Chapter 15 Mood Disorders Part I
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Chapter 15 Mood Disorders Part I






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    Chapter 15 Mood Disorders Part I Chapter 15 Mood Disorders Part I Presentation Transcript

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