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Mood disorder & Manic episode

  1. 1. By- Isha Thapa Magar Nursing Instructor
  2. 2. Introduction • Mood disorders previously referred to as affective disorders. • Mood disorders encompass a large group of disorders; characterized by pervasive dysregulation of mood and psychomotor activity and by related biorhythmic and cognitive disturbances. • Mood disorders are one of the most commonly occurring psychiatric-mental health disorders.
  3. 3. • By the year 2020, mood disorders are estimated to be the second most important cause of disability worldwide. • The prevalence rate of mood disorders is 1.5 percent, and it is uniform throughout the world.
  4. 4. Definitions • Mood disorder is a condition whereby the prevailing emotional mood is distorted or inappropriate to the specified circumstances. • Affective disorders are group of disorders in which fundamental disturbances or changes in mood occur accomplished by overall change in level of activity
  5. 5. • Mood disorder is a clinical condition in which mood change is predominant and persistent, associated with cognitive, psychomotor, psycho-physiological and behavioral difficulties; accomplished by a full or partial manic or depressive syndrome, and occurrence of such manifestations based on client's mood.
  6. 6. Classification of Mood Disorder According to the ICD-10, the mood disorders are classified as follows: F30-F39 :Mood Disorder – F30 - Manic episodes – F31 - Bipolar mood (affective) disorder – F32 - Depressive mood (affective) disorder
  7. 7. – F33 - Recurrent depressive disorder – F34 - Persistent mood disorder (including cyclothymia and dysthymia) – F38 - Other mood disorders (including mixed affective episode and recurrent brief depressive disorder) – F39 - Unspecified mood disorders
  8. 8. Etiology • The etiology of mood disorders is currently unknown. Biological Theories A. Genetic Hypothesis • Genetic factors are very important in predisposing an individual to mood disorders. • The lifetime risk for the first-degree relatives of patients with mood disorder is 25% and of normal controls is 7%.
  9. 9. • The lifetime risk for the children of one parent with mood disorder is 27% and of both parents with mood disorder is 74%. • The concordance rate for monozygotic twins is 65% and for dizygotic twins is 15%.
  10. 10. B. Biochemical theories. • Increased amounts of norepinephrine, serotonin and dopamine activity cause an elevation in mood and the two phases of bipolar disorder whereas decreased amounts lead to depressed mood. C. Neuroendocrine Disturbance • Mood is also affected by the thyroid gland. Approximately 5%-10% of clients with abnormally low level of thyroid hormones suffer form a chronic mood disorder.
  11. 11. • Clients with a mild, symptom-free form of hypothyroidism are more vulnerable to depressed mood than the average person. • Abnormalities of neuroendocrine such as decreased nocturnal secretion of melatonin, decreased levels of prolactin, follicle- stimulating hormone, testosterone , and somatostation and sleep-stimulation of growth hormone cause mood disorders in clients.
  12. 12. Psychological theories A. Psychoanalytic theory • According to Freud depression results due to loss of a 'loved object' and fixation in the oral sadistic phase of development. • In this model, mania is viewed as a denial of depression. B. Behavioural theory • This theory of depression connects depressive phenomena to the experience of uncontrollable events. According to this model, depression is conditioned by repeated losses in the past.
  13. 13. C. Cognitive theory • According to this theory depression is due to negative cognitions which includes: - Negative expectations of the environment - Negative expectations of the self - Negative expectations of the future • These cognitive distortions arise out of a defect in cognitive development and cause of the individual to feel inadequate, worthless and rejected by others.
  14. 14. D. Sociological theory • Stressful life events such as the loss of parent or spouse, financial hardship, illness, perceived or real failure, and midlife crisis etc are factors contributing to the development of a mood disorders. • Certain populations of people including the poor, single persons, or working mothers with young children seem to be more susceptible than others to mood disorders.
  15. 15. Manic Episode
  16. 16. Definition • It is a psychotic medical condition in which client manifests a clinical syndrome characterized by extremely elevated mood, energy, hyperactivity, unusual thought process with flight of ideas and acceleration in speaking process.
  17. 17. Incidence • 0.6 – 1 per cent adults will have mania during their life time. • Onset is most common in late adolescence or early adulthood. • Incidence is more in - Unmarried, separated or divorced cases - Urban, upper socioeconomic groups
  18. 18. - Positive family history, monozygotic twins. - Drug induced manic disturbance - Male : Female ratio 1:1 (Bipolar disorder; males tend to have manic episode first, cycling with depressive episode; females tend to have depressive episode first circle with mania later).
  19. 19. Clinical features A. Elevated, Expansive or Irritable Mood B. Psychomotor Activity Disorder C. Goal Directed activities D. Speech and thought disorder E. Other Features
  20. 20. A. Elevated, Expansive or Irritable Mood The elevated mood in mania has four stages depending on the severity of manic episode: 1. Euphoria ( mild elevation of mood): • An increased sense of psychological well-being and happiness, not in keeping with ongoing events. • This is usually seen in hypomania (Stage I).
  21. 21. 2. Elation (moderate elevation of mood): • A feeling of confidence and enjoyment, along with an increased psychomotor activity. • Elation is classically seen in mania (Stage II). 3. Exaltation (severe elevation of mood): • Intense elation with delusions of grandeur; seen in severe mania (Stage III)
  22. 22. 4.Ecstasy (very severe elevation of mood): • Intense sense of rapture or blissfulness; typically seen in delirious or stuporous mania (Stage IV)
  23. 23. B. Psychomotor activity disorder • Increased psychomotor activity, ranging from over activeness and restlessness to manic excitement. • The activity is usually goal-oriented and is based on extend environmental cues
  24. 24. C. Speech and Thought Disorder • More talkative than usual • Flight of ideas: Thought racing in mind, rapid shift from one topic to another. • Pressure of speech: Speech is forceful, strong and interruptive. Use playful language with rhyming, joking an teasing and speak loudly. • Delusion of grandiosity, persecution • Distractibility
  25. 25. D. Goal-directed Activity • Patient is unusually alert, trying to do many things at one time. • In hypomania, the ability to function becomes much better and there is a marked increase in productivity and creativity. • In mania: - Marked increase in activity with excessive planning and, at times, execution of multiple activities.
  26. 26. - Easily distractibility, there is often a decrease in the functioning ability in later stages - Marked increase in sociability even with unknown people - Person becomes impulsive and disinhibited, with sexual indiscretions, and can later become hypersexual. - Poor judgment
  27. 27. • Usually dressed up in gaudy ( a showy ornament) and flamboyant clothes bright light, orange red colour), although in severe mania there may be poor self care, dress is often inappropriate (bright color that do not match, excessive make up and jewelers, untidy appearance).
  28. 28. - Involved in the high-risk activities such as buying sprees, reckless driving, foolish business investments, and distributing money and/or personal articles to unknown persons.
  29. 29. E. Other Features • Sleep is usually reduced (<3 hours) with a decreased need for sleep. • Appetite may be increased but later these is usually decreased food intake due to marked activity. • Insight is absent, especially in severe mania.
  30. 30. • Psychotic features such as delusions, hallucinations which are not understandable in the context of mood disorder e.g. delusions of control, may be present in some cases.
  31. 31. • Loss of normal inhibitions, resulting in behavior that is inappropriate to the circumstances. • Behavior that is reckless and whose risks the individual does not recognize, e.g. spending sprees, foolish enterprises, reckless driving. • Marked sexual energy • The episode is not attributed to psychoactive substance use or to any organic mental disorder.
  32. 32. Classification of Mania • F30 Manic episode F30.0 Hypomania F30.1 Mania without psychotic symptoms F30.2 Mania with psychotic symptoms F30.8 Other manic episodes F30.9 Manic episode, unspecified
  33. 33. 1. Hypomania • It is mild form of mania. • Hypomania is not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization and it does not include psychotic features.
  34. 34. • Hypomania is a period of - abnormality and persistently mild elevation of mood, - increased energy and activity, and - usually marked feelings of well being and - both physical and mental efficiency lasting 4 days and - including three or four of the additional symptoms (e.g. Increased sociability, talkativeness, over familiarity, increased sexual energy, and decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection but do not impair the person's ability to function and there is no psychotic features (delusions and hallucinations).
  35. 35. 2. Mania without psychotic symptoms • In mania without psychotic symptoms, mood is predominantly elevated, expensive, or irritable, - accompanied by increased energy, resulting in over activity, pressure of speech, a decreased need for sleep, lost in social inhabitation, - marked distractibility in addition Self esteem is inflated, and - definitively abnormal for the individual concerned for at least 1 week leading to severe interference with personal functioning of daily living without psychotic symptoms.
  36. 36. 3. Mania with psychotic symptoms • The episode meets the criteria for mania without psychotic symptoms and hallucination or delusions. • The commonest examples are those with grandiose, self referential, or persecutory content. • The episode is not attributable to psychoactive substance use or to any organic mental disorder.
  37. 37. Diagnosis
  38. 38. Proper history taking Mental status examination (positive criteria or mania) ICD 10 Diagnostic Criteria of Hypomania, Mania without and with psychotic symptoms
  39. 39. 1. Diagnostic criteria for Hypomania (ICD 10 diagnostic criteria) The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least 4 consecutive days. At least three of the following signs must be present, leading some interference with personal functioning in daily living. – Increased activity or physical restlessness – Increased talkativeness
  40. 40. – Distractibility or difficulty in concentration – Decreased need for sleep – Mild overspending of reckless or irresponsible behavior – Increased sexual energy – Increased sociability or over familiarity. – The episode does not meet the criteria for mania, bipolar affective disorder, depressive episode, cyclothymia, or anorexia nervosa. – The episode is not attributable to psychoactive substance use or to any organic mental disorder.
  41. 41. 2. Diagnostic criteria for Mania without psychotic Symptoms Mood must be predominantly elevated, expensive, or irritable, and definitively abnormal for the individual concerned. The mood change must be prominent and sustained for at least 1 week. At least three of the following signs must be present, leading to severe interference with personal functioning of daily living.
  42. 42. There are no hallucinations or delusion, although perceptual disorders may occur. The episode is not attributable to psychoactive substance use or to any organic mental disorder. The mood disturbance is sufficient to cause impairment at work or danger are present to the patient or other.
  43. 43. 3.Diagnostic criteria for Mania with psychotic symptoms • The episode meets the criteria for mania without psychotic symptoms and hallucination or delusions.
  44. 44. Treatment
  45. 45. A. Pharmacotherapy 1. Lithium – Lithium is the drug of choice for the treatment of manic episode (acute phase ) as well as for prevention of further episodes in bipolar mood disorder. – The usual therapeutic dose range is 900-1500 mg of lithium carbonate per day.
  46. 46. Nursing Consideration • Lithium treatment needs to be closely monitored by repeated blood levels, as the difference between the therapeutic and lethal blood levels is not very wide (narrow therapeutic index). - Therapeutic blood lithium = 0.8-1.2 mEq/L - Prophylactic blood lithium = 0.6 – 1.2 mEq/L • A blood lithium level of > 2.0 mEq/L is often associated with toxicity, while a level of more than 2.5-3.0 mEq/L may be lethal.
  47. 47. 2. Antipsychotics • Antipsychotics are an important adjunct in the treatment of mood disorder. • The commonly used drugs include risperidone, olanzapine, quetiapine, haloperidol, and aripraxole.
  48. 48. 3. Other Mood stabilizers i. 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.
  49. 49. ii. Carbamazepine – For acute treatment of mania and prevention of bipolar mood disorder. – Particularly useful in those patients who are refractory to lithium and valproate. – The dose range of carbamazepine is 600-1600 mg/day ( the therapeutic blood levels are 4-12 mg/ml).
  50. 50. iii. Benzodiazepines – Lorazepam (IV or orally) and clonazepam are used for the treatment of manic episode alone rarely; however, they been used more often as adjuvant to antipsychotics.
  51. 51. B. ECT (electro-convulsive therapy) • ECT can also be used for acute mania excitement if it is not adequately responding to antipsychotic and lithium.
  52. 52. C. Psychosocial treatment • Cognitive Behavior Therapy • Interpersonal Therapy • Psychoanalytic Therapy • Behaviour Therapy • Group Therapy • Family and Marital therapy
  53. 53. Nursing Management
  54. 54. Nursing Diagnosis • Potential risk for injury related to extreme hyperactivity and impulsive behavior, evidenced by lack of control over purposeless and potentially injurious movements. • Potential risk for violence; self-directed or directed at others related to manic excitement, delusional thinking and hallucinations. Altered nutrition, less than body requirements related to refusal or inability to sit still long enough to eat, evidenced by weight loss, amenorrhea.
  55. 55. • Impaired social interactions related to egocentric and narcissistic behavior, evidenced by inability to develop satisfying relationships and manipulation of others for own desires. • Self-esteem disturbance related to unmet dependency needs, lack of positive feedback, unrealistic self-expectations. • Altered family processes related to euphoric- mood and grandiose ideas, manipulative behavior, refusal to accept responsibility for own actions.
  56. 56. Nursing Interventions Encouraging taking medications. – Explain to the client and his family members the importance of medicine and contribution of medication as per prescription and treatment plans, effects or complications, if not consuming drugs, etc. in an understanding , simple manner; it is a good to convey the message in their own language. – Administer the drugs according to doctors order and monitor for side effects, record and report the drugs administered, and if any side effects observed.
  57. 57. – Administer the drugs according to doctors order and monitor for side effects, record and report the drugs administered, and if any side effects observed. – While the client is on lithium prescription, monitor the level of serum lithium levels periodically, advice salt restrictions diet. – Encourage the client to perform productive activities – Provide calm and quiet environment.
  58. 58. Prevent from injury – Establish calm and quiet, non-productive or non- stimulating environment. – Keep sharp instruments away from the client. – Provide supportive environment. – Keep the client aside from stressful environment. – Do not provoke or argue with the client or others in the client's unit. – Protect the client by engaging in useful activities.
  59. 59. – Divert the client's by engaging in useful activities. – Divert the client's mind by asking him to participate in calm activities like watching TV, playing with children, reading spiritual materials or interest of his own. – Never allow violent patients stay together or nearby place in same environment. – Establish reliable, framed environment, set priorities and goals for everyday activities.
  60. 60. – Educate the client the coping strategies and deep relaxation techniques to overcome aggressive feelings. – Never leave client all alone, one person has to accompany to observe and guide or assist the patient to perform useful activities. Observe the client's interaction and restrict him to involve in group destructive activities. – Keep the music volume low and dim light in client's room. – Avoid slippery floor to prevent accidents.
  61. 61. Prevent for violence resulting causing harm himself or to others related to manic excitement and perceptual disturbance. – Provide peaceful, safe, environment, establish and maintain low stimuli in client's unit. – Monitor the client's behavior every 15 minutes once and maintain process recording of it, report if to appropriate health care professional. – Remove all hazardous material in client's unit.
  62. 62. – Motivate the client to verbalize his feelings openly, thereby internal conflicts and hesitation will be reduced. – Encourage the client to perform deep breathing exercises, medication and interested activities in a desirable manner. – Promote physical outlet for violent behavior. – Accept the client's feelings, be with him, show positive attitude, concern, and make him to understand that nurses are their well wishers and caretakers. Be brief, clear, direct speech in conversation, make the client to ventilate the emotions.
  63. 63. – Administer the drugs as per order and explain to the client and his relatives its importance. – Always some nursing staff should be ready to handle the client in the time of need (violent behavior or exciting if needed placement of restraints may be necessary. – If restraints are placed, gradually remove one by one by observing his behavior. – Maintain adequate distance with the violent client and be ready to exit during violent behavior.
  64. 64. – Exhibit consistency behavior at all times. – Never hurt inner feeling of the client, do not do any unhealthy comparisons. – Review the incident with client after he gained control over his behavior. – Restrict or limit the client's negative feeling or activities. – Define specified tasks, schedule it, orient and reinforce the cleitn to perform his scheduled activities without postponing , insist for implementation of activities. – Encourage the client to participate in group activities and in small discussions. – Provide minimum furniture.