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also called affective disorders are pervasive alterations in emotion that sre msnifested by depression, mania, or both. they inerfere with a person's life affecting their sel-esteem, occupation, and relationships
mood disorders
what are the primary mood disorders
major depressive disorders and bipolar disorder(formerly called manica-depressive illness) mood disorders affect people irrespective of their ethnicity social status intellect, occupation or age
genetic influence
twin study-if an identical twin developed a major depressive siorder,the other twin had a 70% chance of developing the disorder.
-depression is 2-3 times more common in first degreee relatives with the disorder
-recently a gene was discovered that lies along chromosone 18 which seems to create a pre-disposition for bipolar disorder
-it is believed that genetic, psychosocial and other environmental forces are operating to influence the development and course of mood disorders.
biochemical influence
monoamine neurotransmitters (norepinephrine and serotonin) have shown to be mood regulators

-it is believed that there is a link between seizure thresholds(which are influenced by norepinephrine) and the cycling of mood disorders. This is the rational for using anticonvulsants to treating bipolar disorders.
biophysical influence
the hypothalmic-pituitary-adrenal axis that controls the release of cortisol doesnt appear to function correctly in depression
-50% of patients with depression fail to suppress cortisol levels in a dexamethasone suppression test.
psychosocial and environmental influences:

-identifies the cause of depression as beginning in childhood when a person suffers the real or percieved loss of a valid object if the child does not give appropriately, depression develops.
inrerpersonal theory
-focuses on unexpressed and unconscious rage as a reaction to being helpless or dependant on others or to a loss of loved one. The unexpressed anger is turned inward producing feelings of depression.
psychoanalytic theory
focuses on learned helplessness as an antecedent to depression. a lifetime of experiences has taught them they are powerless to influence their suffering and gratification.
behavior theory
states that clients experience depression because of error in thinking and unrealistic attidues about themselves and the world. these cognitive errors involve undervaaluing oneself, having a negative view of ones ability to achieve goals and being pessimistic resulting in low self-esteem and the inability to experience pleasure.
cognitive theory
what do all these theories agree on?
that psychologic strssors and interpersonal events are triggers for mood disorders.
types of mood disorders:

22% of women and 16% of men experience this episode. Risk increases with age in women and decreases in age with mean, with the usual onset in early adulthood(40), highest incidence occurs in those who are single or divorced. 50% will have 1-2 of these episodes. nearly 15% of patients with this untreated commit suicide, most have sought help from MD within one month of death. 9% of patients experience psychotic features.also called unipolar depression
major depressive disorder
if it occurs after child birth it is called?
postpartum depression
if it occurs without any relationship to external events it is called?
endogenous depression
if it occurs from a lifetime event it is called?
exogenous depression
this is a depressive disorder believed to be triggered by decreased amount of sunlight in winter months
SAD (seasonal affective disorder)
DSM-IV diagnostice criteria:
over 2 weeks, the client has experienced a change from previous functioning with depressed mood or decreased interest or pleasure with at least four of the following:
significant weightloss or marked change in appetite
-hypersomnia or insomnia
-psychomotor agitation or retardation
-fatigue
-feelings of worthlessness or guilt
-difficulty concentrating or indecisiveness
-recurrent thought of death, with or without suicidal ideations
-symptoms cause significant distress or impair functioning
-symptomsd are not caused by a substance or medical condition.
nursing assessment:

general appearance-
sad posture slouched with head down and minimal eye contatct
-psychomotor retardation with latency of response(may take up to 30 seconds to respond)
-psychomotor agitation(pacing, racing thoughts, agrumentativness)
mood and affect
describe themselves as hopeless helpless down or anxious
-experience anhedonia(losing sense of pleasure)
-may be frustrated angry at self or others
-affect is sad, depressed, flat or tearful, may sit alone stare into space
-interact minimally
-withdraw from stimulation (often remaining in bed or chair all day)
thought process and content
experience slow thinking may not respond verbally to questions
-tend to be negative and pesimistic, believing they will always feel this bad
-make self-deprecating remarks criticize self anf have thoughts of dying or suicider
-tend to ruminate
-if depression is severe and they experience psychosis they may have delusions that are responsible for all the tragedies in the world.
judgement and insight
impaired judgment because they dont use cognitive abilities to solve problems this may be realted to their extreme apathy or belif that is "doesnt matter anyway"
-lack of insight into their behavior feelings and illness may be more intact if they have experienced depression previously
-lack of judgemnet and insight often lead to substance abuse.
role and relationship
difficulty fulfilling roles and responsibilities
-often avoids family and social relationships because they feel overwhelmed experience no pleasure from interactions or feel unworthy
-these changes lead to greater feelings of worthlessness
physiologic and self care considerations
lose weight
-usually c/o insomnia
-lose interest in sexual activities
-neglect personal hygiene
-may become constipated dehydrated
nursing considerations
may take several short periods to complete an assessment it is important not to rush clients this is a time to begin developing a trusting relationship. demonstrate empathy. it is also important to determine any hidtory of depression treatment and response to previous treatment.you asses the patients reception by asking them when symptoms started what was happening when they began their duration and what the patient has tried to do about them. Family history or mood disorders suicide or attempted suicide is significant.
depression in children
symptomes includedifficulties with schoolwork lack of enthusiasm and energy social withdrawal impulsive angry outburt. other signs of anxiety and hyperactivity.
depression in the elderly
symptoms include confusion memory loss and agitation, often mistaken for demtia(pseudodementia)
cultural considerations
manifestations of depression vary among cultures and are more apparent in cultures that avoid verbalizing emotions. Asians who are depressed are more likely to have somatic complaints of headache or backache. Latin cultures complain of nerves or headche. middle eastern cultures complain of heart problems.
treatment
researchers believe that levels of neurotransmitters especially norepinephrine and serotonin are decreased in depression usually presynaptic neurons release these neurotransmitters to allow them to enter synapses and bind with postsynaptic receptors
depression results if?
too few neurotransmitters are released.
-they linger to briefly in synapses
-the releasing presynaptic neurons reabrob them too quickly
-condition in synapses do not support linkage with postsynaptic receptors
-number of postsynaptic receptors has decreased
what is the goal of pharmocologic treatment?
to increase the effeciancy of available neurotransmitters and the absorption by postsynaptic receptors
what do anti depressants do?
they establish a blockage for the reuptake of norepinephrine and serotonin into their specific nerver terminals. This permits them to linger longer in synapses and to be more available to postsynaptic receptors.
-they also increase the sensitivity of the postsynaptic receptors
what are the major categories of antidepresents?
SSRI, SNRI, Tricyclic, and MAOI
what is the selsction of antidepressants based on?
they are based on symptoms physical conditions drugs that have or have not worked in the past for patient or blood relative and other medications the patient is taking.
-it takes a minimum of 2-6 weeks for effects of therapy to become fully evident.
-research indicates that people with depression who recieve 18-24 months of antidepressant therapy have fewer relapses.
-they are usually tapered rather than abruptly discontinued.
-if the patient is experiencing psychotic features an anti-psychotic maybe added to the treatment plan. May be withdrawn when psychotic symptoms no longerexist.
used to treat depression in patient who do not respond to antidepressants or those who experience intolerable side effects to drug therapy. It is occassionally used for patients who are actively suicidal and waiting for medication to become effective
electroconvulsive therapy ECT
a combination of psychotherapy and medication is considered the most effective treatment for depressive disorders
psychotherapy
what are the goals of psychotherapy?
symptom remission
-psychosocial restoration
-prevention of relapse
-reduced secondary consequences such as marital discord or occupational difficulties
-increasing treatment compliance
focuses on difficulty in relationships such as greif reactions role disputes and role transitions
ex. person who as a child never learned how to make and trust friend outside of their family.
interpersonal therapy
seeks to increase the frequency of the patients psitively reinforce interaction with environment and to decrease negative interactions. also may focus on improving social skills
behavioral therapy
focuses on how the person thinks about themselves others and the future and interprets his/her experiences. this model focuses on the patients distorted thinking that in turn influences feelings, behavior and functional abilities
cognitive therapy
patient outcomes:
the patient will-
not injure self
-independently carry out ADLs
-establish a balance of adequate nutrition nutrition, hydration and elimination
-establish a balance of rest sleep and activity.
-evaluate self-attributes realistically
-socialize with peers staff family and friends
-comply with medication regimen
-verbalize symptoms of reoccurence
-return to school or work activities
nursing interventions
provide for physical needs
-plan activities during increased energy periods
-assume an active role in initiating communication
-share your observations with patient
-if psychomotor retardation allow reaction time
-dont act overly cheerful but join in his/her humor and point out value of humor
-encourage to discuss and journal feelings
-provide structure routine encourage socialization
-support basic hygiene and positive grooming
-teach patient about medications this is important to prevent relapse
-hellp patient recognize distorted perceptions and link them to his dpression
-encourage practicing positive statements
-recognize suicide potential
a depressed or irrittable mood for most of the day occuring more days then not for at least 2 years (1 year in children and adolescents) the patient had had more than 2 months in which symptoms are not present and has not experienced a manic or depressive episode. considered a milder form of depression. often predates major depression by as much as 3 years. may behave in behaviors to generate excitement such as gambling criminal behavior intensify work substance abuse over eating or promiscuity. Symptoms are similar to depression only milder however they are chronic.
dysthymia
subjective emotions and affect that are a normal response to the experience of loss
greif
outward expression of greif
mourning
this is one of the most difficult and challenging processes of human existence
greiving
examples of losses related to specific human needs (Maslow)
physiologic loss(air exchange)
safety loss(domestic violence)
loss of security and a sense of belonging(divorce)
loss of self-esteem(role function)
loss related to self-actualization(loss of job/miscarriage)
the grieving process:

stge one-
denial
includes denial shock disbelief
ex. i didnt understand what the doctor was even saying
denial is a defense mechanism that is protecttive
stage 2-
anger
ex. its just not fair ,
anger is often directed toward health care members
depression, longing for a loved one, pprotesting the permanence of the loss, obsessive reviewing of the loss(discourage)
guilt
lack of concentration
sleep disturbances
appetite changes, fatigue, general discomfort
step 3-
bargaining(privately with God seeking in vain for a way out
cognitive disorganization, difficulty functioning, confiding in others to emote to cognitively restructure the loss, adapting to the loss, wide variances in emotion and behavior
ex. i cant seem to go to the grocery store and come back wwith what i need, i thought by now i would be over it.
stage 4-
depression
apathetic to the loss, loss of will to try to change things, signs of depression and possibly a lack of desire to live. ex. i dont care anymore
stage 5-
acceptance
cognitive reorganization, reintergrating sense of self, healing, intergrating the loss, acute anguish dissipated
ex. changes checks to include only his/her name, looks back on the loss as a time of personal growth, reaches out to others who grieve.
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