Download Depressive Disorders

Mood Disorders:
Depression and Mania
Prepared by :
Hisham M. El Mudallal
Ibrahim H. Rabea
Mohamed Z. Aish
Supervised by :
Dr. Abd Al Kareem Radwan
Presentation Objectives
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Introduction
Classification
Epidemiology
Etiology
Comorbidity
Unipolar disorders
Bipolar disorder
Diagnostic criteria
Management
Course and prognoses
References
Introduction
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Normal mood: every person experiences from time a
change in his mood, which is related to everyday life
events.
This is considered normal as long as it is appropriate
to the event.
Mood is considered abnormal when it is excessively
depressible or related out of proportion to the life
experience.
Definition
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Mood disorders (affective disorders): are a group
of disorders characterized by disturbance in
regulation of emotion, ranging from intense elation
or irritability to severe depression.
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These disorders often result in personal suffering,
family distress, interpersonal and occupational
impairment, an untold social costs.
Classification of mood disorders
1- Depressive Disorders :
A.
major Depression Disorder (unipolar depression or clinical depression)
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Atypical depression
catatonic depression
melancholic depression
postpartum depression
psychotic major depression
seasonal affective disorders
B.
Dysthymia (double depression)
B.
Depressive disorders not otherwise specified
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recurrent brief depression
minor depressive disorder
Classification of mood disorders cont.
2- Bipolar Disorders (manic depression):
a.
Bipolar I
b.
Bipolar II
c.
Cyclothymic
d.
Bipolar disorder not otherwise specified
3- Substance-induced mood disorders:
a. Alcohol induced M.D.
b. Benzodiazepine M.D.
Epidemiology
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2% of the general population develop a mood disorder
Major depression fourth leading cause of disease
burden in the world (WHO 2002)
21% of women and 13% of men develop major
depression. Ratio M:F ≈ 1:2
Age of onset for major depression disorder ≈ 25
Depression occurs more frequently in lower
socioeconomic groups.
Bipolar disorders occurs more frequently in higher
socioeconomic groups.
Age of onset of bipolar disorder ≈ 20
Prevalence of bipolar disorder ≈ 1% . Ratio M:F ≈ 2:3
Etiologic Factors Related to mood
disorders
1- Neuron biologic factors:
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Altered neurotransmission (biochemical influences):
abnormalities in various neurotransmitters as decrease in
norepinephrine, low levels of serotonin in the brain, decrease
in dopamine
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Neuroendocrine dysregulation: hypothalamus, pituitary,
adrenal, thyroid, and growth hormone.
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Genetic transmission (heredity)
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first degree relatives with mood disorders. (at least 3 times
higher)
concordance between identical twins is high.
Etiology cont.
2- Psychological factors:
 Psychoanalytic theory: depression is a result of loss
- mania is a defense against depression.
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Cognitive theory: depression is a result of negative
processing of thoughts.
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Learned helplessness: depression is a result of
apperceived lack of control over events.
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Life events and stress theory: significant life events
cause stress, which results in depression or mania.
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Personality theory: personality characteristics
predispose an individual to mood disorders.
Etiology cont.
3- Social and environmental factors:
 Adverse childhood experiences lead to depressive
disorders in adult life
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Depression is more common in divorced men.
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Women, who were caring for 3 or more children under
the age of 11, unemployed and without a confiding
relationship, were at high risk of having depression.
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High rates of depression are seen in clients with chronic
or painful physical illnesses
Comorbidity With Other Disorders
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Symptoms of anxiety are common in depressive
disorder.
Depressive features are quite frequent in: generalized
anxiety disorder, panic disorder, obsessive-compulsive
disorder, schizophrenia, schizoaffective disorder, eating
disorder and personality disorder.
Substance-use disorders are common in person with
mood disorder.
The incidence of depressive disorder is quite high in
medical illness such as: chorea, parkinson's disease,
epilepsy, stroke, migrant, myocardial Infraction,
endocrinal disorders, viral infections and rheumatoid
arthritis.
1- Depressive Disorders
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Major depressive disorder (MDD): (unipolar or
clinically depression)
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Is condition characterized by along-lasting
depressed mood or marked loss of interest or
pleasure (anhedonia) in all or nearly all activities.
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Children and adolescents with MDD may be
irritable instead of sad.
Symptoms of Depression: “Space Drugs"
Sleep disturbance: insomnia or hypersomnia nearly everyday.
Pleasure/interest: (lack of) anhedonia in things that normally enjoy.
Agitation: psychomotor agitation nearly everyday.
Concentration:diminished ability to think or concentration, or
indecisiveness.
Energy: fatigue or loss of energy nearly everyday
Depressed mound: most of day
Retardation movement: psychomotor retardation nearly everyday
Appetite disturbance: decreased or increased appetite and weight
change.
Guilt: feeling of worthlessness or excessive or inappropriate guilt.
Suicidal thought: recurrent thoughts of death and suicidal ideation.
Mental Status Examination
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General appearance: psychomotor retardation, decreased
activity level, spontaneous movements, stooped posture and sad
facial expression.
Mood/Affect: depressed mood and he sees the world through
dark glasses.
Speech: slow, monotonous, answers in brief,
Perception: Hallucination, and illusions may occur in depression
Thought: negative thought about themselves, the world and the
future.
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preoccupation with thoughts of loss, worthlessness, guilt and death.
suicidal ideation is present in 21% of patients.
the patient may have delusions of guilt or poverty.
process: thinking is slow and difficult, the patient may take along time
to answer a question.
Mental Status Examination cont.
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Orientation: usually oriented to place, time and person
Memory: most of patients complain of forgetfulness and
poor concentration.
Judgment/Insight: depressed patients emphasize their
symptoms, they are said to have excessive insight into
their condition.
Reliability: Information from depressed patients tend to
emphasize the bad and minimize the good.
Impulse control: 213 of depressed patients have suicide
thoughts, and about 10-15% actually complete suicide.
Diagnostic criteria
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DSM IV criteria for major depression.
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Five (or more) of the symptoms have been
present during the same two week period and
represent a change from previous functioning,
depressed mood or anhedonia should be one of
them.
Subtypes of Major depressive
disorder
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Atypical depression: is characterized by mood reactivity
(ability to react to positive stimuli) and significant went
gainer increased appetite, hypersomnia, a sensation of
heaviness in limbs (leaden paralysis), and significant
social impairment as a consequence of hypersensitivity
to perceived interpersonal rejection.
Melancholic depression: is characterized by a loss of
pleasure in most or all activities, a failure of reactivity to
pleasurable stimuli, a worsening of symptoms in the
morning hours, early morning waking, psychomotor,
retardation, excessive went loss, excessive guilt.
Subtypes of major depressive disorder (cont.)
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Psychotic major depression: major depressive episodes, where the
patient experiences psychotic symptoms such as delusions,
hallucinations.
Catatonic depression: is a rare and severe form of major
depression involving disturbances motor behavior, stupors,
immobile.
Post-partum depression: depression following the birth of a child,
usually occurs within 4 weeks of the birth and having symptoms of
depression.
Seasonal affective disorder (winter depression): some people have
a seasonal pattern, a depressive episodes coming or in the autumn
or winter, and resolving in spring, the diagnosis is made if at least 2
periods have occurred in colder months c none at other times over
a two-year period or longer.
Dysthymic Disorder (double depression)
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Chronic mood disorder includes depression most of the day
for most days for 2 years in adults and 1 year children and
adolescents.
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Diagnosis:
1- Depression for most of day for a period not less than 2 years.
During the period of depression 2 or more of the following
symptoms:
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loss or increase appetite.
insomnia or hypersomnia
loss of energy or exhaustion.
low self esteem and inadequacy
Difficulty c concentration, memory, and decision making.
Dysthymic Disorder (cont.)
2- Absence of episodes of mania, mixed, hypomania or major
depression.
3- The symptoms cause clinical problems, social and
vocational.
Notice:
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It is difficult to differential between major depression and
dysthymia because the symptoms are the same. In major
depression the performance of person is decreasing
significantly, but in dysthymia less severe and its effect on
the performance is less and may continue for years.
 It is believed that 50% of dysthymic pt. will have major
depression later.
Depressive Disorder not otherwise specified:
Any depressive disorder that does not meet the criteria
for a specific disorder. It includes:
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Recurrent brief depression: depressive episodes once
per month at least one year, with individual episodes
lasting less than 2 weeks and typically less than 2-3
days.
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Minor depressive disorder: depression that does not
meet full criteria for major depression but in which at
least two symptoms are present for 2 weeks.
Bipolar Disorders (manic depression)
A mood disorder described by alternating periods of mania
and depression.
Mania: It is mood disorder characterized by abnormal
elevated expanded or irritable mood.
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onset of mania usually rapid, the patient is unaware of
his inappropriate behavior without regard to social or
moral conventions.
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How to Diagnosis: DSM IV criteria
a. Abnormal and persistent elevated, expensive or
irritable mood for at least one week.
b. During the period of mood disturbance, presence of
3(or more) of the following symptoms:
1. Inflated self esteem or grandrosity.
2. decreased need for sleep.
3. more talkative than usual or pressure to keep talking.
4. distractibility.
5. increase in goal-directed activity or psychomotor agitation.
6. flight of ideas or racing.
Mental state examination
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General appearance: hyperactive, dress in colorful but
inappropriate clothes.
Mode/Affect: mood is elevated, expensive, express feeling without
restraint, Elation, Euphoria, and grander.
Speech: pressure speech, rapid and difficult to interrupt.
Thought: Delusions of grandiosity and persecution, thinking is
rapid, flight of idea.
Perception: Hallucination may occur, as religious or sexual type.
Orientation: oriented to time, place and person.
Concentration: poor and are easily distracted by environmental
stimuli.
Memory: is usually intact.
Insight/Judgment: is impaired
impulse control: Impulsive behavior is common, suicide
sometimes.
Reliability: Information not reliable.
Hypomanic Episode
The same symptoms of mania but with different in period and severity
(hypomania is less severity and longer period) it is characterized by:
1. A distinct period of persistently elevated, expensive, or irritable
mood, lasting thought at least 4 days, that is clearly different from
the usual non depressed mood.
2. During the period of mood disturbance, 3 (or more) of the following
symptoms have persisted (4 if the mood is only irritable):
 Inflated self esteem
 decreased need for sleep
 distractibility
 flight of ideas
 more talkative than usual
 increase in goal-directed activity or psychomotor agitation.
 excessive involvement in pleasurable activities that have a high
potential for painful consequence.
Hypomanic Episode Cont.
3.
The episode is associated with an unequivocal in
functioning that is un characteristic of the person when
not symptomatic.
4.
The disturbance in mood and the change in functioning
are observable by others.
5.
The episode is not severe enough to cause marked
impairment in social or occupational functioning or to
necessitate hospitalization, and there are no psychotic
feature.
6.
The symptoms are not due to the direct physiological
effects of a substance.
Subtypes of Bipolar disorder
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Cyclothymic Disorder:
chromic mood disturbance of at least 2 years'
duration.
Many episodes of hypomanic symptoms and
depressive symptoms that do not meet criteria for a
major depressive episode.
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There symptoms are less severe or intense than those
in major depression or manic episode.
Subtypes of Bipolar disorder cont.
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Bipolar I: is distinguish by the presence or history of
one or more manic episodes or mixed episodes with or
without major depressive episodes.
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Bipolar II: consisting of recurrent intermittent hypomanic
and depressive episodes.
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Bipolar disorder not otherwise specified: indicates that
the patient suffers from some symptoms in the bipolar
spectrum but does not fully quality for any of the three
formal bipolar mentioned above.
Management of mood disorders
1- Hospitalization: may require at the onset of disorder
- to control symptoms
- to safety of the p1.
2- Pharmacotherapy:
- antidepressant: TCA'S - MAO'S
-SSRI'S
- lithium carbonate
- Depakine -Tegretol
3- Psychotherapy
- psychoeducation
- family therapy
- cognitive – Behavioral therapy
- interpersonal and social therapy
3- Substance – induced mood
disorders:
Mode disorders occurs due to direct physiologic
effects of psychoactive drug, or other chemical
substance, substance intoxication or withdrawal.
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Alcohol – induced mood disorders: Alcoholism.
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Benzodiazepine – induced mood disorders:
longterm (chronic) used.
Course and programs of mood disorder:
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Depressive episode usually last for 6 months.
The presence of residual symptoms such as somatic
symptoms and poor sleep increase the risk of
recurrence.
The death rate in clients with depressive disorder is
higher.
11-17% of client with severe depression eventually
commit suicide
Clients with younger age of onset show better recovery.
The length of manic episode varies from 3-13 months
Prognosis is much better with treatment
The most serious complication is suicide, and substance
abuse.
Nursing Interventions
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Maintaing supportive contact with the client
 provide quite, non-stimulating environment.
 encourage client to actively engage in life and
relationships.
 assist with ADL'S / hygiene / grooming as needed.
 Assist client to identify previous coping skills
 Identify client's needs
 remove harmful objects/protect from self-harm, others.
 assist with problem solving / decision making
 assist client to set limits on own behavior
 educate about disorder and medication compliance
 monitoring for side effects of drugs
References:
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Katherine M. Fortinasl and Patricia A. Holodayworret (1996) psychiatric Mental Health Nursing,
Newyork, Tornto, 1st edition.
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Rob Newell and Kevin Gournay. (2009) Mental
Health Nursing, New York, Tornto, 2nd edition.