MOOD DISORDERSEllen Gluzman, MD

MOOD DISORDERSLOURADEL ULBATA-ALFONSO, MAN,RN

MOOD VS AFFECTAffect refers to immediate expressions of emotionrange (e.g. restricted, blunted, flat, expansive)appropriateness (e.g. appropriate, inappropriate, incongruous)stability (e.g. stable, labile)Mood refers to emotional experience over a more prolonged period of time.happiness (eg, ecstatic, elevated, lowered, depressed)irritability (e.g. explosive, irritable, calm)stability

Two key emotions on a continuum:

DepressionA Low, sad state marked by significant levels of sadness, lack of energy, low self worth, guilt, or related symptoms

ManiaA state or episode of euphoria or an exaggerated belief that the world is theirs for the taking.

MOOD DISORDERSMood disorders, also called affective disorders, are pervasive alterations in emotions that are manifested by depression, mania, or both. They interfere with a persons life, plaguing him or her with drastic and long-term sadness, agitation, or elation

Categories of Mood DisordersMajor depressive disorderBipolar disorder Related disordersDysthymic disorderCyclothymic disorderSubstance-induced mood disorder; mood disorder due to general medical conditionSeasonal affective disorderPostpartum blues, depression, psychosis

MAJOR DEPRESSIVE DISORDERA major depressive episode lasts at least 2 weeks, during which the person experiences a depressed mood or loss of pleasure in nearly all activities. In addition, four of the following symptoms are present: Changes in appetite or weight, sleep, or psychomotor activityDecreased energyFeelings of worthlessness or guilt; Difficulty thinking, concentrating, or making decisionsRecurrent thoughts of death or suicidal ideation, plans, or attempts.

These symptoms must be present every day for 2 weeks and result in significant distress or impair social, occupational, or other important areas of functioning (American Psychiatric Association [APA], 2000). Some people also have delusions and hallucinations; the combination is referred to as psychotic depression.Categories of Mood Disorders

BIPOLAR DISORDERBipolar disorder is diagnosed when a persons mood cycles between extremes of mania and depression.Mania is a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable. Typically, this period lasts about 1 week but it may be longer for some individuals. At least three of the following symptoms accompany the manic episode: inflated self-esteem or grandiosity;decreased need for sleep pressured speech (unrelenting, rapid, often loud talking without pauses)flight of ideas (racing, often unconnected, thoughts); distractibility;increased involvement in goal-directed activity or psychomotorAgitationexcessive involvement in pleasure- seeking activities with a high potential for painful consequences

Hypomaniais a period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days and including three or four of the additional symptoms described earlier.

A mixed episode is diagnosed when the person experiences both mania and depression nearly every day for at least 1 week. These mixed episodes often are called rapid cycling.

BIPOLAR DISORDER Bipolar I disorderone or more manic or mixed episodes usually accompanied by major depressive episodes.

Bipolar II disorderone or more major depressive episodes accompanied by at least one hypomanic episode

RELATED DISORDERSDysthymic disorder is 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.Cyclothymic disorder is characterized by 2 years of numerous periods of both hypomanic symptoms that do not meet the criteria for bipolar disorder.Substance-induced mood disorder is characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiologic consequence of ingested substances such as alcohol, other drugs, or toxins.

Seasonal affective disorder (SAD) has two 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, is less common, with symptoms of insomnia, weight loss, and poor appetite lasting from late spring or early summer until early fall. SAD is often treated with light therapy. Postpartum or maternity blues are a frequent normal experience after delivery of a baby. They are characterized by labile mood and affect, crying spells, sadness, insomnia, and anxiety. Symptoms begin approximately 1 day after delivery, usually peak in 3 to 7 days, and subside rapidly with no medical treatment.RELATED DISORDERS

Postpartum depression meets all the criteria for a major depressive episode, with onset within 4 weeks of delivery.Postpartum psychosis is 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. This medical emergency requires immediate treatment.RELATED DISORDERS

ETIOLOGY OF MOOD DISORDERS

EtiologyBiologic theoriesGenetic theoriesNeurochemical theories: serotonin, norepinephrine possibly acetylcholine and dopamineNeuroendocrine influences: hormones

EtiologyPsychodynamic theoriesFreud: sefl-depriciationlooked 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.Feeling abandoned by this loss, people became angry while both loving and hating the lost object.Mania: defense against underlying depression

Bibring: ideal egobelieved that ones ego (or self) 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

Jacobson: superego over powerless egocompared the state of depression with a situation in which the ego is a powerless, helpless child victimized by the superego, much like a powerful and sadistic mother who takes delight in torturing the child.Most psychoanalytical theories of mania view manic episodes as a defense against underlying depression, with the id taking over the ego and acting as an undisciplined hedonistic being (child).

Etiology

Meyer viewed depression as a reaction to a distressing life experience such as an event with psychic causality.Horney believed that children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness, making them susceptible to depression and helplessness.Beck saw depression as resulting from specific cognitive distortions in susceptible people. Early experiences shaped distorted ways of thinking about ones self, the world, and the future; these distortions involve magnification of negative events, traits, and expectations and simultaneous minimization of anything positive.Etiology

Cultural ConsiderationsMasking of depression by other behaviors considered age-appropriate School phobia, hyperactivity, learning disorders, failing grades, antisocial behaviorsSubstance abuse, gangs, risk behaviors, eating disorders, compulsive behaviorsSomatic complaintsMajor manifestation among cultures that avoid verbalizing emotions.Asians who are anxious or depressed are more likely to have somatic complaints of headache, backache, or other symptoms. Latin cultures complain of nerves or headaches; Middle Eastern cultures complain of heart problems

MAJOR DEPRESSIVE DISORDERS

Major Depressive DisorderMajor depressive disorder typically involves 2 or more weeks of a sad mood or lack of interest in life activities with at least four other symptoms of depression such as anhedonia and changes in weight, sleep, energy, concentration, decision making, self-esteem, and goals.

EPIDEMIOLOGYAge and Gender:higher in women than it is in men esp after the age of 65

Gender stereotypes, or gender socializationpromotes typical female characteristics, such as helplessness, passivity, and emotionality, which are associated with depression. In contrast, some studies have suggested that masculine characteristics are associated with higher self-esteem and less depression

Social Class

Inverse relationship between social class and report of depressive symptoms. EPIDEMIOLOGY

Race and Culture

depression is more prevalent in whites than it is in blacks, but that depression tends to be more severe, persistent, and disabling in blacks, and they are less likely to be treated

EPIDEMIOLOGY

Marital Status

A number of studies have suggested that marriage has a positive effect on the psychological well-being of an individual (as compared to those who are single or do not have a close relationship with another person)EPIDEMIOLOGY

Seasonality

Two prevalent periods of seasonal involvement:

Spring (March, April, and May) Fall (September, October, and November).

Parallel the seasonal pattern for suicide, which shows a large peak in the spring and a smaller one in October.EPIDEMIOLOGY

TYPES OF DEPRESSIVE DISORDERS

Major Depressive DisorderMajor depressive disorder (MDD) is characterized by depressed mood or loss of interest or pleasure in usual activities which impairs social and occupational functioning that has existed for at least2 weeks, no history of manic behavior, and symptoms that cannot be attributed to use of substances or a general medical condition

Dysthymic DisorderCharacteristics of dysthymic disorder are similar to, if somewhat milder than, those ascribed to MDD. Individuals with this mood disturbance describe their mood as sad or down in the dumps There is no evidence of psychotic symptoms. The essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for most of the day, more days than not, for at least 2 years (1 year for children and adolescents)

Premenstrual Dysphoric DisorderThe essential features include markedly depressed mood, excessive anxiety, mood swings, and decreased interest in activities during the week prior to menses and subsiding shortly after the onset of menstruation

Mood Disorder (Depression)Due to a General Medical ConditionThis disorder is characterized by prominent and persistent depression that is judged to be the result of direct physiological effects of a general medical condition.

Substance-Induced Mood Disorder(Depression)Direct result of physiological effects of a substance (e.g., a drug of abuse, a medication, or toxin exposure) and causes clinically signifi cant distress or impairment in social, occupational, or other important areas of functioningalcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives, hypnotics, and anxiolytics

MANAGEMENT

PsychopharmacologySelective serotonin reuptake inhibitors (Table 15.1)Cyclic antidepressants (Table 15.2)Atypical antidepressants (Table 15.3)Monoamine oxidase inhibitors (MAOIs) (Table 15.4)

Other Medical Treatments and PsychotherapyElectroconvulsive therapy (ECT)Psychotherapy (combined with medications)Interpersonal therapy (Group): relationship difficultiesBehavior therapy: reinforcement of positive interactionsCognitive therapy: correction of cognitive distortions (Table 15.5)Investigational treatments

Major Depressive Disorder and Nursing Process ApplicationAssessment HistoryGeneral appearance, motor behavior (psychomotor retardation, latency of response, psychomotor agitation)Mood, affect (anhedonia)Thought process, content (rumination, suicide)Sensorium, intellectual processes (impaired memory)

Major Depressive Disorder and Nursing Process Application (contd)Assessment Judgment, insight (impairment)Self-concept (worthlessness)Roles, relationships (difficulty in this area)Physiologic, self-care considerationsDepression rating scales Self-rating scales: Zung, BeckClinician rating scale: Hamilton Rating Scale

Nursing DiagnosisAssignment!!! Formulate at least 10 Nursing Diagnoses to Behaviors Commonly Associated With DepressionFormat:

Prioritize and make a nursing care plan for the first 3 nursing diagnoses.

BEHAVIORSNURSING DIAGNOSIS

Major Depressive Disorder and Nursing Process ApplicationInterventionProviding for safety (suicide precautions)Promoting therapeutic relationshipPromoting ADLs, physical careUsing therapeutic communicationManaging medicationsClient, family teachingEvaluation

BIPOLAR DISORDERS

Bipolar DisorderExtreme mood swings from mania to depression Second only to major depression as cause of worldwide disabilityOnset usually in early 20sManic episodes begin suddenly, last from a few weeks to several months

TYPES OF BIPOLAR DISORDERS Bipolar I disorderone or more manic or mixed episodes usually accompanied by major depressive episodes.

Bipolar II disorderone or more major depressive episodes accompanied by at least one hypomanic episode

Cyclothymic Disorderis a chronic mood disturbance of at least a 2-year duration involving numerous episodes of hypomania and depressed mood of insuffi cient severity or duration to meet the criteria for either bipolar I or II disorder.The individual is never without hypomanic or depressive symptoms for more than 2 monthsTYPES OF BIPOLAR DISORDERS

Bipolar Disorder Due to a General Medical Condition

This disorder is characterized by a prominent and persistent disturbance in mood that is judged to be the result of direct physiological effects of a general medical conditionTYPES OF BIPOLAR DISORDERS

Substance-Induced Bipolar Disorder

direct result of physiological effects of a substance (e.g., a drug of abuse, a medication,or toxin exposure).gasoline, paint, organophosphate insecticides, nerve gases, carbon monoxide, and carbon dioxideTYPES OF BIPOLAR DISORDERS

Treatment Psychopharmacology Antimanic agent: lithium Anticonvulsant agent used as mood stabilizer (Table 15.7)Agents helpful in reducing manic behavior, protecting against bipolar depressive cyclesPsychotherapy useful in mildly depressive or normal portion of bipolar cycleNot useful during manic stages

Bipolar Disorder and Nursing Process Application AssessmentHistoryGeneral appearance, behavior (pressured speech, flamboyancy, sexually suggestive)Mood, affect (euphoric, grandiose)Thought process, content (circumstantiality, tangentiality)Sensorium, intellectual processes (disoriented to time)

Bipolar Disorder and Nursing Process Application Assessment Judgment, insightSelf-concept (exaggerated)Roles, relationships (labile emotions)Physiologic, self-care considerationsData analysisOutcome identification

Bipolar Disorder and Nursing Process Application InterventionProviding for safety Meeting physiologic needsProviding therapeutic communicationPromoting appropriate behaviorsManaging medications (Table 15.8)Providing client, family teachingEvaluation

Nursing DiagnosisAssignment!!! Formulate at least 10 Nursing Diagnoses to Behaviors Commonly Associated With Bipolar ManiaFormat:

Prioritize and make a nursing care plan for the first 3 nursing diagnoses.

BEHAVIORSNURSING DIAGNOSIS

THE SUICIDAL CLIENT

Nursing Process: Suicide AssessmentEpidemiological factorsMarital status: Single, divorced, and widowed people have rates four to five times greater than those who are married

Nursing Process: Suicide AssessmentEpidemiological factors Gender: Women attempt suicide more often; however, more men succeed Age: Suicide highest in persons older than 50 years; adolescents also at high risk

Nursing Process: Suicide AssessmentEpidemiological factors Religion: Protestants have significantly higher rates of suicide than Catholics and Jews. A strong feeling of cohesiveness within a religious organization seems to be an important factor.

Nursing Process: Suicide AssessmentEpidemiological factors Socioeconomic status: People in the highest and lowest social classes have higher suicide rates than those in the middle classes. Professionals: Professional healthcare personnel and business executives are at the highest risk.

Nursing Process: Suicide AssessmentEpidemiological factors Ethnicity: Whites are at highest risk for suicide, followed by Native Americans, then by African Americans.

Nursing Process: Suicide AssessmentPresenting symptoms/medicalpsychiatric diagnosis

Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide.Other disorders includeAnxiety disordersSchizophreniaBorderline personality disorderAntisocial personality disorder

Nursing Process: Suicide AssessmentSuicidal ideas or actsAssess: Intent; plan; means; lethality of means; previous attemptsVerbal clues: Direct statements: I want to die.Indirect statements: I dont have anything to live for anymore.

Nursing Process: Suicide Assessment (cont.)Analysis of the suicidal crisisInterpersonal support systemThe precipitating stressorRelevant historyLife-stage issuesPsychiatric/medical/family historyCoping strategies

Nursing ProcessDiagnosis/Outcome Identification

Risk for suicide related to feelings of hopelessness and desperationOutcome: The client has experienced no physical harm to self

Nursing Process (cont.)Diagnosis/Outcome Identification Hopelessness related to absence of support systems and perception of worthlessnessOutcome: Expresses some optimism and hope for the future

Nursing Process (cont.)Planning/ImplementationEstablish a therapeutic relationship to convey acceptance of the person.Communicate the potential for suicide to team members.Stay with the person to convey support throughout the current crisis.

Planning/ImplementationAccept the person, which will show unconditional positive regard.Listen to the person.Secure a no-suicide contract (verbally or in writing) for a specified amount of time.

Intervention with the Outpatient Suicidal ClientDo not leave the person alone.Establish a no-suicide contract.Enlist help of family and friends.Schedule daily appointments.Establish trusting relationship.Talk directly about clients plans for suicide.Discuss current crisis situation.Identify areas of client control.Antidepressant medication.

Information for Family/Friends of Suicidal ClientTake any hint of suicide seriously.Report threats of suicide immediately.Be a good listener; stay with the person.Express concern about the persons welfare.Be aware of resources for assistance.Restrict access to firearms or other means of self-harm.Instill hope. Express love for the person.Encourage professional help.Be nonjudgmental.

Intervention with Families and Friends of Suicide VictimsEncourage them to talk about the suicide.Be aware of blaming or scapegoating.Listen to feelings of guilt.Encourage discussion of relationship with lost loved one.Encourage grieving at own personal pace.Discuss coping strategies.Identify resources that provide support.

Nursing Process/EvaluationEvaluation of the suicidal client is an ongoing process accomplished through continuous reassessment of the client as well as determination of the goal achievement.

Nursing Process/Evaluation (cont.)Long-term goals for the suicidal client would be to:Develop and maintain a more positive self-conceptLearn more effective ways to express feelings to othersAchieve successful interpersonal relationshipsFeel accepted by others and achieve a sense of belonging

END

*EVERYONE OCCASIONALLY FEELS sad, low, and tired, with the desire to stay in bed and shut out the world. Such low periods pass in a few days, andenergy returns. Fluctuations in mood are so common to the human condition that ITS NORMAL LANG FOR US TO HEAR someone say, Im depressed .

Everyday use of the word depressed doesnt actually mean that the person is clinically depressed but, rather, that the person is just having a bad day.

At the other end of the mood spectrum are episodes of exaggeratedly energetic behavior referred to as MANIA. In an elated mood, stamina for work, family,and social events is untiring. This feeling of being on top of the world also recedes in a few days to a euthymic mood (average affect and activity).**Mood disorders are the most common psychiatric diagnoses associated with suicide; depression is one of the most important risk factors for it. Thats why suicide is under this category.*Some people also exhibit delusions and hallucinations during a manic episode.

*The difference is that hypomanic episodes do not impair the persons ability to function (in fact, he or she may be quite productive), and there are no psychotic features (delusions and hallucinations*For the purpose of medical diagnosis, bipolar disorders are described as follows:

People with bipolar disorder may experience a euthymic or normal mood and affect between extreme episodes.*Other disorders as mood disorders but with symptoms that are less severe or of shorter duration include the following:*Various theories for the etiology of mood disorders exist.*GENETIC THEORIES: first-degree relatives, who are at twice the risk for developing depression compared with the general population

Neurochemical influences of neurotransmitters (chemical messengers) focus on serotonin and norepinephrine as the two major biogenic amines implicated in mood disorders.Norepinephrine levels may be deficient in depression and increased in mania. < serotonin causes DEPRESSION

NEUROENDOCRINE: Hormonal fluctuations are being studied in relation to depression. Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression*Other behaviors considered age appropriate can mask depression, which makes the disorder difficult to identify and diagnose in certain age groups.

Example: Children with depression often appear cranky.*This occurrence may be related to gender differences in social roles and economic and social opportunities and the shifts that occur with age.

ThE construction of gender stereotypes, or gender socialization, promotes typical female characteristics, such as helplessness, passivity, and emotionality, which areassociated with depression. In contrast, some studies have suggested that masculine characteristics are associated with higher self-esteem and less depression.*A number of studies have examined seasonal patterns associated with mood disorders.

These studies have revealed

*CONTINUUM OF DEPRESSION*REVIEW YOUR ANTIDEPRESSANTS AND ANTIMANIC DRUGS!*The previous chapter focused on the consequences of complicated grieving as it is manifested by depressive disorders. This chapter looks at mood disorders as theyare manifested by cycles of mania and depression called bipolar disorder.*Risk for Injury related to: Extreme hyperactivity Evidenced by: Increased agitation and lack of control over purposeless and potentially injurious movements

Risk for violence: Self-directed or other-directed related to:Manic excitementDelusional thinkingHallucinations

*Information about suicide is presented here because most suicides are associated with mood disorders.Almost 95 percent of all people who commit or attempt suicide have a diagnosed mental disorder. Depressive disorders account for 80 percent of this figure.*