Mental health & crisis management 7 APRIL qui z

Jack Fowler

Week11-BipolarDisorders-Part2.pptx

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Bipolar Disorders

Week 11 - Part 2

Clinical Picture

Bipolar disorder is marked by shifts in mood, energy and ability to function

Course is variable and symptoms can range in severity and duration:

Bipolar I disorder

Bipolar II disorder

Cyclothymic disorder

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Bipolar I disorder

Marked by severe shifts in mood, energy, and inability to function

Periods of normal functioning may alternate with periods of illness (highs, lows, or a combination of both)

Experience at least one manic episode

Manic episodes usually alternate with depression or a mixed state of anxiety and depression

Mania

is a period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy

these periods last at least 1 week for most of the day, every day

symptoms of mania are so severe that this state is a psychiatric emergency

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Bipolar II disorder

Experience at least one hypomanic episode and at least one major depressive episode

Hypomania

Like mania, hypomania is accompanied by excessive activity and energy for at least 4 days and involves at least three of the behaviours listed under Criterion B in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Unlike mania, psychosis is never present with hypomania

Psychotic symptoms may, however, accompany the depressive side of the disorder

Hospitalization is rare

However, the depressive symptoms can be quite profound and may put those who suffer from it at particular risk for suicide

Underdiagnosed and is often mistaken for major depression or personality disorders, when it actually may be the most common form of bipolar disorder

A source of significant morbidity and mortality, particularly due to the occurrence of severe depression

Anyone with major depression should be assessed for symptoms of hypomania because these symptoms are frequently associated with a progression to bipolar disorder

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Cyclothymic Disorder

Symptoms of hypomania alternating with symptoms of mild to moderate depression for at least 2 years in adults and 1 year in children

Hypomanic and depressive symptoms do not meet the criteria for either bipolar II or major depression, yet the symptoms are disturbing enough to cause social and occupational impairment

As part of the spectrum of bipolar disorders, cyclothymic disorder may be difficult to distinguish from bipolar II disorder

Individuals with cyclothymic disorder tend to have irritable hypomanic episodes

Some people experience rapid cycling and may have at least four changes in mood episodes in a 12-month period

The cycling can also occur within the course of a month or even a 24-hour period

Rapid cycling is associated with more severe symptoms, such as poorer global functioning, high recurrence risk, and resistance to conventional somatic treatments

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Other Bipolar Disorders

Several other bipolar and related disorders are included in the DSM-5. They include:

Substance/Medication-Induced Bipolar and Related Disorder

Bipolar and Related Disorder Due to Another Medical Condition

Other Specified Bipolar and Related Disorder

Unspecified Bipolar and Related Disorder

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Epidemiology

Often misdiagnosed (confused with unipolar depression)

Lifetime risk is 4%

Age of onset of bipolar I is 18 years, and for bipolar II, 20 years

Bipolar I—more common in males

Bipolar II—more common in females

Cyclothymia—usually begins in adolescence or early adulthood

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Etiology

Biological factors

Genetic (strong heritability)

Neurobiological

Neuroendocrine/Hormonal

Psychological factors

Environmental factors

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Biological factors - Genetic

Bipolar illnesses tend to run in families, and the lifetime risk for individuals with an affected parent is 15% to 30% greater

Recent research suggests that there may be an overlap between rare genetic variations linked to bipolar disorder and those implicated in schizophrenia and autism

Some evidence suggests that bipolar disorders are more prevalent in adults who had high intelligence quotients (IQs), and who were particularly verbal, as children

People with bipolar disorders appear to achieve higher levels of education and higher occupational status than individuals with unipolar depression

The proportion of patients with bipolar disorders among creative writers, artists, highly educated men and women, and professionals is higher than in the general population

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Biological factors - Neurotransmitters

Neurotransmitters (norepinephrine, dopamine, and serotonin) have been studied since the 1960s as causal factors in mania and depression

One simple explanation is that having too few of these chemical messengers will result in depression and having an oversupply will cause mania

Proportions of neurotransmitters in relation to one another may be more important

Receptor site insensitivity could also be at the root of the problem—even if there is enough of a certain neurotransmitter, it is not going where it needs to go

Mood disorders are most likely a result of interactions among various chemicals, including neurotransmitters and hormones

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Biological factors – Brain Structure and Function

Structural neuroimaging techniques (e.g., computed tomography [CT] and magnetic resonance imaging [MRI]) provide still pictures of the scalp, skull, and brain

Structural imaging is useful in viewing bones, tissues, blood vessels, tumours, infection, damage, or bleeding

Functional neuroimaging techniques (e.g., positron emission tomography [PET], functional MRI [fMRI], and magnetoencephalography [MEG]) provide measures related to brain activity

With bipolar disorder, functional imaging techniques reveal dysfunction in the prefrontal cortical region, the region associated with executive decision making, personality expression, and social behaviour

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Biological factors – Brain Structure and Function

Dysfunction is also evident in the hippocampus, which is primarily associated with memory, and the amygdala, which is associated with memory, decision making, and emotion

Dysregulation in these areas results in the characteristic emotional lability, heightened reward sensitivity, and emotional dysregulation of bipolar disorder

These abnormalities may be due to grey matter loss in these areas

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Biological factors – Neuroendocrine

The hypothalamic–pituitary–thyroid–adrenal (HPTA) axis has been the object of significant research in bipolar disorder

Hypothyroidism is one of the most common physical abnormalities associated with bipolar disorder

In both manic and depressive states, peripheral inflammation is increased –the inflammation tends to decrease between episode

The role of estrogen in bipolar disorder is also under review - childbirth is known to be associated with the onset of mood and anxiety disorders

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Biological factors – Neuroendocrine

Estrogen studies have shown that women with postpartum psychosis have very low levels of estrogen and improve after estrogen replacement therapy

Selective estrogen receptor modulators (e.g., tamoxifen) have also been shown to produce antimanic effects. Further research in this area is required

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Environmental factors

Bipolar disorder is a worldwide problem that generally affects all races and ethnic groups equally, but some evidence suggests that bipolar disorders may be more prevalent in upper socioeconomic classes - the exact reason for this finding is unclear

The educational levels of individuals with unipolar depressive disorders, on the other hand, appear to be no different from those of individuals with no symptoms of depression within the same socioeconomic class

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Environmental factors

Stressful family life and adverse life events may result in a more severe course of illness in these individuals

Stress is also a common trigger for mania and depression in adults

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Psychological Factors

With the advent of improved neuroimaging techniques and treatment advances, psychological theories are largely dismissed

Mania was once thought to be a defence against underlying anxiety and depression

Mania was also thought to help individuals tolerate loss or tragedy, such as the death of a loved one

Psychodynamic theorists believed that a faulty ego uses mania when it is overwhelmed by pleasurable impulses such as sex or feared impulses such as aggression

An overactive and critical superego being replaced with the euphoria of mania has also been suggested as the cause

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Application to the nursing process

Assessment

Mood

Behaviour

Thought processes and speech patterns

Flight of ideas

Clang associations

Grandiosity

Cognitive functioning

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Self-Assessment

Manic patient

Can be manipulative at times

Demanding

Splitting

Staff member actions

Frequent staff meetings to deal with patient behaviour and staff response

Set limits consistently

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Assessment Guidelines Bipolar Disorder

Danger to self or others

Need for protection from uninhibited behaviours

Need for hospitalization

Medical status

Coexisting medical conditions

Family’s understanding

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Diagnosis

Risk for injury

Risk for violence

Other-directed

Self-directed

Ineffective coping

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Outcomes Identification

Acute phase

Prevent injury

Continuation phase

Relapse prevention

Maintenance phase

Limit severity and duration of future episodes

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Planning

Acute phase

Medical stabilization

Maintaining safety

Self-care needs

Continuation phase

Maintain medication adherence

Psychoeducational teaching

Referrals

Maintenance phase

Prevent relapse

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Implementation

Acute phase

Depressive episodes

Manic episodes

Continuation phase

Prevent relapse with follow-up care

Maintenance phase

Prevent recurrence

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Pharmacological Interventions

Lithium carbonate

Indications

Therapeutic and toxic levels

Therapeutic blood level: 0.6 to 1.2 mEq/L

Toxic blood level: 1.5 mEq/L and above

Maintenance therapy

Contraindications

Adverse effects and toxicity (see Table 14.4 in text)

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Drugs Used for the Treatment of Seizures

Divalproex sodium (Epival)

Carbamazepine (Tegretol)

Lamotrigine (Lamictal)

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Drugs Used for the Treatment of Anxiety and Psychosis

Clonazepam (Rivotril)

Lorazepam (Ativan)

Atypical antipsychotics

Olanzapine (Zyprexa)

Risperidone (Risperdal)

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Other Treatments

Electroconvulsive therapy (ECT)

Milieu management and teamwork

Support groups

Health teaching and health promotion

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Advanced-Practice Interventions

Psychotherapy

Cognitive-behavioural therapy (CBT)

Interpersonal and social rhythm therapy

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Evaluation

Evaluate outcome criteria

Reassess care plan

Revise care plan if indicated

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.