(Test Bank) MENTAL HEALTH AND PSYCHIATRIC NURSING

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1 COURSE TITLE: MENTAL HEALTH AND PSYCHIATRIC NURSING CHAPTER ONE : ETIOLOGY OF PSYCHIATRIC ILLNESS Student learning objectives At the end of the chapter the student should be able to: a. Discuss the difficulties associ ated with etiology in psychiatry. b. Discuss the nature vs. nurture controversy c. Classify cause of psychiatric illness d. Explain some specific etiological factors to psychiatric illness Etiology deals with the science or philosophy of causation of disease. It‘s concerned with ascertaining which features of the individual and the environment are relevant and causal and which mechanisms in the body are involved in the illness. Complexity of causes of psychiatric illness Two factors complicate the etiology of psychi atric illness. Etiology or physical illness is usually straight. 1. Causes are often remote in time from the effects that they produce e.g. childhood experiences may predispose to future problems e.g. rape experience making one fail to establish relationsh ips with opposite sex. Fetal distress predisposing to epilepsy in future. 2. A s ingle cause may lead to several effects e.g. Cause Effects Over loving/ -timidity Protecting -easy depression Parents -poor frustration tolerance Also a simple effect may arise from several causes Genetically vulnerability Parental deprivation Depression 2 Social events e.g. divorce Childhood experiences e.g. Heredity and environment as influences of behavior and development The differences between individuals or groups is attributable to the above two factors. Heredity is the source of both similarit ies and differences among individuals. The environmental influences are those that act upon organism at the earlier stages of development within the mother‘s womb and later ex ternal environment after birth. Studies on mono zygotic twins (identical) reared s eparately have shown that differences are attributable to the environmental factors e.g. Family environment, School environment, Cultural patterns of the society The similarities are due to the hereditary factors. Hereditary & environmental factors are interdependent factors/ forces. Hereditary supplies the potential talent which the favorable environment brings out. It also determines the possible limits of accomplishment for the individual in any given situation. The environment determines how close to the se limits of performance any individual can achieve in a given situation. The Nature – Nature controversy The nature (heredity) – nature (environment) debate really concerns the relative importance of heredity & environment. But the general agreement is t hat human behavior & development is determined by the interaction of the two factors. Therefore, the causation of psychiatric illness is as a result of a complex interaction of a number of factors resid ing within the individual (Intri nsic factors) and envi ronment (extrinsic factors).Initial attempts to establish a single etiological factor were fruitless. Multiple causation is the rule. The relative importance of intrinsic and extrinsic factors varies according to the: -  Type of illness – schizophremia incre ases intrinsic  The individual – psychopath – drug abuse. There is a continuous interaction of intrinsic and extrinsic factors to bring about psychiatric illness. NB: - Therefore in many cases, there is no single cause of mental disorders but multiple facto rs interact to cause the illness. Causes can be put in three classes 3  Predisposing factors -Factors that is usually present early in life.  Precipitating factors -Factors that are present shortly before onset i.e. those factors that induced the illness.  Perpet uating factors -Factors that prolong the course of the disorder. Dysfunctional family patterns. For Example depression might have the following classes of causal factors:  Predisposing factors – genetically susceptibility  Precipitating factor - divorce or los s of a loved one  Perpetuating factors -Poor social support system e.g. poor family support system. Some specific etiological factors 1. Genetical factors These play a predominant role in the causation of psychiatric disorders like major depression, familial alcoholism, personality disorders and mental retardation. Therefore the family history of mental illness is very important in the significance of genetic disorders in the etiology of disease. 2. Physical (or organic) factors These are physical elements e.g. t rauma, infections , Syphilis, Viral encephalitis, Meningitis, Malaria (cerebral) . Drug withdrawal e.g. alcohol withdrawal (sudden) De lirium Treme ns (DTs) that lead to brain damage & subsequently psychiatric illness . A patient with damage to the frontal lobe shows typical psychiatric symptoms/ manifestations – area associated with behavioral functions. Examples of organic psychiatric disorders: - Delirium , Delirium Trem ens (DTS), organic hallucinations, dementia, organic anxiety disorder, organic mood disorder , Parkinsonism disease, Huntington‘s chorea etc. 3. Social - economic factors Poverty is the most vital economic factor associated with psychiatric disorder e.g. delinquency (Juvenile) drug/substance abuse disorder, adverse childhood experiences, malnutrition etc. Social factors are also important e.g. functioning of social institutions/ systems of society e.g. family & learning institutions. Problems that can be associated with social factors include suicide, violence, social conflicts, divorce, adverse child hood experiences like rape, teenage pregnancy with its attend ant problems e.g. premature births, abortions etc. .The n uclear family has chan ged greatly e.g. family size and roles other aspects that have affected the family include: 4  Relocations & mobility. Leaving familiar environ & readjusting to new ones is stressful. Extended family is also left behind hence its supporting role is lost. Cultures also differ in there place hence culture shock common.  Step families. Remarried families have unique problems. Care & management of children in these families difficult. Bonding problem exist with step parents.  Childless families - are stigmatized  Same – gender families – stigmatized due to homosexual lifestyle. Experience verbal harassment or violence. Homophobia – is a prejudice that leads to discrimination and stereotyping & ultimately stigmatization. 4. Psychological factors/stresses Excessive psychological stresses can contribute to psychiatric illness e.g. those related to developmental stages – menopausal stress es, adolescent stresses, marital stresses. Distressing events (natural or man made) e.g. physical or sexual abuse, rape, floods, bombing, fire or violent crime, war, abduction, kidnap, hijack etc can make people experience post traumatic stress disorder – characteristic psychological consequences that persist for at least 1 month after a traumatic event outside the range of usual human experience. 5. Interpersonal factors Relationships with significant others may influence the mental status of the person e.g. Marital relationships, Cohabitation relationships, Child -Parental relationships, maternal child relationships and o ther social relationships. Inadequate social support system may be a factor influencing occurrence of mental disorders e.g. mental disorders are usually common in dysfunctional families than functioning families. Therefore, support from family, friends and relatives is vital for the maintenance of adequate mental health especially during times of stress or major transitions in life. Other fact ors  Cultural factors – cultural differences may cause conflict in an individual  Political factors – wars and other social injustices may be associated with stresses ☺? Critical thinking activity/learning activity 5 1. Define risk factors and identify the d ifferent types of risk factors in psychiatric mental health 2. Describe the importance of intrinsic and extrinsic factors in the etiology of different psychiatric disorders 3. Identify additional etiological factors to mental illness 4. Discuss the theoretical basi s of psychiatric nursing - biologic, psychologic,social and nursing theories 5. Explain the neurotransmitter theory of mental illness causation CHAPTER TWO : GENERAL SYMTOMATOLOGY Student learning objectives At the end of the chapter the learner should be abl e to: a. Define and describe different signs and symptoms of psychiatric disorders b. Classify signs and symptoms as disorders of perception, thinking, speech, motor activity, memory, orientation, mood/affect, consciousness, and cognitive/intellectual functionin g c. Explain the relationship between different psychiatric symptoms Introduction to general symptomatology Symptoms are vital in diagnosis of psychiatric disorders. But diagnosis of a mental disorder shouldn‘t be made on the basis of an individual symptom – which might also be short -lived . Therefore, for proper diagnosis symptoms should occur that are intense and persistent. A syndrome should be established i.e. S igns and symptoms should portray a recognizable pattern. So identification of syndromes is of gre at importance as opposed to individual sign or symptom. Many symptoms in psychiatry have type and content aspect. Psychiatric signs and symptoms fall into groups referred to as systems of psychological functioning. These include: - A. Perception B. Thinking C. Speec h D. Motor activity 6 E. Memory F. Orientation G. Consciousness H. Cognitive (intellectual functioning) I. Mood effect Different psychiatric disorders may affect each of the above systems as discussed below: A. Disorder of perception Perception is the p rocess of becoming aware o f what is presented through the sense organs. Its response to stimuli from five senses or relating various sensory impressions with previous experiences and knowledge. Imagery is the experience within the mind without usually the sense of reality that is p art of perception. eg eidetic imagery is where visual image which is so intense and detailed that it has ―Photographic quality.‖Unlike perceptions, imagery can be called up and terminated by voluntary efforts. There are many disorders that may affect percep tion: i. Illusion Misperceptions of external stimuli e.g. mistake a stick for a snake. When occur: -  When general level of sensory stimulation is reduced e.g. at dusk you perceive the outline of a bush as that of a man.  When level of consciousness is reduced e .g. acute organic syndrome.  In strong affective states e.g. anxiety state you look at a cloud as an angel coming for you.  When attention is not focused on sensory modality.  Also in depression. May also occur in normal persons but are pathological if they p ersist or become excessive. ii. Hallucinations Mental impressions of sensory vividness without adequate external stimuli . A perception experienced in the absence of an external stimulus to the sense organs and with a similar quality to a true perception (compa re with imagery) .Not restricted to the mentally ill. Normal people may experience hallucinations especially when tired. Also occur in healthy people during the transition between sleep and waking. While falling asleep – called hypnagogic hallucinations and 7 While awakening – hypnopo mpic hallucinations. Pseudo hallucinations -Vivid mental images that lack the quality of representing external reality and seem to be within the mind rather than in external space. Lack of vividness of a perception. Hallucinatio ns occur in: -  Severe affective disorder e.g. during strong feelings or conflicts which cannot be controlled by ordinary coping/defense mechanisms e.g. self -approach, excessive fear/ intense religiosity etc.  Schizophrenia  Organic disorders e.g. lesions of t he sensory centers .  Toxic states e.g. alcohol intoxications  Dissociative disorders  Some times in healthy p eople as said above. Hallucinations have two very important qualities i.e. e xperienced as a true perception not imagery and it seems to come from the outside world (except for somatic hallucinations) .Experiences that possess one of these qualities, but not the other are pseudo hallucinations . Types of Hallucinations Grouped according to: -  Complexity  Sensory organ affected. Based on Complexity: I) Elementar y Such experiences as bangs, whistles, flash of light. II) Complex E.g. hearing voices or music, Seeing faces & scenes Based on Sensory system affected 1) Auditory hall ucinations Hears voices which don‘t exist. Voices may command one to do violent acts e.g. kill or commit suicide. May occur in depression. 8 Subtypes Second person auditory hallu cinations - Directly refers to the patient. ―You‖ e.g. you are going to die. Third Person auditory hall ucinations Uses ―he‖ or ―she‖ e.g. She is going to die. 1. Tactile hallucin ations Also called haptic hallu cinations or somatic hallucinations. Sensations of being touched, pricked or strangled usually occur in organic states e.g. marked cocaine toxicosis – called ―cocaine bug s‖ and schizophrenia. A s ubtype here is s exual hallucin ations -special type of tactile hall ucination . E.g. Male schizophrenics may complain of erection & orgasm being forced into them. Female schizo phrenia –may have the sensation of being raped . 3. Visual hallucinations Seeing figured/images that are not present m ay occur in: -Intense fear and o rganic psychosis 4. Gustatory hallucinations Person tastes strange things in the mouth which are actually not there. Occur in: - Schizophrenics and Major/ grandma epilepsy 5. Olfactory hallucinations Perceive peculiar smells which don‘t exist. Occur in: -Temporal epilepsy, Depressive, Schizophrenics Unclassified Reflex hallucinations Where a stimulus in one sensory modality results in hallucinations in another e.g. sound of music provokes visual hallucinations. Perception and meaning -A percept has a meaning for the person who experiences it. In some disorders an abnormal meaning may be associated with a normal percept – called delusional perception . Percepts may also lose their meaning – called agnosia. iii. Depersonalization/Derealizatio n Are alterations in the perception of one‘s reality 9 -Depersonalization Patient feels detached and views himself/herself as strange and unreal. It is ―as if‖ phenomenon and patient is not full convinced. It‘s the change of self -awareness that t he person feels unreal. Derealization Alteration of sense of reality of the environment/outside world. Familiar objects/places/persons seem to have changed in shape and size. NB Depersonalization i s directed towards self while derializations t owards outsid e world. Occurs in: -Depression, Anxiety states , Schizophrenics, Hysteria and in n ormal subjects B. Disorders of thinking/thought disorders Thinking is the most highly organized function of the brain. It combines experiences with perceptions and knowledge whi ch had been stored as memory. Thoughts are understood through speech and writing. Hence disorders of thought are closely related to disorders of speech. Subtypes i) Disorders of sequence of thought/stream/progression of thought – concerns with speed and amoun t of speech.  Flight of ideas / accelerated thinking. Thought are not determined by any overall directing tendency but ideas follow each other in quick succession. Linkage between topics is normal as opposed to loosening of Association where topics have no linkage. Sometimes the t rain of thoughts is governed by chance associations & clang Associations. Clang associations/ punning is where sound govern choice of word rather than its meaning e.g. Am old and bold. I am a male and mail. Thoughts follow one anothe r so rapidly that the expression of an idea is incomplete; one train of thought is incomplete before the other takes over. Occur in: -Mania/ hypomania, Organic states esp. due to hypotha lamic lesions, Excited schizophrenics  Retardation /inhibition of thought / poverty of thoughts Stream of thought is slowed down , speech slow & difficult. Thought s are slow , few & unvaried. Occur usually in severe depression, organic state & schizophrenia.  Perseveration of thought 10 Mental operations persist beyond their relevanc e. Thoughts or theme s repeated though not currently relevant. Patient is not able to break away from the theme. It is p ersistent & inappropriate repetition of same sequence of thoughts as seen by repetition of speech or actions. Also considered a speech di sorder common in p atients . Common in o rganic states e.g. Dementia and sometimes in schizophrenia  Circumstantial thinking/ Circumstantiality. Inclusion of many, unnecessary trivial details which are not essential to the subject being discussed. Thinking proceeds slowly with many unnecessary & trivial details but finally the goal is reached e.g. light amount given. Occur commonly in:-Mania/ hypomania, Organic mental states, Schizophrenics, Obsession personalities  Pressure of thought Patient compelled to think and his thought runs away with him/her. Thoughts unusually rapid, abundant & varied. Common in mania , anxious depressed patients & sometimes schizophrenia.  Thought blocking Stream of thought stops altogether. Thoughts switch off abruptly & sometimes a new one totally unconnected with it takes over. Commonly occur in Schizophrenics and a nxiety states  Tangentiality/ Tangential thinking Same as circumstantiality but the final goal is not reached as the p atient loses track of the original idea.  Fragmented thinki ng/loosening of association . Same as flight of ideas but the topics/ideas have no linkage. Common in: -schizophrenics, organic disorders. Lack of logical connection between parts of a train of thoughts (knights‘ move thinking). Differentiate this from fragm ented thinking that occurs in anxiety or low intelligence. ii. Disorders of thought content a. Delusions Are unshakeable, usually false beliefs which are incompatible with one‘s socio -cultural or educational background, and they cannot be explained on the basis o f reality. They are out of keeping with person‘s education and cultural background. Note that they are u sually false, but 11 not always. The main feature is that it‘s firmly held on inadequate grounds i.e. the belief is not arrived at through the normal proc ess of logical thinking. It arrived at through abnormal thought process. A delusion can be true or subsequently become true e.g. in pathological jealousy (jealousy delusions) a man believes that his wife is unfaithful without any evidence - even if the wife is actually unfaithful at the time, it‘s still delusional. NB: Differentiate this from strongly held non delusional convictions/ beliefs. Delusions arise from internal morbid process e.g. strong feelings of fear, envy, anger, or inferiority which reduce the capacity for critical thinking. Superstition: Someone e.g. witchdoctor forces you to believe something whereas delusions originate from the persons without any compelling force. In delusions, there is usually absence of evidence sufficient for a reasonabl e prudent man to draw such a conclusion as seen in delusion. Types of delusions Based on onset Primary/ autochthonous delusions Appears suddenly and with full conviction but without any mental events leading up to it. Beliefs arrive in the mind suddenly, fu lly formed and in a totally convincing form. One that cannot be understood as arising from other psychological phenomenon. Special primary delusion may include delusional mood, delusional perception and delusional memory. Secondary delusions Derived from s ome preceding morbid/abnormal experience e.g. hallucinations, mood. Someone who hears voices may come to belief that he is being followed or person who is profoundly depressed may believe that people think he is worthless. Based on: theme/content Persecuto ry delusions/ paranoid . Subjects believe that others are plotting against them. He thinks he is the subject of persecution common: -Paranoid schizophrenia, some depressives (severe) , Organic states, Abnormal personalities Grandiose delusions : Also called ex pansive delusions/delusions of grandeur . Subject believes that he is some important person e.g. Jesus, Pope, President, Almighty God etc or endowed with unusual abilities or special in something. May also think that he is related to some important people e .g. MPS, royal family etc.Common in General paralysis of the insane (GPI) very classical in GPI , Mania, and Schizophrenics Nihilistic delusions 12 Belief that one is dead & everything around him has stopped working. May also believe that some portion of him i s non -existence e.g. genitals, belief something, one doesn‘t exist. Chiefly occurs in severe depression. Religious delusions : Obsessional believes that one is holier than others. Fanatics – concerned with guilty divine punishment for small sins or special divine process. Jealous delusions/infidelity delusions: Belief that one‘s partner is unfaithful. May lead to violence. Common in men. Sexual or amorous delusions: Common in women. Belief that she is loved by a man who has never spoken to her and who is in accessible e.g. public figure. Paranoid delusions: False belief that makes one over suspicious due to fear of harm. Delusion of reference : Patient believes that people look at him, talk about him and that his surrounding has a special significant for him. Belief that objects, events & people have significance to him e.g. remark on TV. Common in Schizophrenics, Depressive states, Organic states Delusions of control/ influence: Individual believes that certain objects or persons have control over his or her behavior . Common in s chizophrenia. Somatic delusions: False idea about the functioning of an individual‘s body e.g. one may believe that he is oldest person on earth. Delusions of guilt: One believes that he is very wicked, has committed a terrible sin and deserves punishment. The unforgivable sin is usually that of fornication or masturbation. Common in depressives. Hypo chondriacal delusions : Patient believes that he has cancer, TB or any other dreadful disease. Common in especially elderly: -Depressives , Sch izophrenics, Abnormal personalities May seek plastic surgery services if they think parts of body are abnormal e.g. nose. Delusion of poverty One is convinced that he is utterly impoverished, despite documentary evidence to the contrary. Rare symptom in de pressives. Other types of delusions Double orientation : Where delusions don‘t influence p atients feelings/actions e.g. in chronic schizophrenics. 13 Shared delusions: As a rule, other people recognize delusions as false and argue with pts in an attempt to cor rect them. Occasionally , a person who lives with a deluded patient come to share is delusional beliefs. Also called ―folie a deux‖ .The second person may stop believing when separated from the patient. Partial delusions – delusions characterized by less fi rm belief that they may weaken as a amount of conviction decreases. b. Overvalued ideas Described first by Wenicke (19 00).Defined as an isolated pre -occupying belief, neither delusional nor obsesional in nature, which comes to dominate a person‘s life for man y years and may affect his actions. e.i.It is false belief contrary to the facts presented but in keeping with a person‘s socio -cultural background e.g. Some denominations over -emphasize a small aspect of the Bible as if it‘s the only requirement to purity. A person who mother or sister suffered from cancer one after the other may become pre -occupied with the conviction that cancer is contagious. A second definition is that it‘s an i solated pre -occupying strongly held belief that dominates a persons life and may affect his actions but (unlike del usion) has been derived through normal mental process e.g. a man whose parents developed cancer within a short time may be convinced that cancer is contagious even though his doctor presented evidence to the contrary & may avoid visiting a friend with cancer who has asked to see him. To differentiate a delusion & an overruled idea, the interviewers retrospectively examine how the belief/ idea were formed. iii. Disorders of possession of thought Normally we experience our th oughts as belonging to us or there is a quality of ―my -ness‖ of our thoughts. Apart from this we feel in control of our thinking. Both the control and the possession of thought can be disturbed by mental illness. Patients may be compelled to think his own thoughts against his will or he may experience his thoughts as alienated from himself in some way. a. Obsessions Recurrent, persistent thoughts, impulses or images that enter the mind despite the persons effort to exclude them or Persistent and recurrent idea s, thoughts or impulses, wishes that cannot be eliminated from consciousness by logic or reasoning. The defining characteristic is the subjective 14 sense of a (struggle) resistance against the intruding mental phenomenon. Resistance distinguishes obsession and delusions where it‘s absent. Obsessions can also be defined as undesirable contents of consciousness which cannot be got ten rid of , although when they occur they are judged as being senseless or at least as dominating and persisting without cause. One feels ashamed to tell people about them. Regarded by the person as untrue & occurring against the p atients will.Obsessional thoughts can be about any topic but commonly are centered on the following themes : - Rationale not clear.  Dirt or contamination e.g. of hands by bacteria.  Aggressive actions e.g. that the person may harm another or speak obscenities.  Orderliness - idea that things have to be arranged in a certain way.  Illness – idea that a person may have a certain d isease or get a certain d isease e.g. cancer.  Sex – thoughts or images of practices that the person finds disgusting.  Religion – blasphemous thoughts, doubts about the fundamentals of belief etc. Examples of obsessions  Obsessional ruminations: - repeated themes of more complex nature e.g. endi ng of the world.  Obsessional thoughts – repeated & intrusive words/phrases usually upsetting to the pt e.g. blasphemous phrases coming to a religious person.  Obsessional doubts – repeated themes expressing uncertainty about previous actions e.g. whether cl osed house before sleep or put off electricity. Obsessions are common in: depression, obsessional Neurosis, organic states, schizophrenia, and anxiety. Differentiate obsessions from:  Ordinary preoccupation of healthy people.  Intrusive concerns of anxious o r depressed people.  Recurring thoughts & images associated with disorders of sexual preference.  Recurring thoughts & images associated with drug dependency  Delusions Patients with these non -obsession ideas do not regard them as unreasonable & do not resist them. Obsessions are an essential feature of obsessive – compulsive disorder. Obsessions are closely associated with compulsions / Compulsive rituals which are 15 repeated, stereotyped, and seemingly purposeful actions which the person feels compelled to carry out but resists, recognizing that they are irrational. They are not thoughts but abnormal actions usually closely associated with obsessions because people act to fulfill unwanted urge arising from an obsession. Other times there is no connection e.g. when checking position of objects is associated with aggressive ideas. Compulsions usually produce an immediate lessening of distress associated with obsessional thoughts. Compulsions can be of any kind but four are usually themes common: -  Checking rituals – often concerned with safety e.g. door, gas, electricity  Cleaning rituals – repeated hand washing or domestic cleaning.  Counting rituals – counting to a particular number or counting in threes  Dressing rituals – clothes set out & put on in a particular o rder. Phobias These are forms of obsessions. They are defined as p ersistent, exc essive , irrational fears about a real or imagined object, place or a situation. They are specific pathological fear reaction out of proportion to the stimulus. Fear not proport ional to dangerousness of the object, place, person etc.Could also be called obsessional phobias – which are obsessional thoughts leading to anxiety and avoidance behavior. Examples of phobias include: Zeusophobia – God; Dentophobia – dentist ; Abluthoph obia – bathing ; Lachanophobia – vegetable ; Clinophobia – going to bed ; Arachnophobia – flying ; Anuptaphobia -staying single ; motophobia – automobiles ; Cyberphobia – computers ;Algophobia – pain; Pathophpbia – disease; Zoophobia – animals; Agoraphobia – fear of open spaces or outdoors one of the commonest phobias.; Astraphobia – thunder & lightning ; Gynenophobia – fear of women ; Kakorrhaphiophobia – fear of failure ; Hematophobia – blood ;Cypridophobia – fear of venereal d iseases ; Nyctophobia – darkness ; Mystophobi a – dirt;Sitophobia – eating; Xenophobia – strangers ; Pyrophobia – fire. Social phobia: fear of eating, drinking, speaking, writing, blushing or vomiting in presence of others. Individuals tend to develop avoidance behavior towards the objects that they fear. This interferes with individuals‘ normal functioning e.g. hydrophobia, gynenophobia. NB: Anticipatory anxiety – when one feels anxious about the phobic stimulus on thinking about it. b. Alienation of thought. Patient experience that his thoughts are under control of an outside agency or others are participating in his thinking. 16  Thought withdrawal -One experiences as if thoughts are taken away from his mind.  Thought insertion -Thoughts experienced as being inserted into p atients mind.  Thought broadcasting -Patient has the experience that everyone else is participating in his thinking. All t hese forms of thought alienation characteristic of schizophrenia . C. Disorders of orientation Orientation in three aspects i.e. time, person and p lace Disorientation common in: -Organic mental disorders, Psychotic disorders e.g. schizophrenia . D. Disorders of speech Characteristics of speech include rate, volume, articulation and tone. Closely related to disorders of thinking as speech is frequently an accurate congruency of thinki ng. Hence speech can be : - retardation of speech, blocked speech, fragmented speech, incoherent speech, and accelerated speech There other speech disorders : a. Echolalia Repetition of interviewers words like a parrot. Common in schizophrenia , dementia & autis tic children ( autism ). b. Neologism A patient invents new words/phrases or gives new meaning to standard words. c. Mutism – absence of speech. d. Clang association : Speech directed by the sound of a word rather than its meaning i.e. choice of words is governed by sound rather than their conceptual meaning e.g. ―I am cold and bold ‖ or ― The gold has been sold and sold ‖. e. Word salad : Group of words put together in random fashion without apparent logical connection. f. Loosening of association : Patients shifts ideas from o ne to the other without logical connection between them. E. Disorders of motor activity The level of motor activity closely related to the thought processes which also affects speech. Therefore, motor activity, speech and thoughts are closed/ interlinked. Pro blems of motor activity common in schizophrenics except tics/habits spasms 17  Restlessness Inability to remain still. The person keeps on moving his body or part of it. When associated with anxiety and worry its called agitation.  Stereotypes Repeated movement s that are regular (unlike tics) and without obvious significance (unlike mannerisms) e.g. rocking to and from  Tics/habit spasms Irregular involuntary repeated movements involving a group of muscles e.g. sideway movement of the head or wetting ones lips.  Choreiform movements : Brief involuntary m ovements which are coordinated but purposeless.  Mannerisms – repeated movements that appear to have some functional significance e.g. saluting, matching.  Dysto nia: - muscle spasm – painful & may lead to contortio ns  Posturing : Adoption of unusual bodily postures continuously for a long time. May have symbolic meaning e.g. hands outstretched as if to be crucified or may not have any meaning e.g. standing on one leg.  Ambitendence : Alternate between opposite movemen ts e.g. putting out the arm to shake hands, and then withdrawing it , extending it again and so on.  Echopraxia : Patients purposely imitates the movement of another person. Subject imitates all the actions of the examiner. Common in schizo phrenia and dement ia.  Negativism : An active striving against all external attempts to influence behavior e.g. the more the examiner insists on P hysical examination the greater the resistance. Subjects do opposite of what is asked and actively resist efforts to persuade the m to comply.  Compulsion/C ompulsive ritual Recurrent actions carried out to relieve the urgency of obsessive thoughts e.g. repetitive hand washing in an attempt to relieve an obsession of dirty hands.  Stupor 18 Patient lies or sits motionless and doesn‘t repl y to questions or if he does, he gives muttered monosyllabic replies.  Waxy flexibility/ flexibilit as cerea The examiner encounters plastic resistance like the bending of a wax rod when moving a patient body (or part of it) which is then maintained in an ol d position. Very common in catatonic schizophrenia . F. Disorders of mood/Affect Comprises the most common symptoms of psychiatric disorders. They are typical in anxiety and depressive disorder. But normal people may also experience them in stress. Mood : Emoti onal state of some duration in which the total experience of the subject is completely colored by the prevailing emotion. Emotion that the p atient tells you he feels or is conveyed non-verbally. Affect : Sudden accentuation of emotion of short duration and marked intensity, often reactive how patient‘s mood appears to the examiner – ranges & amount of emotion express Usually these two terms are used synonymously to describe the general emotional state of a person. Mood influences thought, speech and motor a ctivity –changes in f acial expression & posture accompany mood change. E.g. e lated – flight of ideas – accelerated speech – restless in motor activity. Appropriateness – congruency with the subject of conversation – appropriate/not appropriate. Anxiety (pa thological anxiety) An unpleasant affective state with the expectation, but not certainty of something happening. Feeling of apprehension that is out of proportion to the actual situation. Marked anxiety is called fear & when acute called panic. Anxiety is not necessarily negative unless it‘s very high or very low. Phobic anxiety: avoidance behavior relates to stimuli. Tendency to avoid stimuli that evoke anxiety. Anxiety common in: Anxiety disorders, substance abuse, organic states etc. Euphoria/Elation Euphoria : Mild unwarranted cheerfulness. If associated with a sense of bodily wellbeing it is called euto nia. Elation ( pathological elation ) 19 Marked cheerfulness . Pervasive rising of mood accompanied by excessive cheerfulness & even ecstasy. Above terms usual ly used synonymously to mean a feeling of sense of well -being which is exaggerated & inappropriate usually associated with psychomotor acceleration. Common in: Mania /hypomania an Hypothalamic lesions Depression (pathological depression ) Feelings of sadnes s, hopelessness and worthlessness. Usually accompanied by slowed thinking, speech and motor activity. Suicidal ideation may be present. Pervasive lowering of mood accompanied by feeling of sadness, loss of ability to experience pleasure (anhed onia). Mainly occur in depressive disorder & other psychiatric disorders. Inappropriate/ incongruent affect Patient shows insufficient or inadequate affect in relation to the situation e.g. smiling while talking about death of a loved one i.e. emotional tone is out of harmony with the idea thought/speech accompanying it. Common in depressives who smile w hile talking about their inadequacies and in Schizophrenics Flat affect/ apathy/emotional indifference Absence or near absence of any signs of affective expressions in re lation to an event or situation. Patients are usually unresponsive/indifferent. Irritability Ill-humored mood state. Patients are usually unhappy, miserable, angry, resentful and irritable. Common in epilepsy usually but can also occur in depressive states , paranoid mania. Emotional ambivalence Presence of strong overwhelming simultaneous opposite attitudes, feelings, ideas or drives towards an object, person or goal (act).Eugen Bleuler coined this term & identified 3 types of Emotional ambivalence: Affecti ve ambivalence , Intellectual , Ambivalence of will. Ussually common in schizophrenics. Emotional liability & Emotional Incontinence. Emotional liability is when the patient has unstable emotional state and is easily mov ed to tears e.g. in depressives while e motional incontinence occur when subjects burst into tears/laughter for little or no reason. It‘s usually weeping that‘s common. Common in organic states e.g. course brain d isease, especially arteriosclerotic dementia. 20 G. Disorders of memory Some characterist ics of memory/ brain are important to mention: Recognition – feeling of familiarity which accompanies memory. Recall – bringing back specific information to consciousness when desired. No information presented. Registration – add new item to the memory bank . Retention – capacity to store information in our memory. Disorders of memory may include -Amnesia: Loss of memory which is common o rganic states/syndromes e.g. delirium/dementia, anxiety states, trauma/ epilepsy. Subtypes of amnesia include : Anterograde amnesia: Loss of memory of occurring for events taking place after the incident causing amnesia. Occur in people involved in accidents. Occur after a period of unconsciousness . Impairment of memory for events between end complete unconsciousness & the rest oration of consciousness . Retrograde amnesia : Loss of memory for events that occurred before the precipitating incident loss of memory for events before the onset of unconsciousness e.g. after ECT or head injury memory can be: -Immediate – within hours; Recent – within some months/ days/weeks; Past – distant past. -Confabulation: unconscious i nvention of experiences to cover gaps in memory to recent events. Gaps in patient‘s memory filled with fabrications of the p atients which he/she nevertheless accepts ha s facts. Reporting as ―memories‖ of events that didn‘t take place at the time in question. Common in KorsaKoffs (Korsakov‘s) psychosis (syndrome) , Dementia, Cerebral trauma, chronic schizophrenics, and Toxic confusion states e.g. alcoholics and Pathologica l liars. -Jamais vu – Failure to recognize events that have been encountered before. -Déjàvu – Recognition of events as familiar when they have never been encountered Both of these disorders occur in neurological disorders. -Amnesic syndrome: Differential impairment where memory of recent events is most affected & semantic memory least affected. Memory usually affected in:  Depressive disorders – unhappy memories recalled more often than others.  Organic disorders – Long term memory affected – memory of ear lier events less affected than recent events. 21 H. Disorders of consciousness Consciousness is a state of awareness of one‘s self and environment. Ranges from full consciousness to coma. Some disorders that may affect consciousness may include: - Distractibility : Attention is easily diverted by any sensory stimulus e.g. light voices. - Inattention : Difficulty in getting a persons attention. Note that attention is ability to focus on an issue while concentration is the ability to maintain attention. - Confusion – muddled thinking : Impaired comprehension, distortion and poor contact with surroundings. - Clouding of consciousness – state of drowsiness. Incomplete reac tion to stimuli, impaired attention, concentration & memory , slow & muddled thinking. - Delirium : Clouding of consciousness. Common in organic condition in which a person is confirmed, experience delusions, and disorders of perception. - Confusional state – muddled thinking associated with impaired consciousness, health, illusions, delusions & anxiety. - Stupor : Also falls under motor activity. State of reduced responsiveness. State of reduced reactivity to stimuli & less than full awareness of the surroundings. Person mute, immobile & unresponsive but appears conscious bears eyes are open & follow objects = impair ed consciousness. A penny saved is a penny earned People in a glass homes shouldn‘t throw stones. I. Disorders of Intelligence/Cognition State where the subjects intellectual capacity is impaired. Abstract thinking and comprehension can be assessed using a pr overb e.g. A penny saved is a penny earned or people in a glass homes shouldn‘t throw stones. Some problems associated with intelligence/cognition include: - Dementia – permanent loss of intelligence due to a co arse brain d isease - Mental retardation – subnor mal mental ability. J. Disorder of attention & c oncentration Attention is the ability to focus on the matter at hand while c oncentration is the ability to maintain that focus. They both can be impaired in anxiety disorder, depressive, mania, schizophrenia , organic disorders, may not help so much – disease but disability not helps so much 22 K. Insight Defined as correct awareness of one‘s mental condition. It is not just absence or presence of insight but a matter of degree. It‘s described best by use of four crit eria:  Awareness of oneself as presenting phenomena that other people consider abnormal e.g. being unusually active & elated.  Recognition that these phenomena is abnormal  Acceptance that th ese abnormal phenomena is caused by one‘s own mental illness e.g. r ather than e.g. poison.  Awareness that treatment is required. Generally, Insight is lost to a greater extent in psychosis than in non -psychotic disorders. Assessment of insight is extremely important in determining a patient‘s likely cooperation with treatment. ☺? Critical thinking activity/learning activity Read more on symptomatology by e xplain ing the meaning of the following terms as used in psychiatry: Verigeration, transactional analysis, thematic apperception test(TAT), territoriality, split persona lity,sociodrama,scapegoating, Rorschach test, realty testing, overcompensation, manipulation, different forms of mania e.g. dipsomania, kleptomania, nymphomania, pyromania; labella indifference, iatrogenic illness Ganser syndrome -―nonsense syndrome ―/prison psychosis/‖syndrome of approximate answers‖, labile, Functional , folie a deux,fellatio, existential psychotherapy ennui,ego -dystonic,fugue,constitution , castration complex , blotting paper syndrome ,autistic thinking ,anaclitic, ataractic, abreaction. CHAPTER THREE: PSYCHIATRIC ASSESSMENT Student learning objectives At the end of the chapter the learner should be able to: a. Define psychiatric assessment 23 b. Explain the types of psychiatric assessment c. Explain the importance of Biopsychosocial model in psychi atric assessment d. Describe the component of psychiatric history e. Describe the components of mental status examination f. Explain the role of physical examination and special investigations in psychiatric assessment. Introduction In medicine, assessment is diagn osis is usually made through history taking, physical examination and laboratory investigations. Mental status assessment is not considered very critical. However in psychiatric assessment history taking and mental status assessment are the major ways of m aking diagnosisi.Assessement is i mportant for the nurses because it helps in developing effective nursing interventions in the process of developing effective care plans. But laboratory investigation and physical examination are also useful to some extent in psychiatric assessment. In psychiatric Nursing b iopsychosocial model/ approach used as a framework of assessment .Biopsychosocial model is a holistic approach to psychiatric nursing. Psychiatric nursing borrows its knowledge from biological, psychologica l and, social theories. Assessment It‘s a de liberate and systematic collection of and interpretation of biopsychosocial data/information to determine current and past health, functional status and human responses to mental health problems, both actual and potential. Responses can be biological, Psychological and social. Biological domain is grounded in biological sciences, psychological domain in psychological processes and social domain is concerned with how social forces influence person‘s life. Assessme nt is a systematic process occurring over several sessions beginning from the first contact with patient. For the nurse to be effective during assessment she/he should have adequate grounding in h uman social behavior, mental disorders, and therapeutic relationship skills NB: Self awareness on the part of the nurse is very important as it determines how she/he interprets assessment data e.g. biases, values, and prejudices may greatly influence the nurse‘s interpretation of assessment data. It‘s a process of understanding one‘s own beliefs, thoughts, 24 motivations, biases & physical & emotional limitations & recognizing how they affect others with whom we interact.―Know thyself‖ is a basic tenet in psychiatric mental health among. Self concept awareness i.e. b ody image, self esteem, Personal identity are important. e.g. If you have low self esteem, you may not accurately judge clues of low self esteem. Again, if you don‘t maintain eye contact or think it‘s crucial, and then your judgment on assessment will be poor.Biopsychosocial model is used in self awareness process. For example, a nurse who harbors resentments because of sexual childhood abuse may have difficulties dealing with child sexual abuse – Psychosocial domain . Secondly, a nurse who is herself divorced may have problems dealing with a patient who is depressed after divorced – social do main . Types of assessment A. Initial assessment This c an be: - 1. Comprehensive Assessment : Collection of all relevant data to identify problems for which a nursing diagnosis is stated. Use biopsychosocial data collected. May not be accomplished in one session & additional sessions shall be required e.g. with family members. Nurse may need to deal with priority problems so the assessment may not be very comprehensive e.g. suicidal patients . 2. Screening Assessment Collection of data to identify individual who may have a mental disorder but have not yet recognized its symptoms who may be at risk or who have not sought treatment e.g. after disasters, after divorces or other major loses i n life. B. On-going Assessment To monitor progress and outcomes on interventions implemented. These assessments are s horter and more focused than initial assessment e.g. medication effectiveness, Support resources and side effects of drugs. Techniques of data collection include observations which involve non - verbal evaluations and Patient and family interviews, Physical examination and mental status examination, records & diagnostic reports and collaboration with colleagues Interviewing In medicine and also p sychiatry interviews are used to gather information, develop rapport with client / patient and inform and motivate the patient/ client (three function approach by cohen -25 1991) .In psychiatry, examination of mental state is critical and detailed than in medic al exam inations There are certain important considerations during a diagnostic interview The e nvironment – sounds, heat considered. The patient is usually at the side of the desk on left side of a right - handed interviewer. Information is recorded there an d then. Welcome the patient by name .Incase there is a companion inform him how long he shall wait or if to be interviewed Explain the procedure of the interviews and use open ended and make keen observations e.g. how client is talking ,what he/ she is say ing General skills for interviewing  Make eye contact throughout the interview  Adopting a relaxing posture  Making facilitatory noises when listening e.g.…..  Not appearing hurried  Picking up verbal and non -verbal cries of distress  Dealing with over talkativeness  Not offering information too soon Observe whether patient is cooperative, reasonably at ease and able to express ideas coherently Most of the patients are over anxious . Reassure the patient and calm him down before proceedings. If the patient unco operative, try and persuade them to accept it for their own interests. Some patients cannot respond adequately e.g. orientation, memory, and conscious impairment problems; hence informants should give necessary information. Some patients want to dominate t he interview or make it a social conversation the interviewer should explain why he needs to guide the patient to relevant issues. The nature of patients presentation symptoms should be understood before asking their timing and factors that influence them Controlling interview Keep the patient on relevant topics when he strays. Use minimum leadings /closed questions – leading questions suggest the answer e.g. closed question – are you happily married .if open – how do you and your wife get on with one anothe r. When there is no alternative for a open question, the answer should be followed by a request for an example. Use non - verbal expressions to encourage tacitum patients to speak freely e.g. leaning forward in a chair as a show of interest. Over - talkative patients should be informed that they shall be interrupted as