Mental Health Problems Chapter 45 Mental Health Problems The whole person has physical, social, psychological, and spiritual parts. Each part affects the other. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Basic Concepts Mental health involves the mind. Mental health and mental disorders involve stress. Stress is the response or change in the body caused by any emotional, physical, social, or economic factor. Mental health means that the person copes with and adjusts to everyday stresses in ways accepted by society. Mental disorder is a disturbance in the ability to cope with or adjust to stress. Other names include mental illness, emotional illness, and psychiatric disorder. With mental disorders, behavior and function are impaired. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Basic Concepts (cont’d) Causes of mental health disorders include: Not being able to cope or adjust to stress Chemical imbalances Genetics Physical, biological, or psychological factors Drug or substance abuse Social and cultural factors Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Basic Concepts (cont’d) Personality is the set of attitudes, values, behaviors, and traits of a person. Maslow’s theory of basic needs affects personality development. Lower-level needs must be met before higher-level needs. Physical needs are met before safety and security, love and belonging, self-esteem, and self-actualization needs. Unmet needs at any age affect personality development. Growth and development also affect personality development. They occur in a sequence, order, and pattern. Certain tasks must be achieved at each stage. Each stage is the basis for the next stage. Personality starts to develop at birth. It is affected by genes, culture, environment, parenting, and social experiences. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Basic Concepts (cont’d) Freud’s theory of personality development Involves three levels of awareness: Conscious—awareness of the environment and experiences Subconscious—memory, past experiences, and thoughts of which the person is not aware-they are easily recalled Unconscious—experiences and feelings that cannot be recalled Also involves the id, ego, and superego Pleasure is the focus of id. The ego deals with reality. The superego is concerned with right and wrong. With conscious awareness, the person knows what is happening and can control thoughts and behavior. With id, the need for pleasure must be satisfied almost right away. People are not aware that they believe and act in ways to satisfy the id. Thoughts, feelings, reasoning, good sense, and problem solving occur in the ego. The ego decides what to do and when. Morals and values are in the superego. The superego judges what the ego thinks and does. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Anxiety Disorders Anxiety is a vague, uneasy feeling in response to stress. Anxiety often occurs when needs are not met. Some anxiety is normal. Persons with mental health problems have higher levels of anxiety. Signs and symptoms depend on the degree of anxiety. The person may not know why or the cause. Danger—real or imagined—is sensed. The person acts to relieve the unpleasant feeling. Review the Signs and Symptoms of Anxiety in Box 45-1 on p. 728 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Anxiety Disorders (cont’d) Anxiety level depends on the stressor. A stressor is the event or factor that causes stress. A stressor may cause mild anxiety or it can cause higher anxiety at another time. Coping and defense mechanisms relieve anxiety. Some are healthy; others are not. Defense mechanisms are unconscious reactions that block unpleasant or threatening feelings. Some use of defense mechanisms is normal. With mental health disorders, they are used poorly. A stressor can be physical, emotional, social, or economic. Past experiences and the number of stressors affect how a person reacts. Review Defense Mechanisms in Box 45-2 on p. 729 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Anxiety Disorders (cont’d) Panic disorder Panic is the highest level of anxiety. Panic is an intense and sudden feeling of fear, anxiety, terror, or dread. Onset is sudden with no obvious reason. Signs and symptoms of anxiety are severe. A panic attack can last for 10 minutes or longer. Attacks can occur often. Panic disorder can last for a few months or for many years. Refer to Signs and Symptoms of Anxiety in Box 45-1 on p. 728 in the Textbook. The person may feel that he or she is having a heart attack, losing his or her mind, or on the verge of death. Attacks can occur at any time, even during sleep. Many people avoid places where panic attacks occurred. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Anxiety Disorders (cont’d) Phobia means an intense fear. The person has an intense fear of an object, situation, or activity that has little or no actual danger. When faced with the fear, the person has high anxiety and cannot function. Obsessive-compulsive disorder (OCD) An obsession is a recurrent, unwanted thought, idea, or image. Compulsion is repeating an act over and over again (a ritual). The act may not make sense. Anxiety is great if the act is not done. Refer to p. 729 in the Textbook for a list of common phobias. The person with OCD has obsessions and compulsions. Some are obsessed with microbes, dirt, violent thoughts, or things forbidden by religion. Common rituals are hand washing, cleaning, counting things to a certain number, or touching things in a certain order. Rituals can take over an hour every day. They are very distressing and affect daily life. Some persons with OCD also have depression, eating disorders, substance abuse, and other anxiety disorders. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Anxiety Disorders (cont’d) Post-traumatic stress disorder (PTSD) occurs after a terrifying ordeal. There was physical harm or threat of physical harm. PTSD can develop after: Being harmed A loved one was harmed Seeing a harmful event happen Flashbacks are common. A flashback is reliving the trauma in thoughts during the day and in nightmares during sleep. PTSD can develop at any age including childhood. The person may also suffer from depression, substance abuse, and other anxiety disorders. Signs and symptoms of PTSD are listed in Box 45-3 on p. 730 in the Textbook. PTSD can result from many traumatic events including war, a terrorist attack, mugging, rape, torture, kidnapping, being held captive, child abuse, a crash, bombing, or a natural disaster. During a flashback, person may believe that the trauma is happening all over again. Signs and symptoms usually develop about 3 months after the event. Some people recover within 6 months. PTSD lasts longer in other people. The condition may become chronic. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Schizophrenia Schizophrenia means split mind. It is a severe, chronic, disabling brain disorder. It involves: Psychosis—a state of severe mental impairment Delusion—a false belief Hallucination—seeing, hearing, smelling, or feeling something that is not real Paranoia—a disorder of the mind Delusion of grandeur—an exaggerated belief of one’s importance, wealth, power, or talents Delusion of persecution—the false belief that one is being mistreated, abused, or harassed The person does not view the real and unreal correctly. “Voices” are the most common type of hallucination in schizophrenia. The person has false beliefs (delusions) and suspicion about a person or situation. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Schizophrenia (cont’d) The person with schizophrenia has severe mental impairment (psychosis). The person has problems relating to others. The person may have difficulty organizing thoughts. Responses are not appropriate. Communication is disturbed. The person may withdraw. Disorders of movement occur. Some persons regress. People with schizophrenia do not tend to be violent. The person may sit for hours without moving, speaking, or responding. To regress means to retreat or move back to an earlier time or condition. In men, symptoms usually begin in the late teens or early 20s. In women, symptoms begin in the mid-20s and 30s. If a person with paranoid schizophrenia becomes violent, violence is often directed at family members. The violence is usually at home. Some persons with schizophrenia attempt suicide. Review the Focus on Communication: Schizophrenia Box on p. 731 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mood Disorders Mood or affect relates to feelings and emotions. Mood (or affective) disorders involve feelings, emotions, and moods Bipolar disorder Major depression Depression in older persons Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mood Disorders (cont’d) The person with bipolar disorder (manic-depressive illness) has severe extremes in mood, energy, and ability to function. The person may: Be more depressed than manic Be more manic than depressed Alternate between depression and mania The disorder: Tends to run in families Usually develops during the late teens or early adulthood Requires life-long management The person has emotional lows (depression) and emotional highs (mania). Review the Signs and Symptoms of Bipolar Disorder in Box 45-4 on p. 731 in the Textbook. Signs and symptoms may be mild to severe. Mood changes are called episodes. Bipolar disorder can damage relationships and affect school or work performance. Some people are suicidal. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mood Disorders (cont’d) Major depression Depression involves the body, mood, and thoughts. Symptoms affect work, study, sleep, eating, and other activities. The person is very sad. Interest in daily activities is lost. Causes of depression may include: A stressful event Some physical disorders Hormonal factors in women A stressful event such as the death of a partner, parent, or child may cause depression, so can divorce and job loss. Examples of physical disorders that can cause depression are stroke, heart attack, cancer, and Parkinson’s disease. In women, menstrual cycle changes, pregnancy, miscarriage, after childbirth (post-partum), and menopause are factors for depression. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mood Disorders (cont’d) Depression in older persons Depression is common in older persons. They have many losses. Death of family and friends Loss of health Loss of body functions Loss of independence Causes of depression in older persons Loneliness Side effects from some drugs Depression is often overlooked. A wrong diagnosis is made. Depression is often not treated. See the Signs and Symptoms of Depression in Older Persons in Box 45-5 on p. 732 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Personality Disorders Personality disorders involve rigid and maladaptive behaviors. Maladaptive means to change or adjust in the wrong way. Because of behavior, persons with personality disorders cannot function well in society. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Personality Disorders (cont’d) Antisocial personality disorder This is a chronic disorder in which the person’s thinking and behaviors show no regard for right and wrong. The person has poor judgment, lacks responsibility, and is hostile. The person is not loyal to any person or group. Morals and ethics are lacking. The rights of others do not matter. The person with antisocial personality disorder lies, charms, or cons others for personal gain or pleasure. The person has no guilt and does not learn from experiences or punishment. The person is often in trouble with the police. Review the signs and symptoms of antisocial personality disorder on p. 732 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Personality Disorders (cont’d) Borderline personality disorder (BPD) The person has problems with moods, relationships, self-image, behavior, and controlling emotions. Aggression, self-injury, and drug or alcohol abuse may occur. The person may have thoughts of suicide and other mental health disorders. BPD is more common in women than in men. Risk factors may include: A family history of BPD Childhood abuse—sexual, physical Childhood neglect or being abandoned Changes in the brain Brain chemicals that do not function properly The person with borderline personality has intense bouts of anger, depression, and anxiety that may last hours or most of the day. The person may engage in risky behaviors—unsafe driving, unsafe sex, gambling sprees. The person may greatly admire family and friends and then suddenly shift to intense anger and dislike. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse and Addiction Substance abuse or addiction occurs when a person overuses or depends on alcohol or drugs. Physical and mental health are affected. The welfare of others is affected. Substances involved affect the nervous system. They affect the mind and thinking. Substances may depress or stimulate the nervous system. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse and Addiction (cont’d) Over time, heavy drinking damages the brain, central nervous system, liver, kidneys, heart, blood vessels, and stomach. Alcoholism includes these symptoms: Craving—strong need or urge to drink Loss of control—once begun, cannot stop drinking Physical dependence—withdrawal symptoms when drinking is stopped Tolerance—greater amounts of alcohol are needed to get “high” Alcohol slows down brain activity. It affects alertness, judgment, coordination, and reaction time. Heavy drinking also can cause forgetfulness and confusion. Withdrawal symptoms include nausea, sweating, shakiness, and anxiety. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse and Addiction (cont’d) Alcoholism is a chronic disease. Life-style and genetics are risk factors. Some people drink for relief from life stresses. The craving for alcohol can be as strong as the need for food or water. Alcoholism can be treated but not cured. Counseling and drugs are used to help the person stop drinking. The person must avoid all alcohol to prevent a relapse. Alcoholism lasts throughout life. Life stresses may include such things as retirement, lowered income, job loss, failing health, loneliness, or the deaths of loved ones. The alcohol craving can be as strong as the need for food or water. An alcoholic continues to drink despite serious family, health, or legal problems. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse and Addiction (cont’d) Alcohol abuse is just as harmful as alcoholism. A person who abuses alcohol drinks too much but is not dependent on alcohol. Problems linked to alcoholism and alcohol abuse include: Not being able to meet work, school, or family responsibilities Motor vehicle crashes Drunk-driving arrests Drinking-related medical conditions Occasional or regular drinking does not mean a drinking problem. See Symptoms of An Alcohol Use Disorder in Box 45-6 on p. 733 in the Textbook. Even a few symptoms can signal an alcohol use disorder. Review the Focus on Children and Older Persons: Alcoholism and Alcohol Abuse Box on p. 733 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse and Addiction (cont’d) Drug abuse and addiction Drug abuse The over-use of a drug for non-medical or non-therapy effects. Drug addiction A chronic, relapsing brain disease. The person has an overwhelming desire to take a drug. The person repeatedly takes the drug because of its effect. The person has to have the drug. Often higher doses are needed. The person cannot stop taking the drug without treatment. Drugs interfere with normal brain function. While they create powerful feelings of pleasure, they have long-term effects on the brain. Changes in the brain can turn drug abuse into addiction. The person usually takes the drug for its effect of altered mental awareness. Review the points related to drug abuse and addiction on pp. 733-734 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Substance Abuse and Addiction (cont’d) Drug abuse and addiction Affect social and mental function Are linked to crimes, violence, and car crashes Have physical effects Legal and illegal drugs are abused. Legal drugs are approved for use in the United States. Illegal drugs are not approved for use. They are obtained through illegal means. Often, legal drugs also are obtained through illegal means. Treatment depends on the drug and the person. A drug treatment program combines various therapies and services to meet the person’s needs. HIV and AIDS, cardiovascular disease, stroke, sudden death, hepatitis, lung disease, and cancer can occur from one use, high doses, or prolonged drug use. Doctors prescribe legal drugs. Review the contents of Table 45-1 on pp. 734-735 in the Textbook. Drug abuse and addiction are chronic problems. Relapses can occur. Treatment is a long-term process. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Eating Disorders An eating disorder involves extremes in eating patterns. Food intake is severely reduced or the person over-eats Eating disorders can develop in: Childhood The teen years Young or later adulthood Eating disorders are common in women and girls. Depression, anxiety disorders, and drug abuse may be present. The person with an eating disorder is concerned about body weight and shape. The person has a severe disturbance in eating behavior. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Eating Disorders (cont’d) Anorexia nervosa occurs when a person has an intense fear of weight gain or obesity. A fat body image is felt despite being dangerously thin. Poor eating habits include: Avoiding food and meals Eating a few foods in small amounts Weighing and measuring food Intense exercise and vomiting are common. Enemas and laxatives are used to rid the body of food. Diuretic abuse also may occur. Death is a risk from cardiac arrest or suicide. Laxatives are drugs that promote defecation. Diuretic drugs cause the kidneys to produce large amounts of urine. Extra fluid in the body is lost. Weight loss results. The person has a poor self-image and may avoid people. Sleep problems and depression may occur. Females may not have monthly menstrual periods. Serious health problems can result. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Eating Disorders (cont’d) In bulimia nervosa, binge eating occurs. The person eats large amounts of food. Then the body is purged (rid) of the food to prevent weight gain. Methods used include: Vomiting Laxatives Enemas Diuretics Fasting Intense exercise Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Eating Disorders (cont’d) In binge eating disorder, the person often eats large amounts of food. Eating is out of control. Binge eating is not followed by purging, fasting, or exercise. Often, the person is over-weight or obese. Other health problems can occur. High blood pressure Heart disease Diabetes Joint pain Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Suicide Suicide means to kill oneself. According to a 2010 report from the CDC, suicide was the: Eleventh leading cause of death in the U.S. Third leading cause of death among persons aged 15 to 24. If a person mentions or talks about suicide, take the person seriously. Call for the nurse at once. Do not leave the person alone. See p. 736 in the Textbook for additional facts related to suicide according to the 2010 report from the CDC. Risk factors for suicide are listed in Box 45-7 on p. 736 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Suicide (cont’d) Agencies treating persons with mental health problems must identify persons at risk for suicide. They must: Identify specific factors or features that increase or decrease the risk for suicide. Provide the most appropriate setting to treat the person. Provide crisis information to the person and family. A crisis “hotline” phone number is an example. Review the Focus on Communication: Suicide Box on p. 737 in the Textbook. Review the Focus on Children and Older Persons: Suicide Box on p. 737 in the Textbook. Review the Focus on Long-term Care and Home Care: Suicide Box on p. 737 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Suicide (cont’d) Suicide contagion is exposure to suicide or suicidal behaviors within the family, peer group, or media reports of suicide. The exposure has led to more suicides and suicidal behaviors in persons at risk. Adolescents and young adults are at risk for suicide contagion. Following suicide exposure, those close to the victim should be evaluated by a mental health professional. They include family, friends, peers, and co-workers. Persons at risk for suicide need mental health services. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Care and Treatment Treatment of mental health problems involves having the person explore thoughts and feelings. This is done through psychotherapy and behavior, group, occupational, art, and family therapies. Often drugs are ordered. The care plan reflects the person’s needs. Communication is important. Persons with mental health problems may respond to stress with anxiety, panic, or anger. Some become violent. Your first priority is to protect yourself. The needs of the total person must be met. This includes physical, safety and security, and emotional needs. Be alert to nonverbal communication (the person’s and your own). If a person with a mental health problem becomes violent, you must take responsibility for your safety. To protect yourself call for help, keep a safe distance between you and the person, and be aware of your surroundings. Once you are safe, the health team can work together to protect the person and others. Review the Focus on Communication: Care and Treatment Box on p. 737 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.