Week 4 - Depression, Anxiety, OCD, PTSD, bipolar Flashcards
What is the diagnostic criteria for major depressive disorder?
Must be experiencing 5 or more symptoms during a 2-week period and at least one of the symptoms should be depressed mood or loss of interest/pleasure
Acronym = D - SIGECAPS
Depressed mood
Sleep - insomnia or hypersomnia (really tired during day)
Interest - loss of interest or pleasure
Guilt - inappropriate guilt or feeling worthless
Energy - fatigue
Concentration - decreased concentration
Appetite - can eat a lot or very little → weight gain or loss
Psychomotor retardation- slow movements or thinking
Suicidal ideation - thoughts of suicide
Additional required criteria (must have all 4, plus the 5 or more symptoms above)
* Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
* Episode not attributable to physiological effects of a substance or another medical condition
* Episode not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other psychotic disorder
* No history of manic or hypomanic episode
o Manic = abnormally elevated extreme changes in mood emotions, energy levels
o Hypomania = same thing but less severe form
Risk Factors of Depression:
- Prior episodes, family history, lack of social support, stressful life events
- Current substance use, medical comorbidity, economic difficulties
What is the action of antidepressants?
Increases activity of neurotransmitters in brain which lessens symptoms of depression. The neurotransmitters are dopamine, NE, and serotonin.
- Work best when combined with psychotherapy, social support, and self care
What are the functions of dopamine?
o Influences decision making
o Influences motivation
o Influences arousal
o Signals pleasure and reward
MDAP
What are the functions of NE?
o Influences alertness
o Influences motor function
o Regulates blood pressure
o Regulates HR
What is the function of serotonin?
o Regulates mood
o Appetite
o Sleep
o Social behavior
o Sexual desire
SMABS
What are the side effects of SSRIs?
HADSWISS
Headaches
Anxiety
Dry mouth
Stomach upset – N/V, diarrhea
Weight gain
Insomnia
Sedation
Sexual desire - decreased
Name the SSRIs.
- Sertraline (Zoloft)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Citalopram (Celexa)
-ine and -pram
What side effect can SNRIs have on BP?
Increase
SNRI examples:
SNRI (serotonin and norepinephrine reuptake inhibitors)
* Effexor (Venlafaxine)
* Cymbalta (duloxetine)
* Desvenlafaxine (Pristiq)
* Levomilnacipran (Fetzima)
Side Effects: Nausea, drowsiness, dizziness, nervousness, fatigue, loss of appetite, decrease in sexual desire and response, increase in blood pressure
NON-SELECTIVE CYCLICS / TCAs
- Amoxapine
- Amitriptyline (Elavin)
- Imipramine (Tofranil)
Side Effects: Dry mouth, tremors, constipation, sedation, blurred vision, difficulty urinating, weight gain, dizziness,
MAOI is in what class of medications?
Antidepressants
- Isocarboxazid (Marplan)
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Selegiline (Emsam)
Side Effects: Orthostatic hypotension, insomnia, swelling, weight gain
norepinephrine–dopamine reuptake inhibitor (NDRI) is in what class of medications?
Anti-depressants
NDRI
* Buproprion (Wellbutrin, Zyban)
* Mirtazapine (Remeron)
* Trazodone
* Nefazodone
Side Effects: Jitteriness, insomnia
Noradrenergic and specific serotonergic antidepressants (NaSSAs) are what class of meds?
Antidepressants
NaSSA
* Mirtazapine (Remeron)
Side Effects: Drowsiness, weight gain
Explain type 1 bipolar disorder.
Manic episode with increased energy or activity, abnormally elevated mood
Explain type 2 bipolar disorder
Hypomania and depressive episodes
What is mania?
Period of abnormally elevated mood and increased energy or activity
What is the diagnostic criteria for bipolar 1 disorder?
Diagnostic Criteria: Bipolar I
- Distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day
- 3 or more of the following symptoms present during the mania period: (DIGFAST)
Distractibility – gets distracted easily
Impulsivity – does thing without thinking of consequences
Grandiosity – inflated self-esteem
Flight of ideas – lots of thoughts running through mind
Activity - increase
Sleep – decreased need or deficit
Talkativeness – very talkative
Diagnostic Criteria: Bipolar I (additional required criteria)
* The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features
* The episode is not attributable to the physiological effects of a substance
What is the diagnostic criteria for bipolar 2 disorder?
- Criteria have been met for at least one hypomanic episode and at least one major depressive episode
–> Hypomanic episode is same as first two bipolar 1 criteria but lasting at least 4 DAYS instead of 1 week and LESS SEVERE - There has never been a manic episode
- The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder
- The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomanic cause clinically significant distress or impairment in social, occupational or other important areas of functioning
What class of medications are used to treat bipolar disorder?
Mood stabilizers
What is the most widely used mood stabilizer and gold standard for bipolar disorder?
Lithium - Increases NE uptake and serotonin receptor sensitivity
What are the common side effects of lithium?
TWUNT
Thirst
Weight gain
Urination
Nausea
Trembling of hands
and metallic taste
* Less common side effects can include tiredness, vomiting and diarrhea, blurred vision, impaired memory, difficulty concentrating, skin changes, slight muscle weakness, thyroid and kidney function changes
What is the relationship between lithium and sodium and fluid?
Lithium and sodium levels in body have inverse relationship
o High levels of sodium in body lower lithium levels less effect
o Low levels of sodium in body high levels of lithium and can increase side effects (danger)
Fluid applies too:
* If fluid loss from dehydration or hot climate or strenuous exercise lithium levels rising sharply
o Must assess electrolytes before lithium administration
What type of medication is DIVALPROEX/VALPROIC ACID/VALPROATE?
Mood stabilizer - anticonvulsant
What are the most common side effects of DIVALPROEX/VALPROIC ACID/VALPROATE?
Dizzy, drowsy, blurred vision, nausea
DDNB
What class of medications is carbamazepine?
Mood stabilizers - anticonvulsant
What are the common side effects of carbamazepine?
CARBA
- Confusion – dizziness, drowsiness
- Ataxia – lack of muscle coordination, tremors
- Rashes
- Blurred vision
- Anemia
- Common side effects include dizziness, drowsiness, blurred vision, confusion, muscle tremor, nausea, vomiting or mild cramps, increased sensitivity to sun, skin sensitivity and rashes and poor coordination
What is a rare and dangerous side effect of carbamazepine?
- A rare but dangerous side effect is reduced blood cell counts, soreness of the mouth, gums or throat, mouth ulcers or sores and fever or flu-like symptoms can be a side of this effect
What class of medications is lamotrigine?
Mood stabilizer - anticonvulsant
What rare but dangerous effect can occur with lamotrigine?
- Severe skin rash
- Common side effects include fever, dizziness, drowsiness, blurred vision, nausea, vomiting or mild cramps, headache, and skin rash
- combination of lithium and lamotrigine has demonstrated the highest efficacy in reducing suicidal symptoms and depressive relapse
What is the purpose of electroconvulsive therapy?
- An invasive treatment for severe mania, severe depression, treatment refractory depression, catatonia and treatment resistant schizophrenia
How does electroconvulsive therapy work?
- Small electric currents are passed through the brain intentionally triggering a brief seizure while an individual is under anesthetic
- ECT brings about neurophysiological and neurochemical changes in the brain
- The procedure takes about 5 to 10 minutes, with added time for preparation and recovery
- The changes in brain chemistry can result in improvement after as few as 6 treatments
What are the benefits and drawbacks of electroconvulsive therapy (ECT)?
BENEFITS
* Mood stabilizing property is superior to pharmacotherapy for depressive episodes, manic episodes, and mixed episodes in bipolar disorder
* Can return to usual activity a few hours after the procedure
* Can result in rapid symptom improvement
* Can be offered for inpatients and outpatients
DRAWBACKS
* Requires sedation with anesthesia in hospital
* May cause low mild transient side effects including confusion, retrograde amnesia, nausea, headache, jaw pain or muscle ache
* May cause medical complications associated with anesthesia
What is the purpose of repetitive transcranial magnetic stimulation (rTMS)?
- A non-invasive treatment for treatment of refractory depression and bipolar disorder
- Uses targeted magnetic pulses, similar to those used in an MRI machine to activate parts of the brain involved in mood regulation in the dorsolateral prefrontal cortex
- During a session, a helmet containing an electromagnetic coil is placed on the head to stimulate targeted regions of the brain
- Most people see dramatic improvement in depressive symptoms after four weeks –six weeks
BENEFITS
* Well tolerated - not painful or disruptive
* No hospitalization or anesthesia required
* No systemic side effects
* No memory loss
DRAWBACKS
* Common side effects may include headache, scalp discomfort at the site of stimulation, tingling and light headedness spasms of facial muscles and
* Uncommon side effects can include seizures and mania in people with bipolar disorder
* Treatment may not be effective for everyone
What is the purpose of ketamine IV infusion?
An invasive treatment of resistant depression that stimulates a rapid increase in glutamate
How does the ketamine IV infusion function to treat depression?
- Stimulates rapid increase in glutamate
- Glutamate strengthens neural connections in brain that were impaired by depression
- New connections help induce beneficial changes in brain circuit function
- Ketamine is administered IV in subanesthetic doses (0.5mg/kg over 40 min) in an anesthetic care unit under medical supervision
What are the common side effects of ketamine infusion?
High BP and slowed breathing
BENEFITS
* Offers fast acting symptom relieve. (within hours)
* Has anti-suicidal properties
* Well tolerated and safe
DRAWBACKS
* Requires access to operating theatre
* Common side effects may include high blood pressure and slowed breathing
* Uncommon side effects include
* Serial infusions may be required to maintain treatment effect
What is the purpose of esketamine treatment?
- A non-invasive treatment for individuals with treatment-resistant depression who have failed two antidepressant trials of adequate dosages and durations
- Esketamine Increases connections/synapses between brain cells
- Administered intranasally in an outpatient setting under medical supervision
- Provides a rapid acting anti-depressive response that can last 3-14 days
BENEFITS
* Produces rapid acting anti- depressive response
* Has anti-suicidal properties
* Anti-depressive response lasts an average of 3-14 days
DRAWBACKS
* Common side effects include temporary sedation, trouble with attention, judgment and thinking
* Initial treatment involves 6 infusions spread out of 3 weeks
* May require repeated treatments to maintain anti-depressive and anti-suicidal effects in continuation phase of treatment
Mood Disorders: Nursing Assessment
Screening
o Quick Inventory of Depressive
Symptomatology Self report (QIDS-SR)
o General Behavior Inventory (GBI)
Assessment
o Mood Disorder Questionnaire (MDQ)
o Beck Depression Inventory
o Hamilton Depression Rating Scale (HAM-D)
o Patient Health Questionnaire (PHQ-9)
Mental Status Examination
Suicide Risk Assessment
Mood Disorders: Cultural Perspectives & Experiences
- Culture affects the way we express our thoughts, emotions, and behaviors
- There are cultural differences in the way depression is manifested and treated
- One of the main differences seen across cultures is the way depression and mania are expressed
Anxiety Disorders & Obsessive-Compulsive Disorder
- Most prevalent psychiatric disorders associated with a high burden of illness
- Anxiety emotion described as dread of a potentially threatening or uncertain outcome
- Multiple factors contribute to development of anxiety disorders:
o Genetics, parental behaviour, and stressful events a key developmental stages
o Children w/ anxiety disorders more likely to demonstrate suicidal behaviour, drug and alcohol dependence, and educational underachievement later in life - Nearly 1 in 4 people will experience an anxiety disorder at some point in their lives
What is agoraphobia and examples?
Fear of being in places that feel like being trapped, helpless, or embarrassed
* Fear of open spaces, closed spaces, being outside home
* E.g., shopping malls, public transportation, elevators
Anxiety Disorders: Neurobiology
- Genetic inheritance
- Norepinephrine
- Psychosocial adversity in childhood
o Parental behaviours and modelling and stressful life events - Serotonin
- Ongoing or recent psychosocial stress
- Dopamine
Anxiety Disorders: Pharmacotherapeutic Interventions: Antidepressants & Anxiolytics
- Increase activity of neurotransmitters in the brain which help to lessen the symptoms of anxiety
o Dopamine
o Norepinephrine
o Serotonin - Work best when combined with psychotherapy, social support, and self care
What is the diagnostic criteria for specific phobia?
Extreme fear/anxiety when anticipating exposure or being exposed to feared stimulus
*Five categories of specific phobias:
o Animal type (spiders, snakes, dogs)
o Natural environment type (tornadoes, heights, water, fire)
o Blood injection type (needles, medical procedures)
o Situational type (flying on an airplane, enclosed spaces)
o Other type (phobias that do not fit into the previous four categories)
What is the diagnostic criteria for panic disorder?
Diagnostic Criteria: Panic Disorder
1. Extreme surge of intense fear and discomfort due to a perceived loss of control
2. Experience recurrent, unexpected panic attacks
3. Physical symptoms may signal the presence of a panic attack including (at least four or more):
o Dizziness
o Nausea
o Racing heart
o Shaking
o Trembling
o Sweating
o Chills
o Unsteadiness
o Shortness of breath
o Sensation of choking
o Chest pain
o Abdominal pain
o Fear of losing control
o Fear of dying
o Paresthesia (numbness or tingling sensation)
o Derealization (feelings of unreality) or depersonalization (being detached from oneself)
What is the diagnostic criteria for social anxiety disorder?
- Extreme fear of social situations
- Extreme fear of criticism or scrutiny by others in social interactions
- Intense fear often leads to avoidance of the social situation
- Intense fear can cause impairments in school, work, or relationships
- Two types:
o Specific social phobia – fear of only one or two social situations (e.g., eating, writing, or speaking in public)
o Generalized social phobia – fears most social situations (public performances or interactions)
Extra points:
* Intense fear of social situations where individual feels scrutinized (inspected closely) and negatively evaluated by others
o Tend to have poor self-esteem, highly sensitive to disapproval
o Usually occurs in early adolescence
What is OCD and define each component.
- OCD is characterized by severe obsessions (repetitive, intrusive thoughts) and compulsions (repetitive, ritualistic behaviours)
o Obsession cause anxiety, and compulsions are an attempt to eliminate it
o Person tries to ignore or suppress obsessive thoughts, but cannot - Compulsions – uncontrollable urge to do something repeatedly w/ goal to relieve anxiety caused by obsessions
What is the first line of treatment for OCD?
- First line of treatment for OCD is long-term SSRIs
- Cognitive behavioural therapy (CBT) and exposure w/ response prevention (ERP) are front-line psychotherapeutic treatments for OCD
What is the diagnostic criteria for OCD?
Diagnostic Criteria : Obsessive-Compulsive Disorder
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
Obsessions defined by:
Recurrent and persistent thoughts, urges or images that are experienced, 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 thought or action
Compulsions defined by:
Repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly
Behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation, however these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive
What are some examples of OCD?
o Fear of contamination (e.g., dirt)
o Pathologic doubt (e.g., requiring repeated checking that something is done, closed windows)
o Need of symmetry (e.g., table settings, desktop
* Common compulsions:
o Handwashing, checking and arranging things, counting
What is the first line of treatment medication for anxiety?
SSRI and SNRI
- TCA considered when SSRIs or SNRIs have failed d/t its significant side effects
- Benzodiazepines used for treating intensely distressed patients
o Should be used for short periods of time for acute anxiety and sleep disturbance d/t side effects
What are the common side effects of benzodiazepines?
SLDD
* Sedation, loss of balance, drowsiness, dizziness
* Effects are more serious when combined with alcohol or with other sedative medications
What is the first-line psychotherapy treatment for OCD and anxiety disorders?
- CBT is the evidence-based first-line psychotherapy for treatment of anxiety disorders and OCD
- The aim of CBT is to help the client to become aware of inaccurate or negative thoughts so that they can view challenging situations more clearly and respond to them in a more effective way
o Change negative thought patterns
o CBT strategies include:
Psychoeducation, self-monitoring, cognitive restructuring, and somatic exercises - CBT can be helpful either alone or in combination with other therapies
BENEFITS
* Helps individuals with illness self-management
* Has a role in preventing relapse of symptoms of anxiety
DRAWBACKS
* Individuals may feel emotionally uncomfortable at times when they are exploring painful feelings, emotions and experiences
* Individuals may feel physically drained, cry, get upset or feel angry during challenging sessions
What conditions are treated using exposure and response prevention? and what condition is it the gold standard treatment for?
- O.P.A.
- An evidence-based treatment for people living with obsessive compulsive disorder (OCD), panic disorder and agoraphobia
gold standard treatment for OCD
How does exposure and response prevention work?
- Exposure consists of habituating the client degree by degree to the feared situations in imagination and then in vivo
o Basically repeatedly exposed to their anxiety situations until anxiety subsides - The aim is to obtain a habituation of emotional responses and the extinction of avoidance behaviors which are reinforced by anxiety
- Exposure treatment is most effective when used in combination with antidepressants
BENEFITS
* Exposure to feared situations in imagination before being exposed to them in vivo reduces anxiety responses
DRAWBACKS
* Completion of homework exercises between sessions is important to optimize treatment benefits
* Services may not be available through publicly funded health care system
Cognitive Restructuring
- Is a process in which cognitions (automatic thoughts and intermediate and core beliefs) are identified, analyzed, and modified to effect positive change in mood and behaviour
- An evidence-based therapy for anxiety disorders
- Therapy has four key components:
o Breathing retraining to help to control the physiological sensations resulting in panic attacks
o Teaching abdominal breathing (Valsalva technique) to control tachycardia
o Cognitive restructuring to modify misinterpretations of bodily sensations and challenge the “danger” cognitive schemata
o Graded exposure through behavioral experiments to modify agoraphobia - Treatment typically includes 15 to 20 sessions
BENEFITS - Brief intervention is effective in reducing anxiety
DRAWBACKS - Services may not be available through publicly funded health care system
Anxiety Disorders: Nursing Assessment
- Screening
o General Anxiety Disorders test (GAD-7) - Assessment
o Generalized Anxiety Disorder Questionnaire (GADQ)
o Generalized Anxiety Disorder Severity Scale (GADSS)
o Beck Anxiety Inventory (BAI)
o Patient Health Questionnaire (PHQ-9) - Mental Status Examination
- Suicide Risk Assessment
Anxiety Disorders: Nursing Interventions
- Psychoeducation
- Delivering brief structured treatments
- Skill Teaching- illness self- management
- Supportive Counselling
- Family support & education
- Resource matching & referral
- Individual & system level advocacy
- Crisis prevention & intervention
- Monitoring Service Delivery
- Medication monitoring, management & Administration
- Physical activity and relaxation techniques
- Breathing control
o Hyperventilation is common for ppl w/ anxiety disorders
o Slow inhale through nose w/ abdomen rise and exhale slowly
What is the diagnostic criteria of PTSD?
TRAUMA.
Traumatic event occurred
Re-experiences of this event by thoughts, nightmares, etc.
Avoidance – from other people, loss of interest, motivation, from the event, pleasure,
Unable to function properly (socially, occupational, etc.)
Month – symptoms last longer than a month
Arousal (increased) – difficulty sleeping, startled reactions, irritable mood, hypervigilant (constantly assessing potential threats around you)
* Reexperiencing a traumatic event over and over having recurring nightmares
* Experiencing unwanted, disturbing memories of the event
* Acting or feeling as if the event is happening again
* Feeling upset when reminded of the event
* Staying away from activities, places or people that are reminders of the traumatic experience
* Avoiding friends and family
* Losing interest in activities that used to be enjoyable
* Being unable to feel pleasure
* Experiencing difficulty having loving feelings
* Constantly worrying
* Having a hard time concentrating
* Getting angry easily
* Having trouble falling asleep or staying asleep
* Fearing harm from others
* Experiencing sudden attacks or dizziness, fast heartbeat or shortness of breath
* Having fears of dying
Post-Traumatic Stress Disorder: Pharmacotherapeutic Interventions:
Antidepressants & Anxiolytics
Trauma Related Disorders: Non-Pharmacological Interventions: Cognitive Behavior Therapy
- Trauma therapy is the evidence-based treatment of choice for people living with trauma related disorders
- Trauma therapy aims to assist individuals to:
o Successfully handle the reality of traumatic events that occurred in the past
o Eliminate or ameliorate symptoms of trauma
o Change the focus of the past event to the present
o Boost day to day functioning
o Help individuals regain their personal power
o Equip individuals with skills to help prevent deterioration or relapse
BENEFITS - May be conducted online or in person
- Enables people to process their trauma and begin to heal from it
DRAWBACKS - Individuals may feel emotionally uncomfortable at times when they are exploring painful feelings, emotions and experiences
- Individuals may feel physically drained, cry, get upset or feel angry during challenging sessions
What is Eye Movement Desensitization & Reprocessing (EMDR)?
- Used to treat anxiety disorders and PTSD by inducing eye movements while processing traumatic memories
o An evidence-based treatment for anxiety disorders which consists in inducing eye movements when concentrated on feared imagery, bodily sensations and negative statements associated with the trauma in order to reduce anxiety and modify cognition in a positive way
o The brief structured treatment consists of up to six 90-minute sessions
BENEFITS - Well tolerated and safe
- Low dropout rates
DRAWBACKS - Services may not be available through publicly funded health care system
Trauma-Related Disorders: Nursing Assessment
- Screening
o General Anxiety Disorders test (GAD-7) - Assessment
o Generalized Anxiety Disorder Questionnaire (GADQ)
o Generalized Anxiety Disorder Severity Scale (GADSS)
o Beck Anxiety Inventory (BAI)
o Patient Health Questionnaire (PHQ-9) - Mental Status Examination
- Suicide Risk Assessment
Trauma-Related Disorders: Nursing Interventions
- Psychoeducation
- Delivering trauma informed care
- Skill Teaching- illness self- management
- Supportive Counselling
- Family support & education
- Resource matching & referral
- Individual & system level advocacy
- Crisis Prevention & intervention
- Monitoring
- Service Delivery
- Medication monitoring, management & Administration
Ways to Support Mental Health
- Listen
- Offer support
- Connection to Service
- Offer Choice
What neurotransmitters are associated with bipolar disorder?
dopamine, serotonin, NE
What neurotransmitters associated with major depressive disorder?
dopamine, serotonin, NE
What neurotransmitters are associated with schizophrenia?
dopamine, serotonin
What neurotransmitters are associated with anxiety disorders (PTSD, OCD, phobias)?
dopamine, serotonin, NE
What medication classes are associated with anxiety disorders (PTSD, phobias, OCD)?
SSRI, SNRI, TCAs, benzodiazepines, etc.
Cognitive therapies are mainly for ________ disorders
anxiety
Eye Movement Desensitization & Reprocessing (EMDR) is mainly used for _____ disorders
Anxiety (e.g., PTSD)
Phobias, panic disorder, PTSD, OCD, are all _____ disorders
anxiety