NCM105 11th Mood Disorders

7/30/2019 NCM105 11th Mood Disorders

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11 - Mood Disorders

Mood Disorders

Previously referred to as AFFECTIVE DISORDERS The term mood disorders is preferred because it

refers to sustained emotional states, not merely the

external or affective expression of a transitoryemotional state.

It is pervasive alterations in emotions that aremanifested by depression, mania, or both. They

interfere with a persons life, plaguing him or her with

drastic and long-term sadness, agitation, or elation.

Commonly associated with suicide Women are more likely to be affected and to

seek treatment

Mood Disorders by Age Group

Infants may exhibit signs of anaclitic depression(withdrawal, nonresponsiveness, depression, and

vulnerability to physical illness) or failure to thrive

when separated from their mothers.

School-aged Children may experience a mooddisorder along with anxiety, exhibiting behaviors

such as hyperactivity, school phobia, or excessive

clinging to parents.

Adolescents experiencing depression may exhibitpoor academic performance; abuse substances;

display antisocial behavior, sexual promiscuity,

truancy, or running-away behavior; or attempt

suicide

Etiology of Mood Disorders

Genetic Theory:Genetic studies implicate thetransmission of major depression in first-degree

relatives, who have twice the risk of developing

depression compared with the general population.

Biochemical Theory:

Bioamines: Norepinephrine and serotonin, havebeen shown to regulate mood and to control

drives. Increased amounts of these

neurotransmitters at receptor sites in the brain

cause an elevation in mood whereas decreased

amounts can lead to depression. As with

norepinephrine and serotonin, dopamine

activity may be reduced in depressed mood and

increased in mania, the two phases of bipolar

disorder.

Neuroendocrine Regulation: Normally, cortisollevels peak every morning, level off during the

day and reach lowest point in the evening. In

patients with depression, the cortisol levels

start early and remain high all day. Decreased

nocturnal secretion of melatonin, decreased

levels of Prolactin, FSH, testosterone and

somatostatin as well sleep induced stimulationof GH.

Thyroid Gland: Clients with a mild, symptomfree form of hypothyroidism may be more

vulnerable to depressed mood than the average

person

Psychodynamic Theory: Because the source andobject of the grief are unconscious (from childhood),

symptoms are not resolved, but rather persist and

return later in life. Manic episodes seen as a defensereaction due to the client's inability to tolerate on

the situation.

Behavioral Theory: People who receive little positivereinforcement for their activity become withdrawn,

overwhelmed, and passive, giving up hope and

shunning responsibility. This, in turn, leads to a

perception that things are beyond their control. This

perception promotes feelings of helplessness and

hopelessness, both hallmarks of depressed states.

Cognitive Theory: Thoughts are maintained byreinforcement, thus contributing to a mood disorder.People with a depressed mood are convinced that

they are worthless, that the world is hostile, that the

future offers no hope,and that every accidental

misfortune is a judgment of them.

Life Events and Environmental Theory: Stressful lifeevents such as the loss of a parent or spouse,


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financial hardship, illness, perceived or real failure,

and midlife crises are all examples of environmental

factors contributing to the development of a mood

disorder

Categories of Mood Disorder

1. MAJOR DEPRESSIVE DISORDER

Major depressive disorder typically involves 2 ormore 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.

They are referred to as endogenous depressionwhen the depressed mood appears to develop

from within a client, and no apparent cause or

external precipitating factor is identified.

ONSET and CLINICAL COURSE An untreated episode of depression can

last 6 to 24 months before remitting.

Fifty to sixty percent of people who haveone episode of depression will have

another.

Depressive symptoms can vary from mildto severe. The degree of depression is

comparable to the persons sense of

helplessness and hopelessness.

Some people with severe depression havepsychotic features.

SYMPTOMS Depressed mood Anhedonism (decreased attention to and

enjoyment from previously pleasurable

activities)

Unintentional weight change of 5% ormore in a month

Change in sleep pattern Agitation or psychomotor retardation

Tiredness or Fatigue Worthlessness or guilt inappropriate to

the situation (possibly delusional)

Difficulty thinking, focusing, or makingdecisions

Hopelessness, helplessness, and/orsuicidal ideation

DIAGNOSTIC CHARACTEISTICS At least five clinical symptoms in

conjunction with depressed mood or loss

of interest or pleasure

Symptoms occurring most of the day andnearly every day during the same 2-week

period representing an actual change inperson's previous level of functioning.

Significant distress or markedimpairment in persons functioning, such

as in social or occupational areas.

ASSESSMENT History:

several short periods to complete theassessment ;

Previous episodes of depression,treatment, and clients response to

treatment.

Family history, history of mooddisorders, suicide, or attempted

suicide

General Appearance and MotorBehavior

Looks sad; sometimes they justlook ill.

Posture often is slouched withhead down and minimal eye

contact.


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Psychomotor retardation: slowbody movements, slow

cognitive processing, and slow

verbal interaction).

Responses to questions may beminimal with only one or twowords.

Latency of response: clientstake up to 30 seconds to

respond to a question.

Clients also may exhibit signs ofagitation or anxiety, wringing

their hands and having

difficulty sitting still.

Mood and Affect They describe themselves as

hopeless, helpless, down, or

anxious.

They also may say they are aburden on others, a failure at

life, or may make other similar

statements.

They are easily frustrated, areangry at themselves, and can

be angry at others .

They experience anhedoniaand may be apathetic.

Affect is sad or depressed, ormay be flat with no emotional

expressions.

They typically sit alone staringinto space or lost in thought.

They interact minimally with afew words or a gesture.

They are overwhelmed by noiseand people who might make

demands on them, so they

withdraw from the stimulation

of interaction with others.

Thought Process and Content They experience slowed

thinking processes

With severe depression, theymay not respond verbally to

questions.

Negative and pessimistic intheir thinking.

They make self-deprecatingremarks, criticizing themselves

harshly, and focusing only on

failures or negative attributes.

Ruminate: is repeatedly goingover the same thoughts.

Those who experiencepsychotic symptoms have

delusions; they often believe

that they are responsible for all

the tragedies and miseries in

the world.

Thoughts of dying orcommitting suicide.

Sensorium and Intellectual Processes Some clients with depression

are oriented to person, time,

and place; others experience

difficulty with orientation

especially if they experience

psychotic symptoms or are

withdrawn from their

environment.

Assessing general knowledge isdifficult because of their limited

ability to respond to questions.

Memory impairment iscommon.

Extreme difficultyconcentrating or paying

attention.


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If psychotic, clients may heardegrading and belittling voices

or they may even have

command hallucinations that

orders them to commit suicide.

Judgement and Insight Impaired judgment because

they cannot use their cognitive

abilities to solve problems or to

make decisions.

They often cannot makedecisions or choices because of

their extreme apathy or their

negative belief that it doesnt

matter anyway.

Insight may be intact,especially if clients have been

depressed previously.

Others have very limitedinsight and are totally unaware

of their behavior, feelings, or

even their illness.

Self-Concept Sense of self-esteem is greatly

reduced; clients often use

phrases such as good for

nothing or just worthless to

describe themselves.

They feel guilty about not beingable to function and often

personalize events or take

responsibility for incidents over

which they have no control.

They believe that others wouldbe better off without them,

which lead to suicidal thoughts.

Roles and Relationships

Difficulty fulfilling roles andresponsibilities. The more

severe the depression, the

greater the difficulty.

Have problems going to workor school because they seemunable to carry out their

responsibilities. Same is true

with family responsibilities.

Often avoid family and socialrelationships because they feel

overwhelmed, experience no

pleasure from interactions, and

feel unworthy.

Physiologic and Self Care Considerations Pronounced weight loss

because of lack of appetite or

disinterest in eating.

Sleep disturbances arecommon: either they cannot

sleep or they feel exhausted

and unrefreshed no matter

how much time they spend in

bed.

They lose interest in sexualactivities, and men often

experience impotence.

Some clients neglect personalhygiene because they lack the

interest or energy.

Constipation commonlyresults from decreased food

and fluid intake as well as

inactivity. If fluid intake is

severely limited, they also

may be dehydrated.

Dysthymic Disorder

The client with the diagnosis of dysthymicdisorder typically exhibits symptoms that are

similar to those of major depressive disorder or

severe depression. However, they are not as


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severe and do not include symptoms such as

delusions, hallucinations, impaired

communication, or incoherence.

Clinical symptoms usually persist for 2 years ormore and may occur continuously or

intermittently with normal mood swings for afew days or weeks.

Persons who develop dysthymic disorder areusually overly sensitive, often have intense guilt

feelings, and may experience chronic anxiety.

According to DSM-IV-TR criteria, the individual,while depressed, must exhibit two or more of six

clinical symptoms of a major depressive episode,

including poor appetite or overeating, insomnia

or hypersomnia, low energy or fatigue, low self-

esteem, poor concentration or difficulty making

decisions, and feelings of hopelessness.

Clinical symptoms interfere with functioning andare not due to a medical condition or the

physiologic effects of a substance.

Depressive Disorder, Not Otherwise

Specified (NOS)

The diagnosis of depressive disorder, nototherwise specified is used to identify disorderswith depressive features that do not meet the

criteria for major depressive disorder, dysthymic

disorder, adjustment disorder with depressed

mood, or adjustment disorder with mixed

anxiety and depressed mood.

2. BIPOLAR DISORDER

Formerly Manic-Depressive Disorder Involves extreme mood swings from episodes of

mania to episodes of depression

Occurs equally in men and women More common in highly educated people

The Manic Phase

Euphoria Grandiose Irritability Hyperactivity Accelerated Thinking and Speaking Heavy Make-up, Jewelry and Clothes of

Unusual Combinations and of Bright

Colors

Engages in high-risk activities and has noregard of consequences

Oversex, alcohol intake, pathologicalgambling

The Depressed Phase Sad mood Loss of interest in activities Ahedonia Changes in weight, Sleep and energy

The person with bipolar disorder cyclesbetween depression and normal behavior or

mania and normal behavior

Types:Bipolar Mixed: A person with this type

alternates between major

depressive and manic episodes with

periods of normal behavior in

between

Bipolar Type I: Manic Episodes with atleast one depressive episode. The

mood rapidly changes from manic to


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normal with one major depressive

episode. Manic mood lasts for 1

week. Possibility of self harm exists.

Impairment of various areas of

functioning. Alcohol and Drug

dependence, anxiety disorders,

conduct disorder

Bipolar Type II: Recurrent majordepressive episode with one

hypomanic episode

Hypomania: an abnormality of

mood falling between mania and

normal euphoria

Unrealistic optimism

Pressure of speech and activity

Decreased need for sleep

Able to function, behavior different

from baseline

Cyclothymic: Similar to symptomsof Bipolar II. Mood changes are

irregular and abrupt, occurring

within hours. Symptoms occur for 2

years

ASSESSMENT History: Client jumps from subject to

subject

Several short sessions

Gather data through watchingand listening

General Appearance Psychomotor Agitation Perpetual motion Excessive dressing Males: bare chested or

tight revealing shirts

Mood and Affect Either euphoria or

hostility

Laughter or tears Thought Process and Content

Flight of ideas Circumstantiality Many projects started,

accomplishes few

No concern for risk,abilities or resources

Sensorium Oriented to person and

place but not to time

May claim abilities theydo not posses

Judgment and Insight Easily irritated and

angered

Poor insight Thinks they are fine

Self Concept Exaggerated self esteem


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Roles and Relationships Trouble at work and

school

Great need to socialize Cannot delay gratification

MEDICAL MANAGEMENT

Anti Depressant Drugs Tricyclics: preventing the presynaptic

neuron from reabsorbing serotonin,

dopamine, or norepinephrine after release.

Examples: Imipramine (Tofranil) Selective serotonin reuptake inhibitors: A

class of antidepressant drugs that works by

blocking the reuptake of theneurotransmitter serotonin.Examples:

Fluoxetine (Prozac), Setraline (Zoloft),

Fluvoxamine (Luvox), Citalopram (Celexa)

and Paroxetine (Paxil).

MAOIs:A class of antidepressant drugsthat blocks the enzyme monoamine

oxidase. Monoamine oxidase metabolizes

catecholimines and serotonin into inactive

forms.Blockage of the enzyme results in

more of the transmitters in the presynaptic

terminal available for release.

Atypical antidepressants: Works byinhibiting the reuptake of dopamine and to

some extent, norepinephrine but not

serotonin.Example: Bupropion(Wellbutrin)

Drugs for Bipolar Anticonvulsant Drugs: It suppressed swings

between mania and depression.Divalproex(Depakene), gabapentin (Neurontin),

lamotrigine(Lamictal), topiramate (Topamax).

Lithium Salts: A salt that stabilizes mood andprevents relapse in mania or depression.

Example: lithium carbonate (Eskalith), Lithiumcitrate concentrate (Cibalith-S)

Atypical Antipsychotic: May be used to treatacute manic episodes in bipolar disorder.

Example: aripiprazole (Abilify), olanzapine

(Zyprexa), risperidone (Risperdal)

Therapies Somatic Therapy

Electroconvulsive therapy(ECT) is anelectrically induced seizure that is used

for the treatment of severe depression.

Used with patients who have not

responded to antidepressant

medication or are suicidal. Applied

every other day for a period of two

weeks. Side effects include memoryloss. Memory loss can be minimized if

shock is localized to the right

hemisphere.

Phototherapy: Can markedly reversethe symptoms of seasonal affective

disorder (SAD), which occurs in the fall

and winter.Works by shifting the

timing or phase of the circadian

rhythms of the client with depression.

Vagus nerve stimulation (VNS)It helps to regulate the release of

neurotransmitters in the brain.

It manage anxiety disorders, pain

syndromes, obesity, and Alzheimers

disease.

Adverse Effects include:

Voice alteration or hoarseness,

headache, cough, shortness of breath,

neck pain, dysphagia.

Interactive Therapies Cognitive psychotherapy: It is effective

as anti depressant medication in the

treatment of mild-to-moderate

depression.

Occupational and Recreationaltherapy: It used to channel the activity

level of clients exhibiting manic

behavior or psychomotor agitation.

NURSING INTERVENTIONS

Personal Attitudes to Maintain in Taking Care of

Patients with Mood Disorders

Acceptance

Expect that Depressed patients will be unable toexpress feelings and that Manic patients will be

demanding and manipulativeHonesty

People with depression and BPD hatedisappointments

Empathy

Trying to cheer up patients with depression is liketrying to feed plants with human food instead of

water.

They will feel that nurses do not understandthem, causing them to become more isolated

Patience


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Depressed patients find it hard to make simpledecisions

Manic patients could display irritation andfrustration to the caregiver.

DEPRESSION

1. Provide Safetya.

Determine presence of suicidaltendencies

b. Provide safe environmentc. Ask further about suicide pland. Endorse to health team

2. Promote a Therapeutic Relationshipa. Several short visitsb. Presence: conveys genuine interest and

caring

c. Talking is not necessary: Silence canconvey that patient is worthwhile

d. Avoid being overly cheerful3. Promote ADLs and Physical Care

a. Psychomotor Retardationb. Global Task: (e.g. Getting dressed)c. Break task to smaller segmentsd. Direct cliente. Help or assistf. Only when unable to perform: to avoid

dependence on staff

g. Avoid yes or no questionsh. VALIDATIONi. Assessment over time

3.a. Nutrition

Starting eating increases appetite Small, frequent meals: finger foods and

snacks

Sitting with client while eating3.b. Sleep

Short term use of sedatives at night Encourage activity during the day Assess whether patient feels refreshed

when waking

4. Therapeutic Communicationa. Talk about feelingsb. Validatec. No clichs! They belittle clients

feelings, making them guilty or feel

worthless

d. Alternative coping strategies5. Manage Medications

a. Antidepressant irony: energy puts clientat risk for suicide

b. Discharge: thorough assessmentc. SE: Drowsiness, dizziness, orthostatic

hypotension

d. Educate client about symptoms thatshows recurrence of depression

e. Educate familyBIPOLAR DISORDER

1. Provide safetya. Safety in the mania phaseb. Safety of ENVIRONMENT and

OTHERS

c. They have little insight aboutanger and behavior

d. Monitor whereabouts andbehavior all the time

e. Labile emotionf. Set limits: identify behaviors that

are accepted and non accepted

2. Physiologic Needsa. Decrease external stimulib. Bed time routine

2.a. Nutrition

Patients with mania may be toobusy to eat

Loses interest in food quickly Finger foods: foods the patient can

eat while moving

High in calories and protein Snacks between meals Observing and Supervising

3. Therapeutic Communicationa. Short attention span: clear, simple

sentences

b. Information should be brokendown to smaller segmentsc. Brief explanation of proceduresd. Rapid Speech: channel

communication; request for

patient to talk slowly

e. Pronouns: ask patient to identifyperson, places and things

f. Flight of Ideas: search forrelations

g. Pressured speech: Set limits4. Promote Appropriate Behaviors

a. Large motor activities: cater toneed for movement

b. Sexual outbursts: dealt withnonjudgmental

c. Dignity and respectd. No scolding or chastisee. Keep clients in view of boundaries

5. Managing Medsa. Signs of Lithium toxicityb. Adequate water intakec. Toxicityd. Non therapeutice. Normal salt intakef. Check for edemag. Consult if with diarrhea, fever or

flu

h. Thyroid Function test every 6months

6. Educationa. As soon as the patient has the

ability to concentrate

b. Symptoms, Dynamics of Moodbehavior

NCM105 11th Mood Disorders

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