Mental Health Flashcards
Symptoms of depression: emotions
Sadness Anxiety Guilty Anger Mood swings Feelings of helplessness or hopelessness Irritability
Symptoms of depression: thoughts
Frequent self-criticism Impaired memory & concentration Indecisiveness Confusion Thoughts of death and suicide
Symptoms of depression: behavior
Crying Withdrawal from others Neglect responsibilities Changes in personal appearance Moving more slowly Being agitated or unable to settle
Symptoms of depression: physical
Chronic fatigue Lack of energy Sleeping too much or too little Weight gain or loss Loss of motivation Substance abuse Unexplained aches and pains
Psychosis
Loss of reality
Poor judgement
Range from severe mania and hypomania to severe melancholy and mild melancholy with euthymia being normal
8 Major Depressive Disorders (not attribute to recent losses and stressors)
SIGECAPS
Sleep disorders (increased, decreased, not restful)
Interest deficit (anhedonia)
Guilt (worthlessness, hopelessness, regret)
Energy Deficit (restless, anxiety)
Concentration deficit (difficulty learning, remembering)
Appetite disorder (increased or decreased)
Psychomotor (change to either slowed or agitation)
Suicidality (ideation-passive or active)
Other depressive disorders
Disruptive mood dysregulation disorder (<18 years old)
Persistent depressive disorder (2 years old and older)
Premenstrual dysphoric disorder
Post-partum depressive disorder
Depressive disorder associated with another medical condition
Diathesis-stress model
Predisposed then triggered by life stressors and negative events (financial, social, employment, relationships….hopelessness)
Genetic
Tends to run in the family
Inflammatory process
Reduced blood flow and abnormal metabolism in the prefrontal aspect of the cerebral cortex; decrease in neuro-protective metabolites and neuroblasts; increase in neurodestructive metabolites reduces connections to prefrontal regions and increased in striatum, basal ganglia.
Neurotransmitter changes
Basal ganglia connections with the cortex through separate, parallel pathway loops controlling motor (movement), associative (cognitive), and limbic (emotional) => reward, beh, learning, mood.
Dysfunction in any of these circuits can give rise to movement disorders, behavioral, cognitive abnormalities, and mood changes
Assess affect
Blunted, flat, agitation, elation, congruent, or incongruent, etc.
Assess thought process
Slowed, ruminating, tangential, racy, etc.
Assess mood
Sad, euphoric, etc.
Assess feelings
Hopelessness, despair, frustrated, etc.
Assess physical behavior
Withdrawn, restless, etc.
Assess communication
Mute, guarded, poverty of speech, pressured speech, etc.
Assess religious beliefs and spirituality
Punishment, just, comfort, etc.
Assess judgement
Impulsivity, realistic, distorted, etc.
Assess perceptions
Reality based, suspicious, delusional, psychosis, etc.
Components of the nursing process
Prior functional level and patterns (how stressors are dealt with, etc.)
Suicidal ideation (last, present, prior attempts? When? How?)
Recent changes (e.g., financial, losses, etc.)
Medications (e.g., what? When started?)
Age & relationship considerations (G&D, risky ages?)
Cultural considerations- protective (African Americans, Asians, RC)
Self assessment (Transference & countertransference)
Boundaries (individuality vs feeling what others feel)
Goal of treatment
Complete remission of depression with full functional recovery and the development of resilience.
Step 0
Taper and cease any agents that can potentially lower mood
Institute sleep hygiene
Implement appropriate lifestyle changes (e.g., smoking cessation, adopt regular exercise and achieve a healthy diet)
Address substance misuse if relevant
Step 1: generic psychosocial interventions
Psycho education (family, friends, caregivers)
Low intensity interventions (e.g., internet based education)
Formal support groups, community groups
Employment, housing
Step 1: psychological therapy (formulation-based intervention)
Cognitive behavioral therapy (CBT)
Interpersonal therapy
Acceptance and commitment therapy
Mindfulness-based cognitive therapy
Step 1: pharmacotherapy (formulation-based intervention)
First line: SSRIs, SNRIs, NaSSAs, NDRIs, NARIs; melatonin agonist, serotonin modulator
Second line: Tricyclics antidepressants, MAOIs
Step 2
Combine pharmacotherapy and psychological therapy
Increase dose of antidepressant medication
Augment antidepressant medication with lithium and/or antipsychotic medication
Combine antidepressants
rTMS (if available)
Step 3
ECT
What best describes the DSM-5?
It is a medical psychiatric assessment system
What is true regarding cultures and mental health disorders?
Culture may cause variations in symptoms for each clinical disorder
Correct ways to document and report on a patient
The PT in room 19 who is experiencing mania
Incorrect ways to document and report on a patient
The PT in room 19 who is manic
The manic PT in room 19
The maniac in room 19
What should the nurse do to make sure the counter-transference doesn’t interfere with the focus of the relationship?
Recognize their own feelings evoked due to PT behaviors
Erikson’s theory helps guide nurses in the care of PTs by identifying the
Expected tasks and milestones based on age
Which neurotransmitter is most notable for producing a “calming” effect?
GABA
Which of these are part of the therapeutic “mileau” in an inpatient psychiatric unit?
The unit’s environment
Scheduled group sessions and activities
The daily routine and policies
A nurse manager overhears a comment that necessitates immediate intervention to protect the dignity of the PT. This includes statements such as:
My PT is the schizophrenic
My PT is the schizo one
Maslow’s theory provides nurses with
A foundation for holistic assessment
Behavioral therapies are based on the premise that
Behavior is learned and can be changed
What is true about the evolution of mental illness?
Mental illness changes with culture, time in history, political systems, and groups defining it.
What is part of the care that a MH nurse provides?
Writing a plan of care for a diagnosis of ineffective coping
Helping a family express their feelings to one another
What is true of nurses who specialize in psychiatric-mental health nursing?
They use specialized skills to care for PTs
This region of the brain is most responsible for decision-making, concentration, and the attention required to complete complex tasks
The frontal lobe
Freud’s theory of personality development focuses on anxiety produced through ongoing conflicts between
The id, ego, and superego
The “therapeutic use of self” refers to what?
The nurse’s role
A cognitive behavioral therapist would help a PT shift from statements like “I made a horrible mistake cuz I’m so stupid” to
“I’m human and made a bad decision”
Delusions
Fixed, false beliefs, cannot be corrected by logic and are not consistent with culture and education of the PT
Hallucinations
False sensory perception experienced without real external stimulus. They are usually experienced as originated in the outside world, not within the mind as imagination.
Illusions
Misperception of real external stimulus. Most likely to occur when general level of sensory stimulation (consciousness) is reduced.
Dopamine (DA)
Receptors: D1, D2, D3, D4, D5
Involved in fine muscle movement, integration of emotions and thoughts, decision-making, and stimulates the hypothalamus to release hormones (sex, thyroid, adrenal)
Decrease causes: Parkinson’s, Depression
Increase causes: Schizophrenia, Mania
Norepinephrine (NE; noradrenaline)
Receptors: Alpha1, Alpha2, Beta1, Beta2
Level in brain affects mood, attention, and arousal; stimulates the SNS for “fight or flight” in response to stress
Decrease causes: Depression
Increase causes: Mania, Anxiety states, Schizophrenia
Serotonin (5-HT)
Receptors: 5-HT1, 5-HT2, 5-HT3, 5-HT4, others
Plays a role in sleep regulations, hunger, mood states, and pain perception; hormonal activity; plays a role in aggression and sexual behavior
Decrease causes: Depression
Histamine
Receptors: H1, H2
Involved in alertness, inflammatory response, and stimulates gastric secretion.
Decrease causes: Sedation, weight gain
Y-aminobutyric acid (GABA)
Receptors: GABA-A, GABA-B
Play a role in inhibition, reduces agitation, excitation, and anxiety. May play a role in pain perception. Has anticonvulsant and muscle-relaxant properties. May impair cognition and psychomotor functioning.
Decrease causes: Anxiety disorders, Schizophrenia, Mania, Huntington’s Disease
Increase causes: Reduction of anxiety
Glutamate
Receptors: NMDA, AMPA
Is excitatory; AMPA plays a role in learning and memory
Decrease (NMDA) causes: Psychosis,
Increase (NMDA) causes: Prolonged increased state can be neurotoxic, Neurodegeneration in Alzheimer’s disease
Increase (AMPA) causes: Improvement of cognitive performance in behavioral tasks
Acetylcholine (ACh)
Receptors: Nicotinic, muscarinic (M1, M2, M3)
Plays a role in learning, memory. Regulates mood, mania, sexual aggression. Affects sexual and aggressive behavior. Stimulates PNS
Decrease causes: Alzheimer’s disease, Huntington’s disease, Parkinson’s disease
Increase causes: Depression
Substance P
Receptors: SP
Centrally active SP antagonist has antidepressant and antianxiety effects in depression. Promotes and reinforces memory. Enhances sensitivity to pain receptors to activate.
Involved in regulation of mood and anxiety. Role in pain management.
Somatostatin
Receptors: SRIF
Altered levels of associated with cognitive disease.
Decrease causes: Alzheimer’s disease, Decreased levels of SRIF found in spinal fluid of some depressed PTs
Increase causes: Huntington’s disease
Neurotensin
Receptors: NT
Endogenous antipsychotic-like properties
Decreased levels found in spinal fluid of PTs with schizophrenia
Electroencephalograph (EEG)
A recording of electrical signals from the brain made by hooking up electrodes to the subject’s scalp.
Can show the state a person is in: asleep, awake, anesthetized- because the characteristic patterns of current differ for each of these states
Provides findings from a wide range of sources that brain abnormalities exist; may lead to further testing
Computerized Tomography (CT)
A series of x-ray images taken of the brain and a computer analysis that produces “slices” providing precise 3D-like reconstruction of each segment. Can detect: lesions, abrasions, areas of infarct, aneurysm.
Psychiatric Relevance & Preliminary Findings: Schizophrenia, Cortical atrophy, Third ventricle enlargement, Cognitive disorders, Abnormalities
Magnetic Resonance Imaging (MRI)
A magnetic field applied to the brain. The nuclei of H+ atoms absorb and emit radio waves that are analyzed by computer, which provides 3D visualization of the brain’s structure in sectional images. Can detect: Brain edema, ischemia, infection, neoplasm, trauma.
Psychiatric Relevance & Preliminary Findings: Schizophrenia, enlarged ventricles, reduction in temporal lobe and prefrontal lobe
Functional Magnetic Resonance Imaging (fMRI)
Measures brain activity indirectly by changes in blood oxygen in different parts of the brain as subjects participate in various activities. Uses and Preliminary findings are same as MRI
Positron-emission tomography (PET)
Radioactive substance (tracer) is injected, travels to the brain, and shows up as bright spots on the scan. Data collected by the detectors are relayed to a computer, which produces images of the activity and 3D visualization of the CNS. Can detect: O2 utilization, glucose metabolism, blood flow, neurotransmitter-receptor interaction
Psych Relevance & Preliminary Finds: Schizophrenia, Increased D2,3 receptors in caudate nucleus, abnormalities in limbic system, mood disorder, abnormalities in temporal lobes, adult ADHD, decreased utilization of glucose
Single photon emission computed tomography (SPECT)
Similar to PET but uses radionuclides that emit Y-radiation (photons). Measures various aspects of brain functioning and provides images of multiple layers of the CNS (same as PET). Can detect: Circulation of cerebrospinal fluid, similar functions to PET.
Psych Relevance & Preliminary Finds: Same as PET
Psychological theory (Beck’s)
Anxiety is produced from “biased thinking” resulting in distorted thinking
Psychological theory (Freud)
Anxiety arises in response to conflict between one’s desires (id) and conscious (superego) causing inner tension and effecting one’s sense of self (ego). Ego defense mechanisms can be activated consciously or subconsciously to thwart a perceived threat or to decrease anxiety.
Psychobiological theory
Anxiety involves an increase in neurotransmitter activation and sensitivity which produces responses that exceed the clinical threshold as a constellation of symptoms.
How to talk to someone with dementia or experiencing
Closed-ended, generic questions.
Someone with anxiety disorder often has
A mood disorder
Schizoaffective disorder
Primary concern with mood and thought.
Therapeutic milieuB
Provides a calming environment. This can be done with a combination of the physical environment and communication to maintain a safe environment.
Melancholy
Depressed, sad, disoriented, chronically fatigued with no energy, not enjoying life, etc.
Bipolar with mania
Changes thoughts and can include delusions of grandiose
Bipolar with hypomania
The swing upwards that doesn’t lead to distortions
CBT
Belief that self-talk becomes habitual. Idea of this is to recognize negative self-talk, changing the way they thing about themselves and their behaviors. More likely to be bullied, less likely to seek out new things, less likely to stand-up for yourself. Change negative thoughts and perspectives. “This was a difficult exam and I’m not the only one who struggled with it” instead of “I’m a failure”. Stop and think about thinking.
CBT uses
Anxiety disorders, worrisome individuals (how does this help them? have them realize that the worrying isn’t preventing something from happening). Also works for depression, highly stressed individuals, and bipolar diagnoses for medication compliance, OCD. Only works for those who can understand they have an issue- not useful for psychosis.
DBT
Practicing mindfulness. This can be helpful in psychosis, targeted individuals.
Reminiscence therapy
Chronic ___
Delusions
A belief. Typically feel omnipotent and grandiose (e.g., ability to fly) or persecutory (e.g., frightened, withdrawn)
Hallucinations
Relates to the senses. Impaired reality based thinking. Hearing, feeling, tasting, smelling, seeing something that there is no stimuli for.
Illusions
Misinterpreting what something is. Not actually believing this but seeing it differently than what it is.
Risk factors for psychosis/psychotic features
Can be stabilized
Medications (anticholinergics), street drugs, mood disorders, alterations in blood glucose, infections, increased intracranial pressure, fever, etc.
A mood disorder can become manic and lead to psychosis
This is an alteration in the thought process of the individual
Thalamus
Main processing center. All sensory inputs have neuropathways that lead here. Everything observed gives us information on how to behave. The purpose of the thalamus is to respond quickly to stressors. Some signals go to memory. Processes ANS changes to adapt to fight or flight. It then reroutes to the frontal cortex to assess if it is a truly a threat or not.
PTSD, schizophrenia, depression (things that diminish our sensory area), the thalamus tells the limbic system that they are afraid and should react. Maintaining the neuropathways to the frontal cortex to allow then to assess the threat themselves, it extraordinarily important.
Sleeping
Conscious state to be able to assess threats while asleep
SSRIs (sertraline) and SNRIs (venlafaxine/alfaxar)
Serotonin (blocking reuptake to increase serotonin levels can cause a lot of stomach upset/GI issues) with SSRIs.
With SNRIs, norepinephrine and serotonin is increased
Tricyclics (Amitryptilline/Amoril)
Less popular because of the associated side effects. Many side effects include weight gain, sedating, erectile dysfunction. Can commonly cause OD and black box warning for suicidal ideation. Can be used for neuropathic pain because it slows neuronal firing in brain- individuals say they are in a “fog”.
MAOIs (
Avoid aged cheeses, etc. because of tyramine which is a precursor to dopamine which is a precursor to norepinephrine. This can lead to a high blood pressure.
Lithium (0.5-1.5)
Direct replacement for sodium. If sodium decreases, lithium increases. Maintain the same amount of sodium to avoid lithium toxicity (tremor, anorexia, diarrhea, vomiting, etc.). Educate them on what to do if they become toxic. Lithium at 3-4 can see seizures. Those with bipolar that are treated with lithium are estimated to experience toxicity at some point in their life.
Benzos
People can die if mixed with alcohol or other CNS depressants. Develop tolerance- self medication with alcohol is common. Used for anxiety. Antidepressants, SSRIs, SNRIs are better for anxiety. For panic/manic episodes, give an injection of old-fashioned antipsychotics (e.g., Haloperidol); side effects of these include tardive dyskinesia (lip smacking and pill rolling)- have lost favorability because of this. This never goes away. An acute and reversible spasm reaction can be relieved with antihistamines, anticholinergics, Benadryl. Check for extrapyramidal side effects.
Agranulocytosis
Immunosuppressed from a severe decrease in neutrophils- can occurs with Clozapine
Neuroleptic malignant syndrome
increased temperature, ANS changes. Seen within the first few months- can be seen after someone has been on antipsychotics a long time.
Negative symptoms
Apathy, anhedonia, lack of interest, lack of energy, feeling horrible.
Atypical antipsychotics
Less flat in affect, better motivation, more energy
Delirium
Acute confusion: attention, fluctuating level of consciousness, rapid onset of hours to days
Dementia progression
Days to weeks to months, even years to progress.
Delirium when can be reversed
Side effect, ingested, something smoked, off glucose levels, infection, fever, etc. Can get back to homeostasis. If continued over weeks to months- technically diagnosed with schizophrenia.
PTSD
Exaggerated, fear based response. Anxiety and stressed based. Hypothalamus is constantly telling the amygdala to be on guard. Detached feeling (emotional numbness) where things don’t feel super real. Flashbacks, intrusive thoughts, nightmares. Neural connections is activated to the amygdala. There is a decrease in cognitive functioning to the frontal cortex. Therapy can help by reliving the experience in a conscious way.
CAM test
Confusion Assessment Method- ask a series of questions to see if cardinal signs are presence.
4 Cardinal signs:
sudden onset; fluctuating level of consciousness, inattention & disorg thinking
Hypoactive delirium
PTs tend to lay there and not say much. Go unnoticed and outcome tends to be worse.
Hyperactive delirium
May be startled and combative. They tend to be loud and keep others up at night.
Mixed delirium
Someone who is lethargic, not doing much, and loud/combative maybe 30 minutes later.
More things that can lead to delirium
Restraints, catheter, infection, changes in temp, fluid and electrolyte imbalance, polypharmacy, etc.
Important to eliminate unnecessary medications
Polypharmacy can lead to delirium
Planning care for adequate sleep
Without proper sleep, reality and orientation can decrease
Mild anxiety signs and symptoms
sharp senses, increased motivation, heightened awareness, enhanced learning, optimal functioning.
Moderate anxiety S/S
narrowed perceptional field, less alert, decreased concentration, decreased problem solving, muscular tension, restlessness.
Severe anxiety S/S
concentration progressively narrowed, severe impairment of attention, severe cognitive impairment, physical symptoms, emotional symptoms.
Panic anxiety S/S
complete lack of focus, tendency to misperceive environment, marked change in baseline behavior, marked functional impairment, emotional and behavioral dysregulation.
General Adaptation Syndrome: Alarm
Sympathetic: Upon perceiving the stressor, the body reacts with an autonomic response that activates the sympathetic nervous system (see Fight-or-Flight Response), thus mobilizing the body’s resources to respond to the stressor.
General Adaptation Syndrome: Resistance
Parasympathetic: The parasympathetic nervous system attenuates the reaction, returning many physiological functions to homeostasis while other functions remain hyperactive, ensuring that the body remains alert and ready to respond.
General Adaptation Syndrome: Exhaustion
Chronic illness and death: If the nature of the stressor is sufficiently intense or of a protracted nature, it may exceed the body’s capacity to compensate, thus exposing susceptibility to disease and death.
Diseases associated with anxiety disorder
Cancer, Chronic obstructive pulmonary disease, Asthma, Heart Disease, Diabetes, Drug or alcohol withdrawal, Thyroid Disease (Hyperthyroidism or Hypothyroidism), Pheochromocytoma, Chronic Infections, Vestibular dysfunction, Irritable bowel syndrome
Risk factors for anxiety
Age of onset: 11y/o; peek in 30s-50s. Temperament is a risk factor including activity level, distractibility, intensity, regularity, sensory threshold, approach/withdrawal, adaptability, persistence, and mood. Environmental factors manifest as phobias, parental overprotectiveness, parental loss or separation, and physical or sexual abuse. Genetics and physiological can play a role.
Relationship between anxiety, cortisol, glucose levels, and inflammation.
Cortisol, like GABA, is associated with a calming effect; therefore, higher levels of cortisol lead to a decrease in anxiety. During the “fight-or-flight response,” the sympathetic division of its autonomic nervous system interacts with the adrenal cortex to release adrenalin, which causes many physiological responses including the liver to release stored glucose for a quick infusion of energy. Increased inflammation can lead to increase anxiety.
