Understanding Mood Disorders

• Mood disorders are disturbances in mood, behavior, and affect regulation that exceed normal fluctuations.
• Over 20 million people in the United States experience mood disorders
• Mood disorders are a leading cause of disability worldwide.
• Bipolar and depressive disorders can impact thoughts, emotions, behavior, and physical health.
• Many individuals with mood disorders also have coexisting mental and physical disorders.
• Half of those with major depressive disorder also have anxiety.
• Mood describes a pervasive feeling.
• With a mood disorder, a person's mood becomes intensely persistent, interfering with social and psychological functioning.
• Affect is the outward expression of emotion attached to ideas, including facial expressions and vocal modulation.
• Variations in affect are termed the range of emotional expression.
• Patients may display affect abnormalities like blunted affect, flat affect, restricted affect, inappropriate affect, or labile affect.

Challenges in Caring for Patients

• Somatic symptoms may cause mood disorders to be mistaken for physical illnesses.
• Lowered motivation and energy levels may cause patients to neglect self-care.
• Altered family and social relationships may result in frustration, anger, and guilt, potentially leading to abuse.
• Financial hardship may occur if the patient is unable to work.
• Seriously depressed patients may be at risk for suicide.

Causes

• Theories regarding mood disorder causes focus on genetic, biological, and psychological factors.

Genetic Factors

• Genetics plays a significant role in mood disorders.
• Major depressive and bipolar disorders are more frequent among first-degree relatives.
• Identical twin studies reveal that if one twin has major depression, the other has a 70% chance of developing it.

Biological Factors

• Biological research focuses on deficiencies or abnormalities in neurotransmitters like norepinephrine, serotonin, dopamine, and acetylcholine.
• The success of drugs affecting neurotransmitter levels supports the biological roots of these illnesses.

Psychological Theories

• Cognitive, behavioral, and psychoanalytic theories offer explanations for mood disorders.

Cognitive Theory

• Depressed individuals process information negatively.
• They view themselves and the world negatively, believing these perceptions will continue.

Behavioral Theory

• Learned helplessness theory suggests depression arises from negative events causing feelings of helplessness.
• The perceived lack of control dampens motivation, self-esteem, and initiative.
• Lack of social support and poor stress-management increase depression risk after stressful events.

Psychoanalytic Theory

• Depression results from a harsh superego and feelings of loss and aggression.
• Early loss makes a child more susceptible to later depression.

Anger Turned Inward

• Children interpret loss as rejection, feeling unworthy of love.
• Aggressive feelings towards those who rejected him are pushed out of awareness, turning them against himself, leading to depression.

Bipolar Disorders

• Bipolar disorders have severe, pathologic mood swings with extreme highs of mania or hypomania alternating with extreme lows of depression.
• Periods of normal mood occur between the highs and lows.
• Some experience only acute episodes of mania.
• An estimated 3 million people in the United States have bipolar disorders.
• Men and women are equally affected, but women are more likely to have depressive episodes, while men experience more manic episodes.
• Onset occurs between ages 20 and 30, with symptoms sometimes arising in late childhood or early adolescence.
• Roughly 50% of patients with bipolar disorder have difficulties in work performance and psychosocial functioning.

Episodes and Residuals

• Most patients have recurring episodes of mania and depression with symptom-free periods between.
• Up to one-third experience residual symptoms.
• A small percentage have chronic, unremitting symptoms despite treatment.

Mania and Hypomania

• The highs of bipolar disorder may involve either mania or hypomania.
• Mania is characterized by elation, euphoria, agitation, irritability, hyperexcitability, hyperactivity, and rapid speech and thought.
• Mania also presents as exaggerated sexuality and decreased need for sleep.

Hypomania

• An expansive, elevated, or agitated mood that resembles mania but is less intense and lacks psychotic symptoms.
• Hypomania may feel good, bringing high energy, confidence, enhanced social functioning, and productivity.
• May be troublesome and can still progress to severe mania or depression without treatment.

Psychotic Symptoms

• Some patients with bipolar disorder have severe episodes of mania or depression with psychotic symptoms.
• Psychotic symptoms include hallucinations or delusions.
• These patients may be misdiagnosed with schizophrenia.

Implications

• Impulsive behavior during a manic episode may result in divorce, child abuse, joblessness, bankruptcy, and promiscuity.
• People with bipolar disorders have an increased incidence of sexually transmitted diseases and unwanted pregnancies.

Suicide Risk

• Hyperactivity and sleep disturbances may lead to exhaustion and poor nutrition.
• Bipolar disorder also increases the suicide risk.
• A suicide attempt may occur impulsively during a manic episode or after a depressive episode resolves.

Classification

• Bipolar disorder occurs in three major types.
• Bipolar I disorder has manic episodes or mixed episodes alternating with major depressive episodes.
• Bipolar II disorder has milder episodes of hypomania that alternate with depressive episodes.
• Cyclothymic disorder has numerous hypomanic episodes intermingled with depressive episodes that don't meet the criteria for major depressive episodes.
• 10% to 20% of people with bipolar disorder have rapid cycling where four or more distinct periods of depression, mania, hypomania, or mixed states occur within a 12-month period.
• The vast majority of rapid cyclers are women.
• Rapid cycling tends to develop later in the course of illness.
• Some rapid cyclers may experience multiple mood swings within a single week
• Ultra-rapid cyclers can have several mood swings in a single day.
• Experts believe any bipolar patient can switch to a rapid cycling pattern, but most return to their normal bipolar pattern in time.

Precises Causes

• The precise cause is unkown.
• Factors such as genetics, biochemical, and psychological can impact bipolar disorder.

Genetic Factors

• Twin, family, and adoption studies strongly suggest that bipolar disorder has a genetic component.
• First-degree relatives are about seven times more likely to develop the disorder.
• Researchers have found autosomal dominant inheritance in affected families.

Biochemical Factors

• Experts think bipolar disorder stems from neurotransmitter abnormalities or imbalances.
• Some studies suggest the illness is the sensitivity of receptors on nerve cells.

Precipitating events

• Stressful life events may trigger a bipolar episode
• Treatment of depression with an antidepressant drug, which may cause a switch to mania.
• Deprivation of sleep.
• Hypothyroidism.

Bipolar Disorder

• Bipolar disorder can be difficult to diagnose.
• Is assessed by the the Diagnostic and Staristical manual.

During the Manic Phase

• Signs and symptoms include expansive/grandiose, hyperirritable mood, increased psychomotor activity, excessive social extroversion, short attention span, rapid speech, decreased need for food or sleep, impulsivity.

Maximal Mania

• With severe mania, the patient may have delusions, paranoid thinking, and an inflated sense of self-esteem ranging from uncritical self-confidence to marked grandiosity.

During the Depressive Phase

• During a depressive episode, the patient may report/exhibit low self-esteem, overwhelming inertia, social withdrawal, feelings of hopelessness, apathy, self-reproach.
• They may also have difficulty concentrating or thinking clearly, psychomotor retardation, slowing of speech and responses, sexual dysfunction, sleep disturbances, decreased muscle tone, weight loss, slow gait, constipation.

Bipolar Disorder Diagnosis

• Bipolar disorder diagnosis is confirmed if the patient meets the criteria in the DSM-IV-TR.

Treatment

• Bipolar disorder requires drug therapy.
• Lithium is effective in preventing and relieving manic episodes, curbing accelerated thought processes/hyperactivity, potentially preventing depressive episodes (though ineffective in acute depression).
• Lithium has a narrow margin of safety and can easily cause toxicity.
• The patient has to maintain therapeutic blood levels for 7 to 10 days before the desired effects appear, so the doctor may prescribe antypsychotic drugs as well.
• Valproic acid can be prescribed for rapid cyclers/patients who can't tolerate lithium.
• Carbamazepine may be useful in treating mania, though it isn't approved by the FDA for bipolar disorder.

Lithium Alert

• Blood Level Monitoring: Critically important due to drug's narrow therapeutic margin. Regular testing required, especially in first month, renal impairment a contraindication.
• Patient Monitoring: Blood levels checked two or three times weekly for the first month, then weekly to monthly during maintenance therapy, must be done 8- 12 hours after the first dose.
• Patient Teaching:
• Maintain fluid intake of 2,500 to 3,000 ml/day to promote lithium excretion, lithium may cause sodium depletion, dietary changes impacting sodium intake are dangerous, maintain adequate diet intake.
• Salt Intake: Increasing salt intake may increase lithium excretion
• Toxicity - diarrhea, vomiting, tremors, drowsiness, muscle weakness, and ataxia.

During a Manic Episode

• Physical Needs: Prioritize physical needs, activities requiring gross motor movements, encourage eating/offer high-calorie foods, suggest short naps, help with hygiene.
• Diversion: Give diversionary activities suited to a short attention span.
• Calm Environment: Minimize overstimulation (large crowds, loud noises, bright colors), give emotional support and realistic goals for behavior.
• Tactful Conversation: Divert conversation tactfully if it becomes intimately involved with other patients/staff, avoid reinforcing inappropriate comments.

Limit Setting

• Clear, self-confident limits, listen with a neutral attitude, collaborate with staff for consistent responses.

Acting-Out

• Watch for early frustration symptoms.
• Tell the patient that threats and hitting are not acceptable and indicate that he needs help to control his behavior.
• The care team should be alerted promptly when acting out is escalating.
• After the incident ends, the patient will be calmer and in control, discuss his feelings with him.

Lithium Medication

• Take lithium with food to avoid stomach upset, avoid driving/operating dangerous equipment as lithium may impair mental and physical function.
• D/C lithium and contact with doctor for toxicity symptoms.

Depression Episode

• Physical needs.

Cyclothymic Disorder

• Alternation between short periods of mild depression and hypomania, with brief periods of normal mood.
• The person never goes more than 2 months without symptoms of depression or hypomania.
• Affects up to 1% of the population, striking men and women equally, and typically, onset occurs in the teens or early twenties.
• Depressive and hypomanic periods are shorter and less severe than in bipolar I or II disorder. Delusions don’t occur, and few patients require hospitalization.
• May impair social and occupational functioning. Approximately 30% progress to a more severe form of a bipolar illness.

Damage and Instability

• Hypomanic periods of cyclothymic disorder may enhance achievements but also may damage interpersonal and social relationships.
• Patient instability may lead to erratic lifestyle, impulsive changes, and substance abuse.
• Characteristics include odd personality, dramatic features, inability to maintain enthusiasm, interpersonal issues, and abrupt mood changes.

Hypomanic phase

• Insomnia and Hyperactivity.

Depressive phases

• Insomnia or hypersomnia
• Feelings of inadequacy
• Decreased productivity
• Social withdrawal
• Loss of libido
• Loss of interest in pleasurable activities
• Lethargy
• Depressed speech
• Crying

Cyclothymic Treatment

• Diagnose rule out other diseases w/ similar symptoms.
• Doctor must rule out medical condtions.

Causes

• Genetic factios.

Diagnosis

• Doctor must rule out various disorders.
• Psychiatric disorders and medical conditions can mimic symptoms.

Drug Options

• Lithium
• Carbamazepine (Tegretol
• Valproic acid (Depakote)
• Verapamil (Calan)
• Individual psychotherapy and couple or family therapy.

Major Depressice Disorder

• Persistent sad mood lasting 2 weeks or longer.
• Feelin of sadness.

Feelings of Guilt

• Helpfulness or Hopelessness.
• Poor Concentration and sleep distrubances.

May include

• lethargy, appetite loss, anhedonia, lost of mood reactivity, thoughts of death and suicide.

Signs

• Feeling "down in the dumps" increases or decreased appetite. Sleep distrubances

Medical Intervention

• Assess by RISKS FACTOR
• R. Diffictul relationship
• i. Intense hopeless
• S. sex differences
• K- weak kinships
• F. - abuse
• L Extremes age
• C Health problems
• T. Distorted thinking
• 0. A stress
• R Revenger
• S. Substance abuse.

Medical obstacles

• Alway consider the pateint culturel background and values when assesing signs and symptoms of depression.
• As more socially acceptable samatic symptoms

Treatmeants

• Pharmacolic therapy
• medication is the most effective
• types of antidepressaants

Selective serotonin reuptake

• SSRI incudes citalopran, fuoxetin, fluvoxamin, proxine Serotonie neprephine, inhibitor
• Trycliced anti depresants.
• Monoamine oxidase inhbitots.

Short term pyschotherapy

• it also allows ongoing assessment of suicide ideology and suicide risks. Best results come from indiuval, family or gorup therapy with medicacion.