Mental Health PDF

8/27/24 Class 1 Chapter 2: Historical and theoretical concepts Historical: -Primitive thoughts included the thought that the mentally ill were possessed -violent treatments -mental illness was considered witchcraft -18th century in Philadelphia was the first hospital in America to admit patients w...

8/27/24 Class 1 Chapter 2: Historical and theoretical concepts Historical: -Primitive thoughts included the thought that the mentally ill were possessed -violent treatments -mental illness was considered witchcraft -18th century in Philadelphia was the first hospital in America to admit patients with mental illness -Benjamin Rush is the “father of American psychiatry” -Dorthea Dix established the first asylum in America in the 19th century -Psychiatric nursing began in 1873 Concepts: -Safety (Maslow's hierarchy) is the number 1 concern -Definition of mental health “​​The successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms.” - The normality of behavior is determined by the culture -Mental illness is characterized by “maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and that interfere with the individual’s social, occupational, and/or physical functioning” -mental illness once we see its affecting a person's ability to function -Two major primary physiological response patterns to stress is anxiety and grief - Anxiety: A feeling of discomfort and apprehension related to fear of impending danger. The individual may be unaware of the source of his or her anxiety, but it is often accompanied by feelings of uncertainty and helplessness. Peplau’s four levels of anxiety 1. mild: rarely a problem, Individuals employ any of a number of coping behaviors that satisfy their needs for comfort. 2. Moderate: The perceptual field begins to diminish, Sigmund Freud identified the ego as the reality component of the personality, governing problem-solving and rational thinking. As the level of anxiety increases, the strength of the ego is tested, and energy is mobilized to confront the threat. 3. Severe: The perceptual field diminishes greatly, anxiety at this level that remains unresolved over an extended period of time can contribute to a number of physiological  disorders. Measurable pathophysiology can be demonstrated. Extended periods of severe repressed severe anxiety can result in psychoneurotic behavior patterns. 4. Panic: the most intense state, At this extreme level, an individual is not capable of processing what is happening in the environment and may lose contact with reality. Psychosis is defined as a significant thought disturbance in which reality testing is impaired, resulting in delusions, hallucinations, disorganized speech, or catatonic behavior. Exhibit minimal distress Unaware their behavior is maladaptive Unaware of a psychological problem (anosognosia) Exhibiting a flight from reality into a less stressful world or one in which they are attempting to adapt Neurosis: Presents with severe anxiety. Psychiatric disturbances are characterized by excessive anxiety that is expressed directly or altered through defense mechanisms. Appears as symptoms, such as obsession, compulsion, phobia, or sexual dysfunction *Know defense mechanisms * DEFENSE MECHANISMS COMPENSATION: Covering up a real or perceived weakness by emphasizing a trait one considers more desirable Ex. A physically disabled boy is unable to participate in football, so he compensates by becoming a great scholar. RATIONALIZATION: Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors Ex. A patient tells the rehab nurse, “I drink because it’s the only way I can deal with my bad marriage and my worse job.” DENIAL: Refusing to acknowledge the existence of a real situation or the feelings associated with it Ex. A woman drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem. REACTION FORMATION: Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors Ex. A student hates nursing and only attended nursing school to please her parents. During career day, she speaks to prospective students about the excellence of nursing as a career. DISPLACEMENT: The transfer of feelings from one target to another that is considered less threatening or that is neutral Ex. A patient is angry with his physician, does not express it, but becomes verbally abusive with the nurse. REGRESSION: Retreating in response to stress to an earlier level of development and the comfort measures associated with that level of functioning Ex. When a 2-year-old is hospitalized for tonsillitis, he will drink only from a bottle, even though his mother states he has been drinking from a cup for 6 months. IDENTIFICATION: An attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires Ex. A teenager who required lengthy rehabilitation after an accident decides to become a physical therapist as a result of his experiences. REPRESSION: Involuntarily blocking unpleasant feelings and experiences from one’s awareness Ex. A trauma victim is unable to remember anything about the traumatic event. INTELLECTUALIZATION: An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis Ex. A woman’s husband is being transferred with his job to a city far away from her parents. She hides anxiety by explaining to her parents the advantages associated with the move. SUBLIMATION: Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive Ex. A mother whose son was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drunk Driving. INTROJECTION: Integrating the beliefs and values of another individual into one’s own ego structure Ex. Children integrate their parents’ value system into the process of conscience formation. A child says to a friend, “Don’t cheat. It’s wrong.” SUPPRESSION: The voluntary blocking of unpleasant feelings and experiences from one’s awareness Ex. “I don’t want to think about that now. I’ll think about that tomorrow.” ISOLATION: Separating a thought or memory from the feeling, tone, or emotion associated with it Ex. A young woman describes being attacked and raped without showing any emotion. UNDOING: Symbolically negating or canceling out an experience that one finds intolerable Ex. A man is nervous about his new job and yells at his wife. On his way home he stops and buys her some flowers. PROJECTION: Attributing feelings or impulses unacceptable to one’s self to another person Ex. A man who is addicted to alcohol blames his wife for his excessive drinking. 8/29/24 Class 2 Kubler-ross’s five stages of grief response 1. Denial: A stage of shock and disbelief 2. Anger: Envy and resentment toward individuals not affected by the loss are common 3. Bargaining: A “bargain” is made with god in an attempt to reverse or postpone the loss 4. Depression: the sense of loss is intense and feelings of sadness and depression prevail 5. Acceptance: the final stage brings a feeling of peace regarding the loss that has occurred Anticipatory grief- experiencing the grief process before the actual loss occurs (cancer, you know the loss is coming) Resolution- The length of the grief process is entirely individual (may last from a week to years, influenced by many factors) Many factors prolong the length of the grieving process - If the relationship with the lost entity was marked by ambivalence or a “love-hate” association, the reaction may be burdened with guilt - Guilt often lengthens the grieving process Grief can accumulate into an overload - Perceived as difficult or even impossible to overcome The mourning process is resolved - Individuals can regain a sense of organization - Redefine his or her life in the absence of a lost person or object - Pursue new interests and relationships Maladaptive grief response - Occur when an individual is not able to progress through the stages of grieving  - Individuals become fixed in the denial or anger stage of the grief process Types of Grief Responses: Prolonged- characterized by an intense preoccupation with memories of the lost entity for many years after the loss has occurred Delayed or inhibited- the individual becomes fixed in the denial stage of the grieving process Distorted- the individual is fixed in the anger stage of grieving, which may culminate in pathological depression The concept of stress adaptation Stress: individual's reaction to any change that requires and adjustment or response which can be physical mental or emotional Adaptive response - Behavior that maintains the integrity of the individual - Viewed as positive and is correlated with a healthy response Maladaptive response - When behavior disrupts the integrity of the individual - Considered to be negative or unhealthy Selyes general adaptation syndrome: Alarm reaction stage: fight or flight response (can be in response to something physical or can be in response to psychological or emotional stimuli) Stage of resistance: uses physiological responses of the first stage as a defense in an attempt to adapt to the stressor Stage of exhaustion: the body responds to prolonged exposure to a stressor, adaptive energy is depleted, disease of adaptation may occur Stress as an environmental event - This concept defines stress as an event that triggers an individual's adaptive physiological and psychological responses - The change can be either positive or negative  - The event creates a change in the life pattern of the individual requires significant adjustment in lifestyle and tax available personal resources - Stress is measured by the Miller and Rahe Recent Life Changes Questionnaire (RLCQ) Primary appraisal Irrelevant: when the outcome holds no significance for the individual. Benign-positive: outcome is perceived as producing pleasure for the individual. Stress appraisals: include harm/loss, threat, and challenge. Harm/loss appraisals: refer to damage or loss already experienced by the individual. Appraisals of a threatening nature: are perceived as anticipated harms or losses. When an event is appraised as challenging, the individual focuses on the potential for gain or growth rather than on risks associated with the event. Secondary appraisal -The interaction between the primary appraisal of the event that has occurred and the secondary appraisal of available coping strategies determines the quality of the individual’s adaptation response to stress. Predisposing factors to stress - Genetic influences: Genetic influences are those circumstances of an individual’s life that are acquired through heredity. Examples include family history of physical and psychological conditions (strengths and weaknesses) and temperament (behavioral characteristics present at birth that evolve with development). - Past experiences: Past experiences are occurrences that result in learning patterns that can influence an individual’s adaptation response. - Existing conditions: Existing conditions incorporate vulnerabilities that influence the adequacy of the individual’s physical, psychological, and social resources for dealing with adaptive demands. Coping strategies are adaptive when: they protect the individual from harm and strengthen the individual's ability to meet challenging situations Examples: awareness, meditation, relaxation, interpersonal communication, problem-solving, pet, and music therapy Ethical and Legal Issues Restraints and seclusion - Must be a result of immediate risk of self-harm or harm to others - Restraints must never be used as punishment or for convenience  - Restraints must be checked every hour for skin breakdown and perfusion - Make sure there's an order before applying restraints 9/3/2024 Class 3 Therapeutic Communication Impact of pre-existing condition - Values, attitudes, beliefs - Culture or religion - Social status - Education level - Gender - Age or developmental level - The environment in which the transaction takes place - Four kinds of distance in interpersonal interactions - Intimate distance: the closest distance that individuals allow between themselves and others - Personal distance: the distance for interactions that are personal in nature, such as close conversations with friends -Social distance: the distance for conversation with strangers or acquaintances -Public distance: the distance for speaking in public or yelling at someone some distance away *De-escelating a situation; remove everyone from the situation don't try and move the escalating person* Nonverbal communication - Physical appearance and dress - Body movement and posture - Touch - facial expressions - Eye behavior - Vocal cues or paralanguage Therapeutic communication techniques - Using silence: allows the patient to take control of the discussion if he or she so desires - Accepting: conveys positive regard - Giving recognition: acknowledging, indicating awareness  - Offering self: making oneself available - Giving broad openings: allows the client to select the topic - Offering general leads: encourages client to continue - Placing the event in time or sequence: clarifies the relationship of events in time - Making observations: verbalizing what is observed or perceived - Encouraging description of perceptions: asking the client to verbalize what is being perceived - Encouraging comparison: Asking the client to compare similarities and differences in ideas, experiences, or interpersonal relationships - Restating: Lets the client know whether an expressed statement has been understood - Reflecting: Directs questions or feelings back to the client so that they may be recognized and accepted - Focusing: Taking notice of a single idea or even a single word - Exploring: Delving further into a subject, idea, experience, or relationship - Seeking clarification and validation: Striving to explain what is vague and searching for mutual understanding - Presenting reality: Clarifying misconceptions that the client may be expressing - Voicing doubt: Expressing uncertainty as to the reality of the patient’s perception - Verbalizing the implied: Putting into words what the patient has only implied - Attempting to translate words into feelings: Putting into words the feelings the client has expressed only indirectly - Formulating a plan of action: Striving to prevent anger or anxiety from escalating to unmanageable levels when the stressor recurs Nontherapeutic communication techniques - Giving false reassurance: May discourage the patient from the further expression of feelings if the patient believes the feelings will only be downplayed or ridiculed - Rejecting: Refusing to consider the patient’s ideas or behavior - Approving or disapproving: Implies that the nurse has the right to pass judgment on the “goodness” or “badness” of the patient’s behavior. - Agreeing or disagreeing: Implies that the nurse has the right to pass judgment on whether the patient’s ideas or opinions are “right” or “wrong” - Giving advice: Implies that the nurse knows what is best for the patient and that the patient is incapable of any self-direction - Probing: Pushing for answers to issues that the patient does not wish to discuss causes the patient to feel used and valued only for what is shared with the nurse - Defending: To defend what the patient has criticized implies that the patient has no right to express ideas, opinions, or feelings - Requesting an explanation: Asking “why” implies that the patient must defend his or her behavior or feelings  - Indicating the existence of an external source of power: Encourages patient to project blame for his or her thoughts or behaviors on others - Belittling feelings: Causes patient to feel insignificant or unimportant - Making stereotyped comments: Clichés and trite expressions are meaningless in a nurse-patient relationship - Using denial: Blocks discussion with the patient and avoids helping the patient identify and explore areas of difficulty - Interpreting: Results in the therapist telling the patient the meaning of his or her experience - Introducing an unrelated topic: Causes the nurse to take over the direction of the discussion Active listening - To listen actively is to be attentive to what is said, both verbally and nonverbally - Several nonverbal behaviors have been designed to facilitate attentive listening - S: sit squarely facing the patient - O: observe an open posture - L: lean forward toward the patient - E: establish eye contact - R: Relax Feedback - Descriptive rather than evaluative and focused on the behavior rather than on the client - Specified rather than general - Directed toward behavior the client has the capacity to modify - Imparts information rather than offers advice - Is well timed 9/5/24 Class 4 Anxiety, Obsessive-Compulsive and related disorder - Anxiety is emotional, fear is cognitive - Fear involves the intellectual appraisal of threatening stimulus - Anxiety involves the emotional response to that appraisal - Common comorbidities of anxiety include; substance abuse, another anxiety disorder, depression, familial predisposition, childhood trauma Panic: sudden overwhelming feeling of terror or impending doom. Most severe form of emotional anxiety is usually accompanied by behavioral, cognitive, and physiological signs and symptoms Symptoms of panic attack: - Sweating, trembling,shaking - Sob, chest pain, discomfort - Nausea - Dizziness, chills, hot flashes - Numbness or tingling Panic Disorder - Recurrent panic attacks - Unpredictable onset - Manifested by intense apprehension, fear, or terror - Feelings of impending doom - Accompanied by intense physical discomfort Generalized anxiety disorder: chronic unrealistic, and excessive anxiety and worry. Have occurred more days than not for at least 6 months and cannot be attributed to caffeine intoxication or hyperthyroidism - Has to impaired individual socially, occupationally, or other important areas of functioning - Psychodynamic theory: Ego unable to intervene between id and superego; overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety - Cognitive theory:Faulty, distorted, or counterproductive thinking patterns result in anxiety that is maintained by mistaken or dysfunctional appraisal of a situation Biochemical: Abnormal elevations of blood lactate have been noted in patients with panic disorder. Likewise, infusion of sodium lactate into patients with anxiety neuroses produced symptoms of panic disorder. Neurochemical: Strong evidence exists for the involvement of the neurotransmitter norepinephrine in the etiology of panic disorder. Norepinephrine is known to mediate arousal, and it causes hyperarousal and anxiety. Generalized Anxiety Disorder - I: irritability - C: concentration is impaired - A: anxiety, nervousness, worry on most days about many different situations - N: no control over worry - T: time: at least 6 months - R: restlessness, feeling on edge - E: energy decreased - S: sleep impaired - T: tension in muscles Phobia: persistent intensely felt and irrational fear of a specific object or situation that results in a compelling desire to avoid the feared stimulus. Agoraphobia: fear of being in public places or situations from which escape might be difficult or in which help might not be available in panic-like symptoms; in extreme cases the individual is unable to leave his or her home Social anxiety disorder: excessive fear of situations in which the affected person might do something embarrassing or be evaluated negatively by others Obsessive compulsive disorder: - Obsessions: recurrent thoughts, impulses, or images experienced as intrusive and stressful and unable to be expunged by logic or reasoning - Compulsions: repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation Body Dysmorphic disorder: - Exaggerated belief that the body is deformed or defective in some specific way - The persons concern is unrealistically exaggerated and grossly excessive - Symptoms of depression and obsessive-compulsive personality are common 9/10/24 Class 5 Treatment modalities - Individual psychotherapy - Cognitive behavior therapy - Behavior therapy - Systematic desensitization - Reciprocal inhibition - Implosion therapy - Other non pharmacological treatments: deep breathing exercises, progressive muscle relaxation, imagery, mindfulness meditation, and exercises - Psychopharmacology examples of anti-anxiety agents (check HR and BP before giving) - Hydroxyzine * - Alprazolam* - Chlordiazepoxide* - Clonazepam - Clorazepate - Diazepam* - Lorazepam* should be written as prn - Oxazepam - Meprobamate - Buspirone (can be used for longterm management; take weeks to work) Medications for specific disorders - Panic, GAD, phobic disorders - Anxiolytics - Antidepressants - Antihypertensive agents - OCD and body dysmorphic disorder - Antidepressants (fluoxetine, sertraline, escitalopram)* - Hair pulling disorder - Chlorpromazine - Amitriptyline - Lithium carbonate - Ssri - Olanzapine Nursing Diagnoses - Assessment scales - Nursing diagnoses commonly associated with anxiety, OCD, and related disorders - Panic anxiety (panic disorder and GAD) - Powerlessness (panic disorder and GAD) - Fear (phobia) - Social isolation (agoraphobia) - Ineffective coping (OCD) - Ineffective role performance (OCD) - Disturbed body image (body dysmorphic disorder) - Ineffective impulse control (hair-pulling disorder) Outcome criteria - The patient can: - Recognize signs of escalating anxiety and intervene before reaching panic level (panic and GAD) - Maintain anxiety at a manageable level and make independent decisions about life situation (panic and GAD) - Function adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder) - Verbalize a plan of action for responding in the presence of the phobic object or situation without developing panic anxiety (phobic disorder) - Maintain anxiety at a manageable level without resorting to the use of ritualistic behavior (OCD) - Demonstrate more adaptive coping strategies for dealing with anxiety instead of ritualistic behaviors (OCD) Affect: describes the observable emotional reaction Depression - Oldest and one of the most frequently diagnosed psychiatric illness - Symptoms impair functioning - Alteration in mood expressed by sadness, despair, pessimism - Changes in appetite, sleep patterns, and cognition are common - Major depressive disorder (MDD) leading causes of disability in the US - Most common psychiatric disorder - Up to 50% of all depression diagnoses may be bipolar illness - Age and gender - Depressive disorder is twice as high in women than in men - Ages 44 to 65 there's less gender differences - Biological factors -monoamine oxidase, thyroid dysfunction (hypothyroidism causes depression symptoms), hormonal factors - Psychosocial factors - stress sensitivity, multiple social roles, poorer coping mechanisms - Socioeconomic factors -social class, poverty, education level, lack of resources - Marital status - Lack of social connectedness rather than marital status may be associated with a higher incidence of depression - Seasonality -Seasonal affective disorder is referred to as a separate condition “seasonal depression” Scales of Depression Transient Depression - Symptoms at this level are not necessarily dysfunctional - Affective: “the blues” - Behavioral: some crying - Cognitive: some difficulty getting mind off of ones disappointment - Physiological: feeling tired and listless Mild Depression - Symptoms are identifies as those associated with normal grieving - Affective: anger, anxiety - Behavioral: tearful, regression - Cognitive: preoccupied with loss - Physiological: anorexia, insomnia Moderate Depression - Symptoms associated with dysthymic disorder - Affective: helpless, powerless - Behavioral: slowed physical movements, slumped posture, limited verbalization - Cognitive: retarded thinking process, difficulty with concentration - Physiological: anorexia or overeating, sleep disturbance, headache Severe Depression - Symptoms of major depressive disorder and bipolar depression - Affective: feelings of total despair, worthlessness, flat affect - Behavioral: psychomotor retardation, curled-up position, absence of communication  - Cognitive: prevalent delusional thinking, and somatic delusions; confusion;suicidal thoughts - Physiological: a general slow-down of the entire body Types of depressive disorders Major Depressive Disorder - Characterized by depressed mood - Loss of interest or pleasure in usual activities - Symptoms present for at least 2 weeks - No history of manic behavior - Cannot be attributed to use of substances or another medical condition Persistent depressive disorder (dysthymia) - Sad or “down in the dumps” - No evidence of psychotic symptoms - Essential feature is a chronically depressed mood for: most of the day, more days than not, at least 2 years Premenstrual dysphoric disorder (PMDD) - Characterized by markedly depressed mood, excessive anxiety, mood swings, decreased interest in activities during the week prior to menses, improving shortly after the onset of menstruation, and becoming minimal or absent in the week postmenses - PMDD symptoms interfere with ability to function socially at work, or school;recurrent for majority of menstrual symptoms Substance/medication induced depressive disorder - Considered the direct result of physiological effects of a substance (drug of abuse, medication, toxin exposure) - The depressed mood is associated with intoxication or withdrawal from several substances or adverse side effects from many different medications Predisposing factors to depression Biological theories - Genetics - Hereditary factors may be involved - Twin studies - Adoption studies Biochemical influences - Deficiency of norepinephrine, serotonin, and dopamine has been implicated  - Excessive cholinergic transmission may also be a factor - Dysregulation of biogenic amines deficiency in acetylcholine and excessive glutamate are being treated by newer antidepressants Neuroendocrine disturbances - May play a role in the pathogenesis or persistence of depressive illness - Hypothalamic-pituitary-adrenocortical axis - Hypersecretion of cortisol causes heightened symptoms - Hypothalamic-pituitary-thyroid axis - Midbrain disturbances Physiological influences - Medication side effects - Neurological disorders - Electrolyte disturbances - Hormonal disorders - Nutritional deficiencies - Inflammation Developmental Implications Childhood depression 1. Less than age 3: feeding problems, tantrums, lack of playfulness and emotional expressiveness 2. Ages 3-5: accident proneness, excessive self-reproach 3. Ages 6-8: physical complaints, aggressive behavior, clinging behavior 4. Ages 9-12: morbid thoughts and excessive worrying - Precipitated by a loss - Focus of therapy: alleviate symptoms and strengthen coping skills - Parental and family therapy Adolescence depression Symptoms: - Anger, aggressiveness - Running away, delinquency - Social withdrawal, sexual acting out - Substance abuse, restlessness, apathy - Best clue that differentiates depression from normal stormy adolescent behavior: A visible manifestation of behavioral change that lasts for several weeks - Most common precipitant to adolescent suicide: perception of abandonment by parents or close peer relationship - Treatment: supportive psychosocial intervention, antidepressant medication 9/17/2024 Class 6 Postpartum depression - May last for a few weeks to several months - Associated with hormonal changes, tryptophan metabolism, or cell alterations - Treatments of antidepressants and psychosocial therapies - Symptoms include - Fatigue, irritability - Loss of appetite - Sleep disturbances, loss of libido - Concern about inability to care for infant Treatment modalities - Individual psychotherapy - Focus is on interpersonal relations and proceeds through three phases and interventions - Group therapy - Types of groups include therapy, education, and self help - Family therapy - Most effective when used in combination with psychotherapeutic and pharmacotherapeutic treatments - Cognitive therapy - Focuses on changing “automatic thoughts” that contribute to distorted affect - Electroconvulsive therapy (ECT) - Electrical currents are applied to the brain, causing a grand mal (generalized) seizure - Repetitive transcranial magnetic stimulation (rTMS) - Uses short pulses of magnetic energy to stimulate nerve cells in the brain - Vagal nerve stimulation (VNS) and deep brain stimulation (DBS) - VNS and DBS both require the implantation of an electrode; implantation is deeper in DBS - Light therapy - Administered by a 10,000-lux light box with a screen that blocks ultraviolet rays - Recent studies demonstrate that CBT is as effective as light therapy and prevents recurrence - Psychopharmacology - Tricyclics - Selective serotonin reuptake inhibitors (SSRI)(fluoxetine, sertraline, paroxetine, escitalopram, and citalopram)  - Monoamine oxidase inhibitors (MAOI) - Heterocyclics - serotonin-norepinephrine reuptake inhibitor (SNRI)(duloxetine, venlafaxine) - Recently approved ketamine-based nasal spray formulations provide improved depression and suicide symptoms within 4 hours of treatment; some benefits are seen within 2 days Patient/family education related to antidepressants - Continue to take medication for 4 weeks - Do no discontinue medication abruptly - Report sore throat, fever, malaise, yellow skin, bleeding, bruising,(granulocytosis) persistent vomiting or headaches, rapid heart rate, seizures, stiff or sore neck, and chest pain to physician - Rise slowly from sitting position - Maintain good oral care - Avoid foods and medications high in tyramine when taking MAOIs - Aged cheese, wine, beer, chocolate, cola, coffee, tea, sour cream, yogurt, smoked and processed meats, beef and chicken liver, canned figs, caviar, raisins, pickled herring, yeast products, broad beans, soy sauce, cold remedies, diet pills Potential health risks of antidepressants - SNRI or SSRI combined with another medicine that increases serotonin leads to high serotonin levels which causes serotonin syndrome which severe symptoms may be arrhythmia, fits, and unconsciousness - Patients who use SSRIs and TCAs for more prolonged periods are at a higher risk of developing type 2 diabetes - Old patients who take SSRIs may experience a severe drop in sodium levels(hyponatremia) - Antidepressants may increase the risk of self-harm/suicide Pharmacogenomic - Variations in genes can predict a patients response to SSRIs - Between 30 and 50 percent of patients do not respond to first antidepressant prescription - Genotyping has demonstrated benefits in identifying if a patient is prone to certain side effects - Patients often stop taking medications because of side effects, particularly sexual dysfunction Nursing Process/Assessment - Severe depression is marked by distress that interferes with social, occupational, cognitive and emotional functioning Outcome identification - Criteria used for measurement of outcomes in the care of the depressed patient - The patient: - Has experienced no physical harm to self - Discusses feelings with staff and family members - Expresses hopefulness - Sets realistic goals for self - Attempts new activities - Identifies aspects of self-control over life situation - Expresses personal satisfaction and support from spiritual practices - Interacts willingly and appropriately with others - Maintains reality orientation - Concentrates, reasons, solves problems, and makes decisions - Eats a well balanced diet with snacks, to prevent weight loss and maintain nutritional status - Sleeps 6 to 8 hours per night and reports feeling well rested - Bathes, washes and combs hair, dresses in clean clothing without assistance Planning/Implementation - Risk for suicide - Defined as vulnerable to self-inflicted, life-threatening injury - Short term goals: - Client will seek out staff when feeling urge to harm self - Client will not harm self - Long term goal - Client will not harm self - Complicated grieving - Disorder that occurs after the death of a significant other in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment - Low self-esteem/self-care deficit - Low self-esteem:negative self-evaluating/feelings about self or self capabilities - Self care deficit: impaired ability to perform or complete ADLs for self - Powerlessness - Lived experience of lack of control over a situation, including a perception that one's actions do not significantly affect an outcome Evaluation - Reassessment is conducted to determine if nursing actions have successfully achieved care objectives by asking the following questions - Has the patient discussed the recent loss with the staff and family members? - Is the patient able to verbalize feelings and behaviors associated with each stage of the grieving process and recognize own position in the process? - Have obsession with and idealization of the lost object subsided? - Is anger toward the lost object expressed appropriately? - Does the patient set realistic goals for self? - Is the patient able to verbalize positive aspects about self, past accomplishments, and future prospects? - Can the patient identify areas of life situation over which they have control? - Is the patient able to participate in usual religious practices and feel satisfaction and support from them? - Is the patient seeking interaction with others in an appropriate manner? - Does the patient maintain reality orientation with no evidence of delusional thinking? - Is the patient able to concentrate and make decisions concerning own self-care - Is the patient selecting and consuming foods sufficiently high in nutrients and calories to maintain weight and nutritional status? - Does the patient sleep without difficulty and wake feeling rested? - Does the patient attend to personal hygiene and grooming? - Have somatic complaints subsided? 9/24/24 Class 8 Somatic Symptom and Dissociative Disorders Somatic Symptom disorders: physical symptoms suggesting medical disease but without demonstrable organic pathology, symptoms for 6 months - Higher prevalence of conversion disorder includes - Lower socioeconomic groups - Rural populations - Less education - Military personnel exposed to combat situations - Prevalence of illness anxiety disorder is difficult to quantify - Closely associated with deleted diagnosis hypochondriasis Somatic Symptom disorder - Syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and frequent visits to health care professionals - Chronic disorder with symptoms beginning before age 30 - Must experience some set of unexplained somatic symptoms for at least 6 months - Causes persistent thoughts of feelings about symptoms, worry, and anxiety - Mild: only one cognitive symptoms - moderate : two or more cognitive symptoms - Severe: two or more cognitive symptoms and multiple physical symptoms - Comorbidities a patient may have : anxiety, depression, substance abuse, increased risk of suicide - Personality characteristics: heightened emotionality, strong dependency needs, preoccupation with symptoms Illness anxiety disorder(hypochondriac) - Unrealistic or inaccurate interpretation of physical symptoms or sensations - Extremely conscious of bodily sensations and changes - Some have history of doctor shopping while others avoid seeking medical care - Anxiety and depression are common, obsessive-compulsive traits frequently accompany the disorder Conversion Disorder - Loss of or change in body function that cannot be explained by any known medical disorder - 1 or more neurological symptoms that can't be explained by any known medical or neurological disorder - Symptoms affect voluntary motor or sensory functioning suggestive of neurological disease - Symptoms: mutism, blindness, paralysis, anesthesia, paresthesia, abnormal movement, gait disturbance, weakness, tics, jerks - Some instances of conversion disorder may be precipitated by psychological stress - Symptoms typically resolve on their own in 2 to 3 weeks - Psychological factors affecting medical condition - Psychological factors may play a role in virtually any medical conditions - Evidence of a general medical condition that has been precipitated by or is being perpetuated by psychological or behavior circumstances Factitious Disorder (munchausen syndrome(gypsy rose)) - Conscious, intentional feigning of physical and or psychological symptoms - Individual pretends to be ill to receive emotional care and support commonly associated with the role of “client” - Disorder may be imposed on another person under the care of the perpetrator - If parent present with this with their child and you suspect this, as a nurse, you must call CPS because this is child abuse Predisposing factors associated with somatic symptom disorder - Genetic - Hereditary factors are possibly associated with somatic symptom disorder, conversion disorder, and illness anxiety disorder - Biochemical - Decreased levels of serotonin and endorphins(more often when it has to do with pain) may play a role in the etiology of somatic symptom disorder, predominantly pain - Psychodynamic theory - Some view illness anxiety disorder as an ego defense mechanism - Physical complaints are the expression of low self esteem and feelings of worthlessness - Another psychodynamic view of illness anxiety disorder is related to a defense against guilt - Conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptably “converted” into physical symptoms - Family dynamics - In dysfunctional families when a child becomes ill, focus shifts from the open conflict to the childs illness and leaves unresolved underlying issues that the family is unable to confront openly - Somatization brings some stability to the family and positive reinforcement to the child - Learning Theory - SOMATIC COMPLAINTS ARE OFTEN REINFORCED WHEN THE SICK PERSON LEARNS THEY - MAY AVOID STRESSFUL OBLIGATIONS OR BE EXCUSED FROM UNWANTED DUTIES (PRIMARY GAIN) - MAY BECOME THE PROMINENT FOCUS OF ATTENTION BECAUSE OF THE ILLNESS (SECONDARY GAIN)  - MAY RELIEVE CONFLICT WITHIN THE FAMILY AS CONCERN IS SHIFTED TO THE ILL PERSON AND AWAY FROM THE REAL ISSUE (TERTIARY GAIN) - Transactional model of stress/adaptation - Etiology of somatic symptom disorders is most likely influenced by multiple factors Dissociative Disorders - Defined by a disruption in the usually integrated functions of consciousness, memory, and identity - Dissociative responses occur when anxiety becomes overwhelming and the personality becomes disorganized Epidemiological statistics - Dissociative disorders are quite rare - More prevalent in women than in men - Symptoms usually begin in adolescence or early adulthood Types of dissociative disorders Dissociative Amnesia - Defined as an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness, and which is not due to the direct effects of substance use or neurological or other medical condition - Onset usually follows severe psychosocial stress - Localized amnesia: the individual is unable to recall all incidents associated with a stressful period - Selective amnesia: individual can recall only certain incidents associated with a stressful event for a specific period after the event - Generalized type: individual has amnesia for his or her identity and total life history - Dissociative fugue: sudden, unexpected travel away from customary places or by bewildered wandering with inability to recall some or all of ones past Dissociative Identity Disorder - Characterized by the existence of two or more personality states in a single individual - Transition from one personality state to another may be sudden or gradual, and is sometimes quite dramatic Depersonalization-Derealization Disorder - Characterized by a temporary change in the quality of self-awareness, which often take the form of - Feelings of unreality - Changes in body image - Feelings of detachment from the environment  -Depersonalization: disturbance in the perception of oneself -Derealization: alteration in the perception of the external environment -Symptoms: Anxiety and depression, fear of going insane, obsessive thoughts, somatic complaints, disturbance in the subject sense of time Psychodynamic theory - Repression of distressing mental contents from conscious awareness Psychological Trauma slide 35 Somatic Symptom Disorder treatment modalities - Individual psychotherapy - Group psychotherapy (conversion, somatic disorder) - Cognitive behavior therapy and psychoeducation - Psychopharmacology Know what therapies go best with each disorder 9/26/24 Class 9 Medical treatments for dissociative amnesia - Many cases resolve spontaneously when individual is removed from stressful situation - For refractory conditions, intravenous administration of amobarbital is useful in retrieval of lost memories - Psychotherapy is used as the primary treatment - Techniques of persuasion and free association help the client remember - Hypnosis may be required to mobilize memories Dissociative identity disorder medical treatment modalities - Individual psychotherapy - Hypnosis - Supportive care - Cognitive therapy - Group therapy - Integration therapy - Psychopharmacology Depersonalization-derealization disorder medical treatment modalities - Antidepressants, mood stabilizers, anticonvulsants, and antipsychotics - Results have been sporadic at best - Hypnotherapy - Cognitive behavioral therapy Nursing Diagnoses: Somatic system disorders - Ineffective coping evidenced by numerous physical complaints(somatic symptom disorder) - Deficient knowledge(psychological causes for physical symptoms)(somatic symptom disorder) - Chronic pain (somatic symptom disorder) - Fear (of having a serious disease)(illness anxiety disorder) - Disturbed sensory perception (conversion disorder) - Self care deficit (conversion disorder) Nursing Diagnoses: Dissociative disorders - Deficient knowledge (psychological factors affecting medical condition) - Impaired memory(dissociative amnesia) - Powerlessness(dissociative amnesia) - Risk for suicide (DID) - Disturbed personal identity(DID) - Disturbed sensory perception (visual/kinesthetic)(depersonalization-derealization disorder) Treatment is Symptom based not diagnosis based  Schizophrenia (CH 24) - Current diagnostic system classifies the personality disorders into three clusters a. Behaviors described as odd or eccentric (paranoid, schizoid, schizoaffective) b. Behaviors described as dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic) c. Behaviors described as anxious or fearful (avoidant, dependent, obsessive- compulsive personality disorder) Schizophrenia spectrum and other psychotic disorders(CH 24) Introduction - Schizophrenia caused by combination of factors - Genetic predisposition - Biochemical dysfunction - Physiological factors - Psychosocial stress - No single treatment that cures schizophrenia - Requires treatment that is comprehensive and presented in a multidisciplinary effort - Of all mental illnesses, schizophrenia probably causes more: - Lengthy hospitalizations - Chaos in family life - Exorbitant costs to people and governments - Fears - Risk for suicide is a major concern Predisposing factors - Genetics plays an important role in the development of schizophrenia - Schizophrenia may be caused by an excess of dopamine activity in the brain - Factors that have been implicated include: viral infection, anatomical abnormalities (ventricular enlargement, reduction in gray matter, reduction in symmetry of several lobes in the brain)(if person has these, more likely to have a worse prognosis) - Poverty has been linked with the development of schizophrenia - Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse - Schizophrenia is most likely a biologically based disease, the onset of which is influenced by factors in the internal or external environment Nature of the disorder - Psychosis - Severe mental condition in which there is disorganization of the personality deterioration in social functioning and loss of contact with or distortion of reality - May be evidence of hallucinations and delusional thinking - Can occur with or without impairment - Schizophrenia causes disturbances in thought processes, perception, affect - Severe deterioration of social and occupational functioning in schizophrenia - Symptoms generally appear in late adolescence or early adulthood, although they may occur in middle or late adult life - Schizophrenia may be viewed in four phases - Premorbid phase - Prodromal phase - Active psychotic phase (acute schizophrenic episode) - Residual phase 1. Premorbid phase: - Personality and behavior indicators: - Shy and withdrawn - Poor peer relationships - Poor school performance - antisocial behavior - Current research is focused on the premorbid phase to identify potential biomarkers and at-risk individuals in an effort to prevent transition to illness or provide early intervention 2. Prodromal phase - Personality and behavior indicators: - Significant deterioration in function - 50% have depressive symptoms - Social withdrawal - Cognitive impairment - Obsessive-compulsive behavior 3. Active psychotic phase - Personality and behavior indicators: - Psychotic symptoms are typically prominent - Delusions - Hallucinations - Disorganized speech and behavior - Decreased level of functioning in work, personal relationships, self care  4. Residual phase - Personality and behavior indicators: - Active psychotic phase symptoms are either absent or no longer prominent - Positive symptoms may remain - Flat affect and impairment in role functioning are common - Current research indicates that negative symptoms can improve over time; residual impairment often increases with additional episodes of active psychosis. Prognosis - Return to full premorbid functioning is not common - Factors associated with a positive prognosis include: - Good premorbid functioning - Later age at onset - Female gender - Abrupt onset precipitated by a stressful event - Associated mood disturbance - Brief duration of active-phase symptoms - Minimal residual symptoms - Absence of structural brain abnormalities - Normal neurological functioning - Family history of mood disorder - No family history of schizophrenia Other schizophrenia spectrum and psychotic disorders - Delusional disorder - To be diagnoses, patient must be experiencing these non prominent, non bizarre delusions for at least one month - Erotomanic type: belief someone is in love with him/her (usually someone of high status) - Grandiose type: irrational ideas regarding their own worth, talent, knowledge, or power. Could also think they have a special relationship with someone famous - Jealous type: idea that the persons sexual partner is unfaithful - Persecutory type:most common type, individuals believe they are being persecuted or malevolently treated in some way - Somatic type: - Mixed type: - Brief psychotic disorder - Sudden onset of symptoms - May or may not be preceded by a severe psychosocial stressor - At least 1 day but less than 1 month - Eventual full return to normal level of functioning  - Symptoms: incoherent speech, delusions, hallucinations, bizarre behavior, disorientation, catatonic features - Substance-induced psychotic disorder - Presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal - Psychotic disorder associated with another medical condition - Prominent hallucinations and delusions are directly attributable to a general medical condition - Catatonic disorder due to another medical condition - Metabolic disorders ( hepatic encephalopathy, diabetic ketoacidosis, hypo and hyperthyroidism, hypo and hyperadrenalism, hypercalcemia, and vitamin b12 deficiency) - Neurological conditions (epilepsy, tumors, cerebrovascular disease, head trauma, encephalitis) - Schizophreniform disorder - Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months - Schizoaffective disorder - Schizophrenic symptoms accompanied by a strong element of symptomatology associated with either mania or depression Positive symptoms - Disturbances in thought process - Delusions: false personal beliefs - Paranoia: extreme suspiciousness of others - Magical thinking: ideas that one's thoughts or behaviors have control over specific situations Disturbances in thought processes manifested in speech - Loose associations: shift of ideas from one unrelated topic to another - Neologisms: made-up words that have meaning only to the person who invents them - Clang association: choice of words is governed by sound - Word salad: group of words put together in a random fashion - Circumstantiality: delay in reaching that point of a communication because of unnecessary and tedious details - Tangentiality: inability to get to the point of communication due to introduction of many new topics - Preservation: persistent repetition of the same word or idea in response to different questions - Echolalia: reverse to repeating words or phrases spoken by another  - Hallucinations may involve any of the five senses - Auditory (voices, clicks, rushing noises) - Visual (formed images, blurry images, flashes of light) - Tactile (someone feels something on or under their skin) - Gustatory (taste or smells of things are bad and they relate it to poison) - Olfactory ( - Illusions are misperceptions or misinterpretations of real external stimuli - Command hallucinations are most dangerous - Echopraxia imitates movements made by others Negative symptoms - Inappropriate affect: emotions are incongruent with the circumstances - Bland: weak emotional tone - Flat: appears to be void of emotional tone - Apathy: disinterest in the environment - Avolition: inability to initiate goal-directed activity - Lack of interest or skills in interpersonal interaction - Anergia: deficiency of energy - Anhedonia: inability to experience pleasure - Anosognosia: individual who lacks awareness of having an illness or disorder even when symptoms appear obvious to others - Lack of abstract thinking ability - Associated features: - Waxy flexibility - Posturing - Pacing and rocking - Regression - Eye movement abnormalities Outcome identification for patient with schizophrenia - Demonstrates an ability to relate satisfactorily to others - Recognizes distortions of reality - Has not harmed self or others - Perceives self realistically - Demonstrates the ability to perceive the environment correctly - Maintains anxiety at a manageable level - Relinquishes the need for delusions and hallucinations - Demonstrates ability to trust others - Uses appropriate verbal communication in interactions with others - Performs self-care activities independently Psychopharmacological treatments - Antipsychotics: used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders - Works on dopamine by reducing - Antipsychotic Meds to know: - Aripiprazole (abilify) - Haloperidol (halidol) - Chlorpromazine (thorazine) - Quetiapine (seroquel) - Olanzapine (zyprexa) - Risperidone (risperdal) - Clozapine (clozaril) Antipsychotics Side effects - Anticholinergic effects - Skin rash, stevens johnson syndrome - Sedation - Orthostatic hypotension - Photosensitivity (avoid sunlight, always wear sunscreen, wear protective clothing) - Hormonal effects - Electrocardiogram changes - Hypersalivation - Weight gain (offer dietician services and make patient aware) - hyperglycemia/diabetes - Increased risk of mortality in elderly patients with dementia - Reduction in seizure threshold (likeliness of seizure is much higher) - Agranulocytosis (destruction of white blood cells, symptoms: fever,malaise, pain, swelling, flu like symptoms, jaundice) (complication:splenomegaly, sepsis) - Extrapyramidal symptoms (parkinson like symptoms, akinesia, akathisia, dystonia, oculogyric crisis) - Tardive dyskinesia (involuntary repetitive movements) - Neuroleptic malignant syndrome (hyperthermia, rigidity, altered mental status, exposure to antipsychotic, serum creatinine extremely elevation, sympathetic nervous system lability(really high BP or really low BP, really high HR or really low HR) -SSRIS to know for exam paroxetine, Sertraline, citalopram, escitalopram, fluoxetine, fluvoxamine Begin Exam 3 content  Chapter 23 Substance-related and addictive disorders Substance use disorder: - Substance-use disorders (addiction) - Substance-induced disorders (intoxication, withdrawal, delirium, neurocognitive disorders, psychosis, bipolar disorder, depressive disorder, ocd, anxiety disorder, sexual dysfunction, and sleep disorders) - Addiction - Compulsive or chronic requirement. The need is so strong as to generate distress if left unfulfilled. - Substance addiction - Use of the substance interferes with ability to fulfill role obligations (work, school, relationships) - Attempts to cut down or control use fail - Intense cravings lead to excessive amount of time spent trying to procedure the substance or recover from its use - Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated - The person engages in hazardous activities when impaired by the substance - Tolerance develops, and the amount required to achieve the desired effect increased - Substance-specific symptoms occur upon discontinuation of use - Substance-induced disorders - Intoxication: state of disturbance in cognition, perception, behavior, level of consciousness, judgment, and other functions directly attributable to the effects of a psychoactive drug. - Substance intoxication: development of a reversible syndrome of symptoms following excessive use of a substance - Substance withdrawal - Occurs upon abrupt reduction or d/c of a substance use regularly over a prolonged period of time - Substance-specific syndrome includes: clinically significant physical symptoms, psychological changes such as disturbances in thinking, feeling and behavior - Predisposing Factors - Genetics accounts for 40 to 60 % of a person's vulnerability to alcoholism - Psychological factors - Punitive superego - Personality factors - Low self-esteem, frequent depression, passivity, antisocial personality traits, the inability to relax or to defer gratification, and the inability to  communicate effectively are common in individuals who abuse substances. - Cognitive factors - Irrational thinking patterns have long been identified as a problem that is central in addictions - Examples include denial, projection and rationalization - Sociocultural factors - Children and adolescents are more likely to use substances with parents who provide model for substance use - Pleasurable effects from substance use act as positive reinforcement for continued use of substance - Some cultures are more prone to substance abuse than are others Alcohol use disorder - Patterns of use - Phase 1. Pre-alcoholic phase: characterized by use of alcohol to relieve everyday stress and tensions of life - Phase 2. Early alcoholic phase: Begins with blackouts. Alcohol stops being a source of pleasure or relief for the person but rather a drug that is required. Alcohol is now required by the person, and the person typically feels enormous guilt and becomes defensive about his or her drinking. - Phase 3. The crucial phase: Person has lost control; physiological dependence is clearly evident. By this stage, it is not uncommon for individuals to have experienced the loss of job, marriage, friends, family, and self-respect. - Phase 4. The chronic phase: Characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober. Unmanaged withdrawal from alcohol results in a terrifying syndrome of symptoms that include hallucinations, tremors, convulsions, severe agitation, and panic. Depression and ideas of suicide are not uncommon. For long-term, heavy drinkers, abrupt withdrawal of alcohol can be fatal. - Effects of alcohol on the body - Peripheral neuropathy - Characterized by nerve damage, results in pain, burning, tingling, or prickly sensations of the extremities - Alcoholic myopathy - May occur as an acute or chronic condition - Thought to result from some B vitamin deficiency that contributes to peripheral neuropathy - Wernicke's encephalopathy - Most serious form of thiamine deficiency in alcoholic patients  - Symptoms include paralysis of the ocular muscles, diplopia, ataxia, somnolence, and stupor. If thiamine replacement therapy is not given quickly, death will ensue. - Korsakoff's psychosis - Syndrome of confusion, loss of recent memory, and confabulation in alcoholic patients - Alcoholic cardiomyopathy - Effect of alcohol on the heart is an accumulation of lipids in the myocardial cells - Esophagitis - Inflammation and pain in the esophagus - Gastritis - Effects of alcohol on the stomach include inflammation of the stomach lining - Pancreatitis - Acute: usually occurs 1 to 2 days after a binge - Symptoms: constant severe epigastric pain, n/v, and abdominal distention - Chronic: leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus - Alcoholic hepatitis - Caused by long term heavy alcohol use - Enlarged tender liver, n/v, lethargy, anorexia, elevated WBC count, fever, jaundice, ascites and weight loss - Severe cases can lead to cirrhosis or hepatic encephalopathy - Cirrhosis of the liver - Cirrhosis is the end stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use - There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue - Complications of cirrhosis of the liver: - Portal hypertension: Elevation of blood pressure through the portal circulation results from defective blood flow through the cirrhotic liver. - Ascites:A condition, in which an excessive amount of serous fluid accumulates in the abdominal cavity, occurs in response to portal hypertension. The increased pressure results in the seepage of fluid from the surface of the liver into the abdominal cavity. - Esophageal varices:Veins in the esophagus become distended because of excessive pressure due to defective blood flow through  the cirrhotic liver. As this pressure increases, these varicosities can rupture, resulting in hemorrhage and sometimes death. - Hepatic encephalopathy: This serious complication occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia results in progressively impaired mental functioning, apathy, euphoria or depression, sleep disturbance, increasing confusion, and progression to coma and eventual death. - KNOW Lactulose, rifaximin, neomycin. Decrease ammonia in the blood, reduce protein in diet avoid medications that are broken down by the liver and medications that have ammonia in them, - Leukopenia - Impaired production, function, and movement of WBC - Thrombocytopenia - Platelet production and survival are impaired as a result of the toxic effects of alcohol - Sexual dysfunction - Short term: enhanced libido and failure of erection are common - Long-term: gynecomastia(male breasts enlarge), sterility, impotence (inability of erection for man), and decreased libido - Alcohol intoxication: occurs at blood alcohol levels between 100 and 200 mg/dl (slurred speech, impaired coordination) - Alcohol withdrawal: occur within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use (coarse hand tremors, tongue and eye tremors, n/v, tachy, sweating, anxiety, irritability, transient hallucinations) Sedative/hypnotic use disorder 1. Barbiturates 2. Non Barbiturate hypnotics 3. Anti-anxiety agents 4. The effects of CNS depressant are addictive with one another and with the behavioral state of the user 5. CNS depressants are capable of producing psychological addiction 6. Cross tolerance and cross-dependence may exist between various CNS depressants - Patterns of use - Of all drugs used in clinical practice, the sedative, hypnotic, anxiolytic drugs are among the most widely prescribed - Effects on the body  - Central nervous system effects: Sedative, hypnotic, and anxiolytic compounds depress the activity of the brain, nerves, muscles, and heart tissue. Sleeping and dreaming: Barbiturate use decreases the amount of sleep time spent in dreaming. During drug withdrawal, dreaming becomes vivid and excessive. Rebound insomnia and increased dreaming are not uncommon with abrupt withdrawal. - Respiratory system: : Barbiturates are capable of inhibiting the reticular activating system, resulting in respiratory depression and can be lethal in overdose. In addition, additive effects can occur with the concurrent use of other CNS depressants, affecting a life-threatening situation. - Cardiovascular: Hypotension may be a problem with large doses. Only a slight decrease in blood pressure is noted with normal oral dosage. High dosages of barbiturates also compromise cardiac contractility and vascular tone, which may result in cardiovascular collapse. Individuals with congestive heart failure are more susceptible to these effects. - Renal system: In doses high enough to produce anesthesia and in overdose, barbiturates may reduce urine output (oliguria). At the usual sedative or hypnotic dosage, however, there is no evidence that they have any direct action on the kidneys. - Hepatic system: Barbiturates stimulate the production of liver enzymes. Increases in cytochrome P450 isoenzymes inhibit the metabolism of many medications, including antipsychotics, antidepressants, anticonvulsants, and steroid hormones, and accelerates metabolism of barbiturates themselves. Preexisting liver disease may predispose an individual to additional liver damage with excessive barbiturate use. - Thermoregulation: High doses of barbiturates can greatly decrease body temperature. It is not significantly altered with normal dosage levels. - Sexual effects: : CNS depressants have a tendency to produce a biphasic response. There is an initial increase in libido, presumably from the primary disinhibitory effects of the drug. In men, this initial response is then followed by a decrease in the ability to maintain an erection. - Sedative, hypnotic, or anxiolytic intoxication - Effects can range from disinhibition and aggressiveness to coma and death - inappropriate sexual or aggressive behavior, mood lability, impaired judgment, or impaired social or occupational functioning. Slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor or coma. - Sedative, hypnotic, or anxiolytic withdrawal - Onset of symptoms depend on the half-life of the drug - Severe withdrawal can be life-threatening  - Withdrawal symptoms associated with sedatives and hypnotics include autonomic hyperactivity, increased hand tremor, insomnia, nausea or vomiting, hallucinations, illusions, psychomotor agitation, anxiety, or grand mal seizures, and delirium. Stimulant use disorder - Includes psychomotor stimulants, general cellular stimulants, synthetic stimulants - Effects on body - CNS effects:stimulation of the CNS results in tremor, restlessness, anorexia, insomnia, agitation, and increased motor activity. Amphetamines, nonamphetamine stimulants, and cocaine produce increased alertness, decrease in fatigue, elation and euphoria, and subjective feelings of greater mental agility and muscular power. - cardiovascular/pulmonary effects: - Gastrointestinal and renal effects: : GI effects of amphetamines are somewhat unpredictable, but a decrease in GI tract motility commonly results in constipation. Renal effects: Contraction of the bladder sphincter makes urination difficult. Caffeine exerts a diuretic effect on the kidneys. Nicotine stimulates the hypothalamus to release antidiuretic hormone, reducing the excretion of urine. - Sexual function: CNS stimulants appear to increase sexual urges in both men and women. Women, more than men, report that stimulants make them feel sexier and have more orgasms. Some men may experience sexual dysfunction with the use of stimulants. - Stimulant intoxication - Amphetamine and cocaine - Euphoria or affective blunting - Changes in sociability - Hypervigilance - Anxiety - Impaired judgment - Caffeine - Consumption above 250 mg - Stimulant withdrawal - Crashing - Fatigue - Cramps - Depression - Headaches - Nightmares Inhalant use disorder - inhalants are readily available, legal, inexpensive which make adolescents more at risk - Cns effects: central and peripheral nervous system damage Neurological damage, such as ataxia, peripheral and sensorimotor neuropathy, speech problems, and tremors, can occur. - Respiratory effects: Coughing and wheezing, Dyspnea, Emphysema, Pneumonia, Increased airway resistance due to inflammation of the passages - Gi effects: Abdominal pain,Nausea,Vomiting - Renal system effects Opioid-induced disorder - Symptoms of intoxication - Initial euphoria followed by apathy - Dysphoria - Psychomotor agitation or retardation - Impaired judgment - Drowsiness - slurred speech - Severe intoxication can lead to respiratory depression, coma, and death - Pupillary constriction when intoxicated (or dilation due to anoxia (brain injury) from severe overdose;must give narcan and oxygen) Hallucinogen use disorder - Flashbacks can occur months after the drug was taken (hallucinogenic symptoms without taking hallucinogen recently) Cannabis use disorder - Popular in Adolescent population] - Sick like vomiting (constant) and paranoia Treatment modalities - Alcoholics anonymous - Major self help organization for the treatment of alcoholism - Peer support - Acceptance - 12 step program - Assigned sponsor to maintain sobriety Pharmacotherapy - Disulfiram (Antabuse) alcohol deterrent, causes a person to be violently ill if they consume alcohol. - Vitamin replacement: thiamine, folic acid - Medication-assisted treatment - Alcohol withdrawal - Benzodiazepines (Chlordiazepoxide/librium, lorazepam/ativan) - Anticonvulsant medications(carbamazepine, valproic acid, phenobarbital, gabapentin) - Alcohol abstinence - N-acetylcysteine (helps with alcohol toxicity, and alcohol seeking tendencies, protect the liver) - Alcohol abstinence - Naltrexone (pleasure pathway will be activated to reduce alcohol craving) - Acamprosate - N-acetylcysteine - Opioid intoxication - Narcan - Naltrexone - Opioid withdrawal - Methadone (long half-life, prescribers have complete control over dosage) - Buprenorphine - Clonidine - Lofexidine - Stimulant intoxication (only if psychotic symptoms) - Chlordiazepoxide - Haloperidol Chapter 26 Bipolar and Related disorders Mania: An alteration in mood that may be expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, and accelerated speech. It can occur as part of the psychiatric disorder bipolar disorder, as part of some other medical conditions, or in response to some substances. Epidemiology - Average age of onset is 25 years old - Occurs in higher socioeconomic classes - Increased mortality:death by suicide Bipolar Disorder - Mood swings from profound depression to extreme euphoria (mania) with intervening periods of normalcy - Delusions or hallucinations may or may not be part of clinical picture - Onset of symptoms may reflect seasonal pattern - Milder form of mania is called hypomania Types of bipolar disorder - Bipolar I disorder: - Pt is experiencing a manic episode or has a history of one or more manic episodes - May have also experienced episodes of depression - Bipolar II disorder: - Pt presents with symptoms or history of depression or hypomania - Has never met criteria for full manic episode - Has never had symptoms severe enough to cause impairment in social or occupational functioning or to necessitate hospitalizations - Cyclothymic disorder: - Pt has a chronic mood disturbance, lasting at least 2 years - Has numerous periods of elevated mood that do not meet the criteria for hypomanic episodes - Has numerous periods of depressed mood of insufficient severity or duration to meet criteria for a major depressive episode - Is never without symptoms for more than 2 months - Substance-induced bipolar disorder: - Has a mood disturbance as the direct result of physiological effects of a substance - Has a mood disturbance that involves elevated expansive or irritable moods with inflated self esteem decreased need for sleep and distractibility - Bipolar disorder associated with another medical condition: - Has an abnormally and persistently elevated expansive or irritable mood and excessive activity or energy as the direct physiological consequence of another medical condition Predisposing Factors - Biological theories: - Family studies have shown that, if one parent has a mood disorder, the risk that a child will have a mood disorder is between 10 and 25 percent. If both parents have the disorder, the risk is two to three times as high. - Excess of norepinephrine and dopamine - Low serotonin levels - Certain medications trigger manic episodes: Steroids, antidepressants, anticonvulsants, amphetamines, narcotics Developmental implications in childhood and adolescence - Childhood and adolescence: - Lifetime prevalence of pediatric and adolescent bipolar disorders is about 1% - ADHD is the most common comorbid condition - ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled - Atypical symptoms, including non discrete mood episodes, chronic irritability, and temper tantrums. The DSM-5 incorporated a new diagnosis, disruptive mood dysregulation disorder, that more aptly describes this symptom profile. - Psychopharmacology: - Acute mania: lithium, risperidone, aripiprazole, quetiapine, olanzapine, and asenapine - Bipolar depression: Olanzapine/fluoxetine combination drugs and lurasidone - Nonpharmacological interventions - Mood charting - Managing stress and sleep cycles - Maintaining healthy diet and exercise - Avoiding alcohol and drugs - Family interventions - Family focused therapy - Psychoeducation about bipolar disorder - Symptoms - Early recognition - Etiology - Treatment - self-management Stage I: Hypomania - Mood - Cheerful and expansive; underlying irritability surfaces rapidly - Cognition and perception - Exalted; ideas of great worth and ability; flighty thinking; heightened perception of environment; easily distracted - Activity and behavior - Increased motor activity; perceived as extroverted; lacks depth of personality for close friendships Stage II: Acute mania - Mood - Continuous “high”; subject to frequent variation - Cognition and perception - Flight of ideas; distractibility becomes all pervasive - Activity and behavior - Psychomotor activity is excessive; sexual interest increased - Inexhaustible energy; may go for days without sleeping Stage III: Delirious mania - Mood - Very labile; panic-level anxiety may be evident - Cognition and perception - Clouding of consciousness; extremely distractible and incoherent - Activity and behavior - Psychomotor activity is frenzied; exhaustion, injury to self or others, and eventually death could occur without intervention -Safety checks every hour! -clear concise boundaries -Accepting responsibility Treatment Modalities for bipolar disorder - Individual psychotherapy - Group therapy - Family therapy - Cognitive therapy - Recovery model - Used primarily in caring for pts with serious mental illness - Utility for all individuals experiencing emotional conditions that require assistance and who desire to take control and manage their lives more independently - Developing self awareness, taking medications regularly, recognizing earliest symptoms, know when to seek help - Managing lifestyle factors such as sleep time and exercise - Developing a plan for emergencies  - Electroconvulsive therapy (ECT) - Episodes of acute mania are occasionally treated with ECT - When pt doesn't tolerate or fails to respond to lithium or other drug treatment ir when life is threatened by dangerous behavior or exhaustion - Bright light therapy (BLT) - May benefit bipolar depression - Not associated with mood shifts toward a manic episodes - Psychopharmacology - For mania: - Lithium carbonate - Anticonvulsants - Verapamil - Antipsychotics - For depressive phase: - Use antidepressants with care (may trigger mania) Patient and family education - Lithium - Take regularly - Do not drive or operate machinery - Do not skimp on dietary sodium and maintain appropriate diet - Know pregnancy risks - Carry identification noting taking lithium - Be aware of side effects and symptoms of toxicity - Signs of toxicity: Severe vomiting or diarrhea occur , ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, mental confusion - Have serum lithium level checked every 1 to 2 months (normal range 0.6-1.2) - Anticonvulsants - Refrain from d/c the drug abruptly - Report symptoms to MD immediately: skin rash(sjs), unusual bleeding, spontaneous bruising, sore throat fever malaise(granulocystosis), dark urine, and yellow skin or eyes - Do not drive or operate dangerous machinery - Avoid using alcohol and over the counter medications without approval from physician - Common meds Keppra, valproic acid know teaching  - Calcium channel blocker - Take med with meals if GI upset occurs - Use caution when driving; dizziness, drowsiness, and blurred vision can occur - Refrain from stopping med abruptly; this may cause cardiovascular problems - Report symptoms Irregular heartbeat, Shortness of breath, Swelling of the hands and feet, Pronounced dizziness Chest pain Profound mood swings Severe and persistent headache - Common med: verapamil - Rise slowly from sitting or lying position (orthostatic hypotension) - Avoid taking other medications - Carry a card at all times describing medications being taken - Antipsychotics - Do not stop taking abruptly - Use sunblock when outdoors - Rise slowly from sitting or lying positions - Avoid alcohol Report the following symptoms to physician: - Sore throat; fever; malaise - Unusual bleeding; easy bruising; skin rash - Persistent nausea and vomiting - Severe headache; rapid heart rate - Difficulty urinating or excessive urination - Muscle twitching, tremors - Darkly colored urine; pale stools - Yellow skin or eyes - Excessive thirst or hunger - Muscular incoordination or weakness  Chapter 22 Neurocognitive disorders -Disorders that cause clinically significant deficit in cognition or memory exists, representing a significant change from previous level of functioning - Delirium - Rapid change over short periods of time; disturbance in attention and awareness - Difficulty sustaining and shifting attention - Highly distractible - Disorientation to time and place - Disturbances in sleep-wake cycle - Psychomotor activity - Fluctuates between agitated, purposeless movements and a vegetative state - Emotional instability - Fear, anxiety, depression, irritability, anger, euphoria, or apathy - Symptom onset - Begins abruptly (head injury or seizure) - Slower onset (several hours or days of prodromal symptoms; systemic infection or metabolic disorder) - Duration - Usually 1 week; rarely more than 1 month - Symptoms usually diminish over 3 to 7 day period when underlying causes are eliminated - Predisposing factors - Systemic infections - Febrile illness - Metabolic disorders - COPD, hypoxia - Hepatic or renal failure - Seizures - Migraine headaches - Stroke - Nutritional deficiencies - Burns or heat stroke - Social isolation, emotional stress, physical restraints, admission to an intensive care unit - Substance intoxication, substance withdrawal - Medication-induced delirium - Delirium pneumonic - Pain - Infection - Nutrition - Constipation - Hydration - Medication - Electrolytes Neurocognitive disorder - Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking Mild NCD - Focus of early intervention which is critical to preventing or slowing the progression of the disorder Major NCD - Constitutes dementia - Disease process in which there is progressive decline in cognitive ability in the presence of clear consciousness - Involves many cognitive deficits and significantly impairs social and occupational functioning - Reversible NCD may be more appropriately termed temporary dementia - It can occur as a result of: stroke, depression, side effects of medication, nutritional deficiencies, metabolic disorders - Prevalence of the disease doubles for every 5-year age group beyond age 65 - Alzheimers is most common NCD - Symptoms of NCDs - Impaired abstract thinking, judgment, and impulse control - Inappropriate social conduct - Uninhibited social conduct - Neglected personal appearance and hygiene - Language may or may not be affected - Personality changes - As the disease progresses, symptoms may include: - Aphasia - Apraxia - Irritability and moodiness - Inability to care for personal needs - Wandering - Incontinence Stages not on exam but good to know for ati - Progressive symptoms of AD is described according to stages - Stage 1: No apparent symptoms - In the first stage of the illness, there is no apparent decline in memory despite changes that are beginning to occur in the brain. A positron emission tomography (PET) scan can be used to detect these changes. - Stage 2: Very mild changes; forgetfulness - The individual begins to lose things or forget names of people. Losses in short-term memory are common. The individual is aware of the intellectual decline and may feel ashamed, becoming anxious and depressed. Maintaining organization with lists and a structured routine provides some compensation. These symptoms often are not noticed by  others and do not interfere with the individual’s ability to work or live independently. - Stage 3:Mild cognitive decline - In this stage, there are changes in thinking and reasoning that interfere with work performance and become noticeable to coworkers. The individual may get lost when driving his or her car. Concentration may be interrupted. There is difficulty recalling names or words, which becomes noticeable to family and close associates. A decline occurs in the ability to plan or organize. - Stage 4: mild to moderate cognitive decline - At this stage, the individual may forget major events in personal history, such as their own child’s birthday; experience declining ability to perform tasks, such as shopping and managing personal finances; or be unable to understand current news events. Denial that a problem exists and covering up memory loss by creating imaginary events to fill in memory gaps, also known as confabulation. Depression and social withdrawal are common. At this stage, the individual requires some assistance to maintain safety. - Stage 5: moderate cognitive decline - At this stage, individuals lose the ability to perform some ADLs, such as hygiene, dressing, and grooming, and require some assistance to manage these tasks on an ongoing basis. They may forget addresses, phone numbers, and names of close relatives. They may become disoriented about place and time, but they maintain knowledge about themselves. - Stage 6: moderate to severe cognitive decline - At this stage, individuals may be unable to recall the name of a spouse or may misidentify people (e.g., thinking a child is their spouse). Disorientation to surroundings is common, and the person may be unable to recall the day, season, or year. The person is unable to manage ADLs without assistance. Delusions often become apparent, such as maintaining the belief that one must go to work even though the person is no longer employed. Urinary and fecal incontinence are common. Sleeping becomes a problem. Psychomotor symptoms include wandering, obsessiveness, agitation, and aggression. Institutional care is usually required at this stage. - Stage 7: Severe cognitive decline - In the end stages of AD, the individual is unable to recognize family members. He or she most commonly is bedfast and aphasic. Problems of immobility, such as decubiti and contractures, may occur. NCD due to AD predisposing factors - Onset is slow and insidious - Progressive and deteriorating - Biomarkers - Memory impairment is an early and prominent feature - Decreased acetylcholine - Plaques and tangles of neurons in the brain - Head trauma - Genetic factors Vascular NCD predisposing factors - Due to cerebrovascular disease - More abrupt onset than is seen in AD - Hypertension - Cerebral emboli - Cerebral thrombosis NCD due to lewy body disease - Similar to AD but progresses more rapidly - Appearance of lewy bodies in the cerebral cortex and brainstem - Progressive and irreversible - It tends to progress more rapidly, and there is an earlier appearance of visual hallucinations and parkinsonian features. Depression and delusions are also common symptoms in this population. NCD due to prion disease - Caused by infectious agents (prions) characterized by its insidious onset and rapid progression - Problems with coordination and other movement disturbances along with rapidly progressing dementia - Symptoms may develop at any age but typical occur between 40 and 60 years old - Extremely rapid with progression from diagnosis to death in less than two years - Most common form of prion disease in humans is cruetzfeldt-jakobs disease Medical treatment modalities for delirium - Determination and correction of the underlying causes - Additional attention must be given to fluid and electrolyte status, hypoxia, anoxia, and diabetic problems - Staff to remain with client at all times to monitor behavior and provide reorientation and assurance - Room with low stimulus level - Low dose antipsychotic agents to relieve agitation and aggression - Benzodiazepines commonly used when etiology is substance withdrawal Medical treatment modalities for NCD - Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes - Supportive care Psychopharmacology for NCD need to know Mild to moderate - Physostigmine (antilirium) - Tacrine (cogex) - Donepezil (aricept) Moderate to severe - Memantine (namenda) Severe agitation and aggression - Risperidone(risperdal) - Olanzapine(zyprexa) - Quetiapine (seroquel) -Antipsychotics are associated with an increased risk of death in elderly patients with dementia Nonbenzodiazepines to know for sleep disturbances - Zolpidem (ambien) - Eszopiclone (lunesta) - Trazodone (desyrel) - mirtazapine (remeron) Eating disorders Anorexia nervosa - Refusal to maintain body weight at or above a minimally normal weight for age and stature - BMI < 17.5 kg/m2 for older adolescents - Body image distortion is cardinal sign of anorexia nervosa - Restricting type or binge/purge type Bulimia nervosa - Recurrent episodes of binge eating characterized by both of the following: - Eating in a discrete period of time an amount of food that is larger than the norm for most people - A sense of lack of control over eating during the episode - Recurrent inappropriate compensatory behavior to prevent weight gain - Binge eating and inappropriate compensatory behaviors both occur on average at least one a week for 3 months - Does not occur during episodes of AN - Self-evaluation is influenced by body shape and size (not weight or calories) Binge eating disorder - Recurrent episodes of binge eating, characterized by the following: - Eating much more rapidly than normal - Eating until feeling uncomfortably full - Eating large amounts of food when not hungry - Eating alone because of embarrassment - Feeling disgusted with oneself depressed or very guilty after overeating - Marked distress regarding binge eating is present - Binge eating occurs on average at least 2 days a week for 6 months Pathogenesis - Genetic factors explain more than 50% of cause for developing eating disorders - Dysregulation of serotonin metabolism results in binge eating of high carb food - Family history of alcoholism and affective disorders (depression) are more at risk Psychological-Anorexia - Personality traits: negative emotionality, perfectionism, drive for thinness, ineffectiveness, obsessive compulsive anxious, inhibited, controlled - Puberty affects patients Psychological- Bulimia - History of incest, rape, sexual abuse, dysfunctional family interactions - Parental enmeshment to absence - Chaotic, conflicted and critical - Affectively labile under controlled, active Societal factors - Diet culture - Media images and societal standards - Athletic participation - Affluence in industrialized countries Inadequate caloric intake AN - Physical symptoms - Amenorrhea primary(ovarian failure) or secondary(body response to weight loss and lack of calories) - Cold hands or feet - Dry skin and hair - Headaches - Fainting or dizziness - Lethargy - Growth failure or pubertal delay - GI symptoms - Mental/emotional symptoms - Difficulty concentrating - Difficulty making decisions - Irritability - Depression - Social withdrawal - Food obsessions - Positive physical signs - Hypothermia and acrocyanosis - Orthostatic hypotension - Bradycardia - Loss of muscle mass - Edema - Lanugo hair, loss of scalp hair - Significant weight loss or failure to gain as expected Binge eating- Bulimia - Symptoms and signs - Weight gain - Lethargy - Guilt - Depression - Anxiety Purging- Bulimia - Symptoms and signs - Bilateral parotid gland swelling - Loss of tooth enamel - Subconjunctival hemorrhage - Russell's sign scarring - Constipation, rectal bleeding, ga