4. Emotional Responses and Mood Disorders

MOOD - inner tone of emotion. Synonymous with the term feeling.

C. EMOTIONAL RESPONSES and MOOD DISORDERS

CONTINUUM OF EMOTIONAL RESPONSE

Adaptive Response Maladaptive Response

Emotional responsiveness

Uncomplicated grief reaction

Suppression of emotion

Delayed Grief Reaction

Depression / Mania

EMOTIONS – Content (Fear, Joy, Love, Anger, Sadness, Surprise, Happiness)

I. GRIEF REACTION


GRIEF – is a normal subjective reaction to life experiences (loss)

• Universal. •Loss could be in the form of death, separation, loss of job, a cherished possession, status or object.

•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.

•Grieving becomes abnormal and maladaptive if something has prevented it from running its normal course.

I. GRIEF REACTION


Theorist STAGES / PHASESC.M. Parks I.

AlarmII.

DenialIII.

Searching / Barter

IV. Hopelessness / Helplessness

V. Recovery

John Bowlby

I. Denial,

Numbness

II. Yearning

III. Cognitive

disorganization and emotional

despair

IV. Reorganizing Reintegrating

Elizabeth Kubler-Ross

I. DenialII. Anger

III. Bargaining

IV. Depression

V. Acceptance

I. GRIEF REACTION


TWO TYPES OF PATHOLOGICAL GRIEF:1. Delayed Grief Reaction:Undue delay in mourning may be caused by persistent

absence of any emotion. The emotions associated with the loss may be triggered by deliberate recall of circumstances

This can be manifested by the following:Excessive hostilityProlonged feeling of emptiness /numbnessUse of present tense, instead of past tense when referring to loss objectRetention of clothing of the deceased or loss objectInability or refusal to visit grave of the deceased

I. GRIEF REACTION


2. Distorted Grief Reaction

An abnormal extension or over elaboration of sadness and grief.

This pathological grief reaction is known as depression or melancholia

II. DEPRESSION & SUICIDE


DEPRESSION – Psychophysiological deactivation

It 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.

Aspects accompanying depression:AnxietySomatic complaints



DSM-IV-TR DIAGNOSTIC CRITERIA: SYMPTOMS OF 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 situationHopelessnessHelplessness

Physiological: Unintentional weight change of 5% or more in a monthChange in sleep pattern

Cognitive: Inability to concentrate, think, focus or make decisionsSuicidal

Behavioral: Agitation or psychomotor retardationTiredness



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 is 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….”



Suicidal Behaviors:Suicide attempt

Any self-directed actions taken by a person that will lead to death if not stopped

Completed suicideOr simply suicide, is death resulting from self-inflicted injury



PREDISPOSING FACTORS:Psychiatric Diagnosis:

Mood disordersAnxiety disorderSubstance abuseSchizophreniaPersonality traits

HostileImpulsive

Depression

Psychosocial and Environmental factors:

Lack of social support/ support system

Negative life eventsChronic medical illness

Family History:Identification and imitation

of actions of family membersBiochemical Factor: Serotonin

III. MANIA


Psychophysiological activation. The predominant mood is elevated or irritable or hyperactive.

In contrast with depressed patients, manic patients are extremely self-confident with an ego that knows no bounds.

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

III. MANIA


Diagnostic Criteria for Manic EpisodesAt least three of the following must be present to a significant degree at least 1x a week:

Grandiosity (inflated self esteem)Decreased need for sleepPressured speechFlight of ideasDistractibilityPsychomotor agitationExcessive involvement in pleasurable activities without regard for negative consequences (hypersexuality, hyperactivity)

BIPOLAR DISORDER


BIPOLAR I DISORDEROne or more manic or mixed episodes usually accompanied by one depressive disorder

BIPOLAR II DISORDEROne or more major depressive episodes accompanied by at least one hypomanic episode

BIPOLAR MIXEDCycles alternate between periods of mania, normal mood, depression, normal mood, mania and so forth.

BEHAVIORS RELATED TO MOOD DISORDERS


1. 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

2. HOSTILITY AND AGGRESSION – anger expressed through verbal and physical behavior like attack, assault and violence



PHASES OF AGGRESSION CYCLE1. Triggering Phase – Muscular tension

Changes in voice quality, Pacing, Non-complianceRestlessness, irritability, Glaring

2. Escalation phase – movement towards loss of control

3. Crisis Phase – Full blown “acting out”. Fighting, hitting, kicking,

scratching, throwing things4. Recovery Phase –

Cooling down5. 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 patient2. Excessive stimuli – overcrowding3. Excessive or unfair restrictions of rights and privileges4. Lack of resources for excessive energy5. Patient’s perception of lack of control of life and freedom6. Boredom – Lack of structured and unstructured activities4. Hallucinations5. Manipulative behavior


NURSING DIAGNOSIS:1. Ineffective coping mechanism2. Potential for violence directed to self / others3. Dysfunctional grieving4. Hopelessness5. Powerlessness6. Altered role performance7. Altered Self-esteem8. Social isolation9. Sleep pattern disturbance10.Self-care deficit11.Altered nutrition


Treatment Phase1. Acute Treatment Phase - the goal is to eliminate the symptoms. If patients improve with treatment, they are said to have had a therapeutic response. (Pharmacotherapy)

2. Continuation Treatment Phase – the goal is to prevent relapse (return of symptoms), and to promote recovery (Supportive Interventions – Counseling, Group Therapy)

3. Maintenance Treatment Phase – the goal is to prevent recurrence of a new episode of illness. (Pharmacotherapy and Supportive Interventions)


Specific Nursing Interventions:

Somatic therapy: Electro Convulsive Therapy Initiated by Hugo Cerletti (1938)Series of Treatment: 2-3x a week for 6-12/15 treatmentsIndications:• Severe depression, Mania• Bipolar• Catatonia• Schizophrenia

Conditions that do not respond to ECT:• Anxiety Disorder• Personality Disorder• Somatoform Disorder• Phobic Disorder



High Risk Conditions:• Recent M.I. or CVA, Angina Pectoris, CHF• ICP, Glaucoma, Retinal Detachment• Severe Pulmonary Disease• Major Bone Fracture• Thrombophlebitis• (Pregnancy)

Side Effects: Headache; Disorientation; and Temporary memory loss

Electrical dose: 800 milliamps in 1 to 6 secondsEffective seizure: 30sec to 1 minute 10 to 15 minutes: patient is awake



1. Types:a. Modified / Unmodifiedb. Unilateral / Bilateral

2. Nursing Responsibilities:Pre-ECTIntra-ECTPost-ECT

4. Emotional Responses and Mood Disorders

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