Medicine

33. Mental Disorders

Mental Disorders

 

After you have successfully completed this chapter, you should be able to:

Describe the various theories in understanding mental health/illness

Describe developmental influences on mental health/illness

Discuss various cultural influences on mental health/illness

Identify history data as they relate to mental health/illness

Identify physical assessment data as they relate to mental

Describe additional assessment components specific to mental health/illness assessment

Perform a mental health assessment

Document assessment findings

Identify actual/potential health problems stated as nursing diagnoses with supporting data

Learning Outcomes

 A biological risk factor could be a family history of mental illness with a genetic link such as

schizophrenia.A person’s developmental level may be  psychosocial risk factor. External stressors are examples

of environmental factors.

Assessment entails not only identifying your client’s weaknesses but also identifying his or her strengths. So, you need to assess not only for risk factors but also for

protective factors, such as coping mechanisms andresources.

 

 

Mental health is a “state of successful performance of mental function, resulting in productive activities,fulfilling relationships with other people, and the ability to adapt to change and to cope withadversity”(Healthy People 2010).Jahoda (1958) identified six characteristics of positive mental health that address positive self-perception, personality integration, autonomy and independence,perception and reality,and growth and development leading to self-actualization. Mental

health or wellness affects every aspect of one’s life, and the impact of this can be seen when mental illness occurs.The effects are not only mental but also physical.

Current research is providing more and more evidence that there are organic and neurochemical bases for some mental illnesses and behaviors. Be sure to review

the anatomy and physiology section in Chapter 21, Assessing the Sensory-Neurological System. Genetic links have been identified for certain braindisorders such as schizophrenia. Although schizophrenia, depression, bipolar disorder, anxiety disorders, and Alzheimer’s are classified as mental illnesses, biological bases have been identified. Biochemical factors, specifically neurotransmitters, have been identified in depression and mania (Fig.5.1).Another part of the brain is the limbic system,which is called the emotional brain and is associated with fear, rage, love, anger, aggression, hope, sexuality, and social behavior (Fig. 5.2).

 

Biological Basis of Mental Illness

Understanding Mental Disorders

 

Mental disorders affect thinking, mood, or behavior or a combination of all three, leading to impaired function, disability, pain, and even death.The term mental illness is applied to diagnosable mental disorders. All age groups, gender, racial, and ethnic groups are ffected regardless of education or socioeconomic evel.A goal of Healthy People 2010 is “to improve mental ealth and ensure access to appropriate, quality ental health services.”As a nurse, you are well positioned to assess the mental health status of your atients at every level of health prevention and in very area of healthcare.

Prevention

Primary prevention entails decreasing the incidence f mental disorders by identifying those at risk, those ho are vulnerable to developing mental disorders.

Secondary prevention involves reducing theprevalence of mental disorders through screening andinitiating prompt treatment of mental disorders.

Tertiary prevention aims at reducing the severity ofthe illness by providing follow-up and rehabilitativeservices.

 Effects

Understanding Assesment

Cognitive theories provide an understanding by looking ot only at behavior but also at an individual’s cognitions and howa person processes thoughts (distorted

cognitions and maladaptive behaviors). Bandura and Back are cognitive theorists. Cognitive theory is of value when teaching patients new coping skills; individual

collaboration with the therapist and active involvement of the patient are needed for change to take place

(Townsend, 2006).

Developmental theories provide an understanding of the individual’s growth and development over one’s lifetime. Erikson, Piaget,Gilligan, and Miller are developmental theorists.

.

Psychological Theories

Behavioral Theories

Developmental Theories

Social Theories

Cognitive Theories

Developmental, Cultural, and

Ethnic Variations

Psychodynamic theories focus on intrapersonal concepts. These theories look at the development of themind over the course of a lifetime. Freud, the “Father of

Psychiatry,” introduced the psychoanalytic model of the conscious and unconscious mind.Various interpersonal and humanist models followed. Freud identified defense mechanisms, which served to protect the individual from unwanted anxiety.

Behavioral theories focus on normal behaviors rather than the causes of mental illness. Pavlov, Watson, Thorndike, and Skinner are behavioral theorists. The goal is to change behavior through conditioning, behaviorism (which includes frequency and recency), and positive reinforcement (Boyd, 2005).

Social theories include family dynamics, role theories, and sociocultural perspectives; thus, the assessment of

Developmental Level

Mental disorders can occur with any age group,with the incidence of certain disorders higher for specific age groups. For example, learning and behavioral problems are seen with children. Adolescents, known risk takers, have a high incidence of substance abuse. Bipolar illness or psychoses such as schizophrenia more commonly become apparent during young adulthood. Depression is often seen in the older adult.

Children

Because rapid growth and developmental changes occur during childhood, delays are readily detectable. Learning disorders and behavioral disorders often become apparent by the time the child reaches school age.

Mental Health Assessment for Children

Assessing the mental health of children should include both a detailed history and a physical examination.The assessment should include an interview with the child. If abuse is suspected, be sure to interview the child alone without the parents or caregiver present.

Health History

The health history should include a family history with attention to a history of mental health problems. A maternal history is also needed and should identify:

Age and health of mother during pregnancy.

Exposure to medications, alcohol or drugs during

pregnancy.

Course of labor and type of delivery.

Infant’s state of health at birth.

Assess the child’s normal growth and development milestones, such as motor development, bowel and bladder control, speech and language development, and social development. Also, assess the child’s medical health, noting any major illness or injury.

The assessment should also include a current developmental assessment, a mental status examination, and a physical examination. Various instruments are available to assess a variety of mental health disorders in children. Be sure to select the one best suited to meet the child’s

needs.

Scales for Mental Health Disorders

Child Abuse

Child abuse affects all areas of a child’s life and may manifest as a mental or physical disorder. Child abuse takes many forms from physical abuse, neglect, sexual abuse, emotional abuse, factitious disorders by proxy (Munchausen syndrome), and secondary abuse (children of battered women). The assessment should include an interview with the child. If abuse is suspected, be sure to interview the child alone without the parents

or caregiver present.

 

Risk Taking

Adolescents are known risk takers. Experimenting with drug and alcohol is common, and suicide is the second leading cause of death among adolescents. Mental and substance abuse disorders or a combination of disorders are more often than not associated with suicide. A goal of

Healthy People 2010 is to decrease the attempted suicide rate among adolescents from a 12-month average of 2.6 percent of adolescents in grades 9 through 12, to a 12- month average of 1 percent.

Another popular form of risk taking during childhood is the choking game,which produces a high or a state of euphoria by cutting off the blood supply to the brain. If the blood supply is compromised for too long, the child will pass out and feel a “rush” as consciousness returns. Depriving the brain of oxygen may result in permanent and cumulative death to brain cells, stroke, seizures, retinal damage, or death.

This behavior, which is also known as fainting, American dream, flatliner, space cowboy, knockout, gasp, rising sun, airplaning, pass out,blackout, andspace monkey, is most common among children ages 10 through 16. It can be performed either alone or with others.

Use of ligatures and performing this alone increases the risk of death.

Approach to the Mental Assessment

Children who “play” the choking game are usually not troubled children and generally have no history

of drug or alcohol abuse.

 

Learning disorders and behavioral disorders often

become apparent by the time the child reaches

school age.

Depending on the age of the child, play or drawing

can be very helpful in eliciting the child’s perceptions.

INSTRUMENT

Behavior Assessment System for Children (BASC)

Child Behavior Checklist (CBCL)

Children’s Depression Inventory (CDI)

Pediatric Anxiety Rating Scale (PARS)

Yale-Brown Obsessive Compulsive Scale (YBOCS)

Swanson, Nolan, Pelham (SNAP)-IV

ASSESSES FOR

Behavior and emotions for children ages 2–18

Psychopathology and competencies for children ages 4–16

Physical symptoms, harm avoidance, social anxiety, and

separation/panic disorders for children ages 7–17

Severity of anxiety for children ages 6–17

Obsessive compulsive disorder (OCD) for children ages 6–17

Inattention and overactivity (attention deficit hyperactivity disorder [ADHD]) and oppositional defiant disorders

Adapted from Boyd, M.A. (2005). Psychiatric Nursing Contemporary Practice. Philadelphia: Lippincott, Williams & Wilkins.

Risk Factors for Teen Suicide

Depression

Social isolation

History of abuse

Drug and alcohol abuse

Not fitting in with peers

School pressure

Source: Gorman, L., Raines, M., and Sultan, D. (2005). Psychosocial

Nursing for General Patient Care, ed. 2. Philadelphia: F.A. Davis.

Signs and Symptoms of the Choking Game

Unexplained marks or bruises on neck

Severe headaches

Red eyes

Belts, leashes, ropes, and shoelaces tied in strange

knots or in unusual locations

Disorientation after being alone

Locked bedroom doors

Pregnant Women

Although the birth of child is seen as a happy event, mental health disorders can occur, affecting not only the mother but also the entire family.Many mothers experience mild depression, also known as baby blues, usually within 4 weeks following childbirth. If the baby bluespersist for more than a few weeks, postpartum depression may have developed. The depression is more serious and results in postpartum depression with or without

psychosis.The mother may experience severe mood swings and pervasive sadness.The mother often has feelings of guilt and inadequacy as a mother. In addition to the feelings associated with postpartum depression, with postpartum psychosis, the mother experiences delusions and thoughts of harming herself or her baby. If you detect at-risk mothers or postpartum depression,be sure to make the appropriate referrals for followup care.Assessment for postpartum depression is important. Screening tools for postpartum depression include the Postpartum Check List (Beck, 1995) and the Edinburgh Postpartum Depression Scale (Cox,Holden,& Sagovsky, 1989).

Older Adults

Older adults are more at risk for the development of mental health problems for several reasons, ranging from the normal physiological changes associated with aging to acute and chronic illness to side effects associated with polypharmacy. Risk factors may be developmental, situational, internal, or external in nature.

Mental Health Assessment of the Older Adult

Approximately 25 percent of all older adults experience some type of mental disorder (depression, anxiety, substance abuse,and dementia) that is not related to the normal changes associated with aging (Healthy People2010). Alzheimer’s affects 8 percent to 15 percent of older adults over the age of 65 and accounts for 69 percentto 70 percent of all dementia (Healthy People 2010). Assessing the mental health of the older adult shouldinclude both a detailed history and a physical examination. The assessment should focus on mental status,behavioral responses, functional ability, general health,

and social supports of the client. Mental status assessment should include a Mini-Mental State Examination (MMSE), a mental status examination, and assessment for depression, anxiety, and psychosis.A change in mental status has to be carefully evaluated. Changes are often attributed to normal

changes associated with aging. Changes in mental status may be physiological or psychological in nature. Because dementia increases with age, care must betaken to differentiate dementia from delirium and depression.

 Understanding Assesment

Risk Factors for Postpartum Depression

History of mood disorders

Low self-esteem

Unwanted pregnancy

Unemployment of mother or head of household

Poor marital relationship

Father depressed

Poor support systems

External stressors

Physical changes associated with aging that may affect functional ability

Cognitive changes and memory loss

Chronic medical illness

Psychosocial changes, such as retirement, that occur with aging

Limited financial resources

Polypharmacy

Loss and bereavement

Loss of social supports

Delirium should be treated as an emergency because its acute onset may have an underlying life-threatening cause. The MMSE and the Clock Scoring Test are screening instruments used to assess cognitive impairment and screen for dementia.

 

Assessment of behavioral responses includes description of behavior and triggers, with special attention to behavioral changes and problem behaviors. A functional assessment should focus on the client’s ability to perform activities of daily living, physiological functioning,

mobility, and risk for fall assessment. A nutritional assessment and history of substance abuse is included in the assessment of the client’s general

health. Finally, the assessment should identify social supports, family-patient interactions, and caregiver concerns.

Depression

Depression is a major mental health problem for older adults, but it can be easily missed. If left untreated, depression can lead to suicide or self-neglect. In the United States, the suicide rate is highest among older adults, with older men over age 80 at highest risk and guns the most frequent method (Gorman, Raines, & Sultan, 2005). But the suicide rate is probably higher, because older adults can easily commit passive suicideby not complying with medical regimens or failing to eat.

Elder Abuse

Elder abuse, if taking place, affects all areas of the patient’s life and may manifest as a mental or physical disorder.

Elder abuse can take many forms: physical abuse, neglect, sexual abuse, emotional abuse, and financial

Abuse.

Approach to the Mental Assesment

Characteristics of Dementia, Delirium, and Depression

FEATURE DEMENTIA DELIRIUM DEPRESSION

Onset

Prognosis

Course

Attention

Memory

Perception

Psychomotor

behavior

Cause

Abrupt (hours to a few

weeks)

Reversible

Worse in P.M.

Impaired

Impaired recent and

immediate

Impaired

Hypo-/hyperkinetic

Caused by acute illness,

fever, infection,

dehydration, electrolyte

imbalance, medications,

and alcoholism

Gradual (months to years)

Irreversible

Progressive

Normal

Impaired recent and remote

Normal

Normal/apraxia

Caused by many diseases,

including alcoholism,

acquired immunodeficiency

syndrome (AIDS), cerebral

anoxia, and brain infarcts

Either

Variable

Possibly worse in A.M.

Variable

Impairment

Normal

Retardation/agitation

May coincide with life

event, such as death in

the family, loss of a

friend or a pet, or a

move

Risk Factors for Suicide Among Older Adults

Lives alone

Widower

Lack of financial resources

Poor health

Social isolation

Drug and alcohol abuse

Geriatric Depression Scale

Are you basically satisfied with your life? YES/NO

Have you dropped many of your activities and interests?

YES/NO

Do you feel that your life is empty? YES/NO

Do you often get bored? YES/NO

Are you in good spirits most of the time? YES/NO

Are you afraid that something bad is going to happen to

you? YES/NO

Do you feel happy most of the time? YES/NO

Do you often feel helpless? YES/NO

Do you prefer to stay at home rather than going out and

doing new things? YES/NO

Do you feel you have more problems with memory than

most? YES/NO

Do you think it is wonderful to be alive now? YES/NO

Do you feel pretty worthless the way you are now?

YES/NO

Do you feel full of energy? YES/NO

Do you feel that your situation is hopeless? YES/NO

Do you think that most people are better off than you

are? YES/NO

Bold answers _ depression

GDS Scoring:

12–15 Severe depression

8–11 Moderate depression

5–8 Mild depression

0–4 Normal

Source: Yesavage, et al., 1983, pp. 37–47.

GDS website: http://www.stanford.edu/~yesavage/

 

 

 

Cultural Perceptions of Mental Health/Illness

CULTURAL GROUP PRACTICES/BELIEFS

Amish

Appalachian

Arab American

Chinese American

Cuban American

Egyptian American

Filipino American

French Canadian

Greek American

Iran American

Irish American

Jewish American

Mexican American

Native American

Vietnamese American

 

Undrstanding Assessment

Atypical

Signs and Symptoms of Depression in

the Older Adult

Typical

Changes in appetite

Decreased self-esteem

Changes in sleep patterns

Social withdrawal

Feelings of helplessness

Loss of motivation

Constipation

Hostility

Pessimism

Agitation

Guilt

Aggression

Vague somatic complaints—such as constipation, joint pain, fatigue, and memory changes—that seem to be out of proportion to the actual

problem.

Client may become obsessed with the problems and feel that if the problems are relieved, she or he will be fine.Cultural and ethnic variations often influence a patient’s view of mental health. Cultural beliefs influence perceptions, understanding, and treatment of mental illness.

Children with mental or physical differences are seen as “hard learners.”

The mentally ill are generally cared for at home.

Usually takes care of own, so mentally deficient and handicapped are readily accepted.

Mentally handicapped are not crazy, but rather have “bad nerves” or are “quiet

turned” or “bad turned.”

Behaviors that would warrant psychiatric treatment are seen as lazy, mean,immoral, criminal, or psychic and treated by punishment or tolerance.

Mental illness is seen as a social stigma, therefore psychiatric symptoms may be denied, attributed to “bad nerves” or supernatural beings, or caused by a physical ailment or emotional trauma.

Somatic orientation leads to patients’ tolerance of emotional suffering and relatives’ tolerance of behavioral disorders.

Patients with mental distress will somatize symptoms. Somatic treatment for psychiatric disorders is preferred over psychotherapy.

Balance between yang and yin explains mental health/illness.

Mental illness results from metabolic imbalance and organic problem.

Stigma is associated with mental illness, so patient will seek folk healer first.

Does not readily seek treatment for emotional or nervous disorders.

 

Emotional crises are treated by santero, a practioner of santeria (a 300-year-old

Afro-Cuban religion that combines Roman Catholic elements with ancient Yoruba

tribal beliefs and practices).

May act out emotional problems in a non–threatening way, allowing person to

maintain self-esteem.

Mental illness is considered a stigma.

More tolerance for emotional problems.

View mental health problems with a supernatural framework, including “curse”

and “devil.”

Emotional problems of grief and losses are due to wrongdoings of others or

weakness and inability to control and snap out of distress.

Mental and emotional issues are expressed somatically so therefore treated with

psychosomatic interventions.

Seeks family and friends for advice.

Stigma is associated with mental illness.

Mental illness is caused by heredity.

Takes care of mentally ill family member rather than seek mental

healthcare.

Federal Canadian laws protect the mentally disabled from discrimination.

Stigma is associated with mental illness.

Mental illness is seen as hereditary linked, therefore “polluting” the blood line,

bringing shame to family.

Families of mentally ill may experience loss of friends and social isolation.

Mental illness often somatisized. Wide range of acceptable behavior leads to delay

of seeking treatment.

Folk model for “nerva” (nerves) is socially acceptable and treated with medication

rather than with psychotherapy.

Stigma is associated with mental illness.

Mental illness is caused by genetic problem; more likely to be labeled a

“neurological” problem.

Avoids psychotherapeutic treatment.

Symptoms somatasized and treated with psychopharmacology.

High rate of mental illness.

Difficulty expressing emotions and feelings.

Family may take care of mentally ill family member.

Some attribute mental illness to sin and guilt.

Mental health is as important as physical health.

Mental incapacity relinquishes one from all responsibilities.

Mental illness is seen as God’s will.

Family prefers to care for patient at home.

Mental illness is caused by witches; treated by healers.

May wear turquoise to ward off evil.

Some tribes view mentally ill as having special problems.

Mental illness results from offending a deity.

Brings disgrace to family and is therefore concealed, which delays treatment.

Emotional disturbances are caused by malicious spirits, bad luck, or family

inheritance.

Buddhists see mental illness as bad karma from previous misdeeds.

Sometimes nervous system is seen as cause of mental problems.

 Mental Health

Assessment

A thorough assessment includes assessment of the psychological health of the patient.Mental health reflects aperson’s positive attitudes toward self, growth and development,self-actualization, integration, autonomy, reality perception, and environmental mastery (Stuart & Laraia,

2005). As you perform your assessment, look for clues that reflect the mental health status of your patient. Realize that your patient may prefer to have you believe she or he has a physical problem rather than a psychological problem by somatizing feelings. Also,medical problems or drug use (prescribed, over-the-counter[OTC], illegal) may present as mental disorders, such as hyperthyroidism, which may produce signs and symptoms

of anxiety. Comorbidities can also result with patients. Chronic illness can lead to depression, especially as the disease progresses.

Report any suspected abuse or any threat of child or elder abuse. Also report threats of suicide orhomicide. Threats to self or others must always be taken seriously.

Health History

When obtaining a health history, ask yourself,“What can the health history reveal about the mental health of thepatient?” Identify factors that may affect mental health in either a positive or a negative way. Ensure patient confidentiality, but confidentiality should be breached if there is suspected abuse or a threat of child or elder abuse or if the patient poses a threat to herself or himself or others.

Health History as It Relates to Mental Health

RISK/FACTORS/

QUESTIONS TO ASK RATIONALE/SIGNIFICANCE

Response to stressors differs with age.

Identifies possible maturational crises related to

developmental changes.

Women have greater incidence of depression and

affective and anxiety disorders.

Men have greater incidence of psychosocial and

substance abuse disorders.

Age of onset of schizophrenia occurs later in

women than in men.

Men are more likely to be aggressive and selfdestructive

than women.

The higher the socioeconomic and

educational level, the lower the incidence of

depression.

The higher the educational level, the more likely

the individual is to use mental health services if

needed.

The lower the income, the higher the incidence of

psychological symptoms.

African Americans and Hispanics have twice the rate of

being diagnosed with severe mental illness than other

groups.

African Americans are diagnosed with the most

severe types of psychopathology and fewer affective

disorders and are overdiagnosed with schizophrenia.

Ethnic groups have three times more

hospitalizations for mental illness than the general

population.

Married and partnered adults report less stress

than single or divorced adults.

Can affect mental health in either a positive or a

negative way.

Influences perceptions of mental illness.

Identifies supports.

Identifies any signs or symptoms that may reflect

mental illness.

Identify any past mental health problems and

treatments.

Identifies previous psychiatric hospitalization.

Identifies familial/genetically linked psychiatric

disorders. Familial/genetically linked disorders

include:

Schizophrenia.

Depression.

Bipolar disorders.

Anxiety and panic disorders.

Identifies any psychiatric drugs.

Identifies any possible drug interactions.

OTC medications such as pseudoephedrine can

cause anxiety symptoms.

Herbal supplements such as St. John’s wort,

ephedra, ginseng, kava kava, and yohimbe can

interact with psychotrophics or other

medications, or cause anxiety, drowsiness, or

other adverse psychological effects (Pedersen,

2005). (See Psychotropic Drugs and Some

Related Side Effects.)

Identifies possible source of stressor related to

post-traumatic stress syndrome

 

Biographical

Age

How old are you?

Gender

Is the patient male or female?

Socioeconomic and Educational Levels

What is your educational level?

 

Ethnicity

What is the patient’s cultural background?

Marital Status

Are you single, married, or divorced?

Religion

What is your religious affiliation?

Contact Person

Who is your contact person?

Current Health Status

How is your health?

Past Health History

Childhood Illnesses

Did you have any major health problems

(physical or mental) while growing up?

Past Hospitalizations

Have you ever been hospitalized for mental

health problems?

Family History

Does anyone in your family have mental health

problems?

Medications

Are you taking any medications, either

prescribed, OTC, or herbal? If yes, what are you

taking? (See Drugs That May Adversely Affect

Mental Health.)

Military Service

Are you now or did you ever serve in the military?

If yes, when and what was your tour of duty?

General Health Survey

How have you been feeling?

Integumentary

Do you have any problems with your skin? If yes,

describe.

Head, Eyes, Ears, Nose, and Throat (HEENT)

Do you have headaches? If yes, describe.

Do you have thyroid disease?

Respiratory

Do you have any breathing problems? If yes, describe.

Cardiovascular

Do you have any CV problems? If yes, describe.

Fatigue may be associated with depression.

Restlessness may be associated with anxiety.

Sweating, itching associated with anxiety

Headaches associated with depression.

History of migraines and tension headaches

affected by psychological factors.

History of hyperthyroidism and diabetes can be

affected by psychological factors, manifest with

psychological signs or symptoms, or mimic

psychological disorders.

History of breathing problems, such as

hyperventilation, associated with anxiety disorders.

Sighing associated with depression.

Hypertension, angina affected by psychological

factors

Palpitations, racing heart associated with anxiety

Heterocyclic antidepressants—use with caution with

cardiovascular disease

Drugs That May Adversely Affect Mental Health

Drugs Effect

Antihypertensives Depression

Reserpine

Beta blockers

Methyldopa

Oral contraceptives

Corticosteroids

Benzodiazepine

Cancer chemotherapeutic agents

Vincristine

Vinblastine

Interferon

Procarbazine

Psychoactive agents

Alcohol

Amphetamine or cocaine withdrawal

Opioids

Corticosteroids Manic states

Levodopa

Amphetamines

Tricyclic antidepressants (TCAs)

MAO inhibitors

Methylphenidate

Cocaine

Thyroid hormone

Amphetamines Psychotic reactions

Antidepressants (particularly tricyclics)

Anticholinergics (atropine)

Anticonvulsants (carbamazepine, valproic acid)

Antiparkinsonians (levodopa)

Antituberculars (isoniazid)

Antivirals (acyclovir, amantadine)

Antiarrhythmics (lidocaine)

Alcohol

Beta blockers (propranalol)

Corticosteroids

H2-receptor blockers (cimetidine)

Cyclosporine

Disulfiram (Antabuse)

Anesthetics (ketamine)

Antibiotics (cephalosporins, ciprofloxacin, sulfonamides)

Opioids (morphine, hydromorphone)

Lithium Nausea, diarrhea, polyuria, acne, rashes, alopecia, tremors; weight

gain, hypothyroidism; can also precipitate psoriasis and psoriatic

arthritis.

Anticonvulsants Sedation, hepatotoxicity, rash, and Stevens-Johnson syndrome (SJS),

which is a life-threatening mucocutaneous reaction.

Anticholinergics Blurred vision, constipation, dry mouth

TCAs Sedation, blurred vision, dry mouth, constipation, life-threatening

arrhythmias and electrocardiogram (ECG) changes

Selective serotonin reuptake inhibitors Gastrointestinal (GI) symptoms, insomnia, and agitation

Antipsychotics Movement disorders (akathisia) and tardive dyskinesia (especially

conventional antipsychotics [chlorpromazine]), dystonia,

parkinsonism, gynecomastia, and lactation, and possibly treatmentemergent

diabetes

 

A L E R T

Neuroleptic malignant syndrome (NMS) is a potentially fatal side effect from antipsychotic drugs, characterized by fever, tachycardia, sweating, muscle rigidity, tremors, incontinence, stupor, leukocytosis, elevated creatine phosphokinase (CPK), and renal failure

 

Review of Systems

As you proceed with the review of systems, note

any problems that may affect your patient’s mental

health.

Review of Systems

Psychotropic Drugs and Some Related Side Effects

 

C H A P T E R 5 A P P R OA C H TO T H E M E N T A L H E A L T H A S S E S S M E N T 125

Psychosocial Profile

CATEGORY/QUESTIONS TO ASK RATIONALE/SIGNIFICANCE

Health Practices and Beliefs

How would you describe your mental health?

Do you or would you use mental health services?

Typical Day

Can you tell me what your typical day is like?

Nutritional Patterns

Can you tell me what you ate yesterday (24-hour

recall)?

Activity and Exercise Patterns

Do you exercise regularly? If yes, describe.

Recreation, Pets, Hobbies

What do you do for fun?

Do you have pets?

Do you have hobbies?

Sleep/Rest Patterns

How many hours of sleep do you get a night?

Do you have any problems falling asleep, staying asleep?

Do you take or do anything to help you sleep?

Personal Habits

Do you use alcohol, drugs, caffeine, or nicotine? If, yes,

how much?

Occupational Health Occupation?

How do you feel about your work? Your coworkers?

Do you find your work stressful? If yes, how do you

deal with it?

Are there any health risks associated with your work? If

yes, describe.

Environmental

Where do you live?

Are you exposed to any pollutants or toxins?

Roles, Relationships, Self-Concept

How do you see yourself?

Can you identify your various roles and relationships?

Cultural Influences

What is your cultural background?

What influences your perception of health?

Religious/Spiritual Influences

What is your religious background?

What influence does your religious beliefs have on your

perception of health?

Identify perceptions of mental health, mental health

practices, and use of mental health services.

Identifies ability to maintain activities of daily living

(ADLs). Mental health problems such as depression and

schizophrenia, compulsive disorders may affect ability

to perform ADLs.

Nutritional disorders are associated with eating

disorders, anxiety, and depression.

Excessive exercise is associated with eating disorders.

Inactivity is associated with depression.

Inactivity is associated with depression.

Problems with sleep and rest are associated with many

psychological disorders, such as anxiety, depression,

bipolar disorders, and substance abuse.

Identifies history of substance abuse (use of alcohol,

drugs, caffeine, nicotine).

Identify ability to maintain job. Work can be a source of

stress.

Identify risk for head injury, such as construction work

Identifies risk for exposure to toxic substances, such as

lead, mercury, herbicides, solvents, cleaning agents, and

lawn chemicals, that can affect cognitive ability.

Identifies sense of worth and value, which may be

affected by psychological factors such as low self-image

associated with depression and eating disorders.

Roles and relationships may affect or be affected by

psychological factors.

Identifies culture’s perception of mental health and

illness.

Identifies religious/spiritual influences on mental health

and illness.

Gastrointestinal

Do you have any GI problems? If yes, describe.

Have you experienced changes in weight? If yes,

describe.

Have you experienced changes in appetite? If yes,

describe.

Genitourinary (GU)

Do you have any GU problems? If yes, describe.

If your patient is female, ask if she has experienced any

irregularities in her menstrual cycle.

Do you have any concerns about your sexual

performance? If yes, describe.

Musculoskeletal (MS)

Do you have any MS problems? If yes, describe.

Neurological

Do you have any neurological disorders?

Have you experienced seizures, concentration, or

memory problems?

Have you experienced depression, anxiety? If yes,

describe.

Changes in appetite associated with depression,

anxiety, eating disorders, substance abuse

History of peptic ulcer, irritable bowel syndrome,

colitis affected by psychological factors

GI complaints such as nausea, abdominal pain,

diarrhea seen with anxiety

Indigestion and constipation seen with depression

Nausea is a common side effect of many

psychotrophic medications.

History of sexual dysfunction, such as impotence,

frigidity, and premenstrual syndrome (PMS),

affected by psychological factors

Menstrual irregularities associated with eating

disorders

Pressure and frequency of urination associated with

anxiety

Use TCAs (amitriptyline), cautiously with benign

prostatic hyperplasia (BPH)

History of rheumatoid arthritis and idiopathic low

back pain affected by psychological factors

Weakness associated with anxiety

Osteoporosis associated with eating disorders

Use of antipsychotics contraindicated with

myasthenia gravis.

Seizures associated with eating disorders, use TCAs

cautiously with seizures and buproprion is

contraindicated with seizures.

Neuroleptic malignant syndrome and movement

disorders are a side effect of antipsychotic

medications

Cognitive problems, difficulty focusing, inability to

concentrate associated with anxiety, depression,

dementia, and schizophrenia

Family Roles and Relationships

What is your role in your family?

How is your relationship with your family?

Sexuality Patterns

Do you have any concerns about sexual patterns? If yes,

describe.

Do you practice safe sex?

Stress and Coping Patterns

How do you deal with stress?

What do you do when you are upset?

Identifies sources of support or stress on patient’s

mental health.

Mental illness may affect patient’s role and relationship

in family.

Sexual problems are often associated with mental

illness such as depression.

Unprotected sexual activity is associated with substance

abuse.

Identifies current coping skills.

Determines effectiveness of coping skills.

 

 

 

Psychosocial Profile

As you perform the psychosocial assessment, look for clues that would reflect your patient’s mental health.

 

Mental Status Assessment

A mental status assessment, involving a systematic approach to various components, is done to assess and evaluate a patient’s cognitive and mental functions. Each assessment provides information about that patient atthat point in time. (See Mental Status Assessment as it

Relates to Mental Health/Illness.) Additional assessments will demonstrate improvement, regression, or stabilization and will provide a “progress report” as well as “patterns” of functioning. The components of the mental status assessment include:

General appearance.

Behavior/activity.

Speech and language.

Mood and affect.

Thought process and content.

Perceptual disturbances.

Memory/cognitive.

Judgment and insight.

Additional Assessments

Depending of your assessment findings, additional mental health screening may be indicated.Various mental health problems and assessment instruments are available to assess for a variety of mental health problems. Additional mental health assessments are presented below.

Psychosocial Profile (continued)

Physical Assessment

As you perform a head-to-toe physical examination, consider how your patient’s physical findings reflect his or her mental health.

ead-to-Toe Physical Examination as It Relates to Mental Health/Illness

SYSTEM ABNORMAL FINDINGS/RATIONALE

General Health Survey Poor grooming and personal hygiene: Associated with depression

Bright colors or unusual dress: Associated with mania

Poor eye contact: May indicate depression

Inability to maintain attention: Associated with schizophrenia and depression

Labile affect: May reflect mania

Flat, incongruent affect: May reflect schizophrenia

Stooped posture: Associated with depression

Restlessness, tension: Associated with anxiety

Malnourished appearance: May indicate an eating disorder

Slurred speech: May indicate drug and alcohol abuse

Pressured speech: Seen with mania

Disorganized speech: Seen with schizophrenia

Irritability: Associated with anxiety

Suspiciousness: Associated with paranoia

Integumentary Flushed or pallid skin color: Seen with anxiety

Excessive sweating: Seen with anxiety

Injury or scarring: From self-injury or past suicide attempts or self-mutilation

HEENT Dilated or constricted pupils: Seen with drug abuse

Poor eye contact: Seen with depression

Dental caries, parotid swelling: Seen with eating disorders

Erosion of nasal or oral mucosa: May be secondary to drug use

Rope marks on neck: In children, associated with “choking game”

Respiratory Increased respiratory rate and hyperventilation: Seen with anxiety

Cardiovascular Increased pulse rate and blood pressure: Seen with anxiety

Abdominal Increased bowel sounds: Seen with excessive use of laxatives in eating

disorders

Abnormal liver size: Associated with substance abuse

Musculoskeletal Generalized weakness and tremors: Seen with anxiety

Abnormal muscle movement: May be adverse effect of psychotropic drugs

Excessive body movements: Associated with anxiety, mania, or stimulant

abuse

Minimal or no body movement: Associated with depression, catatonic states, or

drug-induced stupor

Repeated movements: Associated with compulsive disorders

Repeated picking at clothes: May be associated with hallucinations, delirium, or toxic

conditions

Neurological Cognitive changes, thought process disorders: Seen with schizophrenia

Loose association: Associated with schizophrenia

Flight of ideas: Associated with mania

Preservation: Associated with brain damage and psychotic disorders

Auditory hallucinations: Associated with schizophrenia

Visual hallucinations: Often organic in nature

Tactile hallucinations: Seen with organic problems, drug abuse, or delirium tremens

(DTs)

Changes in mental status: Seen with mental illness such as schizophrenia, substance

abuse, bipolar disorder

Increased reflexes: Seen with anxiety

Movement disorders: Adverse effect associated with antipsychotic medications

tal Status Assessment as It Relates to Mental Health/Illness

AREA/QUESTIONS ABNORMAL TO ASK NORMAL FINDINGS/RATIONALE

Grooming/dress

Does the patient dress appropriate for age, gender,season, and situation?

Hygiene

Are the patient and his or her clothing clean?

Does the patient present with any unusual odors?

Eye Contact

Does the patient maintain eye contact?

Posture

Does the patient assume a specific position?

Is posture erect?

Identifying Marks/Scars/Tattoos

Are there any obvious marks or scars?

Appearance vs. Stated Age

Does the patient appear stated age, or younger or older?

Behavior/Activity

Do you notice any unusual activity?

Is patient’s behavior appropriate for the situation?

What is the patient’s level of consciousness?

Dress neat and appropriate

Clean, no unusual odors

Maintains eye contact

Comfortably positioned, posture erect

No obvious marks or scars

Appears stated age

Calm, relaxed, no unusual behavior or movements

AAO _ 3 (awake, alert, and oriented to time, place,person)

Disheveled appearance: Associated with depression

Bright-colored clothing: Associated with mania

Poor hygiene: Associated with depression or schizophrenia

Poor eye contact: Associated with depression

Slumped posture: Associated with depression

Defensive posture: Associated with paranoia

Scars: May indicate self-mutilation or past suicide attempts

Older appearance than stated age: May be associated with depression

Hyperactivity: Associated with anxiety,mania, or stimulant abuse

Hypoactivity: Lethargic, thinking slowed; associated with depression, alcohol or drug abuse.

Altered orientation: May be seen with organic disorders or schizophrenia

Agitation: May be seen with dementia or delirium

Psychomotor retardation, slow movements: May be associated with depression

Tremors: May indicate drug/alcohol withdrawal

Tics: May be an adverse effect of psychotropic medications

Unusual movements such as jaw/lip smacking: May be associated with tardive dyskinesia, an adverse effect of antipsychotic medications

Catatonia: May be seen with schizophrenia

Akathisia (restlessness): Seen with extrapyramidal adverse effect from antipsychotic medications

Rigidity: May be a sign of NMS

 

Speech

What are the quality, tone,

volume, fluency, and pace of

speech?

Attitude

What is the patient’s attitude? Is it friendly? Hostile?

Mood (Including Self-Report of Emotional State)

How does patient appear?

How does the patient describe

her or his mood?

Affect (Apparent Emotional

State)

What is the patient’s affect facial expression)?

Thought Process

Can you follow the patient’s thinking? Is it coherent and logical?

Quality and pace of speech normal with no exaggeration

Fluent, pleasant tone

Cooperative

Appropriate for situation

Appropriate for situation

Thought process intact

Responds appropriately

Slow speech: Associated with depression

Rapid and pressured speech: Associated with mania

Mumbling: Seen with Huntington’s chorea

Slurred speech: Seen with alcohol intoxication

Suspicious tone: Associated with paranoia

Volume: Soft associated with depression

Poor fluency (mute/hesitation/latency of response): Less likely to talk with depression

Hesitancy: Seen with mistrust or paranoia

Uncooperative: Associated with paranoia

Warm/friendly/distant: Seen with personality disorders

Suspicious/combative: Seen with paranoia

Guarded/aggressive: Seen with psychosis

Hostile/aloof: Seen with psychosis

Apathetic: Seen with depression

Sad: Associated with depression

Elated: Associated with mania

Irritable/anxious: Associated with anxiety

Fearful/guilty: Seen with phobias

Worried/angry: Seen with personality disorder

Hopeless: Associated with depression

Labile: Associated with mania

Mixed (anxious and depressed): Seen with depression

Flat affect: Seen with schizophrenia

Blunted or diminished affect: Seen with psychosis

Inappropriate/incongruent (sad and smiling or laughing): Associated with schizophrenia

Thought process disturbances: Often seen with psychosis or organic brain disorders.Examples of thought process disturbances

are:

Concrete thinking: Unable to abstract; thinks in concrete terms

Circumstantiality: Excessive, irrelevant detail, but eventually gets to the point

l Status Assessment as It Relates to Mental Health/Illness (continued)

Thought Content

Does the patient’s content of thought make sense and seem reality based?

Does the patient have thoughts about hurting self or someone else?

Perceptual Disturbances

Does the patient haveperceptual disturbances? Auditory disturbances? Visual

disturbances? Olfactory disturbances? Tactile disturbances?

Thought content (what the patient is thinking) reality based

No hallucinations, illusions, or depersonalization.

Tangentiality: Digresses from topic to topic, never getting to the point

Loose association: Loose connection between thoughts that are unrelated

Echolalia: Repetition of words spoken by another

Flight of ideas: Rapidly going from one topic to another

Preservation: Involuntary, excessive repetition of a single response to different questions

Clang association: Association of words by sound

Blocking: Draws a blank

Word salad: Combination of words that have no meaning

Derailment: Off track

Delusions (grandiose/persecution/reference/ somatic): Associated with psychosis

Suicidal/homicidal thoughts: Associated with depression, anxiety, or schizophrenia

Obsessions: Seen with OCD

Paranoia: Seen with schizophrenia

Phobias: Seen with anxiety disorders

Magical thinking (primitive form of thinking

that thinking about something will make it

happen)

Poverty of speech

Visual hallucinations: Often organic in nature

Auditory hallucinations (commenting/ discussing/commanding/loud/soft/other): Associated with schizophrenia

Tactile hallucinations: Seen with organic problems, drug abuse, or DTs

Illusions (misperception of a real external stimulus): Common with dementia of

Alzheimer’s and schizophrenia

A L E R T

If the patient is having homicidal thoughts, identify those toward whom those thoughts are directed.

 

Memory

Immediate

Can patient repeat objects named minutes before?

Remote

Can patient recall anniversaries, past important, historical events?

Insight (Awareness of the Nature of Illness) and Judgment

Does patient have insight into his or her problem? (Ask, “Can you tell me what the problem is?”)

Is judgment appropriate? (Ask the patient to respond to a hypothetical situation, such as,

“If you were walking down the street and saw smoke coming from a window of a home, what would you do?”)

Immediate, recent, and remote memory intact

No confabulation

Insight and judgment intact and appropriate

Depersonalization (altered perception or experience that causes temporarily loss of self or personal identity): Seen with panic

disorder

Memory problems and confabulation: Seen with organic, dissociative, and conversion disorders

Level of alertness: Altered with substance abuse

Poor insight: Seen with psychosis

Poor judgment: Seen with psychosis

Poor impulse control: Seen with OCD, psychosis, mania

Crisis

A crisis results from an acute event that stresses a person’s resources and ability to cope; a crisis can also result from a perceived threat to self. Crises may be maturational or developmental and situational. An example of amaturational crisis would be a child becoming an adolescent.

An example of a situational crisis might be the loss of a loved one. A situational crisis could also be a major disaster, such as a hurricane or a terrorist attack. An event that may be a crisis for one person may not be for another.A stressful event causes disequilibrium forthe person. It is the ability of the person to restore equilibrium that determines the outcome. Whether or not a person adapts to the crisis or not depends upon several

factors:perception of event,situational supports,and coping mechanisms.Once you have performed a crisis assessment,you can then develop interventions that will help your patient deal with the crisis and regain equilibrium.

 

BATHE Technique

When you have only limited time to perform an assessment, it is important to keep the interview focused.The BATHE technique helps the patient identify problems and coping strategies and is supportive of the patient.The acronym is representative of the interview’s components

(Stuart & Lieberman, 1993):

Background—What is going on? What brought you here?

Affect—How does this make you feel?

Trouble—What troubles you most in this situation?

Handling—How are you able to handle this situation/problem?

Empathy—Empathize with client, shows an understanding of client’s view of situation.

A L E R T

The BATHE technique is not intended for use with patients with severe problems, such as patients who are suicidal or those who have suffered severe abuse.

Crisis Assessment

Perception of event

Supports

Coping mechanisms

Can you tell me what has happened? Please be specific.

What caused the crisis?

How has this affected you?

How did this make you feel?

Is there anyone I can call?

Do you live alone?

Do you have family or friends who support you?

Are you active in any religious or community groups?

How have you handled stressful events in the past?

Can you talk about the stressful event?

What do you do to relieve tension? Cry? Talk? Exercise?Use alcohol?

Sleep (increase/decrease)

Interest (diminished)

Guilty/low self-esteem

Energy (poor/low)

Concentration (poor)

Appetite (increase/decrease)

Psychomotor (agitation/retardation)

Suicidal ideation

Past suicide of family member, close friend, or peer

Impulsivity

Mood disorders

Substance abuse

Recent loss of a spouse, partner, friend, or job

Expressed hopelessness (patient sees no future)

Social isolation (patient lives alone, has few friends

or supports)

Stressful life event

Previous or current abuse (emotional, physical, sexual)

Sexual identity crises/conflict

Available lethal methods (guns)

Legal issues/incarceration

 

A depressed mood plus four or more SIGECAPS for 2 weeks or longer indicates a major depressive disorder.A depressed mood plus three SIGECAPS most days for 2 years or longer indicates dysthymia, which is a depressive neurosis with no loss of contact with reality.

 

 

Assessing Depression

Depression poses a major health problem. Major depression has been identified by the World Health Organization as the leading cause of disability for adults in developed countries,such as the United States (Healthy People 2010). In any given year, approximately 6.5 percent of women and 3.3 percent of men will have a major depressive episode.The incidence of major depression is twice as great in women as in men. Identification of

those at risk and accurate assessment of depression can lead to prompt intervention and promotion of mental health.

If you suspect that your patient is depressed, use the mnemonic SIGECAPS to easily recall and review theDSM-IV criteria for major depression:

Suicide Assessment

In the United States, suicide is a major public health problem (Healthy People 2010). It is often the end result of mental illness.More women attempt suicide than do men, but men are four and a half times more likely to succeed at suicide than are women.If you suspect that your client is suicidal,perform a suicide assessment. It is important to identify those at risk for suicide and intervene promptly.

 

Symptoms of dysthymia are similar to those of a major depressive disorder, but milder.

A L E R T

Suicide attempts are more likely to occur as the patient’s symptoms improve because the patient now has the energy to commit suicide.

Feelings of hopelessness

Suicidal ideations

Plan for suicide

Possessions

Auditory hallucinations

Lack of support network

Alcohol or substance abuse

Precipitating event

Media

A key element in assessing for feelings of hopelessess is determining whether the patient is able to see a future with herself or himself in that future.

ASSESSMENT AREA QUESTIONS TO ASK

A L E R T

For many people, holidays can be a precipitating event to a suicidal episode.

Take note if the local media has reported on the suicide of a famous

person or local teenager.

Assessing Substance Abuse

Substance use includes use of prescribed or OTC drugs, alcohol, caffeine, nicotine, steroids, and illegal drugs.

Abuse and addiction exist when substance use has social,professional, or legal consequences.There are two types of substance abuse disorders, substance use disorders and substance-induced disorders.

 Substance use disorders include:

Substance dependence: Repeated use despite substance-related cognitive, behavioral, and psychological problems.Tolerance,withdrawal,and compulsive drugtaking can result.

Substance abuse: Recurrent, persistent substance

use with significant adverse consequences during a 12-month period.

Substance-induced disorders include:

Substance intoxication: Overuse of a substance that

results in a reversible, substance-specific syndrome;can

be indicated by behavioral and psychological changes.

Substance withdrawal: Symptoms differ upon the

substances being used and develop upon their withdrawal

(Pederson, 2005;APA, 2000).

If substance abuse is a concern with your client, it is

important to ask the right questions and obtain an accurate

history. If there is no time to obtain a detailed assessment,a

focused assessment tool such as the CAGE questionnaire

can also identify a possible substance abuse problem.

 

Groups at Risk for Suicide

Elderly persons who are isolated or widowed or who have experienced multiple losses

Males who are widowed and without close supports

Adolescents and young adults

Persons with serious or terminal illness who become depressed or hopeless

Persons with mood disorders,depression,and bipolar

Persons with schizophrenia, either newly diagnosed or those experiencing auditory command hallucinations

Persons who abuse drugs or alcohol, especially persons with a mental disorder

Persons under stress (sometimes multiple stressors) with recent loss or losses

Performing a Suicide Assessment

Substance Abuse History and Assessment Tool

1. When you were growing up, did anyone in your family use substances (alcohol or drugs)? If yes, how did the substance

abuse affect the family?

2. When (how old) did you use your first substance (e.g., alcohol, cannabis) and what was it?

3. How long have you been using a substance(s) regularly? Weeks? Months? Years?

4. What is your pattern of abuse?

a. When do you use substances?

b. How much and how often do you use?

c. Where are you when you use substances and with whom?

5. When did you last use, what was it, and how much?

6. Has substance use caused you any problems with family, friends, job, school, the legal system, other? If yes, describe.

7. Have you ever had an injury or accident because of substance abuse? If yes, describe.

8. Have you ever been arrested for a DUI because of your drinking or other substance use?

9. Have you ever been arrested or placed in jail because of drugs or alcohol?

10. Have you ever experienced memory loss the morning after substance use (can’t remember what you did the night

before)? Describe the event and feelings about the situation.

11. Have you ever tried to stop your substance use? If yes, why were you not able to stop? Did you have any physical

symptoms such as shakiness, sweating, nausea, headaches, insomnia, or seizures?

12. Can you describe a typical day in your life?

13. Are there any changes you would like to make in your life? If so, what are they?

14. What plans or ideas do you have for making these changes?

15. History of withdrawal:

Other comments:

Source: Pedersen, D. (2005). PsychNotes. Philadelphia: F.A. Davis; and modified from Townsend, M. (2005).

Psychiatric Mental Health Nursing, ed. 5. Philadelphia: F.A. Davis.

CAGE Questionnaire

Have you ever felt you should Cut down on your drinking/drug use?

Have people Annoyed you by criticizing your drinking/drug use?

Have you ever felt bad or Guilty about your drinking/drug use?

Have you ever had an Eye opener (use of alcohol or drugs first thing in the morning) to steady your nerves or get rid of

a hangover?

A positive (yes) response to two or more questions suggests that there is an alcohol/substance problem.

Note: The need to cut down is related to tolerance (needing more substance for same effect), and the eye

opener is related to withdrawal syndrome (reduction/cessation of substance).

 

Abused Substances: Effects From Use and Withdrawal

SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL

Depressants

Alcohol (booze, brew, juice, spirits)

Sedatives, hypnotics, and anxiolytics, including barbiturates (barbs, beans,black beauties, blue angel, candy, downers,goof balls, BB,nebbies, reds,sleepers, yellowjackets, yellow)

Benzodiazepine(downers)

Stimulants

Amphetamines(A, AMT, bam, bennies, crystal, diet pills, dolls, eye-openers, pep pills, purple hearts, speed, uppers, wakeups)

Cocaine

(Bernice, bernies, big C, blow, C, Charlie,coke, dust, girl,heaven, jay, lady, nose candy, nosepowder, snow,sugar, whitelady)

Crack (Conan, freebase, rock,toke, white cloud, whitetornado)

Unconsciousness

Respiratory depression

Coma

Death

Hypotension

Nystagmus

Stupor

Cardiorespiratory depression

Coma

Death

Ataxia

High temperature

Seizures

Respiratory distress

Cardiovascular collapse

Coma

Death

High temperature

Seizures

Transient vasospasms (may cause myocardial infarction [MI], cerebrovascular accident[CVA], coma, death)

Depressed cognitive functioning

Impaired psychomotor functioning

Decreased reaction time

Decreased balance and coordination

Decreased REM sleep

Slurred speech

Labile mood

Inappropriate sexual behavior

Loss of inhibition

Drowsiness

Impaired memory

Euphoria

High energy

Impaired judgment

Anxiety

Aggressive behavior

Paranoia

Delusions

Euphoria

Grandiosity

Sexual excitement

Impaired judgment

Insomnia

Anorexia

Nasal perforation

(inhaled route)

Psychosis

Tremors

Diaphoresis

Anxiety

Hallucinations

Delusions

Increased pulse andblood pressure

DTs

Sleep disturbances

Insomnia

Hand tremor

Agitation

Nausea and vomiting

Anxiety

Tinnitus (withbenzodiazepines)

Seizures

Cardiac arrest

Depression

Agitation

Confusion

Vivid dreams followed by lethargy

Fatigue

Depression

Anxiety

Suicidal behavior

(continued)

Marijuana

Cannabis (marijuana,hashish, Acapulco gold, Aunt Mary, broccoli, dope, grass, weed,grunt, hay, hemp,J, joint, joy stick, killer weed, pot, ragweed, reefer,smoke weed)

Opiates

Heroin (H, horse, harry, boy, scag,shit, smack, stuff, white junk, whitestuff)

Morphine

Hydromorphone

Meperidine

Codeine

Oxycodone

Opium

Methadone

Hallucinogens

Hallucinogens

(LSD, DMT, Mescaline, acid, big D, blotter, blue heaven, cap, D, deeda, flash, L, mellow yellow, microdots, paper acid, sugar, ticket,

yello)

Club drug, MDMA (ectasy)

Phencyclidine

Phencyclidine (PCP, angel dust, DOA, dust,elephant, hog,peace pill,supergrass, tictac)

Extreme paranoia

Psychosis

Dilated pupils

Respiratory depression

Seizures

Cardiopulmonary arrest

Coma

Death

Panic

Psychosis with

hallucinations

Cerebral damage

Death

Confusion

Hallucinations

Severe anxiety

Hypertension

Seizures

High temperature

Hallucinations

Psychosis

Seizures

Respiratory arrest

Death

Euphoria

Intensified perceptions

Impaired judgment and motor ability

Increased appetite, weight gain

Sinusitis and bronchitis with chronic use

Anxiety, paranoia

Red conjunctiva

Euphoria

Drowsiness

Impaired judgment

Constricted pupils

Dilated pupils

Diaphoresis

Palpitations

Tremors

Enhanced perceptions of colors and sound

Depersonalization

Grandiosity

Euphoria

Muscle relaxation

Impulsive behavior

Impaired judgment

Belligerent, violent behavior

Ataxia

Muscle rigidity

Nystagmus

Hypertension

None

Yawning

Insomnia

Anorexia

Irritability

Rhinorrhea

Muscle cramps

Chills

Nausea and vomiting

Feelings of panic and doom

None

Psychological dependence can causedepression, flashbacks

None

SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL

Inhalants

Gasoline, glue, aerosol sprays,paint thinners(spray, rush, bolt,huffing, bagging,sniffing)

Nicotine(Cigarettes, cigars, bidis, kreteks, pipe tobacco, chewing tobacco, snuff,nicotine gum or patches)

Psychosis withhallucinations

Cardiac arrhythmias

Central nervous system depression

Coma

Cerebral damage

Death

None

Numbness or diminished response to pain

Euphoria

Impaired judgment

Blurred vision

Unsteady gait

Sense of anxiety reduction

Relief from depression

Satisfaction

None

Insomnia

Depression

Irritability

Anxiety

Poor concentration

Increased appetite

 

RESEARCH TELLS US

Worldwide,mental health problems,with depression and anxiety being the most frequent, occur in approximately 24 percent of patients in primary care (WHO, 2005).Mood disorders with increasing rates of depression and anxiety may be associated with physical illness. Deteriorating physical health and cognitive functioning that is often associated with aging is a major risk factor for developing depression later in life. The purpose of the following study was to examine staff contact and input with mental health problems and to determine their experience, training, and

attitudes to mental health problems.A cross-sectional design was used in the United Kingdom.A 40-item questionnaire was mailed to over 300 staff members in primary care.The return rate was 66 percent (n _ 217, 95 percent confidence interval,with two-thirdsof the respondents RNs).The questionnaire focused on depression in identifying mental problems, interventions,and mental health training.Demographics

were obtained to describe the sample.The Depression Attitude Questionnaire (DAQ), a 20-item instrument,was used to assess staff attitude toward depression. The findings reported that 16 percent of their patients had associated mental health problems,with dementia, depression, and anxiety being the most common.The staff reported a willingness to develop an understanding and skills needed to address mental

health problems with patients, but reported little training in the past 5 years that addressed this issue.

The staff, as revealed by the DAQ,was optimistic about treating depression. The study supports the need for mental health training in primary care as evidenced by the limited detection and treatment of mental health problems. The staff was willing and eager to develop the knowledgeand skills to assess and treat mental health problems. The areas identified included recognition of mental disorders, anxiety management, crisis intervention,

and pharmacologic treatment for depression. Although this study was limited to the United Kingdom, the problem is universal.A better understanding

of assessment and treatment of mental health problems would provide a holistic approach to meeting the patient’s needs.

HEALTH CONCERNS

Healthy People 2010 has identified specific objectives that address mental health/disorders.

Improving Mental Health

Improve mental health and ensure access to appropriate,

quality mental health services.

Reduce the suicide rate.Target: 5 per 100,000 from

11.3 per 100,000 in 1998.

Reduce the rate of suicide attempts by adolescents.

Target: 1 percent over 12 months from 2.6 percent

from grades 9 through 12 in 1999.

Reduce the proportion of homeless adults who

have serious mental illness.Target: 19 percent from

25 percent age 18 and older in 1996.

Increase the proportion of persons with serious mental

illness who are employed.Target:51 percent from

43 percent age 18 and older in 1994.

Improving Treatment

Reduce the relapse rates for persons with eating

disorders.

Increase the number of persons seen in primary

healthcare who receive mental health screening

and assessment.

Increase the proportion of children with mental

health problems who receive treatment.

Increase the proportion of juvenile justice facilities

that screen new admissions for mental health problems.

Increase the proportion of adults with mental disorders

who receive treatment.

Increase the proportion of persons with cooccurring

substance abuse and mental disorders

who receive treatment for both disorders.

Improving State and Local Involvement

Increase the proportion of local government with

community-based jail diversion programs for adults

with serious mental illness.

Increase the number of states (including the

District of Columbia) that track consumers’ satisfaction

with the mental health services they receive.

Increase the number of states and territories

(including the District of Columbia) with an operational

mental health plan that addresses cultural

competence.

Increase the number of states and territories

(including the District of Columbia) with an operational

mental health plan that addresses mental

health crisis interventions, ongoing screening, and

treatment services for elderly persons.

sessment of Common Mental Health Problems

Anxiety

Diffuse feelings of apprehension with feelings of

uncertainty, helplessness

Ranges from mild to panic state that can be paralyzing

Restlessness

On edge

Easily fatigued

Concentration problems

Irritability

Sleep disturbances

Dizziness

Palpitations

Hot/cold flashes

Tightness of chest

Nausea

Decrease appetite

Abdominal pain

Affect

Nervous

Anxious

Fearful

Physical Findings

Sweating

Tremors, rigidity, spasms

Dilated pupils

Increased respirations

Wheezes due to bronchial spasms

Tachycardia, increased blood pressure

Diarrhea

Vomiting

Increased reflexes

Muscle tension

Pacing, clumsy movements

Confusion

Easily distracted

Short attention span

 

Anxiety differs from fear in that fear has an identifiablesource, anxiety may not.

Types: (DSM-IV)

Panic Disorders

Extreme, overwhelming anxiety in response to real or

perceived life-threatening situation

Can lead to phobias, avoidance, and agoraphobia

Phobias

Unreasonable fear response to a specific object or

situation

Causes anxiety

Person realizes fear is unreasonable

Social Anxiety Disorder

Fear of social or performance situations that may cause

embarrassment

OCD

Recurrent thought or ideas (obsession)

Action person cannot refrain from doing

(compulsion)

Obsession and compulsion interfere with social and

occupational functioning

Recognizes thoughts and behaviors are unreasonable

PTSD

Traumatic event

Threat of harm or death, actual death, and helplessness

Re-experiences event (flashback)

Hypervigilant

Recurring nightmares

Anniversary reactions related to trauma

Persistent anxiety

Acute _ 3 mo, chronic _ 3 mo, delayed _ 6 mo

Acute Stress Disorder

Anxiety, dissociation, and other symptoms after exposure

to recent stressors

Anxiety Disorder related to Medical Condition

Generalized anxiety disorder

Excessive worry and anxiety for at least 6 mo

Difficult to control worry

Hypervigilant

Substance-induced anxiety

 

Assessment of Common Mental Health Problems (continued)

Personality Disorders

Pattern of relating and perceiving the world that is

inflexible and maladaptive

Types:

Cluster A includes paranoid, schizoid, schizotypal

personality disorders

Paranoid: Distrustful and suspicious of others,

preoccupied with doubts of loyalty, holds grudges,

unwilling to forgive, quick to react and counter

perceived insults

Schizoid: Detached from social interaction, restricted

expression of emotions, lacks desire for intimacy,

emotionally cold

Schizotypal: Social and interpersonal deficits, odd

beliefs or magical thinking, perceptual alterations, odd

or eccentric behavior

Cluster B includes antisocial, borderline, histrionic, and

narcissistic personality disorders

Antisocial behavior: Pattern of disregard and violation

of rights of others

Borderline: Unstable behavior with changes in

relationships, self-image, and mood

Histrionic: Excessive expression of emotion and

attention-seeking behavior

Narcissistic: Inflated sense of self, need for attention

and admiration, no concern for others

Cluster C includes avoidant, dependent, and obsessive

compulsive personality disorders

Avoidant: Avoids social interaction for fear of criticism

and feelings of inadequacy

Dependent: Needs to be taken care of, submissive, fear

of separation, low self-confidence, difficulty making

decisions and voicing disagreement

Obsessive compulsive: Rigid way of functioning,

excessive detail or controlling ways

Psychotic Disorders

Schizophrenia

Caused by neurobiological factors; influenced by social

and environmental factors

Four “A”s of Schizophrenia

Inappropriate Affect

Cluster A

Distrustful, emotionally detached, eccentric

personalities

Cluster B

Disregard for others, unstable and intense interpersonal

relationships, excessive attention seeking, entitlement

issues with lack of empathy for others

Cluster C

Avoider of social situations, clinging, submissive

personality; and person preoccupied with details, rules,

and order

Borderline Personality Disorder

Pattern of unstable relationships

Fear of abandonment

Splitting: Idealize and devalue (love/hate)

Impulsive (in two areas: sex, substance abuse, binge

eating, reckless driving)

Suicidal gestures/self-mutilation

Intense mood changes lasting a few hours

Chronic emptiness

Intense anger

Transient paranoid ideation

Positive Symptoms _ Excessive function/distortion inbehavior

Delusions

Hallucinations (auditory/visual)

Hostility

Disorganized thinking and behavior

Obsessive compulsive personality disorder differs from OCD in that the person with obsessive compulsive personality disorder has no problem with behavior, whereas the person with OCD is anxious and wants to change

Auditory hallucinations usually begin distant and soft, then become louder, but become softer and distant as client’s condition improves.

In North America, most hallucinations auditory. Not likely to have both auditory and visual together.

Negative Symptoms _ Deficits in behavior, such as reduced function or self-care deficits

At least for 1 mo, two or more:

Delusions

Hallucinations

Disorganized speech

Disorganized behavior

Negative symptoms

Functional disturbances at work or school disturbance

continues for 6 mo

Mood Disorders

Extremes of moods (mania or depression)

Types

Depressive

Major depressive disorder (unipolar depression): At

least 2 wk of depression/loss of interest and four

additional symptoms with one or more major depressive

episodes.

Dysthymic disorder: On-going, low-grade depression of

at least 2 years’ duration for more days than not and

does not meet the criteria for major depression

Depressive disorder not otherwise specified (NOS): Does

not meet criteria for depressions described above.

Bipolar Disorders

Bipolar I disorder: One or more manic or mixed episodes

with a major depressive episode

Bipolar II disorder: One or two major depressive

episodes and at least one hypomanic episode

Cyclothymic disorder: At least 2 years of hypomanic

episodes that do not meet the criteria for other

disorders

Bipolar disorder NOS: Does not meet any of the other

bipolar criteria

Eating Disorders

Types

Anorexia Nervosa

Terrified of gaining weight

Depressive

Depressed mood or loss of interest for at least 2 wk and five or more of:

weight loss/gain

insomnia or hypersomnia

psychomotor agitation or retardation

fatigue

worthless feelings or inappropriate guilt

problem concentrating

recurrent thoughts of death

Mania

Persistent elevated, irritable mood for 1 wk or more, plus three or more (irritable, four or more):

high self-esteem

decreased sleep

increased talking/pressured speech

racing thoughts/flight of ideas

distractibility

extreme goal-directed activity

excessive buying/sex/business investments (painful

consequences)

Anorexia Nervosa

Emaciated appearance

Below normal weight

Hair loss, dry skin

Loose Association

Autistic thoughts

Ambivalence

A L E R T

When working with patients who have depression, it is important to identify any suicidal/homicidalideations.

 

 Common Mental Health Problems (continued)

Weight below minimally accepted (weight _ 85% of

what would be expected for age and height)

Disturbed self-perception of size and shape of body;

even though underweight, still fears becoming

overweight

Self-esteem and self-evaluation based on weight

Introverted, socially isolated, high achiever

Bulimia Nervosa

Recurrent binge eating of large amounts of food over

short period

Lack of control

Self-induced vomiting, use of laxatives, purging,

fasting, excessive exercising

Weight normal, under-/overweight

Fluid and electrolyte imbalance

Impulsive, acting out, more histrionic (pervasive,

excessive expression of emotions and attention-seeking

behaviors)

Amenorrhea

Pedal edema

Bulimia

Normal or overweight

Weight fluctuations

Dehydration

Hoarseness

Parotid gland enlargement (chipmunk facies)

Tooth enamel erosion

Finger or pharynx bruising

 

S U M M A R Y

Holistic nursing care includes assessment of the psychological health of your patient.The developmental level and cultural background of your patient needs to be considered when assessing your patient’s mental health.

When obtaining a health history and physical assessment, look for clues that reflect the mental health of your patient.

A thorough mental health assessment includes a detailed mental status assessment. Specific mental health assessment instruments are available to further assess the mental health needs of your patient.

Identify supports and resources and make referrals as needed to meet the mental healthcare needs of your patient.