1. Bipolar Disorders

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

3. Some Facts About Bipolar Illness 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 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 Must be a history of a manic episode There is a history of Major Depression There is a history of Major Depression More severe More severe  Bipolar II There is a history of a hypomanic episode but NOT Mania There is a history of a hypomanic episode but NOT Mania There is a history of Major Depression There is a history of Major Depression  Cyclothymic Disorder Episodes of hypomania and numerous periods of depressed mood Episodes of hypomania and numerous periods of depressed mood Chronic: Never symptom free Chronic: Never symptom free

5. Symptoms of HYPOMANIA Similar to Mania But to a Lesser Degree  Energetic and driven  Excitable  Overbearing  Highly sociable  Intense and volatile emotions  Seductive  Overspends  Motivates others  May be highly productive  No delusions or hallucinations

6. http://www.nytimes.com/2010/09/19/business/19entre.html?_r=1&scp=1&sq=just%20manic%20Enough&st=Searchwww.nytimes.com/2010/09/19/business/19entre.html Hypomania Article NY Times 9/19/10

7. Signs/Symptoms of MANIA Signs/Symptoms of MANIA  Mood/affect: Euphoric, Labile, Hostile  Activity: Hyperactive Too busy to eat or sleep Too busy to eat or sleep Disorganized activity Disorganized activity  Thought Processes: Disturbed Unable to concentrate, flight of ideas, tangential Unable to concentrate, flight of ideas, tangential  Psychotic thought content Delusions: of grandeur or paranoid Delusions: of grandeur or paranoid Hallucinations Hallucinations  Pressured speech; hyperverbal  Poor judgment and impulse control: with money, sex, any pleasure  Loud clothing, excessive make-up

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. FYI: The Harvard Bipolarity Index and “Bipolar Spectrum Disorder” www.psycheducation.org

10. Manic Behaviors that Result in Altered Relationships  Manipulation  Ability to find vulnerability in others Exploit weaknesses and create conflict Exploit weaknesses and create conflict  Ability to shift responsibility  Limit testing  Alienation of family--may be aggressive and abusive

11. Etiology: 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  availability of GABA and Serotonin

12. Nursing Diagnoses (for Mania)  Risk for Violence (Directed toward self, others)  Insomnia  Altered Nutrition: Less than Body Requirements  Acute Confusion  Disturbed Thought Processes  Impaired Social Interaction

13. Psychotherapeutic Management (Focus of presentation is primarily on management of mania except where otherwise noted)

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

15. Milieu Management, cont’d  Reinforcing appropriate hygiene and dress  Supporting adequate Nutrition and Sleep  Providing activities for excessive energy

16. PSYCHOTHERAPEUTIC MANAGEMENT: MEDICATIONS

17. Medications 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

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

19. Lithium Lithium  Mechanism of action unknown: similarity to action of Na /replaces Na in the body  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  “Normal side effects”- weight gain, fine hand tremor, nausea, metal taste

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

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

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

23. 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

24. Other Anticonvulsants  topiramate: Topamax  gabapentin: Neurontin  oxcarbazepine: Trileptal  lamotrigine: Lamictal-best for bipolar depression. May cause severe rash.

25. Benzodiazepines  Good for acute mania and psychomotor agitation in mania  Used in acute care settings; not for long term tx.  clonazepam (Klonopin)  lorazepam (Ativan)

26. Nursing Implications: Lithium What will the nurse do if a patient shows behaviors/symptoms of what looks like lithium toxicity? A. Stop/hold the medication B. Draw a lithium level, then hold the medication C. Stop/hold med., then draw a lithium level D. Draw a lithium level, keep giving the med. until results are in.

27. Nursing Implications: Mood Stabilizing Medications What are nursing interventions for the client a) starting on, or b) being maintained on Lithium? -Labs -Other testing -Ongoing assessments  What client teaching would the nurse perform for the client, family?