Depressive Disorders

Depressive Disorders 150 150 Tony Guo

Depressive Disorders

  • Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses.
  • Transient symptoms are normal, healthy responses to everyday disappointments in life.
  • Pathological depression occurs when adaptation is ineffective.
  • Depression is an alteration in mood/affect that is expressed by feelings of sadness, despair, and pessimism.

 

Epidemiology 

  • 6.7% of persons aged 18 or older had at least one major depressive episode in the previous year.
  • Gender prevalence
    • Depression is more prevalent in women than in men by about 2 to 1.
  • Age and gender
    • Lifetime prevalence of depressive disorders is higher in those aged 45 years or younger.
  • Social class 
    • There is an inverse relationship between social class and the report of depressive symptoms.
  • Race and culture
    • No consistent relationship between race and affective disorder has been reported.
    • Problems have been encountered in reviewing racial comparisons.
  • Marital status
  • Single and divorced people are more likely to experience depression than are married persons or persons with a close interpersonal relationship (differences occur in various age groups).
  • Seasonal interaction
  • There is evidence that supports a seasonal decrease in social interactions during Fall and Winter seasons which may result in the development of Seasonal Affective Disorder (SAD)

 

Types of Depressive Disorders

  • Major depressive disorder
  • Characterized by depressed mood
  • Loss of interest or pleasure in usual activities
  • Symptoms present for at least 2 weeks
  • No history of manic behavior
  • Cannot be attributed to use of substances or another medical condition
  • Persistent depressive disorder (dysthymia)
    • Sad or “down in the dumps”
    • No evidence of psychotic symptoms
    • Essential feature is a chronically depressed mood for 
      • Most of the day 
      • More days than not 
      • At least 2 years
  • Premenstrual dysphoric disorder
    • Depressed mood
    • Anxiety 
    • Mood swings 
    • Decreased interest in activities
    • Symptoms begin during the week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses.
  • Substance- or medication-induced depressive disorder
    • Considered to be the direct result of physiological effects of a substance
  • Depressive disorder associated with another medical condition
    • Attributable to the direct physiological effects of a general medical condition

 

Predisposing factors to depression

  • Biological theories
    • Genetics 
      • Hereditary factor may be involved
  • Biochemical influences 
    • Deficiency of norepinephrine, serotonin, and dopamine has been implicated.
    • Excessive cholinergic transmission may also be a factor.
  • Neuroendocrine disturbances
    • Possible failure within the hypothalamic-pituitary-adrenocortical axis
    • Possible diminished release of thyroid-stimulating hormone
  • Physiological influences
    • Medication side effects
    • Neurological disorders
    • Electrolyte disturbances
    • Hormonal disorders
    • Nutritional deficiencies
    • Other physiological conditions
    • The role of inflammation
  • Psychoanalytical theory 
    • A loss is internalized and becomes directed against the ego.
  • Learning theory
    • The individual who experiences numerous failures learns to give up trying.
  • Object loss theory
    • Experiences loss of significant other during first 6 months of life
    • Feelings of helplessness and despair
    • Early loss or trauma may predispose client to lifelong periods of depression.
  • Cognitive theory
    • Views primary disturbance in depression as cognitive rather than affective.
    • Three cognitive distortions that serve as the basis for depression.
      • Negative expectations of the environment
      • Negative expectations of the self
      • Negative expectations of the future

 

Development Implications

  • Childhood depression
    • Symptoms
      • < Age 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness
      • Ages 3 to 5: Accident proneness, phobias, excessive self-reproach
      • Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior
      • Ages 9 to 12: Morbid thoughts and excessive worrying
    • Precipitated by a loss
    • Focus of therapy: Alleviate symptoms and strengthen coping skills
    • Parental and family therapy
  • Adolescence
    • Symptoms include
      • Anger, aggressiveness
      • Running away
      • Delinquency
      • Social withdrawal
      • Sexual acting out
      • Substance abuse
      • Restlessness, apathy
    • Best clue that differentiates depression from normal stormy adolescent behavior
      • A visible manifestation of behavioral change that lasts for several weeks.
    • Most common precipitant to adolescent suicide 
      • Perception of abandonment by parents or close peer relationship
    • Treatment with
      • Supportive psychosocial intervention
      • Antidepressant medication
  • For instance, a child who fell a flight of stairs would have a fear of heights in the future.

 

Anxiety Disorder Due to another Medical Condition

  • Medical conditions that may produce anxiety symptoms include
    • Cardiac
    • Endocrine 
    • Respiratory 
    • Neurological

 

Substance- or Medication-Induced Anxiety Disorder

  • May be associated with intoxication or withdrawal from any of the following substances:
  • Alcohol, sedatives, hypnotics, or anxiolytics
  • Amphetamines or cocaine
  • Hallucinogens
  • Caffeine
  • Cannabis
  • Others

 

Obsessive-Compulsive Disorder (O C D)

Assessment data

  • Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment

Obsessions

  • Recurrent thoughts, impulses, or images experienced as intrusive and stressful, and unable to be expunged by logic or reasoning

Compulsions

  • Repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation

 

Body Dysmorphic Disorder

Assessment

  • Characterized by the exaggerated belief that the body is deformed or defective in some specific way
  • If true defect is present, the person’s concern is unrealistically exaggerated and grossly excessive.
  • Symptoms of depression and obsessive-compulsive personality are common.

 

Hair-Pulling Disorder (Trichotillomania)

Assessment

  • The recurrent pulling out of one’s own hair that results in noticeable hair loss
  • Preceded by increasing tension and results in sense of release or gratification
  • The disorder is not common, but it occurs more often in women than in men.

 

Hoarding Disorder

Assessment

  • The persistent difficulty discarding possessions regardless of their value.
  • Additionally, there can be a need for excessive acquiring of items (by purchasing or other means).
  • More men than women are diagnosed with this disorder.

 

Predisposing factors to O C D and Related disorder

Psychoanalytic theory

  • Clients with O C D have weak, underdeveloped egos.
  • Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt.

Learning theory

  • Conditioned response to a traumatic event
  • Passive avoidance
  • Active avoidance

Psychosocial influences related to trichotillomania

  • Stressful situations
  • Disturbances in mother–child relationship
  • Fear of abandonment
  • Recent object loss
  • Possible childhood abuse or emotional neglect

Biological aspects

  • Genetics: Possible with trichotillomania
  • Neuroanatomy: Possible abnormalities in basal ganglia and orbitofrontal cortex with O C D
  • Physiology: Some individuals with O C D exhibit electroencephalogram changes.
  • Biochemical factors: Possible decrease in serotonin with O C D and body dysmorphic disorder

 

Diagnosis/Outcome identification

  • Nursing diagnoses commonly associated with anxiety, O C D, and related disorders
    • Panic anxiety (panic disorder and G A D)
    • Powerlessness (panic disorder and G A D)
    • Fear (phobias)
    • Social isolation (agoraphobia)
    • Ineffective role performance (O C D)
    • Ineffective coping (O C D)
    • Disturbed body image (body dysmorphic disorder)
    • Ineffective impulse control (hair-pulling disorder)

Outcome: The Patient

  • Is able to recognize signs of escalating anxiety and intervene before reaching panic level (panic and G A D)
  • Is able to maintain anxiety at manageable level and make independent decisions about life situation (panic and G A D)
  • Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder)
  • Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety (phobic disorder)
  • Is able to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior (O C D)
  • Demonstrates more adaptive coping strategies for dealing with anxiety than ritualistic behaviors (O C D)
  • Verbalizes a realistic perception of his or her appearance and expresses feelings that reflect a positive body image (body dysmorphic disorder)
  • Verbalizes and demonstrates more adaptive strategies for coping with stressful situations (hair-pulling disorder)

 

Planning/Implementation

  1. Panic Anxiety: Real or perceived threat to biological integrity or self-concept and evident any or all of the physical symptoms identified by the DSM-5
  • Maintain calm, nonthreatening approach.
  • Keep the immediate surroundings low in stimuli.
  • Teach the client signs of escalating anxiety.
  1. Fear: Causing embarrassment to self in front of others, being in a place from which one is unable to escape, or a specific stimulus and evident by behavior directed towards avoidance of the feared object or situation
  • Include the client in making decisions.
  • Encourage the client to explore underlying feelings.
  1. Ineffective Coping: Undeveloped ego, punitive superego; avoidance learning; possible biochemical changes and evident by ritualistic behavior or obsessive thoughts
  • Initially meet the client’s dependency needs.
  • Provide a structured schedule of activities.
  1. Disturbed Body Image: Repressed severe anxiety and evident by preoccupation with imagined defect; verbalizations that are out of proportion to any actual physical abnormalities that may exist; and numerous visits to plastic surgeons or dermatologists seeking relief
  • Help client see his or her body image is distorted.
  • Involve client in activities that reinforce positive sense of self.
  • Make referrals to support groups.
  1. Ineffective Impulse Control: Possible genetic or biochemical factors; poor parent-child relationship; history of child abuse or neglect and evident by recurrent pulling out of the hair in response to stressful situations
  • Convey a nonjudgmental attitude.
  • Practice stress management techniques.
  • Offer support and encouragement.

 

Client/Family Education

  • Nature of the Illness
  • What is anxiety?
  • To what might it be related?
  • What is O C D?
  • What is body dysmorphic disorder? 
  • What is trichotillomania?
  • Symptoms of anxiety, O C D, and related disorders
  • Management of the Illness
    • Medication management
      • Possible adverse effect
      • Length of time to take effect
      • What to expect from the medication
  • Stress management
    • Teach ways to interrupt escalating anxiety.
    • Teach relaxation techniques.
  • Support Services
    • Crisis hotline
    • Support groups
    • Individual psychotherapy

 

Evaluation

  • Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria.
  • Can the client recognize signs and symptoms of escalating anxiety, and interrupt before it reaches panic level?
  • Can the client demonstrate activities that can be used to maintain anxiety at a manageable level?
  • Can the client discuss the phobic object or situation without becoming anxious?
  • Can the client function in the presence of the phobic object or situation without experiencing panic anxiety?
  • Can the O C D client refrain from performing rituals when anxiety level rises and demonstrate substitute behaviors to maintain anxiety at a manageable level?
  • Can the client with trichotillomania refrain from hair-pulling and substitute a more adaptive behavior when urges to pull hair occur?
  • Does the client with body dysmorphic disorder verbalize a realistic perception and satisfactory acceptance of personal appearance?

 

Treatment Modalities

  • Individual psychotherapy
  • Cognitive therapy
  • Behavior therapy
    • Systematic desensitization
    • Implosion therapy
    • Other non-pharmacologic treatments for anxiety

Treatment Modalities: Psychopharmacology

Classifications of Meds used

  • Selective serotonin reuptake inhibitors (SSRIs)—first line
  • Selective serotonin-norepinephrine reuptake inhibitors (SNRIs)—first line
  • Tricyclic antidepressants
    (TCAs)—second or third line
  • Benzodiazepines
  • β-Blockers

Medication for specific disorders

  • Panic and G A D
    • Anxiolytics
    • Antidepressants
    • Antihypertensive agents
  • O C D and body dysmorphic disorder
    • Antidepressants
  • Phobic disorders
    • Anxiolytics
    • Antidepressants
    • Antihypertensive agents
  • Hair-pulling disorder
    • Chlorpromazine
    • Amitriptyline
    • Lithium carbonate
    • Selective serotonin reuptake inhibitors and pimozide
    • Olanzapine

Examples of anti-anxiety agents

  • Hydroxyzine (Vistaril)
  • Alprazolam (Xanax)
  • Chlordiazepoxide (Librium)
  • Clonazepam (Klonopin)
  • Clorazepate (Tranxene)
  • Diazepam (Valium)
  • Lorazepam (Ativan)

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