Module 6 NP2 Theory NWFSC

SSRI VS Tricyclic antidepressants

----SSRI: Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline · SE: headaches, GI disturbance , insomnia, fatigue, initial anxiety, sexual problems, agitation, increased bleeding risk, can also treat anxiety disorders · Can be treated with anti-arrythmic (Cardizem) and Beta-blockers o Severe manifest manifestation can induce hyperpyrexia , cardiovascular shock coma or death. Their risk is greater when an SSRI is combined with a MAOI, and over the counter cold medications. o When switching between antidepressants, wash out two to five week o hyponatremia o increased bleeding tendencies o avoid alcohol and herbal medications ----TCA: Imipramine, Amitriptyline, Desipramine, Nortriptyline, Clomipramine, Maprotiline, Protriptyline, Timipramine, Doxepin, Amoxapine -may take 7-28 days to be effective. · Weight gain, sedation, nausea, anticholinergic symptoms (dry mouth, blurred vision, urinary retention, Constipation, tachycardia), orthostatic hypotension · special considerations: cardiotoxic side effects, avoid alcohol and herbal medications, or birthcontrol · Withdraw syndrome: restlessness, night sweats -Lethal OD, don't double up on doses.

Psychotherapy for Depression

--First-line treatments include the following: • CBT has the largest weight of evidence for its efficacy in the treatment of depression. It is a relatively short-term (20 sessions) therapy that evaluates, challenges, and modifies dysfunctional thoughts that maintain depression. • Interpersonal psychotherapy (IPT) is a structured and brief intervention addressing social issues that maintain depression. • Problem-solving therapy (PST) teaches how to define personal problems, develop multiple solutions, identify the best one and implement it, then assess its effectiveness. --Second-line treatments include the following: • Social skills training (SST): Behavioral treatment that teaches skills and behaviors that help build and maintain social relationships; often also includes assertiveness training. • Behavioral activation (BA): Involves activity scheduling and increasing pleasant activities or positive interactions between a person and the environment. • Psychodynamic therapy (PT): Aims to increase understanding, awareness, and insight about repetitive conflicts (intrapsychic and intrapersonal). --Mindfulness-Based Cognitive Therapy: use of mindfulness , a meditation technique . Effective to MDD --group therapy / medication groups : opportunity to share common feelings and concerns, decrease feelings of isolation.

Hypomania Communication, Affect and Thinking, Physical Behavior

--Hypomania Communication 1. Talks and jokes incessantly, is the "life of the party," and gets irritated when not center of attention 2. Treats everyone with familiarity and confidentiality; often borders on crude 3. Talk is often sexual—can reach obscene, inappropriate propositions to total strangers 4. Talk is tangential; jumps from one topic to the next; pressure of speech (rapid talking, loud, and can be difficult to interrupt) --Affect and Thinking 1. Persistently elevated, expansive, or irritable mood 2. Full of pep and good humor, feelings of euphoria and sociability; may show inappropriate intimacy with strangers 3. Feels boundless self-confidence and enthusiasm. Has elaborate grandiose schemes for becoming rich and famous. Initially, schemes may seem plausible. 4. Judgment often poor. Gets involved with schemes in which job, marriage, or financial status may be destroyed. 5. May write large quantities of letters to rich and famous people regarding schemes 6. Decreased attention span to internal and external cues 7. Limited insight --Physical Behavior 1. Overactive, distractible, buoyant, and busily occupied with grandiose plans (not delusions); goes from one action to the next 2. Increased sexual appetite; sexually irresponsible and indiscreet. Unplanned pregnancies and sexually transmitted diseases. Sex used for escape, not for relating to another human being. 3. May have a voracious appetite, eat on the run, or gobble food during brief periods 4. May go without sleeping; unaware of fatigue; may be able to take short naps 5. Financially extravagant, goes on buying sprees, gives money and gifts away freely, can easily go into debt

Interventions for the Assaultive Phase

-Assaultive Stage: -Seclusion: involuntary confined to a room, physically prevented from leaving. Must monitor them 1 on 1. Monitor every 15min, <14yrs constant monitoring. -Restraint: any manual method, physical or mechanical device, or material or equipment that restricts freedom of movement. Least restrictive first. HCP must come and see patient within 1-2hrs. -Medication: IM of barbiturate, antihistamine, or antipsychotic, depending on physicians order and underlying conditions. If willing to take meds, give PO and remove them from stimuli. -Gradual reintegration or structured reintegration (4pt to 2pt restraints, time out periods, gradually lengthened)

Mania Communication, Affect and Thinking, Physical Behavior

--Mania Communication 1. May change suddenly from laughing to anger or depression; mood is labile 2. Becomes inappropriately demanding of people's attention, and intrusive nature repels others 3. Speech may be marked by profanities and crude sexual remarks to everyone (nursing staff in particular). 4. Speech marked by flight of ideas, in which thoughts race and fly from topic to topic; may have clang associations. --Affect and Thinking 1. Abnormally persistently elevated, expansive, or irritable mood 2. Good humor gives way to increased irritability and hostility and short-lived period of rage, especially when controls are set on behavior. May have quick shifts of mood from anger to submissive. 3. Grandiose delusions—may come to believe they are famous or especially gifted without any basis in fact 4. Judgment is extremely poor. 5. Decreased attention span and distractibility are intensified. 6. Lack of insight about illness or consequences of behavior --Physical Behavior 1. Extremely restless, disorganized, and chaotic. Physical behavior may be difficult to control. May have outbursts, such as throwing things or becoming briefly assaultive when crossed. 2. No time to eat—too distracted and disorganized 3. No time for sleep—psychomotor activity too high; if unchecked, can lead to exhaustion and death 4. Same as in hypomania but in the extreme

Stress response- steps

-AKA "fight or flight" response. It is a survival mechanism, lets the body become immediately ready to meet a threat/stressor. 1. Danger signal sent to amygdala (emotional processing center) 2. Amygdala sends distress signal to hypothalamus 3. Hypothalamus (command center) stimulates ANS 4. The SNS now activated, signals the adrenal glands. 5. The adrenals release epinephrine (adrenalin) 6. Pituitary gland releases ACTH (prolonged stress rx), which makes the adrenals release cortisol 7. Effect: Alertness is heightened. Adrenaline increases HR, BP, RR, and blood flow.

Interventions for child abuse

-Adopt a nonthreatening, nonjudgmental relationship with the parents. -Understand that children do not want to betray their parents. -Provide (or have a physician provide) a complete physical assessment of the child. -Using dolls might help the child tell how the "accident" happened., use of body maps may help. -Forensic Issues: know your states and agencies policy for reporting abuse, contact your supervisor or a social worker for reporting. Ensure procedures are followed and evidence is collected. Keep accurate and detailed records of the incident. Your documentation should be as objective as possible, without the use of subjective language, collect physical evidence and use of photos may be helpful. Forensic examination of child will be done according to protocol. -Features of Successful Child Abuse Protection Programs: Strengthening family ties and linking the family with community supports; coordinating services such as parenting skills, anger management, and coping skills; enhancing community awareness of child abuse and healthy parenting concepts; and providing emergency supports 24hrs/day such as food and shelter for families.

Assessing victim of IPV

-Always see the abused partner alone, without the suspected abuser present. The abuser may show signs of anxiety, frustration, or unwillingness to leave their partner alone to talk to the HCP. -3 questions to ask: · 1. Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom? · 2. Do you feel safe in your current relationship? · 3. Is there a partner from a previous relationship who is making you feel unsafe now? -Always ask if children are being hurt, if it is suspected or confirmed you MUST report it to CPS. The report will put the abused partner at risk, so tell them you have to report it. -Assess their support systems, coping skills, and risk of suicide. -Document verbal statements and physical findings, ask if she will allow photos to be taken. -You can not report IPV unless they want you to, the risk of violence is highest when the partner is about to leave, so they must be willing to do it. If they want you to report it give verbal or written info on attorneys, legal clinics, and/or advocacy groups. If they do not want you to report it given them a list of community resources.

Assessment of Dissociative Disorders

-Amnesia or fugue related to a traumatic event. Sudden travel from home with an inability to recall previous identity. Presence of one or more personalities. -Symptoms of depersonalization; feelings of unreality or body image distortions -Alterations in consciousness, memory, or identity -Disorganization or dysfunction in usual patterns of behavior (absence from work, withdrawal from relationships, changes in role function) -Feeling of being out of control related to memory, behaviors, and awareness -Interrupted family processes related to amnesia or erratic and changing behavior -Inability to explain actions or behaviors when in an altered state -Inability to recall (amnesia): Selected event, Entire life, Own identity, Periods of dissociation -Feelings of suicide or self-harm ideation or harm to others in one or more personalities (alters)

-Anger -Aggression -Violence

-Anger-Is a human emotion that is not always logical but is NORMAL. If channeled in a constructive manner, it is safe. It is unhealthy when it gets in the way of a person's functioning or relationship or puts other people at risk. -Aggression- Self-protective. Forceful goal directed action that may be verbal or physical, the motor counterpart of the effect of rage, anger, or hostility. Maladaptive Aggression- Includes abuse and physical and verbal aggression. Adaptive Aggression-Has calming effect, Can be empowering. -Violence- Has an underlying intention of doing harm to a specific person or group. It is the unwarranted, unjust, or unlawful display of verbal threats, intimidation, or physical force with the intent of causing property damage, personal injury, or even death to another individual.

Anxiety and fear

-Anxiety can be defined as a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized. The most basic human emotion, dysfunctional behavior is a defense against anxiety, when anxiety decreases the dysfunctional behavior will often decrease. -Fear, a similar response, is a reaction to a specific danger, and more often the body reacts "with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviors". -Anxiety and fear are indistinguishable except for the cause. -· Highly occurs with other psychiatric diseases, esp. substance abuse and MDD. Frequently occurs with ED, bipolar, dysthymia. Co-occurs with cancer, heart disease, HTN, IBS, renal or liver dysfunction, reduced immunity.

Assessing the parent for abuse

-Assessing the Parent: often have a Hx of being abused themselves, low self esteem, social isolation/suspiciousness, substance abuse, and rigid expectations of the child's behavior. They may be in a time of crisis, ex. divorce, unemployment, financial hardship. Blame child for hardships, perceive the child as bad/evil, low tolerance for frustration, poor impulse control, Hx of severe mental illness. Ask them open questions within a private environment. Be direct, understanding, and professional, be honest and tell them that abuse must be reported to CPS. Do not display horror, anger or judgement. -DO NOT: attempt to prove accusations or demands, display negative emotional reactions, blame or make judgements about the parents or child.

Complementary/Integrative therapy for Depression

-Complementary/Integrative therapy for Depression Light Therapy Treat seasonal affective disorder with seasonal pattern. Exposure to light suppresses the nocturnal secretion of melatonin , light therapy also increased the availability of serotonin. St. John's Wort Over the counter whole plant product with antidepressants properties that is not FDA approved. Can cause drug interaction that can result in significant toxic effects on the liver. S-Adenosylmethionine (SAMe) Over the counter dietary supplement, effective to MDD coma safe and effective when used alone or as an add on treatment. Peer support: friends and Group support

Culture, religion, & other factors that contribute to or protect against suicide.

-Culture: Judeo-Christian religions may act as a protective factor since "life is a gift" and to take it is considered a sin. Roman Catholic religions have low rates of suicide. Shinto religions believe in reincarnation, suicide may be seen as honorable. -Protective factors: African Americans religion and family ties, Hispanic Americans Catholicism and family, Asian Americans suicide rises with age. Belief systems that emphasize faith, connections between individual and society, self-destruction being seen as selfish/disrespectful. -It is the second-leading cause of death among 15- to 29-year-olds and is a growing problem in those over 65. -The greatest predictor of suicide is a previous suicide attempt. Other factors are impulsive decision during a crisis, such as financial problems, the end of a relationship, or a newly diagnosed or worsening health condition. Being a minority also increases the risk and is thought to be linked to those who experience discrimination, such as refugees; indigenous people; lesbian, gay, bisexual, or transgendered people; and prisoners. People who know someone who has committed suicide are also at greater risk. -More males complete suicide, but more females attempt suicide. Males tend to use more lethal methods, such as firearms, whereas females more often attempt suicide by overdose.

Cycle of Violence

-Cycle of Violence: cycle of violence consists of three phases: 1) tension-building phase, abuser is edgy with minor explosions that could be physical or verbal 2) acute (serious) battering phase, the tension has become unbearable and the victim may provoke the incident to "get it over with", a serious battering incident occurs and the victim may cover it up or get help. 3) honeymoon phase, the abuser makes apologies and promises to never do it again, they may act loving and give gifts to the battered partner. The partner begins to trust again and hope for the best. Many women report that this phase never occurs, their partner never repents and the violence is constant.

ECT for depression

-Electroconvulsive Therapy (ECT) -Small electric currents are passed through the brain, intentionally triggering a brief seizure. Remission rate of 70% to 90% in the present patients within one to two weeks. The usual course of ECT he's two or three treatments per week for a total of 6 to 12 treatments. SE: confusion, short therm memory lost -ECT remains one of the most effective treatments for treatment-resistant depression and major depression with psychotic symptoms and for the treatment of patients with life-threatening psychiatric conditions such as self-harm and acute mania. Clinical depression is considered treatment resistant (atypical, intractable) when two or more pharmacological interventions fail. Treatment-resistant depression accounts for 20% to 30% of depressed individuals. ECT may also be used when the side effects of antidepressants are too uncomfortable or have been ineffective.

Stress reduction techniques

-Elicit relaxation response- meditation, mindfulness, prayer, deep breathing, music, reading, gardening, guided imagery, progressive relaxation, autogenic training, self-hypnosis, biofeedback-assisted relaxation, stitch work. Effect depends on the patient and how they use it. -Physical activity, aerobic exercise. -Social supports- close family ties, acquaintances, spouses, friends. Talking about feelings/events relieves stress. -Reframing- seeing things in a different light, different perception of a problem. "Glass 1/2 full". -Sleep- go to bed 30-60min earlier, instead of waking up later. -Reduce caffeine or eliminate it. -Look for meaning in life, live with and love who ever you choose, associate with gentle people who affirm your personhood, guard your freedom.

Interventions for victim of IPV

-Ensure that medical attention is given to the victim, use a body map, ask permission to take photos. Set up the interview in a private location and ensure confidentiality. Assess abuse in a nonthreatening manner. Encourage them to talk about the abuse and don't interrupt, be nonjudgmental and ask in a kind/gentle manner. Ask how they are dealing with children in the home. Ask if they have a safe place to go to when situation becomes violent, tell her about shelters she can go to or safe houses—provide written info and tell her to keep it hidden. Some hospitals provide a card with info that can fit in a shoe. -Legally: identify if the victim wants to press charges. If yes give info about attorneys, legal clinics, battered women's shelters. If children are involved call CPS. Call law enforcement and make a report. Know the requirements in your state for reporting IPV. Develop a safety and escape plan during escalation of violence, before the violence erupts. Emphasize that the violence is not their fault. Encourage them to reach out to friends/family they may have been isolated from. Know the therapists in the community who have experience working with battered spouses/partners. If they are not ready to take action provide a list of community resources—ex. hotlines, shelters, groups/advocates, therapists, law enforcement, medical assistance, Aid for families with dependent children, CPS resources for support and investigation.

Nursing Interventions for PTSD

1. Any intrusive symptoms (flashbacks and nightmares) 2. Stay with the patient to offer reassurance and emotional safety 3. Help the patient recognize avoidance behaviors and to develop strategies to increase social supports. Psychoeducation. 4. Negative cognition that can lead to survivor's guilt, depression, and anxiety can increase the risk of suicide, self-harm behaviors, and other types of maladaptive coping. Promote adaptive coping. 5. Alterations in arousal can lead to sleep disturbances, angry outbursts and reckless behaviors. 6. Facilitate sleep by providing pharmacological and non-pharmacological interventions.

Vulnerable individuals, sexual assault:

-Gender: Women have a higher vulnerability rate than men (approximately 3 to 1). Both genders are more vulnerable if they are handicapped, have cognitive problems, or have mental disorders. • Age: People 16 to 19 years of age have a higher rate of sexual victimization than any other age group. Children are most vulnerable between 8 and 12 years of age. • Older adults: Domestic violence against older adults includes physical and sexual abuse; the perpetrators are most often adult children, especially sons, but can also include spouses, caregivers, health care providers, and other relatives. Risk increases if they are impaired. • History of sexual violence: Women who were raped before 18 years of age are two to three times more likely to be sexually assaulted as adults. • Drug and alcohol use: The use of alcohol or drugs by the perpetrator, the victim, or both is related to increased rates of victimization. • High-risk sexual behavior: High-risk sexual behavior is a vulnerability that is often a consequence of childhood sexual abuse. • Poverty: Poverty can make women and children more vulnerable and place them in more dangerous situations. • Ethnicity or culture: Sexual violence against indigenous women in the United States is widespread. Native American and Alaskan Native women are more than 2.5 times more likely to be raped or sexually assaulted than other women in the United States. Most of the perpetrators, up to 86%, were non-Native men.

Predisposing factors of depression

-Genetic Factors: inherited traits, associated with age of onset, a greater rate of cormobidity, and an increased risk of current illness. -· Biochemical factors: changes in receptor-neurotransmitters (serotonin, norepinephrine, and dopamine) on the limbic system, hypothalamus, prefrontal cortex, hippocampus, and amygdala. o (5-HT): sleep, appetite, and libido - decreased impulse control, sex drive, appetite, disturbed regulation in body temperature, irritability o Norepinephrine (NE): anergia and anhedonia (inability to find meaning or pleasure in existence), decreased concentration and libido o Dopamine (DA): reward and incentive behavior process, emotional expression, learning processes o GABA and acetylcholine: etiology o Abnormalities on the number of receptor sites, increasing or decreasing the activity of these neurotransmitters · Stress-Diathesis Model of Depression: depression from an environmental, interpersonal, and life-events perspective combine with biological vulnerability or predisposition (diathesis). Interpersonal events, such as life trauma, can trigger neurophysiological and neurochemical changes in the brain. · Learned Helplessness: by Martin Seligman, anxiety is the initial response to a stressful situation, anxiety is replaced by depression. People who believe that an undesired event is their fault. This theory is used to explain depression in certain groups like older adults, impoverished areas, and women.

Elder Abuse

-Growing rapidly because of the baby boomer generation. Elder abuse falls into 3 categories: domestic, institutional, and self neglect. Patients are 65+ years old, and can be victimized through physical, sexual, psychological, financial, and neglect. A subcategory is vulnerable persons abuse. -Elder abuse is often seen in patients with dementia, depression, substance abuse, psychiatric illness—these comorbid issues make them vulnerable and draw attention to their vulnerability. -The Abused: Patients older than 80yrs are 2-3x more likely to suffer abuse/neglect. Victims are 3x more likely to die than those that are not abused. Older women are more likely to be the victims and the majority of victims are Caucasian. -The Abuser: will closely resemble the abuser of IPV/child abuse, but may not be cruel/insensitive, they may be a caring person under extreme stress. The abuser is often the middle aged child of the victim, who is often financially dependent on the victim. The caregiver often has a mental illness, substance abuse problem, or inability to cope. They may have been the victims of abuse themselves at some point. Risk factors are caregiver anxiety, caregiver stress, and Hx of a previously bad relationship. Staff members in nursing homes may also be the abusers, but abuse within these facilities is usually between patients.

Intervention for family and friends ("survivors") of a person who has completed a suicide

-Intervention for family and friends ("survivors") of a person who has completed a suicide—called a postvention—should be initiated within 24 to 72 hours after the death. Family and friends are often faced with the process of mourning without the normal social supports. People are often confused and may be unsure how to help or what to say. They may even blame the family for the death. Families with members who have completed suicide are often stigmatized and isolated; 45% of survivors report mental/emotional deterioration within 6 months.· Survivors will often go through the five stages of grief. · S/S of post-traumatic stress reactions: irritability, sleep disturbances, anxiety, exaggerated startle reaction, nausea, headache, difficulty concentrating, confusion, fear, guilt, withdrawal, anger, and reactive depression. · Goal: reduce the trauma associated with the sudden loss. Post trauma loss debriefing can help initiate an adaptive grief process and prevent self-defeating behaviors. · Self help groups have also been effective for survivors of suicide of family/friend. They are operated by people who have lost someone through suicide.

Interventions for Severely Withdrawn Individuals: Communication

-Interventions for Severely Withdrawn Individuals: Communication 1. When a patient is mute, use the technique of making observations: "There are many new pictures on the wall" or "You are wearing your new shoes." 2. Use simple, concrete words. 3. Allow time for the patient to respond. 4. Listen for covert messages and ask about suicide plans: "Have you had thoughts of killing or harming yourself or others in any way?" 5. Avoid false reassurances such as, "Things will look up" or "Everyone gets down once in a while."

-Interventions for staff after a patient commits suicide -Psychological postmortem assessment

-Interventions for Staff: All health care workers who provided care for a person who completes suicide are similarly traumatized. Staff may also experience symptoms of PTSD, including guilt, shock, anger, shame, and decreased self-esteem. Other patients on the unit who may have suicidal tendencies need to be closely monitored as well. The first 24 hours after inpatient suicide are crucial for both safety and crisis management reasons. · psychological postmortem assessment: The event is carefully reviewed by all members of the treatment team to identify the potential overlooked clues or faulty judgments, as well as to determine changes that are needed to agency protocols. · Agency protocol analysis · Documentation completion—record MUST be complete and done in a timely manner. Legal cases have shown that client should be periodically evaluated for suicide risk, treatment should provide high-level security, and staff should be informed of the patient's treatment.

MDD

-MDD: lessen or even resolved within three months for 20% of individuals and within one year for 80% of individuals even without treatment. When there is reocurrence of symptoms, risk for multiple future reoccurrences. when reoccurrence episodes occur they are usually longer and more severe . Comorbidity increases morbidity and mortality. S/S occur over a 2 week period, 5+ S/S with depressed mood or loss of pleasure being one of them. SIG E CAPS: recognize SS of depression · Sleep disturbance · Interest diminished in pleasure activities · Guilt feeling, feelings of worthlessness · Energy decreased or fatigue, self-esteem loss · Concentration diminished and indecisiveness · Appetite changes with weight changes · Psycho motor retardation or agitation · Suicidal thoughts and behaviors, and thoughts of death

Manic episode, hypomanic episode, depressive episode, cyclothymic disorder

-Manic Episode - DIGFAST: Distractibility, Impulsivity Grandiosity, Flight Of Ideas/Racing Thoughts, Activity/Energy Increase, Sleep Needs Diminished(not tired after 3hrs sleep), Talkative -Hypomanic Episode: Less severe end intense form of mania then must last at least 4 days. -Depressive Episode: Symptoms may include: feeling of hopelessness and sadness, inability to sleep, loss of interest call my loss of energy , changes in appetite and weight, inability to concentrate, thoughts of death and suicide. Patients with bipolar depression are less likely to be female. -Cyclothymic Disorder: psychodynamic disorder presents with hypomanic episodes alternating with persistent depressive episodes for at least two years or one year in children. Tend to have irritable hypomanic episodes. · Rapid-Cycling: 4+ mood episodes in 2 month period, reduces function and increases resistance to treatment. -Mania/hypomania with mixed features: S/S of depression and mania/hypomania occur at the same time. Increases suicide risk, irritability, pessimism, unrelenting worry/despair, reduced need for sleep.

Mild, Moderate, Severe and Panic levels of anxiety

-Mild anxiety: normal experience of everyday living. Perception is brought into sharp focus, problem solving becomes more effective. Physical symptoms such as restlessness, mild irritability, or mild tension-relieving behaviors such as nail biting and finger tapping may be present. - Moderate: perceptual field narrows, leading to selective inattention, learning and problem solving can still take place. Physical symptoms may include tension, pounding heart, increased pulse and respiration, and other mild somatic symptoms. Voice tremors may be noticed. -Severe: perceptual field is greatly reduced. The person may have difficulty noticing events occurring in the environment, even when they are pointed out. Learning and problem solving are greatly reduced. Behavior is automatic and aimed at reducing anxiety. Increased somatic symptoms, esp. hyperventilation and a sense of dread or impending doom. -Panic: the most extreme and results in markedly disturbed behavior. An individual is not able to process events in the environment and may lose touch with reality. Confusion, shouting, screaming, or extreme withdrawal. Possible hallucinations, erratic and impulsive behavior. Automatic behaviors are used to relieve anxiety, efforts may be ineffective. Acute panic may lead to exhaustion. The fight-or-flight response, "freeze" response(may loose memory), pass out, or dissociate.

Interventions for Mild-Moderate Anxiety:

-Mild to moderate anxiety: 1. Identify anxiety. "You look upset." 2. Assess the patient's level of anxiety. 3. Use nonverbal language to demonstrate interest (lean forward, maintain eye contact, nod your head). 4. Encourage the patient to talk about feelings and concerns. 5. Avoid closing off avenues of communication that are important for the patient. Focus on the patient's concerns. 6. Ask questions to clarify what is being said. "I'm not sure what you mean. Give me an example." 7. Help the patient identify thoughts or feelings before the onset of anxiety. "What were you thinking right before you started to feel anxious?" 8. Encourage problem solving with the patient. The person may need some assistance with this. 9. Assist in developing alternative solutions to a problem through role-play or modeling behaviors. 10. Explore behaviors that have worked to relieve anxiety in the past. 11. Provide outlets for dissipating excess energy (walking, exercising).

-Mood -Affect -MDD -PDD

-Mood is defined as the way a person feel, and affect is defined as the observable response to a person's behavior. It can be depressed, normal, or elevated. Depression is a syndrome rather than a disease. A syndrome is a collection of signs and symptoms know to frequently appear together, but without a single cause. -Major Depressive Disorder (MDD) is a medical illness that affect how you feel, think, and behave, causing persistent feelings of sadness. -Persistent Depressive Disorder aka dysthymia (PPD) Unipolar depression is when a person experiences depression without elevated mood or mania.

OCD Assessment

-OCD: Obsessions are defined as thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Obsessions often seem senseless to the individual who experiences them, although they still cause the individual to experience anxiety. Compulsions are ritualistic behaviors that individuals feel driven to perform in an attempt to reduce anxiety. Anxiety relief is achieved by the compulsive rituals, but because the relief is only temporary, the compulsive act must be repeated many times. OCD exists along a continuum. -Severe S/S: Center on dirtiness, contamination, and germs and occur with corresponding compulsions such as cleaning and hand washing. -Most Severe S/S: Include persistent thoughts of sexuality, violence, illness, and death.

PTSD

-PTSD usually occurs after a traumatic event outside the normal human experience, HPA system is abnormal, major depression usually occurs, if left untreated or under treated, painful repercussions can result. Common elements are extraordinary helplessness and hopelessness. -Co-morbidities: substance abuse depression---can lead to suicide. -Involves a traumatic event (exposure or witness), Re-experiencing the trauma, Avoiding the things associated with trauma; and emotional numbing, Unable to function, For 1 Month+, Increased Arousal (hypervigilance, sterile response). -Persistent negative mood/cognition, guilt, detachment, increased arousal--angry outbursts, self destruction, startling, sleep problems. -Assessment: Focus on safety, Hx of trauma, Suicidal ideation, Substance use and withdrawal, Are they in abusive relationship? -Veterans are at high risk of suicide/homicide, high rates of TBI. TBI increases risk of suicide.

PDD-dysthymia

-Persistent Depressive Disorder: SS for at least 2 years. This disorder is hard to distinguish from the person's apparent usual pattern of functioning. PDD has less severe symptoms compared to MDD. Dysthymia. · daytime fatigue · function, but not at an optimal level · chronic low level depressed or irritable mood · eating too much or too little · difficulty with sleeping · loss of energy, fatigue, and chronic tiredness · decreased capacity to experience pleasure · irritability · negative, pessimistic thinking · Low self esteem

-Phobias -Specific phobias -Social Anxiety Disorder or social phobias (SAD) -Agoraphobia

-Phobia: persistent, intense irrational fear of an object, activity, or situation that leads to a desire for avoidance, or actual avoidance of the object, activity, or situation. -Specific phobias: characterized by the experience of high levels of anxiety/fear in response to specific objects, such as dogs, spiders, or heights, or situations, such as closed spaces, tunnels, and bridges. Common and usually do not cause much difficulty because people can avoid the feared object. May cause impairment in social, occupational, or other areas of functioning when faced with the feared object or situation. -Social anxiety disorders or social phobias (SAD): characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation, resulting in feelings of humiliation or embarrassment. -Agoraphobia is an intense, excessive anxiety about or fear of being in places or situations where help might not be available, and escape might be either difficult or embarrassing. Avoidance may cause social/occupational dysfunction.

Rape trauma syndrome and its 2 stages

-Rape-trauma syndrome is a variant of PTSD and is a common sequela of psychological trauma. Left untreated, psychologically traumatic events can have devastating effects. -Acute phase/disorganization: cognitive, affective, and behavioral disruptions, shock, numbness, and disbelief. A person may appear self-contained and calm. At other times, cognitive function may be impaired, and the person may have difficulty making decisions, solving problems, or concentrating. Or the person may cry, become hysterical, be restless or agitated, or even smile or laugh. Eating and sleeping disturbances; and emotional reactions such as anger, fear, anxiety, guilt, humiliation, embarrassment, self-blame, and mood swings. There is no "normal" response to a sexual assault. -Long Term phase: The delayed, or organization, phase may not occur until months or even years after the events and is characterized by flashbacks, nightmares, and phobias as well as somatic and gynecological symptoms. Emotional reactions may include depression, panic disorder, and suicidal ideation and attempts, and substance abuse is more prevalent among survivors of sexual assault. S/S of PTSD may result.

SARTs (Sexual Assault Response Team)

-SARTs (Sexual Assault Response Team): They help victims to cope with the present situation and aftermath of sexual violence. Collaboration with: 1. MH agencies 2. Rape crisis advocates 3. Law enforcement personnel 4. Detectives or investigators 5. Emergency departments 6. SANEs; Sexual Assault Nurse Examiners- Certified forensic nurses 7. Attorneys -Some of the functions of the SANE are to perform a physical examination of the survivor, collect forensic evidence, provide expert testimony regarding the forensic evidence collected, support the psychobiological needs of the survivor, be part of the SART, and work closely with law enforcement agencies and the prosecutor's office.

Safety Plan for victim of IPV Main communication points

-Safety Plan: move to a room with more than 1 exit, avoid rooms with potential weapons, know the quickest route out of the workplace and find resources to protect the employees there, tell neighbors about the abuse and ask them to call police when they hear a disturbance, have a code word to use with kids/family/friends, have a safe place selected in case you have to leave. Pack a bag with clothes, valuables, cell phone, prepaid phone card, address book, 1 month supply of meds—keep this bag hidden and easy to grab, include important legal documents in it. · Main communication points: hide brochures about shelters/agencies for abused, tell them to remember verbal information regarding support services, no one deserves to be beaten, you did not cause them to hurt you, it is not your fault, you have the right to protect yourself and your children, the national domestic hotline is 800-799-7233.

Interventions for Severe-Panic anxiety:

-Severe to Panic: 1. Maintain a calm manner. 2. Always remain with the person experiencing an acute severe to panic level of anxiety. 3. Minimize environmental stimuli. Move to a quieter setting and stay with the patient. 4. Use clear and simple statements. You may need to repeat statements. 5. Use a low-pitched voice; speak slowly. 6. Reinforce reality if distortions occur (seeing objects that are not there or hearing voices when no one is present). 7. Listen for themes in communication. 8. Attend to physical and safety needs when necessary (need for warmth, fluids, elimination, pain relief, family contact). 9. Because safety is an overall goal, physical limits may need to be set. Speak in a firm, authoritative voice: "You may not hit anyone here. If you can't control yourself, we will help you." 10. Provide opportunities for gross muscle motor movement and exercise (walk/pace with nurse). 11. When a person is constantly moving or pacing, offer high-calorie fluids. 12. Assess need for medication.

Interventions for phobias

-Specific Phobias: behavioral therapy seems to be the only effective therapy for specific phobias. Medication is not an effective treatment. -Social Phobias: The beta blocker propranolol reduces the physiological symptoms of anxiety, although not the cognitive worry symptoms. Propranolol is used effectively by many performers and lecturers before appearing in front of an audience. More pervasive social anxiety may respond to antidepressant therapy, such as SSRIs. CBT interventions, along with social skills training, are helpful for many. -Agoraphobia: The disorder can be chronic, although it responds well to CBT. Antidepressants, such as SSRIs, help reduce the anxiety and can treat comorbid depression. Panic attacks may precede agoraphobia 30% to 50% of the time.

What is stress? Distress vs Eustress

-Stress: can be real or perceived. We all have different thresholds for how we tolerate stress. Our responses to it are central to psyc-disorders and the provision of MH care. -Distress: stress that causes problems physically & emotionally. When individuals feel "stressed out," they often have trouble sleeping or eating, experience physical aches and pains, lose interest in favorite activities, feel tense and become irritable, and often feel powerless. Long-term chronic stress can cause physiological harm and chronic emotional difficulties. It can trigger psyc-disorders like PTDS, anxiety, depression, etc. -Eustress: normal & beneficial stress. It heightens our awareness and motivates us to develop the skills needed to problem solve and meet goals.

Risk for Violence

-Strongest predictor of future violence, is past behavior of aggression (childhood violence). Ex setting fires, hurting animals, damaging property, Dx conduct disorder. -Substance abuse is a major factor of violence in the clinical setting--withdrawl can cause violence. -Male gender, age 15-24, family history of violence, low SES---more likely to be the victims and perpetrators of violence. Poorer populations are more likely to expereince discrimination, family breakdown, alienation, and constant fight for survival. Angry/violence rx are learned and reinforced through family/societal norms. -Decreased prefrontal blood flow, reduced vl prefrontal grey matter. No one site for anger, hypothalamus and limbic system contribute to emotions. -Subculture supports intimidation/aggression as a means to problem solve or achieve social status. -Comorbidities: PTSD, substance abuse, depression, anxiety, psychosis-paranoia, PDs.

The battered partner

-The Battered Partner: lives in fear for self and children, doesn't usually initiate violence but may act in self defense, feels powerless, and has low self esteem, keeps the violence a secret, is isolated from friends and family, believes what the abuser says is true, has depression due to financial and emotional dependence on the abuser, high risk for secret substance abuse. May believe that if they "do the right thing" or "don't do anything wrong" the abuse will stop. Frequently loses job because of the partner stalking/harassing. Suicidal ideation is a major risk.

The Batterer

-The Batterer: usually in denial or blames their battered partner, emotionally abuses their partner, isolates their partner—ex. limits family/friends and social events, tracks time it takes to get from home to work, tracks mileage on the car, may demand the partner ask permission to leave the house, demands explanations from partner. They control through intimidation, economic abuse, and power—treat partner like a servant. Violence is a learned behavior used to control others, they often lived in abusive homes, they feel no guilt and lack concern. May appear well adjusted, but are extremely possessive, jealous, and believe in male supremacy. Uses their substance abuse problem as an excuse for behavior. When they have dissocial tendencies (antisocial tendencies) they are thought to be more lethal. Treatment for batterers is not highly effective.

Panic Disorders: Assessment and interventions

-The panic attack is the key feature of panic disorders (PDs). A panic attack is the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom: "I am going to die." Typically, panic attacks occur suddenly, not necessarily in response to an acute stressor. They are extremely intense and can last from 1 to 30 minutes before they subside. People experiencing panic attacks may believe that they are "losing their minds" or are having a "heart attack". In the ED there will be extensive workup to rule out cardiac problems. Patient will be referred to Dx and treat anxiety disorder—PD. -S/S: palpitations, chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, feelings of choking, chills, hot flashes, and gastrointestinal symptoms. -Increased rates of suicide and suicide attempts. -Interventions: Benzodiazepines, such as alprazolam, clonazepam, and lorazepam; usually used for an acute episode and on a short-term basis only. Antidepressants such as SSRIs. Use of cognitive and behavioral therapy either alone or in conjunction with medications to help people learn skills to combat their panic

Risk Factors for Bipolar disorder

-Twin, family, and adoption studies provide evidence that bipolar disorders have a strong genetic component. However, the inheritance of bipolar disorders is an expression of multiple genes. 1st degree relative=7-10x more likely. Two parents with BPD=50% chance of developing. Identical twin=80%. -Earlier age of onset of the disorder in the parent increases the risk of the child developing the disorder. The strongest predictor of later development of bipolar disorder is when the child displays premorbid symptoms of anxiety/depression, affective lability, and low-level manic symptoms prior to the first episode. Having multiple risk factors can lead to a 49% chance of developing bipolar disorders -Researchers are finding evidence that there is a genetic overlap on specific chromosomes among five different major mental illnesses that share the same common inherited genetic variations. The genetic connection is strongest between schizophrenia and bipolar disorder; more moderate between bipolar disorder, depression, and ADHD; and to a lesser extent between schizophrenia and autism. -abnormalities of stress-related molecular pathways off the HPA axis in several brain areas coma triggered by acute Environmental stress. higher levels off ADH and cortisol but not CRH. -It is hypothesized that higher levels of dopamine, norepinephrine, and glutamate result in manic phases, and lower levels of dopamine and norepinephrine lead to bipolar depression. Serotonin can be too low in a depression phase or can cause aggression and poor impulse control in the manic phase. Reduced grey matter vl and hippocampal vl, prefrontal cortex and limbic dysfunction. Neurons more excitable. -Stressful life events can trigger S/S of dz. -Cultural differences/beliefs complicate issue, clinitians misinterpret S/S when they dont know pt culture, ex African Americans more likely to be Dx with schizophrenia when displaying psychotic S/S.

S/S of IPV

-Usually seen in ED, but could be in any medical setting. Injury may be inconsistent with explanation, or the patient will minimize the abuse, or claim to be "accident prone". -If IPV is suspected do a complete physical examination, X-ray, and neurologic exam. Rape may be a part of the abuse, so a gynecological exam may be needed, including pregnancy test, STI test, and collection of evidence. S/S may include pregnancy, exposure to STI, or signs of infection or trauma. -Physical S/S of abuse: burn, bruise, scars, and wounds in various stages of healing—esp. around head and neck. Assess for internal injuries like broken or fractured bones, concussions, perforated eardrums, eye injuries, abdominal injuries. A brief Hx may reveal a series of falls or "accidents" and recent ED visits. -Psychological S/S of abuse: anxiety, stress, insomnia, chest pain, back pain, dizziness, GI upset, anorexia, severe headache. Assess for PTSD.

Prolonged Stress

-When stress is prolonged, chemicals produced by the stress response (cortisol, adrenaline, and other catecholamines) can have damaging effects on the body. Parts of the brain and body are damaged, atrophy can be seen on MRIs of the brains of patients with schizophrenia & PTSD. -Can develop heart dz, platelet aggregation, high cholesterol, high triglycerides, hepatic or renal problems, glucose intolerance, chronic muscle tension, chronic hyperventilation, digestive problems, chronic anger or anxiety. -Also colds/influenza, asthma, stomach ulcers, eczema or skin disorders, cancer, depression, PTSD.

Assessing sexual assault

1. Assess and document the circumstances of the event, including the presence of threats , the location of the incident, and the circumstances surrounding the assault. Document in patient's own words when possible. 2. Gather data that may be used as criminal evidence in court using the institution's protocol. 3. After consent forms have been signed, forensic evidence (debris) should be obtained from clothing, fingernail scrapings, head hair, and pubic hair; smears for sperm and/or acid phosphatase should be taken from any orifice involved. Permission for any photographs taken during the assessment also needs to be obtained. 4. Assess for evidence of any physical trauma (e.g., bites, stab wounds, contusions, gunshot wounds). Use drawings (body map) and photos to identify the areas and size of trauma. 5. Perform pelvic examination to identify vaginal and cervical trauma (perform anal examination in males and sodomized females). Culture for STIs. 6. Perform psychological assessment, noting reactions to the rape event. Describe all behavior in writing. 7. Perform a mental status examination. 8. Determine drug use by either the assailant or the survivor. Assess the situation for the potential involvement of a date rape drug if it occurred in a large gathering. A urine sample might be useful if timing is correct. Emphasize to individuals that even if they were drinking, they are not at fault for being assaulted. 9. Identify the victim's support system, and ask for permission to involve them. Explain possible delayed reactions that might occur.

Forensic Examination

1. Assess the signs and symptoms of physical trauma. 2. Explain and get permission from patient to take photos/videos and specimens. 3. Make a body map to identify size, color, and location of injuries. Ask permission to take photos. 4. Carefully explain all procedures before doing them (e.g., "We would like to do a vaginal [rectal] examination and do a swab. Have you had a vaginal [rectal] examination before?"). 5. Explain the forensic specimens you plan to collect; inform patient that specimens can be used for identification and prosecution of the rapist, for example: Debris in head hair and pubic hair, Skin from underneath nails, Semen samples, Blood, Urine sample (if date rape drug is suspected) 6. Encourage patient to consider treatment and evaluation for sexually transmitted infections before leaving the ED. 7. Offer prophylaxis to pregnancy. a 8. All data must be carefully documented: Verbatim statements, Detailed observations of physical trauma, Detailed observation of emotional status, Results from the physical examination, All lab tests should be noted 9. Offer support follow-up: Rape counselor, Support group, Group therapy, Individual therapy, Crisis counseling

Interventions for dissociative identity disorders:

1. Provide a safe environment and frequent observation. 2. Reassure patient of safety and security by your presence. 3. Orient the patient to current surroundings if necessary (as with dissociative amnesia). 4. Establish a supportive therapeutic relationship. 5. Spend time with the patient and allow venting of feelings. 6. Help the patient identify signs and symptoms of anxiety. 7. Help patient recognize the connection between escalating anxiety and dissociative behaviors. 8. Help the person identify triggers to dissociative behaviors. 9. Assess the patient's current methods of coping, watching for self-destructive behaviors. 10. Teach adaptive coping strategies. 11. Encourage daily journaling. 12. Teach stress reduction techniques. 13. Use grounding techniques (finding or visualizing a safe place, counting, blanket wrapping). 14. Involve the person as much as possible in planning own treatment. 15. Provide support during disclosure of painful experiences.

-Dissociative Disorders -Dissociation -Depersonalization/Derealization Disorder -Dissociative Amnesia -Dissociative Amnesia with Fugue -Dissociative Identity Disorder

1. Dissociative Disorders: This is a disturbance in the normally well-integrated continuum of consciousness, memory, identity, and perception. 2. Dissociation: Unconscious defense mechanism to protect the individual against overwhelming anxiety, usually related to past or current trauma -Associated with borderline personality disorders -Do not display delusional thinking or hallucinations 3. Depersonalization/Derealization Disorder: Characterized by recurrent periods of feeling unreal, unreal, detached, outside of the body, numb, or dreamlike or experiencing a distorted sense of time or visual perception. 4. Dissociative Amnesia: inability to recall information about self, usually traumatic in nature. May be selective towards an event, a time period, or for their entire life Hx. 5. Dissociative Amnesia with Fugue: amnesia for ones identity or personal info, with possible wandering or purposeful travel. 6. Dissociative Identity Disorder: "multiple personality disorder", most severe of the PDs, disruption of identity be 2+ distinct "alters". Patient may loose time, be unaware of the alters. Usually a response to childhood trauma. BPD traits, like self-harm, may co-occur.

Assessing Anxiety disorders:

1. Ensure that a complete physical and neurological examination is performed to help determine whether the anxiety is primary or secondary to another psychiatric disorder, a medical condition, or substance use/substance withdrawal issue. 2. Assess potential for self-harm and/or suicide. It is known that people suffering from high levels of intractable anxiety may contemplate, attempt, or complete suicide. 3. Perform a psychosocial assessment. Always ask the person, "What has happened recently that might be increasing your anxiety?" The patient may identify a problem such as stressful marriage, recent loss, stressful job, or school situation that could be addressed through therapy. There may be no identifiable recent event. 4. Assess cultural beliefs and background. Differences in culture can affect how anxiety is manifested.

Guidelines for Sexual Assault

1. Have someone (friend, neighbor, sexual assault advocate, or staff member) stay with the patient while he or she is waiting to be treated in the emergency department (ED). 2. Very important: Approach patient in a nonjudgmental manner. 3. Confidentiality is crucial. 4. Explain to the patient the signs and symptoms that many people experience during the long-term phase, for example: Nightmares, Phobias, Anxiety, depression, Insomnia, Somatic symptoms 5. Listen and let the patient talk. Do not press the patient to talk. 6. Stress that the patient did the right thing to save his or her life. 7. Do not use judgmental language: Reported not alleged, Declined not refused, Penetration not intercourse, Instead of reporting "no acute distress," describe the behavior

Assessing for Suicide

1. Identify current feeling states. "Sometimes when I feel ___ (fill in the feeling state identified by the patient), I think about suicide." 2. Ask directly. Always ask, when you feel concern: "Are you thinking of, or have you been thinking of, killing or harming yourself?" If yes, evaluate frequency, duration, and intensity. 3. Ask if the person has a plan. "When you think about suicide, do you have a way that you might do this?" 4. Determine the lethality of the plan in terms of risk. · How detailed is the plan? (The more detailed, the greater its lethality.) Availability of means. 5. Gather information about risk factors—patient's age, sex, medical problems, psychiatric problems or emotional distress, excessive use of drugs or alcohol, a recent significant loss, unemployment, lives alone, and so forth—that would put the patient at higher risk. 6. If there is a history of a suicide attempt, assess the following: intent, lethality, injury. 7. Consult with staff and develop a safety plan with the patient. The patient thinks through and writes down ways to cope when feeling suicidal, who can be called, and so forth. 8. If the patient is to be managed as an outpatient, also assess the following: Social supports: Is there someone who can stay with the patient, Significant other's knowledge of the signs of potential suicidal ideation. Provision of safety resources (knowledge of community resources, telephone numbers)

Pre-Assaultive Phase interventions--Deescalation

1. Pay attention to angry and aggressive behavior. Respond as early as possible (see Box 24.1). 2. Emphasize that you are on the patient's side (e.g., "We want to help you, not hurt you.") and that "this is a safe place and you are safe." The clinician should stand at an angle to the patient so as not to appear confrontational. 3. Assess personal safety and provide for self-care. 4. Appear calm and in control. 5. Do not try to speak while the aggressive person is yelling. 6. Speak softly in a nonprovocative, nonjudgmental manner. 7. Demonstrate genuineness and concern. 8. Set clear, consistent, and enforceable limits on behavior (see Box 24.2) (e.g., "It's okay to be angry with Tom, but it is not okay to threaten him. If you are having trouble controlling your anger, we will help you."). 9. If patient is willing, both nurse and patient should sit at a 45-degree angle. Do not tower over or stare at the patient. 10. When patient begins to talk, listen. Use clarification. 11. Acknowledge the patient's needs regardless of whether the expressed needs are rational or irrational, possible or impossible to meet.

Assessment guidelines for Bipolar disorder

Assessment guidelines for Bipolar disorder PHYSIOLOGICAL SAFETY: · Need for hospitalization · medical examination: o Primary: bipolar disorder or cyclothymia o secondary to occur green condition or drug o part of a different medical condition such as brain disease and infections o dehydration: poor skin turgor, dark and skant urinary output, and poor skin integrity o cardiac status: severe exhaustion and their hydration can lead to cardiac collapse o poor sleep leads to physiological exhaustion · other areas of safety: o access whether the patient is a danger to self: not sleeping, not eating, poor impulse control, poor judgment, inappropriate sexual activity, uncontrol spending · when the patient is stable, assess the patients and family understanding of BD.

Acute Stress Disorder

Acute Stress Disorder: S/S resolve in 1 month. Same triggers of PTSD--witnessing/experiencing a gruesome event/death. -S/S: intrusive S/S, avoidance, arousal.

Anticonvulsants - AEDs for bipolar disorder

Anticonvulsants - AEDs --VALPROIC ACID (serum level 85-125)- bipolar, hypomania, or mixed states. Used for people that do not respond to lithium, war in acute mania, experience rapid cycles, or who are in a dysphoric mania · effective in treating BD with multiple comorbid conditions, including alcohol, mental health or addiction, anxiety and panic attacks, PTSD, sleep disturbance, explosive dyscontrol and aggression, and migraine. SE: GI pain, tremor, sedation, hair loss, and weight gain, a pattern toxicity, pancreatitis, blood dyscrasias, birth defects , developmental delays in children, drug to drug interaction CARBAMAZEPINE (serum level 4-12) - for treatment-resistant BD. Carbamazepine lithium concurrently, or carbamazepine and an antipsychotic, patients with rapid cycling, makes it states, an acute mania. SE: empatic disease, blood dyscrasia, risk of fluid overload in hyponatremia, and life threatening dermatological reactions not recommended to use in pregnancy and can decrease effectiveness of birth control pills LAMOTRIGINE: first line, approved for acute and maintenance therapy · well tolerated, concurrent use with valproic acid can increase blood levels and SE · SE: Steven Johson's rash - life threatening, aseptic meningitis (fever, chills, photophobia, painful headache and stomach ache, and stiff neck), can lower effectiveness of oral contraceptives end vice-versa NOT FDA APPROVED: TOPIRAMATE: treatment-resistant mania, bipolar depression, mixed states, less useful for mania · slight risk of birth defects, weight loss, impaired concentration, fatigue, visual disturbance. OXCARBAZEPINE: mania, mixed states, hypomania, rapid cycling, relapsing prevention · hyponatremia, increase risk of fatal harm, may reduce effectiveness of birth control

Assessing Biolar disorder

Assessing Biolar disorder: 1. Assess physiological safety. Need for hospitalization to physically stabilize the individual. Medical examination to determine if manic symptoms are one of the following: • Primary: bipolar disorder or cyclothymia • Secondary to a co-occurring condition or use of a drug or substance or toxin exposure • Part of a different medical condition, such as a brain disease; certain infections, including HIV; and endocrine disorders • Dehydration: A person in acute mania may become severely dehydrated, as evidenced by poor skin turgor, dark and scant urinary output, and poor skin integrity. • Cardiac status: Severe exhaustion and dehydration can lead to cardiac collapse. • Poor sleep and constant activity lead to physiological exhaustion. 2. Other areas of safety. Assess whether the patient is a danger to self: Not sleeping, Not eating (The patient may hoard food while not eating.) Poor impulse control that may result in harm to self or others, Poor judgment, Inappropriate sexual activity, Uncontrolled spending (Protect the patient in mania from bankruptcy.) 3. When the patient is clinically stable, assess the patient's and family's understanding of bipolar disorder, including knowledge of medications and knowledge of support groups and organizations that provide information.

Assessing the child for abuse within the home

Assessing the Child: reassure the child they did nothing wrong because they often blame themselves. They should not feel pressured to talk, the interview is not a trial/acquisition. Be nonthreatening and supportive. Use of dolls or drawings to reenact what happened may help them express themselves. Do not suggest answers or show shock at what they tell you. Do not force them to undress or be examined. Let them know that you may have to report what they say, do not promise confidentiality. Ask open ended questions in a private environment. The child may lie to protect the caregiver because they do not want to 'betray' them. After the initial interview with the parent, get the child alone so they can speak openly—abusers will often find excuses not to leave the room.

Atypical Antidepressants

Atypical antidepressants: may be effective when side effects of other AD are intolerable. · Nefazodone (SARI): avoid alcohol · Mirtazapine (NaSSA): sedation, changes to appetite, help with insomnia, no sexual dysfunction or weight gain o avoid alcohol · Trazodone (SARI): sedation , nausea, priapism (_|_), help with insomnia o avoid alcohol · Bupropion (NDRI): headache, agitation, insomnia, loss of appetite in weight loss , sweating, no sexual side effects o avoid alcohol and herbal medications · Vilazodone (SPARI): fewer sexual side effects, less weight gain, GI problems o serotonin syndrome o caution with antiplatelets / anticoagulant · Vortioxetine (SMS): low risk of sexual side effects, weight gain, sedation o serotonin syndrome, increased risk of abnormal bleeding, hyponatremia

Bipolar Disorder

Bipolar Disorder -Unusual shifts in mood, energy, and activity levels leading to difficulties in carrying out day-to-day tasks. Recurring depression and or recurrent elevated, expensive, and irritable moods - mania. BDS are normally conceptualize as a bridge between depressive disorders and schizophrenic spectrum disorders in terms of symptoms, family history, and genetics. -It can also be a mixed episode, having both depression and mania. · The initial presentation of this disorder for men is usually mania, for females it is depression. Bipolar spectrum disorders -BIPOLAR I DISORDER: at least one episode of mania, accompanied by changes in activity in energy. Psychosis may be present with the manic or depressive episode. -BIPOLAR II DISORDER: at least one period of hypomania alternating with one or more periods of depression. Never experience a full manic episode. A decrease need for sleep in a lot of daytime fatigue are the red flags for hypomania.

Compassion fatigue and secondary trauma:

Compassion fatigue ("stress") and secondary trauma: -It is the physical, emotional, psychological effect of working closely with people suffering from trauma. Can result in the RN being isolated, depressed, and self-medicating. -Burnout: Exhaustion caused by long-term involvement in emotionally demanding situations -S/S: feeling overwhelmed, reduced ability to function, intrusive thoughts/images of another's experience, difficulty separating work and personal life, being pessimistic, critical, irritable, prone to anger, dread working with certain people, depression, doubting your competence as a RN, low self esteem, hopelessness, easily frustrated, insomnia, social withdrawl, self-destructive behaviors meant to self-sooth. -High risk jobs: hospice, peds, ER, oncology, forensics, psychiatric, social workers for trauma patients. -The nurses mind-set can increase risk for compassion fatigue. Must be able to separate yourself from the work and recognize when things are becoming too much for you. Supervisors should watch out for staff. -The nurse manager must decide who is safe to work. -To prevent this, RNs must practice self-care: stress management courses, mindfulness, yoga, exercise, creative activities, and humor.

Critical Incident debriefing--post assaultive phase

Critical Incident debriefing -Staff analysis of an episode of violence, referred to as critical incident debriefing, is crucial for a number of reasons. First, a review is necessary to ensure that quality care was provided to the patient. Staff members need to critically examine their response to the patient. • Could we have done anything that would have prevented the violence? • If yes, then what could have been done, and why was it not done in this situation? • Did the team respond as a team? Were team members acting according to the policies and procedures of the unit? If not, why not? • Is there a need for additional staff education regarding how to respond to violent patients? • How do staff members feel about this patient? About this situation? Feelings of fear and anger must be discussed and handled. Otherwise, the patient may be dealt with in a punitive and nontherapeutic manner. -Second, the profound effects of workplace violence unfortunately do not disappear after the incident is over, and the harm is not only to the individual assaulted. At times some nurses and staff may internalize (depression, avoidance, withdrawal) or externalize (anger, outbursts, fluctuating mood) their emotional and behavioral responses to the event.agencies need to provide support and debriefing to prevent long-term psychological sequelae for all types of workplace violence. -Document violent episode and staff responses.

Emergency Departments Protocol for sexual assault

Emergency Departments: -Victims go here to find emotional support, regain control, and reassurance regarding their safety. -Victims should not be left alone. The staff should provide privacy, and the victim should be a priority in triage. -Consent is needed for photographs, examination and any other procedures to collect evidence -Patient needs to know its confidential, no one can access this info unless it goes to court. -Treatment and documentation need to be accurate and meticulous because the documentation may constitute legal evidence if the individual chooses to prosecute. -After the immediate medical issues of the patient have been addressed, it is important that forensically trained personnel perform as many elements of the forensic examination as the individual will allow. Once the evidence is collected, it is imperative that providers maintain a "chain of custody" until it is turned over to the authorities.

Emergency Measures for Serotonin Syndrome

Emergency Measures for Serotonin Syndrome 1. Discontinue offending agent(s); call health care practitioner immediately. 2. Initiate symptomatic treatment per orders: • Muscle relaxants. Benzodiazepines can help control agitation, seizures, and muscle stiffness; (and /or) dantrolene for muscle relaxation. • Serotonin-production blocking agents, such as cyproheptadine, can help by blocking serotonin production. • Oxygen and intravenous (IV) fluids. O2 helps maintain normal oxygen blood levels, and IV fluids treat dehydration and fever. • Drugs that control heart rate and blood pressure. These may include the following: • Esmolol (Brevibloc) or nitroprusside (Nitropress), to reduce increased heart rate or high blood pressure • Phenylephrine (Neo-Synephrine) or epinephrine (Adrenalin, EpiPen) for hypotension • Cooling blankets for high fever • Use of a breathing tube and machine and medication to paralyze muscles

Treating PTSD

Treating PTSD -CBT: Teaches the person how to evaluate and change upsetting thoughts experienced since the trauma. Changing thoughts can change how you feel. -PE (Prolonged exposure therapy): Teaches the patient to gradually approach trauma related memories, feelings, and situations that have been avoided since the trauma. If these challenges are confronted, symptoms decreases. -Group therapy with other people with PTSD. -Debriefing can lessen S/S of acute stress response. -SSRIs: sertraline(Zoloft) and paroxetine(Paxil). -Off label: SSRI fluoxetine and SNRI venlafaxine are other 1st line treatments in the VA/DoD. -Psychopharmacology is the treatment of choice, meds can target serious S/S when they arise. -Treatment resistent: 2nd generation antipsychotics or anticonvulsants. -Day-time anxiety: benzos. -Sleep: hypnotics

Delirious Mania

Delirious Mania 1. Most severe form of mania; less common 2. Acute onset and rapid progression 3. Consists of symptoms of both delirium and mania 4. Severe clouding of consciousness, disorientation, fluctuating sensorium, psychosis, catatonia, and manic symptoms (excitement, grandiosity, insomnia, etc.)

Assessing Depression, mood/affect, thoughts/cognition

Depression 1. always evaluate the patients risk of suicide or harm to others . 2. Medical and neurological helps determine if the depression is primary or secondary. -a. Drugs or alcohol? -b. Comorbid medical conditions? -c. Evidence of psychosis? 3. Assess for history of depression call mom previous episodes, therapy is used. 4. Assess support system 5. Assess for any events that might have triggered a depressive episode 6. complete a psychosocial assessment and include cultural beliefs in spiritual practice MOOD AND AFFECT: Anxiety is a common symptom associated with depression. · feeling of worthlessness, unrealistic evaluation of self-worth, low self esteem · guilty is commonly seen with depression, can assume psychotic proportions · helplessness: people believe that things will never change · hopelessness · anger in irritability: harm to self or others · alcohol or drug misuse, overeating, and smoking · affect: the patient may not make eye contact coma monotone voice, little or no facial expression, only yes or no responses. Frequent sighting is common. COGNITION AND THOUGHT CONTENT: memory inability to concentrate may be affected. · Inability to focus on their strengths and successes. · inability to solve problems in think clearly. · Judgment may be poor · Indecisiveness is common · Evidence of delusional thinking (MDD with psychotic features)

Generalized Anxiety Disorder: Dx criteria from the DSM-5

Generalized Anxiety Disorder: -Dx criteria in the DSM-5: A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (e.g., work or school performance). No specific trigger/target. B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Restlessness or feeling keyed up or on edge, Being easily fatigued, Difficulty concentrating or mind going blank, Irritability, Muscle tension, Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder

Healthy defense mechanisms:

Healthy defense mechanisms: -Altruism: In altruism, emotional conflicts and stressors are addressed by meeting the needs of others. Unlike self-sacrificing behavior, in altruism, the person receives gratification either vicariously or from the response of others. -Sublimation: is an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not usually considered acceptable. Often these impulses are sexual or aggressive. A man with strong hostile feelings may choose to become a butcher, or he may participate in rough contact sports. -Humor: makes life easier. An individual may deal with emotional conflicts or stressors by emphasizing the amusing or ironic aspects of the conflict or stressor through humor. -Suppression: is the conscious denial of a disturbing situation or feeling.

Interventions after a suicide crisis

o After a Crisis: 1. Arrange for patient to stay with family or friends. If no one is available and the person is highly suicidal, hospitalization must be considered. 2. Weapons and pills are removed by friends, relatives, police, or the nurse. 3. Encourage patients to talk freely about feelings (anger, disappointments) and help plan alternative ways of handling anger and frustration. 4. Encourage patient to avoid decisions during the time of crisis until alternatives can be considered. 5. Contact family members; arrange for individual or family crisis counseling. 6. Activate links to social supports in the community (e.g., self-help groups). 7. If anxiety is extremely high or patient has not slept in days, an antianxiety or antidepressant might be prescribed. Only a 1- to 3-day supply of medication should be given. Family member or significant other should monitor pills for safety.

Immature defense Mechanisms

Immature defense Mechanisms: -Passive Aggression: dealing with emotional conflict or stressors by indirectly expressing aggression toward others. Compliance masks covert resistance, resentment, and hostility. May be expressed through procrastination, failure, inefficiency, or passivity. Individual feels unable to directly express displeasure or disagreement. -Acting-Out Behaviors: individual addresses emotional conflicts or stressors by actions rather than by reflections or feelings--to distract the self from threatening thoughts or feelings. It's a destructive coping style. -Dissociation: A disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. Only seen with severe stressors. -Devaluation: occurs when emotional conflicts or stressors are handled by attributing negative qualities to self or others--the individual then appears good by contrast. -Idealization: emotional conflicts or stressors are addressed by attributing exaggerated positive qualities to others. Idealizing a new person can lead to disappointment, which then leads to lowered self-esteem. Such individuals may then devalue and reject the object of their affection to protect their own self-esteem. If this type of response becomes a pattern, it can lead to interpersonal and occupational problems. -Splitting: inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Prevalent in PDs, esp. BPD. -Projection: person unconsciously rejects emotionally unacceptable personal features in one's self and attributes those unacceptable traits to other people, objects, or situations through projection. Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatization. It can be associated with paranoia. -Denial: involves escaping unpleasant realities by ignoring their existence. ----Denial, splitting, and acting out are all very negative coping mechanisms for a patient to exhibit.

Intermediate Defense mechanisms

Intermediate Defense mechanisms -Repression: is the exclusion (forgetting) of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. It is considered the cornerstone of the defense mechanisms, and 1st line of psychological defense against anxiety. -Displacement: Transfer of emotions associated with a specific person, object, or situation to another person, object, or situation that is nonthreatening Example: The boss yells at the man, the man yells at his wife. The use of displacement is common, not always adaptive. -Reaction Formation: unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion. Example: A person who harbors hostility toward children becomes a Boy Scout leader. -Somatization: repressed anxiety is demonstrated in the form of physical symptoms that have no organic cause. Indirect way to communicate the need for help in a more socially acceptable manner. -Undoing: performing an action to make up for a previous behavior. Example: giving a gift to "undo" an argument. A pathological example of undoing is compulsive hand washing--cleansing oneself of an act or thought perceived as unacceptable. -Rationalization: justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations for the behavior. It is a form of self-deception.

Interventions for Acute Mania: Communication

Interventions for Acute Mania: Communication 1. Use firm and calm approach: "John, come with me. Eat this sandwich." (Maintain control, pt out of control) 2. Use short and concise explanations or statements. 3. Remain neutral; avoid power struggles and value judgments. 4. Be consistent in approach and expectations. 5. Have frequent staff meetings to plan consistent approaches and to set agreed-on limits. 6. With other staff, decide on limits and tell patient in simple, concrete terms with consequences; for example, "John, do not yell at or hit Peter. If you cannot control yourself, we will help you" or "The seclusion room will help you feel less out of control and prevent harm to yourself and others." 7. Continue to use active listening to hear and act on legitimate complaints. 8. Firmly redirect energy into more appropriate and constructive channels. Use distraction techniques as a tool to de-escalate.

Interventions for Acute Mania: Safety and Physical Needs

Interventions for Acute Mania: Safety/Physical Needs --Nutrition 1. Monitor intake, output, and vital signs. (Cardiac collapse) 2. Offer frequent high-calorie protein drinks and milkshakes and finger foods such as sandwiches and fruit. 3. Frequently remind patient to eat. "Tom, finish your milkshake." "Sally, eat this banana." --Sleep/Rest 1. Encourage frequent rest periods during the day. 2. Keep patient in areas of low stimulation. 3. At night, provide warm baths, soothing music, and medication when indicated. Avoid giving patient caffeine. --Hygiene 1. Supervise choice of clothes; minimize flamboyant and bizarre clothing, such as unmatched colors or sexually provocative clothing. (Maintain dignity) 2. Give simple, step-by-step reminders for hygiene and dress. "Here is your razor. Shave the left side ... now the right side. Here is your toothbrush. Put the toothpaste on the brush." --Elimination 1. Monitor bowel habits; offer fluids and foods that are high in fiber. Evaluate need for laxative. Encourage patient to go to the bathroom.

Interventions for Depression: Communication

Interventions for Depression: Communication 1. Help the patient question underlying assumptions and beliefs and consider alternate explanations to problems. 2. Work with the patient to identify cognitive distortions that encourage negative self-appraisal. For example: a. Overgeneralizations b. Self-blame c. Mind reading d. Discounting of positive attributes 3. Encourage activities that can raise self-esteem. Identify need for (a) problem-solving skills, (b) coping skills, and (c) assertiveness skills. 4. Discuss physical activities the patient enjoys, such as running. Explain that initially 10 to 15 minutes a day 3 or 4 times a week has short-term benefits. 5. Encourage the formation of supportive relationships through support groups, therapy, and peer support. 6. Provide information and referrals for spiritual/religious information.

Interventions for elder abuse:

Interventions for elder abuse: o Check the individual state for laws regarding elder abuse. o Involve APS if abuse is suspected, involve law enforcement and/or social services if necessary. o Meet with family to identify stressors and problems. o Notify community agencies: -Support group for elder and abuser -Meals on Wheels -Daycare for seniors and respite services -Visiting nurse services -Assisted living o Encourage abuser's use of counseling. o Suggest family members meet on a regular basis for problem solving and support. -Follow up is crucial in ensuring ongoing safety of the elderly patients and the support of the caregiver or caregiving facility.

Lithium, adverse and expected side effects

LITHIUM is the first line treatment for acute mania coma acute bipolar depression coma in prevention of maniac and depressive episodes. Good for treatment resistant depression. It has significant anti switch side effects. ADVERSE EFFECTS · three to six weeks to show a full therapeutic response · therapeutic serum levels in treating acute mania or 0.5 to 1.2 · maintenance 0.6 to 1.0 · toxic concentrations greater than 1.5 · draw at through level 10 to 12 hours after the last dose · Monitor F/E because imbalances will cause a stronger concentration o Excessive sweating, dehydration or excessive hydration, in high sodium intake . Patients living heart, dry areas need to be careful with dehydration because this can quickly calls this serum lithium tree increase to toxic levels. · Expected SE: <0.4 - 1 o Signs: find hand tremor, polyurea, mild thirst, mild nausea, weight gain coma acne, cognitive problems, hair loss o Interventions: give with food to decrease nausea, diet, exercise, and nutritional management for weight gain

MAOI

Monoamine Oxidase Inhibitors: -MAOIs are antidepressant medications for patients who have not responded to other AD medications and for atypical depression. · Isocarboxazid, Phenelzine, Tranylcypromine, Selegiline (transdermal patch) -MAOIs can also treat panic disorder, social phobia, GAD, OCD, PTSD, bulimia, and refractory anxiety states. It is believed that MAOIs prevent the breakdown of norepinephrine, serotonin, and dopamine, which increases the levels of these amines in the brain, resulting in an elevated mood. -Side Effects: Weight gain, Fatigue and sedation, Sexual dysfunction, Hypotension, Muscle cramps, Urinary hesitancy and constipation -The MAOIs inhibit the breakdown of dietary tyramine in the liver. Increased levels of tyramine can lead to high blood pressure, hypertensive crisis, and potentially a cerebrovascular accident (stroke) and death. -DO NOT ingest anything with tyramine: Ginseng, caffeinated beverages, avocados, fermented bean, soybeans, fava, sauerkraut, figs, bananas in large amounts, aged/spoiled meats, liver, fermented varieties, pickled herring and 'smoked salmon, dried, pickled, or Cured fish, all cheeses, East extract, beers, wines, Chianti, protein dietary supplements, soaps, shrimp paste, soy sauce, TURKEY

Nursing Interventions of Anxiety and OCD:

Nursing Interventions of Anxiety and OCD: · 1. Provide information. Teach the patient and family/significant others about anxiety disorders and OCD. Giving patients information about support groups, useful websites, and the location of nearby clinics is essential. · 2. Support treatment adherence through medication teaching. · 3. People with anxiety disorders are usually able to meet their own basic physical needs. Sleep, however, can be a real and serious problem. Patients with anxiety disorders often experience sleep disturbances. Teaching people ways to promote sleep, such as a warm bath, warm milk, or relaxing music, and monitoring sleep through a sleep diary are useful interventions. CBT for insomnia (CBT-I) is an evidence-based treatment for severe insomnia · 4. Informatics can be an important part of patient teaching by giving them access to information and continue learning the tools to help them reduce symptoms. Teach about the different websites or smartphone apps that can help with relaxation techniques like meditation.

Interventions Targeting the Physical Needs of the Depressed Patient

Nutrition: Anorexia 1. Offer small, high-calorie, and high-protein food and drinks frequently throughout the day and evening. 2. Offer fluids frequently throughout the day and evening. 3. When possible, encourage family or friends to remain with the patient during meals. 4. Ask the patient which foods or drinks are preferred. Offer choices. Involve the dietician. 5. Weigh the patient weekly and observe the patient's eating patterns. Sleep: Insomnia 1. Provide periods of rest after activities. 2. Encourage the patient to get up and dress and to stay out of bed during the day. 3. Encourage the use of relaxation measures in the evening (warm bath, warm milk, progressive muscle relaxation techniques). 4. Reduce environmental and physical stimulants in the evening—provide decaffeinated coffee, soft lights, soft music, quiet activities. Self-Care Deficits 1. Encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment, and so forth. 2. When appropriate, give step-by-step reminders such as, "Wash the right side of your face, now the left." Elimination: Constipation 1. Specifically monitor bowel movements. 2. Offer foods high in fiber and provide periods of exercise. 3. Encourage the intake of fluids. 4. Evaluate the need for laxatives and enemas.

Outcomes for Anxiety disorders:

Outcomes for Anxiety disorders: -Phobia: Develop skills at reframing anxiety-provoking situation (by date). Work with nurse/clinician to desensitize self to feared object or situation (by date). -GAD: State increased ability to make decisions and problem solve.Demonstrate ability to perform usual tasks even though still moderately anxious (by date). Demonstrate one cognitive or behavioral coping skill that helps reduce anxious feelings (by date). Demonstrate one new effective relaxation skill (by date). -OCD: Reports less time having obsessional thoughts. Decrease time spent in ritualistic behaviors. Demonstrate increased amount of time spent with family and friends and on pleasurable activities. State they have more control over intrusive thoughts and rituals (by date).

Physical S/S of depression

PHYSICAL CHANGES - CLINICAL SYMPTOMS: the word is Gray colored, sadness and rejection, sometimes unable to cry. Anergia, fatigue can result in slowed movements, called psycho motor retardation. sometimes psycho motor agitation - patients may pace, bite their nails, smoke, tap their fingers, or engaging some other tension relieving activity. · Grooming, dress, and personal hygiene are markedly neglect. · Vegetive signs of depression: somatic changes, activities necessary to support physical life in growth, such as eating, is sleeping, elimination, and sex. · major depressive disorders: decreased appetite · PDD: overeating · changes in sleep patterns: insomnia, difficulty falling asleep, or middle insomnia (waking at 3:00 or 4:00 AM and staying awake) · sleep can be increased (hypersomnia) and provides escape from painful feelings. Common in younger individuals or whose have depression as part of bipolar disorder · changes in bowel habits: Constipation or diarrhea · interest in sex declines, some men experience impotence · complain of pain with or without reporting psychological symptoms

Pharmacological Interventions for Anxiety and OCD:

Pharmacological Interventions for Anxiety and OCD: -Antidepressants: 1. SSRI-first line treatment for anxiety disorders, OCD, and BDD. Treatment for GAD, panic, agoraphobia, and social anxiety. Some approved by FDA for OCD; some considered off-label. Off-label for body dysmorphic disorder. Common side effects: jitteriness, nausea, restlessness, headache, fatigue, changes in appetite, changes in weight, tremor, sweating, QTC prolongation, sexual dysfunction, diarrhea, constipation, hyponatremia, serotonin syndrome 2. SNRI: Duloxetine used to treat GAD, PDA, SAD. Venlafaxine used to treat GAD, Off-label use for OCD. Common side effects: jitteriness, nausea, restlessness, headache, fatigue, changes in appetite, changes in weight, tremor, sweating, sexual dysfunction, diarrhea, constipation 3. Tricyclic antidepressants: 2nd/3rd-line use for PD, GAD, and SAD; clomipramine is effective in OCD and PDs with agoraphobia.Imipramine has shown good efficacy in the treatment of panic disorders. Common side effects: anticholinergic effects, somnolence, dizziness, cardiovascular effects, weight gain, nausea, headaches, sexual dysfunction Benzodiazapines: 1. End in --pam. Useful for short-term anxiety, Dependence and tolerance may develop. Frequent use linked with rebound anxiety, dementia, increased fall risk, and higher mortality. Should not be combined with opioid medications, or given to pregnant/breastfeeding women. Common side effects: sedation, dizziness, fatigue, impaired driving, impaired cognitive function, CNS depression. Non-benzo anxiolytic: 1. BuSpar: Delayed onset (3 weeks or longer), treats GAD--long term anxiety. Less sedating than benzos. No dependence problems. Common side effects: dizziness, nausea, headache, nervousness, insomnia, light-headedness, excitability ----Antihistamines, anticonvulsants, and antipsychotics can also be used.

Phase I (Acute Mania)

Phase I (Acute Mania) During the acute phase, planning focuses on the physiological stability of the patient while maintaining safety. Hospitalization is usually the safest option for a patient with acute manic symptoms. Nursing care is often geared toward the following: 1. Decreasing excessive physical activity 2. Maintaining adequate food and fluid intake 3. Ensuring at least 4 to 6 hours of sleep per night 4. Alleviating any bowel or bladder problems 5. Intervening to ensure self-care needs are met 6. Providing careful medication management Some patients may require close observation, seclusion, or electroconvulsive therapy (ECT) for severe symptoms.

Phase II and Phase III (Continuation and Maintenance)

Phase II and Phase III (Continuation and Maintenance) Planning focuses on maintaining adherence with the medication regimen and preventing relapse. Interventions are planned in accordance with the assessment data. Areas to consider are as follows: 1. The patient's interpersonal skills, including communication skills and problem solving 2. The patient's stress-reduction skills 3. Cognitive functioning—poor neuropsychological functioning is associated with lower medication adherence for people with a diagnosis of bipolar disorder. 4. Employment status and any legal issues 5. Substance-related problems 6. Social support systems 7. Individualized relapse prevention plan Residual problems resulting from reckless, violent, withdrawn, or bizarre behavior that may have occurred during a manic episode can now be addressed. These can often leave lives shattered and family and friends hurt and distant. For many patients, psychotherapy is needed to address these issues.

Primary risk factors for depression

Primary risk factors for depression • History of prior episodes of depression • Family history of depressive disorder, especially in first-degree relatives • History of suicide attempts or family history of suicide • Member of the lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) community • Female gender • Age 40 years or younger • Postpartum period • Chronic medical illness • Absence of social support • Negative, stressful life events, particularly early trauma • Active alcohol or substance use disorder • History of sexual abuse

Safety in de-escalation of patient

Promoting safety is always a first consideration. Ensure your safety first. 1. Move the individual to a calm and quiet place. 2. All patients should be searched for contraband and dangerous objects when admitted to the unit and after visits. 3. Give the patient space. Always minimize personal risks. Stay at least one arm's length away from the patient. Use more space if the patient is anxious or if you want more space. Always trust your instincts. 4. Provide adequate space for the patient and staff to ensure easy withdrawal from an escalating situation. 5. Know where panic buttons or alarms are located to be able to call for assistance from other staff quickly. Sometimes it is necessary to wear a body alarm to ensure safety. 6. Exit strategies apply to both the nurse and the patient. It is better to stand off to the side and encourage the patient to have a seat. 7. Set limits at the outset using these de-escalation techniques (Box 24.2): • Direct approach: "Violence is unacceptable." Describe the consequences (medications, restraints, seclusion). Best for confused or psychotic patients. • Indirect approach: Use the indirect approach if the patient is not confused or psychotic. Give the patient a choice. 8. When interviewing a patient whose behavior begins to escalate: • Provide feedback about what you observe • If the patient's behavior continues to escalate, then leave the patient. 9. Having enough staff is essential for a show of strength and is often enough to avert confrontation. One person is chosen as a spokesperson, but staff need to maintain an unobtrusive and nonthreatening presence in case the situation escalates. 10. Give the patient the opportunity to walk to the quiet room voluntarily without assistance when team interventions seem appropriate. 11. Do not touch the patient unless the team is with you and you are ready for a possible restraint situation. 12. In the event of a restraint or seclusion situation, the team functions as a single unit, with each member assigned a limb or a function as previously practiced according to unit protocols and policy. 13. Avoid wearing dangling earrings, necklaces, or ponytails. If wearing a lanyard, ensure it has a safety break-away feature.

Psychoeducation for Patients with Bipolar Disorders and Their Families

Psychoeducation for Patients with Bipolar Disorders and Their Families 1. INFORMATION: learn about symptoms, causes, and treatment. BD Chronic, cyclic, and episodic course. long term illness requiring ongoing treatment 2. EMOTIONAL DISCHARGE: exchange ideas about managing the illness. increase acceptance 3. SUPPORT MEDICATION AND OTHER TREATMENT. mood stabilizing medication. tell HCP about side effects, since can be managed. regular blood work. develop a relapse prevention plan. learn specific early warning signs. track your mood overtime, keep a mood diary. family members can be helpful in recognizing. emergency contact numbers. group in individual psychotherapy: supports acceptance, decrease self-stigma, develop skills in relapse prevention, social support, coping skills, medication adherence. CBT. 4. SELF-HELP STRATEGIES: Maintain good sleep, reestablish should sleep/wake rhythms and other daily routines, avoid alcohol and drugs , use caution with caffeine and OTC, reengage with social , familiar, and occupational roles, learn ways to manage stress: psychosocial in environmental stressors can be precipitant of an acute episode -HEALTH CARE WORKERS: lack of insight is a significant problem. minimization and denial are common defenses that require empathy, active listening, and gradual introduction of facts. anger and abusive remarks are symptoms of the acute illness and are not personal -SELF-CARE FOR NURSES: The patient may use humor, manipulation, or demanding behavior. The patient might get involved in power place, clear and consistent limit setting is required, teamwork and collaboration are essential to achieving this consistency, behavior contracts can be useful tools, establishing a therapeutic alliance with the individual is crucial

Second Generation Antipsychotics for bipolar disorder

Second Generation Antipsychotics · Acute mania: Olanzapine, risperidone, aripiprazole, quetiapine, paliperidone, ziprasidone, asenapine · Bipolar depression: Quetiapine monotherapy, olanzapine and fluoxetine, lurasidone · Prevention or relapse of mania and depression: olanzapine and quetiapine monotherapy, olanzapine and quetiapine adjunct with lithium or valproate

Cues to suicidal ideation: behavioral and verbal

o Behavioral Clues: Giving away prized possessions, Writing farewell notes, Making out a will, Putting personal affairs in order, Having global insomnia, Exhibiting a sudden and unexpected improvement in mood after being depressed or withdrawn, Neglecting personal hygiene o Verbal Clues: -Overt statements: "I can't take it anymore.", "Life isn't worth living anymore.", "I wish I were dead.", "Everyone would be better off if I died." -Covert statements: "It's okay now. Everything will be fine.", "Things will never work out.", "I won't be a problem much longer.", "Nothing feels good to me anymore, and probably never will.", "How can I give my body to medical science?"

The Millieu in Bipolar disorder

Structure in a Safe Milieu 1. Maintain low level of stimuli in patient's environment: away from bright lights, loud noises, and people. 2. Provide structured, noncompetitive or solitary activities with nurse or aide. 3. Redirect agitated behavior through physical exercise such as walking. 4. Use antipsychotics, sedative drugs, and seclusion to minimize physical harm when clinically indicated. 5. Observe for signs of lithium toxicity. 6. Protect patient from giving away money and possessions. Hold valuables in hospital safe until rational judgment returns. 7. Protect patient from inappropriate behavior, such as sexual acting out.

S/S of a patient who is beginning to escalate

The first 4hrs on the MHU are the "Golden hrs", more likely to be violent, the flowing 20hrs are the "brown hrs". Monitor closely for first 24hrs. 1. Signs and symptoms that usually (but not always) precede violence: it could be spontaneous --a. Angry, irritable affect --b. Hyperactivity: most important predictor of imminent violence (e.g., pacing, restlessness, slamming doors) --c. Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self (patient may have shortness of breath, sweating, and rapid pulse rate) --d. Verbal abuse: profanity, argumentativeness --e. Loud voice, change of pitch, or very soft voice forcing others to strain to hear --f. Intense eye contact or avoidance of eye contact 2. Recent acts of violence, including property violence 3. Stone silence 4. Suspiciousness or paranoid thinking 5. Alcohol or drug intoxication (withdrawal) 6. Possession of a weapon or object that may be used as a weapon (e.g., fork, knife, rock) 7. Milieu characteristics conducive to violence: --a. Loud --b. Overcrowding --c. Staff inexperience --d. Provocative or controlling staff --e. Poor limit setting --f. Staff inconsistency (e.g., arbitrary revocation of privileges)

Therapies for Anxiety and OCD: -CBT -Acceptance and commitment therapy -Mindfulness based stress reduction -Behavioral therapy

Therapies for Anxiety and OCD: -CBT: can be effective in the treatment of panic disorder, phobias, social anxiety disorder, GAD, and OCD among many other conditions. CBT teaches patients to challenge the cognitive distortion through "cognitive restructuring": Identifying the cognitive distortion, Challenging the cognitive distortion, Replacing the cognitive distortion with a more realistic interpretation. -ACT: is an action-oriented approach to psychotherapy that stems from traditional BT and CBT. Patients learn to accept distressing emotions as appropriate to certain situations, then begin to accept their concerns and commit to making changes in their behavior. Treats workplace stress, test anxiety, social anxiety disorder, depression, OCD, and psychosis. -MBSR: Meditation+Mindfulness. The basic premise is to learn to detach from anxious thoughts. This is achieved by practicing awareness, identifying tension in the body, understanding thinking patterns, and learning how to deal with difficult emotions. Reduces anxiety and increasing a positive sense of self for those with a diagnosis of GAD. -BT: behaviors are learned and unhealthy behaviors can be "unlearned" or changed. Behavior is "learned" through the environment or through reinforcement (rewards), and punishment. "Faulty learning," called conditioning, is the cause of abnormal behavior. Examples of BT: Modeling, Thought Stopping, Systematic Desensitization (phobias), Exposure and response prevention (OCD rituals).

Use the S∗H∗I∗V∗E∗R∗S memory tool to help you recognize the symptoms of serotonin syndrome:

Use the S∗H∗I∗V∗E∗R∗S memory tool to help you recognize the symptoms of serotonin syndrome: • Shivering • Hyperreflexia and myoclonus; muscular rigidity only in more severe cases • Increased temperature, usually only in severe cases; likely caused by muscular hypertonicity • Vital sign instability, presenting as tachycardia, tachypnea, and/or labile blood pressure • Encephalopathy—mental status changes such as agitation, delirium, and confusion • Restlessness and incoordination—common because of excess serotonin activity • Sweating (diaphoresis)—an autonomic response to excessive serotonin stimulation -Severe manifestation can induce hyperpyrexia (excessively high fever), cardiovascular shock, or death.

Depression interventions: VNS, TMS, DBS

Vagus Nerve Stimulation (VNS) Long term treatment for patients with treatment resistant depression this act mechanism is not understood. It does affect the blood flow to specific parts of the brain and affects neurotransmitters. Involves surgically implanting a device called a pulse generator into the upper left chest. The pulse generator is connected by a wire to the left vagus nerve when the generator is stimulated, electrical impulses are transmitted to areas of the brain that affect mood, improving depressive symptoms. Transcranial Magnetic Stimulation (TMS) A electromagnet painlessly delivers a magnetic poles that stimulates nerve cells in the region of the brain involved in mood control and depression. Keto requires a series of 30 to 60 minutes treatment coma carried out daily, five times a week, for 4 to 6 weeks. doesn't cause a seizure. Deep Brain Stimulation (DBS) Used in the treatment of Parkinson's patients and for chronic pain, and with severe, treatment resistant depression or OCD. Electrodes must be surgically implanted into several areas of the brain, a battery powered device generates stimulation to specific areas of the brain.

S/S of the 4 types of abuse in child abuse: Physical, Neglect, Sexual, Emotional/psychological

o Children younger than 4yrs are more vulnerable, as the child increases in age and physical size the abuse tends to lessen. o S/S of Physical Abuse: broken bones, bruises/wounds in various stages of healing, bald patches on scalp, retinal hemorrhage, subdural hematoma (<2yrs old), shaken baby syndrome, death. Nightmares, anxiety, fear of parents or adults, withdrawn, aggressive, regressive behavior. o S/S of Neglect: Physical-malnourished, poorly clothed, living in squalor, poor growth, poor hygiene. Educational- not enrolled in school, school problems or failure. Arrives early or stays late at school, substance abuse, begging/stealing food, truancy/delinquency. Overindulgence is also a form of neglect, results in obesity. o S/S of Sexual Abuse: difficulty walking or sitting, frequent UTIs, bruising or bleeding in genital area, bloody or torn undergarments. Mental disorders, running away, advanced sexual knowlege/behaviors. o S/S of Emotional/Psychological Abuse: speech disorders, lag in physical development, infantile or adult-like behavior, dramatic behavioral changes, poor social skills.

Normal, acute, pathologic anxiety

o "Normal" anxiety is an adaptive life force that is necessary for survival. It provides the energy needed to carry out the tasks involved in striving toward goals. Anxiety motivates people to make and survive change. It prompts constructive behaviors. Sharpens perceptual field. o Acute anxiety is precipitated by an imminent real or potential loss or change that threatens an individual's sense of security. It is frequently triggered by an acute stressor. For example, many entertainers experience acute anxiety before performances. Students may experience acute anxiety before an examination. Patients preparing for surgery often experience acute anxiety. o Pathological anxiety differs from normal anxiety in terms of duration, intensity, and disturbance in a person's ability to function. Pathological anxiety occurs when (1) the intensity of the emotional response is out of proportion to the threat, (2) the emotional response persists after the threat is resolved, and/or (3) the emotional response becomes generalized to benign situations. Pathological anxiety can lead to the development of anxiety disorders.

Interventions for an acutely suicidal patient

o During a Crisis: 1. Follow institutional protocol for suicide regarding creating a safe environment (taking away potential weapons—belts, sharp objects; checking what visitors bring into patient's room). 2. Keep accurate and thorough records of patient's behavior—both verbal and physical, usually every 15min—as well as all nursing and physician actions: · Establish frequent rapport with the person. · Assess patient for his or her ability to seek out staff when struggling with suicidal thoughts. If patient is unable to do this, place on close observation. 3. Suicide precaution (one-on-one monitoring at arm's length away) or suicide observation (15-minute visual check of mood, behavior, and verbatim statements), depending on level of suicide potential. 4. Keep accurate and timely records and document patient's activity—usually every 15 minutes—including what patient is doing, with whom, etc. Follow institutional protocol. Documents may become evidence in court, if it wasn't documented it doesn't 'exist' in a court of law. 5. If accepted at your institution, construct a safety plan with the suicidal patient. Use clear, simple language. Construct a verbal or written 'No-Suicide Contract. The no-suicide contract helps patients know what to do when they begin to feel overwhelmed by pain (e.g., "I will speak to my nurse/counselor/support group/family member when I first begin to think of harming myself"). 6. Encourage patients to talk about their feelings and problem solve alternatives.

Follow-up psychotherapy for a suicidal patient

o Follow-Up Psychotherapy: 1. Identify situations that trigger suicidal thoughts (define the precipitating event). 2. Assess patient's strengths and positive coping skills (talking to others, creative outlets, social activities, problem-solving abilities). 3. Assess patient's coping behaviors that are not effective and that result in negative emotional sequelae: drinking, angry outbursts, withdrawal, denial, and procrastination. 4. Encourage patients to look into their negative thinking and reframe negative thinking into neutral objective thinking. 5. Point out unrealistic and perfectionistic thinking. 6. Spend time discussing patient's dreams and wishes for the future. Identify short-term goals that can be set for the future. 7. Identify things that have given meaning and joy to life in the past. Discuss how these things can be reincorporated in the present lifestyle (e.g., religious or spiritual beliefs, group activities, creative endeavors).

Teen dating violence (TDV)

o Teen dating violence (TDV), the abuse can be directed towards men or women, but women are usually the victims of the abuse. It could be in the form of extreme possessiveness, jealousy, stalking (including technology), manipulation, devaluation, humiliation, threatening suicide, unwanted touching, forcing intimacy or sex. -An abusive relationship is all about instilling fear and wanting to have power and control in the relationship. -Anger is a means of control, which may turn into physical violence. -Depression, PTSD, anxiety, and suicide or suicidal ideation may follow battering.

Assessing for elder abuse

· Assessment of elder abuse: -Similar S/S of IPV or child abuse. Often have 2x as many medical appointments as non-abused patients. Family members are often the abusers, so they may not report out of fear, they may have been threatened, or they don't want to end up in a nursing home. Routinely assess for S/S of abuse and let family/friends speak openly about suspicions, be nonjudgmental when listening to them. o S/S: fear of being alone with caregiver, malnutrition, bed sores or lesions, begging for food, needs medical/dental care, left unattended for long periods of time, reports of abuse/neglect, passive/withdrawn/emotionless, concern over finances or missing valuables. There may be potential caveats going on like dementia, so be aware of that before making assumptions about abuse.

Body dysmorphic disorder Assessment

· Body dysmorphic disorder: highly distressing disorder that ranges along the continuum from distressing to delusional severity. This DSM-5 diagnosis includes preoccupation with an imagined "defective body part." Patients with BDD usually have a normal appearance, although a small number do show a minor physical defect. The average age of onset is younger than 20 years. The diagnosis can include obsessional thinking, such as thinking "I am ugly or deformed," and compulsive behaviors, such as mirror checking, skin picking, or excessive grooming. There can be an impairment of normal activities related to social, academic, or occupational functioning. The obsessional focus for individuals with BDD frequently center around the face, skin, genitalia, thighs, hips, and hair. -Treatment: SSRI and clomipramine, a tricyclic antidepressant. A second-generation antipsychotic added to an SSRI may help in the more severe delusional form of BDD. CBT is another evidence-based treatment strategy.

Lithium toxicity

· Early Signs: <1.5 o Signs: increase nausea , vomiting, diarrhea, thirst, polyurea, slurred speech, muscle weakness o Interventions: hold medication, measure blood levels, re-evaluate dosage · Advanced signs: 1.5 - 2 o signs : course hand tremor , GI upset, confusion, muscle hyperirritability, Electroencephalographic (EEG) changes, Incoordination. o Interventions: hold medication, measure blood levels, revaluate dosage, treat more serious symptoms · Severe Toxicity: 2 - 2.5 o signs: serious EEG changes, ataxia, blurred vision, clonic movements, large output of urine, tinnitus, blurred vision, seizures, stupor, severe hypotension, coma, death secondary to pulmonary complications o interventions: there is no antidote, stop drug and facilitate excretion: if alert, give emetic, gastric lavage, treatment with urea, mannitol, and aminophylline to hasten excretion, Hemodialysis o >2.5 symptoms -may progress rapidly, coma, cardiac dysrhythmia -use interventions listed above + hemodialysis

Planning care for Anxiety and OCD:

· Planning should include patient if they are experiencing mild or moderate anxiety, when severe the patient will not be able to participate in planning—the RN will take a directive role. 1. Use therapeutic communication, milieu therapy, promotion of self-care activities, supportive counseling, health teaching, and health promotion as appropriate. 2. Identify community resources that can offer specialized treatment that is proven to be effective for people with different anxiety disorders. 3. Identify relevant community support groups for patients and significant others.

-Suicide -Suicide attempt -Suicidal Ideation -Physician assisted suicide -Euthanasia

· Suicide or completed suicide is the act of intentionally ending one's own life. · A suicide attempt includes all willful, self-inflicted, life-threatening attempts that have not led to death. · Suicidal ideation refers to the process of thinking about killing oneself. o Always take an individual very seriously if he or she mentions some form of suicidal ideation. o Always ask, "Are you thinking of killing yourself?" o Listen very carefully to what the person does and does not say. · Physician-assisted suicide (PAS) or physician aid in dying (PAD) for the terminally ill, which operates under very strict guidelines--require a patient to be a resident of the state, be at least 18 years old, 6 months or less to live, not have any cognitive impairments, and to have made at least two verbal and one written request for PAS/PAD to a physician, the request is made again after 15 days. · Euthanasia entails the physician or another third party administering the medication, whereas PAD/PAS requires the patient to self-administer the medication and to determine whether and when to do this.