Bipolar Disorder

MRI/PET scans show structural and functional changes in prefrontal cortex, and medial temporal lobe.

Early stages of the disease show changes to prefrontal cortical area, where repeated stages of mania show changes in lateral ventricle area.Later on in progression of disease changes to anterior limbic regions. Think memory, emotions, motivation and fear.

Neurotransmitters involved: dopamine, norepinephrine, serotonin

Risk factors

Blood relatives with bipolar

Stress, stressful family life, excess stress daily.

Upper socioeconomic class

Genetics: diacylglycerol kinase eta and CRY2 gene commonly associated with bipolar.

DSM 5

To be diagnosed with bipolar a person must have experienced at least one episode of mania or hypomania.

Mania

To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day.

With 3 or more of the following present:
Inflated self-esteem or grandiosity
Decreased need for sleep
Racing thoughts
Distracted easily
Increase in goal-directed activity or psychomotor agitation
Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees

Speech and thought process

Clang Association: stringing together of words/rhyming without regard to meaning. ex: here we go, go go go no go, goat boat cut your throat tie.

Grandiosity: inflated self regard

Flight of ideas: Continuous flow of accelerated speech with abrupt changes from topic to topic.

Often loud, profane, sexual, inappropriate.

Monitor weight, blood pressure, mood. Changes need to be reported to Dr. Based on severity, changes to medications may be needed. Monitor depression and suicidal thoughts and report.
HTN can be possible side effects as well as arrhythmia's, ECG may be done to monitor heart health.

Lithium levels

Monitor kidneys and thyroid function.

Lithium Carbonate

TX for Bipolar I with recurrent manic and depressive episodes.

Effectively reduces: Elation, grandiosity, flight of ideas, irritability, anxiety, insomnia, psychomotor agitation, paranoia, hypersexuality etc.

Takes about 7-14 days to reach therapeutic levels 0.8-1.4, maintenance levels 0.4-1.3. Never to go above 1.5

Side effects: tremors, polyuria, thirst, nausea and weight gain.

Toxicity.
Early signs: Fine hand tremor, polyuria, mild thirst and nausea.

Advanced and severe Toxicity: Coarse tremors, persistent GI upset, AMS, muscle hyper irritability, sedation. Ataxia, giddiness, blurred vision, clonic movements, large dilute urine outputs. Seizures, severe hypotension. DEATH

Teaching: Monitor personality /behavioral changes Notify physician if these changes become problematic. Report tremors, ams, ataxia etc immediately. Drink lots of fluids, take as directed, do not chew.

Anticonvulsants

Valproate (Depakote), Carbamazepine (Tegretol), Lamotrigine (Lamictal)

More effective when no family HX.
Superior for rapid cycling
diminishing impulsive and aggressive behavior
beneficial in controlling mania and depression

Valproate: tx lithium nonresponders who are in acute mania, dysphoric mania.

Action: Increase levels of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the CNS

S/E agitation, dizziness, headache, insomnia, sedation, confusion, depression, rash, alopecia, tremors, ataxia nvd.

Teaching: monitor mood changes and thoughts of suicide and notify doctor. May cause daytime sleepiness, be careful driving.

Lamotrigine

Action: stabilizes neuronal membranes by inhibiting sodium transport

S/E: behavior changes, depression, drowsiness, insomnia, tremor, ataxia, blurred vision, photosensitivity.

Teaching: Do not take with alcohol, don't stop taking without speaking to Dr. first, may cause day time sleepiness, be careful operating vehicles.

Carbamazepine

Action: Decreases synaptic transmission in the CNS by affecting sodium channels in neurons. Decreased mania

Ataxia, weight gain, blurred vision, HTN, drowsiness, Be alert for signs of agranulocytosis

Teaching: Be alert for signs of agranulocytosis (fever, sore throat) be alert for suicidal thoughts report immediately, monitor bp, may cause daytime drowsiness be careful operating vehicles.

Antianxiety

Clonazepam (Klonopin)
Lorazepam (Ativan)
Effective in managing psychomotor agitation seen in mania. (not for pt with hx substance abuse)

Antipsychotics

SGA- Olanzapine (Zyprexa) and Risperidone (Risperdal) help with mood stabilization/maintenence

Adjunct therapy to be used with lithium/valproate

Risk for violence to self or others as evidence by agitated behaviors, delusion thinking and verbal threats to others. Patient will be safe and free from injury this shift as well as verbalize control of feelings.

Frequently assess patients behavior for signs of increased agitation

Early detection helps prevent worsening symptoms which increases possibility of harm to self or others by giving seclusion or medications needed to calm patient.

Be firm, calm, and consistent

Provides structure and control when a patient is out of control. If the nurse tries to match the patient by raising voice or yelling, that escalates the problem not decrease it. Consistency provides limits and expectations and decreases chance of manipulation of staff.

decrease stimuli

Providing a calming environment helps decrease escalation of anxiety and manic symptoms.

Self care deficit as evidence by manic excitment, and inability to concentrate on one thing at a time. Patient will shower and wear appropriate clothing this shift.

Provide appropriate clothing options

Limiting options and providing only those appropriate clothes give patient ability to choose what they want, while staying appropriate, also makes the choice easier for them when they aren't thinking clearly and are easily distracted.

Give step by step instructions for hygiene and dressing

Patients who are distracted and have poor concentration, are countered by simple and firm instructions. Ex. Here is your toothbrush, add toothpaste. Here is soap, put on sponge, scrub body, rinse.

Set schedule for patient

Setting a schedule provides structure which provides the patient with expectations of what and how things will happen in the day to reduce anxiety and hopefully provide peaceful transitions between tasks.

Impaired social interactions as evidence by dysfunctional interaction with peers, including manipulation and antagonizing others. Patient will sit through a short small group meeting free from disruptive outbursts this shift.

Monitor patients mania for signs of escalation in agitation/hostility and treat accordingly.

If patient is escalating they may require medications to help ease symptoms and calm them. Or may need to move to a quieter dim lit area to reduce stimuli and help patient to self soothe.

Provide activities that require short attention spans

Walking, painting, coloring etc.. all help patient to focus on something else and release tension in a constructive manner.

Limit setting

Provide limits to what the patient can do, this provides structure and expectations for the patient. If they start to become agitated around others, move them to a quieter place until they calm and can return to group.

Symptoms of hypomania that alternate with mild to moderate depression at least 2 years.

Children s/s: irritability and sleep disturbance

Adults: irritable hypomanic episodes

Rapid cycling: at least 4 mood episodes in a year. Can occur in a 24 hour period or a month.

Severe symptoms: poorer functioning, high recurrence rate, resistant to conventional treatment.