Final mental Health exam!

What is transference?

What is transference?

Patient unconsciously and inappropriately displaces onto nurse feelings and behaviours related to significant figures in patient’s past.

What is counter-transference?

Nurse displaces feelings related to people in nurse’s past onto patient.

Psychosis

A disordered mental state in which the client has difficulty distinguishing reality from his/her own internal perceptions.

Psychosis is characterized by reality misrepresentations, disorganized thinking and lack of awareness regarding truth and reality.

Schizoaffective disorder

persistent mood disorder as well as psychotic symptoms (underlying disorder is depression)

What is the most common type of hallucination for people with schizophrenia?

Auditory hallucinations

Delusional disorder

Persistent delusions

Schizophreniform

Similar to schizophrenia, but duration is less than 6 months

How many months of experiencing symptoms until you can be diagnosed with schizophrenia?

6 months

Substance / medication induced psychosis

Psychosis due medication consumption or withdrawal

5 key features associated with psychotic disorders

• Delusions

• Hallucinations

• Disorganized thinking

• Abnormal motor behaviour

• Negative symptoms

Negative symptoms

Absence of something that should be present.

Example: restricted emotions, lack of self care, social withdrawal, lack abstraction ability (do not understand metaphors / analogies)

Anhedonia

Diminished ability to experience pleasure

Alogia

Poverty of thought and speech

Avolition

Lack of motivation / goals

Ambivalence

Lack of ability to make a decision because of conflicting emotions

Affective blunting

Restriction in range and intensity of emotion

Positive symptoms

Indicate a distortion or excess of normal functioning, including delusions and hallucinations.

Usually occur as the initial symptoms of schizophrenia

What are common types of delusions with schizophrenia? (4)

• grandiose delusions

• persecutory delusions

• somatic delusions

• religious delusions

Grandiose delusion

Excessive feelings of importance

Persecutory delusions

People plotting against you

Somatic delusions

Abnormalities about body structure/function i.e. body rotting, with evidence to the contrary

Religious delusions

Religious preoccupations i.e. believing they are a prophet/deity, etc.

Types of disorganized thinking (3)

Looseness of association – flow of ideas not logical, unexpected shifts

Flight of ideas – rapid or pressured speech – rate intensity & volume

Thought blocking – abrupt pause in speech usually without recall

Common abnormal motor behaviours (4)

• Alterations

• Purposeless activity/irritability (rage, loud)

• Agitation, restlessness

• Bizarre behaviour (rigid demeanor, eccentric dress, stupor, pacing)

people who have schizophrenia have suicide rates _____ times higher than the general population

20 times

What are the three phases of schizophrenia?

1. Prodromal

2. Acute

3. Recovery

What is the prodromal phase of schizophrenia?

Signs vague, hardly noticeable

• withdrawal, depression, anxiety, compulsions

What is the acute phase of schizophrenia?

Psychotic symptoms experienced (positive symptoms)

What is the recovery phase of schizophrenia?

Illness is managed

➢ Potential for relapse

➢ Potential for residual symptoms

What are the factors associated with a positive and negative prognosis of schizophrenia?

• abrupt onset of symptoms is a favourable prognostic sign.

• less positive prognosis = slow onset (2-3 years), younger age at onset, longer duration between first symptoms and first treatment, more negative symptoms

Diathesis-stress model of schizophrenia

Genetic predisposition + environmental factors (stress) = schizophrenia

Dopamine theory

Dopamine over abundance in Mesolimbic pathway results in schizophrenic symptoms

• When using dopamine blockers, positive symptoms were correctable

What neurotransmitters have a role in the development of schizophrenia? (5)

• Dopamine

• Serotonin

• Norepinephrine

• Glutamate

• GABA

What are extrapyramidal symptoms (EPS), and what are the 4 common ones?

result of first generation antipsychotics, can affect motor control and coordination

common EPS symptoms include:

• Akathisia: Feeling restless like you can't sit still.

• Dystonia: When your muscles contract involuntarily.

• Parkinsonism: Symptoms are similar to Parkinson's disease.

• Tardive dyskinesia: Facial movements happen involuntarily.

Overactive dopamine activity in the Mesolimbic pathway leads to what?

overactive dopamine activity leads to positive symptoms (auditory processing/emotion reg.)

What is underactivity of the mesocortical pathway associated with?

under activity associated with negative symptoms (memory and planning)

Nigrostriatal pathway

motor activity affected and EPS Symptoms

Tuberoinfundibular pathway

Endocrine function

What is included in a Mental Status Examination? (7)

• Appearance (observed)

• Behaviour (observed)

• Speech (observed)

• Mood (observed & inquired)

• Thought (observed & inquired)

• Perception (observed & inquired)

• Cognition (inquired)

What is included when examining a patient’s cognition? (6)

• Level of conciousness

• Memory

• Attention + concentration

• Abstract reasoning + comprehension

• Visual or spatial processing

• Fund of knowledge or intelligence

Thought content

Any themes in a person’s expression of speech

Thought process

the logical connections between thoughts and their relevance to the conversation

ex. disorganized, coherent, flight of ideas, neologisms

Neologism

made up word

What is the nursing diagnosis for someone with delusions?

Altered thought processes

Loose associations (thought process)

jumping topics, hard to follow

Circumstantial (thought process)

eventually back to point, wordy

Tangential (thought process)

never gets back to point

Thought blocking (thought process)

stoppage, usually sudden

Echolalia (thought process)

persistent repetition

Disassociation

Occurs when you have the feeling that you’re observing yourself from outside your body, or have a sense that things around you aren’t real

Depersonalization

one aspect of disassociation, a feeling of detachment, especially from oneself and one's identity

For someone with suicidal / homicidal ideation, what must be charted? (3)

• Ideation

• Intent

• Plan

What is included in a psychosocial assessment? (9)

• Previous hospitalizations

• Educational background

• Occupational background

• Social patterns

• Sexual patterns

• Interests and abilities

• Substance use and abuse

• Coping abilities

• Spiritual assessment

Psychiatric evaluation is … (3)

• Systematic

• Ongoing

• Criteria-based

What is included in the HEADSSS interview technique? (7)

• Home environment

• Education and employment

• Activities

• Drug or alcohol use

• Sexuality

• Suicide risk

• Signs of violence, abuse, or aggression

Children typically provide better information about what symptoms?

Internal symptoms (mood, sleep, SI)

Parents usually provide better information about what symptoms?

External symptoms (behaviour, relationships)

What is the most common psychotic disorder?

Schizophrenia

Agranulocytosis

Severely low neutrophil count (type of WBC), can be caused by some antipsychotics

What are the four dopamine pathways?

• Mesolimbic

• Mesocortical

• Nigrostriatal

• Tuberoinfundibular

What are the 1st generation antipsychotics? (2)

• Haloperidol (Haldol)

• Chlorpromazine (Thorazine)

What are the 2nd generation (atypical) antipsychotics? (4)

• Risperidone (Risperdal)

• Olanzapine (Zyprexia)

• Quetiapine (Seroquel)

• Clozapine (Clozaril)

What is a 3rd generation (atypical) antipsychotic?

• Aripiprazole (Abilify)

What are the disadvantages of 1st gen antipsychotics? (6)

• Extrapyramidal side effects (EPS)

• Anticholinergic (ACh) adverse effects

• Tardive dyskinesia

• Weight gain

• Sexual dysfunction

• Endocrine disturbances

What are EPS medications?

Seek to reestablish a balance of acetylcholine and dopamine to reverse dystonias

What is the difference in targeted receptors between 1st gen and atypical antipsychotics?

• 1st gen antipsychotics are only effective on 1 type of receptor (dopamine)

• Newer atypical antipsychotics target several dopamine receptors, and also block reuptake of serotonin and norepinephrine

What is a disadvantage of atypical antipsychotics?

Can cause significant weight gain

What are potential medical emergencies that can be caused by antipsychotics? (3)

• Neuroleptic malignant syndrome (NMS)

• Agranulocytosis

• Anticholinergic syndrome

What is Neuroleptic malignant syndrome (NMS), and what are 4 interventions?

NMS is a reaction to antipsychotic drugs characterized by fever, muscle rigidity, diaphoresis, tachycardia, and hypertension.

• Stop antipsychotic treatment.

• Transfer to medical care / ICU.

• Monitor treatment of symptoms.

• Benzodiazepines / muscle relaxants.

What is Anticholinergic syndrome?

acute psychosis or delirium resulting from inhibition of central cholinergic transmission.

What are affective symptoms of schizophrenia? (3)

• Dysphoria (mental state of dissatisfaction)

• Suicidality

• Hopelessness

What is TVIC? What are the four principles?

Trauma and violence informed care

• Build awareness and understanding.

• Emphasize safety and trust.

• Offer authentic choices through connection & collaboration.

• Find and build on people’s strengths.

What are the four areas where boundaries can be established in nursing care?

• Treatment planning and delivery

• Space

• Comportment (behaviour)

• Location of service delivery

What are NANB’s 5 components of the nurse-client relationship?

• Power

• Trust

• Respect

• Professtional intimacy

• Fiduciary duty (legal responsibility to act solely in the best interest of another party)

What are some methods of communication that help clarify patient statements? (4)

• Paraphrasing

• Restating

• Reflecting

• Exploring

What is the importance of early psychosis intervention?

• Long duration between first symptoms and treatment = poorer prognosis.

Who is at greatest risk for suicide in Canada? (3)

• Suicide is the second leading cause of death among youth and young adults (15 to 34 years).

• Suicide rates 3 times higher among men compared to women.

• First Nations, Inuit, and Metis peoples in Canada, collectively called Indigenous peoples, are especially vulnerable to death by suicide.

What are the essential questions we ask individuals about suicide? (6)

• Have you ever felt that life was not worth living?

• Have you been thinking about ending your life?

• Do you have a plan for what you would do to end your own life?

• If so, what is your plan?

• Do you intend to carry out your plan?

• What is stopping you from carrying out your plan?
  

What are the neurotransmitter changes that can lead to suicide?

Abnormalities in number of serotonergic neurons, serotonin transportation, receptor binding and serotonin levels in key brain areas have all been linked with suicide.

What are the genetic and epigenetic changes that can lead to suicide? (2)

• Hypothalamus-pituitary-adrenal (HPA) axis
  abnormalities.

• (SKA2) gene expression is lower in individuals with suicidal ideation.

What are the 3 levels of intervention with suicidal clients?

Primary – activities that provide support,
information, and education to prevent suicide

Secondary – treatment of the actual suicidal
crisis

Tertiary – interventions with a circle of survivors
left by individuals who completed suicide to
reduce the traumatic aftereffects

What are the 6 principles of bioethics?

1. Autonomy – Respecting the rights of others to
make their own decisions
2. Nonmaleficence – Doing no wrong to a patient
3. Beneficence – The duty to promote good
4. Justice – The duty to distribute resources or care
equally
5. Principle of impossibility – That rights or obligations that cannot be met in the circumstances are no longer obligations
6. Fidelity – Maintaining loyalty and commitment

What are causes of increased signalling between neurons? (2)

• Excess release of neurotransmitter.

• increased numbers of receptors.

What are the criteria of involuntary hospitalization? (3)

1. The person is a danger to themselves, another person, or may unintentionally injure themselves, or

2. The person’s condition is deteriorating and they require hospitalization.

3. Only have authority to detain a person for a period not exceeding 72 hours

What can altered Norepinephrine cause?

Depression

What can altered Serotonin cause?

Depression

What can altered Dopamine cause?

Psychosis

Deficiency in neurotransmission can be due to what? (2)

• Decrease in neurotransmitter release.

• A reduction in the number of postsynaptic receptors.

What are the 4 sites of action where drugs act?

• Receptors

• Ion channels

• Enzymes

• Carrier proteins

What can altered GABA cause?

Anxiety

What is Norepineprine, and what are low levels of it associated with (3)

• An excitatory neurotransmitter

• Stimulating in body

• Low levels associated with low
  energy, poor concentration and
  sleep cycle issues

What is Serotonin, and what is it associated with? (2)

• A balancing / “happy” neurotransmitter

• Associated with emotions, senses,
  sleep, appetite

What do antidepressant drugs do?

• Block the reuptake of a neurotransmitter of one or more of the monoamines: serotonin, norepinephrine, dopamine.

• This keeps these neurotransmitters circulating.

What are SSRIs? (2)

Selective serotonin reuptake inhibitors

• Selectively increase the availability of serotonin

What are SNRIs? (2)

Serotonin–norepinephrine reuptake inhibitors

• Advantages for some with co-occurring
  depression and anxiety

What are side effects of SSRIs? (6)

• Insomnia/anxiety (given in morning)

• Sexual dysfunction (men: ED; women:
  anorgasmia)

• Headache

• Transient nausea

• Vomiting/diarrhea

• Weight gain (esp. paroxetine)

What are the GI side effects of Serotonin Syndrome? (3)

• Nausea

• Vomiting

• Diarrhea

What are the altered mental status side effects of Serotonin Syndrome? (3)

• Agitation

• Irritability

• Confusion

What do MAOI inhibtors do? What do they treat? (2)

• inhibit the activity of monoamine oxidase enzymes

• this allows serotonin, norepinephrine and dopamine to accumulate in the synaptic clefts

• treats depression

What are the neuromuscular hyperactivity side effects of Serotonin Syndrome? (4)

• Restlessness

• Incoordination

• Hyper-reflexia

• Nystagmus