Week 9: Bipolar Disorder

Question 1

Mania***

Answer 1

An abnormally elevated and persistently

• elevated mood
• expansive mood
• irritable mood

Question 2

Expansive mood

Answer 2

Lack of restrains in expression, overvalued self importance

Question 3

Manic episode*

Answer 3

Distinct period of abnormally and persistently elevated, expansive, or irritable mood with abnormally increased goal-directed behavior or energy

Question 4

Mood lability*

Answer 4

Rapid shifts in mood with little or no change in external events (rapid cycling)

Question 5

Rapid cycling*

Answer 5

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

Question 6

Bipolar Disorders (3 types)

Answer 6

BP I
BP II
Cyclothymic

Question 7

BP I

Answer 7

Manic episode that may be followed by or preceded by a depressive or hypomanic state

Question 8

BP II

Answer 8

Lifetime experience of at least one episode of major depression and one hypomanic episode

Question 9

Cyclothymic disorder

Answer 9

Hypomanic and depressive periods for at least 2 years (children, 1 year) without meeting criteria of bipolar I or II disorder

Question 10

Key signs of mania* (5)

Answer 10

Cognitive changes
Elevated self-esteem
Pressured speech
Flight of ideas
Distractibility increase

Question 11

Mania vs Hypomania***

Manic episode

Hypomanic episode

Answer 11

• 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

Question 12

Classic mania symptoms

Answer 12

Inflated self-esteem
Pressured speech
Decreased need for sleep
Flight of ideas
Distractibility
Psychomotor agitation
Increased risk taking

Question 13

Manic episode dx***

Answer 13

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

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility
6. Increase in goal-directed activity, psychomotor agitation
7. Excessive involvement in high risk activity

Question 14

DIGFAST***

Answer 14

Distractibility
Indiscretion and impulsivity
Grandiosity or inflated self-esteem
Flight of ideas
Activity increase 
Sleep deficit
Talkativeness

Question 15

BP disorder: epidemiology

Answer 15

Symptoms often appear before age 25

No gender differences

Question 16

BP female patients risk

Answer 16

Female patients at greater risk for depression and rapid cycling

Question 17

BP male paitents riks

Answer 17

Manic episodes

Question 18

Common comorbidity of BP

Answer 18

Anxiety (panic, and social phobia) and substance use

Question 19

Lifespan considerations

Children and adolescents

Answer 19

Depression usually first – marked by intense rage

Question 20

Lifespan considerations

Older adults

Answer 20

Greater neuro abnormalities and cog disturbances

Incidence of mania decreased with age

Question 21

Biologic theories of BP (3)

Answer 21

Chronobiologic theories
Genetic factors***
Chronic stress and kindling theory

Question 22

Genetic aspect of BP***

Answer 22

One of the mental disorders with the strongest and most clearly established genetic heritability

Question 23

Kindling theory

Answer 23

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

Question 24

Nursing assessment

Biologic Domain

Answer 24

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***

Question 25

Lithium | SE

Answer 25

``` Weight gain* Thirst* Fine head tremor* Drowsiness* Mild diarrhea Metallic taste Increased urinary freq ```

Question 26

Lithium considerations (4)

Answer 26

Risk for cardiac malformations when takin in pregnancy* Avoid alcohol and CNS depressants* Maintain hydration level* Low sodium intake increases lithium levels*

Question 27

Lithium Drug interactions***

Answer 27

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

Question 28

Lithium blood levels***

Answer 28

<1.5 mild side effects 1.5 – 2.5 moderate tox >2.5 severe tox

Question 29

lithum: Mild SE***

Answer 29

Fine hand tremor Diarrhea or loose stools Muscular weakness or fatigue

Question 30

lithium: Moderate tox***

Answer 30

``` N/V Mild-moderate ataxia Incoordination Dizziness, sluggishness, giddiness, vertigo Muscle irritability or twitching ```

Question 31

lithium: Severe tox***

Answer 31

Cardiac arrhythmias Nystagmus Seizures Coma and death

Question 32

Divalporex sodium*** | Indication

Answer 32

Effective for acute mania, first line treatment for patients with rapid cycling or mixed states

Question 33

1st line treatme for rapid cyclin or mixed states

Answer 33

divalporex sodium

Question 34

Divalporex sodium*** | SE

Answer 34

Very sedating*** Tremor GI upset

Question 35

Divalporex soidum | onsiderations

Answer 35

Avoid CNS depressants Hepatotoxic Teratogenic – leads to neural tube defects

Question 36

Signs of hepatotoxicity

Answer 36

``` Malaise Weakness Lethargy Anorexia vomiting ```

Question 37

Carbamazepine*** | class

Answer 37

Anticonvulsant

Question 38

Carbamazepine | SE (5)

Answer 38

``` Dizziness Drowsiness N/v Aplastic anemia Agranulocytosis ```

Question 39

Carbamazepine | Considerations

Answer 39

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)

Question 40

Carbamazepine stable range

Answer 40

8-12 ng/mL

Question 41

Antipsychotic various uses

Answer 41

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***

Question 42

Which antipsychotics for acute mania (3)

Answer 42

Asenapine Olanzapine Ziprasidone

Question 43

BP disorder: Psychological Domain | Nursing Assessment

Answer 43

- mood (assess for mania – Young Mania Rating Scale) - Cognition - Thought disturbances - stress and coping - insight and judgement - risk assessment - strength assessment

Question 44

Interacting w/ person w/ mania***

Answer 44

- 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

Question 45

Psychoeducation checklist: BP I

Answer 45

``` 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 ```

Question 46

BP disorder: Social domain | Nursing assessment

Answer 46

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***

Question 47

BP Emergencey plan (CRISIS PLAN)

Answer 47

``` 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

Question 48

Intensive outpatient care

Answer 48

ACT teams (assertive community treatment) - partial hospitalization - day hospitalization

Question 49

BP II dx

Answer 49

Similar dx to BPD 1 | 1 hypomanic episode plus at least 1 depressive episode

Question 50

Cyclothymic disorder patho

Answer 50

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