PSYCHIATRIC
NURSING
MOOD DISORDERS
Dr. Fadwa Alhalaiqa
S
1
Objectives
S Discuss the epidemiological statistics related to mood
disorders.
S Describe various types of mood disorders.
S Identify etiological implications in the development of
mood disorders.
S Depression related to development stage.
S Discuss symptomatology associated with mood disorders.
2
Mood disorders
S Called affective disorders, are pervasive alterations in
emotions that are manifested by depression, mania, or both.
S They interfere with a person’s life, plaguing him or her with
drastic and long-term sadness, agitation, or elation.
S Accompanying self-doubt, guilt, and anger alter life
activities, especially those that involve self-esteem,
occupation, and relationships.
3
Mood Disorders
• Consequences of dysfunctional grieving is manifested by
Mood disorders.
•
Mood: is the individual’s emotional tone, which
significantly influences behavior, personality, and perception.
• Mood disorders have two major categories:
 Depressive disorders, and
 Bipolar disorders.
 There are also mood disorders due to general medical
condition and substance-induced mood disorder
4
Famous people with MDs
S Abraham Lincoln
S Queen Victoria
S had recurrent episodes of depression
5
Dr. Masa'deh
Epidemiology of Mood
Disorders
S Major depression is one of the leading causes of disability
in the US (10%) of the population.
S Gender: depression is higher in women than men (2:1).
Bipolar is almost equal (1.2 in women to 1 in men).
S Depression ‘‘common cold of psychiatric disorders’’.
S Age: depression is higher in young women (decrease with
age) and old men (increase with age). The median age for
the onset of bipolar disorder 18 for men and 20 years for
women.
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Epidemiology of Mood
Disorders
S Social class: inverse relationship between depression
and social class, while bipolar is higher among
higher social classes (professionals and highly
educated).
S Race: no consistent relationship has been found
S Marital status: depression is higher among divorced
individual, separated and individual without close
interpersonal relation.
S Seasonality: Spring & Fall (peak of suicide is spring)
7
S Mood disorders are the most common
psychiatric diagnoses associated with suicide;
depression is one of the most important risk
factors for it
8
Major Depression
Major Depression
S Characterized by a change in several aspects of a
person’s life and emotional state consistently
throughout at least 14 days.
S Mood state described as down, sad, or feeling
“blah.”
S Clients with bipolar disorder also experience a
depressed mood.
Types of MDs: Depressive Disorders
1.
Major Depressive Disorder (MDD): characterized by:
* Depressed mood or loss of interest or pleasure in usual
activities.
* Evidence of impaired social and occupational function for at
least two weeks.
* No history of manic behavior.
* Symptoms cannot be attributed to the use of substance or
general medical condition (see criteria of the disorder).
10
Classification of MDD
 Episode: Single or recurrent (first diagnosis vs. 2 or more
episodes).
 Severity: mild, moderate, or severe (according to the
number and severity of the symptoms).
 With psychotic features: impairment of reality (delusions
or hallucinations)
 With catatonic features: presence of psychomotor
disturbance (psychomotor retardation, waxy flexibility).
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Classification of MDD
 With melancholic features: sever major depression,
symptoms are exaggerated with anhedonia.
 Chronic: the current episode has been evident for at
least 2 years.
 With seasonal pattern: occur during fall or winter
months
 With postpartum onset: depression symptoms
occur within 4 weeks postpartum.
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Depressive disorders
2. Dysthymic disorder: *characteristics of the mood are milder
than the major depressive disorder.
S Individual with dysthymic disorder describe their mood as
down with no evidence of psychotic symptoms.
S The essential feature is a chronically depressed mood for most
of the day, more days than not for at least 2 years.
S Dysthymic disorder may be classified according to the age of
onset: early onset (before 21 years) and late onset (older than
21) .
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Depressive disorders
3. Premenstrual dysphoric disorder:
The essential features include marked depressed mood,
severe anxiety, mood swing, and decrease interest in
activities during the week prior the menses and subside
shortly after the onset of menstruation.
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Bipolar Disorder
Bipolar Disorder
S The bipolar disorders are a group of mood
disorders that include manic episodes, hypomanic
episodes, mixed episodes, depressed episodes,
and cyclothymic disorder.
S Only clients with Bipolar Disorder experience the
elevated mood symptoms seen in mania and
hypomania.
Types of MDs: Bipolar Disorders
S Bipolar disorders: characterized by mood swing from
profound depression to extreme euphoria (mania) with
intervening periods of normalcy. Psychotic symptoms
such as delusions or hallucinations may or may not be
present.
S In manic episode, the mood is elevated, motor activity
is excessive, occupational functioning and social
activities are impaired (disturbance is sever).
S Hospitalization is required to prevent harm to self &
others.
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Types of MDs: Bipolar Disorders
S In Hypomania, symptoms are less severe with no impairments
in social or occupational functioning and with no psychotic
symptoms that require hospitalization .
S The feature of depression associated with bipolar disorder is
identical to MDD with one addition:
 the client must have a history of one or more manic episode.
S In bipolar disorder, when presentation include rapidly
alternating moods accompanied by depression and mania
symptoms, the individual is given a diagnosis of bipolar
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disorder, mixed.
Types of MDs: Bipolar Disorders (Cont)
1.
Bipolar I disorder: characterized by occurrence of at least
one full manic episode or mixed symptoms in his/her life.
2.
Bipolar II disorder: characterized by at least one hypomanic
episodes and one or more depressive episodes (the depressive
episode can be more frequent/intense than the manic one).
The client has never experienced an episode that meets the
full criteria of mania or mixed symptoms.
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Bipolar Disorders (Cont.)
3. Cyclothymic disorder:
characterized by chronic mood change for at least 2 years
involving numerous episodes of hypomania and mild
depressed mood of insufficient severity to meet bipolar 1
or bipolar 2.
The individual is never without hypomanic or depressive
symptoms for more than 2 months.
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Types of MDs: Other Mood Disorders
1. Mood Disorder due to a general medical condition
S Prominent & persistent disturbance in mood due to the
result of direct physiological effects of a general medical
condition.
2. Substance-induced mood disorder
S The direct result of physiological effects of a substance:
alcohol, amphetamines, cocaine, hallucinogens, inhalants,
opioids, sedatives, hypnotics, and anxiolytics.
S The symptoms can occur with withdrawal from these
substances.
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Dysfunctional
Grieving
Dysfunctional Grieving
S Bereavement is a term that refers to the state of
loss.
S Dysfunctional grieving is a term that describes the
failure of an individual to follow the course of
normal grieving to a point of resolution.
Depressive Disorders Etiology
1. Biological theories
A. Genetics
Genetic link has been suggested through studies, but no definite
mode of genetic transmission has been demonstrated.
S
Twin studies: 50% of monozygotic and 10-25 % in dizygotic
twins.
S
Family studies: major depression is 1.5-3 times more common
among first degree biological relatives of people with the
disorder.
S
Adoption studies: increase risk in biological children of
affected parents.
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Depressive Disorders: Etiology
1. Biological theories
B. Biochemical influences:
S
Biogenic amines: deficiency in reserpine, catecholamine,
serotonin, tryptophan, dopamine, and acetylcholine.
C. Neuroendocrine Disturbances
S Hypothalamic pituitary adrenocortical axis: in depressed
clients, normal system of hormonal inhibition fails, resulting
in a hypersecretion of cortisol.
S Hypothalamic pituitary thyroid axis: Thyorotropin-releasing
factor (TRF) from hypothalamus stimulate Thyroid
stimulating hormone (TSH), which stimulate the thyroid
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gland.
Depressive Disorders: Etiology
1. Biological theories
D. Physiological influences (secondary depression)
S Medication side effects: e.g proporanolol (antihypertensive),
Cortisone, anxiolytics, antipsychotics, and sedative-hypnotics.
S Neurological disorders: CVA, brain tumor, Alzheimer
S Electrolyte disturbances: ↑(NAHCO3, C a., & K ), deficit in
Mg.
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Physiological influences (cont.)
S Hormonal disturbances: hypo and hyperthyroidism,
hyperparathyroidism, adrenal cortex dysfunction
(Addison’s & Cushing’s disease), estrogen &
progesterone imbalance.
S Nutritional deficiencies: deficiencies in vitamin B1,B6,
B12, niacin, vitamin C, iron, folic acid, zinc, calcium,
and K.
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Depressive Disorders: Etiology
2.Psychosocial theories
A. Psychoanalytical theories: ambivalence love relationship:
once the loss has been incorporated into self (ego), the
hostile part of the ambivalence that had been felt for the
lost turned inward against the ego. This cause guilt, selfhate and self-blame and affects the self esteem.
B. Learning theory: when the humans experience numerous
failures the individual then abandons any further attempt
to succeed (learned helplessness) (remember animal
studies).
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Depressive Disorders: Etiology
2.Psychosocial theories
C. Object loss theory: separated from mother in the first 6
months of life (mother is the object). It could also be absence of
attachment.
D. Cognitive theory: depression is the product of negative and
defeated attitude:
 negative expectations of the environment,
 negative expectations of the self, and negative expectations of
the future.
E. Theoretical integration
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Depressive Disorders: Nursing Process
1. Assessment data:
S Transient symptoms of depression (symptoms accompany
everyday disappointments such as failing an exam. These
symptoms subside quickly as the individual advances
toward other goals). DAILY LIFE DISAPPOINTMENTS
S Mild symptoms of depression occurs when the grief is
triggered in response to loss of a valued object. As one is
able to work through the stages of grief, the loss is accepted
and symptoms subside. NORMAL GRIEF RESPONSE
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Assessment data
S Moderate symptoms of depression occurs when grief
is prolonged (fixed in anger stage and the anger turned
inward to the self). Individual is unable to fully
function without assistance. Dysthymic disorder is an
example of moderate depression.
S Severe symptoms of depression has more intense
symptoms and may also manifested by loss of contact
of reality. Complete lack of pleasure in all activities.
Suicide thoughts. Major depression disorder is an
example of sever depression.
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Depressive
Disorders:
Depressive Disorders:
Subjective
Data
Subjective Data
S Feelings of sadness
S Fatigue
S Lack of interest in relationships and activities that
were previously pleasurable
S Feelings of worthlessness
S Impaired concentration
Depressive
Disorders:
Depressive Disorders:
Subjective
Data
continued
Subjective Data (cont'd)
S Impaired decision-making ability
S Sleep disturbances
S Appetite changes; weight loss or weight gain
S Excessive sleep
S Somatic concerns
S Suicidal ideation
Depressive
Disorders:
Depressive Disorders:
ObjectiveObjective
Data
Data
S Females under the age of 40
S Prior episodes of depression
S Family history of depression or bipolar disorder
S A history of a recent stressful event
S Lack of social support
Depressive
Disorders:
Depressive Disorders:
Objective
Data
-continued
Objective Data (cont'd)
S Psychomotor agitation or retardation
S Family may report client agitation or apathy and
anhedonia
S Pattern of social withdrawal
S Lack of social participation
S Be alert to a change in behavior
Bipolar Bipolar
Disorders:
Disorders:
Subjective Data
Subjective Data
S Changes in thought processes
S Inflated self-esteem
S Delusions of persecution
S Ignore fatigue and hunger
S Inability to concentrate
S Distracted by the slightest stimulus
S Hallucinations
Bipolar Bipolar
Disorders:
Disorders:
Objective Data
Objective Data
S Young people in their twenties
S Little gender specificity
S Initial episode is likely to be manic in males and
depressive in females
S No documented evidence of the effect of race or
ethnicity
Bipolar Bipolar
Disorders:
Disorders:
Objective Data - continued
Objective Data (cont'd)
S Hallmark of mania is constant motor activity
S Disordered sleep patterns
S Flight of ideas
S Pressured speech
S Poor judgment
Bipolar Bipolar
Disorders:
Disorders:
Objective Data - continued
Objective Data (cont'd)
S Appearance may be unusual
S Absence of personal hygiene
S Impairment in occupational functioning
S Interpersonal chaos
Nursing Process Cont.
2. Nursing diagnoses:
S Risk for suicide RT depressed mood, anger,
misinterpretation of reality
S Low self-esteem RT learned helplessness, feeling
abandonment by significant others
S Spiritual distress RT dysfunctional grieving and anger
with God.
S Imbalance nutrition, Self care deficit
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Bipolar Disorder (mania): predisposing
factors
1. Biological theories: Genetics:
S Twin studies: monozygotic 60-80%, dizygotic 20%
S Family studies: risk is 28% if one parent have bipolar & 2-3
times greater if both.
2. Biochemical influences:
S Biogenic amines: functional excess of norepinephrine,
serotonin, and/or dopamine.
S Electrolytes: elevated levels of intracellular sodium & ca.
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Manic Disorder: predisposing factors
3. Physiological influences:
S Neuroanatomical Factors: Rt. side brain lesions induce
secondary mania
S Medication side effects: steroids, Amphetamines,
antidepressants, anticonvulsants.
4. Psychosocial theories:
S The credibility of psychosocial theories has declined in
recent years.
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Manic Disorder: nursing process
Assessment data: symptoms of mania can be described in three
stages:
1.
Hypomania (does not cause social/functional impairment):
S Mood: cheerful and expansive. However, rapid change when
desires unfulfilled.
S Cognition & perception: ideas of great worth and ability of
self, thinking is flighty and rapid flow of ideas
S Activity & behavior: increased motor activity and very
sociable. However, they lack depth of personality and
warmth to form close relationships. Talk and laugh a lot
(loudly and inappropriately)
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Manic Disorder: nursing process
2.
Acute mania (functional/social impairment and require
hospitalization):
S Mood: euphoria, elation and high (almost on a
contentious high. However, easily changing to sad and
cry).
S Cognition and perception: racing thoughts, flight of
ideas, pressure of speech and changing from topic to
topic, disorganized and incoherent speech. Delusion
and hallucination (paranoid and grandeur)
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Acute Mania Cont.
S Activity & behavior: psychomotor activity is excessive,
sexual interest increased, great ability to manipulate
others to carry out their wishes. Energy seems
inexhaustible. Need for sleep disappears (many days
without sleep and they don’t feel tired). Hygiene and
grooming neglected. Dress may be disorganized. The
use of excessive make up is common.
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Manic disorder
3.
Delirious mania (clouding of consciousness):
S Mood: very labile and feeling of despair quickly
converting to ecstasy.
S Cognition & perception: clouding of
consciousness, confusion and disorientation.
Delusion (grandeur, persecution) and
hallucination (auditory, visual).
S Activity & behavior: agitated with purposeless
movement. Injury to self or others are very
common.
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Manic Disorder: nursing process
2. Nursing Diagnoses:
S Risk for injury R/T hyperactivity
S Risk for violence R/T manic excitement, delusion,
hallucination
S Imbalanced nutrition R/T inability to sit down and eat
S Disturbed sensory perception
S Impaired social interaction R/T egocentric and
narcissistic behavior
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Mood Disorders: treatment modalities
1.
Psychological treatments:
S Psychotherapy
S Group therapy
S Cognitive therapy
S Family therapy
2. Other treatments:
S Psychopharmacology
S ECT
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Suicide
S Most suicides are associated with mood disorder.
S Depressive disorders account for 80% of committed
and attempted suicide.
S 8th leading cause of death among American adults.
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Suicide
S Suicide Facts
S 8 out of 10 who kill themselves have given definite
warnings about their suicidal intention.
S People who want to kill themselves are only suicidal
for a limited time. If they are saved, they can carry
on a normal life.
S Most suicide occur within 3 months after the
beginning of improvements.
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Suicide
S 50-80% of people who kill themselves have a history of
previous attempt.
S Gunshot wounds are the leading cause of death among
suicidal victims.
S Suicide is not inherited.
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Suicide: Application of the Nursing
Process: Assessment:
S Demographics:
S Age: suicide is higher in persons older than 50.
S Gender: males higher than females
S Ethnicity: white higher than Native Americans.
S Marital Status: single, divorced, & widowed are higher
than married.
S Socioeconomic Status: Highest and Lowest are at higher
risk than in the middle classes.
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Assessment of suicide
S Occupation: professional health care personnel and
business executives are at higher risk.
S Method: gunshots are higher than overdose substances.
S Religion: Protestants are greater than Catholics.
S Family History: risk is higher with a history of suicide
in the family
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Suicide: Application of the Nursing
Process
S Presenting symptoms/Medical-Psychiatric Diagnosis:
S Mood disorders are the most common to proceed suicide.
S Other disorders include: substance use disorders, anxiety,
schizophrenia.
S Suicidal ideas or acts:
S How serious is the intent? Does the person have a plan?
Does he have the mean? How lethal is the mean? Has the
individual ever attempted suicide before?
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Suicide: Application of the Nursing
Process
S Interpersonal Support system:
S Does the person has support system he can rely
during crises? Lack of satisfactory relationships may
implicate an individual at high risk of suicide.
S Analysis of the suicide crisis:
S The precipitating stressor: adverse life event in
combination with other risk factor such as
depression may lead to suicide.
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Suicide: Application of the Nursing
Process
S Relevant history (history of failures)
S Life-stage issues (the ability to tolerate losses is often
different during various life stages (adolescence and
midlife).
S Psychiatric (depression treatment/Medical (terminal
ill)/Family History.
S Coping strategies
S How has the individual handled previous crises?
S How does this situation differ from previous ones.
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Suicide: Application of the Nursing
Process
S Diagnoses:
S Risk for suicide r/t feelings of hopelessness.
S Hopelessness r/t absence of support systems.
S Planning
S Interventions
S Evaluation.
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SuicideSuicide
Prevention
Prevention
S Assess for suicide risk by direct questioning about
suicidal thinking, history of suicide attempts, and
whether the client has a specific suicide plan.
S The more organized the plan is, the more concern
it generates as safety is a priority.
Suicide
Prevention
Suicide Prevention (cont'd)
S Suicidal clients should be placed under suicide
precautions.
YOUR INTERVENTION STRATEGIES: Preventing Inpatient Suicide
and Promoting Safety
Improving
Self-Esteem
Improving Self-Esteem
S Provide distraction
S Explain importance of doing things
S Recognize accomplishments
S Help clients identify personal strengths
S Be accepting
S Teach assertiveness techniques
Medication
Teaching
Medication Teaching
S Proper client education enhances the effectiveness
of medication therapy and can improve client
adherence and diminish non-adherence.
S Client education begins when medication therapy
begins and is repeated during the course of the
client’s hospitalization.
Medication
Teaching
Medication
Teaching
- continued
(cont'd)
S Give instructions verbally and in writing.
S Include family members or significant others if
they will supervise home administration.
Self-Awareness
Self-Awareness
S The process recording method will help to
promote self-awareness.
S A process recording usually consists of three
columns
S One for the nurse’s statements
S One for the client’s statements
S One that identifies the process or action taking place
Nursing Process Cont.
S Symptoms of depression can be described as alterations in
four spheres: affective, behavioral, cognitive, and
physiological.
S Alterations within these spheres differ according to severity
of the symptomatology.
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THANK YOU
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