mood disorder

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General Objective: : 

General Objective: At the end of the discussion, the students should be able to understand the psychobiologic nature of Mood Disorder and Suicide. Specific Objective: Briefly describe the historical perspective of mood disorder; explain the following theories of mood disorder; differentiate depressive disorder and bipolar disorder; recognize the Diagnostic and Statistical Manual of Mental Disorders, text revision, fourth edition criteria and terminology of depressive disorder; describe effective nursing interventions for mood disorders; and, distinguish warning signs and interventions to prevent suicide.


TOPIC OUTLINE: Mood History of Mood Disorder Etiology of Mood Disorder Types of Mood Disorder Symptoms of Mood Disorders Managing symptoms of Mood Disorder Pharmacologic Drug Psychotherapy for Mood Disorder Nursing Intervention of Mood Disorder Suicide

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Mood is a pervasive and sustained feeling that is experienced internally and that influences a person’s behavior and perception of the world. Mood can be normal, elevated or depressed.

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Mood disorders – affective disorders - are a group of clinical condition characterized by a loss of that sense of control and a subjective experience of great distress. (Sadock, 2007)

History of Mood Disorders : 

History of Mood Disorders 4th-5th centuries - the Greek describes the dark mood of depression as melancholia - Hippocrates used the term mania melancholia to describe depression and mania for mental disturbances.

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2nd century AD – Arteaeus of Cappodocia described cyclothymia as a formal mental disease with alternating periods of depression and mania. - Melancholia and cyclothymia were regarded to be separate disease entities

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1854 – Jules Falret described a condition called folie circulaire, in which patients experience alternating moods of depression and mania.

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1880 – four categories of mood disorders existed: mania, melancholia, monomania, dipsomania. 1882 – Karl Kahlbaum, German Psychiatrist, uses the term cyclothymia, described mania and depression as stages of the same illness.

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1899 – Emil Kraeplin, reinforced Kahlbaum’s theory about the continuum of depression. - He introduced the category of manic- depressive psychosis (used to establish the diagnosis of bipolar I disorder) and involutional melancholia (mood disorder that occurs in late adulthood).

Biological Theories for Mood Disorders : 

Biological Theories for Mood Disorders Neurotransmitter Theories: Low levels of serotonin Permissive hypothesis: when serotonin levels are low, other neurotransmitters, such as norepinephrine and dopamine, range more widely & become dysregulated, contributing to mood irregularities Kindling-sensitization model: neurotransmitter systems become more easily dysregulated with each episode of depression or mania

Biological Theories for Mood Disorders : 

Biological Theories for Mood Disorders Genetic Theories: If an individual has a mood disorder, the rates of mood disorders in his/her relatives is 2-3x greater If one twin has a mood disorder, an identical twin is 2-3x more likely than a fraternal twin to have a mood disorder Women have a stronger genetic contribution for depression than men do

Cognitive Theories : 

Cognitive Theories Aaron Beck’s TheoryThe Negative Cognitive Triad: Depressed people tend to have negative views of: (1) themselves; (2) the world; (3) the future. Cognitive distortions cause or maintain depression: Distorted Automatic Thoughts – pervasive, negative thoughts regarding oneself, one’s experience, and one’s future, e.g. “Nothing I do works out.” Maladaptive Assumptions – rigid, punitive, unreasonable rules or guiding principles, e.g. “I don’t deserve to be happy.” Negative Schemas – core beliefs about oneself and others, e.g. “I’m such a loser.”

Interpersonal Theory of Depression : 

Interpersonal Theory of Depression (Klerman, Weissman, Rounsaville, & Chevron) Depression is precipitated or maintained by problematic childhood relationships and current interpersonal difficulties or patterns. Depression occurs in the interpersonal context of: Grief over loss of significant relationships Interpersonal role disputes & conflict Role transitions Interpersonal deficits – e.g. lack of social support or intimacy

Psychodynamic Theory : 

Psychodynamic Theory Early childhood experiences  unhealthy relationship patterns dependence on the approval of others anxiety about separation and abandonment Introjected hostility – person perceives rejection or abandonment and turns anger in one self, e.g. by blaming or punishing him/herself

The Mood Disorders : 

The Mood Disorders Unipolar Disorders: Major Depressive Disorder Dysthymic Disorder Bipolar Disorders: Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder

Major Depression : 

Major Depression Emotional Symptoms: Sadness, depressed mood Anhedonia – lack of interest or pleasure Irritability Excessive or inappropriate guilt Hopelessness Feelings of worthlessness Low self-esteem

Major Depression : 

Major Depression Vegetative Symptoms: Lack of motivation Insomnia or hypersomnia Increased or decreased appetite Weight loss or gain Fatigue, loss of energy Psychomotor retardation or agitation

Major Depression : 

Major Depression Cognitive Symptoms: Impaired concentration & attention Indecisiveness Suicidal ideation Delusions Hallucinations

Major Depression : 

Major Depression Social Symptoms: Social withdrawal & isolation Lack of communication Lack of social initiation Relationship problems & conflict Dependency – clinginess, neediness

Diagnostic Criteria for a Major Depressive Episode : 

Diagnostic Criteria for a Major Depressive Episode 5+ symptoms are present for at least 2 weeks: Depressed mood* Loss of interest or pleasure in most activities* Significant increase or decrease in appetite or weight Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate or indecisiveness Suicidal ideation

Diagnostic Criteria for a Major Depressive Episode : 

Diagnostic Criteria for a Major Depressive Episode At lease one of the symptoms is either depressed mood or loss of interest or pleasure in most activities. Symptoms represent a change from previous functioning. Symptoms cause significant distress or impairment. Symptoms aren’t better accounted for by bereavement (2 month mourning period after loss of a loved one).

Specifiers for Major Depression : 

Specifiers for Major Depression Mild, Moderate, and Severe Single Episode or Recurrent Chronic With Melancholic Features With Psychotic Features With Catatonic Features With Atypical Features With Postpartum Onset With Seasonal Patterns Longitudinal Course Specifiers

Criteria for Specifiers : 

Criteria for Specifiers Severity: Mild, Moderate, or Severe level of functional impairment Single Episode: single episode of major depression Recurrent: 2 or more episodes of major depression Chronic: full criteria for a major depressive episode have been met continually for at least the past 2 years

Criteria for Specifiers : 

Criteria for Specifiers Psychotic Features: delusions or hallucinations Mood Congruent: depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment Mood Incongruent: content doesn’t involve depressive themes, e.g. thought insertion, thought broadcasting, delusions of control, delusions of grandeur, persecutory delusions

Criteria for Specifiers : 

Criteria for Specifiers Catatonic Features: at least 2 of the following: Motoric immobility – catalepsy or stupor Excessive motor activity Extreme negativism (resistance to instructions or attempts to be moved) or mutism Posturing, stereotyped movements, prominent mannerisms or grimacing Echolalia or echopraxia

Criteria for Specifiers : 

Criteria for Specifiers Melancholic Features: 4 or more of the following Loss of pleasure in activities and/or* Lack of reactivity to pleasurable stimuli* Quality of mood is distinct Depression regularly worse in the morning Early morning wakening Marked psychomotor retardation or agitation Significant anorexia or weight loss Excessive or inappropriate guilt

Criteria for Specifiers : 

Criteria for Specifiers Atypical Features: 3 or more of the following: Mood reactivity* Significant weight gain or increase in appetite Hypersomnia Heavy, leaden feeling in arms or legs Interpersonal rejection sensitivity

Criteria for Specifiers : 

Criteria for Specifiers Longitudinal Course Specifiers: With Full Interepisode Recovery – full remission is attained between 2 most recent mood episodes Without Full Interepisode Recovery – full remission is not attained between mood episodes Postpartum Onset: Onset of episode within 4 weeks postpartum

Criteria for Specifiers : 

Criteria for Specifiers Seasonal Pattern: Depressive episodes have developed at a particular time of the year for past 2 years Depression remits or switches to mania or hypomania at a characteristic time of year Usually occur during the start of fall and in winter.

Prevalence Rates For Major Depressive Disorder : 

Prevalence Rates For Major Depressive Disorder Gender: women have 2x the rates as men Age: highest rates among 15-24 year olds Onset: early 20’s

Dysthymic Disorder : 

Dysthymic Disorder Specifiers: Early Onset - onset before 21 yrs old Late Onset - onset at age 21 yrs old or older With Atypical Features Gender Differences: 2-3x more likely for women than men

Diagnostic Criteria For Dysthymia : 

Diagnostic Criteria For Dysthymia Depressed mood for at least 2 years. For children & adolescents, mood may be irritable and duration may be 1 year. Presence of 2 or more of the following: -Poor appetite or over-eating -Insomnia or hypersomnia -Low energy or fatigue -Low self esteem -Poor concentration or difficulty making decisions -Feelings of hopelessness

Diagnostic Criteria For Dysthymia : 

Diagnostic Criteria For Dysthymia C. During the 2 yr period, the person has not been without symptoms for more than 2 months at a time. D. No major depressive episode has been present during the 1st 2 yrs of the disturbance.

Major Depression vs. Dysthymia : 

Major Depression vs. Dysthymia Major Depression: 5 or more symptoms including depressed mood or loss of interest or pleasure At least 2 weeks in duration Dysthymia: 3 or more symptoms including depressed mood At least 2 years in duration

Manic Features : 

Manic Features Changes in Mood: Irritability Excitability, exhilaration Hostility Anxious Hyper, wound-up

Manic Features : 

Manic Features Increased Energy: Little fatigue, despite decreased sleep; insomnia, and difficulty sleeping Increase in activities; increased productivity Doing several things at once Making lots of plans Taking on too many responsibilities Others seem slow Restlessness, difficulty staying still

Manic Features : 

Manic Features Changes in speech Rapid, pressured speech Incoherent speech, clang associations Impaired judgment Lack of insight Inappropriate humor and behaviors Impulsive or thrill-seeking behaviors: increased alcohol consumption; financial extravagance, spending too much money; dangerous driving; sexual promiscuity

Manic Features : 

Manic Features Changes in Thought Patterns Distractibility, inability to concentrate Creative thinking Flight of ideas Racing thoughts Disorientation Disjointed thinking Grandiose thinking

Manic Features : 

Manic Features Changes in Perceptions Inflated self esteem, feeling superior More sensitive than usual: noises seem louder & lights seem brighter than usual Hallucinations Paranoia Increased appetite Increased Social Behavior Unnecessary phone calls Increased sexual activity Talkative & sociable

Criteria for Mania & Hypomania : 

Criteria for Mania & Hypomania 3+ of the following symptoms have persisted to a significant degree for at least a week: Elevated, expansive, irritable mood* Inflated self-esteem, grandiosity Decreased need for sleep Flight of ideas, racing thoughts More talkative than usual, pressured speech Distractibility Increase in goal-directed activity, psychomotor agitation Excessive involvement in pleasurable but dangerous activities, e.g. unrestrained shopping sprees, sexual indiscretions, reckless driving

Differential Diagnosis : 

Differential Diagnosis MANIC EPISODE (Bipolar I) Mood disturbance is severe Causes marked impairment in social or occupational functioning Necessitates hospitalization Has psychotic features HYPOMANIC EPISODE (Bipolar II & Cyclothymia) Mood disturbance is less severe Does not cause marked impairment in functioning The person’s behavior and mood significantly & noticeably change The person no longer seems like him/herself

Mixed Episode : 

Mixed Episode The criteria are met (except for duration) for both Mania & Major Depression nearly every day for at least a week Mood disturbance is severe enough to: cause marked impairment in functioning necessitate hospitalization contain psychotic features

Bipolar I Disorder : 

Bipolar I Disorder Characterized by the occurrence of: 1 or more Manic or Mixed Episodes (usually) 1 or more Major Depressive Episodes

Bipolar II Disorder : 

Bipolar II Disorder Characterized by the occurrence of: 1 or more Major Depressive Episodes At least 1 Hypomanic Episode There has never been a Manic or Mixed Episode

Cyclothymic Disorder : 

Cyclothymic Disorder Characterized by: Chronically fluctuating mood states – numerous periods of hypomania and depression Duration of at least 2 years in adults & 1 year in adolescents and children Person is not without symptoms for more than 2 months at a time There are no Major Depressive, Manic, or Mixed Episodes during the initial 2 years. After the initial 2 years, there may be superimposed Manic, Mixed, or Depressive episodes

Bipolar Specifiers : 

Bipolar Specifiers Current or Most Recent Episode Longitudinal Course Specifiers With Rapid Cycling (at least 4 episodes of mood disturbances in the past 12 months) Mild, Moderate, Severe With Psychotic Features With Postpartum Onset With Catatonic Features (very rare in manic episodes) With Seasonal Pattern

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Average age of onset: 18 for Bipolar I, 22 for Bipolar II, midteens for Cyclothymia 1/3 of bipolar cases begin in adolescence 1/3 of cyclothymics develop full-blown bipolar Chronic & lifelong course Suicide attempts: 17% for Bipolar I & 24% for Bipolar II Rapid cycling responds poorly to treatment

Gender Features : 

Gender Features Bipolar I and Cyclothymia are equally common in men and women Bipolar II is more common in women. Men tend to have more Manic Episodes Women tend to have more Major Depressive Episodes Women are more likely to be rapid cyclers

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Source: American Psychiatric Association (2000).

Drug Treatments for Mood Disorders : 

Drug Treatments for Mood Disorders Drug Treatments for Major Depression – Monoamine Oxidase Inhibitors (MAOI’s) Tricyclic Antidepressants (TCA’s) Selective Serotonin Reuptake Inhibitors (SSRI’s) Drug Treatments for Bipolar Disorder - Lithium, anticonvulsants with mood stabilizers Electroconvulsive Therapy (ECT)

Biological Treatments : 

Biological Treatments Psychotherapy - in conjunction with medication is considered most effective treatment; useful therapies include behavioral, cognitive, interpersonal therapy Vagus Nerve Stimulation - VNS, involves the use of an implanted device to provide periodic stimulation to the vagus nerve. The device was originally developed as a treatment for epilepsy. It has since been approved for treatment-resistant depression in both unipolar depression and bipolar disorder

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Electroconvulsive therapy (ECT) is used when medications are ineffective or side effects are intolerable. 6 to 15 treatments scheduled three times a week Preparation of a client for ECT is similar to preparation for any outpatient minor surgical procedure The client will have some short-term memory impairment person is anesthetized & given muscle relaxant drugs & then electric shock is administered directly to the brain, producing a seizure and convulsions

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Psychosocial Interventions Cognitive Behavioral Therapy examines confused or distorted patterns of thinking.  child learns that thoughts cause feelings and moods which can influence behavior.  For example, if a child is experiencing unwanted feelings or has problematic behaviors, the therapist works to identify the underlying thinking that is causing them. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors. effective in treating depression and anxiety.

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Family Therapy Focuses on helping the family function in more positive and constructive ways by exploring patterns of communication and providing support and education.  Includes the child or adolescent along with parents, siblings, and grandparents.  Couples therapy is a specific type of family therapy that focuses on a couple's communication and interactions (e.g. parents having marital problems). Psychosocial Interventions

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Psychosocial Interventions Group Therapy Uses the power of group dynamics and peer interactions to increase understanding and improve social skills Many different types of group therapy (e.g. psychodynamic, social skills, substance abuse, multi-family, parent support, etc.)

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Psychosocial Interventions Interpersonal Therapy (IPT) Brief treatment specifically developed and tested for depression.  Goals of IPT are to improve interpersonal functioning by decreasing the symptoms of depression. Effective in adolescents with depression.

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Play Therapy Involves the use of toys, blocks, dolls, puppets, drawings and games to help the child recognize, identify, and verbalize feelings.  Therapist observes how the child uses play materials and identifies themes or patterns to understand the child's problems.  Through a combination of talk and play the child has an opportunity to better understand and manage their conflicts, feelings, and behavior. Psychosocial Interventions

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Psychosocial Interventions Psychodynamic Psychotherapy Emphasizes understanding the issues that motivate and influence a child's behavior, thoughts, and feelings. Identifies a child's typical behavior patterns, defenses, and responses to inner conflicts and struggles.  Based on the assumption that a child's behavior and feelings will improve once the inner struggles are brought to light. Psychoanalysis is a specialized, more intensive form of psychodynamic psychotherapy which usually involved several sessions per week.

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Suicide The intentional, direct, & conscious taking of one’s own life Suicide is not classified as a mental disorder, although the suicidal person usually has psychiatric symptoms, such as: Depression Alcohol dependence Schizophrenia

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10 common characteristics of suicide The common purpose is to seek a solution: suicide is seen as the solution to an unsolvable problem; it is not pointless or accidental. The cessation of consciousness is a common goal: consciousness represent constant psychological pain The stimulus for suicide is generally intolerable psychological pain The common stressor in suicide is frustrated psychological need: feelings of frustration, failure, worthlessness, etc. A common emotion in suicide is hopelessness-helplessness

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10 common characteristics of suicide (cont.) The cognitive state is one of ambivalence: although the person may be strongly motivated to end his/her life, there is usually a strong desire to live, as well. The cognitive state is one of tunnel vision: the person has great difficulty seeing the big picture and believes death is the only way out The common action in suicide is escape: goal is escape from an intolerable situation The common interpersonal act in suicide is communication of intention: At least 80% of suicides are precipitated by verbal or nonverbal cues of suicidal intention. The common consistency is in the area of lifelong coping patterns that predispose the person to suicide

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Facts About Suicide Alcohol frequently implicated Men are more likely than women to kill themselves (men use firearms) Common among people under age 25 Men 3 to 4 times as likely to be successful, women more likely to attempt suicide Married people are less vulnerable Socioeconomic level is not a factor

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More Facts About Suicide Over 60% of suicides are committed using firearms, 70% of attempts are from drug overdose Suicide rates are lower in Catholic & Muslim countries Highest rates in U.S. are for Native Americans, lowest for Asian Americans More than 66% of those who commit suicide communicate their intent to do so beforehand High correlation with alcohol consumption

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Perspectives on Suicide Emile Durkheim: suicide may occur because of: alienation from society (egoistic suicide) unbalanced relation to society (anomic suicide) for the greater good (altruistic suicide) Sigmund Freud: Suicide results from the existence of Thanatos, the death instinct antagonistic to the life instinct

Intervention of Suicide : 

Intervention of Suicide 1. Show you care 1.1 Take ALL talk of suicide seriously If you are concerned that someone might take their life, trust your judgment. 1.2 Listen carefully 1.3 Reflect what you hear 1.4Use language appropriate for age of person involved Do not worry about doing or saying exactly the right thing. Your genuine interest is what is most important. 1.5 Be genuine Let the person know you care. Talk about your feelings and ask about his or hers.

Interventions of Suicide : 

Interventions of Suicide 2.Ask about suicide 2.1 Don’t hesitate to raise the subject Talking with people about suicide won’t put the idea on their heads 2.2 You don’t need to solve all of the person’s problem; just engage them 2.3 Ask about treatment 2.4 Know referral resources 2.4.1 Resource Sheet – referral resource sheet from local community 2.4.2 Hotlines

Intervention of Suicide : 

Intervention of Suicide 2.5 Reassure the patient that help is available and that you will help them get help 2.6 Encourage the suicidal person to identify other people in their lives who can also help 3. Get help

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