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Bipolar Disorders

Bipolar Disorders. Diagnostic Terminology. Bipolar Disorder Bipolar I Bipolar II Old terminology Manic-Depressive Bipolar Affective Disorder. Incidence For Bipolar. Bipolar- 2.6% to 3.9% of the population Bipolar I equal among sexes Bipolar II women may have a higher rate

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Bipolar Disorders

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  1. Bipolar Disorders

  2. Diagnostic Terminology • Bipolar Disorder • Bipolar I • Bipolar II • Old terminology • Manic-Depressive • Bipolar Affective Disorder

  3. Incidence For Bipolar • Bipolar- 2.6% to 3.9% of the population • Bipolar I equal among sexes • Bipolar II women may have a higher rate • 1.2 % Bipolar I • Illness is usually chronic with remissions and exacerbations • Suicide rate in clients with Bipolar disorder is 15% • 60% experience chronic interpersonal and occupational difficulties • Age of onset: early 20’s • 90% will have recurrent symptoms • 30-40% of Bipolar have chemical dependency • 8% of people with chemical dependency are Bipolar

  4. Types of Bipolar Disorder • Bipolar I • There must be a history of a manic episode • There is a history of Major Depression • More severe • Bipolar II • There is a history of a hypomanic episode but NOT Mania • There is a history of Major Depression • Cyclothymic Disorder • Episodes of hypomania and numerous periods of depressed mood • Chronic: Never symptom free

  5. Hypomanic Episode • Bipolar I: usually precedes a manic episode • Present in Bipolar II and Cyclothymic Disorder

  6. Symptoms of Hypomania • Forcefully energetic and driven • Highly excitable and overzealous • Full of life • Overbearing • Engages others in an animated, vivacious manner • Intense emotion disorganized thoughts • Energetic Self-Image • A tireless and active person • Motivates others • Volatile charged up • Likes momentary excitement

  7. Hypomania

  8. Symptoms Mania • Grandiose mood; euphoric or irritable • Hyperactive; • too busy to eat or sleep • Sexually inappropriate • Flight of ideas, loose associations • Psychotic Thinking • Delusions of grandeur • Hallucinations • Very distractible, unable to concentrate • Poor judgment • Excess is common • Spending Sprees • Sexual indiscretions • Loud clothing • Excessive make-up

  9. Depressive Episode • Symptoms are atypical • Hypersomnia not Insomnia • Hyperphagia not Anorexia • Craving for Carbohydrates • Leaden paralysis • Paranoid thoughts • Irritability

  10. Mixed Episode • Meets criteria for both Manic and major depression • Rapidly alternating moods of sadness, irritability, and high energy • Agitation, insomnia, appetite disturbance, psychotic features, Suicidal thinking • May be induced by antidepressant • Client is miserable, highly suicidal and may be violent

  11. Manipulation Coercive techniques “you are the only one who understands me” Ability to find vulnerability in others Exploit weaknesses and create conflict Limit testing Push limits by constantly wanting more than the rules allow Ability to shift responsibility Anger at the nurse when there is no breakfast after sleeping late Alienation of family Cyclic nature: 1st gives hope then results in demoralizes late Divorce secondary to abusive nature Five Tendencies that Result in Altered Relationships

  12. Manipulation and Limit Testing • Push limits by constantly wanting more than the rules allow • Coercive techniques • “you are the only one who understands me” • Results in Splitting (All good vs all bad) • The team • Defined by the client as “all bad” • One staff member is split away from the team • Defined by the client as “all good” • Gets the staff to advocate for them so that changes in behavior do not have to occur • When the staff is unsuccessful in fulfilling the clients request/needs they are then defined as “all bad”

  13. Working with the Bipolar Client • Matter of Fact tone • Minimizes defensive response • Avoids power struggles • Clear concise directions and Limit Setting • Used together • Use a command ie STOP, NO then give instructions • No 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.

  14. Working with the Bipolar Client • Reinforce appropriate hygiene and dress • Simple matter of fact reminders • Nutrition • Poor nutrition and lack of sleep plague these client • Foods that can be eaten while moving • High protein • Vitamin supplement • Weigh regularly

  15. Working with the Bipolar Client • ACTIVITIES • Mania • Manage competitive nature • Exercise • Depression • SLEEP • A quiet place to sleep • Structure with calming activities prior to bedtime • Do not allow caffeine around bedtime • Assess amount of sleep the client is getting

  16. Milieu Management • Safety • It is reassuring to clients that the staff will not let them harm themselves or others • Consistency among staff • Decreases Client’s ability to Create Conflict • Agree to use interventions strategies consistently as a team • Reduction of environmental stimuli • Limited activities with others • Encourage gross motor activities • De-escalating clients • Approach in a calm confident manner • May use Haloperidol as a prn

  17. Neurotransmitters • Excess levels of norepinephrine and dopamine • A deficiency of serotonin

  18. A Common Diagnostic Mistake • Diagnosing Major Depressive Disorder when the client is in the Depressive Aspect of Bipolar Disorder • Giving an antidepressant can push the client into Mania

  19. Medications • Atypical Antipsychotic: Zyprexa, Geodon, Abilify • These medications can block dopamine and increase serotonin • Lithium-Slow onset-2 weeks • Unsure of mechanism of action • Anticonvulsants are also Mood Stabilizers • Depakote • Tegretol • Topamax, Neurontin, Trileptal, Lamictal

  20. Lithium • Narrow range of therapeutic level 0.6 to 1.2 mEq/L; the optimum maintenance level is 0.8 mEq/L • Toxic over 1.5 mEq/L • Need to keep NA balanced • Creatinine clearance to test for kidney function • “Normal side effects”- weight gain, fine hand tremor, nausea, metal taste

  21. Lithium Toxicity • Narrow therapeutic range with therapeutic dose being close to a toxic dose. • Mild to Moderate toxic reactions • 1.5 to 2 mEq/L • Diarrhea • Vomiting • Drowsiness • Muscular weakness • Lack of coordination • Dry mouth

  22. Lithium Toxicity • Moderate to severe reactions blurred vision • 2 to 3 mEq/Lblurred vision • All previous symptoms • Ataxia • blurred vision • Giddiness • Tinnitus • Blurred vision • High urinary output (osmotic diuresis) • Delerium • Nystagmus

  23. Lithium Toxicity • Severe reactions Greater than • 3 mEq/L • All previous symptoms • Seizures • Organ failure • Renal failure • Coma • Death

  24. Depakote • Therapeutic Range - 50-100 • Dosing: 250 BID Increase to 500 to 3500 • Side Effects: • Nausea & Vomiting • Weight Gain • Hepatic effects/ decreased Platelet count • Drowsiness

  25. Tegretol • Tegretol Level--4-12 • Side effects—lowered white count, • Drowsiness, mental fogginess • Lots of drug interactions • Usual Dosage 400 mgm to 1.2 Grams

  26. Other Mood Stabilizers • Trileptal (oxcarbamazine)-Headache, diarrhea. • Lamictal (lamotrigine)-Has a very serious side effect of severe rash • Neurontin(gabapentin)-Drowsiness and ataxia • Topamax(topiramate)-Memory problems, Wt loss

  27. The End

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