Psych Exam 1

The professional relationship a nurse (and other health professionals) have with their patients

What is a Therapeutic Relationship?

•90% is for the patient

•10% is for provider (empathy)

A Therapeutic vs. Social relationship is what %?

Therapeutic vs. Social relationship

•The meetings between nurse and client are not for mutual satisfaction

•The nurse can be friendly with the client, but is not there to be the client’s friend

•The majority of the interaction is focused and therapeutic

no social relationship in the future

A certified individual who works with mental health or substance use organizations that the peer relationship can go beyond therapeutic

What is a peer specialist in a therapeutic vs social relationship?

client focused

What relationship?

•The focus remains on the client’s issues rather than on the nurse’s or other issues

•Patients during interactions can shift the topic away from themselves for many reasons

•Painful to discuss issues

•Interest in knowing more about who is providing them care

Goal Directed

What relationship?

•The relationship is purposeful and goal directed

•Together the nurse and client

•The patient is supported in identifying problematic issues

•Professional and patient collaboratively decide needs and how to achieve

•Once goals are established, the nurse and client agree to work toward those goals

•Leader of the team?

•The patient is the leader, we support (not do)

objective vs subjective

What relationship?

•Health professionals can be only be therapeutic if they remain objective.

•Objectivity:

•The professional is free from bias, prejudice, and personal identification in interaction with the client.

•Subjectivity:

•The professional uses or view the interaction through one’s own feelings, attitudes, and opinions

time-limited interactions

What relationship?

•The Therapeutic Relationship is time limited versus open ended

•During establishment of parameters of the relationship

•The days and times they will meet

•The number of meetings that will take place.

•Inpatient: Ex: Until discharge

•Outpatient: Ex: Until housing is found

preorientation

What stage of therapeutic relationship?

•Takes place prior to meeting with the client

•Gather data about the client, his or her condition, and the present situation

•Nurse then examines their thoughts, feelings, perceptions, and attitudes about this particular client

•“Checking Countertransference”

orientation phase

What stage of therapeutic relationship?

The nurse-client become acquainted; build trust and rapport

•A contract is established (Times, Settings Boundaries)

•Client strengths, limitations, and problem areas are identified

•Outcome criteria and a plan of care are established

working phase

What stage of therapeutic relationship?

Begins when the client is working on their own change

•Client shows commitment to working on issues that have caused a life disruption

•Clients’ needs are prioritized- safety and health come first

•RN assists the client to change problematic behaviors in a safe environment

Termination phase

What stage of therapeutic relationship?

•Relationship comes to a close

•Determined when goals developed in orientation are met

•Occurs when the client has improved or has been discharged

thought processes

Refers to how thoughts are formed, organized, and expressed. It involves the flow and coherence of ideas

flight of ideas

Rapidly shifting from one topic to another, with only superficial connections between topics

circumstantial thinking

thought process

•Including unnecessary and irrelevant details before getting to the point.

tangential

thought process:

•Going off-topic and never returning to the original point.

thought blocking

•Sudden cessation of thought or speech, often mid-sentence.

word salad

thought process:

Incoherent mixture of words and phrases that lack logical meaning.

loose associations

thought process:

Disconnected or illogical thoughts that do not follow a coherent narrative.

thought content

•refers to the themes, ideas, and beliefs that occupy a patient's mind. It includes the presence of any delusions, obsessions, or preoccupations.

logical vs illogical

•Refers to whether the patient’s thoughts make sense and are consistent with reality.

abstract vs concrete

•Ability to think in abstract terms versus literal, concrete thinking.

magical thinking

•Belief that thoughts, words, or actions can cause or prevent specific events in a way that defies the laws of causality

obsessions

•Recurrent, intrusive thoughts or images that cause significant distress

ruminations

•Persistent and repetitive thoughts, often about distressing themes

delusions

•Fixed, false beliefs that are not consistent with reality

hallucinations

•Perceptions without an external stimulus. Perception is fully deluded

•Auditory (AH): Hearing sounds or voices that are not present.

•Visual (VH): Seeing objects or figures that are not there.

•Olfactory (OH): Smelling odors that are not present.

•Tactile (TH): Feeling sensations on the skin that are not real.

•Gustatory (GH): Tasting flavors that are not there.

illusions

Misinterpretations of real external stimuli. Perception has no delusion

depersonalization

•Feeling detached from oneself, as if observing oneself outside the body.

derealization

•Feeling that the external world is unreal or distorted

judgement

•Ability to assess and evaluate situations, make rational decisions, understand consequences of behavior, and take responsibility for actions.

•Key Questions:

•Can the patient make sound decisions?

•Do they understand the consequences of their actions?

insight

•Ability to perceive and understand the cause and nature of one's own and others’ situations.

•Key Questions:

•Do they understand their illness?

•Do they have insight into their relationships with others?

•Two physicians to agree that the medication is needed for sanctity of life

•Must have involuntary commitment

What is the forced medications (MOO/FMP) requirement?

•The nurse can engage seclusion and restrain but must follow up:

•Must be face-to-face exam by MD within 1 hour of the application 

•Next 4 hours can have phone order

•Next 4 hours need to have face-to-face exam

•Should reflect that lesser restrictive methods were tried

•The behavior leading to restraint/seclusion

Seclusion and restraint protocol

•Restraints must be rotated every 2 hours

•Food and fluids should be offered at least every two hours

•The patient should be released from restraint immediately after it is reasonably safe for them to do so.

What are the safety guidelines for seclusion and restraints?

unacceptable

If they are sleeping it is acceptable/unacceptable to maintain seclusion/restraint

•To go into the psychiatric locked unit legal agreement to be in the hospital locked floor is required called a “Voluntary Agreement” (201 in PA)

•Safety concerns are still required

•This patient has identified themselves that they are unsafe

•If the patient later requests discharge:

•Patient can be held on the on the unit for up to 72 hours until evaluated for safety

•The patient will be discharged if the provider determines that the patient is safe

Describe voluntary commitment

1.The person is unable without the care, supervision and assistance of others to satisfy his/her need for nourishment, personal or medical care, shelter or self-protection or safety and that death or serious physical debilitation would occur within 30 days unless treatment was provided

2.The person has attempted suicide, or the person has made threats to commit suicide and committed acts in furtherance of the threats

3.The person has mutilated himself/herself or the person has made threats to mutilate and committed acts in furtherance of the threats

4.Danger to others shall be shown by establishing that within the previous 30 days the person has inflicted or attempted to inflict serious bodily harm on another or has threatened serious bodily harm and has committed acts in furtherance of the threat to commit harm to another

Involuntary comittment requirement (1 must be met)

302

•Hospitalization:

•Petitioner must agree to keep the client's belongs secure

•Fax or deliver the warrant to the police who will pick up the client and take to the nearest facility for evaluation

•ER provider agrees with warrant (or doesn’t) and the patient is admitted

•Post-Hospitalization

•Within 5 days the patient will have a hearing to determine the validity of the need for treatment based on the 302 criteria

Physiological: food, water, warmth, rest

Safety: security, safety

Belongingness and love: intimate relationships, friends

Esteem: prestige and feelings of accomplishment

Self-actualization: achieving one’s full potential, including creative activities

What is on Maslow’s hierarchy of needs?

Aaron Beck

Who invented CBT?

•Works to alter how we perceive the world to decrease a negative impact on our mood

•Most widely used therapy

•Most commonly referred to when discussing “therapy”

What is CBT used for?

CBT

•cognitive triad is Beck’s term to identify 3 common characteristics that distort the thinking of people with depression:

•Negative Views of Self - Self image as defective/worthless

•Negative views of the world - Evaluation of ongoing life events negatively

•Negative Views of the future- “future holds no promise and that current difficulties will continue”

•These cognitive distortions occur as automatic negative thoughts

Reframing: Training the individual to be able to evaluate evidence and look at different possibilities

What is the main technique used in CBT?

CBT

•The cognitive techniques help clients notice their own automatic negative thoughts and the connection of those thoughts to moods and actions

•The behavioral techniques are used to show individuals that they are capable of interrupting/reframing dysfunctional patterns

Psychotherapy to benefit characteristics of emotional distress for patient who

•Difficult to think when affective

•Difficulty with social situations

•Conditioned for a chaotic environment

•Deficit in coping skills to distress

What is Dialectical Behavioral Therapy for?

Focuses on:

•Mindfulness: Improving ability to accept and be present in the current moment.

•Distress Tolerance:  Increasing tolerance of negative emotion, rather than trying to escape from it.

•Emotion Regulation :  Skills to manage and change intense emotions

•Interpersonal effectiveness: Techniques that improve communication in a way that is assertive, maintains self-respect, and strengthens relationships

What does Dialectical Behavioral Therapy do?

•Focus is on interpersonal problems rather than on personality reconstruction

•Therapist identifies the nature of the problem that needs resolved

•#1 intervention for adolescents

•4 problem areas have been identified: Grief, Role disputes, Role transitions, Interpersonal deficit

What is Interpersonal Therapy?

•Identification of Interpersonal Issues:

•Identification of specific interpersonal issues/problems that are contributing to their emotional distress

•Communication Analysis:

•Identification of communication styles and patterns that may be contributing to misunderstandings or conflicts in relationships

What does Interpersonal Therapy do?

Feeling keyed up or tense; feeling unusually restless; difficulty concentrating because of worry; fear that something awful might happen; fear of loss of control of self

Overeating, oversleeping, reactive mood, rejection sensitivity

Total absence of movement; the individual’s muscles are waxy and semi-rigid. Mutism, negativism, echolalia, or echopraxia may be present

Early morning awakening, anhedonia, vegetative symptoms, symptoms worse in the morning

Related to depression around childbirth

Previously called seasonal affective disorder, now qualified into this category of MDD.

Symptoms of a Major Depressive Episode

Major Depressive Disorder

Single episode or recurrent

•Depressed mood: most of the day, nearly every day,

•Anhedonia: Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

> 2 weeks

•Psychomotor agitation or slowing

•Low Energy

•Excessive guilt or low self-esteem

•Insomnia or Hypersomnia

•Changes in appetite/weight change

•Issues with concentration or cognition

•Thoughts of suicide/hopelesness

Persistent Depressive Disorder

•Characterized as a lower threshold of depression that does not reach acute levels

•It is not uncommon for people to ignore symptoms or consider them personality traits (Curmudgeon)

•Main symptom: Prolonged subthreshold depressive moods

•Timing: > 2 years without alleviation

•Citalopram (Celexa)

•Escitalopram (Lexapro)

•Fluoxetine (Prozac)

•Sertraline (Zoloft)

What are some SSRI examples?

Block reuptake of serotonin allowing increased levels in synapse

MOA of SSRI

•Headache

•Nausea, vomiting, GI distress

•Increases in anxiety/activation

•Sexual side effects may be problematic and may not resolve with

•QT interval prolongation (caution in the elderly)

•Increased risk for bleeding/thrombocytopenia

•Potential for hyponatremia

•Increases in suicidality – Black Box Warning for children and adolescents

What are side effects of SSRIs?

Block reuptake of serotonin & norepinephrine allowing increased levels in synapse

What do SNRI do?

•Duloxetine (Cymbalta)

•Venlafaxine (Effexor)

What are some SNRI examples?

•Headache

•Nausea, vomiting, GI distress

•Increases in anxiety/activation

•Sexual side effects may be problematic and may not resolve with

•Dose-dependent increases in blood pressure during rapid titration

•Must monitor blood pressure in these patients as a nursing intervention

SNRI side effects?

•Mirtazapine (Remeron)

Trazodone (Desaryl)

What are examples of atypical antipsychotics?

Block reuptake of serotonin and norepinephrine allowing increased levels in synapse

TCA MOA

•Amitriptyline (Elavil)- good for headache

•Nortriptyline (Pamelor)- good for headache

•Clomipramine (Anafranil) – good for OCD

•Desipramine (Norpramin)

What are some examples of TCAs?

cardiac arrythmias – QT prolongation, seizures, LETHAL in overdose

What serious side effects are associated with TCAs?

•Blocks the enzymes that breakdown monoamines allowing increases in synapse

What is the MOA of MAOIs?

•Isocarboxazid (Marplan)

•Phenelzine (Nardil)

•Tranylcypromine (Parnate)

•Selegiline (Emsam)

What are some examples of MAOIs?

•Tyramine must be avoided if consumed, can lead to hypertensive crisis

•Cured meats, red wine, aged cheeses, beer, grapefruit

In MAOIs, what major issue with drug-food interaction is limiting to patient tolerability and acceptability?

increased risk of suicidal thoughts and behaviors

What is the Anti-depressant black box warning?

mania

•Abnormally elevated, expansive, or irritable mood

•Abnormally and persistently increased activity/energy

•Lasting at least 1 week and present most of the day, nearly every day

mania and hypomania

•3+ of the following symptoms are present to a significant degree and represent a noticeable change from usual behavior:

•Inflated self-esteem or grandiosity.

•Decreased need for sleep

•More talkative than usual or pressure to keep talking.

•Flight of ideas or subjective experience that thoughts are racing.

•Distractibility

•Increase in goal-directed activity or psychomotor agitation

•Excessive involvement in activities that have a high potential for painful consequences

Bipolar I

•The presence of 1 MANIC episode

•Typically, even depression is more profound and severe

•Suicidality Risk

•Impulsivity associated with the diagnosis

•Risk of suicide is 15x greater than that of the general population

•Rapid cycling

•Four or more episodes in 12 months

•Associated with poorer outcomes.

Bipolar II

•The presence of

•Hypomanic episode

•One major depressive episodes

•A manic episode excludes this diagnosis

•Diagnosing

•Very difficult to recognize, and can incorrectly be treated with SSRIs which may worsen disease trajectory

•Years of evaluation before eventual identification

•Antidepressants

•Stimulants

•Hormone therapies

What types of meds can disrupt an unprotected mood?

Lithium

Select anti-epileptics

Referred to onwards as “mood stabilizers”

Antipsychotics

Atypical Antipsychotics

Benzodiazepines

What meds can protect mood (adding a break)

•A mood stabilizer or antipsychotic medication is being taken

Stimulants and Antidepressants should generally be avoided as they can induce mania UNLESS:

•Polyuria and polydipsia (nephrogenic diabetes insipidus)

•Diarrhea, nausea, weight gain

•Leukocytosis – (increase in neutrophils) False Positive

•Arrhythmia

What are the short term side effects of lithium?

•Goiter (euthyroid or hypothyroid)

•Renal impairments (10+ years)

What are the long term side effects of lithium?

0.6 – 1.2 mEq/L

What’s the therapeutic range of Lithium?

•Tremor: Can be a normal side effect

•Ataxia,

•Vomiting (very fine tremor may occur even at therapeutic levels)

What are the early signs of Lithium toxicity?

•Mental status changes,

•Confusion,

•Coma

What are the profound signs of Lithium toxicity?

Anticonvulsant and mood stabilizer

•Nausea, vomiting, abdominal pain, dizziness, tremor, weight gain

What is Valproate and what are the basic side effects

•Hepatotoxicity

•Action: Monitor liver function tests, watch for symptoms like jaundice, fatigue, and abdominal pain

•DRESS Syndrome

•Action: Report any signs of rash, fever, swollen lymph nodes

•Thrombocytopenia

•Action: Watch for signs of bruising, bleeding, and report to a healthcare provider

What are the major adverse reactions to Valproate and how do you monitor for them?

•Anticonvulsant and mood stabilizer

What is Lamictal (Lamotrigine)

•Common

•Dizziness, headache, blurred vision, coordination problems, GI disturbances

•Serious

•Severe skin rashes (Stevens-Johnson syndrome, toxic epidermal necrolysis)

•Multi-organ hypersensitivity reactions

•Aseptic meningitis

What are the common and severe side effects of Lamictal?

•Prodromal Phase

•Fever >102°F

•Flu-like symptoms

•Mucosal lesions

•Cutaneous Phase

•Widespread skin rash, often starting on the face and thorax

•Blistering and peeling of the skin

Explain the progression of Stevens Johnson Syndrome

Anticonvulsant and mood stabilizer

What are Carbamazepine and Oxcarbazepine?

•Complete Blood Count (CBC): Watch for signs of blood dyscrasias (e.g., agranulocytosis, aplastic anemia)

•Liver Function: Regular liver function tests

•Sodium Levels: Monitor for hyponatremia

•Skin Reactions: Monitor for signs of SJS/TEN and DRESS syndrome

What do you monitor for with Carbamazepine and Oxcarbazepine?

Stimulants like steroids, ADHD meds, antidepressants; will have to be on mood stabilizer

What are treatments that can induce mania?

think

CBT is how you _____

feel

DBT is how you ___

•MDD

•Mania

•Catatonia

•Psychosis (to a lesser extent)

ECT is a treatment for what types of patients?

•treatment-resistant depression

Transcranial Magnetic Stimulation (TMS) is a treatment for what patients?

•Metal

•Aneurysm Clips

•Arterial Stents

•Pacemaker

•Metallic-type tattoos

What are the contraindications for TMS?

infusions of ketamine

treatment resistant depression

What is ketamine infusion therapy (KIT) and what’s it used for?

Esketamine increases action of dopamine compared to ketamine along with base actions

•Treatment-resistant depression

•Adults with major depressive disorder with acute suicidal ideation or behavior

Explain Esketamine

•Depression

•OCD - WPIC

What does Deep Brain Stimulation treat?

FDA approved for treatment of epilepsy and treatment resistant depression

What is Vagal Nerve Stimulation used for?

•Safe, calm location

•If appropriate location cannot be found proceed anyways

•Closed ended question on the thoughts to kill themselves is therapeutic in this situation

•Main Question

•“Are you having thoughts of killing yourself?” Yes=Go to follow up question, No=Crisis planning

•Follow up: Positive responses to the main question require follow up:

•“Do you have thoughts or plans on how you would kill yourself?”

•Plan present

•Level of intention

•Lethality of the plan

•Access/proximity to plan (realistic)

•No Plan: Passive death wish

•May not need hospitalization but rather a crisis plan

•Needs significant monitoring and treatment

•Discussion of protective factors

•Development of a crisis plan

What’s important for a suicide assessment?

Voluntary: can sign AMA, can’t get forced therapy meds (can get safety ones_

Involuntary: cannot sign AMA

What’s the difference between voluntary and involuntary commitment?