Week 9: Bipolar Disorder Flashcards
Mania***
An abnormally elevated and persistently
- elevated mood
- expansive mood
- irritable mood
Expansive mood
Lack of restrains in expression, overvalued self importance
Manic episode*
Distinct period of abnormally and persistently elevated, expansive, or irritable mood with abnormally increased goal-directed behavior or energy
Mood lability*
Rapid shifts in mood with little or no change in external events (rapid cycling)
Rapid cycling*
In bipolar disorder, the occurrence of 4 or more mood episodes that meet criteria for manic, mixed, hypomanic, or depressive episode during the previous 12 months
Bipolar Disorders (3 types)
BP I
BP II
Cyclothymic
BP I
Manic episode that may be followed by or preceded by a depressive or hypomanic state
BP II
Lifetime experience of at least one episode of major depression and one hypomanic episode
Cyclothymic disorder
Hypomanic and depressive periods for at least 2 years (children, 1 year) without meeting criteria of bipolar I or II disorder
Key signs of mania* (5)
Cognitive changes Elevated self-esteem Pressured speech Flight of ideas Distractibility increase
Mania vs Hypomania***
Manic episode
Hypomanic episode
- lasting at least one week of abnormally elevated, expansive, or irritable mood AND increased activity/energy PLUS 3 of the classic mania symptoms
- hospitalization common
- significantly impairs function
- may be accompanied by psychotic symptoms
- Distinct period lasting a minimum of 4 days of abnormally elevated, expansive or irritable mood AND increased activity/energy PLUS 3 of the classic mania symptoms
- NO hospitalization
- does NOT significancy impact function
- NO psychotic features
Classic mania symptoms
Inflated self-esteem Pressured speech Decreased need for sleep Flight of ideas Distractibility Psychomotor agitation Increased risk taking
Manic episode dx***
A. Distinct period during which there is an abnormally, persistently elevated, expansive, or irritable mood and persistently increased activity or energy that is present for most of the day, nearly every day, for a period of at least 1 week, accompanied by at least 2 additional symptoms from criterion B (if mood is irritable rather than elevated or expansive, at least 4 must be present)
B. Symptoms
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility
- Increase in goal-directed activity, psychomotor agitation
- Excessive involvement in high risk activity
DIGFAST***
Distractibility Indiscretion and impulsivity Grandiosity or inflated self-esteem Flight of ideas Activity increase Sleep deficit Talkativeness
BP disorder: epidemiology
Symptoms often appear before age 25
No gender differences
BP female patients risk
Female patients at greater risk for depression and rapid cycling
BP male paitents riks
Manic episodes
Common comorbidity of BP
Anxiety (panic, and social phobia) and substance use
Lifespan considerations
Children and adolescents
Depression usually first – marked by intense rage
Lifespan considerations
Older adults
Greater neuro abnormalities and cog disturbances
Incidence of mania decreased with age
Biologic theories of BP (3)
Chronobiologic theories
Genetic factors***
Chronic stress and kindling theory
Genetic aspect of BP***
One of the mental disorders with the strongest and most clearly established genetic heritability
Kindling theory
Genetically predisposed individuals experience repetitive subthreshold stressors at vulnerable times
- closely related to allostatic lode
- mood symptoms of increasing intensity and duration occur
- each episode leaves a trace and increases the person’s vulnerability or sensitizes the person to have another episode
- later episodes: little or no stress may precipitate
- over time, time between episodes decreases and episodes intensify
Nursing assessment
Biologic Domain
Physical assessment
- changes in activity, eating, and sleep***
- diet and body weight
- lab testing (thyroid)
- changes in sexual practices/risk taking***
- pharm assessment
- -previous use of antidep
- -use of alcohol and other substances***
Lithium
SE
Weight gain* Thirst* Fine head tremor* Drowsiness* Mild diarrhea Metallic taste Increased urinary freq
Lithium considerations (4)
Risk for cardiac malformations when takin in pregnancy*
Avoid alcohol and CNS depressants*
Maintain hydration level*
Low sodium intake increases lithium levels*
Lithium Drug interactions***
NSAIDS – double lithium levels*
Thiazide and loop diuretics – increase lithium levels*
ACE inhibitors – increase lithium levels*
Osmotic diuretics – decrease lithium
Sodium chloride – high sodium intake decreases lithium levels, low sodium may increase
TCAs – increase tremor
Lithium blood levels***
<1.5 mild side effects
1.5 – 2.5 moderate tox
>2.5 severe tox
lithum: Mild SE***
Fine hand tremor
Diarrhea or loose stools
Muscular weakness or fatigue
lithium: Moderate tox***
N/V Mild-moderate ataxia Incoordination Dizziness, sluggishness, giddiness, vertigo Muscle irritability or twitching
lithium: Severe tox***
Cardiac arrhythmias
Nystagmus
Seizures
Coma and death
Divalporex sodium***
Indication
Effective for acute mania, first line treatment for patients with rapid cycling or mixed states
1st line treatme for rapid cyclin or mixed states
divalporex sodium
Divalporex sodium***
SE
Very sedating***
Tremor
GI upset
Divalporex soidum
onsiderations
Avoid CNS depressants
Hepatotoxic
Teratogenic – leads to neural tube defects
Signs of hepatotoxicity
Malaise Weakness Lethargy Anorexia vomiting
Carbamazepine***
class
Anticonvulsant
Carbamazepine
SE (5)
Dizziness Drowsiness N/v Aplastic anemia Agranulocytosis
Carbamazepine
Considerations
Increasd risk for birth defectse
Monitor CBC and liver function
Requires monthly blood level until patient is on stable dosage
Many drug interactions (increase carb, decrease carb, decrease other drug level)
Carbamazepine stable range
8-12 ng/mL
Antipsychotic various uses
in conjunction with lithium and Divalporex in management of acute mania
- as adjunctive therapy for maintenance
- a few are approved to use as monotherapy for maintenance in pregnant women with BP who cannot take lithium or anticonvulsants***
- for acute mania***
Which antipsychotics for acute mania (3)
Asenapine
Olanzapine
Ziprasidone
BP disorder: Psychological Domain
Nursing Assessment
- mood (assess for mania – Young Mania Rating Scale)
- Cognition
- Thought disturbances
- stress and coping
- insight and judgement
- risk assessment
- strength assessment
Interacting w/ person w/ mania***
- calm non-threatening approach
- be direct and use simple commands
- avoid open-ended sentences
- redirect conversation if flight of ideas occur
- avoid confrontation and arguments
- limit interaction time and recognize patient’s need for space and movement
- Do not place excessive demands on patient
Psychoeducation checklist: BP I
Psychopharmacologic agents Medication regimen adherence Recovery plan* Wellness plan* Crisis plan* Relapse prevention Strategies to decrease agitation and restlessness Safety measures* Self-care management* Follow-up laboratory testing* Support services
BP disorder: Social domain
Nursing assessment
Cultural views of mental illness*
Social and occupation impact of disorder*
Any changes resulting from a manic or depressive epsiode*
Relationship conflicts: changes in social circle and impact on behaviors and self-concept*
BP Emergencey plan (CRISIS PLAN)
List of emergency contacts (PCP family) List of meds (w/ dosages) Info about health problems Symptoms that indicate others need to take responsibility for care Treatment preferences
Should be simple and clear
Include
-personal info
-what person is like when feeling well
-list of useful coping strategies (wellness toolbox)
-list of signs that person is no longer able to care for self
-what crisis looks like for person
-how person feels when in crisis
-possible triggers***
-any useful “code words”
-preferred and unwanted treatments, facilities, and medications
-list of people to contact/NOT contact
-safety plan for safety of client and dependent children or pets
Intensive outpatient care
ACT teams (assertive community treatment)
- partial hospitalization
- day hospitalization
BP II dx
Similar dx to BPD 1
1 hypomanic episode plus at least 1 depressive episode
Cyclothymic disorder patho
Cyclothymic disorder patho Chronic fluctuating mood with symptoms similar to BPD but less severe
-dysthymic episodes and elevated mood episodes don’t meet criteria for depressive, manic, or hypomanic episodes
