Chapter 15 Mood Disorders Part I


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Chapter 15 Mood Disorders Part I

  1. 1. Chapter 15 Mood Disorders Part I
  2. 2. Introduction <ul><li>Depression is the oldest and most frequently described psychiatric illness. </li></ul><ul><li>Transient symptoms are normal, healthy responses to everyday disappointments in life. </li></ul>
  3. 3. Introduction (cont.) <ul><li>Pathological depression occurs when adaptation is ineffective. </li></ul>
  4. 4. Epidemiology <ul><li>Affects almost 10 percent of the population, or 19 million Americans, in a given year </li></ul><ul><li>Considered to be the “common cold” of psychiatric disorders </li></ul>
  5. 5. Epidemiology (cont.) <ul><li>Gender prevalence </li></ul><ul><ul><li>Higher in women than in men by about 2 to 1 </li></ul></ul><ul><ul><li>Incidence of bipolar disorder is roughly equal </li></ul></ul>
  6. 6. Epidemiology (cont.) <ul><li>Age </li></ul><ul><ul><li>Depression more common in young women than in older women; has a tendency to decrease with age </li></ul></ul><ul><ul><li>Opposite is true for men </li></ul></ul><ul><ul><li>Studies of bipolar disorder suggest median age at onset of bipolar disorder is 18 years in men and 20 years in women </li></ul></ul>
  7. 7. Epidemiology (cont.) <ul><li>Social class: There is an inverse relationship between social class and report of depressive symptoms; the opposite is true with bipolar disorder. </li></ul><ul><li>Seasonality: Affective disorders are more prevalent in the spring and in the fall. </li></ul>
  8. 8. Epidemiology (cont.) <ul><li>Race: No consistent relationship between race and affective disorder reported </li></ul><ul><li>Marital status: Single and divorced people more likely to experience depression than married people </li></ul>
  9. 9. Types of Mood Disorders <ul><li>Depressive disorders </li></ul><ul><ul><li>Major depressive disorder </li></ul></ul><ul><ul><li>Dysthymic disorder </li></ul></ul><ul><ul><li>Premenstrual dysphoric disorder </li></ul></ul><ul><li>Bipolar disorder </li></ul><ul><ul><li>Bipolar I disorder </li></ul></ul><ul><ul><li>Bipolar II disorder </li></ul></ul><ul><ul><li>Cyclothymia </li></ul></ul>
  10. 10. Major Depressive Disorder <ul><li>Characterized by depressed mood </li></ul><ul><li>Loses interest or pleasure in usual activities </li></ul><ul><li>Social and occupational functioning impaired for at least 2 weeks </li></ul><ul><li>No history of manic behavior </li></ul><ul><li>Cannot be attributed to use of substances or a general medical condition </li></ul>
  11. 11. Dysthymic Disorder <ul><li>Sad or “down in the dumps” </li></ul><ul><li>No evidence of psychotic symptoms </li></ul><ul><li>Essential feature is a chronically depressed mood for </li></ul><ul><ul><li>Most of the day </li></ul></ul><ul><ul><li>More days than not </li></ul></ul><ul><ul><li>For at least 2 years </li></ul></ul>
  12. 12. Premenstrual Dysphoric Disorder <ul><li>Essential Features </li></ul><ul><ul><li>Depressed mood </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Mood swings </li></ul></ul><ul><ul><li>Decreased interest in activities </li></ul></ul><ul><li>Symptoms occur during the week prior to menses and subside shortly after onset of menstruation </li></ul>
  13. 13. Bipolar Disorders <ul><li>Characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy </li></ul><ul><li>Delusions or hallucinations may or may not be part of clinical picture </li></ul><ul><li>Onset of symptoms may reflect seasonal pattern </li></ul>
  14. 14. Bipolar I Disorder <ul><li>Individual is experiencing, or has experienced, a full syndrome of manic or mixed symptoms </li></ul><ul><li>May also have experienced episodes of depression </li></ul>
  15. 15. Bipolar II Disorder <ul><li>Recurrent bouts of major depression </li></ul><ul><li>Episodic occurrences of hypomania </li></ul><ul><li>Has not experienced an episode that meets the full criteria for mania or mixed symptomatology </li></ul>
  16. 16. Other Mood Disorders <ul><li>Due to general medical condition </li></ul><ul><li>Substance-induced mood disorder </li></ul>
  17. 17. Etiological Implications-Depressive Disorders <ul><li>Biological theories </li></ul><ul><ul><li>Genetics: Hereditary factor may be involved </li></ul></ul><ul><ul><li>Biochemical influences : Deficiency of norepinephrine, serotonin, and dopamine has been implicated </li></ul></ul>
  18. 18. Etiological Implications-Depressive Disorders (cont.) <ul><li>Biological theories (cont.) </li></ul><ul><li>Neuroendocrine disturbances </li></ul><ul><ul><li>Possible dysfunction within the hypothalamic-pituitary-adrenocortical axis </li></ul></ul><ul><ul><li>Possible diminished release of thyroid-stimulating hormone </li></ul></ul>
  19. 19. Etiological Implications-Depressive Disorders (cont.) <ul><li>Physiological influences </li></ul><ul><ul><li>Medication side effects </li></ul></ul><ul><ul><li>Neurological disorders </li></ul></ul><ul><ul><li>Electrolyte disturbances </li></ul></ul><ul><ul><li>Hormonal disorders </li></ul></ul><ul><ul><li>Nutritional deficiencies </li></ul></ul>
  20. 20. Etiological Implications-Depressive Disorders (cont.) <ul><li>Physiological conditions (cont.) </li></ul><ul><ul><li>Secondary depression related to: </li></ul></ul><ul><ul><ul><li>Collagen disorders (e.g., SLE) </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular disease </li></ul></ul></ul><ul><ul><ul><li>Infections (e.g., hepatitis, pneumonia, syphilis) </li></ul></ul></ul><ul><ul><ul><li>Metabolic disorders (e.g., diabetes mellitus) </li></ul></ul></ul>
  21. 21. Etiological Implications-Depressive Disorders (cont.) <ul><li>Psychosocial theories </li></ul><ul><li>Psychoanalytical theory (Freud) </li></ul><ul><ul><li>Mourning </li></ul></ul><ul><ul><li>Melancholia </li></ul></ul><ul><ul><li>Follows loss of a loved object </li></ul></ul>
  22. 22. Etiological Implications-Depressive Disorders (cont.) <ul><li>Learning theory </li></ul><ul><li>Learned helplessness: Repeated failure to control life, leading to defeat and dependence on others, resulting in predisposition to depression </li></ul>
  23. 23. Etiological Implications-Depressive Disorders (cont.) <ul><li>Object loss theory </li></ul><ul><ul><li>Experiences loss of significant other during first 6 months of life </li></ul></ul><ul><ul><li>Early loss or trauma may predispose client to episodes of depression in response to losses later in life </li></ul></ul>
  24. 24. Etiological Implications-Depressive Disorders (cont.) <ul><li>Cognitive theory: Beck </li></ul><ul><li>Primary disturbance in depression is cognitive rather than affective </li></ul><ul><li>Three cognitive distortions serve as basis for depression </li></ul><ul><ul><li>Negative expectations about </li></ul></ul><ul><ul><ul><li>Environment </li></ul></ul></ul><ul><ul><ul><li>Self </li></ul></ul></ul><ul><ul><ul><li>Future </li></ul></ul></ul>
  25. 25. Etiological Implications-Depressive Disorders (cont.) <ul><li>Theoretical Integration </li></ul><ul><li>Etiology of depression likely due to multiple influences of </li></ul><ul><ul><li>Genetics </li></ul></ul><ul><ul><li>Biochemical </li></ul></ul><ul><ul><li>Psychosocial </li></ul></ul>
  26. 26. Developmental Implications <ul><li>Childhood Depression </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li><age 3: feeding problems, </li></ul></ul><ul><ul><li>tantrums, lack of playfulness and </li></ul></ul><ul><ul><li>emotional expressiveness </li></ul></ul><ul><ul><li>Ages 3 to 5: accident proneness, phobias, excessive self-reproach </li></ul></ul><ul><ul><li>Ages 6 to 8: physical complaints, aggressive behavior, clinging behavior </li></ul></ul><ul><ul><li>Ages 9 to 12: morbid thoughts and excessive worrying </li></ul></ul>
  27. 27. Developmental Implications (cont.) <ul><li>Childhood Depression (cont.) </li></ul><ul><li>Precipitated by a loss </li></ul><ul><li>Focus of therapy: alleviate symptoms and strengthen coping skills </li></ul><ul><li>Parental and family therapy </li></ul>
  28. 28. Developmental Implications (cont.) <ul><li>Adolescence </li></ul><ul><li>Symptoms include: </li></ul><ul><ul><li>Anger, aggressiveness </li></ul></ul><ul><ul><li>Running away </li></ul></ul><ul><ul><li>Delinquency </li></ul></ul><ul><ul><li>Social withdrawal </li></ul></ul><ul><ul><li>Sexual acting out </li></ul></ul><ul><ul><li>Substance abuse </li></ul></ul><ul><ul><li>Restlessness; apathy </li></ul></ul>
  29. 29. Developmental Implications (cont.) <ul><li>Adolescence (cont.) </li></ul><ul><ul><li>Best clue that differentiates depression from normal stormy adolescent behavior: </li></ul></ul><ul><ul><ul><li>A visible manifestation of behavioral change that lasts for several weeks </li></ul></ul></ul><ul><ul><ul><li>Most common precipitant to adolescent suicide: perception of abandonment by parents or close peer relationship </li></ul></ul></ul>
  30. 30. Developmental Implications (cont.) <ul><li>Senescence </li></ul><ul><li>Bereavement overload </li></ul><ul><li>High percentage of suicides among elderly </li></ul><ul><li>Symptoms of depression often confused with symptoms of dementia </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Antidepressant medication </li></ul></ul><ul><ul><li>Electroconvulsive therapy </li></ul></ul><ul><ul><li>Psychosocial therapies </li></ul></ul>
  31. 31. Developmental Implications (cont.) <ul><li>Postpartum Depression </li></ul><ul><li>May last for a few weeks to several months </li></ul><ul><li>Associated with hormonal changes, tryptophan metabolism, or cell alterations </li></ul><ul><li>Treatments: antidepressants and psychosocial therapies </li></ul><ul><li>Symptoms include: </li></ul><ul><ul><ul><li>Fatigue </li></ul></ul></ul><ul><ul><ul><li>Irritability </li></ul></ul></ul><ul><ul><ul><li>Loss of appetite </li></ul></ul></ul><ul><ul><ul><li>Sleep disturbances </li></ul></ul></ul><ul><ul><ul><li>Loss of libido </li></ul></ul></ul><ul><ul><ul><li>Concern about inability to care for infant </li></ul></ul></ul>
  32. 32. Nursing Process/Assessment <ul><li>Transient depression </li></ul><ul><ul><li>Symptoms at this level of the continuum not necessarily dysfunctional </li></ul></ul><ul><ul><li>Affective: The “blues” </li></ul></ul><ul><ul><li>Behavioral: Certain amount of crying </li></ul></ul>
  33. 33. Assessment <ul><li>Transient depression (cont.) </li></ul><ul><ul><li>Cognitive: Some difficulty getting mind off one’s disappointment </li></ul></ul><ul><ul><li>Physiological: Feeling tired and listless </li></ul></ul>
  34. 34. Assessment (cont.) <ul><li>Mild depression </li></ul><ul><ul><li>Symptoms with normal grieving are identified by clinicians as associated with normal grieving </li></ul></ul><ul><ul><li>Affective: Anger, anxiety, sadness </li></ul></ul><ul><ul><li>Behavioral: Tearful, regression </li></ul></ul>
  35. 35. Assessment (cont.) <ul><li>Mild depression (cont.) </li></ul><ul><ul><li>Cognitive: Preoccupied with loss; self-blame and blaming of others </li></ul></ul><ul><ul><li>Physiological: Anorexia or overeating, sleep disturbances, somatic symptoms </li></ul></ul>
  36. 36. Assessment (cont.) <ul><li>Moderate depression </li></ul><ul><ul><li>Symptoms associated with dysthymic disorder </li></ul></ul><ul><ul><li>Affective: Helpless, powerless </li></ul></ul><ul><ul><li>Behavioral: Slow physical movement, slumped posture, limited verbalization </li></ul></ul>
  37. 37. Assessment (cont.) <ul><li>Moderate depression (cont.) </li></ul><ul><ul><li>Cognitive: Retarded thinking processes, difficulty with concentration </li></ul></ul><ul><ul><li>Physiological: Anorexia or overeating, sleep disturbances, somatic symptoms, feeling best early in morning and worse as the day progresses </li></ul></ul>
  38. 38. Assessment (cont.) <ul><li>Severe depression </li></ul><ul><ul><li>Includes symptoms of major depressive disorder and bipolar depression </li></ul></ul><ul><ul><li>Affective: Feelings of total despair, worthlessness, flat affect, apathy, anhedonia </li></ul></ul><ul><ul><li>Behavioral: Psychomotor retardation, curled-up position, no interaction with others </li></ul></ul>
  39. 39. Assessment (cont.) <ul><li>Severe depression (cont.) </li></ul><ul><ul><li>Cognitive: Prevalent delusional thinking, with delusions of persecution and somatic delusions; unable to concentrate; confusion </li></ul></ul><ul><ul><li>Physiological: A general slow-down of the entire body, anorexia, insomnia, feels worse early in morning and somewhat better as the day progresses </li></ul></ul>
  40. 40. Diagnosis/Outcome Identification <ul><li>Risk for suicide related to: </li></ul><ul><ul><li>Depressed mood </li></ul></ul><ul><ul><li>Feelings of worthlessness </li></ul></ul><ul><ul><li>Anger turned inward on the self </li></ul></ul><ul><ul><li>Misinterpretations of reality </li></ul></ul>
  41. 41. Nursing Diagnosis <ul><li>Dysfunctional grieving related to: </li></ul><ul><ul><li>Real or perceived loss </li></ul></ul><ul><ul><li>Bereavement overload, evidenced by denial of loss </li></ul></ul><ul><ul><li>Inappropriate expression of anger </li></ul></ul><ul><ul><li>Idealization of or obsession with lost object </li></ul></ul>
  42. 42. Nursing Diagnosis (cont.) <ul><li>Low self-esteem related to: </li></ul><ul><ul><li>Learned helplessness </li></ul></ul><ul><ul><li>Feelings of abandonment by significant others </li></ul></ul><ul><ul><li>Impaired cognition fostering negative view of self </li></ul></ul>
  43. 43. Nursing Diagnosis (cont.) <ul><li>Powerlessness related to: </li></ul><ul><ul><li>Dysfunctional grieving process </li></ul></ul><ul><ul><li>Lifestyle of helplessness, evidenced by feelings of lack of control over life situation </li></ul></ul>
  44. 44. Nursing Diagnosis (cont.) <ul><li>Spiritual distress related to: </li></ul><ul><ul><li>Dysfunctional grieving over loss of valued object evidenced by anger toward God </li></ul></ul><ul><ul><li>Questioning meaning of own existence </li></ul></ul><ul><ul><li>Inability to participate in usual religious practices </li></ul></ul>
  45. 45. Nursing Diagnosis (cont.) <ul><li>Social isolation/Impaired social interaction related to: </li></ul><ul><ul><li>Developmental regression </li></ul></ul><ul><ul><li>Egocentric behaviors </li></ul></ul><ul><ul><li>Fear of rejection or failure of the interaction </li></ul></ul>
  46. 46. Nursing Diagnosis (cont.) <ul><li>Disturbed thought processes related to: </li></ul><ul><ul><li>Withdrawal into self </li></ul></ul><ul><ul><li>Underdeveloped ego </li></ul></ul><ul><ul><li>Punitive superego </li></ul></ul><ul><ul><li>Impaired cognition fostering negative perception of self or environment </li></ul></ul>
  47. 47. Other Nursing Diagnoses <ul><li>Imbalanced nutrition less than body requirements </li></ul><ul><li>Disturbed sleep pattern </li></ul><ul><li>Self-care deficit </li></ul>
  48. 48. Criteria for Measuring Outcomes <ul><li>The client </li></ul><ul><ul><li>Has experienced no physical harm to self </li></ul></ul><ul><ul><li>Discusses the loss with staff and family members </li></ul></ul><ul><ul><li>No longer idealizes or obsesses about the lost object </li></ul></ul>
  49. 49. Outcomes <ul><li>The client (cont.) </li></ul><ul><ul><li>Sets realistic goals for self </li></ul></ul><ul><ul><li>Is no longer afraid to attempt new activities </li></ul></ul><ul><ul><li>Is able to identify aspects of self-control over life situation </li></ul></ul>
  50. 50. Outcomes (cont.) <ul><li>The client (cont.) </li></ul><ul><ul><li>Expresses personal satisfaction with and support from spiritual practices </li></ul></ul><ul><ul><li>Interacts willingly and appropriately with others </li></ul></ul><ul><ul><li>Is able to maintain reality orientation </li></ul></ul><ul><ul><li>Is able to concentrate, reason, and solve problems </li></ul></ul>
  51. 51. Planning/Implementation <ul><li>Nursing Interventions are aimed at: </li></ul><ul><ul><li>Maintaining client safety </li></ul></ul><ul><ul><li>Assisting client through grief process </li></ul></ul><ul><ul><li>Promoting increase in self-esteem </li></ul></ul><ul><ul><li>Encouraging client self-control and control over life situation </li></ul></ul><ul><ul><li>Helping client to reach out for spiritual support of choice </li></ul></ul>
  52. 52. Client/Family Education <ul><li>Nature of the illness </li></ul><ul><ul><li>Stages of grief and symptoms associated with each stage </li></ul></ul><ul><ul><li>What is depression? </li></ul></ul><ul><ul><li>Why do people get depressed? </li></ul></ul><ul><ul><li>What are the symptoms of depression? </li></ul></ul>
  53. 53. Client/Family Education (cont.) <ul><li>Management of the illness </li></ul><ul><ul><li>Medication management </li></ul></ul><ul><ul><li>Assertive techniques </li></ul></ul><ul><ul><li>Stress management techniques </li></ul></ul><ul><ul><li>Ways to increase self-esteem </li></ul></ul><ul><ul><li>Electroconvulsive therapy </li></ul></ul>
  54. 54. Client/Family Education (cont.) <ul><li>Support services </li></ul><ul><ul><li>Suicide hotline </li></ul></ul><ul><ul><li>Support groups </li></ul></ul><ul><ul><li>Legal/financial assistance </li></ul></ul>
  55. 55. Nursing Process/Evaluation <ul><li>Evaluation of the effectiveness of nursing interventions is measured by fulfillment of the outcome criteria. </li></ul>
  56. 56. Evaluation <ul><li>Has self-harm to the client been avoided? </li></ul><ul><li>Have suicidal ideations subsided? </li></ul><ul><li>Does the client know where to seek assistance outside the hospital when suicidal thoughts occur? </li></ul>
  57. 57. Evaluation (cont.) <ul><li>Has the client discussed the recent loss with the staff and family members? </li></ul><ul><li>Is he or she able to verbalize feelings and behaviors associated with each stage of the grieving process and recognize own position in the process? </li></ul>
  58. 58. Evaluation (cont.) <ul><li>Has obsession with and idealization of the lost object subsided? </li></ul><ul><li>Is anger toward the lost object expressed appropriately ? </li></ul><ul><li>Does client set realistic goals for self? </li></ul>
  59. 59. Evaluation (cont.) <ul><li>Is he or she able to verbalize positive aspects about self, past accomplishments, and future prospects? </li></ul><ul><li>Can the client identify areas of life situation over which he or she has control? </li></ul>