MOOD DISORDERS

This comprise of disorders in which the fundamental disturbance is a change in affect or

mood to depression (with or without associated anxiety) or to elation. The mood change is
usually accompanied by a change in the overall level of activity; most of the other symptoms
are either secondary to, or easily understood in the context of, the change in mood and
activity. Most of these disorders tend to be recurrent and the onset of individual episodes can
often be related to stressful events or situations.

ICD 10 CLASSIFICATION
F30-F39 Mood [affective] disorders

F30 Manic episode

F31 Bipolar affective disorder

F32 Depressive episode

F33 Recurrent depressive disorder

F34 Persistent mood [affective] disorders

F38 Other mood [affective] disorders

F39 Unspecified mood [affective] disorder

MANIA/MANIC EPISODE
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.

The word mania is derived from Greek word, it is synonymous with ‘madness’ it is used to
describe a behavior disorder in which three main symptoms predominate, euphoria,
heightened psychomotor activity and flight of ideas.

CLINICAL FEATURES OF MANIA

1. Alterations in thought processes and communication patterns are manifested by the
following:
⮚ Flight of Ideas. There is a continuous, rapid shift from one topic to another.

⮚ Loquaciousness. The pressure of the speech is so forceful and strong that it is

difficult to interrupt maladaptive thought processes.
⮚ Delusions of Grandeur. The individual believes he or she is all important, all
powerful, with feelings of greatness and magnificence.
⮚ Delusions of Persecution. The individual believes someone or something
desires to harm or violate him or her in some way. .

2. Elevated, Expansive or Irritable Mood

Elevated mood in mania has four stages depending on the severity of manic episodes:

⮚ Euphoria (Stage I):

Increased sense of psychological well-being and happiness not in keeping with
ongoing events.
⮚ Elation (Stage II):
Moderate elevation of mood with increased psychomotor activity.
⮚ Exaltation (Stage III):
Intense elevation of mood with delusions of grandeur.
 ⮚ Ecstasy (Stage IV):
Severe elevation of mood, intense sense of rapture or blissfulness.

3. Dress is often inappropriate: bright colors that do not match; clothing inappropriate for
age or stature; excessive makeup and jewelry.
4. The individual has a meager appetite, despite excessive activity level. He or she is unable
or unwilling to stop moving in order to eat.
5. Sleep patterns are disturbed. Client becomes oblivious to feelings of fatigue, and rest and
sleep are abandoned for days or weeks.
6. Spending sprees are common. The individual spends large amounts of money, which is
not available, on numerous items, which are not needed.
7. Increased sexual energy and libido
8. Manipulative behavior and limit testing are common in the attempt to fulfill personal
desires. Verbal or physical hostility may follow failure in these attempts.
9. Projection is a major defense mechanism. The individual refuses to accept responsibility
for the negative consequences of personal behavior.
10. There is an inability to concentrate because of a limited attention span. The individual is
easily distracted by even the slightest stimulus in the environment.
11. Alterations in sensory perception may occur, and the individual may experience
hallucinations.
12. As agitation increases, symptoms intensify. Unless the client is placed in a protective
environment, death can occur from exhaustion or injury.
13. The speech is very loud, rapid and difficult to understand, often it is full of jokes, puns,
plays on words, amusing irrelevance and theatrical with singing and rhetorical
mannerisms
14. Due to grandiose idea and inflated self esteem, the patient may act as an advisor and
consultant in areas the they do not have special knowledge, such as how to fix and
automobile and how to run government, writing novel, composing music or painting
pictures.

CLASSIFICATION OF MANIA (ICD10)

• Hypomania

• Mania without psychotic symptoms

• Mania with psychotic symptoms

• Manic episode unspecified

HYPOMANIA
Hypomania is a lesser degree of mania. There is a persistent mild elevation of mood and
increased sense of psychological well being and happiness not in keeping with ongoing
events.
Concentration and attention may be impaired, thus diminishing the ability to settle down to
work or to relaxation and leisure, but this may not prevent the appearance of interests in quite
new ventures and activities.

In fact, the ability to function becomes better in hypomania, and there's a marked increase in
productivity and creativity; many artists and writers have contributed significantly during
such periods.

The features of hypomania may be specified as follows:

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout 4

days.

2. During the period of mood disturbance, three (or more) of the symptoms mentioned in
mania are present.

4. The disturbance in mood and 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, and there are no psychotic features

ETIOLOGY OF MANIA

1. BIOLOGICAL FACTORS

Genetic factors

⮚ Twin studies have indicated a concordance rate for bipolar disorder among
monozygotic twins at 60% to 80% compared to 10% to 20% in dizygotic twins.
⮚ Family studies have shown that if one parent has bipolar disorder, the risk that a child
will have the disorder is around 28%
⮚ If both parents have the disorder, the risk is two to three times as great.

Biochemical factors:

⮚ Behavioral responses of elation and euphoria may be caused by an excess of

Norepinephrine and dopamine in the brain.
 ⮚ Low level of serotonin
⮚ It has also been suggested that manic individuals have increased intracellular sodium
and calcium.
2. PHYSIOLOGICAL FACTORS

Neuroanatomical:

⮚ Right-sided lesions in the limbic system, temporobasal areas, basal ganglia, and
thalamus have been shown to induce secondary mania.
⮚ Magnetic resonance imaging studies have revealed enlarged third ventricles and
subcortical white matter and periventricular hyperintensities in clients with bipolar
disorder

Medication Side Effects:

⮚ Certain medications used to treat somatic illnesses have been known to trigger a
manic response. The most common of these are the steroids frequently used to treat
chronic illnesses such as multiple sclerosis and systemic lupus erythematosus.
⮚ Amphetamines, antidepressants, and high doses of anticonvulsants and narcotics also
have the potential for initiating a manic episode

Substance Intoxication and Withdrawal:

⮚ Mood disturbances may be associated with intoxication from substances such as

alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine,
sedatives, hypnotics, and anxiolytics.
⮚ Symptoms can occur with withdrawal from substances such as alcohol,
amphetamines, cocaine, sedatives, hypnotics, and anxiolytics.

3. PSYCHOLOGICAL FACTORS

Most psychoanalytical theories of mania view manic episodes as a “defense” against

underlying depression, with the id taking over the ego and acting as an undisciplined,
hedonistic being (child).

TREATMENT OF MANIA
MEDICAL MANAGEMENT
The choice of treatment depends on the patient's co-morbidity, current episode and side
effects. The main aim of treatment is to stabilise mood without any relapses into mania.

1. Antipsychotics: used as a therapeutic trial to treat mania. May be switched to mood

stabiliser once the acute episode resolved. Options can include:

⮚ Haloperidol
⮚ olanzapine
⮚ quetiapine.

2. Mood Stabilizers:
⮚ Lithium Carbonate: Often referred to as the ‘gold-standard’. Used in acute mania,
or long-term maintenance. Its narrow therapeutic window increases the risk of
toxicity and it is teratogenic. Patients on lithium require close monitoring.

3. Antiepileptics:
⮚ sodium valproate,
⮚ lamotrigine
⮚ carbamazepine.

PSYCHOTHERAPIES
Although pharmacologic treatment is acknowledged as the primary method of stabilizing an
acutely ill bipolar client, adjunctive psychotherapy has been recognized as playing an
important role in preventing relapses and improving adjustment.

Individual psychoeducation: trained to identify and cope with early warning signs of mania
and/or depression.

Cognitive behavioural therapy (CBT): talking therapy. Focuses on the emotional response
to thinking and behaviour.

Group psychoeducation: high frequency and intensity sessions to help patients become
experts in their own condition. Aims to improve mood stability, medication adherence and
self-management.

Family-Focused Therapy

Family-focused therapy (FFT) includes both the patient and his parents, spouse, or other
family members. FFT typically lasts about 12 sessions (depending on the family’s needs)
given by a single therapist. Early sessions focus on education about the condition: its
symptoms and how they cycle over time, its causes, how to recognize the early warning signs
of new episodes, and what to do as a family to prevent the episodes from getting worse. Later
sessions focus on communication and problem solving skills, especially to address family
conflicts.

Interpersonal And Social Rhythm Therapy

IPSRT is an individual therapy in which the patient keeps daily records of their bed times,
wake times, and activities, and the effects of changes in these routines on their moods. The
clinician coaches the person on how to regulate their daily routines and sleep-wake cycles as
a way to stabilize moods.

NURSING MANAGEMENT
■ RISK FOR INJURY RELATED TO BIOCHEMICAL ALTERATIONS

1. Reduce environmental stimuli. Assign private room, if possible, with soft lighting, low
noise level, and simple room decor. In hyperactive state, client is extremely distractible, and
responses to even the slightest stimuli are exaggerated.

2. Assign to quiet unit, if possible. Milieu unit may be too distracting.

3. Limit group activities. Help client try to establish one or two close relationships. Client’s
ability to interact with others is impaired. He or she feels more secure in a one-to-one
relationship that is consistent over time.

4. Remove hazardous objects and substances from client’s environment (including smoking
materials). Client’s rationality is impaired, and he or she may harm self inadvertently. Client
safety is a nursing priority.

5. Stay with the client to offer support and provide a feeling of security as agitation grows
and hyperactivity increases.

6. Provide structured schedule of activities that includes established rest periods throughout
the day. A structured schedule provides a feeling of security for the client.

7. Provide physical activities as a substitution for purposeless hyperactivity. (Examples: brisk

walks, housekeeping chores, dance therapy, aerobics.) Physical exercise provides a safe and
effective means of relieving pent-up tension.

8. Administer tranquilizing medication, as ordered by physician. Antipsychotic drugs are

commonly prescribed for rapid relief of agitation and hyperactivity. Atypical forms
commonly used include olanzapine, ziprasidone, quetiapine, risperidone, asenapine, and
aripiprazole.

RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE RELATED TO

MANIC EXCITEMENT
1. Maintain low level of stimuli in client’s environment (low lighting, few people, simple
decor, low noise level). Anxiety and agitation rise in a stimulating environment. A suspicious,
agitated client may perceive others as threatening.

2. Observe client’s behavior frequently. Do this while carrying out routine activities so as to
avoid creating suspiciousness in the individual. Close observation is required so that
intervention can occur if needed to ensure client’s (and others’) safety.

3. Remove all dangerous objects from client’s environment (sharp objects, glass or mirrored
items, belts, ties, smoking materials) so that in his or her agitated, hyperactive state, client
may not use them to harm self or others.

4. Try to redirect the violent behavior with physical outlets for the client’s hostility (e.g.,
punching bag). Physical exercise is a safe and effective way of relieving pent-up tension.

5. Intervene at the first sign of increased anxiety, agitation, or verbal or behavioral

aggression. Offer empathetic response to client’s feelings: “You seem anxious (or frustrated,
or angry) about this situation. How can I help?” Validation of the client’s feelings conveys a
caring attitude and offering assistance reinforces trust.

6. It is important to maintain a calm attitude toward the client. Respond in a matter-of-fact

manner to verbal hostility. Anxiety is contagious and can be transmitted from staff to client.

7. As the client’s anxiety increases, offer some alternatives: participating in a physical

activity (e.g., punching bag, physical exercise), talking about the situation, taking some
antianxiety medication. Offering alternatives to the client gives him or her a feeling of some
control over the situation.

8. Have sufficient staff available to indicate a show of strength to client if it becomes

necessary. This conveys to the client evidence of control over the situation and provides some
physical security for staff.

9. Administer tranquilizing medications as ordered by physician. Monitor medication for

effectiveness and for adverse side effects.

10. If the client is not calmed by “talking down” or by medication, use of mechanical
restraints may be necessary. The avenue of the “least restrictive alternative” must be selected
when planning interventions for a violent client. Restraints should be used only as a last
resort, after all other interventions have been unsuccessful, and the client is clearly at risk of
harm to self or others.

11. If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow
protocol established by the institution.

12. Client in restraints be observed at least every 15 minutes to ensure that circulation to
extremities is not compromised (check temperature, color, pulses); to assist client with needs
related to nutrition, hydration, and elimination; and to position client so that comfort is
facilitated and aspiration can be prevented.
13. As agitation decreases, assess the client’s readiness for restraint removal or reduction.
Remove one restraint at a time, while assessing client’s response. This procedure minimizes
the risk of injury to client and staff.

■ IMBALANCED NUTRITION, LESS THAN BODY REQUIREMENTS RELATED

TO REFUSAL TO SIT STILL LONG ENOUGH TO EAT MEALS

1. In collaboration with dietitian, determine number of calories required to provide adequate

nutrition for maintenance or realistic (according to body structure and height) weight gain.

2. Provide client with high-protein, high-calorie, nutritious finger foods and drinks that can be
consumed “on the run.” Because of hyperactive state, client has difficulty sitting still long
enough to eat a meal. The likelihood is greater that he or she will consume food and drinks
that can be carried around and eaten with little effort.

3. Have juice and snacks available on the unit at all times. Nutritious intake is required on a
regular basis to compensate for increased caloric requirements due to hyperactivity.

4. Maintain accurate record of intake, output, and calorie count. This information is necessary
to make an accurate nutritional assessment and maintain client’s safety.

5. Weigh client daily. Weight loss or gain is important nutritional assessment information.

6. Determine client’s likes and dislikes, and collaborate with dietitian to provide favorite
foods. Client is more likely to eat foods that he or she particularly enjoys.

7. Administer vitamin and mineral supplements, as ordered by physician, to improve

nutritional state.

8. Pace or walk with client as finger foods are taken. As agitation subsides, sit with client
during meals. Offer support and encouragement. Assess and record amount consumed.
Presence of a trusted individual may provide feeling of security and decrease agitation.
Encouragement and positive reinforcement increase self-esteem and foster repetition of
desired behaviors.

9. Monitor laboratory values, and report significant changes to physician. Laboratory values
provide objective nutritional assessment data.

10. Explain the importance of adequate nutrition and fluid intake. Client may have inadequate
or inaccurate knowledge regarding the contribution of good nutrition to overall wellness.

INSOMNIA RELATED TO HYPER ACTIVITY

1. Provide a quiet environment, with a low level of stimulation. Hyperactivity increases and
ability to achieve sleep and rest are hindered in a stimulating environment.

2. Monitor sleep patterns. Provide structured schedule of activities that includes established
times for naps or rest. Accurate baseline data are important in planning care to help client
with this problem. A structured schedule, including time for naps, will help the hyperactive
client achieve much-needed rest.

3. Assess client’s activity level. Client may ignore or be unaware of feelings of fatigue.
Observe for signs such as increasing restlessness, fine tremors, slurred speech, and puffy,
dark circles under eyes. Client can collapse from exhaustion if hyperactivity is uninterrupted
and rest is not achieved.

4. Before bedtime, provide nursing measures that promote sleep, such as back rub; warm
bath; warm, nonstimulating drinks; soft music; and relaxation exercises.

5. Prohibit intake of caffeinated drinks, such as tea, coffee, and colas. Caffeine is a CNS
stimulant and may interfere with the client’s achievement of rest and sleep.

6. Administer sedative medications, as ordered, to assist client achieve sleep until normal
sleep pattern is restored.

■ IMPAIRED SOCIAL INTERACTION RELATED TO DELUSION OF

GRANDIOSITY

1. Recognize the purpose these behaviors serve for the client: to reduce feelings of insecurity
by increasing feelings of power and control. Understanding the motivation behind the
manipulation may facilitate acceptance of the individual and his or her behavior.

2. Set limits on manipulative behaviors. Explain to client what you expect and what the
consequences are if the limits are violated. Terms of the limitations must be agreed on by all
staff who will be working with the client. Client is unable to establish own limits, so this
must be done for him or her. Unless administration of consequences for violation of limits is
consistent, manipulative behavior will not be eliminated.

3. Do not argue, bargain, or try to reason with the client. Merely state the limits and
expectations. Individuals with mania can be very charming in their efforts to fulfill their own
desires. Confront the client as soon as possible when interactions with others are
manipulative or exploitative. Follow through with established consequences for unacceptable
behavior. Because of the strong id influence on the client’s behavior, he or she should receive
immediate feedback when behavior is unacceptable. Consistency in enforcing the
consequences is essential if positive outcomes are to be achieved. Inconsistency creates
confusion and encourages testing of limits.

4. Provide positive reinforcement for non-manipulative behaviors. Explore feelings, and help
the client seek more appropriate ways of dealing with them. Positive reinforcement enhances
self-esteem and promotes repetition of desirable behaviors.

5. Help the client recognize that he or she must accept the consequences of own behaviors
and refrain from attributing them to others. Client must accept responsibility for own
behaviors before adaptive change can occur.
6. Help the client identify positive aspects about self, recognize accomplishments, and feel
good about them. As self-esteem is increased, client will feel less need to manipulate others
for own gratification.

IN CASE OF MANIA WITH PSYCHOTIC SYMPTOMS

DISTURBED THOUGHT PROCESS AND DISTURBED PERCEPTION

Nursing interventions will be same as schizophrenia for both these nursing diagnosis