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Question Answer BIPOLAR LECTURE Bipolar Disorders 1. characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy2. may include: delusions or hallucinations & other psychotic symptoms3. impair occupational functioning or usual social activities or relationships- may require hospitalization to prevent harm to self/others mania 1. alteration in mood- expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, & accelerated thinking & speaking2. not due to meds, substances, other disease acute mania 1. marked impairment in functioning of mood, cognition perception, activity, behavior2. usually requires hospitalization criteria for mania- DSM period of abnormal, persistent elevated, expansive, or irritable mood & abnormally & persistently increased goal directed activity or energy lasting 1 week: most of day every day Criteria for mania-DSM During period at least 3 of following S&S 1. inflated self esteem or grandiosity2. decreased need for sleep3. more talkative than usual or pressured speech4. flight of ideas, racing thoughts5. distractibility, increase in goal-directed acitivity6. psychomotor agitation7. excessive involvement in activities that have high potential for painful consequences criteria for mania-dsm 1. mood disturbance causes marked impairment in social or occupational functioning or necessities hospitalization to prevent harm to self, or there are other psychotic symptoms2. episode is not attributable to effects of substance or another medical condition Bipolar 1 disorder 1. is experiencing, or has experienced, a full syndrome of manic or mixed symptoms2. may also have experienced episodes of depression bipolar variations 1. bipolar disordera. single manic episodeb. most recent episode hypomanicc. most recent episode manicd. most recent episode mixede. most recent episode depressedf. most recent spade unspecific bipolar 1 specifiers 1. mild, moderate, severe2. with or without psychosis3. with catatonic features4. with postpartum onset5. with seasonal pattern6. with rapid cycling bipolar 2 disorder 1. characterized by bouts of major depression with episodic occurrence of hypomania (less severe than mania episode)2. has never met criteria for full manic episode hypomania criteria 1. elevated, expansive, irritable mood for 4 days/ at least 3 or 4 of symptoms of mania2. episode is change for person & is observable by others3. episode not severe enough to impair functioning or require hospitalization4. no psychosis5. not attributable to substance use other bipolar disorders substance/medication induced bipolar disordera. ETOH, amphetamines, decongestants, steroids, cocaine, hallucinogens, inhalants, opioids, PCP, hypnotics, anxiolytics, caffeinebipolar disorder due to another medical conditiona. head injury, CNS tumor, HIB/syphilis infection bipolar disorders (mania) Predisposing factors biological theoriesGenetic:a. strong hereditary implicationsb. ANK2 (ankyrin G) & CACNA1C (alpha 1 C)biochemical influences:a. excess of norepinephrine & dopamineb. low serotoninc. now acetylcholine (too much in depression, not enough in mania) predisposing factorsElectrolytesPhysiological influences a. right sided brain lesions in limbic system cause secondary maniab. MRI's show enlarged ventricle & white matter in bipolar disorderc. medication side effects (steroids) predisposing factorsPsychosocial theories a. credibility of psychosocial theories has declined in recent years-disease of brainb. psychosocial issues: play a role in triggering episodes, but not causative factorc. transaction model transactional model bipolar disorder most likely results from comboteraction between genetic, biological, and psychosocial determinants bipolar disorder: developmental implications CHILDHOOD/ADOLESCENCE FIND:1. Frequency: symptoms occur most days in a week2. Intensity: symptoms are severe enough to cause extreme disturbance3. Number: symptoms occur 3 or 4 times a day4. Duration: symptoms occur 4 or more hours a day treatments 1. psychopharmacology meds first2. note: all women of childbearing age need consistent contraception due to increased risk of congenital abnormalities with all of these medications mood stabilizing medicationsANTIMANIC: LITHIUM CARBONATE (Lithium, Lithobid, Eskalith CR) Lithium carbonate Mechanism of action enhances reuptake of norepinephrine & dopamine = lowering levels in body = decreased hyperactivity lithium carbonate contraindications hypersensitivity, cardiac or renal disease, dehydration, sodium deletion, brain damage, pregnancy or lactation lithium carbonate caution with… thyroid problems, diabetes, urinary retention, hx seizures, elderly side effects : dose related lithium carbonate drowsiness, dizziness, headache, dry mouth, thirst, go upset, n/v, fine hand tremors, hypotension, arrhythmias, pulse irregularities, polyuria, dehydration, weight gain, potential for toxicity Lithium toxicity Lithium therapeutic range 0.6-1.4 mEq/L- Monitor levels once or twice a week till stable then monthly Lithium toxicity begins to appear at…. 1.5 Lithium level 1.5 you should…. hold med & call dr. at this level Lithium level 1.5-2.0 symptoms blurred vision, ataxia, tinnitus, persistent n/v, severe diarrhea, thirst lithium level 2.0-3.5 symptoms excessive dilute urine output, tremors, muscular irritability, psychomotor retardation, confusion, giddiness lithium level >3.5 symptoms impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmia, MI, cardiovascular collapse Lithium teaching 1. Get levels drawn1. similar in structure with sodiuma. if sodium intake is reduced or body depleted of sodium (excessive sweating, fever) lithium reabsorbed by kidneys, increasing change of toxicity2. patients need to have adequate sodium & fluid intake (2500-3000)a. avoid dehydrating fluidsb. call Dr. if V/D3. monitor intake, output & weight daily4. contraception needed female/sperm affect male5. no nsaids/interacts iwht many medication/ETOH6. ID card anticonvulsants as mood stabilizers a. valproic acid (depakote))b. lamotrigine (lamictal)-note: dangerous skin reactions possible (SIS)c. carbamazepine (tegretol)d. clonazepam (klonopin)e. topiramate (topamax)f. oxcarbazepine (trileptal)g. gabapentin (neurontin) anticonvulsants as mood stabilizers MOA ??? anticonvulsants as mood stabilizers contraindications hypersensitivity, liver disease, lactation, caution in elderly, liver, renal, cardiac disease, pregnancy anticonvulsants as mood stabilizers side effects blood dycrasias, nausea, vomiting, prolonged bleeding time, risk of rash (lacimtal) anticonvulsants as mood stabilizers black box warning increased risk for suicidal thoughts & behaviorsdecrease effectiveness of birth control pills valproic acid depakote, depakote ER, stavzor (delayed release) MOA of valproic acid a. decrease firing rate of high frequency neurons- stabilize membraneb. Valproic acid you need what levels? Peak and trough Therapeutic range of valproate acid is… 50-100 mcg/ml What is considered toxic level for valproic acid? >100 mcg/ml What is the black box warning for valproic acid? Hepatoxicity What are the medication interactions of valproic acid Coumadin and aspirin and antacids Calcium channel blockers as mood stabilizers Verapamil (calan) The Moa of verapamil? ??? Contraindications of verapamil Hypersensitivity, heart block, hypotension, cardiogenic shock, congestive heart failure, pregnancy , lactation, caution in liver, renal disease, cardiomyopathy, intracranial pressure, elderly Side effects of verapamil Drowsiness, dizziness, hypotension, bradycardia, nausea, constipation Antipsychotics Used to help control behavior and stabilize mood Work faster than mood stabilizers so used initially until other drugs kick in Used as adjunctive therapy Old typical antipsychotic Haldol New atypical antipsychotics Lurasidone HCL (latuda), quetiapine fumarate (seroquel XR), aripiprazole (abilify), cariprazine (vraylar), olanzapine (zyprexia), ziprasidone (geodon), risperidone (resperdal), asenapine (saphris)*****all risk for EPS Lurasidone HCL (latuda) For depressive episodes cariprazine (vraylar For acute mania Key in all psychopharmacology A. When monotherapy fails-augmentation with second medication is indicatedB. Or switch to another medication Psychological treatment-must be stabilized with mess first to be effective Individual psychotherapyA. Group therapy- include sky help groups like depression and bipolar support allianceB. Family therapy including support from national alliance on mental illness-if disorder affects marriage or family functioningC. Cognitive therapy – focus on change automatic thoughts such as personalizing, all or nothing, mind reading, discounting negatives- environment- self- future Recovery model Client and clinician work to help individual take control and manage their illness Other treartments ECT ECT Used for mania especially if client does not tolerate mess or when life threatening dangerous behavior or exhaustion occurs Child and adolescent bipolar disorder Treatment strategiesA. Psychopharmacology- lithium- divalproex (depakote)- carbamazepine (tegretol)-atypical antipsychoticsB. Family interventions- psycho education about bipolar disorder- communication training – problem solving skills training

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