PSYCHIATRIC NURSING MOOD DISORDERS Dr. Fadwa Alhalaiqa 1.

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PSYCHIATRIC NURSING

MOOD DISORDERSDr. Fadwa Alhalaiqa

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Objectives

Discuss the epidemiological statistics related to mood disorders.

Describe various types of mood disorders.

Identify etiological implications in the development of mood disorders.

Depression related to development stage.

Discuss symptomatology associated with mood disorders.

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Mood disorders

Called affective disorders, are pervasive alterations in emotions that are manifested by depression, mania, or both.

They interfere with a person’s life, plaguing him or her with drastic and long-term sadness, agitation, or elation.

Accompanying self-doubt, guilt, and anger alter life activities, especially those that involve self-esteem, occupation, and relationships.

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• Consequences of dysfunctional grieving is manifested by Mood disorders.

• Mood: is the individual’s emotional tone, which significantly influences behavior, personality, and perception.

• Mood disorders have two major categories:

Depressive disorders, and

Bipolar disorders.

There are also mood disorders due to general medical condition and substance-induced mood disorder

Mood Disorders

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Famous people with MDs

Abraham Lincoln

Queen Victoria

had recurrent episodes of depression

Dr. Masa'deh

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Epidemiology of Mood Disorders

Major depression is one of the leading causes of disability in the US (10%) of the population.

Gender: depression is higher in women than men (2:1). Bipolar is almost equal (1.2 in women to 1 in men).

Depression ‘‘common cold of psychiatric disorders’’. Age: depression is higher in young women (decrease

with age) and old men (increase with age). The median age for the onset of bipolar disorder 18 for men and 20 years for women.

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Epidemiology of Mood Disorders

Social class: inverse relationship between depression and social class, while bipolar is higher among higher social classes (professionals and highly educated).

Race: no consistent relationship has been found

Marital status: depression is higher among divorced individual, separated and individual without close interpersonal relation.

Seasonality: Spring & Fall (peak of suicide is spring)

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Mood disorders are the most common psychiatric diagnoses associated with suicide; depression is one of the most important risk factors for it

Major DepressionMajor Depression

Characterized by a change in several aspects of a person’s life and emotional state consistently throughout at least 14 days.

Mood state described as down, sad, or feeling “blah.”

Clients with bipolar disorder also experience a depressed mood.

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Types of MDs: Depressive Disorders

1. Major Depressive Disorder (MDD): characterized by:

* Depressed mood or loss of interest or pleasure in usual activities.

* Evidence of impaired social and occupational function for at least two weeks.

* No history of manic behavior.

* Symptoms cannot be attributed to the use of substance or general medical condition (see criteria of the disorder).

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Classification of MDD

Episode: Single or recurrent (first diagnosis vs. 2 or more episodes).

Severity: mild, moderate, or severe (according to the number and severity of the symptoms).

With psychotic features: impairment of reality (delusions or hallucinations)

With catatonic features: presence of psychomotor disturbance (psychomotor retardation, waxy flexibility).

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Classification of MDD

With melancholic features: sever major depression, symptoms are exaggerated with anhedonia.

Chronic: the current episode has been evident for at least 2 years.

With seasonal pattern: occur during fall or winter months

With postpartum onset: depression symptoms occur within 4 weeks postpartum.

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2. Dysthymic disorder: *characteristics of the mood are milder than the major depressive disorder.

Individual with dysthymic disorder describe their mood as down with no evidence of psychotic symptoms.

The essential feature is a chronically depressed mood for most of the day, more days than not for at least 2 years.

Dysthymic disorder may be classified according to the age of onset: early onset (before 21 years) and late onset (older than 21) .

Depressive disorders

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Depressive disorders

3. Premenstrual dysphoric disorder:

The essential features include marked depressed mood, severe anxiety, mood swing, and decrease interest in activities during the week prior the menses and subside shortly after the onset of menstruation.

Bipolar DisorderBipolar Disorder

The bipolar disorders are a group of mood disorders that include manic episodes, hypomanic episodes, mixed episodes, depressed episodes, and cyclothymic disorder.

Only clients with Bipolar Disorder experience the elevated mood symptoms seen in mania and hypomania.

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Types of MDs: Bipolar Disorders

Bipolar disorders: characterized by mood swing from profound depression to extreme euphoria (mania) with intervening periods of normalcy. Psychotic symptoms such as delusions or hallucinations may or may not be present.

In manic episode, the mood is elevated, motor activity is excessive, occupational functioning and social activities are impaired (disturbance is sever).

Hospitalization is required to prevent harm to self & others.

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Types of MDs: Bipolar Disorders

In Hypomania, symptoms are less severe with no impairments in social or occupational functioning and with no psychotic symptoms that require hospitalization .

The feature of depression associated with bipolar disorder is identical to MDD with one addition:

the client must have a history of one or more manic episode.

In bipolar disorder, when presentation include rapidly alternating moods accompanied by depression and mania symptoms, the individual is given a diagnosis of bipolar disorder, mixed.

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Types of MDs: Bipolar Disorders (Cont)

1. Bipolar I disorder: characterized by occurrence of at least one full manic episode or mixed symptoms in his/her life.

2. Bipolar II disorder: characterized by at least one hypomanic episodes and one or more depressive episodes (the depressive episode can be more frequent/intense than the manic one). The client has never experienced an episode that meets the full criteria of mania or mixed symptoms.

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Bipolar Disorders (Cont.)

3. Cyclothymic disorder:

characterized by chronic mood change for at least 2 years involving numerous episodes of hypomania and mild depressed mood of insufficient severity to meet bipolar 1 or bipolar 2.

The individual is never without hypomanic or depressive symptoms for more than 2 months.

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Types of MDs: Other Mood Disorders

1. Mood Disorder due to a general medical condition Prominent & persistent disturbance in mood due

to the result of direct physiological effects of a general medical condition.

2. Substance-induced mood disorder The direct result of physiological effects of a

substance: alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, sedatives, hypnotics, and anxiolytics.

The symptoms can occur with withdrawal from these substances.

Dysfunctional GrievingDysfunctional Grieving

Bereavement is a term that refers to the state of loss.

Dysfunctional grieving is a term that describes the failure of an individual to follow the course of normal grieving to a point of resolution.

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Depressive Disorders Etiology 1. Biological theories

A. Genetics

Genetic link has been suggested through studies, but no definite mode of genetic transmission has been demonstrated.

Twin studies: 50% of monozygotic and 10-25 % in dizygotic twins.

Family studies: major depression is 1.5-3 times more common among first degree biological relatives of people with the disorder.

Adoption studies: increase risk in biological children of affected parents.

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Depressive Disorders: Etiology 1. Biological theories

B. Biochemical influences:

Biogenic amines: deficiency in reserpine, catecholamine, serotonin, tryptophan, dopamine, and acetylcholine.

C. Neuroendocrine Disturbances Hypothalamic pituitary adrenocortical axis: in

depressed clients, normal system of hormonal inhibition fails, resulting in a hypersecretion of cortisol.

Hypothalamic pituitary thyroid axis: Thyorotropin-releasing factor (TRF) from hypothalamus stimulate Thyroid stimulating hormone (TSH), which stimulate the thyroid gland.

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Depressive Disorders: Etiology 1. Biological theories

D. Physiological influences (secondary depression)

Medication side effects: e.g proporanolol (antihypertensive), Cortisone, anxiolytics, antipsychotics, and sedative-hypnotics.

Neurological disorders: CVA, brain tumor, Alzheimer

Electrolyte disturbances: ↑(NAHCO3, C a., & K ), deficit in Mg.

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Physiological influences (cont.)

Hormonal disturbances: hypo and hyperthyroidism, hyperparathyroidism, adrenal cortex dysfunction (Addison’s & Cushing’s disease), estrogen & progesterone imbalance.

Nutritional deficiencies: deficiencies in vitamin B1,B6, B12, niacin, vitamin C, iron, folic acid, zinc, calcium, and K.

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Depressive Disorders: Etiology 2.Psychosocial theories

A. Psychoanalytical theories: ambivalence love relationship: once the loss has been incorporated into self (ego), the hostile part of the ambivalence that had been felt for the lost turned inward against the ego. This cause guilt, self-hate and self-blame and affects the self esteem.

B. Learning theory: when the humans experience numerous failures the individual then abandons any further attempt to succeed (learned helplessness) (remember animal studies).

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Depressive Disorders: Etiology 2.Psychosocial theories

C. Object loss theory: separated from mother in the first 6 months of life (mother is the object). It could also be absence of attachment.

D. Cognitive theory: depression is the product of negative and defeated attitude:

negative expectations of the environment,

negative expectations of the self, and negative expectations of the future.

E. Theoretical integration

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Depressive Disorders: Nursing Process

1. Assessment data:

Transient symptoms of depression (symptoms accompany everyday disappointments such as failing an exam. These symptoms subside quickly as the individual advances toward other goals). DAILY LIFE DISAPPOINTMENTS

Mild symptoms of depression occurs when the grief is triggered in response to loss of a valued object. As one is able to work through the stages of grief, the loss is accepted and symptoms subside. NORMAL GRIEF RESPONSE

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Assessment data

Moderate symptoms of depression occurs when grief is prolonged (fixed in anger stage and the anger turned inward to the self). Individual is unable to fully function without assistance. Dysthymic disorder is an example of moderate depression.

Severe symptoms of depression has more intense symptoms and may also manifested by loss of contact of reality. Complete lack of pleasure in all activities. Suicide thoughts. Major depression disorder is an example of sever depression.

Depressive Disorders:Subjective Data

Depressive Disorders:Subjective Data

Feelings of sadness

Fatigue

Lack of interest in relationships and activities that were previously pleasurable

Feelings of worthlessness

Impaired concentration

Depressive Disorders:Subjective Data - continued

Depressive Disorders:Subjective Data (cont'd)

Impaired decision-making ability

Sleep disturbances

Appetite changes; weight loss or weight gain

Excessive sleep

Somatic concerns

Suicidal ideation

Depressive Disorders:Objective Data

Depressive Disorders:Objective Data

Females under the age of 40

Prior episodes of depression

Family history of depression or bipolar disorder

A history of a recent stressful event

Lack of social support

Depressive Disorders:Objective Data -continued

Depressive Disorders:Objective Data (cont'd)

Psychomotor agitation or retardation

Family may report client agitation or apathy and anhedonia

Pattern of social withdrawal

Lack of social participation

Be alert to a change in behavior

Bipolar Disorders:Subjective Data

Bipolar Disorders:Subjective Data

Changes in thought processes

Inflated self-esteem

Delusions of persecution

Ignore fatigue and hunger

Inability to concentrate

Distracted by the slightest stimulus

Hallucinations

Bipolar Disorders:Objective Data

Bipolar Disorders:Objective Data

Young people in their twenties

Little gender specificity

Initial episode is likely to be manic in males and depressive in females

No documented evidence of the effect of race or ethnicity

Bipolar Disorders:Objective Data - continued

Bipolar Disorders:Objective Data (cont'd)

Hallmark of mania is constant motor activity

Disordered sleep patterns

Flight of ideas

Pressured speech

Poor judgment

Bipolar Disorders:Objective Data - continued

Bipolar Disorders:Objective Data (cont'd)

Appearance may be unusual

Absence of personal hygiene

Impairment in occupational functioning

Interpersonal chaos

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Nursing Process Cont.

2. Nursing diagnoses:

Risk for suicide RT depressed mood, anger, misinterpretation of reality

Low self-esteem RT learned helplessness, feeling abandonment by significant others

Spiritual distress RT dysfunctional grieving and anger with God.

Imbalance nutrition, Self care deficit

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Bipolar Disorder (mania): predisposing factors

1. Biological theories: Genetics:

Twin studies: monozygotic 60-80%, dizygotic 20%

Family studies: risk is 28% if one parent have bipolar & 2-3 times greater if both.

2. Biochemical influences:

Biogenic amines: functional excess of norepinephrine, serotonin, and/or dopamine.

Electrolytes: elevated levels of intracellular sodium & ca.

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Manic Disorder: predisposing factors

3. Physiological influences:

Neuroanatomical Factors: Rt. side brain lesions induce secondary mania

Medication side effects: steroids, Amphetamines, antidepressants, anticonvulsants.

4. Psychosocial theories:

The credibility of psychosocial theories has declined in recent years.

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Manic Disorder: nursing process

Assessment data: symptoms of mania can be described in three stages:

1. Hypomania (does not cause social/functional impairment):

Mood: cheerful and expansive. However, rapid change when desires unfulfilled.

Cognition & perception: ideas of great worth and ability of self, thinking is flighty and rapid flow of ideas

Activity & behavior: increased motor activity and very sociable. However, they lack depth of personality and warmth to form close relationships. Talk and laugh a lot (loudly and inappropriately)

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Manic Disorder: nursing process

2. Acute mania (functional/social impairment and require hospitalization):

Mood: euphoria, elation and high (almost on a contentious high. However, easily changing to sad and cry).

Cognition and perception: racing thoughts, flight of ideas, pressure of speech and changing from topic to topic, disorganized and incoherent speech. Delusion and hallucination (paranoid and grandeur)

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Acute Mania Cont.

Activity & behavior: psychomotor activity is excessive, sexual interest increased, great ability to manipulate others to carry out their wishes. Energy seems inexhaustible. Need for sleep disappears (many days without sleep and they don’t feel tired). Hygiene and grooming neglected. Dress may be disorganized. The use of excessive make up is common.

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Manic disorder

3. Delirious mania (clouding of consciousness): Mood: very labile and feeling of despair

quickly converting to ecstasy. Cognition & perception: clouding of

consciousness, confusion and disorientation. Delusion (grandeur, persecution) and hallucination (auditory, visual).

Activity & behavior: agitated with purposeless movement. Injury to self or others are very common.

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Manic Disorder: nursing process

2. Nursing Diagnoses:

Risk for injury R/T hyperactivity

Risk for violence R/T manic excitement, delusion, hallucination

Imbalanced nutrition R/T inability to sit down and eat

Disturbed sensory perception

Impaired social interaction R/T egocentric and narcissistic behavior

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Mood Disorders: treatment modalities

1. Psychological treatments: Psychotherapy Group therapy Cognitive therapy Family therapy2. Other treatments:

Psychopharmacology

ECT

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Suicide

Most suicides are associated with mood disorder.

Depressive disorders account for 80% of committed and attempted suicide.

8th leading cause of death among American adults.

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Suicide

Suicide Facts

8 out of 10 who kill themselves have given definite warnings about their suicidal intention.

People who want to kill themselves are only suicidal for a limited time. If they are saved, they can carry on a normal life.

Most suicide occur within 3 months after the beginning of improvements.

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Suicide

50-80% of people who kill themselves have a history of previous attempt.

Gunshot wounds are the leading cause of death among suicidal victims.

Suicide is not inherited.

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Suicide: Application of the Nursing Process: Assessment:

Demographics:

Age: suicide is higher in persons older than 50.

Gender: males higher than females

Ethnicity: white higher than Native Americans.

Marital Status: single, divorced, & widowed are higher than married.

Socioeconomic Status: Highest and Lowest are at higher risk than in the middle classes.

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Assessment of suicide

Occupation: professional health care personnel and business executives are at higher risk.

Method: gunshots are higher than overdose substances.

Religion: Protestants are greater than Catholics.

Family History: risk is higher with a history of suicide in the family

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Suicide: Application of the Nursing Process

Presenting symptoms/Medical-Psychiatric Diagnosis: Mood disorders are the most common to

proceed suicide. Other disorders include: substance use

disorders, anxiety, schizophrenia.

Suicidal ideas or acts: How serious is the intent? Does the person have

a plan? Does he have the mean? How lethal is the mean? Has the individual ever attempted suicide before?

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Suicide: Application of the Nursing Process

Interpersonal Support system: Does the person has support system he can

rely during crises? Lack of satisfactory relationships may implicate an individual at high risk of suicide.

Analysis of the suicide crisis: The precipitating stressor: adverse life

event in combination with other risk factor such as depression may lead to suicide.

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Suicide: Application of the Nursing Process

Relevant history (history of failures) Life-stage issues (the ability to tolerate losses is

often different during various life stages (adolescence and midlife).

Psychiatric (depression treatment/Medical (terminal ill)/Family History.

Coping strategies How has the individual handled previous crises? How does this situation differ from previous

ones.

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Suicide: Application of the Nursing Process

Diagnoses: Risk for suicide r/t feelings of hopelessness. Hopelessness r/t absence of support

systems.

Planning

Interventions

Evaluation.

Suicide PreventionSuicide Prevention

Assess for suicide risk by direct questioning about suicidal thinking, history of suicide attempts, and whether the client has a specific suicide plan.

The more organized the plan is, the more concern it generates as safety is a priority.

Suicide PreventionSuicide Prevention (cont'd)

Suicidal clients should be placed under suicide precautions.

YOUR INTERVENTION STRATEGIES: Preventing Inpatient Suicide and Promoting Safety

Improving Self-EsteemImproving Self-Esteem

Provide distraction

Explain importance of doing things

Recognize accomplishments

Help clients identify personal strengths

Be accepting

Teach assertiveness techniques

Medication TeachingMedication Teaching

Proper client education enhances the effectiveness of medication therapy and can improve client adherence and diminish non-adherence.

Client education begins when medication therapy begins and is repeated during the course of the client’s hospitalization.

Medication Teaching - continuedMedication Teaching (cont'd)

Give instructions verbally and in writing.

Include family members or significant others if they will supervise home administration.

Self-AwarenessSelf-Awareness

The process recording method will help to promote self-awareness.

A process recording usually consists of three columns One for the nurse’s statements One for the client’s statements One that identifies the process or action taking place

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Nursing Process Cont.

Symptoms of depression can be described as alterations in four spheres: affective, behavioral, cognitive, and physiological.

Alterations within these spheres differ according to severity of the symptomatology.

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