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Silver Linings Playbook

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Chelsea Cooper

on 26 February 2014

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Transcript of Silver Linings Playbook

Bipolar Disorder
Bipolar disorder NOS (not otherwise specified)
Bipolar Disorder Overview
Types of Bipolar:
Bipolar I
Bipolar II
Cyclothymic Disorder
Dysthymic Disorder
Substance/Medication-Induced Bipolar and Related Disorder

History of client's illness
previously undiagnosed
Psychiatric hospital- after incident with wife
Prescribed medication
Psychosocial history- incident in the bathroom led to admit to the hospital, diagnosis, prescription

Chief Complaint

"I hate my illness and I want to contol it"
Control without medication
Bipolar II
Hypomanic episode (s) alternating with major depression. Psychosis is not present.
The hypomania episode of bipolar II tends to be euphoric and the depression tends to place the patient at particular risk for suicide.
Defense mechanisms

Pat thinks that he is going to get back with his wife, Nicki, throughout the entire movie.
Goal setting
Increase in goal-setting activity(either socially, at school or work, or sexually) is common in manic and hypomanic episodes.

Teal Meyer, Chelsea Cooper, Devlin Caskey
Bipolar I
At least one episode of mania alternating with major depression. Psychosis may accompany the manic episode.
Hypomanic episodes alternating with minor depressive episodes (at least 2 years in duration). Individuals with cyclothymia tend to have irritable hypomanic episodes.
includes bipolar features that do not meet criteria for any of the previously specified disorders.
Bipolar I
Characterized by the manic phase.
DSM- Manic episode
DSM- Hypomanic episode
DSM-Major depressive episode
Mood stabilizers
Atypical antipsychotics
Manic episode- may require hospitalization to prevent harm to self or others.
Hypomanic-hospitalization not required and if it does then it should be considered a manic phase. Similar mania S/S, but not as severe.
Major depressive- can include suicidal ideation without a plan.

Levels of Urgency
Some critics have expressed concern that the movie suggests that, in the end, all you need is love (without medication) to heal mental illness.
Myths, Stereotypes, Accuracy of Representation
Textbook pg. 279
The euphoric mood associated with a bipolar illness is unstable. During euphoria patients may state they are experiencing "an intense feeling of well-being," are "cheerful in a beautiful world," or are becoming, "one with God." The overjoyed mood may seem out of proportion to what is occurring in the person's environment, and cheerfulness may be displayed in inappropriate circumstances.

Dysthymic Disorder
Less severe from of depression, lasting at least 2 years.
Low, dark moods invade your life nearly every day for two years or more
S/S feelings of hopelessness, trouble sleeping, poor appetite or eating too much, fatigue, low energy, low self-esteem, trouble making decisions and concentrating
Mood Stabilizer- LITHIUM!
Narrow therapeutic range
Is effective in treating the manic phase, but does not cure.
Patient teaching should include: lab tests until therapeutic levels are reached (0.4-1.3mEq/L) and then once monthly lab draws.
Long term risks:
Kidneys- inability to concentrate urine
Lithium - Adverse Reactions
Expected Side Effects
- fine hand tremor, polyuria, and mild thirst, mild nausea and general discomfort, and weight gain

Early Signs of Toxicity- Nausea, vomitting, diarrhea, thirst, polydypsia, slurred speech, muscle weakness

Symptoms may progress rapidly to result in:
coma, cardiac dysrythmia, peripheral circulatory collapse, proteinuria, oliguria, and death

Atypical antipsychotics
olanzapine (Zyprexa), risperidone (Risperdal), ariprazole (Abilify), ziprasidone (Geodon), and quetiapine (Seroquel
Fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft)
Usually taken when no response to lithium or respond insufficiently
carbamazepine (Tegretol), divalproex (Depakote), and lamotrigine (Lamictal)
Non-pharmalogical Treatment Options
ECT- used to subdue manic behavior
Psychoeducation- Teach loved ones that anger and abusive remarks are symptoms of the disease and not persona.
Psychotherapy- especially important for management during acute manic attacks.
Family focused therapy- teaches entire family to prepare for relapse episodes.
Support Groups

Genetic Considerations
Researchers are finding more and more evidence that there is a genetic link.
A study (pg. 278) demonstrated that both bipolar disorder and schizophrenia definitely share a common genetic cause.
It is not just one gene, multiple genes play a role.
Expected outcomes
Effective coping (especially at onset of mania) and use appropriate support systems (family)
Sleep a minimum of 6 hours
Lithium serum levels tested once every month
Demonstrate knowledge of illness, treatment modalities, and prognosis (family)
Not harm self or others
Disclose and discuss suicidal ideas if present; seek help
Treatment Plan
Medication- (Lithium for maintenance)
Family therapy- Understanding in relationships is imperative.
Regular psychotherapy
Seclusion may be required in a hospital setting as it may be needed to prevent harm to self or others. Some patients may find comfort and relief with seclusion if they can no longer control their own behavior.
provide frequent snacks
Atypical Antipsychotics / ariprazole (Abilify)
Acute maintenance therapy of manic and mixed episodes associated with bipolar disorder (as monotherapy or with lithium or valproate). Adjunctive treatment of depression in adults.
Side Effects-
suicidal thoughts, tremors, drowsiness, extra- pyramidal reactions, constipation
Avoid extreme temperatures (drug impairs thermoregulation),
Instruct pt to take meds as directed and do not double up after a missed dose.

Antidepressants / sertraline (Zoloft)
Indications- Major depressive disorder. OCD. PTSD. Social anxiety disorder
Therapeutic effects- Antidepressant action. Decreased incidence of panic attacks. Decreased OCD. Decreased feelings of intense fear, helplessness, or horror. Decreased social anxiety.
Side effects- dizziness, drowsiness, fatigue, headache, insomnia diarrhea, dry mouth, nausea, sexual dysfunction, sweating, tremors.
Teaching- Caution to avoid driving & other activities requiring alertness; avoid alcohol; frequent mouth rinses, good oral hygiene, and sugarless gum decreases dry mouth; Pregnancy Category C

Anticonvulsant / divalproex sodium (Depakote)
Indications associated with bipolar disorder-
Manic episodes associated with bipolar disorder.
Side Effects-
fever, chills, RU quadrant pain, dark urine, malaise, jaundice/confusion, significant drowsiness
Baseline liver function tests should be preformed & results monitored at regular intervals,
Pregnancy Category D
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Varcarolis, E., M. (2013). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (2nd ed.). St. Louis, MO: Elsevier Inc.
'Silver Linings Playbook' OK on Mental Illness? (n.d.)WebMd. Retrieved from: http://www.webmd.com/mental-health/news/20121227/silver-linings-playbook-mental-illness

Vallerand, A. H. & Sanoski, C. A. (2013). Davis’s drug guide for nurses. Philadelphia, PA: F.A. Davis Company
References- images
Love heart with arrow.svg [Online image] Retrieved February 24, 2014 from http://commons.wikimedi a.org/wiki/File:Love_Heart_with_arrow.svg

Urgency [Online image] Retrieved February 24, 2014 from http:// hoganvisions.com/2012/11/08/urgency/

[Untitled illustration of silver linings playbook movie cover]. Retrieved February 24, 2014 from https:// sites.psu.edu/tjh5442/2013/03/22/silver-linings-playbook/

pg. 279
This mood may change to irritation and quick anger when the elated person is thwarted. The irritability and beligerence may be short-lived, or it may become the prominent feature of a person's manic illness.
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