Comprehensive Notes on Mood Disorders, Psychopharmacology, and Clinical Grief Management

Obsessive-Compulsive Disorder (OCD) Fundamentals

  • Terminology and Definitions:

    • Obsession: Recurrent and persistent thoughts that the individual cannot stop thinking about, often causing distress.
    • Compulsion: Repetitive behaviors or mental acts that a person feels driven to perform to alleviate the tension caused by an obsession.

  • The OCD Cycle:

    • Example: An individual has a superstitious thought: "If I don't tap this three times, I will have bad luck."
    • Mental Struggle: The person realizes the thought is ridiculous and tries to dismiss it, but the obsession persists.
    • Function of the Compulsion: Performing the act (the compulsion) dispels the tension of the obsession. However, this does not resolve the underlying issue.
    • Escalation: The ritual often expands. Tapping three times may lead to tapping four times, then five, and potentially up to 6060 times, becoming highly disruptive to daily life.

  • Treatment Context:

    • Traditionally, OCD is treated through behavioral therapy.
    • The introduction of medications that have an effect on OCD is a significant development in the field.

Advanced Psychopharmacology and Clinical Considerations

  • Newer Antidepressants:

    • Pristiq (Desvenlafaxine): Described as a newer version of Venlafaxine (Effexor). It comes in a unique square-shaped capsule that opens from the inside to inject its contents, leaving the outer shell to pass through the GI tract. It is increasingly appearing in clinical practice.

  • Metabolic Effects (Weight Change):

    • Weight Gain: Most antidepressants are associated with weight gain.
    • Weight Loss: Wellbutrin (Bupropion) is the only antidepressant typically associated with minor weight loss.
    • Neutral: Prozac (Fluoxetine) is generally considered neutral regarding weight gain or loss.
    • Clinical Application: If a patient has Depression and Anorexia Nervosa, Wellbutrin should be avoided to prevent further weight loss. Conversely, if a patient is highly preoccupied with weight gain for medical or self-concept reasons, Prozac or Wellbutrin may be preferred to ensure medication adherence.

  • Legacy and Specific Use Medications:

    • Amitriptyline: An older tricyclic antidepressant (TCA) still commonly prescribed, particularly for neurological pain disorders.
    • Emsam (Selegiline): A transdermal MAOI patch added to treatment regimens due to its unique delivery and efficacy profile.

Discontinuation Syndrome vs. Serotonin Syndrome

  • Discontinuation Syndrome (Non-Emergency):

    • Cause: A sudden decrease in serotonin levels, typically following a missed dose or abrupt cessation of medication.
    • General Rule: Stopping a medication often produces the opposite effect of the drug's purpose (e.g., stopping an antidepressant causes depression; stopping opioids like heroin causes insomnia and diarrhea instead of sleepiness/constipation).
    • Symptoms:
      • Fatigue and lack of motivation.
      • Myalgia: Muscle pain (prefix myo- meaning muscle; suffix -algia meaning pain).
      • Anxiety and Emotional Lability (unstable emotions).
      • Brain Zaps: Sensations of electricity in the brain, most common with SNRIs.

  • Serotonin Syndrome (Medical Emergency):

    • Cause: Excess serotonin in the system. Often results from double-dosing accidentally or the concurrent use of multiple serotonergic medications.
    • Serotonergic Medications to Watch:
      • Antidepressants mixed with Reglan (Metoclopramide) for nausea.
      • Antidepressants mixed with Ritalin.
    • Prioritization (NCLEX Application):
      • Standard Priority: ABCs (Airway, Breathing, Circulation) first, then Maslow’s Hierarchy (Safety).
      • Hyperthermia: The most dangerous symptom. High temperatures (107∘F107^{\circ}\text{F}) can cause seizures and strokes.
      • Other Symptoms: Diaphoresis (sweating), tremors (can lead to seizures), and diarrhea (can lead to dehydration/death on a long timeline).

  • Clinical Signs of Fever:

    • Normal: 98.6∘F98.6^{\circ}\text{F}.
    • Pre-febrile: 98.6∘F98.6^{\circ}\text{F} to 99.9∘F99.9^{\circ}\text{F}.
    • Medically Significant Fever: 100∘F100^{\circ}\text{F} or higher.

Non-Pharmacological Interventions and Therapies

  • Cognitive Behavioral Therapy (CBT):

    • Developed by Aaron Beck.
    • Focuses on the relationship between thoughts, feelings, and behaviors.
    • Self-fulfilling Prophecy: Distorted thoughts (e.g., "I am unlovable") lead to negative behaviors and distorted interpretations of the environment (e.g., viewing a kind gesture as manipulation).

  • Brief Solution-Focused Therapy (BSFT):

    • Used in acute settings like the Psychiatric Emergency Department (ED).
    • Aims to address "what we can fix in the next fifteen minutes to fifteen hours" rather than long-term psychoanalysis of childhood.

  • Group and Family Therapy:

    • Group therapy is a required standard on psychiatric units.
    • Family therapy is rarer inpatient but often involves at least one family meeting.

  • Clinical Management of Suicidality:

    • Includes fifteen-minute checks, one-to-one observation, and environmental safety.
    • This is formally considered a "treatment" or "therapy."

Electroconvulsive Therapy (ECT)

  • Overview: Despite limited understanding of why it works, ECT involves inducing a controlled grand mal seizure to treat severe depression.

  • Seizure Threshold and Benzodiazepines:

    • Seizure Threshold: The level of neuronal activity required for the body to seize.
    • Benzodiazepine Effect: Meds like Ativan, Xanax, and Valium raise the seizure threshold, making it harder to induce a therapeutic seizure.
    • Nursing Protocol: Hold all benzodiazepines from midnight/after the HS (hour of sleep) dose prior to ECT.

  • The Procedure:

    • Conducted under general anesthesia.
    • Started with Unilateral ECT (one electrode on a temple); if ineffective, Bilateral ECT is used.
    • Seizure Duration: Acute phase lasts about 1515 seconds; reverberation lasts 90−12090-120 seconds.

  • Post-Procedural Concerns:

    • Headache: Caused by muscle clenching (masticator, buccinator, temporalis) during the induced seizure, not the electricity itself.
    • Short-term Memory Loss: A common side effect.

  • Pre-ECT Medications:

    • Muscle Relaxer: To prevent fractures or ligament tears from intense clenching.
    • Atropine: To stabilize heart rhythm.
    • Robinul (Glycopyrrolate): An anticholinergic used to dry secretions and prevent aspiration while under anesthesia.

Developmental Presentations of Depression

  • Children:

    • Somatic Complaints: Children often report physical pain (back, stomach) rather than sadness because their bodies are usually resilient and "rubbery."
    • Irritability: Common presentation, especially in boys.
    • Social Withdrawal: Must differentiate from shyness or Autism Spectrum Disorder.
    • Separation Anxiety: Significant if it persists for six months or longer.
    • Medication: Very small doses of Sertraline (Zoloft) are the choice for children.

  • Older Adults:

    • Depression often looks like dementia due to confusion and psychomotor slowing (Pseudodementia).
    • Differentiation: Dementia develops over years; depression-induced confusion can have a rapid onset (one month).
    • Requires Occupational Therapy (OT) consults for functional assessments (making a sandwich, stairs).

Comparative Mood Disorders

  • Persistent Depressive Disorder (PDD):

    • Formerly called Dysthymia.
    • Chronic low mood lasting for more than two years without a severe acute episode (e.g., no suicide attempts or ER visits).
    • High risk if onset is before age 2121; often persists for decades.

  • Bipolar Disorder Spectrum:

    • Bipolar I: Characterized by full mania and major depression.
    • Bipolar II: Characterized by major depression and Hypomania (less severe elevation).
    • Hypomania: Enthusiastic, positive, but not as functionally destructive as mania. Mania includes pressured speech (propulsive, clipping words, thoughts moving faster than speech).

The Grief Process

  • Definitions:

    • Grief: A natural, necessary system for coping with psychological loss.
    • Freud’s Mental Economics: Grieving is disassembling a relationship "brick by brick" to eventually build something new.

  • Grief vs. Depression:

    • Normal grief onset is within two months of loss; the acute phase typically resolves within two months.
    • Symptoms lasting longer than two months may indicate the transition into major depression.

  • Types of Grief:

    • Anticipatory Grief: Knowing a loss is coming (e.g., terminal cancer). Allows for healing conversations.
    • Persistent Complex Bereavement Disorder: Grief that does not resolve after two months; ritualized behaviors (e.g., buying food for the deceased).
    • Disenfranchised Grief: Grief not acknowledged by society (loss of a pet, young love/breakups, public tragedy).
    • Public Tragedy: Events like 9/11 or COVID-19. Unique because everyone is going through it, making it difficult to find an impartial "helper."

  • Five Stages of Grief (Elizabeth Kübler-Ross):

    • Denial, Bargaining, Rage, Despair, Acceptance.
    • These stages are non-linear; individuals can move forward, backward, or skip stages.