Psych Study Guide (Midterm)

DSM-V functions

What does the DSM-5 do?

The DSM-5 provides:

- Descriptions of mental disorders

- Symptoms associated with mental disorders

- Criteria used to diagnose mental disorders

MEDICAL DIAGNOSIS not Nursing DIAGNOSIS

They can:

- Direct care

- Help communication among healthcare disciplines

- Help determine prognosis

- Facilitate education

- Assist with research

Understanding different cultural responses and understanding of mental health issues

- Mental health and illness are often culturally defined.

- She also says nurses should not stereotype or make assumptions based on appearance.

What this means:

Culture can influence:

- What a person considers normal vs. abnormal behavior

- How someone describes emotional distress

- Whether mental illness is accepted or stigmatized

- Whether someone seeks professional treatment

- How symptoms are expressed

- Beliefs about the cause of mental illness

- Which treatments are considered acceptable

Legal principles on the inpatient unit

Voluntary vs. Involuntary Admission

- Voluntary: Patient agrees to admission.

- Involuntary: Patient can be admitted without consent when legal criteria are met.

Major reasons are:

- Danger to self

- Danger to others

- Gravely disabled

Confidentiality guidelines for adults and adolescents

Patients have a right to confidentiality.

- Confidentiality continues after death

- Appropriate interprofessional communication is allowed

- HIPAA applies

- There are specific exceptions

Major exception: Duty to Warn (Tarasoff Law)

- If a patient makes a credible threat against another person, healthcare professionals may have a duty to warn/protect the threatened third party.

- The case originated after a patient told his therapist that he intended to murder a woman; she was not warned and was later killed.

Patient's rights

Self-determination

Patients have the fundamental right to autonomy and may:

- Accept treatment

- Refuse treatment

- Terminate treatment

... without deceit, coercion, undue influence, duress, or prejudice.

Psychiatric Advance Directives

Patients have...

- Rights regarding psychiatric advance directives.

- A psychiatric advance directive allows a person to document preferences concerning future psychiatric care in case they later become unable to make or communicate treatment decisions.

Important Legal Connection:

- Failure to respect a patient's advance directive can constitute medical battery.

Addressing transference/countertransference

Transference:

Patient -> Nurse

- The patient projects characteristics of someone significant in their life onto the nurse/therapist.

Example:

- A patient's mother abandoned them.

They tell the nurse:

- "You're going to leave me just like everyone else."

Countertransference:

Nurse -> Patient

- The nurse projects characteristics of someone significant in their own life onto the patient.

Example:

- The patient reminds the nurse of her younger brother, so she becomes overly protective.

Psychoanalytic (Freud)

Focus:

- Unconscious + childhood

- Freud believed psychopathology resulted from unresolved childhood problems and that personality was largely formed before age 5.

Techniques include:

- Free association: let the patient say whatever comes into their mind

- Dream analysis: places significance on what we dream (talk therapy has its roots in Freud

- Exploring defense mechanisms: Unconscious ways to cope with anxiety

Features of various types of therapy P.2

Rational Emotive Behavior Therapy:

- (REBT) proposes that unrealistic and irrational beliefs cause many emotional problems.

- A form of CBT with a primary emphasis on changing irrational beliefs that cause emotional distress into thoughts that are more reasonable and rational.

Solution-Focused Brief Therapy:

- SFBT focuses on solutions rather than problems.

- Does not challenge the existence of problems

- Instead, it proposes that problems are best understood in relation to their solutions

- Solution-focused therapy assists the client in exploring life without the problem

Examples:

- Miracle questions

- Exception questions

- Scaling questions

- Relationship questions

- Compliments

Brain structures that stimulate an autonomic response: Hypothalamus

The hypothalamus plays a vital role in basic drives and regulates:

- Fear

- Thirst

- Hunger

- Sexual drive

- Aggression

It is also involved in the HPA stress response:

Hypothalamus → Pituitary → Adrenals → Cortisol

Autonomic Nervous System:

Contains:

- Sympathetic + Parasympathetic nervous systems

and participates in the fight-or-flight stress response.

Brain Structure Function: Brainsten

Structure -> Function:

Brainstem: Internal organs, blood gases, BP

Actions of Neurotransmitters Dopamine:

Dopamine

Effects:

- Fine muscle movement

- Integration of emotions and thoughts

- Decision-making

- Stimulates the hypothalamus to release hormones (sex, thyroid, adrenaline)

MH Associations:

- Decreased in Depression and Parkinson's Dx

- Increased in Mania and Schizophrenia

Actions of Neurotransmitters Glutamate (NMDA)

Glutamate (NMDA)

Effects:

- Excitatory

- Plays a role in learning and memory

MH Associations:

• Decreased in psychosis

• Abnormal increase can be neurodegenerative, i.e., Alzheimer's disease

Function of neuroplasticity

- Internal and external influences can alter the synaptic network

- Altered genetic expression or environmental trauma can alter neuronal expression, which can result in consequences for mental function and psychiatric disease

- Hormones can cause short- or long-term changes in neuronal activity, e.g., high doses of prednisone causing psychosis

Elements of the recovery process:

1. advocacy

2. engagement (first step in recovery)

3. hope

4. peer support specialists

5. person-centered care

6. positive mental health

7. psychoeducation

8. recovery-oriented nursing care

9. shared decision-making

Major idea is that recovery is person-centered and involves helping the individual build a meaningful life rather than simply eliminating symptoms.

Main point to remember:

Recovery = hope + empowerment + self-direction + meaningful life + supportive relationships.

Communication priorities with individuals in crisis

Crisis nursing is more directive than usual therapeutic communication and that interventions are time-limited and focused on the current crisis.

Priorities:

SAFETY FIRST

Assess for suicidal and homicidal ideation.

Determine whether the person or others are in immediate danger.

Reduce anxiety so the person can regain control.

Expect intense emotions and possibly illogical/erratic thinking.

Determine how the person perceives the crisis.

Assess existing coping skills and whether they are adequate.

Assess available support systems.

Focus on the immediate problem, not every underlying issue.

Major nursing goals as safety and anxiety reduction.

KNOW: Crisis = SAFETY → ↓ anxiety → assess coping/support → current problem.

1. Remain calm and nonjudgmental — use a calm voice and reassuring presence.

2. Prioritize safety — assess for suicidal thoughts, self-harm, violence, or harm to others.

3. Use simple, clear communication — crisis can make it difficult to process complex information.

4. Listen actively — allow the person to express feelings without interrupting or immediately trying to solve the problem.

5. Acknowledge and validate feelings — e.g., "This sounds very overwhelming for you."

6. Focus on the immediate problem — address what is happening right now, rather than exploring everything from the past.

7. Ask direct questions — especially about suicide/self-harm; asking directly does not encourage suicide.

8. Avoid arguing, challenging, judging, or giving false reassurance such as "Everything will be fine."

9. Offer realistic choices when possible — this helps restore a sense of control.

10. Identify coping skills and support systems the person can use once the immediate crisis is stabilized.

Safety → Calm → Listen → Validate → Focus on the present → Problem-solve/support.

Verbal vs. nonverbal communication

Verbal communication: the actual words spoken or written. The words should be clear and appropriate for the person receiving them.

Verbal communication:

The process of verbal communication involves a sender, a message, and a receiver. The patient is often the sender, and the nurse is often the receiver, but communication is always two ways

Nonverbal communication: everything communicated without the actual words, including:

- Eye contact

- Facial expressions

- Tone of voice

- Posture

- Body positioning

- Physical appearance

- Personal space

Non-verbal communication:

Gestures, facial expressions, and body language communicate more than verbal messages.

* If verbal and nonverbal messages conflict, the listener should rely on the nonverbal message.

- For example, if a patient says that they feel fine but has a sad facial expression and is slumped in a chair away from others, the message of sadness and depression, rather than the patient's report of feeling fine, should be accepted. The same is true of a nurse's behavior.

- People with psychiatric issues often have difficulty verbally expressing themselves and interpreting the emotions of others.

- Nonverbal behavior varies from culture to culture.

- A major concept from your communication material is congruence: your verbal and nonverbal messages should match. Facial expressions and body language can reveal feelings even when your words say something different.

Self-disclosure (not a good idea)

Defintion: The nurse shares personal information about themselves with the patient

One of the most important principles of therapeutic communication for the nurse to follow is to focus the interaction on the patient's concerns.

- Use self-disclosure cautiously and only when the disclosure has a therapeutic purpose

Therapeutic communication with psychotic individuals

Therapeutic communication = ongoing process of interaction which meaning emerges

- The goal is to maintain safety, build trust, decrease anxiety, and keep the person oriented to reality without arguing with them.

- Use calm, simple, clear statements

- Be honest and consistent to build trust.

- Do not argue with or reinforce delusions. Instead, acknowledge the person's feelings while presenting reality.

Patient: "The FBI put cameras in my room."

Nurse: "That sounds frightening. I don't see any cameras in the room."

- For hallucinations, assess what they are experiencing, especially command hallucinations ("Are the voices telling you to hurt yourself or someone else?").

- Present reality without challenging the patient aggressively: "I understand you hear voices, but I do not hear them."

- Focus on the feelings behind the delusion/hallucination rather than trying to prove it isn't real.

- - Maintain appropriate personal space and avoid unexpected touching.

- Give one direction/question at a time and allow extra time for responses.

- Redirect toward reality-based activities or topics when appropriate.

- Avoid "why" questions, excessive questioning, or lengthy explanations.

- Do NOT validate the psychosis, but DO validate the emotion.

- Ex. "It sounds like you're frightened. I don't see anyone following you, but I understand that this feels very real to you."

Priorities in therapeutic communication with suicide risk:

The priority is SAFETY.

Ask directly about:

- Suicidal thoughts

- Plan

- Intent

- Access to means

- Immediate safety

- Don't avoid the word suicide because you're afraid of "putting the idea in their head."

KNOW:

- With suicide risk, safety overrides everything else.

Various defense mechanisms: Acting out

- Acting out: Expressing emotions through actions instead of talking about feelings.

Defense mechanisms: Idealization

- Idealization: Seeing someone as excessively positive or perfect while ignoring their flaws.

Possible complication and dietary modifications with MAOIS

- MAOIs inhibit the breakdown of serotonin and norepinephrine.

- Ex. Phenelzine (Nardil), tranylcypromine (Parnate), and transdermal selegiline.

Major complication: HYPERTENSIVE CRISIS

Avoid foods high in TYRAMINE:

- Strong/aged cheeses

- Cured meats: sausage, pepperoni, salami

- Pickled/fermented foods

- Soy sauce, shrimp sauce, fish sauce, miso, teriyaki

- Soybeans/tofu

- Snow peas/fava beans

- Dried or overripe fruits

- Avocados

- Nuts

- Alcoholic beverages such as beer, red wine, sherry and liqueurs

These foods can cause hypertensive crisis with MAOIs.

KNOW: MAOI + TYRAMINE = HYPERTENSIVE CRISIS

Pharmacodynamics vs. Pharmacokinetics

Pharmacodynamics = what the DRUG does to the BODY.

Includes:

- Mechanism of action

- Receptors

- Ion channels

- Enzymes

- Carrier proteins

- Side effects/drug responses

Pharmacokinetics = what the BODY does to the DRUG.

Think:

A-D-M-E

1. Absorption

2. Distribution

3. Metabolism

4. Excretion

Memory trick: Dynamics = Drug → Body Kinetics = Body → Drug

Pharmacogenetics

Pharmacogenetics = genetic differences can change a person's response to psychiatric medications.

- Genetic variations affect responses to psychotropics.

- Ethnic and individual variations affect drug metabolism.

- Some people metabolize medications differently.

- Genotyping is available for some medications and can be especially useful when there are significant problems with side effects or ineffectiveness

Side effects of antidepressants: TCAs (Tricyclic Antidepressants):

Side effects depend on the class.

TCAs (Tricyclic Antidepressants):

cause...

- Orthostatic effects

- Anticholinergic effects

- Lower seizure threshold

Anticholinergic side effects ACE

Especially associated with TCAs.

- Urinary hesitation

- Blurred vision

- Dry mouth

- Constipation

-> Can't pee, can't see, can't spit, can't shit.

Side effects of antipsychotics

First-generation/typical

Common effects include:

- Orthostatic hypotension:

- Dry mouth

- Urinary retention

- Blurred vision

- Sedation

- EPS (Extrapyramidal Symptoms)

- Risk for tardive dyskinesia

EPS (Extrapyramidal Symptoms):

- Parkinsonism→ slow movements, muscle stiffness, tremors, and balance problems

- Dystonia → abrupt rigidity; can be an emergency

- Akathisia → restlessness, pacing, feels compelled to move

Neuroleptic Malignant Syndrome (NMS):

Very serious:

- Extreme rigidity

- Autonomic instability

- BP changes

- Diaphoresis

- Fever

- Delirium

- Requires hospitalization/ICU.

Tardive dyskinesia:

- Abnormal involuntary movements

- Associated particularly with first-generation medications

- Risk increases with cumulative exposure

- Monitor with AIMS.

Second-generation/atypical

Big concern...

METABOLIC SYNDROME:

- Weight gain

- Hyperlipidemia

- Diabetes

- Monitor weight, lipids, fasting glucose, and A1C.

KNOW: Typical → think MOVEMENT (EPS/TD); Atypical → think METABOLIC

Precautions with lithium

Before starting:

- BUN/creatinine

- TSH

- Pregnancy testing when applicable

After starting:

- Lithium level checked in 5-7 days

- Lecture target therapeutic range: 0.5-1.2

- Toxicity begins at 1.5+

Main takeaway

Lithium has a narrow therapeutic range, so blood-level monitoring is extremely important

Signs of success for clients in groups

- Participates in group + more comfortable sharing.

- Communicates feelings/ thoughts openly

- Listens to and respects others

- Gives and accepts feedback appropriately.

- Develops insight/self-awareness about their own feelings and behaviors.

- Recognizes they are not alone and that others may have similar problems or feelings (universality).

- Develops healthier interpersonal/social skills through interactions with group members.

- Uses new coping and problem-solving skills learned in the group.

- Provides support to others rather than focusing only on themselves.

- Applies what was learned in the group to life outside the group.

Main thing to remember

- Successful group therapy = increased participation + insight + communication + healthy relationships + improved coping.

- A client doesn't necessarily have to be talking constantly to be successful. Listening, gradually becoming involved, accepting feedback, and showing improved coping can all demonstrate progress.

Stress and immune response

- Stress can change and suppress immune functioning, making a person more prone to illness when highly stressed.

Immune changes occur through:

- Hypothalamic-Pituitary-Adrenal (HPA) axis

- Sympathetic Adrenal Medullary axis

The corticosteroid stress response also suppresses reproduction, growth, and immunity.

KNOW: Chronic stress → ↑ cortisol → ↓ immune function → ↑ vulnerability to illness.

Allostatic load:

- Allostasis = how the body adapts to maintain physiological stability during changing demands.

- Allostatic load = the wear and tear on the body caused by chronic stress.

- Chronic stress → chronically ↑ cortisol → physical + psychological damage → depression, illness & poor health.

Easy distinction:

- Allostasis = adaptation

- Allostatic load = COST of constantly adapting

Stress-diathesis definition

- Stress is especially harmful in individuals with a genetic predisposition to psychiatric pathology.

Stress-diathesis model:

- A person has an underlying vulnerability/predisposition (diathesis) to a mental disorder, and stress can interact with that vulnerability and contribute to the disorder becoming expressed.

Think:

- DIATHESIS = vulnerability + STRESS = potential development/expression of disorder

- Severe stress can weaken biological resistance to psychological pathology.

1. Stress + immune system: → Chronic/severe stress can suppress immunity → more prone to illness.

2. Allostatic load: → Wear and tear from chronic stress.

3. Stress-diathesis: → Predisposition/vulnerability + stress → increased risk for development/expression of mental illness.

Chapter 20: Managing Anger, Aggression, and Violence

Q1: Escalating Client Response:

- Early Sign: Hyperactivity/restlessness is the top indicator of escalation.

- De-Escalation: Use least restrictive measures first. Speak slowly, calmly, and simply.

- Interventions: Maintain physical distance, do not touch, identify specific stressors, offer oral PRNs, and clear bystanders.

Chapter 20: Managing Anger, Aggression, and Violence

Q2: History of Violence & RN Behaviors:

- Predictor: Past violence is the #1 predictor of future violent behavior.

- RN Behaviors: Use 1 primary staff speaker with backup nearby, stand in a supportive side stance (>arm's length), keep hands visible, and offer objective feedback ("You seem angry").

- Avoid: Wearing grabable jewelry, inconsistent limit-setting, authoritarian control, or a "show of force."

Chapter 21: Crisis, Bereavement, and Disaster

Q1: Crisis Communication Priorities:

- Directive Care: Nursing interventions during a crisis must be more directive, time-limited, and strictly focused on resolving the current situation.

- Safety First: Assess immediately for suicidal or homicidal ideation (e.g., ask directly: "Do you think you can keep yourself safe?" and "Have you considered killing yourself or someone else since this event?").

- Anxiety Reduction: Assist the individual in drawing upon their inner resources and existing coping mechanisms.

- ABCs of Mental Health First Aid:

--> Arousal: Decrease physical/emotional excitement by providing comfort, caring, and consolation.

--> Behaviors: Assist survivors to function effectively in daily tasks.

--> Cognition: Keep survivors focused on reality in the here and now, practical problem-solving, and available community resources.

Chapter 21: Crisis, Bereavement, and Disaster

Q2: Critical Incident Stress Debriefing (CISD):

- Purpose: Provides a safe, controlled environment for individuals or groups involved in a crisis/disaster to process feelings and thoughts.

- Timing & Effectiveness: The sooner debriefing occurs following an event, the more effective it is.

- Key Considerations: Debriefing is not effective for everyone and should never be compulsory/mandatory.

- Self-Assessment for Nurses: Healthcare workers in disaster settings require support and debriefing to prevent burnout and manage risks (e.g., an unrealistic "need to be needed" or difficulty terminating client relationships).

Chapter 21: Crisis, Bereavement, and Disaster

Question 3: Nature of grief

- Bereavement Concept: Bereavement is a process of healing and adapting to loss, influenced by age, cultural practices, and social support systems.

- Dual Process Model: A non-linear framework where a grieving individual oscillates between loss-oriented coping (preoccupation with the deceased) and restoration-oriented coping (managing lifestyle, financial, and identity changes resulting from the loss).

- Types of Bereavement:

--> Uncomplicated Bereavement: Normal, painful, and disruptive response that naturally moves toward resolution without requiring clinical intervention.

--> Traumatic Grief: Prolonged and difficult grief influenced by traumatic external circumstances surrounding the death (e.g., COVID-19 isolation or delayed funerals).

--> Complicated Bereavement / Prolonged Grief Disorder (PGD): Characterized by intense emotional pain and loneliness persisting 6 months or longer after the loss (occurs in 10-20% of cases, with higher risk if the death was sudden, unexpected, or stigmatic)

Chapter 22: Suicide (Depression and Suicide)

Question 1: Nursing assessment and nursing interventions for suicidal ideation

Suicidal Ideation Assessment & Safety:

- Risk: Previous attempt is the #1 predictor (65-70%). Look for hopelessness or sudden mood improvement.

- Plan Evaluation (LID): Lethality (deadliness), Intention, Detail/Means.

- Safety Interventions: Direct line-of-sight / 1-on-1 observation; remove all hazards (sharps, non-breakaway fixtures); search room/gifts. High risk at admission and shift change

Chapter 22: Suicide (Depression and Suicide)

Q2: Primary Cause of Suicide:

- Primary Cause: Hopelessness is the #1 reason for suicide.

- Other Contributing Factors: Escaping terminal illness, avoiding feeling like a burden, untenable family or personal situations (loss of job/status, public humiliation, financial ruin, anger), avoiding punishment, and lack of social support

Chapter 24: Schizophrenia and Other Psychotic Disorders

Question 1: Nursing interventions and therapeutic communication with individuals with Schizophrenia

Therapeutic Communication:

- Validate reality without arguing with or reinforcing delusions; focus communication on the "here and now".

- Make honest attempts to understand disorganized speech; give simple, clear verbal and written instructions.

- If the patient is ambivalent or struggling to make decisions, limit options and be directive.

Interventions for Auditory Hallucinations (AH):

- Teach distraction/competition strategies (listening to music, reading aloud, counting backward, performing chores).

- Encourage reality testing (looking around to see if others react to the sound).

- Teach self-talk techniques: instruct the client to state "Go away! You aren't real," recognizing voices as symptoms.

General Interventions:

- Avoid power struggles; assist with grooming and hygiene.

- Monitor for polydipsia (excessive fluid intake) to prevent life-threatening hyponatremia and seizures.

- Involve the family in structured support groups (e.g., NAMI Family-to-Family).

Chapter 24: Schizophrenia and Other Psychotic Disorders

Question 2: Effects and side effects for 1st, 2nd & 3rd gen anti-psychotics

1st Gen (Haldol, Thorazine):

- Target positive symptoms; high EPS (Extrapyramidal Symptoms): (dystonia, akathisia, parkinsonism), TD, anticholinergic effects.

2nd Gen (Clozapine, Zyprexa, Risperdal): Target positive + negative symptoms; metabolic syndrome.

- Clozapine: Risk of Agranulocytosis (monitor WBC).

- Ziprasidone: Risk of QT prolongation.

- Lurasidone: Take with a 400-calorie meal.

3rd Gen (Abilify):

- Dopamine stabilizer.

Neuroleptic Malignant Syndrome (NMS):

- Medical emergency! High fever, severe rigidity, autonomic instability, normal pupils. Stop med immediately & cool.

Q3: Side Effect Medications:

- For EPS (Acute Dystonia / Pseudoparkinsonism): Anticholinergic medications: Benztropine (Cogentin), Trihexyphenidyl (Artane), or Amantadine (Symmetrel).

- For Akathisia: Beta-blockers (e.g., Propranolol) or Benzodiazepines.

- For Tardive Dyskinesia (TD): Valbenazine (Ingrezza) (monitored using the AIMS scale)

Q4: Stress-Diathesis Model:

- A model explaining that mental illness results from a biological/genetic vulnerability or predisposition (diathesis) that is activated or triggered by environmental, physical, or psychological stressor

Chapter 25: Depression (Major Depressive Disorder)

Question 1: MAOIs and diet restrictions

- Mechanism: Monoamine Oxidase Inhibitors (e.g., Phenelzine/Nardil, Tranylcypromine/Parnate, Isocarboxazid/Marplan) block the enzyme that breaks down monoamines, including tyramine.

- Dietary Restriction: Patients must strictly avoid foods high in tyramine to prevent a medical emergency known as a Hypertensive Crisis.

- Contraindicated Foods: Aged/preserved cheeses, preserved or cured meats, draft beer/red wine, avocados, figs, tofu, smoked fish, nuts, and bananas.

- Medication Restrictions: Must not be combined with other antidepressants, St. John's Wort, OTC cold remedies/decongestants, or excessive caffeine. (Note: The Selegiline/EMSAM transdermal patch at low doses does not require dietary restrictions)

Question 2: Symptoms of depression

- DSM-V Criteria: Requires 5 or more symptoms for at least 2 weeks, representing a change in functioning (at least one symptom must be depressed mood or anhedonia).

- Core Symptoms: Depressed mood, anhedonia (loss of interest or pleasure), sleep disturbances, fatigue/low energy, changes in appetite or weight, feelings of worthlessness or excessive guilt, difficulty concentrating, psychomotor agitation/retardation, and suicidal ideation.

- Vegetative Physical Symptoms: Significant appetite/weight changes, sleep disruptions, and severe energy depletion

Question 3: Common SEs and cautions associated with antidepressant categories

SSRIs (Selective Serotonin Reuptake Inhibitors)

ex. Fluoxetine/Prozac, Sertraline/Zoloft, Escitalopram/Lexapro:

- Common SEs: Nausea/vomiting, headache, insomnia or drowsiness, agitation, sexual dysfunction, weight gain, emotional blunting.

SNRIs (Serotonin-norepinephrine reuptake inhibitors)

ex. Venlafaxine/Effexor, Duloxetine/Cymbalta:

- Common SEs: Dry mouth, constipation, sweating, vertigo, anxiety, N/V, sexual dysfunction.

NDRIs (Norepinephrine and dopamine reuptake inhibitors)

ex. Bupropion / Wellbutrin:

- Advantages: Little to no sexual dysfunction.

- SEs/Cautions: Tachycardia, weight loss, dry mouth, agitation.

- Key Caution: Can lower the seizure threshold.

SARIs (Serotonin Antagonist and Reuptake Inhibitors)

ex. Trazodone / Desyrel:

- Common SEs: Marked sedation and hypotension.

- Rare Caution: Risk of priapism (painful, prolonged erection).

NaSSAs (Noradrenergic and Specific Serotonergic Antidepressants)

ex. Mirtazapine / Remeron:

- Common SEs: Pronounced sedation, weight gain, and increased appetite.

TCAs (Tricyclic antidepressants)

ex. Amitriptyline/Elavil, Imipramine/Tofranil:

- Common SEs: Anticholinergic effects (dry mouth, severe constipation, urinary retention), orthostatic hypotension, sedation.

- Key Cautions: Low therapeutic index (high lethality in overdose) due to severe cardiac toxicity.

Serotonin Syndrome (SS) Warning:

- Life-threatening overactivation of serotonin receptors when combining serotonergic drugs (or starting MAOIs within 2 weeks of SSRIs).

- Distinct Symptoms: Hyperreflexia (clonus), dilated pupils, and hyperactive bowel sounds

Chapter 26: Bipolar Disorder

Q1: Lithium Levels & Nursing Care:

- Therapeutic Range: 0.4 - 1.3 mEq/L.

- Early Toxicity (1.5 mEq/L): Fine hand tremors, N/V/D, lethargy, muscle weakness.

- Advanced/Severe Toxicity (>1.5-2.5+ mEq/L): Coarse tremors, confusion, ataxia, seizures, coma.

- Lab Timing: Draw trough levels 8-12 hours post-dose, 5 days after starting/changing doses.

- Teaching: Maintain steady salt and fluid intake (dehydration/low sodium causes lithium toxicity).

Q2: Anticonvulsant Mood Stabilizers:

- Valproic Acid / Divalproex (Depakote): First-line maintenance mood stabilizer; carries a rare but serious risk of hepatotoxicity (requires liver function and platelet monitoring).

- Carbamazepine (Tegretol): Used for rapid cycling and acute mania; requires monitoring liver function and platelet counts.

- Lamotrigine (Lamictal): Effective for bipolar depression (not acute mania); carries a black-box warning for a rare, deadly skin rash: Stevens-Johnson Syndrome (SJS).

- Oxcarbazepine (Trileptal): Also carries a risk of Stevens-Johnson Syndrome (SJS).

- Other Anticonvulsants: Topiramate (Topamax) and Gabapentin (Neurontin)

DSM-V 5: Not Functions

What does it NOT provide?

It does not provide:

- Etiology: (cause) what caused the disorder

- Epidemiology: how common the disorder is

- Treatment plans: how to treat the disorder

Volunatary Admission

Individual agrees to admission

Involuntary Admission

Involuntary: Patient can be admitted without consent when legal criteria are met.

Major reasons are:

- Danger to self

- Danger to others

- Gravely disabled

• they still have the right to refuse medications

4 areas of cultural consideration: Communication

Communication: some cultures communicate intensely and w/ intense body language when describing problems

OR

Other cultures are more restricted/reserved with body language

4 areas of cultural consideration: Eye Contact

Cultural norms direct eye contact

Direct eye contact+ disrespect

Avoiding eye contact: respect

OR opposite

• do not use it as a measure of attentiveness

4 areas of cultural consideration: Touch

Touch has different interpretations across gender and class

4 areas of cultural consideration: Cultural Filters

• everyone views the world differently, which affects personal beliefs and behaviors

Types of Involuntary Holds:

California Hold:

- 5150: 72-hour hold

- 5250: Additional 12 days

- 5350: Temporary conservatorship up to 60 days

Writ of Habeas Corpus:

A patient being held involuntarily can legally contest the hold

- A court date is set, and arguments are heard from both sides

- The court then determines if the person is being denied due process of law (ex., being held illegally)/ false imprisonment

Restraints:

LAST RESORT.

Can be used when:

- Patient is physically harmful to self/others

- Behavior creates danger to staff/facility

- Less restrictive interventions have failed

- Sensory overstimulation needs to be decreased

- Patient requests a controlled environment

Requirements include:

- Written MD order

- Specific time limit

- Regular review

- Careful documentation

- Extensions must be reauthorized (every 24 hours)

Patient Right/ Informed Consent

Informed Consent

For consent to be informed, the patient must understand:

1. Nature of the condition/problem

2. Nature and purpose of treatment

3. Risks and benefits

4. Alternative treatments

5. Probability of successful treatment

6. Risks of refusing treatment

... accepting medication implies consent.

Right to Treatment/Refusal

Right to Treatment

Treatment must occur:

- In a humane environment

- With qualified and sufficient staff

- With an individualized plan of care

Right to Refuse

- An involuntarily hospitalized patient can STILL refuse medication.

- Exception: when the patient is imminently dangerous to self or others, or appropriate legal procedures establish treatment authority.

Autonomy:

• Pt right to make choices for themselves based on their own values and beliefs

• A competent patient refuses a prescribed antipsychotic. The nurse explains the risks and benefits, then respects the decision and documents it.

Beneficence:

• Nurse’s duty to do good/cause no harm

• Advocating for a patient with severe depression to get a medication review because their current regimen isn't working

Justice

• Treat others equally and fairly

• Giving a patient with substance use disorder the same quality of care and attention as any other patient, without judgment.

Nonmaleficence:

• Right to not inflict harm

• Not using restraints or seclusion as punishment or for staff convenience, and using them only as a last resort.

Secondary Ethical Principle: Veracity

• The duty to tell the truth

• A patient asks, "Am I going to be locked up here forever?" The nurse doesn't offer false reassurance or deflect. She explains the treatment plan, the review process for his status, and what he can do to work toward discharge, in a calm and sensitive way.

Fidelity:

• Keeping a promise/ Being faithful to one's obligations and duties to others

• The nurse tells an anxious patient, "I'll come back at 2:00 to sit with you." A crisis on the unit delays her, but she still returns as soon as she can, apologizes, and spends the promised time with the patient.

Paternalism:

• Having the expertise to make decisions for others' welfare and using it

• A patient with acute mania has been awake for three days, is giving away all his money, and says he plans to drive across the country tonight. He refuses to stay for treatment. Based on his impaired judgment and safety risk, the team pursues an involuntary hold and administers ordered medication

Cognitive Disorder: Black-and-white (polarized) thinking

• All or nothing/ seeing things as only two extremes, perfect or terrible, with nothing in between.

• Jamie scores 88% on a pharmacology test and says, "That's not an A, so I totally failed."

Cognitive Disorder: Overgeneralization

• One bad event means nothing will go right

• I messed up once, so I'll never be able to do this."

Cognitive Disorder: Filtering

• Negative detail ruins everything (thinking about only the bad)

• A student gets 47 out of 50 on an exam and can only think about the 3 questions they missed all evening

Cognitive Disorder: Labeling

• Turning a characteristic into a fixed label

• After forgetting a medication side effect during clinical, Devon says, "I'm so stupid."

Cognitive Disorder: Catastrophizing

• Expecting the worst possible outcome

• "I'll fail the class, lose my spot in the program, and never become a nurse.

Cognitive Disorder: Jumping to conclusions

• Deciding what's true without real evidence.

• Sam texts a classmate and gets no reply for two hours. Sam thinks, "She must be mad at me."

Cognitive Disorder: Control fallacy

• Seeing yourself as helpless/ victim of fate

• "Nothing I do matters. It's all just luck."

Fallacy of fairness:

• Resentment because life isn't matching your idea of what's "fair."

• Alex studies for 20 hours and gets a B, while a friend studied 5 hours and got an A. Alex thinks, "This isn't fair," and stews about it for days.

Blaming:

• Putting all the fault on others for your pain, or on yourself for everything.

• "My roommate is so loud. That's the only reason I failed."

Shoulds:

• Rigid rules about how you or others “should” act.

• "I should never need help with anything. Good nursing students should get it right the first time."

Emotional reasoning:

• “I feel it”: therefore, believing something is true just because you feel it strongly.

• "I feel like I'm going to fail, so I must be unprepared."

Fallacy of Change:

• Believing you can only be happy if another person changes.

• "I'd be less stressed if my partner would just stop asking about my grades. Nothing will get better until they change."

Always being right:

• Feeling like you must prove you're correct, even if it hurts a relationship or stops you from learning.

• During a study group, Taylor argues for 10 minutes that their answer is right, even after the textbook shows otherwise, because being wrong feels unbearable.

Erikson Lifestage: Trust vs. Mistrust (Infancy)

• Babies learn whether the world is safe and their needs will be met.

• A baby cries when hungry, and a caregiver reliably feeds and comforts them. The baby learns, "People will take care of me."

Erikson Lifestage: Autonomy vs. Shame & Doubt (Toddler) 1-3

• Toddlers want to do things themselves. Being allowed to try builds independence, while constant criticism builds self-doubt.

• A 2-year-old insists on putting on their own shoes. The parent is patient, lets them try, and praises the effort even if the shoes are on the wrong feet.

Erikson Lifestage: Initiative vs. Guilt (Preschool) 3-5

• Children start planning, playing, and taking the lead. Encouragement builds confidence, while being made to feel their ideas are bad builds guilt.

Erikson Lifestage: Industry vs. Inferiority (School Age 6-11)

• ids learn skills and want to feel competent. Success builds a sense of accomplishment, while repeated failure or comparison builds a sense of being "less than."

Erikson Lifestage: Identity vs. Role Confusion Adolsence (12-18)

• Teens ask, "Who am I?" They explore beliefs, friendships, and future goals to form a sense of self.
  Healthy scenario: A 16-year-old tries out for the drama club, volunteers at an animal shelter, and starts thinking about becoming a veterinary technician. They are figuring out what fits them.

Erikson Lifestage: Intimacy vs. Isolation Young Adulthood (19-40)

• Young adults seek close, committed relationships. Being able to share yourself builds intimacy, while fear of closeness leads to loneliness.

Erikson Lifestage: Generativity vs. Stagnation (Middle Adulthood) 40-65 years

• Adults want to contribute to the next generation through parenting, mentoring, work, or community service. Without that sense of purpose, they feel stuck and unproductive.

Erikson Lifestage: Integrity vs. Despair (Older Adulthood) 65 years or older

• Older adults look back on their lives. If they feel satisfied and at peace, they gain integrity. If they feel regret and that time is too short to fix it, they feel despair.

• A 75-year-old dwells on missed chances and broken relationships and says, "My life was wasted, and now it's too late."
  Strength gained: Wisdom

Psychodynamic Therapy:

Grew out of psychoanalysis, BUT:

- Therapist is more active

- Focuses on current problems

- Emphasizes emotional expression

- Looks for recurring patterns

- Explores how past experiences affect current relationships

- Goal = improvement, not necessarily "cure."

Behavioral Therapy:

Does NOT rely on insight.

Focuses on learned behavior.

Examples:

- Token economy: earn privileges

- Modeling: exposure to desired behavior modeled

- Behavior modification: operant conditioning (positive reinforcement)

- Systematic desensitization: Incremental exposure to feared item/situation paired with relaxation techniques

- Aversion therapy: pair problem behavior with something negative

- Biofeedback: used to control physiological responses to stress

Cognitive-Behavioral Therapy:

- Addresses habitual thinking patterns (schemas) made up of automatic thoughts that distort one's sense of reality

- It is an evidence-based practice and is the most common/useful therapy for depression, anxiety, phobias, and chronic pain (other than biological therapies-medications)

- Patients are taught to identify and challenge negative thoughts and distortions, test reality, and substitute or consider more positive alternatives

- People are disturbed not by an event but by the perception of that event.

- Whenever and however a belief develops, the individual believes it.

- Work and practice can modify beliefs that create difficulties in living

Brain structure Function: Reticular activating System (RAS):

Sleep-/wake cycle

Brain structure: Cerebellum

Cerebellum: Coordination + balance

Brain Structure Cerebrum:

Cerebrum: Mental activity, perception, emotion, memory, skeletal muscle control, language

Brain Structure Frontal lobe:

Frontal lobe: Thought processes

Brain Structure: parietal lobe

Parietal lobe: Sensory + motor

Brain structure occipital lobe:

Occipital lobe: Vision

Brain structure: temporal lobe

Temporal lobe: Hearing

Brain structure: hypothalamus

Hypothalamus: Fear, thirst, hunger, sex drive, aggression