Mental health nursing

Mood disorders

Mood disorders

Mood disorders (“affective disorders”) are A change in mood that is more than normal. Prolonged
feeling of sadness and grief(intense sorrow caused by loss of a loved one ). It must affect normal
functioning such as thinking, behavior, sleep and eating.

Mood disorders affect about 10%of the population.

Definition

The mood or affective disorders are mental disorders that primarily affect mood and interfere with the
activities of daily living . Usually it includes major depressive disorder
(MDD) and bipolar disorder(also called manic depressive psychosis)

Classification
Manic episode

Depressive episode

Bipolar mood (affective disorders)

Persistent mood disorder(including cyclothymiacs and dysthymia)

Etiology
1. Biological theories

Genetic hypothesis

Lifetime risk for first degree relatives of parents with bipolar mood disorder is 25% and of
normal control is 7%.

Children with one parent with mood disorders is 74%

Monozygotic twins(either of two twins developed from the same fertilized ovum ,or having
the same genetic material.) with mood disorder is 65%

Dizygotic twins(either of two twins who developed from two separate fertilized eggs) with
mood disorder is 15%

2. Biochemical theories

A deficiency of nor-epinephrine and serotonin has been found in depressed patient and they are
elevated in mania. Dopamine, GABA and acetylcholine are also presumably involved.

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3. Psychological causes

Freud`s psychoanalytic theory

One of the leading psychoanalytic theories concerning depression was first proposed was first proposed
by Sigmund Freud. Freud argued that at some point in early childhood, the depressed patient suffered
the loss, real or imagined, of someone with whom they were very closed. According to Freud depression
result due to loss of a “loved object "and fixation in the oral sadistic phase of development, in this
model, mania is viewed as a denial of depression.

Psychological:

 low self esteem

 Guilt

 Lack of support system, insecurity

 Inability to fulfill expectations

 Separation or object loss

 Over sensitivity

 lack of love

 Inability to cope with stress, failure or anger.

4. Behavioral theory

According to his model, depression is conditioned by repeated losses in the past.(hopeless, loss of
positive reinforcement)

5.Cognitive theory

Cognitive theory: according to this theory depression is due to negative attitude about self , the
environment, and future, bad or inadequate judgment.

6.Social theory:

Social theory: stressful life events e.g death ,marriage ,

classification

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MANIA:

Mania refers to a syndrome in which the central features are over active, mood change and self imports
ideas.

It is an unfound elation, recognized by extreme talkativeness, grandiose plans and new ideas, new bursts
of creativity, pressured, constant speech with jokes, plays on words, rhyming, distractibility, flight of
ideas, speech difficult to interpret. This can make a manic person socially intrusive and lack inhibitions.
at first the mania feels good, often starts off with hypomania the milder form of mania, but everything
seems to get out of control, paranoid and delusion start to occur(sometimes eshallucination).the life
time risk of mania is about 0.8-1%

Classification of mania
1. Hypomania
2. Mania with psychotic symptoms
3. Mania without psychotic symptims
4. Manic episode unspecified

1. Hypomania
It is lesser degree of mania, in which abnormalities of most and behaviour are too presistent but are not
accompanied by hallucinations or delusions.There is persistent mild elevation of mood ,increased energy
and activity , and usually marked feelings of well being and both physical and mental efficiency
.Increased sociability, talkativeness, over familiarity, increased sexual energy, and a decreased need for
sleep are often present but not to the extent that they lead to severe disruption of work or result in
social rejection.

Clinical features of hypomania

1. Elevated ,expansive or irritable mood.
 Euphoria: increased sense of psychological well-being and happiness.

 Elation: moderate elevation of mood increased psychomotor activity.

 Exaltation: moderate elevation of mood with delusion of grandeur.

 Ectasy: severe elevation of mood.

2. Psychomotor activity: hyperactivity or psychomotor agitation.

3. Speech and thought.

 Flight of ideas.

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 Pressure of speech.

 Delusion of persecution

 Distractibility

 Grandiosity, inflated self esteem.

4. Other features

 Decreased need for sleep(<3hrs)

 Decrease food intake due to over-activity.

 Attention easily distracted by unimportant objects or even in the subject`s environment.

 More goals, and goal oriented activities, with word, school and sexually.

 Poor judgement

 Absent insight

 Agitation

 Involvement in high risk activities(reckless driving , foolish business, investment, distributing

money or articles to unknown person).

 Mood disturbance is so severe that it impairs occupational functioning relationships, or social

activities.

 Feeling full of energy

 Laughing inappropriately, inappropate humor.

Mania without psychotic symptoms.

Mood is elevated out of keeping with the individual`s circumstances and may from carefree joviality to
almost uncontrollable excitement. Elation is accomanied by increased energy , resulting in over acttivity,
pressure of speech , and a decreases need for sleep. Normal social inhabitation are lost, attention
cannot be sustained and there is often marked distractibility. Self esteem is inflated, and grandiose are
expressed.

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Diagnostic criteria
1 .Mood must be predominantly elevated, expensive, or irritable , and definitely abnormal for the
individual concerned . The mood change must be prominent and sustained for least 1 week.

2 .At least three o the following signs must be present, leading to severe interference with personal
functioning of daily living.

 Increased activity or physical restlessness.

 Increased talkativeness(presser of speech)

 Fight of idea.

 Loss of normal social inhibitions resulting in behavior that is inappropriate to the circumstances.

 Decreased need for sleep.

 Grandiosity.

 Distractibility or constant changes in activity or plan.

3. There are no hallucinations or delusion, although perceptual disorders may occur.

4. The mood disturbances is sufficient to caused impairment at work or danger are present to the
patient or other.

Mania with psychotic symptoms

The episode meets the criteria for mania without psychotic symptoms and hallucination or delusions.

The commonest examples are those with grandiose, self referential ,or persecutory content.

The episode is not attributable to psychoactive substance use or to any organic mental disorder.

Diagnosis
Proper history taking.

Mental status examination

Treatment.
1. hospitalization.

2. Pharmacotherapy

 Lithium 900-2100mg/day

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 Carbamazepine 600-1800mg/day

 Sodium valporate 600-2600mg/day

 Other drugs: clonazepam, calcium channel blockers.

 Electroconvulsive therapy.

 Psychosocial treatmet.

Nursing management
DIET: special attention must be given to the patient`s diet because he is usually too busy to eat
and hence may loose weight and dehydration may occur. Meals and fluids are given under
supervision.

DRUG: drugs are of great in dealing with problems of restless, sleepleness and fatigue
associated with overactivity.

Maintain safety :because of excitement and destructive activities may result in injuries.

Supervision and direction to maintain personal hygiene like bathing, oral hygiene.

 Carw to be taken that the patient is dressed appropriately.

 Emotional need.
 Approach the patient in a calm/unhurried and consistent manner.
 Always speak quietly , tactfully and patiently.
 Avoid arguments, discussion or situations that are stimulating and irritating.
 Suggestion and persuations are more effective.
 Short. Simple direct answers should be quitely given when the patient ask questions.
 Maintain low level of stimuli in patient`s environment.
 Observe the patient`s behaviour frequently.
 Remove all dangerous objecting from patient environment so that in his or her
hyperactive, agitate state they cannot be used to harm self or others.
Maintaing a therapeutic environment.

 The ward must be quite and pleasant, factors that irritate the patient like excessive noise, bright
colors etc are to be avoided.

 Separate room may ideal with simple furnishing.

 Fluctuating of mood state must be watched.

 Active games, creative work will channalise his energy.

 Drug therapy is essential for sedation.

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Bipolar disorders
This characterized by recurrent episodes of mania and depression in the same patient at differen
times.bipolar disorder is further classified into bipolar I and bipolar II disorder.

1. Bipolar 1 disorder

2. bipolarII

1.Bipolar 1 disorder
Bipolar 1 disorder:is a mood disorder characterized by one or more episodes, possible alternating with
major depressive episodes and severe mania.

Diagnostic criteria (DCM-IVTM)

I. History of major depression and at least one manic episode.

II. The manic episode is not from another disorder.

2.Bipolar II disorder
Bipolar II disorder is a mood disorder with a clinical course that is characterized by at least one major
depressive episode(s) and at least one hypo-manic episode(s)and at least one hypo-manic episode(s)

Diagnostic criteria (DSM-IVTM)

Had/ have at least one major depressive episode. In
Had/ having at least one hypo-manic episode.
Never has a manic or mixed episode.
The episodes, 1or 2 above are from another disorder.
Clinically significant distress from symptms .or imparirment in work , social or other
areas of important functioning.
Treatments
Treatment for Bipolar Disorder is usuall psychotherapy and administered medication(s)

 Mood stabilizers

 Anti-depressants

 Anti –psychotics

 Antimanic.

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DEPRESSION
Depression is recognized as a depressed mood, irritability, loss of interest and inability to do the things.
Sleep disturbances is common, with either insomnia(inability to sleep) or hypersomnia (sleeping too
long).appetite changes are commonly visible with either increased appetite or decreased appetite.
These symptoms and other symptoms should at least 2 weeks.

 Epidemiology of depression
About 6% the general population suffers from depression. The life-time risk of depression in males is 18-
12% and in females is 20-26%. Depression occurs twice as frequently in women as in men.

 Etiology
1. Biological factors

 Genetic hypothesis :- the life time risk for the first – degree relatives.

 Biological theorizes :-a deficiency of nor-epinephrine and serotonin has been found in depressed
patient

2. Psychosocial factor :-

- Low self esteem

- Guilt

- Lack of support system

- Lack of clear goals

- Feeling of failure

- Inability to fulfill expectation

- As a person to separation or object loss

3. Cognitive theory: according to this theory depression due to negative cognitions , which include

- Negative expectation of the environment .

- Negative expectation of the self .

- Negative expectation of the future .

- Inadequate judgment .

4. Behavioral: - hopelessness, loss of positive reinforcement

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5. Socio- Culture factor :-

Social situation that bring feeling of powerlessness and low self esteem.

• Role loss (Empty nest home ) - Injustice

• Stressful life event - Poverty

• Unemployment

Classification (ICD10)

1. Depressive episode

2. Mild depressive episode

3. Moderate depressive episode

4. Severe depressive episode without psychotic symptoms

5. Severe depressive episode with psychotic symptoms

6. Other depressive episodes-atipical depression

7. Depressive episode, unspecified

8. Recurrent depressive disorder.

Classification (DSM III)

• Endogenous depression

• Reactive depression

ENDOGENOUS DEPRESSION(Major Depression)

Refers to syndrome thought to come from inside , i.e. result from internal biological factors and seems
to have a life of its own, rather than being dependent of environment influence . The main feature are

- Absence of environmental precipitant ( deaths , personal losses) and stable premorbid personality .

Melancholic Feature .

1. One of the following

- No pleasure in almost all activities .

- When faced with stimuli that are pleasurable there will be lack of reaction .

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2. At least three of flowing

- Depress mood .

- Depressed mood worse in morning .

- Walking up at lest tow hour before normally awakening

- Psychomotor retardation .

- Weight loss.

- Excessive feeling of guild or guilt for no reason

REACTIVE DEPRESSION

Refers to a syndrome triggered by factor in the environment , rather than biological factor . Such as
depression are characterized by obvious precipitation events , and life stresses , fluctuating of symptoms
according to psychological and environmental factors , and unstable “neurotic” premorbid personality
pattern.

COMMON SIGN AND SYMPTOMS OF DEPRESSION

 Lack of energy, tired , fatigued.

 Feeling sad, unhappy, feeling , like just sucks .

 Loss of concentration

 Poor memory

 Despair, hopelessness, feeling worth less.

 Moving and speaking more slowly than usually.

 Difficulty doing thing and /or getting things done

 Self critical thought, loss of self esteem.

 Felling helpless.

 Withdrawal, social withdrawal.

 Appetite changes, sleep disturbance .

 Irritability, restlessness.

 Feeling life is not worth living.

 Feeling dead or detached.

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 Thought about death.

 Suicidal thought, ideas , actions.

 Withdrawal , social withdrawal.

 Appetiet changes , sleep disturbance .

 Irritability , restlessness.

 Feeling dead or detached.

 Thought about death.

 Suicidal thought ,ideas , actions.

 Diagnostic

 A text book of mental health and psychiatric nursing page 98

 Treatment of dpression and nsg management from Durga subedi .

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