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Bipolar And Mania


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Psychiatric and Mental Health Nursing

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Bipolar And Mania

  1. 1. Essentials of Understanding Abnormal Behavior Mood Disorders and Suicide
  2. 2. Mood Disorders & Suicide <ul><li>Mood Disorders: Disturbances in emotions that cause subjective discomfort, hinder a person’s ability to function, or both; depression & mania are central to these disorders </li></ul><ul><li>Depression: Emotional state characterized by intense sadness, feelings of futility & worthlessness, & withdrawal from others </li></ul><ul><li>Mania: Emotional state characterized by elevated mood, expansiveness, or irritability, often resulting in hyperactivity </li></ul>
  3. 3. Depression and Mania <ul><li>In the “World of Mood,” there are two poles: mania and depression. </li></ul><ul><li>Unipolar disorders: involve only depression </li></ul><ul><li>Bipolar disorders: involve both manic and depressive episodes </li></ul><ul><li>Note that there are no mood disorders involving mania alone. </li></ul>
  4. 4. Mood Disorders (cont’d) <ul><li>Depression occurs ten times as frequently as mania. </li></ul><ul><li>Depression is the most common complaint of individuals seeking mental health care. </li></ul><ul><li>Epidemiologic catchment area survey: </li></ul><ul><ul><li>2.3% of adult males and 5% of adult females in the U.S. have a mood disorder in a one-year period. </li></ul></ul>
  5. 5. Mood Disorders (cont’d) <ul><li>Lifetime prevalence: </li></ul><ul><ul><li>Severe depression: 5-12% of males and 10-25% of females </li></ul></ul><ul><ul><li>Mood disorder: 15% of males and 24% of females </li></ul></ul><ul><li>Risk of another episode increases with each episode </li></ul><ul><ul><li>50% after one episode, 70% after second, 90% after third </li></ul></ul>
  6. 6. Mood Disorders (cont’d) <ul><li>Lifetime prevalence: </li></ul><ul><ul><li>Severe depression: 5-12% of males and 10-25% of females </li></ul></ul><ul><ul><li>Mood disorder: 15% of males and 24% of females </li></ul></ul><ul><li>Risk of another episode increases with each episode </li></ul><ul><ul><li>50% after one episode, 70% after second, 90% after third </li></ul></ul>
  7. 7. The Symptoms of Depression <ul><li>Affective: Depressed mood, dejection, excessive and prolonged mourning, worthlessness, lack of joy </li></ul><ul><li>Cognitive: Pessimism, decreased energy, disinterest, loss of motivation </li></ul><ul><ul><li>Cognitive triad: Negative views of self, outside world, and the future </li></ul></ul><ul><ul><li>Avolition: lack of motivation to do things. This symptom is often responsible for the impairment of functioning that occurs with depression. </li></ul></ul><ul><ul><li>don’t expect to be successful so don’t try, so they are more likely to experience failures. </li></ul></ul><ul><ul><li>depressed individuals may be less effective at solving intellectual problems and may also have memory problems </li></ul></ul>
  8. 8. The Symptoms of Depression (cont’d) <ul><li>Behavioral: Social withdrawal, lowered work productivity, lack of personal cleanliness, slow speech </li></ul><ul><ul><li>Psychomotor retardation: Slowing of bodily movements, expressive gestures, and spontaneous responses </li></ul></ul><ul><ul><ul><li>People with this symptom have more problems with thinking and memory and take longer to recover from depression </li></ul></ul></ul><ul><li>Physiological: Loss of appetite/weight, constipation, sleep disturbance, disruption of menstrual cycle, aversion to sexual activity </li></ul><ul><ul><li>depression also causes decline in the function of the immune system and depressed people produce fewer white blood cells </li></ul></ul><ul><ul><li>There may be agitation; high levels of random activity which does not help them achieve any particular goals- </li></ul></ul>
  9. 9. The Symptoms of Depression <ul><li>Culture influences the experience & expression of symptoms </li></ul><ul><ul><li>Sadness/guilt (U.S. & Western European) versus somatic/bodily complaints (Asian) </li></ul></ul><ul><ul><li>“ Nerves” and headaches (Latino & Mediterranean) </li></ul></ul><ul><ul><li>Weakness, tiredness, “imbalance” (Asian) </li></ul></ul><ul><ul><li>Problems of the “heart” (Middle Eastern) </li></ul></ul><ul><ul><li>Being “heartbroken” (Hopi) </li></ul></ul>
  10. 10. The Symptoms of Mania <ul><li>Affective: </li></ul><ul><ul><li>Elevated, expansive, irritable mood, if frustrated, may become belligerent </li></ul></ul><ul><ul><li>Impaired social & occupational functioning </li></ul></ul><ul><ul><li>Boundless energy, enthusiasm, self-assertion </li></ul></ul><ul><li>Cognitive: </li></ul><ul><ul><li>Flightiness, pressured thoughts, lack of focus & attention, poor judgment </li></ul></ul>
  11. 11. Table 10.1: Symptoms of Depression and Mania
  12. 12. Figure 10.1 Disorders Chart: Mood Disorders Source: American Psychiatric Association (2000).
  13. 13. Figure 10.1: Disorders Chart: Mood Disorders (cont’d) Source: American Psychiatric Association (2000).
  14. 14. Depressive Disorders <ul><li>Major depression : A disorder in which a group of symptoms, such as depressed mood, loss of interest, sleep disturbances, feelings of worthlessness, and inability to concentrate, are present for at least two weeks </li></ul>
  15. 15. Depressive Disorders (cont’d) <ul><li>Dysthymic disorder : Characterized by chronic and relatively continual depressed mood that does not meet the criteria for major depression </li></ul><ul><li>persistently depressed mood, more days than not for at least 2 years (1 for kids) </li></ul><ul><li>includes poor appetite or overeating, sleep disturbance, low energy level, low self-esteem, difficulties in concentration or decisions making, feelings of hopelessness </li></ul><ul><li>average duration 5 years - can last 20. </li></ul><ul><li>Symptoms are NOT less severe; they just do not occur everyday </li></ul><ul><ul><li>Pessimism, guilt, loss of interest, poor appetite or overeating, low self-esteem, chronic fatigue, social withdrawal, concentration difficulties </li></ul></ul>
  16. 16. Bipolar Disorders <ul><li>Bipolar I disorders : The most severe form of bipolar disorder involving full blown mania which includes serious impairment of functioning and/or psychotic features. </li></ul><ul><ul><li>Psychoses tend to be mood-congruent, meaning they fit the person’s expansive mood. A person in full-blown mania would be more likely to believe that he is Superman than to believe he is dying. </li></ul></ul><ul><ul><li>To qualify for a diagnosis of manic episode (bipolar disorder), symptoms must last at least a week. </li></ul></ul>
  17. 17. Bipolar Disorders (cont’d) <ul><li>Bipolar II disorders : Recurrent major depressive episodes with hypomanic episode </li></ul><ul><ul><li>Hypomania is a less severe form of mania which is experienced as an increased in goal-directed activity and energy. A person with hypomania may go unnoticed by others and will not lose contact with reality. </li></ul></ul>
  18. 18. Bipolar Disorders (cont’d) <ul><li>Cyclothymic disorder : Chronic and relatively continual mood disorder with hypomanic episodes and depressed moods that do not meet criteria for major depressive episode </li></ul><ul><ul><li>Symptoms present for more than 2 years, never symptom free for more than 2 months </li></ul></ul>
  19. 19. Other Mood Disorders <ul><li>Mood disorder due to general medical condition : Characterized by depressed mood and/or elevated or irritable mood as a direct result of a general medical condition </li></ul><ul><li>Substance-induced mood disorder : Prominent and persistent disturbance of mood attributable to use of a substance or cessation of substance use </li></ul>
  20. 20. Symptom Features and Specifiers <ul><li>Specifiers : Describe major depressive episodes in terms of severity, presence or absence of psychotic symptoms, and remission status </li></ul><ul><ul><li>Useful for prognosis </li></ul></ul><ul><ul><li>May include information such as: </li></ul></ul><ul><ul><ul><li>Melancholia : Loss of pleasure, lack of reactivity to pleasurable stimuli, depression that is worse in the morning, early morning awakening, excessive guilt, weight loss </li></ul></ul></ul><ul><ul><ul><li>Catatonia : Motoric immobility, extreme agitation, negativism, or mutism </li></ul></ul></ul>
  21. 21. Symptom Features and Specifiers (cont’d) <ul><li>Course specifiers: </li></ul><ul><ul><li>Rapid cycling: Episodes occurred 4 or more times during the previous 12 months </li></ul></ul><ul><ul><li>Seasonal pattern: Moods are accentuated during certain times </li></ul></ul><ul><ul><ul><li>Seasonal affective disorder (SAD): Serious depression fluctuates according to the season </li></ul></ul></ul><ul><ul><li>Postpartum onset: Occurs within 4 weeks of childbirth and lasts longer than 1 month. </li></ul></ul><ul><ul><ul><li>Hallmark symptom: inability to be around the baby or care for the baby. </li></ul></ul></ul><ul><ul><ul><li>Affects 8-10% of new moms. </li></ul></ul></ul><ul><ul><ul><li>75-80% experience “post-partum blues,” lasting 3-4 days after the birth of the child. </li></ul></ul></ul>
  22. 22. The Etiology of Mood Disorders <ul><li>Psychological or Sociocultural Approaches to Depression: </li></ul><ul><ul><li>Psychodynamic: Focus on separation & anger </li></ul></ul><ul><ul><li>Behavioral: Reduced reinforcement leads to less activity; secondary gain from reinforcement of inactivity </li></ul></ul><ul><ul><li>Cognitive: Negative thoughts & errors in thinking </li></ul></ul>
  23. 23. Psychological or Sociocultural Approaches to Depression <ul><li>Cognitive-Learning: </li></ul><ul><ul><li>Learned helplessness: The belief that one is helpless & unable to affect outcomes in one’s life </li></ul></ul><ul><ul><li>Attributional style: People who feel helpless make speculations (causal attributions) about why they are helpless </li></ul></ul><ul><ul><li>Depressed people operate from a primary triad of negative self-views, present experiences, and future expectations. </li></ul></ul><ul><ul><ul><li>Four errors in logic typify this negative schema: </li></ul></ul></ul><ul><ul><ul><ul><li>Arbitrary inference </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Selected abstraction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Overgeneralization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Magnification/ minimization </li></ul></ul></ul></ul><ul><li>Sociocultural: </li></ul><ul><ul><li>Culture, social experiences, & psychosocial stressors, including stress & gender </li></ul></ul>
  24. 24. Table 10.2: Explaining the Findings That Rates of Depression Are Higher Among Women Than Among Men
  25. 25. Biological Perspectives on Mood Disorders <ul><li>The Role of Heredity: </li></ul><ul><ul><li>Adoption studies: Incidence of mood disorders is higher among biological families than among adoptive families </li></ul></ul><ul><ul><li>Twin studies: Concordance rates are higher for monozygotic twins than for dizygotic twins (especially for bipolar disorders), although non-genetic factors also have an influence </li></ul></ul>
  26. 26. Neurotransmitters & Mood Disorders <ul><li>Neurotransmitters: Chemical substances that are released by axons of sending neurons & that are involved in the transmission of neural impulses to the dendrites of receiving neurons </li></ul><ul><li>Catecholamine Hypothesis </li></ul><ul><ul><li>Neurotransmitters are broken down or chemically depleted by MAOs </li></ul></ul><ul><ul><li>Neurotransmitters are reabsorbed by the releasing neuron in the reuptake process </li></ul></ul>
  27. 27. Figure 10.2: The Catecholamine Hypothesis: A Proposed Connection Between Neurotransmitters & Depression
  28. 28. The Treatment of Mood Disorders <ul><li>Biomedical Treatments for Depressive Disorders: </li></ul><ul><ul><li>Medication: </li></ul></ul><ul><ul><ul><li>Tricyclic antidepressants (TCAs) </li></ul></ul></ul><ul><ul><ul><li>Heterocyclic antidepressants (HCAs) </li></ul></ul></ul><ul><ul><ul><li>Monoamine Oxidase Inhibitors (MAOIs) </li></ul></ul></ul><ul><ul><ul><li>Selective Serotonin Reuptake Inhibitors (SSRIs) </li></ul></ul></ul><ul><ul><li>Electroconvulsive Therapy (ECT) </li></ul></ul>
  29. 29. The Treatment of Mood Disorders <ul><li>Psychotherapy & Behavioral Treatments for Depressive Disorders: </li></ul><ul><ul><li>Psychoanalysis: gain insight into unconscious & unresolved feelings of separation or anger </li></ul></ul><ul><ul><li>Behavior therapy: increase exposure to pleasurable events & to improve social skills </li></ul></ul><ul><ul><li>Interpersonal psychotherapy & cognitive-behavioral therapy effective for treating less severe cases </li></ul></ul><ul><ul><li>Combination of psychotherapy & medication may be best </li></ul></ul>
  30. 30. Treatment for Bipolar Disorders <ul><li>Same forms of psychotherapy & behavior therapy used for Unipolar Disorder are also used for Bipolar Disorder </li></ul><ul><li>Typical treatment for Bipolar involves lithium carbonate, which is 60-80% effective </li></ul><ul><li>Anticonvulsant drugs are also being used </li></ul>
  31. 31. Suicide <ul><li>Suicide: The intentional, direct, & conscious taking of one’s own life </li></ul><ul><li>Suicide is not classified as a mental disorder, although the suicidal person usually has psychiatric symptoms, such as: </li></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Alcohol dependence </li></ul></ul><ul><ul><li>Schizophrenia </li></ul></ul>
  32. 32. Figure 10.3: Suicide
  33. 33. 10 common characteristics of suicide <ul><li>The common purpose is to seek a solution : suicide is seen as the solution to an unsolvable problem; it is not pointless or accidental. </li></ul><ul><li>The cessation of consciousness is a common goal: consciousness represent constant psychological pain </li></ul><ul><li>The stimulus for suicide is generally intolerable psychological pain : </li></ul><ul><li>The common stressor in suicide is frustrated psychological need: feelings of frustration, failure, worthlessness, etc. </li></ul><ul><li>A common emotion in suicide is hopelessness-helplessness </li></ul>
  34. 34. 10 common characteristics of suicide (cont.) <ul><li>The cognitive state is one of ambivalence : although the person may be strongly motivated to end his/her life, there is usually a strong desire to live, as well. </li></ul><ul><li>The cognitive state is one of tunnel vision : the person has great difficulty seeing the big picture and believes death is the only way out </li></ul><ul><li>The common action in suicide is escape : goal is escape from an intolerable situation </li></ul><ul><li>The common interpersonal act in suicide is communication of intention : At least 80% of suicides are precipitated by verbal or nonverbal cues of suicidal intention. </li></ul><ul><li>The common consistency is in the area of lifelong coping patterns that predispose the person to suicide </li></ul>
  35. 35. Study of Suicide <ul><li>Psychological Autopsy: Systematic examination of existing information to understand & explain a person’s behavior before his/her death </li></ul><ul><li>Suicide survivors are different from those who succeed: </li></ul><ul><ul><li>Attempter: white female housewife in 20s-30s, marital difficulties, uses barbiturates </li></ul></ul><ul><ul><li>Succeeder: white male, 40s or older, ill health or depression, use guns or hangs himself </li></ul></ul>
  36. 36. Facts About Suicide <ul><li>Alcohol frequently implicated </li></ul><ul><li>Men are more likely than women to kill themselves (men use firearms) </li></ul><ul><li>Common among people under age 25 </li></ul><ul><li>Men 3 to 4 times as likely to be successful, women more likely to attempt suicide </li></ul><ul><li>Married people are less vulnerable </li></ul><ul><li>Socioeconomic level is not a factor </li></ul>
  37. 37. More Facts About Suicide <ul><li>Over 60% of suicides are committed using firearms, 70% of attempts are from drug overdose </li></ul><ul><li>Suicide rates are lower in Catholic & Muslim countries </li></ul><ul><li>Highest rates in U.S. are for Native Americans, lowest for Asian Americans </li></ul><ul><li>More than 66% of those who commit suicide communicate their intent to do so beforehand </li></ul><ul><li>High correlation with alcohol consumption </li></ul>
  38. 38. Perspectives on Suicide <ul><li>Emile Durkheim: suicide may occur because of: </li></ul><ul><ul><li>alienation from society (egoistic suicide) </li></ul></ul><ul><ul><li>unbalanced relation to society (anomic suicide) </li></ul></ul><ul><ul><li>for the greater good (altruistic suicide) </li></ul></ul><ul><li>Sigmund Freud: Suicide results from the existence of Thanatos, the death instinct antagonistic to the life instinct </li></ul>
  39. 39. Perspectives on Suicide (cont’d) <ul><li>Biological explanations: </li></ul><ul><li>Research suggests that low levels of serotonin contribute to vulnerability to suicide. </li></ul><ul><ul><li>Evidence suggests that patients with low levels of 5HIAA ( 5 hydroxyindoleacetic acid - a chemical produced when serotonin is broken down in the body) are more likely than others to commit suicide, more likely to use violent methods, and more likely to have a history of violence, aggression, and impulsiveness </li></ul></ul><ul><ul><li>Other evidence suggests impairment of serotonin receptors in the brain stem and frontal cortex of suicidal individuals. </li></ul></ul><ul><li>Genetics: Although there appears to be a higher rate of suicide among parents and close relatives of people who commit suicide, more evidence is needed to understand this relationship. </li></ul>
  40. 40. Preventing Suicide <ul><li>Assumption: Potential victims are ambivalent – they have a strong wish to die, but also a wish to live. </li></ul><ul><li>Lethality : The probability that a person will choose to end his/her life </li></ul><ul><li>Three-step process for working with a potentially suicidal person: </li></ul><ul><ul><li>Know factors correlated with suicide </li></ul></ul><ul><ul><li>Determine probability for person attempting suicide </li></ul></ul><ul><ul><li>Implement appropriate action </li></ul></ul>
  41. 41. Preventing Suicide <ul><li>Telephone Crisis Intervention: </li></ul><ul><ul><li>Maintain contact/establish relationship </li></ul></ul><ul><ul><li>Obtain necessary information </li></ul></ul><ul><ul><li>Evaluate suicidal potential </li></ul></ul><ul><ul><li>Clarify nature of stress & focal point </li></ul></ul><ul><ul><li>Assess strengths & resources </li></ul></ul><ul><ul><li>Recommend & initiate action plan </li></ul></ul>