Mood Disorders

Mood Disorders
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Characterized by a disregulation of emotion Persons with mood d/os demonstrate a wide range of emotions, from intense elation or irritability to severe depression Characterized by a constellation of sx including:
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Impaired cognition Physiologic disturbances Lowered self-esteem Impairment in social and occupational functioning

Etiology of Mood D/os

Neurobiologic Factors
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Altered neurotransmission Neuroendocrine dysregulation Genetic transmission

Neurobiologic Factors—Altered Neurotransmission

It is believed that the monoamine NT systems, especially those of NE and 5-HT, their metabolites, and their receptors are somehow altered during episodes of depression and mania

Proposed that there is an overactivity of neurotransmission in mania and an underactivity in depression

Neurobiologic Factors—Altered Neurotransmission (cont)

Kindling

Neurotransmission is initially altered by stress, resulting in a first episode of depression This initial episode creates an electrophysiologic sensitivity to future stress, requiring less stress to evoke another depressive or manic episode Creates long lasting alterations in neuronal functioning

Neurobiologic Factors—Altered Neurotransmission (cont)

PET (positron emission tomography) scans

Indicate a decreased blood flow and decreased activity in the frontal areas of the brain in depressed patients

Neurobiologic Factors— Neuroendocrine Dysregulation
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Dysregulation of the HPA axis is associated with depression The HPA axis controls the physiologic responses to stress
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In response to stress, the hypothalamus releases CRH This stimulates the anterior pituitary to secrete corticotropin Corticotropin then causes the adrenal cortex to release cortisol into the blood

Neurobiologic Factors— Neuroendocrine Dysregulation

Hyperactivity of the HPA axis is often evident in depression

Up to 50% of clients with moderate to severe depression exhibit elevated serum cortisol levels This led to the creation of the dexamethasone suppression test (DST) which was hoped to be a biologic diagnostic indicator of depression

Neurobiologic Factors— Neuroendocrine Dysregulation

Sleep-wake cycles are disrupted in mood disorders

Depressed patients
Go into REM sleep more quickly  Have a deficit of stage 3 and 4 sleep  Have an abnormality in the distribution of dream sleep throughout the night

Genetic Transmission

Mood d/os tend to run in families, and it is commonly believed to some extent that genetic transmission is responsible for their manifestation

Results of studies consistently demonstrate that 1st degree relatives of persons with bipolar d/o and depression have a greater risk of developing a mood d/o

Etiology of Mood D/os

Psychosocial factors
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Psychoanalytic theory Cognitive theory Learned helplessness Life events and stress theory Personality theory

Psychoanalytic Theory

Freud viewed both depression and mania as a response to loss

In depression, the loss generates intense, hostile feelings toward the lost object that are turned inward onto self creating guilt and loss of self-esteem Mania is explained as a defense against depression

The client denies feelings of anger, low selfesteem, and worthlessness and reverses the affect such that there is a triumphant feeling of self-confidence

Cognitive Theory
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Looks at errors in logical thinking as causative factors for depression Beck proposed a triad of negative thinking that gives rise to the development of depression
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Negative views of self Pessimistic views of the world, so that life experiences are interpreted in a negative way The belief that negativity will continue into the future

Learned Helplessness Theory

1st described in an experiment with dogs in 1975 Found that stressful events that are experienced as uncontrollable result in the development of helplessness, apathy, powerlessness, and depression

Life Events and Stress Theory

Significant life events cause stress, which results in depression or mania Researchers have also been investigating how social support attributes to the development of depression

Personality Theory

Personality Characteristics Associated with Depression:
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Negativity Pessimism Low sense of self-worth Proneness to worry and anxiety Self-denial Tendency to be serious and overly responsible

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Demandingness Feeling of being bored or empty Hypochondriasis Quietness Incapacity for enjoyment and relaxation Dependence on others love or affection

Epidemiology

Epidemiology
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Lifetime prevalence of developing any affective d/o is 19.3% Women and men have about an equal lifetime prevalence of developing bipolar d/o 21.3% of women and 12.7% of men develop major depression Average age of onset for bipolar d/o is mid to late 20s Average age of onset of depression is mid 30s

Depressive Disorders
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Major depression Dysthymic Disorder Depressive Disorder NOS Melancholic depression Atypical depression Seasonal Affective Disorder

MDD

Five or more of the following symptoms have to be present during the same two week period and represent a change from previous functioning At least one of the symptoms is either
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(1) depressed mood or (2) loss of interest or pleasure (anhedonia)

MDD

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others 2. Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day 3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day ( 5% in one month)

MDD
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4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly everyday (observable by others not merely subjective feelings of restlessness or being slowed down) 6. Fatigue or loss of energy nearly every day

MDD

7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

MDD

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The sx occur as a result of the d/o and not from the effects of a substance medical condition or loss of a loved one within the previous 2 months There cannot be a hx of a manic episode

Types of Depression

Melancholic

Anhedonia, lack of reactivity to usual pleasurable stimuli, psychomotor retardation, anorexia or weight loss, EMA, guilt, depression worse in the AM Mood reactivity (mood brightens in response to positive events), weight gain, hypersonia, increased appetite and weight gain, leaden paralysis Episodes begin in fall or winter and remit in the spring Pattern has occurred for 2 yrs

Atypical

Seasonal Affective Disorder
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Dysthymic Disorder
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Chronic low grade depression that does not fit criteria for MDD Lasts for at least 2 years
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depressed mood most of the day, nearly every day and at least 2 of the following sx:
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Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Difficulty making decisions Feelings of hopelessness

MDD superimposed on dysthymia = double depression

Mnemonic: SIGECAPS
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S I G E C A P S

Sleep Interest Guilty feelings Energy Concentration Appetite Psychomotor agitation or retardation Suicidal thoughts

Nursing Management: Assessment Psychological
 Assessment

scales self-report  Mood and affect  Thought content  Suicidal behavior  Cognition and memory

Nursing Diagnoses Psychological Domain
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Anxiety Decisional conflict Fatigue Grieving, dysfunctional Hopelessness Self-esteem, low Risk for suicide

Psychological Interventions
Nurse-Patient Relationship

Withdrawn patients have difficulty expressing feelings. Nurse should be warm and empathic, but not a cheerleader. See Therapeutic Dialogue.

Psychological Interventions
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Cognitive therapy - psychotherapy Behavior therapy Interpersonal therapy Marital and family therapy Group therapy Patient and family education

Nursing Management: Assessment Social Domain
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Developmental history Family psychiatric history Quality of support system Role of substance abuse in relationships Work history Physical and sexual abuse

Social Nursing Interventions
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Patient and family education Medication adherence Marital and family therapy Group therapy

Continuum of Care
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Non-psychiatric setting Acute care – hospitalization Outpatient See appendices for clinical pathways.

Bipolar Disorders

DSM-IV Bipolar Disorders

Bipolar Disorder Type 1

manic episode never had manic episode at least 1 hypomanic & depressive episode

Bipolar Disorder Type 2
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Cyclothymic Disorder

Manic Episode

Feeling unusually “high”, euphoric, irritable for at least one week Four of the following:
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Needing little sleep, great amount of energy Talking fast, others can’t follow Racing thoughts Easily distracted Inflated feeling of power, greatness or importance Reckless behavior (money, sex, drugs)

Types of Bipolar

Bipolar I
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Combinations of major depression and full manic episode Mixed episodes: alternating between manic and depressive episodes Combination of major depression and hypomania (less severe form of mania)

Bipolar II

Specifiers
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Mixed episodes – criteria for both manic and depressive episodes met Hypomanic episode – same as manic but less than four days Secondary mania – caused by medical disorders or treatment Rapid cycling – four or more episodes within 12 months

Clinical Course
• •

Chronic cyclic disorder Later episodes occur more frequently than earlier. Interpersonal relationships and occupational functioning are affected. Patient may have rapid cycling.

Bipolar in Special Populations: Children

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Recently recognized in children, it is characterized by intense rage episodes for up to two to three hours. Symptoms of bipolar disorder reflect the developmental level of the child. First contact with mental health agency is 5 to 10 years old. Often have other psychiatric disorders

Bipolar Disorder: Elderly People

More neurologic abnormalities and cognitive disturbances Late-onset bipolar disorder recently recognized Poorer prognosis because of comorbid medical conditions

Bipolar Disorder: Epidemiology
• • • •

Prevalence - 0.4 to 1.6% of population Onset: 21-30 years Men and women equally Ten to 15% of adolescents with recurrent depressive episodes develop bipolar I. Many comorbid disorders (substance abuse, in particular)

Gender and Ethnic/Cultural Differences
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No gender difference in incidence Gender differences reported in phenomenology, course and treatment.

Females at greater risk for depression and rapid cycling

Etiology Biologic

Neurobiologic theories
• – – –

Neurotransmitter hypotheses Chronobiologic theories Sensitization and kindling theory Genetic factors

Bipolar I – 4 to 24% first-degree relatives – 80% concordance rate in identical twins Bipolar II – 1 to 5% first-degree relatives Contribute to the timing of the disorder

Psychosocial factors

Treatment Issues
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Complex issues treated by an interdisciplinary team Priority issues:
Safety from poor judgement and risk-taking behaviors  Risk for suicide during depressive disorders

Devastating to families, especially dealing with the consequences of impulsive behavior

Nursing Management: Biologic Domain

Assessment
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Evaluation of mania symptoms Sleep may be nonexistent. Irritability and physical exhaustion Eating habits, weight loss Lab studies - thyroid Hypersexual, risky behaviors Pharmacologic (may be triggered by antidepressant), alcohol use Disturbed sleep pattern, sleep deprivation Imbalanced nutrition, hypothermia, deficit fluid balance

Nursing diagnosis
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Nursing Interventions: Biologic Domain
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Physical care Pharmacologic
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Acute - symptom reduction and stabilization Continuation – prevention of relapse Maintenance - sustained remission Discontinuation - very carefully, if at all

Electroconvulsive therapy

Mood Stabilizers

Lithium Carbonate (Eskalith)
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Mechanism of action: unknown Blood levels 0.5-1.2 Side effects: GI, weight gain

Divalproex Sodium (Depakote)
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Increase inhibitory transmitter, GABA Sedation, tremor

Carbamazepine

Mood Stabilizers

Lithium Carbonate
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Drug profile Lithium blood levels

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Divalproex sodium (Depokote) (Drug Profile) Carbamazapine (Tegretol)

Baseline liver function tests and complete blood count Lamotrigine (Lamictal) Gabapentin (Neurontin) Topiramate (Topamax)

Newer anticonvulsants
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Other Medications Used

Antidepressants
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Used during depressed phases Can trigger manic phase Psychosis Mania Dosage usually lower Short-term for agitation

Antipsychotics
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Benzodiazepines

Other Medication Issues
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Monitoring important Side effect monitoring important because taking more than one medication Drug-drug interactions

Especially, alcohol, drugs, OTC and herbal supplements Lithium (Change in salt intake can affect lithium.) Most of these medications cause weight gain. Check before using OTC.

Teaching points
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Nursing Management: Psychological Domain
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Assessment Mood Cognitive Thought Disturbances Stress and coping factors Risk assessment

Nursing Diagnosis

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Disturbed sensory perception Disturbed thought processes Defensive coping Risk for suicide Risk for violence Ineffective coping

Nursing Management: Social Domain

Assessment
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Social and occupational changes Cultural views of mental illness Ineffective role performance Interrupted family processes Impaired social interaction Impaired parenting Compromised family coping

Nursing Diagnosis
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Nursing Interventions: Social Domain
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Protect from over-extending boundaries Support groups Family interventions

Marital and family interventions

Continuum of Care
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Inpatient management – short-term Intensive outpatient programs Frequent office visits Crisis telephone calls Family session or -

Hypomanci Episode
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Expansive mood occurs for at least 4 days Not as severe to cause impairment in social and/or occupational functioning During a hypomanic episode, clients may appear extremely happy and congenial, at ease with social conversation, and offer humorous input

Cyclothymic Disorder
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At least 2 years in duration Periods of hypomania, depressed mood, and anhedonia Less severe symptoms than MDD and mania

Adjustment Disorders

Adjustment Disorders

Occur in response to a precipitating stressor (an event leading to marked distress and impairment) Stressors can include:
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Separations Divorce Unemployment Miscarriage Diagnosis of an acute or chronic illness Leaving home Going to college

Adjustment Disorders (cont)

Some of sx of adjustment d/os are similar to those of mood and anxiety d/os Adjustment d/os are considered less serious and often represent transient episodes in the lives of otherwise mentally healthy individuals This dx is made after other psychiatric conditions are ruled out

DSM-IV Criteria for Adjustment Disorders
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A. The development of emotional or behavioral sx in response to an identifiable stressor B. These sx cause either:
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Marked distress that is in excess of what would be expected from exposure to the stressor Significant impairment is social or occupational functioning

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The stress related disturbance does not meet criteria for another Axis I d/o The sx do not represent bereavement

Adjustment Disorder

Acute

If the disturbance lasts < 6 months If the disturbance lasts > 6 months With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Unspecified

Chronic

6 subtypes of adjustment disorder:
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Symptoms

Changes in mood and behavior are common

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Can feel fearful, nervous, depressed, angry, worried, or a mixture of these states Stressor may interfere with the ability to think or concentrate Lowered confidence and self-esteem may occur Sleep disturbances can occur Difficulties in interpersonal relationships may emerge

Etiology—Crisis Model

An adjustment disorder results from an individual’s inability to use existing coping methods or create new methods in response to a situation This results in a situation where a client feels overwhelmed, helpless, and confused further depleting his or her ability to utilize resources

Epidemiology

Adult adjustment d/os are thought to be common The DSM-IV cites prevalence rates between 5-20% in outpt populations

Prognosis

Once identified, the course of illness is usually limited to weeks or months Some people may be at risk of suicide because of the nature and severity of their sx Left untreated, these d/os may progress to anxiety and mood d/os

Treatment Considerations

Meds are used sparingly

The d/o is expected to resolve after the immediate cause is identified and processed

Benzos are sometimes prescribed for brief periods of time to treat sx of anxiety

Treatment Considerations (cont)

Supportive therapies
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CBT IPT Family therapy—may be indicated when the stressor involves the family system

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