Bipolar Disorders - lecture notes - Psychiatric Mental Health Nursing PDF

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Topic 5 Bipolar Disorders Bipolar Disorder I (Severe)  

Manic episodes that last at least 7 days Symptoms that are so severe that require immediate hospital care

Bipolar Disorder II 

Pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes in bipolar I

Cyclothymic Disorder (Chronic) 

Numerous periods of hypomanic symptoms as well as dysthymic (low-grade depression) symptoms lasting for at least 2 years (1 year in children and adolescents)

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Bipolar I & II are more common in creative persons and those who are highly educated Substance abuse is NOT considered a cause of bipolar disorder, but it can worsen it by interfering with recovery o May induce a more severe depressive phase Genetic predisposition to sleep-wake cycle problems that may trigger symptoms of depression and mania Antidepressants can trigger manic episode o Use of anti-manic drug (creates a ceiling for mood elevation, protecting the patient from antidepressant-induced mania)

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Manic = fast; Depressive = Slow Hypomania  Mania  Delirious mania Dysphoric mania = higher risk for suicide Phases of Mania Treatment Acute phase   

Medical stabilization Maintaining safety Self-care needs o Structure in a safe milieu o Nutrition o Sleep o Hygiene o Elimination

Continuation phase   

Maintaining medication adherence Psychoeducational teaching Referrals

Maintenance phase 

Preventing relapse

Psychopharmacology for Bipolar Disorders 

For mood stabilization o Lithium  First-line agent for bipolar disorder  Do NOT limit sodium while taking lithium  Monitor for dehydration  Do NOT take diuretics with lithium  Can result in o Renal damage, hypothyroidism  Therapeutic range: 0.6-1.2  Kidney function exams  TSH, T3, T4  Lithium Toxicity  NARROW THERAPEUTIC INDEX (high risk for toxicity)  >1.5 = toxic; >2 severe toxicity  Mild toxicity: muscle weakness, muscle twitching & ataxia, confusion, slurred speech, GI effects, thirst, polyuria  Advanced toxicity: significant coarse hand tremor, persistent GI upset, ataxia & clonic movements, incoordination, EEG changes  Severe toxicity: Ataxia & clonic movements, blurred vision, large output of dilute urine, seizures, tinnitus, stupor, severe hypotension, coma  >2.5: client decline due to cardiac dysrhythmias, peripheral circulatory collapse, proteinuria, oliguria, and death may occur (due to pulmonary complications)  Treatment for lithium toxicity: o Stop lithium administration o Hydrate o Supportive measures o Certain anticonvulsants  Divalproex (Depakote)  Effective for lithium non-responders  Black box warning: hepatotoxicity, pancreatitis, and teratogenicity  May cause birth defects, polycystic ovarian syndrome  Symptoms of toxicity

 Ataxia, confusion, coma, hallucinations, irritability, somnolence Lamotrigine  Notorious for severe skin reaction called stevens-Johnson syndrome  Start at very small dose and follow a titration regimen to increase to a dose that provides good symptom control  Report ANY sign of rash to their provider immediately to be assessed for stevens-Johnson syndrome o Certain atypical antipsychotics  Olanzapine  Second-generation atypical antipsychotic  Aripiprazole For episodes of acute mania o Certain benzodiazepines  used in emergent situations, primarily acute mania (short term use only)  Lorazepam  Clonazepam  ALPRAZOLAM SHOULD NOT BE USED FOR ACUTE MANIA  INCREASED AGITATION AND AGGRESSION o Certain atypical antipsychotics (used to supplement lithium during acute mania) lower the physical activity present during acute mania during the several weeks it will take the lithium to become fully effective  Olanzapine  Risperidone  Aripiprazole  Ziprasidone For episodes of mixed mania o Certain antipsychotics 

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Childhood impulse control disorders Oppositional Defiant Disorder (ODD) 

Pattern of angry/irritable mood, argumentative/defiant behavior lasting at east 6 months as evidenced by at least 4 symptoms from any of the following categories o Often loses temper o Easily annoyed o Angry o Argumentative with authority figures o Defies or refuses to follow rules o Annoyance o Vindictive?

Conduct Disorder (CD) – doesn’t care for anyone or anything

Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated: (antisocial behaviors) destruction of property, steal, and even hurt pets Childhood-onset (before age 10)     

Physically aggressive (to people and/or animals) Poor peer relationships Shows little concern for others Lacks guilt and remorse More likely to continue into adulthood

Adolescent-onset (10-18)   

Less aggressive form of CD Acts out misconduct with peer group Less likely to continue into adulthood

Treatment for Childhood Impulse Control Disorders  

Parenting classes and management training necessary to help parents deal with these disorders, including limit setting Individual and parent management training (family therapy)

Impulse Control Disorders (kleptomania)    

Decreased ability to resist an impulse to perform certain acts o Tension builds until a particular action is taken which releases the tension Similar to OCD, however there isn’t an associated obsession They realize that the acts are illogically wrong, but despite their efforts, the urge to act overwhelms them Shame and distress accumulating from the unacceptable behaviors increases the risk of developing depression and of committing suicide

Psychopharmacology for Impulse Control Disorders 

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Kleptomania o SSRIs o Bupropion o Naltrexone Conduct Disorders o Lithium o Methylphenidate o Risperidone Nonpharmacologic treatments o Hypnotherapy o CBT  Focus: habit reversal & sensitization to consequences

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Biofeedback Behavioral conditioning Group psychotherapy...