mental health nursing

1. MOOD DISORDER
MANIA

2. OBJECTIVE
• introduce about the topic
• explain the concept of mood and affect
• define mood disorder.
• discuss the etiology of the mood disorder
• enlist the classification of mood disorder.
• explain about duration of the persisting symptoms of mood disorder.
• discuss the stages of mania
• explain about clinical triad of mania.
• explain clinical feature of mania.
• explain DSM V criteria for mania.
• discuss the treatment modalities.
• explain about lithium and its toxicity
• enumerate the management of lithium toxicity.
• explain the assessment and Nursing management.

3. INTRODUCTION
Mood disorders comprise of a group of disorders where the predominant
feature is an alteration in the mood.
Basically, two types of disorder are recognized, mania consisting of an
elevation of mood or a happy mood and the other is depression or a sad
mood.
But of late mood disorders are classified into the following: major
depression, cyclothymia (a mild form of bipolar disorder), seasonal
affective disorder (SAD), and mania.

4. CONCEPT OF MOOD AND AFFECT
MOOD is a persistent and sustained emotional feeling. It can be
Elevated mood, Normal mood, depressed mood.

5. Elevated mood can be range from
• Ecstasy-very severe
• Exaltation-severe
• Elation-moderate
• Euphoria-mild

6. AFFECT- It is outward expression feelings.it is of following types)
Flat affect-No emotional expression
Constricted or restricted affect-reduction in the individual's emotional
response
Blunt/shallow affect-Lack of affect is more severe than constricted or
restricted affect but less severe than flat affect
Labile affect (or) Pseudobulbar affect (PBA) (or) Involuntary Emotional
Expression Disorder (IEED)- Emotional incontinence, i.e. immediate and
urge in expression of emotions. Affect which is appropriate to mood (or)
affect which is not appropriate to mood .

7. MEANING/DEFINITION
It is also known as "affective disorders. It is classified
as unipolar disorder (Depression) and bipolar disorder.
In depression, client may experience one or more
episodes of low level of mood known as unipolar
disorder. In bipolar disorder, client may experience
Both the low mood (depression) and elevated mood
(Mania or hypomania) Two or more episodes of
elevated mood (Mania or hypomania).

8. ETIOLOGY
Age: Onset is usually at 25 years of age in bipolar disorder.
Gender: Mania and depression both are more common in females. First
episode as depression is common in females and first episode as mania is
common in men. As per the National Mental Health Survey report,
conducted by (NIMHANS), Bangalore in 2016 explored the lifetime
prevalence rate of Mood disorders: (Male 5.19, Female 6.00)
Bipolar Affective disorder (Male - 0.58, Female - 0.42)
Depressive disorder (Male -4.75, Female -5.72).
Prevalence rate of mood disorders in urban metro cities is double the
prevalence rate in rural area.

9. Sociocultural: Incidence is high among unmarried individuals.
Neurotransmitter: Levels of norepinephrine, serotonin and dopamine are
found to be decreased in depression and increased in mania as shown in
Biopsychosocial Factors -Biological causes include imbalance in
neurotransmitters and hereditary factors (Primary relatives with mood
disorders and monozygotic twins). The psychological causes are
hopelessness, helplessness and worthlessness, Social causes are social
pressure, stressful life events, loss of loved ones and social isolation.

10. CLASSIFICATION OF MOOD DISOREDR
ICD-10 Classification of Mood Disorders
F30 Manic episode
F31 Bipolar affective disorder
F32 Depressive episode
F33 Recurrent depressive disorder
F34 Persistent mood (affective) disorders
F38 Other mood (affective) disorders
F39 Unspecified mood (affective) disorder

11. DURATION OF THE PERSISTING SYMPTOMS OF
MOOD DISORDER

12. STAGES OF MANIA
1.HYPOMANIA
The mood disorder in which symptoms are not severe to cause significant
impairment in social or occupational functioning is known as hypomania.
Psychotic features are absent
2.ACUTE MANIA
When intensified manic symptoms are present in a patient the disorder is that is
known as hypomania and if patient requires hospitalization it is known as acute
mania. It is characterized by euphoria (or) elation, frequent moo variation,
thinking that may have psychotic features, raised sexual interest with poor control
of impulse, high energy level and the patient may deny grooming.
3.DELIRIOUS MANIA
Severe clouding of consciousness with confusion or disorientation or stupor,
extreme labile mood, delusion with grandiosity or religiosity or persecution,
auditory or visual hallucinations, increased psychomotor activity which has risk
of harming to self or others. If left untreated, death may occur.

13. CLINICAL TRIAD OF MANIA
PRESSURE OF SPEECH
INCREASED
PSYCHOMOTOR ACTIVITY
ELEVATED MOOD

14. CLINICAL FEATURE OF MANIA
• Persistent elated, expansive (non-stop and unselective high-level
enthusiasm to interact with others) and irritable mood (easily provoke
anger for silly things)
• Increased goal directed activity
• Manic patients will be overactive and restless (On the toe-On the Go),
excessive planning/doing many activities at the same time, performing
high risk activities (Reckless driving in a heavy traffic and do playful
activities (cracking jokes, talking loud, jumping etc.)
• Thought • Grandeur (strong unshakable belief that client has acquired a
supreme power)
• Persecution (Suspiciousness)

15. Mood congruent psychotic features: Grandiose delusion is present. In
auditory hallucination, patient might hear voices verbalizing that the patient
has supreme power.
Mood incongruent psychotic symptoms: Delusion of persecution,
delusion of reference and voices heard in auditory hallucinations might be
telling that, 'you are unworthy and deserve punishment .
episode, but the psychotic symptoms elicited are not congruent with the
patient's mood.
Hallucinations (Auditory and visual)
Speech: Mental status examination reveals the flight of ideas that leads to
incoherence (rapid shift from one idea to other and increased pressure of
speech (Flight of ideas without pressure is termed as prolixity)

16. Perception: Raised perceptual sensitivity can be seen in patients such as
hyperacusis (Little sounds has been heard in high volume) and seeing vivid
colors
Miscellaneous: Patient will have decreased need for sleep and absence of
insight. There is no relation with any organic cause. Patient will have a
severe interference in personal functioning and sometimes exhibit
irresponsible behavior, example - Spending too much of money for
unnecessary things)

17. DSM V CRITERIA OF MANIA
Three or more criteria in a person indicate mania:
Persistent elated, expansive and irritable mood
Inflated self-esteem/grandeur
Decrease need for sleep
Raised pressure of talk
Flight of ideas
Excess involvement in pleasurable activities
Easily distracted
Goal directed activity

18. TREATMENT
Treatment includes:
1.Lithium (0.6-1.2mEq/L)
•Tab. lithium carbonate (Eskalith. Lithobid)40 mg
•Syrup Lithium citrate3000mg
2.Sodium valproate(50-150mg)
3.Carbamazepine (6-12) mg
4.Anticonvulsant
•Gabapentine300mg/day at bed time
•Topiramate 250-500mg/day
5.Calcium channel blocker-Verapamil(40-360mg)
6.Electroconvulsive therapy (ECT)

19. LITHIUM
Dr John Frederick Joseph Cade AO 1912-1980 an Australian psychiatrist
discovered Lithium in 1948. He explored the effects of lithium carbonate as
a mood stabilizer and it is also useful in treatment of bipolar disorder.
The usual dosage is 600-900 mg/day and is given in divided or single dose
initially with the maintenance serum level of 0.6-1.2 mmol/L.

20. MNEMONIC TO REMEMBER LITHIUM SIDE
EFFECTS ARE "LITHIUM"
L: LeuKocytosis
I:Insipidus (Nephrogenic diabetes insipidus)
T: Tremors (or) thirst (or) taste as metallic (or) teratogenic (Teratogenic-
Epstein’s anomaly)
H: Hypothyroidism
U: Urinary (Polyuria)
M: Miscellaneous (ECG changes T wave flattening, QRS widening and
sinus node dysfunction, rashes, gastrointestinal (GI) upset, weight gain,
fatigue, rashes, ataxia, nystagmus, muscle weakness, delirium, hair loss,
psoriasis, peripheral

21. MANAGEMENT OF LITHIUM TOXICITY
•Gastric lavage can be given to remove the contents from gastrointestinal
tract. Charcoal helps to bind with lithium. Tab. propranolol decreases the
tremors.
•Sodium and water retention must be avoided.
•Patients are advised to take more oral fluids/water. Electrolyte
abnormalities have to be corrected.
•IV fluids can be administered. If the patient has consumed lithium extended
release tablets in last 24 hours, in that case, whole bowel irrigation is
advisable in order to prevent absorption of lithium.
•In case of severe lithium toxicity, hemodialysis is the only option. Grades
of lithium toxicity with its manifestations and management

22. NURSING MANGEMENT
ASSESSMENT
Young mania rating scale (YMRS): It is the scale used to
assess manic symptoms. It is an observer rated scale which
has 11items, 4 items rated from 0 to 8 and 7 items rated from
O to 4.
Another mood disorder questionnaire was developed by
Hirschfeld, Williams, Spitzer, Calabrese, et al. (2000). It is a
screening tool with13-item checklist. It's efficiently lies in the
fact that it helps to identify 7 out of 10 patients in case of
bipolar disorder. It also effectively screens out 9 out of 10
patients who as may be without bipolar disorder.

23. Semantic Differential Feelings and Mood Scales (SDFMS) is developed
by Maurice Lorr and Richard A Wunderlich. It helps to measure the state
of mood. It has 35 differential items which has one-to-five-point scale and
they help to assessing and determining the mood. It has five factors as
listed below:
A = Elated-Depressed
B = Relaxed-Anxious
C = Confident-Unsure
D = Energetic-Fatigue
E=Good Natured-Grouchy

24. NURSING INTERVENTION
1. Risk for self directed violence related to suicidal feelings.
Determine the suicidal risk.
Obtain the suicidal contract from the client
Decrease the environment stimuli.
Remove sharp object.
Provide recreational activities.
Stay with client.

25. 2.Risk for violence directed towards other related to manic excitement,
delusion and hallucinations.
Maintain the low environmental stimuli.
Keep observing the client every 15 min.
Encourage the client to talk
Divert the client when he is experiencing hallucination.
Involve the client in sports or other activities

26. 3.Impaired nutrition ,less than body requirement related to refusal of
the food as evidence by weight loss.
Assess the clients likes and dislikes
Provide them high calorie diet
Food has to be colorful and attractive
Advice the patient caregiver to follow small frequent diet as suggested in
menu plan.
Give more oral fluid and salt adequately to the patient.
 Monitor the weight regularly.

28. Write short note on mood disorder(5
marks)

29. THANK YOU