Interactive Processes Exam 3

Bipolar 1 Disorder

defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care

Bipolar 1 Disorder clinical picture

- most severe form

- highest mortality rate of the 3

- at least 1 manic episode accompanied by major depressive episodes

- sudden onset, escalates rapidly

- frequent hospitalization

Bipolar 1 Disorder characterisitics

- shifts in mood energy and ability to function

- poor judgement and hyperactivity

- interpersonal and occupational difficulties

- psychotic episodes

- mania followed by exhaustion and depression

Bipolar II Disorder

defined by a pattern of depressive episodes and hypomanic episodes, but not full-blown manic episodes

Bipolar II disorder clinical picture

- at least 1 hypomanic episode

- at least 1 major depressive episode

- no hx of manic episodes

- most common but under or miss diagnosed

Bipolar II Disorder Characteristics

- mania is less severe than Bipolar I

- verbal and behavioral outburst in adolescents

Cyclothymic Disorder (Cyclothymia)

defined by numerous periods of hypomanic symptoms as well numerous periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

cyclothymic disorder clinical picture

- hypomania with dysthymic episodes (symptoms of mild to moderate depression) for at least 2 years (adults) & 1 year in children

- rapid cycling possible

cyclothymic disorder characteristics

- not severe enough to meet criteria for Bipolar I or II, but disturbing enough to cause social and occupational impairment

- irritable hypomania

- sleep disturbances

Risk factors

- genetics: runs in the family

- neurotransmitters: imbalance or norepinephrine, dopamine, serotonin

- brain structure and function: prefrontal cortical dysfunction

-- decision-making, personality expression, and social behavior (euphoric or aggressive behaviors)

- Neuroendocrine

-- hypothalamic-pituitary-thyroid-adrenal axis

-- hypothyroidism

- Environment

-- stress, adverse life events

Bipolar mania

•Elevates/expansive mood

•Inflated sense of self esteem

•Racing thoughts; distractibility

•Flamboyant gestures

•Decreased sleep

•Increased involvement in pleasurable activities

•Delusions or hallucinations

•Loud, rapid speech

Bipolar depression

•More withdrawn and poverty of speech

•Hopeless

•Increase in hypersomnia

•Increase in motor retardation

•Increased chance or paranoid thoughts and hallucinations

hypomania

- similar to mania, but not as severe

- episode is at least 4 days in length

- hospitalization is not required

- notable change from typical behavior

- increase in goal-directed behavior

- decreased need for sleep

pressured speech

Speech that is increased in amount, accelerated, and difficult or impossible to interrupt. Usually it is also loud and emphatic.

circumstantial speech

adding unnecessary details when communicating with others; person eventually gets to the point

tangential speech

The listener responds by taking the topic in a different, but related direction, never gets back to the main point

loose associations

disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts

flight of ideas

symptom of mania that involves an abruptly switching in conversation from one topic to another

clang associations

the stringing together of words that rhyme but have no other apparent link

grandiose delusions

beliefs that one holds special power, unique knowledge, or is extremely important

persecutory delusions

beliefs of being targeted by others

Assessment guidelines for bipolar disorder

- Danger to self or others

- Need for protection from uninhibited behaviors

- Need for hospitalization

- Medical status

- Coexisting medical conditions

- Family's understanding

Acute phase

prevent injury (6-12 weeks)

continuation phase

relapse prevention (4 to 9 months)

Maintenance phase

limit severity and duration of future episodes ( 1 year or more)

Planning and Interventions for Bipolar disorder

- always keep underlying pathology in mind

- #1 priority is SAFETY

- give clear, concise directions

- set limits and be consistent in approach

- reinforce reality as needed

- managing medications

- decreasing physical activity

- increasing fluid and food intake (finger foods, high cal, high protein)

- ensuring at least 4 to 6 hours of sleep per night

- intervening so that self-care needs are met

- respond to legitimate compliants

- redirect into more healthy activity (distraction)

- intervene early with escalating behaviors

- reduce environmental stimuli

- maintain structure & routine

- seclusion, restraint or electroconvulsive therapy (ECT) may be considered during the acute phase

depressive episodes

- Hospitalization for suicidal, psychotic, or catatonic signs

- Medication concerns about bringing on a manic phase

manic episodes

- hospitalization for acute mania (bipolar 1 disorder)

- communicating challenges and strategies

Pharmacological interventions for Bipolar Disorder

- Lithium first-line agent and drug of choice

- Olanzapine (Zyprexa)- used to treat mania and bring hyperactivity under control

- Anticonvulsants used to bring rapidly changing moods under control

- Know drug levels and signs of toxicity for lithium

- Mood stabilization most often requires long-term (lifetime) medication management

- Antidepressants, stimulants, steroids & anticholinergics can potentiate mania

- High risk for non-compliance

- Many side effects subside within 7-10 days (sedation and cognitive dulling)

Lithium Carbonate

- used to treat acute mania, refractory unipolar depression and bipolar maintenance

- specific anti-suicide effect

- 10-21 day response time

- side effects range from normal to severe

- take with meals to nausea

- HIGH teratogenicity, NOT recommended for women of child bearing age

- Contraindicated in patients with cardiovascular or renal disease

- use with caution in elderly patients, monitor closely

Lithium carbonate med characterisitcs

- dosing 300mg BID-TID

- monitor blood levels on a regular basis; 12 hours after last dose

- Therapeutic blood level: 0.6-1.4mEq/L

- Toxic blood level: 1.5mEq/L and above

- q 6-12 month monitor TSH, SCr, Na, CBC, and lithium level

Lithium carbonate side effects

- common side effects: nausea, fine hand tremors, polyuria

- Can cause dehydration (interferes with the regulation of NA & H2O) (maintain normal fluid intake)

- interacts with NSAIDS, ACE inhibitors, thiazide diurectics

- adverse effects: diaphoresis, weakness, severe nausea

Valporate (Depakote)

- very effective for acute mania and mania secondary to a general medical condition

- Used in conjunction with atypical antipsychotics to stop manic attacks or as a first-line agent for mixed episodes

- normalize & stabilize neuronal activity

- rapid onset

- generally well-tolerated

- can have transient hair loss, weight gain, GI disturbances, tremor & thrombocytopenia

- Black box warning: pancreatitis, hepatitis, teratogen

Carbamazepine (Tegretol) adverse effects

Nausea, anorexia, sedation drowsiness, anemia & rarely thrombocytopenia

Carbamazepine (Tegretol) considerations

Do not respond to lithium or valproates; rapid cycling; therapeutic range 4-12 mcg/ml; use with SSRIs can cause toxic effect; weekly CBC ; taper slowly

Lamotrigine (Lamictal) adverse effects

dizziness, HA, nausea; Black box for stevens- johnson syndrome & toxic epidermal necrolysis

Lamotrigine (Lamictal) considerations

Effective with bipolar depression & long term maintenance; taper slowly

depressive disorders

All share symptoms of

- sadness, emptiness, irritability, somatic (body) concerns, and impairment of thinking

All impact a person's ability to function

Disruptive Mood Dysregulation Disorder

- constant and severe irritability and anger in children 6-18 years of age

- Onset before 10 years of age

- To be diagnosed must exhibit irritability, anger, and temper tantrums in at least two settings: home, school, or with peers

Persistent Depressive Disorder (Dysthymia)

- low-level depressive feelings through most of each day, for the majority of days

- at least 2 years in adults

- at least 1 year in children and adolescents

- must have 2 or more of the following:

-- decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness

premenstrual dysphoric disorder

- symptoms cluster in last week prior to onset of a woman's period; include mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating

- symptoms decrease significantly or disappear with the onset of menstruation

substance-induced depressive disorder

Person does not experience depressive symptoms in the absence of drug or alcohol use or withdrawal

Depressive disorder associated with another medical condition

- can be caused by kidney failure, Parkinson's disease, and Alzheimer's disease

- symptoms that result from medical diagnoses or certain medications are not considered major depressive disorder

major depressive disorder

five or more of the following in 2-week period

- weight loss and appetite changes

- sleep disturbances

- fatigue

- worthlessness or guilt

- loss of ability to concentrate

- recurrent thoughts of death

PLUS- at least one symptom is also either...

- depressed mood

- loss of interest or pleasure (anhedonia)

Major depressive disorder symptoms

- persistent for minimum 2 weeks to 6 weeks months

- Chronic: lasting more than 2 years

- recurrent episodes common

- symptoms cause distress or impaired function

- an episode not attributed to physiological effects

- the absence of a manic or hypomanic episode

- anhedonia- lack of interest

- anergia- abnormal lack of energy

biological factors

- genetic disposition

- biochemical: stressful life events

- alteration in hormonal regulation

- inflammatory process- New research

- diathesis-stress model

-- genetic, biochemical, personality structure

-- life events

psychological factors

- cognitive theory (optimist vs. pessimist)

- learned helplessness (lack of resilience)

Areas of Assessment

- affect

- thought processes

- mood

- feelings

- physical behavior

- communication

- religious beliefs and spirituality

nursing diagnosis

- risk for suicide-- safety is always the highest priority

- hopelessness

- ineffective coping

- social isolation

- spiritual distress

- self-care deficit

nursing interventions

- empathic and trusting

- unobstructed observation and routine suicide screening

- reframing of negative thoughts

- medication education and treatment reinforcement

what to think about when choosing an antidepressant...

- symptom profile of the patient

- side-effect profile

- ease of administration

- history of past reponse

- safety and medical considerations

Selective Serotonin Reuptake Inhibitors (SSRIs)

- first-line therapy

- rare risk for serotonin syndrome (cause manic episodes)

- monitor for the initial increase in suicidal thoughts

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

SSRIs may be tolerated better

Tricylic Antidepressants

anticholinergic adverse reactions

Monoamine Oxidase Inhibitors adverse effects

hypertensive crisis; insomnia, confusion

MAOIs nursing considerations

rarely used, require closely monitoring, potentially fatal drug & food interactions, OTC interactions, contraindicated in people taking SSRI's, tyramine-restricted diet

MAOI dietary restrictions

Avoid Tyramine ....Avoid aged foods like yeast products, processed meats, avocados

- diet example: most fresh fruits and vegetables, fresh meat should be ate

electroconvulsive therapy (ECT)

- the most effective depression treatment

- psychotic illnesses= second most common indication

- ECT is the primary treatment in:

-- severe malnutrition, exhaustion and dehydration due to lengthy depression

-- safer than meds with certain medical conditions

-- delusional depression

-- the failure of previous medication trials

-- schizophrenia with catatonia

Nursing care after ECT

- Priority # 1- physiological stability

- Reducing disorientation and confusion

- May have short term memory loss or confusion. Do not operate machinery or make important decisions.

transcranial magnetic stimulation (TMS)

- noninvasive

- Uses MRI- strength magnetic pulses to stimulate focal areas of the cerebral cortex

- the presence of metal is the only contraindication

transcranial magnetic stimulation (TMS) adverse reactions

- headache and lightheadedness

- no neurological deficits or memory problems

- seizures rarely

- most are mild and include scalp tingling and discomfort at the administration site

vagus nerve stimulation

- Originally used to treat epilepsy

- Decreases seizures and improves mood

- Electrical stimulation boosts the level of neurotransmitters

vagus nerve stimulation side effects

-Voice alteration (nearly 60% of patients)

-Neck pain, cough, paresthesia, and dyspnea, which tend to decrease with time

deep brain stimulation

- Surgically implanted electrodes (in the brain)

- Stimulates those regions identified as underactive in depression

- More invasive than VNS

-- Electrodes placed directly into the brain

light therapy

- First-line treatment for seasonal affective disorder (SAD)

- Efficacy due to influence of light on melatonin

- Effective as medication for SAD

- Negative effects: headache and jitteriness

St. John's Wort

- Flower processed into tea or tablets

- Thought to increase serotonin, norepinephrine, and dopamine in the brain

- Useful in mild to moderate depression

excerise

- biological, social, and psychological effects

- increases serotonin availability

cognitive-behavioral therapy (CBT)

removing negative thought patterns

Schizophrenia

a psychotic disorder that disturbs the fundamental ability to determine what is real

DSM-V Criteria for Schizophrenia

* At least two of the following 5 symptoms have to be present, whereby at least one

of the symptoms needs to be delusions, hallucinations, or disorganized thinking.

1. Delusions

2. Hallucinations

3. Disorganized thinking (speech)

4. Grossly disorganized or abnormal motor behavior

5. Negative Symptoms

* Significant deterioration of functioning in one or several areas (work, interpersonal

relations, self-care).

* Continuous signs of disturbance persist for at least 6 months.

* Symptoms are not caused by substance use or a medical condition.

What is schizophrenia?

a serious mental disorder characterized by significant disturbances in the following:

- perception: ability to perceive reality

- thought: concrete vs abstract

- feeling: inability to express emotions appropriately

- behavior: bizarre; stilted, rigid; catatonia

- attention

- motivation

risk factors of schizophrenia

- multi-factorial causes (psychodynamic, biological and environmental)

- neuro structural differences in the brain of those with schizophrenia

- inherited predisposition to schizophrenia

- significant changes in brain functioning for those with schizophrenia

- stress can exacerbate the schizophrenic process

- dopamine hypothesis

positive symptoms of schizophrenia

- hallucinations

- delusions

- disorganized speech (associative looseness

- bizarre behavior

cognitive symptoms of schizophrenia

- Inattention, easily distracted

- Impaired memory

- Poor problem-solving skills

- Poor decision-making skills

- Illogical thinking

- Impaired judgment

negative symptoms of schizophrenia

- blunted effect

- poverty of thought (alogia)

- loss of motivation (avolition)

- inability to experience pleasure or joy (anhedonia)

Affective symptoms of schizophrenia

dysphoria, suicidality, hopelessness

All Dimensions Alter the Individual's

- Ability to work

- Interpersonal relationships

- Self-care abilities

- Social functioning

- Quality of life

positive symptoms

- alterations in reality testing

- alterations in speech

- distortions of thought

- alterations in perception

- alterations in behavior

alterations in reality testing

- delusions (false, fixed beliefs without evidence to support)

- Nursing diagnosis: disturbed belief system, altered thought processes

- Nursing interventions:

-- acknowledge the patients experience, feelings

-- convey empathy regarding fearfulness and reassurance of intentions

-- AVOID questioning the delusion itself and focus on help the patient feel safe

Alterations in speech

- associative looseness

- neologisms: made up words, meaning for the patient onlu

- echolalia: pathological repetition of another's words

- clang association: words chosen based on sound

- word salad: most extreme form; a jumble of words meaningless to a listener

alteration in speech: nursing interventions

- Do NOT pretend to understand when you don't

- Place the difficulty in understanding on yourself, not the patient

- Tell the patient what you do understand and reinforce clear communication of needs

- Look for reoccurring issues or themes in what the patient is saying

- Summarize or paraphrase the patient's communication to role model clearer communication

- speak concisely, clearly, and concretely in sentences rather than paragraphs

distortions of thought

- paranoia (irrational fear, may result in defensive actions)

- others: thought blocking, insertions, deletion, and magical thinking

- Nursing diagnosis: risk for other-directed violence; restlessness agitation; risk for self-directed violence

Distortions of thought: Nursing interventions

- reduce excess stimuli

- acknowledge the patient's feelings, then work on bringing them back to reality

- Explore the patient's feelings and promote verbal expression of negative emotions

- Increase supervision when risk is present and ensure safe environment

- Medications/seclusions/physical restraints as a last resort

Alterations in perception

- hallucinations (sensory experience without stimuli)

- Other: depersonalization, derealization, illusions

- Nursing diagnosis: disturbed sensory perception: auditory/visual; risk for self-directed/ other-directed violence

- SX: darting eyes, tilted head, mumbling to self

Alterations in perception: Nursing interventions

- assess for symptoms of hallucinations

- focus on understanding the patient's experiences and responses

- ensure safety when suicidal or homicidal themes are present

- close monitoring required

- help the patient feel safe

- call the patient by name and speak clearly and concisely in a supportive manner

- maintain eye contact and redirect the patient's focus to your conversation

Alterations in behavior

- Catatonia

- Motor retardation

- Motor agitation

- Stereotyped behaviors

- Waxy flexibility

- Echopraxia

- Negativism

- Impaired impulse control

- Gesturing or posturing

- Boundary impairment

negative symptoms

- self-care

- anhedonia

- avoliation

- asociality

- affective blunting

- apathy

- alogia

anhedonia

a reduced ability or inability to experience pleasure in everyday life

avoliation

lack of motivation; difficulty beginning and sustaining goal-directed activities reduction in motivation or goal-directed behavior

Asociality

decreased desire for, or comfort during, social interaction

affective blunting

reduced or constricted affect

apathy

a decreased interest in, or attention to, activities or beliefs that would otherwise be interesting or important.

alogia

reduction in speech, sometimes called poverty of speech

affect assessment of negative symptoms

- flat: immobile or blank facial expression

- blunted: reduced or minimal emotional response

- constricted: reduced in range or intensity; shows sadness or anger but no other moods

- inappropriate: incongruent with the actual emotional state or situation

- bizarre: odd, illogical, inappropriate, or unfounded; included grimacing

Affective symptoms

dysphoria, suicidality, hopelessness, depression

- involve the experience and expression of emotions

- they are common and increases patients suffering

- mood may be unstable, erratic, labile, or congruent

cognitive symptoms

- concrete thinking

- impaired memory

- impaired attention

- impaired executive functioning- problem solving; decision making

- illogical thinking

- impaired judgement

schizophreniform disorder

Psychotic disorder involving the symptoms of schizophrenia but lasting less than 6 months.

brief psychotic disorder

Psychotic disturbance involving delusions, hallucinations, or disorganized speech or behavior but lasting from 1 day to 1 month; often occurs in reaction to a stressor.

delusional disorder

> 1 month, not severe to impair daily functioning or occupation

schizoaffective disorder

concurrent with sx of schizophrenia, along with uninterrupted period of depression, mania or mixed episodes