Mood & Anxiety Disorders

Anxiety

Anxiety is at the root of many, if not all, of our psychological disorders.  It is, physically, a kind
of fear response, involving the activation of the sympathetic nervous system, in response to a
dangerous situation.  More specifically, anxiety is the anticipation of danger, learned through
repeated stress or trauma.  Some people are innately more sensitive to stress, and so are more
likely to experience anxiety and develop anxiety disorders.  But everyone becomes sensitized to
stress and trauma with repeated experiences:  Each experience "tunes" the nervous system to
respond more quickly and more profoundly to perceived danger.

Anxiety is a normal state of dread, tension, and unease. It is considered a normal response to
stress or uncertain situations. Prolonged or intense periods of anxiety may suggest an anxiety
disorder. A disorder may also be indicated if: Anxiety occurs without an external threat (“free-
floating” anxiety).

While Stress is the wear and tear that life causes on the body. It occurs when a person has
difficulty dealing with life situations, problems, and goals.

- is an individual experience that is vague, non-specific; uneasy feeling that is has both subjective
& objective characteristics that is occurring as a result of threats.

-Is a disorder which is the most prominent feature is anxiety. Overwhelming emotional
discomfort that is accompanied by physical response.

Types of anxiety

 Normal – healthy types of anxiety that mobilizes a person to act

 Acute – precipitated by imminent loss or change that threatens the sense of security

 Chronic – anxiety that individual has lived with for a long time

Stages of Reaction to Stress

• Alarm reaction stage

• Resistance stage

• Exhaustion stage

Anxiety as a Stress Response

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 • Mild anxiety: sensation that something is different and warrants special attention; sensory
stimulation increases; focus attention to learn, solve problems, think, act, feel, and protect
self; motivated

• Moderate anxiety: feeling that something is definitely wrong; nervous or agitated; can
still process information, solve problems, and learn new things with assistance from
others; difficulty concentrating but can be redirected

• Severe anxiety: trouble thinking and reasoning; muscles tighten; vital signs increase;
pacing; restless, irritable, and angry; uses other emotional-psychomotor means to release
tension

• Panic anxiety: fight, flight, or freeze responses; cognitive process focuses on the person’s
defense

ANXIETY DISORDERS

Panic Disorder

 An individual may suddenly experience frightening and uncomfortable symptoms

 May include terror, sense of unreality or fear of loosing control

 Attack: 1 minute and 1 hour

Phobic Disorder

 Phobia is an irrational fear of an object, place, activity or situation.

 Avoidance will allow the individual to be free from anxiety.

Examples:

 Agoraphobia - fear of open places and of being alone in public places.

 Social phobia - irrational fear of criticism, humiliation or embarrassment.

 Acrophobia - fear of heights

 Algophobia - fear of pain

 Claustrophobia - fear of enclosed place

 Thanatophobia - fear of crowds

 Pathophobia - fear of disease

 Monophobia - fear of being alone

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Generalized Anxiety Disorder (GAD)

 Unrealistic, excessive anxiety and is unable to control worry.

 Clients may experience: fatigue, irritability, restlessness, muscle tension, sleep disturbance

Obsessive Compulsive Disorder

 Is characterized by recurrent obsessions and compulsions that interfere with normal life.

Obsession: Refers to persistent, painful intrusive thought, emotion or urge that one is unable to
suppress or ignore.

Compulsion : Refers to repetitious uncontrollable act and sometimes a purposeful act to prevent
a certain mistake in an event or situation.

Post-Traumatic Stress Disorder (PTSD)

 Is the delayed reaction of the person who has been involved or exposed to a traumatic events.

 Symptoms of this disorder are:

 intense psychological distress

 feeling of detachment or estrangement from others

 insomnia

 decreased concentration

 avoidance of thoughts and feelings

 recurrent distressing dreams

 inability to recall an important aspect of the trauma

ANXIETY RELATED DISORDERS

Somatization Disorder

 Free floating anxiety disorder

 Clients:

 express emotional turmoil or conflict through physical symptoms.

 usually seek for repeated medical attention.

 may exhibit antisocial behavior and may attempt suicide.

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 Associated with anxiety and depression

Dissociative Amnesia

 Inability to recall extensive amount of important information

 Caused by trauma

 Characterized by:

 Disorientation

 Purposeless wandering

 Impairment in ability to perform ADL

 Rapid recovery generally occur

Nursing process

1- Assessment:

-Assessment will usually involve determining if the anxiety is from a secondary source (medical
condition) or a primary source (anxiety disorder). Symptoms specific to various anxiety
disorders include panic attacks, phobias, obsessions, and compulsions

-Self-Assessment: Nurse’s feelings may include tension or anxiety, frustration, anger, being
overwhelmed, fatigue, desire to withdraw, and guilt related to having negative feelings

Assessment Guidelines:

• 1) Physical and neurological examinations will help determine if anxiety is primary or

secondary

• 2) Assess for potential for self-harm and suicide

• 3) Do a psychosocial assessment to identify problems that should be addressed by

counseling

• 4) Note that cultural differences can affect the way in which anxiety is manifested

2-Nursing Diagnoses:

• Anxiety, ineffective coping, disturbed thought processes, chronic low self-esteem,

situational low self-esteem, powerlessness, deficient diversional activity, social isolation,
ineffective role performance, ineffective health maintenance, disturbed sleep pattern, self-
care deficit, imbalanced nutrition, and impaired skin integrity

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3- Outcome Criteria:

• Describe the client’s state or situation that is expected to be influenced by nursing

interventions. Examples of outcomes for anxiety control include the following: client
will monitor intensity of anxiety, eliminate precursors of anxiety, seek information to
reduce anxiety, plan successful coping strategies, use relaxation techniques, report
adequate sleep, report decrease in frequency of episodes, etc

4- Planning:

• Selecting interventions that can be implemented in a community setting, since clients

with anxiety disorders are not usually hospitalized in an inpatient psychiatric unit

• Clients with mild to moderate anxiety should be encouraged to be involved in planning,

whereas for clients with severe anxiety, the nurse will need to be more directive

5- Intervention:

• 1) identify community resources that can off the client effective therapy

• 2) identify community support groups that can offer the client effective therapy

• 3) assess need for intervention for families and significant others

• 4) provide thorough teaching when medications are used

Interventions for Anxiety Disorders:

-Anxiety reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an

unidentified source of anticipated danger

-Coping enhancement: Assisting a client to adapt to perceived stressors, changes, or threat that
interfere with meeting life demands and roles

-Hope instillation: Facilitation of the development of a positive outlook in a given situation

-Self-esteem enhancement: Assisting a client to increase his/her personal judgment of self-worth

-Simple relaxation: Use of techniques to encourage and elicit relaxation for the purpose of
decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety

6- Evaluation:

• Identified outcomes serve as a basis for evaluation. In general, evaluation will focus on
whether or not there is reduced anxiety, recognition of symptoms as anxiety-related,
reduced incidence of symptoms, performance of self-care activities, maintenance of

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 satisfying interpersonal relationships, assumption of usual roles, and use of adaptive
coping strategies.

ANXIETY DISORDERS

Individuals experience a degree of anxiety that is so high that it interferes with personal, occupational, or social
CONCEPT functioning. ANXIETY DISORDERS are the most common form of psychiatric Disorder in the USA.
OBSESSIVE-
TYPES/ PANIC DISORDER GENERALIZED PHOBIAS COMPULSIV POST-TRAUMATIC STRESS
SUBTYPE ANXIETY E DISORDER DIRORDER (PTSD)
S DISORDER (GAD) (OCD)
1.The patient experiences 1. More than 6 1. The client 1. The client 1. Exposure to a traumatic
recurrent panic attacks months of fears a has intrusive event causes intense fear,
2. Episodes typically last uncontrollable, specific object thoughts of horror, flashbacks, feelings of
15-30 minutes excessive, unrealistic or situation to unrealistic detachment and foreboding,
3. Four or more of the worries (inadequacy an obsessions and restricted affect, and
following symptoms are in interpersonal unreasonable tries to control impairment for longer than 1
present: relationships, job level. Phobias these thoughts month after the event.
-Palpitations, SOB, responsibilities, include: with Symptoms may last for years.
Choking or Smothering finances, health of -SOCIAL compulsive -ACUTE PTSD: Symptoms last
Sensation, Chest Pain, family members, PHOBIA behaviors, less than 3 months-CHRONIC
FEATURE Nausea, Feelings of household chores, - which are PTSD: Symptoms last more
S Depersonalization, Fear and lateness for AGORAPHO repetitive – than 3 months
of Dying, Chills or Hot appointments) BIA ritualistic- SYMPTOMS:
Flashes, Fear of going 2. GAD causes -SPECIFIC -Clients who -Recurrent, intrusive
crazy, Decreased significant PHOBIAS: engage in recollection of event
perceptual and cognitive impairment in one or -Fear of constant -Dreams or images
abilities more areas of specific ritualistic -Reliving through flashbacks,
4. Pt may experience functioning. objects behaviors may illusions, or hallucinations
Changes in Behavior 3. At least 3 of the (snakes, have difficulty -Irritability, difficulty with
and/or Persistent Worries following symptoms spiders, meeting self- concentration, sleep
about when the next are present: strangers) care needs-If disturbances, avoidance of
attack will occur -Fatigue -Fear of rituals include stimuli associated with trauma,
5. May experience -Restlessness specific constant inability to show feelings.
Agoraphobia due to fear -Inability to experiences handwashing or (it differs from Acute Stress
of being in places where Concentrate (flying, being cleaning, skin Disorder in that ASD occurs
previous panic attacks -Irritability in the dark, damage and after exposure to a traumatic
occurred. -Muscle Tension riding an infection may event, causing numbing,
*MAY BE CONFUSED -Sleep Disturbances elevator, occur. detachment and amnesia about
WITH A HEART 4. Characterized by being in an the event for NOT MORE than
ATTACK Remissions and enclosed 4 weeks following the event,
*DOES NOT exacerbations (no space) with symptoms lasting from 2
NECESSARILY acute anxiety attack) days to 4 weeks)
FOLLOWS AN
STRESSFUL,
IDENTIFIABLE
EVENT
1. Perform a thorough Physical and Neurological examination to help determine if anxiety is primary or is
secondary to another psychiatric disorder, a medical condition, or substance use.
ASSESSM 2. Assess Risk for Suicide
ENT 3. Perform psychosocial assessment (To help client identify the problem to be addressed by counseling (stressful
marriage, recent loss, stressful job or school situation)
4. Assess coping mechanisms
5. Use a standardized assessment scale, such as Hamilton Rating Scale for Anxiety.

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EXPECTE 1. Client uses coping mechanisms to prevent panic anxiety when stressful situations occur.
D 2. Client verbalizes acceptance of life situations over which he or she has no control
OUTCOM 3. The client is able to recognize signs of anxiety and intervene to prevent panic levels
ES
1. Ensure Safety
In General, Interventions for Anxiety disorders 2. Stay with the client and provide support (Provide
INTERVE attempt to: reassurance, use therapeutic communication skills, use
NTIONS open-ended questions, encourage client to verbalize
1. Reduce Anxiety feelings)
2. Increase Self Esteem 3. Use relaxation breathing techniques as needed
3. Increase Reality Testing 4. Reduce environmental stimuli
4. Enhance Coping Mechanisms 5. Encourage physical activity like walking
5. Instill Hope 6. Administer medications as prescribed (SSRIs, TCAs,
6. Relaxation Therapy MAOIs, Benzodiazepines (anxiolytics), Beta Blockers,
Mood stabilizers)
7. Instill hope (but avoid false reassurance)
8. Enhance Self Esteem by encouraging positive statements
about self and discussion of past achievements.
9. Postpone teaching until acute anxiety subsides: clients
with panic attack or severe anxiety are unable to
concentrate or learn.
10. Teach to limit nicotine and caffeine
11. Promote sleep with comfort measures
PANIC DISORDER: GENERALIZED PHOBIAS OBSESSIVE- POST-TRAUMATIC STRESS
ANXIETY COMPULSIV DISORDER (PTSD)
MEDICAT DISORDER (GAD) E DISORDER
IONS 1. SSRIs (OCD) 1. SSRIs
2. Benzodiazepine 1. SSRI 2. TCAs
s 1. SSRIs s 1. SSRIs 3. Benzodiazepines
*SSRIs are 3. TCAs 2. TCAS 2. Benz (Especia 4. SNRIs
First line 4. MAOIs 3. Buspirone odiaz lly 5. MAOIs
for all 5. Beta Blockers (Buspar) epine Luvox) 6. Beta-Blockers
anxiety 6. Depakote 4. SNRIs s 2. TCAs 7. Carbamazepine
Disorders (Valproic Acid) 5. Depakote 3. Busp (Especia (Tegretol)
except (Valproic irone lly
AAA (see Acid) (Bus Anafrani
bellow) par) l) +
+ 4. Beta
*Benzodia Bloc -Cognitive-Behavioral
zepines Cognitive-Behavioral + kers -Family
shouldn’t Therapy 5. Gaba -Group Therapy with survivors
be used to Cognitive-Behavioral penti +
treat GAD: Therapy n
this is a (Neu Behavioral
chronic *No Benzodiazepines ronti Therapy
disease and n)
benzos
should +
only be
used for Cognitive-
short Behavioral
periods of Therapy
time, like
in Acute
Anxiety

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Attack
(AAA)
Defense mechanisms: Nursing Diagnosis:
-Risk for Suicide (=Risk for self- FOR ACUTE ANXIETY ATTACK (AAA)
MISC Phobia: Displacement directed violence) First Line of Treatment: Benzodiazepines (the only
Compulsion: Undoing -Risk for others-directed violence time this group is first line for anxiety disorders)
Obsession: Reaction- -Risk for injury to self or others
Formation/ Intellectualization -Anxiety (moderate, severe)
PTSD: Isolation/ Repression -Ineffective role performance
-Ineffective coping
-Disturbed thought process
-Disturbed Sleep Pattern
-Self-care deficit

Mood Disorders

Defined as Pervasive alterations in emotions those are manifested by depression, mania,

or both, and interfere with the person’s ability to live life.

As the name implies, mood disorders are defined by pathological extremes of certain
moods - specifically, sadness and elation.  While sadness and elation are normal and
natural, they may become pervasive and debilitating, and may even result in death, either
in the form of suicide or as the result of reckless behavior.  In any one year, roughly 7%
of Americans suffer from mood disorders.

Categories:

 The two main types of mood disorders are:

– Depression

 Characterized by anergia (lack of energy), exhaustion, agitation, noise

intolerance, and slowed thinking process

– Bipolar Disorders

 Diagnosed when a person’s mood cycles between extremes of mania and

depression

SUBTYPES OF DEPRESSIONS

-Major Depression: Severe depression which lasts for at least 2 weeks during which the person
experiences a depressed mood or loss of pleasure in nearly all activities

-Dysthymic Depression: It is less severe than major depression. It is characterized by at least 2

years of depressed mood for more days than not with some additional less severe symptoms that
do not meet the criteria for a major depressive episode

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 -Depression Not Otherwise Specified: Depression that lasts for 2 days to 2 weeks

SUBTYPES OF BIPOLAR DISORDERS

-Manic: The diagnosis of manic episode or mania requires at least 1 week of unusual and
incessantly heightened, grandiose or agitated mood in addition to three or more of the following
symptoms:

 Exaggerated self-esteem

 Sleeplessness

 Pressured speech

 Flight of ideas

 Reduced ability to filter extraneous stimuli

-Hypomanic :

- Less severe than mania

-Lasts for at least 4 days

-Bipolar I: With history of mania

 The patient exhibits:

– Manic episodes

– Periods of normal behavior

– Periods of profound depression

-Bipolar II: No history of mania

 The patient exhibits:

– Depression

– Normal behavior

– At least one hypomanic episode, but NOT manic

-Cyclothymia :

-Characterized by two years of numerous periods of both hypomanic symptoms that do not meet
the criteria for bipolar disorder

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 -Numerous episodes of hypomania and depressed mood that lasts for at least two years

MOOD DISORDERS (AFFECTIVE DISORDERS)

DEPRESSION BIPOLAR DISORDER

TYPES/  Bipolar disorders are mood disorders with recurrent
SUBTYPES MAJOR DEPRESSIVE DYSTHYMIC episodes of depressionand mania. Phases vary depending
DISORDER DISORDER on the type of bipolar disorder.
(MDD) (DD) OR  Bipolar disorders usually emerge in late
DYSTHYMIA adolescence/early adulthood, but can be diagnosed in the
 A single, recurrent,  A milder form school-age as well.
or chronic episode of depression TYPES OF BIPOLAR DISORDERS:
CONCEPT (s) of depression that usually has BIPOLAR I: At least 1 episode of Mania alternating w/
resulting in a an early onset, Major Depression.
significant change in such as BIPOLAR II: Hypomanic episodes alternating w/ Major
the client’s normal childhood or Depressive ones.
functioning (social, adolescence CYCLOTHYMIA: At least 2 years of alternating episodes of
occupational, self- (Chronic Hypomanic Episodes alternating w/ Minor Depressive
care) accompanied Depressed episodes (dysthymia)
by at least 5 specific Mood) IT BEHAVIORS shown with Bipolar Disorders include:
symptoms. LASTS: MANIA: Abnormally elevated mood, also described as
 These symptoms  More than 1 expansive or irritable. HYPOMANIA: A less severe episode
must happen almost year (for of mania that lasts at least 4 days accompanied by 3 or 4
every day, last most Children and symptoms of mania.
of the day, and occur Adolescents) MIXED EPISODE: A manic episode and an episode of major
continuously for a  More than 2 depression experienced by the client simultaneously. Marked
minimum of 2 years. years (For impairment in functioning and may require admission to
Adults) prevent self-harm or others-directed violence.
 Contains at RAPID CYCLING: Four or more episodes of acute mania
least 3 within 1 year
symptoms of
depression, and ***BIPOLAR DISORDER IS ASSOCIATED WITH THE
may, later in HIGHEST RATE OF SUICIDE OF ANY PSYCHIATRIC
life, become DISORDERS.
Major
Depressive
Disorder
 Depressed Mood  Depressed
 Insomnia/Hypersom Mood MANIA HYPOMANIA
nia  Insomnia/Hype
 Decreased ability to rsomnia 1. Severe enough to cause a 1. Associated with an
concentrate  Decreased marked impairment in unequivocal change in
 Anergia (Lack of ability to occupational activities, functioning that is
Energy) concentrate usual social activities, or uncharacteristic of the
 Significant weight  Anergia relationships. person when not
loss or gain (of  Decreased Self symptomatic
more than 5% of Esteem OR
body weight in 1  Feelings of 2. The disturbance in mood
FEATURES month) Hopelessness 2. Necessitates and the change in
 Indecissiveness and Despair hospitalization to functioning are observed
 Increase or  Decreased/Incr prevent harm to self or by others

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 Decrease in motor eased Appetite others, or there are
activity psychotic features
 ****Suicidal Specifiers 3. Absence of marked
Ideations **** (Features) 3. Symptoms are not due to impairment in social or
 Anhedonia direct physiological occupational
(Inability to feel  Early Onset effects of substance functioning.
pleasure in life) (before 21 y/o) (drug abuse, medication,
Specifiers (Features):  Late Onset (21 alcohol) other medical 4. Hospitalization not
years or older) condition indicated
 PSYCHOTIC  Atypical (hyperthyroidism)
FEATURES Features
(Hallucinations, (Appetite 5. Symptoms are not due to
Delusions etc) changes, direct physiological
 POSTPARTUM weight gain, effects of substance
ONSET (Begins Hypersomnia, (drug abuse, medication,
within 4 weeks of extreme alcohol) other medical
childbirth, known as sensitivity to condition
Postpartum perceived (hyperthyroidism)
Depression) interpersonal
 SEASONAL rejection)
FEATURES
(SEASONAL
AFFECTIVE
DISORDER –
SAD-) (Generally
occurring in fall or
winter, and
remitting in Spring)
 CHRONIC
FEATURES
(Episode lasts over
2 years)

 History of prior episodes of depression BIOLOGICAL THEORIES:

ETIOLOGY  Family history of depression, especially  Genetic Factors: Strong genetic component
& Risk first degree relatives  Neurobiological Factors: Neurotransmitters
Factors  History of Suicide attempts and/or family (NE,Dopamine and Serotonin) INCREASED:
history of suicide Mania DECREASED: Depression
 Female Gender  Neuroendocrine Factors: Hypothyroidism:
 Age 40 years or younger Depressed mood and rapid-cycling
 Postpartum period  Neuroanatomical: Prefrontal cortex (PFC) and
 Medical Illness Medial Temporal Lobe (MTL) dysregulation
 Absence of Support System SOCIOLOGICAL FINDINGS: More prevalence in the
 Negative, stressful life events upper socioeconomic classes. Reason unclear; it seems
 Active alcohol or substance abuse people with BD achieve higher levels of education and
higher occupational status than nonbipolar individuals
PSYCHOLOGICAL INFLUENCES: There seems to exist
an association between high expressed emotions and relapse.
Abused children tend to reveal BD earlier in life than non
abused ones.

MAJOR DEPRESSIVE DYSTHYMIC MANIA HYPOMANIA

DISORDER DISORDER
(DD) OR

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 DYSTHYMIA
 Assess Suicide Potential (applies also  Labile moods  Talks and jokes
ASSESSME for Bipolar Disorder)  Inappropriate and incessantly (“life of the
NT Follow Algorithm “SAD PERSONS” (Sex intrusive behavior party”)
+ _male- Age –25-44 or more 65-Depressed  Profane speech; crude  Demands constant
Additional mood, Previous attempt(s), ETOH-alcohol-, sexual remarks attention
Symptoms Reality testing impaired, Social support (lack),  Flight of ideas; may have  Treats everyone with
Organized plan, No spouse, Sickness (severe or clan associations familiarity; often crude.
chronic) (rhyming)  Sexual talk often
 Assess Risk factors for Depression  Good humor turns into inappropriate and
Follow the algorithms “SIGECAPS” (Sleep rage and hostility, obscene; proposes to
disturbances, Interest –decreased-,Guilt, especially when not strangers
Energy -decreased-, Concentration – getting his way or  Flits from topic to topic
decreased-, Appetite –decreased/increased-, controls are set.  Full of pep, humor,
Psychomotor movements, Suicidal Ideation  Quick shifts in moods, euphoria and sociability
Other areas to assess: hostile to docility  Inflated self confidence
 Affect  Grandiose delusions and enthusiasm. Many
 Thought processes  Judgment extremely poor plan to become rich and
 Feelings  Decreased attention span famous
 Guilt and distractibility  Poor judgment; involved
 Physical Behavior  Restless, disorganized with schemes in which
 Communication and chaotic behavior job, financial, o marriage
difficult to control; is destroyed.
 Remains Safe frequent outbursts and  High degree of
 Verbalizes hope for the future briefly assaultive when involvement with the rich
EXPECTED  Identifies precursors of depression crossed and famous; world-wide
OUTCOME  Reports improved mood  Too busy for sex phone calls
S  Develops strategies to cope with stress  No time to eat or sleep.  Decreased attention span,
and painful feelings Too distracted and overactive
disorganized  Increased sexual appetite,;
 Severely hyperactive and sexually irresponsible and
restless. Can result in indiscreet; illegitimate
exhaustion and death. pregnancies, increased
 Same as Hypomanic with incidence of venereal
finances, but extreme diseases. Sex used for
escape, not for relating.
 Voracious appetite,
gobbles food, eats on the
run
 May go without sleeping,
unaware of fatigue
 Financially extravagant;
buying sprees, gives
money and gifts freely.
Goes easily into debt.
 Wears extravagant, often
inappropriate clothes and
jewelry.
 Exhibits no evidence of physical injury
FOR DEPRESSION:  Has not harmed self or others
 Safety!! Prevent Suicide!!  Is not longer exhibiting signs of physical agitation
 Encourage to verbalize feelings  Eats a well-balanced diet with snacks to prevent weight
 Assist through grief process loss and maintain nutritional status
 Accepts responsibility for own behaviors

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  Increase Self Esteem and Reality  Does not manipulate others for gratification of own
Testing needs
 Decrease Anxiety  Interacts appropriately with others
 Confront anger  Ensure safety in the environment
 Administer medications & assess  Decrease Anxiety: use firm, calm approach, use short
effects and concise explanations
INTERVEN  Teach coping mechanisms, disease  Remain neutral,
TIONS process and medication regimen  Give simple step-by-step instructions
 Ensure all basic needs are met  Set limits and tell in concrete terms consequences of
 Approach: caring, supportive, and firm inappropriate behavior
 Have patient sign “No Suicide  Firmly Redirect violent behavior (use distraction)
Contract”: To take responsibility and  Decrease environmental stimuli
make commitment.  Structured solitary activities with staff
FOR SUICIDE  High calorie, high protein “finger foods” snacks and
 Safety in the environment!! drinks. Avoid caffeine.
 One-to-one nurse-client relationship  Provide frequent rest periods
 “No Suicide” contract  Administer and make sure pt takes prescribed
 Non-judgmental, accepting attitude medications
 Encourage verbalization of feelings  When violent or extreme agitation use antipsychotics
 Provide Hope and seclusion
 Assist in meeting basic needs  Monitor lithium levels/observe s & s of toxicity
 Provide diversional activity
MEDICATI 1. SSRIs (First Line treatment)
ONS/ 2. TCAs
TREATME 3. MAOIs 1. ANTIPSYCHOTICSs & BENZODIAZEPINES
NT 4. ATYPICAL ANTIDEPRESSANTS (Initially, used to calm manic symptoms until
MODALITI Lithium therapeutic levels and full effects are
ES PSYCHOLOGICAL TREATMENTS: achieved, in approx. 14 days)
 Individual Psychotherapy 2. MOOD STABILIZERS (Lithium,
 Group Therapy Anticonvulsives)
 Family Therapy
 Cognitive Therapy
ORGANIC TREATMENTS:
 ECT
 PSYCHOPHARMACOLOG
Y
 ALTERNATIVE OR
COMPLEMENTARY
THERAPY
Suicide Facts
OTHER 1. Depression is the fourth leading cause  Most common method: firearm
FACTS of disability in the US.  Most common sex: males
2. Twice as common in women as in  Most common occupations: Physicians, dentists, nurses,
men Social workers
3. Suicides are more common in men  Elderly attempt suicide less often, but have higher
than women completion rate (more lethal methods)
4. It is partially hereditable  Suicide is more common in people with comorbidities
(Major depression, bipolar disorder, schizophrenia,
alcohol and substance abuse, borderline and antisocial
personality disorders, panic disorder)

Nursing Process for Depressive Disorders:

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Assessment

• History: the client’s perception of the problem, behavioral changes, any previous
episodes of depression, treatment, response to treatment, family history of mood
disorders, suicide, or attempted suicide

• General appearance and motor behavior: slouched posture, latency of response,

psychomotor retardation or agitation

• Mood and affect: hopeless, helpless, down, anxious, frustrated, anhedonia, apathetic;
affect is sad, depressed, or flat

• Thought processes and content: slowed thinking processes, negative and pessimistic,
ruminate, thoughts of dying or committing suicide

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

concentrating

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

• Self-concept: low self-esteem, guilty, believe that others would be better off without them

• Roles and relationships: difficulty fulfilling roles and responsibilities

• Physiologic considerations: weight loss, sleep disturbances, lose interest in sexual

activities, neglect personal hygiene, constipation, dehydration

• Depression rating scales: Zung Self-Rating Depression Scale, Beck Depression

Inventory, the Hamilton Rating Scale for Depression

Data Analysis

Nursing diagnoses may include:

• Risk for Suicide

• Imbalanced Nutrition: Less Than Body Requirements

• Anxiety

• Ineffective Coping

• Hopelessness

• Ineffective Role Performance

• Self-Care Deficit

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 • Chronic Low Self-Esteem

• Disturbed Sleep Pattern

• Impaired Social Interaction

Outcomes

The client will:

• Not injure himself or herself

• Independently carry out activities of daily living (showering, changing clothing,

grooming)

• Establish a balance of rest, sleep, and activity

• Establish a balance of adequate nutrition, hydration, and elimination

• Evaluate self-attributes realistically

• Socialize with staff, peers, and family/friends

• Return to occupation or school activities

• Comply with antidepressant regimen

• Verbalize symptoms of a recurrence

Intervention

• Providing for the client’s safety and the safety of others

• Promoting a therapeutic relationship

• Promoting activities of daily living and physical care

• Using therapeutic communication

• Managing medications

• Providing client and family teaching

Evaluation

• Does the client feel safe?

• Is the client free of uncontrollable urges to commit suicide?

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• Is the client participating in therapy and medication compliance?

• Can the client identify signs of relapse?

• Will the client agree to seek treatment immediately upon relapse?

Nursing Process for Bipolar Disorders:

Assessment

• General appearance and motor behavior: psychomotor agitation; flamboyant clothing or

makeup; think, move, and talk fast; pressured speech

• Mood and affect: euphoria, exuberant activity, grandiosity, false sense of well-being,
angry, verbally aggressive, sarcastic, irritable

• Thought processes and content: flight of ideas, circumstantiality, tangentiality, possible

grandiose delusions

• Sensorium and intellectual processes: oriented to person and place but rarely to time,
impaired ability to concentrate, may experience hallucinations

• Judgment and insight: judgment poor, insight limited

• Self-concept: exaggerated self-esteem

• Roles and relationships: rarely can fulfill role responsibilities, invade intimate space and
personal business of others, can become hostile to others, cannot postpone or delay
gratification

• Physiologic and self-care considerations: inattention to hygiene and grooming, hunger or

fatigue

Data Analysis

Nursing diagnoses may include:

• Risk for Other-Directed Violence

• Risk for Injury

• Imbalanced Nutrition: Less Than Body Requirements

• Ineffective Coping

• Noncompliance

• Ineffective Role Performance

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 • Self-Care Deficit

• Chronic Low Self-Esteem

• Disturbed Sleep Pattern

Outcomes

The client will:

• Not injure self or others

• Establish a balance of rest, sleep, and activity

• Establish adequate nutrition, hydration, and elimination

• Participate in self-care activities

• Evaluate personal qualities realistically

• Engage in socially appropriate, reality-based interaction

• Verbalize knowledge of his or her illness and treatment

Intervention

• Providing for safety of client and others

• Meeting physiologic needs

• Providing therapeutic communication

• Promoting appropriate behaviors

• Managing medications

• Providing client and family teaching

Evaluation

• Safety issues

• Comparison of mood and affect between start of treatment and present

• Adherence to treatment regimen of medication and psychotherapy

• Changes in client’s perception of quality of life

• Achievement of specific goals of treatment including new coping methods

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Suicide

Assessment

Men commit suicide three times the rate of women

Women are four times more likely than men to attempt suicide

Populations at risk

• Men, young women, Caucasians, adults older than 65, and separated and divorced people

• Clients with psychiatric disorders

Environmental factors include isolation, recent loss, lack of social support, unemployment,
critical life events, and family history of depression or suicide

Behavioral factors include impulsivity, erratic or unexplained changes from usual behavior, and
unstable lifestyle

• Warnings of suicidal intent

• Risky behaviors

• Lethality assessment

– Does the client have a specific plan?

– Are the means available to carry out this plan?

– If the client carries out the plan, is it likely to be lethal?

– Has the client made preparations for death?

– Where and when does the client intend to carry out the plan?

– Is the intended time a special date or anniversary that has meaning for the client?

Outcomes

The client will:

• Not injure self or others

• Engage in a therapeutic relationship

• Establish a no-suicide contract

• Create a list of positive attributes

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 • Generate, test, and evaluate realistic plans to address underlying issues

Intervention

• Using an authoritative role

• Providing a safe environment

• Initiating a no-suicide contract

• Creating a support system list

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