mental health1 Flashcards
obsessions are defines by
recurrent and persistent thoughts, urges, or images that are experiences, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress
the individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action
compulsions are defined by
repetitive behaviours or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly
the behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation, however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive
DSM V criteria for ocd
presence of obsessions, compulsions, or both
the obsessions or compulsions are time consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
the obsessive compulsive symptoms are not attributable to the physiological effects of a substance
the disturbance is not better explained by the symptoms of another mental disorder
prevalence of ocd
About 1.2 % will develop OCD over a lifetime
Early onset predicts poorer treatment outcomes
Females are diagnosed slightly more than males
Higher rates among individuals who are
Young, divorced or separated, and unemployed
prevalence of ocd across the lifespan
Children & Adolescence
1-3%
More males than females
Young children are more difficult to diagnose
Older Adult
Late onset is more likely to occur in females
Increased occurrence of PTSD
comorbidities of ocd
Mood disorders
Particularly depression and bipolar disorder
Anxiety and panic disorders
Impulse control disorders
Eating disorders
Tourette syndrome
Frequently occurs with OCD
Personality disorders
Occurs in about 80% of individuals diagnosed with OCD
Somatic Disorder
Substance disorders
Occurs in about 1/3 of individuals diagnosed with OCD
genetics and ocd
Genetic
Strong Heritability
First degree relatives
Increased prevalence if relatives also have Tourette’s syndrome, an anxiety disorder, or a mood disorder
Polygenic disease
neuropathological and ocd
Neuropathological
Hyperactivity of the
orbitofrontal cortex Has the most dopamine receptors anterior cingulated cortex Part of the limbic system caudate nucleus Part of the basal ganglia where GABA mediates dopamine
Increased cerebral glucose metabolism
biochemical and ocd
Biochemical
The most studied neurotransmitter in conjunction with OCD is Serotonin
This is based on the effectiveness of Serotonin specific reuptake inhibitors (SSRI)
Serotonin is one of the transmitters that
Initiates the fight or flight response
Influences how emotions are prioritized in the amygdala
Influences how meaning is connected to memories in the pre-frontal cortex
psychodynamic and ocd
Psychodynamic
Arise form unconscious defense mechanisms
Isolation – separation of affect from thoughts and impulse
Undoing – performing a behavior to avoid the consequences of another behavior
Reaction formation – a behavior or attitude that opposes another behavior or attitude
behavioral and ocd
Behavioral
Conditioned stimuli
Behaviors that would typically be considered neutral, provoke anxiety
To manage anxiety individuals begin to perform other behaviors
The more a behavior decreases anxiety the more frequently an individual will engage in the behavior
assessments for ocd
MSE
Risk Assessment
Physical Assessment
Family
SEDoHs
mental status exam for ocd
General Appearance Affect & Mood Speech & Language Thought Process Thought Content Perceptual Functioning Cognitive Functioning Insight Judgment
risk assessment for ocd
Assess both the obsession and compulsion for
Type
Severity
Inquire about
Access to means
Protective factors
It is importance to:
Allow enough time for the assessment
Gather collateral information
Consider insight and judgment
Is there increased impulsivity? Does the patient feel the need to punish themselves?
physical assessment for ocd
Dermatological Includes assessments of skin and hair Behaviors include: Repetitive hand washing Excessive cleaning (skin breakdown also due to cleaning agents) Skin picking Pulling out hair
Dental Care
Behaviors include:
Excessive teeth brushing (leads to decreased tooth enamel)
possible outcomes of physical assessment for ocd
Possible Outcomes Osteoarthritis Trichotillomania Body dysmorphic disorder Infection Electrolyte imbalances Particularly if there have been changes in nutrition due to decreased enamel.
*These outcomes would require additional assessment
family assessment for ocd
Individuals are more likely
To remain single
Have higher rates of celibacy
Evaluate the families understanding of OCD
Is education required?
Is the family ready to change their behaviors?
How much is the family able to adapt?
Is the family enabling the patient’s compulsions?
Does the family need assistance caring for the patient?
impact of sedohs and ocd
Impact of SEDoHs Financial Can the patient work? Is the patient safe alone or is constant caregiving required ? Is funding required and/or available
Outside supports
Does the patient have social supports (friends, volunteer groups, etc.)?
Education
What education has the patient completed?
How does this impact employment?
How does this impact peer groups?
Social Functioning
Is it awkward to participate in social activities?
consequences of ocd on the patient
Alienation from family and friends
Lack of intimate relationships
Additional health problems
Co-morbid conditions
Con-current conditions
Legal
Acting on obsessions
Financial
Unable to work
body image definition
a mental picture of how one’s own body looks
body image distortion definition
an individual perceives his/her own body different than the world perceives it
interoceptive awareness definition
describes the sensory response to emotional and visceral cues, such as hunger
purge definition
purposeful evacuation of stomach or bowel contents through artificial means such as vomiting or laxatives
DSM V criteria for anorexia nervosa
restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected
intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight
disturbance in the way in which one’s own body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or persistent lack of recognition of the seriousness of the current low body weight
prevalence of anorexia
About 0.5 – 1%
Onset is in early Adolescence (age 14-16)
Females
10x more likely than males
Early menses (age 10/11) is an important predictor
Usually a chronic condition with relapses
Precipitated by distorted body image
Impacted by
Culture
SEDoHs (Decreased socioeconomic status, Decreased education
anorexia across the lifespan
Most often begin in childhood and adolescence
May have serious dieting before the signs of starvations are noticeable
comorbidities of anorexia
Anxiety disorders
OCD predates anorexia nervosa by 5 years
Perfectionism
Depression
Co-morbidities seem to resolve when the anorexia is successfully treated
changes in the orbitofrontal cortex and striatum and anorexia
The orbitofrontal cortex has the most dopamine receptors in the brain
Decreased dopamine may decrease the pleasure an individual experiences with eating
genetics and anorexia
Strong Heritability
First degree relatives account for 50-80% of heritability
neuroendocrine and neurotransmitter and anorexia
Increase in endogenous opioids
Patients exercise excessively
Decreased thyroid function
Related to malnutrition and chronic stress this puts on the body systems
Decreased serotonergic functioning
Decreased weight
history and anorexia
It has been thought that the underlying psychological factors have been related to unresolved conflict in developing autonomy.
Dieting and weight control were a means to defend against feelings of inadequacy
internalization of peer pressure and anorexia
learned from peers
Reflect: How is a therapeutic environment created on an in-patient child/adolescent psychiatric unit?
body dissatisfaction and anorexia
Comparison with others (especially in the media) results in a struggle to develop his/her own identity
Implications when the individual falls short of the ideal
Reflect: Why is it important for nurses to educate adolescents and families about normal growth and development patterns, in particular the increased weight gain that supports changes that occur in puberty?
societal theories and anorexia
Societal messages
Appearance
Roles
What roles are women most likely to pursue?
If a women is in a significant leadership role, are there expectations for how they will look and behave?
Achievements
Do we have expectations for what successful people looks like?
Confusion between character and appearance
“It doesn’t matter what is on the outside. It’s what’s on the inside that matters?”
Does this align with values and beliefs about equity?
Do we live out these values and beliefs?
Awareness of obesity
Media awareness of plus sized models
Dedicated clothing stores for particular sizes
risk factors for anorexia
Puberty
Low self-esteem
Dieting/Attitudes about healthy eating
Feelings of inadequacy
Athleticism
SEDoHs
assessments for anorexia
MSE
Risk Assessment
Physical Assessment
Family
SEDoHs
general appearance for anorexia
Dry skin, sunken facial features,
Wears baggy clothing, long sleeve shirts, long pants, layers
May look older than actual age
May have difficulties with balance
affect and mood for anorexia
Blunted affect
May be unable to describe mood
Ambivalence (affect incongruent with context)
speech and language for anorexia
Speech generally at normal rate, volume, and rhythm Circumstantial speech (talking around the core problem – around the circumstance)
thought process for anorexia
Obsessional thinking
Irrelevant details
May eventually get to the point
thought content for anorexia
*Especially important to listen for strengths
Often hopelessness and helplessness are present
Depressive or anxious cognitions (may be about talking about the subject or other concerns or worries)
perceptual functioning for anorexia
Maybe altered due to physical functioning (significantly altered electrolytes)
cognitive functioning for anorexia
Maybe altered due to physical functioning and physical changes in the brain
Decreased ability to remember, concentrate
insight for anorexia
May not acknowledge there is a problem even thought they become physically unwell
judgement for anorexia
Poor. Continue to want to loose weight
risk assessment for anorexia
7% - 10 % mortality rate
Suicide is the leading cause of death Use highly lethal means Inquire about A plan (time/date/place) Access to means (even if there is no plan as insight and judgment are usually impaired) Protective factors
Collaborative information
physical assessment for anorexia
Multiple physical systems are compromised by starvation
musculoskeletal and anorexia
Loss of muscle mass, fat (leads to osteoporosis)
metabolic and anorexia
Hypothyroidism
Hypoglycemia
Decreased insulin sensitivity
cardiac and anorexia
Bradycardia and ventricular tachycardia
Arrhythmias (atrial and ventricular premature contractions)
Hypotension
Loss/diminished cardiac muscle
Prolonged QT interval (consider potentiated effect with antidepressants like Remron)
Sudden death syndrome
gastrointestinal and anorexia
Delayed gastric emptying
Bloating
Constipation/diarrhea (outcome of continued laxative use and poor nutrition)
Abdominal pain
reproductive and anorexia
Irregular menses to Amenorrhea
Low levels of luteinizing hormone
Low levels of follicle-stimulating hormone
dermatological and anorexia
Dry, cracking skin & brittle nails (dehydration)
Lanugo (fine baby –like hair) over the whole body
Edema
Bluish hands and feet (result of poor nutrition and dehydration –decreased blood volume and decreased iron to carry oxygen)
Thinning hair
hematological and anorexia
Leukopenia
anemia,
Thrombocytopenia
Increased cholesterol
neuropsychiatric and anorexia
Abnormal taste sensation (related to zinc deficiency) Depression Apathy Sleep disturbances (decreased serotonin) Fatigue (but will continue to exercise)
psychological symptoms and anorexia
Decreased interoceptive awareness Sexuality conflict or fears Maturity fears Ritualistic behaviors Difficulty expressing negative emotions Low self esteem Perfectionism Body dissatisfaction
family assessment and anorexia
There is no evidence that family interactions are the primary cause of eating disorders.
Behaviors which may contribute to an individual’s need to control eating and weight
Unrealistic attitudes (weight, shape and size)
Decreased affection, communication and time spent together
Inability to manage conflict
Enmeshment (Erikson’s stages of development – low autonomy, excessive lack of boundaries intrudes privacy)
Overprotectiveness (decreases the development of autonomy)
Rigidity (maintaining the status quo; change and conflict are avoided)
consequences of anorexia for patient
Alienation from family and friends
Lack of intimate relationships
Additional health problems
Co-morbid conditions
Con-current conditions
Financial
Unable to work
Death
DSM V criteria for bulimia
recurrent episodes of binge eating (eating in a discrete period of time, an amount of food that is definitely larger than what most individuals would in a similar period of time or circumstance. a sense of lack of control over eating during the episode)
recurrent inappropriate compensatory behaviors in order to prevent weight gain such as self induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, excessive exercise
the binge eating an inappropriate compensatory behaviours occur both at least once a week for 3 months
self evaluation is unduly influenced by body weight and shape
the disturbance does not occur exclusively during episodes of anorexia
prevalence of bulimia
About 1% – 2.3%
Onset is between 15-24 years old
Females
10x more likely than males
Influenced also by
Culture
SEDoHs
comorbidities of bulimia
Anxiety disorders
Depression
Substance abuse
Borderline and avoidant personality
History of childhood sexual abuse
biological factors of bulimia
Genetic
Strong Heritability
Biochemical Decreased serotonin Contributes to vegetative shifts which can contribute to weight gain Decreased plasma tryptophan Can lead to depressed mood
cognitive perspective and bulimia
Cognitive distortions form the basis of binge eating (i.e. all or nothing thinking, discounting positive changes, fortune telling)
Psychological triggers can cause physiological responses and therefore are currently seen as an explanation for continuation of the behavior (bulimia nervosa) not as a cause
psychological triggers and bulimia
Increased stress
Negative emotions
Both physical and emotional trigger the opioid system in the anterior cingulate cortex (ACC) to release endogenous opioids. Our bodies do not make an endless supply of endogenous opioids and these can be depleted over a prolonged experience of pain.
Environmental cues
Environmental stimuli can be linked to memories in the hippocampus
In this way, these cues trigger neurochemicals to respond in a way similar to when the initial event was experienced.
As a result, even a visual or the smell of a desired food can cause a increase in dopamine levels.
separation-individuation process and bulimia
Moving between developmental stages
Usually occurs between adolescence and adulthood
Individuals are unprepared for emotional separation
Blurred boundaries
Individuals may feel guilt about making their own decisions
additional risk factors for bulimia
Societal perceptions
Dietary restraint
Low self-esteem
History of sexual abuse
Feelings of inadequacy
assessments for bulimia
MSE
Risk Assessment
Physical Assessment
Family
SEDoHs
general appearance with bulimia
Wears baggy clothing, long sleeve shirts, long pants
May look older than actual age
May look overweight, but may also appear an appropriate weight or under weight
affect and mood with bulimia
May be unable to describe mood
Ambivalence (affect incongruent with context)
speech and language with bulimia
Speech generally at normal rate, volume, and rhythm Circumstantial speech (talking around the core problem – around the circumstance)
thought process with bulimia
Obsessional thinking
Irrelevant details
May eventually get to the point
thought content with bulimia
*Especially important to listen for strengths
May perseverate on weight, size or shape of their body
Depressive or anxious cognitions (may be about talking about the subject or other concerns or worries)
perceptual functioning with bulimia
no negative changes
cognitive functioning with bulimia
Decreased ability to remember, concentrate due to perseveration
insight with bulimia
May not acknowledge there is a problem even thought they become physically unwell
judgement with bulimia
Poor. Continue the binge-purge cycle
risk assessment for bulimia
High suicide risks
Independent of other co-morbid/con-current disorders
High risk for self-mutilation
Increased impulsivity
Legal and Financial difficulty
Related to increased impulsivity
Inquire about
A plan (date/time/location)
Access to means (even if there is no plan)
Protective factors
metabolic and bulimia
Electrolyte abnormalities (hypokalemia, hypomagnesemia Increased blood urea nitrogen levels (possible kidney damage)
cardiac and bulimia
Ipecac-related cardiomyopathy arrhythmias
Ipecac syrup is used to induce vomiting
Chronic vomiting can alter sodium and calcium levels
gastrointestinal and bulimia
Salivary gland and pancreatic inflammation and enlargement (increased serum amylase)
Esophageal and gastric erosion/rupture
Dysfunctional bowel syndrome
dental and bulimia
Dental
Erosion of dental enamel (front teeth)
Decay
*Both 1 & 2 occur because of increased acid in the mouth when the individual is vomiting.
integument and bulimia
Fingers and knuckles may be dry and cracked which is the result of the acidity of the vomit
neuropsychiatric and bulimia
Seizures Due to the fluid shift and electrolyte disturbances Mild neuropathies Fatigue Weakness
psychological assessment and bulimia
Decreased interoceptive awareness
Sexuality conflict or fears
Related to their perception of their body
Maturity fears
Difficulties with taking responsibility and being accountable
Fear of failure
Low self-esteem
Body dissatisfaction
Could be related to weight, size, and shape
Behaviors which may contribute to an individual’s need to control eating and weight
Inability to manage conflict
Enmeshment
Erikson’s stages of development - excessive boundaries intrudes privacy which may lead to sneaking behavior; lack of boundaries may lead to decreased sense of the individual’s own identity
Overprotectiveness
Impedes the development of autonomy
Rigidity
Maintaining the status quo – change and conflict are avoided
consequences of bulimia on patient
Alienation from family and friends
Lack of healthy relationships
Additional health problems
Co-morbid conditions
Con-current conditions
Financial and legal implications
