7. Mood disorders

Mood disorders are characterized by a depressed or an elevated mood. These disorders manifest symptoms that indicate dysfunction in affect, emotions, thinking, and general activities.

Depressive Disorders

DSM-IV CATEGORIES

296.xx Major depressive disorder

296.2x Major depressive disorder, single episode

296.3x Major depressive disorder, recurrent

300.4 Dysthymic disorder

311 Depressive disorder NOS

The criterion for a major depressive disorder is one or more episodes of at least 2 weeks' duration characterized by depressed mood or decreased interest or pleasure in all or almost all activities. These symptoms must occur almost every day and must be present for most of each day. For many clients, there's impairment in social, occupational, and general functioning; some people may appear to function normally but exert great effort to maintain that level of functioning. The diagnosis of major depressive disorder isn't made if the client exhibits signs of a manic episode or a mixed (depressive and manic) episode. For clients with a less severe mood disturbance, the diagnosis is dysthymic disorder.

Typical symptoms of depression include severe fatigue, inability to concentrate or make decisions, and feelings of sadness, worthlessness, or extreme guilt. There are significant changes in appetite, with either a loss or gain in weight. Sleep disturbances, decreased libido, and psychomotor agitation or retardation are frequently observed. Recurrent thoughts of death are common. There may also be suicidal ideation, suicidal gestures, or suicide attempts. Clients may exhibit tears, irritability, anxiety, obsessive rumination, and preoccupation with concerns about physical health. In adolescents, there may be other symptoms, such as strong negativism, social isolation, and antisocial acting out. With children, common symptoms are lack of appetite, lethargy, lack of interest in activities, and fear of separation from or death of a caretaker. Depression in the older client may be manifested as memory loss, disorientation, inability to concentrate, and a decrease or loss of interest in usual activities. Such changes in elderly clients may lead to the erroneous diagnosis of dementia. Its important to differentiate between true dementia (see chapter 4. Delirium, Dementia, and Amnestic and Other Cognitive Disorders) and dementia related to depression (pseudodementia). As the major depressive disorder is treated in the elderly client, memory problems often disappear. Sometimes a major depressive episode in an elderly person may be the first sign of irreversible dementia.

Scientists have discovered evidence linking mood disorders to abnormalities on chromosomes 4, 11, 18, and 21. However, the specific pattern of genetic inheritance is complicated and the transmission component of major depressive disorder isn't known. Depressed clients have imbalances in the release of the major neurotransmitters serotonin, norepinephrine, dopamine, acetylcholine, and gamma-aminobutyric acid. During a depressive episode, there's a deficiency in the basic neurotransmitters. and during a manic episode, there's a surplus of them. Research indicates problems with the enzymes that regulate and produce these chemicals.

Positron emission tomographic scans and single-photon emission computed tomographic scans of depressed clients show an abnormal slowing of activity in the prefrontal cortex and temporal lobes. Depressed clients don't metabolize glucose properly in these brain areas. When the depression is resolved, the metabolic activity returns to normal. In addition, the hypothalamic-pituitary-adrenal axis that regulates cortisol release doesn't function properly; frequently depressed clients show cortisol hypersecretion in the dexamethasone suppression test.

Some medical disorders, such as multiple sclerosis, Epstein-Barr disease, thyroid disease, Addison's disease, acquired immunodeficiency syndrome, and hepatitis, are also associated with depression. Alcohol and certain drugs, such as antihypertensives, steroids, hormones, sedatives, and antibacterials, may cause secondary depression.

Major depression may occur at any point in the life cycle; the average age of onset is typically the late 20s. Depression occurs more frequently in females than in males. The high incidence of successful violent suicide, alcohol abuse, and drug abuse among men may indicate a higher than reported rate of depression among men. Common factors that predispose a person to depression include chronic physical illness, disability, and substance abuse or dependence. Depression can be precipitated by severe stress, such as death of a family member or loved one, divorce, childbirth, and job loss. (For further information, see Factors That Contribute to Suicide Risk, Physiologic Symptoms of Depression, and Cognitive Distortions Found in Depression.)

COMMUNICATION STRATEGIES

• Use simple, direct questions, and allow the client time to respond to questions because cognitive processes may be impaired.
• Encourage the client to explore feelings, and try to identity-sources of anger and healthy ways to deal with the anger.
• Suggest appropriate ways to get needs met.
• Be aware of the client's indirect expression of feelings.
• Listen for communication about suicide.
• Encourage the client to discuss life situations and relationships that are problematic.
• Recognize strengths by identifying appropriate actions demonstrated by the client.
• Acknowledge and explore somatic complaints related to the client's depression.
• After rapport is established, gently confront negative statements about self and challenge the irrational belief system.
• Work to eliminate the client's focus on perfectionism.
• Discuss new coping responses and resources for support.

FACTORS THAT CONTRIBUTE TO SUICIDE RISK

Demographic factors Gender (women, more attempts: men, higher success rate) Age (high-risk groups are clients younger than age 19, older tins age 45 and particularly those over age 65) Emotional and medical stain or symptoms Severe depression Feelings of helplessness or hopelessness Substance abuse or mental health disorders Compulsive gambling Delusions or auditory hallucinations commanding self-harm Chronic, debilitating, or severe Illness Severe pain Severe, unrelenting anxiety Loss of self-esteem Severe overreaction to stress Lack oflmputse control or poor judgment Feelings of rage, hostility, or revenge Repression of angry feelings Severe internal conflicts, such as overwhelming guilt or ambivalence Stressors History of abuse Dysfunctional family Relationship difftcufties Legal problems or criminal involvement Severe financial problems Experience of a serious toss or multiple losses Extreme social Isolation from lack of social support system Spiritual distress Feeling that there is no future Cult membership Family history of suicide Previous suicide attempts or threats Suicidal plan Suicidal ideation Getting personal business in order or giving away possessions Having a high lethallty suicide plan (definite plan for time, place, and means by which the person will quickly die by the method selected) Access to the means by which to kill self Unwilllngness to commit to a no-suicide contract (contract signed by the client that contains a statement such as "I will not kill mysetl, either on purpose or accldently, for any reason")

PHYSIOLOGIC SYMPTOMS OF DEPRESSION
Headaches Sleep disturbances Chronic fatigue Chest pain Indigestion, nausea, or vomiting Constipation Weight loss or gain Urine retention	Back pain Slouched posture Decreased motor activity Restlessness and agitation Amenorrhea Impotence Decreased libido

COGNITIVE DISTORTIONS FOUNO IN DEPRESSION
DISTORTION	EXPLANATION
All-or-nothing thinking	Labeling life events in simple, absolute terms, such as good or bad, correct or wrong, aft or nothing.
Disqualifying the positive	Disregarding positive experiences by focusing exclusively on the negative.
Fortune-telling	Predicting that a negative event will occur ami believing it as an accomplished fact.
Jumping to conclusions	Coming to a negative conclusion without facts to validate the conclusion.
Labeling or mislabeling	Applying emotionally charged words or an extreme label to a person or situation based on an isolated event.
Magnifying or minimizing	Either exaggerating the importance of a situation or reducing the significance of an event in a way that grossly distorts it.
Mental filter	Using a single negative detail as a lens that colors the view of alt other events.
Fortune-telling	Predicting that a negative event will occur ami believing it as an accomplished fact.
Mind reading	Assuming that another person thinks or feels a particular way.
Overgeneralization	Believing that a single negative event is part of an ongoing negative pattern.
Personalization	Viewing negative external events as being personally related to one's self when there is no basis for making such a relationship.
"Should" statements	Overly relying on should, should not, must, and ought statements in self-talk and In conversation with others.

NURSING DIAGNOSIS: DYSFUNCTIONAL GRIEVING

Probable Causes	Defining Characteristics
Delayed or denied grieving response to personal bereavement Cumulative unresolved losses Unhealthy or ambivalent relationships Social, cultural, or familial norms Personal feelings of insecurity	Guilt, anger, sadness, or regret Limited or few relationships Frequent crying episodes Use of drugs or alcohol to cope Physiologic symptoms

Long-Term Goal
The client will acknowledge the feelings and behaviors associated with the grieving process and work toward resolution of personal grief.

Short-Term Goal #1:The client will express thoughts and feelings related to loss.

Interventions and Rationales

• Encourage the client to discuss the actual or perceived loss. Before grief resolution can begin, it's essential for both the diem and the nurse to acknowledge the object of the client's grief.
• Explain the phases of grief and encourage the client to identify the stage that seems to describe current feelings. Acknowledging grief as a normal process with identifiable stages enables the client to view grief as a universal and self-limiting phenomenon.
• Encourage exploration of feelings connected with loss. This intervention facilitates expression, acceptance, and clarification of feelings.
• Encourage the client to talk about the anger, sadness, guilt, and loneliness that usually accompany grief. When clients stop denying distressing feelings, it becomes possible to redirect their energy into coping with their losses instead of maintaining denial.

Short-Term Goal #2: The client will develop resources for effective coping.

• Help the client determine goals for handling grief It's often helpful to spend time with old friends, go through a loved one's possessions in order to discard or store them, or visit someplace meaningful to both the client and the deceased person. Formulating realistic goals helps the client identify needs and develop a sense of personal competence.
• Teach healthy options, especially physical outlets, for expression of strong feelings, and encourage the client to use these alternatives on a daily basis. Developing physical outlets, such as exercise, music, and art, for the expression of strong feelings helps the client strengthen coping skills.
• Teach the client problem-solving, assertiveness, self-affirmation, and other appropriate coping skills. By strengthening the client's repertoire of coping skills, the nurse enhances the client's ability to successfully complete the grieving process.
• Identify sources of support, talk about how support may have changed with the loss, and initiate new supports. The client needs assistance in identifying and developing sources of support.
• Help the client examine spiritual needs, and obtain spiritual support if desired. Clients obtain comfort and strength from spiritual support.

NURSING DIAGNOSIS: SELF-ESTEEM

Probable Causes	Defining Characteristics
Frequent negative messages about self from family and others Lack of experience with or opportunities to master life events Lack of role models and of resources Multiple losses, with difficulty integrating them History of body image problems	Negative self-talk Expressions of guilt or shame Inability to accept positive feedback from others Inability to acknowledge responsibility for problems Cognitive distortions

Long-Term Goal
The client will verbalize and demonstrate behaviors that indicate positive self-worth and acceptance of self.

Short-Term Goal #1:The client will identify self-defeating thought patterns and behaviors and practice positive thought patterns and coping strategies for handling stress and solving problems.

Interventions and Rationales

• Assess the level and intensity of the client's depression. Baseline data and information on suicide potential are essential for safe. effective nursing care.
• Question and gently challenge negative self-statements made by the client. Challenging the client's negative assumptions helps the client begin to give up the habit of self-criticism.
• Help the client discover and examine her own irrational beliefs or other cognitive distortions. The client needs to be aware of self-defeating beliefs to change them.
• Encourage the client to identify current real problems and stressors. Recognition of problems is the first step toward deaiing with them.

Short-Term Goal #2: The client will verbalize a positive sense of self and effective ways to increase self-concept.

Interventions and Rationales

• Have the client identify positive aspects of self The clients view of self shapes the personality.
• Teach the client how to find the positives in thoughts and feelings about self Identification of strengths is often overlooked when a person is depressed.
• Encourage the client to talk about past situations that engendered feelings of self-worth. The recall of past accomplishments and positive experiences facilitates self-validation and affirmation.
• Teach the client effective interpersonal communication. Healthy interpersonal relationships promote the client's positive sense of self.
• Assist the client in strengthening coping skills by teaching how to anticipate stressful situations and develop a repertoire of healthy responses. This could be done by role-playing various situations. Having effective coping skills facilitates problem solving and decreases the client's avoidance of troublesome situations.
• Teach the client relaxation or meditation techniques. Useful methods include the quieting techniques and acceptance techniques. Relaxation promotes the client's ability to cope with the tensions of daily living and contributes to a healthy lifestyle.
• Have the client participate in group therapy. Group work can provide support, feedback, and recognition, which enhance self-esteem.

NURSING DIAGNOSIS: IMPAIRED SOCIAL INTERACTION

Probable Causes	Defining Characteristics
Severe depression Inadequate social skills Substance abuse Personal relationships without appropriate boundaries Inability to establish healthy personal ego boundaries	Actual or perceived lack of significant others Immature and inappropriate behaviors Little or no communication with others Verbalization of negative feelings about others Feelings of insecurity, loneliness, and rejection

Long-Term Goal
The client will demonstrate appropriate interactions and interdependence with others.

Short-Term Goal #1:The client will establish a therapeutic relationship with the nurse and will use the security of this relationship to allow examination of thoughts, feelings, and conflicts in other relationships.

Interventions and Rationales

• Establish a daily interaction time with the client. Allocating time to be with the client enhances the client's feeling of self-worth and provides an opportunity to develop a therapeutic relationship.
• Help the client assess the quantity and quality of current interpersonal relationships. Self-assessment of relationships helps the client identify areas of concern and helps both the nurse and client agree on treatment goals.
• Help the client identify and verbalize which circumstances and stressors result in social withdrawal. Awareness is the first step toward understanding feelings and behavior.
• Help the client identify conflicts and stressors present in typical roles and relationships. Anxiety and depression can be decreased by recognizing conflicts and stressors.
• Address interpersonal situations that promote negative feelings about self and discomfort in social situations. Its important to determine if the negative feelings are related to irrational beliefs or external factors.

Short-Term Goal #2: The client will establish healthy, mutually rewarding relationships with other people.

Interventions and Rationales

• Encourage the client to identify and discuss factors that contribute to problems in social relationships. The client's own identification of socialization problems facilitates an interest in solving those problems.
• Introduce simple, structured initial interaction opportunities with peers. Socialization opportunities in a structured environment enable the client to feel safe and begin to develop comfort interacting with others.
• Encourage the client to attend group activities. Group activities can help the client attain social skills and enhance self-confidence.
• Help the client identify and discuss the positive and negative aspects of interacting with others. This action enables collection of data for problem solving.
• Establish guidelines with the client for promoting effective relationships by teaching respect for the personal boundaries of others and by taking, control of impulsive behavior. A client who demonstrates immaturity and displays inappropriate behaviors needs to learn interactional skills.
• Arrange for brief visits by a family member or friend. Visitors can decrease isolation and provide social experiences.

NURSING DIAGNOSIS: DYSFUNCTIONAL GRIEVING

Probable Causes	Defining Characteristics
Emotional pain Depression or the inability to express anger or rage Biochemical changes History of abuse	Expression of guilt or shame Expressions of helplessness or hopelessness Self-defeating behaviors Verbalization of distorted thoughts

Long-Term Goal
The client will learn coping skills that reduce the chance of relying on self-destructive behavior.

Short-Term Goal #1:The client will seek assistance when feeling self-destructive.

Interventions and Rationales

• Establish a no-suicide contract with the client. The primary purpose of the contract is that the client will seek out staff when feeling suicidal and talk through feeliangs rather than act them out. Another purpose is to have time to explore alternatives with the client. Negotiating for a time frame suicide prevention contract with. the client is based on the client's ability to cooperate with care.
• Determine the necessary level of suicide precautions, and re-evaluate suicide potential on a daily basis. A depressed client can be at greater risk for suicide when treatment progresses and the energy level increases.
• Search the client's personal possessions for dangerous objects This action promotes safety and prevents the client from self-injury by using personal possessions.
• Closely monitor the client during shift changes, mealtimes, and days when fewer staff members are available. Clients tend to commit suicide when staff members are preoccupied or engaged in multiple tasks.
• Encourage the client to express intense feelings to staff. The client needs encouragement to learn and practice appropriate expression of feelings.

Short-Term Goal #2: The client will verbalize and demonstrate coping skills used to handle stress and frustration.

Interventions and Rationales

• Teach the client nondestructive methods of expressing intense emotions. Knowledge of healthy options to handle intense emotions decreases the frequency of impulsive or acting out behaviors.
• Teach problem-solving and decision-making skills. This promotes practice with rational thinking.
• Have the client devise and discuss several alternative methods for handling problems. The client needs practice expanding the repertoire of acceptable methods to handle daily life stressors.
• Discuss with the client how to identify initial symptoms of depression and prevent self-destructive behaviors. Knowledge of early symptoms enables the client to obtain assistance before symptoms become severe.
• Encourage the client to develop both emotional and social support systems. The client needs to develop support systems for [he purpose of obtaining feedback from and becoming comfortable expressing feelings to other people.

THERAPIES

Individual Therapy

• Explore feelings of loss, and facilitate the grieving process.
• Discuss self-defeating behaviors, unrealistic expectations, and possible distortions of reality.
• Examine how the client's cognitive distortions contribute to depression.
• Encourage verbalization of frustration, anger, and despair.
• Work to change automatic negative thinking patterns about self others, environment, and future.
• Provide opportunities for the client, such as discussions and role playing, to work on interpersonal problems.
• Monitor physiologic problems that are induced or exacerbated by the depression.
• Encourage discussion about sexuality so that the client shares concerns, understands how depression affects libido, and realizes that sexual desire usually returns as depression decreases.

Family Therapy

• Assess family functioning, communication patterns, role expectations, problem-solving skills, and stressors.
• Obtain information from each family member about the current family situation.
• Determine how conflict or crisis is handled, and evaluate members' support of one another.
• Examine the degree of closeness and detachment of family members.
• Focus on identifying and intervening with cognitive distortions that impede healthy family functioning.
• Teach family members communication skills, problem-solving skills, stress management skills, and constructive expression of feelings.
• Facilitate verbalization of anxiety, anger, and feelings of powerlessness and hostility, and teach ways to deal effectively with the threatening aspects of the current situation.
• Examine guilt and blame that may result from unrealistic viewing of the crisis situation.

Group Therapy

• Work to increase self-esteem and acknowledgment of each member's strengths.
• Teach clients how to develop and sustain interpersonal relationships, especially after experiencing loss.
• Help the client develop strategies for obtaining social support decreasing loneliness, securing feedback from others, and handling stressors.
• Teach clients how—with peer support and assistance—to learn to decrease and then eliminate cognitive distortions.

MEDICATIONS

• Selective serotonin reuptake inhibitors (SSRls) have been extremely useful the treating depression, especially because they have fewer anticholinergic adverse effects, less cardiac toxicity, and a quicker onset of action than tricyclic antidepressants and monoamine oxidase (MAO) inhibitors.
• Tricyclics and MAO inhibitors, first-generation antidepressants, are used less frequently since the advent of SSRls and atypical SSRls.
• Antipsychotics are sometimes used to manage psychotic features of severely depressed clients.
• Benzodiazepines are sometimes used to treat sleep disturbances and moderate anxiety.
• The doctor may order electroconvulsive therapy (ECT) if severe depression is present, the client is extremely suicidal, or the client is not responding to antidepressant medication protocols. (For further information, see Electroconvulsive Therapy, and Appendix D for medication information.)

FAMILY CARE

• Help the family understand depression, the impact that it has on the family, and the associated treatment.
• Talk about how to evaluate changes in the client's cognition, feelings, somatic symptoms, and behaviors that may indicate relapse.
• Direct the family's attention toward reinforcing problem-solving skills and daily accomplishments.
• Work with family members to develop clear, open communication.
• Teach the family how emotional factors impact on the family s level of functioning.
• Discuss how ongoing stressors, particularly abuse and dependent relationships, make family members more susceptible to depression.
• Help the family understand the purpose and value of the client's therapy and the temporary adverse effects of ECT if this treatment is undertaken by the client.
• Tell the family about community resources, such as bereavement groups and suicide hot lines. Obtain available educational, materials from pharmaceutical companies, such as Propartners by Lilly and Rhythms by Pfizer.

ELECTROCONVULSIVE THERAPY

Definition In electroconvulsive therapy (ECT), an electric shock is delivered to the bran by way of electrodes placed on the temples. Electrodes can be placed bilaterally or unilaterally (less confusion may occur if they are placed unilaterally). Indications for ECT The client is severely depressed and hasn't benefited from antidepressarrt medications. The client has endogenous depression with active suicidal ideation. The risk associated with other therapies is greater than that associated with ECT. The client has unipolar or bipolar disorder. The client is schizophrenic and does not respond to psychotropic drugs. The client prefers ECT. Procedure Give preoperative medication such as atropine to decrease secretions, prevent aspiration, and decrease bradycardia-like arrhythmias. Also. administer a short-acting anesthetic such as thiopental (Pentothal) to relax the client before the procedure. Place an airway in the mouth. Just before delivering electrical stimulus, give succinylcholine (Anectine) to block impulse of motor nerves to skeletal muscles. A seizure occurs for 30 to 60 seconds, accompanied by short periods of apnea, followed by stertorous respirations. The muscle relaxant paralyzes respiratory muscles, so the anesthetist administers 100% oxygen by way of mask with positive pressure. The client sleeps about 10 minutes after the seizure, slowly awakens, and doesn't remember the treatment. The number of treatments is typically 12. After three treatments, improvement can usually be seen. Complications Back pain. Fractures (if osteoporosis is present) . Cardiac arrhythmias, transient bradycardia. Respiratory arrest. Confusion or memory loss occurring for up to 6 weeks. Nurse's role Provide the client and family with information, including an explanation of the procedure and what to expect after ECT. Discuss and dispel any myths associated with the procedure. Make sure informed consent has been obtained. Arrange for the client to have a complete physical examination before the procedure. Keep the client on NPO status for 8 hours before the procedure. Have the client void and remove dentures, glasses, contact tenses, hairpins, and hearing aids before the treatment. Administer preoperative medications as ordered. Monitor the client's vital signs, and observe for seizure activity. Support the client, and continue to explain what is happening as the I.V. catheter is inserted and the electrodes attached. Have the crash cart, with oxygen and suction, readily available in case an emergency occurs. Monitor the client's gag reflex before giving fluid, medication, or food. Deal with the client's anxiety, provide support, orient the client after treatment, and teach and support the family as needed.

Bipolar Disorders

DSM-IV CATEGORIES

296.xx Bipolar I disorder

296.0x Single manic episode, specify if mixed

296.40 Bipolar disorder, most recent episode hypomanic

296.4x Bipolar disorder, most recent episode manic

296.6x Bipolar disorder, most recent episode mixed

296.5x Bipolar disorder, most recent episode depressed

296.7 Bipolar disorder, most recent episode unspecified

296.89 Bipolar 11 disorder (specify [current or most recent episode: hypomanic/depressed])

301.13 Cyclothymic disorder

296.80 Bipolar disorder NOS

293.83 Mood disorder due to ... (indicate the general medical condition); specify type: with depressive features/with major depressive-like episode/with manic features/with mixed features

__._ Substance-induced mood disorder (refer to substance-related disorders for substance-specific codes); specify type: with depressive features/with manic features/with mixed features

296.90 Mood disorder NOS

Bipolar I disorder, single manic episode, is used to describe a first-time episode of mania (extreme euphoria with loss of reality testing). The major characteristic of bipolar I disorder is a clinical course that features the occurrence of one or more manic episodes or mixed (both depressed and manic) episodes. Some clients have also had one or more major depressive episodes. An episode of substance-induced mood disorder or mood disorder caused by a general medical condition doesn't apply toward a diagnosis of bipolar 1 disorder. Bipolar I disorder is subdivided according to whether the client is experiencing a first episode or the disorder is recurrent. The shift in polarity of the episode (going from a depressive episode to a manic or mixed episode or from a manic or mixed episode to a depressive episode) or the period between episodes is at least 2 months without evidence of manic symptoms.

The other diagnostic classifications under bipolar disorders (bipolar II disorder, cyclothymia, and bipolar NOS) refer to the nature of the most recent or current episode in clients with recurrent mood disorders. Bipolar 11 disorder presents a clinical course that is manifested by the occurrence of one or more major depressive episodes and at least one hypomanic (mild elation' episode.

In some people, hypomanic episodes don't cause significant impairment, but depressive episodes induce fluctuating and capricious interpersonal and occupational functioning. During a hypomanic episode, the client demonstrates an elevated, expansive. or irritable mood along with some symptoms of mania. Typically the symptoms aren't severe enough to affect the person's relationships with others. Many hypomanic individuals are productive and creative in their endeavors.

During a manic episode, the client is euphoric, expansive, or irritable. Noticeable symptoms include delusions of grandeur, flight of ideas, extreme talkativeness, distractibility, psychomotor agitation, and overindulgence in pleasurable activities to the extent that negative consequences occur. The mood disturbance is severe enough to impair the person's family, social, and occupational functioning. Hospitalization is often required to prevent the client from harming himself or others. Clients tend to spend money recklessly, engage in high-risk sexual behaviors, or become involved in foolish financial transactions. Usually, the person demonstrates a decreased need for sleep and may not meet self-care needs. Bizarre activities, such as wearing excessive makeup and jewelry, dressing in inappropriate garments, and giving money or advice to strangers, are noted. Bipolar disorders occur equally in women and men, with the usual age of onset being the early 20s.

Evidence exists that bipolar disorder occurs in families. Research implies that gene abnormalities on chromosomes 18 and 21 indicate a predisposition for developing bipolar disorder. The major neurotransmitters, such as serotonin, norepinephrine, dopamine, acetylcholine, and gamma-aminobutyric acid, are being studied to determine their relation to and role in bipolar disorder. During a manic episode, higher than usual levels of neurotransmitters are present. In addition, the hypothalamic-pituitary-adrenal axis is believed to be altered in clients with bipolar disorder. Clients who are rapid cyclers have increased blood levels of cortisol. Some medications, such as antidepressants, steroids, decongestants, and bronchodilators, can induce a manic episode.

CYCLOTHYMIA

Clients with cyclothymiacs have manifested at least a 2-year period of chronic mood disorder characterized by many episodes of both depressive and hypomanic symptoms. Both types of symptoms lack sufficient duration or intensity to meet the cnteria for bipolar disorder. Usually, the client with cyclothymic disorder hasn't been symptom-free for longer than 2 months. There has also been no evidence of the occurrence of a major depressive episode, manic episode, or mixed episode during the past 2 years of the disturbance. The symptoms of cyclothymia cause the client impairment in social, occupational, and other areas of functioning. (For further information, see Physiologic Symptoms Associated with Mania)

COMMUNICATION STRATEGIES

• Communicate in a consistent way, and have uniform expectations.
• Help the client stay focused on a single topic.
• Set limits on hostile complaints and sarcastic comments.
• Don't encourage the client's use of jokes or sexual innuendos.
• Don't reinforce the client's dramatic affectations.
• Limit the client's intrusions into the interactions of others.
• Don't reinforce the client's delusional thinking or euphoria.
• Use gentle confrontation; don't confront the client when others are present, and ask the client, "Do you hear what you're saying?"
• Talk about the painful feelings that are sometimes masked by the euphoria. Accept the anger and anxiety expressed by the client.

PHYSIOLOGIC SYMPTOMS ASSOCIATED WITH MANIA
Headache Vertigo Agitation Muscle weakness, cramps, or pain Tremors Palpitations or tachycardia Hypertension Increased respirations or shortness of breath Dry mouth Indigestion, nausea, or vomiting Diarrhea and flatulence Urinary frequency Menstrual changes Increased libido

NURSING DIAGNOSIS: SELF-CARE DEFICIT IN HYGIENE, GROOMING, FEEDING, OR TOILETING

Probable Causes	Defining Characteristics
Grandiose ideas Disregard for personal pain High metabolic rate Impaired judgment and lack of impulse control Limited attention span and tendency to be easily distracted	Disorganized manner Denial of physical needs Inability to sit down to eat a meal Inability to carry out proper hygiene Less than commonly acceptable living conditions

Long-Term Goal
The client will perform self-care activities appropriately and develop healthy lifestyle habits.

Short-Term Goal #1:The client will regain the ability to perform self-care activities.

Interventions and Rationales

• Supervise the client's bathing, grooming, and toileting.The client's inability to concentrate may prevent the completion of necessary self-care tasks.
• Provide step-by-step instructions and suggestions for self-care activities.Manic clients respond well to suggestions: clear, simple instructions keep the client focused on the task.
• Oversee the client's selection of attire, makeup, and jewelry.Tactful supervision protects the client from being ridiculed for inappropriate appearance and having to resort to defensive manic behaviors.
• Monitor the client's nutritional intake. Information is required to devise a plan to meet nutritional needs because the client doesn’t demonstrate an awareness of them.
• Give the client small, frequent amounts of high-calorie foods that can be eaten or drunk while being active.The client is too distracted to eat regular meals or to focus on nutritional needs.
• Monitor the client's elimination.The client may develop urine retention or fecal impaction from dehydration and decreased peristalsis.
• Teach the client how to perform or maintain self-care activities.The client needs energy redirected to self-care and must be refo-cused on physical health requirements.

Short-Term Goal #2: The client will develop a consistent, habitual routine for performing self-care.

Interventions and Rationales

• Have the client establish and practice a daily health routine; for example, establishing a morning routine of toileting, washing afterward, and then combing hair. A routine can eventually lead to automatic behavior.
• Explain how compliance with the prescribed drug regimen can facilitate the ability to perform self-care.Medication decreases manic symptoms and facilitates the ability to care for self.
• Encourage the client to seek support with self-care or other needs that influence ability to function.It's imperative that the client have at least one support person available in times of stress.

NURSING DIAGNOSIS: SLEEP PATTERN DISTURBANCE

Probable Causes	Defining Characteristics
Hyperactivity Altered thought processes Emotional liability Disorganized behavior Metabolic or body chemistry alteration	Perpetual involvement with activities Extreme restlessness Inability to sleep, or sleeping for very short periods Interrupted sleep Very late retiring and very early rising

Long-Term Goal
The client will sleep without interruption at least 6 hours during the night.

Short-Term Goal #1:The client will develop a sleep ritual and sleep initially at least 4 hours each night.

Interventions and Rationales

• Assess the client's sleep-wake pattern, and establish a normal day-night pattern of behavior.Baseline assessment is the first step toward developing a plan to promote sleep.
• Work with the client to develop a means of slowing down and-.c preparing for sleep. A nighttime routine prepares the client to relax by decreasing the focus on environmental stimuli.
• Make the environment conducive to rest and sleep.A quiet. peaceful environment promotes relaxation and preparation for sleep.
• Restrict the client's use of caffeine and nicotine near bedtimeThese substances are stimulants and interfere with sleep.
• Offer a back rub, warm bath, soft music, or other nursing actions at bedtime. These activities promote relaxation, a prerequisite for sleep.
• Administer sleep-inducing medication as a temporary intervention.Medication is used only until an acceptable sleep pattern :s restored.

Short-Term Goal #2: The client will engage in a sleep ritual independently of the nurse and sleep at least 6 hours each night.

Interventions and Rationales

• Have the client begin to monitor his own sleep-wake pattern and identify factors or situations that interfere with sleep.The client needs to develop an awareness of factors that impact on the sleep-wake pattern to deal with them.
• Have the client establish and maintain a daily exercise routine early in the day. Exercise normally tires a person and promotes sleep.
• Encourage the client to use relaxation techniques, such as progressive relaxation and guided imagery.These methods decrease anxiety and enhance relaxation, which facilitate rest and sleep
• Encourage the client to share progress with the nurse and to obtain feedback and assistance if difficulty sleeping recurs.Support, encouragement, and additional resources can be prcviaec cy the nurse if the client needs them.

NURSING DIAGNOSIS: SLEEP PATTERN DISTURBANCE

Probable Causes	Defining Characteristics
Underlying feelings of inadequacy and insecurity Underlying feelings of aggression Defense against stress Dysfunctional family relationships Altered thought processes	Delusional thinking Unsuccessful interactions with peers and family Egocentric behavior Envy or jealousy of others Lack of impulse control

Long-Term Goal
The client will demonstrate appropriate interpersonal skills.

Short-Term Goal #1:The client will demonstrate new or enhanced social skills.

Interventions and Rationales

• Identify with the client manipulative behavior, such as deceiving others about his ability to pay his own way and flattering another before asking for a favor, and its effects on others. The client needs to understand what constitutes manipulative behavior and how the behavior affects others.
• Help the client develop limits and guidelines for behavior and a sensitivity for the tendency to violate the rights of others by consistently putting personal needs first. The client must learn how to set limits and control his own behavior in social situations.
• Teach and provide opportunities for the client to practice socially acceptable behaviors through interacting within a small group or role-playing appropriate behaviors. The client needs to have opportunities to perform behaviors, critique them, and have positive actions reinforced.

Short-Term Goal #2: The client will vary the responses given to others so that they are appropriate for the situation.

Interventions and Rationales

• Help the client identify and discuss behaviors that interfere with appropriate interactions with others. .!f clients identify problem behavior, they're more motivated to change the behavior.
• Prepare the client for building daily social relationships by role-playing and practicing new skills. .Giving the client guidance about building social relationships facilitates comfort with the process.
• Encourage the client to express feelings in a realistic and honest way. .The client often assumes extreme positions on topics of conversation rather than being honest and genuine about himself.
• Facilitate one-to-one opportunities to interact in a conversation with a peer. .The client needs to experience social situations to practice building a one-to-one or friendship type of relationship.
• Help the client identify comfortable and uncomfortable situations and how stress may cause reliance on defensive behaviors. .The client must develop the capacity to distinguish between positive circumstances and stressful situations to behave appropriately.
• Frequently evaluate the client's newly learned social skills, and provide feedback, encouragement, and reinforcement for successful interactions with others. .Reinforcement, feedback about ways to further develop skills, and encouragement are essential for maintaining the relationships that the client has }ust established.

THERAPIES

Individual Therapy

• Promote understanding of the disorder and the behavioral symptoms, and teach the client how to access assistance when necessary.
• Explore the uncomfortable feelings and dependency needs with which the client struggles.
• Identify and work to decrease manipulative behavior.
• Assist with the development of new relationships and social skills.
• Encourage the learning and use of problem-solving skills.

Family Therapy

• Assess family functioning, communication patterns, role expectations, problem-solving skills, and stressors.
• Determine how the client's extreme behaviors or crises are handled, and evaluate to what extent members support one another.
• Examine the degree of closeness and detachment of family members.
• Work to identify the concerns and problems that the family sees as needing to be resolved.
• Address the family's feelings of shame or blame for the client s chronic disorder.
• Have the family discuss issues of legal responsibility that surround the client's illness, such as resolving power of attorney issues if the client enters an uncontrolled manic phase after discharge from care.

MEDICATIONS

• Lithium carbonate, an antimanic drug, is the drug of choice for clients with bipolar disorder.
• Antipsychotic medications are used for clients with severe hyperactivity and for management of manic behaviors.
• Anticonvulsants are sometimes used for their ant manic efficacy.
• Antianxiety medications, such as clonazepam (Klonopin) and lorazepam (Ativan), are sometimes used for clients with acute manic episodes and those who are difficult to treat.
• The combination of lithium and an anticonvulsant has been used for rapidly cycling bipolar disorders. (See Appendix D for medication information.)

FAMILY CARE

• Help the family understand bipolar disorder and its impact on the couple and family relationships.
• Encourage family members to discuss their fears and feelings.
• Teach the family ways to resolve conflicts without confronting the client or creating a power struggle.
• Help family members assess their needs and develop ways to protect themselves against the client's episodes of manic behavior (such as overspending).
• Teach the family about the need for and use of medications.
• Teach family members communication skills so that they can handle concurrent interpersonal problems.
• Teach the family to recognize the prodromal signs and symptoms of bipolar disorder relapse.
• Discuss methods of obtaining support, and provide information about community resources.