BIPOLAR AFFECTIVE DIS ORDERS

AND SCHIZOPHRENIA
ODONGO SHADRACK
 Disorders of mood and affect
• Affect is:- an observed emotional expression
or response
• Mood is:- an emotional state
Depression
– Depression is a state of low mood and aversion to
activity that can affect a person's thoughts,
behavior, feelings and sense of well-being
 Depression
• Depressed people may feel sad, anxious, empty, hopeless, worried,
helpless, worthless, guilty, irritable, hurt, or restless.
• They may lose interest in activities that once were pleasurable,
experience loss of appetite or overeating, have problems
concentrating, remembering details, or making decisions, and may
contemplate or attempt suicide.
• Insomnia, excessive sleeping, fatigue, loss of energy, or aches,
pains, or digestive problems that are resistant to treatment may
also be present
• Depression can affect anyone—even a person who appears to live
in relatively ideal circumstances. But several factors can play a role
in the onset of depression:
• There is no specific cause of depression but the following have
been implicated in it’s causation
 Causes of depression
Biochemistry
Abnormalities in two chemicals in the brain, serotonin and
norepinephrine, might contribute to symptoms of depression,
including anxiety, irritability and fatigue. Other brain networks
undoubtedly are involved as well; scientists are actively seeking new
knowledge in this area.
Genetics
Depression can run in families.
Personality
People with low self-esteem, who are easily overwhelmed by stress, or
who are generally pessimistic appear to be vulnerable to depression.
Environmental factors
Continuous exposure to violence, neglect, abuse or poverty may make
people who are already susceptible to depression all the more
vulnerable to the illness. Also, a medical condition (e.g., a brain tumor
or vitamin deficiency) can cause depression, so it is important to be
evaluated by a psychiatrist , clinical psychologist or other
physician/nurses to rule out general medical causes
 Role of serotonin in the body
• Although historically depression has been considered a character
condition, evidence has accumulated suggesting the role of a biological
substrate, namely serotonin, in subgroups of depressed patients.
• In the brainstem, the most primitive part of the brain, lie clusters of
serotonin neurons.
• The nerve fiber terminals of the serotonergic neurons extend all
throughout the central nervous system from the cerebral cortex to the
spinal cord.
• This neurotransmitter is responsible for controlling fundamental
physiological aspects of the body.
• In the central nervous system (CNS), serotonin has widespread and often
profound implications, including a role in sleep, appetite, memory,
learning, temperature regulation, mood, sexual behavior, cardiovascular
function, muscle contraction, and endocrine regulation.
• Not only does this bioamine control physiological aspects of the body, but
it also has an involvement in behaviors like eating, sleeping and
aggression.
• Serotonin has been noted to produce an inhibitory effect on the nervous
system that calms, soothes and generates feelings of general
contentment and satiation.(thus the high implication of serotonin
deficiency in depression )
 Diagnostic criteria for major depression
• 5 or more of the following symptoms have persisted in the
same 2 week period(at least symptoms 1 & 2 are present)
1. Depressed mood most of the day, nearly every day as
indicated by subjective report or observation by others
2. Markedly diminished interest or pleasure in all, nearly all
activities all the day or nearly every day.
3. significant weight loss or gain when not dieting or decrease
or increase in appetite, nearly every day
4. Insomnia or hypersomnia nearly everyday
5. Psychomotor retardation or agitation nearly every day
6. Fatigue or loss of energy nearly everyday
7. Feelings of worthlessness or excessive inappropriate guilt
8. Diminished ability to think or concentrate or indecisiveness
recurrent thoughts of death, recurrent suicidal ideation
without specific plan, or a suicide attempt or a specific plan
for committing suicide
 Assessment of depression
• Patient Health Questionnaire (PHQ-9): this is a nine-item questionnaire
which helps both to diagnose depression and to assess severity. It is based
directly on the diagnostic criteria for major depressive disorder in the
Diagnostic and Statistical Manual - Fourth Edition (DSM-IV). It takes about
three minutes to complete. Scores are categorized as minimal (1-4), mild
(5-9) , moderate (10-14), moderately severe (15-19) and severe
depression (20-27). It can be downloaded free from the internet.
• Hospital Anxiety and Depression (HAD) Scale: despite its name, this has
been validated for use in primary care. It is designed to assess both
anxiety and depression. It takes about 5 minutes to complete. The anxiety
and depression scales each have seven questions, and scores are
categorized as normal (0-7), mild (8-10), moderate (11-14) and severe (15-
21).
• Beck Depression Inventory - Second Edition (BDI-II): this also uses DSM-
IV criteria. it takes about five minutes to complete. It is an assessment of
the severity of depression and is graded as minimal (0-13), mild (14-19),
moderate (20-28) and severe (29-36). It consists of 21 items to assess the
intensity of depression in clinical and normal patients. Each item is a list of
four statements arranged in increasing severity about a particular
symptom of depression. It is also not free but can be purchased from the
supplier's website.
 Nurses’ assessment for depression
• 1. Depression
a. Subjective data:
Not being able to express their opinions and lazy talk. Often argued somatic
complaints. Feeling themselves are not useful anymore, no meaning, no
purpose in life, feeling hopeless and suicidal.
b. Objective data:
Body movements were blocked, curved body and when sitting with
slumped attitude, facial expressions moody, slow gait dragged by step. It
can sometimes happen as stupor. Patients seem lazy, tired, no appetite,
difficulty sleeping and crying.
– The thinking process too late, as if his mind blank, impaired
concentration, had no interest in, can not think, do not have any
imagination. In patients with depressive psychosis there is a deep sense
of guilt, unreasonable (irrational), Objective Data delusions,
depersonalization, and hallucinations.
Sometimes patients prefer hostile, irritable and do not like to be
disturbed.
• 2. Maladaptive coping
a. Subjective Data: declare hopeless and helpless, unhappy.
b. Objective Data: look sad, irritable, agitated, unable to control impulses.
 Nurses’ diagnosis and management for depression
•

1. Risk for Self Harm related to depression

2. Depression related to maladaptive coping.

Nursing Interventions for Depression

General Purpose: Clients do not self-injure.
Specific Purpose:
1. Clients can build a trusting relationship
Action:
Introduce yourself to the client
• Interact with the patient as much as possible with the four attitudes.
• Listen to patient statements, patient manner, empathy and use more non-
verbal language. For example: a touch, a nod of the head.
• Note the patient talks and give responses according to her wishes.
• Speak with a low tone of voice, clear, concise, simple and easy to
understand.
• Accept the patient is without comparing with others.
 Management continued
• 2. Clients can use adaptive coping
Action:
Give encouragement to express his feelings and said
that nurses understand what the patient feels.
– Ask the patient the usual way to overcome feeling sad /
painful.
– Discuss with patients the benefits of coping used.
– With patients looking for alternatives coping.
– Encourage the patient to choose the most appropriate
coping and acceptable.
– Encourage the patient to try to coping have been.
– Instruct the patient to try other alternatives in solving the
problem.
 Management continued
• 3. Clients are protected from self injuring behavior
Action:
Monitor carefully the risk of suicide / self-mutilation.
• Keep and store the tools that can be used by patients to
injure himself / others, in a safe and locked.
• Keep the tool material harm to the patient.
• Supervise and place the patient in a room that is easily
monitored by nurses.
•
4. Clients can increase self-esteem
Action:
Help to understand that the client can overcome despair.
• Assess and internal sources mobilized individuals.
• Help to identify the sources of expectations (eg, interpersonal
relationships, beliefs, things to be resolved).
 Management continued
• 5. Clients can use social support
Action:
Assess and use individual external sources (those closest to the
team of health care, support groups, religious affiliation).
• Assess support systems beliefs (values, past experiences, religious
activities, religious beliefs).
• Make referrals as indicated (eg, counseling, religious leaders).
•
6. Clients can use the medication correctly and appropriately
Action:
Discuss medications (name, frequency, effects and side effects of
medication).
• Help for using drugs; really patient, medication, method, period.
• Encourage talking about the effects and side effects are felt.
• Give positive reinforcement when using the drug proper
 Bio-psycho-social management
Biological
• Antidepressants may be prescribed to correct imbalances in the
levels of chemicals in the brain. These medications are not
sedatives, “uppers” or tranquilizers. Neither are they habit-forming.
Generally antidepressant medications have no stimulating effect on
those not experiencing depression.
• Antidepressants may produce some improvement within the first
week or two of treatment. Full benefits may not be realized for two
to three months. If a patient feels little or no improvement after
several weeks, the dose of the medication will be altered or will
added or substituted with another antidepressant.

• It is usually recommend that patients continue to take medication

for six or more months after symptoms have improved. After two
or three episodes of major depression, long-term maintenance
treatment may be suggested to decrease the risk of future
episodes.
 Bio management continued
• There are three common types of
antidepressants that are used to manage
depression i.e.
• Selective Serotonin Reuptake Inhibitors
(SSRIs),
• Tricyclics (TCAs)
• Irreversible Monoamine Oxidase Inhibitors
(MAOIs).
 SSRI’s
• Selective serotonin reuptake inhibitors (SSRIs) are the most commonly
prescribed antidepressants. They can ease symptoms of moderate to
severe depression, are relatively safe and generally cause fewer side
effects than other types of antidepressants do.

How SSRIs work

• SSRIs ease depression by affecting naturally occurring chemical
messengers (neurotransmitters), which are used to communicate
between brain cells. SSRIs block the reabsorption (reuptake) of the
neurotransmitter serotonin in the brain. Changing the balance of
serotonin seems to help brain cells send and receive chemical messages,
which in turn boosts mood.
• Most antidepressants work by changing the levels of one or more of these
neurotransmitters. SSRIs are called selective because they seem to
primarily affect serotonin, not other neurotransmitters.

They include
Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac)
Paroxetine (Paxil, Pexeva), Sertraline (Zoloft)
 SSRI’s side effects
• Nausea
• Nervousness, agitation or restlessness
• Dizziness
• Reduced sexual desire or difficulty reaching orgasm or
inability to maintain an erection (erectile dysfunction)
• Drowsiness
• Insomnia
• Weight gain or loss
• Headache
• Dry mouth
• Vomiting
• Diarrhea
 Irreversible Monoamine Oxidase Inhibitors
(MAOIs)
• Monoamine oxidase inhibitors (MAOIs) were the
first type of antidepressants developed. They're
effective, but they've generally been replaced by
antidepressants that are safer and cause fewer
side effects, like ssri’s.
• Use of MAOIs typically requires diet restrictions
because they can cause dangerously high blood
pressure when taken with certain foods or
medications. In spite of side effects, these
medications are still a good option for some
people. In certain cases, they relieve depression
when other treatments have failed
 MAOIs
How MAOIs work
• Antidepressants such as MAOIs ease depression by affecting
chemical messengers (neurotransmitters) used to communicate
between brain cells. Like most antidepressants, MAOIs work by
changing the levels of one or more of these naturally occurring
brain chemicals.
• An enzyme called monoamine oxidase is involved in removing the
neurotransmitters norepinephrine, serotonin and dopamine from
the brain. MAOIs prevent this from happening, which makes more
of these brain chemicals available. This is thought to boost mood by
improving brain cell communication.
• MAOIs also affect other neurotransmitters in the brain and
digestive system, causing side effects. MAOIs are sometimes used
to treat conditions other than depression, such as Parkinson's
disease.
They include;
Isocarboxazid (Marplan), Phenelzine (Nardil),Selegiline
(Emsam),Tranylcypromine (Parnate)
 MAOIs side effects
The most common side effects of MAOIs include:
• Dry mouth
• Nausea, diarrhea or constipation
• Headache
• Drowsiness
• Insomnia
• Skin reaction at the patch site
• Dizziness or lightheadedness
Other possible side effects include:
• Involuntary muscle jerks
• Low blood pressure
• Reduced sexual desire or difficulty reaching orgasm
• Sleep disturbances
• Weight gain
• Difficulty starting a urine flow
• Muscle aches
• Prickling or tingling sensation in the skin (paresthesia)
 Tricyclic and Tetracyclic antidepressants (TCAs)
• Tricyclic and tetracyclic antidepressants, also
called cyclic antidepressants, were among the
earliest antidepressants developed.
• They're effective, but they've generally been
replaced by antidepressants that cause fewer
side effects.
• Other antidepressants are prescribed more
often, but cyclic antidepressants are still a
good option for some people. In certain cases,
they relieve depression when other
treatments have failed
 TCAs
How tricyclic and tetracyclic antidepressants work
• Tricyclic and tetracyclic antidepressants ease depression by
affecting naturally occurring chemical messengers
(neurotransmitters), which are used to communicate between
brain cells.
• Cyclic antidepressants block the absorption (reuptake) of the
neurotransmitters serotonin and norepinephrine, making more of
these chemicals available in the brain. This seems to help brain cells
send and receive messages, which in turn boosts mood. Most
antidepressants work by changing the levels of one or more
neurotransmitters.
• Cyclic antidepressants also affect other chemical messengers, which
can lead to a number of side effects.
They include
Amitriptyline, Amoxapine,Desipramine (Norpramin), Doxepin
Imipramine (Tofranil), Nortriptyline (Pamelor), Protriptyline (Vivactil)
Trimipramine (Surmontil)
 Side effects of TCAs
• Dry mouth
• Blurred vision
• Constipation
• Urinary retention
• Drowsiness
• Increased appetite leading to weight gain
• Drop in blood pressure when moving from sitting to standing,
which can cause lightheadedness
• Increased sweating
Other side effects may include:
• Disorientation or confusion, particularly in older people when the
dosage is too high
• Tremor
• Increased or irregular heart rate
• More-frequent seizures in people who have seizures
• Difficulty achieving an erection, delayed orgasm or low sex drive
 Psychological management
• Psychotherapy
• CBT
• Family therapy
• Psycho education
• Individual counseling
• Psychodynamics
• Motivational interviewing
 Sociological management
• Occupational therapy
• Family therapy
• Community sensitization
 MANIA
• Mania is a state of abnormally elevated or irritable mood, arousal, and/or
energy levels. In a sense, it is the opposite of depression. Mania is a
necessary symptom for certain psychiatric diagnoses(BAD). The word IS
derived from the Greek word "μανία" (mania), "madness, frenzy“ and also
from the verb "μαίνομαι" (mainomai), "to be mad, to rage, to be furious".

• Mania varies in intensity, from mild mania (hypomania) to full-blown

mania with extreme energy, psychotic features, including hallucinations,
delusion of grandeur, suspiciousness, catatonic behavior, aggression, and
a preoccupation with thoughts and schemes that may lead to self-neglect.
Standardized tools such as Altman Self-Rating Mania Scale and Young
Mania Rating Scale can be used to measure severity of manic episodes

• Manic episodes begin suddenly and with a rapid escalation of symptoms

over a few days. They may follow psychosocial stressors or a major
depressive episode.
 Causes of Mania
• Manic syndromes have many neurologic, toxic, and metabolic causes. It is
important for clinicians to be able to distinguish these organic disorders
from primary idiopathic mania (bipolar disorder).
• The cardinal symptom of organic mania is an abnormally and persistently
elevated or irritable mood. Organic mania usually develops in patients
who are older than 35 years of age, whereas bipolar disorder generally
has its onset between late adolescence and age 25 years.
• In patients with the first episode of mania, the clinician should thoroughly
elicit information about current symptoms, recent infections, use of
drugs, and past or family history of psychiatric disorders.
• In addition, a complete medical examination, computed tomography of
the head, electroencephalography, and screening for drugs and toxins
should be done. Treatment of organic mania includes correcting the
underlying disorder when possible
 Causes of mania
• Neurologic disorders can produce "secondary" mania. Clinicians must
distinguish secondary mania from primary, idiopathic manic-depressive
illness (MBI).
• In addition to medical and drug-induced causes of secondary mania,
neurologic causes usually develop in older patients who may lack a strong
family history of BDI.
• Neurologic causes of mania include focal strokes in the right
basotemporal or inferofrontal region, strokes or tumors in the
perihypothalamic region, Huntington's disease and other movement
disorders, multiple sclerosis and other white matter diseases, head
trauma, infections such as neurosyphilis and Creutzfeldt-Jakob disease,
and frontotemporal dementia.
• Patients with new-onset mania require an evaluation that includes a
thorough history, a neurologic examination, neuroimaging, and other
selected tests.
• The management of patients with neurologic mania involves correcting
the underlying disorder when possible and the use of drugs such as the
anticonvulsant medications.
 Diagnostic criteria for Mania
• A Manic Episode is defined by a distinct period
during which there is an abnormally and
persistently elevated, expansive, and irritable
mood. This period of abnormal mood must
last at least 1 week (or less if hospitalization is
required). The mood disturbance must be
accompanied by at least three symptoms.
1.A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood lasting at least 1 week (or any duration
if hospitalization is necessary).
 Diagnostic criteria for Mania
2. During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have
been present to a significant degree:
– inflated self-esteem or grandiosity
– decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
– more talkative than usual or pressure to keep talking
– flight of ideas or subjective experience that thoughts are racing
– distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)
– increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation
– excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., engaging in unrestrained
buying sprees, sexual indiscretions, or foolish business investments)
 Diagnostic criteria for Mania
3. The symptoms do not meet criteria for a Mixed Episode
(characterized by the symptoms of both a Manic Episode and
Major Depressive Episode)
4. The mood disturbance is sufficiently severe to cause marked
impairment in occupational functioning or in usual social
activities or relationships with others, or to necessitate
hospitalization to prevent harm to self or others, or there are
psychotic features.
5. The symptoms are not due to the direct physiological effects
of a substance (e.g., a drug of abuse, a medication, or other
treatment) or a general medical condition (e.g.,
hyperthyroidism).
 Differential diagnosis for mania
• A Manic Episode must be distinguished from a Mood Disorder
Due to a General Medical Condition.
• The appropriate diagnosis would be Mood Disorder Due to a
General Medical Condition if the mood disturbance is judged
to be the direct physiological consequence of a specific
general medical condition.
• This determination is based on the history, laboratory
findings, or physical examination.
• If it is judged that the manic symptoms are not the direct
physiological consequence of the general medical condition,
then the primary Mood Disorder is recorded.
• A late onset of a first Manic Episode (e.g., after age 50 years)
should alert the clinician to the possibility of an etiological
general medical condition or substance
 Nursing diagnosis and care plan for Mania
• Clients in the grip of a manic episode must be assessed for
risk of suicide, risk of violence or harm to others, and for their
level of ability to adhere to treatment.
• Any antidepressants currently being taken should be
stopped, and the use of alcohol or other substances of abuse
evaluated and treated. This includes addressing how much
sugar (often in the form of "energy drinks"); caffeine and
nicotine are being used to support or maintain the feelings of
mania.
Assessment
– a physical assessment of the patient
– assessment of the patient's ability and any assistance they
need to accomplish their activities of daily living with the
disease
Nursing diagnosis and care plan for
Mania
– data collected from the medical record (information in the doctor's
history and physical, information in the doctor's progress notes, test
result information, notes by ancillary healthcare providers such as
physical therapists and dietitians
– knowing the pathophysiology, signs/symptoms, usual tests ordered,
and medical treatment for the medical disease or condition that the
patient has. this includes knowing about any medical procedures that
have been performed on the patient, their expected consequences
during the healing phase, and potential complications. if this
information is not known, then you need to research and find it.
– Nursing diagnoses vary among patients experiencing mania. Primary
consideration in acute mania is prevention of exhaustion and death
from cardiac collapse. Most probable diagnosis is risk for injury due to
excessive and constant motor activity, poor judgment etc
 Goals for nursing a person experiencing mania
Appropriate goals for caring for a person with mania in a
community or hospital setting include:
• Develop a relationship with the person based on empathy and trust.
• Ensure that the person remains free from injury.
• Assist the person to decrease their agitation and hyperactivity.
• Promote an understanding of the features and appropriate management
of mania, such as
– mood regulation strategies or behaviors.
– Promote positive health behaviors, including medication compliance and healthy
lifestyle choices (for example, diet, exercise, not smoking etc.).
• Promote the person’s engagement with their social and support network.
• Ensure effective collaboration with other relevant service providers,
through development of effective working relationships and
communication.
• Support and promote self-care activities for families and carers of the
person with mania.
 Bio- Psycho – Social management of Mania
• The treatment of mania starts with a correct diagnosis and elementary
measures to prevent risks for the patient, relatives, and others.
Sometimes, compulsory admission and treatment may be required for a
few days.
• Patients with psychotic or mixed mania may be more difficult to treat. At
the present time, there is solid evidence supporting the use of lithium,
the anticonvulsants valproate and carbamazepine, and the
antipsychotics chlorpromazine, haloperidol, risperidone, olanzapine,
quetiapine, ziprasidone, aripiprazole, and asenapine in acute mania, and
some evidence supporting the use of clozapine or electroconvulsive
therapy in treatment-refractory cases.
• However, in clinical practice, combination therapy is the rule. The
treatment of acute mania deserves a long-term view, and the evidence
base for some treatments may be stronger than for others. When taking
decisions about treatment, tolerabiliiy should also be a major concern, as
differences in safety and tolerability may exceed differences in efficacy for
most compounds, Psychoeducation of patients and caregivers is a
powerful tool that should be used in combination with medication for
optimal long-term outcome. Functional recovery should be the ultimate
goal.
 Psychological treatment
• psychoeducation – finding out more about the
disorder
• mood monitoring – helps you to pick up when
your mood is swinging
• mood strategies – to help you stop your mood
swinging into a full-blown manic episode
• help to develop general coping skills
• cognitive behavioral therapy (CBT) for
depression.
 Social treatment
• For group research
 Bipolar Affective Disorder/ Manic depression
• Bipolar disorder used to be called ‘manic depression’.
• As the older name suggests, someone with bipolar disorder will have
severe mood swings. These usually last several weeks or months and are
far beyond what most of us experience
• Bipolar Affective Disorder is a disease of extremes. Bipolar Affective
Disorder (aka bipolar disorder, bipolar disease, or manic-depression)
consists of excessive swings in mood very different from the normal ups
and downs of daily life we all experience.
• The shifts in mood, energy, and the ability to function in life that spring
from bipolar disease can manifest in several forms ranging from periods of
hyper-energy to intervals of deeply morbid depression, and can lead to
job loss, damage to relationships, and even suicide.
• Often the presence of bipolar disease goes unrecognized, and untreated.
When diagnosed, treatment for bipolar disease differs from that
conventionally used for unipolar depression.
• The ability of health professionals to recognize signs of bipolar mood
swings is an important skill, as is the understanding of current treatment
and management of this potentially life crippling disorder
 BAD as a spectrum disorder
• It may be helpful to think of the various mood
states in bipolar disorder as a spectrum or
continuous range.
• At one end is severe depression, above which
is moderate depression and then mild low
mood, which many people call “the blues”
when it is short-lived but is termed
“dysthymia” when it is chronic.
• Then there is normal or balanced mood,
above which comes hypomania (mild to
moderate mania), and then severe mania.
Diagrammatic representation of BAD
 Cause of Bipolar disorder
• Experts do believe that bipolar disorder often runs in
families, and there is a genetic part to this mood
disorder.
• There is also growing evidence that environment and
lifestyle issues have an effect on the disorder's
severity. Stressful life events or alcohol or drug abuse
can make bipolar disorder more difficult to treat.
The Brain and Bipolar Disorder
• Experts believe bipolar disorder is partly caused by
an underlying problem with specific brain circuits
and the balance of brain chemicals called
neurotransmitters
 Causes of BAD
• Three brain chemicals noradrenaline (norepinephrine),
serotonin, and dopamine are involved in both brain and
bodily functions.
• Noradrenaline and serotonin have been consistently linked to
psychiatric mood disorders such as depression and bipolar
disorder.
• Dopamine is commonly linked with the pleasure system of
the brain. Disruption to the dopamine system is linked to
psychosis and schizophrenia, a severe mental disorder
characterized by distortions in reality and illogical thought
patterns and behaviors.
• The brain chemical serotonin is linked to many body functions
such as sleep, wakefulness, eating, sexual activity, impulsivity,
learning, and memory.
• Researchers believe that abnormal functioning of brain
circuits that involve serotonin as a chemical messenger
contribute to mood disorders
 Causes of BAD
Genetics
• Many studies of bipolar patients and their relatives
have shown that bipolar disorder can run in families.
Perhaps the most convincing data come from twin
studies.
• In studies of identical twins, scientists report that if
one identical twin has bipolar disorder, the other
twin has a greater chance of developing bipolar
disorder than another sibling in the family.
• Researchers conclude that the lifetime chance of an
identical twin (of a bipolar twin) to also develop
bipolar disorder is about 40% to 70%.
 Causes of BAD
Environment and Lifestyle
• Research reveals that children of bipolar parents are often
surrounded by significant environmental stressors, such as
living with a parent who has a tendency toward mood swings,
alcohol or substance abuse, financial and sexual indiscretions,
and hospitalizations.
• Although not all bipolar offspring will develop bipolar
disorder, many children of bipolar parents do progress to a
different psychiatric disorder such as ADHD, major
depression, schizophrenia, or substance abuse.
• Environmental stressors also play a role in triggering bipolar
episodes in those who are genetically predisposed.
 Nursing assessment and diagnosis of BAD
• Assess signs and symptoms of mania and
hypomania, depression, psychotic symptoms,
and mixed affective states
• Clinical assessment according to criteria from
the International Classification of Diseases of
the World Health Organization, 10th edition
(ICD-10) and the Diagnostic and Statistical
Manual, 4th edition (DSM-IV)
• Clinical Interview for DSM (SCID)
• Present State Examination (PSE)
• Diagnostic scales (refer to depression and
mania)
 Guidelines for nursing diagnosis for BAD
Defining Characteristics for sensory distortion
• Change in behavior pattern; change in problem-solving abilities; change in sensory
acuity; change in usual response to stimuli; disorientation; hallucinations; impaired
communication; irritability; poor concentration; restlessness; sensory distortions
Related Factors
• Related to; Altered sensory integration; altered sensory reception; altered sensory
transmission; biochemical imbalance; electrolyte imbalance; excessive
environmental stimuli; insufficient environmental stimuli; psychological stress
Defining Characteristics for self neglect
• Inadequate personal hygiene; inadequate environmental hygiene; non adherence
to health activities
Related Factors
• Related to Capgras syndrome; cognitive impairment (i.e., dementia); depression;
learning disability; fear of institutionalization; frontal lobe dysfunction and
executive processing ability; functional impairment; lifestyle/choice; maintaining
control; malingering; obsessive compulsive disorder; schizotypal personality
disorder; paranoid personality disorder; substance abuse; major life stressor (i.e.,
coping difficulty); mental retardation
 Guidelines for nursing diagnosis for BAD
• Consider ineffective individual coping
• Risk for self harm etc
• Risk for other – directed violence
 Bio –Psych – Social management of BAD
• Bipolar disorder requires lifelong treatment,
even during periods when you feel better
• The treatment team includes psychiatrists,
psychologists, social workers, psychiatric
nurses, PCOs, and Occupational therapists
• The primary treatments for bipolar disorder
include medications; individual, group or
family psychological counseling
(psychotherapy), psycho education and
support groups.
 Medications for bipolar disorder
• Lithium. Lithium (Lithobid) is effective at stabilizing mood and
preventing the extreme highs and lows of certain categories
of bipolar disorder and has been used for many years.
– Periodic blood tests are required, since lithium can cause thyroid and
kidney problems. Common side effects include restlessness, dry
mouth and digestive issues.
• Anticonvulsants. These mood-stabilizing medications include
valproic acid (Depakene, Stavzor), divalproex (Depakote) and
lamotrigine (Lamictal).
– The medication asenapine (Saphris) may be helpful in treating mixed
episodes.
– Depending on the medication you take, side effects can vary. Common
side effects include weight gain, dizziness and drowsiness. Rarely,
certain anticonvulsants cause more serious problems, such as skin
rashes, blood disorders or liver problems.
 Medications for bipolar disorder
• Antipsychotics. Certain antipsychotic medications, such as
aripiprazole (Abilify), olanzapine (Zyprexa), risperidone
(Risperdal) and quetiapine (Seroquel), may help people who
don't benefit from anticonvulsants. The only antipsychotic
that's specifically approved by the U.S. Food and Drug
Administration (FDA) for treating bipolar disorder is
quetiapine. However, other medications can also be
prescribed for bipolar disorder. Side effects depend on the
medication, but can include weight gain, sleepiness, tremors,
blurred vision and rapid heartbeat. Weight gain in children is
a significant concern. Antipsychotic use may also affect
memory and attention and cause involuntary facial or body
movements.
• Treatment is holistic (combination therapy). Consider anti
depressants, anxiolitics (benzodiazepines). ECT,
Hospitalization
 Psychological management for BAD
• Cognitive behavioral therapy
• Psycho education
• Family therapy
• Group therapy
Class assignment
• Management of bipolar in pregnancy
• Different types of bipolar
• Management of the different types of bipolar
 Major psychiatric illness
(Schizophrenia)
• Schizophrenia is a chronic, severe, and disabling brain
disorder that has affected people throughout history.
• People with the disorder may hear voices other people don't
hear. They may believe other people are reading their minds,
controlling their thoughts, or plotting to harm them.
• This can terrify people with the illness and make them
withdrawn or extremely agitated.
• People with schizophrenia may not make sense when they
talk. They may sit for hours without moving or talking.
• Sometimes people with schizophrenia seem perfectly fine
until they talk about what they are really thinking.
 Causes of Schizophrenia
• The exact causes of schizophrenia are unknown, but research suggests
that a combination of physical, genetic, psychological and environmental
factors can make people more likely to de
Genetics
• Schizophrenia tends to run in families, but no individual gene is
responsible. It is more likely different combinations of genes might make
people more vulnerable to the condition. However, having these genes
does not necessarily mean you will develop schizophrenia
Environmental factors
• social factors are largely responsible in causing schizophrenia as it is a
psychosocial disorder. Traumatic events in life, poor relationships and
sudden disastrous changes play an important role in onset of this illness.
Patients become paranoid and fear anything new coming in their lives.
they are unable to cope with the physical or environmental changes and
stress, and anxiety occurs. Hostile or critical parentage can also increase
the risk of schizophrenia.
 Causes of schizophrenia
Neurotransmitters
• Research suggests schizophrenia may be caused by a change in the level
of two neurotransmitters, dopamine and serotonin. Some studies
indicate an imbalance between the two may be the basis of the problem.
Others have found a change in the body’s sensitivity to the
neurotransmitters is part of the cause of schizophrenia.
Pregnancy and birth complications
• Although the effect of pregnancy and birth complications is very small,
research has shown the following conditions may make a person more
likely to develop schizophrenia in later life:
• bleeding during pregnancy, gestational diabetes or pre-eclampsia
(conditioning affecting expectant mothers in the second trimester might
present with high BP, edema of the feet, )
• abnormal growth of a baby while in the womb, including low birth weight
or reduced head circumference
• exposure to a virus while in the womb
• complications during birth, such as a lack of oxygen (asphyxia) and
emergency caesarean section
 Assessment and diagnosis of schizophrenia
• Positive symptoms
– Delusions (Reference, persecution, grandeur, erotomania,
control)
– Hallucinations (mainly auditory at times visual but not very
common)
– Disorganized speech (loosening of association, neologisms,
perseveration, clang; meaningless use of rhyming words )
– Disorganized behavior
• Negative symptoms
– Lack of interest or enthusiasm
– Lack of emotional expression
– Lack of interest in the world
– Speech difficulties and abnormalities
Assessment and diagnosis of schizophrenia
• Schineiderian first rank symptoms
Nursing diagnosis
• Analysis of positive and negative symptoms.
• Analysis of strengths and weaknesses of clients, including:
Self-care ability, socialization, communication, reality-testing
job skills, support system
• Analysis of factors that increase the risk of behavioral
expression of the unconscious, including: agitation, angry
suspicious, and the existence of hallucinations that threaten
• Establish and prioritize nursing diagnoses for clients and their
families. e.g. Low self esteem, chronic Ineffective family coping:
worsening, Impaired home maintenance management
Ineffective individual coping, Lack of knowledge (please
specify.
 Nursing management
SHORT TERM GOALS
• Sufficient and regular Nutrition, adequate rest and safe
activity.
• Keep the patient in a safe environment.
• Establish communication and build trust. Helping the patient
to participate in the therapeutic community.
• Increase the patient’s ability to communicate with others.
• Decrease of hallucinations, delusions and other psychotic
symptoms.
• Reduce injury .
• Increase self-esteem
 Nursing management
LONG TERM GOALS
• Identify and use the patient’s forces and
potentialities, and develop a better self-
image.
• Achieve and maintain the highest standards of
operation/functionality.
• Cause the patient to accept and effectively
manage the disease.(Psycho education)
 Nursing Management
• Reduce inhibited behavior, provide a structured goal-directed
activity:
– Spend time with the patient even if he/she can not respond verbally.
Direct our concern and care.
– Promise only what you can accomplish realistically.
– Providing the opportunity to learn that their feelings are valid and do
not differ much from others
– Limit the patient’s environment to increase their feelings of safety.
– Assign team members to attend the patient therapeutic.
– Start with interactions one by one, and then make progress for the
patient to join small groups as tolerated (enter slowly).
– Establish and maintain a daily routine; explain any variation in this
patient.
 Nursing management
• Increase patient’s self-esteem and feelings of worth:
– Provide care in a sincere manner.
– Support your patient in all your successes-enforcement
responsibilities within the service, projects, interactions
with members of the treatment team and other patients,
and so on.
– Helping the patient to improve their appearance help him
when necessary to shower, get dressed, try washing their
clothes, etc..
– Assist the patient to accept greater responsibility for their
personal hygiene to the extent that he/she can do it on
their own.
– Spend enough time with the patient.
 Nursing management
• orient the patient in reality:
– Reorient the patient in person, place and time as needed (call it
by name, say the name of the nurse, tell where you are, give
the date, etc..).
• Increase the ability of the patient to differentiate
between the concept of self and the external
environment:
– Helping the patient to distinguish what is real and what is not.
Assess the patient’s actual perceptions and sensory perception,
correct errors in a form that is attached to the facts. Do not
argue with the limited validity of patient’s perceptions nor
provide support for them.
 Nursing management
• Helping the patient to restore the boundaries of the
self:
– Stay with the patient ,if you are afraid, sometimes
touching the patient can be therapeutic. Evaluate the
effectiveness of physical contact use in each patient
before you start using consistently.
– Be simple, honest and concise when speaking with the
patient.
– Talk with the patient specific issues and simple, avoid
ideological or theoretical discussions.
– Direct the activities to help the patient to accept the
reality and keep in touch with her, using creative
occupational therapy when appropriate.
 Nursing management
• Ensuring a safe environment for the patient.
– Re affirm the patient of the security of the environment
by explaining the procedures followed in the service,
routines, tests, etc., In a brief and simple manner.
– Protect the patient from self-destructive tendencies
(removing objects that could be used in self-destructive
behavior).
– Realize that the patient is up to actions that are
harmful to themselves and others in response to
auditory hallucinations.
 Nursing management
• Keep a safe, therapeutic environment for other
patients.
– Remove the patient from the group if their behavior
becomes too crowded, annoying or dangerous to others.
– Help the group of patients to accept ‘strange’ behavior give
simple explanations to the group of patients when necessary
(for example, “the patient is very ill at this time, he/she will
need our understanding and support”).
– Consider the needs of other patients and plan for at least
one member of the treatment team to be available to other
patients if others are needed for patient care for the
newcomer.
 Nursing management
• Helping the patient to overcome his regressive behavior.
– Remember: The regression is a purposeful return (conscious or
unconscious) to a lower level of functioning-an attempt to eliminate
anxiety and restore balance.
– Assess the current level of functioning of the patient and go from that
point to your attention.
– Contact the patient’s level of behavior, then try to encourage him to
leave his regressive behavior and integrated into adult behavior. Help
identify unmet needs or feelings that cause regressive behavior.
Encouraging children to express these feelings and help relieve
anxiety.
– Establish realistic objectives and expectations everyday.
– Ensure that the patient becomes aware of what is expected from him.
 Bio- psycho- social Management
• In first-episode schizophrenia, antipsychotic
pharmacological treatments should be introduced
with great care due to the higher risk of
extrapyramidal symptoms
• Antipsychotics are usually recommended as the initial
treatment for the symptoms of an acute schizophrenic
episode. Antipsychotics work by blocking the effect of
the chemical dopamine on the brain.
• Antipsychotics can usually reduce feelings of anxiety
or aggression within a few hours of use, but may take
several days or weeks to reduce other symptoms, such
as hallucinations or delusional thoughts.
 Bio- psycho- social Management
• You may only need antipsychotics until your acute
schizophrenic episode has passed. However, most
people take medication for one or two years after their
first psychotic episode to prevent further acute
schizophrenic episodes occurring and for longer if the
illness is recurrent.
• There are two main types of antipsychotics:
– Typical antipsychotics which are the first generation of
antipsychotics developed during the 1950s e.g. haloperidol,
chlorpromazine and fluphenazine. (have more extra pyramidal
side effects)
– Atypical antipsychotics which are the second generation of
antipsychotics developed during the 1990s. E.g. clozapine,
aripiprazole, resperidone and olanzapine (have less
extrapyramidal side effects)
 Bio- psycho- social Management
• Some patients experience predominant negative symptoms,
demonstrating a lack of goal-directed behavior, a lack of
emotional expressiveness and a lack of spontaneous
speech. For these patients, additional treatment with
certain antidepressants may result in improvements in
these symptoms. SSRIs and Benzodiazepines have been
found to be helpful
• For patients presenting with catatonic features, the option
of ECT should be considered earlier when insufficient
response to benzodiazepines is observed.
 Bio- psycho- social Management
• Psychosocial treatment may not “work” if the term work is
narrowly applied to remission of acute episodes, control of
symptoms, and prevention of relapses. However, these are not
the only criteria by which an intervention for this complex
disease should be judged.
• Schizophrenia is characteristically a multiply handicapping,
chronic disorder involving marked impairments in social role
functioning (eg, as a spouse or a worker), excess rates of
medical illness, and poor quality of life.
• Psychosocial interventions can play a critical role in a
comprehensive intervention program, and are probably
necessary components if treatment is viewed in the context of
the patient's overall level of functioning, quality of life, and
compliance with prescribed treatments.
 Bio- psycho- social Management
Current thinking suggests that, in addition to
medication, effective care, and management,
patients with schizophrenia require:
• Problem-specific psychosocial treatment
• Family psycho education
• Day hospital/vocational rehabilitation and
educational opportunities
• Access to crisis counseling
• Easily available inpatient psychiatric care