Bipolar Disorders
Bipolar 1 vs 2
- Bipolar I disorder is the diagnosis given to a client who is currently experiencing a manic episode or has a history of one or more manic episodes. The specifier might be single manic episode or current episode manic, hypomanic, mixed, or depressed. Psychotic or catatonic features may also be present.. At least one episode of mania alternating with depression.
- Bipolar II disorder is characterized by recurrent bouts of major depression with episodic occurrence of hypomania. The individual may present with symptoms of depression or hypomania. The client has never experienced a full manic episode.
Manic Manifestations
•Labile mood with euphoria
•Agitation and irritability
•Restlessness
•Dislike of criticism
•Increase in talking or activity
•Flight of ideas
•Grandiosity
•Impulsivity
•Demanding or manipulative behavior
•Distractibility
Poor judgment
Attention seeking behavior
Impairment in social or occupational functioning
Decreased sleep
Neglect of ADLs (nutrition, hydration, etc)
Possible presence of delusions or hallucinations
Denial of illness
Non Pharmacological Treatments
Therapy - individual, group, behavior, social skills training, cognitive remediation (eye contact, voice intonation, interpersonal skills— improve relationship development)
Cognitive remediation
Family therapy
Program of Assertive Community Treatment - A program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness
•Recovery model - a concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve their full potential
•Research provides support for recovery as an obtainable objective for individuals with schizophrenia.
•RAISE - Recovery After an Initial Schizophrenia
Episode (RAISE) - a program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness.
Cluster A
Paranoid
Pervasive, persistent distrust of others based on unfounded beliefs.
Constantly on guard/hypervigilant, untrusting, insensitive to feelings of others, oversensitive, tends to misinterpret cues
Schizoid: profound defect in the ability to form personal relationships —>failure to respond to others in a meaningful, emotional way.
Cold, unempathetic, uncooperative, appears shy, no close friends, lacking in nurturing
Schizotypal - behaviors are odd/eccentric but does not decompensate to the level of schizophrenia
Aloof, isolated, magical thinking, bland/apathetic behavior, depersonalization, superstitious
Mood Stabilizers
Lithium Carbonate was treatment of choice for bipolar mania for many years.
•MOA: produces neurochemical changes in the brain, including serotonin blockade
•Potential Complications: nausea, diarrhea, GI pain, fine hand tremors, polydipsia, weight gain, goiter/hypothyroidism, hypotension, electrolyte imbalance.
•Maintenance Dose Therapeutic Range: 0.6-1.2 mEq/L
•Initial treatment of manic episode higher levels may be required: 1.-1.5 mEq/L
Cyclothymic Disorder
- Chronic mood disturbance of at least 2 years, involving numerous periods of elevated mood that do not meet the criteria for a hypomanic episode, and numerous periods of depressed mood of insufficient severity or duration to meet the criteria for a major depressive episode. The individual is never without the symptoms for more than 2 months.
Transactional Model of Stress & Coping
Explains how people cope and adapt to challenges and problems. It contended that a person's capacity to cope and adjust to challenges and problems is a consequence of transactions (or interactions) that occur between a person and their environment.
Schizophrenia Definition & Four Phases
Schizophrenia: Affects thinking, behaviors, emotions, and the ability to perceive reality. Typical age of onset is teens/early 20’s. Psychotic thinking or behavior for at least 6 months. Areas of functioning including school, work, self-care, and interpersonal relationships are significantly impaired.
Premorbid phase: Shy and withdrawn, poor peer relationships, doing poorly in school, antisocial behavior
Prodromal phase: Lasts from a few weeks to a few years with deterioration in role functioning and social withdrawal, substantial functional impairment. Depressed mood, poor concentration, fatigue. May experience sudden onset of obsessive-compulsive behavior.
Acute schizophrenic episode: in the active phase of the disorder, psychotic symptoms are prominent. Delusions and hallucinations likely present. Impairment in work, social relations, and self-care
Residual phase: symptoms of the acute stage are no longer prominent, but negative symptoms may remain. Flat affect and impairment in role functioning are prominent.
Cluster B
Antisocial - behave in a manner that is socially irresponsible, exploitative, without remorse - disregard for others rights
Failed to sustain employment/conform to law, difficulty developing relationships, lack of empathy, sense of entitlement, non adherence to traditional morals/values, verbally charming and engaging
Borderline - chronic depression, inability to be alone, clinging/distancing behaviors, splitting, manipulation, impulsivity, pattern of chaotic/unstable relationships, emotionally unstable, self destructive
Pattern of intense and chaotic relationships, with affective instability and fluctuating attitudes toward other people. These individuals are impulsive, are directly and indirectly self-destructive, and lack a clear sense of identity.
Histrionic - behavior is excitable, emotional, colorful, dramatic, extroverted
Self dramatizing, attention seeking, overly gregarious, seductive, distractable, exhibitionistic, difficulty paying attention
Narcissistic - exaggerated sense of self worth
Lack of empathy, belief in inalienable rights to receive special consideration, lack humility, overly self-centered, need for constant admiration
Anticonvulsants
•Anticonvulsants that act as mood stabilizers, prevent relapse of manic and depressive episodes.
•Valproate and carbamazepine may treat acute mania
•Have specific blood level ranges to be monitored regularly.
•Lamotrigine used for maintenance therapy in bipolar mania
•Needs to be titrated slowly to prevent AE.
•MOA: slowing entrance of sodium and calcium back into the neuron and potentiating inhibitory effects of GABA and glutamate.
The Recovery Model
The Recovery Model has been used primarily in caring for individuals with serious mental illness, such as schizophrenia and bipolar disorder who have a desire to take control and manage their lives more independently. Recovery is a continuous process. The individual identifies goals based on personal values or what the client defines as giving meaning and purpose to life. The clinician and client work together to develop a treatment plan that is in alignment with the goals set forth by the client.
Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and social life.
Hypomania
Hypomania states exhibit less severe symptoms, last at least 4 days accompanied by at least three manifestations of mania – hospitalization not required. Can progress to mania.
The disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning. The mood of a hypomanic person is cheerful and expansive. There is an underlying irritability that surfaces rapidly when the person’s wishes and desires go unfulfilled.
Perceptions of the self include ideas of great worth and ability. Thinking is flighty, with a rapid flow of ideas. Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli, and goal-directed activities are difficult.
Hypomanic individuals exhibit increased motor activity. They are perceived as being very extroverted and sociable, but they lack the depth of personality and warmth to formulate close friendships. They talk and laugh a great deal, usually very loudly and often inappropriately
Schizophreniform vs Brief Psychotic Disorder vs Schizoaffective Disorder
Schizophreniform: Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months. Social or occupational dysfunction might not be apparent.
Brief Psychotic Disorder: Sudden onset of symptoms lasting 1 day to 1 month. May or may not be preceded by a severe psychosocial stressor. Return to full premorbid level of functioning after.
Schizoaffective Disorder: Schizophrenic symptoms accompanied by a strong element of symptomatology associated with mood disorders of either mania or depression. Meets the criteria for both schizophrenia and depressive or bipolar disorder. Decisive factor in diagnosis: Presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episodes.
Cluster C
Avoidant - extreme sensitivity to rejection, social withdrawal and avoidance
Awkward/anxiety in social situations, feelings of inadequacy, desire close relationships but avoid due to fear of rejection, perceived as timid/withdrawn
Dependent - lack of self confidence and extreme reliance on others, sometimes to the point of discomfort with being alone for even a short period
Obsessive Compulsive Disorder - inflexibility about the way in which things must be done
Devotion to productivity to the exclusion of personal pleasure
Relatively common- seen more in men, and oldest children.
Antidepressants
•Buproprion, venlafaxine, SSRIs (fluoxetine)
•May help manage depressive symptoms/episodes
•Typically prescribed with a mood stabilizer to prevent rebound mania.
Bipolar Disorder Non Pharmacological Treatments
Individual psychotherapy
Family therapy
Group therapy
Cognitive therapy
ECT
Acute Mania
Symptoms of acute mania may be a progression in intensification of those experienced in hypomania, or they may be manifested directly. Most individuals experience marked impairment in functioning and require hospitalization.
Acute mania is characterized by euphoria and elation – abnormally elevated mood. May be expansive or irritable. The person appears to be on a continuous high, but mood is always subject to frequent variation.
Cognition and perception become fragmented and often psychotic in acute mania. Accelerated thinking proceeds to racing thoughts, overconnection of ideas, and rapid, abrupt movement from one thought to another. It may be manifested by a continuous flow of accelerated, pressured speech to the point where trying to converse with this individual may be extremely difficult. Attention can be diverted by even the smallest of stimuli. Hallucinations and delusions are common.
Psychomotor activity is excessive. Sexual interest is increased. There is poor impulse control, low frustration tolerance, and the individual who is normally discreet may become socially and sexually uninhibited. Energy seems inexhaustible, and the need for sleep is diminished. They may go for many days without sleep and still not feel tired. Hygiene and grooming may be neglected. Dress may be disorganized, flamboyant, or bizarre, and the use of excessive make-up or jewelry is common.
Symptoms last at least one week.
Alterations in Speech
•Associative looseness (also called loose association): Shift of ideas from one unrelated topic to another
•Neologisms: Made-up words that have meaning only to the person who invents them
•Echolalia: Repeating of words or phrases spoken by someone else
•Clang associations: Choice of words governed by sound (often rhyming)
•Word salad: Group of words put together in a
random fashion
•Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details
•Tangentiality: Inability to get to the point of communication due to the introduction of many new topics
•Perseveration: Persistent repetition of the same word or idea in response to different questions
Treatments
Interpersonal therapy
CBT
Group therapy
Dialectical behavioral therapy: CBT for clients who exhibit self injurious behaviors
Case managers very useful
Pharmacology
antidepressants
Antipsychotics
Mood stabilizers
Anxiolytics
Bipolar Medication Options
For mania
•Lithium carbonate
•Anticonvulsants
•Verapamil
•Antipsychotics
For depressive phase use antidepressants with care (may trigger mania).
Education
- nature of the illness, such as the causes of bipolar disorder, and symptoms of depression and mania
- management of the illness, including appropriate medication management, symptoms of lithium toxicity, and anger management
- support services, including crisis hotlines and support group information.
- case management to f/u with family
- therapy may improve problem solving and interpersonal skills
- precipitating factors of relapse (sleep disturbance, use of alcohol or caffeine) – regulate sleep, meal, and activity
- physical exhaustion and possible death – in a true manic state may not sleep or eat/drink --> medical emergency
Delirious Mania
Delirious mania is a grave form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania.
The mood of the delirious person is very labile. The person may exhibit feelings of despair, quickly converting to unrestrained merriment and ecstasy or becoming irritable or totally indifferent to the environment.
Cognition and perception are characterized by a clouding of consciousness, with accompanying confusion, disorientation, and sometimes stupor. Other common manifestations include religiosity, delusions of grandeur or persecution, and auditory or visual hallucinations. The individual is extremely distractible and incoherent.
Psychomotor activity is frenzied and characterized by agitated, purposeless movements. The safety of these individuals is at stake unless this activity is curtailed. Exhaustion, injury to self or others, and eventually death could occur without intervention.
Alterations in Behavior
•Waxy flexibility: Passive yielding of all movable parts of the body to any effort made at placing them in certain positions
•Posturing: Voluntary assumption of inappropriate or bizarre postures
•Pacing and rocking: Pacing back and forth and rocking the body
•Regression: Retreat to an earlier level of development
•Eye movement abnormalities
•Extreme agitation
•Automated obedience
•Catatonia, stupor
•Anergia: Deficiency of energy
•Anhedonia: Inability to experience pleasure
•Lack of abstract thinking ability
•Alogia – poverty of thought/speech
Interprofessional Care
Depending on the therapeutic goals, psychotherapy with personality disorders may be time-limited interpersonal psychotherapy, or it may involve long-term psychoanalytic therapy. Interpersonal psychotherapy may be particularly appropriate because personality disorders largely reflect problems in interpersonal relationship skills.
Group therapy is especially appropriate for individuals with antisocial personality disorder, who respond more adaptively to support and feedback from peers. In milieu or group therapy, feedback from peers is more effective than in one-to-one interaction with a therapist.
Behavioral strategies offer reinforcement for positive change. Social skills training and assertiveness training teach alternative ways to deal with frustration. Cognitive strategies help the client recognize and correct distorted and irrational thinking patterns. There is also some limited evidence that cognitive therapy is beneficial for clients with schizotypal personality disorder.
Psychopharmacology may be helpful in some instances. Although these drugs have no effect in the direct treatment of the disorder itself, some symptomatic relief can be achieved. Among the cluster A disorders, there has been some limited evidence of the benefits of antipsychotic medication in the treatment of schizotypal personality disorder, but the risk-to-benefit ratio is unclear.
For antisocial personality disorder, pharmacotherapy is generally not recommended unless it is being used to treat a comorbid condition and, among the cluster C group of personality disorders, no randomized trials have been published that support pharmacological treatment for these disorders.
Antipsychotics
First Generation – haloperidol, loxapine, chlorpromazine
-->Classified as low- medium- or high- potency depending on their association with extrapyramidal symptoms (EPSs), level of sedation, and anticholinergic adverse effects.
•MOA: blocks dopamine, acetylcholine, histamine, and norepinephrine receptors in the brain and periphery inhibition of psychotic findings.
•Nursing Care: Encourages sugarless gum, eat/drink 2-3L water per day, eat foods high in fiber to reduce risk of extrapyramidal symptoms.
•Used to decrease positive symptoms such as agitation and psychotic symptoms of schizophrenia and other psychotic disorders
Second Generation – olanzapine, risperidone, quetiapine
•Often chosen as first line treatment for schizophrenia – initial treatments and breakthrough episodes.
•More effective with less adverse effects (EPS, tardive dyskinesia) due to less dopamine blockade.
•Used to relieve both positive and negative symptoms, decrease SI. Can be useful in early treatment to promote sleep and decrease anxiety/agitation.
•Nursing Care: Follow a healthy diet, exercise to prevent weight gain. Monitor for sedation, agitation, dizziness, etc.
•Blood tests needed to monitor for agranulolcytosis
Third Generation – ariprazole, clozapine
•Used to treat both positive and negative symptoms while improving cognitive function.
•Decreased risk of EPS or tardive dyskinesia, lower risk of weight gain and anticholinergic side effects.
Antipsychotic Potential - anticholinergic, nausea, orthostatic hypotension, weight gain, EPS (pseudoparkinsonism, akinesia, akathesia, dystopia, oculgyric crisis)
Nursing Education - do not stop abruptly, avoid sun, report weekly for labs if appropriate, avoid alcohol, check with provider before starting new meds