Download THE CLIENT EXPERIENCING MANIA

THE PATIENT EXPERIENCING MANIA
MANIA
• Common disorder with elevated, expansive, irritable mood
• The exact opposite of depression – markedly elevated mood
• Individuals are talkative, excitable, energetic
Rapidly move from topic to topic
• Exhibit grandiosity—inflated self-esteem
• Indiscriminate, impulsive sexual behavior
• Divided into categories based on severity of the symptoms
Manic Individuals May:
• Lose touch with reality - Become psychotic
• Be paranoid, agitated, delusional
• Have poor impulse control
• Have hallucinations
• Become dangerous to self and others
• Cycle between mania and other moods
• Recognize their own manic behavior
MANIC EPISODE
• Distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week
• Three or more symptoms listed in DSM-IV-TR have persisted
Markedly elevated mood
Talkativeness
Inflated self-esteem and grandiosity
Poor impulse control
Hypersexuality, indiscriminate sexual behavior
Delusions
Paranoia
• Marked impairment in job or personal functioning not due to illness, drugs, or medications
HYPOMANIA
• Mild manic state
• Beyond normal happiness
• Involves fewer symptoms and a shorter duration
• No disturbance in functioning
• May become abnormal when they are recurrent, lengthy, & associated with a change in functioning
• Criteria include same 7 criteria as mania
Need have only 3 of criteria
Need to last only 4 days
Need not cause disturbance in functioning, but must be observable by others
BIPOLAR DISORDERS (BPD)
• Combination of mania and depression
• Conditions may occur simultaneously, but they most often occur sequentially
Most often mania occurs first, followed by depression
• Mood change is called switch process
• Cyclothymic patterns are episodes of mood changes that do not meet diagnostic criteria
• May greatly influence the quality of lives
• Clients with Bipolar Disorder do not have long periods free of symptoms, but spend a good proportion of
their lives dealing with the symptoms of mania, depression, or both
EPIDEMIOLOGY
• Prevalence is low – not common in population as a whole
2.6 persons per million newly hospitalized for mania each year
• Rapid cyclers have four or more episodes in a year
Most rapid cyclers are women
• Clients usually become ill in their 30s or earlier – onset can occur from childhood to old age
• Symptoms of mania may differ in young children from those of adults
ETIOLOGY
• Tendency to be inherited - genetics seem to be the strongest influence
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Risk for identical twins – 70% chance if one has it so will the other
Often passed from parent to child
Cause is unknown
May be due to genetically determined biochemical abnormality of the brain
Switching from depression to mania may often be provoked by antidepressant medications (especially
tricyclics), by use of St John’s wort, & also from stopping antidepressants
Some drugs (corticosteroids & levodopa) and physical diseases may cause mania (syphilis, HIV, Lyme’s,
thyroid, & endocrine disorders)
CLINICAL COURSE
• Includes recurrent episodes of mania and depression
• May last months to a year or more
• Length of an individual’s episodes are fairly constant
• Mania typically shorter than depression
Manic episodes appear suddenly
Depressive symptoms more likely to develop over days or weeks
• Continuous cycling—switching from mania to depression without normal periods
SOCIAL PROGNOSIS
• Many work when recovered
• Social prognosis of Bipolar Disorder is not uniformly good
• Many do not have employment
• All-cause mortality is twice as high for those with BPD as for age-matched controls
• Coexisting medical conditions account for most natural causes of death
• Are at higher risk of suicide
One or more suicide attempts occur in 25-50% of those with BPD
Treatment with Lithium has been associated with a decreased risk of suicide
• Coexisting medical conditions may increase risk of death
ASSOCIATED DISORDERS / DUAL DIAGNOSES
• Substance abuse
Alcohol: Strong association, especially in men
about 35% of all persons with BPD abuse alcohol
Drugs: Excessive use of narcotics, marijuana, & hallucinogens
• Schizoaffective disorder – bipolar type
Elements of schizophrenia combine with bipolar disorder
Prolonged delusions or hallucinations when mood disorder in remission
Psychotic & more difficult to treat than purely BPD clients
• Borderline personality
Often overlap with Bipolar II disorder
Have rapid mood swings that tend to react more to their environment
Antidepressants may trigger a manic attack in these clients
BIPOLAR DISORDER AND CREATIVITY
• Mania and mood disorders are linked with artistic and creative persons
Poets, writers, artists, musicians
Ned Beatty, Robert Downey Jr., Patty Duke, Linda Hamilton, Margo Kidder, Jean-Claude Van Damme, Ben
Stiller
• Illness contributes to artistic greatness
• Many also have lesser forms of mania and mood swings
PHARMACOLOGICAL TREATMENT
Acute mania may be treated with:
• Benzodiazepines
Klonopin useful in controlling nonpsychotic symptoms
• Neuroleptic agents
Olanzapine to manage acute mania
• Antipsychotics
Haldol for delusions, flight of ideas, combativeness
• Valproic acid – Depakene
Has a direct mood-stabilizing effect
Starts to work within 24-72 hours
MAINTENANCE TREATMENT
Recommended Treatment
• For all persons who have had 3 or more episodes of major depression or for those with 2 or more episodes
of major depression & 1 of the following:
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Family history of BPD or recurrent major depression
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History of recurrence within 1 year after medication being discontinued
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First episode occurring before age 20
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Episodes that were both severe, sudden, or life-threatening & occurred within 3 years
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Single episode justifies long term prophylaxis if:
Client is male
Onset is sudden or later than age 30
Episode is severe or suicidal
No external precipitants were involved
The client is adolescent
LITHIUM
• Used to treat individual episodes of mania & prevent recurrence of mania & depression
• Most effective in person whose symptoms began after puberty & who are not short cyclers (<4
episodes/year)
• Must evaluate
Thyroid – for hypothyroidism
Kidneys – decreases renal concentrating ability
Nervous system – tremor & decreased motor coordination
• Monitor lithium levels to prevent toxicity from overdose
• Side effects—increased thirst, appetite, weight gain, memory problems, impaired motor coordination
• Compliance is a problem
• May interfere with creativity
ANTICONVULSANTS
• Quicker action make them of value in acute mania
• Some rapid cycling clients don’t respond well to Lithium
• Carbamazepine - Tegretol
• Side effects: drowsiness, ataxia, dizziness, visual difficulties, tremor, nausea, rash, liver test abnormalities,
changes in white blood counts
• Valproic acid
• Side effects: sedation, tremor, headache, visual disturbance, some clients develop massive liver damage –
occurs without warning, is independent of dosage, & rarely affects persons over 12 years old
ATYPICAL ANTIPSYCHOTICS
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Olanzapine, clozapine, quetiapine, risperidone, ziprasidone are useful in long-term management of BPD
May be safer than other drugs
Used in monotherapy (by themselves)
May be combined with other agents
Traditional antipsychotics are not generally effective in the long-term management of BPD
ANTIDEPRESSANTS
• May stimulate mania and rapid cycling
• Do not increase effectiveness of other meds
• Are one option with depressive symptoms
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PSYCHOTHERAPY
May be valuable in combination with medications
One of major goals is to increase compliance with medications
Can help with common problems experienced by those with BPD
Educates client and family
OTHER TREATMENTS
• Electroconvulsive therapy
Rarely used, but is effective in treating mania
May be used with Lithium is contraindicated – such as early stages of pregnancy
• Calcium channel blockers
May help in mania unresponsive to Lithium or anticonvulsants
FAMILIES
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Seek support & education about the disease from nurses
Need someone to listen to their feelings
Worry about becoming ill
Worry about handling client
Feel guilt due to genetic aspect
Nurse’s role is one of both support & listening as well as educating family & friends about the disease & what
to expect
• Family & friends need to be aware of the risk of self-injury & suicide
EXPERIENCED NURSES GIVE ADVICE
• Manic clients may upset the ward
• Take a deep breath & relax
• Calm and peace are contagious the same as anxiety
• Nursing team should work together & project an image of patience and confidence
• Treat all persons with respect and dignity
• Private room may be needed to give the manic client enough personal space so that he does not disturb
others with behavior he cannot control
ASSESSMENT
• Presenting symptoms
• History of manic/depressive cycles
• Medication compliance
• Supporting data
• New clients may require further assessment
7 Questions to ask When Assessing a Manic Client
• 1. Do you experience ups & downs in your moods?
• 2. Do you have difficulty focusing your thoughts or conversations?
• 3. Have you spent more money than usual lately?
• 4. When is the last time you slept, & how long did you sleep?
• 5. Have you noticed a change in your sexual interest or sexual activity lately?
• 6. Do you feel irritated when other people tell you to slow down or when they do not seem to follow your
thoughts?
• 7. Do you believe you have extraordinary abilities or powers?
NURSING DIAGNOSIS
Needs are grouped into categories:
• Safety needs
• Physical needs
• Social needs
• Cognitive needs
• Family needs
OUTCOME IDENTIFICATION
• Safety and physical needs met first
• Social needs are next
• Assisting client to manage illness last
PLANNING/INTERVENTIONS
• Safe and structured environment
• Concise and clear communication necessary
• Minimal social contacts until stabilized
• Prevent embarrassing situations
• Focus on teaching client to manage disease
• Assist family as needed
EVALUATION
• Check potential hazards
• Compare functioning to beginning of treatment
• View progress in terms of degree
• Recovery process may be long