Ch 26 Bipolar Related Disorders

Stage III: Delirious Mania

(rare) Delirious mania is a grave form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania. Mood - very labile. - may exhibit feelings of despair, quickly converting to unrestrained merriment and ecstasy or becoming irritable or totally indifferent to the environment. - Panic anxiety may be evident. Cognition and Perception - clouding of consciousness, with accompanying confusion, disorientation, and sometimes stupor. - Other common manifestations include religiosity, delusions of grandeur or persecution, and auditory or visual hallucinations. -extremely distractible and incoherent. Activity and Behavior - Psychomotor activity is frenzied and characterized by agitated, purposeless movements. - The safety of these individuals is at stake unless this activity is curtailed. - Exhaustion, injury to self or others, and eventually death could occur without intervention.

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 consequence of another medical condition - The mood disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. - Types of physiological influences are included in the discussion of predisposing factors associated with bipolar disorders. stroke, MS

Bipolar II

- Characterized by bouts of major depression with episodic occurrence of hypomania (not severe enough to cause marked impairment in social or occupational functioning) - Has NEVER met criteria for full manic episode - Could have psychotic or catatonic feature if it is a major depressive episode - May present with symptoms (or history) of depression or hypomania. - The diagnosis may specify whether the current or most recent episode is hypomanic, depressed, or with mixed features.

Predisposing - Psychosocial Theories

- Credibility declined - bipolar considered disease of brain

Childhood and Adolescence

- Diagnosis difficult because the developmental courses and sx are unique from those of adult - Sx may present with co-moid conduct disorders or ADHD - Guidelines for diagnoses and treatment have been developed

Bipolar 1

- Diagnosis given to an individual who is experiencing a manic episode or has a history of one or more manic episodes. - May also have experienced episodes of depression. - Current or most recent behavioral episode experienced. Ex: The specifier might be single manic episode (to describe individuals having a first episode of mania) or the specifier may be identified as current (or most recent) episode manic, hypomanic, mixed, or depressed (to describe individuals who have had recurrent mood episodes). - Psychotic or catatonic features may also be noted.

Criteria for measuring outcome

- Exhibits no evidence of whys 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 environment - Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations - Accepts responsibility for own behavior - 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 - 8 hours per night

Treatment modalities for Bipolar Disorder

- Individual Psychotherapy - Group Therapy - Family Therapy - Cognitive Therapy - ECT - Psychopharmacology

Bipolar nursing diagnoses

- Risk for Injury R/T extreme hyperactivity, inc agitation, and lack of control over purposeless and potentially injurious movements - Risk for Violence: Self directed or other directed R/T - Imbalanced Nutrition less than body requirements R/T refusal or inability to sit still long enough to eat AEB loss of weight, amenorrhea - Disturbed thought processes R/T biochemical alteration in brain, AEB delusions of grandeur and persecution and inaccurate interpretation of the environment - Disturbed sensory perception R/T biochemical alteration in the brain and to possible sleep deprivation AEB auditory and visual hallucinations - Impaired social interaction R/T egocentric and narcissistic behavior - Insomnia R/T excessive hyperactivity and agitation

Predisposing - Biological Theories

- cholinergic agents have profound effects on mod; there may be an imbalance between the biogenic mines and acetylcholine o Genetics- twin studies, family studies, other genetic studies o Biochemical influences- biogenic amines (deficiency of NE and dopamine; acetylcholine; cholinergic agents have profound effects on mood) o Physiological influences

Substance Induced bipolar disorder

- considered to be the direct result of physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication). -The mood disturbance may involve elevated, expansive, or irritable mood, with inflated self-esteem, decreased need for sleep, and distractibility. -clinically significant distress or impairment in social, occupational, or other important areas of functioning. -Mood disturbances are associated with intoxication from substances such as alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives, hypnotics, and anxiolytics. - Symptoms can occur with withdrawal from substances such as alcohol, amphetamines, cocaine, sedatives, hypnotics, and anxiolytics.

Developmental Childhood and Adolescence

- prevalence of pediatric and adolescent bipolar disorders is estimated to be about 1%,but children and adolescents are often difficult to diagnose -The developmental courses and symptom profiles of psychiatric disorders in children are unique; therefore, approaches to diagnosis and treatment cannot merely rely on strategies examined and implemented in a typical adult population - Symptoms difficult to assess - may also present with comorbid conduct disorders or attention-deficit/hyperactivity disorder (ADHD). - Because there is a genetic component and children of bipolar adults are at higher risk, family history may be particularly important

Diagnostic Criteria for Hypomanic Episode BOX 26 - 2

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment).

Diagnostic Criteria for Manic Episode BOX 26 -1

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree, and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy), but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

Lithium Toxicity

Acute mania 1.0 to 1/5 mEq/L maintenance 0.6 to 1.2 mEq/L blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea (initial symptoms of toxicity) Serum levels: 1.5-2.0mE/L blurred vision ataxia tinnitus nausea and vomiting and severe diarrhea 2.0-3.5 excessive dilute urine inc tremors muscular irritability psychomotor retardation confusion

Stage I: Hypomania

At this stage the disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization (APA, 2013). Mood - cheerful and expansive - underlying irritability that surfaces rapidly when the person's wishes and desires go unfulfilled, however- The nature of the hypomanic person is very volatile and fluctuating (see Box 26-2). Cognition and Perception - Perceptions of the self are exalted—ideas of great worth and ability. Thinking is flighty, with a rapid flow of ideas. Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli that goal-directed activities are difficult. Activity and Behavior - Hypomanic individuals exhibit increased motor activity. - very extroverted and sociable, and because of this they attract numerous acquaintances. - lack the depth of personality and warmth to formulate close friendships. - talk and laugh a great deal, usually very loudly and often inappropriately. - Increased libido is common. - Some individuals experience anorexia and weight loss. - The exalted self-perception leads some hypomanic individuals to engage in inappropriate behaviors, such as phoning the President of the United States, or buying huge amounts on a credit card without having the resources to pay.

Bipolar 1 disorder (BOX 26-1)

Client is experiencing or has experienced a full syndrome of manic or mixed symptoms specifiers such as single manic episode, current episode manic, hypomanic, mixed or depressed features full spectrum of manic episode takes place; pt has manic episode or has a history of one or more manic episodes; pt may also have experienced episodes of depression; can experience a single manic episode or a current episode manic, hypomanic, mixed, or depressed

Treatment modalities for Bipolar Disorder o Cognitive Therapy

Client is taught to control thoughts and distortions o depression is characterized by 3 neg distortions; related to expectations of the environment, self, and future - environment and activities within it are viewed as unsatisfying, the self is unrealistically devalued, and the future is perceived as hopeless o Mania is characterized by exaggeratedly positive cognitions and perceptions; the individual perceives the self as highly valued and powerful; future is viewed with unrealistic optimism; therapy focuses on changing "automatic thoughts" that occur spontaneously and contribute to the distorted bipolar mania • Personalizing: "she's this happy only when she's with me" • All or nothing: "everything I do is great" • Mind reading: "she thinks I'm wonderful" • Discounting negatives: " none of those mistakes are really important"

Substance Induced bipolar disorder BOX 26 -3

For at least 2 years (at least one year in children and adolescents) there have been numerous periods with hypomanic 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. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With anxious distress

Psychopharmacology for Mania

Lithium carbonate Anticonvulsants Verapamil Antipsychotics

Management of Illness

Medication management such as dosage, SE, required blood tests, and not to stop meds abruptly, assertive techniques, and anger management

A suicidal client with a history of manic behavior is admitted to the ED. The client's diagnosis is documented as bipolar I current episode depressed. What is the rationale or this diagnosis instead of a diagnosis of major depressive disorder

Past history of mania and current suicide attempt support Bipolar i

Symptoms may be categorized by degree of severity

Stage I: Hypomania Stage II: Acute Mania Stage III: Delirious Mania

Stage II: Acute Mania

Symptoms of acute mania may be a progression in intensification of those experienced in hypomania, or they may be manifested directly. Most individuals experience marked impairment in functioning and require hospitalization (see Box 26-1). Mood - characterized by euphoria and elation. - The person appears to be on a continuous "high." However, the mood is always subject to frequent variation, easily changing to irritability and anger or even to sadness and crying. Cognition and Perception - become fragmented and often psychotic in acute mania. -Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speech (loquaciousness), with abrupt changes from topic to topic. - When flight of ideas is severe, speech may be disorganized and incoherent. - Distractibility becomes all-pervasive. Attention can be diverted by even the smallest of stimuli. Hallucinations and delusions (usually paranoid and grandiose) are common. Activity and Behavior Psychomotor activity is excessive. Sexual interest is increased. There is poor impulse control, and the individual who is normally discreet may become socially and sexually uninhibited. Excessive spending is common. - Individuals with acute mania have the ability to manipulate others to carry out their wishes, and if things go wrong, they can skillfully project responsibility for the failure onto others. - Energy seems inexhaustible, and the need for sleep is diminished. They may go for many days without sleep and still not feel tired. - Hygiene and grooming may be neglected. - Dress may be disorganized, flamboyant, or bizarre, and the use of excessive makeup or jewelry is common.

9. The nurse is prioritizing nursing diagnoses in the plan of care for a client experiencing a manic episode. Number the diagnoses in order of the appropriate priority. ____ a. Disturbed sleep pattern evidenced by sleeping only 4-5 hours per night ____b. Risk for injury related to manic hyperactivity ____ c. Impaired social interaction evidenced by manipulation of others ____d. Imbalanced nutrition: Less than body requirements evidenced by loss of weight and poor skin turgor

a = 3, b = 1, c = 4, d = 2

3. The physician orders lithium carbonate 600 mg tid for a newly diagnosed client with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. Therapeutic range for acute mania is: a. 1.0 to 1.5 mEq/L b. 10 to 15 mEq/L c. 0.5 to 1.0 mEq/L d. 5 to 10 mEq/L

a. 1.0 to 1.5 mEq/L

4. Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? (Select all that apply.) a. Olanzepine (Zyprexa) b. Paroxetine (Paxil) c. Carbamazepine (Tegretol) d. Lamotrigine (Lamictal) e. Tranylcypromine (Parnate)

a. Olanzepine (Zyprexa) c. Carbamazepine (Tegretol) d. Lamotrigine (Lamictal)

Mania

alteration in mood that is expressed by feelings of elation inflate self esteem grandiosity hyperactivity agitation and accelerated thinking and speaking biological or psychological disorder

Medications that have been known to evoke mood symptoms:

anesthetics, analgesics anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antinuclear agents, cardiac meds, oral contraceptives, psychotropic meds, muscle relaxants, steroids, and sulfonamides

Psychopharmacology for Depression

antidepressants with care may trigger mania

5. Margaret, a 68-year-old widow experiencing a manic episode, is admitted to the psychiatric unit after being brought to the emergency department by her sister-in-law. Margaret yells, "My sister-in-law is just jealous of me! She's trying to make it look like I'm insane!" This behavior is an example of: a. A delusion of grandeur b. A delusion of persecution c. A delusion of reference d. A delusion of control or influence

b. A delusion of persecution

1. Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sisterin- law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is: a. Imbalanced nutrition: less than body requirements related to not eating b. Risk for injury related to hyperactivity c. Disturbed sleep pattern related to agitation d. Ineffective coping related to denial of depression

b. Risk for injury related to hyperactivity

7. A nurse is educating a client about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the client to be on the alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. Occipital headache, palpitations, chest pain d. Skin rash, marked rise in blood pressure, bradycardia

b. Tinnitus, severe diarrhea, ataxia

2. Margaret, age 68, is diagnosed with bipolar I disorder, current episode manic. She is extremely hyperactive and has lost weight. One way to promote adequate nutritional intake for Margaret is to: a. Sit with her during meals to ensure that she eats everything on her tray. b. Have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." d. Tell Margaret that she will be on room restriction until she starts gaining weight.

c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run."

8. A client experiencing a manic episode enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell the client she cannot wear this outfit while she is in the hospital. b. Do nothing and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate. d. Explain to her that if she wears this outfit she must remain in her room.

c. Quietly walk with her back to her room and help her change into something more appropriate.

10. A child with bipolar disorder also has attention-deficit/hyperactivity disorder (ADHD). How would these co-morbid conditions most likely be treated? a. No medication would be given for either condition. b. Medication would be given for both conditions simultaneously. c. The bipolar condition would be stabilized first before medication for the ADHD would be given. d. The ADHD would be treated before consideration of the bipolar disorder.

c. The bipolar condition would be stabilized first before medication for the ADHD would be given.

Bipolar

characterized by mood swings from profound depression to extreme euphoria with intervening period of normalcy o Delusions/hallucinations may or may not be a part of the clinical picture, and onset of symptoms may reflect a seasonal pattern

Cyclothymic Disorder

chronic, at least 2 years duration, involving numerous periods of elevated mood that do not meet the criteria for a hypomanic episode and numerous periods of depressed mood of insufficient severity or duration to meet the criteria for major depressive episode; the individual is never without the symptoms for more than 2 months

Support Services

crisis hotline support groups individual psychotherapy Legal/financial assisstance

6. The most common comorbid condition in children with bipolar disorder is: a. Schizophrenia b. Substance disorders c. Oppositional defiant disorder d. Attention-deficit/hyperactivity disorder

d. Attention-deficit/hyperactivity disorder

Transactional model:

disorder results from interactions among genetic, biological, and psychosocial determinants

Evaluation

effectiveness of nursing interventions has client avoided personal injury nutritional status and weight stabilized have hallucinations ceased is behavior socially acceptable can they sleep do they understand the importance of continuing mendication

Affect

emotional reaction associated with an experience

Electroconvulsive Therapy

episodes of mania treated client does not tolerate med does not respond to med

Treatment modalities for Bipolar Disorder o Family Therapy

goal is to restore adaptive family functioning, most effective with psychotherapeutic and pharmacotherapeutic treatment

Treatment modalities for Bipolar Disorder o Group Therapy

helpful after acute phase has passed, have peer support

mood stabilizing agents

indication: prevent and treat of manic episodes associated with bipolar ex:

Lithium

may modulate the effects of certain neurotransmitters such as norepinephrine serotonin dopamine SE: drowsniess dizziness thirst GI upset fine hand tremors pulse irrgularities polyuria, dehydration

Treatment modalities for Bipolar Disorder o Individual psychotherapy

not best bc client is trying to please the therapist and relationship remains shallow and rigid

Mood

pervasive and sustained emotion that may have a major influence eon a persons perception of the world o Depression, joy, elation, anger, anxiety

Treatment modalities for Bipolar Disorder o Electroconvulsive Therapy

used when the client doesn't tolerate or fails to respond to lithium or other drug treatment, or when life is threatened by dangerous behavior or exhaustion

Treatment modalities for Bipolar Disorder o Psychopharmacology with mood stabilizing agents

• LITHIUM: • Acute mania: 1.0-1.5 mEq/L • Maintenance: 0.6-1.2 mEq/L • Serum levels of 1.5-2.0 mEq/L- blurred vision, ataxia, tinnitus, persistent N/V/D • Serum levels of 2.0-3.5 mEq/L- excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness • Serum levels above 3.5 mEq/L- impaired consciousness, nystagmus, seizures, coma, oligura/anuria, arrhythmias, MI, cardiovascular collapse • If sodium intake is reduced or the body is depleted of its normal sodium, lithium is reabsorbed by the kidneys, increasing the possiblilty of toxicity; client must consume a diet adequate in sodium as well as 2,500-3,000 mL of fluid dialy • MOA not understood; 1-3 weeks for symptoms to subside

Developmental Childhood and Adolescence SYMPTOMS

■ Euphoric/expansive mood. Extremely happy, silly, or giddy. ■ Irritable mood. Hostility and rage, often over trivial matters. The irritability may be accompanied by aggressive and/or self-injurious behavior. ■ Grandiosity. Believing that his or her abilities are better than everyone else's. ■ Decreased need for sleep. May sleep only 4 or 5 hours per night and wake up fresh and full of energy the next day. Or he or she may get up in the middle of the night and wander around the house looking for things to do. ■ Pressured speech. Rapid speech that is loud, intrusive, and difficult to interrupt. ■ Racing thoughts. Topics of conversation change rapidly, in a manner confusing to anyone listening. ■ Distractibility. It needs to reflect a change from baseline functioning, needs to occur in conjunction with a "manic" mood shift, and cannot be accounted for exclusively by another disorder, particularly ADHD Distractibility during a manic episode may be reflected in a child who is normally a B or C student and is unable to focus on any school lessons. ■ Increase in goal-directed activity/psychomotor agitation. A child who is not usually highly productive, during a manic episode becomes very projectoriented, increasing goal-directed activity to an obsessive level. Psychomotor agitation represents a distinct change from baseline behavior. ■ Excessive involvement in pleasurable or risky activities. hyper sexual, exhibiting behavior that has an erotic, pleasure-seeking quality about it. Adolescents may seek out sexual activity multiple times in a day. ■ Psychosis. psychotic symptoms, including hallucinations and delusions, are frequently present in children with bipolar disorder ■ Suicidality. Although not a core symptom of mania, at risk of suicidal ideation, intent, plans, and attempts during a depressed or mixed episode or when psychotic

Developmental Childhood and Adolescence To differentiate between occasional spontaneous behaviors of childhood and behaviors associated with bipolar disorder- F-I-N-D

■ Frequency: Symptoms occur most days in a week. ■ Intensity: Symptoms are severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains. ■ Number: Symptoms occur three or four times a day. ■ Duration: Symptoms occur 4 or more hours a day.