Understanding Acute and Chronic Stress

• Good stress (Eustress) motivates and energizes; preparing for a test or wedding.
• Bad stress (Distress) leads to negative physical and mental reactions and is chronic and ongoing; financial burden or long-term work/family stress.

Acute Stress

• Short-term "fight or flight" response
• Rapid physical changes occur; increased heart rate, faster breathing, elevated blood pressure, dilated pupils, sweating, dry mouth, and sympathetic nervous system activation.
• Key neurotransmitters are Norepinephrine (fight or flight) and Acetylcholine (muscle control).

Chronic Stress

• Long-term stress leads to physical and biological changes.
• Weight changes, fatigue, frequent illness (suppressed immune system), high blood pressure, irritable bowel syndrome (IBS), sleep disturbances, and headaches.
• Hormonal changes, elevated cortisol
• C-Reactive Protein (CRP) is a marker for inflammation and indicates chronic stress-related physical issues.
• Cardiovascular effects include changes in triglycerides and cholesterol and contributes to heart disease.

Pharmacological Treatments

• Benzodiazepines treat acute anxiety/stress
• Buspirone is a non-sedating alternative to benzodiazepines.
• SSRIs are used for long-term management of stress-related anxiety or depression.

Non-Pharmacological Stress Reduction

• Guided imagery, deep breathing, and relaxation techniques reduce stress.
• Exercise releases endorphins, reducing stress.
• Yoga and Tai Chi can aid in stress reduction.
• Spirituality and religious practices can reduce stress.
• Journaling as a form of cognitive-behavioral therapy (CBT) can help with stress
• Herbal supplements include St. John's Wort, but caution with SSRIs due to the risk of serotonin syndrome.

Serotonin Syndrome

• Serotonin syndrome can be caused by combining SSRIs with St. John's Wort.
• Fever, increased heart rate, agitation, muscle rigidity, and confusion are symptoms.

Bipolar Disorder

• Caused by extreme mood swings between mania and depression
• Bipolar 1 and Bipolar 2 differ in the severity and duration of manic and depressive episodes.
• Bipolar 1 causes manic episodes and major depressive episodes.
• Bipolar 2 causes hypomanic episodes and more pronounced depressive episodes.
• Cyclothymic Disorder causes chronic mood disturbances with less severe hypomanic and depressive episodes that last for at least 2 years.

Mania Symptoms

• Elevated mood (feeling euphoric or overly confident)
• Rapid speech and flight of ideas
• Increased activity level
• Impulsiveness and risky behavior
• Decreased need for sleep.

Medications

• Lithium has potential key side effects: Lithium toxicity (e.g., tremors, confusion, nausea).
• Lithium is most effective at therapeutic levels between 0.6 to 1.2 mEq/L.
• Lithium toxicity occurs with anything greater than 1.5 mEq/L.
• Hydration is key; patients maintain fluid and sodium balance to avoid lithium toxicity.
• Anticonvulsants are used to manage mania.
• Antipsychotics help stabilize mood.
• Electroconvulsive Therapy (ECT) is for severe cases of bipolar disorder when medications are ineffective.
• The nursing priority is to ensure safety and prevent harm during manic episodes
• Provide food and hydration during episodes

Approach

• Use calm, slow communication and avoid joining in their manic behavior to de-escalate

Suicide Prevention

• Suicide is a symptom, not a diagnosis.
• Questions to ask include: “Are you thinking of harming yourself?” and “Do you have a plan?"
• Behaviors like giving away possessions, talking about death or saying goodbye, social withdrawal, and engaging in risky behaviors are all warning signs to look for.
• Risk increases when patients start feeling better after beginning antidepressants and when people appear calm or “better” just before an attempt.

Safety and Precautions

• Remove dangerous items
• Close monitoring is needed for patients at high risk of self-harm.

Major Depressive Disorder (MDD)

• MDD Symptoms last a long period and include persistent sadness, hopelessness, loss of interest, sleep disturbances, weight changes, decreased energy, and feelings of worthlessness
• Persistent Depressive Disorder (Dysthymia) is chronic and moderate
• Pharmacological Treatments involve SSRIs/SNRIs, cognitive behavioral therapy (CBT), and electroconvulsive therapy (ECT) for treatment.

Mental Health Treatments

• Therapeutic communication uses specific strategies to help patients express their thoughts, feelings, and concerns in a safe, supportive, and non-judgmental environment, fostering a trusting nurse-patient relationship.
  • Non-judgmental listening does not pass any form of judgment, criticism, or blame about the patient's thoughts, behaviors, or emotions, providing a safe enviroment.
  • Empathetic listening involves understanding and sharing feelings of the patient by listening actively and communicating that you understand their emotional state.
• Active listening, clarifying, open-ended questions and reflecting feelings are important techniques

Defense Mechanisms

• Defense mechanisms cope with anxiety, stress, and conflict to be adaptive (healthy) or maladaptive (unhealthy).
• Adaptive (Healthy) helps individuals cope effectively with stress or conflict.
  • Sublimation is channeling negative emotions or impulses into socially acceptable activities.
  • Altruism is helping others to deal with personal stress
  • Suppression is consciously deciding to put aside disturbing thoughts or feelings in order to focus on something else.
• Humor provides tension relief when coping with stressful situations.
• Maladaptive (Unhealthy) defense mechanisms lead to emotional and behavioral problems over time.
  • Denial refuses to acknowledge an obvious reality.
  • Projection attributes one's own negative feelings or thoughts to others.
  • Regression returns to an earlier stage of development .
  • Repression pushes painful or distressing memories out of conscious awareness.

Cognitive Behavioral Therapy (CBT)

• CBT is a structured, time-limited psychotherapy to help individuals identify and change negative thought patterns and behaviors that contribute to emotional distress through thoughts that influence feelings and behaviors.

CBT Techniques

• Cognitive restructuring identifies irrational/negative thoughts and replace them with balanced and realistic ones.
• Behavioral techniques teach new behaviors to cope with distressing situations.
• A thought record writes down negative thoughts and replace them with realistic thoughts.
• Graded exposure involves gradually confronting feared situations or memories in a controlled and safe way.
• Activity scheduling plans positive activities throughout the week to improve mood.

Common Cognitive Distortions (Thinking Errors)

• All-or-Nothing Thinking: Seeing things in black-and-white terms
• Catastrophizing: Expecting the worst possible outcome
• Overgeneralization: Taking one instance and applying it to all future situations
• Mind Reading: Assuming you know what others are thinking
• Emotional Reasoning: Believing that because you feel a certain way, it must be true

CBT Practices

• Therapists for Depression helps patients challenge negative beliefs by examining evidence and considering perspectives as well as challenges social situations.
• Therapists for Anxiety help the patient challenge speaking fear by gradually exposing the patient to less intimidating social situations, slowly building confidence.

Antidepressants

• SSRIs (Selective Serotonin Reuptake Inhibitors)
  • Common medications include Fluoxetine (Prozac), Sertraline (Zoloft), and Escitalopram (Lexapro).
  • Increases serotonin levels in the brain by inhibiting its reuptake in the synapse, improving mood, sleep, and appetite.
  • Treats Major depressive disorder (MDD), Generalized anxiety disorder (GAD), panic disorder, OCD, and PTSD.
  • Side effects include Nausea, insomnia, sexual dysfunction, dry mouth, and weight gain.
  • Can cause Serotonin Syndrome, caused by excessive serotonin, from other serotonergic drugs
  • Symptoms include Agitation, fever, sweating, tremors, rigidity, tachycardia, confusion, and seizures.

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Common Medications include Venlafaxine (Effexor) and Duloxetine (Cymbalta).
• Increases serotonin and norepinephrine levels in the brain by blocking their reuptak.
• Treats MDD, GAD, panic disorder, chronic pain, and fibromyalgia.
• Side effects include Drowsiness, dizziness, dry mouth, insomnia, and hypertension

TCAS (Tricyclic Antidepressants)

• Common Medications include Amitriptyline, Nortriptyline (Pamelor), and Imipramine.
• Blocks the reuptake of norepinephrine and serotonin but has antihistamine properties.
• Treats MDD, chronic pain, neuropathy, insomnia, and migraines.
• Side effects include Anticholinergic effects, sedation, weight gain, and orthostatic hypotension
• Increased risk for overdose due to cardiac effects

MAOIS (Monoamine Oxidase Inhibitors)

• Common Medications include Phenelzine (Nardil), Tranylcypromine (Parnate), and Selegiline.
• Inhibits the enzyme monoamine oxidase
• Treats resistant depression, anxiety disorders, and certain phobias.
• Side Effects include Orthostatic hypotension, insomnia, dry mouth, and weight gain.
• Interacts with foods with with high concentrations of tyramine

Anti-psychotics and Mood Stablizers

• First-Generation Antipsychotics (Typical)
  • Common Medications include Haloperidol or Chlorpromazine
  • Blocks dopamine receptors
  • Treats Schizophrenia, acute psychosis, and agitation.
  • Side effects include tremors rigidity bradykinesia

Second-Generation (Atypical)

• Common Medications includes Risperidone, Olanzapine, Quetiapine, and Aripiprazole.
• Blocks dopamine and serotonin receptors, reducing psychotic symptoms.
• Treats schizophrenia, bipolar disorder, and adjunctive treatment for depression.
• Side effects include weight gain, diabetes, sedation, and metabolic syndrome.
• Lithium helps with Bipolar Disorder
  • Alters sodium transport in nerve and muscle cells
  • Treats Bipolar disorder
  • Key side effects include tremors and weight gain. Therapeutic levels: 0.6-1.2 mEq/L

Anti Anxiety Medications

• Benzodiazepines
  • diazepam, lorazepam, clonazepam
  • Action: GABA which has an inhibitory effect on the central nervous system, producing a calming effect.
  • Indications: Short-term management of anxiety, insomnia, and alcohol withdrawal.
  • Side Effects: Sedation, dizziness, memory impairment, and tolerance/dependence
• Buspirone (Buspar)
  • Action: Selectively affects serotonin receptors, has anxiolytic effects without sedative or addictive properties.
  • Indications: Generalized anxiety disorder (GAD).
  • Side Effects: Dizziness, headache, and nausea

Med Precautions

• Sexual Dysfunction: A common side effect of SSRIs/SNRIs
• Anticholinergic Effects: Found with older antidepressants like TCAs (e.g., dry mouth, constipation).
• Weight Gain: Seen with certain antidepressants
• Discontinuation Syndrome: Can occur with sudden stopping of SSRIs/SNRIs

Stimulants (ADHD and Narcolepsy)

• Common Medications include Methylphenidate and Amphetamine salts.
  • Action: Increase dopamine and norepinephrine
  • Indications: Attention-deficit hyperactivity disorder (ADHD),
  • Side Effects: Insomnia and Hypertension

Antidepressants During Pregnancy

• Safe Antidepressants During Pregnancy is SSRIs but should be used wIth caution.