mental health exam 3

bipolar disorder

-characterized by periods of mania or hypomania that alternate with depression

-typically develops in late adolescence or early adulthood

-may take years to diagnose and even longer to manage effectively

-hard to diagnose/treat d/t 2 diff. symptoms

mania

alteration in mood, expressed by:

-feelings of elation

-inflated self-esteem

-grandiosity (feel invincible)

-hyperactivity

-agitation

-accelerated thinking and speaking (pushed/rapid speech)

hypomania

less severe form of mania

epidemiology of bipolar disorder

-prevalence: estimated 2.4%

-gender incidence roughly equal, FEMALES are at greater risk for depression, and MALES for manic episodes

-average age at onset: late teens/early 20’s

-no significant racial and ethnic differences (lack of representation and impact→ african american individuals with BPD are more likely to be misdiagnosed with schizophrenia)

most common co-morbidities of BPD

anxiety disorders & substance use, and disruptive/impulse control disorders

bipolar 1 disorder

-classic manic-depressive disorder

-mood swings alternating from depressed to manic

-mania: distinct period (of at least 1 wk) of abnormally increased goal-directed behavior

bipolar 2 disorder

-primarily depressed with brief periods of elevated, expansive, or irritable moods

-characterized by hypomania; never a manic episode

cyclothymic disorder

-hypomania alternating with numerous periods of depressive symptoms

-symptoms less severe than the bipolar disorders

-at least 2-yr duration

DIG FAST

D- distractibility

I-impulsivity (spending lots of money, substances, gambling, hypersexuality)

G- grandiosity

F- flight of ideas

A- activity increased

S- sleep deficit

T- talkativeness (decreased appetite, too busy, don’t sit still)

bipolar 1 disorder: clinical course

-chronic multisystemic, cyclic

-earlier onset→ more frequent episodes

-progressive (prodromal-early onset)

-symptomatic (acute phase)

-residual

-can lead to severe functional impairment

predisposing factors (BPD)

-likely resulting from an interaction between a genetic predisposition and psychosocial

biological theories

-strong hereditary implications

-chronobiology/circadian dysregulation

-BIOCHEMICAL INFLUENCES: possible excess of serotonin, norepinephrine, and dopamine

-chronic stress stress and inflammation

psychosocial theories

-behavioral approach system dysregulation

-social rhythm disruption theory

childhood and adolescence (BPD)

-diagnosis is difficult, takes years

-depression usually appears first

hallmark symptom of BPD in children and adolescents

-INTENSE RAGE

-unprovoked episodes lasting for hours

-co-morbid with ADHD and conduct disorder

-help Pt eat with finger foods

-low stimulation, meds to help sleep

nursing diagnosis for BPD

risk for injury r/t:

-extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements

risk for violence (BPD)

-manic excitement

-delusional thinking

-hallucinations

-impulsivity

nutrition (BPD)

imbalanced nutrition less than body requirements d/t:

-refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea

disturbed thought processes (BPD)

biochemical alterations in the brain, evidenced by delusions of grandeur and persecution and inaccurate interpretation of the environment

disturbed sensory perception

biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations

impaired social interaction (BPD)

egocentric and narcissistic behavior

insomnia (BPD)

excessive hyperactivity and agitation

nursing interventions (BPD)

-protection from injury d/t hyperactivity

-protection from harm to self or others

-restoration of nutritional status

-progression toward resolution of the grief process

-improvement in interactions with others

-acquiring sufficient rest and sleep

treatment modalities (BPD)

-individual psychotherapy

-cognitive-behavior therapy (CBT)

-family therapy

-complementary therapies

-ECT

-psychopharmacology (most important)

pharmacology (mania)

-mood stabilizing agents

-lithium carbonate (most commonly prescribed)

-anticonvulsants (defacote/tegradol)

-atypical antipsychotics (less S/E’s)

why aren’t antidepressants recommended for BPD?

they may trigger mania (increased serotonin, already high during mania)

lithium

-most widely used mood stabilizer

-approx 70% of patients experience symptom improvement

-during acute phase, often need supplemental antipsychotics, benzo’s

-MOA unknown; thought to decrease dopamine, increase neurotransmission, increase norepinephrine reuptake, and increase GABA

lithium S/E’s

-drowsiness, difficulty concentrating (be familiar with normal sx’s vs. signs of toxicity)

-metallic taste (low appetite)

-polydipsia and polyuria (lithium is a salt)

-FINE hand tremors

-N/D

-edema in hands or feet

-potential for toxicity

lithium toxicity

-INITIAL SYMPTOMS: lethargy, blurred vision, ataxia, tinnitus, persistent nausea/vomiting, diarrhea, dizziness

-then progresses to BLACKOUTS, gross tremors, seizures, cardiac arrhythmias, coma, and death

tx for lithium toxicity

-PUSH FLUIDS, lower salt content

-normal/balanced salt and fluid intake

client/family education for LITHIUM

-take meds regularly

-normal diet (normal salt intake)

-drink 6-8 glasses of water each day

-notify physician if vomiting/diarrhea occur (first sx’s of toxicity)

TOXICITY: sedative, lethargic, gross tremors, blurred vision

divalproex sodium (depakote)

-anticonvulsant

-broader spectrum of efficiency

MOA: unknown, thought to increase GABA (inhibitory neurotransmitter)

S/E (divalproex sodium)

-sedation, tremor, n/v, anorexia/wt loss, SLIGHT ELEVATION IN LIVER ENZYMES, THROMBOCYTOPENIA

-get baseline liver function tests and CBC w/ platelets

-optimal blood levels: 50-150ng/ml (weekly then Q6mo)

BBW for divalproex sodium

hepatotoxicity, pancreatitis, fetal harm

carbamazepine

-anticonvulsant

-may be effective for those not responsive to lithium

-MOA unknown, thought to increase GABA (inhibitory neurotransmitters)

S/E’s of carbamazepine

-dizziness, drowsiness, n/v

-get baseline LFT’s and CBC w/ diff

-optimal blood levels: 8-12ng/ml

BBW for carbamazepine

aplastic anemia and agranulocytosis

lamotigrine

-anticonvulsant

-approved for maintenance treatment of BPD

-particularly effective for rapid cycling and depressed phase of BPD

-MOA weak inhibitory effect on serotonin

S/E’s of lamotigrine

-dizziness, somnolence, and other signs of CNS depression

BBW of lamotigrine

stevens-johnson syndrome (full body rash)

antipsychotics (BPD)

-atypicals

-doses generally lower than for those with schizophrenia

antipsychotic S/E’s

-drowsiness, dizziness

-anticholinergic effects

-increased appetite, weight gain

-ECG changes

-EPS

-hyperglycemia and diabetes

ECT (BPD)

-for severe mania with unremitting physical activity

-acute mania that is unresponsive to mood stabilizers or are of high suicide risk

-NOTE: use of valproate or carbamazepine will elevate seizure threshold

TMS (BPD)

primarily for depressive phase rather than mania

nature of illness (BPD)

-causes of bipolar disorder

-cyclic nature of the illness (relapse is common)

-symptoms of depression (suicidal)

-symptoms of mania (acting reckless)

MGMT of BPD

-medication management

-assertive techniques

-anger management

support services (BPD)

-crisis hotline

-support groups

-individual psychotherapy

-legal/financial assistance

measuring client outcomes (BPD)

-exhibits no evidence of physical injury

-has not harmed self or others

-is no longer exhibiting signs of physical agitation

-eats well-balanced diet with snacks to prevent weight loss and maintain nutritional

-verbalizes an accurate interpretation of the environment

-exhibits no evidence of hallucinations

-accepts responsibility for own behaviors

-does not manipulate others for gratification of own needs

interacts appropriately with others

evaluation (BPD)

-has the client avoided personal injury?

-has violence to client or others been prevented?

-has agitation subsided?

-have nutritional status and weight been stabilized?

-have delusions and hallucinations ceases?

-is the client able to make decisions about own self-care?

-is behavior socially acceptable?

-is the client able to sleep 6-8hrs per night and awaken feeling rested?

-does the client understand the importance of maintenance medication therapy?

OCD and related disorders

-obsessive-compulsive disorder

-body dysmorphic disorder

-excoriation disorder

-trichotillomania

-hoarding disorder

obsessions

-excessive, unwanted, intrusive and persistent thoughts, impulses, or images causing anxiety and distress

-not under the patient’s control, incongruent with the patient’s usual thought patterns

-intrusive and unwanted

compulsions

-repetitive behaviors and acts that are performed in a ritualistic pattern with a goal to prevent or relieve anxiety/distress caused by obsessions

-interferes with a person’s normal activities

-1 hour or more/day

diagnostic criteria (OCD)

-presence of obsessions, compulsions, or both

-causes severe disturbance in daily routines, relationships, or occupational function

-taking longer than one hour a day to complete

-stressful and interfere with normal daily routines

-insight may vary

epidemiology (OCD)

-gradual symptom onset (generally, in early adolescence and then in early adulthood)

-lifetime prevalence of 2.3%

-all ages affected, lifelong illness

-comorbid with anxiety, mood, eating disorders, and other obsessive-compulsive disorders

biologic theories (OCD)

-genetic link

-dysregulation of neurotransmitters, especially serotonin

psychodynamic theories (OCD)

-undoing; reaction formation

behavioral theories (OCD)

-obsessions: conditioned stimuli, compulsions develop to reduce anxiety from obsession

nursing assessment for OCD

-type and severity of obsessions and compulsions and degree of interference in daily functioning

RATING SCALES: yale-brown obsessive compulsive scale (YBOCS)

-functional status

-stress/coping patterns

-social network/support systems

medications for OCD

-SSRI’s (fluvoxamine or paroxetine)

-TCA (clomipramine)

MAY NEED HIGHER DOSES

therapy for OCD (CBT)

-exposure and response prevention

-thought stopping

-relaxation techniques

-cognitive restructuring

GRADUALLY DECREASE AMOUNT OF TIME SPENT PERFORMING RITUALS

trichotillomania

-chronic self-destructive hair pulling that results in noticeable hair loss

-person has an increase tension prior to pulling hair out; feels sense of relief after pulled

-person may ritualistically eat the hair, or discard it

-onset generally among children before the age of 5 years and in adolescents

-1-2% of the population

-anxiety, loneliness, anger, fatigue, guilt, frustration, and boredom can trigger hair-pulling behaviors

tx for trichotillomania

CBT (goal: substitute with positive behaviors)

-olanzapine, clomipramine have also shown some effectiveness

excoriation

-repetitive and compulsive picking of skin

-causes tissue damage

-most common sites: face, arms, hands

-can pick with fingers (most common), tweezers, or pins

-causes significant distress to the person

-prevalence around 3% (more in people with OCD)

interventions for excoriation

-behavioral: CBT and ACT

-pharm: SSRI’s

(care similar to those w/ trichotillomania)

body dysmorphic disorder

-preoccupation with real (but slight) or imagined flaws in physical appearance that are not observable or appear slight to others

-very self conscious→ functional impairment at work/home

-prevalence around 2%

-usually begins in adolescence and continues through adulthood

-high risk of depression and suicidal ideation

-TREATMENT: CBT

hoarding disorder

-difficulty parting with/discarding possessions, regardless of their value

-have a need to save, and very distressed if their items are discarded

-prevalence 2-6%

-familial link; comorbid with chronic anxiety and depression (over 50%)

-health and safety risk for families

tx for hoarding disorder

CBT (pharm for co-morbid disorders)

physical trauma

from an accident, self-inflicted damage, or violence perpetrated by others

psychological trauma

emotional injury caused by an overwhelmingly stressful event that threatens one’s survival and sense of security

resilience

capacity to withstand stress and catastrophe (develops over time and is the culmination of multiple internal and external factors)

trauma and stressor-related disorders

-PTSD (>1mo)

-acute stress disorder (<1mo)

ASD & PTSD

-occurs following exposure to an actual or threatened traumatic event

-traumatic events include those that are directly experienced, witnessed, learned about from others, or due to repeated exposure to aversive events

PTSD symptoms

-persisting for at least one month or more

-intrusive symptoms, avoidance of person (s), places, or objects that are a reminder of a traumatic event (flashbacks, nightmares)

-negative mood/thoughts

-hyperarousal (aggression, self-destructive behavior)

-sleep disturbances or hypervigilance

ALL FOR AT LEAST ONE MONTH

ASD symptoms

-short term stress-related symptoms occur within one month of traumatic event, persist for less than one month, and cause significant distress

-can develop into PTSD if symptoms persist longer than one month

PTSD epidemiology

-lifetime prevalence 6% in US

-women 2-3x more likely to experience PTSD than men

-discrimination associated with higher rates in minority groups

-men’s triggers include fires, disasters, accidents, assaults, combat, being held captive

-women’s triggers include anxiety, depression, child abuse, sexual and/or physical abuse, and traumatic events prior to 18y/o

-high rates of PTSD in veterans

risk factors for PTSD

extent, duration, and intensity of trauma involved:

environmental factors, high anxiety and low self-esteem increase risk

PTSD assessment

-trauma

-physical health (sleep, nutrition, medicine/substance use)

-psychosocial (behavioral response, stress/coping patterns, functional status, social networks/support)

trauma-informed approaches

-establishing wellness and recovery goals

-trustworthiness and transparency

-peer support

-collaboration and mutuality

-empowerment

recovery-oriented care for PTSD

-safety

-pharmacotherapy (SSRI’s, SNRI’s, atypical antipsychotics and mood stabilizers)

-NOT BENZO’s (dependency)

PSYCHOTHERAPY:
-psychodynamic psychotherapy

-cognitive-behavioral therapy (CBT)

-eye movement, desensitization, and reprocessing (EMDR)

-group therapy and family therapy

other trauma/stressor-related disorders

-acute stress disorder

-reactive attachment disorder

-disinhibited social engagement disorder

-adjustment disorder (one of the most common diagnoses for hospitalized persons)

-dissociative disorders (dissociative identity disorder)

anxiety

-uncomfortable feeling of apprehension or dread

-response to internal or external stimuli

-physical, emotional, cognitive, and behavioral symptoms (pacing, etc)

epidemiology for anxiety

-anxiety disorders are most common of all psychiatric illnesses (chronic and persistent, approximately 18% of US adults)

-more common in women than men

-first onset generally in late adolescence/early adulthood)

-associated with other mental and physical disorders (high association between depression and anxiety)

-person may have more than one anxiety disorder

how much anxiety is too much?

-when anxiety is out of proportion to the situation that is creating it

-when anxiety interferes with social, occupational, or other important areas of functioning (mild, moderate, severe, PANIC)

-perceptual field narrows as anxiety gets worse

anxiety disorders

-panic disorder

-generalized anxiety disorder

-phobias (agoraphobia, specific phobias, social anxiety disorder/social phobia)

panic disorder

-extreme, overwhelming form of anxiety often experienced when an individual is placed in a real or perceived life-threatening situation (panic attacks)

-characterized by recurrent panic attacks

-sudden, discrete (short-term) periods of intense fear or discomfort accompanied by significant physical (tachycardic, HTN, “heart attack”, can’t breathe, parasthesia) and cognitive symptoms (scattered thoughts, can’t concentrate, illogical thinking)

panic disorder

-approximately 4% lifetime rate (isolated panic attacks in 20-25% population)

-higher risk in females, middle aged, low SES, and widowed/separated/divorced

-occur across all cultures, though symptoms may present differently

biological theories (panic disorder)

-genetic link (hereditability approximately 40%)

-brain abnormalities in fear network

-serotonin and NE; GABA ARE ALL LOW

cognitive-behavioral theories (panic disorder)

-lots of evidence behind this

-interoceptive conditioning

diagnostic criteria (panic disorder)

-recurrent and unexpected panic attacks, with/out agoraphobia

-at least one panic attack is followed by one month (or more) of the following

1. -persistent concern/worry about having another attack or the consequences

2. -significant changes in behavior because of fear of the attacks

planning/implementation for panic disorder

emergency care (in midst of panic attack)

-stay w/ patient

-reassure them that you will not leave (tell them the episode will end)

-give clear directions

-assist patient to an environment with minimal stimulation

-walk with the patient

-administer PRN meds (benzo only short-term)

-rule out life-threatening events

psychoeducation (panic disorder)

-breathing control

-relaxation techniques (focus on a spot on the floor, etc)

-nutritional planning

-increased physical activity

SSRI’s (panic disorder)

-first line option for long term treatment

-fluoxetine, sertraline, paroxetine

SNRI’s (panic disorder)

venlafaxine

benzo’s (panic disorder)

-for intensely distressed (just rapid-acting, work TOO WELL)

-give low dose for around 7-10 days with SSRI’s

-clonazepam, alprazolam

-RISK: REBOUND ANXIETY(can become more irritable)

S/E’s for benzo’s (panic disorder)

sedation, cognitive slowing, DEPENDENCE

generalized anxiety disorder

-characterized by CHRONIC, UNREALISTIC, and EXCESSIVE anxiety and worry (key feature)

-occurs in all ages

-association with mild depression

-highly somatic (frequently to primary care setting)

-comorbid with depression and other anxiety disorders

diagnostic characteristics (GAD)

-excessive worry and anxiety for at least 6mo

-anxiety does not usually pertain to a specific situation

-interferes with daily personal or social life

interventions (GAD)

-similar to those for panic disorder

-relaxation techniques

-supportive therapies

-CBT (cognitive behavioral therapy)

medications (GAD)

-SSRI’s (first line)

-SNRI

-buspirone (buspar)

-beta blockers (propanolol/inderal)

client outcomes (GAD)

-is able to recognize signs of escalating anxiety and intervene before reaching panic level

-is able to maintain anxiety at manageable level and make independent decisions about life situation