Theories of Mental Disorders and Somatoform Disorders

Theories Related to Emotions and Disorders

• Biological causes:
  • Neurotransmitters and hormones are involved in mood regulation.
  • Neurotransmitters: Help nerve impulses go from one nerve cell to another.
  • Monoamines: Longer-acting neurotransmitters that modify the sensitivity of neurons.
  • Pituitary gland: Controls hormones by balancing thyroid and adrenal hormones.
  • Biological rhythms of depressed persons differ from those of nondepressed persons, indicating a biological basis for depression.
  • Depression is related to physical illness, especially chronic conditions.
• Other Theories:
  • Psychoanalytic theories: Mood disorders are seen as anger turned inward.
  • Behaviorists: View depression as a group of learned responses.
  • Social theorists: Consider depression a result of faulty social interactions.
  • Holistic view: Used by health care providers to care for the whole person.

Characteristics of Mood Disorders

• A disorder in a person's mood, expressed in different ways.
  • Mania:
    • Elated, expansive reactions.
    • Irritable but happy.
    • Loss of identity, increased activity, and grandiose thoughts and actions.
  • Depression:
    • Feelings of sadness, disappointment, and despair.
    • Mild: Short-lived, triggered by life events.
    • Moderate (Dysthymia): Persists over time.
    • Major: Severe, lasts longer than two weeks.
      • Symptoms range from paralysis to agitation.
      • Suicidal thoughts may occur.
  • Bipolar Disorder: Two extremes of moods.
    • Bipolar I: Episodes of depression alternate with episodes of mania.
      • More severe form; delusions are common during mania, and hallucinations might occur.
    • Bipolar II: Major depressive episodes alternate with periods of hypomania.
      • Marked by one to two weeks of severe lethargy followed by several days of mania.
  • Cyclothymic Disorder:
    • Repeated mood swings alternating between hypomania and depressive symptoms.
    • A cycling pattern where symptoms start, stop, and then restart.
  • Seasonal Affective Disorder (SAD):
    • Winter depression, from October to April.
    • Lack of sunlight exposure contributes to symptoms.
    • Daily exposure to sunlight or full-spectrum light lessens symptoms.
  • Postpartum Depression:
    • Occurs after childbirth with variable symptoms and levels.
    • Ranges from baby blues (mild, short-term) to postpartum depression and psychosis.
  • Substance-Induced Mood Disorder:
    • Emotional disturbances directly traced to the effects of a chemical substance.

Therapeutic Intervention

• Acute treatment phase: First 6–12 weeks.
• Continuation phase: 4–9 months.
• Maintenance treatment: Indefinite.
• Mood disorders require long-term treatment.
• Current standards include:
  • Psychotherapy
  • Pharmacologic therapy
  • Electroconvulsive therapy (ECT)
    • Requires inpatient facility setting with anesthesiologists involved.
    • Electrical currents affect nerve impulse transmission in the brain.
  • Transcranial direct current stimulation
    • Requires inpatient facility setting with anesthesiologists involved.
    • Electrical currents affect nerve impulse transmission in the brain.
• Antidepressants:
  • Tricyclics
  • Nontricyclics
  • Monoamine oxidase inhibitors (MAOIs):
    • Significant interactions with other medications.
    • Nurses must ensure other medications are safe to administer with MAOIs.
  • SSRIs
  • Atypical antidepressants
    • Require two to four weeks to note effects.
• Antimanics:
  • Lithium
    • Maintain normal sodium levels and hydration.
    • Therapeutic blood level: 0.6 to 1.2
    • The need for lithium decreases dramatically once manic episodes subside.

Nursing Process

• Assess the level of depression or mania.
• Nursing diagnosis and therapeutic interventions are chosen based on the client's most distressing problems, including physical issues.
• Holistic interventions:
  • Physical
  • Emotional
  • Social interaction
  • Intellectual
  • Spiritual

Mood Disorders Overview

• Definition: Psychological disorders characterized by severe disturbances in mood and emotions, most often depression, but also mania and elation.
• Normal Mood Fluctuation vs. Mood Disorders:
  • Normal moods fluctuate.
  • Mood disorders involve extreme fluctuations that impair the ability to function.
• Umbrella Term: Mood disorders is an umbrella term.

Depressive Disorders

• Defining feature: Depression.
• Description: Extremely negative mood and hopelessness that can be so severe that regular drives such as hunger and even sex drives are reduced or eliminated altogether.

Bipolar and Related Disorders

• Defining feature: Mania.
• Description: The exact opposite of depression. Extremely positive mood in which a person is really talkative, has grandiose ideas, thinks they can do anything, has so much energy, and they behave recklessly at the same time.

Major Depressive Disorder (MDD)

• Characterized by:
  • Depressed mood most of the day, nearly every day.
  • Anhedonia: Inability to experience pleasure: a decreased motivation to engage in activities that you used to find enjoyable; and doing those activities, if you can force yourself to do them, isn't really enjoyable either.
• Diagnostic Criteria:
  • Five related symptoms for at least two weeks.
  • Examples:
    • Weight and/or appetite disturbances (extreme weight loss or overeating).
    • Sleep disturbances (insomnia or excessive sleeping).
    • Psychomotor agitation (fidgety and jittery) or retardation (slowed movements and speech).
    • Fatigue or loss of energy.
    • Feelings of worthlessness or guilt.
    • Difficulty concentrating or indecisiveness.
    • Suicidal ideation (thoughts of death, planning or attempting suicide).
• Duration Requirement: Symptoms need to last only for two weeks due to the severity of symptoms like suicidal thoughts.

Subtypes of Depression

• Seasonal Pattern Depression: Symptoms occur only at particular times of the year, e.g., colder months.
• Peripartum Onset Depression: Symptoms occur during pregnancy or in the four weeks following childbirth (postpartum depression).
  • Often accompanied by panic attacks, feelings of guilt, and agitation.
  • Affects approximately 14% of women who give birth.
• Persistent Depressive Disorder:
  • Consistent depression lasting at least two years.
  • Accompanied by at least two symptoms of major depressive disorder.
  • Previously called dysthymia.
  • People generally don't meet criteria for major depressive disorder because the intensity and duration of symptoms are different.

Bipolar Disorder

• Characterized by extreme shifts in mood from one polar opposite to the other. Commonly from mania to depression and back, although it doesn't have to be that way.
  • Requires manic episodes for diagnosis but not necessarily depressive episodes.
  • Previously known as manic depression.
• Manic Episode:
  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least one week.
  • Symptoms:
    • Extremely talkative.
    • Flight of ideas (frequently shifting from one topic to another).
    • Reckless and dangerous behaviors (e.g., not sleeping for days, quitting jobs).
• Rapid Cycling Subtype:
  • Experiencing at least four manic episodes or a combination of four manic and depressive episodes within a single year.

Etiology (Causes) of Mood Disorders

• Biological Factors:
  • Genetic component:
    • Twin concordance rate for major depressive disorder: 50% for identical twins, 38% for fraternal twins.
    • Twin concordance rate for bipolar disorder: 67% for identical twins, 16% for fraternal twins.
  • Imbalance of neurotransmitters (serotonin and norepinephrine).
• Diathesis-Stress Model:
  • Biological factors (diathesis) are accompanied by psychological or environmental factors (stress).
• Cognitive Factors:
  • Cognitive distortions: Viewing problems as much bigger than they really are (catastrophizing).
  • Rumination: Thinking about problems over and over again.
  • Learned helplessness: Negative emotions are accompanied by negative expectations.
• Cognitive Triad:
  • Negative thoughts about:
    • The self (I'm ugly, I'm worthless, I'm a failure).
    • The world (No one loves me).
    • The future (I feel hopeless).

Treatment of Mood Disorders

• Mood Stabilizers:
  • Used when antidepressants are not adequately effective.
  • Examples: Cerebral XR, Ritalopoi, and Gruzla.

Signs Indicating Possible Bipolar Disorder

• Family history of bipolar disorder.
• Depression does not respond to antidepressants.
• Full recovery from a mood stabilizer.

Role of Emotions in Health

• Stress response mechanism (fight or flight) protects during times of threat or illness.
• Physiologic Stress Response:
  • Fight or flight system.
• General Adaptation Syndrome:
  • Biochemical reactions of stress response and their effect on various body systems.

Impact of Stress

• Immune system is affected by stress levels.
• Increased likelihood of getting sick when highly stressed.
• Physical problems arising from psychological sources:
  • Somatoform disorders
  • Psychosomatic disorders
  • Psychophysical disorders

Distinguishing Disorders

• Somatoform Disorder: Physical symptoms with no identifiable physical cause.
• Psychosomatic Disorder: Mental distress manifests as real physical symptoms, even when no underlying medical conditions explain them.
  • There is a real physical illness caused or worsened by emotional or psychological factors.
• Psychophysical Disorder: Physical conditions influenced by psychological factors, especially stress and emotions (often used interchangeably with psychosomatic disorder).

Examples

• Somatoform: Stomach hurts with no identifiable cause.
• Psychosomatic: Stomach hurts due to stress leading to an ulcer.
• Psychophysical: Headache as a symptom of hypertension caused by stress.

Childhood Sources

• How to perceive and respond to stress in childhood is a learned response.
• Unstable home environment may cause adults to react to stress with exaggerated hormonal mechanisms.
• Families who emotionally support and encourage their children to effectively cope with their stresses have fewer physical complaints.

Common Psychophysical Problems

• Cardiovascular: Migraine and tension headaches, hypertension, angina.
• Musculoskeletal: Rheumatoid arthritis and lower back pain (stress can trigger rheumatoid arthritis).
• Respiratory: Hyperventilation and asthma (emotions can trigger asthma attacks).
• Gastrointestinal: Anorexia nervosa, obesity, peptic ulcer, irritable bowel syndrome, colitis.
• Skin: Neurodermatitis, eczema, psoriasis (another autoimmune disease triggered by stress), pruritus.
• Genitourinary: Impotence, rigidity, premenstrual syndrome.
• Endocrine: Hyperthyroidism and diabetes (stress can contribute to type 2 diabetes).

Stress Response Theories

• Carl Jung's Theory: Symbolism is attached to a symptom or illness.
• Eric Fromm's Theory: Certain personality types are prone to develop certain illnesses (e.g., Type A personalities and cardiovascular issues).
• Organic Weakness Theory: Every individual has one body system that is more sensitive than other systems.

Somatoform Disorders

• Somatization: Feeling symptoms in the absence of disease.
• Signs and symptoms of illness may be the client's way of coping with emotional distress or avoiding a situation.
• Emotional stress depletes the body's energies, reducing immune function.
• Cultural issues can affect expression of physical complaints.

Criteria for Diagnosis

• No organic medical condition explains the symptoms.
• The disorder significantly disrupts or impairs one's level of functioning.
• The client is unaware of any emotional distress being expressed.

Types of Somatoform Disorders

• Hysteria/Polysymptomatic Disorder: Many signs and symptoms; both genetic and environmental factors can contribute.
• How to differentiate from a medical problem?
  • Involvement of multiple organ systems suggests a somatization disorder.
  • Early onset and is a chronic condition in which no physical changes occur over time.
  • The absence of any significant lab values indicates the underlying problems may be emotionally based.
• Conversion Disorder: Individual presents problems related to sensory or motor functions.
  • More common in persons of lower socioeconomic status, those living in rural areas, and individuals with little health care knowledge.
  • Signs and symptoms tend to align with the individual's understanding of what the problem should be.
• Illness Anxiety Disorder (Hypochondria):
  • Intense fear or preoccupation with having a serious disease or medical condition based on misinterpretation of body signs and symptoms.
  • Clients commonly doctor shop.

The Mind and Body