Distress refers to a person and/or their groups emotional experience – often
characterised by feelings of sadness, stress, frustration, guilt, agitation, anger etc.
Dysfunction occurs when a persons ability to maintain their normal behaviour in relationship with their group/relational norms. I.e. behaviour in daily activities, occupation and relationships becomes altered for a sustained period of time.
Disability describes a loss of capacity to continue living a satisfying life as defined in relationship within a group. What is deemed to be 'disability’ is highly dependent on the persons social and cultural environment.
problems with classification of mental disorders
In physical healthcare diagnosis is normally defined as, “the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory test results and procedures.”
This approach is dependent on identifying illnesses based on objective data.
This approach is problematic in mental health because unlike physical illness, objective data such as pathology tests and x-rays cannot be used to identify any of the mental disorders.
Classification categories in mental health therefore rely on social constructs inferred from social expectations, norms and interests (business, political etc).
Throughout history there has been a lack of consistency and reliability in mental health diagnosis and classification (see lecture 1).
In the past 50 years there has been an exponential increase in the number of diagnostic categories of mental illness along with the removal of other categories since the first publication of diagnostic manuals in the 1950’s.
For example DSM-III listed 205 mental illnesses. In 2013 DSM-5 identified over 300 mental illnesses.
Both diagnostic manuals are intimately linked to the administration of private health insurance schemes and the administration of business and legal frameworks United States, UK, Australia etc (Susceptible to being influenced by money and power).
Cultural and gender bias, conflict of interest, medicalizing ‘normal’ behaviour (homosexuality removed in 1970’s).
Two main classification systems in mental health.
- International Classification of Diseases (ICD) - WHO.
- Diagnostic and Statistical Manual of Mental Disorders (DSM) – USA.
The value of classification of mental disorders
It is important not to throw the baby out with the bath water because mental distress, dysfunction and disability is experienced by a large proportion of people worldwide.
Classification systems of mental disorders within the ICD (since 1946) and DSM (since 1952) are not as objective as ICD classifications of physical healthcare but they are the best we have.
These systems have assisted society to move towards more humanistic approaches that are understandable and accessible to wider groups of people rather than historical approaches which were often influenced by race, sexuality and religion.
Based on similarity, problems and patterns can be identified.
These similarities contribute to the ongoing development of better healthcare, analysis, critic and development of novel approaches.
While these classification systems are useful we need to be cognizant that our actions as nurses will be highly influenced by the classification system and theoretical perspective we employ.
In this talk we will be referring to the ICD 11 Beta. (the latest version of ICD 11)
Successive national mental health surveys since 1997 have suggested that the most commonly experienced mental disorders in Australia are mood disorders, anxiety disorders and substance use disorders.
what is mood
A useful and important subjective emotional state, that influences personality and life functioning.
For example: sadness; happiness; elation.
Variations in mood are natural.
Mood is useful in a wide range of ways ie social interaction, physiological arousal, lethargy, art, music, love, intimacy, fear and anger.
Extremes in mood can be linked with extremes in human experience e.g. Creativity, despair, ecstasy.
Mood fluctuations considered normal occur within socially accepted and personally manageable boundaries.
what r mood disorders
Disturbance of mood that has a sustained negative effect on a persons ability to maintain their normal activities (work/study) and relationships.
Several conditions and disorders of varying degrees of intensity (mild, moderate, severe) and duration.
Two common mood disorders are:
The word depression is often used to mean “feeling down” or “feeling blue.”
Most people experience feeling down every now and again, usually in response to life events/circumstances but are brief in duration.
When someone feels persistently sad and their mood begins to negatively effect their normal activities and relationships, they may be diagnosed as a depressive disorder.
When does ‘depression’ become a problem?
Depressive disorders are characterized by depressive mood (e.g., sad, irritable, empty) or loss of pleasure accompanied by other cognitive, behavioural, or neurovegetative symptoms that significantly affect the individual’s ability to function.
A depressive disorder should not be diagnosed in individuals who have ever experienced a manic, hypomanic episode or mixed episode, which would indicate the presence of a bipolar disorder.
Clustered symptoms of depression
- last more than 2 weeks
types of depression - single episode depressive disorder
Single episode depressive disorder is characterized by the presence or history of one depressive episode when there is no history of prior depressive episodes. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.
Depressive disorders according to intensity, mild, moderate and severe.
6A50.1Single episode depressive disorder, mild: None of the symptoms of the Depressive episode are present to an intense degree. An person with Mild depressive episode has some, but not considerable, difficulty in continuing with ordinary work, social, or domestic activities.
6A50.2 Single episode depressive disorder, moderate: In a moderate depressive episode, several symptoms of a depressive episode are present to a marked degree, and the person has considerable difficulty in continuing with work, social, or domestic activities, but is still able to function in at least some areas.
6A50.4 Single episode depressive disorder, severe: Either many symptoms are present to a marked degree or a smaller number of severe symptoms that include a significant risk of suicide are present. The individual is unable to continue with work, social, or domestic activities, except to a very limited degree.
Depressive disorders according to duration
6A51 Recurrent depressive disorder: Characterized by a history or at least two depressive episodes separated by at least several months without significant mood disturbance. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.
6A52 Dysthymic disorder: Characterized by a persistent depressive mood as reported by the individual (feeling down, sad) or manifested as a sign (i.e., tearful, downtrodden appearance) during more of the time than not over a period of at least 2 years. Most of the time, the number or duration of symptoms is not sufficient to meet the definitional requirements of a depressive episode. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.
6A53 Mixed depressive and anxiety disorder: Mixed depressive and anxiety disorder is characterized by symptoms of both anxiety and depression more days than not for a period of two weeks or more. Neither set of symptoms, considered separately, is sufficiently severe, numerous, or persistent to justify a diagnosis of a depressive episode, dysthymia or an anxiety and fear-related disorder. Depressed mood or diminished interest in activities must be present accompanied by additional depressive symptoms as well as multiple symptoms of anxiety. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.
Depression & other diagnostic considerations
stat on suicide rates in AUS
men has 3X higher suicide rate than women
susceptible age group is > 85 yrs old men
what is mania
Mania differentiates depressive disorders from bipolar and related disorders. Mania is a mood state characterised by abnormally and persistently elevated or irritable mood, increased activity, and poor judgment.
e.g. pressure speech, skipping topics in conversation
types of mania
Milder symptoms of mania, for shorter period of time. Usually does not require hospitalisation.
Mania (without psychotic symptoms)
More severe symptoms; impairment in functioning.
Mania (with psychotic symptoms) Usually requires hospitalisation Delusions sometimes with hallucinations (usually mood-congruent)
Clustered symptoms of mania
Bipolar and related disorders
6A40 Bipolar type I disorder: episodic mood disorder charecterised by occurrence of one or more manic or mixed episodes. A manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention characterized by euphoria, irritability, or expansiveness, and by increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behavior, and rapid changes among different mood states (i.e., mood lability). A mixed episode is characterized by either a mixture or very rapid alternation between prominent manic and depressive symptoms on most days during a period of at least 2 weeks. Although the diagnosis can be made based on evidence of a single manic or mixed episode, typically manic or mixed episodes alternate with depressive episodes over the course of the disorder.
6A41 Bipolar type II disorder: Episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode. The symptoms represent a change from the individual’s typical behavior and are not severe enough to cause marked impairment in functioning. There is no history of manic or mixed Episodes.
6A42 Cyclothymic disorder: Characterized by a persistent instability of mood over a period of at least 2 years, involving numerous periods of hypomanic (e.g., euphoria, irritability, or expansiveness, psychomotor activation) and depressive (e.g., feeling down, diminished interest in activities, fatigue). The depressive symptomatology has never been sufficiently severe or prolonged to meet the diagnostic requirements for a depressive episode (see Bipolar type II disorder). Nonetheless the symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other
important areas of functioning.
Potential causes of mood disorders
The causes of mood disorders are complex and different for every individual. Common contributing causes include:
Modern myth: the ‘Chemical imbalance theory’
overly reductionism - untrue - drugs work so its biological problem - wrong
myth developed bacause
- the idea of drug makes people better, feel good
Some reasons why the chemical imbalance theory is ‘fake news.’
There is no scientific evidence regarding what a ‘balanced’ level of serotonin or any other neurochemical is (Leo and Lecasse 2007).
It is not possible to measure serotonin and norepinephrine in the brains of patients. Estimates of brain neurotransmitters can only be inferred by measuring the biogenic amine breakdown products (metabolites) in the urine and cerebrospinal fluid. The assumption underlying this measurement is that the level of biogenic amine metabolites in the urine and cerebrospinal fluid reflects the amount of neurotransmitters in the brain.
Although some depressed patients have low levels of serotonin and norepinephrine, the majority do not. Estimates vary, but a reasonable average from several studies indicates that only about 25 percent of depressed patients actually have low levels of these metabolites.
Some depressed patients actually have abnormally high levels of serotonin and norepinephrine, and some patients with no history of depression at all have low levels of these amines.
Large meta analyses show placebo (sugar pills) works as well as SSRI’s for mild-moderate depression and nearly as effectively in people with severe depression (Kirsch, 2013).
Tianapetine which is a Selective serotonin reuptake enhancer (SSRE) used in Europe, works just as effectively as SSRI’s.
Reducing levels of norepinephrine, serotonin and dopamine does not actually produce depression in humans.
Drugs that really powerfully raise serotonin and norepinephrine. The theory cannot explain why there are drugs that alleviate depression despite the fact that they have little or no effect on either serotonin or norepinephrine.
Drugs that powerfully raise levels of serotonin, nor ephedrine and dopamine, such as amphetamine and cocaine, do not alleviate depression.
Useful theory about what causes mood disorders (Aetiology) 1. Stress vulnerability model (Zubin & Spring, 1977)
Accumulation of daily stressors, specific major life events, psychological
Family history, biological and psychological preconditions can predispose an individual to mental illness
Stress management skills. social support, effective problem solving and
coping skills can protect people against mental illness.
Family history, coping skills, interpersonal conflict, stressful events, drug and alcohol use?
Stress vulnerability model (Zubin & Spring, 1977)
AB is the personal threshold for mental illness.
A) People with low vulnerability need to experience high stress to cross their threshold.
B) Those with high vulnerability may become unwell with lower stress
What works for depression?
Psychological therapies - for mild to moderate:
Cognitive Behaviour Therapy (CBT)
Interpersonal Therapy (IPT)
Computerised therapy, self-help books.
Lifestyle and complementary therapies –as addendum in mild to moderate: Exercise – either cardio or weights, Nutrition, Massage.
Medical treatment - for moderate to severe: Antidepressants and other medications
Go slow (with diagnosis), stay low (with psychotropic medication -> cause harm)
Bio-psycho-social stepped care approach
Mental health assessment
Physical health promotion
Assessment must include patients potential of harm to self, others and “social reputation”.
For suicide risk assessment remember CPR:
Aggression? Violence? Homicidal?
What is Anxiety?
An emotion subjectively experienced
A feeling of worry, nervousness, or unease about something with an uncertain outcome. (Oxford Dictionary)
A good experience that helps us to survive a variety of different scenarios and threats.
Occurs as a result of perceived/real threat to person’s being, self-esteem, or identity (stress; change; fear)
Normal, unless becomes intense and prolonged, with symptoms (“fight, flight or freeze”)
Physiological response causing psychological and physical symptoms.
Progressive levels: ‘Normal’, moderate, severe, and panic.
Fluctuations in anxiety are normal
Anxiety fluctuations considered normal occur within socially accepted and personally manageable boundaries
When is anxiety a problem?
Extreme maladaptive emotions (varying degrees of severity and intensity) with surges of autonomic arousal (necessary for fight or flight)
Usually related to features of:
stress and fear (emotional response)
anticipation of future threat; thoughts of immediate danger related behavioural disturbances (vigilance; avoidance)
common fear response: Panic attacks
Negatively impacts on the person’s capacity and overall level of functioning.
Disrupts the person’s daily life
Causes significant distress
Symptoms cannot be easily controlled or managed
Physical Symptoms of Anxiety
The defining features of anxiety disorders are often very physical symptoms
A persons experience of anxiety my be linked to symptoms that effect the Nervous System, the Cardiovascular system, the Respiratory System, the Digestive System, the Excretory System, the Endocrine System...
PSNS VS SNS role in anxiety
Discreet episode of discomfort or intense fear, apprehension, fearfulness or terror in the absence of “real” danger
Abrupt/sudden onset reaching peak within minutes
Common symptom in various anxiety disorders
Intense anxiety and sympathetic nervous system overstimulation (fight or flight response)
Panic attacks symptoms
Palpitations; pounding heart; accelerated heart rate; chest pain
Trembling or shaking
Feeling of choking
Nausea or abdominal distress
Dizzy; unsteady; lightheaded or faint
Derealisation or depersonalisation
Paraesthesia (numbness or tingling sensations)
Chills or hot flushes
Sensations of shortness of breath/smothering
Fear of losing control or going crazy or dying
Clustered symptoms of anxiety disorders
Useful theories about what causes anxiety disorders (aetiology)
Lack of exercise
Other physical health conditions
Substance use, stimulants, opiates, hallucinogens etc.
Personality trait theories (canary in coalmine) High Neuroticism
Family psychological patterns
Adverse life events and major loss
Learnt behaviour: children of parents with panic disorder or depression display a sig. higher prevalence of anxiety disorders and depression than children of parents with no mental disorder
Principles of nursing care in anxiety pt
Be aware of role and clinical context
Recognize early stages of anxiety to work to prevent escalation & loss of control. Immediate intervention important
Recognize & monitor anxiety in the nurse to ensure effectiveness of therapeutic interventions
Identify client’s adaptive strengths & maladaptive coping mechanisms & work to support adaptive and reduce maladaptive
Assess ‘Bio’ first: Several conditions may provoke symptoms of anxiety
Substance use/abuse (include caffeine!)
(eg.: bronchodilators; calcium channel blockers/antihypertensives; pseudoephedrine)
Nursing interventions for anxiety disorders
Psychological therapies are first choice of treatment
Cognitive behaviour therapy (CBT) and graded exposure
Physical health promotion, reduce caffeine/stimulants, sleep hygiene, regular exercise, check diet and any other medications or drug use.
Self-help books based on CBT, internet based tools etc
Relaxation training, mindfulness training
Social advocacy and support
Educate and enlist family/friends or other supportive people
Medication may be needed in severe cases and/or dependent on persons context. Stick to SSRI’s and if possible avoid benzodiazapines.
All medication should be carefully monitored and done as an adjunct to psychological and other therapies
Substance use fluctuations are common
In mental healthcare the term ‘Substances’ generally refers to any psychoactive substance that can be consumed by the human body.
Substance use fluctuations considered normal occur within socially accepted and personally manageable boundaries.
What are substance use problems?
Using alcohol or drugs is not normally problematic.
However anyone who uses alcohol or drugs risks developing substance use problems
A substance use problem occurs when a persons use of a substance begins causing problems in their ability to maintain their normal activities and or relationships.
Disorders due to substance use or addictive behaviours
Disorders due to substance use and addictive behaviours are mental and behavioural disorders that develop as a result of the use of predominantly psychoactive substances, including medications, or specific repetitive rewarding and reinforcing behaviours.
Disorders due to substance use include single episodes of harmful substance use, substance use disorders (harmful substance use and substance dependence), and substance-induced disorders such as substance intoxication, substance withdrawal and substance-induced psychotic, mood and anxiety disorders.
Three common drug types cause addictive behaviours
DEPRESSANTS: including alcohol, cannabis, benzodiazepines, opiates and
opioids including heroin, morphine, codeine and pethidine etc.
STIMULANTS: mild stimulants include caffeine and nicotine. Stronger stimulants include amphetamines, methamphetamine, cocaine and ecstasy etc.
HALLUCINOGENS: including ketamine, LSD, magic mushrooms etc.
While Cannabis can sometimes have hallucinogenic qualities it is in its own
6B50 Disorders due to use of alcohol
Disorders due to use of alcohol are characterized by the pattern and consequences of alcohol use. Included in this grouping are:
Alcohol intoxication, Harmful use of alcohol, Alcohol dependence, Alcohol withdrawal, and Alcohol-induced mental and behavioural disorders (specific types of mental or behavioural symptoms developing in the context of alcohol use).
These are by far the most common disorders caused by substance use in Australia by far.
Substance use disorders – 5.1%.
Alcohol use disorder – 4.3%
Short-term problems: physical injuries, aggression and antisocial behaviour, risk taking, suicide and self-injury.
Long-term problems: other SUDs, depression, anxiety, social and physical health comorbidities
6B53 Disorders due to use of opioids
Disorders due to use of opioids are characterized by the pattern and consequences of opioid use, including heroin, methadone, buprenorphine and prescription opioid analgesics. Included in this grouping are Opioid intoxication, Harmful use of opioids, Opioid dependence, Opioid withdrawal, and Opioid-induced mental and behavioural disorders (specific types of mental or behavioural symptoms developing in the context of opioid use).
Opoids produce short-term feelings of euphoria and wellbeing but have a high risk of creating dependence.
People who are dependent on opoids often have associated problems such as depression, alcohol dependence and criminal behaviour.
6B56 Disorders due to use of stimulants including amphetamines, methamphetamine or methcathinone
Disorders due to use of amphetamines or other stimulants including methamphetamine and methcathinone but excluding caffeine, cocaine and synthetic cathinones are characterised by the pattern and consequences of amphetamine or other stimulant use. Included in this grouping are amphetamine or other stimulant intoxication, harmful use of amphetamines or other stimulants, amphetamine or other stimulant dependence, amphetamine or other stimulant withdrawal, and amphetamine or other stimulant-induced mental disorders (specific types of mental or behavioural symptoms developing in the context of amphetamine or other stimulant use).
Amphetamines have the temporary effect of increasing energy and mental alertness.
Methamphetamine, an amphetamine related derivative used by Adolph Hitler and the Nazi’s, is presently the most commonly used illegal drug in Australia. It is more potent than other forms of amphetamines and can precipitate psychosis. The person generally recovers as the drug wears off but are vulnerable to further episodes of psychosis if the drug is used again.
6B54 Disorders due to use of sedatives, hypnotics or anxiolytics
Disorders due to use of sedatives, hypnotics or anxiolytics are characterized by the pattern and consequences of sedative, hypnotic or anxiolytic use. Included in this grouping are Sedative, hypnotic or anxiolytic intoxication, Harmful use of sedatives, hypnotics or anxiolytics, Sedative, hypnotic or anxiolytic dependence, Sedative, hypnotic or anxiolytic withdrawal, and Sedative-, hypnotic- or anxiolytic-induced mental and behavioural disorders (specific types of mental or behavioural symptoms developing in the context of sedative, hypnotic or anxiolytic use).
Clusters of symptoms due to substance use
Comorbidity of the big three is common