From the given case study it has been found that the patient (Sally) was experiencing mood disorders and this started just she and her husband met with an accident resulting in the death of him. Sally showed various signs of mood disorders such as she tried killing herself, started to hear voices, was feeling the presence of someone even if no one was there. Sally took medications but the medications didn’t provide her of any relief. Sally was diagnosed with psychotic depression which further lead to deterioration of her health. Depression is a lifelong psychological disorder that occurs in changes of mood, feeling, actions and physical health This is a common yet harmful or debilitating disease which can destroy a person's will to function and causes even the easiest daily activities to degrade or there can be complete loss of functions. Aside from the ongoing nature of this psychological condition, the symptoms sometimes replicate themselves and are life-threatening. Depression is a heterogeneous condition that is often confused for a particular medical illness in clinical culture. There are several causes of depression which can be less to very intense as psychotic depression in which patients suffer symptoms of psychotic episodes (Fekadu, Shibeshi, & Engidawork, 2017). Psychotic disorder or severe depression with psychotic symptoms is a medical illness when a person suffers from the mix of depressive and delusional behaviour, the psychosis typically being a nihilistic paranoia, feels horrible things are happening or are going to happen (Rothschild, 2013). The pathophysiology has been difficult to elucidate because of the clinical and etiological heterogeneity of the major depressive disorder. The Corticotropin release hormone (CRH) has been shown to be released from hypothalamus in a response to psychological stress in cortical brain regions when the stress hormones and cytokines have been examined (Rothschild,2013). This hormone activates the secretion of the corticotropin pituitary, which induces the adrenal gland to release cortisol to plasma. The physiological response to stress is sexual in part: women are usually more to stress than men, correlated with the increased prevalence of severe depression among women. There is convergent evidence that CRH plays a significant role in pathogenesizing certain forms of depression. Furthermore, CRH induces numerous physiological and behavioural modifications that elicit extreme depressive symptoms, including reduced appetite, disrupted sleep, lowered libido and psychomotor alterations. Over the course of the disorder, there are high chances for depressive symptoms alter. Typically the first episode is "reactive,"i.e. triggered by large psychological distress, and the following episodes are getting more and more "endogous," i.e. randomly induced by low stressors. It has been clearly shown that hippocampal volume reduction and other brain regions are associated with depression duration, suggesting that unresolved depression leads to hippocampal dysfunction, which may lead to increased stress intensity and increased recurrence danger (Hasler, 2010).
B) Various hypotheses or theories relevant to psychotic depression and how they act to cause symptoms of psychotic depression have been recorded. One of the hypothesis is Serotonin hypothesis,Serotonin is a monoamine neurotransmitter whose distribution across the central nervous system is broad It interacts with biochemical functions such as discomfort, appetite regulation, with the regulation of aggression and behavior. System malfunction of serotonergic system was correlated to anxiety and mood disorders. The cause for this can be that the first antidepressant medications were able to recover the diminished activity of monoamine in the brain(Fekadu, Shibeshi, &Engidawork, 2017). Later on it was seen that SSRIs alone were adequate to effectively treat depression symptoms. This reality further confirmed the role of 5-HT in disease pathogenesis. The other hypothesis would be Neurothrophic hypothesis according to which prefrontal cortex and hippocampal areas, neurotrophic hypothesis results in depression and reduced activity of nerve growth factors (NGFs), such as BDNF (Fekadu, Shibeshi, &Engidawork, 2017). BDNF is an essential regulator of genomic developers and plasticity regulator. It improves the neuron's survival, promotes dendrites' growth and improves backbone density and includes the maturation of exciting synapses which are essential to the learning and adjustment processes which seem to be deficient in depression. Neuropeptides and Psychotic disorder hypothesis evidence suggests that such neuropeptides are involved in stress induced behaviour and attitude regulations by responding to neurokinine receptors type 1 (NK1). The substance P (SP), noted for its wide distribution in the brain and its position with 5-HT and NE neurons, is one of these neuropeptides. Higher concentrations of CSF SP after exposure to a traumatic stimulus were identified in depressed patients and patients with PTSD. In addition, it has been shown that central SP administration causes a response to stress. The antidepressant activity of the NK-1 antagonists confirms this. Genetic susceptibility and contact with the environment is now a convincing case for surface depression since a complex gene-environmental interaction needs to be established which will further modify an individual response to stressful situations(Fekadu, Shibeshi, & Engidawork, 2017). The hypothalamic hormone arginine vasopressin (AVP) induces some of the main signs of the major depressive disorder. In patients with this mental condition, the level of theseeen to be high.AVP has a role inhe management of stress, one of the key features of depression, since AVP interacts with CRF at the hypophysical stage, which causes ACTH release. Elevated concentrations of AVP in patients with psychotic depressive disorder are also associated with psychomotor retardation (Krishnan, & Nestler,2010).
Clinical nursing care should start with clinical reasoning cycle at the first 24 hour of the episode and should focus upon subjective and objective cues. The subjective cues in the given case scenario are unable to deal with or seek help, interruption of sleep, fatigue, abuse of chemical agents, symptoms of muscle or emotional stress, and reduction of patient's appetite. The objectives cues are lack of goals or problem-solving issues, weak problem solving process, reduced use of social support, inadequate fulfilment of desires, essential needs and unhealthy acts (e.g. excessive consumption, smoking / drink, overuse of prescription / OTC drugs and illicit drug consumption) and in this suicidal tendencies as the patient said that she tried committing suicide after the death of her husband (Gummesson, C., Sundén, A. and Fex, A., 2018). In the case of psychotic depression, the various interventions which can be proposed include: providing the patient with physical requirements. Care for personal health and self-care. Encourage the patient to eat food or eat food with them. Give warm milk or rub their back to improve bedtime sleep. Schedule workouts for instances when the individual’s stress magnitude increases, actively participate in the negotiation process.
The very first approach should be be done with patient assessment. As several health disorders may have symptoms similar to endogenous hysteria, euphoria, or other acute psychological disorders, except medical etiologies for symptoms, medical aetiology is necessary before psychiatric care starts. It is particularly important to distinguish between delirium and psychosis; the misdiagnosis and treatment of delirium as a psychoses can endanger life (Zeller, 2010). Speaking slowly and allowing them enough time to reply, encouraging them to communicate, to compose their thoughts, and having a structured plan that may involve a non - cooperative activity can be a good start. Provide patient details about the disorder, explain that expressing feelings and taking part in enjoyable experiences will alleviate depression, help patients understand and relate unrealistic perceptions to their psychotic depression.. Emphasize upon the need to comply with medicine. Extension of the understanding of our own behaviour-compatible skills and feelings or capable of fulfilling the physiological needs shown by an effective expression of feelings, recognition of alternatives and use of resources, and provision of long lasting needs and behaviours to patients, and guaranteeing the existence of support services or relevant references.
Various non pharmacological interventions can be given in the case of Sally such as cognitive behavioural therapy, family counseling. According to the NHS (n.d)report on cognitive therapy, cognitive behavioural therapy ( CBT) includes a speech therapist who can assist one to solve their issues by improving your thoughts and behaviour. CBT is based on the idea of being interwoven with desires, beliefs, bodily interactions and acts and of being drawn into a swirling vortex of negative thoughts and feelings. By breaking it into smaller pieces, CBT allows you to deal more constructively with overwhelming challenges. In the given case through CBT, the patient can be explained that how such pessimistic thoughts can be modified to elevate her mood in the context of her feeling anxious or frightened all the time. Family counselling is a formal type of psychotherapy that aims to minimise anxiety and tension by strengthening the family members' relationship mechanisms. It is an effective therapy tool to help family members adapt to an extended family member that is dealing with an illness, medical problem or condition of mental health. Family therapists, in particular, are relational therapist and are usuallyost interested in what happens within people, rather than between one or more people((Varghese, Kirpekar, &Loganathan,2020). Based on the issues nd the results of treatment to date, a psychiatrist might concentrate on examining individual historical cases of confrontation, such as evaluating a past occurrence and recommending different ways in which family members may have responded to it, or pointing out relationship trends that may not have been observed by the patient(Varghese, Kirpekar, &Loganathan,2020).
Some suggest treatment recommendations pairing an antidepressant and an antipsychotic. However, there is still controversy as to whether antipsychotic combinations with an antidepressant are more successful than antidepressant or antipsychotic monotherapy. According to practise, antidepressants function against depression and antipsychotics operate toward insanity. Thus, it seems to be natural to treat psychotic symptoms with antipsychotic and suicidal tendencies with antidepressant. In Sally’s case antidepressants such as Lorpiprazole woud help since it prevents serotonin, dopamine reuptake and further antagonizes adrenergic receptors (Jarema et al, 2011). However, since psychotic illness is known to be the utmost serious type of disorder, and where hysteria is regarded as the distal result of that intensity, medication with an antidepressant alone would seem rational. In the other hand, it is not feasible to handle an antipsychotic entirely, in fact one of the newest atypical antipsychotics with potential antidepressant effects ruling out (Wijkstra, 2017)
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