1. Bipolar Disorders

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

3. Incidence For Bipolar Incidence For Bipolar Bipolar- 2.6% to 3.9% of the population Bipolar- 2.6% to 3.9% of the population Bipolar I equal among sexes Bipolar I equal among sexes Bipolar II women may have a higher rate Bipolar II women may have a higher rate 1.2 % Bipolar I 1.2 % Bipolar I Illness is usually chronic with remissions and exacerbations Illness is usually chronic with remissions and exacerbations Suicide rate in clients with Bipolar disorder is 15% Suicide rate in clients with Bipolar disorder is 15% 60% experience chronic interpersonal and occupational difficulties 60% experience chronic interpersonal and occupational difficulties Age of onset: early 20’s Age of onset: early 20’s 90% will have recurrent symptoms 90% will have recurrent symptoms 30-40% of Bipolar have chemical dependency 30-40% of Bipolar have chemical dependency 8% of people with chemical dependency are Bipolar 8% of people with chemical dependency are Bipolar

4. Types of Bipolar Disorder Bipolar I Bipolar I There must be a history of a manic episode There 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 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 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. Hypomanic Episode Bipolar I: usually precedes a manic episode Bipolar I: usually precedes a manic episode Present in Bipolar II and Cyclothymic Disorder Present in Bipolar II and Cyclothymic Disorder

6. Symptoms of Hypomania Forcefully energetic and driven Forcefully energetic and driven Highly excitable and overzealous Highly excitable and overzealous Full of life Full of life Overbearing Overbearing Engages others in an animated, vivacious manner Engages others in an animated, vivacious manner Intense emotion disorganized thoughts Intense emotion disorganized thoughts Energetic Self-Image Energetic Self-Image A tireless and active person A tireless and active person Motivates others Motivates others Volatile charged up Volatile charged up Likes momentary excitement Likes momentary excitement

7. Hypomania

8. Symptoms Mania Symptoms Mania Grandiose mood; euphoric or irritable Grandiose mood; euphoric or irritable Hyperactive; Hyperactive; too busy to eat or sleep too busy to eat or sleep Sexually inappropriate Sexually inappropriate Flight of ideas, loose associations Flight of ideas, loose associations Psychotic Thinking Psychotic Thinking Delusions of grandeur Delusions of grandeur Hallucinations Hallucinations Very distractible, unable to concentrate Very distractible, unable to concentrate Poor judgment Poor judgment Excess is common Excess is common Spending Sprees Spending Sprees Sexual indiscretions Sexual indiscretions Loud clothing Loud clothing Excessive make-up Excessive make-up

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

10. Mixed Episode Meets criteria for both Manic and major depression Meets criteria for both Manic and major depression Rapidly alternating moods of sadness, irritability, and high energy Rapidly alternating moods of sadness, irritability, and high energy Agitation, insomnia, appetite disturbance, psychotic features, Suicidal thinking Agitation, insomnia, appetite disturbance, psychotic features, Suicidal thinking May be induced by antidepressant May be induced by antidepressant Client is miserable, highly suicidal and may be violent Client is miserable, highly suicidal and may be violent

11. Five Tendencies that Result in Altered Relationships Manipulation Manipulation Coercive techniques Coercive techniques “you are the only one who understands me” “you are the only one who understands me” Ability to find vulnerability in others Ability to find vulnerability in others Exploit weaknesses and create conflict Exploit weaknesses and create conflict Limit testing Limit testing Push limits by constantly wanting more than the rules allow Push limits by constantly wanting more than the rules allow Ability to shift responsibility Ability to shift responsibility Anger at the nurse when there is no breakfast after sleeping late Alienation of family Alienation of family Cyclic nature: 1 st gives hope then results in demoralizes late Divorce secondary to abusive nature

12. Manipulation and Limit Testing Push limits by constantly wanting more than the rules allow Push limits by constantly wanting more than the rules allow Coercive techniques Coercive techniques “you are the only one who understands me” “you are the only one who understands me” Results in Splitting (All good vs all bad) Results in Splitting (All good vs all bad) The team The team Defined by the client as “all bad” Defined by the client as “all bad” One staff member is split away from the team One staff member is split away from the team Defined by the client as “all good” Defined by the client as “all good” Gets the staff to advocate for them so that Gets the staff to advocate for them so that changes in behavior do not have to occur When the staff is unsuccessful in fulfilling the When the staff is unsuccessful in fulfilling the clients request/needs they are then defined clients request/needs they are then defined as “all bad”

13. Working with the Bipolar Client Matter of Fact tone Matter of Fact tone Minimizes defensive response Minimizes defensive response Avoids power struggles Avoids power struggles Clear concise directions and Limit Setting Clear concise directions and Limit Setting Used together Used together Use a command ie STOP, NO then give instructions Use a command ie STOP, NO then give instructions No we are not going outside now; we will go at 10am. No we are not going outside now; we will go at 10am. Stop scratching your arm, come with me and we will see if there is a medication you can have to help you feel more calm. Stop scratching your arm, come with me and we will see if there is a medication you can have to help you feel more calm. Give but Limit Choices: I can get you a snack right now or you can wait one hour for lunch. Give but Limit Choices: I can get you a snack right now or you can wait one hour for lunch.

14. Working with the Bipolar Client Reinforce appropriate hygiene and dress Reinforce appropriate hygiene and dress Simple matter of fact reminders Simple matter of fact reminders Nutrition Nutrition Poor nutrition and lack of sleep plague these client Poor nutrition and lack of sleep plague these client Foods that can be eaten while moving Foods that can be eaten while moving High protein High protein Vitamin supplement Vitamin supplement Weigh regularly Weigh regularly

15. Working with the Bipolar Client ACTIVITIES ACTIVITIES Mania Mania Manage competitive nature Manage competitive nature Exercise Exercise Depression Depression SLEEP SLEEP A quiet place to sleep A quiet place to sleep Structure with calming activities prior to bedtime Structure with calming activities prior to bedtime Do not allow caffeine around bedtime Do not allow caffeine around bedtime Assess amount of sleep the client is getting Assess amount of sleep the client is getting

16. Milieu Management Safety Safety It is reassuring to clients that the staff will not let them harm themselves or others It is reassuring to clients that the staff will not let them harm themselves or others Consistency among staff Consistency among staff Decreases Client’s ability to Create Conflict Decreases Client’s ability to Create Conflict Agree to use interventions strategies consistently Agree to use interventions strategies consistently as a team Reduction of environmental stimuli Reduction of environmental stimuli Limited activities with others Limited activities with others Encourage gross motor activities Encourage gross motor activities De-escalating clients De-escalating clients Approach in a calm confident manner Approach in a calm confident manner May use Haloperidol as a prn May use Haloperidol as a prn

17. Neurotransmitters Excess levels of norepinephrine and dopamine Excess levels of norepinephrine and dopamine A deficiency of serotonin A deficiency of serotonin

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

19. Medications Medications Atypical Antipsychotic: Zyprexa, Geodon, Abilify Atypical Antipsychotic: Zyprexa, Geodon, Abilify These medications can block dopamine and increase serotonin These medications can block dopamine and increase serotonin Lithium-Slow onset-2 weeks Lithium-Slow onset-2 weeks Unsure of mechanism of action Unsure of mechanism of action Anticonvulsants are also Mood Stabilizers Anticonvulsants are also Mood Stabilizers Depakote Depakote Tegretol Tegretol Topamax, Neurontin, Trileptal, Lamictal Topamax, Neurontin, Trileptal, Lamictal

20. Lithium Lithium Narrow range of therapeutic level 0.6 to 1.2 mEq/L; the optimum maintenance level is 0.8 mEq/L 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 Toxic over 1.5 mEq/L Need to keep NA balanced Need to keep NA balanced Creatinine clearance to test for kidney function Creatinine clearance to test for kidney function “Normal side effects”- weight gain, fine hand tremor, nausea, metal taste “Normal side effects”- weight gain, fine hand tremor, nausea, metal taste

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

22. Lithium Toxicity Moderate to severe reactions blurred vision Moderate to severe reactions blurred vision 2 to 3 mEq/L blurred vision 2 to 3 mEq/L blurred vision All previous symptoms All previous symptoms Ataxia Ataxia blurred vision blurred vision Giddiness Giddiness Tinnitus Tinnitus Blurred vision Blurred vision High urinary output (osmotic diuresis) High urinary output (osmotic diuresis) Delerium Delerium Nystagmus Nystagmus

23. Lithium Toxicity Severe reactions Greater than Severe reactions Greater than 3 mEq/L 3 mEq/L All previous symptoms All previous symptoms Seizures Seizures Organ failure Organ failure Renal failure Renal failure Coma Coma Death Death

24. Depakote Therapeutic Range - 50-100 Therapeutic Range - 50-100 Dosing: 250 BID Increase to 500 to 3500 Dosing: 250 BID Increase to 500 to 3500 Side Effects: Side Effects: Nausea & Vomiting Nausea & Vomiting Weight Gain Weight Gain Hepatic effects/ decreased Platelet count Hepatic effects/ decreased Platelet count Drowsiness Drowsiness

25. Tegretol Tegretol Level--4-12 Tegretol Level--4-12 Side effects—lowered white count, Side effects—lowered white count, Drowsiness, mental fogginess Drowsiness, mental fogginess Lots of drug interactions Lots of drug interactions Usual Dosage 400 mgm to 1.2 Grams Usual Dosage 400 mgm to 1.2 Grams

26. Other Mood Stabilizers Trileptal (oxcarbamazine)-Headache, diarrhea. Trileptal (oxcarbamazine)-Headache, diarrhea. Lamictal (lamotrigine)-Has a very serious side effect of severe rash Lamictal (lamotrigine)-Has a very serious side effect of severe rash Neurontin(gabapentin)-Drowsiness and ataxia Neurontin(gabapentin)-Drowsiness and ataxia Topamax(topiramate)-Memory problems, Wt loss Topamax(topiramate)-Memory problems, Wt loss

27. The End