Mental Health Disorders
Study anxiety, depression, bipolar disorder, schizophrenia, personality disorders, and key psychiatric medications.
Mental Health Disorders
Mental health disorders are a significant focus on the NCLEX, appearing in both psychosocial integrity and pharmacological questions. This review covers the major psychiatric diagnoses, their hallmark features, first-line medications, and nursing considerations. Understanding positive vs. negative symptoms, medication side effects, and therapeutic approaches is essential for exam success.
Anxiety Disorders
Anxiety disorders involve excessive fear or worry that interferes with daily functioning. Key types include:
- Generalized Anxiety Disorder (GAD): Persistent, excessive worry about multiple areas of life lasting at least 6 months. Symptoms include restlessness, fatigue, difficulty concentrating, muscle tension, and sleep disturbance.
- Panic Disorder: Recurrent, unexpected panic attacks characterized by intense fear, palpitations, chest pain, dyspnea, dizziness, and a sense of impending doom. Attacks peak within minutes. Nursing priority: ensure the client that they are safe and that the symptoms will pass.
- Phobias: Intense, irrational fear of a specific object or situation. Treatment includes systematic desensitization (gradual exposure) and cognitive-behavioral therapy (CBT).
- Obsessive-Compulsive Disorder (OCD): Intrusive, recurring thoughts (obsessions) and repetitive behaviors (compulsions) performed to reduce anxiety. Do not interrupt rituals abruptly; work with the client to gradually reduce compulsive behavior.
- Post-Traumatic Stress Disorder (PTSD): Develops after exposure to a traumatic event. Symptoms include flashbacks, nightmares, hypervigilance, avoidance of triggers, and emotional numbing. Onset may be delayed.
Key medications for anxiety: SSRIs (sertraline, paroxetine) are first-line for most anxiety disorders. Benzodiazepines (lorazepam, alprazolam) are used for short-term relief but carry risk of dependence. Buspirone is used for GAD; it takes 2-4 weeks to become effective and has no sedation or dependence risk.
Depressive Disorders
Major depressive disorder (MDD) involves persistent depressed mood or loss of interest/pleasure for at least 2 weeks, along with changes in sleep, appetite, energy, concentration, and self-worth. Assess all depressed clients for suicidal ideation.
Key nursing consideration: When antidepressants begin to take effect (typically 2-4 weeks), the client may have increased energy to act on suicidal thoughts before mood fully improves. This is a period of heightened suicide risk.
Medications:
- SSRIs (fluoxetine, sertraline, escitalopram): First-line treatment. Side effects include sexual dysfunction, GI upset, and serotonin syndrome risk when combined with other serotonergic drugs.
- SNRIs (venlafaxine, duloxetine): Also first-line; useful for comorbid pain conditions.
- Tricyclic antidepressants (TCAs): Amitriptyline, nortriptyline. Effective but higher risk of toxicity in overdose (cardiac arrhythmias). Monitor for anticholinergic effects.
- MAOIs (phenelzine, tranylcypromine): Used for treatment-resistant depression. Require strict dietary restrictions -- avoid tyramine-containing foods (aged cheese, cured meats, red wine, soy sauce) to prevent hypertensive crisis.
Bipolar Disorder
Bipolar disorder is characterized by alternating episodes of mania (or hypomania) and depression. During manic episodes, the client may exhibit:
- Elevated, expansive, or irritable mood
- Grandiosity, decreased need for sleep
- Pressured speech, flight of ideas, racing thoughts
- Increased goal-directed activity or psychomotor agitation
- Impulsive, high-risk behavior (spending sprees, risky sexual behavior)
Lithium is the classic mood stabilizer for bipolar disorder. Critical nursing considerations:
| Parameter | Details |
|---|---|
| Therapeutic level | 0.6-1.2 mEq/L |
| Toxic level | Greater than 1.5 mEq/L |
| Early toxicity signs | Nausea, vomiting, diarrhea, fine hand tremor, drowsiness |
| Severe toxicity signs | Coarse tremors, confusion, seizures, oliguria, cardiovascular collapse |
| Monitoring | Draw lithium levels 8-12 hours after last dose; monitor renal function, thyroid function, sodium levels |
| Key teaching | Maintain adequate sodium and fluid intake; dehydration and low sodium increase lithium levels. Avoid NSAIDs and diuretics, which increase lithium levels. |
Other mood stabilizers include valproic acid (monitor liver function and platelet count) and carbamazepine (monitor CBC for agranulocytosis). Atypical antipsychotics (quetiapine, olanzapine, aripiprazole) are also used.
Schizophrenia
Schizophrenia is a chronic psychotic disorder characterized by disturbances in thought, perception, and behavior. Symptoms are categorized as:
| Positive Symptoms (excess/distortion) | Negative Symptoms (deficit) |
|---|---|
| Hallucinations (most commonly auditory) | Flat affect (diminished emotional expression) |
| Delusions (fixed false beliefs) | Alogia (poverty of speech) |
| Disorganized speech and behavior | Avolition (lack of motivation) |
| Thought broadcasting, thought insertion | Anhedonia (inability to feel pleasure) |
| Social withdrawal |
Antipsychotic medications:
- First-generation (typical) antipsychotics: Haloperidol, chlorpromazine. Effective for positive symptoms. Major side effects include extrapyramidal symptoms (EPS).
- Second-generation (atypical) antipsychotics: Risperidone, olanzapine, quetiapine, clozapine, aripiprazole. Treat both positive and negative symptoms with lower EPS risk. Clozapine is reserved for treatment-resistant schizophrenia and requires regular CBC monitoring due to risk of agranulocytosis.
Extrapyramidal Symptoms (EPS):
- Dystonia: Sudden muscle spasms (neck, tongue, eyes). Treat with benztropine or diphenhydramine. Can occur within hours of starting medication.
- Akathisia: Restlessness, inability to sit still. May be treated with beta-blockers or benzodiazepines.
- Pseudoparkinsonism: Tremor, shuffling gait, rigidity, bradykinesia. Treat with anticholinergics (benztropine).
- Tardive dyskinesia: Involuntary movements of the face, tongue, and extremities. Develops after long-term use. May be irreversible. Discontinue or switch the medication.
Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening reaction: high fever, muscle rigidity ("lead pipe"), altered consciousness, and autonomic instability. Stop the antipsychotic immediately; this is a medical emergency.
Personality Disorders
Personality disorders are enduring patterns of inner experience and behavior that deviate markedly from cultural expectations. They are grouped into three clusters:
- Cluster A (odd/eccentric): Paranoid, schizoid, schizotypal. These individuals appear withdrawn, suspicious, or eccentric.
- Cluster B (dramatic/erratic): Antisocial, borderline, histrionic, narcissistic. Borderline personality disorder (BPD) is most frequently tested -- characterized by unstable relationships, fear of abandonment, impulsivity, self-harm, identity disturbance, and splitting (viewing people as all good or all bad). Maintain firm, consistent boundaries.
- Cluster C (anxious/fearful): Avoidant, dependent, obsessive-compulsive personality disorder. These individuals tend to be anxious and seek reassurance.
Therapeutic Milieu
A therapeutic milieu is a structured, safe environment designed to promote healing in psychiatric settings. Key features include consistent routines, clear expectations, group activities, and opportunities for clients to practice social skills. The nurse maintains safety, enforces boundaries, and models appropriate behavior.
NCLEX Mental Health Question Strategies
Focus on safety first (suicidal clients, NMS, serotonin syndrome). Know therapeutic drug levels (especially lithium). For hallucinations, present reality without arguing. For personality disorders, maintain boundaries and avoid splitting. Review the Mental Health Disorders Cheat Sheet, the Psychosocial Study Guide, and Psychosocial Flashcards for additional practice.