Psychiatric nursing- Nursing Management of Patients with Mood Disorders for B.Sc nursing Students

1. Mood
Disorders
Mr.Visanth V S
Asso. Professor
IGSCON, Amethi

2. Introduction
 Manic-depressive illness is known since the era
of Hippocrates (460–357 BC), Galen (131–201
AD) and Areteus from Cappadocia, and is
described in ancient medical texts.
 The ancient Greeks and Romans coined the
terms "melancholia" and "mania." Hippocrates
was the first to describe melancholia which is
the Greek word for "black bile".

3. What is a mood disorder?
 Affect(objective appearance of mood) which is
a short-lived emotional response to an idea or
an event
 Mood (person’s subjective emotional state)
which is a sustained and pervasive emotional
response which colors the whole psychic life.

4. Mood Disorders/Affective
Disorder
 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.
 The prevalence of mood disorders is 1.5 % and it
is uniform through out the world.
 The mood change is usually accompanied by a
change in the overall level of activity.

5. Contd……….
 Most of these disorders tend to be recurrent, and
the onset of individual episodes is often related
to stressful events or situations.
 The mood disorders may be subdivided into
unipolar and bipolar types:
1. those that are characterized by depression
only
2. those that are characterized by manic
episode either alone or in combination with
depression

6. Classification
 F 30 -Manic Episode
 F 32 -Depressive Episode
 F31 -Bipolar Mood( Affective) Disorder
 F 33 -Recurrent Depressive Disorder
 F34- Persistent Mood Disorder8-Other
 F39 - Unspecified mood (affective) disorder

7. Manic Episode

8. Manic Episode
Mania is a mood disorder characterized
by elevation of mood, increased
psychomotor activity, self important
ideas

9. Triad Symptoms Of Mania
MANIA
Elevation of mood
Increased Self
Esteem
Increased Psychomotor
activity

10. Incidence
The life-time risk of manic episode is about
0.8- 1%.
This disorder tends to occur in episodes
lasting usually 3-4 months, followed by
complete clinical recovery.
The future episodes can be manic,
depressive or mixed

11. Etiology
 Genetic Factors
 Affective disorders are known to have a marked
genetic predisposition.
 Studies of first degree relatives of elderly manic
patients have found a quarter to a half are affected.
 Monozygotic twins have a higher degree of chance
than dizygotic.
 5-10% chance in first degree relatives. 40-70%
chance in identical twins.

12. Biochemical Factors
Biochemical hypothesis of manic
episode is related to the excessive levels
of serotonin, norepinephrine and
dopamine.
Psychodynamic Theories
This includes faulty family dynamics
during the early years of life and as a
defense against denial of depression.

13. Brain Diseases
Elderly people with mania have found a
significant association between brain
disease and mania.
Cerebrovascular disease
chronic alcohol misuse
head injury
right-sided lesions may contribute to manic
disorders.

14. Stress Adaptation Model Of Mania

15. Types of Mania
F30 Manic episode
F30.0Hypomania
F30.1Mania without psychotic symptoms
F30.2Mania with psychotic symptoms
F30.8Other manic episodes
F30.9Manic episode, unspecified

16. Hypomania
 Lesser degree of mania
 Mild elevation of mood for at least several
days
 Increased activity & energy
 Not disturb the social & occupational life
 Increased sociability, talkativeness, over
familiarity, increased sexual energy, and a
decreased need for sleep are often present.
 There are no hallucinations or delusions

17. Mania Without Psychotic Features
 Symptoms are severe, Disturbance in social & occupational
life
 last for at least 1 weak, elation is accompanied by increased
energy, resulting in over activity, pressure of speech, and a
decreased need for sleep
 normal social inhibition are lost, attention cannot be
sustained, and there is often marked distractibility
 self-esteem is inflated, and grandiose or over-optimistic
ideas are freely expressed
 the individual may embark on extravagant and impractical
schemes, spend money recklessly, or become aggressive,
amorous, or factious in inappropriate circumstances.

18. Mania With Psychotic Features
 More severe form
 Psychotic features like hallucination and delusion may
develop
 Disturbs social and occupational life
 Inflated self-esteem and grandiose ideas may develop
into delusions, and irritability and suspiciousness into
delusions of persecution
 Sustained physical activity and excitement may result in
aggression or violence, and neglect of eating, drinking,
and personal hygiene may result in dangerous states of
dehydration and self neglect

19. Clinical Features
 Elevated, Expansive or Irritable Mood
 The elevated mood can pass through following four stages;
 Euphoria: mild elevation of mood), an increased sense of
psychological well-being and happiness. This is usually seen in
hypomania (Stage I).
 Elation: moderate elevation of mood with an increased
psychomotor activity. Elation is classically seen in mania
(Stage II).
 Exaltation: severe elevation of mood, with delusions of
grandeur; seen in severe mania (Stage III).
 Ecstasy: very severe elevation of mood, intense sense of
rapture or blissfulness; typically seen in delirious or stuporous
mania (Stage IV).

20. Contd…………..
Psychomotor Activity
There is an over activity with excessive energy
Restlessness,
Manic excitement where the person is ‘on-the-
toe-on-the-go’, (i.e. involved in ceaseless
activity).
Rarely, a manic patient can go in to a
stuporous state (manic stupor).

21. Contd…………..
 Speech and Thought
 The person is more talkative than usual
 Develops pressure of speech; uses playful language with
punning, rhyming, joking and teasing
 Speaks loudly.
 Flight of ideas develops.
 Distractibility
 Delusions of grandeur
 Delusions of persecution may sometimes develop.
 Hallucinations often with religious content, can occur
 Since these psychotic symptoms are in keeping with the
elevated mood state, these are called mood congruent psychotic
features.


22. Others
 Decreased need for sleep.
 Increased libido (may lead to sexual
indiscretions).
 Unusually alert
 Increased social communication
 Poor judgment
 Insight is absent
 Decreased food intake
 Suicidal ideas in BMD

23. Diagnosis
 Psychiatric History Collection
 Mental Status Examination
 Mania rating scales eg. Young mania
rating scale

24. Management
 Hospitalization
 Psychopharmacology
 Lithium -900-2100mg/day
 Carbamazepine-600-1800/day
 Sodium valproate-600-2600mg/day
 Others- calcium channel blockers, Clonazepam, etc
 Electro Convulsive Therapy

25. Nursing Diagnosis
 Risk for injury R/T extreme hyper activity.
 Risk for violence self directed or other directed R/T
manic excitement, delusional thinking, hallucinations.
 Imbalanced nutrition less than body requirement R/T
refusal or inability to sit long enough to eat .
 Impaired social interaction R/T egocentric and
narcissistic behavior.

26. Nursing Care Plan for Mania
Nursing diagnosis: Risk for injury related to extreme hyperactivity evidenced by
increased agitation and lack of control over purposeless and potentially injurious
movements
Outcome Identification Nursing Intervention
Client will not experience
injury
1. Reduce environmental stimuli.
2. Assign single room and keep lighting and noise
level low.
3. Remove hazardous objects and substance
4. Stay with the client who is hyperactive and
agitated.
5. Provide physical activities.
6. Administer tranquilizing medication as ordered by
physician.

27. Nursing diagnosis: Risk for violence self-directed or other-directed related to
manic excitement, delusional thinking, hallucinations
Outcome Identification Nursing Intervention
Client will not harm self
or others
1. Maintain low level of stimuli
2. Observe client’s behavior at least every 15 minutes.
3. Ensure that all sharp objects have been removed
from client’s environment.
4. Redirect violent behavior.
5. Encourage client to express his anger verbally
6. Have sufficient staff to indicate a show of strength
to client if necessary.
7. Administer tranquilizing medication. If client
refuses, use of mechanical restraints may be
necessary.
8. Observe the client in restraints every15 minutes.
9. Remove restraints gradually, one at a time.

28. Nursing diagnosis: Impaired social interaction related to egocentric and narcissistic
behavior evidenced by inability to develop satisfying relationships and
manipulation of others for own desires
Outcome Identification Nursing Intervention
Client will interact
appropriately with others.
1. Recognize that manipulative behaviors help to
reduce feelings of insecurity by increasing feelings
of power and control.
2. Set limits on manipulative behaviors.
3. Explain what is expected and the consequences if
limits are violated.
4. Discourage the client to argue, bargain, or charm his
or her way out of the limit setting.
5. Give positive reinforcement for non manipulative
behaviors.
6. Discuss consequences of client’s behavior and how
attempts are made to attribute them to others.
7. Help client identify positive aspects about self,
recognize accomplishments, and feel good about
them.

29. Depression

30. Depression
The common cold of psychological
disorders.
 It is a widespread psychiatric problem
affecting many people.
 It is characterized by depressed mood or
loss of interest or pleasure in usual
activities.

31. Epidemiology
 Lifetime risk in males 8-12% & in females 20-26%.
 Lifetime prevalence is in the range of 15 - 25 %.
 The mean age of onset is about 40 years (25 - 50
years).
 It may occur in childhood or in the elderly.
 It occurs twice as frequently in women as in men.
 It is commonly associated with a variety of medical
conditions

32. Types of Depression
 F32.0: Mild depressive episode.
 F32.1: Moderate Depressive episode
 F32.2: Severe depressive episode without
psychotic symptoms
 F32.3: Severe depressive episode with psychotic
symptoms
 F32.8: Other depressive episodes
 F32.9: Depressive episodes, unspecified
 F33: Recurrent Depression disorder.

33. Etiology

34. Biological Theories
 Genetics:
Twin studies suggest that about 50
percent of monozygotic twins and 10-25
% of dizygotic twins are at risk of mood
disorders.
Major depression is 1.5 to 3 times more
common among first degree relatives of
people with mood disorder than general
population.

35.  Biochemical : Depressive illness may be related to a
deficiency of the neurotransmitters norepinephrine,
serotonin, and dopamine.
 Brain Imaging: Neuroimaging studies (CT, MRI)
shows include ventricular dilatation, white matter hyper-
intensities, and changes in the blood flow and
metabolism in several parts of brain.
 Psychoanalytical theory: Sigmund Freud observed that
melancholia occurs after the loss of a loved object.
 Object Loss Theory: This theory suggests that
depressive illness occurs as a result of having been
abandoned by or otherwise separated from a significant
other during the first 6 months of life.

36.  Stress: Increased number of stressful life events have
a precipitating effect in depression .
 Medications : Certain medications used alone or in
combination can cause side effects much like the
symptoms of depression. Examples of these include
the anxiolytics, antipsychotics, and sedative
hypnotics.
 Neurological Disorders
 Nutritional Deficiencies
 Major Illnesses

37. Clinical Features
 Depressed Mood
Sadness of mood or loss of interest and/or
pleasure in almost all activities
Present throughout the day (persistent
sadness).
Other features related to mood include;
 Anhedonia
 Irritability.
 Frustration.
 Tension.

38. Depressive Ideation/Cognition
Pessimism, which can result in following
ideas;
Present: patient sees the unhappy side of
every event.
Past: unjustifiable guilt feeling and self-
blame.
Future: gloomy preoccupations; hopelessness,
helplessness, death wishes (may progress to
suicidal ideation and attempt).

39.  Psychomotor Activity
 In younger patients psychomotor retardation is more
common and is characterized by
 Slowed thinking and activity
 Decreased energy
 Monotonous voice.
 In a severe form, the patient can become stuporous
(depressive stupor).
 In the older patients (e.g. post-menopausal women),
agitation is commoner.
 It often presents with marked anxiety, restlessness
 Subjective feeling of unease.
 Anxiety is a frequent accompaniment of depression.

40.  Psychotic Features
 About 15-20% of depressed patients have psychotic symptoms
such as delusions, hallucinations.
 Delusions
– Delusion of guilt
– Nihilistic delusion
– Delusion of poverty and impoverishment.
– Persecutory delusion
 Hallucinations:
– Usually second person auditory hallucinations
– Visual hallucinations (scenes of death and destruction)
may be experienced by a few patients.

41.  Appearance & Behaviour
 Neglected dress and grooming.
 Facial appearance of sadness
 Psychomotor retardation (sometimes agitation).
 Lack of motivation and irritation.
 Social isolation and withdrawal.
 Delay of tasks and decisions.
 Loss of interest in work and pleasure activities.

42. Diagnosis
 Detailed Psychiatric history
 Mental Status Examination
 History of medication uses, neurological
disorders etc.
 Psychological tests like depression scale

43. Management
 Hospitalization is necessary for the client with
depression and is indicated for:
 Suicidal or homicidal patient.
 Patient with severe psychomotor retardation who is
not eating or drinking.
 Diagnostic purpose (observation, investigation).
 Drug resistant cases.
 Severe depression with psychotic features.

44.  Psychopharmacology
 Antidepressants
 Tricyclics (TCA) / Mono-amino oxidase inhibitors
(MAOI), Selective serotonin reuptake inhibitors (SSRIs).
 After a first episode of a unipolar major depression,
treatment should be continued for six months after clinical
recovery, to reduce the rate of relapse.
 Lithium Carbonate can be used as prophylaxis.
 Antipsychotics are an important adjunct in the treatment of
mood disorder.
 The commonly used drugs include risperidone, olanzapine,
quetiapine, haloperidol.

45. Psychosocial Therapies
 CBT
 Interpersonal therapy
 Psychoanalytic psychotherapy
 Behavior therapy
 Group therapy
 Family & Marital therapy

46. Nursing Process
Nursing diagnosis: Risk for self directed violence related to depressed mood,
feelings of worthlessness, anger turned inward on the self.
Outcome
Identification
Nursing Intervention
Client will not harm
self
1. Assess for suicidal ideations
2. Do not allow the client to be alone in the ward.
3. Remove all the sharp instruments, ropes from
the vicinity of the client.
4. It may be desirable to place the patient near
nursing station for close observation.
5. Do not allow the client to put bolt on his side
door and bathroom.
6. Encourage the client to express feelings.

47. Nursing diagnosis: Dysfunctional grieving related to real or perceived loss,
bereavement overload, evidenced by denial of loss, inappropriate expression
of anger, inability to carry out activities of daily living.
Outcome
Identification
Nursing Intervention
Client will be able to
verbalize
normal behaviors
associated
with grieving and
begin progression
toward resolution
1. Assess stage of fixation in grief process
2. Develop trust. Show empathy, concern, and
unconditional positive regard.
3. Explore feelings of anger and help client direct
them toward the intended object.
4. Promote the use of large motor activities for
relieving pent-up tension.
5. Teach normal behaviors associated with
grieving.
6. Help client with honest review of relationship
with lost object.

48. Nursing diagnosis: Self esteem disturbance related to learned helplessness, feelings of
abandonment by significant other, or impaired cognition fostering negative view of
self, evidenced by expressions of worthlessness, hypersensitivity to a slight or criticism,
and a negative, pessimistic outlook.
Outcome
Identification
Nursing Intervention
Client will interact
appropriately with
others.
1. Develop a trusting relationship with client
2. Encourage the client to become involved with staff and
other clients through interaction
3. Explore feelings of anger and help client direct them
toward the intended object or person.
4. Encourage the client for recreational activities
5. Provide simple activities and shift gradually to complex
activity
6. Give positive feedback for each accomplished activities
7. Explore with the client his or her personal strengths,
making a written list is sometimes helpful.

49. BIPOLAR DISORDERS

50. Bipolar Disorders
 This disorder, earlier known as manic
depressive psychosis (MDP), is characterized
by recurrent episodes of mania and depression
in the same patient at different times.
 People with MDP changes back and forth
between periods of depression and mania

51. Epidemiology
 The lifetime prevalence is between 0.5 and 1%.
 Suicidality is about 19%.
 Comorbidity increases with alcohol and drug
abuse.
 The first episode may occur at any age from
childhood to old age.

52. Types
 F31.0: Bipolar disorder current episode hypomania
 F31.1: Bipolar disorder current episode mania without psychotic
symptoms
 F31.2: Bipolar disorder current episode Manic with psychotic
symptoms
 F31.3: Bipolar disorder current episode Mild or moderate
depression
 F31.4: Bipolar disorder current episode severe depression,
without psychotic symptoms
 F31.5 : Bipolar disorder current episode severe depression, with
psychotic symptoms,
 F31.6: Mixed, or in remission.

53. Graphic Representation of Bipolar Disorder

54. Bipolar mood disorder is classified in to;
Bipolar I – It is characterized by episode of
severe mania and severe depression.
Bipolar II – It is characterized by hypomania
and severe depression.

55. Etiology
 Exact cause is unknown
 Genetic, biochemical and psychosocial causes
may have a role
 Stressful life events
 Sleep deprivation and endocrine factors

56. Treatment
 Lithium
 Valproic acid
 Carbamazepine
 Antidepressants
 Antipsychotics

57. Rapid Cycling Bipolar Disorder
 This is characterized by alternating episodes (4
or more) of depression, mania or hypomania in
the previous 12 months, separated by intervals
of 48 - 72 hours.
 It is usually more chronic than non-rapid
cycling disorders.
 Around 80 % are lithium-treatment failures.
 Carbamazepine or sodium valproate is usual
agents of choice.

58. RECURRENT DEPRESSIVE DISORDER
This disorder is characterized by recurrent
(at least two) depressive episodes (unipolar
depression).
 The current episode may be mild,
moderate, severe without psychotic
symptoms, or severe with psychotic
symptoms.

59. PERSISTENT MOOD DISORDER
 These disorders are characterized by persistent mood
symptoms which last for more than 2 years (1 year in
children and adolescents).
 If the symptoms consist of persistent mild depression,
the disorder is called as dysthymia.
 If symptoms consist of persistent instability of mood
between mild depression and mild elation, the disorder
is called as cyclothymia.

60. Dysthymia
 It was also called “depressive neurosis/neurotic depression/exogenous
depression”
 In this a mild depression that lasts for at least 2 years in adult and 1 year in
children.
 It is twice common in women as in men
 Dysthymia is characterized by the following:
 Presence of mild to moderate depression.
 Depressive symptoms usually occur in response to a stressful situation.
 Other ‘neurotic’ symptoms such as anxiety, obsessive symptoms,
phobic symptoms, and multiple somatic symptoms, are often present.
 The typical course of neurotic depression is chronic, with fluctuations.
 Delusions, hallucinations and other psychotic features are
characteristically absent.

61. Treatment
 Short term psychotherapy
 Behavioral therapy
 Group therapy
 Antidepressants such as SSRI, TCA etc.

62. Cyclothymia
 Less severe bipolar mood disorder with
continuous mood swings; alternating periods of
hypomania and moderate depression.
 It is non-psychotic chronic disorder.
 It starts in late adolescence or early adulthood.
 The treatment is similar to that of bipolar mood
disorder.

63. Other Mood Disorders

64. Melancholia
 Described by Kraeplin, this is a form of severe
depression which occurs in the involutional
period of life (i.e. 40-65 years of age).
 It is characterized by marked agitation, presence
of psychotic features
such as delusions of persecution
tactile and auditory hallucinations
multiple somatic symptoms

65. Masked Depression
 In masked depression, the depressive mood is not easily
apparent and is usually hidden by somatic symptoms.
 This is especially common in the elderly
 The somatic symptoms range from;
 chronic pain
 Insomnia
 Atypical facial pain
 paraesthesia.
 The depressive symptoms can also be masked by drug
and/or alcohol misuse.

66.  Double Depression
 This is a major depressive episode superimposed
on an underlying dysthymia or neurotic
depression.
 The response to treatment is usually poor.
 Agitated Depression
 This is a type of severe depression with marked
motor restlessness or agitation.
 It is either seen alone or along with involutional
melancholia.
 It is more common after the age of 40 years.

67. Secondary Depression and Secondary Mania
 Both depressive and manic episodes can
occur secondary to certain physical
diseases and drugs.
Substance-induced mood disorder
 Characterized by prominent and persistent
disturbance in mood that is judged to be a
direct physiological consequence of a drug
abuse, toxin exposure, or a medication.

68. Mixed Anxiety Depressive Disorder
This disorder is characterized by the
presence of depressive and anxiety
symptoms.
The symptoms should not meet the
criteria of either an anxiety disorder or a
mood disorder.

69.  Seasonal Mood Disorder
 This is either a bipolar mood disorder or recurrent depressive
episode which tends to occur in the same season on each
occasion.
 It is usually more commonly seen in women.
 For example the depression begins in the fall or winter, or
when there is a decrease in sunlight.
 Mania would occur in the month of summer.
 Seasonal affective disorder is characterized by atypical
features of depression, hypersomnia, hyperphagia, weight
gain, and increased fatigue.
 This is related to abnormal melatonin metabolism.
 It can be treated with exposure to light (artificial light for 2 –
6 hours a day).
 It may occur as part of bipolar I or II disorders.