Mood disorders

MOOD DISORDER

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Mood Disorder

• Characterized by disturbances in feelings, thinking, and behavior that tend to occur on a continuum, ranging from severe depression to severe mania (hyperactivity).

• Is the most common psychiatric diagnoses associated with suicide.

• Two Categories:a.Major Depressive Disorderb.Bipolar Disorder (Manic-Depressive

Illness)

1. Major Depressive Disorder

• Characterized by at least two weeks of a depressed mood or loss of interest in pleasure and activities.

• Also includes at least 4 of the following symptoms of depression:

a. Increase or decrease in appetiteb. Increase or decrease in sleepc. Psychomotor agitation or retardationd. Feelings of worthlessness or guilte. Fatigue and loss of energyf. Decreased ability to think and concentrateg. Recurrent thoughts of suicide

• These symptoms must be present everyday for 2 weeks and result in significant distress or impair important areas of functioning.

• Referred to as PSYCHOTIC DEPRESSION if combined with delusions and hallucinations.

2. Bipolar Disorder• Diagnosed when a person’s mood cycles

between extremes of mania and depression.

• Mania – an emotional state characterized by elation, high optimism, increased energy, and an exaggerated sense of importance and invincibility.

• May last for about 1 week but may be longer for some individuals.

• At least 3 of the following symptoms accompany the manic episode:a.Inflated self-esteem or grandiosityb.Decreased need for sleepc.Pressured speechd.Flight of idease.Distractibilityf. Increased involvement in goal-directed activity or

psychomotor agitationg.Excessive involvement in pleasure-seeking activities

with a high-potential for painful consequences

2. Bipolar Disorder• HYPOMANIA – a period of abnormally and

persistently elevated, expansive, or irritable mood lasting for days and including 3 or 4 of the additional symptoms described earlier.

• MIXED EPISODE - Diagnosed when the person experiences both mania

and depression nearly everyday for at least 1 week. - A person with mixed episodes experiences both mood

"poles"--mania and depression--simultaneously or in rapid sequence.

• BIPOLAR I DISORDER – one or more manic or mixed episodes usually accompanied by major depressive episodes.

• BIPOLAR II DISORDER – one or more major depressive episodes accompanied by at least one hypomanic episode.

Related Disorders

• Dysthymic Disorder - Characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode.

- This disorder usually does not affect social or occupational functioning.

• Cyclothymic Disorder – characterized by at least 2 years of several periods of hypomanic symptoms not as severe as those in a manic episode.

• Substance-Induced Mood Disorder – characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiologic consequence of ingested substances.

• Mood Disorder due to a general medical condition- Characterized by a prominent and persistent

disturbance in mood that is judged to be a direct physiologic consequence of a medical condition.

Other Disorders

• Seasonal Affective Disorder (SAD) – 2 Subtypes:

- WINTER DEPRESSION OR FALL-ONSET SAD: people experience increased sleep, appetite and carbohydrate cravings; weight gain; interpersonal conflict; irritability; and heaviness in the extremities beginning in late autumn and abating in spring and summer.

- SPRING-ONSET SAD: less common; with symptoms of insomnia, weight loss, and poor appetite lasting from late spring or early summer until early fall.

• Postpartum or “Maternity” Blues- Frequent, normal experience after delivery of a baby.- Symptom begin approximately 1 day after delivery,

usually peak in 3 to 7 days, and disappear rapidly with no medical treatment.

Other Disorders

• Postpartum Depression- Meets all the criteria for a major depressive

episode, with onset within 4 weeks of delivery.

• Postpartum Psychosis- A psychotic episode developing within 3

weeks of delivery and beginning with fatigue, sadness, emotional lability, poor memory, and confusion and progressing to delusions, hallucinations, poor insight and judgment, and loss of contact with reality.

- Considered a medical emergency that requires immediate treatment.

Etiology

BIOLOGIC THEORIES

• Major Depressive Disorder- 3 times more common among first-

degree biological relatives.- Twin studies reveal a higher rate of

concordance in monozygotic twins than dizygotic twins.

• Bipolar Disorder- The risk increases 4% to 24% in first-

degree relatives of people with bipolar disorder.

- Twin studies of monozygotic twins indicate a 65% concordance rate.

Etiology

NEUROCHEMICAL THEORIES

• Biogenic Amine Theory- Depressive Disorder: ↓ NE and serotonin- Bipolar Disorder: ↑ NE and serotonin

• Kindling Theory- External environmental stressors activate

internal physiologic stress responses, which trigger the first episode of a mood disorder, the first episode then creates electrophysiologic sensitivity to future episodes so that less stress is required to evoke another episode.

Etiology

NEUROENDOCRINE INFLUENCES

Depression• Increased cortisol secretion in 40% of clients.• Increased thyroid-stimulating hormone in 5% to 10%

of clients.

PSYCHODYNAMIC THEORIES

• Freud: looked at the self-depreciation of people with depression and attributed that self-reproach to anger turned inward related to either a real or perceived loss. (Introjection)

• Bibring: believed that one’s ego aspired to be ideal and that to be loved and worthy, one must achieve these high standards. Depression results when, in reality, the person was not able to achieve these ideals all the time.

Etiology

PSYCHODYNAMIC THEORIES• Jacobson: ego is a powerless, helpless child

victimized by the superego.

• Mania episodes: “defense” against underlying depression, with the id taking over the ego acting as an undisciplined hedonistic being.

• Meyer: depression as an reaction to a distressing life experience

• Horney: children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness, making them susceptible to depression and helplessness.

• Beck: depression results from specific cognitive distortions in susceptible people; involves magnification of negative events and minimization of anything positive.

Major Depressive Disorder

• Involves 2 or more weeks of a sad mood or lack of interest in life activities with at least 4 other symptoms of depression.

• Twice as common in women than men.

• Has 1.5 to 3 times greater incidence in first-degree relatives than in the general population.

• Its incidence decreases with age in women and increases with age in men; single and divorced people have the highest incidence.


Symptoms:

a. Depressed moodb. Anhedonismc. Unintentional wight change of 5% or more in a

month.d. Change in sleep patterne. Agitation or psychomotor retardationf. Tirednessg. Worthlessness or guilt inappropriate to the

situationh. Difficulty thinking, focusing or making

decisions.i. Hopelessness, helplessness, and/or suicidal

ideation.


Onset and Clinical Course• An untreated episode of depression can last

6 to 24 months before remitting.• 50% to 60% of people who have one episode

of depression will have another. • After a second episode, there is 70% chance

of recurrence.

Treatment and Prognosis• Psychopharmacology (TCAs, MAOIs, SSRIs,

Atypical Antidepressants)


• Psychotherapy

- Interpersonal Therapy: focuses on difficulties in relationships, such as grief reactions, role disputes, and role transitions.

- Behavior Therapy: seeks to increase the frequency of the client’s positively reinforcing interactions with the environment and to decrease negative interactions.

- Cognitive Therapy: focuses on how the person thinks.


Electroconvulsive Therapy

- Involves application of electrodes to the head of the client to deliver an electrical impulse to the brain; this causes a seizure.

- It is believed that the shock stimulates brain chemistry to correct the chemical imbalance of depression.

- A series of 6 to 15 treatments is scheduled 3 times a week.

- The client receives a short-acting anesthetic so he or she is not awake during the procedure.

- A muscle relaxant is given to relax all muscles that will greatly reduce the outward signs of the seizure.


Electroconvulsive Therapy

- After the therapy:a. The client may be confused; provide frequent

orientation and reassurance.b. Assess the gag reflex prior to giving the client

fluid, foods, or medication.

- Potential Side Effects:a. Major side effects with bilateral treatment are

confusion, disorientations, and short-term memory loss.

b. The client may be confused and disoriented on awakening.

c. Memory deficits may occur, but memory usually recovers completely; although some clients have memory loss lasting up to six months.

Application of the Nursing Process

Depression Assessment

• History- It may take several short periods to complete the

assessment because clients who are severely depressed feel exhausted and overwhelmed.

- Nurses must not rush the client because it can lead to frustration and incomplete assessment data.

- Nurses must ask about the behavioral changes, previous episodes of depression, treatment, and client’s response to treatment; and family history if suicide.

• General Appearance and Motor Behavior- Looks sad and ill; slouched posture, makes minimal

eye contact. - Psychomotor retardation, latency of response,

psychomotor agitation.



• Mood and Affect- Anhedonia- Affect: sad or depressed or may be flat with no

emotional expression.- They are overwhelmed by noise and people who

might make demands on them, so they withdraw from the stimulation of interaction with others.

• Thought Process and Content- Slowed thinking process; negative and

pessimistic, makes self-depreciating remarks; tends to ruminate.

- Has thoughts of dying or committing suicide.



• Sensorium and Intellectual Process- Others are oriented, but others experience

difficulty.- Has limited ability to respond to questions.- Memory impairment is common.- Has extreme difficulty concentrating or paying

attention.

• Judgment and Insight- Cannot make decisions or choices because of their

extreme apathy or their negative belief that it “doesn’t matter anyway.”

• Self-Concept- Low self-esteem- “good for nothing”; “worthless”



• Roles and Relationships- Inability to fulfill their roles - Withdraw from relationships

• Physiologic and Self-Care Considerations- Pronounced weight loss due to lack of

appetite or disinterest in eating.- Sleep disturbances are common.- Lose interest in sexual activity- Neglect personal hygiene- Constipation commonly results


Depression Data Analysis

• Risk for Suicide• Imbalance Nutrition: Less Than Body

Requirements• Anxiety• Ineffective coping• Hopelessness• Ineffective Role Performance• Self-Care Deficit• Chronic Low Self-Esteem• Disturbed Sleep Pattern• Impaired Social Interaction


Depression Outcome Identification

The client will:• Not injure himself or herself.• Independently carry out ADLs• Establish a balance of rest, sleep, and activity.• Establish a balance of adequate nutrition,

hydration, and elimination.• Evaluate self-attributes realistically.• Socialize with staff, peers, and family/friends.• Return to occupation or school activities.• Comply with antidepressant regimen.• Verbalize symptoms of a recurrence.


Depression Interventions

• Encourage the client to express sadness or anger and allow adequate time for verbal responses.

• Spend short periods of time throughout the day with the client.

• Sit in silence with the client who is not verbalizing.

• Avoid a cheerful attitude.

• Assess for suicide clues and intervene to provide safety precautions as necessary.

• Assist with activities of daily living if the client is unable to perform them.


Depression Interventions

• Provide activities for easy mastery to increase self-esteem and help in alleviating guilt feelings.

• Provide activities that do not require a great deal of concentration (simple card games, drawing)

• Offer small, high-calorie, high-protein snacks and fluids throughout the day.

• Encourage to dress and stay out of bed during the day.


Depression

Evaluation

Participation in therapy and medication compliance produce more favorable outcomes for clients with depression.

Bipolar Disorder

• Involves extreme mood swings from episodes of mania to episodes of depression.

• During manic phases, clients are euphoric, grandiose, energetic, and sleepless; they have poor judgment, rapid thoughts, actions, and speech.

• Onset and Clinical Course- Occurs in the early twenties or in adolescence; or in ages older than 50.

- Manic episodes typically begin suddenly, with rapid escalation of symptoms over a few days, and last from a few weeks to several months.

- They tend to be briefer and to end more suddenly than depressive episodes.

Bipolar Disorder

Typical symptoms of Mania:

• Heightened, grandiose, or agitated mood• Exaggerated self-esteem• Sleeplessness• Pressured speech• Flight of ideas• Reduces ability to filter out extraneous

stimuli; easily distractible• Increased number of activities with increased

energy• Multiple, grandiose, high-risk activities,

using poor judgment, with severe consequences

Bipolar Disorder

TreatmentPsychopharmacology• Lithium: - For bipolar mania but could also partially or

completely mute the cycling toward bipolar depressions.

- Contraindicated during pregnancy.

• Anticonvulsant Drugs- Exact mechanism is unknown but may raise

the brain’s threshold for dealing with stimulation.

- Given to clients who have problems in lithium therapy (SEs, drug interactions, renal disease)

- Carbamazepine, Valproic Acid, Clonazepam

Bipolar Disorder

TreatmentPsychotherapy

• Useful in the mildly depressive or normal portion of the bipolar cycle. It is not useful during acute manic stages because the person’s attention span is brief and he or she can gain little insight during times of accelerated psychomotor activity.


Bipolar Disorder

Assessment•History

- Taking history can be difficult- Obtain data in several short sessions,

talking to family members may be necessary.

• General Appearance and Motor Behavior- Psychomotor agitation (sitting still id

difficult)- Wears brightly-colored, flamboyant,

attention-getting, and perhaps sexually suggestive clothes.

Exhibit pressured speech.


Bipolar Disorder

Assessment• Mood and Affect- Mood is labile (loud laughter/episodes of tears)- Projection of an all-knowing and all-powerful image may be an unconscious defense against underlying low self-esteem.

•Thought Process and Content- Thinking is confused and jumbled with thoughts racing one after another.- Starts many projects at one time but cannot carry any to completion. - Some experience psychotic features during mania


Bipolar Disorder Assessment

• Sensorium and Intellectual Process- Oriented to person and place, but rarely to

time.- They may claim to have abilities they do not

possess.- Impaired ability in concentration or in

paying attention.- If also psychotic, hallucinations may be

present.

• Judgment and Insight- Impulsive; poor judgment- False sense of well-being masks difficulties

with chronic low self-esteem.


Bipolar Disorder Assessment

• Roles and Relationships- They are too distracted and hyperactive to pay attention to children or ADLs.

- Begins many tasks/projects but completes few.- Excessive, overpowering, and confrontational social interactions.

- Invades the intimate space and personal business of others.

- Labile emotions that fluctuate between euphoria and hostility.

•Physiologic and Self-Care Considerations- Can go on days without sleep or food and not even realize they are hungry or tired.

- They may even physically injure themselves or be unaware of health needs.


Bipolar Disorder

Data Analysis

• Risk for other-directed violence• Risk for injury• Imbalanced Nutrition: Less than body

requirements• Ineffective coping• Noncompliance• Ineffective role performance• Self-Care deficit• Chronic low self-esteem•Disturbed sleep pattern


Bipolar Disorder Outcome Identification

The client will:• Not injure self or others.• Establish a balance of rest, sleep, and activity.

• Establish adequate nutrition, hydration, and elimination.

• Participate in self-care activities.• Evaluate personal qualities realistically.• Engage in socially appropriate, reality-based interaction.

• The client will verbalize knowledge of his or her illness and treatment.


Bipolar Disorder Interventions

• Providing for Safety-Provide a safe environment for clients and others.-Assess directly for suicidal ideation.- Set limits. Clearly identify the unacceptable behavior and the expected, appropriate behavior.

- Remind the client to respect distances between staff and others.

• Meeting physiologic needs-Decrease environmental stimulation; provide a quiet environment.

-Establish a bedtime routine to help clients to calm down to rest.

-Provide “finger foods” or things clients can eat while moving around to improve nutrition. (sandwiches, protein bars)



• Providing Therapeutic Communication- Nurses must use clear simple sentences when communicating.

- Clarify the meaning of client’s communication.- Set limits regarding taking turns in speaking and listening.

• Promoting Appropriate Behaviors- Direct the clients’ need for movement into socially acceptable, large motor activities such as arranging chairs or walking. - Protect the client’s dignity when inappropriate behavior occurs.



• Managing Medications- Monitor serum lithium levels.- Clients should drink adequate water and continue

with the usual amount of dietary table salt. (table)- Too much salt and water = Lithium blood level is

too low- Too little salt and water = Lithium toxicity- Monitor fluid balance by measuring I and O- Monitor thyroid function tests and renal status.

• Providing Client and Family Teaching- Client and family teaching for the client with mania



• Providing Therapeutic Communication-Nurses must use clear simple sentences when communicating.-Clarify the meaning of client’s communication.-Set limits regarding taking turns in speaking and listening.

• Promoting Appropriate Behaviors-Direct the clients’ need for movement into socially acceptable, large motor activities such as arranging chairs or walking. -Protect the client’s dignity when inappropriate behavior occurs.

• Managing Medications-Monitor serum lithium levels.

Suicide

• The intentional act of killing oneself.

• The nurse caring for a depressed client always considers the possibility of suicide.

• Commonly occurs in clients with:- Psychiatric Disorders: depression, bipolar,

schizo, substance abuse, PTSD, and BPD.- Chronic medical illness: Cancer, HIV, DM,

CVA, head and spinal cord injury.- Environmental factors

Suicide

Assessment:

• A history of previous suicide attempts increases risk for suicide. (The first 2 years after an attempt represent the highest risk period, especially the first 3 months)

• Family history (the closer the relationship, the greater the risk)

• Suicidal clues:- Giving away personal, special, and prized possessions

- Cancelling social engagements- Making out or changing a will

Suicide

Suicidal clues:

- Taking out or changing insurance policies- Positive or negative changes in behavior- Poor appetite- Sleeping difficulties- Feelings of hopelessness- Difficulty in concentrating - Loss of interest in activities- Client statements indicating an intent to

attempt suicide- Sudden calmness or improvement in depressed

client.- Client inquiries about poisons, guns, or other

lethal objects.

Suicide

Interventions

• Remove harmful objects such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens and even clothing with drawstrings.

• Clients must be in direct sight of and no more than 2 to 3 feet away from a staff member for all activities.

• Initiate a no-suicide contract• Identify support systems• Keep the client active by assigning achievable tasks.

• Encourage Active participation in own care. • Continue to assess the client’s suicide potential.

Date post:	01-Dec-2014
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Mood disorders

Health & Medicine