11.2 Mood, Anxiety & Psychotic Disorders

11.2 Mood, Anxiety & Psychotic Disorders

Psychiatric disorders encompass complex neurobiological, psychological, and environmental disturbances that alter affective regulation, cognitive processing, reality testing, and behavioral adaptation. Within inpatient psychiatric units, emergency departments, and acute care hospital wards, registered nurses encounter patients experiencing acute depressive crises, life-threatening suicidality, hyperactive manic exhaustion, debilitating panic states, and psychotic decompensation. Evidence-based clinical assessment, proactive milieu management, and decisive safety interventions are essential to stabilize psychiatric crises and prevent catastrophic harm.

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Depressive Disorders & Suicide Risk Assessment

Major Depressive Disorder (MDD) is a debilitating affective illness characterized by persistent depressed mood, severe functional impairment, and neurovegetative dysregulation resulting from dysregulated monoaminergic neurotransmission (serotonin, norepinephrine, and dopamine).

The SIGECAPS Diagnostic Framework

The clinical manifestations of Major Depressive Disorder are systematically evaluated using the established SIGECAPS diagnostic criteria:

• S — Sleep Disturbance: Insomnia (most classically middle-of-the-night awakening or terminal early-morning awakening 2 to 3 hours before dawn) or hypersomnia (sleeping 12 to 16 hours daily while feeling unrefreshed).
• I — Interest Diminished (Anhedonia): Pervasive loss of pleasure or interest in previously enjoyable activities, hobbies, work, social interactions, and intimacy.
• G — Guilt & Worthlessness: Excessive, inappropriate, or delusional self-reproach, rumination over minor past failings, and profound feelings of worthlessness.
• E — Energy Loss / Chronic Fatigue: Unremitting, profound lethargy where even basic self-care tasks (bathing, dressing, eating) feel physically insurmountable.
• C — Concentration Deficits: Significant impairment in cognitive processing, executive functioning, sustained attention, and decision-making.
• A — Appetite & Weight Changes: Significant unintended weight loss or gain (> 5% of body weight in a single month) secondary to severe anorexia or comfort hyperphagia.
• P — Psychomotor Agitation or Retardation: Observable slowing of motor movements, speech, and thought processing (psychomotor retardation), or restless, purposeless pacing, wringing of hands, and agitation.
• S — Suicidal Ideation: Recurrent thoughts of death, passive death wishes, active suicidal ideation, or concrete suicide plans and attempts.

Vegetative Signs of Severe Depression

Beyond psychological dysphoria, severe depression produces profound autonomic and physiological slowing, known as vegetative symptoms:

• Severe chronic constipation secondary to decreased physical mobility, diminished dietary fiber, and reduced intestinal motility.
• Neglect of personal hygiene, grooming, oral care, and skin integrity.
• Psychomotor poverty of speech (poverty of speech, latency of response, whispering inaudibly).
• Disruption of the hypothalamic-pituitary-adrenal (HPA) axis leading to elevated baseline cortisol levels, blunted immune function, and altered circadian rhythms.

Suicide Risk Assessment & Clinical Stratification

Suicide represents a critical psychiatric emergency. Assessment must never rely on subjective intuition; nurses must utilize standardized, evidence-based instruments such as the Columbia-Suicide Severity Rating Scale (C-SSRS). The nurse must directly and unequivocally evaluate:

1. Ideation: Passive ideation ("I wish I would go to sleep and not wake up") versus Active ideation ("I want to end my life").
2. Intent: The client's explicit determination or desire to carry out suicidal thoughts.
3. Plan: The presence of a concrete, detailed method ("I have saved fifty sleeping pills in my jacket").
4. Access to Lethal Means: Immediate physical availability of the chosen method (e.g., possession of pills, firearms at home, proximity to heights).
5. Lethality of Chosen Method: Highly lethal methods (firearms, hanging, jumping from bridges, carbon monoxide inhalation) afford little to no window for rescue compared to lower-lethality methods.

Inpatient Environmental Safety & Suicide Precautions

• 1:1 Continuous Visual Observation: The gold standard for patients with active suicidal intent, concrete plans, or recent attempts. The designated staff member must remain within arm's length of the patient 24 hours a day, including during bathroom use, showering, and sleeping.
• Staggered 15-Minute Checks: Utilized only for lower-risk, monitored clients. Checks must be performed at unpredictable, irregular intervals (e.g., 7, 12, 14 minutes) to prevent the patient from timing safety sweeps.
• Environmental Sweeping & Ligature Resistance: Meticulous removal of all potential suspension points, cords, call bells, shoelaces, belts, drawstrings, plastic trash bags, and wire hangers. Inpatient psychiatric rooms must feature tamper-proof screws, break-away curtain tracks, recessed lighting, and weighted furniture. Searching personal belongings and visitor gifts for sharps, razor blades, and medications is mandatory upon admission and after off-unit visits.

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Bipolar Spectrum Disorders & Acute Manic Crisis

Bipolar disorders are characterized by cyclic fluctuations between depressive episodes and states of elevated, expansive, or irritable mood. Bipolar I Disorder requires at least one lifetime manic episode; Bipolar II Disorder involves recurrent major depressive episodes alternating with hypomanic episodes (elevated mood lasting at least 4 days that does not cause marked social impairment or require hospitalization; full mania never occurs).

The DIGFAST Diagnostic Mnemonic for Mania

Acute mania is characterized by the DIGFAST criteria:

• D — Distractibility: Inability to filter irrelevant environmental stimuli; shifting attention rapidly between ambient noises and objects.
• I — Impulsivity & Indiscretion: Reckless pursuit of pleasurable activities with high potential for painful consequences (e.g., unrestrained shopping sprees, gambling life savings, sexual indiscretions, dangerous driving).
• G — Grandiosity & Inflated Self-Esteem: Belief in possessing extraordinary powers, divine status, vast wealth, or influential connections that defy reality.
• F — Flight of Ideas: Continuous, accelerated flow of speech with abrupt topic transitions based on superficial associations, rhyming, or environmental distractions.
• A — Activity Increase & Psychomotor Agitation: Frenetic engagement in multiple simultaneous projects, non-stop pacing, moving furniture, and inability to sit still.
• S — Sleep Deficit: Profoundly decreased need for sleep (feeling energetic and rested after only 1 to 2 hours of sleep per night).
• T — Talkativeness & Pressured Speech: Rapid, loud, emphatic speech that is virtually impossible to interrupt; forceful verbal output driven by racing thoughts.

Nursing Interventions for Acute Manic Exhaustion

In acute mania, patients are at profound physiological risk for cardiac collapse, severe dehydration, rhabdomyolysis, and acute physical exhaustion due to non-stop hyperactivity and metabolic demand.

1. Nutritional & Hydration Support: Patients in acute mania rarely sit down to consume a full tray of food. The nurse must provide high-calorie, high-protein, nutrient-dense finger foods (e.g., meat and cheese wraps, peanut butter sandwiches, boiled eggs, fruit skewers, nutrient shakes) that can be eaten while walking. Offer fluids (water, electrolyte solutions) hourly; strictly monitor daily weights, intake, and output.
2. Milieu Management & Low-Stimulation Environment: Place the patient in a private room situated far from high-traffic nursing stations, noisy dayrooms, and televisions. Dim ambient lighting, maintain soft background tones, and restrict visitors during peak agitation. Avoid competitive games or complex group activities that exacerbate agitation.
3. Firm, Calm Communication & Limit-Setting: Use short, concise, unambiguous statements spoken in a calm, firm, neutral tone. Avoid debating, arguing, or attempting to disprove grandiose claims. Establish clear, consistent behavioral boundaries on manipulative, intrusive, or hypersexual conduct ("Mr. Tariq, walking into other patients' bedrooms is not permitted. Please return to the lounge with me now").
4. Rest & Sleep Promotion: Establish a structured, non-stimulating bedtime routine; encourage scheduled rest periods during the day; administer prescribed mood stabilizers, atypical antipsychotics, or sedating agents (e.g., olanzapine, clonazepam) as ordered.

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Anxiety Disorders & The Continuum of Anxiety

Anxiety exists on a dynamic continuum ranging from mild physiological arousal that enhances adaptation to acute panic that shatters cognitive and emotional functioning. Hildegard Peplau categorized anxiety into four progressive levels, each demanding distinct nursing interventions:

Table: Levels of Anxiety, Clinical Manifestations, and Nursing Interventions

Specific Anxiety Disorders

• Panic Disorder: Recurrent, unexpected panic attacks characterized by abrupt surges of intense fear reaching a peak within minutes, accompanied by palpitations, sweating, tremors, dyspnea, and fear of dying or losing control.
• Generalized Anxiety Disorder (GAD): Chronic, excessive, uncontrollable worry occurring on more days than not for at least 6 months regarding multiple everyday domains (finances, health, family), accompanied by motor tension and sleep disturbance.
• Obsessive-Compulsive Disorder (OCD): Characterized by intrusive, unwanted recurrent thoughts (obsessions) that create severe anxiety, compelled into ritualistic, repetitive behaviors (compulsions) executed to neutralize the anxiety. Nursing Rule: In the initial treatment phase, allow the patient sufficient time to perform the compulsive ritual (unless harmful), as interrupting the ritual abruptly precipitates severe panic. As the therapeutic alliance matures, collaboratively set gradual time limits while teaching alternative coping mechanisms.

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Schizophrenia Spectrum & Psychotic Disorders

Schizophrenia is a severe, chronic psychiatric disorder characterized by fundamental distortions in thinking, perception, reality testing, language, and emotional expression. Pathophysiologically, it involves excessive dopaminergic activity in the mesolimbic pathway (generating positive symptoms) and dopaminergic hypofunction in the mesocortical pathway (generating negative symptoms).

Positive versus Negative Symptoms

• Positive Symptoms (Distortions or Excesses of Normal Function):

  • Hallucinations: Sensory perceptions without an external environmental stimulus. Auditory hallucinations are the most prevalent (hearing voices commenting, arguing, or commanding). Command Hallucinations: The nurse must urgently determine whether voices are issuing commands to commit suicide, violence, or harm ("What are the voices instructing you to do?").
  • Delusions: Fixed, false beliefs impervious to logical argument. Common subtypes include persecutory (believing oneself targeted by enemies or agencies), grandiose (possessing supernatural identity or omnipotence), somatic (belief that bodily organs are rotting or transformed), ideas of reference (attributing personal coded messages to public broadcasts), and thought broadcasting/insertion (believing thoughts are being transmitted into the public or placed into one's mind).
  • Disorganized Speech & Thought Processes: Loose associations (ideas shifting between unrelated subjects), neologisms (inventing non-existent words), clang associations (rhyming words devoid of conceptual connection), word salad (incoherent mixture of words), and echolalia (involuntary echoing of another person's speech).

• Negative Symptoms (Deficits or Losses of Normal Function):

  • Known clinically as the 5 A's:
    1. Affective Flattening: Blunted facial expression, absence of emotional animation, monotone vocal delivery.
    2. Avolition: Severe impairment in initiating and sustaining goal-directed activities; inability to start basic hygiene, grooming, or daily chores.
    3. Alogia: Poverty of speech fluency and content; brief, monosyllabic, empty responses.
    4. Anhedonia: Complete incapacity to experience pleasure from physical, social, or emotional activities.
    5. Asociality: Profound lack of interest in social relationships and withdrawal from interpersonal contact.
  • Negative symptoms are highly disabling, persist chronically, and respond poorly to first-generation antipsychotics.

Evidence-Based Nursing Management of Psychosis

1. Communicating with Hallucinating Patients:

   • Acknowledge and validate the patient's internal emotional experience without validating the false perception: "I understand that hearing those voices is terrifying for you, but I do not hear anyone speaking in the room."
   • Ground the patient in the shared immediate physical environment: "You are safe here with me in the hospital clinic."
   • Screen immediately for command directives to assess safety risk.
   • Never argue, debate, mock, or pretend to hear the voices.
   • Encourage reality-based distraction techniques (listening to music via personal headphones, engaging in structured, simple hand crafts).

2. Communicating with Delusional Patients:

   • Respond to the underlying emotional core of the delusion rather than debating the factual premise: "It must feel exhausting and frightening to believe that people are tracking your movements."
   • Never validate, reinforce, or confirm the delusion, but avoid aggressive confrontation or logical debates, as argumentation forces the patient to defend and entrench the delusion.
   • Gently inject doubt when the patient is receptive: "I know that feels very real to you, but it is difficult for me to imagine the hospital staff would want to harm you."
   • Redirect conversation toward concrete, reality-oriented topics and collaborative activities.

3. Managing Severe Paranoia:

   • Avoid whispering, laughing, or standing in private huddles within the patient's line of sight, as paranoid clients interpret non-verbal ambiguity as conspiratorial plotting.
   • Maintain a predictable, structured schedule with consistent primary nurse assignments.
   • If the patient has persecutory delusions regarding food or medication poisoning, provide factory-sealed, pre-packaged food containers, allow the patient to select their own meal tray, and open medication unit-dose blister packs in the patient's direct presence.