CENTRAL PHILIPPINE UNIVERSITY

COLLEGE OF NURSING
The First Nursing School in the Philippines, 1906
Iloilo City, Philippines 5000
Tel. No. (63-33) 3291971 to 79 Local 1037 / 2133
Website: http://www.cpu.edu.ph | Email: [email protected]

Lecture Notes on
NCM 3218
(Care of Clients with Maladaptive Patterns of Behavior-Acute/Chronic)

MOOD DISORDERS

DEFINITION
● pervasive alterations in emotions that are manifested by depression, mania, or both

MOOD
● sustained emotional state
● it can be:
- dysphoric
- elevated
- irritable
AFFECT
● outward expression of emotion, emotional display & responsiveness
● types:
- appropriate
- flat
- blunted
- restricted
- inappropriate
- labile

ETIOLOGY
Genetics  0-70% - identical twin
 15% - parent/sibling
 5-10% - grandparents/aunt/uncle

Neurochemical  Serotonin
 Norepinephrine
 Acetylcholine
 Dopamine

Neuroendocrine  Hypersecretion of cortisol

 Low levels of thyroid hormone
 Postpartum hormone alterations
 PMS

Biological  circadian rhythm disturbances

Cognitive  Depressed patients – process information in a negative way

 Experience cognitive distortions & thinking errors
 Cognitive Triad:
o Negative perception of self
1 | Mood Disorders – Prof. Borlado
 o Negative interpretations of experiences
o Negative view of future

Behavioral  “Learned Helplessness”

Psychodynamic  faulty family dynamics
 real or perceived loss = anger turned inward
 tyrannical superego → guilt, self-criticism,
 defense reaction against underlying depression = mania
Life Events and  stressful life events
Environmental o loss of parent/spouse
o financial hardships
o midlife crises; illness
o perceived or real failure
o relocation
o loss/change of employment
o retirement
o trauma
o abuse
o parental neglect

I. BIPOLAR DISORDER
● involves extreme mood swings from episodes of mania to episodes of depression
● Types:

o Bipolar 1 one or more manic or mixed episodes accompanied by major depressive

episode for at least 1 week

o Bipolar 2 one or more major depressive episodes accompanied by at least 1 hypomania

● terms are used to describe the labile affect:

Euphoria exaggerated feeling of physical and emotional well-being

Elation state of extreme happiness, delight, or excitability

Hypomania mood falling somewhere between normal euphoria and mania; no

psychotic symptoms

Mania characterized by excessive elation, inflated self-esteem, and

grandiosity that lasts for a week

Rapid Cycling characterized by the occurrence of four or more mood episodes

during the previous 12 months

● ONSET: early 20’s (late adolescence - early adulthood)

● Symptoms of Manic Attack:

D – distractability
I – indiscretion
G – grandiosoty

2 | Mood Disorders – Prof. Borlado

 F – flight of ideas
A – activity increase
S – sleep disturbance
T – talkativeness

● Sympotms of Depressive State:

✔ Low self-esteem and hopelessness
✔ Overwhelming inertia
✔ Social withdrawal
✔ Difficulty concentrating/thinking clearly
✔ Decrease mental and psychomotor processes
✔ Slowed speech and responsiveness
✔ Anhedonia
✔ Sleep Disturbances
✔ Suicidal ideation

● Treatment:
✔ Psychoactive Drugs
a. ANTIMANIC & ANTICONVULSANT
- Lithium (Eskalith)
- Valproic Acid (Depakote)
- Carbamazepine (Tegretol)
- Gabapentine (Neurontin)
- Guidelines in Lithium Therapy:
o Maintain fluid intake at 2.5-3 L/day (10-13 glasses)
o Maintain adequate dietary salt intake
o Watch out for signs of toxicity
o Take medication with meals - avoid GI upset
o Caution against driving and operating dangerous machinery
o Don’t abruptly stop or alter dosage of medication
o Avoid excessive exercise in warm weather
o Avoid crash or fad diets
o Monitor lithium level regularly

b. ATYPICAL ANTIPSYCHOTICS
- Abilify (aripiprazole)
- Zyprexa (olanzapine)
- Risperdal (risperidona)

✔ Alternative/Complementary Therapies
a. Kava-kava- ↓ restlessness
b. Black cohosh root- PMDD anPMS
c. Valerian- herb used as sedative/ hypnotic

✔ Psychotherapy
✔ Diagnostic test
d. Mania test

● Nursing Interventions:
a. Provide safety
b. Set limits on client’s behavior
c. Use short, simple sentences to communicate
d. Clarify the meaning of client’s communication

3 | Mood Disorders – Prof. Borlado

 e. Frequently provide finger foods that are high in calories and protein
f. Promote rest and sleep
g. Protect the client’s dignity when inappropriate behavior occurs
h. Channel client’s need for movement into socially acceptable motor activities

● Nursing Diagnosis:
a. Risk for Other-Directed Violence
b. Risk for Injury
c. Imbalanced Nutrition: Less Than Body Requirements
d. Non compliance to Medication
e. Self-Care Deficit
f. Disturbed Sleep Pattern
g. Ineffective Coping
h. Ineffective Role Performance
i. Chronic Low-Self-Esteem

II. CYCLOTHYMIC DISORDER

● characterized by 2 years of short periods of mild depression alternating with short periods of
hypomania; between the depressive and manic episodes, brief periods of normal mood occur

III. DYSTHYMIC DISORDER

● alternating periods of moderate depression and normal mood that lasts at least 2 years in adult or 1
year in children but do not meet criteria for major depression
● not severe,no delusions, no hallucinations, no impaired communication, or no incoherence
● overly sensitive, intense guilt feelings and chronic anxiety

IV. MAJOR DEPRESSIVE DISORDER

● 2 or more weeks of nearly everyday of sad mood or lack of interest in life activities with at least 5 or
more of the 9 other symptoms of depression
● may be coded as:
- mild, moderate, or severe
- with or without psychotic features
- partial or full remission

● Depression Assessment:
S – sleep disturbances
I – interest decrease in pleasure activities and sex
G – guilty feelings
E – energy decreased
C – concentration
A – appetite
P – psychomotor function
S – suicidal ideations

● Psychological Tests for Diagnosis

Beck’s depression inventory 5-minute, 21-item scale that assesses intensity of depression in
individuals between ages of 13 to 80 years

Zung’s self- rating depression scale 20  item that  measures the level and pervasiveness of
depression

Miller Hope Scale Measures 11 critical elements of hope

Hamilton Rating Scale Clinician-rated depression scale used like a clinical interview
4 | Mood Disorders – Prof. Borlado
 Dexamethasone Suppression Test Showing failure to suppress cortisol secretion in depressed
patients

Geriatric Depression Scale 30 item  scale for depressed older adults answerable by yes or
no

● Treatment
✔ ANTIDEPRESSANTS
a. SSRI – Sertraline (Zoloft); Paroxetine (Paxil); Citalopram (Celexa)
b. SNRI – Venlafexine (Effexor)
c. TCA – Imipramine (Tofranil)
d. MAOI – PA (Parnate)Tranylcypromin; NA (Nardil) Phenelzine; MA (Marplan)
Isocarboxacid

✔ Somatic Therapy
a. ECT
b. Vagus Nerve Stimulation

✔ Psychotherapy

✔ Complementary/Alternative Therapy
a. St. John Wort
b. SAM-e

● Nursing Interventions:
a. Provide for the safety of the client and others. Institute suicide precautions if indicated
b. Begin a therapeutic relationship by spending non-demanding time with the client
c. Promote completion of activities of daily living by assisting the client only as necessary
d. Establish adequate nutrition and hydration
e. Promote sleep and rest
f. Attitude therapy - kind firmness
g. Engage the client in activities
h. Encourage the client to verbalize and describe emotions.
i. Work with the client to manage medications and side effects

● Nursing Diagnosis:
a. Risk for Suicide
b. Imbalanced Nutrition: Less Than Body Requirements
c. Anxiety
d. Ineffective Coping
e. Hopelessness
f. Ineffective Role Performance
g. Self-Care Deficit
h. Chronic Low Self-Esteem
i. Disturbed Sleep Pattern
j. Impaired Social Interaction

V. DEPRESSIVE DISORDER NOT OTHERWISE SPECIFIED

● with depressive features that do not meet the criteria for MDD, DD, adjustment disorder with depressed
mood, or adjustment disorder with mixed anxiety and depressed mood

5 | Mood Disorders – Prof. Borlado

VI. SUBSTANCE-INDUCED MOOD DISORDER
● characterized by a prominent and persistent disturbance in mood that is judged to be a direct
physiologic consequence of ingested substances such as alcohol, other drugs, or toxins
VII. MOOD DISORDER DUE TO GENERAL CONDITION
● characterized by a prominent and persistent disturbance in mood that is judged to be a direct
physiologic consequence of a medical condition

VIII. SEASONAL AFFECTIVE DISORDER

● subtypes:
✔ winter depression or fallonset SAD
✔ spring-onset SAD

IX. POSTPARTUM BLUES

● Frequent normal experience after delivery of a baby
● Symptoms begin after 1 day from delivery
● Peak: 3 to 5 days (labile mood, crying spells, sadness, insomnia)
● Disappear rapidly and no medical treatment needed

X. POSTPARTUM DEPRESSION
● meets all the criteria for a major depressive episode, with onset within 4 weeks of delivery
XI. POSTPARTUM PSYCHOSIS
● psychotic episode developing within 3 weeks of delivery and beginning with:
- fatigue
- sadness
- emotional lability
- poor memory
- confusion
and progressing to:
- delusions
- hallucinations
- poor insight and judgment
- loss of contact with reality
● risk for suicide and infanticide

XII. PREMENSTRUAL DYSPHORIC DISORDER

● a recurring and severe form of premenstrual syndrome (PMS) causing impaired social and occupational
functioning, influencing interpersonal relationships with family and friends
● he result of a response to abnormally high estrogen and progesterone levels in women
● affects approximately 3% to 7% of menstruating women

XIII. SUICIDE
● intentional act of killing oneself
● associated with thwarted/ unfulfilled needs, feelings of hopelessness and helplessness
● ambivalent conflicts between survival and unbearable stress
● narrowing of perceived options and need to escape
● Suicidal Ideation – thoughts about wanting to die
● Suicidal Intent – thoughts about a concrete plan to commit suicide
● Suicidal Threat – expression of a person’s desire to end his/her life
● Attempted Suicide – self-destructive behavior, an act that either failed or was incomplete
● Complete Suicide – self-destructive behavior that resulted to death
● Common Expressions of a Suicidal Patient:
✔ Cry for help
6 | Mood Disorders – Prof. Borlado
 ✔ Form of escape
✔ Heroic act
✔ Manipulation
✔ Relief of Pain
✔ Retaliation
✔ Reunion wish or fantasy

● Etiology:
a. Genetic and Biological
o close relationship- greater risk (twins, families)
o neurochemical changes (serotonin)

b. Sociological
o Egoistic suicide
o Altruistic suicide
o Anomic suicide
c. Psychological
o Theory of Self
o Interpersonal-Psychological Theory
o Theory of Parasuicidal Behavior
- Trichotillomania (TTM)
- Dermatillomania

● Alexithymia - “having no word for emotions”

● Euthanasia (health care provider’s deliberate act to cause a client’s death) and Physician-Assisted
Suicide (PAS)
● Population at Risk:
✔ Single
✔ Men
✔ young women
✔ Whites
✔ separated or divorced
✔ older adults more than 65 years old, 15 to 24 years old
✔ psychiatric disorders( depression, bipolar disorder, schiz, substance abuse, ptsd, borderline
personality)
✔ chronic medical illnesses
✔ critical life events
✔ family history of depression
✔ unstable lifestyle

● Diagnostic Tools:

Beck Hoplessness Scale assess clients level of optimism and pessimism

Suicidal Ideation Questionnaire (SIQ) used to screen for suicidal ideation in adolescents age 13 to 18
years

Multiple Attitude Suicide Tendency ● a 30-item measure assessing risk for suicidal behavior
Scale for Adolescents (MAST) that evolves as a result of a basic conflict among
attitudes toward life and death

7 | Mood Disorders – Prof. Borlado

 ● Four (4) sets of attitude:
- attraction toward life
- repulsion by life
- attraction to death
- repulsion by death

SAD PERSONS S – sex

A – age
D – depression
P – previous attempts
E – excessive alcohol/drug use
R – rational thinking loss
S – social support lacking (separated, divorced, widowed)
O – organized plan
N – no spouse
S – sickness

● Nursing Diagnosis
a. Risk for Injury
b. Risk for Suicide

● Treatment: ANTIDEPRESSANTS – 2 to 4 weeks

● Nursing Interventions:
a. Execute a no suicide contract
b. Ask direct questions
c. Use of seclusion and restraints
d. Be alert for cues → 80% give clues
o Behavioral cues:
- Depression to gaiety- lifted
- Continuous early morning awakening (3 to 7 am)
- Talking directly and indirectly about suicide (leaving, gone)
- Previous suicidal attempts
- Giving away personal possessions of unusual value-taking out an insurance
policy, giving jewelry
- Asking questions regarding lethal doses of substances or drugs, drug or alcohol
abuse
- Small pupil, glassy look and vacant stare
- Rehearsing suicide or seriously discussing specific suicide method
- Writing forlorn love notes

8 | Mood Disorders – Prof. Borlado

 - Drug or alcohol abuse

o Situational cues: unexpected death of loved one, divorce, job failure, malignant
diagnosis
e. Provide safe environment
f. Encourage to ventilate feelings and thoughts
g. Assume a non judgmental, caring attitude-stress the person’s life is important to you and to
others
h. Keep active in daily activities- assign simple tasks
i. Don’t promise confidentiality
j. Make patient realize that the tendency to commit suicide is due to a disturbance in the brain
chemistry that is treatable- temporary condition
k. Provide structured schedule and involve in activities with others to self worth and divert
attention
l. Provide an unconditional positive regard
m. Administer medications and monitor client’s responses
n. Conduct suicide lethality assessment (plan of death- method, time, place)
o. Create a support system list

● SOS (Suicide Prevention Program)

✔ a school-based prevention program that has significantly reduced self-reported suicide attempts
among high-school students in high-risk settings
o A – acknowledge
o C – care
o T – tell
● Postvention
✔ therapeutic program for bereaved survivors of a suicide
✔ begins within 24 hours of suicide and ends on the 1st anniversary of suicide

● ALWAYS REMEMBER:
a. Suicidal person wants to die only during the period of suicidal crisis- during this time the person
is ambivalent about living and dying
b. Suicidal people give warning
c. Persons recovering from depression are high risk for suicide from 9-15 months after recovery
d. Suicidal people are extremely unhappy but not always mentally ill.

9 | Mood Disorders – Prof. Borlado