MADE BY: ENRIQUEZ, REANNE S.
ATENEO DE ZAMBOANGA UNIVERSITY
Mood and Bipolar Disorders; Somatoform Disorders
Introduction
• Mood disorders, also called affective disorders,
are pervasive alterations in emotions that are
manifested by depression or mania or both.
• Drastic and long-term sadness, agitation, or
elation. Accompanying self-doubt, guilt, and
anger alter life activities, especially those that
involve self-esteem, occupation, and
relationships.
• Mood disorders are the most common
psychiatric diagnoses associated with suicide;
depression is one of the most important risk
factors
Categories of Mood disorders
• Major depressive disorder
• Bipolar disorder
MAJOR DEPRESSIVE DISORDER
• typically involves 2 weeks or more of a sad
mood or lack of interest in life activities
• least four other symptoms of depression:
o Anhedonia and changes in weight
o Sleep, energy, concentration
o Decision-making, self-esteem, and
goals
• Common in women and increases with age in
men; single and divorced people have high risk
Related Disorders
1. Persistent depressive (Dysthymic)
disorder—chronic, persistent mood disturbance
characterized by symptoms of:
- Insomnia
- Loss of appetite
- Decreased energy
- Low self-esteem
- Difficulty concentrating
- Feelings of sadness and hopelessness
2. Disruptive Mood Dysregulation disorder—
persistent angry or irritable mood, punctuated by
severe, recurrent temper outburst that are not in
keeping with provocation or situation, beginning
before age 10
3. Cyclothymic disorder—mild mood swings
between hypomania and depression without loss
of social or occupational functioning
4. Substance-induced depressive or bipolar
disorder—significant disturbance in mood that
is a direct physiological consequence of
BSN3-L
Ilah Reanne S. Enriquez
ingested substances such as alcohol, other
drugs, or toxins
5. Seasonal Affective disorder (SAD): often
treated with light therapy
a. Winter depression or fall-onset SAD—
increased sleep, appetite, and
carbohydrate cravings; weight gain;
interpersonal conflict; irritability and
heaviness in the extremities beginning in
late autumn and abating in spring and
summer
b. Spring-onset SAD—is less common, with
symptom of insomnia, weight loss, and
poor appetite lasting from late spring or
early summer until early fall
6. Postpartum or “maternity” blues—mild,
predictable mood disturbance occurring in the
first several days after delivery of a baby
- Symptoms are labile mood and affect; crying spells;
sadness; insomnia and anxiety
- Symptoms subside without treatment, but mothers
do benefit from the support and understanding of
friends and family
7. Seasonal affective disorder
a. Postpartum depression—common
complication of pregnancy with onset within
4 weeks of delivery
b. Postpartum psychosis—is severe and
debilitating psychiatric illness, with acute
onset in the days following childbirth;
Requires immediate treatment
i. Fatigue, sadness, emotional liability
ii. Poor memory, confusions and progress
to delusions, hallucinations, poor
insight, and judgement
iii. Loss of contact with reality
c. Premenstrual dysphoric disorder—
severe form of Premenstrual syndrome and
is defined as recurrent, moderate
psychological and physical symptoms that
occur during the week before menses and
resolving with menstruation.
i. Premenopausal women are affected
by affective and/or somatic symptoms
that can cause severe dysfunction in
social or occupational functioning
such as:
ii. Labile mood; irritability; increased
interpersonal conflict; difficulty
concentrating; feeling overwhelmed or
unable to cope and feelings of anxiety,
tension, or hopelessness
d. Non-suicidal self-injury—involves
deliberate, intentional cutting, burning,
Mood and Bipolar Disorders; Somatoform Disorders
scraping, hitting, or interference with wound
healing.
i. Some persons who engage in self-
injury (sometimes called self-
mutilation) report reasons of
alleviation of negative emotions, self-
punishment, seeking attention, or
escaping a situation or responsibility.
ii. Others report the influence of peers
or the need to “fit in” as contributing
factors
Onset and Clinic Course
• An untreated episode of depression can last
from a few weeks to months or even years,
though most episodes clear in about 6 months.
• Depressive symptoms can vary from mild to
severe.
• The degree of depression is comparable with
the person’s sense of helplessness and
hopelessness.
Etiology
A. Biologic Theories
1. Genetics
• Major depression:
o first-degree relatives who are at twice
the risk for developing depression
compared with general population
o For all mood disorder, identical twins
have higher chance of having the
disorder than fraternal twins
• Bipolar disorder:
o First-degree relatives of people with
bipolar disorder have a sevenfold risk
for developing bipolar disorder
o Indications of a genetic overlap
between early-onset bipolar disorder
and early-onset alcoholism
o People with both problems have a
higher rate of mixed and rapid cycling,
poorer response to lithium, slower rate
of recovery, and more hospital
admissions.
o Mania displayed by these clients
involves more agitation than elation;
clients may respond better to
anticonvulsants than to lithium
o victim” and his or her family
2. Neurochemical
o influences of neurotransmitters
(chemical messengers) focus on
serotonin and norepinephrine as the
two major biogenic amines implicated
in mood disorders.
Ilah Reanne S. Enriquez
o Serotonin has many roles in behavior:
mood, activity, aggressiveness and
irritability, cognition, pain, biorhythms,
and neuroendocrine processes
o Deficits of serotonin occur in people
with depression; reduced metabolism
in the prefrontal cortex, which may
promote depression.
o Norepinephrine levels may be
deficient in depression and increased
in mania. This catecholamine
energizes the body to mobilize during
stress and inhibits kindling
o Kindling is the process by which
seizure activity in a specific area of the
brain is initially stimulated by reaching
a threshold of the cumulative effects of
stress, low amounts of electric
impulses, or chemicals such as
cocaine that sensitize nerve cells and
pathways.
o It is theorized that kindling may
underlie the cycling of mood disorders
as well as addiction. Anticonvulsants
inhibit kindling; this may explain their
efficacy in the treatment of bipolar
disorder.
o Cholinergic drugs alter mood, sleep,
neuroendocrine function, and the
electroencephalographic pattern;
therefore, acetylcholine seems to be
implicated in depression and mania.
3. Neuroendocrine
• Mood disturbances have been documented
in people with endocrine disorders, such as
those of the thyroid, adrenal, parathyroid,
and pituitary glands.
• Postpartum hormone alterations precipitate
mood disorders such as postpartum
depression and psychosis.
• About 5% to 10% of people with depression
have thyroid dysfunction, notably an
elevated thyroid-stimulating hormone
B. Psychodynamic
• Many theories suggest the cause of mood
disorders is seemed to be “blaming the
• The self-depreciation of people with
depression becomes self-reproach and
“anger turned inward” related to either a
real or perceived loss. Feeling abandoned
by this loss, people are then angry while
both loving and hating the lost object.
Mood and Bipolar Disorders; Somatoform Disorders
• A person’s ego (or self) aspires to be ideal
(i.e., good and loving, superior or strong),
and that to be loved and worthy, must
achieve these high standards. Depression
results when, in reality, the person is not
able to achieve these ideals all the time.
• The state of depression is like a situation in
which the ego is a powerless, helpless child
who is victimized by the superego, much
like a powerful and sadistic parent who
takes delight in torturing the child.
• Most psychoanalytical theories of mania
view manic episodes as a “defense”
against underlying depression, with the ID
taking over the ego and acting as an
undisciplined hedonistic being (child).
• Children raised by rejecting or unloving
parents are prone to feelings of insecurity
and loneliness, making them susceptible to
depression and helplessness
• Early experiences shape distorted ways of
thinking about oneself, the world, and the
future; these distortions involve
magnification of negative events, traits, and
expectations and simultaneous
minimization of anything positive.
Treatment and Prognosis
1. Psychopharmacology
- Antidepressants: cyclic antidepressants, Monoamine
oxidase inhibitors (MAOIs), Selective serotonin
reuptake inhibitors (SSRIs), Atypical antidepressants
Antidepressants
- The choice of which antidepressant to use is based
on the client’s symptoms, age, and physical health
needs; drugs that have or have not worked in the
past or that have worked for a blood relative with
depression; and other medications that the client is
taking.
i. levels of neurotransmitters,
especially norepinephrine and
serotonin, are decreased in
depression; Usually, presynaptic
neurons release these
neurotransmitters to allow them to
enter synapses and link with
postsynaptic receptors
ii. The goal is to increase the efficacy of
available neurotransmitters and the
absorption by postsynaptic receptors.
- Patients who have depression with psychotic
features, an antipsychotic is used in combination
with an antidepressant
- The antipsychotic treats the psychotic feature;
several weeks into treatment, the client is
Ilah Reanne S. Enriquez
reassessed to determine whether the antipsychotic
can be withdrawn and the antidepressant
maintained
- Antidepressant therapy should continue for longer
than 3 to 6 months.
i. Fewer relapses occur in people with
depression who receive 18-24
months of antidepressant therapy
ii. The dosage of antidepressants
should be tapered before being
discontinued
Selective Serotonin Reuptake Inhibitors
(SSRIs)
- Most frequently prescribed category of
antidepressants, are effective for most clients.
- Their action is specific to serotonin reuptake
inhibition; these drugs produce few sedating,
anticholinergic, and cardiovascular side effects,
which make them safer for use in older adults due to
low side effects and relative safety
- Insomnia decreases in 3-4 days; appetite returns to
a more normal state in 5-7 days, and energy returns
in 4-7 days. In 7-10 days, mood, concentration, and
interest in life is improved.
Medications:
1. Fluoxetine (Prozac)—produces a
slightly higher rate of mild agitation and
weight loss but less somnolence. It has
a half-life of more than 7 days which
differs from 25-hour half-life of other
SSRIs.
2. Sertraline (Zoloft)
3. Paroxetine (Paxil)
4. Citalopram (Celexa)
5. Escitalopram (Lexapro)
6. Vortioxetine (Trintellix)
Cyclic Antidepressants
- Tricyclics, introduced for the treatment of depression
in the mid-1950s, are the oldest antidepressants.
- They relieve symptoms of hopelessness,
helplessness, anhedonia, inappropriate guilt,
suicidal ideation, and daily mood variations
- Other indications include panic disorder, obsessive–
compulsive disorder, and eating disorders
- Tricyclic (and also heterocyclic) antidepressants
have a lag period of 10 to 14 days before reaching a
serum level that begins to alter symptoms; they take
6 weeks to reach full effect.
- There is a lag period of 1 to 4 weeks before steady
plasma levels are reached and the client’s
symptoms begin to decreases. They cost less,
primarily because they have been around longer and
generic forms are available.
Mood and Bipolar Disorders; Somatoform Disorders
- Contraindicated in severe impairment of liver
function and in myocardial infarction; Cannot be
given with MAOIs due to their anticholinergic side
effects.
- Overdosage of tricyclic antidepressants occurs over
several days and results in confusion agitation,
hallucinations, hyperpyrexia, and increased reflex.
- Seizures, coma, and cardiovascular toxicity can
occur with ensuing tachycardia.
i. It is used less in geriatric population
Medications: Tricyclic antidepressants
1. Amitriptyline (Elavil)
2. Amoxapine (Asendin)—may cause
extrapyramidal symptoms, tardive
dyskinesia and neuroleptic malignant
syndrome.
3. Doxepin (Sinequan)
4. Imipramine (Tofranil)
5. Desipramine (Norpramin)
6. Nortriptyline (Pamelor)
7. Maprotiline (Ludiomil)—carries risk for
seizures, severe constipation, and
urinary retention etc. Drug is started and
withdrawn gradually
Atypical Antidepressants
- are used when the client has an inadequate
response to or side effects from SSRIs.
Medications:
1. Venlafaxine (Effexor) SNRI—blocks the
reuptake of serotonin, norepinephrine, and
dopamine (weakly),
2. Desvenlafaxine (Pristiq) SNRI
3. Duloxetine (Cybalta) SNRI—selectively
blocks both serotonin and norepinephrine.
4. Bupropion (Wellbutrin)—inhibits the
reuptake of norepinephrine, weakly inhibits
the reuptake of dopamine, and has no
effects on serotonin
5. Nefazodone (Serzone)—inhibits reuptake of
serotonin and norepinephrine and has few
side effects. It can be used in clients with
liver and kidney disease
6. Mirtazapine (Remeron)
7. Vilazodone (Viibryd)
Monoamine Oxidase Inhibitors
- MAOIs have been used infrequently because of
potentially fatal side effects and interactions with
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numerous drugs, both prescription and over-the-
counter preparations
- may be superior to typical medications for treatment
of typical and treatment-resistant depression
- The most serious side effect is hypertensive crisis, a
life-threatening condition that can result when a
client taking MAOIs ingests tyramine-containing
foods, fluids, or other medications
- These can lead to hyperpyrexia, cerebral
hemorrhage, and death. The MAOI–tyramine
interaction produces symptoms within 20 to 60
minutes after ingestion. For hypertensive crisis,
transient antihypertensive agents, such as
phentolamine mesylate, are given to dilate blood
vessels and decrease vascular resistance
- There is a 2- to 4-week lag period before MAOIs
reach therapeutic levels; Due to the lag period,
adequate washout periods of 5 to 6 weeks are
recommended between the times that the MAOI is
discontinued and another class of antidepressant is
started
Medication:
1. Isocarboxazid (Marplan)
2. Phenelzine (Nardil)
3. Tranycypromine (Parnate)
Other Medical Treatments and Psychotherapy
1. Electroconvulsive therapy—to treat
depression in select groups of clients such as
- clients who do not respond to antidepressant
- who experience intolerable side effects at
therapeutic doses
- Pregnant women safely have ECT while many
medications are not safe for use during pregnancy.
- Clients who are actively suicidal may be given ECT if
there is a concern for their safety while waiting
weeks for full effects of antidepressant medication
- It shows high efficacy for patients with psychotic
features and marked psychomotor disturbances
o ECT involves application of electrodes to the
head of the client to deliver an electrical
impulse to the brain; this causes a seizure.
o It is believed that the shock stimulates brain
chemistry to correct chemical imbalance of
depression.
o Client usually receives a series of 6-15
treatments scheduled three times a week.
o Generally, a minimum of six treatments are
needed to see sustained improvement in
depressive symptoms.
o Maximum benefit is achieved in 12-15
treatments
Pre-procedure:
- NPO after midnight
Mood and Bipolar Disorders; Somatoform Disorders
- No fingernail polishes
- Void before the procedure
- IV line is started for medication
- Client receives a short-acting anesthetic
- Administration of muscle relaxant/paralytic usually
Succinylcholine—relaxes all muscles to reduce
greatly the outward signs of the seizure (Clonic-tonic
muscle contractions)
Procedure:
- Electrodes are placed in the client’s head; one on
either side (bilateral) or on one side (unilateral)
- The electrical stimulation is delivered which causes
seizure activity in the brain that is monitored by an
Electroencephalogram (EEG)
- The client receives oxygen and is assisted to
breathe with an Ambu bag—client begins to awaken
after a few minutes
Post-procedure:
- Vital signs are monitored, the client is assessed for
the return of the gag reflex
- Client may be mildly confused or briefly disoriented,
tired and often has a headache.
- Symptoms are just like from a Grand mal seizure.
- Short term memory impairment.
- Client may eat as soon as he or she is hungry and
usually sleeps for a period.
- Unilateral: less memory loss but more treatments
may be needed to see sustained improvement;
Bilateral ECT results in more rapid improvement but
with increased short-term memory loss
2. Psychotherapy
• A combination of psychotherapy and
medications is considered the most effective
treatment for depressive disorders in both
children and adults
• The goals of combined therapy are symptom
remission, psychosocial restoration,
prevention of relapse or recurrence, reduced
secondary consequences
• Interpersonal therapy focuses on difficulties
in relationships such as grief reactions, role
disputes and role transitions
• Behavior therapy seeks to increase the
frequency of the client’s positively
reinforcing interactions with the environment
and to decrease negative interactions.
Cognitive distortion Distortions addressed by
Cognitive therapy
Absolute Tendency to view everything in
dichotomous thinking polar categories
Arbitrary inference Drawing a specific conclusion
without sufficient evidence (i.e.,
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jumping to [negative]
conclusions)
Specific abstraction Focusing on a single (often
minor) detail while ignoring
other, more significant aspects of
the experience (i.e.,
concentrating on one small
[negative] detail while
discounting positive aspects)
Overgeneralization Forming conclusions based on
too little or too narrow
experience (i.e., if one
experience was negative, then
all similar experiences will be
negative)
Magnification and Overvaluing or undervaluing the
minimization significance of a particular event
(i.e., one small negative event is
the end of the world or a positive
experience is totally discounted)
Personalization Tendency to self-reference
external events without basis
(i.e., believing that events are
directly related to oneself,
whether they are or not)
Application of the Nursing Process: Depression
History
• The nurse can collect assessment data from the
client and family or significant others, previous chart
information, and others involved in the support or
care.
• To assess the client’s perception of the problem, the
nurse asks about behavioral changes: when they
started, what was happening when they began, their
duration, and what the client has tried to do about
them
• Assessing the history is important to determine any
previous episodes of depression, treatment, and the
client’s response to treatment. The nurse also asks
about family history of mood disorders, suicide, or
attempted suicide.
General Appearance and Motor Behavior
• Many people with depression look sad; sometimes
they just look ill.
• Slouched with head down with minimal eye contact
• Psychomotor retardation (slow body movements,
slow cognitive processing, and slow verbal
interaction)
• Minimal response to question with only one or two
words; Late response with 30 seconds
• May answer question with “I don’t know” because
they are simply too fatigue and overwhelmed to think
of an answer or respond in any detail
• Exhibit signs of agitation or anxiety: wringing their
hands and having difficulty sitting still.
Mood and Bipolar Disorders; Somatoform Disorders
• Psychomotor agitation—increased body movements
and thought which includes pacing, accelerated
thinking, and argumentativeness
Mood and Affect
• Depressed clients describe themselves as hopeless,
helpless, down, or anxious.
• Some would say they are a burden on others or are
a failure at life
• Easily frustrated, angry with themselves, and can be
angry with other.
• Anhedonia, losing sense of pleasure from activities
they formerly enjoyed
• Apathetic, not caring about themselves, activities, or
much of anything
• Their affect is sad, or depressed or may be flat with
no emotional expressions.
• Sits along, staring into space or lost in thought
• Overwhelmed by noise and people who might make
demands on them, so they withdraw from the
stimulation of interaction with others
Thought Process and Content
• Clients with depression experience slow thinking
processes, their thinking seems to occur in slow
motion
• With severe depression, they may not respond
verbally to questions.
• Tend to be negative and pessimistic in their thinking
• Self-deprecating remarks, criticizing themselves
harshly, and focusing only on failures or negative
attributes
• Tend to ruminate—repeatedly going over the same
thoughts such as suicidal thoughts
• Those who experience psychotic symptoms have
delusions; often believe they are responsible for
tragedies and miseries in the world
Sensorium and Intellectual Processes
• Some are oriented to person, time, and place; other
struggle with orientation especially with psychotic
symptoms
• Assessing general knowledge is difficult because of
limited ability to respond to questions
• Memory impairment and difficulty concentrating or
paying attention.
• If psychotic, clients may hear degrading and
belittling voices, command hallucinations that order
them to commit suicide
Judgement and Insight
• Has impaired judgement because they cannot use
their cognitive abilities to solve problems or make
decisions.
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• Cannot make decisions or choices because of their
extreme apathy or their negative belief that it “it
doesn’t matter anyway”
• Insight may be intact especially if clients have been
depressed previously.
• Some are unaware of their behaviors, feelings or
illness.
Self-Concept
• Sense of self-esteem is greatly reduced
• They feel guilty not being able to function and often
personalize events or take responsibility for
incidents over they have no control
Roles and Relationship
• Clients have difficulty fulfilling roles and
responsibilities.
• The more severe the depression, the greater the
difficulty.
• Societal, family, and work-related responsibilities are
unable to meet or achieved.
Physiological and Self-Care Considerations
• Weight loss due to lack of appetite or disinterest in
eating.
• Sleep disturbances are common;
• Loss interest in sexual activities; men experience
impotence.
• Neglect personal hygiene due to lack of interest and
energy
• Constipation results from decreased food and fluid
intake as well as from inactivity
Nursing Care Plan: Depression
Nursing Diagnosis: Ineffective coping: Inability to form a
valid appraisal of the stressors, inadequate choices of
practiced responses, and/or inability to use available
resources
Assessment Data
• Suicidal ideas or behavior
• Slow mental processes
• Disordered thoughts
• Feelings of despair, hopelessness, and
worthlessness
• Guilt; Anhedonia; disorientation; generalized
restlessness or agitation
• Sleep disturbances: early awakening, insomnia, or
excessive sleeping
• Anger or hostility
• Rumination; delusions, hallucination, or other
psychotic symptoms
• Diminished interest in sexual activity
• Fear of intensity of feelings; anxiety
Mood and Bipolar Disorders; Somatoform Disorders
Expected Outcomes
Immediate: the client will
• Be free from self-inflicted harm throughout
hospitalization
• engage in reality-based interactions within 24 hours
• Be oriented to person, place, and time within 48-72
hours
• Express anger or hostility outwardly in a safe
manner (Talking to staff members within 5-7 days)
Stabilization: the client will
• Express feelings directly with congruent verbal and
nonverbal messages
• Be from psychotic symptoms
• Demonstrate functional level of psychomotor
activity
Community: the client will
• Demonstrate compliance with and knowledge of
medications, if any
• Demonstrate an increased ability to cope with
anxiety, stress, or frustration
• Verbalize or demonstrate acceptance of loss or
change, if any.
• Identify a support system in the community
Implementation
Nursing Interventions
Provide a safe environment for the client
Remain aware of this suicide potential at all times
Observe the client closely, especially under the following
circumstances:
- After antidepressant medication begins to raise the
client’s mood
- Unstructured time on the unit or times when the number
of staff on the unit is limited
- After any dramatic behavioral change (sudden
cheerfulness, relief, or giving away personal
belongings)
Reorient the client to person, place, and time as indicated
(call the client by name, tell the client your name, tell the
client where he or she is, and so forth)
Spend time with the client
If the client is ruminating, tell him or her that you will talk
about reality or about the client’s feelings, but limit the
attention given to repeated expressions of rumination.
Initially assign the same staff members to work with the
client whenever possible.
When approaching the client, use a moderate-level tone of
voice. Avoid being overly cheerful.
Use silence and active listening when interacting with the
client. Let the client know you are concerned and you
consider the client a worthwhile person.
Be comfortable sitting with the client in silence. Let the client
know you are available to converse, but do not require the
client to talk.
When first communicating with the client, use simple, direct
sentences; avoid complex sentences or directions.
Ilah Reanne S. Enriquez
Avoid asking the client many questions, especially questions
that require only brief answers.
Do not belittle the client’s feelings. Accept the client’s
verbalizations of feelings as real and give support for
expressions of emotions, especially those that may be
difficult for the client (like anger).
Encourage the client to ventilate feelings in whatever way is
comfortable—verbal and nonverbal. Let the client know you
will listen and accept what is being expressed.
Allow (and encourage) the client to cry. Stay with and
support the client if he or she desires. Provide privacy if the
client desires and it is safe to do so.
Interact with the client on topics with which he or she is
comfortable. Do not probe for information.
Talk with the client about coping strategies he or she has
used in the past. Explore which strategies have been
successful and which may have led to negative
consequences.
Teach the client about positive coping strategies and stress
management skills, such as increasing physical exercise,
expressing feelings verbally or in a journal, or meditation
techniques. Encourage the client to practice this type of
technique while in the hospital.
Teach the client about the problem-solving process: Explore
possible options, examine the consequences of each
alternative, select, and implement an alternative, and
evaluate the results.
Provide positive feedback at each step of the process. If the
client is not satisfied with the chosen alternative, assist the
client in selecting another alternative
Bipolar disorder
• It is diagnosed when a person’s mood fluctuates to
extremes of mania and/or depression.
• A person with bipolar disorder cycles between
depression and normal behavior (bipolar
depressed); Mania and normal behavior (bipolar
manic)
• A person with bipolar mixed episodes alternates
between major depressive and manic episodes
interspersed with periods of normal behavior
Mood and Bipolar Disorders; Somatoform Disorders
• Mania—distinct period during which mood is
abnormally and persistently elevated, expansive, or
irritable.
o During manic phases, clients are euphoric,
grandiose, energetic, and sleepless
o Poor judgement, and rapid thoughts,
actions, and speech
• Lasts about 1 week (unless the person is
hospitalized and treated sooner), but it may be
longer for some individuals
• Manic episodes include:
o Inflated self-esteem or grandiosity
o Decreased sleep
o Excessive and pressured speech
(unrelenting, rapid, and often loud talking
without pauses)
o Flight ideas
o Psychomotor agitation and excessive
involvement in pleasure-seeking or risk-
taking activities with high potential for painful
consequences
o Excessively cheerful, or the person may be
irritable especially when told ‘No’ or has
rules to follow
o The person will deny any problems and
place blame on others for any difficulties.
o Some would exhibit delusions and
hallucinations during manic episodes
• Hypomania—period of abnormally and persistently
elevates or irritable mod and some other milder
symptoms of mania.
o The difference is hypomanic do not impair
the person’s ability to function (can be
productive) and there are no psychotic
features (delusions and hallucinations)
• Rapid cycling—A mixed episode is diagnosed when
the person experiences both mania and depression
nearly every day for at least 1 week.
• Bipolars are described as follows:
o Bipolar mixed—cycles alternate between
periods of mania, normal mood, depression,
normal mood, mania and so forth:
o Bipolar I disorder—one or more manic or
mixed episodes accompanied by at least
one hypomanic episode
o Bipolar II disorder—one or more major
depressive episodes accompanied by at
least one hypomanic episode
o Bipolar III disorder—a person has
hypomania that alternate frequently with
brief periods of depression
• A person with bipolar disorder may experience a
Euthymic or normal mood and affect between
extreme episodes or depressed mood swing after
manic episode before returning to a euthymic mood.
Ilah Reanne S. Enriquez
o Euthymic periods between extremes are
quite short but some lasts months or even
years
Incidence
• Bipolar disorder occurs almost equally among
men and women.
• Commonly in highly educated people.
o Some people with bipolar illness deny
their mania, prevalence rate may actually
be higher than reported
Onset and Clinical Course
• The first manic episode generally occurs in a
person’s teens, 20s, or 30s.
• Manic episodes typically begin suddenly with
rapid escalation of symptoms over a few days,
and they last from a few weeks to several
months.
• Adolescents are more likely to have psychotic
manifestations.
• The diagnosis of a manic episode or mania
requires at least 1 week of unusual and
incessantly heightened, grandiose, or agitated
mood in addition to three or more of the
following symptoms:
o Exaggerated self-esteem
o Sleeplessness
o Pressured speech
o Flight of ideas
o Reduced ability to filter extraneous
stimuli, distractibility, increased activities
with increased energy, and multiple,
grandiose, high-risk activities involving
poor judgement and severe
consequences
Treatment
Psychopharmacology
• Involves a lifetime regimen of medications—
antimanic agent (Lithium) or Anticonvulsant
medications used as mood stabilizers
• Lithium can help reduce manic behavior and
protect against the effects of bipolar depressive
cycles
• Antipsychotic agent is administered in addition
to the bipolar medications
1. Lithium:
o action peaks in 30 minutes to 4 hours for
regular forms and in 4 to 6 hours for the
slow-release form
o Onset of action is 5 to 14 days; with this lag
period, antipsychotic or antidepressant
agents are used carefully in combination
Mood and Bipolar Disorders; Somatoform Disorders
with lithium to reduce symptoms in acutely
manic or acutely depressed clients.
o half-life of lithium is 20 to 27 hours
o Lithium use during pregnancy is not
recommended because it can lead to first-
trimester developmental abnormalities.
2. Anticonvulsant:
o Several anticonvulsants traditionally used to
treat seizure disorders have proved helpful
in stabilizing the moods of people with
bipolar illness.
o they may raise the brain’s threshold for
dealing with stimulation; this prevents the
person from being bombarded with external
and internal stimuli
1. Carbamazepine (Tegretol)—used for grand
mal and temporal lobe epilepsy as well as
for trigeminal neuralgia
2. Divalproex (Depakote)—used for simple
absence and mixed seizures, migraine
prophylaxis, and mania
3. Clonazepam (Klonopin)—used in simple
absence and minor motor seizures, panic
disorder, and bipolar disorder.
4. Aripiprazole (Abilify), Brexpiprazole
(Rexulti), and Cariprazine (Vraylar)—
dopamine system stabilizer antipsychotic
medications used as adjuncts to other
mood-stabilizing drugs.
5. Ziprasidone (Geodon), lurasidone (Latuda),
and quetiapine (Seroquel)—Second
generation antipsychotic medications are
often used in conjunction with mood
stabilizers or antidepressants to treat bipolar
disorder
Psychotherapy
• can be useful in the mildly depressive or normal
portion of the bipolar cycle.
• Psychotherapy combined with medication can
reduce the risk for suicide and injury, provide
support to the client and family, and help the
client accept the diagnosis and treatment plan
Application of the Nursing Process: Bipolar Disorder
History
• Obtaining data in several short sessions as well as
talking to family members may be necessary. The
nurse can obtain much information, however, by
watching and listening.
General Appearance and Motor Behavior
• Psychomotor agitation
• Sitting sit is difficult
Ilah Reanne S. Enriquez
• Clients can become exhausted or injure themselves
• In manic phase, clients may wear clothes that
reflect the elevated mood—brightly colored,
flamboyant, attention-getting, and perhaps sexually
suggestive.
• They think, move, and talk fast
• Pressured speech; as evidenced by unrelentingly
rapid and often loud speech without pauses
• They ignore verbal and non-verbal cues
Mood and Affect
• Mania is reflected in periods of euphoria, exuberant
activity, grandiosity, and false sense of well-being
• Projection of an all-knowing powerful image may be
an unconscious defense against underlying low
self-esteem
• Some clients manifest mania with an angry,
verbally aggressive tone, sarcastic and irritable,
especially when others set limits on their behavior
Thought Process and Content
• Cognitive ability or thinking is confused and
jumbled with thoughts racing one after another,
which is often referred to as flight of ideas
• cannot connect concepts, and they jump from one
subject to another
• At times, clients may be unable to communicate
thoughts or needs in ways that others understand.
• These clients start many projects at one time, but
cannot carry any to completion.
• Some clients experience psychotic features during
mania; they express grandiose delusions involving
importance, fame, privilege, and wealth.
Sensorium and Intellectual Process
• Clients may be oriented to person and place but
rarely to time
• The ability to concentrate or to pay attention is
grossly impaired.
• Intellectual functioning is difficult to assess during
the manic phase
Judgement and Insight
• In manic phase, they are easily angered and
irritated and strike back at what they perceive as
censorship by others because they impose no
restrictions on themselves.
• Impulsive and rarely think before acting or
speaking leads poor judgement
• Insight is limited due to clients believing they are
“fine”’ and have no problems
• They blame any difficulties on others
Mood and Bipolar Disorders; Somatoform Disorders Ilah Reanne S. Enriquez
Self-Concept

• In manic phase, they have exaggerated self-

esteem
• Rarely discuss their self-concept realistically
• False sense of well-being masks difficulties with
chronic low self-esteem

Roles and Relationships

• Rarely fulfill role responsibilities

• Trouble at work or school and are too distracted
and hyperactive to pay attention to children or
activities of daily living
• Clients invade the intimate space and personal
business of others.
• Arguments result when others feel threatened by
such boundary invasions.
• a great need to socialize but little understanding
of their excessive, overpowering, and
confrontational social interactions. Their need for Implementation
socialization often leads to promiscuity.
• Labile emotions—emotions are unstable and can
fluctuate readily between euphoria and hostility.

Physiological and Self-Care Considerations

• In manic phase, client can go days without sleep

or food and not even realize they are hungry or
tired
• May be on the brink of physical exhaustion but
are unwilling or unable to stop, rest or sleep.
• Ignores personal hygiene; may throw away
possessions or destroy valued items
• Physically injure themselves and tend to ignore
health needs that can worsen

Nursing Care Plan: Mania

Nursing Diagnosis: Disturbed Thought Processes: Disruption
in cognitive operations and activities

Assessment Data:

Expected outcomes
Mood and Bipolar Disorders; Somatoform Disorders
Suicide
• Intentional act of killing oneself
• Suicidal thoughts are common in people with
mood disorders, especially depression
• Suicidal ideation—thinking about killing oneself
• Active suicidal ideation—person thinks about
and seeks ways to commit suicide; more
potentially lethal
• Passive suicidal ideation—person thinks about
wanting to die or wishes he/she were dead but
has no plans to cause his/her death
Treatment: Antidepressants and Suicide Risk
• increased risk for suicide in the first few weeks
of therapy
• increase in energy from the antidepressant but
remain depressed—more likely to act on suicidal
ideas and make them capable of carrying them
out.
• because antidepressants take several weeks to
reach their peak effect, clients may become
discouraged and act on suicidal idea
Somatic Symptom Illnesses
• The term psychosomatic began to be used to
convey the connection between the mind
(psyche) and the body (soma) in states of health
and illness.
• The mind can cause the body either to create
physical symptoms or to worsen physical
illnesses.
• When a person is under a lot of stress or is not
coping well with stress, symptoms of these
medical illnesses worsen.
• Hysteria refers to multiple physical complaints
with no organic basis; the complaints are usually
described dramatically.
Overview of Somatic Symptom Illnesses
• Somatization is defined as the transference of
mental experiences and states into bodily
symptoms.
• characterized as the presence of physical
symptoms that suggest a medical condition
without a demonstrable organic basis to account
fully for them.
• three central features of somatic symptom
illnesses
o Physical complaints suggest major medical
illness but have no demonstrable organic
basis.
o Psychological factors and conflicts seem
important in initiating, exacerbating, and
maintaining the symptoms.
Ilah Reanne S. Enriquez
o Symptoms or magnified health concerns are
not under the client’s conscious control.
Somatic Symptom Disorders
1. Somatic symptom disorder - characterized by
one or more physical symptoms that have no
organic basis. Individuals spend a lot of time and
energy focused on health concerns, often
believe symptoms to be indicative of serious
illness, and experience significant distress and
anxiety about their health
2. Conversion disorder (conversion reaction)-
unexplained, usually sudden deficits in sensory
or motor function (e.g., blindness, paralysis);
deficits suggest a neurologic disorder but are
associated with psychological factors. There is
usually significant functional impairment. There
may be an attitude of la belle indifference, a
seeming lack of concern or distress, about the
functional loss.
3. Pain disorder has the primary physical
symptom of pain, which is generally unrelieved
by analgesics and greatly affected by
psychological factors in terms of onset, severity,
exacerbation, and maintenance.
4. Illness anxiety disorder, formerly
hypochondriasis, is preoccupation with the fear
that one has a serious disease (disease
conviction) or will get a serious disease (disease
phobia). It is thought that clients with this
disorder misinterpret bodily sensations or
functions.
Onset and Clinical Course
• Conversion disorder usually occurs between the
ages of 10 and 35 years. Pain disorder and
illness anxiety disorder can occur at any age.
• All somatic symptom illnesses are either chronic
or recurrent, lasting for decades for many
people.
• Clients with somatic symptom illnesses tend to
go from one physician or clinic to another, or
they may see multiple providers at once
• often believe their disease could be diagnosed if
providers were more competent
Related Disorders
1. Malingering—intentional production of false or
grossly exaggerated physical or psychological
symptoms; motivated by external incentives
such as avoiding work, evading criminal
Mood and Bipolar Disorders; Somatoform Disorders Ilah Reanne S. Enriquez
prosecution, obtaining financial compensation, o Women more often receive treatment for
or obtaining drugs; no real physical symptoms or psychiatric disorders with strong somatic
grossly exaggerate relatively minor symptoms; components such as depression
purpose is some external incentive can stop the
physical symptoms as soon as they have gained Treatment
what they wanted.
• focuses on managing symptoms and improving
quality of life.
2. Munchausen syndrome /Factitious disorder
imposed on self • health care provider must show empathy and
• person intentionally produces or feigns • sensitivity to the client's physical complaints.
physical or psychological symptoms solely • A trusting relationship helps ensure clients stay
to gain attention with and receive care from one provider instead
• may even inflict injury on themselves to of "doctor shopping."
receive attention
• antidepressants help in some cases
3. Munchausen syndrome by proxy • Selective serotonin reuptake inhibitors:
• person inflicts illness or injury on someone fluoxetine (Prozac), sertraline (Zoloft), and
else to gain attention of emergency paroxetine (Paxil)
medical personnel or to be "hero" for
saving victim. Antidepressants Used to Treat Somatic Symptom Illness
Drug Usual dose Nursing Considerations
• Ex. nurse who gives excess intravenous (mg/day)
potassium to client then "saves his life" by Fluoxetine 20-60 Monitor for rash, hives,
performing CPR (Prozac) insomnia, headache, anxiety,
drowsiness, nausea, loss of
4. Medically unexplained symptoms (MUS) and appetite, avoid alcohol
Paroxetine 20-60 Monitor for nausea, loss of
functional somatic syndromes are terms used
(Paxil) appetite, dizziness, dry mouth,
more frequently in general medical setting. They somnolence or insomnia,
refer to physical symptoms and limitations of sweating, sexual dysfunction;
function that has no medical diagnoses to avoid alcohol
explain their existence Sertraline 50-200 Monitor for nausea, loss of
(Zoloft) appetite, diarrhea, headache,
Etiology insomnia, sexual dysfunction,
avoid alcohol
Internalization—people with somatic symptom
illnesses keep stress, anxiety, or frustration inside
Nursing Care Plan: HYPOCHONDRIASIS/ILLNESS
rather than expressing them outwardly
ANXIETY DISORDER
Somatization
• Ineffective Coping: Inability to form a valid appraisal
• Associated most often with women, as evidenced of the stressors, inadequate choices of practiced
by the old term hysteria (Greek for “wandering responses, and/or inability to use available
uterus”). resources
• Ancient theorists believed that unexplained female • Teaching Coping Strategies:
pain resulted from migration of the uterus o emotion-focused coping strategies help
throughout the woman’s body. clients relax and reduce feelings of stress
• Psychosocial theorist posit that increased incidence o problem-focused coping strategies help
of somatization in women may be related to various resolve or change a client's behavior or
factors: situation or manage life stressors
o Americans are taught to be stoic and to
INTERVENTIONS: Somatic Symptom Illnesses
“take it like a man”, causing them to offer
fewer physical complaints as adults - Health teaching - Limit time spent on
o Women seek medical treatment more often - Establish a daily routine physical complaints.
than men, and it is more socially - Promote adequate - Limit primary and
nutrition and sleep secondary gains.
acceptable for them to do so.
- Expression of emotional - Coping strategies
o Childhood sexual abuse, which is related to feelings symptoms - Emotion-focused coping
somatization, happens more frequently to strategies such as
girls relaxation techniques
Mood and Bipolar Disorders; Somatoform Disorders Ilah Reanne S. Enriquez
- Recognize relationship deep breathing, guided
between stress/coping imagery, and distraction
and physical - Problem-focused
coping strategies such
as problem-solving/
strategies and role-
playing

Evaluation:

• client should make fewer visits to physicians as a

result of physical complaints, use less medication
and more positive coping techniques, and increase
functional abilities.