PSYCHIA CHAPTER 17

• Everyone occasionally feels sad, low, and tired, with the desire to stay in bed and shut out the world. These episodes are often accompanied by anergia (lack of energy), exhaustion, agitation, noise intolerance, and slow thinking processes, all of which make decisions difficult.
• Such “low periods” pass in a few days, and energy returns. Fluctuations in mood are so common to the human condition that we think nothing of hearing someone saying, “I’m depressed because I have too much to do.”
• Sadness in mood can also be a response to misfortune; death of a friend or relative, financial problems, or loss of a job may cause a person to grieve.
• Mood spectrum

  ➢ Episodes of exaggeratedly energetic behavior.

  ➢ The person has the sure sense that he or she can take on any task or relationship.

  ➢ Elated mood, stamina for work, family, and social events is untiring.

  > Feeling of being “on top of the world” also recedes in a few days to a euthymic mood (average affect and activity).

  > Happy events stimulate joy and enthusiasm.
• Mood disorders

  • also called affective disorders
  • Pervasive alterations in emotions that are manifested by depression, mania or both, and interfere with the person's ability to live life.
  • Mood disorders are the most common psychiatric diagnoses associated with suicide; depression is one of the most important risk factors for it (Rhimer & Pompili, 2017)
• CLASSIFICATION:

  • F30 Manic Episode
  • F31 Bipolar Affective Disorder
  • F32 Depressive Episode
  • F33 - Recurrent Depressive Disorder
  • F34 - Persistent Mood Disorder (cyclothymia and dysthymia)
  • F30 other mood disorders
• Categories of Mood Disorders

  Major Depression - 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms

  Bipolar disorder - formerly called "manic-depressive illness): mood cycles of mania and/or depression and normalcy and other symptoms
• wave wave

  
• Related Disorders

  Dysthymia: sadness, low energy, but not severe enough to be diagnosed as major depression disorder

  Cyclothymia: mood swings not severe enough to be diagnosed as bipolar disorder

  Substance-induced mood disorder: Mood disorder due to a general medication condition
• Seasonal affective disorder (SAD) -2 subtypes

  1. Winter depression or fall-onset SAD > people experience 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.
  2. . Spring-onset SAD > less common, with symptoms of insomnia, weight loss, and poor appetite lasting from late spring or early summer until early fall. SAD is offen treated with light therapy (Leahy, 2017).
• Postpartum or "maternity" blues

  > mild, predictable mood disturbance occurring in the first several days after delivery of a baby

  Symptoms: 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 (Langan & Goodbred, 2017).
• Postpartum depression

  > the most common complication of pregnancy in 658 developed countries (Langan & Goodbred, 2017).

  > Meets all the criteria for a major depressive episode, with onset within 4 weeks of delivery
• Postpartum psychosis

  > A psychotic episode developing within 3 weeks of delivery and beginning with fatigue, sadness, emotional lability, poor memory, and confusion and progressing to delusions, hallucinations, poor insight and judgment, and loss of contact with reality.
• Premenstrual dysphoric disorder

  > severe form of premenstrual syndrome

  > defined as recurrent, moderate psychological and physical symptoms that occur during the week before menses and resolving with menstruation.

  > 20% to 30% of premenopausal women are affected by affective and/or somatic symptoms that can cause severe dysfunction in social or occupational functioning,

  > labile mood, irritability, increased interpersonal conflict, difficulty concentrating, feeling overwhelmed or unable to cope, and feelings of anxiety, tension, or hopelessness (Appleton, 2018).
• Nonsuicidal self-injury

  > involves deliberate, intentional cutting, burning, scraping, hitting, or interference with wound healing.

  > alleviation of negative emotions, self-punishment, seeking attention, or escaping a situation or responsibility.
• Biologic Theories

  • Major Depressive Disorder - 3 times more common among first-degree biological relatives.
  • Twin studies reveal a higher rate of concordance in monozygotic twins than dizygotic twins.
  • Bipolar Disorder - The risk increases 4% to 24% in first-degree relatives of people with bipolar disorder. - Twin studies of monozygotic twins indicate a 65% concordance rate
• NEUROCHEMICAL THEORIES.

  • Biogenic Amine Theory - Depressive Disorder: ↓ NE and serotonin - Bipolar Disorder: ↑ NE and serotonin.
  • Kindling Theory - External environmental stressors activate internal physiologic stress responses, which trigger the first episode of a mood disorder, the first episode then creates electrophysiologic sensitivity to future episodes so that less stress is required to evoke another episode.
• NEUROENDOCRINE INFLUENCES

  • Depression - increased cortisol secretion in 40% of clients and increased thyroid-stimulating hormone in 5% to 10% of clients.
• PSYCHODYNAMIC THEORIES

  Freud: looked at the self-depreciation of people with depression and attributed that self-reproach to anger turned inward related to either a real or perceived loss. (Introjection)

  Bibring: believed that one's ego aspired to be ideal and that to be loved and worthy, one must achieve these high standards. Depression results when, in reality, the person was not able to achieve these ideals all the time.
• PSYCHODYNAMIC THEORIES

  • Horney: children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness, making them susceptible to depression and helplessness.
  • Beck: depression results from specific cognitive distortions in susceptible people; involves magnification of negative events and minimization of anything positive.
• PSYCHODYNAMIC THEORIES

  • Jacobson: ego is a powerless, helpless child victimized by the superego.
  • Mania episodes: "defense" against underlying depression, with the id taking over the ego acting as an undisciplined hedonistic being.
  • Meyer: depression as an reaction to a distressing life experience
• CULTURAL CONSIDERATIONS

  > Other behaviors considered age-appropriate can mask depression

  > Somatic complaints are a major manifestation among cultures that avoid verbalizing emotions

  > Asians who are anxious or depressed are more likely to have somatic complaints of headache, backache, or other symptoms Latin cultures complain of "nerves" or headaches

  > Middle Eastern cultures complain of heart problems
• MAJOR DEPRESSIVE DISORDER

  Twice as common in women and more common in single or divorced people

  Involves 2 or more weeks of sad mood, lack of interest in life activities, and at least four other symptoms:

  Changes in appetite or weight, sleep, or psychomotor activity

  Decreased energy

  Feelings of worthlessness or guilt

  Difficulty thinking, concentrating, or making decisions

  Recurrent thoughts of death or suicidal ideation, plans, or attempts
• Onset and Clinical Course of MAJOR DEPRESSIVE DISORDER

  > untreated episode of depression can last 6 to 24 months before remitting.

  > 50% to 60% of people who have one episode of depression will have another.

  >After a second episode, there is 70% chance of recurrence.
• Treatment and Prognosis

  Antidepressants

  SSRIs (Prozac, Zoloft, Paxil, Celexa) prescribed for mild and moderate depression

  TCAS (Elavil, Tofranil, Norpramin, Pamelor, Sinequan) used for moderate and severe depression

  Atypical antidepressants (Effexor, Wellbutrin, Serzone)

  MAOIS (Marplan, Parnate, Nardil) used infrequently because interaction with tyramine causes hypertensive crisis
• Electroconvulsive therapy (ECT)

  > used when medications are ineffective or side effects are intolerable.

  6 to 15 treatments scheduled three times a week

  Preparation of a client for ECT is similar to preparation for any outpatient minor surgical procedure

  The client will have some short-term memory impairment

  Psychotherapy in conjunction with medication is considered most effective treatment; useful therapies include behavioral, cognitive, interpersonal therapy
• Application of the Nursing Process: Major Depressive Disorder

  Assessment

  • Mood and affect: hopeless, helpless, down, anxious, frustrated, anhedonia, apathetic; affect is sad, depressed, or flat
  • Thought processes and content: slowed thinking processes, negative and pessimistic, ruminate, thoughts of dying or committing suicide
• Application of the Nursing Process: Major Depressive Disorder

  Assessment

  • History: the client's perception of the problem, behavioral changes, any previous episodes of depression, treatment, response to treatment, family history of mood disorders, suicide, or attempted suicide
  • General appearance and motor behavior: slouched posture, latency of response, psychomotor retardation or agitation
• Application of the Nursing Process: Major Depressive Disorder (con't)

  Assessment

  Sensorium and intellectual processes: oriented, memory impairment, difficulty concentrating

  Judgment and insight: impaired judgment, insight may be intact or limited

  Self-concept: low self-esteem, guilty, believe that others would be better off without them
• Application of the Nursing Process: Major

  Roles and relationships: difficulty fulfilling roles and responsibilities

  Physiologic considerations: weight loss, sleep disturbances, lose interest in sexual activities, neglect personal hygiene, constipation, dehydration

  Depression rating scales: Zung Self-Rating

  Depression Scale, Beck Depression Inventory, the Hamilton Rating Scale for Depression
• Application of the Nursing Process: Major Depressive Disorder (Con't)

  Data Analysis

  Nursing diagnoses may include:

  Risk for Suicide

  Imbalanced Nutrition: Less Than Body Requirements

  Anxiety

  Ineffective Coping

  Hopelessness

  Ineffective Role Performance

  Self-Care Deficit

  Chronic Low Self-Esteem

  Disturbed Sleep Pattern

  Impaired Social Interaction
• Bipolar Disorder

  Onset and Clinical Course

  • Occurs almost equally among men and women
  • It is more common in highly educated people
  • The mean age for a first manic episode is the early 20s or in adolescence; or in ages older than 50
  • Involves mood swings of depression (same symptoms of major depressive disorder) and mania.
  • Manic episodes typically begin suddenly, with rapid escalation of symptoms over a few days, and last from a few weeks to several months.
  • They tend to be briefer and to end more suddenly than depressive episodes
• Major symptoms of mania include:

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • Pressured speech
  • Flight of ideas
  • Distractibility

  Increased involvement in goal-directed activity or psychomotor agitation

  Excessive involvement in pleasure-seeking activities

  with a high potential for painful consequences
• Treatment

  Psychopharmacology

  Lithium

  For bipolar mania but could also partially or completely mute the cycling toward bipolar depressions. - Contraindicated during pregnancy.

  • Anticonvulsant Drugs

  Exact mechanism is unknown but may raise the brain's threshold for dealing with stimulation. Given to clients who have problems in lithium therapy (SES, drug interactions, renal disease)

  • Carbamazepine, Valproic Acid, Clonazepam
• Psychotherapy

  Useful in the mildly depressive or normal portion of the bipolar cycle.

  It is not useful during acute manic stages because the person's attention span is brief and he or she can gain little insight during times of accelerated psychomotor activity.
• Suicide

  • The intentional act of killing oneself.
  • The nurse caring for a depressed client always considers the possibility of suicide.

  Commonly occurs in clients with:

  > Psychiatric Disorders: depression, bipolar, schizo, substance abuse, PTSD, and BPD.

  ‣ Chronic medical illness: Cancer, HIV, DM, CVA, head and spinal cord injury.

  Environmental factors
• Suicide Suicidal clues:

  • Taking out or changing insurance policies
  • Positive or negative changes in behavior Poor appetite
  • Sleeping difficulties
  • Feelings of hopelessness
  • Difficulty in concentrating
  • Loss of interest in activities
  • Client statements indicating an intent to attempt suicide
  • Sudden calmness or improvement in depressed client.

  Client inquiries about poisons, guns, or other lethal objects.