W3_Mood Disorders Flashcards
Bipolar, AD, OCD
What is bipolar disorder?
Bipolar disorder (manic depression) is a treatable medical illness marked by extreme changes in mood, thought, energy, and behaviour.
Bipolar disorder
a person’s mood can alternate between the “poles” mania (highs) and depression (lows).
This change in mood or “mood swing” can last for hours, days, weeks or even months
What are the different types of bipolar disorder?
**Bipolar l **Disorder
A distinct period of severe manic episode for at least a week with rapid shift of mood.
Bipolar ll Disorder
at least 1 hypomanic episode but has not had a full manic episode.
Cyclothmyia
numerous periods with manic and depressive symptoms not severe enough to meet criteria for major episodes.
Prevalence and course of Bipolar I and II
Lifetime: 0.6 to 0.8% (USA); 1.6% (Singapore)
Male to Female Ratio (1.1 : 1)
Men > manic episodes
Women > depressive episodes; > rapid cycling; > alcohol use.
Average age of onset = 20 years old
Chronic condition
15 times more likely to have complete suicide
60-70% of manic episodes occur before or after a depressive episode
Bipolar Mood disturbance period
Diagnostic criteria
what are the symptoms and how many?
During mood disturbance period
(3 or more of the following symptoms
- Inflated self-esteem/ grandiosity
- Decrease need of sleep
- More talkative
- Flight of ideas
- Distractibility
- Psychomotor agitation (Hypersexual)
- High risk behavior
What are the treatment options for Bipolar patients?
Mood stabilizers
Mood stabilizers include agents that treat mania while preventing manic relapse, and agents that treat bipolar depression while preventing depressive relapse.
List the various categories of Mood stabilizers and adjunctive therapy
-Mood Stabilizer: Lithium Carbonate
Anti-convulsants/ antiepileptics
Atypical Antipsychotics
Mood stabilizer:
Lithium Carbonate
Most popular/ effective mood stabilizer
1st drug to be FDA approved for treatment of manic episodes in bipolar disorder in 1970.
Significant side effect burden, poorly tolerated in at least 1/3 of treated pts
Narrow therapeutic window (0.4 to 1.0 mmol/L)
Changes in dietary sodium intake can affect Lithium levels
Fluid volume affects lithium levels may lead to increase in side effects, progressing to lethal Li toxicity
Therapeutic window for Lithium Carbonate
(0.4 to 1.0 mmol/L)
What are the patient education that you will provide for patients taking Lithium Carbonate?
- Do drink enough water as the drug is excreted through the urinary system
- Changes in dietary sodium intake can affect lithium levels.
Name some of the anti-convulsants used to treat Bipolar
Valporate,
Carbamazepine,
Lamotrigine
Name some of the adjunctive therapy used together with anticonvulsants for patients that shows signs of ………..
Antipsychotics are used in adjunctive therapy with anticonvulsants.
When patients show signs of irritability or aggression then we will use olanzapine and quetiapine,
Name some of the adjunctive therapy used together with anticonvulsants
Antipsychotics such as Olanzapine, Risperidone, Quetiapine, Aripiprazole,
Ziprasidone, Clozapine
remember the anti-“P”sychotics drugs ends with ~”P”ine, Done and zole
What are the lab-tests to be done before starting Lithium Carbonate?
(❤️🩸🫘🍘⚖️
- Full blood count (FBC) with differentials
Leukocytosis – benign - Renal function test, U/E/Cr
Renal impairment - Thyroid function test
Hypothyroidism - ECG If > 40yrs old or existing cardiac disease
- Cardiac malformation, neonatal hypothyroidism
- Weight (We do not want patient to gain weight)
- Exclude Pregnancy (contraindicated to patients who are pregnant, concerns of birth defects)
How frequent should we conduct Lithium monitoring for patients?
Serum Lithium level monitoring:
* Sample** 5-7 days** after initiation,
* Change in dose/formulation
* Introduction of interacting medication.
* Monitor 2 weekly in acute phase until stable, 3 to 6 monthly thereafter.
* Obtain sample at least 12 hrs after last dose
* Therapeutic range: 0.4 – 1.0mmol/L
If we are conducting Lithium Monitoring for the patient tomorrow morning at 9am, when should be the last dose of Lithium Carbonate?
Last dose: 8pm today
Do not serve the morning dose at 8am and obtain sample
Nursing interventions for Bipolar Disorder
1) Establish TNPR
Non-judgemental
Active listening
Explore with patients
Encourage patient to verbalize if they have the mood to live on.
2) Milieu Management
Set boundaries
Check environment (noise levels etc.)
un-obtrusive suicide monitoring
3) Medication administration and monitoring
Side effects of the drug, after 2-3 weeks
behavioral charting
check for hoarding
4) Ensuring Patient’s Safety
(prevent single room, 1-1 monitoring, prevent patient self-lock, increased monitoring every 15mins)
**5) Caring for Patient’s ADLs **
(Hygiene & I/O Charting)
List the various types of Anxiety Disorders
(all the Ds)
PD is not Parkinson Disease yea
1) Generalised Anxiety Disorder (GAD)
- Anxiolytics only in Panic stage.
2) Social Anxiety Disorder (SAD) = Social Phobia
3) Panic Disorder w/ wo agoraphobia - Pharm
4) Simple Phobia - Psycho
5) Obsessive Compulsive Disorder (OCD) Pharm+Psycho
6) Adjustment Disorder
Fear of Height
Acrophobia
Fear of Open Space
Agoraphobia
Fear of closed space
Claustrophobia
Fear of Strangers
Xenophobia
Fear of dirt and germs
Mysophobia
Fear of water
Hydrophobia
Fear of fire
Pyrophobia
Fear of animals
Zoophobia
Fear of cats
Ailurophobia
Fear of dogs
Cynophobia
Prevalence & Risk factors
of GAD in Singapore
Singapore Mental Health Survey
2016 Prevalence of GAD 1.6%;
Female: Male
3.6 : 1
Commodity:
Major Depressive Disorder (MDD),
Dysthymia = (PDD)
Panic Disorder & Agoraphobia
Social Phobia
**Risk factors: **
Older age,
Chinese ethnicity Being divorced
What is the Level of Anxiety State:
When patient presents with selective inattention?
Moderate Anxiety
What is the Level of Anxiety State:
When patient is alert presents with heightened perceptual field?
Mild Anxiety, patient can identify a source of anxiety
What is the Level of Anxiety State:
When patient presents with complete self absorption, focused on specific detail only?
What happens to their perceptual field?
Severe anxiety
Perceptual Field greatly reduced.
What is the Level of Anxiety State:
When patient presents with lack of focus on the environment, state of terror & emotional paralysis, panicky?
Patient in this anxiety state may also present with ……. or …….. de…… ?
Panic anxiety state.
Patient may also present with hallucination or delusion.
What is the Level of Anxiety State:
When patient presents with severe shakiness, sleeplessness, severe withdrawal, immobility or severe hyperactivity?
Panic anxiety state
What is the Level of Anxiety State:
When patient presents with confusion, sense of impending doom, tachycardia, threats and demand, feeling of drea, loud & rapid speech?
Severe anxiety
What are the 4 levels of anxiety?
Mild
Moderate
Severe
Panic
What is the Level of Anxiety State:
When patient presents with Voice tremors?
Moderate anxiety
What is the Level of Anxiety State:
When patient presents with attention seeking behaviour?
Mild Anxiety
What is the Level of Anxiety State:
When patient presents with tension-relieving behavior such as biting nails.
Mild Anxiety
What is the Level of Anxiety State:
When patient presents with irritability and/or restlessness?
MIld Anxiety
What is the Level of Anxiety State:
When patient presents with repetitive questioning?
Moderate Anxiety
What is the Level of Anxiety State:
When patient presents with pacing, banging hands on table?
Moderate Anxiety
What is the Level of Anxiety State:
When patient presents with Loud & rapid speech, hyperventilation, sense of impending doom?
Severe anxiety
What is the Level of Anxiety State:
Patient is able to solve problems but not at optimal capacity
Moderate anxiety
What is the Level of Anxiety State:
Patient is able to effectively work towards a goal and examine alternatives
Mild anxiety
What is the Level of Anxiety State:
When patient is unable to see connections between events or details
Severe anxiety
What is the Level of Anxiety State:
When patient is unable to learn and solve problems, disorganized or irrational reasoning.
Panic stage of Anxiety
What are anxiety disorders?
Anxiety is a normal response to threatening situations.
Anxiety is pathological when it is excessive and persistent or when it no longer serves to signal danger.
Persons with anxiety use rigid, repetitive, and effective behaviors to control anxiety.
Anxiety disorders interfere with personal, occupational, or social functioning.
Mental aspects of Anxiety Disorders.
- Worry - A state of unease/ uncertainty over actual or potential problems
- Fear – A state of alarm due to an immediate threat to the individual
-
Rumination – Prolonged and compulsively focused
attention on certain thoughts, often “looping” - Preoccupation – A state of being deeply absorbed in thought
- Catastrophising – Imagining the worst or most terrifying outcome
- Focusing on the negative – Remembering only the bad things that happen and leaving out the good
Physical aspects of Anxiety Disorders
Heart pounding
Rapid breathing
Chest pressure
Dizziness
Muscle tension
Weak legs
Behavioural aspects of Anxiety Disorders
SEEKING REASSURANCE
SEEKING HELP
AVOIDANCE
SICK ROLE
DEPENDENCE
RESTLESS
PACING
What are the main difference in nursing management between the level of anxiety?
- mild & moderate
- Severe & panic
Importance of milieu therapy and the use of medications for severe & panic level of anxiety
Social Anxiety Disorder (SAD) is commonly known as?
Social Phobia
A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny of others
The individual fears that he or she will act in a way that will be humiliating or embarrassing
Exposure of feared situation provokes anxiety
Recognises fear as excessive or unreasonable
Simple Phobias
Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation
Exposure to the phobic stimulus provokes anxiety
Recognises fear as excessive or unreasonable
avoids the phobic object or situation
What are the 2 essential features of OCD?
Obsession
Recurrent and intrusive thoughts, feelings, idea, and sensation.
Compulsion
A conscious recurrent** behaviour** such as cleaning, counting, checking, or avoiding.
What are some of the Common Obsessions?
Contamination
Pathological Doubt
Need for symmetry
Somatic Obsession
Worry about discarding something important
Pharmacotherapy for OCD
Tricyclics (TCAs)
- Clomipramine (Oral)
Selective Serotonin Reuptake Inhibitor (SSRI)
-Fluoxamine (Luvox)
-Fluoxatine (Prozac)
-Paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram
Tricyclics/SSRI with Buspirone/ clonazepam (if anxious)
Tricyclics/SSRI with antipsychotics (if delusional)
Psychotherapy for OCD
Research shows that “behaviour therapy” was an effective treatment for OCD
Therapeutic Techniques
Exposure in vivo (directly facing a feared objection, situation or activity)
Exposure in fantasy
Response prevention (Delaying performance & ritual)
Patient Education
Managing anxiety during exposure sessions
Group Therapy
Cognitive Reconstructuring
Record Keeping
Combined pharmacotherapy & psychotherapy
Panic Attack
A discrete period of intense fear or discomfort
Abrupt onset, reached a peak within 10 mins
Four or more symptoms:
* palpitations,
* chest pain,
* shortness of breath, choking, nausea,
* abdominal distress,
* sweating, trembling, dizzy,
* derealisation, depersonalisation,
* fear of losing control,
* fear of going crazy or of dying
Panic Disorder
Recurrent unexpected panic attacks
Persistent concern about having further attacks
Worry about consequences of attack
e.g. Fear of losing control, of dying, of heart attack or stroke, of becoming crazy
First panic attack occurs when subjects are engaged in an ordinary aspect of life
Young life-threatening age 20 – 30
Background of life threatening illness, loss of close relationship, prolonged strain
Repeated visits to GP and ED
May be associated with Agoraphobia
Course is highly variable, waxing and waning
Pharmacological treatment early in the illness often leads to complete remission
5 year study: 34% recovered, 46% minimally impaired, 20% moderate to severely impaired
