Psychiatry 101

8/3/2019 Psychiatry 101

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MOOD DISORDERSDEPRESSION,

BIPOLARANDSUICIDE

Prepared by:Prepared by:Jeffrey A.Jeffrey A. NelmidaNelmida, RN, RN


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Mood disorders-

Affective disorders

Pervasive alterations in emotionsthat are manifested bydepression, mania or both


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What is Depression?

It is an alteration in mood.

Top 10 Facts about Depression1. Sadness is a natural response, while

Depression is a physical illness which is onthe rise among all the communities in the

world.2. It is more common in women than men

3. It affects people in all age groups.


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4. Depression today is 10 times more commonthan it was in 1945

5. Stress and trauma are the major reasons fordepressive illness

6. Some people are genetically predisposed todevelop depression; however, it is usuallytriggered by a traumatic or stressful event

7. It may contribute to fatal heart attack; by 2020it will be the 2nd largest killer after heartdisease.

8. 15% of depressed people will commit suicide

9. It is a treatable condition but the majority (80%)do not take an treatment

10. Antidepressants will work only in 30-45% of thedepressed people


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Global Statistics

About 20% of teens will experiencedepression before they reach adulthood.

America

- 8.3% of teenagers suffer from depression Australia

- 16 out of400 children were found to be

clinically depressed UK

- 1 in 8 adolescents may have depression


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Singapore

- 300-4

00 of the entire teenage populationsuffers from depression

Japan

- adolescents depression can be as high as

20% or higher

Mindanao

- 9% of the entire population are depressed


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Major Depressive Disorder

Formerly called the Manic Depressive

Disorder

Episodes last at least 2 weeks in which theperson experiences depressed mood or lossof pleasure in nearly all activities ( anhedonia)

In addition 4 of the ff. symptoms

changes in appetite

changes in Weight

changes in Psychomotor activity


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F eeling of worthlessness Decreased energy

Guilt Difficulty thinking Concentrating Making decisions Recurrent thoughts of suicide


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Insomnia

Beginning

- take few hours before able to sleep

Middle- fall asleep, wakes up, then fall asleep again

Terminal

- late, wakes up at 3 am, then cannot sleep

anymore.


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Predisposing Factors

1. Death in the Family

2. Separation or Divorce

3. Physical Illness

4. Sexual Identity Threat

5. Failure

6. Disappointment in a child

7. Medical Disorder

8. Major life events


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Theories associated with

Depression Psychoanalytical Theory

- Depression is due to a loss according toSigmund Freud-loss of parent before 11 y/o

Biochemical

- Genetic illness- Level of Serotonin, low nor epinephrine

IrrationalBeliefs by Albert Ellis/Illogical Becks Triad Thinking of Depression(Cognitive

Theory)1. Negative view of self


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2. View of World

3. Reinforcement

Martin Seligmans Learned Helplessness

-no control of the environment

Personality Organization Theory

-Borderline, OCPD, Hysterical personality

Genetic 3-8% first degree family

1% general pop.


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Neuroendocrine

40% -elderly

5-10%- Thyroid dysfunction

Agrresion turned inward Theory- overdevelopedsuper ego


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BIPOLAR DISORDERS

mood cycles between mania and depression

Mania- distinct period during which mood is

abnormally and persistently elevated,expansive or irritable.

Period may last about for 1 week

Symptoms:

Inflated self-esteem(grandiosity) Decreased need for sleep

Pressured speech


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RELATED DISORDERS

Dysthemic D/O- 2 years of depressed mood,

less severe symptoms

Cyclothemic D/O- 2 years of numerousperiods of hypomania

Substance induced mood d/o- judge to be

physiologic congruence of ingestedsubstance

Mood D/o due to medical condition


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Other disorders

SAD- seasonal affective disorders Winter depression; fall onset SAD-increased

appetite,sleep,weight gain, interpersonal conflicts

Spring onset SAD-insomnia, eight loss

Post partum blues- 3-7 days after delivery

-labile mood and affect, crying speels,

anxiety, sadnessPost partum depression-after 4 weeks of

delivery-meet the criteria of MDD

Post partum psychosis-3 weeks of delivery


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2Biological Markers of

Depression1. Disturbance in sleeping pattern

2. Disturbance in eating pattern


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Signs and Symptoms of

Depression1. Emotional

a. sad, gloomy, melancholic

b. withdrawal, isolation

c. irritable2. Cognitive

a. slowed thinking

b. Poverty of thought

c. Delusion

d. low self esteem

e. Indecisive


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3. Motor

a. hypoactive

b. fatigue

c. mute/mutism

d. anorexic

e. insomnia

f. decreased libido

g. suicidal ideation and more attempt


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Nursing Interventions

To assess the risk is the role of a nurse.1. Communication

- KISS- Keep IT Short and Simple/ brief and clear2. Nutrition

- small frequent feedings- substitute nutritious snacks

- ask the patient what he likes to eat3. Elimination

- increased OFI- increased fiber in diet- increased physical activity

Lastly: use of laxative or enema


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4. Grooming and Hygiene

- Let the patient perform independent ADL (Rule

of Thumb)- Provide hygiene kit then give step by step

instructions (NGT if coma)

5. Rest and Sleep Pattern

- Provide daily routine- ADL accomplishment

- Give a glass of milk before sleeping

- back massage or warm bath or shower

6. Activity

- 1 0n 1 activity

- Group activities


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Pharmacologic Management

1. Tricyclic antidepressantsExamples: Pamelor, Elavil, Anavil, Tofranil, Anafranil,

Norpramin, Vivactyl, Surmontil, Aventyl

2. Atypical antidepressants

Examples: Venlafaxine, Amoxafin, Mirtazapine

3. SSRI- Selective Serotonin Reductase Inhibitor

Examples: Prozac, Zoloft, Paxil, Luvox, Lexapro,Celexa

- take in the morning

- 3-4 days: induced sleep

- 5-7 days: induced eating


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4. MAOI- Monoamine Oxidase Inhibitor

- Pa-rnate (tranylcypromine)

- Ma-rplan (generic isocarboxazid)

- Na-rdil (phenelzine)

- may cause Hypertensive crisis: occipital or

nape pain as the 1st sign

- (-) tyramine in diet= (-) HPN crisis same withTCAs

Tyramine rich foods: pizza, wine, aged cheese,vinegar, beer, soy sauce, sardines, liver,

avocado, banana, tocino, etc


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Electroconvulsive Therapy ECT

- mechanism of action is unknown- passage of electrical current on the lobes of thebrain to induced Grand Mal seizure

2 Phases:

1.Tonic- loss of consciousness, skeletal muscle tense,extremities extend toward or away from the body,lip smacking

2. Clonic- muscle contracts and relax resulting oconvulsion, twitching of legs, confusion andcomplete amnesia upon regaining consciousnessbut gradually wears off

3. 150 volts for .5 to 2 seconds

4. To correct serotonin imbalance

*Aura- awareness of incoming seizure for several mins


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Brevital

Anectin

Atropine Sulfate


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Non-pharmacologic Treatment Cognitive

- change (-) thought into (+) thoughts

Behavior- encourage deep breathing exercises, inhalethen exhale

Talk

- find someone where you can verbalize yourfeelings

Literary

- Read about positive books, esp. the bible Music Guided Imagery


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Suicide

Anger turn inside resulting to harm Suicidal people are homicidal people

Remember: SADPERSONSS- ex: males- 4x high risk of successful

females- 4x high risk of attempted

A- ge: 19y/o and below; then 45y/o and aboveD- epression: Suicidal ideation


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P- revious attempt: occurs at 1st 90 days afterdischarged, then next 2 years.

E- thanol: alcoholics

R- ational Thinking Loss

S- upport System is lacking

O- rganized plan: highest risk for successful

suicide

N- o Spouse: divorced, separated, single

S- ickness or debilitating condition: e.g.Terminal Cancer, Diabetes Mellitus


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Nursing Interventions:

Priority- SAFETY!!!

1. Remove all potentially dangerous objects

2. 1-1 close supervision- q15 mins+ frequent

irregular unscheduled rounds.

3. No Harm-No Suicide Contract

Contract: Agreement- let the patient say,

I promise that I wont hurt myself norcommit a suicide either by accident or by

purpose


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Suicide: True or False

1. Suicide is an impulsive act.2. Suicide is an inherited trait.

3. Suicidal persons are fully intent on dying.

4. Suicidal persons give NO warning.

5. Suicide is used as a form of manipulation.

6. Suicide lessens when the depression improves.

7. The topic on suicide should be avoided when

talking to a suicidal persons.8. People from rags to riches are better protected

against suicide than those from fortune topoverty.


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Somatoform Disorders

are internalized, unresolved anxiety

Criteria:1. (+) Physical symptoms

2. (-)Organic Basis


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A. Hypochondriasis

Localized, multiple consultations

Fear of having a serious illness

Check for reassurance Doctor Shopping/Hopping


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B. Somatization

Could lead to depression

Recurrent, frequent, multiple physical

symptoms over the years Symptoms like pain, GI, sexual, and

pseudoneurologic

Impairment in social and occupational

functioning


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C. Conversion

Anxiety provoking situation

Unexplained, sudden deficits in sensory or

motor function

*La Belle Indifference

- Lack of concern about the disorder


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D. Pain disorder/Psychogenic

Pain that is unrelieved by analgesics

Overly exaggerated pain

Doctor Shoppers*Placebo


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E. Body Dysmorphic

Imagined or exaggerated defect in physical

appearance

Recurrent cosmetic surgery

2 Gains:

1. Primary Gain- relief of anxiety2. Secondary Gain- attention


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Malingering

Feign Physical symptom- Fake symptoms

End Goal- avoid work or responsibility

Munchausens Syndrome/Factitious Disorder

Feign physical symptoms/ Inflict injury tothemselves/BorderlinePersonality

End Goal- get attention

Expected Response of a Nurse: ANGER!!!!!

Munchausens by Proxy On someone else, then relieves the pain

End Goal- to be a HERO


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Interventions

Expression of emotional feelings

Limit time spent on physical symptoms

Adaptive coping strategies- EMOTION FOCUSED: relaxation

techniques, deep breathing, guided imagery,

and distraction

- PROBLEM FOCUSED: such as role playing

or psychodrama


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Cognitive Disorders

P- erception, illusion ( with stimulus),hallucination (without stimulus)

O- rientationR- easoning and Judgment

M- emory

A- ttention


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Delirium Vs Dementia

DELIRIUM DEMENTIA

Loss of Consciousness Memory

Sudden Onset Gradual OnsetAcute Insiduous

Hours to Days Months to Years

Fluctuates duringthe day

Stable over thecourse of the day

Reversible Irreversible


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Alzheimers disease

Most common type of Dementia

A progressive, deteriorating and

degenerative disease among elderly Low level of Acetylcholine

Irreversible


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Causes:

Hereditary

Cerebral Atrophy

Senile plaques

Neurofibrillary tangles

Amyloid Deposits


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4 As of Alzheimers disease

Agnosia- Failure to recognize familiar objects

Amnesia- Recall

Apraxia- Slowed motor movement Aphasia

Types:

1. Expressive- difficulty in forming words2. Receptive- language is not understood

3. Global- combination of the two


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Confabulation

- filling in of a memory gap

- purpose: to maintain self- esteem

Sundowners Phenomenon

- increased agitation, confusion,

disorientation in the late afternoon


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Pharmacologic Management

C- ognex ( tacrine)

A- ricept (donepezil)

R- eminyl (galantamine) E- xelon ( rivastigmine)

Steroids/NSAIDs Ginkgo Biloba

Vitamin C and E


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Nursing Interventions

Trust and safety

Consistency

Music therapy

Reminiscence therapy

- photos, videos, letters, diaries

Plant therapy

Pet therapy


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Childhood Disorders

A. Mental RetardationCauses:

Trisomy 21 (Downs syndrome)- Karyotyping

Phenylketonuria- autosomal recessive

genetic disorder, phenylalanine hydroxylase,

amino acid phenylalanine to tyrosine to

phenylpyruvate. FAS (Fetal Alcohol Syndrome)


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Comparison

Mild 55-69 Grade IV Educable

Moderate 40-54 Grade II Trainable

Severe 25-39 Toddler Constant

Supervison

Profound 24 and below Infant Custodial

Care


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B. Autism

Schizoid pesonality

Hereditary

Onset is before 3 years old Echolalia- imitation of words


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Signs and Symptoms

- Poor facial expression,

- little eye contact,

- prefer inanimate objects,

- self- stimulating acts,

- aloof/indifferent to others,- preoccupied with peculiar interest,

- language is delayed

Focus of Treatment

-Speech Therapy

- Interpersonal relationship


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Attention Deficit

Hyperactivity Disorder

Onset is 7-8 years old

Causes:

Perinatal insults

Head injury

Lead poisoning

Diet ( Food allergies or sensitive to food)


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Signs and Symptoms

- low attention span

- restless

- overactive

- distractible

- reckless

- impulsive

- hyperactive

- inattentive


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Ritalin

- Drug of choice- given in the morning

- insomnia, after meals (appetite depressant)

Focus of Treatment

Structured environment

Set Limit SAFETY is priority

Offer FINGER foods


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Oppositional Defiant

DisorderSymptoms:

Blame others

Low frustration Argumentative

Disobedience

Explosive anger outburst


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Conduct Disorder

Cruelty to animals

Lying

Aggression Stealing


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Psychiatry 101

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