Bipolar DisordersBipolar Disorders

Diagnostic TerminologyDiagnostic Terminology

Bipolar DisorderBipolar DisorderBipolar IBipolar IBipolar IIBipolar II

Old terminologyOld terminologyManic-DepressiveManic-DepressiveBipolar Affective DisorderBipolar Affective Disorder

Incidence For BipolarIncidence For Bipolar Bipolar- 2.6% to 3.9% of the populationBipolar- 2.6% to 3.9% of the population

Bipolar I equal among sexesBipolar I equal among sexes Bipolar II women may have a higher rateBipolar II women may have a higher rate

1.2 % Bipolar I1.2 % Bipolar I Illness is usually chronic with remissions and Illness is usually chronic with remissions and

exacerbationsexacerbations Suicide rate in clients with Bipolar disorder is 15%Suicide rate in clients with Bipolar disorder is 15% 60% experience chronic interpersonal and occupational 60% experience chronic interpersonal and occupational

difficultiesdifficulties Age of onset: early 20’sAge of onset: early 20’s

90% will have recurrent symptoms90% will have recurrent symptoms 30-40% of Bipolar have chemical dependency 30-40% of Bipolar have chemical dependency 8% of people with chemical dependency are Bipolar8% of people with chemical dependency are Bipolar

Types of Bipolar DisorderTypes of Bipolar Disorder

Bipolar IBipolar I There must be a history of a manic episodeThere must be a history of a manic episode There is a history of Major DepressionThere is a history of Major Depression More severeMore severe

Bipolar IIBipolar II There is a history of a hypomanic episode but There is a history of a hypomanic episode but

NOT ManiaNOT Mania There is a history of Major DepressionThere is a history of Major Depression

Cyclothymic DisorderCyclothymic Disorder Episodes of hypomania and numerous periods Episodes of hypomania and numerous periods

of depressed moodof depressed mood Chronic: Never symptom freeChronic: Never symptom free

Hypomanic EpisodeHypomanic Episode

Bipolar I: usually precedes a manic Bipolar I: usually precedes a manic episodeepisode

Present in Bipolar II and Cyclothymic Present in Bipolar II and Cyclothymic DisorderDisorder

Symptoms of HypomaniaSymptoms of Hypomania

Forcefully Forcefully energeticenergetic and and drivendriven Highly excitable and overzealous Highly excitable and overzealous Full of life Full of life OverbearingOverbearing Engages others in an animated, vivacious Engages others in an animated, vivacious

mannermanner Intense emotion disorganized thoughts Intense emotion disorganized thoughts Energetic Self-Image Energetic Self-Image A A tireless and activetireless and active person person Motivates othersMotivates others Volatile charged upVolatile charged up Likes momentary excitementLikes momentary excitement

HypomaniaHypomania

Symptoms ManiaSymptoms Mania Grandiose mood; euphoric or irritableGrandiose mood; euphoric or irritable Hyperactive; Hyperactive;

too busy to eat or sleep too busy to eat or sleep Sexually inappropriateSexually inappropriate

Flight of ideas, loose associationsFlight of ideas, loose associations Psychotic ThinkingPsychotic Thinking

Delusions of grandeurDelusions of grandeur HallucinationsHallucinations

Very distractible, unable to concentrateVery distractible, unable to concentrate Poor judgment Poor judgment

Excess is commonExcess is common Spending SpreesSpending Sprees Sexual indiscretionsSexual indiscretions Loud clothingLoud clothing Excessive make-upExcessive make-up

Depressive EpisodeDepressive Episode

Symptoms are atypicalSymptoms are atypicalHypersomnia not InsomniaHypersomnia not InsomniaHyperphagia not AnorexiaHyperphagia not AnorexiaCraving for CarbohydratesCraving for CarbohydratesLeaden paralysisLeaden paralysisParanoid thoughts Paranoid thoughts IrritabilityIrritability

Mixed EpisodeMixed Episode

Meets criteria for both Manic and major Meets criteria for both Manic and major depressiondepression

Rapidly alternating moods of sadness, irritability, Rapidly alternating moods of sadness, irritability, and high energyand high energy

Agitation, insomnia, appetite disturbance, Agitation, insomnia, appetite disturbance, psychotic features, Suicidal thinkingpsychotic features, Suicidal thinking

May be induced by antidepressantMay be induced by antidepressant Client is miserable, highly suicidal and may be Client is miserable, highly suicidal and may be

violentviolent

Five Tendencies that Result in Five Tendencies that Result in Altered RelationshipsAltered Relationships

ManipulationManipulation Coercive techniquesCoercive techniques

““you are the only one you are the only one who understands me”who understands me”

Ability to find Ability to find vulnerability in othersvulnerability in others Exploit weaknesses and Exploit weaknesses and

create conflictcreate conflict

Limit testingLimit testing Push limits by Push limits by

constantly wanting constantly wanting more than the rules more than the rules allowallow

Ability to shift Ability to shift responsibilityresponsibility Anger at the nurse Anger at the nurse

when there is no when there is no breakfast after sleeping breakfast after sleeping latelate

Alienation of familyAlienation of family Cyclic nature: 1Cyclic nature: 1stst gives gives

hope then results in hope then results in demoralizes latedemoralizes late

Divorce secondary to Divorce secondary to abusive nature abusive nature

Manipulation and Limit Manipulation and Limit TestingTesting

Push limits by constantly wanting more than Push limits by constantly wanting more than the rules allowthe rules allow

Coercive techniquesCoercive techniques““you are the only one who understands me”you are the only one who understands me”

Results in Splitting (All good vs all bad)Results in Splitting (All good vs all bad)The teamThe team

Defined by the client as “all bad”Defined by the client as “all bad”One staff member is split away from the teamOne staff member is split away from the team

Defined by the client as “all good”Defined by the client as “all good” Gets the staff to advocate for them so that Gets the staff to advocate for them so that changes in behavior do not have to occurchanges in behavior do not have to occur When the staff is unsuccessful in fulfilling theWhen the staff is unsuccessful in fulfilling the clients request/needs they are then defined clients request/needs they are then defined as “all bad” as “all bad”

Working with the Bipolar Working with the Bipolar ClientClient

Matter of Fact toneMatter of Fact tone Minimizes defensive responseMinimizes defensive response Avoids power struggles Avoids power struggles

Clear concise directions and Limit SettingClear concise directions and Limit Setting Used togetherUsed together

Use a command ie STOP, NO then give instructionsUse a command ie STOP, NO then give instructionsNo we are not going outside now; we will go at 10am.No we are not going outside now; we will go at 10am.Stop scratching your arm, come with me and we will Stop scratching your arm, come with me and we will

see if there is a medication you can have to help you see if there is a medication you can have to help you feel more calm.feel more calm.

Give but Limit Choices: I can get you a snack right Give but Limit Choices: I can get you a snack right now or you can wait one hour for lunch.now or you can wait one hour for lunch.

Working with the Bipolar Working with the Bipolar ClientClient

Reinforce appropriate hygiene and Reinforce appropriate hygiene and dressdressSimple matter of fact remindersSimple matter of fact reminders

Nutrition Nutrition Poor nutrition and lack of sleep plague Poor nutrition and lack of sleep plague

these clientthese clientFoods that can be eaten while movingFoods that can be eaten while movingHigh proteinHigh proteinVitamin supplementVitamin supplementWeigh regularlyWeigh regularly

Working with the Bipolar Working with the Bipolar ClientClient

ACTIVITIESACTIVITIESManiaMania

Manage competitive natureManage competitive natureExerciseExercise

DepressionDepressionSLEEPSLEEP

A quiet place to sleepA quiet place to sleepStructure with calming activities prior to bedtimeStructure with calming activities prior to bedtimeDo not allow caffeine around bedtimeDo not allow caffeine around bedtimeAssess amount of sleep the client is gettingAssess amount of sleep the client is getting

Milieu ManagementMilieu Management SafetySafety

It is reassuring to clients that the staff will not let them It is reassuring to clients that the staff will not let them harm themselves or othersharm themselves or others

Consistency among staffConsistency among staff Decreases Client’s ability to Create ConflictDecreases Client’s ability to Create Conflict Agree to use interventions strategies consistently Agree to use interventions strategies consistently as a teamas a team

Reduction of environmental stimuliReduction of environmental stimuli Limited activities with othersLimited activities with others Encourage gross motor activitiesEncourage gross motor activities

De-escalating clientsDe-escalating clients Approach in a calm confident mannerApproach in a calm confident manner May use Haloperidol as a prnMay use Haloperidol as a prn

NeurotransmittersNeurotransmitters

Excess levels of norepinephrine and Excess levels of norepinephrine and dopaminedopamine

A deficiency of serotoninA deficiency of serotonin

A Common Diagnostic A Common Diagnostic MistakeMistake

Diagnosing Major Depressive Diagnosing Major Depressive Disorder when the client is in the Disorder when the client is in the Depressive Aspect of Bipolar Depressive Aspect of Bipolar DisorderDisorder

Giving an antidepressant can push Giving an antidepressant can push the client into Maniathe client into Mania

MedicationsMedications Atypical Antipsychotic: Zyprexa, Geodon, Abilify Atypical Antipsychotic: Zyprexa, Geodon, Abilify

These medications can block dopamine and increase These medications can block dopamine and increase serotoninserotonin

Lithium-Slow onset-2 weeksLithium-Slow onset-2 weeks Unsure of mechanism of actionUnsure of mechanism of action

Anticonvulsants are also Mood StabilizersAnticonvulsants are also Mood Stabilizers Depakote Depakote TegretolTegretol

Topamax, Neurontin, Trileptal, LamictalTopamax, Neurontin, Trileptal, Lamictal

LithiumLithiumNarrow range of therapeutic level 0.6 to Narrow range of therapeutic level 0.6 to

1.2 mEq/L; the optimum maintenance level 1.2 mEq/L; the optimum maintenance level is 0.8 mEq/Lis 0.8 mEq/L

Toxic over 1.5 mEq/LToxic over 1.5 mEq/LNeed to keep NA balancedNeed to keep NA balancedCreatinine clearance to test for kidney Creatinine clearance to test for kidney

functionfunction““Normal side effects”- weight gain, fine Normal side effects”- weight gain, fine

hand tremor, nausea, metal tastehand tremor, nausea, metal taste

Lithium ToxicityLithium Toxicity

Narrow therapeutic range with therapeutic Narrow therapeutic range with therapeutic dose being close to a toxic dose.dose being close to a toxic dose.

Mild to Moderate toxic reactions Mild to Moderate toxic reactions 1.5 to 2 1.5 to 2 mEq/LmEq/L

DiarrheaDiarrhea VomitingVomiting DrowsinessDrowsiness Muscular weaknessMuscular weakness Lack of coordinationLack of coordination Dry mouthDry mouth

Lithium ToxicityLithium ToxicityModerate to severe reactionsModerate to severe reactions blurred blurred

visionvision2 to 3 2 to 3 mEq/LmEq/Lblurred visionblurred vision

All previous symptomsAll previous symptomsAtaxiaAtaxiablurred visionblurred visionGiddinessGiddinessTinnitusTinnitusBlurred visionBlurred visionHigh urinary output (osmotic diuresis)High urinary output (osmotic diuresis)DeleriumDeleriumNystagmusNystagmus

Lithium ToxicityLithium Toxicity

Severe reactions Greater than Severe reactions Greater than 3 3 mEq/LmEq/L

All previous symptomsAll previous symptomsSeizuresSeizuresOrgan failureOrgan failureRenal failureRenal failureComaComaDeathDeath

DepakoteDepakoteTherapeutic Range - 50-100Therapeutic Range - 50-100Dosing: 250 BID Increase to 500 to 3500Dosing: 250 BID Increase to 500 to 3500Side Effects:Side Effects:

Nausea & VomitingNausea & VomitingWeight GainWeight GainHepatic effects/ decreased Platelet countHepatic effects/ decreased Platelet countDrowsinessDrowsiness

TegretolTegretolTegretol Level--4-12Tegretol Level--4-12Side effects—lowered white count, Side effects—lowered white count, Drowsiness, mental fogginessDrowsiness, mental fogginessLots of drug interactionsLots of drug interactionsUsual Dosage 400 mgm to 1.2 GramsUsual Dosage 400 mgm to 1.2 Grams

Other Mood StabilizersOther Mood Stabilizers

Trileptal (oxcarbamazine)-Headache, diarrhea.Trileptal (oxcarbamazine)-Headache, diarrhea. Lamictal (lamotrigine)-Has a very serious side Lamictal (lamotrigine)-Has a very serious side

effect of severe rasheffect of severe rash Neurontin(gabapentin)-Drowsiness and ataxiaNeurontin(gabapentin)-Drowsiness and ataxia Topamax(topiramate)-Memory problems, Wt Topamax(topiramate)-Memory problems, Wt

loss loss

The EndThe End