Lect 5 Bipolar Disorder PDF

Chapter 26 Bipolar and Related Disorders Copyright ©2021 F.A. Davis Company  Introduction  Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of t...

Chapter 26 Bipolar and Related Disorders Copyright ©2021 F.A. Davis Company  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 include depression, joy, elation, anger, anxiety.  Affect is described as the emotional reaction associated with an experience. Copyright ©2021 F.A. Davis Company  Introduction (continued)  Mania An alteration in mood that may be expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, and accelerated speech. It can occur as part of the psychiatric disorder bipolar disorder, as part of some other medical conditions, or in response to some substances. Copyright ©2021 F.A. Davis Company  Historical Perspective  Ancient Greece “Torpid, dull, and sorrowful”  Persia (1025) The Canon of Medicine ‒ “Bestial madness characterized by rapid onset and remission, with agitation and irritability.”  France (1854) “Dual-form insanity” and “circular insanity” Copyright ©2021 F.A. Davis Company  Historical Perspective (continued)  Emil Kraepelin (1913) Manic-depressive  American Psychiatric Association (1980) Bipolar disorder ‒ “...period of mood elevation and excitation” as a defining characteristic replacing the term “mania” because descriptions of people as “maniacs” was considered stigmatizing. ‒ Mania is still used to describe an abnormal mood state of elation. Copyright ©2021 F.A. Davis Company  Epidemiology  Bipolar disorder affects approximately 4.4 percent American adults; 82.9 percent of cases are severe.  Gender incidence is roughly equal.  Average age at onset is age 25 years.  Associated with increased mortality in general; particularly with death by suicide Copyright ©2021 F.A. Davis Company  Epidemiology (continued)  Occurs more often in higher socioeconomic classes  Sixth-leading cause of disability in middle age group Copyright ©2021 F.A. Davis Company  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. Copyright ©2021 F.A. Davis Company  Types of Bipolar Disorder  Bipolar I Disorder Diagnosis requires that the patient: ‒ Is experiencing a manic episode or has a history of one or more manic episodes ‒ May have also experienced episodes of depression Diagnosis is further specified by the current or most recent behavioral episode. Copyright ©2021 F.A. Davis Company  Types of Bipolar Disorder (continued_1)  Bipolar II disorder Diagnosis requires that the patient: ‒ Presents with symptoms (or history) of depression or hypomania ‒ Has never met criteria for full manic episode ‒ Has never had symptoms severe enough to cause impairment in social or occupational functioning or to necessitate hospitalization Copyright ©2021 F.A. Davis Company  Types of Bipolar Disorder (continued_2)  Cyclothymic disorder Diagnosis requires that the patient: ‒ Has a chronic mood disturbance, lasting at least 2 years ‒ Has numerous periods of elevated mood that do not meet the criteria for a hypomanic episode; or ‒ Has numerous periods of depressed mood of insufficient severity or duration to meet criteria for a major depressive episode; and ‒ Is never without the symptoms for more than 2 months Copyright ©2021 F.A. Davis Company  Types of Bipolar Disorder (continued_3)  Substance-induced bipolar disorder Diagnosis requires that the patient: ‒ Has a mood disturbance as the direct result of physiological effects of a substance ‒ Has a mood disturbance that involves elevated, expansive, or irritable moods with inflated self- esteem, decreased need for sleep and distractibility Copyright ©2021 F.A. Davis Company  Types of Bipolar Disorder (continued_4)  Bipolar disorder associated with another medical condition Diagnosis requires that the patient: ‒ Has an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy as the direct physiological consequence of another medical condition ‒ Has a mood disturbance causing clinically significant distress or impairment in social, occupational, or other areas of functioning Copyright ©2021 F.A. Davis Company  Types of Bipolar Disorder (continued_5) 1. A suicidal client with a history of manic behavior is admitted to the emergency department. The client’s diagnosis is documented as bipolar I 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 that the patient is suffering from major depression. B. The patient has experienced a manic episode in the past. C. The patient does not exhibit psychotic symptoms. D. There is no history of major depression in the patient’s family. Copyright ©2021 F.A. Davis Company  Types of Bipolar Disorder (continued_6) Correct Answer: B  The patient’s past history of mania and current suicide attempt support the diagnosis of Bipolar I Disorder: Current Episode Depressed.  According to the DSM-5 criteria, a manic episode rules out the diagnosis of Major Depressive Disorder. Copyright ©2021 F.A. Davis Company  Predisposing Factors  Biological theories Genetics ‒ Twin and family studies ‒ Other genetic studies Biochemical influences ‒ Possible excess of norepinephrine and dopamine Copyright ©2021 F.A. Davis Company  Predisposing Factors (continued_1)  Biological theories (continued) Physiological influences ‒ Neuroanatomical factors ‒ Medication side effects Copyright ©2021 F.A. Davis Company  Predisposing Factors (continued_2)  Psychosocial theories Interest in psychosocial theories has declined in favor of focus on genetic and biochemical factors. Bipolar disorder is viewed as a disease of the brain.  Transactional model of stress and adaptation Bipolar disorder clearly results from an interaction between genetic, biological and psychosocial determinants. Copyright ©2021 F.A. Davis Company  Developmental Implications in Childhood and Adolescence  Childhood and adolescence Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1 percent. Studies indicate that in 50 to 66 percent of diagnoses, bipolar disorder began before age 18 years; as many as 14 percent had an onset at or before age 12 years. Copyright ©2021 F.A. Davis Company  Developmental Implications in Childhood and Adolescence (continued_1)  Childhood and adolescence (continued) Treatment strategies ‒ Attention deficit/hyperactivity disorder (ADHD) is the most common comorbid condition. ‒ ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled. Copyright ©2021 F.A. Davis Company  Developmental Implications in Childhood and Adolescence (continued_2)  Treatment strategies Psychopharmacology ‒ Acute mania: lithium, risperidone, aripiprazole, quetiapine, olanzapine, and asenapine ‒ Bipolar depression: olanzapine/fluoxetine combination drugs, and lurasidone Nonpharmacological interventions ‒ Mood charting ‒ Managing stress and sleep cycles ‒ Maintaining healthy diet and exercise ‒ Avoiding alcohol and drugs Copyright ©2021 F.A. Davis Company  Developmental Implications in Childhood and Adolescence (continued_3)  Childhood and adolescence (continued) Family interventions ‒ Family-focused therapy (FFT)  Psychoeducation about bipolar disorder » Symptoms » Early recognition » Etiology » Treatment » Self-management Copyright ©2021 F.A. Davis Company  Nursing Process/Assessment—Mania  Stage I: Hypomania Mood ‒ Cheerful and expansive; underlying irritability surfaces rapidly Cognition and Perception ‒ Exalted; ideas of great worth and ability; flighty thinking; heightened perception of environment; easily distracted Activity and Behavior ‒ Increased motor activity; perceived as extroverted; lacks depth of personality for close friendships Copyright ©2021 F.A. Davis Company  Nursing Process/Assessment—Mania (continued_1)  Stage II: Acute Mania Mood ‒ Continuous “high”; subject to frequent variation Cognition and Perception ‒ Flight of ideas; distractibility becomes all-pervasive Activity and Behavior ‒ Psychomotor activity is excessive; sexual interest increased ‒ Inexhaustible energy; may go for days without sleeping Copyright ©2021 F.A. Davis Company  Nursing Process/Assessment—Mania (continued_2)  Stage III: Delirious Mania Mood ‒ Very labile; panic-level anxiety may be evident Cognition and Perception ‒ Clouding of consciousness; extremely distractible and incoherent Activity and Behavior ‒ Psychomotor activity is frenzied; exhaustion, injury to self or others, and eventually death could occur without intervention. Copyright ©2021 F.A. Davis Company  Nursing Process/Diagnosis—Mania  Risk for injury  Risk for violence  Imbalanced nutrition  Disturbed thought processes  Disturbed sensory-perception  Impaired social interaction  Insomnia Copyright ©2021 F.A. Davis Company  Nursing Process/Outcomes—Mania  The patient 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 Copyright ©2021 F.A. Davis Company  Nursing Process/Outcomes—Mania (continued_1)  The patient (continued) 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 Copyright ©2021 F.A. Davis Company  Nursing Process/Outcomes—Mania (continued_2) 2. 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 Copyright ©2021 F.A. Davis Company  Nursing Process/Outcomes—Mania (continued_3) Correct Answer: 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. Copyright ©2021 F.A. Davis Company  Nursing Process/Planning and Implementation—Mania  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 is available to assist. Goals and interventions Copyright ©2021 F.A. Davis Company  Nursing Process/Planning and Implementation—Mania (continued_1)  Impaired social interaction Set limits on manipulative behaviors. Do not argue, bargain, or try to reason with the client. Provide positive reinforcement. Goals and interventions Copyright ©2021 F.A. Davis Company  Nursing Process/Planning and Implementation—Mania (continued_2)  Imbalanced nutrition: Less than body requirements/insomnia Provide patient with high-protein, high-calorie foods. Maintain an accurate record of intake, output, and calorie count. Monitor sleep patterns. Goals and interventions Copyright ©2021 F.A. Davis Company  Nursing Process/Planning and Implementation—Mania (continued_3)  Concept care mapping Diagrammatic teaching and learning strategy that allows visualization of interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments  Patient/family education The role of client teacher is important in the psychiatric area, as it is in all areas of nursing. Copyright ©2021 F.A. Davis Company  Nursing Process/Evaluation—Mania  Has the individual avoided personal injury?  Has violence to the patient or others been prevented?  Has agitation subsided?  Have nutritional status and weight been stabilized? Is the patient able to select foods to maintain adequate nutrition? Copyright ©2021 F.A. Davis Company  Nursing Process/Evaluation—Mania (continued_1)  Have delusions and hallucinations ceased? Is the patient able to interpret the environment correctly?  Is the patient able to make decisions about own self-care? Has hygiene and grooming improved?  Is behavior socially acceptable? Is patient able to interact with others in a satisfactory manner? Has the patient stopped manipulating others to fulfill own desires? Copyright ©2021 F.A. Davis Company  Nursing Process/Evaluation—Mania (continued_2)  Is the patient able to sleep 6 to 8 hours per night and awaken feeling rested?  Does the patient understand the importance of maintenance medication therapy? Does he or she understand that symptoms may return if medication is discontinued?  Can the patient taking lithium verbalize early signs of lithium toxicity? Does he or she understand the necessity for monthly blood level checks? Copyright ©2021 F.A. Davis Company  Treatment Modalities for Bipolar Disorder  Individual psychotherapy  Group therapy  Family therapy  Cognitive therapy Copyright ©2021 F.A. Davis Company  Treatment Modalities for Bipolar Disorder (continued_1)  Recovery model Used primarily in caring for patients with serious mental illness, such as schizophrenia and bipolar disorder. The concepts of the recovery model have utility for all individuals experiencing emotional conditions that require assistance and who desire to take control and manage their lives more independently. Copyright ©2021 F.A. Davis Company  Treatment Modalities for Bipolar Disorder (continued_2)  Recovery model (continued) Developing self-awareness Becoming an expert on the disorder Taking medications regularly Recognizing earliest symptoms Identifying and reducing sources of stress Knowing when to seek help Developing a personal support system Copyright ©2021 F.A. Davis Company  Treatment Modalities for Bipolar Disorder (continued_3)  Recovery model (continued) Managing lifestyle factors such as sleep time and exercise Developing a plan for emergencies 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. Copyright ©2021 F.A. Davis Company  Treatment Modalities for Bipolar Disorder (continued_4)  Electroconvulsive therapy (ECT) Episodes of acute mania are occasionally treated with ECT. ‒ Particularly when the patient does not tolerate or fails to respond to lithium or other drug treatment or when life is threatened by dangerous behavior or exhaustion  Bright light therapy (BLT) May benefit bipolar depression Not associated with mood shifts toward a manic episode Copyright ©2021 F.A. Davis Company  Psychopharmacology  For mania Lithium carbonate Anticonvulsants Verapamil Antipsychotics  For depressive phase Use antidepressants with care (may trigger mania) Copyright ©2021 F.A. Davis Company  Patient/Family Education  Lithium Take the medication regularly. Do not drive or operate dangerous machinery. Do not skimp on dietary sodium and maintain appropriate diet. Know pregnancy risks. Carry identification noting taking lithium. Be aware of side effects and symptoms of toxicity. Notify physician if vomiting or diarrhea occur. Have serum lithium level checked every 1 to 2 months. Copyright ©2021 F.A. Davis Company  Patient/Family Education (continued_1)  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. Do not drive or operate dangerous machinery. Carry identification noting taking lithium. Avoid using alcohol and over-the-counter medications without approval from physician. Copyright ©2021 F.A. Davis Company  Patient/Family Education (continued_2)  Calcium channel blocker The patient should: ‒ Take medication with meals if gastrointestinal upset occurs. ‒ Use caution when driving or when operating dangerous machinery. Dizziness, drowsiness, and blurred vision can occur. ‒ Refrain from discontinuing the drug abruptly. To do so may precipitate cardiovascular problems. Physician will administer orders for tapering the drug when therapy is to be discontinued. Copyright ©2021 F.A. Davis Company  Patient/Family Education (continued_3)  Calcium channel blocker (continued) The patient should (continued): ‒ Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure. ‒ Avoid taking other medications (including over-the- counter medications) without a physician’s approval. ‒ Carry a card at all times describing medications being taken. Copyright ©2021 F.A. Davis Company  Patient/Family Education (continued_4)  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. Copyright ©2021 F.A. Davis Company  Patient/Family Education (continued_5)  Antipsychotics (continued) 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 Copyright ©2021 F.A. Davis Company  Patient/Family Education (continued_6) 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 1,000 mL of fluid per day. D. Adjust the dose if you feel out of control. Copyright ©2021 F.A. Davis Company  Patient/Family Education (continued_7) Correct Answer: A  Patients taking lithium should consume a diet adequate in sodium and drink 2,500 to 3,000 mL 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. Copyright ©2021 F.A. Davis Company