Mental Health Exam #2 Flashcards
Define “personality”.
Personality: how we perceive and interact with the world
–Personality traits –> stylistic peculiarities that all people bring to social relationships
What are traits/characteristics of a personality disorder?
Personality disorder traits:
- Difficulty accurately perceiving and interpreting the world around them
- Difficulty with impulse control
- Inappropriate emotional responses
- Blaming (genuinely unaware that their personality traits are causing their problems)
Personality disorder characteristics:
- Avoidance and fear of rejection
- Blurring of boundaries between self and others (fusion)
- Insensitivity to other’s needs
- Demanding
- Fault finding (“grievance collectors”)
- Inability to trust
- Lack individual accountability
- Passive-aggressive
- Tendency to evoke intense interpersonal conflict
What causes personality disorder (PD)?
No single cause exists for PD
PD is due to a combination of hereditary and temperamental traits, as well as environmental and developmental events
Personality traits are present from infancy
Disorder usually emerges in adolescence
Genetic factors
- Research supports the dominant role of genetics
- Identical twin studies
Neurobiological factors
- Aggressive, impulse behaviors
- Affective instability (ex: can be d/t stroke, TBI)
Psychologic influences
- Childhood neglect is particularly damaging
- Childhood trauma (excessively harsh and erratic discipline, alcoholic parent(s), etc.)
- Abuse and chaotic home life are risk factors for borderline PDs (BPD) and antisocial PDs
- Sexual abuse is a risk factor for BPD
What are the clusters of PDs?
Cluster A Disorders – odd
- Seen as “odd” or eccentric
- Have unusual beliefs
- Avoid interpersonal relationship, often indifferent
Cluster B Disorders – emotional
- Emotional reactivity
- Poor impulse control
- Manipulative
- Unclear sense of identity
Cluster C Disorders – anxious
- High anxiety and outward signs of fear
- Internalized blame (even when not to blame)
What types of PDs fall under Cluster A?
Schizotypal Personality Disorder
- Resembles schizophrenia, but with no psychosis
- Odd, eccentric behavior and speech
- Cognitive perceptual distortion (without psychosis)
- May display magical thinking and rituals
- Give-and-take conversations are difficult
- Genuinely unhappy about lack of relationships
- Social anxiety and unhappiness may increase over time
Paranoid Personality Disorder
- Persistent, inappropriate suspicion and distrust of others
- Present as hostile, irritable, injustice collectors
- Jealous, lacking warmth
- May appear businesslike and efficient (but generate fear and conflict in others)
- Find malice in benign comments and behaviors (ideas of reference)
Schizoid Personality Disorder
- Flat affect; appear indifferent to both praise and criticism
- Unable to establish relationships
- Restricted range of interpersonal emotions
- Invest little energy in human relationships; conversely, may invest enormous energy in nonhuman interests (mathematics, astronomy, etc.) and often connect more with animals
- Often creative, original thinkers
What types of PDs fall under Cluster B?
Antisocial Personality Disorder – “Mob bosses”
- Persistent disregard for others
- Persistent violation of others’ rights
- Absence of remorse for hurting others (callousness)
- Sense of entitlement
- Deceitfulness
- Impulsiveness; risky behaviors to “feel alive”
Borderline Personality Disorder – “Manipulators”
- Unstable, intense relationships
- Instability of affect, frequent mood changes
- Emotional lability (shifting from anxiety to irritability, etc.)
- Poor impulse control; self-destructive, suicide prone, often self-harm
- Chronic depression
- Projected identification
- Splitting (pit staff against each other)
Narcissistic Personality Disorder – “Trump”
- Grandiose sense of personal achievement
- Sense of entitlement
- Lack of empathy, exploiting others to meet own needs
- Increasing attention seeking over time
- Envious of others
- Use of splitting, tantrums
- Can be sadistic, with paranoid tendencies
Histrionic Personality Disorder – “Jessica Rabbit”
- Manipulative, insensitive
- Dramatic, rapidly shifting, charming, flamboyant; use sexually seductive behaviors
- Need to become and remain the center of attention, love, and admiration
- Constant, sudden emotional shifts and lability
- Superficial, shallow, short-lived relationships
- Lack insight into cause of relationship failures
What types of PDs fall under Cluster C?
Avoidant Personality Disorder
- Feelings of low self-worth
- Hypersensitive to criticism or rejection
- Avoid situations requiring socialization, withdrawal
- Fearful of disappointment or ridicule
- Reluctant to express irritation or anger, even when justified
- Social phobia
Obsessive-Compulsive Personality Disorder
- Orderliness, stubbornness, attention to detail
- Indecisiveness
- Emotional constriction
- Pervasive pattern of perfection and inflexibility
- Perseveration (persistent pursuit of an action even in the face of repeated failures)
- High achievers
- Superficial, rigidly controlled intimacy
- Stinginess
Dependent Personality Disorder
- Belief in inability to survive if left alone
- Excess need to be taken care of
- Solicit caretaking through clinging and submission
- Excessive submission
- Intense fear of separation and being alone
- Tolerant of poor, even abusive relationships
- If relationship does end, the individual has an urgent need to get into another
- Inability to make decisions without excessive reassurance
How do you assess patients with PDs?
Personality disorder assessment:
- Assess suicidal/homicidal thoughts
- Determine whether the patient has a medical disorder or another psychiatric disorder
- View the assessment of personality function from ethnic, cultural, and social backgrounds
- Ascertain recent and important losses
- Evaluate for changes in personality in middle adulthood or later (may signal unrecognized substance use disorder)
- Be aware of strong negative emotions that patient evoke
How do you manage PD behaviors?
Managing behaviors:
- Assess the patient for a short period before labeling him or her as manipulative
- Set limits on manipulative behaviors
- –Arguing or begging
- –Using flattery or seductiveness
- –Instilling guilt and clinging
- –Constantly seeking attention
- –Pitting one person, staff member, or group against another
- –Frequently disregarding the rules
- –Constant engaging in power struggles
- –Exhibiting angry, demanding behaviors
- Behaviors should be objectively documented (time, date, and circumstances)
- Provide clear boundaries and consequences
- Enforce consequences
What should you avoid around people with personality disorders (PDs)?
Avoid:
- Discussing yourself or other staff members with patients
- Promising to keep a secret
- Accepting gifts from patients
- Doing special favors for patients
How should you communicate with someone who has a PD? What are the goals of this therapeutic relationship?
Nurses gently enhance their ability to be therapeutic when they use
- Limit-setting
- Trustworthiness
- Dealing with manipulations
- Authenticity with their own natural style
Goal of therapeutic relationship
- Identify what precedes impulse acts
- Explore effects on self and others
- Recognize cues
- Identify triggers
- Discuss alternative behaviors
- Teach coping skills
What are some barriers to a therapeutic relationship with someone who has a PD?
Creating a therapeutic relationship with some who has a PD is especially difficult
- Suspiciousness, aloofness, and hostility will set up failure
- Guarded and secretive style produces an atmosphere of combativeness
- When patients blame or attack others, the nurse needs to understand the context of the complaints
- Attacks spring from a feeling of being threatened
- The more intense the complaints, the greater the fear of potential harm or loss
What types of therapies are used for PDs?
Psychotherapy
Cognitive behavioral therapy (CBT)
Dialectical behavior therapy (DBT)
What is the goal of DBT?
DBT = Dialectical Behavior Therapy Goal: regulate emotions and achieve behavioral control (through developing distress tolerance skills and crisis interventions) Decrease target behaviors, such as… -Life-threatening suicidal behaviors -Therapy-interfering behaviors -Quality-of-life interfering behaviors
What is the goal of STEPPS?
STEPPS = Systems Training for Emotional Predictability and Problem Solving
- Offers a 20-week manual-driven program
- Reduces the intensity of the core aspect of BPD
- Does NOT reduce hospital utilization and suicidal ideation
- DOES reduce suicide attempts and visits to the emergency department
What medications are used to treat PDs?
There are no medications specifically for PD, but some meds can alleviate symptoms of PD
Benzodiazepines – NOT appropriate because of the potential of abuse and overdose; may only be used in emergency situations
-SSRIs – treats co-morbid depression and panic attacks
-Trazodone and venlafaxine – have low toxicity in overdose
-Carbamazepine – target impulsivity and self-harm
-Lithium, anticonvulsants – minimize aggression
-Atypical antipsychotics – help with psychotic features of BPD under stress
What factors make someone more likely to develop depression?
- People with co-occurring chronic medical problems (HTN, backache, DM, heart problems, arthritis)
- Women more likely (hormones)
- Older adults (>65 yo.) more likely (often goes undiagnosed)
- Accompanies other psychiatric disorders
- Rate is growing in children and adolescents
What causes depression?
Biological Model
- Biological theories – genetic factors (twin and adoption studies)
- Biochemical factors – serotonin and norepinephrine are two major neurotransmitters involved in depression
- Hormones – alterations in hormonal regulation
Diathesis Stress Model
- Environmental
- Interpersonal
- Life events combined with biological predisposition (diathesis)
- Psychologic stressors that trigger brain changes
Psychosocial theory
- The stress-diathesis model of depression
- Learned helplessness
- Cultural considerations
Cognitive theory (Beck’s cognitive triad)
(1) Negative, self-deprecating view of self
(2) Pessimistic view of the world
(3) Belief that negative reinforcement will continue
What are the subtypes of depression?
Psychotic features Melancholic features Atypical features Catatonic features Postpartum onset Seasonal affective disorder (SAD)
How do you assess patients with depression?
Depression assessment:
- Self-assessment (RN) – unrealistic expectations of self, feeling what the patient is feeling
- Assessment tools – MSE, psychosocial assessment
- Assessment of suicidal potential
- Key assessment findings (lack of self-care, flat affect, hopelessness, etc.)
How do you assess for suicidal potential?
Mood
Anhedonia (inability to experience pleasure)
Anergia (lack of energy)
Anxiety
Worthlessness, guilt, helplessness, hopelessness
Anger and irritability
How should you communicate with someone who has depression?
Communication guidelines:
- Person with depression may speak and comprehend very slowly
- Extreme depression – person may be mute
- Nurses should not be uncomfortable with silence
- Sitting with a patient in silence is a valuable intervention
What medications are used to treat depression?
For people with depression, but without psychotic features, a combination of specific psychotherapies (CBT, etc.) and antidepressant therapy may be superior to psychotherapy or psychopharmacologic treatment alone.
SSRIs = Selective Serotonin Reuptake Inhibitors
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
MOA: increase serotonin
Side effects: some anticholinergic effects (thought fewer than TCAs), N/V, serotonin syndrome risk (especially when administered with MAOIs)
TCAs = Tricyclic antidepressants
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
MOA: increases norepinephrine
Side effects: anticholinergic effects, LETHAL if OD occurs
MAOIs = Monoamine Oxidase Inhibitors
Phenelzine (Nardil)
Tranylcypromine (Parnate)
EMSAM (selegiline transdermal system) – delivers MAOIs through skin
MOA: inhibits monoamine oxidase (which inactivates and degrades neurotransmitters)
Side effects: HTN crisis can occur if patient ingests tyramine foods (in some OTC meds (decongestants), cured meats, beer, wine, aged cheese, avocados, etc.)
Dietary restriction of tyramine must be maintained for 2 weeks after stopping MAOIs
Atypical antidepressants
Bupropion (Wellbutrin)
MOA: do not act on serotonin system; inhibit nicotinic acetylcholine receptors to reduce addictive effects
Good for nicotine withdrawal.
Mirtazapine (Remeron)
MOA: increase serotonin and norepinephrine
Combined with SSRIs to augment efficacy or counteract serotonergic side effects
What are the safety risks with antidepressants?
Antidepressants might contribute to suicidal behavior
No conclusive evidence supports that either new or old antidepressants precipitate suicide
FDA provides a “black box” warning
FDA recommends close observation for worsening depression or suicidal thoughts
Close observation is especially recommended in children, adolescents, and older adults starting antidepressant therapy.
What are some somatic therapies used for depression?
Electroconvulsive Therapy (ECT)
During ECT, the client is treated with pulses of electrical energy through electrodes applied to the scalp; the electrical stimulus is sufficient to cause a brief convulsion. General anesthesia and a skeletal muscle relaxant are administered to minimize the motor seizure and prevent musculoskeletal injury.
Indications for ECT
-Suicidal/homicidal
-Agitation or stupor is extreme
-Life-threatening illness that is a result of the refusal of foods or fluids
-History includes a poor drug response
-Standard medical treatment has no effect
Client teaching
- NPO status is required for 6-8 hours prior to treatment except for sips of water with medications.
- Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure.
- Driving is not permitted during the course of ECT treatment
- Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT
Other therapies
- Vagus nerve stimulation
- Rapid transcranial magnetic stimulation (rTMS)
- Light therapy (for SAD)
- St. John’s wort
- S-adenosylmethionine (SAMe)
- Peer support
- Exercise
What are the subtypes of bipolar disorder?
Bipolar I disorder – manic and depressive episodes
Bipolar II disorder – primarily depressive episodes
Cyclothymic disorder – mood swings between mild depression and hypomania
Bipolar unspecified
Rapid-cycling bipolar disorder – switch at least 4x/year between mania and depression
Mania or hypomania with mixed features – mania: euphoric, irritability; hypomania: a less severe version of mania
What illnesses often co-occur with bipolar disorder?
Psychologic -Anxiety disorders -Panic attacks -Behavioral disorders -Substance use Note: substance and anxiety disorders worsen the prognosis and increase the risk of suicide
Medical
- Cardiovascular/cerebrovascular
- Metabolic disorders
- CNS system stimulation
- Hypo/hyperthyroidism
- Seizure disorders
- HIV
What causes bipolar disorder?
Biological theories
- Genetics
- Neurobiological
- Neuroendocrine
- Neuroanatomical
Psychologic influences and cultural considerations
- Stressful life events can trigger symptoms of borderline personality disorder (BPD)
- Cultural difference and beliefs can vastly complicate the issue
What are the phases of mania?
- Acute phase
- Medical stabilization
- Maintaining safety
- Self-care needs
Continuation phase
- Maintaining medication adherence
- Psychoeducational teaching
- Referrals
Maintenance phase
-Preventing relapse
How should you communicate with someone who has bipolar disorder?
Communication guidelines
- Consistent limit setting is important to treatment
- All team members need to communicate challenges
- Patients with bipolar disorder are often ambivalent about treatment
- Nonadherence to medication is a major cause of relapse
- Therapeutic alliance is crucial
What communication strategies are effective with patients in acute mania?
Display a firm, calm approach
Express short, concise explanations or statements
Remain neutral
Maintain consistency
Conduct frequent staff meetings to agree on limit setting
Hear and act upon legitimate complaints
Firmly redirect energy
What is Milieu therapy (seclusion)?
Control during the acute phase of hyperactive behavior almost always includes immediate treatment with an antipsychotic medication. However, when a patient is dangerously out of control, seclusion or restraints may also be indicated.
Use of seclusion
- Reduces overwhelming environmental stimuli
- Protects a patient from harm to self or others
- Prevents the destruction of property
Seclusion indications
- Risk of harm to others or self
- Patient is unable to control actions
- Other measures (setting limits, beginning with verbal de-escalation, or using chemical restraints) have failed
What medications are used to treat bipolar disorder?
Lithium Carbonate (LiCO3) – Lithobid, Lithonate, Lithotabs First-line agent for bipolar disorder
MOA: Alters sodium transport in nerve and muscle cells and inhibits the release of norepinephrine and dopamine; (when sodium is gone, lithium takes over TOXICITY); does not inhibit the release of serotonin
Lithium blood levels
- Therapeutic blood level (0.8 to 1.4 mEq/L)
- Maintenance blood level (0.4 to 1.3 mEq/L)
- Toxic blood level (1.5 to 2.0 mEq/L)
Contraindications: dehydration, kidney problems, N/V, sun exposure, exercise
Side effects (expected): hand tremors, weight gain, polyuria, thirst
Toxic side effects
- Early signs (N/V, polyuria, slurred speech, muscle weakness)
- Advanced signs (coarse hand tremors, mental confusion, ECG changes)
- Severe signs (ataxia, blurred vision, seizures, stupor, coma, pulmonary complications, severe hypotension, death)
Anticonvulsant drugs – for rapid cycling and dysphoric mood; rough on liver
- Divalproex (Depakote) – check Depakote levels
- Carbamazepine (Tegretol)
- Lamotrigine (Lamictal) - blood dyscrasias, Steven-Johnson rash
Anxiolytics – used in mania
- Clonazepam (Klonopin)
- Lorazepam (Ativan)
Atypical antipsychotics – used in mania; sedative properties
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
- Aripiprazole (Abilify)
- Ziprasidone (Geodon)
- Quetiapine (Seroquel)
What is schizophrenia?
Schizophrenia is a devastating brain disease that targets young people in their teens and early twenties
Schizophrenia spectrum disorders are a group of psychotic disorders
Psychosis is not a diagnosis, but a symptom
Psychosis refers to a total inability to recognize reality (ex: delusion and hallucinations)
What illnesses often co-occur with schizophrenia?
Substance abuse disorders Anxiety disorders Depression OCD Panic disorders Obesity (probably due to antipsychotic medications) risk of DM and cardiovascular disease
What causes schizophrenia?
Combination of genetics and extreme non-genetic factors
Genetics:
- Brain structure abnormalities (neuroanatomical)
- Neurochemical (dopamine, serotonin, and glutamate abnormalities)
Non-genetic risk factors:
- Prenatal stressors
- Psychologic stressors – developmental, psychologic, physical, family stress
- Environmental stressors – social adversity, chronic poverty, growing up in areas of crime, street drugs under 21 years
What are the phases of schizophrenia?
Prodromal – pre-psychotic phase (secluded, withdrawn)
Acute phase – positive and negative symptoms
Stabilization – decrease in severity
Maintenance phase – symptoms are in remission, with possible presence of milder, residual symptoms
What are the four types of schizophrenia symptoms?
Positive: + something to your life you are not supposed to have
- Hallucinations
- Delusions
- Bizarre behavior
- Catatonia
Negative: - something from your life you are supposed to have
- Apathy
- Lack of motivation
- Anhedonia
- Blunted or flat affect
- Poverty of speech
- Poverty of thought
Mood symptoms: (affective)
- Depression
- Anxiety
- Demoralization
- Dysphoria
- Suicidality
Cognitive symptoms: (memory and thoughts)
- Impaired memory
- Inability to reason
- Inability to solve problems
- Lack of focus
What are alterations in thinking?
Impaired reality testing – absence of ability to correct errors in thinking
Delusions – false fixed beliefs not corrected by reasoning
- Thought broadcasting (thinking everyone knows what you are thinking)
- Thought insertion (thinking some put something into your head)
- Thought withdrawal
- Delusion of being controlled
Concrete thinking – impaired ability to think abstractly
Ex: “the grass isn’t always greener”
What are alterations in speech?
- Associative looseness (no correlation between thoughts)
- Neologisms (new words)
- Clang association (things that sound alike, rhyme, start with the same letter, etc.)
- Word salad (words that don’t go together)
- Echolalia (pathologic repeating of another’s words) – seen in catatonia
- Echopraxia (mimicking the movements of another) – seen in catatonia
What are alterations in perception?
- Depersonalization (out-of-body experience)
- Hallucinations (sees something not there)
- Illusions (sees something real, but thinks it’s something else that is really not; ex: thinks IV tubing is a snake)
- Command hallucination (telling them to do something; ex: hurt someone or self)
- Derealization (feel like environment is changing around you; ex: one arm is bigger than the other)
What are alterations in behavior?
- Bizarre behavior
- Extreme motor agitation
- Stereotyped behaviors (ex: former truck driver pretends they are driving)
- Waxy flexibility (someone remains in one position for an abnormally long amount of time)
- Stupor
- Negativism (do the exact opposite of what you tell them to do)
- Automated obedience (listens to you without thinking)
Loss of impulse control may result in agitated behaviors (ex: abruptly grabbing the TV remote from someone else and changing the channel)
How should you assess someone with schizophrenia?
Verify medical workup to rule out medical or substance-related psychosis (ex: PCP, LSD) Then, assess for -Drug and alcohol use -Command hallucinations -Belief system -Comorbidity -Medication regimen -Family dynamics/support system
What are the outcomes identification for the phases of schizophrenia?
Phase I (Acute)
- *Patient safety
- Medical stabilization
- Refrain from acting on delusions/hallucination
Phase II (Stabilization) and Phase III (Maintenance)
- Medical adherence, understanding, and compliance
- Continual recovery and functional improvement
- Control and relapse prevention
