Bipolar Disorder PDF

Mental health nursing Dr: Mohammed -Senan Bipolar Disorder Most people have emotional ups and downs from time to time. But if you have a brain condition called bipolar disorder, your feelings can reach abnormally high or low levels. Sometimes you ma...

Mental health nursing Dr: Mohammed -Senan Bipolar Disorder Most people have emotional ups and downs from time to time. But if you have a brain condition called bipolar disorder, your feelings can reach abnormally high or low levels. Sometimes you may feel immensely excited or energetic. Other times, you may find yourself sinking into a deep depression. Some of these emotional peaks and valleys can last for weeks or months. There are types of bipolar disorder: 1) bipolar 1 disorder 2) bipolar 2 disorder 3) cyclothymic disorder (cyclothymia) 4) Bipolar disorder due to general medical condition. 5) Substance-induced bipolar disorder. Bipolar 1 and 2 disorders are more common than the other types of bipolar disorder. Read on to learn how these two types are alike and different. ▪ Bipolar I disorder :-( manic +depression) is the diagnosis given to an individual who is experiencing, or has experienced, a full syndrome of of manic or mixed symptoms; the client may also have experienced periods of depression. ▪ Bipolar II disorder. (major depression+ hypomanic) Bipolar II disorder is characterized by recurrent bouts of major depression with the episodic occurrence of hypomania; this individual has never experienced a full syndrome of manic or mixed symptoms. 11 Mental health nursing Dr: Mohammed -Senan ▪ Cyclothymic disorder. ( depression+ hypomanic) The essential feature is a chronic mood disturbance of at least 2 years’ duration, involving numerous periods of depression and hypomania, but not of sufficient severity and duration to meet the criteria for either bipolar I or bipolar II disorder. ▪ Bipolar disorder due to general medical condition. This disorder is characterized by a prominent and persistent disturbance in mood (bipolar symptomatology) that is judged to be the direct result of the physiological effects of a general medical condition. ▪ Substance-induced bipolar disorder. The bipolar symptoms associated with this disorder are considered to be the direct result of the physiological effects of a substance (e.g., use or abuse of a drug or a medication, or toxin exposure). Pathophysiology The pathophysiology of bipolar disorder, or manic-depressive illness (MDI), has not been determined, and no objective biologic markers correspond definitively with the disease state. The genetic component of bipolar disorder appears to be complex; the condition is likely to be caused by multiple different common disease alleles, each of which contributes a relatively low degree risk on its own. Many loci are now known to be associated with the development of bipolar disorder.. 12 Mental health nursing Dr: Mohammed -Senan Causes Predisposing factors to bipolar disorder include: ▪ Biological. Twin studies have indicated a concordance rate for bipolar disorder among monozygotic twins at 60% to 80% compared to 10% to 20% in dizygotic twins. ▪ Biochemical. Just as there is an indication of lowered levels of norepinephrine and dopamine during an episode of depression, the opposite appears to be true of an individual experiencing a manic episode. ▪ Physiological. Right-sided lesions in the limbic system, basal ganglia, and thalamus have been shown to induce secondary mania. ▪ Medication side effects. Certain medications used to treat somatic illnesses have been known to trigger a manic response; the most common of these are the steroids frequently used to treat chronic illnesses such as multiple sclerosis and systemic lupus erythematosus. Clinical Manifestations These are the symptoms of bipolar disorder: ❖ Heightened, grandiose, or agitated mood. The effect of a manic individual is one of elation (motor activity)and euphoria(happiness) a continuous “high”. ❖ Exaggerated self-esteem.(irritability) Usual inhibitions are discarded in favor of sexual and behavioral indiscretions. ❖ Sleeplessness. Sleep patterns are disturbed; client becomes oblivious to feelings of fatigue, and rest and sleep are abandoned for days or weeks. ❖ Pressured speech. Loquaciousness, or pressured speech, is so forceful and strong that it is difficult to interrupt maladaptive thought processes. 13 Mental health nursing Dr: Mohammed -Senan ❖ Flight of ideas. There is a continuous, rapid shift from one topic to another. ❖ Reduced ability to filter out extraneous stimuli; easily distractible. There is inability to concentrate because of a limited attention span; the individual is easily distracted by even the slightest stimulus in the environment. ❖ Increased number of activities with increased energy. Motor activity is constant; the individual is literally moving at all times. ❖ Multiple, grandiose, high risk activities, using poor judgment; with severe consequences. Assessment and Diagnostic Findings A number of reasons exist for obtaining selected laboratory studies in patients with bipolar disorder; an extensive range of tests is indicated, because bipolar disorder encompasses both depression and mania and because a significant number of medical causes for each state exist. ▪ Complete blood count. A complete blood count with differential is used to rule out anemia as a cause of depression in bipolar disorder. ▪ Erythrocyte sedimentation rate. The erythrocyte sedimentation rate (ESR) is determined to look for underlying disease process such as lupus or an infection; an elevated ESR often indicates an underlying disease process. ▪ Fasting glucose. In some cases, a fasting glucose level is indicates to rule out diabetes. ▪ Electrolytes. Serum electrolyte concentrations are measured to help diagnose electrolyte problems, especially with sodium, that are related to depression. ▪ Proteins. Low serum protein levels found in patients who are depressed may be a result of not eating. 14 Mental health nursing Dr: Mohammed -Senan ▪ Thyroid hormones. Thyroid tests are performed to rule out hyperthyroidism (mania) and hypothyroidism (depression). ▪ cretonne and blood urea nitrogen. Kidney failure can present as depression; treatment with lithium can affect urinary clearances, and serum cretonne and blood urea nitrogen (BUN) levels can increase. ▪ Substance and alcohol screening. Alcohol abuse and abuse of a wide variety of drugs can present as either mania or depression. ▪ MRI. The total value of performing MRI in a patient with bipolar disorder remains unclear; however, a couple of reasons do exist for performing an imaging study. ▪ Electrocardiography. Many of the anti-depressants, especially the tricyclic agents and some of the antipsychotics can affect the heart and cause conduction problems. Medical Management of Bipolar Disorder The treatment of bipolar disorder is directly related to the phase of the episode (i.e. depression or mania) and the severity of that phase. ▪ Psychotherapy. Psychotherapy helps patients with bipolar disorder but does not cure the disorder itself; when shuttle and colleagues looked at psychotherapy for patients, family, and care givers, they found that although results were heterogeneous, most studies demonstrated relevant positive results in regard to decreased relapse rates, improved quality of life, increased functioning, or more favorable symptom improvement. ▪ Electroconvulsive therapy. Electroconvulsive therapy (ECT) is useful in a number of instances in patients with bipolar disorder, such as when rapid, definitive medical/psychiatric treatment is needed; when the risks of ECT are less than that of other treatments; when the bipolar 15 Mental health nursing Dr: Mohammed -Senan disorder is refractory to an adequate trial with other treatment strategies; and when the patient prefers this treatment modality. ▪ Diet. Patients should be advised not to make significant changes in their salt intake, because increased salt intake may lead to reduced serum lithium levels and reduced efficacy, and reduced intake may lead to increased levels and toxicity. ▪ Activity. Patients in the depressed state are encouraged to exercise; these individuals should try to develop a regular daily schedule of major activities, especially times of going to bed and waking up. ▪ Pharmacological Management ▪ Appropriate medication for managing bipolar disorder depends on the stage the patient is experiencing. ▪ Anxiolytics, benzodiazepines. By binding to specific receptor sites, benzodiazepines appear to potentiate the effects. ▪ Mood stabilizers. Lithium is the drug commonly used for prophylaxis and treatment of manic episodes. ▪ Anticonvulsants. Anticonvulsants have been effective in preventing mood swings associated with bipolar disorder, especially in those patients known as rapid cyclers. ▪ Antipsychotics, 2nd generation. Second generation, or atypical, antipsychotics are increasingly being used for treatment of both acute mania and mood stabilization in patients with bipolar I disease. ▪ Antipsychotics, 1st generation. First-generation antipsychotics, also known as conventional or typical antipsychotics, are efficacious in treating both psychotic and nonpsychotic manic and mixed episodes, as well as hypomania. ▪ Antipsychotics, phenothiazine. Phenothiazine antipsychotics, which are classified as first-generation 16 Mental health nursing Dr: Mohammed -Senan antipsychotics, are efficacious in treating both psychotic and nonpsychotic manic and mixed episodes, as well as hypomania. ▪ Antiparkinsons agents, dopamine agonists. Dopamine agonists are non-ergot agents that bind to D2 and D3 dopamine receptors in the striatum and substantia nigra. ▪ Nursing Management for Bipolar Disorder Nursing Management for Bipolar Disorder ▪ Providing for safety. A primary nursing responsibility is to provide a safe environment for client and others; for clients who feel out of control, the nurse must establish external controls emphatically and nonjudge mentally. ▪ Meeting physiologic needs. Decreasing environmental stimulation may assist client to relax; the nurse must provide a quiet environment without noise, television, and other distractions; finger foods or things client can eat while moving around are the best options to improve nutrition. ▪ Providing therapeutic communication. Clients with mania have short attention spans, so the nurse uses simple, clear sentences when communicating; they may not be able to handle a lot of information at once, so the nurse breaks information into many small segments. ▪ Promoting appropriate behavior. The nurse can direct their need for movement into socially acceptable, large motor activities such as arranging chairs for a community meeting or walking. ▪ Managing medications. Periodic serum lithium levels are used to monitor the client’s safety and to ensure that the dose given has increased the serum lithium level to a treatment level or reduced it to a maintenance level. 17 Mental health nursing Dr: Mohammed -Senan ▪ Provide structured solitary activities with the assistance of a nurse or aide. ▪ Provide frequent rest periods. ▪ Provide frequent high-calorie fluids to Prevents the risk of serious dehydration. 18