MOOD DISORDERS

MODULE 6

MOOD DISORDERS
Group of disorders characterized by a decrease or entire loss of control over mood. May occur in different patterns of severity, duration, alone or in combination. Also known as AFFECTIVE disorders, are pervasive alterations in a persons emotions, manifested by depression and mania.

MOOD DISORDERS
Mood disorders are present in early history of mankind. There was no treatment for mood disorders until mid-1950s There are still no cure for mood disorders today, but there are now effective treatments for both depression and mania.

CATEGORIES OF MOOD DISORDERS UNIPOLAR DISORDERcharacterized by depression and dysthymic disorder BIPOLAR DISORDER- also known as (manic-depressive illness), a cycle of extreme mania and depression with normalcy in between

CATEGORIES OF MOOD DISORDERS

Mania- is abnormally elevated mood in which the person is extraordinarily energetic; needs little sleep and rest or food has exaggerated sense of self- importance, inflated selfesteem, poor judgment, increased libido, expanded socialization, high distractibility, easy irritation and grandiose behavior

CATEGORIES OF MOOD DISORDERS

Depressive disorders- include major depressive disorders, dysthymic disorder and depressive disorder.
Note: Depression is present on 80% of those who attempt or commit suicide. Suicide- is an option to end helplessness, hopelessness and internalized anger of mood disorder

RELATED DISORDERS
1. MIXED ANXIETY-DEPRESSIVE DISORDER - Sad mood that lasted more than 4 weeks, along with such behaviors as altered sleep, interference with concentration, irritability, freeting, little energy, tearfulness, hypervigilance, pessimism, worthlessness and anticipation of failure.

RELATED DISORDERS 2. SOMATOFORM DISORDER - Can be mistaken for mood disorder, the person has a combination of symptoms affecting multiple areas of the body, including pain, GIT, GU, sexual, and pseudoneurologic symptoms.

RELATED DISORDERS
3. SEASONAL AFFECTIVE DISORDER - Depressive episodes that occurs in yearly cycles, happens during winter months. The person is deenergized, sleeps more, gains weight, has anhedonia and is cranky. As spring appears, the person gains energy and pleasant personality, becomes active and is less sleepy.

RELATED DISORDERS
4. GRIEF 5. PREMENSTRUAL DYSPHORIC DISORDER (mood lability, agitation, anhedonism, fatigue, appetite and sleep changes, interpersonal conflict and physical symptoms) 6. DEPRESSIVE PERSONALITY DISORDER

MOOD DISORDERS: ETIOLOGY Genetic theory

- Transmission of unipolar depression in first-degree relatives - Monozygotic twins: 54% - Dizygotic twins: 24% - Link between bipolar disorder to red/green color blindness, G6PD deficiency - Chromosomal anomaly (Cromosome 11) - Bipolar disorder and early-onset of alcoholism

MOOD DISORDERS: ETIOLOGY Neurochemical theory - Focuses on serotonin and norepinephrine - Depression: deficits of serotonin and norepinephrine - Mania: increase of norepinehrine - PET scan shows reduced metabolism in the prefontal cortex which may promote depression

MOOD DISORDERS: ETIOLOGY Neuroendocrine influences - Thyroid adrenal, parathyroid and pituitary disorders have been documented in mood disorders - Postpartum hormone alterations - Premenstrual syndrome

MOOD DISORDERS: ETIOLOGY Biologic Cycles - Seasonal affective disorder- a depression that occurs when there is less sunlight - Hormonal shifts induced by lunar cycles; premenstrual syndrome - Circadian rhythms are also being researched in relation to diurnal mood variations

MOOD DISORDERS: ETIOLOGY Psychodynamic Theories - Freud (1917)- depression stemmed from the rage of abandonment of the infant - Loss of love object produces insecurity, emptiness, sadness and anger - Occurs in the ORAL stage - The use of INTROJECTION

MOOD DISORDERS: ETIOLOGY Psychodynamic Theories - Freud and Karl Abraham (1927)sadness felt in grieving is similar to depression - Grieving that occurs before a loss is called anticipatory grieving - The chief difference between grief and depression is that grieving is time-limited usually 1 to 2 years.

MOOD DISORDERS: ETIOLOGY Psychodynamic Theories - Mania is related to fear that the childs increasing autonomy will leave the parent without significance in childs life. - Conflict between autonomy and dependence - Depression: weak ego and overpowering superego - Mania: id-dominated and weak superego

MOOD DISORDERS: ETIOLOGY Cognitive Theories - Aaron Beck theorized that depression is a result of the persons comprehensive negative thoughts - They view themselves, their world, their future as distorted failure mode

MOOD DISORDERS: ETIOLOGY Social/Environmental Theories - Ambivalent, abusive, rejecting or highly dependent family relationship - Loss of relationship or an important life role may precede depression - Physical or sexual abuse - Social isolation and severely limited finances

Depression
Persistent sad or depressed mood. Loss of interest in things that were once pleasurable with disturbance in sleep, appetite (and weight), energy and concentration.

Subtypes of Depression
Major Depression severe, last for at least 2 weeks. Dysthymic Depression less severe (last for 2 yrs or more) Depressed Not Otherwise Specified (DNOS) last for 2 days-2weeks

Major Depression
Chronic Fatigue Psychomotor retardation Psychomotor agitation Sleep disturbances Disturbance in appetite Somatic complaints Drug addiction

Impaired libido Hopelessness Helplessness/ ruminations of inadequacy Thoughts of Death Guilt feelings Indecisiveness Lack of selfconfidence Alterations of perceptions

Other Subtypes
Melancholia subtype
Similar to major depressive episode Five or nine symptoms are present

Seasonal Affective Disorder (SAD)

Depressive episodes at characteristic times of the year Begin in the fall and winter and remit in spring Hypersomnia, anergia and a craving for sweets TX: Light therapy and SSRIs

Diagnostic Criteria
Dysphoria Anhedonia Hyperphagia Insomnia or hypersomnia Psychomotor agitation or retardation Anergia Feeling of worthlessness or inappropriate guilt Decrease ability to think or concentrate, indecisiveness Suicidal ideation, plan or attempt

Bipolar Disorder
Two extreme mood states of mania and depression Theories: Biological, Psychodynamic, existential, cognitive-behavioral, developmental theories

A distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week 3 or more of the following: Psychomotor over excitability or excitement Insomnia with fatigue Euphoria or elated mood Distractibility Pressured speech Flight of ideas Manipulative or demanding behavior Destructive or combative behavior Delusions of grandeur Impaired judgment

Bipolar Disorders

Subtypes of Bipolar Disorder

Manic severe, last for at least 1 wk. Hypomanic less severe, last for at least 4 days Bipolar I with history of mania Bipolar II no history of mania Cyclothymia numerous episodes of hypomania and depressed moods that last at least 2 yrs

Stages of Mania
Stage 1 Stage 2 Stage 3

Mood

Labile, euphoric, Irritable if not satisfied

Expansive, grandiose, overconfident, sexual & religious preoccupation Increased psychomotor activity, rate of speech, spending, smoking telephone use

Increased dysphoria, open hostility, anger

Flight of ideas, disorganization, delusions

Panic-stricken, hopeless

Cognition

Incoherent, looseness of association

Behavior

Increased psychomotor activity, occasional assaultive behavior

Frenzied, frequently bizarre activity

Manipulative Behavior
Typical behaviors Care Strategies Limit setting Assuming Establish instant boundaries Introduce shift intimacy nurses to illustrate Using flattery shift-shift teamwork Acknowledge Claiming grievances without defensiveness Entitlement Firm kindness approach Splitting

Sexually Provocative Behaviors

Care Strategies: Flirting Set boundaries Redirect personal Excessive use of questioning flattery Document interactions Touching in sexually and behaviors suggestive manner Develop a consistent approach Making sexist Evaluate pre-existing remarks problems that may Discussing sexual affect behavior prowess Set limits on behaviors Give positive reinforcements when appropriate

Mania
Appearance Behavior Communication Nursing Dx
Nsg Care Priority
colorful Highly Driven, hyperactive

Depression
Sad Passivity/ psychomotor retardation Monotonous speech Risk for injury self directed

Talkative (flight of ideas) Risk for injuries directed at others

safety
Lithium Non-stimulating Quiet type avoid competative

Safety
ECT Stimulating Monotonous activity eg. Counting Kind firmness

Tx of Choice Millieu Therapy

Appropriate Activity Attitude Therapy

Matter of fact (attitude of casualness)

Suicide
cry for help Major interventions: Prevention & listen Priority Nsg Dx: risk for injury-self directed ultimate form of self-destruction

Risk Factors
Sex Unsuccessful previous attempt History of family member who committed suicide Chronic Illness Depression Age Lethality of previous attempts

Areas to Consider Stress Depression

Low Risk
0 Mild, feelings slightly down

Moderate Risk
Moderate reaction to loss Moderate: some moodiness

High Risk
Severe reaction Overwhelming

Coping behavior

Occasional thoughts about suicide

ADL little change

More than 1 per month

Some ADLs affected Support unwilling to help consistently Interpersonalized suicide goal

May resist help

Constant suicidal thoughts, delusions Not available or hostile Non verbal expression

Social support Communication

Help available readily Direct expression of feelings

Previous suicide attempts

Suicide plan details

None or low lethality

Vage, means not available, no time, others can still present

Multiple of low lethality

Some specificity, time within a few hours, support available when called upon

Suicide attempts over past weeks

Well thought off, knows when where and how, has the means in hand, will die ASAP, no one there

Who Will Commit Suicide?

S- ex - Male (more successful); female
(hesitant) A- ge 15-25 y/o or above 45 y/o D- epression P- atient with previous attempts (will try again) E- thanol (Alcoholics) R- ational (opposite) S- ocial support (lacks) O- rganized plan (greater risk) N- o family S- ickness (terminal stage)

If patient is suicidal: RN should:

D irect question are you

going to commit suicide?

I irregular interval of visit to

patients room

E arly AM & endorsement period (time patients commit

suicide)

General Care Strategies

Be available to the patients, have someone to stay with them. Take the patient seriously Make rounds at irregular times Assess and evaluate for changes Help patient to evaluate strengths and other ways to cope such as seeking interpersonal support or other anxiety reducing activities Encourage the patient to verbalize feelings and plans Obtain a NO SUICIDE contract Increase suicide preventive measures or raise alert when patient manifests improve behavior or affect.

Suicide Precautions
One-on-one monitoring Arms length when actively suicidal Also during toileting and at night Convey to the client that
Crisis is temporary Unbearable pain can be survived Help is available They are not alone

Environmental Control
Use plastic utensil No sharp objects (Forks, knives, nail files, etc) NO private room nor private time. Jump-proof and hang-proof bathrooms by installing break-away shower rods and recessed shower nozzles Keep electrical cords at a minimal length Use of unbreakable glass windows. Take all potentially harmful gifts Lock of all utility rooms, kitchens, adjacent stairwells and offices. Search clients for harmful objects.

NURSING CONSIDERATIONS:DEPRESSION Provide a safe environment Continually assess clients potential for suicide Observe the client closely (during course of antidepressants, change in behavior, unstructured time on the unit, staff is limited) Spend time with the client Initially, assign same nurse to work with the client if possible When approaching the client, use a moderate tone of voice, avoid being overly cheerful Use silence and active listening Use simple and direct sentences

NURSING CONSIDERATIONS:DEPRESSION Avoid asking the client many questions Be comfortable with silence, let the client know that you are available Allow the client to cry, provide privacy only if safety is assured Do not belittle the clients feelings, accept patients feelings as real Encourage client to express feelings Interact with the client on topics which he or she is comfortable Teach the client about problem-solving process Provide positive feedback

NURSING CONSIDERATIONS: MANIA Provide for clients physical safety and safety of those around the client Remind the client to respect distances between self and others Use simple, short sentences to communicate Ask the client to identify each person, place and thing being discussed Ask the client to decode metaphors, themes and symbols used in speech Provide client list of daily activities Ensure that nutritional and fluid balance is met Channel client's need for movement into socially acceptable motor activities