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.
Incidence/Prevalence
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
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.
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
Major Depressive Disorder
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.
Major Depressive Disorder
CLINICAL
FEATURES
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.
Major Depressive Disorder
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