PMH Nursing Learning Objectives for Final Exam PDF

​Chapter 22 Depressive, Bipolar, and Related Disorders (Depression is the focus this week) Depressive Disorders: Major depressive disorder, single or recurrent; and dysthymic disorder ○ Additionally specifiers used to classify diagnoses… Severity Specifi...

​Chapter 22 Depressive, Bipolar, and Related Disorders (Depression is the focus this week) Depressive Disorders: Major depressive disorder, single or recurrent; and dysthymic disorder ○ Additionally specifiers used to classify diagnoses… Severity Specifier: mild, moderate, or severe With Mixed Features: allows for the presence of manic symptoms in depressed patients who do not meet the full criteria for a manic episode With Anxious Distress: allows for the presence of anxiety because the addition of anxiety may affect prognosis, treatment, and patient response to treatment Seasonal Depression: recognized, recurrent, annual pattern with a specific onset related to seasonal light deprivation, typically occurring during the fall and winter months, followed by symptom reprieve during the spring and summer. Seasonal variations in mood occur most commonly in northern latitudes Peripartum Onset: recognized onset of an episode during pregnancy or within the first 4 weeks postpartum Can disrupt the maternal-fetal/infant bond and affect the infant's development trajectory ○ May occur as a single episode, although recurrent episodes often occur Considered a persistent and recurrent disorder  ○ Often co-occurs with other mental illness, particularly anxiety and substance-use disorders 1. To articulate how Depressive Disorder affects individuals and is also a worldwide concern ○ Depression is most costly public health concern worldwide Time worked loss Medication/treatment costs Family/community effects ○ Lifetime rate of major depression is 1.98-2.02x greater in females than males Women are 2x as likely to meet the criteria for major depression Women are prescribed antidepressants 2x as often as men Prevalence of mood disorders in Canada are greatest in age groups 18-34 years old ○ Depression is often linked to the incidence of chronic diseases, such as HTB, arthritis, pain, heart disease, diabetes, and COPD. ○ Accessing effective care may be inhibited by the need to keep the diagnosis hidden, even from oneself due to stigma 1. Describe how affect is manifested with Depressive Disorders ○ Depressive disorders “include the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function” ○ Mood: the predominant, pervasive, and sustained emotion colouring the patient’s perception of the world and ability to function in it. Normal variations in mood occur as responses to life experiences, are time limited, and are not associated c/ significant functional impairment Mood is the primary alteration in depression, rather than thought or perceptual disturbances ○ Mood Disorders: recurrent disturbances or alterations in mood that cause psychological distress and behavioural impairment Mood disorders have an alteration in mood but NOT thoughts or perceptions ALTHOUGH people experiencing thought or perception alterations can have an impacted mood (i.e., someone who is hallucinating figures may have an angry or fearful mood) ALTHOUGH mood can be so high (mania) or low (depression) that individuals experience thought alteration and/or psychotic symptoms ○ Affect: the observable expression of a person's mood inferred by the examiner Blunted: significantly reduced intensity of emotional expression  Flat: absent or nearly absent affective expression Inappropriate: discordant affective expression accompanying speech content or ideation Labile: varied, rapid, and abrupt shifts in affective expression Restricted/Constricted: mildly reduced in range and intensity of emotional expression 1. Be familiar with Depressive Disorders in the Special populations described in the text ○ Children & Adolescents Rise of prevalence Psychiatric visits increasingly common, especially in ages 14-21, high-acuity cases, and for those c/ symptoms of anxiety and mood disorders Pre-puberty, rates occur equally among females and males In adolescence, MDD is 2x more common in females Less common to experience psychosis, but when they do, auditory hallucinations are more common Less likely to express subjectivity, hopelessness, and dysphoria More likely to have anxiety symptoms characterized as internalizing disorders (internal emotional distress and symptoms that are not outwardly disruptive or defiant in nature) More often expressed somatically, as headaches or stomach aches Externalizing behaviors (fear of separation, aggression, hyperactivity, rule-breaking) are more common in young children Sleep disruptions and irritability, rather than sad mood, are more common in adolescence Adolescent boys are more likely to present with disruptive behavior disorders and ADHDs Risk for suicide highest between 13-15 for females, and 15+ for males Transgender boys/men are at a higher risk for suicide ○ Older Adults Estimated 8-20% of older adults in community, and up to 33% in primary care settings experience depressive symptoms Many do not always meet the criteria for MDD May manifest comorbidly with dementia, making identification and treatment difficult  Treatment is successful in 60-0% of cases, but response to treatment is slower than in younger populations Often associated with chronic illnesses, such as heart disease, diabetes, stroke, and cancer Rates for suicide, and successful completion, are higher among men especially above 80 years old ○ Indigenous Populations Potentially 2x higher rate than non-Indigenous populations Higher rates of suicide Symptoms may be different due to cultural differences May be described as somatic symptoms, "nerves," headaches, weakness, tiredness, "imbalance" ○ COVID-19 Affected the health, safety, and wellbeing of individuals and communities causing insecurity, emotional isolation, stigma, financial loss, school closure, and inadequate medical and mental health resources/response Those with physical health concerns, socioeconomic stressors, and family stress from confinement are at a higher risk of low perceived mental health 1. Recognize several Epidemiology and Aetiology factors for Depressive Disorders ○ Epidemiology (determinants, occurrence, and distribution_ Prevalence between 1994-2012 has remained relatively stable, around 4.7% Stability may be due to heightened public recognition, increased mental health literacy, improved diagnosis, and increased access to treatment + antidepressants Prevalence is among higher unemployed persons Occurs comorbidly with other medical disorders, such as endocrine disorders, cardiovascular disease, neurologic disorders, autoimmune conditions, infectious diseases, cancers, and nutritional deficiencies Risk Factors… Childhood adverse experiences (emotional, physical, and sexual abuse) Prior episode of depression Family history of depressive disorder Lack of social support Stressful life events  Current substance use Medical comorbidity Economic difficulties ○ Etiology (causes) Biopsychosocial-spiritual components Genetics More common among first-degree relatives Epigenetics approach, in which early life experiences can trigger changes in the association between gene and environment expression Neurobiology Increased phasic rapid eye movement sleep Poor sleep maintenance Elevated cortisol levels Psychoneuroimmunology Impaired cellular immunity Cytokines released from immune cells signal the brain Decreased dorsolateral prefrontal cortex activity Low levels of serotonin metabolite, 5-hydroxy-indolecetic acid (5-HIAA) Increased limbic responses Decreased hippocampal volume Abnormalities in the excretion or receptor function of neurotransmitters Norepinephrine Dopamine Serotonin Acetylcholine Endocrine alterations Higher cortisol Thyroid-stimulating hormone Hypothalamic-pituitary-adrenal axis (HPA) Increased HPA activity associated with the stress response Sustained hypercortisolism damages the HPA axis Hyperactivity of HPA and increased glucocorticoid hormones attributed due to disrupted feedback regulation and altered glucocorticoid receptor functioning  Hypothalamic-pituitary thyroid axis Hypothalamic-pituitary-gonadal axis Psychological Theories Psychodynamic factors Freud's "drive theory" believed early lack of love, care, warmth, and protection, resulting in anger, guilt, and helplessness turned inward Modern hypothesis follow 4 major presuppositions… Forces behind the scenes are influential. This includes biologic impulses, psychological motives, and cultural pressures. Personality shapes experience. A person’s development, preferred defensive processes, and the manifestation of psychological health affect personal experience. The past is powerful. Past relationships shape the lens through which people see future relationships and feelings. Psychic determinism is real. Unawareness and hidden forces impact people’s lives Behavioural Factors Depression results from a severe reduction in rewarding activities or an increase in unpleasant events in one's life Developmental Factors Depression results from early adverse life events that eventually develop into core dysfunctional attitudinal patterns activated by later life stressful events i.e., child maltreatment, parental loss, emotionally inadequate parenting, disrupted attachment system, negative familial interactional influences Social Theories Family Factors Maladaptive "circular" patterns in family interactions contribute to depression Social Factors Social isolation, lack of connectedness, diminished sense of belonging, loneliness, and financial distress Loss or traumatic event 1. Be familiar with psychotropic medications used for Depression including precautions and side effects ○ Antidepressants… Uses: Depression, Bipolar Disorder, OCD, Bulimia Nervosa, Postpartum Depression, Premenstrual Dysphoria Disorder, PD, PTSD, SAD, GAD Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) MOA: inhibit serotonin (and norepinephrine) reuptake from the synaptic cleft Take 1-2 weeks for effects to start, and 4-6 weeks for full therapeutic effect\ Energy and cognition improvements being before mood improvements SSRI Examples: Sertraline, Escitalopram, Citalopram, Fluoxetine, Paroxetine SNRI Examples: Venlafaxine, Duloxetine, Desvenlafaxine Precautions… Pregnancy Herbal supplement concurrent use (St. Johns Wort [SSRI/SNRI] Kava [SNRI], Valarian [SNRI]) MAOIs concurrent use (serotonin syndrome risk) TCA concurrent use (serotonin syndrome risk) Antiplatelet and Anticoagulants Liver failure (impaired metabolism) Kidney failure (impaired excretion) Seizure disorder GI bleed history Bipolar disorder Recent MI Interstitial lung disease Side Effects… Acute: nausea, diaphoresis, tremor, fatigue, drowsiness, weight loss, suicidal ideation Long-Term: insomnia, headache, sexual dysfunction, weight gain, GI bleeding, hyponatremia, serotonin syndrome, bruxism (involuntary teeth grinding), withdrawal, postural hypotension, suicidal ideation, rash, blurred vision Atypical Antidepressants MOA: Inhibit norepinephrine and dopamine reuptake Used to treat depression, smoking cessation, SAD, ADHD  Examples: Bupropion, Vilazodone, Mirtazapine, Trazodone Precautions… Pregnancy Breast feeding MAOI concurrent use Grapefruit juice [Vilazodone] Side Effects… Anticholinergic effects (headache, dry mouth, GI distress, constipation, tachycardia, hypertension, restlessness, insomnia), nausea, vomiting, anorexia/weight loss, seizures With Trazodone -> priapism (ridged erection in the absence of appropriate stimuli) With Trazodone and Mirtazapine -> Sedation Nursing Considerations: usually given in the evening because of sedative effect Tricyclic Antidepressants (TCA) MOA: block reuptake of norepinephrine, serotonin, and dopamine reuptake, and blocks acetylcholine and histamine receptors Takes 10-14 days for effects to start, and 4-8 weeks for full therapeutic effects Used to treat depression, bipolar disorder, anxiety, neuropathic pain, OCD, ADHD, insomnia, fibromyalgia Examples: Amitriptyline, Imipramine, Amoxapine, Doxepin, Clomipramine Precautions… Pregnancy Seizure disorder MI Elderly patients Coronary artery disease Diabetes Liver failure Kidney failure Respiratory disorders Urinary retention Glaucoma Urinary retention (due to anticholinergic effects) BPH (due to anticholinergic effects)  Hyperthyroidism MAOI concurrent use Anticholinergic medication concurrent use Sympathomimetics (increases dopamine, ephedrine, amphetamines, and epinephrine) Alcohol (CNS depressant) Opioids (CNS depressant) Antihistamines (CNS depressant) Side Effects… Orthostatic hypotension, anticholinergic effects, sedation, toxicity, decreased seizure threshold, excessive sweating, suicidal ideation Nursing Considerations: get baseline ECG and vital signs in case of toxicity effects, usually given at night due to sedation effects Nursing Education: Treating anticholinergic effects (chewing gum, dipping water, sunglasses, high fiber foods, exercise, regular fluid intake, void before taking medications) Take at nighttime (due to sedation) May be given in a 1 week suppl due to toxicity and suicide risk Monoamine Oxidase Inhibitors (MAOIs) ○ MOA: blocks monoamine oxidase enzymes, increasing norepinephrine, dopamine, serotonin, and tyramine transmission ○ Takes 2-4 weeks for therapeutic effects ○ Takes about 14 days before medication fully leaves the system ○ Used to treat depression, bulimia nervosa, PD, SAD, GAD, OCD, PTSD (usually the last option chosen for medication therapy) ○ Examples: Phenelzine, Isocarboxazid, Selegiline, Tranylcypromine ○ Precautions… Pregnancy Diabetes seizure disorder Pheochromocytoma Heart failure CVD Renal failure Sympathomimetics (increase hypertensive crisis risk)  Other antidepressant concurrent use (serotonin syndrome risk) Antihypertensives Meperidine concurrent use (hyperpyrexia) Tyramine rich foods (increased hypertensive crisis risk) Vasopressors (increased hypertensive crisis risk) General anesthesia ○ Side Effects… CNS stimulation, Orthostatic hypotension, hypertensive crisis, rash ○ Nursing Education: Wait 14 days before starting other antidepressants Avoid tyramine rich foods Medical Emergencies… ○ Serotonin Syndrome: toxic levels of serotonin accumulation Occurs when taking a combination of medications, herbal supplements, dose changes, and illicit substances that increase serotonin A risk when using pretty much any antidepressant Symptoms (occurring within 2-72 hours of treatment)… Mild: agitation, restlessness, insomnia, confusion, tachycardia, hypertension, dilated pupils, muscle twitching, rigidity, sweating, diarrhea, headache, shivering Severe: extreme fever, tremors, seizures, arrhythmias, coma, death Treatment… Stop serotonin increasing medications Serotonin-receptor blockers Cooling blankets Anticonvulsants Artificial ventilation Resuscitation ○ Hypertensive Crisis: Specifically risky for people taking MAOIs and tyramine or other medications concurrently Tyramine Rich Foods: aged cheese, smoked meats, avocados, figs, fermented foods, soy sauce, alcohol Symptoms… Headache, nausea, tachycardia, BP > 180/120, stroke, death Treatment…  Phentolamine IV Nifedipine Sublingual Telemetry monitoring Cardiorespiratory support (resuscitation) Non-Antidepressants used for Depression… ○ Antipsychotics Usually used adjunctively when psychotic symptoms are present, depression is resistant, or there are sleep disturbances Examples: Aripiprazole, Quetiapine, Brexpiprazole, Carlprazine, Lurasidone 1. Recognize the goals of treatment for Depression ○ Goals of treatment… Reduce/control symptoms and, if possible, eliminate signs and symptoms of the depressive syndrome Improve occupational and psychosocial functioning as much as possible Reduce the likelihood of relapse and recurrence Maintaining patient safety (from suicide or self-harm) Help the patient be as independent as possible Achieve stability, remission, and recovery from depression 1. Recognize and be able to describe several diagnostic Criteria of Major Depressive Disorder 2. Recognize the various types of Depressive Disorders described by DSM-V ○ Major Depressive Disorder (MDD): One of the leading causes of disability in Canada and the US More common in wealthier countries Affects women 2x more than men Affects 20-25% of individuals at any given time More common in the fall or winter months More common in unmarried or separated/divorced individuals Highest in people **Watchful Eating -> Inc. Weight/Shape Preoccupation -> Clinical Eating Disorders *This includes BED **This is not mindful eating Recognize the various types of Eating Disorders Disorder Description Signs/Symptoms Anorexia ○ Greek origin, meaning ○ Dietary restraint Nervosa "lack or absence of ○ Rigid appetite" all-or-nothing ○ Characterized by… thinking 1. Restriction of food ○ Perfectionism intake leading to ○ Extreme significantly low denial/lack of body weight awareness about 2. Intense fear of severeness gaining ○ Lack of ability to weight/becoming define feelings fat ○ Irritability 3. Distorted body ○ Insomnia image ○ Physical ○ Characterized by level of symptoms that severity… "prevent" eating 1. Mild: BMI > 17 (i.e., abdominal 2. Moderate: BMI pain, nausea) =16-16.99 ○ Intense 3. Severe: BMI = preoccupation 15-15.99 with 4. Extreme: BMI < 15 food/cooking, but ○ Subtypes.. not eating 1. Restricting ○ Weight loss 2. Binge-purge (even ○ Distorted body after image/ Body normal/small-sized dissatisfaction snacks) ○ Can be in partial/full remission ○ Often associated with a stressful transition ○ Higher all-cause mortality than all other psychiatric disorders (except substance misuse) ○ Variable prognosis: 50% recovery ○ Most common in women, adolescence, and early adulthood Bulimia ○ Greek origin, meaning ○ B/P activities Nervosa "ravenous hunger" done in secret ○ Characterized by… Vomiting Recurrent Exercising binge-eating Laxatives episodes Diuretics Ingesting a Emetics large portion ○ Hedonic Hunger: of food within desire to eat a 2-hour without period physiological Feeling that need one cannot ○ Tooth control/stop pain/erosion eating ○ Swelling in Recurrent cheeks of jaw inappropriate ○ Dehydration compensatory from behaviors in order vomiting/lack of to prevent weight intake gain ○ Rapid ingestion Behaviors of feed during a increase risk short period of of further time binge by ○ Guilt, remorse, reinforcing self-contempt that ○ View that they compensator are "unlovable" y behaviors ○ Impulsivity control weight Behaviors occur a least 1x a week for 3 months Self-evaluation is unjustifiably influenced by body shape and weight  Disturbance does not occur exclusively during anorexic episodes ○ Characterized by level of severity based on compensatory behaviours… Mild: 1-3 episodes/week Moderate: 4-7 episodes/week Severe: 8-13 episodes/week Extreme: 14+ episodes/week ○ Usual onset in late adolescence and young adulthood onward More common in women ○ Lower mortality and better outcomes than anorexia Binge ○ Eating a large amount of ○ Overweight/obes Eating food in a short amount of ity Disorder time and feeling you can't ○ Gallbladder control what or how disease much you eat ○ Missing ○ Characterized by… school/work/soci Recurrent al activities to binge-eating eat episodes ○ Extreme distress Ingesting a about eating large portion habits of food within ○ Isolation a 2-hour ○ Social insecurity period ○ Self-deprecation Feeling that ○ Negative mood one cannot control/stop eating Binge eating episodes associated with 3 or more or the following… Eating much more rapidly than normal Eating until feeling uncomforta bly full Eating large amounts when not physically hungry Eating alone because of embarrassm ent  Feeling disgusted with oneself, depressed, or very guilty after eating Marked distress regarding binge eating Occurs on average, at least 1x per week for 3 months Not associated with regular use of compensatory behaviors ○ Characterized by level of severity based on binge eating episodes… Mild: 1-3 episodes/week Moderate: 4-7 episodes/week Severe: 8-13 episodes/week Extreme: 14+ episodes/week ○ Typically begins in late adolescence/early adulthood Commonly after a period of significant weight loss/dieting ○ More prevalent than anorexia and bulimia  Recognize importance of body image, body dissatisfactions, and gender identity in developmental theories that explain aetiology of anorexia nervosa, bulimia nervosa, and binge-eating disorder ○ Sense of self-esteem is primarily determined by their ability to control weight and shape ○ Body Dissatisfaction: the belief that one’s current body size differs from a highly valued ideal body size and that this difference deserves negative appraisal Be able to describe some impacts of sociocultural norms on the development of eating disorders Disorder Theories of Aetiology Anorexia Nervosa ○ Genetics - Higher prevalence in 1st degree relations Learned behavior? Similar stress/trauma? ○ Comorbid with MDD, OCD, Anxiety, phobias, panic disorders, and Cluster C Personality Disorders ○ Neurobiological changes - brain changes, possibly the result of prolonged starvation ○ Psychosocial origins - media, fashion industry, peer pressure, religion, family enmeshment/overprotection Social Comparison Theory: valuing yourself against what other people view as ideal/set as standards Developmental stage struggles (i.e., puberty) ○ Adverse Childhood Events - sexual abuse Bulimia Nervosa ○ Genetics - Higher prevalence in 1st degree relations ○ Comorbid with depression, anxiety, OCD, BPD, ADHD, and substance misuse History of loneliness, fear or rejection, isolation, lack of support, and feelings of unworthiness ○ Neurobiology lowered serotonin and dopamine transmission Decreased cholecystokinin (CCK) - associated with satiety ○ Psychosocial origins - preceding stress Binge Eating Disorder ○ Genetics - Higher prevalence in 1st degree relations ○ Comorbid with mood disorders, anxiety, depression, and OCD Describe the risk factors and protective factors associated with the development of eating disorders Risk Factors Protective Factors ○ Dieting ○ Family unity ○ Genetics ○ Spiritual health ○ Overexercising/Athletes ○ Females ○ Family weight- or appearance-teasing ○ History of obesity ○ OCD/Anxiety disorders ○ Idealization of thinness media ○ Enmeshment with family ○ Perfectionism ○ Impulsivity ○ Sexuality conflicts ○ Decreased awareness of emotions ○ Body dissatisfaction ○ Low-self esteem ○ Sociocultural ideals Formulate nursing care problems for individuals living with eating disorders Disorder Intervention/Treatments Anorexia Nervosa ○ Team approach with skilled, specialized professionals ○ Preventing death ○ Building a trusting therapeutic relationship Avoid power struggles Role model acceptance, non-judgement, patience Spending quality time Eating with patients ○ Slow nutritional support Caution for Refeeding Syndrome ↓ Thiamine - ataxia, confusion, psychosis ↓ Phosphate - neuro, muscle, and cardia issues ↓ Magnesium ↓ Potassium - weakness, ECG changes ○ Limitations on exercise ○ Psychotherapies… Cognitive Behavioral Therapy (CBT) Dialectical Behavioral Therapy (DBT) Emotion-Focused Therapy (EFT): learning to manage emotions, as opposed to controlling eating to manage emotions Family-Based Treatment (FBT) ○ Psychopharmaceuticals to treat comorbid conditions ○ No SSRIs until weight is up and stable (require higher protein levels in order to be metabolized) SSRIs can help c/ obsessiveness, perfectionism, and ritualism ○ No Bupropion (can lower seizure threshold) Bulimia Nervosa ○ Psychotherapies… Cognitive Behavioral Therapy (CBT) Dialectical Behavioral Therapy (DBT) Emotion-Focused Therapy (EFT): learning to manage emotions, as opposed to controlling eating to manage emotions Family-Based Treatment (FBT) Group therapy ○ Education about physical health, boundaries, healthy limits, and self-esteem ○ Psychopharmaceuticals Binge Eating Disorder ○ Lisdexamfetamine dimesylate (Vyvanse): used for ADHD but also helpful for moderate to severe BED ○ Psychopharmaceuticals to treat comorbid conditions ○ Psychoeducation ○ CBT ○ Therapy/Counselling Discuss the prevention of Eating Disorders ○ Target adolescents and young children through education (always consult with experts) ○ Awareness programs for parents and teachers ○ Monitoring media to pressure them to remove unhealthy advertisements and articles From your text make note of: Table 25.1 pg 599 Complications of Eds (FOCUS) Chapter 27 Personality and Disruptive, Impulse-Control and Conduct Disorder Discuss the concepts of personality and personality traits Personality: a relatively stable and enduring set of characteristic behavioral and emotional traits, largely outside the person's awareness ○ a complex pattern of psychological characteristics that, while not easily altered, can change and evolve across the lifespan ○ Emerges from a complex interaction of genetics, neurobiological dispositions, psychosocial experiences, and environmental situations Personality Traits: persistent patterns of perceiving, thinking, feeling, and behaving that shape the way a person responds to the world. ○ Specific ways of perceiving, thinking, and feeling about self, others, and the environment ○ Expressed in almost every facet of functioning ○ About 50% inherited and 50% environmentally determined Describe the features and specific diagnostic criteria of Personality Disorders "Normal" personalities are able to… ○ Function autonomously and with competence ○ Be adaptive in relation to one's social environment ○ Be able to self-develop and experience contentment Disordered personalities feature… ○ Adaptive inflexibility ○ Self-defeating patterns of behavior ○ Lack of resilience under subjective stress Personality Disorder: diagnosed when the perceptions, emotion, cognition, and behaviour of an individual substantially deviate from cultural expectations in a persistent and inflexible way, causing distress or impairment ○ DSM originally started with 27 personality disorders, which was later reduced to 10 in the DSM-IV(4). The DSM-V(5) grouped the 10 PDs into 3 clusters ○ Once labeled with a personality disorder, patients tend to receive less support, empathy, and tolerance from care providers ○ Estimated 6-15% of the population have PDs  Most common: 1) OCPD, 2) AVPD, 3) PPD, 4) BPD, 5) STPD BPD is the most commonly seen PD among clinical populations ASPD may be more common among substance use clinics, prisons, and/or forensic settings PDs may exist comorbidly ○ Personality disorders feature deeply ingrained patterns of… Maladaptive cognitive schema (Impaired Metacognition) 1. Metacognition: the ability to consider and identify one's own state of mind, as well as the state of mind of others, reflect upon these mental states, deliberate upon their accuracy, and the apply this knowledge to problem solving 2. Causes misinterpretations of other people's actions or reactions and events 3. Results in dysfunctional ways of responding, especially maladaptive in interpersonal contexts Maladaptive emotional response (Affectivity and emotional instability) 1. Over- or under-emotional arousal (or both) 2. Pattern of instability remains stable over time and significantly impairs functioning 3. Behavior is often egosyntonic: does not directly distress the person; "compatible with one's values and ways of thinking" Impaired self-identity and interpersonal functioning 1. Poor boundaries, impaired, or "incomplete" self-identity 2. Impaired goal-directed behaviour Impulsivity and destructive behaviors 1. Difficulty seeing consequences 2. Poor self control 3. Unable to delay gratification 4. Impulsive to the point of danger Five components of maladaptive personality functioning… 1. Self-control EX: stable; self-reflective; emotional; aggressive regulation 2. Identity integration EX: enjoyment; purposefulness; self-respect; frustration tolerance 3. Relational capacities EX: intimacy, enduring relationships, feeling recognized  4. Responsibility EX: trustworthiness, responsible industry 5. Social concordance EX: respect, cooperation Personality Description Symptoms Disorder (A) Paranoid "a stable pattern of ○ Mistrust of others (PPD) nonpsychotic paranoid ○ Desire to avoid behavior" relationships where one is not in control EXCLUDES: psychotic ○ Guarded symptoms (e.g., paranoid ○ Actions often delusions, hallucinations) misinterpreted as: Deception Associated with: Deprecation Low income Betrayal (i.e., Disadvantaged cheating) populations ○ Social isolation Stress, trauma, neglect ○ Outwardly Brain injury argumentative and Alzheimer's dementia abrasive Dopaminergic tract ○ Wants to appear rigid dysfunction and in control ○ Reacts emotionally Clinical considerations: Nervousness PPD is a predictor of Anger aggressive behavior. Envy Typically lack social Jealously supports ○ Hypersensitivity to Matter-of-fact approach criticism Non-threatening ○ Projection environment ○ Aggressive pursuit of Explain actions, individual rights, even demonstrate openness when not threatened ○ Hostile, unforgiving, holding grudges ○ Extreme anxiety (A) Schizoid ○ Overlap with negative (SZPD) symptoms of Aetiology: schizophrenia Adrenergic-cholinergic ○ Does not desire imbalances (?) emotional/physical intimacy ○ Interpersonally unengaged ○ Expressively impassive ○ Anhedonia ○ Introvertive and reclusive ○ Distant, aloof, apathetic, emotionally detached ○ Difficulties making friends ○ Gain little satisfaction in personal relationships ○ "appear to be incapable of forming social relationships" Interests are directed at objects, things, and abstractions ○ Obscure thought processes, particularly about social matters ○ Communication is confused and lacks focus ○ Minimal introspection and self-awareness (A) ○ Overlap with positive Schizotypal symptoms of (STPD) Aetiology: schizophrenia Strong genetic link to ○ Can develop psychosis schizophrenia if under stress ○ Social and interpersonal deficits ○ Do not form friendships easily May only be close with 1st-degree relatives ○ Beliefs about the world appear odd and inconsistent with cultural norms and appear odd to others ○ Ideas of Reference: incorrect interpretations of events as having special, personal meaning ○ Highly anxious ○ Unusual perceptual delusions ○ Odd, circumstantial, and metaphorical thinking and speech ○ Constricted/inappropria te mood ○ Excessive social anxiety ○ Eccentric/peculiar behavior/appearance (B) "a pervasive pattern of ○ Fail to conform to Antisocial disregard for, and violation ethical and social (ASPD) of, the rights of others that standards of begins in childhood or early community adolescence and continues ○ Lack empathy and into adulthood" compassion Must have a history of ○ Easily irritated symptoms of conduct ○ Often act out disorder before the aggressively without age of 15 concern for consequences Aetiology: ○ Impairments in Genetics perspective taking, Non-shared social cognition, and environmental factors social sensitivity" Antisocial behaviors of ○ Impaired mentalization mother ○ Superficial charm Childhood victimization ○ conscious manipulation (B) "a pervasive pattern of ○ Consider themselves Borderline instability of interpersonal bad (BPD) relationships, self-image, ○ Instability (mood, and affects, and marked self-image, identity, impulsivity that begins in interpersonal early adulthood and is present relationships, in a variety of contexts" impulse/behavior control) Aetiology: Affective Genetics Instability: erratic Abnormal serotonergic emotional function responses to Altered situations and hypothalamus-pituitary- intense adrenal (HPA) axis sensitivity to response criticism or Abnormalities/dysfuntio perceived slights n in… Emotional ○ Prefrontal region Dysregulation ○ Frontolimbic Emotions network are felt ○ Amygdala intensely Childhood maltreatment and Invalidating deeply environment Identity Diffusion: a person lacks aspects of personal identity or personal identity is poorly developed ○ Dichotomous Thinking: evaluation of experiences, people, and objects in terms of mutually exclusive categories (i.e., good of bad; success or failure) ○ Dissociation ○ Paranoid ideation ○ Impaired-Problem solving ○ Parasuicidal behaviours ○ Unrealistic high self-expectations Intense shame, self-hatred, and self-directed anger ○ "Live from one crisis to the other" ○ Feelings of emptiness ○ Impulsive destructive behaviour Suicide Self-mutilation ○ Difficulty with interpersonal relationships Intense Idealize and devalue others Frantic if they feel they will be abandoned ○ Poor coping skills ○ Hx unstable, insecure attachments ○ Restrict relationships to ones where they feel in control (B) Histrionic ○ Do not see themselves (HPD) as bad ○ "attention seeking" ○ Difficulty seeking genuine intimacy in interpersonal relationships ○ Get bored very easily, don't stick with things for long ○ Moody ○ Emotions almost seem superficial and insincere ○ Lively and dramatic ○ Helplessness when others are disinterested ○ Apparent openness ○ "life of the party" ○ Strong opinions without supporting facts ○ Persistent need for attention and approval (B) Possession of "a form of ○ Inexhaustible need for Narcissistic self-love that causes problems admiration (NPD) for [the patient] and affects ○ Grandiose sense of their relationships with others" importance Preoccupied Aetiology: with fantasies of Inheritance unlimited Temperament success, power, Psychological trauma beauty, or ideal love Strong sense of entitlement ○ Lack of empathy ○ Vulnerable self-esteem ○ Feelings of shame ○ Sensitivity and intense reactions to humiliation ○ Emptiness ○ Vocational irregularities ○ Difficulties tolerating criticism (C) Avoidant "a desire for affiliation that is ○ Avoids social situations (AVPD) affected by a sense of ○ Only engage in personal inadequacy and interpersonal intense fear of social rejection" relationships where they are sure to be liked ○ Appear timid, shy, and hesitant ○ Perceive themselves as socially inept and inadequate ○ Avoid new activities ○ Withdrawing into fantasies ○ Tension, sadness, and anger ○ Fear of criticism  ○ Chronic low self-esteem ○ Impaired coping (C) "desperate to keep others ○ Difficulty with Dependent close and will be over willing to decision-making (DPD) do anything to maintain ○ Adapt behaviour to closeness, including being please those to whom submissive and without regard they lean on for to self" guidance ○ Fearful of adult responsibilities ○ "gullible" ○ Warm, tender, non-competitive ○ Timidly avoid social tension and interpersonal conflicts ○ Excessive need for advice and reassurance (C) "the person does not ○ Perfectionism Obsessive- demonstrate obsessions ○ Need to be in control and compulsions as much as ○ Preoccupation with an overall inflexibility, orderliness, details, Compulsive perfectionism, and need to rules, organization, (OCPD) be in mental and schedules, and lists interpersonal control" ○ Difficulty delegating tasks and working with others who do things differently than them ○ Difficult adapting to change ○ Rigidity and stubbornness Describe what is known about the aetiology of personality disorders ○ Etiology…  "when the genetic endowment is so unfavorable, early nurturing so deficient, or life experiences so severe that emotional development suffers, a personality disorder will often be the result" Potentially and interaction between… Genetics Epigenetics Neurobiological changes Trauma and stress Environmental Distinguish among the 3 clusters (A. B, C) of personality disorders; Know the difference between the 3 clusters (criteria) Cluster Disorders Key Characteristics A: "Odd" "Mad" "Weird" 1. Paranoid ○ Rarely seen in Social aversion (PPD) MH treatment 2. Schizoid unless severe (SZPD) ○ Low 3. Schizotypal reward-depend (STPD) ence and social attachment B: "Dramatic" "Bad" 1. Antisocial ○ High "Wild" (ASPD) novelty-seekin Dysregulated 2. Borderline g emotion and (BPD) behaviour 3. Histrionic (HPD) 4. Narcissistic (NPD) C: "Anxious" "Sad" 1. Avoidant ○ High harm "Worried" (AVPD) avoidance fearfulness 2. Dependent ○ Generally (DPD) treated with 3. Obsessive-Co psychotherapy mpulsive in the (OCPD) community  Apply the nursing process to clients with Borderline Personality disorders, and formulate nursing assessment and interventions for BPD Establishing boundaries… ○ State clearly the enduring limits Maintain these throughout all care given ○ Documenting in the client chart the agreed-on expectations ○ Sharing the treatment plan with the client ○ Confronting violations of the agreement in a non-punitive way ○ Discussing the purpose of limits on the therapeutic relationship ○ Respond in a very neutral manner, avoiding confrontation Communication Triad, a sentence consisting of 3 parts: 1. An "I" statement to identify the prevailing feeling 2. A nonjudgemental statement of the emotional trigger 3. What the individual would like differently, or what would restore comfort to the situation  Mental Status Exam (MSE): one type of focused assessment used to systematically assess an individual’s psychological, emotional, social, and neurologic functioning ○ Captures a "snapshot" in time of the clients current cognitive and emotional functioning ○ Assesses the individuals appearance, affect, behaviour, and cognitive processes ○ Used in the clinical setting to evaluate developmental, neurologic, and psychiatric disorders ○ Components… Appearance:  Describe the person's general appearance/presentation in terms of… Gender Cultural background Actual and apparent age Body build Attire Grooming and hygiene Physical abnormalities Jewelry and cosmetic use Other identifying features (i.e. tattoos, make up, piercings, scars, unusual hair loss, belongings) Note the manner and appropriateness of these aspects (Psychomotor) Behavior: Behavior/body language during the interview Posture Gait Motor coordination Facial expressions Eye contact Mannerisms Compulsions Ability to follow commands/requests Gestures Activity Appearing to respond to internal stimuli Cues to the person's emotional state (i.e. muscle tension, purposeless repetitive movements, restlessness) Cooperation/Attitude toward interviewer: Possible descriptors… Accommodating Cooperative Open Easy to engage Friendly Apathetic Bored Guarded Suspicious Defensive Hostile  Evasive Withdrawn Child-like Mood: a pervasive and sustained emotion and is what the persons report about their prevailing emotional state Document the client’s response verbatim Use probing questions to find out whether this is typical or is a response to some recent life event Affect: the client’s expressed or observed emotion and is inferred by the examiner from facial expressions, vocalizations, and behaviour ○ Described in terms of range, intensity, appropriateness, congruency (what is being said vs what is being displayed) and stability ○ In evaluating the appropriateness of a particular response, the nurse must consider both the meaning of the event to the individual and cultural norms ○ Terms to describe range… Broad Constricted ○ Terms to describe intensity… Normal Heightened Blunted (limited emotional expression) Flat (near absence of expression; monotone voice; little/no facial expression) ○ Terms to describe stability… Mobile (normal) Labile (range of strong emotions in a relatively short period) ○ Terms to describe affect… Euthymic (calm, cheerful) Euphoric (elated, elevated) Dysphoric (depressed, distressed, disturbed) Anxious Blunted Flat Reactive  Speech: ○ Described in terms of its quantity, rate, and fluency of production, organization, and quality/tone ○ Terms to describe quantity… Talkative Verbose Spontaneous Expansive Paucity Poverty (lack of content in speech) ○ Terms to describe rate… Slow Normal Hesitant Fast Pressured (rapid, increased in amount, and difficult to understand) [associated with mania] ○ Terms to describe fluency (apparent ease in which speech is produced)… Clear, with appropriately placed inflections Hesitant Good/poor articulation Aphasic ○ Terms to describe quality/tone (characteristics)… Monotone Whispered Weak Sharp Slurred Mumbled Staccato Loud ○ Note speech impediments, response latency (length of time it takes the individual to respond), and repetition, rhyming, or unusual word use Perception: complex series of mental events involved with taking in of sensory information from the environment and the processing of that information into mental representations ○ Hallucinations: false sensory perceptions not associated with external stimuli and are not shared by others May be experienced by any of the 5 major senses: auditory, visual, tactile, olfactory, or gustatory  Command Hallucinations: the false perception of commands or orders that an individual feels obligated to obey ○ Illusions: misperception or misrepresentation of real sensory stimuli (e.g., misidentifying the wind as a voice calling one’s name or thinking that a label on a piece of clothing is an insect) Thought: ○ Not directly observable, so must be assessed through language with respect to its content and process (form) ○ Though Content: the subject matter occupying a person’s thoughts Terms to describe though content… Delusions (fixed false beliefs) Intrusive/unwelcomed thoughts Preoccupations Obsessions Phobias Poverty of though Undisturbed Worthlessness  Responding to thought content… ○ Agree with the truth ○ Agree in principle (i.e. "I believe that you believe…") ○ Offer affirmations ○ Offer reflections Thought Process/Form: the manner in which thoughts are formed and expressed ○ Consider logic, relevance, organization, flow, and coherence of though in response to interview questions ○ Terms to describe though process/form… Linear Goal-driven Circumstantial (thoughts unrelated to the conversation being had) Tangential Loose associations (unusual/unrelated associations between things) Incoherent Evasive Racing Blocking Perseveration Neologisms Level of Consciousness (LOC): ○ Arousal or wakefulness  ○ If unresponsive, apply increasing levels of stimulation (i.e. verbal -> tactile -> painful) to elicit a response ○ Terms used to describe LOC… Alert/Awake Vigilant Confused Lethargic Asleep Somnolent Stuporous Comatose Fluctuating Cognitive Functioning ○ Concentration and Attention To test attention and concentration, the nurse asks the client to count backward, aloud, from 100 by increments of 7 (e.g., 93, 86, 79, and so on) or to start with 20 and subtract 3. Alternatively, the client can be asked to spell a simple word (i.e. house) backwards ○ Memory Immediate retention and recall Assessment: give the persons three unrelated words to remember and asks them to recite these words immediately and at 5- and 15-minute intervals during the interview Recent memory Assessment: asks questions about events of the past few hours or days Short-term memory  Assessment: ask questions about event occurring in the past few days or months Remote/Long-term memory Assessment: asking about events of years ago (if personal experiences/events, may need to verify the client’s responses with others to assess their accuracy) ○ Orientation Ask in order of time, person, and place (as impairments tend to occur in this order) Begin with specific questions about the date, time of day, location of interview, and name of interviewer, before moving into more general questions (i.e. year, season, grocery store vs. hospital) ○ Determine the most appropriate assessments based on client education and understanding Knowledge: ○ Are there gaps or deficits in knowledge? ○ What level of education was attained by the client? Insight: the client’s awareness and understanding of their circumstances ○ Awareness of their own thoughts and feelings and an ability to compare them with the thoughts and feelings of others Judgement: the ability to consider a situation and to determine a reasonable course of action after examining and analyzing various possibilities ○ Throughout the interview, the nurse evaluates the person’s problem-solving abilities and capacity to learn from past experience ○ Alternatively, judgement questions such as “What would you do if you found a bag of money outside a bank on a busy street?” can be asked  Endings (Homicidally/Suicidality): ○ Use the C-SSRS Screener to assess level of suicidal ideation Questions to ask… Inquire into homicidal ideation ○ Questions to ask… Reliability: the congruency between the subjective and objective information gathered Understand and be able to recognize and articulate components of Alterations in Thought Content and in Thought Process Assessment Mnemonic: ABCSTAMPLICKER A- Appearance B- Behaviour C- Cooperation S- Speech T- Though Content and Form A- Affect M- Mood P- Perception L- Level of Consciousness I- Insight and Judgement C- Cognition K- Knowledge E- Endings R- Reliability Know that everywhere in Canada has some form of MHA Know what a MHA is Know why they were and are established Focus your energies on the BC MHA Know the difference between voluntary and involuntary admissions Know how patients can be brought to hospital for an assessment under the MHA  Know what forms are most commonly used for Adult involuntary admissions (4.1, 4.2, 5, 6, 13, 15, 16, 17, 19, 20, 21) ○ Form 4.1 - First Medical Certificate - Completed by a MD or NP to explain why a person requires involuntary admission ○ Form 4.2 - Second Medical Certificate - Completed by an MD within 48 hour of form 4.1 completion to extend involuntary admission up to one month minus a day ○ Form 5 - Consent for Treatment - completed by the patient or director to consent to psychiatric treatments ○ Form 6 - Medical Report on Examination of Involuntary Patients (aka Renewal Certificate) - completed to extend involuntary status at intervals of 1 month, 3 months, and 6 months 1st form 6: completed to extend involuntary admission for 1 more month 2nd form 6: completed to extend involuntary admission for 3 more months 3rd form 6: completed to extend involuntary admission for 6 more months ○ Form 13 - Notification of Involuntary Patient Rights Under MHA - describes the patient's rights to them and asks for a signature ○ Form 15 - Nomination for Near Relative - selects a designated person to notify of the patient involuntary admission status ○ Form 16 - Notification of Near Relative - notifies nominated person of the patient's involuntary admission status and rights ○ Form 17- Notification to Near Relative (Discharge of Involuntary Patient) - informs the nominated person that the involuntary patient has been discharged ○ Form 19 - Certificate of Discharge - a non-mandatory form provided to patients when they are discharged from the MHA ○ Form 20 - Leave Authorization - completed when a person requires continued involuntary support but no longer in an in-patient environment ○ Form 21 - Directors Warrant (Apprehension of Patient) - completed and sent to the RCMP when a patient absconds from involuntary admission or requires readmission to the hospital after extended leave Know which form makes a patient involuntary (4.1 both section 1 and 2) Know the time frames for involuntary admissions from the 4.1, 4.2, 6 (4.1 = 48 hours, 4.2 = 1 month, first form 6 = 1 month, second form 6 = 3 months, third form 6 = 6 months)  Know the difference between the 4.1+4.2 and 5 (know the name difference and what they actually do) ○ Form 4.1 - First Medical Certificate - Completed by a MD or NP to explain why a person requires involuntary admission ○ Form 4.2 - Second Medical Certificate - Completed by an MD within 48 hour of form 4.1 completion to extend involuntary admission up to one month minus a day Know that patients can only be admitted under the MHA as an involuntary patient in a Designated Facility Know that forms 5, 13, 15, 16 need to be completed within 24 hours of a patient being involuntarily admitted under the MHA Know what Forms are used for Adult voluntary admissions (1, 2) ○ Form 1 - Request for Admission (Voluntary Patient) - completed when a person voluntarily seeks psychiatric care or caregivers of an underage person are reqesting care ○ Form 2 - Consent for Treatment (Voluntary Patient) - voluntary consent to treatment