Mania-NOTES

MANIA

Introduction

Mania is a mood disorder. Mood is a prolonged emotional state that influences the person’s whole personality and life functioning. Mood can be normal, elevated, or depressed. In mania, there is an extreme elevation of mood.

Kraepelin in 1921, described a manic patient as follows;

Stranger to fatigue, his activity goes on day and night; work becomes very easy to him; ideas flow to him. He cannot stay long in bed; early in the morning, even at four o’clock he gets up, he clears out lumber rooms, discharges business that was in arrears, undertakes morning walks, excursions. He begins to take part in social entertainments, to write many long letters, to keep a diary, to go in a great deal for music and authorship. Especially the tendency of rhyming … is usually very conspicuous. … his pressure of activity causes the patient to change about his furniture, to visit distant acquaintances, to take himself up with all possible things and circumstances, which formerly he never thought about

Definition of mania

The DSM-V defines mania as a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy.

Mania can be defined as a state of extreme physical and emotional elation lasting at least 1 week (or less if hospitalization is required).

Signs and symptoms

According to DSM-IV, the cardinal symptoms of mania are the following:

Heightened mood (either euphoric or irritable); The person feels extremely ‘high’, happy and full of energy; he or she may describe the experience as feeling on top of the world and invincible. The person may shift rapidly from an elevated, happy mood to being angry and irritable if they perceive they have been obstructed.
Flight of ideas; Patient has too many ideas coming into his mind hence, talks quickly and erratically, jumping rapidly between ideas and thoughts.
Pressure of speech; patient talks so much and so fast that others can not interrupt.
Increased energy: patient is never getting tired and finds it difficult to remain still. and work becomes very easy for him as he spends long hours working on something.
Insomnia: patient has reduced need for sleep. He may just sleep for a few hours and still feel rested.
Hyperactivity: patient will be seen moving up and down excessively due to increased energy.
Grandiose ideas (Ideas of self exaltation): It is quite common for a person in a hypomanic or manic state to believe that he or she is unusually talented or gifted or has special friends in power. For example, the person may believe that he or she is on a special mission from God.
Chance association (commenting on anything within sight)
Exaggerated type of dressing, often using bright colours
Pleasurable activities with painful consequences e.g. increased spending, increased libido, speeding, substance use

Predisposing factors of mania

There is no specific known cause of Mania. However, predisposing factors include the following:

Genetics: Mania is hereditary in nature. First degree relatives or children of people with these disorders are more likely to develop the mania than people in the general population.

Biochemistry: Research has shown that people with mania have too much of serotonin and epinephrine.

Psychological factors

Traumatic life experiences either during childhood or as an adult is likely to lead to mania. These traumatic experiences could be Physical, sexual or emotional abuse.

Social factors

Stressful life events, lack of social support, and environmental stress and poverty can predispose a person to mood disorders.

Drug and substance abuse: Some medications can cause hypomania or mania as a side effect, either while you are taking them or as a withdrawal symptom when you stop. This includes medications for physical conditions and psychiatric medications – including some antidepressants.

Altered sleep pattern: Brain imaging studies have shown that sleep deprivation causes disrupted communication within the mood control network of the brain in healthy individuals that is strikingly similar to that seen in persons with bipolar disorder.

Diagnostic criteria

A manic episode is defined in the American Psychiatric Association's diagnostic manual as a "distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration, if hospitalization is necessary),“ where the mood is not caused by drugs/medication or a non-mental medical illness (e.g., hyperthyroidism), and:

A. Is causing obvious difficulties at work or in social relationships and activities, or

B. Requires admission to hospital to protect the person or others, or

C. The person is suffering psychosis.

To be classified as a manic episode, while the disturbed mood and an increase in goal directed activity or energy is present, at least three (or four, if only irritability is present) of the following must have been consistently present:

Inflated self-esteem or grandiosity.
Decreased need for sleep (e.g., feels rested after 3 hours of sleep).
More talkative than usual, or acts pressured to keep talking.
Flights of ideas or subjective experience that thoughts are racing.
Increase in goal directed activity, or psychomotor acceleration.
Distractibility (too easily drawn to unimportant or irrelevant external stimuli).
Excessive involvement in activities with a high likelihood of painful consequences.(e.g., extravagant shopping, improbable commercial schemes, hypersexuality).

Classification of mania

Mania can be classified into 3; these are

Mixed states: In a mixed state the individual has co-occurring manic and depressive features.

Hypomania: In hypomania, there is less need for sleep and both goal-motivated behaviour and metabolism increase.

Associated disorders: A single manic episode is sufficient to diagnose bipolar I disorder.

Treatment of a manic patient

NOTE: This treatment is taken from Zambia treatment guidelines for mental illnesses of 2022.

Investigations

FBC, U & Es, LFT and KFT, RPR & HIV, TSH, Hepatitis B & C, Vitamin B12 levels, pregnancy test, MRI, CT scan, DOA6, EEG, ECG

Treatment:

Treatment is immediate and long-term aimed at reducing self-harm, harm to others and destruction of property. If patient is violent, refer to general management of aggressive and violent patients

Immediate treatment (Pharmacotherapy):

i. Haloperidol 2.5mg-5mg PO/IM (if patient is aggressive or violent)

MOA: blocks post-synaptic dopamine receptors in the brain.

S.E: Dizziness, Constipation

N.I: Get out of bed slowly, advise client to get more fibre into his diet, take patients vital signs before and after medication.

ii. Diazepam 5mg-10mg PO/IV (If patient is aggressive or violent), can repeat in intervals of 6 hours till a maximum of 40mg/day

PLUS

iii. Sodium valproate 500mg OD PO, then can increase to BD PO

MOA: increases the amount of GABA in the brain.

S.E: Dry mouth, black tarry stools, feeling sleepy

N.I: Teach client about drug side effects. Perform liver function tests.

iv. Sodium divalporex 500mg OD PO, then increase to BD PO

v. Carbamazepine 200mg BD PO, then can increase to 400mg PO, BD

Maintenance (Pharmacotherapy): Long treatment is aimed at preventing relapse and

reducing the intensity of symptoms. Medication as above, can continue with either Sodium valproate OR Sodium divalproex OR Carbamazepine.

i. Sodium valproate 500mg-1g

ii. Carbamazepine 200mg-400mg PO, BD,

iii. Sodium divalproex 500mg-1g PO, OD/BD.

If psychotic persist can add

1st line

i. Haloperidol 2.5mg-5mg PO, OD

ii. Chlorpromazine 50mg-100mg PO, OD

2nd line

Risperidone 2mg OD PO

Continue with sodium valproate//divalproex or carbamazepine; wean off benzodiazepines

within 5-7 days and consider weaning off antipsychotics within 4 weeks. Monitor HB levels

as carbamazepine causes anaemia. Do HB once a month and FBC once in 6 months.

NURSING CARE

AIMS

To promote quick recovery
To promote patient comfort.
To prevent suicide ideation
To prevent injury to self or others.
To promote good nutrition status
To promote nurse- patient relationship
To prevent further complication

SAFE ENVIRONMENT

Take note that the patient with mania has a high risk of injury to self-due to hyper activeness. Therefore, maintaining safety is a priority. In your intervention focus on the following.

Nurse the patient in a clean well-ventilated environment to prevent nosocomial infection and well-lit environment for easy observation.
Nurse the patient in an environment which does not have any hazardous items such as, naked electrical wires, sharp objects, loose codes, which may be harmful to the patient or others or used by the patient to harm himself.
Seclusion of the patient maybe be considered only in certain circumstances, for example, as a corrective measure, or when he is aggressive to others in the ward.
Since client makes to many movements, make sure he is nursed in a ward with a non-slippery floor to prevent injuries due to falls.
Remove all shoelaces, belts long-sleeved sheets to prevent suicide ideation or attempt.
Make sure that all drugs are locked up in a drug locker to prevent drug abuse.

ESTABLISHING THERAPEUTIC RELATIONSHIP

Take note that, this intervention should not be left out when dealing with most mental illnesses. Patients with mania, may be paranoid and psychotic establishing a therapeutic relationship will help build trust and cooperation. This can be done in the following ways.

Introduce yourself to the patient and explain your roles as a nurse and that you wish them to recover this will promote patient cooperation.
Be non-judgmental and convey genuine respect to the patient this will build patients confidence to confide in you for anything.
Spend short moments with your client in your busy schedule and actively listen to him and respond accordingly, this will strengthen the relationship and build trust.
Avoid any actions that may be misinterpreted by the patient if they are paranoid such as whispering in front of the patient.

OBSERVATION

NOTE: the its important to observe the client to rule out any deviations from normal and detect behaviours that would indicate something serious before they become worse. We therefore must do the following:

Check the vital signs such as temperature, blood pressure, pulse and respirations to rule out any deviations from normal.
Observe client’s social interactions and behaviours to rule out early signs of altered social interaction and behaviours that would lead to violence or aggression.
Observe the clients feeding patterns this will help you detect any unwanted patterns and work towards promoting good nutrition.
Observe for the sleeping patterns of the patient to rule out insomnia.
Observe the side effects of medications for possible changing of medication or dosages if side effects are severe.

PSYCHOLOGICAL CARE.

NOTE: psychological care is also known as psychotherapy or talking therapy. One of the aims is to relieve anxiety.

Explain the condition in simple terms to both the patient and the relatives to promote cooperation.
Always get consent before touching the patient as this can be perceived as an attack.
Explain all the procedures to be done to promote cooperation.
Explain the side effects of the drug the person that is on to both the patient and the relatives to promote cooperation.
Explain the rules of the ward to the patient most especially fighting and any desirable behaviours either be rewarded or punished.

MAINTENANCE OF GOOD SLEEPING PATTERN

Advise the patient to exercise during the daytime so to allow enough sleep at night.
Advise the present avoid taking any caffeinated drinks at bedtime to promote rest.
Do bed making to prevent irritation during sleep
Remove any noise from the environment to promote rest.
Make sure that the light is dim to promote rest.
Do nursing care in Block to promote enough time to rest.
Take all the trolleys to the maintenance department to have them oiled to prevent noise.
Encourage the patients not take any fluids during bedtimes to promote rest

PROMOTION OF GOOD NUTRITION STATUS

Give small frequent meals as the patient may not have time to sit down and eat large amounts of food at once.
Give the patient meals together with other patients so that he can be motivated to eat and prevent suspicions.
Encourage relatives to the patient to prepare my patients favourite foods to promote good nutrition.
If the patient has no appetite give prescribed mult- vitamins to promote appetite.
Involve the nutritionist in the planning of meals to prepare a well-balanced diet.
Give the patient water to drink or remind him to drink water to prevent dehydration

HYGIENE AND CLEANNESS

Dumb dust the patients unity to prevent nosocomial infection
I have removed and changed to the soiled linen to prevent nosocomial infection
I will observed all sterile techniques in my nursing procedures to the patient to prevent contamination
I have done assisted bath to promote good grooming and good blood circulation
I have done assisted and supervised or a care to prevent Halistosis.
I have done nail care to my person to prevent harboring microorganism
I have done hair care to my patients to prevent lice or pediculosis
I will assist my patient how to make their own bed to promote good grooming and enhance behavioral modification.

SELF AWARENESS

I will examine myself the mood am in that day if I’m not in good mood I will counsel myself before coming in contact with my patient to prevent exhibiting aggressive behaviours to the patient

EFFECTIVE COMMUNICATION

·I will speak in a non provoking manner to prevent aggression
·I will avoid making eye contact on my patients to prevent exhibiting aggressive behaviours
·I will wear a comb appearance to prevent aggressive behaviour.

BEHAVIOURAL MODIFICATION

I will teach my patient how to make their own beds to enhance behaviour modification
I’ll teach my patient accepted behaviours in the ward to enhance behavioral modification
I’ll give praises and gifts whenever the patient does something that is to good to promote continuity
I will warn my patient that bad behaviours are punishable and can warranty to locked into seclusion
I will involve my patient into social skills group to impart good behaviour modification

SOCIAL SKILLS TRAINING

I’ll teach my patient how to live with others in the society eg how to greet and respect elders
I will teach my patient how to maintain relationships in the society to promote social skills
I will teach my patient to hold a conversation in social to my patient to promote social skills
I teach my patient how to handle himself when he or she is upset to prevent exhibiting aggressive behaviour to others

ASSERTIVE TRAINING

I’ll teach my patient appropriate assertive skills such as saying no to unreasonable request without hating others feeling to promote assertiveness

STRESS MANAGEMENT

I will teach my patient stress management skills such as playing soccer, watching TV , to relieve stress.

I will minimize environmental stimuli by dimming lights, closing curtains, and reducing noise levels around the patient to help prevent exacerbation of manic symptoms by reducing external triggers that may increase stress or overstimulation.

I will work with the patient to create a consistent daily schedule for meals, medication, and activities to reduce stress by providing structure, helping the patient feel more grounded and less overwhelmed.

I will teach the patient simple relaxation techniques such as deep breathing exercises or progressive muscle relaxation to activate the body’s relaxation response, which can help reduce stress levels and decrease hyperactivity associated with mania.

I will encourage the patient to take short, scheduled breaks throughout the day in a quiet space to rest to help prevent exhaustion and reduce stress by providing moments of calm, which are important for emotional regulation in patients with mania.

I will educate the patient on healthy coping mechanisms for managing stress, such as engaging in light physical activity, journaling, or engaging in creative activities to help the patient manage emotions and reduce the risk of stress-triggered escalation of manic symptoms.

PSYCHOTHERAPY

In this therapy we are changing the mind of a patient through counseling. So all the principles and skills of counseling should be followed and applied during Psychotherapy.

Allow the patient to express himself during counseling to know what he is thinking
Use probing skill in order to get some more information from the patient.
Use open ended questions during counseling in order to get more information from the patient
Educate the patient on the important of accepting the treatment in order to promote quick recovery
Ask the patient how he feels about her conditions in order to know his concerns
Connect the patient to other health care team member such as psychologist for more treatment

GROUP THERAPY

In group therapy we are treating the patient with mental Illness by using group as treatment

Patients are put in groups where they gain knowledge and experience on how to deal with their illness Put the patient in group therapy to promote social skills.Putt the patient with mental illness or Schizophrenia in
A group with people with same condition to make the patient feel that he is not the only person with mental illness or Schizophrenia as a result stigma will be relieved
Show the patient the people in the group who have recovered from the same illness to make him gain hope that his condition will also be resolved
Give tasks within the group to improve problem solving skills of the patient
Demonstrate appropriate behavior to the group members to change behavior through modeling technique
Make sure every patient in the group is participating to promote social interaction.

FAMILY THERAPY

Mental illness does not just affect the patient they also affect
The family of mentally ill patient. So the nurse should help the family in coping up with the patient‘s condition
Involve the family in the care of the patient to make the patient not feel neglected by the family
Explain the condition of the patient to the family to impart Knowledge
Tell the family not to be calling the patient by his illness in order to reduce stigma
Encourage the family to be involving the patient in decision naking of the family to make the patient feel that he is also important
Encourage the family to be giving something to the patient when he does well to work as positive reinforcement
Encourage the family not to be isolating the patient in order to promote social skills to the patient
Tell the family to bring the patient for review according to the date for continuity of care
Encourage the family to bring the patient to the hospital if he become violent or uncontrollable to prevent injury to himself and to other

MILLEU THERAPY

Milleu Therapy is a scientific structuring of the environment in order to effect Behavioural changes and to improve the psychological health and functioning of the individual. In psychiatric it is believed that the environment is one of the factor which expose someone to mental illness. Because of this many Psychiatrists came up with a therapy which uses environment to treat mental illness.

The environment where the patient is will have a lot of activities which teach the patient concerning life, such as art therapy, music therapy, sports and recreational activities, group therapy, religious therapy
I will create a safe and welcoming space by organizing the unit and ensuring it is clean, comfortable, and conducive to healing to help the patient feel secure and supported, which is essential for promoting engagement in treatment and facilitating recovery.
I will engage in active listening and open communication with patients, allowing them to express their feelings and concerns to encourage the patient to share their thoughts and feelings, which is essential for effective therapy and helps them feel valued and understood.

I will facilitate group therapy sessions and structured group activities to promote social interaction and communication among patients to help the patient practice interpersonal skills, build social connections, and learn from one another’s experiences, fostering a sense of community and belonging.

I will implement a structured daily schedule that includes time for therapeutic activities, meals, rest, and recreation to provide the patient with predictability, which can help reduce anxiety and enhance their sense of control and stability within the therapeutic environment.

I will encourage patients to participate in self-care activities and take responsibility for their daily routines, such as dressing, hygiene, and medication management to empower patients, boosts their self-esteem, and encourages a sense of accomplishment, which can enhance their overall mental well-being.

BEHAVIORALTHERAPY

Bad behaviors are called Maladaptive behavior while good behaviour are called Adaptive behavior
Behavioral Therapy is a type of psychotherapy in which we modify or change Maladaptive behavior by re-inforcing more adaptive behavior through techniques.
Involve the patient in roleplaying activity so as to change behaviour through modeling techniques portray acceptable behaviour and tell the patient to imitate your behaviour to act as a role model to the patient
If the patient becomes violent, lock the patient in the isolation room to prevent him from getting attention from others
Ignore some behaviour which need to be ignored to change behaviour through extinct technique form a contract with the patient. In this contract include behaviour expected from them, positive reinforcement that will be given and also the negative reinforcement that will be given if the patient fails, in order to change behaviour through contingency contracting technique

MEDICATION

Explain the mode of action and side effects of drugs to the patient to impart knowledge
Give medication on time to prevent overdose
Make sure the patient swallow these medications in your presence to act as evidence that he has taken the medication
Sign in the drug chart after giving the patient drug to act as evidence that you have given the patient
Follow the 6 rights of drug administration to prevent drug reaction.

DISCHARGE PREPARATION

· As soon as the patient is admitted in my ward I’ll tell her or him that he will be discharged and they will join his or her family members and friends to rule out institutionalization.

· I will keep on telling the patient and relatives that as soon as he or she stabilize we shall discharge the patient.

Information, Education, and Communication (IEC) for a Manic Patient

1. Educate Client About Drugs

Information: I will provide the client with clear and concise information about the medications prescribed for their condition, including their names, dosages, and how they work.
Key Points:
- Purpose: Explain how these medications help stabilize mood and reduce manic symptoms.
- Side Effects: Discuss potential side effects and what to do if they experience them.
- Duration: Emphasize the need for consistent use, even if they feel better, to maintain stability.

2. Educate Client About the Importance of Treatment Compliance

Information: I will stress the importance of adhering to the prescribed treatment plan, including medication and therapy.
Key Points:
- Benefits: Explain how compliance can prevent relapse and promote better overall health.
- Consequences: Discuss the risks of non-compliance, including the potential for worsening symptoms and hospitalization.
- Support: Encourage the client to communicate any concerns about medications or side effects.

3. Educate Client About the Importance of Review Dates

Information: I will explain the significance of attending scheduled follow-up appointments and reviews.
Key Points:
- Monitoring: Highlight that regular reviews help healthcare providers monitor progress and make necessary adjustments to treatment.
- Assessment: Discuss how these appointments allow for assessment of medication effectiveness and side effects.
- Involvement: Encourage the client to actively participate in these discussions to share their experiences and concerns.

4. Educate Family About Their Possible Roles in the Care of the Patient

Information: I will provide family members with information on how they can support the patient during treatment.
Key Points:
- Observation: Teach them to recognize signs of mania or potential relapse, enabling early intervention.
- Encouragement: Emphasize the importance of providing emotional support and encouraging medication adherence.
- Communication: Encourage open communication between family members and the patient about feelings and concerns related to the illness.

5. Teach Client About the Importance of Rest and Sleep

Information: I will educate the client on the critical role of rest and sleep in managing their condition.
Key Points:
- Restoration: Explain how adequate sleep helps restore mental and physical health, reducing the risk of mania.
- Sleep Hygiene: Provide tips on good sleep hygiene, such as maintaining a regular sleep schedule, creating a comfortable sleep environment, and avoiding stimulants before bed.
- Stress Reduction: Discuss how relaxation techniques, such as mindfulness or deep breathing, can help improve sleep quality.

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