1. Bipolar Disorders

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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. PSYCHOTHERAPEUTIC MANAGEMENT: MEDICATIONS

15. 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

16. 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

17. 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

18. 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

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

20. 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

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

22. 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?