Mood Disorders
Chapter 15
Barbara Fickley,
RN,MSN,CS
Definitions
Ø
What is mood?
Sustained emotional state and how you subjectively feel.
Ø
What is affect?
Observable emotional expression of mood, which you communicate verbally
and nonverbally.
MOOD RANGE
Causative Theories
1. Genetic
2. Neurobiological
3. Intrapersonal
4. Learning Theory
5. Cognitive Theory
6. Social-Cultural Theory
7.Physiological Influences
GENETIC THEORY
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Genetic Predisposition
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40-50% with unipolar
depression
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70% with bipolar depression
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Gender: Women higher 2:1
depression
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Bipolar Gender: roughly the same
Ø
Age: Women- depression as
young women-decrease with age; Men increases with age
Ø
Socioeconomics- Higher
social classes= higher incidence of bipolar
Ø
Marital status- more common
in divorced and singles ( without close supports)
Ø
Seasonality- depression
peaks in Spring and Fall ( so does suicidality!)
Neurobiological Theories
1.Prefrontal cortex- decreased
activity, decreased glucose metabolism, decreased blood flow in ant. Cingulate
cortex leading to abnormal processing of emotions.
2.Neurotransmitters-serotonin,dopamine,norepinepherine,
acetylcholine in the CNS implicated in depression. Functional decrease in depressive
episode; excess during mania
3.Monoamine Oxidase deactivates
neurotransmitters after their release from receptor sites: Sensitivity of
receptors
Neurobiological Theories
Continued
Amount of available sunlight-SADS
Internal desynchronization of biological rhythms
Intrapersonal Theories
Anger Related to loss (real or symbolic)
Anger turned
inward and against self due to inability to express it.
Learning Theories
External locus of control vs
internal
Learned helplessness (Seligman)
people feel they have no control over the outcome of events in their lives
Cognitive Theories
Negative view of self and a focus on the negative
messages in the environment
Do not see
positive experiences
In mania focus is only on the positive without regard
for any negative consequences
Social Theory
Ø
Cultural stereotypes
influence the way one sees oneself
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Feminist theory
Girls have been socialized into being docile, nice,
fitting in and not learning how to manage conflict leading to decreased coping
skills and decreased self esteem
Physiological Influences
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Secondary depression
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Medication induced- certain
antihypertensives, interferon, acutane
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List on page 304
MOOD RANGE
Dysthymia
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Mild symptoms of
depression, chronic ‘down in the dumps’ feelings,
for most of the day, more often than not
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No psychotic symptoms
Ø
Generally, not suicidal
MOOD RANGE
Major Depression
Diagnosis
is made when the person has loss of interest in life and a depressed mood that
moves from mild to severe( severe phase lasting at least two weeks)
Behavioral Characteristics of
Major Depression
Decreased
desire to participate in activities
Feel incompetent, inadequate
Avoid social activities and withdrawal
Feel lonely, but can not get themselves to join
Become more dependent
often totally dependent
Feel unlovable
Affective Characteristics of Major
Depression
Sadness, despair over past,
present and future, guilt, crying episodes to feelings of inability to cry,
decreased pleasure to anhedonia, loss of emotional attachment to disengaging
from everyone, feel powerless, helpless and hopeless, feel like things will not
get any better, suicidal
Cognitive Characteristics in Major
Depression
Ø
Major Depression
Focus on failures, low self esteem, self deprecatory,
self blame, catastrophizing, negative thoughts, inferior, pessimistic, over
generalize, every thing looks bad, dichotomous (all good or all bad) thinking,
may as well be dead, people would be better off with out them, difficulty
making decisions, can not problem solve, slowed speech, poverty of speech, loss
of meaning to life and faith
Social Characteristics in Major
Depression
Ø
Major Depression
Dysfunctional interpersonal skills, leading to further
pain and feelings of failure, family conflict and frustration,
Physiological Characteristics
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Major
Depression
Change in appetite- increase or
decrease
Sleep patterns disrupted-may sleep
more and wake up early. In severe depression may sleep only a few hours
Fatigued move slow, may develop
wringing of hands or pacing
Constipation due to decreased
intake and activity
Decreased interest in appearance
and hygiene, no energy
Thyroid dysfunction affecting
neurotransmitters
High cortisol levels decreasing
immune function
Risk for osteoporosis due to loss
of bone density
4 Variations on Types of
Depression
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Age Specific- Child,
Adolescence. Senescence
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Premenstrual Dysphoric
Disorder
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Maternal- Post Partum
Psychosis, Baby Blues
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Psychotic Depression
Age Specific Characteristics
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Children -irritability, sleep changes,
anger, sadness, withdrawal, poor grades
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Adolescence- bipolar may be seen
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Pseudo dementia-older clients with depression may exhibit signs of cognitive
impairment leading to incorrect diagnosis of dementia
Premenstrual Dysphoric Disorder
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Depressed mood
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Anxiety
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Mood swings
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Decreased interest in
activites during the week before menses ans subsiding shortly after the onset
of the menses
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Table 15-3
Maternal Depression
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Postpartum blues- starts
within the first 10 days postpartum and lasts few days to two weeks. Symptoms
disappear spontaneously
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Post partum depression can
occur any time in the first year post parted- and symptoms lasting more than
two weeks
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Post partum psychosis- a
medical emergency
Depression with Psychotic Features
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Depression with the
addition of psychotic features- delusions, hallucinations,
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Often responsive to ECT
MOOD RANGE
Cyclothymia
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Numerous periods of mood swings between hypomania and depressed moods
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BUT insufficient severity or duration to meet
criteria for bipolar disorder
MOOD RANGE
Bipolar Disorder
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Diagnosis of Bipolar
Disorder is made when symptoms have lasted for at least one week
Affective Characteristics in
Bipolar Disorder
Unstable mood, cheerful escalating
to euphoria, excitable, mood is unstable and an deteriorate to argumentative
and combative, intolerant of criticism, experience no guilt or ability to
understand the feelings of others,
constant need for excitement, form
intense emotional attachments quickly, many sexual relationships, feel all
powerful
Behavioral Characteristics
in Bipolar Disorder
Distractible
Reckless,
Poor judgment,
Poor impulse control,
Talkative and gregarious,
Argumentativeness,
Sarcasm and irritable
Feel independent of everyone
Cognitive Characteristics in
Bipolar Disorder
Exaggerated self concept,
grandiose, do not see their behavior as inappropriate, do not see that they
need help, go on sprees with no thought of consequences,
impulsive, short attention span,
flight of ideas, exaggerated self esteem, delusions of grandeur or erotomania,
do not want to give up the experience of mania
Social Characteristics of Bipolar
Disorder
Caregiver burden
Impact of sexual dysfunction on marriage
Cultural Characteristics of
Bipolar Disorder
Ø
Different cultures allow
for expression of emotion differently
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Somatization- psychological
distress is experienced and communicated in the form of somatic
symptoms-headaches, heart pain, dizziness, weakness
Physiological Characteristics
Ø
Bipolar
Disorder
Decreased nutrition and fluid
intake -can’t remain
still long enough
Decrease in sleep-full of energy
on two hours of sleep
Hyperactivity no awareness of
fatigue
Constipation R/T not paying
attention to urge to move bowels
Extravagant makeup, frequent
changes of clothes not matching and bright colors
Stages
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I Hypomania: cheery, expansive, irritable if ideas are challenged,
thinking is flighty, rapid flow of ideas, increased libido, spending,
friendships
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II Acute Mania; Very high, with variations to crying, irritable; pressured
speech, flight of ideas; psychomotor excess
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III Delirious; labile, confused, psychotic, frenzied motor activity
Kinds of Bipolar Depression
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Bipolar Disorders include
manic episodes, mixed episodes, depressed episodes, and cyclothymia disorder
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Mood alternates between
extremes of depression and elation with periods of normal mood in between
Concomitant Disorders
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Anxiety
disorders such as agoraphobia, panic attacks, OCD, GAD frequently occur with depression
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Substance
abuse- Primary mood disorder? Primary substance disorder? Or both Primary?
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60% of
those with bipolar have substance abuse
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Treatment
of both disorders should be concurrent
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Should be
drug free for at least a month before diagnosis of mental illness is made
Nursing Interventions
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Safety is
always a first priority
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Asses for
suicide ,lethality
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Assessment:
mood scale
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Assess
energy and ability to respond to questions
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Assess ability to eat/ sleep
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Assess
affect
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Assess
family history
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Assess
substance abuse, domestic violence
Nursing Interventions
Ø
Manage
activity
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Protected from the exhaustion
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Limit
caffeine
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Establish
a daily routine
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Use
simple, concrete language
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Set limits
on intrusive behavior Cognitive reframing/restructuring
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Help
client identify negative self statements
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Challenge
the truth of the negative thinking.
Nursing Interventions
Decrease
social isolation
May need to do solitary one-on-one activities with
client
In manic episode, client may need to be protected from
his intrusive, sarcastic behavior towards others
May need to be kept out of group until mania has
subsided
Nursing Interventions
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Teach:
Impulse Control
Relapse prevention- identification
of early cues of impending relapse
Medication management
Signs and symptoms of the disease
process to client and family
Relaxation techniques to help with
sleep and racing thoughts
Community resources for client and
family
Assess what has helped client in
the past.
Assess spiritual resources. What
has helped client get through difficult times in the past
Nursing Interventions
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Assess
family communication, and education
needs
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Monitor
physiological needs and assist client with:
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daily hygiene
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Nutrition-
Tryptophan is the precursor of 5-HT niacin and Vit B6 also needed for 5-HT
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Tyrosine
is needed for increasing NE and DA
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Choline is
increased when higher levels of Ach are needed.
Multidisciplinary Interventions
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Medication
Evaluation and Management
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Electroconvulsive
Therapy
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Family Therapy
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Alternative
Therapies
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Transcranial
Magnetic Stimulation
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Vagus
Nerve Stimulation
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Exercise-stimulates
endorphins, increases levels of DA, 5-HT, NE
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Yoga/Relaxation
Medication Therapy
Antidepressants
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All the
meds. take 2-4 weeks to attain effectiveness and up to 6 weeks for maximum
benefits. Must continue to assess
patient for thoughts of self injury or suicide and assess life style issues.
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Many
things are considered when prescribing: Patients age and cardiovascular status
( tricyclics can cause dysrhythmias), cost, previous history of benefit or
adverse effects from meds
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Medical
history such as diabetes, seizures
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Whether
the client is having insomnia or wanting to sleep all the time. Tricyclics tend
to cause drowsiness, SSRIs tend to interfere with sleep
Antidepressant Medications
Increase neurotransmitters
blocks or inhibits the reuptake of neurotransmitters
Tricyclic antidepressants
MAO
Inhibitor
SSRIs
Others; Wellbutron, Deseryl, Effexor. Remeron
Mood Stabilizing Medications
l
Lithium carbonate
l
Anticonvulsants
l
Verapamil (Calcium channel
blocker)
l
Zyprexia (Antipsychotic)
Interventions
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Herbal Medications
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St. John’s Wort
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SAMe
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Vit. B12
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Tyrosine
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Melatonin
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DHEA
Interventions
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Omega-3 Fatty Acids
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Aromatherapy-Olfactory
receptors are the only sensory pathways that open directly to the brain, to
limbic system influencing emotion and behavior
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Acupuncture
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Pets
Questions
Suicide Power Point