1|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

MOOD DISORDERS Psychological theories

 are disturbances in the regulation of mood,  cognitive, behavioral, and psychoanalytic

behavior, and affect that go beyond the theories offer explanations for mood
normal fluctuations that most people disorders:
experience 1. cognitive theory - suggests that people
who suffer from depression process
MOOD AND AFFECT information in a characteristically negative
 mood - refers to a pervading feeling; a person way (they view themselves and the world
with mood disorder, mood becomes so in a negative light and believe these
intense and persistent that it interferes with negative perceptions will continue in the
social and psychological functioning future)
 affect - outward expression of emotion 2. behavioral theory - according to the
attached to ideas including but not limited to learned helplessness theory. people may
facial expression and vocal modulation; become depressed after a negative event,
patients with mood disorders may exhibit such as a loved one's death or loss of a
various abnormalities in affect, such as: job, if the event makes them feel helpless
1. blunted affect - severe reduction in the (the perceived lack of control over life
intensity of outward emotional expression events dampens motivation, self-esteem,
2. flat affect - complete or almost complete and initiative; lack of social support and
absence of outward expressional ineffective stress-management and
expression problem-solving skills increase the risk of
3. restricted affect - reduction in the depression after stressful events)
intensity of outward emotional expression 3. psychoanalytic theory - depression results
4. inappropriate affect - affect that doesn't from a harsh superego (the "conscience"
match the situation or the content of the of the unconscious mind) and feelings of
verbalized message (for instance, laughter loss and aggression
when describing a loved one's death) BIPOLAR DISORDERS
5. labile affect - rapid and easily changing
affective expression, unrelated to external  also called manic-depressive disorders
events or stimuli  are mood disorders marked by severe,
pathologic mood swings
CAUSES
 patient experiences extreme highs (mania or
 center on genetic, biological, and hypomania) alternating with extreme lows
psychological factors (depression)

Genetic factors MANIA AND HYPOMANIA

 appear to play a major role in mood disorders;  the highs of bipolar disorder may involve
major depressive disorder and bipolar either mania or hypomania
disorders occur much more often in first-  mania is characterized by:
degree relatives than in the general 1. elation
population 2. euphoria
3. agitation or irritability
Biological factors 4. hyperexcitability
 focuses on deficiencies or abnormalities in the 5. hyperactivity
brain's chemical messengers which are the 6. rapid thought and speech
neurotransmitters such as norepinephrine, 7. exaggerated sexuality
serotonin, dopamine, and acetylcholine 8. decreased sleep
2|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

PSYCHOTIC SYMPTOMS  easy distractibility

 rapid response to external stimuli, such as
 hallucinations (hearing, seeing, touching,
background noise or a ringing telephone
smelling, or tasting things that aren't actually
there) During the depressive phase
 delusions (false beliefs not influenced by
 low self-esteem
logical reasoning or explained by a person's
 overwhelming inertia
usual cultural concepts)
 social withdrawal
CLASSIFICATION  feelings of hopelessness, apathy, or self-
reproach
1. Bipolar I disorder
 difficulty concentrating or thinking clearly
 the classic and most severe disease
(without obvious disorientation or intellectual
form
impairment)
 patient has manic episodes or mixed
episodes (with symptoms of both TREATMENT
mania and depression) that alternate
with major depressive episodes;  drug therapy
depressive phase may immediately  lithium - highly effective in both preventing
precede or follow a manic phase, or it and relieving manic episodes and may prevent
may be separated from the manic the recurrence of depressive episodes
phase by months or years (although it's ineffective in treating acute
2. Bipolar II disorder depression)
 patient doesn't experience severe OTHER DRUGS
mania but instead has milder episodes
of hypomania that alternate with  Valproic acid (Depakote) - for rapid cyclers or
depressive episodes for patients who can’t tolerate lithium
3. Cyclothymic disorder  Carbamazepine (Tegretol) - useful in treating
 patient has a history of numerous mania, although it isn’t approved by FDA for
hypomanic episodes intermingled bipolar disorder
with numerous depressive episodes DIAGNOSTIC CRITERIA
that don't meet the criteria for major
depressive episodes For a manic episode

CAUSES  The patient experiences a distinct period of

abnormally and persistently elevated,
 precise cause of bipolar disorder isn't known, expansive, or irritable mood that lasts at least
however, genetic, biochemical, and 1 week (or, if hospitalization is needed, for any
psychological factors probably play a role duration)
SIGNS AND SYMPTOMS  During the mood disturbance period, at least
three of these symptoms persist (four, if the
During the manic phase mood is only irritable) and are present to a
 expansive, grandiose, or hyperirritable mood significant degree:
 increased psychomotor activity, such as 1. inflated self-esteem or grandiosity
agitation, pacing, or hand-wringing 2. decreased need for sleep
 excessive social extroversion 3. increased talkativeness
4. flight of ideas or a subjective experience
 short attention span
that thoughts are racing
 rapid speech with frequent topic changes
5. distractibility
(flight of ideas)
6. increased goal-directed activity or
 decreased need for sleep and food
psychomotor agitation
 impulsivity
 impaired judgment
3|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

7. excessive involvement in pleasurable  Symptoms don't result from the direct

activities with a high potential for painful physiologic effects of a substance or a general
consequences medical condition
 Symptoms don't meet the criteria for a mixed
For bipolar 1 disorder, single manic episode
episode.
 The mood disturbance is severe enough to  The patient experiences only one manic
cause any of these results: episode and has had no past major depressive
1. marked impairment in occupational episodes.
functioning or in usual social activities or  The manic episode isn't better explained by
relationships schizoaffective disorder and isn't
2. hospitalization to prevent harm to self or superimposed on schizophrenia,
others schizophreniform disorder, delusional
3. evidence of psychotic features disorder, or psychotic disorder not otherwise
 Symptoms don't result from the direct specified.
physiologic effects of a substance or a general
medical condition. For bipolar 1 disorder, most recent episode hypomanic

For a hypomanic episode  The patient is currently experiencing or most

recently experienced a hypomanic episode.
 The patient experiences a distinct period of  He previously had at least one manic episode
abnormally and persistently elevated, or mixed episode.
expansive, or irritable mood lasting at least 4  Mood symptoms cause clinically significant
days. The mood is clearly different from the distress or impairment in social, occupational,
usual non-depressed mood. or other important areas of functioning.
 During the mood disturbance period, at least  The first two exacerbations of the mood
three of these symptoms persist (four, if the episode described previously aren't better
mood is only irritable) and are present to a explained by schizoaffective disorder and
significant degree: aren't superimposed on schizophrenia,
1. inflated self-esteem or grandiosity schizophreniform disorder, delusional
2. decreased need for sleep disorder, or psychotic disorder not otherwise
3. increased talkativeness specified.
4. flight of ideas or a subjective experience
that thoughts are racing For bipolar I disorder, most recent episode manic
5. distractibility  The patient is currently experiencing or most
6. increased goal-directed activity or recently experienced a manic episode.
psychomotor agitation  He previously had at least one major
7. excessive involvement in pleasurable depressive episode, manic episode, or mixed
activities that have a high potential for episode.
painful consequences  The first two exacerbations of the mood
 The episode is associated with an unequivocal episode described previously aren’t better
change in functioning not seen during explained by schizoaffective disorder and
asymptomatic periods. aren't superimposed on schizophrenia,
 Others can recognize the mood disturbance schizophreniform disorder, delusional
and the change in functioning. disorder, or psychotic disorder not otherwise
 The episode isn't severe enough to markedly specified.
impair social or occupational functioning or to
necessitate hospitalization to prevent harm to For bipolar I disorder, most recent episode mixed
self or others. Also, no psychotic features ap-
 The patient is currently experiencing or most
pear.
recently experienced a mixed episode.
4|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

 He previously had at least one major For bipolar Il disorder

depressive episode, manic episode, or mixed
 The patient currently has, or his history
episode.
includes, one or ma major depressive
 The first two exacerbations of the mood
episodes.
episode described previously aren't better
 He currently has, or his history includes, at
explained by schizoaffective disorder and
least one hypo manic episode.
aren't superimposed on schizophrenia,
 He has never had a manic or a mixed episode.
schizophreniform disorder, delusional
 The first two exacerbations of the mood
disorder, or psychotic disorder not otherwise
episode described previously aren't better
specified.
explained by schizoaffective disorder and
For bipolar I disorder, most recent episode depressed aren't superimposed on schizophrenia,
schizophreniform disorder, delusional
 The patient is currently experiencing or most
disorder, or psychotic disorder not otherwise
recently experienced a major depressive
specified.
episode.
 Symptoms cause clinically significant distress
 He previously had at least one manic episode
or impairment in social, occupational, or other
or mixed episode.
important areas of functioning.
 The first two exacerbations of the mood
episode described previously aren't better NURSING INTERVENTIONS
explained by schizoaffective disorder and
During a manic episode
aren't superimposed on schizophrenia,
schizophreniform disorder, delusional  Provide for the patient's physical needs.
disorder, or psychotic disorder not otherwise Involve him in activities that require gross
specified. motor movements.
 Encourage him to eat. He may jump up and
For bipolar I disorder, most recent episode unspecified
walk around the room after every mouthful
 Except for duration, the patient meets or most but will sit down again if you remind him. If he
recently met the criteria for a manic, can't sit still long enough to finish a meal, offer
hypomanic, mixed, or major depression high-calorie finger foods, sandwiches, and
episode. cheese and crackers to supplement his diet.
 He previously had at least one manic episode  Suggest short daytime naps, and help with
or mixed episode. personal hygiene. As symptoms subside,
 Mood symptoms cause clinically significant encourage him to assume responsibility for
distress or impairment in social, occupational, personal care.
or other important areas of functioning.  Provide diversionary activities suited to a
 The first two exacerbations of the mood short attention span.
episode describe previously aren't better  Firmly discourage the patient if he tries to
explained by schizoaffective disorder and overextend himself.
aren't superimposed on schizophrenia,
During a depressive episode
schizophreniform disorder, delusional
disorder, or psychotic disorder not otherwise  Provide for the patient's physical needs. If he's
specified. too depressed to care for himself, help with
 The first two exacerbations of the mood personal hygiene.
episode didn't from the direct physiologic  Encourage him to eat, or feed him if
effects of a substance or a gene: medical necessary. If he's constipated, add high-fiber
condition. foods to his diet; offer small, frequent meals;
and encourage physical activity.
 To help the patient sleep, give back rubs or
warm milk at bed-time.
5|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

CYCLOTHYMIC DISORDER DIAGNOSIS

 short periods of mild depression alternate  medical disorders that can mimic cyclothymia
with short periods of hypomania include:
 between the depressive and manic episodes, 1. acquired immunodeficiency syndrome
brief periods of normal mood occur 2. Cushing's disease
 person never goes more than 2 months 3. epilepsy
without symptoms of depression or 4. Huntington's disease
hypomania 5. hyperthyroidism
6. premenstrual syndrome
SIGNS AND SYMPTOMS 7. migraines
 an odd, eccentric, or suspicious personality 8. multiple sclerosis
 dramatic, erratic, or antisocial personality 9. neoplasm
features 10. postpartum depression
 inability to maintain enthusiasm for new 11. stroke
projects 12. systemic lupus erythematosus
 a pattern of pulling close and then pushing 13. trauma
away in interpersonal relationships 14. uremia
 abrupt changes in personality from cheerful, 15. vitamin deficiency
confident, and energetic to sad, blue, or mean 16. Wilson's disease

During the hypomanic phase DIAGNOSTIC CRITERIA

 insomnia  For at least 2 years, the patient experiences

numerous periods with hypomanic symptoms
 hyperactivity
as well as numerous periods with depressive
 inflated self-esteem
symptoms that don't meet the criteria for a
 increased productivity and creativity
major depressive episode.
 over-involvement in pleasurable activities,
 During this 2-year period, the patient hasn't
including sex
been without the previously described
 physical restlessness
symptoms for more than 2 months at a time.
 rapid speech
 No major depressive, manic, or mixed episode
During the depressive phase occurred during the first 2 years of the
disturbance. (After the first 2 years of cy-
 insomnia or hypersomnia
cyclothymic disorder, superimposed manic or
 feelings of inadequacy mixed episodes may occur, in this case, both
 decreased productivity bipolar I disorder and cyclothymic disorder
 social withdrawal may be diagnosed. If superimposed major
 loss of libido depressive episodes also occur, both bipolar Il
 loss of interest in pleasurable activities disorder and cyclothymic disorder may be
 lethargy diagnosed).
 depressed speech  Symptoms aren't better explained by
 crying schizoaffective disorder and aren't
CAUSES superimposed on schizophrenia,
schizophreniform dis-order, delusional
 genetic factors influence the development of disorder, or psychotic disorder.
cyclothymic disorder  Symptoms don't result from the direct
 many patients have a family history of bipolar physiologic effects of a substance or a general
disorder, major depression, substance abuse, medical condition.
or suicide  Symptoms cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
6|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

NURSING INTERVENTIONS  patient may report that symptoms are worse

in the morning
 Explore ways to help the patient cope with
 during the physical examination, you may note
frequent mood changes.
agitation (such as hand wringing or
 Encourage vocational opportunities that allow
restlessness) or psychomotor retardation
flexible work hours.
(slow movements)
 Urge a patient with artistic ability to pursue a
 with severe depression, the patient may have
career in the arts, where mood changes may
delusions of persecution or guilt, which can
be better tolerated.
have an immobilizing effect
MAJOR DEPRESSIVE DISORDER DIAGNOSIS
 also called unipolar major depression  Beck Depression Inventory - to determine
 is a syndrome of a persistent sad mood lasting symptom onset, severity, duration, and
2 weeks or longer progression
 feeling of sadness is accompanied by:  Dexamethasone suppression test - may show
1. feelings of guilt, helplessness, or failure to suppress cortisol secretion in
hopelessness depressed patients (although this test has a
2. poor concentration high false-negative rate)
3. sleep disturbances  Toxicology screening - may suggest drug-
4. lethargy induced depression
5. appetite loss  diagnosis is confirmed if the patient meets the
6. anhedonia (inability to feel pleasure) criteria in the DSM-IV-TR
7. loss of mood reactivity (failure to feel a
mood uplift in response to something DIAGNOSTIC CRITERIA
positive
 At least five of those symptoms are present
8. thoughts of death
nearly every day during the same 2-week
CAUSES period, and represent a change from the
patients previous functioning. One symptom
 genetic, biochemical, physical, psychological, must either depressed mood or loss of
and social factors have been implicated in interest in previously pleasurable activities:
major depression • depressed mood most of the day, as
 patient history often reveals a specific indicated by either sub-jactive account or
personal loss or severe stress where according others' observation
to one theory, the stressor interacts with the • markedly diminished interest or pleasure in
person's predisposition to provoke major all, or almost all, activities, most of the day
depression • significant weight loss or gain when not
SIGNS AND SYMPTOMS dieting, or a decrease or increase in appetite
(in children, consider failure to make expected
 feeling "down in the dumps" weight gains)
 increased or decreased appetite • insomnia or hypersomnia
 sleep disturbances (for example, insomnia or • psychomotor agitation or retardation
early awakening) • fatigue or loss of energy
 disinterest in sex • feelings of worthlessness or excessive or
 difficulty concentrating or thinking clearly inappropriate quit
 easy distractibility • diminished ability to think or concentrate, or
 indecisiveness indecisiveness
 low self-esteem • recurrent thoughts of death, recurrent
 poor coping suicidal ideation with no specific plan, a
 constipation or diarrhea suicide attempt, or a specific plan for
committing suicide
7|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

• symptoms don't meet the criteria for a (Tofranil), Nortriptyline (Pamelor), and
mixed episode Trimipramine (Surmontil)
• symptoms cause clinically significant distress  inhibit the reuptake of norepinephrine,
or impairment in social, occupational, or other serotonin, and dopamine and cause a gradual
important areas of functioning decline in beta-adrenergic receptors
• symptoms don't result from the direct  aren't used as first-line agents
physiologic effects of a substance or a general
Monoamine oxidase inhibitors (MAOI)
medical condition
• symptoms aren't better explained by  Phenelzine (Nardil) and Tranylcypromine (Par-
bereavement, they last longer than 2 months, nate)
or they're characterized by marked functional  increase norepinephrine, serotonin, and
impairment, morbid preoccupation with dopamine levels by inhibiting MAO, an
worthlessness, suicidal ideation, psychotic enzyme that inactivates them
symptoms, or psychomotor retardation  may be prescribed for patients with atypical
TREATMENT depression (for example, depression marked
Selective serotonin reuptake inhibitors (SSRI) by an increased appetite and increased sleep,
rather than anorexia and insomnia) or for
 Citalopram (Celexa), Fluoxetine (Prozac), patients who don't respond to TCAs
Fluvoxamine (Luvox), Paroxetine (Paxil), and  rarely used today - although conservative
Sertraline (Zoloft) doses may be combined with a TCA for
 these agents inhibit serotonin reuptake and patient’s refractory to either type of drug
may inhibit the reuptake of other alone
neurotransmitters as well
 become the first-choice treatment for most Other antidepressants
patients  Mirtazapine (Remeron) and Nefazodone
Serotonin/norepinephrine reuptake inhibitors (SNRI) (Serzone)
 used as second-line agents
 Venlafaxine (Effexor)
 used as second-line agents for patients with Electroconvulsive therapy
major depressive disorder  a tiny electrical current is applied to the
Atypical antidepressants patient's brain through electrodes wherein
current produces a seizure lasting from 30
 Bupropion (Wellbutrin), Nefazodone seconds to 1 minute
(Serzone), Trazodone (Desyrel), and
Mirtazapine (Remeron) NURSING INTERVENTIONS
 Buproprion is thought to inhibit reuptake of  Provide for the patient's physical needs. If he's
serotonin, nor-epinephrine, and dopamine to too depressed to perform self-care, help him
varying degrees with personal hygiene. Encourage him to eat,
 Nefadazone and trazadone inhibit serotonin or feed him if necessary. If he's constipated,
and norepinephrine reuptake add high-fiber foods to his diet; offer small,
 Mirtazapine is thought to inhibit serotonin frequent meals; and encourage physical
and norepinephrine reuptake while blocking activity and fluid intake. Give him warm milk
two specific serotonin receptors or back rubs at bedtime to improve sleep.
 are used as second-line agents  Record all observations and conversations
with the patient. They're valuable in
Tricyclic antidepressants (TCA)
evaluating his response to treatment.
 Amitriptyline (Elavil), Amoxapine (Asendin),  Plan activities for times when the patient's
Clomipramine (Anafranil), Desipramine energy level peaks.
(Norpramin), Doxepin (Sinequan), Imipramine
8|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

DSTHYMIC DISORDER/DYSTHYMIA DIAGNOSTIC CRITERIA

 refers to mild depression that lasts at least 2  During the period of depression, at least two
years in adults or 1 year in children of these symptoms are present:
 depression is relatively mild or moderate, and • poor appetite or overeating
most patients aren't certain when they first • difficulty sleeping or increased need for
became depressed sleep
• low energy or fatigue
CAUSES • low self-esteem
 Biological, psychological, and medical factors • poor concentration or difficulty making
may play a role in dysthymic disorder. Many decisions
dysthymic patients have below-normal • feelings of hopelessness
serotonin levels, so it's likely that serotonin is • During the 2-year period, the patient has
involved in development of this disorder. never been without depression or the
 As with many other psychiatric disorders, previously described symptoms for more than
personality problems and multiple stressors, 2 months at a time.
combined with inadequate coping skills, may • The patient didn't experience major
increase a person's vulnerability to this depressive disorder during the first 2 years of
disorder. the disturbance. Or, if major depressive
disorder did occur, he had a full remission
SIGNS AND SYMPTOMS (with no significant signs or symptoms for 2
months) before dysthymic disorder
 persistent sad, anxious, or empty mood
developed.
 loss of interest in activities previously enjoyed
• The patient has never had a manic,
 excessive crying
hypomanic, or mixed episode and has never
 increased feelings of guilt, helplessness, or
met the criteria for cyclothymic disorder.
hopelessness
• The disorder doesn't occur within the course
 weight or appetite changes
of a chronic psychotic disorder, such as
 sleep difficulties
schizophrenia.
 poor school or work performance
• Symptoms don't stem directly from
 social withdrawal
substance abuse, other medication use, or a
 conflicts with family and friends
general medical condition (such as
 increased restlessness and irritability hypothyroidism).
 poor concentration • Symptoms cause multiple functional
 inability to make decisions impairments, such as impaired social and
 reduced energy level occupational functioning.
 thoughts of death or suicide, or suicide
attempts TREATMENT
 physical symptoms, such as headache or  Short-term psychotherapy - teaches the
backache patient more constructive ways of
DIAGNOSIS communicating with family, friends, and
coworkers and it also allows ongoing
 patient may be diagnosed with dysthymic assessment of suicidal ideation and suicide
disorder after a careful psychiatric risk
examination and medical history are  Behavioral therapy - may be used to
performed by a psychiatrist or other mental reeducate the patient in social skills and help
health professional him make attitude changes
 diagnosis is confirmed if the patient meets the  Group therapy - can help him change
criteria in the DSM-IV-TR maladaptive social functioning
 Pharmacologic treatment - may involve
antidepressants, such as SSRIs or TCAs
9|C H A P T E R 5 : M O O D D I S O R D E R S - E VA N G E L I S TA

NURSING INTERVENTIONS

 Provide supportive measures, such as

reassurance, warmth, availability, and
acceptance — even if the patient becomes
hostile.
 Teach the patient about the illness and
prescribed antidepressant medication.
 Urge him to engage in activities that enhance
his sense of accomplishment.
 Encourage positive health habits, such as
eating well-balanced meals, avoiding drugs
and alcohol (which can worsen depression),
and getting physical exercise (which can lift his
mood).