This document provides information on nursing management of patients with mood disorders. It begins with definitions of mood and mood disorders. It then covers the epidemiology, classification, etiology, psychopathology and clinical features of mood disorders like mania, hypomania, and depression. It also discusses the historical perspectives, treatment modalities including pharmacotherapy and psychosocial treatment. Finally, it outlines nursing assessments, diagnoses and interventions for patients experiencing mania.

1. NURSING MANAGEMENT
OF PATIENT WITH
MOOD
(AFFECTIVE)DISORDERS
PREPARED BY
MRS. DIVYA PANCHOLI
ASSISTANT PROFESSOR, SSRCN, VAPI
MRS. DIVYA PANCHOLI 1

2. DEFINITION OF MOOD
◦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.
MRS. DIVYA PANCHOLI 2

3. MOOD DISORDERS
 DEFINITION
Mood disorders are
characterized by disturbances
of mood, accompanied by a
full or partial maniac or
depressive syndrome, which is
not due to any other physical
or mental disorder.
MRS. DIVYA PANCHOLI 3

4.  If the mood is excessively happy
without any cause we call it as
MANIA.
 If the mood is sad without any
cause or it remains sad for a long
time we call it as DEPRESSION.
 If the mood is changing and patient
gets both attacks of mania or
depression we call it as BIPOLAR
DISORDER. MRS. DIVYA PANCHOLI 4

5. MRS. DIVYA PANCHOLI 5

6. 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.
MRS. DIVYA PANCHOLI 6

7. EPIDEMIOLOGY OF MOOD
DISORDERS
 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.
MRS. DIVYA PANCHOLI 7

8.  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. MRS. DIVYA PANCHOLI 8

9. CLASSIFICATION OF
MOOD DISORDERS
F30-F39 Mood (Affective) disorders
• F30 Manic episode.
• F31 Bipolar affective disorder.
• F32 Depressive episodes.
• F33 Recurrent depressive episodes.
• F34 Persistent mood disorder.
• F 38 Other mood disorders.
• F 39 Unspecified mood disorder
MRS. DIVYA PANCHOLI 9

10. DEFINITION OF MANIA
Mania refers to a syndrome in
which the central features are over
activity, mood change(which may
be towards elation or irritability)
and self important ideas.
MRS. DIVYA PANCHOLI 10

11. TRIATS OF MANIA
Increased psychomotor
activity
Elevated mood
Increased production of speech
MRS. DIVYA PANCHOLI 11

12. Classification of mania
 F30 – Manic episode
 F30.0 - Hypomania
 F30.1 - Mania without psychotic
symptoms
 F30.2 - Mania with psychotic
symptoms
 F30.8 – other manic episodes
 F30.9 - Manic episode unspecified
MRS. DIVYA PANCHOLI 12

13. Etiology
1. Neurotransmitter and structural
hypotheses:
 Manic episodes are related to
excessive levels of norepinephrine and
dopamine, imbalance between
cholinergic and noradrenergic systems
or a deficiency of serotonin.
 Biologic findings suggest that lesions
are more common in this population in
areas of brain such as the right
hemisphere or bilateral subcortical and
periventricular grey matter.MRS. DIVYA PANCHOLI 13

14. 2. Genetic factors:
 Monozygotic twins have a higher
rate of incidence than normal
siblings and other close relatives.
Siblings and close relatives have
a higher incidence of manic-
depressive illness than a general
population.
 First degree relative: 5-10%
 Identical twin with bipolar
disorders: about 40-70% chance.
MRS. DIVYA PANCHOLI 14

15. 3. Psychodynamic theories:
Developmental theories have
hypothesized that faulty family
dynamics during early life are
responsible for manic
behaviours in later life.
Another hypothesis suggest
that maniac episodes as a
defence against or denial of
depression. MRS. DIVYA PANCHOLI 15

16. PSYCHOPATHOLOGY OF MANIA
 Manic states shows lack of inhibition,
quickness of psychological reaction,
distractibility, and flight of ideas.
 Elation of mood is accompanied by a
feeling of general wellbeing, which in
the maniac state is manifested as lack
of insight.
 Manic episodes may reflect an inability
to tolerate a developmental tragedy,
such as the loss of parents.
MRS. DIVYA PANCHOLI 16

17. Clinical features
 An acute manic episode is characterized by the following
features which should last for at least one week:
1. Elevated, Expansive & Irritable mood:
 Elevated mood in mania has four stages depending on
severity of manic episodes:
 EUPHORIA (Stage I): Increased sense of psychological
wellbeing & happiness not in keeping with ongoing
events.
 ELATION (Stage II): Moderate elevation of mood with
increased psychomotor activity.
 EXALTATION (Stage III): Intensive elevation of mood
with delusions of grandeur.
 ECSTASY (Stage IV): Severe elevation of mood, intense
sense of rapture or blissfulness seen in delirious or
stuporous mania. MRS. DIVYA PANCHOLI 17

18.  Expansive mood is unceasing &
unselective enthusiasm for
interacting with people &
surrounding environment.
 Sometimes irritable mood may be
predominant, especially when the
person is stopped from doing
what he wants.
 There may be rapid, short-lasting
shifts from euphoria to depression
and anger.
MRS. DIVYA PANCHOLI 18

19. 2. Psychomotor activity:
There is an increased
psychomotor activity ranging
from over activeness &
restlessness to manic
excitement.
The person involves in
ceaseless activity.
These activities are goal-
oriented & based on external
environment cues.MRS. DIVYA PANCHOLI 19

20. 3. Speech & thought:
 Flight of ideas: Thoughts racing in
mind, rapid shifts from one topic to
another
 Pressure of speech: speech is
forceful, strong & difficult to interpret.
Uses playful language with punning,
rhyming, joking & teasing & speaks
loudly
 Delusions of grandeur
 Delusions of persecution
 Distractibility
MRS. DIVYA PANCHOLI 20

21. 4. Other features:
 Increased sociabilities
 Impulsive behaviour
 Hypersexual behaviour
 Poor judgement
 High risk activities (buying sprees, reckless
driving, foolish business investments,
distributing money or other articles to unknown
persons)
 Dressed up in gaudy & flamboyant clothes
although in severe mania there may be poor
self-care
 Decreased need for sleep(<3hrs)
 Decreased food intake due to over activity
 Decreased attention & concentration
 Poor judgement
 Absent insight MRS. DIVYA PANCHOLI 21

22. Hypomania
 Hypomania is a lesser degree of mania.
 There is a persistent mild elevation of mood &
increased sense of psychological wellbeing &
happiness not in keeping with ongoing events.
 Hypomania is different, as it may cause little or no
impairment in function.
 The hypomanic person's connection with the external
world, and its standards of interaction, remain intact,
although intensity of moods is heightened.
 But those who suffer from prolonged unresolved
hypomania do run the risk of developing full mania,
and indeed may cross that "line" without even
realizing they have done so.
MRS. DIVYA PANCHOLI 22

23.  In some cases irritability, conceit (too much
pride in yourself, abilities and importance) &
boorish behaviour (insensitive to other’s
feelings) may take the place of the more
usual euphoric sociability.
 Concentration & attention may be impaired,
thus diminishing the ability to settle down to
work or to relaxation & leisure, but this may
not prevent the appearance of interests in
quite new ventures & activities.
 In fact, the ability to function becomes better
in hypomania there is marked increase in
productivity & creativity; many artists & writers
have contributed significantly during such
periods. MRS. DIVYA PANCHOLI 23

24. Features of Hypomania
1. A distinct period of persistently elevated, expansive,
or irritable mood, lasting throughout 4 days, that is
clearly different from the usual non depressed
mood.
2. During the period of mood disturbance, three of the
following symptoms are persistent:
 Inflated self-esteem or grandiosity
 Decreased need for sleep
 More talkative than usual
 Flight of ideas
 Distractibility
 Increase in goal directed activity
 Excessive involvement in pleasurable activities that
have a high potential for painful consequences.
MRS. DIVYA PANCHOLI 24

25. Conti....
3. The episode is associated with an
unequal change in functioning
4. The disturbance in mood & the
change in functioning are observable by
others.
5. The episode is not severe enough to
cause marked impairment in social or
occupational functioning, or to
necessitate hospitalization, & there are
no psychotic features.
MRS. DIVYA PANCHOLI 25

26. Diagnosis
 Psychological test such as young
mania rating scale.
 DSM-V diagnostic criteria.
 Based on signs and symptoms
MRS. DIVYA PANCHOLI 26

27. Treatment modalities for
mania
 Pharmacotherapy:
◦ Lithium 900-2100mg/day
◦ Carbamazepine 600-1800mg/day
◦ Sodium valporate 600-2600mg/day
◦ Others: Clonazepam, Calcium channel
blockers
MRS. DIVYA PANCHOLI 27

28.  Electro convulsive therapy:
◦ If adequately not responding to
antipsychotics and lithium can go for ECT
MRS. DIVYA PANCHOLI 28

29. 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.)
MRS. DIVYA PANCHOLI 29

30. NURSING ASSESSMENT FOR
MANIA
OBJECTIVE SIGNS SUBJECTIVE SIGNS
Disturbance of Speech Feelings of joy
Rapid Speech Rapid mood swings
Loud, pressured speech Sleep disturbances
Easily distracted Delusions and
hallucinations
Over activity
Mood lability
Weight changes MRS. DIVYA PANCHOLI 30

31. NURSING DIAGNOSIS INTERVENTION
PROBLEM RELATED
TO
EVIDENCED
BY
High
risk
for
injury
extrem
e
hypera
ctivity
and
impulsi
ve
behavi
or
lack of
control
over
purpose
less and
potential
ly
injurious
events
(a) Keep environmental stimuli to a minimum;
assign single room; limit interactions with
others; keep lighting and noise level low. Keep
his room and immediate environment
minimally furnished.
(b) Remove hazardous objects and
substances, caution the patient when there is
possibility of an accident.
(c) Assist patient to engage in activities, such
as writing, drawing and other physical
exercise.
(d) Stay with patient as hyperactivity
increases.
(e) Administer medication as prescribed by
physician.
MRS. DIVYA PANCHOLI 31

32. NURSING DIAGNOSIS INTERVENTION
PROBLEM RELATE
D TO
EVIDENC
ED BY
High
risk for
violenc
e; self-
directe
d or
directe
d at
others
manic
excite
ment,
delusi
onal
thinki
ng
and
halluci
nation
s.
(a) Maintain low level of stimuli in patient's environment, provide
unchallenging
environment. Observe patient's behavior at least every 15
minutes.
Ensure that all sharp objects, glass or mirror items, belts, ties,
matchboxes have been removed from patient's environment.
Redirect violent behavior with physical outlet.
Encourage verbal expression of feelings.
Engage him in some physical exercises like aerobics
Maintain and convey a calm attitude to the patient. Respond
matter-of-factly to verbal
hostility. Talk to him in low, calm voice, use clear and direct
speech.
Have sufficient staff to indicate a show of strength to patient if
necessary. State
limitations and expectations.
Administer tranquilizing medication; if patient refuses, use of
restraints may be
necessary. In such a case, explain the reason to the patient.
Following application of restraints observe patient every 15
minutes.
Remove restraints gradually once at a time
MRS. DIVYA PANCHOLI 32

33. NURSING DIAGNOSIS INTERVENTION
PROBLE
M
RELATE
D TO
EVIDEN
CED BY
Altere
d
nutriti
on,
less
than
body
requir
ement
s
refusal
or
inabilit
yto sit
stilllon
g
enoug
h
to eat,
weight
loss,
amen
orrhea
.
(a) Provide high-protein, high caloric, nutritious
finger foods and drinks that can be consumed 'on
the run.'
(b) Find out patient's likes and dislikes and
provide favorite foods.
(c) Provide 6 - 8 glasses of fluids per day. Have
juice and snacks on unit at all times.
(d) Maintain accurate record of intake, output and
calorie count. Weigh the patient
regularly.
(e) Supplement diet with vitamins and minerals.
(f) Walk or sit with patient while he eats.
MRS. DIVYA PANCHOLI 33

34. NURSING DIAGNOSIS INTERVENTION
PROBLE
M
RELATED
TO
EVIDENC
ED BY
Impair
ed
social
intera
ction
egocen
tric
and
narcissi
stic
behavio
r
by
inability
to
develop
satisfyi
ng
relation
ships
and
manipul
ation
of
others
for own
desires.
(a) Recognize that manipulative behavior helps Understanding the rationale
behind
to decrease feelings of insecurity by increasing the behavior may facilitate
greater
feelings of power and control. acceptance of the individual.
(b) Set limits on manipulative behavior. Explain Consequences for violation of
limits
the consequences if limits are violated. must be consistently administered.
Terms of the limits must be agreed upon
by all the staff who will be working with
the patient
(c) Ignore attempts by patient to argue or bargain Lack of feedback may
decrease
his way out of the limit setting. these behaviors.
(d) Give positive reinforcement for non- To enhance self-esteem and promote
manipulative behaviors. repetition of desirable behavior.
(e) Discuss consequences of patient's Patient must accept responsibility for
behavior and how attempts are made to own behavior before adaptive change
attribute them to others. can occur.
(f) Help patient identify positive aspects As self-esteem increases patient
about self, recognize accomplishments and will experience a lesser need to
manipulate
feel good about them. others for own gratification.
MRS. DIVYA PANCHOLI 34

35. NURSING DIAGNOSIS INTERVENTION
PROBLE
M
RELATED
TO
EVIDE
NCED
BY
Self-
esteem
disturb
ance
unmet
depende
ncy
needs,
lack of
positive
feedback,
unrealisti
c
self-
expectati
ons.
(a) Ask how client would like to be addressed.
Avoid approaches that imply different
perception of the client's importance.
(b) Explain rationale for requests by staff unit
routine etc; strictly adhere to courteous
approaches, matter-of-fact style and friendly
attitudes.
(c) Encourage verbalization and identification of
feelings related to issues of chronicity, lack of
control over self, etc.
(d) Offer matter-of-fact feedback regarding
unrealistic plans. Help him to set realistic
goals for himself.
(e) Encourage client to view life after discharge
and identity aspects over which control is
possible. Through role play, practice how he will
MRS. DIVYA PANCHOLI 35

36. NURSING DIAGNOSIS INTERVENTION
PROBLE
M
RELATE
D TO
EVIDEN
CED BY
Altered
family
proces
ses
euphori
c -
mood
and
grandio
se
ideas,
manipu
lative
behavi
or,
refusal
to
accept
respon
sibility
for own
actions
.
(a)Determine individual situation and feelings of
individual family members like guilt, anger,
powerlessness, despair and alienation.
(b) Assess patterns of communication. For
example: Are feelings expressed freely? who
makes decisions? What is the
interaction between family members?
Determine patterns of behavior displayed by
patient in his relationships with others, e.g.
manipulation of self-esteem of others, limit
testing, etc.
Assess the role of patient in the family, like
provider etc, and how the illness affects the roles
of other members.
Provide information about behavior patterns and
expected course of the illness.
MRS. DIVYA PANCHOLI 36

37. MRS. DIVYA PANCHOLI 37