Emotional Disorder

NCM 117 (LEC)
MALADAPTIVE PATTERNS OF BEHAVIOR

HANDOUT
B. EMOTIONAL RESPONSES AND MOOD DISORDERS
I. EMOTIONAL RESPONSE
MOOD - is a prolonged emotional state that influences the person’s whole personality and life
functioning. It pertains to inner tone of emotion and is synonymous with the term feeling.
EMOTIONS – Content
Fear, Joy, Love, Anger, Sadness, Surprise, Happiness
GRIEF REACTIONS
Grief – is the subjective state that follows loss. It is one of the most powerful emotional states
and affects all aspect of a person’s life.
• It forces the person to stop normal activities and focus on present feelings and need.
• Loss could be in the form of death, separation, loss of job, a cherished possession,
status or object.
• Grieving is a normal reaction to life experiences and is universal.
People who experience a significant loss can exhibit feelings and behaviors similar to
depression. They may cry, feel hopeless about the future, have disruptions in eating and
sleeping, and may not find pleasure in everyday activities.
They may even experience a lack interest in caring for themselves and neglect normal
hygiene.
Prepared by Prof. Amelia Z. Manaois for AU - College of Nursing to be used as Instructional Material only for the Lecture in Maladaptive
Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the AU-CN
At what point does grief become pathological? This is a controversial question and one that is
not easily answered.
Before, clinicians were advised against diagnosing a person with depression in the first 2
months following a significant loss. This was called the bereavement exclusion.
The reason for avoiding a psychiatric diagnosis within this period of time is that:
1. Normal mourning could be labeled pathological.
2. If given a psychiatric diagnosis it could result in a life-long label.
3. Unnecessary medications might be prescribed.
Nowadays, although controversial, a diagnosis of depression can now be given in the first 2
months following death of a loved one or other form of 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.
Further research about grief may clarify diagnostic categories and prevent overdiagnosis of
depression in the presence of grief.
Stages of Grieving:
Theorist STAGES / PHASES

C.M. Parks I. Alarm II. Denial III. Searching / IV. Hopelessness / V. Recovery
Barter Helplessness
John I. Denial, II. Yearning III. Cognitive IV. Reorganizing

Bowlby Numbness disorganization Reintegrating
and emotional
despair
Elizabeth I. Denial III. Bargaining IV. Depression V. Acceptance

Kubler-Ross II. Anger
• A maladaptive response to loss implies that something has prevented it from running
its normal course.
• Two Types of pathological grief:

1. Delayed Grief Reaction -
Persistent absence of any emotion may signal an undue delay in mourning. The
emotions associated with the loss may be triggered by a deliberate recall or
circumstances
This can be manifested by the following:
• Excessive hostility
• Prolonged feeling of emptiness/ Numbness
• Use of present tense, instead of past tense when referring to loss object
• Retention of clothing of the deceased or loss object
• Inability or refusal to visit the grave of the deceased
2. Distorted Grief Reaction
An abnormal extension or over elaboration of sadness and grief.
The person who does not mourn can experience the pathological grief reaction
known as depression or melancholia.
II. MOOD DISORDERS
A. DEPRESSION AND SUICIDE
DEPRESSION - is the oldest and most common psychiatric illness. It can be a sign, a
symptom, syndrome, emotional state, reaction, disease, or clinical entity.
Depression that is classified as clinical illness is severe, maladaptive and

incapacitating.
Many behaviors are associated with depression. This can be divided into affective,
physiological, cognitive, and behavioral.
Aspects accompanying depression: Anxiety & Somatic complaints
SUICIDE – self-inflicted injury resulting to possible death
Persons with severe mood disturbances must always be assessed with potential for
suicide. The intensity of anger, guilt and worthlessness may precipitate suicidal
thoughts, feelings or gestures.
All types of self-injury are often mistaken for potential suicide: Assess the lethality of
self-injury
Psychodynamic: Relief from the tension
A “cry for help”
A form of “manipulation”
A result of “hallucination”
Suicidal Behaviors:
• Suicide ideation (Passive Action)

Actions or statement indicating self-inflicted death. The person has vague or
no plans of how to cause his death. The suicidal person may make a statement
such as “will you remember me when I’m gone?”
• Suicide threat (Active action)

A direct or indirect warning, either verbal or non-verbal, behavior indicating plan
to take one’s own life. The suicidal person may make a statement such as
“I’ll jump from the 10th floor….”
• Suicide attempt
Any self-directed actions taken by a person that will lead to death if not stopped
• Completed suicide
Or simply suicide, is death resulting from self-inflicted injury
WHY DO WE HAVE TO KNOW ALL THESE SUICIDAL BEHAVIORS?
The evaluation of a suicide plan is extremely important in determining the degree of
suicidal risk.
There are three main elements to consider when evaluating lethality:

(1) Is there a cue for suicidal PLAN?
(2) What are the details of or proposed METHOD?
(3) Is there ACCESS to the planned method? People who have definite plans
for the time, place, and means are at highest risk.
PLAN + METHOD + ACCESS = LETHALITY OF SUICIDE
Based on the lethality of a method, which indicates how quickly a person would die by
that mode is classified according to:
Higher-risk methods, also referred to as hard methods, include:

• Using a gun
• Jumping off a high place
• Hanging
• Poisoning with carbon monoxide
• Staging a car crash
Lower-risk methods, also referred to as soft methods, include:

• Cutting one’s wrists
• Inhaling natural gas
• Ingesting pills
When the patient confirms access to the proposed method, the situation is more
serious. A man who has access to a high building and states that he will jump from it
or a woman who has a gun and says that she will shoot herself is at serious risk for
suicide.
When people are experiencing psychotic episodes, they are also at high risk—
regardless of the specificity of details—because impulse control and judgment are
grossly impaired.
A person suffering psychosis is particularly vulnerable when depressed or having

command hallucinations.
PREDISPOSING FACTORS:
• Psychiatric Diagnosis:
Mood disorders
Anxiety disorder
Substance abuse
Schizophrenia
Neuroticism:
o A negative personality trait characterized by anxiety, fear, moodiness,
worry, envy, frustration, jealousy, loneliness, hostile, Impulsive
Depression
Personality Disorders
• Chronic or disabling medical conditions
• Psychosocial and Environmental factors:
Female Gender
Lack of social support/ support system
Adverse childhood experiences
Negative life events
Chronic medical illness
Family History:
o Identification and imitation of actions of family members
o First degree family members with major depressive disorder
• Biochemical Factor:
The main neurotransmitters involved in mood: Serotonin
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. Which are observable among individuals with mood
disorders
Norepinephrine modulates attention and behavior. It is stimulated by stressful

situations, 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 apathy, reduced
responsiveness, or slowed psychomotor activity. Which are again manifested
by individuals with mood disorders
o Neurotransmitter depletion occur.

o Reduction in neurogenesis (ability of the brain to produce new brain
cells.)
DSM-V DIAGNOSTIC CRITERIA: MAJOR DEPRESSIVE DISORDER
(At least 5 of the following (including 1 of the first two) must be present most of the day, nearly
daily or at least 2x a week):
Affective: Sad
Anhedonism (decreased attention to and enjoyment from
previously pleasurable activities)
Worthlessness or guilt inappropriate to the situation
Hopelessness
Helplessness
Physiological: Unintentional weight change of 5% or more in a month
Change in sleep pattern
Cognitive: Inability to concentrate, think, focus or make decisions
Suicidal
Behavioral: Agitation or psychomotor retardation
Tiredness
B. MANIA
The essential feature of mania is a distinct period of intense psychophysiological

activation.
The predominant mood is elevated or irritable accompanied by one or more of the
following symptoms: hyperactivity, pressured speech, flight of ideas, distractibility,
inflated self-esteem and hypersexuality.
In contrast with depressed patients, manic patients are extremely self-confident with
an ego that knows no bounds. But accompanying this supreme self-esteem is lack of
guilt and shame.
In contrast with depressed patients, manic patients have abundant energy and
heightened sexual appetite
DSM-V DIAGNOSTIC CRITERIA: MANIA
At least three of the following must be present to a significant degree at least 1x a week:
Grandiosity (inflated self-esteem)

Decreased need for sleep
Pressured speech
Flight of ideas
Distractibility
Psychomotor agitation
Excessive involvement in pleasurable activities without regard for negative consequences
(hypersexuality, hyperactivity)
C. TYPES OF MOOD DISORDERS
1. Major Depressive Disorder (MDD):

This is what we often hear referred to as major depression or clinical depression. It
involves long periods of extreme sadness, hopelessness, and/or fatigue that last for
two weeks or more.
2. Seasonal Affective Disorder (SAD):

This type of depression typically strikes during the short days of the year when the sun
isn't out long.
3. Bipolar I disorder: Also referred to in the past as "manic depression," or

"manic depressive disorder"
One or more manic or mixed episodes usually accompanied by one depressive
disorder
Mania is experienced as euphoric and/or irritable moods and increased energy or
activity. Activities can result in harmful consequences to self and / or others
4. Bipolar II disorder
One or more major depressive episodes accompanied by at least one hypomanic
episode
5. Cyclothymic disorders: Alternate emotional highs and lows.

The highs include: an elevated mood (hypomanic symptoms). The lows consist: mild
or moderate depressive symptoms. "Mood Swings"
D. THREE NEW DEPRESSIVE DISORDERS INCLUDED IN THE DSM-V
1. Disruptive mood dysregulation disorder:

This depressive disorder for children up to 18 years of age who exhibit persistent
irritability and frequent episodes of extreme behavioral dyscontrol, which is a
pattern of abnormal, episodic, and frequently violent and uncontrollable social
behavior without any significant provocation.
2. Persistent Depressive Disorder:

This diagnosis is meant to include both chronic major depressive disorder that has
lasted for two or more years and what was previously known as dysthymic
disorder or dysthymia, a low-grade form of depression.
3. Premenstrual Dysphoric Disorder:

This diagnosis is based on the presence of specific symptoms in the week before
the onset of menstruation, followed by the resolution of these symptoms after
onset.
Symptoms must include one or more of the following: mood swings, irritability
or anger, depressed mood or hopelessness, anxiety or tension
E. OTHER TYPES OF MOOD DISORDERS

1. Mood disorder due to a general medical condition
Characterized by a prominent and persistent disturbance in mood that is judged to
be a direct physiologic consequence of a medical condition such as:
a. Degenerative neurologic conditions
b. Cerebrovascular disease
c. Metabolic or endocrine conditions
d. Autoimmune disorders
e. Human immunodeficiency virus infections
f. Certain cancers
2. Substance -induced mood disorder
Characterized by a prominent persistent disturbance in mood that is judged to be
direct physiologic consequence of ingested substances such as alcohol, other
drugs, or toxins
3. Post-partum depression or maternity blues are frequent of newly delivered

mothers, experience up to 4 weeks after delivery
*Post partum psychosis is a psychotic episode developing within 3-4th week of
delivery, beginning with fatigue, psychotic symptoms and loss of contact to reality.
III. BEHAVIORS RELATED TO MOOD DISORDERS
A. ANGER – a normal human emotion, a strong, uncomfortable, emotional response to

a real or perceived provocation. Anger results when a person is frustrated, hurt or
afraid
Although anger is normal, it is often perceived as a negative feeling. Anger can

become negative when the person denies it, suppresses it, or expresses it
inappropriately
B. HOSTILITY AND AGGRESSION – anger expressed through verbal and physical

behavior like attack, assault and violence
PHASES OF AGGRESSION CYCLE:
1. Triggering Phase – Muscular tension
Changes in voice quality,
Pacing, Non-compliance
Restlessness, irritability, Glaring
2. Escalation phase –
Movement towards loss of control
3. Crisis Phase –
Full blown “acting out”. Fighting, hitting, kicking, scratching, throwing
things
4. Recovery Phase – Cooling down
5. Post Crisis –
Client attempts reconciliation with others. Crying and apologies are
evident. Quiet and withdrawn behavior
VARIABLES LEADING TO PATIENT AGGRESSION

1. Transmission of nurse’s fear and anxiety to patient
2. Excessive stimuli – overcrowding
3. Excessive or unfair restrictions of rights and privileges
4. Lack of resources for excessive energy
5. Patient’s perception of lack of control of life and freedom
6. Boredom – Lack of structured and unstructured activities
7. Hallucinations
8. Manipulative behavior
IV. NURSING PROCESS
A. ASSESSMENT
Major depressive disorder and manic disorder, often goes unrecognized and
underdiagnosed, yet early treatment can result in improved outcomes. Nurses at both
the generalist and advanced practice levels are frequently in the position to screen
and assess for signs of depression or mania, thereby facilitating early and
appropriate treatment.
1. Use of Assessment Tools – screening tools used by every institution according

to their existing policies
2. Suicide potential
Patients diagnosed with major depressive disorder 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, and acute suicidal ideation.
The following statements and questions help set the stage for assessing suicide
potential:
• “You 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
plan?”
• “Do you have the means to carry out your plan?”
• “Is there anything that would prevent you from carrying out your plan?”
3. Key Assessment Findings (Mental Status Examination):

a. Affect and mood
b. Thought Processes
c. Physical behavior
4. USE OF DSM-V DIAGNOSTIC CRITERIA
Assessment Guidelines for Depression:

1. Always evaluate the patient’s risk of 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 and medications. A thorough medical and neurological
examination helps determine if the depression is primary or secondary to another
disorder. 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 history of depression and suicidality. Determine what
strategies helped alleviate depressive symptoms in the past.
4. Assess support systems, family, significant others, and the need for information
and referrals.
Assessment Guidelines for Mania / Bipolar:

1. Assess whether the patient is a danger to self and others:
• Patients may not eat or sleep, often for days at a time
• Poor impulse control may result in harm to others or self.
• Assess the need for protection from uninhibited behaviors. External
control may be needed to protect the patient and others
• Assess the need for hospitalization to safeguard and stabilize the
patient.
2. Assess medical status. A thorough medical examination helps determine whether
mania is primary (a mood disorder—bipolar disorder or cyclothymic disorder) or
secondary to another condition
3. Assess the need for hospitalization to safeguard and stabilize the patient.
4. Assess medical status. A thorough medical examination helps determine whether
mania is primary (a mood disorder—bipolar disorder or cyclothymic disorder) or
secondary to another condition.
5. Assess the patient’s and family’s understanding of mania / bipolar disorder,
knowledge of medications, and knowledge of support groups and organizations
that provide information on bipolar disorder.
B. NURSING DIAGNOSIS:
A high priority for the nurse is determining the risk of suicide, and the nursing diagnosis
of risk for suicide is always considered
1. Potential for violence directed to self / others

2. Ineffective coping mechanism
3. Dysfunctional grieving
4. Hopelessness
5. Powerlessness
6. Altered role performance
7. Altered Self-esteem
8. Social isolation
9. Sleep pattern disturbance
10. Self-care deficit
11. Altered nutrition
C. PLAN OF CARE / IMPLEMENTATION OF TREATMENT PLANS
PLAN OF CARE:
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 students, nurses,
and members of the healthcare team must be aware of the potential for suicide.
Assessment of risk for self-harm (or harm to others) is ongoing. A combination of
therapy (cognitive, behavioral, or interpersonal) and psychopharmacology is an
effective approach to the treatment of depression across all age groups. Safety is
always the highest priority
IMPLEMENTATION OF TREATMENT PLANS:
TREATMENT PHASE
1. Acute Treatment Phase – (6 to 12 weeks)
The goal is to eliminate the symptoms. If patients improve with treatment, they are
said to have had a therapeutic response. (Hospitalization as needed,
Pharmacotherapy, Somatic)
2. Continuation Treatment Phase – (4 to 9 months)
The goal is to prevent relapse (return of symptoms), and to promote recovery
(Depression-Specific psychotherapy: Supportive Interventions – Counseling,
Group Therapy, pharmacotherapy)
3. Maintenance Treatment Phase – (1 year or more)
The goal is to prevent recurrence of a new episode of illness. (Pharmacotherapy
and Supportive Interventions)
It is important to keep in mind that both the continuation and maintenance phases are
geared toward maintaining the patient as a functional and contributing member of the
community after recovery from the acute phase.
General Guidelines of Nursing Interventions:
1. Environmental Interventions
2. Nurse-patient relationship / Attitude Therapy
3. Physiological treatment:
a. Physical care
b. Psychopharmacology
c. Somatic therapy (ECT, sleep deprivation therapy, light therapy,
Transcranial magnetic stimulation-TMS, Vagal nerve stimulation- VNS)
4. Expressing Feelings
a. Individual Counseling
5. Cognitive Strategies:
a. Increase patient’s sense of control over goals and behavior
b. Increase patient’s self esteem
c. To help patient modify dysfunctional thinking pattern.
6. Behavioral approach
a. Occupational therapy
b. Recreational therapy
c. Community skills group
7. Social Skills
a. Community meeting
b. Group therapy
c. Community skills group
d. Socialization
8. Family Therapy
9. Mental Health Education
a. Individual Counseling
b. Patient Education Group
c. Discharge Planning Group
10. Pharmacotherapy
PHARMACOTHERAPY: ANTIDEPRESSANTS
Mood elevators
Treat depression brought about by shortage of neurotransmitters: SEROTONIN,
Dopamine and Norepinephrine
CLASSIFICATIONS:
1. Non – Selective Reuptake Inhibitors (NSRI)
Neurotransmitter inhibitor with multiple effects on reuptake system
• Serotonin and norepinephrine reuptake inhibition
• Acetylcholine blocking (anticholinergic effect)
• Sodium conductance
a. TCA (Tricyclic Antidepressant)
• Oldest classes of antidepressant
• Potentiation of Norepinephrine and SEROTONIN activity by
blocking their reuptake presynaptically
• It includes a strong anticholinergic activity (blocking acetylcholine)
thus responsible for many of its side effects
• COMMON DRUG LIST:
o Amitriptyline (Elavil)
o Desipramine (Norpramin)
o Doxepin (Sinequan)
o Imipramine (Tofranil)
o Nortriptyline (Pamelor)
o Protriptyline (Vivactil)
o Trimipramine (Surmontil)
• SIDE EFFECTS:
o Dryness of mouth, increased appetite weight gain
o Drowsiness, dizziness and blurred vision
o Constipation and urinary retention
o Postural hypertension, cardiac arrythmias and palpitation
o Confusion especially in older adult
• CONTRAINDICATIONS:
o Cardiac, renal, GI, and liver disorders
o Older adults
o Glaucoma
o Obesity
o Seizure disorders
o Pregnancy and lactation
b. B. MAOIs (Monoamine Oxidase Inhibitors)

• By inhibiting the MAO enzyme, SEROTONIN, Norepinephrine and
Dopamine concentration will increase in the neuronal synapses
o Phenelzine (Nardil)
o Tranylcypromine (Parnate)
o Isocarboxazid (Marplan)
o Selegiline (Emsam)
• SIDE EFFECTS:
o Nervousness, agitation, insomnia
o Head ache, stiff neck
o HPN or Hypertension crisis (fatal)
o Tachycardia, palpitation, chest pain, N/V, diarrhea
o Blurred vision
• CONTRAINDICATIONS:
o Cerebrovascular, heart, liver and renal disease
o Children under 16 years old
o Abrupt discontinuation
2. Selective Reuptake Inhibitors (SRI)

a. SSRIs (Selective Serotonin Reuptake Inhibitors)
• The antidepressant selectively blocks the reabsorption of the
neurotransmitter SEROTONIN, thus help restore brain’s chemical
balance
• Fewer side effects (1 to 3% less)
• Increased patient compliance
• First line medication treatment
o Citalopram (Celexa)
o Escitalopram (Lexapro)
o Fluoxetine (Prozac)
o Paroxetine (Paxil)
o Sertraline (Zoloft)
•
SIDE EFFECTS:
o Nausea, anorexia, diarrhea, sweating
o Insomnia, anxiety, nervousness, tremor, drowsiness,
fatigue, dizziness, headache
o Sexual dysfunction
• POTENTIAL TOXIC EFFECT: SEROTONIN SYNDROME
o Hyperactivity or restlessness
o Tachycardia → cardiovascular shock
o Fever → hyperpyrexia
o Elevated blood pressure
o Altered mental states (delirium)
o Irrationality, mood swings, hostility
o Seizures → status epilepticus
o Myoclonus, incoordination, tonic rigidity
o Abdominal pain, diarrhea, bloating
o Apnea → death
• INTERVENTIONS: SEROTONIN SYNDROME
o Remove offending agent(s)
o Initiate symptomatic treatment:
▪ Serotonin-receptor blockade with cyproheptadine,
methysergide, propranolol
▪ Cooling blankets, chlorpromazine for hyperthermia
▪ Dantrolene, diazepam for muscle rigidity or rigors
▪ Anticonvulsants
▪ Artificial ventilation
▪ Induction of paralysis
• CAUTION:
o Suicide prone
o Bipolar disorders – may precipitate manic attacks
o Liver or renal impairment
o Diabetes
o Underweight, eating disorders
b. HCA (Heterocyclic Antidepressant)
• Second generation heterocyclic antidepressant are comparable to
the efficacy of the first generation TCA with differing effects on
Dopamine, Serotonin and Norepinephrine.
• Activating antidepressant -Norepinephrine and Dopamine
Reuptake Inhibitors (NDRIs)
o Severe depression with extreme fatigue, lethargy and
psychomotor retardation
o Example. Bupropion (Wellbutrin)
• Calming antidepressant – Serotonin and Norepinephrine Reuptake
Inhibitor
o Agitated depression, mixed anxiety and depression
o Example: Mirtazapine (Remeron)
3. Receptor Blockers - 5-HT2 receptor antagonist

• This results in more serotonin to stimulate other nerves
• Trazodone (Desyrel)
• Nefazodone (Serzone)
PHARMACOTHERAPY: ANTIMANIC AGENT
LITHIUM
• The drug of choice for Bipolar disorders (manic-depressive) but are not
recommended for depression alone.
• Mood stabilizing drug
• Decreases norepinephrine release and increasing serotonin synthesis
• Lithium is particularly effective in reducing the following:
o • Elation, grandiosity, and expansiveness
o • Flight of ideas
o • Irritability and manipulation
o • Anxiety
o • Self-injurious behavior
• To a lesser extent, lithium controls the following:
o • Insomnia
o • Psychomotor agitation
o Threatening or assaultive behavior
o Distractibility
o Hypersexuality
o Paranoia
• COMMON LIST OF DRUGS:
o Lithium (Eskalith, Lithobid)
o Carbamazepine (Tegretol)
o Valproate (Depakote, Depakene)
o Olanzapine/ Fluoxetine (Symbyax)
• SIDE EFFECTS:
o GI distress: Nausea and Vomiting
o Cardiac arrythmias and hypotension
o Thirst and polyuria
o Tremors
o Hypothyroidism
• LITHIUM TOXICITY
o Drowsiness, confusion, blurred vision, photophobia
o Tremors, muscle weakness, seizures, coma, CV collapse
• Therapeutic blood level for lithium therapy is maintained between:
o 0.8 and 1.8 mEq/L
o Lithium Blood Level Monitoring: every 1 to 3 months
HEALTH TEACHINGS ON PHARMACOTHERAPY:

a. The patient and family should be told that drug effect may take from 7 to 28
days. Up to 6 to 8 weeks may be required for the full effect to be reached
b. The family should reinforce this frequently to the patient. Depressed people
have trouble remembering and respond to explanations
c. The patient should be informed that drowsiness, dizziness, and hypotension
usually subside after the first few weeks.
d. The patient should be cautioned to be careful working around machines, driving
cars, and crossing streets because of possible altered reflexes, drowsiness, or
dizziness.
e. Alcoholic beverages are strictly prohibited. Alcohol can block / potentiate the
effects of antidepressants / mood stabilizers.
f. The patient should never double the dose.
g. Sudden stopping of medication can cause nausea, altered heartbeat,
nightmares, and cold sweats in 2 to 4 days.
h. Refrain from taking foods high in Tyramine (overripe fruits, beans, fermented,
smoked fish and meat, cheese, yeast, beer, wine)
i. LITHIUM specific:
o Continue taking the drug even after the current episode subsides.
o Lithium is not addictive.
o It is important to monitor lithium blood levels closely until a therapeutic
level is reached. After this level is reached continued monitoring will be
required to prevent toxicity.
o Maintain a consistent fluid intake (1500-3000 mL/day)
o Sodium intake can affect lithium levels. High sodium intake leads to
lower levels of lithium and less therapeutic effect. Low sodium intake
leads to higher lithium levels, which could produce toxicity.
o Stop taking lithium if excessive diarrhea, vomiting, or sweating were
noted. All of these symptoms can lead to dehydration and increase
blood lithium to toxic levels.
o Thyroid, parathyroid, and renal function should be regularly checked
due to risk for hypothyroidism, hyperthyroidism, hyperparathyroidism,
and decreased kidney function
o Steroid and even Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen,
naproxen) may influence lithium levels.
o Take lithium with meals to avoid stomach irritation.
o Additional weight gain may occur, particularly with females.
ELECTROCONVULSIVE THERAPY (ECT)

• Somatic therapy
• Initiated by Hugo Cerletti (1938)
• Series of Treatment: 2-3x a week for 6-12/15 treatments
• Electrical dose: 800 milliamps in 1 to 6 seconds
• Effective seizure: 30sec to 1 minute
• 10 to 15 minutes: patient is awake
• Indications:
o Severe depression, Mania
o Bipolar
o Catatonia
o Schizophrenia
• Conditions that do not respond to ECT:
o Anxiety Disorder
o Personality Disorder
o Somatoform Disorder
o Phobic Disorder
• High Risk Conditions:
o Recent M.I. or CVA, Angina Pectoris, CHF
o ICP, Glaucoma, Retinal Detachment
o Severe Pulmonary Disease
o Major Bone Fracture
o Thrombophlebitis
o (Pregnancy)
• Side Effects:
o Headache; Disorientation; and Temporary memory loss
• Types:
a. Modified / Unmodified
b. Unilateral / Bilateral
• Nursing Responsibilities:
• Pre-ECT
o Informed consent should be signed.
o CP clearance (40y.o. and above)
o NPO post midnight.
o Remove fingernail polish.
o IV line initiation.
o Administration of short-acting anesthetic.
o Administration of a sedative or muscle relaxant
(succinylcholine). Atropine is also given to decrease bronchial
secretions which could block the airways during seizures.
o Let the client void before the procedure.
o Preparation of mouth gag at bedside
o Baseline vital sign
• Intra-ECT
o During ECT
o Place electrodes on the client’s head on one side (unilateral) or both
(bilateral).
o Brain monitoring through electroencephalogram (EEG).
o Oxygen administration with an Ambu-bag.
o Loosely supporting extremities during tonic-clonic episodes
• Post-ECT
o If not contraindicated, place head to side to drain secretion
o Encourage circulation
o Assess LOC and orientation
o Obtain vital signs.
o Assess client for the return of gag reflex.
o Allow the client to eat (with a positive gag reflex).
D. EVALUATION
Sample Outcomes for Depression
SIGNS & SYMPTOMS NURSING OUTCOMES

DIAGNOSIS
Previous suicidal attempts, Risk for self-directed Expresses feelings, verbalizes
putting affairs in order, giving violence suicidal ideas, refrains from
away prized possessions, suicide attempts, plans for the
suicidal ideation (has plan, Risk for suicide future
ability to carry it out), overt or
covert statements regarding
killing self, feelings of
worthlessness, hopelessness,
helplessness
Difficulty with simple tasks, Ineffective coping Identifies ineffective and
inability to function at previous effective coping, uses support
level, poor problem solving, system, uses new coping
poor cognitive functioning, strategies, engages in personal
verbalizations of inability to actions to manage stressors
cope effectively
Dull/sad affect, no eye contact, Social isolation Attends group meetings,
preoccupation with own interacts spontaneously with
thoughts, seeks to be alone, others, talks with the nurse in
uncommunicative, withdrawn, 1:1, demonstrates interest in
feels rejected and not good engaging with family and others
enough
Feelings of helplessness, Hopelessness Expresses hope for a positive
hopelessness, powerlessness Powerlessness future, believes that personal
actions impact outcomes,
demonstrates optimism and
describes plans for the future
Questioning meaning of life Spiritual distress Shares feelings of
and existence, anger toward connectedness with self, others,
greater power, feeling and a higher power, identifies
abandoned, perceived meaning and purpose in life
suffering
Exaggerates negative Chronic low Identifies strengths, verbalizes
feedback about self, excessive selfesteem self-acceptance, participates in
seeking of reassurance, guilt, groups, expresses a personal
indecisive and nonassertive judgment of self-worth
behavior, poor eye contact,
shame
Vegetative signs of depression: Self-care deficit Increases baseline personal
grooming and hygiene (bathing, dressing) care each day, reports adequate
deficiencies, significantly sleep, eating and elimination
reduced appetite, changes in Insomnia normalize, returns to a normal
sleeping, eating, elimination, Imbalanced nutrition: level of physiologic activity
sexual patterns less than body
requirements
Constipation
Sexual dysfunction
Sample Outcomes for Mania
SIGNS & SYMPTOMS NURSING OUTCOMES

DIAGNOSIS
Alteration in cognitive Risk for injury Remains in secure area when
functioning, compromised unaccompanied, can be
nutrition, alteration in affective redirected from unsafe activities,
orientation free from injury
Alteration in cognitive Risk for other- Refrains from harming others,
functioning, impulsiveness, directed violence controls impulses, avoids
sexual advances, threatening violating others’ space
violence, psychotic disorder
Agitation, anxiety, confusion, Sleep deprivation Sleeps 4-6 hours a night, reports
perceptual disorders, feeling rejuvenated after sleep
restlessness
Grandiosity, difficulty Altered thought Demonstrates increase in
organizing and attending to processes concentration, improved
information, poor memory, and hallucinations are
absent
concentration, agitation,
hallucinations
Minimal calorie intake, poor Self-care deficit Completes meals, tends to
hygiene, clothing unclean (feeding, bathing, hygiene, dresses in clean
dressing) clothing
Dysfunctional interaction with Impaired social Initiates and maintains goal-

others, pressured speech, interaction directed and mutually satisfying
flight of ideas, annoyance or verbal exchanges
taunting of others, loud and
crass speech
References:
• Margaret Jordan Halter, Varcaroli’s Foundations of Psychiatric-Mental Health Nursing, 8th
edition, 2018
• Shiela L. Videbeck, Psychiatric Mental Health Nursing 6th edition 2011.

Emotional Disorder

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Emotional Disorder

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NCM 117 (LEC)

MALADAPTIVE PATTERNS OF BEHAVIOR

B. EMOTIONAL RESPONSES AND MOOD DISORDERS

Theorist STAGES / PHASES

John I. Denial, II. Yearning III. Cognitive IV. Reorganizing

Elizabeth I. Denial III. Bargaining IV. Depression V. Acceptance

• Two Types of pathological grief:

II. MOOD DISORDERS

A. DEPRESSION AND SUICIDE

Depression that is classified as clinical illness is severe, maladaptive and

Aspects accompanying depression: Anxiety & Somatic complaints

SUICIDE – self-inflicted injury resulting to possible death

• Suicide ideation (Passive Action)

• Suicide threat (Active action)

WHY DO WE HAVE TO KNOW ALL THESE SUICIDAL BEHAVIORS?

There are three main elements to consider when evaluating lethality:

PLAN + METHOD + ACCESS = LETHALITY OF SUICIDE

Higher-risk methods, also referred to as hard methods, include:

Lower-risk methods, also referred to as soft methods, include:

A person suffering psychosis is particularly vulnerable when depressed or having

• Chronic or disabling medical conditions

• Psychosocial and Environmental factors:

Serotonin is an important regulator of sleep, appetite, and libido.

Norepinephrine modulates attention and behavior. It is stimulated by stressful

o Neurotransmitter depletion occur.

DSM-V DIAGNOSTIC CRITERIA: MAJOR DEPRESSIVE DISORDER

The essential feature of mania is a distinct period of intense psychophysiological

DSM-V DIAGNOSTIC CRITERIA: MANIA

Grandiosity (inflated self-esteem)

C. TYPES OF MOOD DISORDERS

1. Major Depressive Disorder (MDD):

2. Seasonal Affective Disorder (SAD):

3. Bipolar I disorder: Also referred to in the past as "manic depression," or

5. Cyclothymic disorders: Alternate emotional highs and lows.

1. Disruptive mood dysregulation disorder:

2. Persistent Depressive Disorder:

3. Premenstrual Dysphoric Disorder:

E. OTHER TYPES OF MOOD DISORDERS

3. Post-partum depression or maternity blues are frequent of newly delivered

III. BEHAVIORS RELATED TO MOOD DISORDERS

A. ANGER – a normal human emotion, a strong, uncomfortable, emotional response to

Although anger is normal, it is often perceived as a negative feeling. Anger can

B. HOSTILITY AND AGGRESSION – anger expressed through verbal and physical

VARIABLES LEADING TO PATIENT AGGRESSION

IV. NURSING PROCESS

1. Use of Assessment Tools – screening tools used by every institution according

3. Key Assessment Findings (Mental Status Examination):

4. USE OF DSM-V DIAGNOSTIC CRITERIA

Assessment Guidelines for Depression:

Assessment Guidelines for Mania / Bipolar:

1. Potential for violence directed to self / others

C. PLAN OF CARE / IMPLEMENTATION OF TREATMENT PLANS

IMPLEMENTATION OF TREATMENT PLANS:

b. B. MAOIs (Monoamine Oxidase Inhibitors)

2. Selective Reuptake Inhibitors (SRI)

3. Receptor Blockers - 5-HT2 receptor antagonist

HEALTH TEACHINGS ON PHARMACOTHERAPY:

ELECTROCONVULSIVE THERAPY (ECT)

Sample Outcomes for Depression

SIGNS & SYMPTOMS NURSING OUTCOMES

Sample Outcomes for Mania

SIGNS & SYMPTOMS NURSING OUTCOMES

Dysfunctional interaction with Impaired social Initiates and maintains goal-