Mental Health Learning Materials

Mental Health • The WHO defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. Mental Illness • The APA (2000) defines a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom". Deviant behavior does not necessarily indicate a mental disorder Diagnostic and statistical manual of mental disorders • The DSM-IV-TR is a taxonomy published by the ARA. The DSM-IV-TR describes all mental disorders, outlining specific criteria for each based on clinical experience and research. The DSM-IV-TR has 3 purposes: • To provide standardized nomenclature and language for all mental health professionals. • To present defining characteristics or symptoms that differentiates specific diagnoses. • To assist in identifying the underlying causes of disorders. Standards of Psychiatric mental health clinical nursing practice. • Standard I. Assessment -the psychiatric-mental health nurse collects health data •Standard II. Diagnosis The psychiatric-mental health nurse analyzes the data in determining diagnoses. • Standard III. Outcome identification The psychiatric-mental health nurse identifies expected outcomes individualized to the client. •Standard IV. Planning The psychiatric-mental health nurse develops a plan of care that prescribes interventions to attain expected outcomes. • Standard V. Implementation The psychiatric-mental health nurse implements the interventions identified in the plan of care. • Standard Va. Counseling The psychiatric-mental health nurse uses counseling interventions to assist clients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability. • Standard Vb. Milieu Therapy The psychiatric-mental health nurse provides structures, and maintains a therapeutic environment in collaboration with the client and other health care practitioners. • Standard Vc. Self-care activities The psychiatric-mental health nurse structures interventions around the client's activities of daily living to foster self-care and mental and physical well-being. • Standard Vd. Psychobiologic Interventions The psychiatric-mental health nurse uses knowledge of psychobiologic interventions and applies clinical skills to restore the client's health and prevent further disability. • Standard Ve. Health Teaching The psychiatric-mental health nurse, through health teaching, assists clients in achieving, satisfying, productive, and healthy patterns of living. • Standard Vf. Case Management The psychiatric-mental health nurse provides case management to coordinate comprehensive health services and ensure continuity of care • Standard Vg. Health promotion and maintenance. The psychiatric-mental health nurse employs strategies and interventions to promote and maintain mental health and prevent illness. Areas of practice • Counseling • Interventions and communication techniques • Problem solving • Crisis intervention • Stress management • Behavior modification Milieu therapy • Maintain therapeutic environment • Teach skills • Encourage communication between clients a others • Promote growth through role modeling Self-care activities • Encourage independence • Increase self-esteem • Improve function and health Psychobiologic interventions • Administer medications • Teaching • Observations Health teaching Case management Health promotion and maintenance Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes. The Nervous system and how it works • The cerebrum is the center for coordination and integration of all information needed to interpret respond to the environment. • The cerebellum is the center for coordination of movements and postural adjustments. • The brain stem contains centers that control cardiovascular and respiratory functions, sleep, consciousness, and impulses. • The limbic system regulates body temperature, appetite, sensations, memory, and emotional arousal Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. • They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitory). • After neurotransmitters are released into the synapse (point of contact between the dendrites and the next neuron) and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be stored for late use (reuptake) or are metabolized and inactivate by enzymes, primarily monoamine oxidase (MAO). Dopamine, a neurotransmitter located primarily in the brain stem. Dopamine is generally excitatory and is synthesized from tyrosine, a dietary amino acid. • Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity. Norepinephrine and Epinephrine • Norepinephrine, the most prevalent neurotransmitter, is located primarily in the brain stem. It plays a role in mood regulation. • Epinephrine is also known as noradrenaline and adrenaline. Epinephrine has limited distribution in the brain but controls the fight-or-flight response in the peripheral nervous system. Serotonin • A neurotransmitter found only in the brain, is derived from tryptophan, a dietary amino acid. The function of serotonin is mostly inhibitory, involved in the control of food intake, sleep and wakefulness, temperature regulation, pain control of food intake, sleep, and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions Histamine • The role of histamine in mental illness is under investigation. Acetylcholine • Acetylcholine is a neurotransmitter found in the brain, spinal cord, and peripheral nervous system. It can be excitatory or inhibitory. It is synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep-wake cycle and to signal muscles to become active. • Studies have shown that people with Alzheimer's disease have decreased acetylcholine secreting neurons. Glutamate • Glutamate is an excitatory amino acid that at high levels can have major neurotoxic effects. Gamma-Aminobutyric Acid (GABA) • GABA is a major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than to provide a direct stimulus. • Drugs that increase GABA function such as benzodiazepines are used to treat anxiety and to induce sleep. Psychosocial Theories and Therapy Sigmund Freud, the Father of Psychoanalysis Founded the personality components; Id, Ego, • Id: The part of one’s nature that reflects l such a pleasure seeking behavior, aggress impulses. The id seeks instant gratification thinking behavior, and has no rules or re convection. • Superego: The part of one’s nature that re concepts, values, parental and social exp is the directional opposite to the id. is the directional opposite to the id. • Ego: The balancing or mediating force between the id and the superego. The ego represents mature and adaptive behavior that allows a person to function successfully. Psychosexual development • Oral (birth to 18 months) • Anal (18 to 36 months) • Phallic/Oedipal (3 to 5 years) • Latency (5 to 11 or 13 years) • Genital (11 or 13 years) Transference and Countertransference • Transference occurs when the client onto the therapist/nurse attitudes and feelings that the client previously felt in other relationships. • Countertransference occurs when the therapist/nurse displaces onto the client attitudes or feelings from his or her past. Developmental Theorists; Erikson and Piaget Erikson focused on personality development across the life span while focusing on social and psychological development in life stages. Erikson believed that psychosocial growth occurs in sequential stages, and each stage is dependent on the completion of the previous stage/life task. • Trust vs. Mistrust (infant) • Autonomy vs. Shame and Doubt (toddler) • Initiative vs. guilt (preschool) Industry vs. Inferiority (school age) • Identity vs. Role confusion (adolescence) • Intimacy vs. isolation (young adult) • Generativity vs. stagnation (middle adult) • Ego integrity vs. despair (maturity) Piaget explored how intelligence and cognitive functioning develop in children. • Sensorimotor (birth to 2 years): The child develops a sense of self as separate from the environment and the concept of object permanence. Begins to form mental images. • Preoperational (2-6 years): Child begins to express himself with language, understands the meaning of symbolic gestures, and begins to classify objects. • Sensorimotor (birth to 2 years): The child develops a sense of self as separate from the environment and the concept of object permanence. Begins to form mentil images. • Preoperational (2-6 years): Child begins to express himself with language, understands the meaning of symbolic gestures, and begins to classify objects. • Concrete operations (6-12 years): Child begins to apply logical thinking, understands reversibility, is increasingly social and able to apply rules; however, thinking is still concrete. • Formal operations (12 to 15 years and beyond): Child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity. Mood disorders Categories of Mood disorders • Unipolar -Major depression • Bipolar -Mania -Depression -Period of normalcy Helpful hints to care for bipolar clients • You can't teach a manic client • Safety is a huge issue because their judgment is poor. • Only spend short periods of time with patient • Must be flexible in taking intake assessment; may need to obtain datain several short sessions as well as talking to family members. • Ask the client to explain any coded speech • Assist the client to meet socially accepting behaviors. "Kathy, you are too close to my face. Please stand back two feet." • Feed them finger foods high in calories while in a manic phase; provide nutritional support! • Use simple sentences when communicating. It is also helpful to ask client to repeat brief messages to ensure they have heard and incorporated them. "Please speak more slowly. I'm having trouble following you." • Avoid becoming involved in power struggles over who will dominate the conversation Suicide • 4 out of 5 who actually commit suicide have made at least one prior attempt • In a majority of cases, there are clear indicators hat the person was very troubled. • Few than 15% of suicide victims leave suicide notes • The suicide risk is greatest in the 90 days following a major depressive episode. • "survivor guilt" happens when 1 or more family members feel guilty that they are still living • "Separation anxiety" may cause they surviving to "join the beloved deceased" • Make the patient sign a "contract for life" • Crisis intervention-may need 1:1 care. The client is no more than 2-3 feet away from a staff member at any time, including going to the bathroom. Anxiety’ disorder • Panic disorder • Phobic disorder • Agoraphobia • Obsessive-compulsive • PTSD • Generalized anxiety • Anxiety related to medical conditions • Substance-induced anxiety disorder Obsessive-Compulsive Disorder (OCD) • Obsessions: Recurrent thoughts, ideas, visualizations, or inappropriate impulses that disturb a person's life; has no control over them. • Compulsions: Behaviors or rituals continuously carried out to get rid of the obsessive thoughts and reduce anxiety. • Higher incidence with groups in higher economic status and with more education • Though a chronic disease, there will be periods of reduced symptoms followed by "flare-ups", often stressful times in person's life. • Relief is only temporary; usually both obsessions and compulsions occur together • Recognize thoughts or behaviors are irrational; but are compelled to continue them "against their will". Treatment: • Exposure and response prevention • SSRIs help reduce symptoms of OCD-monitor for side effects • Inject reality, If a teenager thinks she is pregnant despite a negative pregnancy test, tell her the TEST IS NEGATIVE. Take them back into reality.• Inject reality. If a teenager thinks she is pregnant despite a negative pregnancy test, tell her the TEST IS NEGATIVE. Take them back into reality. • If they repetitively do an act over and over again; help them set a goal. For instance, "Let's try to only wash your hands once every ten minutes." Post-Traumatic Stress disorder Three clusters if symptoms are present •Reliving the event Memories, dreams, or flashbacks •Avoiding reminders of the event Staying away from any stimuli that could associated with the trauma. •Being on guard (hyper-arousal) Less responsive to stimuli Insomnia, irritability, or angry outbursts •Children in traffic accident (and the parents) Symptoms of PTSD occur 3 months or more after the trauma. Compulsions Washing, cleaning, constant checking, mental counting rituals • Touching, ordering, rearranging • Asking for reassurance or confessing • Masturbation— especially seen in children who haven't yet discovered this is socially unacceptable behavior Nursing interventions: • Remember, a lot of the time people feel guilty about their thoughts and behaviors. • Do not try to stop the act unless the act is harmful (dangerous) • Talk to them! Use "|" statements • If they are too down on themselves—limit your time with them. For instance, "I hate myself. No one cares about me. I'm fat and ugly." The nurse would then say, "I am going to come back in 30 minutes. In that time frame, I want you to think of your good qualities." • Do not argue with OCD person. Some more signs of PTSD: • Have issues with authority figures • Their first emotions are anger, rage, and guilt • Their guilt comes out as anger (violent behavior) • Isolate themselves • Cry • Don't want to talk about it • Drug and alcohol abuse • Nightmares Manifests in physiological symptoms (HA, GI distress) • Irritable • Insomnia Nursing interventions: • Have specific staff members assigned to client to facilitate building trust • Consistency is the key • Be non-judgmental; encourage client to talk • Help them acknowledge where grief is coming from • Involve family • Give positive feedback Goals for PSTD Short term: Safety, decrease insomnia, identify source, grieve! Long term: Accept the fact that the experience happened and live healthy. Schizophrenia Types of schizophrenia • Paranoid schizophrenia Suspiciousness Hostility • Delusions Auditory hallucinations Anxiety and anger • Aloofness Persecutory schemes • Violence Disorganized schizophrenia • Extreme social withdrawal • Disorganized speech or behavior • Flat or inappropriate affect • Silliness unrelated to speech • Stereotyped behaviors • Grimacing mannerisms • Inability to perform activities of daily living Catatonic • Significant psychomotor disturbances • Immobility • Stupor • Waxy flexibility • Excessive purposeless motor activity • Echolalia • Automatic obedience • Stereotyped ore repetitive behavior Undifferentiated schizophrenia • Undifferentiated schizophrenia does no criteria for paranoid, disorganized, or c schizophrenia • Delusions and hallucinations • Disorganized speech • Disorganized or catatonic behavior • Flat affect • Social withdrawal Residual schizophrenia • Diagnosed as schizophrenic in the past • Time limited between attacks but may last for many years • The client exhibits considerable social isolation and withdrawal and impaired role functioning Interventions • Assess the client's physical needs • Set limits on the client's behaviors when it interferes with others and becomes disruptive • Maintain a safe environment Initiate one-on-one interaction and progress to small groups as tolerated -Although, reintegrating the client into the milieu as soon as possible is essential • Spend time with the client even if client is unable to respond • Monitor for altered thought processes • Maintain ego boundaries and avoid touching the client -Touching others without warning or invitation -Intruding in others' living spaces -Talking to or caressing inanimate objects -Undressing, masturbating, or urinating in public • Limit the time of interaction with the client -Initially, the client may only tolerate 5-10 minutes of contact at one time. • Avoid an overly-warm approach; a neutral approach is less threatening • Do not make promises to the client that cannot be kept • Establish daily routines • Assist the client to improve grooming and to accept responsibility for self-care • Sit with the client in silence if necessary • Provide short, brief and frequent contact with the client • Tell the client when you are leaving • Tell the client when you do not understand • Do not "go along" with the clients delusions or hallucinations • Provide simple concrete activities such as puzzles or word games • Reorient the client as necessary • Help the client establish what is real and unreal • Stay with the client if he is frightened • Speak to the client in a simple direct and concise manner • Help the client establish what is real and unreal • Stay with the client if he is frightened • Speak to the client in a simple direct and concise manner • Reassure the client that the environment is safe • Remove the client from group situations if the client's behavior is too bizarre, disturbing, or dangerous to others -Reassure others that the client's inappropriate behaviors or comments are not his fault (without violating confidentiality). • Set realistic goals • Initially do not offer choices to the client, and graduall assist the client in making own decisions • Use canned or packaged food, especially with the paranoid schizophrenic client • Provide a radio or tape player at night for insomnia • Explain to the client everything that is being done • Set limits on the client behavior if the client is unable t do so • Decrease excessive stimuli in the environment Monitor for suicide risk • Assist the client to use alternative means to express feelings through must or art therapy or writing. Nursing interventions for the client experiencing delusions • Ask the client to describe the delusion • Be open and honest in interactions to reduce suspiciousness • Focus the conversation on reality based topics rather than the delusion • Encourage the client to express feelings and focus on the feelings that the delusions generate • If the client obsesses on the delusion, set firm limits on the amount of time for talking about the delusion • Do not dispute with the client or try to convince the client that the delusions are false • Validate if part of the delusion is real • Recognize accomplishments and provide positive feedback for successes Nursing interventions for the client experiencing hallucinations • Monitor for hallucination cues • Elicit description of hallucination to protect the client and others -The nurses understanding of the hallucination helps the nurse know how to calm or reassure the client • Intervene with one on one contact • Decrease stimuli or move the client to another area • Avoid conveying to the client that others are also experiencing the hallucination • Respond verbally to anything real the client talks abou • Avoid touching the client • Encourage the client to express feelings • During a hallucination, attempt to engage the client's attention through a concrete activity -Teaching the client to talk back to the voices forcefully also may help him or her manage auditory hallucinations • Accept and do not judge or joke about the client's behavior • Provide easy activities and a structured environment with routine activities of daily living • Monitor for signs or increasing fear, anxiety, or agitation • Provide seclusion if necessary • Administer medications as prescribed Language and communication disturbances • Clang association: Repetition of words or phrases that are similar in sound but in no other way. • Echolalia: Repetition of words or phrases heard from another person • Mutism: Absence of verbal speech • Neologism: A new word devised that has a special meaning to the client • Word salad: Form of speech in which words or phrases are connected meaninglessly • Latency of response: hesitation before the client responds to questions. This latency or hesitation may last 30-45 seconds and usually indicates the client's difficulty with cognition or thought processes. • Thought broadcasting: believe that others can hear their thoughts • Thought withdrawal: believe others are taking their thoughts • Thought insertion: others are placing thoughts in their mind against their will Abnormal motor behaviors • Akathisia: Displaying motor restlessness and muscular quivering; the client is unable to sit or lie quietly • Echopraxia: Repeating the movements of another person • Waxy flexibility: having one's arms or legs placed in a certain position and holding that same position for hours • Dyskinesia: Impairment of the power of voluntary movement Autistic disorder • Most prevalent in boys; identified no later than 3-years of age • Child has little eye contact, few facial expression, doesn't use gestures to communicate • Does not relate to parents or peers, lacks spontaneous enjoyment, apparent absence of mood and emotional affect, can not be engaged in play or make believe • Repetitive motor behaviors such as hand-flapping, body twisting, or head banging • May improve as child acquires language skills • Short term impatient therapy is used when behaviors such as head banging or tantrums are out of control Haldol or Risperadol may be effective (prn, of course) Goals of treatment: • Reduce behavioral symptoms • Promotes learning and develop • Language skills development Attention deficit disorder • Characterized by patterns of inattention, hyperactivity, and impulsiveness • Account for most mental health referrals • Needs to be physically seen for a renewal of ADHD drugs monthly • Often diagnosed when a child starts school • Distinguishing bipolar disorder from ADHD can be difficult but is crucial because treatment is so different for each disorder Signs and symptoms • Inattentive behaviors • Hyperactive/impulsive behaviors -Fidgets -Often leaves seat -Can't play quietly -Interrupts -Cannot wait turn Eating Disorder Somatoform Disorder Anorexia Nervosa • A life-threatening eating disorder characterized by the client's refusal or inability to maintain a minimally normal body weight, intense fear of gaining weight or becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists. • Has experienced amenorrhea for at least 3 consecutive cycles • Complaints of constipations and abdominal pain Cold intolerance • Hypotension, hypothermia, bradycardia • Elevated BUN and decreased albumin Somatization: The transference of mental experiences and states into bodily symptoms. Somatoform disorders: Characterized as the presence of physical symptoms that suggest a medical condition without demonstrable organic basis to account fully for them. The three central features of somatoform disorders are as follows Bulimia Nervosa • Characterized by recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate measures to avoid weight gain such as purging (vomiting, laxatives, diuretics, enemas, or emetics), fasting, or excessively exercising. • Engaging in binge eating secretly • Binging or purging episodes are often precipitated by strong emotions and followed by guilt, remorse, shame, or self-contempt. • Recurrent vomiting destroys tooth enamel, has dental caries and ragged or chipped teeth. Dentists are often the first health care professionals to recognize this. • Bulimia is typically diagnosed at 18 or 19. • Clients with bulimia are aware that their eating behavior is pathologic and go great lengths to hide it from others. • Clients with a co-morbid personality disorder tend to have poorer outcomes than those without. • Most are treated on an outpatient basis • Antidepressants are more effective than the placebos in reducing binge eating The five specific somatoform disorders are as followed: • Physical complaints suggest major medical illness but have no demonstrable organic basis. • Psychological factors and conflicts seem important in initiating, exacerbating, and maintaining the symptoms. • Symptoms or magnified health concerns are not under the client's conscious control. Somatization disorder: Characterized by multiple physical symptoms. It begins by 30 years of age, extends over several years, and includes a combination of pain and Gl, sexual, and pseudoneurologic symptoms. -Client's jump from one physician to the next, or may see several providers at once in an effort to obtain relief of symptoms. -They tend to be pessimistic about the medical establishment and often believe their disease could be diagnosed of the providers were more competent. Conversion disorder: Involves unexplained, usually sudden deficits in sensory or motor function (blindness, paralysis). These deficits suggest a neurological disorder but are associated with psychological factors. An attitude of la belle indifference, a seemingly lack of concern or distress, is the key feature. Pain disorder: Pain is the primary physical symptom which is generally unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance. Hypochondriasis: Preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). It is thought that clients with this disorder misinterpret bodily sensations or functions. Body dysmorphic disorder: Preoccupation with an imagined or exaggerated defect in personal appearance such as thinking one's nose is too large or teeth are crooked and unattractive. Symptoms of a somatization disorder • Pain symptoms: complaints of headache, pain in the abdomen, head, joints, back, chest, rectum; pain during urination, menstruation, or sexual intercourse. • Gl symptoms: nausea, bloating, vomiting (other than pregnancy), diarrhea, or intolerance of several foods. • Sexual symptoms: Sexual indifference (don't care to do the dirty), erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding. • Pseudoneurologic symptoms: Impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia (loss of speech sounds), urinary retention, swollen tongue, hallucinations, double vision, blindness, deafness, seizures; disassociative symptoms such as amnesia; or loss of consciousness other than fainting. related condition: • Malingering: The intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. Their purpose is some external incentive or outcome that they view as important and results directly from their illness. People who malinger can stop the physical symptoms as soon as they have gained what they wanted. • Factitious disorder: This is also known as Munchausen syndrome. Occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. -Munchausen syndrome by proxy occurs when a person inflicts illness or injury to someone else to gain the attention of emergency medical personnel or to be a "hero" for saving the victim. This occurs most often in people who are in or familiar with medical professions, such as nurses, physicians, medical technicians, or hospital volunteers. • Primary gain: Direct external benefits that being sick provides, such as relief of anxiety, conflict, or distress. • Secondary gains: Internal or personal benefits received from others because one is sick, such as attention from family members and comfort measures (being brought tea, receiving a back rub). Treatment: • Treatment focuses on managing symptoms and improving quality of life. • A trusting relationship helps to ensure that client's stay with and receive care from one provider instead of "doctor shopping." • SSRis are commonly used for depression that may accompany somatoform disorders.  Hallucinations false sensory perceptions or perceptual experiences that do not exist in reality  Ideas of reference false impressions  Delusions fixed false beliefs  Echopraxia imitation of movements and gestures  Perseveration persistent adherence to a single idea or topic; verbal repetition of a sentence, word, phrase resisting attempts to change the topic  Ambivalence contradictory beliefs or feelings  Flight of Ideas continuous flow of verbalization from one topic to another  Associative looseness fragmented or poorly related thoughts or idea  Alogia poverty of speech  Blunted affect restricted range of emotional feeling, tone or mood  Catatonia client seems motionless  Flat affect absence of facial expression  Anhedonia absence of joy or pleasure  Lack of volition absence of will, ambition or drive  Apathy feelings if indifference toward people, activities or event