Exam 2 Flashcards
Bipolar I disorder
- most severe bipolar; shifts in mood, energy, and ability to function
- at least one Mania episode followed by hypomanic or major depressive episode; chronic interpersonal or occupational difficulties exist even during remission
Bipolar I comorbidities (5)
-75% also have anxiety (panic attacks, social anxiety, specific phobias)
->50% have AUD (probably due to self-medication attempts).
-ADHD, disruptive,impulse-control, conduct disorders likely
-higher rates of migraines
-metabolic syndrome -> heart disease, stroke, diabetes
Bipolar II (3)
a.at least one hypomanic episode and at least one major depressive episode
b. psychosis possible in depressive episodes but hypomania has no psychosis
c. assess anyone with depression for hypomania due to bipolar’s increased mortality and morbidity
Comorbidities of Bipolar II (3)
- 75% have anxiety (usually prior to episodes)
- 14% have eating disorders (binge-eating) which is associated with depressive side
-37% have SUD which is associated with hypomanic side
Cyclothymic Disorder (2)
-episodes do not meet criteria of major depressive or bipolar II, but symptoms disturbing enough to cause social and occupational impairment; 15-50% progress to bipolar
-symptoms of hypomania alternate with symptoms of mild to moderate depression for at least 2 yrs in adults and 1 yr in children
How does hypomania differ in clyclothymic vs bipolar
-tend to have irritable hypomanic episodes (children have irritability and sleep disturbance)
Comorbidities of Cyclothymic (3)
SUD, Sleep disorders, ADHD (for children)
How does mood look in bipolar disorder? (3)
-Unstable euphoria that could quickly change to irritation and anger
-Boundless enthusiasm, friendliness, self-confidence
-More time depressed vs manic
How does behavior look in bipolar? (5)
o Big appetites for social, spending, activities, sex
o Makes grand plans and stays busy all hours of day and night
o Easily distracted
o May manipulate and exploit vulnerabilities of others
o May skip sleep for days -> worsens mania and physical exhaustion
Pressured speech
fast (rapid to frenetic) with inappropriate sense of urgency; often loud and incoherent; individual may dominate conversation
Circumstantial speech
addition of unnecessary details when communicating; person eventually gets to the point
Tangential speech:
similar to circumstantial speech, but they forget the point but often a common word connects sentences to each other (awareness of losing the point and less tangential speech indicate less thought disturbance)
Name the Thought Process:
Ex. I had to do my laundry that day because it was Saturday. On Saturday, I always watch Ninja Turtles on television. Have you seen those 60-inch televisions? Giants. I used to think of giants as I fell asleep, and I thought that sleep activated them.
Tangenital speech
Loose associations
disordered way of processing information; thoughts are only loosely connected to each other in person’s conversation
Name the thought process
Ex. The sky’s the limit now that I have money. I took a flight, you know, from Kennedy. Drinking beer is a belly full of bags
Loose associations
Flight of ideas
continuous flow of rapid, verbose, circumstantial speech with abrupt changes from topic to topic
Speech may be disorganized and incoherent; often uses associations, plays on words, jokes, teasing
Name the thought process:
How are you doing, kid, no kidding around, I’m going home … home sweet home … home is where the heart is, the heart of the matter is I want out and that ain’t hay … hey, Doc … get me out of this place.
Flight of ideas
Clang associations (and when it happens)
stringing together of words because of their rhyming sounds, w/o regard to meaning
may happen after flight of ideas as mania escalates
Name the thought process:
Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.
Clang associations
Grandiose delusions
highly inflated self-regard; apparent in both ideas expressed and person’s behavior (religious, science fiction, supernatural themes are common)
ex. Brianna believes she is a famous playwriter
Persecutory delusions
common in BPD and Schizo; Believing that one is being singled out for harm or prevented from making progress by others
Ex. God or FBI is watching
Who experiences cognitive deficits in BPD?
-Some people have mild cognitive deficits like those seen in schizophrenia (More likely with BPD I vs BPD II)
What are the clinical implications of cognitive dysfunction bipolar disorder? (3)
-Impaired overall function
-correlated w/ greater # of manic episodes, history of psychosis, chronicity of illness, and poor functional outcome.
-Medication selection should consider not only the efficacy of the drug but also the cognitive impact
on patient
Why is early diagnosis and treatment crucial for BPD? (3)
to prevent illness progression, cognitive deficits, and poor outcome.
What is the nursing diagnosis and outcome for the following signs and symptoms:
Auditory hallucinations, agitation, impulsivity, poor judgment
Diagnosis: risk for injury
Outcome: No injury: Delusional content reduced or eliminated, hallucinations reduced or eliminated, thinking is objectively clearer, redirectable
What is the nursing diagnosis and outcome for the following signs and symptoms:
Alteration in cognitive functioning, impulsiveness, sexual advances, threatening violence, agitation
Diagnosis: risk for violence
Outcome: No aggressive behavior: Refrains from harming others, controls impulses, respects others’ space
What is the nursing diagnosis and outcome for the following signs and symptoms:
Agitation, anxiety, confusion, perceptual disorders, restlessness
Diagnosis: sleep deprivation
Outcome: Adequate sleep: Sleeps 4–6 h a night, reports feeling refreshed after sleep
What is the nursing diagnosis and outcome for the following signs and symptoms:
Deficits in verbal communication, working memory, executive functioning, reasoning, problem solving
Diagnosis: Impaired cognition; Impaired concentration
Outcome: Improved cognition: Demonstrates increase in concentration, improved memory, and hallucinations are absent
What is the nursing diagnosis and outcome for the following signs and symptoms:
Minimal calorie intake, poor hygiene, clothing unclean
Diagnosis: self-care deficit
Outcome: Able to self-care: Completes meals, tends to hygiene, clean and appropriate clothing
What is the nursing diagnosis and outcome for the following signs and symptoms:
Dysfunctional interaction with others, pressured speech, flight of ideas, annoyance or taunting of others, loud and crass speech
Diagnosis: impaired socialization
Outcome: Improved socialization: Initiates and maintains goal-directed and mutually satisfying verbal exchanges
Goal for acute interventions of BPD
Goals: symptom reduction and achieving remission
Goal for maintenance interventions of BPD
Goals: prevent future exacerbation of mania or hypomania through education, support, problem-solving
6 patient outcome goals for acute BPD
i. well hydration
ii. stable cardiac status
iii. tissue integrity
iv. Sufficient sleep and rest
v. Self-control with aid of staff or medication
vi. No self-harm attempts
4 patient outcome goals for maintenance BPD
i. identify risk factors for development of acute mania
ii. Attend daily group therapy
iii. resume function in community
iv. Identify new coping skills
What planning happens in maintenance BPD? (2)
a. May need medication for a lifetime
b. Often have to face the hardships that resulted from acute phase, so patients need support to recover from illness and repair their lives
5 barriers to BPD treatment
- individuals often ambivalent (avg. 10 yrs before getting treatment)
- lack of adherence to mood stabilizers often leads to relapse.
- self-medicating w/ alcohol complicates things and delays treatment
- patients may minimize or deny consequences of their behavior
- patient may be reluctant to give up the mania or hypomania
When is hospitalization indicated for BPD depressive episodes?
when suicidal ideation, psychosis, catatonia
What is purpose of hospitalization in acute BPD? (3)
a. provide safety in BPD I mania via imposing external control and stabilizing with medication
b. limits set in firm, nonthreatening, and neutral manner to prevent escalation of behavior and safe boundaries
c. Ensure structure, clear expectations, needs are met (nutrition, sleep, hygiene, elimination)
What is key to BPD maintenance? (4)
medication adherence, regular sleep, healthy nutrition, community support
Why are outpatient clinics and psychiatric home care useful in BPD maintenance? (4)
Provide structure, medication management, decrease in social isolation, offer channel for time and energy
Three areas of health teaching for BPD
-stress importance of regular sleep patterns (poor sleep can lead to exhaustion and manic behavior), meals, exercise, coping strategies
-aim teaching at weight reduction and management b-c many BPD medicine have metabolic syndrome as an adverse effect
-to improve treatment adherence, follow collaborative-care model and use self-managed responsibility
What can restraints never be for?
punishment or staff convenience
What is usually the immediate treatment in acute phase of BPD?
antipsychotic for BPD
What is the rationale for the following intervention in BPD?
Use firm and calm approach: “John, come with me. Eat this sandwich.”
Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.
What is the rationale for the following intervention in BPD?
Use short and concise explanations or statements.
Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.
What is the rationale for the following intervention in BPD?
Be consistent in approach and expectations.
Consistent limits and expectations minimize potential for patient’s manipulation of staff.
What is the rationale for the following intervention in BPD?
Identify expectations in simple, concrete terms with consequences.
Example: “John, do not yell at or hit Peter. If you cannot control yourself, we will help you.” Or “The seclusion room will help you feel less out of control and prevent harm to yourself and others.”
Clear expectations help the patient experience outside controls as well as understand reasons for medication, seclusion, or restraints (if he or she is not able to control behaviors).
What is the rationale for the following intervention in BPD?
Hear and act on legitimate complaints.
Underlying feelings of helplessness are reduced, and acting-out behaviors are minimized.
What is the rationale for the following intervention in BPD?
Firmly redirect energy into more appropriate and constructive channels.
Distractibility is the most effective tool with the patient experiencing mania.
What is the rationale for the following intervention in BPD?
Maintain low level of stimuli in patient’s environment (e.g., away from bright lights, loud noises, and people).
Escalation of anxiety can be decreased.
What is the rationale for the following intervention in BPD?
Provide structured solitary activities with nurse or aide.
Structure provides security and focus.
What is the rationale for the following intervention in BPD?
Provide frequent high-calorie fluids.
Serious nutritional deficiencies and dehydration are addressed.
What is the rationale for the following intervention in BPD?
Redirect aggressive behavior.
Physical exercise can decrease tension and provide focus.
What is the rationale for the following intervention in BPD?
In acute mania, use as needed medication, seclusion, and/or restraint to minimize physical harm.
Exhaustion can result from dehydration, lack of sleep, and constant physical activity.
What is the rationale for the following intervention in BPD?
Encourage frequent rest periods during the day.
Lack of sleep can lead to exhaustion and increase mania.
What is the rationale for the following intervention in Bipolar Disorder?
Keep patient in areas of low stimulation.
Relaxation is promoted, and manic behavior is minimized.
What is used for severe agitation in Bipolar Disorder? What about less severe agitation?
Severe: Lithium OR divalproex plus an SGA (olanzapine, risperidone)
Less severe: one of the above
Which benzodiazepines are used in Bipolar Disorder agitation? What is their purpose? Why are they short-term
clonazepam and lorazepam—high potency may be used
Purpose: calm agitation, reduce insomnia, aggression, and panic
-short term only for mania b-c dependency concerns)
Purpose of lithium in Bipolar Disorder
acute mania and maintenance to prevent relapse
What to note about onset of Lithium? (2)
10-21 days (slow, so often supplemented with SGA, anticonvulsants and antianxiety drugs)
-weight gain may happen initially esp for females
What to note about taking lithium? (4)
-Not addictive but taper dose to reduce relapse of mania though)
- maintain sodium and fluid levels( 1500–3000 mL/day or six 12-oz glasses of fluid)
-take with meals to reduce stomach irritation)
-narrow therapeutic range so check levels regularly
Signs of <1.5 mEq/L Lithium toxicity (8)
-N/V/D
-thirst
-polyuria (producing too much urine)
-lethargy, sedation
- fine hand tremor
- Renal toxicity
- goiter
- hypothyroidism
Interventions of <1.5 mEq/L Lithium toxicity (2)
Doses should be kept low.
assess Kidney function and thyroid levels before treatment and then on an annual basis.
Interventions of 1.5-2.0 mEq/L early Lithium toxicity (2)
-hold medication
-measure blood lithium levels
-reevaluate dosage
Signs of 1.5-2.0 mEq/L early Lithium toxicity (7)
-GI upset
- coarse hand tremor
- confusion
- hyperirritability of muscles,
- EEG changes
-sedation
-incoordination
Signs 2.0–2.5 mEq/L advanced Lithium toxicity (10)
Ataxia
giddiness
serious EEG changes
blurred vision
clonic or seizure movements
large output of dilute urine, stupor
severe hypotension
coma
Death is usually secondary to pulmonary complications.
Interventions of 2.0–2.5 mEq/L advanced Lithium toxicity (3)
-hospitalization
-hold drug and haste excretion
- Whole bowel irrigation may be done to prevent further absorption
Signs of >2.5 mEq/L severe Lithium toxicity (3)
convulsions, oliguria (none or small amount of urine), death
Interventions of >2.5 mEq/L severe Lithium toxicity
-same as others plus hemodialysis
5 precautions for lithium
avoid diuretics, NSAIDS, if N/V/D present
7 Contraindications for Lithium
- children under 12
pregnant and breast-feeding
brain damage
Cardiovascular,renal, thyroid diseases
myasthenia gravis
When are anticonvulants used in BPD? (5)
o continuously cycling patients
o no family history of BPD
o to diminish impulsive and aggressive behavior in nonpsychotic pts
o useful when alcohol or benzodiazepine withdrawal
o useful to control mania (within 2 wks) and depression (within 3 wks)
Valporate usage
- FDA approved anticonvulsant for acute mania and preventing future manic episodes; black box warning though for teratogenicity
o Divalproex and valproic acid
Why is Carbamazepine a 2nd line treatment for BPD?
anticonvulsant; 2nd line due to black box for stevens-Johnson syndrome and toxic epidermal necrolysis (greatest for asian descent
6 common Adverse effects of Valporate
weakness, somnolence, indigestion, diarrhea, dizziness, vomiting
Lamotrigine
o FDA approved for BPD maintenance therapy (18 and up)
Unique and most serious side effects of Lamtrigine
Unique side effects: rash
Most serious side effects (greater risk in children 2-16 and with valproate coadministration): toxic epidermal necrolysis, Stevens-Johnson syndrome
Role of SGAs in BPD treatment
-many approved for acute mania
-sedative properties help with insomnia, anxiety, agitation; also some mood-stabilizing properties
7 SGAs used in BPD
Olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, asenapine, cariprazine
What is treatment for Bipolar depression? Why should you not treat with just antidepressant
treatment with only antidepressant increases risk of manic episode, so combine with a mood stabilizer
o SGAs (lurasidone, quetiapine, cariprazine)
o Symbyax (combo of SGA olanzapine and SSRI fluoxetine)
6 Risk factors for suicide
-previous attempts
- SUD
- psychiatric conditions
- family hx of suicide
-hx of trauma
- suicide survivor (close to someone who committed suicide
2 Protective factors for suicide
-access to mental health
-strong social life
Verbal and nonverbal cues of suicide (2)
- Clues may be in overt/open or concealed/covert statements to someone patient trusts like nurse)
- be wary of sudden bursts in energy, giving away possessions
5 Hard methods of suicide
gun, hanging, poison, car crash, jumping
3 soft methods of suicide
pills, gases, cutting wrists
6 specific questions to ask about suicide
- Have you ever felt that life was not worth living?
- Have you been thinking about death recently?
- Do you ever think about suicide?
- Have you ever attempted suicide?
- Do you have a plan for ending your life?
- If so, what is your plan for suicide?
What are four suicide precautions in the hospital?
- One-to-one observation, 24hrs
- Record mood, verbatim statements, behavior (esp hands)
- Remove glass, silverware, “sharps”, strangulation risks
- Observe patient swallowing medication
What is a patient safety plan?
six step written plan identifying patient’s warning signs, coping strategies, social settings, reasons to live, people who can distract; it also includes who patient should contact for help
Persistent Depressive disorder (2)
chronic low-level depression most of the day for the majority of days AND at least two of the following: increased/decreased appetite, insomnia/hypersomnia, low energy, poor self-esteem, difficulty thinking, hopelessness
-feelings last 2 yrs in adults, 1 yr in children and adolescents; often early onset
-not severe enough for hospitalization
Major depressive disorder (3)
-persistent depression lasting a minimum of 2 weeks (may last 5-6 months or even > 2 yrs)
-Primary symptoms: depressed mood, loss of interest/pleasure
-Secondary symptoms: significant weight changes, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue, feeling worthless, thinking problems, thoughts on death (suicidal ideation, hx of suicide, suicide plan)
Bereavement exclusion and 3 rationales
in the past clinicians would not diagnose someone with depression in 1st 2 months after significant loss;
Rationale:
* Normal mourning may be labeled pathological
* Psychiatric diagnosis can result in lifelong label
*Unnecessary medications may be prescribed
Seasonal Affective Disorder
major depressive disorder with seasonal pattern; typically depression in fall and winter and remission in spring
-at least two seasonal depressive episodes within 2 yrs
5 Key findings of depression assessment
depressed mood, anhedonia (inability to fell pleasure), anxiety; difficulty recognizing their strengths, comorbid chronic pain
5 factors that increase risk of comorbid suicidality and depression
hopelessness, SUD, recent loss or separation, hx of past attempts, and acute suicidal ideation
What to note about depression in children and adolescents? (2)
Children and Adolescents (often overlooked)
-Core symptoms: sadness and loss of pleasure but may look clinically different from adult aka crying, withdrawal, SUD, sexual promiscuity
What to note about depression and older adults (3)
Older Adults (often overlooked)
-difficult to determine if fatigue, pain, weakness result of illness or depression
-Use Geriatric Depression Scale (yes or no questions, reliable and valid)
Appearance in depression (3)
neglected personal hygiene, grooming, dressing; lack of eye contact; slumped posture
Behavior in depression (5)
-Anergia (abnormal lack of energy)
-psychomotor retardation (fixed gaze, slow movements, lack of facial expressions, even incontinence)
-some have psychomotor agitation (pacing, tension-relieving behaviors)
-Vegetative signs of depression (alteration in physical life and growth activities) including appetite changes, bowel changes, sleep disturbance
-low libido or impotence
Feelings and Emotions in depression (5)
specific and can change quickly
- worthlessness (inadequate to unrealistic negative self-eval),
- guilt (ruminate over failures),
- helplessness (inability to problem solve)
- hopelessness (^ suicidality),
- anger and irritability (active byproducts)
Affect vs mood in depression
Mood is general emotional state (often depressed)
Affect is outward emotional state; may be congruent or incongruent with mood (often constricted, blunt, or flat)
Speech in depression
slow and softy; may also be monotone and lack spontaneity
Thought Processes in depression
poverty of thought (slow thinking), responses slow or absent, may even be mute in severe depression
Thought content and perceptions in depression
psychosis (delusions and hallucinations) may be present and ^ suicidality; psychosis may be mood congruent or incongruent
Cognitive Changes and judgement in depression
impaired concentration ( attention, short-term and working memory, verbal and nonverbal learning) which may linger after treatment
-poor judgment may lead to indecisiveness
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Previous suicidal attempts, putting affairs in order, giving away prized possessions, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness
Diagnosis: risk for suicide
Outcomes:Decreased suicide risk: Expresses feelings, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope
Diagnosis: Impaired coping
Outcomes: Improved coping: Identifies ineffective and effective coping, uses support system, uses new coping strategies, engages in personal actions to manage stressors effectively
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Dull/sad affect, no eye contact, preoccupation with own thoughts, seeks to be alone, uncommunicative, withdrawn, feels rejected and not good enough
Diagnosis: social isolation
Outcomes: Decreased social isolation: Attends group meetings, interacts spontaneously with others, talks with the nurse in 1:1, demonstrates interest in engaging with others
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Questioning meaning of life and existence, anger toward greater power, feeling abandoned, perceived suffering
Diagnosis: spiritual distress
Outcomes: Decreased spiritual distress: Shares feelings of connectedness with self, others, and a higher power, identifies meaning and purpose in life
What is the nursing diagnosis and outcome for the following signs and symptoms in depression:
Exaggerates negative feedback about self, excessive seeking of reassurance, guilt, indecisive and nonassertive behavior, poor eye contact, shame
Diagnosis: chronic low self-esteem
Outcomes: Improved self-esteem: Identifies strengths, verbalizes self-acceptance, participates in groups, expresses a personal judgment of self-worth
Recovery model in depression management
used with partnerships with patient and healthcare professionals so patients exercise control over treatment to reach their individual goals
What does inclusion of family in health teaching for depression accomplish? (3)
increase their understanding and acceptance of patient, increase patient’s adherence to aftercare facilities, and improves patient adjustment after discharge
Main treatment of depression
combo of psychotherapy and antidepressant
What may be used if someone acutely suicidal since antidepressants have slow onset?
Electroconvulsive therapy
Goals for acute and maintenance MDD treatment
Acute: reduction of symptoms and restoration of psychosocial and work function
Maintenance: prevention of relapse
What do all antidepressants have in common? (5)
- All have similar efficacy( in improving self-concept, social withdrawal, vegetative signs, activity level)
- May induce psychotic or manic episode in those with schizophrenia or bipolar disorder
- All have delayed response (3 month trials)–1-3 wks for improvement to be seen, maintain for 6-9 months after remission of symptoms
-discontinuation syndrome
- black box warning for suicidal thoughts and behaviors
What determines selection of antidepressant? (5)
safety profiles, side effects, ease of administration, hx of past response, genotyping ( when available)
What symptoms do antidepressants target? (8)
sleep, appetite, fatigue, libido, psychomotor issues, diurnal variations in mood (bad in morning), impaired concentration, anhedonism
4 things to note about SSRIs and depression
- 1st line of treatment for major depression (w/ anxiety and psychomotor agitation as well)
-Some SSRIs activate and others sedate; choice depends on patient symptoms
-Risk of lethal overdose minimized with SSRIs
-low side-effect profile and no anticholinergic effects
Most toxic effect of SSRIs
serotonin syndrome (rare and life-threatening, increased risk when coadministration with MAOI or lithium; wait 2-5 wks between the two
10 Symptoms of Serotonin syndrome
- Hyperactivity or restlessness
- Tachycardia → cardiovascular shock
- Fever → hyperpyrexia
- Elevated BP
- Delirium
- Irrationality, mood swings, hostility
- Seizures → status epilepticus
- Myoclonus (jerk), incoordination, rigidity
- Abdominal pain, diarrhea, bloating
- Apnea → death
5 interventions for Serotonin Syndrome
- Serotonin-receptor blockade with cyproheptadine, methysergide, propranolol
- Cooling blankets, chlorpromazine for hyperthermia
- Dantrolene, diazepam for muscle rigidity
- Anticonvulsants
- Induction of Paralysis
Two SNRIs used in depression
venlafaxine and duloxetine
Side effects of Esketamine (5)
Side effects: nausea and vomiting (avoid eating 2 hrs before or drinking 30 minutes before), elevated BP (monitor at least 2 hrs post admin), dissociation, dizziness, sedation, vertigo, anxiety
Esketamine
formally ketamine, FDA approved for treatment-resistant depression; off-label for acute suicidality
o Available as nasal spray and used with oral antidepressants
5 SSRIs used in depression
Citalopram, Escitalopram, Fluoxetine, Paroxetine (also treats menopausal hot flashes), Sertraline
4 Patient teaching for MAOI
- give wallet card with MAOI regimen
-avoid asian restaurants
-go to ED immediately if severe headache
-maintain dietary and drug restrictions for 14 days after MAOI stopped
Symptoms of MAOI hypertensive crisis (5 early)
Early symptoms: irritability, anxiety, flushing, sweating, and a severe headache.
Symptoms of MAOI hypertensive crisis (4 late)
Late symptoms: severe fever, seizures, cerebrovascular accident, intracranial hemorrhage
Hypertensive crisis
happens with MAOIs due to inability to break down tyramine sufficiently
Occurs within 15 to 90 minutes of ingestion of the offending substance
Interventions for hypertensive crisis (3)
-gastric lavage and charcoal may be helpful.
- short-acting antihypertensive agent such as nitroprusside, nitroglycerine, or phentolamine may be used.
-IV benzodiazepines are useful for agitation and seizure control.
11 common side effects of MAOIs
orthostatic hypotension
weight gain
edema
change in cardiac rate and rhythm
constipation or urinary hesitancy
sexual dysfunction
vertigo
overactivity or insomnia
muscle twitching
hypomanic and manic behavior
weakness and fatigue
Other foods with Tyramine
protein dietary supplements, soups with protein extract, shrimp paste, soy sauce
Food with yeast with Tyramine
yeast extract (marmite, bovril)
milk products with Tyramine
most cheeses except cottage cheese, cream cheese, yogurt, and milk
Fish with Tyramine
Dried or cured fish; fermented, smoked, aged, or spoiled fish
Sausages with tyramine
fermented (bologna, pepperoni, salami)
Meats with Tyramine
fermented, smoked, aged, spoiled meats, and liver, unless very fresh
Fruits with tyramine
figs, bananas in large amounts
Vegetables with tyramine
avocados, fermented bean curd, soybean or soybean paste
5 Conditions contraindicate with MAOIs
cardiac or liver disease
hypertension
recurrent headaches
surgery (within 10-14 days)
under 16 yrs
1st, 2nd, and 3rd line antidepressants
SSRIs and SNRIs are first line
TCAs are 2nd line
MAOIs are 3rd line
3 MAOIs used in depression
Isocarboxazid, Phenelzine, and Selegiline (patch w/o strict diet at lowest dose),
8 Drug contraindications for MAOIs
-SSRIs
-TCAs (imipramine, amitriptyline)
-OTC meds for colds, allergies, or congestion (containing ephedrine, phenylephrine hydrochloride, or phenylpropanolamine)
-Narcotics
- antihypertensives (methyldopa, guanethidine, reserpine)
- Amine precursors (levodopa, L-tryptophan)
-sedatives (alcohol, barbiturates, benzodiazepines)
- Stimulants (amphetamines, cocaine)
Why are TCAs lethal in overdose?
risk of cardiac conduction abnormalities (may present as CNS stimulation -> CNS depression)
What are the benefits of TCAs?
May work better in melancholic depression and in people with comorbid medical conditions
6 Anticholinergic effect of TCAs
Dry mouth, constipation, tachycardia, urinary retention, blurred vision, esophageal reflux
Who to cautiously use TCAs in? (7)
suicidal individuals, older adults with cardiac disorders, elevated intraocular pressure (glaucoma), hyperthyroidism, seizure disorders, and liver or kidney dysfunction (also pregnant individuals)
What is the rationale for the following intervention with depression:
When a patient is silent, use the technique of making observations: “There are many new pictures on the wall.” “You are wearing your new shoes.”
When a patient is not ready to talk, direct questions can raise the patient’s anxiety level and frustrate the nurse. Pointing to commonalities in the environment draws the patient into and reinforces reality.
What is the rationale for the following intervention with depression:
Avoid platitudes such as “Things will look up” or “Everyone gets down once in a while.”
Platitudes tend to minimize the patient’s feelings and can increase feelings of guilt and worthlessness because the patient cannot “look up” or “snap out of it.”
What is the rationale for the following intervention with depression:
Use simple, concrete words.
Slowed thinking and difficulty concentrating impair comprehension.
What is the rationale for the following intervention with depression:
Allow time for the patient to respond.
Slowed thinking necessitates time to formulate a response.
What is the rationale for the following intervention with depression:
Listen for covert messages, and ask about suicide plans.
People often experience relief and decrease in feelings of isolation when they share thoughts of suicide.
What is the rationale for the following intervention with depression:
Encourage formation of supportive relationships, such as individual therapy, support groups, and peer support.
Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs.
What is the rationale for the following intervention with depression:
Provide information referrals, when needed, for religious or spiritual support
Spiritual and existential issues may ^ during episodes; people find strength, support, and comfort in spirituality or religion
What is the rationale for the following intervention with depression:
Work with the patient to identify cognitive distortions that result in a negative self-perception. For example:
- Overgeneralizations
- Self-blame
- Mind reading
- Discounting of positive attributes
Cognitive distortions reinforce a negative inaccurate perception of self and world.
- Taking one fact or event and making a general rule out of it (“He always…”; “I never…”).
- Consistently blaming self.
- Despite a lack of evidence, assumes that others don’t like him or her.
- Focusing on the negative
Schizophrenia Disorder Diagnosis
have at least one psychotic symptom (hallucinations, delusions, disorganized speech or thought) unrelated to SUD or medical conditions
- Symptoms must disrupt normal activities and developmental milestones
- Must persist for 6 months (at least one month of psychotic symptoms)—often periods of relapse and dormancy
Prodromal phase of Schizophrenia
Mild changes in thinking or mood; odd speech and obsessive thoughts; compulsive behavior; deteriorating social functioning
-OC and anxiety behaviors may be present
Acute phase of Schizophrenia
Hallucinations; delusions; disorganized behavior; impaired judgment; functional impairment; may last several months and person usually has difficulty coping
Stabilization phase of Schizophrenia
Symptoms are diminishing; may last for months; care may be outpatient, partial, group or residential home
Maintenance/residual phase of Schizophrenia
Positive symptoms diminished or absent; negative and cognitive symptoms remain; person can live at home
Positive vs negative symptoms of Schizophrenia
Schizophrenia: presence of symptoms that should not be present; often dramatic and precipitate treatment.
B. Negative Symptoms of Schizophrenia: the absence of qualities that should be present; more difficult to treat compared to positive symptoms
Reality Testing
automatic and unconscious process by which we determine what is and is not real; impaired reality testing leads to delusions and hallucinations
Delusions
false beliefs that are held despite a lack of evidence to support them
Referential delusion and example
A belief that events or circumstances that have no connection to you are somehow related to you
Ex. Sarah believes that songs on the radio are chosen to send her a message.
Nihilistic delusion and example
The conviction that a major catastrophe will occur
Ex. Deepesh is giving away all his belongings since they won’t be of any use when the comet hits.
Word Salad and example
Extreme associative looseness; jumble of words which are meaningless to listener
Ex: agents want strength of policy on a boat reigning supreme
Echolalia
pathological repetition of another’s words, may be due to patient’s thought processes being so impaired that they are unable to generate speech of their own.
Neologism
Words that have meaning for patient but a different or nonexistent meaning of others
Ex. His mannerologies are poor
Cognitive Retardation
Generalized slowing of thinking, which is represented by delays in responding to questions or difficulty finishing thoughts.
Paranoia
An irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you)
Why is paranoia dangerous in the schizophrenic?
may result in dangerous defensive actions such as harming another person before that person can harm the patient”
Alterations in perception
errors in how one interprets perceptions or perceived reality
Hallucinations
perception of sensory experience for which no external source exists
4 ways to recognize person is experiencing an auditory hallucination
- tracking motions (turning one’s head in the direction of the perceived sound)
- lips moving silently
- talking as if to another when no one is present
- otherwise unexplained changes in affect (e.g., suddenly laughing with no apparent reason).
Why are command hallucinations particularly concerning?
particularly concerning because person is directed to take action and may be warning of a psychiatric emergency
Three things to assess in a patient whom you feel is experiencing command hallucinations?
- Assess what patient hears
- the source it is attributed to
- patient’s ability to recognize the hallucination as not real and resist commands
What is the most common visual hallucinations?
seeing individuals and animals that are not there
Alterations in behavior
changes in the speed of movement and behaviors that are illogical or inappropriate
Catatonia (definition, most common, persistent impact)
pronounced increase or decrease in the rate and amount of movement.
Most common form is when the person moves little or not at all
Persistent catatonia may contribute to rigidity/catalepsy, exhaustion, pneumonia, blood clotting, malnutrition, or dehydration
-in schizophrenia
Motor retardation or agitation
Pronounced slowing of movement or excited behavior in response to internal or external stimuli.
-in schizophrenia
Stereotyped behaviors
Repetitive behaviors that do not serve a logical purpose
-in schizophrenia
Echopraxia
The mimicking of movements of another
-in schizophrenia
Impaired impulse control
A reduced ability to resist one’s impulses.
Ex: interrupting others or throwing unwanted food on the floor; increases risk of assault.
-in schizophrenia
Boundary impairment
An impaired ability to sense where one’s body or influence ends and another’s begins
-in schizophrenia
Why do positive symptoms seem more urgent than negative symptoms? Which is more difficult to treat?
positive symptoms are obvious. negative are more difficult to treat
5 negative symptoms of schizophrenia
Anhedonia (lack of pleasure)
Avolition (lack of goal-directed behavior or motivation)
Asociality (decreased desire for social interaction)
Apathy (decreased interest in activities)
Alogia (reduction in speech)
5 affects seen in schizophrenia
i. Flat: Immobile or blank facial expression
ii. Blunted: Reduced or minimal emotional response
iii. Constricted: Reduced in range or intensity (e.g., shows sadness or anger but no other moods)
iv. Inappropriate: Incongruent with the actual emotional state or situation (e.g., laughing in response to a tragedy)
v. Bizarre: Odd, illogical, inappropriate, or unfounded; includes grimacing
How do cognitive symptoms affect schizophrenics?
Lead to poor judgment and leave person less able to cope, learn, manage health, or succeed in school or work
Concrete thinking in Schizophrenia
impaired ability to think abstractly and respond or understand things like humor, love, sarcasm or recognize social cues
Impaired executive functioning in Schizophrenia
(difficulty reasoning, setting priorities, comparing options, anticipating, and inhibiting impulses)
Anosognosia in Schizophrenia
inability to realize one is ill; can lead to treatment resistance
Early signs of Schizophrenia relapse (3)
reduced sleep, social withdrawal, worsened concentration
Implementations for acute phase of Schizophrenia
Safety is priority; 24-hour support in hospital provides support and structure; usually short stay (days to weeks) which ends when acute symptoms are stable)
Maintenance supports for Schizophrenia (3)
- Community mental health centers (medication support, monitoring, structured activities, case management, crisis and psychiatric emergency services)
- Support groups
- Educational resources (NAMI, Best Practices in Schizophrenia Treatment Center)—can provide w/o patient consent if family requests it and the info is provided w/o violating confidentiality
Evaluation for Schizophrenia treatment
small goals are easier to identify progress
6 interventions for Hallucinations
- Avoid referring to hallucinations as if they were real. Do not ask, “What are the voices saying to you?” Ask, “What are you hearing?”
- Do not negate the patient’s experience but offer your own perceptions and convey empathy. “I don’t hear angry voices that you hear, but that must be very frightening for you.”
- Focus on reality-based “here and now” activities, such as conversations or simple projects.
- Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accusing voices.
- Promote and guide reality testing and guide pt to interpret the hallucinations as symptoms of illness. “The voice you hear is part of your illness, and it cannot hurt you. Try to listen to me and the others you can see around you.”
- Transcranial magnetic stimulation may enhance relief from auditory hallucinations.
4 Interventions for managing delusions
- Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner.
- Avoid questioning the delusion itself
- Focus on the feelings or themes within the delusion. (Ex. If a patient believes that he is a famous leader, comment: “It would feel good to be more powerful.” If the patient believes that others intend to hurt him, comment: “It must feel frightening to believe others want to hurt you.)
- Focus on helping patient feel safe and identify triggers
Why should you not question delusions? What should you do instead?
Trying to prove the delusion is incorrect can intensify the delusion and cause patient to view staff as people who cannot be trusted
You can clarify misinterpretations of the environment and gently suggest more reality-based perspective
2 FGAs for schizophrenia
haloperidol
chloropromazine
. Why are first-generation antipsychotics used less often than second-generation antipsychotics?
Used less often due to lack of impact on negative symptoms and higher challenging side effects
What are two benefits of using first-generation antipsychotics?
Less expensive and no metabolic syndrome
What does blockage of D2 receptors in motor areas cause?
Extrapyramidal side effects
What are the 4 EPSs with FGAs
Acute dystonic reactions
Akathisia
Pseudoparkinsism
Tardive Dyskinesia
Treatment of Early EPS
Oral antiparkinsonian drugs prophylactically or when EPS develop, but these often have anticholinergic effects or abuse potential
Ex. Trihexyphenidyl (mainly), benztropine, and diphenhydramine
Treatment for Tardive Dyskinesia
valbenazine and deutetrabenazine which reduce the severity of abnormal movements in tardive dyskinesia but tardive does not go away completely
Adverse effects: sleepiness and QT prolongation.
What can you do if Tardive dyskinesia develops?
Switch to a SGA, reducing or (paradoxically) increasing FGA dosage can help too
Acute dystonic reactions
EPS rarely dangerous but cause anxiety.
Acute painful contractions of the muscles causing backward arching of the head, neck, and spine, eyes roll back
Laryngeal dystonia: could threaten airway (rare)
Akathisia
EPS
Motor restlessness that causes pacing and/or an inability to stay still or remain in one place. It can be severe and distressing to patients and can be mistaken for anxiety or agitation
tardive form persists despite treatment
Pseudoparkinsonism
Masklike face, stiff and stooped posture, shuffling gait, bradykinesia, drooling, tremor, “pill-rolling” finger movements, dysphagia or reduction in spontaneous swallowing
Tardive Dyskinesia
persistent EPS involving involuntary rhythmic movements usually after prolonged treatment and persists after the medication has been discontinued
5 points on Tardive Dyskinesia
- More common with FGAs
- Increased risk with smoking, alcohol, stimulant use
- Usually begins in oral and facial muscles and progresses to include the fingers, toes, neck, trunk, or pelvis.
- More common in women
- varies from mild to severe, and can be disfiguring or incapacitating
5 SGAs for Schizophrenia
Clozapine
Risperidone
Olanzapine
Quetiapine
Ziprasidone
FGAs vs SGAs (3)
-equally effective
-SGAs treat positive symptoms AND negative symptoms while FGAs only treat positive.
-SGAs less likely to cause tardive dyskinesia or EPS, but have metabolic syndrome
Clozapine 5 problems
severe neutropenia
myocarditis
new onset diabetes
life-threatening bowel emergencies
ketoacidosis
What is clozapine approved for that the others aren’t?
acute suicidality
4 Symptoms of metabolic syndrome
-primary problem of SGAs
a. weight gain
b. dyslipidemia
c. increased blood glucose
d. insulin resistance
Why is it important to prevent metabolic syndrome with SGAs?
It increases risk of diabetes, certain, cancers, hypertension, and cardiovascular disease
Severe neutropenia Symptoms (3)
Symptoms: reduced neutrophil counts (<500) and increased frequency and severity of infections. Any symptoms suggesting infection (e.g., sore throat, fever, malaise, body aches) should be carefully evaluated.
3 things to note about severe neutropenia
-more common with Clozapine
-Left untreated, this life-threatening condition leads to death, most commonly through bacterial infection of the blood, or septicemia.
-some groups naturally have low ANC levels and this does not make them more susceptible
2 things to note about anticholinergic toxicity
-more common with FGAs
-greatest risk for older adults and those on multiple anticholinergic drugs (antipsychotics, OTC cold/allergy meds, antiparkinson meds)
4 Symptoms of Anticholinergic Toxicity
- ANS instability
- dilated pupils
- urinary retention,
-delirium with altered mental status; evaluate anyone with worsened psychosis
Neuroleptic malignant syndrome 5 main features
-more common with FGA
Hyperpyrexia (temp > 103 F)
reduced consciousness and responsiveness
hypertension, tachycardia
autonomic dysfunction,
increased muscle tone (muscular rigidity)
5 severe complications of NMS
organ failure
rhabdomyolysis (protein in blood from muscle)
respiratory failure (big predictor of mortality)
sepsis
kidney injury
Bipolar II
Excessive activity and energy for at least four days
Psychosis is never present
Low-level and less dramatic mania
4 notes on Somatic Symptom Disorder
-often have high level of help seeking but rarely eases concerns
-often multiple symptoms and one is severe (usually pain is primary symptom and subjective)
-primary predictor of misdiagnosis is PCP’s dissatisfaction with clinical encounter
-often these individuals are hard on themselves and have limited self-compassion
5 common somatic/physical symptoms (and difference for children)
somatic/physical symptoms (head pain, back pain, chest pain, paralysis, unexplained skin rashes)
-children may have abdominal pain, headache, fatigue, nausea but don’t worry about seriousness
Somatic Symptom Disorder
focus on somatic/physical symptoms to point of excessive concern, preoccupation, and fear; used to be hypochondriasis
4 treatments for Somatic Symptom Disorder
-hypnotherapy with strong, supportive approach useful
-avoid repetitive and unnecessary testing
-CBT and medication helpful
-TCA (amitriptyline) and SSRI (fluoxetine)
5 notes on Illness Anxiety Disorder
-frequent self-scanning for signs of illness
-actual symptoms and complaints of symptoms are mild or absent
-thoughts about illness are intrusive and hard to dismiss even when patient realizes their fears are unrealistic
- may be reassurance seekers or care avoiders
-often declines mental health treatment
3 guidelines for Nursing Care with Illness Anxiety Disorder
-allow time to discuss illness concerns, but limit amount of time in favor of other topics
-emphasize and reassure patient that psychiatric care will supplement medical care; not replace it
-encourage socialization due to loneliness relation
3 treatments for Illness Anxiety Disorder
-symptomatic pain relief with NSAIDs, laxatives, complementary medicine
-SSRIs may treat anxiety
-ECT and CBT useful as well
Conversion Disorder (3)
functional neurological disorder; neurological symptoms in absence of a neurological diagnosis
-deficits in voluntary motor or sensory functions (paralysis, blindness, movement, gait disorder, numbness, paresthesia)
-emotional conflicts or stressors manifest in physical symptoms
La belle Indifference
in Conversion disorder; aspect where patients show lack of emotional concern about often dramatic symptoms; despite this providers should assume organic cause of symptoms until ruled out
2 Guidelines for Nursing Care of Conversion Disorder
-avoid direct confrontation of the conversion symptom
-provide reassurance and support for the patient’s feelings and beliefs
4 Treatments for Conversion Disorder
-hypnosis-> rapid resolution
-Narcoanalysis with amobarbital -> immediate cessation of symptoms
-body-oriented psychological therapy (use nonverbal expressive behavior to expression of emotions with change)
-PT for motor symptoms
Common Psychological Factors affecting Cardiovascular disease
MI after sudden stress preceded by loss, frustration, disappointment
Depression linked with CAD
Common Psychological Factors affecting Peptic Ulcer (via H. pylori)
Social tension, stress; after losses or menopause
Common Psychological Factors affecting Cancer
Prolonged intensive stress; feelings of depression
Common Psychological Factors affecting
Tension headache
Anxiety and depression
Common Psychological Factors affecting
Essential hypertension
Life changes; traumatic events; stressful job; seen in areas of social stress and conflict
8 Assessment guidelines for Somatic Symptom Disorder
- Assess for nature, location, onset, characteristics, and duration of the symptom(s).
- Explore past history of ACEs. (essential)
- Identify symptoms of anxiety, depression, and past trauma that may be contributing to somatic symptoms and the ability to meet basic physical and safety/security needs.
- Determine current quality of life, social support, and coping skills, including spirituality.
- Identify any secondary gain that the patient is experiencing from symptom(s).
- Explore the patient’s cognitive style and ability to communicate feelings and needs.
- Assess current psychosocial and biological needs.
- Screen for misuse of prescribed medication and substance use.
Why is assessment of f/e balance, elimination, and nutrition high priority in cases of potential Somatic Symptom Disorder?
due to complaints on GI distress, diarrhea, constipation, anorexia
How does symptom reporting differ in conversion vs somatic or illness anxiety disorder?
Conversion disorder may matter-of-factly state problems while somatic symptom disorder or illness anxiety disorder may discus in dramatic terms
What does patient communication style look like in somatic symptom disorder?
-difficulty communicating their emotional needs or feelings especially those related to anger, guilt, and dependence
-somatic symptoms may be patient’s way of communicating emotional needs
Why is therapeutic relationship vital with Somatic Symptom Disorders? (2)
1) patient is resistant to concept that no physical cause for the symptoms exists
2) patient’s tendency to go from provider to provider
6 general recommendations for Somatic Symptom Disorder
- Provide continuity of care.
- Avoid unnecessary tests and procedures.
- Provide frequent, brief, and regular office visits.
- Always conduct a physical examination.
- Avoid making disparaging comments such as “Your symptoms are all in your head.”
- Set reasonable therapeutic goals such as maintaining function despite ongoing pain.”
What is the diagnosis and outcome for the following s/s with Somatic Symptom Disorder:
Ineffective coping strategies, insufficient access of social support, insufficient problem-solving skills, inability to meet role expectations
Difficulty coping
Improved coping: Identifies ineffective coping patterns, identifies alternate coping strategies, uses support system
What is the diagnosis and outcome for the following s/s with Somatic Symptom Disorder:
Presence of secondary gains by adoption of sick role
Pain, acute or chronic
Reduced pain: Recognizes associated symptoms of pain, reports pain control
What is the diagnosis and outcome for the following s/s with Somatic Symptom Disorder:
Absence of support system, disabling condition, preoccupation with own thoughts, friends and family alienated by physical obsessions
Impaired socialization
Improved socialization: identifies support system, willing to call on others for assistance, identifies a support group
What is the diagnosis and outcome for the following s/s with Somatic Symptom Disorder:
Nonassertive behavior, exaggerates negative feedback about self, excessive seeking of reassurance, repeatedly unsuccessful in life events
Chronic low self-esteem
Improved self-esteem: Verbalizes positive regard for self, describes self as successful, strong beliefs that decisions and act
Treatment of Factitious Disorder (2)
-CBT
-no benefit from various medical interventions such as antidepressants and antipsychotics
Factitious Disorder
consciously controlled and compulsive; pretend to be ill (physical or psychiatric) to have their emotional needs met and achieve status of patient
3 notes on Factitious disorder
-dramatic fabrication or self-infliction of violence with goal of assuming sick role; unusually proper medical terminology
-often conceals true nature of their alleged illness through deception
-results in disability and immeasurable costs to the healthcare system
Malingering (3)
elated to factitious disorders; consciously motivated act of fabricating an illness or exaggerating symptoms
- Done for secondary gain (SSI, insurance fraud, prescriptions, evade military, reduce prison)
- Reports of pain are vague and hard for clinicians to prove or disprove
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Offer explanations and support during diagnostic testing.
Reduces anxiety while ruling out organic illness
What is the rationale for the following Intervention in Somatic Symptom Disorder:
After physical complaints have been investigated, avoid further reinforcement (e.g., do not take vital signs each time patient complains of palpitations).
Directs focus away from physical symptoms
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Spend time with patient at times other than when patient summons nurse to voice physical complaint.
Rewards non-illness-related behaviors and encourages repetition of desired behavior
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Observe and record frequency and intensity of somatic symptoms. (Patient or family can give information.)
Establishes a baseline and later enables evaluation of effectiveness of interventions
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Do not imply that symptoms are not real.
Acknowledges that symptoms are real to the patient
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Shift focus from somatic complaints to feelings or to neutral topics.
Conveys interest in patient as a person rather than in patient’s symptoms; reduces need to gain attention via symptoms
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Use matter-of-fact approach to patient exhibiting resistance or covert anger.
Avoids power struggles; demonstrates acceptance of anger and permits discussion of angry feelings
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Have patient direct all requests to case manager.
Reduces manipulation
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Help patient look at effect of illness behavior on others.
Encourages insight; can help improve intrafamily relationships
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Teach assertive communication.
Provides patient with a positive means of getting needs met; reduces feelings of helplessness and need for manipulation
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Show concern for patient while avoiding fostering dependency needs.
Shows respect for patient’s feelings while minimizing secondary gains from “illness”
What is the rationale for the following Intervention in Somatic Symptom Disorder:
Reinforce patient’s strengths and problem-solving abilities.
Contributes to positive self-esteem; helps patient realize that needs can be met without resorting to somatic symptoms
PTSD (definition and 3 notes)
persistent re-experiencing of a highly traumatic event (actual or threatened death or serious injury to self or others)
-can occur after any traumatic event outside range of usual experiences (includes diagnosis with life-threatening illness or treatment for serious illness)
-symptoms appear anywhere from 1 month to years after exposure
person often does not know where symptoms are coming from, so patient attributes them to present circumstances and past becomes present
4 major features of PTSD
- Re-experiencing the trauma through recurrent intrusive recollections of the event (flashbacks) or dreams about the event.
- Avoidance of stimuli associated with the trauma (activities, people, or places) –avoidance is accompanied by feelings of detachment, emptiness, and numbing.
- Persistent symptoms of increased arousal, as evidenced by irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response.
- Alterations in mood, such as chronic depression, negative appraisals, and lack of interest in previously pleasurable activities
3 outcomes for PTSD
- manages anxiety as demonstrated by the use of relaxation techniques, adequate sleep, and the ability to maintain a role or work requirements.
- enhanced self-esteem, as demonstrated by maintenance of grooming/hygiene, maintenance of eye contact, positive statements about self, and acceptance of self-limitations.
- enhanced ability to cope evidenced by decrease in physical symptoms, an ability to ask for help, and seeking info about treatment. (learns it is not their fault and not indication of weakness)
3 outcomes for PTSD
- manages anxiety as demonstrated by the use of relaxation techniques, adequate sleep, and the ability to maintain a role or work requirements.
- enhanced self-esteem, as demonstrated by maintenance of grooming/hygiene, maintenance of eye contact, positive statements about self, and acceptance of self-limitations.
- enhanced ability to cope evidenced by decrease in physical symptoms, an ability to ask for help, and seeking info about treatment. (learns it is not their fault and not indication of weakness)
General Treatment for PTSD
Primary is psychotherapy
-antidepressants used for depression, anxiety, sleep problems and concentration
Treatments for PTSD
FDA approved (2)
Off-label (5)
Not recommended (5)
(SSRIs-sertraline, paroxetine)—FDA approved
(fluoxetine, venlafaxine, nefazodone, imipramine, phenelzine)—off-label
(SGAs, citalopram, amitriptyline, topiramate, lamotrigine)—not recommended
2 things besides length of time that may differ in Acute Stress Disorder
-may have more difficulty sharing their symptoms
-more likely to experience derealization which makes person less secure in the environment (need nonrushed and reassuring approach to assessment)
Acute Stress Disorder
after exposure to highly traumatic event
-diagnosed 3 days to 1 month after the traumatic event (after 1 month resolves or becomes PTSD)
Display 8 of 14 symptoms:
-A subjective sense of numbing
-Derealization (a sense of unreality related to the environment)
- Inability to remember at least one important aspect of the event
- Intrusive distressing memories
- Recurrent distressing dreams
- Feeling as if the event is recurring
- Intense prolonged distress
- Avoidance of thoughts about the event
- Sleep disturbances
- Hypervigilance
- Irritable, angry, or aggressive behavior
- Exaggerated startle response
- Agitation or restlessness
3 treatments of Adjustment Disorder
-psychotherapy to encourage verbalization of emotions
-depressive symptoms treated with antidepressants
-anxiety symptoms treated with benzodiazepines
Adjustment Disorder (definitions, time frame, symptoms)
milder, less specific version of ASD and PTSD
-precipitated by stressful event but not as severe i.e retirement, chronic illness, breakup
-diagnosed immediately or within 3 months
-Symptoms: all forms of distress and physical complaints; role performance deficits
Complicated grieving
specific type of adjustment disorder during 12-month period after loss of loved one; includes intense yearning, preoccupation, emotional pain for deceased, with effects on sense of self and relationships
Dissociation
unconscious defense mechanism which protects individual against overwhelming anxiety through an emotional separation which results in memory, perception, and identity disturbances
-may serve protective function to decrease immediate distress of trauma (seen in children who cling to abusive caregivers
Positive and negative symptoms of Dissociative Disorders
-Positive symptoms: unwanted additions of mental activity; flashbacks
-Negative symptoms: memory problems; inability to sense or control different parts of the body
Treatments of Dissociative Disorders (2)
-no specific but medications prescribed for hyperarousal and intrusive symptoms (includes antidepressants, anxiolytics, antipsychotics)
-SUD and suicide risk are common so careful selection needed
3 Outcomes for Dissociative Disorders
Phase 1: Establishing safety, stabilization, and symptom reduction
Phase 2: Confronting, working through, and integrating traumatic memories
Phase 3: Identity integration and rehabilitation
What is the rationale for the following Intervention for Dissociative Disorders:
Provide an undemanding, simple routine.
Reduces anxiety
What is the rationale for the following Intervention for Dissociative Identity Disorders:
Ensure patient safety by providing safe, protected environment and frequent observation
Sense of bewilderment may lead to inattention to safety needs; some alters may be thrill-seeking, violent, or careless
What is the rationale for the following Intervention for Dissociative Disorders:
Confirm the identity of patient and orientation to time and place.
Supports reality and promotes ego integrity
What is the rationale for the following Intervention for Dissociative Disorders:
Encourage patient to do things for self and make decisions about routine tasks.
Enhances self-esteem by reducing sense of powerlessness and reduces secondary gain associated with dependence
What is the rationale for the following Intervention for Dissociative Disorders:
Assist with major decision making until memory returns.
Lowers stress and prevents patient from having to live with the consequences of unwise decisions
What is the rationale for the following Intervention: for Dissociative Disorders
Support patient during the exploration of feelings surrounding the stressful event.
Helps lower the defense of dissociation used by patient to block awareness of the stressful event
What is the rationale for the following Intervention: for Dissociative Disorders
Do not flood patient with data regarding past events.
Memory loss serves the purpose of preventing severe to panic levels of anxiety from overtaking and disorganizing the individual
What is the rationale for the following Intervention: for Dissociative Disorders
Provide support through empathetic listening during disclosure of painful experiences.
Can be healing, while minimizing feelings of isolation
What is the rationale for the following Intervention: for Dissociative Disorders
Teach patient grounding techniques, such as taking a shower, deep breathing, touching fabric on chair, exercising, or stomping feet.
Helps to keep the person in the present and decrease dissociation
What is the rationale for the following Intervention: for Dissociative Disorders
Accept patient’s expression of negative feelings.
Conveys permission to have negative or unacceptable feelings
What is the rationale for the following Intervention: for Dissociative Disorders
If patient does not remember significant others, work with involved parties to reestablish relationships.
Helps patient experience satisfaction and relieves sense of isolation
Dissociative Identity Disorder (definition and 3 notes)
presence of two or more distinct personality states that recurrently take control of behavior which take shifts ranging from minutes to months (usually short)
- Transitions may happen dramatically or be barely noticeable; often during times of stress
- Often misdiagnosed as schizophrenic due to infrequency of episodes (minutes to months but shorter shifts common)
- Extremely high suicide risk and difficult to assess due to presence of multiple personalities
Alter vs primary personality in Dissociative Identity Disorder
o Alternate personality (alter) fixated on trauma but has its own pattern of perception, relations, and thinking of self and environment (may behave as different sex, race, religion, intelligence, EEG changes); often believe they are separate and unaffected by other’s actions (cognitive distortion)
o Primary is usually moralistic, pleasure seeking, nonconforming and not aware of alters so confused by lost time and unexplained events; blocks assess to traumatic memories
Dissociative Amnesia (definition and 2 notes)
Dissociative Amnesia: inability to recall important personal info; localized or selective; often trauma or stressful events
-too pervasive to be explained by ordinary forgetfulness
-autobiographical memory available but inaccessible (pt with generalized amnesia would be unable to recall entire life)
Dissociative fugue (definition and 3 notes)
subset of dissociative amnesia but less dysfunctional than amnesia; sudden, unexpected travel away from customary locale and inability to recall one’s identity and info about some or all of the past
-may assume whole new identity
-often live simple, uncomplicated lives in fugue state
-may remember former identity in a few months and become amnesiac to time spent in fugue state
4 notes on treatment for Dissociative Amnesia
-no specific
-benzos for anxiety short-term and IV benzos in acute may cause dramatic memory retrieval
-dissociative amnesia usually resolves spontaneously after resolution of stressful situation or when person exposed to cues from past
-hypnosis may be used for regression
3 notes on Depersonalization/Derealization Disorder Treatment
-usually go away without treatment
-comorbidities treated with antianxiety, antidepressants
-repetitive transcranial magnetic stimulation has been used to treat successfully
Depersonalization/Derealization Disorder (definition and two notes
persistent or recurrent episodes of depersonalization and derealization
-mostly transient episodes; but may be constant
-severe stress and illegal drug use precipitate an episode
Depersonalization vs derealization
- Depersonalization: an extremely uncomfortable feeling of being an observer of one’s own body or mental processes.; feelings of unreality, detachment, or unfamiliarity
- Derealization: recurring feeling that one’s surroundings are unreal or distant.
o Visual ( blurriness, changes in the visual field, object sizes) and Auditory distortions(muting or heightening of sound)
