Mood disorder- Bipolar disorder

Question 1

What is a Bipolar disorder?

Answer 1

affective disorder; Characterized by dramatic changes or extreme of mood (includes depressive disorder & Bipolar disorder)
Swing between mania and depression

Question 2

What are the 3 classes of Bipolar disorder?

Answer 2

Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder

Question 3

Describe Bipolar I disorder.

Answer 3

Severe shift in mood, energy between Major depressive and Manic episodes
Have experienced at least one manic episode
Initially euphoric, energized, don’t sleep or aet, take risks, poor insight
May proceed to psychosis, irritation, agitation, exhaustion and depression

Question 4

What are the diagnostic criteria for Bipolar I disorder, DSM-5?

Answer 4

Manic episode
1. Abnormally persistent elevated mood (irritability), goal-directed activity or energy lasting a minimum of 1 week, persistent most of the day
2. Must exhibit at least 3 symptoms (4 if only irritable)
Grandiose, Decrease need sleep, Talkative, Flight of ideas, Distractibility, Increase goal directed activity or psychomotor agitation, Activities with painful consequences
3. Severe impairment in social or work function or need for hospitalization for safety or psychotic features
4. Not caused by substances or medical condition

Question 5

Describe Bipolar II disorder.

Answer 5

Experience at least one hypomanic episode with a major depressive episode
Hypomania is a lower level, less dramatic mania
Still causes significant issues in functioning

Question 6

Describe a hypomania episode in a Bipolar II patient.

Answer 6

Excessive energy & activity for at least 4 days
Involves at least 3 behaviours:
Grandiosity, Decrease need for sleep, Talkative, Flight of ideas, Distractibility, Increase goal directed activity or psychomotor agitation, Activities with painful consequences

Psychosis is never present*

Question 7

Describe Cyclothymic disorder.

Answer 7

Alternates between hypomania and mild/moderate depression
over 2 years adult: irritable, hypomania
over 1 year kids: irritable, sleep disturbance
Rapid cycling: >4 mood changes over 12 months, or 1 mos, or 1 day: More difficult to treat

Question 8

What are other Bipolar disorders?

Answer 8

Substance/Medication - Induced Bipolar & Related Disorder
Bipolar & Related Disorder due to another medical condition
Other Specific Bipolar and Related Disorder
Unspecific Bipolar and Related Disorder

Question 9

What is the epidemiology of Bipolar disorder?

Answer 9

Lifetime risk is 4%
Age of onset of Bipolar I is 18 years, and Bipolar II is 20 years
Men increase legal probs, violence
Women increase abuse alcohol, suicide, thyroid: Severe post partum < 2 wks = 4x higher
d/t hormone, sleep deprive?

Question 10

What is the epidemiology of Cyclothymia disorder?

Answer 10

Usually begins in adolescence or early adulthood
15 - 50% risk BP I or II
Genetic risk if family has BP

Question 11

What are the comorbidity for Bipolar I?

Answer 11

75% have anxiety disorder
1/2 have a substance use disorder
Difficult to differentiate from other disorder (ADHD, impulse, conduct disorder)
Higher than normal rate or serious medical condition (migraines,metabolic syndrome)

Question 12

What are the comorbidity for Bipolar II?

Answer 12

75% have anxiety disorder (d/t depressive side)
37% have substance use disorder (hypomanic symptoms)
Eating disorder 14%

Question 13

What are the comorbidity with Cyclothymic disorder?

Answer 13

Substance use disorder rt self med
Sleep disorder
ADHD (children) more common

Question 14

What is the etiology for environmental and psychological factors?

Answer 14

Environmental:
Worldwide, all ethnic groups
Slightly more: high SES, educated
Children low SES, stress and adversity

Psychological:
psychological theories are largely dismissed

Question 15

What are the etiology for Biological factors?

Answer 15

Genetics: Twins 70%, Genetica markers, 15- 30 % if one parent, High IQ’s, Verbal in childhood, Artist/writer/ highly educated
Neurobiological: Role of neurotransmitters, Most likely interactions among various chemicals
Brain structure/function: Imaging=changes, Dysfunction prefrontal cortical region, Dysfunction hippocampus & amygdala
Neuroendocrine: HPA (axis), Hypothyroidism increase, Increase peripheral inflammation, Role of estrogen

Question 16

What are the assessments for Bipolar disorder?

Answer 16

• Bipolar patients tend to be in the depressed state more than the manic state
  Assessment tool
  The Mood disorder Questionnaire (MDQ)

Question 17

What are the characteristics of a Manic patient?

Answer 17

Euphoria: intense feeling of well-being, overly joyous
++ energy, lack sleep
Mood quickly change to irritation, anger, restless
Hypomania->mania= ideas come too fast, overwhelming, confused

Question 18

What are the behaviours of a hypomania patient with Bipolar disorder?

Answer 18

Social,
Reduced sleep, food
Non stop physical activity (dangerous)

Question 19

What are the behaviours of a Mania patient with Bipolar I disorder?

Answer 19

Change activity/projects constantly
Hyperactivity- mild/mod/wild activity
Sex, spending +++
Religious preoccupation
Manipulative, profane ->alienate

Question 20

What are the thought processes/speech patterns with Bipolar disorder?

Answer 20

Flight of ideas
Clang association
Grandiosity
Sexually explicit, vulgar

Question 21

What are the assessments guidelines for a Bipolar disorder?

Answer 21

Danger to self or others
Need for hospitalization
Coexisting medical conditions
Need for protection from uninhibited behaviours
Medical status
Family's understanding

Question 22

What are the outcomes for a Bipolar disorder patient?

Answer 22

Acute phase: Prevent injury (maintain hydration, rest/sleep)
Continuation phase: 4 -9 months, relapse prevention (get knowledge, insight, know S/S of relapse)
Maintenance phase: relapse prevention & limit recurrent episodes (not go in manic episode, after hospitalization)

Question 23

What type of communication would you like to have with patient experiencing acute mania?

Answer 23

1. Use firm, calm approach
2. Use simple, concise explanations
3. Remain neutral
4. Be consistent with approach/expectations/limits
5. Staff should all be on the same page

Question 24

What are the interventions for structure in a safe Milieu in a patient experiencing acute mania?

Answer 24

Low level stimuli
Structured solidarity activities
Medication/seclusion PRN
Watch for lithium toxicity
Redirect violent behaviour

Question 25

What are the interventions for Self-care needs: Nutrition in a patient experiencing acute mania?

Answer 25

Frequent snack: high protein & calories, finger foods Remind to eat Cheese & crackers

Question 26

What are the interventions for Self-care: Sleep in a patient experiencing acute mania?

Answer 26

Provide periods of rest Reduce stimuli/stimulants Provide relaxation tools before bed Antipsychotics Benzodiazepines

Question 27

What are the first line treatment for medication with Bipolar disorder patients?

Answer 27

Lithium, Valproic acid, Atypical antipsychotics for mania Combinations for depression & mania: Olanzapine + SSRI (depression) Lithium/valproic acid + SSRI or NDRI (anxiety) Benzodiazepines short term agitation/insomnia (panic attack, insomnia)

Question 28

What are other treatments for Bipolar disorder patients?

Answer 28

Electroconvulsive therapy: treatment resistant mania, Rapid cycling (cicletimia) Milieu management: Restraints, Olanzapine, Support groups Health teaching/ promotion Psychotherapy

Question 29

Which behaviour exhibited by a person with mania should the nurse choose to address first? a. The immediate safety of the person and other patients on the unit is the priority. Limits regarding patient-to-patient contact and relations should be communicated, and behaviour should be monitored. b. While excessive spending of money is commonly found in mania, it is not an immediate safety issue. c. Being “at one with the world” may be part of a delusional (false thoughts) system that commonly happens during mania. Delusions should be monitored, but this one does not sound dangerous or in need of any particular action. d. Flight of ideas, or jumping from topic to topic, is also a common symptom in mania. While it may make communication difficult, it is not a priority concern.

Answer 29

a. The immediate safety of the person and other patients on the unit is the priority. Limits regarding patient-to-patient contact and relations should be communicated, and behaviour should be monitored.

Question 30

The nurse is caring for a person experiencing mania. Which is the most appropriate nursing intervention? a. Patients experiencing mania have the ability to “staff split,” or divide the staff into “good guys” and “bad guys.” Providing consistency among all staff members is imperative. b. Limit access to money because excessive spending is common during mania. c. Limits must be set and carried out by all staff members if the plan of care is to be effective. d. The nurse cannot control the patient’s emotions; the preferred approach is to establish and maintain limits for the duration of admission.

Answer 30

a. Patients experiencing mania have the ability to “staff split,” or divide the staff into “good guys” and “bad guys.” Providing consistency among all staff members is imperative.

Question 31

The nurse is planning care for a person experiencing the acute phase of mania. Which is the priority intervention? a. Keep the person safe by setting limits on behaviours as the person may exhibit aggressiveness toward others during an acute phase of mania. b. Encourage the person to take rest periods during the day and to sleep at night in order to ensure sufficient sleep. c. Instruct the person to exercise (brisk walk around the unit) frequently during the day in order to reduce restlessness and wakefulness during the night. d. Provide small snacks between meals for the person to maintain adequate nutrition during an acute episode of mania.

Answer 31

a. Keep the person safe by setting limits on behaviours as the person may exhibit aggressiveness toward others during an acute phase of mania.

Question 32

What critical information should the nurse provide about the use of lithium? a. Lithium is helpful in controlling hypersexuality that may come with mania. b. Lithium is helpful in controlling feelings of anxiety, elation, grandiosity, and expansiveness. c. Lithium takes 7 to 14 days and sometimes longer to reach therapeutic levels in the patient’s blood. d. Lithium helps stabilize bipolar disorder; it is not a cure.

Answer 32

c. Lithium takes 7 to 14 days and sometimes longer to reach therapeutic levels in the patient’s blood.

Question 33

The nurse has provided education for a patient in the continuation phase after discharge from the hospital. What indicates that the plan of care has been successful? Select all that apply. a. The plan of care has been effective when the person can identify signs and symptoms of relapse, describe the purpose of his or her medications, and describe problem-solving techniques. b. Stating that his wife does not mind his drinking indicates that the person has not considered the consequences of substance addictions that may contribute to future relapse. c. Stating that he wants to discontinue the medication despite its helpfulness indicates that the patient does not fully understand the process related to bipolar disorder and the purpose of medications. d. Stating that he does not have a disorder indicates that the patient does not fully understand the process related to bipolar disorder.

Answer 33

a. The plan of care has been effective when the person can identify signs and symptoms of relapse, describe the purpose of his or her medications, and describe problem-solving techniques.