Understanding Bipolar Disorder

Bipolar Disorder

• Individuals with bipolar disorders tend to spend more time in depressed states than manic states
• Treatment is very similar to Major Depressive Disorder (MDD)
• During the manic phase, individuals can experience flight, clang, and graniosity
  • Flight: content is often sexually explicit and inappropriate
  • Clang: "cinema I and II, last row. Row, row, row your boat. Don't be cutthroat! Cut your throat. Get your goat. Go out and vote. And so I wrote"
  • Graniosity: example à God is speaking to them, they are secretly friends with celebrities
• As the manic phase progresses from hypomania to mania, sociability and euphoria are replaced by hostility, irritability, and paranoia
• Rapid Cycling: 4 or more episodes of mood changes (depression and/or mania) within a 12-month period
  • Associated with severe symptoms and high recurrence rate
  • This can happen in all mood disorders, not just bipolar
  • Resistant to traditional treatments

Phases of Bipolar Disorder

• Acute:
  • Keep individuals hydrated
  • Promote sleep and rest
  • Encourage self-control
  • DO NOT ATTEMPT SELF HARM
• Continuation:
  • Educate individuals about their disease, medication, and consequences of substance addiction/relapse
  • Teach individuals about early signs and symptoms
  • Help individuals control and decrease stress

Assessing an Individual with Bipolar Disorder

• Safety: Mania is exhausting. Individuals may not eat or sleep. Poor impulse control can lead to harmful behaviors
• Protection: Individuals may give away all possessions or go into bankruptcy
• Medical Status: Determine if the individual's behavior is substance induced. Rule out other medical conditions or medications that may contribute to their behavior.

Main Medications

• Lithium: Inhibits about 80% of acute manic and hypomanic episodes in 10-21 days
  • Ensure salt is NOT reduced and ensure plenty of fluids (~2-3L/day)
  • Low serum sodium leads to toxicity
  • Suspect toxicity if excessive diarrhea, vomiting, or diuresis
  • Avoid diuretics
  • Do not give with NSAIDs
  • Ensure proper hydration!
  • Want a salt balance – don’t add extra salt, but do not reduce intake
  • Link to hypothyroidism

Lithium Side Effects

• Leukocytosis (high WBC)
• Increased urination
• Thirst and tremor
• Hypothyroidism
• Interactions with medications are common
• Upset stomach (nausea, vomiting, diarrhea)
• Must get levels checked frequently

Signs of Lithium Toxicity

• All signs advance as lithium toxicity becomes more severe
• Tremor may become seizure, lethargy may become confusion, then coma
• Early signs include scattered thoughts and tremors
• Clients with lithium toxicity may develop polyuria, due to the resistance to anti-diuretic hormone potentially leading to nephrogenic diabetes insipidus with chronic lithium toxicity

Lithium Level Monitoring:

• It may take some time to get to a proper lithium level, an antipsychotic or benzodiazepine may be used in the meantime to prevent exhaustion, coronary collapse, and death until lithium reaches therapeutic levels
• Antipsychotics act promptly. They may be discontinued when lithium takes effect
• EPS (Extrapyramidal Symptoms): involve involuntary motor symptoms similar to those associated with Parkinson's disease. Also known as pseudoparkinsonism and includes such symptoms as akathisia (distressing motor restlessness) and acute dystonia (painful muscle spasms)
  • Akathisia is often misdiagnosed as anxiety, restless leg syndrome, or agitation.
  • Watch for EPS in individuals taking antipsychotics, especially 1st generation and SSRIs
• TD (Tardive Dyskinesia): symptoms are most common with 1st-generation antipsychotics
  • Symptoms usually improve with ceasing medication, but may not always be reversible.

Depression (DSM-5)

• Must have symptom #1 or 2 and a minimum of 5/9 in total
  • Symptom #1: Depressed mood
  • Symptom #2: Diminished interest in activities
  • Symptom #3: Significant weight loss or gain
  • Symptom #4: Insomnia or hypersomnia
  • Symptom #5: Psychomotor agitation or retardation
  • Symptom #6: Fatigue/loss of energy
  • Symptom #7: Feelings of worthlessness or guilt
  • Symptom #8: Decreased concentration or indecisiveness
  • Symptom #9: Suicidal ideation or attempt

Other Types of Depression

• Dysthymia (Persistent Depressive Disorder)
  • Also known as Persistent Depressive Disorder (PDD)
  • occurs when depression occurs most of the day, on the majority of days
  • Differs from MDD
  • The symptoms in dysthymia are lower-level and last at least 2 years in adults, or 1 year in children
• Persistent Depressive Disorder (PDD):
  • Depressed mood + two or more additional symptoms
    • Symptom #1: Decreased appetite or overeating
    • Symptom #2: Insomnia or hypersomnia
    • Symptom #3: Low energy
    • Symptom #4: Poor self-esteem
    • Symptom #5: Difficulty thinking
    • Symptom #6: Hopelessness
  • Symptoms cause significant distress and impairment of critical areas of functioning

Public Perception

• Although we've come a long way in public perception and understanding over the last number of years, many people still view depression as a disease for the 'weak'
• We have no more control over our neurotransmitters than we do over our blood pressure. It isn't an issue of strong or weak, simply biology.

Beck's TRIAD

• Beck & Rush (1995) found that individuals with depression process information in negative ways, even in the midst of positive factors.
• Components:
  • A negative, self-deprecating view of self: "Nobody loves me, I'm worthless and inadequate"
  • A pessimistic view of the world: "Everyone is against me, because I am worthless"
  • The belief that negative reinforcement (or no validation for the self) will continue in the future: “I will always be a failure”
• Beck argues that by challenging these thoughts, an individual can experience new feelings and beliefs.

Treatments for Depression

• CBT (Cognitive Behavioral Therapy): Skill training and problem-solving through therapy
• ECT (Electroconvulsive Therapy): Used if resistant to treatment with medication with good results
• Medications: SSRIs and SNRIs are most common, may also have atypical antidepressants, or tricyclic antidepressants

SSRI's (Selective Serotonin Reuptake Inhibitors)

• First choice treatment
• Monitor for suicide and serotonin syndrome
• MONITOR FOR SUICIDE RISK WITH ALL ANTIDEPRESSANTS!

Colorectal Cancer

• Average risk = Ages 50 to 74 with no first-degree relative diagnosed with colorectal cancer and no personnal history of precancerous colorectal polyps requiring surveillance or inflammatory bowel disease (i.e., Crohn's disease involving the colon, or ulcerative colitis)
• Screening:
  • Every 5 years: for people with a first-degree relative who was diagnosed with colorectal cancer before age 60
  • Every 10 years: for people with a first-degree relative who was diagnosed with colorectal cancer at age 60 or older

Diagnosis

• General Physical Exam: Includes a digital rectal examination
• Lab and Blood Tests: Testing of stool sample for occult (hidden) blood
• Colonoscopy: Scope that looks at the entire bowel
• Biopsy: Removal of a small portion of the colon or rectum to examine under a microscope. This is the most accurate test of all, but because it involves cutting the body, the other tests are usually done first
• CT Scan: Can see the tumor and if the cancer has spread

Surgery and Follow-Up Care

• Surgery: Various types of surgery can be done based on multiple factors (i.e. tumor resection vs. hemicolectomy)
• Chemotherapy/Radiation: Based on cancer staging
• Monitor:
  • The patient’s bowel patterns
  • The patient’s diet modification, and assess the adequacy of his nutrition intake
• Diet: Encourage a high fiber diet
• Caution: Only take laxatives or antidiarrheal medications as prescribed by a doctor
• Screenings: Inform the patient about screening and early detection.