1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 25: Bipolar Disorders: Management of Mood Lability

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Terms Mania: an abnormally and persistently –Elevated mood: euphoria or elation –Expansive mood: lack of restraints in expression; overvalued self-importance –Irritable mood: easily annoyed and provoked to anger Manic episode: distinct period of mania Mood lability: rapid shifts in mood with little or no change in external events

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Bipolar Disorders Mania or hypomania alternating with depression (refer to Key Diagnostic Characteristic 25.1) –Bipolar I (major depressive, manic, or mixed episodes) –Bipolar II (major depression and hypomania) –Cyclothymic disorder (hypomania and depressive episodes not meeting full criteria for major depressive episode)

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Bipolar Disorders Across the Lifespan Children and adolescents –Depression usually occurring first; marked by intense rage –Symptoms reflective of developmental level of the child Older adults –Greater neurologic abnormalities and cognitive disturbances –Incidence of mania decreased with age

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Epidemiology Lifetime prevalence: 1.0% bipolar I; 1.1.% bipolar II; 2.4% subthreshhold bipolar disorder Symptoms before age 25 years No gender differences in incidence Female patients at greater risk for depression and rapid cycling than male patients Male patients at greater risk for manic episodes Common comorbid conditions: anxiety disorders (most prevalent: panic disorder and social phobia) and substance use)

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology Biologic theories –Chronobiologic theories –Genetic factors –Kindling theory Psychological and social theories –Focus on reducing environmental stress and trauma in genetically vulnerable individuals

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Interdisciplinary Treatment and Recovery Goals of treatment –Minimize and prevent either manic or depressive episodes –Help the patient and family learn about the disorder and manage it throughout a lifetime Priority care issues –Safety

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? An expansive mood is characterized by euphoria.

9. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. An elevated mood is characterized as euphoria. An expansive mood is one involving a lack of restraints in expression and overvalued self-importance.

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Assessment for the Biologic Domain Changes in activity, eating, and sleep patterns Diet and body weight Laboratory testing: thyroid function Changes in sexual practices Pharmacologic assessment –Previous use of antidepressants –Discontinuation of mood stabilizers

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Diagnoses for the Biologic Domain Manic phase: –Disturbed Sleep Pattern –Sleep Deprivation –Imbalanced Nutrition –Hypothermia –Deficient Fluid Volume –Nonadherence Depressive phase: –Disturbed Sleep Pattern –Imbalanced Nutrition –Fatigue; Nausea –Self-Care Deficit –Disturbed Thought Processes –Sexual Dysfunction

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Interventions for the Biologic Domain Education about physical care Mood stabilizers –Lithium (refer to Tables 25.1 to Table 25.3 and Box 25.4) –Divalproex sodium (refer to Box 25.5) –Carbamazepine (refer to Table 25.4) –Lamotrigine (refer to Box 25.6) Antipsychotics (adjunct or monotherapy)

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Interventions for the Biologic Domain (cont’d) Administering and monitoring medication Monitoring and managing side effects Monitoring for drug interactions Promoting adherence Teaching points Other somatic interventions: electroconvulsive therapy

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Assessment for the Psychological Domain Mood Cognition Thought disturbances Stress and coping Risk assessment

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which agent would most commonly be prescribed for a patient with bipolar I disorder? A.Lamotrigine B.Lithium C.Carbamazepine D.Divalproex

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Lithium Although divalproex, carbamazepine, and lamotrigine may be used as mood stabilizers, lithium is the most widely used mood stabilizer.

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Diagnoses for the Psychological Domain Disturbed Sensory Perception Disturbed Thought Processes Defensive Coping Risk for Suicide Risk for Violence Ineffective Coping Nonadherence

18. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Interventions for the Psychological Domain Psychoeducation (refer to Boxes 25.8 and 25.9) Individual cognitive behavioral therapy Individual interpersonal therapy Adjunctive therapies Psychotherapy

19. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Assessment for the Social Domain Cultural views of mental illness Social and occupational changes Any changes resulting from a manic or depressive episode

20. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Diagnoses for the Social Domain Ineffective Role Performance Interrupted Family Processes Impaired Social Interaction Impaired Parenting Compromised Family Coping Delayed Growth and Development (children and adolescents) Caregiver Role Strain

21. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Interventions for the Social Domain Protection from self-harm, as well as harm from other patients Support groups Family interventions –Parenting skills –Counseling sessions –Intensive family therapy Family psychoeducation

22. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Continuum of Care Inpatient management Intensive outpatient programs –Partial hospitalization –Day hospitalization Spectrum of care –Extended and continued follow-up

23. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Protecting the patient from self-harm is crucial during a manic phase.

24. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. During mania, patients usually violate others’ boundaries, and they may miss the cues indicating anger and aggression from others. Thus, protecting the patient from self-harm as well as harm from others is important.

25. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion During remission periods: –Teach stress management –Practice relaxation techniques –Develop a plan for managing emerging symptoms