Exam 2 Study Notes: Stress and Psychological Disorders

• These study notes cover key concepts for Exam Two, including stress management, bipolar and depressive disorders, anxiety and obsessive-compulsive disorders, PTSD and dissociative disorders, and somatic symptom disorders.

Short-Term and Long-Term Physiological Consequences of Stress

• Short-term stress causes the heart to beat faster, blood vessels to dilate, pushing more blood into large muscles, and raising blood pressure.
• Long-term stress can lead to consistently elevated heart rate, blood pressure, and stress hormones, increasing the risk of heart attack, stroke, and hypertension.
• Long-term stress can also cause insulin resistance, obesity, atherosclerosis, and protein breakdown.

Cannon's Fight-or-Flight vs. Selye's General Adaptation Syndrome (GAS)

• Fight-or-flight prepares the body for survival by increasing heart rate (HR), blood pressure (BP), respiratory rate (RR), and cardiac output; neural responses differ between men and women.
• GAS stages:
  • Alarm/acute activates the sympathetic nervous system and the HPA axis for alert status.
  • Resistance/adaptation allows sustained resistance to the stressor with recovery, repair, and renewal.
  • Exhaustion occurs when resources are depleted, leading to chronic stress.
• Females often use "tending or befriending" as a coping mechanism.

Eustress vs. Distress

• Distress is negative and draining, leading to anxiety, depression, hopelessness, confusion, and fatigue (e.g., losing a loved one, trauma).
• Eustress is positive and motivating, resulting in positive feelings and purposeful movement (e.g., personal achievement, physical challenge, exciting events).

Relaxation Techniques

• Biofeedback uses devices to provide immediate feedback on temperature, HR, BP, and brain waves for greater voluntary control.
• Deep breathing involves slow, deep, even breaths for quick calming.
• Other techniques include:
  • Guided imagery
  • Progressive relaxation
  • Meditation
  • Mindfulness
  • Physical exercise
  • Cognitive reframing (replacing irrational thoughts with positive ones)
  • Journaling
  • Humor

Bipolar I vs. Bipolar II

• Bipolar I: The most severe form that includes at least one manic episode lasting at least 1 week most of the day, every day, mania can cause psychosis.
• Bipolar II: Requires at least one hypomanic and one major depressive episode; hypomania lasts at least 4 days and never involves psychosis.
• DIGFAST mnemonic for symptoms: Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, Talkativeness.

Nursing Care for Acute vs. Maintenance Phases of Mania and Hypomania

• Acute phase nursing goals: Preventing injury, maintaining stable cardiac status and hydration, ensuring adequate rest and sleep, promoting self-control, prevent self-harm
• Safety measures: May include hospital, seclusion, Electroconvulsive therapy (ECT) or restraint.
• Maintenance phase nursing goals: Understanding the disorder, its management, and medications, identifying risk factors and preventative strategies, sources of support, and coping skills.
• Relapse prevention: Managing medication compliance, limiting the severity of future episodes, and supporting the patient through lifelong medications
• Communication strategies for mania: Staying calm, calm and redirecting, setting limits on behavior, and reducing stimulation in the environment.
• Communication strategies for depression: Offering empathy and support, asking open ended questions, encouraging small tasks and routines, and assessing for suicide risk

Medications for Mood Stabilization

• Lithium: Requires monitoring of lithium levels (therapeutic range: 0.6-1.2).
  • Side effects: Tremor, polyuria, polydipsia, weight gain, thyroid dysfunction.
  • Monitor kidney function and thyroid levels
  • Teach patients to take with meals and maintain consistent salt intake.
• Anticonvulsants: - Valproate, - Carbamazepine, - Lamotrigine: Monitor liver function, CBC, and ammonia levels to monitor for skin reactions. - Side effects of anticonvulsants: Nausea/vomiting, sedation, tremor, weight changes.
• Second-Generation Antipsychotics: - Olanzapine, Risperidone, Aripiprazole: Monitor weight, glucose, and lipids for metabolic effects. - Side effects: Sedation, extrapyramidal symptoms, hyperprolactinemia, risk of tardive dyskinesia (with long-term use).

Lithium Toxicity Signs

Major Depressive Disorder Symptoms

• Diagnostic criteria: Five or more symptoms during a 2-week period, including either depressed mood or loss of interest/pleasure (anhedonia).
• Symptoms encompass: Changes in weight/appetite, sleep disturbances, fatigue, worthlessness/guilt, impaired concentration, recurrent thoughts of death, and psychomotor changes.
• Vegetative signs: Alterations in activities that support physical life, such as eating (appetite loss), elimination (constipation/diarrhea), sleeping (insomnia), and sex (loss of libido).

Assessment of Patients with Depression

• Observe and assess behavior, mood, feelings, thought processes, thought content, and perception
• Common findings:
  • Behavior changes include anergia (lack of energy) with psychomotor retardation or agitation.
  • Mood can include good, bad, euthmyic (normal), euphoric (overly happy), angry irritable, anxious, and apathetic
  • Verbalized feelings of worthlessness, guilt, helplessness, anger, and anhedonia.
  • Slowed thought processes and difficulty responding.
  • Psychotic features such as delusions, hallucinations, are possible

Therapeutic communication with patients with depression

• Principles include:
  • Helping the patient question assumptions, identifying cognitive distortions, exploring coping skills, encouraging exercise and supportive relationships, and providing education.

Interventions targeting the vegetative signs of depression

• Anorexia interventions
  • Offer small, high-calorie and high-protein snacks, and fluids frequently.
  • Encourage family or friends to have the patient joint them when eating
  • Include the patient in choosing foods and drinks
  • Weigh the patient regularly
• Insomnia interventions - Provide periods of rest after activities - Encourage the patient to get up and dress - Encourage relaxation measures like warm baths, soothing music, and decaffeinated drinks
• Self-Care interventions
  • Encourage the patient to use necessary supplies, such as toothbrushes, washcloths and soap
  • Offer step-by-step reminders for performing tasks
  • Constipation interventions
    • Monitor and record bowel movements
    • Offer foods with fiber
    • Evaluate the need for laxatives

Antidepressant Classifications, Advantages, Disadvantages, and Side Effects

• Selective Serotonin Reuptake Inhibitors (SSRIs:)
  • Advantages: Low side-effect profile, minimal anticholinergic effects
  • Disadvantages: Include sexual dysfunction and serotonin syndrome (if combined with MAOIs)
  • Side Effects: Agitation, anxiety, sleep disturbances, tremor, sexual dysfunction, dry mouth, headache, weight change, nausea, loose bowel movements, restlessness, and hyponatremia.
• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
  • Side effects similar to SSRIs
  • May increase blood pressure and effects of anticoagulants. Discontinuation symptoms may occur
• Serotonin Antagonists and Reuptake Inhibitors (SARIs)
  • Side effects: Sedation, hepatotoxicity, hypotension, nausea, constipation, and vomiting.
• Norepinephrine Dopamine Reuptake Inhibitor (NDRI)
  • Side Effects: Agitation, insomnia, headache, nausea, vomiting, and seizures (rare)
• Noradrenergic and Specific Serotonergic Antidepressant (NaSSA):
  • Side Effects: Weight gain, dry mouth, constipation, sedation, dizziness, headache, sexual dysfunction, hypotension, and blurred vision.
• Monoamine Oxidase Inhibitors (MAOIs):
  • Side Effects: Orthostatic hypotension, weight gain, edema, changes in heart rate, constipation, urinary hesitancy, sexual dysfunction, vertigp, overactivity, twitching, hypomanic and manic behavior, insomnia,, weakness and fatiuge
  • Avoid foods with tyramine due to risk of hypertensive crisis; contraindicated in cerebrovascular disease, hypertension, and congestive heart failure.

Serotonin Syndrome vs. Hypertensive Crisis

• Serotonin Syndrome includes: Hyperactivity, restlessness, tachycardia, fever, elevated blood pressure, altered mental states, irrationality, mood swings, seizures.
• Hypertensive Crisis marked by: Early symptoms irritability, anxiety, flushing, sweating, and a severe headache, which can progress to seizures, coma, or death.

Brain Therapies for Major Depressive Disorder: Electroconvulsive Therapy (ECT)

• An electroencephalogram (EEG) monitors the brain waves, brief seizures (30-60 seconds) are deliberately induced by electrical current.
• Post treatment typically includes confusion and disorientation for several hours with frequent memory is usually impaired after

Other Therapies for Depression

• Exercise: Regular exercise elevates mood and increases social involvement.
• Cognitive Behavioral Therapy (CBT): Changes thoughts, feelings, and behaviors through collaboration between the therapist and client.
• Interpersonal Therapy (IPT): Addresses problems within relationships and aims to improve mood by resolving interpersonal issues.
• CBT uses cognitive restructuring and IPT examines past interpersonal difficulties

Anxiety Levels, Characteristics, and Interventions

• Mild Anxiety: Leveraging everyday problem-solving; not harmful. Includes muscle tension, and fidgeting
• Moderate Anxiety: Selective inattention and increased vitals.
• Severe Anxiety: Results in impaired problem-solving and communication. Includes feelings of impending doom.
• Panic: Disturbed behavior and processing of reality; possible chest pain, sweating, or fight/flight/freeze response.

Clinical Manifestations of Anxiety Disorders

• Separation Anxiety Disorder: Excessive concern over separation from significant others. Nightmares.
• Specific Phobias: irrational fear of specific objects, activity, or situations.
• Social Anxiety Disorder: Anxiety/fear provoked by social or performance situations.
• Panic Disorder: Abrupt surge of intense discomfort that reaches peak within minutes.
• Agoraphobia: Fear about being in places/situations from which escape might be difficult.
• Generalized Anxiety Disorder (GAD): Chronic excessive worry/anxiety for 6+ months. SCARE.

Basic Nursing Interventions for Anxiety Disorders

• Establish trust, calm non-threatening manner; Remain w client always when levels of anxiety are high.
• Administer medications if needed.
• Teach S/S of escalating anxiety and ways to interrupt its progression.
• Non pharmacological interventions: deep breathing, listen to calming music
• Move client to quite environment;
• Admin med for high level of panic attack
• Use short simple directions when the client is at high levels of anxiety

Medications for Anxiety Disorders

• Benzodiazepines
• Non-Benzodiazepines: - Buspirone - Antihistamines. - Beta Blockers. - SSRIs, SNRI, Tricyclic antidepressants

Psychological Therapies for Anxiety Disorders

• Cognitive Behavioral Therapy(CBT): Demonstrating how to adapt to situations - Systematic desensitization: Getting used to anxiety triggers - Flooding: Exposure to extreme therapy - Thought-stopping: Learn to identify when anxiety is increasing

Clinical Manifestations of Obsessive-Compulsive and Related Disorders

• Obsessive-Compulsive Disorder (OCD): Thoughts or impulses that cant be dismissed with repetitive behaviors to reduce anxiety.
• Hoarding Disorder includes obsessive accumulation of objects
• Body Dysmorphic Disorder is when assumption about appearance, obsession cause fear of rejection
• Trichotillomania is a body focused repetitive behavior, hair pulling.
• Excoriation Disorders is Skin picking.

Nursing Interventions for Obsessive-Compulsive Disorders with mnemonic "COPING"

• C: concerns and feeling discussed.
• O: offer routine.
• P: practice thought stopping.
• I: initiate behavioral contract.
• N: nurture ways to reduce anxiety.
• G: get patient for perform relaxation techniques promote self-care, monitor skin integrity

Medications For Obsessive-Compulsive Disorders

• SSRIs for OCD
• None for body dysmorphic disorder, hoarding disorder, excoriation, or trichotillomania

Psychological Therapies for Obsessive-Compulsive Disorders

• Exposure and response prevention (first-line cognitive behavior). Patient to triggers and prove show the anxiety will not subside.
• Flooding (expose the patient to a large amount of trigger).

Symptoms and Etiology of PTSD in Adults and Children

• Adults face military combat, crime-related events, natural/human disasters. Manifest as intrusive thoughts, negative moods, alterations in arousal, and symptoms of avoidance of stimuli.
• Children react with reduction in play, negative emotions, social withdrawal, aggressive/self-destructive behavior, sleep disturbances, problems concentrating, and hypervigilance.

Nursing Process for PTSD in Adults as Children

• Assessment should include using DSM -5 and mental health
• Diagnosis of anxiety, ineffective coping, social isolation and ineffective coping
• Planning- Relaxations techniques
• Implementation- safety, decrease arousal, improve socialization

Pharmacological and Psychological Treatment for PTSD in Adults

• Pharmacological: Antidepressants, Anxiolytics
• Psychological: CBT, psychodynamic psychotherapy, exposure therapy, modified EMDR therapy

Acute Stress Disorder

• Symptoms are similar to PTSD but last 3 days to 1 month after a traumatic event, with dissociation is hallmark
• Treatment includes: Provide relaxation techniques, CBT, and benzodiazepines

Dissociative Disorders with descriptions

• Dissociative Amnesia: Inability to recall important personal.
• Dissociative Identity Disorder: Presence of two or more distinct personality states (alters).
• Depersonalization-Derealization Disorder: Persistent episodes, feelings of one's unreality, and detachment.

Somatic Symptom Disorder (SSD)

• Characterized by: Physical symptoms (pain/fatigue) to the point of excessive concern.
• Note Symptoms can include: Chest pain, swelling back pain, abdominal pain

Disorders Similar to Somatic Disorders

• Conversion Disorder. neurological symptoms in the absence of a neurological diagnosis, patients Show Lack of emotion
• Illness Anxiety Disorders, with no complaints from signs of illness,
• Malingering, fabricating of illness to get gain in secondary.

Nursing Interventions for Factitious Disorders

• Maintain patient safety, professional boundaries.
• Communication:non judgment all talk to the Health Care provide

Interventions for Obsessive-Compulsive Disorders with mnemonic "COPING"

• C: concerns and feeling discussed.
• O: offer routine.
• P: practice thought stopping.
• I: initiate behavioral contract.
• N: nurture ways to reduce anxiety.
• G: get patient for perform relaxation techniques promote self-care, monitor skin integrity