NUR 201 MODULE C

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NUR 201MODULE C

• INTRODUCTION TO MENTAL HEALTH CONCEPTS AND ISSUES

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MENTAL HEALTH VS. MENTAL ILLNESS

• The concepts of mental health and mental illness
  are culturally defined.
• Individuals experience both physical and
  psychological responses to stress.

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MENTAL HEALTH

• Maslow identified
• A hierarchy of needs
• Self-actualization as fulfillment of ones
  highest potential
• Defined as The successful adaptation to
  stressors from the internal or external
  environment, evidenced by thoughts, feelings, and
  behaviors that are age-appropriate and congruent
  with local and cultural norms.

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MENTAL ILLNESS

• Defined as Maladaptive responses to stressors
  from the internal or external environment,
  evidenced by thoughts, feelings, and behaviors
  that are incongruent with the local and cultural
  norms and interfere with the individuals social,
  occupational, or physical functioning.

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MENTAL ILLNESS (cont)

• Horwitz describes cultural influences that affect
  how individuals view mental illness. These
  include
• Incomprehensibility
• Cultural relativity

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PHYSICAL RESPONSE

• Hans Selye defined stress as the state
  manifested by a specific syndrome which consists
  of all the nonspecifically induced changes within
  a biologic system.
• Selyes General Adaptation Syndrome
• The Fight-or-Flight Syndrome
• Sustained physical responses to stress promote
  susceptibility to diseases of adaptation

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PSYCHOLOGICAL RESPONSES

• Anxiety and grief
• A variety of thoughts, feelings, and behaviors
• Adaptation

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PSYCHOLOGICAL RESPONSES (CONT.)

• Peplaus four levels of anxiety
• Mild - seldom a problem
• Moderate - perceptual field diminishes
• Severe - perceptual field is so diminished that
  concentration centers on one detail only or on
  many extraneous details
• Panic - the most intense state

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PSYCHOLOGICAL RESPONSES (CONT.)

• Behavioral adaptation responses to anxiety
• At the mild level
• At the mild to moderate level

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PSYCHOLOGICAL RESPONSES (CONT.)

• defense mechanisms

• Compensation
• Denial
• Displacement
• Identification
• Intellectualization
• Introjection
• Isolation
• Projection

• Rationalization
• Reaction formation
• Regression
• Repression
• Sublimation
• Suppression
• Undoing

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PSYCHOLOGICAL RESPONSES (cont)

• Anxiety at the moderate to severe level
• Extended periods of functioning at the panic
  level of anxiety

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PSYCHOLOGICAL RESPONSES (CONT.)

• Grief
• The subjective state of emotional, physical, and
  social responses to the loss of a valued entity
  the loss may be real or perceived.
• Elisabeth Kübler-Ross
• (5 Stages of Grief)
• Maladaptive grief responses

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MENTAL ILLNESS THROUGH THE AGES

• EVIL SPIRITS DEMONS
• WILDERNESS TO FEND FOR THEMSELVES
• RATIONAL THEORIES OF GREEKS
• DEMONS LUNACY
• SUPERTITIONS, WITCHES, BURNING
• LUNATIC ASYLUM
• BRAIN DISORDER VS DEMONS
• CRUEL, HARSH TREATMENT

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EMERGENCE OF MENTAL HEALTH

• PHILIPPE PINEL
• DOROTHEA DIX
• DR. BENJAMIN RUSH
• CLIFFORD BEERS

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IMPACT OF WWs I II

• Need for mental health services
• National Committee for Mental Hygiene in 1917
• National Mental Health act 1946
• Funds for research, training and treatment for
  mental illness

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PSYCHOTHERAPEUTIC DRUGS

• Drugs affecting the mind
• Alters emotions, perceptions, consciousness
• Psychopharmacologic agents, psychoactive,
  psychotropic
• Lithium carbonate in 1949
• Thorazine in 1956
• Imipramine
• Late 50s/early 60s antianxiety (Valium)

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DEINSTITUTIONALIZATION

• 1950s half of hospital beds in U. S. were psych
  beds
• Psychotherapeutic drugs assisted people in
  controlling behavior
• Persons were then discharged from mental
  institutions
• Least restrictive alternative

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COMMUNITY MENTAL HEALTH CENTER

• 1961 Joint Commission on Mental Health
• 1963 Congress passed Community Mental Health
  Centers Act
• 1965 Medicare/Medicaid bill
• Along with Mental Health Centers act
• 75 of institutionalized persons were discharged
• Communities not ready
• 1970s funding cut
• 1975 Congress passed amendments for funding
  community mental health centers

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OMNIBUS BUDGET RECONCILIATION ACT

• 1981
• Repealed Mental Health System Act
• Block grant funding each state received a
  designated amount of money
• Many states not committed to mental health

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OMNIBUS BUDGET REFORM ACT

• 1987
• Decrease inappropriate placement of chronically
  mentally ill
• Persons discharged from nursing homes etc
  sometimes to the streets.
• Funding for mental health care has continued to
  decrease

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INPATIENT PSYCH CARE

• SAFE ENVIRONMENT
• FOCUSES ON WORKING WITH PROBLEMS
• CONTINUED EMOTIONAL SUPPORT
• INTENSIVE INPATIENT THERAPY
• MONITORING TREATMENT, MEDICATIONS
• OPPORTUNITIES FOR RESOLVING INTERPERSONAL ISSUES
• NEW COPING SKILLS TRIED
• DETOX FROM CHEMICALS

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OUTPATIENT CARE

• ALLOWS MENTALLY ILL PERSONS TO LIVE AND WORK
  WITHIN THEIR OWN COMMUNITIES WITHIN A LEAST
  RESTRICTIVE SETTING

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MENTAL HEALTH ADMISSIONS

• VOLUNTARYCLIENT ORIGINATES OR AGREES WITH
• INVOLUNTARY ADMISSION PROCESS IS INITIATED BY
  SOMEONE OTHER THAN THE CLIENT

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SETTINGS

• COMMUNITY HOSPITAL EMERGENCY ROOMS
• RESIDENTIAL PROGRAMS
• PARTIAL HOSPITALIZATION PROGRAMS
• PSYCHIATRIC HOME CARE VISITS
• COMMUNITY MENTAL HEALTH CENTERS

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CULTURAL INFLUENCES ON MENTAL HEALTH AND MENTAL
ILLNESS

• A way of life
• The learned pattern of behavior that shapes an
  individuals thinking and that serves as the
  basis for ones social, religious, and family
  structure.
• A shared system of values that helps provide the
  framework for who we are

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Ethnicity

• The socialization patterns, customs, and cultural
  habits
• Ethnic groups play important roles in preserving
  cultures
• Values, traditions, expectations, and customs
• Help people form relationships
• Provide established guidelines for living
• Function as focal points
• Ethnicity helps establish ones point of view

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Religion

• Relates to a defined, organized, and practiced
  system of worship
• The values of religious groups range from those
  that allow for individual variation to those that
  require a commitment to place the religion before
  family, work, or friends

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Stereotyping Mental Health Clients

• Stereotype an oversimplified mental picture of
  a cultural group
• Extreme form of negative stereotyping is
  prejudice
• Traditional stereotyping assumes that all
  members of a culture behave in a certain manner
  or are a certain way

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Six Components of Cultural Assessment

• Communication
• Space
• Social organization
• Time
• Environmental control
• Biological variations

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Nursing Diagnoses

• Altered Health Maintenance
• Ineffective Management of Therapeutic Regimen
• Impaired Thought Processes
• Fear
• Anxiety
• Powerlessness
• Self-esteem Disturbance
• Impaired Coping
• Social Isolation

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NURSING PROCESS

• Expected outcomes and goals are developed with
  cultural preferences in mind
• Nursing care is formulated and then communicated
  by means of a written care plan
• Implementation includes actual delivery of the
  planned nursing actions.
• Client responses to care are assessed.
• Many nursing actions are culturally significant
  to the client
• Open mind is needed when observing clients
  responses
• Many reactions are culturally determined

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DSM-IVTR MULTIAXIAL EVALUATION SYSTEM

• Axis I - Clinical disorders and other conditions
• that may be a focus of clinical
  attention
• Axis II - Personality disorders and mental
• retardation
• Axis III - General medical conditions
• Axis IV - Psychosocial and environmental
• problems
• Axis V - The measurement of an individuals
• psychological, social, and
• occupational functioning on
  the GAF
• Scale

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Multidisciplinary Mental Health Team

• Main purpose
• Psychiatrists, social workers, psychologists,
  nurses and others
• Develop comprehensive therapeutic plans
• Cost-effective
• Clients and significant others contribute to the
  plan of care
• Remain actively involved
• Interdisciplinary mental health care team

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Health team members and their roles

• Psychiatrist
• Clinical Psychologist
• Psychiatric Clinical Nurse Specialist
• Psychiatric Nurse
• Mental Health Technician
• Psychiatric Social Worker

• Occupational Therapist
• Recreational Therapist
• Music Therapist
• Art Therapist
• Dietician
• Chaplain

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LEGAL AND ETHICAL ISSUES

• Ethics
• Bioethics
• Moral behavior
• Values
• Values clarification
• Right
• Absolute right
• Legal right

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ETHICAL CONSIDERATIONS

• Theoretical perspectives
• Utilitarianism
• Kantianism
• Christian ethics
• Natural law theories
• Ethical egoism

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ETHICAL DELIMMAS

• Ethical dilemmas occur when moral appeals can be
  made for taking either of two opposing courses of
  action.
• Taking no action is considered an action taken.

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ETHICAL PRINCIPLES

• Autonomy
• Beneficence
• Nonmaleficence
• Justice
• Veracity

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A MODEL FOR MAKING ETHICAL DECESIONS

• Assessment
• Problem identification
• Plan
• Implementation
• Evaluation

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Ethical Issues in Psychiatric/Mental Health
Nursing

• The right to refuse medication
• The right to the least restrictive
• treatment alternative

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LEGAL CONSIDERATIONS

• Nurse Practice Act defines the legal parameters
  of professional and practical nursing
• Types of Laws
• Statutory law
• Common law

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Classifications Within Statutory and Common Law

• Civil Law - protects the private and property
  rights of individuals and businesses
• Torts
• Contracts
• Criminal law - provides protection from conduct
  deemed injurious to the public welfare

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Legal Issues in Psychiatric/Mental Health Nursing

• Confidentiality and right to privacy
• Doctrine of privileged communication
• Informed consent
• Restraints and seclusion
• False imprisonment
• Commitment issues
• Voluntary commitment
• Involuntary commitment
• Emergency commitment
• The mentally ill person in need of treatment
• Involuntary outpatient commitment
• The gravely disabled client

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Legal Issues in Psychiatric/Mental Health Nursing
(cont.)

• Malpractice and negligence
• Types of lawsuits that occur in psychiatric
  nursing
• Breach of confidentiality
• Defamation of character
• Libel
• Slander
• Invasion of privacy
• Assault and battery
• False imprisonment

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LEAST RESTRICTIVE ALTERNATIVE

• Providing mental health in the least restrictive
  environment.
• Utilizing the least restrictive treatment.
• Must look at alternatives such as day treatment,
  group home, home health etc.
• Application of protective devices and restrains
  may constitute false imprisonment.
• Must be used only to protect the client/others
  and as a last alternative.

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RESTRAINTS

• Physical and chemical
• Documentation of other interventions and their
  lack of success r/t safety
• Written orderif ER situation, verbal order may
  be obtained, then written within 4-8 hours.
• Q15 min checks
• Bathroom, exercise of limbs, offer liquids etc
  q2h
• Released as soon as behavior under control

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Nursing Actions to Avoid Liability

• Responding to the patient
• Educating the patient
• Complying with the standard of care
• Supervising care
• Adhering to the nursing process
• Documentation
• Follow-up

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THERAPUTIC RELATIONSHIPS

• The nurse-client relationship
• The therapeutic interpersonal relationship
• Therapeutic use of self
• Interpersonal communication techniques

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The Therapeutic Nurse-Client Relationship

• Therapeutic nurse-client relationships .
• Therapeutic relationships are goal
• Identify the clients problem.
• Promote discussion of desired changes.
• Discuss aspects that cannot realistically be
  changed and ways to cope with them more
  adaptively.
• Discuss alternative strategies for creating
  changes the client desires to make.

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The Therapeutic Nurse-Client Relationship (cont)

• Weigh benefits and consequences of each
  alternative.
• Help client select an alternative.
• Encourage client to implement the change.
• Provide positive feedback for clients attempts
  to create change.
• Help client evaluate outcomes of the change and
  make modifications as required.

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THEORIES

• Personality
• Life-cycle develop mentalists
• Stages are identified by age.
• It is possible for behaviors from an
  unsuccessfully completed stage to be modified and
  corrected in a later stage.
• Stages overlap, and individuals may be working on
  tasks from more than one stage at a time.
• Individuals may become fixed in a certain stage
  and remain developmentally delayed.

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THEROIES (cont.)

• The DSM-IV-TR states that personality disorders
  occur when personality traits become inflexible
  and maladaptive, causing either significant
  functional impairment or subjective distress.

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Psychoanalytic Theory Freud

• Freud believed basic character was formed by age
  5 years.
• He organized the structure of the personality
  into three major components
• Id
• Ego
• Superego
• Topography of the Mind
• The conscious
• The preconscious
• The unconscious

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Psychoanalytic Theory Freud (cont.)

• Dynamics of the personality
• Psychic energy
• Cathexis
• Anticathexis
• Development of the personality
• Oral stage (birth to 18 months)
• Anal stage (18 months to 3 years)
• Phallic stage (3 6 years)
• Latency stage (6 12 years)
• Genital stage (13 20 years)

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Interpersonal Theory Sullivan

• Based on the belief that individual behavior and
  personality development are the direct result of
  interpersonal relationships
• Major concepts of this theory
• Anxiety
• Satisfaction of needs
• Interpersonal security
• Self-system

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Interpersonal Theory Sullivan (cont.)

• Stages of development
• Infancy (birth - 18 months)
• Childhood (18 months 6 years)
• Juvenile (6 - 9 years)
• Preadolescence (9 12 years)
• Early adolescence (12 14 years)
• Late adolescence (14 21 years)

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Theory of Psychosocial Development Erikson

• Stages of Development
• Trust vs Mistrust (birth - 18 months)
• Autonomy vs Shame and Doubt (18 months 3 years)
• Initiative vs Guilt (3 - 6 years)
• Industry vs Inferiority (6 - 12 years)
• Identity vs Role Confusion (12 - 20 years)
• Intimacy vs Isolation (20 - 30 years)
• Generativity vs Stagnation (30 - 65 years)
• Ego Integrity vs Despair (65 years - death)

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Theory of Object Relations Mahler

• Stages of development
• Phase I The Autistic Phase
• Phase II The Symbiotic Phase
• Phase III - Separation-Individuation

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A Nursing Model - Peplau

• Peplau identifies six nursing roles in which
  nurses function to assist individuals in need of
  health services
• Resource person
• Counselor
• Teacher
• Leader
• Technical expert
• Surrogate

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A Nursing Model Peplau (cont.)

• Four stages of personality development
• Stage 1 Learning to count on others
• Stage 2 Learning to delay satisfaction
• Stage 3 Identifying oneself
• Stage 4 Developing skills in participation

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MENTAL HEALTH THERAPY

• BEHAVIORAL THERAPY
• SOMATIC THERAPY
• ECT
• COGNITIVE THERAPY
• ALTERNATIVE AND COMPLEMENTARY THERAPIES
• MILIEU MANAGEMENT
• GROUP THERAPY
• FAMILY THERAPY
• GENOGRAM

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BEHAVIORAL THERAPY

• PAVLOV MODEL OF CLASSICAL CONDITIONING
• SKINNER OPERANT CONDITIONING
• BEHAVIORAL MODIFICATION
• For the program to be successful, the client
• must perceive that he or she is in control of
• the treatment.

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SOMATIC THERAPY

• Electroconvulsive Therapy
• For depression and mania
• Mechanism of action thought to increase levels
  of biogenic amines
• Side effects temporary memory loss and confusion
• Risks mortality permanent memory loss
• brain damage
• Medications pretreatment medication muscle
  relaxant short-acting anesthetic

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COGNITIVE THERAPY

• Cognitive Therapy
• Commonly used in the
• treatment of mood disorders
• Teaches ways to control thought distortions that
  may be a factor in the development and
  maintenance of mood disorders

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ALTERNATIVE AND COMPLEMENTARY THERAPIES

• The connection between mind and body is well
  recognized.
• Allopathic medicine
• Alternative medicine
• Insurance coverage.

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MILIEU THERAPY

• Milieu therapy, or therapeutic community, is
  defined as a scientific structuring of the
  environment to effect behavioral changes and to
  improve the psychological health and functioning
  of the individual.

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GROUP THERAPY TYPES OF GROUPS

• Task groups
• Teaching groups
• Supportive/therapeutic groups

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GROUP THERAPY

• Therapeutic groups vs. group therapy
• Group therapy
• Therapeutic groups
• Leaders of both types of groups must be
  knowledgeable about group process (the way in
  which group members interact with each other) and
  group content (the topic or issue being discussed
  in the group).
• Self-help groups

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Family Therapy

• Involves educating the family about the
• disorder
• Assesses the familys impact on
• maintaining the disorder
• Assists in methods to promote normal
• functioning of the patient
• GENOGRAM

70
CRISIS

• Assumptions on which the concept of crisis is
  based
• Crisis occurs in all individuals at one time or
  another and is not necessarily equated with
  psychopathology.
• Crises are precipitated by specific identifiable
  events.
• Crises are personal by nature.
• Crises are acute, not chronic, and are resolved
  in one way or another within a brief period.
• A crisis situation contains the potential for
  psychological growth or deterioration.

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PHASES IN THE DEVELOPMENT OF CRISIS

• The individual is exposed to a precipitating
  stressor.
• When previous problem-solving techniques do not
  relieve the stressor, anxiety increases further.
• All possible resources, both internal and
  external, are called on to resolve the problem
  and relieve the discomfort.
• If resolution does not occur in previous phases,
  the tension mounts beyond a further threshold or
  its burden increases over time to a breaking
  point. Major disorganization of the individual
  occurs, often with drastic results.

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TYPES OF CRISIS

• Dispositional crisis
• Crisis of anticipated life transitions
• Crisis resulting from traumatic stress
• Maturational/developmental crisis
• Crisis reflecting psychopathology
• Psychiatric emergency

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CRISIS INTERVENTION

• The minimum therapeutic goal of crisis
  intervention is psychological resolution of the
  individuals immediate crisis and restoration to
  at least the level of functioning that existed
  before the crisis period.
• A maximum goal is improvement in functioning
  above the precrisis level.

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Phases of Crisis Intervention The Role of the
Nurse

• Phase 1. Assessment
• Phase 2. Planning of therapeutic intervention
• Phase 3. Intervention
• Phase 4. Evaluation of crisis resolution and
  anticipatory planning.

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Anger/aggression management

• ASSESSMENT
• Anger can be identified by
• a cluster or characteristics
• that include
• Intense distress
• Frowning
• Pacing
• Eyebrow displacement
• Clenched fists

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COGNITIVE DISORDERS

• DELIRIUM
• AMNESTIC
• DEMENTIA

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DELIRIUM

• Symptoms
• Difficulty sustaining and shifting attention
• Extreme distractibility
• Disorganized thinking
• Speech that is rambling, irrelevant,
• pressured, and incoherent

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DELIRIUM (cont)

• Symptoms include autonomic manifestations such as
• Tachycardia
• Sweating
• Flushed face
• Dilated pupils
• Elevated blood pressure

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PREDESPOSING FACTORS

• Delirium due to a General Medical Condition
• Substance-Induced Delirium
• Substance-Intoxication Delirium
• Substance-Withdrawal Delirium
• Delirium due to Multiple Etiologies

80
DEMENTIA

• Symptoms
• Impairment exists in abstract thinking, judgment,
  and impulse control.
• Conventional rules of social conduct are
  disregarded.
• Personal appearance and hygiene are neglected.
• Language may or may not be affected.
• Personality change is common.

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DEMENTIA (cont)

• As the disease progresses, signs include
• Apraxia
• Irritability and moodiness, with sudden
  outbursts over trivial issues
• Inability to care for personal needs
  independently
• Wandering away from the home or
• care setting

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DEMENTIA OF THE ALZHEIMERS TYPE (DAT)

• Etiologies may include
• Acetylcholine alterations
• Accumulation of aluminum in body
• Alterations in the immune system
• Head trauma
• Genetic factors

83
DEMENTIA OF THE ALZHEIMERS TYPE (DAT)

• The progressive nature of symptoms associated
  with DAT has been described according to the
  following stages
• Stage 1. No apparent symptoms
• Stage 2. Forgetfulness
• Stage 3. Early confusion
• Stage 4. Late confusion
• Stage 5. Early dementia
• Stage 6. Middle dementia
• Stage 7. Late dementia

84
VASCULAR DEMENTIA

• Etiologies may include
• Arterial hypertension
• Cerebral emboli
• Cerebral thrombosis

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DEMENTIA (cont)

• DUE TO HIV
• DUE TO HEAD TRAUMA
• DUE TO PARKINSONS DISEASE

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AMNESTIC

• Amnestic disorders are characterized by an
  inability to
• Learn new information despite normal attention
• Recall previously learned
• information
• Other symptoms

87
AMNESTIC (CONT)

• Onset may be acute or insidious, depending on
  underlying pathological process.
• Duration and course may be variable and are
  correlated with extent and severity of the cause

88
AMNESTIC (CONT)

• Amnestic Disorder due to a General Medical
  Condition
• Head trauma
• Cerebrovascular disease
• Cerebral neoplastic disease
• Cerebral anoxia
• Herpes simplex encephalitis
• Poorly controlled insulin-dependent diabetes
• Surgical intervention to the brain

89
AMNESTIC (CONT)

• Substance-Induced Persisting Amnestic Disorder
• Related to the persisting effects of abuse of, or
  exposure to, substances such as
• Alcohol
• Sedatives, hypnotics, and anxiolytics
• Medications (e.g., anticonvulsants, intrathecal
  methotrexate)
• Toxins (e.g., lead, mercury, carbon monoxide,
  organophosphate insecticides, industrial
  solvents)

90
NURSING PROCESS

• The client history Areas of concern to be
  addressed
• Type, frequency, and severity of mood swings
• Personality and behavioral changes
• Catastrophic emotional reactions
• Cognitive changes
• Language difficulties
• History Areas of concern to be addressed
• Orientation to person, place, time, and
  situation
• Appropriateness of social behavior
• Current and past use of medications, drugs,
• and alcohol
• Possible exposure to toxins
• Client and family history of specific illnesses

91
NURSING PROCESS (CONT)

• Physical assessment
• Assessment for diseases of various organ systems
  that can induce confusion, loss of memory, and
  behavioral changes
• Neurological examination to assess mental status,
  alertness, muscle strength, reflexes, sensory
  perception, language skills, and coordination
• Psychological tests to differentiate between
  dementia and pseudodementia (depression)

92
NURSING PROCESS (CONT)

• Diagnostic laboratory evaluations
• Other diagnostic evaluations may include
• Electroencephalogram (EEG)
• Computed tomography (CT) scan
• Positron emission tomography (PET)
• Magnetic resonance imaging (MRI)
• Lumbar puncture to examine cerebrospinal fluid
  (CSF)

93
NURSING DIAGNOSIS

• Risk for trauma related to impairments in
  cognitive and psychomotor functioning
• Risk for suicide related to depressed mood
• Risk for other-directed violence related to
  impairment of impulse control
• Disturbed thought processes related to cerebral
  degeneration
• Low self-esteem related to loss of independent
  functioning
• Self-care deficit related to disorientation,
  confusion, memory deficits

94
OUTCOMES

• The client
• Has not experienced physical injury
• Has not harmed self or others
• Has maintained reality orientation to the best of
  his or her capability
• Discusses positive aspects about self and life
• Fulfills activities of daily living (ADLs) with
  assistance

95
NURSING PROCESS

• Planning and Implementation
• Formulate a plan of care for the client with a
  cognitive disorder
• Nature of the illness
• Management of the illness
• Support services
• EVALUATION
• Based on the accomplishment of outcome criteria

96
TREATMENT MODALITIES

• Dementia
• Primary consideration is given to etiology, with
  focus on identification and resolution of
  potentially reversible processes.
• For cognitive impairment
• Antilirium
• Cogex
• Aricept
• Exelon
• Reminyl
• For agitation, aggression, hallucinations,
  thought disturbances, and wandering
• Risperdal
• Zyprexa
• Seroquel
• Geodon

97
ANXIETY DISORDERS

• GENERALIST ANXIETY DISORDERS
• PANIC DISORDERS
• OBSESSIVE COMPULSIVE DISORDER
• PHOBIC DISORDERS
• ACUTE STRESS/POST TRAUMATIC STRESS DISORDER
• SOMATOFORM DISORDER
• DISSASOCIATIVE DISORDERS

98
ANXIETY DISORDERS

• Anxiety provides the motivation for achievement,
  a necessary force for survival.
• Anxiety is often used interchangeably with the
  word stress however, they are not the same.
• Anxiety may be differentiated from fear in that
  the former is an emotional process, whereas fear
  is cognitive.
• Epidemiological statistics
• Anxiety disorders most common type of all
  psychiatric illnesses
• More common in women than men
• Also occurs in children
• More prevalent in girls than in boys
• Children in lower socioeconomic environments at
  greatest risk

99
PANIC DISORDERS

• Panic disorder assessment
• Characterized by recurrent panic attacks, onset
  of which are unpredictable, and manifested by
  intense apprehension, fear, or terror, often
  associated with feelings of impending doom and
  accompanied by intense physical discomfort
• Panic disorder with agoraphobia
• Assessment
• Characterized by same symptoms characteristic of
  panic disorder
• In addition, affected person experiences a fear
  of being in places or situations from which
  escape might be difficult (or embarrassing) or in
  which help might not be available in the event
  that a panic attack should occur

100
Generalized anxiety disorder

• Panic and generalized anxiety disorders
• Psychodynamic theory
• Overuse or ineffective use of ego defense
  mechanisms results in maladaptive responses to
  anxiety.
• Cognitive theory
• Faulty, distorted, or counterproductive thinking
  patterns accompany or precede maladaptive
  behaviors and emotional disorders.
• Biological aspects
• Genetics
• Neuroanatomical
• Biochemical
• Neurochemical
• Medical conditions

101
NURSING DIAGNOSIS

• Panic anxiety related to real or perceived
  threat to biological integrity or self-concept
• Powerlessness related to impaired cognition

102
PHOBIAS

• Agoraphobia without history of panic disorder
• Social phobia Assessment
• Specific phobia Assessment
• DSM-IV-TR subtypes
• Animal type
• Natural environment type
• Blood-injection-injury type
• Situational type
• Other type

103
PHOBIAS (CONT)

• Etiological implications for phobias
• Psychoanalytical theory
• Learning theory
• Cognitive theory

104
NURSING DIAGNOSIS

• Fear related to causing embarrassment to self in
  front of another, to being in a place from which
  one is unable to escape, or to a specific
  stimulus
• Social isolation related to fears of being in a
  place from which one is unable to escape

105
OBSESSIVE COMPULSIVE DISORDERS (OCD)

• Assessment data
• Obsessions
• Compulsions

106
Etiological implications of OCD

• Psychoanalytical theory
• Learning theory
• Biological aspects
• Neuroanatomy
• Physiology
• Biochemical

107
Diagnosis outcome identification

• Ineffective coping related to underdeveloped ego,
  punitive superego avoidance learning, possible
  biochemical changes
• Ineffective role performance related to need to
  perform rituals evidenced by inability to fulfill
  usual patterns of responsibility

108
POST-TRAUMATIC STRESS DISORDER

• Assessment
• Development of characteristic symptoms following
  exposure to an extreme traumatic stressor
  involving a personal threat to physical integrity
  or to the physical integrity of others
• Characteristic symptoms include re-experiencing
  the
• traumatic event, a sustained high level of
  anxiety or
• arousal, or a general numbing of
  responsiveness.
• Intrusive recollections or nightmares of the
  event
• are common.

109
Etiological implications

• Psychosocial theory
• The traumatic experience
• The individual
• The recovery environment
• Learning theory
• Cognitive theory
• Biological aspects

110
Diagnosis/Outcome Identification

• Post-trauma syndrome related to distressing event
  considered to be outside the range of usual human
  experience
• Dysfunctional grieving related to loss of self as
  perceived before the trauma or other actual or
  perceived losses incurred during or after the
  event

111
Anxiety Disorder

• Anxiety Disorder due to General Medical Condition
• Assessment - Symptoms of this disorder are judged
  to be the direct physiological consequence of a
  general medical condition.
• Substance-Induced Anxiety Disorder
• Assessment - Prominent anxiety symptoms that are
  judged to be due to the direct physiological
  effects of a substance

112
CLIENT/FAMILY EDUCATION

• Nature of the illness
• Symptoms of anxiety disorders
• Management of the illness
• Management of the illness
• Support services
• Crisis hotline
• Support groups
• Individual psychotherapy

113
TREATMENT MODALITIES

• Individual psychotherapy
• Cognitive therapy
• Behavior therapy
• Group/family therapy
• Psychopharmacology
• Panic and generalized anxiety disorder
• Phobic disorders
• OCD
• PTSD

114
SOMATOFORM DISORDERS

• Somatoform disorders are more commonly found in
• Women than men
• The poorly educated
• Residents of rural communities
• Lower socioeconomic classes
• Dissociative disorders are thought to be rare.
• Amnesia is the most common dissociative symptom.
• DID is more prevalent in women than men.
• Brief episodes of depersonalization symptoms
  appear to be common in young adults, particularly
  in times of severe stress.

115
Types of psychophysiological disorders

• Asthma
• Cancer
• Coronary heart disease
• Peptic ulcer
• Essential hypertension
• Migraine headache
• Rheumatoid arthritis
• Ulcerative colitis

116
NURSING DIAGNOSIS

• Ineffective coping
• Deficient knowledge
• Low self-esteem
• Ineffective role performance
• Outcomes identified formeasuring the
  effectiveness ofnursing care

117
Types of somatoform disorders

• Somatization disorder
• Chronic anxiety, depression, and suicidal
  ideations are frequently manifested
• Drug abuse and dependence are not uncommon
• Personality characteristics

118
Pain disorder

• Pain disorder may be maintained by
• Primary gains
• Secondary gains
• Tertiary gains
• Symptoms of depression andsubstance abuse are
  common.

119
Hypochondriasis

• A preoccupation with the fear of contracting,
  or the belief of having, a serious disease.
• The fear becomes disabling
• Symptoms are grossly disproportionate to the
  degree of pathology.
• Anxiety and depression are common

120
Conversion disorder

• A loss of or change in body function resulting
  from a psychological conflict, the physical
  symptoms of which cannot be explained by any
  known medical disorder orpathophysiological
  mechanism
• classic conversion symptoms are those that
  suggest neurological disease
• la belle indifference

121
Body dysmorphic disorder

• Family dynamics
• Learning theory
• PRIMARY GAIN
• SECONDARY GAIN
• TERTIARY GAIN
• Hypochondriasis

122
NURSING DIAGNOSIS

• Ineffective coping
• Chronic pain
• Fear
• Disturbed sensory perception
• Disturbed body image

123
Dissociative disorders

• Dissociative amnesia involves
• An inability to recall important personal data
  that is too extensive to be explained by ordinary
  forgetfulness
• Finding is not due to the direct effects of
  substance use or a general medical condition

124
Treatment modalities

• Somatoform disorders
• Individual psychotherapy
• Group psychotherapy
• Behavior therapy
• Psychopharmacology
• Five types of disturbance in recall
• Localized amnesia
• Selective amnesia
• Continuous amnesia
• Generalized amnesia
• Systematized amnesia

125
APPLICATION OF THE NURSING PROCESS (CONT)

• Dissociative fugue
• Dissociative identity disorder (DID)
• Depersonalization disorder
• Symptoms of depersonalization disorder are often
  accompanied by
• Anxiety and depression
• Fear of going insane
• Obsessive thoughts
• Somatic complaints
• Disturbance in the subjective sense of time

126
Etiological Implications

• Genetics
• Neurobiological
• Psychodynamic theory
• Psychological trauma

127
NURSING PROCESS

• Disturbed thought processes
• Ineffective coping
• Disturbed personal identity
• Disturbed sensory perception

128
MEDICAL TREATMENT MODALITIES

• Individual psychotherapy
• Hypnosis
• Supportive care
• Integration therapy (DID)

129
SUICIDE

• FACTS AND FABLES
• RISK FACTORS
• PROTECTIVE FACTORS
• ASSESSING DEGRESS OF RISK
• NO HARM CONTRACT
• SOURCES FOR INFORMATION

130
ADVERSE EFFECTS OF MENTAL HEALTH ALTERATIONS ON
OBSTETRIC AND PEDIATRIC CLIENTS

• OBSTETRIC
• POSTPARTUM DEPRESSION
• FALSE PREGNANCY
• PEDIATRIC
• SEPERATION ANXIETY