Download Thought Process Disorders

Chapter 35
Care of the Patient with a
Psychiatric Disorder
- Organic Mental Disorders
- Thought Process Disorders
- Major Mood Disorders:
Depression and Bipolar Disorder
- Anxiety Disorders
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Care of the Patient with a Psychiatric
Disorder
• The nurse should have basic understanding of the
classifications of human responses and treatments
for mental illness.
• It is important for nurses to be able to interact
therapeutically with both the physical and emotional
aspects of patient care.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Care of the Patient with a Psychiatric
Disorder
• Neurosis


Ineffective coping with stress that causes mild
interpersonal disorganization
Remains oriented to reality but may have some
degree of distortion of reality manifested by a strong
emotional response to the trigger event
• Psychosis

Out of touch with reality and severe personality
deterioration, impaired perception and judgment,
hallucinations, and delusions
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Organic Mental Disorders
• Identifiable brain disease or dysfunction is bases for
behavior
• Cognitive or intellectual abilities are affected
• Effects could be mild lapses in memory to severe
behavioral changes
• Predominant characteristic is disorientation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Organic Mental Disorders
• Delirium


A rapid change in consciousness that occurs over a
short time
Associated with
• Reduced awareness and attention to surroundings,
disorganized thinking, sensory misinterpretation, and
irrelevant speech
• Sleep patterns are disturbed

Causes
• Physical illness

Fever, heart failure, pneumonia, azotemia, or malnutrition
• Drug intoxication
• Anesthesia
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Organic Mental Disorders
• Delirium (continued)

Symptoms
• Reduced awareness and attention to surroundings,
disorganized thinking, sensory misinterpretation, and
irrelevant speech
• Disturbed sleep patterns
• Nocturnal delirium or Sundowning syndrome:

increased disorientation and agitation during the evening
and nighttime
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Slide 6
Organic Mental Disorders
• Delirium (continued)

Treatment
• Homeostatic imbalance

i.e. hypoxemia, electrolyte imbalance, or malnutrition
o Focused on problem causing the imbalance
• Chemical agents or drugs

Chemicals or drugs should be withdrawn or the dosage
should be reduced
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Organic Mental Disorders
• Dementia



Altered mental state secondary to cerebral disease
A slow and progressive loss of brain function that is
often irreversible
Causes
• Cerebral disease



Alzheimer’s (most common type)
Vascular dementia
Symptoms
•
•
•
•
Impaired memory and judgment
Personality changes
Decreased cognitive function
Impaired orientation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Organic Mental Disorders
• Dementia (continued)

Treatment
• Medications


Agitation: lorazepam, Haldol
Dementia: Cognex, Aricept
• Nutrition

Finger foods; frequent feedings
• Safety



Removing burner controls at night
Double-locking all doors and windows
Constant supervision
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Organic Mental Disorders
• Dementia and Delirium

Nursing interventions
• Reality orientation techniques



Clock and calendar
Curtains open and lights on during the day
Calm supportive approach
• Decreased sensory stimuli


No crowds
One instruction at a time; keep it simple
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 10
Organic Mental Disorders
• Dementia and Delirium (continued)

Nursing Interventions
• Provide for safety






Bed in low position
Side rails up
Rails in hallways
Chair and bed alarms
Call light and personal articles in reach
Sufficient night light
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 11
Organic Mental Disorders
• Dementia and Delirium (continued)

Nursing interventions
• Adequate nutrition



Reduce dining distractions: TV.
Encourage snacks: finger foods.
Monitor weight.
• Self-care support



Assist with ADLs as needed.
Encourage mobility and other activities that use large
muscle groups.
Daily routine should be the same time each day.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 12
Thought Process Disorders
• Schizophrenia


Bizarre, non-reality–based thinking
Characterized by
• Gross distortion of reality, disturbance of language and
communication, withdrawal from social interaction, and
disorganization and fragmentation of thought, perception,
and emotional reaction



Strikes young adulthood, both sexes equally and about
1% of population will experience it in their lifetime
Chronic disorder with residual disability in functioning
Aggravated by stresses in life
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 13
Thought Process Disorders
• Schizophrenia – cont’d

Causes
• Brain tissue changes


Ventricles of the brain larger than normal
o Left larger than right ventricle
Cerebral cortex smaller that normal
o Accounts for disorganized thinking, hallucinations
and delusions
• Excessive dopamine (neurotransmitter)
• Pupils differ in size and blinking rate may be faster or
slower than normal
• Clumsiness and difficulty distinguishing right and left
sides of body are attributed to enlarge ventricle of the
brain
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 14
Thought Process Disorders
• Schizophrenia – cont’d

Symptoms are individualized but include
• Hallucination; disordered thinking
• Apathy and social withdrawal
• Flat affect; delusions

Behaviors
• Positive or excessive and negative or absent



Prognosis with positive behavior pattern is good
Fewer structural changes in brain and better response to
drug therapy
Positive behavior pattern
o Delusions, hallucinations, disordered thinking
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 15
Thought Process Disorders
• Schizophrenia – cont’d

Delusion
• False, fixed belief that cannot be corrected by feedback
and is not accepted as true by others in culture
• Starts with false premise, believing it to be true
• Logically fits this false premise into his or her
interpretation of reality
• Due to strong logic supporting false premise, it is
difficult for the individual to accept what is really true
• Types of delusion: see box 35-1, pg 1145

grandeur, ideas of reference, persecution, somatic
delusions, thought broadcasting, thought insertion,
thought withdrawal
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 16
Thought Process Disorders
• Schizophrenia – cont’d

Hallucination
• Sensory experience without a stimulus trigger
• Auditory is the most experienced type
• Visual, olfactory, and tactile can also occur

Disordered thinking
• Individual cannot interpret information being received in
brain
• Exhibited by loose association in speech
• Conversation does not flow logically
• Concreteness, a sign of disordered thinking

i.e. picture is being taken and schizophrenic person is
told to “watch the birdie” that person will look up into the
tree for bird instead of smiling
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 17
Thought Process Disorders
• Schizophrenia – cont’d

Negative behaviors
• Apathy (avolition), social withdrawal, alogia, blunted
emotional response, anhedonia

Apathy
• lack of energy, a contentment to just sit and do nothing
• unkempt appearance is a reflection of apathy

Social withdrawal
• Attempt to reduce stimulus to brain
• Person is frightened or overwhelmed by experience of
trying to communicate with someone and find it easier
to withdraw from event
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 18
Thought Process Disorders
• Schizophrenia – cont’d

Alogia
• Reduced content of speech
• Part of overload of information that occurs in
conversation and schizophrenics need time to sort out
messaged received

Flat affect and Anhedonia
• Lack of expressed feelings
• Flat affect is lack of nonverbal expression of emotions
• Anhedonia is inability to experience happiness or joy

Bizarre posturing or behaviors such as laughing when
given news about a death in family
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 19
Thought Process Disorders
• Schizophrenia – cont’d

Five Subtypes
• Disorganized

Flat or inappropriate affect, incoherence; prognosis is poor
• Paranoid

Delusions, auditory hallucinations; prognosis is good with
treatment
• Catatonic

Features stupor, negativism, rigidity, excitement, posturing;
prognosis is fair
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 20
Thought Process Disorders
• Schizophrenia – cont’d

Five Subtypes – cont’d
• Undifferentiated

Delusions, hallucinations, incoherence, gross
disorganization (does not fit categories of other types);
prognosis is fair
• Residual

Demonstrates typical signs and symptoms associated
with schizophrenia without displaying evidence of gross
disorganization, incoherence, delusions, and
hallucinations; prognosis is poor
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 21
Thought Process Disorders
• Schizophrenia – cont’d

Four stages marked by acute episodes of psychosis
alternating with periods of relatively normal functions
•
•
•
•
Prodromal phase
Prepsychotic pahse
Acute phase
Residual phase
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 22
Thought Process Disorders
• Schizophrenia – cont’d

Four stages
• Prodromal phase


Begins in adolescence and begins with lack of energy or
motivation and withdrawal
Symptoms
o Affect becomes blunted; beliefs and ideas become
odd; person develop excessive interest in philosophy
or religion; self-care and personal hygiene are ignored;
presence of emotional lability; speech is difficult to
follow; complain about multiple physical problems
o Magical thinking or believing one’s thoughts control
events
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 23
Thought Process Disorders
• Schizophrenia – cont’d

Four stages
• Prepsychotic phase




Quiet and passive behavior
Prefers to be alone
Hallucinations and delusions
Odd, suspicious, or eccentric behavior patterns
• Acute phase


Disturbances of thought, perception, emotion and
behavior
Individual loses contact with reality and is unable to
function in most basic way
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 24
Thought Process Disorders
• Schizophrenia – cont’d

Four stages
• Residual phase




Symptoms similar that in prodromal phase
Follows acute phase
Following residual is remission period wherein person is
able to experience symptoms relief and manage basic
activities in life
Prognosis to recovery is fair to poor
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 25
Thought Process Disorders
• Schizophrenia (continued)

Treatment
• Psychotherapies

Allow patient for self-expression
• Antipsychotic drug therapy

To control symptoms
• Therapeutic relationship

Maintained for years to provide continuity for individual
who suffers a lifelong illness
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 26
Major Mood Disorders: Depression and
Bipolar Disorder
• Mood Disorders


Also known as affective disorders
Psychotic disorders characterized by
• Severe and inappropriate emotional responses
• Prolonged and persistent disturbances of mood and
related thought distortions
• Other symptoms associated with either depressed or
manic states
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 27
Major Mood Disorders: Depression and
Bipolar Disorder
• Mood Disorders

Cause
• Hereditary factors

Account for about 60-80%
• Biologic

May be inherited or environmental factors such as
prolonged stress or brain trauma.
o Depression: insufficiency of norepinephrine and
serotonin
o Mania: excess norepinephrine
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 28
Major Mood Disorders: Depression and
Bipolar Disorder
• Mood Disorders (continued)

Symptoms: Depression
• Mood disturbance characterized by exaggerated
feelings of sadness, despair, lowered self-esteem, loss
of interest, and pessimistic thoughts

Neglect of appearance, difficulty concentrating,
complaints of physical problems, disturbed sleeping or
eating patterns, loss of self-esteem, feelings of
helplessness, hopelessness, extreme anxiety or panic
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 29
Major Mood Disorders: Depression and
Bipolar Disorder
• Mood Disorders (continued)

Symptoms: Depression
• Unipolor

Major depression (severe depressive episodes lasting
more than 2 years)
• Disthymic disorder

Daily moderate depression lasting more than 2 years
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 30
Major Mood Disorders: Depression and
Bipolar Disorder
• Mood Disorders (continued)

Mania
• Persistent abnormal overactivity and an euphoric state
• Hypomanic

When manic symptoms are not severe
• Bipolor

Manic-depressive
• Cyclothymic

Involves repeated mood swings of hypomania and
depression
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 31
Major Mood Disorders: Depression and
Bipolar Disorder
• Mood Disorders (continued)

Treatment
• Antidepressants

Prozac (flouxetine);Desyrel (trazodone); Elavil
(amitriptyline); Effexor (venlafaxine)
• Lithium


Used to treat bipolar disorders
Must be monitored closely
• Electroconvulsive therapy (ECT)

May be used when drug therapy is ineffective
• Psychotherapy
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 32
Anxiety Disorders
• Anxiety is a normal response to stress or a threat.
• Anxiety is a state of feeling of apprehension,
uneasiness, agitation, uncertainty, and fear resulting
from the anticipation of some threat or danger.
• Signal anxiety

A learned response to an event such as test taking
• Free-floating anxiety

Feelings of dread that cannot be identified
• Anxiety trait

A learned aspect of personality; anxious reactions to
relatively nonstressful events
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 33
Anxiety Disorders
• Generalized anxiety disorders are characterized by a
high degree of anxiety and/or avoidance behavior.

Panic: acute, intense, and overwhelming anxiety
 Agoraphobia: high anxiety brought on by possible
situation such as people, places, or events
 Obsessive-compulsive disorder: recurrent, intrusive,
and senseless thoughts and behaviors that are
performed in response to the obsessive thoughts
 Post-traumatic stress disorder (PTSD): response to an
intense traumatic experience that is beyond normal
experience
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 34
Anxiety Disorders
• Treatment

Panic Disorders
• Educate on the nature of the disorder.
• Assist to develop better coping mechanisms.

Block attacks pharmaceutically.
 Post-traumatic Stress Disorder
• Antidepressant or antiseizure medications
• Cognitive therapy or behavioral therapy
• Debriefing right after the event
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Slide 35