Course Flashcards
“mental disorder”
means a substantial disorder of thought,
mood, perception, orientation or memory that grossly
impairs
(i) judgment,
(ii) behaviour,
(iii) capacity to recognize reality, or
(iv) ability to meet the ordinary demands of life,
but does not include a disorder in which the resulting
impairment is persistent and is caused solely by an acquired
or congenital irreversible brain injury;
Admission certificate
When a qualified health professional examines a person and is of the opinion that the person
(a) is suffering from mental disorder,
(b) has the potential to benefit from treatment for the mental
disorder,
(c) is, within a reasonable time, likely to cause harm to others
or to suffer negative effects, including substantial mental or
physical deterioration or serious physical impairment, as a
result of or related to the mental disorder, and
(d) is unsuitable for admission to a facility other than as a
formal patient,
the qualified health professional may, not later than 24 hours after
the examination, issue an admission certificate in the prescribed
form with respect to the person.
Person detained under Criminal Code
3 If a person has been detained under the Criminal Code (Canada)
or the Youth Criminal Justice Act (Canada) as unfit to stand trial,
not criminally responsible on account of mental disorder or not
guilty by reason of insanity and the person’s detention under the
Criminal Code (Canada) or the Youth Criminal Justice Act
(Canada) is about to expire, a qualified health professional is
authorized to examine the person and assess the person’s mental
condition and may, if the prerequisites for the issuance of an
admission certificate set out in section 2 are met, issue an
admission certificate in the prescribed form with respect to the
person.
Mental competence
For the purposes of this Part, a person is mentally competent to
make treatment decisions if the person is able to understand the
subject-matter relating to the decisions and able to appreciate the
consequences of making the decisions.
formal patient
means a patient detained in a facility
pursuant to 2 admission certificates or 2 renewal certificates;
Mood disorders (also called affective disorders)
are a group of psychiatric disorders including depression and bipolar disorder
Major depressive disorder (MDD)
is one of the most common psychiatric disorders. Women experience depression approximately two times more often than men and approximately one in eight adults (12.6%) have identified symptoms that met the criteria for a mood disorder at some point during their lifetime.
Depression
is the lead- ing cause of disability worldwide
MDD, or major depression is characterized by a
persistently depressed mood lasting for a minimum of 2 weeks. The length of a depressive episode may vary. About 20% of cases become chronic (i.e., lasting more than 2 years). While de- pression begins with a single occurrence, most people experience recurrent episodes. People experience a recurrence within the first year about 50% of the time and within a lifetime up to 85% of the time.
The diagnosis for MDD may include one of the following specifiers to describe the most recent episode of depression:
Psychotic features
Melancholic features
Atypical features
Catatonic features
Postpartum onset
Seasonal features (seasonal affective disorder [SAD])
The full criteria for MDD are listed in
Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5): Diagnostic Criteria for Major Depressive Disorder.
Psychotic features.
Indicates the presence of disorganized thinking, delusions or hallucinations
(e.g.,
delusions of guilt or of being punished for sins,
somatic delusions of horrible disease or body rotting,
delusions of poverty or going bankrupt),
or hallucinations (usually auditory, voices berating person for sins).
Melancholic features
(not attributable to environmental stressors)
characterized by severe apathy, weight loss, profound guilt, symptoms that are worse in the morning, early morning awakening, and often suicidal ideation.
Atypical features.
Refers to dominant vegetative symptoms (e.g., overeating, oversleeping).
Onset is younger, psychomotor activities are slow, and anxiety is often an accompanying problem, which may cause misdiagnosis.
Catatonic features.
Marked by non-responsiveness, extreme psychomotor retardation (may seem paralyzed), withdrawal, and negativity.
Postpartum onset.
Indicates onset within 4 weeks after childbirth.
It is common for psychotic features to accompany this depression. Severe ruminations or delusional thoughts about the infant signify increased risk of harm to the infant.
Seasonal features (seasonal affective disorder [SAD]).
Indicates that episodes mostly begin in fall or winter and remit in spring. These patients have reduced cerebral metabolic activity. SAD is characterized by anergia (lack of energy or passivity), hypersomnia (excessive daytime sleep), overeating, weight gain, and a craving for carbohydrates; it responds to light therapy.
anergia
(lack of energy or passivity)
hypersomnia
(excessive daytime sleep)
Disruptive mood dysregulation disorder
is a disorder characterized by severe and recurrent temper outbursts that are inconsistent with developmental level.
The basic symptoms of disruptive mood dysregulation disorder are constant and severe irritability and anger in individuals between the ages of 6 and 18. Onset is before age 10. Temper tantrums with verbal or behavioural outbursts out of proportion to the situation occur at least three times a week.
To be diagnosed with disruptive mood dysregulation disorder, individuals need to exhibit the irritability, anger, and temper tantrums in at least two of these settings: home, school, and with peers.
It is more common in males than females, and it is more common in children than adolescents.
Treatment: symptom-based approach. If the disorder resembles major depression, antidepressants may be considered. If the disorder is accompanied by attention-deficit/hyperactivity disorder (ADHD), medications for that condition could be tried. Antidepressants may be used to address irritability. The second-generation antipsychotics risperidone (Risp- erdal) and aripiprazole (Abilify) have approval from Health Canada for irritability in autism and are sometimes used for disruptive mood dysregulation disorder.
Psychosocial interventions such as cognitive behavioural therapy (CBT). Parent training helps parents to interact with a child in such a way as to predict and reduce aggression and irritability through consistency and rewarding appropriate behaviour. There is some evi- dence that these young people may be misperceiving others’ facial ex- pressions as angry.
Persistent depressive disorder
(dysthymia) is diagnosed when feel- ings of depression occur most of the day, for the majority of days. These low-level depressive feelings last at least 2 years in adults and 1 year in children and adolescents.
In addition to depressed mood, individuals with this disorder have at least two of the following: decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness.
Because the onset of persistent de- pressive disorder usually occurs in teenage years, patients frequently express that they have “always felt this way” and that being depressed seems like a normal way of functioning. It is not uncommon for people with this low-level depression to also have periods of full-blown major depressive episodes.
Treatment for this disorder is similar to that for MDD. Psychotherapy, particularly CBT, is quite useful in managing symptoms. Antidepressants such as se- lective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), and tricyclics are the other main treatments.
Premenstrual dysphoric disorder
It refers to a cluster of symptoms that occur in the last week before the onset of a menstrual period. Premenstrual dysphoric disorder causes problems severe enough to interfere with the ability to work or interact with others. Symptoms include mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating. Other physical manifestations include lack of energy, overeating, hypersomnia or insomnia, breast tender- ness, aching, bloating, and weight gain. Symptoms decrease significantly or disappear with the onset of menstruation.
Treatment for this disorder includes regular exercise, particularly aerobic exercise. Other recommendations include eating food rich in complex carbohydrates and getting sufficient sleep. Acupuncture, light therapy, and relaxation therapy have also been used to reduce symptoms.
Several drugs have Health Canada approval for treatment of this disorder. A drospirenone and ethinyl estradiol combination (Yaz) is a contraceptive that improves symptoms. Fluoxetine (Prozac), sertraline (Zoloft), and controlled-release paroxetine (Paxil CR) have been used successfully. Diuretics may be useful in reducing bloating and weight gain brought on by water retention.
Substance/medication-induced depressive disorder
is a depressive disorder, such as MDD, that is a result of prolonged use of or withdraw- al from drugs and alcohol. The depressive symptoms last longer than the expected length of physiological effects, intoxication, or withdrawal of the substance. The person with this diagnosis would not experience depressive symptoms in the absence of drug or alcohol use or withdrawal. Symptoms appear within 1 month of use. Once the substance is removed, depressive symptoms usually remit within a few days to several weeks.
Medications associated with depressive symptoms include antiviral agents, cardio- vascular drugs, retinoic acid derivatives, antidepressants, anticonvulsants, antimigraine agents, antipsychotics, hormonal agents, smoking cessation agents, and immunological agents.
Depressive disorder due to another medical condition
may be caused by disorders that affect the body’s systems or from long-term ill- nesses that cause ongoing pain.
It is important to review medications being used for the medical condition to rule out them being the causative agents.
There are clear associations, along with neuroanatomical changes, with some disease states. The prevalence rate of depression in people who have suffered a cerebrovascular accident (stroke) is high, 20% to 50%, in the first year
Parkinson’s disease, Huntington’s disease, Alzheimer’s disease, and traumatic brain injury are also clearly associated with depressive disorders. Neuroendocrine conditions such as Cushing’s disease and hypothyroidism are also commonly accompanied by depression. Arthritis, back pain, metabolic conditions (e.g., vitamin B12 deficiency), human immunodeficiency virus (HIV), diabetes, infec- tion (including COVID-19), cancer, and autoimmune problems may also contribute to depressions.
Depression and Grieving
People who experience a significant loss can exhibit feelings and behaviours similar to depression. They may cry, feel hopeless about the future, have disruptions in eating and sleeping, and lose pleasure in everyday activities. They may even experience a lack interest in caring for themselves and neglect normal hygiene.
The rationale for avoiding a psy- chiatric diagnosis follows:
- Normal mourning could be labelled pathological.
- A psychiatric diagnosis could result in a lifelong label.
- Unnecessary medications might be prescribed.
Although controversial, a diagnosis of depression can now be given
in the first 2 months following death of a loved one or other loss. The reason for the change is that grief, like other stressors, can result in depression. For some people, waiting 2 months for an official diagnosis of major depression may delay treatment and adversely affect prognosis.
EPIDEMIOLOGY of depressive disorders
Depression is the leading cause of disability in the world. The lifetime prevalence of a major depressive episode or the total number of adults in Canada who will experience the disorder within their lifetime is 11.3%
The average age of MDD onset is between 15 and 45 years of age. Studies find that mood disorders are more common in women than men.
MDD tends to have higher prevalence rates in lower-income or unemployed populations and unmarried or divorced people.
Children and Adolescents: Children as young as 3 years of age have been diagnosed with depression; however, the prevalence is relatively low, with little difference be- tween boys and girls. Levels rise in the early teen years, more sharply among girls than boys.
Older Persons: Although depression in older persons is common, it is NOT a normal result of aging. The risk for depression in the elderly increases as health deteriorates. About 1% to 5% of older persons who live in the community have depression. This statistic rises to 11.5% for hospitalized older persons and 13.5% for those requiring home care. Many older persons suffer from SUBSYNDROMAL depression in which they experience many, but not all, of the symptoms of a major depressive episode. These individuals have an increased risk of eventually developing major depression. Sometimes the psychomotor slowing and cognitive effects of depression lead others to believe that the older person is developing a neurocognitive disorder such as Alzheimer’s disease. This condition is referred to as pseudodementia, a problem that can be reversed when the underlying depression is treated and eliminated.
COMORBIDITY of depressive disorders
A depressive syndrome frequently accompanies other psychiatric dis- orders, such as anxiety disorders, schizophrenia, substance use, eating disorders, and schizoaffective disorder. People with anxiety disorders (e.g., panic disorder, generalized anxiety disorder, obsessive-compulsive disorder) commonly present with depression, as do people with per- sonality disorders (particularly borderline personality disorder), adjust- ment disorder, and brief depressive reactions.
ETIOLOGY of depressive disorder (Biological)
Although many theories attempt to explain the cause of depression, many psychological, biological, and cultural variables make identification of any one cause difficult; furthermore, it is unlikely that there is a single cause of depression. The high variability in symptoms, response to treatment, and course of the illness support the supposition that depression results from a complex interaction of causes. For example, genetic predisposition to the illness combined with childhood stress may lead to significant changes in the central nervous system (CNS) that result in depression.
Biological Factors (GENETIC): genetic factors play a role in the development of depressive disorders. The concordance rate for MDD among monozygotic (identical) twins is nearly 50%. That is, if one twin is affected, the second has about a 50% chance of being affected as well. or in- stance, certain genetic markers seem to be related to depression when accompanied by early childhood maltreatment or a history of stressful life events. In this case there is no gene directly related to the development of the mood disorder; however, there is a genetic marker associated with depression in the context of stressful life events. One of the more important aspects of understanding the role of ge- netics in relation to mental illness such as major depression may be in pharmacological treatments. Understanding genetic influences on the role of the transport of certain neurotransmitters, such as serotonin, across synapses will make it much easier to prescribe effective medical treatment of depression based on individual genetic patterns.
Biochemical: The brain is a highly complex organ that contains billions of neurons. There is much evidence to support the concept that many CNS neurotransmitter abnormalities may cause clinical depression. Research suggests that depression results from the dysregulation of a number of neurotransmitter systems beyond serotonin and norepinephrine.
Hormonal: The neuroendocrine characteristic most widely studied in relation to depression has been hyperactivity of the hypothalamic–pituitary– adrenal axis. People with major depression have increased urine cor- tisol levels and elevated levels of corticotrophin-releasing hormone. Dexamethasone, an exogenous steroid that suppresses cortisol, is used in the dexamethasone suppression test (DST) for depression. Results of this test are abnormal in about 50% of people with depression, which indicates hyperactivity of the hypothalamic–pituitary–adrenal axis.
Inflammation: Inflammation is the body’s natural defence to physical injury. There is growing evidence that inflammation may be the result of psychological injury as well. Researchers have focused on two important blood com- ponents related to inflammation, C-reactive protein and interleukin-6. In young females with a history of adversity depression is accompanied by elevations in these blood components, but this elevation does not occur in children without a history of adversity. Adversity in life may compromise resilience and place children at risk for depression and other disorders. While we do not believe that inflammation causes depression, research indicates that it does play a role. Support for this belief includes the finding that about a third of people with major depression have elevated inflammatory biomarkers in the absence of a physical illness. Also, people who have inflammatory diseases have increased risk for major depression. Finally, people treated with cytokines to enhance immunity during cancer treatment develop major depression at a high rate.
Diathesis–Stress Model: The diathesis–stress model of depression takes into account the inter- play of biology and life events in the development of depressive disorders. It is believed that psychosocial stressors and interpersonal events trigger neurophysical and neurochemical changes in the brain. Early life trauma may result in long-term hyperactivity of the CNS corticotropin-releasing factor (CRF), which releases the cortisol hormone, and norepinephrine systems, with a consequent neurotoxic effect on the hippocampus, which leads to overall neuronal loss. These changes could cause sensitization of the CRF circuits to even mild stress in adulthood, leading to an exaggerated stress response
ETIOLOGY of depressive disorder (PSYchological factors)
Cognitive Theory: in cognitive theory the underlying assumption is that a person’s thoughts will result in emotions. If a person looks at their life in a posi- tive way, the person will experience positive emotions, but negative in- terpretation of life events can result in sorrow, anger, and hopelessness. Cognitive theorists believe that people may acquire a psychological predisposition to depression due to early life experiences. These experi- ences contribute to negative, illogical, and irrational thought processes that may remain dormant until they are activated during times of stress.
Theorists found that people with depression process information in negative ways, even in the midst of positive factors. They believed that automatic, negative, repetitive, un- intended, and not readily controllable thoughts perpetuate depression. Three thoughts constitute
Beck’s cognitive triad:
1. A negative, self-deprecating view of self
2. A pessimistic view of the world
3. The belief that negative reinforcement (or no validation for the self)
will continue in the future
Realizing that one has an ability to interpret life events in positive ways provides an element of control over emotions and, therefore, over depression.
Learned Helplessness:
An older but still plausible theory of depression is that of learned help- lessness. Seligman (1973) stated that although anxiety is the initial response to a stressful situation, it is replaced by depression if the person feels no control over the outcome of a situation. A person who believes that an undesired event is their fault and that nothing can be done to change it is prone to depression.
Depression BIOCHEMICAL
Two of the main neurotransmitters involved in mood are serotonin (5-hydroxytryptamine [5-HT]) and norepinephrine. Serotonin is an important regulator of sleep, appetite, and libido. Therefore serotonin circuit dysfunction can result in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability. Norepinephrine modulates attention and behaviour. It is stimulated by stressful situa- tions, which may result in overuse and a deficiency of norepinephrine. A deficiency, an imbalance as compared with other neurotransmitters, or an impaired ability to use available norepinephrine can result in apa- thy, reduced responsiveness, or slowed psychomotor activity.
Research suggests that depression results from the dysregulation of a number of neurotransmitter systems beyond serotonin and norepi- nephrine. For example, glutamate is a common neurotransmitter that increases the ability of a nerve fibre to transmit information. A deficit in glutamate can interfere with normal neuron transmission in the ar- eas of the brain that affect mood, attention, and cognition.
Stressful life events, especially losses, seem to be a significant fac- tor in the development of depression. Norepinephrine, serotonin, and acetylcholine play a role in stress regulation. When these neurotrans- mitters become overtaxed through stressful events, neurotransmitter depletion may occur. Research indicates that stress is associated with a reduction in neurogenesis, which is the ability of the brain to produce new brain cells.
At this time, no single mechanism of depressant action has been found. The relationships among the serotonin, norepinephrine, dopa- mine, acetylcholine, gamma-aminobutyric acid (GABA), and glutamate systems are complex and need further assessment and study. However, treatment with medication that helps regulate these neurotransmitters has proven to be empirically successful in the treatment of many patients.
BOX 13.1 Risk Factors for Depression
Female gender
* Early childhood trauma
* Stressful life events
* Family history of depression, especially in first-degree relatives
* High levels of neuroticism (a negative personality trait characterized by
anxiety, fear, moodiness, worry, envy, frustration, jealousy, and loneliness)
* Other disorders such as substance use, anxiety, and personality disorders
* Chronic or disabling medical conditions
General Assessment
Assessment tools:
Beck Depression Inventory:
Hamilton Depression Rating Scale: asks about depressed mood, feelings of guilt, suicide, somatic symptoms (loss of appetite, heavy feelings in abd), general somatic symptoms (heaviness in limbs, back/ head), reproductive symptoms, illness anxiety, motor (slowness of thought and speech, decreased motor activity), work and activities, agitation
Zung Self-Rating Depression Scale:
Geriatric Depression Scale:
The Patient Health Questionnaire–9 (PHQ-9), a short inventory that highlights predominant symptoms of depression, is presented here be- cause of its ease of use.
Many clinicians also use the mnemonic SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal thoughts) to guide their assessment.
Assessment of Suicide Potential
Suicidal ideation. The most dangerous aspect of MDD is a pre- occupation with death. A patient may fantasize about their funeral or experience recurring dreams about death. Beyond these passive fan- tasies are thoughts of wanting to die. As a whole, all of these nihilistic thoughts are referred to as suicidal ideation.
Suicidal ideation, especially that in which the patient has a plan for suicide and the means to carry the plan out, represents an emergency requiring immediate intervention.
Suicidal thoughts are a major reason for hospitalization for patients with major depression.
Patients diagnosed with MDD should always be evaluated for suicidal ideation. Risk for suicide is increased when depression is accompanied by hopelessness, substance use problems, a recent loss or separation, a history of past suicide attempts, or acute suicidal ideation.
The following statements and questions help set the stage for assessing suicide potential:
- You have said you are depressed. Tell me what that is like for you. * When you feel depressed, what thoughts go through your mind? * Have you gone so far as to think about taking your own life?
- Do you have a suicide plan?
- Do you have the means to carry out your plan?
- Is there anything that would prevent you from carrying out your plan?
anhedonia
(loss of ability to experience joy or pleasure in living)
Key Assessment Findings of depressive disorders
A depressed mood and anhedonia (loss of ability to experience joy or pleasure in living) are the key symptoms of depression. Almost 97% of people with depression have anhedonia.
Anxiety, a common symptom in depression, is seen in about 60% to 90% of patients with depression.
Psychomotor agitation may be evidenced by constant pacing and wringing of hands. The slowed movements of psychomotor retardation, however, are more common. Somatic complaints (e.g., headaches, malaise, backaches) are also common. Vegetative signs of depression, alterations in those activities necessary to support physical life and growth (e.g., change in bowel movements and eating habits, sleep distur- bances, lack of interest in sex), are universally present.
Areas to Assess in depressive disorders
Affect is the outward presentation of a person’s internal state of being. It is reported as an objective finding based on the nurse’s assessment. A person who has depression sees the world through grey- coloured glasses. Posture is poor, and the patient may look older than their stated age. Facial expressions convey sadness and dejection, and the patient may have frequent bouts of weeping. Conversely, the patient may say that they are unable to cry. Feelings of worthlessness, guilt, anger, helplessness, hopelessness, and despair are readily reflected in the person’s affect. For example, the patient may not make eye contact, may speak in a monotone, may show little or no facial expression (flat affect), and may make only “yes” or “no” responses.
Thought processes. During a depressive episode, the person’s abil- ity to solve problems and think clearly is negatively affected. Judgement is poor, and indecisiveness is common, largely because thinking is slow and memory and concentration are poor. People with depression also dwell on and exaggerate their perceived faults and failures and are un- able to focus on their strengths and successes. They may experience delusions of being punished for doing bad deeds or being a terrible person. Common statements of delusional thinking are “I have com- mitted unpardonable sins,” “God wants me dead,” and “I am wicked and should die.”
Mood. Mood is the patient’s subjective experience of sustained emotions or feelings. People, when asked to describe their mood, will describe how they are feeling. Should a patient describe a feeling when asked about their mood, the clinician needs to follow up with a question asking about how long they have felt this way. Mood is about feel- ings that last over several days, weeks, or months.
Feelings. Feelings frequently reported by those with depression include worthlessness, guilt, helplessness, hopelessness, and anger. Feelings of worthlessness range from feeling inadequate to having an unrealistically negative evaluation of self-worth. These feelings reflect the low self-esteem that is a painful partner to depression. Statements such as “I am no good” or “I’ll never amount to anything” are common. Anhedonia (an “without” + hedone “pleasure” = inability to feel happy) refers to the absence of happiness or pleasure in aspects of life that once made the patient happy.
Guilt is a nearly universal accompaniment to depression. A person may ruminate over present or past failings: “I was never a good par- ent,” or “it’s my fault that project at work failed.”
Cognitive changes. Helplessness is demonstrated by a person’s inability to solve problems in response to common concerns. In severe situations helplessness may be evidenced by the inability to carry out the simplest tasks (e.g., grooming, doing housework, working, caring for children) because they seem too difficult to accomplish. With feelings of helplessness come feelings of hopelessness, which are particularly correlated with suicidality. Even though most depressive episodes are time limited, people experiencing them believe that things will never change. This feeling of utter hopelessness can lead people to view suicide as a way out of constant mental pain. Hopelessness includes the following attributes:
* Negative expectations for the future
* Loss of control over future outcomes
* Passive acceptance of the futility of planning to achieve goals
* Emotional negativism, as expressed in despair, despondency, or de-
pression
Physical behaviour. Lethargy and fatigue may result in psychomotor retardation, in which movements are extremely slow, facial expres- sions are decreased, and the gaze is fixed. The continuum of psycho- motor retardation may range from slowed and difficult movements to complete inactivity and incontinence. Psychomotor agitation, in which patients constantly pace, bite their nails, smoke, tap their fingers, or engage in some other tension-relieving activity, may also be observed. At these times, patients commonly feel fidgety and unable to relax.
Vegetative signs of depression refer to alterations in those activities necessary to support physical life and growth (e.g., eating, sleeping, elimination, sex). Appetite changes vary in individuals experiencing depression. Appetite loss is common, and sometimes patients can lose up to 5% of their body weight in less than a month. Other patients find they eat more often and complain of weight gain.
Change in sleep pattern is a cardinal sign of depression. Often people experience insomnia, wake frequently, and have a total reduction in sleep, especially deep-stage sleep. Waking at 3 or 4 a.m. and then staying awake is common, as is sleeping for short periods only. For some, sleep is increased (hypersomnia) and provides an escape from painful feelings.
Grooming, dressing, and personal hygiene may be markedly neglected. People who usually take pride in their appearance and dress may allow themselves to look shabby and unkempt.
Sexual interest declines (loss of libido) during depression. Some men experience impotence, and a declining interest in sex often occurs among both men and women, which can further complicate marital and social relationships.
Changes in bowel habits are common. Constipation is seen most frequently in patients with psychomotor retardation. Diarrhea occurs less frequently, often in conjunction with psychomotor agitation or anxiety.
Communication. A person with depression may speak and comprehend very slowly. The lack of an immediate response by the patient to a remark does not necessarily mean the patient has not heard or chooses not to reply; the patient may need more time to comprehend what was said and then compose a reply.
Religious beliefs and spirituality. Many studies have found a negative correlation between relational spiritual factors and depression. Specifically, it seems to be spiritual instability and a disappointment in a higher power that are predictors of depression. Encouraging a connection with religious or spiritual practices that have brought the pa- tient comfort in the past may be therapeutic.
Anger
is a strong feeling of displeasure or hostility. It is a natural outcome of profound feelings of helplessness. Anger in depression is often expressed inappropriately through hurtful verbal attacks, physical aggression toward others, or destruction of property, and anger may be directed toward the self in the form of suicidal or otherwise self- destructive behaviours (e.g., alcohol abuse, substance use, overeating, smoking). These behaviours often reinforce feelings of low self-esteem and worthlessness.
Assessment of children and adolescents for depressive disorders
The core symptoms of depression in children and adolescents are the same as for adults, which are sadness and loss of pleasure. What differs is how these symptoms are displayed. For example, a very young child may cry, a school-aged child might withdraw, and a teenager may become irritable in response to feeling sad or hopeless. Younger children may suddenly refuse to go to school while adolescents may engage in substance use or sexual promiscuity and be preoccupied with death or suicide.
Assessment of older persons for depressive symptoms
Because older persons are more likely to complain of physical illness than emotional concerns, depression might be overlooked. Older patients actually do have comorbid physical prob- lems, and it is difficult to determine whether fatigue, pain, and weakness are the result of an illness or depression. The Geriatric Depression Scale is a 30-item tool that is both valid and reliable in screening for depression in the older person.
Self-Assessment
Patients with depression often reject the advice, encouragement, and understanding of the nurse and others, and they often appear not to respond to nursing interventions and seem resistant to change. When this occurs, the nurse may experience feelings of frustration, hopeless- ness, and annoyance. These problematic responses can be altered in the following ways:
* Recognizing any unrealistic expectations for yourself or the patient * Identifying feelings that originate with the patient
* Understanding the roles that biology and genetics play in the pre-
cipitation and maintenance of a depressed mood
Realistic expecta- tions of self and the patient can decrease feelings of helplessness and increase a nurse’s self-esteem and therapeutic potential.
You can discuss feelings of annoyance, hopelessness, and helplessness with peers and supervisors to separate personal feelings from those origi- nating with the patient. If personal feelings are not recognized, named, and examined, the nurse is likely to withdraw.
People instinctively avoid situations and other people that arouse feelings of frustration, annoyance, or intimidation. If the nurse also has unresolved feelings of anger and depression, the complexity of the situation is compounded. There is no substitute for competent and sup- portive supervision to facilitate growth, both professionally and per sonally. Being supervised by a more experienced clinician and sharing with peers help minimize feelings of confusion, frustration, and isolation and can increase your therapeutic potential and self-esteem while you care for individuals with depression.
Depression
1.Always evaluate the patient’s risk for harm to self or others. Overt hostility is highly correlated with suicide.
2. Depression is a mood disorder that can be secondary to a host of medical or other psychiatric disorders, as well as to medications. A thorough medical and neurological examination helps determine if the depression is primary or secondary to another disorder. Essentially, evaluate whether:
* The patient is psychotic
* The patient has taken drugs or alcohol
* Medical conditions are present
* The patient has a history of a comorbid psychiatric syndrome (eating
disorder, borderline or anxiety disorder)
3. Assess the patient’s past history of depression, what past treatments
worked and did not work, and any events that may have triggered this epi-
sode of depression.
4. Assess support systems, family, significant others, and the need for infor-
mation and referrals.
DIAGNOSIS of depressive disorder
Depression is a complex disorder, and individuals with depression have a variety of needs; therefore nursing diagnoses are many. How- ever, a high priority for the nurse is determining the risk for suicide,
and the nursing diagnosis of Risk for suicide is always considered.
Other key targets for nursing interventions are represented by the diagnoses of Hopelessness, Ineffective coping, Social isolation, Spiritual distress, and Self-care deficit (bathing, dressing, feeding, toileting).
Potential Nursing Diagnoses for Depression
Previous suicide attempts, putting affairs in order, giving away prized possessions, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness
Risk for suicide
Risk for self-mutilation
Risk for self-harm
———–
Lack of judgement, memory difficulty, poor concentration, inaccurate interpretation of environment, negative ruminations, cognitive distortions
Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope
Ineffective coping
Interrupted family processes
Risk for impaired attachment
Ineffective role performance
Difficulty making decisions, poor concentration, inability to take action
Decisional conflict
Feelings of helplessness, hopelessness, powerlessness
Hopelessness
Powerlessness
__________
Questioning the meaning of life and own existence, inability to participate in usual religious practices, conflict over spiritual beliefs, anger toward spiritual deity or religious representatives
Spiritual distress
Impaired religiosity
Risk for impaired religiosity
___________
Feelings of worthlessness, poor self-image, negative sense of self, self-negating verbalizations, feeling of being a failure, expressions of shame or guilt, hypersensitivity to slights or criticism
Chronic low self-esteem
Situational low self-esteem
___________
Withdrawal, non-communicativeness, monosyllabic speech, avoidance of contact with others
Impaired social interaction
Social isolation
Risk for loneliness
____________
Vegetative signs of depression: changes in sleeping, eating, grooming and hygiene, elimination, sexual patterns
Self-care deficit (bathing, dressing, feeding, toileting)
Imbalanced nutrition: less than body requirements
Disturbed sleep pattern
Constipation
Sexual dysfunction
OUTCOMES IDENTIFICATION of depressive disorders
The Recovery Model: The recov- ery model emphasizes that individuals with mental illnesses, including depression, can learn to live with their disease. It is individuals who define who they are, not their diseases. Recovery is attained through partnership with health care providers who focus on the patient’s strengths. Treatment goals are mutually developed based on the patient’s personal needs and values, and interventions are evidence informed. The recovery model is consistent with the focus on patient-centred care, which is a key component of safe, quality health care. Remember that MDD can be a recurrent and chronic illness. Care should be directed not only at the resolution of the acute phase but also at long-term management.
PLANNING
The planning of care for patients with depression is geared toward the patient’s phase of depression, particular symptoms, and personal goals. At all times during the care of a person with depression, nurses and members of the health care team must be cognizant of the potential for suicide; therefore assessment of risk for self-harm (or harm to oth- ers) is ongoing. A combination of therapy (cognitive, behavioural, and interpersonal) and psychopharmacology is an effective approach to the treatment of depression across all age groups.
Be aware that the vegetative signs of depression (e.g., changes in eating, sleeping, and sexual satisfaction), as well as changes in concentration, activity level, social interaction, care for personal appearance, and so on, often need targeting. The planning of care for a patient with depression is based on the individual’s symptoms and goals, and it at- tempts to encompass a variety of areas in the person’s life.
Safety is always the highest priority.
IMPLEMENTATION for depressive disorders
There are three phases in the treatment of and recovery from major depression:
- The acute phase (6 to 12 weeks) is directed at reduction of depres- sive symptoms and restoration of psychosocial and work function. Hospitalization may be required.
- The continuation phase (4 to 9 months) is directed at prevention of relapse through pharmacotherapy, education, and depression- specific psychotherapy.
- The maintenance phase (1 year or more) of treatment is directed at prevention of reoccurrences of depression.
It is important to keep in mind that the primary goal of both the continuation and the maintenance phases is keeping the patient a func- tional and contributing member of the community after recovery from the acute phase.
Counselling and Communication Techniques
Some patients with depression may be so withdrawn that they are un- willing or unable to speak. Nurses often experience some difficulty communicating with patients without talking; just sitting with them in silence may seem like a waste of time or be uncomfortable. As anxi- ety increases, the nurse may start daydreaming, feel bored, remember something that “must be done now,” and so on. It is important to be aware, however, that this time can be meaningful, especially for the nurse who has a genuine interest in learning about the patient with depression.
Health Teaching and Health Promotion
One basic premise of the recovery model of mental illness is that each person controls their own treatment based on individual goals. Within this model, health teaching is especially important because it allows patients to make informed choices. Health teaching is also an avenue for providing hope to the patient and should include the following in- formation:
- Depression is an illness that is beyond a person’s voluntary control.
- Although it is beyond voluntary control, depression can be managed through medication and lifestyle.
- Illness management depends in large part on understanding personal signs and symptoms of relapse.
- Illness management depends on understanding the role of medication and possible adverse effects of medication.
- Long-term management is best assured if the patient undergoes
psychotherapy along with taking medication. - Identifying and coping with the stress of interpersonal relationships, whether they are familial, social, or occupational, is a key to illness management.
- Including the family in discharge planning is also important and helps the patient in the following ways:
- Increases the family’s understanding and acceptance of the family member and helps family recognize the importance of medication adherence during the aftercare period.
- Increases the patient’s use of aftercare facilities in the community.
- Contributes to higher overall adjustment in the patient after discharge.
Nursing outcomes Related to Depression
Depression self-control: Personal actions to minimize melancholy and maintain interest in life events
Intermediate indicators:
Reports improved mood Adheres to therapy schedule Takes medication as prescribed Follows treatment plan
Short-term indicators:
Monitors intensity of depression
Identifies precursors of depression
Plans strategies to reduce effects of precursors Reports changes in symptoms to health care provider
Communicating With Severely Withdrawn People
Intervention
When a patient is mute, use the technique of making observations: “There are many new pictures on your wall.” “You are wearing your new shoes.” “You ate some of your breakfast.”
Use simple, concrete words.
Allow time for the patient to respond.
Listen for covert messages and ask about suicide plans.
Avoid platitudes such as “Things will look up,” “Everyone gets down once in a while,” or “Tomorrow will be better.”
Rationale
When a patient is not ready to talk, direct questions can raise the patient’s anxiety level and frustrate the nurse. Pointing to commonalities in the environment draws the patient into and reinforces reality.
Slowed thinking and difficulty concentrating impair comprehension.
Slowed thinking necessitates time to formulate a response.
People often experience relief and a decrease in feelings of isolation when they share thoughts of suicide.
Platitudes tend to minimize the patient’s feelings and can increase feelings of guilt and worthlessness, because the patient cannot “look up” or “snap out of it.”
Counselling People With Depression
Intervention
Help the patient question underlying assumptions and beliefs and consider alternative explanations for problems.
Work with the patient to identify cognitive distortions that encourage negative self-appraisal. For example:
a. Overgeneralizations
b. Self-blame
c. Mind reading
d. Discounting of positive attributes
Encourage activities that can raise self-esteem. Identify need for (1) problem-solving skills, (2) coping skills, and (3) assertiveness skills.
Encourage exercise, such as running or weight lifting.
Encourage formation of supportive relationships, such as through sup- port groups, therapy, and peer support.
Provide information referrals, when needed, for religious or spiritual information (e.g., readings, programs, tapes, community resources).
Rationale
Reconstructing a healthier and more hopeful attitude about the future can alter depressed mood.
Cognitive distortions reinforce a negative, inaccurate perception of self and world.
a. The patient takes one fact or event and makes a general rule out of it (“He always …”;
“I never…”).
b. The patient consistently blames self for everything perceived as negative.
c. The patient assumes others do not like them without any real evidence that assump-
tions are correct.
d. The patient focuses on the negative.
Many people with depression, especially women, are not taught a range of problem-solv- ing and coping skills. Increasing social, family, and job skills can change negative self- assessment.
Exercise can improve self-concept and potentially shift neurochemical balance.
Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs.
Spiritual and existential issues may be heightened during depressive episodes; many people find strength and comfort in spirituality or religion.
Promotion of Self-Care Activities
In addition to feelings of hopelessness, despair, and physical discomfort, signs of physical neglect may be apparent, in which case nursing measures for improving physical well-being and promoting adequate self-care are initiated.
Milieu Management: Teamwork and Safety
Safe, quality inpatient care requires the skills of a well-coordinated team.
Treating a patient with depression requires the skills of nurses and prescribers. Other members of the team include mental health technicians, pharmacists, dietitians, social workers, and the patient’s significant others.
Safety becomes the most important issue facing a team that cares for people with depression who may be at high risk for suicide. Suicide pre- cautions are usually instituted and include the removal of all harmful ob- jects such as “sharps” (e.g., razors, scissors, nail files), strangulation risks (e.g., belts), and medication that can be used to overdose. Some patients with severe depression may need to have someone check on them frequently, perhaps every 15 minutes, or even have one-to-one observation.
TABLE 13.4 Interventions Targeting the Vegetative Signs of Depression
Nutrition—Anorexia
Offer small, high-calorie and high-protein snacks frequently throughout the day and evening.
Low weight and poor nutrition render the patient susceptible to illness. Small, frequent snacks are more easily tolerated than large plates of food when the patient is anorexic.
_____
Offer high-protein and high-calorie fluids frequently throughout the day and evening.
These fluids prevent dehydration and can minimize constipation.
______
When possible, encourage family or friends to remain with the patient during meals.
This strategy reinforces the idea that someone cares, can raise the patient’s self-esteem, and can serve as an incentive to eat.
_______
Ask the patient which foods or drinks they like. Offer choices. Involve the dietitian.
The patient is more likely to eat the foods provided.
______
Weigh the patient weekly and observe the patient’s eating patterns.
Monitoring the patient’s status gives the information needed for revision of the intervention.
______
Sleep—Insomnia
Provide periods of rest after activities.
Fatigue can intensify feelings of depression.
______
Encourage the patient to get up and dress and to stay out of bed during the day.
Minimizing sleep during the day increases the likelihood of sleep at night.
______
Encourage the use of relaxation measures in the evening (e.g., tepid bath, warm milk).
These measures induce relaxation and sleep.
________
Reduce environmental and physical stimulants in the evening—provide decaffeinated coffee, soft lights, soft music, and quiet activities.
Decreasing caffeine and epinephrine levels increases the possibility of sleep.
________
Self-Care Deficits
Encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment, and so forth.
Being clean and well groomed can temporarily increase self-esteem.
_______
When appropriate, give step-by-step reminders such as “Wash the right side of your face; now the left.”
Slowed thinking and difficulty concentrating make organizing simple tasks difficult.
_________
Elimination—Constipation
Monitor intake and output, especially bowel movements.
Many patients with depression are constipated. If the condition is not checked, fecal impaction can occur.
_________
Offer foods high in fibre, and provide periods of exercise.
Roughage and exercise stimulate peristalsis and help evacuation of fecal material.
________
Encourage the intake of fluids.
Fluids help prevent constipation.
_________
Evaluate the need for laxatives and enemas.
These measures prevent fecal impaction.
Antidepressant Drugs
Antidepressant drugs can positively alter poor self-concept, degree of withdrawal, vegetative signs of depression, and activity level. Target symptoms include:
* Sleep disturbance
* Appetite disturbance (decreased or increased) * Fatigue
* Decreased sex drive
* Psychomotor retardation or agitation
* Diurnal variations in mood (often worse in the morning) * Impaired concentration or forgetfulness
* Anhedonia
A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. If a patient is acutely suicidal, electro- convulsive therapy can be a reliable and effective alternative.
The goal of antidepressant therapy is the complete remission of symptoms.
Antidepressants may precipitate a psychotic episode in a person with schizophrenia or a manic episode in a patient with bipolar dis- order. Patients with bipolar disorder often receive a mood-stabilizing drug along with an antidepressant.
Neurobiology of Depression and the Effect of Antidepressants
The imbalance of certain neurotransmitters (serotonin and norepinephrine) contributes to depression in certain parts of the brain.
Prefrontal cortex: regulates role in executive functions and emotional control and memory.
Limbic system: regulates activities such as emotions, physical and sexual drives, and the stress response, as well as processing,
learning, and memory (amygdala, hypothalamus, hippocampus).
Anterior cingulate cortex: regulates heart rate and blood pressure. Other functions include decision making, emotional regulation, error detection, preparation for tasks, and executive functions.
Various Parts of the Brain Along the Noradrenergic Pathway;
The axons of these neurons project upward through the forebrain to the cerebral cortex, the limbic system, the thalamus, and the hippocampus.
Norepinephrine (NE) and the Noradrenergic System: plays a major role in mood and emotional behaviour as well as energy, drive, anxiety, focus, and metabolism.
Norepinephrine- receptors (a1, a2, B1, B2); causes changes in mood, in attention and arousal, stimulate sympathetic branch of ANS for fight or flight in response to stress; [decreases- depression, increases- anxiety states, mania, schizoprenia]
Various Parts of the Brain Along the Serotonergic Pathway
The axons of serotonergic neurons originate in the raphe nuclei of the brainstem and project to the cerebral cortex, the limbic system, cerebellum, and spinal cord.
Serotonin (5-HT) and the Serotonergic System: involved in the regulation of pain, depression, pleasure, anxiety, panic arousal, sleep cycle, carbohydrate craving, and premenstrual syndrome.
Serotonin: receptors (5-HT); plays a role in sleep regulation, hunger, mood states, and pain perception, alters hormonal activity, play a role in agression and sexual behaviour, involved in alertness and inflammatory response, stimulates gastric secretion [decreases- depression, increases- anxiety states]
Medications for Depression
Medications for depression include the selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), serotonin antagonist and reuptake inhibitors (SARIs), norepinephrine–dopamine reuptake inhibitor (NDRI), noradrenergic and specific serotonergic antidepressants (NaSSAs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs).
They all work equally well and are chosen by their safety profile and side effects.*
All have a delayed response, a discontinuation syndrome, and a Black Box Warning for suicide.
All antidepressants work to
increase the availability of one or more of the neurotransmitters, serotonin, nor- epinephrine, or dopamine.
Each of the antidepressants has different adverse ef- fects, costs, safety issues, and maintenance considerations. Selection of the appropriate antidepressant is based on the following considerations:
* Adverse-effect profile (e.g., sexual dysfunction, weight gain)
* Ease of administration
* History of past response
* Safety and medical considerations
Selective Serotonin Reuptake Inhibitors (SSRIs)
Citalopram (Celexa)
Fluoxetine (Prozac)
Fluvoxamine (Luvox) P
aroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Cipralex)
LINE/TINE/MINE/PRAM
Blocks the reuptake of serotonin
First-line treatment for major depression
Some SSRIs activate and others sedate; choice depends on patient symptoms
Risk of lethal overdose minimized with SSRIs
AE: Agitation, insomnia, headache, nausea
and vomiting, sexual dysfunction, hyponatremia, blurred vision, urinary retention
Warning;
Discontinuation syndrome— dizziness, insomnia, nervousness, irritability, nausea, and agitation—may occur with abrupt withdrawal (depending on half-life); taper slowly
Contraindicated in people taking MAOIs
Essentially, the SSRIs selectively block the neuronal uptake of serotonin (e.g., 5-HT, 5-HT1 receptors), which increases the availability of serotonin in the synaptic cleft.
Because the SSRIs cause relatively few adverse effects and have low cardiotoxicity, they are less dangerous than older antidepressants when taken in overdose.
Indications. The SSRIs have a broad base of clinical use. In addi- tion to their use in treating depressive disorders, the SSRIs have been prescribed with success to treat some anxiety disorders, in particular, obsessive-compulsive disorder and panic disorder. Fluoxetine has been found to be effective in treating some women who suffer from late luteal phase dysphoric disorder and bulimia nervosa.
Common adverse reactions. Drugs that selectively enhance synap- tic serotonin within the CNS may induce agitation, anxiety, sleep dis- turbance, tremor, sexual dysfunction (primarily anorgasmia), or tension headache.
**The effect of the SSRIs on sexual performance may be the most significant undesirable outcome reported by patients.
Autonomic reactions (e.g., dry mouth, sweating, weight change, mild nausea, loose bowel movements) may also be experienced with the SSRIs.
Potential toxic effects. One rare and life-threatening event associ- ated with SSRIs is serotonin syndrome. This syndrome is thought to be related to overactivation of the central serotonin receptors, caused by either too high a dose or interaction with other drugs, including non-prescription medication like St. John’s wort. Symptoms include abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental state (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change. Severe manifestations can induce hyperpyrexia (excessively high fever), car- diovascular shock, or death. The risk of this syndrome seems to be greatest when an SSRI is ad- ministered in combination with a second serotonin-enhancing agent, such as a monoamine oxidase inhibitor (MAOI).
Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs)
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
VD
Blocks the reuptake of serotonin and norepinephrine
Effexor is a popular next-step strategy after trying SSRIs
Cymbalta has the advantage of decreasing neuropathic pain (similar to TCAs)
AE:
Hypertension (venlafaxine), nausea, insomnia,
dry mouth, sweating, agitation, headache, sexual dysfunction
Warning:
Monitor blood pressure with Effexor, especially at higher doses and with a history of hypertension
Hypertension may be particularly noted in the diastolic measurement
Discontinuation syndrome (see SSRIs above)
Contraindicated in people taking MAOIs
The SNRIs inhibit the reuptake of both serotonin and norepinephrine. Pharmacological adverse effects are similar to those of the SSRIs, although the SSRIs may be tolerated better. The SNRIs are indicated for MDD.
Norepinephrine Reuptake Inhibitors (NRIs)
Venlafaxine (Effexor XR)
Duloxetine (Cymbalta)
Blocks the reuptake of norepinephrine and
enhances its transmission
Antidepressant effects similar to SSRIs and TCAs
Useful with severe depression and impaired social functioning
AE
Insomnia, sweating, dizziness, dry mouth, constipation, urinary hesitancy, tachycardia, decreased libido
Warning
Contraindicated in people taking MAOIs
Norepinephrine–Dopamine Reuptake Inhibitors (NDRIs)
Bupropion (Wellbutrin)
Blocks the reuptake of norepinephrine and
dopamine
Not indicated for patients under 18 years of age
Stimulant action may reduce appetite
May increase sexual desire Used as an aid to QUIT SMOKING
AE
Agitation, insomnia, headache, nausea and vomiting, seizures (0.4%)
Warning
Contraindicated in people taking MAOIs
High doses increase seizure risk, especially in people who are predisposed to seizures
Serotonin–Norepinephrine Disinhibitors (SNDIs)
Mirtazapine (Remeron)
Blocks α1-adrenergic receptors that normally inhibit norepinephrine and serotonin
Antidepressant effects equal SSRIs and may occur faster
AE
Weight gain, sedation, dizziness, headache; sexual dysfunction is rare
Warning
Drug-induced somnolence exaggerated by alcohol, benzodiazepines, and other CNS depressants
Contraindicated in people taking MAOIs
Tricyclic Antidepressants (TCAs)
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Nortriptyline (Aventyl)
Inhibits the reuptake of serotonin and norepinephrine (similar to SNRIs)
Antagonizes adrenergic, histaminergic, and muscarinic receptors
Therapeutic effects similar to SSRIs, but adverse effects are more prominent
May work better in melancholic depression
TCAs can worsen many cardiac and other medical conditions
AE
Antichollinergic effects
Dry mouth, constipation, urinary retention, blurred vision, orthostatic hypotension, cardiac toxicity, sedation
Warning
Lethal in overdose
Use cautiously in older persons and those with cardiac disorders, elevated intraocular pressure, urinary retention, hyperthyroidism, seizure disorders, or liver or kidney dysfunction
Contraindicated in people taking MAOIs
The TCAs inhibit the reuptake of nor- epinephrine and serotonin by the presynaptic neurons in the CNS, increasing the amount of time norepinephrine and serotonin are available to the postsynaptic receptors. This increase in norepineph- rine and serotonin in the brain is believed to be responsible for mood elevations.
Indications. The sedative effects of the TCAs are attributed to the blockage of histamine receptors A stimulating TCA, such as desipramine (Desipramine), may be best for a patient who is lethargic and fatigued. If a more sedating ef- fect is needed for agitation or restlessness, drugs such as amitriptyline (Elavil) and doxepin (Sinequan) may be more appropriate choices. Re- gardless of which TCA is given, the initial dose should always be low and increased gradually.
Common adverse reactions. The chemical structure of the TCAs closely resembles that of antipsychotic medications, and the anticholinergic actions are similar (e.g., dry mouth, blurred vision, tachycardia, constipation, urinary retention, esophageal reflux). These adverse effects are more common and more severe in patients taking antidepressants than in patients taking antipsychotic medica- tions. They usually are not serious and are often transitory, but uri- nary retention and severe constipation warrant immediate medical attention. Weight gain is also a common complaint among people taking TCAs.
The α-adrenergic blockade of the TCAs can produce postural-or- thostatic hypotension and tachycardia. Postural hypotension can lead to dizziness and increase the risk for falls.
Administering the total daily dose of TCA at night is beneficial for two reasons: (1) most TCAs have sedative effects and thereby aid sleep, and (2) the minor adverse effects occur while the individual is sleeping, which increases adherence to drug therapy.
Potential toxic effects. The most serious effects of the TCAs are cardiovascular: dysrhythmias, tachycardia, myocardial infarction, and heart block have been reported. Because the cardiac adverse effects are so serious, TCA use is considered a risk in older persons and patients with cardiac disease.
Adverse drug interactions. A few of the more common medi- cations usually not given while TCAs are being used are MAOIs, phenothiazines, barbiturates, disulfiram, oral contraceptives (or other estrogen preparations), anticoagulants, some antihyperten- sives, benzodiazepines, and alcohol.
Contraindications. People who have recently had a myocardial infarction (or other cardiovascular problems), those with narrow-angle glaucoma or a history of seizures, and women who are pregnant should not be treated with TCAs, except with extreme caution and careful monitoring.
Monoamine Oxidase Inhibitors (MAOIs)
Phenelzine (Nardil) & Tranylcypromine (Parnate); Inhibits the enzyme monoamine oxidase, which normally breaks down neurotransmitters, including serotonin and norepinephrine
Moclobemide (Manerix); Acts on serotonin, norepinephrine, and dopamine
Efficacy similar to other antidepressants, but dietary restrictions and potential drug interactions make this drug type less desirable
AE
Insomnia, nausea, agitation, confusion
Potential for hypertensive crisis or serotonin syndrome with concurrent use of other antidepressants
Warning
Contraindicated in people taking other antidepressants
Tyramine-rich food could bring about a hypertensive crisis
Many other drug interactions
Monoamine oxidase inhibitors. The enzyme monoamine oxidase is responsible for inactivating, or breaking down, certain monoamine neurotransmitters in the brain, such as norepinephrine, serotonin, do- pamine, and tyramine. When a person ingests an MAOI, these amines do not get inactivated, and there is an increase of neurotransmitters available for synaptic release in the brain. The increase in norepinephrine, serotonin, and dopamine is the desired effect because it results in mood elevation. The increase in tyramine, on the other hand, poses a problem. When the level of tyramine increases, and it is not inactivated by monoamine oxidase, high blood pressure, hypertensive crisis, and eventually cerebrovascular accident can occur. Therefore people taking these drugs must reduce or eliminate their intake of foods and drugs that contain high amounts of tyramine.
Because people with depression are often lethargic, confused, and apathetic, adherence to strict dietary limitations may not be realistic. That is why MAOIs, although highly effective, are not often given as a first-line treatment.
Indications. MAOIs are particularly effective for people with atypical depression (characterized by mood reactivity, oversleeping, and overeating), along with panic disorder, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and bulimia. The MAOIs commonly used in Canada at pres- ent are phenelzine (Nardil) and tranylcypromine sulphate (Parnate).
Common adverse reactions. Some common and troublesome long-term adverse effects of the MAOIs are orthostatic hypotension, weight gain, edema, change in cardiac rate and rhythm, constipation, urinary hesitancy, sexual dysfunction, vertigo, overactivity, muscle twitching, hypomanic and manic behaviour, insomnia, weakness, and fatigue.
Potential toxic effects. The most serious reaction to the MAOIs is an increase in blood pressure, with the possible development of in- tracranial hemorrhage, hyperpyrexia, convulsions, coma, and death. Therefore routine monitoring of blood pressure, especially during the first 6 weeks of treatment, is necessary.
Because many drugs, foods, and beverages can cause an increase in blood pressure in patients taking MAOIs, hypertensive crisis is a constant concern. The hypertensive crisis usually occurs within 15 to 90 minutes of ingestion of the contraindicated substance. Early symptoms include ir- ritability, anxiety, flushing, sweating, and a severe headache. The patient then becomes anxious, restless, and develops a fever. Eventually the fever becomes severe, seizures ensue, and coma or death is possible.
When a hypertensive crisis is suspected, immediate medical atten- tion is crucial. If ingestion is recent, gastric lavage and charcoal may be helpful. Pyrexia is treated with hypothermic blankets or ice packs. Fluid therapy is essential, particularly with hyperthermia. A short- acting antihypertensive agent such as nitroprusside, nitroglycerine, or phentolamine may be used. Intravenous benzodiazepines are useful for agitation and seizure control.
Contraindications. The use of MAOIs may be contraindicated with each of the following:
* Cerebrovascular disease
* Hypertension and congestive heart failure
* Liver disease
* Consumption of foods containing tyramine, tryptophan, and dopamine
* Use of certain medications
* Recurrent or severe headaches
* Surgery in the previous 10 to 14 days
* Age younger than 16 years
Serotonin Syndrome: Symptoms
and Interventions
Symptoms
* Hyperactivity or restlessness
* Tachycardia → cardiovascular shock
* Fever → hyperpyrexia
* Elevated blood pressure
* Altered mental states (delirium)
* Irrationality, mood swings, hostility
* Seizures → status epilepticus
* Myoclonus, incoordination, tonic rigidity
* Abdominal pain, diarrhea, bloating
* Apnea → death
Interventions
* Remove offending agents
* Initiate symptomatic treatment:
* Serotonin receptor blockade with cyproheptadine, methysergide, propranolol
* Cooling blankets, chlorpromazine for hyperthermia
* Dantrolene, diazepam for muscle rigidity or rigours
* Anticonvulsants
* Artificial ventilation
* Paralysis
PATIENT AND FAMILY TEACHING for Tricyclic Antidepressants (TCAs)
The patient and family should be told that mood elevation may take from 7 to 28 days. Up to 6 to 8 weeks may be required for the full effect to be reached and for major depressive symptoms to subside.
* The family should reinforce this information frequently to the family mem- ber with depression, who may have trouble remembering and may respond to ongoing reassurance.
* The patient should be reassured that drowsiness, dizziness, and hypoten- sion usually subside after the first few weeks.
* The patient should be cautioned to be careful when working around ma- chines, driving cars, and crossing streets because of possible altered re- flexes, drowsiness, or dizziness.
* Alcohol can block the effects of antidepressants. The patient should be told to refrain from drinking.
* If possible, the patient should take the full dose at bedtime to reduce the experience of adverse effects during the day.
* If the bedtime dose (or the once-a-day dose) is missed, the patient should take the dose within 3 hours; otherwise, the patient should wait until the usual medi- cation time on the next day. The patient should not double the dose.
* Suddenly stopping TCAs can cause nausea, altered heartbeat, nightmares, and cold sweats within 2 to 4 days. The patient should call the primary care provider or take one dose of the TCA until the primary care provider can be contacted.
Foods That Can Interact With Monoamine Oxidase Inhibitors (MAOIs)
Avocados, especially if over-ripe; fermented bean curd; fermented soybean; soybean paste
Figs, especially if over-ripe; bananas, in large amounts
Meats that are fermented, smoked, or otherwise aged; spoiled meats; liver, unless very fresh
Fermented varieties; bologna, pepperoni, salami, others
Dried or cured fish; fish that is fermented, smoked, or otherwise aged; spoiled fish
Practically all cheeses
Yeast extract (e.g., Marmite, Bovril)
Some imported beers, Chianti wines
Protein dietary supplements; soups (may contain protein extract); shrimp paste; soy sauce
Drugs That Can Interact With Monoamine Oxidase Inhibitors (MAOIs)
- Over-the-counter medications for colds, allergies, or congestion (any product containing ephedrine or phenylpropanolamine)
- Tricyclic antidepressants (imipramine, amitriptyline)
- Narcotics
- Antihypertensives (methyldopa, spironolactone)
- Amine precursors (levodopa, L-tryptophan)
- Sedatives (alcohol, barbiturates, benzodiazepines)
- General anesthetics
- Stimulants (amphetamines, cocaine)
PATIENT AND FAMILY TEACHING
Monoamine Oxidase Inhibitors (MAOIs)
- Educate and provide details to the patient and family to avoid certain foods and all medications (especially cold remedies) unless prescribed by and discussed with the patient’s primary care provider
- Give the patient a wallet card describing the MAOI regimen.
- Instruct the patient to avoid Chinese restaurants (sherry, brewer’s yeast,
and other contraindicated products may be used). - Advise the patient to go to the emergency department immediately if they
have a severe headache. - Ideally, blood pressure should be monitored during the first 6 weeks of
treatment (for both hypotensive and hypertensive effects). - After the MAOI is stopped, instruct the patient that dietary and drug restrictions should be maintained for 14 days.
Use of antidepressants by pregnant people.
There is evidence that depression has a negative effect on birth outcomes. Pre- eclampsia, diabetes, and hypertension have all been associated with maternal depression. Low birth weight, preterm birth, and small size for gestational age have been noted effects in infants born to maternal depression. It is known that antidepressants cross the placenta. Treat- ment of severe depression, particularly with suicidal ideation, must weigh out the risks versus the benefits.
Adverse Reactions to and Toxic Effects of Monoamine Oxidase Inhibitors (MAOIs)
AE
Hypotension
Insomnia
Changes in cardiac rhythm Anorgasmia or sexual impotence Urinary hesitancy or constipation Weight gain
Hypotension is a normal adverse effect of MAOIs.
Orthostatic blood pressures should be taken—first lying down, then sitting or standing after 1–2 minutes. Hypotension may be a dangerous adverse effect, especially in older persons who may fall and sustain injuries as a result of dizziness from the blood pressure drop.
Toxic effects
Hypertensive crisis
* Severe headache
* Tachycardia, palpitations
* Hypertension
* Nausea and vomiting
Patient should go to local emergency department immediately—blood pressure should be checked. One of the following may be given to lower blood pressure:
* 5 mg intravenous phentolamine
* Sublingual nifedipine to promote vasodilation
Patients may be prescribed a 10 mg nifedipine capsule to carry in case of emergency.
Use of antidepressants by children and adolescents.
In 2005 Health Canada issued a Black Box Warn- ing for all antidepressants, alerting the public to the increased risk for suicidal thinking or suicide attempts in children or adolescents under the age of 18 who are taking antidepressants. Following the Black Box Warning, the number of prescriptions written for SSRIs for children and young adults decreased, but the rates of suicide in those age groups actually increased.
Dudley and colleagues concluded that the risk for suicide is greater in children and adolescents with depression who do not take antidepressants. To minimize the risk for suicide in people taking antidepressants, close monitoring by health care providers and patient and caregiver educa- tion are essential.
Use of antidepressants by older persons.
Polypharmacy and the normal process of aging contribute to concerns about prescribing antidepressants for older persons. SSRIs are a first-line treatment for older persons, but they have the potential for aggravated adverse ef- fects. Starting doses are recommended to be half the lowest adult dose, with dose adjustments occurring no more frequently than every 7 days.
TCAs and MAOIs have adverse-effect profiles that are more dan- gerous for older persons, specifically cardiotoxicity with TCAs and hypotension with both classes. Any medication with an adverse effect of hypotension or sedation in older persons increases the risk for falls. Older persons should be cautioned against abrupt discontinuation of antidepressants because of the possibility of discontinuation syndrome, which causes anxiety, dysphoria, flulike symptoms, dizziness, excessive sweating, and insomnia.
Electroconvulsive Therapy for depressive disorders
(ECT) is a procedure in which electrical currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful
Indications. ECT is an effective acute treatment for non-responsive depression. Psychotic illnesses are the second most common indication for ECT. For drug-resistant patients with psy- chosis, a combination of ECT and antipsychotic medication has resulted in sustained improvement about 80% of the time. Depression associated with bipolar disorder remits in about 50% of the cases after ECT.
While medication is generally the first line of treatment, ECT may be a primary treatment in the following cases:
* When a patient is experiencing intense suicidal ideation, and there is a need for a rapid, definitive response
* When a patient is severely malnourished, exhausted, and dehydrated due to lengthy depression (after rehydration)
* If previous medication trials have not successfully treated the illness
* If the patient chooses
* When there is marked agitation, marked vegetative symptoms, or catatonia
* For major depression with psychotic features
* In pregnant people
* For people with rapid cycling mood swings (four or more in one year)
ECT is not effective, however, in patients with dysthymia, atypical depression, personality disorders, drug dependence, or depression secondary to situational or social difficulties.
Risk factors. Using ECT requires clinicians to weigh the risk of us- ing this method versus the risk of suicide, quality of life, and potential complications. Several conditions pose risks and require careful assess- ment and management. For example, because the heart can be stressed at the onset of the seizure and for up to 10 minutes after, careful as- sessment and management of hypertension, congestive heart failure, cardiac arrhythmias, and other cardiac conditions is warranted. ECT also stresses the brain as a result of increased cerebral oxygen, blood flow, and intracranial pressure. Conditions such as brain tumours and subdural hematomas may increase the risk of using ECT. Providers of care and patients need to weigh the risk of continued disability or potential suicide from depression against ECT treatment risks.
Procedure. The usual course of ECT for a patient with depression is two or three treatments per week to a total of 6 to 12 treatments. The procedure is explained to the patient, and informed consent is obtained from the patient or the patient’s substitute decision maker. The patient is usually given a general anesthetic to induce sleep and a muscle-par- alyzing agent to prevent muscle distress and fractures. These medica- tions have revolutionized the comfort and safety of ECT.
Patients should have a pre-ECT assessment, including a chest X- ray, electrocardiogram (ECG), urinalysis, complete blood count, blood urea nitrogen, and electrolyte panel. Benzodiazepines should be dis- continued, as they will interfere with the seizure process.
An electroencephalogram (EEG) monitors brain waves, and an ECG monitors cardiac responses. Brief seizures (30 to 60-plus seconds) are deliberately induced by an electrical current (as brief as 1 second) transmitted through electrodes attached to one or both sides of the head.
Adverse reactions. Patients wake about 15 minutes after the pro- cedure. The patient is often confused and disoriented for several hours. The nurse and family may need to orient the patient frequently during the course of treatment. Most people experience what is called retro- grade amnesia, which is a loss of memory of events leading up to and including the treatment itself.
Transcranial Magnetic Stimulation
(TMS) is a non-invasive treatment modality that uses magnetic resonance imaging (MRI)–strength mag- netic pulses to stimulate focal areas of the cerebral cortex (Figure 13.6).
Indications. In 2002 Canada approved the use of TMS for patients who have been unresponsive to at least one antidepressant. Research- ers suggest that TMS be used to enhance cognitive function in healthy, non-depressed individuals.
Risk factors. The only absolute contraindication to this procedure is the presence of metal in the area of stimulation. Cochlear implants, brain stimulators, or medication pumps are examples of metals that could interfere with the procedures
Procedure. Outpatient treatment with TMS takes about 30 min- utes and is typically ordered for 5 days a week for 4 to 6 weeks. Pa- tients are awake and alert during the procedure. An electromagnet is placed on the patient’s scalp, and short, magnetic pulses pass into the prefrontal cortex of the brain. These pulses are similar to those used by MRI scanners but are more focused. The pulses cause electrical charges to flow and induce neurons to fire or become active. During TMS, patients feel a slight tapping or knocking in the head, contraction of the scalp, and tightening of the jaw.
Potential adverse reactions. After the procedure, patients may ex- perience a headache and lightheadedness. No neurological deficits or memory problems have been noted. Seizures are a rare complication of TMS. Most of the common adverse effects of TMS are mild and include scalp tingling and discomfort at the administration site.
Nerve Stimulation
The use of vagus nerve stimulation (VNS) originated as a treatment for epilepsy. VNS is approved in Canada for treatment-resistant depression (TRD). Clinicians noted that while VNS decreased seizures, it also appeared to improve mood in a population that normally experiences increased rates of depression. The theory behind VNS relates to the action of the vagus nerve, the longest cranial nerve, which extends from the brainstem to organs in the neck, chest, and abdomen.
Researchers believe that electrical stimulation of the vagus nerve results in boosting the level of neurotransmitters, thereby improving mood and also improving the action of antidepressants.
Procedure. The surgery to implant VNS is typically an outpatient procedure. A pacemaker-like device is implanted surgically into the left chest wall. The device is connected to a thin, flexible wire that is threaded upward and wrapped around the vagus nerve on the left side of the neck.
After surgery, an infrared magnetic wand is held against the chest while a personal computer or personal digital assistant is used to program the frequency of pulses. Pulses are usually delivered for 30 seconds, every 5 minutes, 24 hours a day. Antidepressant action usually occurs in several weeks.
Non-surgical methods of VNS include deep diaphragmatic breath- ing, “om” chanting, and collecting saliva in your mouth and then sub- merging your tongue in the saliva pool.
Potential adverse reactions.
The implantation of VNS is a surgical procedure, carrying with it the risks inherent in any surgical procedure (e.g., pain, infection, sensitivity to anesthesia). Ad- verse effects of active VNS therapy are due to the position of the lead on the vagus nerve, which is close to the laryngeal and pharyngeal branches of the left vagus nerve. Voice alteration occurs in more than half of patients. Other adverse effects include neck pain, cough, paresthesia, and dyspnea, which tend to decrease with time. The device can be temporarily turned off at any time by placing a special magnet over the implant.
Advanced-Practice Interventions
Nurses and nurse practitioners are qualified to provide counselling, so- cial skills training, and group therapy
Psychotherapy for depressive disorders
CBT, interpersonal therapy (IPT), time-limited focused psychotherapy, and behavioural therapy all are considered especially effective in the treatment of mild to moderate depression.
However, only CBT and IPT were shown to demonstrate superiority in the maintenance phase.
CBT helps people change their negative thought patterns and behaviours, whereas IPT focuses on working through personal relationships that may contribute to depression.
Group therapy. for depressive disorders
Group therapy is a widespread modality for the treatment of depression; it increases the number of people who can receive treatment at a decreased cost per individual. Another advantage is that groups offer patients an opportunity to socialize and share common feelings and concerns, which decreases feelings of isolation, hopelessness, helplessness, and alienation. Therapy groups also provide a controlled environment in which patients can explore their patterns of interaction and response to others, which may contribute to or exac- erbate their depression.
Future of Treatment for depressive disorders
Priority areas for further development and research are:
* Improving screening for high-risk ages and groups, including:
* Individuals in late adolescence and early adulthood
* Women in reproductive years
* Adults and older persons with medical problems (e.g., pain)
* People with a family history of depression
* Increasing education, particularly about the link between physical symptoms and depression
* Integrating psychopharmacological treatment augmented with psy- chological and other non-pharmacological therapies
* Inclusion of more self-care strategies, such as:
* Promotion of sleep hygiene
* Increase in exercise
* Better overall health care
Evaluation
Outcomes relating to thought processes, self-esteem, and social interactions are frequently formulated, because these areas are often problematic in people with depression.
Physical needs warrant nursing or medical attention. If a patient has lost weight because of anorexia, is the appetite returning? If the patient was constipated, are the bowels now functioning normally? If the pa- tient was suffering from insomnia, are they now sleeping 6 to 8 hours per night? If indicators have not been met, an analysis of the data, nurs- ing diagnoses, goals, and planned nursing interventions is made. The care plan is reassessed and reformulated as necessary.
Depression example
Diagnosis
The nurse evaluates Ms. Glessner’s strengths and weaknesses and decides to concentrate on two initial nursing diagnoses that seem to have the highest priority: 1. Risk for suicide related to separation from 2-year relationship, as evidenced by actual suicide attempt
Outcomes Identification
Patient refrains from attempting suicide.
Planning
Because Ms. Glessner is discharged after 48 hours, the issue of disturbance in self-esteem continues to be addressed in her therapy after discharge. Ms. Ward later reviews the goals for her work with Ms. Glessner in the community.
Implementation
Short-Term Goal
1. Patient expresses at least one reason to live, apparent by the second day of hospitalization.
Intervention
1a. Observe patient every 15 minutes while she is suicidal.
1b.Remove all dangerous objects from patient.
1c. Obtain a “no self-harm” contract with patient for a specific period of time, to be renegotiated (Note: some provinces no longer use contracting).
1d.Spend regularly scheduled periods of time with patient throughout the day.
1e. Assist patient in evaluating both positive and negative aspects of her life.
1f. Encourage appropriate expression of angry feelings.
1g.Accept patient’s negativism.
Rationale
1a, b. Patient safety is ensured. The risk for impulsive self-harmful
behaviour is minimized.
1c. Contract may help patient gain a sense of control and a feeling of responsibility.
1d.This interaction reinforces that the patient is worthwhile and builds her experience in relating better to the nurse on a one-to-one basis.
1e. A person with depression is often unable to acknowledge any positive aspects of life unless they are pointed out by others.
1f. Providing for expression of pent-up hostility in a safe environment can reinforce more adaptive methods of releasing tension and may minimize need to act out self-directed anger.
1g.Acceptance enhances feelings of self-worth.
Goal Met
By the end of the second day, Ms. Glessner states that she really did not want to die; she just couldn’t stand the loneliness in her life. She states that she loves her sons and would never want to hurt them.
Short term goal
2. Patient will identify two outside supports she can call on if she feels suicidal in the future.
Intervention
2a. Explore usual coping behaviours.
2b.Assist patient in identifying members of her support system.
2c. Suggest a number of community- based support groups she might wish to discuss or visit (e.g., hotlines, support groups, women’s groups).
2d.Assist patient in identifying realistic alternatives she is willing to use.
Rationale
1g.Acceptance enhances feelings of self-worth.
2a. Behaviours that need reinforcing and new coping skills that need to be introduced can be identified.
2b.Strengths and weaknesses in her available support systems can be evaluated.
2c. Patient needs to be aware of community supports to use them.
2d.Unless patient agrees with any plan, she will be unable or unwilling to follow through in a crisis.
Goal Met
By discharge, Ms. Glessner states that she is definitely going to try cognitive behavioural therapy. She also discusses joining a women’s support group that meets once a week in a neighbouring town.
Evaluation
During the course of her work with Ms. Ward, Ms. Glessner decides to go to some meetings of Parents Without Partners. She states that she is looking forward to getting back to work and feels much more hopeful about her life. She has also lost 1.5 kg while attending Weight Watchers. She states, “I need to get back into the world.” Although Ms. Glessner still has negative thoughts about herself, she admits to feeling more hopeful and better about herself, and she has learned important tools to deal with her negative thoughts.
KEY POINTS TO REMEMBER
- There are a number of subtypes of depression and depressive clinical phenomena. The two primary depressive disorders are major depres- sive disorder (MDD) and persistent depressive disorder (dysthymia).
- The symptoms of major depression are usually severe enough to interfere with a person’s social or occupational functioning. A per- son with MDD may or may not have psychotic symptoms, and the symptoms usually exhibited during an episode of major depression are different from the characteristics of the normal personality pri- or to the onset of MDD.
- The symptoms of persistent depressive disorder are often chronic (lasting at least 2 years) and are considered mild to moderate. Usu- ally, a person’s social or occupational functioning is not greatly im- paired. The symptoms in persistent depressive disorder are often congruent with the person’s usual pattern of functioning.
- Many theories exist about the cause of depression. The most ac- cepted is biological (genetic and biochemical) factors; however, cognitive theory, learned helplessness theory, and the diathesis– stress theory help explain triggers to depression and maintenance of depressive thoughts and feelings.
- Nursing assessment includes the evaluation of affect, thought pro- cesses (especially suicidal thoughts), mood, feelings, physical behav- iour, communication, and religious beliefs and spirituality. The nurse also must be aware of the symptoms that may mask depression.
- Nursing diagnoses can be numerous. Individuals with depression are always evaluated for risk for suicide. Some other common nurs- ing diagnoses are Disturbed thought processes, Chronic low self-es- teem, Imbalanced nutrition, Constipation, Disturbed sleep pattern, Ineffective coping, and Interrupted family processes.
- Working with people who have depression can evoke intense feel- ings of hopelessness and frustration in health care workers. Nurses must clarify expectations of themselves and their patients and sort personal feelings from those communicated by the patient via em- pathy. Peer supervision and individual supervision by an experi- enced nurse clinician, psychiatric social worker, or psychologist are useful in increasing therapeutic potential.
- Interventions for patients who have depression involve several ap- proaches. Basic-level interventions include using specific principles of communication, planning activities of daily living, administering or participating in psychopharmacological therapy, maintaining a therapeutic environment, and teaching patients about the biochem- ical aspects of depression.
- Advanced-practice interventions may include several short-term psychotherapies that are effective in the treatment of depression including interpersonal therapy (IPT), cognitive behavioural thera- py (CBT), skills training (assertiveness and social skills), and some forms of group therapy.
- Depression is often overlooked in children, adolescents, and older persons because symptoms of depression are often mistaken for signs of normal development.
- Children and adolescents with disruptive mood dysregulation dis- order had previously been diagnosed with bipolar disorder. Usually people with this disorder grow up and are diagnosed with MDD or an anxiety disorder.
- Planning and interventions for patients with depression are based on the recovery model, which involves a therapeutic alliance with health care providers in order to achieve outcomes based on indi- vidual patient needs and values.
- Evaluation is ongoing throughout the nursing process, and patients’ outcomes are compared with the stated outcome criteria and short- term and intermediate indicators. The care plan is revised when in- dicators are not being met.
Mania
an exaggerated euphoria or irritability
3 types of bipolar disorders
bipolar I, bipolar II, and cyclothymic disorder.
Bipolar I disorder
is marked by severe shifts in mood, energy, and in- ability to function.
Periods of normal functioning may alternate with periods of illness (highs, lows, or a combination of both).
Experience chronic interpersonal or occupational difficulties even during remission.
Individuals with bipolar I disorder have experienced at least one manic episode. Mania is a period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy. These periods last at least 1 week for most of the day, every day.
Symptoms of mania are so severe that this state is a psychiatric emergency. Manic episodes usually alternate with depression or a mixed state of anxiety and depression.
Initially, individuals experiencing a manic episode feel euphoric and energized, they don’t sleep or eat, and they are in perpetual motion. They often take significant risks and engage in hazardous activities.
As the mania intensifies, individuals may become psychotic and ex- perience hallucinations, delusions, and dramatically disturbed thoughts and behaviour. Hallucinations tend to be auditory, and individuals may begin to hear voices, sometimes the voice of God. They may believe that they are a person of extreme influence and power.
The initial euphoria of mania gives way to agitation and irritabil- ity. Utter exhaustion eventually happens, and many people ultimately collapse into depression. Depression and the agitated state of mania is a dangerous combination that can lead to extreme behaviours such as violence or suicide.
People may be at equal risk for developing anxiety as depression after an episode of mania. They may even experience a major depressive disorder and generalized anxiety disorder simultaneously after a manic event.
Bipolar II Disorder
Individuals with bipolar II disorder have experienced at least one hypomanic episode and at least one major depressive episode.
Hypomania
Hypomania refers to a lower-level and less dramatic mania. However, this level of mania still causes significant issues in relationships and oc- cupational functioning. Like mania, hypomania is accompanied by ex- cessive activity and energy for at least 4 days and involves at least three of the behaviours listed under Criterion B in the Diagnostic and Statis- tical Manual of Mental Disorders, fifth edition (DSM-5).
Unlike mania, psychosis is never present with hypomania. Psychotic symptoms may, however, accompany the depressive side of the disorder. Hospitaliza- tion is rare. However, the depressive symptoms can be quite profound and may put those who suffer from it at particular risk for suicide.
Diagnostic Criteria for Bipolar I Disorder
Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irrita- ble) are present to a significant degree and represent a noticeable change from usual behaviour:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrel-
evant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation (i.e., purposeless non–goal-directed
activity).
7. Excessive involvement in activities that have a high potential for pain-
ful consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments).
C.The mood disturbance is sufficiently severe to cause marked impairment
in social or occupational functioning or to necessitate hospitalization to
prevent harm to self or others, or there are psychotic features.
D.The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical
condition.
Hypomanic episode
A. The mood change must be accompanied by persistently increased energy or activity levels.
B. Same criteria as manic episode except:
- shorter duration (may last only 4 days)
- does not cause significant impairment (without psychotic features or
requiring hospitalization)
Depressive episode
A. 5 or more of the following symptoms (at least one of which is 1 or 2) 1. depressed mood
2. diminished interest in activities
3. significant weight loss or gain
4. insomnia or hypersomnia
5. psychomotor agitation or retardation
6. fatigue/loss of energy
7. feelings of worthlessness or guilt
8. decreased concentration/indecisiveness 9. suicidal ideation/attempt
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syn- dromal level beyond the physiological effect of that treatment is suf- ficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
Note: Criteria A through D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.
Cyclothymic Disorder
Cyclothymic disorder has symptoms of hypomania alternating with symptoms of mild to moderate depression for at least 2 years in adults and 1 year in children. Hypomanic and depressive symptoms do not meet the criteria for either bipolar II or major depression, yet the symptoms are disturbing enough to cause social and occupational impairment.
As part of the spectrum of bipolar disorders, cyclothymic disorder may be difficult to distinguish from bipolar II disorder. Individuals with cyclothymic disorder tend to have irritable hypomanic episodes. Children with cyclothymic disorder experience irritability and sleep disturbance.
Some people experience rapid cycling and may have at least four changes in mood episodes in a 12-month period.
EPIDEMIOLOGY of bipolar disorder
Men and women have nearly equal rates of bipolar disorders, yet they respond somewhat differently to their conditions. Men with a bi- polar disorder are more likely to have legal problems and commit acts of violence. Women with a bipolar disorder are more likely to abuse alcohol, commit suicide, and develop thyroid disease.
Women who experience a severe postpartum psychosis within 2 weeks of giving birth have a four times greater chance of subsequent conversion to bipolar disorder. Giving birth may act as a trigger for the first symptoms of bipolar disorder. The precipitant may be hormonal changes and sleep deprivation.
Children and Adolescents of bipolar disorder
The existence of bipolar disorder in non-adults has been the subject of controversy. The most fundamental issue was that these children and adolescents did not usually go on to have bipolar disorder as adults. More commonly, they would eventually be diagnosed with major depression. Unfortunately, a bipolar diagnosis is a lifelong label, one that is stigmatized more than depression. This diagnosis also results in exposure to powerful medications during crucial growth periods.
Bipolar disorder in adolescence, particularly late adolescence, is a serious problem. The prevalence rate in this age group mirrors that of adults. Researchers estimate that one in five young people with mania plus depression will attempt suicide. Also, these young people experience nearly 2 months per year of role impairment. This impairment has significant implications for individuals who are positioning themselves for a lifetime and a career, as well as developing relationship patterns.
Cyclothymic Disorder (BD)
Cyclothymic disorder usually begins in adolescence or early adult- hood. There is a 15% to 50% risk that an individual with this disor- der will subsequently develop bipolar I or bipolar II disorder. A major risk factor for developing cyclothymic disorder is having a first-degree relative, parent, sibling, or child, with bipolar I disorder.
COMORBIDITY of bipolar disorder
Bipolar I Disorder
About 75% of people with bipolar I disorder also experience an anxiety disorder. These individuals may experience panic attacks, social anxiety disorder, and specific phobias.
A substance use disor- der is present in more than half of individuals with bipolar I, perhaps in an attempt to self-medicate or as a symptom related to increased risk taking. More than 50% of individuals have an alcohol use disorder, which in turn elevates the risk for suicide.
Further complicating treatment is a higher than normal rate of seri- ous medical conditions. Migraines are more common. Metabolic syn- drome, a cluster of problems such as high blood pressure, high blood glucose, excess body fat around the waist, and abnormal cholesterol levels, may lead to pre-mature death due to heart disease, stroke, and diabetes.
Bipolar II Disorder
As with bipolar I, about 75% of individuals with bipolar II disorder have a comorbid anxiety disorder. Typically, the anxiety disorders come about before the hypomania and depressive symptoms. Substance use disorders are also common and affect about 37% of people with bipolar II.
Cyclothymic Disorder
As with the bipolar disorders, substance use disorders are common with cyclothymic disorder. This may be due to efforts to self-medicate and sub- due the bipolar symptoms. Sleep disorders where people have difficulty going to sleep and staying asleep are often present in this disorder. Attention-deficit/hyperactivity disorder is more common among children with cyclothymic disorder.
ETIOLOGY of BD
Depressive episodes in bipolar disorder affect younger people, produce more episodes of illness, and require more frequent hospitalization. They are also characterized by higher rates of divorce and marital conflict.
Theories of the development and onset of bipolar disorders focus on biological, psychological, and environmental factors.
Biological Factors: Genetic
Bipolar illnesses tend to run in families, and the lifetime risk for in- dividuals with an affected parent is 15% to 30% greater.
The concordance rate among identical twins is around 70%. This means that if one twin has the disorder, 70% of the time the other one will, too. Despite the high concordance rate in identical twins, it is uncommon for clinicians to find a positive family history for bipolar disorder in these twins’ families. This finding probably means that the disease is polygenic or that a number of genes contribute to its expression.
Some evidence suggests that bipolar disorders are more prevalent in adults who had high intelligence quotients (IQs), and who were particularly verbal, as children. People with bipolar disorders appear to achieve higher levels of education and higher occupational status than individuals with unipolar depression. Also, the proportion of patients with bipolar disorders among creative writers, artists, highly educated men and women, and professionals is higher than in the general population.
Biological: Neurobiological for bipolar disorder
Neurotransmitters (norepinephrine, dopamine, and serotonin) have been studied since the 1960s as causal factors in mania and depression. One simple explanation is that having too few of these chemical messengers will result in depression and having an oversupply will cause mania.
Receptor site insensitivity could also be at the root of the problem, even if there is enough of a certain neurotransmitter, it may not be going where it needs to go.
Biological: Brain Structure and Function
Structural neuroimaging techniques (e.g., computed tomography [CT] and magnetic resonance imaging [MRI]) provide still pictures of the scalp, skull, and brain. Structural imaging is useful in viewing bones, tissues, blood vessels, tumours, infection, damage, or bleeding. Func- tional neuroimaging techniques (e.g., positron emission tomography [PET], functional MRI [fMRI], and magnetoencephalography [MEG]) provide measures related to brain activity.
Functional imaging reveals activity and chemistry by measuring the rate of blood flow, chemical activity, and electrical impulses in the brain during specific tasks.
With bipolar disorder, functional imaging techniques reveal dys- function in the prefrontal cortical region, the region associated with executive decision making, personality expression, and social behaviour.
Dysfunction is also evident in the hippo- campus, which is primarily associated with memory, and the amygdala, which is associated with memory, decision making, and emotion. Dysregulation in these areas results in the characteristic emotional lability, heightened reward sensitivity, and emotional dysregulation of bipolar disorder. These abnormalities may be due to grey matter loss in these areas.
Biological: Neuroendocrine
The hypothalamic–pituitary–thyroid–adrenal (HPTA) axis has been the object of significant research in bipolar disorder. In fact, hypothy- roidism is one of the most common physical abnormalities associated with bipolar disorder. Typically, the thyroid dysfunction is not dramat- ic and the problem is often undetected.
In both manic and depressive states peripheral inflammation is in- creased. This inflammation tends to decrease between episodes.
Estrogen studies have shown that people with postpartum psychosis have very low levels of estrogen and improve after estrogen replacement therapy.
Environmental Factors BD
Bipolar disorder is a worldwide problem that generally affects all races and ethnic groups equally, but some evidence suggests that bipolar disorders may be more prevalent in upper socioeconomic classes. The exact reason for this finding is unclear; however, people with bipolar disorders appear to achieve higher levels of education and higher oc- cupational status than individuals with unipolar depression. The edu- cational levels of individuals with unipolar depressive disorders, on the other hand, appear to be no different from those of individuals with no symptoms of depression within the same socioeconomic class.
Assessment of bipolar disorder
Individuals with bipolar disorder are often misdiagnosed or underdi- agnosed. Early diagnosis and proper treatment can help people avoid:
* Suicide attempts
* Alcohol or substance use
* Marital or work problems
* Development of medical comorbidity
Individuals with bipolar disorder tend to spend more time in a de- pressed state than in a manic state.
The characteristics of mania discussed in the following sections are (1) mood, (2) behaviour, (3) thought processes and speech patterns, and (4) cognitive function.
Mood. The euphoric mood associated with mania is unstable. During euphoria, patients may state that they are experiencing an in- tense feeling of well-being, are “cheerful in a beautiful world,” or are becoming “one with God.” The overly joyous mood may seem out of proportion to what is going on, and cheerfulness may be inappropriate for the circumstances, considering that patients are full of energy with little or no sleep. Their mood may change quickly to irritation and anger when they are thwarted. The irritability and belligerence may be short-lived, or it may become the prominent feature of the manic phase of bipolar disorder.
People experiencing a manic state may laugh, joke, and talk in a continuous stream, with uninhibited familiarity. They often demonstrate boundless enthusiasm, treat others with confidential friendliness, and incorporate everyone into their plans and activities. They know no strangers, and energy and self-confidence seem boundless.
To people experiencing mania, no aspirations are too high, and no distances are too far, no boundaries exist to curtail them. Often during impulsive, intrusive, and demanding behaviours, they can become easily angered and show a shift in mood at anyone attempting to stop them or set limits.
As the clinical course progresses from hypomania to mania, sociability and euphoria are replaced by a stage of hostility, irritability, and paranoia.
Behaviour. When people experience hypomania, they have appe- tites for social engagement, spending, and activity, even indiscriminate sex. The increased activity and a reduced need for sleep prevent proper rest. Although short periods of sleep are possible, some patients may not sleep for several days in a row. This non-stop physical activity and the lack of sleep and food can lead to physical exhaustion and worsen- ing of mania.
When in full-blown mania, a person constantly goes from one ac- tivity, place, or project to another. Many projects may be started, but few, if any, are completed. Inactivity is impossible, even for the short- est period of time. Hyperactivity may range from mild, constant mo- tion to frenetic, wild activity. Flowery and lengthy letters are written, and excessive phone calls are made. Individuals become involved in pleasurable activities that can have painful consequences, for example, spending large sums of money on frivolous items, giving money away indiscriminately, throwing lavish parties, visiting expensive night clubs and restaurants, or making foolish business investments that can leave an individual or family penniless. Sexual indiscretion can dissolve re- lationships and marriages and lead to sexually transmitted infections. Religious pre-occupation is a common symptom of mania. Individuals experiencing mania may be manipulative, profane, fault finding, and adept at exploiting others’ vulnerabilities. They constantly push limits. These behaviours often alienate family, friends, employers, health care providers, and others. Modes of dress often reflect the person’s grandiose yet tenuous grasp of reality. Dress may be described as outlandish, bizarre, colourful, and noticeably inappropriate. Makeup may be garish and overdone. People with mania are highly distractible. Concentration is poor, and individuals with mania go from one activity to another without completing anything. Judgement is poor. Impulsive marriages and divorces can take place.
Thought processes and speech patterns. Flight of ideas is a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words. When the condition is severe, speech may be disorganized and incoherent. The incessant talking often includes joking, puns, and teasing: “How are you doing, kid? No kidding around, I’m going home … home sweet home … home is where the heart is, the heart of the matter is I want out, and that ain’t hay … hey, Doc … get me out of this place.” The content of speech is often sexually explicit and ranges from grossly inappropriate to vulgar. Themes in the communication of the individual with mania may revolve around extraordinary sexual prow- ess, brilliant business ability, or unparalleled artistic talents (e.g., writ- ing, painting, dancing). Speech is not only profuse but also loud, bellowing, or even scream- ing. One can hear the force and energy behind the rapid words. As mania escalates, flight of ideas may give way to clang associations. Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning: “Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.” Grandiosity (inflated self-regard) is apparent in both the ideas ex- pressed and the person’s behaviour. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe that they have great powers.
Cognitive function. The onset of bipolar disorder is often preceded by comparatively high cognitive function. However, there is growing evidence that about one-third of patients with bipolar disorder display significant and persistent cognitive problems and difficulties in psychosocial areas. Cognitive deficits in bipolar disorder are milder but similar to those in patients with schizophrenia. Cognitive impairments are greater in bipolar I but are also present in bipolar II.
The potential cognitive dysfunction among many people with bipo- lar disorder has specific clinical implications:
* Cognitive function affects overall function.
* Cognitive deficits correlate with a greater number of manic episodes,
history of psychosis, chronicity of illness, and poor functional outcome. * Early diagnosis and treatment are crucial to prevent illness progres-
sion, cognitive deficits, and poor outcome.
* Medication selection should consider not only the efficacy of the
drug in reducing mood symptoms but also the cognitive impact of the drug on the patient.
Self-Assessment for BD
The person experiencing mania (who is often out of control and resists being controlled) can elicit numerous intense emotions in a nurse. The person may use humour, manipulation, power struggles, or demand- ing behaviour to prevent or minimize the staff ’s ability to set limits on and control dangerous behaviour. People with mania have the ability to “staff split,” or divide the staff into the “good guys” and the “bad guys”: “The nurse on the day shift is always late with my medication and never talks with me. You are the only one who seems to care.” This divisive tactic may pit one staff member or group against another, undermin- ing a unified front and consistent plan of care. Frequent team meetings to deal with the behaviours of the person and the nurses’ responses to these behaviours can help minimize staff splitting and feelings of anger and isolation. Limit setting (e.g., lights out after 2300 hours) is the main theme in treating a person with mania. Consistency among staff is im- perative if the limit setting is to be carried out effectively.
The person can become aggressively demanding, which often trig- gers frustration, worry, and exasperation in health care providers. The behaviour of a person experiencing mania is often aimed at decreas- ing the effectiveness of staff control, which could be accomplished by staff members getting involved in power plays. For example, the person might taunt the staff by pointing out faults or oversights and drawing negative attention to one or more staff members. Usually this taunt- ing is done in a loud and disruptive manner, which provokes staff to become defensive and thereby escalates the environmental tension and the person’s degree of mania.
If you are working with a person experiencing mania, you may find yourself feeling helplessness, confusion, or even anger. Understanding, acknowledging, and sharing these responses and counter-transference reactions will enhance your professional ability to care for the person and perhaps promote your personal development as well. Collaborating with the interprofessional team, accessing the supervision (as a nursing student) of your nursing faculty member, and sharing your experience with peers in post-conference may be helpful, perhaps essential.
Nursing Diagnosis
Excessive and constant motor activity
Poor judgement
Lack of rest and sleep
Poor nutritional intake (excessive or relentless mix of above behaviours can lead to cardiac collapse)
Risk for injury
Risk for self-neglect
Loud, profane, hostile, combative, aggressive, demanding behaviours
Risk for other-directed violence
Risk for self-directed violence
Risk for suicide
Intrusive and taunting behaviours Inability to control behaviour
Rage reaction
Ineffective coping
Self-neglect
Manipulative, angry, or hostile verbal and physical behaviours Impulsive speech and actions
Property destruction or lashing out at others in a rage reaction
Defensive coping
Ineffective coping
Ineffective impulse control
Racing thoughts, grandiosity, poor judgement
Ineffective coping
Ineffective impulse control
Giving away of valuables, neglect of family, impulsive major life changes (divorce, career changes)
Interrupted family processes
Caregiver role strain
Continuous pressured speech, jumping from topic to topic (flight of ideas)
Impaired verbal communication
Constant motor activity, going from one person or event to another Annoyance or taunting of others, loud and crass speech Provocative behaviours
Impaired social interaction
Risk for ineffective relationships
Failure to eat, groom, bathe, or dress self because person is too distracted, agitated, and disorganized
Imbalanced nutrition: less than body requirements
Deficient fluid volume
Self-care deficit (bathing, dressing, feeding, toileting)
Inability to sleep because patient is too frantic and hyperactive (sleep deprivation can lead to exhaustion and death)
Disturbed sleep pattern
ASSESSMENT GUIDELINES
Bipolar Disorder
- Assess whether the person is a danger to self or others:
* People experiencing mania can exhaust themselves to the point of death.
* People experiencing mania may not eat or sleep, often for days at a time.
* Poor impulse control may result in harm to others or self.
* Uncontrolled spending may occur. - Assess the need for protection from uninhibited behaviours. External con- trol may be needed to protect the person from such things as bankruptcy because people experiencing mania may give away all of their money or possessions.
- Assess the need for hospitalization to safeguard and stabilize the person.
- Assess medical status. A thorough medical examination helps to determine whether mania is primary (a mood disorder, bipolar disorder or cyclothymia)
or secondary to another condition.
* Mania may be secondary to a general medical condition.
* Mania may be substance induced (caused by use or abuse of a drug or
substance or by toxin exposure). - Assess for any coexisting medical condition or other situation that warrants
special intervention (e.g., substance use, anxiety disorder, legal or financial
crises). - Assess the person’s and family’s understanding of bipolar disorder, knowl-
edge of medications, and knowledge of support groups and organizations that provide information on bipolar disorder.
Acute Phase BD
The acute phase occurs during an intense manic, hypomanic or depres- sive episode. The overall outcome of the acute phase is injury preven- tion. The person may be hospitalized during this phase. Outcomes in the acute phase reflect both physiological and psychiatric issues. For example, the patient will:
* Be well hydrated
* Maintain stable cardiac status
* Maintain and obtain tissue integrity * Get sufficient sleep and rest
* Demonstrate thought self-control
* Make no attempt at self-harm
Continuation Phase BD
During this stage the presenting symptoms are being controlled but the individual’s mental health is still quite fragile. The continuation phase lasts for 4 to 9 months. Although the overall outcome of this phase is relapse prevention, many other outcomes must be accomplished to achieve relapse prevention. These outcomes include:
* Psychoeducational classes for the patient and family related to:
* Knowledge of disease process
* Knowledge of medication
* Consequences of substance addictions for predicting future re-
lapse
* Knowledge of early signs and symptoms of relapse
* Support groups or therapy (cognitive behavioural, interpersonal)
* Communication and problem-solving skills training
Maintenance Phase BD
The overall outcomes for the maintenance phase continue to focus on prevention of relapse and limitation of the severity and duration of future episodes.
Ad- ditional outcomes include:
* Participation in learning interpersonal strategies related to work, interpersonal, and family problems
* Participation in psychotherapy, group, or other ongoing supportive therapy modality
Planning BD
Planning care for an individual with bipolar disorder is usually geared to- ward the particular phase of mania the person is in (acute, continuation, or maintenance), as well as any other co-occurring issues identified in the assessment (e.g., risk for suicide, risk for violence to person or prop- erty, family crisis, legal crises, substance use, risk-taking behaviours)
Acute Phase BD
During the acute phase, planning focuses on medically stabilizing the person while maintaining safety. Therefore the hospital is usually the safest environment for accomplishing this stabilization. Nursing care is geared toward managing medications, decreasing physical activity, increasing food and fluid intake, ensuring at least 4 to 6 hours of sleep per night, alleviating any bowel or bladder problems, and intervening to see that self-care needs are met. Some patients may require seclusion or even electroconvulsive therapy (ECT) to assist with stabilization.
Continuation Phase BD
During the continuation phase, planning focuses on maintaining ad- herence to the medication regimen and prevention of relapse. Inter- ventions are planned in accordance with the assessment data regarding the person’s interpersonal and stress-reduction skills, cognitive func- tioning, employment status, substance-related problems, and social support systems. During this time, psychoeducational teaching is nec- essary for the patient and family. The need for referrals to community programs, groups, and support for any co-occurring disorders or prob- lems (e.g., substance use, family problems, legal issues, financial crises) is evaluated.
Evaluation of the need for communication skills training and prob- lem-solving skills training is also an important consideration.
Maintenance Phase BD
During the maintenance phase, planning focuses on preventing relapse and limiting the severity and duration of future episodes.
Acute phase BD
Depressive episodes. Depressive episodes of bipolar disorder have the same symptoms and risks as those of major depression. Hospitalization may be required if suicidal ideation, psycho- sis, or catatonia is present. Pharmacological treatment is affected by concerns of bringing on a manic phase.
Manic episodes
Acute phase. Hospitalization provides safety for a person experiencing acute mania (bipolar I disorder), imposes external controls on destructive behaviours, and provides for medication stabilization. There are unique approaches to communicating with and maintaining the safety of the person during the hospitalization period. Staff members continuously set limits in a firm, non-threatening, and neutral manner to prevent further escalation of mania and provide safe boundaries for the person and others.
Continuation phase. The continuation phase is crucial for patients and their families. The outcome for this phase is prevention of relapse, and community resources are chosen based on the needs of the person, the appropriateness of the referral, and the availability of resources. Medication adherence during this phase is perhaps the most important treatment outcome. Often, this follow-up is handled in a community mental health clinic. However, adherence to the medication regimen is also addressed in outpatient clinics and psychiatric home care visits.
Maintenance phase. The goal of the maintenance phase is to pre- vent recurrence of an episode of bipolar disorder.
TABLE 14.3 Interventions for the Patient Experiencing Acute Mania
Communication
Use firm and calm approach: “John, come with me. Please eat this sandwich.” Structure and control are provided for the person who is out of control. Feelings of security can result: “Someone is in control.”
Use short and concise explanations or statements. Short attention span limits comprehension to small bits of information.
Remain neutral; avoid power struggles and value judgements. Person can use inconsistencies and value judgements as justification for arguing and escalating mania.
Be consistent in approach and expectations. Consistent limits and expectations minimize potential for person’s manipulation of staff.
Have frequent staff meetings to plan consistent approaches and set agreed-on Consistency of all staff is needed to maintain controls and minimize manipulation by patient.
With other staff, decide on limits, and communicate these with the person in simple, concrete terms with consequences. Example: “John, do not yell at or hit Peter. If you cannot control yourself, we will help you.” Or, “The seclusion room will help you feel less out of control and prevent harm to yourself and others.” Clear expectations help the person experience outside controls, as well as understand reasons for medication, seclusion, or restraints (if they are not able to control behaviours).
Hear and act on legitimate complaints. Underlying feelings of helplessness are reduced, and acting-out behaviours are minimized.
Firmly redirect energy into more appropriate and constructive channels. Distractibility is the nurse’s most effective tool with the person experiencing mania.
Structure in a Safe Milieu
Maintain low level of stimuli in patient’s environment (e.g., away from bright Escalation of anxiety can be decreased. lights, loud noises, people).
Provide structured solitary activities with nurse or aide. Structure provides security and focus.
Provide frequent high-calorie fluids. Serious dehydration is prevented.
Provide frequent rest periods. Exhaustion is prevented.
Redirect violent behaviour. Physical exercise can decrease tension and provide focus.
When warranted in acute mania, use phenothiazines and seclusion to minimize Exhaustion and death can result from dehydration, lack of sleep, and constant physical harm. physical activity.
Observe for signs of lithium toxicity. There is a small margin of safety between therapeutic and toxic doses.
Prevent person from giving away money and possessions. Hold valuables in Person’s “generosity” is a manic defence that is consistent with irrational, hospital safe until rational judgement returns. grandiose thinking.
Physiological Safety: Self-Care Needs
Nutrition
Monitor intake, output, and vital signs. Adequate fluid and caloric intake are ensured; development of dehydration and cardiac collapse are minimized.
Offer frequent, high-calorie, protein drinks and finger foods (e.g., sandwiches, Constant fluid and calorie replacement are needed. Person may be too active to sit fruits, milkshakes). at meals. Finger foods allow “eating on the run.”
Frequently remind person to eat. “Tom, finish your milkshake.” “Sally, eat this The person experiencing mania is unaware of bodily needs and is easily banana.” distracted. Needs supervision to eat.
Sleep
Encourage frequent rest periods during the day. Lack of sleep can lead to exhaustion and death.
Keep person in areas of low stimulation. Relaxation is promoted, and manic behaviour is minimized.
At night, provide warm baths, soothing music, and medication when indicated. Relaxation, rest, and sleep are promoted. Avoid giving person caffeine.
Hygiene
Supervise choice of clothes; minimize flamboyant and bizarre dress (e.g., garish The potential is decreased for ridicule, which lowers self-esteem and increases stripes or plaids and loud, unmatching colours). the need for manic defence. The person is helped to maintain dignity.
Give simple, step-by-step reminders for hygiene and dress. “Here is your razor. Distractibility and poor concentration are countered through simple, concrete Here are your toothbrush and toothpaste.” instructions.
Elimination
Monitor bowel habits; offer fluids and foods that are high in fibre. Evaluate need Fecal impaction resulting from dehydration and decreased peristalsis is prevented. for laxative. Monitor input and output.
Pharmacological Interventions for bipolar disorder
Lithium carbonate, valproic acid (Depakene), and several atypical antipsychotics continue to be first-line treatments for acute mania.
For the management of bipolar depression, lithium, divalproex, lamotrigine (Lamictal), and quetiapine (Seroquel) are used for a monotherapy therapy approach.
Olanzapine plus a selective serotonin reuptake inhibitor (SSRI) (except paroxetine), or lithium or valproic acid plus an SSRI or bupropion (Wellbutrin) are used as first- line options when combination therapy is required (Goldberg, 2019).
Due to the concern of dependen- cy, use of benzodiazepines is usually short term until the mania sub- sides.
Mood Stabilization: Lithium carbonate
Mood stabilizers refer to classes of drugs used to treat symptoms as- sociated with bipolar disorder.
Lithium carbonate. Lithium carbonate (LiCO3 or Li+) is effective in the treatment of bipolar I acute and recurrent manic and depressive epi- sodes. Onset of action is usually within 10 to 21 days. Because the onset of action is so slow, it is usually supplemented in the early phases of treatment by atypical antipsychotics, anticonvulsants, or antianxiety medications.
The clinical benefits of lithium can be incredible. However, newer medications have been introduced and approved that carry lower tox- icity, have fewer adverse effects, and require less frequent laboratory testing. The use of these newer medications has resulted in a decline in lithium use.
Assessment of renal function; determination of thyroid status, including lev- els of thyroxine and thyroid-stimulating hormone; and evaluation for dementia or neurological disorders, which presage a poor response to lithium. Other clinical and laboratory assessments, including an electrocardiogram, are performed as needed, depending on the individual’s physical condition.
Lithium is particularly effective in reducing:
* Elation, grandiosity, and expansiveness
* Flight of ideas
* Irritability and manipulation
* Anxiety
To a lesser extent, lithium controls:
* Insomnia
* Psychomotor agitation
* Threatening or assaultive behaviour
* Distractibility
* Hypersexuality
* Paranoia
Therapeutic and toxic levels. There is a small window between the therapeutic and toxic levels of lithium. Lithium must reach therapeutic blood levels to be effective. This usually takes 7 to 14 days, or longer for some patients. Blood serum levels should reach 0.6 to 1.2 mEq/L. Lithium levels should not exceed 1.5 mEq/L to avoid serious toxicity.
Lithium levels should be measured at least 5 days after beginning lithium therapy and after any dosage change, until the therapeutic level has been reached. Blood levels are determined every month. After 6 months to a year of stability, it is common to measure blood levels every 3 months. Blood should be drawn in the morning, 10 to 12 hours after the last dose of lithium is taken.
Patient and family should be given careful instructions about (1) the pur- pose and requirements of lithium therapy, (2) its adverse effects, (3) its toxic effects and complications, and (4) situations in which the physician should be contacted. The patient and family should also be advised that suddenly stopping lithium can lead to relapse and recurrence of mania.
People taking lithium need to know that two major long-term risks of lithium therapy are hypothyroidism and impairment of the kidneys’ ability to concentrate urine. Therefore a person receiving lithium therapy must have periodic follow-ups to assess THYROID and RENAL function.
Taking lithium carries a high risk of hypercalcemia and hyperparathyroidism. Symptoms of hypercal-emia and hyperparathyroidism can include fatigue, depression, mental confusion, nausea, vomiting, excessive thirst, appetite loss, abdominal pain, frequent urination, muscle and joint aches, and muscle weakness. In the most serious situations, these conditions lead to coma and death.
Contraindications. Lithium therapy is generally contraindicated in patients with cardiovascular disease, brain damage, renal disease, thyroid disease, or myasthenia gravis. Whenever possible, lithium is not given to people who are pregnant because it may harm the fetus.
PATIENT AND FAMILY TEACHING
Lithium Therapy
The patient and the patient’s family should be given the following information, be encouraged to ask questions, and be given the material in written form as well.
- Lithium treats your current emotional problem and also helps prevent relapse.
Therefore it is important to continue taking the medication after the current
episode is over. - Because therapeutic and toxic dosage ranges are so close, it is important to
monitor lithium blood levels very closely, more frequently at first and then
once every several months after that. - Lithium is not addictive.
- It is important to eat a normal diet, with normal salt and fluid intake (1500 to
3000 mL or six 350-mL glasses of fluid). Lithium decreases sodium reabsorption in the kidneys, which could lead to a deficiency of sodium. A low sodium intake leads to a relative increase in lithium retention, which could produce toxicity. - You should stop taking lithium if you have excessive diarrhea, vomiting, or sweating. All of these symptoms can lead to dehydration. Dehydration can raise lithium levels in the blood to toxic levels. Inform your physician if you have any of these problems.
- Do not take diuretics (water pills) while you are taking lithium.
- Lithium is irritating to the lining of your stomach. Take lithium with meals. 8. It is important to have your kidneys and thyroid checked periodically, especially if
you are taking lithium over a long period. Talk to your doctor about this follow-up. 9. Do not take any over-the-counter medicines without checking first with your
doctor. - If you find that you are gaining a lot of weight, you may need to talk this
change over with your doctor or dietitian. - Many self-help groups are available to provide support for people with
bipolar disorder and their families. The local self-help group is (give name
and telephone number). - You can find out more information by calling (give name and telephone
number). - Keep a list of adverse effects and toxic effects handy, along with the name
and number of a person to contact if these effects occur (see Table 14.4). - If lithium is to be discontinued, your dosage will be tapered gradually to
minimize the risk of relapse.
Anticonvulsant drugs.
In the 1980s researchers hypothesized that mood instability could be viewed much the same as epilepsy and that a chain reaction of sensitivity, or kindling, was responsible for the worsening of bipolar symptoms over time. This hypothesis led to the use of anticonvulsant drugs, such as carbamazepine (Tegretol), valproic acid (Depakene), and lamotrigine (Lamictal), as a treatment for mania that has been refractory to lithium therapy. They also proved useful in treating people who need rapid de-escalation and who do not respond to other treatment approaches.
Anticonvulsant drugs are thought to be:
* Superior for continuously cycling patients
* More effective when there is no family history of bipolar disorder
* Effective at dampening affective swings in schizoaffective patients
* Effective at diminishing impulsive and aggressive behaviour in
some non-psychotic patients
* Helpful in cases of alcohol and benzodiazepine withdrawal
* Beneficial in controlling mania (within 2 weeks) and depression
(within 3 weeks or longer)
Anticonvulsant: Valporate
Divalproex sodium (Epival).
Valproate (available as divalproex sodium [Epival] and valproic acid [Depakene]) has surpassed lithium in treating acute mania. Valproate is also helpful in preventing future manic episodes.
Although serious complications are rare, it is important to monitor liver function and platelet count periodically.
Divalproex doses can cause drowsiness and dizziness and increase thoughts of suicide; therefore mood, ideations, and behaviour should be monitored on a regular basis.
Therapeutic serum levels that range from 50 to 100 mcg/ mL and 50 to 125 mcg/mL for mania should be monitored to prevent toxicity and overdose.
Symptoms of cen- tral nervous system toxicity can include confusion, fatigue, dizziness, hallucinations, headache, and ataxia.
Anticonvulsants: Carbamazepine
Some patients with treatment-resistant bipolar disorder improve after taking carbamazepine (Tegretol) and lithium, or carbamazepine and an antipsychotic.
Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients experiencing manias rather than in euphoric, overactive, overly friendly patients experiencing manias.
It is thought to also be more effective in dysphoric patients experiencing manias.
Liver enzymes should be monitored at least weekly for the first 8 weeks of treatment because the drug can increase levels of liver enzymes that can speed its own metabolism. In some instances this can cause bone marrow suppression and liver inflammation. Complete blood counts should also be done periodically since carbamazepine is known to cause leukopenia and aplastic anemia.
Anticonvulsants: Lamotrigine
Lamotrigine (Lamictal) is a first-line treatment for bipolar depression and is approved for acute and maintenance therapy. Lamotrigine is generally well tolerated but has one serious, though rare, dermatological reaction: a potentially life-threatening rash. Patients should be instructed to seek immediate medical attention if a rash appears, although most are likely benign.
Adverse drug reactions (ADRs), as indicated by the Canadian Net- work for Mood and Anxiety Treatments (CANMAT), that require pa- tient safety monitoring are:
- Both valproic acid and carbamazepine may cause blood dyscrasias,
hepatotoxicity, and teratogenicity. - Carbamazepine has also been linked to hyponatremia and serious
dermatological adverse effects. - Valproic acid has been associated with polycystic ovary syndrome, weight gain, acute pancreatitis, and hyperammonemic encephalopathy.
- The severe ADRs associated with lamotrigine are dermatological,
namely Stevens–Johnson syndrome. - Drug interactions such as lamotrigine–valproic acid and carbam-
azepine–hormonal contraceptives are also important to be aware of.
Other drugs for bipolar disorder
Antianxiety drugs. Diazepam (Valium), clonazepam (Rivotril), and lorazepam (Ativan) are antianxiety (anxiolytic) drugs useful in the treatment of acute mania in some patients who are resistant to other treatments. These drugs are also effective in managing the psychomo- tor agitation seen in mania. They should be avoided, however, in pa- tients with a history of substance use.
Atypical antipsychotics. Many of the second-generation antipsychotics are approved for acute mania. In addition to showing sedative properties during the early phase of treatment (help with in- somnia, anxiety, agitation), the second-generation antipsychotics seem to have mood-stabilizing properties. Most evidence supports the use of olanzapine (Zyprexa) or risperidone (Risperdal).
This classification of drugs may bring about serious adverse effects that stem from a tendency toward weight gain that may lead to insulin resistance, diabetes, dyslipidemia, and cardiovascular impairment.
Electroconvulsive Therapy
ECT is used to subdue severe manic behaviour, especially in patients with treatment-resistant mania and in those with rapid cycling (i.e., those who experience four or more episodes of illness per year). ECT seems to be far more effective than medication-based therapy for treatment-resistant bipolar depression. Depressive episodes, particularly those with severe, catatonic, or treatment resistant depression, are an indication for this treatment.
Milieu Management
Control of hyperactive behaviour during the acute phase almost always includes immediate treatment with an antipsychotic medication. How- ever, when a person is dangerously out of control, use of a seclusion room or restraints may also be required. A seclusion room provides comfort and relief to many patients who are unable to control their own behaviour.
Seclusion serves the following purposes: for BD
Reduces overwhelming environmental stimuli
* Protects a person from injuring themself or others, including staff * Prevents destruction of personal property or property of others
Seclusion is warranted when documented data collected by the nursing and medical staff reflect the following points:
* Substantial risk of harm to others or self is clear.
* The person is unable to control their actions.
* Problematic behaviour has been sustained (continues or escalates
despite other measures).
* Other measures have failed (e.g., setting limits beginning with ver-
bal de-escalation or using chemical restraints).
Milieu Management
Control of hyperactive behaviour during the acute phase almost always includes immediate treatment with an antipsychotic medication. How- ever, when a person is dangerously out of control, use of a seclusion room or restraints may also be required. A seclusion room provides comfort and relief to many patients who are unable to control their own behaviour. Seclusion and observation levels and care protocols must be carefully adhered to as per individual hospital or employer policy.
Seclusion protocols also identify specific nursing responsibilities, such as how often the patient’s behaviour is to be observed and documented (e.g., every 15 minutes), how often the patient is to be offered food and fluids (e.g., every 30 to 60 minutes), and how often the patient is to be toileted (e.g., every 1 to 2 hours). Medication is often administered to patients in seclusion; therefore vital signs should be measured frequently, as per hospital policy.
Careful and precise documentation is a legal necessity. The nurse documents the following:
* The behaviour leading up to the seclusion or restraint
* The actions taken to provide the least restrictive alternative
* The time the patient was placed in seclusion
* Every 15 minutes, the patient’s behaviour, needs, nursing care, and
vital signs
* The time and type of medications given and their effects on the
patient
When a patient requires seclusion to prevent self-harm or violence toward others, it is ideal for one nurse on each shift to work with the patient on a continuous basis. Communication with a patient in se- clusion is concrete and direct but also empathic and limited to brief instructions. Patients need reassurance that seclusion is only a tem- porary measure and that they will be returned to the unit when their behaviour is more controlled and they demonstrate the ability to safely be around others.
Frequent staff meetings regarding personal feelings are necessary to prevent using seclusion as a form of punishment or leaving a patient in seclusion for long periods of time without proper supervision. Restraints and seclusion are never to be used as punishment or for the convenience of the staff. Refer to Chapter 7 for a more detailed discussion of the legal implications of seclusion and restraints. Chapter 4 provides more information on milieu therapy.
BD drugs
Lithium carbonate
Acute mania
Maintenance
Mood stabilizer
Depression (off label)
First-line treatment for bipolar depression Recommended for acute mania
Treatment and prevention of manic episodes
__________
Anticonvulsants
Valproic acid (Depakene) Divalproex sodium (Epival) Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Gabapentin (Neurontin) and topiramate (Topamax)
for acute mania
depression (off label)
Recommended for acute mania
First-line maintenance treatment for bipolar disorder
Recommended for maintenance treatment of bipolar disorder, mood-stabilizing effect
First-line treatment for bipolar depression
Recommended for maintenance treatment of bipolar disorder Recommended for maintenance treatment of bipolar disorder
__________
Atypical Antipsychotics
Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine fumarate (Seroquel)
Risperidone (Risperdal) Ziprasidone (Zeldox)
For mania, maintenance
depression (off label)
Support Groups for BD
Patients with bipolar disorder, as well as their friends and families, ben- efit from forming mutual support groups.
Health Teaching and Health Promotion BD
Emphasis on its chronic and highly recurrent nature. In ad- dition, patients and families need to be taught the warning signs and symptoms of impending episodes. For example, changes in sleep patterns are especially important because they usually precede, accompany, or precipitate mania.
Health teach- ing stresses the importance of establishing regularity in sleep patterns, meals, exercise, and other activities.
Most of the medications used to treat bipolar disorder may cause weight gain and other metabolic disturbances such as altered metabo- lism of lipids and glucose. These alterations increase the risk for diabe- tes, high blood pressure, dyslipidemia, cardiac problems, or all of these in combination (metabolic syndrome). Not only do these disturbances impair quality of life and lifespan, they are also a major reason for non- adherence. Teaching aimed at weight reduction and management is es- sential to keep patients physically healthy and emotionally stable.
Recovery concepts are particularly important for patients with bi- polar disorder, who often have issues with adherence to treatment. The best method of addressing this problem is to follow a collaborative care model in which responsibilities for treatment adherence are shared. In this model patients are responsible for making it to appointments and openly communicating information, and the health care provider is responsible for keeping current on treatment methods and listening carefully as patients share perceptions. Through this sharing, treatment adherence becomes a self-managed responsibility.
- Patients with bipolar disorder and their families need to know:
* The chronic and episodic nature of bipolar disorder
* The fact that bipolar disorder is long term. Treatment will require that
one or more mood-stabilizing medications be taken for a long time
* The expected side effects and toxic effects of the prescribed medication,
as well as who to call and where to go in case of an adverse reaction
* The signs and symptoms of relapse that may “come out of the blue”
* The role of family members and others in preventing a full relapse
* The phone numbers of emergency contact people, which should be kept
in an easily accessed place - The use of alcohol, drugs of abuse, caffeine (particularly in energy drinks),
and over-the-counter medications can cause a relapse. - Good sleep hygiene is critical to stability. Frequently, the early symptom of
a manic episode is lack of sleep. In some cases, mania may be averted by
the use of sleep medications. - Coping strategies are important for dealing with work, interpersonal, and
family problems to lower stress, to enhance a sense of personal control,
and to increase community functioning. - Group and individual therapy are valuable for gaining insight and skills in
relapse prevention, providing social support, increasing coping skills in interpersonal relations, improving adherence to the medication regimen, reducing functional morbidity, and decreasing need for hospitalization.
Psychotherapy BD
Many patients have strained in- terpersonal relationships, marital and family problems, academic and occupational problems, and legal or other social difficulties. Psycho- therapy can help them work through these difficulties, decrease some of the psychic distress, and increase self-esteem. Psychotherapeutic treatments can also help patients improve their functioning between episodes and attempt to decrease the frequency of future episodes.
Cognitive behavioural therapy. CBT is typically used as an adjunct to pharmacotherapy in many psychiatric disorders. It involves iden- tifying maladaptive thoughts (“I am always going to be a loser”) and behaviours (“I might as well drink”) that may be barriers to a person’s recovery and ongoing mood stability.
CBT focuses on adherence to the medication regimen, early de- tection and intervention for manic or depressive episodes, stress and lifestyle management, and the treatment of depression and comorbid conditions. Some research demonstrates that patients treated with cog- nitive therapy are more likely to take their medications as prescribed than are patients who do not participate in therapy, and psychotherapy results in greater adherence to the medication regimen.
Interpersonal and social rhythm therapy. Depression and manic- type states impair a person’s ability to interact with others. Even in be- tween episodes, relationships have been so damaged it may seem im- possible to correct the problems. The advanced-practice nurses can use a specialized approach, interpersonal and social rhythm therapy. This approach aims to regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse. Psychoeducation is a major component of this therapy and includes symp- tom recognition, adherence with medication and sleep routines, stress management, and maintenance of social supports.
Family-focused therapy. Family-focused therapy helps improve communication among family members. Negative patterns of communicating develop and become part of the fabric of the family. Advanced-practice nurses can help people recognize and reduce negative expressed emotion and stressors that provoke episodes.
EVALUATION for BD
Outcome criteria often dictate the frequency of evaluation of short- term and intermediate indicators. Are the person’s vital signs stable? Are they well hydrated? Is the person able to control personal behaviour or respond to external controls? Is the person able to sleep for 4 or 5 hours a night or take frequent, short rest periods during the day? Does the family have a clear understanding of the patient’s disorder and need for medication? Do the patient and family know which community agencies might help them?
Were the data incorrect or insuf- ficient? Were nursing diagnoses inappropriate or outcomes unrealistic? Was intervention poorly planned? After the outcomes and care plan are reassessed, the plan is revised, if indicated. Longer-term outcomes include adherence to the medication regimen; resumption of functioning in the community; achievement of stability in family, work, and social relationships and in mood; and improved coping skills for reducing stress.
Mania nursing AAPIE
Diagnosis- 1. Risk for injury related to dehydration and faulty judgement, as evidenced by inability to meet own physiological needs and set limits on own behaviour
Outcomes Identification
Physical status will remain stable during manic phase.
Short-Term Goal
1. Person will be well hydrated, as evidenced by good skin turgor and normal urinary output and specific gravity, within 24 hours.
Intervention
1a. Give olanzapine (Zyprexa) intramuscularly immediately and as ordered.
1b.Check vital signs frequently (every 1–2 hours).
1c. Place person in private or quiet room (whenever possible).
1d.Stay with person and divert person away from stimulating situations.
1e. Offer high-calorie, high- protein drink (250 mL) every hour in quiet area.
1f. Frequently remind person to drink: “Take two more sips.”
1g.Offer finger food frequently, in quiet area.
1h.Maintain record of intake and output.
1i. Weigh person daily.
Rationale
1a. Continuous physical activity and lack of fluids can eventually lead to cardiac collapse and death.
1b.Cardiac status is monitored. 1c. Environmental stimuli are
reduced—escalation of mania
and distractibility are minimized. 1d.Nurse’s presence provides
support. Ability to interact with
others is temporarily impaired. 1e. Proper hydration is mandatory for
maintenance of cardiac status.
1f. Person’s concentration is poor; she is easily distracted.
1g.Person is unable to sit; snacks she can eat while pacing are more likely to be consumed.
1h.Such a record allows staff
to make accurate nutritional assessment for person’s safety.
1i. Monitoring of nutritional status is necessary.
Evaluation
After 3 hours, person takes small amounts of fluid (60–120 mL per hour).
After 5 hours, patient starts taking 250 mL per hour with a lot of reminding and encouragement.
After 24 hours, urine specific gravity is within normal limits.
________
Goal 2
Person will sleep or rest 3 hours during
the first night in the hospital with aid of medication and nursing interventions.
2a. Continue to direct person to
areas of minimal activity. 2b.When possible, try to direct
energy into productive and calming activities (e.g., pacing to slow, soft music; slow exercise; drawing alone; writing in quiet area).
2c. Encourage short rest periods throughout the day (e.g., 3–5 minutes every hour) when possible.
2d.Drinks such as coffee, tea, and colas should be decaffeinated only.
2e. Provide nursing measures at bedtime that promote sleep (e.g., warm milk, soft music).
Rationale
2a. Lower levels of stimulation can decrease excitability.
2b.Directing patient to paced, non- stimulating activities can help minimize excitability.
2c. Person may be unaware of feelings of fatigue. Can collapse from exhaustion if hyperactivity continues without periods of rest.
2d.Caffeine is a central nervous system stimulant that inhibits needed rest or sleep.
2e. Such measures promote non- stimulating and relaxing mood.
Evaluation
Person is awake most of the first night. Sleeps for 2 hours from 0400 to 0600 hours.
Person is able to rest on the second day for short periods and engage in quiet activities for short periods (5–10 minutes).
___________
Goal 3
Person’s blood pres- sure (BP) and pulse (P) will be within normal limits within 24 hours, with the aid of medication and nursing interventions.
Intervention
3a. Continue to monitor BP and P frequently throughout the day (every 30 minutes).
3b. Keep staff informed, by verbal and written reports, of baseline vital signs and patient progress
Rationale
3a. Physical condition is presently a great strain on patient’s heart.
3b. Alerting all staff regarding person’s status can increase medical intervention if a change in status occurs.
Goal Met
Baseline measures on unit are not obtained because of hyperactive behaviour. Information from family physician states that baseline BP is 130/90 mm Hg and baseline P is 88 beats per minute.
BP at end of 24 hours is 130/70 mm Hg; P is 80 beats per minute.
Key points for Bipolar disorder
- Bipolar I disorder is characterized by the presence or history of at least one manic episode, whereas bipolar II disorder is character- ized by the presence or history of at least one hypomanic episode.
- Cyclothymia is a bipolar-related disorder with symptoms of hypo- mania and symptoms of mild to moderate depression.
- Genetics plays a strong role in the risk for the bipolar disorders.
- Neurotransmitter (norepinephrine, dopamine, serotonin) excess and imbalance are also related to bipolar mood swings, supporting the existence of neurobiological influences. Neuroendocrine and neuroanatomical findings provide strong evidence for biological
influences. - Early detection of bipolar disorder can help diminish comorbid
substance use, suicide, and decline in social and personal relation-
ships and may help promote more positive outcomes. - Bipolar disorder often goes unrecognized.
- The nurse assesses the person’s level of mood (hypomania, acute
mania), behaviour, and thought processes and is alert to cognitive
dysfunction. - Analyzing the objective and subjective data helps the nurse formu-
late appropriate nursing diagnoses. Some of the nursing diagnoses appropriate for patients with mania are Risk for violence, Defensive coping, Ineffective coping, Disturbed thought processes, and Situation- al low self-esteem. - During the acute phase of mania, physical needs often take priority and demand nursing interventions. Therefore Deficient fluid vol- ume, Imbalanced nutrition, Imbalanced elimination, and Disturbed sleep pattern are usually addressed in the nursing plan.
- The diagnosis of Interrupted family processes is vital. Support groups, psychoeducation, and guidance for the family can greatly affect the person’s adherence to the medication regimen.
- Planning involves identifying the specific needs of the patient and family during the three phases of mania (acute, continuation, and maintenance). Can the patient benefit from communication skills training, improvement in coping skills, legal or financial counsel- ling, or further psychoeducation? What community resources does the person need at this time?
- Health care workers, family, and friends often feel angry and frus- trated by the person’s disruptive behaviours. When these feelings are not examined and shared with others, the therapeutic potential of the staff is reduced, and feelings of confusion and helplessness remain.
- Mood stabilizers are usually the first line of defence for bipolar dis- order and include lithium and several anticonvulsants.
- Lithium is approved for treating acute mania and maintenance. Blood levels, kidney function, and thyroid function should be as- sessed regularly.
- Most anticonvulsant drugs are approved for acute mania. Lamotrigine is approved for maintenance.
- Antipsychotic medications, particularly the second-generation antipsychotics, are used for their sedating and mood-stabilizing properties. Screening for metabolic problems (e.g., diabetes) is es- sential in this population.
- For some patients, ECT may be an appropriate medical treatment.
- Patient and family teaching takes many forms and is most impor- tant in encouraging adherence to the medication regimen and re-
ducing the risk of relapse. - Evaluation includes examining the effectiveness of the nursing in-
terventions, changing the outcomes as needed, and reassessing the nursing diagnoses. Evaluation is an ongoing process and is part of each of the other steps in the nursing process.
Personality
is an individual’s characteristic patterns of relatively permanent thoughts, feelings, and behaviours that define the quality of experiences and relationships.
personality trait
is a stable characteristic of a person, such as neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness.
personality type
is a way to describe a cluster of traits.
For example, a person with an authoritarian personality has traits that relate to maintaining orderliness, command, and power. In contrast, a person’s character involves defining an individual’s integrity.
Personality disorders clinical picture
Individuals with personality disorders display significant challenges in self-identity or self-concept, they have problems with empathy and have difficulty establishing healthy, stable relationships. Individuals with personality disorders believe that the problems originate outside of themselves. They believe that if others behaved differently toward them or treated them differently, then all their problems would be solved.
In the treatment of personality disorders, a key factor to success is that the person with the personality disorder recognizes and takes re- sponsibility for the contributions they make to their relational and so- cial difficulties. Treating personality disorders is difficult and complex, as people with these disorders have difficulty recognizing or owning the fact that their difficulties are problems of their personality.
Thinking about personality as being made up of self-identity and self-concept is an important consideration when interacting with a person with a personality disorder.
How they form opinions, and what actions they take, are influenced by how they see themselves in relation to the world.
This impacts how the therapeutic relationship can be established and used. It is essential that the health- care team establish parameters to help staff deal with “splitting” behaviours.
10 personality disorders.
These 10 disorders are grouped into three clusters of similar behaviour patterns and personality traits. These clusters are:
Cluster A: Individuals with these disorders share characteristics of eccentric behaviours, such as social isolation and detachment. They may also display perception distortions, unusual levels of suspicious- ness, magical thinking, and cognitive impairment.
* Paranoid personality disorder
* Schizoid personality disorder
* Schizotypal personality disorder
Cluster B: People living with cluster B personality disorders show patterns of responding to life demands with dramatic, emotional, or erratic behaviour. Problems with impulse control, emotion processing and regulation, and interpersonal difficulties characterize this cluster of disorders. Insight into these issues is generally limited. To get their needs met, individuals with cluster B personality disorders may resort to behaviours that are considered desperate or entitled, including act- ing out, committing anti-social acts, or manipulating people and circumstances.
* Borderline personality disorder (BPD) * Narcissistic personality disorder
* Histrionic personality disorder
* Anti-social personality disorder
Cluster C: An individual with these types of personality disorders will demonstrate a consistent patterns of anxious and fearful behaviours, rigid patterns of social shyness, hypersensitivity, need for orderliness, and relationship dependency.
* Avoidant personality disorder
* Dependent personality disorder
* Obsessive-compulsive personality disorder
EPIDEMIOLOGY of personality disorders
The life- time prevalence of personality disorders is between 4% and 15%
While narcissistic and schizotypal personal- ity disorders (STPDs) are relatively rare, borderline, avoidant, and obsessive-compulsive personality disorders have been established by meta-analyses (which pull together the best and most relevant research) to be common among both community and clinical popuations
CULTURE has an influence on the rate of diagnosing personality disorders. For example, personality disorders are more often diag- nosed in high-income countries when compared to low to moderate- income countries
COMORBIDITY
Personality disorders frequently co-occur with disorders of mood and eating, anxiety, and substance use. Personality disorders often amplify emotional dysregulation.
The aging process has some effect on the prevalence of personality disorders. The dramatic, emotional, or erratic cluster B disorders may mute with age as individuals become less impulsive. This dampening may be due to a general tuning down of neurotransmitters. Other disorders such as obsessive-compulsive personality disorder or paranoid personality disorder may worsen with age, per- haps due to anxiety regarding declining sensory and cognitive capacity.
Personality traits are amplified during the experience of a crisis and any illness; therefore it is pre-mature and not in the best interest of the individual for a personality disorder to be diagnosed during the ac- tive phase of another illness, especially a psychiatric episode or major stressful life event such as grief and loss or trauma.
Emotional dysregulation
a term that describes poorly modulated mood characterized by mood swings. Individuals with emotion regu- lation problems have ongoing difficulty managing painful emotions in ways that are healthy and effective.
ETIOLOGY of personality disorders
Genetic, neurobiological, neurochemical, and environmental factors.
Biological Factors
Genetics: Individual children may perceive family experiences in unique ways and therefore respond differently from other family members. Children are also affected by forces outside the family that influence personality development.
Neurobiology and Neurochemistry: Influences on the development of personality disorders probably incorporate a complex interaction of genetics, neurobiology, and neurochemistry. The chemical neurotransmitter theory proposes that certain neurotransmitters, including neurohormones, may regulate and influence temperament. Research in brain imaging has also revealed some differences in the size and function of specific structures of the brain in people with some personality disorders.
Psychological Factors: Learning theory emphasizes that children develop maladaptive responses based on modelling of or reinforcement by important people in the child’s life. Cognitive theories emphasize the role of beliefs and assumptions in creating emotional and behavioural responses that influence one’s experiences within the family environment. Psychoanalytic theory focuses on the use of primitive defence mechanisms by individuals with personality disorders. Defence mechanisms such as repression, suppression, regression, undoing, and splitting have been identified as dominant.
Environmental Factors: Childhood neglect and trauma have been established as risk factors for personality disorders. This association has been linked to possible neurotransmitter changes in response to early life stress and emotional reactivity. While the family environment is influential on development, there are other environmental factors besides upbringing that shape an individual’s personality.
Diathesis–Stress Model
(Personality Disorder)
This theory helps us understand how personality disorders emerge from the multi-faceted factors of biology and environment.
Diathesis refers to genetic and biological vulnerabilities and includes personality traits and temperament.
Temperament is our tendency to respond to challenges in predictable ways.
Examples of descriptors of temperament may be laid back, referring to a calm temperament, or uptight, referring to an anxious temperament.
In this model stress refers to immediate influences on personality such as the physical, social, psychological, and emotional environment. Stress also includes what happened in the past, such as growing up in one’s family with exposure to unique experiences and patterns of interaction.
The diathesis–stress model proposes that, under conditions of stress, some people have maladaptive personal- ity development, resulting in the emergence of a personality disorder
Genetic and biological traits are believed to influence the way an individual responds to the environment while, at the same time, the environment is thought to influence the expression of inherited traits.
Many studies have suggested a strong correlation between trauma, neglect, and other dysfunctional family or social patterns of interaction and the development of personality disorders among individuals with particular personality traits and temperament.
- STPD is a schizophrenia spectrum disorder and is genetically
linked, meaning that there is a higher incidence of schizophrenia-
related disorders in family members of people with STPD. - Anti-social personality disorder is genetically linked, and twin studies indicate a predisposition to this disorder. This predisposi- tion is set into motion by a childhood environment of inconsistent
parenting, significant abuse, and extreme neglect. - BPD has traditionally been thought to develop as a result of early
abandonment, which results in an unstable view of self and others.
*Narcissistic personality disorder may be the result of childhood neglect and criticism. The child does not learn that other people can be a source of comfort and support. As an adult, the individual hides feelings of emptiness with an exterior of invulnerability and self-sufficiency. - Avoidant personality disorder has been linked with parental and peer rejection and criticism.
- Obsessive-compulsive personality disorder may be related to ex- cessive parental criticism, control, and shame. The child responds to this negativity by trying to control their environment through perfectionism and orderliness.
Paranoid Personality Disorder
CLUSTER A
is characterized by a long-standing dis- trust and suspiciousness of others based on the belief, which is unsupported by evidence, that others want to exploit, harm, or deceive the person.
These individuals are hypervigilant (highly alet), anticipate hostility, and may provoke hostile responses by initiating a counterattack. The prevalence of paranoid personality disorder has been estimated at about 2% to 4%. Slightly more men than women are diagnosed with this disorder.
Symptoms may be apparent in childhood or adolescence. Parents may notice that their child does not have friends and experiences social anxiety. Young people with this disorder are frequently teased due to their odd behaviour.
As adults, relationships are difficult due to jealousy, controlling behaviours, and unwillingness to forgive. Projection is the dominant defence mechanism whereby people attribute their own unacknowledged feelings to others. For example, they may accuse their partner of being hypercritical when they themselves are attentively fault finding.
Guidelines for Nursing Care
* Considering the degree of mistrust, promises, appointments, and schedules should be strictly adhered to.
* Being too nice or friendly may be met with suspicion. Instead, give clear and straightforward explanations of tests and procedures beforehand.
* Use simple language and project a neutral but kind affect.
* Limit setting is essential when threatening behaviours are present.
Treatment
Individuals with paranoid personality disorder tend to reject treatment. If they somehow end up in a psychiatric treatment setting, they may appear puzzled and obviously suspicious about why this is happening. Paranoid people are difficult to interview because they are reluctant to share information about themselves for fear that the information will be used against them.
Psychotherapy is the first line of treatment for paranoid personality disorder. Individual therapy focuses on the development of a professional and trusting relationship. Due to fears, patients may behave in a threatening manner. Therapists should respond by setting limits and dealing with delusional accusations in a realistic manner without humiliating the patients.
Group therapy is threatening to people with paranoid personality disorder. However, the group setting may be useful in improving social skills. Role-playing and group feedback can help reduce suspicious- ness. For example, if the patient says, “I think the therapist is singling me out,” other groups members may provide a reality check or describe similar feelings in the past.
An anti-anxiety medication such as diazepam (Valium) may be used to reduce anxiety and agitation. More severe agitation and delusions may be treated with antipsychotic medi- cation such as haloperidol in small doses for brief periods of time to manage the mildly delusional thinking or severe agitation. The first- generation antipsychotic medication pimozide may be useful in reducing paranoid ideation.
Schizoid Personality Disorder
CLUSTER A
People with schizoid personality disorder exhibit a lifelong pattern of social withdrawal. They are somewhat expressionless and operate with a restricted range of emotional expression. Others tend to view them as odd or eccentric due to their discomfort with social interaction.
The prevalence rate may be nearly 5% of the population. Males are more often affected. Symptoms of schizoid personal- ity disorder appear in childhood and adolescence. These young people tend to be loners, do poorly in school, and are the objects of ridicule by their peers for their odd behaviour. There is increased prevalence of the disorder in families with a history of schizophrenia or STPD. Abnormalities in the dopaminergic systems may underlie this problem.
Relationships are particularly affected due to the prominent feature of emotional detachment. People with this disorder do not seek out or enjoy close relationships. Neither approval nor rejection from others seems to have much effect. Friendships, dating, and sexual experiences are rare. If trust is established, the person may divulge numerous imaginary friends and fantasies.
The patient may describe feelings of depersonalization or detachment from oneself and the world.
Guidelines for Nursing Care
* Nurses should avoid being too “nice” or “friendly.”
* Do not try to increase socialization.
* Patients may be open to discussing topics such as coping and
anxiety.
* Conduct a thorough assessment to identify symptoms the patient is
reluctant to discuss.
* Protect against ridicule from group members due to patient’s
distinctive interests or ideas.
Treatment
Patients with schizoid personality disorder tend to be introspective. This trait may make them good, if distant, candidates for psychotherapy. As trust develops, these patients may describe a full fantasy life and fears, particularly of dependence. Psychotherapy can help improve sensitivity to others’ social cues. Group therapy may also be helpful, even though the patient may frequently be silent. Group therapy provides experience in practising interactions with and receiving feedback from others. Group members may become quite important to the person with schizoid personality disorder and may be the only form of socialization they have.
Antidepressants such as bupropion (Wellbutrin) may help increase pleasure in life. Second-generation antipsychotics, such as risperidone or olanzapine (Zyprexa), are used to improve emotional expressiveness.
Schizotypal Personality Disorder
CLUSTER A
People with STPD do not blend in with the crowd. Their symptoms are strikingly strange and unusual. Magical thinking, odd beliefs, strange speech patterns, and inappropriate affect are hallmarks of this disorder.
Estimates of the prevalence of STPD vary from 0.6% to 4.6%. It is more common in men than women.
Like the other cluster A personality disorders, symptoms are evident in young people. People who have first-degree relatives with schizophrenia are at more risk for this disorder. Abnormalities in brain structure, physiology, chemistry, and functioning are similar to schizophrenia. For example, both disorders share reduced cortical volume.
The Diagnostic and Statistical Manual of Mental Disorders, fifth edi- tion (DSM-5) (APA, 2013), identifies this problem as both a personality disorder and the first of the schizophrenia spectrum disorders. The ICD-10 (World Health Organization, 2016), used throughout the world, classifies schizotypal disorder along with schizophrenia and no longer lists schizotypal disorder as a personality disorder.
Like schizoid personality disorder, individuals with STPD have severe social and interpersonal deficits. They experience extreme anxiety in social situations. Contributions to conversations tend to ramble, with lengthy, unclear, overly detailed, and abstract content. An additional feature of this disorder is paranoia. Individuals with STPD are overly suspicious and anxious. They tend to misinterpret the motivations of others as being out to get them and blame others for their social isolation. Odd beliefs (e.g., being overly superstitious) or magical thinking (e.g., “He caught a cold because I wished he would”) are also common.
Psychotic symptoms seen in people with schizophrenia, such as hal- lucinations and delusions, may also exist with STPD, but to a lesser degree and only briefly. A major difference between this disorder and schizophrenia is that people with STPD CAN BE MADE AWARE of their suspiciousness, magical thinking, and odd beliefs. Schizophrenia is characterized by far stronger delusions.
Guidelines for Nursing Care
* Respect the patient’s need for social isolation.
* Nurses should be aware of the patient’s suspiciousness and employ
appropriate interventions.
* Perform careful assessment as needed to uncover any other medical
or psychological symptoms that may need intervention (e.g., suicidal thoughts).
* Be aware that strange beliefs and activities, such as strange religious
practices or peculiar thoughts, may be part of the patient’s life.
Treatment
The principles of psychotherapy used are similar to those for schizoid personality disorder. However, clinicians should be aware that these patients may also be actively involved in groups such as cults and unusual religious groups and engage in occult activities.
While there is no specific medication for STPD, associated conditions may be treated. People with STPD seem to benefit from medications that help to control their symptoms. For example, antipsychotic medications for such symptoms as ideas of reference or illusions. Co- morbid symptoms related to depression and anxiety may be treated with antidepressants and anti-anxiety medications.
Borderline Personality Disorder
CLUSTER B
Neurobiology of Borderline Personality Disorder
Borderline personality disorder (BPD) is a serious and disabling brain disorder marked by impulsivity and emotional dysregulation.
Serotonin: Altered functioning of serotonin in the brain has been linked to depression, aggression, and difficulty in controlling destructive urges. The serotonin transporter gene 5-HTT is thought to have shorter alleles in BPD, which have been associated with lower levels of serotonin and increased impulsive aggression.
Emotional dysregulation: Emotional responses that are poorly modulated (regulated) (e.g., angry outbursts, rage, marked fluctuation of mood, self-harm) and that can shift within seconds, minutes, or hours
Brain imaging (functional magnetic resonance imaging) findings
Pre-frontal cortex: In times of stress this part of the brain helps us regulate emotions and refrain from inappropriate actions. The pre-frontal cortex helps with reality testing and guides attention and thought. In people with BPD this part of the brain does not respond. Instead, there is an extreme perception and intensity of negative emotions.
Limbic system/amygdala: In BPD parts of the emotional centre of the brain are overstimulated and take longer to return to normal. Also, certain neurotransmitters that act as constraints in normal circumstances may underfunction in BPD, leaving a person in a prolonged fight-or-flight response.
____________________
Medications
Selective serotonin reuptake inhibitors, anticonvulsants, second-generation antipsy- chotics, lithium: Helps brain switch from sympathetic nervous system (arousal) to parasympathetic nervous system (relaxation mode)
Dialectical behavioural therapy (DBT): Mindfulness, deep breathing, relaxation techniques- Helps dampen angry, impulsive, labile behaviour
___________________
There is evidence of dysfunction that accompanies the borderline trait of impulsivity. It may also contribute to the depression and aggression that commonly accompany this disorder. The serotonin transporter gene 5-HTT may have shorter alleles, which have been asso- ciated with lower levels of serotonin and increased impulsive aggression.
[One of two or more versions of a genetic sequence at a particular region on a chromosome. An individual inherits two alleles for each gene, one from each parent.]
Structural and functional magnetic resonance imaging have revealed abnormalities in the pre-frontal cortex and limbic regions.
The frontal region is implicated in regulatory control processes, and the limbic region is essential for emotional processing.
Limbic hyper-reactivity and diminished control by the frontal brain may explain poor emotion processing, impulsivity, and interpersonal disturbances.
_______________
BPD is the most well known and dramatic of the personality disorders. BPD prevalence may be as high as 5.9% in the general population and be about 20% among people receiving inpatient psychiatric care
The major features of this disorder are patterns of marked in- stability in emotion regulation, unstable interpersonal relationships, identity or self-image distortions, and unstable mood. These symptoms result in severe functional impairments, a high mortality rate (approximately 30%), and extensive use of health care services
People with BPD seek out treatment for depression, anxiety, suicidal and self-harming behaviours, and other impulsive behaviours including substance use. Although hospitalization may decrease self-destructive risk for patients with BPD, it is not regarded as an effective long-term solution.
BPD is around five times more common in first-degree biological relatives with the same disorder compared with the general population
This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation
_______
Mahler and colleagues (1975) believed that psychological problems are a result of the dis- ruption of the normal separation-individuation of the child from the mother.
According to Mahler, an infant progresses from complete self- absorption with an inability to separate themself from the mother to a physically and psychologically differentiated toddler. Mahler em- phasized the role of the significant other (traditionally the mother) in providing a secure emotional base of support that promotes enough confidence for the child to separate. This support is achieved through a balance of holding (emotionally and physically) a child enough for the child to feel safe, while at the same time fostering and encouraging independence and natural exploration.
Problems may arise in this separation-individuation process. If a toddler leaves their mother on the park bench and wanders off to the sandbox, ideally two things should happen. First, the child should be encouraged to go off into the world with smiles and reassurance: “Go on, honey, it’s safe to go away a little.” Second, the mother needs to be reliably present when the toddler returns, thereby reward- ing their efforts. Clearly, parents are not perfect and are sometimes distracted and short tempered. Mahler notes that raising healthy children does not require that parents never make mistakes and that “good enough parenting” will promote successful separation- individuation.
Stages of this process are as follows:
* Stage 1 (birth–1 month): Normal autism. The infant spends most
of their time sleeping.
* Stage 2 (1–5 months): Symbiosis. The infant perceives the mother-
infant as a single fused entity. Infants gradually distinguish the in-
ner world from the outer world.
* Stage 3 (5–10 months): Differentiation. The infant recognizes dis-
tinctness from the mother. Progressive neurological development and increased alertness draw the infant’s attention away from self to the outer world.
* Stage 4 (11–18 months): Practising. The ability to walk and explore greatly expands the toddler’s sense of separateness.
* Stage 5 (18–24 months): Rapprochement. Toddlers move away from their mothers and come back for emotional refuelling. Periods of helplessness and dependence alternate with the need for inde- pendence.
* Stage 6 (2–5 years): Object constancy. When children compre- hend that objects (in this case, the object is the mother) are per- manent even when they are not in their presence, the individuation process is complete.
Children who later develop BPD may have had this process dis- rupted.
Pathological Personality Traits Seen in People With BPD
One of the pathological personality traits seen in people with BPD is negative affect. This affect is characterized by emotional lability, that is, moods that alternate rapidly from one emotional extreme to another. Other characteristics of a negative affect include responding to situations with emotions that are out of proportion to the circumstances, pathological fear of separation, and intense sensitivity to perceived personal rejection. Other disruptive traits common in people with BPD are impulsivity and antagonism. Impulsivity is manifested in acting quickly in response to emotions without considering the con- sequences. This impulsivity results in damaged relationships and even suicide attempts.
BPD is also characterized by feelings of antagonism, manifested in hostility, anger, and irritability in relationships. Physical violence toward intimate partners and non-intimate partners alike may oc- cur. Rarely, a homicide of family members or others occurs. Vio- lence is also manifested in destructive behaviours such as property damage.
In addition, ineffective and harmful self-soothing habits, such as cutting, promiscuous sexual behaviour, and numbing with sub- stances, are common and may result in unintentional death. Chronic suicidal ideation is also a common feature of this disorder and in- fluences the likelihood of accidental death.
A number of non-psychiatric diagnoses are also associated with BPD. They in- clude diabetes, high blood pressure, chronic back pain, fibromyalgia, and arthritis, and must be considered when determining treatment approaches.
Splitting, the primary defence or coping style used by people with BPD, is the inability to incorporate positive and negative aspects of oneself or others into a whole image. This kind of dichotomous think- ing and coping behaviour is believed to be partly a result of the person’s failed experiences with adult personality integration and is likely influ- enced by exposure to earlier psychological, sexual, or physical trauma. For example, the individual may tend to idealize another person (e.g., friend, lover, health care provider) at the start of a new relationship, hoping that this person will meet all of their needs. However, at the first disappointment or frustration, the individual quickly shifts to devaluation, despising the other person.
Guidelines for Nursing Care
- A therapeutic relationship is essential with patients who have BPD because most of them have experienced failed relationships, includ- ing therapeutic alliances.
- The therapeutic relationship often follows an initial hesitancy on the part of the patient, then an upward curve of idealization by the patient toward the caregiver. This idealization is invariably followed by a devaluation of the staff member when the patient is disappoint- ed by unmet, frequently impossible, expectations.
- Conduct a thorough assessment of current or past physical, sexual, or emotional abuse and level of current risk for harm from self or others.
- Clinical supervision and additional education are helpful and sup- portive to health care providers.
- Awareness and monitoring of one’s own stress responses to patient behaviours facilitate more effective and therapeutic intervention, regardless of the therapeutic approach being used.
- Evaluating treatment effectiveness in this patient population is difficult. Nurses may never know the real results of their interventions.
Treatment
People with BPD are usually admitted to psychiatric treatment pro- grams because of symptoms with comorbid disorders or dangerous behaviour. Emotions such as anxiety, rage, and depression and behav- iours such as withdrawal, paranoia, and manipulation are among the most frequent that health care workers must address. When patients blame and attack others, the nurse needs to understand the context of their complaints. These attacks originate from the feeling of being threatened. The more intense the complaints are, the greater the pa- tients’ fear of potential harm or loss is. Be aware of manipulative behav- iours such as flattery, seductiveness, and instilling guilt.
Realistic outcomes are established for individuals with BPD based on the perspective that personality change occurs with one behavioural solution and one learned skill at a time. This can be expected to take a lot of time and repetition. In the acute care setting the focus is on the presenting problem, which may be depression or severe anxiety. Health care providers do not expect resolution of chronic behaviour problems during the hospital stay, but rather expect to be met with appropri- ate therapeutic feedback and incremental steps toward recovery in an outpatient setting.
People with BPD are impulsive and may be suicidal, self-mutilating, aggressive, manipulative, and even psychotic during periods of stress. Provide clear and consistent boundaries and limits. Use straightforward communication. When behavioural problems emerge, calmly review the therapeutic goals.
There are no approved medications for treating BPD. When medi- cations are used, their purposes are to maintain patients’ cognitive function, relieve symptoms, and improve quality of life. People with BPD often respond to antidepressants such as selective serotonin reup- take inhibitors (SSRIs), anti-convulsants, and lithium for mood and emotional dysregulation symptoms. Naltrexone, an opioid receptor antagonist, has been found to reduce self-injurious behaviours. Second-generation antipsychotics may control anger and brief psychosis.
Community meetings, coping skills groups, and socializing groups are all helpful for these patients. They have the opportunity to interact with peers and staff to discuss goals and learn problem-solving skills.
Common problems resulting from staff splitting can be mini- mized if the unit leaders hold weekly staff meetings in which staff members are allowed to express their feelings about conflicts with patients and each other. This process is often acted out in the treat- ment milieu and can interrupt the delivery of care. For example, a female patient may briefly idealize her male nurse on the inpatient unit, telling staff and patients alike that she is “the luckiest person because she has the best nurse in the hospital.” The rest of the team understands that this comment is an exaggeration. After days of her constant dramatic praise for the nurse and subtle insults to the rest of the staff, some members of the team may start to feel inadequate and resentful of the nurse. They begin to make critical remarks about minor events to prove that the nurse is not perfect.
Anti-social Personality Disorder
CLUSTER B
Anti-social personality disorder is a pattern of disregard for, and vio- lation of, the rights of others. People with this disorder may be more commonly referred to as sociopaths.
This diagnosis is reserved for adults, but symptoms are evident by the mid-teens. Symptoms tend to peak during the late teenage years and into the mid-twenties. By around 40 years of age, the symptoms may abate and improve even without treatment. The prevalence of anti-social personality disorder is between 0.2% and 3.3%. While the disorder is much more common in men, women may be underdiagnosed due to the traditional close association of this disorder with males.
Anti-social personality disorder is genetically linked, and twin studies indicate a predisposition to this disorder. It is likely that the genetic predisposition for characteristics of anti-social personality disorder such as a lack of empathy may be set into motion by childhood maltreatment. Inconsistent parenting and discipline, significant abuse, and extreme neglect are associated with this disorder. Children reflect parental attitudes and behaviours in the absence of more prosocial inluences. Virtually all individuals who eventually develop this disorder have a history of impulse control and conduct problems as children and adolescents.
The main pathological traits that characterize anti-social personality disorder are antagonistic behaviours such as being deceitful and ma- nipulative for personal gain or being hostile if needs are blocked. The disorder is also characterized by disinhibited behaviours such as high level of risk taking, disregard for responsibility, and impulsivity. Criminal misconduct and substance use are common in this population.
People with this disorder are mostly concerned with gaining personal power or pleasure, and in relationships they focus on their own gratification to an extreme. They have little to no capacity for intimacy and will exploit others if it benefits them in relationships. One of the most disturbing qualities associated with anti-social personality dis- order is a profound lack of empathy, also known as callousness. This callousness results in a lack of concern about the feelings of others, the absence of remorse or guilt except when facing punishment, and a disregard for meeting school, family, and other obligations.
These individuals tend to exhibit a shallow, unexpressive, and su- perficial affect. They may also be adept at portraying themselves as concerned and caring if these attributes help them to manipulate and exploit others. A person with anti-social personality disorder may be able to act witty and charming and be good at flattery and manipulating the emotions of others.
Guidelines for Nursing Care
* Nurses should be aware and monitor their responses to patient be- haviours to facilitate effective and therapeutic responses.
* Conduct a thorough assessment of current life stressors, history of violent thoughts and behaviours (including suicidal ideation), and substance use.
* Be aware that distrust, hostility, and a profound inability to connect with others will impair the usual process of developing a therapeu- tic relationship.
* Evaluating treatment effectiveness in this patient population is difficult. Nurses may never know the real results of their interventions.
Treatment
In the context of anti-social personality disorder the role of the nurse will be to provide consistency, support, boundaries, and limits. Provid- ing realistic choices (e.g., selection of a particular group activity) may enhance adherence to treatment. People with anti-social personality disorder may be involuntarily admitted to psychiatric units for evalua- tion. With their freedom limited, they tend to be angry, manipulative, aggressive, and impulsive. Try to prevent or reduce untoward effects of manipulation (flattery, seductiveness, instilling of guilt). Set clear and realistic boundaries and consequences and ensure that all staff follow these limits. Carefully document behaviours and signs of manipula- tion. Be aware that anti-social patients can manipulate with feelings of guilt when they are not getting what they want.
The safety of patients and staff is a prime consideration in work- ing with individuals in this population. To promote safety, the entire treatment team should follow a solid treatment plan that emphasizes realistic limits on specific behaviour, consistency in responses, and consequences for actions. Careful documentation of behaviours will aid in providing effective interventions and in promoting teamwork.
Therapeutic communication techniques are valuable tools for work- ing with individuals with anti-social personality disorder. Simply being heard can defuse an emotionally charged situation. For example, the nurse can listen to a patient’s emotional complaints about the staff and the hospital without correcting errors, simply noting that the patient truly feels hurt. Showing empathy may also decrease aggressive out- bursts if the patient feels that staff members are trying to understand feelings of frustration.
There are no approved medications for treating anti-social personality disorder. Medications are used to treat concurrent comorbid disorders. The advanced-practice psychiatric mental health registered nurse may care for individuals with this type of personality disorder in a variety of inpatient and community settings.
Histrionic Personality Disorder
CLUSTER B
People with histrionic personality disorder are excitable and dramatic yet are often high functioning. They may be referred to in terms of be- ing a “drama queen” or “drama major.” Classic characteristics of this population include extraversion, flamboyancy, and colourful person- alities. Despite this bold exterior, those with histrionic personality dis- order tend to have limited ability to develop meaningful relationships.
Histrionic personality disorder occurs at a rate of nearly 2% in community samples. In clinical settings it tends to be diagnosed more frequently in women than in men. Symptoms begin by early adulthood. Inborn character traits such as emotional expressiveness and egocentricity have also been identified as predisposing an individual to this disorder.
This disorder is characterized by emotional attention-seeking be- haviours, including self-centredness, low frustration tolerance, and excessive emotionality. The person with histrionic personality disorder is often impulsive and may act flirtatiously or provocatively. Relation- ships do not last because the partner often feels smothered or reacts to the insensitivity of the histrionic person. The individual with histrionic personality disorder does not have insight into a personal role in break- ing up relationships.
Guidelines for Nursing Care
* Nursing care should reflect an understanding that seductive behav- iour is a response to distress.
* Keep communication and interactions professional.
* Patients may exaggerate symptoms and difficulty in functioning.
* Encourage and model the use of concrete and descriptive rather
than vague and impressionistic language.
* Assist patients to clarify feelings because they often have difficulty
identifying them.
* Teach and role model assertiveness.
* Assess for suicidal ideation. What was intended as a suicide gesture
may inadvertently result in death.
Treatment
Individuals with histrionic personality disorder may be out of touch with their feelings. Psychotherapy may pro- mote clarification of inner feelings and appropriate expression. Group therapy may be useful in this population, although distracting symptoms may be disruptive to group functioning.
There are no specific pharmacological treatments available for people with histrionic personality disorder. Medications such as antidepressants can be used for depressive symptoms. Anti-anxiety medications may be helpful in treating anxiety. Antipsychotics may be used if the patient exhibits derealization or illusions.
Narcissistic Personality Disorder
CLUSTER B
Narcissistic personality disorder is characterized by feelings of entitlement, an exaggerated belief in one’s own importance, and a lack of empathy. In reality, people with this disorder suffer from a weak self- esteem and hypersensitivity to criticism. Narcissistic personality dis- order is associated with less impairment in individual functioning and quality of life than the other personality-based disorders.
The prevalence of narcissistic personality disorder ranges from 0% to about 6% in community samples. It tends to be more common in males than in females.
There may be a familial tendency for this disorder, as parents with narcissism may attribute an unrealistic sense of talent, importance, and beauty to their children. These attributions put the children at higher risk for the disorder.
People with narcissistic personality disorder come across as arrogant and as having an inflated view of their self-importance. The individual with this disorder has a need for constant admiration along with a lack of empathy for others, a factor that strains most relationships over time. They are very sensitive to rejection and criticism and can be disparaging to others. A sense of personal entitlement paired with a lack of social empathy may result in the exploitation of other people.
Underneath the surface of arrogance, people with narcissistic personality disorder feel intense shame and have a fear of abandonment. In keeping with these descriptions the main pathological personality trait of narcissism is antagonism, represented by grandiosity and attention-seeking behaviours. Those with narcissistic personality disorder tend to tolerate rejection poorly. As a result, narcissistic individuals may seek help for depression or may seek to be validated by therapists and loved ones for their emotional pain of not being appreciated by others for their efforts or special qualities.
Guidelines for Nursing Care
* Nurses should remain neutral and recognize the source of narcis- sistic behaviour, shame and fear of abandonment.
* Use the therapeutic nurse–patient relationship as an opportunity to practise engaging in meaningful interaction.
* Avoid engaging in power struggles or becoming defensive in re- sponse to the patient’s disparaging remarks.
* Role model empathy.
Treatment
Because individuals are not likely to seek help for their own problems, they are more likely to be involved in couples or fam- ily therapy than in individual treatment. In these family-oriented ap- proaches narcissistic individuals are likely to deflect suggestions that they contribute to family problems and will instead blame others.
If a person with narcissistic personality disorder somehow seeks treatment, individual cognitive behavioural therapy is helpful in de- constructing faulty thinking. Group therapy can also assist the person in sharing with others, seeing their own qualities in others, and learn- ing empathy.
There are no approved medications for treating narcissistic per- sonality disorder. Medications are used to treat concurrent comorbid disorders.
Avoidant Personality Disorder
CLUSTER C
The main pathological personality traits associated with avoidant per- sonality disorder are low self-esteem related to functioning in social situations, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people. Some individuals with avoidant personality disorder can function in a protective environment. However, if their support system fails, they can suffer from depression, anxiety, and anger. They are especially sensitive to and pre- occupied with rejection, humiliation, and failure. They often avoid new interpersonal relationships or activities due to their fears of criticism or disapproval.
Avoidant personality disorder occurs in approximately 2.4% of the population. It is found equally among men and women. Early symptoms of the disorder are often evident in infants and children. These symptoms include shyness and avoidance that, unlike common shyness, increases during adolescence and early adulthood.
Guidelines for Nursing Care
* Nurses should use a friendly, accepting, reassuring approach and remember that being pushed into social situations can cause ex- treme and severe anxiety for these patients.
* Convey an attitude of acceptance toward patient fears.
* Provide the patient with exercises to enhance new social skills, but use these with caution because any failure can increase feelings of
poor self-worth.
* Assertiveness training can assist the person to learn to express
needs.
Treatment
Individual and group therapy is useful in processing anxiety-provoking symptoms and in planning methods to approach and handle anxiety- provoking situations. Psychotherapy focuses on trust and assertiveness training.
Anti-anxiety medications can be helpful. Beta-adrenergic receptor antagonists (e.g., atenolol) help reduce autonomic nervous system hy- peractivity. Antidepressant medications, such as SSRIs like citalopram (Celexa) and serotonin–norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (Effexor), may reduce social anxiety. Serotonergic medications may help individuals with avoidant personalities feel less sensitive to rejection.
Dependent Personality Disorder
CLUSTER C
Dependent personality disorder is characterized by a pattern of sub- missive and clinging behaviour related to an overwhelming need to be cared for. This need results in intense fears of separation.
Dependent personality disorder is fairly rare, with an estimated prevalence rate of about 0.5%
May be the result of chronic physical illness or punishment for independent behaviour in childhood. The inherited trait of submissiveness may also be a factor.
People with dependent personality disorder have a high need to be taken care of. This need can lead to patterns of submissiveness with fears of separation and abandonment by others. Because they lack con- fidence in their own ability or judgement, those with dependent per- sonality disorder may manipulate others to assume responsibility for such activities as finances or child rearing. This may create problems by leaving them more vulnerable to exploitation by others because of their passive and submissive nature. Feelings of insecurity about their self-agency and lack of self-confidence may interfere with attempts to become more independent. They may experience intense anxiety when left alone for even brief periods of time
Guidelines for Nursing Care
* Nurses can help the patient identify and address current stressors. * Be aware that strong counter-transference may develop because of
the patient’s demands for extra time and crisis states.
* The therapeutic nurse–patient relationship can provide a testing ground for increased assertiveness through role modelling and
teaching of assertive skills.
Treatment
Psychotherapy is the treatment of choice for dependent personality disorder
Cognitive behavioural therapy can help patients develop more healthy and accurate thinking by examin- ing and challenging automatic thoughts that result in fearful behaviour. This process can help in developing new perspectives and attitudes about the need for other people.
There are no specific medications indicated for this disorder, but symptoms of depression and anxiety may be treated with the appropriate antidepressant and anti-anxiety medications. Panic attacks can be helped with the tricyclic antidepressant imipramine.
Obsessive-Compulsive Personality Disorder
CLUSTER C
Obsessive-compulsive personality disorder is characterized by limited emotional expression, stubbornness, perseverance, and indecisiveness. Pre-occupation with orderliness, perfectionism, and control are the hallmarks of this disorder.
Obsessive-compulsive personality disorder is one of the most prevalent personality disorders. The prevalence rate ranges from 2.1% to 7.9%
It is more common in men than in women. Oldest siblings tend to be affected more often than subsequent siblings. Risk factors for this disorder include a background of harsh discipline and having a first- degree relative with this disorder. Obsessive-compulsive personality dis- order has been associated with increased relapse rates of depression and an increase in suicidal risks in people with co-occurring depression.
The main pathological personality traits are rigidity and inflexible standards of self and others. People with obsessive-compulsive person- ality disorder rehearse over and over how they will respond in social situations. They persist in goal seeking long after it is necessary, even if it is self-defeating or relationship defeating. The pre-occupation often results in losing the major point of the activity. Projects are often in- complete due to overly strict standards.
There is a difference between obsessive-compulsive disorder and obsessive-compulsive personality disorder. Obsessive-compulsive dis- order is characterized by obsessive thoughts and by repetition or ad- herence to rituals. Those with obsessive-compulsive disorder are aware that these thoughts and actions are unreasonable.
Obsessive-compulsive personality disorder is characterized more by an unhealthy focus on perfectionism. Those with obsessive-compulsive personality disorder think that their actions are right and feel comfortable with such self-imposed systems of rules.
Guidelines for Nursing Care
* Nurses should guard against power struggles with these patients, as their need for control is very high.
* Patients with this disorder have difficulty dealing with unexpected changes.
* Provide structure, yet allow patients extra time to complete habitual behaviour.
* Assist patients to identify ineffective coping and to develop effective coping techniques
Treatment
Typically, patients seek help for obsessive-compulsive personality dis- order, as they are aware of their own suffering. They may also seek treatment for anxiety or depression. The treatment course is often long and complicated. Both group therapy and behavioural therapy can be helpful, so that the person can learn new coping skills for their anxiety and see direct benefits for change from feedback within the group.
Clomipramine (Anafranil) may help reduce the obsessions, anxiety, and depression associated with this disorder. Other serotonergic medi- cations such as fluoxetine (Prozac) may also be effective.
Assessment Tools for personality disorders
semistructured interview obtained by clinicians.
These types of interviews have standard questions and a standard format for ask- ing the questions. These interviews go beyond asking the patient to self-report symptoms because individuals with personality disorders often lack insight into their behaviours and motivations and therefore have difficulty accurately describing themselves.
One way to elicit more objective information is to ask the person if family members and col- leagues perceive them in a certain way. For example, “You said that you don’t think you’re emotionally distant. How would your wife describe you?” Cultural norms and expectations also need to be considered when evaluating the presence of a personality disorder. Personality dis- orders are often assessed through identifying pathology within one or more personality dimensions.
The five main dimensions of personalities are (1) extraversion versus introversion, (2) antagonism versus adherence, (3) constraint versus impulsivity, (4) emotional dysregulation versus emotional stability, and (5) unconventionality versus closedness to experience.
Open-ended or subjective interviews, which do not have standard questions or a standard question format, are more likely to result in biased and culturally based decisions about diagnosis and treatment delivery.
Minnesota Multi-phasic Personality Inventory, are useful because they have built- in validity and reliability scales for the clinician to refer to when interpreting test results. Other more focused questionnaires and rating scales can be used to assess several symptoms. These include:
* Feelings of emptiness
* An inclination to engage in risky behaviours such as reckless driv-
ing, unsafe sex, substance use, binge eating, gambling, or over-
spending
* Intense feelings of abandonment that result in paranoia or feeling
spaced out
* Idealization of others and becoming close quickly
* A tendency toward anger, sarcasm, and bitterness
* Self-mutilation and self-harm
* Suicidal behaviours, gestures, or threats
* Sudden shifts in self-evaluation that result in changing goals, values, and career focus
* Extreme mood shifts that occur in a matter of hours or days * Intense, unstable romantic relationships
* Feelings of insecurity
* Rigidity
* Perfectionism
Patient History for personality disorder
Taking a full medical history can help determine if the problem is a psychiatric one, a non-psychiatric medical one, or both. Non-psychiatric illness should never be ruled out as the cause for problem behaviour until the data support this conclusion. Important issues in assessing for personality disorders include a history of suicidal or aggressive ide- ation or actions, current use of medications and illegal substances, abil- ity to handle money, and legal history.
Personality Dimensions
Extraversion versus introversion
Antagonism versus adherence
Constraint versus impulsivity
Emotional dysregulation versus emotional stability
Unconventionality versus closedness to experience
Extraversion versus introversion
Activity, aloofness, assertiveness, detachment, entitlement, excitement seeking, exhibitionism, exploratory excitability, extravagance, gregariousness, histrionic sexualization, intimacy problems, optimism, positive emotionality, restricted expression, schizoid orientation, shyness, sociability, social avoidance, social closeness, social potency, stimulus seeking, warmth, well-being
Antagonism versus adherence
Adherence, aggression, agreeableness, alienation, altruism, attachment, callousness, compassion, conduct problems, dependency, diffidence, empathy, entitlement, helpfulness, insecure attachment, interpersonal disesteem, manipulativeness, mistrust, modesty, narcissism, passive oppositionality, psychopathy, pure-heartedness, rejection, sentimentality, social acceptance, social closeness, straightforwardness, submissiveness, suspiciousness, tender- mindedness, trust
Constraint versus impulsivity
Achievement striving, childishness, competence, compulsivity, conscientiousness, deliberation, disorderliness, dutifulness, eagerness of effort, harm avoidance, impulsivity, irresponsibility, obsessionality, order, perfectionism, propriety, resourcefulness, responsibility, risk taking, self-discipline, traditionalism, workaholism
Emotional dysregulation versus emotional stability
Affective lability, alienation, angry hostility, anticipatory worry, anxiousness, dependency, depressiveness, dysphoria, emotional dysregulation, fear of uncertainty, hostility, hypochondriasis, identity problems, inferiority, introspection, irritability, negative affect, pessimism, self-acceptance, self-consciousness, self-harm, sensitivity, stress reaction, unhappiness, vulnerability, worthlessness
Unconventionality versus closedness to experience
Absorption, dissociation, eccentric perceptions, eccentricity, openness to experience, perceptual cognitive distortion, rigidity, spiritual acceptance, thought disorder, transpersonal identification
Self-Assessment for personality disorder
Because enduring patterns of interpersonal difficulties are central to the problems faced by people diagnosed with personality disorders, it is un- derstandable that their relationship problems with their caregivers sur- face in the treatment milieu. Anticipating that people with personality disorders will likely have a disrupted, intense interpersonal experience with caregivers is helpful to the caregivers as they monitor their own personal stress responses. It is important to keep in mind that these dys- functional behaviours may really represent the person’s best efforts to cope because they lack the necessary skills to be effective in their lives.
Planning
It is often difficult to create a therapeutic relationship with individuals who have personality disorders because most of them have experienced failed relationships, including therapeutic alliances. Individuals with BPD or anti-social personality disorder will distrust relationships and demonstrate hostility toward others, thus making the establishment of a therapeutic relationship difficult. People with personality disorders require a sense of control over what is happening to them. Giving them realistic choices (e.g., selection of a particular group activity) may en- hance adherence to treatment. It is also important to plan individual patient treatment within the context of their family. Patients, families, and health care providers can access further information on person- ality disorders from the Internet; two reliable Canadian sites are the Canadian Mental Health Association (https://www.cmha.ca) and Here- toHelp (https://www.heretohelp.bc.ca). Refer to Table 19.4 for guide- lines for nursing care for the major clusters of personality disorders. Case Study and Nursing Care Plan 19.1 presents a person with BPD.
Implementation
People with BPD are impulsive (e.g., suicidal, self-mutilating), aggres- sive, manipulative, and even psychotic during periods of stress. Indi- viduals with anti-social personality disorder are often involuntarily admitted and are manipulative, aggressive, and impulsive. Refer to Boxes 19.1 to 19.3 for interventions to address these behaviours, based on the Nursing Interventions Classification (NIC) (Butcher et al., 2019).
Finding an approach that works with people in the setting in which they are treated is important. Therapies such as dialectical behaviour therapy (DBT) and mindfulness-based therapies offer staff evidence- informed interventions, clinical structure, and formalized support for identifying best practices.
Diagnosis of personality disorder
When people with personality disorders are admitted to hospital, it is usually because of symptoms of comorbid disorders, dangerous be- haviour, or court-ordered treatment. BPD and anti-social personality disorder both present a challenge for health care providers because the behaviours central to these disorders often cause disruption in psychiatric and medical-surgical settings. Emotions such as anxiety, rage, and depression and behaviours such as withdrawal, paranoia, and manipulation are among the most frequent concerns that health care workers must address.
Outcomes Identification:
Realistic outcomes are established for individuals with personality disorders based on the perspective that personality change occurs with one behavioural solution and one learned skill at a time. This change can be expected to take much time and repetition.
In the acute care setting the focus is on the presenting problem, which may be depression or severe anxiety.
Planning:
People with personality disorders require a sense of control over what is happening to them. Giving them realistic choices (e.g., selection of a particular group activity) may en- hance adherence to treatment. It is also important to plan individual patient treatment within the context of their family.
Implementation:
People with BPD are impulsive (e.g., suicidal, self-mutilating), aggres- sive, manipulative, and even psychotic during periods of stress. Indi- viduals with anti-social personality disorder are often involuntarily admitted and are manipulative, aggressive, and impulsive.
ASSESSMENT GUIDELINES
Personality Disorders
- Assess for suicidal or homicidal thoughts. If such thoughts are present, the person needs immediate attention.
- Determine whether the person has a medical disorder or another psychi- atric disorder that may be responsible for the symptoms (especially a sub- stance use disorder).
- View the assessment about personality functioning from within the per- son’s ethnic, cultural, and social background.
- Ascertain whether the person experienced a recent important loss. Person- ality disorders are often exacerbated after the loss of significant supporting people or in a disruptive social situation.
- Evaluate for a change in personality, in middle adulthood or later, that sig- nals the need for a thorough medical workup or assessment for an unrecognized substance use disorder.
Safety and Teamwork
When individuals with personality disorders are receiving treatment from a team of health professionals, milieu management is a significant part of treatment. Most individuals with personality disorders are admitted to hospital because of a risk to themselves or others. Patient and staff safety is a priority.
When patients are actively involved in developing their treatment plans (e.g., being included in daily staff rounds to set goals and evaluate progress), they typically take more responsibility for themselves and the success of implementing the plan. Having limits and being con- fronted about negative behaviour are better accepted by the person if staff members first employ empathic mirroring (i.e., reflecting back to the person an understanding of the person’s distress without a value judgement). For example, the nurse can listen to a person’s emotional complaints about the staff and hospital without correcting any errors but simply noting that the person truly feels hurt. Showing empathy may also decrease aggressive outbursts if the person feels that staff members are trying to understand feelings of frustration.
A final approach that is useful for people with BPD relates to the re- sponse to superficial self-destructive behaviours. Acting in accordance with unit policies, the nurse remains neutral and dresses the cutting wound in a matter-of-fact manner. Then the person is instructed to write down the sequence of events leading up to the injury, as well as the consequences, before staff will discuss the event. This cognitive exercise encourages the person to think independently about their own behaviour instead of merely ventilating feelings. It facilitates the discus- sion with staff about alternative actions.
Pharmacological Interventions for personality disorders
There is no direct pharmacological treatment for personality disor- ders. However, people with personality disorders may be helped by a broad array of psychotropic medications, all geared toward maintain- ing cognitive function and relieving symptoms. Depending on the chief complaint, antidepressant, anxiolytic, or antipsychotic medication may be ordered for symptom relief and improved quality of life.
- People with STPD seem to benefit from low-dose atypical antipsychotic medications for their psychotic-like symptoms and day-to-day functioning.
- People with anti-social personality disorder respond to mood- stabilizing medications like lithium to help with aggression and impulsivity.
- People with BPD often respond to anti-convulsant mood-stabiliz- ing medications, low-dose antipsychotic medications, and omega-3 supplementation for mood and emotion dysregulation symptoms. Naltrexone hydrochloride, an opioid receptor antagonist, has been found to reduce self-injuring behaviours.
- People with avoidant personality disorder seem to respond positive- ly to medications similar to those used for anxiety disorders, such as SSRIs like citalopram (Celexa) and SNRIs such as duloxetine (Cym- balta).
Potential Nursing Diagnoses for Personality Disorders
Crisis, high levels of anxiety
Ineffective coping
Anxiety
Self-mutilation
__________
Anger and aggression; child, older adult, or spouse abuse
Risk for other-directed violence
Ineffective coping
Impaired parenting
Disabled family coping
_________
Withdrawal
Social isolation
____________
Paranoia
Fear
Disturbed sensory perception
Disturbed thought processes
Defensive coping
__________
Depression
Hopelessness
Risk for suicide
Self-mutilation
Chronic low self-esteem
Spiritual distress
_____________
Difficulty in relationships, manipulation
Ineffective coping
Impaired social interaction
Defensive coping
Interrupted family processes
Risk for loneliness
______________
Failure to keep medical appointments, late arrival for appointments, failure to follow prescribed medical procedure or medication regimen
Ineffective therapeutic regimen management
_____________
Non-adherence
NOC Outcomes for Manipulative, Aggressive, and Impulsive Behaviours
Nursing Outcome and Definition:
Social interaction skills: Personal behaviours that promote effective relationships
Intermediate indicator: Uses conflict-resolution methods
Short term indicators:
Exhibits receptiveness
Exhibits sensitivity to others
Cooperates with others
Uses assertive behaviours as appropriate Uses confrontation as appropriate
____________
Nursing outcome and definition: ersonal resiliency: Positive adaptation and function of an individual following significant adversity or crisis
Intermediate indicators: Uses effective coping strategies
Short term indicators:
Expresses emotion
Seeks emotional support
Uses strategies to promote safety
Takes responsibility for own actions
Uses strategies to avoid violent situations
Identifies available community resources
Obtains needed support
Self-initiates goal-directed behaviour
Expresses belief in ability to perform action
Expresses that performance will lead to desired outcome
___________
Nursing outcome and definition: Aggression self-control: Self-restraint of assaultive, combative, or destructive behaviours toward others
Intermediate indicator:
Communicates needs appropriately
Identifies when frustrated
Identifies when angry
Short term indicators:
Identifies responsibility to maintain control Identifies alternatives to aggression Identifies alternatives to verbal outbursts Vents negative feelings appropriately Refrains from striking or harming others
_________________
Impulse self-control: Self-restraint of compulsive or impulsive behaviours
-Controls impulses
-Identifies harmful impulsive behaviours
Identifies feelings that lead to impulsive actions
Identifies consequences of impulsive actions to self or others Avoids high-risk environments and situations
Seeks help when experiencing impulses
Case Management for personality disorder
Case management is helpful for individuals with personality disorders who are persistently and severely impaired. Many have had multiple hospitalizations, have been unable to maintain work or personal rela- tionships, and are relatively alone in their attempts to care for them- selves. In the acute care setting case management focuses on three goals: to gather pertinent history from current or previous providers; to support reintegration with family or loved ones as appropriate; and to ensure appropriate referrals to outpatient care, including substance disorder treatment, if needed. In the long-term outpatient setting case- management objectives include reducing hospitalization by providing resources for crisis services and enhancing the social support system.
Cluster A
* Paranoid personality disorder
* Schizoid personality disorder
* Schizotypal personality
disorder
Characteristics:
Manifestation of ideas of reference
Cognitive and perceptual distortions
Social ineptness
Anxiety
Odd and eccentric behaviours
Nursing Guidelines:
- Respect patient’s need for social isolation.
- Be aware of patient’s suspiciousness, and employ appropriate interventions.
- Perform careful diagnostic assessment as needed to uncover any other medical or psychological symptoms that may need intervention (e.g., suicidal thoughts).
Suggested Therapies:
Supportive psychotherapy
Cognitive and behavioural measures Group therapy to try to improve social
skills
Low-dose antipsychotics and anti- depressants
Cluster B
* Borderline personality disorder
* Narcissistic personality
disorder
* Histrionic personality disorder
* Anti-social personality disor-
der
Characteristic:
Ability to seem normal Manipulative Exploitive of others Disparaging
Impulsive (suicide, self-mutilation)
Splitting (adoring then devaluing people)
Grandiose
Filled with rage
Very sensitive to rejection, criticism Inability to experience empathy
Nursing Guidlines:
1. Try to prevent or reduce untoward effects of manipulation (flattery, seductiveness, instilling of guilt):
a. Set clear and realistic limits on specific
behaviour.
b. Ensure that limits are adhered to by all staff.
c. Carefully document signs of manipula- tion or aggression.
d. Document behaviours (give times, dates, circumstances).
e. Provide clear boundaries and consequences.
2. Be aware that patients can instill guilt when they are not getting what they want. Guard against being manipulated through feelings of guilt.
3. Use clear and straightforward communi- cation.
4. When behavioural problems emerge, calmly review the therapeutic goals and boundaries of treatment.
5. Avoid rejecting or rescuing.
6. Assess for suicidal and self-mutilating
behaviours, especially during times of stress.
7. Remain neutral; avoid engaging in power struggles or becoming defensive in response to the patient’s disparaging remarks.
8. Convey unassuming self-confidence.
Suggested Therapies:
ndividual psychotherapy Dialectical behaviour therapy Group therapy Pharmacotherapy for anxiety,
depression
Careful use of addictive medications (e.g., benzodiazepines)
Anti-convulsants may help impulsive behaviour
Antipsychotics to control anger and brief psychosis.
Cluster C
* Avoidant personality disorder
* Dependent personality
disorder
* Obsessive-compulsive person-
ality disorder
Characteristic
Excessively anxious in social situations
Hypersensitive to negative evaluation
Desiring of social interaction Perfectionistic
Has need for control Inflexible, rigid
Pre-occupied with details Highly critical of self and others
Nursing Guidlines
1. Being pushed into social situations can cause extreme and severe anxiety.
2. Guard against power struggles with patient. Need for control is very high.
3. A friendly, accepting, reassuring approach is the best way to treat patients.
4. The most common defence mechanisms are intellectualization, rationalization, reaction formation, isolation, and undoing.
Suggested Therapies
Supportive or insightful psychotherapy Group therapy
Assertiveness training Anti-depressants
Anti-anxiety medications
Beta-adrenergic receptor antagonists help reduce autonomic nervous system hyperactivity
NIC Interventions for Aggressive Behaviour Anger Control Assistance
Definition of anger control assistance: Facilitation of the expression of anger in an adaptive, non-violent manner
Activitiesa
* Determine appropriate behavioural expectations for expression of anger, given person’s level of cognitive and physical functioning.
* Limit access to frustrating situations until person is able to express anger in an adaptive manner.
* Encourage person to seek assistance from nursing staff during periods of increasing tension.
* Monitor potential for inappropriate aggression, and intervene before its expression.
* Prevent physical harm if anger is directed at self or others (e.g., restraint and removal of potential weapons).
* Provide physical outlets for expression of anger or tension (e.g., punching bag, sports, clay, journal writing).
* Provide reassurance to person that nursing staff will intervene to prevent person from losing control.
* Assist person in identifying source of anger.
* Identify function that anger, frustration, and rage serve for person.
* Identify consequences of inappropriate expression of anger.
NIC Interventions for
Manipulative Behaviour Limit Setting
Definition of limit setting: Establishing the parameters of desirable and acceptable personal behaviour
Activities
* Discuss concerns about behaviour with person.
* Identify (with input when appropriate) undesirable personal behaviour.
* Discuss with person, when appropriate, what desirable behaviour is in a
given situation or setting.
* Establish consequences (with person’s input when appropriate) for occur-
rence or non-occurrence of desired behaviours.
* Communicate established behavioural expectations and consequences to
person in language that is easily understood and non-punitive.
* Refrain from arguing or bargaining with person about established behav-
ioural expectations and consequences.
* Monitor person for occurrence or non-occurrence of desired behaviour.
* Modify behavioural expectations and consequences, as needed, to accom-
modate reasonable changes in person’s situation.
Advanced-Practice Interventions
Psychotherapy. Advanced-practice nurses are highly involved in and are often the clinical leaders in providing individual and group psy- chotherapy using dialectical behaviour therapy. DBT is an evidence- informed therapy developed by Dr. Marsha Linehan to treat chroni- cally suicidal people with BPD.
DBT is based on a biosocial theory that views the self-harming behaviour as a behaviour used to cope with or eliminate distress brought on by a negatively perceived environmental event, self-generated behaviours, and individual temperaments. There are three primary reasons why individuals use this means of coping: (1) low stress tolerance, (2) deficiencies in emotional regulation, and (3) self-harm is regarded as a reasonable means of problem solving. For example, if an individual is facing an intolerable and inescapable life problem, it would be only reasonable to think about suicide.
DBT combines cognitive and behavioural techniques with mind- fulness, which emphasizes being aware of thoughts and actively shap- ing them. Interventions that are common to DBT and other behaviour therapies include cognitive restructuring, therapist reciprocal vulnera- bility, skills training, and reinforcement. Unique DBT interventions in- clude the use of emotional regulation and opposite action skills, dialec- tics, distress tolerance skills, higher degree of therapist self-disclosure, validation as an explicit therapist skill set, and microanalytic chain analysis.
DBT encourages balance and synthesis of acceptance and change.
The goals of DBT are to increase the person’s ability to manage distress and improve interpersonal effectiveness. Treatment focuses on behaviour targets, beginning with identification of and interventions for suicidal behaviours and then progressing to a focus on interrupting destructive behaviours. Finally, DBT addresses quality- of-life behaviours across a hierarchy of care. Optimally, DBT is delivered as a skills training group program combined with individual therapy with a DBT-trained therapist who may be a nurse, social worker, or psychologist.
Evaluation of personality disorders
Each therapeutic experience offers an opportunity for the person to ob- serve themself interacting with caregivers who consistently try to teach positive coping skills. Effectiveness can be measured by how success- fully the nurse is able to be genuine with the person, maintain a helpful posture, offer substantial instruction, and still maintain their own self care. Specific short-term outcomes may be accomplished, and overall, the person can be given the message of hope that quality of life can always be improved.
Borderline Personality Disorder
Diagnosis
Annie formulates two initial nursing diagnoses that have the highest priority during this time:
1. Ineffective coping related to inadequate psychological resources, as evidenced by self-destructive behaviours
Outcomes Identification
1. Person will consistently demonstrate the use of effective coping strategies. 2. Person will refrain from injuring self.
Planning
The initial plan is to maintain personal safety and to encourage verbalization of feelings and impulses instead of action.
Implementation
Annie’s plan of care is personalized as follows:
Nursing diagnosis: Ineffective coping
Outcome: Ada will consistently demonstrate the use of effective coping strategies.
Short-Term Goal
Ada will consistently demonstrate a decrease in stress as evidenced by talking about feelings with staff every day and an absence of acting-out behaviours.
Intervention
1. Encourage verbalization of feelings, perceptions, and fears.
- Support the use of appropriate defence mechanisms
Rationale
1. Discussing and understanding the dynamics of frustration help reduce the frustration by helping the person take positive action.
- Discussing and understanding the meaning of defences help reduce the potential for acting out.
Goal Met
Ada was able to experience problems and deal with them appropriately. Acting out was minimal or absent. Example: Ada had an appointment for a job interview. She wanted to stay in bed and avoid the interview, but instead she talked with the nurse about her fear of “growing up” and was able to get up and go to the interview.
Short-Term Goal
Ada will consistently demonstrate that she will seek help when feeling the urge to injure herself, as evidenced by the absence of self-injurious behaviours and talking to staff about her troubling feelings on a daily basis.
Intervention
1. Assist the person to identify situations and feelings that may prompt self-harm.
2. Instruct the person in coping strategies.
3. Provide ongoing surveillance of the person and environment.
Rationale
1. Observing, describing, and analyzing thoughts and feelings reduce the potential for acting them out destructively.
2. Alternative behaviours are offered that can be more satisfying and growth promoting.
3. Times of increased anxiety, frustration, or anger without external controls could increase the probability of the person using self-mutilating behaviours
Evaluation
Goal Met
Ada was able to experience troubling thoughts and feelings without self-mutilation. She stated, “I was mad at my therapist today and decided to cut my arms after the session. Instead, I told her I was angry, and together we figured
out why.”
KEY POINTS TO REMEMBER
- All personality disorders share characteristics of inflexibility and difficulties in interpersonal relationships that impair social or oc- cupational functioning.
- Personality disorders are most likely caused by a combination of biological and psychosocial factors.
- People with personality disorders often enter psychiatric treatment because of distress from a comorbid major mental illness.
- Nurses may experience intense emotional reactions to individuals with personality disorders and need to make use of clinical supervi- sion to maintain objectivity.
- Despite the relatively fixed patterns of maladaptive behaviour, some individuals with personality disorders are able to change their be- haviours over time as a result of treatment.
Schizophrenia & Psychosis
Schizophrenia spectrum and other psychotic disorders are complex disorders that affect a person’s thinking, language, emotions, social be- haviour, and ability to perceive reality accurately. These disorders are characterized by psychosis, which refers to altered cognition, altered perception, and/or an impaired ability to determine what is or is not real (an ability known as reality testing).
Psychosis itself is a symptom and not classified as a mental illness
The most severe disorder defined by the presence of psychosis is schizophrenia
Schizophrenia
affects 1 in every 100 people in Canada, with 56% of people diagnosed being male and 44% being female
“Schizophrenia is one of the most widely misunder- stood and feared illnesses in society. The lingering stigma and myths as- sociated with this illness often result in discrimination and, consequently, a reluctance to seek appropriate help”
Negative attitudes toward people living with schizophrenia can interfere with recovery and impair their quality of life
Overall, people who experience mental illness are much more likely to be victims of crime, hate, and discrimination then to be the perpetrators of them. Violence directed to oneself is a greater likelihood, with high levels of self-harm and suicide attempts reported in individuals with psychosis.
Self-harm in these cases was associated with younger age of onset, female gender, comorbid depressive episode, comorbid alcohol abuse or dependence, current suicidality, awareness of illness, and low adherence to prescribed medication.
Practices that concentrate on building trusting therapeutic relationships are practical ways to counter discrimination and promote recovery in the care of those experiencing psychosis and schizophrenia
LEAP approach which is based on the belief that trusting relationships are key to healing partnerships:
Listen—Both nurses listened with compassion and genuineness.
* Empathize—It is clear that both nurses were able to convey that
they cared about understanding what Tammy was feeling.
* Agree—Both nurses believed in Tammy, affirmed that she was in- deed worried and struggling. They supported her in her goals, never looking down on her or judging her but helping her on her own
road to recovery.
* Partner—Clearly, both nurses respected Tammy and worked with
her as partners for recovery.
There are five key features associated with psychotic disorders:
- Delusions: Alterations in thought content (what a person thinks about). Delusions are false fixed beliefs that cannot be corrected by reasoning or evidence to the contrary. Beliefs maintained by one’s
culture or subculture are not delusions. - Hallucinations: Perception of a sensory experience for which no
external stimulus exists (e.g., hearing a voice when no one is speaking). - Disorganized thinking: The loosening of associations, manifested as jumbled and illogical speech and impaired reasoning.
- Abnormal motor behaviour: Alterations in behaviour, including bizarre and agitated behaviours (e.g., stilted, rigid demeanor; eccen- tric dress, grooming, and rituals). Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement.
- Negative symptoms: The absence of something that should be present but is not, for example, the ability to make decisions or to follow through on a plan. Negative symptoms contribute to poor social functioning and social withdrawal.
All those diagnosed with schizophrenia exhibit at least one psychotic symptom, such as delusions; hallucinations; or disorganized thinking, speech, or behaviour. The person experiences extreme difficulty with or an inability to function in family, social, or occupational realms and frequently neglects basic needs such as nutri- tion or hygiene. Over a period of 6 months, there may be times when the symptoms of psychosis are absent, and in their place the person may experience apathy or depression. It is important to note, the course of illness is unique in all individuals and each presentation may be different.
Delusions
Alterations in thought content (what a person thinks about). Delusions are false fixed beliefs that cannot be corrected by reasoning or evidence to the contrary. Beliefs maintained by one’s
culture or subculture are not delusions.
Hallucinations
Perception of a sensory experience for which no
external stimulus exists (e.g., hearing a voice when no one is speaking).
Disorganized thinking:
The loosening of associations, manifested as jumbled and illogical speech and impaired reasoning.
Abnormal motor behaviour:
Alterations in behaviour, including bizarre and agitated behaviours (e.g., stilted, rigid demeanor; eccen- tric dress, grooming, and rituals). Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement.
Negative symptoms:
The absence of something that should be present but is not, for example, the ability to make decisions or to follow through on a plan. Negative symptoms contribute to poor social functioning and social withdrawal.
EPIDEMIOLOGY of schizophrenia
The lifetime prevalence of schizophrenia is 1% worldwide; anyone can develop schizophrenia, it affects people of all races and cultures.
It is more common among persons growing up in urban areas.
Onset in males is usually between the ages of 15 and 25 years and is associated with poorer functioning and more structural abnormality in the brain. The onset tends to be somewhat later in women (ages 25 to 35 years), who tend to have a better prognosis and experience fewer structural changes in the brain.
People who are diagnosed later in life with schizophrenia often experience an earlier prodromal phase during which some milder symptoms of the disorder develop, often months or years before the disorder becomes fully apparent.
Childhood schizophrenia, although rare, does exist, occurring in 1 out of 40 000 children. Early onset occurs more often in males and is associated with poor functioning before onset and increased levels of apathy. Individuals with a later onset are more likely to be female, have less structural brain abnormality, and have better outcomes.
COMORBIDITY of schizophrenia
Substance use disorders (particularly alcohol and marijuana related) have a greater prevalence for individuals living with schizophrenia and other psychotic disorders
Approximately 21% of people living with schizophrenia are diagnosed with alcohol use disorder in their lifetime and 27% are diagnosed with cannabis use disorder.
Cannabis and stimulant use in particular are associated with the development of symptoms of psychosis
Nicotine use is reported in 60% to 90% of people living with schizophrenia
Anxiety, depression, and suicide co-occur frequently in schizophrenia. Anxiety may be a response to symptoms (e.g., hallucinations) or circumstances (e.g., isolation, overstimulation) and may worsen schizo- phrenia symptoms and prognosis.
(1) higher risk factors for many chronic dis- eases and some types of cancer; (2) the iatrogenic effects of some psy- chiatric medications; (3) higher rates of suicide, accidental, and violent death; and (4) disparities in health care access and use
Barriers that are reported in the literature include illness symptoms, treatment effects, lack of support, and negative staff attitudes; incentives include peer and staff support, staff participation, reduction of symptoms, knowledge, and personal attributes
ETIOLOGY of schizophrenia
While there is not one specific cause of schizophrenia, the scientific consensus is that schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors (viral infections, birth injuries, pre-natal malnutrition) and are influenced by environmental and social factors. These alter the structures of the brain, affecting the brain’s neurotransmitter systems, injuring the brain directly, or doing all three. This effect is called the diathesis–stress model of schizophrenia.
Biological Factors
Genetic Factors
About 80% of the risk of schizophrenia comes from genetic and epigenetic factors (factors such as toxins or psychological trauma that affect the expression of genes). More than 100 loci in the human genome are associated with an increased risk for schizophrenia.
Having a first-degree relative with schizophrenia increases the risk to 10%. Further, a variability of expression of schizophrenia has been identified, and it depends on environmental factors; schizoaffective disorder and cluster A personality disorders are more common in relatives of people living with schizophrenia. Concordance rates (i.e., how often one twin will have the dis- order when the other twin has it) are about 50% for identical twins and about 15% for fraternal twins.
Neurobiological Factors of schizophrenia
Dopamine theory. The dopamine theory of schizophrenia is de- rived from the study of the action of the first antipsychotic medications, collectively known as conventional (or first-generation) antipsychotic medication (e.g., haloperidol and chlorpromazine). These medications block the activity of dopamine D2 receptors in the brain, limiting the activity of dopamine and reducing some of the symptoms of schizophrenia.
However, because the dopamine-blocking medications do not alleviate all symptoms of schizophrenia, it is recognized that other neurochemicals are involved in generating the symptoms of schizophrenia. Amphetamines, cocaine, methylphenidate (Ritalin), and levodopa increase the activity of dopamine in the brain and, in biologically susceptible people, may precipitate the onset of schizophrenia. If schizophrenia is already present, these substances may also exacerbate its symptoms. Almost any drug of abuse, particularly marijuana, can increase the risk for schizophrenia in biologically vulnerable individuals
Other neurochemical hypotheses. A newer class of medications, collectively known as atypical (or second-generation) antipsychotic medications, block serotonin as well as dopamine, which suggests that serotonin may play a role in schizophrenia as well. A better under- standing of how atypical medications modulate the expression and targeting of 5-hydroxytryptamine 2A (5-HT2A) and its receptors would likely lead to a better understanding of schizophrenia.
Researchers have long been aware that phenylcyclohexyl piperidine (PCP) induces a state closely resembling schizophrenia. This observation led to interest in the N-methyl-D-aspartate (NMDA) receptor complex and the possible role of glutamate in the pathophysiology of schizophrenia.
Glutamate, dopamine, and serotonin act synergistically in neurotransmission, and thus glutamate may also play a role in causing psychosis
Neurotransmission by another calming neurotransmitter, gamma-aminobutyric acid (GABA), is also impaired in schizophrenia.
Kesby et al. (2018) suggest, “ex- cessive dopamine signalling in the associative striatum may directly lead to symptoms of psychosis by compromising the integration of cortical inputs” (p. 4).
Brain Structure Abnormalities in schizophrenia
Disruptions in communication pathways in the brain are thought to be severe in schizophrenia. Therefore it is conceivable that structural abnormalities cause disruption of the brain’s functioning. Structural differences may be due to errors in neurodevelopment or errors in the normal pruning of neuronal tissue that happens in late adolescence and early adulthood. Inflammation or neurotoxic effects from factors such as oxidative stress, infection, or autoimmune dysfunction may also alter the brain’s structure
Using brain imaging techniques—computed tomography (CT), magnetic resonance imaging (MRI), functional MRI (fMRI), and positron emission tomography (PET)—researchers have demonstrated structural brain abnormalities, including:
* Reduced volume in the right anterior insula (may contribute to negative symptoms)
* Reduced volume and changes in the shape of the hippocampus
* Accelerated age-related decline in cortical thickness
* Grey matter deficits in the dorsolateral prefrontal cortex area, thala- mus, and anterior cingulate cortex, as well as in the frontotemporal,
thalamocortical, and subcortical-limbic circuits
* Reduced connectivity among various brain regions
* Neuronal overgrowth in some areas, possibly due to inflammation
or inadequate neural pruning
* Widespread white matter abnormalities (e.g., in the corpus callosum)
In addition, MRI and CT scans demonstrate lower brain volume and more cerebrospinal fluid in people living with schizophrenia. PET scans also show a lowered rate of blood flow and glucose metabolism in the frontal lobes, which govern planning, abstract thinking, social adjustment, and decision making, all of which are affected in schizophrenia.
Postmortem studies on individuals with schizophrenia reveal a reduced volume of grey matter in the brain, especially in the temporal and frontal lobes; those with the most tissue loss had the worst symp- toms (e.g., hallucinations, delusions, bizarre thoughts, depression).
Psychological, Social, and Environmental Factors of schizophrenia
Pre-natal Stressors: A history of pregnancy or birth complications is associated with an in- creased risk for schizophrenia.
According to Hodgins and Klein (2017), the abnormal neural development in schizophrenia begins in utero as environmental factors interact with specific genotypes (p. 90). Pre-natal risk factors include viral infection, poor nutrition, hypoxia or poor neural development, and exposure to toxins. Infection during pregnancy increases the risk for mental illness in the child.
Pre-natal infections in the mother also increase the risk for infection in the child after birth, and those infections in the children also can make them more vulnerable to mental illness. Psychological trauma and increased stress during pregnancy can also contribute to the development of schizophrenia.
Psychological Stressors
Although there is no evidence that stress alone causes schizophrenia, psychological and physical stress increase cortisol levels, impeding hypothalamic development and causing other changes that may precipitate the illness in vulnerable individuals. Schizophrenia often manifests at times of developmental and social stress, such as beginning university or moving away from one’s family. Social, psychological, and physical stressors may also play a significant role in both the severity and course of the disorder and the person’s quality of life.
Other risk factors include childhood sexual abuse, exposure to so- cial adversity (e.g., chronic poverty), migration to or growing up in a foreign culture, and exposure to psychological trauma or social defeat.
Environmental Stressors: Environmental factors such as toxins, including the solvent tetrachlo- roethylene (used in dry cleaning and to line water pipes, and some- times found in drinking water), are also believed to contribute to the development of schizophrenia in vulnerable people. Environmental factors within broader social environments are also believed to contribute to the development of schizophrenia in vulner- able people. These include exposure to social adversity (e.g., living in chronic poverty) and migration to or growing up in a foreign culture.
Psychotic Disorders Other Than Schizophrenia
Schizophreniform Disorder
The features of schizophreniform disorder are similar to schizophrenia, but the total duration of the illness is less than 6 months. This disorder may or may not develop into schizophrenia.
Brief Psychotic Disorder
This disorder involves a sudden onset of psychosis or grossly disorganized or catatonic behaviour lasting less than 1 month. It is often precipitated by extreme stressors and is followed by a return to premorbid functioning.
Schizoaffective Disorder
Schizoaffective disorder is a subgroup of psychoses in which affective symp- toms and symptoms of schizophrenia are prominent simultaneously. The symptoms are not due to any substance use or to a medical condition and pres- ent with either bipolar or depressive affective symptoms alongside psychosis.
Delusional Disorder
Delusional disorder is characterized by nonbizarre delusions (i.e., situations that could occur in real life, such as being followed, being deceived by a spouse, or having a disease). The person’s ability to function is not mark- edly impaired nor is behaviour otherwise odd or psychotic. A related disorder, Capgras syndrome, involves a delusion about a significant other (e.g., family member, pet) being replaced by an imposter; this disorder may be a result of psychiatric or organic brain disease (Salvatore et al., 2014).
Substance- or Medication-Induced Psychotic Disorder
Psychosis may be induced by substances such as drugs of abuse, alcohol, or medications.
Psychosis or Catatonia Associated With Another Medical Condition or Another Mental Disorder
Psychoses may also be caused by a medical condition (delirium, neurological or metabolic conditions, hepatic or renal diseases, and many others) as well as by mental illness such as post-traumatic stress disorder (Alsawy et al., 2015) or depression, particularly with co-existing victimization from sexual violence or bullying (Nam et al., 2016). Medical conditions and substance use must always be ruled out before a diagnosis of schizophrenia or other psychotic disorder can be made.
Course of the Disorder
The onset of symptoms or forewarning (prodromal) symptoms may appear a month to a year before the first psychotic break or full-blown manifestations of the illness; such symptoms represent a clear deterioration in previous functioning. The course of the disorder thereafter typically includes recurrent exacerbations separated by periods of reduced or dormant symptoms. Some people will have a single episode of schizophrenia without recurrences or have several episodes and none thereafter.
Remission and recovery are increasingly common out- comes with early detection, appropriate treatment, and social support.
In the prodromal phase complaints about anxiety, phobias, obses- sions, dissociative features, and compulsions may be noted. As anxiety increases, indications of a thought disorder become evident. Concen- tration, memory, and completion of school- or job-related work dete- riorate. Intrusive thoughts, “mind wandering,” and the need to devote more time to maintaining one’s thoughts are reported.
The person may feel that something “strange” or “wrong” is hap- pening. Events are misinterpreted, and mystical or symbolic meanings may be given to ordinary events. For example, the person may think that certain colours have special powers or that a song on the radio is a message from a higher being.
Reducing misunderstandings and fear of schizophrenia can reduce stigma and support individuals living with this illness
Phases of Schizophrenia
Phase I—Acute: Onset or exacerbation of florid, disruptive symp-
toms (hallucinations, delusions, apathy, withdrawal) with resultant loss of functional abilities; increased care or hospitalization may be required.
* Phase II—Stabilization: Symptoms are diminishing, and there is movement toward one’s previous level of functioning (baseline); day hospitalization or care in a residential crisis centre or a super- vised group home may be needed.
* Phase III—Maintenance: The person is at or nearing baseline (or premorbid) functioning; symptoms are absent or diminished; level of functioning allows the person to live in the community. Ideally, recovery with few or no residual symptoms has occurred. Most people in this phase live in their own residences. Although this phase has been termed maintenance, current literature shows a trend toward reframing it with a greater emphasis on recovery.
Prognosis of schizophrenia
An abrupt onset of symptoms is usually a favourable prognostic sign, and those with good premorbid social, sexual, and occupational functioning have a greater chance for a good remission or a complete recovery.
Reducing the frequency, intensity, and duration of relapse (when previously controlled symptoms return) is believed to improve the long-term prognosis.
While there is no cure for schizophrenia, schizophrenia is treatable.
Successful treatment of schizophrenia requires an organized, recovery- oriented, mental health system with coordinated services.
“in Canada, mental health services are delivered through provincially funded services. The or- ganization, funding and delivery of mental health services vary from province to province; there are no national standards for service delivery, although there is a National Strategy. In Canada, the Mental Health Strategy identifies supporting recovery as a core value for mental health services” (pp. 662–663).
Early detection:
Some clinicians suggest that there is an earlier prodromal (or pre- psychotic) phase, in which subtle symptoms or deficits associated with schizophrenia are present. Detection and treatment programs in most major Canadian cities aim to detect psychosis in the prodromal phase and prevent acute episodes of schizophrenia. Strategies of health promo- tion to improve outcomes, include reducing the duration of untreated psychosis, reducing delay in treatment, and providing early and appropriate interventions adapted for younger people (adolescents) and their families during the early course of the illness.
Family involve- ment in early intervention has been found to be an important com- ponent of treatment, the most functional and adaptive family coping approaches being those that involve planning, seeking social support, positive reinterpretation, acceptance and turning to religion, and rare use of “avoidant” coping strategies (e.g., denial or disengagement, use of alcohol and non-prescription medications). A systematic review of family interventions for psychosis established that such interventions improved patient functioning and reduced the likelihood of relapse. Symptoms of psychosis were significantly reduced in the longer term; however, caregiver well-being did not sustain the same benefit over time.
