Assignment: Assessing and Treating Clients with Bipolar Disorder

Assignment: Assessing and Treating Clients with Bipolar Disorder

Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients often present as depressive or manic, but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology.  Assignment: Assessing and Treating Clients with Bipolar Disorder. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder.

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Learning Resources:

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

 

· Chapter 6, “Mood Disorders”

· Chapter 8, “Mood Stabilizers”

Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge University Press.

 

To access the following chapters, click on the Illustrated Guides tab and then the Mood Stabilizers tab.

· Chapter 4, “Lithium and Various Anticonvulsants as Mood Stabilizers for Bipolar Disorder”

· Chapter 5, “Atypical Antipsychotics as Mood Stabilizers for Bipolar Disorder”

Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331-333. doi:10.1007/s40263-013-0060-3

To prepare for this Assignment: Assignment: Assessing and Treating Clients with Bipolar Disorder

· Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.

The Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

· Decision #1

· Which decision did you select?

· Why did you select this decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this decision? Assignment: Assessing and Treating Clients with Bipolar Disorder. Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

· Decision #2

· Why did you select this decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Assignment: Assessing and Treating Clients with Bipolar Disorder

· Decision #3

· Why did you select this decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. Assignment: Assessing and Treating Clients with Bipolar Disorder. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Citation for book pages sent for Chapters 6 and 8:

Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved March 21, 2019 from

http://stahlonline.cambridge.org.ezp.waldenulibrary.org/essential_4th_chapter.jsf?page=chapter6_summary.htm&name=Chapter%206&title=Summary

  // Bipolar Therapy

Bipolar Therapy Client of Korean Descent/Ancestry

 

BACKGROUND INFORMATION

The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? Assignment: Assessing and Treating Clients with Bipolar Disorder. I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weights 110 lbs. and is 5’ 5”

SUBJECTIVE

Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago. Assignment: Assessing and Treating Clients with Bipolar Disorder

MENTAL STATUS EXAM

The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. Assignment: Assessing and Treating Clients with Bipolar Disorder. She is currently denying suicidal or homicidal ideation.

The Young Mania Rating Scale (YMRS) score is 22

  // Bipolar Therapy

Bipolar Therapy Client of Korean Descent/Ancestry

sian girl

Assignment: Assessing and Treating Clients with Bipolar Disorder

Decision Point One

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/04/mm/bipolar_therapy/img/pill-red.pngBe I started Lithium 300mg orally BID

gin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”

·  Today’s presentation is similar to the first day you met her

Decision Point Two

Be I decided to assess for rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology.t00

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client states that the drug makes her nauseated and gives her diarrhea

·  Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

Decision Point Three

Be I decided to change Lithium to sustained release preparation at same dose and frequency.

RESULTS OF DECISION POINT THREE

Guidance to Student In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Assignment: Assessing and Treating Clients with Bipolar Disorder. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.  Assignment: Assessing and Treating Clients with Bipolar Disorder

Mood disorders

This chapter discusses disorders characterized by abnormalities of mood: namely, depression, mania, or both. Included here are descriptions of a wide variety of mood disorders that occur over a broad clinical spectrum. Also included in this chapter is an analysis of how monoamine neurotransmitter systems are hypothetically linked to the biological basis of mood disorders. Assignment: Assessing and Treating Clients with Bipolar Disorder. The three principal monoamine neurotransmitters are norepinephrine (NE; also called noradrenaline or NA), discussed in this chapter, dopamine (DA), discussed in , and serotonin (also calledChapter 4 5-hydroxytryptamine or 5HT), discussed in .Chapter 5

The approach taken here is to deconstruct each mood disorder into its component symptoms, followed by matching each symptom to hypothetically malfunctioning brain circuits, each regulated by one or more of the monoamine neurotransmitters. Genetic regulation and neuroimaging of these hypothetically malfunctioning brain circuits are also discussed. Coverage of symptoms and circuits of mood disorders in this chapter is intended to set the stage for understanding the pharmacological concepts underlying the mechanisms of action and use of antidepressants and mood stabilizing drugs, which will be reviewed in the following two chapters ( and ). Assignment: Assessing and Treating Clients with Bipolar Disorder

Chapters 7 8

Clinical descriptions and criteria for how to diagnose disorders of mood will only be mentioned in passing. Assignment: Assessing and Treating Clients with Bipolar Disorder. The reader should consult standard reference sources for this material.

Description of mood disorders

Disorders of mood are often called affective disorders, since affect is the external display of mood, an emotion that is felt internally. Depression and mania are often seen as opposite ends of an affective or mood spectrum. Classically, mania and depression are "poles" apart, thus generating the terms depression (i.e., patients who just experience the or depressed pole) and unipolar down

(i.e., patients who at different times experience either the [i.e., manic] pole or the bipolar up down [i.e., depressed] pole). Depression and mania may even occur simultaneously, which is called a

mood state. Mania may also occur in lesser degrees, known as , or switch somixed hypomania

Figure 6-1. . Bipolar disorder is generally characterized by four types of illness episodes: manic,Mood episodes major depressive, hypomanic, and mixed. A patient may have any combination of these episodes over the course of illness; subsyndromal manic or depressive episodes also occur during the course of illness, in which case there are not enough symptoms or the symptoms are not severe enough to meet the diagnostic criteria for one of these episodes. Thus the presentation of mood disorders can vary widely. Assignment: Assessing and Treating Clients with Bipolar Disorder

fast between mania and depression that it is called .rapid cycling

Mood disorders can be usefully visualized not only to contrast different mood disorders from one another, but also to summarize the course of illness for individual patients by showing them mapped onto a mood chart. Thus, mood ranges from hypomania to mania at the top, to euthymia (or normal mood) in the middle, to dysthymia and depression at the bottom ( ). The most common andFigure 6-1 readily recognized mood disorder is major depressive disorder ( ), with single or recurrentFigure 6-2

Assignment: Assessing and Treating Clients with Bipolar Disorder

episodes. Dysthymia is a less severe but long-lasting form of depression ( ). Patients with aFigure 6-3 major depressive episode who have poor inter-episode recovery, only to the level of dysthymia, followed by another episode of major depression are sometimes said to have "double depression," alternating between major depression and dysthymia, but not remitting ( ).Figure 6-4

Patients with bipolar I disorder have full-blown manic episodes or mixed episodes of mania plus depression, often followed by a depressive episode ( ). When mania recurs at least fourFigure 6-5 times a year, it is called rapid cycling ( ). Patients with bipolar I disorder can also haveFigure 6-6A rapid switches from mania to depression and back ( ). By definition, this occurs at leastFigure 6-6B four times a year, but can occur much more frequently than that.

Bipolar II disorder is characterized by at least one hypomanic episode that follows a depressive episode ( ). Cyclothymic disorder is characterized by mood swings that are not as severeFigure 6-7 as full mania and full depression, but still wax and wane above and below the boundaries of normal mood ( ). Assignment: Assessing and Treating Clients with Bipolar Disorder. There may be lesser degrees of variation from normal mood that are stable andFigure 6-8 persistent, including both depressive temperament (below normal mood but not a mood disorder) and hyperthymic temperament (above normal mood but also not a mood disorder) ( ).Figure 6-9 Temperaments are personality styles of responding to environmental stimuli that can be heritable patterns present early in life and persisting throughout a lifetime; temperaments include such independent personality dimensions as novelty seeking, harm avoidance, and conscientiousness. Some patients may have mood-related temperaments, and these may render them vulnerable to mood disorders, especially bipolar spectrum disorders, later in life. Assignment: Assessing and Treating Clients with Bipolar Disorder

Figure 6-2. . Major depression is the most common mood disorder and is defined by theMajor depression occurrence of at least a single major depressive episode, although most patients will experience recurrent episodes. Assignment: Assessing and Treating Clients with Bipolar Disorder

Figure 6-3. . Dysthymia is a less severe form of depression than major depression, but long-lastingDysthymia (over 2 years in duration) and often unremitting.

Figure 6-4. . Patients with unremitting dysthymia who also experience the superimpositionDouble depression of one or more major depressive episodes are described as having double depression. This is also a form of recurrent major depressive episodes with poor inter-episode recovery.

Figure 6-5. . Bipolar I disorder is defined as the occurrence of at least one manic or mixedBipolar I disorder (full mania and full depression simultaneously) episode. Patients with bipolar I disorder typically experience major depressive episodes as well, although this is not necessary for the bipolar I diagnosis. Assignment: Assessing and Treating Clients with Bipolar Disorder

Figure 6-6

A. . The course of bipolar disorder can be rapid cycling, which means that at least fourRapid cycling mania episodes occur within a 1-year period. This can manifest itself as four distinct manic episodes, as shown here. Many patients with this form of mood disorder experience switches much more frequently than four times a year.

B. . A rapid cycling course (at least four distinct mood episodes within 1 year) can alsoRapid cycling switches manifest as rapid switches between manic and depressive episodes.

Figure 6-7. . Bipolar II disorder is defined as an illness course consisting of one or moreBipolar II disorder major depressive episodes and at least one hypomanic episode. Assignment: Assessing and Treating Clients with Bipolar Disorder

Figure 6-8. . Cyclothymic disorder is characterized by mood swings between hypomaniaCyclothymic disorder and dysthymia but without any full manic or major depressive episodes.

Figure 6-9. . Not all mood variations are pathological. Individuals with depressive temperamentTemperaments may be consistently sad or apathetic but do not meet the criteria for dysthymia and do not necessarily experience any functional impairment. However, individuals with depressive temperament may be at greater risk for the development of a mood disorder later in life. Assignment: Assessing and Treating Clients with Bipolar Disorder. Hyperthymic temperament, in which mood is above normal but not pathological, includes stable characteristics such as extroversion, optimism, exuberance, impulsiveness, overconfidence, grandiosity, and lack of inhibition. Individuals with hyperthymic temperament may be at greater risk for the development of a mood disorder later in life.

Assignment: Assessing and Treating Clients with Bipolar Disorder