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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 - PowerPoint PPT Presentation
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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