Mood disorders

Mood Disorders
Presented by:
Ms. Bhoomika Patel
Assistant Professor
Sumandeep Nursing college
SumandeepVidyapeeth
SUMANDEEP NURSING COLLEGE, SVDU

INTRODUCTION
 A lot of people are familiar with the term
mood disorder, however very few people
actually know specifically.
 More importantly how to distinguish the
different and varying types of mood
disorders.This post is going to talk about
what mood disorders actually are.

 A mood disorder is also known as an affective
disorder, and is a type of mental health problem.
Mood disorders are not concentrated to one gender,
age or type of person and they can occur in almost
anyone including children.
 The root cause of mood disorders isn’t fully
understood, however many scientists have attributed
mood disorders to an imbalance of certain brain
chemicals that are technically known as
neurotransmitters.
 However sometime it is not due to this imbalance,
and in these cases the cause of mood disorders falls
on substance and drug abuse and traumatic life
events.

MOOD
 Definition:
◦ Mood is a pervasive and sustained emotion
that may have a major influence on a persons
perception of the world.
◦ Eg of Mood: Depression, joy, elation and
anxiety.

Historical perspectives
 Many ancient culture (Egyption) believed
that supernatural or divine origin of
depression and mania.
 Hippocrates Strongly rejected the idea of
the divine origin. He believed that
Melancholia was caused by an excessive of
black Bile.
 Contemporary thinking has been shaped a
great deal by the work of Sigmund Freud.
Mood disorder generally encompasses the
interpsychic, Behavioral and biological
perspectives.

Epidemiology
 Gender:
◦ Depressive disorder Higher in women than men.
About 2:1.
 Age:
◦ Depression is higher in the young women and
tendency to decrease with the age.The same
opposite for men.
 Social class:
◦ Bipolar disorder mostly seen among the High
socioeconomic classes.

 Marital status:
◦ Highest depressive symptoms seen individual
without close interpersonal relationship and
the person who are divorced or separated.
◦ And highest among married women and single
men.
 Seasonality:
◦ One in the spring (March,April and may) and
one in the fall (September, October and
November) This is the seasonal pattern for
the suicide.Which shows large peak in the
Spring and smaller one in October.

MOOD DISORDERS
DSM-IV lists of mood disorders
• Manic episode.
• Bipolar affective disorder.
• Depressive episodes.
• Recurrent depressive episodes.
• Persistent mood disorder.
• Other mood disorders.
• Unspecified mood disorder.

MANIA

Manic episode
 Definition:
◦ An alteration in mood that is expressed by
feeling of elation, inflated Self-esteem,
Grandiosity, Hyperactivity,Agitation and
accelerated thinking and speaking. Mania can
occur as a biological or psychological disorder
or a response to substance use or a general
medical condition.

Classification of mania
 Manic episode
 Hypomania
 Mania with psychiatric symptoms

Etiology
 Genetic consideration:
◦ Identical twin with bipolar disorders: about 40-70%
chance.
◦ Family studies have shown that if one parent has
Bipolar disorder, the risk that the child will have the
disorder around 28%.
◦ ANK3 protein
 Biochemical influences:
◦ Depression with the functional deficiency of
norepinephrine and dopamine and mania functional
excess of these Amines.
◦ Deficiency in serotonin will appear in both states.
◦ Biogenic mines and acetylecholine

 Electrolytes:
◦ Normal electrolyte transfer across cell
membranes in Bipolar disorder resulting in
elevated level of intracellular Sodium and
Calcium. Calcium channel blockers can reduce
the symptoms of Bipolar Disorder.
 Biological findings:
◦ Lesions are more common in this population
in area of the brain Such as Rt. hemisphere
and gray matter.

◦ Increase in the volume of the lateral ventricles
◦ Increase in the rates of deep white
matter hyperintensities.
 Psychodynamic theories:
◦ Faulty family dynamics during early life are
responsible for manic behaviors in later life.
 Psychosocial theory:
◦ Environmental stressors will cause the Bipolar
disorder.

PSYCHOPATHOLOGY OF MANIA
 Manic states shows lack of inhibition,
quickness of psychological reaction,
distractibility, and flight of ideas.
 Manic episodes may reflect an inability to
tolerate a developmental tragedy, such as
the loss of parents.

Clinical features
 An acute manic episode is characterized by
the fallowing features which should be last for
at least one week.
 Elevated, expansive or irritable mood:
◦ Elevated mood in mania has 4 stages
 Euphoria (sense of wellbeing and happiness)
 Elation (Moderate elevated mood with increased
psychomotor activity)
 Exaltation (Intense elevation of mood with delusion)
 Ecstasy (Severe elevation of mood , delirious or
stuporous mania)

 Psychomotor Activity:
◦ There is an increased psychomotor activity ranging
from over activeness and restlessness to manic
excitement.
 Speech and thought:
◦ Flight of ideas: thoughts racing in the mind, Rapid
shift from one topic to another.
◦ Pressure of speech: Speech is forceful, Strong and
difficulty to interrupt.
◦ Delusion of grandeur
◦ Delusion of persecution
◦ Distractibility.

 Other features:
◦ Increased sociability
◦ Impulsive behavior
◦ Hypersexual
◦ High risk activity
◦ Decreased need for sleep
◦ Decreased food intake
◦ Decreased attention
◦ Poor judgment
◦ Absent insight

Hypomania
 Hypomania at this stage the disturbance is not
sufficiently severe to cause marked impairment in
social or occupational functioning or to require
hospitalization.
 Mood:
◦ The mood of the hypomanic person is cheerful and
expansive.
◦ Person get irritable when he desires go unfulfilled.
◦ Hypomanic person is veryVolatile and fluctuating.
 Cognition and perception:
◦ Thinking is flighty, with the rapid flow of ideas.
Perception of the environment is hightened and
individual easily get distracted

 Activity and behavior:
◦ Increased motor activity, they are perceived as
being very extroverted and sociable.
◦ They talk and laugh very loudly and
inappropriately.
◦ Increased libido is common.
◦ Anorexia and weight loss.

Mania with Psychotic Symptoms
 Mania with psychotic symptoms represents a
more severe form of mania:
◦ Inflated self-esteem and grandiose ideas may develop into
delusions, and irritability and suspiciousness into delusions of
persecution
◦ In severe cases, grandiose or religious delusions of identity
or role may be prominent, and flight of ideas and pressure of
speech may result in the individual becoming
incomprehensible
◦ Sustained physical activity and excitement may result in
aggression or violence, and neglect of eating, drinking, and
personal hygiene may result in dangerous states of
dehydration and self neglect.

SIGNS
OBJECTIVE
 Disturbance of
speech
 Rapid, loud,
pressured speech
 Easily distracted
 Over activity
 Mood lability
 Weight changes
SUBJECTIVE
 Feeling of joy
 Rapid mood Swings
 Sleep disturbances
 Delusion and
Hallucinations

Diagnosis
 Psychological test such as young mania
rating scale.
 ICD 10 diagnostic criteria.
 Based on signs and symptoms

Treatment modalities for mania
 Pharmacotherapy:
◦ Lithium 900-2100mg/day
◦ Carbamazepine 600-1800mg/day
◦ Sodium valporate 600-2600mg/day
◦ Others: Clonazepam, Calcium channel
blockers
 Electro convulsive therapy:
◦ If adequately not responding to antipsychotics
and lithium can go for ECT

Psychosocial treatment
 Family and marital therapy is used to decrease
interfamilial and interpersonal difficulties and
to reduce or modify the stressors.
 Group therapy (Peer support providing a
feeling of security)
 Cognitive therapy (individual is taught to
control their thought distortions.)

Nursing diagnosis
 High risk for injury related to extreme
hyperactivity evidenced by lack of control
over purposeless movements.
S.No Interventions
1 Keep the environment stimuli minimum eg(Single room)
2 Remove Hazardous objects and substances
3 Assign patient to engage in activities like drawing, writing etc
4 Stay with the patient when having hyperactivity
5 Administer the medication

 High risk for violence , self directed or directed at others
related to mania excitement, delusional thinking.
S.No Interventions
1 Keep the environment stimuli minimum eg(Single room)
2 Observe the patient behavior every 15 mins
3 Remove Hazardous objects and substances (Glass, matchboxes)
4 Redirect the violent behavior in physical outlet
5 Encourage the verbal expression of the feelings
6 Encourage him in physical exercises
7 Maintain and convey the calm attitude (Low calm voice etc)
8 Administer theTranquilizing medication if pt refuses can restraints
9 Follow application of restraints every 15 mins (Need of H2O &
elimination) SUMANDEEP NURSING COLLEGE, SVDU

 Imbalanced nutrition less than body
requirement related to inability to sit still long
enough to eat as evidenced byWt loss.
S.No Interventions
1 High protein, High calories pt can be consumed on the Run ( Pt cant sit
for long time)
2 Find out the likes and dislikes
3 Provide the 6-8 glasses of water per day (over activity)
4 Maintain the intake and output
5 Supplement vitamins and minerals
6 Walk or sit with the patient while he eats

 Impaired social interaction related to
egocentric and narcissistic behavior as
evidenced by inability to develop satisfying
relationship.
S.No Interventions
1 Recognize and determine the manipulative behavior helps to decrease the
feeling of insecurity
2 Set limits on manipulative behavior. Explain the consequences if limits or
violated.
3 Ignore attempts by patients to argue or Bargain.
4

 Self esteem disturbances related to unmet
dependency needs.
 Altered family process related to
euphoric mood and grandiose ideas.

Bipolar affective disorder

Introduction
 Bipolardisorder or bipolar affective dis
order, historically known as manic–
depressive disorder, Characterized by
mood swings from profound depression to
extreme Euphoria. Delusions or
Hallucination may or may not be a part of
the clinical pictures.

Definition
 Bipolar disorder is a major affective
disorder in which an individual alternates
between states of deep depression and
extreme elation.

Epidemiology
 Prevalence estimated between: 1-3%
(depends on diagnostic criteria)
 M=F
 Found across cultures and ethnicities

Causes
 Genetic
◦ Genetic studies have suggested
many chromosomal regions and candidate
genes appearing to relate to the development
of bipolar disorder, but the results are not
consistent and often not replicated.
 Environmental
◦ Traumatic/Abusive experiences in childhood
◦ PTSD

 Physiological
 Abnormalities in the structure and/or function of
certain brain circuits could underlie bipolar
 increase in the volume of the lateral ventricles
 increase in the rates of deep white
matter hyperintensities.
 The "kindling" theory asserts that people who
are genetically predisposed toward bipolar
disorder can experience a series of stressful
 There is evidence of hypothalamic-pituitary-
adrenal axis (HPA axis) abnormalities in bipolar
disorder due to stress.

Subtypes
Bipolar I
A full syndrome Mania or Mixed symptoms and the
client may also have experienced episodes of
depression.
Bipolar II
Hypomania alternating with major depression.

Signs and symptoms
 Depressive episode
 Manic episode
 Hypomanic episode
 Mixed affective episode

Mania: clinical features
 Elated, euphoric high mood
 Pressure of speech
 Fights of ideas, rhymes and puns, clang
associations, racing of thoughts
 Distractibility
 Increased goal directed pleasurable activities
 Grandiose delusions
 Decreased need for sleep
 Increased psychomotor activity
 Duration more than 1 week
 Impaired functioning

DEPRESSIVE EPISODE
 Low self esteem
 Feeling of hopelessness, apathy
 Difficulty concentrating, disorientation,
intellectual impairement
 Psychomotor retardation
 Anhedonia
 Suicidal ideation

Diagnosis
 Diagnosis is based on the self-reported
experiences of an individual as well as
abnormalities in behavior reported by
family members, friends or co-workers.
 The Bipolar spectrum diagnostic scale

TREATMENT OPTIONS
 Hospitalization for mania, severe
depression
 Mood stabilizers, antipsychotics and
antidepressants
 ECT – most effective treatment
 Supportive psychotherapy and CBT
 Lifestyle change
 Substance abuse treatment if co-morbid.

LITHIUM CARBONATE
 900 – 1500 mg/d .8-1.3 mEq/L
 Most effective medication
 SE’s include :
tremor, gastric upset, more thirst,
polyuria,, acne, cardiac conduction
problems, teratogenicity, cognitive
impairment , renal dysfunction ,
hypothyroidism

CARBAMAZEPINE
 400 – 1000 mg/d
 Most effective for mixed states, rapid
cycling
 SE’s – sedation, ataxia, aplastic anemia,
agranulocytosis

VALPROATE
 500 – 2000 mg/d; Highest blood level for
effect. Highest dose is 60 mg/kg/d
 SE’s – GI upset, weight gain, alopecia,
teratogenicity, liver problems
 Best for mixed states, rapid cycling,
secondary mania. Ineffective for depression

ATYPICAL ANTIPSYCHOTICS
 Olanzepine – 2.5-20 mg/d; very effective; significant
wt gain and lipid problems in some
 Risperdal - .5-4.0 mg/d; more EPS.
 Clozapine - For truly refractory patient, but can be
remarkably effective. Slow response, serious SE
profile and significant wt gain

Depression

Definition
 Depression is overwhelming feeling of
sadness, isolation and despair that affects
how a person thinks, feels and functions.
The condition may significantly interfere
with a person’s daily life and may prompt
thoughts of suicide.

Epidemiology
 Incident rate in male 8-12% and in female
20-26%.
 Depression occur twice frequently in
women as in men.
 Mainly occurs in the persons who are
divorced and separated.
 Depression is associated with variety of
medical conditions, substances and drugs.

Classification
Depressive episode
 Mild depressive episode
 Moderate depressive episode
 Severe depressive episode with
psychotic symptoms

Etiology
 Biological theory
◦ Neurotransmitter (Decreased level of Nor-
epinephrine and Serotonin, and deregulation of
Acetylcholine and GABA.
◦ Genetics
◦ Endocrine (Hypothalamic-pitutary- adrenal axis
getting affected by stress.)
◦ Circadian rhythm theory (Changes in circadian
rhythm cause for depressive disorder) the
changes might be the cause of medications,
physical and psychological illness, hormonal
fluctuation.

 Changes in brain anatomy:
◦ Loss of neuron in the frontal lobes and cerebellum.
 Psychosocial theory:
◦ Psychoanalytic theory ( Fixation in the oral stage)
◦ Behavioral theory (Repeated losses of past.)
◦ Cognitive theory (Negative cognition )
 Eg: negative expectations
 Negative towards self
 Negative future
◦ Sociological theory: (Stressful life events, Eg, Death,
marriage and financial loss.)

Mild Depressive Episode
 Two or three of the symptoms are usually present.
 For mild depressive episode are typical
depressed mood, anhedonia and increased fatigability.
The afflicted person is usually distressed by the
symptoms and has some difficulty in continuing with
ordinary work and social activities, but will probably
not cease to function completely.

Clinical Manifestation
 Symptoms at the mild level of depression
 Affective: Denial of feelings,Anger,Anxiety,
Helplessness, hopelessness and sadness.
 Behavioral:Tearfulness, regression,
restlessness, agitation and withdrawal.
 Cognitive: Preoccupation with the loss,
Self blame and blaming others.
 Physiological:Anorexia or overeating,
insomnia or hypersomnia, head ache,
chest pain back ache etc

Moderate Depressive Episode
 An individual with moderate depressive episode
suffers from more symptoms (four or more of the
above symptoms are usually present) of greater
severity and will usually have considerable difficulty
in continuing with social, work or domestic
activities.

 Symptoms at the moderate level of depression
 Affective: Powerlessness, Helplessness, hopelessness
feeling of sadness gloomy and pessimistic and low self
esteem.
 Behavioral: Slowed physical movement, Slumped
posture, slowed speech, Social isolation, increased use
of substances, self destructive behavior decreased in
personal hygiene.
 Cognitive: Retarded thinking process, Difficulty in
concentration and attention, repetitive thoughts,
negativism and suicidal ideas.
 Physiological:Anorexia or overeating, insomnia or
hypersomnia, head ache, chest pain back ache,
abdominal pain, low energy level and fatigue etc

Severe Depressive Episode without
Psychotic Symptoms
 In a severe depressive episode, the sufferer usually
shows considerable distress or agitation. Loss of self-
esteem or feelings of uselessness or guilt are likely to
be prominent, and suicide is a distinct danger in
particularly severe cases. ; a number of "somatic"
symptoms are usually present.

 Symptoms at the Severe level of depression
 Affective: Feeling of total despair, worthlessness, flat
affect, feeling if emptiness,Apathy, loneliness, sadness and
inability to feel pleasure.
 Behavioral: Retarded physical movement, or
psychomotor Behavior manifestation rapid, agitated,
purposeless movements, rigidity, no personal hygiene
and Social isolation.
 Cognitive: Delusional thinking, Confusion, Difficulty in
concentration and attention, negativism and suicidal
ideas.
 Physiological:A general slowness of the entire body,
constipation, urinary retention, amenorrhea, impotence,
diminished libido,Anorexia, weight loss and difficulty in
falling and awaking in sleep.

Severe Depressive Episode with
Psychotic Symptoms
 Psychotic symptoms may be present, such as
 delusions (ideas of sin, poverty or imminent
disasters)
 hallucinations (defamatory or accusatory voices or
of rotting filth or decomposing flesh)
 depressive stupor
 Severe ordinary social activities are impossible
 When the psychotic symptoms are consistent
with the patient’s mood, they are referred to
as mood congruent, when they are
inconsistent, they are referred as mood
incongruent. SUMANDEEP NURSING COLLEGE, SVDU

Treatment modalities for
depression
 Psychological treatment
◦ Individual psychotherapy
◦ Group therapy
◦ Family therapy
◦ Cognitive therapy
 Organic treatement
◦ Tricyclic acid (Clomipramine, Imipramine)
◦ SSRIs (Fluoxetine)
◦ Monoamaine oxidase inhibitors (Phenelzine)
◦ NRIs –Nonselective reuptake inhibitors
(duloxetine)

Nursing Diagnosis
 High risk of self directed violence related
to depressed mood, feeling of
worthlessness
 Dysfunctional grieving related to real or
perceive loss
 Powerlessness related to dysfunctional
grieving
 Self-esteem disturbances related to
learned helplessness, impaired cognition.

 Impaired communication process related
to depressive cognition, withdrawn.
 Impaired sleeping pattern related to
depressed mood, depressive cognitions
evidenced by difficulty in falling sleep.
 Impaired nutrition less than body
requirements related to depressive mood
and lack of appetite or lack of interest in
taking food.
 Self care deficit related to depressive
mood, feeling of worthlessness.

Persistent mood disorder
 Dysthymic Disorder:This is somewhat
milder than, those ascribed to major
depression.
 “Down in the dumps”
 There is no evidence of psychotic
symptoms.
 Depressed and irritable mood.
 At least 2 years.

 Cyclothymic disorder: is a chronic mood
disturbances of at least 2 years of
duration.
 Numerous of hypomania and depressed
mood of insufficient severity or duration
to meet the criteria foe either bipolar 1
or II disorder.
 Individual is never without hypomanic or
depressive symptoms more than 2
months.

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