Lesson 7

Manic – depressive psychosis

• Also called affective disorders.
• They affect both the mood and psychromotes
activates.
• The disease comes in the two phases.
• The manic phase.
• The depressive phase.
Patient may be admitted one time with main
phase and depressive.
 Manic phase

• Psychomoter activities;
1. Hyperactive.
• Patient on the move all the time.
• Notice to seat even a second.
 2. Speech :(pressure of speech)

• Talk and talk all the time until he becomes

horsed.
• Flight of ideas – take this one ,not complete.
• Talk don’t make sense.
3.Memory
Very good memory – hyperamuelsia.
Able to recall incidences which happened long
time ago as if they happened yesterday.
 continuation of manic phase

4.Delusion of granduer.
• The lack of his ideas .
• Talk of their relatives who are very senior.
5.Mood
 They are
 Look happy and cheerful.
 Create infection laughter.
6. Very critical.
• Always make critical negative comment about patient and
staffs.
7 . Very extravagant with money – can spent a lot of money
anyhow.
 Continuation of manic phase
8.Sexual libido – can seduce anybody with no shame at
all.
9. Sleep very little – they can feel that the sleep is not
necessary.
10.At times very destructive properties.
11. If restricted they become aggressive.
12. Can create fight with the patients due to her behavior
(i) critical.
(ii) Interference.
 Causes
• Genetic factor – tend to run from the families.
• Biological factor – ne like the serotonin ,
norepinephrine's.
• Constitutional factors –
• The disease most common to female and the
men.
 Management

• Admission
• A single room to restrict the movement.
• Clean ad well ventilated.
• The room should be almost empty .
• Should be warm.
 Medication
• Haloperidol the drug of choice.
• Dose 1.5 – 12 mgs tds
• Chorpiamazine. 100 – 200g
• Astene.
• Effects.
• E.C.T 6 doses.
• Lithium carbonate sat.
• Given to present the re occurrence.
• Note ;blood lithium level checked once a weeks – 2 MEQ|
L.
 TOXICITY
(i) Gastro intestinal
 Gastric pain
 Vomiting.
 Diarrhea
(ii) Neuro muscles
(iii) Muscle twitching.
(iv )Tenuous.
(v) Alexia.
(Vi) C.N.S
(vii) Confusion
(viii) Comma Death
Feeding

• Level balanced diet.

• Personal hygiene and daily bathe
• Occupation
• Perception
• Psychotherapy
 Prognosis
• Very good if treated early but tend to have
releases
 Hypomania

• Mild level of full brown menia

• Patient have the above symptoms but at the
mild level
• If not treated grows to full brown menia
• RX the sane.
Depressive phase or reaction
• The other reaction the patient present with
• Patient portray the following symptoms
• Simply the patient portrays the opposite
symptoms to the above
Depressed mood
• Patient looks very sad
• Sometimes the patient is tearing
• If asked what he is feeling testifies that he is
feeling very bad
• Facial appearance is gloomy and mask facial
expression no stimulation
Psychomotor activities
• Most of them come with reterntation of psychomotor activities
• All the activities reduced
• Patient feels settled sitting in one place.
• Sit at one place for long
• Don’t want to do anything for long
• Complains of tiredness ,feeling of heaviness of the whole
body, disinterest of everything
• Patient slowed in all her movement
• If the contusions continues they reach stage called stupor
• Here the activities done to zero-may think he is dead
•
 Mental activities
• Also affected
• Mental processing reduced
• Affect the thinking and reasoning leading to speech
retardation
• Patient cant construct a sentence
• Answers questions by one word or simple says I don’t
know or simply keep quiet or simply says she cant think.
Eventually may reach the stage of mutism – no talking at
all.
 Delusions
• Very common with severe depression
• Most common delusion are of
• Guilty delusion
• Suffers from intense guilty feeling
• Beliefs he had done something wrong either to God or nation.
• Feels he has committed a crime he cant be forgiven
• Blame himself for anything
• Appearing like accidents wars
• When the above happen to believe the world punished to his sins
• Because of the above he may wish to die
 Nihilistic delusion
• Another common delusion
• May believe a part of his body is not there like
stomach head mouth
• May even refuse to eat
• May believe he has a terrible disease like
cancer,syphilis,or U.D
• MAY BELIEVE he is dead or part of his body
is dead or believe the relative is dead.
 Hallucinations
• Very rarely present but when there is auditory
hallucinations
• Patients hearing voices accusing him
 Sleeping pattern
• very disturbed sleeping pattern
• Usually they sleep late at night waking up very
early at night at 2 to 3 am.
• On waking up they feel very bad
• They feel hopeless,desparate
• When they look at there past life only see failure in
life
• When they look at there future, they see black
future
 Suicidal ideas
• Develop this because of what they feel
• Usually commit suicide when improving from
depression because after being put on drug the
psychomotor activities improve fast before the
mental status.
• Risk to all the depressed patients
• The ideas is there all through but when he is
psychomotor retardation he cant carry out the act
 Clues
• I wish I were dead
• I wish it were one doing my sleep
• Why cant I be given poison
• The risk is worse if
• There is history of previous attempt
• Family history of suicide
• If the patient has made this clues
 Appetite
• No appetite at all
• Some refuse the food because they want to die
• Others due to delusion
• Other think they are so poor to afford the
hospital food
• Sometimes mays may have to be feed through
the tube.
 Elimination
• They are so depressed to have time to open
there bowls
• Severe constipation
• Distended bladders
 Physical symptoms
• They suffer from severe constipation due to lack of
exercises and also retaining there stools
• Loos of weight due to no feeling, no sleeping, no exercise
• Low blood pressure, low pulse, sexual lipids reduced
• No interest with sex
• Female ligid
• Men becomes impotent
• also complains of body aches here and there
• No menstruation for the females
 Types of depression

• Exogenous depression also called reactive depression or

neurotic depression
• The depression Is usually caused by the external stimulus
• Has a precipitating factor which a patient can easily identify
Like:
 loss of loved one
Loss of status
Loss of valuable items
Sickness
Normally it is not a deep depression
It is cleared by removing the precipitating facts if possible
Respond well on psychotherapy
It is like extended moving
 Endogenous depression
• This is also called psychotic depression
• The depression develops from the individuals or
within
• No precipitating fact the patient may identify
• If there is anything she can point out it is usually a
very trial to send the depression
• May say he is depressed because he abused his
mother 20 years ago.
• This is the type we have described above.
 Difference between the two depression.

Nature of the haleness

• Endogenous – genetically determined
• Exogenous- individual reacting to a problem
he may not be able to solve
 Environment
• Endogenous- the depression not affected by
the environment
• Pleasant environment has nothing to do with it.
• Exogenous-depression lifted marked in
cheerful environment ;e.g. disco.
 Sleeping patterns
• Endogenous-sleep late and wake up early at 2
-3 am
• Exogenous - may or may not be aware of
when they get a problems.
 Physical symptoms

• Endogenous – present.
• Exogenous – very minimal if any are not
released to the diseases
 Self devaluation
• Endogenous –present patient feeling hopeless .
• Exogenous – not present
 Retardation of psychomotor

• Endogenous – present
• Exogenous – not realy there
-Patient complain of tiredness
 Speech
• Endogenous –severely affected
• Exogenous – very talkative patient.
-Anxious.
 Self blame
• Endogenous – blame himself to his problem
• Blame himself for anything.
• Exogenous – blame other people for his
problem.
• Alternatively blame the environment.
 Delusion

• Endogenous – present
• Exogenous – not present
 Insight of their problems
• Endogenous – no insight.
• Exogenous – present
 Evolutional melancholia.

• Sometimes called involutonal depression .

• The attract noticed for the first time from 45 – 50
years of age.
• Mostly common to women at menopause.
• Men are at the retirement from his work.
• The patient is extremely restless.
• Facing up and down all the day.
• Keeps of wriggling their hand.
 Continuation of evolutional
• Keep on mourning about their suffering.
• Also suffers from intense quilt .
• Sometimes could be destructive to their
properties.
• Also are paramount and attack the one they
suspect .
• Also hydrondriacal in nature.
 The person likely to suffer this condition

• A female who is neurotic person.

• Narrow minded person.
• Extremely pussy.
• A perfections.
• Other conscientious.
• Also exaggerate concern for health rigid
people.
• Also ambitious people.
 Note
1.Imipramine – drug of choice for depressed patient with
psychomotor activities.
• Dose 75 – 300mgs per day.

• 2. desprimane – drug of choice for constipated patients,

• Dose 75 – 200 mgs per day.

3 .amitriptyline – choice for major insomnia patient causes

sedation
 Management of the patient.

• Medication .
• Antidepressants.
• Good fertile diseases but takes too long to
produce the effect 3 -4 weeks.
• Tend to increase the neurotic sitters of the
brain.
 Two types
• Tricyclic type
• The first line of treatment.
• Produces less drastic side effects.
• Examples :
• Topsail – (imipramine ) 50 - 150 mgs per day.
• Laroxyl (amitriptyline ) 50 – 150 mgs per day.
• Elavil (typtizol) 30 - 60mgs per day.
 Monoamine ixidase inhibitors (M.A.C)

• The second life of management.

• Also takes long like the above usually produce
severe side effects.
• Only preferred if a patient don’t respond for
the first group.
• Note : act by inhibit monoamine oxidase
which destroys monoamine neuro sitters in the
brain.
 Example
• Nadal (phenelzinze ) 15 – 75mgs
• Parnale (tranylcypromine ) 10 – 30 mgs
• niamid (50 – 100mgs
• Note :age meal
• Cheese .
• Wine
• bear .
• chicken
 General side effect
• Dry mouth
• Dizziness.
• Blood pressure and pulse rate .
• Constipation
• sedative effects
 E.C.T
• The best form of treatment for the patient.
• Act quickly especially the patient is suicidal.
After that the patient put out antidepressant.
• 6 doses given.
• Most of the patient improve first.
 Psychotherapy
• Good especially after the patient improves.
• But the best treatment for the exogamic type
of depression

• Continuation of phenothiazine + antidepre if

there is delusions.
• Severe depression.
 Nursing care of the patient
• Admission
• Clean environment.
• Well ventilated room.
• The bed should be clean and warm.
• Make sure admitted in the cube with other
patient due to suicidal risks.
• Again feel very bad if admitted in single room.
 Medication
• Must be given strictly .
• Ensure he has swallowed her drugs .
• Check their mouth before you leave .
• If no energy to swallow then crush the m
together and ensure he has swallowed.
• Occasionally use injections.
 Communication
• Patient may not be talking but explain the
;procedure
• Should be simple and understanding.
• If you ask a question expect ayes or no.
• don’t force a patient to construct a sentence
hence frustrated or depressed.
 Staffs

• Should be kin d to the patient.

• Should respect the patient and avoid critics.
• Don’t make negative comment to him
• Be patient with him when you ask anything
because you know he is slow.
• Give her all the time for to do all her activities.
 Feeding
• Ensure he has eaten his meal.
• May have to fed him with spoon,
• Occasionally may have to fed him through
tube .especially stupor.
• Ensure All the meals have been taken.
• Ensure he has enough fluids. etc. if on tube
feeding maintain fluids chest.
 Security
• Patient likely to be beaten by the other patient
be with him all the time.
• Make sure you remove all the items which can
be used as weapon by the other patients.
 Psychological support.

• Very important to him

 Protection from suicide.

• Patient observed for 24 hours.

• A nurse assigned to her 24 hours and should be handed over.
• Every where the nurse is should be able to see him.
• Check his bed daily and keep the items he can use.
• Should not go out of the ward alone.
• Ask the relative not to bring thing to her, she can use like razor
blade..
• Talk to her and asses if she has an idea.
• Try to remove the patient from the idea.
• Address him by his name.
• Explain all the procedure to him although he may not respond
 Offer yourself to him.

• Sitting with him after the activities .

• May not be even talking but just there feels
recognized and accepted by the staffs.
• Please avoid comments like pull yourself gentle
man.
• Stand up and join the others – the patient interpret
that as the abuse and make him more depressed.
• But slight press on the should cause a lot of support
 Elimination.

• Don't eliminate.
• Ensure he has opened the bowel
• Encourage some exercises no matter how
slight the patient is.
• Also feed with a lot of roughage to prevent
constipation.
• Allow a lot of fluids.
 Counsel him about the future

• He feels hopeless and don’t see his future.

• Let him know he is important.
• Let her view the future with promise.
• Remind him of all good thing she has done.
• Let her see the good side of her.
 General care
• Ensure he has a bath daily.
• Give her some exercises to encourage blood
circulation.
• Ensure her he is taken care of.
• Nails cut shot .
• Her uniform cleaned and her bedding changed
if possible
 Occupation

• Ensure he is occupied to prevent hathucination.

• Also to prevent them from being bored.
• Also a form of socializing him with others.
• Give the patient some task to perform.
• To start with the simple one he can do without any
problem.
• If too complicated frustrate him more depression.
• Also don’t give dirty task.
• Patient believe he is helpful so you will be reinforcing that
believe.
 Group therapy

• Involve him into the group.

• Review problems affecting him and gain
insights of his problem.
• Family therapy also good.
 Recreational activities.

• Good to him like foot ball , dance.

Rehabilitations.
• To the routines .
• Prepare for discharge.