Mental Health Exam 2

Bipolar disorders

Mood disorders with recurrent episodes of depression and mania, alternate between periods of baseline functioning and illness, onset usually is in early adulthood but can occur in pediatrics

Risk factors for bipolar disorder

- First degree relative with bipolar

- Neurotransmitter dysregulation or circadian rhythm dysregulation

- Endocrine and metabolic dysfunction

- Brain structure and function abnormalities

- Stress

Common comorbidities with bipolar

- Substance use disorder

- Anxiety disorders

- BPD

- Oppositional defiant disorder

- Phobias

- Seasonal affective disorder

- ADHD

- Migraines

- Metabolic syndrome

Objective characteristics of depressive episodes

- Flat, blunt, labile affect

- Tearful or crying

- Self-destructive behavior

- Decreased personal hygiene

- Psychomotor retardation or agitation

- Social withdrawal and isolation

- Unintended significant weight change

Subjective characteristics of depressive episodes

- Anergia

- Anhedonia

- Complaints of discomfort or pain

- Difficulty concentrating, focusing, or problem solving

- Change in appetite and elimination patterns

- Change in sleep

- Low self esteem, feeling hopeless, suicidal

Characteristics of manic episodes

- Labile mood with euphoria or dysphoria

- Agitation, irritability, restlessness, distractability or impulsivity

- Intolerance of criticism

- Flight of ideas, grandiose view of self

- Demanding or manipulative behavior

- Poor judgement

- Attention-seeking, seductive or inappropriate behavior

- Decreased sleep and neglect of ADLs

- Delusions and hallucinations are possible

- Denial of illness

Criteria for Bipolar 1 disorder

Atleast one episode of mania alternating with major depression, most severe

Criteria for Bipolar 2 disorder

One or more hypomanic episodes alternating with major depressive episodes

Criteria for Cyclothymic disorder

2+ years of repeated hypomanic manifestations that do not meet criteria for hypomania, alternating with minor depressive episodes

Mania criteria

- Lasts atleast one week

- Persistent, abnormally elevated, expansive or irritable mood

- Presence of 3 or more manifestations of mania

- Marked functional impairment

- Possible psychosis

- Usually requires hospitalization

Hypomania criteria

- Less severe than mania

- Lasts atleast 4 days

- Presence of 3 or more manifestations of mania

- No psychosis

- Hospitalization not required

- Can progress to mania

- More severe depressive episodes than mania

Can someone be considered in a manic/hypomanic state if they have taken substances?

No, symptoms must be present without substance use

Rapid cycling

- Atleast 4 episodes of hypomania or acute mania within 1 year

- Mood changes happen fast and over a few days or hours

- Associated with increased recurrence rate and treatment resistance

Challenges of bipolar disorder

- Underdiagnosed

- Self-neglect

- Financial hardship

- Dangerous behaviors

- Alienation

- Liking the feeling of mania and not wanting to take medication

- Risk for divorce, suicide, abuse, STI, exhaustion, malnutrition, unwanted pregnancies

Phases of bipolar

- Acute: hospitalization, risk of harm, reduce mania and increase safety

- Continuation: 4-9 months, prevent relapse, psychotherapy, med adherence

- Maintenance: treatment continues through lifetime, prevent manic episodes

Nursing care for acute manic episode

- Focus on safety and maintaining physical help

- Protect from impulsive behavior and poor judgement

- Continually assess potential for harming others, sitter

- Decrease stimulation without isolation

- Monitor sleep and encourage rest

- Monitor fluid intake and nutrition, provide portable nutritious foods because they likely won't sit down for long periods to eat

- Provide outlets for physical activity that are simple and short

- Communicate calmly and matter of fact

- Set realistic goals for behavior

- Reinforce nonmanipulative behavior and act on legitimate concerns

- Listen with a neutral attitude

- Administer meds as prescribed

Nursing care for acute depressive episode

- Promote safety and provide for physical needs

- Encourage eating and physical activity

- Encourage sleep and hygiene

- Provide continuous positive reinforcement

- Provide a structured routine

Pharmacologic treatment of bipolar

1. Lithium carbonate, 1st line

2. Mood stabilizing antiepileptic drugs, 2nd line

3. Antipsychotics, for treatment resistant bipolar and psychotic features

4. Benzodiazepines, during acute phase of mania, works fast

5. Antidepressants with low overdose risk, can increase risk of mania

Lithium Carbonate MOA

Unknown, produces neurochemical changes and serotonin receptor blockage

Lithium carbonate uses

- Bipolar disorder

- Control episodes of acute mania

- Prevent return of mania or depression

- Decreases incidence of suicide

Lithium carbonate adverse effects

- GI distress, weight gain, metallic-taste in mouth

- Fine hand tremors

- Polyuria and thirst

- Renal toxicity

- Goiter and hypothyroidism

- Bradydysrhythmias, hypotension, electrolyte imbalance

Lithium carbonate contraindications

- Severe renal or cardiac disease

- Thyroid disease, seizure disorder, diabetes, schizophrenia

- Pregnancy

How much liquid should you drink a day if on lithium

1.5-3L a day with consistent sodium intake

Lithium carbonate nursing considerations

- Frequent blood draws

- Watch for toxicity

- Take with food or milk to decrease Gi effects

- Effects begin within 5-7 days and max benefit in 2-3 weeks

Therapeutic range for lithium

0.5-1.5 mEq/L

Effects of 1.5-2 lithium

- Early indication of toxicity, withhold next dose and notify provider

- Confusion, incoordination, sedation

- Coarse tremors

- Worsening Gi distress

Effects of 2-2.5 lithium

- Advanced indications of toxicity, may need lavage

- Extreme polyuria or dilute urine

- Tinnitus

- Giddiness or jerking

- Blurred vision

- Ataxia, seizures

- Hypotension

- Stupor leading to coma or death

Effects of >2.5 lithium

- Severe toxicity that can lead to coma and death, may need hemodialysis

- Rapid progression of advanced manifestations

Common antiepileptic mood stabilizers

- Carbamazepine

- Lamotrigine

- Valproate

Antiepileptic mood stabilizer MOA

potentiates inhibitory GABA, suppresses CNS excitation, slows entrance of sodium into neurons

Antiepileptic mood stabilizer adverse effects

- Carbamazapine and Lamotrigine are similar: CNS, SJS, dermatitis, fluid overload, hypersensitivity rash that can be fatal, blood dyscrasias

- Valproate: GI effects, hepatotoxicity, pancreatitis, thrombocytopenia, weight gain

Antiepileptic mood stabilizer contraindications

- Pregnancy

- Plasma levels and avoiding grapefruit

- Decrease effectiveness of oral contraceptives

- Valproate contraindicated with liver disorders

Antiepileptic mood stabilizer nursing care

- Avoid using during pregnancy

- Carbamazepine: take at night, monitor bleeding, infection, edema, UOP, HTN, sunscreen and avoid grapefruit

- Lamotrigine: caution with certain activities, alternate birth control, sunscreen

- Valproate: take with food, monitor bleeding, healthy diet and physical activity

What is ECT

The use of electrical shock current delivered to the brain to induce a seizure that treats depression, involves serotonin, dopamine and norepinephrine, performed 2-3 times a week for 6-12 treatments

Indications for ECT

- Major depressive disorder nonresponsive to medication or need rapid treatment

- Schizophrenia spectrum disorders

- Acute manic episodes nonresponsive to medications

- Ineffective for substance use disorders and bersonality disorder

Procedural care for ECT

- Consent must be obtained

- Pre-ECT workup with chest x-ray, blood work, ECG or any medications that will interfere with induction of seizure

- Medications are given 30 minutes prior to procedure, atropine to decrease secretions, anesthesia, and succinylcholine

- Monitor vital signs for risk of HTN, cardiac rhythm, mental status, EEG

- IV placed, EEG leads on scalp, 100% O2, cardiac and SpO2 monitoring

- Teaching, make sure pt and family understand procedure, pts do not generally experience tonic-clonic seizures especially due to muscle relaxants and anesthesia

ECT complications

- Short term memory loss, disorientation, and confusion

- Anesthesia reactions

- Cardiovascular changes, monitor for arrhythmias and hypertension

- Condition relapse, weekly or monthly maintenance may be needed

Trauma disorders

- Acute stress disorder

- PTSD

- Adjustment disorder

- Reactive attachment disorder (RAD)

- Disinhibited social engagement disorder

Acute stress disorder

Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event 3 days but no more than one month.

PTSD

Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event for longer than 1 month after the event and can last for years

Pts who are at risk for ASD and PTSD

- Exposure to a traumatic event

- Exposure to a natural disaster

- Exposed to repeat trauma in an occupational setting

- Living through a traumatic event experienced by a family member or friend

- Bad coping mechanisms or insufficient treatment and support

Expected findings for PTSD and ASD

- Intrusive memories, flashbacks, dreams and avoidance

- Anxiety, depression, anger, guilt, cognitive distortions, detachment from others

- Aggression, hyper vigilance, difficulty focusing and sleep disturbances

Adjustment disorder

A stressor triggers a reaction causing changes in mood and/or dysfunction in performing usual activities. The stressor and effects are less severe than with ASD or PTSD

Adjustment disorder risk factors

- Pattern of life-long difficulty accepting change

- Learned pattern of difficulty with social skills or coping struggles, which when a stressor occurs, can trigger a stress response out of proportion to the stressor

Adjustment disorder findings

- Depression

- Anxiety

- Changes in behavior

Depersonalization

feeling that a person is observing one's own personality or body from a distance

Derealization

feeling that outside events are unreal or part of a dream or that objects appear larger or smaller than they should be

Dissociative amnesia

Inability to recall personal information related to traumatic or stressful events, can be a period of time or just certain details

Dissociative fugue

A type of dissociate amnesia where a pt travels to a new area and is unable to remember their own identity and some of their past, can last weeks or months after a truamatic event

Dissociative identity disorder

Patient displays more than one distinct personality, with a stressful event precipitating the change from one personality to another

Risk factors of dissociative disorders

- Traumatic life event

- Childhood abuse or trauma

Nursing care for dissociative disorders

- Grounding techniques, decrease stress

- Journaling, emotional processing, insight development

- Allow patient to share traumatic events in their own time

Reactive attachment disorder

- Child does not turn to attachment figure for comfort or social interaction

- Typically results in child becoming withdrawn from adults or caregivers

- Diagnosed before age 5

Disinhibited social engagement disorder

- Child is overly familiar towards strangers

- Decreased social boundaries

- Results from inadequate caregiving

- Diagnosed after 9 months of age

Universal trauma precautions

●Acknowledge and assume everyone has experienced trauma.

●Consider the tone of voice, eye contact, and body language in all communications.

●Respect culture, gender, race, ethnicity, and sexual orientation.

●Support client choices when possible

●Minimize noise levels

●Practice self-care and reach out to others when needed.

Therapeutic procedures for trauma

- CBT: The patient is helped to change distorted appraisal oof events and negative thoughts.

- Prolonged exposure therapy: Combines the use of relaxation techniques with exposure to the traumatic situation.

- Psychodynamic psychotherapy: Getting in touch with conscious and unconscious thought processes

- EMDR: Can be used with children and adults. Uses rapid eye movements during desensitization techniques in a multi-phase process by a trained therapist.

- Group or family therapy: support groups or formal therapy.

- Crisis intervention: immediately following a traumatic incident

- Somatic (relating to the body, distinct from the mind) therapy for dissociative disorders: Psychotherapy works over time to increase awareness of the present and decrease dissociation episodes.

- Hypnotherapy: used with dissociative disorders.

- Biofeedback/neurofeedback: helps the client learn how to increase awareness and gain control of reactions to a trigger.

Medication management for trauma disorders

- SSRI, paroxetine, setraline, fluoxetine, escitalopram, fluvoxamine

- SNRI, venlafaxine

- TCA, amitriptyline, imipramine

- MAOI, phenelzine

Anxiety vs Anxiety disorders

- Anxiety is a normal healthy response to stress that is essential to survival

- Anxiety disorders and elevated and persistent anxiety that causes behavioral changes and impairment in function, the anxiety response is triggered everyday by nonharmful stimuli

Mild anxiety

a sensation that something is different and warrants special attention, sharpened senses, irritability, restlessness, fidgeting

Moderate anxiety

the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated, have some difficulty but can still process information and solve problems, attention is limited, muscle tension, sweating, headache, GI upset, speak simply to patient and help them with coping skills

Severe anxiety

significant feeling of dread, difficulty reasoning and thinking, can no longer pay attention or take in information, nausea, vomiting, trembling, pale, vertigo, chest pain, crying, stay with patient and lower level of anxiety

Panic

A feeling of sudden, intense fear with flight, fight, fawn or freeze, patient cannot process info or make rational decisions, passes in 5-30 minutes, increased BP, dilated pupils, cant move or communicate verbally, delusions, may be suicidal or run, remain with patient and keep them safe, reassure and try to calm down

Risk factors for anxiety disorders

- Female

- Family hx

- Neurotransmitter imbalance

- Medical conditions

- Trauma

- Lifestyle choices

Agoraphobia

fear or avoidance of situations, reaction is out of proportion with the actual danger of the place, such as crowds or wide open places, where one has felt loss of control and panic, disrupts ability to maintain employment and leads to remaining in ones house, impact on daily functioning

Panic disorder

Recurrent, unexpected panic attacks followed by persistent worry about future attacks or significant behavioral change, panic attacks usually last a few minutes and include at least 4 manifestations, fear of additional panic attacks becomes debilitating

Panic disorder manifestations that you need at least 4 of

- SOB

- Palpitations

- Choking

- Nausea

- Chills

- Hot flashes

- Feelings of depersonalization

- Chest pain

- Dizziness

- Fear of losing control/dying/insanity

Generalized anxiety disorder

persistent, excessive worry about everyday situations such as work, health, finances, or family even when there is little to no reason for concern, difficult to control and often accompanied by physical symptoms

GAD s/sx

- Uneasiness/restlessness/avoidance

- Muscle tension

- Inability to make decisions

- Insomnia

- Irritability

- Fatigue

GAD diagnostic criteria

Symptoms must be present for the majority of days for at least 6 months

GAD nursing care

- provide reassurance

- promote stress-management strategies

- support appropriate treatment such as therapy and medication when needed

Assessing anxiety disorders

- Hamilton Rating scale or GAD-7

- Suicide risk or self harm

- Structured assessment interview, keep client focused on present not past

- Assess for substance use disorder

Nursing interventions for anxiety disorders

- Provide trauma-informed care

- Remain with the client and provide safety, comfort, and calm reassurance

- Utilize relaxation techniques and coping strategies with the client

- Instill hope for a positive outcome and enhance self esteem

- Identify counseling, group therapy, and other resources

- Postpone health teaching until after acute anxiety subsides

- Utilize structured and safe milieu therapy

Treatment for anxiety disorders

- Therapy, primary option

- Medication

- Combination, most effective

Cognitive behavioral therapy for anxiety

- Cognitive: changes cognitive distortions and helps identify and reframe negative thoughts that produce anxiety

- Behavioral: helps modify behaviors that worsen anxiety, relaxation training, modeling, systematic desensitization, flooding, response prevention, thought stopping

SSRIs

- ex. paroxetine, citalopram, escitalopram, fluoxetine, fluvoxamine

- Increase availability of serotonin, improves mood and reduces anxiety

- First line treatment for anxiety disorders and OCD, long term

- Early side effects: nausea, sweating, tremor, fatigue, drowsiness

- Late side effects: sexual dysfunction, weight gain, headaches, hyponaturemia

- Black box for suicide

SSRI contraindications

- Avoid alcohol

- Avoid use with TCAs, MAOIs, and St Johns wort

- Use caution in patients with bipolar due to risk of mania

- May take 4 weeks to notice effects

- GI bleeds and ulcers

Serotonin syndrome

Potentially life-threatening condition from excess serotonin that occurs 2-72 hours after increasing drug dose, can range from mild to severe, notify provider and hold medication

Serotonin syndrome symptoms

- SHIVERS mneumonic

- Shivering

- Hyperreflexia

- Increased body temperature

- Vital sign instability

- Encephalopathy, altered LOC, confusion

- Restlessness

- Sweating

Benzodiazepine anxiolytics

- diazepam, lorazepam, alprazolam

- CNS depressant, enhances inhibitory effects of GABA

- used for rapid anxiety relief in 30-60 mins, short term treatment of GAD and panic disorder

- Can cause respiratory depression, CNS depression, sedation, lightheadedness, amnesia, rebound anxiety, and withdrawal effects

Benzodiazepine anxiolytics contraindications

- Schedule IV med, high risk for tolerance and dependence

- Avoid use with other CNS depressants

- Pregnancy/breastfeeding

- Caution in patients with hx of SUD

Benzodiazepine pt education

- Significant tolerance can develop

- do NOT stop taking abruptly, dose tapering is required

- Monitor for s/sx of toxicity and rebound anxiety

Buspirone

- thought to bind to serotonin and dopamine receptors for long term maintenance of generalized anxiety disorder

- side effects: CNS effects such as dizziness, agitation, headache

- May take 1-4 weeks to work and tolerance is not an issue, take with food

Busiprone contraindication

- dont use with MAOIs and St johns wart

- Pregnancy and breastfeeding

- Grapefruit juice

Tricyclic antidepressants

- Act on norepinephrine and serotonin reuptake systems

- Can cause orthostatic hypotension and anticholinergic effects

- Lag period of 10-14 days, 6 weeks to get full effects

- one of the oldest antidepressants, but has several side effects and interactions

SNRIs

- 2nd line treatment for depression

- venlafaxine, duloxetine, desvenlafaxine

- Inhibit reuptake of serotonin and norepinephrine, with minimal dopamine inhibition

- used for MDD, panic disorder, GAD

- can take up to 4 weeks

SNRI AE

- headache, nausea, agitation, anxiety

- sleep disturbance, dry mouth, sexual dysfunction

- anorexia, weight loss

- hyponaturemia

- serotonin syndrome

- increased diastolic blood pressure

SNRI contraindications

- use cautiously with hx of hypertension

- avoid use of duloxetine with hepatic disease or alcohol

Stressors

- physical or psychological factors that produce stress

- are cumulative, can add up ontop of one another

Symptoms of chronic stress

- Chronic anxiety or panic attacks

- Depression, chronic pain, sleep issues

- Weight gain or loss

- Increased risk for MI or stroke

- Poor diabetes control and HTN

- Fatigue, irritability, decreased concentration

- Weakened immunity

Symptoms of acute stress

- Apprehension

- Unhappiness

- Decreased appetite

- Increased RR/HR/BP

- Increased metabolism and glucose use

- Decreased immune system

- Body returns to homeostasis once stressor resolves

Protective factors from stress

- Physical health

- Humor

- Relationships

- Religious or spiritual beliefs

- Optimism

- Hobbies

- Strong sense of self

- Strong support system

Stress management techniques

- Being able to re-condition and view stressors as positive

- Cognitive techniques and reframing

- Meditation

- Guided imagery

- Breathing exercises

- Progressive muscle relaxation

- Exercise

- Journaling

- Priority restructuring

- Biofeedback

- Mindfullness and grounding

- Assertiveness training

- Hobbies

Major depressive disorder criteria

- 5 or more symptoms

- Must occur almost every day for 2 weeks

- Single episode or recurrent episodes of unipolar depression

- Cannot be attributed to another medical condition or substances

Major depressive disorder s/sx for dx

- depressed mood

- difficulty sleeping or excessive sleeping

- indecisiveness

- decreased ability to concentrate

- suicidal ideation

- increase or decrease in motor activity

- inability to feel pressure

- increase or decrease in weight by more than 5% of total body weight over 1 month

Common depression comorbidities

- Anxiety disorder

- Eating disorder

- Personality disorder

- Psychotic disorder

- Substance use disorder

Expected depressive findings

- Anergia

- Anhedonia

- Anxiety

- Sluggishness

- Change in eating patterns

- Somatic reports

- Look sad

- Blunted affect

- Agitation

- Social isolation

- Slowed movements, speech, decreased verbalization

- Poor hygiene/grooming

Other depressive conditions

- Seasonal affective disorder, usually in the winter and treated with light therapy

- Persistent depressive disorder, milder form of depression that lasts for +2 yrs in adults and +1 yrs in children with 3 or more depression findings

- Premenstual dysphoric disorder, associated with luteal phase, can cause mood swings, irritability, fatigue, bloating, breast tenderness, weight gain, dx is 1 yr and 5 or more s/sx, treat with diet, exercise and relaxation therapy

- Substance-induced depressive disorder, clinical findings of depression associated with use of or withdrawal from drugs and alcohol

Nursing care for depressive disorders

- Safety and suicide risk

- Promote self care and reorient patient

- Provide therapeutic communication

- Provide community resources

- Promote self-esteem, actively listen, allow pt to cry

- Aid in education to change negative thinking to positive thinking

- Promote CBT and coping strategies

- Patient education

Other depressive disorder treatment

- Light therapy

- ECT

- CBT

- Interpersonal therapy

- Group therapy

- Family therapy

Phases of schizophrenia

- Prodromal: onset with mild changes

- Acute: exacerbation of symptoms

- Stabilization: symptoms diminishing

- Maintenance: new baseline established, relapses may occur