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MOOD DISORDERS Psychological theories
 are disturbances in the regulation of mood,
behavior, and affect that go beyond the
normal fluctuations that most people
experience
MOOD AND AFFECT
 mood - refers to a pervading feeling; a person
with mood disorder, mood becomes so
intense and persistent that it interferes with
social and psychological functioning
 affect - outward expression of emotion
attached to ideas including but not limited to
facial expression and vocal modulation;
patients with mood disorders may exhibit
various abnormalities in affect, such as:
1. blunted affect - severe reduction in the
intensity of outward emotional expression
2. flat affect - complete or almost complete
absence of outward expressional
expression
3. restricted affect - reduction in the
intensity of outward emotional expression
4. inappropriate affect - affect that doesn't
match the situation or the content of the
verbalized message (for instance, laughter
when describing a loved one's death)
5. labile affect - rapid and easily changing
affective expression, unrelated to external
events or stimuli
CAUSES
 center on genetic, biological, and
psychological factors
Genetic factors
 appear to play a major role in mood disorders;
major depressive disorder and bipolar
disorders occur much more often in first-
degree relatives than in the general
population
Biological factors
 focuses on deficiencies or abnormalities in the
brain's chemical messengers which are the
neurotransmitters such as norepinephrine,
serotonin, dopamine, and acetylcholine
 cognitive, behavioral, and psychoanalytic
theories offer explanations for mood
disorders:
1. cognitive theory - suggests that people
who suffer from depression process
information in a characteristically negative
way (they view themselves and the world
in a negative light and believe these
negative perceptions will continue in the
future)
2. behavioral theory - according to the
learned helplessness theory. people may
become depressed after a negative event,
such as a loved one's death or loss of a
job, if the event makes them feel helpless
(the perceived lack of control over life
events dampens motivation, self-esteem,
and initiative; lack of social support and
ineffective stress-management and
problem-solving skills increase the risk of
depression after stressful events)
3. psychoanalytic theory - depression results
from a harsh superego (the "conscience"
of the unconscious mind) and feelings of
loss and aggression
BIPOLAR DISORDERS
 also called manic-depressive disorders
 are mood disorders marked by severe,
pathologic mood swings
 patient experiences extreme highs (mania or
hypomania) alternating with extreme lows
(depression)
MANIA AND HYPOMANIA
 the highs of bipolar disorder may involve
either mania or hypomania
 mania is characterized by:
1. elation
2. euphoria
3. agitation or irritability
4. hyperexcitability
5. hyperactivity
6. rapid thought and speech
7. exaggerated sexuality
8. decreased sleep
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PSYCHOTIC SYMPTOMS
 hallucinations (hearing, seeing, touching,
smelling, or tasting things that aren't actually
there)
 delusions (false beliefs not influenced by
logical reasoning or explained by a person's
usual cultural concepts)
CLASSIFICATION
1. Bipolar I disorder
 the classic and most severe disease
form
 patient has manic episodes or mixed
episodes (with symptoms of both
mania and depression) that alternate
with major depressive episodes;
depressive phase may immediately
precede or follow a manic phase, or it
may be separated from the manic
phase by months or years
2. Bipolar II disorder
 patient doesn't experience severe
mania but instead has milder episodes
of hypomania that alternate with
depressive episodes
3. Cyclothymic disorder
 patient has a history of numerous
hypomanic episodes intermingled
with numerous depressive episodes
that don't meet the criteria for major
depressive episodes
CAUSES
 precise cause of bipolar disorder isn't known,
however, genetic, biochemical, and
psychological factors probably play a role
SIGNS AND SYMPTOMS
During the manic phase
 expansive, grandiose, or hyperirritable mood
 increased psychomotor activity, such as
agitation, pacing, or hand-wringing
 excessive social extroversion
 short attention span
 rapid speech with frequent topic changes
(flight of ideas)
 decreased need for sleep and food
 impulsivity
 impaired judgment
 easy distractibility
 rapid response to external stimuli, such as
background noise or a ringing telephone
During the depressive phase
 low self-esteem
 overwhelming inertia
 social withdrawal
 feelings of hopelessness, apathy, or self-
reproach
 difficulty concentrating or thinking clearly
(without obvious disorientation or intellectual
impairment)
TREATMENT
 drug therapy
 lithium - highly effective in both preventing
and relieving manic episodes and may prevent
the recurrence of depressive episodes
(although it's ineffective in treating acute
depression)
OTHER DRUGS
 Valproic acid (Depakote) - for rapid cyclers or
for patients who can’t tolerate lithium
 Carbamazepine (Tegretol) - useful in treating
mania, although it isn’t approved by FDA for
bipolar disorder
DIAGNOSTIC CRITERIA
For a manic episode
 The patient experiences a distinct period of
abnormally and persistently elevated,
expansive, or irritable mood that lasts at least
1 week (or, if hospitalization is needed, for any
duration)
 During the mood disturbance period, at least
three of these symptoms persist (four, if the
mood is only irritable) and are present to a
significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep
3. increased talkativeness
4. flight of ideas or a subjective experience
that thoughts are racing
5. distractibility
6. increased goal-directed activity or
psychomotor agitation
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7. excessive involvement in pleasurable
activities with a high potential for painful
consequences
 Symptoms don't meet the criteria for a mixed
episode.
 The mood disturbance is severe enough to
cause any of these results:
1. marked impairment in occupational
functioning or in usual social activities or
relationships
2. hospitalization to prevent harm to self or
others
3. evidence of psychotic features
 Symptoms don't result from the direct
physiologic effects of a substance or a general
medical condition.
For a hypomanic episode
 The patient experiences a distinct period of
abnormally and persistently elevated,
expansive, or irritable mood lasting at least 4
days. The mood is clearly different from the
usual non-depressed mood.
 During the mood disturbance period, at least
three of these symptoms persist (four, if the
mood is only irritable) and are present to a
significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep
3. increased talkativeness
4. flight of ideas or a subjective experience
that thoughts are racing
5. distractibility
6. increased goal-directed activity or
psychomotor agitation
7. excessive involvement in pleasurable
activities that have a high potential for
painful consequences
 The episode is associated with an unequivocal
change in functioning not seen during
asymptomatic periods.
 Others can recognize the mood disturbance
and the change in functioning.
 The episode isn't severe enough to markedly
impair social or occupational functioning or to
necessitate hospitalization to prevent harm to
self or others. Also, no psychotic features ap-
pear.
 Symptoms don't result from the direct
physiologic effects of a substance or a general
medical condition
For bipolar 1 disorder, single manic episode
 The patient experiences only one manic
episode and has had no past major depressive
episodes.
 The manic episode isn't better explained by
schizoaffective disorder and isn't
superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise
specified.
For bipolar 1 disorder, most recent episode hypomanic
 The patient is currently experiencing or most
recently experienced a hypomanic episode.
 He previously had at least one manic episode
or mixed episode.
 Mood symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
 The first two exacerbations of the mood
episode described previously aren't better
explained by schizoaffective disorder and
aren't superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise
specified.
For bipolar I disorder, most recent episode manic
 The patient is currently experiencing or most
recently experienced a manic episode.
 He previously had at least one major
depressive episode, manic episode, or mixed
episode.
 The first two exacerbations of the mood
episode described previously aren’t better
explained by schizoaffective disorder and
aren't superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise
specified.
For bipolar I disorder, most recent episode mixed
 The patient is currently experiencing or most
recently experienced a mixed episode.
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 He previously had at least one major
depressive episode, manic episode, or mixed
episode.
 The first two exacerbations of the mood
episode described previously aren't better
explained by schizoaffective disorder and
aren't superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise
specified.
For bipolar I disorder, most recent episode depressed
 The patient is currently experiencing or most
recently experienced a major depressive
episode.
 He previously had at least one manic episode
or mixed episode.
 The first two exacerbations of the mood
episode described previously aren't better
explained by schizoaffective disorder and
aren't superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise
specified.
For bipolar I disorder, most recent episode unspecified
 Except for duration, the patient meets or most
recently met the criteria for a manic,
hypomanic, mixed, or major depression
episode.
 He previously had at least one manic episode
or mixed episode.
 Mood symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
 The first two exacerbations of the mood
episode describe previously aren't better
explained by schizoaffective disorder and
aren't superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise
specified.
 The first two exacerbations of the mood
episode didn't from the direct physiologic
effects of a substance or a gene: medical
condition.
For bipolar Il disorder
 The patient currently has, or his history
includes, one or ma major depressive
episodes.
 He currently has, or his history includes, at
least one hypo manic episode.
 He has never had a manic or a mixed episode.
 The first two exacerbations of the mood
episode described previously aren't better
explained by schizoaffective disorder and
aren't superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise
specified.
 Symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
NURSING INTERVENTIONS
During a manic episode
 Provide for the patient's physical needs.
Involve him in activities that require gross
motor movements.
 Encourage him to eat. He may jump up and
walk around the room after every mouthful
but will sit down again if you remind him. If he
can't sit still long enough to finish a meal, offer
high-calorie finger foods, sandwiches, and
cheese and crackers to supplement his diet.
 Suggest short daytime naps, and help with
personal hygiene. As symptoms subside,
encourage him to assume responsibility for
personal care.
 Provide diversionary activities suited to a
short attention span.
 Firmly discourage the patient if he tries to
overextend himself.
During a depressive episode
 Provide for the patient's physical needs. If he's
too depressed to care for himself, help with
personal hygiene.
 Encourage him to eat, or feed him if
necessary. If he's constipated, add high-fiber
foods to his diet; offer small, frequent meals;
and encourage physical activity.
 To help the patient sleep, give back rubs or
warm milk at bed-time.
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CYCLOTHYMIC DISORDER DIAGNOSIS

 short periods of mild depression alternate  medical disorders that can mimic cyclothymia
with short periods of hypomania include:
 between the depressive and manic episodes, 1. acquired immunodeficiency syndrome
brief periods of normal mood occur 2. Cushing's disease
 person never goes more than 2 months 3. epilepsy
without symptoms of depression or 4. Huntington's disease
hypomania 5. hyperthyroidism
6. premenstrual syndrome
SIGNS AND SYMPTOMS 7. migraines
 an odd, eccentric, or suspicious personality 8. multiple sclerosis
 dramatic, erratic, or antisocial personality 9. neoplasm
features 10. postpartum depression
 inability to maintain enthusiasm for new 11. stroke
projects 12. systemic lupus erythematosus
 a pattern of pulling close and then pushing 13. trauma
away in interpersonal relationships 14. uremia
 abrupt changes in personality from cheerful, 15. vitamin deficiency
confident, and energetic to sad, blue, or mean 16. Wilson's disease

During the hypomanic phase DIAGNOSTIC CRITERIA

 insomnia  For at least 2 years, the patient experiences

numerous periods with hypomanic symptoms
 hyperactivity
as well as numerous periods with depressive
 inflated self-esteem
symptoms that don't meet the criteria for a
 increased productivity and creativity
major depressive episode.
 over-involvement in pleasurable activities,
 During this 2-year period, the patient hasn't
including sex
been without the previously described
 physical restlessness
symptoms for more than 2 months at a time.
 rapid speech
 No major depressive, manic, or mixed episode
During the depressive phase occurred during the first 2 years of the
disturbance. (After the first 2 years of cy-
 insomnia or hypersomnia
cyclothymic disorder, superimposed manic or
 feelings of inadequacy mixed episodes may occur, in this case, both
 decreased productivity bipolar I disorder and cyclothymic disorder
 social withdrawal may be diagnosed. If superimposed major
 loss of libido depressive episodes also occur, both bipolar Il
 loss of interest in pleasurable activities disorder and cyclothymic disorder may be
 lethargy diagnosed).
 depressed speech  Symptoms aren't better explained by
 crying schizoaffective disorder and aren't
CAUSES superimposed on schizophrenia,
schizophreniform dis-order, delusional
 genetic factors influence the development of disorder, or psychotic disorder.
cyclothymic disorder  Symptoms don't result from the direct
 many patients have a family history of bipolar physiologic effects of a substance or a general
disorder, major depression, substance abuse, medical condition.
or suicide  Symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
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NURSING INTERVENTIONS
 Explore ways to help the patient cope with
frequent mood changes.
 Encourage vocational opportunities that allow
flexible work hours.
 Urge a patient with artistic ability to pursue a
career in the arts, where mood changes may
be better tolerated.
MAJOR DEPRESSIVE DISORDER
 also called unipolar major depression
 is a syndrome of a persistent sad mood lasting
2 weeks or longer
 feeling of sadness is accompanied by:
1. feelings of guilt, helplessness, or
hopelessness
2. poor concentration
3. sleep disturbances
4. lethargy
5. appetite loss
6. anhedonia (inability to feel pleasure)
7. loss of mood reactivity (failure to feel a
mood uplift in response to something
positive
8. thoughts of death
CAUSES
 genetic, biochemical, physical, psychological,
and social factors have been implicated in
major depression
 patient history often reveals a specific
personal loss or severe stress where according
to one theory, the stressor interacts with the
person's predisposition to provoke major
depression
SIGNS AND SYMPTOMS
 feeling "down in the dumps"
 increased or decreased appetite
 sleep disturbances (for example, insomnia or
early awakening)
 disinterest in sex
 difficulty concentrating or thinking clearly
 easy distractibility
 indecisiveness
 low self-esteem
 poor coping
 constipation or diarrhea
 patient may report that symptoms are worse
in the morning
 during the physical examination, you may note
agitation (such as hand wringing or
restlessness) or psychomotor retardation
(slow movements)
 with severe depression, the patient may have
delusions of persecution or guilt, which can
have an immobilizing effect
DIAGNOSIS
 Beck Depression Inventory - to determine
symptom onset, severity, duration, and
progression
 Dexamethasone suppression test - may show
failure to suppress cortisol secretion in
depressed patients (although this test has a
high false-negative rate)
 Toxicology screening - may suggest drug-
induced depression
 diagnosis is confirmed if the patient meets the
criteria in the DSM-IV-TR
DIAGNOSTIC CRITERIA
 At least five of those symptoms are present
nearly every day during the same 2-week
period, and represent a change from the
patients previous functioning. One symptom
must either depressed mood or loss of
interest in previously pleasurable activities:
• depressed mood most of the day, as
indicated by either sub-jactive account or
others' observation
• markedly diminished interest or pleasure in
all, or almost all, activities, most of the day
• significant weight loss or gain when not
dieting, or a decrease or increase in appetite
(in children, consider failure to make expected
weight gains)
• insomnia or hypersomnia
• psychomotor agitation or retardation
• fatigue or loss of energy
• feelings of worthlessness or excessive or
inappropriate quit
• diminished ability to think or concentrate, or
indecisiveness
• recurrent thoughts of death, recurrent
suicidal ideation with no specific plan, a
suicide attempt, or a specific plan for
committing suicide
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• symptoms don't meet the criteria for a
mixed episode
• symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning
• symptoms don't result from the direct
physiologic effects of a substance or a general
medical condition
• symptoms aren't better explained by
bereavement, they last longer than 2 months,
or they're characterized by marked functional
impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation
TREATMENT
Selective serotonin reuptake inhibitors (SSRI)
 Citalopram (Celexa), Fluoxetine (Prozac),
Fluvoxamine (Luvox), Paroxetine (Paxil), and
Sertraline (Zoloft)
 these agents inhibit serotonin reuptake and
may inhibit the reuptake of other
neurotransmitters as well
 become the first-choice treatment for most
patients
Serotonin/norepinephrine reuptake inhibitors (SNRI)
 Venlafaxine (Effexor)
 used as second-line agents for patients with
major depressive disorder
Atypical antidepressants
 Bupropion (Wellbutrin), Nefazodone
(Serzone), Trazodone (Desyrel), and
Mirtazapine (Remeron)
 Buproprion is thought to inhibit reuptake of
serotonin, nor-epinephrine, and dopamine to
varying degrees
 Nefadazone and trazadone inhibit serotonin
and norepinephrine reuptake
 Mirtazapine is thought to inhibit serotonin
and norepinephrine reuptake while blocking
two specific serotonin receptors
 are used as second-line agents
Tricyclic antidepressants (TCA)
 Amitriptyline (Elavil), Amoxapine (Asendin),
Clomipramine (Anafranil), Desipramine
(Norpramin), Doxepin (Sinequan), Imipramine
(Tofranil), Nortriptyline (Pamelor), and
Trimipramine (Surmontil)
 inhibit the reuptake of norepinephrine,
serotonin, and dopamine and cause a gradual
decline in beta-adrenergic receptors
 aren't used as first-line agents
Monoamine oxidase inhibitors (MAOI)
 Phenelzine (Nardil) and Tranylcypromine (Par-
nate)
 increase norepinephrine, serotonin, and
dopamine levels by inhibiting MAO, an
enzyme that inactivates them
 may be prescribed for patients with atypical
depression (for example, depression marked
by an increased appetite and increased sleep,
rather than anorexia and insomnia) or for
patients who don't respond to TCAs
 rarely used today - although conservative
doses may be combined with a TCA for
patient’s refractory to either type of drug
alone
Other antidepressants
 Mirtazapine (Remeron) and Nefazodone
(Serzone)
 used as second-line agents
Electroconvulsive therapy
 a tiny electrical current is applied to the
patient's brain through electrodes wherein
current produces a seizure lasting from 30
seconds to 1 minute
NURSING INTERVENTIONS
 Provide for the patient's physical needs. If he's
too depressed to perform self-care, help him
with personal hygiene. Encourage him to eat,
or feed him if necessary. If he's constipated,
add high-fiber foods to his diet; offer small,
frequent meals; and encourage physical
activity and fluid intake. Give him warm milk
or back rubs at bedtime to improve sleep.
 Record all observations and conversations
with the patient. They're valuable in
evaluating his response to treatment.
 Plan activities for times when the patient's
energy level peaks.
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DSTHYMIC DISORDER/DYSTHYMIA
 refers to mild depression that lasts at least 2
years in adults or 1 year in children
 depression is relatively mild or moderate, and
most patients aren't certain when they first
became depressed
CAUSES
 Biological, psychological, and medical factors
may play a role in dysthymic disorder. Many
dysthymic patients have below-normal
serotonin levels, so it's likely that serotonin is
involved in development of this disorder.
 As with many other psychiatric disorders,
personality problems and multiple stressors,
combined with inadequate coping skills, may
increase a person's vulnerability to this
disorder.
SIGNS AND SYMPTOMS
 persistent sad, anxious, or empty mood
 loss of interest in activities previously enjoyed
 excessive crying
 increased feelings of guilt, helplessness, or
hopelessness
 weight or appetite changes
 sleep difficulties
 poor school or work performance
 social withdrawal
 conflicts with family and friends
 increased restlessness and irritability
 poor concentration
 inability to make decisions
 reduced energy level
 thoughts of death or suicide, or suicide
attempts
 physical symptoms, such as headache or
backache
DIAGNOSIS
 patient may be diagnosed with dysthymic
disorder after a careful psychiatric
examination and medical history are
performed by a psychiatrist or other mental
health professional
 diagnosis is confirmed if the patient meets the
criteria in the DSM-IV-TR
DIAGNOSTIC CRITERIA
 During the period of depression, at least two
of these symptoms are present:
• poor appetite or overeating
• difficulty sleeping or increased need for
sleep
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making
decisions
• feelings of hopelessness
• During the 2-year period, the patient has
never been without depression or the
previously described symptoms for more than
2 months at a time.
• The patient didn't experience major
depressive disorder during the first 2 years of
the disturbance. Or, if major depressive
disorder did occur, he had a full remission
(with no significant signs or symptoms for 2
months) before dysthymic disorder
developed.
• The patient has never had a manic,
hypomanic, or mixed episode and has never
met the criteria for cyclothymic disorder.
• The disorder doesn't occur within the course
of a chronic psychotic disorder, such as
schizophrenia.
• Symptoms don't stem directly from
substance abuse, other medication use, or a
general medical condition (such as
hypothyroidism).
• Symptoms cause multiple functional
impairments, such as impaired social and
occupational functioning.
TREATMENT
 Short-term psychotherapy - teaches the
patient more constructive ways of
communicating with family, friends, and
coworkers and it also allows ongoing
assessment of suicidal ideation and suicide
risk
 Behavioral therapy - may be used to
reeducate the patient in social skills and help
him make attitude changes
 Group therapy - can help him change
maladaptive social functioning
 Pharmacologic treatment - may involve
antidepressants, such as SSRIs or TCAs
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NURSING INTERVENTIONS

 Provide supportive measures, such as

reassurance, warmth, availability, and
acceptance — even if the patient becomes
hostile.
 Teach the patient about the illness and
prescribed antidepressant medication.
 Urge him to engage in activities that enhance
his sense of accomplishment.
 Encourage positive health habits, such as
eating well-balanced meals, avoiding drugs
and alcohol (which can worsen depression),
and getting physical exercise (which can lift his
mood).