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Chapter 35
Care of the Patient with a
Psychiatric Disorder
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Mental Health
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Slide 2
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.
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Slide 3
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
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Slide 4
Involuntary admission
• Pg.1135
• Also referred to as “probating”
• Carried out by a judge, physician or clinical
psychologist
• Must prove that the patient is thought to be a danger
to himself or others
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Slide 5
Organic Mental Disorders
• Delirium


A rapid change in consciousness that occurs over a
short time
Causes
• Physical illness

Fever, heart failure, pneumonia, azotemia, or
malnutrition
• Drug intoxication
• Anesthesia
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Slide 6
Organic Mental Disorders
• Delirium (continued)

Symptoms
• Reduced awareness and attention to surroundings,
disorganized thinking, sensory misinterpretation, and
irrelevant speech
• Disturbed sleep patterns
• Sundowning syndrome: increased
disorientation and agitation during the
evening and nighttime

Treatment
• Focused on problem causing the imbalance
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Slide 7
Organic Mental Disorders
• Dementia



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
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Slide 8
Organic Mental Disorders
• Dementia (continued)

Treatment
• Medications


Agitation: lorazepam, Haldol
Dementia: Cognex, Aricept etc…
• Nutrition

Finger foods; frequent feedings
• Safety



Removing burner controls at night
Double-locking all doors and windows
Constant supervision
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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
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Slide 10
Organic Mental Disorders
• Dementia and Delirium (continued)

Nursing interventions (continued)
• 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
Consistency and simplicity
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Slide 11
Organic Mental Disorders
• Dementia and Delirium (continued)

Nursing interventions (continued)
• 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.
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Slide 12
Thought Process Disorders
• Schizophrenia


Bizarre, non–reality-based thinking
Causes
• Brain tissue changes


Ventricles of the brain larger than normal
Cerebral cortex smaller that normal
• Dopamine hypothesis :Excessive dopamine
(neurotransmitter) (no longer a hypothesis)

Symptoms are individualized but include
•
•
•
•
Hallucination; disordered thinking (positive behavior)
Apathy and social withdrawal (negative behavior)
Flat affect (negative behavior)
Delusions (positive behavior)
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Slide 13
Schizophrenia
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Slide 14
Behavior Patterns (page 1140)
• Positive behavior patterns: include
delusions, hallucinations and disordered thinking
which also includes “loose association and
concreteness.” Loose association creates
conversations that are difficult to follow. Responses
may not relate to the question asked. Prognosis is
good…fewer structural changes in the brain and better
response to medication therapy. Positive behaviors
are also considered “excessive.”
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Slide 15
Hallucinations
• A sensory experience that cannot be corrected by
feedback and is not accepted as true by others in
culture
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Slide 16
Delusions
•
•
•
•
•
•
•
Grandeur
Ideas of Reference
Persecution
Somatic
Thought broadcasting
Thought insertion
Thought withdrawal
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Slide 17
Behavior patterns cont’d (page 1140)
• Negative behavior patterns: include apathy,
social withdrawal, alogia, blunted emotional
responses, and anhedonia.
Apathy is lack of energy, wants to “sit around and do
nothing.” May include an “unkempt” appearance, no
desire to “clean up” etc…
Social withdrawal is the result of “over stimuli” to the
brain. Tend to “withdraw” from contact, isolate.
Alogia is a reduced content of speech due to
“overload.”
Flat affect and anhedonia are terms describing the
lack of expressed feelings. See page 1141
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Slide 18
Thought Process Disorders
• Schizophrenia (continued) page 1141

Five subtypes
• Disorganized: flat affect, poor prognosis
• Paranoid : delusions etc…prognosis good with
treatment
• Catatonic : stupor etc…prognosis fair
• Undifferentiated : delusions, hallucinations
etc…prognosis fair
• Residual : typical S & S associated with schizophrenia
without “gross disorganization,” delusions
etc…prognosis poor
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Slide 19
Stages of schizophrenia (page 1141)
• Prodromal : may begin in adolescence. Lack of
energy, motivation…tend to withdraw. Affect may
become blunted, beliefs odd etc…
• Prepsychotic : quiet, passive, prefers to be alone.
Hallucinations and delusions may occur. Odd
behaviors…family members notice
• Acute phase: S & S vary widely, looses contact with
reality and is unable to function.
• Residual phase: similar to prodromal phase, follows
the acute phase.
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Slide 20
Thought Process Disorders
• Schizophrenia (continued)

Treatment
• Psychotherapies
• Antipsychotic drug therapy: refer
to handout
(psychotherapeutic medications)
• Therapeutic relationship
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Slide 21
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
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Slide 22
Major Mood Disorders: Depression
and Bipolar Disorder
• Mood Disorders (continued)

Cause
• Hereditary factors

Account for about 60% to 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
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Slide 23
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
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Slide 24
Depression
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Slide 25
Major Mood Disorders: Depression
and Bipolar Disorder
• Mood Disorders (continued)

Symptoms: Depression
• Unipolar

Major depression (severe depressive episodes lasting
more than 2 years)
• Dysthymic disorder

Daily moderate depression lasting more than 2 years
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Slide 26
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
• Bipolar

Manic-depressive
• Cyclothymic

Involves repeated mood swings of hypomania and
depression
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Slide 27
Bipolar Mania
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Slide 28
Major Mood Disorders: Depression
and Bipolar Disorder
• Mood Disorders (continued)

Treatment
• Antidepressants

Prozac (fluoxetine); Desyrel (trazodone); Elavil
(amitriptyline); Effexor (venlafaxine)
• Lithium



Used to treat bipolar disorders
Must be monitored closely
Refer to handouts etc. for further information, know
symptoms of toxicity and levels
• Electroconvulsive therapy (ECT)

May be used when drug therapy is ineffective
• Psychotherapy
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Slide 29
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
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Slide 30
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
 Posttraumatic stress disorder (PTSD): Response to
an intense traumatic experience that is beyond normal
experience
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Slide 31
Mental Health
• Agoraphobia

Anxiety about being in
places or situations where
escape may be difficult or
embarrassing
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Slide 32
Mental Health
• Obsessive – Compulsive
Disorder

Obsession:
• Recurrent and intrusive
thoughts that cause marked
distress

Compulsions:
• Repetitive behaviors or
mental acts that affect person
feels driven to perform in
response to obsessive
thoughts
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Slide 33
Anxiety Disorders
• Treatment

Panic disorders
• Educate on the nature of the disorder.
• Assist to develop better coping mechanisms.
• Block attacks pharmaceutically.

Posttraumatic stress disorder
• Antidepressant or antiseizure medications
• Cognitive therapy or behavioral therapy
• Debriefing right after the event
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Slide 34
Mental Health
• Post-Traumatic Stress Disorder


First recognized in war veterans
Debilitating condition that follows an
extreme traumatic stressor.
• Persistent reexperiencing of the
traumatic event
• Avoidance of stimuli associated with
the trauma
• Numbing of general responsiveness
• Increased arousal, exaggerated startle
response, hypervigilance
• Flashbacks
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Slide 35
Anxiety
• Physical symptoms
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Slide 36
Personality Disorders
• Inflexible and maladaptive patterns of behavior or
thinking that are associated with significant
impairment of functioning.
• Characterized by




Lack of insight, concrete thinking, poor attention,
unable to understand consequences of behavior
Distorted self-perception, either hatred or idealizing of
self
Impaired relationship, projects own feelings onto
others, poor impulse control
Inflexible behavioral response patterns; cannot handle
change
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Slide 37
Personality Disorders
• Personality disorders are
inflexible, maladaptive
patterns of behavior or
thinking associated with
significant impairment of
functioning.









Abusive personality
Dependent personality
Paranoid personality
Borderline personality
Antisocial personality
Lack of insight
Concrete thinking
Poor attention
Inability to understand
consequences of behavior
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Slide 38
Personality Disorders
Borderline Personality Disorder
No self-identity
Fears being alone
Severe abandonment issues
High drama
Instigates staff-splitting
Requires a high level of structure and consistency
Broken record approach
Assign to only one staff member
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Slide 39
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Slide 40
Personality Disorders
•
•
•
•
•
Box 35-3 pg1147
Abusive personality
Dependent personality
Paranoid personality
Borderline personality
Antisocial personality
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Slide 41
Nursing Interventions
• Refer to handout “ Basic Guidelines for Working with
•
•
•
the Mentally Ill Patient”
Staff need to be “on the same page”
Firmness and consistency
Nonjudgmental
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Slide 42
Sexual Disorders
• “Normal” sexual behavior is difficult to define
because of cultural influences, religious institutions,
and a society’s laws, all of which affect an
individual’s belief of what is acceptable and
unacceptable sexual behavior.

Adaptive sexual behaviors
• Occur in private between two consenting adults
• Satisfying and not forced on each other

Maladaptive sexual behaviors
• Harmful sexual actions to self or others
• May be performed publicly and sometimes without the
other’s consent
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Slide 43
Sexual Disorders
• Sexual Orientation

The preference one chooses for his or her sex partner
• Heterosexual

Individuals who express their sexuality with members of
the opposite sex
• Homosexual

Individuals who express their sexuality with members of
the same sex
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Slide 44
Sexual Disorders
• Sexual Dysfunction


A disturbance during sexual response
May be psychological or physiological
• Dyspareunia

Painful intercourse
• Hypoactive sexual desire
• Premature ejaculation
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Slide 45
Sexual Disorders
• Paraphilias

A group of sexually gratifying activities that are not
common to the general public and are illegal in some
countries, including the United States
• Pedophilia

Fondling and/or other sexual activities with a child by an
adult
• Exhibitionism (flashing)

Exposing one’s genitals to unsuspecting people to
achieve arousal
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Slide 46
Sexual Disorders
• Paraphilias (continued)

Voyeurism
• Sexual gratification by observing others during
intercourse or by viewing another’s genitals

Frotteurism
• Sexual arousal achieved by rubbing against or touching
a nonconsenting individual

Fetishism
• Using an object, usually an article of clothing, to attain
sexual arousal
• Usually followed by masturbation
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Slide 47
Sexual Disorders
• Paraphilias (continued)

Transvestic fetishism
• Wearing clothing of the opposite sex (cross-dressing) to
obtain sexual gratification

Sexual sadism
• Sexual arousal by inflicting pain or humiliation on
another; spanking, stabbing, or strangulation

Masochism
• Sexual arousal by receiving mental or physical abuse;
punishment necessary to achieve sexual gratification
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Slide 48
Sexual Disorders
• Gender Identity Disorder

Conflict of biological sex identity and gender
perception
 Person believes he or she was born in the body of the
incorrect sex
 Transsexualism
• A persistent desire to have the body of the opposite sex
• Biologic sex change



Psychological counseling
Hormone treatments
Major surgical procedures; not reversible
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Slide 49
Sexual Disorders
• Therapeutic Interventions




Intervention depends on the type or disorder.
Most are treated on an outpatient basis.
Psychosexual problems can be complex and require
the skill of specially educated physicians, nurses, or
therapists.
Nurses need to be aware of their own attitudes and
values about sexual behavior.
• Be careful of nonverbal messages.
• Quality of nursing judgment and care must not be
affected.
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Slide 50
Psychophysiologic Disorders
• Psychosomatic illness

Physical disorder brought on by a psychological
trigger
• Implication is that “it’s all in your head.”
• Physical signs of emotional distress are very real.
• Psychophysical illness


More recent term
Stress-related problems that can result in physical signs
and symptoms
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Slide 51
Psychophysiologic Disorders
• Somatization

This disorder is characterized by recurrent, multiple,
physical complaints and symptoms for which there is
no organic cause.
 An individual’s feelings, needs, and conflicts are
manifested physiologically.
 Diagnosis is made by ruling out any possible physical
causes of dysfunctions, any drug or other toxic
substance reaction, or mental health problems.
 It may be referred to as Briquet’s syndrome.
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Slide 52
Somatization
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Slide 53
Eating Disorders
• Anorexia Nervosa




Severe form of self-starvation that can lead to death
Occurs predominantly in adolescent girls of aboveaverage intelligence
Intense fear of obesity, bizarre attitudes toward food,
and a disturbed self-image
Not about food; about self-control and willpower
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Slide 54
Eating Disorders
• Anorexia Nervosa (continued)

Nursing interventions
• Develop a trusting relationship.
• Promote better nutrition.


Stress-free meal time
Frequent small meals
• Set limits to decrease manipulation and procrastination
behavior.
• Encourage to express feelings.
• Offer unconditional acceptance of both negative and
positive feelings expressed.
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Slide 55
Eating Disorders
• Bulimia Nervosa


Closely related to anorexia nervosa
Episodes of overeating followed by purging
• Induced vomiting, laxatives, diuretics, fasting, vigorous
exercise

Occurs primarily in white females of high-school age,
middle- to upper-class and well-educated
• Low self-esteem; lack of control
• Guilt; anxiety; depression
• Physical signs: hoarseness and esophagitis, dental
erosion, palate lacerations, weakness or fatigue,
electrolyte imbalance
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Slide 56
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Slide 57
Eating Disorders
• Anorexia Nervosa and Bulimia Nervosa

Treatment
•
•
•
•
Behavior modification
Individual psychotherapy
Family therapy
Psychopharmacology


Fluoxetine (Prozac)
Sertraline (Zoloft)
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Slide 58
Eating Disorders
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Slide 59
Overview of Treatment Methods
• Communication and Therapeutic Relationship

Psychotherapy
•
•
•
•
•
•
•
Behavior therapy
Cognitive therapy
Group therapy
Play therapy
Hypnosis
Psychoanalysis
Adjunctive therapies
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Slide 60
Overview of Treatment Methods
• Electroconvulsive Therapy (ECT)


Treatment for depression, mania, or schizophrenia
disorders that do not respond to other treatments
A very small amount of electrical current required to
trigger a tonic-clonic (grand mal) seizure
• Temporary memory loss

Last a few hours to a few days
• Confusion

Lasts a few hours
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Slide 61
Overview of Treatment Methods
• ECT (continued)

Nursing Interventions
• Pre-ECT




Informed consent; NPO for 8 hours
Baseline vital signs; void prior to treatment
All jewelry, glasses, contacts, dentures, and hairpins
removed
IV line inserted; pre-ECT medications given
• Post-ECT



Frequent vital signs; warm bath
Constant supervision due to confusion
Cannot drive themselves home due to use of anesthetics
and procedure itself
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Slide 62
Psychopharmacology
• Refer to Pharmacological Aspects of Nursing Care
Chapter 28 and handouts.
• Antidepressants

Selective serotonin reuptake inhibitors (SSRIs)
• Fluoxetine (Prozac), sertraline (Zoloft), venlafaxine
(Effexor), citalopram (Celexa), paroxetine (Paxil)

Serotonin syndrome
o
o
Potentially life-threatening condition
Occurs due to an interaction between SSRI and
another serotonergic agent
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Slide 63
Psychopharmacology
• Antidepressants (continued)

Tricyclics (tend to cause sedation)
• Amitriptyline (Elavil), amoxapine (Asendin), desipramine
HCl (Norpramin), imipramine HCl (Tofranil), nortriptyline
HCl (Avnetyl, Pamelor)

Monoamine oxidase inhibitors (MAOIs)
• Phenelzine sulfate (Nardil)
• Tranylcypromine sulfate (Parnate)

Triazolopyradines
• Trazodone (Desyrel)
• Bupropion (Wellbutrin)
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Slide 64
Psychopharmacology
• Antimanics


Stabilizes mood and behavior of a patient with mania
Therapeutic blood level required
• May take 7 to 10 days to achieve

Lithium carbonate (Eskalith, Lithobid)
• Monitor for lithium toxicity


Serum level above 1.5 mEq/L
Nausea, vomiting, diarrhea, drowsiness, muscle
weakness, and ataxia
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Slide 65
Psychopharmacology
• Antipsychotics




Major tranquilizers
Treatment of schizophrenia, organic mental disorders
with psychosis, and the manic phase of bipolar mood
disorder
Provide symptomatic control; not a cure
Side effects
•
•
•
•
Postural hypotension
Sedation
Photosensitivity
Autonomic reactions
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 66
Psychopharmacology
• Antipsychotics (continued)

Side effects
• Extrapyramidal symptoms





Pseudoparkinsonism
Akathisia
Dystonias
Dyskinesia
Tardive dyskinesia
• Treatment of extrapyramidal symptoms

Reduce or stop the drug, parenteral diphenhydramine,
antiparkinson drugs
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Slide 67
Psychopharmacology
• Antipsychotics (continued)
•
•
•
•
•
•
•
Chlorpromazine (Thorazine)
Thioridazine HCl (Mellaril-S)
Trifuloperazine HCl (Stelazine)
Fluphenazine HCl (Prolixin, Permitil)
Perphenazine (Trilafon)
Thiothixene (Navane)
Haloperidol (Haldol)
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Slide 68
Psychopharmacology
• Antianxiety




Minor tranquilizers
Help individuals experiencing moderate to severe
anxiety
Drugs in this category are commonly abused
Examples
•
•
•
•
•
•
Alprazolam (Xanax)
Busipirone (Buspar)
Chlordiazepoxide HCl (Librium)
Clorazepate dipotassium (Tranxene)
Lorazepam (Ativan)
Oxazepam (Serax)
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Slide 69
Alternative Therapies
• Use of natural or herbal medications has gained
tremendous popularity.
• Control and manufacture of these medications do
not fall under the laws of the U.S. Food and Drug
Administration.


Quality and quantity vary from manufacturer to
manufacturer.
Claims and clinical studies are not always consistent.
• Nurse should ask about the use of herbs when
obtaining drug history.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 70
Alternative Therapies
• Examples

St. John’s wort (Hypericum)
• Used for mild depression – may also precipitate mania
in a bipolar patient

Kava (Piper methysticum)
• Used in treating anxiety and insomnia

Ginkgo and ginseng
• Used to improve memory and boost energy

Aromatherapy
• Used to enhance or potentiate another remedy
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 71