Chapter 17 Bipolar and Related Disorders

Epidemiology

-Bipolar disorder affects approximately 4.4% of American adults. -Gender incidence is roughly equal. -Average age at onset is 25 years. -Occurs more often in the higher socioeconomic classes -Sixth-leading cause of disability in the middle-age group

Bipolar Disorder

-Bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy. -Delusions or hallucinations may or may not be part of clinical picture. -Onset of symptoms may reflect seasonal pattern. -A somewhat milder form of mania is called hypomania.

Historical Perspective

-Documentation of the symptoms associated with bipolar disorder dates back to the 2nd century in Greece. -In early writings, mania was categorized with all forms of "severe madness." -The modern concept of manic-depressive illness began to emerge in the 19th century, with terms such as "dual-form insanity" and "circular insanity." -The term manic-depressive was first coined in 1913, and the American Psychiatric Association adopted the term bipolar disorder in 1980.

Criteria for Measuring Outcomes: The Client

-Exhibits no evidence of physical injury -Has not harmed self or others -Is no longer exhibiting signs of physical agitation -Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status -Verbalizes an accurate interpretation of the environment -Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations -Accepts responsibility for own behaviors -Does not manipulate others for gratification of own needs -Interacts appropriately with others -Is able to fall asleep within 30 minutes of retiring -Is able to sleep 6 to 8 hours per night

Treatment Modalities for Bipolar Disorder

-Individual psychotherapy -Group therapy -Family therapy -Cognitive therapy

Developmental Implications: Childhood and Adolescence

-Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1%. -Diagnosis is difficult. Treatment strategies •Psychopharmacology ‒ Lithium ‒ Divalproex ‒ Carbamazepine ‒ Atypical antipsychotics • Attention deficit/hyperactivity disorder (A D H D) is the most common comorbid condition. • A D H D agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled. • Family interventions ‒ Psychoeducation about bipolar disorder ‒ Communication training ‒ Problem-solving skills training

Introduction

-Mood is defined as a pervasive and sustained emotion that may have a major influence on a person's perception of the world. -Examples of mood: Depression, joy, elation, anger, anxiety -Affect is described as the emotional reaction associated with an experience. -Mania is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. -Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.

Nursing Process/Assessment

-Symptoms may be categorized by degree of severity. -Stage 1. Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization • Cheerful mood • Rapid flow of ideas; heightened perception • Increased motor activity Stage 2. Acute mania: Marked impairment in functioning; usually requires hospitalization • Elation and euphoria; a continuous "high" • Flight of ideas; accelerated, pressured speech • Hallucinations and delusions • Excessive motor activity • Social and sexual inhibition • Little need for sleep • Manipulation of others Stage 3. Delirious mania: A grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare because the advent of antipsychotic medication. • Labile mood; panic anxiety • Clouding of consciousness; disorientation • Frenzied psychomotor activity • Exhaustion and possibly death without intervention

In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? A. Risk for injury related to excessive hyperactivity B. Disturbed sleep pattern related to manic hyperactivity C. Imbalanced nutrition, less than body requirements, related to inadequate intake D. Situational low self-esteem related to embarrassment secondary to high-risk behaviors

A According to Maslow's hierarchy of needs, maintaining client safety is always a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury.

3. A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? A. Do not skimp on dietary sodium intake. B. Have serum lithium levels checked every 6 months. C. Limit fluid intake to 1000 milliliter of fluid per day. D. Adjust the dose if you feel out of control.

A Clients taking lithium should consume a diet adequate in sodium and drink 2,500 to 3,000 milliliter of fluid per day. Lithium is a salt and competes in the body with sodium. If sodium is lost, the body will retain lithium with resulting toxicity. Maintaining normal sodium and fluid levels is critical to maintaining therapeutic levels of lithium and preventing toxicity.

11. A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 lb by the end of the week? 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

ANS: 1 Rationale: The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 lb by the end of the week. Because of the hyperactive state, the client will have difficulty sitting still to consume large meals.

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

ANS: 1 Rationale: The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt.

17. Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.) 1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitter levels vary considerably in accordance with age. 4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. 5. Genetic predisposition is not a reliable diagnostic determinant.

ANS: 1, 2 Rationale: It is difficult to diagnose a child or adolescent with bipolar disorder, because bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder.

15. Which of the following instructions regarding lithium therapy should be included in a nurses discharge teaching? (Select all that apply.) 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Restrict sodium content. 5. Restrict fluids to 1,500 mL per day.

ANS: 1, 2, 3 Rationale: The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high because of the narrow margin between therapeutic doses and toxic levels. Fluid or sodium restriction can impact lithium levels.

13. A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the clients diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts.

ANS: 2 Rationale: A full manic episode emerging during antidepressant treatment (medication, electroconvulsive therapy, etc.), but persisting beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis.

14. Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

ANS: 2 Rationale: The basic premise of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care and to enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

ANS: 2 Rationale: The nurse should anticipate that the physician may prescribe valproic acid in order to increase this clients medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss.

9. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. Risky Activity tool 2. FIND tool 3. Consensus Committee tool 4. Monotherapy tool

ANS: 2 Rationale: The nurse should use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

7. A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. Thats strange. Weight loss is the typical pattern. 2. What have you been eating? Weight gain is not usually associated with lithium. 3. Weight gain is a common, but troubling, side effect. 4. Weight gain only occurs during the first month of treatment with this drug.

ANS: 3 Rationale: The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication adherence and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.

3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? Client Outcomes: 1. Maintains nutritional status 2. Interacts appropriately with peers 3. Remains free from injury 4. Sleeps 6 to 8 hours a night 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3

ANS: 3 Rationale: The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the clients safety and physical health as most important.

12. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

ANS: 3 Rationale: Three or more of the following symptoms may be experienced in both hypomanic and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas and racing thoughts, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments). If there are psychotic features, the episode is, by definition, manic.

1. A highly agitated client paces the unit and states, I could buy and sell this place. The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior? 1. Rates mood 8/10. Exhibiting looseness of association. Euphoric. 2. Mood euthymic. Exhibiting magical thinking. Restless. 3. Mood labile. Exhibiting delusions of reference. Hyperactive. 4. Agitated and pacing. Exhibiting grandiosity. Mood labile.

ANS: 4 Rationale: The nurse should document that this clients behavior is Agitated and pacing. Exhibiting grandiosity. Mood labile. The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that ones abilities are better than everyone elses.

6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The clients spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. Zyprexa in combination with Eskalith cures manic symptoms. 2. Zyprexa prevents extrapyramidal side effects. 3. Zyprexa increases the effectiveness of the immune system. 4. Zyprexa calms hyperactivity until the Eskalith takes effect.

ANS: 4 Rationale: The nurse should explain to the clients spouse that olanzapine can calm hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine, has been determined to be the first-line treatment for bipolar I disorder.

8. A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.

ANS: 4 Rationale: The nurse should interpret that the clients symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly with maintenance therapy to ensure proper dosage.

10. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. Treatment is compromised when clients cant sleep. 2. Treatment is compromised when irritability interferes with social interactions. 3. Treatment is compromised when clients have no insight into their problems. 4. Treatment is compromised when clients choose not to take their medications.

ANS: 4 Rationale: The nursing student is accurate when stating that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose not to take their medications. Clients diagnosed with bipolar disorder feel most productive and creative during manic episodes. This may lead to purposeful medication nonadherence. Symptoms of bipolar disorder will reemerge if medication is stopped.

16. A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) 1. Symptoms lasting for a minimum of two years 2. Numerous periods with manic symptoms 3. Possible comorbid diagnosis of a delusional disorder 4. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode

ANS: 4, 5 Rationale: The following are selected criteria for the diagnosis of cyclothymic disorder. For at least one year in children and adolescents there have been numerous periods with hypomanic, not manic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. The symptoms are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not elsewhere classified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

18. ___________________________ is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

ANS: Mania Rationale: Mania is an alteration in mood that is expressed by feelings of elation, inflated self- esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.

Client/Family Education: Anticonvulsants

Anticonvulsants • Refrain from discontinuing the drug abruptly. • Report the following symptoms to the physician immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes. • Avoid using alcohol and over-the-counter medications without approval from physician.

Client/Family Education: Antipsychotics

Antipsychotics • Do not discontinue drug abruptly. • Use sunblock when outdoors. • Rise slowly from a sitting or lying position. • Avoid alcohol and over-the-counter medications. • Continue to take the medication, even if feeling well and as though it is not needed; symptoms may return if medication is discontinued. • Report the following symptoms to physician: ‒ Sore throat; fever; malaise, unusual bleeding; easy bruising; skin rash, persistent nausea and vomiting ‒ Severe headache; rapid heart rate, difficulty urinating or excessive urination, muscle twitching, tremors ‒ Darkly colored urine; pale stools ‒ Yellow skin or eyes ‒ Excessive thirst or hunger ‒ Muscular incoordination or weakness

A suicidal client with a history of manic behavior is admitted to the emergency department. The client's diagnosis is documented as bipolar 1 disorder: current episode depressed. What is the rationale for this diagnosis instead of a diagnosis of major depressive disorder? A. The physician does not believe the client is suffering from major depression. B. The client has experienced a manic episode in the past. C. The client does not exhibit psychotic symptoms. D. There is no history of major depression in the client's family.

B The client's past history of mania and current suicide attempt support the diagnosis of Bipolar 1 Disorder: Current Episode Depressed. According to the D S M-5 criteria, a manic episode rules out the diagnosis of major depressive disorder

Predisposing Factors

Biological theories • Genetics ‒ Twin and family studies ‒ Other genetic studies • Biochemical influences ‒ Possible excess of norepinephrine and dopamine • Physiological influences ‒ Brain lesions ‒ Enlarged ventricles ‒ Medication side effects Psychosocial theories • Credibility of psychosocial theories has declined in recent years. • Bipolar disorder is viewed as a disease of the brain.

Bipolar 2 disorder

Characterized by bouts of major depression with episodic occurrence of hypomania Has never met criteria for full manic episode

Bipolar 1 disorder

Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms. May also have experienced episodes of depression

Evaluation

Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria. -Has the client avoided personal injury? -Has violence to the client or others been prevented? -Has agitation subsided? -Have nutritional status and weight been stabilized? -Have delusions and hallucinations ceased? -Is the client able to make decisions about own self-care?-Is behavior socially acceptable? -Is the client able to sleep 6 to 8 hours per night and awaken feeling rested? -Does the client understand the importance of maintenance medication therapy?

Psychopharmacology

For mania • Lithium carbonate • Anticonvulsants • Verapamil • Antipsychotics For depressive phase • Use antidepressants with care (may trigger mania).

Client/Family Education: Lithium

Lithium • Take the medication regularly. • Do not skimp on dietary sodium. • Drink six to eight glasses of water each day. • Notify physician if vomiting or diarrhea occur. • Have serum lithium level checked every 1 to 2 months, or as advised by physician. • Notify physician if any of the following symptoms occur: ‒ Persistent nausea and vomiting ‒ Severe diarrhea ‒ Ataxia ‒ Blurred vision ‒ Tinnitus ‒ Excessive output of urine ‒ Increasing tremors ‒ Mental confusion

2. A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

NS: 2 Rationale: The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Because of the clients rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and physical health.

Patient and Family Education

Nature of the illness • Causes of bipolar disorder • Cyclic nature of the illness • Symptoms of depression • Symptoms of mania Management of the illness • Medication management • Assertive techniques • Anger management Support services • Crisis hotline • Support groups • Individual psychotherapy • Legal/financial assistance

Planning/Implementation

Risk for Violence: Self-Directed or Other-Directed • Remove all dangerous objects from the environment. • Maintain a calm attitude. • If restraint is deemed necessary, ensure that sufficient staff are available to assist. Impaired Social Interaction • Set limits on manipulative behaviors. • Do not argue, bargain, or try to reason with the client. • Provide positive reinforcement. Imbalanced Nutrition: Less than Body Requirements / Insomnia • Provide client with high-protein, high-calorie foods. • Maintain an accurate record of intake, output, and calorie count. • Monitor sleep patterns.

Nursing Diagnosis

Risk for injury related to • Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements Risk for violence: self-directed or other-directed related to • Manic excitement • Delusional thinking • Hallucinations • Impulsivity Imbalanced nutrition less than body requirements related to • Refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea Disturbed thought processes related to • Biochemical alterations in the brain, evidenced by delusions of grandeur and persecution, as well as inaccurate interpretation of the environment Disturbed sensory perception related to • Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations Impaired social interaction related to • Egocentric and narcissistic behavior Insomnia related to • Excessive hyperactivity and agitation

Client/Family Education: Verapamil

Verapamil • Do not discontinue the drug abruptly. • Rise slowly from sitting or lying position to prevent sudden drop in blood pressure. • Report the following symptoms to physician: ‒ Irregular heartbeat; chest pain ‒ Shortness of breath; pronounced dizziness ‒ Swelling of hands and feet ‒ Profound mood swings ‒ Severe and persistent headache

Substance- and medication-induced bipolar disorder

• A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance (for example, ingestion of or withdrawal from a drug of abuse or a medication or other treatment)

Bipolar disorder due to another medical condition

• Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological effects of another medical condition

Cyclothymic disorder

• Chronic mood disturbance • At least 2-year duration • Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either bipolar 1 or 2 disorder

Electroconvulsive therapy (E C T)

• Episodes of mania may be treated with E C T when ‒ Client does not tolerate medication. ‒ Client fails to respond to medication. ‒ Client's life is threatened by dangerous behavior or exhaustion.

The Recovery Model

• Learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with serious mental illness. • In bipolar disorder, recovery is a continuous process. ‒ Client identifies goals. ‒ Client and clinician develop a treatment plan. ‒ Client and clinician work on strategies to help the individual manage the bipolar illness. ‒ Clinician serves as support person to help the individual achieve the previously identified goals. • Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and social life.