Mental Health Nursing
Subtopic:
Mental health
Mental health is a state of balance between the individual and the surrounding world.
Mental health is a state of harmony between oneself and others.
Mental health is a co-existence between the realities of the self and that of other people and that of the environment.
HEALTH: it is a state of well being of an individual, socially, physically, mentally, not merely the absence of a disease or infirmity. (WHO)
PSYCHIATRY: is a branch of medicine which deals with assessment, diagnosis and treatment of mental disorders.
Concepts of Mental Health
There are many concepts of mental health and each person or society sees mental health in different perspective.
Medical Concept: According to the Medical concept, one is considered to be mentally healthy if he or she is described to be free from pain, gross pathology, and disability.
Cultural Concept: The cultural concept of mental health describes it as the capacity to be competent in the performance of social roles within a wide range of behaviours.
Statistical Concept: The statistical concept of mental health is described as the behaviours distributed within a normal curve with deviant behaviours occurring at both extremities. Statistics indicate that:
Legal Concept: The legal concept of insanity is described as the inability to distinguish right from wrong and to conform behaviour to law. Codes to define mental health are being developed by the states.
Process Concept: The process concept of mental health is the ability to effectively integrate biological, psychological, and social systems as life events are met at progressive stages of growth and development.
Stress and Mental Health
Stress:
Is a stimulus or demand that generates disruption in homeostasis or produces a reaction.
Is a state of disequilibrium that occurs when there is a disharmony between demands occurring within an individual’s internal and external environment and his or her ability to cope with those demands.
Stressor:
A demand from within an individual’s internal and external environment that elicits a physiological and or psychological response.
Is a source of stress.
Stress can produce adaptive and maladaptive responses.
Responses to Stress
Neurobiological responses: Stimulation of the autonomic nervous system prepares the person for “fight and flight.” Physical manifestations of stress include:
Increased heart beat
Increased respiration rate
Increased visual acuity
Behavioural responses: Behavioural responses are determined by the client’s coping mechanism/skills. These responses include:
Anger
Uncooperativeness
Perceptual disturbances
Sensory disturbances
Determinants of response to stress
Responses are influenced by internal and external resources.
Internal resources include:
Personality traits: determine one’s appraisal of events, tolerance to stress, self-esteem, and ability to form meaningful relationships. Coping patterns.
Biological response to stress: are determined by one’s cognitive processes, genetic predisposition, developmental stage, and biochemical processes that influence the appraisal of the event. One person’s stress may be uneventful to another. When an event is appraised as threatening, the usual responses are anxiety, fear, worry, agitation/restlessness, or denial. Neuro-endocrine system is mobilized to maintain biological stability (homeostasis).
External resources: close relationship with others that foster support, protection, and self-reliance during stressful periods. The quality of the relationships influences susceptibility to maladaptive responses and buffers people against distress.
Other factors include:
Number of stressors
Severity of the stressor
Causes:
Bewitching
Spirits from ancestors
Failure to perform cultural rituals.
Lack of respect from the elders
Over reading books
Treatment:
Prayer
Performing cultural rituals
Visiting traditional healers
Left to roam about
Chased away from homes
Home and property are destroyed
Other beliefs include:
A normal person will never be abnormal.
Mentally sick should be treated in asylums
Mental illness is incurable
There is no treatment for mental illness
Mental patient admitted in mental hospital is dangerous.
Mental illness is not related to physical illness.
Mental illness is something to be ashamed of.
How does the belief affect health care delivery
Delayed treatment
Refusal to accept modern medicine
The disorder becomes chronic
Frequent relapses
Characteristics of a mentally healthy person
He has the ability to make adjustments
He has a sense of personal worth, feels worthwhile and important
He solves his problems largely by his own effort and makes his own decisions
He has a sense of personal security and feels secure in a group, shows understanding of other people’s problems and motives
He has a sense of responsibility
He can give and accept love
He lives in a world of reality rather than fantasy
He shows emotional maturity in his behavior and develops a capacity to tolerate frustration and disappointment in his daily life
He has developed a philosophy of life that gives meaning and purpose to his daily activities
He has a variety of interests and generally lives in a well balanced life of work, rest and recreation.
Adequate contact with reality
Control of thoughts and imaginations
Efficiency in work and play
Social acceptance
Positive self concept
A healthy emotional life
MENTAL ILLNESS
Mental illness is the maladjustment in living.
The inability to cope with stress and environment.
It produces a disharmony in the person’s ability to meet human needs comfortably or effectively and function with culture
Mentally ill person loses his ability to respond according to the expectations he has for himself and the demands that society has for him
In general an individual may be considered to be mentally ill if:
The personal behavior is causing distress to self and others
The person’s behavior is causing disturbance in his day-to-day activities, job and interpersonal relationships
Common signs and symptoms of mental illness
Disturbances in motor behavior: motor retardation, stupor, stereotype, negativism, ambitendency, waxy flexibility, echopraxia, restlessness, agitation and excitement
Disorders of thought, language and communication: pressure of speech, poverty of speech, flight of ideas, circumstantiality, loosening of association, tangentially, incoherence, perseveration, neologism, clang associations, thought block, thought insertion, thought broadcasting echo-Lilia, delusions, obsessions and phobias
Disorders of perception: illusions, Hallucinations: depersonalization, derealization.
Disorders of emotions: blunt affect, labile affect, elated mood, euphoria, ecstasy, dysphoric mood, depression, anhedonia.
Disturbances of consciousness: clouding of consciousness, delirium and coma.
Disturbances in attention: distractibility, selective inattention
Disturbance in orientation: disorientation of time, place or person.
Disturbance of memory: amnesia, confabulation
Impairment judgment
Disturbance in biological function: e.g. Persistence deviations in temperature, pulse and respiration, nausea, vomiting, headache, loss of appetite or increased appetite, loss of weight, pain, fatigue, weight gain, insomnia or hypersomnia and sexual dysfunction.
PROBLEMS ASSOCIATED WITH MENTAL DISODERS
Self –care limitations or impaired functioning related to mental illness.
Significant deficits in biological, emotional and cognitive functioning
Disability, life-process changes
Emotional problems such as anxiety, anger, sadness, loneliness and grief
Physical symptoms that occur along with altered psychological functioning
Alteration in thinking, perceiving, communicating and decision making
Difficulties in relating with others
Behavior may be dangerous to self or others
Adverse effects on the well-being of the individual, family and community
Financial, marital, family, academic and occupational problems
ETIOLOGY OF MENTAL ILLNESS
Many factors are responsible for the causation of mental illness. These factors may predispose an individual to mental illness, precipitate or perpetuate the mental illness
Predisposing factors
These factors determine an individual’s susceptibility mental illness. They interact with precipitating factors resulting in mental illness
These are:
Genetic make up
Physical damage to the central nervous system
Adverse psychological influence
Precipitating factors
These are factors that occur shortly before the onset of a disorder and appear to have induced it
These are:
Physical stress
Psychosocial stress.
Perpetuating factors
These factors are responsible for aggravating or prolonging the disease already existing in an individual.
Psychological stress is an example
Thus etiological factors of mental illness can be:
Biological factors
Psychological factors
Social factors
Biological factors
Heredity: What one inherits is not the illness or its symptom, but a predisposing to the illness which is determined by genes that we inherit directly. Studies have shown three –fours of mental defectives and one third of psychotic individuals owe their condition mainly to unfavorable heredity.
Biochemical factors: Biochemical abnormalities in the brain are considered to be the cause of some psychological disorders. Disturbances in neuro-transmitters in the brain is found to play an important role in etiology of certain psychiatric disorders
Brain damage: Any damage to the structure and functioning of the brain may be due to one of the following causes.
Infection: e.g. neuro syphilis, encephalitis, HIV infection
Injury: loss of brain tissue due to head injury
Intoxication: damage to the brain tissue due to toxins such as alcohol, barbiturate, lead etc
Vascular: poor blood supply, bleeding, (intra-cranial hemorrhage)
Alteration in brain function: changes in blood chemistry that interfere with the brain functioning such as disturbance in blood glucose levels, hypoxia, anoxia and fluid and electrolyte imbalance.
Tumors: brain tumors
Vitamin deficiency and malnutrition: in particular deficiency of vitamin B complex
Degenerative diseases: dementia
Endocrine disturbances: hypothyroidism, thyrotoxicosis etc
Physical defects and physical illness: acute physical illness as well as chronic illnesses with all their handicapping conditions may result in loss of mental capacities.
Physiological changes: It has been observed that mental disorders are more likely to occur at certain critical periods of life namely-puberty, menstruation, pregnancy, delivery, puerperium and climacteric.. These periods are marked not only by also by psychological issues that diminish the adaptive capacity of the individual. Thus the individual becomes more susceptible to mental illness during this period
Psychological factors
It’s observed that some specific personality types are more prone to develop certain psychological disorders. For example those who are unsocial and reserved (schizoid) are vulnerable to schizophrenia when they face adverse situations and psychosocial stresses.
Psychological factors like, strained interpersonal relationships at home, place of work, school or college, bereavement, loss of prestige, loss of job etc
childhood insecurities due to parents with pathological personalities, faulty attitude of parents (over-strictness, over-leniency), abnormal parent child relationship (over-protection, rejection, unhealthy comparisons)
deprivation of child’s essential psychological and social needs etc
Social and recreational deprivations resulting in boredom, isolation and alienationation.
Marriage problems like, forced bachelorhood, disharmony due to physical, emotional, social, educational or financial incapability, childlessness or having too many children etc
Sexual difficulties arising from improper sex education, unhealthy attitudes towards sexual functions, guilt feelings about masturbation, pre and extra –marital sexual relations, worries about sexual perversions.
Stress, frustration, climatic conditions and seasonal variations, seasonal variations and seasonal differences are sometimes noted in the occurrence of mental diseases.
Social factors
Poverty, unemployment, injustice, insecurity, migration, urbanization.
Gambling, alcoholism, prostitution, broken home, divorce, very big family, religion, traditions political up heals and other social crises.
Difference between neurosis and psychosis
| Neurosis | Psychosis. |
| A minor form of M.I | Severe form of M.I |
| no loss of contact with reality | Loss of contact with reality |
| No abnormal thoughts and beliefs | Abnormal thoughts and beliefs |
| No abnormal sensory experience and illusion | Abnormal sensory experience and illusion |
| Have sight | No sight |
| Doesn’t require hospitalization | Hospitalization is mandatory |
| Continue to function socially at work | Does not act normally in society and can easily hurt himself or others |
| The patient frequently talks about his symptoms (has sight) | Patient denies that there’s nothing wrong with him/her. |
NEWLY ADOPTED TWO MAIN CLASSIFICATIONS
Diagnostic and Statistical Manual for Classification of Mental disorders (DSM) – American.
International Classification of Disorders (ICD) – WHO.
ICD-10
More general categories.
Generally single axis.
But uses broad aetiology. Uses term neurotic.
DSM-IV-TR
Larger no. of discrete categories. Uses a multi-axial system. Uses term psychotic.
The inclusion of the axes reflect the assumption that most disorders are caused by the interaction of:
Biological
Sociological
Psychological factors.
The patient is assessed more broadly giving a more global in depth picture.
Conditions include:
Disorders usually first diagnosed in infancy, childhood or adolescence
Delirium, Dementia & amnestic, & other cognitive disorders
Mental disorders due to a general medical condition
Substance related disorders
Schizophrenia & other psychotic disorders
Mood disorders
Anxiety disorders
. Somatoform disorders
10.Factitious disorders
Dissociative disorders
Sexual & Gender identity disorders
Eating disorders
Sleep disorders
Impulse control disorders not elsewhere classified
Adjustment disorders
Personality disorders
Other conditions that may be a focus of clinical attention
THE FIVE AXES OF THE DSM-IV-TR.
Axis I: Clinical syndromes. (All mental disorders & criteria for rating them except personality disorders/mental retardation, also abuse/neglect)
Axis II: Personality disorders, Mental retardation. (Life long deeply ingrained, inflexible & maladaptive)
Axis III: General medical condition. (Any medical condition that could affect the patients mental state.)
Axis IV: Psychosocial & environmental problems. (Stressful events that have occurred within the previous year)
Axis V: global assessment functioning. (How well the patient performed during the previous year)
GENERAL SYMPTOMATOLOGY OF MENTAL DISORDERS
Symptoms of mental disorders are exaggerated of normal patterns of behavior in everyday life. These exaggerations occur in mood, beliefs, perception, awareness and memory.
Most people who suffer from mental disorders may present with unexplained persistent headaches, vague, but general health, change in pattern of general gainful economic activity.
Signs and symptoms of mental disorders
The signs and symptoms of mental disorders are going to be described according to the area of the brain they affect and or the behavior cause and these are;
Appearance: One can identify mental disorders from a person’s appearance. A person with mental disorders may have poor grooming and hygiene .these will include dirty clothing, hair, and nails.
Behavior: This refers to how a person reacts to present situation e.g. mentally ill person may be withdrawn, hostile, uncommunicative, guarded etc
Disorders of movement: These symptoms include the way the patients move their limbs and body .symptoms include:
Slow in movement and speech (psychomotor retardation)
One cannot sustain purposeful movement (restlessness)
Imitating other people’s behavior
Pacing up and down in one spot
Involuntary movement of the muscles like uncontrolled shaking (tremors and ties )
Bizarre posturing (involuntarily taking on abnormal posture for a long time), also called mannerisms, for example a person prolonged facial expressions, standing in one position for a long time.
Speech: Is the way we put together statements, when we are talking, their meaning and appropriateness, tone and rate. Symptoms of mental disorders in relation to speech are:-
The speed –speaking too fast (extremely rapid )or too slow (can be slurred ,not clear )
Volume of speech, the volume may be low or whispered or inappropriately loud and difficult to understand as in mania.
Absent speech or muteness as may occur in depression
The appropriateness of speech –where it may be relevant to a particular situation.
Echolalia –echoing or repeating everything that the health provider or another people around the patient say.
Slow with speech (taking too long to answer) as in depression.
Pressured and forceful speech (talking too much or too fast without giving the health work the chance to ask more )
Word salad –saying words that do not connect to make an intelligible sentence.
Neologism –the patient makes up words of which the meaning is only understood to him /her.
Mood and effect: Mood is the state of one’s sustained feelings or emotions which often influence individuals’ behavior and their perception of the world as described as sadness or happiness. A person’s emotions or feelings need to be appropriate to the situation that they are in .in mental disorders the mood may be elated ‘extreme happiness’ or depression ‘extreme sadness’ Affect refers to the health provider’s assessment of the appropriateness of emotions of the health provider. This maybe normal, elated, depressed, labile ‘alternating between extremes’, inappropriate, blurred or flat ‘total or nearly absent emotional expression’
Perception: Perception is the process through which we become aware of our environment through the five senses of touch, taste, hearing, smell and sight. Some mental disorders affect the way can occur in any of these five senses. Perceptions include; Illusions and hallucinations
An illusion refers to the misinterpretation of a sensory stimulus e.g. mistaking a rope for a snake in broad day light. Illusions occur in normal people and should be associated with other symptoms to detect mental disorder.
Hallucinations; refers to a perception without sensory stimulus .symptoms may present in all sensory modalities as follows
Auditory hallucinations –hearing voices or sounds which other people cannot hear. this is the most common type of hallucination
Visual hallucinations; seeing things which other people cannot see.
Tactile hallucination-feeling something on the skin without existing stimulus, such as feeling insects crawling on the body.
Olfactory hallucinations; smelling things which other people cannot smell
Gustatory; hallucinations-a sense of taste which other people cannot taste.
Thinking: This is the ability to process information in one’s mind .the processing of information includes stream, content and form. Symptoms associated with thinking include;
Stream of thoughts: Stream of thought refers to the mount and speed of things one reports that they are thinking about .the symptoms are ;
Pressure of thought-thoughts are rapid ,abundant and varied .the patient will feel over whelmed by these thoughts
Flight of ideas; too many varied ideas that don’t connect.
Poverty of thoughts :the patient will report feelings un able to sustain thinking i.e. very few thoughts
Thought block-this is when the mind is suddenly empty and the individual loses truck of his / her own thoughts. The patient may report that the thoughts are being stolen from him
Form of thought: this refers to the logical order of the flow of ideas or how ideas are connected and related to each other .the symptoms of thought are
Perseveration. Persistent repetition of the some words or ideas irrespective of the nature of question or conversation
An abstract thought is the ability to interpret complex information according to expected ability.
Content of thought. This refers to what the patient is thinking about. The disorders of thought content include delusions, phobias and obsessions
Delusions: these are personal beliefs that cannot be changed by rational arguments or evidence and they are not shared by people with same social, culture or religious background and experiences.
Types of delusions include
Grandiose delusions; the patient believes s/he is somebody great /important ,knowledgeable or powerful contrary to the social cultural ,religious background and experiences
Delusion of guilty and worthlessness; the patient believes s/he is not worth to live even though there’s nothing to justify this belief.
Delusions of jealousy –the patient believes that spouse/partner is being unfaithful even when there is no evidence to suggest so.
Delusion of persecution: the patient believes they’re being deliberately wronged, conspired or harmed by another person or agency even when there’s no evidence to suggest so.
Religious delusions; the individual believes he or she has a special link withGod that is out keeping with people of the same religious belief.
Delusions of control, influence or phenomenon , these are three types ;belief that the person performs activities as a result of an extreme force .
This includes
Thought insertion; the patient will report that his ideas are not his own and have been inserted into his mind by another person or force.
Thought withdrawal; the patient states that his ideas, thoughts are being taken away by another person for use.
Thought broadcasting; this is where the patient feels that his ideas are being broadcasted live by other people on radio, television or newspaper.
Phobia; these are excess fears e.g. fear of a cat.
**Obsessions –**excessive, preoccupation with an idea e.g. excessive orderliness, cleanliness etc
AWARENESS AND MEMORY: This includes the level of consciousness, orientation, attention, concentration, memory, intellect and abstract thoughts.
Level of consciousness: consciousness refers to the state of alertness of a person. Disturbance of consciousness usually fluctuate from mild (lethargy or drowsiness) to severe impairment of consciousness (coma). Progressive symptoms of consciousness include:
Clouding of consciousness or lack of clear mindedness in perception and attitude.
Delirium or being bewildered, confused, restless and disoriented.
State of sustained motionlessness despite being aware of what’s going on around them.
Coma or unconsciousness and the patient cannot be aroused
Orientation: this refers to a state in which an individual is aware of his current place in time .the person can tell what the day it is, where he is and correctly identifies the people around him.
Attention and concentration: attention refers to the ability of an individual to focus his mind on a task at hand, while concentration refers to the ability to sustain this focus. Concentration can be assessed by asking the individual to name the month of the year. The individual is expected to give correct answers in a maximum of two and half to three minutes .a person with poor attention and concentration may fail to learn new information and will therefore have poor registration and short term memory.
Depersonalization and derealization
Depersonalization: this is when the patient says his body has changed, looks different or looks unreal. Depersonalization is a change of awareness of the self, and is sometimes described as being unable to feel emotion
Derealisation; is a sense of being detached from ones environment. This is when the patient states that everything in his surrounding looks changed, strange and feels distanced from the world .this may occur in anxiety, stress, fatigue, affective disorder and hyperventilation.
Memory: Refers to the a ability to recall present and past events and general knowledge .Symptoms manifest in the form of forgetfulness and inability to remember important things .symptoms related to memory can be immediate ,short and long term.
Intellect; refers to the ability to receive, process, interpret and use information and other forms of experience for survival and adaptation in life. It is also the ability to learn and retain new information .for example, ask the patient what they would do if they found a child playing with a a razor blade.
Insight: refers to the individual’s awareness of his or her situation and illness. There are varying degrees of insight .lack of insight generally means that it will be difficult to encourage the individual to accept treatment
Others: Symptoms of mental disorder may also present with problems in relationships, appetite and sleep disturbances
Relationship: is the way we interact with others. Symptoms related with relationships include
Social withdrawal: Not wanting or desiring to participate in social activities.
Isolation keeping to one’s self, even when in a social environment
Poor interpersonal relations: Gets into fights or quarrels very easily with other people.
Appetite and weight: Appetite and weight disorders tend to go together .one who has an increased appetite will gain weight whereas on with a decreased appetite will lose weight .one may refuse one may refuse to eat, hind the food and is excessively worried about their weight and body image.
Sleep disorders: Patients with mental disorder may present with sleep problems .The examples of these include;
Altered pattern of sleep i.e. awake all night, dozing all day.
Failure to fall asleep in the early hours of the night
Failure to sleep in late in late hours i.e. from 3 am to dawn .i.e. early morning awakening that occurs in depression.
Interrupted sleep associated with horrifying dreams or with florid dreams.
Quality of sleep; some people may sleep the whole night through but wake up not feeling refreshed
CLASSIFICATION OF MENTAL ILLENESS
It’s important to classify mental illness because it serves as a guide to Diagnosis and prognosis (outcome)
In psychiatry classification is based on clinical description of disease.
General classification
Neurosis
It means a group of mental disorder which have a combination of symptoms in which there’s is no evidence of organic brain disorder .People who suffer from those conditions don’t lose touch with the external reality ,the behavior may be affected but remains within socially acceptable limits.
In neuroses, there are no hallucinations and delusions.
Patients may have insight and seek help.
Examples of neurosis are:
Anxiety Disorders: occur in various combination of psychological and physical or symptoms. Anxiety is vague feeling, worry and tension characterized by excessive fear and apprehension.
Obsessive Compulsive disorder [OCD]: recurred, persistent thought, impulses or images that the pt regards as unwanted, while recognizing them as physical and dissociative problems
Phobic – fear
Panic – Extreme of fear.
PTSD [post – Traumatic stress Disorders]: This is a group of mental symptoms that usually follow a traumatizing experience like war, floods, and epidemics like Ebola, rape, defilement, and accident. The condition is characterized by severe anxiety persistent disturbing and reoccurring thought or night mares of the experience.
Conversion and dissociation disorder: (Hysteria) present as physical problem present as psychological.
Psychosis:
This is a severe form of mental disorder that is characterized by loss of touch with reality.
A person who has lost touch with reality has abnormal thoughts or beliefs (delusions) and abnormal sensory experience (hallucinations)
She or he may also have disorganized speech and behavior.
Psychoses are divided into function and organic psychosis.
ORGANIC PYSCHOSIS.
Results from identifiable cause e.g malaria, HIV/AIDS, gonorrhea, syphilis, head injury.
Organic mental disorder can be acute or chronic.
Acute organic disorder (delirium): In this condition there’s fluctuation level of consciousness or clouding of consciousness, hallucinations and loss of memory.
Chronic organic disorder (dementia): There is no impairment of consciousness but there’s a gross impairment of memory which is due to drainage.
FUNCTIONAL PSYCHOSIS.
Don’t result from early identifiable cause.
No structure damage in brain cell e.g. schizophrenia which is one of the worst form of chronic illness characterized by loss of touch with reality, social withdraw, disturbed thinking, altered perception and behavior.
Affective disorder: It’s characterized by mood changes i.e. mania and depression.
Depression: Is one of the most mental disorders in the community characterized by persistent low mood, reduced activity and persistent physical complaints.
Mania: Is one of the major mental disorders characterized by excessive happiness increased activity and pressure of speech.
Note: The classification of mental disorders into psychosis and neurosis of an old way of classifying mental disorders though still being used by many clinicians.