Bipolar Disorders

Diagnostic Terminology Bipolar Disorder Bipolar I Bipolar II Old terminology Manic-Depressive Bipolar Affective Disorder

Some Facts About Bipolar Illness Usually chronic with remissions and exacerbations Suicide rate in clients with Bipolar disorder is 15% 60% experience chronic interpersonal and occupational difficulties Age of onset: early 20’s 90% will have recurrent symptoms 30-40% of Bipolar have chemical dependency

Types of Bipolar Disorder Bipolar I (many subtypes) Must be a history of a manic episode There is a history of Major Depression More severe Bipolar II There is a history of a hypomanic episode but NOT Mania Cyclothymic Disorder Episodes of hypomania and numerous periods of depressed mood Chronic: Never symptom free

Symptoms of HYPOMANIA Similar to Mania But to a Lesser Degree Energetic and driven Excitable Overbearing Engages others in an animated, vivacious manner Intense emotions: volatile Seductive Overspends Motivates others May be highly productive No delusions or hallucinations

Signs/Symptoms of MANIA Euphoric or irritable mood Hyperactive Too busy to eat or sleep Sexually inappropriate Flight of ideas, loose associations Psychotic Thinking Delusions of grandeur Hallucinations Very distractible, unable to concentrate Pressured speech; hyperverbal Poor judgment with money, sex, any pleasure Loud clothing, excessive make-up

Symptoms of Depressive Episode Symptoms are atypical Hypersomnia not Insomnia Hyperphagia not Anorexia Craving for Carbohydrates Leaden paralysis Paranoid thoughts Irritability

Bipolar I: Mixed Episode Meets criteria for both Mania and Major depression symptoms Severely disturbed, rapidly alternating moods Not caused by other drugs or alcohol May be induced by antidepressant Client is miserable, may be highly suicidal and/or may be violent

Manic Behaviors that Result in Altered Relationships Manipulation Ability to find vulnerability in others Exploit weaknesses and create conflict Ability to shift responsibility Limit testing Alienation of family

Nurse-Client Relationship and Milieu Management Matter-of-Fact Tone Clear, concise directions Limit Setting     Safety Consistency among staff Reduction of environmental stimuli De-escalating the client

Milieu Management, cont’d Reinforcing appropriate hygiene and dress Supporting adequate Nutrition and Sleep

Biologic Theories Ion dysregulation: causes oversensitivity of neuron to stimuli Alteration in transcription of messengers in nerve cell nucleus Neurotransmitters involved in mania/bipolar: Excessive Dopamine and Norepinephrine Decreases in availability of GABA and Serotonin

A Common Diagnostic Mistake Diagnosing Major Depressive Disorder when the client is in the Depressive Aspect of Bipolar Disorder Giving an antidepressant can push the client into Mania

PSYCHOTHERAPEUTIC MANAGEMENT: MEDICATIONS

Antipsychotics All Atypicals: olanzepine: Zyprexa, quetiapine: Seroquel, ziprasidone: Geodon, risperidone: Risperdal and Risperdal Consta, aripiprazole: Abilify are FDA approved mood stabilizing agents. Used alone or with other mood stabilizing agents Other antipsychotics: used prn for agitation

Lithium Mechanism of action unknown: similarity to Na Slow onset: 2 weeks Narrow range of therapeutic level 0.6 to 1.2 mEq/L; the optimum maintenance level is 0.8 mEq/L Toxic over 1.5 mEq/L Need to keep NA balanced Creatinine clearance to test for kidney function “Normal side effects”- weight gain, fine hand tremor, nausea, metal taste

Lithium Toxicity Narrow therapeutic range: therapeutic dose is close to a toxic dose. Mild to Moderate toxic reactions: 1.5 to 2 mEq/L Diarrhea Vomiting Drowsiness Muscular weakness Lack of coordination Dry mouth

Lithium Toxicity Moderate to Severe reactions All previous symptoms & 2 to 3 mEq/L All previous symptoms & Ataxia Tinnitus Blurred vision High urinary output (osmotic diuresis) Delirium Nystagmus

Lithium Toxicity Severe reactions:  than 3 mEq/L All previous symptoms Seizures Organ failure Renal failure Coma Death

Mood Stabilizing Medications: Anticonvulsants valproic acid/divalproex: Depakote and Depakene carbamazepine: Tegretol Side effects: many drug interactions; CNS effects; blood disorders ( RBC, bone marrow, WBC’s), liver failure; toxic reactions common

Other Anticonvulsants topiramate: Topamax gabapentin: Neurontin oxcarbazepine: Trileptal lamotrigine: Lamictal-best for bipolar depression

Nursing Implications: Mood Stabilizing Medications What are nursing interventions for the client taking Lithium or an anticonvulsant for the treatment of bipolar disorder? What client teaching would the nurse perform for the client, family?