Bipolar Disorders

Objectives: Recognize the DSM-IV criteria Describe symptoms of bipolar Etiology theories Psychotherapeutic management Pschychopharmacology

DSM-IV-TR

Cyclothymic d/o Hypomanic episode Manic episodes Bipolar I, mixed Bipolar II (Keltner, pg 371)

Medical Conditions that cause Mania

Anoxia Hyperthyroidism Hemodialysis Lyme disease Stroke Brain tumor MS Medications

Useful NANDA Diagnoses

Anxiety Impaired verbal communication Risk for injury Self-care deficit Disturbed sleep pattern Imbalanced nutrition Violence, risk for self-directed/other-directed

Manic Episode

Elevated mood for at least one week Mood disturbance causing social, work, or IP problems Three of the following:

Inflated self-esteem grandiosity Decreased need for sleep Very talkative Flight of ideas/racing thoughts Distractible Increased goal-directed activity/agitation Excessive involvement in pleasurable activities

Etiology

Psychodynamic theories Neurotransmitter and structural hypotheses Genetic consideration

* Co-Morbidity issues

Psychotherapeutic Management

Matter-of-fact tone Clear, firm, concise directions Limit setting Reinforcement of reality Respond to legitimate complains Redirect energy into healthier activities Consistent approach and expectations Be neutral:

Avoid power struggles Do not join in joking

Milieu Management

Safety Staff consistency Reduced environmental stimuli Provide de-escalation measures Reinforce appropriate hygiene/dress Monitor nutrition (finger foods, high-protein, high calorie
snacks, weigh regularly)

Monitor sleep

(quiet environment, reduce caffeine intake, warm milk, quiet activities at HS, assess sleep/rest pattern)

Education

Illness Signs of relapse Medication Coping with symptoms Providing support

Antimanic Medications
Bipolar Disorder Dysfunction: Na, K ATPase pump Lithium substitutes for Na (blocks norepinephrine and serotonin reuptake)

Lithium Pharmacokinetics

Absorption: GI track Excretion: Kidneys Plasma half-life: 24 hrs Narrow therapeutic index:

0.6-1.2 mEq/l Li Side effects (nausea, dry mouth, diarrhea, thirst, weight gain, mild hand tremor, bloating, insomnia) Toxicity(vomiting, severe tremor, sedation, muscle weakness, vertigo) Late signs (ataxia, tinnitus, blurred vision, increased output of diluted urine, coma)

Patient Teaching

Take Li with meals Drink 10-12 glasses H2O daily Elevate feet Maintain consistent salt intake Take more salt if diaphoretic Avoid conception Dont drive until stabilized Importance of blood work for Li levels

Other Antimanic Drugs

Valproates:Rapid action (Depakene, Depakote), blood levels Carbemazepine:Rapid action, inhibits kindling (Tegretol), blood levels Olanzapine: Mood stabilzer (Zyprexa) Other agents: topamax, clonopin, ativan, neurontin, clozaril

Relationships

Diuretics: increased Li retention NSAIDS: increased Li retention Renal disease: increased half-life (decrease dose) Increased dietary Na:decreases Li levels Decreased dietary Na: increases Li levels Decreased Na via sweating, diarrhea: increased Li levels