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Chapter 55
Psychiatric Disorders
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Learning Objectives
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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.
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Establishing Therapeutic
Relationships
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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
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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
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Clarifying
• One way of validating that you understand
what the patient is saying
• Asking questions may also help patients clarify
their thoughts
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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
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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
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Nursing Assessment of the
Psychiatric Patient
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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
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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)
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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
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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
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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)
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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”)
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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
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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
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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
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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
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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
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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
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Types of Psychiatric Disorders:
Anxiety Disorders
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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
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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
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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
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Agoraphobia
• The person is extremely fearful of situations outside
the home
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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
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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
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Acute Stress Disorder
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Types of Psychiatric Disorders:
Somatoform Disorders
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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
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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
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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
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Hypochondriasis
• Individuals convinced that they have a serious
medical problem in spite of the absence of any
concrete medical findings
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Types of Psychiatric Disorders
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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
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Dissociative Disorders
• In a sense, persons unconsciously dissociate or
remove themselves psychologically from anxietyprovoking 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
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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)
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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
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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
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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
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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
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Schizophrenia
• Medical treatment: drug therapy
• Neuroleptic (antipsychotic), antiparkinsonian drugs
• Anxiolytics administered with the neuroleptics
• Side effects
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Agitation and akathisia
Orthostatic hypotension
Extrapyramidal side effects (EPS)
Acute dystonic reactions
Parkinsonian syndrome
Tardive dyskinesia
Neuroleptic malignant syndrome
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Schizophrenia
• Assessment
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Appearance
Activity
Mood and affect
Speech and language
Thought content
Perceptual disturbances
Insight and judgment
Sensorium
Memory
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Schizophrenia
• Interventions
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Disturbed Thought Processes
Disturbed Sensory Perception
Impaired Verbal Communication
Self-Care Deficit
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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
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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
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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)
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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
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Mood Disorders
• Nursing care of the patient with major
depression
• Interventions
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Risk for Self-Directed Violence
Chronic or Situational Low Self-Esteem
Altered Nutrition: Less Than Body Requirements
Disturbed Sleep Pattern
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Mood Disorders
• Nursing care of the patient with bipolar disorder
with manic episodes
• Risk for Injury
• Risk for Other-Directed Violence
• Imbalanced Nutrition: Less Than Body
Requirements
• Disturbed Sleep Pattern
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Cognitive Disorders
• Impairments in cognition or memory
• Delirium and dementia: deficits in orientation,
memory, language comprehension, and
judgment
• Delirium is potentially reversible, whereas dementia
is not
• Delirium is usually fairly rapid in onset; dementia is
slow in its onset
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Cognitive Disorders
• Causes of delirium are meningitis, neoplasms,
drugs ranging from alcohol to steroids,
electrolyte imbalance, endocrine dysfunction,
liver abnormalities, renal failure, thiamine
deficiency, and postoperative states
• Common types of dementia are dementia of
the Alzheimer’s type, vascular dementia, Pick’s
disease, and Parkinson’s disease
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Personality Disorders
• Paranoid personality disorder—distrust and
suspiciousness; others’ motives interpreted as hostile
• Schizoid personality disorder—detachment from social
relationships and a restricted range of emotional
expression
• Schizotypal personality disorder—difficulties in social
and interpersonal relationships in which the person
suffers from acute discomfort with close relationships
and therefore has a decreased capacity for such
relationships
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Personality Disorders
• Antisocial personality disorder—disregard for and
violation of the rights of others
• Borderline personality disorder—instability in
interpersonal relationships, self-image, and affect;
marked impulsivity
• Histrionic personality disorder—excessive emotionality
and attention seeking
• Narcissistic personality disorder—grandiosity, need for
admiration, and lack of empathy
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Personality Disorders
• Avoidant personality disorder—social inhibition
accompanied by feelings of inadequacy and
hypersensitivity to negative evaluation
• Dependent personality disorder—submissive and
clinging behavior related to an excessive need to be
taken care of
• Obsessive-compulsive personality disorder—
preoccupation with orderliness, perfectionism, and
control
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Borderline Personality Disorder
• Person has unstable relationships, unstable
self-image, and unstable mood
• Two theories
• First, because families of patients with this disorder
have a greater history of alcoholism, a genetic
influence is thought to exist
• The second explanation is related to particular
developmental experiences
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Borderline Personality Disorder
• Assessment
• Mood, affect, feelings: patient may experience mood
swings or chronic feelings of emptiness and
boredom or intense anger
• Insight and judgment: patient makes repeated
suicidal threats and gestures and exhibits selfmutilating behavior
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Borderline Personality Disorder
• Interventions
• Risk for Self-Directed Violence/Risk for SelfMutilation
• Impaired Social Interaction
• Disturbed Personal Identity
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