mental health 1 Flashcards
Pica
Consistent eating of nonfood, nonnutritive substances for a month or more, usually early childhood, sometimes part of an intellectual disability. Can occur during pregnancy but not elevated to a diagnosis unless the severity poses medical risks.
Rumination Disorder
Undigested food being regurgitated – then re-chewed or re-swallowed or spit out. Can be fatal in infants. Teens might hide it with fake coughing.
Avoidant/Restrictive Food Disorder
Often due to sensory disgust of food characteristics and leads to failure to thrive. Not an eating disorder.
Anorexia Nervosa (AN)
Morbid fear of weight gain with failure to recognize low BMI, severity defined by BMI. Subtypes (1) Restricting type (2) Binge/Purge type
Bulimia Nervosa (BN)
Distress experienced: severe body dissatisfaction, severity defined by frequency of binge eating and compensatory behavior cycles.
Binge-Eating Disorder (BE)
Distress (self-disgust, guilt, embarrassment, depressed, physically uncomfortable) due to out of control binge-eating, severity defined by frequency of binge eating.
Anorexia Nervosa Severity Guide
Severity defined by BMI (FYI healthy body weight aprox. 18.5-25)
Mild: >/= 17kg/m2
Mod: 16 to 16.99
Severe: 15-15.99
Extreme: < 15
Restricting type AN
no binge-eating or purging, might fast or exercise excessively -not counted as “purge” behavior
Binge-eating/Purge type AN
some binge-eating or purging, example: self-induced vomiting after eating a small meal
Bulimia Nervosa Severity Guide
Mild: binge-eating with 1-3 episodes of compensatory behavior per week
Mod: binge-eating with 4-7 episodes
Severe: binge-eating with 8-13 episodes
Extreme: binge-eating with 14 or more episodes
Binge Eating Definition
consuming a large quantity (more than what most people would eat) of food over 2 hours or more
Compensatory behaviors
exercise, fasting, and purging (self-induced vomiting – most common, misuse: laxative/enemas, diuretics, thyroid hormone, omit needed insulin), some texts mix-up terms
Binge-Eating Disorder
No purging behavior, severity defined by frequency of binge-eating.
Mild: binge-eating 1-3 episodes per week
Mod: binge-eating 4-7 episodes
Severe: binge-eating 8-13 episodes
Extreme: binge-eating 14 or more episodes
Anorexia/Starvation S/S
Low efficacy for antidepressants due to lack of endocrine function/hormones/enzyme, and lack of tryptophan intake.
Osteopenia and osteoporosis from ↓ Calcium
Cold and weak from ↓ Thyroid function and decreased VS
Amenorrhea due to lack of hormones
Lanugo (theory – increase warmth)
Hypercarotenemia – orange hue to skin
Excessive exercise
Constipation
Watch for refeeding edema (increased heart rate ….)
EMERGENCIES Below 75% ideal body weight, rapid weight loss, Temp < 96.8, HR < 40, Systolic BP < 70 mm Hg
Purge Bulimia Nervosa
self-induced vomiting is most common, also use of laxatives, diuretics, ipecac, skipping insulin, and thyroid hormone abuse. Might use purge markers such as red smarties before binge
Russel’s sign
calluses on back of hand from teeth grazing hand during self-induced vomiting
Bulimia Nervosa s/s
Russel’s sign, enlarged parotid glands (from high serum amylase), dental caries (from acidic emesis)
Emergencies can include: Potassium < 3 mEq/L, severe dehydration, cardiac arrhythmias, metabolic alkalosis (from increased serum bicarbonate) r/t vomiting, metabolic acidosis (decreased serum bicarbonate) r/t laxatives
High comorbidity: 94% psychiatric issues, 30% substance abuse issues, self-injurious behavior and other impulsive behaviors
Cognitive Distortions s/s
Overgeneralizations - single negative event is equated with never ending negative situation: “no one will like me if I am fat.”
All-or-nothing thinking - also known as black or white thinking: “I can either have all the cake or none at all.”
Catastrophizing – exaggerating the importance of an event leading to an intolerable situation: “If I gain weight my life will be meaningless.”
Personalization - “Everyone is talking about how fat I am.”
Emotional reasoning – mixing up feelings with facts: “I feel puffed up so I know everyone sees me as gross and fat.”
Long Term Goals: Eating Disorders
AN: - Weight gain is the priority. Medical Hospitalization – restore 75% ideal body weight before discharge
Acute Inpatient psych/Eating Disorder Rehab Center – 85%
Partial Hospitalization/OP 90% or more
BN: Interrupting the binge-eating/purging cycles is the priority
Reduce binge/purge cycle
Unless the binge/purge BX causes a medical emergency that becomes the priority
In reality address both weight gain and interrupting the cycles
BE: Reducing the binge-eating episodes is the priority, may also be a bariatric patient
Therapeutic Relationship: Eating Disorders
do not blame the client
“Help rejecting” can elicit strong countertransference
The nurse’s own relationship with their body and with food needs to be healthy.
Be careful to NOT take a guard or parental approach even when the client is childlike in their behavior
Resistance to change is pervasive and strong, it is part of the illness
Express empathy
AN Interventions
Supervise meals- provide low stress environment while watching for food avoidance. Record how much was eaten.
Locked bathroom one hour after meals
Weigh client 3 times a week – gown only, in morning before breakfast after voiding (watch for water loading or hiding heavy items before weight-in
Monitoring VS
Groups and one-to-one talks with nurse: to challenge cognitive distortions, insight into vicious cycles in eating disorders, and providing education on healthy eating
BN Interventions
No exercise until binge/purge cycle is more controlled
Acknowledge strong emotions that surface when binge or purge behaviors are interrupted and help client to use healthy coping skills
Help the client make the connections between BN and avoiding life problems
Encourage discussion of the common distress is related to body shame or guilt over body size and shape (FYI – clients with binge eating DO experience distress over out of control binge eating)
Watch for hypokalemia
Watch for risk behaviors and substance abuse behaviors that are more common in individuals with BN versus AN
General Adaptation Syndrome
Alarm reaction stage
Fight, flight, or freeze response starts to prepare for defense
-Adrenal glands – epinephrine and norepinephrine
-Liver converts glycogen stores to glucose
Resistance stage
-blood shunted away from areas such as the GI system to lungs and heart to deliver more oxygen to muscles
Exhaustion stage
-Continual arousal of defense systems and emotions
-Body stores depleted
-Low resistance to disease
Mild Level of Anxiety
Mild - special attention:
Increased sensory stimulation
Motivational, increased learning, effective problem solving
“Butterflies”
Moderate Level of Anxiety
Moderate - something definitely wrong:
Focus on one task only
Hard to make connections between concepts – hard to learn on own
Example – nursing students learning new skill anxiety with prompts
Increased pulse, dry mouth, speech rate and pitch, urination, irritation
Nurse able to redirect the patient
Severe Level of Anxiety
Severe - trouble thinking and reasoning:
Reduced perceptual field
Can focus on one detail only or scattered details
Cannot complete tasks or respond to redirection
Tightened muscles, ↑ VS, N&V, restless, irritable, angry, crying, vertigo
Panic Level of Anxiety
Panic: fight, flight, or freeze response:
Increased vital signs and behaviors, dilated pupils, bolting or freezing
Self-focused, cannot talk, cannot process stimuli, may not even see danger
Irrational, distorted perceptions, may experiencing hallucinations/delusions
May be suicidal
Anxiety Defense Mechanisms
Compensation, conversion, denial, displacement, dissociation, identification, intellectualization, projection, rationalization, reaction formation, regression, repression, splitting, sublimation, suppression, undoing
General Criteria for Mental Health Disorders
The symptoms cause clinical distress or significant inability/impairment to work, complete education, perform usual roles, socialize or function
- The symptoms are not due to substance use/withdrawal or other medical conditions – standard of practices:
Rule out medical issues or physical issues
Rule out other psychiatric issues that may better explain the signs and symptoms
Separation Anxiety
Excessive distress when anticipating or experiencing separation
Excessive worry about losing significant other, accidents, kidnapping, refusal to sleep over or go out, nightmares, somatic issues
Specific Phobic
Marked and out or proportion fear towards a situation or object, must be 6 months or more. Interferes with functions of daily life, avoids situation or object
Social Anxiety
Similar to a specific phobia
Distress caused by possible scrutiny of others and social interactions
Panic Disorder
Recurrent and unexpected panic “attacks” followed by (for at least a month)
Persistent worry of another attack OR avoidance of situations that might trigger an attack
Agoraphobia
Similar to a specific phobia
Fear 2 of the following 5
Using public transportation
Open spaces
Enclosed spaces
Standing in a crowd or line
Being outside the home alone
Generalized Anxiety Disorder (GAD)
Over half the time in the last 6 months:
Excessive anxiety and worry
and with 3 or more of the following
Restlessness/on edge
Easily fatigued
Decreased concentration
Increased irritability
Muscle tension
Sleep disturbance
Obsessive-Compulsive Disorder (OCD)
Obsessions are unwanted, intrusive, repetitive thoughts or images. Thoughts lead to intense fear or distress
Compulsions are repetitive behaviors or alternative thoughts, used to decrease OR PREVENT the obsessive thoughts, fear, or distress
Experience one or both for at least an hour a day
Body Dysmorphic
Preoccupied with a perceived physical body defect
Excessive observation, grooming, other BX targeting the “defect”
Example – excessively discussing the differences between their nose and your nose
Hoarding
Cannot part with possessions regardless of actual value
Worries that they will need the item in the future
Clutter compromises use of home OR it is orderly but only due to helpers
Trichotillomania
Recurrent pulling out of hair
Results in hair loss
Repeated attempts by patient to stop pulling out hair
Common areas: scalp, eyebrows, eyelids
Excoriation
Skin picking resulting in lesions
Most common – face, arms, hands – using fingernails
Can pick healthy skin or skin with a irregularity
Disruptive Mood Dysregulation DO
temper outbursts in younger folk
Major Depressive DO
Includes MDD with seasonal pattern (old term “Seasonal Affective DO”)
Persistent Depressive DO (Dysthymia)
milder depression than MDD
Premenstrual Dysphoric DO
S/S week before menses, improves a few days after menses
Bipolar I DO
has had mania or hospitalization or psychosis
Bipolar II DO
less severe than Bipolar I DO (no psychosis, never mania, never need for hospitalization)
Cyclothymic DO
less severe than Bipolar II
Depression Assessment
Always assess if the client has:
SI, psychosis (hallucinations, delusions, disorganized brain), anxiety (50-60% will have anxiety)
Comorbidity Concern: Bipolar and Depression
we do not want them to flip into a drug induced mania caused by using only an antidepressant, people with bipolar disorders need a mood stabilizer
HAM-D 17 items to score
Depressed mood, Guilt feelings, suicide, insomnia (early, middle and late), work and activities, retardation - psychomotor, agitation, anxiety, somatic symptoms, sexual dysfunction, hypochondria, unintended weight loss, insight
HAM-D Scoring
0 - 7 = Normal
8 - 13 = Mild Depression
14-18 = Moderate Depression
19 - 22 = Severe Depression
>23 = Very Severe Depression
ECT “Electroconvulsive Therapy”
check BM
High efficacy for MDD
Highly regulated but relatively safe
Temporary memory loss is frequent
Done under general anesthesia, 3 x week for 12 treatments, then monthly
Bipolar II DO bumped up to Bipolar I if the client
Has, or has had, full blown mania in their mood cycles for a period of a week or more
Has, or has had, periods of psychosis
Has, or has had, S&S severe enough to require acute psychiatric hospitalization
Bipolar I High Risk Behaviors
spending sprees, bad business investments, indiscriminate sex, gambling, stealing
Five Steps in the SAFE-T approach
Identify Risk Factors
Identify Protective Factors
Assess Suicidal Ideation (SI)
Determine Risk Level and Appropriate Interventions
Document
Stages of Change and Addiction
Pre-contemplation (‘denial’)
Contemplation
Preparation
Action
Maintenance
Relapse
Assess the stage to focus on the best intervention for that stage
Negative Symptoms Schizo
Affective blunting - minimal emotional response (but has feelings)
Avolition - decrease in motivation/initiative/spontaneity.
Alogia -decreased (old term: poverty) of speech and thought
Anergia - lack of energy
Anhedonia - lack or loss of pleasure in pleasurable activities
Anosognosia
NOT DENIAL(this is a symptom, not a defense mechanism or coping skill, and
usually leads to decreased interest in taking prescribed medication).
Anosognosia negatively correlates with and predicts prognosis.
Asociality - lack of interest in social interactions
Attention Impairment – not able to focus on important details
Catatonia
Waxy flexibility – slow even resistance and then a possible “melt” when clinician moves pts limbs
Catalepsy – pt. maintains the position after the clinician has moved pt. limbs (even if it is against gravity)
Posturing (active) pt. demonstrates spontaneous posture and holds it, even if against gravity
Echopraxia (mimic movement of others)
Stereotypy (repetitive non-goal bx)
Mutism/Stupor (non-reactive)
Staring
