MENTAL HEALTH NURSING
UNIT:VII MOOD DISORDERS AND ITS MANAGEMENT
Prepared By :Mrs Bemina JA
Assistant Professor
ESIC College of Nursing
Kalaburagi
Introduction
Healthy persons experience a wide range of moods and
have a large repertoire of emotional expressions, feel in
control
Mood disorders are a group of clinical conditions
which are characterized a by sense of loss of control
over one’s mood and subjective sense of distress,
impaired interpersonal, social and occupational
functioning
History
About 400 BCE, Hippocrates - alignment of the planets caused the
spleen to secrete black bile, which then darkened the mood =
melancholia.
Around 30 AD, the Roman physician Celsus : melancholia - work De
re medicina - as a depression caused by black bile.
In 1854, Jules Falret - folie circulaire - alternating moods of depression
and mania.
In 1882, the German psychiatrist Karl Kahlbaum - cyclothymia,
described mania and depression as stages of the same illness.
In 1899, Emil Kraepelin : – manic-depressive psychosis using most of
the criteria -bipolar I disorder – differentiated it from dementia praecox
(as schizophrenia was then called) – involutional melancholia = a form
of mood disorder that begins in late adulthood
Definition
Mood :
– Pervasive and sustained
– Feeling tone
– that is expressed internally
– That influences a person’s behavoir and perception of the world
– Distinguished from affect
– the external expression of mood
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
Mood disorders - are a group of clinical conditions characterised by – loss of the sense
of control & – a subjective experience of great distress.
Elevated mood Depressed mood Others Expansiveness Lack of energy /interest
Change in activity level Flight of ideas Feelings of guilt Change in Cognitive abilities
Decreased sleep Difficulty in concentration Change in speech Grandiose ideas Loss of
appetite Change in biological functions Thoughts of death /suicide Importance:
virtually always impair interpersonal, social and occupational functioning
Introduction
Bipolar disorder is mood disorder characterized by mood swings
from manic episodes to depressive episodes in the same patient
at different times and usually accomplished by abnormalities in
thinking, perception and behavior arising out of mood
disturbances.
It was formerly known as "Manic Depressive Psychosis"
(MDP).
During manic phases, client are euphoric, grandiose, energetic
and sleepless. They have poor judgment and rapid thoughts,
actions and speech.
During depressed phases, mood behavior and thoughts are the
same as persons diagnosed with major depression.
Classification
F30 - Manic Episode
F31 - Bipolar Affective Disorder
F32 - Depressive Episode
F33 - Recurrent Depressive Disorder
F34 - Persistent Mood Disorder (cyclothymia and
dysthymia)
F30 – other mood disorders F30 – unspecified mood
disorder
Bipolar mood disorder has an earlier age of onset i.e. third
decade and an average episode last for 3-4 months while a
depressive episode lasts from 4-6 months. With rapid
institution of treatment, the major symptoms of mania are
controlled within 2 weeks and of depression within 6-8 weeks.
5. In case of depressive episodes; nearly 40% of
depressives with episodic course improve in 3 months, 60%
in 6 months and 80% improve within a period of one year,
15-20% of patients develop chronic course of illness, which
may last for two or more years.
6
. Etiology The etiology of mood disorders is not known currently,
A. Biological Theories 1. Genetic Hypothesis • The life-time risk for
the first degree relatives of bipolar mood disorder patients is 25%,
and of recurrent depressive disorder patients is 20% • The life-time
risk for the children of one parent with bipolar mood disorder is 27%
and of both parents with bipolar mood disorder is 74%.
7. • The concordance rate in bipolar disorders for monozygotic twins
is 65% and for dizygotic twins is 20%. 2. Biochemical Theories • An
abnormality in norepinephrine, dopamine, serotonin, Acetylcholine
and GABA are involved in bipolar mood disorders. • The side effects
of antidepressants and mood stabilizers also cause bipolar mood
disorders.
8.
3. Neuroendocrine Theories • Endocrine function is often disturbed in
depression such as hypothyroidism, Crushing's disease, and Addison's
disease. 4. Sleep studies • Sleep abnormalities are common in mood
disorders e.g. decreased need for sleep in mania; insomnia and frequent
awakening in depression.
9. • In depression, the commonly observed abnormalities include
decreased REM latency ( i.e. the time between falling asleep and the first
REM period is decreased), increased duration of the first REM period, and
delayed sleep onset.
10. 5. Brain Imaging • In mood disorders, brain imaging studies; findings
include ventricular dilatation, white matter hyper-intensities, and changes
in the blood flow and metabolism in several parts of brain (such as
prefrontal cortex, anterior cingulated cortex, and caudate).
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. B. Psychosocial Theories 1. Psychoanalytic Theories • In depression, loss
of a libidinal object, introjections of the lost object, fixation in the oral
sadistic phase of development, and intense craving for narcissism or self-
love are some of the postulates of different psychodynamic theories. •
Mania represents a reaction formation to depression according to the
psychodynamic theory.
12. 2. Stress • Increased number of stressful life events before the onset or
relapse has a formative rather than a precipitating effect in depression
though they can serve a precipitant in mania. • Increased stressors in the
early period of development are probably more important in depression.
13. 3. Cognitive and Behavioral Theories • The mechanisms of causation of
depression, according to these theories, include - depressive negative
cognition, - learned helplessness and - anger directed inwards.
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. Classification of Bipolar Disorders 1. Bipolar I Disorder 2. Bipoalar II Disorder 3. Cyclothymia 4.
Bipolar Disorder Not otherwise Specific (BP- NOS)
15. 1. Bipolar I Disorder • Bipolar I disorder is characterized by at least one manic episodes or mixed
episodes and one or more major depressive episodes. • These episodes last for at least one week but may
continue for months. • Between episodes, there may be periods of normal functioning.
16. • Bipolar I disorder is the most severe form of the illness. • The manic symptoms are sometimes so
severe that the person may require immediate hospital admission.
17. 2. Bipolar II Disorder • Bipolar II Disorder is characterized by one or more major depressive episodes
with at least one hypomanic episode(Not requiring hospitalization). • Between episodes, there may be
periods of normal functioning. • Bipolar II disorder is believed to occur more frequently in women than
in men.
18. 3. Cyclothymic Disorder • Cyclothymic Disorder refers to a persistent instability in mood between
mild depression and mild elation lasting more than 2 years. • Milder form of bipolar disorder the periods
of both mild depressive and hypomanic symptoms are shorter, less severe and do not occur with
regularity.
19. 4. Bipolar Disorder Not otherwise Specific (BP-NOS) • In this, symptom does exist but does not meet
the criteria of either Bipolar disorder I or II or cyclothymia. • The symptoms are out of the range of
person normal behavior.
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. Clinical Features A. Depressive episodes • Constantly feeling sad or
worthless • Sleeping too much or too little • Feeling tired and having
little energy • Appetite and weight changes • Problems focusing •
Thoughts of suicide
21. B. Manic episodes • Increase in energy level • Less need for sleep
• Easily distracted • Nonstop talking • Increased self confidence •
Focused on getting things done, but does not accomplish much •
Involved in risky activities even though bad things may happen
22. C. A current episode can be; • Hypomanic • Manic without
psychotic symptoms • Manic with psychotic symptoms • Mild or
moderate depression • Severe depression without psychotic symptoms
• Severe depression psychotic symptoms • Mixed
23
. Diagnosis History Taking Mental Status
Examination Diagnostic Criteria of Diagnostic and
Statistical Manual of Mental Disorders (DSM) For
bipolar disorder are:
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. 1. Bipolar I Disorder • Bipolar disorder is defined by manic or mixed episodes
that last at least seven days, or by manic symptoms that are so severe that the
person needs immediate hospital care. • Usually, depressive episodes occur as
well, typically lasting at least 2 weeks.
25. 2. Bipolar II Disorder defined by a pattern of depressive episodes and
hypomanic episodes, but no full-blown manic or mixed episodes. 3. Bipolar
Disorder Not Otherwise Specified (BP-NOS) diagnosed when symptoms of the
illness exist but do not meet diagnostic criteria for either bipolar I or II.
However, the symptoms are clearly out of the person’s normal range of
behavior.
26. 4. Cyclothymic Disorder • It is a mild form of bipolar disorder. • People with
cyclothymia have episodes of hypomania as well as mild depression for at least
2 years and the symptoms do not meet the diagnostic requirements for any other
type of bipolar disorder.
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. Treatment A. Mood stabilizers (Lithium) • Mood stabilizers are usually the first choice to treat bipolar
disorder. Lithium also known as is an effective mood stabilizer for treating both manic and depressive
episodes.
B. Other mood stabilizers
1. Sodium valproate – For acute treatment of mania and prevention of bipolar mood disorder. – Particularly
useful in those patients who are refractory to lithium. – The dose range is usually 1000-3000mg/day (the
therapeutic blood levels are 50-125 mg/ml). – It has a faster onset of action than lithium, therefore, it can be
used in acute treatment of mania effectively.
2. Carbamazepine – For acute treatment of mania and prevention of bipolar mood disorder. – Particularly
useful in those patients who are refractory to lithium and valproate. – Particularly effective when EEG is
abnormal (although this is not necessary for the use of carbamazepine). – The dose range of carbamazepine is
600-1600 mg/day ( the therapeutic blood levels are 4-12 mg/ml).
3. Lamotrigine – Lamotrigine si particularly effective for bipolar depression and is recommended by several
guidelines. 4. T3 and T4 as adjuncts for the treatment of rapid cycling mood disorder and resistant
depression.
B. Atypical antipsychotics drugs such as risperidone, olanzapine, quetiapine are sometimes used to treat
symptoms of bipolar disorder. Often, these medications are taken with other medications, such as
antidepressants.
C. Antidepressants such as Fluoxetine , paroxetine, sertraline, and bupropion; are sometimes used to treat
symptoms of depression in bipolar disorder.
. Psychotherapy Cognitive behavioral therapy (CBT), which
helps people with bipolar disorder learn to change harmful or
negative thought patterns and behaviors.
Family-focused therapy, which involves family members. It
helps enhance family coping strategies, such as recognizing new
episodes early and helping their loved one. This therapy also
improves communication among family members, as well as
problem-solving.
Interpersonal and social rhythm therapy, which helps people
with bipolar disorder improve their relationships with others and
manage their daily routines. Regular daily routines and sleep
schedules may help protect against manic episodes
Psychoeducation; which teaches people with bipolar
disorder about the illness and its treatment.
Psychoeducation can help to recognize signs of an
impending mood swing so they can seek treatment early,
before a full-blown episode occurs. It may also be helpful
for family members and caregivers.
35. E. Electroconvulsive Therapy (ECT) •
Electroconvulsive therapy (ECT) may be useful for patient
with severe bipolar disorder who have not been able to
recover with other treatments.
36.
Nursing Management Nursing Diagnosis • Potential risk for injury related to
extreme hyperactivity evidenced by increased agitation, and lack of control over
purposeless and potentially injurious movement. • Potential risk for violence: self-
directed or other directed related to manic excitement, delusional thinking,
hallucinations.
37. • Imbalanced nutrition: less than body requirement related to refusal or inability
to sit still long enough to eat evidenced by loss of weight. • Disturbed thought
processes related to biochemical alterations in the brain evidenced by delusions of
grandeur and persecution.
38. • Disturbed sensory perception related to biochemical alterations in the brain,
possible sleep deprivation, evidenced by auditory and visual hallucinations. •
Impaired social interaction related to ego centric and narcissistic behavior evidenced
by inability to develop satisfying relationships and manipulation of others for own
desires. • Disturbed sleep pattern related to excessive hyperactivity and agitation
evidenced by difficulty falling asleep and sleeping only short periods.
