EXAM 3 MENTAL HEALTH

intoxication

a reversible syndrome of sx following excessive use of a substance

tolerance

person requires a higher dose of drug to achieve the same level of response achieved initially

withdrawal

physiological sx that occur when a person stops using a substance

addiction

disease of the brain reward and related circuitry; dysfunction in these circuits is connected to pathologically pursuing reward/relief by substance use

recovery

a process of change, movement toward improved health and wellness

what are the predisposing factors to substance-related disorders (5)

biological factors: genetics, neuronal pathways create memory for pleasure sensation

psychological factors: developmental influences, personality factors

Social Learning & Conditioning

Cultural & Ethnic Influences

Risks: overdose, suicide, homicide

substance use (3)

- larger amounts, over a longer time

- time obtaining, using, recovering from use

- craving, intense desire/urge to use

social impairment (2)

- inability to fulfill role obligations

- continued use despite problems

risky use

use of substances in hazardous situations

physical effects of ETOH use

intoxication, tolerance, withdrawal

opioid withdrawal assessment

sx can occur after the abrupt cessation of heavy opioid use

- use COWS (clinical opiate withdrawal scale)

opioid withdrawal tx

methadone (opioid agonist)

buprenorphine (opioid partial agonist)

clonidine (alpha 2 agonist; reduces sx of diarrhea, cramps, palpitations, sweating; doesn't help with cravings)

opioid use disorder: tx modalities

buprenorphine and methadone (reduce cravings)

naltrexone (opioid antagonist prevents intoxication and rewarding/euphoric effects)

- injectable, long-acting given IM once a month to prevent relapse

- should be free of opioids 1 week before initiating

opioid use disorder psychological tx (2)

- individual therapy, family therapy, group therapy, social skills training

- peer-led support groups, Narcotics Anonymous (NA)

alcohol use disorder (5)

problematic pattern of use, leading to clinically significant impairment or distress

- alcohol taken in larger amounts, or over a longer time

- craving, or a strong desire to use alcohol

- failure to fulfill major role obligations

- continued use despite physical or psychological problems

- tolerance & withdrawal sx occur

Alcohol Use Disorder: systemic effects (8)

peripheral neuropathy: B vitamin deficiency = nerve damage, pain, tingling of extremities

alcoholic myopathy: results from the same B vitamin deficiency

alcoholic cardiomyopathy: accumulation of lipids in myocardial cells

esophagitis, gastritis, pancreatitis (acute or chronic)

leukopenia/thrombocytopenia

fetal alcohol syndrome

alcoholic hepatitis: enlarged liver; N/V, anorexia, fever, jaundice, ascites

cirrhosis of the liver: destruction of liver cells; portal HTN, esophageal varices & hepatic encephalopathy

wernicke-korsakoff syndrome

related to thiamine deficiency, caused by poor nutrition associated with alcohol use or malabsorption of nutrients

wernicke encephalopathy syndrome sx and tx

altered gait, confusion, vestibular and ocular motility, abnormalities,

treatment: IV thiamine; acute and reversible (may progress into korsakoff)

korsakoff syndrome sx and tx

sx: confusion, loss of memory, confabulation

tx: thiamine for 3 to 12 months; chronic w/ recovery rate of 20%

alcohol withdrawal (2)

signs begin 6-8 hours after alcohol cessation

- mild to moderate sx: agitation, N/V, impaired cognition, increased BP, HR, temp

- withdrawal seizures may occur within 12 to 24 hrs after cessation

delirium tremens (DTs) (2)

can happen anytime in the first 72 hours

- autonomic hyperactivity: tachycardia, diaphoresis, fever, anxiety, HTN, delusions, and hallucinations

- withdrawal delirium: can result in death if untreated

alcohol withdrawal assessment (3)

used to prevent delirium; VS q2-4hrs; CIWA q2-4hrs

- oral lorazepam or diazepam for acute agitation, DTs, hallucinosis

- if delirium appears; IV lorazepam

- dehydration can be corrected with oral or IV fluids

pharmacotherapy for alcohol use disorder (4)

- folic acid, multivitamin, thiamine

- disulfiram (inhibits aldehyde dehydrogenase enzyme; blocks alcohol metabolism) NOT given within 12hr of alc consumption

- acamprosate: inhibits glutamate

- naltrexone: reduces the rewarding effects of alcohol

psychological treatments for ETOH abuse

- individual therapy, family therapy, group therapy

- peer-led support groups, Alcoholics Anonymous (AA)

substance use disorder: screening and assessment

screening, brief intervention, and referral treatment (SBIRT)

- screening: nurse assesses the severity of substance use and identifies the appropriate level of tx

- brief intervention: nurse focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change

- referral to treatment: nurse provides those identified as needing more extensive tx w/ access to specialty care

nursing interventions: Motivational Interviewing (MI)

evidence-based approach based on transtheoretical or stages of change theory

- MI uses a person-centered approach to strengthen motivation for change

what are the stages of the transtheoretical change model

precontemplation, contemplation, determination, action, maintenance, relapse

precontemplation

in denial, not thinking about changing

contemplation

awareness that a problem exists but ambivalent about changing (struggling with ambivalence)

determination

committed to making a change and has plans to act

action

motivated, makes a plan, and practices new behavior

maintence

Maintaining behavior change has achieved goals

relapse

expected element of change, evaluate triggers for relapse, plan and support efforts to change

what are therapeutic groups

nurses can lead both in hospital and community settings

- psychoeducation groups, health teaching groups, support groups

substance-related disorders: therapeutic groups

group format has advantages like: increased feedback, opportunity to practice new skills in a safe environment, mutual learning, and instilling a sense of belonging

- Recovery groups: AA, GA, OA, NA, Al-Anon (friends/families of persons with alcohol use disorder)

what are somatic symptom disorders

characterized by physical sx --> suggesting a medical disease but w/o a identifiable cause

what is somatization

psychological and emotional expression of stress through physical sx

- instead of anxiety/depression/etc --> see HA, back or chest pain, etc

what are our somatic sx and related disorders (4)

- somatic symptom disorder

- conversion disorder

- illness anxiety disorder

- factious disorder

what is the definition of somatic sx disorder

focus on somatic (physical) sx like pain or fatigue to the point of EXCESSIVE concern, preoccupation, and fear

- health-related quality of life severely impaired; clients see sx as threatening, harmful, etc

what does somatic sx disorder look like (4)

- multiple somatic sx that cannot be explained medically

- psychosocial distress, frequent hospital visits

- persistently high level of anxiety about health or sx

- excessive time and energy devoted to these sx or concerns

what is the defintion of illness anxiety disorder

extreme worry and fear about the possibility of having a disease; this worry leads to frequent self-scanning for signs of illness

what does illness anxiety disorder look like (3)

- preoccupation with having or acquiring a serious illness; thoughts about illness may be intrusive and hard to dismiss

- high anxiety level about health; client easily alarmed, extremely conscious of bodily sensations

- chronic and relapsing; sx can become amplified during times of increased stress

what is the definition of conversion disorder

functional neurological disorder; neurological sx in the absence of neurological diagnosis

- deficits in voluntary movement, numbness, loss of vision/hearing, episodes resembling epilepsy

what else can be seen with conversion disorder (3)

- emotional stressors are transferred to physical sx

- many show a lack of emotional concern about sx

- psychiatric comorbidity present in 74% of clients

what is the definition of factitious disorder

deliberately fabricating sx, or self-inflicting injury with the goal of assuming the sick role

- imposed on self: self-inflicted harm

- imposed on another (by proxy): harm to another person

what are the other parts of factitious disorder (4)

- under CONSCIOUS control (despite other somatic disorders)

- individuals consciously conceal the true nature of alleged illness (deception)

- contrived illness may be physical or psychiatric

- also identified as "Munchausen syndrome"

what can psychological factors do to medical conditions

can increase the risk of medical disease OR magnify and adversely affect a medical condition

what is associated with negative health outcomes

- loneliness and weak interpersonal connections

- adverse childhood experiences (ACEs)

- childhood trauma is consistently linked with physical disorders later in life

what are nursing dx for somatic symptoms disorders

ineffective coping (somatic sx disorder)

chronic pain (somatic sx disorder)

fear of having a serious disease (illness anxiety disorder)

disturbed sensory perception (conversion disorder)

self-care deficit (conversion disorder)

what are the S/S of the nursing dx of difficulty coping (4)

- ineffective coping strategies

- insufficient access to social support

- insufficient problem-solving skills

- inability to meet role expectations

what are the outcomes for difficulty coping

- improved coping

- identifies effective coping patterns

- identifies alternate coping strategies

- uses support system

what are the S/S of the nursing dx of pain, acute or chronic

- presence of secondary gains by adoption of sick role

what are the outcomes for pain, acute or chronic

- reduced pain

- recognize associated sx of pain

- reports pain control

what are S/S of the nursing dx of impaired socialization

- absence of support system

- disabling condition

- preoccupation with own thoughts

- family and friend alienated by physical obsessions

what are the outcomes for impaired socialization

- improved socialization

- identifies support system

- willing to call on others for assistance

- identifies a support group

what are the S/S of the nursing dx of chronic low self-esteem

- nonassertive behavior

- exaggerates negative feedback about self

- excessive seeking of reassurance

- repeatedly unsuccessful in life events

what are the outcomes for chronic low self-esteem

- improved self-esteem

- verbalizes positive regard for self

- describes self as successful

- strong beliefs that decisions and actions control health outcomes

what does therapeutic interventions do for somatic symptom disorders

address ways to help the client have needs met without resorting to somatization

what do clients with somatic symptom disorders have issues with and need training on?

- difficulty communicating emotional needs (can describe physical sx but unable to verbalize feelings)

- assertiveness training

what is body-oriented psychological therapy (BOPT)

fosters symbolic enactments of trauma to explore alternative coping strategies

what is dialectical behavior therapy (DBT)

skills to target emotional dysregulation, distress tolerance, and interpersonal conflicts

what does cognitive-behavioral therapy focus on?

trauma!

anxiety

feelings of apprehension, uneasiness, uncertainty, or dread from a real or perceived threat

- EMOTIONAL response

- normal healthy reaction ; necessary for survival

fear

reaction to a specific danger

- COGNITIVE response

what are our anxiety disorders (5)

- generalized anxiety disorder (GAD)

- panic disorder

- social anxiety disorder (social phobia)

- specific phobias

- seperation anxiety disorder

what is mild anxiety

not usually a problem; comes from day-to-day living

- sharpens senses, motivates action

- increases the perceptual field

what is moderate anxiety

anxiety increases; it diminishes the perceptual field

- less alert to events in environment

- more direction to problem-solving

- increased restlessness & muscle tension

what is severe anxiety

overwhelming anxiety; difficulty completing simple tasks

- physical: HA, palpitations, insomnia

- emotional: dread and horror

what is panic

most intense state of anxiety; terror and physical sx feel life-threatening

- may lose contact with reality

- marked dysregulated behavior

what are the defenses against anxiety

adaptive use of defense mechanisms: helps lower anxiety and achieve goals

maladaptive use of defense mechanisms: when one or several are used in excess, particularly immature defenses

seperation anxiety disorder

developmentally inappropriate levels of concern over being away from a significant other

- fear that something horrible will happen

- distracts from activities, causes sleep disturbances

what are the sx of seperation anxiety

physical sx; GI disturbances and HA

when is separation anxiety a normal part of infant development

peak: 8 months - 18 months

- declines after 18 months

phobia

persistent, irrational fear of a specific object, activity, or situation

- leads to the avoidance of things

specific phobia (and example of agoraphobia)

excessive or unreasonable fear when in the presence of, or anticipation of, a specific object or situation

- agoraphobia: fear of being in places or situations from which escape might be difficult, or help might not be available

social anxiety disorder

aka social phobia: anxiety or fear provoked by exposure to a social or performance situation

- people avoid such situations

- if they are unable to avoid them: clients endure the situation w/ anxiety and emotional distress

social anxiety disorder sx in small children and adolescents

small children: mute or nervous

adolescents: paralyzed by fear of speaking in class or interacting with peers

panic disorder

client experiences panic attacks: sudden onset of extreme apprehension or fear, associated w/ feelings of impending doom

- functioning is suspended

- may believe they are losing their minds or having a heart attack

what else might someone with panic disorder experience

preoccupied with the possibility of future episodes; they avoid pleasurable and adaptive activities, experiences, and obligations

generalized anxiety disorder

characterized by excessive anxiety and worry

- anxiety/worry or physical sx cause clinically significant distress or impairment in social, occupational, or other areas of functioning

what are the general symptoms of GAD (4)

- difficult to control the worry

- restlessness, feelings on edge

- difficulty concentrating

- sleep disturbances, easily fatigued

what is big about anxiety's general assessment in nursing

determine whether anxiety is the PRIMARY problem (like anxiety disorder) or SECONDARY to another cause (like a medical condition or substance use)

what are nursing dx for anxiety related disorders

- anxiety (moderate, severe, panic)

- impaired coping

what do nurses want to do with anxiety-related disorders (4)

- evaluates the effective use of coping mechanisms in the past

- uses relaxation exercises to initiate a relaxation response

- applies new behaviors to manage anxiety

- considers alternatives and activities that may relieve feelings of inner tension

what are outcomes related to anxiety (nursing dx)

reduced anxiety

- monitor intensity of anxiety

- use relaxation techniques

- decreases environmental stimuli as needed

- controls anxiety response

- maintains role performance

what are outcomes related with impaired coping (nursing dx) (5)

improved coping

- identifies ineffective coping patterns

- asks for assistance

- seeks information about illness and tx

- identifies multiple coping strategies

- modifies lifestyle as needed

what are specific nursing interventions for anxiety (8)

- provide calm presence

- teach coping strategies & assist w/ problem-solving

- intervene in unhealthy defense mechanisms

- cognitive restructuring

- teach relaxation techniques

- health teach (reducing caffeine!!)

- provide physical outlets

- pharmacotherapy

what are specific nursing interventions with panic attacks (6)

PSYCHIATRIC EMERGENCIES

- do not leave client alone

- remain calm, stay w/ patient

- clear, concise instructions, speak calmly

- administer medications (as ordered!)

- provide structure, ensure safety

- decrease environmental stimuli

what are the treatment modalities for anxiety (4)

- pharmacotherapy

- antidepressants/antianxiety/other classes

- psychological therapies

- behavioral therapy/cognitive-behavioral therapy

antidepressants drugs

SSRIs; 1st line tx for most anxiety-related disorders

- paroxetine, fluoxetine, escitalopram, sertraline

- teaching: 6 weeks for anxiety to work, sexual dysfunction

SNRI; another 1st line tx

- venlafaxine

- teaching: dose-dependent HTN

anti-anxiety drugs (1/2)

benzodiazepines; potentiate the inhibitory effects of GABA

- rapid onset of action

- risk dependence & withdrawal; used for short periods of time

- SE: sedation, ataxia, decreased cognitive function

not recommended in pt w/ comorbid substance abuse

anti-anxiety drugs (2/2)

buspirone; serotonin 5 HT partial agonist

- does NOT cause dependence

- takes 2-4 weeks for effects

- not recommended w/ impaired hepatic or renal function

- SE: dizziness, nausea, HA

other medications for anxiety (4)

antihistamines (hydroxyzine, diphenhydramine): non-addictive alternatives to benzos; used in clients with substance use problems

beta-blockers: reduce physical sx by slowing HR & reducing blushing in social anxiety disorder

anticonvulsants (gabapentin, pregabalin): some benefit in GAD and social anxiety disorder

antipsychotic: used to tx severe sx of anxiety disorders

what are psychological therapies for anxiety (4)

- modeling

- systematic desensitization

- flooding

- cognitive-behavioral therapy

what is modeling

therapist acts as a role model, demonstrating appropriate behavior in a feared situation

what is systematic desensitization

client is gradually introduced to a feared object or experience through a series of steps, from least frightening to most frightening

what is flooding

method exposes the client to a large amount of an undesirable stimulus to extinguish the anxiety responses

what is cognitive-behavioral therapy

includes cognitive restructuring, psychoeducation, muscle relaxation, self-monitoring for sx, vivo (real-life) exposure to feared objects or situations

what are our obsessive-compulsive disorders (5)

- obsessive compulsive disorder (OCD)

- body dysmorphic disorder (BDD)

- hoarding disorder

- trichotillomania

- excoriation disorder

obsessive-compulsive disorder

recurrent obsessions or compulsions that are severe enough to be time-consuming or cause marked distress or significant impairment

- obsessions

- compulsions