Psychopathology of Mood Disorders

Terry Campbell RN, MSc, BSc, Cert. Psych. Nrsg. Caribbean School of Nursing

College of Health Sciences University of Technology, Jamaica

October 08, 2013

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.

Objectives

What are Mood Disorders?

http://www.fotosearch.com/SPS503/1166-2965a/

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.

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.

Overview

HOW ARE YOU

FEELING TODAY?

Classification of Mood Disorders

Mood Disorders

Bipolar Disorder Major Depressive Disorder

Dysthymia

Depressive Disorder NOS

MDD with Postpartum Onset

Cyclothymia

Bipolar II Disorder

Bipolar I Disorder

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)

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.



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.


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

The causal basis of mood disorder is not

known.

Several factors appear to work to:

Cause

Precipitate

Etiology/ Causation

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

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 Obsessive-Compulsive & 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

Etiology/ Causation

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.


The World Health Organization and

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


Major Depression can be of three types:

Major Depression Single Episode

Major Depression Recurrent Episode

Dysthymia


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

Risk Factors

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

Clinical Features:

Depressed mood for most of the day nearly

every day.

Anhedonia

Appetite changes +/-

Sleep Changes

Psychomotor agitation or retardation


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


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 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

Dysthymia

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

Screening Tool

INDICATORS 0 1

S SEX F M

A AGE N Y

D DEPRESSION N Y

P PREVIOUS ATTEMPT N Y

E ETHANOL/DRUG USE N Y

R RATIONAL THOUGHT LOSS (PSYCHOSIS) N Y

S SOCIAL SUPPORT GOOD POOR

O ORGANIZED PLAN N Y

N NO SPOUSE F T

S SICKNESS N Y

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 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.

Bipolar I Disorder

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.

Hypomania

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.

Bipolar Disorder II

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.

Cyclothymia

Risk for Injury

Risk for Violence

Ineffective Coping

Self-Care Deficit

Impaired Social Interaction

Nursing Diagnosis - MDD

Risk for Violence

Risk for Injury

Altered Thought Process

Impaired Nutrition

Nursing Diagnosis - BD

Psychotherapy

Pharmacotherapy

Cognitive therapy

Behavior therapy

Hospitalization

Family therapy

Treatment

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.

Scenario

THANK YOU

Documents

Psychopathology of Mood Disorders