Tuesday, August 20, 2013
NOTES VI - PSYCHIATRIC NURSING PART 3
PSYCHIATRIC
DISORDERS
ANXIETY
DISORDERS
•
PANIC DISORDERS
•
SPECIFIC PHOBIA
•
SOCIAL PHOBIA
•
OCD
•
PTSD
•
ACUTE STRESS DISORDER
•
GENERALIZED ANXIETY DISORDER
PANIC
ATTACKS
•
Discrete period of intense fear
or discomfort in which at least 4 if the ff sx develop abruptly and peak within
10 mins:
–
Palpitations, pounding heart, or
accelerated HR
–
Sweating
–
Trembling or shaking
–
Sensations of SOB and smothering
–
Feeling of choking
–
Chest pain or discomfort
–
Nausea or abd. Pain
–
Feeling dizzy, unsteady,
lightheaded or faint
–
Derealization or
depersonalization
–
Fear of losing control or going
crazy
–
Fear of dying
–
Paresthesias
–
Chills or hot flashes
SPECIFIC¨
PHOBIA © SOCIAL
•
Excessive and unreasonable cued
by the presence or anticipation of a specific object or situation
•
Defense mech commonly used
include repression and displacement
•
Fear of social performance
situations in which the person is exposed to unfamiliar people or to possible
scrutiny by others
OBSESSION COMPULSION
•
Recurrent and persistent
thoughts, impulses, or images are experienced during the disturbance as
intrusive and inappropriate
•
Cause anxiety or distress
• Px
knows that these are just product of one’s own mind.
•
Px feels driven to perform
repetitive behaviors or mental acts in
response to obsession or according to the rules that one deems must be applied
rigidly.
•
Aimed at reducing anxiety
OBSESSION COMPULSION
•
Fear
of dirt & germs
•
Fear
of burglary or robbery
•
Worries
about discarding something important
•
Concerns
about contracting a serious illness
•
Worries
that things must be symmetrical or matching
•
Excessive
hand washing
•
Repeated
checking of door and window locks
•
Counting
and recounting of objects in everyday life
•
Hoarding
of objects
•
Excessive
straightening, ordering, or of arranging things
•
Repeating
words or prayers silently
POST
TRAUMATIC STRESS SYNDROME
•
Person has experienced, witnessed
or been confronted with an event that involved actual or threatened death or
serious injury, or a threat to physical integrity
•
Person reexperiences these in the
mind
•
Involves intense fear,
helplessness, or horror and numbing of general responsiveness (PSYCHIC NUMBING)
ACUTE GENERALIZED
•
Meets the criteria for exposure
to a traumatic event and person experiences 3 of the ff sx:
–
sense
of detachment,
–
reduced
awareness of one’s surroundings,
–
derealization,
–
depersonalization,
–
dissociated
amnesia
•
Excessive anxiety or worry,
occurring in more days than not for at least 6 mos, about a number of events or
activities
•
Finds it difficult to control the
worry
MOOD/
AFFECTIVE DISORDERS
•
BIPOLAR D/O
–
BIPOLAR I: current or past
experience of manic episode, lasting at least a week, that is severe enough to
cause extreme impairment in social or occupational functioning.
• MANIA: hyperactivity
• DEPRESSED: extreme sadness or
withdrawal
• MIXED
–
BIPOLAR II: hx of 1 or more mj
depressive episodes & at least 1 hypomanic episode; no mania
•
MAJOR DEPRESSIVE D/O
–
@ least 5 sx of same 2- wk period with one
being either depressed mood or loss of interest or pleasure.
–
Single episode or recurrent
–
Other sx: wt loss, insomnia,
fatigue, recurrent thoughts of death, diminished ability to think, psychomotor
agitation or retardation, feelings of worthlessness.
•
CYCLOTHYMIC D/O
–
Hx of 2 yrs of hypomania with
numerous periods of abnormally elevated, expansive or irritable moods.
–
Does not meet the criteria of
mania or depression.
•
DYSTHYMIC D/O
–
@ least 2 yrs of usually
depressed mood and at least 1 of the sx of mj depression without meeting the
criteria for it
•
SEASONAL AFFECTIVE D/O
–
Depression that comes with
shortened daylight in fall and winter that disappears during spring and summer.
Dealing with
Inappropriate Behaviors
AGGRESSIVE
BEHAVIOR
•
Assist the client in identifying
feelings of frustration and aggression
•
Encourage the client to talk out
instead of acting out feelings of frustration
•
Assist the client in identifying
precipitating events or situations that lead to aggressive behavior
•
Describe the consequences of the
behavior on self and others
•
Assist in identifying previous
coping mechanisms
•
Assist the client in the
problem-solving techniques to cope with frustration or aggression
DEESCALATION
TECHNIQUES
•
Maintain safety
•
Maintain large personal space and
use nonaggressive posture
•
Use calm approach and communicate
with a calm, clear tone of voice (be assertive not aggressive
•
Determine what the client
considers to be his or her need
•
Avoid verbal struggles
•
Provide clear options that deal
with behavior
•
Assist with problem-solving and
decision making regarding the options
MANIPULATIVE
BEHAVIORS
•
Set clear, consistent, realistic,
and enforceable limits and communicate expected behaviors
•
Be clear about consequences
associated with exceeding set limits
•
Discuss behavior in nonjudgmental
and nonthreatening manner
•
Avoid power struggles
•
Assist in developing means of
setting limits on own behavior
SCHIZOPHRENIA
•
characterized by impairments in
the perception or expression of reality and by significant social or
occupational dysfunction.
•
Once considered as a deadly
disease
•
There is lack of insight in
behavior
•
Dx: late adolescence and early
adulthood
–
15-25
y.o. (men); 25-35 y.o. (women)
•
Obsolete term: dementia praecox =
“cognitive deterioration early in life”
•
Eugene Bleuler: schiz “split”;
phren “mind”
Risk
factors
•
Genetics:
identical twins 50%, 15% for fraternal twins
•
Biochemical
factors
–
Dopamine hypothesis: overactive
–
Serotonin imbalance
–
Decreased brain volume, enlarged
ventricles, deeper fissures, and loss or underdeveloped brain tissue
•
Psychoanalytic
–
lack of trust during the early
stages
–
Weak ego
–
Defenses: REPRESSION, REGRESSION,
PROJECTION
•
Environment
influences: poverty, lack of social support, hostile home environment,
isolation, unsatisfactory housing, disruption in interpersonal relationships (divorce
or death), job pressure or unemployment
Subtypes
•
Catatonic type
–
prominent psychomotor
disturbances are evident. Symptoms can include catatonic stupor and waxy
flexibility
•
Disorganized type
–
where thought disorder and flat
affect are present together
•
Paranoid type
–
where delusions and
hallucinations are present but thought disorder, disorganized behavior, and
affective flattening are absent
•
Residual type
–
where positive symptoms are
present at a low intensity only
•
Undifferentiated type
–
psychotic symptoms are present
but the criteria for paranoid, disorganized, or catatonic types has not been
met
Symptoms
According
to Bleuler: 4 A’s
–
Affect is inappropriate
–
Associative looseness
–
Autistic thinking
–
Ambivalence
Symptoms
•
Positive symptoms
–
delusions, auditory
hallucinations and thought disorder and are typically regarded as
manifestations of psychosis.
•
Negative symptoms
–
considered to be the loss or
absence of normal traits or abilities
–
E.G. flat, blunted or constricted
affect and emotion, poverty of speech and lack of motivation.
Symptoms
•
Social isolation
•
Catatonic behavior
•
Hallucinations
•
Incoherence (marked looseness of
association)
•
Zero/ lack of interest, energy and
initiative
•
Obvious failure to attain expected level
of dev’t
•
Peculiar behavior
•
Hygiene and grooming impaired
•
Recurrent illusions and unusual
perception experiences
•
Exacerbations and remissions are common
•
No organic factors accounts for the
symptoms
•
Inability to return to baseline
functioning after relapse
•
Affect is inappropriate
Nsg
Dx: Abnormal thought process
•
BLOCKING: sudden cessation of a
thought in the middle of a sentence, unable to continue the train of thought
•
CIRCUMSTANTIALITY: before getting
to the point of answering a question, the individual gets caught up in
countless details and explanations
•
CONFABULATION
•
LOOSENESS OF ASSOCIATION
•
NEOLOGISM
•
WORD SALAD
Interventions
•
Assess physical needs
•
Set limits
•
Maintain safety
•
Initiate one-on-one interaction
& progress to small groups
•
Spend time with clients
•
Monitor for altered thought process
•
Maintain ego boundaries, avoid
touching
•
Limit time of interaction
•
Be neutral
•
Do not make promises that can’t
be kept
•
Establish daily routines
•
Do not “go along” with the
client’s delusions or hallucinations
•
Provide simple complete
activities
•
Reorient
•
Speak to the client in simple
direct and concise manner
•
Set realistic goals
•
Explain everything that is being
done
•
Decrease stimuli
•
Monitor for suicide risk
•
Environment
–
Provide safe environment
–
Limit stimuli
•
Psychological Ttt
–
Behavior therapy
–
Social skills training
–
Self-monitoring
•
Social ttt
–
Milieu therapy
–
Family therapy
–
Group therapy (long-term ttt)
Related
psychotic disorders
•
SCHIZOAFFECTIVE DISORDER schiz +
mood disorder (mania/ depression)
•
BRIEF PSYCHOTIC DISORDER sudden
onset of psychotic symptoms, lasts less than 2 mos and client returns to
premorbid level of functioning
•
SCHIZOPHRENIFORM DISORDER schiz
sx lasting between 1 month and <6mos
•
DELUSIONAL DISORDER characterized
by prominent, nonbizarre delusions
PERSONALITY
DISORDERS
•
CLUSTER A (odd & eccentric)
–
paranoid, schizoid, schizotypal
•
CLUSTER B (bad, dramatic &
erratic)
–
antisocial, borderline, histrionic,
narcissistic
•
CLUSTER C (anxious & fearful)
–
avoidant, dependent, OCD
CLUSTER
A: ODD & ECCENTRIC
•
PARANOID
–
chronic
hostility projected to others; suspicious and mistrusts people
–
Seen
mostly in men
•
SCHIZOID
–
social
detachment = “loner” & “introvert”
–
Restriction
of emotions
–
Attention
fixed on objects rather than people
–
Functions
well in vocations
•
SCHIZOTYPAL: interpersonal
deficits
–
Magical
thinking, telepathy
–
Apparent
in childhood or adolescence
Interventions
for PARANOID D/O
•
Asses for suicide risk
•
Avoid direct eye contact
•
Establish trusting relationship
•
Promote increased self-esteem
•
Remain calm, nonthreatening and
nonjudgmental
•
Provide continuity of care
•
Respond honestly to the client
•
Follow thru on commitments
•
Provide a daily schedule of
activities
•
Gradually introduce client to
groups
•
Do not argue with delusions
•
Do not whisper in presence of
client
•
Assure that the client will be
safe
•
Provide opportunity to complete
small tasks
•
Monitor eating, drinking,
sleeping and elimination patterns
•
Limit physical contact
•
Monitor for agitation and
decrease stimuli as needed
CLUSTER
B: ERRATIC, DRAMATIC, OR EMOTIONAL
•
ANTISOCIAL
–
Syn: sociopath, psychopathic
& semantic d/o
–
Etiology:
• Genetics interfere in the dev’t
of positive interpersonal relationships
• Brain damage or trauma
• Low socioeconomic status
• Faulty family relationships:
neglect
• Secondary gains
–
15-40 y.o.
•
Signs
–
Lack of remorse or indifference
to persons hurt
–
Immediate gratification
–
Failure to accept social norms
–
Impulsivity
–
Consistent irresponsibility
–
Aggressive behavior
–
Reckless behavior that disregards
the safety of others
•
80-90% of all crime is committed
by antisocials (NIHM, 2000)
•
BORDERLINE
–
Latent, ambulatory and abortive
schizophrenics
–
Between moderate neurosis and
frank psychosis but quite stable
–
Theories
•faulty
separation from mother; parent and child are bound by guilt
•Trauma
at 18 mos (weakening of ego)
•Unfulfilled
need for intimacy
•
Signs
–
instability
–
Impulsivity: unpredictable
gambling, shoplifting, sex & substance abuse
–
hypersensitivity,
self-destructive, profound mood shifts
–
unstable & intense relations
–
Disturbance in self concept
•
Common in women
•
Defenses: denial, projection,
splitting, projective identification
•
HISTRIONIC
–
Pattern of theatrical or overtly
dramatic behavior
–
Signs
• Discomfort when the client isn’t
the center of attention
• Self-dramatization and
exaggerated emotions
• uses physical appearance,
sexually seductive and provocative behavior
• Excessively impressionistic
speech lacking in detail (labile emotions)
–
Problems in dependence &
helplessness
–
More frequent in women
•
NARCISSISTIC
–
Exaggerated or grandiose sense of
self-importance
–
Develop early in childhood
–
Preoccupied with fantasies of
unlimited success, power and beauty
–
Signs
• arrogance, need for admiration,
• lack of empathy,
• seductive, socially exploitative,
manipulative
–
Occurs more in men
CLUSTER
C: ANXIOUS OR FEARFUL
•
AVOIDANT
–
Sensitive to rejection,
criticism, humiliation, disapproval, or shame
–
Interferes with participation in
occupational activities, dev’t of relationships, and take personal risks
–
social inhibition, longs for
relationships
–
Anxiety, anger and depression are
common
–
Social phobia may occur
–
Seen in 10% of clients in mental
clinics
•
DEPENDENT
–
Lacks confidence and unable to
function in an independent role
–
Allows other persons to be
responsible of their lives
–
Most frequent personality
disorder in the mental health clinic
–
submissive behavior, low
self-esteem, inadequate, helpless
•
OBSESSIVE-COMPULSIVE
–
Preoccupied with rules &
regulations, overly concerned about trivial detail, excessively devoted to
their work
–
Depression is common
–
Men are more affected than women
UNDER
STUDY PERSONALITY D/O
•
PASSIVE-AGGRESSIVE: sullen and
argumentative, resents others, resists fulfilling responsibilities, complains
of being unappreciated
•
DEPRESSIVE: gloomy, brooding
pessimistic, guilt-prone, highly critical of self and others, cheerless.
Interventions
•
Maintain safety against
self-destructive behaviors
•
Allow the client to make choices
and be as independent as possible
•
Encourage the client to discuss
feelings rather than act them out
•
Provide consistency in response
to the client’s acting out
•
Discuss expectations and
responsibilities with the client
•
Inform the client that harm to
self, others, and property is unacceptable
•
Identify splitting behavior
•
Assist the client to deal
directly with anger
•
Develop a written contract with
the client
•
Encourage the client to
participate in group activities, and praise nonmanipulative behavior
•
Set and maintain limits
•
Remove the client from group
situations in which attention-seeking behaviors occur
•
Provide realistic praise for
positive behaviors in social situations
PSYCHOLOGICAL
SEXUAL D/O
•
Hypoactive sexual disorder
(asexuality)
•
Sexual aversion disorder
(avoidance of or lack of desire for sexual intercourse)
•
Female sexual arousal d/o
(failure of normal lubricating arousal response)
•
Male erectile d/o
•
Female orgasmic disorder
•
Male orgasmic disorder
•
Premature ejaculation
•
Vaginismus
•
Secondary sexual dysfxn
•
Paraphilias
•
Gender identity d/o
•
PTSD due to genital mutilation or
childhood sexual abuse
Other
sexual problems
•
Sexual dissatisfaction (non-specific)
•
Lack of sexual desire
•
anorgasmia
•
Impotence
•
STD
•
Infidelity
•
Delay or absence of ejaculation,
despite adequate stimulation
•
Inability to control timing of
ejaculation
•
Inability to relax vaginal
muscles enough to allow intercourse
•
Inadequate vaginal lubrication
preceding and during intercourse
•
Burning pain on the vulva or in
the vagina with contact to those areas
•
Unhappiness or confusion related
to sexual orientation
•
Persistent sexual arousal
syndrome
•
Sexual addict
•
hypersexuality
•
Post Ejaculatory Guilt Syndrome,
the feeling of guilt after the male orgasm
SEXUAL
EXPRESSION
•
HETEROSEXUALITY
•
HOMOSEXUALITY
•
BISEXUALITY
•
TRANSVESTISM
PARAPHILIAS
•
EXHIBITIONISM: the recurrent urge
or behavior to expose one's genitals to an unsuspecting person.
•
FETISHISM: the use of non-sexual
or nonliving objects or part of a person's body to gain sexual excitement. Partialism
refers to fetishes specifically involving nonsexual parts of the body.
•
FROTTEURISM: the recurrent urges
or behavior of touching or rubbing against a nonconsenting person.
•
SEXUAL MASOCHISM: the recurrent
urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made
to suffer.
•
SEXUAL SADISM: the recurrent urge
or behavior involving acts in which the pain or humiliation of the victim is
sexually exciting.
•
TRANSVESTIC FETISHISM: a sexual
attraction towards the clothing of the opposite gender.
•
PEDOPHILIA: the sexual attraction
to prepubescent or peripubescent children.
•
VOYEURISM: the recurrent urge or
behavior to observe an unsuspecting person who is naked, disrobing or engaging
in sexual activities, or may not be sexual in nature at all.
•
Other paraphilias not otherwise
specified ("Sexual Disorder NOS")
–
telephone scatalogia (obscene
phone calls)
–
necrophilia (corpses)
–
partialism (exclusive focus on
one part of the body)
–
zoophilia(animals)
–
coprophilia (feces)
–
klismaphilia (enemas)
–
urophilia (urine)
•
SOMATIZATION D/O: hx of many
physical complaints beginning before the age of 30 occurring over a pd of
several yrs resulting in ttt being sought or significant occupational or social
fxning.
•
CONVERSION D/O: 1 or more sx of
deficits affecting voluntary motor or sensory function suggesting a
neurological or general medical condition; preceded by conflicts or stressors;
can’t be explained and sanctioned by cultural behavior.
–
Most
common: blindness, deafness, paralysis, inability to talk
–
“La
belle indifference”
•
HYPOCHONDRIASIS: preoccupation
with fears of having, or ideas that one has, a serious dse based on the person’s
misinterpretation of bodily sx and persist despite appropriate medical eval and
reassurance and has existed for @ least 6 mos. (e.g.:extensive use of home
remedies)
•
PAIN D/O: pain in 1 or more
anatomical sites severe enough to warrant clinical attention and causes
clinically significant distress or impairment in fxning.
Interventions
•
Do not reinforce the sick role
•
Discourage verbalization about
physical symptoms by not responding with positive reinforcement
•
Explore with the client the needs
being met by the physical symptoms
•
Convey understanding that the
physical symptoms are real to the client
•
Report and assess any new
physical complaint
»
next
EATING
DISORDER BEHAVIORS
•
BINGE: rapid consumption of large
quantities of food in a discrete period of time. (A: hundrends of
•
PURGE: Maladaptive eating
regulation response that includes excessive exercise, forced vomiting, OCD Rx
diuretics, diet pills, laxatives and steroids.
•
FAST/ RESTRICT: Includes
vegetarian diet eliminating all meat without substituting nonanimal sources of
protein, OC about food choices, and eating habits.
ANOREXIA BULIMIA
•
Rare
vomiting or diuretic/laxative abuse
•
More
severe wt loss
•
Slightly
younger
•
More
introverted
•
Hunger
denied
•
Eating
behavior may be considered normal and a source of esteem
•
Sexually
inactive
•
Obsessional
and perfectionist features dominate
•
Frequent
•
Less
wt loss
•
Slightly
older
•
More
extroverted
•
Hunger
experienced
•
Eating
behavior considered foreign and source of distress
•
More
sexually active
•
Avoidant,
dependent, or borderline features as well as obsessional features
ANOREXIA BULIMIA
•
Death from starvation (or
suicide, in chronically ill)
•
Amenorrhea
•
Fewer behavioral problems (these
increase with level of severity)
•
Death from hypokalemia or suicide
•
Menses irregular or absent
•
Drug and alcohol abuse,
self-mutilation, and other behavioral problems
DELIRIUM
•
The
medical dx term that describes an organic mental disorder characterized by a
cluster of cognitive impairments with an acute onset with a specific
precipitating factor.
•
Sx:
diminished awareness of the environment, disturbances in psychomotor activity
and sleep-wake cycle.
•
COGNITIVE:
the mental process characterized by knowing, thinking, and judging.
–
COGNITIVE DISSONANCE: arises when
2 opposing beliefs exists at the same time.
–
COGNITIVE DISTORTIONS: (+) or (-)
distortions of reality that might include errors of logic, mistakes in
reasoning, or individualized view of the world that do not reflect reality.
–
Term: confusion = cognitive
impairment
» See dementia
DEMENTIA
•
The medical dx term that
describes an organic mental d/o characterized by a cluster of cognitive
impairments of generally gradual onset and irreversible without identifiable
precipitating stressors.
•
Types:
–
VASCULAR
or MULTI-INFARCT
–
VASCULAR
WITH ALZHEIMER’S DSE
–
AD:
most common
–
DEMENTIA
WITH LEWY BODIES: 2nd most common; neurofilament material
–
PARKINSONIAN
DEMENTIA
–
AIDS
DEMENTIA COMPLEX
–
FRONTAL LOBE DEMENTIA or PICK’S
DSE: cytoplasmic collections; 3rd most common; loss of expressive
language & comprehension
–
CREUTZFELDT-JAKOB DSE: prion (proteinaceous
infectious particles) = spongy brain; related to TSE
& BSE in mad cow dse
–
CORTICOBASAL DEGENERATION or
–
SUPRANUCLEAR PALSY: clumping of
protein tau = slow mov’t, weak eye mov’t (esp. downward), impaired walking
&balance
•
Reversible Causes:
–
Subdural
hematoma
–
Tumor
(meningioma)
–
Cerebral
vasculitis
–
Hydrocephalus
•
Terms: disorientation, memory
loss (sensory, primary, secondary,
tertiary, working memory), confabulation, confusion
•
Disturbing behaviors
–
Aggressive
psychomotor
–
Nonaggressive
psychomotor
–
Verbally
aggressive
–
Passive
–
Functionally
impaired: loss of ability to do self-care
DELIRIUM vs.
DEMENTIA
•
Rapid onset w/ wide fluctuations
•
Hyperalert to difficult to arouse
LOC
•
Fluctuating affect
•
Disoriented, confused
•
Attention & sleep disturbed
•
Memory impaired
•
Disordered reasoning
•
Gradual, chronic with continuous
decline
•
Normal LOC
•
Labile affect
•
Disoriented, confused Attention
intact, sleep usually normal
•
Memory impaired
•
Disordered reasoning &
calculation
DELIRIUM vs.
DEMENTIA
•
Incoherent, confused, delusional,
stereotyped
•
Illusions, hallucinations
•
Poor judgment
•
Insight may be present in lucid
moment
•
Poor but variable in MSE
» next
•
Disorganized, rich in content,
delusional, paranoid
•
No change in perception
•
Poor judgment
•
No insight
•
Consistently poor &
progressively worsens in MSE
ALZHEIMER’S
DEMENTIA
•
Most common type of dementia
•
Stages:
–
MILD: impaired memory, insidious
loses in ADL, subtle personality changes, socially normal
–
MODERATE: obvious memory loss,
overt ADL impairment, prominent behavioral difficulties, variable social
skills, supervision needed
–
SEVERE: fragmented memory, no recognition
of familiar people, assistance needed with basic ADL, fewer troublesome
behaviors, reduced mobility (4 A’s)
Symptoms
•
AGNOSIA: Difficulty recognizing
well-known objects
•
APHASIA: Difficulty in finding
the right word
•
APRAXIA: Inability or difficulty
in performing a purposeful organized task or similar skilled activities
•
AMNESIA: Significant memory
impairment in the absence of clouded consciousness or other cognitive symptoms
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