Mood (Affective) Disorder

Nabina Paneru
 Terminology

• Emotion: It is an intense feeling that people experience that are directed at someone or something.

• Affect: Which is shrot, lived emotional response to an ideas or an event.

• Mood: is an internal emotional state of an individual Which is sustained and pervasive and sustained

emotional response that may influence a person’s behavior and perception of the world. Mood can be

normal, elevated or depressed. E.g. depression, joy,eletion, anger and anxiety.

• Mania: Alteration in mood that is expressed by feeling of elation characterized by over activities, mood

changes, self important activites/ideas.

 
 Mood disorder

• A mood state of a normal individual fluctuates between mild depressions to mild

elation for brief periods depending on many factors. It is only when the mood
swing is excessive in severity and duration and when it interferes with a person’s
day to day activities that it becomes a mood disorder.
• Mood disorders are a group of clinical conditions characterized by a loss of that
sense of control and subjective experience of great distress.
 Contd.
• People with this diagnosis have an abnormal mood characterized by:
– Depression
– Mania, or
– Both symptoms in alternating fashion

• The abnormal mood may or may not impair the person’s social or
occupational functioning
 Classification:

According to ICD-10 the classification of mood disorder is as following:

• Manic/hypomanic episodes

• Depressive episode

• Bipolar mood/affective episode

– Bipolar I disorder

– Bipolar II disorder

• Persistent Mood disorder (including cyclothymic and dysthymia)

• Recurrent depressive episode

• Persistent mood disorders

• Other mood disorders

• Unusually and persistently elevated, expansive, or irritable mood that
is distinctly different from the person’s non-manic state
• Marked impairment, requires hospitalization

Characterstics:
• Elevated expansive or irritable mood
• Increase psychomotor activity
• Increase pressure of speech e.g. joyful, playful, joking, teasing,
speaking loudly, flight of ideas
 Hypomania
Hypomania is a less severe form of mania. Hypomania is a mood that many don't
perceive as a problem. It actually may feel pretty good. He/she have a greater sense
of well-being and productivity. However, for someone with bipolar disorder,
hypomania can evolve into mania -- or can switch into serious depression.
• Less severe variant of mania; no need of hospitalization.
 Depressive episode

• Major depressive disorder (Unipolar) is characterized by depressed mood or loss

of interest in usual activities, and somatic symptoms may be evident without any

hypomanic or manic states: the patient is either depressed or average in mood,

but experiences no mania. Change in appetite and sleep patterns are common.
 Bipolar disorder

• Bipolar disorder is characterized by manic or hypomanic states: the

patient is either depressed, euthymic (normal in mood), or
hypomanic/manic.

Bipolar I: Is defined as having a clinical course of one or more manic

episodes and sometimes, major depressive episodes (a complete set of
mania symptoms occurs during the course of the disorder).
 Contd..
Bipolar II: Bipolar disorder characterized by episodes of major depression and
hypomania rather than mania is known as bipolar II disorder ( the episodes of manic
like symptoms do not quite meet the diagnostic criteria for a full manic syndrome).
 Persistent Mood Disorder
• Dysthymia: refers to clinically significant major depressive symptoms somewhat
milder, that are present for 2 years or more but do not reach the threshold (with
respect to severity and/or number of symptoms) for major depression. There is no
evidence of psychotic symptoms.
 Contd.
• Cyclothymias: is a chronic mood disturbance of at least a 2 year duration involving
numerous episodes of hypomania and depressed mood of insufficient severity or
depressive symptoms do not reach the threshold for diagnosis of a major depressive
episode.
 Epidemiology
Type Lifetime prevalence (%)

Major Depressive Episode 5-17 (12)

Bipolar disorder 0.3 – 1.5

Dysthymic disorder 3 – 6 (5)

Minor Depressive Disorder 10

Full unipolar spectrum 2.0 – 2.5

Full bipolar spectrum 2.6 – 7.8

Cyclothymia 0.5 – 6.3

Hypomania 2.6 – 7.8

Sadock and Sadock, 2004

Mood disorders affect about 10% of the population
 Contd.
• According to gender
- In bipolar disorder, the prevalence in males and females is equal
- Two fold greater prevalence of major depressive disorder in women than in men
- Manic episodes are more common in men.
 Contd.
• According to age
- The onset of bipolar disorder is earlier than that of major depressive disorder
- The mean age of onset of bipolar disorder is 17 to 27 years
- The mean age of onset for major depressive disorder is 20 and 50 (mean age – 40
years). But the incidence of major depressive disorder may be increasing among
people younger than 20 years of age.
 Contd.
• According to marital status
- Seen in persons without close interpersonal relationship or in those who are divorced
or separated.
 Etiology
• Idiopathic
 Contd.
Biological Theories:
a. Genetic Theory
b. Biochemical Theories
c. Alterations in hormonal regulation

Psychosocial Theories Etiology

a. Psychoanalytic theory Sociological
b. Behavioral theory Theory
c. Cognitive theory
 Contd.
1. Biological Theories

a. Genetic theories:

- The lifetime risk for the first degree relative of patient with bipolar disorder is 25%

- The lifetime risk for the children of one parent with disorder is 27% and of both
parents with mood disorder is 74%

- concordance rate for mood disorder in the monozygotic (MZ) twins of 70 to 90

percent compared with the same-sex dizygotic (DZ) twins of 16 to 35 percent.
 Biological Theory Contd.
b. Biochemical Theories

Serotonin
Do
• pa
• Depletion of serotonin: R mi
• ed ne
precipitate depression • Incr uce
M ea d i
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in es de ay b lim in m pre
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e p d e rec pres e dy ic d ani ssio
in n ia de ept sion sfu op a n
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N fi c in sio ay
D e
s ed n do nal e p
• ea be pa in at
r hy m i hw
Inc po n e ay
• ac D
tiv 1
ei
n
 Biochemical Theories Contd.

Gamma –
Aminobutyric acid Gl
(GABA) the utam
: inh ma ate
in
e - Has an inhibitory in ibit jor and
ol the ory exc gl
ch a se a n in effect on mesocortical -G CN ne itat ycin
l e
t y n c r in n d m s c and mesolimbic hy luta uro ory e
e S
Ac an i oms n, a pto systems de perc mat tra an are
t eff leter orti e w ns d
- C mp ssio sym ot tion es Decreased plasma, de ects ious ole th s i
mi
tt e
sy pre ase ut n ac ang rs
de cre a b t re ch and CSF and brain GABA N pres of ne mia
M s sev uro =
de ani cien uce ity sion levels in depression ha D i o
m ffi ind ctiv res ve A r n er re cogn
a n e ce cu i t i
s u a n A a de p tid p t rre ve
- C HP  ep ors nt
re s a
in e e p san nta
sl t e gon
ffe ist
ct s s
 Contd.
c. Alterations in hormonal regulation
Stimulated by dopamine and Nor epinephrine and inhibited by
Growth Hormone somatostatin
• Decreased CSF somatostatin = depression
• Increased CSF somatostatin = mania

Prolactin Released by serotonin and inhibited by dopamine

• A blunted prolactin response to various serotonin (depression)

Thyroid Stimulating
hormone
• About one fourth depressed people have a reduced thyroid
stimulating hormone
 Etiology contd.
2. Psychosocial Theories
According to Freud depression results due to loss of a
loved object, and fixation in the oral sadistic phase of
development. In this model, mania is viewed as denial
of depression (Mania represents the reaction formation
to depression).

According to this model,

depression is conditioned by
repeated loses in the past.

According to this theory

depression is due to negative
cognition.
 Etiology Contd.
3. Sociological Theory:

a. Life Events and Environmental Stress

• – One theory : stress = long-lasting changes in the brain's biology = alter the

functional states of various neurotransmitter and intraneuronal signaling systems =

loss of neurons and an excessive reduction in synaptic contacts.

• high risk of undergoing subsequent episodes even without an external stressor.

– losing a parent before age 11,

– loss of a spouse

– Unemployment
 Sociological Theory Contd.
b. Personality Factors

– Persons with certain personality disorders may be at greater risk for depression

• OCD,

• histrionic,

• Borderline

– antisocial or paranoid personality disorder can use projection and other externalizing

defense mechanisms to protect themselves from their inner rage.

– Recent stressful events are the most powerful predictors of the onset of a depressive

episode.
 Depression
Depression is a common psychiatric disorder, characterized by a
persistent lowering of mood, loss of interest in usual activities
and diminished ability to experience pleasure.
 Epidemiology
Epidemiology of Depression

Incidence (yr) 1/100 men and 3/100 women

Prevalence 2-3/100 men and 5-10/100 women

Lifetime risk 10-20%

Lifetime suicide rate (depression) 15%

Age 40 – mean age, 50% occur before age 40

Sex 2:1 women/men

Marital Status Persons without close interpersonal relationships or

in those who are divorced or separated

Family history Approx. 10 – 13% risk for first-degree relatives

Monozygotic concordance rate higher than
dizygotic but ratio not as high as seen in bipolar
 Etiology
• Exact cause of depression is still unknown. However most probable theories of
developing the depression are as follows:

A. Bio physiological

1. Genetic: The disorder is 1.5 to 3 times more common among first degree relatives.

2. Reduction in Biogenic Amines: Norepinephrine, serotonin and dopamine.

3. Alterations of Hormonal Regulation: Elevated levels of serum cortisol and

decreased levels of thyroid stimulating hormone.

4. Thyroid Axis Activity: An elevated basal thyroid – stimulating hormone (TSH)

level.
 Biophysiological contd.
5. Alterations of Sleep Neurophysiology: Depression is associated with a premature loss

of deep sleep and an increase in nocturnal arousal.

6. Immunological Disturbance/ Physiological Conditions: Depressive disorders are

associated with electrolyte disturbances, hormonal disturbances, nutritional

deficiencies, and with certain physical disorders.

7. Medication Side Effects: Anxiolytics, antipsychotics, and sedative – hypnotics,

antihypertensive medications such as propranolol and reserpine have been known to

produce depressive symtoms.

 Contd.
B. Psychosocial Factors: Life events and Environmental Stress
C. Cognitive Theory: According to this, depression results from cognitive
distortions, anger turned inward.
D. Behavioral Theory: The learned helplessness: Following numerous failures,
the individual feels helpless to succeed at any endeavor and therefore gives
up trying. This “learned helplessness” is viewed as a predisposition to
depressive illness.
 Diagnostic Criteria
Other/
Cardinal
Somatic
Symptoms
Symptoms
1. Reduced confidence or self – esteem
2. Reduced concentration
1. Depressed mood 3. Ideas of guilt or unworthiness
2. Loss of interest or pleasure 4. Pessimistic thoughts
3. Decreased energy or increased 5. Ideas of self harm (death or suicide)
fatigability (Psychomotor 6. Disturbed sleep: waking in the
retardation) morning 2 hours before the usual time
7. Diminished appetite: Change in
weight
 Contd.
Categories
Mild Depression Moderate Depression

4 s/s (2+2), continue most 5/6 s/s (2+3/ or 4), difficulties to

activities continue activities

Severe Depression
7 s/s (3+4), unlikely can function, Other characteristics:
somatic s/s usually present,
psychotic s/s might be present
- Depression worse in the morning
- Marked loss of libido
- Subjective poor memory
- Menstrual and sexual disturbances
- Vague physical symptoms such as
fatigue, aching discomfort,
constipation etc.
 Clinical Features
All from diagnostic criteria plus following:

• The affect: sadness, dejection, helplessness and hopelessness. Gloomy outlook, pessimistic and
feeling of worthlessness.

• Speech: Decreased rate and volume of speech

• Delusions or hallucinations and catatonic features (mute, not bathing, soiling)

• Thought: negative views of world and themselves, suicidal ideation

• Concentration: may be impaired and forgetfulness

• Social participation is diminished

 Treatment
• Pharmacological treatment

- Antidepressants, anxiolytics
• Electroconvulsive therapy

- Treatment of choice for psychotic depression, depression refractory to pharmacotherapy and

for acutely suicidal.
- Patients with recurrent depression will need either prophylactic medication or maintenance
ECT
- Side effects include temporary short term memory loss
 Contd.
• Family Therapy: to reduce or modify stressors
• Group interventions: useful for mild to moderate cases of depression.
Helps by optimizing socialization, venting feelings, exploring and
establishing coping mechanisms, establishing personal goals, thus
reducing isolation and hopelessness.
 Contd.
• Psychotherapeutic interventions:

- Cognitive therapy: address systematic errors in the client’s thinking that maintain negative cognitive

processing. It aims at correcting such cognition by examining logically and replacing them with new

cognitive and behavioral responses.

- Behavioral therapy: activity scheduling, social skill training, decision making techniques, self – control

therapy.

- Interpersonal therapy: emphasized on social functioning and interpersonal relationships. The goal of

therapy is to understand the social context of current problems based on earlier relationships and

managing current interpersonal problems.

 Contd.
• Suicidal assessment and management
 Nursing Management
• Assessment

- Have you had thoughts about death or about killing yourself?

- How persistent was the thoughts?

- Have you formulated a plan? What is it?

- Have you actually rehearsed or practiced how you would kill yourself?

- Do you think you would really do it? Have you told anyone?

- Do you tend to be impulsive or can you resist the impulse to do this?

- What have stopped you doing this?

- Have you heard voices telling you to hurt or kill yourself?

- History or previous attempt especially the degree of intent.

- Family history of depression or suicide

Nursing diagnosis with interventions
1. Risk for suicide related to anger turned inward/or, irrational feelings
of guilt/ or depressed mood/ or hopelessness/ or hallucinations/ or
delusional thinking.
• Ask client directly: “Have you thought about harming yourself in any way?
• Create a safe environment for the client. Remove all potentially harmful objectives.
• Formulate a short term verbal or written contract with the client that he or she will
not harm self during specific period.
• Maintain close observation of client. Place in room close to nurse’s station: do not
assign to private room.
• Make records at frequent, irregular intervals (especially at night, toward early
morning, at change of shift, or other predictably busy time or staffs.
• Encourage client to express angry feelings within appropriate limits. Provide safe
method of hostility release.
• Identify community resources that client may use as support system, and from
whom he or she may request help if feeling suicidal.
2. Social Isolation/Impaired social Interaction related to unresolved
grief/ or altered thought processes (delusional thinking/ or fear of
rejection or failure of the interaction.

• Spend time with client

• Develop a therapeutic nurse client relationship through frequent, brief contacts and an
accepting attitude. Show unconditional positive regard.

• Encourage client to take as much responsibility as possible for own self – care practices.

• Help client to recognize and focus on strengths and accomplishments.

• Help client set realistic goals.

• Encourage participation in social activities and provide positive reinforcement.

3. Disturbed thought process related to impaired cognition fostering
negative perception of self and the environment.

• Do not argue or deny the belief

• Use the techniques of consensual validation and seeking clarification.

• Reinforce and focus on reality. Talk about real events and real people.

• Give positive reinforcement as client is able to differentiate between reality – based

and nonreality – based thinking.

• Teach client to intervene, using thought – stopping techniques, when irrational or

negative thoughts prevail.
4. Imbalanced nutrition less than body requirement related to liability
to ingest food because of depressed mood, loss of appetite, energy level
too low to meet own nutritional needs, ideas of self – destruction.

• Ensure high fiber diets to prevent constipation. Encourage client to increase fluid
consumption and physical exercise.
• Weigh client daily.
• Determine client’s likes or dislikes.
• Administer vitamin and mineral supplements and stool softeners or bulk extenders, as
ordered by physician.
• Stay with client during meals.
• Explain the importance of adequate nutrition and fluid intake.
 5. Insomnia related to depression or repressed fears.
• Keep strict records of sleeping patterns.

• Discourage sleep during day.

• Administer antidepressants medication on bedtime.

• Assist with measure that may promote sleep, such as warm, non stimulating drinks, light snacks, warm baths,

back rubs, relaxation exercises, and soft music.

• Limit intake of caffeinated drinks such as tea, coffee and colas.

• Administer sedative medications as ordered.

• Some depressed clients may use excessive sleep as an escape. For them limit time spent in a room. Plan

stimulating diversionary activities on daily schedule.

• Depressed people are more likely to engage in behaviors that contribute to poor health such as smoking, limited

or no exercise, poor eating habit and are likely to have greater difficulty managing their co-morbid conditions.