mood disorders helps for basic bsc students

Mood Disorder

1. M o o d D i s o r d e r s Mr. Pradeep Kadiwal Asso. Professor G G CO N , Gadag

2. Introduction Manic-depressive illness is known since the era of Hippocrates (460–357 BC), Galen (131–201 AD) and Areteus from Cappadocia, and is described in ancient medical texts. The ancient Greeks and Romans coined the terms "melancholia" and "mania." Hippocrates was the first to describe melancholia which is the Greek word for "black bile".

3. What is a mood disorder? Affect (objective appearance of mood) which is a short-lived emotional response to an idea or an event Mood ( person’s subjective emotional state ) which is a sustained and pervasive emotional response which colors the whole psychic life.

4. Mood Disorders/Affective Disorder Mood disorders are characterized by a disturbance of mood , accompanied by a full or partial manic or depressive syndrome, which is not due to any other physical or mental disorder. The prevalence of mood disorders is 1.5 % and it is uniform through out the world. The mood change is usually accompanied by a change in the overall level of activity.

5. Contd………. Most of these disorders tend to be recurrent, and the onset of individual episodes is often related to stressful events or situations. The mood disorders may be subdivided into unipolar and bipolar types: those that are characterized by depression only those that are characterized by manic episode either alone or in combination with depression

6. Classification F 30 -Manic Episode F 32 -Depressive Episode F31 -Bipolar Mood( Affective) Disorder F 33 -Recurrent Depressive Disorder F34- Persistent Mood Disorder F39 - Unspecified mood (affective) disorder

7. Manic Episode

8. Manic Episode Mania is a mood disorder characterized by elevation of mood, increased psychomotor activity, self important ideas

9. Triad Symptoms Of Mania MA N IA Elevation of mood Increased Self Esteem Increased Psychomotor activity

10. Incidence The life-time risk of manic episode is about 0.8- 1%. This disorder tends to occur in episodes lasting usually 3-4 months, followed by complete clinical recovery. The future episodes can be manic, depressive or mixed

11. Etiolo g y Genetic Factors Affective disorders are known to have a marked genetic predisposition. Studies of first degree relatives of elderly manic patients have found a quarter to a half are affected. Monozygotic twins have a higher degree of chance than dizygotic. 5-10% chance in first degree relatives. 40-70% chance in identical twins.

12. Biochemical Factors Biochemical hypothesis of manic episode is related to the excessive levels of serotonin, norepinephrine and dopamine. Psychodynamic Theories This includes faulty family dynamics during the early years of life and as a defense against denial of depression.

13. Brain Diseases Elderly people with mania have found a significant association between brain disease and mania. Cerebrovascular disease chronic alcohol misuse head injury right-sided lesions may contribute to manic disorders.

14. Stress Adaptation Model Of Mania

15. Types of Mania F30 Manic episode F30.0Hypomania F30.1Mania without psychotic symptoms F30.2Mania with psychotic symptoms F30.8Other manic episodes F30.9Manic episode, unspecified

16. Hypomania Lesser degree of mania Mild elevat i on o f m o od for a t l ea s t se v er a l days Increased activity & energy Not disturb the social & occupational life Increased sociability, talkativeness, over familiarity, increased sexual energy, and a decreased need for sleep are often present. There are no hallucinations or delusions

17. Mania Without Psychotic Features Symptoms are severe, Disturbance in social & occupational life last for at least 1 weak, elation is accompanied by increased energy, resulting in over activity, pressure of speech, and a decreased need for sleep normal social inhibition are lost, attention cannot be sustained, and there is often marked distractibility self-esteem is inflated, and grandiose or over-optimistic ideas are freely expressed the individual may embark on extravagant and impractical schemes, spend money recklessly, or become aggressive, amorous, or factious in inappropriate circumstances.

18. Mania With Psychotic Features More severe form Psychotic features like hallucination and delusion may develop Disturbs social and occupational life Inflated self-esteem and grandiose ideas may develop into delusions, and irritability and suspiciousness into delusions of persecution Sustained physical activity and excitement may result in aggression or violence, and neglect of eating, drinking, and personal hygiene may result in dangerous states of dehydration and self neglect

19. Clinical Features Elevated, Expansive or Irritable Mood The elevated mood can pass through following four stages; Euphoria : mild elevation of mood), an increased sense of psychological well-being and happiness. This is usually seen in hypomania (Stage I). Elation : moderate elevation of mood with an increased psychomotor activity. Elation is classically seen in mania (Stage II). Exaltation : severe elevation of mood, with delusions of grandeur; seen in severe mania (Stage III). Ecstasy : very severe elevation of mood, intense sense of rapture or blissfulness; typically seen in delirious or stuporous mania (Stage IV).

20. Contd………….. Psychomotor Activity There is an over activity with excessive energy Restlessness, Manic excitement where the person is ‘on-the- toe-on-the-go’, (i.e. involved in ceaseless activity). Rarely, a manic patient can go in to a stuporous state ( manic stupor ).

21. Contd………….. Speech and Thought The person is more talkative than usual Develops pressu r e o f speec h ; u ses p l ay f ul lang u age with punning, rhyming, joking and teasing Speaks loudly. Flight of ideas develops. Distractibility Delusions of grandeur Delusions of persecution may sometimes develop. Hallucinations often with religious content, can occur Since these psychotic symptoms are in keeping with the elevated mood state, these are called mood congruent psychotic features. 

22. Others Decreased need for sleep. Increased libido (may lead to sexual indiscretions). Unusually alert Increased social communication Poor judgment Insight is absent Decreased food intake Suicidal ideas in BMD

23. Diagn o sis Psychiatric History Collection Mental Status Examination Mania rating scales eg. Young mania rating scale

24. Management Hospitalization Psychopharmacology Lithium -900-2100mg/day Carbamazepine-600-1800/day Sodium valproate-600-2600mg/day Others- calcium channel blockers, Clonazepam, etc Electro Convulsive Therapy

25. Nursing Diagnosis Risk for injury R/T extreme hyper activity. Risk for violence self directed or other directed R/T manic excitement, delusional thinking, hallucinations. Imbalanced nutrition less than body requirement R/T refusal or inability to sit long enough to eat . I m paired s o cial i n t era c tion R/T egocent r ic and narcissistic behavior.

26. Nursing Care Plan for Mania Nursing diagnosis: Risk for injury related to extreme hyperactivity evidenced by increased agitation and lack of control over purposeless and potentially injurious movements Outcome Identification Nursing Intervention Client will not experience injury Reduce environmental stimuli. Ass i gn s i ngle r o o m a n d k e ep l i ght i ng a n d n o i se level low. Remove hazardous objects and substance Stay with the client who is hyperactive and agitated. Provide physical activities. Administer tranquilizing medication as ordered by physician.

27. Nursing diagnosis: Risk for violence self-directed or other-directed related to manic excitement, delusional thinking, hallucinations Outcome Identification Nursing Intervention Client will not harm self or others Maintain low level of stimuli Observe client’s behavior at least every 15 minutes. Ensure that all sharp objects have been removed from client’s environment. Redirect violent behavior. Encourage client to express his anger verbally Have sufficient staff to indicate a show of strength to client if necessary. Administer tranquilizing medication. If client refuses, use of mechanical restraints may be necessary. Observe the client in restraints every15 minutes. Remove restraints gradually, one at a time.

28. Nursing diagnosis: Impaired social interaction related to egocentric and narcissistic behavior evidenced by inability to develop satisfying relationships and manipulation of others for own desires Outcome Identification Nursing Intervention Client will interact appropriately with others. Recognize that manipulative behaviors help to reduce feelings of insecurity by increasing feelings of power and control. Set limits on manipulative behaviors. Explain what is expected and the consequences if limits are violated. Discourage the client to argue, bargain, or charm his or her way out of the limit setting. Give positive reinforcement for non manipulative behaviors. Discuss consequences of client’s behavior and how attempts are made to attribute them to others. Help client identify positive aspects about self, recognize accomplishments, and feel good about them.

29. Depression

30. Dep r ession 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.

31. Epidemiology Lifetime risk in males 8-12% & in females 20-26%. Lifetime prevalence is in the range of 15 - 25 %. The me a n age of onset i s a bout 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

32. Types of Depression F32.0 : Mild depressive episode. F32.1 : Moderate Depressive episode F32.2 : Severe depressive episode without psychotic symptoms F32.3 : Severe depressive episode with psychotic symptoms F32.8 : Other depressive episodes F32.9 : Depressive episodes, unspecified F33 : Recurrent Depression disorder.

33. Etiolo g y

34. 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.

35. 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.

36. 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 and sedative t h e anxiolytics, antips y c h otics, hypnotics. Neurological Disorders Nutritional Deficiencies Major Illnesses

37. Clinical Features Depressed Mood Sadness of m ood o r l oss o f i nte r est and / or pleasure in almost all activities Present thr o u g hout th e day ( p e rs i ste n t sadness ). Other features related to mood include; Anhedonia Irritability. Frustration. Tension.

38. Depressive Ideation/Cognition 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).

39. Psychomotor Activity I n you n g e r pat i e n ts psyc h o m o t o r r e ta r d at i on is m o r e common and is characterized by Slowed thinking and activity Decreased energy Monotonous voice. I n a sev e r e fo r m , t h e p a t ient can b ec o m e stup o rous ( depressive stupor ). I n t h e o l d e r p a t i en t s ( e .g. p o s t - m e no p a u sal w o m e n ), agitation is commoner. It often presents with marked anxiety, restlessness Subjective feeling of unease. Anxiety is a frequent accompaniment of depression.

40. 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.

41. 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.

42. Dia g nosis Detailed Psychiatric history Mental Status Examination History of medication uses, neurological disorders etc. Psychological tests like depression scale

43. Mana g ement Ho s pi t ali z a t i o n is nec e s s ary f o r the client with depression and is indicated for: Suicidal or homicidal patient. Patient with severe p s ycho m o t or retardati o n who is not eating or drinking. Diagnostic purpose (observation, investigation). Drug resistant cases. Severe depression with psychotic features.

44. 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.

45. Psychosocial Therapies CBT Interpersonal therapy Psychoanalytic psychotherapy Behavior therapy Group therapy Family & Marital therapy

46. Nursing Process Nursing diagnosis: Risk for self directed violence related to depressed mood, feelings of worthlessness, anger turned inward on the self. Outcome Identification Nursing Intervention Client will not harm self Assess for suicidal ideations Do not allow the client to be alone in the ward. Remove all the sharp instruments, ropes from the vicinity of the client. It may be desirable to place the patient near nursing station for close observation. Do not allow the client to put bolt on his side door and bathroom. Encourage the client to express feelings.

47. Nursing diagnosis: 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 Identification Nursing Intervention Client will be able to verbalize normal behaviors associated with grieving and begin progression toward resolution 1. Assess stage of fixation in grief process 2. Develop trust. Show e m path y , c o nce r n, and unconditional positive regard. 3. Explore feelings of anger and help client direct them toward the intended object. 4. Pro m ote the use of la r g e m otor ac ti v it i es for relieving pent-up tension. 5. T each nor m al beha v io r s assoc i ated with grieving. 6. Help client with honest review of relationship with lost object.

48. Nursing diagnosis: 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 Identification Nursing Intervention Client will interact appropriately with others. Develop a trusting relationship with client Encourage the client to become involved with staff and other clients through interaction Ex p l ore fe e l i ngs o f a n g e r a nd he l p c l i e nt d i re c t t hem toward the intended object or person. Encourage the client for recreational activities Provide simple activities and shift gradually to complex activity Give positive feedback for each accomplished activities Ex p l ore wi t h the c l i e nt hi s o r h e r p e r s onal s t r e ngt h s, making a written list is sometimes helpful.

49. BIPOLAR DISORDERS

50. Bipolar Disorders This disorder, earlier known as manic depressive psychosis (MDP), is characterized by recurrent episodes of mania and depression in the same patient at different times. People with MDP changes back and forth between periods of depression and mania

51. Epidemiology The lifetime prevalence is between 0.5 and 1 %. Suicidality is about 19%. Comorbidity increases with alcohol and drug abuse . The first episode may occur at any age from childhood to old age.

52. Types F31.0: Bipolar disorder current episode hypomania F31.1: Bipolar disorder current episode mania without psychotic symptoms F31.2: Bipolar disorder current episode Manic with psychotic symptoms F31.3: Bipolar disorder current episode Mild or moderate depression F31.4 : Bipolar disorder current episode severe depression, without psychotic symptoms F31.5 : Bipolar disorder current episode severe depression, with psychotic symptoms, F31.6: Mixed, or in remission.

53. Graphic Representation of Bipolar Disorder

54. Bipolar mood disorder is classified in to; Bipolar I – It is characterized by episode of severe mania and severe depression. Bipolar II – It is characterized by hypomania and severe depression.

55. Etiolo g y Exact cause is unknown Genetic, biochemical and psychosocial causes may have a role Stressful life events Sleep deprivation and endocrine factors

56. Treatm e nt Lithium Valproic acid Carbamazepine Antidepressants Antipsychotics

57. Rapid Cycling Bipolar Disorder This is characterized by alternating episodes (4 or more) of depression, mania or hypomania in the previous 12 months, separated by intervals of 48 - 72 hours. It is usually more chronic than non-rapid cycling disorders. Around 80 % are lithium-treatment failures. Carbamazepine or sodium valproate is usual agents of choice.

58. RECURRENT DEPRESSIVE DISORDER This disorder is characterized by recurrent (at least two) depressive episodes (unipolar depression). The current episode may be mild, moderate, severe without psychotic symptoms, or severe with psychotic symptoms.

59. PERSISTENT MOOD DISORDER These disorders are characterized by persistent mood symptoms which last for more than 2 years (1 year in children and adolescents). If the symptoms consist of persistent mild depression, the disorder is called as dysthymia . If symptoms consist of persistent instability of mood between mild depression and mild elation, the disorder is called as cyclothymia .

60. Dysthy m ia It was also called “depressive neurosis/neurotic depression/exogenous depression” In this a mild depression that lasts for at least 2 years in adult and 1 year in children. It is twice common in women as in men Dysthymia is characterized by the following: Presence of mild to moderate depression. Depressive symptoms usually occur in response to a stressful situation. Oth e r ‘neur o t i c ’ sy m p t o m s su ch as a nxi e ty, obsess i ve sy m p t o m s, phobic symptoms, and multiple somatic symptoms, are often present. The typical course of neurotic depression is chronic, with fluctuations. Del u sions, h a l l u c i n a t i ons a n d o t her psyc h o t ic fea t ure s are characteristically absent.

61. Treatment Short term psychotherapy Behavioral therapy Group therapy Antidepressants such as SSRI, TCA etc.

62. Cyclothymia Less severe bipolar mood disorder with continuous mood swings; alternating periods of hypomania and moderate depression. It is non-psychotic chronic disorder. It starts in late adolescence or early adulthood. The treatment is similar to that of bipolar mood disorder.

63. Other Mood Disorders

64. Melancholia Described by Kraeplin, this is a form of severe depression which occurs in the involutional period of life (i.e. 40-65 years of age). It is characterized by marked agitation, presence of psychotic features such as delusions of persecution tactile and auditory hallucinations multiple somatic symptoms

65. Masked Depression In masked depression, the depressive mood is not easily apparent and is usually hidden by somatic symptoms. This is especially common in the elderly The somatic symptoms range from; chronic pain Insomnia Atypical facial pain paraesthesia. The depressive symptoms can also be masked by drug and/or alcohol misuse.

66. Double Depression This is a major depressive episode superimposed on an underlying dysthymia or neurotic depression. The response to treatment is usually poor. Agitated Depression This i s a type of se vere de p ression w ith mark e d motor restlessness or agitation. I t i s e ither seen a lone o r a long wi t h involutional melancholia. It is more common after the age of 40 years.

67. Secondary Depression and Secondary Mania Both depressive and manic episodes can occur secondary to certain physical diseases and drugs. Substance-induced mood disorder Characterized by prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a drug abuse, toxin exposure, or a medication.

68. Mixed Anxiety Depressive Disorder This disorder is characterized by the presence of depressive and anxiety symptoms. The symptoms should not meet the criteria of either an anxiety disorder or a mood disorder.

69. Seasonal Mood Disorder This is either a bipolar mood disorder or recurrent depressive episode which tends to occur in the same season on each occasion. It is usually more commonly seen in women. For example the depression begins in the fall or winter, or when there is a decrease in sunlight. Mania would occur in the month of summer. Seasonal affective disorder is characterized by atypical features of depression, hypersomnia, hyperphagia, weight gain, and increased fatigue. This is related to abnormal melatonin metabolism. It can be treated with exposure to light (artificial light for 2 – 6 hours a day). It may occur as part of bipolar I or II disorders.