The Anxiety Continuum as a Basis for Mental Health Disorders Objectives: By the end of this learning experience, the student will be able to: 1. Define anxiety. 2. Discuss the concept of anxiety and describe the physiological, perceptual, cognitive and behavioral effects. 3. Compare and Contrast the meanings of the following concepts: Anxiety and fear, Primary and secondary anxiety, Acute and chronic Anxiety. 4. Define the term anxiety disorder. 5. Discuss a variety of anxiety disorders in terms of their major signs and symptoms. 6. Discuss how psychological factors affect physical status. 7. Apply the nursing process to a case study of a patient with anxiety disorder. COMPLETE THIS TABLE BEFORE CLASS Level of Anxiety MILD

MODERATE

SEVERE

PANIC

Physiological Effects

Perceptual/Cognitive Effects

Behavioral Effects

Anxiety Continuum

Mild

Moderate

Severe

Panic

Check out this web-site for an updated Holmes and Rahe Social Readjustment Scale: http://www.kirstimd.com/stressors.htm

ETIOLOGY

ANXIETY DEFINED

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“A feeling of apprehension, uneasiness, uncertainty, or dread resulting from real or a perceived threat whose actual source is unknown or unrecognized.” unrecognized.” (Varcarolis, Varcarolis, 1994)

EPIDEMIOLOGY Who is most effected by anxiety?? „ We will look at those statistics as we go through the anxiety related disorders „

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Biochemical ‹ ↑ sympathetic nervous system ‹ ↑ in norepinephrine ‹ Δ Serotonin levels ‹ ↓ GABA ‹ Δ in brain chemistry (studies conducted using PET scans show Changes in brain activity in the frontal, occipital and temporal lobes) Δ in brain structures; some people may be more susceptible to anxiety. Genetics Stress indicators - What do you think cause you anxiety??

Four levels of anxiety…this is covered in your critical thinking piece… Mild: Mild: ⇑ motivation, sharpened senses and learning is enhanced „ Moderate: Moderate: perceptual field diminishes, attention span ⇓, needs help with problem solving „ Severe: Severe: Can focus on only one detail, severely limited attention, physical symptoms common, behavior aimed at relief of anxiety „

FEAR VS. ANXIETY Unable to focus on even one detail. Misperception of environment is common „ May have delusions or hallucination „ Fear of dying or going insane „ Prolonged episode can lead to physical or emotional exhaustion „ „

FEAR IS A REACTION TO A SPECIFIC DANGER

PRIMARY VS SECONDARY ANXIETY PRIMARY • CAUSED BY  PSYCHOLOGICAL  FACTORS – phobias

SECONDARY • CAUSED BY  PHYSIOLOGICAL  DISORDERS – brain  tumor

ACUTE VS. CHRONIC ACUTE (AKA state) „

A great disruption in one’s routine life triggering the fight or flight response

CHRONIC (AKA trait) „

Permanent anxiety Features; insomnia, fatigue, great disruptions in relationships

‹

Anxiety has advantages… • Primary Gain = relief  • Secondary Gain =  from anxiety  by use  advantages realized  by a person’s use of  of ego defense  symptoms or relief  mechanisms – Regression in the person  behaviors with physical illness

WHEN IS IT A DISORDER THEN???? We are about to venture into the disorders… You will start to identify with these; personally, professionally and within your own relationships „ A disorder becomes A DISORDER when it becomes so intense that it interferes with personal, occupational or social functioning

– Stomach Ache – Won’t  have to go to school and  take that test! 

Common features of anxiety disorders Single or multiple symptoms Perceived as intensely uncomfortable „ Reality testing „ Disorder continues without treatment „ No organic factor is present

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ANXIETY DISORDERS „

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PHOBIA continued ‹

PHOBIAS

Clinically significant anxiety provoked by exposure to certain types of social or performance situations  20% of the population fears speaking in public (you?).. Only 2% of those really warrant the diagnosis of social phobia  Usually lifelife-long

Anxiety about, or avoidance of places or situations where escape is difficult. Fear of having a panic attack  95% of agoraphobics have panic disorder  Occurs persistently for years 

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Social Phobia 

Agoraphobia

THOSE SPECIFIC PHOBIAS

Clinically significant anxiety provoked by exposure to a specific object or situation, leading to avoidance behavior ‹ Common types; animal, natural environment, bloodblood-injectioninjection-injury, situation and other ‹ Onset in childhood and midmid-20’ 20’s ‹

Epidemiology of panic Women > men ½ of all pts with panic D/O have an episode of major depression „ Many suffer form alcohol abuse „ ½ have a personality D/O too „ Agoraphobia usually occurs within one year of the first panic attack

DISORDER: Presence of recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about having a subsequent panic attack „ ASSOCIATED FEATURES: excessive visits to health care professionals – ill feelings are interpreted as catastrophic events… events…. „

Distinguishing features between Panic Disorder and MI

„ „

„ „ „ „ „ „

Panic D/O Palpitations, ↑ HR Sweating SOB, smothering sensation Chest pain Nausea or abdominal distress…… distress…… Fear of dying

Myocardial Infarction Same symptoms as anxiety… anxiety… „ Changes in EKG „ Cardiac enzymes are „

↑

Generalized Anxiety D/O

O.C.D

Characterized by at least 6 months of persistent and excessive anxiety and worry, where the individual finds it difficult to control the worry „ 5% of the population will endure this „ Women > men (slightly) „ Most with this D/O have felt anxious or “nervous” nervous” all of their lives

OBSESSION THOUGHTS „ Recurrent, persistent ideas, thoughts, images „ Impulses „ Invaded by the thoughts

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COMPULSIVE ACTS „ More than 1 hour/day „ Differs from personality d/o = orderliness, perfectionism and control „

POST-TRAUMATIC STRESS DISORDER „ Who gets this????

OCD

Equal opportunity disorder ‹Begins in adolescence and early adult ‹Focus is usually around contamination

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Post-Traumatic Stress Disorder (applies to acute or delayed) First identified in war vets (Vietnam) A prevalent diagnosis, widely used today „ Some causes are; war, disasters, rape, violent attacks „ Characteristics… Characteristics…see next slide „ „

Acute Phase Symptoms appear within 6 months of the “event” event” (s)

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Delayed Phase Symptoms appear 6 months + after the “event” event” (s)

ReRe-experiencing Denial (AKA psychic numbing) „ Perceptual distortions „ Feelings of being pressured, confused, disorganized „ Impaired memory „ Preoccupation with event „ Startle reaction „ Somatic feelings „ Changes in reality „ Withdraw from society „ „

PSYCHOPHYSIOLOGIC DISORDERS SOMATIZIATION = multiple sx.s physical/chronic that can not be explained „ CONVERSION = loss of body function, can not be explained „ HYPOCHONDRIASIS = unrealistic preoccupation with the fear of having an illness. Grossly exaggerates symptoms. „

More on DISSOCIATIVE

DISSOCIATIVE DISORDERS AMNESIA = inability to recall information; usually that which is traumatic or stressful „ FUGUE = sudden unexpected travel away from home or work locale. Takes on new identity. Once recovered, does not remember the fugue „ DISSOCIATIVE IDENTITY DISORDER 2+ distinct personality. Associated with extreme psychological stress „

NURSING DIAGNOSES/OUTCOMES ↓ Anxiety (level to level) „ ↑ Problem solving/decision making..be specific with the goals ____________ „ Desensitize!! (rapid vs. over time) „

Severe level of anxiety „ Dissociation feels like the person is actually coming apart… apart…feeling almost like out of body and can not control it „ Nurse can: offer a safe place; ice in hands = ↑focusing; wrap in blanket „

PANIC/GENERAL „ Anxiety (panic) „ Powerlessness _________________ PHOBIAS „ Fear „ Social Isolation

NURSING DIAGNOSES/OUTCOMES OCD „ Ineffective individual coping „ Altered role performance (Agoraphobia too) PTSD „ PostPost-trauma response „ Dysfunctional grieving

List ways of more positive coping strategies „ Through limit setting, break the O/C ____________________ „ Through supportive measures - ↓ Anxiety (level to level) „ ↑ Problem solving/decision making..be specific with list

INTERVENTIONS

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Individual psychotherapy; psychotherapy; „ Cognitive therapy; restructuring thoughts „ Behavior therapy; systematic desensitization, implosion therapy „ Group/family therapy „ Psychopharmacology; anxiolytics – “benzos” benzos” & Buspar „

Intervening During Crisis Objectives:

By the end of this learning experience, the student will be able to : 1. Define crisis. 2. Describe behavior changes in the client experiencing crisis. 3. Identify the types of crisis and apply to case situations. 4. Discuss the goals and methods utilized by persons who intervene during crisis. 5. Apply the nursing process to a case study involving a crisis situation.

DEFINITION „ Temporary state of disequilibria (↑ (↑ anxiety – panic) in which a person’ person’s coping mechanisms or problem solving methods fail WHAT OCCURS „ Disequalibrium last 44-6 weeks „ Patient will; return to mental health – develop new coping skills – or decompensate „ In recovery; problem solving skills are learned, new perception of the problem is seen, support is given

THE CRISIS WORKER „ „ „ „ „ „

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Calm & empathetic Objective, identifies facts, thinks clearly Aware of cultural values Dose not impose own values or beliefs Courageous Good listener; can tolerate uncomfortable feelings (sadness & anger) Commitment to individuals in crisis

Diagnoses / Outcomes

TYPES OF CRISIS „ „ „

Nursing Process ASSESSMENT „ Feelings; empathy, silence, encourage expression „ Perception; Pt. To describe perception „ Support systems; to determine resources available – family, community „ Coping skills; evaluate level of anxiety, coping mechanisms (+/(+/-) „ Potential for self/others harm; important assessment

INTERVENTIONS „

Diagnoses „ Ineffective individual coping „ Ineffective family coping „ Altered thought processes „ Anxiety

Outcomes „ Realistic goals „ Include the patient/family „ Patient is responsible for problem solving

MATURATIONAL SITUATIONAL ADVENTITIOUS

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GROWTH; pt. Realizes can grow through this HELP; ↑ ability to ask for help ADAPTIVE COPING; more health coping strategies PROBLEM RESOLUTION; focused on the problem, redirect TEAM; multidisciplinary CRISIS GROUPS; group therapy provides insight and understanding of not being alone with feelings

Mood Disorders Objectives: 1. 2. 3. 4. 5. 6.

By the end of this learning experience, the student will be able to: Compare and contrast depression and bipolar disorder. Apply the biological and Psychosocial theories to mood disorders. Discuss primary, secondary and tertiary prevention of mood disorders. Apply the nursing process to a case study discussing mood disorders. Through review of pharmacology, discuss the common medications used to treat mood disorders. Discuss personal feelings and attitudes about caring for patients with mood disorders.

Critical Thinking Activity (Varcarolis, 1994) Name two pieces of data one might expect to find upon assessment of a person who is depressed. Affect ___________________ _________________ Thinking ___________________ _________________ Feeling ___________________ _________________ Physical behavior ___________________ _________________ Communication ___________________ _________________

MOOD DISORDERS

MOOD DISORDERS „

A pervasive and sustained emotion that, in the extreme, markedly colors the person’ person’s perception

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COGNITIVE ‹ Predisposition through early life experiences; develop negative, illogical and irrational thought processes… processes…dormant until times of stress ‹ Self depreciating ‹ Pessimistic view of environment ‹ Negative view of future

LEARNED HELPLESSNESS „ Stress → anxiety → response to anxiety is depression → feels a loss of control over the given situation „ The stress → anxiety → “can’ can’t control this” this” → depression …. Cycle occurs throughout life …

TYPES ‹ Major depression; life time disorder ‹ Dysthymic; Dysthymic; 2 years in duration ‹ Special features or specifics  psychotic (delusions/hallucinations)  SAD (Seasonal Affective Disorder)  Catatonic, melancholic and postpost-partum THEORIES ‹ Biological; strongest theory today, neurochemicalneurochemical-excitatory ↓ serotonin, dopamine, norepinephrine ‹ Psychosocial; loss, negative thoughts, mad at inner self, learned in family to be helpless

PSYCHOANALYTICAL „ Depression = anger turned inward „ Loss of mothering figure (physical or emotional) → feeling unworthy of love → Term: Introjection ‹ Loss of someone → hostility towards that person is turned inward → anger directed at self → internal feelings become reality

BIOLOGICAL… BIOLOGICAL…. „

When in stress… stress…and anxiety rises… rises…the chemicals necessary to help one cope are insufficient… insufficient…leading to symptoms of depression… depression…

What does depression look like?

ASSESSMENT KEY TERMS Anhedonia – AN –HE –DOEDOE-KNEEKNEE-AH Inability to find meaningful pleasure „ Anergia – AH – NER –GEE – AH ↓ energy „ Anxiety – U – DER –ING – A – TEST ! 90% of depressed people suffer anxiety too „

THOUGHTS/FEELINGS AFFECT/MOOD „ Views world through “gray colored glasses” glasses” „ Appears sad, dejected, apathetic „ Verbalizes guilt, anger, hostility „ Stooped posture

„ 2/3 contemplate suicide „ Problem solving

and clear thinking is impaired by negative thoughts „ Memory, judgment, concentration are poor „ Delusions include “God wants me dead” dead” „ Distorted perception; hallucinations „ Poor insight

PHYSICAL APPEARANCE „ Sleeping difficulties „ ↓ muscle tone

COMMUNICATION

„ Constipation

„ Speaks slowly

„ ↓ sex drive „ Fatigued „ ↓weight „ Unkempt grooming

„ May

be mute in extreme depression

„ Communication is focused “in the

negative” negative”

Nursing Process

Interventions

Common Diagnoses: Hopelessness, Risk for Violence – Self directed Planning: „ Always for safety „ Eventually to work with issues of negative thoughts and learned patterns of coping

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Psychotherapy

Psychopharmacology

Cognitive: Altering dysfunctional beliefs „ Reframing one’ one’s thoughts from negative to positive; pessimistic to optimistic

WHY ECT? Meds not effective „ Rapid need; patient will not eat or is very suicidal „ The patient wants it WHAT ARE THE OUTCOMES? „ Those who have responded to meds will respond better to ECT; 50% chance of improvement if medications have not been successful „

Assess for suicidal ideations Promote selfself-care; ↑ independence, ADLs, ADLs, grooming „ Encourage expression of feelings; groups, 1:1 „ ↑ activity; group activity → ↑ self esteem and worthiness „

Antidepressants: Takes time for TCAs: TCAs: Major problem; arrhythmias → especially with OD „ MAOIs: MAOIs: Avoid “party” party” foods & OTC meds „ SSRIs: SSRIs: Lower side effects; avoid alcohol & caution when stopping the med „ Novel: Specific problems associated with each; Welbutrin → Sz. Sz. D/O „

PRE-OP DETERMINE CANIDACY ‹ Meets criteria (previous slide) ‹ Will take 66-12 treatments over 22-3 weeks ‹ Is contraindicated in people with; Hx. Hx. MI, CVA, any intracranial mass „ EXPLAIN ‹ Informed consent ‹ NPO р MN ‹ SE; confusion, disorientation, STML „

PRE-OP

INTRA-OP

V.S. Baseline assessment Patient voids „ Hair pins removed „ Dentures removed „ Meds given; Atropine (↓ (↓secretions), Conscious Sedation initiated

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POST-OP

Evaluation

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Monitor vital signs Administer prescribed medications „ Assess SE, reassure patient about memory loss

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SOMEONE FROM CLASS TO EXPLAIN

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REVIEW THE DEFINITIONS Mania (minimum of 1 week in manic state) Hypomania (maximum of 4 days in manic state) Bipolar Type I: Mania with at least one „ episode of major depression Type II: Hypomania alternating with „ major depression „ Type III: Not in DSM IV, indicates mania due to use of antidepressants. Cyclothymia (at least 2 year duration of hypomania/dysthimia hypomania/dysthimia))

Was safety maintained? Did the patient’ patient’s behaviors change? ‹ ↑ physical activity, ↑ ADLs, ADLs, ↑communication

THEORIES „

„

BIOLOGICAL ‹ Genetic; twin studies ‹ Neurochemical; Neurochemical; ↑ in mania  Like depression, stress→ stress→changes in neurochemical levels PSYCHOSOCIAL ‹ Social View  Tend to be higher educated, creative and professionals …and Freud??

Another Ego Defense Mechanism REACTION FORMATION „ A defense against depression; acting manic is the reverse action of depression, thus..a reaction formation

THOUGHT PROCESSES Grandiose delusions; grandeur or persecutory „ Thinking is difficult, limited to few topics „ Flight of ideas „

PHYSICAL (note, not physiological) EFFECTS – BEHAVIOR „ Continuous activity → dehydration and ↓ nutrition „ Bizarre dress „ Collects objects „ Begins many projects, but does not finish „ Pressured speech; may include shouts „ Clang association; rhyming words with no meaning

ASSESSMENT AFFECT Euphoria „ Rapid mood changes; happy →angry or irrational, especially when told what to do „ Inappropriate; jokes „ Talks in a continuous stream „ Boundless enthusiasm, confidence and energy „

INTELLECTUAL „ Usually very intelligent „ Makes poor judgments;

spending sprees, giving money away

APPEARANCE: „ „

In many cases you would not guess The choice of dress however… however….

Nursing Diagnoses „

Always safety oriented ‹ Risk for injury ‹ Dehydration ‹ Less than body requirements ‹ Altered thought pattern; lack of judgment

More Interventions „

ENERGY ‹ Reduce stimuli ‹ Rest periods ‹ Structure activities ‹ Protect from injury to physical and emotional self

Medicinal Help!!! FIRST LINE OF DEFENSE… DEFENSE…ANTIPSYCHOTICS „ LITHIUM ‹ Undesirable SE, levels need to be checked ‹ Difference between therapeutic and toxic is slim… slim…needs to be toxic initially to achieve a therapeutic level and mood stabilization More… More….

Plan and Interventions WILL MAINTAIN SAFETY WILL SUSTAIN REQUIRED FLUID AND NUTRITIONAL NUTRITIONAL NEEDS „ Therapeutic communication ‹ Firm and calm ‹ Short and concise ‹ Remain neutral ‹ Avoid being led by joking ‹ Redirect inappropriate energy

More Interventions NUTRITION/HEALTH Monitor I/O „ ↑ caloric foods – AVOID caffeine „ Remind to finish meals „ Warm showers „ Supervise dress „

ANTIEPILEPTICS Slows down neuronal firing „ Used when lithium can not be tolerated „ Klonopin ( a benzo too) ‹ Is often used to reduce anxiety associated with the mania „ Benzodiazepines ‹ Reduces anxiety associated with mania „

Suicide - "No one really wants to die, there is always a Key” Objectives: 1. 2. 3. 4. 5. 6.

By the end of this learning experience, the student will be able to:

Define suicide as a self-destructive behavior. Describe factors that relate to the incidence of suicide. Describe the biologic, sociologic, and psychological theories. Assess behavioral changes related to suicide. State the legal and ethical responsibilities relevant to the suicidal patient. Apply the nursing process for the care of the patient presenting with suicidal behavior.

Critical Thinking Activity: (false) next to each statement. 1. 2. 3. 4. 5. 6. 7.

(Varcarolis, 1994) Place a T (true) or F

Attempted suicide is associated with depression and alcoholism. People with antisocial disorders also have a high suicide rate. Once a person is over the suicide crisis, he or she most likely will not attempt suicide in the future. Nonwhites in a low socioeconomic status have the highest rates for suicide. If the nurse thinks that a client may be thinking of suicide, the nurse should not bring up the subject, otherwise the person may get ideas. The suicide rate is higher among gifted individuals, immigrants, police officers, doctors, and the elderly compared to the general population. A person who has had a family member commit suicide, is divorced, or has suffered multiple losses is a risk for possible suicide.

Looking at the Anxiety continuum…. • Look at your text book (Anxiety chapter) note  where the different disorders are placed…  • Suicide is not listed, however it is on the high end of  Mood Disorders (which fall between severe and  panic)   • Someone seriously considering suicide would fall  more towards the panic level.. When someone is  ready to act on the thoughts their anxiety will  reduce .. And look very calm

“NO ONE REALLY WANTS TO DIE, THERE IS ALWAYS A KEY” SOS Presentation - 1997 What does that mean???

It means that no person who is in that much emotional pain really wants to die. That person just wants to depart the pain and anguish being experienced. Finding that key is essential in helping the suicidal person begin to unlock the pain and embrace hope.

CLASSIFICATIONS…why do people suicide?

„ More men than women die by suicide.

Humans are the only creatures aware of their own mortality (as far as we know) and who are able to contemplate the past and future

„ 73% of all suicide deaths are white

„ The gender ratio is 4:1.

males. „ 80% of all

„ „ „ „

GIVE EXAMPLES EGOISTIC – Uses suicide as a means of escaping from the consequences of ones actions ANOMIC – Loss of social contacts and feels one does not belong ALTURISTIC - a response to societal demands LUDIC – excessive risk taking

firearm suicide deaths are white males. „ Among the highest rates (when categorized by gender and race) are suicide deaths for white men over 85, who had a rate of 59/100,000.

Suicide was the 11th leading cause of death in the United States. „ It was the 7th leading cause of death for males, and 16th leading cause of death for females. „ More… „

Finally, Firearms; most common method „ Professionals have higher than average suicide rates „ Some American Indian tribes have rates 5 X the national average „ African American Women and Adolescent suicide rates have been climbing 80%/200+% over the last 2020-25 years „

THEORIES BIOLOGICAL „ Alteration in serotonin – other neurotransmitters – excitatory ↓ SOCIOLOGICAL/INTERPERSONAL „ A rejecting society – peer group rejects „ Isolation – demographics or rejection „ Family rejects „ Distraught about relationships

Suicide was the 3rd leading cause of death among young people 15 to 24 years of age, following unintentional injuries and homicide. „ There are an estimated 12-25 attempted suicides to one completion; the ratio is higher in women and youth and lower in men and the elderly „ More women than men report a history of attempted suicide, with a gender ratio of 3:1 „

COMMON STRESSORS A stressful situations precedes an attempt Divorce, rape, death of a significant other, illness, legal problems, financial problems „ illness „ Loss of great magnitude „ Difficulty with forming or maintaining relationships (BPD) „ Some are sensitive to loss – having insecure or unreliable childhood experiences „ „

THEORIES PSYCHOANALYTICAL… PSYCHOANALYTICAL…and Freud thought… thought….. „ A repressed desire to kill someone else „ “Murder in the 180th degree” degree” „ A wish to get rid of the “hated self” self” or to be at peace with the internalized person

NURSING PROCESS ASSESSMENT „ Determine ‹ Intent ‹ Plan - lethalness ‹ Mental state – level of anxiety ‹ Support of s/o ‹ Coping strategies

More Assessment… SUICIDE INDICATORS Behavioral changes ‹ Anxiety ‹ Poor concentration ‹ Despair ‹ Anger ‹ Anorexia ‹ Insomnia ‹ calmness

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More… RISK PERIODS „ Holidays „ Spring time „ On the nursing unit between 10 AM and 6 PM „ During change of shift FAMILY OR SIGNIFICANT OTHER „ If appropriate, ask for their input DON’ DON’T FORGET YOUR OWN FEELINGS

NURSING DIAGNOSES RISK FOR SUICIDE INEFFECTIVE INDIVIDUAL COPING

INTERVENTIONS

PLAN

Address the crisis Do not leave the patient – If they continue to voice ideation and intent „ Mobilize coping skills „ Assess need for hospitalization „ If hospitalized, follow therapeutic guidelines „

STG: REMAIN SAFE – CONTRACT LTG: PT WILL… WILL…. „ LIST 3 + COPING MECHANISMS „ NAME AT LEAST 2 SUPPORT PEOPLE „ STATE “I WANT TO LIVE” „ NAME ONE ALTERNATIVE TO SUICIDE

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THERAPEUTIC COMMUNICATION GUIDELINES

EVALUATION Did the patient remain safe?? Coping strategies increased?? „ Plan to remain safe in the community?? „ Document everything!!! Patients who are suicidal and have an intent/plan..will commit suicide… suicide…you must be careful to document what your patients changes in behavior

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SUPPORT DEMONSTRATE CONCERN „ ESTABLISH CONTRACT „ ↑ DECISION MAKING „ STRENGTHS – KEY TO LIVING „ PROTECTION „ OFFER COMMUNITY SUPPORT

Mental Health and Aging Objectives: 1. 2. 3. 4. 5. 6.

By the end of this learning experience, the student will be able to:

Differentiate the persons who society identifies as elderly. Review and discuss the aging process. State key physiological, behavioral and psychosocial changes in the elderly person. Identify health teaching strategies that enhance positive adaptation to aging. Discuss the common psychiatric disorders affecting the elderly population. Express feelings about growing older in relation to personal experiences.

Critical Thinking Activity: CASE STUDY: Lillian is an eighty year old woman who has been a widow for 10 years. She has been very independent for most of her life. She raised her two young children while her husband was enlisted in the Army during W.W.II, learned how to paint portraits and teach others the art and was a champion at crossword puzzles. In the last few years, Lillian’s children and grandchildren began to notice her becoming forgetful and repeating the same stories over and over. They also found her to be disinterested in her crossword puzzles. She painted, now and then, but only at the request of a family member or friend. Just last week she failed to show up at her Doctor’s office for her Flu shot, then missed lunch with her granddaughter. The family was becoming quite concerned. Finally, a neighbor called her son and informed him his mother was in his living room and didn’t seem to know who he was or where she was. The family and the attending physician decided to place Lillian in the hospital, where she was admitted to the geropsychiatric unit.

1.

What relevant assessment data can you gather from the above case study?

2.

What are the two priority nursing diagnoses for Lillian?

3.

Describe two nursing interventions for the nursing diagnoses above.

4.

Describe relevant outcome criteria for evaluating the nursing care for Lillian.

Cognitive Disorders Objectives; 1. 2. 3. 4. 5. 6. 7.

By the end of this learning experience, the student will be able to: Define the term cognitive mental disorder. Describe the incidence and significance of cognitive mental disorders. Discuss the probable etiologies of cognitive disorders. Explain the behaviors related to specific cognitive disorders. Apply the nursing process to a patient with cognitive disorder. Identify key communication techniques used when caring for an elderly patient with a cognitive disorder. State 3 community resources available to the elder experiencing a cognitive or organic brain disorder.

Critical Thinking Activity: (Adapted from Townsend, 1993) Circle the following cognitive (organic mental) disorders as acute or chronic (A or C) and reversible or irreversible (R or I). Primary Degenerative Dementia; the Alzheimer type

A

C

R

I

Multi-Infarct Dementia

A

C

R

I

Alcohol-Induced Withdrawal

A

C

R

I

Nicotine-Induced Withdrawal

A

C

R

I

Alcohol-Induced Delirium

A

C

R

I

Alcohol-Induced Dementia

A

C

R

I

Dementia with uncontrolled epilepsy

A

C

R

I

PCP-Induced Hallucinations

A

C

R

I

Organic Mood Disorder related to amphetamine withdrawal

A

C

R

I

Delirium associated with inhalant intoxication

A

C

R

I

CURRENT STATISTICS The older population (65+) numbered 35.0 million in 2000 (the most recent year for which data are available), an increase of 3.7 million or 12.0% since 1990 About one in every eight, or 12.4 percent, of the population is an older American More ………

And… And…. About 3.4 million older persons lived below the poverty level in 2001. The poverty rate for persons 65+ continued at a historically low rate of 10.1 percent. Another 2.2 million older adults were classified as "near poor" (income between poverty level and 125 percent of this level

Normal Changes – Helping the Elder to Adapt PHYSIOLOGICAL What are the normal physiological changes that occur with aging?

Persons reaching age 65 have an average life expectancy of an additional 17.89 years (19.2 years for females and 16.30 years for males) Half of older women age 75+ live alone Almost 400,000 grandparents aged 65 or more had the primary responsibility for their grandchildren who lived with them By the year 2030, the older population will more than double to about 70 million

MENTAL HEALTH AND THE ELDERLY 18 –25% suffer a mental illness Psychosis ↑ significantly after 65 Suicide is more frequent Prevalence of Senile Dementia 15% of those with chronic physical problems will have an accompanying Axis I diagnoses; most likely depression or anxiety

The RN will help the elder learn to adapt and cope with these changes by… by…

Teaching:

– This is a normal process: Decreases, deteriorates and looses – Ways to maintain physiological integrity through diet and exercise

Š Š Š Š

Continued… Continued… TEACH Memory preservation Socialization Negative coping; dangers of substances even prescribed meds

ORGANIC BRAIN DISORDERS DEFINED AKA Organic Mental Disorder or now known as…………… as…………… Cognitive Disorder

Losses Isolation Anxiety Negative coping

COMMON DISORDERS DEPRESSION: Geriatric Depression Scale SUICIDIALITY: Remember the statistics SUBSTANCE ABUSE: Negative coping (isolation) SUNDOWNING NEED TO RESTRAINT DUE TO CONFUSION (DELERIUM OR DEMENTIA)

DELERIUM A state of cognitive impairment and confusion usually of recent onset related to another illness or stressor

VS.

DEMENTIA

An irreversible state of cognitive impairment and short term memory loss related to organic brain disease most commonly Alzheimer's disease or multiple cerebral infarcts.

COGNITIVE DISORDERS Abnormal psychological or behavioral signs and symptoms in which the origin lies in a medically identified cerebral disease or dysfunction (Detwiler (Detwiler,, 1993). Varcarolis (1998) states, “disturbances in orientation, memory, intellect, judgment, and affect due to physiological changes in the brain. Delirium and dementia are examples of two cognitive impairment syndromes” syndromes”.

ETIOLOGY OF COGNITIVE D/O

INCIDENCE

The U.S. Congress Office of Technology Assessment estimates that 1.8 million Americans have severe dementia and another 1 to 5 million Americans have mild to moderate dementia. According to the Alzheimer’s Association, approximately 4 million of these people are afflicted with Alzheimer’s disease. By the year 2040, the number of persons with Alzheimer’s disease may exceed 6 million. The prevalence of Alzheimer's disease doubles every five years after age 65, and nearly half of all people age 85 and older are thought to have some form of dementia.

COMMOM BEHAVIORS ASSOCIATED WITH COGNITIVE D/O Sensorium and Attention:

DELERIUM; drug induced DEMENTIA; Alzheimer’ Alzheimer’s Disease vs. Korsakoff’ Korsakoff’s syndrome AMNESIA; loss of memory due to injury or illness

PERCEPTUAL – Hallucinations and delusions

MEMORY – Impaired Short Term > Long Term

DEGENERATIVE – ↓ in brain tissue is irreversible – Remember neurons do not regenerate

– Mood changes rapidly, accompanied by physical behaviors – ↓ concentration

Disorientation – Makes interview complicated

See next slide… slide…

NURSING PROCESS ASSESSMENT – Diagnostics MRI SPECT** nuclear imaging – blood flow PET ** nuclear imaging – brain activity

– Mental status exam – Physical exam – Labs – used to rule out other causes

NURSING DIAGNOSES BEGIN WITH THE HIGHEST PRIORITY – Risk for Injury Pt. Will remain safe

– Fluid Volume Deficit Adequate hydration

– Sleep Pattern Disturbance Need adequate sleep; regular

PLANNING AND INTERVENTION SAFETY HEALTH MAINTENANCE FAMILY SOCIALIZATION/INDEPENDENCE COMMUNICATION (SEE SYLLABUS) COMMUNITY RESOURCES

More… More… Altered Thought Processes – Validation and Reminiscence vs. Orientation to person, place, time

Altered Family Coping – Respite

Objectives: 1. 2. 3. 4. 5. 6. 7.

Schizophrenia By the end of this learning experience, the student will be able to: Define schizophrenia. Identify the predisposing factors of schizophrenia. State the types of schizophrenia. Describe the behaviors of the schizophrenic patient and use this information in patient assessment. Describe effective interventions for thought, affective and social/behavioral disturbances. Describe the impact of a schizophrenic member on the family, community and society. Discuss personal feelings and attitudes about caring for a schizophrenic patient.

Critical Thinking Activity: Schizophrenia Types Paranoid

Catatonic

Schizoaffective

Perceptions

Complete the table below Behaviors

Thoughts

Speech Patterns

Known Facts 1. Cause is basically unknown:

Theories suggest multicausal factors. 2. Treatment is comprehensive utilizing a multidisciplinary team. 3. The most feared mental illness, costs are high due to lengthy hospitalizations, family chaos results. 4. Severe deterioration of social and occupational functioning. 5. Estimated approximately 1% of population will develop this disorder.

MORE FACTS: •Schizophrenia is a disease that strikes young people in their prime •The disease distorts the senses, making it very difficult for the individual to tell what is real from what is not real •Usual age of onset is between 16 and 25. •Schizophrenia is a medical illness. Period

PREDISPOSING FACTORS •Schizophrenia is found all over the world -- in all races, in all cultures and in all social classes •It affects 1 in 100 people worldwide. •For men, the age of onset for schizophrenia is often ages 16 to 20 •For women, the age of onset is sometimes later -- ages 20 to 30

WHAT’S THE CURENT THEORY? • Genetic vulnerability/ environmental contributors • Developmental disorder • Abnormal brain structures

CURRENT RESEARCH

PREDISPOSING FACTORS • BIOCHEMICAL: – Dopamine – Glutamate – another excitatory neurotransmitter

• PHYSIOLOGICAL – Stress – Viral

• Psychological – Our friend Freud • Environmental – Family “Scapegoat”

Utilizing increasingly precise imaging techniques, scientists are studying the structure and function of the living brain. New molecular tools and modern statistical analyses are enabling researchers to close in on the particular genes that affect brain development or brain circuitry involved in schizophrenia. Scientists are continuing to investigate possible prenatal factors, including infections, which may affect brain development and contribute to the development of schizophrenia.

Common Observations THE 4 “A”s 1. Autism „ Creating one’s own world and reality

2. Associated Looseness „ Confused thinking and illogical speech

3. Affect

WHEN IS POSITIVE IS NEGATIVE? • Positive symptoms of Schizophrenia • “Positive” refers to having overt symptoms that should not be there • "psychotic" symptoms, include delusions and hallucinations

„ Flat, blunted, inappropriate or bizarre

4. Ambivalence „ Emotional Apathy

• Delusions cause the patient to believe that people are reading their thoughts or plotting against them, that others are secretly monitoring and threatening them, or that they can control other people's minds. • Hallucinations cause people to hear or see things that are not there.

NEGATIVE SYMPTOMS • Flatness or lack of expression • An inability to start and follow through with activities • Speech that is brief and lacks content • Lack of pleasure or interest in life. • "Negative" does not, therefore, refer to a person's attitude, but to a lack of certain characteristics that should be there.

And…. Cognitive? • Confused thinking and speech • Trouble communicating in coherent sentences or carrying on conversations with others • Limited attention span • Difficulty making sense of everyday sights, sounds and feelings • BUT, SCHIZOPHRENIA IS NOT A COGNITIVE D/O, IT IS A THOUGHT DISORDER

TYPES • Catatonic – disturbances in movement

• Paranoid – presence of auditory hallucinations or prominent delusional thoughts about persecution or conspiracy

• Schizoaffective – both severe mood swings (mania and/or depression), and some of the psychotic symptoms of schizophrenia

TYPES • Induced Psychotic Disorder – A delusional system develops in the context of a close relationship with another person who already has a psychotic disorder….very interesting isn’t it??

– C/O “mind wandering” – consumed with thoughts – Misinterprets the environment – Begins to suffer from rejection, lack of self-respect, loneliness, feelings of hopelessness – Odd mannerisms – Hallucinations = withdraws from reality

More to assess… • PERCEPTION – Hallucinations; sensory

• AFFECT – Flat, inappropriate

• SENSE OF SELF – Loss of ego boundaries – Derealization

• IMPAIRED INTERPERSONAL FUNCTIONING – Withdrawn – Isolation

NURSING PROCESS ASSESSMENT • PRODROMAL SYMPTOMS – these occur 1 month to 1 year prior to the first psychotic break – Withdrawn, lonely depressed – Vague plans for the future, difficulty concentrating at work or school – May begin with anxieties, phobias or obsessions

What does the nurse assess? • CONTENT OF THOUGHT – Delusions – Concrete thinking – Magical thinking

• FORM OF THOUGHT – through speech – Looseness of Association – Neologisms – Clang words – Echolalia

Still more…. • PSYCHOMOTOR BEHAVIOR – Bizarre – Agitated – Violent = based on voice commands

• OTHER • ↑ water intake – intoxication • Substance abuse

NURSING DIAGNOSES • Violence; directed at self and others • Alteration in thought.. • What else????

INTERVENTIONS • • • • • •

DETECTIVE WORK REALITY HALLUCINATIONS FAMILY INCLUSION THERAPIES PREVENTION

• TYPICAL – OLDER MEDS – Target the positive sx.s – ↑ EPS – NMS – Decononate = longer acting • ATYPICAL – NEW MEDS – Target positive and some negative sx.s – Less side effects

PLANNING • Multidisciplinary – Social services • Family and patient – Psychiatrist – Nurse – Mental health worker – Pharmacist… • Short and long term goals based on; safety, knowledge and coping

THE MEDS • Neuroleptics are the principle drugs used to treat schizophrenia. However, other drugs may be used for anxiety, inability to sleep, depression, cycling mood, and to counteract the main drug's unwanted effects • approximately 30 neuroleptics used in North America

Personality Disorders Objectives: 1. 2. 3. 4. 5. 6.

By the end of this learning experience, the student will be able to: Differentiate Personality and Personality Disorder. After completing the Pre-test, state the various key terms associated with personality disorders and their definitions. Identify where personality disorders fit on the Mental Health continuum. Discuss clustering and the dynamics of selected personality disorders. Analyze the typical behavior patterns common to all personality disorders. Apply the nursing process to the care of a patient with a selected personality disorder.

Critical Thinking Activity: Match the personality disorder most commonly associated with the behaviors described on the right. _____

1.

Paranoid

a.

shows no remorse for exploitation and manipulation of others.

_____ _____

2. 3.

Schizoid Schizotypical

b.

accepts a job he doesn’t want to do, then does a poor job and delays past the deadline.

_____

4.

Antisocial

c.

_____

5.

Borderline

d.

believes she is entitled to special privileges others do not deserve. They are suspicious of all others with whom they come in contact.

_____

6.

Histrionic

_____

7.

Narcissistic

e.

Swallows a bottle of pills after therapist leaves on vacation.

_____

8.

Avoidant f.

Believes he has a “sixth sense” and know what others are thinking.

_____

9.

Dependent

_____

10.

Obsessive/Compulsive

g.

Allows others to make all her important decisions for her.

_____

11.

Passive aggressive

h.

Refuses to enter into a relationship due to fear of rejection

.i.

Demonstrates highly emotional and overly dramatic behaviors.

k.

Believes everyone must follow the rules and that the rules can be “bent” for no one.....ever.

j.

Has a lifelong pattern of social withdrawal.

PERSONALITY DISORDER Cluster A: PARANOID

PERCEPTION

COGNITION

AFFECT

•

•

•

•

• • •

•

Acute and intense Hones in on clues and real meanings in other’s life events Unexpected events = threat Others = dishonest, out to get them Self = self sufficient, objective, rational, emotionally balanced and very independent Inflated self value to cover up low self esteem

• • •

•

Ideas of reference = misinterprets trivial events to fit grandiose self Persecutory, collects injusts Critical of others Can’t handle criticism = betrayal, jealousy and envy TOTAL LACK OF TRUST

• • •

Prepared for attack On edge Distant and secretive Verbal testing of others trustworthiness

BEHAVIOR DISTURBANCE • Argumentative • sarcastic • complaining • aloof, quietly hostile

LEVEL OF ADAPTATION • Life long adaptation problems • Can have some remissions with decreased anxiety

Cluster B: ANTISOCIAL

• • • •

•

Sees others and world as hostile and harmful Undermines others Expects malice, humiliation and betrayal Sees self as super independent, assertive, self sufficient and tough, competitive, powerful and superior Rejects attributes of warmth and caring

• • • •

•

“Might makes right” Beat others to the punch Others are evil Entitled to outwit sham or punish adversaries Rigid, dogmatic and cunning

• •

•

Hostile, punitive and vengeful Uses projection; mistrusts others especially those who are warm and caring Anxious when can’t get rid of threatening people

• •

• • • •

Cold, callous and insensitive Gracious and cheerful without warmth or compassion Thrill seeking from boredom Aggressive sexual behavior Vandal Explosive behavior

•

• • •

Best adapted in business, politics and military Usually harsh and punishing as parents Seldom seeks mental health services Little progress when in help

Cluster B: BORDERLINE

•

• •

Perceives others • as either good or bad SPLITTING Lacks a clear self view Identity • disturbance; self-image, sexual orientation, • social and work roles

Cognitive confusion; secondary to shifting beliefs regarding all good and all bad Fail to learn from life experiences Little problem solving abilities

•

•

• • • • • •

Unstable → Normal → Anger → Normal Intensity of affect; anger, loneliness, emptiness, impatient Fear of loss and abandonment Intense, long depressions Entitled to special privileges scattered Life meaning from others External locus of control

• • • • • • • •

Extra spending Sexual promiscuity food and drugs Lying and stealing Self mutilation Manipulation, whining and self criticism Evokes anger in others Seldom assaultive, though intimidating

• • • • • •

•

Series of beginnings and ends Numerous relationships School and work record changes Drastic lifestyle changes Seldom realizes full potential Many see Mental Health services; depression, psychosis or suicide Difficult to adapt

Cluster C: OBSESSIVECOMPULSIVE

•

•

Inattention to new information or different viewpoint Sharp focusselect detail

• •

•

Rigid thinking; rules, rules rules Intellectual rigidity = unable to change topics Rules, standard, codes, moralities or legalist “dogmatic”

• • •

•

Anxious and ambivalent Forbidden emotions and impulses Fixed belief (lack of sense of humor affection lust) Resents others

• • • • • • • •

Stubbornness Conformity and obedience Excessive Neat and Clean Controlling Insist on “the right way” Cold, self centered demanding pack rat

• • • •

Adaptive in some settings Ideal efficient worker Not drawn to therapy therapy only if stress overwhelms coping; presents with symptoms of anxiety, sexual problems, exhaustion and depression

PERSONALITY The evolution of an individual’ individual’s pattern of thinking, perceiving and experiencing. The patterns develop early in childhood and become lifelong patterns of behavior, determining whether an individual is liked, how one is judged by others and what the individual’ individual’s goals and accomplishments are in life.

How does one become diagnosed with a personality disorder??? To diagnose requires evaluation of long term functioning. More than one interview is needed, in fact several will occur over a time period. Common Axis I diagnoses accompanying a personality disorder; mood, anxiety, psychotic, eating or substance abuse disorders.

When does personality become a disorder??? When personality traits are inflexible and maladaptive and significantly impair social or occupational functioning. Individuals with personality disorders demonstrate disturbances in perceptual, cognitive, affective, and behavioral functioning.

COMMON CHARACTERISTICS Inflexible and maladaptive response Disability in working and loving „ Ability to evoke interpersonal conflict „ Capacity to “get under the skin” skin” of others „ „

ETIOLOGY: Biochemical Are we born with a preexisting temperament? „ Studies are looking at identified personality traits of infants and determining if these are precursors to development of personality disorders „

ETIOLOGY: Biochemical Biological studies have not found any close genetic link/family inheritance for personality disorders „ Have found that there is an ↑ potential for a person living in a family with a member who has a personality disorder… disorder…suggesting learning theory „

ETIOLOGY: Chronic Trauma

ETIOLOGY: Psychodynamic

Persistent denial Belief that everyone has the same type of issues „ Becomes disconnected from emotions „ Results in manipulation and power struggles in relationships „ If a close relationship is established the person feels closed in – a “captive” captive”

„

„ „

PHYSICAL - behaviors EMOTIONAL - affect „ COGNITIVE – thoughts, perceptions, problem solving skills „ SOCIAL – relationships, impulsive acts, legal system „ SPIRITUAL – belief about life; higher power… power… „ „

Lots of issues buried in the unconscious mind: repression… repression…as well as suppression and add in a fair amount of regression „ Treatment involves understanding the patient’ patient’s perspective; helps the patient to view the disorder realistically; improves relationships; corrects the maladaptive responses

CLUSTERING THE PERSONALITY DISORDERS CLUSTER A CLUSTER B CLUSTER C Let’s take a look….

Splitting – all good vs. all bad Projection – fault finding, blame „ Passive aggressive – indirect expression of anger „ Acting out – direct expression of feelings through behavior „ Narcissism – self love “better than others” others” „ Dependency – unreasonable expectations of others „ No win relationships – relationships go no where

ASSESSMENT CONTINUED

„ „

A NURSE MUST CONSIDER THE DOMAINS PHYSICAL EMOTIONAL „ COGNITIVE „ SOCIAL „ SPIRITUAL „ „

PLANNING AND INTERVENTION

NURSING DIAGNOSES High risk for Violence; self and others „ Self Mutilation „ Defensive Coping „ SelfSelf-Esteem Disturbance „ Impaired Social Interaction „ Knowledge Deficit „

SELF AWARENESS: be aware of your emotion and potential to become frustrated „ TRUST: Develop, respect, congruence „ CONTERPOJECTION: Point out blaming „ TIMETIME-OUT: From the 1:1 if needed „ CONFORNTATION: ASAP - behavior „ LIMIT SETTING: Consistent , like a broken record! Continuity between staff „

Are meds ever used???

EVALUATION

Nothing out there for the Personality Disorder itself… itself…just meds for Axis I and III „ Moods; antidepressants, lithium, anticonvulsants „ Anxiety; anxiolytics, anxiolytics, anticonvulsants „ Violent behavior; antipsychotics, antipsychotics, may use beta blocking agents

„

„

Remember, we all have personalities and these have been with us a very long time… time…undoing nonnon-productive personality traits takes a great deal of understanding, patience and persistence on both the patient’ patient’s and nurses’ nurses’ part… part….good luck…… luck……

Dealing with Escalating Behavior Objectives By the end of this learning experience, the student will be able to: 1. 2. 3. 4. 5. 6.

Differentiate between hostility, anger, aggression and suspicion. Compare the theories of aggression. Describe the verbal and nonverbal clues significant in the assessment of an aggressive patient. Apply the nursing process to patients who demonstrate suspicious, hostile or aggressive behaviors. Explain the “Rule of Five”. Analyze the escalation of a patient who is acting out and may become assaultive.

Critical Thinking Activity: List five nonverbal and five verbal clues you have been exposed to in your personal life that indicated to you someone is demonstrating (or about to demonstrate) aggressive behavior.

Define the following…give examples

ETIOLOGY – give examples for each theoretical area

„

Aggression Hostility „ Suspicion „ Anger

„

„

„

Psychological Biological „ Physiological „ Genetic „ Sociocultural

ADAPTIVE/MALADAPTIVE IN HANDLING STRESS

↑

↓ Anxiety

ANXIETY Primitive Behaviors

Assess factors related to Aggression/Assaultive Behavior Personal: Hx. Of violence, child abuse, family psych. disorders ‹ Social: Frustration, direct provocation, exposure to violence ‹ Situational: ↑physiological arousal, pain, erotica (abuse in nature) ‹ Environmental: Noise, heat, crowds, smog ‹

Adaptive Problem Solving STRESS

„

Destructive Relief Behaviors

MORE TO ASSESS „

Assess factors related to Aggression/Assaultive Behavior Personal: Hx. Of violence, child abuse, family psych. disorders ‹ Social: Frustration, direct provocation, exposure to violence ‹ Situational: ↑physiological arousal, pain, erotica (abuse in nature) ‹ Environmental: Noise, heat, crowds, smog ‹

VERBAL CLUES ‹ Name some of these NONVERBAL CLUES ‹ Name some of these CLUES TO ESCALATION ‹ How do you know someone is about to “go off?” off?” ‹ Take a look at the next page in your syllabus

NURSING DIAGNOSIS AND PLANNING „ „

Assaultive Aggressive ‹ Frustration - Powerlessness ‹ Low self esteem

INTERVENTIONS continued.. „

Medications ‹ Anxiolytic ‹ Neuroleptic ‹ Lithium ‹ Anticonvulsant ‹ Beta Blocker

INTERVENTIONS Important to set limits Positive interventions – list some „ Negative interventions – list some „ Restraint/seclusion ‹ It is about safety „ „

THERAPEUTIC COMMUNICATION Talking works Calm but direct „ √ your feelings „ Minimize your gestures „ Lower your voice „ Be respectful „ RULE OF FIVE ‹ What is that?????????????????? „ „