Ch. 17 Bipolar Disorders

Question 1

Mania is…

Answer 1

An alteration in mood that may be expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, and accelerated speech. Mania can occur as part of the psychiatric disorder bipolar disorder, as part of some other medical conditions, or in response to some substances.

Question 2

Bipolar disorder is…
Age of onset

Answer 2

Characterized by mood swings from profound depression to extreme euphoria (mania) with intervening periods of normalcy.
Delusions or hallucinations may or may not be a part of the clinical picture, and onset of symptoms may reflect a seasonal pattern.
The diagnostic picture for depression associated with bipolar disorder is similar to that described for major depressive disorder, with one major distinction: the client must have a history of one or more manic episodes.
Average age at onset is 25 years.

Question 3

Manic episode vs. hypomania

Answer 3

• During a manic episode, the mood is elevated, expansive, or irritable. The disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others or to require hospitalization to prevent harm to self or others. Motor activity is excessive and frenzied. Psychotic features may be present.
• Hypomania is not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization, and it does not include psychotic features.

Question 4

Diagnostic Criteria for a Manic Episode

Answer 4

• 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 of 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.

Question 5

Diagnostic Criteria for a Hypomanic Episode

Answer 5

• 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).

Question 6

Bipolar I Disorder is…

Answer 6

• 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.
• Further specified by the current or most recent behavioral episode experienced: single manic episode (to describe individuals having a first episode of mania) or current (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.
• Length of manic episodes (and depressive episodes) is variable when an individual has more than four manic and depressive episodes in a year, he or she is referred to as having rapid cycling bipolar disorder.

Question 7

Bipolar II Disorder is…

Answer 7

• Characterized by recurrent bouts of major depression with episodic occurrence of hypomania.
• May present with symptoms (or history) of depression or hypomania.
• Client has never experienced a full manic episode, and the symptoms are “not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization”
• Diagnosis may specify whether the current or most recent episode is hypomanic, depressed, or with mixed features
• If the current syndrome is a major depressive episode, psychotic or catatonic features may be noted.

Question 8

Cyclothymic disorder is…

Answer 8

• Essential feature is a chronic mood disturbance of at least 2 years’ duration
• Involves numerous periods of elevated mood that do not meet the criteria for a hypomanic episode
• Numerous periods of depressed mood of insufficient severity or duration to meet the criteria for major depressive episode.

Question 9

Diagnostic criteria for Cyclothymic disorder

Answer 9

• A. For at least 2 years 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 2-year period, 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

Question 10

Substance/Medication-Induced Bipolar Disorder is…

Answer 10

• The disturbance of mood associated with this disorder is considered to be the direct result of physiological effects of a substance
• The mood disturbance may involve elevated, expansive, or irritable mood with inflated self-esteem, decreased need for sleep, and distractibility.
• The disorder causes 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 also occur during withdrawal from substances such as alcohol, amphetamines, cocaine, sedatives, hypnotics, and anxiolytics.
• Anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antiulcer agents, cardiac medications, oral contraceptives, psychotropic medications, muscle relaxants, steroids, and sulfonamides

Question 11

Bipolar Disorder Due to Another Medical Condition is…

Answer 11

• 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.

Question 12

Biological Theories of Bipolar Disorders
Genetics

Answer 12

Research suggests that bipolar disorder strongly reflects an underlying genetic vulnerability. Evidence from family, twin, and adoption studies exists to support this observation.
- Twins: Concordance rate for bipolar disorder among monozygotic twins at 60 to 80 percent
- In general, family studies have shown that if one parent has a mood disorder, the risk that a child will have a mood disorder is between 10 and 25 percent
- “A family history of bipolar disorder conveys a greater risk for mood disorders in general and, specifically, a much greater risk for bipolar disorder”

Question 13

Biochemical Influences of Bipolar Disorders

Answer 13

• Early studies have associated symptoms of mania with a functional excess of norepinephrine and dopamine.
• The neurotransmitter serotonin is believed to remain low in both depression and mania.
• Excess levels of acetylcholine
• Excessive levels of glutamate, an excitatory neurotransmitter have been associated with bipolar disorder. Many of the mood stabilizers used to treat bipolar disorder inhibit the actions of glutamate.

Question 14

Neuroanatomical Factors of Bipolar Disorders

Answer 14

Neuroanatomical changes have been correlated with dysfunction in the prefrontal cortex, basal ganglia, temporal and frontal lobes of the forebrain, and parts of the limbic system, including the amygdala, thalamus, and striatum.

Question 15

Medication Side Effects that affect Bipolar Disorder

Answer 15

• Steroids frequently used to treat chronic illnesses such as multiple sclerosis and systemic lupus erythematosus (SLE)
• Amphetamines, antidepressants, and high doses of anticonvulsants and narcotics also have the potential for initiating a manic episode.

Question 16

Psychosocial Theories of Bipolar Disorders

Answer 16

• Conditions such as bipolar disorder are more often viewed as diseases of the brain with biological etiologies.
• However, studies have confirmed a link between childhood trauma (emotional, physical, and sexual abuse) and the development of bipolar disorder
• Childhood trauma interacts with genes along several pathways, which influences not only an increased risk for bipolar disorder but also earlier onset, more severe symptoms, substance abuse, and suicide risk.

Question 17

Developmental Implications of Bipolar Disorders

Answer 17

• The lifetime prevalence of adolescent bipolar disorders is estimated to be about 1 percent and in younger children the incidence is very rare, but children and adolescents are often difficult to diagnose
• Thought to be a connection between ADHD and the development of bipolar disorder in youth
• Studies also found that youth who were given BP I diagnosis more often manifested with a host of atypical symptoms, including nondiscrete mood episodes, chronic irritability, and temper tantrums.
• Disruptive mood dysregulation disorder more aptly describes the symptom profile.
• When true mania associated with bipolar disorder does occur in adolescents, it is frequently accompanied by flight of ideas, grandiose or persecutory delusions, and hallucinations.

Question 18

Treatment Strategies of Bipolar Disorders in Children
Psychopharmacology

Answer 18

• Monotherapy with the traditional mood stabilizers (e.g., lithium, divalproex, carbamazepine) or atypical antipsychotics (e.g., olanzapine, quetiapine, risperidone, aripiprazole) = first line treatment
• ADHD has been identified as the most common comorbid condition in children and adolescents with bipolar disorder. Because stimulants can exacerbate mania, it is suggested that medication for ADHD be initiated only after bipolar symptoms have been controlled with a mood-stabilizing agent
• Nonstimulant medications indicated for ADHD (e.g., atomoxetine, bupropion, the tricyclic antidepressants) may also induce switches to mania or hypomania.

Question 19

Family Interventions for Bipolar Disorders

Answer 19

• Interventions with family members must include education that promotes understanding that at least part of the client’s negative behaviors are attributable to an illness that must be managed.
• Family-focused treatment (FFT) is an evidence-based intervention for reducing relapses and increasing medication adherence in bipolar clients
• FFT includes sessions that deal with psychoeducation about bipolar disorder (i.e., symptoms, early recognition, etiology, treatment, self-management), communication training, and problem-solving skills training.
• Teaching the client and family about early warning signs and management strategies provides the client with a needed support system and the family with tools and resources to provide that support.

Question 20

Hypomania
Mood:
Cognition and Perception:
Activity and Behavior:

Answer 20

Mood:
- Cheerful and expansive.
- Underlying irritability that surfaces rapidly when the person’s wishes and desires go unfulfilled.
- The nature of the hypomanic person is volatile and fluctuating.
Cognition and Perception:
- Perceptions of the self are exalted.
- The individual has 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:
- Increased motor activity.
- Perceived as being very extroverted and sociable, but 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.
- Inappropriate behaviors like calling the President or buying huge amounts of merchandise.

Question 21

Acute mania “manic episode”
Mood:
Cognition and Perception:
Activity and Behavior:

Answer 21

Mood:
- Euphoria and elation.
- Continuous “high”
- Subject to frequent variation, easily changing to irritability and anger or even to sadness and crying.
Cognition and Perception:
- Fragmented and often psychotic
- Accelerated thinking proceeds to racing thoughts
- Overconnection of ideas
- Rapid, abrupt movement from one thought to another (flight of ideas)
- Continuous flow of accelerated, pressured speech (loquaciousness) to the point where trying to converse with them is difficult.
- 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
- Poor impulse control
- Low frustration tolerance
- The individual who is normally discreet may become socially and sexually uninhibited.
- Little insight with regard to their behavior and communication
- Unreliable reporting of events and denial of problems when confronted by friends or family, both of which may be interpreted as lying.
- Energy seems inexhaustible, and the need for sleep is diminished. (days without sleep)
- Hygiene and grooming may be neglected.
- Dress may be disorganized, flamboyant, or bizarre, and the use of excessive makeup or jewelry is common.

Question 22

Delirious Mania is…

Answer 22

A grave form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania “manic episode”. This condition has become relatively rare since the availability of antipsychotic medication.

Question 23

Delirious Mania
Mood
Cognition and Perception
Activity and Behavior

Answer 23

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
- Religiosity
- Delusions of grandeur or persecution,
- Auditory or visual hallucinations.
- Extremely distractible and incoherent.
Activity and Behavior
- Psychomotor activity is frenzied and characterized by agitated, purposeless movements
- Safety is at stake unless this activity is curtailed
- Exhaustion, injury to self or others, and eventually death could occur without intervention.

Question 24

The following criteria may be used for measuring outcomes in the care of the patient experiencing a manic episode:

Answer 24

■ 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.
■ 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 without medication.

Question 25

Risk for Injury
Behaviors

Answer 25

Extreme hyperactivity
Increased agitation and lack of control over purposeless and potentially injurious movements

Question 26

Risk For Violence: Self-Directed or Other-Directed
Behaviors

Answer 26

Manic excitement
Delusional thinking
Hallucinations
Impulsivity

Question 27

Imbalanced Nutrition: Less Than Body Requirements
Behaviors

Answer 27

Loss of weight
Amenorrhea
Refusal or inability to sit still long enough to eat

Question 28

Disturbed Thought Processes
Behaviors

Answer 28

Delusions of grandeur and persecution
Inaccurate interpretation of the environment

Question 29

Disturbed Sensory-Perception
Behaviors

Answer 29

Auditory and visual hallucinations; disorientation

Question 30

Impaired Social Interaction
Behaviors

Answer 30

Inability to develop satisfying relationships
Manipulation of others for own desires
Use of unsuccessful social interaction behaviors

Question 31

Insomnia
Behaviors

Answer 31

Difficulty falling asleep
Sleeping only short periods

Question 32

Risk for Injury
Goals for Patient

Answer 32

■ Patient will no longer exhibit potentially injurious movements after 24 hours, with administration of tranquilizing medication.
■ Patient will not experience injury.

Question 33

Risk for Injury
Nursing Interventions and Rationales

Answer 33

1. Reduce environmental stimuli. Assign private room with simple decor on quiet unit if possible. Keep lighting and noise level low.
   - Pt is extremely distractible and responses to even the slightest stimuli are exaggerated. A milieu unit may be too stimulating.
2. Remove hazardous objects and substances (including smoking materials).
   - Rationality is impaired, and patient may harm self inadvertently.
3. Stay with the patient who is hyperactive and agitated.
   - Nurse’s presence may offer support and provide feeling of security for the patient.
4. Provide structured schedule of activities that includes established rest periods throughout the day. Limit group activities.
   - A structured schedule and one-to-one activities provide a feeling of security for the client.
5. Provide physical activities.
   - Physical activities help relieve pent-up tension.
6. Administer tranquilizing medication as ordered by physician.
   - Antipsychotics are common and are very effective for providing rapid relief from symptoms of hyperactivity.

Question 34

Risk For Violence: Self-Directed or Other-Directed
Goals for Patient

Answer 34

■ Patient’s agitation will be maintained at a manageable level with the administration of tranquilizing medication during the first week of treatment (decreasing risk of violence to self or others).
■ Patient will not harm self or others.

Question 35

Risk For Violence: Self-Directed or Other-Directed
Nursing Interventions and Rationales

Answer 35

1. Maintain low level of stimuli in patient’s environment
   - Minimizes anxiety, agitation, and suspiciousness.
2. Assess for concurrent substance use issues.
   - High incidence of comorbid substance use disorders in clients with bipolar disorder and these can increase risk for harm to self or others.
3. Observe patient’s behavior frequently. Do this while carrying out routine activities so as to avoid creating suspiciousness in the individual.
   - Important to identify the need for redirection or limit setting and to protect patient safety.
4. Remove all sharp objects, glass or mirrored items, belts, ties, and smoking materials from patient’s environment.
   - Minimize risks that patient (in an agitated, hyperactive state) harms self or others.
5. Intervene at the first signs of increased anxiety, agitation, or verbal or behavioral aggression using empathic responses such as “You seem anxious” or “How can I help?”
   - Validation of the patient’s feelings conveys an attitude of caring and collaboration and facilitates establishing trust. Because the patient is highly distractible, providing a distraction can also aid in diffusing anxiety and agitation.
6. Maintain and convey a calm attitude. Respond matter-of-factly to verbal hostility.
   - Facilitates de-escalation of patient’s anxiety and agitation.
7. As anxiety increases, offer some alternatives: to participate in a physical activity, talking about the situation, taking some antianxiety medication.
   - Empowers pt to have a sense of control over the situation.
8. Have sufficient staff available to indicate a show of strength to patient if it becomes necessary.
   - Ensures staff and pt safety and shows evidence of control over the situation, which can be comforting to a pt when they are feeling fearful of losing control of self.
9. If patient is not calmed by “talking down” or by medication, use of mechanical restraints may be necessary.
   - Should be offered the “least restrictive alternative” to maintain safety. Restraints should be used only as a last resort
10. If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow protocol established by the institution.
    - Patient safety is a nursing priority.
11. Observe the patient in restraints continuously and assess patient at least every 15 minutes
    - Ensures that needs for circulation, nutrition, hydration, and elimination are met.
12. As agitation decreases, assess the patient’s readiness for restraint removal or reduction. Remove restraints gradually, one at a time while assessing the patient’s response.
    - Gradual removal of restraints minimizes potential for injury to patient and staff.

Question 36

Imbalanced nutrition: Less than body requirements
Goals for Patient

Answer 36

■ Patient will consume sufficient finger foods and between-meal snacks to meet recommended daily allowances of nutrients.
■ Patient will exhibit no signs or symptoms of malnutrition.

Question 37

Imbalanced nutrition: Less than body requirements
Nursing Interventions and Rationales

Answer 37

1. Provide high-protein, high-calorie, nutritious finger foods and drinks that can be consumed “on the run.”
   - Because the pt has difficulty sitting still long enough to eat a meal, they are more likely consume food/drinks that can be carried around/eaten with little effort.
2. Have juice and snacks available on the unit at all times.
   - Nutritious intake is required on a regular basis to compensate for increased caloric requirement due to hyperactivity.
3. Maintain accurate record of intake, output, calorie count, and weight. Monitor daily lab values.
   - Important nutritional assessment data.
4. Determine patient’s likes and dislikes and collaborate with dietitian to provide favorite foods.
   - Pt more likely to eat foods that he or she particularly enjoys.
5. Supplement diet with vitamins and minerals.
   - Improves nutritional status
6. Walk or sit with patient while he or she eats.
   - The nurse’s presence offers support and encouragement to patient to eat food that will maintain physical wellness.

Question 38

Impaired Social Interaction
Goals for Patient

Answer 38

■ Patient will verbalize which of his or her interaction behaviors are appropriate and which are inappropriate within 1 week.
■ Patient will demonstrate use of appropriate interaction skills as evidenced by lack of, or marked decrease in, manipulation of others to fulfill own desires.

Question 39

Impaired Social Interaction
Nursing Interventions and Rationales

Answer 39

1. Recognize the purpose manipulative behaviors serve for the patient: to reduce feelings of insecurity by increasing feelings of power and control.
   - Understanding the motivation behind the manipulation may facilitate acceptance of the individual and his or her behavior.
2. Set limits on manipulative behaviors. Explain to the patient what is expected and what the consequences are if the limits are violated. Terms of the limitations must be agreed on by all staff who will be working with the patient.
   - When the patient is unable to establish own limits this must be done for him or her. Unless administration of consequences for violation of limits is consistent, manipulative behavior will not be eliminated.
3. Do not argue, bargain, or try to reason with the patient. Merely state the limits and expectations. Confront the patient as soon as possible when interactions with others are manipulative or exploitative. Follow through with established consequences for unacceptable behavior.
   - Pt should receive immediate feedback when behavior is unacceptable. Consistency in enforcing the consequences is essential if positive outcomes are to be achieved. Inconsistency creates confusion and encourages testing of limits.
4. Provide positive reinforcement for non-manipulative behaviors. Explore feelings and help the patient seek more appropriate ways of dealing with them.
   - Positive reinforcement enhances self-esteem and promotes repetition of desirable behaviors.
5. Help patient recognize that he or she must accept the consequences of own behaviors and refrain from attributing them to others.
   - The patient must accept responsibility for own behaviors before adaptive change can occur.
6. Help the patient identify positive aspects about self, recognize accomplishments, and feel good about them.
   - As self-esteem is increased, patient will feel less need to manipulate others for own gratification.

Question 40

Evaluation of the nursing actions for the patient experiencing a manic episode may be facilitated by gathering information using the following types of questions:

Answer 40

■ Has the individual avoided personal injury?
■ Has violence to the patient and others been prevented?
■ Has agitation subsided?
■ Have nutritional status and weight been stabilized? Is the patient able to select foods to maintain adequate nutrition?
■ Have delusions and hallucinations ceased? Is the patient able to interpret the environment correctly?
■ Is the patient able to make decisions about his or her own self-care? Has hygiene and grooming improved?
■ Is behavior socially acceptable? Is the patient able to interact with others in a satisfactory manner? Has the patient stopped manipulating others to fulfill own desires?
■ 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?

Question 41

How is Individual Psychotherapy used to treat Bipolar Disorders?

Answer 41

• Interpersonal and social rhythm therapy (IPSRT) is a type of therapy specifically designed for bipolar patients.
• The focus of this therapy is helping clients to regulate their social rhythms, or daily activities such as the sleep–wake cycle and exercise routines, that may otherwise disrupt underlying biological rhythms and contribute to mood disturbances.
• In combination with this strategy, IPSRT also engages principles of interpersonal therapy to help clients address interpersonal problems.

Question 42

How is Group Therapy used to treat Bipolar Disorders?

Answer 42

• Once an acute phase of the illness is passed, groups can provide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise out of having a serious affective disorder.
• The element of peer support may provide a feeling of security because troublesome or embarrassing issues are discussed and resolved.
• Support groups help members gain a sense of perspective on their condition and tangibly encourage them to link up with others who have common problems.
• A sense of hope is conveyed when the individual is able to see that he or she is not alone or unique in experiencing affective illness.

Question 43

How is Family Therapy used to treat Bipolar Disorders?

Answer 43

• The ultimate objectives in working with families of clients with mood disorders are to resolve the symptoms and initiate or restore adaptive family functioning
• Family therapy is indicated if the disorder jeopardizes the patient’s marriage or family functioning or if the mood disorder is promoted or maintained by the family situation.
• Family functioning and marital relationships are often disrupted in clients with bipolar disorder, especially when symptoms are contributing to disloyalty in the marriage and to financial problems related to the client’s excessive spending behaviors.

Question 44

How is Cognitive Therapy used to treat Bipolar Disorders?

Answer 44

• The individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of mood disorders.
• The general goals in cognitive therapy are to obtain symptom relief as quickly as possible, assist the client in identifying dysfunctional patterns of thinking and behaving, and guide the client to evidence and logic that effectively test the validity of the dysfunctional thinking. Therapy focuses on changing “automatic thoughts” that occur spontaneously and contribute to the distorted affect.
• Personalizing: “I’m the only reason my husband is a successful businessman.”
• All or nothing: “Everything I do is great.”
• Mind reading: “She thinks I’m wonderful.”
• Discounting negatives: “None of those mistakes are really important.”
  The client is asked to describe evidence that both supports and disputes the automatic thought. The logic underlying the inferences is then reviewed with the client.

Question 45

In the process of recovery, the client and clinician work on strategies to help the individual with bipolar disorder take control of and manage his or her illness. Some of these strategies include the following:

Answer 45

■ Become an expert on the disorder.
■ Take medications regularly.
■ Become aware of earliest symptoms.
■ Develop a plan for emergencies.
■ Identify and reduce sources of stress: Know when to seek help.
■ Develop a personal support system.
■ Develop a plan for emergencies.

Question 46

How is Electroconvulsive Therapy used to treat Bipolar Disorders?

Answer 46

Episodes of acute mania are occasionally treated with ECT, particularly when the client does not tolerate or fails to respond to lithium or other drug treatment, or when life is threatened by dangerous behavior or exhaustion

Question 47

Psychopharmacology used in Bipolar Disorders
Antimanic:
Anticonvulsants:
Calcium Channel Blockers:
Antipsychotics:

Answer 47

Antimanic:
- Lithium carbonate
Anticonvulsants:
- Carbamazepine (Tegretol)
- Clonazepam (Klonopin)
- Valproic acid (Depakene; Depakote)
- Lamotrigine (Lamictal)
- Gabapentin (Neurontin)
- Topiramate (Topamax)
- Oxcarbazepine (Trileptal)
Calcium Channel Blockers:
- Verapamil (Calan; Isoptin)
- Diltiazem (Cardizem, Tiazac)
- Isradipine (DynaCirc)
- Nimodipine (Nymalize)
Antipsychotics:
- Olanzapine (Zyprexa)
- Olanzapine and fluoxetine (Symbyax)
- Aripiprazole (Abilify)
- Lurasidone (Latuda)
- Chlorpromazine
- Quetiapine (Seroquel)
- Risperidone (Risperdal)
- Ziprasidone (Geodon)
- Asenapine (Saphris)

Question 48

Patient and Family Education for Lithium

Answer 48

• Therapeutic range:
  Acute mania: 1,800-2,400 mg
  Maintenance: 900–1,200 mg/
  Acute mania: 0.5–1.5 mEq/L
  Maintenance: 0.6–1.2 mEq/L
• Take medication on a regular basis, even when feeling well. Discontinuation can result in return of symptoms.
• Don’t drive or operate dangerous machinery until lithium levels are stabilized. Drowsiness and dizziness can occur.
• Don’t skimp on dietary sodium intake. Eat a variety of healthy foods and avoid junk foods. Dink 6-8 glasses of water each day and avoid excessive use of beverages containing caffeine, which promote increased urine output.
• Notify the physician if vomiting or diarrhea occurs.
• Carry a card or other identification noting that he or she is taking lithium.
• Be aware of appropriate diet should weight gain become a problem. Include adequate sodium and other nutrients while decreasing number of calories.
• Be aware of risks of becoming pregnant while receiving lithium therapy. Use contraception. Notify HCP if pregnancy is suspected or planned.
• Be aware of side effects and symptoms associated with toxicity.
• Refer to written materials furnished by HCP while receiving self-administered maintenance therapy. Keep appointments for outpatient follow-up; have serum lithium level checked every 1 to 2 months or as advised by HCP

Question 49

Signs of lithium toxicity

Answer 49

Persistent nausea and vomiting
Severe diarrhea
Ataxia
Blurred vision
Tinnitus
Excessive output of urine
Increasing tremors
Mental confusion.

Question 50

Patient and Family Education for Anticonvulsant Mood Stabilizers
The patient should:

Answer 50

• Refrain from discontinuing the drug abruptly. HCP will administer orders for tapering the drug when therapy is to be discontinued.
• Not drive or operate dangerous machinery until reaction to the medication has been established.
• Avoid consuming alcoholic beverages and non-prescription medications without approval from HCP
• Carry a card at all times identifying the name of medications being taken.

Question 51

Patient and Family Education for Calcium Channel Blocker
The patient should:

Answer 51

• Take medication with meals if GI 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. HCP will administer orders for tapering the drug when therapy is to be discontinued.
• Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.
• Avoid taking other medications (including OTC) without HCP’s approval.
• Carry a card at all times describing medications being taken.

Question 52

Patient and Family Education for Antipsychotics
The patient should:

Answer 52

• Use caution when driving or operating dangerous machinery. Drowsiness and dizziness can occur.
• Refrain from discontinuing the drug abruptly after long-term use. To do so might produce withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia, and tremulousness.
• Use sunblock lotion and wear protective clothing when spending time outdoors. Skin is more susceptible to sunburn, which can occur in as little as 30 minutes.
• Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.
• Take frequent sips of water, chew sugarless gum, or suck on hard candy, if dry mouth is a problem. Good oral care (frequent brushing, flossing) is very important.
• Consult the physician regarding smoking while on antipsychotic therapy. Smoking increases the metabolism of these drugs, requiring an adjustment in dosage to achieve a therapeutic effect.
• Dress warmly in cold weather and avoid extended exposure to very high or low temperatures. Body temperature is harder to maintain with this medication.
• Avoid drinking alcohol while on antipsychotic therapy. These drugs potentiate each other’s effects.
• Avoid taking other medications (including OTC) without the physician’s approval.
• Be aware of possible risks of taking antipsychotics during pregnancy. Safe use during pregnancy has not been established.
• Be aware of side effects of antipsychotic medications
• Continue to take the medication, even if feeling well and feeling as though it is not needed. Symptoms may return if medication is discontinued.
• Carry a card or other identification at all times describing medications being taken.

Question 53

Symptoms to report to HCP while on antipsychotics

Answer 53

Sore throat
Fever
Malaise
Unusual bleeding
Easy bruising
Persistent nausea and vomiting,
Severe headache
Rapid heart rate
Difficulty urinating
Muscle twitching
Tremors
Darkly colored urine
Excessive urination
Excessive thirst
Excessive hunger
Weakness
Pale stools
Yellow skin or eyes
Muscular incoordination
Skin rash.

Question 54

Symptoms to report to HCP while on Calcium Channel Blockers

Answer 54

Irregular heartbeat
Shortness of breath
Swelling of the hands and feet
Pronounced dizziness
Chest pain
Profound mood swings
Severe and persistent headache

Question 55

Symptoms to report to HCP while on Anticonvulsant Mood Stabilizers

Answer 55

Skin rash
Unusual bleeding
Spontaneous bruising
Sore throat
Fever
Malaise
Dark urine
Yellow skin or eyes.