Chapter 55

1. Chapter 55 Psychiatric Disorders

2. Learning Objectives • Describe the differences between social relationships and therapeutic relationships. • Describe key strategies in communicating therapeutically. • Describe the components of the mental status examination. • Identify target symptoms, behaviors, and potential side effects for the following types of medications: antianxiety (anxiolytic), antipsychotic, and antidepressant drugs. • Summarize current thinking about the etiology of schizophrenia and the mood disorders. • Identify key features of the mental status examination and their relevance in anxiety disorders, schizophrenia, mood disorders, cognitive disorders, and personality disorders. • Identify common nursing diagnoses, goals, and interventions for persons with anxiety disorders, schizophrenia, mood disorders, cognitive disorders, and personality disorders.

3. Establishing Therapeutic Relationships

4. Being Available When working with a patient, direct your attention completely toward that person Avoid involvement in any other activity, such as reading a newspaper or watching television, which might be interpreted by the patient as lack of availability Avoid interruptions in your conversation with the patient as much as possible

5. Listening Concentrate on what patient is saying; try to hear how he/she experiences and describes his/her life When listening therapeutically, avoid cutting the patient off or jumping to conclusions Get essence of how patient perceives his/her situation, experiences certain symptoms, and describes circumstances Listening is done by concentrating on the patient and by refraining from thinking of responses while the patient is speaking

6. Clarifying One way of validating that you understand what the patient is saying Asking questions may also help patients clarify their thoughts

7. Sharing Observations Patients benefit from knowing what you see and hear while listening Provides patient with input that he/she is heard and that you are really listening

8. Accepting Silence Sometimes therapeutic to allow moments of silence between you and the patient Important that you feel comfortable with silence because silence enables patients to consider their own thoughts as well as what you are communicating to them Silences allow patients to sort through their feelings and organize their thinking

9. Nursing Assessment of the Psychiatric Patient

10. Psychiatric History Ask patient to tell you what has been happening recently that has caused him/her to seek treatment Inquire about past psychiatric history Ask if patient has been treated for anxiety, depression, or other mental health problems

11. Appearance Appearance in relation to stated age Appropriateness of clothing in relation to patient’s particular peer group or subculture Personal grooming and hygiene Unique physical characteristics Motor activity Recent change in the patient’s activity level (increase or decrease)

12. Mood and Affect Mood A sustained feeling state or emotion that a person experiences in several aspects of life Assessed by intensity, depth, duration, and fluctuation Words that describe mood: irritable, anxious, depressed, euphoric, labile (up and down), and despairing

13. Mood and Affect Affect External presentation of a feeling state and emotional responsiveness Ranges from blunted, flat, and constricted to euphoric, expansive, and intense Normal affect: person’s body language, mannerisms, and verbal responses consistent with person’s mood and within an average range of emotional intensity Appropriate affect: person’s outward emotional expression matches what he/she is saying or doing

14. Speech and Language Speech is normal rate, rhythm, volume Unusual findings include mutism (not speaking), long pauses before responding, minimal or very little speech (paucity), and pressured speech (loud and insistent) Clues to problems of thought evidenced in a person’s speech (see following section)

15. Thought Content Tangential speech Patient starts toward a particular point but veers away Commonly an indicator of disorganized thinking Thought blocking Person stops speaking before reaching the point Loose associations Continual shifting from topic to topic—and shifting between topics to the point of incoherence (“word salad”)

16. Thought Content Obsessions—repetitious, unwanted thoughts Compulsions—actions repeatedly carried out in a specific manner; typically include washing, counting, or checking Phobias—unrealistic fears of specific objects or situations Delusions—false ideas not based on reality and not congruent with the patient’s specific religious and cultural orientation Suicidal ideations—thoughts and/or plans of killing oneself

17. Perceptual Disturbances Involve any of the senses such as vision, hearing, taste, touch, and smell Illusion Specific stimulus, such as a spot on the wall, misinterpreted Hallucination Sensory experience that occurs without an external stimulus May include a person sitting alone, talking as if someone were present, or looking around as if someone is talking to or calling the patient

18. Insight and Judgment Insight The ability to understand the correct cause or meaning of a situation Judgment The ability to assess a situation accurately and determine appropriate course of action Insight and judgment are often considered in relation to suicide potential

19. Sensorium Orientation in terms of time, place, person, and self Data obtained by asking patient direct questions Patient’s level of consciousness noted Comatose, stuporous, drowsy, or alert

20. Memory and Attention Assessed by comparing patient’s memory of past events with what is recalled by other reliable historians A quick way to determine recent memory is to ask what was eaten at the previous meal

21. General Intellectual Level Estimated by determining the patient’s vocabulary and knowledge of current events Ask patient to name the president of the United States and the name of the previous president Abstract thinking Evidence of the intellectual level by asking the patient to identify the common element of two objects such as a banana and an apple

22. Types of Psychiatric Disorders: Anxiety Disorders

23. Manifestations Patient with anxiety disorder directly experiences uncomfortable feeling of anxiety or a symptom like compulsive hand washing that prevents or reduces the occurrence of anxiety Signs and symptoms: increased heart rate, elevated blood pressure, sweaty palms, trembling, urinary frequency, diarrhea, a tight sensation in the chest, and difficulty breathing Psychological manifestations: irritability, restlessness, tearfulness, thought blocking, and lack of concentration

24. Types of Anxiety Disorders Mild anxiety can be useful May motivate a person to take constructive action or focus attention on a particular task Moderate anxiety often considered the optimal level for learning to take place As anxiety progresses to severe or panic levels, an individual’s ability to think clearly and to solve problems become impaired All people experience anxiety For most it is episodic; does not interfere with day-to-day functioning

25. Panic Disorder The person experiences recurrent panic attacks, which are episodes of intense apprehension of variable length, at times to the point of terror, and are often accompanied by feelings of impending doom Physical symptoms of severe anxiety, such as increased pulse, elevated blood pressure, trembling, diaphoresis, shortness of breath, chest pain, and nausea also are present

26. Agoraphobia The person is extremely fearful of situations outside the home

27. Obsessive-Compulsive Disorder Recurrent obsessions (thoughts) or compulsions (behaviors), or both, that produce distress, are time-consuming, and interfere with functioning Obsessions involve intrusive thoughts about unpleasant or even violent acts that a person cannot stop Compulsive behaviors evolve as a way to reduce the anxiety experienced as a result of obsessive thoughts The person experiencing obsessions and compulsions knows these thoughts and behaviors are not “normal” and often is embarrassed by them

28. Posttraumatic Stress Disorder Cluster of symptoms following distressing event that is outside the range of normal events; person experienced intense fear, helplessness, and/or horror Symptoms: reexperiencing the trauma through repeated and intrusive recall; avoiding situations that remind person of event; feeling detached from other people; having a heightened sense of arousal, which is experienced as difficulty falling asleep, hypervigilance, an exaggerated startle response, or a combination of these

29. Acute Stress Disorder

30. Types of Psychiatric Disorders: Somatoform Disorders

31. Definition Individual experiences physical symptoms without actual physiologic dysfunction or with physical cause(s) that are affected by psychological factors in terms of onset, severity, duration, or continuance of symptoms

32. Conversion Disorder Symptoms may include blindness, deafness, or paralysis of the legs without a physiologic cause Usually symptoms are neurologic and occur in response to some threatening or traumatic event

33. Pain Disorder Patient experiences pain in one or more sites that causes significant distress or impairment in function Psychological factors play a significant role in the experience of the pain; however, the pain is not intentionally produced or contrived

34. Hypochondriasis Individuals convinced that they have a serious medical problem in spite of the absence of any concrete medical findings

35. Types of Psychiatric Disorders

36. Dissociative Disorders A change in identity, memory, or consciousness Change may be sudden or gradual, transient or occurring over a long period, and is thought to be an escape from anxiety

37. Dissociative Disorders In a sense, persons unconsciously dissociate or remove themselves psychologically from anxiety-provoking situations Amnesia: a gap in memory, usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness Dissociative identity disorder is a relatively rare dissociative disorder in which two or more distinct personalities exist within the person and repeatedly take control of the person’s behavior

38. Medical Treatment Drug therapy Anxiolytic (antianxiety) Benzodiazepines Diazepam (Valium), chlordiazepoxide (Librium), lorazepam (Ativan), alprazolam (Xanax), and clonazepam (Klonopin) Antidepressants Venlafaxine (Effexor), nefazadone (Serzone), duloxetine (Cymbalta)

39. Care of the Patient with Anxiety, Somatoform, or Dissociative Disorder Assessment Patient’s symptoms and objective observations help determine the presence and level of anxiety (mild, moderate, severe, or panic). Relevant mental status examination categories include motor activity, speech and language, and thought content

40. Care of the Patient with Anxiety, Somatoform, or Dissociative Disorder Interventions Remain calm; speak firmly with short, simple instructions; and walk to a less stimulating area of the unit Once anxiety is reduced to a manageable level, assist patients in exploring what happened, clarifying their usual ways of relieving anxiety and identifying what triggered the anxiety

41. Schizophrenia Group of very serious, usually chronic, thought disorders in which the affected person’s ability to interpret the world accurately is impaired by psychotic symptoms Psychosis Person has distorted perceptions of reality Psychotic symptoms include delusions, hallucinations, and impaired speech or behavioral patterns

42. Schizophrenia Etiology and risk factors The cause is not certain Stress-diathesis model Integrates diverse potential causes states that patients who are most vulnerable to acquiring the disorder encounter factors (stress) that precipitate the disorder In men, first occurs between 15 and 25 years Usual age for women is 25 to 35

43. Schizophrenia Medical treatment: drug therapy Neuroleptic (antipsychotic), antiparkinsonian drugs Anxiolytics administered with the neuroleptics Side effects Agitation and akathisia Orthostatic hypotension Extrapyramidal side effects (EPS) Acute dystonic reactions Parkinsonian syndrome Tardive dyskinesia Neuroleptic malignant syndrome

44. Schizophrenia Assessment Appearance Activity Mood and affect Speech and language Thought content Perceptual disturbances Insight and judgment Sensorium Memory

45. Schizophrenia Interventions Disturbed Thought Processes Disturbed Sensory Perception Impaired Verbal Communication Self-Care Deficit

46. Mood Disorders Significantly elevated or depressed moods An episode of persistent depressed mood is major depression Elevated mood is a manic episode Alternation between significantly depressed mood and significantly elevated mood over time is bipolar disorder

47. Mood Disorders Etiology and risk factors Definite causes have not been established Probable causes: neurotransmitter dysregulation, neuroreceptor deficits, neuroendocrine dysfunctions, genetic factors, loss of significant others, learned helplessness, and negative thoughts about life experiences

48. Mood Disorders: Medical Treatment Drug therapy Antidepressant medications Selective serotonin reuptake inhibitors (SSRIs), newer agent antidepressants such as nefazodone (Serzone), venlafaxine (Effexor), and duloxetine (Cymbalta), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) Manic medications Lithium or divalproex (Depakote)

49. Mood Disorders: Medical Treatment Electroconvulsive therapy Electrical current is introduced to the brain through electrodes placed on the temples Produces a grand mal seizure; however, drugs administered to minimize the manifestations of a seizure Temporary memory loss and confusion are common side effects of ECT, and instances of prolonged memory loss have occurred

50. Mood Disorders Nursing care of the patient with major depression Interventions Risk for Self-Directed Violence Chronic or Situational Low Self-Esteem Altered Nutrition: Less Than Body Requirements Disturbed Sleep Pattern