level 3 exam 2 psych powerpoint notes

Inhalant Use Disorder

A profile of the substance Aliphatic and aromatic hydrocarbons found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners Patterns of use/abuse Effects on the body CNS effects Respiratory effects Gastrointestinal effects Renal system effects Intoxication Develops during or shortly after use of or exposure to volatile inhalants Symptoms include: Dizziness, ataxia, muscle weakness Euphoria, excitation, disinhibition, slurred speech Nystagmus, blurred or double vision Psychomotor retardation, hypoactive reflexes Stupor or coma

Hallucinogen Use Disorder

A profile of the substance Naturally occurring hallucinogens Synthetic compounds Patterns of use Use is usually episodic Hallucinogens: Effects on the Body: Physiological Nausea/vomiting Chills Pupil dilation Increased blood pressure, pulse Loss of appetite Insomnia Elevated blood sugar Decreased respirations Psychological Heightened response to color, sounds Distorted vision Sense of slowed time Magnified feelings Paranoia, panic Euphoria, peace Depersonalization Derealization Increased libido Intoxication Occurs during or shortly after using the drug Symptoms include perceptual alteration, depersonalization, derealization, tachycardia, and palpitations. Symptoms of phencyclidine intoxication include belligerence and assaultiveness, and may proceed to seizures or coma.

Prognosis schiz

A return to full premorbid functioning is not common. Factors associated with a positive prognosis include Good premorbid functioning Later age at onset Female gender Abrupt onset precipitated by a stressful event Associated mood disturbance Brief duration of active-phase symptoms Factors associated with a positive prognosis include (cont'd) Minimal residual symptoms Absence of structural brain abnormalities Normal neurological functioning Family history of mood disorder No family history of schizophrenia

Application of the Nursing Process: Stressor-Related Disorders

Adjustment disorders -Characterized by a maladaptive reaction to an identifiable stressor or stressors that results in the development of clinically significant emotional or behavioral symptoms -Symptoms occur within 3 months of the stressor and last no longer than 6 months. Exception: The "related to bereavement" subtype Discuss the symptoms and assessment of adjustment disorders. An adjustment disorder is characterized by a maladaptive reaction to an identifiable stressor or stressors that results in the development of clinically significant emotional or behavioral symptoms. This response occurs within 3 months after onset of the stressor and has persisted for no longer than 6 months after the stressor has ended. The individual shows impairment in social and occupational functioning or exhibits symptoms that are in excess of an expected reaction to the stressor. The symptoms are expected to remit soon after the stressor is relieved, or if the stressor persists, when a new level of adaptation is achieved.

Phobias

Agoraphobia Fear of being in places or situations from which escape might be difficult or in which help might not be available in the event of panic-like symptoms or other incapacitating symptoms. Examples Traveling in public transportation Being in open spaces Being in shops, theaters, or cinemas Standing in line or being in a crowd Being outside of the home alone in other situations Social anxiety disorder (social phobia) Excessive fear of situations in which the affected person might do something embarrassing or be evaluated negatively by others Specific phobia Fear of specific objects or situations that could conceivably cause harm, but the person's reaction to them is excessive, unreasonable, and inappropriate Exposure to the phobic object produces overwhelming symptoms of panic, including palpitations, sweating, dizziness, and difficulty breathing. Type specifiers Animal Natural environment type Blood-injection-injury type Situational type Other type Predisposing factors to phobias Psychoanalytical theory Unconscious fears may be expressed in a symbolic manner as phobia. Learning theory Fears are conditioned responses and thus are learned by imposing reinforcements for certain behaviors. Cognitive theory Anxiety is the product of faulty cognitions or anxiety-inducing self-instructions. Negative self-statements Irrational beliefs Biological aspects Temperament Characteristics with which one is born that influence how he or she responds throughout life to specific situations (e.g., innate fears) Life experiences Early experiences may set the stage for phobic reactions later in life.

Classes of Psychoactive Substances

Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives/hypnotics Stimulants Tobacco

Dynamics of Substance-Related Disorders

Alcohol use disorder Patterns of use Phase I. Prealcoholic phase: Characterized by use of alcohol to relieve everyday stress and tensions of life Phase II. Early alcoholic phase: Begins with blackouts—brief periods of amnesia that occur during or immediately following a period of drinking; alcohol is now required by the person. Phase III. The crucial phase: Person has lost control; physiological dependence is clearly evident. Phase IV. The chronic phase: Characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober. Alcohol exerts a depressant effect on the CNS, resulting in behavioral and mood changes. The effects of alcohol on the CNS are proportional to the alcoholic concentration in the blood. Alcohol can be harmless and enjoyable if used in moderation, but like any other mind-altering drug, has the potential for abuse. Jellinek outlined four phases through which an alcoholic's pattern of drinking progresses. Describe these four phrases. Phase I. The Prealcoholic Phase. This phase is when alcohol is used to relieve the everyday stress and tensions of life. As a child, the individual may have observed parents or other adults drinking alcohol and enjoying the effects. Tolerance develops, and the amount required to achieve the desired effect increases steadily. Phase II. The Early Alcoholic Phase. This phase begins with blackouts, and alcohol stops being a source of pleasure or relief for the individual but rather a drug that is required. Common behaviors include sneaking drinks or secret drinking, preoccupation with drinking and maintaining the supply of alcohol, rapid gulping of drinks, and further blackouts. The individual feels enormous guilt and becomes very defensive about his or her drinking. Phase III. The Crucial Phase. In this phase, the individual has lost the inability to choose whether or not to drink, and addiction is clearly evident. Binge drinking is common. These episodes are characterized by sickness, loss of consciousness, squalor, and degradation. In this phase, the individual is extremely ill. Anger and aggression are common manifestations. By this phase of the illness, it is not uncommon for the individual to have experienced the loss of job, marriage, family, friends, and most especially, self-respect. Phase IV. The Chronic Phase. This phase is characterized by emotional and physical disintegration. Emotional disintegration is evidenced by profound helplessness and self-pity. Impairment may result in psychosis. Life-threatening physical manifestations may be evident in virtually every system of the body. Unmanaged withdrawal from alcohol results in a terrifying syndrome of symptoms that include hallucinations, tremors, convulsions, severe agitation, and panic. Depression and ideas of suicide are not uncommon. For long term, heavy drinkers, abrupt withdrawal of alcohol can be fatal. Effects of alcohol on the body Peripheral neuropathy, characterized by: Peripheral nerve damage Pain Burning Tingling Prickly sensations of the extremities Alcoholic myopathy: Thought to result from same B vitamin deficiency that contributes to peripheral neuropathy Acute: Sudden onset of muscle pain, swelling, and weakness; reddish tinge to the urine; rapid rise in muscle enzymes in the blood Chronic: Gradual wasting and weakness in skeletal muscles Effects of alcohol on the body (cont'd) Wernicke's encephalopathy: Most serious form of thiamine deficiency in alcoholic patients Korsakoff's psychosis: Syndrome of confusion, loss of recent memory, and confabulation in alcoholic patients - Alcoholic cardiomyopathy: Effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition. -Esophagitis: Inflammation and pain in the esophagus - Gastritis: Effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention -Pancreatitis Acute: Usually occurs 1 or 2 days after a binge of excessive alcohol consumption. Symptoms include constant, severe epigastric pain; nausea and vomiting; and abdominal distention. Chronic: Leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus - Alcoholic hepatitis Caused by long-term heavy alcohol use Symptoms: Enlarged, tender liver; nausea and vomiting; lethargy; anorexia; elevated white blood cell count; fever; and jaundice. Also ascites and weight loss in severe cases. -Cirrhosis of the liver Cirrhosis is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use. There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue. - Complications of cirrhosis of the liver can include: Portal hypertension Ascites Esophageal varices Hepatic encephalopathy - Leukopenia: Impaired production, function, and movement of white blood cells Thrombocytopenia: Platelet production and survival are impaired as a result of the toxic effects of alcohol. -Sexual dysfunction In the short term, enhanced libido and failure of erection are common. Long-term effects include gynecomastia, sterility, impotence, and decreased libido. Alcohol use during pregnancy can result in fetal alcohol spectrum disorders (FASDs). Fetal alcohol syndrome (FAS): Problems with learning, memory, attention span, communication, vision, and hearing Alcohol-related neurodevelopmental disorder Alcohol-related birth defects Characteristics of FAS: Abnormal facial features Small head size Shorter-than-average height Low body weight Poor coordination Hyperactive behavior Difficulty paying attention Poor memory Difficulty in school Learning difficulties Speech and language delays Intellectual disability Poor reasoning skills Sleep and sucking problems as a baby Vision or hearing problems Problems with the heart, kidneys, or bones Alcohol intoxication: Occurs at blood alcohol levels between 100 and 200 mg/dL Alcohol withdrawal: Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use

Treatment Modalities for Substance-Related Disorders

Alcoholics Anonymous (AA) A major self-help organization for the treatment of alcoholism Based on the concept of: Peer support Acceptance Understanding from others who have experienced the same problem Alcoholics Anonymous (cont'd) The 12 steps that embody the philosophy of AA provide specific guidelines on how to attain and maintain sobriety. Total abstinence is promoted as the only cure; the person can never safely return to social drinking. These steps include: 1. Admitting powerlessness over alcohol 2. Believing that a greater power could restore sanity. 3. Make a decision to turn lives over to the care of God. 4. Making a moral inventory. 5. Admitting wrongs. 6. Become ready to have God remove defects of character. 7. Ask God to remove shortcomings. 8. Make a list of all persons harmed. 9. Made direct amends to such people wherever possible except when to do so would injure them or others. 10. Continued to take personal inventory admit wrongdoing. 11. Seek to improve conscious contact with God. 12. Carry the message to other alcoholics. Various support groups patterned after AA but for individuals with problems with other substances Counseling Group therapy Pharmacotherapy for alcoholism Disulfiram (Antabuse) Other medications Naltrexone (ReVia) Nalmefene (Revex) Selective serotonin reuptake inhibitors (SSRIs) Acamprosate (Campral) Psychopharmacology for substance intoxication and substance withdrawal Alcohol Benzodiazepines Anticonvulsants Multivitamin therapy Thiamine Psychopharmacology for substance intoxication and substance withdrawal (cont'd) Opioids Narcotic antagonists Naloxone (Narcan) Naltrexone (ReVia) Nalmefene (Revex) Methadone Buprenorphine Clonidine Psychopharmacology for substance intoxication and substance withdrawal (cont'd) Depressants Phenobarbital (Luminal) Long-acting benzodiazepines Psychopharmacology for substance intoxication and substance withdrawal (cont'd) Stimulants Minor tranquilizers Major tranquilizers Anticonvulsants Antidepressants Psychopharmacology for substance intoxication and substance withdrawal (cont'd) Hallucinogens and cannabinols Benzodiazepines Antipsychotics

Planning/Implementation A.OCD

Anxiety (Panic) Maintain calm, nonthreatening approach. Keep the immediate surroundings low in stimuli. Teach the client signs of escalating anxiety. Fear Include the client in making decisions. Encourage the client to explore underlying feelings. Ineffective Coping Initially meet the client's dependency needs. Provide a structured schedule of activities. Disturbed Body Image Help client see his or her body image is distorted. Involve client in activities that reinforce positive sense of self. Make referrals to support groups. Ineffective Impulse Control Convey a nonjudgmental attitude. Practice stress management techniques. Offer support and encouragement.

Body Dysmorphic Disorder

Assessment Characterized by the exaggerated belief that the body is deformed or defective in some specific way If true defect is present, the person's concern is unrealistically exaggerated and grossly excessive. Symptoms of depression and obsessive-compulsive personality are common.

Hoarding Disorder

Assessment The persistent difficulty discarding possessions regardless of their value. Additionally, there can be a need for excessive acquiring of items (by purchasing or other means). More men than women are diagnosed with this disorder.

Hair-Pulling Disorder (Trichotillomania)

Assessment The recurrent pulling out of one's own hair that results in noticeable hair loss Preceded by increasing tension and results in sense of release or gratification The disorder is not common, but it occurs more often in women than in men.

Obsessive-Compulsive Disorder (OCD)

Assessment data Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment Obsessions Recurrent thoughts, impulses, or images experienced as intrusive and stressful, and unable to be expunged by logic or reasoning Compulsions Repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation

Pharmacogenomics

Between 30 and 50 percent of patients do not respond to first antidepressant prescription. -A study is needed to identify benefits of routine testing, cost effectiveness, and ability to provide timely results.

Predisposing Factors SA

Biological factors Genetics: Apparent hereditary factor, particularly with alcoholism Biochemical: Alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction. Psychological factors Developmental influences Punitive superego Fixation in the oral stage of psychosexual development Psychological factors (cont'd) Personality factors: Certain personality traits are thought to increase a tendency toward addictive behavior. Cognitive factors: Irrational thinking patterns have long been identified as a problem that is central in addictions. Sociocultural factors Social learning: Children and adolescents are more likely to use substances with parents who provide model for substance use. Use of substances may also be promoted within peer group. Sociocultural factors (cont'd) Conditioning: Pleasurable effects from substance use act as a positive reinforcement for continued use of substance. Cultural and ethnic influences: Some cultures are more prone to substance abuse than are others.

Predisposing Factors schiz

Biological influences Genetics A growing body of knowledge indicates that genetics plays an important role in the development of schizophrenia. Biological influences (cont'd) Biochemical influences One theory suggests that schizophrenia may be caused by an excess of dopamine activity in the brain. Abnormalities in other neurotransmitters have also been suggested. Physiological influences Factors that have been implicated include: Viral infection Anatomical abnormalities Histological changes in brain Physiological influences (cont'd) Various physical conditions Epilepsy Huntington's disease Birth trauma Head injury in adulthood Alcohol abuse Cerebral tumor Cerebrovascular accident Systemic lupus erythematosus Myxedema Parkinsonism Wilson's disease Psychological influences These theories no longer hold credibility. Researchers now focus their studies of schizophrenia as a brain disorder. Psychosocial theories probably developed early on out of a lack of information related to a biological connection. Environmental influences Sociocultural factors: Poverty has been linked with the development of schizophrenia. Downward drift hypothesis: Poor social conditions seen as consequence of, rather than a cause of, schizophrenia Environmental influences (cont'd) Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse. Studies of genetic vulnerability for schizophrenia have linked certain genes to increased risk for psychosis and particularly for adolescents who use cannabinoids. Theoretical integration Schizophrenia is most likely a biologically based disease, the onset of which is influenced by factors in the internal or external environment.

Predisposing Factors to Depression

Biological theories Genetics Hereditary factor may be involved Biochemical influences Deficiency of norepinephrine, serotonin, and dopamine has been implicated. Excessive cholinergic transmission may also be a factor. Neuroendocrine disturbances Possible failure within the hypothalamic-pituitary-adrenocortical axis Possible diminished release of thyroid-stimulating hormone Physiological influences Medication side effects Neurological disorders Electrolyte disturbances Hormonal disorders Nutritional deficiencies Other physiological conditions Psychosocial theories Psychoanalytical theory A loss is internalized and becomes directed against the ego. Learning theory Learned helplessness: The individual who experiences numerous failures learns to give up trying. Object loss Experiences loss of significant other during first 6 months of life Feelings of helplessness and despair Early loss or trauma may predispose client to lifelong periods of depression. Cognitive theory Views primary disturbance in depression as cognitive rather than affective. Three cognitive distortions that serve as the basis for depression. Negative expectations of the environment Negative expectations of the self Negative expectations of the future

Predisposing Factors bipolar

Biological theories -Genetics Twin and family studies Other genetic studies -Biochemical influences Possible excess of norepinephrine and dopamine The exact etiology of bipolar disorder has yet to be determined. Scientific evidence supports a chemical imbalance in the brain. Theories that consider a combination of hereditary factors and environmental triggers seem to be the most credible. Discuss biological theories of the causes of bipolar disorders. Research suggests that bipolar disorder strongly reflects an underlying genetic vulnerability. Evidence from family, twin, and adoption studies exists to support this observation. Twin studies have indicated a concordance rate for bipolar disorder among monozygotic twins at 60 to 80 percent compared to 10 to 20 percent in dizygotic twins. Family studies have shown that, if one parent has a mood disorder, the risk that a child will have a mood disorder is between 10 and 25 percent. If both parents have the disorder, the risk is two to three times as high. Ongoing genetic research will continue to shed light on the genetic influences in the development of bipolar disorder and the genetic factors that influence response to treatments. Studies have associated symptoms of mania with a functional excess of norepinephrine and dopamine. The neurotransmitter serotonin is believed to remain low in both depression and mania. Acetylcholine is another neurotransmitter believed to be related to bipolar disorder. Although several neurotransmitters have been implicated in influencing symptoms, the cause of bipolar disorder remains unknown. Biological theories: Physiological influences Brain lesions Enlarged ventricles Medication side effects Neuroanatomical changes have been correltated with dysfunction in the prefrontal cortex, basal ganglia, temporal and frontal lobes of the forebrain, and to parts of the limbic system including the amygdala, thalamus, and striatum. The different symptoms in bipolar disorder may be correlated to those specific areas of dysfunction. Certain medications used to treat somatic illnesses have been known to trigger a manic response. The most common of these are the steroids frequently used to treat chronic illnesses such as multiple sclerosis and systemic lupus erythematosus (SLE). Amphetamines, antidepressants, and high doses of anticonvulsants and narcotics also have the potential for initiating a manic episode Psychosocial theories: Credibility of psychosocial theories has declined in recent years. Bipolar disorder is viewed as a disease of the brain. Psychosocial theories of the causes of bipolar disorders have declined in recent years. Conditions such as schizophrenia and bipolar disorder are more often viewed as diseases of the brain with biological etiologies. The etiology of these illnesses remains unclear, however, and it is possible that both biological and psychosocial factors may be influential.

Types of Bipolar Disorders

Bipolar I disorder Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms. May also have experienced episodes of depression Bipolar I disorder is the diagnosis given to a client who is currently experiencing a manic episode or has a history of one or more manic episodes. This diagnosis is further specified by the current or most recent behavioral episode experienced. The specifier might be single manic episode or current episode manic, hypomanic, mixed, or depressed. Psychotic or catatonic features may also be present. Bipolar II disorder Characterized by bouts of major depression with episodic occurrence of hypomania Has never met criteria for full manic episode . The individual may present with symptoms of depression or hypomania. The client has never experienced a full manic episode. The diagnosis may specify whether the current or most recent episode is hypomanic, depressed, or with mixed features. If the current syndrome is a major depressive episode, psychotic or catatonic features may be present. Cyclothymic disorder Chronic mood disturbance At least 2-year duration Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either bipolar I or II disorder Substance-induced bipolar disorder A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication or other treatment) Mood disturbances are associated with intoxication from substances such as alcohol, amphetamines, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedatives, hypnotics, and anxiolytics. Symptoms can also occur during withdrawal from substances such as alcohol, amphetamines, cocaine, sedatives, hypnotics, and anxiolytics. A number of medications have also been known to evoke mood symptoms, including anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antiulcer agents, cardiac medications, oral contraceptives, psychotropic medications, muscle relaxants, steroids, and sulfonamides. Bipolar disorder associated with another medical condition Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological effects of another medical condition

Epidemiology bipolar

Bipolar disorder affects approximately 5.7 million American adults. Gender incidence is roughly equal: Ratio of women to men is about 1.2 to 1. Average age at onset is the early 20s. More common in single than in married persons Occurs more often in the higher socioeconomic classes Sixth leading cause of disability in the middle age group Bipolar disorder affects approximately 5.7 million American adults, or about 2.6 percent of the U.S. population age 18 and older in a given year and 82.9 percent of these cases are considered severe. The average age of onset for bipolar disorder is 25 years of age, and following the first manic episode, the disorder tends to be recurrent. Bipolar disorder is the sixth leading cause of disability in the middle age group but for those who respond to lithium treatment, bipolar disorder is completely treatable, with no further episodes.

Bipolar Disorder

Bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy. Delusions or hallucinations may or may not be part of clinical picture. Onset of symptoms may reflect seasonal pattern. A somewhat milder form of mania is called hypomania. During a manic episode, the mood is elevated, expansive, or irritable. The disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others or to require hospitalization to prevent harm to self or others. The diagnostic picture for depression associated with bipolar disorder is similar to major depressive disorder, but the client must have a history of one or more manic episodes.

Cannabis Use Disorder

Cannabis use disorder A profile of the substance Marijuana Hashish Patterns of use Effects on the body Cardiovascular Respiratory Reproductive CNS Sexual functioning Describe the effects of cannabis on the body. Cannabis ingestion induces tachycardia and orthostatic hypotension. With the decrease in blood pressure, myocardial oxygen supply is decreased. Tachycardia in turn increases oxygen demand. Marijuana produces a greater amount of "tar" than its equivalent weight in tobacco. Because marijuana is most commonly smoked larger amounts of tar are deposited in the lungs, promoting deleterious effects to the lungs. Although the initial reaction to the marijuana is bronchodilation, thereby facilitating respiratory function, chronic use results in obstructive airway disorders. Frequent marijuana users often have laryngitis, bronchitis, cough, and hoarseness. Cannabis smoke contains more carcinogens than tobacco smoke. Some studies have shown that, with heavy marijuana use, men may have a decrease in sperm count, motility, and structure. In women, heavy marijuana use may result in a suppression of ovulation, disruption in menstrual cycles, and alteration of hormone levels. Many people report a feeling of being "high." Symptoms include feelings of euphoria, relaxed inhibitions, disorientation, depersonalization, and relaxation. At higher doses, sensory alterations may occur, including impairment in judgment of time and distance, recent memory, and learning ability. Physiological symptoms may include tremors, muscle rigidity, and conjunctival redness. Toxic effects are generally characterized by panic reactions. Very heavy usage has been shown to precipitate an acute psychosis that is self-limited and short-lived once the drug is removed from the body. Heavy long-term cannabis use is also associated with a condition called amotivational syndrome. Amotivational syndrome is defined as lack of motivation to persist in or complete a task that requires ongoing attention. Marijuana is reported to enhance the sexual experience in both men and women. The intensified sensory awareness and the subjective slowness of time perception are thought to increase sexual satisfaction. Marijuana also enhances the sexual functioning by releasing inhibitions for certain activities that would normally be restrained. Intoxication Symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, and impaired judgment. Physical symptoms include conjunctival injection, increased appetite, dry mouth, and tachycardia. Impairment of motor skills lasts for 8 to 12 hours. Withdrawal Occurs upon cessation of cannabis use that has been heavy and prolonged Symptoms occur within a week following cessation of use. Symptoms include irritability, anger, aggression, anxiety, sleep disturbances, decreased appetite, depressed mood, stomach pain, tremors, sweating, fever, chills, or headache.

Developmental Implications bipolar

Childhood and adolescence Lifetime prevalence of pediatric and adolescent bipolar disorders is estimated at about 1 percent. Diagnosis is difficult. In the past decade, diagnosis of bipolar I disorder in children and adolescents has rapidly increased to 40 times what it had been historically. It was thought that there was a connection between ADHD and the development of bipolar disorder in youth but research has not supported this. Studies also found that youth who were given this diagnosis more often manifested with a host of atypical symptoms including non-discrete mood episodes, chronic irritability, and temper tantrums. A study of children with non-episodic irritability found that, while these children had higher risk for anxiety and depression, they were not typically at higher risk for developing bipolar disorder. Childhood and adolescence: Treatment strategies Psychopharmacology Lithium Divalproex Carbamazepine Atypical antipsychotics Monotherapy with the traditional mood stabilizers or atypical antipsychotics has historically been the first-line treatment for children. Augmentation with a second medication is indicated when monotherapy fails. Bipolar disorder in children and adolescents appears to be a chronic condition with a high risk of relapse. Maintenance therapy incorporates the same medications used to treat acute symptoms, although few research studies exist that deal with long-term maintenance of bipolar disorder in children. Childhood and adolescence: Treatment strategies (cont'd) Attention deficit/hyperactivity disorder (ADHD) is the most common comorbid condition. ADHD agents may exacerbate mania and should be administered only after bipolar symptoms have been controlled. ADHD has been identified as the most common comorbid condition in children and adolescents with bipolar disorder. Because stimulants can exacerbate mania, it is suggested that medication for ADHD be initiated only after bipolar symptoms have been controlled with a mood stabilizing agent. Nonstimulant medications indicated for ADHD may also induce switches to mania or hypomania. Childhood and adolescence: Treatment strategies (cont'd) Family interventions Psychoeducation about bipolar disorder Communication training Problem-solving skills training Family dynamics and attitudes can play a crucial role in the outcome of a client's recovery. Interventions with family members must include education that promotes understanding that at least part of the client's negative behaviors are attributable to an illness that must be managed. Studies show that family-focused psychoeducational treatment (FFT) is an effective method of reducing relapses and increasing medication adherence in bipolar clients. This is important for adult clients as well for children and adolescents with bipolar disorder. FFT includes sessions that deal with psychoeducation about bipolar disorder, communication training, and problem-solving skills training.

Developmental Implications

Childhood depression Symptoms < age 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness Ages 3 to 5: Accident proneness, phobias, excessive self-reproach Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior Ages 9 to 12: Morbid thoughts and excessive worrying Childhood depression (cont'd) Precipitated by a loss Focus of therapy: Alleviate symptoms and strengthen coping skills Parental and family therapy Adolescence Symptoms include Anger, aggressiveness Running away Delinquency Social withdrawal Sexual acting out Substance abuse Restlessness, apathy Adolescence (cont'd) Best clue that differentiates depression from normal stormy adolescent behavior A visible manifestation of behavioral change that lasts for several weeks. Most common precipitant to adolescent suicide Perception of abandonment by parents or close peer relationship Adolescence (cont'd) Treatment with Supportive psychosocial intervention Antidepressant medication NOTE: All antidepressants carry a Food and Drug Administration black-box warning for increased risk of suicidality in children and adolescents. Senescence Bereavement overload High percentage of suicides among elderly Symptoms of depression often confused with symptoms of neurocognitive disorder Treatment Antidepressant medication Electroconvulsive therapy Psychosocial therapies Postpartum depression May last for a few weeks to several months Associated with hormonal changes, tryptophan metabolism, or cell alterations Treatments Antidepressants and psychosocial therapies Symptoms include Fatigue Irritability Loss of appetite Sleep disturbances Loss of libido Concern about inability to care for infant

Dual Diagnosis SA

Clients with a coexisting substance disorder and mental disorder may be assigned to a special program that targets the dual diagnosis. Program combines special therapies that target both problems.

Client/Family Education Related to Antidepressants depression

Continue to take medication for 4 weeks. Do not discontinue medication abruptly. Report sore throat, fever, malaise, yellow skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck and chest pain to physician. Avoid foods and medications high in tyramine when taking MAOIs. These include: Aged cheese Wine; beer Chocolate; colas Coffee; tea Sour cream; yogurt Smoked and processed meats Beef or chicken liver Canned figs Caviar Raisins Pickled herring Yeast products Broad beans Soy sauce Cold remedies Diet pills

Codependency

Defined by dysfunctional behaviors that are evident among members of the family of a chemically dependent person, or among family members who harbor secrets of physical or emotional abuse, other cruelties, or pathological conditions Codependent people sacrifice their own needs for the fulfillment of others to achieve a sense of control. Derives self-worth from others Feels responsible for the happiness of others Commonly denies that problems exist Keeps feelings in control, and often releases anxiety in the form of stress-related illnesses, or compulsive behaviors such as eating, spending, working, or use of substances May have experienced abuse or emotional neglect as a child Outwardly focused on others and know very little about how to direct their lives from their own sense of self Classic characteristics Caretaking Perfectionism Denial Poor communication Treating Codependence: Recovery process Survival stage Re-identification stage Core issues stage Reintegration stage

Types of Schizophrenia and Other Psychotic Disorders

Delusional disorder The existence of prominent, nonbizarre delusions Erotomanic type Grandiose type Jealous type Persecutory type Somatic type Mixed type Erotomanic Type. The individual believes that someone, usually of a higher status, is in love with him or her. Famous persons are often the subjects of erotomanic delusions. Grandiose Type. Individuals with grandiose delusions have irrational ideas regarding their own worth, talent, knowledge, or power. They may believe that they have a special relationship with a famous person, or even assume the identity of a famous person. Grandiose delusions of a religious nature may lead to assumption of the identity of a deity or religious leader. Jealous Type. Jealous delusions center on the idea that the person's sexual partner is unfaithful. The idea is irrational and without cause, but the individual with the delusion searches for evidence to justify the belief. The sexual partner is confronted regarding the imagined infidelity.. Persecutory Type. In persecutory delusions, which are the most common type, individuals believe they are being persecuted or malevolently treated in some way. Frequent themes include being plotted against, cheated or defrauded, followed and spied on, poisoned, or drugged. Repeated complaints may be directed at legal authorities, lack of satisfaction from which may result in violence toward the object of the delusion. Somatic Type. Individuals with somatic delusions believe they have some type of general medical condition. Mixed Type. When the disorder is mixed, delusions are prominent, but no single theme is predominant. Brief psychotic disorder Sudden onset of symptoms May or may not be preceded by a severe psychosocial stressor Lasts less than 1 month Return to full premorbid level of functioning Substance-induced psychotic disorder The presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal Psychotic disorder associated with another medical condition Prominent hallucinations and delusions are directly attributable to a general medical condition. The catatonic features specifier Catatonic features may be associated with other psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder. Symptoms of catatonic disorder include: Stupor and muscle rigidity or excessive, purposeless motor activity Waxy flexibility, negativism, echolalia, echopraxia Catatonic disorder associated with another medical condition This diagnosis is made when the catatonic symptoms are directly attributable to the physiological consequences of a general medical condition. Schizophreniform disorder Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months Schizoaffective disorder Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders either mania or depression

Nursing Process: Assessment suicide

Demographics Age Gender Ethnicity Martial status Socioeconomic status Occupation Lethality and availability of method Religion Family history of suicide The following items should be considered when conducting a suicidal assessment: demographics, presenting symptoms/medical-psychiatric diagnosis, suicidal ideas or acts, interpersonal support system, analysis of the suicidal crisis, psychiatric/medical/family history, and coping strategies. Discuss the list of demographics on slide 17 and how they relate to suicide as covered in the risk factors section of the lecture. Presenting symptoms/medical-psychiatric diagnosis Suicidal ideas or acts Seriousness of intent Plan Means Verbal and behavioral clues Interpersonal support system Assessment data must be gathered regarding any psychiatric or physical condition for which the client is being treated. Mood disorders (major depression and bipolar disorders) are the most common disorders that precede suicide. Individuals with substance use disorders are also at high risk. Other psychiatric disorders in which suicide risks have been identified include anxiety disorders, schizophrenia, anorexia nervosa, and borderline and antisocial personality disorders. Individuals may leave both behavioral and verbal clues as to the intent of their act. Examples of behavioral clues include giving away prized possessions, getting financial affairs in order, writing suicide notes, or sudden lifts in mood (may indicate a decision to carry out the intent). Lack of a meaningful network of satisfactory relationships may implicate an individual as a high risk for suicide during an emotional crisis. Analysis of the suicidal crisis Precipitating stressor Relevant history Life-stage issues Psychiatric/medical/family history Adverse life events in combination with other risk factors such as depression may lead to suicide. Life stresses accompanied by an increase in emotional disturbance include the loss of a loved person either by death or by divorce, problems in major relationships, changes in roles, or serious physical illness. The ability to tolerate losses and disappointments is often compromised if those losses and disappointments occur during various stages of life in which the individual struggles with developmental issues. The individual should be assessed with regard to previous psychiatric treatment for depression, alcoholism, or for previous suicide attempts. Medical history should be obtained to determine presence of chronic, debilitating, or terminal illness. Is there a history of depressive disorder in the family, and has a close relative committed suicide in the past?

Introduction depression

Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses. Transient symptoms are normal, healthy responses to everyday disappointments in life. Pathological depression occurs when adaptation is ineffective. Mood is also called affect. Depression is an alteration in mood that is expressed by feelings of sadness, despair, and pessimism.

Nursing Process: Diagnosis/Outcome Identification schiz

Disturbed Sensory Perception (auditory and visual) related to panic anxiety, extreme loneliness, and withdrawal into self -Disturbed Thought Processes related to inability to trust, panic anxiety, or possible hereditary or biochemical factors Social Isolation related to inability to trust, panic anxiety, weak ego development, delusional thinking, regression Risk for Violence: Self-directed or Other-directed related to Extreme suspiciousness Panic anxiety Catatonic excitement Rage reactions Command hallucinations Impaired Verbal Communication related to Panic anxiety Regression Withdrawal Disordered unrealistic thinking Self-Care Deficit related to Withdrawal Regression Panic anxiety Perceptual or cognitive impairment Inability to trust Disabled Family Coping related to difficulty coping with client's illness Ineffective Health Maintenance related to disordered thinking or delusions Impaired Home-Maintenance related to Regression Withdrawal Lack of knowledge or resources Impaired physical or cognitive functioning

Nursing Process: Planning/Implementation schiz

Disturbed Sensory Perception: Auditory/Visual Observe the client for signs of hallucinations. Help client understand connections between anxiety and hallucinations. Distract the client from hallucinations. Disturbed Thought Processes Do not argue or deny the belief. Reinforce and focus on reality. Risk for Violence Observe client's behavior. Maintain calm attitude. Have sufficient staff on hand. Impaired Verbal Communication Facilitate trust and understanding. Orient the client to reality.

Historical Perspective bipolar

Documentation of the symptoms associated with bipolar disorder dates back to the second century in Greece. -In early writings, mania was categorized with all forms of "severe madness." Documentation of the symptoms associated with bipolar disorder dates back to ancient Greece. Aretaeus of Cappadocia, a Greek physician, is credited with associating these extremes of mood as part of the same illness. In 1025, the Persian physician, Avicenna, wrote The Canon of Medicine in which he described mania as "bestial madness characterized by rapid onset and remission, with agitation and irritability." The modern concept of manic-depressive illness began to emerge in the 19th century, with terms such as "dual-form insanity" and "circular insanity." The term manic-depressive was first coined in 1913, and the American Psychiatric Association adopted the term bipolar disorder in 1980. In 1854, Jules Baillarger presented information to the French Imperial Academy of Medicine in which he used the term "dual-form insanity" to describe the illness. In the same year, Jean-Pierre Falret described the same disorder, which he termed "circular insanity." Contemporary thinking has been shaped a great deal by the works of Emil Kraepelin, who first coined the term manic-depressive in 1913. His approach became the most widely accepted theory of the early 1930s.

Evaluation bipolar

Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria. Has the client avoided personal injury? Has violence to client or others been prevented? Has agitation subsided? Have nutritional status and weight been stabilized? Have delusions and hallucinations ceased? Is the client able to make decisions about own self-care? Is behavior socially acceptable? Is the client able to sleep 6 to 8 hours per night and awaken feeling rested? Does the client understand the importance of maintenance medication therapy?

Epidemiology depression

During their lifetime, about 21 percent of women and 13 percent of men will become clinically depressed. Major depressive disorder (MDD) is one of the leading causes of disability in the United States. The lifetime prevalence of depression is about 17% which makes it the most prevalent psychiatric disorder. Gender prevalence Depression is more prevalent in women than in men by about 2 to 1. Age Depression is more common in young women than in young men. The gender difference is less pronounced between ages 44 and 65, but after age 65, women are again more likely to be depressed than are men. Social class There is an inverse relationship between social class and report of depressive symptoms. Race No consistent relationship between race and affective disorder has been reported. One recent survey revealed: Depression is more prevalent in whites than in blacks. Depression is more severe and disabling in blacks. Blacks are less likely to receive treatment than are whites. Marital status Single and divorced people are more likely to experience depression than are married persons or persons with a close interpersonal relationship (differences occur in various age groups). Seasonality Affective disorders are more prevalent in the spring and in the fall.

Nursing Process: Evaluation schiz

Evaluation questions Has client established trust with at least one staff member? Is anxiety level maintained at a manageable level? Is delusional thinking still prevalent? Is client able to interrupt escalating anxiety with adaptive coping mechanisms? Is client easily agitated? Is client able to interact with others appropriately?

Nursing Process: Evaluation SA

Evaluation involves reassessment to determine whether the nursing interventions have been effective in achieving the intended goals of care. Evaluation of the client with a substance-related disorder may be accomplished by using information gathered from the following reassessment questions: Has detoxification occurred without complications? Is the client still in denial? Does the client accept responsibility for his or her own behavior? Has he or she acknowledged a personal problem with substances? Has a correlation been made between personal problems and the use of substances? Does the client still make excuses or blame others for use of substances? Has the client remained substance-free during treatment? Does the client cooperate with treatment? Does the client refrain from manipulative behavior and violation of limits? Is the client able to verbalize motivation toward alternative adaptive coping strategies to substitute for substance use? Has the use of these strategies been demonstrated? Does positive reinforcement encourage repetition of these adaptive behaviors? Has nutritional status been restored? Does the client consume diet adequate for his or her size and level of activity? Is the client able to discuss the importance of adequate nutrition? Has the client remained free of infection during hospitalization? Is the client able to verbalize the effects of substance abuse on the body?

Evaluation T&S disorders

Evaluation of care for the client with a trauma-related disorder is based on successful achievement of the previously established outcome criteria. Can the client discuss the traumatic event without experiencing panic anxiety? Has the client learned new, adaptive coping strategies for assistance with recovery? Evaluation of the nursing actions for the client with a trauma-related disorder may be facilitated by asking the following types of questions: Can the client discuss the traumatic event without experiencing panic anxiety? Does the client voluntarily discuss the traumatic event? Can the client discuss changes that have occurred in his or her life because of the traumatic event? Does the client have "flashbacks?" Can the client sleep without medication? Does the client have nightmares? Has the client learned new, adaptive coping strategies for assistance with recovery? Can the client demonstrate successful use of these new coping strategies in times of stress? Can the client verbalize stages of grief and the normal behaviors associated with each? Can the client recognize his or her own position in the grieving process? Is guilt being alleviated? Has the client maintained or regained satisfactory relationships with significant others? Can the client look to the future with optimism? Does the client attend a regular support group for victims of similar traumatic experiences? Does the client have a plan of action for dealing with symptoms, if they return?

Nursing Process/Evaluation A.OCD

Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria. Can the client recognize signs and symptoms of escalating anxiety, and interrupt before it reaches panic level? Can the client demonstrate activities that can be used to maintain anxiety at a manageable level? Can the client discuss the phobic object or situation without becoming anxious? Can the client recognize signs and symptoms of escalating anxiety? Can the client use skills learned to interrupt the escalating anxiety before it reaches the panic level? Can the client demonstrate the activities most appropriate for him or her that can be used to maintain anxiety at a manageable level (e.g., relaxation techniques; physical exercise)? Can the client maintain anxiety at a manageable level without medication? Can the client verbalize a long-term plan for preventing panic anxiety in the face of a stressful situation? Can the client discuss the phobic object or situation without becoming anxious? Can the client function in the presence of the phobic object or situation without experiencing panic anxiety? Can the OCD client refrain from performing rituals when anxiety level rises and demonstrate substitute behaviors to maintain anxiety at a manageable level? Can the client function in the presence of the phobic object or situation without experiencing panic anxiety? Can the OCD client refrain from performing rituals when anxiety level rises? Can the OCD client demonstrate substitute behaviors to maintain anxiety at a manageable level? Does the OCD client recognize the relationship between escalating anxiety and the dependence on ritualistic behaviors for relief? Can the client with trichotillomania refrain from hair-pulling and substitute a more adaptive behavior when urges to pull hair occur? Does the client with body dysmorphic disorder verbalize a realistic perception and satisfactory acceptance of personal appearance?

Application of the Nursing Process SA

Nurses must begin relationship development with a substance abuser by examining own attitudes and personal experiences with substances.

Psychopharmacology bipolar

For mania Lithium carbonate Anticonvulsants Verapamil Antipsychotics For depressive phase Use antidepressants with care (may trigger mania). For many years, the drug of choice for treatment and management of bipolar mania was lithium carbonate. However, in recent years, a number of investigators and clinicians in practice have achieved satisfactory results with several other medications, including anticonvulsant drugs which have a mood stabilizing effect either alone or in combination with lithium. Clients who respond to lithium can virtually be symptom free over the long term and about 33% of people treated with lithium respond positively.

Non-Substance Addictions

Gambling disorder Persistent and recurrent problematic gambling behavior that intensifies when the individual is under stress. As the need to gamble increases, the individual may use any means required to obtain money to continue the addiction. Gambling behavior usually begins in adolescence, although compulsive behaviors rarely occur before young adulthood. The disorder usually runs a chronic course, with periods of waxing and waning. The disorder interferes with interpersonal relationships, social, academic, or occupational functioning. Predisposing Factors to Gambling Disorder: Biological influences Genetic Increased incidence among family members Physiological Abnormalities in neurotransmitter systems Psychosocial influences Loss of a parent before age 15 Inappropriate parental discipline Exposure to gambling activities as an adolescent Family emphasis on material and financial symbols Lack of family emphasis on saving, planning, and budgeting Psychosocial influences (cont'd) The psychoanalytical view suggests that gambling is used to release a build-up of tension. Treatment Modalities for Gambling Disorder: Behavior therapy Cognitive therapy Psychoanalysis Psychopharmacology SSRIs Clomipramine Lithium Carbamazepine Naltrexone Gamblers Anonymous Organization modeled after AA Only requirement for membership is an expressed desire to stop gambling Reformed gamblers help others resist the urge to gamble.

Nursing Process: Planning/Implementation suicide

Guidelines for treatment of the suicidal client on an outpatient basis: Do not leave the person alone. Establish a no-suicide contract with the client. Enlist the help of family or friends. Schedule frequent appointments. Establish rapport and promote a trusting relationship. Guidelines for treatment of the suicidal client on an outpatient basis include the following: The person should not be left alone. Arrangements must be made for the client to stay with family or friends. If this is not possible, hospitalization should be reconsidered. A no suicide contract may be established with the client but only as an adjunct to other interventions. The focus of this intervention is to formulate a written or verbal contract that the client will not harm himself or herself in a stated period of time. Enlist the help of family or friends to ensure that the home environment is safe from dangerous items, such as firearms or stockpiled drugs. Give support persons the telephone number of the counselor, or an emergency contact person in the event that the counselor is not available. Appointments may need to be scheduled daily or every other day at first until the immediate suicidal crisis has subsided. Establish rapport and promote a trusting relationship. It is important for the suicide counselor to become a key person in the client's support system at this time. Guidelines for treatment of the suicidal client on an outpatient basis (cont'd) Be direct and talk matter-of-factly about suicide. Discuss the current crisis situation in the client's life. Identify areas of self-control. Give antidepressant medications. Be direct. Talk openly and matter-of-factly about suicide. Listen actively and encourage expression of feelings, including anger. Discuss the current crisis situation in the client's life. Use the problem-solving approach. Help the client identify areas of the life situation that are within his or her control and those that the client does not have the ability to control. Discuss feelings associated with these control issues. The physician or nurse practitioner may prescribe antidepressants for an individual who is experiencing suicidal depression. It is wise to prescribe no more than a 3-day supply of the medication with no refills. Information for family and friends of the suicidal client: Take any hint of suicide seriously. Do not keep secrets. Be a good listener. Express feelings of personal worth to the client. Know about suicide intervention resources. Restrict access to firearms or other means of self-harm. Take any hint of suicide seriously. Anyone expressing suicidal feelings needs immediate attention. Do not keep secrets. Suicidal individuals are ambivalent about dying, and suicidal behavior is a cry for help. It is that ambivalence that leads the person to confide to you the suicidal thoughts. Be a good listener. If people express suicidal thoughts or feel depressed, hopeless, or worthless, be supportive. Let them know you are there for them and are willing to help them seek professional help. Many people find it awkward to put into words how another person's life is important for their own well-being, but it is important to stress that the person's life is important to you and to others. Emphasize in specific terms the ways in which the person's suicide would be devastating to you and to others. Express concern for individuals who express thoughts about committing suicide. Familiarize yourself with suicide intervention sources, such as mental health centers and suicide hotlines. Ensure that access to firearms or other means of self-harm is restricted. Information for family and friends of the suicidal client: Acknowledge and accept the person's feelings. Provide a feeling of hopefulness. Do not leave him or her alone. Show love and encouragement. Seek professional help. Remove children from the home. Do not judge or show anger toward the person or provoke guilt in him or her. Acknowledge and accept their feelings and be an active listener. Try to give them hope and remind them that what they are feeling is temporary. Stay with them. Do not leave them alone. Go to where they are, if necessary. Show love and encouragement. Hold them, hug them, and touch them. Allow them to cry and express anger. Help them seek professional help. Remove any items from the home with which the person may harm himself or herself. If there are children present, try to remove them from the home. Perhaps another friend or relative can assist by taking them to their home. DO NOT: judge suicidal people, show anger toward them, provoke guilt in them, discount their feelings, or tell them to "snap out of it." Interventions with family and friends of suicide victims: Encourage him or her to talk about the suicide. Discourage blaming and scapegoating. Listen to feelings of guilt and self-persecution. Talk about personal relationships with the victim. Recognize differences in styles of grieving. Assist with development of adaptive coping strategies. Identify resources that provide support. Suicide of a family member can induce a whole gamut of feelings in the survivors. It has long been recognized that the bereavement process in families where a member has taken their own life, is complicated and requires an understanding by health care providers of some unique burdens of this type of loss.

Evaluation depression

Has self-harm to the client been avoided? Have suicidal ideations subsided? Does the client know where to seek assistance outside of the hospital when suicidal thoughts occur? Has the client discussed the recent loss with the staff and family members? Is he or she able to verbalize feelings and behaviors associated with each stage of the grieving process and recognize own position in the process? Have obsession with and idealization of the lost object subsided? Is anger toward the lost object expressed appropriately ? Does client set realistic goals for self? Is the client able to verbalize positive aspects about self, past accomplishments, and future prospects? Can the client identify areas of life situation over which he or she has control?

Other Nursing Diagnoses depression

Imbalanced nutrition less than body requirements Insomnia Self-care deficit All related to depressed mood

Treatment Modalities A.OCD

Individual psychotherapy Cognitive therapy Behavior therapy Systematic desensitization Implosion therapy Discuss the various treatment possibilities for clients with anxiety, obsessive-compulsive, and related disorders. Therapy can be beneficial to a client suffering from bipolar disorder. Supportive psychotherapy is designed to help the client identify their personal strengths and explore adaptive coping mechanisms. Insight-oriented psychotherapy, which is rooted in Freudian psychology, is designed to help the client identify, explore, and resolve internal psychological conflicts that are contributing to anxiety. Cognitive therapy strives to assist the individual to reduce anxiety responses by altering cognitive distortions. Anxiety is described as being the result of exaggerated, automatic thinking. Cognitive therapy for anxiety is brief and time limited, usually lasting from 5 to 20 sessions. Brief therapy discourages the client's dependency on the therapist, which is prevalent in anxiety disorders, and encourages the client's self-sufficiency. Behavior modification has been used to treat trichotillomania. Various techniques have been tried, including covert desensitization and habit-reversal therapy (HRT). These may include a system of positive and negative reinforcements in an effort to modify the hair-pulling behaviors. With HRT, in an attempt to extinguish the unwanted behavior, the individual learns to become more aware of the hair pulling, identify times of occurrence, and substitute a more adaptive coping strategy. Other forms of behavior therapy include systematic desensitization and implosion therapy (flooding). In systematic desensitization, the client is gradually exposed to the phobic stimulus, either in a real or imagined situation. In implosion therapy, the therapist "floods" the client with information concerning situations that trigger anxiety in him or her. The therapist describes anxiety-provoking situations in vivid detail and is guided by the client's response; the more anxiety provoked, the more expedient is the therapeutic endeavor. Psychopharmacology Examples of anti-anxiety agents Hydroxyzine (Vistaril) Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan) Oxazepam Meprobamate Buspirone (BuSpar) Medication for specific disorders Panic and GAD Anxiolytics Antidepressants Antihypertensive agents Benzodiazepines have been used with success in the treatment of generalized anxiety disorder. They can be prescribed on an as-needed basis when the client is feeling particularly anxious. Alprazolam, lorazepam, and clonazepam have been particularly effective in the treatment of panic disorder. Several antidepressants are effective as major antianxiety agents. The tricyclics clomipramine and imipramine have been used with success in clients experiencing panic disorder. However, since the advent of SSRIs, the tricyclics are less widely used because of their tendency to produce severe side effects at the high doses required to relieve symptoms of panic disorder. Several studies have called attention to the effectiveness of beta blockers (e.g., propranolol) and alpha2-receptor agonists (e.g., clonidine) in the amelioration of anxiety symptoms. Psychopharmacology (cont'd) Medication for specific disorders (cont'd) Phobic disorders Anxiolytics Antidepressants Antihypertensive agents Benzodiazepines have been successful in the treatment of social anxiety disorder (social phobia). Controlled studies have shown the efficacy of alprazolam and clonazepam in reducing symptoms of social anxiety. The tricyclic imipramine and the monoamine oxidase inhibitor (MAOI) phenelzine have been effective in diminishing symptoms of agoraphobia and social anxiety disorder. In recent years, the SSRIs have become the first-line treatment of choice for social anxiety disorder, and paroxetine and sertraline have been approved for this purpose. Beta-blockers, propranolol and atenolol, have been tried with success in clients experiencing anticipatory performance anxiety. This type of phobic response produces symptoms such as sweaty palms, racing pulse, trembling hands, dry mouth, labored breathing, nausea, and memory loss. The beta-blockers appear to be quite effective in reducing these symptoms in some individuals. Psychopharmacology (cont'd) Medication for specific disorders (cont'd) OCD and body dysmorphic disorder Antidepressants The SSRIs fluoxetine, paroxetine, sertraline, and fluvoxamine have been approved by the FDA for the treatment of OCD. The tricyclic antidepressant clomipramine was the first drug approved by the FDA in the treatment of OCD. Clomipramine is more selective for serotonin reuptake than any of the other tricyclics. Its efficacy in the treatment of OCD is well established, although the adverse effects, such as those associated with all the tricyclics, may make it less desirable than the SSRIs. The most positive results of pharmacological therapy with body dysmorphic disorder have been with clomipramine (Anafranil) and fluoxetine (Prozac). These medications have been shown to reduce symptoms in more than 50 percent of clients with the disorder. Psychopharmacology (cont'd) Medication for specific disorders (cont'd) Hair-pulling disorder Chlorpromazine Amitriptyline Lithium carbonate Selective serotonin reuptake inhibitors and pimozide Olanzapine

Treatment Modalities depression

Individual psychotherapy Group therapy Family therapy Cognitive therapy Electroconvulsive therapy Mechanism of action: Thought to increase levels of biogenic amines Side effects: Temporary memory loss and confusion Risks: Mortality; permanent memory loss; brain damage Medications: Pretreatment medication; muscle relaxant; short-acting anesthetic Transcranial magnetic stimulation Vagal nerve stimulation and deep brain stimulation Light therapy Psychopharmacology Tricyclics Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors (MAOIs) Heterocyclics Serotonin-norepinephrine reuptake inhibitors

Treatment Modalities for Bipolar Disorder

Individual psychotherapy Group therapy Family therapy Cognitive therapy Therapy, whether in a one-on-one environment or with a group, can be beneficial to a client suffering from bipolar disorder. Interpersonal and social rhythm therapy (IPSRT) is a type of therapy specifically designed for bipolar patients. Developed by Frank, the focus of this therapy is helping clients to regulate their social rhythms, or daily activities such as the sleep-wake cycle and exercise routines, that may otherwise disrupt underlying biologic rhythms and contribute to mood disturbances. Once an acute phase of the illness is passed, groups can provide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise out of having a serious affective disorder. Both group psychoeducation and group CBT have demonstrated benefits for this population. The element of peer support may provide a feeling of security, as troublesome or embarrassing issues are discussed and resolved. Self-help groups offer another avenue of support for the individual with bipolar disorder. These groups are usually peer led and are not meant to substitute for, or compete with, professional therapy. The ultimate objectives in working with families of clients with mood disorders are to resolve the symptoms and initiate or restore adaptive family functioning. Some studies with bipolar disorder have shown that behavioral family treatment combined with medication substantially reduces relapse rate compared with medication therapy alone. In cognitive therapy, the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of mood disorders. The general goals in cognitive therapy are to obtain symptom relief as quickly as possible, to assist the client in identifying dysfunctional patterns of thinking and behaving, and to guide the client to evidence and logic that effectively tests the validity of the dysfunctional thinking. The Recovery Model Learning how to live a safe, dignified, full, and self-determined life in the face of the enduring disability which may, at times, be associated with serious mental illness. In bipolar disorder, recovery is a continuous process: Client identifies goals. Client and clinician develop a treatment plan. Client and clinician work on strategies to help the individual manage the bipolar illness. Clinician serves as support person to help the individual achieve the previously identified goals. Although there is no cure for bipolar disorder, recovery is possible in the sense of learning to prevent and minimize symptoms, and to successfully cope with the effects of the illness on mood, career, and social life. Electroconvulsive therapy (ECT): Episodes of mania may be treated with ECT when Client does not tolerate medication. Client fails to respond to medication. Client's life is threatened by dangerous behavior or exhaustion.

Nursing Diagnosis/Outcome Identification SA

Ineffective Denial related to weak, underdeveloped ego Outcome: Client will demonstrate acceptance of responsibility for own behavior and acknowledge association between personal problems and use of substance(s). Ineffective Coping related to inadequate coping skills and weak ego Outcome: Client will be able to demonstrate more adaptive coping mechanisms that can be used in stressful situations (instead of taking substances). Imbalanced Nutrition less than body requirements/Fluid volume deficit related to drinking or taking drugs instead of eating Outcome: Client will be free from signs or symptoms of malnutrition/dehydration. Risk for Infection related to malnutrition and altered immune condition Outcome: Shows no signs or symptoms of infection. Chronic Low Self-Esteem related to weak ego, lack of positive feedback Outcome: Exhibits evidence of increased self-worth by attempting new projects without fear of failure and by demonstrating less defensive behavior toward others. Deficient Knowledge (effects of substance abuse on the body) related to denial of problems with substances evidenced by abuse of substances Outcome: Verbalizes importance of abstaining from use of substances to maintain optimal wellness. For the client withdrawing from CNS depressants Risk for Injury related to CNS agitation For the client withdrawing from CNS stimulants Risk for Suicide related to intense feelings of lassitude and depression, "crashing," suicidal ideation

Sedative/Hypnotic-Induced Disorder

Intoxication With these central nervous system (CNS) depressants, effects can range from disinhibition and aggressiveness to coma and death (with increasing dosages of the drug). Withdrawal Onset of symptoms depends on the half-life of the drug from which the person is withdrawing. Severe withdrawal from CNS depressants can be life threatening. Stimulant use disorder A profile of the substance Amphetamines Synthetic stimulants Non-amphetamine stimulants Cocaine Caffeine Nicotine Patterns of use Effects on the body CNS effects Cardiovascular effects Pulmonary effects Gastrointestinal and renal effects Sexual functioning Intoxication Amphetamine and cocaine intoxication produce euphoria, impaired judgment, confusion, and changes in vital signs (even coma or death, depending on amount consumed). Caffeine intoxication usually occurs following consumption in excess of 250 mg. Restlessness and insomnia are the most common symptoms. Withdrawal Amphetamine and cocaine withdrawal may result in dysphoria, fatigue, sleep disturbances, and increased appetite. Withdrawal from caffeine may include headache, fatigue, drowsiness, irritability, muscle pain and stiffness, and nausea and vomiting. Withdrawal from nicotine may include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite.

Anxiety Disorders

Introduction Anxiety is an emotional response to anticipation of danger, the source of which is largely unknown or unrecognized. Anxiety is a necessary force for survival. It is not the same as stress. A stressor is an external pressure that is brought to bear on the individual. Anxiety is the subjective emotional response to that stressor. Anxiety may be distinguished from fear in that anxiety is an emotional process, whereas fear is a cognitive one. Historical Aspects: Anxiety was once identified by its physiological symptoms, focusing largely on the cardiovascular system. Freud was the first to associate anxiety with neurotic behaviors. For many years, anxiety disorders were viewed as purely psychological or purely biological in nature Epidemiological Statistics: Anxiety disorders are the most common of all psychiatric illnesses. More common in women than in men Minority children and children from low socioeconomic environments are at risk. A familial predisposition probably exists. How Much Is Too Much? When anxiety is out of proportion to the situation that is creating it When anxiety interferes with social, occupational, or other important areas of functioning

The Chemically Impaired Nurse

It is estimated that 10 to 15 percent of nurses suffer from the disease of chemical dependency. Alcohol is the most widely abused drug, followed closely by narcotics. High absenteeism may be present if the person's source is outside the work area. Or, the person may rarely miss work if the substance source is at work. Increase in "wasting" of drugs, higher incidences of incorrect narcotic counts, and a higher record of signing out drugs for other nurses may be present. Poor concentration, difficulty meeting deadlines, inappropriate responses, and poor memory or recall Problems with relationships Irritability, tendency to isolate, elaborate excuses for behavior Unkempt appearance, impaired motor coordination, slurred speech, flushed face Patient complaints of inadequate pain control, discrepancies in documentation State board response May deny, suspend, or revoke a license based on a report of chemical abuse by a nurse Diversionary laws allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. During the suspension period Successful completion of an inpatient, outpatient, group, or individual counseling treatment program Evidence of regular attendance at nurse support groups or 12-step program Random negative drug screens Employment or volunteer activities Peer assistance programs serve to assist impaired nurses to: Recognize their impairment Obtain necessary treatment Regain accountability within profession

Client/Family Education drugs bipolar

Lithium Take the medication regularly. Do not skimp on dietary sodium. Drink six to eight glasses of water each day. Notify physician if vomiting or diarrhea occur. Have serum lithium level checked every 1 to 2 months, or as advised by physician. Notify physician if any of the following symptoms occur: Persistent nausea and vomiting Severe diarrhea Ataxia Blurred vision Tinnitus Excessive output of urine Increasing tremors Mental confusion Anticonvulsants: Refrain from discontinuing the drug abruptly. Report the following symptoms to the physician immediately: skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes. Avoid using alcohol and over-the-counter medications without approval from physician. Verapamil: Do not discontinue the drug abruptly. Rise slowly from sitting or lying position to prevent sudden drop in blood pressure. Report the following symptoms to physician: Irregular heart beat; chest pain Shortness of breath; pronounced dizziness Swelling of hands and feet Profound mood swings Severe and persistent headache Antipsychotics: Do not discontinue drug abruptly. Use sunblock when outdoors. Rise slowly from a sitting or lying position. Avoid alcohol and over-the-counter medications. Continue to take the medication, even if feeling well and as though it is not needed; symptoms may return if medication is discontinued. Report the following symptoms to physician: Sore throat; fever; malaise Unusual bleeding; easy bruising; skin rash Persistent nausea and vomiting Severe headache; rapid heart rate Difficulty urinating or excessive urination Muscle twitching, tremors Darkly colored urine; pale stools Yellow skin or eyes Excessive thirst or hunger Muscular incoordination or weakness

Introduction bipolar

Mood is defined as a pervasive and sustained emotion that may have a major influence on a person's perception of the world. -Examples of mood: Depression, joy, elation, anger, anxiety Affect is described as the emotional reaction associated with an experience. Mood was defined in the previous chapter as a pervasive and sustained emotion that may have a major influence on a person's perception of the world. Affect is described as the external, observable emotional reaction associated with an experience. Mania is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. -Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.

Types of Depressive Disorders

Major depressive disorder Characterized by depressed mood Loss of interest or pleasure in usual activities Symptoms present for at least 2 weeks No history of manic behavior Cannot be attributed to use of substances or another medical condition Dysthymic disorder Sad or "down in the dumps" No evidence of psychotic symptoms Essential feature is a chronically depressed mood for Most of the day More days than not At least 2 years Premenstrual dysphoric disorder Depressed mood Anxiety Mood swings Decreased interest in activities Symptoms begin during week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses Substance-induced depressive disorder Considered to be the direct result of physiological effects of a substance Depressive disorder associated with another medical condition Attributable to the direct physiological effects of a general medical condition

Historical Perspectives depression

Many ancient cultures believed in the supernatural or divine origin of mood disorders. Hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain.

Risk Factors suicide

Marital status -The suicide rate for single persons is twice that of married persons. Gender -Women attempt suicide more often, but more men succeed. -Men commonly choose more lethal methods than do women. The suicide rate for single, never married persons is twice that of married persons and divorce increases risk for suicide particularly among men, who are three times more likely to take their own lives than divorced women. Widows and widowers also have high risk. Women attempt suicide more, but men succeed more often. Successful suicides number about 70 percent for men and 30 percent for women. This has to do with the lethality of the means. Women tend to overdose; men use more lethal means such as firearms. Transgender individuals are also a high risk population for suicide with an alarming 41 percent lifetime prevalence Age -Risk of suicide increases with age, particularly among men. -White men older than 80 years are at the greatest risk of all age, gender, and race groups. The most recent statistics revealed that in 2013 the highest rate of suicide occurred in the 45-64 age group and the second highest rate was for those 85 or older. A high rate of suicide in these age groups has been a consistent trend from 2000 to 2013 but the 45-64 age group has shown a steady incline in suicide rates over the same period. Although adolescents may statistically have a lower rate of suicide than some other age groups, it is still important to note that it has been, over several years, the third leading cause of death in this population. Several factors put adolescents at risk for suicide, including impulsive and high-risk behaviors, untreated mood disorders, and substance abuse. Among children under 10 years of age, the statistics demonstrate a low number of suicides and some have argued that younger children don't really have the capacity to intentionally consider and follow through with a suicide attempt. Anecdotal evidence has shown this is not always the case, with some therapists identifying 5-9 year olds actively talking about suicide. While the elderly make up just over 13 percent of the population, they account for almost 15 percent of all suicides. n general, 70 % of all suicides are among white males but white males over the age of 80 are at the greatest risk of all age/gender/race groups. Religion -Affiliation with a religious group decreases risk of suicide. Catholics have lower rates than do Protestants or Jews. Socioeconomic status -Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle class. Ethnicity -Whites are at highest risk for suicide followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans. Historically, suicide rates among Protestants and Jews have been higher than Roman Catholic or Muslim populations but the degree of orthodoxy and affiliation with one's religion may be an important variable. Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle classes. With regard to occupation, suicide rates are higher among physicians, artists, dentists, law enforcement officers, lawyers, and insurance agents. There are more suicides among the unemployed and during recessions or depressions in the economy. With regard to ethnicity, statistics show that whites are at highest risk for suicide, followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans. Recent research has highlighted two trends that illuminate issues of concern within specific ethnic groups. First, while suicide rates among whites are higher in adults and the elderly, within the Native American community young adults have a higher risk for suicide than any other ethnicity and higher than the general population. Another recent study looked at suicide trends among school aged children under the age of. A significant finding was that suicide rates for black children, aged 5 to 11 years of age nearly doubled over the period from 1993 to 2012 while the overall suicide rate in this age group remained relatively stable during the same time period. Other risk factors -Psychiatric illness: Mood and substance use disorders are the most common psychiatric illnesses that precede suicide. Other psychiatric disorders that account for suicidal behavior include: Schizophrenia Personality disorders Anxiety disorders -Severe insomnia is associated with increased risk of suicide. More than 90 percent of people who kill themselves have a diagnosable mental disorder, most commonly a mood disorder or a substance abuse disorder. Individuals who have been hospitalized for a psychiatric illness have five to ten times greater suicide risks than those with psychiatric illness in the general population. Severe insomnia is associated with increased suicide risk, even in the absence of depression. Other risk factors (cont'd) -Use of alcohol and barbiturates -Psychosis with command hallucinations -Affliction with a chronic, painful, or disabling illness -Family history of suicide -Homosexual individuals have a higher risk of suicide than do their heterosexual counterparts. Use of alcohol, and particularly a combination of alcohol and barbiturates, increases the risk of suicide. Withdrawal from stimulants increases suicide risk as the person begins to "crash". Psychosis, especially with command hallucinations, poses a higher risk. Affliction with a chronic painful or disabling illness also increases the risk of suicide. Several studies have indicated a higher risk factor for suicide among gay men and lesbians. A report from the Centers for Disease Control and Prevention identified that in a study of youth, grades 7 to 12, LGB youth were two times more likely to attempt suicide than their heterosexual peers. Higher risk is also associated with a family history of suicide, especially in a same-gender parent. Other risk factors (cont'd) -Having attempted suicide previously increases the risk of a subsequent attempt. About half of those who ultimately commit suicide have a history of a previous attempt. -Loss of a loved one through death or separation About half of individuals who kill themselves have previously attempted suicide. Loss of a loved one through death or separation and lack of employment or increased financial burden also increase risk. In recent years, a number of suicides have been reported in the media among young people who are the victims of bullying.

Substance-Induced Anxiety Disorder

May be associated with intoxication or withdrawal from any of the following substances. Alcohol, sedatives, hypnotics, or anxiolytics Amphetamines or cocaine Hallucinogens Caffeine Cannabis Others

Anxiety Disorder Attributable to Another Medical Condition

Medical conditions that may produce anxiety symptoms include Cardiac Endocrine Respiratory Neurological

Client/Family Education schiz

Nature of illness What to expect as illness progresses Symptoms associated with illness Ways for family to respond to behaviors associated with illness Management of the illness Connection of exacerbation of symptoms to times of stress Appropriate medication management Side effects of medications Importance of not stopping medications When to contact health-care provider Relaxation techniques Social skills training Daily living skills training Support services Financial assistance Legal assistance Caregiver support groups Respite care Home health care

Client/Family Education bipolar

Nature of the illness Causes of bipolar disorder Cyclic nature of the illness Symptoms of depression Symptoms of mania Management of the illness Medication management Assertive techniques Anger management Support services Crisis hotline Support groups Individual psychotherapy Legal/financial assistance

Client/Family Education SA

Nature of the illness Effects of (substance) on the body Alcohol Other CNS depressants Hallucinogens Inhalants Opioids Cannabinols Ways in which use of substance affects life Management of the illness Activities to substitute for (substance) in times of stress Relaxation techniques Progressive relaxation Tense and relax Deep breathing Autogenics Management of the illness (cont'd) Problem-solving skills Essentials of good nutrition Support services Financial assistance Legal assistance Alcoholics Anonymous (or other support group specific to another substance) One-to-one support person

Client/Family Education depression

Nature of the illness Stages of grief and symptoms associated with each stage What is depression? Why do people get depressed? What are the symptoms of depression? Management of the illness Medication management Assertive techniques Stress-management techniques Ways to increase self-esteem Electroconvulsive therapy Support services Suicide hotline Support groups Legal/financial assistance

Client/Family Education A.OCD

Nature of the illness What is anxiety? To what might it be related? What is OCD? What is body dysmorphic disorder? What is trichotillomania? Symptoms of anxiety, OCD, and related disorders Management of the illness Medication management Possible adverse effect Length of time to take effect What to expect from the medication Stress management Teach ways to interrupt escalating anxiety. Teach relaxation techniques. Support services Crisis hotline Support groups Individual psychotherapy

Planning/Implementation T&S disorders

Nursing care of the client with a trauma-related disorder is aimed at: Reassurance of safety Decrease in maladaptive symptoms Demonstration of more adaptive coping strategies Adaptive progression through the grieving process Describe planning and implementation stages of the nursing process for clients with PTSD or ASD. Post-trauma syndrome is defined as "a sustained maladaptive response to a traumatic, overwhelming event." Goals in treatment should include beginning healthy grief resolution, helping the client demonstrate ability to deal with emotional reactions in an appropriate manger, and establishing meaningful goals for the future. Interventions include establishing a trusting relationship, obtaining an accurate history about the trauma, encouraging the client to talk about the trauma, and assisting in comprehending the trauma. Complicated grieving is defined as "a disorder that occurs after the death of a significant other (or any other loss of significance to the individual), in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment." Goals in treatment should include helping the client verbalize feelings associated with the trauma and verbalizing a sense of optimism and hope for the future.

Diagnosis/Outcome Identification A.OCD

Nursing diagnoses commonly associated with anxiety, OCD, and related disorders Panic anxiety (panic disorder and GAD) Powerlessness (panic disorder and GAD) Fear (phobias) Social isolation (agoraphobia) Nursing diagnoses (cont'd) Ineffective coping (OCD) Ineffective role performance (OCD) Disturbed body image (body dysmorphic disorder) Ineffective impulse control (hair-pulling disorder)

Nursing Process: Diagnosis/Outcome Identification suicide

Nursing diagnoses for the suicidal client may include Risk for suicide Hopelessness Nursing diagnoses for the suicidal client may include the following: Risk for suicide related to feelings of hopelessness and desperation. Hopelessness related to absence of support systems and perception of worthlessness. The following criteria may be used for measurement of outcomes in the care of the suicidal client. The Client: Has experienced no physical harm to self. Sets realistic goals for self. Expresses some optimism and hope for the future.

Nursing Diagnosis/Outcome Identification T&S disorders

Nursing diagnoses for trauma-related disorders may include: Posttrauma syndrome Complicated grieving Using information collected during the assessment, the nurse completes the client database, from which the selection of appropriate nursing diagnoses is determined. Discuss diagnosis and outcome identification for clients with PTSD or ASD. Some common nursing diagnoses for clients with trauma-related disorders include: Post-trauma syndrome related to distressing event considered to be outside the range of usual human experience evidenced by flashbacks, intrusive recollections, nightmares, psychological numbness related to the event, dissociation, or amnesia. Complicated grieving related to loss of self as perceived before the trauma or other actual or perceived losses incurred during or after the event evidenced by irritability and explosiveness, self-destructiveness, substance abuse, verbalization of survival guilt, or guilt about behavior required for survival.

Opioid Use Disorder

Opioid use disorder A profile of the substance Opioids of natural origin Opioid derivatives Synthetic opiate-like drugs Patterns of use/abuse Effects on the body CNS effects Gastrointestinal effects Cardiovascular effects Sexual functioning Opioid-Induced Disorders: Intoxication Symptoms are consistent with the half-life of most opioid drugs and usually last for several hours. Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment. Severe opioid intoxication can lead to respiratory depression, coma, and death Withdrawal From short-acting drugs (e.g., heroin) Symptoms occur within 6 to 8 hours, peak within 1 to 3 days, and gradually subside in 5 to 10 days. From long-acting drugs (e.g., methadone) Symptoms occur within 1 to 3 days, peak between days 4 and 6, and subside in 14 to 21 days. From ultra-short-acting meperidine Symptoms begin quickly, peak in 8 to 12 hours, and subside in 4 to 5 days. Symptoms of opioid withdrawal Dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia

Application of the Nursing Process: Trauma-Related Disorders T&S disorders

PTSD A reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone, such as natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape or other crimes Puri and Treasaden describe PTSD as "a reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone, such as natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape, or other crimes." These symptoms are associated with events that would be markedly distressing to almost anyone. The individual may experience the trauma alone or in the presence of others. Characteristic symptoms include: Re-experiencing the traumatic event A sustained high level of anxiety or arousal A general numbing of responsiveness Intrusive recollections or nightmares Amnesia to certain aspects of the trauma Depression; survivor's guilt Substance abuse Anger and aggression Relationship problems Characteristic symptoms include re-experiencing the traumatic event, a sustained high level of anxiety or arousal, or a general numbing of responsiveness. Intrusive recollections or nightmares of the event are common. Some individuals may be unable to remember certain aspects of the trauma. Symptoms may begin within the first 3 months after the trauma, or there may be a delay of several months or even years The full symptom picture must be present for more than 1 month and cause significant interference with social, occupational, and other areas of functioning. The disorder can occur at any age. Symptoms may begin within the first 3 months after the trauma, or there may be a delay of several months or even years.

Application of Nursing Process panic disorder GAD

Panic disorder: Assessment Characterized by recurrent panic attacks, the onset of which are unpredictable and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort May or may not be accompanied by agoraphobia Symptoms of panic attack: Sweating, trembling, shaking Shortness of breath, chest pain or discomfort Nausea or abdominal distress Dizziness, chills, or hot flashes Numbness or tingling sensations Derealization or depersonalization Fear of losing control or "going crazy" Fear of dying Generalized anxiety disorder (GAD) Characterized by chronic, unrealistic, and excessive anxiety and worry

Nursing Process: Assessment schiz

Positive symptoms Content of thought Delusions: False personal beliefs Religiosity: Excessive demonstration of obsession with religious ideas and behavior Paranoia: Extreme suspiciousness of others Magical thinking: Ideas that one's thoughts or behaviors have control over specific situations Positive symptoms (cont'd) Form of thought Associative looseness (also called loose association): Shift of ideas from one unrelated topic to another Neologisms: Made-up words that have meaning only to the person who invents them Concrete thinking: Literal interpretations of the environment Clang associations: Choice of words is governed by sound (often rhyming) Form of thought (cont'd) Word salad: Group of words put together in a random fashion Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details Tangentiality: Inability to get to the point of communication due to introduction of many new topics Mutism: Inability or refusal to speak Form of thought (cont'd) Perseveration: Persistent repetition of the same word or idea in response to different questions Positive symptoms (cont'd) Perception: interpretation of stimuli through the senses Hallucinations: False sensory perceptions not associated with real external stimuli Auditory Visual Tactile Gustatory Olfactory Illusions: Misperceptions of real external stimuli Positive symptoms (cont'd) Sense of self: The uniqueness and individuality a person feels Echolalia: Repeating words that are heard Echopraxia: Repeating movements that are observed Identification and imitation: Taking on the form of behavior one observes in another Depersonalization: Feelings of unreality Negative symptoms Affect: The feeling state or emotional tone Inappropriate affect: Emotions are incongruent with the circumstances Bland: Weak emotional tone Flat: Appears to be void of emotional tone Apathy: Disinterest in the environment Negative symptoms (cont'd) Volition: Impairment in the ability to initiate goal-directed activity Emotional ambivalence: Coexistence of opposite emotions toward same object, person, or situation Deterioration in appearance: Impaired personal grooming and self-care activities Negative symptoms (cont'd) Impaired interpersonal functioning and relationship to the external world Impaired social interaction: Clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable Social isolation: A focus inward on the self to the exclusion of the external environment Negative symptoms (cont'd) Psychomotor behavior Anergia: Deficiency of energy Waxy flexibility: Passive yielding of all movable parts of the body to any effort made at placing them in certain positions Posturing: voluntary assumption of inappropriate or bizarre postures Pacing and rocking: Pacing back and forth and rocking the body Negative symptoms (cont'd) Associated features Anhedonia: Inability to experience pleasure Regression: Retreat to an earlier level of development

Historical and Epidemiological Data T&S disorders

Posttrauma response was historically known as shell shock, battle fatigue, accident neurosis, or posttraumatic neurosis. -Renewed interest about the disorder began in the 1970s, in response to problems encountered by Vietnam veterans. -Diagnosis of posttraumatic stress disorder (PTSD) first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-3, 1980). Posttrauma response has been known through history by other names such as shell shock, battle fatigue, accident neurosis, and posttraumatic neurosis. Reports of symptoms and syndromes with PTSD-like features have existed in throughout history. In the early part of the 20th century, traumatic neurosis was viewed as the ego's inability to master the degree of disorganization brought about by a traumatic experience. Very little was written about posttraumatic neurosis during the years between 1950 and 1970 but this was followed in the 1970s and 1980s with an explosion in the amount of research and writing on the subject. Many of the papers written during this time were about Vietnam veterans. The diagnostic category of PTSD did not appear until the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, after increasing numbers of problems with Vietnam veterans and victims of multiple disasters indicated a need. More than half of all individuals will experience a traumatic event in their lifetime, but less than 10 percent will develop PTSD. -The traumatic event is described as one that is "outside the range of usual human experience." -PTSD is more common in women than in men. About 60 percent of men and 50 percent of women are exposed to a traumatic event in their lifetime. Women are more likely to experience sexual assault and childhood sexual abuse, whereas men are more likely to experience accidents, physical assaults, combat, or to witness death or injury. Less than 10 percent of trauma victims develop PTSD Historically individuals who experienced stress reactions that followed exposure to an extreme traumatic event were given the diagnosis of PTSD. Individuals who have difficulties with stress reactions to more "normal" events may be diagnosed with adjustment disorder. -Adjustment disorders are quite common and can occur at any age. Adjustment disorder carried its own classification, and was identified as a psychological response to an identifiable stressor or stressors. A number of studies have indicated that adjustment disorders are probably quite common. Adjustment disorders are more common in women, unmarried persons, and younger people.

Trauma-Related Disorders

Predisposing factors -Psychosocial theory --Seeks to explain why some individuals exposed to massive trauma develop PTSD while others do not --Variables include characteristics that relate to: The traumatic experience The individual The recovery environment Specific characteristics relating to trauma have been identified as crucial elements in the determination of an individual's long-term response. They include: Severity and duration of the stressor Extent of anticipatory preparation for the event Exposure to death Numbers affected by life threat Amount of control over recurrence Location where the trauma was experienced (e.g., familiar surroundings, at home, in a foreign country) Variables that are considered important in determining an individual's response to trauma include: Degree of ego-strength Effectiveness of coping resources Presence of preexisting psychopathology Outcomes of previous experiences with stress/trauma Behavioral tendencies (temperament) Current psychosocial developmental stage Demographic factors (e.g., age, socioeconomic status, education) It has also been suggested that the quality of the environment in which the individual attempts to work through the traumatic experience is correlated with the outcome. Environmental variables include: Availability of social supports The cohesiveness and protectiveness of family and friends The attitudes of society regarding the experience Cultural and subcultural influences Learning theory: -Negative reinforcement leads to the reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. -Avoidance behaviors -Psychic numbing Learning theorists view negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. The avoidance behaviors and psychic numbing in response to a trauma are mediated by negative reinforcement. Cognitive theory: A person is vulnerable to PTSD when fundamental beliefs are invalidated by experiencing trauma that cannot be comprehended and when a sense of helplessness and hopelessness prevail. Cognitive theory models focus on the cognitive appraisal of an event and the assumptions that an individual makes about the world. Epstein outlined three fundamental beliefs that most people construct within a personal theory of reality: The world is benevolent and a source of joy. The world is meaningful and controllable. The self is worthy (e.g., lovable, good, and competent). As life situations occur, some disequilibrium is expected to occur until accommodation for the change has been. An individual is vulnerable to trauma-related disorders when the fundamental beliefs are invalidated by a trauma that cannot be comprehended. Biological aspects: -It is suggested that the symptoms related to the trauma are maintained by the production of endogenous opioid peptides that are produced in the face of arousal, and which result in increased feelings of comfort and control. -When the stressor terminates, the individual may experience opioid withdrawal, the symptoms of which bear strong resemblance to those of PTSD. It has been suggested that an individual who has experienced previous trauma is more likely to develop symptoms after a stressful life event. Hollander and Simeon also report on studies that suggest an endogenous opioid peptide response may assist in the maintenance of chronic PTSD. Opioids, including endogenous opioid peptides, have the following psychoactive properties: Tranquilizing action Reduction of rage/aggression Reduction of paranoia Reduction of feelings of inadequacy Antidepressant action Biological aspects: Disregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may also be involved in the pathophysiology of PTSD. Other biological systems have also been implicated in PTSD. Norepinephrine, dopamine, and benzodiazepine receptors are some of the neurotransmitters believed to be dysregulated in individuals with PTSD. Data has supported that the hypothalamic-pituitary-adrenal axis, noradrenergic, and endogenous opiate systems are hyperactive in some patients with PTSD. Trauma-informed care: Trauma-informed care generally describes a philosophical approach that values awareness and understanding of trauma when assessing, planning, and implementing care. Experts highlight the importance of trauma-informed care as essential to improving the quality of care for clients. Trauma-informed care is a strength-based framework that is grounded in understanding of and responsiveness to the impact of trauma that emphasizes physical, psychological, and emotional safety for both providers and survivors to rebuild a sense of control and empowerment."

Phase I schiz

Premorbid phase Social maladjustment Antagonistic thoughts and behavior Shy and withdrawn Poor peer relationships Doing poorly in school Antisocial behavior

Phase II schiz

Prodromal phase Lasts from a few weeks to a few years Deterioration in role functioning and social withdrawal Substantial functional impairment Sleep disturbance, anxiety, irritability Depressed mood, poor concentration, fatigue Perceptual abnormalities, ideas of reference, and suspiciousness herald onset of psychosis

Predisposing Factors to OCD and Related Disorders

Psychoanalytic theory Clients with OCD have weak, underdeveloped egos. Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of aggression from surfacing and producing intense anxiety fraught with guilt. Learning theory Conditioned response to a traumatic event Passive avoidance Active avoidance Psychosocial influences related to trichotillomania Stressful situations Disturbances in mother-child relationship Fear of abandonment Recent object loss Possible childhood abuse or emotional neglect Biological aspects Genetics: Possible with trichotillomania Neuroanatomy: Possible abnormalities in basal ganglia and orbitofrontal cortex with OCD Physiology: Some individuals with OCD exhibit electroencephalogram changes. Biochemical factors: Possible decrease in serotonin with OCD and body dysmorphic disorder

Predisposing Factors Panic and GADs

Psychodynamic theory Ego unable to intervene between id and superego Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety Cognitive theory Faulty, distorted, or counterproductive thinking patterns result in anxiety that is maintained by mistaken or dysfunctional appraisal of a situation. Biological aspects Genetics Neuroanatomical Biochemical Neurochemical

Predisposing Factors: Theories of Suicide

Psychological theories: Anger turned inward Hopelessness Desperation and guilt History of aggression and violence Shame and humiliation Discuss the psychological theories on suicide. Anger Turned Inward. Freud believed that suicide was a response to the intense self-hatred that an individual possessed. The anger had originated toward a love object but was ultimately turned inward against the self. He interpreted suicide to be an aggressive act toward the self that often was really directed toward others. Hopelessness and Other Symptoms of Depression. Hopelessness has long been identified as a symptom of depression and as an underlying factor in the predisposition to suicide. While many of the symptoms that are identified in suicide assessment tools attempt to assess for seriousness of suicide ideation, current research is attempting to glean which symptoms might be more predictive of the move from ideation to attempts. History of Aggression and Violence. A history of violent behavior or impulsive acts has been associated with increased risk for suicide although recent evidence suggests that impulsive traits are higher in individuals with suicide ideation but not necessarily associated with more attempts. Shame and Humiliation. Some individuals have viewed suicide as a "face-saving" mechanism—a way to prevent public humiliation following a social defeat such as a sudden loss of status or income. Often these individuals are too embarrassed to seek treatment or other support systems. Psychological theories: Anger turned inward Hopelessness Desperation and guilt History of aggression and violence Shame and humiliation Anger Turned Inward. Freud believed that suicide was a response to the intense self-hatred that an individual possessed. The anger had originated toward a love object but was ultimately turned inward against the self. He interpreted suicide to be an aggressive act toward the self that often was really directed toward others. Hopelessness and Other Symptoms of Depression. Hopelessness has long been identified as a symptom of depression and as an underlying factor in the predisposition to suicide. While many of the symptoms that are identified in suicide assessment tools attempt to assess for seriousness of suicide ideation, current research is attempting to glean which symptoms might be more predictive of the move from ideation to attempts. History of Aggression and Violence. A history of violent behavior or impulsive acts has been associated with increased risk for suicide although recent evidence suggests that impulsive traits are higher in individuals with suicide ideation but not necessarily associated with more attempts. Shame and Humiliation. Some individuals have viewed suicide as a "face-saving" mechanism—a way to prevent public humiliation following a social defeat such as a sudden loss of status or income. Often these individuals are too embarrassed to seek treatment or other support systems. Sociological theory: Durkheim's three social categories of suicide Egoistic suicide Altruistic suicide Anomic suicide Egoistic suicide is the response of the individual who feels separate and apart from the mainstream of society. Integration is lacking and the individual does not feel a part of any cohesive group (such as a family or a church). Altruistic suicide is the opposite of egoistic suicide. The individual who is prone to altruistic suicide is excessively integrated into the group. The group is often governed by cultural, religious, or political ties, and allegiance is so strong that the individual will sacrifice his or her life for the group. Anomic suicide occurs in response to changes that occur in an individual's life that disrupt feelings of relatedness to the group. An interruption in the customary norms of behavior instills feelings of "separateness," and fears of being without support from the formerly cohesive group. Biological theories: Genetics Neurochemical factors Genetics. Twin studies have shown a much higher concordance rate for monozygotic twins than for dizygotic twins. Some studies with suicide attempters have focused on the genotypic variations in the gene for tryptophan hydroxylase, with results indicating significant association to suicidality. Tryptophan hydroxylase is an enzyme associated with the synthesis of serotonin and diminished serotonin has implications for both depression and suicidal behavior. These findings suggest the potential for genetic predisposition toward suicidal behavior. Neurochemical Factors. A number of studies have revealed a deficiency of serotonin (measured as a decrease in the levels of 5-hydroxyindole acetic acid [5-HIAA] in the cerebrospinal fluid) in depressed clients who attempted suicide). These studies as well as postmortem studies have supported the hypothesis that deficiencies in CNS serotonin are associated with suicide.

Treatment Modalities schiz

Psychological treatments Individual psychotherapy: Long-term therapeutic approach; difficult because of client's impairment in interpersonal functioning Group therapy: Some success if occurring over the long-term course of the illness; less successful in acute, short-term treatment Psychological treatments (cont'd) Behavior therapy: Chief drawback has been inability to generalize to community setting after client has been discharged from treatment. Social skills training: Use of role play to teach client appropriate eye contact, interpersonal skills, voice intonation, posture, and so on; aimed at improving relationship development Social treatments Family therapy: Aimed at helping family members cope with long-term effects of the illness Program of Assertive Community Treatment A program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness The Recovery Model A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential The Recovery Model (cont'd) Research provides support for recovery as an obtainable objective for individuals with schizophrenia. Recovery after an initial schizophrenia episode A program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness Psychopharmacology Antipsychotics Used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders Psychopharmacology (cont'd) Action Typicals: Dopaminergic blockers with various affinity for cholinergic, α-adrenergic, and histaminic receptors Atypicals: Weak dopamine antagonists; potent 5HT2A antagonists; also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors

Phase IV schiz

Residual phase Symptoms similar to those of the prodromal phase. Flat affect and impairment in role functioning are prominent.

Planning/Implementation bipolar

Risk for Violence: Self-Directed or Other-Directed Remove all dangerous objects from the environment. Maintain a calm attitude . If restraint is deemed necessary, ensure that sufficient staff is available to assist. Impaired Social Interaction Set limits on manipulative behaviors. Do not argue, bargain, or try to reason with the client. Provide positive reinforcement. Imbalanced Nutrition: Less than Body Requirements/Insomnia Provide client with high-protein, high-calorie foods. Maintain an accurate record of intake, output, and calorie count. Monitor sleep patterns.

Planning/Implementation SA

Risk for injury Provide safe and supportive environment. Administer substitution therapy. Denial Develop trust. Identify maladaptive behaviors or situations. Ineffective coping Establish trust. Set limits. Explore options. Dysfunctional family processes Review history. Provide information. Involve the family.

Nursing Diagnosis bipolar

Risk for injury related to Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements Risk for violence: self-directed or other-directed related to Manic excitement Delusional thinking Hallucinations Impulsivity Imbalanced nutrition less than body requirements related to Refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea Disturbed thought processes related to Biochemical alterations in the brain, evidenced by delusions of grandeur and persecution and inaccurate interpretation of the environment Disturbed sensory perception related to Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations Impaired social interaction related to Egocentric and narcissistic behavior Insomnia related to Excessive hyperactivity and agitation

Planning/Implementation depression

Risk for suicide Be direct. Maintain close observation at irregular intervals. Encouraging verbalizations of honest feelings. Complicated grieving Develop a trusting relationship with the client. Encourage the client to express emotions. Communicate that crying is acceptable. Low self-esteem/self-care deficit Be accepting of the client. Encourage the client to recognize areas of change. Encourage independence in the performance of activities of daily living. Powerlessness Encourage the client to take responsibility. Help the client set goals. Help the client identify areas of his or her life that they can and cannot control.

Nursing Process: Diagnosis/Outcome Identification depression

Risk for suicide related to Depressed mood Feelings of worthlessness Anger turned inward on the self Misinterpretations of reality Complicated grieving related to Real or perceived loss Bereavement overload Low self-esteem related to Learned helplessness Feelings of abandonment by significant others Impaired cognition fostering negative view of self Powerlessness related to Complicated grieving process Lifestyle of helplessness Spiritual distress related to Complicated grieving process over loss of valued object evidenced by anger toward God, questioning meaning of own existence, inability to participate in usual religious practices Social isolation/Impaired social interaction related to Developmental regression Egocentric behaviors Fear of rejection or failure of the interaction Disturbed thought processes related to Withdrawal into self Underdeveloped ego Punitive superego Impaired cognition fostering negative perception of self or environment

Phase III schiz

Schizophrenia In the active phase of the disorder, psychotic symptoms are prominent. Delusions Hallucinations Impairment in work, social relations, and self-care

Nature of the Disorder schiz

Schizophrenia causes disturbances in Thought processes Perception Affect With schizophrenia, there is a severe deterioration of social and occupational functioning. In the United States, the lifetime prevalence of schizophrenia is about 1 percent. Premorbid behavior of the patient with schizophrenia can be viewed in four phases

Outcomes schiz

The client Demonstrates an ability to relate to others satisfactorily Recognizes distortions of reality Has not harmed self or others Perceives self realistically The client (cont'd) Demonstrates ability to perceive the environment correctly Maintains anxiety at a manageable level Relinquishes need for delusions and hallucinations The client (cont'd) Demonstrates ability to trust others Uses appropriate verbal communication in interactions with others Performs self-care activities independently

Sedative/Hypnotic Use Disorder

Sedative/hypnotic use disorder A profile of the substance Barbiturates Nonbarbiturate hypnotics Antianxiety agents Club drugs Patterns of use Effects on the body Effects on sleep and dreaming Respiratory depression Cardiovascular effects Renal function Effects on the body (cont'd) Hepatic effects Body temperature Sexual functioning Intoxication With these central nervous system (CNS) depressants, effects can range from disinhibition and aggressiveness to coma and death (with increasing dosages of the drug). Withdrawal Onset of symptoms depends on the half-life of the drug from which the person is withdrawing. Severe withdrawal from CNS depressants can be life threatening.

Antipsychotics

Side effects Anticholinergic effects Nausea; gastrointestinal upset Skin rash Sedation Orthostatic hypotension Photosensitivity Hormonal effects Electrocardiogram changes Hypersalivation Weight gain Hyperglycemia/diabetes Increased risk of mortality in elderly clients with dementia Reduction in seizure threshold Agranulocytosis Extrapyramidal symptoms Tardive dyskinesia Neuroleptic malignant syndrome Extrapyramidal symptoms (EPS) include Pseudoparkinsonism Akinesia Akathisia Dystonia Oculogyric crisis Antiparkinsonian agents may be prescribed to counteract EPS.

Acute Stress Disorder (ASD) T&S disorders

Similar to PTSD in terms of precipitating traumatic events and symptomatology -Symptoms are time limited: up to 1 month following the trauma. -If the symptoms last longer than 1 month, the diagnosis is PTSD. The DSM-5 describes another disorder called acute stress disorder (ASD). There are similarities between this and PTSD in terms of precipitating traumatic events and symptomatology, but in ASD, the symptoms are time limited, up to 1 month following the trauma. If the symptoms last longer than this, the diagnosis would be PTSD.

Substance Use Disorder

Substance addiction Physical dependence Need for increasing amounts to produce the desired effects Psychological dependence Overwhelming desire to repeat the use of a particular drug to produce pleasure or avoid discomfort Substance addiction (cont'd) Use of the substance interferes with ability to fulfill role obligations Attempts to cut down or control use fail Intense craving for the substance Excessive amount of time spent trying to procure the substance or recover from its use Substance addiction (cont'd) Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated Engages in hazardous activities when impaired by the substance Tolerance develops and the amount required to achieve the desired effect increases Substance-specific symptoms occur upon discontinuation of use Substance intoxication Development of a reversible syndrome of symptoms following excessive use of a substance Direct effect on the central nervous system Disruption in physical and psychological functioning Judgment is disturbed and social and occupational functioning is impaired. Substance withdrawal Development of symptoms that occurs upon abrupt reduction or discontinuation of a substance that has been used Symptoms are specific to the substance that has been used. Disruption in physical and psychological functioning

suicide

Suicide is the act of taking one's own life and it derives from the latin words for "one's own killing." Many religions believe that suicide is a sin and it is strictly forbidden. In the field of psychiatry, suicide is considered an irrational act associated with mental illness and most commonly with depression. More than 90 percent of all persons who commit or attempt suicide have a diagnosed mental disorder. Suicide is not a diagnosis or a disorder; it is a behavior. -More than 90 percent of suicides are by individuals who have a diagnosed mental disorder.

Epidemiological Factors suicide

Suicide is: -The third leading cause of death among Americans 15 to 24 years of age -The fourth leading cause of death for ages 25 to 44 -The eighth leading cause of death for ages 45 to 64 Discuss the epidemiological factors of suicide. More than 41,000 people committed suicide in 2013 the latest year for which statistics have been recorded. This is the highest rate of suicide in 15 years. These recent statistics have established suicide as the second leading cause of death among young Americans ages 15 to 34 years, the fourth leading cause of death for ages 35 to 44, the fifth leading cause of death for individuals age 45 to 64, and the tenth leading cause of death overall. With a steady incline in rates of suicide, it has become a major health-care problem in the United States today. Reports of dramatic rises in suicide rates among military personnel since 2008 have led to greater public awareness, concern and interest in research on this topic. Confusion exists over the reality of suicide. Some of the more common accepted myths relating to suicide include: The idea that people who talk about suicide do not commit suicide. In reality, 8 out of 10 people who kill themselves have given clues and warnings about their intentions. Improvement after severe depression means that the risk of suicide is over. In reality, most suicides occur within 3 months after the beginning of improvement. Suicidal threats should be considered attention-seeking behavior. In reality, all suicidal behavior must be approached with the gravity of the potential act in mind. A more comprehensive list of myths and facts can be found in Table 12-1 in the text.

Nursing Process/Assessment bipolar

Symptoms may be categorized by degree of severity. Stage I. Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization Cheerful mood Rapid flow of ideas; heightened perception Increased motor activity Symptoms of manic states can be described according to three stages: hypomania, acute mania, and delirious mania. Describe the symptoms of Stage I: Hypomania. At this stage the disturbance is not sufficiently severe to cause marked impairment in social or occupational functioning. The mood of a hypomanic person is cheerful and expansive. There is an underlying irritability that surfaces rapidly when the person's wishes and desires go unfulfilled. Perceptions of the self includes ideas of great worth and ability. Thinking is flighty, with a rapid flow of ideas. Perception of the environment is heightened, but the individual is so easily distracted by irrelevant stimuli and goal-directed activities are difficult. Hypomanic individuals' exhibit increased motor activity. They are perceived as being very extroverted and sociable, but they lack the depth of personality and warmth to formulate close friendships. They talk and laugh a great deal, usually very loudly and often inappropriately. Stage II. Acute mania: Marked impairment in functioning; usually requires hospitalization: Elation and euphoria; a continuous "high" Flight of ideas; accelerated, pressured speech Hallucinations and delusions Excessive motor activity Social and sexual inhibition Little need for sleep Stage II: Hypomania. Symptoms of acute mania may be a progression in intensification of those experienced in hypomania, or they may be manifested directly. Most individuals experience marked impairment in functioning and require hospitalization. Acute mania is characterized by euphoria and elation. The person appears to be on a continuous high, but mood is always subject to frequent variation. Cognition and perception become fragmented and often psychotic in acute mania. Accelerated thinking proceeds to racing thoughts, overconnection of ideas, and rapid, abrupt movement from one thought to another and may be manifested by a continuous flow of accelerated, pressured speech to the point where trying to converse with this individual may be extremely difficult. Attention can be diverted by even the smallest of stimuli. Hallucinations and delusions are common. Psychomotor activity is excessive. Sexual interest is increased. There is poor impulse control, low frustration tolerance, and the individual who is normally discreet may become socially and sexually uninhibited. Energy seems inexhaustible, and the need for sleep is diminished. They may go for many days without sleep and still not feel tired. Hygiene and grooming may be neglected. Dress may be disorganized, flamboyant, or bizarre, and the use of excessive make-up or jewelry is common. Stage III. Delirious mania: A grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare since the advent of antipsychotic medication. Labile mood; panic anxiety Clouding of consciousness; disorientation Frenzied psychomotor activity Exhaustion and possibly death without intervention Stage III: Delirious Mania Delirious mania is a grave form of the disorder characterized by severe clouding of consciousness and an intensification of the symptoms associated with acute mania. The mood of the delirious person is very labile. He or she may exhibit feelings of despair, quickly converting to unrestrained merriment and ecstasy or becoming irritable or totally indifferent to the environment. Cognition and perception are characterized by a clouding of consciousness, with accompanying confusion, disorientation, and sometimes stupor. Other common manifestations include religiosity, delusions of grandeur or persecution, and auditory or visual hallucinations. The individual is extremely distractible and incoherent. Psychomotor activity is frenzied and characterized by agitated, purposeless movements. The safety of these individuals is at stake unless this activity is curtailed. Exhaustion, injury to self or others, and eventually death could occur without intervention.

Criteria for Measuring Outcomes bipolar

The client Exhibits no evidence of physical injury Has not harmed self or others Is no longer exhibiting signs of physical agitation Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status Verbalizes an accurate interpretation of the environment Verbalizes that hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations Accepts responsibility for own behaviors Does not manipulate others for gratification of own needs Interacts appropriately with others Is able to fall asleep within 30 minutes of retiring Is able to sleep 6 to 8 hours per night

Criteria for Measuring Outcomes depression

The client Has experienced no physical harm to self Discusses the loss with staff and family members No longer idealizes or obsesses about the lost entity Sets realistic goals for self Attempts new activities without fear of failure Is able to identify aspects of self-control over life situation Expresses personal satisfaction and support from spiritual practices Interacts willingly and appropriately with others Is able to maintain reality orientation Is able to concentrate, reason, and solve problems

Outcomes A.OCD

The client Is able to recognize signs of escalating anxiety and intervene before reaching panic level (panic and GAD) Is able to maintain anxiety at manageable level and make independent decisions about life situation (panic and GAD) Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder) Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety (phobic disorder) Is able to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior (OCD) Demonstrates more adaptive coping strategies for dealing with anxiety than ritualistic behaviors (OCD) Verbalizes a realistic perception of his or her appearance and expresses feelings that reflect a positive body image (body dysmorphic disorder) Verbalizes and demonstrates more adaptive strategies for coping with stressful situations (hair-pulling disorder)

Client/Family Education schiz

The client should Not stop taking the drug abruptly. Use sunscreens and wear protective clothing when spending time outdoors. Report weekly (if receiving clozapine therapy) to have blood levels drawn and to obtain a weekly supply of the drug. Be aware of possible risks of taking antipsychotics during pregnancy. The client should (cont'd) Not drink alcohol while receiving antipsychotic therapy Not consume other medications (including over-the-counter drugs) without the physician's knowledge

Outcome Criteria T&S disorders

The client: Can acknowledge the trauma and the impact on his or her life Can demonstrate adaptive coping strategies Has made realistic goals for the future Has worked through feelings of survivor's guilt Attends support group of individuals recovering from similar traumatic experiences Verbalizes desire to put trauma in the past and progress with his or her life Can acknowledge the traumatic event and the impact it has had on his or her life. Is experiencing fewer flashbacks, intrusive recollections, and nightmares than he or she was on admission (or at the beginning of therapy). Can demonstrate adaptive coping strategies (e.g., relaxation techniques, mental imagery, music, art). Can concentrate and has made realistic goals for the future. Includes significant others in the recovery process and willingly accepts their support. Verbalizes no ideas or intent of self-harm. Has worked through feelings of survivor's guilt. Gets enough sleep to avoid risk of injury. Verbalizes community resources from which he or she may seek assistance in times of stress. Attends support group of individuals who have recovered or are recovering from similar traumatic experiences. Verbalizes desire to put the trauma in the past and progress with his or her life.

Nursing Process: Evaluation suicide

The long-term goals of individual or group psychotherapy for the suicidal client would be for him or her to: Develop and maintain a more positive self-concept. Learn more effective ways to express feelings to others. Achieve successful interpersonal relationships. Feel accepted by others and achieve a sense of belonging. Evaluation of the suicidal client is an ongoing process accomplished through continuous reassessment of the client, as well as determination of goal achievement. Once the immediate crisis has been resolved, extended psychotherapy may be indicated. A suicidal person feels worthless and hopeless. These goals serve to instill a sense of self-worth, while offering a measure of hope and a meaning for living.

Introduction schiz

The word schizophrenia is derived from the Greek words skhizo (split) and phren (mind). Schizophrenia is probably caused by a combination of factors, including Genetic predisposition Biochemical dysfunction Physiological factors Psychosocial stress Schizophrenia requires treatment that is comprehensive and presented in a multidisciplinary effort. Of all mental illnesses, schizophrenia probably causes more Lengthy hospitalizations Chaos in family life Exorbitant costs to people and governments Fears

history of suicide

Throughout history, suicide was considered an offense against the state and was viewed as a selfish or even criminal act. Individuals who committed suicide were often denied cemetery burial and their property was confiscated and shared by the crown and the courts. In ancient Greece, suicide was an offense against the state, and individuals who committed suicide were denied burial in community sites. -In the culture of the imperial Roman army, individuals sometimes resorted to suicide to escape humiliation or abuse. -In the Middle Ages, suicide was viewed as a selfish or criminal act. During the Renaissance, the view became more philosophical, and intellectuals could discuss suicide more freely. -Most philosophers of the 17th and 18th centuries condemned suicide, but some individuals began to associate suicide with mental illness. The issue of suicide changed during the period of the Renaissance and intellectuals began to discuss the issue more freely. Most philosophers of the 17th and 18th centuries condemned suicide, but some writers recognized a connection between suicide and melancholy or other severe mental disturbances. Suicide was illegal in England until 1961, and only in 1993 was it decriminalized in Ireland.

Nursing Process/Assessment depression

Transient depression Symptoms at this level of the continuum are not necessarily dysfunctional. Affective: The "blues" Behavioral: Some crying Cognitive: Some difficulty getting mind off of one's disappointment Physiological: Feeling tired and listless Mild depression Symptoms of mild depression are identified by clinicians as those associated with normal grieving. Affective: Anger, anxiety Behavioral: Tearful, regression Cognitive: Preoccupied with loss Physiological: anorexia, insomnia Moderate depression Symptoms associated with dysthymic disorder Affective: Helpless, powerless Behavioral: Slowed physical movements, slumped posture, limited verbalization Cognitive: Retarded thinking processes, difficulty with concentration Physiological: Anorexia or overeating, sleep disturbance, headaches Severe depression Includes symptoms of major depressive disorder and bipolar depression Affective: feelings of total despair, worthlessness, flat affect Behavioral: psychomotor retardation, curled-up position, absence of communication Cognitive: prevalent delusional thinking, with delusions of persecution and somatic delusions; confusion; suicidal thoughts Physiological: a general slow-down of the entire body

Treatment Modalities T&S disorders

Trauma-related disorders Cognitive therapy Prolonged exposure therapy Group/family therapy Eye movement desensitization and reprocessing Psychopharmacology Discuss the various treatment possibilities for clients with PTSD and ASD. Cognitive therapy for PTSD and ASD strives to help the individual recognize and modify trauma-related thoughts and beliefs. The individual learns to modify the relationships between thoughts and feelings, and to identify and challenge inaccurate or extreme automatic negative thoughts. Prolonged exposure therapy (PE) is a type of behavioral therapy somewhat similar to implosion therapy or flooding. It can be conducted in an imagined or real (in vivo) situation. Group therapy has been strongly advocated for clients with PTSD. It has proved especially effective with military veterans. Eye movement desensitization and reprocessing (EMDR) is a type of psychotherapy that was developed in 1989 by psychologist Francine Shapiro. EMDR has been shown to be an effective therapy for PTSD and other trauma-related disorders. The exact biological mechanisms by which EMDR achieves its therapeutic effects are unknown. Some studies have indicated that eye movements cause a decrease in imagery vividness and distress, as well as an increase in memory access. The selective serotonin reuptake inhibitors (SSRIs) are now considered first-line treatment of choice for PTSD because of their efficacy, tolerability, and safety ratings. Paroxetine and sertraline have been approved by the FDA for this purpose. The tricyclic antidepressants amitriptyline(Elavil) and imipramine (Tofranil have been supported by several well controlled studies. MAO inhibitors (e.g., phenelzine), and trazodone have also been effective in the treatment of PTSD. Alprazolam has been prescribed for PTSD clients for its antidepressant and antipanic effects. Other benzodiazepines have also been used, despite the absence of controlled studies demonstrating their efficacy in PTSD. Buspirone, which has serotonergic properties similar to the SSRIs, may also be useful. Further controlled trials with this drug are needed to validate its efficacy in treating PTSD. The beta blocker propranolol and alpha2-receptor agonist clonidine have been successful in alleviating some of the symptoms associated with PTSD. Carbamazepine, valproic acid, and lithium carbonate have been reported to alleviate symptoms of intrusive recollections, flashbacks, nightmares, impulsivity, irritability, and violent behavior in PTSD clients. Adjustment disorders Individual psychotherapy Family therapy Behavior therapy Self-help groups Crisis intervention Psychopharmacology Individual psychotherapy is the most common treatment for adjustment disorder. Individual psychotherapy allows the client to examine the stressor that is causing the problem, possibly assign personal meaning to the stressor, and confront unresolved issues that may be exacerbating this crisis. In family therapy, the focus of treatment is shifted from the individual to the system of relationships in which the individual is involved. The maladaptive response of the identified client is viewed as symptomatic of a dysfunctional family system. The goal of behavior therapy is to replace ineffective response patterns with more adaptive ones. The situations that promote ineffective responses are identified, and carefully designed reinforcement schedules, along with role modeling, and coaching are used to alter the maladaptive response patterns. Group experiences, with or without a professional facilitator, provide an arena in which members may consider and compare their responses to individuals with similar life experiences. Members benefit from learning that they are not alone in their painful experiences. In crisis intervention the therapist, or other intervener, becomes a part of the individual's life situation. Because of increased anxiety, the individual with adjustment disorder is unable to problem solve, so he or she requires guidance and support from another to help mobilize the resources needed to resolve the crisis. Crisis intervention is short-term, relies heavily on orderly problem-solving techniques and structured activities that are focused on change. Adjustment disorder is not commonly treated with medications, as their effect may be temporary and only mask the real problem and psychoactive drugs carry the potential for physiological and psychological dependence.

Adjustment Disorders

Types of adjustment disorders: With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Related to bereavement Unspecified Identify the different presentations of adjustment disorder. Adjustment Disorder with Depressed Mood. This category is the most commonly diagnosed adjustment disorder. The clinical presentation is one of predominant mood disturbance, although less pronounced than that of major depressive disorder (MDD). The symptoms, such as depressed mood, tearfulness, and feelings of hopelessness, exceed what is an expected or normative response to an identified stressor. Adjustment Disorder with Anxiety. This category denotes a maladaptive response to a stressor in which the predominant manifestation is anxiety. The clinician must differentiate this diagnosis from those of anxiety disorders. Adjustment Disorder with Mixed Anxiety and Depressed Mood. The predominant features of this category include disturbances in mood and manifestations of anxiety that are more intense than what would be expected or considered to be a normative response to an identified stressor. Adjustment Disorder with Disturbance of Conduct. This category is characterized by conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules. Differential diagnosis must be made from conduct disorder or antisocial personality disorder. Adjustment Disorder with Mixed Disturbance of Emotions and Conduct. The predominant features of this category include emotional as well as disturbances of conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules. Adjustment Disorder Unspecified. This subtype is used when the maladaptive reaction is not consistent with any of the other categories. The individual may have physical complaints, withdraw from relationships, or exhibit impaired work or academic performance, but without significant disturbance in emotions or conduct. Predisposing factors: Biological theories Genetics Vulnerability related to neurocognitive or intellectual developmental disorders Chronic disorders, such as neurocognitive or intellectual developmental disorders, are thought to impair the ability of an individual to adapt to stress, causing increased vulnerability to adjustment disorder. Genetic factors also may influence individual risks for maladaptive response to stress. Psychosocial theories: Childhood trauma, dependency, arrested development Constitutional factor (birth characteristics) Developmental stage and timing of the stressor Available support systems Dysfunctional grieving process Some proponents of psychoanalytic theory view adjustment disorder as a maladaptive response to stress that is caused by early childhood trauma, increased dependency, and retarded ego development. Other psychoanalysts put considerable weight on the constitutional factor, or birth characteristics that contribute to the manner in which individuals respond to stress. Some studies relate a predisposition to adjustment disorder to factors such as developmental stage, timing of the stressor, and available support systems. When a stressor occurs, and the individual does not have the developmental maturity, available support systems, or adequate coping strategies to adapt, normal functioning is disrupted, resulting in psychological or somatic symptoms. Transactional model of stress/adaptation: Interaction between individual and environment Type of stressor Situational factors Intrapersonal factors The transactional model takes into consideration the interaction between the individual and the environment. The type of stressor that one experiences may influence one's adaptation. Sudden-shock stressors occur without warning, and continuous stressors are those that an individual is exposed to over an extended period. Although many studies have been directed to individuals' responses to sudden-shock stressors, it has been found that continuous stressors were more commonly cited than sudden-shock stressors as precipitants to maladaptive functioning. Both situational and intrapersonal factors most likely contribute to an individual's stress response. Situational factors include personal and general economic conditions; occupational and recreational opportunities; and the availability of social supports such as family, friends, neighbors, and cultural or religious support groups. Other intrapersonal factors that might influence one's ability to adjust to a painful life change include social skills, coping strategies, the presence of psychiatric illness, degree of flexibility, and level of intelligence. Nursing diagnosis: Complicated grieving Risk-prone health behavior Anxiety Nursing diagnoses may be used for the client with an adjustment disorder include: Complicated grieving related to real or perceived loss of any concept of value to the individual, evidenced by interference with life functioning, developmental regression, or somatic complaints. Risk-prone health behavior related to change in health status requiring modification in lifestyle (e.g., chronic illness, physical disability), evidenced by inability to problem-solve or set realistic goals for the future. NOTE: This diagnosis would be appropriate for the person with adjustment disorder if the precipitating stressor was a change in health status. Anxiety (moderate to severe) related to situational and/or maturational crisis evidenced by restlessness, increased helplessness, and diminished productivity. Outcome criteria: The client: Verbalizes acceptable grieving behaviors Demonstrates a reinvestment in the environment Accomplishes activities of daily living independently Demonstrates ability to function adequately Accepts change in health status Sets realistic goals for the future Demonstrates ability to cope effectively with change in lifestyle The Client: Verbalizes acceptable behaviors associated with each stage of the grief process. Demonstrates a reinvestment in the environment. Accomplishes activities of daily living independently. Demonstrates ability for adequate occupational and social functioning. Verbalizes awareness of change in health status and the effect it will have on lifestyle. Solves problems and sets realistic goals for the future. Demonstrates ability to cope effectively with change in lifestyle. Planning/implementation Nursing intervention for the client with an adjustment disorder is aimed at Adaptive progression through the grief process Helping the client achieve acceptance of a change in health status Assisting with strategies to maintain anxiety at a manageable level Describe planning and implementation stages of the nursing process for clients with adjustment disorders. Complicated grieving is defined as "a disorder that occurs after the death of a significant other (or any other loss of significance to the individual), in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment." Goals should include helping the client express anger toward the lost entity, and helping the client verbalize behaviors associated with the normal stages of grief. Interventions include developing a trusting relationship with the client, assisting the client in discharging pent-up anger, and encouraging the client to review his or her perception of the loss. Risk-prone health behavior is defined as "impaired ability to modify lifestyle/behaviors in a manner that improves health status." Goals for treatment should include helping the client discuss lifestyle change and formulating a plan to incorporate those changes. Interventions include encouraging the client to talk about his or her lifestyle, helping with decision making, and ensuring that the client is knowledgeable about the physiology of the change in health status. Evaluation Evaluation is based on accomplishment of previously established outcome criteria. Does client demonstrate progression in the grief process? Does client discuss the change in health status and modification of lifestyle it will affect? Does client set realistic goals for the future? Evaluation of the nursing actions for the client with an adjustment disorder may be facilitated by answering the following types of questions: Does the client verbalize understanding of the grief process and his or her position in the process? Does the client recognize his or her adaptive and maladaptive behaviors associated with the grief response? Does the client demonstrate evidence of progression along the grief response? Can the client accomplish activities of daily living independently? Does the client demonstrate the ability to perform occupational and social activities adequately? Does the client discuss the change in health status and modification of lifestyle it will affect? Does the client demonstrate acceptance of the modification? Can the client participate in decision making and problem solving for his or her future? Does the client set realistic goals for the future? Does the client demonstrate new adaptive coping strategies for dealing with the change in lifestyle? Can the client verbalize available resources to whom he or she may go for support or assistance should it be necessary?

Nursing Process: Assessment SA

Various assessment tools are available for determining the extent of the problem a client has with substances. Drug history and assessment Clinical Institute Withdrawal Assessment of Alcohol Scale Michigan Alcoholism Screening Test (MAST) CAGE Questionnaire CAGE Questionnaire Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?