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Ellen Gluzman, MD



• Affect refers to immediate expressions
of emotion
– range (e.g. restricted, blunted, flat, expansive)
– appropriateness (e.g. appropriate, inappropriate,
– stability (e.g. stable, labile)

• Mood refers to emotional experience
over a more prolonged period of time.
– happiness (eg, ecstatic, elevated, lowered,
– irritability (e.g. explosive, irritable, calm)
– stability


low self worth. or related symptoms Mania A state or episode of euphoria or an exaggerated belief that the world is theirs for the taking. . sad state marked by significant levels of sadness.Two key emotions on a continuum: Depression A Low. lack of energy. guilt.

are pervasive alterations in emotions that are manifested by depression.MOOD DISORDERS • Mood disorders. agitation. or both. also called affective disorders. or elation . plaguing him or her with drastic and long-term sadness. mania. • They interfere with a person’s life.

mood disorder due to general medical condition – Seasonal affective disorder – Postpartum blues. psychosis .Categories of Mood Disorders • Major depressive disorder • Bipolar disorder • Related disorders – Dysthymic disorder – Cyclothymic disorder – Substance-induced mood disorder. depression.

sleep. concentrating. 2000). • These symptoms must be present every day for 2 weeks and result in significant distress or impair social. • In addition. . or attempts. plans.Categories of Mood Disorders • MAJOR DEPRESSIVE DISORDER • A major depressive episode lasts at least 2 weeks. occupational. Difficulty thinking. • Some people also have delusions and hallucinations. or making decisions Recurrent thoughts of death or suicidal ideation. or other important areas of functioning (American Psychiatric Association [APA]. four of the following symptoms are present: – – – – – Changes in appetite or weight. during which the person experiences a depressed mood or loss of pleasure in nearly all activities. the combination is referred to as psychotic depression. or psychomotor activity Decreased energy Feelings of worthlessness or guilt.

rapid. • At least three of the following symptoms accompany the manic episode: – – – – – – – inflated self-esteem or grandiosity. – Typically. • Mania is a distinct period during which mood is abnormally and persistently elevated. often unconnected. expansive.seeking activities with a high potential for painful consequences . or irritable. thoughts). often loud talking without pauses) flight of ideas (racing.• BIPOLAR DISORDER • Bipolar disorder is diagnosed when a person’s mood cycles between extremes of mania and depression. decreased need for sleep pressured speech (unrelenting. increased involvement in goal-directed activity or psychomotor Agitation excessive involvement in pleasure. this period lasts about 1 week but it may be longer for some individuals. distractibility.

Hypomania • is a period of abnormally and persistently elevated. . expansive. These mixed episodes often are called rapid cycling. or irritable mood lasting 4 days and including three or four of the additional symptoms described earlier. • A mixed episode is diagnosed when the person experiences both mania and depression nearly every day for at least 1 week.

• • Bipolar II disorder—one or more major depressive episodes accompanied by at least one hypomanic episode .BIPOLAR DISORDER • • Bipolar I disorder—one or more manic or mixed episodes usually accompanied by major depressive episodes.

less severe symptoms that do not meet the criteria for a major depressive episode. • Substance-induced mood disorder – is characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiologic consequence of ingested substances such as alcohol. or toxins. . other drugs. • Cyclothymic disorder – is characterized by 2 years of numerous periods of both hypomanic symptoms that do not meet the criteria for bipolar disorder.RELATED DISORDERS • Dysthymic disorder – is characterized by at least 2 years of depressed mood for more days than not with some additional.

and subside rapidly with no medical treatment. and heaviness in the extremities beginning in late autumn and abating in spring and summer. and carbohydrate cravings. sadness. – Spring-onset SAD. insomnia. and poor appetite lasting from late spring or early summer until early fall. appetite. and anxiety.RELATED DISORDERS • Seasonal affective disorder (SAD) has two subtypes. . people experience increased sleep. SAD is often treated with light therapy. is less common. • Postpartum or “maternity” blues – are a frequent normal experience after delivery of a baby. usually peak in 3 to 7 days. crying spells. with symptoms of insomnia. weight gain. weight loss. – Winter depression or fall onset SAD. interpersonal conflict. They are characterized by labile mood and affect. irritability. – Symptoms begin approximately 1 day after delivery.

and loss of contact with reality. and confusion and progressing to delusions. emotional lability. poor memory. poor insight and judgment. hallucinations.RELATED DISORDERS • Postpartum depression – meets all the criteria for a major depressive episode. . – This medical emergency requires immediate treatment. • Postpartum psychosis – is a psychotic episode developing within 3 weeks of delivery and beginning with fatigue. sadness. with onset within 4 weeks of delivery.


norepinephrine  possibly acetylcholine and dopamine – Neuroendocrine influences: hormones .Etiology • Biologic theories – Genetic theories – Neurochemical theories:  serotonin.

people became angry while both loving and hating the lost object.Etiology • Psychodynamic theories – Freud: sefl-depriciation • looked at the self-depreciation of people with depression and attributed that selfreproach to anger turned inward related to either a real or perceived loss. – Mania: defense against underlying depression . • Feeling abandoned by this loss.

in reality.Etiology • Bibring: ideal ego – believed that one’s ego (or self) aspired to be ideal and that to be loved and worthy. – Depression results when. one must achieve these high standards. the person was not able to achieve these ideals all the time .

. with the id taking over the ego and acting as an undisciplined hedonistic being (child). much like a powerful and sadistic mother who takes delight in torturing the child. helpless child victimized by the superego. – Most psychoanalytical theories of mania view manic episodes as a “defense” against underlying depression.Etiology • Jacobson: superego over powerless ego – compared the state of depression with a situation in which the ego is a powerless.

making them susceptible to depression and helplessness. • Horney – believed that children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness.Etiology • Meyer – viewed depression as a reaction to a distressing life experience such as an event with psychic causality. • Beck – saw depression as resulting from specific cognitive distortions in susceptible people. and expectations and simultaneous minimization of anything positive. – Early experiences shaped distorted ways of thinking about one’s self. these distortions involve magnification of negative events. traits. . the world. and the future.

Cultural Considerations • Masking of depression by other behaviors considered age-appropriate – School phobia. backache. or other symptoms. gangs. failing grades. compulsive behaviors • Somatic complaints – Major manifestation among cultures that avoid verbalizing emotions. – Latin cultures complain of “nerves” or headaches. hyperactivity. risk behaviors. – Asians who are anxious or depressed are more likely to have somatic complaints of headache. antisocial behaviors – Substance abuse. eating disorders. – Middle Eastern cultures complain of heart problems . learning disorders.


Major Depressive
• Major depressive disorder typically
involves 2 or more weeks of a sad
mood or lack of interest in life
activities with at least four other
symptoms of depression such as
anhedonia and changes in weight,
sleep, energy, concentration, decision
making, self-esteem, and goals.

• Age and Gender:
– higher in women than it is in men esp after the
age of 65

• Gender stereotypes, or gender socialization
– promotes typical female characteristics, such as
helplessness, passivity, and emotionality, which
are associated with depression.
– In contrast, some studies have suggested that
“masculine” characteristics are associated with
higher self-esteem and less depression

• Social Class
• Inverse relationship between social
class and report of depressive

and disabling in blacks.EPIDEMIOLOGY • Race and Culture – depression is more prevalent in whites than it is in blacks. persistent. but that depression tends to be more severe. and they are less likely to be treated .

EPIDEMIOLOGY • Marital Status – A number of studies have suggested that marriage has a positive effect on the psychological well-being of an individual (as compared to those who are single or do not have a close relationship with another person) .

and November). and May) – Fall (September.EPIDEMIOLOGY • Seasonality • Two prevalent periods of seasonal involvement: – Spring (March. which shows a large peak in the spring and a smaller one in October. April. October. . • Parallel the seasonal pattern for suicide.


no history of manic behavior. and symptoms that cannot be attributed to use of substances or a general medical condition .Major Depressive Disorder • Major depressive disorder (MDD) is characterized by depressed mood or loss of interest or pleasure in usual activities which impairs social and occupational functioning that has existed for at least2 weeks.


for at least 2 years (1 year for children and adolescents) . those ascribed to MDD. if somewhat milder than. • The essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for most of the day. more days than not. • Individuals with this mood disturbance describe their mood as sad or “down in the dumps” • There is no evidence of psychotic symptoms.Dysthymic Disorder • Characteristics of dysthymic disorder are similar to.


Premenstrual Dysphoric Disorder • The essential features include markedly depressed mood. mood swings. excessive anxiety. and decreased interest in activities during the week prior to menses and subsiding shortly after the onset of menstruation .

Mood Disorder (Depression) Due to a General Medical Condition • This disorder is characterized by prominent and persistent depression that is judged to be the result of direct physiological effects of a general medical condition. .

Substance-Induced Mood Disorder (Depression) • Direct result of physiological effects of a substance (e. and anxiolytics . sedatives. cocaine. phencyclidine. hypnotics. a drug of abuse.g. inhalants. amphetamines. occupational. or toxin exposure) and causes clinically signifi cant distress or impairment in social. hallucinogens. or other important areas of functioning • alcohol.. a medication. opioids.



Psychopharmacology • Selective serotonin reuptake inhibitors (Table 15.1) • Cyclic antidepressants (Table 15.2) • Atypical antidepressants (Table 15.3) • Monoamine oxidase inhibitors (MAOIs) (Table 15.4) .

5) • Investigational treatments .Other Medical Treatments and Psychotherapy • Electroconvulsive therapy (ECT) • Psychotherapy (combined with medications) – Interpersonal therapy (Group): relationship difficulties – Behavior therapy: reinforcement of positive interactions – Cognitive therapy: correction of cognitive distortions (Table 15.

motor behavior (psychomotor retardation. suicide) – Sensorium. affect (anhedonia) – Thought process. content (rumination. psychomotor agitation) – Mood.Major Depressive Disorder and Nursing Process Application • Assessment – History – General appearance. intellectual processes (impaired memory) . latency of response.

relationships (difficulty in this area) – Physiologic.Major Depressive Disorder and Nursing Process Application (cont’d) • Assessment – Judgment. Beck • Clinician rating scale: Hamilton Rating Scale . insight (impairment) – Self-concept (worthlessness) – Roles. self-care considerations – Depression rating scales • Self-rating scales: Zung.

Nursing Diagnosis • Assignment!!! – Formulate at least 10 Nursing Diagnoses to Behaviors Commonly Associated With Depression – Format: BEHAVIORS NURSING DIAGNOSIS – Prioritize and make a nursing care plan for the first 3 nursing diagnoses. .

Major Depressive Disorder and Nursing Process Application • Intervention – Providing for safety (suicide precautions) – Promoting therapeutic relationship – Promoting ADLs. physical care – Using therapeutic communication – Managing medications – Client. family teaching • Evaluation .


last from a few weeks to several months .Bipolar Disorder • Extreme mood swings from mania to depression • Second only to major depression as cause of worldwide disability • Onset usually in early 20s • Manic episodes begin suddenly.

• Bipolar II disorder—one or more major depressive episodes accompanied by at least one hypomanic episode .TYPES OF BIPOLAR DISORDERS • Bipolar I disorder—one or more manic or mixed episodes usually accompanied by major depressive episodes.

TYPES OF BIPOLAR DISORDERS • Cyclothymic Disorder – is a chronic mood disturbance of at least a 2-year duration involving numerous episodes of hypomania and depressed mood of insuffi cient severity or duration to meet the criteria for either bipolar I or II disorder. – The individual is never without hypomanic or depressive symptoms for more than 2 months .

TYPES OF BIPOLAR DISORDERS • Bipolar Disorder Due to a General Medical Condition • This disorder is characterized by a prominent and persistent disturbance in mood that is judged to be the result of direct physiological effects of a general medical condition .

paint.g. organophosphate insecticides. carbon monoxide.. and carbon dioxide . a medication.TYPES OF BIPOLAR DISORDERS • Substance-Induced Bipolar Disorder – direct result of physiological effects of a substance (e. or toxin exposure). • gasoline. nerve gases. a drug of abuse.

protecting against bipolar depressive cycles • Psychotherapy useful in mildly depressive or normal portion of bipolar cycle – Not useful during manic stages .7) – Agents helpful in reducing manic behavior.Treatment • Psychopharmacology – Antimanic agent: lithium – Anticonvulsant agent used as mood stabilizer (Table 15.

tangentiality) – Sensorium. flamboyancy. grandiose) – Thought process. intellectual processes (disoriented to time) . affect (euphoric. sexually suggestive) – Mood. behavior (pressured speech.Bipolar Disorder and Nursing Process Application • Assessment – History – General appearance. content (circumstantiality.

relationships (labile emotions) – Physiologic. insight – Self-concept (exaggerated) – Roles.Bipolar Disorder and Nursing Process Application • Assessment – Judgment. self-care considerations • Data analysis • Outcome identification .

8) – Providing client. family teaching • Evaluation .Bipolar Disorder and Nursing Process Application • Intervention – Providing for safety – Meeting physiologic needs – Providing therapeutic communication – Promoting appropriate behaviors – Managing medications (Table 15.

Nursing Diagnosis • Assignment!!! – Formulate at least 10 Nursing Diagnoses to Behaviors Commonly Associated With Bipolar Mania – Format: BEHAVIORS NURSING DIAGNOSIS – Prioritize and make a nursing care plan for the first 3 nursing diagnoses. .



divorced. and widowed people have rates four to five times greater than those who are married .Nursing Process: Suicide Assessment • Epidemiological factors – Marital status: • Single.

Nursing Process: Suicide Assessment • Epidemiological factors – Gender: Women attempt suicide more often. however. adolescents also at high risk . more men succeed – Age: Suicide highest in persons older than 50 years.

Nursing Process: Suicide Assessment • Epidemiological factors – Religion: Protestants have significantly higher rates of suicide than Catholics and Jews. . A strong feeling of cohesiveness within a religious organization seems to be an important factor.

Nursing Process: Suicide Assessment • Epidemiological factors – Socioeconomic status: People in the highest and lowest social classes have higher suicide rates than those in the middle classes. – Professionals: Professional healthcare personnel and business executives are at the highest risk. .

followed by Native Americans. . then by African Americans.Nursing Process: Suicide Assessment • Epidemiological factors – Ethnicity: Whites are at highest risk for suicide.

Nursing Process: Suicide Assessment • Presenting symptoms/medical– psychiatric diagnosis – Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide. – Other disorders include • • • • Anxiety disorders Schizophrenia Borderline personality disorder Antisocial personality disorder .

” • Indirect statements: “I don’t have anything to live for anymore. lethality of means.Nursing Process: Suicide Assessment • Suicidal ideas or acts – Assess: Intent.” . previous attempts – Verbal clues: • Direct statements: “I want to die. plan. means.

Nursing Process: Suicide Assessment (cont.) • Analysis of the suicidal crisis – Interpersonal support system – The precipitating stressor – Relevant history – Life-stage issues – Psychiatric/medical/family history – Coping strategies .

Nursing Process • Diagnosis/Outcome Identification – Risk for suicide related to feelings of hopelessness and desperation – Outcome: The client has experienced no physical harm to self .

) Diagnosis/Outcome Identification Hopelessness related to absence of support systems and perception of worthlessness • Outcome: Expresses some optimism and hope for the future .Nursing Process (cont.

– Stay with the person to convey support throughout the current crisis. . – Communicate the potential for suicide to team members.) • Planning/Implementation – Establish a therapeutic relationship to convey acceptance of the person.Nursing Process (cont.

. • Secure a no-suicide contract (verbally or in writing) for a specified amount of time. • Listen to the person.Planning/Implementation • Accept the person. which will show unconditional positive regard.

Identify areas of client control. Establish trusting relationship. Antidepressant medication. Establish a no-suicide contract. Discuss current crisis situation. Enlist help of family and friends. Schedule daily appointments. Talk directly about client’s plans for suicide. .Intervention with the Outpatient Suicidal Client • • • • • • • • • Do not leave the person alone.

Information for Family/Friends of Suicidal Client • • • • • • Take any hint of suicide seriously. Be aware of resources for assistance. Report threats of suicide immediately. Be a good listener. . Express concern about the person’s welfare. stay with the person. Express love for the person. Restrict access to firearms or other means of self-harm. • Be nonjudgmental. • Instill hope. • Encourage professional help.

Intervention with Families and Friends of Suicide Victims • • • • Encourage them to talk about the suicide. . • Discuss coping strategies. Be aware of blaming or scapegoating. • Encourage grieving at own personal pace. Listen to feelings of guilt. Encourage discussion of relationship with lost loved one. • Identify resources that provide support.

.Nursing Process/Evaluation • Evaluation of the suicidal client is an ongoing process accomplished through continuous reassessment of the client as well as determination of the goal achievement.

Nursing Process/Evaluation (cont.) • Long-term goals for the suicidal client would be to: – Develop and maintain a more positive selfconcept – Learn more effective ways to express feelings to others – Achieve successful interpersonal relationships – Feel accepted by others and achieve a sense of belonging .