Problems of Mental Health

7/27/2019 Problems of Mental Health

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Problems of Mental Health

ANXIETY-RELATED DISORDERS

ANXIETY AND DISSOCIATIVE DISORDERSAnxiety disorders are the most common of all psychiatric

disorders. An individual with one of these disorders

experiences physiologic, cognitive, and behavioral

symptoms of anxiety. The physiologic manifestations are

related to the fight-or-flight response and result in

cardiovascular, respiratory, neuromuscular, and GI

stimulation. The cognitive symptoms include subjective

feelings of apprehension, uneasiness, uncertainty, or dread.Behavioral manifestations include irritability, restlessness,

pacing, crying and sighing, and complaints of tension and

nervousness. The common theme among anxiety disorders

is that the individual experiences a level of anxiety that

interferes with functioning in personal, occupational, and

social areas.

Anxiety experienced in response to a traumatic event mayinterrupt the formation of memories related to the event and

disrupt learning processes resulting in dissociation.

Disassociation can be initially viewed as an adaptive

defense against painful memories or feelings of

helplessness. When aspects of disassociation interfere with

the ability of the individual to function socially,

vocationally or interpersonally, then such dissociative

aspects may be considered a disorder.

In most situations of disassociation the response to a

traumatic event is not consciously connected to memories

of the event. Such dissociative disorders are characterized

by an alteration in conscious awareness, which includes


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forgetfulness and memory loss for past stressful events.

Other dissociate methods of withdrawing from anxiety

producing stimuli are depersonalization (a feeling of

disconnection from one's self) and derealization (a feelingof being disconnected from the surrounding environment).

The individual may also develop what appear to be

distinctly different personalities

Classification

Anxiety-related disorders, as defined by the Diagnostic and

Statistical Manual of Mental Disorders, Fourth Edition

Text Revision (DSM-IV-TR), include those listed here.

Anxiety Disorders Panic disorder without agoraphobia

Panic disorder with agoraphobia

Agoraphobia without history of panic disorder

Specific phobia

Social phobia

Obsessive-compulsive disorder (OCD)

Posttraumatic stress disorder (PTSD) Acute stress disorder

Generalized anxiety disorder

Anxiety disorder due to a general medical condition

Substance-induced anxiety disorder

Anxiety disorder not otherwise specified

Dissociative Disorders

Dissociative amnesia Dissociative fugue

Dissociative identity disorder

Depersonalization disorder

Dissociative disorder not otherwise specified


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Pathophysiology and Etiology

The underlying etiology of anxiety disorders as well as any

of the psychiatric disorders, is complex, having multiple

factors that interact. Therefore, it is essential to examine thebiochemical, genetic, psychosocial, and sociocultural

factors.

Biochemical Factors

The limbic system, which is called the emotional

brain, regulates emotional responses. Anxiety

disorders are associated with abnormalities within this

system (including thefrontal cortex, hypothalamus, amygdala, hippocampus,

brain stem, and the autonomic nervous system).

Neurotransmitters and their specific receptor sites

function to transmit inhibiting or stimulating messages

across the synapses between nerve cells in the brain.

Abnormalities in the neurotransmitters or the receptor

sites have been associated with multiple psychiatricdisorders, including anxiety disorders.

Gamma-aminobutyric acid (GABA) is an inhibitory

neurotransmitter that normally acts to decrease anxiety

responses. An individual that genetically produces

lower amounts of GABA may have an increased

likelihood of developing anxiety or stress-related

disorders (eg, PTSD).

Norepinephrine is a stimulating neurotransmitter,

which is released as part of the fight-or-flight response

and is associated with the cardiovascular and

respiratory effects of anxiety. Serotonin is a

neurotransmitter that regulates multiple responses,


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including sleep and alertness and sensations of hunger

and satiation. Genetic variation resulting in a decrease

in the number of select serotonin receptors

(particularly 1A) may be associated with thedevelopment of panic disorder.

Panic disorders may be related to the reception of a

false signal from the brain that there is a shortage of

oxygen or an increase in carbon dioxide (suffocation

alarm theory). People who have panic attacks have

also been reported to have higher levels of

norepinephrine.

Suppression of cortisol through administration ofdexamethasone has been associated with PTSD,

suggesting heightened glucocorticoid feedback

sensitivity.

Positron-emission tomography (PET) and computed

tomography (CT) scanning have shown abnormalities

in glucose metabolism in the frontal and prefrontal

cortex and the basal ganglia of the brains ofindividuals with panic disorder. PET scans have also

demonstrated increased blood flow and cerebral

metabolism in the basal ganglia and frontal cortex of

individuals with OCD.

OCD has been associated with increased serotonin

responsiveness as well as striatum dysfunction. The

striatum controls voluntary movement, and it is

hypothesized that individuals with OCD may be doing

repetitive rituals to self-medicate for serotonin

deficiencies.

Dissociative symptoms have been related to shrinkage

of the hippocampus. Studies of physically, sexually,


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and psychologically abused children found increased

EEG abnormalities in the frontal and temporal lobes.

Genetic Factors

First-degree relatives of individuals with panicdisorder have a four to seven times greater chance of

developing this disorder. Twin studies demonstrate a

higher concordance rate for monozygotic than

dizygotic twins.

Approximately 20% of first-degree relatives of

persons with agoraphobia also have agoraphobia.

Approximately 3% to 7% of persons with OCD havefirst-degree relatives with the same disorder.

Approximately 25% of first-degree relatives with

generalized anxiety disorder are also affected by

generalized anxiety disorder.

Dissociative disorders have not been identified as

being genetically transmitted.

Psychosocial Factors Psychodynamic theory describes unconscious conflicts

having early childhood origin and resulting from

repressed wishes and drives. These conflicts cause

guilt and shame, which lead to anxiety and associated

symptoms.

Interpersonal theory implicates early relationships,

which directly affect development of self-concept andself-esteem. Individuals with poor self-concept and

decreased self-esteem have increased susceptibility to

anxiety-related disorders.


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Behavioral theory describes anxiety and associated

symptoms as a conditioned response to internal and

external stressors.

Cognitive theory describes faulty thinking patternsthat lead to an individual's misperceiving events

affecting self, the future, and the world. These faulty

thinking patterns contribute to the subjective

experience of anxiety.

Dissociative disorders are generally associated with

traumatic events. An individual responds to severe

trauma (especially in early childhood) by splitting

off or dissociating the self from the memory of thetrauma. Severe physical, sexual, and psychological

abuse in early childhood is associated with

dissociative identity disorder.

Sociocultural Factors

Anxiety disorders and ritualistic behaviors are

commonly seen in high-technology societies. There is a higher incidence of anxiety disorders in

urban communities than in rural communities.

Women are diagnosed more commonly with anxiety

disorders except with OCD, which affects men and

women equally. It is thought that this may represent a

sociocultural rather than a genetic factor.

Clinical ManifestationsSee Table below (Diagnostic Criteria for Anxiety

Disorders)

Diagnostic Evaluation


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Measurement tools for anxiety:

o Hamilton Rating Scale for Anxiety

o The State-Trait Anxiety Inventory

Measurement tools for OCDs:o Yale-Brown Obsessive-Compulsive Scale

o Florida Obsessive-Compulsive Inventory (FOCI)

Measurement tools for panic disorders:

o Acute Panic Inventory

o Sheehan Client-Rated Anxiety Scale

Sodium lactate infusion or carbon dioxide inhalation

will likely produce a panic attack in a person with

panic disorder. Increased arousal may be measured through studies of

autonomic functioning (ie, heart rate,

electromyography, sweat gland activity) in a person

with PTSD.

Dexamethasone suppression test (DST) may be used

to demonstrate heightened glucocorticoid feedback in

individuals with PTSD. Measurement tools for dissociation:

o Dissociation Impulsivity Scale (DIS)

o Dissociative Experiences Scale (DES)

o Dissociative Disorders Interview Schedule

(DDIS)

Diagnostic Criteria for Anxiety Disorders

ANXIETY DISORDERS

Acute stress disorder

Person has been exposed to a traumatic event either

witnessed or experienced


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Develops three or more of these dissociative

symptoms:

o Subjective sense of numbing

o

Absence of emotional responsivenesso Feeling dazed

o Derealization

o Depersonalization

o Dissociative amnesia

Duration of 2 days to 4 weeks

Generalized anxiety disorder

Persists for at least 6 months Symptoms present from three of the four categories:

o Motor tension (eg, trembling, restlessness,

inability to relax, and fatigue)

o Autonomic hyperactivity (eg, sweating,

palpitations, cold clammy hands, urinary

frequency, lump in throat, pallor or flushing,

increased pulse, and rapid respirations)o Apprehensiveness (eg, worry, dread, fear,

rumination, insomnia, and inability to

concentrate)

o Hypervigilance (eg, feeling edgy, scanning the

environment, and distractibility)

Obsessive-compulsive disorder

Preoccupation with persistent intrusive thoughts(obsessions), repeated performance of rituals designed

to prevent some event (compulsions), or both


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Anxiety occurs if obsessions or compulsions are

resisted and from feeling powerless to resist the

thoughts or rituals

Panic disorder

Recurrent unexpected anxiety attacks

Sudden onset with intense apprehension and dread

At least four of the following symptoms:

o Dyspnea

o Chest discomfort

o Dizziness

o Hot or cold flasheso Tingling of hands or feet

o Feelings of unreality

o Palpitations

o Syncope

o Diaphoresis

o Trembling

o

Fear of losing control, going crazy, or dyingPosttraumatic stress disorder

After experiencing a psychologically traumatic event

outside the range of usual experience (eg, rape,

combat, bombings, kidnapping), the person

reexperiences the event through recurrent dreams and

flashbacks.

Emotional numbness, detachment, and estrangementmay be used to defend against anxiety.

May experience sleep disturbance, hypervigilance,

guilt about surviving, poor concentration, and


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avoidance of activities that trigger memory of the

event.

Phobias

Irrational fear of an object or situation that persists,although the person may recognize it as unreasonable

Types include:

o Agoraphobia: Fear of being alone in open or

public places where escape might be difficult;

may not leave home

o Social phobia: Fear of situations in which one

might be seen and embarrassed or criticized; fearof eating in public, public speaking, or

performing

o Specific phobia: Fear of a single object, activity,

or situation (eg, snakes, closed spaces, and

flying)

Anxiety severe if the object, situation, or activity

cannot be avoidedSubstance-induced anxiety disorder

Prominent anxiety, panic attacks, or obsessions or

compulsions predominate

Symptoms developed within 1 month of substance

intoxication or withdrawal

Drug use related to disturbance

Disturbance does not occur exclusively during thecourse of delirium

Significant distress or impairment in social and

occupational functioning results

DISSOCIATIVE DISORDERS


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Depersonalization disorder

Persistent or recurrent experience of feeling detached

from and outside one's mental processes or body

Reality testing intact Experience causes significant impairment in social or

occupational functioning or causes marked distress

Does not occur exclusively during course of another

mental disorder

Dissociative amnesia

One or more episodes of inability to recall important

information usually of a traumatic or stressfulnature

Other psychological (eg, multiple personality disorder)

and physical (eg, substance-induced) disorders ruled

out

Dissociative fugue

Sudden, unexpected travel away from home or one's

place of work with inability to remember past Confusion about personal identity or assumption of

new identity

Presence of two or more distinct identities, each with

its own patterns of relating, perceiving, and thinking

At least two of these identities take control of the

person's behavior

Inability to recall important personal information tooextensive to be explained by ordinary forgetfulness

Other causes ruled out

Footnote


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Adapted from American Psychiatric Association (APA)

(2000). Diagnostic and statistical manual of mental

disorders (Fourth edition Text revision). Washington, D.C.:

APA.Management

Various levels and sites of care can be provided:

psychiatric inpatient, outpatient, or home care. Most

care is provided on an outpatient basis. Site of care is

based on many factors, including degree of disability

of affected individual, community services available,

and insurance and managed care considerations.

Generally, the recommended treatment is acombination of drugs and psychotherapy, along with

education of the individual and family.

Psychoeducational strategies:

o Relaxation techniques

o Progressive muscle relaxationo Guided imagery or visualization exercises

o Stress management

o Assertiveness training

Psychotherapy:

o Psychodynamic assists persons in

understanding their experiences by identifying

unconscious conflicts and developing effectivecoping behaviors.

o Behavioral focuses on the individual

problematic behavior and works to modify or

extinguish the behavior. One form of behavioral


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therapy effective in management of phobic

disorders is systematic desensitization.

o Cognitive assists patient to question faulty

thought patterns (reframing) and examinealternatives. In PTSD and dissociative disorders,

the patient is assisted to view self as a survivor

rather than a victim.

o Hypnotherapy can be used as part of therapy

for those suffering dissociative disorders.

o Support group therapy useful in providing a

supportive and psychoeducational approach for

patients with anxiety or dissociative disorders. Somatic therapies:

o Biofeedback relaxation through biofeedback is

achieved when a person learns to control

physiologic mechanisms that are not ordinarily

within one's awareness. Awareness and control

are accomplished by monitoring body processes,

including muscle tone, heart rate, and brainwaves.

o Psychopharmacologic drugs used to treat

anxiety-related disorders are those that will

increase GABA (benzodiazepines), regulate

serotonin levels (antidepressants), or reduce

physiologic effects of anxiety by causing

peripheral beta-adrenergic blockade (beta-

adrenergic blockers).

o Narcotherapy sodium amobarbital or I.V.

sodium thiopental may assist the therapist in

gaining access to a patient's repressed memories

and buried conflicts. In a person experiencing


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dissociative amnesia or dissociative fugue, the

therapist may explore dissociated events. If the

person is diagnosed with dissociative identity

disorder, this type of interview may facilitate theaccess of other personalities.

Complications

Undiagnosed medical reasons for anxiety could lead to

physical deterioration and a delay in obtaining

appropriate medical care. It is important to screen for

co-existing medical illness.

If panic and phobic disorders are left untreated, theycan lead to increasing social withdrawal and isolation,

which may severely impair the person's social and

work life.

Untreated OCD can lead to aggressive behavior

toward self or others as well as depression. It can also

lead to injuries from compulsive behavior such as skin

breakdown from repeated hand washing. Undiagnosed or untreated PTSD or acute stress

disorder can lead to substance abuse or dependence,

aggressive or violent behavior, and possibly suicide.

If a person with a dissociative disorder goes untreated,

aggressive behavior may develop toward self or

others. Such behaviors may include assaults,

depression, PTSD, psychoactive substance abuse

disorder, rape, self-mutilation, and suicide attempts.

Nursing Assessment


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Assess psychological, cognitive, and behavioral

symptoms.

o Defense mechanisms or coping measures used

o

Moodo Suicide potential

o Thought content and process

o Severity of subjective experience of anxiety

o Understanding of specific disorder

Explore social functioning.

o Ability to function in social and work situations

o Impact of symptoms on the patient's

relationships, especially work and familyrelationships

o Diversional and recreational behavior

o Identification of stressors related to self-concept,

role performance, life values, social status, and

support systems

o Benefits (primary and secondary gains) and risks

of the presenting symptoms

Nursing Diagnoses

Anxiety related to unexpected panic attacks or related

to re-experiencing traumatic events

Disturbed Thought Processes related to severe anxiety

Social Isolation related to avoidance behavior or

related to embarrassment and shame associated with

symptoms Ineffective Role Performance related to inability to

function in usual social and occupational situations

secondary to anxiety-related symptoms


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Disturbed Personal Identity related to a traumatic

event

Risk for Injury related to compulsive behaviors

Nursing Interventions

Reducing Symptoms of Anxiety

Help patient identify anxiety-producing situations and

plan for such events.

Assist patient to develop assertiveness and

communication skills.

Practice stress-reduction techniques with patient.

Teach patient to monitor for objective and subjectivemanifestations of anxiety.

o Tachycardia, tachypnea

o Signs and symptoms associated with autonomic

stimulation perspiration, difficulty

concentrating, insomnia

Promote use of stress reduction techniques in

managing symptoms of anxiety. Encourage patient to verbalize feelings of anxiety.

Administer prescribed anxiolytics to decrease anxiety

level.

DRUG ALERT

Benzodiazepines are associated with tolerance and

dependence and are appropriate for short-term use.

Withdrawal symptoms may occur when drug is abruptlydiscontinued. Gradual dosage reduction is necessary.

Overdose or taking benzodiazepines with alcohol or other

central nervous system (CNS) depressants can cause

respiratory depression requiring emergency intervention.


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Improving Concentration

Use short, simple sentences when communicating with

patient. Maintain a calm, serene manner.

Use adjuncts to verbal communication, such as visual

aids and role-playing, to stimulate memory and

retention of information.

Teach relaxation techniques to diminish distress that

interferes with concentration ability.

Increasing Social Interaction Encourage discussion of reasons for and feelings

about social isolation.

Help patient identify specific causes and situations

that produce anxiety that inhibits social interaction.

Recommend participation in programs directed at

specific conflict areas or skill deficiencies. Such

programs may focus on assertiveness skills, bodyawareness, managing multiple role responsibilities,

and stress management.

Encouraging Independence

Identify secondary benefits, such as decreased

responsibility and increased dependency that inhibit

patient's move to independence.

Provide experiences in which patient can besuccessful.

Explore alternative methods of meeting dependency

needs.


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Explore beliefs that support a helpless or dependent

mode of behavior.

Teach and role-play assertive behaviors in specific

situations. Provide instruction in decision-making skills, allowing

opportunities for practice and rehearsal of techniques

in role-play situations.

Assist patient to improve skills based on performance.

Encourage family members to avoid fostering

dependency.

Strengthening Identity Develop an honest, nonjudgmental relationship with

patient.

Try to establish open communication.

Do not overwhelm patient.

Teach patient containment techniques to assist in

coping with the painful memories becoming conscious

(eg, visualizing a safe environment, recall of pastsuccesses in dealing with anxiety, focusing on slowing

of physiologic responses).

Reducing Harm from Behavior

Encourage limit setting on ritualistic behavior as part

of established treatment plan.

Assist patient in listing all objects and places that

trigger anxiety as part of exposure-responseprevention program.

Use cognitive strategies, such as reframing, to assist

patient in placing thoughts and feelings in a different

perspective.


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Participate as member of treatment team in

establishing program for systematic desensitization.

Intervene as needed and obtain emergency assistance

when patient is in immediate danger.Community and Home Care Considerations

Patients with anxiety-related disorders are generally

treated in an outpatient setting. Many of these patients

may not see a mental health professional but will be

treated by their family health care provider, utilizing

pharmacologic therapy. Nurses who encounter patients

taking prescribed drugs for anxiety should assesseffectiveness and patient knowledge base regarding

safe use of these drugs. Patients should be encouraged

to utilize anxiety-reduction techniques.

Because anxiety disorders will affect family

functioning, the nurse should provide support for the

family, including teaching family members about the

disorder and treatment measures. Patients may elect to utilize alternative and

complementary therapies in order to obtain relief from

symptoms. Advise patients not to use nutritional

supplement or natural remedy, such as St. John's

wort or kava kava, without discussing it with a health

care provider; many drug interactions exist

Several community support groups are available to

provide the patient with continued support. The patientmay also be able to learn further techniques for the

management of anxiety through participation in these

programs. Such programs may also provide the patient


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with an opportunity to practice previously learned

skills in a supportive environment.

Patient Education and Health Maintenance

Teach patient and family members about anxiety.o Define anxiety and differentiate it from fear.

o Explain causes of anxiety.

o Identity events that can trigger anxiety.

o Identify relevant signs and symptoms of anxiety.

Describe the drug regimen, including significant

action, adverse effects, dosage considerations, and any

food or drug interactions. Identify, describe, and practice deep-muscle relaxation

techniques, relaxation breathing, imagery, and other

relaxation therapies

Teach family to give positive reinforcement for use of

healthy behaviors.

Teach family not to assume responsibilities or roles

normally assigned to patient. Teach family to give attention to patient, not patient's

symptoms.

Teach alternative ways to perform activities of daily

living (ADLs) if physical or emotional disability

inhibits function and performance.

For additional information and support, refer to such

agencies as Anxiety Disorders Association of

America, http://www.adaa.org.

Many Web sites provide support for individuals and family

members. Some examples include Agoraphobics Building

Independent Lives: http://www.anxietysupport.org/(for
https://remote.smh.ca/,DanaInfo=www.adaa.org+https://remote.smh.ca/,DanaInfo=www.anxietysupport.org+https://remote.smh.ca/,DanaInfo=www.adaa.org+https://remote.smh.ca/,DanaInfo=www.anxietysupport.org+


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sufferers from anxiety disorders); and for panic and anxiety

disorders, http://www.anxietynetwork.com/pdhome.html.

Evaluation: Expected Outcomes Identifies stressors and demonstrates normal heart

rate, respirations, sleep pattern, and subjective feelings

of anxiety

Demonstrates improved concentration and thought

processes through improved ability to focus, think,

and solve problems

Reports increased participation and enjoyment in

family- and community-related events Reports going to work, keeps appointments

Uses coping strategies in situations that are anxiety

provoking

Does not injure self or others

SOMATOFORM DISORDERS

Somatoform disorders are characterized by complaints ofphysical symptoms that cannot be explained by known

physical mechanisms. These disorders have in common the

belief that physical symptoms are real despite evidence to

the contrary. The affected individual experiences changes

or loss in physical function. The physical symptoms are not

under the individual's voluntary control. Significant

impairment occurs in social or occupational functioning.

Classification

Somatization disorder

Undifferentiated somatoform disorder

Conversion disorder
https://remote.smh.ca/,DanaInfo=www.anxietynetwork.com+pdhome.htmlhttps://remote.smh.ca/,DanaInfo=www.anxietynetwork.com+pdhome.html


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Pain disorder

Hypochondriasis

Body dysmorphic disorder

Somatoform disorder not otherwise specifiedPathophysiology and Etiology

The underlying etiology of somatoform disorders is

difficult to define. The following factors may interact in the

individual with these disorders.

Biochemical Factors

An individual with a somatoform disorder may

experience high levels of physiologic arousal(increased awareness of somatic sensations).

The phenomenon of alexithymia, or deficient

communication between brain hemispheres, may

result in difficulty expressing emotions directly, and

therefore distress may be expressed as physical

symptoms.

The concept of somatosensory amplification, in whichthere is the tendency to experience somatic sensation

as intense, noxious, and disturbing, may be related to

the development of somatoform disorders.

Genetic Factors

Somatization disorder has been found to have a 10%

to 20% frequency in first-degree female biologicalrelatives of women with this disorder.

Twin studies have validated some increased risk in

conversion disorder in monozygotic twins.


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The genetic basis for other somatoform disorders is

not well established.

Psychosocial Factors

Psychodynamic theory: the psychological source ofego conflict is denied and finds expression through

displacement of anxiety onto physical symptoms. Both

primary gain (anxiety relief) and secondary gains

(increased dependence and relief from normal

responsibilities) are common to these disorders.

Behavioral theory: the child learns from parent to

express anxiety through somatization; secondary gainsreinforce symptoms.

Cognitive theory: the individual has cognitive

distortions in which benign symptoms are magnified

and interpreted as serious disease.

Family theory: a family system that is overly

enmeshed may utilize dysfunction in one person as a

means to handle anxiety. In such families, theindividual may not see self as a separate and distinct

person; instead the person may view himself as an

extension of the family.

Sociocultural Factors

Incidence of somatoform disorders is highest in rural

populations and in low socioeconomic groups.

Somatic symptoms are more common in cultures thatview direct expression of emotions as unacceptable.

Women may experience certain chronic pain

conditions more commonly than men (this may have

more of a cultural than a genetic basis).


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Clinical Manifestations

See Diagnostic Criteria for Somatoform Disorders

Diagnostic Evaluation Individuals with somatoform disorders will present in

the medical rather than the psychiatric setting because

of their belief that the problems are medical.

The individual should receive a thorough medical

evaluation (if possible, avoiding repeating tests that

have already had negative results).

The diagnosis of somatoform disorder will be made

after a thorough medical evaluation in which noorganic basis for the symptoms is validated.

Management

Level and setting of care to be provided is determined.

In general, the individual will be treated on an

outpatient basis, unless underlying mood disorder is

present leading to risk for self-harm. Referral to psychiatric treatment is generally rejected

by the individual with a somatoform disorder;

therefore, the goal of management is to maintain a

long-term relationship with a specific health care

provider to prevent the patient from seeking multiple

providers with multiple recommendations for testing,

treatments, and drugs.

Psychotherapy:o Psychodynamic: assist the individual to express

conflicts and emotions verbally rather than

displacing them onto physical symptoms.


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o Behavioral: establish a program whereby

adaptive behavior is reinforced and illness

behaviors do not receive secondary gains.

o

Cognitive: restructure belief system thatperpetuates illness-related behaviors.

o Family therapy: assist family members to define

appropriate boundaries and support patient in

increasing self-responsibility.

Somatic therapies: somatoform disorders are usually

not treated with psychopharmacologic drugs because

these patients are susceptible to dependency on drugs

used. Mood disorders, especially depression, are a common

co-morbid problem in individuals with somatoform

disorders. Antidepressant drugs may be used to treat

the mood disorder.

Complications

The patient with a known history of a somatoformdisorder may also have a co-existing medical

condition that may go undiagnosed. Careful screening

is essential to rule out medical problems.

Increased risk of suicide and substance abuse and

dependence disorders is possible in the patient with an

untreated somatoform disorder.

Nursing Assessment Assess physical complaints.

o Current and past history as well as duration of

problems

o Diagnostic testing completed


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o Number of health care providers consulted

o Types and amounts of drugs as well as whether

self-medicating (over-the-counter) or prescribed

Assess psychological processes.o Perception of illness and current stressors

o Self-concept and body image

o Secondary gains from physical symptoms

o Mood

o Suicide potential

Explore social functioning.

Refer to section on Anxiety Disorders for assessment data.

Nursing Diagnoses

Anxiety related to multiple physical symptoms and

belief that serious disease exists

Ineffective Coping related to preoccupation with

physical symptoms

Other nursing diagnoses and nursing interventions under

Anxiety Disorders may apply.

Diagnostic Criteria for Somatoform Disorders

BODY DYSMORPHIC DISORDER

Preoccupation with some imagined defect in

appearance in a normal-appearing person (or excessive

concern, if the defect is present)

o Preoccupation causes significant impairment in

social or occupational functioning or causes

marked distress


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CONVERSION DISORDER

Development of a symptom or deficit suggesting:

o Neurologic disorder (blindness, deafness, loss of

touch, or pain sensation)o Involuntary motor function (aphonia, impaired

coordination, paralysis, or seizures)

Not due to malingering or factitious disorder and not

culturally sanctioned

Causes impairment in social or occupational

functioning, causes marked distress, or requires

medical attention

HYPOCHONDRIASIS

Preoccupation with fears of having or the idea that one

has a serious disease

Preoccupation persists despite appropriate medical

tests and assurances to the contrary

Other disorders are ruled out; for example, somatic

delusional disorders Preoccupation causes significant impairment in social

or occupational functioning or causes marked distress

PAIN DISORDER

Pain in one or more anatomic sites is a major part of

the clinical picture

Causes significant impairment in social or

occupational functioning or causes marked distress Psychological factors are thought to cause onset,

severity, or exacerbation

If a medical condition present, it plays a minor role in

accounting for pain


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SOMATIZATION DISORDER

History of many physical complaints before age 30,

occurring over a period of years and resulting in

change of lifestyle Complaints must include all of the following:

o History of pain in at least four different sites or

functions

o History of at least two GI symptoms other than

pain

o History of at least one sexual or reproductive

symptom

o History of at least one symptom defined as orsuggesting a neurologic disorder

UNDIFFERENTIATED SOMATOFORM DISORDER

One or more physical complaints:

o Fatigue

o Loss of appetite

o

GI symptomso Urinary symptoms

No physiologic explanation revealed by investigation

Symptoms cause clinically significant distress or

impairment in social or occupational functioning

Duration of the disturbance at least 6 months

Footnote

Adapted from American Psychiatric Association (APA)(2000). Diagnostic and statistical manual of mental


APA.


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Encouraging Recognition of Anxiety

Discuss current life stressors in the areas of social,

occupational, and family functioning. Assist patient to identify anxiety-producing situations

and plan coping strategies.

Avoid focus on physical symptoms (after appropriate

screening to rule out physical etiology).

Maintain focus on feelings and emotional responses

rather than on somatic symptoms.

Improving Coping Teach and reinforce problem-solving approach to

stressors.

Practice use of stress-reduction techniques with

patient.

Encourage use of support groups.

Set limits on manipulative behaviors in a matter-of-

fact manner. Decrease reinforcement of secondary gains for

physical symptoms.

Help patient identify and use positive means to meet

emotional needs.

Community and Home Care Considerations

Encourage patient to cooperate with referrals for

psychiatric or psychotherapy treatments. Promote patient attendance and participation at

community support groups.


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Teach patient and family importance of remaining

with one health care provider to ensure continuity of

care.

Nurses who encounter patients with somatoformdisorders in the community should maintain a matter-

of-fact attitude in order to decrease emphasis on

dramatic symptoms. Any approach to the patient

should include a focus on patient's strengths and

capabilities rather than on disability


Teach patient and family about the relationshipbetween stressors, anxiety, and physical symptoms.

Family should expect person to function despite

physical symptoms; doing things and making

decisions for patient will increase dependent

behaviors.

Encourage family therapy, which may be helpful in

order to clarify roles, communication, andexpectations.

Evaluation: Expected Outcomes

Verbalizes anxiety about specific problems rather than

expressing anxiety with physical symptoms

Makes decisions on own: demonstrates less

dependence on family and friends.

MOOD DISTURBANCES

DEPRESSIVE DISORDERS


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Depressive disorders are considered mood disorders. A

mood is a sustained emotion that, when extreme, colors the

person's view of the world. Mood disorders are

characterized by disturbances in feelings, thinking, andbehavior. These disorders may occur on a continuum

ranging from severe depression to severe mania

(hyperactivity). A depressive illness is painful and can be

psychophysiologically debilitating. Depression is much

more than just sadness; it affects the way one feels about

the future and can alter basic attitudes about the self. A

depressed person can become so despairing as to express

hopelessness. When moods become severe or prolonged orinterfere with a person's interpersonal or occupational

functioning, this may signal a mood disorder.


The exact causes for depressive disorders have not been

established. These disorders are thought to result from

complex interactions among various factors.

Biochemical Factors

Biogenic amine theory proposes that there is a

norepinephrine and serotonin deficiency in individuals

with a depressive disorder. Changes in quantity and

sensitivity of receptor sites for these neurotransmitters

may also be important.

Kindling theory describes a process whereby external

environmental stressors activate internal physiologic

stress responses, which trigger the first depressive

episode. Subsequent episodes can occur with less

stress in response to the electrophysiologic sensitivity


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that was established in the brain from the initial

episode.

Neuroendocrine dysfunction:

o

Hypothalamic-pituitary-adrenal axis dysfunctionmay be present in some individuals.

Abnormalities include increased cortisol levels,

resistance of cortisol to suppression by

dexamethasone, and blunted adrenocorticotropin

hormone response to corticotropin-releasing

factor.

o Subclinical hypothyroidism has been associated

with depression, especially in women.o Dysfunction of circadian rhythms has been

theorized to be related to depression. Abnormal

sleep EEGs have been demonstrated in many

individuals. Increased early morning awakening

is common, as are multiple nighttime

awakenings.

Genetic Factors

Risk of developing a mood disorder is 1 to 3 times

greater in individuals with a first-degree relative with

a mood disorder.

Twin studies reveal a higher rate of concordance in

monozygotic twins than in dizygotic twins.

Mood states are associated with activation of several

neuroendocrine pathways within the central andperipheral nervous systems. These pathways involve a

number of neurochemical processes that involve

activation of a particular binding protein identified as

cyclic amp response binding protein 1 (CREB-1).


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Genetic profiles of individuals with depression have

found evidence that genes involved in the cellular

signaling pathways utilizing CREB-1 are associated

with major depression. There then may be alleles(coding genes) that are related to the development of

mood disorder.

Genetic variation in a certain region of the serotonin

transporter gene (5-HTT) has been found to interact

with the perception of stressful events (possibly

through neuroendocrine pathways) to produce higher

levels of depressive and suicidality than in individuals

without this variation. While genetic evidence has supported

conceptualizations of neurochemical and biologic

alteration in the development of mood and other

psychiatric disorders, no one single gene or factor has

appeared to emerge as the main culprit. Most likely a

number of different genes and disposing factors are

involved. Possible genes include 5-HTT, brain-derivedneurotrophic growth factor, and the monoamine

oxidase A gene.

Medical Factors

Many drugs have the adverse effect of depression,

including hormones, cardiovascular drugs,

psychotropic drugs, and anti-inflammatory and anti-

ulcer drugs. Clinically significant depressive symptoms are

detected in approximately 12% to 36% of individuals

with a nonpsychiatric general medical condition.


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Psychodynamic theory describes the occurrence of a

significant loss (object loss) that is associated with

anger and aggression, which is turned inward andleads to negative feelings about self. The negative

feelings about the self, including shame and guilt, then

lead to depression.

Life events and environmental stress, such as loss of a

family member through death, divorce, or separation;

lack of social support; and significant health problems,

have all been associated with the onset of depression.

Cognitive theory describes how faulty thoughtpatterns, including negative distortions of life

experiences, produce negative self-evaluation,

pessimistic thinking, and hopelessness.

Learned helplessness theory posits that a person who

internalizes the belief that an unwanted event is his

own fault and that nothing can be done to avoid or

change it is prone to developing depression.


See Characteristics of Depressive Disorders


Rating scales of depression to determine presence

and severity of the problem:

o Zung Depression Scaleo Raskin Depression Rating Scale

o Hamilton Rating Scale for Depression

o Beck Depression Inventory

Laboratory studies:


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o Thyroid function tests and thyrotropin-releasing

hormone stimulation test to detect underlying

hypothyroidism, which may cause depression.

o

DST to evaluate depression that may beresponsive to antidepressant or electroconvulsive

therapy (ECT).

o Twenty-four hour urinary 3-methoxy-4-

hydroxyphenylglycol (MHPG) may show

slightly lower level in unipolar depression than in

bipolar depression.

Polysomnography an increase in the overall

amount of rapid-eye-movement (REM) sleep andshortened REM latency period in patients with major

depression.

Additional diagnostic tests to evaluate physical

conditions, such as CT scan or magnetic resonance

imaging (MRI), complete blood count (CBC),

chemistry panel, rapid plasma reagin (RPR), human

immunodeficiency virus (HIV) test, EEG, vitamin B12and folate levels, and toxicology studies.

Management

Patients may receive treatment in acute inpatient

psychiatric hospitals or in the community in an

outpatient program. Decision about treatment setting

is made according to the severity of the patient's

illness, with primary concern being the risk of self-harm (suicide) as well as the presence of symptoms

that are severely disabling.


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Inpatient treatment is directed toward drug

management and supportive psychotherapy using

milieu management.

Somatic therapies:o Psychopharmacologic: drugs used to treat

depression are those that will increase serotonin

and norepinephrine

Pharmacology of Antidepressant Dru

DRUG:

CLASS/GENERIC/TRADE

NAME

ADULT

THERAPEUTIC

DOSAGERANGE

(MG/DAY)

ADVER

Tricyclic Agents For all tr

tetracycl

trigg

epispati

effe

cons

visio

effe

effe

hypo

palp

incr

Amitriptyline (Elavil, Endep)50-300 mg

Clomipramine (Anafranil) 25-250 mg

Desipramine (Norpramin,

Pertofrane)

75-300 mg

Doxepin (Adapin, Sinequan) 75-300 mg

Imipramine (Tofranil,

Tofranil-PM, Janimine, SK-

pyramine)

75-300 mg

Nortriptyline (Aventyl,

Pamelor)

25-150 mg

Protriptyline (Vivactil) 15-60 mg

Trimipramine (Surmontil) 75-200 mg


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effe

wav

prolTetracyclic Agent See Tricy

incr

weigcons

Mirtazapine (Remeron) 15-45 mg

Bicyclic Agent

weig

hype

Venlafaxine (Effexor) 75-375 mg

Selective Serotonin Reuptake Inhibitors

(SSRIs)

mou

drowdela

ejac

imp

orga

nerv

anxidizz

diar

mou

Citalopram (Celexa) 20-60 mgEscitalopram (Lexapro) 10-20 mg

Fluoxetine (Prozac) 20-80 mg

Paroxetine (Paxil) 10-50 mg

Sertraline (Zoloft) 50-150 mg

Fluvoxamine (Luvox) 50-300 mg


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mou

som

diar

trem

diarMonoamine Oxidase Inhibitors (MAOIs) For all M

hypo

gain

sexu

myo

painanti

beve

tyra

with

com

drug

caus

Isocarboxazid (Marplan) 30-50 mg

Phenelzine (Nardil) 45-90 mg

Tranylcypromine (Parnate) 20-60 mg

Pargyline (Eutonyl) 150 mg

Selegiline (Eldepryl,

Deprenyl)

10 mg

Dibenzoxazepine Agent

Amoxapine (Asendin) 100-600 mg

orth

refle


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extr

mov

Unicyclic Agent

Bupropion (Wellbutrin) 225-450 mg

cons

inso

agit

irreg

seiz

Triazolopyridine Agent

Trazodone (Desyrel) 150-600 mg

orthdizz

naus

Phenylpiperazine Agent

Nefazodone (Serzone) 200-600 hypo

nerv

o ECT may be used to treat severe depression thatis unresponsive to antidepressant drugs.

o Ultraviolet light therapy may be recommended

for depression that occurs during fall and winter

months (seasonal affective disorder).

The patient may select complementary and alternative

treatments. The use of herbal supplements, especially

St. John's wort, is a popular alternative for

antidepressant drugs .Use of nutritional or herbal

supplements should be discussed with the health care

provider due to the potential for drug interactions.

Psychotherapy:


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o Psychodynamic therapy assists the patient to

become aware of unconscious anger directed

toward object loss and work through these

feelings to alleviate depression.o Cognitive therapy is the recommended

psychotherapeutic approach for depression. This

approach includes identifying and challenging the

accuracy of the patient's negative thought

patterns and encouraging behaviors designed to

counteract depressive symptoms.

o Family therapy assists the patient and family

members in developing a sense of self that isseparate from that of the family as a whole. The

patient is then encouraged to take responsibility

for his own actions.

Characteristics of Depressive Disorders

Major Depressive Disorder

Occurs over a 2-week period Represents a change in previous functions

Impairs social and occupational functioning

Five or more of the following occur nearly every day

for most waking hours:

o Depressed mood

o Anhedonia (inability to experience pleasure)

o Significant weight loss or gain (more than 5% of

body weight per month)o Insomnia or hypersomnia

o Increased or decreased motor activity

o Anergy (fatigue or loss of energy)


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o Feelings of worthlessness or inappropriate guilt

(may be delusional)

o Decreased concentration or indecisiveness

o

Recurrent thought of death or suicidal ideation(with or without plan)

Specifiers

Severity

Psychotic features

Remission chronic

Seasonal affective disorder related to either winter or

summer Catatonic features

Melancholic features

Atypical features

Postpartum onset

Dysthymic Disorder

Occurs over a 2-year period (1 year for children and

adolescents), presence of depressed mood Still able to function in social and occupational

spheres

Presence of some of the following:

o Decreased or increased appetite

o Insomnia or hypersomnia

o Anergy or chronic fatigue

o Anhedoniao Decreased self-esteem

o Poor concentration or difficulty making decisions

o Perceived inability to cope with routine

responsibilities


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o Feelings of hopelessness or despair

o Pessimistic about the future, brooding over the

past, or feeling sorry for self

o

Recurrent thoughts of death or suicideFootnote




APA.

DRUG ALERT

Antidepressant therapy takes 2 to 4 weeks before beneficialeffects occur. Antidepressant drugs cannot be combined

due to additive serotonergic effects leading to serotonin

syndrome, a state of excessive serotonin in the synaptic

cleft. Symptoms include insomnia, confusion, agitation,

hyperreflexia, involuntary movements, and hypotension.

Hypertensive crisis can occur if patients take a monoamine

oxidase inhibitor antidepressant in combination with asympathomimetic drug or eat foods high in tyramine.

Complications

An undiagnosed medical condition causing depressive

symptoms could lead to physical deterioration and

delay in obtaining appropriate treatment.

Untreated depressive illness can lead to suicide.

Use of alcohol or drugs to feel better or numbdysphoric feelings.

Nursing Assessment

Assess posture and affect for:


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o Poor or slumped posture.

o Appearance of being older than stated age.

o Facial expression of sadness, dejection.

o

Episodes of weeping.o Anhedonia inability to experience pleasure.

Assess thought processes:

o Identify the presence of suicidal thoughts.

o Poor judgment, indecisiveness.

o Impaired problem solving, poor concentration.

o Negative thoughts.

Explore feelings for:

o Anger and irritability.o Anxiety, guilt.

o Worthlessness.

o Helplessness, hopelessness.

Assess physical behavior for:

o Psychomotor agitation or retardation.

o Vegetative signs of depression.

Change in eating patterns Change in sleeping patterns

Change in elimination patterns

Change in level of interest in sex

Change in personal hygiene

Assess for evidence of masked depression:

o Hypochondriasis.

o Psychosomatic disorders.

o Compulsive gambling.

o Compulsive overwork.

o Accident proneness.

o Eating disorders.

o Addictive illnesses.


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Assess for risk of suicide

NURSING ALERT

All mentally ill individuals, especially those who are

depressed, should be assessed for suicide risk and referredfor crisis intervention if they are deemed at risk.

Nursing Diagnoses

Hopelessness related to depressive thoughts

Risk for Injury related to hopelessness and impaired

problem solving

Bathing or Hygiene Self-Care Deficit related to lack ofmotivation and poor concentration

Disturbed Sleep Pattern related to insomnia


Strengthening Coping and Sense of Hope

Initiate interaction with patient at a regularly

scheduled time.

Be clear and honest about your own feelings related topatient's behavior.

Encourage verbal expression of feelings.

Validate feelings that are appropriate to the situation.

Explore with patient what is producing and

maintaining the feeling of depression.

Encourage patient to identify events that cause

unpleasant emotional responses. Assess significant losses patient has experienced.

Identify cultural and social factors that may contribute

to how patient copes with loss and feelings.

Assess patient's support network.


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Maintaining Safety

Assess current suicide risk.

Implement appropriate level of observation based on a

focused suicide assessment (eg, constant observationor 15-minute checks).

Explain observation precautions to patient.

Remove harmful objects from patient's possession,

and assess environmental safety of patient's room and

unit.

Encourage patient to negotiate a no-self-harm and

no-suicide agreement with the staff.

Monitor need to revise level of observation. Provide additional structure by keeping patient

involved in therapeutic and psychorehabilitative

activities.

Encouraging Participation in ADLs

Collaborate with occupational and physical therapists

to determine patient's functional capacity toaccomplish ADLs.

If patient cannot accomplish ADLs independently,

provide hygiene activities in collaboration with

patient.

Acknowledge and reinforce patient's efforts to

maintain appearance; do not rush patient when self-

care is slow.

Reinforce what patient can do rather than what patientcannot do without assistance.

Remain with patient during mealtime to determine the

level of need for assistance or cueing in the ability to

eat.


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Facilitating Sleep

Determine patient's past and current sleep patterns and

sleep hygiene.

Ask what strategies patient has already used toimprove sleep, and elicit which ones have been

successful.

Consider decreasing the amount of daytime sleep by

encouraging participation in an activity.

Discuss alternative methods for facilitating sleep:

o Avoid caffeine and nicotine.

o Avoid emotionally charged or upsetting

discussions before bedtime.o Avoid exercise 30 minutes to 1 hour before bed.

o Increase physical activity within functional

limits.

o Use relaxation techniques.

o Try a warm bath or warm milk.

Administer prescribed drugs that cause sleepiness at

bedtime; avoid giving drugs that cause insomnia atnight.

Community and Home Care Considerations

Mood disorders tend to be chronic, with acute

episodes that may require inpatient treatment. The

patient in the home or community setting will require

ongoing monitoring regarding the use of drugs as well

as support and education in terms of the disorder. Community health care providers, including nurses,

must be aware of the need for primary and secondary

prevention programs directed at education as well as

early case finding and prompt treatment.


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Instruct patient and family members about symptoms

of depression.

Instruct patient and family members about purpose ofantidepressant drugs, effects, adverse effects and their

management, and how to recognize early signs and

symptoms of relapse.

Instruct patient and family members about the effect

of a depressive disorder on the family system.

Provide patient and family members with written

material on coping with depression.

Provide patient and family members with informationabout appropriate community-based programs and

support groups. Contact the National Foundation for

Depressive Illness, http://www.depression.org.


Reports improvement in mood and increased interest

in daily living Remains free from self-harm

Accomplishes ADLs in an independent manner

Obtains a minimum of 5 hours of uninterrupted sleep

BIPOLAR DISORDERS

Bipolar disorders, also considered mood disorders, include

the occurrence of depressive episodes and one or more

elated mood episodes. An elated mood can include a rangeof affect, from normal mood to hypomania to mania. In the

most intense presentation, the person with bipolar disorder

experiences altered thought processes, which can produce

bizarre delusions.
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Genetic Basis

Twin studies reveal a concordance rate of 65% inmonozygotic twins for bipolar disorder.

Risk for developing bipolar disorder is increased 4%

to 24% in first-degree relatives of people with bipolar

disorder.

Current research indicates that defective genes located

within chromosomes 18 and 21 may be related to

bipolar disorder.

Biochemical Factors

Patients with bipolar disorders may have lower plasma

norepinephrine, urinary MHPG, and platelet serotonin

uptake and higher red blood cell/plasma lithium rates

than do unipolar populations.

Pathology of the limbic system, basal ganglia, and

hypothalamus is proposed to contribute to thedevelopment of mood disorders.


Psychosocial stressors appear to have an important

role early in the illness, in concert with the electrical

kindling and behavioral sensitization models.

Mania and hypomania have been viewed by

psychoanalytic theorists as a defense againstdepression.


See Characteristics of Bipolar Disorders


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Rating scale assessment tools:

o Young Mania Rating Scale

o

Manic State Rating Scale There appear to be no laboratory features that

distinguish major depressive episodes found in major

depressive disorder from those in bipolar I or bipolar

II disorder.

Complete psychophysiologic examination.

Complete assessment to rule out medical conditions.

Management Patients may receive treatment in acute inpatient

psychiatric hospitals or in the community in an

outpatient program. The decision about treatment

setting is made according to severity of patient's

illness, including degree of mania or depression as

well as risk of self-harm or harm to others.

Inpatient treatment is directed toward drugmanagement as well as supportive psychotherapy in

order to alleviate the acute manic symptoms.

Pharmacologic treatment for acute mania consists of

the following:

o Lithium (Lithobid)

o Anticonvulsants, such as carbamazepine

(Tegretol) and valproate (Depakene), for mood-

stabilizing propertieso Neuroleptic agents, such as risperidone

(Risperdal), for acute psychotic thinking

o Benzodiazepines, such as clonazepam (Klonopin)

or lorazepam (Ativan), for acute agitation


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Psychotherapy is used as described above in the

section related to depression.

Psychiatric home care nursing to facilitate compliance

with drugs and therapeutic interventions. Community-based support group participation.

DRUG ALERT

Patients taking lithium can develop toxicity related to

elevated levels in the blood; therefore, lithium blood levels

must be monitored periodically. Initial therapy requires

daily monitoring until a safe, therapeutic level is attained;

weekly and then monthly monitoring is then recommended.Lithium toxicity is related to decreased serum sodium

levels and inadequate hydration. Therefore, patients taking

lithium must have normal sodium intake and drink at least

2 to 3 qt (2 to 3 L) of water daily.

Complications

Untreated bipolar disorder can lead to physicalexhaustion.

Poor judgment and risk-taking behavior can lead to

financial problems.

Alcohol and drug abuse problems can develop and

cause disruption in the family.

Concurrent medical conditions may be exacerbated.

Nursing Assessment Assess mood for stability; range of affect, from elation

to irritability to severe agitation; laughing, joking, and

talking continuously; uninhibited familiarity with

interviewer.


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Assess behavior for constant activity, starting many

projects but finishing few, mild to severe

hyperactivity, spending large sums of money,

increased appetite, indiscriminate sex, minimal to nosleeping, outlandish or bizarre dress, poor

concentration.

Assess thought processes for flight of ideas; pressured

speech, usually with content that is sexually explicit;

clang associations (sound of word, rather than its

meaning, directs subsequent associations); delusions;

hallucinations.

Characteristics of Bipolar Disorders

BIPOLAR I DISORDER

Presence of only one manic episode

No past major depressive episodes

Manic episode not accounted for by schizoaffective

disorder

Manic episode not superimposed on schizophrenia,schizophreniform disorder, delusional disorder, or

psychotic disorder

Specifiers

Mixed symptoms

Severity/psychotic

Remission specifiers

Catatonic features Postpartum onset

BIPOLAR II DISORDER

Presence or history of one or more major depressive

episodes


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Presence or history of at least one hypomanic episode

No manic or mixed episodes

Symptoms cause clinically significant distress or

impairment in social or occupational functioningSpecifiers

Hypomanic

Depressed

CYCLOTHYMIC DISORDER

Over a 2-year period, there are numerous periods

without hypomanic symptoms and numerous periodswith depressive symptoms that do not meet criteria for

a major depressive episode

During the 2-year period, the patient has not been

without these symptoms for more than 2 months at a

time

No major depressive episode, manic episode, or mixed

episode during the first 2 years of the disturbance

Symptoms are not due to physiologic aspects Symptoms cause clinically significant distress or

impairment in all aspects of functioning

Footnote




APA.

Nursing Diagnoses


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Disturbed Thought Processes related to biological

changes as demonstrated by agitation, hyperactivity,

and inability to concentrate

Disturbed Sleep Pattern related to hyperactivity andperceived lack of need for sleep

Compromised Family Processes related to role

changes, economic strain, and lack of knowledge

about the patient's illness

Imbalanced Nutrition: Less Than Body Requirements

related to hyperactivity

Nursing InterventionsImproving Thought Processes and Decreasing Sensory

Overload

Assess patient's degree of distorted thinking.

Redirect patient when you are unable to follow

thought processes.

Use brief explanations.

Remain consistent in approach and expectations. Frequently orient patient to reality; speak in a clear,

simple manner.

Provide patient with a relaxing area with decreased

environmental stimulation.

Assist patient with a gradual and progressive

integration into the social environment while

observing for behavioral changes that indicate

readiness for participation in further activities.

Improving Sleep Pattern

Establish a distraction-free environment at bedtime.

Help patient avoid the intake of caffeine and nicotine.


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Administer prescribed drugs as ordered, and monitor

patient's response.

Improving the Effect of Bipolar Illness on Family

Assess family's external support network, andencourage participation in family therapy and support

groups.

Assess communication and boundaries within family.

Observe and assess interaction patterns within family,

and discuss their influence on patient and family

functioning.

Provide patient and family with information aboutbipolar disorder and the treatment plan, prognosis, and

aftercare plan.

Ensuring Adequate Nutrition

Maintain accurate documentation of food and fluid

intake.

Offer small, frequent meals of high-calorie foods.

Include foods that the patient likes and that can beeaten on the move.

Serve patient meals in a low-stimulus environment.

Monitor patient's serum electrolyte and albumin levels

and weigh patient every other day.

Monitor patient's vital signs.


Instruct patient and family about bipolar illness,

including symptoms of relapse.

Instruct patient and family members about

psychopharmacologic treatment, including its purpose,

effects, adverse effects, and management.


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Advise patient and family members about community-

based support groups or health care agencies that are

relevant to his care.

For additional information, refer them to suchorganizations as the National Association of Mental

Illness, http://www.nami.org.


Improved thought processes demonstrated by clear

sentences with no evidence of flight of ideas and

completion of simple tasks

Sleeps for at least 5 hours at night Family members verbalize realistic, goal-directed

thinking related to the patient's abilities, recovery, and

control of condition

No weight loss noted

THOUGHT DISTURBANCES (PSYCHOTIC

DISORDERS)

SCHIZOPHRENIA, SCHIZOPHRENIFORM, ANDDELUSIONAL DISORDERS

Schizophrenia, schizophreniform, and delusional disorders

included in this section have defining features of psychotic

symptoms. Psychotic symptoms are produced by a loss of

ego boundaries or a gross impairment in reality testing,

which includes prominent hallucinations and delusions,

disorganized speech, and grossly disorganized or catatonicbehavior. Schizophrenia can be classified as positive or

negative type, although most patients have a mixture of

these symptoms. The positive symptoms include

hallucinations, delusions, loose associations, and bizarre or
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disorganized behavior. The negative symptoms include

restricted emotion (flat affect), anhedonia (lack of interest

in pleasurable activities), avolition (lack of motivation or

initiative), alogia (lack of speech, or poverty of content),and social withdrawal.


The exact cause of these disorders remains unclear. The

current consensus is that they result from complex

interactions among various factors.

Schizophrenia, Schizophreniform Disorder

Genetic factors:o Studies of monozygotic twins reveal a 50%

concordance rate with a 15% rate with dizygotic

twins.

o If one parent is affected with schizophrenia, a

12% rate is demonstrated in the children, while

having two parents with the disorder increases

the risk to 35% to 39%.o Research is focused on a number of different

genes that may be related to the development of

schizophrenia. An increased risk of schizophrenia

is seen in individuals with genetic variation in the

catechol-O-methyltransferase gene, which is

involved in the manufacture of an enzyme that

metabolizes neurotransmitters. Other current

candidate genes include GRM3, DISC1,

dysbindin, and neuregulin.

Biochemical and structural brain factors:


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o Dopamine hypothesis hyperactivity in the

dopaminergic system, possibly due to receptor

neurons that are functionally hyperactive.

o

Norepinephrine, serotonin, glutamate, and GABAmay also play a role in modulating the symptoms

of schizophrenia.

o Endogenous dysfunction of N-methyl-D-

aspartate receptor-mediated neurotransmission

could lead to the development of schizophrenia.

o Neuroanatomic studies cerebral ventricular

enlargement; sulcal enlargement; cerebellar

atrophy; decreased cranial, cerebral, and frontalsize; abnormalities in basal ganglia; structural

abnormalities at the cellular level, particularly in

the limbic and periventricular regions.

o Functional and metabolic studies regional

cerebral blood flow studies demonstrated

hypofrontality: schizophrenic patients were

unable to increase blood flow to their frontallobes during a task thought to increase frontal

lobe functions; PET studies also consistently

found evidence for a relative hypofrontality.

o Electrophysiologic studies EEG findings in

schizophrenic patients demonstrated decreased

alpha and increased delta activity; changes in

evoked potential studies and amplitude reduction

may occur in responses reflecting selective

attention and stimulus evaluation. P300 response

(reduced amplitude to unexpected stimuli using

auditory and visual parameters) is the most

pronounced and is prolonged. This defect leads to


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information or sensory overload and an inability

to screen out irrelevant stimuli.

o Research evidence supports speculation that

schizophrenia is a neurodevelopmental disorderthat may result from brain injury occurring early

in life and interfering with normal developmental

events.

Psychosocial factors:

o Psychodynamic theory proposes that the essential

feature of schizophrenia is a defect in

interpersonal relationships due to a withdrawal of

the libido into the self.o Interpersonal theory proposes that the lack of a

warm, nurturing relationship in the early years of

life contributes to the lack of self-identity, reality

misperception, and relationship withdrawal that is

apparent in the disorder.

o Family theory related to the role of the family in

the development of schizophrenia has not beenvalidated by research. An area of family

functioning that has been implicated is increased

relapse risks in families characterized by high

expressed emotion. This characteristic is

described as emotional overinvolvement along

with hostile and critical feedback.

Delusional Disorder Little has been established about the etiology of

delusional disorder.

There is no demonstrated genetic linkage.


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It is possible that psychosocial stressors have a role in

the etiology of delusional disorder in some persons.

This is illustrated in some of the rarer conditions such

as shared psychotic disorder.Clinical Manifestations

See Characteristics of Schizophrenia, Schizophreniform,

and Schizoaffective Disorders


Clinical diagnosis is developed on historical

information and thorough mental status examination. No laboratory findings have been identified that are

diagnostic of schizophrenia.

Routine battery of laboratory tests may be useful in

ruling out possible organic etiologies, including CBC,

urinalysis, liver function tests, thyroid function tests,

RPR, HIV test, serum ceruloplasmin (rules out an

inherited disease, Wilson's disease, in which the bodyretains excessive amounts of copper), PET scan, CT

scan, and MRI.

Rating scale assessment:

o Scale for the Assessment of Negative Symptoms

o Scale for the Assessment of Positive Symptoms

o Brief Psychiatric Rating Scale

ManagementSchizophrenia and Schizophreniform Disorder

Patients may receive treatment in inpatient settings or

in community-based outpatient programs or

psychiatric home care. The level of care depends on


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the severity of symptoms and the risk of harm to self

and others.

These disorders generally require long-term treatment;

therefore, a case management approach is important inorder to coordinate multiple services.

Pharmacologic therapy with either the typical or

atypical neuroleptics (antipsychotics) is the mainstay

of treatment.The typical neuroleptics have multiple

adverse effects that require careful management .The

atypical neuroleptics have fewer adverse effects and

may also be more effective in decreasing the negative

symptoms of schizophrenia. Pharmacologic therapywith both the typical and atypical neuroleptics can

include the use of long-lasting, or depot, injections.

Three drugs are currently available in depot

formulations, haloperidol (Haldol), fluphenazine

(Prolixin), and risperidone (Risperdal). The reader is

directed to a pharmacology source for further details

regarding the typical and atypical neuroleptics.

Pharmacology of Antipsychotic Drugs

DRUG:

CLASS/GENERIC/TRADE

NAME

ADULT

THERAPEUTIC

DOSAGE

RANGE

(MG/DAY)

ADVERSE

REACTIONS

ButyrophenoneHaloperidol (Haldol) 2-40 mg Extrapyramida

adverse effect

are common.

Decreased


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incidence of

orthostatic

hypotension a

compared withphenothiazine

Aliphatic Phenothiazines

Chlorpromazine (Thorazine) 30-800 mg Orthostatic

hypotension,

sedation, dry

mouth,

extrapyramida

adverse effectagranulocytos

ocular change

Piperidine Phenothiazines

Mesoridazine (Serentil) 100-400 mg Sedation,

orthostatic

hypotension,

fewerextrapyramida

symptoms tha

other

phenothiazine

Thioridazine (Mellaril) 200-800 mg

Piperazine Phenothiazines

Fluphenazine (Prolixin) 2.5-40 mg Extrapyramida

symptoms, an

lower incidenc

of orthostatic

hypotension

than with othe

phenothiazine

Perphenazine (Trilafon) 8-64 mg

Trifluoperazine (Stelazine) 15-40 mg


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Dibenzoxipine

Loxapine (Loxitane) 60-250 mg Extrapyramida

adverse effect

hypotension,dizziness

Thioxanthene

Thiothixene (Navane) 20-60 mg Extrapyramida

adverse effect

hypotension,

tachycardia,

insomnia

Atypical Antipsychotics Extrapyramidaadverse effect

can occur with

the use of any

of the atypical

antipsychotics

although the

incidence ofoccurrence

usually less

than that seen

with other

classes of

antipsychotic

medications

Aripiprazole (Abilify) 10-30 mg Headache,

anxiety,

insomnia,

nausea,

vomiting,


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dizziness, and

drowsiness

Clozapine (Clozaril) 150-600

mg(requirescareful titration)

Seizure,

agranulocytos(weekly white

blood cell

count),

hypotension,

tachycardia,

cardiac

dysrhythmia,

drowsiness,sedation,

increased

salivation

Olanzapine (Zyprexa) 5-20 mg Orthostatic

hypotension,

tachycardia,

drowsiness,agitation,

akathisia,

constipation

Pimozide (Orap) 1-10 mg Orthostatic

hypotension,

tachycardia,

drowsiness,

sedation,

akathisia,

akinesia

Quetiapine (Seroquel) 200-800 mg Orthostatic

hypotension,


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tachycardia,

drowsiness,

dizziness, dry

mouthRisperidone (Risperdal) 4-16 mg Orthostatic

hypotension,

tachycardia,

drowsiness,

dizziness, dry

mouth

Ziprasidone (Geodon) 20-80 mg Dysrhythmia,

drowsiness,dizziness,

nausea,

restlessness,

constipation

Management of Adverse Effects of Neuroleptic Drugs

SYMPTOM MANAGEMENT

Orthostatic Hypotension Assess for orthostatic bloodpressure changes and dizziness

and teach the patient:

o When rising from bed

chair, get up slowly.

o Sit at side of bed for a

few minutes, dangling legs.

o Do ankle pumps before

standing.

o Once standing, move

slowly.

o Do not twist or turn

quickly.


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o Use assistive devices,

hand rails, canes, walkers

when necessary for

functional deficits.o Do not drive or operate

machinery when dizzy.

Peripheral Anticholinergic Effects

Dry mouth and nose, blurred

vision, constipation, urine

retention

Dry mouth:

o Brush teeth after each

meal with a fluoridated

toothpaste.o Rinse mouth frequently

o Limit caffeinated or

alcoholic drinks because the

can be dehydrating.

o Stop smoking due to th

irritation of oral mucosa.

o

Suck on sugarless candor gum; avoid sugared cand

to decrease the risk of funga

infections and dental caries.

o Avoid dry or spicy

foods.

o Drink fluids between

meals unless you are on a

specific fluid restriction.o Avoid acidic beverage

due to potential irritation.

o Use dressing, juices, or

sauces (if allowed) to moist


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food.

Constipation:

o Drink fluids (within

prescribed limits set by healcare provider).

o Eat roughage: fruits,

vegetables (raw leafy types)

to increase bulk and help

soften stool.

o Eat dried fruits, such a

prunes or dates, for laxativeeffect.

o Maintain activity level

within functional limits.

o Consult with health car

provider to determine

appropriate use of over-the-

counter laxatives (MetamucCitrucel) or prescribed stool

softeners.

Urine retention:

o Void at regular interva

o Ensure privacy.

Extrapyramidal Adverse Effects

Short-TermAkathisia: restless legs,

jitters, nervous energy, motor

agitation

o Reassure patient.

o Differentiate between

agitation and akathisia.

o Consider reducing


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dosage.

o Consider switching

patient to another class of

antipsychotic.Akathisia: Weakness

(hypotonia), fatigue, painful

muscles, anergy (lack of

energy), absence of

movement

o Assess functional

ability.

o Dose reduction or

cessation should improve

movement if problems are

due to akinesia versus

psychotic symptoms.

Dystonias, dyskinesias:grimacing, torticollis,

intermittent spasms,

opisthotonos, oculogyric

crises, head-neck stiffness,

myoclonic twitches,

laryngeal-pharyngeal

dystonia

o Consider prophylaxiswith anticholinergic

medications.

o Treat with I.M. or I.V.

anticholinergics, as

prescribed.

Parkinsonian effects: muscle

stiffness, cog wheel rigidity,

shuffling gait, stooped

posture, drooling

o Treat with

anticholinergics, as

prescribed.

o Stop the antipsychotic,

as directed.

Long-Term

Tardive dyskinesia: a

delayed effect of neuroleptic

drugs usually occurring after

6 months of treatment

involving abnormal,

involuntary, irregular, and

o Complete regular

objective rating/assessment

of the movement disorder.

o Reduce or stop

neuroleptic as directed.

o Consider clozapine


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choreoathetoid movements

of the muscles of the head,

limbs, and trunk

(Clozaril) or risperidone

(Risperdal).

o Comprehensive medica

psychiatric assessmentnecessary with close

monitoring of movement

disorder.

Psychosocial treatments (social skills training, ADL

instruction).

Supportive therapy that is reality oriented and

pragmatic.

Family therapy. Psychoeducational individual, group, and family

support.

Support groups in the community.

Community-based partial hospitalization programs.

Psychiatric home care nursing.

Vocational and social skills education.

Characteristics of Schizophrenia, Schizophreniform,

and Schizoaffective Disorders

SCHIZOPHRENIA SUBTYPES

Paranoid

Dominant hallucinations and delusions

No disorganized speech, disorganized behavior, ordisorganized affect present

Disorganized


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Dominant disorganized speech and disorganized

behavior

Delusions and hallucinations if present are not

prominent or fragmentedResidual

No longer has positive symptoms, such as delusions,

hallucinations, or disorganized speech or behaviors

However, persistence of some symptoms is noted,

such as:

o Marked social isolation or withdrawal

o Marked impairment in role function (wageearner, student, or homemaker)

o Markedly peculiar behavior

o Marked impairment in personal hygiene

o Marked lack of initiative, interest, or energy

o Blunted or inappropriate affect

Catatonic

Motor immobility (waxy flexibility) Excessive purposeless motor activity (agitation)

Extreme negativism or mutism

Peculiar voluntary movement

o Posturing

o Stereotyped movements

o Prominent mannerisms

o Prominent grimaces Echolalia or echopraxia

Undifferentiated

Has positive symptoms (does have hallucinations,

delusions, and bizarre behaviors)

Documents

Problems of Mental Health