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DEPRESSION
Minor Depression: sustained depressed mood w/o full
depressive syndrome; pessimistic attitude & self-pity required
for dx; may be chronic & complicated by superimposed major
depressive episode
Major Depressive Disorder (MDD): experience substantial
pain & suffering; psychological, social & occupational
disability; significant change in functioning
Subtypes: specifiers w/ MDD
-psychotic features- break w/ reality (hallucinations,
delusions)
-catatonic features- peculiar voluntary mvmt, echopraxia or
echolalia, negativism
-melancholic features- anorexia, wt loss, diurnal variations w/
symptoms worse in am, early am awakening
-postpartum onset (w/in 4 wks postpartum)- severe anxiety,
possible psychotic features
-seasonal features- generally occurring in fall or winter &
remitting in spring; tx w/ light therapy
-atypical features- appetite changes, wt gain, hypersomnia,
extreme sensitivity to perceived interpersonal rejections
Dysthymic Disorder (DD): early & insidious onset, chronic
depressive syndrome usually present most of day, more days
than not, for at least 2 yrs, often cannot be distinguished from
person’s usual pattern of functioning
Biological Theories:
-genetic factors- inc’d heritability is assoc’d w/ earlier age of
onset, greater rate of comorbidity & inc’d risk of recurrent
illness
-biochemical factors-serotonin (dysfunction result in poor impulse control, low sex
drive, dec’d appetite, irritability);
-norepinephrine (dec’d anergia, anhedonia, dec’d
concentration, diminished libido)
-dopamine, acetylcholine, GABA also believed involved
-alterations in hormonal regulation
-sleep abnormalities
Cognitive theory: Beck proposed people acquire
psychological predisposition to depression through early life
experiences
-Beck’s cognitive triad-negative, self-deprecating view of self
-pessimistic view of world
-belief that negative reinforcement will continue in future
Learned Helplessness: Seligman- although anxiety is initial
response to stress, it is replaced by depression if person feels
that self has no control over outcome of situation
Symptoms: depressed mood, anhedonia, anergia, anxiety;
may experience delusions of being punished or being a terrible
person; psychomotor agitation or retardation; vegetative signs
(change in bm & eating habits; sleep disturbances; disinterest
in sex); pain; hopelessness (negative expectations for future,
loss of control over future outcomes, passive acceptance of
futility of planning to achieve goals, emotional negativism) &
despair; suicidal ideation; feelings of anxiety, worthlessness,
guilt, helplessness, hopelessness, anger & irritability, guilt
BIPOLAR
marked by shifts in person’s mood, energy & ability to fxn;
episodes of mania, hypomania, depression, concurrent mania
& depression
Bipolar I- classic; at least 1 episode of mania alternating w/
major dep
Bipolar II- hypomanic episode(s) alternating w/ major dep
Cyclothymia: hypmanic episodes alternating w/ minor dep (at
least 2 yrs duration)
Rapid cyclers- >4 episodes in 12 mos
Mania- elevated irritable or expansive mood; talkative,
excitable, energetic, rapid changing conversation, inflated self
esteem
Mania characteristics:
-mood- euphoric; may change to irritation & quick anger;
irritability, belligerence; cheerful @ inappropriate times;
boundless energy & self confidence
-behavior- sexual indiscretion; constantly push limits;
voracious appetites; too busy to sleep
-thought process- flight of ideas; speech is rapid, verbose &
circumstantial, loud; grandiosity
-cognitive fxn- impaired
Mixed episodes:
Dysphoric mania-sense of unhappiness, fearfulness,
depression, accomp’d by high energy levels, racing thouths,
pressured speech
Exalted depression- dep’d w/ symptoms but still have
delusions of grandeur
Things that mimic mania: steroids, levadopa, catapril, meth,
cocaine, syphilis, HIV, lyme disease, hyperthyroid, tumors,
brain injuries
SCHIZOPHRENIA
Affects thinking, language, emotions, social behavior, ability
to perceive reality accurately
Onset- typically late teens/early twenties
Subtypes:
Paranoid type- hallucinations, delusions,
Disorganized type- disorganized speech & behavior,
inappropriate affect
Catatonic type- motor immobility (waxy flexibility or stupor)
Undifferentiated type- active-phase symptoms, no one
presentation dominates
Residual type- no longer has active-phase symptoms, some
persistent symptoms noted
Schizoaffective disorder- uninterrupted period of illness w/
major depressive, manic or mixed episode, concurrent w/
symptoms that meet criteria for schizo.
Other psychotic disorders:
Delusional disorder- nonbizarre delusions, ability to fxn not
markedly impaired nor is behavior obviously odd or bizarre
Schizophreniform disorder- essential features of schizo
except total duration is >1mo but <6mos
Brief Psychotic disorder-sudden onset of symptoms or
disorganized or catatonic behavior; lasts >1day but <1mo
Shared Psychotic disorder (folie a deux)- individual close to
another who has disorder w/ delusion comes to share the
delusional beliefs in total or in part
Induced or Secondary Psychosis- caused my substances or
general medical condition
Theories:
Neurobiological-inc’d dopamine; serotonin; glutamate
Genetic- inc’d rate w/ h/o relatives
Neuroanatomical- enlarged lateral cerebral ventricles, third
ventricle dilation &/or ventricular asymmetry; cortical
atrophy; cerebellar atrophy; atrophy of frontal lobe; inc’d size
of fissures; reduced grey matter esp temporal & frontal lobes
Nongenetic- prenatal risk from viral infection, poor nutrition
or starvation, exposure to toxins, lack of O2 during birth;
stress
Signs of schizo: the fours A’s
-affect- flat, blunted, inappropriate, bizarre
-associative looseness- haphazard & confused thinking
manifested by jumbled & illogical speech & reasoning
-autism- thinking not bound to reality, reflects private
perceptual world of individual; delusions, hallucinations,
neologisms
-ambivalence- simultaneously holding two opposing
emotions, attitudes, ideas or wishes toward person/situation or
object
Course of disease:
Acute: periods of florid positive symptoms (hallucinations,
delusions) & negative symptoms (apathy, withdrawal, lack of
motivation)
Maintenance: acute symptoms decrease in severity
Stabilization: symptoms in remission, there may be milder
persistent symptoms
Prepsychotic early symptoms- may appear a month to year
before first psychotic break
-acute or chronic anxiety, phobia, obsessions compulsions
-feelings of rejections, lack of self-respect, loneliness,
hopelessness
-withdrawal increase feelings of isolation & inability to trust
-preoccupied w/ religion, matters of mysticism, metaphysical
causes of creation, speech characterized by obscure
symbolism
-sexual activity altered; preoccupation w/ homosexual themes
(most prominent in paranoid schizo); exaggerated needs,
altered performance; fears of intimacy
Positive symptoms: hallucinations, illusions, delusions,
bizarre behavior, paranoia, positive formal thought disorder &
speech patterns
Alterations in thinking:
Delusions- false fixed beliefs that cannot be corrected by
reasoning (ideas of reference, persecution, grandiosity,
somatic sensations, jealousy, control)
-thought broadcasting-others can hear your thoughts
-thought insertion- you hear others thoughts
-thought withdrawal- thoughts have been removed from mind
-delusion of being controlled- body/mind controlled by
outside agency
Concrete thinking-overemphasis on specific details &
impairment of ability to use abstract concepts
Alterations in Speech:
Associative looseness- thinking is haphazard, illogical,
confused
Neologisms- made up words
Echolalia- pathological repeating of another’s word
Echopraxia- mimicking movements of another
Clang association- meaningless rhyming of words
Word salad- jumble of words that is meaningless
Alterations in Perception:
Hallucinations- sensory perceptions for which no external
stimulus exists
-auditory- hearing voices or sounds
-visual- seeing persons or things
-olfactory- smelling odors
-gustatory- experiencing tastes
-tactile- feeling bodily sensations
Command hallucinations- voices command person to do
something
Personal boundary difficulties:
Depersonalization- nonspecific feeling that person has lost
identity, self is different or unreal
Derealization- false perception by person that environment
has changed
Alterations in Behavior:
Extreme motor agitation- excited physical behavior
Stereotyped behaviors- motor patterns that originally had
meaning but are now mechanical & lack purpose (sweeping
floor, washing windows)
Automatic obedience- performance by catatonic client of all
simple commands in robotlike fashion
Waxy flexibility- seen in catatonia, excessive maintenance of
posture
Stupor- catatonic client is motionless for long periods & may
appear to be in coma
Negativism- equivalent to resistance, client does opposite of
what told to do
Negative symptoms: affect flat, inappropriate or bizarre;
alogia; avolition, apathy; anhedonia, asociality; attention
deficits, anergia
cognitive symptoms- difficulty w/ attention, memory or
executive fxns; disorganized thinking
depressive & other mood symptoms
Stages of Relapse
Stage I: overextension
Stage II: restricted consciousness
Stage III: disinhibition
Stage IV: psychotic disorganization
Stage V: psychotic resolution
INTERVENTIONS FOR ALL DISORDERS:
Phase I: Acute- (6-12 wks)- client safety & medical
stabilization (well hydrated, maintain stable cardiac status,
maintain tissue integrity, sufficient sleep, thought self-control,
no attempt at self harm); hospitalization if client is danger to
self or others, refusing to eat or drink, too disorganized to
provide self care; reduction of symptoms & restoration of
psychosocial & work fxn,
Phase II: Maintenance- helping client adhere to med
regimens, understand disease, health teaching,
psychoeducational classes (disease process, medication,
consequences of substance addictions, early s/s), support
groups or therapy, communication & problem solving; relapse
prevention skills
Phase III: Stabilization- target neg symptoms: ability to
participate in social, vocation, self care skills training,
involvement in socializing groups; prevention of relapse &
limit severity & duration of future episodes: learning
interpersonal strategies, participate in therapy (CBT, family,
psychotherapy), support groups
-maintain regular sleep pattern; reduce alcohol, drug &
caffeine intake; keep in touch w/ supportive friends/family;
stay active; have routine daily & weekly schedule; take meds
regularly
Basic level interventions: milieu management (protection
from suicidal acts, supervised environment for regulating
meds, ECT), counseling, promotion of self care activities,
psychobiological interventions, health teaching, health
promotion & maintenance, case management
Acute: acute psychoparm tx; supportive & directive
communications; limit setting; psych, med & neur eval
Milieu Therapy: Seclusion for Bipolar- provides comfort &
relief- reduces overwhelming stimuli; protects client from
injuring self, others or staff; prevent destruction of property
-warranted when- substantial risk of harm to others or self; u/a
to control actions; problematic behavior is sustained; other
measures have failed
Advanced practice interventions:
Med maintenance most important in preventing relapse
Individual therapy: social skills training, cognitive
remediation, cog adaptation training, CBT,
Group therapy
Family therapy