Mood Disorders

Outlines:-
1. Introduction
2. Definitions
3. Classification of mood disorders
3. Etiological factors of mood disorders
A-Depressive Disorders:
a. Introduction
b. Types of depressive disorders
c. Nursing management
B- Bipolar disorders:
a. Definition
b. Types of bipolar disorders
c. Differences between mania and hypomania
d. Nursing management
-References

By Psychiatric Nursing Staff Department

2019

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 Introduction

Disorders of mood are often called affective disorders, since affect

is the external display of mood or emotion which is, however, felt internally.
Depression and mania are often seen as opposite ends of an affective or
mood spectrum. Classically, mania and depression are “poles” apart, thus
generating the terms “unipolar” depression (i.e., as in patients who just
experience the down or depressed pole) and “bipolar” [i.e., as in patients
who at different times experience either the up (manic) pole or the down
(depressed) pole].

Mood: a feeling state reported by the patient and significantly influences

behavior, personality, and perception.

Mood disorders: Pervasive alterations in emotions that are manifested by

depression, mania, or both, and interfere with the person’s ability to live life

Grief: is the subjective state of emotional, physical and social responses to

the loss of valued entity (real e.g. death of a loved one, or perceived e.g. loss
of the feeling of femininity after hysterectomy or mastectomy).

Mourning: is the period during which the characteristics emotions and

behaviors of grief take place.

The 'normal morning" process is adaptive and is characterized by feeling of

sadness, guilt, anger, helplessness and despair. Absence of mourning can be
viewed as "maladaptive"

Classification of Mood Disorders:

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Mood disorders are categorized into:

1. Depressive disorders
 Major Depressive Disorders
 Dysthymic Disorders
 Premenstrual Dysphoric Disorder
2. Bipolar disorders
 Bipolar I Disorders
 Bipolar II Disorders
 Cyclothymic Disorder
3. Other Mood Disorders
 Mood disorders due to general medical condition
 Substance-Induced Mood disorder
Etiological factors of mood disorder:

A- Biological factors

1. Genetic theory

 The genetic theory supported by the following studies.

 The incidence is greater in relatives as much as 5 to 10 times higher than
in the general population.
 Up to 25% of those with major depressive disorders have a first- degree
relative with a mood disorders.
 Studies of identical twins (whose genes are the same) show that if one
twin suffer from depression, the chance that the other twin will develop the
illness is 50% to 90%.
 Identical twins are more concordant for bipolar disorder (78% to 80%)
than fraternal twins (14% to 19%)
 Adoption studies also support the view that depressive illness is inherited.
Children of affectively ill parents who are adopted into families having no

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history of these illnesses still show three times as many depressive disorders
as biological children in the same families.
 More recently, researchers have identified two genes (G72 and G30)
located on the long arm of chromosome 13 that are associated with bipolar
disorders as well as schizophrenia.
2. Role of neurotransmitters in the cause of depression.

 Neurotransmitters (nor epinephrine, dopamine, and serotonin)

have been studied since the 1960s as causal factors in mania and depression.
 During a manic episode, patients with bipolar disorder demonstrate
significantly higher plasma levels of nor-epinephrine and epinephrine.
 In depression there is a deficit of one or more of neurotransmitters
mainly serotonin, dopamine, and nor epinephrine.
3. Neuroendocrine factors:

 Hypothyroidism is seen with depressed mood, and hypothyroidism is

seen in some patients who are experiencing rapid cycling.
 increased cortisol secretion (from adrenal gland) is apparent in 20% to
40% of depressed out patients and 40% to 60% of depressed inpatients
4. Physiological influences.

Depressive and manic symptoms that occur as a consequence of

non-mood disorder or as an adverse effect of certain medication, electrolyte
disturbance, hormonal disturbance, and nutritional deficiencies.

B- Psychosocial factors.

1. Psychoanalytical and developmental theories:

Psychoanalytic theory developed by Freud, seeks to uncover unconscious

conflicts that contribute to depression. This theory views depression as

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 Depression is triggered by a loss of loved object, either actually by death,
or emotionally by rejection.
 Loss during childhood is a predisposing factor for adult depression.
 Depression is the result of a harsh and punitive superego; Depression is
aggression -turned inward toward the self.
 Freud believed that depression and mania were maladaptive response to
loss.
 Mania is viewed as a reaction formation, denial of, or defense against to
depression.
2. Learning theory:

Focused on learned helplessness- hopelessness the learned

helplessness - hopelessness was first proposed by Seligman. He defined
helplessness as (a belief that no one will do anything to help you) it is
existed in humans who have experienced numerous failures and
hopelessness as nothing change and it is prone to depression by imposing a
feeling of lack of control over their life situation.

3-Cognitive theory

Cognitive or distorted thinking is another view of depression.

"Cognitive triad" Beck one of the cognitive theorists, proposes that
depression is a cognitive problem dominated by a negative evaluation of
self, the environment and the future.

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 Depressive disorders
Definition

Depression: refers to a wide range of mental health problems

characterized by the absence of a positive affect (a loss of interest and
enjoyment in ordinary things and experiences), low mood and a range of
associated emotional, cognitive, physical and behavioral symptoms.

Types of depressive disorders:

1. Major depressive disorder:

Also called clinical depression or major depression, this disorder is

characterized by sad mood or loss of interest or pleasure in usual activities.
Evidence of impaired social and occupational functioning has existed for at
least 2 weeks. There is no history of manic behavior and the symptoms
cannot be attributing to use of substance or a general medical condition.

2. Dysthymia

Is a chronic, moderate type of depression that lasts at least 2 years

in adults or 1 year in children. Symptoms are not severe to meet the criteria
of major depression; People with Dysthymia usually suffer from poor
appetite or overeating, insomnia or oversleeping and low energy or fatigue.
People with Dysthymia are often unaware that they have an illness because
their functioning is usually not greatly impaired. They go to work and
manage their lives, but are frequently irritable and often complaining about
stress.

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3. Premenstrual Dysphoric disorder

The essential features include markedly depressed mood, marked

anxiety, mood swings, and decreased interesting activities during the

week prior menses and subsiding shortly after the onset of menstruation.

Nursing management major depressive disorder:

I. Assessment

1. Affect and mood (Emotion)

Feelings frequently reported by depressed people include

 Feelings of sadness
 powerlessness
 gloomy and pessimistic outlook
 Worthlessness
 Shame and guilt feeling is common with depression. Extreme guilt
can assume psychotic proportions: "I have committed terrible sins. God is
punishing me for my evil ways."
 Helplessness: is evidenced by inability to carry out the simplest tasks.
-Everything is too difficult to accomplish (e.g. Grooming, housework, job,
& caring for children).

 Hopelessness: A person may experience unusually persistent

pessimistic &may express despair in suicidal statement or acts.
 Anger and irritability (directed toward self): are the natural outcomes
of profound feelings of helplessness.
- Anger in depression is often expressed inappropriately. For example anger
may be expressed in destruction of property, hurtful verbal attacks, or
physical aggression toward others.

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 - However, in people who are depressed, anger may be directed toward the
self in the form of suicidal or sub- suicidal behaviors (alcohol abuse,
substance abuse, overeating, smoking, etc.) these behaviors often result in
feelings of low self- esteem and worthlessness.

Anxiety: is present in about 90% of depressed persons.

Anhedonia (inability to feel pleasure).
2-Behavior:

- Slowed physical movements (hypoactive).

-Personal hygiene is markedly neglected; there is a lake of willpower

leading to a state of indecision, and psychomotor-retardation.

-Social withdrawal and refusal to see people.

-Changes in eating are common .About 60to70% of people who Are

depressed report having anorexia; overeating occurs more often in
Dysthymia.

-Changes in sleep patterns .Often depressed people have insomnia Waking

at 3 or 4 Am and staying awake or sleeping only for short Periods. For some
people sleep is increased (hypersomnia) and provides an escape from
painful feelings.

-Changes in bowel habits are common constipation is seen most frequently

in patient with psychomotor retardation. Diarrhea occurs less frequently,
often in conjunction with psychomotor agitation. Food is often described by
the patient as tasteless.

-Interest in sexual declines (loss of libido: feeling of sexual pleasure)

during depression. Some men experience impotence, and a declining
interest in sex

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often occurs among both men and women, which can further complicate
marital and social relationships.

- Headache.

3. Thought

 Retarded thinking which is difficult, slow and remain circling

monotonously around the sorrowful experience without being able to
change the thought contents.
 Impaired judgment, and indecisiveness is common.
 Memory disturbance and inability to concentration.
 Attention all the time the patient is preoccupied with his worries and
attention to his environment is considerable impaired.
 Delusions , Most common delusional thinking includes : delusion of
guilt, somatic delusion and poverty delusion
 Excessive self-deprecation, self-blame, and thoughts of suicide
4. Communication

 A person speak \ comprehend very slowly.

 The patient talks in a low monotonous hesitant voice.
 His answer is usually short with a delayed reaction time to reply.
 In extreme depression, however, a person may be mute.
 The patient may not make eye contact, may make only yes or no
responses.
 Frequent sighing is common.
5. Additional areas to be assessed:

Safety first: Assessment of Suicide Potential/ self-destructive behavior.

The patient should be evaluated for suicidal or homicidal ideation.

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About 10% to 15% of depressed people eventually commit suicide.

Suicide is defined as conscious attempt to kill oneself

Assessment area will be:

a. Clues to suicidal ideation as:
 Direct statement (overt)
 Life isn't worth living anymore
 I wish 1 will die
 Everyone would be better off if I died
 Indirect statement (convert)
 It's okay now, soon everything will be fine"
b. Behaviors

 Giving away personal possessions

 Making out a will
 Sudden change in behavior
c. Emotional clues

 Social withdrawal
 Feeling of hopelessness and helplessness, Irritability.
d. Assessing lethality of suicide plan

Lethality refers to seriousness of suicide threat, including the means that

the patient plans to use to commit the suicide and the availability of those
means.

If the patient knows exactly how he will commit suicide and the method
available to him, this patient is at high risk.

Low lethality in women (just attempts), and high lethality in men (commit).

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e. Assessing high- risk factors

 People with previous history.

 People with a family of history of suicide.
 People who experience extreme guilt.
 People who lives alone.
II. Nursing diagnosis:

1. Risk for suicide (violence directed toward self)May be related to:

Neurological changes, feeling of hopelessness

Evidenced by :any s & S

The goal will be:

 Patient remains safe & will learn coping skills that reduce the chance of
relying on self-harm behaviors.
Nursing Intervention:

Ensure safety environment

 Assess a suicide plan.

 Removing all sharp or hazardous objects from the patient's room.
 Requesting that food be served with paper plates and cups and plastic
eating utensils.
 Taking away potentially hazardous personal items, such as shoelaces,
belts, glass objects, and lighters.
 Telling visitors not to leave anything with the patient unless the nurse
approves.
 Observing the patient to make sure he swallows medications.
 Placing him in a room with another patient.

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 Share time with patient, particularly if the patient is high risk of suicide.
This decreases the patient's isolation.
 Provide close observation place him in a room close to nurse's station.
 Be alert when patient is using bathroom.
 Find ways to assist the patient to find hope without negating emotional
pain.
Working through it

 Reassess patient at least once per shift to determine his current level of
suicidal intent.
 Use the comparisons to help patient understand what factors may or may
not be decreasing his suicidal thoughts or underlying depression. For
instance, did he have visitors, receive cards or flowers, sleep well, or
participate in self-care? This will give him some insight into factors
contributing to his improved mood or sense of hope.
 Talking about his experience in a sincere and supportive way.
 Spend time, but not necessarily long, periods with him.
 One approach is to relieve the observer for breaks and meals.
 Focus your interactions on your patient's present crisis. For example, you
might say, "Help me understand. Can you tell me what's going on in your
life that's unbearable?" This approach encourages him to talk about his
circumstances and perceptions.
 Help patient to regain a sense of hope. This process begins with helping
him identify personal strengths and setting small achievable goals.
 If your patient is discharged home, ask his permission to have a family
member ensure that the home environment is safe and free from weapons,
potentially dangerous medications, and other hazards.
3.Self-care deficit (hygiene, grooming. eating. sleeping, elimination)

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May be related to:

 Hopelessness, helplessness, depression

Evidenced by:

Poor grooming and dress, loss of appetite, weight loss, loss of

energy & motivation to eat, decreased frequency of bowel movement
difficulty getting in sleep.

The goal patient will be:

 Establish adequate personal hygiene.

 Gain weight progressively until reach appropriate body weight.
 The patient will achieve adequate sleep.
Nursing Intervention:
Nursing intervention for hygiene:
 Encourage the use of toothbrush, soap, and shaving equipment.... etc
 Give step by step reminders such as "wash the right side of Your face,
now the left"
 Maintain a routine for dressing grooming & hygiene.
 Be gentle &firm in setting limits regarding time spent in bed.
Nursing intervention for eating:

 Offer small high-caloric & high protein snacks frequently throughout the
day and evening.
 Consult dietitian, if necessary.
 Weight the patient weekly.
 Observe the patient’s eating patterns.
 Ask the patient which foods or drinks he or she likes. Offer choices.
 When possible, encourage family and friends to remain with the patient
during meals.

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 Monitor intake &output, especially bowel movements.
 Offer foods high in fiber & provide periods of exercise.
 Encourage the intake of fluids.
 Evaluate the need for laxatives & enemas.
Nursing intervention for insomnia;

 Ask about the reason firstly.

 Quite, secure environment.
 Relaxation techniques
 Night light decrease
 Number of distraction e.g. taking temperature during night
 Structured bedtime routine for the patient e.g. bath, reading, warm milk,
music
 Consistent structured day time activities include physical exercise as
tolerated
 Discourages napping.
3. Impaired social interaction

May be related to:

 Psychomotor retardation, hypersomnia, fatigue depressed mood

Evidenced by:

Withdrawal, seeking to be alone, and failure to initiate interactions

with others.

The goal: the patient will strength ability to relate to others

Nursing Intervention:

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 Initially, interact with patient on a one-to-one (with Nurse) basis progress
to facilitating social interaction between the patient & other patients. Then
in small group & gradually larger group.
 Establish a daily interaction time with the patient.
 Encourage the patient to purse personal interests, Hobbies & recreational
activities.
 Help the patient to identify and discuss the positive and negative aspect of
interacting with others.
 Encourage visits by friends, relatives, etc.
4. Self-esteem disturbance
May be related to:
 Depressed mood
 Hopelessness.
 Learned helplessness
It's evidence by: Verbalization of ideas that convey low self-esteem,

Hypersensitivity to criticism, negative pessimistic outlook, inability to take

decision.

The goal will be: Verbalize positive feelings of self-worth, express

satisfaction with self.
Nursing Intervention:
 Be accepting of patient and spend time with him even though pessimism
and negativism.
 Focus on strength and accomplishments and minimize failures
 Give the Patient positive feedback for completion of Responsibilities.
 At first provide simple activities that can be accomplished easily and
quickly.
 Gradually increase the number and complexity of Activities.

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 Explore with the patient his or her personal strengths.
 Encourage increasing decision making (ask for Participation in planning
for own care) and be independent as possible.
 Convey an attitude of confidence in the abilities of the Patient.

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 Bipolar disorders

Introduction:

Everyone has occasional highs and lows in their moods. But people
with bipolar disorder have extreme mood swings. They can go from feeling
very sad, despairing, helpless, worthless, and hopeless (depression) to
feeling as if they are on top of the world, hyperactive, creative, and
grandiose (mania). This disease is called bipolar disorder because the mood
of a person with bipolar disorder can alternate between two completely
opposite poles, euphoric happiness and extreme sadness.

Types of bipolar disorders:

1. Bipolar I disorder: At least one episode of mania alternating with major

depression
2. Bipolar II disorder: Hypomanic episode(s) alternating with major
depression
3. Cyclothymic disorder the essential features of this disorder is a chronic
mood disturbance of at least 2 years' duration, involving numerous episodes
of hypomania and depressed mood of insufficient severity and duration to
meet the criteria for either bipolar I or II disorder.
Difference between Mania & Hypomania

Hypomania Mania

Symptoms are less severe than in manic episode Severe enough to cause marked impairment in
occupational, social, activities (relationship)

Absence of delusion. Absence of marked impairment in Delusions may be present (grandiose, paranoid, or both)
social or occupational functioning

Hospitalization is not indicated Hospitalization is a need to protect patient &other from

irresponsible or aggressive behavior

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Nursing management

Assessment

The three most common initial symptoms in the onset of mania are:

 Elated mood
 Increased activity
 Reduced sleep
The nurse evaluates these characteristic when assessing the manic
patient's

1. Assessing mood:

 Elated mood,
 Euphoria with loss of reality testing
 He is experiencing an intense feeling of well-being, is "cheerful in a
beautiful world" or is becoming "one with God".
 Mood swing, the mood may be change to irritation and quick anger when
the elated person does not get his way.
 Most of the time patient laughs, jokes, talkative, pressure in speech, and
talks in Continuous stream.
 Manic people treat everyone with confidential friendliness, and
incorporate everyone into their plans and activities.
 They know no strangers. Energy and self-confidence seem boundless.
2. Assessing behavior:

 Intrusive.
 High energy, Hyperactivity may range from mild to extreme.
 busy all hours of the day &night.
 Manic patient flits from one activity to another, one place to another,

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 The patient dress is bizarre, colorful & inappropriate.
 Makeup may be overdone.
 Impulsive marriages and divorces take place.
 A reduced need for sleep is experienced by all manic patients, and some
may not sleep for several days.
 The manic person is have no time to eat, or engage in sexual activities.
This due to non-stop physical activity & the lack of sleep and food.
3. Assessing thought:

 Flight of ideas.
 Pressure of speech.
 Talking often includes joking, playing on words (puns) and teasing.
 Clang association e.g. good luck, duck…… etc
 The manic patient is highly distractible, inflated esteem, and self
-confidence.
 Poor concentration and judgment.
 Delusions of grandeur, persecution are common.
 Hallucinations may occur. However, in hypomania there is no evidence of
delusion or hallucination.
Nursing diagnosis:

1. Risk for injury directed to self or others

May be related to:

 Hyper activity.
It is evidence by:
 Agitation.
 Poor impulse control may result in harm to others or self.
 Delusions of grandeur or persecution

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The goal: the patient will be
 free from injury
 Demonstrate increased control of motor and verbal behavior.
Nursing Intervention:
 Provide safe environment to prevent accidental and or purposeful Injury
to other and self.
 Removing all sharp or hazardous objects (including plastic bags and
metal coat hangers) from the patient’s room.
 Telling visitors not to leave anything with the patient unless the nurse
approves.
 Provide close observation
 Maintain low level of stimuli in the environment (e.g. away from bright
lights, loud noises &people )
 Be alert to patient's wish to leave hospital (escape). Keep patient in sight
of staff at all times.
 Provide structured solitary activities with nurse or aide.
 Redirect hyperactivities behaviors, through physical exercises which can
decrease tension and provide focus.
 Instruct the patient to seek out staff when experiencing feeling of
Agitation & hostility
 Remove the patient from provoking situations or grandiose ideas.
 Use physical restraints only when verbal intervention and seclusion have
failed.
2. Altered thought process

May be related to:

 Psychomotor hyperactivity
 Psychosocial stressors
 anxiety

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 Neurological changes.
Evidenced by:
 Inability to concentrate.
 Flight of ideas.
 Pressured speech and delusions.
 Poor judgment.
 Poor insight.
The goal:
 The patient will be able to express realistic ideas and plans,
 Express self logically and clearly.
Nursing Intervention:
 Use a firm and calm approach.
 Voicing doubt, not argue with patient or share him in delusion.
 Use short and concise explanations or statements.
 Remain neutral avoid power struggles and value judgments.
 Focus on the feeling and meaning of his delusion without sharing this
believes.
 Redirect the patient to here and now activities and topics to provide a
reality.
 Avoid use of touch with delusional patient.
 Be consistent in approach and expectations.
 Firmly redirect energy into more appropriate and constructive channels
3. Self-care deficit (altered nutrition, sleep pattern, hygiene. And
grooming
Related to:
 Biochemical alteration.
 Hyperactivity, Impulsivity, Poor judgment.

Evidenced by:

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 Wearing inadequate and or inappropriate clothing.
 Observed inadequate intake.
 Inattention to meal times or distraction from task of eating.
 Interrupted night time sleep.
The goal:

Patient will be dress self appropriately and maintain hygiene.

 Increased attention to eating behavior

 Demonstrates weight again.
 Re-establish sleep pattern (sleep 6-8 hours at night).
Nursing Interventions:

Eating

Regularly assess nutritional and fluid intake.

Weight patient regularly.
Provide opportunity to select foods when ready to ideal with choices.
Offer high protein and carbohydrate diet.
Provide interval feeding, using finer foods (e.g. sandwiches, fruit, or milk
snakes.)
Ensure minimum of 2000cc per 24 hours fluid.
Frequently remind patient to eat ( Ahmed , finish your milk snakes)
Sleep

Decrease environmental stimuli in room & in common areas provide quite

room if needed.
Discourage intake of caffeine and cigarettes after 6 pm.
Offer small snack and or warm milk at bed time or when a wake during
the night
Discourage engaging in physical activities and exercise during the day.

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Restrict activities in the evening prior to bed time.
Administer medication as prescribed.
Hygiene

 Provide physical assistance, supervisions directions reminders

encouragements and support as needed
 Give simple step by step reminders for hygiene and dress (here is
your razor, shave the left side ...now the Right .here is your toothbrush put
the toothpaste on the brush).
 Limit the selection of clothing available.
Other nursing diagnosis:

 Family dysfunction
 Altered role performance
 Ineffective individual coping

References
1-Louise R (2014). Mood disorders, Basic Concept of Psychiatric-
Mental Health Nursing, 7th ed. Lippincott Williams & Wilkins. CH.21,
pp. 324-360

2-Elizabeth M (2012). Mood disorders: Depression & Bipolar.

Foundation of Psychiatric Mental Health Nursing, A clinical approach.
5th ed. Elsevier Inc. ch.18 & 19, pp 326 -380.

3- Mary C (1996). Mood disorders, Psychiatric Mental Health Nursing,

2nd ed. F.A. Davis company.CH 24, pp. 436-466.

4- Brown E L (2002). Assessing Behavioral Health Using OASIS Part 1

Depression and Suicidality, Home Healthcare Nurse, Lippincott Williams
& Wilkins. CH.20, pp. 154-16.

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