BIPOLAR DISORDERSPresented by:Eric F. Pazziuagan, RN, MAN
BIPOLAR DISORDERS• Bipolar disorders are those in which individuals experience the extremes of mood polarity.• Persons may feel euphoric or very depressed.• A recurrent mood disorder featuring one or more episodes of mania or mixed episodes of mania and depression. (DSM- IV- TR)• Bipolar disorders differ from major depression in that there is a history of manic or hypomanic (milder and not psychotic) episodes.• Manic- depressive: diagnostic equivalent; less precise.
• Mood disturbances range from pure euphoria, or elation, to irritability to a labile admixture that also includes dysphoria (unpleasant mood).• Kinds of mood episodes: ▫ Mania ▫ Hypomania ▫ Depression ▫ Mixed episodes (symptoms of both mania and depression at the same time or alternating frequently during the day).
Symptoms occurring during manicepisodes:▫ Common Symptoms Elevated mood Grandiosity Irritability Anger Insomnia Anorexia Flight of ideas Distractibility Hyperactivity Involvement in pleasurable activities Loud, rapid speech
▫ Other symptoms Lack of awareness of illness. Resistance to treatment Labile mood Depression Delusions Hallucinations
DSM- IV CRITERIA FOR BIPOLARDISORDERS• Manic episode: ▫ A distinct period of abnormal and persistent elevated, expansive, or irritable mood that lasts at least 1 week (or less if hospitalization is required). ▫ At least three of the following symptoms must occur during the episode (or four if the patient is only irritable). Inflated self- esteem or grandiosity. Decreased need for sleep. Very talkative. Flight of ideas or subjective feeling that thoughts are racing. Distractibility. Increase in goal- oriented activity (social, occupational, educational, or sexual) or psychomotor agitation. Excessive involvement in pleasurable activities that have a higher potential for personal problems (e.g., sexual promiscuity, spending sprees, bad business investments).
▫ Mood disturbances severe enough to cause problems socially, interpersonally, or at work, or the person has to be hospitalized to prevent harm to self and others.▫ Not due to a substance.
• Hypomanic episode: ▫ The person experiencing a hypomanic episode meets most of the criteria for manic episode, with two major exceptions: the symptoms must be at least four days and the person must manifest an unequivocal change in functioning that is observable by others. A hypomanic episode is not severe enough to result in significant impairment or to require hospitalization.
• Bipolar disorders ▫ Bipolar episodes are divided into Bipolar I and Bipolar II.In Bipolar I, the patient must have a history of manic episodes. ▫ Bipolar II: The patient has experienced a major depression and hypomanic episodes (but not a manic episode).• Cyclothymic disorder ▫ For a period of two years, the patient has had numerous periods of hypomanic symptoms and numerous periods of depressed mood. The patient is never symptom- free for more than two months at a time. The patient has never experience major depression.
BIPOLAR I• Six separate criteria sets: ▫ Single manic episode ▫ Most recent episode hypomanic ▫ Most recent episode manic ▫ Most recent episode mixed ▫ Most recent episode depressed ▫ Most recent episode unspecified.
BIPOLAR II• Similar to bipolar I, with major exception that the person has never experienced a manic episode.• Requires the presence of a full hypomanic and a major depressive episode.• Remains underused because hypomania is frequently not recognized, especially when occurring in the context of atypical depression.
CYCLOTHYMIA• Sometimes categorized as Bipolar III• Marked by Manic and depressive states, yet neither is of sufficient intensity nor duration to merit a diagnosis of bipolar disorder or major depressive disorder.• There is a history of hypomania but no prior episodes of mania or major depression.• Characterized by mood swings that have occurred for at least 2 years without symptom remission for more than 2 months.
EPIDEMIOLOGY• Bipolar disorder I affects 1 to 1.5% of the general population• Bipolar II: 0.5 to 0.6% of the population, females more affected than males• Economic cost in US: 45 billion dollars• Males display more hyperactivity, grandiosity, and risky behavior, and females more often display racing thoughts and distractibility.• Sixth leading cause of disability• 19% die from suicide
Objective behavior• Manic episode appears enthusiastic and euphoric; recognized as excessive by others.• Disturbances of speech ▫ Loud in a rapid- fire fashion ▫ Monopolizes the dialogue and deflect by others to contribute ▫ Filled with jokes and puns ▫ Sarcastic and biting remarks ▫ Tendency to complain often and loudly ▫ Speech is dramatic ▫ Ability to engage staff in members in debate and place them on the defensive ▫ Flight of ideas
Altered social, interpersonal, andoccupational relationships• Manipulation of the self-esteem of others. ▫ Patients use coercive techniques to increase or decrease another’s self esteem• Ability to find vulnerability of others. ▫ Can exploit weakness in others or create conflicts among staff members.• Ability to shift responsibility.• Limit testing ▫ Patients keep pushing the limits on the psychiatric unit.• Alienation of family.
Alterations in activity andappearance• Hyperactive and agitated• Pacing, flamboyant gestures, colorful dress, singing, and excessive use of make- up• May dress sloppily and omit personal grooming• May not need sleep, or perhaps need only a few hours per night• May drop form exhaustion• May suffer from poor nutrition.
Alterations of affect• Euphoria and high regard to self (may reach levels of grandiosity)• Elevated mood, a feeling of joy, and greatness.• Sense of invincibility.• Labile or quick changing affect.
Alterations of perception• Delusions and hallucinations may occur, and their content is typically consistent with their mood.
Psychodynamic, Existential, Cognitive- Behavioral, and DevelopmentTheories• Biological and genetic factors may be the most significant etiological factors.• Psychosocial stressors can precipitate the onset of illness episodes (when biologic or genetic factors are present).• Family Dynamics ▫ Faulty family dynamics during early life are responsible for manic behaviors in later life. ▫ May be related to an alternating identification with parents: depression with the mother and mania with the father figure.• Mania as a Defense ▫ Manic episodes as defense against massive denial of depression.
Biological Theories• Neurochemical and Neuroendocrine Factors• Biogenic Amine Theory of depression essentially implies that an imbalance of relative deficiency exists in relation to certain neurotransmitters or biogenic amines such as norepinephrine and serotonin.• Deficiencies in the substances mentioned above results in neurochemical imbalance.• Depression is related to increased cholinergic activity and mania is related to increased noradrenergic activity.• Neuroanatomical Factors• Lesions in the white matter of the brain that tend to concentrate in areas that are responsible for emotional processing.
Genetic Factors• The risk to relatives of those individuals with bipolar disorder is significantly greater than the risk for those individuals without bipolar disorder in family history.• Greatest risk when disorder is present in first- degree family members.
Other Factors• Chronobiology: circadian rhythm or sleep- wake cycle of the body ▫ Involved in the pathogenesis of Bipolar disorder. ▫ Sleep deprivation and the development of manic symptoms suggest disruption of circadian rhythm may precipitate affective relapse. ▫ Seasonal variations in circadian rhythm may precipitate affective episodes.
• Kindling theory ▫ Analogous to the use of kindling to build a fire. ▫ Bipolar disorders develop as a result of biologic and genetic predisposition in addition to environmental factors. ▫ This process often results in less severe episodes of mood disturbances that initially occur infrequently and escalate overtime. ▫ As this repetitive cycle occurs, the mood disturbance becomes more severe at more frequent intervals, finally resulting in full- blown bipolar disorder.
Childhood and Adolescence• Once thought to be rare in children.• Researchers are discovering that not only it can begin very early in life, it is much more common than previously believed.• Parents describe their children as being different from early infancy.• Infants: sleeping erratically; not sleeping long; being irritable, fussy, and difficult to settle; temperamental; and extremely anxious, often experiencing great difficulty with separation from the mother.• Night terrors, rages, fear of death, and behaviors that fit into the diagnostic criteria of oppositional defiant disorder are often aspect of bipolar disorder.
Older Adulthood • Bipolar is frequently missed or misdiagnosed. • Depression is more readily diagnosed. • Mood elevation, increase in energy, and other subtle manifestations are often left unrecognized. • Increases the risk of suicide. • Complicating the assessment and diagnosis is that the client may present with various medical conditions such as dementia.
COMORBIDITY• 87% have a comorbid mental health disorder• Other 50% of patients have borderline personality disorder, ADHD, generalized anxiety disorder, panic disorder, social phobias, OCD, PTSD
TREATMENT GOALS:• Getting acute mania under control.• Preventing relapse once remission occurs.• Returning to prior level of functioning (social, occupational, interpersonal)
Mood Stabilizers• Two properties: ▫ Provide relief from acute episodes of mania or depression or prevent them from occurring ▫ Do not worsen depression or mania or lead to increase in cycling.• Before administering, check the basic laboratory studies (electrolytes, CBC, chemistries, and pregnancy test in women of childbearing age).
• Lithium carbonate: first psychotropic agent shown to prevent recurrent episodes of illness. ▫ Major indications: prevention and treatment of mania ▫ Maintain blood levels between 0.6 to 1.2 mEq/L. ▫ Dosage: 900 to 1200mg/ day.• Anticonvulsants: ▫ valproic acid (Depakene), divalproex (Depakote), and carbamazepine (Tegretol) ▫ newer agents: lamotrigine (Lamictal) and topiramate (Topamax)
Benzodiazepines• Antianxiety agents often used in the acute phase of mania or to treat the accompanying symptoms of overwhelming anxiety and panic in patients experiencing Bipolar symptoms.• Lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax)
Calcium ChannelBlockers• For treatment- resistant mania as well as for clients who cannot tolerate lithium(preganant women, brain injury, etc.)• Verapamil (Calan) and nifedepine (Procardia)
Antipsychotics• Adjunct to antidepressant therapy to treat psychotic symptoms of either acute mania or depression.• Current Atypical Antipsychotics: ▫ Olanzapine (Zyprexal) ▫ Quetiapine (Seroquel) ▫ Risperidone (Risperdal) ▫ Clozapine (Clozaril) ▫ Zeprasidone (Geodon)
Electroconvulsive Therapy• Effective and often lifesaving treatment for mania or depression if pharmacologic interventions fail or if symptom severity requires immediate relief.
Treatment Considerations• Most important consideration: SAFETY• Important issues: confidentiality and supportive resources for the individual and family.• Learning to live with Bipolar Disorder requires that the client be educated about the disorder and receive specific instructions. ▫ Maintain a stable sleep pattern. ▫ Maintain a regular pattern of activity. ▫ Do not use alcohol or other substances.
▫ Ask for and use the support of family and friends.▫ Reduce stress at home and at work.▫ Be aware of own early warning signs (often the first clue is change in sleep needs).▫ Develop a repertoire or problem- solving skills.▫ Develop awareness of automatic negative thinking and approaches to combat them.
Milieu Management in the AcuteSettingGOALS:• Provide a SAFE environment.• Decrease environmental stimuli.• Eliminate danger to self and others.• Stabilization and medication compliance.• Thought processes intact.
• Elimination of perceptual disturbances.• Improved social interaction/ decreased isolation.• Improved self- esteem.• Improved sleeping and eating patterns.• Psychoeducation regarding medications and psychotherapy.
MILIEU MANAGEMENT• Safety. ▫ Prevent patients from hurting themselves or others. ▫ Consistency among staff. Nursing and other staff should meet often to diffuse conflict and clarify communication. ▫ Reduction of environmental stimuli. Helpful environmental modifications: limited activities with others, gross motor activities (walking, sweeping, aerobics) Free public room form TV or stereo.
▫ Dealing with patients who are escalating. Deal in a calm, confident manner. Administer Haloperidol.▫ Reinforcement of appropriate hygiene and dress.▫ Nutrition and sleep issue. Patients too busy to eat. Provide patients with foods that can be eaten on the run (finger foods) because some patients cannot sit long enough to eat. Provide high- protein, high calorie snacks for patients. A vitamin supplement might be indicated. Weigh patients regularly (sometimes weighing daily is needed).
Patients who cannot sleep. Provide a quiet place to sleep. Structure patient’s days so that there are fewer stimulating activities toward bedtime. Do not allow caffeinated drinks before bedtime. Assess the amount of rest that patients are receiving. Manic patients are not capable of judging the need for rest, and exhaustion and death have resulted from lack of rest.
Community Setting• Focus: maintenance and monitoring of medications, moods, and behaviors.• Client and nurse must develop a healthy plan of daily living.• Assist the patient in understanding the importance of continuing to take prescribed medications and participating in any prescribed psychotherapy.• Psychotherapy: individual, family, or group therapy.
Family Focused• Affective lability, financial extravagance, fluctuations in level of sociability, sexual indiscretions, and violent behaviors- source of turmoil, conflict and concern to the SOs.• Education of the FAMILY is paramount during acute periods. ▫ Functions: Helps family cope with their pain and suffering and prepares them for difficult times. Encourages them to become active partners in the treatment process. Tailor the involvement of SO to the special needs of the individual.
NURSE- PATIENT RELATIONSHIP• Matter of fact tone. ▫ Minimizes need for the patient to respond defensively and avoids power struggles. ▫ Nurse conveys control of the situation and empathy.• Clear, concise directions and comments. ▫ The nurse can raise hand and say “Wait, just a minute. I do not want to be rude, but I would like to say something.”
▫ Work out a nonverbal signal to indicate need for the patient to stop and let someone else speak.▫ Keep remarks brief and simple.▫ Limit setting.▫ Reinforcement of reality.▫ Respond to legitimate complaints. To diffuse irritability and develop trust.▫ Redirect patients into more healthy activity.