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Chapter 55 Psychiatric Disorders Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 1 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. Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 2 Establishing Therapeutic Relationships Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 3 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 4 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 5 Clarifying • One way of validating that you understand what the patient is saying • Asking questions may also help patients clarify their thoughts Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 6 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 7 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 8 Nursing Assessment of the Psychiatric Patient Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 9 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 10 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) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 11 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 12 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 13 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) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 14 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”) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 15 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 16 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 17 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 18 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 19 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 20 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 21 Types of Psychiatric Disorders: Anxiety Disorders Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 22 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 23 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 24 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 25 Agoraphobia • The person is extremely fearful of situations outside the home Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 26 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 27 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 28 Acute Stress Disorder Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 29 Types of Psychiatric Disorders: Somatoform Disorders Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 30 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 31 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 32 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 33 Hypochondriasis • Individuals convinced that they have a serious medical problem in spite of the absence of any concrete medical findings Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 34 Types of Psychiatric Disorders Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 35 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 36 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 37 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) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 38 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 39 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 40 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 41 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 42 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 43 Schizophrenia • Assessment • • • • • • • • • Appearance Activity Mood and affect Speech and language Thought content Perceptual disturbances Insight and judgment Sensorium Memory Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 44 Schizophrenia • Interventions • • • • Disturbed Thought Processes Disturbed Sensory Perception Impaired Verbal Communication Self-Care Deficit Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 45 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 46 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 47 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) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 48 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 49 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 50 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 51 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 52 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 53 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 54 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 55 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 56 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 57 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 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 58 Borderline Personality Disorder • Interventions • Risk for Self-Directed Violence/Risk for SelfMutilation • Impaired Social Interaction • Disturbed Personal Identity Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 59