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Emotions, mood, and affect are critical elements of the human experience, each referring to unique psychosocial attributes. **Emotions**: - Emotions are individual feeling responses to stimuli. - They are reactionary, intense, focused, and relatively short-lived. - Examples include joy, su...

Emotions, mood, and affect are critical elements of the human experience, each referring to unique psychosocial attributes. **Emotions**: - Emotions are individual feeling responses to stimuli. - They are reactionary, intense, focused, and relatively short-lived. - Examples include joy, surprise, fear, anger, and disgust. - Emotions often lead to physiologic responses such as smiling, frowning, clenching fists, pacing, sweating, and increased heart rate. - Nonverbal expression of emotions is common, even if verbal communication is absent. **Moods**: - Moods are similar to emotions but last longer, are less focused, and less intense. - A mood might have one trigger, multiple triggers, or no specific cause. - Moods shape a person's general expectations about the future. - Moods do not produce observable physiologic reactions and can only be described by the individual. **Affect**: - Affect refers to an individual's automatic reaction to an event or situation. - It is the immediate, observable expression of mood, evidenced by verbal and nonverbal responses. - Affect involves unconscious responses to something as either good or bad. - Affective reactions occur faster than emotional reactions. **Mental Health**: - Mood and affect significantly impact an individual's mental health. - Mental health is defined as a state of well-being where an individual can work productively, cope with change and adversity, engage in meaningful relationships, and realize their potential. - Severe alterations in mood and affect can lead to mental illness, which affects emotions, thinking, behavior, or a combination of these. - Mental illness is typically confirmed when there is serious and lengthy impairment in functioning. **Conditions**: - Depression and bipolar disorder are serious mental illnesses affecting daily functioning and life goals. - Assessment, collaborative therapies, and nursing care are essential for individuals with mood and affect alterations. **Normal Mood and Affect** - Defining normal mood and affect is complex due to cultural and individual differences. - **Mood**: Exists on a continuum from depression to mania. - **Depression**: Abnormally lowered mood with sadness, emptiness, irritability. - **Mania**: Abnormally elevated mood impairing functioning. - **Euthymia**: Stable mood range, neither elevated nor depressed; appropriate fluctuations do not impair function. - **Affect**: Evaluated by healthcare providers based on several characteristics: - **Appropriateness/Congruence**: Match between affect, emotional state, and situation. - **Range**: Variety of feelings conveyed through affect. - **Broad/Full Range**: Ability to convey many feelings; considered normal. - **Restricted Affect**: Limited range of feelings. - **Intensity**: Degree of emotion displayed in affect. - **Moderate**: Emotion level appropriate to situation. - **Overreactive**: Disproportionate or extreme emotion level. - **Blunted**: Dulled or muted emotion level. - **Flat**: No visible emotional cues. - **Stability**: Consistency of affect without provocation. - **Stable Affect**: Consistent affect; considered normal. - **Labile Affect**: Rapidly changing affect, often disproportionate to stimulus. **Factors Contributing to Mood and Affect** - **Neurologic Function** - **Personality** - **Stress Level** - **Social Interactions** - **Illness Status** **Neurologic Function** - Emotions, mood, and affect originate in the *limbic system*. - Key structures in the limbic system: *hippocampus*, *hypothalamus*, and *amygdala*. - The *medial prefrontal cortex (MPFC)* regulates the limbic system. - Dysfunction in the MPFC leads to overactive limbic system, causing mood alterations. - Individuals with mood disorders show decreased gray-matter volume and lower metabolic activity in the MPFC. - Mood disorders are linked to alterations in *neurotransmitter* activity and *neuronal* receptivity. - Proper *glial cell* function is crucial for normal mood and affect. **Personality** - Personality traits influence mood and affect. - High emotional instability and introversion, along with low conscientiousness and agreeableness, lead to negative affect and depressed mood. - Emotional stability, high extraversion, conscientiousness, and agreeableness lead to positive affect and elevated mood. **Stress** - Chronic stress disrupts brain function, particularly in the hippocampus. - It affects the reward circuitry within the MPFC. - Chronic stress leads to hormonal imbalances, inadequate sleep, poor diet, and physical disease, all of which affect mood and affect. **Social Interactions** - Positive social interactions and high-quality social support contribute to stable, positive mood and affect. - Greater perceived social support and larger, more diverse social networks lower the risk of depression. **Illness Status** - Physical disease or injury can alter mood and affect, especially conditions affecting brain tissue or hormone levels. - There is a link between autoimmune diseases and mood disorders. - Chronic conditions like heart disease, diabetes, and cancer contribute to negative mood due to ongoing stress, physical limitations, and concerns about mortality. - Depression is a common complication of chronic disease and can worsen the disease course if not managed. **Alterations to Mood and Affect** - **Mood and Affect Alterations** - Impair daily life coping abilities - Prolonged changes can lead to depressive or bipolar disorders needing professional intervention - **Depressive Disorder** - Characterized by *depressed mood* (sadness, emptiness) - Core symptoms: *anhedonia* (loss of interest), *fatigue*, *sleep disturbances*, *somatic complaints* - In children/adolescents, *irritability* is common - **Bipolar Disorder** - Alternating episodes of *major depression* and *mania* or *hypomania* - *Mania*: Abnormal elevated mood lasting at least 1 week, significant impairment - *Hypomania*: Elevated mood lasting at least 4 days, less severe than mania - **Anxious Distress** - Common in depressive and bipolar disorders - Symptoms: *restlessness*, *impaired concentration*, *fear of impending doom*, *fear of losing control* - Increased risk of *suicide* in combination with mood disorders - **Prevalence** - Affects nearly 10% of adults, with 45% severe cases - Impacts productivity, absenteeism, short-term disability - Increased risk of *suicide* without treatment - **Pathophysiology of Altered Mood** - Involves limbic system and MPFC disruptions - Focus on *neurotransmitter activity* and *biological rhythms* - **Alterations in Neurotransmission** - Involves *serotonin* (5-HT) and *norepinephrine* (NE) - Dysregulation linked to mood disorders - Other neurotransmitters: *dopamine* (DA), *acetylcholine* (ACh), *GABA*, *glutamate* - **Disruption of Biological Rhythms** - Affects *circadian rhythms* - Dysregulation in hypothalamus - Linked to symptoms of bipolar disorder - **Common Manifestations** - **Maladaptive Coping Responses**: *Avoidance*, *escape*, *rumination*, *denial*, *helplessness* - **Altered Thought Processes**: *Decreased concentration*, *poor memory*, *impaired problem-solving* - **Sleep Disturbances**: Difficulty sleeping, insomnia, excessive sleepiness - **Somatization**: Physical symptoms like *headache*, *nausea*, *fatigue* - **Difficulties with Adaptive Functioning**: Issues with daily life activities - **Disorders of Mood and Affect** - **Depressive Disorders**: Includes *major depressive disorder* (MDD) and *persistent depressive disorder*(dysthymia) - **Adjustment Disorder with Depressed Mood**: Maladaptive reaction to stressors - **Bipolar Disorders**: Includes *bipolar I* (mania and depression) and *bipolar II* (hypomania and depression) - **Peripartum Mood Disorders**: *Postpartum depression* and *postpartum psychosis* - **Suicide**: Risk factors include *past history*, *gender*, *living alone*, *hopelessness* - **Genetic Considerations and Nonmodifiable Risk Factors** - Genetics play a role in depressive and bipolar disorders - *Family history* increases risk  **Mood and Affect Concepts**: - Mood and affect are interconnected with numerous concepts and systems, including addiction, cognition, health, wellness, illness, injury, healthcare systems, stress, coping, and trauma.  **Addiction**: - High rate of comorbidity between mood disorders and substance use disorders. - Depressive disorders are common among people with alcohol use disorder. - Individuals with alcohol dependence are more likely to have major depressive disorder. - Bipolar disorders are associated with high rates of alcohol and substance abuse. - Suicide is a leading cause of death among individuals with substance use disorders.  **Cognition**: - Mood disturbances often lead to changes in thought processes. - Mania can cause racing thoughts. - Depression can cause slow or cloudy thinking. - Other cognitive changes include decreased concentration, memory issues, and impaired problem-solving and decision-making abilities. - Hallucinations, delusions, and psychosis may occur with mood disorders.  **Health, Wellness, Illness, and Injury**: - Depressive and bipolar disorders affect functioning and overall wellness. - Both disorders can cause sleep disturbances. - Poor sleep quality is linked to negative mood and affect. - Regular physical activity may protect against depression and negative affect. - Severe mood and affect alterations can lead to neglect of physical health, personal hygiene, and changes in eating patterns and weight. - Poor health outcomes can impact overall functioning.  **Healthcare Systems**: - Patients with mental illness may lack insurance for health services. - Providing free community resources and scheduling appointments with community mental health centers can improve access to care.  **Stress and Coping**: - Individuals with mood disorders often have a history of trauma. - Prolonged and overwhelming stress can result in depression or trigger manic episodes. - Anxiety disorders often co-occur with depression. - Poorly managed anxiety can deplete coping reserves needed to prevent depressive or manic episodes. **Health Promotion related to Mood and Affect** - **No definitive prevention for depression** due to genetic and biological factors. - Strategies to modify stressors and environmental factors: - **Dietary choices:** - Reduce intake of sugar, saturated fat, and refined foods. - Increase consumption of fruits, vegetables, legumes, fish, and whole grains. - **Nutrients with protective roles:** Omega-3 fatty acids, folic acid, vitamin D, selenium, and calcium. - **Adequate sleep** and **regular exercise** are crucial. - **Smoking cessation** may decrease the risk of depression and other mental disorders. **Primary Prevention Strategies:** - **Psychosocial factors:** - Education on stress management, coping strategies, and positive parenting. - Community-specific strategies: - Facilitated discussions and coping strategies for families undergoing stressful situations like divorce. - Family-based cognitive-behavioral interventions can reduce depression risk in children of depressed parents. **Secondary and Tertiary Prevention Strategies:** - **Secondary strategies:** - Regular screening for mood disorders. - Referrals for accurate diagnosis and treatment. - Counseling about the risks of developing mood disorders. - **Tertiary strategies:** - Collaborative care programs for patients with mood disorders. - Clinic- and home-based approaches for older adults and those with chronic health problems. - Community-based mental health services for individuals experiencing homelessness or poverty. **Screenings:** - **USPSTF recommendations:** - Screen all adults, including pregnant and postpartum women, for depression. - Screen adolescents aged 12-18 for depression. - Early detection and appropriate treatment improve clinical outcomes. - **Screening instruments:** - **Patient Health Questionnaire (PHQ-9):** Commonly used, available in over 30 languages. - Patients scoring in the indicative range should be referred for thorough diagnostic evaluation. **Care in the Community:** - Most mental illness treatments occur in community settings. - **Deinstitutionalization** has increased the need for public services at lower levels of care. - Community services include: - Outpatient services. - Intensive outpatient programs (part-day, approx. 4 hours). - Partial hospitalization (full day at hospital, home in the evenings). - **Support groups** and **hotlines** available for public use. - **Group homes:** Residences for functional but chronically mentally ill individuals. - **Halfway houses:** Step down from rehabilitation. **Nursing Assessment for Mood and Affect** - **Therapeutic Relationship** - Establish mutual trust with the patient. - Use open-ended questions and allow time for response. - Remain nonjudgmental and validate the patient's feelings. - Reduce patient anxiety if necessary. - Communicate with brief, clear statements. - Verify and clarify patient understanding. - **Observation and Patient Interview** - Observe for behavioral changes indicating mood disorders (e.g., poor hygiene, irritability, exhaustion, grandiosity). - Assess energy level, psychomotor symptoms, dietary and fluid intake. - Inquire about mental illness history, family history, sleep quality, eating patterns, cognition, chronic illness, and substance use. - Evaluate mood, affect, cognition, thought content, communication patterns, and pain history. - Gather information on mood fluctuations, perception of wellness, and functioning. - Assess coping patterns, home environment, financial status, and cultural beliefs. - Utilize self-reporting scales for depression screening. - **Cultural Considerations** - Understand cultural influences on mood, affect, and mental illness perceptions. - Recognize help-seeking behaviors vary by culture (e.g., reliance on family and faith). - Address distrust of the medical community among certain cultural groups. - Provide culturally aware and community-based interventions for immigrants. - **Depression in Recent Immigrants** - Immigrants face stressors like family separation, unemployment, discrimination, language barriers, and new environments. - Immigrant children often act as interpreters, increasing stress. - Deportation and separation cause psychological trauma and economic hardship. - Interventions include community support groups and access to available assistance programs. - **Physical Examination** - Obtain vital signs, including pain. - Record baseline weight and BMI for monitoring purposes. - Assess sleep, nutrition, activity, and elimination patterns. - Rule out medical or drug-related causes of symptoms. - Identify comorbid medical illnesses. - **Diagnostic Tests** - No specific tests for mood disorders; use tests to rule out medical conditions. - Tests may include hormone levels, thyroid function, electrolyte panels, urinalysis, toxicology, and liver function. ### Independent Interventions for Mood and Affect - **Pregnancy tests** for women of reproductive age. ### Independent Interventions - **Key role of nurses**: Provide caring interventions for patients with depressive or bipolar disorders and their families. - **Primary goals**: Prevent patient suicide and promote patient and family safety. - Nurses often serve as the sole provider for many patients. ### Clinical Practice Guidelines for Treating Mood and Affect Disorders - **Establish safety** - **Promote treatment adherence** - **Coordinate care** - **Monitor responses to treatment** - **Provide education** to patients and families ### Preventing Suicide and Promoting Safety - **High-risk periods**: Risk of suicide increases as severe depression begins to improve. - **Reporting**: Suicidal thoughts/actions must be reported to the treatment team immediately. - **Immediate intervention**: Necessary for high-risk patients. #### Guidelines to Prevent Inpatient Suicide - **Follow facility policies** and implement guidelines. - **Regular evaluation** of suicide intent and appropriate supervision. - **Ensure a safe environment**: Remove sharp objects, razors, glass items, etc. - **One-to-one observation**: Required for patients at high risk of suicide; family cannot substitute for staff. - **Be vigilant** during shifts, holidays, and times of distraction. - **Monitor visitors' items**: Ensure they do not bring prohibited items. - **Develop a therapeutic alliance**: Maintain a nonjudgmental attitude. - **Use a calm, reassuring approach**: Encourage patients to express all their feelings. ### Communicating with Patients - **Introductory Phase**: - **Stigma around suicide**: Be aware and address discomfort openly. - **Nonverbal cues**: Pay attention to signs like downcast eyes, slumped posture, monotone speech, and poor hygiene. - **Empathy and direct questions**: Use open-ended statements to explore feelings. - **Assist transition from hospital to home**: Help identify triggers and coping methods. ### Monitoring Patient Response to Treatment - **Close monitoring**: To ensure adherence and effectiveness of the treatment regimen. - **Investigate nonadherence**: Identify barriers and develop strategies to overcome them. - **Adjust treatment if necessary**: Collaborate with the healthcare team for adjustments. - **Monitor improving symptoms**: Ensure recovery pace is appropriate and re-evaluate treatment approaches. ### Support Family Functioning - **Family involvement**: Early involvement in treatment to assist in maintaining the treatment plan. - **Coping skills**: Reinforce coping skills for both the patient and family. - **Education**: Provide information on the nature of the patient's illness and treatment plan. ### Teach Assertive Behavior - **Model and encourage assertiveness**: Assertiveness is learned behavior and vital for communication. - **Differentiate behaviors**: - **Aggressive behavior**: Getting what one wants without considering others. - **Passive behavior**: Avoiding conflict at the expense of one's own happiness. - **Assertive behavior**: Expressing oneself without ignoring others\' opinions. ### Maintain Professional Boundaries - **Avoid maladaptive dependence**: - Emphasize short-term nature of the relationship. - Be aware of patients singling out one staff member. - Do not give hope for continuing the relationship post-therapy. - Refuse requests for personal contact information. - Discuss any inclination to continue relationships with a supervisor or peer. **Collaborative Therapies for Mood and Affect** **Collaborative Therapies** - Includes *pharmacotherapy*, *Cognitive Behavioral Therapy (CBT)*, other *psychotherapies*, and *complementary health approaches*. - Combining therapies often leads to greater success. - Nurses help determine the best combination, encourage adherence, and suggest alternatives if ineffective after 6 weeks. **Pharmacologic Therapy for Depressive Disorders** - *Antidepressants*: First-line treatment for depressive and some anxiety disorders. - Affect neurotransmitters: norepinephrine, dopamine, serotonin. - Mechanisms: Block enzymatic breakdown of norepinephrine and slow serotonin reuptake. - **Serotonin Syndrome**: Risk when taking multiple serotonin-increasing medications. - Symptoms: *altered mental status* (anxiety, disorientation, agitation), *neuromuscular abnormalities* (tremor, muscle rigidity), *autonomic hyperactivity* (GI distress, hypertension, tachypnea, tachycardia, diaphoresis). - Treatment: Supportive measures and discontinuation of medications. **Nursing Considerations for Antidepressants** - Assess health history, including sexual dysfunction. - Monitor for suicidal ideation and behaviors. - Obtain baseline body weight to monitor for weight gain. **Patient Education for Antidepressants** - Full therapeutic effect may take weeks. - Suicide risk increases as therapeutic effect begins. - Report increased suicidal thoughts and behaviors. - Keep follow-up appointments. - Report side effects: nausea, vomiting, diarrhea, sexual dysfunction, fatigue. - Avoid other prescription drugs, OTC medications, herbal remedies without consulting HCP. - Avoid alcohol and CNS depressants. - Discuss pregnancy intentions with HCP. - Monitor caloric intake to avoid weight gain. - Do not discontinue medication abruptly. **Safety Alert: FDA Black Box Warning** - Increased risk of suicidal thoughts and behaviors, especially in patients 24 and younger. - Educate patients and families to monitor for suicidal ideation and provide 24-hour emergency contact numbers. **Pharmacologic Therapy for Bipolar Disorders** - *Mood Stabilizers*: Used to moderate extreme emotional shifts. - Includes lithium carbonate, atypical antipsychotics (e.g., aripiprazole, olanzapine), antiseizure medications (e.g., carbamazepine, valproic acid). - **Nursing Considerations for Bipolar Disorder Medications** - Monitor drug levels, blood glucose, electrolyte panels. - Monitor and report signs of suicidality, cardiovascular status, extrapyramidal symptoms, neuroleptic malignant syndrome. - Monitor neurologic and neuromuscular status, especially in older adults. **Safety Alert** - Bipolar patients in the depressive phase are at risk of switching to mania if prescribed only an antidepressant; mood stabilizers are also prescribed. **Nonpharmacologic Therapy** - Used in conjunction with pharmacologic therapy. - Includes *psychotherapy*, *light therapy*, *support groups*, *meditation*, and *ECT* for treatment-resistant depression. - **CBT**: Effective in improving functioning and quality of life. - Focuses on current situations, changing negative thought patterns, and developing coping strategies. **Cognitive-Behavioral Therapy (CBT)** - Focuses on the impact of thoughts on behaviors and actions. - Effective in treating mood disorders. - Core aspects: - Change negative thought patterns. - Learn effective coping strategies. - Recognize distortions in thinking. - Understand behavior and motivation of self and others. - Use problem-solving skills for difficult situations. - Develop confidence in abilities. - Techniques: Problem identification, exploring automatic thoughts, cognitive modification, mindfulness training. **Electroconvulsive Therapy (ECT)** - Uses electric current to induce a seizure, effective for treatment-resistant MDD and bipolar disorder. - Administered 2-3 times weekly for 3-4 weeks. - Effective in over 80% of depression cases, rapid response within 3 weeks. - Used in severe, treatment-resistant cases and in pregnant women under careful consideration. - Outpatient procedure with anesthesia, requires informed consent. - Risks: Short-term memory loss, rare permanent amnesia, anesthesia-related risks. **Transcranial Magnetic Stimulation (TMS)** - FDA-approved for depression and anxiety. - Uses electromagnetic coil to stimulate the prefrontal cortex. - Faster onset and response rate than medications, fewer short-term cognitive effects than ECT. - Benefits are fewer and shorter duration than ECT. **Complementary Health Approaches** - Include *exercise*, *vitamin B*, *omega-3 fatty acids*, *acupuncture*. - **Exercise**: Reduces anxiety, promotes overall health, recommended for mild to moderate depression. - **Safety Alert**: St. John's wort is not a proven therapy, should not replace conventional treatment, may cause serotonin syndrome if combined with certain antidepressants. - **Vitamin B**: Long-term supplementation may be helpful. - **Omega-3 Fatty Acids**: May enhance antidepressant effects when used together. - **Acupuncture**: Reduces depression severity, enhances therapeutic response of SSRIs, effective for pregnant women with depression. **Lifespan Considerations for Mood and Affect** **Mood and Affect in Children and Adolescents** - **Determinants**: Similar to adults but greater emotional lability is common. - **Causes of Mood Swings**: - Anxiety about physical changes - Hormonal fluctuations with puberty onset - Immaturity of the prefrontal cortex - Pressures of new roles and expectations - **Mood Disorders**: Considered when mood and affect fall outside the normal range. - **Depression Statistics**: - 3.2% of children aged 3 to 17 years have diagnosed depression. - Girls are affected nearly twice as often as boys. - Depression rates rise during teenage years, with 13.3% of adolescents aged 12 to 17 experiencing depression. - **Bipolar Disorder**: Rare in children, onset typically in late adolescence or twenties. - **Treatment**: - Initial: Psychotherapy alone - If unsuccessful: Medication (fluoxetine is FDA-approved for children) - Start with lower doses and titrate up - **FDA Warning (2004)**: Increased risk of suicidal thoughts/behavior with SSRIs. - **Safety Alert**: - Paroxetine (Paxil) not recommended due to increased suicidal thinking and behavior. **Mood and Affect in Pregnant Women** - **Causes of Depression**: - Anxiety about fetus's health and birth process - Concern about relationship changes and maternal role adaptation - Physical and hormonal changes - Recurrence of previous depression - **Prevalence**: 12-20% of women experience depression during the antepartum period. - **Consequences of Untreated Depression**: - Pregnancy complications - Premature birth - High-risk maternal behavior - Postpartum depression - Intrauterine growth restriction - Developmental difficulties in childhood - **Treatment Options**: - Group therapy or psychotherapy - Pharmacologic treatment often avoided due to perceived risks - **Medication Risks**: - No psychotropic drug has a Category A rating. - SSRIs present low risk of major birth defects (except paroxetine). - Slightly elevated risk of persistent pulmonary hypertension and neonatal withdrawal with SSRIs. - TCAs considered low risk; MAOIs not recommended. **Mood and Affect in Older Adults** - **Depression**: Not a normal part of aging, requires attention when symptoms present. - **Causes**: - Major life changes (retirement, loss of loved ones, downsizing, loss of physical function) - Chronic illness - **Treatment**: - Thorough evaluation to rule out medical causes before prescribing medication. - Start with the lowest dose and increase slowly. - SSRIs usually preferred. - **Safety Considerations**: - Increased risk of orthostatic hypotension; educate on fall prevention. - Conduct thorough medication history and periodic reconciliation to manage polypharmacy. - **Effective Treatments**: Antidepressants, psychotherapy, or combination. - **Safety Alert**: - Atypical antipsychotics have an FDA warning for increased mortality from pneumonia in older adults with dementia-related psychosis. - Monitor carefully when used for bipolar disorder.