Psychopathology of Mood Disorders

Terry Campbell RN, MSc, BSc, Cert. Psych. Nrsg.
Caribbean School of Nursing

College of Health Sciences
University of Technology, Jamaica
October 08, 2013
Objectives
At the end of this discussion students will be able to:
Explain what is meant by mood disorders
Outline the various types of mood disorders
Discuss the Incidence and Prevalence of mood

disorders
Analyze theories about the etiology/causation of
mood disorders
Objectives
Outline clinical features presented in mood
disorders according to the DSM-IV-TR.
Describe interdisciplinary treatments for clients
with bipolar disorder.
Apply the nursing process to the care of clients
with Bipolar/mood disorders.
What are Mood

Disorders?
http://www.fotosearch.com/SPS503/11662965a/
Mood Disorders Defined
Mood disorders are psychiatric

disorders that predominantly affects
the internal emotional state of
individuals.
It has multiple aspects inclusive of
biological, behavioral, social and
psychological.
Overview
Mood is the internal subjective
experience of the patient that colors

and sustains an individuals psychic life.
Affect is the external observable

manifestation of the emotion, which
can be blunt, labile, constricted etc.
HOW
ARE
YOU
FEELING
TODAY?
Classification of Mood Disorders

Mood
Disorders
Major Depressive Disorder
Dysthymia
Bipolar Disorder
Bipolar I Disorder
Depressive Disorder
NOS
MDD with Postpartum
Onset
Bipolar II Disorder
Cyclothymia
Incidence/Prevalence
MDD is a common disorder, lifetime prevalence of

15% may be 25% in women.
Sex Male : Female = 1:2 for MDD
1:1 for BD I
1:2 for BD II (Baldassano et al., 2005)
Lifetime prevalence of BD is 3.9% (Kessler et al, 2005)
Although conventional wisdom holds

that depression is most closely
associated with menopause, in fact, the
childbearing years are marked by the
highest rates of depression, followed by
the years prior to menopause.
Women between 18 and 45 comprise the majority of

those with MDD.
Mean age of onset MDD 40 yrs

BD I 5/6 50 yrs
No Racial Differences
MDD occurs most often in divorced, separated or single
persons with no close interpersonal relationships.
BD I may be more common in divorced or single
persons.
Socioeconomic and Cultural Considerations

There is no correlation between SES and MDD
Higher incidence of BD I in upper
socioeconomic groups
Depression is more in rural than urban areas
BD I seen more in college students
Etiology/ Causation
The causal basis of mood disorder is not

known.
Several factors appear to work to:
Cause
Precipitate
http://www.topnews.in/files/brain_ADHD.jpg
Etiology/ Causation
The Neurotransmitter Theory

The theory suggest deficit in neurotransmitter
Primarily norepinephrine (NE) and Serotonin (5HT)
Excess NE Mania
NE Depression
Switch Phenomenon for Mania Depression Dopamine
(DA) and NE activity.
NE Depression
DA Mania
Etiology/ Causation
Neuroendocrine Regulation
Major axes of interest in mood disorders is the
adrenal, thyroid and growth hormone axes.
Correlation between hypersecretion of cortisol
and depression.
Thyroid disorders often associated with
affective symptoms.
Etiology/ Causation
Genetic Factors
First degree relatives of persons with BD I
are 8-18 times more likely to have BD I and
2-10 times more likely to have MDD.
50% of all BD I patients have at least one
parent who had a mood disorder, most likely
MDD.
Etiology/ Causation
Genetics contd.
Twin studies reveal that 33-90% risk for BD I
and 50% for MDD in monozygotic twins.
5-25% and 10-25% for BD I and MDD
respectively for dizygotic twins.
Etiology/ Causation
Psychosocial
Loss of parent before age 11
Loss of spouse
Stressful life events
Environmental stress
Premorbid Personality factors ObsessiveCompulsive & Hysterical personalities at greater
risk for depression.
Etiology/ Causation
Psychoanalytic Theory
Object loss traumatic separation from
significant objects of attachment.
Freud the depressed patients rage is internally
directed because of identification with the lost
object; a way by which the ego relinquishes the
object.
Etiology/ Causation
Psychoanalytic Theory contd..

Melanie Klein manic-depressive cycles were
seen as a reflection of failure in childhood to
establish loving introjects.
Depressed patients suffer the concern that they
have destroyed loving objects through their own
destructiveness and greed.
Etiology/ Causation
Cognitive Theory
Negative distortions of life experiences
Negative self evaluation
Pessimism
Hopelessness
Learnt helplessness
Etiology/ Causation
Other Causes Include:

Social Influence
Other Psychiatric Disorders
Secondary to Disease State
Stress Diathesis Model
Decreased Neurogenesis
Neurotoxicity
Major Depressive
Disorder
Major Depressive
Disorder
Illness characterized by feelings of
hopelessness, sadness, worthlessness,

changes in appetite, sleep patterns, delusions
and hallucinations.
Mental disorder characterized by a pervasive

low mood, low self-esteem, and loss of
interest or pleasure in normally enjoyable
activities.
Major Depressive
Disorder
The World Health Organization and

the World bank found major
depression to be the leading cause of
disability worldwide.
Major Depressive
Disorder
Major Depression can be of three types:

Major Depression Single Episode
Major Depression Recurrent Episode

Dysthymia
Risk Factors
Prior episodes of depressive illness
Family history of depression
Prior suicide attempts

Postpartum period
Chronic medical condition e.g. DM, CHD, Cancer

Lack of social support
History of Post-Traumatic Stress Disorder
Major Depressive
Disorder
Criteria for Diagnosing MDD:

5 or more of the following symptoms
present during the same two-week period
or more and represent a change from
previous functioning. At least one of the
symptoms is either depressed mood or
loss of interest or pleasure.
CLINICAL
FEATURES
Major Depressive
Disorder
Clinical Features:
Depressed mood for most of the day nearly
every day.
Anhedonia
Appetite changes +/-
Sleep Changes
Psychomotor agitation or retardation
Major Depressive
Disorder
Clinical Features:
Fatigue, loss of energy most days
Feelings of worthlessness
Difficulty in thinking or concentrating

Recurrent thoughts of death and suicide
Nihilism view that existence is senseless
or hopeless
Major Depressive
Disorder
Increased Risk for Suicide:
Male (Adolescent or >40yrs)

Divorced, widowed or separated
Hstory of previous attempt
Impulsive or seclusive personality
Giving away possession
Lack of support system
When mood begins to lift following
depression.
Dysthymia
Dysthymia
Chronic disturbance of mood involving a
depressed mood for most of the day, most
days for at least two years.
Condition in which the person suffers
from unceasing, low-grade depression.
Dysthymia
Mood never seems to relinquish for more

than a day or two.
Some people grow used to being depressed
that they think its a part of who they are.
Symptoms are not as severe as major
depression, so functioning is somewhat
better.
Dysthymia
Because of its chronicity relationships and

work usually suffer.
High risk for other mental difficulties e.g.
disorders of anxiety, eating, personality and
substance abuse.
Dysthymia
Most common form of depression

May begin in childhood or adulthood
More common in women
It is estimated that up to 3% of people

have dysthymia.
Dysthymia
Causes/Risk Factors:
Changes in serotonin levels in the brain
Personality problems
Medical conditions e.g. Thyroid disorders
Stress
Previous episode of MDD from which the
person never fully recovered.
Dysthymia
Clinical Features:
A. Depressed mood for most of the day, most days for
at least 2 years.
B. Presence while depressed of two or more of the

following:
Appetite +/ Sleep +/ Low energy or fatigue
Low self-esteem
Poor concentration or thinking
Feelings of hopelessness
Dysthymia
C. During the 2 yr period (1 yr for children) the
person has never been without the symptoms in

A or B for more than 2 months at a time.
D. No major depressive episode present for the

first two years.
E. No manic, mixed or hypomanic episodes
F. Not due to GMC
Screening Tool
Aim: To aid clinical judgment in suicide risk

Sum the score
Maximum Total Score = 10, the higher the worse
Low
0-3
Moderate 4-6
High
>=7
INDICATORS
SEX
AGE
DEPRESSION
PREVIOUS ATTEMPT
ETHANOL/DRUG USE
RATIONAL THOUGHT LOSS (PSYCHOSIS)
SOCIAL SUPPORT
ORGANIZED PLAN
NO SPOUSE
SICKNESS
GOOD POOR
BIPOLAR
DISORDER
Bipolar Disorder
Previously known as Manic-Depression

Disorder
Most common psychotic disorder occurring

in 1% of people among all age groups.
Cyclic disorder with periods of emotional
highs and lows encompassing the extremes
of human experiences i.e. episodes of mania
and depression.
Bipolar Disorder
Early-Onset Bipolar Disorder. In one survey, 59% of

bipolar disorder patients had their first symptoms
when they were children or adolescents.
The initial episodes are more likely to be depressive.
In fact, a 2001 study reported that 33% of children
who experienced major depression developed
bipolar I by age 21 and 15% of them had bipolar II
disorder.
Bipolar Disorder
Adult-Onset Bipolar Disorder. Bipolar disorder can

also appear for the first time in people over the age
of forty. In fact, age 40 is another peak of onset for
women.
Onset Late in Life. Bipolar disorder that occurs late in

life often either follows many years of repeated
episodes of unipolar depression or it accompanies
medical and neurological problems (particularly
cerebrovascular disease, such as stroke).
Bipolar I Disorder
The American Psychiatric Association divides the

disorder into two types:
Type I characterized by the person having
experienced one or more manic episodes, usually
alternating with major depressive episodes.
Type II characterized by a major depressive

episode (current or past) and at least one
hypomanic episode.
Bipolar I Disorder
The difference with mania and hypomania is

the period of time for which the episodes last.
Mania lasts for one week or more
Hypomania lasts for 4 days
Bipolar I Disorder
Clinical Features:
Distinct period of abnormally and
persistently elevated, expansive or irritable
mood, lasting for at least one week.
During the period of mood disturbance, 3
or more of the following symptoms have
persisted to a significant degree:
Bipolar I Disorder
Clinical Features:
Inflated self esteem or grandiosity

Decreased need for sleep
More talkative (excessive speech)
Flight of ideas (racing thoughts)
Easy Distractibility
Increased goal directed activity or agitation
Excessive involvement in pleasurable activities
with high potential for painful results.
Bipolar I Disorder
Do not meet criteria for mixed episode

Marked impairment in fucntioning
Not due to effects of substances or GMC.
Hypomania
Distinct period of persistently elevated,

expansive or irritable mood for at least four
days.
Mild degree of mania.

Person may have inflated self-esteem,
irritability, impatience and demanding
attitude.
Hypomania
Occurs without psychotic features

Does not impair functioning or require
hospitalization.
Mostly occurs immediately before or after a
major depressive episode.
Bipolar Disorder II
Presence (or history) of one or more major
depressive episodes.
At least one hypomanic episode
Never a manic episode or mixed episode

Clinically significant distress or impairment.
Cyclothymia
Chronic disorder with frequent mood swings

and single episodes lasting for at least two
years.
Behavioral Manifestations:
Intoverted self-absorbed vs. uninhibited
people seeking.
Taciturn vs. talkative
Cyclothymia
Unexplained tearfulness vs. buoyant

jocularity
Psychomotor inertia vs. restless pursuit of
activities.
Nursing Diagnosis - MDD
Risk for Injury
Risk for Violence

Ineffective Coping
Self-Care Deficit
Impaired Social Interaction
Nursing Diagnosis - BD
Risk for Violence
Risk for Injury

Altered Thought Process
Impaired Nutrition
Treatment
Psychotherapy
Pharmacotherapy
Cognitive therapy
Behavior therapy
Hospitalization
Family therapy
Scenario
Belmera is a 45 year old woman who was admitted

to the psychiatric hospital yesterday because she was
no longer able to work and care for herself and her
family. Her 25 yr old daughter, Amanda became
worried when she noticed that her mother was
sleeping all the time, not eating, and talked about
ending it all because life is just too difficult. She
shares that her brother is in prison. He was
incarcerated 6 months ago and Amanda tells you
that her mother has not been the same since.
THANK
YOU

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Terry Campbell RN, MSc, BSc, Cert. Psych. Nrsg.

Caribbean School of Nursing

Discuss the Incidence and Prevalence of mood

What are Mood

Mood Disorders Defined

Mood disorders are psychiatric

Mood is the internal subjective

experience of the patient that colors

Affect is the external observable

Classification of Mood Disorders

MDD is a common disorder, lifetime prevalence of

Although conventional wisdom holds

Women between 18 and 45 comprise the majority of

Mean age of onset MDD 40 yrs

Socioeconomic and Cultural Considerations

BD I seen more in college students

The causal basis of mood disorder is not

The Neurotransmitter Theory

Psychoanalytic Theory contd..

Other Causes Include:

Illness characterized by feelings of

hopelessness, sadness, worthlessness,

Mental disorder characterized by a pervasive

The World Health Organization and

Major Depression can be of three types:

Major Depression Recurrent Episode

Prior suicide attempts

Chronic medical condition e.g. DM, CHD, Cancer

Criteria for Diagnosing MDD:

Difficulty in thinking or concentrating

Increased Risk for Suicide:

Male (Adolescent or >40yrs)

Mood never seems to relinquish for more

Because of its chronicity relationships and

Most common form of depression

It is estimated that up to 3% of people

B. Presence while depressed of two or more of the

C. During the 2 yr period (1 yr for children) the

person has never been without the symptoms in

D. No major depressive episode present for the

Aim: To aid clinical judgment in suicide risk

RATIONAL THOUGHT LOSS (PSYCHOSIS)

Previously known as Manic-Depression

Most common psychotic disorder occurring

Early-Onset Bipolar Disorder. In one survey, 59% of

Adult-Onset Bipolar Disorder. Bipolar disorder can

Onset Late in Life. Bipolar disorder that occurs late in

The American Psychiatric Association divides the

Type II characterized by a major depressive

The difference with mania and hypomania is

Inflated self esteem or grandiosity

Do not meet criteria for mixed episode

Not due to effects of substances or GMC.

Distinct period of persistently elevated,

Mild degree of mania.

Occurs without psychotic features

Presence (or history) of one or more major

Never a manic episode or mixed episode

Chronic disorder with frequent mood swings