mental health volume 2

INTRODUCTORY MENTAL HEALTH NURSING

Volume 2, Module 5, L. Briska RN BSN
Chapters Covered: Womble, Kincheloe, Chapters 2, 5, 11, 12, 14 - 17

KEYS TERMS

  • Ketamine: A substance acting as a glutamate receptor antagonist in the treatment of psychiatric disorders.

  • Glutamate: An excitatory neurotransmitter involved in various brain functions.

  • Persecutory: Related to a feeling of being harassed or persecuted.

  • Antagonist: A substance that inhibits the action of another; used in the context of medications.

  • Mania: A state of abnormally elevated or irritable mood, arousal, and/or energy levels.

  • Hypnagogic: Pertaining to the state immediately before falling asleep.

  • Hallucination: A perception in the absence of an external stimulus that has qualities of real perception.

  • Psychosis: A severe mental disorder characterized by a disconnection from reality, including delusions and hallucinations.

SCHIZOPHRENIA

  • Derived from Greek:

    • Schizo: To split

    • Phrenia: Mind

  • Epidemiology:

    • Affects 1 in 222 adults (approximately 0.45%)

    • 2/3 of affected individuals do not receive appropriate medical treatment

    • Life expectancy is reduced by 10-20 years compared to the general population

  • Age of Onset:

    • Males: Ages 18–25

    • Females: Ages 25–30 (often with less severe symptoms)

  • Symptoms:

    • Disorganization and discord in thought, mood, and behavior

    • Altered perception of reality

PHASES OF SCHIZOPHRENIA

  1. Schizoid Personality Phase:

    • Secretive and isolated

    • Lack of interest in socialization

  2. Prodromal Phase:

    • Mood changes (anxiety, depression, mood swings)

    • Sleep disturbances and irritability

    • Impaired role functioning and eccentric behavior

  3. Active Phase (Schizophrenia):

    • Exhibits positive symptoms

SYMPTOMS OF SCHIZOPHRENIA

Positive Symptoms

  • Actual disease symptoms:

    • Hallucinations: Perceptions without stimuli

    • Illusions: Misinterpretations of real external stimuli

    • Depersonalization: Feeling detached from oneself

    • Bizarre Behavior: Unusual actions that do not conform to social norms

    • Agitation: Increased motor activity, often without purpose

    • Catatonia: Immobility or excessive movement in response to sensory stimuli

    • Autism: Social withdrawal from reality

Negative Symptoms

  • Reflect a diminished capacity to cope with life:

    • Blunt or Flat Affect: Reduced expression of emotions

    • Anhedonia: Inability to feel pleasure from activities

    • Avolition: Lack of motivation for self-care and daily tasks

    • Impoverished Speech: Limited amount of spontaneous conversation

    • Substance Use: Abuse of drugs to cope

    • Depression: Associated states of hopelessness and suicidal ideation

    • Violent Behavior: Possible violent outbursts due to frustration

TYPES OF SCHIZOPHRENIA

  1. Paranoid Schizophrenia:

    • Characterized by suspicion and delusions

    • Auditory hallucinations and hostile behavior

  2. Disorganized Schizophrenia:

    • Indifference to social norms, inappropriate emotional responses

    • Often diagnosed in adolescence

  3. Undifferentiated Schizophrenia:

    • Symptoms do not fit criteria for other types

    • Generally less severe psychotic symptoms

  4. Catatonic Schizophrenia:

    • Exhibits two forms:

      • Catatonic Stupor: Immobility, lack of facial expressions

      • Catatonic Excitement: Agitated, impulsive behavior

PROGNOSIS OF SCHIZOPHRENIA

  • Rule of Quarters:

    • 25% recover fully and lead symptom-free lives

    • 25% show significant improvement but retain residual symptoms

    • 25% have a chronic course, requiring ongoing support

    • 25% experience poor outcomes with severe symptoms

  • Determinants:

    • Early onset correlates with poorer outcomes

    • Support systems positively affect prognosis

    • Family history and marital status contribute to outcomes

    • Compliance with medication is crucial

SCHIZOAFFECTIVE DISORDER

  • Definition: Requires the presence of primary positive symptoms of schizophrenia and episodes of mood disorders (either Major Depressive Disorder or Bipolar Disorder).

  • Characteristics: Chronic and disabling condition often requiring comprehensive treatment.

TREATMENT OF SCHIZOPHRENIA

Medications

  • Anti-psychotic medications are crucial; may include time-released pills

  • Anticholinergic medications may be needed to combat side effects

  • Long-acting injectables (LAI): For non-compliant patients; intervals of 2–4 weeks

  • Allopurinol: Shows promise in reducing both positive and negative symptoms in resistant cases

  • Electroconvulsive Therapy (ECT): Changes levels of neurotransmitters affecting mood and cognition

  • Psychotherapy:

    • Social skills training

    • Coping skills development

ANTI-PSYCHOTIC MEDICATION POTENCY

  • Definition: Refers to the effectiveness of the medication and its side effects

  • High Potency Medications:

    • Extrapyramidal side effects prevalent

    • Includes:

    • Haloperidol (Haldol)

    • Fluphenazine (Prolixin)

  • Moderate Potency Medications:

    • Includes:

    • Loxapine (Loxitane)

    • Perphenazine (Trilafon)

  • Low Potency Medications:

    • Anticholinergic side effects prevalent

    • Includes:

    • Chlorpromazine (Thorazine)

    • Thioridazine (Mellaril)

SIDE EFFECTS OF ANTI-PSYCHOTICS

Anticholinergic Reactions

  • Symptoms include:

    • Dry mouth

    • Blurred vision

    • Urinary retention

    • Constipation

    • Hypotension

Extrapyramidal Side Effects

  • Result from blocking dopamine pathways, leading to movement disorders:

    • Akathisia: Restlessness

    • Dystonia: Abnormal muscle contractions

    • Tardive Dyskinesia: Irreversible involuntary movements, often late-appearing

    • Neuroleptic Malignant Syndrome: Serious condition characterized by muscle rigidity, hyperthermia, and changes in levels of consciousness

TARDIVE DYSKINESIA

  • Definition: An involuntary movement disorder caused by long-term use of neuroleptic drugs; characterized by uncontrollable movements of the face and limbs.

NURSING CARE FOR PATIENTS WITH SCHIZOPHRENIA

  • Nursing Process:

    • Assess for non-compliance with medication

    • Identify knowledge deficits regarding drug therapy

    • Monitor for side effects

    • Encourage safety and activity of daily living (ADLs)

    • Build a trusting relationship and engage in non-judgmental communication

    • Reality orientation and managing hallucinations by refocusing conversations

    • Combat oral dryness created by medications with sugarless candy and increased oral hygiene

    • Emphasize the importance of medication compliance

SUBSTANCE ABUSE

Definitions

  • Addiction: A chronic condition characterized by compulsive substance use despite harmful consequences.

  • Tolerance: The need for increased amounts of a substance to achieve the same effect.

  • Withdrawal: Unpleasant symptoms experienced when reducing or stopping substance use.

  • Relapse: The return to substance use after a period of abstinence.

Substance Dependency (Criteria)

  • Requires three or more symptoms for at least one month:

    • Tolerance

    • Withdrawal symptoms

    • Desire to cut down use

    • Significant time spent acquiring or using substances

    • Reduction of activities due to substance use

    • Continued use despite problems caused by substance use

ALCOHOL (ETOH) ABUSE

  • Characteristics: Central Nervous System depressant leading to effects such as:

    • Relaxation

    • Slurred speech

    • Impaired coordination

  • Long-term Effects:

    • Cardiomyopathy

    • Cirrhosis and Hepatitis

    • Wernicke-Korsakoff Syndrome linked to thiamine deficiency, including memory loss and confusion

ASSESSMENT TOOLS FOR ALCOHOLISM

  • Use of MAST (Michigan Alcohol Screening Tool) and CAGE questions to evaluate alcohol use patterns:

    • C: Have you felt you should cut down?

    • A: Have people annoyed you?

    • G: Have you ever felt guilty about drinking?

    • E: Have you had an eye-opener drink?

TREATMENT FOR ETOH – ETHANOL ALCOHOL

  • Detoxification: Usually lasts 4-6 hours after the last drink, with symptoms such as anxiety, tremors, and withdrawal seizures.

  • Severe Withdrawals: Known as Delirium Tremens (DTs), marked by severe symptoms including seizures, hallucinations, and agitation.

  • Nursing Care During Detox: Manage symptoms with medications and provide nutritional support.

  • Post-Detox Treatment: Use of medications like Antabuse to deter drinking, Naltrexone to decrease cravings, and therapy support.

COMMONLY ABUSED DRUGS

Cannabis

  • Active Ingredient: Tetrahydrocannabinol (THC)

  • Intoxication Symptoms: Hallucinations, anxiety, increased appetite, and short-term memory impairment.

  • Detection:

    • Urine: 3-4 days

    • Blood: 3-4 weeks

Stimulants

  • Cocaine: Causes immediate dependence, hallucinations, and increased heart rate.

  • Opiates: Highly addictive; lead to severe consequences like respiratory depression and overdose crisis.

    • Antidote: Narcan

Hallucinogens

  • Alter perceptions of time and reality; notable examples include LSD and PCP with intense visual and auditory hallucinations.

Anxiolytics

  • Commonly abused benzodiazepines and barbiturates with sedating effects, leading to impaired cognition and decision-making capabilities.

TREATMENTS FOR DRUG ABUSE

Support Groups

  • Narcotics Anonymous and similar programs

  • Includes physiological care, therapy, and coping skill development

PERSONALITY DISORDERS

  • Patterns of interpersonal behavior that may cause social and occupational difficulties.

  • Diagnosed typically in childhood or adolescence with traits resulting in manipulation and difficulties in relationships.

Cluster A (Odd/Eccentric)

  • Paranoid: Distrustful

  • Schizoid: Withdrawn

  • Schizotypal: Eccentric beliefs

Cluster B (Dramatic/Erratic)

  • Borderline: Unstable self-image

  • Narcissistic: Grandiosity and need for admiration

  • Antisocial: Manipulative, often related to criminal behavior

  • Histrionic: Excessive emotionality and attention-seeking

Cluster C (Anxious/Fearful)

  • Obsessive-Compulsive: Perfectionism

  • Dependent: Excessive need for support

  • Avoidant: Sensitivity to negative evaluation

BORDERLINE PERSONALITY DISORDER

  • Common in females with patterns of intense emotions and unstable relationships.

  • Symptoms include impulsivity, mood swings, and self-harm.

  • Interventions: Cognitive Behavioral Therapy, safety contracts, and anger management.

DEPENDENT PERSONALITY DISORDER

  • Characterized by a lack of self-confidence and a preoccupation with fears of being abandoned.

  • Interventions: Encourage autonomy and decision-making.

NARCISSISTIC PERSONALITY DISORDER

  • Exhibits grandiosity, a need for admiration, and lacks empathy.

  • Interventions: Teach coping skills, direct communication, and healthy relationships.

ANTISOCIAL PERSONALITY DISORDER

  • Marked by a disregard for others and impulsive behavior.

  • High risk of criminal behavior.

  • Interventions: Protect others, manage anger, and set enforcement limits.

PARANOID PERSONALITY DISORDER

  • Features include chronic hostility, jealousy, and projection of insecurities onto others.

  • Interventions: Focus on cognitive-behavioral therapies to help develop trust and flexibility.

DISSOCIATIVE IDENTITY DISORDER (MULTIPLE PERSONALITIES)

  • Often a result of severe childhood trauma; characterized by two or more distinct identities affecting behavior.

NURSING CARE FOR PERSONALITY DISORDERS

  • Essential for the patient to accept the need for help first.

  • Employ therapeutic communication and paternalization techniques.

EATING DISORDERS

  • Involves chronic disruptions in eating behaviors due to emotional issues.

  • Major forms:

    • Anorexia Nervosa: Intense fear of gaining weight, leads to significant weight loss.

    • Symptoms include cardiac issues, amenorrhea, and skin problems.

    • Bulimia Nervosa: Binge eating followed by compensatory behaviors (vomiting, laxatives) while typically remaining at a normal weight.

  • Complications: May lead to dental problems, electrolyte imbalances, and neurological deficits.

NURSING CARE FOR EATING DISORDERS

  • Focus on nutritional counseling, monitoring weight, and providing IV support as needed.

  • Encourage therapy addressing underlying emotional issues.

SEXUAL DISORDERS

  • Include dysfunction related to interest, arousal, and pain; gender dysphoria is also noted.

  • Treatment typically involves hormone therapy and psychotherapy.

CRISIS INTERVENTION

  • A temporary state of emotional imbalance; occurs in five phases:

    1. Pre-Crisis

    2. Impact

    3. Crisis

    4. Adaptive

    5. Post-Crisis

  • Goals include ensuring safety, diffusing anxiety, and returning to a pre-crisis functioning level.

THERAPEUTIC MILIEU

  • Environment designed to support recovery with a focus on safety, structure, and regulated behavior.

  • Goals: Improve behavior, build self-esteem, and teach coping skills.