MOOD DISORDERS

JISHA MARY GEORGE

Mood disorders

 Mood :- Mood is a state of feeling (emotional) usually temporary resulting from a

specific stimulus. the word mood is derived from ancient English word “mod”
which means courage especially during the time of war.
 Mood: mood refers to an internal emotional state of an individual
 Affect: affect is the external expression of internal emotional content
Meaning

 Mood disorders are characterized by a disturbance of Mood accompanied by full

or partial manic or depressive syndrome not due to any other physical or mental
disorder
Definition

 Mood disorders or affect disorders are described by Marked disruption in emotions,

severe lows called the depression or Highs called mania
 there are two groups of mood disorders depressive disorders and bipolar disorders
 bipolar disorder is characterized by intermittent episodes of mania or hypomania and
depressive episodes ;rapid cycling, mixed state and psychotic symptoms occur in some
cases
 depression is a serious mental disorder that manifest with depressed mood, loss of
interest or pleasure, feelings of guilt or low self worth, disturbed sleep or appetite, low
energy and poor concentration
 mania is a state of abnormally elevated or irritable mood, arousal, and/or increased
energy level
Prevalence and incidence

 The onset of mood disorders usually occurs during adolescence

 The lifetime prevalence of bipolar disorder is about 4%
 according to global burden of disease study 1990- 2017, the crude prevalence rate
for depressive disorders was 3.3%
 depressive disorders are ranked as the single largest contributor to non-fatal health
loss affecting 4.4% of global population
 in 2017 45.7 million people suffered from depressive disorders in India. bipolar
disorders had prevalence of 0.6%
 the mean age of onset of bipolar disorder is aroud around 25 years. men typically
have an earlier age of onset than women (18 years in men and 20 years in women)
 women are more likely to experience many mood episodes in a given year
compared to men
 two thirds of bipolar patients have at least one close relative who was also
diagnosed with the disease or with unipolar depression
Manic episode

 it is a state of abnormally elevated or irritable mood, arousal and or energy level

 a manic episode is a mood state characterised by period of at least one week
where an elevated, expensive or and usually irritable mood exists
Triggers of mania

 not sleeping properly or missing night sleep

 stress at work
 being really busy with activities and hobbies
 being away a lot at weekends and or not having enough down time to relax
 drinking too much caffeine or alcohol
 skipping meals
warning signs of mania

 staying up until early hours of morning, & finding it hard to stop activities and go
to bed
 being more chatty than usual & wanting to be with other people all time
 buying lots of new clothes & wanting to wear loud outfits one would not normally
 spending a lot of time on social media
 feeling impairement with the people, like they cannot keep up with me
Etiological factors

 genetic or hereditary factors

 family history
 the exact genetic factor remains unknown
 monozygotic or identical twins have higher rate of incidence than normal siblings
and close relatives
 siblings and close relatives have higher incidence than general population
 first degree relatives: 5- 10%
 identical twins with the bipolar disorders 40 -7%
lneurotransmitters

 excessive levels of norepinephrine & serotonin

 imbalance between cholinergic or noradrenergic system
 deficiency of serotonin
Structural hypothesis

 lesions in the areas of brain such as right hemisphere or bilateral subcortical and
peri ventricular gray matter
 kindling theory: external environmental stressors activate internal physiologic
stress responses, trigger first episode. Then the first episode creates
electrophysiological sensitivity to future episodes
Psycho dynamic theory

 faulty family dynamics during early life

 Defense against or denile of depression

Environmental factors
 Increased stressful events prior to first onset and reccurrence of mood episodes
 psycho social stresses cause relapse
organic disorders

 physical illness illness such as thyroid disorders, HIV/ AIDS lupus, encephalitis
 neurological conditions like a dementia, huntington's disease, brain injury,
multiple sclerosis cause symptoms of hypomania or mania
 high levels of stress
 changes in sleep pattern or lack of sleep
 use of stimulus such as drugs or alcohol
 seasonal changes: mainly in spring
 significant change in life: moving house, going through a divorce
 side effect of medication: antidepressants
Clinical features

 elevated mood:- has four stages

 stage 1: Euphoria: increased sense of psychological well being and happiness not
in keeping with ongoing events
 stage II: elation: moderate elevation of mood, with increased psycho motor
activity
 stage III: exaltation Intense elevation of mood with delusions of grandeur
 stage IV: ecstasy: severe elevation of mood, intense sense of rapture or
blissfulness seen in delirious or stuporous mania
 Expansive mood: extreme expression of emotions characterized by inflated self
importance and exaggerated behavior, unending and unselective in enthuciasm for
interacting with people and the surrounding environment
 irritable mood is predominant when person is stopped from doing what he wants
 there may be rapid shift from Euphoria to irritability or anger
 Psycho motor activity increased psycho motor activity ranging from
overactiveness and restlessness to many excitement
Psychomotor activity

 Increased Psychomotor activity ranging from over activeness and restless to

manic excitement
 Ceaseless activities being goal oriented and based on external environmental cues
Speech and thought

 flight of Ideas
 pressure of speech: uses playful language with rhyming, joking, teasing & speaks
loudly
 clang association
 grandiose delusions
 other delusions: delusions of Paranoia
 distractability: selective attention, function apparently deteriorates
other features

 engage in goal directed activities that may result in harmful consequences

 high risk activities
 involved in property damage or even harm themselves or others through verbal or
physical assault
 increased sociability
 impulsive behavior, highly aggressive and agitated
 disinhibition
 hyper sexual and promiscous behaviour
 poor judgement
 dressed up in gaudy &flamboyant clothes
 decreased need for sleep
 decreased food intake due to over activity
 decreased attention and concentration
 absent insight
 rapid cycling in bipolar disorders is defined as having at least 4 or more episodes
in 12 month period. the mood episodes may be mania, hypomania or depressive
disorders. these episodes must separated by a periods of partial or full remission
of at least 2 months.
stages of mania

 Stage I: hypomania
 Disturbance is not sufficiently severe to cause marked impairment in social or
occupational functioning or to require hospitalisation
Mood
 Mood of hypomanic person is cheerful and expansive
 Getting irritable when the person’s wishes or desires go unfullfilled
 Nature is volatile & fluctuating
cognition and perception

 perception of self are exalted, ideas of great worth and ability

 thinking is flighty with the rapid flow of Ideas
 perception of the environment is hightened but easily distracted by irrelevant
stimuli
activity and behaviour

 increased motor activity

 extroverted and sociable, attract numerous acquaintances
 lack the depth of personality and warmth to formulate close relationship
 talk & laugh a lot, usually very loudly and often inappropriately
 increased libido
Stage II: acute mania

 symptoms of a cute mania may be progression in intensification in hypomania, or

may be marked directly
 marked impairment in functioning and require hospitalisation
 mood: Euphoria and elation
 person appears to be on continuous high
cognition and perception

 fragmented and often psychotic in acute mania

 flight of ideas
 pressured speech
activity and behaviour

 psychomotor activity is excessive

 increase in sexual interest
 poor impulse control
 energy seems inexhaustible
 many days without sleep and still not feel tired
 hygiene and grooming may be neglected
 dress may be disorganized, flamboyant or bizzare
 use of excessive makeup or jewellery
Stage III: delirious mania

 severe clouding of consciousness and an intensification of symptoms associated

with acute mania
 rare condition
Mood

 Labile mood
 feeling of despair
 irritable and indifferent to the environment
cognition and perception

 clouding of consciousness, with accompanying confusion, disorientations and

sometimes stupor
 religiosity, delusion of grandeur or persecution
 auditory or visual hallucination
 extremely distractible and incoherent
activity and behaviour

 psychomotor activity is frenzied characterized by agitated, purposeless movement

 safety is at stake unless this activity is curtailed
 exhaustion, injury to self for others, eventually death could occur without
intervention
Diagnosis

1. ICD 11
2. DSM 5 criteria
 A distinct period of normally and persistently elevated expansive or irritable mood
and abnormally and a persistently increased goal directed behaviour or energy
lasting for at least one week and present most of the day, nearly every day
 during the period of mood disturbance and increased energy or activity, 3 or more
of the following symptoms have persisted are present to significant degree and
represent a noticeable change from usual behavior
 inflated self esteem or grandiosity
 decreased need for sleep
 more talkative than usual or pressure to keep talking
 flight of ideas or subjective experience that thoughts are racing
 distractibility as reported or observed
 increase in goal directed activity, (at work or school, or sexually) or psychomotor
agitation
 excessive involvement in activities that have a high potential for painful
consequences
 the mood disturbance is sufficiently severe to cause marked impairment in social
or occupational functioning or to necessitate hospitalization to prevent harm to
self or to others, or there are psychotic features
 the episode is not attributable to the direct physiological effects of a substance or
another medical condition
 3. psychological tests as young Mania Rating Scale
 4. MSE
Treatment modalities

 Mood stabilizers:-
 Lithium: 900-2100 mg/day
 Carbamazepine: 600-1800 mg/day
 Sodium valproate: 600-2600 mg/day
 Lamotrigine: 25-200 mg/day
Antipsychotics:- in case of delusion and hallucination
 Olanzapine
 Aripiprazole
 Risperidone
 quetiapine
Other drugs

 Clonazepam
 Diazepam
 Calcium channel blockers etc.
 ECT:- for acute manic episode (if no adequate response to antipsychotics &
lithium
 Psychological intervention
 Psychoeducation:- educate client & family about disease, and educate the client about coping
strategies in stress
 Cognitive behavioural therapy: to help to identify the patterns that lead to hypomania and develop
ways to change these.
 Family Education
 Mindfulness- based cognitive therapy
 Interpersonal therapy
Prognosis

 Prognosis is favourable with medication & therapy

 Factors associated with poor outcome are:
 History of abuse
 Psychosis
 Low socio economic status
 Comorbid illness
 Young age of onset
 Nursing management
 Nursing assessment
 The nurse should assess:
 Severity of disease
 Causes
 Effect of behavior on other people
 Changes in sleep, activity, hunger, & irritability
 Mental status examination
General appearance & behaviou:
 Psychomotor agitation: difficulty in sitting at one place, wearing clothes that reflect elevated
mood,bright coloured clothes, flamboyant, attention seeking, pressured speech
 Mood and affect: euphoric, grandiosity, false sense of wellbeing
 Thought process: flight of ideas, circumstantiality, tangentiality, grandiosity
Perception & cognition:
 Orientation present
 Impaired attention & concentration
 Difficult intellectual function
 Judgement: impaired
 Insight:- limited
 Nursing diagnosis
 High risk for injury related to extreme hyperactivity and impulsive behavior evidenced by lack of
control over purposeless and potentially injurious movements

 Objectives: patient will not injure self

 1. Reduce environmental stimuli.
 2. Assign single room and keep lighting and noise level low.
 3. Remove hazardous objects and substance
 4. Stay with the client who is hyperactive and agitated.
 5. Provide physical activities.
 6. Administer tranquilizing medication as ordered by physician.
 High risk for violence self-directed or other-directed related to manic excitement,
delusional thinking, hallucinations Outcome Identification Nursing Intervention
 Objectives
 Client will not harm self or others
Intervention
 1. Maintain low level of stimuli
 2. Observe client’s behavior at least every 15 minutes.
 3. Ensure that all sharp objects have been removed from client’s environment.
 4. Redirect violent behavior.
 5. Encourage client to express his anger verbally
 6. Have sufficient staff to indicate a show of strength to client if necessary.
 7. Administer tranquilizing medication. If client refuses, use of mechanical restraints may be
necessary.
 8. Observe the client in restraints every15 minutes.
 9. Remove restraints gradually, one at a time
 Impaired social interaction related to egocentric and narcissistic behavior evidenced by inability to
develop satisfying relationships and manipulation of others for own desires
 Outcome
 Client will interact appropriately with others.
 Nursing Intervention
1. Recognize that manipulative behaviors help to reduce feelings of insecurity by increasing feelings of
power and control.
2. Set limits on manipulative behaviors.
3. Explain what is expected and the consequences if limits are violated.
4. Discourage the client to argue, bargain, or charm his or her way out of the limit setting
5. Give positive reinforcement for non manipulative behaviors.
6. Discuss consequences of client’s behavior and how attempts are made to attribute them to others.
7. Help client identify positive aspects about self, recognize accomplishments, and feel good about them
 Imbalanced nutritional status less than body requirements, related to refusal or inability to sit still
long enough to eat evidenced by weight loss, amnenorrhoea

 Objective
 Patient will not exhibit signs and symtoms of malnutrition
 Provide high protein, high caloric nutritious finger foods that can be consumed on
the run
 Provide favourite foods
 Maintain intake output chart
 Suppliment diet with vitamins and minerals
 Walk or sit with the patient while he eats
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
Classification of depression

 6A70: Single episode depressive disorder

 6A70.0: Single episode depressive disorder, mild
 6A70.1: Single episode depressive disorder, moderate without psychotic symptoms
 6A70.2: Single episode depressive disorder, moderate with psychotic symptoms
 6A70.3: Single episode depressive disorder, severe without psychotic symptoms
 6A70.4: Single episode depressive disorder, severe with psychotic symptoms
 6A70.5: Single episode depressive disorder, unspecified severity
 6A70.6: Single episode depressive disorder, currently in partial remission
 6A70.7: Single episode depressive disorder, currently in full remission
 6A71: Recurrent depressive disorder
 6A71.0: Recurrent depressive disorder, current episode, mild
 6A71.1: Recurrent depressive disorder, current episode, moderate without psychotic symptoms
 6A71.2: Recurrent depressive disorder, current episode, moderate with psychotic symptoms
 6A71.3: Recurrent depressive disorder, current episode, severe without psychotic symptoms
 6A71.4: Recurrent depressive disorder, current episode, severe with psychotic symptoms
 6A71.5: Recurrent depressive disorder, current episode, unspecified severity
Onset & clinical Course

 Untreated episode of depression can last to 6 t0 24 months before remitting

 50-60% people have recurrence for second time
 After second episode, there is 70% chance of recurrance
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 the
anxiolytics, antipsychotics, 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

 Hopelessness, helplessness, worthlessness

 Self blame
 Suicidal ideation
 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
 Significant decrease in appetite or weight
 Early morning awakening
 Diurnal variation (worst in morning)
Other features

 Difficulties in thinking and concentration

 Subjective poor memory
 Menstrual and sexual disturbances
 Vague physical symptoms: fatigue, aching discomfort, constipation etc.
Diagnosis

 Detailed Psychiatric history

 Mental Status Examination
 History of medication uses, neurological disorders etc.
 Psychological tests like depression scale
 Dexamethasone suppression test: cortisol secretion
 DSM V Criteria
 Five or more of the following symptoms have been present during the same 2- week period and
represent a change from previous functioning; atleast one of the symptoms is either
a. A depressed mood
b. Loss of interest or pleasure
Do not include symptoms that are attributable to another medical condition
a. Depressed most of the day
b. Markedly diminished interest or pleasure in all
c. Significant weight loss
d. Insomnia or hypersomnia
e. Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feeling of worthlessness or excessive or inappropriate guilt
 Diminished ability to think or concentrate
 Recurrent thought of death, recurrent suicidal ideation
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

 Antidepressants
 Tricyclics (TCA) / Mono-amino oxidase inhibitors (MAOI), Selective serotonin
reuptake inhibitors (SSRIs).
 After a first episode of a unipolar major depression, treatment should be
continued for six months after clinical recovery, to reduce the rate of relapse.
 Lithium Carbonate can be used as prophylaxis.
 Antipsychotics are an important adjunct in the treatment of mood disorder.
 The commonly used drugs include risperidone, olanzapine, quetiapine,
haloperidol.
Psychosocial Therapies

 ECT
 Psychotherapy
 Repatative trans cranial magnetic stimulation and vagus nerve stimulation
 CBT
 Interpersonal therapy
 Psychoanalytic psychotherapy
 Behavior therapy
 Group therapy
 Family & Marital therapy
 Nursing Process
 Nursing Assessment
 History collection and physical examination:-
 Use active listening
 Give open questions and give enough time to answer without interrupting
 Collect past history
 History of suicide
 Assess suicide risk
Mental status examination

 Appearance
 Behaviour
 Mood/affect
 Thought process
 Perceptual disturbances
 Cognition
 Insight and judgment
Nursing diagnosis:
 Risk for self directed violence related to depressed mood, feelings of worthlessness, anger turned inward
on the self.
Outcome
 Client will not harm self
Intervention
1. Assess for suicidal ideations
2. Do not allow the client to be alone in the ward
3. Remove all the sharp instruments, ropes from the vicinity of the client
4. It may be desirable to place the patient near nursing station for close observation.
5. Do not allow the client to put bolt on his side door and bathroom
6. Encourage the client to express feelings.
 Dysfunctional grieving related to real or perceived loss, bereavement overload, evidenced by denial of
loss, inappropriate expression of anger, inability to carry out activities of daily living.
 Outcome Client will be able to verbalize normal behaviors associated with grieving and begin progression
toward resolution
Nursing Intervention
1. Assess stage of fixation in grief process
2. Develop trust. Show empathy, concern, and unconditional positive regard
3. Explore feelings of anger and help client direct them toward the intended object
4. Promote the use of large motor activities for relieving pent-up tension
5. Teach normal behaviors associated with grieving
6. Help client with honest review of relationship with lost object.
Self esteem disturbance related to learned helplessness, feelings of abandonment by significant other, or
impaired cognition fostering negative view of self, evidenced by expressions of worthlessness,
hypersensitivity to a slight or criticism, and a negative, pessimistic outlook.
Outcome
Client will interact appropriately with others.
Nursing Intervention
1. Develop a trusting relationship with client
2. Encourage the client to become involved with staff and other clients through interaction
3. Explore feelings of anger and help client direct them toward the intended object or person
4. Encourage the client for recreational activities
5. Provide simple activities and shift gradually to complex activity
6. Give positive feedback for each accomplished activities
7. Explore with the client his or her personal strengths, making a written list is sometimes helpful
Bipolar disorder

 It is also an known as manic- depressive illness, is a brain disorder that causes

unusual shift in mood, energy, activity levels, and the ability to carry out day- to-
day tasks
Etiology
 there is no single course
 many factors likely act together to produce the illness or increase risk
 brain and bipolar disorder
 noradrenaline and serotonin linked to depression, and bipolar disorder
 serotonin is connected to body function such as sleep wakefulness, eating, sexual
activity, impulsivity, learning and memory.
 abnormal serotonin levels contribute to mood disorders
 dopamine linked with the pleasure system of brain. disruption of the dopamine
system is connected to psychosis
 Genetics
 children with a parent or sibling who has bipolar disorder are four to six times more
likely to develop the illness, compared with children who not have a family history of
bipolar disorder
 identical twins of persons with the bipolar disorder does not always developed the
disorder
 Many different genes and a person’s environment are involved
Epidemology

 bipolar disorder affects men and women equally as well as all races, ethnic
groups, socio- economic classes
 develops in person’s late teens or early adult years
 atleast half of the case of start before age of 25
 Classification
 6A 60- Bipolar type 1 disorder
 6A 60.0- Bipolar type 1 disorder current episode manic, without psychotic symptoms
 6A 60.1- Bipolar type 1 disorder current episode manic, with psychotic symptoms
 6A 60.2- Bipolar type 1 disorder current episode hypomanic
 6A 60.3- Bipolar type 1 disorder current episode depressive, mild
 6A 60.4- Bipolar type 1 disorder current episode depressive, moderate without psychotic symptoms
 6A 60.5- Bipolar type 1 disorder current episode depressive, moderate with psychotic symptoms
 6A 60.6- Bipolar type 1 disorder current episode depressive severe, without psychotic symptoms
 6A 60.7- Bipolar type 1 disorder current episode depressive severe, with psychotic symptoms
 6A 60.8- Bipolar type 1 disorder current episode depressive, unspecified severity
 6A 60.9- Bipolar type 1 disorder current episode mixed, without psychotic symptoms
 6A 60.A- Bipolar type 1 disorder current episode mixed, with psychotic symptoms
 6A 60.B- Bipolar type 1 disorder currently in partial remission, most recent episode manic or hypomanic
 6A 60.C- Bipolar type 1 disorder currently in partial remission, most recent episode depressive
 6A 60.D- Bipolar type 1 disorder currently in partial remission, most recent episode mixed
 6A 60.E- Bipolar type 1 disorder currently in partial remission, most recent episode unspecified
 6A 60.Y- other specified Bipolar type 1 disorder
 6A 60.Z- Bipolar type 1 disorder, unspecified
 6A 61 Bipolar type II disorder
 6A 6.0 Bipolar type II disorder, current episode depressive hypomanic
 6A 61.1 Bipolar type II disorder, current episode depressive mild
 6A 61.2 Bipolar type II disorder, current episode depressive, moderate without psychotic symptoms
 6A 61.3 Bipolar type II disorder, current episode depressive, moderate with psychotic symptoms
 6A 61.4 Bipolar type II disorder, current episode depressive, severe without psychotic symptoms
 6A 61.5 Bipolar type II disorder, current episode depressive, severe with psychotic symptoms
 6A 61.6 Bipolar type II disorder, current episode depressive, unspecified severity
 6A 61.7 Bipolar type II disorder, currently in partial remission, most recent episode hypomanic
 6A 61.8- Bipolar type II disorder currently in partial remission, most recent episode depressive
 6A 61.9- Bipolar type II disorder currently in partial remission, most recent episode unspecified
 6A 61.A- Bipolar type II disorder currently in full remission
 6A 61.Y- other specified Bipolar type II disorder
 6A 60.Z- Bipolar type II disorder, unspecified


Clinical features

 Experience usually intense emotional States that occur in distinct periods called
mod episodes
 overly joyful or overexcited states called manic episode
 extremely sad or hopeless state called depressive episode
 sometime symptoms of both mania and depression called mixed states
symptoms of mania or Manic episode
includes
Mood changes
 long periods of feeling “high” or an overly happy or outgoing mood.
 extremely irritable mood, agitation, feeling “jumpy” or weird
Behavioural changes

 talking very fast, jumping from one idea to another, having racing thoughts
 being easily districted
 increasing goal directed activities such as taking on new projects
 being restless
 sleeping little
 having an unrealistic belief in one’s abilities
 behaving impulsive and taking part in a lot of pleasurable, high-risk behaviours
such as spending sprees, impulsive sex and impulsive business investment
symptoms of depression or depressive
episode includes
Mood changes
 a long period of feeling worried or empty, loss of interest in activities once
enjoyed, including sex
Behavioural changes

 feeling tired or slowed down

 having problems concentrating, remembering and making decisions
 being restless or irritable
 changing eating, sleeping on other habits
 thinking of death or suicide or attempting suicide
Types of bipolar

 there are four basic types of bipolar disorder

 bipolar I disorder
 it is defined by manic or mixed episode that last at least 7 days or by Manic
symptoms that are so severe that the person needs immediate hospital care.
Usually, the person also has depressive episodes, typically lasting at least two
weeks. the symptoms of mania or depression must be major change from the
person’s normal behaviour
bipolar II disorder

 it is defined by a pattern of depressive episodes shifting back and forth with the
hypomanic episodes, but no full- blown manic or mixed episode
bipolar disorder not otherwise specified (BP-NOS)
 diagnosed when a person has symptoms of the illness that do not meet diagnostic
criteria for either bipolar I more II. The symptoms may not last long enough, or
person may have too few symptoms, to be diagnosed with bipolar I or II.
symptoms are clearly out of person’s normal range of behaviour
cyclothymic Disorder or Cyclothymic

 it is a mild form of bipolar disorder.

 People have episodes of hypomania that shift back and forth with mild depression
for at least 2 years
Diagnosis

 ICD-11 criteria
 A manic episode is an extreme mood state lasting at least one week unless
shortened by a treatment intervention characterised by europhia, irritability, or
expansiveness and by increased activity or a subjective experience of increased
energy, accompanied by other characteristic symptoms such as rapid or pressured
speech, flight of ideas, increased self esteem or grandiosity, decreased need for
sleep, distractibility, impulsive or reckless behavior, and rapid changes among
different mood states
 a mixed episode is characterised by either a mixture or very rapid alteration
between prominent and depressive symptoms on most days during a period of at
least 2 weeks
 although the diagnosis can be made based on evidence of a single manic or mixed
episode, typically manic or mixed episodes alternative with depressive episodes
over the course of the disorder
Psychological evaluation

 family history of bipolar disorder

 alcohol and drug abuse
 mood charting- daily record of patients moods, sleep patterns
 mood disorder questionnaire
Nursing assessment

 History collection
 information about patient’s clinical and psychosocial status, medical psychiatric
co-morbidities, current and past medications and medication compliance
Physical examination

 signs of suicide, self- harm

 thyroid gland problems
 Mental status examination
 Appearance and Behaviour:
 Manic episode: energetic, excited, talkative, frequently hyperactive