Psych Exam 1

Mental illness

Clinically significant behavioral or psychological syndromes

• distress, disability or risk of suffering disability or loss of freedom

• must have impairment to functioning

Diagnostic: DSM-5 manual

Biopsychosocial model for mental health

Patient rights

Self-determination: individual chooses a course of action w/o being restrained by others’ expectations

• ex.:

  • to refuse tx, to choose tx not favored by provider, to seek second opinion

Confidentiality

Ethical duty of nondisclosure

Breach of confidentiality (instances when it is nurse’s duty):

• any threat/harm to persons

• suspected child/elder abuse

• allegations of sexual misconduct with members of healthcare team

Competency

Is a legal determination - degree to which a pt can understand and appreciate info given during consent process

• may change over time

Conditions for involuntary commitment

Have a mental illness AND:

1. danger to self → can include gross inability to care for self AND/OR

2. danger to others

*state law requires that individual is “imminently” dangerous

Pts still have right to 1) least restrictive environment 2) right to refuse tx/meds

Restraints

Types:

• Chemical

  • use of med to alter behavior

• Physical

  • devices, seclusion

Requirements:

• provider order, cannot be indefinite, regular review of pt condition (q15minutes)

Therapeutic relationship

Focus is on the pt’s problems and needs → not about YOU

Stages (in order):

• introduction/orientation → working → termination

Factors:

• genuineness, empathy, positive regard (respect)

Therapeutic Communication

Therapeutic Communication IS NOT:

• Therapy

• Assessment

Therapeutic Communication IS:

• Active Listening

Boundaries

Role should be clearly defined:

• all interactions should happen within tx setting

• all resources provided should be through established channels

Warning signs boundaries are blurred:

• receiving feedback your behavior is intrusive, difficulty setting limits, relating to pt like friend, hugging/touching

Maslow’s

Psychoanalyic/dynamic theory

Transference and Countertransference

Transference: feelings of pt directed towards nurse

Countertransference: feelings of nurse towards pt

Interpersonal theory

Purpose of all behavior is to get needs met through interpersonal interactions and to reduce anxiety

• recognizes the importance of social forces or what one does in relation to others

• self system or persona

• healthy individuals characterized by self reliance and cooperation

Behavioral theory

Cognitive theory

Thinking drives emotion and behavior

Developmental theory

Erikson’s

Cognitive development

Humanists

• People have an innate desire for growth

• the correct conditions need to be present

• unconditional positive regard:

  • acceptance, love, respect w/o conditions is necessary for people to grow/thrive

Neuron

The core cellular unit

• At the synapse (synaptic cleft) → where neurotransmitters communicate btwn neurons

Limbic system

Role in emotional status and psychological functions

Comprised of several structures:

• hippocampus, thalamus, hypothalamus, amygdala

Executive functioning

All functions of prefrontal cortex, including logic, reasoning, emotional regulation

Neuroplasticity

Capacity of neurons and neural networks in the brain to change their connections and behavior in response to new info, sensory stim, devlopment, dysfunction

• brain capable of change throughout lifetime

• neurons that fire together, wire together

Epigenetics

Neurotransmitters

Acetylcholine (Ach) → associated w/ concentration, focus, and learning

Biogenic Amines

• dopamine → attributed to positive feeling states and reinforcing behaviors

  • too much → psychosis

• norepinephrine → drives fight/flight

• serotonin → associated w/ mood and anxiety

GABA → inhibitory and associated w/ relaxation response and sleep

Glutamate

Psychotropic medications

Antidepressants → 4-6 wks to reach efficacy

• Common side effects: appetite change, sleep disturbance, somnolence, hypersomnia, nausea, low libado/altered sexual performance, nervous/agitated

• Types

  • MAOIs

    • drug/food interactions lead to hypertensive crisis

      • foods high in tyramine → aged cheese, fermented, smoked

  • TCAs

    • lethal in overdose

    • can be prescribed in primary care for sleep

  • SSRIs → first line for depression and anxiety

    • suicide risk in pt <24 yrs old

    • risk of serotonin syndrome

Mood stabilizers

*can be used for bipolar

Anticonvulsants

• valproic acid

  • metabolized in liver → monitor LFTs

• carbamazepine, lamotrigine

  • risk of rash, SJS

Lithium

• Li is an electrolyte so levels are affected by fluid/sodium balance

• metabolized in kidney (monitor BUN, creatinine)

• antimanic + antidepressant efffects

Controlled substances

Types:

• benzodiazepines

  • CNS depressant, can’t be combined w/ other CNS depressant (opiates/ ETOH)

• psychstimulants

Safety: carry risk of abuse/diversion

Antipsychotics

Types:

• conventional

  • ex. haldol, chlorpromazine (thorazine)

• atypical

  • block dopamine but have serotoniergic effects that are believed to reduce risk of movement disorders and affective flattening

  • impacts dopamine & serotonin

  • screen for metabolic syndrome: weight, bp, glucose, lipid, waist size

  • ex. risperidone (risperdal)

Monitor for:

• extrapyramidal side effects (EPS)

• serotonin syndrome

• neuroleptic malignant syndrome (NMS)

Extrapyramidal side effects (EPS)

Includes:

• tardive dyskinesia → excessive fast movement (lip smacking, tongue rolling)

• akathisia → inability to remain still

• acute dystonia → intense, acute muscle spasm

• pesudoparkinsonism → repetitive unconcious movement (muscle rigidity, tremors), if no tx → permanent disability

Serotonin syndrome

Due to excess serotonin:

• Confusion

• clonic muscle activity

NMS

High fever, muscle rigidity, confusion

Hypertensive crisis

Caused by excess tyramine and marked by uncontrolled hypertension

• side effect of MAOIs

TCA Toxicity

Associated w/ cardiovascular and neurobiologic instability

Therapeutic Milieu

The Clinical Environment

• Should be healing/non-harming

• Aspects include physical and emotional safety