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50 Cards in this Set

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Incidence of mood disorders
Depression is the __ leading cause of disability in the US.
Depression is the 4th leading cause of disability in the US (by 2020 is expected to be the 2nd)
4 common theories of depression
1) Biological
2) Psychodynamic Influences & Life Events
3) Cognitive
4) Learned helplessness
Psychodynamic Influences theory
Life events may influence the development and recurrence of depression through the psychological and biological experience of stress in some people, which results in changes in the connections among nerve cells in the brain.
Hopelessness Theory
perception by that person of negativity -> if negative thoughts continue over and over again they set up that cycle in the brain and it changes the neurotransmitters -> this is why it is important to treat the cognitive part in addition to medication or the pathway will not change.
Learned Helplessness
anxiety leads to depression if the person feels that they have no control over the outcome of a situation
Beck's Cognitive triad (theory of depression)
3 automatic negative thoughts are responsible for the development of depression
1) Negative self view
2) Pessimistic world view
3) Belief that negative reinforcement will continue in the future.
*this triad seems to exist in all types of depression.
automatic negative thoughts
thoughts that are repetitive, unintended, and not readily controllable
Biologic Theories of Depression
- 2 primary neurotransmitters involved
- Associated neuroendocrine
- Genetic predisposition
- Serotonin & Norepinephrine
(others: dopamine, GABA)
-Neuroendocrine: Adrenal (cortisol), Thyroid
-Circadian Rhythms - Assoc. w/ sleep disturbances (initial, middle, late)
Biologic theories of Bipolar
-Primary Neurotransmitters:
-Assoc. neuroendocrine:
-Significant high genetic links
- Primary neuro: NE, dopamine, 5HT, **combinations
-neuroendocrine: Thyroid
Kindling
repetitive stimulation -> seizure

irritated neuron causes action potential, spreads more and more. Similar to chemical seizure in the brain. Need to stop as soon as you can so it does not become worse.
Example of associated combinations of Bipolar disorder

increased NE, w/ low levels of 5HT
high levels of NE and low leves of 5HT, (they usually follow each other, but in this they are not). You would not want to give Prozac for this reason b/c they would become manic b/c the NE levels are already high.
Euthymia
all the levels of emotion within the normal levels – highs and low – (green line in center - on mood disorder comparison graph)
Features of Major Depressive Episode


most serious consequence:
- often follows a phychosocial stressor - marital, academic, occupational problem
- somatic complaints
- tearfullness, anxiety, phobias
-most serious consequence: suicide
Common Key Findings of Major Depressive Episode
-Depressed mood and anhedonia are the key findings.
- 97% have anergia
• Depressed mood - usually all day
• Anhedonia (unable to experience pleasure)
• Anxiety – seen in 60-90%
• Psychomotor changes – brain is slow so person is slow
• Somatic Symptoms – physical hurts – muscle pain, aches, HA
• Vegetative signs – have to do to sustain life
o Eating – will see weight loss
o Sleeping – more sleeping then ususal
o Elimination – peristalsis is slow, constipation, also lack of hydration effects, also at risk for UTI
o Sex – loss of sex drive
Criteria for Major depressive episode


(dont need to memorize criteria just be able to distinguish from from each type of mood disorder)
5 or more present during the same 2 week period, one of which is either
1) depressed mood
2) loss of pleaure
other criteria
-significan wt gain or loss
-insomnia or hypersomnia
-psychomotor agitation or retardation
-fatigue or loss of energy
-feelings of worthlessness or excessive guilt
-diminished ability to think or concentrate
-recurrent thoughts of death or suicide, attempt, or plan
Course of a major depressive episode
-prodromal symptoms may include anxiety and mild depressive symptoms
- majority return to premorbid level of functioning
-20-30% may have symptoms that never reach full criteria, persist for months to years and my be assoc w/ some disability or distress
Dysthymic Disorder
-criteria:
-% of pop
-Onset:
-High co-morbidity w/:
-criteria: at least 2 years of depressed mood (children/teens 1 yr); never more then 2mon w/o symptoms. (if symptoms interupted by MDD would not be diagnosed w/ dysthymic disorder)
-*significant distress in functional areas, but still able to function
- 2 or more: inc. or dec appetite, insomnia, hypersomnia, fatigue, dec self esteem, hopelessness/ despair, dec. concentration/ decision making ability.
- 3-5% of pop (more common in men)
-high comorbidity w/: anxiety disorders
-Onset: childhood or late adolescence
Therapeutic Management of Mood disorders - in order of priority
1) Suicide assessment (depressed is the highest pop most likely commit suicide
2) Assess risk to others
3) History of current episode - mood and cognitive changes, behavior and physical changes
4) Physical examination and health history
5) focused history assessment
6) Support and coping
How to assess the hisotory of current of episode for the patient with mood distorders.
- questions to ask r/t mood and cognitive changes
- questions to ask r/t behavior and physical changes
- Mood and Cognitive Changes – moods that were high and low, how long?, difficulty concentrating, does this seem odd to you?
- Behavior and physical changes – have other people noticec changes,
o Ask the opposites of the mood or behavior – if they have felt low on energy have they ever had moments of high energy.
Common changes with depression:
-COGNITIVE
-MOOD/ AFFECT
-BEHAVIORAL
-PHYSIOLOGICAL
-COGNITIVE: loss of interest, poor communication, self-doubt/ blame, pessimism, ambivalence, suicidal thoughts.
-MOOD/ AFFECT: apathetic, anxious, angry, despondent, isolative, powerless, overwhelmed
-BEHAVIORAL: sluggish & slow, lack of spontaneity, poor hygiene, poverty of speech, withdrawl,
-PHYSIOLOGICAL: excessive sleeping, GI upset, changes in appetite, wt. loss/ gain, somatic complaints (HA, backache, etc)
Mental status findings w/ Depression
Appearance:
Behavior:
Mood & Affect:
Intellectual Performance:
Thought process & content:
Appearance: flat
Behavior: sad, angry
Intellectual: slow, cant concentrate
Thought: negative thinking pessimistic
Bipolar Disorder - difference btwn Type 1 and Type 2
Type 1: history of depressive disorder AND at least one manic or mixed episode.

Type 2: history of depressive episode AND at least one HYPOmanic episode.
(*manic or mixed had never occurred)
Bipolar disorder
-% of population:
-onset for men and women:
-% that attempts suicide and type of episode during attempt.
-1% type 1; .5% type 2
-men and women affected equally, men 1st episode usually manic, women - depressed.
-Divorced, single, non college graduates
-20% attempt suicide (1/3 are depressed episode, 2/3 are in a mixed episode, 0 in a manic episode)
Bipolar prognosis of recurrent episode
40-50% have recurrent episode w/in 2 years, 90% have >1 episode, 40% have > 10 episodes

7% no recurrence of symptoms
50-60% good control of symptoms
40% have chronic symptoms w/ decline in level of functioning
Criteria of a Manic episode
criteria
Associated features of a Manic episode
Associated features of Manic episode
Course of manic episode
Course of manic episode
Associated features of hypomanic episode.
Features of Hypomanic episode
Course of hypomanic episode
Course of Hypomanic episode
Mixed episode
- Criteria:
- Features:
- Course
Criteria: 1) Criteria are met for both manic and major depressive episodes (except for duration). 2) Severe enough to cause impairment or necessitate hospitalization to prevent harm, or there are psychotic features.

Features:
- rapid alternating moods - manic to major depressive
- frequently presents w/ agitation, insomnia, change in appetite, suicidal thoughts, psychotic features

Of the bipolars these are the most at most risk for suicide and harm to others.

Course:
-Can evolve from manic or major depressive or on its own.
- may last wks to several months
- may remit w/ few or no symptoms or evolve into a major depressive episode
-Uncommon to evolve into a manic episode.
Cyclothymic Disorder (Cyclothymia)
.5% of population, begins in adolescence or early adult, = occurrence in men & women, 15-50% risk of developing a bipolar DO

at least 2 years of fluctuating mood disturbance involving numerous periods of hypomanic symptoms and depressive symptoms
Management of Bipolar in order of priority
1) Suicide Assessment
2) Assess for risk to others
3) Mental status safety screening - Impaired attn and judgment puts them at risk.
4) History of current episode
- mood and cognitive changes
- behavior and physical changes
5) Physical examination and health history.
6) Focused history assessment
7) Support and coping
Rapid cycling
is different from mixed episode – has at least 4 episodes in 12 months and will most likely respond to ECT.
Common Changes with Mania

COGNITIVE
MOOD/ AFFECT
BEHAVIOR
PHYSIOLOGICAL
-COGNITIVE: easily distracted, grandiosity, FOI, lack of judgement, denial of danger, psychosis.
-MOOD/ AFFECT: confident, euphoric, extroverted, intolerant, irritable, suspicious
-BEHAVIORAL: impulsive, intrusive, hyperactive, aggressive, argumentative, uninhibited, poor hygiene
-PHYSIOLOGICAL: lack of need for sleep, dehydration, poor nutrition, weight loss.
Mental status findings for mania
-Appearance
-Behavior
-Mood/ Affect
-Intellectual performance
-thought process and content
- Appearance – neglect appearance, odd appearance – change clothes, make up to extremes, dye hair frequently
- Behavior- nonstop physical activity -> physical exhaustion -> medical emergency
- Mood and Affect - **lability, lability, lability is key!
- Intellectual Performance – FOI, lack of concentration, loss of time, impulsive, not much in sight in middle of episode, suicidal thoughts, gradiouse delusions
-Thought process - FOI -> clang associations
Length of time for phases of treatment for mood disorders.
Acute & Sub-acute
Continuation
Maintenance

Goals of treatment:
A & S: 6 -12 weeks - will have a better outcome if able to stop progression
Cont: 4-9 months
Main.: 1 and/or + yrs

Goal: stabilize, limit severity, limit duration, prevent relapse
Physiolgoical (self-care) needs for patient with mania.
- Nutrition and Fluid inake - ignore body sensations - can have lethal dehydrations.
- Elimination: Constipation b/c not paying attn to body sensation. At risk for UTI.
- Sleep/ rest and exercise
- Hygiene: cant pay attention long enough to take care of themselves. May get 1/2 dressed.
After safety what is the most important need for the patient with mania?
Hydration
Depressive and Bipolar disorders have similar nursing diagnosis but the r/t is often different. In bipolar the r/t is often associated with?
Being distracted.
Pharm treatment for
- Depressive Disorders
- Bipolar Disorders
DD: SSRI's, TCA's (can cause heart problmes), MAOI's (HT from tyrmine), atypicals, adjunct
Bipolar: Lithium, Antiepileptic, Anticonvulsants, Adunct
# that indicates toxic Lithium levels
1.5

When Na is displaced, lithium takes its place, and the kidneys go to waste.
Communication strategies for the Depressed patient.
Depressed – take it slow, observe what is going to try and keep them in reality, keep it simple and concrete.
Make observations
Allow time to answer – wait, allow silence. *LISTEN. Avoid platitudes like, “everything is going to be okay”. Don’t be bubbly.
Communication strategies for the manic patient.
Manic – be firm and calm, they need outside control. Short, consise b/c short attn span. Need limits b/c may be volatile. Explain that this is to help them have some control outside of themselves. Be consistent b/c some will manipulate the situation to get what they want. Be firm and redirecting to help w/ lack of ability to maintaion attn.
Therapeutic relationship must offer the patient 3 things?
Empathy
Honesty
HOPE
Facilitating expression involves
-Therapeutic alliance/ relatioship
-Active Listening
-Open-ended, facilitative techniques
-Validation
-Clarification
Facilitating self-esteem
Decrease in self-esteem r/t feelings of powerlessness, worthlessness, helplessness or hopelessness

Needs of patient?
Significance and competence
Electroconvulsive Therapy (ECT)
- Indications:
induction of a generalized seizure

Indications: radid need, extreme agitation or stupor, risk of other Rx outweigh the risk of ECT; history of poor medication response, +ECT response (or both)
Client populations that receive ECT
MDD
BPAD
Manic (lith. resistant)
Rapid Cycler
psychotic illness
Adverse effects of ECT
-confusion and delirium
-memory impairment
-mild transient cardiac arrhythmias
-mortality .002% per treatment; .01 per patient
Therapeutic management tools
-Group & Family interventions
group theapy
psychoeducational groups
health teaching
support groups and organizations
- Phototherapy - exposure to artificial light.
- Vagus nerve stimulator- implant
- Exercise (depression)