1
Q
is bipolar disorder chronic and a life threatening illness?
A
yes
2
Q
Explain how bipolar disorder “cycles”
A
pts with bipolar disorder cycle through different periods of normal functioning, mania, hypomania, or periods of depression.
3
Q
What are the ranges of symptoms on a continuum of bipolar disorder?
A
mania
depressive symptoms
mixed (Both)
4
Q
at what age does bipolar disorder usually onset?
A
18
5
Q
can bipolar disorder be induced by menopause?
A
yes
6
Q
which gender does bipolar 1 disorder effect more?
A
both male and female equally
7
Q
which gender does bipolar 2 disorder effect more?
A
female
8
Q
Why does bipolar disorder occur? What are the causes?
A
- genetics
- neurobiological factors
- neuroendocrine factors
- neuroanatomical factors
- environmental and psychological influences
- cultural considerations
9
Q
What are neuroanatomical factors of bipolar disorder?
A
- pts have less gray matter volume
- smaller amygdala
10
Q
what are some examples of neuroendocrine factors of bipolar disorder?
A
hormones play a BIG ROLE
Women who have bipolar disorder have worse PMS symptoms
11
Q
What can lead to a relapse of bipolar disorder?
A
sleep
12
Q
what are some examples of environmental and psychological influences in bipolar disorder?
A
- stress
- interpersonal conflict
- poor sleep
13
Q
What three diagnoses do pts with bipolar 1 disorder cycle between?
A
- at least one episode of mania
- major depressive disorder
- possible psychosis
14
Q
Does a pt with bipolar disorder 1 experience psychosis? What do they experience with psychosis?
A
yes, delusions or hallucinations
15
Q
in a pt with bipolar disorder 1, and experiencing psychosis, what “kind” of delusions do they experience?
A
- grandeur delusions
- paranoid delusions
16
Q
What are signs of mania in bipolar 1 disorder?
A
- euphoria or agitation
- irritability or anger
- increased energy
- rapid speech
- flight of ideas
- delusions of grandeur
- decreased need for sleep
17
Q
Define mania
A
when someone has a persistent or elevated or irritable mood accompanied by these changes in these activities or energy
18
Q
What is KEY to know if someone is going through a manic episode?
A
Decreased need for sleep
they won’t sleep for days or weeks
19
Q
What is the key difference between bipolar 1 and bipolar 2 disorder?
A
Bipolar 1 has MANIA
Bipolar 2 has HYPO mania
20
Q
Difference between mania and hypomania?
A
someone with mania CANNOT function but someone with HYPOmania can function and can sleep
21
Q
What do pts with bipolar disorder 2 typically cycle between?
A
- at least one period of mania
- one or more periods of depression
22
Q
What are some depressive characteristic s of a pt with bipolar 2 disorder?
A
1.hoplessness/ sadness
2. altered sleep
3. appetite and weight changes
4. inability to concentrate
5. inability to make decisions
6. suicidal thoughts
23
Q
what do pts with bipolar2 disorder not experience that is KEY in bipolar 1?
A
no psychosis
no hallucinations
no delusions
24
Q
Hypomania or Mania
EX: Treats everyone with familiarity and confidentiality; often borders on crude
A
hypomania
25
hypomania or mania
EX: Becomes inappropriately demanding of peoples attention, and intrusive nature repels others
mania
26
Hypomania or Mania
EX: May have a voracious appetite, eat on the run, or gobble food during brief periods
hypomania
27
hypomania or mania
EX: no time to eat-too distracted and disorganized
mania
28
What "type" of foods are the best option for Mania pts?
finger foods because they don't think too eat
29
Explain delirious mania
happens acutely, life threatening, and happens quickly and suddenly.
1. disoriented
2. psychosis
3. catatonia
30
What is cyclothymic disorder
When they alternate between hypomania and depression
**they have multiple hypomania episodes**
31
If someone is showing symptoms of mania, what are the PRIORITIES to find in your assessment?
1. dehydration
2. cardiac status
3. sleep
4. safety
PHYSIOLOOGICAL PRIORITIES
**We want to make sure they aren't using up too much energy that leads up to these issues**
32
What can lead to cardiac collapse?
not getting enough sleep
33
If a patient is impulsive what is a priority?
Ex: blurting out words or making certain gestures
safety safety safety
34
What is a "good" amount of sleep for someone with mania?
4-6 hours of sleep
35
how often should you get vitals for someone with mania?
multiple times during the day
***attempt like around every hr or at least the HR**
36
Would competitive activities be optimal for someone with bipolar disorder/mania?
Naurrrrr
these individuals are very competitive, they will deplete their energy
**distarct them to something more solitary**
37
What are some interdisciplinary treatments for those with Bipolar disorder?
1. pharmacotherapy
2. psychosocial support
3. CBT
4. interpersonal and social rhythm therapy
5. family therapy
6. support groups
38
are those with bipolar disorder able to deal with change well?
Naurrrrr so interpersonal and social rhythm therapy help them cope with change.
**change may induce manic episodes**
39
What are the pharmacological therapies?
1. Mood stabilizers
2. anticonvulsants
3. anxiolytics
4. second gen antipsychotics
5. ECT
40
What is lithium used for?
Used as a mood stabilizer and is used as the first line of tx
41
What disorders does lithium target/help treat?
1. acute mania
2. acute BP depression
3. Prevention of manic and depressive episodes
42
How long does it take lithium to have a full response?
3-6 weeks
43
What is a contraindication of lithium?
1. NSAIDS
2. caution with diuretics, lithium level might go up
44
let's say someones sodium level goes down, what happens to the lithium level? What does this increase the risk for?
Sodium DOWN
Lithium UP
(Vice versa)
**INCREASES RISK FOR LITHIUM TOXICITY**
45
What is the therapeutic level for lithium?
0.5-1.2 mEq/L
46
does a level of 1.2-1.5 lithium level indicate toxicity?
No, its not toxic buuuuut its a red flag
47
What are the common EXPECTED side effects of someone taking lithium?
1. fine hand tremors
2. polyuria, mild thirst
3. nausea
4. weight gain
5. sedation
6. acne
48
Therapeutic level for ADVANCED signs of lithium toxicity
1.5-2
49
therapeutic level for SEVERE lithium toxicity
2+
50
If the therapeutic level of lithium is between 1.2-1.5 what should you do?
1. Hold medication
2. Call doc
3. Get the dosage reevaluated
**usually if the pt skips a dose that's enough to get them to a safer range**
51
If the therapeutic level is between 1.2-1.5, what symptoms may the pt experience?
1. n/v/d
2. slurred speech
3. muscle weakness
52
What level is the KEY to know if the lithium level is toxic?
**anything above this level is toxic**
ANYTHING ABOVE 1.5 IS EL TOXICOOOOO
53
What are some symptoms someone will experience in advanced signs of toxicity? 1.5-2mEq/L
1. coarse hand tremor
2. GI upset
3. Mental confusion
4. Muscle hyper-irritability
5. EEG changes
6. incoordination
54
What is usually the tx for someone who has a lithium lab level of 1.5-2?
Give a saline bolus to bring the lithium level down
(Giving them sodium to bring that lithium level down)
55
If the lithium level is 2+, which is severe toxicity, what tx do they usually need to get rid of the lithium?
dialysis to get rid of the lithium in the body because it affects the kidneys at this point
56
What are some symptoms a pt will experience with lithium levels of 2+?
1. ataxia
2. Serious EEG changes
3. Blurred vision
4. clonic movements, seizures
5. Stupor
6. Coma
7. Death
57
What are some general long term side effects of lithium?
1. HYPOthyroidism, goiter
2. kidney dysfunction
58
When someone is taking lithium, what do we usually want to get a baseline test of?
Baseline thyroid function test because they are susceptible to HYPOthyroidism
59
Since lithium can affect the kidneys, what do we want to monitor?
BUN and creatinin levels
60
What are commonly seen anticonvulsants?
*all the same med*
(HINT)
2 Vaginas
2 Dicks
= orgasms looks like SEIZURES lol
1. Valproic acid
2. Depakote
3. Divalproex
4. Valproate
61
if you see that the pt has a valproic acid level but you dont see them taking valproic acid what does that mean?
Valproic acid is the lab draw so their probably taking depakote or divalproex
62
What are anticonvulsants usually effective in tx of?
1. Bipolar mania
2. hypomania
3. mixed states
4. Rapid cycling
63
What are the side effects of anticonvulsants?
(HINT mnemonic)
Grace
Tried
Sucking
His
Weiner
buuuut didn't like his enlarged prostate from his...
B
P
H
G: GI pain
T: Tremors
S: Sedation
H: Hair loss
W: Weight gain
B: Blood Dyscrasias
P: Pancreatitis
H: Hepatotoxicity
64
Since anticonvulsants can have a side effect of blood dycrasias, what should we monitor?
always monitor CBC
65
Why would anticonvulsants be the first line of tx for someone with kidney issues?
Because its Hepatotoxic not Nephrotoxic
Lithium can cause kidney dysfunction... so for someone who has kidney issues give them an anticonvusant for someone with liver issues give them lithium
66
What is the therapeutic level for anticonvulsants?
85-125
67
anticonvulsant toxicity symptoms
ataxia
confusion
somnolence
coma
68
TX for anticonvulsant toxicity
stop medication
give fluids
69
What is carbamazepine?
anticonvulsant
70
What is Carbamazepine effective in tx of?
1. Rapid cycling
2. Mixed states
3. Acute mania
4. Prevents relapse of mania
71
What are the side effects of Carbamazepine?
1. Hepatic disease
2. Blood dycrasias
3. fluid overload
4. Hyponatremia
5. life threatening dermatological reactions (SJS/rash)
72
what does carbamazepine decrease the effectiveness of?
birth control pills
73
What is the therapeutic level of Carbamazepine?
4-12 mcg/mL
74
Symptoms of toxicity of carbamazepine?
1. Fatigue, nausea
2. Diplopia
3. Blurred vision
4. Ataxia
75
What kind of med is Lamotrigine?
anticonvulsant
76
What is Lamotrigine effective in tx of?
1. Bipolar depression
2. Both acute and maintenance
77
What are the SERIOUS side effects of lamotrigine?
1. SJS
2. Aseptic meningitis (Monitor for stiff neck)
3. Can lower effects of birth control
78
What are anxiolytics?
Benzodiazepines
79
What are some examples of Anxiolytics?
Clonazepam
Lorazepam
80
When do we usually give a benzo?
if were concerned about them collapsing
1. adjunctive agents
2. acute mania
3. Psychomotor agitation
81
What are second gen antipsychotics effective in tx of?
1. Acute mania
2. Bipolar disorder
3. Prevent relapse of mania and depression
82
What is primary psychosis?
Ex: schizophrenia, something genetic, part of genes
83
What is secondary psychosis?
secondary to some medications or secondary to a brain tumor
84
What is the onset age for males with schizo?
onset: 18-25
85
What is the onset age for females with schizo?
onset: 25-35
86
what are some comorbidities of Schizo?
1. Substance use disorder (up to 50% have this disorder)
2. Tobacco use disorder (up to 50% have this disorder)
3. Cannabis use
4. Attempted suicide
5. Anxiety disorders
6. Metabolic Syndrome
7. HIV/AID
87
What are the phases of Schizo?
1. Prodromal phase
2. Acute phase
3. Stabilization phase
4. Maintenance phase
88
Explain what happens in the prodromal phase
warm up phase
What happens before someone is diagnosed with shizo, socially withdrawn, deterioration in functioning, depressed, start acting strange.
*very hard to catch when someone in this phase*
89
Explain the acute phase of schizo
full blown psychotic break, when they start to hallucinate or have delusions
90
Explain the stabilization phase of schizo
When they starts to decrease in severity, symptoms are not acute or full blown but they are not 100% back to baseline
91
Explain the maintenance phase of schizo
when the symptoms are in remission or symptoms are so mild that they aren't really noticeable
92
Is it possible for someone for someone to go from the maintenance phase back into the acute phase? What are some warning signs
yes they can go back.
Signs: If they start having a hard time sleeping or start having poor concentration
93
What are the categorical symptoms of schizo?
1. positive symptoms
2. Negative symptoms
3. Cognitive symptoms
4. affective symptoms
94
If someone has positive symptoms of schizo, what may they have alterations of?
1. Thinking
2. Thought process
3. Perception
4. Behavior
5. Boundaries
95
Define delusions
a false fixed belief
they believe its true but its not
96
What are the different alterations of THINKING in people with schizo?
1. Ideas of reference
2. paranoid/ persecutory
3. Grandiosity
4. Somatic
5. Jealousy
6. Control
7. Thought broadcasting
8. Thought insertion
9. Thought withdraws
10. concrete thinking
97
Explain idea of reference delusions
A specific even has a personal meaning
EX: a classroom laughs and they think those people are laughing them (no connection) or TV is talking to them
98
Explain paranoid/ persecutory delusions
The belief that someone is out to get you
the FBI is coming to get me, the doctor is poisoning me
99
Explain Grandiosity delusions
The belief that they are superior, they own the hospital and they're gonna fire you because you're a terrible nurse
100
Explain somatic delusions
Belief that internal organs are abnormal
they may believe that their preggo but aren't but they have a tumor or hernia
101
Explain jealousy delusions
feeling that you're significant other is unfaithful
102
Explain control delsions
the belief that ones mind is being controlled by another
103
Explain thought broadcasting delusions
belief that the thoughts are being broadcasted to the world
they can read my mind I better not think hat
104
explain thought insertion delusions
Thoughts are being INSERTED into my mind
105
explain thought withdrawal delusions
the belief that thoughts are being removed from your mind
106
explain concrete thinking delusions
they can't think abstractly, literal interpretation
when we see gardening tools but they see things with wooden handles
107
What are some alternations in thought process that are altered in the way that they speak for someone with schizo?
1. associative looseness
2. circumstantiality
3. tangential
4. neologisms
5. world salad
6. echolalia
7. clang associations
108
Describe associate looseness
they have illogical shifts between topics
109
describe circumstantiality
when you talk to someone and they give you way too many excessive details about the story
110
describe tangential
when someone goes off on a tangent
111
describe neologism
they have a made up word
112
describe word salad
someone gets a bunch of words puts them in a bowl and throws them out (nothing makes
sense)
113
describe echolalia
echoes
Ex: phone phone phone where's the phone
114
in positive symptoms of schizo, what are some examples of alteration in PERCEPTION
1. hallucinations (5 senses)
2. Illusions, they think a cord is a snake
*gustatory taste poison
*olfactory they smell gas its a sign of a brain tumor
*tactile if they feel bugs its meth induced
115
What are some alterations in behavior in positive symptoms of schizo?
1. bizarre demeanor
2. eccentric, grooming, and rituals
3. impaired impulse control
116
describe bizarre demeanor
tick like movements
117
what are some alterations in boundaries in positive symptoms of schizo?
1. depersonalization
2. derealization
118
what are symptoms of negative symptoms of schizo
1. anergia
2. avolition
3. anhedonia
4. affective blunting
5. poverty of speech
6. social withdrawal
119
describe anergia
loss of energy
120
describe avolition
loss of motivation
121
describe anhedonia
inability to experience pleasure
122
describe effective blunting
inability to express emotions on face
123
describe poverty of speech
no talking, or one word answers
124
What are symptoms of cognitive symptoms
1. memory impairment
2. Disruption in social learning
3. poor judgment and focus
4. impaired insight (they dont think they have schizo)
125
What are symptoms of affective symptoms
1. Depression
2. Anxiety
3. Demoralization
4. suicidality
5. excitability
6. agitation
126
Describe catatonia
1. extreme and abnormal motor behavior
2. slowing-down of thought
3. reduction in physical movements
127
What is a CLASSIC sign of catatonia
waxy flexibility
128
tx for someone with catatonia
HIGH level of benzos
129
What are examples of other psychotic disorders?
1. Schizophrenirform disorder
2. brief psychotic disorder
3. Schizoaffective disorder
4. Delusional disorder
5. substance/
medication-induced psychotic disorder
130
Describe Schizophreniform
You have this for 6 months then its deemed schizophrenic
131
describe brief psychotic disorder
induced from a stressful event
**symptoms only last for a month VERY BRIEF
132
describe schizoaffective
Schizophrenia and a mood disorder
ex: Schizo and depression or schizo and mood disorder
133
Describe delusional disorder
when someone has a delusion
134
What are some examples of outcomes for schizo?
1. pt will refrain from inflicting injury
2. pt will take meds without prompting
3. pt will state two coping mechanisms to reduce anxiety
135
What are some examples of interdisciplinary tx for schizo?
1. family psychoeducation/ therapy
2. CBT
3. cognitive remediation
4. social skills training
5. pharmacological therapies
136
What is important to know about first gen antipsychotics?
1. traditional dopamine antagonists
2. used less frequently (side effects are severe)
3. minimal impact on negative symptoms
137
If someone has negative symptoms what antipsychotic do you not give them?
NO FIRST GEN
138
What are the first gen antipsychotics?
1. Chlorpromazine
2. Loxapine
3. Fluphenazine
4. Haloperidol
139
What are symptoms of EPS? Extrapyramidal symptoms
1. Psuedoparkinsonism
2. Acute dystonia
3. Akathisia
4. Tardive dyskinesia
140
What are symptoms of pseudo parkinsonism
1. stooped posture
2. shuffling gait
3. Rigidity
4. Bradykinesia
5. tremors at rest
6. pill-rolling motion of the hand
141
what are symptoms of acute dystonia
1. facial grimacing
2. involuntary upward eye movement
3. muscle spasms of the tongue
4. laryngeal spams
142
what are symptoms of akathisia?
1. restless
2. Trouble standing still
3. Paces the floor
4. feet in constant motion
143
what are symptoms of tar dive dyskinesia?
1. protrusion and rolling of the tongue
2. sucking and smacking movements of the lips
3. chewing motion
4. facial dyskinesia
5. involuntary movements of the body and extremities
144
When someone is having EPS symptoms of acute dystonia what is most concerning?
Laryngeal spams, MONITOR AIRWAY
145
If dosage is too high for pt what can happen?
PT can get acute dystonia
146
tx for EPS symptom of acute dystonia
1. diphenhydramine
2. Benztropine
147
Is tardrive dyskinesia reversible?
no its irreversible
148
as soon as you see symptoms of tardrivei dyskinesia what do you do
stop med
149
what is the tx for someone with tar dive dyskinesia?
1. lower dosage or switch med
2. benztropine
150
For a pt with EPS symptoms of akathisia what do you monitor for?
monitor for suicide
151
What is the tx for akathisia?
1. propanolol
2. Benzodiazepines (helps reduce restlessness)
152
What is the tx for pseudo parkinsonism?
1. Benztropine
2. Trihexyphenidyl
153
what are pts with pseudo
parkinsonism at risk for
falls
154
What are other side effects of antipsychotics?
1. sedation
2. orthostatic hypotension
3. lowered seizure threshold
4. increased prolactin
5. prolonged QT interval
6. Anticholinergic toxicity
7. neuroleptic malignant syndrome
155
what can increased prolactin lead to?
1. sexual dysfunction
2. galactorrhea
3. Amernorrhea
4. Gynecomastia
156
*****What is metabolic syndrome? ****
know this
a combination of more diseases
1. obesity
2. HTN
3. Diabetes
4. Dyslipidemia
157
signs of anticholinergic toxicity
1. anxiety
2. delirium
3. disorientation
4. hallucinations
5. hyperactivity
6. seizures
158
if someone is experiencing anticholinergic toxicity what should you do
stop med
159
signs of neuroleptic symptoms
SEVERE
1. muscle rigidity
2. high fever
3. fluctuating BP
4. irregular and increased HR
5. AMS (altered mental status)
160
If someone is experiencing muscle rigidity and fluctuating BP what would you assume?
that when these two are paired together that the pt is experiencing NEUROLEPTIC MALIGNANT SYNDROME
161
What are pts with NMS at high risk for?
DVT and Rhabdomyolysis
162
What are the second and third gen antipsychotics?
1. aripiprazole
2. Clozapine
3. Lurasidone
4. Olanzipine
5. Quetipine
6. Risperidone
163
What should be known about aripiprazole?
its very sedating
164
what should be known about olanzapine?
cause weight gain
165
what should be known about Quetiapine?
Highly abused (its seraquil)
dont give to homeless they won't take it they will sell it
166
what should be known about Risperidone?
places pt at higher risk for heat stroke
167
Are second and third gen antipsychotics more or less likelyto cause EPS?
Less likely to cause EPS
they are also milder and better tolerated
168
Which antipsychotic is the LAST resort med?
Clozapine
169
Why don't we like to give clozapine?
side effects are severe and common
170
what are side effects of clozapine?
1. agranulocytosis
2. mycarditis
3. Siallorhea
171
Why would you not want to give clozapine to someone with a low WBC count?
because it causes agranulocytosis because they are at higher risk for sepsis and infection
172
What is Siallorhea
they wake up drenched in their saliva
173
what us the tx for siallorhea
atropine eyedrops under the tongue
174
What are some long acting injectables?
1. Olanzipine
2. Plaperidone
3. Ziprasidone
4. Haldol
5. Aripriprazole
