Psych Final Exam Flashcards
Epidemiology of eating/feeding disorders
More common in women
Binge eating more common
Trauma
ED is their one sense of control
Onset teens to early 20s
Anorexia may start earlier 7 -12
Often comorbid mood or anxiety disorder, (adolescents ODD may be accompanying), increase incidence of personality disorder (OC, Borderline)
Biological of anorexia
Genetic-60% heritability, no single gene
Neurobiological of anorexia
Role of tryptophan-only in diet-essential to serotonin synthesis (need to gain 90% optimal weight for antidepressants to be effective)
Altered serotonin function, positive feedback loop of euphoria with calorie restriction eventually leads to dysphoria
fMRI in anorexia
↓ gray & white matter in CNS
Exhibit ↓ in size and/or function of:
Hypothalamus, basal ganglia, & somatosensory cortex
Regions of the insula, amygdala, & dorsolateral prefrontal cortex appear larger or experience ↑ activation
Insula associated with awareness/sensation of fullness
Anorexia
Intense fear of weight gain
Distorted body image (restricting vs binge purge)
Extremely thin, maybe cachectic, more dangerous for this patient to binge purge
Restricted calories with significantly low BMI
Subtypes of anorexia
Restricting (no consistent bulimic features)
Binge/eating/purging type (primarily restriction, some bulimic behaviors)
General assessment of anorexia
perception of problem
eating habits
hx of dieting
methods of weight control
value of weight to them
Interpersonal and social functioning
MSE and physiological parameters (thyroid, cardiac, electrolytes)
When is hospitalization necessary for anorexia nervosa?
Weight loss >30% over 6 months
Inability to gain weight outpatient (want them to gain 1-2 pounds a week during treatment)
Hypothermia (lower than 96.8)
Heart rate < 40 bpm
Systolic BP < 70 mm Hg
Hypokalemia (<3 mEq/L)
EKG abnormalities (arrhythmias)
Suicidal or very depressed
Psychosis/delirium/confusion
Non-compliance outpatient treatment
Acute care for anorexia
Suicidal ideation first
Psychosocial interventions
Pharmacological interventions-none approved, though SSRI-Fluoxetine (Prozac) ↓ OC behaviors
Integrative medicine
Health teaching and health promotion
Safety and teamwork
Refeeding syndrome
Seen in anorexia when someone eats a lot all of a sudden after being anorexic
Body is used to no micronutrients. Now you’re eating regular food. When you lose weight your body breaks down muscle and fat for energy. When you eat normally again, your body pulls micronutrients from blood
Effects of refeeding syndrome
Low potassium, phosphate, and magnesium
heart attacks from electrolyte imbalance
Double vision, swallowing problems, trouble breathing, kidney dysfunction, muscle weakness, confusion and disorientation, seizures, cardiomyopathy (heart weakness), N/V, hypotension)
Advance practice interventions for anorexia
Psychotherapy
Individual therapy
Group therapy
Family therapy
Journaling
Family communication and conflict resolution
Meal planning
Relapse of anorexia
Relapse rate is high up to 50% first year
Up to 40% meet criteria for 4 years
Goal-restore weight and establish healthful eating habits
Bulimia assessment
Appear well
At or near ideal body weight (maybe a few pounds over)
Episodes of binge eating (1500-5000 cals within 2 hour period followed by compensatory behavior)
Eating when they’re alone
Trying to lose the calories every day by vomiting, laxatives, etc
Physical signs of bulimia
Enlarged parotid glands, inflamed and scarred fingers from vomiting, dental erosion, and caries if the patient has been inducing vomiting.
Emotional and relationship signs of bulimia
Impulsivity and compulsivity more than anorexia. No breakdown of muscle and fat since they’re eating, normal electrolytes and stuff
Chaotic, non-nurturing family relationships more than anorexia
Familial and/ or social instability
Difficult interpersonal relationships
Acute interventions for bulimia
Teamwork and safety
Pharmacological interventions-FDA approval-SSRI Fluoxetine (Prozac). TCAs & Topamax (anticonvulsant for BD, weight neutral)
Counseling-establish rapport–patient sees it as a problem
Health teaching and health promotion-Healthy diet, coping skills, cognitive distortions, relaxation techniques, yoga!!
Cardiac output in bulimia
Decreased
Outcomes in bulimia
Electrolytes in balance; adequate cardiac output; satisfaction with body image; effective coping; verbalizes confidence; makes informed life decisions; expresses independent decision-making; willingness to call others for assistance; develops sense of belonging
Binge eating disorder
Weight significantly over ideal weight
Dysfunctional eating pattern (response to internal cues)
Sedentary lifestyle
Gastric bypass surgery (can’t eat the same as before, you’ll still gain weight)
Embarrassment due to weight, body dissatisfaction
Loss of control of eating, shame and guilt
Eats normally around others, will binge somewhere else, sometimes they replace food
Fear reactions of others
Feelings of dread
Outcome identification for binge eating
The nurse will need to help these patients manage dysregulation of the entire gastrointestinal tract.
Remember, eating is not about the food, it is about coping with emotions
Pharm acute care for binge eating
Pharmacological interventions-BMI >30 or >27 if accompanied by health problem
Belviq/lorcaserin
Qsymia
Vyvanse (Lisdexamfetamine dimesylate)
Other acute interventions for binge eating
Surgical interventions: bariatric surgery (for obesity), sometimes other things recommended like meal plan or exercise
Psychosocial interventions-CBT and Interpersonal Therapy, along with behavioral weight loss programs
Health teaching and health promotion-GI problems such as heartburn, dysphagia, pain , bowel changes associated with binging
Pica
Persistently eating nonfood items (dirt, paint) well past toddlerhood
Not part of other illness
Begins in early childhood & lasts for a few months
Can be in any age
Rumination disorder
Regurgitation with rechewing, re swallowing, or spitting out
No medical or mental reason
Infants 3-12 mos., but can happen at any age
Interventions for rumination disorder
Reposition infants and children while eating so there’s not much regurgitation
Make mealtimes pleasant (don’t yell during mealtime)
Improve communication between caregiver and child
Distract the child when the behavior starts
Family therapy if needed (not preferred)
Avoidant/restrictive food intake
Starts in infancy & early childhood
Note: 40% of “picky” eaters resolve on their own
Low BMI
No distorted body image
Prematurity, FTT, and autism (usually in boys)
Diagnostic criteria for binge eating
…
Biological factors of neuro disorders in children
Genetic-increased risk
Neurobiological-brain developing rapidly (finishes at 25)
Children are great at learning languages at this point
FTT or family conflict/environment, synapses prune back and aren’t being used. Causes delays. Pruned synapses are normal but not much
psychological factors of neuro disorders in children
Temperament-coping style
Resilience-inborn strength & success handling stress
Environmental factors of neuro disorders in children
Impact of trauma-Witnessing violence
Role of caregivers/parents-Neglect and abuse
Challenges in family environment (one or both parents, maybe one parent won’t speak up)
Not only socioeconomically driven, also seen in rich ppl
Being poor can definitely contribute but not always
Bullying
Cultural factors of neuro disorders in children
Cultural expectations
Presence of stressors
Lack of support
Assessment of psych disorders in children
History of present illness (child doesn’t speak, parent speaks for them)
Developmental history (deficits)
Developmental assessment
Neuro assessment
Medical history
Family history
MSE
Interventions for psych disorders in children
Family therapy–child does the talking
Group therapy or play therapy for young kids
Behavioral therapy
CBT
Disruptive Behavior Management
Creative expression: art/music
Bibliotherapy–books
Journaling
Psychopharmacology
Restraints for children
Office of mental health is huge, bigger than joint commission, we DON’T restrain a child, also adolescent but specifically children
Can’t even hold child for more than 4 minutes, that’s a restraint
Group therapy for children
Younger children: uses play and ideas
Grade-school children: combines play, learning skills, and talk
Adolescents: identifying emotions, modifying responses, learning skills and talking, focusing largely on peer relationships and addressing specific problems
CBT for children
Replacing negative, self-defeating thoughts with more realistic and accurate appraisals to improve functioning
Neurodevelopmental disorders of children and adolescents
Communication disorders
Motor disorders
Specific learning disorder
Intellectual developmental disorder
Autism Spectrum Disorder (ASD)
Attention Deficit Hyperactivity Disorder (ADHD)- predominantly inattentive or predominantly hyperactive
Speech disorders in children
Problems making sounds–wabbit
Can be hard to make friends because you talk funny
Language disorders in children
Receptive language disorder-difficulty understanding or in using words in context and appropriately Expressive language disorder–know what they wanna say and what you’re saying, can’t say their own thoughts. Don’t follow directions
Social communication disorder–very anxious and can’t communicate. Also seen in writing, can’t write a card with friends
Child onset fluency disorder–a form of stuttering
developmental coordination disorder in children
Impairments in motor skill development
Coordination below the child’s developmental age
Ie: delayed sitting, walking, jumping, shoelace tying
stereotypic movement disorder
Repetitive, purposeless movements for 4 weeks or more, ie: rocking, head banging, hand waving
Needs early intervention
Naltrexone (opioid antagonist, euphoria from behavior so this blocks euphoric effect which makes them stop)
Tic disorders
Sudden, nonrhythmic and rapid motor movements or vocalizations
Tourette’s disorder
Treating tic disorders
Behavioral techniques-CBITS-comprehensive behavior interventions-habit reversal
Deep brain stimulation (DBS)- a fine wire in brain, connected to a device under collarbone. Pacemaker for the brain. Pt controls it
Meds for tic disorder
Haldol, Orap (1st gen psy.), Abilify (2nd gen psy.), Risperdal, Clonodine, Klonopin (trying to steer away because it’s sedating/addictive) & Botox (muscle relaxant)
Specific learning disorders
Dyslexia (reading)
Dyscalculia (math)
Dysgraphia (written expression)
Screening is crucial for early intervention
Supported by the Disabilities Education Improvement Act
IEP
Plans can go in place as early as Kindergarten
Psychology and social work work together
Intellectual development disorder
now called intellectual disability
Deficits in intellectual (reasoning, prefrontal cortex, multi-faceted), social (impaired communication and social cues), or daily functioning
Teachers notice very early on, parents deny it
nursing process in intellectual developmental disorders
Assess: delays (get frustrated and impulsive bc can’t do what others can, can they have civil conversations, etc) or neglect/abuse (malnourished, doesn’t have to be neuro)
Outcome ID: Nursing outcome classification (NOC) Strength based, how can we strengthen what the child needs?
Implementation: psychosocial, Strength based, how can we strengthen what the child needs?
ASD
Deficits in social relatedness and relationships
Stereotypical repetitive speech
Obsessive focus on specific objects
Over adherence to routines or rituals
Hyper- or hypo-reactivity to sensory input
Extreme resistance to change
Appears in early childhood
Complex neurobiological AND biological
Implementation in ASD
Psychosocial interventions-early intervention program
Psychobiological interventions-pharmacology: atypical like Abilify & Risperdal FDA appr for 5-6 & older-improve associated agitation, Off label-SSRI’s-improve mood & anxiety, Stimulants-↓ hyperactivity, impulsivity or inattention.
Evaluation
ADHD
Inappropriate degree of
Inattention–previously ADD, now primarily ADHD with inattention
Impulsiveness-ADHD with impulsivity and hyperactivity
Hyperactivity
Symptoms present for at least 6 months in at least 2 settings, before age 12
Assessment of ADHD
Level of physical activity, attention span, talkativeness
Social skills-how do they perceive it
Comorbidity
If they get admitted, ask school if teachers know, if social work is involved, how they behave in school, etc
Implementation in ADHD
CBT-recognize ineffective coping
Psychobiological interventions
Psychopharmacology-stimulants-Methylphenidate (Ritalin), Adderall & Non-stimulating- Atomoxetine (Strattera, watch for liver dx)
Medications for aggressive behaviors-mood stabilizers, antipsychotics
Intermittent explosive disorder and age
after the age of six, during teenage years/young adults
IED is also a type of explosive if that helps you remember that these people blow up
Biological factors of impulse control disorders
Genetic-familial risk
Neurobiological-brain differences
Cognitive factors of impulse control disorders
Negative reinforcement methods
Low self esteem
Environmental factors of impulse control disorders
ACEs, family distress, inadequate parenting, dysfunctional families, abuse, attachment issues, socioeconomic status (also seen in very affluent communities)
Oppositional defiant disorder
Angry and irritable mood
Defiant and vindictive behavior (twice within prev. 6 mo.)
social difficulties but they don’t care or need friends
Conflicts with authority
Academic problems
Pretty much seen in childhood
Risk factors for ODD
Genetic component; family history of mental illness
Numerous neurobiological causes identified
Environment: family dysfunction can play a role
Treatment of ODD
Psychosocial interventions-manage anger, improve problem solving, reduce impulsivity & improve social interactions
Psychobiological interventions-No meds FDA approved-Off label use of Divalproex sodium (Depakote/depakene) for reactive aggression & irritability. Also works in bipolar for reactivity
Intermittent Explosive Disorder
Pattern of behavioral outbursts seen as:
Inability to control aggressive impulses (verbal or physical, aggressive towards others and property, not as much themselves)
Begins in childhood-adult under age 50
Leads to problems with interpersonal relationships, occupational difficulty, academic issues, and criminal difficulty
Comorbidities with intermittent explosive disorder
Depressive (low self esteem, driving factor), anxiety, and substance use disorders
Antisocial and borderline personality disorders
Diabetes and HTN seen for some reason
Risk factors of intermittent explosive disorder
Neurobiological abnormalities
Conflict or violence in family of origin
Treatment of Intermittent Explosive Disorder
Psychosocial-individual & group CBT
Pharmacologic-off label-SSRI’s (serotonergic dysfunction), antipsychotics, & beta-blockers
Inderal used to be given for anxiety
Atypicals work well for depression
Conduct disorder
Precursor for antisocial personality disorder
Behavior is usually abnormally aggressive-before age 13
Rights of others are violated and societal norms or rules are disregarded; lack of remorse
Childhood-onset conduct disorder-before age 10
Adolescent-onset conduct disorder-after age 10
Complications of conduct disorder
Academic failure, school suspensions and dropouts, juvenile delinquency, drug and alcohol abuse (even though IED is more criminality), and juvenile court involvement
Epidemiology and comorbidity of conduct disorder
Epidemiology-4x more common with prev. dx. ODD
Comorbidity-ADHD & ODD
Risk factors of conduct disorder
Genetic
Neurobiological factors
Adolescents have reduced gray matter in cortex (decisions and reasoning)&
amygdala (emotion)- structural
Children reduced ability to empathize-functional-MRI
reduced blood flow to region (dysfunction in folds of the brain)
Environmental factors
Treatment approaches of conduct disorder
Psychosocial interventions-anger management, dysfunctional parent-child relationship
Need parental participation
Pharmacologic treatment-No FDA approved, but off label use-antidepressants, mood stabilizers, antipsychotics, & anticonvulsants
Therapy works very well!
For the tremendous aggression and lack of remorse
Callousness in antisocial goes away
Have to stay in therapy to prevent risk and family needs to be involved
Two problems related to impulse control disorders
Pyromania
Kleptomania
pyromania
repeated deliberate fire setting
Kleptomania
repeated failure to resist urges to steal objects not needed for personal use or monetary value–might steal for others
Assessment in impulse control disorders
Suicide risk r/t low self esteem, depression, and anxiety
Self assessment (they’re okay with how they’re living, see no problem, so they don’t adhere to treatment))
Diagnoses and outcomes in impulse control disorders
Risk for suicide
Impaired impulse control
Risk for other-directed violence
Defensive coping related to impulse control
Aggressive behavior
Impaired parenting
Common negative attitudes in impulse control disorder
A belief that the patient is choosing not to get better.
A belief that concerns for safety may be exaggerated (child says I’m gonna kill sibling and nobody believes it. Also kid gets jealous)
Nurses’ ethical and professional responsibility
Provide equal care to all people
Empathy
Consider the patient’s environment of origin and history of constant negative responses
Implementation in impulse control disorders
Psychosocial
Pharmacological interventions-aimed at symptoms–divalproex sodium (depakote), atypical antipsychotics like aripiprazole (abilify), risperidone (risperdal), SSRIs, mood stabilizers, beta-blockers, avoid benzodiazepines (addictive properties)
CBT for impulse control disorders
feelings, thoughts, behaviors
Psychodynamic psychotherapy for impulse control disorders
underlying feelings & motivations
for adolescents, they love to talk
Dialectical behavioral therapy (DBT) for impulse control disorders
Impulse control
Parent-child interaction therapy (PCIT) for impulse control disorders
Parent plays with child with ear piece and on the other side of the glass is someone watching also with an ear piece. The other person can see the parent and child, parent and child can’t see other person. Other person coaches parent. Several weeks to months, changes interaction pattern, very effective
Parent management training (PMT) for impulse control disorders
parent provided with positive behaviors & short neg consequences for bad behavior
Multisystemic therapy (MST) for impulse control disorders
violent juvenile offenders
What can cause communication disorders in children
substance, brain injury (intellectual disabilities, neurodevelopmental disorders, cleft palate, hearing loss). Want early diagnosis and intervention, picked up in preschools which is good
Tourette’s disorder
multiple motor tics and at least one vocal tic, has to be seen for at least a year, usually seen from ages 2-7 but can be later and go on into adulthood
Persistent motor or vocal tic disorder
single or multiple of one or the other for more than one year (NOT BOTH)
Provisional tic disorder
either or, LESS than one year
When are communication disorders seen
Happens in childhood but can be seen later
Family and communication disorders
Difficult for family to work with child, affects socialization and academic performance
Levels of ASD and savant
Level 1: not much support
Level 2: some support
Level 3: maximum support
Savant syndrome: GENIUS in one area
Assessment in ASD
Functioning, deficits, etc
Ability to cooperate with others
Very concrete in what they say
Biological pharmacotherapy for ASD
Used to improve relatedness and decrease anxiety, compulsive behaviors, or agitation
ABA for ASD
Applied behavior analysis
Encourages positive behaviors and discourages negative behaviors (don’t reinforce them, but don’t ignore them, just move onto something positive)
Why are stimulants annoying
they’re taken at like 8AM and they run out of energy around 4PM so they take another dose and have energy until 3AM which is bad especially for school-age children
2nd dose should be between 12-3 the latest
Concerta
For ADHD
Side effects: Nervousness, trouble sleeping, loss of appetite, weight loss, dizziness, N/V, headache. If ant of these effects last or get worse, talk to your doctor
Children may complain of upper abdominal GI discomfort
An empty tablet shell may appear in your stool. This is harmless because your body already absorbed the medication
Jornay
Taken at night, delayed release so it doesn’t start working until early morning. Covered all day
No spikes which is nice
JorNAYYY covers you all DAYYYY
EIBI for ASD
Early intensive behavioral intervention
Improves language and cognitive skills
ESDM for ASD
Early start Denver model
One to one interactions, joint play, and activity routines with the adult and child
