MOOD (AFFECTIVE) DISORDERS

Introduction
• Mood disorders also called affective disorders are pervasive
alterations in emotions that are manifested by depression,
mania, or both.
• They are very common with a high level of morbidity and
mortality
• The fundamental disturbance is a change in mood or affect,
usually to depression (with or without associated anxiety) or to
elation.
• The mood change is usually accompanied by a change in the
overall level of activity.
• Most of these disorders tend to be recurrent, and the onset of
individual episodes is often related to stressful events or
situations.
Classification of Mood Disorders (ICD-10)

 Depressive episode
 Manic episode
 Bipolar affective disorder
 Recurrent depressive disorder
 Persistent mood (affective) disorders
 Other mood (affective) disorders
 Unspecified mood (affective) disorder
 Depressive Episode
• Depression is an alteration in mood that is expressed by
feelings of sadness, despair, and pessimism.
• A major depressive episode lasts at least 2 weeks,
during which the person experiences a depressed mood
or loss of pleasure in nearly all activities.
• In addition, four of the following symptoms are present
– changes in appetite or weight, sleep, or psychomotor activity;
– decreased energy; feelings of worthlessness or guilt;
– difficulty thinking, concentrating, or making decisions;
– recurrent thoughts of death or suicidal ideation, plans, or
attempts
 Types of Depressive Disorders
• Major Depressive Disorder (MDD)
• characterized by depressed mood or loss of interest
or pleasure in usual activities.
• Evidence will show impaired social and occupational
functioning that has existed for at least 2 weeks
• No history of manic behavior, and symptoms that
cannot be attributed to use of substances or a
general medical condition
• It may be single (the individual’s first encounter) or
recurrent episode
 Classification of MDD
 Mild depressive episode
 Moderate depressive episode
 Severe depressive episode without psychotic
symptoms
 Severe depressive episode with psychotic
symptoms
 Other depressive episodes
 Depressive episode, unspecified
 Mild Depressive Episode
• Two or three of the above symptoms are usually
present.

• For mild depressive episode are typical

depressed mood, anhedonia and increased
fatigability.

• The patient is usually distressed by the

symptoms and has some difficulty in continuing
with ordinary work and social activities, but will
probably not cease to function completely.
 Moderate Depressive Episode
• An individual with moderate depressive episode
suffers from more symptoms

• Four or more of the above symptoms are usually

present

• Symptoms are of greater severity and will

usually have considerable difficulty in continuing
with social, work or domestic activities.
 Severe Depressive Episode without
Psychotic Symptoms
• In a severe depressive episode, the sufferer usually
shows considerable distress or agitation.
• Loss of self-esteem or feelings of uselessness or guilt
are be prominent,
• Suicide is a distinct danger in particularly severe cases.
• A number of "somatic" symptoms are usually present.
– Significant decrease in appetite or weight.
– Early morning awakening
– Diurnal variation
– Pervasive lack of interest and lack of reactivity to pleasurable
stimuli.
– Psychomotor agitation or retardation
Severe Depressive Episode with Psychotic
Symptoms
• Psychotic symptoms is present, such as
• delusions (ideas of sin, poverty or imminent
disasters)
• hallucinations (defamatory or accusatory
voices or of rotting filth or decomposing
flesh)
• depressive stupor
• Ordinary social activities are impossible
 Dysthymic Disorder
• The essential feature is a chronically depressed
mood (or possibly an irritable mood in children
or adolescents) for most of the day, more days
than not, for at least 2 years (1 year for children
and adolescents).

• The diagnosis is identified as early onset

(occurring before age 21 years) or late onset
(occurring at age 21 years or older).
 Premenstrual Dysphoric Disorder

• The essential features include markedly

depressed mood, excessive anxiety, mood
swings, and decreased interest in activities
during the week prior to menses and
subsiding shortly after the onset of
menstruation
 Other Depressive Disorders
• Mood Disorder (Depression) Due to a General
Medical Condition
• judged to be the result of direct physiological
effects of a general medical condition

• Substance-Induced Mood Disorder

• Direct result of physiological effects of a
substance (e.g., a drug of abuse, a medication,
or toxin exposure)
 Recurrent Depressive Disorder
• Recurrent depressive disorder is characterized by repeated
episodes of depression without any history of independent
episodes of mood elevation and overactivity.
• Recovery is usually complete between episodes, but a substantial
part of patients will have a recurrence and about 30% may
develop a persistent depression.

• Seasonal affective disorder - onset of mood symptoms is

connected with changes of seasons, with depression typically
occurring during the winter months and remissions or changes
from depression to mania occurring during the spring.
 Etiological Implications
 Genetic/heredity
 Twin studies; family studies; adoption studies
 Biochemical Influences
 ↓norepinepherine, serotonin, and dopamine
 Hormonal imbalance
 Psychoanalytic theory: depression results due to loss of a
“loved object”
 Sociological theory: Stressful life events, e.g. death, marriage,
financial loss before the onset of the disease or a relapse
probably have a formative effect
 Behavioural theory: repeated losses in the past
 Cognitive theory: due to negative cognitions which include:
 Negative expectations of the environment
 Negative expectations of the self
 Negative expectations of the future
 Treatment
• Pharmacotherapy: Antidepressants are the
treatment of choice
• Cognitive therapy: It aims at correcting the
depressive negative cognitions like hopelessness,
worthlessness, helplessness and pessimistic
ideas and replacing them with new cognitive and
behavioural responses.
• Supportive psychotherapy: Various techniques
are employed to support the patient. They are
reassurance, ventilation, occupational therapy,
relaxation and other activity therapies.
 Treatment
• Group therapy: useful for mild cases of
depression.
• Family therapy: used to decrease intra-familial
and interpersonal difficulties and to reduce or
modify stressors, Electroconvulsive therapy (ECT)
• Behaviour therapy: social skills training, problem
solving techniques, assertiveness training, self-
control therapy, activity scheduling and decision
making techniques.
 Manic Episode
• Mania refers to a syndrome in which the central
features are over-activity, mood change and self
important ideas.
• A distinct period during which mood is abnormally
and persistently elevated, expansive, or irritable.
• The period lasts 1 week. At least three of the
following symptoms are present:
• inflated self-esteem or grandiosity;
• decreased need for sleep;
• pressured speech ;
• flight of ideas;
• distractibility;
• psychomotor agitation; and
• excessive involvement in pleasure-seeking activities with a high
potential for painful consequences
 Classification of Manic Episode
 Hypomania
 Mania without psychotic symptoms
 Mania with psychotic symptoms
 Other manic episodes
 Manic episode, unspecified
 Hypomania
• A period of abnormally and persistently elevated,
expansive, or irritable mood lasting 4 days and
including three or four of the additional symptoms
described earlier.

• The episodes do not impair the person’s ability to

function and there are no psychotic features
(delusions and hallucinations).
 Mania without Psychotic Symptoms
• Mania without psychotic symptoms:
– last for at least 1 weak
– mood is elevated out of keeping with individual’s circumstances
and may vary from carefree joviality to almost uncontrollable
excitement
– elation is accompanied by increased energy, resulting in
overactivity, pressure of speech, and a decreased need for sleep
– normal social inhibition are lost, attention cannot be sustained,
and there is often marked distractibility
– self-esteem is inflated, and grandiose or over-optimistic ideas
are freely expressed
– perceptual disorders may occur
– the individual may embark on extravagant and impractical
schemes, spend money recklessly, or become aggressive,
amorous, or factious in inappropriate circumstances.
 Mania with Psychotic Symptoms
• A more severe form of mania:
– inflated self-esteem and grandiose ideas may develop into
delusions, and irritability and suspiciousness into delusions of
persecution
– in severe cases, grandiose or religious delusions of identity or
role may be prominent, and flight of ideas and pressure of
speech may result in the individual becoming incomprehensible
– sustained physical activity and excitement may result in
aggression or violence, and neglect of eating, drinking, and
personal hygiene may result in dangerous states of dehydration
and self neglect
• Mania with:
– mood-congruent psychotic symptoms
– mood-incongruent psychotic symptoms
• Manic stupor
 Treatment of Mania
• Mood stabilizers:
– lithium 900-2100 mg/day
– Carbamazepine 600-1800 mg/day.
– valproate 600-2600 mg/day
• Anticonvulsants:
– gabapentine
– topiramate
– lamotrigine
• Agitated or psychotic patient – coadministartion of
– antipsychotics of second generation (olanzapine,
risperidone)
– benzodiazepines (lorazepam, clonazepam)
• ECT
 Nursing Interventions
Provide for client’s physical safety and safety of those
around client.
• Set limits on client’s behavior when needed.
• Remind the client to respect distances between self and
others.
• Use short, simple sentences to communicate.
• Clarify the meaning of client’s communication.
• Frequently provide finger foods that are high in calories
and protein.
• Promote rest and sleep.
• Protect the client’s dignity when inappropriate behavior
occurs.
• Channel client’s need for movement into socially
acceptable motor activities.
 Bipolar Affective Disorder
• A bipolar disorder is characterized by mood swings from
profound depression to extreme euphoria (mania), with
intervening periods of normalcy
• During a manic episode, the mood is elevated,
expansive, or irritable. Motor activity is excessive and
frenzied. Psychotic features may be present.
• The diagnostic picture for depression associated with
bipolar disorder is identical to that described for major
depressive disorder, with one addition: the client must
have a history of one or more manic episodes.
• Bipolar mood disorders is further classified into bipolar I
and bipolar II disorder
 Bipolar I
• The diagnosis given to an individual who is experiencing,
or has experienced, a full syndrome of manic or mixed
symptoms.
• The client may also have experienced episodes of
depression.
• This diagnosis is further specified by the current or most
recent behavioral episode experienced.

• For example, the specifier might be “single manic

episode” (to describe individuals having a first episode of
mania). For individuals who have had recurrent mood
episodes, the current (or most recent) episode may be
identified as manic, hypomanic, mixed, or depressed
 Bipolar II
• This diagnostic category is characterized by
recurrent bouts of major depression with episodic
occurrence of hypomania.

• The individual who is assigned this diagnosis may

present with symptoms (or history) of depression or
hypomania.
•
• The client has never experienced an episode that
meets the full criteria for mania or mixed
symptomatology.
 Dysthymia
• A chronic, milder form of depression which does
not fulfill the criteria for recurrent depressive
disorder especially in terms of severity.

• Sufferers usually have periods of days or weeks

when they describe themselves as well, but most
of the time they feel tired and depressed.

• It usually begins in adult life and lasts for at least

several years, sometimes indefinitely.
 Cyclothymia
• For cyclothymia persistent instability of mood,
involving periods of mild depression and mild elation
is typical.

• This instability usually develops early in adult life

and pursues a chronic course, although the mood
may be normal and stable for months at a time.

• The mood swings are usually perceived by the

individual as being unrelated to life events.
Bipolar Affective Disorder
 Medication
• Psychopharmacology
• Lithium; Anticonvulsants
• ECT
• Psychotherapy
 Nursing Diagnoses
• Risk for Other-Directed Violence
• Risk for Injury
• Imbalanced Nutrition: Less Than Body Requirements
• Ineffective Coping
• Noncompliance
• Ineffective Role Performance
• Self-Care Deficit
• Chronic Low Self-Esteem
• Disturbed Sleep Pattern
 Nursing Intervention
• Provision of safety
• Meeting physiologic need
• Promoting therapeutic relationship
• Promoting activities of daily living
• Provide physical care
• Promoting appropriate behaviour
• Managing medication
• Providing client and family teaching