Chapter II: Symptoms and Psychosocial Assessments

Depressive Disorder

Amongst the general psychiatric disorders, mood disorders are most common: One-fourth of all patients in public mental health facilities have such disorders. Additionally, 65% of all psychiatric outpatients, as well as 10% of all patients seen in other clinical settings, have one or more mood disorders. Even amongst the generally healthy population, more than 20% of women and 10% of men are expected to experience a mood disorder over the course of their life (Beers et. al., 1999). Some symptoms of mood disorders are relatively common and difficult to detect, but it is possible to assess a person for Depressive or Bipolar Disorder if a professional knows what symptoms to look for.

Therefore, it becomes critical for social workers, nurses and other professionals to understand what symptoms define these disorders and how to differentiate these symptoms from normal behavior. A final decision regarding the diagnosis of the disorder, the viability of the suggested treatment, as well the preblockedion of medicine needed for the cure, depend on the analysis made by a licensed doctor or qualified expert. It is important to know what to look for so that proper referrals and recommendations can be made when required.

With regard to the symptoms of Clinical Depression, it must be clarified that not every individual will experience all of the symptoms, and the intensity of the symptom may vary during the day, or over a period of time. Additionally, the elderly, children, men and women may exhibit different symptoms; therefore, an awareness of the person’s demographics and social background is also important. The list of symptoms for Depressive Disorder includes

• A depressed mood for the majority of the day on a continual basis. In the case of children or young adolescents the mood can be defined as highly irritable by observers.
• A loss of interest or an inability to get pleasure from the activities of life.
• The patient may report feeling sad or having “a feeling of emptiness” inside themselves. Observations made by others regarding the situation of the patient can be helpful in this case since they can tell the professional if they have seen or heard the person cry, and how frequently such episodes have occurred.
• Signs of sleeping too much or sleeping too little.
• Sudden positive or negative change in weight with decreased or increased appetites reflected in daily intake of food. The symptom in children may be a lack of normal weight gain.
• Observed condition of lowered activity levels, stopping exercise or other regular ambulation. This does not include a self-described feeling of being restless or feeling slow.
• Continually feeling tired, lethargic or experiencing a loss of energy.
• Guilt ridden emotions (possibly delusional) and feeling worthless.
• Displaying a lack of concentration, indecision, or diminished judgment; disabilities which can be self reported or observed by others.
• Suicidal thoughts which can be with or without an attempt or a plan.
• Anxiety over meeting new people (usually displayed by children).
• Physical Symptoms such as aches and pains without injuries or illness (more common in children).
• Talking about or trying to run away from home (commonly present in children).
• Destructive behavior (usually displayed by children).

A person with Major Depressive Disorder will exhibit five or more of the symptoms listed above, and at least one of the symptoms would be having a depressed mood or losing interest in the pleasures of life (Bland, 1997). Of course, nurses and other professionals need to be aware of symptoms which have been caused by mood altering drugs, other medical conditions, or any hallucinations experienced by the patient. A person can exhibit one or more of these symptoms even if they are perfectly normal; therefore, the assessment criteria adds the qualification that the severity of the symptoms should be high enough to cause distress to the patient, or cause difficulties in the work environment or other social situations like being at school (AACAP, 2004).

With this, as in any diagnosis, the healthcare professional should rule out other causes of the symptoms.There is a common misconception that elder people are supposed to feel depressed and it is normal for them to be depressed because of their age; however, many older people continue to live normal and happy lives despite their age. The symptoms described above can affect anyone at any age; therefore, these symptoms should not be ignored when examining or meeting older individuals. An older person may not be able to engage in activities he once enjoyed, and may even show some signs of depression due to medication or feeling weak, but such signs could also be indicative of Major Depressive Disorder, especially if there is no medication involved.

Additionally, other sources for the symptoms described should be eliminated while making an assessment. For example, a person undergoing the physiological effects of substance abuse could experience the same symptoms on a daily basis. Similarly, a person who is experiencing the side effects of certain medication could also report the same effects. Even certain medical conditions (e.g. hypothyroidism) could manifest themselves with similar symptoms (Schulberg & Burns, 1988). Social factors, like losing one’s job or the loss of a loved one, can also be used to account for the conditions mentioned above rather than clinical depression. Lastly, the symptoms described by the subject should not exhibit any elements from the manic episode of Bipolar Disorder.

The Bipolar Disorder

The development of Bipolar Disorder causes a shifting mood that swings like a pendulum between two extreme sets of symptoms. They are quite different from the normal changes in energy or mood levels which a person may go through during the day since the symptoms are usually quite severe (Licinio, 2005). The person who is afflicted with Bipolar Disorder can have considerable difficulties in successfully maintaining social/intimate relationships, a sustained performance level at school or work, and may even commit suicide during a state of an extreme low (Pelkonen & Marttunen, 2003). Commonly, the Bipolar Disorder develops in a person’s early adult years, although in some cases even children or the elderly can exhibit the symptoms associated with the disorder (Sajatovic, 2002).

As a mental disorder, it is notoriously difficult to diagnose because the patient moves between various moods with periods of normalcy in between (Foltz, 2006). In relation to the Depression Disorder, the treatment period may be considerably longer, and the management of this disease is quite difficult without family or other forms of social support groups (Feirman, 2005). The basic symptom of this disorder is mood swings where one state is mania and the other is depression. Along with the mood, the mental state, personal abilities and exhibited energy levels of the individual are also changed. For example, in a state of mania or during the manic episode, the patient may:

• Behave in a hyper-energetic, overactive or aggressive manner
• Show signs of an extremely good mood going towards a state of euphoria
• Have rapid thoughts coming to mind
• Jump from topic to topic, even in simple discussions
• Show a lack of concentration
• Need only a few hours or minutes of rest before feeling fully charged
• Have delusions of grandeur and unrealistic faith in his/her abilities
• Display an increased sex drive
• Put him/herself and others at a risk of bodily harm
• Refuse to accept that anything is wrong with him/her
• Display a lack of judgment with poor decision making skills
• Spend a lot of money needlessly
• Show reckless behavior

Become irritable (only part of a diagnosis if four additional symptoms from the list are also present) If one or more of the symptoms listed above are present in a person for the majority of the time they are awake, and the symptoms last for a week or longer, then the person can be diagnosed as going through a manic episode. Additionally, a change in the mood which describes a depressive episode must also be detected before the diagnosis of Bipolar Disorder can be confirmed. The depressive episode displays symptoms such as:

• A gloomy, uneasy or empty mood
• A pessimistic attitude towards life
• Feelings of despair, guilt or loss of self-esteem
• A loss of physical and mental energies
• Memory loss coupled with an inability to recall or make decisions
• Insomnia or sleeping too much
• A feeling or restlessness
• Chronic pain in the body which is not attributable to any illness or injury
• Changes in eating behaviors
• Thoughts of death and suicidal tendencies

If five or more of these symptoms are present then a possible diagnosis of a depressive episode with Bipolar Disorder can be made.

A case of Bipolar Disorder where the manic episode is mild (Hypomania) may feel quite good to the person experiencing it. In fact, a good mood may even cause a person to improve their work output and enhance their social functions beyond normal abilities. However, it must be recognized that it is a temporary state and, without proper therapy and treatment, the case of Hypomania may become a situation with severe mania or Clinical Depression coupled with Psychosis (Bland, 1997).

If an individual has mood shifts between the manic state and the depressive state more than four times in a given year the disorder is called Rapid-Cycle Bipolar Disorder. Some individuals may even experience four or more episodes within a seven day period, or even during the course of a single day. In rare cases, a person may enter into a Mixed Bipolar State where he experiences both the symptoms of a manic episode, as well as symptoms of a depressive episode. For instance, a patient may describe feeling extremely depressed and sad while having suicidal thoughts, yet feel energized and refuse to accept that anything is wrong with him (Feirman, 2005).

Quick shifts in a person’s mood also indicate that the disease has entered its later stages and the patient is in need of immediate medical assistance. With effective treatment, the disease can often be brought down to a manageable level, although a small percentage of individuals will continue to experience residual symptoms throughout their lives (Sajatovic, 2002). While many people can live healthy and unaffected lives while having Bipolar Disorder, they often need to depend on medications and other control methods to maintain a normal living standard.

Psychosis

Patients suffering from Bipolar Disorder or Clinical Depression can both experience certain elements of psychosis of which the primary symptoms are hallucinations and delusions. In terms of hallucinations, a person can hear or see things which are not present in the room. The delusions, on the other hand, are internalized with manic episodes, creating images of grandeur and strength, such as believing oneself to be particularly powerful or wealthy. The delusions of a depressive episode come with an idea that the patient is guilty of something terrible or has no social standing whatsoever (Tyrka et. al., 2006). Interestingly, these are also the symptoms of schizophrenia, which can complicate the diagnostic or assessment process for both Bipolar Disorder and Clinical Depression (Foltz, 2006).

Psychosocial Assessment of Mood Disorders

An assessment regarding mood disorders can be made by a medical practitioner, family therapist, or a social worker. The purpose of the assessment is to understand the patients’ current psychological behavior and to examine the sources of stress within the person’s environment which could be leading to or contributing towards the mood disorder. Fundamentally, the assessment seeks to review the psychological as well as social development of the individual and understand how the patient’s background could have an influence on their present state (Foster, 2005).

As noted earlier, a patient’s family history and genetic make up connects directly with the incidence of Bipolar and Depression Disorders; therefore, the psychosocial assessment has to look at the family background and incidents of mood disorders in the patient’s family. The assessment made by the field professional becomes a very important and a well-assessed patient would have better chances of making a full recovery (Foltz, 2006).

Nurses, as well as social service officers, should make sure that the psychosocial assessment is not delayed and an attempt should be made to complete the assessment as soon as first contact is made with the patient. Information can be added to the assessment over time, but the sooner it is started and completed the better. There can be situations where it is impossible to interview a person since she may be comatose, mentally unable to comprehend or respond to the questions, or even refuse to talk to the service provider. In these cases it might be more prudent to complete as much of the assessment as is possible with the help of family members or friends and neighbors (Foster, 2005).

The assessment looks for many different social and psychological problems which a patient may have. These cover a wide range of findings of present problems including medical issues like diabetes, high blood pressure, and obesity. It also looks at psychological problems such as disorientation, hallucinations, lack of concentration, obsessive thoughts, sleep disturbances, sexual preoccupation and aggressiveness. The social situations are examined by looking at things such as legal issues, family conflicts, homelessness, language barriers, even attitude towards religion (Foster, 2005). Of course, there are legal implications/limitations concerning confidentiality and privacy (i.e.: suspected child abuse, etc) while such an examination is being conducted and those need to be clarified to the patient before an assessment is to be made.

An assessment of the social and psychological conditions of the case would be incomplete without noting the set of assets and liabilities which a patient has (Foster, 2005). For example, the assets with a patient which could help in the recovery and treatment of the mood disorder are as follows:

• Level of Education
• Employment Status
• Understanding of personal problems
• Motivation for treatment
• Family or other social support network

Even a person’s sense of humor and willingness to cooperate with social workers and medical professionals is an asset for treatment. On the other hand, a patient can also have liabilities which hinder the treatment that must be noted in the assessment process. These liabilities are as follows:

• Lack of support from family or social groups
• Legal or financial issues towards getting help
• Recent loss of a job or healthcare coverage
• Present living conditions

A person may even have religious/cultural conflicts with the idea of getting treatment for a mood disorder which could act as a liability towards the help offered to the patient. Again, these things need to be recorded in the assessment so a proper treatment plan can be formulated (Foster, 2005).

For minors, the required signatures and acceptance forms should be filled out by a parent or present guardian. The patient’s family and loved ones can also be interviewed in the process if the patient gives his/her consent for them to be questioned. The family members of the patient can be quite useful in giving information about mental illness in the family or other cases of mood disorders experienced by siblings of the patient (Donahue & Fristad, 2005). If cases of mental illness or mood disorders are present, then it is important to know which treatments were given to the family members and which worked for them.

It must be remembered that the more detail which can be gathered about the patient the better the assessment would be. When looking at symptoms the aim should be to find out the complete history of symptoms. For example, when did the patient start experiencing them, the level of their severity and was there ever a time when the symptoms diminished? The assessment should also inquire about previous treatments given to the patient and get an understanding about the patient’s drug and alcohol use. Quite often, even asking the patient directly if she feels depressed would help in judging the presence or absence of a mood disorder (Foster, 2005).

Throughout the process of obtaining information for a psychosocial assessment, the nurse or social worker should be on the lookout for the patient’s deblockedions of feelings and emotions or signs which suggest that the patient is suffering from one or more mood disorders. Finally, the process requires that a patient should be informed if others will be allowed to see the information to be involved in the treatment or review process (Foster, 2005). Once the assessment is complete, and a positive diagnosis has been made by a qualified physician, then the treatment of the patient can start in earnest.