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Mood Disorders and Suicidal Behavior
Topic Started: Thu 09 Jul 2009 07:37:00 (360 Views)
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Mood Disorders and Suicidal Behavior
Mood Disorder: disturbances in feelings, thinking and behavior that tend to occur on a continuum, ranging from severe depression to severe mania.

Depression: an emotional state characterized by sadness, discouragement, guilt, decreased self-esteem and feelings of helplessness or hopelessness.

Mania: an emotional state characterized by elation, high optimism, increased energy and an exaggerated sense of importance and inavilability.

Unipolar Depression: mood disturbance with only depression but no occurrence of mania.

Bipolar Disorder: mood disturbance in which the symptoms of mania have occurred at least one time; an episode of depression may or may not have occurred.

Grief: a normal response to a loss(death, divorcé, illness or hospitalization, job loss or loss o0f personal possessions)
a) acute grieving- may occur up to 3 mos. After a significant loss.
b) grief resolution-characterized by the grieving person’s ability to remember comfortably and realistically both the pleasures and disappointments associated with lo0ss.- may take up to 3 years.
c) maladaptive grief response- can lead to a mood disorder, the response may be delayed, inhibited, prolonged or exaggerated.
d) loss of self-esteem in the grieving person is not characteristic of normal grieving and may indicate a mood disorder.

Types of Mood Disorders
A. Major Depressive Disorder
- characterized by at least 2 weeks of a depressed mood or loss of interest in pleasure and activities
-includes at least 4 of the following symptoms of depression:
a) increase or decrease in appetite
b) increase or decrease in sleep
c)psychomotor agitation or retardation
d) fatigue and loss of energy
e)decreased ability to think to concentrate
f) recurrent thoughts of suicide
-impairment in social and occupational functioning.

Subtypes of Major Depressive Disorders
1) Melancholic features
-anhedonia or lack of mood reactivity to usually pleasurable activities.
-waking early in the morning, feeling worsen the morning and excessive guilt.
2) Atypical features (assortment of symptoms)
-exhibits mood reactivity (ability to respond to positive environmental stimuli)
-increase levels of anxiety
-changes in appetite and sleep
-increased sensitivity to interpersonal rejection
3) Psychotic features
-depression is accompanied by delusions and hallucinations
4) Postpartum onset
-symptoms occur within 4 weeks of delivery
-affects 1 in 10 new mothers
-symptoms similar to a major depressive episode and psychotic features may also be present.
5) SAD ( Seasonal Affective Disorder)
-seasonal pattern specifies
-occur during one season of the year, usually winter (when daylight hours are shorter) and remit when the season is over
-symptoms: hypersomnia
Overeating of CHO craving
Weight gain
-treatment: Sunlight exposure
B) Dysrthymia
-characterized by a chronically depressed mood occurring most of the day, more days than not, for at least a 2 year period during periods of depressed mood, at least 2 or more of the other symptoms of depression must be present.
-usually does not affect social or occupational functioning.
C) Bipolar Disorder
1) Bipolar 1 Disorder
- manic depressive disorder(1 or more manic or mixed episodes accompanied by a major depressive episode)
-symptoms of manic episodes:
a) flight ideas
b) inflated self-esteem or grandiosity
c)distractibility
d) decreased need for sleep
e) increased or pressured speech
f) increased involvement in goal-directed activities
g) excessive involvement in pleasurable activities that have a high potential for painful consequences
-charging expensive items on a credit card that is already at max limit
-sleeping with multiple partners without regard to safe sex practices
2) Bipolar 11 Disorder
-characterized by one or more major depressive episodes accompanied by at least one hypomanic episode
-hypomanic episode- at least 3 or more of the symptoms of mania are present (elation, high optimism, increased energy, exaggerated sense of importance, invincibility, inability to sleep)
See illustration
D) Cyclothymiacs
-characterized by at least 2 years of several periods of hypomania symptoms not as severe as those in a manic episodes.
E) Pseudo dementia
-disorder associated with depression in elderly client
-depression is similar to symptoms associated with cognitive impairment disorder.

Depression in the Elderly Client with a Cognitive Impairment Disorder
• onset: gradual(weeks to months) obvious symptoms apparent at least 2 weeks
• initial symptoms: depressed mood, lack of interest in usual activities
• continuing symptoms: memory loss, poor concentration, helplessness, hopelessness, sleep problems, loss of appetite, weight loss
*physical symptoms: headache, muscle aches, G I symptoms
-self neglect, poor hygiene, thought of suicide
*treatment: same with treatment of dementia

Etiology of Mood Disorders
-unknown
-Implicating Factors:
a) Genetic Predisposition
*MOD- 3 tomes more common among 1st degree biological relative
-higher incidence in monozygotic twins
-defective gene on chromosome 4
-26 times more likely to be hospitalized for severe depression and suicide attempt, ongoing research in chromosome 11, 18, 21.
* Bipolar Disorder-risk increased 4-24% in first degree relatives of people with bipolar disorder
- Monozygotic twins indicate a 65% concordance rate.
b) Neurotransmission Dysregulation
* Biogenic Amine Theory
-decrease norepinephrine, decreased serotonin in depressive disorder but increased in Bipolar Disorder
* Kindling Theory
-external environmental stressor activate internal; psychological stress responses which trigger the first episode of a mood disorder.
-thus, the first episode creates electrophysiological sensitivity to future episodes so that less stress is required to evoke another r episode
c) Neuroendocrine Dyrregulation
-increased cortisol level
-resistance of cortisol to suppression by dexamethasone
-blunted adrenocorticotropin hormone response
-elevated corticotrophin-releasing factor in CSF
-subclinical hypothyroidism-more in women
-Circadian Rhythm changes
-abnormal sleep EEG activity mood disorder
d) Medication use and Medical Conditions
* Depression: hormones ( oral contraceptives, glucocorticoids)
- CVD Drugs ( beta-blockers, Ca channel blockers, thiazide
diuretics, digitalis preparations)
- Psychotropic Drugs- benzodiazepines, neurolepitics
-Anti-inflammatory and anti-infective Drugs (NSAIDS, anti-
TB,sulfonamides)
-Anti-ulcers-cimitidine, ranitidine
*Clinically significant Depressive Symptoms: 36%
.CVA .Cancer
.Dementia .AIDS
.DM .Chronic Fatigue syndrome
.CAD
e) Psychosocial and Environmental Factors
* Objective loss-psychoanalytical theory
-depression is a result of inward directed anger and aggression
over a significant loss.
*Beck’s Theory- depression is a problem of cognitive patterns that have developed in an individual over time.
-negative view of self, the world, the future
-views self as unattractive and incompetent, views the
outward environment as demanding and unyielding and the future as hopeless.
*Environmental Factors:
a) Loss of family members, lack of social support system, health problems-> mood disorder
b) Sleep deprivation -> manic episode

Management of Mood Disorders
1) Hospital Based Acute Psychiatric Care
-severe Mood Disorder
-dangerous self-harm and harm others.
-suicidal behavior
-supportive psychotherapy and milieu management
-Cognitive-behavioral therapy
-antidepressant, neuroliptic, mood stabilizer agents
-ECT- severe depression that is unresponsive to antidepressant
2) Community- based Treatment Case Finding
-adequate exercise and rest
-stress management
-use of supportive system
-good nutrition
-verbalizing feelings
-assertive training program
3) Crisis Intervention- suicidal
4) Medication Management
-antidepressants, antipsychotics, mood stabilizers
-ultraviolet light therapy-> SAD
5) Cognitive –behavior Therapy
-psychotherapy approach
-identifying and challenging the accuracy of the clients negative cognitions, reinforcing more accurate perceptions and encouraging behaviors that are designed to counteract the depressive symptoms.

* Xerox-Selected medication for treating Mood Disorders

Nursing Management of the Client with a Mood Disorder

A) Assessment
-Include assessment of suicidal risk factors
Sex-more men than women
Age –adolescents/ older than age 50
Depression

Previous attempts
Ethanol/ Alcohol abuse
Rational thinking-impair judgments, psychotic thought
Social Support-lack
Organized plan
No spouse-unmarried, divorced, widowed, separated

Sickness-chronic, debilitating, cancer
Symptoms-sleep disturbance,depression,hopelessness
Communication-lack
Acute vs Chronic aspects-increased sudden onset
Reaction of significant others-defensive, rejecting
Stress
B) Nursing Diagnosis
Anxiety
Chronic Low Self-esteem
Deficient Knowledge
Disturbed sleep pattern
Disturbed thought process
Dysfunctional grieving
Hopelessness
Imbalance Nutrition; less
Ineffective coping
Ineffective sexuality patterns
Interrupted family process
Powerlessness
Risk for self directed or other directed violence
Social Isolation
Spiritual Distress
C) planning and Outcome Identification
-set realistic goals
-desired outcome-client and family
D) Implementation
1) Depressive Disorders
-accept client, do not criticize
-adequate nutrition-food preference
-avoid excessive cheerfulness, sympathy and superficiality
-adequate activity and rest
-sleep with bedtime relaxation-quiet time, back rubs, music, guided imagery
-activities-art, music, dance therapy
-self-help/support groups
2) Bipolar Disorder
-high caloric food eaten on run, increase CHON
-reduce environmental stimuli-private room
-remove hazardous objects
-story with client when agitated or excited
-provide physical activity-floor polishing, bed making, making leaves
-set limits on manipulative behavior

3) Suicidal Behavior
-establish a supportive relationship
-question client directly about suicide, ask about specific plan
-remove dangerous and sharps
-no-suicide contract


Drug of Choice/ Mood Stabilizer/ Anti-manics
*Lithium Carbonate (Eskalith)
Lithium levels: 0.5-1.5 meq/l
1-1.5 (acute)
-monitor once/twice a week after the initial treatment then monthly if
levels have stabilized.
-blood drawn 12 hours after last dose

Toxicity symptoms
-blurred vision
-ataxia
-tinnitus
-nausea and vomiting
-severe diarrhea
-excessive output of diluted urine
-tremors
-impaired LOC
NSG. Considerations for Lithium
-maintain sodium intake
-6-8 glasses of water(2-3 liters per day)
-no caffeinated drinks (increase urine output)
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