The document discusses bipolar disorder and mood disorders. It covers biological, psychosocial and developmental theories of bipolar disorder. Symptoms of mania in children and adolescents are provided. Treatment strategies discussed include psychopharmacology, family interventions, and addressing comorbid conditions like ADHD. Nursing assessments, diagnoses, interventions, education and evaluations related to bipolar disorder and suicide risk are also summarized.

1. Chapter 16 Mood Disorders Part II

2. Bipolar Disorder (Mania) Etiological implications Biological theories : Strong hereditary implications Biochemical influences : Possible excess of norepinephrine, serotonin, and/or dopamine

3. Bipolar Disorder (Mania) (cont.) Biological theories (cont.) : Electrolytes Physiological influences Brain lesions Medication side effects-most common steroids, also amphetamines, antidepressants, and high doses of anticonvulsants during manic episodes

4. Bipolar Disorders (Mania) (cont.) Psychosocial theories Credibility of psychosocial theories has declined in recent years Bipolar disorder viewed as brain disorder Theoretical integration Bipolar disorder likely results from an interaction between genetic, biological, and psychosocial determinants.

5. Bipolar Disorder: Developmental Implications Childhood and adolescence Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1%. Diagnosis is difficult. Guidelines for diagnosis and treatment have been developed by the Child and Adolescent Bipolar Foundation (CABF).

6. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) The CABF recommends the use of FIND (frequency, intensity, number, and duration) in making a diagnosis of bipolar disorder in children and adolescents.

7. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) FIND: Frequency : Symptoms occur most days in a week Intensity : Symptoms are severe enough to cause extreme disturbance Number : Symptoms occur 3 or 4 times a day Duration : Symptoms occur 4 or more hours a day

8. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Symptoms include: Euphoric/expansive mood : Extremely happy, silly, or giddy. Irritable mood : Hostility and rage, often over trivial matters. Grandiosity : Believes abilities to be better than everyone else’s. Decreased need for sleep : May only sleep 4 or 5 hours per night and wake up feeling rested.

9. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Symptoms (cont.): Pressured speech : Loud, intrusive, difficult to interrupt. Racing thoughts : Rapid change of topics Distractibility : Unable to focus on school lessons Increase in goal-directed activity/psychomotor agitation : Activities become obsessive. Increased psychomotor agitation.

10. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Symptoms (cont.): Excessive involvement in pleasurable or risky activities : Exhibits behavior that has an erotic, pleasure-seeking quality about it. Psychosis : May experience hallucinations and delusions. Suicidality : May exhibit suicidal behavior during a depressed or mixed episode or when psychotic.

11. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Treatment strategies: Psychopharmacology: Lithium Divalproex Carbamazepine Atypical antipsychotics

12. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Treatment strategies (cont.): ADHD is most common comorbid condition ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled

13. Bipolar Disorder: Developmental Implications (cont.) Childhood and adolescence (cont.) Treatment strategies (cont.): Family interventions: Psychoeducation about bipolar disorder Communication training Problem-solving skills training

14. Nursing Process/Assessment Symptoms may be categorized by degree of severity Stage I—Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization Mood: cheerful and expansive Cognition and perception: self- exultation; easily distracted Activity and behavior: increased motor activity; extroverted; superficial

15. Assessment Stage II—Acute mania: intensification of hypomanic symptoms; requires hospitalization Mood: euphoria and elation Cognition and perception: fragmented, disjointed thinking; pressured speech; flight of ideas; hallucinations and delusions Activity and behavior: excessive psychomotor behavior; increased sexual interest; inexhaustible energy; goes without sleep; bizarre dress and make-up

16. Assessment (cont.) Stage III—Delirious mania: A grave form of the disorder, characterized by severe clouding of consciousness and representing an intensification of the symptoms associated with acute mania. Has become relatively rare since the availability of antipsychotic medication

18. Nursing Diagnosis Risk for Injury related to: Extreme hyperactivity Evidenced by: Increased agitation and lack of control over purposeless and potentially injurious movements

19. Nursing Diagnosis (cont.) Risk for violence: Self-directed or other-directed related to: Manic excitement Delusional thinking Hallucinations

20. Nursing Diagnosis (cont.) Imbalanced Nutrition less than body requirements related to: Refusal or inability to sit still long enough to eat Evidenced by : Loss of weight, amenorrhea

21. Nursing Diagnosis (cont.) Disturbed thought processes related to: Biochemical alterations in the brain Evidenced by delusions of grandeur and persecution

22. Nursing Diagnosis (cont.) Disturbed sensory perception related to: Biochemical alterations in the brain and to possible sleep deprivation Evidenced by: auditory and visual hallucinations

23. Nursing Diagnosis (cont.) Impaired social interaction related to: Egocentric and narcissistic behavior Insomnia related to: Excessive hyperactivity and agitation

24. Criteria for Measuring Outcomes The client: Exhibits no evidence of physical injury Has not harmed self or others Is no longer exhibiting signs of physical agitation

25. Criteria for Measuring Outcomes (cont.) The client (cont.): Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status Verbalizes an accurate interpretation of the environment Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations

26. Criteria for Measuring Outcomes (cont.) The client (cont.): Accepts responsibility for own behaviors Does not manipulate others for gratification of own needs Interacts appropriately with others

27. Planning/Implementation Nursing interventions are aimed at: Maintaining safety of client and others Restoring client nutritional status Encouraging appropriate client interaction with others Assisting client to define and test reality Meeting client’s self-care needs

28. Client/Family Education Nature of illness Causes of bipolar disorder Cyclic nature of the illness Symptoms of depression Symptoms of mania

29. Client/Family Education (cont.) Management of illness Medication management Assertive techniques Anger management

30. Client/Family Education (cont.) Support services Crisis hotline Support groups Individual psychotherapy Legal/financial assistance

31. Evaluation Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria.

32. Evaluation (cont.) Has the client avoided personal injury? Has violence to client or others been prevented? Has agitation subsided?

33. Evaluation (cont.) Have nutritional status and weight been stabilized? Have delusions and hallucinations ceased?

34. Treatment Modalities for Mood Disorders Psychological treatment Individual psychotherapy Group therapy Family therapy Cognitive therapy

35. Treatment Modalities for Mood Disorders (cont.) Organic treatments-may take up to 4 weeks for symptoms to subside! Psychopharmacology For depression Tricyclic antidepressants MAO Inhibitors SSRIs Others * Maprotiline * Mirtazapine * Amoxapine * Nefazodone * Trazodone * Venlafaxine * Bupropion * Duloxetine

36. Treatment Modalities for Mood Disorders (cont.) Psychopharmacology (cont.) For mania: Lithium carbonate Anticonvulsants Verapamil Atypical antipsychotics

37. Treatment Modalities for Mood Disorders (cont.) Electroconvulsive therapy For depression and mania Mechanism of action: thought to increase levels of biogenic amines Side effects: temporary memory loss and confusion Risks: mortality; permanent memory loss; brain damage Medications: pretreatment medication; muscle relaxant; short-acting anesthetic

38. Nursing Process: Suicide Assessment Epidemiological factors Marital status : Single, divorced, and widowed people have rates four to five times greater than those who are married

39. Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Gender : Women attempt suicide more often; however, more men succeed Age : Suicide highest in persons older than 50 years; adolescents also at high risk

40. Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Religion : Protestants have significantly higher rates of suicide than Catholics and Jews. A strong feeling of cohesiveness within a religious organization seems to be an important factor.

41. Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Socioeconomic status : People in the highest and lowest social classes have higher suicide rates than those in the middle classes. Professionals : Professional healthcare personnel and business executives are at the highest risk.

42. Nursing Process: Suicide Assessment (cont.) Epidemiological factors (cont.) Ethnicity : Whites are at highest risk for suicide, followed by Native Americans, then by African Americans.

43. Nursing Process: Suicide Assessment (cont.) Presenting symptoms/medical – psychiatric diagnosis Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide. Other disorders include Anxiety disorders Schizophrenia Borderline personality disorder Antisocial personality disorder

44. Nursing Process: Suicide Assessment (cont.) Suicidal ideas or acts Assess: Intent; plan; means; lethality of means; previous attempts Verbal clues: Direct statements: “I want to die.” Indirect statements: “I don’t have anything to live for anymore.”

45. Nursing Process: Suicide Assessment (cont.) Analysis of the suicidal crisis Interpersonal support system The precipitating stressor Relevant history Life-stage issues Psychiatric/medical/family history Coping strategies

46. Nursing Process Diagnosis/Outcome Identification Risk for suicide related to feelings of hopelessness and desperation Outcome: The client has experienced no physical harm to self

47. Nursing Process (cont.) Diagnosis/Outcome Identification (cont.) Hopelessness related to absence of support systems and perception of worthlessness Outcome: Expresses some optimism and hope for the future

48. Nursing Process (cont.) Planning/Implementation Establish a therapeutic relationship to convey acceptance of the person. Communicate the potential for suicide to team members. Stay with the person to convey support throughout the current crisis.

49. Planning/Implementation Accept the person, which will show unconditional positive regard. Listen to the person. Secure a no-suicide contract (verbally or in writing) for a specified amount of time.

50. Intervention with the Outpatient Suicidal Client Do not leave the person alone. Establish a no-suicide contract. Enlist help of family and friends. Schedule daily appointments. Establish trusting relationship. Talk directly about client’s plans for suicide. Discuss current crisis situation. Identify areas of client control. Antidepressant medication.

51. Information for Family/Friends of Suicidal Client Take any hint of suicide seriously. Report threats of suicide immediately. Be a good listener; stay with the person. Express concern about the person’s welfare. Be aware of resources for assistance. Restrict access to firearms or other means of self-harm. Instill hope. Express love for the person. Encourage professional help. Be nonjudgmental.

52. Intervention with Families and Friends of Suicide Victims Encourage them to talk about the suicide. Be aware of blaming or scapegoating. Listen to feelings of guilt. Encourage discussion of relationship with lost loved one. Encourage grieving at own personal pace. Discuss coping strategies. Identify resources that provide support.

53. Nursing Process/Evaluation Evaluation of the suicidal client is an ongoing process accomplished through continuous reassessment of the client as well as determination of the goal achievement.

54. Nursing Process/Evaluation (cont.) Long-term goals for the suicidal client would be to: Develop and maintain a more positive self-concept Learn more effective ways to express feelings to others Achieve successful interpersonal relationships Feel accepted by others and achieve a sense of belonging