Download Bipolar Disorders

MOOD DISORDERS
Mood disorders
Depression
Bipolar
Anxiety
Name the
Depressive
Disorders
Etiology of Depressive D/O
 Biochemical factors
 Neurotransmitter imbalance
 Genetic factors
 Cognitive factors
 Stressful life events
 Other causes
 Medical conditions
 Substances/medications
Depression is on a Continuum
Mild (grieving, loss)
Moderate
Severe (major depressive disorder)
Sad versus Depressed
 Everyone is sad feels depressed at times
 Feeling depressed versus Clinical Depression
 Leading cause of disability in the US
 Often accompanies other disorders like schizophrenia,
substance abuse and eating disorders
 Anxiety disorders like OCD, GAD, panic disorders usually
have depression
 Borderline personality disorders usually have depression
Biochemical
 Two main neurotransmitters
 Serotonin
 Norepinephrine
When a stressful life event
occurs these
neurotranmitters are
overtaxed and depletion
occurs
Depressive D/O Diagnostic Criteria
 Major Depressive D/O
 Persistent depressive disorder
D/O-chronic or neurotic
depression
Be able to differentiate between MDD and DD
Psychosocial Assessment
Occupation
2. Educational level
3. Past history: medical, psychiatric*,
medications
4. Client’s chief complaint/client’s
perception
5. Labs
6. Comorbid medical &/or current
neurological issues
7. Current prescribed medications/OTC
meds

Allergies

Use of Alcohol/Tobacco
8. Coping abilities
9. Support systems
10. Cultural or spiritual beliefs or practices
1.
What information
would you like to
obtain?
A nurse in the ER is assessing a client suspected of being suicidal.
Number the following assessment questions, beginning with the
most critical and ending with the least critical.
___ “Are you currently thinking
about suicide?”
___ “Do you have a gun in your
possession?”
___ “ Do you have a plan to commit
suicide?”
___ “Do you live alone? Do you have
local friends or family?”
Cognitive Theory
 A person’s thoughts will result in emotions.
 Researchers believe that negative early life experiences lead
to illogical, irrational thoughts that remain dormant until
major stress occurs.
 So automatic, negative repetitive thoughts cause depression
Becks cognitive triad
Assessment
 1 Standardized depression screening tools


Becks Depression Inventory
Geriatric Depression Scale
 2- Assess for suicide potential
 Key assessment findings
 Anergia
 Anxiety
 Psychomotor agitation (pacing) or
 Psychomotor retardation
 Somatic complaints- headaches, backaches
 Change in bowel or eating habits
 Sleep disturbances
 Feelings of helplessness and guilt
Pharmacological Interventions
 Antidepressants
 SSRI’s
 Tricyclic antidepressants
 SNRI’s
 MAOI’s
 S/E- anticholinergic

sedation
Psychotherapy
 Cognitive therapy because people may acquire a
predisposition to depression due to early life experience.
 And if bad enough where suicide is a constant threat ECT Treatment
Dementia
Delirium
Depression
Onset
• Months to years
• Hours to days
• Weeks to months
Cause or
contributing
factors
• Alzheimer’s disease,
vascular disease, HIV,
neurological disease,
chronic alcoholism, head
trauma
• Underlying medical condition;
hypoglycemia, fever, dehydration,
hypotension, infection (urinary tract),
head injury, pain, adverse drug
reaction, intoxication
• Lifelong history, losses,
loneliness, crises, declining
health, medical conditions
(stroke)
LOC
• Not altered
• Altered
• Not altered
Activity level
• Not altered; behaviors
may worsen in evening
(sundown syndrome)
• Increased or reduced; restlessness,
sundowning, sleep-wake cycle may
be reversed
• Usually decreased;
lethargy, fatigue, lack of
motivation, may sleep poorly
and awaken in early morning
Emotional
state
• Flat; delusions
• Rapid swings; can be fearful,
anxious, suspicious, aggressive, may
have hallucinations &/or delusions
• Extreme sadness, apathy,
irritability, anxiety, paranoid
ideation
Speech &
language
• Incoherent, slow,
inappropriate, rambling,
repetitious
• Rapid, inappropriate, incoherent,
rambling
• Slow, flat, low
Course
• Chronic, with deterioration
over time
• Acute, responds to treatment
• Chronic, responds to
treatment
Bipolar Disorders
 Old term was manic-depression
 Its chronic
 Recurrent illness
 It is one type of mood disorders (disturbances in how one
feels)
 Bipolar:
 Marked by shift in mood, energy and ability to function
 Swing from severe euphoria to severe depression
Bipolar Disorder
 Bipolar I Disorders
 Bipolar II Disorder
Describe Some Theories That
Explain the Cause of Bipolar
D/Os
 Biochemical factors
 Neurotransmitter imbalance
Increase in norepinephrine & epinephrine

Complex interactions among various
chemicals, including neurotransmitters and
hormones

Overstimulation of the brain
 Genetic factors
 Stressful life events can trigger symptoms of
bipolar disorder

Assessment BiPolar
 Mental Status Examination
(MSE)
 Appearance
 Behavior
 Speech
 Thought processes
 Perceptual disturbance
 Cognition
 Ideas of harming self or others
Alcohol or substance abuse
Martial or work problems
 Euphoric mood is unstable
 One minute over cheerful and joyous and suddenly angery





and irritable
S/sx:
Laugh,joke,continuous talking
Know no strangers
Boundless energy and self-confidence
Hostility, irritability, paranoia
 Flight of ideas- accelerated speech abruptly changing topics
often leading to speech that is disorganized and incoherent
 Grandiosity- inflated self regard
Nursing Interventions
Safe/Supportive milieu
Medication stabilization
3. Limit setting-manipulating
behavior
4. Environment
1.
2.




5.
6.
7.
Decreased stimuli
Consistent & structured
Time outs
Quiet times
Monitor for poor judgment
Focus on reality
Provide structured solitary
activity
Pharmacologic Treatment
 Mood Stabilizer
 Antimanic
 lithium carbonate
 Therapeutic range
o 0.6- 1.2 mEq/L

Early signs of toxicity
o <1.5 mEq/L

Advanced signs of toxicity
o 1.5-2.0 mEq/L

Severe toxicity
o 2.0-2.5 mEq/L
 Anticonvulsants
 Anxiolytics
 Antipsychotics
Pharmacological Treatments
Bipolar
 1-usually need combination of drugs
 2- Antianxiety medications reduce agitation/anxiety
Clonazepam (Klonopin)

Lorazepam (Ativan)
 3-Antipsychotic agents reduce delusions/hallucinations
 4-Antidepressants reduce bipolar depression

 These type of drugs are used for a limited time only
 3-Antipsychotic agents reduce delusions/hallucinations



Helps with insomnia
Anxiety
Aggitation
 Zyprexa
 Quetiapine (Seroquel)
 Risperidone (Risperdal)
 Aripiprazole (Abilify)
Tricyclic Antidepressants
 Name Some TCA’s
 clomipramine (Anafranil)
 Can be used for the Anxiety D/O,
Obsessive Compulsive D/O (OCD)
 amitriptyline (Elavil)
 Can be used for nerve pain or for
sedation
 doxepin (Sinequan)
 Can be used for agitation or
restlessness
AND MORE
These have limited use
But bipolar is a life long problem so
what drugs are life long
maintenance therapy???
Lithium
 Treats mania
 Reduces:
 Depressive episodes
 Grandiosity
 Prevents their recurrence
 Flight of ideas
 Anxiety
 Works when in therapeutic
range takes 7-14 days
 Remember-it’s a treatment
not a cure
 Irritability
 manipulativenss
Antiepileptic Drugs
 If lithium not tolerated well some have been helped with
antiepileptic drugs
 Carbamazepine (Tegretol)
 Divalproex (Depakote)
 Lamotrigine (Lamictal)
Anxiety and Obsessive-Compulsive
Disorders
Types
 Mild-a normal experience of living
 Moderate- Now some problems grasping




information(selective inattention)
Severe-Perceptual field very reduced problem solving
impossible
Panic- Marked disturbed behavior
Running, shouting, screaming or with
drawal
Anxiety disorders
 Separation anxiety
 Panic disorder
 Agoraphobia
 Generalized anxiety disorder
Body dysmorphic disorder
 Have normal appearance but they think they have a defective




body.
Obsessed thinking about body
Constant checking the mirror
False assumptions about importance of appearance with fear
of rejection
Plastic surgery, over and over again
Behavioral theories
 Anxiety is a learned response to specific stimuli or a
conditioned response
 A child with an abusive mother is afraid of all women
 Or a child who has a parent afraid of lightening, is also afraid
 Both can benefit from modeling others behaviors- how
people act in a storm or a woman who is safe and loving
Behavioral therapy interventions
 Relaxation training
 Modeling
 Desensitization
 Thought stopping
Cognitive theories
 Anxiety are caused by distortions in a peseon thoughts and
perceptions. Overreacting to situations by making them
appear dangerous.
Cognitive therapy Interventions
 Cognitive restructuring by identifying negative beliefs,
explore basis for this thought, reevaluate the situation,
replace negative self talk with supportive ideas
Nursing Interventions
 Maintain calm manner
 Always remain with the patient having acute severe panic
 Minimize environmental stimuli. Move to a quiet setting
 Speak low and slow
 Reinforce reality
 Keep patient safe
Pharmacology
 Antidepressants
 Antianxiety drugs
Crisis
 Acute, time limited occurrences linked to extreme emotion
 Name some in the country’s history
 Name some in the news lately
 Think of some in your personal life
Crisis theory and the nursing process
 Nurses called on to deal with crisis in patients often both on
an individual basis, community basis and world wide basis
 Crisis theory :
 Type of crisis
 Phases of crisis
 Aspects of crisis
Types of crisis
 Maturational
 Situational
 Adventitious (disasters)
 These can be seen in combination and in that case even
harder
Phases of crisis
 1- conflict occurs causing anxiety. Problem solving
techniques used to solve the problem and therefore lower
anxiety
 2- if this fails, anxiety will rise along with feelings of
discomfort. Trial and error methods used to solve problem
 3- if trial and error fails, anxiety reaches severe and panic
levels. Grief behavior begins such as withdrawn and flight.
 4- if the problem continues, anxiety overwhelms and
personality disorganization, depression, confusion and
suicidal behavior can occur
Nursing process
 Assessment:
 What is the persons perception of the event?
 What support system does the person have?
 What are the person’s personal coping skills?
Diagnosis
 Made from assessment information
 Examples- overwhelmed, depressed- risk for self directed
violence, hopelessness, powerlessness
 Confused, highly anxious- disturbed thought process, acute
confusion
 Unable to function at work, school- ineffective coping
planning
 Uses disaster nursing, mobile crisis units, group work, victim
outreach programs
 Nurses involved in planning and intervening with individuals,
group work or community work
Implementation
 2 major goals
 Patient safety
 Anxiety reduction
 Uses crisis intervention models showing interest and
support.
 Never give false assurances- everything will be all right
 Nurse is adviser- It is the patient that solves the problem
never the nurse
grief
 The reaction to loss:
 Depression
 Loss of sleep
 Poor appetite
 Plus Kubler-Ross 4 stages:
 Shock
 Denial
 Anger
 Bargaining
acceptance
Disenfranchised grief
 Grief that is felt but cannot be publicly shown or openly
acknowledged
 Example- a nurse losing a patient they had developed a bond
with
 A lover, a neighbor, a co-worker etc
 This grief can be solitary and uncomfortable and very
difficult to resolve because it can remain unspoken
Grief Engendered by public tragedy
 Common public tragedies:
Middle Eastern Terrorists
Unrest in Middle East
 Explosion of the Challenger space ship
 Terrorist assaults 9/11
 Katrina
 Yarnell firefighters
 Gabby Gifford
 Mass shootings in public places
Theories of Grief
 One such theory was just discussed: Kubler-Ross
 The stages for every human do not occur exactly in that
order taking a certain amount of time.
 Everyone reacts within their own framework
 The order it occurs can vary and well as the time in each
phase varies
 Models help organize the stages but don’t provide a focus of
care when assisting a patient though the process
Nursing Considerations
 Grieving is normal
 Complicated grieving impairs functioning
 Things not common with normal grieving:
 guilt about actions taken or not taken by the survivor
 feelings that they are better off dead or should have died
with the person
 preoccupation with worthlessness
 psychomotor retardation
 hallucinatory experience-seeing or hearing the deceased
Interventions
 Give your full self-make eye contact, be in the moment,






active listening
Allow time for silence
Know and share about the phenomena of normal grieving
process
Encourage support of family and friends
Offer spiritual support and referrals if needed
Be aware some people need grief counseling and support
groups
Remember, people in crisis are able to make decisions, help
them
PTSD
 1- War
 2- Violence like home invasions, rape
 Symptoms show up 3-4 months after the occurrence
 Entering the ER, don’t leave them alone!
 Flashbacks triggered by sight, sound, smell, feel
 Feels detached or empty inside
 Shows hyper vigilance or distrusting of people and or
situations
 Avoids people and places that arouse painful memories