What is a mood disorder?

 Biochemical hypothesis of manic episode is

related to the excessive levels of serotonin,
Affect (objective appearance of mood) which is a short- norepinephrine and dopamine.
lived emotional response to an idea or an event

Mood (person's subjective emotional state) which is a Psychodynamic Theories

sustained and pervasive emotional response which colors  This includes faulty family dynamics during the
the whole psychic life. early years of life and as a defense against denial
of depression.
Mood Disorders/Affective Disorder
Brain Diseases
 Mood disorders are characterized by a Elderly people with mania have found a significant
disturbance of mood, accompanied by a full or association between brain disease and mania.
partial manic or depressive syndrome, which is  Cerebrovascular disease
not due to any other physical or mental disorder.  chronic alcohol misuse
 The prevalence of mood disorders is 1.5% and it
 head injury
is uniform through out the world.
 right-sided lesions may contribute to manic
 The mood change is usually accompanied by a
 disorders.
change in the overall level of activity.

Contd.........

Most of these disorders tend to be recurrent, and the

onset of individual episodes is often related to stressful Types of Mania
events or situations.  F30 Manic episode
 F30.0 Hypomania
The mood disorders may be subdivided into unipolar and
 F30.1 Mania without psychotic symptoms
bipolar types:
 F30.2 Mania with psychotic symptoms
1. those that are characterized by depression only
 F30.80ther manic episodes
2. those that are characterized by manic
 F30.9 Manic episode, unspecified
episode either alone or in combination with depression

Hypomania
Manic Episode
 Lesser degree of mania
Mania is a mood disorder characterized by elevation of
mood, increased psychomotor activity, self-important  Mild elevation of mood for at least several
ideas. days
 Increased activity & energy
 Not disturb the social & occupational life over
 Increased sociability, talkativeness, familiarity,
increased sexual energy, and a decreased need
for sleep are often present.
 There are no hallucinations or delusions.

Mania Without Psychotic Features

 Symptoms are severe, Disturbance in social &
occupational life
 last for at least 1 weak, elation is accompanied
ggg by increased energy, resulting in over activity,
pressure of speech, and a decreased need for
sleep
 normal social inhibition are lost, attention
cannot be sustained, and there is often marked
Incidence distractibility
 The life-time risk of manic episode is about 0.8-  self-esteem is inflated, and grandiose or over-
1%. optimistic ideas are freely expressed
 This disorder tends to occur in episodes lasting  the individual may embark on extravagant and
usually 3-4 months, followed by complete clinical impractical schemes, spend money recklessly, or
recovery. become aggressive, amorous, or factious in
 The future episodes episode can be manic, inappropriate circumstances.
depressive or mixed.  More severe form
 Psychotic features like hallucination and delusion
Etiology may develop
Genetic Factors  Disturbs social and occupational life
 Affective disorders are known to have a marked  Inflated self-esteem and grandiose ideas may
genetic predisposition. develop into delusions, and irritability and
 Studies of first-degree relatives of elderly manic suspiciousness into delusions of persecution
patients have found a quarter to a half are  Sustained physical activity and excitement may
affected. result in aggression or violence, and neglect of
 Monozygotic twins have a higher degree of eating, drinking, and personal hygiene may result
chance than dizygotic. in dangerous states of dehydration and self
 5-10% chance in first degree relatives. 40-70% neglect
chance in identical twins.
Clinical Features
Biochemical Factors Elevated, Expansive or Irritable Mood
The elevated mood can pass through following four stages;
  Euphoria: mild elevation of mood), an increased  Risk for violence self directed or other directed
sense of psychological well-being and happiness. R/T manic excitement, delusional thinking,
This is usually seen in hypomania (Stage 1). hallucinations.
 Elation: moderate elevation of mood with an  Imbalanced nutrition less than body requirement
increased psychomotor activity. Elation is R/T refusal or inability to sit long enough to eat.
classically seen in mania (Stage II).  Impaired social interaction R/T egocentric and
 Exaltation, severe elevation of mood, with narcissistic behavior.
delusions of grandeur; seen in severe mania
(Stage III).
 Ecstasy: very severe elevation of mood, intense
sense of rapture or blissfulness; typically seen in
delirious or stuporous mania (Stage IV).

Contd........
Psychomotor Activity
There is an over activity with excessive energy
 Restlessness,
 Manic excitement where the person is 'on-the-
toe-on-the-go', (i.e involved in ceaseless
activity).
 Rarely, a manic patient can go in to a stuporous
state (manic stupor).

Speech and Thought

 The person is more talkative than usual
 Develops pressure of speech; uses playful
language with punning, rhyming, joking and
teasing
 Speaks loudly.
 Flight of ideas develops.
 Distractibility
 Delusions of grandeur
 Delusions of persecution may sometimes
develop.
 Hallucinations often with religious content, can
occur
 Since these psychotic symptoms are in keeping
with the elevated mood state, these are called
mood congruent psychotic features.
 Decreased need for sleep.
 Increased libido (may lead to sexual
 indiscretions).
 Unusually alert
 Increased social communication
 Poor judgment
 Insight is absent
 Decreased food intake
 Suicidal ideas in BMD

Diagnosis
 Psychiatric History Collection
 Mental Status Examination
 Mania rating scales eg. Young mania Rating Scale

The Young Mania Rating Scale (YMRS) is one of the most

frequently utilized rating scales to assess manic symptoms.
The scale has 11 items and is based on the patient's
subjective report of his or her clinical condition over the
previous 48 hours.

Management
Hospitalization
Psychopharmacology
 Lithium -900-2100mg/day
 Carbamazepine-600-1800/day
 Sodium valproate-600-2600mg/day
 Others- calcium channel blockers, Clonazepam,
etc
Electro Convulsive Therapy

Nursing Diagnosis
 Risk for injury R/T extreme hyper activity. DEPRESSION
Depression
 The common cold of psychological
disorders.
 It is a widespread psychiatric problem
affecting many people.
 It is characterized by depressed mood or
loss of interest or pleasure in usual
activities.
Epidemiology
 Lifetime risk in males 8-12% & in females
20-26%.
 Lifetime prevalence is in the range of 15 -
25 %.
 The mean age of onset is about 40 years (25
- 50 years).
 It may occur in childhood or in the elderly.
 It occurs twice as frequently in women as in
men.
 It is commonly associated with a variety of
medical conditions
Types of Depression
 F32.0: Mild depressive episode.
 F32.1: Moderate Depressive episode
 F32.2: Severe depressive episode without
psychotic symptoms
 F32.3: Severe depressive episode with
psychotic symptoms
 F32.8: Other depressive episodes
 F32.9: Depressive episodes, unspecified
 F33: Recurrent Depression disorder.
Etiology
Biological Theories
Genetics:
 Twin studies suggest that about 50 percent
of monozygotic twins and 10-25 % of
dizygotic twins are at risk of mood
disorders.
 Major depression is 1.5 to 3 times more
common among first degree relatives of
people with mood disorder than general
population.
 Biochemical: Depressive illness may be
related to a deficiency of the
neurotransmitters; norepinephrine,
serotonin, and dopamine.
 Brain Imaging: Neuroimaging studies (CT,
MRI) shows include ventricular dilatation,
white matter hyper- intensities, and
changes in the blood flow and metabolism
in several parts of brain.
 Psychoanalytical theory: Sigmund Freud
observed that melancholia occurs after the
loss of a loved object.
 Object Loss Theory: This theory suggests
that depressive illness occurs as a result of
having been abandoned by or otherwise
separated from a significant other during
the first 6 months of life.
 Stress: Increased number of stressful life events
have a precipitating effect in depression .
 Medications: Certain medications used alone or
in combination can cause side effects much like
the symptoms of depression. Examples of these
include antipsychotics.
 the anxiolytics, and sedative hypnotics.
 Neurological Disorders
 Nutritional Deficiencies
 Major Illnesses
Clinical Features
Depressed Mood
 Sadness of mood or loss of interest and/or
pleasure in almost all activities
 Present throughout the day (persistent sadness).
Other features related to mood include:
 Anhedonia
 Irritability.
 Frustration.
 Tension.
Depressive Ideation/Cognition
 Pessimism, which can result in following ideas:
 Present: patient sees the unhappy side of every
event.
 Past: unjustifiable guilt feeling and self- blame.
 Future: gloomy preoccupations; hopelessness,
helplessness, death wishes (may progress to
suicidal ideation and attempt).
Psychomotor Activity
In younger patients psychomotor retardation is more
common and is characterized by
 Slowed thinking and activity ☐Decreased
energy
 Monotonous voice.
 In a severe form, the patient can become
stuporous (depressive stupor).
In the older patients (e.g. post-menopausal women),
agitation is commoner.
■It often presents with marked anxiety, restlessness
Subjective feeling of unease.
■ Anxiety is a frequent accompaniment of
depression.
Psychotic Features
☐ About 15-20% of depressed patients have
psychotic symptoms such as delusions, hallucinations.
■ Delusions
 Delusion of guilt
 Nihilistic delusion
 Delusion of poverty and impoverishment.
 Persecutory delusion
Hallucinations:
 Usually second person auditory
hallucinations
 Visual hallucinations (scenes of death and
destruction) may be experienced by a few
patients.
Appearance & Behaviour
  Neglected dress and grooming.
 Facial appearance of sadness
 Psychomotor retardation (sometimes agitation).
 Lack of motivation and irritation.
 Social isolation and withdrawal.
 Delay of tasks and decisions.
 Loss of interest in work and pleasure activities.

Diagnosis
 Detailed Psychiatric history
 Mental Status Examination
 History of medication uses, neurological
disorders etc.
 Psychological tests like depression scale

Management
Hospitalization is necessary for the client with depression
and is indicated for:
 Suicidal or homicidal patient.
 Patient with severe psychomotor retardation
who is not eating or drinking.
 Diagnostic purpose (observation, investigation).
 Drug resistant cases.
 Severe depression with psychotic features.

Psychopharmacology
BIPOLAR DISORDERS
Antidepressants
Bipolar Disorders
 Tricyclics (TCA) / Mono-amino oxidase inhibitors
 This disorder, earlier known as manic depressive
(MAOI), Selective serotonin reuptake inhibitors
psychosis (MDP), is characterized by recurrent
(SSRIs).
episodes of mania and depression in the same
 After a first episode of a unipolar major
patient at different times.
depression, treatment should be continued for
 People with MDP changes back and forth
six months after clinical recovery, to reduce the
between periods of depression and mania.
rate of relapse.
 Lithium Carbonate can be used as prophylaxis.
Epidemiology
■ Antipsychotics are an important adjunct in the
 The lifetime prevalence is between 0.5 and 1%.
treatment of mood disorder.
 Suicidality is about 19%.
■The commonly used drugs include risperidone,
 Comorbidity increases with alcohol and drug
olanzapine, quetiapine, haloperidol.
abuse.
 The first episode may occur at any age from
Psychosocial Therapies
childhood to old age.
 Cognitive Behavioral Therapy
 Interpersonal therapy
 Psychoanalytic psychotherapy
 Behavior therapy
 Group therapy
 Family & Marital therapy

Types
 F31.0: Bipolar disorder current episode
hypomania
 F31.1: Bipolar disorder current episode mania
without psychotic symptoms
 F31.2: Bipolar disorder current episode Manic
with psychotic symptoms
 F31.3: Bipolar disorder current episode Mild or
moderate depression
 F31.4: Bipolar disorder current episode severe
depression, without psychotic symptoms
 F31.5: Bipolar disorder current episode severe
depression, with psychotic symptoms,
 F31.6: Mixed, or in remission.

Bipolar mood disorder is classified in to;
 Bipolar I It is characterized by episode of severe
mania and severe depression.
 Bipolar II - It is characterized by hypomania and
severe depression.
Etiology
 Exact cause is unknown
 Genetic, biochemical and psychosocial causes
may have a role
 Stressful life events
 Sleep deprivation and endocrine factors
Treatment
 Lithium
 Valproic acid
 Carbamazepine
 Antidepressants
 Antipsychotics.
Rapid Cycling Bipolar Disorder
 This is characterized by alternating episodes (4)
or more) of depression, mania or hypomania in
the previous 12 months, separated by intervals
of 48-72 hours.
 It is usually more chronic than non-rapid cycling
disorders.
 Around 80 % are lithium-treatment failures.
 Carbamazepine or sodium valproate is usual
agents of choice.
RECURRENT DEPRESSIVE DISORDER
 This disorder is characterized by recurrent (at
least two) depressive episodes (unipolar
depression).
 The current episode may be mild, moderate,
severe without psychotic symptoms, OT severe
with psychotic symptoms.
PERSISTENT MOOD DISORDER
 These disorders are characterized by persistent
mood symptoms which last for more than 2
years (1 year in children and adolescents).
 If the symptoms consist of persistent mild
depression, the disorder is called as dysthymia.
 If symptoms consist of persistent instability of
mood between mild depression and mild elation,
the disorder is called as cyclothymia.
Dysthymia
It was also called "depressive neurosis/neurotic
depression/exogenous depression"
■In this a mild depression that lasts for at least 2 years in
adult and 1 year in children.
■It is twice common in women as in men
■Dysthymia is characterized by the following:
 Presence of mild to moderate depression.
 Depressive symptoms usually occur in response
to a stressful situation.
 Other 'neurotic' symptoms such as anxiety,
obsessive symptoms, phobic symptoms, and
multiple somatic symptoms, are often present.
The typical course of neurotic depression is
chronic, with fluctuations.
 Delusions, hallucinations and other psychotic
features are characteristically absent.
Treatment
 Short term psychotherapy
 Behavioral therapy
 Group therapy
 Antidepressants such as SSRI, TCA etc.
Cyclothymia
 Less severe bipolar mood disorder with
continuous mood swings; alternating periods of
hypomania and moderate depression.
 It is non-psychotic chronic disorder.
 It starts in late adolescence or early adulthood.
 The treatment is similar to that of bipolar mood
disorder.
Other Mood Disorder
Melancholia
Described by Kraeplin, this is a form of severe depression
which occurs in the involutional period of life (i.e. 40-65
years of age).
It is characterized by marked agitation, presence of
psychotic features
 such as delusions of persecution
 tactile and auditory hallucinations
 multiple somatic symptoms
Masked Depression
In masked depression, the depressive mood is not easily
apparent and is usually hidden by somatic symptoms.
This is especially common in the elderly
The somatic symptoms range from;
 chronic pain Insomnia
 Atypical facial pain
 paraesthesia.
 The depressive symptoms can also be masked by
drug
 and/or alcohol misuse.
Double Depression
 This is a major depressive episode superimposed
on an underlying dysthymia or neurotic
depression.
 The response to treatment is usually poor.
Agitated Depression
 This is a type of severe depression with marked
motor restlessness or agitation.
 It is either seen alone or along with involutional
melancholia.
 It is more common after the age of 40 years.
Secondary Depression and Secondary Mania
 Both depressive and manic episodes can occur
secondary to certain physical diseases and drugs.
Substance-induced mood disorder
 Characterized by prominent and persistent
disturbance in mood that is judged to be a direct
 physiological consequence of a drug abuse, toxin
exposure, or a medication.

Mixed Anxiety Depressive Disorder

 This disorder is characterized by the presence of
depressive and anxiety symptoms.
 The symptoms should not meet the criteria of
either an anxiety disorder or a mood disorder.

Seasonal Mood Disorder

 This is either a bipolar mood disorder or
recurrent depressive episode which tends to
occur in the same season on each occasio
 It is usually more commonly seen in women.
 For example the depression begins in the fall or
winter, or when there is a decrease in sunlight.
 Mania would occur in the month of summer.
 Seasonal affective disorder is characterized by
atypical features of depression, hypersomnia,
hyperphagia, weight gain, and increased fatigue.
 This is related to abnormal melatonin
metabolism.
 It can be treated with exposure to light (artificial
light for 2 6 hours a day).
 It may occur as part of bipolar I or II disorders.