Mental Illness and Disorders

Introduction to Mental Illness

  • Course: Mental Illness Volume I, Module 4
  • Author: Lisa Briska RN
  • Textbooks:
    • Introductory Mental Health Nursing, 5th Edition
    • Introductory Medical-Surgical Nursing, Timby & Smith, Chapter 67

Organic Mental Disorders

  • Definition: Result directly from a medical condition or physical cause, also referred to as Organic Disorders.
  • Diagnosis: Consists of gathering information through:
    • Patient’s history
    • Physical examinations
    • Laboratory findings
  • Examples of conditions leading to Organic Disorders:
    • High fever
    • Drug/alcohol abuse
    • AIDS
    • Brain trauma
    • Brain tumors
    • Low blood sugar

Delirium

  • Definition: A disturbance in cognitive ability characterized by a sudden onset that is acute and reversible.
  • Common in the elderly, typically has a specific, treatable cause.
  • Symptoms include:
    • Confusion
    • Reduced awareness
    • Sleep disturbances
    • Restlessness
    • Anxiety
    • Delusions
    • Hallucinations
    • Fear

Dementia

  • Definition: A mental disorder characterized by multiple cognitive deficits, primarily memory impairment.
  • Associated impairments:
    • Aphasia: Deterioration of language function affecting speaking ability.
    • Echolalia: Parroting of what is heard.
    • Palilalia: Repetition of words or sounds.
  • Additional cognitive impairments include:
    • Apraxia: Intact motor function but impaired execution of motor tasks.
    • Agnosia: Intact sensory abilities but inability to recognize or name objects.
    • Disturbed executive function: Affected abstract thinking and ability to plan and monitor behaviors.
  • Sundowners Syndrome: Also known as nocturnal delirium; characterized by agitation and confusion during late afternoon or evening.

Types of Dementia

  • Major types include:
    • Alzheimer's Disease
    • Vascular Dementia: Resulting from small cerebral infarctions.
    • Lewy Body Disease
    • Frontotemporal Dementia: Affects frontal lobes, speech and language; includes Pick’s disease (most common form).
    • Creutzfeldt-Jakob Disease: Rare, rapidly progressive; believed to result from a virus or overgrowth of glia.
    • Alcohol-Related Dementia: Such as Wernicke’s encephalopathy.
    • Down Syndrome associated with Alzheimer's Disease.
    • AIDS-associated dementia: Occurring in the final stage of the AIDS disease process.
    • Chronic Traumatic Encephalopathy (CTE): Dementia resulting from repeated head injuries affecting brain function over time.
    • Childhood Dementia: Including various conditions such as inborn errors of metabolism, lysosomal disorders, mucopolysaccharidoses, peroxisomal diseases, neurodegeneration with brain iron accumulation (NBIA), and leukodystrophies.

Alzheimer’s Disease

  • Prevalence: Most common type of dementia with gradual onsets and irreversible progression.
  • Pathological features include:
    • Amyloid Plaques: Accumulation of beta-amyloid proteins around brain cells.
    • Neurofibrillary Tangles: Twisted tau proteins within brain cells.
    • Brain Shrinkage: Primarily in areas related to memory, learning, and decision-making (e.g., hippocampus).
    • Loss of Neural Connections: Neurons lose communication ability, disrupting brain networks.
    • Inflammation: Chronic brain inflammation damaging neurons and advancing the disease.
  • Symptoms include:
    • Memory loss
    • Loss of motor function and speech
    • Behavioral changes: paranoia, delusions, hallucinations
    • Neglect of hygiene
    • Belligerence

Risk Factors for Alzheimer’s Disease

  • Increased age (especially over 65 years)
  • Family history or genetic mutations on chromosomes 21 or 14
  • History of Down syndrome (extra chromosome 21) and conditions like head trauma, cerebrovascular accidents (CVA), or Parkinson’s Disease
  • Demographic factors: More prevalent in females, African-Americans, individuals with lower educational and occupational status.
  • Lifestyle factors: High-fat diet, free-radicals, lack of exercise, stress, exposure to environmental toxins.

Seven Stages of Alzheimer’s Disease

  1. Stage 1: No symptoms
  2. Stage 2: Very mild cognitive decline
  3. Stage 3: Mild cognitive decline
  4. Stage 4: Moderate cognitive decline (early Alzheimer's)
  5. Stage 5: Moderately severe cognitive decline (mid-stage Alzheimer's)
  6. Stage 6: Severe cognitive decline
  7. Stage 7: Severe Alzheimer's disease

Treatments for Alzheimer’s Disease

  • Medications:
    • Start low and go slow with cholinesterase inhibitors (e.g., Donepezil (Aricept®), Rivastigmine (Exelon®), Galantamine (Razadyne®)).
    • NMDA receptor antagonists (e.g., Memantine (Namenda®)).
    • Immunotherapy targeting amyloid proteins (e.g., Remternetug, Lecanemab, Donanemab).
    • Treat symptomatically depending on the patient's condition utilizing antipsychotics, anti-anxiety medications, and antidepressants.
  • Nutritional Support: Following a Mediterranean diet rich in fruits, vegetables, whole grains, legumes, fish, seafood, olive oil, while limiting red meat, eggs, and sweets.

Nursing Care for Alzheimer’s Disease

  • Basic Needs: Ensure grooming, feeding assistance, toileting, and promoting activity.
  • Safety: Protect from wandering, particularly during sundowers syndrome.
  • Orientation: Use easy-to-read clocks, calendars with simple boxes, and introduce oneself each time.
  • Structured Activities: Maintain a consistent schedule.
  • Assistance with Vision and Hearing: Provide glasses and hearing aids, ensure adequate lighting.
  • Communication Techniques: Rephrase information, aid in food choices to stimulate sensory engagement.
  • Supportive Environment: Create a non-judgmental milieu, maintain dignity, utilize reminiscence therapy, and engage family support.

Anxiety

  • Definition: Anxiety is a state characterized by feelings of uneasiness or apprehension along with the autonomic nervous system's activation in response to an unclear threat, leading to a fight-or-flight response.

Physical Adaptations to Stress and Anxiety

  • Physical changes include:
    • Secretion of adrenaline (epinephrine) from adrenal glands
    • Increased respiratory rate for heightened oxygen intake
    • Dilated pupils to enhance sensory perception
    • Increased heart rate and blood pressure, boosting strength of cardiac contractions
    • Constricted peripheral blood vessels
    • Elevated glycogenolysis to increase glucose supply.

Phases of Anxiety

  1. Crisis Phase: Activation of the fight or flight response. Symptoms include vascular constriction and release of norepinephrine and epinephrine.
  2. Adaptation Phase: Hormonal levels adjust, returning to homeostasis.
  3. Exhaustion Phase: Immune system challenges may arise, potentially leading to cardiac or renal failure, and in severe cases, death.

Levels of Anxiety

  • Mild: Everyday stress; enhances awareness and safety.
  • Moderate: Physical symptoms begin, such as tension.
  • Severe: Patient can only focus on the stressor, inability to process new information.
  • Panic: Overwhelming anxiety with severe physical symptoms.

Physical Maladaptations to Stress

  • Chronic stress can lead to:
    • Decreased immunity
    • Headaches
    • Gastrointestinal issues (e.g., gastric ulcers)
    • Hypertension and related kidney damage
    • Coronary artery disease
    • Cancer
    • Asthma
    • Burnout

Automatic Relief Behaviors

  • Definition: Unconscious behaviors that may not be acknowledged by the patient, such as:
    • Clicking pens, tapping feet, leg bouncing.
  • Free-floating Anxiety: Anxiety not connected to a specific cause.
  • Anticipatory Anxiety: Occurs ahead of an upcoming event.

Generalized Anxiety Disorder (GAD)

  • Characterization: Chronic worry and high anxiety occurring more than half the time for a duration of six months or more. Can sometimes relate to a medical diagnosis.
  • Symptoms include:
    • Excessive worry
    • Negative self-talk
    • Fatigue
    • Insomnia
    • Increased startle reflex
    • Muscle tension, headaches, irritability
    • Inability to control anxiety and concentration issues
    • Tremors and gastrointestinal disturbances
    • Other symptoms: bruxism, frequent urination

Treatment and Interventions for GAD

  • Strategies include creating a calm environment, identifying triggers, promoting relaxation techniques, providing short, clear explanations, and using prescribed anti-anxiety medications.

Panic Disorder

  • Description: Episodes lasting 15-30 minutes, characterized by escalated anxiety and severe physical discomfort associated with a sense of dread, choking, and rapid heartbeat.

Symptoms of Panic Disorder

  • Physical symptoms: heartbeat acceleration, perspiration, chills or flushing, tingling in the extremities, nausea, chest pain, difficulty breathing, and feelings of dread or losing control.

Nursing Intervention for Panic Disorder

  • Strategies include:
    • Creating a non-stressful environment
    • Assisting in identifying triggers
    • Teaching relaxation techniques
    • Proactive therapeutic listening
    • Providing non-judgmental emotional support.

Behavior Modification

  • Definition: Manipulating variables to promote behavioral changes, aimed at diminishing inappropriate or unhealthy behaviors.
  • Desired outcomes encompass:
    • Replacing negative thoughts with positive actions
    • Reinforcing new behaviors through consistent nursing practices and clear expectations.
  • Patient Teaching: Ensure understanding of behavioral changes through effective communication skills.

Phobias

  • Definition: An illogical, excessive fear rooted in faulty thought processes.
  • Examples of phobias include:
    • Zoophobia: Fear of animals
    • Claustrophobia: Fear of confined spaces
    • Acrophobia: Fear of heights
    • Aviophobia: Fear of flying

Treatment for Phobias

  • Interventions may include:
    • Relaxation techniques
    • Desensitization strategies
    • Behavior modification therapies for addressing fears.

Obsessive Compulsive Disorder (OCD)

  • Definition: A condition where individuals possess recurrent intrusive thoughts that provoke anxiety (obsessions) and engage in repetitive behaviors or rituals (compulsions) to alleviate this anxiety.
  • Characteristic features:
    • Hoarding Disorder: Accumulating items excessively.
    • Trichotillomania: Hair-pulling disorder.

Acute Stress Disorder vs. Post Traumatic Stress Disorder (PTSD)

  • Acute Stress Disorder: Symptoms occurring within one month post-trauma, lasting less than four weeks.
  • PTSD: Behavioral patterns arising after a trauma, emerging about three months post-event. Symptoms include:
    • Intense fear or dread post-trauma
    • Emotional numbness
    • Avoidance of reminders of the trauma
    • Hypervigilance
    • Poor social functioning
    • Irritability
    • Suicidal ideation
    • Substance abuse issues.

Treatment for PTSD

  • Encouragement of verbal expression regarding trauma, active listening, identification of triggers, and medication options including SSRIs, SNRIs, antidepressants, and beta-blockers.

Somatic Disorders

  • Definition: Disorders associated with physical symptoms resulting from stress.
  • Types include:
    • Conversion Disorder: Physical symptoms with no medical explanation.
    • Hypochondriasis: Exaggeration of minor ailments.
    • Body Dysmorphic Disorder: Perception of nonexistent physical flaws.

Treatment of Anxiety Disorders

  • Pharmacological interventions include anti-anxiety agents, antidepressants, and antipsychotics.
  • Psychotherapy aims to lower emotional discomfort, improve social functioning, and enhance appropriate behavior patterns.

Nursing Process - ADPIE

  1. Assessment: Physical symptoms, coping mechanisms, and behavioral patterns.
  2. Diagnosis: NANDA diagnoses include anxiety, fear, ineffective coping, impaired social interaction, social isolation, powerlessness, and knowledge deficits.
  3. Planning: Goals set for acute, stabilization, and community phases focusing on anxiety reduction and coping mechanisms.
  4. Implementation: Techniques for a calming environment, fostering trust, effective communication, and documentation.
  5. Evaluation: Assessment of behavior, thoughts, emotions, and actions following interventions.

Mood Disorders

  • Overview: A collection of clinical conditions that disrupt mood control and result in distress.
  • Types include:
    • Major Depressive Disorder (MDD)
    • Dysthymic Disorder
    • Bipolar Disorder
  • Kindling Hypothesis: Stressful events may alter neurotransmitter activity.

Major Depressive Disorder (MDD) and Dysthymic Disorder

  • Etiology: Unipolar; characterized by prolonged disturbances of mood resulting in physical and psychomotor changes.
  • Symptoms: Include changes in appetite, sleep issues, hopelessness, low self-esteem, and suicidal ideation. Organic causes may include hormonal changes or traumatic situations.

Treatments for Mood Disorders

  • Medications: Including SSRIs, SNRIs, tricyclic antidepressants, and MAOIs—each with specific side effects and contraindications.
  • Psychotherapy: Foster interpersonal skills, address emotional discomfort, and build coping strategies.
  • Electroconvulsive Therapy (ECT): For severe cases unresponsive to medication; involves inducing seizures to reposition neurotransmitter levels.

Nursing Considerations for ECT and Depressive Disorders

  • Ensure informed consent, patient safety, and support throughout the ECT process.

Nursing Care for Patients with Major Depression and Dysthymic Disorders

  • Prioritize patient needs related to mental health, ensure protection against suicidality, and create realistic goals and activities.

Bipolar Disorder (Manic-Depressive)

  • Describe cyclical shifts between mania and depression. Treatment includes mood stabilizers, anticonvulsants, tranquilizers, and psychotherapeutic approaches.

Nursing Care for Bipolar Patients

  • Emphasize protection, maintaining a structured environment, and promoting appropriate behaviors.

Suicide

  • Categories: Direct and indirect suicidal behaviors related to social alienation, impulsivity, and psychiatric disorders.
  • Warning Signs: Include verbal indications of suicidal thoughts, giving away possessions, sudden changes in mood, and increased substance use.

Myths about Suicide

  • Dispelling common misconceptions about suicide, emphasizing the importance of open communication and understanding mental health needs in vulnerable groups.

Nursing Care for Suicide Attempts

  • Mandated reporting procedures, commitments for safety, one-on-one monitoring, medication adherence, and therapeutic communication.