module 4

Mental Illness Volume I Module 4

• Source Texts:

  • Introductory Mental Health Nursing, Fifth Edition, Chapters 2, 9, 10, 19

  • Introductory Medical-Surgical Nursing, Timby & Smith Chapter 67

Organic Mental Disorders

• Definition:

  • Disorders classified based on a physical cause, also referred to as organic disorders.

• Etiological Factors:

  • Direct result of a consequence of a medical condition.

  • Can be diagnosed through patient’s history, physical examinations, and laboratory findings.

  • Examples include:

  • High fever

  • Drug/alcohol abuse

  • AIDS

  • Brain trauma

  • Brain tumor

  • Low blood sugar

  • If no known cause is identified, it is termed a functional disorder.

Delirium

• Definition:

  • Disturbance of cognitive ability characterized by a sudden onset, acute nature, and reversibility.

• Characteristics:

  • More prevalent in elderly populations.

  • Specific causes can be treated.

  • Symptoms include:

  • Confusion

  • Reduced awareness

  • Sleep disturbances

  • Restlessness

  • Anxiety

  • Delusions

  • Hallucinations

  • Fear

Dementia

• Definition:

  • A mental disorder involving multiple cognitive deficits, primarily affecting memory.

• **Key Symptoms: **

  • Aphasia: Deterioration of language function to the extent that verbal communication becomes impossible.

  • Echolalia: Parroting words or sounds heard.

  • Palilalia: Repetition of words or phrases.

Dementia Symptoms Continued

• Apraxia:

  • Intact motor ability but impaired execution of motor function.

• Agnosia:

  • Intact sensory ability with an inability to recognize or name objects.

• Disturbed Executive Functioning:

  • Impaired abstract thinking and planning abilities.

• Sundowner’s Syndrome:

  • Extreme agitation and confusion occurring in late afternoon or early evening.

Types of Dementia

• Common Types:

  • Alzheimer's disease

  • Vascular dementia

  • Lewy Body disease

  • Frontotemporal dementia

  • Alcohol-related dementia

  • Down syndrome associated with Alzheimer's disease

  • HIV-associated dementia

  • Chronic Traumatic Encephalopathy (CTE) dementia: impacts from repeated head injuries.

  • Childhood dementia related to inborn metabolic errors including:

  • Lysosomal disorders

  • Mucopolysaccharidoses

  • Peroxisomal disease

  • Neurodegeneration with brain iron accumulation (NBIA)

  • Leukodystrophy

Alzheimer’s Disease

• Description:

  • Most common type of dementia with a gradual onset and progressive, irreversible nature.

• Physical Changes:

  • Enlarged 3rd & 4th ventricles of the brain.

• Symptoms:

  • Memory loss

  • Loss of motor function and speech

  • Behavioral changes including paranoia, delusions, hallucinations, and neglect of hygiene or personal care.

  • Increased belligerence.

Risk Factors for Alzheimer’s Disease

• Age: Increases after age 65.

• Family History: Previous history of Down syndrome, head trauma, cerebrovascular accidents (CVA), Parkinson’s disease.

• More prevalent in females.

• Increased risk in African Americans and those with low educational and occupational levels.

• Lifestyle factors:

  • High fat diet

  • Lack of exercise

  • Stress

  • Environmental toxins.

Seven Stages of Alzheimer’s Disease

• Stage 1: No symptoms.

• Stage 2: Very mild cognitive decline.

• Stage 3: Mild cognitive decline.

• Stage 4: Moderate cognitive decline (mild or early Alzheimer's).

• Stage 5: Moderately severe cognitive decline (mid-stage Alzheimer's).

• Stage 6: Severe cognitive decline.

• Stage 7: Severe Alzheimer's.

Treatments for Alzheimer’s Disease

• Medical Treatments:

  • Start low dose and gradually increase.

  • Cholinesterase Inhibitors:

  • Medications include:

    • Donepezil (Aricept®)

    • Rivastigmine (Exelon®)

    • Galantamine (Razadyne®)

  • NMDA Inhibitors:(N-methyl-D-aspartate inhibitors)

  • Memantine (Namenda®)

  • Immunotherapy: Targeting amyloids.

  • Examples include Remternetug, Lecanemab, Donanemab.

  • Treatment depends on individual symptoms and may include:

  • Antipsychotics

  • Anti-anxiety medications

  • Antidepressants.

• Nutritional Support:

  • Foods recommended include:

  • Mediterranean diet: fruits, vegetables, whole grains, legumes, fish, seafood, olive oil, limited amounts of red meat, eggs, and sweets.

Nursing Care for Alzheimer’s Disease

• Basic Needs: Must be adequately met, including personal grooming, assistance with feeding, toileting, and encouraged activity participation.

• Safety Measures:

  • Prevent wandering due to sundowners syndrome.

  • Use psych-specific floor settings.

• Behavioral Management:

  • Maintain orientation using:

  • Easy to read clocks and calendars with simple boxes.

  • Color-coding instead of linguistic instructions.

  • Reintroduce self and support personnel each time.

• Structured Activities: Implement a daily schedule to help provide a sense of normalcy.

Continuing Nursing Care for Alzheimer’s Patients

• Assistive Devices:

  • Glasses and hearing aids may need to be provided.

• Room Arrangement:

  • Optimize lighting and safety within the living space.

• Rephrasing Information:

  • Simple language to communicate with patients.

• Sensory Stimulation:

  • Assist in choosing food based on smell and taste preferences.

• Maintain supportive environment:

  • Foster non-judgmental attitudes.

Maintaining Dignity in Alzheimer’s Patients

• Therapeutic Interventions:

  • Reminiscence therapy may be employed.

• Family Support:

  • Encouragement of support groups or counseling.

• Validation Therapy:

  • Naomi Feil's approach advocates validating feelings.

Anxiety

• Definition:

  • A state where individuals experience feelings of uneasiness or apprehension, often tied to the activation of the autonomic nervous system in response to a vague or non-specific threat. This state links to the fight-or-flight response.

Physiological Adaptations to Stress/Anxiety

• Fight or Flight Response:

  • Activation leads to secretion of adrenaline (epinephrine) from adrenal glands thereby:

  • Increasing respiratory rate (allowing for greater O2 intake)

  • Dilating pupils to enhance information input.

  • Increasing blood pressure and heart rate for better physical readiness.

  • Constraining peripheral blood vessels, and enhancing glycogen breakdown.

Phases of Anxiety

• Crisis Phase:

  • Fight or flight is initiated, leading to:

  • Blood vessel constriction.

  • Release of norepinephrine and epinephrine.

  • Elevated blood pressure.

• Adaptation Phase:

  • Hormonal levels normalize, body functions return to homeostasis.

• Exhaustion Phase:

  • Challenges to immune system may arise, which can lead to:

  • Enlarged lymph nodes.

  • Risks of cardiac and renal failure.

  • May be life-threatening complications.

Levels of Anxiety

• Four Levels Identified:

  • Mild Anxiety: Encountered daily; enhances awareness and safety.

  • Moderate Anxiety: Physical symptoms begin to manifest.

  • Severe Anxiety: Patient's focus narrows solely on stressors, inhibiting their ability to process new information.

  • Panic Anxiety: Individuals overwhelmed by severe physical and emotional symptoms.

Maladaptive Physical Responses to Stress

• Negative health impacts may include:

  • Decreased immunity.

  • Headaches.

  • Gastric ulcers.

  • Hypertension and renal issues.

  • Increased potential for coronary artery disease, cancer, asthma, and burnout.

Anxiety-Related Behaviors

• Automatic Relief Behaviors:

  • Unconscious habits such as tapping pens, leg bouncing.

• Free-Floating Anxiety:

  • Inability to link anxiety to specific causes or stimuli.

• Anticipatory Anxiety:

  • Anxiety felt prior to an event.

Generalized Anxiety Disorder (GAD)

• Definition:

  • Excessive and chronic anxiety occurring more often than not over six months or longer.

• Symptoms Related:

  • Can be tied to medical diagnoses and characterized by:

  • Chronic excessive worry

  • Negative self-dialogue

  • Fatigue and insomnia

  • Heightened startle response

  • Persistent feelings of tension or being on edge.

  • Difficulty concentrating along with physical symptoms such as tremors and gastrointestinal disturbances.

Treatment for Generalized Anxiety Disorder

• Interventions Include:

  • Providing a calming environment.

  • Identifying triggers for anxiety.

  • Relaxation techniques to diminish anxiety levels in patients.

  • Providing focused attention with short, simple explanations.

  • Administering anti-anxiety medications as prescribed.

Panic Disorder

• Description:

  • Characterized by episodes lasting 15-30 minutes with rapidly escalating anxiety.

• Accompanying Symptoms:

  • Intense fear associated with physiological discomfort, creating feelings of dread, choking sensations, tremors, rapid heartbeat, and faintness.

Symptoms of Panic Disorder

• Manifestations include 4 or more of the following:

  • Increased, pounding heart rate

  • Excessive perspiration

  • Chilling sensations or flushing

  • Paresthesia (tingling/numbness of extremities)

  • Nausea and chest discomfort

  • Feelings of choking or dying.

  • Manifestations of agoraphobia and potential depressive states.

Treatments for Panic Disorder

• Recommended Approaches:

  • Maintain a calm, quiet environment for patients.

  • Help clients in identifying and avoiding triggers.

  • Teach relaxation techniques.

  • Utilize therapeutic listening and communication for better understanding.

Nursing Interventions for Anxiety Disorders

• Create a non-stressful environment for patients.

• Offer non-judgmental emotional support.

• Remain present with the client while practicing interventions.

Behavior Modification Strategy

• Behavior Modification:

  • Manipulation of variables for behavior changes aimed at diminishing unhealthy behaviors.

  • Desired outcomes: Replacing negative thoughts with positive ones and establishing productive behaviors.

• Nursing Considerations:

  • Positive reinforcement of new behaviors.

  • Clear communication of expected behaviors consistently upheld in patient care.

  • Ensuring patient understanding of behavioral changes.

Phobias

• Definition:

  • Conditional fear attributable to faulty thought processes.

• Types of Phobias:

  • Agoraphobia: Difficulty escaping from situations.

  • Social Phobia: Fear of embarrassment or scrutiny from others such as in public speaking.

  • Simple Phobias: Specific objects or situations.

Specific Phobias Examples

• Zoophobia: fear of animals.

• Pyrophobia: fear of fire.

• Amaxophobia: fear of riding in a car.

• Somniphobia: fear of sleep.

• Claustrophobia: fear of confined spaces.

• Arachnophobia: fear of spiders.

• Xanthophobia: fear of the color yellow.

• Phasmophobia: fear of ghosts.

• Hematophobia: fear of blood.

• Triskaidekaphobia: fear of the number 13 and others like acrophobia, gephyrophobia, etc.

Treatment of Phobias

• Therapeutic Techniques:

  • Implementation of relaxation techniques.

  • Desensitization experiences.

  • Support encouragement for behavior modification approaches.

Obsessive Compulsive Disorder (OCD)

• Definition:

  • Characterized by unconscious thoughts and compulsive rituals to mitigate anxiety.

• Key Features:

  • Obsessions: Intrusive thoughts causing significant anxiety impacting social functioning.

  • Compulsions: Repetitive behaviors performed to relieve anxiety that a person feels they must complete.

• Notable Variants:

  • Hoarding Disorder.

  • Trichotillomania (hair-pulling disorder).

Acute Stress Disorder and Post-Traumatic Stress Disorder (PTSD)

• Acute Stress Disorder:

  • Symptoms manifest within one month but last less than four weeks following a traumatic event.

• PTSD:

  • Symptoms persist and can involve emotional numbness, avoidance of reminders associated with the event, and significant distress below referring to an event involving actual death or severe injury.

Symptoms of PTSD

• Common Symptoms Include:

  • Severe fear and dread following a traumatic event.

  • Mentally replaying the event.

  • Emotional numbing, leading to avoidance behaviors or withdrawal from social interactions.

  • Increased vigilance, irritability, and difficulties in interpersonal relationships.

  • Risk of substance abuse and self-harming behaviors such as depression and suicidal ideation.

Treatment for PTSD

• Recommended Interventions:

  • Encourage verbalization of experiences associated with trauma.

  • Employ active listening strategies.

  • Identify troubling aspects of experiences to regain control.

  • Utilize SSRIs, SNRIs, and other medication classes for symptoms such as anxiety and sleep issues.

  • Therapeutic approaches including cognitive-behavioral therapy, prolonged exposure therapy, and stress inoculation training.

Somatic Disorders

• Conversion Reaction:

  • Presentation of physical symptoms stemming from stress without a medical explanation (Conversion Disorder).

• Chronic Pain Disorder:

  • Persistent pain concentration improperly diagnosed with possible fibromyalgia differentiations.

• Hypochondriasis:

  • An exaggerated preoccupation with personal health.

• Cyberchondriasis:

  • Self-diagnosis via Internet-based information.

• Body Dysmorphia:

  • A persistent perception of physical flaws that are nonexistent.

• Factitious Disorder:

  • Symptoms intentionally produced or feigned.

Treatment for Anxiety Disorders

• Medication Options:

  • Anti-anxiety agents, antidepressants, and sometimes antipsychotics.

• Psychotherapeutic Approaches:

  • Aiming to reduce emotional distress and improve social functioning and appropriate behaviors by increasing social skills.

• Cognitive Therapy:

  • Shifting negative perceptions to more positive reflections while addressing underlying sources of anxiety.

• Behavioral Modification:

  • Engaging patients gradually in coping strategies across group therapy settings to foster self-esteem and support networks.

Nursing Process - ADPIE Framework

• Assessment:

  • Identification of physical symptoms and coping mechanisms displayed by the patient through the Mental Health Status Exam (MHSE).

Mini Mental State Examination (MMSE)

• Components of the Exam:

  • Questions assessing orientation such as:

  • Naming the year, season, date, day of the week, and specific location queries (place).

  • Memory recall tasks and attention calculation tasks (e.g., counting backward from 100 by sevens).

  • Evaluation of language ability through repetition and following commands (e.g., “Close your eyes”).

  • Scoring: Normal range (24-30), Moderate cognitive impairment (18-23), Marked cognitive impairment (0-17).

NANDA Diagnosis/Patient Problems

• Potential diagnoses include:

  • Anxiety

  • Fear

  • Ineffective Coping

  • Impaired Social Interaction

  • Social Isolation

  • Powerlessness

  • Knowledge deficit

Planning for Patient Care

• Acute Phase Goals:

  • Establish verbalization of decreased anxiety.

  • Ensure patient safety from harm.

• Stabilization Phase Goals:

  • Encourage understanding of personal responses to stress.

  • Enhance ability to express feelings and try new stress reduction methods.

• Community Phase Goals:

  • Develop effective coping mechanisms and demonstrate adequate functioning in everyday life.

Nursing Interventions

• Care Recommendations:

  • Provide a calming environment.

  • Build trust with the patient and limit choices.

  • Introduce relaxation techniques.

  • Observe for suicidal ideation.

  • Use concise, clear communication encouraging productive activities.

Evaluation of Progress

• Change Assessment:

  • Evaluating behavior, thought patterns, and emotional responses:

  • What we think, what we feel, and what we do.

Mood Disorders

• Group Classification:

  • Clinical conditions marked by mood disturbances, which can lead to distress and impact daily functioning.

  • Major mood disorders include:

  • Major depressive disorder

  • Dysthymic disorder

  • Bipolar disorder.

Major Depressive Disorder (MDD)

• Etiology:

  • Unipolar alterations leading to depressive moods sustained over intended durations.

  • Significant link to suicide rates.

  • Symptoms include:

  • Neuro-vegetative changes: sleep, appetite, energy alterations.

  • Psychomotor changes, especially reduced activity and anhedonia.

Diagnosis of Major Depressive Disorder

• Criteria: Presence of 2 or more of the following symptoms:

  • Changes in appetite (increase or decrease).

  • Sleep disturbances.

  • Fatigue

  • Hopelessness or worthlessness feelings.

  • Poor concentration and decision-making abilities.

  • Anhedonia (lack of interest in pleasurable activities).

  • Suicidal thoughts or feelings of death.

Physical Causes of Depression

• Medical Contexts:

  • Possible organic causes: medications, hypothyroidism, stroke, neurological disorders, diabetes, chronic illness, and serious losses.

Treatments for Depression

• Medications:

  • Selective Serotonin Reuptake Inhibitors (SSRIs) as first-line treatments with milder side effects and include:

  • Celexa, Lexapro, Prozac, Paxil, Zoloft.

  • Serotonin & Norepinephrine Reuptake Inhibitors (SNRIs).

  • Tricyclic antidepressants necessitating monitoring due to potential side effects and health impacts.

  • Monoamine Oxidase Inhibitors (MAOIs): require dietary modifications to mitigate risks of hypertensive crises.

Psychotherapeutic Interventions for Depression

• Focus on:

  • Interpersonal skill development, emotional distress reduction, and self-awareness.

• Approaches:

  • Psychoanalytical treatment insights.

  • Cognitive-behavioral therapy methodologies linking thoughts to feelings and behaviors.

Electro Convulsive Therapy (ECT)

• Use Cases:

  • When medications fail to be effective or lead to severe side effects.

• Process:

  • Administration induces seizures aimed at altering neurotransmitter levels over a series of 3 sessions per week for 3-4 weeks with gradual observed benefits.

Nursing Considerations for ECT

• Pre-Procedural Considerations:

  • Patient must consents.

  • NPO for 6-8 hours before the procedure, undergoing anesthesia, and voiding requirements.

  • Equipment such as dentures and jewelry should be removed.

• Post-Procedure Care:

  • Monitor airway and support mechanisms post-anesthesia due to potential short-term memory loss.

Nursing Care for Patients with Major Depressive Disorder

• Prioritize care based on perceived needs.

• Communicative engagement with the patient while ensuring protection from self-harm due to suicide risks.

• Maintain consistency with caregiver interactions and ensure safe environments.

• Coping Strategies:

  • Allow participation in goals and activities while assisting in daily living tasks as required.

  • Encouragement of realistic goals and fulfilling spiritual needs.

  • Ensure compliance with prescribed medication plans.

Dysthymic Disorder

• Definition:

  • Chronic depression but less severe, with ongoing symptoms similar to MDD including:

  • Poor appetite or overeating, insomnia or excessive sleep, low energy, and feelings of hopelessness.

Bipolar Disorder (Manic-Depression)

• Overview:

  • Characterized by cyclical mood shifts including significant mood highs (mania) paired with depressing lows.

• Subtypes:

  • Bipolar I: predominantly manic episodes.

  • Bipolar II: predominantly depressive episodes with periods of hypomania.

Symptoms of Bipolar Disorder

• Manic Features:

  • Elevated mood leading to high energy levels with increased self-esteem.

  • Restlessness, distractibility, risky behavior, and dangerous self-concept development with decreased sleep requirements.

Depression During Bipolar Disorder

• Symptoms include:

  • Prolonged low mood, decreased interest in activities, fatigue, inability to concentrate, and cyclical death thoughts.

Bipolar Disorder Treatment

• Medications:

  • Use of mood stabilizers such as lithium for manic phases, anticonvulsants like Depakote and Klonopin, and antipsychotics (with sparing use).

• Lithium Specifics:

  • Mechanism stabilizes mood within 10 days, requiring careful monitoring for dehydration and maintaining sodium intake for therapeutic level stabilization.

• Toxicity Considerations:

  • Regular monitoring of lithium levels: normal range 0.6-1.2 mEq/L, elevated levels can cause adverse effects.

Psychotherapeutic Approaches for Bipolar Disorder

• Treatment Focuses on:

  • Cognitive-behavioral therapies for shaping thoughts and behaviors.

  • Interpersonal relationships and psychosocial dynamics.

• Family Therapy Advantages:

  • Helps identify and fix dysfunctional patterns within family units.

Nursing Considerations for Bipolar Disorder Patients

• Maslow’s Hierarchy:

  • Prioritize physical and emotional needs while providing protective measures against harm;

• Facilitate Routine:

  • Therapeutic communication, patience, reducing environmental stimuli, and nutritional considerations should inform care.

Suicide Ideation Definitions

• Categories of Suicidal Behaviors:

  • Direct: Conscious and voluntary intentions.

  • Indirect: Behaviors that may risk life without intent to die.

• Psychosocial Factors:

  • Including feelings of alienation, anger, the desire for reunion, or ends of emotional distress.

High-Risk Groups for Suicide

• Populations:

  • Elderly, adolescents, police personnel, creative individuals, and those with predispositions such as gender, psychiatric histories, and previous attempts.

Warning Signs of Suicide

• Verbalization of Ideas:

  • Giving away possessions or suddenly exhibiting happiness after long periods of sadness.

  • Changes in sleep patterns, increased substance use, and previous suicide attempts.

Myths Surrounding Suicide

• Clarified Misconceptions:

  • Discussing suicidal thoughts does not incite actions.

  • Not all individuals who attempt suicide are mentally ill or seeking attention.

  • Signs of increased energy may be false security; individuals may attempt suicide during manic uplift phases.

Nursing Care for Patients with Suicide Attempts

• Mandates and Commitments:

  • Involuntary psychiatric commitments, individual monitoring with specific safety measures.

  • Use of therapeutic communication and “No suicide” contracts to address intentions and planning.