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Terry Campbell RN, MSc, BSc, Cert. Psych. Nrsg.

Caribbean School of Nursing


College of Health Sciences
University of Technology, Jamaica
October 08, 2013

Objectives
At the end of this discussion students will be able to:
Explain what is meant by mood disorders
Outline the various types of mood disorders

Discuss the Incidence and Prevalence of mood


disorders
Analyze theories about the etiology/causation of
mood disorders

Objectives
Outline clinical features presented in mood
disorders according to the DSM-IV-TR.
Describe interdisciplinary treatments for clients
with bipolar disorder.
Apply the nursing process to the care of clients
with Bipolar/mood disorders.

What are Mood


Disorders?

http://www.fotosearch.com/SPS503/11662965a/

Mood Disorders Defined

Mood disorders are psychiatric


disorders that predominantly affects
the internal emotional state of
individuals.
It has multiple aspects inclusive of
biological, behavioral, social and
psychological.

Overview

Mood is the internal subjective

experience of the patient that colors


and sustains an individuals psychic life.

Affect is the external observable


manifestation of the emotion, which
can be blunt, labile, constricted etc.

HOW
ARE
YOU
FEELING
TODAY?

Classification of Mood Disorders


Mood
Disorders
Major Depressive Disorder

Dysthymia

Bipolar Disorder

Bipolar I Disorder

Depressive Disorder
NOS
MDD with Postpartum
Onset

Bipolar II Disorder

Cyclothymia

Incidence/Prevalence

MDD is a common disorder, lifetime prevalence of


15% may be 25% in women.
Sex Male : Female = 1:2 for MDD
1:1 for BD I
1:2 for BD II (Baldassano et al., 2005)
Lifetime prevalence of BD is 3.9% (Kessler et al, 2005)

Incidence/Prevalence

Although conventional wisdom holds


that depression is most closely
associated with menopause, in fact, the
childbearing years are marked by the
highest rates of depression, followed by
the years prior to menopause.

Incidence/Prevalence

Women between 18 and 45 comprise the majority of


those with MDD.

Mean age of onset MDD 40 yrs


BD I 5/6 50 yrs
No Racial Differences
MDD occurs most often in divorced, separated or single
persons with no close interpersonal relationships.
BD I may be more common in divorced or single
persons.

Incidence/Prevalence

Socioeconomic and Cultural Considerations


There is no correlation between SES and MDD
Higher incidence of BD I in upper

socioeconomic groups
Depression is more in rural than urban areas

BD I seen more in college students

Etiology/ Causation

The causal basis of mood disorder is not


known.
Several factors appear to work to:
Cause
Precipitate

http://www.topnews.in/files/brain_ADHD.jpg

Etiology/ Causation

The Neurotransmitter Theory


The theory suggest deficit in neurotransmitter
Primarily norepinephrine (NE) and Serotonin (5HT)
Excess NE Mania
NE Depression
Switch Phenomenon for Mania Depression Dopamine
(DA) and NE activity.
NE Depression
DA Mania

Etiology/ Causation

Neuroendocrine Regulation
Major axes of interest in mood disorders is the
adrenal, thyroid and growth hormone axes.
Correlation between hypersecretion of cortisol
and depression.
Thyroid disorders often associated with
affective symptoms.

Etiology/ Causation

Genetic Factors
First degree relatives of persons with BD I
are 8-18 times more likely to have BD I and
2-10 times more likely to have MDD.
50% of all BD I patients have at least one
parent who had a mood disorder, most likely
MDD.

Etiology/ Causation

Genetics contd.
Twin studies reveal that 33-90% risk for BD I
and 50% for MDD in monozygotic twins.
5-25% and 10-25% for BD I and MDD
respectively for dizygotic twins.

Etiology/ Causation

Psychosocial
Loss of parent before age 11

Loss of spouse
Stressful life events

Environmental stress
Premorbid Personality factors ObsessiveCompulsive & Hysterical personalities at greater
risk for depression.

Etiology/ Causation

Psychoanalytic Theory
Object loss traumatic separation from
significant objects of attachment.
Freud the depressed patients rage is internally
directed because of identification with the lost
object; a way by which the ego relinquishes the
object.

Etiology/ Causation

Psychoanalytic Theory contd..


Melanie Klein manic-depressive cycles were
seen as a reflection of failure in childhood to
establish loving introjects.
Depressed patients suffer the concern that they
have destroyed loving objects through their own
destructiveness and greed.

Etiology/ Causation

Cognitive Theory
Negative distortions of life experiences
Negative self evaluation

Pessimism
Hopelessness

Learnt helplessness

Etiology/ Causation

Other Causes Include:


Social Influence
Other Psychiatric Disorders
Secondary to Disease State
Stress Diathesis Model
Decreased Neurogenesis
Neurotoxicity

Major Depressive
Disorder

Major Depressive
Disorder

Illness characterized by feelings of

hopelessness, sadness, worthlessness,


changes in appetite, sleep patterns, delusions
and hallucinations.

Mental disorder characterized by a pervasive


low mood, low self-esteem, and loss of
interest or pleasure in normally enjoyable
activities.

Major Depressive
Disorder

The World Health Organization and


the World bank found major
depression to be the leading cause of
disability worldwide.

Major Depressive
Disorder

Major Depression can be of three types:


Major Depression Single Episode

Major Depression Recurrent Episode


Dysthymia

Risk Factors
Prior episodes of depressive illness
Family history of depression

Prior suicide attempts


Postpartum period

Chronic medical condition e.g. DM, CHD, Cancer


Lack of social support
History of Post-Traumatic Stress Disorder

Major Depressive
Disorder

Criteria for Diagnosing MDD:


5 or more of the following symptoms
present during the same two-week period
or more and represent a change from
previous functioning. At least one of the
symptoms is either depressed mood or
loss of interest or pleasure.

CLINICAL
FEATURES

Major Depressive
Disorder

Clinical Features:
Depressed mood for most of the day nearly
every day.
Anhedonia
Appetite changes +/-

Sleep Changes
Psychomotor agitation or retardation

Major Depressive
Disorder

Clinical Features:
Fatigue, loss of energy most days
Feelings of worthlessness

Difficulty in thinking or concentrating


Recurrent thoughts of death and suicide
Nihilism view that existence is senseless
or hopeless

Major Depressive
Disorder

Increased Risk for Suicide:

Male (Adolescent or >40yrs)


Divorced, widowed or separated
Hstory of previous attempt
Impulsive or seclusive personality
Giving away possession
Lack of support system
When mood begins to lift following
depression.

Dysthymia

Dysthymia
Chronic disturbance of mood involving a
depressed mood for most of the day, most
days for at least two years.
Condition in which the person suffers
from unceasing, low-grade depression.

Dysthymia

Mood never seems to relinquish for more


than a day or two.
Some people grow used to being depressed
that they think its a part of who they are.
Symptoms are not as severe as major
depression, so functioning is somewhat
better.

Dysthymia

Because of its chronicity relationships and


work usually suffer.
High risk for other mental difficulties e.g.
disorders of anxiety, eating, personality and
substance abuse.

Dysthymia

Most common form of depression


May begin in childhood or adulthood
More common in women

It is estimated that up to 3% of people


have dysthymia.

Dysthymia
Causes/Risk Factors:
Changes in serotonin levels in the brain

Personality problems
Medical conditions e.g. Thyroid disorders
Stress
Previous episode of MDD from which the
person never fully recovered.

Dysthymia
Clinical Features:
A. Depressed mood for most of the day, most days for
at least 2 years.

B. Presence while depressed of two or more of the


following:
Appetite +/ Sleep +/ Low energy or fatigue
Low self-esteem
Poor concentration or thinking
Feelings of hopelessness

Dysthymia

C. During the 2 yr period (1 yr for children) the

person has never been without the symptoms in


A or B for more than 2 months at a time.

D. No major depressive episode present for the


first two years.
E. No manic, mixed or hypomanic episodes
F. Not due to GMC

Screening Tool

Aim: To aid clinical judgment in suicide risk


Sum the score
Maximum Total Score = 10, the higher the worse
Low
0-3
Moderate 4-6
High
>=7

INDICATORS

SEX

AGE

DEPRESSION

PREVIOUS ATTEMPT

ETHANOL/DRUG USE

RATIONAL THOUGHT LOSS (PSYCHOSIS)

SOCIAL SUPPORT

ORGANIZED PLAN

NO SPOUSE

SICKNESS

GOOD POOR

BIPOLAR
DISORDER

Bipolar Disorder

Previously known as Manic-Depression


Disorder

Most common psychotic disorder occurring


in 1% of people among all age groups.
Cyclic disorder with periods of emotional
highs and lows encompassing the extremes
of human experiences i.e. episodes of mania
and depression.

Bipolar Disorder

Early-Onset Bipolar Disorder. In one survey, 59% of


bipolar disorder patients had their first symptoms
when they were children or adolescents.
The initial episodes are more likely to be depressive.
In fact, a 2001 study reported that 33% of children
who experienced major depression developed
bipolar I by age 21 and 15% of them had bipolar II
disorder.

Bipolar Disorder

Adult-Onset Bipolar Disorder. Bipolar disorder can


also appear for the first time in people over the age
of forty. In fact, age 40 is another peak of onset for
women.

Onset Late in Life. Bipolar disorder that occurs late in


life often either follows many years of repeated
episodes of unipolar depression or it accompanies
medical and neurological problems (particularly
cerebrovascular disease, such as stroke).

Bipolar I Disorder

The American Psychiatric Association divides the


disorder into two types:
Type I characterized by the person having
experienced one or more manic episodes, usually
alternating with major depressive episodes.

Type II characterized by a major depressive


episode (current or past) and at least one
hypomanic episode.

Bipolar I Disorder

The difference with mania and hypomania is


the period of time for which the episodes last.
Mania lasts for one week or more
Hypomania lasts for 4 days

Bipolar I Disorder

Clinical Features:
Distinct period of abnormally and
persistently elevated, expansive or irritable
mood, lasting for at least one week.
During the period of mood disturbance, 3
or more of the following symptoms have
persisted to a significant degree:

Bipolar I Disorder

Clinical Features:

Inflated self esteem or grandiosity


Decreased need for sleep
More talkative (excessive speech)
Flight of ideas (racing thoughts)
Easy Distractibility
Increased goal directed activity or agitation
Excessive involvement in pleasurable activities
with high potential for painful results.

Bipolar I Disorder

Do not meet criteria for mixed episode


Marked impairment in fucntioning

Not due to effects of substances or GMC.

Hypomania

Distinct period of persistently elevated,


expansive or irritable mood for at least four
days.

Mild degree of mania.


Person may have inflated self-esteem,
irritability, impatience and demanding
attitude.

Hypomania

Occurs without psychotic features


Does not impair functioning or require
hospitalization.
Mostly occurs immediately before or after a
major depressive episode.

Bipolar Disorder II

Presence (or history) of one or more major

depressive episodes.
At least one hypomanic episode

Never a manic episode or mixed episode


Clinically significant distress or impairment.

Cyclothymia

Chronic disorder with frequent mood swings


and single episodes lasting for at least two
years.

Behavioral Manifestations:
Intoverted self-absorbed vs. uninhibited
people seeking.
Taciturn vs. talkative

Cyclothymia

Unexplained tearfulness vs. buoyant


jocularity
Psychomotor inertia vs. restless pursuit of
activities.

Nursing Diagnosis - MDD

Risk for Injury

Risk for Violence


Ineffective Coping
Self-Care Deficit
Impaired Social Interaction

Nursing Diagnosis - BD

Risk for Violence

Risk for Injury


Altered Thought Process
Impaired Nutrition

Treatment

Psychotherapy

Pharmacotherapy
Cognitive therapy

Behavior therapy
Hospitalization
Family therapy

Scenario

Belmera is a 45 year old woman who was admitted


to the psychiatric hospital yesterday because she was
no longer able to work and care for herself and her
family. Her 25 yr old daughter, Amanda became
worried when she noticed that her mother was
sleeping all the time, not eating, and talked about
ending it all because life is just too difficult. She
shares that her brother is in prison. He was
incarcerated 6 months ago and Amanda tells you
that her mother has not been the same since.

THANK
YOU