Mood
Behaviors and
Symptom
Management
In Skilled Nursing
With Dr. Michael Changaris

 Unipolar Depression: Disrupts life
through increased irritability, isolation
and robs people of joy.
 Bipolar Disorder a Disorderly
Disorder. It leads to extremes in
behaviors and moods.
 An Unique Mind is a memoir by Dr
Kay Redfield Jamison who lives with
bipolar disease.
 She is a well respected psychiatrist
with a prestigious career.
 Had personal struggles with wanting
to take medications.

 400 BC - Hippocrates links
the black bile of melancholia with the
yellow bile of mania.
 1899 - Emil Kraepelin introduces the term
"manic-depressive” into
psychiatric textbooks.
 1949 - Australian doctor John Cade
discovers the efficacy of lithium as a
treatment.
 1968 - The DSM changes to the term
manic-depressive illness and biological
perspectives come to dominate.
 2010 - New draft of DSM proposed.

 For most the onset for Bipolar occurs in
late teens and early 20’s.
 Rates in general population for adults is between 1% and
4% depending on criteria.
 In elders in community rates are between 1% and .5%
 Rates in nursing homes are as high 10%.
 Psychosocial factors increase severity of symptoms and
predicts health, behavioral problems, and rate of relapse.
 Family relationships, Poverty, Racism, Lack of Social
Relationships, Life Stress are Key Factors in Prognosis.

1. Identify episode of
mania, hypomania, depression or mixed
episode.
2. From the episode the diagnosis is given.
3. In bipolar the rate of change and severity
of symptoms are key diagnostic
questions.

 Bipolar I disorder: One or more manic episodes. Subcategories
specify whether there has been more than one episode, and the type
of the most recent episode.
 Bipolar II disorder: No manic episodes, but one or more hypomanic
episodes and one or more major depressive episode.Hypomanic
episodes do not go to the full extremes of mania.
 Cyclothymia: A history of hypomanic episodes with periods of
depression that do not meet criteria for major depressive episodes.
 Bipolar Disorder NOS (Not Otherwise Specified): This is a
catchall category, diagnosed when the disorder does not fall within a
specific subtype.
 Rapid cycling: Most people who meet criteria for bipolar disorder
experience a number of episodes, on average 0.4 to 0.7 per
year, lasting three to six months.Rapid cycling is defined as having
four or more episodes per year.

Bipolar Disorder: Sami Khalife, Vivek Singh, David J. Muzina
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/bipolar-disorder/#f0015

 People can loose jobs, face jokes, feel judged for
behavior and can feel isolated.
 Bipolar disorder is associated with creativity:
Painters, Writers, Actors.
 One 2011 Study found, “We propose that
creativity in BD might be linked to the putative
hyperdopaminergic state of mania and be
dependent on intact executive function.”
 Positive social and emotional functioning increase
executive functioning

 The overall heritability of the bipolar spectrum has
been put at 0.71.
 Bipolar disorder co-occurs in 67% of
monozigotic twins and 19% of dizigotic
 Half of adults diagnosed with bipolar disorder
report traumatic/abusive experiences in
childhood (independent of trauma due to increased
health destructive behaviors).
 Childhood abuse relates to severity of
symptoms, prognosis and symptoms later in life.

 MRI studies in bipolar disorder: Increase in the volume of the
lateral ventricles, globus pallidus, abnormalities in
hypothalamic-pituitary-adrenal axis (HPA axis).
 The "kindling" theory: A genetic predisposition is catalyzed by
stressors that lowers threshold for mood episodes and
disrupts emotional regulation. After this occurs often enough
mood symptoms self-perpetuate.
 Disruptions in mitochondria and neuron pump also have been
identified.
 Individuals with bipolar disorder have alterations in:
Circadian rhythms, sleep, diurnal cortisol and melatonin.

 Individuals with bipolar disorder can lead very
productive lives if there is the right social and
emotional support.
 More then individuals with psychosis individuals with
bipolar tend to be in higher paying work.
 However there is often a lower reported quality of life
for individuals with bipolar disorder despite successes.
 If there are significant life stressors, poor social
support, chaos, etc. there is another life course for the
illness.

 Medications: Lithium, Anticonvulsants
(depakote&tegretol), Atypical
Antipsychotics.
 Anti-depressants are not effective.
 Psychotherapy regard to relapse
prevention:
• Cognitive behavioral therapy.
• Family-focused therapy.
• Psychoeducation
 Psychotherapy regard to residual
depr. symptoms:
• Social rhythm therapy.
• Cognitive-behavioral therapy.

 Cognitive Behavioral Therapy: Targets the
relationship between thoughts, feelings and
behaviors.
 Family Focused Therapy: Helps recognize signs
of impending episodes or relapses, increase
communication and conflict resolution, teaches
problem-solving skills, and helps individual create
concrete steps to get support in a crisis.
 Psychoeducation: Teaches individuals about the
disorder and helps develop tools to manage
symptoms.

 Is a treatment combining psychological and
medical interventions.
 Finds “dysregulation in circadian rhythms” as a
cause for episodes.
 PET found effects of sleep deprivation in the
medial prefrontal cortex (mood and emotion
regulation centers).
 Sleep deprivation leads to increase in positive
mood for people who are depressed.

1) Stressful life events.
2) Disruptions in social
rhythms.
3) Medication
non-adherence.

1) The link between mood and life events.
2) The importance of maintaining regular daily rhythms.
3) The identification and management of potential
precipitants of rhythm dysregulation with special
attention to interpersonal triggers.
4) The facilitation of mourning the lost healthy self.
5) The identification and management of affective
symptoms.

 Instruction on the importance of medication compliance
(e.g., log and review of medication record and what
medications were taken, what time, date).
 Management of BD.
• Improvement of communication.
• Counseling regarding marital relationship and related issues.
• Caregiver support and education.
 Observation and assessment of postoperative medical
conditions including chest pains, pedal edema, and urinary
incontinence.
 Counseling regarding nutrition-specifically a low fat, low
salt, and low sugar diet.

 Behaviors are a chain reaction
• Triggering events.
• Internal events (thoughts, emotions).
• Vulnerability factors (lack of sleep, feeling rejected).
• Consequences that either make a behavior more or less likely.

 In the skilled nursing context people are isolated from
social support, have pain, adjustment to illness, anxiety
about health, and challenges with sleep.
 Regularity in skilled nursing of meals and therapies
could be very supportive.
 Evening noise, pain, racing thoughts, difficulty falling
asleep or waking up multiple times per night is
common.
 There are multiple risk factors that increase bipolar
behaviors and multiple protective factors against the
development of a bipolar episode.

 Keep Healthy Boundaries
• Be careful what you reinforce.
• What you reinforce will continue.
• Mice can be reinforced for a behavior with a fight just like it was the best tasting
food.
 Treat Symptoms
• Depression or manic episode
• Anxiety
• Paranoia
• Grief, Pain, Sleep, Social Connection etc.
 Behavioral Chain Analysis
• Consult with behavioral health.
• Assess triggers, internal factors, precipitating factors.
• Change triggers, internal factors, precipitating factors.
 Self-regulate: Your emotions are contagious. Individuals who have
bipolar, traumatic histories or personality problems have a
heightened sensitivity to the emotions of others.