bipolar disorders Flashcards
epidemiology
misdx as MDD -> 1st episode is dep, longer phase
1 = M, more severe, start earlier
2 = F
cyclothymia: usually begins in adolescence/early adulthood
onset can begin at any age
rf
exact cause unknown
bio: genetic (strong), NT ( dep = too few, manic = too much), neurobio = receptro sites, change in structure and function of brain parts -> prefrontal cortical region, hippocampus, amygdala (emotional dysregulation and mood lability; neuroendocrine = HPTA axis (hypothyroidism)
env: stressful fam life, adverse events (more severe), diathesis stress model
disorders
1, 2, cyclothymic, substance/med induced, d/t another med condition, other specified, unspecified
clinical picture
1: most severe, high mortality, at least 1 manic episode
2: at least 1 hypomanic, at least 1 major dep
cyclothymic: alternate with s/s of mild-mod dep for at least 2 years, rapid cycling possible
BP1: dx criteria
abn or persistently elevated, expansive, irritable mood and goal directed activity or energy, >1wk
3+ of following s/s (4 if mood is only irritable): inflated self esteem, gradiosity, decreased need for sleep, more talkative or pressure to keep talking, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal directed activity or psychomotor agitation, excess involvement in pleasurable activities with high potential for painful consequences
s/s cause marked impairment in social or occupational funcitoning or require hospital, psychotic features
not caused by susbstance, med, med condition
BP1
usually recognizable s/s of alternating manic episodes with MDE and/or hypomanic episode
psychotic episode or MDE may be absent over lifetime but unusual
more manic episodes = more intense -> med adherence!
manic highs mimic lows in depth and intensity
mania s/s: DIG FAST
med emergency
distractibility (overlapping projects, unusual hrs)
indiscretion: excessive involvement of pleasurable activities with increased potential with negative consequences -> generosity, gamble, sexual
grandiosity: delusion, increased self esteem
flight of ideas: racing thoughts
activity increase: restless, pacing
sleep deficit: decreased need, cant sleep
talkativeness: pressured, talk to everyone
mania s/s
mood lability: rapid extreme mood swings, irritability or sudden outburst of misplaced rage
quick to anger/feels misunderstood, low frustration tolerance
pacing (nutrition, hydrate), dramatic mannerisms, uses jokes/puns, flamboyant or sexually suggestive dress
manipulative -> set limits
BP2
slightly milder
never manic, impairment of funcitoning in at least 1 area, no psychosis with hypomania but may have it during depressive side, get good hx of ups and downs -> dep v bpd, collateral from friends
usually get help during dep phase, tend to like hypomanic
BP2: dx criteria
hypomanic + mdd
mixed features
s/s of dep and mania at same time
rapid cycling
4+ manic episodes at least 2 wk in 12 mo, not mood lability
partial/full remission for 2 mo at time or switch to opposite
increased r/o recurrence, resistant to drug, increased severity, dep s/s predominate
hypomanic episode
same criteria as manic with following exceptions
noticeable (by others) change in functioning, uncharacteristic for individual
not severe enough to cause marked impairment in social or occupational functioning or hx
no psychotic features
elevated, expansive, irritable mood for at least 4 days
cyclothymic
not as extreme ups and downs, persistent
at least 2 yrs in adults -> 1 in child/adolescent
multiple hypomanic s/s but not episode
dep s/s but no MDE, manic or mixed
s/s present more than half the time, has not been without s/s for >2 mo at a time
fluctuating hypomanic s/s and dep s/s
alternate with s/s of mild-mod dep for >2yr
rapid cycling possible
can progress to 1 or 2
assess
mood: manic, hypomanic, dep, lability
behavior: agitated, manipulative, restless, pacing
thought process: loose associations, tangential, flight of ideas, circumstantial
thought content: grandiose, paranoid, persecutory delusions
speech patterns: pressured, clang associations (rhyme), loud, rapid, large
cognitive functioning: deficits possible, danger, need for protection (poor impulse control, gambling, bankruptcy), hospitalization (stable),med status (eat, drink, sleep), coexisting med condition, fam understanding (edu, support, resources)
outcomes identification
primary outcome for acute manic phase -> injury prevent
hydrate, stable cardiac, tissue integrity, sleep and rest, self control, no self harm
nc acute mania
manage meds, decrease PA, increase food and fluid (on the go finger food), 4-6 hrs sleep, set limits (seclusion/restraint), self care needs met (prompt them)
bp disorder fam teaching
chronic and episodic, long term, meds taken for long, SE of meds and toxic, when to call, where to go, s/s relapse - may come out of no where, role of fam members and others in preventing full relapse, emergency contact people
OH, drugs, caffeine, OTC meds can cause relapse (stim like ephedrine)
need good sleep
coping strategies, fam functioning, decrease stress, enhance med adherence
group and individual therapies
meds for acute mania
mood stabilizers: Li and antipsych or divalproex and antipsych (2nd gen/atypical)
atypical antipsych: risperidone, quetiapine, aripiprazone, olanzapine
benzos: severe, addictive, only short term
meds for acute mood stabilization
anticonvulsant mood stabilizers: valproate, carbamezapine, lamotrigme,, gabapentin (rapid cycling)
Li carbonate
combo med: olanzapine + fluoxetine -> more dep, bp2
2nd gen antipsych: olanzapine, risperidone, aripiprazole, lurasidone, quetiapine, ziprasidone
avoid just using antidep bc can send into mania
Li carbonate
I: acute mania and maint tm
therapeutic and toxic -> start low and titrate
CI: CVD, renal disease, brain damage, thyroid disease, preg or breast feed
onset: 5 -7 days, up to 2 wk
moa: uncertain, cross cell membranes, alter Na transport, not protein bound
teaching: increased r/o SI with d/c, dont restrict Na (normal intake, F+E), hydrate (increase with activity and vom), blood tests
Li carbonate: SE - expected
Nausea, vomiting, diarrhea, thirst, polyuria (producing too much urine), lethargy, sedation, and fine
hand tremor
Renal toxicity may occur with long-term use
Goiter and hypothyroidism
interventions:
Symptoms often subside during treatment
Doses should be kept low
Kidney function and thyroid levels should be assessed before treatment and then on an annual basis
Li carbonate: SE - early
Gastrointestinal upset, coarse hand tremor, confusion, hyperirritability of muscles,
electroencephalographic changes, sedation, incoordination
interventions:
Medication should be withheld, blood lithium levels measured, and dosage reevaluated.
Li carbonate: SE - advanced
Ataxia, giddiness, serious electroencephalographic changes, blurred vision, clonic movements, large
output of dilute urine, seizures, stupor, severe hypotension, coma. Death is usually secondary to
pulmonary complications.
interventions
Hospitalization is indicated. The drug is stopped, and excretion is hastened. Whole bowel irrigation may be done to prevent further absorption of lithium.
Li carbonate: SE - severe
Convulsions, oliguria (producing none or small amounts of urine), and death can occur.
interventions
in addition to the interventions above, hemodialysis may be used in severe cases.
Li carbonate: labs
1-2/wk then…
cre, TH, cbc q6 mo
kd risk, thyroid function may decrease, usually after 6-18 mo -> dry skin, hair loss, c, brady, cold intol
anticonvulsant mood stabilizers: valproate
check serum levels, broader spectrum of efficacy of s/s bpd, longer periods of mood stabilization
anticonvulsant mood stabilizers: carbamazepine
check serum levels, r/o decreased wbc (monitor), check hepatic and renal, effective in those without response to Li or with secondary mania (breakthrough), rash may be life threatening
anticonvulsant mood stabilizers: topiramate
yes
anticonvulsant mood stabilizers: lamotrigine
rapid cyclng and dep phase, rash life threatening, add on in refractory mood disorders
anticonvulsant mood stabilizers: gabapentin
may be effective for acute mania, mood stabilization, rapid cycling
lamotrigine rash
stop med, can advance to sjs, w/n first few mo, med change, or anytime
flu like, sore throat, fever, chills, blisters, burning eyes
allergic rxn
can further advance to toxic epidermal necrosis (top layer of skin separates
other tm
ect: severe mania, tm resistant, rapid cycling (4+ episodes/yr), tm resistant bp dep -> severe, catatonic
teamwork and safety, seclusion, support groups, edu, health promo
advanced practice: cbt, interpersonal and social rhyth,, fam focused
