Mental Health Exam 2

Personality Disorders

typically hard to diagnose because they don't really cause you to end up in the hospital

- usually secondary and often co-occur with other mental health diagnoses such as depression, anxiety, and eating and substance use disorders

- must be 18 years old or older to get a diagnosis

Personality Disorders: Expected Findings

exhibit one or more of the following common pathological personality characteristics

- inflexibility/maladaptive responses of stress

- Compulsiveness and lack of social restrain

- Inability to emotionally connect in social and professional relationships

- Tendency to provoke interpersonal conflict

Cluster A Personality Disorders

possess odd or eccentric traits; includes: Paranoid, Schizoid, and Schizotypal

- social isolation

- defensive coping

- ineffective individual coping

biological roots

Interventions: Emphasize client skill & resource development in finding & maintaining interpersonal relationships

Personality Disorders: Children

may exhibit difficulties in developing social relationship and school classwork

Personality Disorders: Adults

may have trouble forming intimate relationships. maintain or establishing careers, and fulfilling opportunities to mentor future generations

Personality Disorders: Adolescents

may report being bullied or having odd habits, behaviors, or ideas

Paranoid

Characterized by distrust and suspiciousness toward others based on unfounded beliefs that others want to harm, exploit, or deceive the person

Schizoid

Characterized by emotional detachment, disinterest in close relationships and indifference to praise or criticism; often uncooperative

- show little emotion

Schizotypal

Characterized by odd beliefs leading to interpersonal difficulties, an eccentric appearance, and magical thinking or perceptual distortions that are not clear delusions or hallucinations

- avoid close relationships

Cluster A Personality Disorders

possess odd or eccentric traits; includes: Paranoid, Schizoid, and Schizotypal
- social isolation
- defensive coping
- ineffective individual coping
Intervention: emphasizes client skill and resource development in finding and maintaining interpersonal relationships
biological roots

Cluster B Personality Disorders

possess dramatic, emotional, or erratic traits; includes: Antisocial, Borderline, Histrionic, and Narcissistic

- self-mutilation (ex: cutting yourself)

- risk for violence

- powerlessness

- altered family processes

psychodynamic roots

Interventions: Develop skills to limit dramatic & inappropriate behaviors

Antisocial

Characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, failure to accept personal responsibility; evidence of conduct disorder before age 15, sense of entitlement, manipulative, impulsive, and seductive behaviors; non-adherence to traditional morals and values; verbally charming and engaging

- psychopaths, physically unable to show empathy

Borderline

Characterized by instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment

- often tries self-injury and may be suicidal; ideas of reference are common; often accompanied by impulsivity

- altered self image

- ALL IN ALL the time

- splitting is a defense mechanism

Splitting

commonly associated with borderline personality disorder; the inability to incorporate positive and negative aspects of oneself or others into a whole image

EX: "You are the worst person in the world" ...a few hours later... "You are the best, but the nurse from the last shift is absolutely terrible"

Histrionic

Characterized by emotional attention-seeking behavior, in which the person needs to be the center of attention; often seductive and flirtatious

- display emotions outwardly

Narcissistic

Characterized by arrogance, grandiose views of self-importance, the need for consistent admiration, and a lack of empathy for others that strains most relationships; often sensitive to criticism

- HUGE egos, truly believe they are better

- can feel empathy, it's just suuuuper hard

Cluster C Personality Disorders

possess anxious or fearful traits; insecurity and inadequacy; includes: Avoidant, Dependent, and Obsessive-Compulsive

- anxiety

- self-esteem disturbance

- hopelessness

chronic trauma roots

Intervention: Provide education & therapies to learn how to best manage feelings of anxiety

Avoidant

Characterized by social inhibition and avoidance of all situations that require interpersonal contact, despite wanting close relationships, due to extreme fear of rejection; have feelings of inadequacy and are anxious in social situations

- avoid criticism

Dependent

Characterized by extreme dependency in a close relationship with an urgent search to find a replacement when one relationship ends

- clingy

Obsessive-Compulsive

characterized by indecisiveness and perfectionism with a focus on orderliness and control to the extent that the individual might not be able to accomplish a given task

Nursing Care for Personality Disorders

- perform a self-assessment prior to caring for clients

- safety is always a priority concern because clients are at a risk for self-injury or violence

- set clear, strict boundaries

- plan for how to respond to impulsive, aggressive, or manipulative behaviors

- prepare for transference and protect from countertransference

- trustworthy, genuine, and respectful care

- case management

Personality disorders treatment

- Antidepressant

- Anxiolytic

- Antipsychotic

- mood stabilizer (Lithium)

Standardized Screening Tools for Eating Disorders

- Eating Disorders Inventory

- Body Attitude Test

- Diagnostic Survey for Eating Disorders

- Eating Attitudes Test

- SCOFF Questionnaire

PROS: increases self-awareness and they're pretty accurate

CONS: patients can lie (secrecy)

Anorexia Nervosa: Risk Factors

- family history (genetic or environmental)

- developed countries (societal norms, access to food)

- history of child/adolescent abuse

- commonly begins in teen years

- high achieving

- athletes/dancers

- high expectations to perform, goal-oriented families or personalities

- need to control

- most common in females: white, highly educated and high academic achievement (SWAG: SKINNY WHITE AFFLUENT GIRLS)

Anorexia Nervosa

- Fewer calories taken in than required - significantly lowered body weight (UNDERWEIGHT)

- Developed rigid rules around food

- Intense fear of gaining weight or refusal to maintain healthy weight

- Obsessed with food & dieting

- Weighing several times a day (before AND after meals)

- Extreme perfectionism

- Minimal amounts of food consumption w/ excessive exercise, diuretics, laxatives, caffeine

- Lack of recognition of the seriousness of body weight (deny having a weight problem)

- levels of severity are based on BMI and determine the treatment plan

- HIGHEST DEATH RATE (suicide/starvation)

Signs of Anorexia Nervosa

- cutting food into tiny pieces in order to appear to be eating

- re-heat food multiple times

- self-induced vomiting

- refusing to eat in the presence of others

- wears baggy clothes to hide their body/they're cold

- use of diuretics, laxatives, enemas and diet pills

- malnourishment (brittle hair and nails; dry, yellow skin; lanugo)

What is the HALLMARK SIGN of Anorexia Nervosa

fine downy hair (lanugo) where there was none previously (face and back)

- the body's response to being cold

- LATE SIGN

Anorexia Nervosa: Clinical Manifestations

- Cold or unable to maintain body heat

- damage to brain, kidneys, heart, and bones (brittle)

- emaciated (abnormally thin/weak)

- sunken eyes, skeletal appearance

- lanugo growth

- bradycardia, hypotension, arrhythmias (may lead to cardiac arrest)

- delayed gastric motility (abdominal pain/distension)

- hypothyroid-like state (cold extremities)

- peripheral edema with advanced starvation (impaired circulation and possible decreased albumin) - END STAGE

"Cathy Didn't Eat So Logan Brought Down Her Plate"

Anorexia Nervosa: Treatments

- cognitive behavioral therapy: Maudsley Approach (parents take responsibility for feeding child - one parent must be with child for every meal/snack), journaling, etc

- Concerns: takes away autonomy, not learning how to feed themselves, a lot of responsibility on parents

- Antidepressants (SSRIs/Fluoxetine) for off label use

- NO FDA approved drug available to help the client gain weight

Refeeding Syndrome

the potentially fatal complication (enteral--> NG tube or parenteral--> IV fluid) that can occur when fluids, electrolytes, and carbs are introduced to a severely malnourished client (pancreas not used to releasing insulin)

- body is in SHOCK!

- hallmark is HYPOPHOSPHATEMIA

- fluid balance, electrolyte, and glucose metabolism abnormalities

- very frequent vital signs, place on cardiac monitor, initiation of thiamine

Anorexia Nervosa: Nutritional Nursing Care

work with a VERY SPECIALIZED dietician to:

- consider the client's preferences and their ability to consume food

- provide a structured and INFLEXIBLE eating schedule initially (no RR breaks for at least an HOUR after eating)

- 1 on 1 observation for all meals and bathroom breaks + suicide watch

- provide small, frequent meals

- provide a diet high in fiber and low in sodium

- limit high-fat, gassy foods

- administer a multivitamin and mineral supplement

- instruct the client to avoid caffeine and herbal supplements

- anticipate manipulative behavior (crisis mode)

- Goals for weight gain? 1-2 lb

Bulimia Nervosa: Signs

- commonly begins in teen years, early adulthood

- obsessed with body appearance

- often coincides with mood disorder, anxiety, substance abuse, and self-injurious behavior (cutting is common)

- MORE COMMON than anorexia, but often goes undiagnosed

- feelings of guilt for loss of control

Anorexia Nervosa: Restricting Type

the individual drastically restricts food intake and does not binge or purge

Anorexia Nervosa: Binge-Eating/Purging type

the individual engages in binge eating or purging behaviors

How long do you need to be exhibiting signs to be diagnosed with an eating disorder?

an average of once per week for 3 months

Bulimia Nervosa

clients recurrently eat large quantities of food over a short period of time (binge eat) then purge it to prevent weight gain; rapid consumption of an uncommonly large amount of food in a short amount of time

- clients have a sense of lack of control over eating

- most clients maintain a weight WNL or slightly higher; BMI 18.5 to 30

- average age of onset in female clients is late adolescence or early adulthood

- history of hoarding and sneaking food (secretive behaviors)

- cutting

MOST COMMON EATING DISORDER

Bulimia Nervosa: purging type

the client uses self-induced vomiting laxatives, diuretics' , and/or enemas to lose or maintain weight

Bulimia Nervosa: non-purging type

the client compensates for binge eating through other means (excessive exercise and the misuse of laxatives, diuretics, and/or enemas)

DSM-5 criteria for bulimia?

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

- Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time & under similar circumstances

- A sense of lack of control overeating during the episode

- Recurrent inappropriate compensatory behavior in order to prevent weight gain

Bulimia Nervosa: Clinical Manifestations

- typically normal weight or overweight

- hoarseness/sore throat

- esophagitis/GERD/"heartburn" (from the constant vomiting)

- broken blood vessels in/around eyes

- dental enamel carries/cavities (often the first sign)

- abrasions or calluses on fingers/knuckles, middle finger stained yellow after inducing vomiting

- perceive they have a problem

- metabolic acidosis/alkalosis, potassium losses, dehydation

- cardiac arrythmias

- death is rare, but can occur from esophageal tears, gastric rupture

What is the HALLMARK SIGN of Bulimia Nervosa?

dental erosion and caries (if the client is purging)

- FIRST SIGN

also Russel's sign: calluses or scars on hand

Bulimia Nervosa: Treatment

FLUOXETINE is the only FDA-approved drug

- cognitive behavioral therapy

- long process

Binge Eating Disorder: Risk Factors

- hormone imbalance

- brain trauma

- congenital abnormality (Prader-Willi Syndrome)

- strong desire to "fill the empty space" (emotional or literal)

- Affects ALL ages, but most common in adults ages 46-55, men AND women EQUALLY

Binge Eating Disorder

Episodes of rapid food consumption in which the client is unable to stop eating

- May feel a sense of relief or fulfillment, which gives way to feelings of disgust, worthlessness, & depression

- excessive food consumption accompanied by a sense of lack of control

- weight gain increases the client's risk for other disorders (DM2, hypertension, cancer)

- severity based on the number of episodes per week

- diagnosis is made by a mental health professional based on assessment, no diagnostic screening tool

Binge Eating Disorder: Clinical Manifestations

- eating much more rapidly than normal

- eating until uncomfortably full

- eating large amounts without feeling hungry

- eating alone due to feelings of embarrassment/shame

Binge Eating Disorder: Treatment

- antidepressants (SSRIs/SNRIs)

- psychotherapy (childhood trauma)

- cognitive behavioral therapy (focuses on present problems and how to solve them; individualized or group therapy)

Nursing Care for Eating Disorders

- promote cognitive-behavioral therapies (cognitive reframing, relaxation techniques, journal writing, desensitization exercises)

- use behavioral contracts to modify client behaviors (not legal)

- reward the client for positive behaviors (positive reinforcement!!!)

- closely monitor the client during and after meals/to the restroom to prevent purging

- *provide highly structure milieu in an acute care unit for the client requiring intensive therapy*

Eating Disorder Care After Discharge

long-term treatment!

- maintenance plan

- follow-up treatment

- support groups

- individual and family therapy

PICA

eating nonfood items like dirt, soap, or paint chips as if they were food

Rumination Disorder

Regurgitating food after eating it

(maybe be referred to as chewing and spitting)

Avoidant/restrictive food intake disorder

a lack of interest in eating certain type of food, which leads to poor growth and nutrition

Major Depressive Disorder (MDD)

a single episode or recurrent episodes of unipolar depression resulting in a significant change in a client's normal functioning accompanied by at least one of the following specific clinical findings, which must occur almost every day for a minimum of 2 weeks, and last most of the day:

1. depressed mood

2. difficulty sleeping or excessive sleeping

3. indecisiveness

4. decreased ability to concentrate

5. suicidal ideation

6. increase or decrease in motor activity

7. inability to feel pleasure (anhedonia)

8. increase or decrease in weight of more than 5% of total body weight over 1 month

- Specific DSM-5 criteria for MDD have psychotic features (auditory hallucinations or delusions) or a *postpartum onset* (begins w/in 4 wks of childbirth ---> delusions, putting infant at risk for being harmed)

Psychotic Feature

the presence of auditory hallucinations or the presence of delusions

Postpartum onsest

a depressive episode that begins within 4 weeks of childbirth

Seasonal Affective Disorder (SAD)

occurs seasonally, usually during the winter, when there is less daylight; light therapy is the FIRST-LINE treatment for 30 min

Persistent Depressive Disorder

a milder form of depression that usually has an early onset (childhood/adolescence) and lasts at least 2 years for adults (1 year for children).

- exhibits at least 3 clinical findings of depression

- can progress to MDD

- minor; not usually hospitalized for treatment(Important to keep screening clients)

Premenstrual Dysphoric Disorder (PMDD)

associated with the luteal phase of the menstrual cycle; very severe

- emotional manifestations: mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating

- physical manifestations: lack of energy, overeating, hyper- or insomnia, breast tenderness, bloating, weight gain

- treatment: exercise, diet, and relaxation therapy

Substance-Induced Depressive Disorder

Clinical findings of depression that are associated with the use of, or withdrawal from, drugs and alcohol.

- you should always want to rule this out

Acute Phase of depression

severe clinical findings of depression

- treatment is generally 6 to 12 weeks long

- potential need for hospitalization

- reduction of depressive manifestations is the goal of treatment

- ASSESS SUICIDE RISK, and implement safety precautions or 1:1 observation as needed

- No harm Phase: pt has contract that states they won't harm themselves!!

Continuation Phase of depression

increased ability to function

- treatment is generally 4 to 9 months long

- relapse prevention through education, meds, and psychotherapy is the GOAL of treatment

Maintenance Phase of depression

remission of manifestations (reduction)

- this phase can last for years (we WANT it to)

- prevention of future depressive episodes is the GOAL of treatment

What questions do ask to assess for Suicide risk?

1. Are you suicidal or have you been suicidal in the last 2-3 weeks?

2. Do you have a plan?

3. What is that plan?

4. Do you have access to the resources to carry out that plan?

Nursing interventions to increase patient safety in depressive disorders

Milieu Therapy: SAFETY!

1. 1:1 observation

2. Paper gowns if admitted to inpatient

3. No cords, lines, shoes w/laces, hoodies, jewelry

4 Ask client to open mouth & move tongue side-side

5. No bras w/underwires

6. No phones

Signs of Hopelessness

- Using "always" or "never"

- Giving away belongings

Medications for Depression

SSRIs (#1!)

Tricyclic antidepressants TCAs

Monoamine oxidase inhibitors MAOIs

Atypical Antidepressants

SNRIs

SSRIs

Includes: Fluoxetine, Sertraline, Paroxetine, Escitalopram

FIRST-LINE med for depression

- Paroxetine causes CNS stimulation, which can cause insomnia(teratogenic - avoid in pregnancy)

- Complications:

- CNS stimulation (agitation, insomnia, anxiety)

- Serotonin syndrome - NO TCAS or ST. Johns Wort

- hyponatremia

- bruxism (give pt mouth guard)

- take med in the MORNING with food

- stop taking MAOIs 14 days before, and stop taking Fluoxetine for 5 wks before MAOI

- use acetaminophen for pain

SSRIs A/E (early)

first few days/weeks

· Nausea

· Diaphoresis

· Tremor

· Fatigue

· Drowsiness

- These effects should soon subside

SSRIs A/E (after 5-6 weeks)

· Sexual dysfunction (#1 reason men stop taking it) : impotence, delayed/absent orgasm, delayed/absent ejaculation, decreased sexual interest

· Weight gain (#1 reason women stop taking it)

· Headache

- Dose might need to be reduced or medication change if these occur

What is it important for nurses to know if patients with MDD are using herbs? What are we trying to prevent?

the use of SSRIs with ST. John's Wort can cause the potentially fatal serotonin syndrome

Serotonin Syndrome

Can begin 2-72 hr after starting treatment can be lethal

- Confusion, agitation, restlessness

- Disorientation(loss of coordination), hallucinations, delirium

- Seizures leading to status epilepticus

- Tachycardia leading to cardiovascular shock

- Liable BP (mostly HTN)

- Diaphoresis

- Fever leading to hyperreflexia

- N/V/diarrhea, abdominal pain

- Coma leading to apnea (severe)

Nursing Actions: give meds to create serotonin receptor blockade and muscle rigidity, cooling blankets, anticonvulsants, and artificial ventilation

SSRI A/E: withdrawal syndrome

- Sensory disturbances

- Unease

- Malaise (lack of energy)

- Anxiety

- Nausea

- Tremor

DO NOT STOP ABRUPTLY, taper med.

SSRI’s Nursing Admin

take with food

take in the morning to avoid sleep disturbances

take on the daily to establish therapeutic plasma levels

takes up to 4 weeks for therapeutic affects

SNRIs

Includes: Vanlafaxine, Duloxetine

Inhibit the uptake of serotonin & norepinephrine; minimal inhibition of dopamine; works well for chronic pain

- Complications: headache, nausea, agitation, anxiety, insomnia, weight gain, dry mouth, sleep disturbances, sexual dysfunction --> report to provider

- Hyponatremia: (older adults taking diuretics)

- Anorexia resulting in weight loss: monitor weight

- Hypertension

- do not stop abruptly, avoid alcohol

- Teratogenic

- Contraindicated with MAOIs

TCAs (Tricyclic antidepressants)

Includes: Amitriptyline, Doxepin

- can take 10 to 14 days or longer to work & max effect in 4 to 8 wks

- Orthostatic hypotension: monitor BP & change positions slowly

- Anticholinergic effects: Increase fluid intake to 2-3 L/day and chew sugarless gum

- Cardiac toxicity: PT can go into complete heart block so if they are suicidal and plan to overdose, do not put them on A TCA

- toxicity (give no more than a 1-wk supply at a time)

- seizures, diaphoresis, increased appetite, can increase suicide risk

- take at BEDTIME

- contraindicated if seizure disorders

- use with MAOIs can cause severe hypertension

MAOIS

Phenelzine, Selegiline (transdermal)

first-line treatment for atypical depression (especially in adolescences)

Complications:

- ortho hypo

- hypertensive crisis (AVOID TYRAMINE)(continuous cardiac monitoring)

- give phentolamine IV or nifedipine for hypertensive crisis

- contraindicated if taking SSRIs/SNRIs

- Use MAOIs & TCAs cautiously

What are some foods containing Tyramine?

- Aged cheese

- Ripe avocados or figs

- Fermented or smoked meats

- Dried or cured fish, liver

- cheese and wine

Why do we avoid Bupropion (atypical antidepressant) in anorexia patients?

Causes appetite suppression

- Monitor food intake & weight

What alternative herbs are sometimes used for depression?

St. John's Wort --> just make sure they aren't taking with an SSRI

Electroconvulsive Therapy (ECT)

can be useful for some clients who have a depressive disorder and are unresponsive to other treatments

- a specially trained nurse is responsible for monitoring the client before and after therapy

Transcranial Magnetic Stimulation

Uses electromagnetic stimulation (MRI strength magnetic pulsation) to stimulate focal areas of the cerebral cortex. It is indicated for depressive disorders that are resistant to other forms of treatment

Vagus Nerve Stimulation

uses an implanted device that stimulates the vagus nerve. It can be used for client who have depression that is resistant to antidepressant medications

- invasive and involves a surgical procedure

Deep brain stimulation

- Surgically implants electrodes into the brain to stimulate underactive regions

- For clients who have tried many other Tx that have failed

- invasive and involves a surgical procedure

Behaviors Shown with Bipolar Disorders

1. mania

2. hypomania

3. rapid cycling

Mania

Abnormally elevated mood, expansive or irritable

- Manic episodes last at least 1 week & usually requires hospitalization

- can have hallucinations and delusions

- they won't stop talking so u need to be ASSERTIVE and interrupt them

Hypomania

Less severe episode of mania that lasts at least 4 days, hospitalization is not required(outpatient clinic)

· Less impaired, can progress to mania

- no hallucinations or delusions

- they won't stop talking so u need to be ASSERTIVE and interrupt them

Rapid Cycling

4 or more episodes of hypomania or acute mania w/in 1 year and associated with increase recurrence rate and resistance to treatment

- need to be on an anti-epileptic (valproate/carbamazepine) for mood stabilization

Bipolar 1 Disorder

the client has at least 1 episode of mania altering with major depression

Bipolar 2 Disorder

the client has 1 or more hypomaniac episodes alternating with major depressive episodes

Cyclothymic Disorder

Client has at least 2 years of repeated hypomanic manifestations that do not meet criteria for hypomanic episodes alternating with minor depressive episodes

Bipolar: Genetics

having an immediate family member who has a bipolar disorder

Bipolar: physiological

neurobiological and neuroendocrine disorder

Bipolar: Environmental

increased stress in the environment can trigger mania and depression and increase risk for severe manifestations in children

Medications for Bipolar Disorder

Lithium, Mood Stabilizing Antiepileptics, Second Generation Anti-psychotics

Bipolar Standard Screening tool: ASRM

Altman Self Rating Mania Scale

assesses the clients placement on the continuum from depression to mania

Bipolar: Electroconvulsive Therapy (ECT)

can be used to moderate extreme manic behavior, especially when pharmacological therapy (lithium) has not worked.

Lithium carbonate

treats bipolar disorders by controlling episodes of acute mania, helps to prevent the return of mania/depression, and decreases the incidence of suicide

Nausea, diarrhea, abdominal pain: admin. Meds. w meals 2 to 3 times a day (short half-life)

- Fine hand tremors: admin. Propranolol, adjust dosage(COMMON sign)

- Polyuria, mild thirst: consume fluids 1.5-3L/day

- Weight gain: follow a healthy diet & exercise

- Renal toxicity: Monitor I&O, BUN/Cr

- Goiter & hypothyroidism: with long term Tx

· Baseline T3, T4, & TSH levels

· Admin. Levothyroxine

· Monitor for hypothyroidism Sx: cold, dry skin, decreased HR, weight gain

- Stress the importance of adequate fluids and sodium ---> decreased sodium = increased lithium toxicity )

- Bradydysrythmias, hypotension

Therapeutic: 0.6 to 1.2

- NO diuretics, NSAIDs, or anticholinergics

Early Indications of Lithium Toxicity

LITHIUM LEVEL: 1.5 to 2.0

· Mental confusion, sedation, poor coordination, coarse tremors, & ongoing N/V, diarrhea

· Withhold med. & notify provider

· Admin. New dosage based on lithium & sodium levels

Advances Indications of Lithium Toxicity

LITHIUM LEVEL: 2.0 to 2.5

- Extreme polyuria, tinnitus, giddiness, jerking movements, blurred vision, ataxia, seizures, severe hypotension, & stupor leading to coma & possible death from respiratory complications

- Admin. emetic to alert client or gastric lavage

- Urea, mannitol, aminophylline to increase rate of excretion

Severe Indications of Lithium Toxicity

LITHIUM LEVEL: more than 2.5

- Manifestations: rapid progression of manifestations leading to coma and death

- may need hemodialysis to get levels down quickly

Mood-stabilization antiepileptic medication names

- Carbamazepine

- Valproate

- Lamotrigine

Avoid driving or performing activities that require visual acuity for ALL