MODULE 9: MOOD DISORDERS

Depression Disorders
• Major Depressive Disorder (MDD)
o Depressed mood, including symptoms which impairs functioning
o 56% of people will experience one episode
o 29% will experience two episodes
o 15.4% will experience three or more episodes
• Major Depressive Disorder Sub-types
o Psychotic features - disorganized thinking, delusions or hallucinations (voices, thinking they are sinful)
o Melancholic features – severe form of endogenous depression (within the person not in environment)
(profound guilt, weight loss, severe apathy)
o Atypical features – dominant vegetative symptoms (over eating, over sleeping, feeling anxious,
depression difficult to assess)
o Catatonic features – non-responsiveness (non responsive but not in a coma, they’re withdrawn, affect is
flat, not engaging, really seriously shut down)
o Postpartum onset – symptoms within four weeks of childbirth
o Seasonal features (seasonal affective disorder (SAD)) – typically begin in fall and winter, lasts until
spring (Calgary have high SAD because of the long winters)
• Epidemiology
o Leading cause of disability
o Lifetime prevalence of 10.8%
o Higher prevalence rates in lower-income, unemployed populations, and for unmarried or divorced
people
o Co-morbidity
• Patient Health Questionnaire – independently, assess yourself using this tool
• Bipolar Disorders
o Epidemiology – Often misdiagnosed (confused with unipolar depression)
▪ Estimated that between 0.6% and 1% of adults will have a manic episode during their lifetime
▪ Bipolar I – more common in males – manic episode with depression →psychosis may accompany
manic episode (delusions, hallucinations)
▪ Bipolar II – more common in females – hypomanic episode alternates with depression → no
psychosis
▪ Cyclothymia – usually begins in adolescence or early adulthood – hypomanic episodes with
minor depressive episodes (not as severe depression)
o Etiology
▪ Biological factors: genetic (strong heritability), neurobiological, neuroendocrine)
▪ Psychological factors – Bipolar is higher in people with higher IQs, creative, and highly educated
people
▪ Environmental factors
• Clinical Picture
o Bipolar I disorder – one episode of mania alternating with major depressive disorder, may see psychosis,
severe shifts in mood, energy, and ability for that person to function
o Bipolar II disorder – hypomania, psychosis not usually present, sometimes hypomania propel a person
towards increased functioning but can cause significant issues in their relationships
o Cyclothymia – hypomania, alternating minor depression in at least 2 years
• Case study: a patient was just admitted to your unit with bipolar disorder I and is in a manic state.
o What symptoms might you expect to see? Anger, change in sleep, excessive talking, pressured speech,
raising thoughts, distractibility, often purposelessness, lots of movement and highly aroused but with no
purpose, engage in very dangerous activities with no concept of the consequences of that behavior
▪ Talking rapidly, feeling unusually optimistic or extremely irritable, sleeping very little, highly
distractible, acting recklessly and impulsively, can easily break other’s boundaries
o What are some problems that can be avoided if your manic patient gets proper treatment?
▪ Interpersonal relationship issues, marital issues, work issues, alcohol issues, avoiding suicide
attempts
▪ Just because a person is in manic phase doesn’t mean they can’t have suicidal thoughts
• Assessment
o Mood – stable or unstable, sleepy, irritated, can joke around a lot, laugh, heightened, so much energy
and enthusiasm, don’t have a concept of boundaries and personal boundaries = will approach anybody
o Behavior and cognitive functioning
o Thought processes and speech patterns
▪ Flight of ideas ▪ Grandiosity
▪ Clang associations
• Assessment Guidelines Bipolar Disorder
o Danger to self or others • Nursing Diagnosis
o Need for protection from uninhibited o Risk for injury
behaviors o Risk for violence
o Need for hospitalization ▪ Other-direct
o Medical status ▪ Self-directed
o Coexisting medical conditions o Ineffective coping
o Family’s understanding
• Nursing Interventions – what are some nursing interventions for a patient experiencing acute mania?
o Safe environment for the patient
o Pay attention how the patient navigates on the unit when they’re not in their room and help them with
interpersonal relations
o Quiet environment
o Milieu therapy
o Keep them busy with some type of constructive activity
o Calm approach and remain neutral with the patient
• Pharmacological Interventions
o Lithium carbonate
▪ Indications ▪ Adverse effects and toxicity
▪ Therapeutic and toxic levels o Anticonvulsants
▪ Maintenance therapy o Antianxiety drugs (benzodiazepines)
▪ Contraindications o Antipsychotics
• Other Treatments
o Electroconvulsive therapy (ECT)
o Teamwork and safety
o Support groups (OBAD)
o Health teaching and health promotion
o Psychotherapy
MODULE 10: ANXIETY, OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

• Anxiety – apprehension, uneasiness, uncertainty, or dread from real or perceived threat

• Fear – reaction to specific danger
• Normal anxiety – necessary for survival
• Anxiety Disorders
o Epidemiology
o Comorbidity
o Etiology
▪ Biological → genetics
▪ Neurobiological
• Levels of Anxiety
o Mild: normal experience of everyday living – allows individuals to perceive reality in sharp focus
o Moderate: person with moderate anxiety have narrow perceptual field and may display selective
inattention
o Severe anxiety: the perceptual field in severe anxiety is greatly reduced
o Panic: most extreme level of anxiety resulting in noticeable disturbed behaviors, not able to function –
CRISIS
• Defense Mechanism
o Defined as automatic coping styles that protect people from anxiety
o Can be healthy (adaptive) or unhealthy (maladaptive)
o Adaptive defense mechanism = shield that allows us to deflects but maintain emotional well being
(humor)
o Maladaptive defense mechanism = rigid armor, doesn’t allow our emotion to come through (denial =
blocks out the negative and positive emotions) → hinders how we deal with the problem
• Defenses against anxiety

• Anxiety Disorders
o The following disorders share symptoms related to excessive fear and anxiety that results in behavior
changes
▪ Panic disorder ▪ Substance-Induced Anxiety Disorder
▪ Phobias ▪ Anxiety due to nonpsychiatric Medical Condition
▪ General Anxiety Disorder
• Panic Disorders
o An anxiety disorder characterized by recurring severe panic attacks
o Significance behavioral changes lasting at least a month
o Panic attack is sudden onset of extreme apprehension or fear
o Sometimes sudden onset of symptoms (out of nowhere)
o Symptoms may include:
▪ Chest pain ▪ Nausea
▪ Palpitations ▪ Chills or hot flashes
▪ Difficulty breathing
o Agoraphobia – the term used to describe individuals who actively avoid situations from which escape
might be difficult or embarrassing
• Clinical Picture: Panic Disorder (what does a panic attack look like?)
o Sudden onset of extreme apprehension or fear
o Feelings of impending doom
o Perceptual field limited – tunnel vision, can’t take in information outside of self (intervention breathe
into a paper bag)
o Severe personality disorganization evident
o Reality misinterpretation may occur
o Physical symptoms:
• Treating a panic attack
o Stay with the person
o Encourage slow deep breaths if hyperventilating
o Keep expectations and instructions simple and minimal (I’m gonna stay with you until this passes)
o Help connect feelings before attack with onset
o Help them realize symptoms are anxiety and not a catastrophic physical problem (may think they are
having a heart attack)
o Reframing and self talk in relation to anxiety “I can control this”
o Safety!!
• Panic Disorder: Sarah
o Clinical Manifestations: Sarag experiences sudden, intense panic attacks characterized by heart
palpitations, shortness of breath, and a feeling of impending doom
o Behaviors: She avoids situations she associates with past panic attacks and isolates herself
o Assessment Findings: Rapid heart rate, trembling, and chest pain during panic attacks. She may have a
history of recurrent panic episodes
• Phobias
o Persistent, irrational fear of a specific object, activity, or situation that lead to a desire of avoidance
despite the awareness and reassurance that it is not dangerous
o May impair daily functioning
• Social Phobia or Social Anxiety Disorder (SAD)
o Severe anxiety or fear by exposure to a social or performance situation
o Fear of public speaking – is a common example
o Problems arise when alcohol and drugs are used to self-medicate
• Phobias: Mark
o Clinical Manifestations: Mark has an intense, irrational fear of spiders, leading to panic-like symptoms
when confronted with them
o Behaviors: He goes to great lengths to avoid spiders and becomes highly distressed if he encounters one
 o Assessment Findings: Profound anxiety, sweating, and increased heart rate when exposed to spiders.
Mark’s fear is often excessive and unreasonable
• General Anxiety Disorder
o Persistent and exaggerated apprehension and tension
o Excessive worry that lasts for months
o Chronic anxiety
o Symptoms may include:
▪ Restlessness
▪ Fatigue
▪ Irritability
▪ Poor concentration
▪ Tension
▪ Sleep disturbance
• Generalized Anxiety Disorder: Emma
o Clinical Manifestations: Emma worries excessively about various aspects of her life, even when there’s no
apparent reason
o Behaviors: She is restless, has difficulty concentrating, and experiences muscle tension
o Assessment Findings: Emma’s constant worrying, sleep
• Substance-Induced Anxiety Disorder
o Characterized by symptoms of anxiety, panic attacks, obsessions and compulsions that develop with the
use of substance or within a month of discontinuing use of the substance
• Substance-Induced Anxiety Disorder: Michael
o Clinical Manifestations: After using methamphetamine, Michael experience severe anxiety, paranoia, and
hallucinations
o Behaviors: He becomes agitates, paranoid, and may exhibit aggressive behavior
o Assessment Findings: Dilated pupils, rapid heartbeat, and erratic behavior following substance use
• Anxiety due to Nonpsychiatric Medical Condition
o Symptoms of anxiety results from physiological changes associated with medical condition
o What are some of the examples? Someone with asthma which leads to breathlessness and often
frequent panic attacks (they start to worry about feeling of breathlessness and it increases their
respiratory rate)
• Anxiety due to Nonpsychiatric Medical Condition: Maria
o Clinical Manifestations: Maria has anxiety as a result of her chronic respiratory disease, which leads to
breathlessness and frequent panic attacks
o Behaviors: She avoids activities that trigger breathlessness and becomes socially isolated
o Assessment Findings: Elevated respiratory rate, panic attacks, and constant fear of breathlessness
• Other Anxiety Disorders
o Obsessive Compulsive Disorder (OCD)
o Trauma and Stressor Related Disorder
o Somatic Symptom and Related Disorders
o Dissociative Disorders
• Obsessive Compulsive Disorder (OCD)
o Obsessions – thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from
the mind
o Compulsions – ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety
o In order to be diagnosed with OCD must have both obsessions and compulsions
 • Obsessive Compulsive Disorder: Alex
o Clinical Manifestations: Alex experiences intrusive thoughts about contamination and performs extensive
hand-washing rituals
o Behaviors: He washes his hands repeatedly, spends hours on cleaning, and can’t focus on anything else
o Assessment Findings: Dermatitis from excessive hand-washing, signs of anxiety and distress during the
rituals
• Trauma and Stressor related Disorder
o Acute Stress Disorder: occurs within 1 month of highly traumatic event; it resolves within 4 weeks
o Post Traumatic Stress Disorder: emotional response to traumatic event or situation involving severe
environmental stress; people with PTSD re-experience the traumatic event
• Trauma and Stressor related Disorder: Laura
o Clinical Manifestations: Laura is a war veteran with post-traumatic stress disorder (PTSD). She has
flashbacks, nightmares, and heightened arousal
o Behaviors: She avoids reminders of the trauma, experiences intense distress, and struggles with sleep
disturbances
o Assessment Findings: Laura’s flashbacks, hypervigilance and distress when discussing or encountering
triggers related to her traumatic experiences
• The Nursing Process
o How would you assess and what would you assess for in a patient with an anxiety disorder?
o What are potential nursing diagnoses for anxiety disorders?
o What are some nursing interventions? Quiet space, use clear simple language, calm voice, speak slowly,
recognize the person is distress without judgement, stay with the person
• Application of the Nursing Process
o Implementation
▪ Determine the level of anxiety ▪ Health teaching and health promotion
▪ Psychological intervention ▪ Milieu therapy
▪ Counselling ▪ Promotion of self-care activities
• Implementation
o Advanced interventions
▪ Cognitive therapy
▪ Behavioral therapy
• Modelling • Flooding
• Systemic • Response prevention
desensitization • Thought stopping
▪ CBT (cognitive behavioral therapy) and Somatic therapy
o Pharmacological interventions
▪ Antidepressants ▪ Other classes
▪ Anti-anxiety drugs
MODULE 11: SOMATIC SYMPTOM AND DISSOCIATIVE DISORDERS

• Somatic Disorders (Clinical Picture)

o Somatic symptom disorder (SSD)
o Illness anxiety disorder (previously hypochondriasis)
o Conversion disorder (also called functional neurological symptom disorder)
o Psychological factors affecting medical condition
o Factitious disorder
• Somatic Symptom Disorder (SSD)
o Characterized by physical symptoms that can’t be explained (no medical explanation)
o Symptoms are distressing to patients (usually pain with no diagnosis – blood work and other tests are
normal)
o Patient suffering (pain) is authentic
o How do you think patients with undiagnosed somatic symptom disorder may be treated by health care
staff? How do you think this makes patients feel?
o As nurses we need to be empathetic and understand that their pain is real
• Illness Anxiety Disorder (hypochondriasis)
o Misinterpretation of physical sensations
o Over concerned for health and preoccupied with symptoms and physical sensation
o Extreme worry and fear
o May have s&s of disease and fear (of being diagnosed with something from pain or dizziness, etc.)
o They would look up (google) their symptoms and constant seek of doctor to be diagnosed with
something
• Conversion Disorder
o Also known as functional neurological symptom
o Characterized with having neurological symptoms in absence of a neurological diagnosis
o Symptoms may include paralysis, blindness, movement and gait disorders, numbness, loss of hearing, or
episodes resembling epilepsy
• Factitious Disorder
o Serious mental disorder in which someone deceives others by appearing sick or by purposely getting sick
or by self injury
o Usually have some sort of neglect in childhood where the child will get attention of some sort or the
child was very sick and got so much attention from their family
o Artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury
o Do not have any physical symptoms
o Single or recurrent
o Motivated goal to assume a sick role
o Munchausen’s Syndrome by Proxy: A caregiver deliberately feigns illness in a vulnerable dependent
▪ The caregiver want the people they are giving care for to remain sick so they can give care to
them
▪ Britney’s mom gives her small doses of poison in order for her to remain sick to the point where
she was wheelchair bound, had g-tubes and ng-tubes (she ended up killing her mom in the end)
• Psychological Factors Affecting Medical Condition
o Attitudes or behaviors have a negative effect on a medical disorder; such as cardiovascular,
gastrointestinal, neurological, and rheumatological disorders, cancers
o Diagnosed if a psychological factor clearly affects how a disorder progresses
o Takes a long time (may be suffering from symptoms for years) to be diagnosed
o Diagnosed by psychiatrist and work closely with the patient
o Example: severe stress can temporarily weaken the heart or chronic work-related stress can increase the
risk of high blood pressure
o Time consuming and expensive in order to find the support needed
o Usually there are severe stress or trauma early on life that are reflected by their symptoms
• Dissociative Disorder
o Occur after significant adverse experiences or traumas (military or spent time in the war, aggressive
fight, rape, etc.)
o Individuals respond to stress with severe interruption of consciousness
o Unconscious defense mechanism
o Protects individual against overwhelming anxiety through emotional separation
• Dissociative Disorders (Clinical Picture)
o Depersonalization/Derealization disorder
o Dissociative amnesia
o Dissociative identity disorder
o Sometimes you can get all 3 in 1 patient
• Depersonalization/Derealization Disorder
o May cause a person to feel mechanical, dreamy like, or detached from the body
o May experience depersonalization, derealization or both
▪ Depersonalization – focus on self
▪ Derealization – focus on outside world
o They feel like dreamlike, sort of not part of their person anymore as way to unplug from the trauma
• Dissociative Amnesia
o Inability to recall important personal information
o Often of traumatic or stressful nature
o Autobiographical memory is available, but the information is not accessible
o Common with accidents
o Brain’s way to protect ourselves from the traumatic event
o Improves but can stay for a long time
o For example: they went out to grab coffee but does not remember that at all
• Dissociative Identity Disorder (Multiple personality disorder)
o Presence of two or more distinct personality states
o Usually with some sort of personality disorder
o Very real to patients
o Takes time, lots of therapy, cognitive therapy
o Each alternate personality (alter) has own pattern of:
▪ Perceiving
▪ Relating to
▪ Thinking about the self and environment
• Nursing Process – Assessments
o What would you assess in someone who has a diagnosis of a dissociative identity disorder?
▪ Identity and memory
• Signs of dissociation
• History of similar episode in the past
▪ Past abuse, trauma, loss of child
▪ Mood, level of anxiety
▪ Psychosocial assessment – support system
▪ Self harm history or risk
• Nursing Process – Interventions
o Determining levels of distress
o Counselling
 o Milieu therapy – safe environment and therapeutic relationship, building routine (ADLs, activities,
communication)
▪ Environmental process that focuses on routine
o Promotion of self-care activities
o Grounding exercises – tapping feet, massaging heads, clapping hands (to get back into your body)
▪ Usually used for dissociative disorder
o Pharmacological interventions (antidepressants and anti-anxiety drugs)
o Advanced interventions (behavioral therapy, cognitive therapy, cognitive behavioral therapy)

MODULE 12 Part A: EATING DISORDERS

• Canadian Stats on Eating Disorders (ED)

o Approximately 1 million Canadian have an ED diagnosis
o High mortality rate of estimated between 10-15%
o Suicide is the second leading cause of death (after cardiac disease) of someone suffering from anorexia
o 20% with anorexia and 25-35% with bulimia attempt suicide in their lifetime
o Females aged 12-24 suffering from anorexia have a 12x greater mortality rate than all other deaths
combined
o 12-30% of females and 9-24% of males aged 10-14 are using dieting to lose weight
o Incidence of ED in children is estimated to be 2-4x greater than type 2 diabetes
• Although it is in our nature to binge or restrict eating but eating disorders have a pattern and does not know the
difference of what is normal and abnormal behavior

• Anorexia Nervosa – the refusal to maintain a minimally normal weight for their height and express an intense
fear of gaining weight
• Possible S&S of Anorexia Nervosa
o Low eight o Impaired renal functions – due to fluid and
o Amenorrhea electrolyte imbalance
o Yellow skin o Hypokalemia
o Lanugo o Anemia
o Cold extremities o Decreased bone density
o Peripheral edema (hypoalbuminemia) o Will have a restricting pattern to their eating (low
o Muscle weakening calorie diet) = early signs
o Constipation
• Medical complications of Anorexia Nervosa:
o Can go through periods of delirium, dementia because the mind is truly shutting down
o They get worse before they get better (mental health aspect)
• Bulimia Nervosa – characterized by the repeated binge eating followed by compensatory behaviors such as self-
induced vomiting, misuse of medications (laxatives and diuretics), fasting, or excessive exercise
o 1000 to 5000 calories in one sitting of binging
o They won’t remember eating that many food as a way to dissociate from the event
o Very good at hiding it
o Feeling of heaviness and that they want to get is out of their system which is why they purge
• Possible S&S of Bulimia Nervosa
o Normal to slightly low/high weight o Swelling in stomach area
o Weight loss, aversion to food, restriction o Parotid swelling
of exercise o Gastric dilation, rupture
o Molars or back of teeth can rot because o Calluses, scars on hand (Russell’s signs)
of the stomach acid o Peripheral edema
o Dental caries, tooth erosion o Muscle weakening
o Inside of their mouths can be scaly from o Cardiovascular abnormality
intense vomiting o Cardiac failure
• Medical complications of Bulimia Nervosa?
• Binge Eating Disorder – characterized by repeated episodes of binge eating, then significant distress
(uncontrollable need to eat because of restriction)
• Etiology:
o Biological factors (genetics, neurological)
o Psychological factors
o Environmental factors
• Epidemiology/ Co-morbidity
o Many people with disordered eating patterns do not present for help
o Statistics do not reflect the magnitude of the problem
o Incidence: women o Incidence: men
▪ Anorexia nervosa – 0.9% ▪ Anorexia nervosa – 0.3%
▪ Bulimia nervosa – 1.5% ▪ Bulimia nervosa – 0.5%
▪ Binge eating disorder – 3.5% ▪ Binge eating disorder – 2%
• Assessment
o Perception of problem o Values attached to a specific shape and weight
o Eating habits o Interpersonal and social functioning
o History of dieting o Mental status and physiological parameter
o Methods used to achieve weight control
• Diagnosis
o Imbalanced nutrition o Low self-esteem
o Decreased cardiac output o Disturbed body image
o Risk for injury o Ineffective coping
o Risk for imbalanced fluid volume o Powerlessness
o Anxiety o Hopelessness
• Interventions
o Acute care o Psychosocial interventions
▪ Physical ▪ Weight restoration programs
▪ Psychological ▪ Milieu therapy
▪ Social
o Pharmacological interventions: SSRIs, antianxiety
 o Health teaching and health promotion
o Counselling
o Advanced Practice Interventions: psychotherapy

MODULE 12 Part B: DISORDERS OF CHILDREN & ADOLESCENTS

• Introduction
o 14-25% of Canadian children and youth meet the diagnostic criteria for at least one mental disorder
o Suicide is the 2nd leading cause of death among children and youth
▪ 5-6x greater rate in Aboriginal communities
o Disruption to normal pattern of childhood development
o Difficulty diagnosing
o 2/3 of children and youth with mental health problems not receiving treatment
o Lack of services and premature termination of treatment
• Etiology & Risk Factors
o Biological factors
▪ Genetics ▪ Temperament
▪ Brain development and ▪ Resilience
biochemical (big impact)
o Environmental factors
▪ Cultural factors
• Assessment Data
o Usually by a psychiatrist with several visits (usually does not want to put label on the child)
o History of present illness o Medical history
o Developmental history o Family history
o Developmental assessment o Mental Status Examination
o Neurological assessment
• Many “risk factors” can lead to developmental of mental illnesses
• Characteristics of a “resilient child”
• Neurodevelopmental Disorders
o Intellectual Disorders – problem solving, reasoning, judgment, communication, self-care activities and
social participation
o Communication Disorders – expressive or receptive (dyslexia, etc)
o Autism Spectrum Disorder
▪ Evident in first 3 years of life
▪ Issues with social interaction and communication skills
o Attention Deficit/ Hyperactivity Disorder – inattention, impulsiveness and hyperactivity
o Specific learning disorder
▪ Dyslexia (reading)
▪ Dyscalculia (mathematics)
▪ Dysgraphia (written expression)
o Motor disorder
▪ Stereotypic movement disorder
▪ Tourette’s Disorder
• Disruptive, Impulse Control and Conduct Disorder
o Oppositional defiant disorder – characterized by negativistic, disobedient, hostile, defiant behavior
towards authority figures which may violate the basic rights of others
 o Conduct disorder – characterized by a persistent pattern of antisocial behavior (brain can’t handle a lot
of people in one go; too overwhelming)
• Anxiety Disorders
o Separation anxiety disorder – tends to be in the younger years (when going to school)
o Generalized anxiety disorder
• Other Disorders
o Depressive disorder and bipolar and related disorder
▪ Bipolar – hard/tricky to diagnose; usually don’t have s&s until after puberty age 20 or 21 (can
take years to find the right medications)
o Post Traumatic Stress Disorder – defense mechanism of body from a trigger of stress or trauma
o Feeding and eating disorders – from trauma or environment if things get out of control
• Nursing Diagnosis
o Ineffective coping
o Self harm
o Detachment
• General Interventions for Children and Adolescents
o Family therapy o Play therapy
o Group therapy o Therapeutic drawing
o Behavioral therapy o Music therapy
o Cognitive-behavioral therapy o Psychopharmacology
o Disruptive behavior management o Team work and safety
o Time out o Animal therapy
o Quiet room