Mood Disorders

Chapter 11: Psychotic Disorders

1. Define mood and affect as they relate to an abnormal state.

Mood is an emotion that is prolonged to the point that it colors an individual’s entire
psychological thinking. The feelings are changeable depending on the person’s
perception of sensory stimuli. An individual might respond to a separation or divorce
with deep feelings of sadness, regret, and failure, while another might feel a more
contented feeling of relief and freedom.
Affect describes the facial expression an individual displays in association with the mood
(e.g., smiling when happy, grimacing when angry). Alterations in mood can range from
mild to severe. When the mood alterations are mild, the person may experience minor
changes in daily routine with minimal impairment in functioning.
Severe mood alterations, however, can result in significant impairment of the person’s
ability to function. For example, the cancelled lunch date might be seen as personal
rejection and a reason to become socially reclusive, and the loss of a pet could be
followed by despair and depression. The prolonged inability to regain a sense of
emotional balance is considered abnormal.

2. Describe signs and symptoms of common depressive disorders.

Decreased decision-making ability
Sleep disturbances and difficulties
Fatigue, anergia
Weight and appetite changes
Difficulty concentrating
Depression symptoms
Feelings of inadequacy, failure, emptiness

3. Describe the identifying criteria for bipolar and related disorders.

In the DSM-5 criteria for bipolar disorder, the mood change must be accompanied by
persistently increased activity or energy levels that are obvious to those observing the
person.
Based on the severity of the episodes and duration, individuals may be diagnosed with
bipolar II disorder or cyclothymic disorder. If the person has four or more mood shifts
within a year, the person is said to be rapid cycling. This feature is more common in later
stages of the illness.

4. Identify treatment methods for individuals with depressive and bipolar disorders.
Treatment of depressive disorders may include pharmacologic, psychotherapeutic,
psychosocial, and electroconvulsive therapy (ECT) approaches. Psychotherapeutic drug
agents are used very successfully in managing depression. Drug therapy includes the
 antidepressants and mood-stabilizing drugs.
The two most common psychotherapies are interpersonal and cognitive behavior
therapy. Both have been demonstrated to be effective in the treatment of depression
and dysthymia.
5. Discuss the use of mood-stabilizing agents in the treatment of bipolar disorder.
Mood-stabilizing agents are the drugs of choice to treat clients with bipolar disorders.
These drugs may be used alone or in combination with selected atypical antipsychotics,
and are used along with psychotherapy to stabilize and control the initial extreme mood
swings. Lithium carbonate was the first to be named a mood-stabilizer drug because of
its combined antimanic and antidepressant properties.
Today, the term mood stabilizer is currently used to describe psychotropic drugs that
reduce mood swings and the likelihood of subsequent episodes. In addition to lithium,
anticonvulsants and second-generation antipsychotic drugs are included in this
category. It is important to note that lithium carbonate is used to treat both spectrums
of mood shifts, whereas other drugs in this category are primarily agents that keep the
manic episodes under control. Lithium is more effective in treating highs or manic
periods than in preventing lows or depressive periods. It is used in the management of
bipolar illness, both to treat manic episodes and to prevent the recurrence of these
episodes.
6. Describe the nursing process related to antidepressant and mood-stabilizing drug
therapy.
A nursing assessment will include information regarding any previous incidence of
mental illness or psychotic episodes. Assess the client’s condition in relation to
depressive disorders. Identify clients at risk for current or potential depression. Observe
for signs and symptoms of depression. When a client appears depressed or has a history
of depression, assess for suicidal thoughts and behaviors. Identify the client’s usual
coping mechanisms for stressful situations.
After careful review of the data, nursing diagnoses can be formulated. Approaches to
treatment are usually selected on their ability to reduce and control the symptoms.
Nursing care should be planned to focus on symptomatic relief as well, with careful
attention to the physical, emotional, and social needs imposed by impaired mental
functioning.
Selecting appropriate interventions that the client can tolerate requires careful
planning. It is important to avoid expecting too much, but at the same time it is
important to encourage clients to maximize their ability to function. Understanding the
client’s ability to focus, process, and follow instructions provides direction for the
selection of nursing interventions. It is important to consider the holistic picture of the
client, including physiological, emotional, cultural, and spiritual needs. It is also
important to assess the client for escalating behavior and intervene.
The anticipated outcomes for the client will depend on the level of functioning
demonstrated by the client. This will depend on the severity of symptoms and the
effectiveness of antipsychotic drug therapy or other therapeutic approaches. It is
important that the goals and time frame for improvement be realistic. Use measures to
prevent or decrease the severity of depression. General measures include supportive
 psychotherapy and reduction of environmental stress. Observe for behaviors indicating
lessened depression.

7. Describe nursing assessment of clients with a mood disorder.

During the assessment of a person with a mood disorder, collect data about mood and
affect, thinking and perceptual ability, somatic complaints, sleep disturbances, changes
in energy level, and the character of speech patterns. Mood and affect should be
assessed for congruency. Because mood is a subjective experience, it is important to ask
the client what feeling or emotion he or she is experiencing.
8. Develop appropriate nursing diagnoses related to mood disorders.
Risk for Injury, related to side effects of drowsiness and dizziness
Risk for Poisoning, related to lithium toxicity
Risk for Injury, related to sodium imbalance
Risk for Violence, Self-Directed or OtherDirected, related to manic excitement,
impulsive behavior
Risk for Deficient Fluid Volume, related to side effects of medication (n/v diarrhea)
Sensory Perception, Disturbed, related to chemical alterations
Self-Esteem, Chronic Low, related to perceived lack of control
Deficient Knowledge, related to prescribed drug and side effects

9. Plan expected outcomes for categories of mood disorders.

Has increased energy level
Identifies personal strengths
Demonstrates improved skills to deal with loss
Experiences decreased feelings of self-blame and doubt
Openly expresses feelings
Resumes sexual functioning with partner
Demonstrates increased interaction with others

10. Identify appropriate nursing interventions for clients with mood disorders.
Monitor for changes in current depressive symptoms or development of new ones
Ask the client about any suicidal thoughts indicating a plan of how, when, or where the
client might harm or kill self
Assess the client’s energy level—as energy increases, the ability to carry out a plan for
suicide increases
Provide positive feedback when the client makes efforts toward goals
Provide a safe environment by removing potentially dangerous items
Educate client regarding depression and treatment
Stress the importance of taking medications as ordered
 Encourage the client to explore feelings and communicate them in a safe manner
Assist the client to express anger and other negative feelings appropriately
Help client to recognize situations he or she can control and explore alternatives for
those that cannot be controlled
Encourage the client to recognize negative thoughts and teach reframing techniques
Teach alternative methods of coping that are constructive and safe
Focus on client’s strengths and positive attributes
Assist the client in establishing realistic goals It is important to remember that because
of the nature of mania,

11. Define psychosis.

The term psychosis is linked with a variety of meanings. Most often it makes reference
to a set of symptoms, including perceptual disturbances, disorganized thinking, and
behavior alterations, that demonstrate disorganization in the mental processes.
These symptoms reflect the behavior, emotional response, and thought processes of the
person who has lost contact with reality. Most people associate the disturbances of
“hearing voices” or other strange behaviors with this psychosis. Those who experience
these symptoms also tend to withdraw from society and retreat into their own unreal
world.

12. Describe common characteristics of psychotic disorders.

The major symptoms of psychotic disorders are the occurrence of delusions and
hallucinations. Some individuals may experience this as a single psychotic event, such as
that seen after an extremely stressful event or trauma. The episode may last a few days
but usually resolves within several weeks.

13. Describe treatment methods for clients with psychotic disorders.

Most types of psychotic disorders are treated with a combined approach of medications
and psychotherapy. The most common type of psychotropic agents used is the
antipsychotic drugs. These medications do not provide a cure for the disorders, but are
used in various levels of effectiveness in managing the problematic symptoms.
Various types of psychotherapy including individual, group, and family therapy may be
used in conjunction with the administration of the drugs. Some clients may require
hospitalization for stabilization of their conditions, while many can be managed as
outpatients.

14. Describe the relationship of antipsychotic drug agents to the treatment of psychosis.
Antipsychotic agents, also referred to as neuroleptics, are used to treat serious mental
illness such as bipolar affective disorder, depressive and drug-induced psychosis,
schizophrenia, and autism. Because the symptoms of the psychoses are extremely
uncomfortable for most people, the effects of antipsychotic drugs are one of the most
dramatic in modern medicine. Today, these drugs can reverse most or all symptoms in
many with psychotic illness, which shortened hospital stays and longer periods of
functional community living for many whose symptoms are controlled with
 antipsychotic medication.

15. Identify extrapyramidal side effects and their effect on compliance with drug therapy.
Antipsychotic agents are capable of producing numerous side effects. The higher
potency drugs can produce severe extrapyramidal side effects. These side effects block
the neurotransmitter dopamine causing irritation of the pyramidal tracts of the CNS that
coordinate involuntary movements. These reactions are much more devastating than
anticholinergic and antiadrenergic side effects and contribute to the noncompliance
exhibited by many clients for whom these drugs are prescribed. The resistance to
treatment leads to relapse and return of symptoms with readmission to acute
hospitalization.
Extrapyramidal side effects include Akathisia, Dystonias, Tardive dyskinesia, Drug
induced parkinsons, and Neuroleptiv maglignant syndrome. The physician can make
dosage adjustments or prescribe medications to counteract these effects if they occur
and are recognized early.

16. Describe components of a nursing assessment of the client with a psychotic disorder.
A nursing assessment will include information regarding any previous incidence of
mental illness or psychotic episodes. Because the person with schizophrenia may not
always be a reliable source of information, be sure to consult family members or other
people familiar with the client. Data are most often compiled according to the nature of
the symptoms, including perceptual alterations such as
Hallucinations or illusions.
Identify the type of disturbance the client is experiencing.
Ask the client about feelings while thought alterations are evident.
Determine theme and content of delusional thinking. If the delusion is persecution
oriented, assess the nature of the threat and whether there is a risk for violence as a
result.
Assess speech patterns associated with the delusions. Delusional thinking is
characterized by speech in which the person jumps from one unrelated subject to
another.
Note the affect and emotional tone of the client and whether they are appropriate in
relation to the present situation. Apathy or a lack of interest in the environment and
flatness of affect are characteristic signs of schizophrenia.
Observe behavior patterns, activity, sleep habits, and interactions with other clients.
Observe for posturing or other psychomotor disturbances.
Assess for extrapyramidal side effects of antipsychotic drug agents.
Assess the person’s appearance, hygiene, and ability to perform self-care activities.
Determine any suicidal intent or recent attempts that may have been made.

17. Select appropriate nursing diagnoses for the client with a psychotic disorder.
Risk for Self-Directed or Other-Directed Violence, related to suspiciousness or command
hallucinations
Dysfunctional Family Processes, related to chronic illness
 Ineffective Coping, related to chronic illness, substance use
Self-Care Deficit, related to withdrawal and apathy
Disturbed Thought Processes, related to delusional thinking
Impaired Social Interaction/Social Isolation, related to lack of trust
18. Identify expected outcomes for problems seen in the client with a psychotic disorder.
Develops reality-based ways to communicate and meet self-needs
Remains oriented to self and the environment
Interacts appropriately with others
Has not injured self or others
Family members express realistic expectations of individual member
Performs self-care and hygiene with minimal prompting
Demonstrates increased trust of others
Exhibits increased ability to associate behavior with misperceived environmental stimuli
19. Identify appropriate nursing interventions for the client with a psychotic disorder.
Interentions include:
Show acceptance of the client, separating the person from the behavior. Provide a safe
environment by removing unsafe objects and diffusing potentially violent situations
before they escalate.
Maintain a reality-based approach to communication with the client. Clients
experiencing delusions are mistrusting and suspicious making them resistant to taking
medications and accepting information. Avoiding a confrontation or argumentative
approach while also not reinforcing the delusional belief will reinforce reality. Make
direct statements that shed doubt on the illogical thinking of the client.
Provide a nonstimulating environment that reduces external stimuli.
20. Discuss evaluation of the effectiveness of nursing care delivered to clients with a
psychotic disorder.
When evaluating the effectiveness of planned interventions, the nurse should look for
signs that indicate improved functioning of the client. It is anticipated that compliance
with drug therapy will diminish the positive symptoms of psychosis the client
experiences. Hopefully, this is accompanied by an increase in the client’s understanding
of actual and real events that precipitate the perceptual and delusional alterations.
This is demonstrated as the client is able to identify these factors and practice
diversional techniques to avoid the anxiety that encourages the psychotic behavior.
Communication with staff and other clients in an appropriate and reality-based
conversation is evidence of improved thinking processes. A decrease in bizarre and
inappropriate behavior will occur as thoughts and perceptions decrease the need for
their use.
Compliance with taking medications and increased food intake are also evidence that
the client has decreased fear of poisoning by ingested substances