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Bipolar Disorders. Diagnostic Terminology Bipolar Disorder Bipolar Disorder Bipolar I Bipolar I Bipolar II Bipolar II Old terminology Old terminology

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  • Bipolar Disorders

  • Diagnostic TerminologyBipolar DisorderBipolar IBipolar II

    Old terminologyManic-DepressiveBipolar Affective Disorder

  • Incidence For BipolarBipolar- 2.6% to 3.9% of the populationBipolar I equal among sexesBipolar II women may have a higher rate1.2 % Bipolar IIllness is usually chronic with remissions and exacerbationsSuicide rate in clients with Bipolar disorder is 15%60% experience chronic interpersonal and occupational difficultiesAge of onset: early 20s90% will have recurrent symptoms30-40% of Bipolar have chemical dependency 8% of people with chemical dependency are Bipolar

  • Types of Bipolar DisorderBipolar IThere must be a history of a manic episodeThere is a history of Major DepressionMore severeBipolar IIThere is a history of a hypomanic episode but NOT ManiaThere is a history of Major DepressionCyclothymic DisorderEpisodes of hypomania and numerous periods of depressed moodChronic: Never symptom free

  • Hypomanic EpisodeBipolar I: usually precedes a manic episodePresent in Bipolar II and Cyclothymic Disorder

  • Symptoms of HypomaniaForcefully energetic and drivenHighly excitable and overzealous Full of life OverbearingEngages others in an animated, vivacious mannerIntense emotion disorganized thoughts Energetic Self-Image A tireless and active person Motivates othersVolatile charged up Likes momentary excitement

  • Hypomania

  • Symptoms ManiaGrandiose mood; euphoric or irritableHyperactive; too busy to eat or sleep Sexually inappropriateFlight of ideas, loose associationsPsychotic ThinkingDelusions of grandeurHallucinationsVery distractible, unable to concentratePoor judgment Excess is commonSpending SpreesSexual indiscretionsLoud clothingExcessive make-up

  • Depressive EpisodeSymptoms are atypicalHypersomnia not InsomniaHyperphagia not AnorexiaCraving for CarbohydratesLeaden paralysisParanoid thoughts Irritability

  • Mixed EpisodeMeets criteria for both Manic and major depressionRapidly alternating moods of sadness, irritability, and high energyAgitation, insomnia, appetite disturbance, psychotic features, Suicidal thinkingMay be induced by antidepressantClient is miserable, highly suicidal and may be violent

  • Five Tendencies that Result in Altered RelationshipsManipulationCoercive techniquesyou are the only one who understands me

    Ability to find vulnerability in othersExploit weaknesses and create conflict

    Limit testingPush limits by constantly wanting more than the rules allow

    Ability to shift responsibilityAnger at the nurse when there is no breakfast after sleeping late

    Alienation of familyCyclic nature: 1st gives hope then results in demoralizes lateDivorce secondary to abusive nature

  • Manipulation and Limit TestingPush limits by constantly wanting more than the rules allowCoercive techniquesyou are the only one who understands meResults in Splitting (All good vs all bad)The teamDefined by the client as all badOne staff member is split away from the teamDefined by the client as all goodGets the staff to advocate for them so that changes in behavior do not have to occurWhen the staff is unsuccessful in fulfilling the clients request/needs they are then defined as all bad

  • Working with the Bipolar ClientMatter of Fact toneMinimizes defensive responseAvoids power struggles Clear concise directions and Limit SettingUsed togetherUse a command ie STOP, NO then give instructionsNo we are not going outside now; we will go at 10am.Stop scratching your arm, come with me and we will see if there is a medication you can have to help you feel more calm.Give but Limit Choices: I can get you a snack right now or you can wait one hour for lunch.

  • Working with the Bipolar ClientReinforce appropriate hygiene and dressSimple matter of fact remindersNutrition Poor nutrition and lack of sleep plague these clientFoods that can be eaten while movingHigh proteinVitamin supplementWeigh regularly

  • Working with the Bipolar Client

    ACTIVITIESManiaManage competitive natureExerciseDepressionSLEEPA quiet place to sleepStructure with calming activities prior to bedtimeDo not allow caffeine around bedtimeAssess amount of sleep the client is getting

  • Milieu ManagementSafetyIt is reassuring to clients that the staff will not let them harm themselves or othersConsistency among staffDecreases Clients ability to Create ConflictAgree to use interventions strategies consistently as a teamReduction of environmental stimuliLimited activities with othersEncourage gross motor activitiesDe-escalating clientsApproach in a calm confident mannerMay use Haloperidol as a prn

  • NeurotransmittersExcess levels of norepinephrine and dopamineA deficiency of serotonin

  • A Common Diagnostic MistakeDiagnosing Major Depressive Disorder when the client is in the Depressive Aspect of Bipolar DisorderGiving an antidepressant can push the client into Mania

  • MedicationsAtypical Antipsychotic: Zyprexa, Geodon, Abilify These medications can block dopamine and increase serotoninLithium-Slow onset-2 weeksUnsure of mechanism of actionAnticonvulsants are also Mood StabilizersDepakote TegretolTopamax, Neurontin, Trileptal, Lamictal

  • LithiumNarrow range of therapeutic level 0.6 to 1.2 mEq/L; the optimum maintenance level is 0.8 mEq/LToxic over 1.5 mEq/LNeed to keep NA balancedCreatinine clearance to test for kidney functionNormal side effects- weight gain, fine hand tremor, nausea, metal taste

  • Lithium ToxicityNarrow therapeutic range with therapeutic dose being close to a toxic dose.Mild to Moderate toxic reactions 1.5 to 2 mEq/LDiarrheaVomitingDrowsinessMuscular weaknessLack of coordinationDry mouth

  • Lithium ToxicityModerate to severe reactions blurred vision2 to 3 mEq/Lblurred visionAll previous symptomsAtaxiablurred visionGiddinessTinnitusBlurred visionHigh urinary output (osmotic diuresis)DeleriumNystagmus

  • Lithium ToxicitySevere reactions Greater than 3 mEq/LAll previous symptomsSeizuresOrgan failureRenal failureComaDeath

  • DepakoteTherapeutic Range - 50-100Dosing: 250 BID Increase to 500 to 3500Side Effects:Nausea & VomitingWeight GainHepatic effects/ decreased Platelet countDrowsiness

  • TegretolTegretol Level--4-12Side effectslowered white count, Drowsiness, mental fogginessLots of drug interactionsUsual Dosage 400 mgm to 1.2 Grams

  • Other Mood StabilizersTrileptal (oxcarbamazine)-Headache, diarrhea.Lamictal (lamotrigine)-Has a very serious side effect of severe rashNeurontin(gabapentin)-Drowsiness and ataxiaTopamax(topiramate)-Memory problems, Wt loss

  • The End