Schizophrenia
Etiology
Definition
• Considered as a heterogenous disorder, a group of several
distinct collection of disorders with some common features
like disturbance in thinking and an extreme occupation within
self and inner fantasies
• Cannot be defined as a single illness, rather, schizophrenia
is thought of as a syndrome or disease process with many
different varieties and symptoms
• Diagnosed in late adolescence or early adulthood
• Peak incidence of onset:
o Men: 15 to 25 years of age
o Women: 25 to 35 years of age
• DSM – IV – TR
1. Paranoid Type Schizophrenia
o Characterized by persecutory (feeling
victimized or spied on) or grandiose
delusions, hallucinations and occasionally,
excessive religiosity (delusional religious
focus) or hostile and aggressive behavior
2. Disorganized Type Schizophrenia
o Characterized by grossly inappropriate of flat
affect, incoherence, loose associations and
extremely disorganized behavior
3. Catatonic Type Schizophrenia
o Characterized by marked psychomotor
disturbance, either motionless or excessive
motor activity
o Motor immobility may be manifested by
catalepsy (waxy flexibility) or stupor
o Excessive motor activity is apparently
purposeless and is not influenced by external
stimuli
o Other features include extreme negativism,
mutism, peculiarities of voluntary movement,
echolalia and echopraxia
4. Undifferentiated Type Schizophrenia
o Characterized by mixed schizophrenic
symptoms (of other types) along with
disturbances of thought, affect and behavior
5. Residual Type Schizophrenia
o Characterized by at least one previous,
though not a current, episode, social
withdrawal, flat affect and looseness of
associations
• Related Disorders
1. Schizophreniform Disorder
o Exhibits s/s of schizophrenia but for less than
the 6 months necessary to meet the
diagnostic criteria
o Social or occupational functioning may or
may not be impaired
2. Schizoaffective Disorder
o Exhibits s/s of psychosis and, at the same
time, all the features of a mood disorder,
either depression or mania
3. Delusional Disorder
o Has one or more nonbizarre delusions – that
is, the focus of the delusion is believable
o Psychosocial functioning is nor markedly
impaired and behavior is not obviously odd or
bizarre
4. Brief Psychotic Disorder
o Experiences sudden onset of at least
psychotic symptom, such as delusions,
hallucinations or disorganized speech or
behavior which lasts from 1 day to 1 month
5. Shared Psychotic Disorder
o Two people share a similar delusion
o Develops this delusion in context of a close
relationship with someone who has psychotic
delusions
• Interpersonal theorists suggested that schizophrenia
resulted from dysfunctional relationships in early life and
adolescence
• Some therapists believe that schizophrenia results from
dysfunctional parenting or family dynamics
• Results from a type of brain dysfunction
o Neurochemical/neurologic theories are supported by
the effects of antipsychotic medications, which help to
control psychotic symptoms and neuroimaging tools
such as CT scan, which shown that the brains of people
with schizophrenia differ in structure and function from
the brains of control subjects
• Biologic Theories
o Focus on genetic factors, neuroanatomic and
neurochemical factors (structure and function of the
brain) and immunovirology (the body’s response to
exposure to a virus)
1. Genetic Factors
§ The closer the family relationship, the higher the
incidence of schizophrenia in the relatives
§ Identical Twins have a 50% risk for Schizo
§ Fraternal Twins have 15% risk for Schizo
§ Children with one biologic parent with
schizophrenia have a 15% risk
§ Children with both biologic parents with
schizophrenia have 35% risk
§ More recently, the results of research studies have
suggested that schizophrenia seems to occur
through the interaction of a genetic susceptibility
with some kind of environmental stress
2. Neuroanatomic Factors
§ People with schizophrenia have relatively less
brain tissue and cerebrospinal fluid
§ Thus, presenting a failure in development or a
subsequent loss of tissue
§ CT scans show enlarged ventricles in the brain,
cortical atrophy, and disturbances in cerebral
metabolism and electrical activity
§ PET studies suggest glucose metabolism and
oxygen are diminished in the frontal cortical
structures of the brain
§ Research consistently shows a decreased brain
volume and abnormal brain function in the frontal
and temporal areas of person with schizophrenia
o Positive Signs – Temporal Lobe
o Negative Signs – Frontal Lobe
§ Intrauterine influences such as poor nutrition,
tobacco, alcohol and other drugs and stress also
are being studied as possible causes of the brain
pathology found in people with schizophrenia
3. Neurochemical Factors
§ Links schizophrenia to certain patterns of
hemispheric dysfunction of the brain
o Left hemisphere overactivation and
consequent temporal abnormalities and
delays in processing sensory information
§ Alterations in the neurotransmitter systems of the
brain in people with schizophrenia
o Malfunction in the neuronal networks that
transmit information by electrical signals from
a nerve cells through its axon and across the
synapses to post synaptic receptors on other
nerve cells
§ On theory suggest that excess dopamine is the
cause of schizophrenia (based on two
observations)
o Drugs that increase activity in the
dopaminergic system, such as amphetamine
and levodopa, sometimes induce a paranoid
psychotic reaction similar to schizophrenia
 o Drugs blocking postsynaptic dopamine
receptors reduce psychotic symptoms
o The greater the ability of the drug to block
dopamine receptors, the more effective it is in
decreasing symptoms of schizophrenia
§ Serotonin has been included among the
leading neurochemical factors affecting
schizophrenia
o Serotonin modulates and helps to
control excess dopamine
4. Immunovirologic Factors
§ Exposure to a virus of the body’s immune
response to a virus could alter the brain
physiology of people with schizophrenia
§ It is believed that cytokines may have a role in the
development of major psychiatric disorders such
as schizophrenia
o Cytokines are chemical messengers between
immune cells, mediating inflammatory and
immune responses
o Specific cytokines also play a role in signaling
the brain to produce behavioral and
neurochemical changes needed in the face of
physical or psychological stress to maintain
homeostasis
Symptomatology
• Positive or Hard Symptoms
o Represent a distortion or exaggeration of normal
functions
o Delusions, hallucinations and grossly disorganized
thinking, speech and behavior
• Negative or Soft Symptoms
o Represent a diminution or loss of function
o Flat affect, lack of volition and social withdrawal or
discomfort
o Presents a major barrier to recovery and improved
functioning in the client’s daily life
• Medications can control the positive symptoms, but
frequently the negative symptoms persist after positive
symptoms have occurred
• According to Eugene Bleuler
o Fundamental symptoms or Four A’s
1. Associative looseness or disturbance
2. Apathy or affective disorder, that is a flat or
blunted affect
3. Autism, detachment from external reality and
withdrawal from fantasies
4. Ambivalence, simultaneous existence of
opposing feelings, thoughts and desires
5. Auditory hallucinations
• Clinical Course
Onset
§ May be abrupt and insidious
§ Slowly and gradually develops s/s of social
withdrawal, unusual behavior, loss of interest in
school or work and neglected hygiene
§ Diagnosis of Schizophrenia
o Made when the patient begins to display
more actively positive symptoms of
delusions, hallucinations and disordered
thinking (psychosis)
Immediate Course
§ First Pattern: Experiences on – going psychosis
and never fully recovers
§ Second Pattern: Experiences episodes of
psychotic symptoms that alternate with episodes
of relatively complete recovery from the psychosis
Long – Term Course
§ Regain some degree of social and occupational
functioning
§ Disease become less disruptive to life and easier
to manage
§ Early detection and aggressive treatment of the
first psychotic episode are associated with
improved outcomes
Medical Management
a. Laboratory Tests
a. CT scans show enlarged ventricles in the brain, cortical
atrophy, and disturbances in cerebral metabolism and
electrical activity
b. PET studies suggest glucose metabolism and oxygen are
diminished in the frontal cortical structures of the brain
b. Medications and Treatments
Psychopharmacology
o Past: Electroconvulsive therapy, insulin shock
therapy and psychosurgery were used
o 1952: Thorazine
o Antipsychotic Medications or Neuroleptics
§ Prescribed to decrease psychotic
symptoms
§ Do not sure schizophrenia but manages
the symptoms of the disease
o Atypical, Antipsychotic Medications
§ Are both dopamine and serotonin
antagonists
o Conventional Antipsychotic
§ Target positive symptoms of
schizophrenia
§ Delusions, hallucinations, disturbed
thinking and other psychotic symptoms,
but have no observable effects on the
negative signs
o Atypical Antipsychotic
§ Not only diminish positive symptoms
§ Lessens the negative signs of lack of
volition and motivation, social
withdrawal and anhedonia
• Maintenance Therapy
o Fluphenazine (Prolixin)
o Haloperidol (Haldol)
o Vehicle for depot injections is sesame oil
(therefore absorbed slowly over time into the
client’s system)
o Effects last 2 to 4 weeks eliminating the need for
daily oral antipsychotic medications
• Side Effects
o From mild discomfort to permanent movement
disorders
1. Extrapyramidal Side Effects
§ Reversible movement disorders induced by
neuroleptic medication
§ Include dystonic reactions, parkinsonism and
akathisia
§ Dystonic reactions
• Appear early in the course of treatment
and characterized by spasms in discrete
muscle groups such as the neck
muscles or eye muscles
• Spasms may be accompanied by
protrusion of the tongue, dysphagia and
laryngeal/pharyngeal spasm that can
compromise airway
• Treatment: Diphenhydramine (Benadryl)
or Benzotropine (Cogentin)
2. Pseudoparkinsonism
§ “Neuroleptic Induced Parkinsonism”
§ Includes shuffling gait, masklike facies,
continuous muscle stiffness, drooling and
akinesia (slowness and difficulty initiating
movements)
§ Appear in the first few days of starting or
increasing the dosage of an antipsychotic
medications
3. Akathisia
§ Characterized by restless movement, pacing,
inability to remain still and the client’s report
of inner restlessness
 § Happens when the dose is started or d. Keep to simple, basic and reality – based topics of
increased conversation – helps them focus and comprehend
§ Treatment: Beta blockers such as propranolol reality – based issues
or Benzodiazepines e. Work with client to help reduce anxiety and distract
4. Tardive Dyskinesia to hallucinatory materials – remove client to
§ Characterized by abnormal, involuntary stressful environments
movements such as lip smacking, tongue 4. Disturbed thought processes related to biochemical and
protrusion, chewing, blinking, grimacing and neurologic imbalances
choreiform movements of the limbs and feet a. Safety measures to protect clients or others – client
§ Irreversible once it appeared may hurt others and self
§ Take Clozapine (Clozaril) instead b. Identify feelings related to delusions
5. Seizures c. Do not touch client – use gestures carefully – might
§ Infrequent side effects misinterpret as either aggressive or sexual
§ Treatment: Lowered dosage or a different d. Interact with clients on the basis of things in the
antipsychotic medication environment – client will be free from delusional
6. Neuroleptic Malignant Syndrome thinking during the time
§ Serious and frequently fatal condition e. Encourage healthy habits to optimize functioning
§ Characterized by muscle rigidity, high fever, 5. Defensive coping related to perceived threat to hurt self and
increased muscle enzymes and leukocytosis others
§ Treatment: Stopping the medication a. Use a nonjudgmental, respectful and neutral
7. Agranulocytosis approach with the client
§ Potentially fatal side effect of Clozapine b. Be honest and consistent regarding expectations
§ Failure of the bone marrow to produce and enforcing rules – provides an atmosphere in
adequate white blood cells which trust can grow
§ Characterized by malaise, ulceratives, sore c. Use clear and simple language when
throat and leukopenia communicating – minimize opportunity for
§ Treatment: Drug must be discontinued miscommunication
immediately d. Maintain low level of stimuli and enhance
• Psychosocial Treatment nonthreatening environment
o Individual and group therapy session are e. Provide solitary, noncompetitive activities
supportive in nature, giving the client an
opportunity for social contact and meaningful Prognosis
relationships with other people The earlier treatment is started, the better the outcome.
o Family education and therapy are known to During the first 5 years after onset of symptoms, functioning may
diminish the negative side effects of schizophrenia deteriorate and social and work skills may decline, with progressive
and reduce the relapse rate neglect of self-care. Negative symptoms may increase in severity, and
cognitive functioning may decline. Thereafter, the level of disability tends
Nursing Diagnosis and Interventions to plateau. Some evidence suggests that severity of illness may lessen
1. Impaired verbal communication related to biochemical in later life, particularly among women. Spontaneous movement
alteration in the brain of certain neurotransmitters disorders may develop in patients who have severe negative symptoms
a. Plan short, frequent periods with client throughout and cognitive dysfunction, even when antipsychotics are not used.
the day – giving the client a chance to develop
familiarity and safety
b. Use simple words and keep directions simple –
client may have difficulty processing even simple
words
c. Keep voice low and speak slowly – aids
understanding
d. Use therapeutic techniques to understand client’s
concerns – try getting to the feelings behind them
e. Keep the environment quiet and free from stimuli as
possible – may increase confusion and
hallucinations and delusions
2. Impaired social interaction related to impaired thought
processes (hallucinations or delusions)
a. Assess if medication has reached in therapeutic
levels – positive symptoms will subside with
medications
b. Keep client in an environment free from stimuli – to
decrease agitation, anxiety and increased inability
to concentrate
c. Make structured activities – helps client to develop
a sense of safety in a nonthreatening environment
d. Engage patient and SO in social interactions –
client continues to feel safe and competent
e. Provide opportunities for the client to learn adaptive
social skills – helps the client adapt and function at
a higher level in society and increases quality of life
3. Disturbed sensory perception: Auditory and visual related to
neurologic and biochemical changes
a. Environmental precautions – early assessment and
interventions might save lives for suicidal clients
b. Decrease environment stimuli when possible –
decrease potential for anxiety, calm the client
c. Accept the fact that they hear voices, but tell them
that you do not hear them – validate reality
Mood Disorders
Definition and Symptomatology
• Also called as “Affective Disorders” are pervasive alterations
in emotions that are manifested by depression, mania or
both
• Are the most common psychiatric diagnoses associated with
suicide, depression is one of the most important risk factors
for it
• Categories
§ Primary Mood Disorders
o Major Depressive Disorder
§ Lasts at least 2 weeks, during which the person
experiences a depressed mood or loss of
pleasure in nearly all activities
§ Untreated episode of depression an last up to 6
to 24 months before remitting
§ Four of the following symptoms are present
§ Changes in appetite or weight, sleep,
psychomotor activity, decreased energy,
feelings of worthlessness or guilt,
difficulty thinking, concentrating or
making decisions, recurrent thoughts of
death or suicidal ideation, plans or
attempts
§ Result is significant distress or impair
social, occupational or other important
areas of functioning
§ Some have delusions and hallucinations
(psychotic depression)
o Bipolar Disorders
§ Diagnosed when a person’s mood cycles is
between extremes of mania and depression
§ Described as
• Bipolar 1 Disorder – One or more manic
or mixed episodes usually accompanied
by major depressive episodes
• Bipolar 2 Disorder – One or more major
depressive episode accompanied by at
least one hypomanic episode
• May experience a euthymic or normal
mood and affect between extreme
episodes or they may have a depressed
mood swing following a manic episode
before returning to a euthymic mood
ü Mania
§ A defense against depression
characterized by varying degrees of
elation, hyperactivity, agitation and
accelerated thinking and speaking
§ Lasts for 1 week
§ At least three of the following symptoms
accompany the manic episode
• Inflated self – esteem or
grandiosity, decreased need for
sleep, pressured speech, flight of
ideas, distractibility, increased
involvement in goal – directed
activity or psychomotor agitation
and excessive involvement in
pleasure seeking – activities with a
high potential for painful
consequences
• Some also exhibit delusions and
hallucinations during manic
episode
ü Hypomania
§ A period of abnormally and persistently
elevated, expansive or irritable mood
lasting for 4 days and including 3 to 4 of
the additional symptoms described
above
§ Do not impair the person’s ability to
function and there are no psychotic
features (delusions and hallucinations)
ü Mixed Episodes
§ Diagnosed when the person
experiences both mania and depression
nearly every day for at least 1 week
§ Often called “Rapid – Cycling”
• Related Disorders
1. Dysthymic Disorder
o Characterized by at least 2 years of
depressed mood for more days than not with
some additional less severe symptoms that
do not meet the criteria for a major
depressive episode
2. Cyclothymic Disorder
o Characterized by 2 years of numerous
periods of both hypomanic symptoms that do
not meet the criteria for bipolar disorder
3. Substance – Induced Mood Disorder
o Characterized by a prominent and persistent
disturbance in mood that is judged to be a
direct physiological consequence of ingested
substances such as alcohol, other drugs or
toxins
4. Mood Disorder due to a General Medical Condition
o Characterized by prominent and persistent
disturbance in mood that is judged to be a
direct physiological consequence of a
medical condition
§ Degenerative neurological
conditions, cerebrovascular
disease, metabolic or endocrine
conditions, autoimmune disorders,
HIV infections or certain cancers
• Other Disorders
1. Seasonal Affective Disorder (SAD)
o Subtypes
o Winter Depression of Fall – Onset SAD
§ Increased sleep, appetite and
carbohydrate cravings, weight gain,
interpersonal conflict, irritability and
heaviness in the extremities beginning
in late autumn and abating in spring and
summer
o Spring – Onset SAD
§ Insomnia, weight loss, and poor appetite
lasting from late spring or early summer
until early fall
2. Postpartum or “Maternity Blues”
o Characterized by labile mood and affect,
crying spells, sadness, insomnia and anxiety
o Appears 1 day after delivery (Peak at 3 to 7
days)
3. Postpartum Depression
o Meets all the criteria for a major depressive
episode with onset within 4 weeks of delivery
4. Postpartum Psychosis
o Psychotic episode developing within 3 weeks
of delivery beginning with fatigue, sadness,
emotional lability, poor memory and
confusion and progressing to delusions,
hallucinations, poor insight and judgment and
loss of contact with reality
Etiology
o Genetic Theories
o First degree relatives have twice the risk of
developing depressions
o First degree relatives of people with bipolar
disorder have a 3% to 8% risk of developing
bipolar disorder
o For all mood disorders, identical twins have a
concordance rate of 2 to 4 times higher than the
fraternal twins
o Neurochemical Theories
o Serotonin and norepinephrine
 o Serotonin (5 – HT) has many roles in
behavior: mood, activity, aggressiveness and
irritability, cognition, pain, biorhythms and
neuroendocrine disorders
§ Deficits in serotonin found in the blood
or CSF occur in people with depression
o Positron emission tomography (PET) scans
demonstrate reduced metabolism in the
prefrontal cortex, which may promote
depression
o Norepinephrine levels may be deficient in
depression and increased in mania
§ This catecholamine energizes the body
to mobilize during stress and inhibits
kindling (the process by which seizure
activity in a specific area of the brain is
initially stimulated by reaching a
threshold of effects of stress, low
amounts of electric impulses or
chemicals that sensitize nerve cells and
pathways)
§ Anticonvulsants inhibit kindling, this may
explain their efficacy in the treatment of
bipolar disorder
o Neuroendocrine Influences
o Hormonal fluctuations in relation to
depression
o Elevated glucocorticoid activity is associated
with the stress response and increased
cortisol secretion is apparent among
depressive clients
o 5% to 10% of people with depression have
thyroid dysfunction (elevated TSH)
o Psychodynamic Theories
o Freud – real or perceived loss, feeling of
abandonment, loving and hating lost subject
o Bibring – person was not able to achieve
ideals
o Jacobson – ego is powerless, helpless child
victimized by the superego
o Meyer – reaction to a distressing life
experience
o Horney – children raised by rejecting or
unloving parents were prone to feelings of
insecurity and loneliness
o Beck – specific cognitive distortions in
susceptible people
Medical Management
c. Laboratory Tests
o Positron emission tomography (PET) scans demonstrate
reduced metabolism in the prefrontal cortex, which may
promote depression
d. Medications and Treatments
Psychopharmacology
o Cyclic antidepressants, monoamine oxidase
inhibitors (MAOIs), selective serotonin reuptake
inhibitor (SSRIs) and atypical antidepressants
o Depression results if too few neurotransmitters are
released
o Usually presynaptic neurons release these
neurotransmitters to allow them to enter synapses
and link with postsynaptic receptors
§ To do so, antidepressants establish a
blockade for the reuptake of
norepinephrine and serotonin into their
specific nerve terminals
§ This permits them to linger longer in
synapses and to be more available to
postsynaptic receptors
o SSRIs
§ Specific to serotonin reuptake inhibition
§ Produce few sedating, anticholinergic
and cardiovascular side effects, which
makes them safer for use in children
and older adults
§ Prozac produces slightly higher rate of
mild agitation and weight loss but less
somnolence
o Cyclic Antidepressants
§ Blocks the activity of norepinephrine and
serotonin or increasing the sensitivity of
postsynaptic receptors sites
§ Contraindicated in severe impairment of
liver function and myocardial infarction
o Tetracyclic Antidepressants
§ Amoxapine (Asendin) may cause
extrapyramidal symptoms, tardive
dyskinesia and neuroleptic malignant
syndrome
§ Increases appetite and causes
weight gain and cravings for
sweets
§ Maprotilin (Ludiomil) carries a risk of
seizures, severe constipation and
urinary retention and stomatitis
o Atypical antidepressants
§ Has an inadequate response to or side
effects from SSRIs
§ Venlafaxine blocks the reuptake of
serotonin, norepinephrine and dopamine
§ Bupropion inhibits the reuptake of
dopamine and has no effects on
serotonin
§ Nefazodone inhibits the reuptake of
serotonin and norepinephrine and has
few side effects
§ Remeron also inhibits the reuptake of
serotonin and epinephrine, has few
sexual side effects, but has higher
incidence of weight gain, sedation and
anticholinergc side effects
o MAOIs
§ Most serious side effect: Hypertensive crisis
§ A life – threatening condition that can
result when a client taking MAOIs
ingests tyramine – containing foods and
fluids or other medications
§ S/S are occipital headache,
hypertension, nausea and vomiting,
chills, sweating, restlessness, nuchal
rigidity, dilated pupils, fever and motor
agitation
§ Treatment: Phentolamine Mesylate
§ Given to dilate blood vessels ad
decrease vascular resistance
• Other Medical Treatments and Psychotherapy
Electroconvulsive Therapy
o To treat depression who do not respond to
antidepressants or those who experience
intolerable side effects at therapeutic doses
o The shock stimulates brain chemistry to correct
the chemical imbalance of depression
o NPO post midnight, no nail polish, voids just prior
to procedure, IV insertion for medications
o Muscle relaxant: Succinylcholine
Psychotherapy
o A combination of psychotherapy and medications
is considered the most effective treatment for
depressive disorders
o Goals: Symptom remission, psychosocial
restoration, prevention of relapse or recurrence,
reduced secondary consequences and increasing
treatment compliance
o Interpersonal Therapy
o Focuses on difficulties in relationships such
as grief reactions, role disputes and role
transitions
o Behavior therapy
o Increase the frequency of the client’s
positively reinforcing interactions with the
 environment and to decrease negative
interactions
o Cognitive therapy
o Focuses on how the person thinks about
self, others and the future and interprets
his or her experiences
Nursing Diagnosis and Interventions
1. Risk for self – directed violence related to severe depression,
loneliness and social isolation
a. Determine level of suicide precautions needed, have a suicide
plan, admit previous suicide attempts
b. Encourage clients to talk freely about feelings (anger,
disappointments)
c. Help clients plant alternate ways to handle anger and
frustration
d. Implement a no – suicide contract which reinforces action the
client can take when feeling suicidal
e. Contact family, arrange for crisis counseling – to help diminish
personal feelings of worthiness, isolation and helplessness
2. Disturbed thought processes related to severe anxiety or
depressed mood
a. Identify client’s previous level of cognitive functioning (from
client, family, friends and previous medical records) to
evaluate client’s progress
b. Minimize client’s responsibilities while depressed
c. Use simple, concrete words
d. Structure environment that can help re – establish set
schedules and predictable routines during severe depression
e. Work with client to recognize negative thinking and thoughts
– negative ruminations add to feelings of hopelessness
3. Impaired social interaction related to self – concept disturbance
a. While depressed, involve the client in one – to – one activity
to maximize the potential for interactions while minimizing
anxiety levels
b. Engage client in activities involving gross motor activity that
needs limited concentration to elevate mood
c. Eventually increase contact and interaction with others
d. Refer to self – help groups
4. Ineffective coping related to inadequate level of perception of
control
a. Administer anti – manic medication and tranquilizers as
ordered
b. Observe for destructive behavior towards self and others –
early detection and intervention can prevent harm to client or
others
c. Maintain firm, calm and neutral approach at all times to
escalate environmental stimulation and manic activity
d. Assess and recognized signs of manipulative behavior and
intervene appropriately and then set limits
5. Self – care deficit related to cognitive and perceptual impairment
a. Encourage small, high calorie and high – protein snack and
fluids frequently throughout the day
b. Encourage eating with others
c. Provide rest periods after activities
d. Reduce environmental and physical stimulants in the evening
e. Assist in doing hygiene techniques
f. Offer foods high in fiber and provide periods of exercise

Prognosis
Remission after affective episodes is frequently incomplete.
Residual symptoms are common in psychiatric and general practitioner
patients and in cases identified in community studies. Chronic residual
symptoms are those typical of depression: mood, anxiety, genital
symptoms, (24) insomnia, headaches, neurasthenic complaints,
reduced libido, and gastrointestinal symptoms. They are frequently
treated by long-term antidepressant medication, which should not be
withdrawn until the patient has had 4 months completely free of
symptoms.
The long-term outcome of mood disorders is usually
unfavourable. Bipolar disorder has a poorer outcome than depression.