Exemplar: Bipolar Disorder - EXAM I

Question 1

which constitutes an exaggerated elevated, expansive, or irritable mood, accompanied by a persistent increase in activity and/or energy.

Answer 1

mania (or hypomania)

Question 2

the other pole of bipolar disorder that adds to morbidity.

Answer 2

depressive episode

Question 3

alternating mood episodes are characterized by mania, hypomania, depression and even concurrent mania and depression, which is known as ….

Answer 3

mixed episodes

Question 4

patients with BSP have a significant morbidity and mortality rates. It is estimated that 25-__% of people with BSD have attempted suicide. BSD has the highest rate of completed suicide.

Answer 4

50%

Question 5

at least one episode of persistent or elevated, expansive, or irritable mood (mania), and at least one clearly recognizable episode of major depression. marked impairment of social and occupational functioning. Psychosis can accompany maniac episodes. DSM-5 looks for anxious distress, mixed features, rapid cycling, melancholic features, atypical features, and peripartum onset.

Answer 5

Bipolar I Disorder

Question 6

presents with recent severe and prolonged periods of depression that alternate with brief periods of hypomania episodes which is known as a less severe and less cases. These periods of hypomania alternate with depressive episodes that are more prolonged. A decreased need for sleep and a lot of daytime fatigue are red flags for hypomania. Specifiers for bipolar II include anxious to distress, mixed features, rapid cycling, mood congruent or mood incongruence, peripartum onset with catatonia. Psychosis does not occur with _____________ and the hypomania for ____________ tends to be euphoric and the depression tends to place the patient at risk for suicide. (more common in females)

Answer 6

Bipolar II disorder

Question 7

presents with hypomaniac episodes alternating with persistent depressive episodes (dysthymia) for at least 2 years duration, and 1 year in children. typically have irritable hypomaniac episodes.

Answer 7

Cyclothymic Disorder

Question 8

designation with bipolar features that do not meet criteria for any of the previously specified disorders. Although these disorder can cause distress and disruption in the individual’s work, social, and private life, they are not distinct bipolar disorder and are noted as “other specified”

Answer 8

Bipolar disorder unspecified

Question 9

consists of two or more distinct episodes of alternating episodes of both mania and depression (depression-mania-depression-mania) in a 12 month period. Usually indicates more severe symptoms.

Answer 9

Rapid Cycling

Question 10

used when a patient in a full bipolar mania or hypomania mood displays depressive symptoms at the same time - for example, increased activity/agitation and feelings of worthlessness or SI at the same time. Essential symptoms: significant SI risk, marked irritability, pessimism or unrelenting worry or despair, and decreased need for sleep.

Answer 10

mixed features

Question 11

more unilateral than bipolar. affects women more than men, and is commonly associated with menopause. appears later in life. general insomnia, difficulty falling asleep, agitated depression and waking repeatedly at night. loss of appetite. depressive episodes last longer.

Answer 11

unipolar

Question 12

affects men and women equally. onset is usually much younger (usually around 18 years old), disturbances in sleep manifest as hypersomnia, excessive tiredness, difficult morning waking. Binge eating, then loss of appetite. Psychomotor retardation. Higher risk for drug abuse, and suicide.

Answer 12

bipolar

Question 13

some drugs like __________ may mimic manic symptoms and use of antidepressants during a mixed or depressive phase of the illness without a mood stabilizer can trigger a manic episode in susceptible individuals.

Answer 13

amphetamines

Question 14

Genetic factors provide significant evidence to support the view that bipolar disorders have a strong genetic component. Inheritance of bipolar disorders is not a matter of “one gene, one illness”, but rather an expression of multiple genes and chromosomes. First degree relatives of a person with bipolar are 7 to 10 times more likely to develop bipolar than the general population.

Answer 14

Biological findings dealing with bipolar disorder

Question 15

during manic episodes, patients with bipolar disorder demonstrate significantly higher plasma levels or norepinphrine and epinephrine, and people with depression have decreased levels of epinephrine and norepinephrine. One study reported that people with BSD have about one third more neurotransmitters in two major areas of the brain, which cause overstimulation in the brain.

Answer 15

Neurobiological Factors dealing with bipolar disorder

Question 16

hypothalamic-pituitary-adrenal axis and hormonal imbalances could contribute to the clinical outcomes of BSD. Severity of bipolar episodes tend to be correlated to the degree of neuroendocrine alteration.

Answer 16

neuroendocrine factors

Question 17

some patients have been identified with enlarged ventricles, cortical atrophy, and sulcal widening. Reduced volumes in the hippocampus, medial orbital cortex, and anterior cingulum.

Answer 17

Neuroanatomical factors

Question 18

has also been shown that stressful life events can trigger some symptoms of bipolar disorder. Family atmosphere suggests an association between high expressed emotion and relapse.

Answer 18

psychological factors

Question 19

• during this phase people are highly distractible
• non stop physical activity and the lack of sleep and food can lead to physical exhaustion and even death if not treated, and therefore constitutes a medical emergency
• the person constantly switches from one activity to another, one place to another, and one project to another. During ____ patients can be manipulative, profane, fault finding, and adept at exploiting other’s vulnerabilities.

Answer 19

Mania

Question 20

nearly continuous flow of accelerated speech with abrupt changes among topics that are usually based on understandable associations or a play on words (puns). Speech is rapid, verbose, and circumstantial. When the condition is severe, speech may be disorganized and incoherent.

Answer 20

Flight of ideas

Question 21

stringing together of words because of their rhyming sounds, without regard to their meaning.

Answer 21

Clang associations

Question 22

inflated self regard, apparent in persons behavior and expressed ideas

Answer 22

Grandiosity

Question 23

overall goal is to prevent injury. Outcomes reflect physiological as well as behavioral issues. For instance, patient will be well hydrated, maintain stable cardiac function, maintain tissue integrity, get sufficient sleep, etc

Answer 23

outcome identification of phase I (acute mania)

Question 24

lasts 2-6 months, and overall goal is to relapse prevention. For example, patient will go to psychoeducational classes, go to support group therapy, and learn communication and problem solving skills.

Answer 24

outcome identification of phase II (continuation of treatment)

Question 25

overall outcome for maintenance treatment is to continue to focus on prevention of relapse and to limit the severity and duration of future episodes. For example, participation in psychotherapy group, knowledge of factors in relapse prevention, and medication education.

Answer 25

outcome identification of phase III (maintenance of treatment)

Question 26

up to the first 2 months. Planning focuses on medically stabilizing the patient while maintaining safety. Nursing care is typically geared toward decreasing physical activity, increased food/fluid intake, ensuring 4-6 hours of sleep, alleviating bowel/bladder problems, and intervening to see that self-care needs are met. Some patients may need ECT, seclusion, and careful medication management.

Answer 26

Acute Phase in regards to planning

Question 27

2-6 months. focus is on maintaining medication compliance with medication regimen and preventing relapse. Psychoeducational teaching is priority for the patient and the family. Referrals to community programs are made. Communication skills training may be needed (can help their return to work and social interactions). For many patients, specific psychotherapy is needed to address specific issues for each patient.

Answer 27

Continuation Phase in regards to planning

Question 28

Begins about 6 months, and planning focuses of the prevention of relapse and limiting severity and duration of episodes. Psychosocial therapies, support or psychoeducational groups and periodic evaluations help patients maintain their family/social lives in order to continue employment and minimize relapse.

Answer 28

Maintenance Phase in regards to planning

Question 29

what are the interventions for acute mania?

Answer 29

• safety is the number one priority
• firm, calm approach
• short concise explanations or statements
• consistent in approach and expectation
• frequent staff meeting to plan consistent approaches
• decide limits with other staff members so that everyone is on the same page
• firmly redirect energy into more appropriate and constructive channels
• milieu therapy: low level stimulation, solitary, or noncompetitive activities
• remind them to eat (high protein, high calorie foods)
• rest periods
• redirect violent behavior
• monitor I and O and VS
• monitor clothing, and remind to tend to hygiene
• verbal deescalation may be needed
• anti psychotic or benzodiazepine may be needed

Question 30

Bipolar has a _____ onset

Answer 30

earlier onset (18 years old)

Question 31

• begins gradually or abruptly
• increased activity lead to cardiac exhaustion or collapse
• continued episodes of maniac behavior result in grave consequences such as: (infidelity, failing business, financial ruin, suicide attempts/completions)

Answer 31

Characteristics of Acute Mania

Question 32

when one is in _____ they are the life of the party. everyone is a friend. they are obscene and sexually occupied, and have a flight of ideas. They are peppy and humorous and very friendly with strangers. Enthusiastic and self confident. They are overly active and easily distracted. Grandiose is increased as well as their sexual appetite. They may not be able to sleep and will probably go on a lot of shopping sprees

Answer 32

hypomania

Question 33

when one is in ______ they are labile. Demanding of time and are very intrusive. Uses profanities and crude sexual remarks, and a flight of ideas. may use clang association (rhyming). Their humor can quickly turn hostile when they are not getting their way. Grandiose opinions of themselves and have poor judgment. Very restless and disorganized. too busy for sex, no time to eat or sleep. extremely extravagant with spending.

Answer 33

acute mania

Question 34

when one is in _______ they are very out of touch with reality. uses clang association. very destructive and aggressive in their communication manner. may have hallucinations and become delirious. They have hyperactive motor activity. They are incoherent and agitated. No sex, can’t sleep or eat. Too disorganized to do anything.

Answer 34

Delirious mania

Question 35

What do you assess for with those who have bipolar disorder?

Answer 35

are they are danger to their self or others?

• suicidal thoughts/plans
• homicidal thoughts/plans
• intrusive behavior
• delusions of grandeur
• self care needs

Question 36

a manic patient is…

Answer 36

manipulative, splitting, and aggressively demanding
(as a staff member limits must be set consistently, and there should be frequent staff meetings to deal with patient behavior and the staff response)

Question 37

When communicating with a bipolar patient that is in mania:

Answer 37

• use firm, calm approach
• use short and concise explanations
• remain neutral (avoid power struggles)
• be consistent in approach and expectations
• firmly redirect energy into more appropriate areas

Question 38

what is involved in the implementation phase of dealing with someone in acute mania?

Answer 38

• controlling destructive behavior
• medical stabilization
• establishing communication
• milieu therapy
• pharmacologic therapy
• ECT

Question 39

This drug:

• acts as a mood stabilizer
• labs should be monitored biweekly, weekly, then monthly
• therapeutic levels are reached 5-21 days after start
• encourage 1.5-3L of fluids/day
• must not be discontinued abruptly so watch for rebound effects
• places patient at risk for hypothyroidism and impaired renal function
• monitor for changes in mood
• very harmful to a fetus
• give this medication with food
• weight gain is a side effect so encourage a healthy diet and exercise regimen

Answer 39

Lithium Carbonate (LiCO3) therapeutic levels (0.4-1.0)

Question 40

antipsychotics are given to:

Answer 40

• slow speech
• inhibit aggression
• and decrease psychomotor activity

Question 41

Benzodiazepine (ex: Ativan (lorazepam) and Klnonopin (clonazapam) is given to:

Answer 41

• prevent exhaustion
• coronary collapse
• calm patient symptoms

Question 42

Lithium has a narrow window in regards to therapeutic effect. With that being said \_\_\_\_ to \_\_\_\_ mEq/L means that there is early signs of lithium toxicity. 
S/sx:
-nausea/vomiting
-diarrhea
-thirst
-polyuria (frequent urination)
-slurred speech
-muscle weakness
mimic routine side effects (basic) -- nurse response is to call physician and make them aware. advice will be to hold medication, obtain lithium levels.

Answer 42

1.0 to 1.5 mEq/L

Question 43

Advanced toxicity is evident in levels ranging from ___ to ____ mEq/L.
s/sx:
course hand tremors
severe GI upset
confusion (means toxic build up in the brain)
muscle hyper-irritability (muscles seizing)
ECG changes
Uncoordinated

Answer 43

1.5 to 2.0 mEq/L

Question 44

Severe lithium toxicity is evident in levels ranging from \_\_\_\_ to \_\_\_\_\_ mEq/L.
s/sx:
ataxia
serious ECG changes
blurred vision
clonic movements 
large output of diluted urine
seizures
stupor
severe hypotension
coma
death
(there is no antidote, stop the medication and hasten excretion of the drug. administer an antiemetic)

Answer 44

2.0 to 2.5 mEq/L

Question 45

Lithium is contraindicated in those with:

Answer 45

renal dx
hypothyroidism
myasthenia gravia
cardiovascular disorders
brain damage
pregnancy
breast feeding
children younger than 12 years old 
(as well as medications: NSAIDS, hydrocholorthiazide, angiotensin-converting enzymes, caffeine, alcohol, and diurectics (excretes the lithium too fast)

Question 46

_______ is used a for a quick cure, rapid cycling, dysphoric mania, bipolar mania, schizoaffective, and impulsive aggression. start low and go slow. monitor for liver toxicity damage. infants, elderly, children may require increased dose.

Answer 46

anticonvulsants

• Lamotrigine
• Carbamazepine
• Divalproex .
• Topiramate

Question 47

anxiolytics (Lorezapm and Clonazepam)
there are some second generation anxiolytics 
-olanzapine
-ziprasidone HCL
-Aripiprazole (Xiprexia)
-Risperidone
-Quetiapine (not for mixed mania)

Answer 47

used to treat symptoms of bipolar disorder

Question 48

some patients may not tolerate lithium and they will show improvement with ______ drugs. They have proven beneficial in controlling mania, superior to dysphoric mania (depressive thoughts), superior rapid cycling, more effective when there isn’t a family history of BSD, effective in diminishing aggressive behaviors, helpful with benzodiazepine or EtOH withdrawal

Answer 48

anticonvulsant drugs

Question 49

helpful in the treatment of lithium non-responders with acute mania, rapid cycles, dysphoric mania, and helps prevent manic episodes

Answer 49

divalproex (depakote)

Question 50

seems to work better with patients with rapid cycling and in severely paranoid and angry patients with mania than in patients with euphoric, overactive manic behaviors. Blood levels should be monitored for the first 8 weeks of treatment b/c the drug can increase liver enzyme levels that accelerate its own metabolism. In some instances, it can cause bone marrow suppression and liver inflammation.

Answer 50

Carbamazepine (Tegretrol)

Question 51

first line treatment for bipolar and is approved for maintenance therapy. Generally, well tolerated but does have the risk of rare reaction of Steven Johnson Syndrome. Patients should seek immediate medical attention is rash appears. Aspetic meningitis is rare but serious side effect.

Answer 51

Lamotrigine (Lamictal)

Question 52

_______ is a mood stabilizer

Answer 52

Lithium Carbonate (0.4 - 1.0 meq/L)

Question 53

type of anticonvulsant that has a normal range of 4-12 mg, and is good for the resistant mania or the paranoid angry type or any mania that is difficult to treat. labs are done bi weekly and then monthly

Answer 53

Carbamazepine

Question 54

type of anticonvulsant used for acute mania when an individual is not responsive to Lithium Carbonate. requires a liver function and platelet study. highly liver toxic. 50-100 mg. caution during the child bearing years because it can cause birth defects.

Answer 54

Divalproex

Question 55

type of anticonvulsant that is associated with mania. does not cause weight gain but rather weight loss

Answer 55

Topiramate