Exam 3 Flashcards
Bipolar I Disorder
Most severe form
Highest mortality rate
At least 1 manic episode
Bipolar II Disorder
At least 1 hypomanic episode
At least 1 major depressive episode
Cyclothymic Disorder
Alternate with symptoms of mild to moderate depression for at least 2 years
Rapid cycling possible
Epidemiology of Bipolar Disorder
Up to 21% of patients with major depression may actually have undiagnosed bipolar disorder
Bipolar I–more common in males
Bipolar II–more common in females
Cyclothymia–usually begins in adolescence or early adulthood
Risk Factors for Bipolar Disorder
Biological factors: genetic, neurobiological, neuroendocrine (hypothyroidism)
Psychological factors
Environmental factors
Assessment for Bipolar Disorder
Mood
Behavior
Thought processes and speech patterns
Cognitive functioning (decreased attention span, distracted easily)
Speech patterns (pressured speech, circumstantial speech, tangential speech, loose associations, flight of ideas, clang associations)
Thought content (grandiose delusions, persecutory delusions)
Self-Assessment for Bipolar Disorder
Manic patient (manipulative, demanding, splitting)
Staff member actions (frequent staff meetings to deal with patient behaviors and staff response, set limits consistently)
Assessment Guidelines for Bipolar Disorder
Danger to self or others Need for protection from uninhibited behaviors Need for hospitalization Medical status Coexisting medical conditions Family's understanding
Planning for Bipolar Disorder
Medical stabilization
Maintaining safety
Nursing care (managing medications, decreasing physical activity, increasing food and fluid intake, ensuring sleep)
Planning for Acute Manic Phase
Medical stabilization
Maintaining safety
In-hospital nursing care
Seclusion, restraint, or ECT may be considered
Implementation for Depressive Episodes
Hospitalization for harmful thoughts
Medication concerns about bringing on a manic phase
Implementation for Manic Episodes
Hospitalization for acute mania
Communicating strategies and challenges
Lithium Carbonate
Mood stabilizer; decreased mania
Therapeutic level: 0.8-1.4
Maintenance blood level: 0.4-1.3
Toxic blood level: 1.5 and above
Takes 10-21 days to get levels stabilized
Give with meals, drink adequate fluids, monitor for weight gain, check renal and thyroid function before giving and monitor those levels throughout due to nephrotoxicity/thyroid toxicity
Contraindications: renal disease, thyroid disorders, brain injury
Lithium Toxicity
- 5-2.0: mental confusion/sedation, poor coordination/coarse tremors, GI distress
- 0-2.5: tinnitus/blurred vision/ataxia, slurred speech/seizures/polyuria, hypotension
Level > 2.5: coma, death
Anticonvulsant Mood Stabilizers
Valproate (Depakote)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Other Treatments for Bipolar
ECT Teamwork and safety Seclusion protocol Support groups Health teaching and health promotion
Persistent Depressive Disorder
Formerly known as dysthymia
Low-level depressive feelings through most of each day, for the majority of days
Two or more of the following: decreased appetite, overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, hopelessness
Premenstrual Dysphoric Disorders
Symptom cluster in last week prior to onset of a woman’s period; include mood swings, irritability, depression, anxiety, feeling overwhelmed, difficulty concentrating
Symptoms decrease significantly or disappear with the onset of menstruation
Major Depressive Disorder
Five or more of the following in a 2 week period: weight loss, appetite changes, sleep disturbances, fatigue, worthlessness or guilt, loss of ability to concentrate, recurrent thoughts of death
PLUS depressed mood or loss of interest or pleasure (anhedonia)
Persistent for 2 weeks to 6 months
Lasts more than 2 years
Recurrent episodes common
Epidemiology of Depression
Leading cause of disability in the US
Comorbidities include schizophrenia, personality disorders, eating disorders
Etiology of Depression
Biological Factors: genetic, biochemical, alterations in hormonal regulation, inflammatory process
Psychological factors: cognitive theory, learned helplessness
Assessment of Depression
Depressed mood and anhedonia Anergia Anxiety Psychomotor agitation or retardation Vegetative sides Chronic pain
Depression Recovery Model
Focus on patient’s strengths
Treatment goals mutually developed
Based on patient’s personal needs and values
Planning geared towards patient’s phase of depression, particular symptoms, personal goals
Phases of Depression
Acute Phase (6-12 weeks)
Continuation Phase (4-9 months)
Maintenance Phase (1 year or more)
How to Choose an Antidepressant
Symptom profile of the patient Side-effect profile Ease of administration History of past response Safety and medical considerations
Antidepressants
SSRIs (first-line therapy, rare risk of serotonin syndrome)
SNRIs
Tricyclic Antidepressants (anticholinergic adverse reactions)
MAOIs (effective for unconventional depression)
Other Treatments for Depression
ECT
TMS
Vagus nerve stimulation
Deep brain stimulation
Light therapy
St. John’s Wort
Exercise
Electroconvulsive Therapy
The most effective depression treatment; also used for psychotic illnesses
Used for lengthy depression, delusional depression, schizophrenia with catatonia
Transcranial Magnetic Stimulation
Noninvasive
Uses MRI-strength magnetic pulses to stimulate focal areas of the cerebral cortex
Presence of metal is only contraindication
Adverse Reactions to TMS
Headache and lightheadedness
No neurological deficits or memory problems, seizures rarely, scalp tingling, discomfort
Vagus Nerve Stimulation
Originally used to treat epilepsy
Decreases seizures and improves mood
Electrical stimulation boosts the level of neurotransmitters
Side Effects of Vagus Nerve Stimulation
Voice alteration
Neck pain, cough, paresthesia, dyspnea
Deep Brain Stimulation
Surgically implanted electrodes in the brain
Stimulates those regions identified as underactive in depression
More invasive than VNS
Light Therapy
First-line treatment for SAD
Efficacy due to influence of light on melatonin
Effective as medication for SAD
Negative effects include headache and jitteriness
St. John’s Wort
Flower processed into tea or tablets
Thought to increase serotonin, norepinephrine, anti-dopamine in the brain
Useful in mild to moderate depression
Trauma-Related Disorders in Children
Posttraumatic stress disorder in preschool children
Reactive attachment disorder
Disinhibited social engagement disorder
Comorbidities of Trauma-Related Disorders in Children
Learning disorders
Increased stress
Biological Factors of Trauma-Related Disorders in Children
Genetic: how individuals react to trauma
Neurobiological: trauma dysregulates neural pathways that integrate emotional regulation and arousal; triggers hyperaroused state leading to dissociation; polyvagal theory
Psychological factors: attachment theory
Environmental factors: dependence on adults and systems; external factors that support stress
Intervention Stages for Trauma-Related Disorders in Children
Stage 1: provide safety and stabilization
Stage 2: reduce arousal and regulate emotion through symptom reduction
Stage 3: catch up on developmental and social skills; develop a value system
Interventions for Child with PTSD
Establish trust and safety
Use developmentally appropriate language
Teach relaxation techniques
Use art and play to promote expression of feelings
Involve caretakers in 1:1s, unless they are the cause of trauma
Educate child and caretakers about grief process
Assist caregivers in resolving personal distress
Posttraumatic Stress Disorder
Re-experiencing of the trauma
Avoidance of stimuli associated with trauma
Persistent symptoms of increased arousal
Alterations in mood
Acute Stress Disorder
Immediately after a highly traumatic event
Symptoms persist for 3 days
Diagnosis made within month
After 1 month: resolution or becomes PTSD
Diagnosis of Acute Stress Disorder
Alterations in concentration
Anger
Dissociative amnesia
Headache
Irritability
Nightmares
Implementation for Acute Stress Disorder
Establish therapeutic relationship
Assist to problem solve
Connect person to supports
Collaborate for coordination of care
Ensure and maintain safety
Refer to a licensed mental health provider
Monitor response and/or adherence to treatment
Adjustment Disorder
Trauma-related disorder in adults
Precipitated by stressful events
Debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning
Responses to stressful event may include combinations of depression, anxiety, and conduct disturbances
Dissociative Disorders
Occur after significant adverse experiences/trauma
Individuals respond to stress with severe interruption of consciousness
Unconscious defense mechanism
Protects individual against overwhelming anxiety through emotional separation
Depersonalization Disorder
Focus on self
Derealization Disorder
Focus on outside world
Dissociative Amnesia
Inability to recall important personal information
Often of traumatic or stressful nature
Dissociative fatigue
Dissociative Identity Disorder
Presence of two or more distinct personality states
Each alternate personality has own pattern of perceiving, relating to, and thinking about the self and environment
Dissociative Disorders Assessment
History
Moods
Impacts on patient and family
Suicide risk
Self-assessment
Dissociative Disorders Planning
Phase 1: establishing safety, stabilization, and symptom reduction
Phase 2: confronting, working through, and integrating traumatic memories
Phase 3: identity integration and rehabilitation
Oppositional Defiant Disorder
Angry and irritable mood
Defiant and vindictive behavior
Experience social difficulties, conflicts with authority figures, academic problems
Risk Factors for Oppositional Defiant Disorder
Genetic component
Numerous neurobiological causes identified
Family dysfunction can play a role
Intermittent Explosive Disorder
Inability to control aggressive impulses
Adults 18 years or older
Leads to problems with interpersonal relationships, occupational difficulties, criminal difficulties
Comorbidities of Intermittent Explosive Disorder
Depressive, anxiety, and substance use disorders
Antisocial and borderline personality disorders
Risk Factors for Intermittent Explosive Disorder
Neurobiological abnormalities
Conflict or violence in family of origin
Conduct Disorder
Behavior is usually abnormally aggressive
Rights of others are violated and societal norms or rules are disregarded; lack of remorse
Complications of Conduct Disorder
Academic failure
School suspensions and dropouts
Juvenile delinquency
Drug and alcohol abuse
Juvenile court involvement
Personality Disorders
Cluster A (Eccentric): paranoid, schizoid, schizotypal
Cluster B (Erratic): borderline, narcissistic, histrionic, antisocial
Cluster C (Anxious): avoidant, dependent, obsessive-compulsive
Paranoid Personality Disorder
Prevalence: 2% to 4%
Characteristics: may be apparent in childhood, social anxiety in childhood, jealous and controlling as adults, unwillingness to forgive and projection of feelings
Treatment of Paranoid Personality Disorder
Counteract mistrust by adhering to schedules, avoiding being overly friendly, and projecting a neutral but kind affect
Psychotherapy versus group therapy
Short-term antidepressants
Schizoid Personality Disorder
Prevalence: nearly 5% of population
Characteristics: symptoms appear in childhood/adolescence, loners, poor academic performance, increased prevalence of disordered family life, avoid close relationships, depersonalization
Treatment of Schizoid Personality Disorder
Avoid being too nice or friendly, do not try to increase socialization, assess for symptoms the patient is reluctant to discuss, protect against group’s ridicule
Treatment: psychotherapy, group therapy, antidepressants
Schizotypal Personality Disorder
Prevalence: varies from 0.64 to 4.6% of population
Characteristics: severe social and interpersonal deficits, anxiety in social situations, rambling conversations, paranoia, suspiciousness, anxiety, distrust, intermittent episodes of hallucinations, can be made aware of their own odd beliefs, may be vulnerable to involvement with cults
Treatment of Schizotypal Personality Disorder
Respect patient’s need for social isolation
Be aware of and intervene appropriately with patient’s suspiciousness
Perform careful diagnostic assessment for symptoms that may need intervention
Withhold judgment or ridicule
Psychotherapy
Low-dose antipsychotics
Histrionic Personality Disorder
Prevalence: nearly 2% of population
Characteristics: excitable, dramatic, high functioning, bold external behaviors, limited ability to develop meaningful relationships, attention-seeking, self-centered, excessive emotions, may be provocative, no insight into disorder or role in ruining relationship
Treatment for Histrionic Personality Disorder
Psychotherapy is treatment of choice
Know that seductive behavior is a response to stress
Keep interactions professional and ignore flirtations
Model concrete language
Help patient clarify inner feelings
Teach and role-model assertiveness
Narcissistic Personality Disorder
Prevalence: 0 to 6%
Characteristics: feelings of entitlement, exaggerated self-importance, tendency to exploit others, weak self-esteem and hypersensitivity to criticism, constant need for admiration, less functional impairment
Treatment for Narcissistic Personality Disorder
Remain neutral
Avoid power struggles or becoming defensive
Role model empathy
Difficult to treat; patients not likely to seek help
Cognitive-behavioral therapy
Group therapy
Lithium for mood swings
Antisocial Personality Disorder
Prevalence: 1.1%
Characteristics: antagonistic behaviors, disinhibited behaviors, profound lack of empathy, absence of remorse or guilt
Assessment of Antisocial Personality Disorder
Patients tend to not answer assessments honestly
Self-assessment
Clinical Picture of Borderline Personality Disorder
Severe impairments in functioning
Emotional lability
Impulsivity
Self-destructive behaviors
Antagonism
Splitting: inability to view both positive and negative aspects of others as part of a whole
Borderline Personality Disorder
Prevalence: 1.6%
10% suicide and mortality rate
85% of BPD patients have another mental illness
High genetic association
Separation-individuation factors
Assessment for Borderline Personality Disorder
Semi-structured interview
Use of MMPI
Self-assessment
Treatment of Borderline Personality Disorder
Psychotropics geared toward symptom relief
CBT
Dialectical behavior therapy
Schema-focused therapy
Avoidant Personality Disorder
Prevalence: 2.4%
Characteristics: low self-esteem, shyness that increases with age, feelings of inferiority, reluctance to engage with new people, subject to depression, preoccupied with rejection and failure
Dependent Personality Disorder
Prevalence: 0.5%
Characteristics: high need to be taken care of, submissiveness, fears of separation and abandonment, manipulating others to take responsibilities, intense anxiety when left alone
Treatment of Dependent Personality Disorder
Help address current stressors
Set limits
Be aware of strong countertransference
Psychotherapy
Obsessive-Compulsive Disorder
Prevalence: 2 to 8%
Characteristics: inflexible standards for others and self, constant rehearsal of social responses, excessive goal-seeking, strict standards that interfere with project completion, unhealthy focus on perfection
Treatment for Obsessive-Compulsive Disorder
Patients tend to seek help for anxiety and depression
Group and behavioral therapy
Clomipramine or fluoxetine for obsessions, anxiety, and depression
