxiety Drugs Clonazepam (Klonopin) Lorazepam (Ativan) Copyright © 2018, Elsevier Inc. All rights reserved.

Milieu Therapy: Seclusion Room or Restraints Used in an emergency for patient when: Clear risk of harm to patient or others Patient's behavior has continued despite use of less restrictive methods to keep patient and others safe

Objectives Evaluate specific indications for the use of seclusion for a patient experiencing mania. Discuss the use of ECT for a patient in specific situations. Copyright © 2018, Elsevier Inc. All rights reserved.

Other Treatments ECT Teamwork and safety Seclusion and restraints Support groups Health teaching and health promotion Copyright © 2018, Elsevier Inc. All rights reserved.

Advanced Practice Interventions Cognitive-behavioral therapy (CBT) Interpersonal and social rhythm therapy Family-focused therapy Copyright © 2018, Elsevier Inc. All rights reserved.

Evaluation Evaluate outcome criteria Reassess care plan Revise care plan if indicated Copyright © 2018, Elsevier Inc. All rights reserved.

Quality Improvement Standards for Bipolar Excellence Project 15 evidence-based performance measures regarding screening, assessment, treatment, and monitoring bipolar disorder and its care Provides tools for research, teaching, and quality improvement Copyright © 2018, Elsevier Inc. All rights reserved.

Audience Response Questions Which anticonvulsant medication might be prescribed for a patient with bipolar disorder? Divalproex sodium (Depakote) Clonazepam (Klonopin) Olanzapine (Zyprexa) Lithium (Lithobid) Copyright © 2018, Elsevier Inc. All rights reserved.

Audience Response Questions Lithium toxicity may result in which one of the following? Neuroleptic malignant syndrome Dystonia Blurred vision Akathisia

Case Study Discussion Ms. A is started on lithium. Discuss what patient teaching about this medication the nurse should provide before the patient is discharged. Copyright © 2018, Elsevier Inc. All rights reserved.