14.2 Common Psychiatric Disorders: Depression, Bipolar, Schizophrenia & Psychosis

14.2 Common Psychiatric Disorders: Depression, Bipolar, Schizophrenia & Psychosis

Quick Answer: Psychiatric nursing relies on the structured Mental State Examination (MSE) to assess current mental functioning across appearance, behavior, speech, mood, affect, thought, perception, cognition, insight, and judgment. Schizophrenia involves positive symptoms (dopamine excess in mesolimbic tract) and negative symptoms (dopamine deficit in mesocortical tract), treated with first- or second-generation antipsychotics. First-generation agents risk Extrapyramidal Side Effects (EPSE) and Neuroleptic Malignant Syndrome (NMS). Mood disorders include Major Depressive Disorder (SIG E CAPS) and Bipolar Mania (DIG FAST), managed with SSRIs, TCAs (cardiotoxic in overdose), and mood stabilizers like Lithium (therapeutic window 0.6–1.2 mmol/L).

---

The Mental State Examination (MSE)

The Mental State Examination (MSE) is the structured, objective clinical assessment of a patient's psychological and behavioral functioning at the exact time of the interview. Just as a physical assessment examines organ systems, the MSE evaluates psychological domains.

Comprehensive Components of the MSE

1. Appearance & General Behavior:
   • Physical presentation: Nutritional status, personal hygiene, grooming, disheveled dress, posture, physical deformities, clothing appropriateness for the climate;
   • Motor activity: Psychomotor agitation, pacing, waxy flexibility, catatonic posturing, echopraxia (involuntary imitation of movements), tremors, or psychomotor retardation;
   • Eye contact & demeanor: Cooperative, guarded, hostile, suspicious, indifferent, or evasive.
2. Speech:
   • Rate: Rapid, pressured (cannot be interrupted, common in mania), or slowed (retarded depression);
   • Volume & Tone: Whispering, mute (mutism), loud, dramatic, monotonous;
   • Quantity: Poverty of speech (laconic, answering only in monosyllables), latency of response (prolonged pause before answering).
3. Mood & Affect:
   • Mood (Subjective): The patient's sustained, pervasive internal emotional state in their own words ("depressed", "ecstatic", "furious", "terrified", "euthymic");
   • Affect (Objective): The clinician's observed, immediate outward emotional expression:
     • Flat affect: Complete absence of emotional expression, immobile facies;
     • Blunted affect: Severely reduced emotional intensity;
     • Constricted affect: Narrowed range of emotional expression;
     • Labile affect: Rapid, abrupt, dramatic shifts in emotional expression unrelated to external stimuli;
     • Congruence: Whether affect aligns with stated thought content (e.g., smiling while describing a parent's death represents incongruent affect).
4. Thought Process (Form) vs. Thought Content:
   • Thought Process (How the patient thinks):
     • Circumstantiality: Over-inclusion of tedious, trivial details; speaker wanders but eventually reaches the original point;
     • Tangentiality: Thoughts diverge from the original topic; speaker never returns to answer the initial question;
     • Flight of Ideas: Rapid, continuous verbalization skipping quickly from one topic to another based on loose associations or phonetic puns (hallmark of mania);
     • Loosening of Associations (Derailment): Ideas shift from one subject to another with no logical or comprehensible connection;
     • Clang Associations: Association of words governed by rhyming sound rather than logical meaning;
     • Neologisms: Invention of entirely new words or idiosyncratic word combinations meaningless to the listener;
     • Thought Blocking: Sudden, involuntary cessation in the train of thought midway through a sentence.
   • Thought Content (What the patient thinks):
     • Delusions: Fixed, false beliefs unshakeable by logical argument or objective evidence, out of keeping with the individual's cultural and religious background:
       • Persecutory / Paranoid: Belief that one is being targeted, poisoned, spied on, or plotted against;
       • Grandiose: Inflated belief of possessing exceptional wealth, divine power, special identity, or royal status;
       • Delusions of Reference: Belief that neutral external events, television broadcasts, or strangers' gestures have direct personal significance;
       • Somatic Delusions: False belief that one's body is diseased, rotting, infested with parasites, or deformed;
       • Delusions of Control / Passivity: Belief that one's feelings, impulses, or limbs are controlled by an outside force, machine, or entity;
       • Thought Insertion, Withdrawal, and Broadcasting: Belief that thoughts are being inserted into one's mind, stolen out of one's head, or broadcasted aloud to the public.
     • Obsessions, Phobias, and Overvalued Ideas.
5. Perception:
   • Hallucinations: False sensory perceptions occurring in the absence of an actual external sensory stimulus:
     • Auditory: Most frequent in schizophrenia; includes elementary noises, voices arguing, third-person commentary (voices discussing the patient in the third person), and command hallucinations (voices instructing specific acts, carrying high violence/suicide risk);
     • Visual: Sighting formed figures or shadows; common in organic delirium, toxic withdrawal, and neurological lesions;
     • Tactile (Haptic): Sensations of touch, burning, or formication (bugs crawling on skin, characteristic of alcohol/cocaine withdrawal);
     • Olfactory & Gustatory: Unpleasant smells or tastes; often associated with temporal lobe epilepsy or organic brain pathology.
   • Illusions: Misinterpretations of real, existing external sensory stimuli (e.g., mistaking a coat rack for an intruder in a dim room).
6. Cognition: Assessment of orientation to time, place, and person; immediate registration, short-term, and remote memory; concentration (serial 7s or spelling "WORLD" backward); and abstract thinking (interpreting common proverbs).
7. Insight: The patient's degree of awareness and understanding of their mental illness.

The Six Grades of Insight

1. Judgment: The capacity to evaluate a situation, anticipate consequences, and make safe, socially appropriate decisions (e.g., "What would you do if you smelled smoke in a crowded cinema?").

---

Schizophrenia & Psychotic Disorders

Schizophrenia is a severe neurodevelopmental psychiatric disorder characterized by fundamental distortions in thinking, perception, emotional responsiveness, and social interaction.

Diagnostic Criteria (DSM-5 / ICD-11)

• Active Phase Symptoms: At least two (2) or more of the following symptoms present for a significant portion of time during a 1-month period (at least one must be symptoms 1, 2, or 3):
  1. Delusions;
  2. Hallucinations;
  3. Disorganized speech (e.g., derailment, incoherence);
  4. Grossly disorganized or catatonic behavior;
  5. Negative symptoms.
• Continuous Disturbance: Continuous signs of disturbance must persist for at least 6 months (including prodromal and residual phases);
• Functional Deterioration: Marked social, occupational, academic, or self-care dysfunction below pre-illness baseline.

Positive vs. Negative Symptoms

+-----------------------------------------------------------------------------------------+
|                            SCHIZOPHRENIA SYMPTOM PROFILES                               |
|                                                                                         |
|       POSITIVE SYMPTOMS (Type I)                 NEGATIVE SYMPTOMS (Type II)            |
|       - Mesolimbic Hyperdopaminergia             - Mesocortical Hypodopaminergia        |
|       - Delusions & Hallucinations               - Affective Flattening & Alogia        |
|       - Disorganized Speech & Behavior           - Avolition, Anhedonia & Asociality    |
|       - Highly responsive to typical FGAs        - Responsive to atypical SGAs/rehab    |
+-----------------------------------------------------------------------------------------+

• Positive Symptoms (The "Added" Experiences): Reflect excess or distortion of normal psychological functions. Driven primarily by hyperactivity of dopamine (D2 receptors) in the mesolimbic pathway.
• Negative Symptoms (The 5 A's - The "Subtracted" Functions): Reflect loss or diminution of normal functions. Linked to dopamine hypofunction in the mesocortical pathway and prefrontal cortical atrophy:
  1. Avolition: Profound lack of motivation, initiative, and ability to initiate goal-directed tasks;
  2. Anhedonia: Inability to experience pleasure from previously enjoyable activities;
  3. Alogia: Poverty of speech, laconic responses, diminished fluency of thought;
  4. Affective Flattening: Immobile facial expression, lack of vocal inflections, unresponsive eye contact;
  5. Asociality: Severe social withdrawal, detachment from interpersonal relationships.

---

Antipsychotic Pharmacotherapy: Typical vs. Atypical

[!IMPORTANT] Exam Alert: Long-Acting Depot Antipsychotics For non-adherent chronic schizophrenia patients in Ghanaian community settings, Fluphenazine decanoate (Modecate) or Haloperidol decanoate is administered as a deep intramuscular depot injection every 2 to 4 weeks. Nurses must never administer depot preparations intravenously, and patients must be screened for tolerability using short-acting oral formulations before starting depot therapy.

---

Extrapyramidal Side Effects (EPSE) & Clinical Management

Extrapyramidal side effects arise when first-generation antipsychotics block dopamine D2 receptors in the nigrostriatal pathway, disrupting the balance between dopamine and acetylcholine.

Detailed EPSE Breakdown Table

---

Neuroleptic Malignant Syndrome (NMS)

Neuroleptic Malignant Syndrome (NMS) is an idiosyncratic, life-threatening complication of antipsychotic pharmacotherapy characterized by severe central dopamine D2 receptor blockade.

The Clinical Tetrad of NMS

1. Severe Hyperthermia: Extreme fever, frequently ranging between 38.5°C and 41.0°C, unyielding to conventional antipyretics;
2. "Lead-Pipe" Muscle Rigidity: Severe, generalized muscular rigidity across all limbs and axial musculature;
3. Autonomic Instability: Profuse diaphoresis, marked tachycardia (>120 bpm), labile/fluctuating blood pressure, tachypnea, and cardiac arrhythmias;
4. Altered Level of Consciousness: Confusion, delirium, mutism, stupor, progressing rapidly to coma.

Laboratory Hallmarks

• Massive Creatine Kinase (CK) Elevation: Ranging from >1,000 to >50,000 IU/L, reflecting extensive rhabdomyolysis;
• Leukocytosis: White blood cell count elevated (15,000 to 30,000/mm³);
• Renal Function Derangements: Elevated blood urea nitrogen (BUN) and creatinine caused by myoglobinuric acute tubular necrosis.

Emergency Management Protocol for NMS

1. Immediate Discontinuation: Stop all neuroleptics and dopamine-blocking agents immediately;
2. Emergency Airway & Supportive Care: Secure airway; transfer immediately to the Intensive Care Unit (ICU);
3. Active External Cooling: Apply cooling blankets, ice packs to axillae and groins, and initiate tepid sponging;
4. Aggressive IV Hydration: Infuse cold normal saline (3 to 4 liters daily) to maintain renal perfusion and flush rhabdomyolysis myoglobin cast formations;
5. Pharmacological Antidotes:
   • Dantrolene sodium: Direct-acting skeletal muscle relaxant (1–2.5 mg/kg IV bolus, up to 10 mg/kg/day) to halt hyperthermia and muscular contracture;
   • Bromocriptine mesylate: Central dopamine D2 receptor agonist (2.5–5 mg orally or via nasogastric tube every 8 hours) to overcome dopamine blockade;
   • Amantadine: Dopaminergic and NMDA antagonist alternative.

---

Mood Disorders: Depression & Bipolar Disorder

Mood disorders represent severe, pervasive disturbances in affect that impair occupational, biological, and psychosocial functioning.

Major Depressive Disorder (MDD)

MDD requires the presence of at least five (5) symptoms during the same 2-week period, representing a change from previous functioning. At least one symptom must be depressed mood or anhedonia (loss of interest/pleasure).

+-----------------------------------------------------------------------------------------+
|                         SIG E CAPS — MNEMONIC FOR MAJOR DEPRESSION                      |
|                                                                                         |
|  S — Sleep disturbance (insomnia, early morning awakening, or hypersomnia)              |
|  I — Interest loss (profound anhedonia in all activities)                               |
|  G — Guilt (feelings of worthlessness, excessive self-reproach, despair)                 |
|  E — Energy loss (chronic disabling fatigue, anergia)                                   |
|  C — Concentration deficits (indecisiveness, memory lapses)                             |
|  A — Appetite changes (weight loss or marked weight gain)                               |
|  P — Psychomotor changes (observable agitation or severe retardation)                   |
|  S — Suicidal ideation (recurrent thoughts of death, plan, or attempt)                  |
+-----------------------------------------------------------------------------------------+

• Somatization in the Ghanaian Context: Depressive symptoms in Ghanaian clinical practice frequently present as somatic complaints: "heat in the head", crawling sensations, internal body vibrations, or chronic generalized bodily pains.

Bipolar Affective Disorder: Mania vs. Hypomania

• Bipolar I Disorder: Characterized by at least one manic episode. Major depressive episodes are common but not strictly required for a Bipolar I diagnosis.
• Bipolar II Disorder: Characterized by at least one hypomanic episode AND at least one major depressive episode. A full manic episode never occurs.
• Manic Episode Characteristics (The DIG FAST Mnemonic):
  • D — Distractibility: Rapid shifting of attention to irrelevant external stimuli;
  • I — Indiscretion: Unrestrained participation in high-risk pleasurable ventures (reckless spending, sexual indiscretion, foolish business schemes);
  • G — Grandiosity: Inflated self-esteem, delusions of superhuman status or divine missions;
  • F — Flight of Ideas: Racing thoughts, rapid speech skipping tangentially from topic to topic;
  • A — Activity Increase: Markedly increased goal-directed motor activity, pacing, restlessness;
  • S — Sleep Deficit: Decreased need for sleep (feeling fully refreshed and energized after only 1–2 hours of sleep);
  • T — Talkativeness: Pressured speech, explosive volume, rapid delivery that cannot be interrupted.

---

Mood Disorder Pharmacotherapy

1. Antidepressants: SSRIs & Tricyclics

• Selective Serotonin Reuptake Inhibitors (SSRIs): Fluoxetine, Sertraline, Citalopram.
  • Mechanism: Selectively inhibit presynaptic serotonin reuptake transporters (SERT);
  • Adverse Effects: Nausea, headache, insomnia, sexual dysfunction;
  • Black Box Warning: Paradoxical increase in suicidal ideation during the initial 10 to 14 days of therapy as physical energy improves before mood lifts;
  • Serotonin Syndrome: Toxic accumulation of serotonin manifesting as mental status changes, autonomic hyperactivity, hyperreflexia, and clonus.
• Tricyclic Antidepressants (TCAs): Amitriptyline, Imipramine.
  • Mechanism: Inhibit reuptake of both norepinephrine and serotonin; block histamine, alpha-1, and muscarinic receptors;
  • Adverse Effects: Anticholinergic toxicity (dry mouth, blurred vision, urinary retention, constipation, tachycardia), orthostatic hypotension, sedation;
  • Lethality in Overdose: High cardiotoxicity! TCAs block cardiac fast sodium channels, prolonging the QTc and QRS intervals, inducing fatal ventricular arrhythmias (torsades de pointes, ventricular fibrillation) and refractory hypotension. Antidote: IV Sodium Bicarbonate to alkalinize serum and displace TCA from cardiac sodium channels.

2. Mood Stabilizers: Lithium Carbonate

Lithium carbonate remains the gold standard mood stabilizer for acute mania and long-term bipolar maintenance, uniquely possessing direct anti-suicidal properties.

+-----------------------------------------------------------------------------------------+
|                         LITHIUM THERAPEUTIC WINDOW & TOXICITY                           |
|                                                                                         |
|  [0.6 - 1.2 mmol/L]       [1.5 - 2.0 mmol/L]        [2.0 - 2.5 mmol/L]       [> 2.5]    |
|   THERAPEUTIC RANGE        MILD-MODERATE             SEVERE TOXICITY        CRITICAL    |
|   - Maintenance: 0.6-0.8   - Coarse tremor           - Dysarthria           - Seizures  |
|   - Acute Mania: 0.8-1.2   - Vomiting, diarrhea      - Ataxia, confusion    - Coma, ARF |
|                            - Muscle weakness         - Hyperreflexia        - DIALYSIS  |
+-----------------------------------------------------------------------------------------+

• Narrow Therapeutic Window: Serum concentrations must be maintained between 0.6 and 1.2 mmol/L. Serum blood samples must be drawn precisely 12 hours after the evening dose (trough level).
• Renal Handling & Electrolyte Balance: Lithium is excreted entirely by the kidneys. In the proximal tubule, lithium competes directly with sodium for reabsorption. Therefore, hyponatremia, dehydration, severe diarrhea, vomiting, fever, low-sodium diets, and medications like NSAIDs, thiazide diuretics, and ACE inhibitors drastically increase lithium reabsorption, precipitating life-threatening toxicity.
• Patient Education: Instruct patients to drink 2 to 3 liters of fluid daily, maintain normal dietary salt intake, avoid NSAIDs (substituting paracetamol for analgesia), and recognize early toxicity signs.
• Routine Lab Monitoring: Baseline and periodic Serum Lithium levels, Renal Function Tests (Creatinine, BUN, eGFR), Thyroid Function Tests (TSH, free T4 - lithium inhibits thyroid hormone release, causing hypothyroidism and goiter), and baseline ECG.

3. Anticonvulsant Mood Stabilizers

• Sodium Valproate / Divalproex: Highly effective for rapid-cycling bipolar disorder. Monitor liver enzymes and platelets (hepatotoxicity, thrombocytopenia). Teratogenic Alert: Absolute contraindication in pregnancy due to neural tube defects (spina bifida);
• Carbamazepine: Monitor complete blood counts due to risks of aplastic anemia and agranulocytosis; strong inducer of cytochrome P450 enzymes.