Behavioral Exam 2

Cluster A (ODD/Eccentric)

Paranoid, Schizoid, and Schizotypal; distant and mistrust, do not force closeness, use simple and direct communication; do not joke w/ patient

Cluster B (Dramatic/Erratic)

Borderline, Histrionic, Narcissistic, and antisocial; interactions may be emotionally intense or attention seeking, must stay professional and avoid power struggles, must be consistent among staff

Cluster C (Anxious/Fearful)

Avoidant, Dependent, Obsessive-compulsive; want connection but fear rejection, humiliation and low self esteem; strong need to be cared for and perfectionism with inflexible standards

Paranoid

distrust and suspicion, jealous and controlling factors, may project feelings; nursing must be neutral and direct

Schizoid

Detachment and limited desire for close relationships, nursing must not force socialization

Schizotypal

social deficits, odd beliefs and communication and perceptual disturbances; nursing needs to assess carefully

Histrionic

dramatic and attention seeking, may be provocative and seductive; nursing must stay professional and use concrete language

Narcissistic

entitlement and exaggerated self importance, needs admiration and lack empathy; nursing must be neutral and avoid power struggle

Borderline Personality Disorder

Severe impairment may involve lability, impulsivity, and unstable relationships with disturbed identity; splitting= difficulty holding positive and negative aspects of another person together

Borderline Personality Disorder Modalities

psychotropics used for symptom relief; psychosocial use of CBT and DBT

Antisocial Personality Disorder

must be 18 y/o for diagnosis; antagonism, disinhibition, profound lack of empathy and absent remorse or guilt, high risk behaviors with substance misuse and impulsivity

Antisocial Personality Disorder Treatment

no meds treat, but some may be used for aggression; main treatment is psychological therapies; focusing on observable behaviors and impulse control

Avoidant

friendly, accepting and reassuring; validate fears and gradually build social skills

Dependent

address current stressors and set limits without punishment; watch for countertransference

OCPD

guard against power struggles and prepare for unexpected changes, provide structure and allow reasonable time for habitual behaviors

Assessment across Personality disorders

assess suicidal and homicidal ideations, consider medical/substance issues, ask about recent loss and interpret ethnic, cultural and social context

Major Depressive Disorder

>5 symptoms during the same 2 week period, at least one is depressed mood or loss of pleasure, appetite or weight changes, sleep issues, fatigue, guilt, impaired cog. or thoughts of death, not history of mania or hypomania

Persistent Depressive Disorder

depressed mood most of the day, more days than not, >2 years in adults and >1 year in adolescents

Disruptive mood dysregulation disorder

ages 6-18, severe persistent irritability with recurrent outbursts

Premenstrual Dysphoric Disorder

cyclical mood/anxiety symptoms in the final premenstrual week that improves with onset of menses

Depression prevalence and co-morbidity

leading cause of disability in the US and worldwide, frequently occurs with other psychiatric disorders

Older adults with depression

disproportionate number of depressed older Americans die by suicide, 4 M’s include mentation, matters, mobility, and medication

Biochemical factors for depression

serotonin affects sleep, appetite and libido; Norepinephrine affects energy, concentration, libido and anhedonia

Diathesis stress model of depression

factors include environmental, interpersonal, life events, biological vulnerability and predisposition, and psychological stressors

Beck’s Cognition Triad

negative self deprecating view of self, pessimistic view of the world, believing negative

Nursing Assessment for Depression

becks depression inventory, Hamilton depression scale, geriatric depression scale, patient health questionnaire; along with sleep, movement, mood and affect, communication and support systems

First line psychotherapy interventions for depression

CBT, IPT, PST, CBT-I, group therapy and mindfulness cognitive therapy

Pharmacological Treatment for Depression

SSRI=#1, SNRI, antidepressants and MAOI’s=#2

Serotonin Syndrome

SHIVERS- shivering, hyperreflexia, increased temp, encephalopathy, restlessness, and sweating

Electroconvulsive Therapy (ECT)

used in suicidal pts, extremely agitated, severely manic or refusing food and fluids, no treatment works

Alternative Treatments for Depression

VNS and TMS, light therapy, st. johns wort, peer support and physical activity

Risk factors for suicide

a crisis, mental health/SUD, previous attempt, hopelessness, chronic illness, recent loss, access to lethal means and cultural/social context

Medical Aid in dying

legally and clinically distinct from suicide, must assess suffering, psychiatric symptoms, decision making, and safety in clinical context

Theories on suicide

Freud: murderous attack on self; Menninger: revenge depression or guilt; Shneidman: unbearable psychological pain with self destructive behaviors; Hendin: depression and suicide with no medication

Neurobiological aspects of suicide

strong association between suicide and low serotonin, biological response to stress may be risk factor, overactive noradrenergic system and hypothalamic-pituitary-adrenal axis abnormalities

Cultural Considerations with suicide

stereotyping, culture, religion, geography and community context, ask what certain things mean to patients

Sudden behavior changes with suicide

sudden or unexpected improvement of mood, giving away possessions, farewell notes, making a will, neglecting hygiene and failing to sleep

Columbia Suicide Severity Rating Scale (C-SSRS)

structured assessment of SI useful in triage and highly reliable, six questions and can evaluate lifetime and last three months

Delusional Disorder

delusions, grandiose, somatic or referential with largely intact functioning; >1 month

Brief Psychotic Disorder

sudden onset of delusions, hallucinations, disorganized speech or behavior for >1 day and <1 month, return to baseline is expected

Schizophreniform Disoreder

same symptoms as schizophrenia, impairment is not apparent yet, 1- <6months

Schizoaffective Disorder

major mood episode concurrent with symptoms of schizophrenia; psychosis is also present

Risk Factors for Schizophrenia

6x genetic risk, dopamine, glutamate and serotonin imbalances; less grey and white matter in frontal lobe; childhood trauma, poverty, and SUD

Early Onset of Schizo

around 15-25 with more structural brain abnormalities, more prominent negative and disabling symptoms with poorer prognosis

Later onset Schizo

ages 25-36, more likely to be female, less brain structure changes and better long term outcomes

Prodromal Phase of Schizo

mild changes in thinking, mood, concentration, and social functioning; 1-12 months before first episode

Acute Phase of Schizo

exacerbation of positive symptoms often the point of hospitalization

Stabilization Phase of Schizo

symptoms diminish, movement towards previous level of functioning

Maintenance phase of Schizo

a new baseline is established with focus on relapse revention

Positive Symptoms: Thought and Speech of Schizo

Thought: delusions, paranoia, thought blocking, thought insertion, and magical thinking

Speech: associative looseness, clang association, neologisms, echolalia, flight of ideas and circumstantiality v tangentiality

Positive Symptoms: Perception and Behavior of Schizo

Perception: hallucinations, illusions, depersonalization, and derealization

Behavior: Echopraxia, stereotyped behavior, posturing, catatonia

Negative Symptoms of Schizo

6 A’s- Anhedonia, avolition, asociality, affective blunting, apathy, alogia

Cognitive and Affective Symptoms of Schizo

Cog: concrete thinking, impaired memory, impaired executive functioning, anosognosia

Affective: assess for depression, SI risk, signal impending release, SUD

Implementation for Acute Phase Schizo

psychiatric and medical evaluation, meds, education, *monitor for polydipsia

First generation Antipsychotics

Haldol, Chlorpromazine and Fluphenazine; dopamine antagonist, positive treatment; mx for EPS, tardive dyskinesia and anticholinergic

Second generation Antipsychotics

Clozapine, Risperidone, Olanzipine and Paliperidone; serotonin and dopamine antagonist, treats positive and negative symptoms; monitor for weight gain and metabolic syndrome

Neuroleptic Malignant Syndrome

signs= muscle rigidity, fever, high CPK, diaphroesis and unstable BP, decreased responsive

response= hold antipsychotic, cooling and hydration; Dantrolene or Bromocriptine

Anticholinergic Toxicity

signs= hot and dry, urine retention, dilated pupils and tachy, delirium

response= hold all meds, cool and cath, sedate and use physostigmine

Cognition and 6 domains

the mental process of acquiring knowledge and understanding through thought, experience and senses; affects all parts of life; 6 domains=complex attention, executive functioning, learning and memory, language, perceptual motor abilities, and social cognition

Delerium

acute, transient disturbance, caused by an underlying physiological problem that is usually reversible and a medical emergency

Delirium signs

disturbances in attention and awareness, abrupt onset with lucid period, poor recall, disorganized thinking, *Illusions

Risk factors for delirium

cognitive impairment, infection, dehydrated, sleep deprivation, immobilization, vision or hearing impairment and psychoactive meds

Type of Delirium

Hyperactive= restlessness, pacing, agitation, rapid mood swings

Hypoactive= reduced anxiety, sluggish, drowsy, dazed *least recognized

Mixed= switches between hyper and hypo active

Delirium Assessment

Physiological disturbances, baseline vitals, LOC, onset, and worsening or improving factors; care for them by reorienting them

Mild NCD

modest decline in one or more domains; affects 20% of adults over 65, independence in ADL’s preserved, not due to mental disorders

Major NCD

Significant decline in more than one domain, interferes with daily functioning and independence, progresses

Causes of Major NCD

Alzheimer’s, CVA, Lewy body dementia, frontotemporal, parkinson’s, TBI

Alzheimer’s Signs

memory loss, executive dysfunction (problem solving), aphasia, apraxia, agnosia, diminished emotional expression

Alzheimer’s Assessment

confabulation(making up stories), preservation, agraphia, hyperorality, sundowning

Risk Factors for Alzheimer’s

more common in women, genetics, CV disease, head injury or trauma, late onset; modifiable risks are exercise, adequate sleep, social engagement, healthy diet, education

Alzheimer’s diagnosis

complete neuro workup, CT and PET scans, MSE, recent symptoms, rule out reversible causes

Treatment for Alzheimer’s

Cholinesterase inhibitors, NMDA receptor antagonist, anti-amyloid monoclonal antibodies, SSRI’s and sleep aids

Addiction

a chronic relapsing brain disease, compulsive drug seeking despite harm, long lasting changes in the brain

DSM-5 Criteria for SUD

impaired control with attempts to cut down unsuccessful and cravings, social impairment with giving up on activities and failing obligations, risky use, and physical effects of tolerance and withdrawal

^{Risk factors for SUD}

genetics account for 40-60%, prenatal exposure, adverse childhood events, inadequate parental supervision, poverty

Dual Diagnosis for SUD

two or more substance use and mental health disorders together, depression anxiety, bipolar, ptsd and schizo; must treat both at the same time

Intoxication

slurred speech, unsteady gait, drowsiness, lower VS, impaired judgment and impaired memory

Overdose

cardiovascular or respiratory depression, shock, seizures, coma and death

Withdrawal

elevated VS, n/v, tremors, sweats, hallucinations, seizures, delirium

Problem Drinking

binge- 4+ drinks (w) or 5+ drinks(m) on one occasion

Heavy- binge drinking on 5+ days a month

Complications of Alcohol Use disorder

hepatitis, cirrhosis, esophagitis and gastritis, pancreatitis, cardiomyopathy, peripheral neuropathy, leukopenia, thrombocytopenia, and h/n cancer

Wernicke-Korsakoff Syndrome

thiamine deficiency, confusion, ataxia, eye movement problems(wern), memory loss, confabulation, often permanent(kor)

Alcohol Withdrawal Timeline

6-24 hours- tremors, anxiety, sweating, nausea, increased VS

12-48 hours- hallucinations and withdrawal seizures

48-72 hours- delirium tremors, disorientation, severe autonomic instability

Nursing Priorities with Withdrawal

can be fatal, stay ahead of the withdrawal, use thiamine before glucose, patients may under report use

Treatment for Withdrawal

Antabuse- must avoid alcohol including mouth wash, cough syrup

Naltrexone- reduces cravings

Acamprosate- reduces post withdrawal distress and cravings

Opioid Overdose Triad and Respone

pinpoint pupils, respiratory distress, and coma; must support breathing first, then narcan, expect sudden withdrawal

Opioid Withdrawal Timelines

8-24 hours- anxiety, cravings, yawning, sweating and runny nose

72 hours- peak, chills, fever, body aches, diarrhea, insomnia, dilated pupil

1 week+- depression, anxiety, cravings

Medications for Opioid Use

Methadone- full agonist, daily clinic based

Suboxone- partial agonist, office based

Clonidine- ease withdrawal symptoms

Stimulant Use Disorder

cocaine, crack, meth; can cause agitation, aggression, paranoia, hallucinations and anxiety; can cause tachy and MI and Stroke

Stimulant Withdrawal symptoms

depression, fatigue, sleep and concentration problems; must watch for suicide risk

Treatment for Stimulant use

no FDA meds, contingency management and CBT; bupropion may help