Exam II Study Guide MH

o Concrete thing:

'its raining dogs out there' they might actually believe cats and dogs are coming out of the sky. Take things very literally

Selective Serotonin Reuptake Inhibitor and Serotonin Receptor Agonist

-Generic (trade): Vilazodone (Viibryd) -Action: Main mechanism of action is blocking the synaptic reuptake of serotonin; also activates serotonin receptors -Notes: Has been reported to result in lower rates of sexual side effects and weight gain as compared to SSRIs -Side effects: diarrhea, nausea, headache -Warnings: Withdrawal symptoms may occur if discontinued abruptly. Use with caution in pregnancy.

-Serotonin syndrome

-symptoms: hyperactivity or restlessness, tachycardia leads to cardiovascular shock, fever leads to hyperpyrexia, elevated blood pressure, altered mental states (delirium), irrationality/mood swings/hostility, seizures lead to status epilepticus, myoclonus/incoordination/tonic rigidity, abdominal pain/diarrhea/bloating, apnea leads to death -Interventions: remove offending agent(s), initiate symptomatic treatment: serotonin receptor blockade with cyproheptadine/methysergide/propranolol, cooling blankets/chlorpromazine for hyperthermia, dantrolene/diazepam for muscle rigidity or rigors, anticonvulsants, artificial ventilation, induction of parilysis. Serotonin syndrome w/ SSRIs ● R/t over-activation of serotonin receptors caused by too high of a dose or interaction w/ other drugs (e.g. MAOI) ● Symptoms include: abdominal pain, diarrhea, sweating, fever, tachycardia, elevated BP, altered mental state (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, & mood change ● When severe: hyperpyrexia, cardiovascular shock, or death

● Identify and become familiar with the alterations in speech, perceptions and behavior Alterations in behavior

Alterations in behavior ● Catatonia (increase or decrease in the rate and amount of movement) ● Motor retardation (slowing of movement) ● Motor agitation (excited behavior such as running or pacing rapidly) ● Stereotyped behaviors (repeated motor behaviors that serve no purpose) ● Waxy flexibility (extended maintenance of posture) ● Echopraxia (mimicking movements of another) ● Negativism (active- does the opposite of what is requested, passive-fails to do what is requested) ● Impaired impulse control ● Gesturing or posturing (unusual and illogical expressions or positions) ● Boundary impairment (impaired ability to sense where one's body or influence ends and another's begins

● Identify and become familiar with the alterations in speech, perceptions and behavior Alterations in perception

Alterations in perception ● Depersonalization (feeling that one is different/unreal or has lost their identity ● Derealization (false perception that the environment has changed) ● Hallucinations (perceiving a sensory experience for which no external stimuli exists) ● Command hallucinations (direct a person to take an action) o Perceptions are off • Hallucinations, delusions, illusion (misperception of real stimuli. It might be super cold, but you might think of it as an artic blast • Affect: if affect is flat you might tell a story and not have any emotion about it. • Issues with sense of self: repeating a question that they ask-echolalea and echopraxia. Copying what someone says and does. How are you? How are you? Moves hand to nose, moves hands to nose. • Depersonalization: feeling of unreality. Don't feel that they are in reality. Not feeling like your body is there or feeling detached from your body. • Autism like behavior: focus inward, feel a part of a fantasy world. • Deterioration of appearance: poor hygiene, wearing 2 coats and boots in 80 degrees, perceptions are off. Not managing ADLs

● What are the etiological factors involved in depression? (page 254)

BIOLOGICAL FACTORS o Genetic: average concordance rate for mood disorders among monozygotic twins is 37%. Some genetic markers may be related to depression. o Biochemical: CNS neurotransmitter abnormalities may result of genetic, environmental, or medical conditions. Serotonin and norepinephrine. -Stressful life event: significant facot in development of depression. Norepinephrine, serotonin, and acetylcholine play a role in stress regulation, when they are overtaxed depletion may occur -Neurogenesis: ability of the brain to produce new brain cells o Alterations in Hormonal Regulation: : hyperactivity of the hypothalamic pituitary adrenal cortical axis. Decliines in level of estrogen around menstruation and menopause create changes in nerve structures in the brain called dendritic pruning associated with depression o Inflammatory Processes: inflammation may be defense system also in psychological injury. Inflammation play sa role in depression: have elevated inflammatory biomarkers in absence of physical illness. o Diathesis-Stress Model: interplay between gentic and biological predisposition toward depression and life events. 2 people exposed to similar events may respond differently-one with depression another with resilience. PSYCHOLOGICAL FACTORS Cognitive theory: person's thoughts will result in emotions. Automatic, negative, repetitive, unintended, and not readily controllable thoughts perpetuate depression. Beck's cognitive triad 1. A negative, self deprecating view of self 2. A pessimistic view of the world 3. The belif that negative reinforcement (or no validation for self) will continue in the future Learned Helplessness: anxiety is initial response, then replaced by depression if person feels no control over outcome of a situation.

Norepinephrine Dopamine Reuptake Inhibitor (NDRI)

Bupropion (Wellbutrin) -Action: Blocks the synaptic reuptake of norepinephrine and dopamine -Notes: Stimulant action may reduce appetite, may increase sexual desire, used as an aid to quit smoking -Side effects: agitation, insomnia, headache, N&V, seizures -Warnings: High doses increase seizure risk, especially in people who are predisposed to them

Deep brain stimulation:

Deep brain stimulation: electrodes surgically implanted into specific areas of brain to stimulate these regions. Approved for Parkinson's, no beig investigated for depression. More invasive

● Identify the types of delusions

Delusion: false belief ○ Control: believing that another person, group of people, or existential force controls thoughts, feelings, impulses, or behaviors ○ Ideas of reference: giving personal significance to unrelated or trivial events / perceiving events as related to you when they are not ○ Persecution: believing that one is being singled out for harm by others ○ Grandeur: believing that one is a very powerful or important person ○ Somatic: believing that the body is changing in unusual ways (rotting inside, etc.) ○ Erotomanic: believing that another person desires you romantically ○ Jealousy: believing that one's mate in unfaithful

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Desvenlafaxine (Pristiq) -Action: Blocks the synaptic reuptake of serotonin and norepinephrine -Notes: A metabolite of venlafaxine -Side effects: nausea, headache, dizziness, insomnia, diarrhea, dry mouth, sweating, constipation -Warnings: Neonates with in utero exposure have required respiratory support and tube feeding Duloxetine (Cymbalta) -Action: blocks the synaptic reuptake of serotonin and norepinephrine -Notes: Cymbalta may be more effective than SSRIs in the treatment of severe depression -Side effects: Nausea, dry mouth, insomnia, somnolence, constipation, reduced appetite, fatigue, sweating, blurred vision -Warnings: May reduce pain associated with depression and is approved for fibromyalgia and pain of diabetic peripheral neuropathy Venlafaxine (Effexor) -Action: Blocks the synaptic reuptake of serotonin and norepinephrine -Notes: Effexor is a popular next-step strategy after trying SSRIs. -Side effects: Hypertension, nausea, insomnia, dry mouth, sedation, sweating, agitation, headache, sexual dysfunction -Warnings: monitor blood pressure, especially at higher doses and with a history of hypertension. Discontinuation syndrome

Dx criteria for dysthymic disorder

Dx criteria for dysthymic disorder ● Feelings of depression persist consistently for minimum of 2 yrs ● Symptoms bring about social & occupation distress, but not severe enough for hospitalization ● Onset usually in teenage years so pt's express they have "always felt this way" and that feeling depressed seems normal ● They may have periods of major depressive episodes

Dx criteria for major depressive disorder aka major depression

Dx criteria for major depressive disorder aka major depression ● Persistently depressed mood lasting for a minimum of 2 weeks ● In children, they tend to be irritable rather than depressed ● 5 out of 9 symptoms need to be met ○ Feeling depressed ○ Lack of interest in previously pleasurable activity (anhedonia) ○ Fatigue ○ Sleep disturbances ■ Insomnia ■ Terminal insomnia ← red flag for depression ■ Hypersomnia ○ Changes in appetite ■ Loss in appetite; weight loss ■ Increased appetite; weight gain ○ Feelings of hopelessness or worthlessness ■ "I never seem to do anything right" ■ "I was never a good parent" ■ "It's my fault that project at work failed" ○ Persistent thoughts of death or suicide ■ Abnormally preoccupied w/ death ○ Inability to concentrate or make decisions ■ Can't concentrate at work, easily distracted while they try to study, or they can't make up their mind on what to wear or what to eat ■ When severe, pt's cannot complete tasks at work or attend class and cannot get dressed or select, plan or prepare a meal ○ Change in physical activity ■ Psychomotor retardation ● Less motor mvmt; tends to stay in bed or sit in one spot most of the day ● When they move, they move slow & posture is stooped w/ head down ■ Psychomotor agitation ● Restless, changes position often, may wring their hands & fidget; may pace up & down the hall

Electroconvulsive therapy

Electroconvulsive therapy: physically induced seizure Indications: used most commonly for depression. Suicidal thoughts. Psychotic illnesses are second most common. Drug resistant patients, combo of ECT and antipsychotic medication has resulted in improvement. ECT may be a priary treatment: when a patient is suicidal and homicidal and need for rapid response, if previous medication rtrials have failed, when there is marked agitation/marked vegetative symptoms or catatonia, for major depression with psychotic features or for pervasive hallucinations. Used for depression, manic patients, rapid cyclers of bipolar disorders, schizophrenia, psychotic pateints who are pregnant, patients with Parkinson's. ECT is not effective with dysphoric disorder, unconventional depression, personality disorders, drug dependence, or depression secondary to situational or social difficulties. 2-3 treatments per wekk with total of 6-12 treatments. Asses for heart conditions, brain tumors, subdural hematomas. Weigh risk vs benefits Initiating electroconvulsive therapy: informe consent. General anesthetic to induce sleep, muscle paralyzing agent to prevent muscle distress and fractures. EEG monitors brain waves and ECG monitors cardiac. Brief seizures 30-60 seconds are induced by an electrical current transmitted through electrodes attached to one or borth sides of the head Potential adverse reactions: confused and disoriented after waking. Memory deficits. Not a permanent cure

Exercise:

Exercise: enhance mood, increase serotonin, damper activity of hypothalamic pitiutiary adrenocorticoid axis, which is overly active in depression. Mood elevated

● Describe metabolic syndrome

○ Includes significant weight gain, dyslipidemia, and altered glucose metabolism thought to be due to increased insulin resistance -- is a significant concern in most second generation antipsychotics and increases the risk of diabetes, hypertension, and atherosclerotic heart disease. Mood stabilizers: may cause weight gain and other metabolic disturabncesc such as altered metabolism of lipids and glucose. Risk for diabetes, high blood pressure, dyslipidemia, cardiac problems, metabolic syndrome.

Main ANXIETY neurotransmitter

GABA

● Identify several Mood stabilizers

○ Lithium ○ Anticonvulsants ○ Antipsychotics (Seroquel, Resperidol)

Light therapy

Light therapy: accepted for first line treatment of seasonal affective disorder SAD. Seasonal depression. Exposure to light suppresses the nocturnal secretion of melatonin, therapeutic for people with AD. 30-45 min per day, 10,000 lux light source. Negative effects: jitteriness, heache

Take the Hamilton Anxiety Scale (you can use this as a measure throughout nursing school!)

Measures anxiety: anxious mood, tension, fears, insomnia, intellectual (difficulty concentrating), depressed mood, somatic (muscular) pains and twitching, somatic (sensory) tinnitius/blurred visions/hot or cold falshes etc, cardiovascular symptoms, respiratory symptoms, GI symptoms, GU symptoms, autonomic symptoms (dry mouth/sweat/flushing etc), behavior at interview

Norepinephrine and Serotonin Specific Antidepressant (NASSA)

Mirtazapine (Remeron) -Action: Blocks alpha1-adrenergic receptors that normally inhibit norepinephrine and serotonin -Notes: Antidepressant effects equal SSRIs and may occur faster -Side effects: Weight gain/appetite stimulation, sedation, dizziness, headache, sexual dysfunction is rare -Warning: drug induced somnolence exaggerated by alcohol, benzodiazepines, and other CNS depressants

Monoamine Oxidase Inhibitors (MAOIs)

Monoamine Oxidase Inhibitors: enzyme monozmine oxidase is responsible for inactivating, or breaking down, certaine monoamine neurotransmitters in the brain, such as norepinephrine, serotonin, dopamine, and tyramine. Increase in norepinephrine, serotonin, and dopamine elevates mood. Increase in tyramine can cause high BP, hypertensive crisis, and CV accident. They are highly effective but not first line of treatment due to dietary restrictions. -Avoid foods high in tyramine: Vegetables: avocados, fermemnted bean curd, fermented soybean, soybean paste. Fruits: figs, bananas in large amounts Meats: fermented, smoked, or aged. Spoled meats, liver Susages: fermented, bolognia, pepperoni, salami Fish: dried or cured, fermented, smoked, aged, spoiled Milk/milk prodcuts: almost all cheese Food with yeast Beer wine: Some imported bears, chianti wines Other foods: protein dietary supplements, soups, shrimp paste, soy sauce -Avoid foods that contain other vasopressors -Chocolate -Fava beans -Ginseng -Caffeniated beverages -Drugs that interact with monoamine oxidase inhibitors (MAOIs): -OTC meds for colds, allergies, or conestion -Tricyclic antidepressants -Narcotics -Antihypertensive (methyldopa, guanethidine, reserpine) -Amine precursors (levodopa, I-tryptophan) -Sedatives (alcohol, barbiturates, benzodiazepines) -General anestehtics -Stimulants (amphetamines, cocaine) -Indications: MAOIs are effective for unconvential depression (mood reactivity, oversleeping, overeating) and panic disorder, social phobia, generalized anxiety disorder, OCD, PTsD, bulimia. Commonly used: Phenelzine (Nardil0 and tranylcypromine sulfate (Parnate) and Selegiline (Emsam) -Common adverse reactions: orthostatic hypotension, weight gain, edema, change in cardiac rate and rhythm, constipation, urinary hesitance, sexual dysfunction, vertigo, overactivity, muscle twitiching, hypomanic and manic behavior, insomnia, weakness, fatigue -Potential toxic effects: increase in BP, can develop intracranial hemorrhage, hyperpyrexia, convulsions, coma, death. Monitor BP. Crisis may begin with headaches, stiff or sore neck, palpitations, increase or decrease in HR (chest pain), N&V, or increase in temp. Use antihypertensives to treat -Contraindications: cerebrovascular disease, hypertension and CHF, liver disease, consumption of foods containing tyramine, tryptophan, dopamine, use of certain meds, recurrent or severe headaches, surgery in previous 10-14 days, age younger than 16 years -Patient and family teaching: teach to avoid listed foods and meds, give the patient a card about MAOI regimen, avoid Chinese restaurants, go to ER with severe headache, BP should be monitored for first 6 wks of treatment, after MAOI is stopped the patient should maintain dietary and drug restrictions for 14 days -Adverse reaction sto MAOIs: -hypotension (Expected side effect) Take orthostatic blood pressure, can be dangerous side effect -Sedation, weakness, fatigue -Insomina -Changes in cardiac rhythm -Muscle cramps -Anorgasmia or sexual impotence -Urinary hesitancy or constipation -Weight gain -Toxic effects -Hypertensive crisis: severe headache, tachycardia, palpitations, hypertension, N&V. Go to ER, give IV phentolamine or siblingual nifedipine Monoamine Oxidase Inhibitors (MAOIs) -Generic (trade): Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline Transdermal System patch, Tranylcypromine (Parnate) -Action: Inhibits the enzyme monoamine oxidase, which normally breaks down neurotransmitters, including serotonin and norepinephrine. -Notes: Efficacy similar to other antidepressants, but strict dietary (tyramine) restrictiosn and potential drug interactions make this drug class much less desirable -Side effects: insomnia, nausea, agitation, and confusion. Hypertensive crisis -Warnings: Contraindicated in people taking SSRIs, used cautiously in people taking TCAs. Tyramine-rch food could bring about a hypertensive crisis. Many other strong drug and dietary interacions.

● Identify Interventions for mild to moderate anxiety

○ Provide a calm presence ○ Recognize patient's distress, anticipate anxiety-provoking situations ○ Ask questions to clarify, ask open-ended questions ○ Evaluate past coping mechanisms ○ Encourage problem solving ○ Help the patient identify thoughts or feelings before the onset of anxiety ○ Use role play or modeling behaviors to develop alternate solutions to problems ○ Provide outlets for working off excess energy (walking, dancing, exercising)

Serotonin Antagonists and Reuptake Inhibitors

Nefazodone (Serzone) -Action: Selective blockage of serotoin2 receptors and alpha1-adrenergic receptors -Notes: Lower risk of long term weight gain than SSRIs or TCAs. Lower risk of sexual side effects than SSRIs. -Side effects: sedation, hepatotoxicity, dizziness, hypotension, paresthesias -Warnings: life threatning liver failure is possible but rare. Priapism of penis and clitoris is rare but serious side effect Trazodone (Desyrel, Oleptro) -Action: Moderate blockade of 5-HT synaptic reuptake -Notes: Significant sedative effect. Helps with antidepressant induced insomnia -Side effects: severe sedation, hypotension, nausea -Warnings: Pripapism has been reported

Main DEPRESSION neurotransimtters

Norepinephrine and serotonin

Transcrnial magnetic stimulation:

Transcrnial magnetic stimulation: noninvasive treatment that uses MRI strength magnetic pulses to stimulate focal areas of the cerbreal cortex Indications: patients unresponsive to other methods of treatment for depression. Effective stand alone treatment Initiating transcranial magnetic stimulation: outpatient tx, 30 min, orderd 5 days per week for 4-6 wks. Patient is awake and alert during procedure, electromagnet placed on scalp and shor tmagnentic pulses pass through the brain. Induce neurons to activate. Feel a slight tapping or knocking in the head, contraction of the scalp, tightening of jaw Potential adverse reactions: heache, lightheadedness. No neuro deficits or memory problems. Seizures are rare. Scalp tingling, discomfort at administration site

Major depressive disorder:

one of the most common mental disorders. Persistent depressed mood lasting for a minimum of 2 weeks Associated with lack of interest in a previously pleasurable activity (anhedonia), fatigue, sleep disturbances, changes in appetite, feelings of hopelessness or worthlessness, persistent thoughts of death or suicide, an inability to concentrate or make decisions, and change in physical activity. Must have 5 out of 8 of these symptoms

SSRIs

SSRIs--first line of tx for MDD: mode of action, side effects, warnings ● citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft) ○ Mode of action ■ Blocks the synaptic reuptake of serotonin ○ Side effects ■ Agitation, insomnia, headache, N&V, sexual dysfunction, hyponatremia ○ Warnings Taper slowly; abbrupt withdrawal leads to: dizziness, insomnia, nervousness, irritability, nausea, & agitation Selective serotonin reuptake inhibitors: first line therapy for most types of depression. Selectively block the neuronal uptake of serotonin, which increases the availbability of serotonin in the synaptic cleft. -Less side effects (no anticholinergic effects such as dry mouth, bluured vision, or urinary retention). Less lethality. -Common adverse reactions: may induce agitation, anxiety, sleep disturbance, tremor, sexual dysfunction, or tension headache. Autonomic reactions (dry mouth, sweating, weight change, mild nausea, lowose bowel movements) -Potential toxic effects: serotonin syndrome: too much serotonin from too high a dose or interaction with toher drugs. Symptoms; abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered metnal state, myoclonus, increased motor activit, irritability, hostility, mood change. Severe manifestations can include hyperpyrexia (high fevr), cardiovascular shock, death. Risk is greatest when SSRI is combined with MAOI. -Patient teaching: may cuase sexual dysfunction. May cause anxiety, insomnia, nervousness. May interact with other meds. No OTC drugs without doctor consideration. Common side effects: fatigue, nasea, diarrhea, dry mouth, dizziness, termor, and sexual dysfunction. Potential for drowsiness and dizziness-careful driving. Avoid alcohol. Liver and renal function tests should be performed. Meds should not be dc'd abruptly, can lead to serotonin withdrawal. -These symptoms should be reported to the physician immediately: increae in depression or suicidal thoughts, rash or hives, rapid heartbeat, sore throat, difficulty urinating, fever/malaise, anorexia and weight loss, unusual bleeding, initiation of hyperactive behavior, severe headache Selective Serotonin Reuptake Inhibitors (SSRIs) -Generic (trade): citalopram (celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (luvox), paroxetine (paxil), sertraline (Zoloft) -Action: blocks the synaptic reuptake of serotonin -Notes: First line of treatment for major depression, some SSRIs activate and others sedate, choice depends on patient symptoms. Risk for lethal overdose minimized with SSRIs. -Side effects: agitation, insomnia, headache, N&V, sexual dysfunction, hyponatremia -Warnings: Discontinuation syndrome-dizziness, insomnia, nervousness, irritability, nausea, agitation-may occur with abrupt withdrawal (depending on half life). Taper slowly

● Identify interventions for patients with dissociative disorders.

○ Psychoeducation ■ Teaching ground techniques that bring the person's awareness to noticing real things in the present helps to counter dissociative episodes ○ Pharmacological Interventions: ■ Antidepressant medication, anxiolytics, and antipsychotics ○ Advanced Practice Interventions: ■ Somatic Therapy: ● Specific type of somatic psychotherapy, sensorimotor psychotherapy, combines talking therapy with body centred interventions and movement to address the dissociative symptoms inherent to trauma.

St. John's wort:

St. John's wort: flower that can be processed into tea or tablets. Increases serotonin, norepinephrine, dopamine, antidepressant effects. Useful for mild to moderate depression. Not standardized or backed by FDA

● For the patient experiencing severe to panic levels of anxiety, what is the nurse's number one concern?

○ Safety of the patient and others

● Define sexual assault, sexual violence, rape and attempted rape

○ Sexual assault and sexual violence: broad terms that encompass unwanted sexual advances and sexual harassment to stranger rape, marital rape, date rape, and drug facilitated sexual assault ■ Incest, human sex trafficking and female genital mutilation are other examples of sexual assault. ○ Rape: defined in the context of non consensual activity and involves any penetration of the vagina or anus with any object or body part or the oral penetration by a sex organ of another person. ○ Attempted rape: refers to threats of rape or intention to rape that is unsuccessful.

Tricyclic antidepressants

Tricyclic antidepressants: inhibit the reuptake of norepinephrine and serotonin by the presynaptic neurons in the CNS, increasing the amount of time norepinephrine and serotonin are available. Mood elevation -Indications: sedative effects. Must take therapeutic dosese of TCAs for 10-14 days or longer before they work. May be stimulating TCA (desipramine or protriptyline) oor sedating (amitriptyline and doxepin). -Common adverse reactions: similar to antipsychitc meds, anticholinergic actions (dry mouth blurred vision, tachycardia, constipation, urinary retention, and esophageal reflux). Side effects are more common and more severe in patients taking antidepressants. Urinary retention and severe constipation warrant immediate attention. Weight gain common. Alpha-adrenergic blockade of the TCAs can produce postural orthostatcic hyptension and tachycardia. Monitor for dizzy and falls. Administer at night (Sedative, and minor side effects will occur during sleep) -Potential toxic effects: cardiovascular: dysrhythmias, tachycardia, myocardial infarction, and heart block. Considered a risk in older adults and patients with cardiac disease -Adverse drug interactions: meds NOT given while TCAs are used: monoamine oxidase inhibitors, phenothiazines, barbiturates, disulfiram (Antabuse), oral contraceptives (or other estrogen preparations), anticoagulants, some antihypertensives (clonidine, guanethidine, reserpine), benzodiazepines, and alcohol. -Contraindications: recently had a myocardial infarction or other cardiovascular problems, narrow angle glaucoma or history of seizures, and women who are pregnant -Patient and family teaching: mood eleveation may take 7-28 days up to 6-8 weeks for full effect, family should reinforce this frequently, patient should be reassured that drowsiness/dizziness/hypotension usually subside after the first few weeks, patient shouldbe cautioned when driving, do not drink alcohol, take full dosea t bedtime, take dose within 3 hours or wait until next day, suddenly stopping TCAs can cause nausea/altered heartbeat/nightmares/cold sweats in 2-4 days Tricyclic Antidepressants (TCAs) -Generic (trade): Amitriptyline (Elavil), Amoxapine (Asendin), Clomipramine (Anafranil), Desipramine ((Norpramin), Doxepin (Adapin, Sinequan), Imipramine (Tofranil), Maprotiline (Ludiomil), Nortiptyline (Aventyl, Pamelor), Protriptyline (Vivactil), Trimipramine (Surmontil) -Action: Inhibits the synaptic reuptake of serotonin and norepinephrine. Antagonizes adrenergic, histaminergic, muscarinic, and dopaminergic receptors -Notes: therapeutic effects similar to SSRIs, but side effects are more prominent. May work better in melancholic depression and in people with comorbid medical conditions. Some therapeutic serum levels may be monitored -Side effects: dry mouth, constipation, urinary retention, blurred vision, hypotension, cardiac toxicity, sedation -Warnings: lethal in overdose. Use cautiously in the elderly, w/ cardiac disorders, elevated intraocular pressure, urinary retention, hyperthyroidism, seizure disorders, and liver or kidney dysfunction

Vagus nerve stimulation:

Vagus nerve stimulation: originally treatment for epilepsy. Decreased seizures, improved mood. Dlectrical stimulation of vagus nerve boosts level of neurotransmitters, improving mood Indivations: approved for treatment resistant depression. Initiating vagus nerve stimulation: outpatient surgery, pacemaker device implanted surgically into left chest wall. Wire wraps around vagus nerve. Infared magnetic wand held against chest while a personal computer is used to program frequency fo pulses. Delivered for 30 seconds, every 5 m in, 24 horurs a day Potential adverse reactions: risk of surgical procedures. Voice alteration, neck pain, cough, paresthesia, dyspnea

● Identify covert and overt suicidal statements.

Verbal and nonverbal clues: Overt statements: I cant take it anymore, life isn't worth living anymore, I wish I were dead, everyone would be ebttter of if I died Covert statements: It's okay now soon everything will be fine, things will never work out, I wont be a problem much longer, nothing feels good to me anymore and probably never will, How can I give my body to medical science Talk about suicidal thoughts: have you ever felt that life was not worth living etc. Establish therapeutic relationship, crisis intervention techniques

World salad:

bunch of words put together randomly

o Clang association

choice of words governed by sounds usually by rhyming: mad, sad, glad

Dysthymic disorder

feelings of depression persist consistently for at least 2 years. Not as severe. May have episodes of full blon major depression

o Neologism:

made up words, have no meaning, but mean something to the person saying it

Norepinephrine

mood, attention and arousal, stimulates "flight or fight" responses to stress Increased: schizophrenia, mania, anxiety Decreased: depression

● What factors are involved in the etiology of Bipolar disorders? Page 229-230

o Biological Factors: ▪ Genetic: strong heritability. Polygenic disease ▪ Neurobiological: Neurotransmitters (norepinephrine, dopamine, and serotonin) too few may cause depression and too many may cause mania. Functional imaging MRI shows changes in the brain caused by disorder ▪ Neuroendocrine: hypothalamic-pituitary-thyroid-adrenal axis has been closely scrutinized in people with mood disorders. Hypothyroidsm-depression, hyperthyroidism-mania o Psychological Factors: may be triggered by stressful event: may be more present in upper SES. Higher education levels. Stressful family environemnts and adverse life events may increase vulnerability to genetically predisposed people o Environmental factors: may be more present in upper SES. Higher education levels. Stressful family environemnts and adverse life events may increase vulnerability to genetically predisposed people

● Identify the difference between Bipolar I and Bipolar II disorder

o Bipolar 1 disorder: characterized by at least one week long manic episode that results in excessive activity and energy. ▪ People may have periods of time when they may be symptom free it is such a severe disorder that the person experiencing it tends to have difficulty in maintaining social connections and employment. ▪ Psychosis may occur during manic episodes ▪ Mania can be euphoric or dysphoric ● Euphoric: feels wonderful in the beginning, but it turns scary and dark as it progresses toward loss of control and confusion. ● Dysphoric mania: referred to as a mixed state or agitated depression, with depressive symptoms along with mania. o Bipolar 2 disorder: low-level mania alternates with profound depression. ▪ Low level symptomatology hypomania. ● Tends to be euphoric and often increases functioning ● Accompanied by excessive activity and energy for at least four days and involves at least three of the behaviors listed under mania (see next question) ▪ Psychosis is never present in hypomania although it may be present in the depressive side of the disorder. ▪ Not usually severe enough to cause serious impairment in occupational or social functioning, and hospitalization is rare. 1. Bipolar I disorder: at least 1 week long manic episode that resultsin excessive activity and energy. May alternate with depression or mixed state of agitation and depression. Psychosis may occur. Presence of three of the following behaviors constitutes mania: extreme drive and energy, inflated sense of self importance, drastically reduced sleep requirements, excessive talking combined with pressured speech, personal feeling of racing thoughts, distraction by environmental events, unusually obsessed with and overfocused on goals, purposeless arousal and movement, dangerous activities such as indiscriminate spending, reckless sexual encounters, or risk investments a. Euphoric mania: feels wonderful in the beginning but it turns scary and dark as it progresses toward loss of control and confusion b. Dysphoric mania: referred to as mixed state or agitated depression, with depressive symptoms along with mania. 2. Bipolar II disorder: low level mania alternates with profound depression. Low level symptomology is called hypomania a. Hypomania: tends to be euphoric and often increases functioning. Psychosis not present in mania, but may be present in depression. Not usually severe enough for hospitalization or cuase occupational or social dysfunction

● Identify thought processes and speech patterns that are found in bipolar symptomatology

o Flight of ideas is a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words. o Speech is rapid, verbose, and circumstantial. ▪ When condition is severe, speech may be disorganized and incoherent o Content of speech is often sexually explicit and ranges from grossly inappropriate to vulgar. ▪ Themes may revolve around extraordinary sexual prowess, brilliant business ability, or unparalleled artistic talents (writing, painting, and dancing). o As manaia escalates, the flight of ideas may give way to clang associations. ▪ Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning. ▪ Example: Row, row, row your boat. Don't be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so i wrote. o Grandiosity (inflated self regard) is apparent in both the ideas expressed and the person's behavior. ▪ People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers. Flight of ideas: nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually bsed on understandable associationsor play son words. Severe: speech is disorganized and incoherent. Speech is loud. Clang associations: stringing together of words because of their rhyming sounds without regard to their meaning Grandiosity: (inflated self regard) apparent in both the ideas expressed and the person's behavior Cogniitve function: onset of bipolar disorder is often preceded by comparatively high cognitive function. May display significant and persistent cognitive problems and difficulties in psychosocial areas. The potential cognitive dysfunction among many people with bipolar disorder has specific clinical implications: cognitive function affects overall function, cognitive deficits correlate with greater number of manic episodes, history of psychosis, chronicity of illness, and poor functionoutcome, early diagnosis and treatment are cruicial to prevent illness progression, cognitive deficits, and poor outcomes, medication nselction should consider not only the efficacy of the drug in reducing mood symptoms but also the cognitive impact of the drug on the patient

● What is the difference between a Major depressive disorder and a dysthymic disorder?

o Major Depressive Disorder: ▪ Characterized by a persistently depressed mood lasting for a minimum of two weeks. o Dysthymic disorder: ▪ Occurs when feelings of depression persist consistently for at least two years

● Identify nursing interventions for depressed patients

o Pharmacological Interventions: SSRIs, tricyclics, MAOIs o Electroconvulsive Therapy o Transcranial Magnetic Stimulation o Vagus Nerve Stimulation o Deep Brain stimulation o Light Therapy o St. John's Wort o Exercise o Advanced Practice Interventions ▪ Psychotherapy ▪ Group Therapy Implementation: 3 phaes in treatment and recovery from major depression: 1. Acute phase (6-12 weeks): reduction of depressive symptoms and restoration of psychosocial and work function. Hospitlization may be required, medication or other biological treatments may b einitiated 2. Continuation phase (4-9 months): prevention of relapse through pharmacotherapy, education, and depression specific psychotherapy 3. Maintenance phase (1 year or more): prevention of further episodes of depression. Depending on risk factors of relapse, meds may be phased out or continued Counseling and communication techniques: time in silence with person with depression is meaningful. Keep working with withdrawn person.Make observations, use simple concrete words, allow time for patient to respond, listen to ccovert messages and ask about suicide plans, avoid plattiudes such as things will lok up -help patient identifying underlying assumptions and beliefs and consider alternate explanations to problems. Encourage patient to identify cognitive distortions: overgeneralizations, self-blame, mind reading, discounting of positive attributions. Encourage activities that can raise self-esteem, identify need for problem solving skills, coping skills and assertiveness skills. Encourage exercise, encourage formation of supportive relationships, provide information referrals Health teaching and health promotion: each individual controls treatment based on individual goals. Health teaching is important for informed choices. Provides hoep to patient: depression is an illness beyond voluntary control, depression can be manged through meds and lifestyle, chronic illness management depends on understanding personal S&S, depends on understand roles of meds, best with psychotherapy and meds, identify coping with stress. Include family in discharge: ensure understanding and acceptance of depression, increase pateints use of after care facilities in facilities, contributes to higher overall adjustment in the patient after discharge Promotion of self care activities: improving physical well bein g and promoting adequate self care nursing interventions. -Nutrition (anorexia): offer small, high calories snacks. OFffer high protein and high calorie fluids. Encourage family or friends to remain with patient during meals. Give patient food and drinks they like. Weigh patient weekly -Sleep (insomnia): provide periods of rest after activities, encourage patient to get up and dress and to stay out of bed during the day, encourage use of relaxation measures in evening, reduce environmental and physical stimulatints in evening -Self care deficitits: encourage use of toothbrush, washcloth, soap, etc. Give step by step reminders -Elimination (constipation): monitor I&O and /BMs, offer foods high in fiber, exercise, encourage fluids, evaluate need for laxatives and enemas

• Bipolar disorder:

signs, major areas of concern when you see the signs. Know how to prioritize nursing care. What would you do first?

● Identify symptoms of manic behavior

o Presence of three of the following behaviors constitutes mania: ▪ Extreme drive and energy ▪ Inflated sense of self-importance ▪ Drastically reduced sleep requirements ▪ Excessive talking combined with pressured speech ▪ Personal feelings of racing thoughts ▪ Distraction by environmental events ▪ Unusually obsessed with and over focused on goals ▪ Purposeless arousal and movement ▪ Dangerous activities, such as indiscriminate spending, reckless sexual encounters or risky investments. a. Euphoric mania: feels wonderful in the beginning but it turns scary and dark as it progresses toward loss of control and confusion b. Dysphoric mania: referred to as mixed state or agitated depression, with depressive symptoms along with mania. a. Hypomania: tends to be euphoric and often increases functioning. Psychosis not present in mania, but may be present in depression. Not usually severe enough for hospitalization or cuase occupational or social dysfunction

● What milieu interventions are important to have in place with suicidal patients?

o Primary Intervention: activities that provide support, information, and education to prevent suicide. o Secondary Intervention: treatment of the actual suicidal crisis. o Tertiary intervention: refers to the interventions with the circle of survivors of a person who has completed suicide. o Box 23-3 Suicide precautions: one on one nursing observation and interaction 24 hr a day, chart patient's whereabouts and record mood, verbatim statements, and behavior ever 15-30 min per protocol. Ensure that meal trays contain no glass or metal silverway. Hands should always be in view. Carefully observe patient swallow each dose of meds. The nurse and physician should explain to patient what they are doing and why, and document it. Use plastic eating utensils, do not assign patient to private room and ensure door remains open, jump proof and hang proof bathrooms. Keep electrical cords in a minimal length. Install unbreakable glass, lock windows. Lock all rooms and stairwells. Take away potentially hamful gifts and go through belongings before visitors come. Go through personal belongings for potentional harmful objects. Ensure that visiotrs do not leave harmful objects in rom. Search patient for harmful objects if allowed to leave on unit.

suicide protective factors

o Protective factors: ▪ Sense of responsibility to family (spouse, children) ▪ Pregnancy ▪ Religious beliefs ▪ Satisfaction with life ▪ Positive social support ▪ Access to health care ▪ Effective coping skills ▪ Effective problem-solving skills ▪ Intact reality testing Protective factors: sense of respoinsbility to family, pregnancy, religious beliefs, satisfaction with life, positivie social support, access to health care, effective coping skills, effective problem solving skills, intact reality testing

Risk factors of suicide

o Risk factors: ▪ ~2/3 of those who complete suicide is experiencing depression. ● About 15% of patients who have major depression or bipolar disorder will complete suicide. ▪ Loss of relationships, financial difficulty, and impulsivity are factors in this population. ▪ Suicide is more than 50x higher among patients with schizophrenia than in the general population, especially in the first few years of diagnosis. ▪ Patients with alcohol or substance use disorders also have a higher suicide risk ▪ Suicide is usually accompanied by intensely conflicted feelings of pain, hopelessness, guilt, and self-loathing, coupled with the believe that there are no solutions and things will not improve. ▪ People who survive serious suicide attempts often report that it is these feelings that fuel the sense of isolation and despair. ▪ Other risk factors include: ● Male gender: 4x more than women, ● Increasing age: men: peak after 45, women: peak after 35, ● Race white males commit 2 out of 3 ● Religion: protestants and Jews have higher rates than roman Catholics ● Marriage: married reduces risk, divorced increases risk ● Profession: higher risk for suicide, particularly if there is a fall in status. (Law enforcement personnel, dentists, artists, mechanics, insurance agents, and lawyers are also at a higher risk). ● Physical health: ½ of those who complete suicide has physical illnesses. Loss of mobility, disfigurement, and chronic pain are especially associated with suicide. ▪ BOX 25-2, page 483 for more Risk fators Suicidal ideation: manifestation of inner pain, hopelessness, and helplessness suffered by invdividuals Completed suicides: psychiatric disorders accompany 90% of completed suicides. Most are experining depression. Some Major depression and bipolar.. Higher in schizophrenia. High in substance or alcohol abuse disorders. Other risk factors: male gender, increasing age, Caucasian, less religion, not married, professionals at higher risk, half of those who complete suicide have physical illnesses. Suicide attempts: people who survive report feeling isolated, despairity, pain Psychological autopsies: retrospective reviews of the deceased person's life within several months of death to establish likely diagnoses at the time of death. Suicide risk factors: suicidal ideation with intent, lethal suicide plan, history of suicide attempt, co-occcuring psychiatric illness, co=occurring medical illness, hx of childhood abuse, family hx of suicide, recent lack of social support, unemployment, recent stressfull life event, hopelessness, panic attacks, feeling of shame or humiliation, impulsivity, aggressiveness, loss of cognitive function, access to firearms and other highly lethal means, substance abuse, impending incarceration, low frustration tolerance, seual orientation issues.

● What symptoms of a bipolar patient cause the nurse to give a nursing dx "risk for injury?"

o Risk for injury Signs and symptoms: hyperactivity risk for injury (exhaustion, dehydration, cardiac collapse, poor judgment)

● What are the two main neurotransmitters involved in depression?

o Serotonin 5-hydroxytryptamine [5-hT] and norepinephrine

● When a patient is thought to have a depressed mood, it is very important to that patients safety to also assess what?

o Suicide Potential

● What are the signs and symptoms of Depression?

o Table 14-2, page 261 o Depressed mood and anhedonia o Anergia: lack of energy or physical passivity o Anxiety o Psychomotor agitation (constant pacing and wringing of hands) o Psychomotor retardation: slowed movements. o Somatic complaints (headaches, malaise, backaches) o Vegetative signs of depression: change in bowel movements and eating habits, sleep disturbances, and disinterest in sex. Key assessment findings: depressed mood and anhedonia are key symptoms. Thinking slow, concentration decreased. Dwell on and exaggerate their perceived faults and failures and are unable to focus on their strengths and successes. Delusions of being punished for committing bad deeds or benig a terrible person. Feelings of worthlessnss, hopelessness, guilt, anger, and helplessness are common Anergia: lack of energy or physical passivity Anxiety: common symptom Psychomotor agitation: constant pacing and wrining of hands Psychomotor retardation: slowed movements sometimes more common -Somatic complaints (headaches, malaise, backaches) Vegetative signs of depression: change in BMs and eating habits, sleep disturbances, disinterest in sex -Chronic pain: disabling pain

● What might the nurse be feeling when working with a highly symptomatic bipolar patient? Page 233

o Witnessing mania can elicit numerous intense emotions in a nurse. o Frequent staff meetings to deal with the behaviors of the patient and the nurses'' responses to these behaviors can help minimize staff splitting and feelings of anger and isolation. o Consistency among staff is imperative if the limit setting (e.g. lights out after 11pm) is to be carried out effectively.

● When is Lithium toxic; what level; what are the symptoms? Page 240

oExpected side effects: 0.4-1.0mEq/L (therapeutic level) ▪ Signs: fine hand tremor, polyuria, and mild thirst. ▪ Mild nausea and general discomfort ▪ Weight gain oEarly SIgns of Toxicity: 1.5mEq/L ▪ Signs: nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness and find hand tremor oAdvanced Signs of Toxicity: 1.5-2.0mEq/L ▪ Signs: coarse hand tremor, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, electroencephalographic changes, incoordination, sedation. oSevere Toxicity: 2.0-2.5mEq/L ▪ Signs: ataxia, giddiness, serious electroencephalographic changes, blurred vision, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, coma. ▪ Death is usually secondary to pulmonary complications. o>2.5mEq/L ▪ Signs: convulsions, oliguria, and death can occur Lithium carbonate: effective treatment of bipolar I acute and recurrent manic and depressive episodes. Takes 7-14 days to be effective. Lithium is for maintane it doesn't cure. Indications: -Reduces the following: elation/grandiosity/expansiveness, fight of ideas, irritability and manipulation, anxiety -Lesser extent: insomnia, psychomotor agitation, threatening or assaultive behavior, distractibility, hypersexuality, paranoia Therapetuic and toxic levels -300-600 mg BID or TID PO. Signs of toixicity will occur, can cause death, hemodialsysi may be necessary, start low and slow with older patients Maintenance therapy: some need for a year, some need for lifetime, some can lower dosages. Monitor for adverse effects. 2 major long term risks of lithium therapy are hypothyroidism and impairment of kidney's ability to conectrate urine Contraindications: impaired renal function, thyroid problems, dementia or neuro disorders. Cardovascular disease, brain damage, renal disease, thyroid disease, myasthenia gravis, pregnancy, breast feeding Lithium level above 3.5: lithium level at which there is impaired consciousness, nystagmus, seizures, coma arrhythmias, cardiovascular collapse KNOW YOUR LITHIUM FOR TEST 0.4-1.0 is expected. Above 1.4 is early signs of toxicity

• Know how to respond to patients.

• Know how to respond to patients. Therapeutic communication-best way to respond to patient who is showing symptomology of bipolar disorder, OCD etc

• Psych assessment

• Psych assessment: do a full physical assessment first. Check physiological symptoms of anxiety and depression, check what they are somatizing

• Sucide:

• See suicide people in 1-2 weeks. Risk for suicide is always highest priority. Lethality of their suicide plan-is it specific and do they have the means for it. Ask if they have a plan to hurt themselves, ask specifically about the plan.

● Define Extrapyramidal side effects; provide examples.

○ First generation antipsychotics are dopamine D2 antagonists in both the limbic and motor centers. ○ This blockage of D2 dopamine receptors in the motor areas causes extrapyramidal side effects (EPSs) ○ Three of the more common EPS's are acute dystonia, akathisia, and pseudoparkinsonism. ○ Examples: ■ Pseudoparkinsonism: masklike facies, stiff and stooped posture, shuffling gait, drooling, tremor, "pill-rolling" phenomenon ■ Acute dystonic reactions: acute contractions of tongue, face, neck and back ■ Opisthotonos: tetanic heightening of entire body, head and belly up ■ Oculogyric crisis: eyes locked upward ■ Laryngeal dystonia: could threaten airway (rare) ■ Akathisia: motor inner driven restlessness ■ Tardive dyskinesia ○ Treatment: Cogentin • Antipsychotics: 1st generation would cause EPS o Extra parametal side effects: pseudo parkinson's (sticking tongue out, movements that look like restlessness, repetitive, weakness, no control, they can be IRREVERSIBLE TEST! How can we treat these effects: Cogentin (anti-dopamine, anticholinergic). Can be constipating.

● Identify and become familiar with the alterations in speech, perceptions and behavior ○ Alterations in speech

○ Alterations in speech ● Associative looseness (thinking is illogical, jump from one thing to another) ● Clang association (choosing words based on sounds rather than meaning) ● Word salad (jumble of words that is meaningless to the listener) ● Neologisms (made-up words that have meaning to the patient but a different or nonexistant meaning to others) ● Echocalia (repeating of another's words) ● Religiosity (preoccupation to religious themes) ● Magical thinking (believe they can control others) ● Concrete thinking ● Paranoia ● Circumstantiality (involving unnecessary and tedious details) ● Tangeability (going off on tangents that leads the conversation off-topic) ● Perseverating (persistent repition of words) ● Cognitive retardation (generalized slowing in the pace of thinking) ● Alogia/poverty of speech (reduction in spontaneity or volume of speech ● Rapid or pressured speech ● Flight of ideas (moving rapidly from one thought to the next ● Thought blocking (abrupt stoppage of thought that derails conversation) ● Thought deletion (belief that one's thoughts have been taken or are missing) ● Illogical, disorganized, or bizarre thinking ● Inability to maintain attention o Tangentially: inability to get to the point because too many topics are beign introduced o Perseveration: persistent repetition of word or theme. Can apply to anxiety: Anxious thought would get in her head and repeat o having magical thinking (thoughts having control over other people, my thoughts are making you do things, I made the twin towers come down with my thoughts), form of thought: associative loosesnss, shifting from one point to another

● Define Personality disorder

○ An enduring pattern of experience and behavior that deviates significantly from the expectations within the individual's culture.

● Identify the three clusters of Personality disorders Table 24-2, page 464-465

○ Antisocial ■ Can seem normal. ■ Exhibits no anxiety or depression ■ Manipulative, exploitive of others, aggressive, seductive, callous toward others ○ Avoidant ■ Excessively anxious in social situations ■ Hypersensitive to negative evaluation ■ Desire social interaction ○ Borderline ■ Shows separation anxiety ■ Manifests ideas of reference ■ Impulsive (suicide, self-mutilation) ■ Engages in splitting (adoring then devaluing persons) ○ Dependent ■ Excessively clingy ■ Self-sacrificing, submissive ■ Needy, gets others to care for him or her ○ Histrionic ■ Seductive, flamboyant, attention seeking, shallow, depressive and suicidal when admiration withdrawn ○ Narcissistic ■ Exploitive, grandiose, disparaging, filled with rage ■ Very sensitive to rejection, criticism ■ Cannot show empathy ■ Handles aging poorly ○ Obsessive-compulsive ■ Perfectionistic, has need for control, inflexible and rigid ■ Preoccupied with details ■ Highly critical of self and others ○ Paranoid ■ Projects blame, suspicious and mistrustful ■ Hostile and violent ■ Shows cognitive and perceptual distortions ○ Schizoid ■ Reclusive, avoidant, uncooperative ○ Schizotypal ■ Manifests ideas of reference, shows cognitive and perceptual distortions ■ Socially inept ■ anxious

● What should be known about the elderly and providing pain medications?

○ BOX 30-3 pg 572 ○ Older adults often receive pain meds less often than younger adults ○ Safe administration is complicated because of possible interactions with drugs used to treat multiple chronic disorders, nutritional alterations, and altered pharmacokinetics ○ Analgesics have a higher peak and a longer duration of action in older adults ■ Start with one fourth to one half the adult dose and titrate up carefully ○ Give oral analgesics around the clock when initiating pain management, administer on prn basis later on ○ If acute confusion occurs, assess for other contributing factors before changing the medication or stopping the analgesic use ■ Confusion in postop patients has been found to be associated with unrelieved pain rather than with opiate use ○ Acetaminophen is effective in older adults but has an increased risk of end-stage renal disease with long-term use ○ Analgesics and adjuvants, such as anticholinergics and pentazocine, may produce increased confusion in older adults ○ NSAIDs can cause confusion in older adults during their initial period of administration ○ Morphine is a safer choice than meperidine because its duration of action is longer, so a smaller overall dose is needed ○ Assess bowel function daily

● Define what is meant by "secondary gains"

○ Benefits derived from the symptoms alone ○ Ex.: a patient is not able to perform the usual family, work, and social functions so receives extra attention from loved ones

● Identify nursing guidelines and therapies for Borderline and OCD patients table 24-2

○ Borderline: ■ Nursing Guidelines: ● 1. Set realistic goals, use clear action words ● 2. Be aware of manipulative behaviors (flattery, seductiveness, instilling of guilt) ● 3. Provide clear and consistent boundaries and limits ● 4. Use clear and straightforward communication ● 5. WHen behavioral problems emerge, calmly review the therapeutic goals and boundaries of treatment ● 6. Avoid rejecting or rescuing. ● 7. Assess for suicidal and self-mutilating behaviors, especially during times of stress. ■ Therapies : ● 1. Individual psychotherapy ● 2. Dialectical behavior therapy ● 3. Group therapy ● 4. Antipsychotics may control anger and brief psychosis ● 5. Antidepressants such as SSRIs and MAOIs ● 6. Benzodiazepines help anxiety. ○ OCD: ■ Nursing Guidelines: ● 1. Guard against power struggles with patient. Need for control is very high. ● 2. Intellectualization, rationalization, reaction formation, isolation, and undoing are the most common defense mechanisms. ■ Therapies : ● 1. Supportive or insightful psychotherapy ● 2. Clomipramine and SSRIs for obsessional thinking and depression. 1. Obssessive compulsive disorder • Obsessions: repetitive negative thoughts that cause anxiety • Compulsions: repetitive behaviors that are done to ease the anxiety • Trying to manage anxiety by performing these rituals. Do something 4x, they get ready for bed in order for 2 hours, when they do these compulsions they are managing their anxiety and are in control • OCD can be due to traumatic event Nursing diagnoses Ineffective individual coping Impaired skin integrity (Washing hands, picking skin) We want client to live without rituals, complete ADLs Somebody has OCD omes on the unit: talk to her feelings about anxiety, let her perform rituals, in the future work on shortening the time and amount of rituals. Instead of washing hands 5x can we reduce it to 3x. Katula started patient on Lexapro (SSRI) 5 mg a small amount so serotonin doesn't flood, upped it to 10 mg still anxious, upped it to 15 mg-rituals decreased just with the meds

● Identify key neurotransmitters and their role in mental health

○ Brainstem: regulates neurotransmitters ■ respond to stimuli, conduct electrical impulses, regulate neurotransmitters ○ Depression neurotransmitters: serotonin, norepinephrine ■ too much norepinephrine: schizophrenia, mania ■ not enough norepinephrine: depression ■ too much serotonin: anxiety ■ not enough serotonin: depression ○ Anxiety neurotransmitters: GABA ■ not enough GABA: anxiety, schizophrenia ○ Schizophrenia and mania neurotransmitters: dopamine ■ too much dopamine: schizophrenia and mania ■ not enough dopamine: Parkinson's ○ Too much acetylcholine: depression ○ Not enough acetylcholine: Huntington's ○ Hormones also play a role in mood

● Identify several types of abuse

○ Child Abuse ○ Intimate Partner Abuse ○ Older Adult Abuse

● Identify several defense mechanisms and two that you may use in everyday life

○ Compensation: counterbalance perceived deficiencies by emphasizing strengths ○ Conversion: unconscious transformation of anxiety into a physical symptom ○ Denial: ignoring the existence of anxiety-causing thoughts and feelings) ○ Displacement: transference of emotions associated with a person, object or situation to one that is nonthreatening ○ Dissociation: disruption in consciousness, memory, identity, or perception, of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself ○ Identification: attributing to oneself the characteristics of another person or group ○ Intellectualization: events are analyzed without passion ○ Projection: unconscious rejection of emotionally unacceptable features and attributing them to others ○ Rationalization: justifying illogical ideas/actions/feelings by developing acceptable explanations that satisfy the teller as well as the listener ○ Reaction formation: unacceptable feeling/behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion ○ Regression: reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been previously exhibited ○ Repression: unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness ○ Splitting: inability to integrate the positive and negative qualities of oneself or others into a cohesive image ○ Sublimation: unconscious process of substituting mature and socially acceptable activity for immature and unacceptable impulses ○ Suppression: conscious denial of a disturbing situation or feeling Undoing: making up for an act or communication

● Identify guidelines for communicating with patients experiencing hallucinations

○ Cues of hallucinations: eyes tracking an unheard speaker, muttering, talking to self, appearing distracted, or watching a vacant area of the room ○ Call the patient by name, speak simply and loudly ○ Present in a non-threatening and supportive manner ○ Maintain eye contact ○ Redirect the patient's focus to your conversation as needed ○ Ask the patient directly about the hallucinations ("What are you hearing?") ○ Avoid referring to hallucinations as if they are real ○ Focus on reality-based, "here and now" activities, such as conversations or simple projects ○ Tell the patient "The voice you hear is part of your illness; it cannot hurt you. Try to listen to me." ○ Be alert to signs of anxiety (may indicate the hallucinations are increasing) ○ Encourage the use of competing auditory stimuli such as listening to music with headphones ○ Address any underlying emotion, need, or theme that seems to be indicated by the hallucination

● Distinguish between delirium and dementia

○ Delirium ■ Acute cognitive disturbance and often-reversible condition that causes fluctuations in consciousness and changes in cognition ■ ACUTE (emerges abruptly over hours or days) ■ Signs include seeming quiet, sleepy and confused, or restless and very distressed ○ Dementia ■ Progressive deterioration of cognitive functioning and global impairment of intellect with no change in consciousness ■ CHRONIC (slowly evident over months or years) ■ Signs include forgetfulness, confusion, trouble speaking and understanding others

● Identify several dissociative disorders

○ Dissociative disorders: occur after significant adverse experiences/traumas, and individuals respond to stress with a severe interruption of consciousness. ■ Dissociative amnesia: marked by the inability to recall important personal information, often of a traumatic or stressful nature; this lack of memory is too pervasive to be explained by ordinary forgetfulness. ● Autobiographical memory is available not accessible. ■ Dissociative fugue: characterized by sudden, unexpected travel away from the customary locale and inability to recall one's identity and information about some or all of the past. ■ Dissociative identity disorder: presence of two or more distinct personality states that recurrently take control of behavior. ● Each alternate personality has its own pattern of perceiving, relating to, and thinking about the self and the environment. 1. Dissociative disorders: inaibility to recall extensive data that is too extraordinary to excuse as normal forgetfulness. Frogetful process. Not due to direct effects of substance abuse or medical condition. • Amnesias; inability to recall important extensive data that is too much to excuse as ordinary forgetfulness 1. Localized amnesia: person is not able to recall all incidents 2. Selective amnesia: can not recall only certain aspects of traumatic even 3. Continuous: event happens and theyre forgetting everything now 4. Generalized amnesia: forget everything that happened in their life time including personal identity • Dissociative fugue: sudden unexpected travel away from home or work place. Individual is unable to recall their personal identity, and assume new identity. o Travel somewhere, leave and you've gone somewhere. • Dissociative identity disorder: 2 or more personalities within a single individual. Transform from personality to personality with a sudden and drastic transformational o Most often horrifically abused.

● Identify several basic level interventions for patients with somatoform disorders

○ Do not imply that the symptoms aren't real ○ Shift focus from somatic complaints to feelings or neutral topics ○ Assess for secondary gains ○ Use matter-of-fact approach to patient exhibiting resistance or covert anger ■ Support patients while expecting them to feed, bathe, or groom themselves ■ Show concern but avoid fostering dependency needs ○ Assertiveness training, teach assertive communication ■ Provides patient with positive means of getting needs met and reduces hopelessness and need for manipulation ○ Teach patient stress-reduction techniques (meditation, relaxation, and mild physical exercise, etc.)

● Identify barriers to leaving an abusive situation

○ Economic considerations are usually the only reason women stay in abusive situations. ○ Fear of injury or death ○ Financial dependence, welfare of children

● Somatization

○ Expression of physiological stress through physical symptoms ○ Instead of feeling anxiety, depression or irritability, some people may experience pain paralysis, rashes, etc.

● Identify several factitious disorders

○ Factitious disorder: people consciously pretend to be ill to get emotional needs met and attain the status of "patient" ■ The most insidious form of factitious disorders is factitious disorder imposed on another (commonly called Munchausen Syndrome by proxy) ■ Malingering: consciously motivated act to deceive based on the desire for material gain.

● Identify the Etiology of Anxiety disorders

○ Genetic ○ Neurobiological ■ Too little GABA (chemical released by neurons that regulates anxiety) ○ Psychological ■ Psychodynamic theories: unconscious childhood conflicts are basis for future symptom development ● Freud: anxiety results when threatening repressed ideas or emotions are close to breaking through from the unconscious to the conscious ● Sullivan: anxiety results when early needs go unmet or disapproval is experienced ■ Behavioral ● Anxiety is a learned response to specific environmental stimuli (classic conditioning) ■ Cognitive ● Anxiety is caused by distortions in an individual's thoughts and perceptions

● Identify interventions for abused victims

○ Implementation ■ Reporting ABuse ■ Counseling ■ Case Management ■ Therapeutic Environment ■ Promotion of Self-Care Activities ■ Health Teaching and health promotion ○ Advanced Practice Interventions ■ Individual Psychotherapy ■ Family Psychotherapy ■ Group Psychotherapy

● Identify several types of advanced directives that supports the Patient Self-Determination Act.

○ Living will ■ Personal statement of how and where one wishes to die ■ Activated only when the person is terminally ill and incapacitated ■ A competent patient may alter living will at any time ○ Directive to physician ■ A physician is appointed to serve as a surrogate medical decision maker ■ Used in cases of terminal illness when an individual has no family ■ Physician must verify the terminal illness and the patient must be competent at the time of signing ■ The physician must agree in writing to be the patient's agent and must be one of the two physicians who made the original determination that the patient is terminally ill ■ Can be revoked orally at any time without regard to patient competency (unlike living will) ○ Durable power of attorney for health care ■ Designation of a person to act as the patient's medical decision maker ■ Patient must be competent when making the appointment and must also be competent in order to revoke the power ■ Do not need to be terminally ill or incompetent to allow the empowered individual to act on their behalf ○ Guardianship ■ Court-ordered relationship in which one party (the guardian) acts on behalf of an individual (the ward) ■ The law regards the ward as lacking capacity to manage their own personal and/or financial affairs (after evaluation by a physician or psychologist) ■ Many people with mental illness, mental retardation, traumatic brain injuries, and organic brain disorders such as dementia

● Identify situations in which a person may develop PTSD. What movies have you seen that may have a character with PTSD?

○ Military combat ○ Prisoners of war ○ Natural disasters (floods, tornadoes, earthquakes, etc.) ○ Human disasters (plane/train accidents, etc.) ○ Crime-related events (bombing, assault, rape, etc.) ○ Diagnosis of a life-threatening illness -Sexual assault ○ Movies: Saving Private Ryan (war), Perks of Being a Wallflower (car accident), Forrest Gump (war)

● Identify several functions of the brain. (Box 3-1 page 38)

○ Monitor changes in the external world ○ Monitor the composition of body fluids ○ Regulate the contractions of the skeletal muscles ○ Regulate the internal organs ○ Initiate and regulate the basic drives: hunger, thirst, sex, aggressive self protection ○ Mediate conscious sensation ○ Store and retrieve memories ○ Regulate mood (affect) and emotions ○ Think and perform intellectual functions ○ Regulate the sleep cycle ○ Produce and interpret language ○ Process visual and auditory data ○ Frontal lobe: executive function (planning, decision-making, motivation, judgement) ■ not fully developed in adolescents - impulsive, poor judgement ○ Temporal lobe: language comprehension, stores sounds as memories, limbic system (emotional part of brain) ○ Occipital lobe: interprets visuals as memories ○ Parietal lobe: receive and identify sensory information, body movements, reading, mathematics ○ Amigdilla: emotions, learning memory ○ Circadian rhythm: emotion, Neurotransmitters: major: dopamine effects schizophrenia. Major: gama affects anxiety. dopamine is the neurotransmitter that is involve din schizophrenia. When you have increase in dopamine you will have schizophrenia and mania. Decrease in dopamine: parkinson's and depression. Noriepinephrine: Frontal lobe: decision making, insight, motivation, social judgment, executive functioning ooccurs. Under 25 it's still developing. Myelin sheath still thickening. Temporal lobe: stores sounds into memory. Conects with limbic system. Emotional part of brain. OCcipatal lobe: visual images, visual memoreies, some language formation Periteal lobe: receives and identifies sensory information, body movement, reading and mathematics. Amigdila: emotions, basic drives, learning, memory. Anger and aggression, intense joy. Tiny almond in the middle of the brain Pineal gland: helps with emotion, food satieation Frontal lobe Autopsy with ftonal lobe degeneration they show odd and strange behavior. They eventually pass away.

● Define Neurotransmitter

○ Neurotransmitter: chemical substance that functions as a neural messenger. ■ Released from the axon terminal of the presynaptic neuron when stimulated by an electrical impulse.

● Describe Neuroleptic malignant syndrome page 219

○ Occurs in about 0.2% to 1% of patients who have taken first generation antipsychotics but can occur with second generation antipsychotics as well. ○ Caused by excessive dopamine receptor blockage, NMS is a life threatening medical emergency that is fatal in about 10% of cases. ○ Usually occurs early in therapy but has been reported in patients after 20 years of treatment ○ Characterized by reduced consciousness increased muscle tone (muscle rigidity), and autonomic dysfunction - including marked hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. ○ Treatment: early detection, discontinuation of the antipsychotic, management of fluid balance, rapid temperature reduction, and monitoring for complications such as deep vein thrombosis and rhabdomyolysis.

● Identify medications and side effects used for schizophrenia

○ Old neuroleptics (mainly used in ER) ○ Atypical antispychotics: Seroquel MEDS: 1st generation antipsychotics: Haldol, clozorill, thorazine. Used in the ER more than units. Bad side effects 2nd gen antipsychotic (called atypical meds): less side effects: Seroquel, giadone, risparidol, cyprexa Most effective treatment: • Skills training: eye contact, working in milieu, family work (education, support) • Antipsychotics: 1st generation would cause EPS o Extra parametal side effects: pseudo parkinson's (sticking tongue out, movements that look like restlessness, repetitive, weakness, no control, they can be IRREVERSIBLE o TEST! How can we treat these effects: Cogentin (anti-dopamine, anticholinergic). Can be constipating. Give lowest dose possible. Med that we give to treat EPS symptoms • Antipsychotics: 2nd generation: less EPS effects MEDS: 1st, 2nd, Cognentin

● Describe ways in which to identify pain for those patients who are unable to speak to this issue

○ Pain Assessment in Advanced Dementia (PAINAD) scale ■ Evaluates five domains: ● Breathing ● Negative vocalization ● Facial expression ● Body language ● Consolability

● Identify the positive and negative symptoms of schizophrenia

○ Positive: presence of something that is not normally present, acute onset ■ Ex.: hallucinations, delusions, allusions, bizarre thinking, paranoia, abnormal movements, gross errors in thinking ○ Negative: absence of something that should be present ■ Impede one's ability to initiate/maintain conversations and relationships, obtain/maintain employment, make decisions, follow through with plans, and maintain adequate hygiene ■ Ex.: interest in hygiene, motivation, ability to experience pleasure Positve symptoms of schizophrenia: Delusions and hallucinations Negative symptoms of schizophrenia: flat affect, poverty of speech

● Identify the etiology of a dissociative identity disorder

○ Presence of 2 or more distinct personality states that recurrently take control of behavior, each having it's own pattern of perceiving, relating to, and thinking about the self and the environment ○ May be predisposed by severe sexual, physical, or psychological trauma in childhood

● Identify 5 somatoform disorders

○ Somatic symptom disorder ■ Characterized by a combination of distressing symptoms and an excessive or maladaptive response or associated health concerns without significant physical findings and medical diagnosis ■ Suffering is authentic, high level of function impairment ○ Illness anxiety disorder (previously hypochondriasis) ■ Preoccupation with disease or illness ■ Different from somatic symptom disorder because somatic symptoms are NOT present, or mild at most ○ Conversion disorder (functional neurological disorder) ■ Neurological symptoms in the absence of a neurological diagnosis ■ Deficits in voluntary motor or sensory function (paralysis, blindness, movement disorder, gait disorder, numbness, paresthesia, loss of vision or hearing, epileptic-type seizures ■ La belle indifference: lack of emotional concern about the symptoms ○ Psychological factors affecting medical conditions ■ Ex.: major depressive disorder is a risk factor for coronary heart disease and cancer ○ Factitious disorder ■ Consciously pretend to be ill to get emotional needs met and attain the status of "patient" • physical symptoms suggesting medical disease, but there isn't any organic reason or pathology or mechanism. It's not there, there's nothing wrong, but they really feel the disease. Person has a specific thing that they're sick over (different from hypochondriac). • Chronic, constantly seeking help from Health care professionals, drugs or alcohol to manage anxiety, may have depression or suicide ideation 1. Conversion disorder: loss or change in body function resulting from a psychological conflict. Physical symptoms can not be explained by medical disorders. Mom comes home from giving birth, and all of a sudden she can't move her arms and can't take care of baby. The tell tale of conversion disorder is they're not particularly bothered by it. Lack concern. Labile indifference 2. Body dysmorphic disorder: exaggerated belief that body is disformed in some specific way. They see in the mirror that their nose is tkang up all their face-might hide, try and get nose job.

● Define and provide an example of splitting

○ Splitting: ■ A primitive defense mechanism in which the person sees self or others as all good or all bad, failing to integrate the positive and negative qualities of the self and others into a cohesive whole.

● Identify 5 areas to assess when working with a person who has been sexually assaulted.

○ The nurse should assess the patient's: ■ 1. Level of anxiety ■ 2. Coping mechanisms ■ 3. Available support systems ■ 4. Signs and symptoms of emotional trauma, and ■ 5. Signs and symptoms of physical trauma.

● Identify the comorbidities of Abuse

○ The occurrence of one type of abuse is a fairly strong predictor of the occurrence of another type ○ Depression and PTSD are two of the most prevalent disorders resulting from childhood trauma. ○ Family violence is common in the childhood histories of juvenile offenders, runaways, violent criminals, prostitutes and those who in turn are violent towards others. ○ Exposure to abuse can adversely affect a child's development ■ The energy needed to successfully accomplish developmental tasks goes instead to coping with abuse. ○ Abused adolescents exhibit more psychopathological changes, poorer coping and social skills, a higher incidence of dissociative identity disorder, and poorer impulse control than do other adolescents. ○ Women who are victims of prolonged childhood sexual abuses are more likely to develop major psychiatric distress.

● Identify the different categories of antidepressants and provide examples

○ Tricyclics: block effects of serotonin and norepinephrine ■ Elavil, Asendin, Anafranil, Pamelor, Adepine, Vivactil ○ SSRIs: block uptake of neurotransmitters ■ Celexa, Lexapro, Luvox, Prozac, Paxil, Zoloft ○ SNRIs: reabsorb serotonin and norepinephrine ■ Cymbalta, Serzone, Effexir ○ MAOIs: block destruction of serotonin and norepinephrine ■ Marplan, Nardil, Parnate

● Why are anticonvulsant drugs used to treat mania?

○ Valproate, carbamazepine, and lamotrigine's properties derive from the alteration of electrical conductivity in membranes ■ They reduce the firing rate of very-high-frequency neurons in the brain.

● Identify nursing behaviors that could lead to an abuse disclosure page 536

○ When interviewing, sit near the patient and spend some time establishing trust and rapport before focusing on the details of the violent experience ○ Establishing trust is crucial is the patient is to feel comfortable enough to self disclosure. ○ Interview should be nonthreatening and supportive ○ THe person who experienced the violence should be allowed to tell the story without interruption. ○ Reassure the patient that he or she did nothing wrong. ○ Things you should do during the interview: Box 28-3 ■ Do conduct the interview in private ■ Do be direct, honest, and professional ■ Do use language the patient understands ■ Do ask the patient to clarify words not understood ■ Do be understanding ■ Do be attentive ■ Do inform the patient if you must make a referral to Children's Or Adult Protective Services and explain the process. ■ Do assess safety and help reduce danger (at discharge).

● Describe the etiology of schizophrenia

○Biological ■ Genetics ■ Increased levels of dopamine (can be brought on by amphetamines) ■ Serotonin, phencyclidine piperidine (PCP), glutamate,, abnormal maturation of the CNS ■ Brain abnormalities (disruptions in communication pathways) ○Psychological and Environmental ■ Prenatal stressors ● Poor nutrition, hypoxia, infections (herpes, human endogenous retrovirus 2), physical trauma to mother, father older than 35, being born in late winter or early spring ■ Physiological stressors ● Beginning college/moving away, childhood sexual abuse, etc. ■ Environmental stressors ● Toxins such as tetrachloroethylene ○10% die by suicide, 40-50% attempt suicide

● Identify several atypical antipsychotics page 218, table 12-5

○First Generation ■ Low Potency ● Chlorpromazine (thorazine) ● Thioridazine (mellaril) ■ Medium Potency ● Loxapine (loxitane) ● Molindone (moban) ● Perphenazine (trilafon) ■ High Potency: ● Trifluoperazine (generic only) ● Thiothixene (navane) ● Fluphenazine (prolixin) ● Haloperidol (haldol) ● Pimozide (Orap) ○Second Generation ■ Asenapine (saphris) ■ Clozapine (clozaril) ■ Iloperidone (fanapt) ■ Lurasidone (latuda) ■ Olanzapine (zyprexa) ■ Paliperidone (invega) ■ Risperidone (seroquel) ■ Ziprasidone (risperdal) -Third Generation (Geodon) ■ Aripiprazole (abilify)

● Describe the levels of anxiety

○Mild ■ Occurs in the normal experience of everyday life ■ Heightened perceptual field ■ Sees, hears, and grasps more information, aware of anxiety ■ Problem solving is effective ■ Symptoms: slight discomfort, restlessness, irritability, and mild-tension relieving behaviors (nail biting, tapping, fidgeting ○Moderate ■ Narrowed perceptual field, grasps less of what's going on ■ Sees, hears, and grasps less information and may demonstrate selective inattention (only certain things in the environment are seen or heard unless they are pointed out) ■ Less able to pay attention ■ Ability to think clearly is hampered, learning and problem solving not at optimal level ■ Symptoms (sympathetic nervous system): tension, pounding heart, tachycardia, tachypnea, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency) ○Severe ■ Perceptual field greatly reduced and distorted ■ May focus on one particular detail or many scattered details and have difficulty noticing what is going on in the environment even when it's pointed out ■ Attention is scattered ■ Learning and problem solving not possible ■ Behavior is automatic and aimed at reducing/relieving anxiety ■ Symptoms: dazed, confused, trembling, pounding heart, hyperventilation, somatic symptoms (headache, nausea, dizziness, insomnia) ○Panic ■ Most extreme, results in disturbed behavior ■ Unable to process what is going on and may lose touch with reality ■ Depersonalization (feeling unreal) and derealization (world is unreal) ■ Focus is lost ■ Behavior is automatic to reduce anxiety although it may not be effective ■ Symptoms: pacing, running, shouting, screaming, withdrawal, hallucinations, uncoordination, impulsiveness

● Identify the phases of schizophrenia

○Phase I - Acute: ■ onset or exacerbation of florid, disruptive symptoms with ● Hallucinations, delusions, apathy, withdrawal ■ loss of functional abilities ■ Increased care or hospitalization required ○Phase II - Stabilization ■ symptoms diminish ■ Movement toward one's previous level of function/baseline ■ Partial hospitalization in a residential crisis center of a supervised group home may be needed ○Phase III - Maintenance ■ At or nearing baseline functioning ■ Symptoms absent or diminished ■ Level of functioning allows patient to live in community Several phases of schizophrenia 1st phase or premorbid phase: person seems indifferent, aloof, loner, limited range in affect (kind of flat), not interested in relationships 2nd phase or prodromal phase: neglect hygiene, socially withdrawan, blunted or inappropriate affect, bizzare ideas, lack of initiative, disturbed communication 3rd phase or active phase: People might have delusions and hallucinations. Delusion: false belief EX: Thinking you're God. Hallucination: false sensory perception (hearing, seeing, feeling, smelling things that aren't there), maybe illusions (misperception of real stimuli) 4th or residual phase: similar to prodromal phase, symptoms withdraw, period of remission, should be medicated now

Hypertensive crisis w/ MAOIs

● Hypertensive crisis may begin w/ headaches, stiff or sore neck, palpitations, increase or decrease in HR (often assoc. w/ chest pain), nausea, vomiting, or increase in temperature ○ Immediate medical attn crucial ● When a patient who is taking a monoamine oxidase inhibitor (MAOI) ingests a food that contains tyramine (e.g. aged cheese, pickled or smoked fish, or red wine) ● Most serious rxn to MAOIs → increased BP w/ possible development of intracranial hemorrhage, hyperpyrexia, convulsions, coma, & death ○ Routine monitoring of BP, esp. during first 6 wks of tx necessary phentolamine IM

Dx criteria of cyclothymic disorder

● Symptoms of hypomania alternate w/ symptoms of mild to mod. depression for min. of 2 yrs in adults & 1 yr in children ● The symptoms that occur isn't enough to get an actual dx of hypomania or depression, but it's disturbing enough to cause social & occupational impairment ● Irritable hypomanic episodes ● In children, marked by irritability & sleep disturbance Cyclothymic disorder: low level bipolar disorder for 2 years. Hypomania. 1. Cyclothymic disorder: symptom of hypomania alternate with symptoms of mild to moderate depression for at least 2 years in adults and one year in children.