Mood and Affect

QUIZ on what we go over todays class

Major Depression": Depletion of neurotransmitters: norepinephrine, dopamine and or serotonin. Increased inflammatory markers cytokines. Higher levels of cortisol and corticotrophin. Two week or more worried, 6 months no improvement then depression.

Generalized anxiety disorder: Decrease in GABA (gamma-aminobutyl acid) and increase in norepinephrine.

Stress trigger → brain perceives this as a threat → amygdala sounds alarm to body → hypothalamus releases stress hormone to the pituitary gland→ signals adrenal gland to release cortisol and adrenaline → tachycardia, shaky, flushed, tachypnea, diaphoretic, dilated pupils, heightened alertness.

Postpartum depression: Sudden drop in hormones estrogen and progesterone. Decrease of neurotransmitters, the same as major depression. Stops working, not using the baby names just as it or they baby, more than 2 weeks.

RF: Family hx of anxiety or other mental health disorders due to genetically dispositioned, chemical balances. Chronic medical conditions-increased hospitalizations and stress. Substance abuse or withdrawal- feelings of shame, impaired coping, substance increase dopamine which becomes reliant on it, exposure to trauma or stressful life events- coping, stress, chemical brain changes from chronic stress, low socioeconomic status or financial difficulties-stress about money/meeting needs, access to mental health care, female gender-PPD, increased hormones, social roles, gender disparities, Imbalanced diet or nutritional deficines- impairs brain function and contributes to hormone changes

Primary prevention: Mindfulness, mediation, prayer, support groups, breathing exercise, physical exercise, education, healthy diet, hydration, good sleep, vitamin D (sunshine), encourage social connections, reduce environmental stressors,

Impaired coping, Imapired mood & afect, Impaired family dynamics, self-care deficit, impaired cognition (hearing voices/other stuff), risk for injury or risk for self-harm, impaired nutrition (could be risk for), impaired parenting.

GAD

Nonpharmacolgoical: Breathing excersis, stress management, cognitive behavior therapy (teaches client to identify behavoirs that increases anxiety and change response), talk therapy, guided imagery, group threrapy, pet therapy, excersise, yoga, meditation, arma therapy, massage, stop simulation, decrease caffine, journuling, vit D,

Pharmacological: SSRI- Long term management (takes 6 weeks or more to work and it makes them feel worse before it gets better therfore risk for suicide).

Benzodiazepine (-pam), lorazepam, diazepam for acute anxiety. Also prescribe flumazenil-reversal agent.

Anti-histamines (hydroxyzine)-blocks histamine response for acute anxiety. Safe for pregnancy

Buspar(buspirone) - long term mangements (takes 1-4 weeks to work)

Beta blockers (propralol) - Acute feelings of panic/anxiety attack - lower BP and HR

Gabapentin - off label use for anxiety

Major depression disorder: the same as anxiety althought they have magnetic seizure therapy = brain stimulation therapy. St. john wart (it may interact with antidepressents which can cause selective serotoinin syndrome)

Pharmacological: SSRIs-slows the reuptake of serotonin in the brain, increasing availability of serotonin, improve mood. Risk for serotonin syndrome-life threatening

SNRIs-same thing but with norphrine, still risk for serotnin syndrome, takes the same time to wrok.

NDRIs- slows reuptake of norepinephrine and dopamine

MAOIs- phenelzine sulfate- inhibite monoamine oxidase, which is the protein that breaks down neurotransmitters. Warning black box (can decrease glucose, causeing hypoglycemia, therefore wear a medical alert bracelt) can cause hypertensive crisis as interaction with tyramine.

Tricyclic antidpresents 0 inhibits reuptake of both norepinephrine and serotinin. Amitrpyline.

Atypical antidepresents: busparione, trazadone (sedative prpoerties), ariprprazole, mitrazapine

Postartum depression

Nonpharm: breastfeeding support, postartum depression hotline

Pharm: Meds that are safe for breastfeeding

1st choice: Sertaline: low levels in breastmilk

2nd choice: Paroxetine (paxel)

UNSAFE: Wellbutrin, citalopram, fluoxetine, doxepin

Sit: LacMed→ can check what is safe when you are unsure!

Panic disorder: Intense fear anxiety, and sense of impending doom that is triggered suddnenly and has lots of physical mainfestation.

Pain attack and afriead of paninc attack then its the painc disorder.

S/s: Palpitations, tachycardia, SOB, chest pain, tachypnea, diaphoretic, shaky, flight of thoughts, racing thoughts, pacing, rocking, lightheaded, dizzy, dilated pupils, feels like I am dying, GI upset, numbness, and tingling.

Isolation, disinterst in previous hobbies, avoid triggers of last panic attack

Non-pharmgologic: Acute: Breathing exercises, focal point/grounding 5 things see 4 things hear 3 smell, reducing external stimulation, offering self do not leave them alone, don’t restrain them, don’t worsen the panic, have an exit, remove itmes from room

, Long term: CBT, rapid eye movement therapy (thinking about it while moving eye rapidly),

Pharmacologic:

Acute:

Benzos

hydroxocine

Long term
SSRIs

Busprion

Antidepresents

Phobias: Intense or irrational fear of an object or situation whether real or perceived. Symptoms must last more than 6 months regardless of age.

Common phobias:Height, claustrophobia - fear of enclosed spaces consideration for MRI or CT. open spaces/crowds, dark, germs, blood and animals (snakes, bugs, spiders), needles, public speaking, death, shapes, sounds, people, clowns, driving, bridges, tunnels

Non-pharm: CBT and exposure/desentilzation therapy. Stress/anxiety/relaxation

Pharm:

Long term: SSRIs for long term underlying treatment

Acute: Benzodiazepines (pre-medication),

pretty much therapy to fix it

PTSD: Physical and psycholgical response to a traumatic event

Triggers: Military service, traumatic injury/illness, sexual assault, domestic violence, natural disasters, unnatural disasters, emotional trauma/relationships/sudden death of loved one

Symptoms: Flash backs, mood changes, cognitive changes, nightmares, or insomnia, hypervigilance, ineffective coping strategies-substance abuse, social isolation, exaggerates responses, difficulty maintaining relationships, keeping their job.

Non-pharm: Assessing triggers-what could be potential trigger in this environment that we need to avoid, ensuring safety, assessing nonverbal communications. Grounding, support groups, pet therapy/support/emotional animal, coping mechanisms - CBT, EMD,

Pharm:SSRIs or antidepresents

Benzos, Hydrozyine, buspirone

OCD: Repetitive thoughts and behaviors that a person feels compelled to complete.

Symptoms: Repetitive rituals (ex; handwashing), counts, seeting rules for themsels (needing things in a specific order/position), horading/collecting items not needed, overly organized, ruminating

Nonpharmacolgic: CBT, desentization therapy, family therapy

Pharm: SSRI, SNRI, antidepresends. Benzos, hydrozyzine, buspar

Bipolar disorder

1: Mania&depresion → has psychotic features(rollercoaster)

2: Depression&euthemia→longer depression but less mania

Sympomts: Periods of mania and depression in a cycle, mania: very high thought of self, delusions, not sleeping, not eating, overly active, over spending, hypersexual, risky beahvoirs, stop taking meds b/c they think they dont need it, altered judgment and decision making.

Depression: risk for suicide, low self-esteem, sadness, low acitivety, etc.

Non-pharm: CBT, ECT (electrical treatment for drug resisitant depressive phases, not the first line of defnense).

Pharm: Antipsychoitcs, antidepressents, lirhium (drug level d/t lithium toxicity, lab monitoring, increase risk of neural tube defects in baby), dicalproex, valproic acid, carbamazepine, lamotrigine,

biopolar one the best is pharm

Personality disorders: How someone presents all the time. Never going to take ownership

Behavoirs: trying to change their environment rather than themselves. Do not take respobility for thier actions. Failure to understand how thier actions affect people around them.

Symptoms:
Types: Narcisstic disorder, multiple personiality disorder/borderline personality disorder, antisocial, obessive compulsice, paranoid

Non-pharm: CBT, psychotherapy, family therapy, schema-focused therapy-try to get them to change their own self-perception. Set clear limits. Maintain professional boundaries. Follow though on agreements.

Pharm: not really but only to treat the symptoms of the disorder there is no cure the gold standard is therapy.

Most common type of hallucinations is auditory and visual.

The most dangerous type of hallucination is command, which is when patients hears voices telling them to do something.

Interperting something as something else is an illusion.

Delusion is a fixed false belief that the patient does not waiver on.

Patient with atypical antipsychoitc should have routine ECGS due to the cardiac side effects that can cause arrythmias.

Antipsychoits affect the dopamin neurotransmitter.

Antipsychoitcs can be used for psychoissi sysmptoms, stress, agressive bahvoirs, alzheimer disease, and mania.

Euthymia

Flight vs flight response, physiological and psychological response to stress

Primary prevention

Stress management

Coping skills

Secondary

Mood screening

Anxiey and Depression Screening

Suicide Screening

Edinburgh Postpartum Depression Screening

PTSD Screening

SCOFF Screening

tertiary

Eating disorder recovery programs

Disease management

Refeeding Syndrome

Assessment

Russell’s Sing

BMI

Dental caries

Skin integrity signs of self-harm

Labs CBC, CMP, albumin, thyroid function, urinalysis

Diagnosits: ECG

Exemplars

Depression

Postpartum depression

Bipolar disorder

Types

Bipolar I: Episodes of severe mania and depression

Bipolar II: Episodes of hypomania (not full blown mania) and depression

Cyclothymic disorder: Periods of hypomanic and depressive symptoms lasting > 2 yeards

Mania s/s: Very talkative, easily distracted, inability to stay still, labile mood, excessively happy and excited, racing thoughts. Potentially agressive. Imparied judgment, risky or detrimental behavoirs (unsafe sexual practices, excessive spending), decrease in appetitie and sleep

Depresive s/s: flat afffect, slow speech, minimal movemnt, adhedonia, negative thoughts, feeling of worthlessness and hopelessness.

Dx: mood episodes imapct functional, social, or occupational enviroment and are not caused by subtance use or underlying disorder (thyroid funciton)

Tx: Mood stabilizer, atypical antipsychotics, ECT, CBT, ACT for indiciuals with severe and persistent bipolar disorder

NC: decrease stimuli, remove dangerous objects. Maintain a calm attitude, set clear limits. Monitor pt intake & output and sleep patterns. Provide high=protein, high-calorie finger foods that can be eaten on the go. Protect pt from poor judgment.

Suicide

RF: Family hx, age >50, unmarries, race white, previous suicide attempts, chronic illness, mental health disorders, subtance abuse, isolation, lack of access to mental health services, job loss, financial difficulties, access to a firearm

Signs of impending suicide: Talking about death/suicide, statments about hopelessness, getting affairs in order (making a will), writing a suidcide note, giving away prized possessions, increase of substance use, withdrawl, sudden improvement of mood ( everything will be alright soon)

Personality Disorders

Generalized Anxiety Disorders

Anxiety is the feeling of apprehension or dread in response to a situation, when its uncontrolled it can cause panic, fear, or overwhelming worry that can lead to various disorders that impact quality of life.

Caused by a primary concern or secondary to a current situation the pt is experiencing.

Dx: Hamilton rating scale.

S/S: HR/BP elevated, tremors, pacing, hand-wringing, foot-tapping, fidgeting, signs of restlessness. Changes in voice/speech. Difficulty concentrating. c

NI: Deep breathing, guided imagery, cognitive restructuring. Provide a safe environment and privacy.

Phobias

OCD

Intrusive thoughts resulting in rituals to decrease anxiety

S/S

Obsessions: unwants, intrusive thoughts, urges, or images causing anxiety (fear of contamintionn)

Compulsions: inability to resist repetitive behavoirs, thoughts, or rituals to reduce anxiety* countind, excessive hand-washing)

Dx: obsession/compulsions are time consuming and disrupt social/occupational environments

Tx: SSRIs, CBT, antipsychotics

NC: In begining of treatment, allow time for the pt to perform rituals, then gradually limit time allotted for behavoir. Assist pt with “thought stopping” or relaxation techniques

Panic disorders

PTSD

RF: Childhood abuse, sex (female), mental health illness, lack of support, lowsocioeconmoic status

S/S: Flashbacks, nightmares, insomnia, re-experiencing event, hypervigilance, irritability, difficulty concentrating, exaggerated startle response, distorted cognition (self-blame/guilt), feeling of detachment from others.

Dx: traumatic event (stressor) preceding symptoms, disruption to social and/or occupational functioning

Tx: CBT, EMDR, SSRIs, SNRIs, trazodone for sleep assistance

NC: Patient saftey - assess for sucidide risk, stay with pt during periods of flashback/nightmares. Assess for maladaptive coping (substance abuse), and encourage healthy coping mechanisms used in the past.

Eating disorder

Bulimia Nervosa: Binge eating follows by measures to avoid gaining weight (vomiting, laxative use, extreme exercise)

S/S: parotid gland sweeling, dental erosion, russels sign (calluses on the knuckles), weight fluctuations (not underweight), dehydration, chronic inflamed/sore throat, GI issues

Labs: hypokalmeia, hyponatermia, metabolic alklosis

Anorexia Nervosa: Restriction of calorie intake resulting in dangerously low body weight

S/S: Extreme thinees (emaciation), amenorrhea, lanugo (downy hair growth), cold intolerance, brittle hair/nails, severe constipation, lethargy. Decreased HR, RR, BP

Tx: indicual/group/gamily talk therapy. CBT, nurtitional consueling, medications for comorbid psychiatric conditions (antidepressants)

NC: Strict I&Os, weight in morning.Stay with pt during meals and >1 hr after meals. Offer privaleges for treament compliance and weight gain. inadequate oral intake tube feedings may be ordered. Restirct strenuous activit. Moniotr for refeeding syndrome.

Non-pharm

Cognitive behavioral therapy: Therapy amide at modifying the pts patterns of thinking and behavoir

indications: Depression, anxiety disorders, substance abuse, eating disorders, personality disorders

Emphaiss: Amid at addressing and changingig the following

Automatic thought: immediate, distorted thoughts a pt may have when interpreting events

cognitive distortions: errors in logical thinking (fortune telling, catastrophizing)

underlying beliefs: core beliefs about the self and world (I am incapable of love, I am a failure)

Goals: Help replace negative, distorted thoughts with postive, rational ones. May use of thought recording (writing down and examining associations between situations, thoughts and feelings)

Exposure therapy

Support/group therapy

complementary therapies (yoga, deep breathing, exercise, medication, journaling, etc)

Pet therapy/service animals

Refeeding protocol

Refeeding syndrom, when nutrition is introduced too rapidly after prolonged starvation (s/s: severe electrolyte and fluid imbalances, arrhythmias, seizures, coma)

Suicide precautions

Brain stimulation therapy

Herbal: St. John wart

Increases risk of serotonin syndrom with serotonin reuptake inhibitors, decreases effectiveness of oral contraceptives, anticoagulants, and digoxin

Bulimia nervosa anorexia nervosa

Pharm

Antidepressants

Monoamine oxidase inhibitors

SE: Daytime sedation, weight gain, sexual dysfunction. HTN crises if the pt eats food that contain tyramine such as aged meats, cheses, fave beans, tofu, overripe fruit, acodcadoesl alchol, concentarted yeast, yourgur, sour cream, peanuts.

Selective serotonin reuptake inhibitors:

SE: Anxiety, agitation, akathisia, weight gain, sexual dysfuntion

, Citalopram,

Fluoxetine and sertraline

Indications: Anxiety, depression, OCD, PTSD

MOA: inhibits serotonin reuptake

Interactions: St. John wort’s

SE: Sexual dysfunction, weight gain, insomnia

NC: Assess for symptoms of serotonin syndrome (agitation, fever, diaphoresis, tremors

PT: Full effects not felt for 2 weeks or more

Selective norepinephrine reuptake inhibitors

SE: Sedation, headaches, dizziness, seizures with high doses of bupropion

tricyclic antidepressants

SE: Anticholinergic effects like dry mouth, and constipation. Ileus, change in mental status, weight gain, sexual dysfunction.

Norepinephrine and Dopamine Reuptake Inhibitors: Bupropion

Mood stabilizer

Lithium

Indications: Bipolar disorder

MOA: Affects sodium transport and neurotrasmitter metabolism

Contraindications: renal disease

SE: Renal disease, fine hand tremors, polyuria, increase thirst, electorlyte imbalances, hypothyroidsm, leukocytosis, GI upset, weight gain, fatigue. Lithium toxicity.

Interactions: Diuretics, NSAIDs

NC: Monitors for s/s of toxicity (plasma levels greater than 1.5 meq/l and coarse tremors, confusion, hypotenstion, seizures, tinnitus. Monitor serum levels of lithium,sodium, BUN, creatin.

PT Maintaine adequate fluid and sodium intacke (low sodium = hight lithium levels). Avoid excessive sweathing. Report illnesses with vomiting.

Benzodiazepine

Anticonvulsants

Valproic acid

Indications: Bipolar disorder, seizures

MOA: Increases GABA in CNS to decrease manic episodes related to bipolar disorder and suppress seizure activity

SE: GI upset, thrombocytopenia

Hepatotoxcity, pancreatits, fetal risk

NC: Monitor liver function (AST, ALT, LDH, bilirubin) and CBC levels

PT: Baseline liver lalbs needed before taking med

Carbamazepine and lamotrigine

Indications: Bipolar disorder, seizure/epilepsy

Carbamazepine

MOA: decrease synaptic transmission in CNS

SE: Blood dyscrasias (anemia, leukopenia, thrombocytopenia), vision issues (nystagmus, diplopia)

Sevens Johnson syndrome, toxic epidermal necrolysis, aplastic anemia, agranulocysosis

NC: Monitor CBC levels

Lamotrigine

MOA: inhibits sodium transport, stabilizing neuronal membranes

SE: Dizziness, GI upset, photosensitivity

Serious rashes (e.g.stevens johnson sysndrome

PT wear sunscreen, decreases effectiveness of oral contraceptives

Diavalproex

Gabapentin

Indications: Neuropathy, fibromyalgia, restless leg syndrome, seizures

MOA: inhibits excitatory neuron acitivy

Se: Dizziness, drowsiness, dry mouth, edema, potential for abuse

PT: Avoid alcohol. Discontinue gradually.

Antiolytics

Buspirone

Indications: Anxiety

MOA: Binds to serotonin and dopamine receptors in the brain

SE: Dizziness, nausea, headache

PT: take with the same amount of food each time to prevent a change in absorption level. No grapefruit juice. Full effects may not be felt for several weeks.

Long term use ok

Hydroxyzine

hydroxyzine

TPN

Practice questions

Is it true that a small amount of anxiety can be beneficial?

True.

Explantion: A small amount of anxiety can be beneficial due to it promoting ambition and achievement of tasks.

When should anxiety intervention techniques be taught?

When the pt is calm.

Explanation: Teaching anxiety intervention techniques should be taught when the pt is calm so they can practice the tools during an event.

Match the Hamilton rating scale for anxiety to its correct severity number.

Mild severity: less than 17

Moderate severity: 18-24

Moderate to severe: 25-30

Which are nursing interventions that can assist a pt experiencing anxiety?

Deep breathing, guided imagery, cognitive restructuring techniques

Which of the following is a selective serotonin reuptake inhbitor (SSRI) phenelzine, sertraline, amitriptyline, venlafaxine.

Sertraline

Explanation:Sertraline is an SSRI. Venlafaxine is a serotonin and norepinephrine reuptake inhibitor. Phenelzine is a monoamine oxidase inhibitor (MAOI), and amitriptyline is a trycyclic antidepressent.