PSYCHIATRIC NURSING Mental Disorders

PSYCHIATRIC NURSINGMental Disorders Sources: Mental Health Nursing, 4th ed., Fontaine & Fletcher, Addison Wesley Longman Inc., 1999 Psychiatric Nursing, NSNA Review Series, National Student Nurses´Association Incorporated, 1994

Mental Disorders • Anxiety Disorders • Eating Disorders • Mood Disorders • Schizophrenic Disorders • Substance-Abuse Disorders • Personality Disorders • Cognitive Impairment Disorders

Anxiety DisordersCategories and Types of Disorders • Anxiety Disorders • Generalized Anxiety Disorder • Panic Disorder: with or without agoraphobia • Obsessive-Compulsive Disorder • Phobic Disorders: Specific, Social, Agoraphobia • Posttraumatic Stress Disorder

Types and categoris of anxiety disorders (cont´d) • Dissociative Disorders • Dissociative Amnesia • Dissociative Fugue • Depersonalization Disorder • Dissociative Identity Disorder • Somatoform Disorders • Somatization Disorder • Conversion Disorder • Pain Disorder • Hypochondriasis • Body Dysmorphic Disorder

ANXIETY DISORDERS Generalized Anxiety Disorder (GAD) • Chronic disorder characterized by persistent anxiety without phobias or panic attacks • Affects more than 5% of the population • Excessive worry about everyday concerns such as paying bills, job performance, etc. • In severe cases, preoccuption with catastrophic thoughts and visions • Overall fatigue, muscular tension and restlessness, especially during and after attacks • This unremitting stress and tension can suppress the immune system and make one more susceptible to disease

ANXIETY DISORDERSPanic Disorder • Panic attack is the highest level of anxiety characterized by disorganized thinking, feelings of terror (premonition of doom), helplessness and nonpurposeful behaviour • Accompanying symptoms with intense symptoms lasting from a few minutes to an hour or so: shortness of breath, hyperventilation, choking sensations, dizziness, tingling, trembling, sweating, chest pain, tachycardia (heart palpitations) • Panic DISORDER is diagnosed when there are recurrent panic attacks • Many people with this disorder develop severly restricted lifestyles which result in chaotic family systems • A variation of panic attack is NOCTURNAL PANIC: panic awakens person usually within 1-4 hours after falling asleep

ANXIETY DISORDERSObsessive-Compulsive Disorder(OCD) • Unwanted repetitive thoughts or behaviours • The thoughts and behaviours are triggered by anxiety and the need for control/the fear of not being in control or losing control. • The often bizarre thoughts and behaviours are attempts to decrease anxiety and feel in control. • Realizing that the person is not controlling them triggers additional anxiety, guilt and shame, which becomes a vicious cycle

Types of OCDs/Obsessions • OBSESSIONS • Fear of dirt, germs, contamination • Fear of something dreadful happening • Constant doubting • Somatic concerns • Aggressive and/or sexual thoughts (inappropriate and dominant) • Religious ideation (morbid preoccupation with supernatural interpretations)

Types of OCDs/Compulsions • COMPULSIONS • Grooming, such as washing hands, showering, bathing, brushing teeth • Cleaning personal space • Repeating movements, such as going in and out of doorways, getting in and out of chairs, touching objects • Checking, e.g. Doors, locks, appliances, written work • Counting silently or out loud • Hoarding • Frequent confession (of anything) • Constant need to ask for reassurance • The need to have objects in fixed positions May be Mild (less than 1 h/day), Moderate (1-3 h/day), Severe (3-8 h/day) or Extreme (nearly constant)

PHOBIC DISORDERS • Specific phobias: fearing a specific object or situation. Usually not disabling unless unavoidable. • Social phobias: fear of social situations. • Agorahobia: the most common and serious phobic disorder. It is a fear of being away from home and alone in public places. • The predominant affective characteristic is FEAR.

POSTTRAUMATIC STRESS SYNDROME (PTSD) • PTSD develops after a dangerous or life-threatening experience • It is acute if the symptoms appear immediately and chronic when symptoms appear months or years later • Traumatic events may result in symptoms of UNDERCONTROL or OVERCONTROL • Those with UNDERCONTROL relive the event. Their diagnosis is PTSD. • Those with OVERCONTROL experience denial and amnesia and are diagnosed as having a dissociative disorder. ### ### ### • Main affective characteristics: chronic tension and fear • Main cognitive characteristics: long-lasting changes in thinking patterns, especially self-image, memory, reasoning and memory • DIAGNOSIS OF PTSD IS GIVEN IF SYMPTOMS PERSIST FOR MORE THAN 4 WEEKS

DISSOCIATIVE DISORDERSCHARACTERISTICS • Alteration in conscious awareness of behaviour, affect, thoughts and memory • Alteration in the consistency of identity – identity loss or multiple identities may develop • All sufferers at times demonstrate behaviour totally different from their usual behaviour • PRECIPATATING FACTOR: often a traumatic event

DISSOCIATIVE DISORDERSTYPES • Dissociative fugue: rare dissociative disorder characterized by wandering off and adopting a new identity for a while. Person may appear oriented or disoriented, but is doing something inconsistent with own personality.

DISSOCIATIVE DISORDERSTYPES • Depersonalization disorder: persistent or recurrent feelings of being detached from one´s body or thoughs or being a robot or living in a dream. Little is known about it.

DISSOCIATIVE DISORDERSTYPES • Dissociative identity disorder (DID): formely called multiple personality disorder. - The most severe form of dissociative disorders. The diagnosis is given when at least two distinct personalities or ”alters” coexist, each having its own value system, memory and complex patterns. - One personality can be ill the other well. The personalities can be an aggressive self, a protective self, an assertive self, a withdrawn self, and so on. (Each side of the person assumes a separate entity) • Even the physiology of the ”alters” may be significantly different which is prompting research into the power of the mind to actually change physiology. THIS DISORDER IS A FORM OF ”SELF-HYPNOSIS” THAT STARTS OUT BY AN ATTEMPT TO MANAGE STRESS, TENSION AND CONFLICT THEN GETS OUT OF CONTROL.

SOMATOFORM DISORDERS • Physical symptoms for which no underlying organic basis exists • Somatization: several symtoms for which no medical explanation is found • Conversion disorder: one persistent inexplicable symptom • Hypochondriasis: the belief that one has a serious disease despite all medical evidence to the contrary. Or a persistent fear of contracting a disease. IMPORTANT: These people keep seeking medical attention and duplicating tests and consultations. It is worthwhile to establish a good long-term caring relationship with such clients in order to maintain them within one health care system. When nobody listens to them their symtoms worsen and they book frequent appointments in various places, unnecessarily raising medical costs.

CONCOMITANT DISORDERS • There is a high correlation between ANXIETY DISORDERS and SUBSTANCE ABUSE, DEPRESSION, SUICIDE AND OTHER MENTAL ILLNESSES.

ANXIETY DISORDERSNursing interventions • Etiology of Anxiety disorders: many contributing factors such as altered neurobiology, inefficient defence mechanisms, problems with interpersonal relationships, cognitive expectations, learned avoidance responses and rigid gender-role expectations. • Techniques for reducing anxiety include muscle relaxation, deep breathing, physical exercise, distraction techniques, changing sensory experiences, doing acitivites and positive affirmations. • Cognitive interventions include guided self-dialogue, thought stopping, changing irrational ways of thinking. • Nutritional interventions include teaching clients to increase their intake of niacin and vitamin B6 which are necessary for the production of 5-HT (necessary in neurotransmission)

EATING DISORDERSAnorexia and Bulimia • Development of extreme rituals concerning eating and exercise • The behaviour is a result of a desperate need to please others. Rigidity and perfectionism develop into obsessions with eating. • In Anorexia, it is typical to starve oneself or to over-exercise to ”earn calories” or get rid of perceived excess • In Bulimia, there is a cyclical pattern of binging – consuming huge amounts of calories (about 3500 kcal in an hour) then purging oneself of the ingested food (for example by inducing vomiting).

EATING DISORDERSCOGNITIVE DISTORTIONS • Selective abstraction: ”I´m still too fat – look at how big my hands and feet are.” • Overgeneralization: ”You don´t see fat people on televeision. Therefore, you have to be thin to be successful at anything in life.” • Magnification: ”If I gain 2 kg I know everyone will notice it.” • Personalization: ”Jim and Bob were talking and laughing together today. I am sure they were talking about how fat I am.” • Superstitious thinking: ”If I wear white clothes, I will lose weight faster.” • Dichotomous thinking: ” If I gain even 1 kg that means I am totally out of control and might as well gain 50 kg.”

EATING DISORDERSCHARACTERISTICS • Self-evaluation: overcritical • Decision-making: perfection-seeking • Rituals: highly ritualistic or cyclical • Sense of control: unrealistic • Phobia: food phobia in anorexia • Exercise: obsessive or sporadic routines • Guilt: markedly high • Defense mechanisms: denial • Insight into illness: ego-syntonic in anorexia and ego-dystonic in bulimia

EATING DISORDERSCHARACTERISTICS (cont´d) • Body image: delusional distortions esp. in anorexia • Relationships: attempts to please, placate, avoid conflicts, suppression, struggle with dependency vs. Autonomy • Social isolation: isolation and need for privacy to binge • Weight loss: severe in anorexia not always noticeable in bulimia • Death: may result from starvation in anorexia and from hypokalemia (deficiency of potassium) or suicide in bulimia • Culture-Specific Characteristics: THERE IS CONSIDERABLE EVIDENCE THAT EATING DISORDERS ARE RATHER UNCOMMON OUTSIDE THE WESTERN WORLD AND THAT THEY ARE MEDIA-INFLUENCED. Recent studies also show that ethnic minorities with different beauty ideals than the mainstream Western population are less susceptible to these maladies.

MOOD DISORDERSAffect • AFFECT is the immediate and observable emotional expression of mood which you communicate verbally and nonverbally. • Affect may be described as follows: • Appropriate: congruent with situation • Inappropriate: unrelated to immediate situation • Stable: resistant to sudden (unprovoked) changes • Labile: mood shifts suddenly and out of context • Elevated: euphoria not related to immediate situation • Depressed: despondency • Overreactive: out of proportion • Blunted: dull response • Flat: no visible cues to person´s mood

MOOD DISORDERSGlossary • Depression: an emotional state of excessive and or/persistent sadness; may range from mild dejection to extreme despair; one of the most common mental health problems • Grief: state of sadness in response to a real or perceived loss such as separation or death of a loved person, the loss of a job, possession, bodily function or body part – anything a person values • Lithium: a mecidation based on a naturally occurring salt that acts as a mood stabilizer for clients with mania by altering neurotransmitter actions • Mania: pathologic state in which mood is abnormally elevated, expansive, excited, or irritable; impairs concentration • Monoamine oxidase inhibitors (MAOIs): antidepressant medications that inhibit the metabolism of neurotransmittes serotonin and norepinephrine at the presynaptic neuron in the central nervous system; also inhibit metabolism of tyramine • Tricyclic antidepressants: medications that regulate the supply of the neurotransmitters serotonin and norepinephrine to the CNS

MOOD DISORDERSGeneral symptoms • Depression • Fatigue or lethargy • Suicidal thoughts • Loss of interest and enjoyment • Feeling of inadequacy and low self-esteem • Helplessness • Loss of motivation • Indecisiveness • Pessimism • Sleeping or eating disorder • Psychomotor retardation • Mania • Egotism • Aggressiveness • Elation or euphoria • Hyperactivity (social, sexual, verbal) • Irritability • Excessiveness of action or thought • Insomnia • Inadequate nutrition

MOOD DISORDERSTypes of Depressive Disorders • MAJOR DEPRESSIVE EPISODE a) At least 5 (including either depressed mood or loss of interest or pleasure) of the following symptoms occurring daily or almost daily during a 2-week period: • Depressed mood most of the day (may be irritable mood in children or adolescents) • Marked lessening of interest or pleasure in all or almost all activities • Significant loss or gain of weight or increase or decrease in appetite • Insomnia or excessive sleeping • Psychomotor agitation or slowness • Fatigue or lack of energy • Feelings of worthlessness or excessive guilt • Diminished ability to think or concentrate • Thoughts of death or suicide or a plan for suicide b) Includes symptoms causing clinically significant distress or social or job impairment c) May be a single episode or may be recurrent d) May range from mild to severe, with or without psychotic features

MOOD DISORDERSTypes of Depressive Disorders • Dysthymic Disorder • Depressed mood for most of the day and for more days than not for 2 years in adults and for 1 year in children and adolescents • At least 3 of the following symptoms, along with depression: • Low self-esteem, low self-confidence or feelings of inadequacy • Feelings of pessimism, despair, hopelessness • Loss of interest or pleasure • Withdrawal • Chronic fatigue • Feelings of guilt or brooding about the past • Subjective irritability or excessive anger • Lessening of activity or productivity • Poor concentration or memory and ineffectiveness b) May have early onset (before age 21) or late onset (age 21 or older)

MOOD DISORDERSBipolar Disorder/Manic episode • MANIC EPISODE • A period of at least 1 week during which mood is abnormally and persistently elevated, expansive or irritated • At least 3 of the following symptoms (if irritable 4 of them): • Inflated self-esteem or grandiose behaviour • Decreased need for sleep • Unusual talkativeness • Flight of ideas or feeling that thoughts are racing • Easy distractability • Increase in goal-directed activity or psychomotor agitation • Excessive involvement in activities that give pleasure but carry a high risk c) May range from mild to severe with or without delusions or hallucinations d) Includes social impairment e) May require hospitalization to prevent harm to self or others

MOOD DISORDERSBipolar Disorder/Hypomanic episode • Period of 4 days during which mood is sustained at elevated, expansive, or irritable levels • Symptoms same but less severe than in mania (no psychotic features and no marked impairment on work and social life) • Behaviour obviously uncharacteristic of person

Mood DisordersCyclothymic disorder • Numerous periods of hypomanic symptoms and of depressed mood or loss of pleasure for at least 2 years (1 year for children and adolescents) • Occurs more than 2 months at a time • No evidence of manic episode or major depressive episode

Mood disordersBipolar disorder • Manic episodes may occur alternately with major depressive episodes • Manic and major depressive episodes may occur together or may be mixed: every day for at least 1 week symptomatic behaviours of a major depressive and manic episodes occur • A single manic episode can occur without a major depressive episode

Mood disordersOther mood disorder categories • Mood disorder due to a general medical condition • Substance-induced mood disorder • Mood disorder not otherwise specified

Mood disordersCausation theories • Evidence of genetically inherited susceptibility – if triggered (psychophysiologic theory) • Biochemical factors such as imbalances in neurotransmitters, hormones and biologic rhythms as well as effects of medications • Pent up aggression that is directed at self or great loss as a trigger (psychoanalytic theory) • Disturbed thinking and lack of life mastery (cognitive model) • Learned, practiced before and reinforced (behavioural model) • Lack of resources (family, friends, income) (social model)

Mood disordersNursing interventions • Promote advocacy! • Encourage clients to believe in themselves • Help clients set clear goals • Provide accurate information • Help them identify resources (close people, self-help gourps, etc.) • Foster effective communication: be brief, direct and firm

Mood disordersNursing interventions (cont´d) • Between acute episodes, help client develop advance directives and to make plans regarding who must make decisions for them when they are unable to take decisions. These should include: • Symptoms that indicate that the client is unable to take decisions • Names and numbers of at least three people who should make decisions on their behalf (including caregivers) • A list of medications/treatments and treatment facilities - ranked as preferred or unacceptable, including reasons

Mood disordersNursing interventions (cont´d) • Clients are encouraged to DEVELOP their own health file (not a duplicate of health care facility records, but compiled by themselves) containing information about their diagnoses, medications, self-help strategies and resources. • These should include the aforementioned advance directives

Mood disordersNursing interventions (cont´d) • Assess the following: - Risk of violence to self or others • Attention span • Energy level • Hygiene and self-care • Thought process • Communication patterns • Self-esteem • Spiritual distress

Mood disordersNursing intervention (cont´d) • Work on ”early warning signs” with patient – these help the patient be alert and alert others before a relapse. The relapse might be prevented or its severity more controlled • It is good to have a preplanned action plan to alleviate symptoms if they persist for more than a few days • Clients should be taught to monitor themselves

Mood disordersRevision and some additional notes • Mood disorders are: • MAJOR DEPRESSION (UNIPOLAR D.) • DYSTHYMIC DISORDER • BIPOLAR DISORDER • CYCLOTHYMIC DISORDER • SCHIZOAFFECTIVE DISORDER

Mood disordersAlert! • Nursing assessment must often be conducted in segments of 15-20 minutes for clients who have little energy or for those who are hyperactive or psychotic. • Client safety is the first priority. • Educate clients • Educate families and caregivers.

PSYCHIATRIC NURSING Mental Disorders