15-18

Chp 15- Schizophrenia

early intervention and a comprehensive, patient-centered approach offer hope for a recovery process and improved quality of life for this population.

SMI is serious mental illness like schizophrenia

inc risk of suicide

Men typically have poorer outcomes than women do; women respond better to treatment with antipsychotic medications.

nature of disorder

psychosis : disorganization of the personality, deterioration in social functioning, and loss of contact with or distortion of reality

• hallucinations, delusions

• can occur w/ or w/o impairment

Schizophrenia: disturbances in thought processes, perception, affect, and behavior invariably result in a severe deterioration of social and occupational functioning.

s/s start in early adolescent → progressive neurodevelopmental disorder with a chronic and severely symptomatic course

phases

I. Premorbid: clear evidence of illness

• very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating asocial behavior

II. Prodromal: clearly s/s of schizophrenia → onset of psychotic

• significant deuteriation

• depressive symptoms, social withdrawal, cognitive impaired, OCD

early intervention for long-term outcomes

→ therapeutic interventions that offer support with identified problems, cognitive therapies to minimize functional impairment, family interventions to improve coping, and involvement with the schools to reduce the possibility of failure.

III. Active Psychotic Phase → chronic illness that is characterized by acute episodes

DSM-5-TR criteria

1. Two or more during 1 month period

   • delusions

   • hallucinations

   • disorganized speech (frequent derailment or incoherence)

   • Grossly disorganized or catatonic behavior

   • negative s/s

2. level of role functioning is markedly below previous onset

3. Continuous signs of the disturbance persist for at least 6 months. w/ (1) criteria + prodromal or residual s/s

4. rule out Schizoaffective disorder and depressive or bipolar disorder with psychotic features since

   1. no major depressive or manic episodes have occurred concurrently with the active-phase symptoms or

   2. if they do occur, only for a minority of time

5. not attributed of substance or medical condition

6. if hx of autism or communication disorder → dx only made if prominent delusions or hallucinations + (1)

7. Specify

   1. First episode, currently in acute, partial, or full remission; Multiple episodes, currently in acute, partial or full remission; Continuous; Unspecified; With catatonia

   4. Specify current severity.

IV. Residual: periods of remission and exacerbation

• symptoms of the acute stage are either absent or no longer prominent

• positive s/s are better but negative remain

• flat affect and impairment in role

• residual impairment inc w/ additional ep of active psychosis

predisposing factors

• genetics → additive and interacting combinations of genes, environmental factors, and the moderation of gene expression through interaction with environmental factor (COMT and ATK1)

biochemical:

• dopamine hypothesis: excess of dopamine = increased production or release of the substance at nerve terminals, increased receptor sensitivity, too many dopamine receptors, or a combination of these mechanisms.

  • hypothesis came since amphetamines inc dopamine and mimic psychosis → first gen antipsychotics

  • more affective w/ positive s/s

• Abnormalities in the neurotransmitters norepinephrine, serotonin, acetylcholine, and gamma-aminobutyric acid and in the neuroregulators, such as prostaglandins and endorphins

  • excess of serotonin (adm clozapine),

  • NMDA can produce s/s w/o disorder

Physiological

• viral infection from neurotoxic virus (prenatal Toxoplasma gondii)

  • NMDA glutamate autoimmune encephalopathy ~ schizo s/s

• anatomy:

  • ventricular enlargement, low gray matter, hippocampus, limbic system → brain volume reduction

• electrophysiology: neural circuit deficit in schizo

• physical:

  • Acute intermittent porphyria

  • Brain abscesses, Cerebrovascular disease, CNS infections/ trauma, Meningitis, Neurosyphilis

  • Cushing’s syndrome, Huntington’s disease

  • Deafness

  • Encephalitis, Herpes encephalitis, NMDA glutamate receptor autoimmune encephalopathy

  • Hypoadrenocorticism, Hypo- or hyperparathyroidism, Hypo- or hyperthyroidism

  • Metabolic conditions (e.g., hypoxia; hypercarbia; hypoglycemia), Fluid or electrolyte imbalances

  • Migraine headache, Normal pressure hydrocephalus, Temporal lobe epilepsy

  • Neoplasms, Systemic lupus erythematosus

  • Renal disease, Hepatic disease, Vitamin deficiency (e.g., B12), Wilson’s disease

psychological/ environmental

schizophrenia can contribute to significant disruption in communication and relationships among family member → trauma informed care

sociocultural:

• lack of material resources (including housing and access to health care) and fragmented social relationships increase the risk

• social cohesion and ethnic density (the concentration of a given ethnic group in a particular area) are protective.

• downward drift: difficulty maintaining gainful employment and “drift down” to a lower socioeconomic level

stressful events: can contribute to severity and course of illness

Cannabis: if genetic vulnerability (COMT and ATK1) + cannabis (especially in adolescent)

→ shorter periods of remission and more frequent relapses

brain areas affected:

• mesolimbic → memory, emotion, arousal, and pleasure = positive s/s

  • block dopamine

• mesocortical → cognition, social behavior, planning, problem-solving, motivation, and reinforcement in learning = negative s/s

  • low activity in D3

• nigrostriatal → motor control → degeneration causes Parkinson like s/s from antipsychotics

• tuberoinfundicular → endocrine function, digestion, metabolism, hunger, thirst, temperature control, and sexual arousal

  • inc of prolactin → dec dopamine + galactorrhea , erectile disorder, and anorgasmia.

antipsychotic

FGA: dopamine receptors

• Phenothiazines : D2 → EPS, hyper prolactin, NMS,

• Haloperidol: ACh, alpha 1, H1, weak 5-TH → anticholinergic, high HR, tremor, insomnia, postural hypotension

SGA: weaker D, stronger serotonergic

• Clozapine, olanzapine, quetiapine (-apine)

• risperidone, iloperidone, ziprasidone, paliperidone, , lurasidone, (-idone)

• aripiprazole, asenapine, cariprazine

  • (ameliorate positive symptoms with some improvement in negative symptoms—particularly cariprazine)

• MAO:

  • strong 5-TH, moderate D2, ~ACh, adrenergic, H1, / partial agonist of D2/3, HT1A (inc improvement of negative)

• ADR:

  • weight gain, sedation

  • SD, GI, h/a

  • anticholinergic, high HR, tremor, insomnia, postural hypotension

  • low potential for EPS and ejaculatory difficulty

schizo spectrum and psychotic disorders

additional specifier of catatonia = significant motor disturbance that may range from stupor (no motor activity) to excessive motor activity and agitation

• brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance-induced psychotic disorder, neurodevelopmental disorder, major depressive disorder, and bipolar disorders I and II

Delusion disorder: presence of delusions for at least a month

• hallucinations are not prominent, and behavior is not bizarre.

• specifier of whether delusions are bizarre (implausible)

  • erotomanic, grandiose, jealous, persecutory, somatic, and mixed

Brief psychotic disorder: sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor (1<x<1month) → full return to premorbid functioning

• emotional turmoil or overwhelming perplexity or confusion.

• impaired reality w/ incoherent speech ,delusion, hallucination, bizarre

• catatonic can be present

Substance or medication induced

psychotic/ catatonic due to another medical condition

Schizophreniform: (1) but duration of all phases is 1m<x<6m → if more then schizo

• good prognosis if: not blunted or flat, rapid onset of psychotic symptoms from the time the unusual behavior is noticed, confusion or perplexity, or the premorbid social and occupational functioning was satisfactory

• ~catatonic

schizoaffective: schizo + mood disorders → presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episode but mood s/s are prominent most of the time

• ~catatonic

positive/ negative s/s

Positive

: delusions, hallucinations, disorganized thinking, abnormal motor behavior

• delusion:

  • Persecutory—belief that one is going to be harmed by other(s)/ paranoid

  • Referential—belief that cues in the environment are specifically referring to them

    • Ideas of reference: less rigid (ex thinking people are laughing at them but with more info stop thinking)

  • Grandiose—belief that they have exceptional greatness

  • Somatic—beliefs that center on one’s body functioning

  • control or influence — believe that sm has control of their behavior ~ to magical thinking

  • nihilistic — false idea that the self, a part of the self, others, or the world is nonexistent

  • jealous — idea that the person’s sexual partner is unfaithful

• disorganized thinking:

  • Loose association

    Tangentiality

    Circumstantiality

    Incoherence (includes word salad)

    Neologisms

    Clang associations

    Echolalia

  • Perseveration occurs when the individual persistently repeats the same word or idea in response to different questions.

• grossly disorganized/ abnormal motor behavior:

  • Hyperactivity

    Hypervigilance

    Hostility

    Agitation

    Childlike silliness

    Catatonia (ranging from rigid or bizarre posture and decreased responsivity to complete lack of verbal or behavioral response to the environment)

    Catatonic excitement (excessive and purposeless motor activity)

    Stereotyped, repetitive movements

    Unusual mannerisms or postures

• hallucinations

  • formication, the sensation that something is crawling on or under the skin.

• Echopraxia occurs when a client imitates movements made by others

negative:

lack of emotional expression, lack of motivation (avolition), decreased verbal communication (alogia), diminish ability for abstract thinking

• inappropriate affect, the individual’s emotional tone is incongruent with the circumstances

• flat affect → emotional tone is weak

• apathy, asociality, anosognosia, anergia, anhedonia (lack of pleasure = inc suicide risk)

associated features

• waxy flexibility ~ catatonia = allows body parts to be placed in bizarre or uncomfortable positions for long periods

  • posturing: voluntary assumption of inappropriate or bizarre postures.

• pacing back and forth and body rocking

• regression to earlier development

• eye movement abnormalities: difficulty maintaining focus on a stationary object and difficulty with smooth pursuit of a moving object

nursing

assessment:

Patients in an acute episode of their illness may not be able to make significant contributions to their history. Data may be obtained from family members if possible, from old medical records if available, or from other individuals who are able to report on the progression of the patient’s symptoms.

working memory, attention, speed of processing thoughts, and verbal learning, with substantial deficit in reasoning, abstract thinking, and problem-solving

NANDA

1. disturbed sensory perception/ thought process

2. social isolation

3. risk for violence: self-directed or other directed

4. impaired verbal communication

5. self-care deficit

6. interrupted family process

7. ineffective health maintenance

8. ineffective home maintenance

tx

individual psychotherapy

• recovery-oriented psychotherapy and cognitive therapies

• primary focus → decrease anxiety and increase trust

  • pt may respond to attempts at closeness with suspiciousness, anxiety, aggression, or regression

  • tx honesty, simple directness, and a manner that respects the client’s privacy and human dignity

    • no exaggerated warmth or friendship

• then → reality orientation, Methods for improving interpersonal communication, emotional expression, and frustration tolerance

group therapy: effective with drug

• not at inpatient since it is when pt is in crisis

• long-term is best → social interaction, sense of cohesiveness, identification, and reality testing

behavior therapy

• reducing the frequency of bizarre, disturbing, and deviant behaviors and increasing appropriate behaviors

• requires:

  • clearly defining goal and how they are measured

  • attach reinforcements to adaptive and maladaptive behavior

  • use simple, concrete instructions

social skills training:

• nonverbal behavior, paralinguistic features, verbal content, interactive balance ← shaping (rewarding successive approximations toward the target behavior)

• uses role-play → immediate feedback, repetition

• milieu therapy

cognitive remediation: help w/ attention, memory, social cognition, and executive functions w/ repetitive drills and practice

family therapy:

• psychoeducational programs as resource = biological basis for schizophrenia and the impact that stress has on the client’s ability to function.

• programs are long-term, improve adherence of meds, provide info of illness to family,

Assertive Community tx (ACT)[mobile treatment teams and community support programs]: providing comprehensive, community-based psychiatric treatment, rehabilitation, and support

• individually tailored for each client,/ intended to be proactive,

• teaching of basic living skills,

• helping clients work with community agencies,

• assisting clients in developing a social support network.

• Vocational expectations are emphasized, and supportive work settings (i.e., sheltered workshops)

• substance abuse treatment,

• psychoeducational programs,

• family support and education,

• mobile crisis intervention

• attention to health-care needs.

24-365

housing first → for homeless for schizophrenia

recovery model: (patient centered care)

• Functional recovery focuses on the individual’s level of functioning in such areas as relationships, work, independent living, and other kinds of life functioning

• process recovery, there is no defined end point, but recovery is viewed as a process that continues throughout the individual’s life and involves collaboration between client and clinician.

RAISE: Recovery After an Initial Schizophrenia Episode

• community treatment, recovery model approaches, family approaches, and comprehensive care models

• through early and comprehensive intervention, the long-term, debilitating consequences of schizophrenia can be averted or minimized.

Pharmacological:

FGA:

• Chlorpromazine

• Fluphenazine

• Haloperidol (Haldol)

• Loxapine

• Perphenazine

• Pimozide (Orap)

• Prochlorperazine

• Thioridazine

• Thiothixene (Navane)

• Trifluoperazine

SGA:

• Aripiprazole (Abilify) (Abilify MyCite; with tracking sensor)

• Aripiprazole lauroxil (Aristada)

• Asenapine (Saphris) (SL) (Secuado) (transdermal)

• Brexpiprazole (Rexulti)

• Lumateperone (Caplyta)

• Cariprazine (Vraylor)

• Clozapine (Clozaril)

• Iloperidone (Fanapt)

• Lurasidone (Latuda)

• Olanzapine (Zyprexa)

• Paliperidone (Invega) (Invega Sustenna—once a month)(Invega Trinza—once every 3 months)

• Quetiapine (Seroquel)

• Risperidone (Risperdal) /Long-acting risperidone (Perseris)

• Ziprasidone (Geodon)

education

• drowsiness and heavy machinary/ orthostatic hypotension / ACH

• don’t stop abruptly

• use sunblock

• clozapine = WBC

• avoid other meds, smoking, alcohol

antiparkingson:

• Benztropine (Cogentin)

• Biperiden (Akineton)

• Trihexyphenidyl

• Diphenhydramine (Benadryl)

• Amantadine

• Valbenazine

• Deutetrabenazine

Chp 16 Depressive disorder

Mood is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world.

• Examples of mood include depression, joy, elation, anger, and anxiety.

Affect is described as the external, observable emotional reaction associated with an experience.

• A flat affect describes someone who lacks emotional expression and it is often seen in severely depressed clients.

Depression: alteration in mood that is expressed by feelings of sadness, despair, and pessimism

• loss of interest in usual activities, and somatic symptoms

• Changes in appetite, sleep patterns, and cognition

• → suicide ideation and/or attempts.

Melancholia is currently used to describe a severe form of major depressive disorder in which symptoms are exaggerated and interest or pleasure in virtually all activities is lost.

age/sex:

• higher in 45 and younger

• women>men = high monoamine oxidase, greater thyroid dysfunctions, hormonal changes, social roles, poor coping

socioeconomic: economic hardship, lack of social connection

seasonality: fall/winter

• Seasonal affective disorder (SAD) but DSM-5-TR is not dx

• bright light therapy

Types of disorder

Major depressive disorder (MDD):

1. 5 or more s/s in 2w + change in previous function = either depressed mood or loss of interest/pleasure

   1. depressed mood for most of day, nearly every day

   2. diminished interest most of day, nearly every day

   3. significant weight loss/gain and appetite (5% body weight)

   4. insomnia/ hypersomnia nearly every day

   5. psychomotor agitation/ retardation/ fatigue nearly every day

   6. feeling worthless or inappropriate guilt nearly every day

   7. diminished ability to concentrate/ think nearly every day

   8. recurrent thoughts of death, suicidal ideation/ attempt

2. s/s significant distress/ impaired social

3. not due to substance/ medical condition

   1. response to significant loss should be considered

   2. A/B/C = major depressive ep

4. not better explained by schizo spectrum

5. no maniac/ hypomanic ep

6. specify: With anxious distress , mixed/ melancholic/ atypical /mood-congruent psychotic/ mood-incongruent psychotic features, catatonia, peripartum onset, seasonal pattern

Persistent Depressive disorder (dysthymia):

1. depressed mood for most of day, for at least 2y

2. 2 or more s/s while depressed

   1. 1. Poor appetite or overeating

      2. Insomnia or hypersomnia

      3. Low energy or fatigue

      4. Low self-esteem

      5. Poor concentration or difficulty making decisions

      6. Feelings of hopelessness

3. during 2y, never w/o s/s for (1)(2) more than 2 months

4. no manic/hypomanic

5. not better explain w/ schizo spectrum

6. not due to medical or substance

7. cause significant distress and impaired social function

8. specify:

   1. anxious/ atypical distress

   2. With pure dysthymic syndrome

      With persistent major depressive episode

      With intermittent major depressive episodes, with current episode

      With intermittent major depressive episodes, without current episode

   3. partial/ full remission

   4. Early onset if onset is before age 21 years

      Late onset if onset is at age 21 years or older

   5. mild/ moderate / severe

Premenses Dysphoric disorder (PMDD): s/s severe that interfere w/ social and are recurrent

• markedly depressed mood, excessive anxiety, mood swings, and decreased interest in activities during the week prior to menses

• improving shortly after the onset of menstruation

• becoming minimal or absent in the week postmenses

substance/ medical

• stroke, myocardial infarction, traumatic brain injuries, thyroid disorders, Cushing’s disease, Huntington’s disease, Parkinson’s disease, and multiple sclerosis.

predisposing factor

genetics: MTHFR C677T gene mutation → dec folate → dec synthesis of neurotransmitters

• more common in 1st degree biological

Biochem:

• biogenic amines:

  • low norepinephrine, serotonin, and dopamine/ high cortisol

    • tryptophan (precursor of 5-TH) for antidepressant

  • Abnormal levels of acetylcholine, glutamate, glycine, and gamma-aminobutyric acid (GABA)

• hypothalamic-pituitary- adrenocortical/ thyroid axis

• physiological influences:

  • medical

  • neurological disorder: CVA

    • agitation depression: Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease, MS, SLE

    • hormonal deficiency: Cushin, Addison, hypo/hyperthyroid/ para, progesterone imbalance

    • nutritional deficiency: vit1/2/6/12,

    • tx resisntant depression = high inflammation CRP/ TNF

psychosocial theories:

psychoanalytical: melancholia after loss of something

learning theory: learned helplessness

object loss: abandoned by significant other in 1st 6 months of life → continues in life

• excessive crying, anorexia, withdrawal, psychomotor retardation (sluggish physical movements), stupor, and a generalized impairment in the normal process of growth and development

cognitive theory:

1. Negative expectations of the environment

2. Negative expectations of the self

3. Negative expectations of the future

CBT = alter mood and behavior

• control negative thought distortions that lead to pessimism, lethargy, procrastination, indecisiveness, and low self-esteem

transactional model of stress and adaptation: combined effects of genetic, biochemical, and psychosocial influences on an individual’s susceptibility to depression

Developmental

children

children: irritable mood, excessive self-reproach, and excessive clinging to parents

changes in grades, getting into trouble at school, refusal to go to school, and school phobias

adolescent: hyperactivity, delinquency, psychosomatic complaints, sleeping and eating disturbances, social isolation, delusional thinking, and suicidal thoughts or actions

disruptive mood dysregulation disorder:

1. severe recurrent temper outburst verbally and behaviorally out of proportion

2. inconstant w/ development level + 3 or more / week

3. 12 or more month and at least in 2/3 settings

4. 6-18

5. onset is before 10y

6. no period for more than 1 day where maniac/ hypomanic

7. not better explained by another mental disorder, or depressive disorder, or substance or medical

   1. oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder

genetic predisposition precipitated by stressful situation ( detachment from caregiver)

Parental therapy and family therapy, SSRI

adolescence

Feelings of sadness, loneliness, anxiety, and hopelessness may be normal emotional stressors

2nd cause of death in adolescents = suicide

inappropriately expressed anger, aggressiveness, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, and apathy. Loss of self-esteem, sleeping and eating disturbances, and psychosomatic complaints

mood disorder = behavioral change that lasts for several weeks

manifestation of the stress and independence conflicts associated with the normal maturation process.

SSRI (Fluoxetine) but careful w/ suicide ideation

senescence

due to society’s standards youth, vigor, and uninterrupted productivity

and financial problems, physical illness, changes in bodily functioning, and an increasing awareness of approaching death

bereavement overload

Anticholinergic side effects associated with tricyclic antidepressants can be problematic for the elderly,

SSRIs have been associated with inducing significant hyponatremia in this population. Careful evaluation and monitoring are essential.

Electroconvulsive therapy (ECT): acute suicidal risk or is unable to tolerate antidepressant medications

interpersonal, behavioral, cognitive, group, and family psychotherapies.

postpartum depression

baby blues = worry, sadness, and fatigue after having a baby subdue 1-2w → moderate: more bad days than good, tending to be worse toward evening and associated with fatigue, irritability, loss of appetite, sleep disturbances, and loss of libido, great deal of concern about her inability to care for her baby.

w/ psychotic features: depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. lack of interest in or rejection of the baby or a morbid fear that the baby may be harmed, accompanied by delusions and hallucinations. Risks of suicide and infanticide

due to hormonal changes, tryptophan metabolism, or alterations in membrane transport during the early postpartum period

supportive psychotherapy, group therapy, and possibly family therapy, Brexanolone → sedation, sudden loss of consciousness

in brain

• Hippocampus: Memory impairments, feelings of worthlessness, hopelessness, and guilt

• Amygdala: Anhedonia, anxiety, reduced motivation

• Hypothalamus: Increased or decreased sleep and appetite; decreased energy and libido

• Other limbic structures: Emotional alterations

• Frontal cortex: Depressed mood; problems concentrating

• Cerebellum: Psychomotor retardation/agitation

medication:

SSRI, SNRI, MAOIS, TCA,

→ ADR:

• ne = tremor, arrhythmias, SD, HTN

• serotonin = GI, inch agitation, SD

• Dopamine= psychomotor activation

• ACh

nursing assess

assessment: Zung Self-Rating Depression Scale and the Beck Depression Inventory,

Hamilton Depression Rating Scale (HDRS):

1. depressed mood

2. guilt

3. suicide

4. insomnia: early night/ morning/ middle

5. work activities

6. psychomotor retardation

7. agitation

8. anxiety (psychic/ somatic)

9. somatic: GI/ general

10. genital

11. loss of weight: subjective/ objective

12. insight

(1) affective, (2) behavioral, (3) cognitive, and (4) physiological

transient depression: not dysfunctional can be typical human emotion

■ Affective: Sadness, dejection, feeling downhearted, having the blues

■ Behavioral: Some crying

■ Cognitive: Some difficulty getting mind off one’s disappointment

■ Physiological: Feeling tired and listless

mild depression: grieving

■ Affective: Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency

■ Behavioral: Tearfulness, regression, restlessness, agitation, withdrawal

■ Cognitive: Preoccupation with the loss, self-blame, ambivalence, blaming others

■ Physiological: Anorexia or overeating, insomnia or hypersomnia, headache, backache, chest pain, or other symptoms associated with the loss of a significant other

moderate depression: persistent depressive disorder

■ Affective: Feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities

■ Behavioral: Psychomotor retardation; slumped posture; slowed speech; limited verbalizations, possibly consisting of ruminations about life’s failures or regrets; social isolation with a focus on the self; increased use of substances possible; self-destructive behavior possible; decreased interest in personal hygiene and grooming

■ Cognitive: Slowed thinking processes; difficulty concentrating and directing attention; obsessive and repetitive thoughts, generally portraying pessimism and negativism; verbalizations and behavior reflecting suicidal ideation

■ Physiological: Anorexia or overeating; insomnia or hypersomnia; sleep disturbances; amenorrhea; decreased libido; headaches; backaches; chest pain; abdominal pain; low energy level; fatigue and listlessness; feeling best early in the morning and continually worse as the day progresses (this may be related to the diurnal variation in the level of neurotransmitters that affect mood and level of activity)

severe depression:

■ Affective: Feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect, appearing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure

■ Behavioral: Psychomotor retardation so severe that physical movement may literally come to a standstill, or psychomotor behavior manifested by rapid, agitated, purposeless movements; slumped posture; sitting in a curled-up position; walking slowly and rigidly; virtually nonexistent communication (when verbalizations do occur, they may reflect delusional thinking); no personal hygiene and grooming; social isolation is common, with virtually no inclination toward interaction with others

■ Cognitive: Prevalent delusional thinking with delusions of persecution and somatic delusions being most common; confusion, indecisiveness, and an inability to concentrate; hallucinations reflecting misinterpretations of the environment; excessive self-deprecation, self-blame, and thoughts of suicide

NOTE: Because of the low energy level and slow thought processes, the individual may be unable to follow through on suicidal ideas. However, the desire is strong at this level.

■ Physiological: A general slowdown of the entire body, reflected in sluggish digestion, constipation, and urinary retention; amenorrhea; impotence; diminished libido; anorexia; weight loss; difficulty falling asleep and awakening very early in the morning; feeling worse early in the morning and somewhat better as the day progresses (as with moderate depression, this may reflect the diurnal variation in the level of neurotransmitters that affect mood and activity); pain syndromes.

NANDA:

• risk for suicidal behavior

• maladaptive grieving

• low self-esteem

• powerlessness

• spiritual distress

• social isolation/ impaired social interaction

• disturbed thought process

• imbalanced nutrition

• insomnia

• self-care deficit

tx:

interpersonal psychotherapy: current interpersonal relations

I: determine the extent of the illness

II: resolve maladaptive grief reactions, which may include resolving the ambivalence with a lost relationship and assistance with establishing new relationships

III: termination:

• emphasis on reassurance, clarification of emotional states, improvement of interpersonal communication, testing of perceptions, and performance in interpersonal settings, interpersonal psychotherapy

Group therapy: self-help groups

Family therapy:

CBT: assist the client in identifying dysfunctional patterns of thinking and behaving, and to guide the client to evidence and logic that effectively test the validity of the dysfunctional thinking.

Electroconvulsive therapy:

• acutely suicidal, treatment of severe depression, particularly in those clients who are also experiencing psychotic symptoms and those with psychomotor retardation and neurovegetative changes, such as disturbances in sleep, appetite, and energy.

• after a trial of therapy with antidepressant medication has proved ineffective.

• support anticonvulsant and neutrophil effects

• inc in gray matter

• ADR: temporary memory loss

  • processing speed, attention, verbal and visual memory, spatial problem-solving, and executive functioning deficits, but resolve in 3 days

• CV complication inc mortality

• meds w/ ECT:

  • 30 mins before tx atropine sulfate or glycopyrrolate (Robinul) to decrease secretions and prevent X

  • IV anesthetic: propofol (Diprivan) or etomidate (Amidate)

  • muscle relaxant: succinylcholine chloride + O2

Repetitive transcranial Magnetic stimulation (rTMS): stim nerve cells w/ magnetic energy and do nit result in seizure activity

Vagus Nerve Stimulation + Deep brain stim:

• implant device to stim X → chronic alters 5-TH and has anticonvulsant

• same but device is further implanted (it is reversable and ez control)

psychopharmacology:

black box warning for risk of sudden death in elderly patients with neurocognitive disorders + recent population-based cohort study identified that there is a similar increased risk of mortality in middle-aged adults

• TCA:

  • Amitriptyline

    Amoxapine

    Clomipramine (Anafranil)

    Desipramine (Norpramin)

    Doxepin

    Imipramine (Tofranil)

    Nortriptyline (Aventyl; Pamelor)

    Protriptyline (Vivactil)

    Trimipramine (Surmontil)

• SSRI:

  • Citalopram (Celexa)

    Escitalopram (Lexapro)

    Fluoxetine (Prozac; Serafem)

    Fluvoxamine (Luvox)

    Paroxetine (Paxil)

    Sertraline (Zoloft)

    Vilazodone (Viibryd) (also acts as a partial serotonergic agonist)

    Vortioxetine (Brintellix)

• MAOI:

  • Isocarboxazid (Marplan)

    Phenelzine (Nardil)

    Tranylcypromine (Parnate)

    Selegiline Transdermal System (Emsam)

• atypical:

  • Bupropion (Wellbutrin)

    Maprotiline

    Mirtazapine (Remeron)

    Nefazodone

    Trazodone

• SNRI:

  • Desvenlafaxine (Pristiq)

    Duloxetine (Cymbalta)

    Venlafaxine (Effexor)

• Psychotherapeutic:

  • Olanzapine and fluoxetine (Symbyax)

    Chlordiazepoxide and fluoxetine (Limbitrol)

    Perphenazine and amitriptyline (Etrafon)

education:

• s/s down after 4 weeks

• drowsiness and machinery, orthostatic, dry mouth

• do not stop abruptly:

  • nausea, vertigo, insomnia, headache, malaise, nightmares, and return of symptoms for which the medication was prescribe

• sunblock

• MAOI, no smoking

• prolongued erection w/ tradoze

chp17 Bipolar

Mania is an alteration in mood that may be expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, racing thoughts, and accelerated speech.

types of bipolar disorder

A bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania) with intervening periods of normalcy

Motor activity is excessive and frenzied. Psychotic features may be present

Mania:

• last at least 1 week → elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy,

• during ep = 3 or more

  1. Inflated self-esteem or grandiosity

  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

  3. More talkative than usual or pressure to keep talking

  4. Flight of ideas or subjective experience that thoughts are racing

  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed

  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity)

  7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

• enough to mark impairment and hospitalization

• not due to substance or medical

• full ep during antidepressant tx = maniac = bipolar I dx

Hypomanic: not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization and no psychotic feature

• at least 4 consecutive days

bipolar I: manic episode or who has a history of one or more manic episodes

single manic episode (to describe individuals having a first episode of mania) or current (or most recent) episode manic, hypomanic, mixed, or depressed (to describe individuals who have had recurrent mood episodes).

rapid cycle bipolar → more than 4 maniac and depressive ep

bipolar II: recurrent bouts of major depression with episodic occurrence of hypomania

never a full maniac ep

cyclothymic disorder: chronic mood disturbance of at least 2 years’ duration for not at least 2 months

• hypomanic s/s that do not meet hypomanic ep and depressive s/s that do not meet major depressive ep

• not better explained by schizoaffective disorder and subtance/ medical

• in distress for social, occupational functioning

predisposing

genetics: first degree

• schizo is correlated w/ bipolar

• ANK3 → lithium reduces expression

• CACNA1C: calcium channels → CCB

• CLOCK → sleep wake

biochemical:

low 5-TH in depression and mania but don’t give SSRI

ACh, excessive glutamate

physiological

neuroanatomical: dysfunction prefrontal cortex, basal ganglia, temporal and frontal lobes of the forebrain, and parts of the limbic system, including the amygdala, thalamus, and striatum

→ circadian disturbance

medication s/e: MS, SLE steroids

Amphetamines, antidepressants, and high doses of anticonvulsants and narcotics

psychosocial theory: childhood trauma and bipolar

transactional model of stress and adaptation: genetic, biological, and psychosocial determinants

development

ADHD and bipolar

youth w/ no discrete mood episodes, chronic irritability, and temper tantrums → disruptive mood dysregulation disorder

family hx

tx

lithium, risperidone, aripiprazole, quetiapine, olanzapine, and asenapine, olanzapine/fluoxetine

mood charting, managing stress and sleep cycles, maintaining healthy diet and exercise, and avoiding alcohol and drugs,

nostim ADHD tx (atomoxetine, bupropion, the tricyclic antidepressants) can inc mania/ hypomania

Family-focused treatment (FFT)

nursing

assess

hypomania:

• mood: cheerful/ expansive, but irritability when wishes are unfufilled

• cognition/perception: ideas of great worth and ability, flight of ideas, heighten perception but ez distracted

• activity/ behavior: motor activity, extroverted but lack to formulate close friendship, inc libido, inappropriate behaviors

acute mania: marking impairment

• mood: euphoria/ elation, high, but frequent variation to sadness

• cognition and perception: fragmented and psychotic

  • racing thoughts, flight of ideas, pressured speech, disorganized, incoherent, very distractable

• activity and behavior: excessive, and inc libido, poor impulse control/ frustration, unreliable report of events and denial of problems

delirious: severe clouding of consciousness and an intensification of the symptoms associated with acute mania.

• labile mood: despair, ecstasy, irritable, panic anxiety

• cognition/ perception: confusion, disorientation, and sometimes stupor, religiosity, delusions of grandeur or persecution, and auditory or visual hallucinations

• activity and behavior: frenzied and characterized by agitated, purposeless movements. safety is at stake

NANDA:

• risk of injury

• risk for violence

• imbalanced nutrition

• disturbed thought process/ sensory-perception

• impaired social interaction

• insomnia

tx:

individual psychotherapy: psychoeducation, cognitive behavior therapy, FFT, interpersonal and social rhythm therapy (IPSRT), and integrated care management

• IPSRT for bipolar= regulate social rhythm and sleep/wake cycl and exercise routine + interpersonal therapy

group therapy: support/ self-help

family therapy

CBT

recovery model

ECT when lithium fails

meds

lithium:

• eat less sodium and drink more water

mood stabilizers: combination of olanzapine and fluoxetine, quetiapine, and lurasidone

• aripiprazole, chlorpromazine, quetiapine, ziprasidone, asenapine

antidepressants trigger depression to mania

CCB:

• take w/ meals

• check w/ swelling, palpitations, SOB, chest pain, persistent h/a

anticonvulsants: carbamazepine, clonazepam, valproic acid, lamotrigine, gabapentin, topiramate, oxcarbazepine,

Chp 18 Anxiety, OCD

Anxiety is a feeling of discomfort, apprehension, or dread related to anticipation of danger, the source of which is often nonspecific or unknown.

fear is related to danger

neuro

serotonin: decreased in anxiety disorder

norepinephrine: inc in anxiety disorder

gamma-aminobutyric acid (GABA) : decreased in anxiety to allow inc cellular excitability

• Amygdala: Fear, which is particularly important in panic and phobic disorders

• Hippocampus: Associated with memory related to fear responses

• Locus ceruleus: Arousal

• Brainstem: Respiratory activation, heart rate

• Hypothalamus: Activation of stress response

• Frontal cortex: Cognitive interpretations

• Thalamus: Integration of sensory stimuli

• Basal ganglia: Tremor

meds

• BZ, SSRI, SNRI, noradrenergic (propranolol, clonidine) , barbiturates, buspirone

parental psychiatric history, childhood trauma, and negative life events

pathological anxiety if:

1. it is out of proportion

2. interferes w/ functioning

panic/ GAD disorders

Panic disorder: panic attacks → feelings of impending doom + discomfort

■ Palpitations, pounding heart, or accelerated heart rate

■ Sweating

■ Trembling or shaking

■ Sensations of shortness of breath or smothering

■ Feelings of choking

■ Chest pain or discomfort

■ Nausea or abdominal distress

■ Feeling dizzy, unsteady, lightheaded, or faint

■ Chills or heat sensations

■ Paresthesias (numbness or tingling sensations)

■ Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself)

■ Fear of losing control or going crazy

■ Fear of dying

• risk factors: . Genetic vulnerability, tendency toward negative emotions, history of trauma, respiratory disturbances such as asthma, and smoking

GAD: persistent, unrealistic, and excessive anxiety and worry over 6m → impair function, decision making

• restless or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance

• + depressive and somatic s/s

• chronic

theory:

• psychodynamic: inability of ego to intervene when conflict with id and superego = anxiety but uncured if not able to compromise

  • defense mechanism

• cognitive: faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders

• biological:

  • genetic

  • neuroanatomical: temporal/frontal lobes and limbic dysfunction

  • biochemical: high lactate and CO2

    • CBT → dec CO2

  • neurochem: norepinephrine

    • 5-th and GABA low in disorder (BZ /SSRI)

phobia

irrational fear of a specific object or situation resulting in an intense aversion toward the feared stimulus.

agoraphobia: the fear of being vulnerable and unable to get help or escape the setting (6m<)

extreme → unable to leave home w/o sm → imparied

• fear of 2 or more:

  • 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes)

    2. Being in open spaces (e.g., parking lots, marketplaces, bridges)

    3. Being in enclosed places (e.g., shops, theaters, cinemas)

    4. Standing in line or being in a crowd

    5. Being outside of the home alone

• fear these situations bc difficulty or embarrassing s/s w/o help

• always provoke fear or anxiety, and are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety

• fear is out of proportion

• not related to other disorders

Social anxiety disorder (SAD): excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others

• fear/anxiety out of proportion about social interactions → avoid

• not due other medical/ SUD/

specific phobia: fear of specific objects or situations that could conceivably cause harm but over reaction → overwhelming symptoms of panic, including palpitations, sweating, dizziness, and difficulty breathing

theory

psychoanalytic: unconscious fear

learning: conditioned fear, direct learning ( from parent)

cognitive: negative self-statements and irrational beliefs; beyond pt control

biological:

• neurotomical: prefrontal cortex, amygdala → releases flight-fight

• temperament: innate fears → down → based on events reinforced

• life experiences

due to another medical/ substance: CV, resp, hypoglycemia, hypo/hyperthyroid, neuro( seizures, neoplasm, encephalitis)

obsession compulsive

Obsessions

Intrusive thoughts that are recurrent and stressful. Although they are recognized by the individual as irrational, they continue to be repetitive and cannot be ignored.

attempts to ignore or suppress thoughts by other thought or action → compulsion

Compulsions

Repetitive ritualistic behaviors or mental acts that the individual feels driven to perform according to rigidly applied rules and which are intended to reduce the anxiety associated with obsessive thoughts

• hand washing, ordering, checking, praying, counting, and repeating words silently.

they are time consuming (1hr more/ day)

not due to mental disorder, substance

specify:

• With good or fair insight

  With poor insight

  With absent insight/delusional beliefs

• tic-related

body dysmorphic

exaggerated belief that the body is deformed or defective in some specific way

• preoccupation w/ one or more perceived defect/ flaw o

• repetitive behaviors or mental acts

  • mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing their appearance with that of others)

• impair

• not eating disorder

trichotillomania (hair pulling)

impulse is preceded by an increasing sense of tension and results in a sense of release or gratification from pulling out the hair

child under 6, adolescence, or early adult accompanied w/ → nail biting, head banging, scratching, biting, or other acts of self-mutilation.

hoarding

“persistent difficulties discarding or parting with possessions, regardless of their actual value”

hoard → narrow hallways, rotten food, dozens of pets

Change is slow, and the relapse rate is high → CBT + SSRI

theory OCD

psychoanalytic: underdeveloped egos (unsatisfactory parent-child relationship, conditional love, or provisional gratification)

• regression, isolation, undoing, displacement, reaction formation

learning: due to traumatic event → passive avoidance → active avoidance (behaviors)

psychosocial: stressfull, mother-child relationship, fear of abandonment, and recent object loss

Biological

• genetic: 1st degree

• neuroanatomy: motor inhibition, blunted activity in the connection in emotional and higher thinking

• biochemical: Dopaminergic, serotonergic, and glutamate

  • clomipramine (tricyclic antidepressant), SSRI

nursing

assess

Beck Anxiety Inventory and the Zung Self-Rated Anxiety Scale.

Hamilton Anxiety Rating Scale (HAM-A):

14 – 17 = Mild Anxiety

18 – 24 = Moderate Anxiety

25 – 30 = Severe Anxiety

NANDA:

• anxiety (severe/ panic)

• powerlessness

• fear

• social isolation

• ineffective coping

• ineffective role performance

• disturbed body image

• ineffective impulse control

tx:

individual psychotherapy

CBT

behavior therapy: habit reversal training→ positive and negative reinforcements in an effort to modify the hair-pulling behaviors

• systematic desensitization: gradually exposed to the phobic stimulus, in either a real or an imagined situation

  • reciprocal inhibition: restriction of anxiety prior to the effort of reducing avoidance behavior → relax before anxiety

  • 1. Training in relaxation techniques

    2. Progressive exposure to a hierarchy of fear stimuli while in the relaxed stat

• implosion therapy (flooding): for a prolonged period, must imagine situations or participate in real-life situations they find extremely frightening.

tx

anxiolytics, atypical antipsychotics; mirtazapine (a tetracyclic antidepressant); gabapentin or pregabalin (analgesic and mood stabilizer that also carries a risk for dependence); antihistamines such as diphenhydramine, hydroxyzine; and other anticonvulsants such as lamotrigine and topiramate, meprobamate,

GAD: 1st SSRI . SNRI ( venlafaxine), buspirone (lag period)→ BZ

• Alprazolam, lorazepam, and clonazepam = panic

• propranolol for acute anxiety

• clonidine for opioid/ withdrawal

• pregabalin

Phobic:

• SSRI, SNRI, SAD

• BB propranolol, atenolol for somatic

• new: neuropeptides, glutamatergic agents (such as ketamine and d-cycloserine), and cannabinoids

OCD: SSRI, TCA clomipramine

Body dysmorphic: SSRI

trichotillomania: none but SSRI