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Questions and Answers
What symptom is specifically associated with premenstrual dysphoric disorder?
What symptom is specifically associated with premenstrual dysphoric disorder?
Which condition is characterized by a disturbance in mood due to substance intoxication or withdrawal?
Which condition is characterized by a disturbance in mood due to substance intoxication or withdrawal?
Which diagnosis does not require full criteria of depressive disorders?
Which diagnosis does not require full criteria of depressive disorders?
What is an example of a condition that might cause depressive symptoms due to physiological effects?
What is an example of a condition that might cause depressive symptoms due to physiological effects?
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What is a characteristic development timeline for bipolar and related disorder due to another medical condition?
What is a characteristic development timeline for bipolar and related disorder due to another medical condition?
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Which mood disorder diagnosis includes symptoms that persist for at least 2 weeks and have to include specific depressive symptoms?
Which mood disorder diagnosis includes symptoms that persist for at least 2 weeks and have to include specific depressive symptoms?
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Which diagnosis is characterized by a prominent and persistent disturbance in mood developed during or soon after substance use?
Which diagnosis is characterized by a prominent and persistent disturbance in mood developed during or soon after substance use?
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What distinguishes unspecified depressive disorder from other types of depressive disorders?
What distinguishes unspecified depressive disorder from other types of depressive disorders?
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Which of the following is NOT a symptom required for the diagnosis of Persistent Depressive Disorder?
Which of the following is NOT a symptom required for the diagnosis of Persistent Depressive Disorder?
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What is one of the required criteria for diagnosing a manic episode?
What is one of the required criteria for diagnosing a manic episode?
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In the context of mood disorders, what defines clinically significant distress?
In the context of mood disorders, what defines clinically significant distress?
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For children or adolescents, how long must an irritable mood persist for it to be classified under Persistent Depressive Disorder?
For children or adolescents, how long must an irritable mood persist for it to be classified under Persistent Depressive Disorder?
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Which of the following best differentiates Bipolar I disorder from other mood disorders?
Which of the following best differentiates Bipolar I disorder from other mood disorders?
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Which of these symptoms must be present nearly every day to consider a diagnosis of major depressive episodes?
Which of these symptoms must be present nearly every day to consider a diagnosis of major depressive episodes?
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Which factor is NOT considered when diagnosing mood disorders?
Which factor is NOT considered when diagnosing mood disorders?
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What must an individual experience during a 2-year period to meet the criteria for Persistent Depressive Disorder?
What must an individual experience during a 2-year period to meet the criteria for Persistent Depressive Disorder?
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Which interpersonal factor is NOT typically associated with depression?
Which interpersonal factor is NOT typically associated with depression?
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What does the theory of 'disorder fostering disorder' propose?
What does the theory of 'disorder fostering disorder' propose?
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Which of the following mood disorders is specifically associated with cannabis use?
Which of the following mood disorders is specifically associated with cannabis use?
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What is true about the relationship between mood disorders and substance abuse?
What is true about the relationship between mood disorders and substance abuse?
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Which diagnostic category includes chronic irritability and temper outbursts in children?
Which diagnostic category includes chronic irritability and temper outbursts in children?
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In persistent depressive disorder, how long must the depressive mood persist?
In persistent depressive disorder, how long must the depressive mood persist?
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Which of the following is NOT a recognized mood disorder induced by substance use?
Which of the following is NOT a recognized mood disorder induced by substance use?
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Which of these factors is commonly implicated in the co-occurrence of mood disorders and substance abuse?
Which of these factors is commonly implicated in the co-occurrence of mood disorders and substance abuse?
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Study Notes
Care of Individuals with Mood Disorders and Substance Abuse
- Students should be able to understand the causes of mood disorders and their co-occurrence with substance abuse by the end of the session
- Students should be able to identify the signs and symptoms of mood disorders by the end of the session.
- Students should be able to describe the nursing care and treatment of clients with mood disorders and substance abuse by the end of the session
- Students should be able to develop knowledge in suicidal management by the end of the session.
Aetiology of Mood Disorders
Genetic Factors
- The risk of developing a mood disorder is 1.5 to 3 times greater in individuals whose first-degree relative is affected with a mood disorder.
- If one parent has depressive disorder, there is a 10%-13% chance the child will have the disorder.
- If one parent has bipolar disorder, there is a 25% chance the child will have a mood disorder; the chance rises to 50%-75% if both parents have bipolar disorder.
- If one dizygotic twin has bipolar disorder, there is a 20% chance in the other twin to have a mood disorder; the chance rises to 40%-70% for the other twin if one monozygotic twin has bipolar disorder.
Biochemical Factors
- Depressive disorder is associated with deficiencies in norepinephrine, epinephrine, dopamine, and serotonin.
- Mania is associated with excessive high levels of norepinephrine and dopamine and dysregulation of serotonin.
Pharmacological Factors
- Mania can be secondary to drugs, particularly steroids, amphetamines, cocaine, hallucinogens, opiates, and tricyclic antidepressants.
- Depression can be induced by hormones (e.g., oral contraceptives, glucocorticoids), psychotropics (e.g., benzodiazepines, neuroleptics), cardiovascular drugs (e.g., digitalis, beta-blockers, calcium channel blockers), anti-inflammatory and anti-infective drugs (e.g., nonsteroidal anti-inflammatory drugs, antituberculosis drugs, sulfonamides), and anti-ulcer medications (e.g., cimetidine, ranitidine).
Endocrinological Factors
- Many depressed and manic patients have high levels of cortisol in plasma and urine.
- Depression is related to hypothyroidism. Mania can be associated with hyperthyroidism, Cushing's syndrome, and Addison's disease.
- Postpartum depressive patterns can occur in some women following childbirth, apparently due to hormonal changes.
Medical Conditions
- Depressive symptoms can be detected in individuals with general medical conditions such as cerebrovascular accident (CVA), diabetes, coronary artery disease, cancer, AIDS, epilepsy, Parkinson's disease, and chronic fatigue syndrome.
- Mania can be triggered by infections (e.g., influenza), neoplasms (e.g., diencephalic glioma), neurologic disorders (e.g., multiple sclerosis), metabolic disturbances (e.g., vitamin B12 deficiency), and collagen vascular disease (e.g., systemic lupus erythematosus).
Circadian Rhythm Theories
- Individuals experiencing circadian rhythm changes are at an increased risk of developing depression.
- Changes can be due to medications, nutritional deficiencies, physical or psychological illnesses, hormonal fluctuations, or aging.
- Changes lead to shortened latency in rapid eye movement and sleep disturbances in depressed individuals.
Changes in Brain Anatomy
- Depression might result from or cause atrophy of specific brain locations, such as loss of neurons and white matter in the frontal lobes, cerebellum, and basal ganglia.
Psychosocial Factors
- Psychosocial stressors can precede the onset of bipolar disorder; manic episodes may follow a stressful event.
- Depressive symptoms can result from stressful life events, such as trauma, significant loss, financial problems, perceived or real failure, and life transitional crises.
- Certain attitudes and beliefs can increase the personal risk of developing depression, eg. low self-esteem, lack of personal goals and direction, tendency to avoid difficult situations, passivity in interpersonal relationships & internalization of blame.
- Depression can be associated with some vulnerability factors: lack of social support, low social status, family conflict, and childhood adversity including violence.
Psychodynamic Theories
- Depression is understood in psychoanalysis as anger turned inward after a real or perceived loss.
- Learned helplessness theory: Depression occurs in people who perceive their own behavior out of control and feel helplessness.
- Cognitive theory: Depression is a problem of cognitive patterns that have developed over time; the individual holds negative views of self, the world, and the future.
- Interpersonal psychotherapeutic model: Depression is related to multiple interpersonal factors (eg. unsatisfactory early interpersonal experience, stress in current interpersonal relationships, and lack of supportive relationships).
Theories Related to Co-occurrence of Mood Disorders and Substance Abuse
- Disorder fostering disorder: Mood disorders may motivate individuals to resort to drugs and alcohol to cope with their negative affective states.
- Overlapping neurobiological pathways: Abuse of alcohol and cocaine can sensitize neurons contributing to increased use of these substances. Mood disorders often follow a similar course of increasingly distressing symptomatic episodes separated by progressively shorter periods of remission.
- Underlying genetic factors: Both substance abuse and mood disorders have genetic risk factors; families with substance abusers are more likely than those without to also have members with mood disorders.
Examples of Mood Disorders Associated with Substance Abuse (ICD-11)
- Alcohol-induced mood disorder
- Cannabis-induced mood disorder
- Cocaine-induced mood disorder
- Opioid-induced mood disorder
- Stimulant-induced mood disorder
- Hallucinogen-induced mood disorder
- Sedative, hypnotic, or anxiolytic-induced mood disorder
- Mood disorder induced by multiple specified psychoactive substances.
Mood Range and Mood Disorders
(Diagram showing a range of moods from depressed to manic with examples of various mood disorders)
DSM-5-TR Diagnostic Categories for Mood Disorders
(Detailed descriptions of major depressive disorder, persistent depressive disorder, disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder, bipolar disorders, etc as outlined in the document)
DSM-5-TR Diagnostic Criteria for Major Depressive Disorder, Persistent Depressive Disorder and Bipolar I Disorder, Bipolar II Disorder, and Others.
(Detailed diagnostic criteria)
Substance-related disorders
- Substance use disorders
- Substance-induced disorders
- Intoxication
- Withdrawal
- Other substance/ medication-induced mental disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium and neurocognitive disorders)
DSM-5-TR Criteria for Substance Use Disorders
(Detailed descriptions of criteria)
DSM-5-TR Criteria for Substance Intoxication
- Includes the development of a syndrome specific to a substance
- Includes clinically significant behavioural changes
DSM-5-TR Criteria for Substance Withdrawal
(Detailed descriptions of criteria)
DSM-5-TR Criteria for Substance/Medication-Induced Mental Disorders
- Presents a clinically significant symptomatic presentation of a relevant mental disorder
- Includes evidence of either or both substance intoxication, substance withdrawal or medication exposure/withdrawal
- The involved substance is capable of producing the mental disorder
- Not exclusive to deliriums
- Causes clinically significant distress or impairment in social or occupational functioning
Alcohol
- Alcohol problems affect 10-20% of the population in western society.
- Alcohol abuse is a growing problem in Chinese society.
- Destructive outcomes include divorce, suicide, traffic accidents, crime, and violence.
- Alcohol involvement is often involved in domestic violence.
- Physical problems: anemia, nutritional deficiency, liver diseases, gastric ulcer, hypertension, stroke, heart disease, and respiratory infections
- Mental problems: alcoholic delusion of jealousy, alcoholic hallucinosis, Korsakoff's psychosis, & dementia
Safe Limit of Alcohol Intake
- 2 standard drinks daily (males); 1 standard drink daily (females)
- At least 2 days a week without alcohol
Common Alcoholic Drinks in Hong Kong and their Standard Drink Units
(Table of different alcoholic drinks and their associated alcohol content and volume per serving, number of standard drinks)
Alcohol Intoxication
- Evidence of recent alcohol consumption
- Slurred speech, impaired coordination, unsteady gait, delayed reflexes, impaired concentration & memory, mood changes.
- Changes in sexual behavior
- Stuporous behavior, coma, or blackout if drinking continues.
Alcohol Withdrawal
- Shakiness
- Tremors
- Psychomotor restlessness
- Agitation
- Increased pulse rate
- Sweating
- Nausea and vomiting
- Sleep pattern alteration
- General anxiety
- Development of symptoms hours or days after discontinuation of alcohol consumption
Mood and Substance Use Comorbidity
- Comorbidity worsens clinical course, treatment outcome, and prognosis.
- Greater risk of suicide.
- Successful alleviation of one condition facilitates recovery from comorbidities.
Nursing Management
Assessment
- Thorough physical and neurological examination to assess if the mood disorder is primary or secondary.
- Identify any substance use and abuse (alcohol, illegal drugs, sedatives, oral contraceptives, and steroids).
- Evaluate risk of harm to self or others as appropriate.
- Use validated assessment tools (PHQ 9, BDI, HDS, CES-D, AUDIT, DAST-10, ASI)
Depression
- Instill hope
- Regulate emotions/ behaviors
- Promote self-esteem
- Manage self-care deficits
- Mobilize social support
Mania
- Provide safety
- Meet physiologic needs (nutrition, fluid, sleep, cleanliness)
- Reinforce appropriate interaction skills
- Promote reality orientation/ eliminate sensory misperception
- Monitor medication adherence/ prevent drug intoxication
Abuse (Acute Stage)
- Provide safe, comfortable, and low-stimulation environment.
- Orient to time, place, and person
- Monitor vital signs
- Maintain adequate nutrition and fluid balance.
- Monitor for delirium tremens, psychotics symptoms, and suicide/ seizure risk.
- Provide emotional support to patient and family
Abuse (Withdrawal Stage)
- Monitor withdrawal symptoms (nausea, vomiting, tremors, paroxysmal sweats, anxiety, agitation, tactile/ auditory/ visual disturbances, headache/ disorientation)
- Administer withdrawal medication (e.g., anticonvulsants/ benzodiazepines) as prescribed.
Abuse (Rehabilitative Stage)
- Help client develop motivation and commitment to abstinence, lifestyle change, and recovery.
- Help complete detoxification from all mood-altering substances.
- Administer medications as needed to enhance abstinence and recovery
- Provide support -Facilitate hope
- Enhance coping/ communication & problems-solving skills.
- Educate about relapse prevention
Suicidal Management
- Risk recognition: Identify significant risk of suicide attempts/ self-harm
- Risk assessment: Assess for demographics and clinical risk factors (depression, age, gender, marital status, trauma/abuse history, mental illness, substance use, chronic physical illness, history of suicidal attempts, negative life events/stress, family history of suicide, living alone/social isolation).
- Risk assessment of client depression: Assess mood-related symptoms, physical symptoms, cognitive symptoms, and social/interpersonal symptoms.
- Assess the degree of hopelessness and helplessness.
- Explore the suicidal ideation, specificity, lethality, availability & proximity of plans.
- Assess client self-control, past/ familial attempts of suicide, and suicidal intent.
- Risk management: Listen and empathic/ supportive relationship,Provide safety and limit access to harmful items (knives, scissors, etc),Suicide observation/frequent monitoring,Encourage no-suicide contract, Encourage discussion of stress & help with coping strategies & alternatives,Communicate and cooperate with medical officer and among all professionals about the suicidal risk/condition,Identify risk periods & staff strength.
Motivational Interviewing
- A systematic intervention for changing addictive behavior.
- Helps resolve ambivalence in people who are reluctant to change.
- Aims to increase intrinsic motivation for change.
- Five general principles: Express empathy, Develop discrepancy, Avoid argumentation, Roll with resistance, Support self-efficacy.
- Stages of change: Pre-contemplation, Contemplation, Determination, Action, Maintenance, Relapse
Services provided in Hong Kong for Substance Abusers
- Compulsory placement programs (Hei Ling Chau, Nei Kwu, Lai Sun, Lai King Correctional Institutions)
- Voluntary outpatient methadone treatment program
- Voluntary inpatient treatment/residential drug rehabilitation programs (Christian New Life Association Ltd., Mission Ark Limited, etc)
- Counselling programs for psychotropic substance abusers
- Substance abuse clinics
- Self-help support programs
Evaluation
- Evaluate if the patient is aware of the consequences of substance abuse/addictive behaviors.
- Determine if the client safely completes the withdrawal process.
- Assess if the client makes the commitment to stop substance use & learns coping strategies
- Monitor if the client begins to practice recovery behaviors during treatment.
- Assess if the client accepts having a substance use disorder and the inability to use the substance.
Biopsychosocial Interventions
- Biological: Antidepressants (MAOIs, TCAs, SSRIs, NDRIs, SNRIs, SARIs, and NaSSAs), Mood Stabilizers (lithium carbonate, anticonvulsants), Electroconvulsive Therapy (ECT), Transcranial Magnetic Stimulation (TMS)
- Psychological: Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Motivational Interviewing.
- Social: Patient & family education, marital & family therapies, & self-support groups (e.g. Alcoholics Anonymous)
References
(List references for all cited materials. The information in the example text must be referenced with the author and year. No additional assumptions are to be made for additional references. )
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