behavioral health exam 1

agoraphobia

"Fear of the Marketplace" Fear of being in places or situations where escape may be difficult

Course objectives (: *anxiety, obsessive-compulsive and related disorders

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Electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) (:

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History of Behavioral Health Nursing (:

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Nurse Client Relationship Development (:

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alteration in thought processes - schizophrenia(:

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anxiety, obsessive-compulsive, and related disorders(:

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bipolar and related disorders(:

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clients in crisis(:

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cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT) and talk therapy (:

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communication with others (:

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course objectives - Electroconvulsive Therapy and Transcranial Magnetic I(;

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course objectives - cognitive behavioral therapy and dialectical behavioral therapy (:

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course objectives - substance-related and addictive disorders (:

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course objectives -- bipolar and dual diagnosis(:

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course objectives -- clients in crisis(:

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course objectives -- depressive disorders (:

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course objectives -- depressive disorders in adolescents (:

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course objectives -- nurse client relationship development (;

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course objectives -- schizophrenia (:

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course objectives -- suicide (;

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depressive disorders (:

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depressive disorders in adolescents (:

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diagnostic systems for behavioral health care(:

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quiz 2(:

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recovery model(:

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substance-related and addictive disorders(:

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suicide and depression(:

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the client with personality disorder(:

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Epidemiology of depressive disorders

*Leading cause of disability in the US Depression linked to increasing coronary artery disease 2014- Six percent ages 18+ diagnosed with at least one major depressive episode Increasing among teens and adults Most prevalent psychiatric disorder- 17% lifetime prevalence (Townsend, Morgan 2018)

intoxication

- A physical and mental state of exhilaration and emotional frenzy or lethargy and stupor reversible syndrome of symptoms following excessive use of a substance. Direct effect on CNS. Judgement disturbed, resulting in inappropriate and maladaptive behaviors, and social and occupational functioning are impaired.

Nurse effectiveness depends on:

-Genuineness - use of "I" statements -Honesty - many of these clients have experienced many broken promises. Be careful not to promise -Authenticity (trustworthiness) - be real -Respect for humanity and dignity - goes without saying.

Numerous somatic complaints of GAD

- serious physical complaints brought on by psychological causes -Severe shoulder pain; leg won't move -Psychological troubles manifest as physical complaints

characteristics of schizophrenia -- disordered thinking

--One form of thought disorder is called "disordered thinking". This is when a person has trouble organizing his or her thoughts or connecting them logically. They may talk in a garbled way that is hard to understand. Another form is called "thought blocking". This is when a person stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking, the person may say that it felt as if the thought had been taken out of his or her head. The person with schizophrenic thought disorder may also make up meaningless words, or "neologisms".

DSM V

-A new classification professional development since 2007 -Over 13 international conferences -Just released Spring 2013 -Still some criticisms -Psychiatrists meet to improve classification of mental illness and to plan the DSM V that has just been released -Criticisms: --DSM V needs to focus on brain structure (imaging) and function --DSM V needs a shorter, less complex manual

major behaviors

-Acting out- son who is angry at his mother for marrying again. -Although he is 21 yo, he responds by chopping up her wedding dress. -Seduction- after being in treatment with a psychotherapist for five years, the client succeeds in getting the therapist emotionally involved. In so doing, she gains control of their relationship. -Splitting—Inability to integrate and accept both positive and negative feelings. People and life situations are either all good or all bad. (you are the good nurse. She is the bad nurse) -Manipulation- client compliments the nursing stdenton his uniaueabilities to help him solve his emotional problems. The student becomes convinced that the majority of the health care team members are erring in their assessment of the patient. -Dependency- the client who refuses to get a job, learn to drive, balance a checkbook, et. -Passive-aggressive tendencies—client who comes to appointments late, forgets to pay bill, forgets to call in ill, just does not show up for work..... -Self-destructive behaviors—repetitive, self-mutilative behaviors such as cutting; scratching; and burning. Classic in BPD. Designed to elicit a rescue response.

Positive techniquest of personal communication

-Active listening -Silence -Broad openings --"What do you think about..." --"Tell me about..." -Restating -Clarification --"Are you saying that..." --"So are you thinking..." -Reflection -Focusing -Directing the conversation --"Let's talk more about that"... -Informing --Giving facts and information -Suggesting --Asking the client to consider an alternate meaning of coping -Confronting --Pointing out inconsistencies

Identify types of crisis and nursing interventions **dispositional crisis

-Acute response to an external situation stressor -A man who is under extreme pressure at his work, beings abusing his wife and baby. The wife has had enough and seeks help at an abuse shelter -Nursing Intervention: Physical wounds are priority and screening for domestic violence issues

6 classes of crisis 1. dispositional crisis

-Acute response to an external situational stressor -i.e.) a man who is under extreme pressure at his work, begins abusing his wife and baby. The wife has had enough and seeks help at an abuse shelter -Nursing intervention: physical wounds are priority. Screen for domestic violence. Provide mental health resources such as counseling, etc.

types of phobias

-Agoraphobia --Fear of the marketplace --Fear of being in places or situations where escape may be difficult -Social anxiety disorder (social phobia) --Excessive fear that an individual will do something embarrassing or be evaluated negatively by others --Onset late in childhood or early adolescence --Runs a chronic, somethings lifelong course -Specific phobia --Fear of specific objects or situations that can cause harm --Heights or snakes --Treatment when the specific phobia interferes with activities of daily living

Panic disorder

-Characterized by recurrent panic attacks -Onset is unpredictable -Intense apprehension -Fear -Terror -"I feel like I am dying" "I am dying"- r/t cardiac symptoms -Intense physical discomfort—they believe they are having a heart attack because the discomfort is so intense -Usually last minutes or more rarely, hours. -Varying degrees of nervousness and apprehension—symptoms may not be the same each time (each panic attack) -Symptoms of depression -Average age of onset is late 20's but can be sooner (recently began diagnosing it sooner) -Frequency and severity vary widely --Can last a few weeks/months or can last for years

Formulate Nursing diagnoses and outcomes of care for clients with schizophrenia and other psychotic disorders

-Altered Perception (hallucinations - auditory, visual, tactile, gustatory, olfactory) -Altered sense of self --Lacks this feeling of uniqueness and experiences a great deal of confusion regarding his or her identity. --Echolalia - repeat words that they hear --Echopraxia - client who exhibits echopraxia may purposelessly imitate movements made by others --Identification and imitation - the client takes on behavior they see in another person because they are confused about their own identity --Depersonalization - the unstable self-identity of an individual with schizophrenia may lead to feeling of unreality -Anxiety -Impaired verbal communication -Ineffective coping -Elevated risk for accidental injury -Altered nutrition -Powerlessness -Self care deficit -Self esteem disturbance -Social isolation -Elevated risk for violence, self and other directed -Outcomes --Develop a trusting relationship between patient and nurse --Be oriented, able to test reality --Be protected from injury --Be able to recognize impending loss of control --Adhere to medication schedule --Participate in activities --Increase ability to care for self

Personality disorder (DSM V)

-An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment -We all have our quirks and not so healthy behaviors. Some have neurotic symptoms such as the way they organize their home or their lives. But until it becomes intense, frequent and disrupts their lives, can you diagnose it as OCD. You must be careful. You may be diagnosing friends or family members as you learn about diagnoses in this course, but until it is frequent, intense, disruptive to their lives, etc. it is not an illness.

Discuss Schizophrenia and other psychotic disorders

-Approximately 1% of population -Onset --Males - adolescence to early adulthood --Females - usually later than males --Usually not diagnosed after the age of 45 yrs --Child - onset schizophrenia is growing -Other assessment Factors --Changes in thoughts, speech, affect --Ability to perform self-care, activities and maintain nutrition --Suicidal potential --Aggression --Regression --Impaired communication

Apply techniques of ECT And TMS within the context of the nursing process

-Assessment of cardiac and pulmonary status -Informed consent -Important to document: mood, suicidal ideations, plan, means, level of anxiety, thought and communication patterns, current and past medication -Diagnosis --Can be anxiety, knowledge deficit, risk for injury from procedure, decreased cardiac output, self-care deficit -Specific nursing interventions --NPO for 6-8 hours --Approximately one hour before ECT: ---Vital signs, remove dentures, eyeglasses, jewelry, and hairpins ---Have client void, change gown --Approximately 30 mins before ECT ---Pre-treatment medications - decrease secretions/prevention of aspiration ---Blood pressure cuff on lower leg inflated to just above systolic pressure - so as to better observe the seizure activity in the toe --During ECT: ---Place the airway bite block ---Electrode bilaterally or unilaterally as ordered ---Monitor airway --Post ECT: ---Post procedure vital signs, document recovery

secondary appraisal of an event

-Assessment of skills, resources and knowledge that a person possesses to deal with the situation. --Coping strategies --Will the option I choose be effective? --Ability to use the strategies in an effective manner

Treatment of GAD

-Benzodiazapines- Called "benzos" enhances the effects of GABA and the efficacy of the SSRI's. All lead to increases of serotonin. --Need to watch for tolerance and possible addiction -Textbook supports the positive effects of deep breathing on elevating GABA leading to reduced heart rate through vagus nerve stimulation.

Predisposing factors of bipolar disease -- biological

-Biogenic amines --Excess norepinephrine and dopamine. Depressed level of serotonin. Acetylcholine also related. Excess in glutamate. -Neuroanatomical factors --Dysfunction in prefrontal cortex, basal ganglia, temporal and frontal lobes but also part of the limbic system like the amygdala, thalamus and striatum.

Identify predisposing factors in the development of bipolar disorder

-Biological explanation: --Biogenic amines --Neuroanatomical factors -Strong genetic connection/Bipolar disorder is an inherited disease --Most impressive are the studies of twins and bipolar disorder. Identical twins 60-80% chance of having bipolar disorder if one twin has it --10-25% risk of getting bipolar disease if one parent has it --50-75% risk of both parents have bipolar disorder -Psychosocial explanation --Environmental stressors - child abuse or trauma

bipolar disorder

-Bipolar disorder is linked closely with depression. Involves a manic and depressive cycle. Usually the mania comes first than the depressive part comes next. Make no mistake bipolar disorder is a serious neurobiological disorder that often leave people destitute, with shattered friendships, dissolved partner and family relationships, and job loss. Some theories say bipolar disorder is genetically transferred. There is a 25% risk of getting bipolar disorder if one parent has had bipolar disorder. There is a 25% risk of getting bipolar disorder if one parent has had bipolar disorder. Medication adherence is key along with psychotherapy. -Men --Begins at age 18 -Women --Begins at age 20

Discuss historical aspects and epidemiological statistics related to other anxiety disorders

-Body dysmorphic Disorder --Exaggerated belief that the body is deformed -Trichotillomania (hair pulling disorder) --Recurrent pulling out of one's hair that results in hair loss in scalp, eyebrows, or eyelashes --Increase sense of tension --Tension released or sense of gratification when the hair is pulled out --Comorbid psych disorders include: MDD, GAD, OCD, substance use disorder -Hoarding Disorder --Persistent difficulties discarding or parting with possessions --Can also hoard food or animals

3 values of a therapeutic relationship

-Caring --Caring about the well being of the client is a basic nursing function -Generosity --Important on both part: client and the nurse -Courage --Very much a part of a therapeutic relationship. Sometimes it is courage that gets us through those first uncomfortable minutes

Identify types of crisis and nursing interventions **maturational/developmental crisis

-Crisis that occur as result of failed attempts to master developmental tasks associated with life transitions -Nursing Intervention: --Primary intervention is to help with anxiety reduction --When have intense anxiety, their ability to gain insight about contributing factors and explore options for behavior change is impaired.

Discuss implications of bipolar disorder related to developmental stage

-Childhood and adolescence --The lifetime prevalence of adolescent bipolar disorders is estimated to be about 1 percent. -A connection is thought to exist between attention-deficit/hyperactivity disorder and the development of bipolar disorder in youth, but research has not supported this theory -When true mania associated with bipolar disorder does occur in adolescents, it is frequently accompanied by flight of ideas, grandiose or persecutory delusions, and hallucinations.

Cyclothymic disorder

-Chronic mood disturbance -At least 2 years in duration -Numerous periods of elevated mood that do not meet the criteria for hypomanic episode -Numerous periods of depressed mood of insufficient severity or duration to meet the criteria for major depressive episode -Client never without symptoms for more than 2 months 2 years in duration but only one year in child and adolescents. -There are other bipolar disorders due to another medical condition—cardiac diseases, seizure disorders, parkinsons, obesity, sleep apnea. Substance abuse /medication-induced bipolar disorder—comes from intoxication, etc. This is also this "other or unspecified bipolar" and related disorder.

Discuss risks and contraindications of ECT and TMS **ECT

-Contraindications --MI or CVA within the last 3-6 months --aortic/cerebral aneurysm --Severe hypertension --Congestive heart failure --Intracranial lesions --Severe osteoporosis --acute/chronic pulmonary disorders --High risk pregnancy -Risks --Mortality ---0.002% or 0.01% for each client ---Although rare, the major cause of death with ECT is from cardiovascular complications --Memory loss ---Can be 4 hrs to 10 hrs ---Most clients return to their cognitive baselines after 6 months ---Persistent memory loss is often associated with clients who have seen little improvement in their depression from ECT therapy --Brain damage --Still a concern by critics --No evidence supports this

Describe the phases of relationship development and the tasks associated with each phase --orientation phase

-Creating healing environment. Contracting -Creating an environment for the establishment of trust and -rapport. -Establishing a contract for intervention that details the expectations and responsibilities of both nurse and client. -Gathering assessment information to build a strong client database. -Identifying the client's strengths and limitations. -Formulating nursing diagnoses. -Setting goals that are mutually agreeable to the nurse and client. -Developing a plan of action that is realistic for meeting the established goals. -Exploring feelings of both the client and nurse in terms of the introductory phase.

6 classes of crisis 4. maturational/developmental crisis

-Crises that occur as result of failed attempts to master developmental tasks associated with life transitions -i.e.) a middle-aged man begins drinking heavily as he reflects up on his life and realizes he has few investments and limited financial security. His drinking gets so bad that his family commits him to a treatment center -Nursing Interventions: conduct regular intake assessment. Reassure client safety. Provide resources for the family to assist with support for loved one with addiction. Encourage client to attend all therapy.

6 classes of crisis 5. crisis reflecting psychopathology

-Crises that occur as result of failed attempts to master developmental tasks associated with life transitions -i.e.) a middle-aged man begins drinking heavily as he reflects up on his life and realizes he has few investments and limited financial security. His drinking gets so bad that his family commits him to a treatment center -Nursing Interventions: conduct regular intake assessment. Reassure client safety. Provide resources for the family to assist with support for loved one with addiction. Encourage client to attend all therapy. -Sonja, 29 yr old, diagnosed with borderline personality disorder at age 18. this disorder is deeply rooted in fears of abandonment. The thought of a therapist familiar to the client moving to another state can send the client into crisis.

Identify types of crisis and nursing interventions **crisis reflecting psychopathology

-Crisis influenced or triggered by preexisting psychopathology -Nursing Intervention: --Initial intervention is aimed at helping to reduce anxiety --Stay with the patient and reassure them of their safety and security. --After the feelings of panic and anxiety have subsided, should be encouraged to verbalize her feelings of abandonment. --Regressive behaviors should be discouraged --Positive reinforcement should be given for independent activities and accomplishment

6 classes of crisis 3. crisis resulting from traumatic stress

-Crisis precipitated by an unexpected external stressor over which the client has little control over -i.e.) a night shift waitress is abducted and raped in the parking lot while walking to her car. The physical wounds have healed, but the trauma is relived in her mind daily. -Nursing Intervention: Follow policy for rape kit processing. Allow client the opportunity to talk about the incident. Provide support. Refer if necessary. Implement grief and loss interventions.

Identify types of crisis and nursing interventions **crisis resulting from traumatic stress

-Crisis precipitated by an unexpected external stressor over which the client has little control over -Nursing Intervention: --Should offer the opportunity to talk about the experience and express her/his feelings about the trauma when she demonstrates readiness. --Should offer reassurance and support; discuss stages of grief and how rape may precipitate feelings of loss, including loss of control, loss of power, and loss of a sense of self-worth, triggering the reif response --Identify support systems --Explore new methods of coping with emotions arising from a situation with which they has had no previous experience

6 classes of crisis 6. psychiatric emergencies

-Crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility for his or her behavior -i.e.) acute suicide risk, drug overdose, reactions to hallucinogenic drugs, acute psychoses, uncontrollable anger, and alcohol intoxication -Nursing Interventions: Emergency medical care. Monitor vital signs. Activated charcoal if client has overdosed. Once stable, encourage client to express feelings and provide therapeutic listening techniques.

Identify types of crisis and nursing interventions **psychiatric emergencies

-Crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility for his or her behavior -Nursing Intervention: --Emergency medical care, including monitoring vital signs, ensuring maintenance of adequate airway, and initiating gastric lavage and/or activated charcoal, is the priority. --Discussing feelings about self-esteem, rejection, and loss will help explore more adaptive methods of dealing with stressful situations.

Client outcomes in disaster client will:

-Demonstrate behaviors necessary to protect self from further injury -Identify interventions to prevent/reduce risk of infection -Is free of infection and /or physical injury -Maintains anxiety at manageable level -Expresses beliefs and values about spiritual issues -Demonstrates ability to deal with emotional reactions in an individually appropriate manner -Demonstrates an increase in activities to improve community functioning

Major depressive disorder (MDD)

-Depressed mood or loss of interest in usual activity -Impaired social and occupational functioning lasting 2 weeks -No history of manic episodes -Symptoms not attributed to chemicals or a general medical condition (diabetes) -Categorized as mild, moderate, severe -Fits DSM V diagnostic criteria: "5 or more symptoms present in the same 2 week period" -Interfering with social, occupation, or personal life

DSM V diagnostic criteria (has 5 or more)

-Depressed mood present most of the day, every day -Markedly decreased interest in activities that they previously enjoyed -Significant weight loss or weight gain -Insomnia or hypersomnia -Psychomotor agitation or retardation observable by others -Fatigue nearly every day -Feelings of worthlessness or excessive inappropriate guilt -Diminished ability to think or concentrate -Recurrent thoughts of death (suicidal ideation without a plan, or an attempt)

Nursing interventions in disaster

-Determine degree of anxiety/fear and associated behaviors -Note degree of disorganization -Create a quiet healing environment -Develop trusting relationship with client -Identify whether disaster has reactivated preexisting or coexisting situations -Determine presence of physical symptoms -Identify psychological responses -Discuss with client what is causing the anxiety from their point of view -Assist client to correct distortions and share the distortions with client

What is a relationship?

-Developed from an interaction between two or more persons -The interaction can be either positive or negative -Defines that series of interactions between two or more people -Defines that series of interactions between two or more people -If we desire a therapeutic relationship, we need therapeutic communication. That means any message we are sending via verbal and/or non-verbal communication must have the same intended meaning to the receiver

NANDA has 3 parts:

-Diagnosis (diagnostic label) (ex: risk to harm to self, altered relationships, altered coping) -Definition (defining characteristics) ---The defining characteristics provide the observable criteria that must be present to make the diagnosis. For example hopelessness. The definition is a subjective state in which an individual sees limited or no alternative or personal choices available and is unable to mobilize energy on own behalf. The defining characteristics include "passivity, decreased affect, and verbal cues such a 'I cant' and sighing, lack of involvement in care, lack of initiative, and decreased appetite". -Related factors (r/t schizophrenia manifested by hearing voices)

Describe various types of depressive disorders -- substance/medication induced depressive disorder

-Direct result of physiological effects of a substance or medication or toxin exposure -Can be associated with intoxication with withdrawal of a substance or chemical -Medications that can cause MDD: --Anesthetics --Analgesics --Anticholinergics --Anticonvulsant --Antihypertensives --Anti-parkinson's agents --Ulcer medications --Cardiac medications --Contraceptives

19th century - a system of state asylums

-Dorthea Dix—a former New England school teacher --Lobbied on behalf of the mentally ill --Believed mental illness as curable and that state hospitals should provide humanistic therapeutic care --Got the ball rolling on mental illness legislature -Soon the institutions became overcrowded and conditions deteriorated -Therapeutic care reverted to custodial care

Discuss historical perspectives associated with cognitive therapy

-Early 1960's developed by Beck who studied under Freudian psychoanalytic view, who observed in clients a pattern of negative cognitive processing in thought and dreams -CBT is based on the client's individual cognition or appraisal of an event -"Life is 1-% of what happens to us and 90% of how we react to it" - -Modification of distorted cognition and maladaptive behaviors

Describe the phases of relationship development and the tasks associated with each phase --termination phase

-Evaluate goal attainment -Ensure therapeutic closure -Progress has been made toward attainment of mutually set goals. -A plan for continuing care or for assistance during stressful life experiences is mutually established by the nurse and client. -Feelings about termination of the relationship are recognized and explored. Both the nurse and client may experience feelings of sadness and loss. The nurse should share his or her feelings with the client. Through these interactions, the client learns that it is acceptable to have these kinds of feelings at a time of separation. With this knowledge, the client experiences growth during the process of termination. This is also a time when both nurse and client may evaluate and summarize the learning that occurred as an outgrowth of their relationship

Preconceived roles

-Exist in all relationships -Nurses sometimes feel like they are always in the role of giving -Sometimes it is the patient who gives to the nurse -Do not presume that we are always going to be the provider of care in a relationship. Sometimes when we care for clients in mental health, we are the recipients of much more than we give. What preconceptions do you have of the experience you will have with your clients?

Discuss dialectical behavioral therapy (DBT) technique

-Focused on the prevention of self-harm and suicide prevention -Rooted in belief that the client's primary problem is emotional dysregulation -Combining cognitive, behavioral and interpersonal therapies with mindfulness meditation --Mindfulness meditation: ---Used for mental health symptoms or basic relaxation ---Focus on the present ---Keeps the client from focusings on stressful events of the future ---Deep breathing, meditation postures and techniques ---Client goal driven - they set the goals

Predisposing factors to GAD -biological

-Genetics (parents and grandparents had it—carrying predisposition to anxiety) -Neuroanatomical- childhood injury; physical injury to brain or head --temporal lobes esp. the hippocampus or amygdala --Frontal cerebral cortex -Biochemical- abnormal blood lactate levels -Neurochemical- Norepinephrine increased; Serotonin and GABA decreased

Component of a suicide safety plan include:

A: All the above (identifying people or agencies the client can go to for help, identifying warning signs and coping strategies, identifying people and social setting that provide distraction)

Characteristics of a therapeutic relationship

-Goal directed -Facilitates client coping skills -Offers potential for growth -Involves goals and then interventions to meet those goals -All therapeutic relationships lead to goals. Give the interaction order. By interacting with the client in a therapeutic way, they are able to develop positive coping skills. Therapeutic relationship also leads to client growth (sometimes the student nurse as well). It is all about broadening perspectives

Background assessment in a disaster

-Grieving- a natural response following any loss -Emotional effects of loss and disruption can be immediate or show up weeks later -Responses include: --Anger --Disbelief --Sadness --Anxiety --Fear --Irritability --Arousal --Numbing --Sleep disturbances --Increase in alcohol, tobacco, and caffeine use -Physically harmed versus the emotionally harmed. "walking wounded.

Apply techniques of dialectical behavioral therapy within the context of the nursing process

-Group skills training --Clients are taught skills relevant to the problems experienced by people with BPD, such as core mindfulness skills, interpersonal effectiveness skills, emotion modulation skill, and distress tolerance skill -Individual psychotherapy --Weekly session address dysfunctional behavioral patterns, personal motivation, and skills strengthening -Telephone contact --The therapists available to the client by telephone, according to limits set by the therapist but usually for 24 hours a day. -Therapist consultation/team meeting: --Therapist meet regularly to review their work with their clients --Meetings are focused specifically on providing support for each other, keeping the therapists motivated, and providing effective treatment to their clients

Identify various techniques used in the modification of client behavior

-Guided discovery -Guided relaxation and behavioral rehearsal -Automatic thought records -Modifying automatic thought --Questioning the evidence --Examining options and alternatives --Decatastrophizing --Reattribution --Daily record of dysfunctional thoughts --Cognitive rehearsal -Behavioral interventions --Active scheduling --Graded task assignments --Distraction --Miscellaneous techniques --Relaxation exercises --Assertiveness training --Role modeling --Social skills training --Contingency management contracts

Outcomes for clients with depression

-Has experienced no physical harm to self -Discusses feelings with staff and family members -Expresses hopefulness -Sets realistic goals for self -Is no longer afraid to attempt new activities -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

Personality traits

-Help to describe a person's personality -Stable patterns or characteristics -Influence how a person looks, behaves, and reacts to life events

Treatment modalities

-Individual psychotherapy -Cognitive therapy- CBT -Behavior therapy --Systematic Desensitization --Implosion therapy -Medications --anxiolytics, antidepressants, anti-hypertensives, anticonvulsants try to use medications no longer than 4 months --Benzodiazepines are very addictive --Buspirone and other SSRIs not addictive

Predisposing factors in the discussion of STRESS

-Influence whether the response to the stress is either adaptive or maladaptive -Genetic influences-family history of strengths/weaknesses when it comes to stress -Past experiences-result in learned patterns that can influence an individual's adaptation response -Existing conditions- incorporate vulnerabilities that influence the adequacy of the individuals physical, psychological, and social resources for dealing with adaptive demands (health status, financial status, age, education, coping strategies, support system)

primary appraisal of an event

-Irrelevant- outcome holds no significance -Benign-positive—outcome is perceived as bringing pleasure to the individual -Stressful—include harm/loss; threat; and challenge -Harm/loss—damage or loss already experienced -Threat- anticipated harms/losses -Challenge- produces a threat, even though the emotions associated with it (eagerness or excitement) are viewed as positive -Focus is on gain or growth rather than risk

Current focus of care for the mentally ill

-Less time in the hospital -More care delivered in the communities -NAMI -Southeastern Behavioral Health -Cayman court residential treatment -5th Street Connection -Families

The beginnings of psychiatric nursing

-Linda Richards—first American psychiatric nurse --Established many psychiatric hospitals --Established the first school of psychiatric nursing --McLean Asylum in Waverly, Mass -Training in custodial care

Psychopharmacy of bipolar disorder

-Lithium (0.6-1.2 meq/liter) --most effective in clients who are not short cyclers. What is a short cycler? Watch for the lithium levels. Want to keep it at 0.6-1.2 meq/L. Entirely eliminated by the kidneys so watch Bun/creat. -Divalproex/valproicacid --works with in 24-72 hrs. -Antipsychotic agents --Risperdoland Clozipine. More effective with chronic management -Benzodiazapines --watch for addiction -Anticonvulsants --begin at a low dose and increase over time. Can be used with rapid cyclers. Klonopin, dilantin, tegretol, mysoline, depakote. -Antidepressants --be careful that this doesn't put your client into mania.

Identify symptomatology associated with bipolar disorder

-Mania symptoms(3 or more) --Inflated self-esteem --Decreased need for sleep --More talkative --Flight of ideas --Spending spree --Distractibility --Foolish business investment --Increase in goal-directed activity --Excessive involvement in pleasurable activities --Sexual indiscretion -Behavioral Symptoms of Mania --Euphoric --Jumping from subject to subject --Disturbed speech, loud, rapid --Rapid mood shift --Can be paranoid --Impatient --Manipulative --Pacing on the unit -Physical Changes in Mania --Intense period of psychosis --Weight loss --hallucination/delusion --Increased blood pressure --Increased heart rate

prementstrual dysphoric disorder

-Markedly depressed mood -Excessive ansiety -Mood swings -Decreased interest in activities -ALL of the above occurring the week prior to menses and becoming minimal or absent the week after menses.

Boundaries in the nurse/client relationship

-Material—fences around the hospital -Social- Established within a culture and dictate how individuals interact with one another -Personal- physical distance and emotional boundaries -Professional— spaces between a nurse's power and client's vulnerability --Self-disclosure --Gift giving --Touch --friendship/romantic association

Middle ages view on psychological illness (500-1500 AD)

-Mental illness associated with witchcraft -Many were sent out to sea on ships with very little guidance --"Ship of fools" --Some islamic countries believed that the mentally ill needed to be housed within special units within hospitals as well as residential institutions specifically designed for this purpose - the first asylums

Describe various types of depressive disorders -- postpartum depression

-Mild postpartum depression --Worry --Sadness --Fatigue --Symptoms subside in 1-2 weeks -Moderate --Worry, sadness, fatigue --Irritability --Loss of appetite --Sleep disturbances --Loss of libido --Concern about caring for baby --Symptoms take few weeks to several months to go away -Severe --Depressed mood --Agitation --Indecision --Lack of concentration --Guilt --Symptoms severe and incapacitating --Risk of suicide and infanticide as well as postpartum psychosis

Characteristics of mentally ill clients (they tend to):

-Misinterpret reality - due to delusions, poor communication skills -Lack interpersonal skills - antisocial personalities, or Axis II can act as if they have good IPR skills but they are really an act. Sometimes what they are saying is all "cliche" -Over Sensitive to rejection or perceived slights - may interpret a nurses "aloofness" or preoccupation as rejection *a client's behavior at any given time represents his best adaptation to stress

Epidemiology of anxiety disorders

-Most common of all psychiatric diseases -More common in women than in men by 2:1 -Prevalence rates of anxiety in the US: --Specific Phobia (clostrophobia, aracnophobia, fear of heights) 8.7% --Social anxiety disorder 6.8% --Posttraumatic stress disorder 3.5% --Generalized anxiety disorder 3.1% --Panic disorder 2.7% --Obsessive-compulsive disorder 1%

Facts and Myths about suicide

-Myth: people who talk about suicide do not act on their ideas. Suicide happens without warming --Fact: 8/10 people who kill themselves have given definite clues and warnings. Subtle clues can be ignored -Myth: you cannot stop a suicidal person. He or she is fully intent on dying --Fact: most suicidal clients are very ambivalent about their feelings regarding living or dying. Most are crying for help -Myth: once a person is suicidal, they are suicidal forever --Fact: not necessarily. Depends on the interventions and resources given -Myth: improvement after severe depression means that the suicidal risk is over --Fact: most suicides occur within about 3 months, after the beginning of "improvement" when the client has the energy to carry out suicidal intention

Identify types of crisis and nursing interventions **crisis of anticipated life transition

-Normal life cycle transition that are anticipated but once they actually occur they cause feelings of loss of control -Nursing intervention: --Physical examination should be performed and ventilation of feelings encouraged. --Reassurance and support should be provided as needed.

6 classes of crisis 2. crisis of anticipated life transition

-Normal life cycle transitions that are anticipated but once they actually occur, they cause feelings of loss of control -i.e.) student placed on probationary status due to low grades. His wife had to quit her job once the baby was born. The male student increases his hours at work from part-time to full-time to compensate. Soon he is failing all of his classes. He presents to the campus nurse complaining of all sorts of health problems. -Nursing Intervention: provide physical examination first. Reassure and support the client. Refer to services such as financial counseling and college counseling center

Characteristics of a crisis

-Occurs in all individuals at one time or another - happens to anyone. Not always associated with psychopathology -Precipitated by specific identifiable events - usually the straw that broke the camel's back -Personal by nature - what may be a crisis to one, is not necessarily a crisis to another -Acute, not chronic - most likely resolved within a short period -Potential for psychological growth or deterioration -Quickly and unexpected

Postpartum depression

-On a continuum from mild to severe depression -50% of postpartum depression occurs prior to delivery -Major depression with psychotic features occurs in about 1-2 / 1,000 postpartum women -Symptoms: --Mild: ---Worry ---Sadness ---Fatigue ---Symptoms subside in 1-2 weeks --Moderate ---Worry, sadness, fatigue ---Irritability ---Loss of appetite ---Sleep disturbances ---Loss of libido ---Concern about caring for baby ---Symptoms take few weeks to several months to go away --Severe ---Depressed mood ---Agitation ---Indecision ---Lack of concentration ---Guilt ---Symptoms severe and incapacitating ---Risk of suicide and infanticide as well as postpartum psychosis

Discuss historical aspects and epidemiological statistics related to generalized anxiety disorder (GAD)

-Persistent, unrealistic, and excessive anxiety and worry that have occured more days than not for at least 6 months and cannot be attributed to specific organic factors such as caffeine intoxication or hyperthyroidism. -Also muscle tension, restlessness, or feeling keyed up or on edge -Clients either avoid activities or events that may result in negative outcomes or they spend an incredible amount of time preparing for such events -Repeated questions about "who will be there, do you think they will like me? What if this happens?" -Onset child or adolescent years -Can be first diagnosed in the 20s -Depressive symptoms common numerous somatic complaints -Chronic with frequent stress - related exacerbations

Generalized anxiety disorder (GAD)

-Persistent, unrealistic, and excessive anxiety and worry that have occurred more days than not for at least 6 months and cannot be attributed to specific organic factors such as caffeine intoxication or hyperthyroidism. -Also muscle tension, restlessness, or feeling keyed up or on edge -Clients either avoid activities or events that may result in negative outcomes or they spend an incredible amount of time preparing for such events --i.e.) repeated questions about "who will be there, do you think they will like me?, what if this happens.." --Onset child or adolescent years --Can be first diagnosed in the 20's -Depressive symptoms common

18th century first mental health hospital

-Philadelphia -Dr. Benjamin Rush—father of psychiatry -Initiated the provision of humanistic treatment --Kindness --Exercise --Socialization -Also started some not so nice treatments --Blood letting --Purging --Physical restraints --Extremes of temperatures

Nursing care plan for risk for suicide

-Short term goal: --Client will seek out staff when feeling urge to harm self --Client will not harm self -Long term goal: --Client will not harm self for at least 1 year -Intervention: --Create a safe environment for the client. Remove all potentially harmful objects from client's access (sharp objects, straps, belts, glass items, alcohol, guns)

Settings for therapeutic communication

-Physical space --The physical space between two individuals as well as the design of the room and the furniture that contributes to the environment, have great meaning in communication --Space between 2 persons gives a sense of their relationship and like all aspects of communication, is linked to cultural norms and values. The areas of practice include behavioral health nursing. -Creating an environment of healing

Maslow's in review related to mental health

-Physiological needs—food water, air sleep, exercise, elimination, shelter, and sexual expression -Safety and security—avoiding harm, maintaining comfort, physical safety, freedom from fear, and protection -Love and belonging—need for giving and receiving affection -Self-esteem and esteem of others- achieve success and recognition in work, and desires prestige from accomplishments -Self-actualization—feeling of self-fulfillment and the realization of his or her highest potential

Describe the phases of relationship development and the tasks associated with each phase --pre-interaction

-Preparation for the first encounter -Obtaining available information about the client from his or her chart, significant others, or other health-care team members. From this information, the initial assessment begins. The nurse may also become aware of personal responses to knowledge about the client. -Examining one's feelings, fears, and anxieties about working with a particular client. For example, the nurse may have been reared in an alcoholic family and have ambivalent feelings about caring for a client who is dependent on alcohol. All individuals bring attitudes and feelings from prior experiences to the clinical setting. The nurse needs to be aware of how these preconceptions may affect his or her ability to care for individual clients.

Discuss historical aspects and epidemiological statistics related to obsessive compulsive disorder (OCD)

-Presence of obsessions, compulsions, or both -Severe enough to cause distress or impairment in social, occupational, or other important areas of functioning. -Common compulsions: --Handwashing --Ordering --Checking --Praying --Counting -Onset- adolescence or adulthood -Equally common among men and women -Obsessions - intrusive thoughts that are recurrent and stressful. Repetitive and cannot be ignored -Compulsions - repetitive ritualistic behaviors or mental acts an individual feels driven to perform which are intended to reduce the anxiety associated with obsessive thoughts

1960s began the community care

-President John F Kennedy wanted psychiatric care to be the responsibility of the communities and families and NOT the custodial care model. -Many psychiatric patients were released from the hospitals -This burdened the communities and families -Many organizations such as NAMI(National Alliance for Mentally Ill) developed

Historical overview of psychiatric care

-Primitive belief (supernatural)—dispossessed soul. The only way one could be cured is if the soul returned. -Also correlated to demonology—The client must have angered God. Exorcism was sometimes the treatment. -Hippocrates (400 B.C.)—began the movement away from the supernatural and towards the irregularity in the interaction of the four body fluids --Blood --Black bile --Yellow bile --Phlegm --Treatment was to induce vomiting or diarrhea

Describe the phases of relationship development and the tasks associated with each phase --working phase

-Promote client change -Maintaining the trust and rapport established during the orientation phase. -Promoting the client's insight and perception of reality. -Problem-solving using the model presented earlier in this chapter. -Overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues. -Continuously evaluating progress toward goal attainment.

National mental health act 1946

-Provided funds for Psychologists, Psychiatrists, Social Workers, and Psychiatric Nurses. -Graduate level degrees for psychiatric nursing developed -Introduction of antipsychotic medications

MDD psychosocial predisposing factors

-Psychoanalytical theory- related to loss and poor love relationships -Learning theory- helplessness -Object Loss theory- can be physical or emotional -Cognitive theory- cognitive distortions resulting in negative thinking or defeated attitudes

Identify predisposing factors in the development of GAD

-Psychodynamic - inability of the ego to intervene when conflict occurs between the Id and superego -Cognitive - faulty distorted or counterproductive thinking patterns are present. Because of distorted thinking, anxiety is maintained by erroneous or dysfunctional appraisal of situation. Loss of ability to reason. -Biological: --Genetics --Neuroanatomical ---Temporal lobes esp. Hippocampus or amygdala ---Frontal cerebral cortex --Biochemical - abnormal blood lactate levels --Neurochemical - norepinephrine increased; serotonin and GABA decreased

Describe predisposing factors implicated in the etiology of suicide

-Psychological --Anger turned inward --Hopelessness and depression --Aggression and violence --Shame and humiliation -Sociological --Connection to society --Interpersonal theory of suicide -Biological --Genetic predisposition to suicide --Deficiency of serotonin

Diagnostic and statistical manual for mental disorders (DSM)

-Published by the American psychiatric association. Many changes have taken place since the DSM III. now the DSM IV has a multi axial system that allows for developmental and other disorders to be considered along with psychiatric diagnoses -Published since 1952 -DSM V is used today -NOS = not otherwise specified (not a lot of evidence that shows they meet all the criteria or had it for 6 months duration)

Schizophrenia

-Schizophrenia is a chronic debilitating brain disorder. People with the disorder hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated. Shades of grey. Some people may not make sense when they talk. Some appear perfectly fine until they talk about what they are really thinking. -As you saw in the film, "A Beautiful mind, some people with schizophrenia can have jobs, do well for a period of time, and when they need to, they have to change medicines or even quit their job" In any event, most people with schizophrenia need to rely on others to help. -Approximately 1% of the population

Maslow's hierarchy and mental health

-Self-actualization means to be psychologically healthy, fully human, and highly evolved -Included: --Appropriate perception of reality --Ability to accept oneself, others and human nature --Ability to manifest spontaneity --Ability to achieve satisfactory personal relationships

Persistent depressive disorder (PDD) or dysthymia

-Similar to MDD -Symptoms are milder -No evidence of psychotic symptoms -Chronically depressed mood "I just feel punk" OR Irritable mood --Most of the day, more days than not for at least 2 yrs(one year for child/adolescent) -Early onset- before 21 years of age -Late onset- after 21 years of age

North american nursing diagnosis association (NANDA)

-Since 1973 -Started by a group of nurses -Met in St. Louis, MO -First national conference for the classification of nursing diagnoses -Nurses realized that much of what we might call "the essence" of nursing remained undocumented. Without an independent diagnostic system, nurses were seen as merely carriers of physician orders -NANDA taxonomy: a listing of phenomena of concern to nursing and permits one to identify client concerns as nursing diagnoses

Evaluate Nursing care of clients with anxiety, obsessive-compulsive, and related disorders

-Stay with client and offer reassurance of safety and security. Do not leave client in panic anxiety alone -Maintain a clam, nonthreatening matter-of-fact approach -Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences -Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes that amount of carbon dioxide in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist client to breathe into a small paper bag held over the mouth and nose. Six to 12 natural breaths should be taken, alternating with short periods of diaphragmatic breathing. -Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor) -Administer tranquilizing medication, as ordered by physician. Assess for effectiveness and for side effects. -When level of anxiety has been reduced, explore possible reasons for occurence -Teach signs and symptoms of escalating anxiety, and ways to interrupt its progression (relaxation techniques, such as deep-breathing exercises and meditation, or physical exercise, such as brisk walks and jogging)

Discuss how age, race and gender are associated with suicide risk

-Suicide risk and age are positively correlated among men - -Highest rates of suicide are among 45-64 yrs of age and over 85 yrs old -Adolescents --Suicide is 3rd leading cause of death in this population for many years, jumping to 2nd leading cause of death in year 2013 where it remains. -Children --They are actively talk about it. Social media? --Age 5-11 yrs old lose 33/yr to suicide (suffocation and hanging) --Ages 3-7 yrs old show 11% suicidal ideation

Define Codependency and identify behavioral characteristics associated with the disorder

-The codependent person is able to achieve a sense of control only through fulfilling the needs of others. -Have a long history of focusing thoughts and behavior on other people. -Are "people pleasers" and will do almost anything to get the approval of others. -Outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all. -Have experienced abuse or emotional neglect as a child. -Are outwardly focused toward others and know very little about how to direct their own lives from their own sense of self. -Dysfunctional behaviors evident among family members of a chemically addicted client -Profound sense of powerlessness - -More about fulfilling the needs of others -Personal identity is relinquished and boundaries with the other person become blurred -Dysfunctional relationship with oneself

Precipitating event

-The event precipitates a response on the part of the individual -The response is influenced by the individual perception -Cognitive Appraisal—individual's evaluation of the personal significance of the event or occurrence. -Question: talk about the sequence of events related to losing a job and the subsequent heart attack of a client. Talk about the sequence of events surrounding a move from an apartment to a home.

withdrawal

-The physiological and mental readjustment that accompanies the discontinuation of an addictive substance clinically significant signs and symptoms as well as psychological changes

Identify and discuss essential conditions for a therapeutic relationship to occur --respect

-To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior. -The nurse, in fact, may not approve of the client's lifestyle or behavior patterns. However, with unconditional positive regard, the client is accepted and respected for no other reason than that he or she is considered to be a worthwhile and unique human being. -The nurse can convey an attitude of respect by --Calling the client by name (and title, if he or she prefers). --Spending time with the client. --Allowing sufficient time to answer the client's questions and concerns. --Promoting an atmosphere of privacy during therapeutic interactions with the client and during physical examination or therapy. --Always being open and honest with the client, even when the truth may be difficult to discuss. --Listening to the client's ideas, preferences, and opinions and making collaborative decisions concerning his or her care whenever possible. --Striving to understand the motivation behind the client's behavior regardless of how unacceptable it may seem.

Describe various treatment modalities for treatment of depression

-Treatment of Adolescent Depression --Outpatient ---Talk therapy ---Group therapy --Medication ---Outpatient therapy at avera behavioral -Inpatient --For severe depression --Hospitalization at avera behavioral health --Threat of imminent suicide --Threat of harm to self or others --Extreme family situations --Antidepressant Medication in children and Adolescent --Health advisory on increased risk of suicidal thoughts and behavior in children and adolescents being treated with antidepressants --Close monitoring advised --Fluoxetine (Prozac) approved for treatment of depression in children 8 yrs and older --Escitalopram (Lexapro) approved in 200 adolescents 12 years and older --SSRT --SNRI --Treatment modalities for MDD ---Individual psychotherapy ---Group therapy ---Family therapy ---Cognitive therapy ---ECT ---TMS ---Vagal nerve stimulation ---Light therapy ---Medications

Child expression of MDD symptoms

-Up to age 3yrs- feeding, tantrums, lack of playfulness, development delays, and failure to thrive -Ages 3 to 5yrs- accident prone, phobias, aggressiveness, and excessive self-reproach for minor infractions -Ages 6 to 8 yrs- vague physical complaints and aggressive behvavior, clingy -Ages 9 to 12 years- morbid thoughts, excessive worrying, poor self-esteem, lack of interest in playing with friends --May feel that they have disappointed their parents in some way

The History of Anxiety

-Usually linked to cardiac disease -Freud first to call it 'Anxiety Neurosis' 1895- anxiety bringing about neurotic behavior -Many tried to tie the symptoms to something physical in nature—someone's having chest pain→actually just having anxiety -Researchers now focus on the INTERRELATEDNESS of the physical and psychological ---Psychoimmunology—if we have something going on psychologically, it will eventually start affecting us physically

Where does nursing practice occur?

-Wherever the client is -"We must meet the person where they are, in the situation they are in..." -Nursing practice occurs when we are in relationship with our clients -Communication occurs within the relationship between the nurse and client

MDD biological predisposing factors

-genetics -biochemical amine imbalances (neurotransmitter imbalances) --norepinephrine --serotonin --dopamine -Neuroendocrine disturbances (adrenocorticoid, Thyroid, etc) -Physiologic influences- med side effects; electrolyte levels; hormones; nutrition; etc

Personality Disorder is derived from:

-individual's temperament -family upbringing -life experiences --All of these things, the individuals temperament, family upbringing, and life experiences—they strongly color an affected client's reaction to stress and illness, as well as other psychiatric disorders. You can say that Depression, Mania, Schizophrenia, Panic Disorder are constant across all personality types, but their impact on the client and their management are strongly influenced by underlying personality factors. --As Axis II disorders, personality disorders are NOT illnesses or conditions that a person acuiresat some point in his/her life—personality disorders are descriptions of the characteristics that an individual has and expresses that make up the whole of who the individual is. These characteristics impact virtually every other aspect of the person's psychosocial functioning.

Obsessive compulsive disorder (OCD)

-presence of obsessions, compulsions, or both Obessions happen first in brain- try to deal with it with compulsion Severe enough to cause distress or impairment in social, occupational, or other important areas of functioning

addiction

-primary chronic disease of brain reward, motivation, memory and related circuitry where a dysfunction in these circuits is connected to an individual pathologically pursuing reward and or relief by substance use and other behaviors -DSM V has listing of criteria for specific substances, including alcohol, cannabis, hallucinogens, inhalants, opioids, sedative-hypnotics, simulants, and tobacco. Subtanceuse disorder label is used when clients substance use interferes with the ability to fulfill role obligations at work, school, or home. Client wants to control use of the substance, but attempts to do so fail. Spirals.

Other diagnostic considerations of MDD

-symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning -Depressive episodes are not attributable to physiological effects of a chemical or medical diagnosis -Depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or NOS schizophrenia -Never been a manic or hypomanic episode

Apply nursing process to care of victims of disasters

1. Background assessment data gathering -Grieving - a natural response following any loss -Emotional effects of loss and disruption can be immediate or show up weeks later -Responses include: --Anger --Disbelief --Sadness --Fear --Anxiety --Irritability --Arousal numbing --Sleep disturbance --Increase in alcohol, tobacco, and caffeine use 2. Nursing diagnosis and outcome identification a. Diagnosis --Risk for injury --Risk for infection --Anxiety (panic) --Fear --Spiritual distress --Risk for PTSD --Ineffective community coping b. Outcome Identification -Demonstrate behaviors necessary to protect self from further injury -Identify interventions to prevent/reduce risk of infection -Is free of infection and/or physical injury -\ -Maintains anxiety at manageable level -Expresses beliefs and values about spiritual issues -Demonstrates ability to deal with emotional reactions in an individually appropriate manner -Demonstrates an increase in activities to improve community functioning 3. Planning and implementation -Interventions: --Determine degree of anxiety/fear associated in behaviors --Note degree of disorganization --Create a quiet healing environment --Develop trusting relationship with client --Identify whether disaster has reactivated preexisting or coexisting situations --Determine presence of physical symptoms --Identify psychological responses --Discuss with client what is causing the anxiety from their point of view --Assist client to correct distortions and share the distortions with client 4. Evaluation

Describe goals, principles, and basic concepts of cognitive therapy

1. Goals -Monitor his or her negative, automatic thoughts -Recognize the connections between cognition, affect, and behavior -Examine the evidence for and against distorted automatic thoughts -Substitute more realistic interpretations for these biased cognitions -Learn to identify and alter the dysfunctional beliefs that predispose him or her to distort experiences 2. Principles -Based on ever-evolving formation of the client and his/her problems in cognitive terms -Requires a sound therapeutic alliance -Emphasized collaboration and active participation -Goal oriented and problem focused -Initially emphasizes the present -Educative, aims to teach the client to be their own therapist - emphasizing relapse prevention -Time limited -Sessions are structured -Teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs -Uses a variety of techniques to change thinking, mood, and behavior

4 primary DBT treatment modes

1. Group skills training—clients taught skills such as core mindfulness, interpersonal effectiveness, emotion modulation and distress tolerance 2. Individual psychotherapy—weekly sessions addressing dysfunctional behavioral patterns, personal motivation,, andskills strengthening. Learning the balance of acceptance and change. 3. Telephone contact—making self available to client via telephone 24hrs/day to provide support in their application of skills they are learning. Like you are a personal coach assisting the client in their reactions to a stressful situation. 4. Therapist consultation /team meeting—like an interdisciplinary team meeting. Mostly for therapist to discuss their client cases and provide support to each other about the care of their clients. Keeps therapists motivated.

bipolar Incidence/ratio of women to men

1.2:1

1.Echolalia

1.Echolalia- repeat words that they hear. 1.. i.ei) one nurse says to another: "Let's go to lunch" Client says, "LUNCH LUNCH LUNCH"

Schizophrenia negative symptoms

1.Inappropriate affect- Laugh when everyone is crying 2.Flat affect- dull response 3.Apathy- indifference or disinterest in the environment 4.Emotional ambivalence-coexisting opposite emotions 5.Deteriorated Appearance- personal grooming and self-care activities are neglected 6.Impaired Social Interaction-Cling to others and intrude on personal space. 7.Social Isolation- focus inward on themselves to the exclusion of the external environment 8.Anergia- No energy to conduct ADLs 9.Waxy Flexibility- body parts placed in bizarre and strange positions. Keeping your arm in the same position as when the blood pressure was taken 10.Posturing—voluntary assumptions of inappropriate or bizarre postures. 11.Pacing and Rocking- 12.Anhedonia- inability to experience pleasure, this sometimes compels some clients to commit suicide. 13.Regression-retreat to an earlier level of development

causes of mania

1.Molecular/genetic 2.Drug or substance cause -alcohol withdrawal -cocaine, PCP, or amphetamine use 3.Infectious Disease -syphilis -HIV -Lyme disease -Cushingsdisease 4.Life Stressors -psychotic break - a psychotic break lasts a day, but less than a month

Keys for preventing burnout by caring for this group of clients is:

1.Self awareness—know your limits 2.Rely on your coworkers to relieve your stress from a heavy assignment 3.Surround yourself with nurses experienced in caring for clients with personality disorders

bipolar dual diagnosis

1.Substance Abuse 2.Schizoaffective Disorder 3.Borderline Personality One of the factors complicating both understanding and treatment of bipolar disorder is that many people who suffer from bipolar disorder also have other complicating psychiatric illnesses.

Discuss historical aspects and epidemiological statistics related to anxiety(prevalence)

18% adults, 25.2% children 13-18 years

Echopraxia-

2.Echopraxia- Client who exhibits echopraxia may purposelessly imitate movements made by others

Discuss epidemiological statistic and risk factors related to suicide

2014 over 42,000 people died by suicide Suicide is 2nd leading cause of death among young americans aged 10-34 yrs Many more attempt suicide than die by suicide Suicide is on the rise Suicide has increased in our military population High rates of suicide among youth on indian reservations Risk factors Marital status Gender Age Religion Socioeconomic status Ethnicity Other risk factors

The following phrase by a student demonstrates the defense mechanism RATIONALIZATION

A: "The nest had too many trick questions; I really know all of the material but our instructor is out to get me"

A nurse who is helping a client in the preparation phase of the Psychological Recovery Model might include which of the following interventions?

A: ( I don't know, got it wrong and it doesn't give you the right answer, it is not listen actively while the client composes his or her personal story)

Which of the following is true of the term codependency?

A: All of the above

Which of the following behaviors suggests a possible breach of professional boundaries? A. the nurse repeatedly requests to be assigned to a particular client B. the nurse shares details of their divorce with the client C. the nurse makes arrangements to meet the client outside of the therapeutic environment D. the nurse shares how he/she dealt with a similar situation

A. the nurse repeatedly requests to be assigned to a particular client B. the nurse shares details of their divorce with the client C. the nurse makes arrangements to meet the client outside of the therapeutic environment

John is a client at the 5th Street Connection. He is depressed, has been expressing suicidal ideation, and has been seeing the psychiatric nurse every 3 days. He has been taking 100 mg of sertraline daily for about a month, receiving small amounts of the medication from his nurse at each visit. Today he come to 5th street Connection in a cheerful mood, much different than he seemed just 3 days ago, and he is giving away some of his personal possessions. How might the nurse assess his behavioral change?

A: He may have decided to carry out his suicide plan

A client has a history of excessive drinking, which had led to multiple arrests for driving under the influence (DUI). The client states, "I work hard to provide for my family. I don't see why I can't drink to relax". The nurse recognizes the use of which defense mechanism?

A: Rationalization

Leon, a veteran of the war in Iraq, has been diagnosed with PTSD. He has been hospitalized after swallowing a handful of his anti-panic medication. His physical condition has been stabilized in the emergency department, and he has been admitted to the psychiatric unit. In developing his initial plan of care, which is the priority nursing diagnosis that the nurse selects for Leon?

A: Risk for suicide

A nurse admits a client with symptoms of severe depression and a diagnosis of anxiety disorder. Several hours later the nurse observes the client pacing in the hall. The client asks the nurse to check him because he feels like he is "running a fever". His vital signs are: blood pressure, 140/98 mm Hg; pulse 133 beats/minute; respirations 24 breaths/minute; and temperature 99.2 F (37.3 C). What should the nurse infer or conclude from these findings?

A: The client needs further evaluation for illness

You are working with a chemically impaired nurse on your unit. Which of the following signs point to a chemically impaired nurse?

A: The patient son the unit report poor pain control

A mother recuses two of her four children from a house fire. In an emergency department, she cries "I should have gone back in to get them. I should have died, not them." which of the following responses by the nurse is an example of reflection?

A: You're feeling guilty because you weren't able to save your children

A nurse who is helping a client with mental illness recovery using the WRAP Model says to the client, "first you must create a wellness toolbox." This nurse explains to the client that a wellness toolbox is which of the following?

A: a list of strategies and skills the client has used in the pat that help relieve disturbing symptoms

The following is an example of the defense mechanism UNDOING

A: a man nervous about his new job yells at his wife. He then buys her some flowers.

A new psychiatric nurse states, "this client's use of defense mechanisms should be eliminated." which is the correct evaluation of this nurse's statement?

A: defense mechanisms can be self-protective responses to stress and need not be eliminated.

Jane hates Nursing. She attended nursing school to please her parents. During career day, she speaks to 8th graders about the excellence of a nursing career. Jane is practicing which defense mechanism?

A: reaction formation

With the John F Kennedy administration, mental health hospitals emptied and the care of the mentally ill fell upon

A: the community and families

A client admitted with Major Depression tells the nurse "Life isn't worth living. I can't stand the pain any longer" The nurse should recognize this state as indicative of:

A: the need for a suicide assessment or the need for a pain assessment

A client on the Avera Behavioral Health B Unit begins attending AA meetings post discharge. Which of the statements by your client reflects the purpose of this organization?

A: they claim they will help me stay sober

Symptoms of alcohol withdrawal include:

A:Diaphoresis, nausea and vomiting, and tremors

Which of the following is a true statement about mental health recovery:

A:Mental health recovery is a collaborative process between the medical model and the recovery model of care

OCD onset

Adolescence or adulthood Equally common among men and women

Define addiction, intoxication, and withdrawal

Addiction - primary chronic disease of brain reward, motivation, memory and related circuitry where a dysfunction in these circuits is connected to an individual pathologically pursuing reward and or relief by substance use and other behaviors Intoxication - a physical and mental state of exhilaration and emotional frenzy or lethargy and stupor Withdrawal - the physiological and mental readjustment that accompanies the discontinuation of an addictive substance

risk factors for suicide -age

Age- suicide rates among men increase with age. Highest rates in the 45-64 age bracket (AFSP, 2016)

CBT cognitive strategies -guided relaxation and behavioral rehearsal

Aimed at reducing autonomic response to anxiety. Deepbreathing, imagery, mindfulness meditation, and other exercises. All techniques increase awareness of conscious control over breathing anxiety symptoms, and thoughts.

Define various treatment modalities

Alcoholics anonymous Pharmacotherapy (i.e) Disulfiram (Antabuse) Naltrexone Talk therapy or counseling Group therapy

medications that can cause MDD

Anesthetics Analgesics Anticholinergics Anticonvulsants Anti-hypertensives Anti-parkinsonsagents Ulcer medications Cardiac medications Contraceptives

psychological predisposing factors to suicide

Anger turned inward Hopelessness and depression Aggression and violence Shame and humiliation

Cognitive behavioral therapy

Cognitive (Def)- the mental process of thinking and reasoning Use of various techniques to create change in the client's thinking and belief system in an effort to bring about lasting emotional and behavioral change Distorted cognition - the root of behavioral health disorders Changing the way clients think

CBT cognitive strategies -modifying automatic thought: cognitive rehearsal

Cognitive rehearsal—Mental Imagery to uncover potential automatic thoughts in advance of their occurrence in a stressful situation,

Predisposing factors to GAD -cognitive

Cognitive- Faulty distorted or counterproductive thinking patterns are present. Because of distorted thinking, anxiety is maintained by erroneous or dysfunctional appraisal of a situation. Loss of ability to reason

Formulate Nursing diagnoses and outcome criteria for clients with anxiety, obsessive-compulsive and related disorders

Anxiety Fear Ineffective coping Disturbed body image Ineffective impulse control

anxiety

Anxiety- Subjective emotional response to a stressor (on a continuum- mild, moderate, severe) Anxiety is an emotional process. Anxiety is a vague diffuse apprehension—may not be able to define why they're feeling anxious.

Bipolar nursing assessment

Ask if others in the family have bipolar disorder Controversy about a dominant x-linked gene Enzyme that metabolized serotonin in the brain is often to blame. How often are the bipolar cycles? How many times manic? How many times depressed? One cycle= one manic/hypomanic phase and one depressive phase What family intervention works best Asking how often the bipolar cycles are is very important.

dopamine

Associated with the way the body reacts to mood and behavior

Active symptoms - form of thought of schizophrenia---associative looseness

Associative Looseness-thinking characterized by speech in which ideas shift from one unrelated subject to another. Severe cases speech incoherent. Client is unaware that the topics are unconnected. "we wanted to take the bus, but the airport took all the traffic.

social relationship

At a very young age, children, friends. No predetermined goal or definitive ending

projection

Attribution of one's own thoughts, feelings or impulses to others. "I'm not attracted to him. My best friend is..."

Adaptive coping strategies

Awareness Relaxation Meditation Interpersonal communication with caring other Problem Solving (facts, goals, alternatives, risk/benefit, select alternative, implementation, evaluate, second option if necessary Pets Music

schizophrenia altered sense of self

Because of extremely weak ego boundaries, the individual with schizophrenia lacks this feeling of uniqueness and experiences a great deal of confusion regarding his or her identity. 1. echolalia 2. echopraxia 3. identification and imitation 4. depersonalization

Dimensions of a therapeutic relationship

Begins with a nurse's view of the client As they are and as they have to potential to be

Apply techniques of cognitive behavioral therapy within the context of the nursing process

Behavioral strategies offer reinforcement for positive change Social skills training and assertiveness training teach alternative ways to deal with frustration. Cognitive strategies help the client recognize and correct distorted and irrational thinking patterns

biochemical theory etiology

Biochemical; Dopamine excess at the level where neurons are active in the brain. Can be that too much dopamine is released, there may be too many receptor cells, or increased receptor sensitivity, or a combination of all of these. Brain studies post mortem have shown more than average number of dopamine receptors in about 2/3s of all brains studied. Other biochemical points to the neurotransmitter glutamate being present in high numbers. N-methylDasparate. Physiological factors: viral infection, ventricular enlargements in the brain, disarray of cells, linked with epilepsy.

Discuss predisposing factors implicated in the etiology of substance-related and addictive disorders

Biological -Genetics --Heredity --Children of alcoholics - 4 times more likely than other children to become alcoholics --Twin studies -Biochemistry --Neurotransmitter opioid, catecholamine: dopamine and GABA --NEural pathways linked to pleasure centers Psychological -Developmental influences -Personality factors -Cognitive factors Sociocultural -Social learning -Conditioning -Cultural and ethnic influences

Identify predisposing factors in the development of depression

Biological Genetics Biochemical amine imbalances (neurotransmitter imbalances) Norepinephrine - key neurotransmitter in the bodies response to stressful situations Serotonin - involved in the body's regulation of mood, anxiety, arousal, irritability and cognition Dopamine - associated with the way the body reacts to mood and behavior Neuroendocrine disturbances (adrenocortical, thyroid, etc.) Physiological influences - med side effects; electrolyte levels; hormones; nutrition; etc. Psychosocial Predisposing Factors Psychoanalytic theory - related to loss and poor love relationships Learning theory - helplessness Object loss theory - can be physical or emotional Cognitive theory - cognitive distortions resulting in negative thinking or defeated attitudes

Describe goals, principles, and basic concepts of ECT and TMS **ECT

CNS systems affected by ECT: Hormones, neuropeptides and neurotrophic factors Neurotransmitters affect by ECT: Serotonin, norepinephrine and dopamine Increased GABA transmission and endogenous opioids Increased gray matter White matter microstructure Induction of grand mal (generalized) seizure through the application of electrical current to the brian Electrodes are placed bilaterally or unilaterally on the right side Right hemisphere of the brain is involved in sustaining depressed mood Most clients require 6-12 treatments, but some may requires as many as 20

Describe appropriate Nursing interventions for behaviors associated with depression

Care plans for risk of suicide Create a safe environment for the client. Remove all potentially harmful objects from client's access

sublimation

Channelling of socially unacceptable impulses into socially acceptable activities. i.e.) a young man who is dealing with aggression by playing socially acceptable activities.

Describe various types and symptoms of schizophrenia and other psychotic disorders

Characteristics -Disordered thinking -Delusions -Hallucinations -Depersonalization -Feeling strange - not one's self -Impaired personal relationships -Regression to an earlier developmental stage (incontinence, mute, masturbation) -Movement disorders Condition of client -May be seriously impaired; unable to care for self -Some can be violent is they have delusions -Attempt suicide more than others -Potential for suicide major concern

Discuss cyclothymic disorder and interventions

Chronic mood disturbance At least 2 years duration Numerous periods of elevated mood that do not meet the criteria for hypomanic episode Numerous periods of depressed mood of insufficient severity or duration to meet the criteria for major depressive episode Client never without symptoms for more than 2 months

Active symptoms - form of thought of schizophrenia---circumstantiality

Circumstantiality- A delay in reaching the point of the communication. Start a story and just stop. Nurse must keep interrupting the client to keep them on track.

Active symptoms - form of thought of schizophrenia---clang associations

Clang Associations- choice of words governed by sounds. "It is very cold, I am very old, and bold"

suicide risk assessment -client and family history

Client and family history- Previous treatment for suicidal thoughts. Treatment for depression, substance use, previous suicide attempts.

CBT cognitive strategies -guided discovery (socratic dialogue)

Client asked to describe feelings associated with specific scenarios. Nurse questions are basically mirror or reflecting statements using clients own words in a way that stimulates client insights

OCD compulsions

Compulsions- Repetitive ritualistic behaviors or mental acts an individual feels driven to perform which are intended to reduce the anxiety associated with obsessive thoughts

severe anxiety

Concentration centers on only one particular detail only or on many extraneous details

Active symptoms - form of thought of schizophrenia---concrete thinking

Concrete thinking- Literal interpretation of the environment. Abstract thinking is very difficult. Have trouble understanding things like "Its raining cats and dogs"

sociological predisposing factors to suicide

Connection to society Interpersonal theory of suicide

suicide risk assessment -coping strategies

Coping strategies- what is the suicide plan? Who are the major support systems?

Peplau's phases of a therapeutic relationship - orientation phase

Create environment for trust/rapport Establish contract for intervention detailing expectations Gather assessment information Identify client strengths/weaknesses Formulate nursing diagnosis Set mutually agreeable goals Develop plan Explore feelings of both client and nurse

Describe relevance of a therapeutic Nurse/Client relationship

Creates climate of healing; growth promotion; and illness prevention

suicide risk assessment -demographics

Demographics- age 45-64; males more than females; highest among whites followed by Native American; single, divorced, and widowed are more likely than married

Nursing diagnoses associated with substance-related and addictive disorders

Denial Ineffective coping Imbalanced nutrition: less than body requirements Chronic low self-esteem Deficient knowledge Risk for injury Risk for suicide

Nursing diagnosis for depression BEHAVIORS: Inappropriate thinking, confusion, difficulty concentrating, impaired problem-solving ability, inaccurate interpretation of environment, memory deficit

DIAGNOSIS: Disturbed thought processes

Nursing diagnosis for depression BEHAVIORS: Expressions of helplessness, uselessness, guilt, and shame, hypersensitivity to slight or criticism, negative, pessimistic outlook, lack of eye contact, self-negating verbalizations

DIAGNOSIS: Low self-esteem

Nursing diagnosis for depression BEHAVIORS: Depressed mood, feelings of hopelessness and worthlessness, anger turned inward in the self, misinterpretations of reality, suicidal ideation, plan an d available means

DIAGNOSIS: Risk for Suicide, Risk for harm to self

CBT cognitive strategies -modifying automatic thought: daily records of dysfunctional thoughts

Daily record of dysfunctional thoughts—3 column approach. Situation/Automatic thoughts/Emotional response. Done in journal format, getting the client to record the situations in the 3-column format.

CBT cognitive strategies -modifying automatic thought: decatastrophizing

Decatastrophizing - Assist the client to examine the validity of a negative automatic thought. This is NOT saying,"It can't possibly be that horrible"!

Identify Nursing diagnoses common to clients with substance-related and addictive disorders, and select appropriate Nursing interventions for each

Denial Ineffective coping Imbalanced nutrition: less than body requirements Chronic low self-esteem Deficient knowledge Risk for injury Risk for suicide

Describe various types of depressive disorders -- MDD

Depressed mood or loss of interest in usual activity Impaired social and occupational functioning lasting 2 weeks No history of manic episodes Symptoms not attributed to chemicals or general medical condition Categorized as mild, moderate, severe Fits DSM V diagnostic criteria: "5 or more symptoms present in the same two week period

Major Depressive disorder Symptoms (5 or more)

Depressed mood present most of the day, everyday Markedly decreased interest in activities that they previously enjoyed Significant weight loss or weight gain Insomnia or hypersomnia Psychomotor agitation or retardation observable by others Fatigue nearly every day Feelings of worthlessness or excessive inappropriate guilt Diminished ability to think or concentrate Recurrent thoughts of death (suicidal ideation without a plan, or an attempt)

Diagnostic picture for depression in bipolar disorder

Depression presentation is associated with Bipolar disorder Depression symptoms for bipolar disorder are similar to MDD Must have 1 or more manic episodes to meet the Bipolar Disorder criteria

substance/medication-induced bipolar disorder

Direct result of physiological effects of a substance May involve elevated, expansive, or irritable mood with inflated self-esteem, decreased need for sleep, and distractibility Causes clinically significant distress or impairment Mood disturbances associated with intoxication as well as withdrawal from a variety of substances

bipolar medications - induced

Direct result of physiological effects of a substance May involve elevated, expansive, or irritable mood with inflated self-esteem ,decreased need for sleep, and distractibility Causes clinically significant distress or impairment Mood disturbances associated with intoxication as well as withdrawal from variety of substances.

substance/medication-induced depressive disorder

Direct result of physiological effects of a substance or a medication or toxin exposure Can be association with intoxication or withdrawal of a substance or chemical

Maladaptive behavior

Disrupts the integrity of the individual's equilibrium Negative Unhealthy

Process recording

Documentation of a one to one conversation At least 4 exchanges of conversation between nurse and client Will submit one process recording this semester. International students exempt from this assignment. You will do with Janell.

Behavioral health nursing is everywhere

ER/ICU Society Cinema Our families Hospital inpatient Community outpatient Judicial systems Homeless populations

Differentiate between positive and negative symptoms of Schizophrenia (negative)

Emotions (apathy, depression, feelings of emptiness, amotivational) Social behavior (aggression, bizarre conduct, extreme social withdrawal) Cognitive (poor problem-solving, poor decision-making, illogical thinking)

Identify and discuss essential conditions for a therapeutic relationship to occur --empathy

Empathy is the ability to see beyond outward behavior and understand the situation from the client's point of view. With empathy, the nurse can accurately perceive and comprehend the meaning and relevance of the client's thoughts and feelings. The nurse must also be able to communicate this perception to the client by attempting to translate words and behaviors into feelings. With empathy, while understanding the client's thoughts and feelings, the nurse is able to maintain sufficient objectivity to allow the client to achieve problem resolution with minimal assistance. With sympathy, the nurse actually feels what the client is feeling, objectivity is lost, and the nurse may become focused on relief of personal distress rather than on helping the client resolve the problem at hand. The following is an example of an empathetic and sympathetic response to the same situation.

Predisposing factors of bipolar disease -- psychosocial explanation

Environmental stressors-child abuse or trauma PET scan shows decreased function in the left side leads to depression and decreased function in the right side leads to mania.

risk factors for suicide -gender

Gender- more women than men attempt, but men succeed more often (men 70 % and women 30%). Men use more lethal means

risk factors for suicide -ethnicity

Ethnicity- Whites are at highest risk for suicide (14.7%) followed by Native Americans (10.9%) then Hispanics (6.3%)

Behavioral symptoms of mania

Euphoric Jumping from subject to subject Disturbed speech, loud, rapid Rapid mood shift Can be paranoid Impatient Manipulative Pacing on the unit

stress - environmental event

Event or thing that triggers the adaptive physiological and psychological responses Recent life changes questionnaire (RLCQ) Life changes questionnaires are criticized because they do not include the individual's perception of the event.

intimate relationship

Ex: two people who are committed and care for each other, respect each other but still interested in own needs We never forget a good intimate relationship

Identify predisposing factors in the development of Schizophrenia

Exact etiology unknown Genetic theory -1 in 9 people in families where one sibling already has a diagnosis of Schizophrenia -Elevated incidence in relatives of a patient - It is 10% to 16% more likely that a child will develop the disease than that a member of the general population -Twin - studies have shown that identical twins have a greater incidence of schizophrenia than fraternal Biochemical Theory -Excess dopamine activation responsible for the symptoms of schizophrenia -New biochemical theories discuss an interaction between dopamine, serotonin and other neurotransmitters Psychoanalytic Theory -Fragile ego - resorts to a dysfunctional use of defense mechanisms and these defense mechanisms usually fail -Poor parent - child relationship -Dysfunctional family systems

Body Dysmorphic Disorder

Exaggerated belief that the body is deformed

CBT cognitive strategies -modifying automatic thought: examining options and alternatives

Examining options and alternatives - Help the client see a broader range of possibilities

Social Anxiety Disorder (Social Phobia)

Excessive fear that an individual will do something embarrassing or be evaluated negatively by others Onset late childhood or early adolescence Runs a chronic, sometimes lifelong course

biological predisposing factors to suicide

Genetic predisposing to suicide Deficiency of serotonin

In the end it all comes to:

Explorations of the nurse Expectations of the client Nurses need to keep in mind that the client's behavior is his best adaptation at the present time (if he could do better, he would). The client may be feeling internal stress from trying to please the nurse. The nurse may need to access the receive assistance of another colleague to provide clinical supervision

common defense mechanisms -- reaction formation

Expression of a feeling that is the opposite of one's authentic feeling or of feelings that would be appropriate in the situation. (A client who brings gifts to the nurse at whom he is really mad)

Antidepressant medication in children and adolescents

FDA Public health advisory on increased risk of suicidal thoughts an dbehaviorin children and adolescents being treated with antidepressant medication Close monitoring advised Fluoxetine (Prozac) approved for treatment of depression in children 8yrs and older Escitalopram (Lexapro) approved in 2009 adolescents 12yrs and older SSRI SNRI Mayo Clinic study in 2016 stated 4% taking antidepressants had an increase in suicidal thought

Nursing diagnoses for anxiety, OCD, etc

Fear Anxiety Ineffective coping Disturbed body image Ineffective impulse control

Specific Phobia

Fear of specific objects or situations that can cause harm (heights, or snakes) Treatment when the specific phobia interferes with activities of daily living

fear

Fear- A cognitive process involving the intellectual appraisal of a threatening stimulus Fear is a cognitive process. Fear has an object.

Nurses develop relationships that help clients with...

Fears Symptoms Interpersonal problems

characteristics of schizophrenia -- others

Feeling strange-not at all one's self-impaired reality testing (psychosis) Impaired personal relationships Regression to an earlier developmental stage - (incontinence, mute, masturbation)

inpatient Treatment of adolescent depression

For severe depression Hospitalization at Avera Behavioral health Threat of immanent suicide Threat of harm to self or others Extreme family situations

describe bipolar I

Full syndrome Includes one or more manic/mixed episodes One or more depressive/one or more mania

genetic theory etiology

Genetic theory—relatives of schizophrenia have a much higher probability of getting schizophrenia. Whereas lifetime risk of getting schizophrenia is 1%, the risk of a sibling getting schizophrenia is 10%. Children of a person with schizophrenia have 6% risk of developing it. No definitive biological marker.

Identify and discuss essential conditions for a therapeutic relationship to occur --rapport

Getting acquainted and establishing rapport is the primary task in relationship development. Rapport implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.

Identify goals of the Nurse/Client relationship

Goal oriented 0 ideally decided by both nurse and client Sometimes based on solving a problem: The problem may be anxiety But the GOAL may be develop more positive coping strategies for dealing with

Explore the 4 DBT treatment modes

Group skills training Individual psychotherapy Telephone contact or skills coaching Therapist consultation/team meeting

common compulsions

Handwashing Ordering Checking Praying Counting

depression in adolescents

Harder to recognize " just the normal stresses of growing up" Suicide second leading cause of death among 15-25 year old group (NCHS 2015)

goal of care for MDD

Has experienced no physical harm to self Discusses feelings with staff and family members Expresses hopefulness Sets realistic goals for self Is no longer afraid to attempt new activities 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

Defense mechanisms

Help us adapt Sometimes viewed as negative If we did not have defense mechanisms we would "implode

Discuss the incidence of suicide among Native Americans

High rates of suicide among youth on indian reservations

Discuss dynamics of therapeutic Nurse/Client relationship according to Nurse theorist Hildegard Peplau

Human to human relationship - more than just nurse/client -Beliefs -Attitudes -Values Therapeutic use of self - ability to use one's own personality consciously and in full awareness in an attempt to establish relatedness and structure nursing intervention

Formal classifications relevant to behavioral health nursing practice

ICD DSM NANDA

common symptoms of depression in adolescents

Inappropriately expressed anger Aggressiveness Running away Delinquent behavior Social withdrawal Sexual acting out, Substance abuse Restlessness Apathy Low self-esteem Sleep disturbances Eating disorder

Identify symptomatology associated with depression and use this information in client assessment

Inappropriately expressed anger Aggressiveness Running away Delinquent behavior Social withdrawal Sexual acting out Substance abuse Restlessness Apathy Low self-esteem Sleep disturbances Eating disorders Visible symptoms lasting more than several weeks The normal outgoing teenage who is now withdrawn and isolating themselves Good student with good grades now failing and skipping class Previously confident teen who is now irritable and defensive with others

Treatment modalities for MDD

Individual psychotherapy Group psychotherapy Family therapy Cognitive therapy (CBT) Electroconvulsive therapy (ECT) Transcranial Magnetic Stimulation (TMS) Vagal nerve stimulation (VNS) Light therapy (SAD Light) Medications

Discuss epidemiological statistics related to depression

Leading cause of disability in the US Depression linked to increasing coronary artery disease 2014 - six percent ages 18+ diagnosed with at least one major depressive episode Increasing among teens and adults Most prevalent psychiatric disorder - 17% lifetime prevalence

Mania needs 3 or more of these symptoms

Inflated self-esteem Decreased need for sleep More talkative Flight of ideas Spending Spree Distractibility Foolish business investment Increase in goal-directed activity Excessive involvement in pleasurable activities Sexualindescretion Decreased need for sleep Pacing in the hallway or on the unit. Rapid-fire speech. Pressured speech, loud, garrulous rhyming or punning.

Discuss risks and contraindications of ECT and TMS **TMS

Inform provider if pregnant or thinking of becoming pregnant You have any metal or implanted medical devices in your body. Not recommended for some who have the following evidence: -Aneurysm clips or coils -Stents -Implanted stimulators -Implanted vagus nerve or deep brain stimulators -Implanted electrical devices -Electrodes for monitoring brain activity -Any magnetic implants -Cochlear implants for hearing -Bullet fragments -Any other metal device or object implanted in your body Risks -Seizures - rare -Mania - rare -Headache ro scalp irritation are more common -Remission may not be as long as ECT

- carl Rogers - psychologist

Initial phase Middle working phase Termination phase

rationalisation

Intellectual explaining away of threatening circumstances. "The test had too many trick question; I really know all the material; our instructor was out to get me."

moderate anxiety

Less alert to events occurring in the environment Assistance with problem solving may be required

Physical changes in mania

Intense period of psychosis Weight loss Hallucination/Delusions Increased blood pressure Increased heart rate 75% of individuals with one manic episode will most likely have a repeat manic episode Hallucinations or Delusions—WHETHER IS IT A PERSON WITH SCHIZOPHRENIA OR A PERSON WITH BIPOLAR IN THE MANIC PHASE DO NOT EVER TELL THEM WHAT THEY ARE SEEING/HEARING IS NOT THERE! Be more empathetic. Say, "I am not seeing/hearing what you just told me just now. I am sure that for you these things you are seeing/hearing are real, but I just want to be clear that I am not seeing/hearing them,

Peplau's phases of a therapeutic relationship termination phase

Mutually agreed upon goals may have been reached Client discharge from hospital End of clinical rotation Main task is bringing a therapeutic conclusion to the relationship Most important phase

Discuss importance of self-awareness in the Nurse/Client relationship

Knowing oneself is important in a nurse/client relationship Gaining self awareness VAlues clarification Can change throughout the lifetime

Peplau's phases of a therapeutic relationship -working phase

Maintain trust/rapport Promote client insight and perception of reality Problem-solve Overcome resistant behaviors of client as level of anxiety rises in response to discussion Continuously evaluate progress Sometimes they move forward, sometimes they go back

Adaptive behavior

Maintains the integrity of the individual, with a timely return to equilibrium Healthy response

Types of depressive disorders

Major Depressive Disorder (MDD) Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/medication-induced Depressive Disorder Depressive Disorder due to another medical condition

Talking to someone in crisis

Make sure the situation is safe Talk calmly to the client Verbally reassure that they are safe Speak in short sentences and not long explanations Give positive reinforcement for positive actions of communication or coping Summarize the conversation every so often

risk factors for suicide -marital status

Marital Status—Suicide rate for the single never-been-married person is twice the rate of married clients. Divorced and widowed clients have higher rates of suicide.

Describe various types of depressive disorders -- premenstrual dysphoric disorder

Markedly depressed mood Excessive anxiety Mood swings Decreased interest in activities ALL of the above occurring the week prior to menses and becoming minimal or absent that week after menses

Goals in treatment of bipolar

Med compliance Interpersonal/vocational issues Dealing with fear of recurrence of Manic episodes Genetic issues Therapy compliance Keep them on their meds. Sometimes they do not like how they make them feel "like Zombies". These people need help with maintaining their jobs and their relationships. Involve the significant other. Fear of recurrent manic episodes. This is serious. They wear themselves out, sometimes embarrass themselves, say things they can't take back, etc. Genetic issues involve: Should I reproduce? What precautions do I take?

Formulate nursing diagnosis and goals of care for clients with bipolar disorder **goals in treatment

Med compliance interpersonal/vocational issues Dealing with fear of recurrence of manic episodes Genetic issues Therapy compliance Exhibits no evidence of physical injury Has not harmed self or others Is no longer exhibiting signs of physical agitation Eats well-balanced diet with snacks to prevent weight loss and maintain nutritional status Verbalizes an accurate interpretation of the environment Verbalizes theat hallucinatory activity has ceased and demonstrates no outward behavior indicating hallucinations Accepts responsibility for own behaviors Does not manipulate others gor 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 without medication

Discuss epidemiological statistics related to bipolar disorder

Men - begins at age 18 Women - begins at age 20 5.7 million american adults 2.6% of the US population ages 18 yrs and older (82.9% considered severe) Incidence/ratio of women to men is 1.2:1 (so about equal)

Colonial american view of mental illness

Mental illness behaviors punished because they were thought to be associated with withcraft Burned at the stake or incarcerated

describe bipolar II

Most common One or more depressive/at least one hypomanic episode Client has never experienced a full manic episode

Discuss historical aspects and epidemiological statistics related to anxiety (epidemiology)

Most common of all psychiatric disease More common in women (2:1) Specific Phobia - 8.7% Social anxiety - 6.8% PTSD - 3.5% GAD - 3.1% Panic - 2.7% OCD - 1%

Active symptoms - form of thought of schizophrenia---mutism

Mutism- inability or refusal to speak.

Differentiate between facts and myths regarding suicide

Myths -People who talk about suicide do not act on their ideas. Suicide happens without warning -You cannot stop a suicidal person. He or she is fully intent on dying -Once a person is suicidal, they are suicidal forever -Improvement after severe depression means that the suicidal risk is over Facts -8/10 people who kill themselves have given definite clues and warnings. Subtle clues can be ignored -Most suicide clients are very ambivalent about their feelings regarding living or dying. Most care crying for help -Not necessarily suicidal forever. Depends on the interventions and resources given - -Most suicides occur within 3 months, after the beginning of "improvement" when the client has the energy to carry suicidal intentions.

denial

Negation of reality of threatening situation, despite factual evidence Client refuses to admit to anger, even though the situation warrants it and the client's voice indicates anger

Differentiate between positive and negative symptoms of Schizophrenia (active)

Neologisms - client invents new words that are meaningless to others but have symbolic meaning to the client Concrete thinking - literal interpretation of the environment Clang associations - choice of words governed by sounds World salad - a group of words that are put together randomly, without any logical connection Circumstantiality - a delay in reaching the point of the communication Tangentiality - never gets to the point of the conversation. New topics are introduced Mutism - inability or refusal to speak Perseveration - persistently repeats the same word or idea in response to different questions

Active symptoms - form of thought of schizophrenia---neologisms

Neologisms-client invents new words that are meaningless to others but have symbolic meaning to the client "she wanted t give me a ride in her new UNIPHORUM"

bipolar psychotherapy

Never by itself Never by itself, it will never work. So if someone says, "we already tried psychotherapy and it didn't work" it may be because they did not have meds on board beforehand. Assess whether they have started medication therapy prior to psychotherapy CBT DBT

therapeutic relationship

Nurse and client working together. Goal of assisting client to regain their inner resources to meet life challenges and facilitate growth

identify counter transference

Nurse's emotional or behavioral response to the client in which the nurse transfers past feelings or experiences onto the client Can be unresolved feelings from the nurse's past (i.e) Nurse has difficulty setting limits on the client because the client reminds the nurse of a favorite niece (i.e) Nurse is very rude to the client because the client looks a lot like a sibling that the nurse does not like

areas of practice

Observe your own level of comfort In what setting are most clients likely to approach you? How do you interpret the social space on the unit?

OCD obsessions

Obsessions- Intrusive thoughts that are recurrent and stressful. Repetitive and cannot be ignored

Define Crisis

Occurs in all individuals at one time or another Precipitated by specific identifiable events Personal by nature Acute, not chronic Potential for psychological growth or deterioration

Describe appropriate nursing interventions for behaviors associated with these disorders

Offer the use of self in development of therapeutic relationship Use of silence Set time for interactions with the client Encourage reality orientation (while realizing the hallucinations and delusions are real to the client) Assist with feeding, dressing, and other cares as necessary Remove harmful objects Contract with the client to let you known when she/he is anxious to prevent loss of control Administer antipsychotic medications

Borderline personality disorder (BPD)

Often overlaps with a Bipolar II diagnosis Very rapid mood swings that tend to react much more to their environment Recognizing subtle bipolar features is important during nursing assessment React much more to their environment than do those with purely hypomanic disorder. Many creative artists and political/military leaders have been borderline personalities: Napolean Bonaparte, Alexander Hamilton, Robert E Lee, Theodore Roosevelt, and Winston Churchill.

Dialectical behavior therapy (DBT)

Originally developed for use in Borderline Personality Disorder clients (BPD) •-Focused on the prevention of self-harm and suicide prevention •-Now used with BPD, substance use disorders, eating disorders, schizophrenia, and PTSD •Rooted in belief that the client's primary problem is emotional dysregulation •Combining cognitive, behavioral and interpersonal therapies with mindfulness meditation

risk factors for suicide -other risk factors

Other risk factors- mood disorder or substance abuse. Bullying. Unintentional suicides due to opioid overdose.

DSM V criteria for panic disorder 4 or more symptoms must be present:

Palpitations, pounding heart, accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Chills or heat sensations Paresthesias (numbness or tingling) Derealization (feelings of unreality) Fear of losing control Fear of dying

Discuss historical aspects and epidemiological statistics related to panic disorder (criteria)

Palpitations, pounding heart, accelerated heart rate Sweating Trembling/shaking Sensations of SOB Feelings of choking Chest pain, discomfort Nausea, abdominal distress Dizzy, unsteady, lightheaded, faint Chills or heat sensations Paresthesias Derealization (feelings of unreality) Fear of losing control Fear of dying

Differentiate between positive and negative symptoms of Schizophrenia (positive)

Perceptions (hallucinations and delusions) Thinking (delusions, paranoid and disorganized thought) Emotions (agitation and emotional dyscontrol) Language (associative looseness, poverty of speech) Associative looseness - thinking characterized by speech in which ideas shift from one unrelated subject to another. Severe cases speech incoherent. Movement (agitated/catatonic)

Active symptoms - form of thought of schizophrenia---perseveration

Perseveration- persistently repeats the same word or idea in response to different questions. Answer the same answer for different questions

Hoarding Disorder

Persistent difficulties discarding or parting with possessions Can also hoard food or animals Happens a lot to people who used to live in extreme poverty

phobia

Persistent, intensely felt, and irrational fear of a specific object or situation that results in a compelling desire to avoid the feared stimulus. Intense anxiety or panic attacks

personality

Personality involves a whole group of adjustable techniques and equipment that are characteristic for a given individual in meeting the various situations of life. How many of you did the strengths quest as freshman? Wasn't it mandatory? What are your strengths? What are strengths you have identified since that test? Who are you now? You know about me that I am passionate about organ and tissue donation. I'm sort of a quiet person, I believe humor should be allowed in all situations, and If I were to pick out of some of the disorders that we are going to talk about today, I would say I have some tendencies towards borderline, dependency. I have learned that I am a huge enabler with my kids. This may be an overcompensation from being the oldest child in an alcoholic family. Who knows? I am still learning about myself. So you will keep learning about yourself. Some more than others, struggle with personality disorders each day of their lives. This makes reacting to life's stressors, much more difficult.

Describe 4 phases of crisis development

Phase 1 - Exposure to a precipitating stressor Phase 2 - previous problem - solving techniques do not relieve and anxiety increases Phase 3 - all possible resources (internal/external) are called on Phase 4 - burden increases over time to a breaking point

4 phases of crisis development

Phase 1- exposure to a precipitating stressor-anxiety increases and previous problem solving techniques are applied. Phase 2- previous problem-solving techniques do not relieve and anxiety escalates- coping mechanisms that worked in the past are not helping and anxiety gets even worse (crying, screaming) Phase 3- all possible resources (internal/external) are called on—new problem-solving techniques may be tried. They may work or they may not. Phase 4- burden increases over time to a breaking point- if previous techniques do not work, tensions mount to an uncontrollable level. "All Hell breaks loose", but if new techniques work, you can possible bring the client to a place of calmness. Sometimes full resolution.

Phases of alcohol use disorder

Phase I - Pre-alcoholic phase. Use of alcohol to relieve everyday stress and tensions of life Phase II - Early alcoholic phase. Blackouts or brief periods of amnesia that occur during or immediately following a period of drinking. Alcohol no longer a source of pleasure or relief. Phase III - Crucial phase. Lost control of use, physiological addiction is clearly evident.Sickness; loss of consciousness; pitiful;. Drinking is the total focus. Phase IV -Chronic phase. Emotional and physical disintegration. Intoxicated more than they are sober.

stress - biological response

Physiological responses to stress Fight or Flight Adaptation

Peplau's phases of a therapeutic relationship -pre-interaction phase

Preparation for the first encounter Obtain available information (kardex, report, etc) Examine one's own feelings, fears, and anxieties about working with a particular client

suicide risk assessment -presenting symptoms.

Presenting symptoms- IS PATH WARM? Ideation, substance abuse, purposelessness, anger, trapped, hopelessness, withdrawal, anxiety, recklessness, mood

suicide risk assessment -presenting symptoms

Presenting symptoms- what is client being treated for. MDD or Bipolar? Substance use disorder, anxiety disorder, bpd, schizophrenia

Depressive disorder due to another medical condition

Prove symptoms are a direct physiological response to another medical condition The depression causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Describe various types of depressive disorders -- depressive disorder due to another medical condition

Prove symptoms are a direct physiological response to another medical condition The depression causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

psychoanalytical theory etiology

Psycho analytical: poor parent-child relationships and dysfunctional families. Psychotic break due to environmental influences—stressful life event.

Predisposing factors to GAD -psychodynamic

Psychodynamic- inability of the ego to intervene when conflict occurs between the id and superego

space

Public - 12 feet Social - 9-12 feet Personal - 18 inches - 4 feet Intimate - closer than 18 inches The nurse can use her knowledge of the meaning of space and distance between two persons to understand and interpret nonverbal behaviors. Some clients may be comfortable sitting next to the nurse in social space, and some may get up and walk away indicating that social interaction may feel too invasive at that moment. Always allow the client to have an exit from a room or space. But do not endanger yourself in the process

CBT cognitive strategies -modifying automatic thought: questioning the evidence

Questioning the evidence - Make the automatic thought the hypothesis and the nurse assists the client in questioning the facts associated with their thinking.

Essential conditions for a therapeutic relationship to occur

Rapport - a close and harmonious relationship in which the people or group concerned understand each other's feelings or ideas and communicate well Trust Respect Genuineness Empathy

CBT cognitive strategies -modifying automatic thought: reattribution

Reattribution—through reflective statements by the nurse, this technique aims to reverse negative attribution of clients form self-blame (depression) or placing blame on others(personality disorder) to more balanced attribution of responsibility.

Discuss historical aspects and epidemiological statistics related to Panic disorder

Recurrent panic attack Onset unpredictable Intense apprehension Fear, terro Intense physical discomfort, believe having a heart attack Usually last minutes or more rarely hours Varying degrees of nervousness and apprehension Symptoms of depression Average age onset is late 20's but can be sooner Frequency and severity vary widely Can last a few week/months or can last for years

Trichotillomania (Hair pulling disorder)

Recurrent pulling out of one's hair that results in hair loss in scalp, eyebrows, or eyelashes Increased sense of tension Tension released or sense of gratification when the hair is pulled out Comorbid psych disorders include: MDD, GAD, OCD, Substance Use Disorder

bipolar interventions

Reduce environmental stimuli Assign to a quiet unit Limit group activities Remove hazardous objects Stay with client and offer support Structured schedule of events Tranquilizing medications may be needed Intervene at the first sign of violence Reduce behaviors by encouraging physical activity

Describe appropriate Nursing interventions for clients experiencing a manic episode

Reduce environmental stimuli Assign to a quiet unit Limit group activities Remove hazardous objects Stay with client and offer support Structured schedule of events Tranquilizing medications may be needed Intervene at the first sign of violence Reduce behaviors by encouraging physical activity

risk factors for suicide -religion

Religion- Suicide rates among protestants and Jews higher than Roman Catholics and Muslim populations. Religious affiliation is correlated to decreased attempts at suicide.

Nursing diagnoses in disaster

Risk for injury Risk for infection Anxiety (panic) Fear Spiritual distress Risk for post-traumatic syndrome Ineffective community coping

Formulate nursing diagnosis and goals of care for clients with bipolar disorder *nursing diagnosis

Risk for injury Risk for violence: self-directed or other-directed Imbalanced nutrition: less than body requirements Disturbed thought processes Disturbed sensory - perception Impaired social interaction Insomnia

MDD nursing diagnosis

Risk for suicide Risk for self harm Complicated grieving Disturbed thought process Low self-esteem

mild anxiety

Seldom a problem. Sometimes helps to accomplish tasks

outpatient Treatment of adolescent depression

Talk therapy Group therapy Medication Outpatient therapy at Avera Behavioral

Describe various types of depressive disorders -- persistent depressive disorder

Similar to MDD Symptoms are milder No evidence of psychotic symptoms Chronically depressed mood "I just feel punk" OR irritable mood --Most of the day, more days than not for at least 2 years (one year for child/adolescent) Early onset - before 21 years of age Late onset - after 21 years of age

risk factors for suicide -socioeconomic status

Socioeconomic status- Highest and lowest social classes have higher suicide rates than those in the middle classes.

Describe goals, principles, and basic concepts of ECT and TMS **TMS

Stimulation of nerve cells in the brain Very short pulses of magnetic energy directed at localized areas of the brain Similar to ECT but no generalized seizure activity induced Non-invasive 30-36 sessions 40 minutes each session 3-5 times a week Combined with medications Combined with DBT self-study

Differentiate between stress, anxiety and fear

Stress - an external pressure brought to bear on an individual Anxiety - subjective emotional response to a stressor. Anxiety is an emotional process, vague diffuse apprehension Fear - a cognitive process involving the intellectual appraisal of a threatening stimulus. Fear is an object. Fear is a cognitive process

stress

Stress- an external pressure brought to bear on an individual

Predisposing factors of bipolar disease -- genetic

Strong genetic connection. Bipolar disorder is an inherited disease. Most impressive are the studies of twins and bipolar disorder. Identical twins 60-80% chance of having bipolar disorder if one twin has it. 10-25% risk of getting bipolar disease if one parent has it 50-75% risk if both parents have bipolar disorder

suicide risk assessment -suicidal ideation or acts

Suicidal ideation or acts- does the person have a plan? Do they have the means

Apply the Nursing process to individuals exhibiting suicidal behavior

Suicide risk assessment -Demographics -Presenting symptoms and medical/psychiatric diagnosis -Suicidal ideation or acts -Client and family history -Coping strategies -Presenting symptoms Suicide safety plan -Detailed plan developed by the client with the Nurse or therapist about what to do in the instance of severe suicidal ideation Suicide Assessment Five Step Evaluation and Triage -Identify risk factors -Identify protective factors --Note these can be enhanced -Conduct suicide inquiry --Evaluate suicidal thoughts, plans, behavior, and intent -Determine risk level and intervention --Choose appropriate interventions to address and reduce level of risk -Document --Record assessment of risk, rationale, intervention, and follow-up

Discuss implications of depression related to developmental stage

Symptoms of depression to be manifested differently in childhood, and the picture changes with age Other symptoms of childhood depression may include hyperactivity, delinquency, school problems, psychosomatic complaints, sleeping and eating disturbances, social isolation, delusional thinking, and suicidal thoughts or actions. In many depressed children, there is a genetic predisposition toward the condition

Active symptoms - form of thought of schizophrenia---tangentiality

Tangentiality- Never really gets to the point of the conversation. New topics are introduced. Unrelated topics are introduced and the focus of the original discussion is lost. Don't just stop the topic. Just start a new one. Nurse must say "slow down, what are we talking about this or this"

Long term use of antipsychotics

Tardive Dyskinesia(TD) uncontrolled muscle movements (mouth), bizarre facial and tongue movements, stiff neck, difficulty swallowing *drug should be withdrawn at the first sign of side effects! Some of these side effect may be irreversible. People respond to antipsychotics in different ways. Symptoms like delusions usually go away with in a few weeks of starting antipsychotics. Symptoms of schizophrenia, such as feeling agitated and having hallucinations usually go away within days.

Discuss the issue of substance abuse and addiction disorders within the Nursing profession

The chemically impaired nurse Alcohol is the most widely abused chemical followed by narcotics Nurses are often handling controlled substances High absenteeism if the chemical abused is found outside of work Low absenteeism if the chemical abused is found at the workplace Poor concentration Difficulty meeting deadlines Inappropriate responses Poor memory recall

3.Identification and Imitation

The client takes on behavior they see in another person because they are confused about their own identity. . -Because of their ego boundaries end and another begins, their behavior often takes the form of that which they see in the other person.

Identify and discuss essential conditions for a therapeutic relationship to occur --genuineness

The concept of genuineness refers to the nurse's ability to be open, honest, and "real" in interactions with the client. To be real is to be aware of what one is experiencing internally and to allow the quality of this inner experience to be apparent in the therapeutic relationship. When one is genuine, there is congruence between what is felt and what is expressed

The elderly populations

The elderly make up 14.5 % of the US population Depression is the most common psychiatric disorder of the elderly in the US (Aging 2016) Society's value on youth, vigor, uninterrupted productivity Elderly financial problems and physical illness Bereavement overload Avoid medications for depression in an already over-medicated population ECT Treatments

epidemiology

The study of factors that lead to the occurrence of disease in a population of people. Epidemiological investigation begins with a careful definition of clinical phenomena.....

4.Depersonalization

The unstable self-identity of an individual with schizophrenia may lead to feelings of unreality. 1.. i.e.) feelings that ones extremities have changed in size. Or a sense of seeing oneself from a distance. Like watching themselves in a movie.

Identify and discuss essential conditions for a therapeutic relationship to occur --trust

To trust another, one must feel confidence in that person's presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested.

repression

Unconscious blocking from awareness material that is threatening or painful. "I never got angry at my father, our family lived in harmony and love: (when such descriptions of the family life would not fit with anyone else's interpretation of the events)

identify transference

Unconscious displacement or transfer to the nurse feelings formed toward a person from his or her past Can be triggered by something the nurse is wearing or something the nurse is doing Can interfere with the nurse/client relationship when feelings are "anger" or "hostility"

Child expression of MDD symptoms

Up to age 3 years - -Feeding, tantrums, lack of playfulness, development delays, and failure to thrive Ages 3 - 5 years -Accident prone, phobias, aggressiveness, and excessive self-reproach for minor infractions Ages 6-8 yrs -Vague physical complaints and aggressive behavior, clingy Ages 9-12 yrs -Morbid thoughts, excessive worrying, poor self-esteem, lack of interest in playing with friends -May feel that they have disappointed their parents in some way

Discuss historical aspects and epidemiological statistics related to anxiety (history)

Usually linked to cardiac disease Freud first to call it "anxiety neurosis" Many tried to tie symptoms to something physical in nature

Differentiating depression from normal adolescent behavior

Visible symptoms lasting more than several weeks The normal outgoing teenage who is now withdrawn and isolating themselves The good student with good grades who is now failing and skipping class The previously confident teen who is now irritable and defensive with others

Role of the nurse in CBT

Well within the psychiatric nursing scope of practice •Nurses can gain certification in CBT therapy •Teach client about relationship between their illness and the distorted thinking patterns •Help the client to recognize their negative automatic thought or cognitive error •Use behavioral change techniques to assist the client to modify the dysfunctional thinking patterns

Active symptoms - form of thought of schizophrenia---word salad

Word Salad- a group of words that are put together randomly, without any logical connection."Most forward action grows life double plays circle uniform"

characteristics of schizophrenia -- depersonalization

a state in which one's thoughts and feelings seem unreal or not to belong to oneself, or in which one loses all sense of identity.

classification

a system of categorization that allows useful distinctions to be established, distinctions that may lead to a deeper understanding of natural phenomena.

common defense mechanisms -- regression

retreat to a previous developmental level (a child starts to suck his thumb when admitted to hospital after 2 years of not thumb sucking)

regression

retreat to a previous developmental level. i.e.) a child who starts to suck his thumb (after 2 years of not thumb sucking) when admitted to the hospital.

A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? Select one or more: a. "What occurred prior to the rape, and when did you go to the emergency department?" b. "Can you tell me about your day?" c. "I notice you seem uncomfortable discussing this." d. "How can we help you feel safe during your stay here?"

b. "Can you tell me about your day?"

After being laid off work, a client becomes increasingly withdrawn and fatigued, spends entire days in bed, is unkempt and doesn't eat for 2-3 days. Based on these findings, the nurse would suspect his psychological diagnosis to be what? Select one or more: a. Schizophrenia b. MDD or Major Depressive Disorder c. Anxiety Disorder d. Suicidal Ideation

b. MDD or Major Depressive Disorder

Common cognitive errors or automatic thought -personalization

client takes complete responsibility for situations without considering that other circumstances may have contributed to the outcome

A client whose husband died 6 months ago is diagnosed with Major Depressive Disorder. She says to the nurse, 'I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? Select one or more: a. "Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b. "I can understand how you must feel" c. "Those feelings are a normal part of the grief response." d. Just think about the good times that you had with Harold while he was alive"

c. "Those feelings are a normal part of the grief response."

Crisis Planning is part of the WRAP Recovery model. Which one of the following statements is correct in the crisis planning with a client? Select one or more: a. Speak to the client in long flowing sentences. b. Do not let the client tell you who to call because YOU are the nurse. c. Assess for treatment preferences of the client d. Do not listen to the client, listen only to the police officer called to the domestic violence situation

c. Assess for treatment preferences of the client

serotonin

involved in the body's regulation of mood, anxiety, arousal, irritability and cognition

An accident victim can remember nothing about their accident. This is an example of which defense mechanism?

repression

A physically challenged by is unable to participate in football, so he works hard at become a great scholar. Which defense mechanism is e incorporating?

compensation

suppression

conscious or unconscious attempt to keep threatening material out of consciousness. i.e.)Failure to remember a significant childhood event, such as the death of a grandmother.

orientation phase

creating healing environment. Contracting.

A client states, "You won't believe what my husband said to me during visiting hours. He has no right treating me that way." Which nursing response would best assess the situation that occurred? Select one or more: a. "Does your husband treat you like this very often?" b. "What do you think is your role in this relationship?" c. "Why do you think he behaved like that?" d. "Describe what happened during your time with your husband."

d. "Describe what happened during your time with your husband."

A client has just been admitted to Avera Behavioral Health Hospital with a diagnosis of Major Depressive Disorder. Which of the following behavioral manifestations might the admitting nurse expect to see? Select one or more: a. Slumped posture b. Feelings of hopelessness c. Delusional thinking d. All of the above

d. All of the above

Cognitive strategies

eventually preparing the client to become their own CBT therapist

mental illness stigma

dangerous character flaw

A client is angry with their health care provider but does not express anger to the health care provider. Instead, the client becomes verbally abusive towards the nurse. This is an example of which defense mechanism?

displacement

*The initial/orientation phase

establishing trust. Provide a supportive environment in which the client can feel free to express his feelings.

reaction formation

expression of a feeling that is the opposite of one's authentic feeling or of feelings that would be appropriate in the situation. i.e.) a client who brings gifts to the nurse at whom he is really angry with.

True or False. The 4 dimensions of recovery are: Home, Health, Community, and Income

false *The dimensions of recovery are Home, Health, Purpose, and community

introjection

incorporating without examination or thought, the qualities or attitudes of others. i.e) the adolescent who takes on all the values and styles of an admired teacher.

common defense mechanisms -- introjection

incorporating, without examination or thought, the qualities or attitudes of others. (the adolescent who takes on all the values and styles of an admired teacher)

common defense mechanisms -- rationalization

intellectual explaining away threatening circumstances.

A young man has just been admitted to the Avera Behavioral Health Hospital after the anniversary of the 911 attacks on the Twin Towers. The admission diagnosis was PTSD sparked by crisis. What type of defense mechanism might this client use?

isolation projection suppression

norepinephrine

key neurotransmitter in the bodies response to stressful situations

common defense mechanisms -- denial

negation of reality of threatening situations despite factual evidence. (refusing to admit to anger, even though the situation warrants it and the client's voice indicates anger)

the termination phase

nurse and client evaluate progress and determine that the client is ready to move on.

bipolar 1

one or more episodes of MAJOR DEPRESSION plus one or more periods of clear-cut MANIA. ( at least one week) Full syndrome Includes one or more manic/mixed episodes One or more depressive/one or more mania

bipolar II

one or more periods of MAJOR DEPRESSION plus at least one HYPOMANIC EPISODE (`at least 4 days) Most common One or more depressive/at least one hypomanic episode Client has never experienced a full manic episode

common defense mechanisms -- projection

placing blame onto someone or something else that totally belongs to you. "I am not the one who changed tv channels, it was Jesse"

Relationship development and phases (Peplau's phases of a therapeutic relationship)

pre-interaction orientation phase working phase termination phase

pre-interaction phase

preparation for the first encounter

Your client is being interrogated about some missing CD's on the unit. When confronted your client said, "I did not take the music CD's. IT WAS JEREMY! He was the one who did not want music therapy today, NOT me." this defense mechanisms is indicative of:

projection

working phase

promote client change; client does the most work during this time and you're helping them get better.

A mother whose son was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drunk Driving. This is the defense mechanism:

sublimation

A young child when discussing the death of her brother 4 months ago says "I don't want to talk about that today. Let's talk about that tomorrow" is using which of the following defense mechanisms?

suppression

working phase

the nurse identifies and implements interventions that facilitate positive changes for the client. Client listens to the nurses reactions and explores his methods of interaction and coping. Most of the work gets done here. Extremely rewarding phase. Not unusual for the client to become very attached to the nurses.

common defense mechanisms -- displacement

transfer of feelings or reactions evoked by one topic or event to another that is less threatening (mad at wife so kicks the dog)

displacement

transfer of feelings or reactions evoked by one topic or event to another that is less threatening. i.e.) the husband who is angry at this wife and yells at the family dog rather than deal directly with his anger.

True or False. Anxiety is when a client is fearful of something that they cannot readily define.

true

True or False. One component of the WRAP recovery model is the daily maintenance list.

true

True or False. The National Mental Health ACt of 1946 led to funding for psychologists and psychiatric nurses

true

True or false, the defense mechanism repression is involuntary (an unconscious effort)

true

True or false, therapy groups and self-help groups such as AA are complementary of each other

true

common defense mechanisms -- repression

unconscious blocking from awareness material that is threatening or painful. "I never got angry at my mother; our family lived in harmony and love" (when other family members talk about violent verbal confrontations.....)

common defense mechanisms -- suppression

unconscious or conscious attempt to keep threatening material out of consciousness.(failure to remember a significant childhood event such as the death of a grandmother)

symbolization

use of an object, idea, or act to express emotion that is not expressed directly. i.e.) the client who leaves the nurse a flower rather than directly saying she cares about the nurse.

CBT cognitive strategies -automatic thought records

written journal. Homework.

Stress as a transaction between the individual and the environment

§Relationship between the individual and the environment §Personal characteristics §Nature of the event

Diagnostic systems and computerized health records ´EHR's Serve 3 functions:

´1. Documentation of Diagnoses/Outcomes ´2. Epidemiological Evaluations of Populations ´3. Management of Care based on Data

DRG's used most in mental health

´Acute psychosis ´Suicidal ideation ´Suicide attempts ´Manic exacerbations

DRG (diagnostic related grouping)

´Page 799 of your text ´Regan administration ´Attempt to contain medical costs ´Set forth pre-established amounts of reimbursement for each medical diagnosis i.e.) schizophrenia cost the same no matter how many days hospitalized

International classification of diseases (ICD)

´Published by WHO ´Comprehensive listing of clinical diagnoses, each associated with a numerical code ´ICD number followed by a decimal and single digit [296.2 = Major Depressive Disorder] ´ICD 9 is currently followed in the US ´(ICD 10 in other countries) ´ICD 10 will begin in the US in 2016

Nursing care of client with anxiety and fear-based disorders

ÑApproach with a perspective of caring and understanding. ÑClient anxieties, obsessions, and fears of failure are very real ÑGive control when possible and appropriate ÑEncourage the client to manage his own environment, in his own way Approach with a perspective of caring and understanding. Client anxieties, obsessions, and fears of failure are very real Give control when possible and appropriate Encourage the client to manage his own environment, in his own way Clients with Avoidant Personality will need great patience and encouragement to take on even small responsibilities.

Cluster B - dramatic and emotional

ÑBorderline Personality Disorder ÑNarcissistic Personality Disorder ÑHistrionic Personality Disorder ÑAntisocial Personality Disorder

historic personality disorder characteristics

ÑCenter of attention ÑInappropriate sexually seductive/provocative ÑRapid shifts of emotion ÑPhysical appearance to draw attention ÑDramatization or exaggerated expression of emotion ÑSuggestible ÑConsiders relationships to be more intimate than they really are Flamboyant. career in theatre usually. My psych patient from Flint Michigan.

Paranoid personality disorder - cluster A

ÑChildhood with cruel, abusive, sadistic parents ÑBecomes suspicious, learns not to cry, etc. Ñ2.5% of the general population ÑUnwarranted suspiciousness of others From an early age they feel that they have been exploited or doubt trustworthiness of friends. Your text talks about the 60yrold who was brought to the psych ER with a clinical picture suggesting paranoid schizophrenia. There was no previous history prior to several days before the visit wehenshe became intensely delusional and agitated, fearing for her life. In the exploration of her presecutorythoughts, she reported that her persecutors had begun their assault by throwing her to the ground, taking her breath, and "wrenching" her chest. An EKG revealed a recent anterior wall myocardial infarction. When her medical illness was explained and she was transferred to the CCU, her agitation and delusions disappeared, leaving her underlying stable, paranoid personality disorder. These individuals are very critical of others but have difficulty accepting criticisms of themselves. Very suspicious, very hypervigilant, fear people are after them

cluster A personality disorder grouping

ÑCluster A—Odd and eccentric (paranoid, schizoid, schizotypal)

cluster B personality disorder grouping

ÑCluster B—Dramatic, emotional, erratic (antisocial, borderline, histrionic, narcissistic)

cluster C personality disorder grouping

ÑCluster C—Anxiety and fear based (avoidant, dependent, obsessive-compulsive)

Schizotypal personality disorder - cluster A

ÑDemonstrates pervasive pattern of acute discomfort with social and interpersonal relationships. ÑExhibits cognitive or perceptual distortions and eccentricities of behavior ÑMore distortions of reality than in schizoid disorder. ÑTheir perception of reality is much more distorted than schizoid ÑOdd and eccentric, lack of friends, unusual experiences Cause unknown. Found in more than one family member. Many can maintain their schizotypal personality throughout adult like and still never be diagnosed as schizophrenic. BUT THE DEFICITS IN SOCIAL RELATIONSHIPS IS THE SAME AS SCHIZOPHRENIA. Peculiarities of ideation, appearance, and behavior. Magical thinking; ideas of reference; social isolation; illusions; odd speech patterns; aloof, cold suspicious behavior and undue social anxiety.

4 plus of the following for diagnosed schizoid personality disorder

ÑDenial of close relationships ÑPractices solitary activities ÑLittle interest in sexual activity ÑTakes pleasure in few activities ÑLacks close friends ÑIndifferent towards praise or criticism ÑShows emotional coldness

Schizoid personality disorder - cluster A

ÑDetachment ÑAloofness ÑLack of warmth ÑIndifference to the feelings of others ÑChildhoods bleak, cold, unempathetic ÑDiagnosed more in males than females These clients are described as loners and therefore choose occupations that allow them to work in isolated environments. These clients do not seem to obtain satisfaction from being members of a family or social group. These kids grew up most likely in homes with not a lot of warmth, social play, or spontaneity. ONE CANNOT DISTINGUISH SCHIZOPHRENIA BY WHETHER OR NOT A SCHIZOID PERSONALITY WAS PRESENT OR NOT. Schizophrenia is a relentless progressive disorder and schizoid personality is pretty constant.

Dependent personality disorder - cluster C

ÑDifficulty making everyday decisions ÑNeeds others to assume responsibility for major areas of his /her life ÑDifficulty expressing disagreement ÑDifficulty initiating projects ÑGoes to excessive lengths to obtain nurturance from others ÑFeels uncomfortable or helpless when alone ÑSeeks relationships as a source of support ÑUnrealistically preoccupied with fears of being left to take care of self Need to be taken care of by others. Clinging, submissive and fears separation from the known. Trouble making decisions and difficulty expressing disagreements with others.

Antisocial personality disorder - cluster B

ÑDisregard for social obligations ÑLack of feeling for others/ cold affect ÑImpetuous violence or callous unconcern ÑBehavior not modified by experience or punishment ÑAbnormally aggressive/irresponsible ÑLow tolerance for frustration ÑBlame others ÑOffer plausible rationalizations ÑLack motivation to change or insight Ñ3% of men and 1% of women in general pop. Commonly called the sociopath, psychopath. Socially irresponsible, exploitive, and guiltless behavior. Fail to conform to the law, fail to hold a job, deceptive. Fail to conform to the law or maintain stable employment Act as though rules do not apply to them. Sometimes if you see them in psychiatric settings, it is to avoid legal consequences, Sociopath Irresponsible Lying, stealing, drug and alcohol abuse Disregard the rights of others

Narcissistic personality disorder - cluster B

ÑGrandiose sense of self ÑPreoccupied with fantasies of unlimited success ÑExhibitionist need for constant attention/admiration ÑCharacteristic responses to threats to self-esteem ÑEntitlement Abnormal love for oneself Insecure with low self-esteem and distorted self image, cover it up by putting others down ÑInterpersonally exploitive ÑLacks empathy Extremely self-centered or self-absorbed. Abilities and achievements tend to be unrealistically overestimated. For example: Family revolves around the child. No give and take—only taking. Parents who may attempt to live their lives vicariously through their children. Found in 1% of the general population. 3-16% of the clinical population. DSM IV REQUIRES 5 OF THE 8 CRITERIA TO BE PRESENT FOR NARCISSISTIC PERSONALITY DISORDER. Some theory that says this diagnosis comes about from the selfless love and adoration of a significant adult—so that the child escapes reality-based experiences. Other theory says that the child is a product of ever present criticism of never being perfect.

5+ of the following for diagnosis Schizotypal personality disorder

ÑIdeas of reference ÑOdd beliefs or magical thinking ÑUnusual perceptual experiences ÑOdd thinking and speech ÑSuspiciousness or paranoid ideation ÑOdd, eccentric, peculiar behavior ÑLack of close friends ÑExcessive social anxiety

Borderline personality disorder - cluster B

ÑLong history of unstable and intense personal relationships ÑMarked reactivity of moods Intense mood swings Problems with self worth Impulsive self destructive behavior Intense feelings of emptiness and loneliness Alternate between positive and negatives of others and shift back and forth (relationships difficult) Paranoid and delusional Frantic fear of abandonment (make lots of friends) ÑImpulsive ÑUnpredictable Ñ2% of general population ÑTwice as common in women ÑCan't be alone ÑClinging and distancing behaviors ÑRapid shifts in affect or mood ÑRecurrent suicidal behaviors We talked a little about borderline personality during the anxiety and depressive lectures more in the frame of cycles. BPD is characterized by instability in a variety of areas. Their impulsivity, marked shifts in attitude, etc. can lead to poor self image, gender identity, long-term goals or values, ability to be alone, and causes feelings of emptiness or boredom. Splitting—Inability to accept negative or positive feelings. Manipulation, self-destructive, depersonalization, impulsivity. UNABLE TO ACHIEVE A STABLE SIMULTANEOUSLY OCCURRING AMBIVALENCE. HE/SHE CANNOT SEE SELF OR A COMPANION HAVING A BALANCE OF BOTH AFFECTIONATE AND HOSTILE FEELINGS AND INTENTIONS. When there is a threat of simultaneous recognition of these usually segregated good and bad representations, a state of flooded anxiety may occur. This may result in confusion, disorientation, and rerealization. He/she may suffer depersonalization. When feeling tone is positive, expectations of the future are globally optimistic. When negative—the future appears catastrophically bleak. Can people with BPD be successful? ABSOLUTELY!

Nursing interventions for the client with personality disorder

ÑMedication therapy is based on the psychological diagnosis and then medication is geared to behaviors. ÑBe Consistent ÑDe-escalate the client before they disrupt the whole unit or group ÑDo not let the client's angry behavior provoke you to do something or say something non-therapeutic.

Histrionic personality disorder - cluster B

ÑMental disorder characterized by dramatic and exaggerated behavior that draws attention to oneself. Prone to exaggeration and often acts out a role, such as "victim"or "princess"without being aware of it. Ñ2 to 3% of the general population ÑIn both females and males Excessive need for approval Attention-seeking Inappropriately seductive behavior Intense and unstable emotions and distorted self-image Constantly seeking reassurance and self-centered May seem fake or shallow Want to be the center of attention Your text talks about the histrionic personality in males where they want to be the center of attention. The male histrionic focuses on the "macho" behavior and talk, often involving physical or athletic prowess. REMEMBER THE HISTRIONIC MALE WISHES TO BE THE CENTER OF ATTENTION, WHERE THE NARCISSISTIC MALE SEEKS POWER AND DOMINATION OVER OTHERS. Symptoms include exaggerated expression of emotions; drawing attention to oneself; overreaction to minor events; constantly seeking approval of others; vain.

Nursing care of client with OCPD

ÑOCPD tend to be overly concerned with control ÑNurse should give as much control to the client as is safe and reasonable ÑAvoid getting into power struggles with OCPD clients

Cluster C - anxiety and fear based

ÑObsessive Compulsive Personality Disorder ÑAvoidant personality disorder ÑDependent Personality Disorder

cluster A

ÑOdd and Eccentric group ÑOften described as "different""odd" ÑIsolated from others ÑUnconcerned about how others perceive them ÑDisconnected living patterns ÑSchizoid Personality Disorder ÑSchizotypal Personality Disorder ÑParanoid Personality Disorder

Obsessive compulsive personality disorder (OCPD) - cluster C

ÑPreoccupation with orderliness, cleanliness, control, lists, and perfectionism ÑRules, details, and procedures are important ÑExcessively devoted to work/productivity ÑAvoid leisure or pleasurable pursuits ÑHighly inflexible "stiff" ÑDifficulty accepting physical illness ÑDifficulty expressing tender feelings ÑInsist that others submit to their way of doing things OCPD IS NOT OCD!!! More often in males than females. OCPD is diagnosed in 1% of the general population. OCPD- rational and desirable perfectionsis OCD - unwanted, time consuming and stressful

paranoid personality features

ÑSuspect, without sufficient basis that others are exploiting, harming, or deceiving them. ÑSuspicious about the loyalty of others ÑReluctant to confide in others for fear of information shared getting out. ÑRead hidden or demeaning meaning into benign remarks or events ÑPersistently bears grudges ÑPerceive attacks on their character or reputation that are not apparent to others ÑSuspicious of spouse or sexual partner fidelity

Avoidant personality disorder - cluster C

ÑUnwilling to get involved with people unless certain of being liked ÑShows restraint in intimate relationships for fear of being shamed, ridiculed or rejected ÑInhibited in interpersonal relationships because of feelings of inadequacy ÑViews self as socially inept and inferior ÑUnusually reluctant to take personal risks Ñ1% of the general population Often a childhood history of being in a family where the opinions of others were held in high importance and the opinion of he child not highly regarded or noticed. As a result, the child learns that public exposure can result in humiliation. The individual has a desire to be sociable but also a fear that being closer to others may bring rejection or humiliation or both. Sometimes perceive criticism by others when it is not there.

Nursing care of clients with personality disorders

ÑUsually clients present with a diagnosis other than the personality disorder ÑThe personality disorder can be secondary ÑFirst recognize the personality disorder ÑSecondly, provide care to minimize the negative symptoms of the personality disorder Behavioral health nurses have to pay close attention to a few things when personality disorders are involved.

Specific nursing interventions ÑBorderline Personality Disorder

ÓMost concerning because of risk of suicide and self-mutilating behaviors ÓYoung person with BPD at highest risk of suicide ÓOnce the person with BPD reaches age 30-40 the risk significantly decreases ÓDialectical Behavioral Therapy (DBT)- ÔStructured therapy combining CBT and Life Skills ÔOnce weekly individual and twice weekly group Nurses caring for these clients often become frustrated and angry because the client demands an excessive amount of time and attention. It often seems that , compared t other clients on the unit, the client with any of the personality disorders in this cluster (B) has a minor problem and the nurse wants to give care to the other seemingly more deserving clients. Nurses need to remember that clients with personality disorders have diagnosable problems but cannot change who they are. These client cannot wait graciously while the nurse attends to the others; it is not part of their makeup to do so. The nurse will need to set limits, state clearly what she can and cannot do, and keep to the schedule. When the client complains about or criticizes the nurse, the nurse must understand that this, too, is part of the personality dynamics.

ÑIn working with the client with a personality disorder:

ÓSelf Awareness ÓSystem Awareness ÓBe absolutely consistent and supportive of other health care team workers Know yourself first!!! Know your vulnerabilities and prejudices. Then know the system you work in—know how to work as a team and support other team members to function as a group is essential.

characteristics of schizophrenia -- movement disorders

—agitated body movements-where they keep repeating certain motions over and over. Catatonic—a state in which a person does not move and does not respond to others.

characteristics of schizophrenia -- delusions

—false beliefs not part of the person's culture and do not change- even after they are proven wrong.Bizarre-lie a neighbor is controlling their thoughts. They may also believe that people on television are directing special messages to them, etc. Delusions of grandeur persecution.

characteristics of schizophrenia -- hallucinations

—things a person's, sees, hears, smells, or feel. Voices—most common hallucination. i.e.-a voice may tell a person to pluck their eye out. The other type of hallucinations is visual—seeing people or objects that are not there. Smelling odor that no one else detects and feelings things like invisible fingers touching their bodies when no one is there.

ECT side effects

•**Temporary memory loss/confusion- Most common •-Some researchers believe this may be permanent or lead to irreversible brain damage •Bilateral electrode placement may be more effective than unilateral electrode placement •-The drawback of bilateral electrode placement may be more memory loss/confusion than unilateral placement

6 steps of the WRAP recovery model

•1) Develop a Wellness Toolkit --List tools, strategies, skills (journaling, guided imagery, exercise) •2) Daily maintenance list --List to keep on the wellness track. Drink water, exercise, then advance on to things like: do the laundry, write some letters, things that need to be done •3) Triggers --What to watch out for. Work stress, family friction •4) Early warning signs •5) Things breaking down or getting worse --Headaches, inability to sleep, eating or not eating •6) Crisis Planning --Caregiver stage. Identify symptoms and make a plan. •--Gather information •--Identify the symptoms •--Provide names of supporters previously identified •--Include name of health-care provider and contact info. •--Include preferred treatments •--Identify preference in treatment facilities •--Identify alternate facilities if necessary •--Client expectations •--Client identified indicators to provide supporters clues that their help no longer needed

termination phase

•1) Evaluate goal attainment •2) Ensure therapeutic closure ***Most important phase

Principles of CBT

•1. CBT based on ever-evolving formulations of the client and his/her problems in cognitive terms •2. CBT requires a sound therapeutic alliance •3. CBT emphasized collaboration and active participation •4. CBT is goal oriented and problem focused •5. CBT initially emphasizes the present -better leads to symptom reduction. Present problems first and then can shift to past problems •6. CBT is educative, aims to teach the client to be their own therapist-emphasizing relapse prevention. From the get go, client is taught about the cognitive model or how thoughts influence emotions and behavior. Then about the process of CBT. Client is taught how to set goals, plan behavioral change,and intervene on their own behalf •7. CBT is time limited •8. CBT sessions are structured •9. CBT teaches clients to identify, evaluate, and respond to their dysfunctional thoughts and beliefs 10. CBT uses a variety of techniques to change thinking, mood, and behavior

5 goals of CBT

•1. Monitor his or her negative , automatic thoughts •2. Recognize the connections between cognition, affect, and behavior •3. Examine the evidence for and against distorted automatic thoughts •4. Substitute more realistic interpretations for these biased cognitions •5. Learn to identify and alter the dysfunctional beliefs that predispose him or her to distort experiences

Treating codependency

•1. Survival Stage-the letting go of the denial that the problem exists •2. Reidentification Stage- accept the label of codependent and take responsibility for their own dysfunctional behavior •3. Core Issues Stage- Face the fact that certain things are out of their control •4. Reintegration Stage- Self-acceptance and will to change occurs here

10 tidal recovery commitments

•1. Value the voice - listen actively and record the story in the client's own words •2. Respect the language - client own words, swear words, stories •3. Develop genuine curiosity - clarifying questions. Client's own place •4. Become the apprentice - based on the client's needs and wishes •5. Use the available toolkit - past successes •6. Craft the step beyond - help client define interventions to get towards the goal of recovery •7. Give the gift of time - help client identify importance of time and planning •8. Reveal the personal wisdom - what have they learned so far •9. Know that change is constant - change is always happening •10. Be transparent - give copies of all documents used in the client care

The chemically impaired nurse

•10% of Americans suffer from chemical addictions •5.1% of employed nurses in America stated they were addicted to chemicals •Alcohol is the most widely abused chemical followed by narcotics •Nurses are often handling controlled substances

TMS treatment

•30-36 sessions •40 minutes each session •3-5 times/week •Combined with medications •Combined with DBT self-study

Heroin- an opioid derivative

•435,000 heroin used aged 12 yrsand older in the US in 2014 (SAMHSA) •Alarming rate of overdose deaths associated with fentanyl mixed with heroin •4.3 million in the US use prescription drugs non-medically •Since 1999, prescription rates for painkillers and accidental overdoses from opioids have quadrupled. (CDC, 2016)

History of electroconvulsive therapy (ECT)

•A negative history that began in the 1700's •The most controversial treatment today •The amount of electrical current applied is a point of controversy among physicians •Used continuously for 50 years •Better than the alternatives of Insulin coma therapy and intramuscular injection therapy

Behavioral interventions

•Active Scheduling •Graded task assignments •Distraction •Miscellaneous techniques •-Relaxation exercises •-Assertiveness training •-Role modeling •-Social skills training •-Contingency management contracts

Treatment modalities for substance related clients

•Alcoholics Anonymous •Pharmacotherapy- i.e.) Disulfiram (Antabuse) or Naltrexone •Talk therapy or counseling •Group therapy

Therapeutic nurse client relationship

•An interaction between 2 people (caregiver and care receiver) •Input from both participants •Creates climate of healing; growth promotion; and illness prevention

Analysis - nursing diagnosis includes: for schizophrenia

•Anxiety •Impaired verbal communication •Ineffective coping •Elevated risk for accidental injury •Altered nutrition •Powerlessness •Self care deficit •Self esteem disturbance •Social isolation •Elevated risk for violence, self and other directed

Common cognitive errors or automatic thought -arbitrary inference

•Arbitrary Inference—coming to a conclusion about something without the facts to support

Role of the nurse in ECT therapy

•Assessment •-Cardiac and Pulmonary •-Informed consent- is the client competent to give consent? •-Important to document: mood, suicidal ideation, plan, means, level of anxiety, thought and communication patterns, current and past medications •Diagnosis •-Can be Anxiety, knowledge deficit, risk for injury from procedure, decreased cardiac output, self-care deficit •Planning and Implementation •Evaluation

ECT Mechanism of action

•CNS Systems affected by ECT: •-Hormones, neuropeptides, and neurotrophic factors •Neurotransmitters affected by ECT: •-Serotonin, norepinephrine, and dopamine (same as anti-depressant meds) •Increased GABA transmission and endogenous opioids (raise the seizure threshold) •Increased gray matter--Gray matter is greatly reduced in volume with clients with depression •White matter microstructure- still being researched. ECT somehow increases the white matter in clients suffering from depression. Increased GABA and endogenous opioids (raise the seizure threshold)

Contraindications

•Cardiovascular disease •--MI or CVA within the last 3-6 months •--Aortic/cerebral aneurysm •--Severe hypertension •--Congestive Heart Failure (CHF) •Intracranial lesions •--Can be controlled with dexamethasone or controlling the client's blood pressure •Severe Osteoporosis •Acute/chronic pulmonary disorders •High risk pregnancy (ECT increases oxytocin and therefore increased contractions and premature birth) -Mostly due to the client's bodily response to seizure activity. First there is the vagal response, that leads to bradycardia,, then the blood pressure drops. This is followed by rebound tachycardia, and a hypertensive response.

Common cognitive errors or automatic thought -catastrophic thinking

•Catastrophic Thinking—Always thinking that the worst will occur without considering the possibility of more likely positive outcomes

Other assessment factors for schizophrenia

•Changes in the thoughts, speech, affect •Ability to perform self-care, activities and maintain nutrition •Suicide potential •Aggression •Regression •Impaired communication

schizophrenia Planning implementation (goals)

•Client will...... •Develop a trusting relationship between patient and nurse •Be oriented, able to test reality •Be protected from injury •Be able to recognize impending loss of control •Adhere to medication schedule (regimen) •Participate in activities •Increase ability to care for self

Suicide safety plan

•Detailed plan developed by the client with the nurse or therapist about what to do in the instance of severe suicidal ideation

WRAP recovery model

•Developed 1997 •Structured system for monitoring uncomfortable and distressing symptoms •Planned responses help eliminate the stress •Step-wise process for managing distressing symptoms

•Psychological Recovery Model

•Developed in 2011 •Establishment of a fulfilling, meaningful life and a positive sense of identity •Founded on Hopefulness and Self-determination •Focus is on client self-determination

tidal recovery model

•Developed late 1990's •The power of metaphor to engage with the person in stress •Focus is on the client's personal story

Predisposing factors to substance-related disorders psychological

•Developmental influences •Personality factors •Cognitive factors

Common cognitive errors or automatic thought -dichotomous thinking

•Dichotomous Thinking- Views situations in terms of all-or-nothing; black/white; good or bad

Side effects of antipsychotics

•Drowsiness •Dizziness when changing position (orthostatic) •Blurred vision •Rapid heartbeat •Sensitivity to sun •Skin rashes •Menstrual problems for women •Weight gain—atypical side effect Most schizophrenic patients should not drive when beginning antipsychotic therapy or when changing their medications. Other side effects include: Muscle rigidity, persistent muscle spasms, tremors, restlessness.

codependency

•Dysfunctional behaviors evident among family members of a chemically addicted client •Profound sense of powerlessness •More about fulfilling the needs of others •Personal identity is relinquished and boundaries with the other person become blurred •Dysfunctional relationship with oneself -People Pleasers" Outwardly very confident but inwardly feel very needy,helpless or perhaps nothing at all. Have experienced abuse or emotional neglect as a child -Are outwardly focused toward others and know very little about how to direct their own lives form their own sense of self.

History of cognitive behavioral therapy

•Early 1960's developed by Beck who studied under Freudian psychoanalytic view, who observed in clients a pattern of negative cognitive processing in thought and dreams •CBT is based on the client's individual cognition or appraisal of an event •"Life is 10% what happens to us and 90% how we react to it" •Modification of distorted cognition and maladaptive behaviors

negative symptoms of schizophrenia (alterations in:)

•Emotions (apathy, depression, feelings of emptiness, amotivational) •Social behavior (aggression, bizarre conduct, extreme social withdrawal) •Cognitive (poor problem-solving, poor decision-making, illogical thinking) Negative Symptoms - reflect a loss of normal functions. They are associated with the mesocortical system. Begins earlier-childhood. Children with negative schizophrenia often observed as being cold and withdrawn. The negative symptoms are more damaging to the quality of life.

biological Predisposing factors to substance-related disorders

•Genetics •-Heredity •-Children of alcoholics- 4 times more likely than other children to become alcoholics •-Twin studies-monozygotic twins have more concordance with alcoholism •Biochemistry •-Neurotransmitters opioid, catecholamine: dopamine and GABA •-Neural pathways linked to pleasure centers

Goals of nurse/client relationship

•Goal oriented- Ideally decided by both nurse and client •Sometimes based on solving a problem: •The problem may be anxiety •But the GOAL may be develop more positive coping strategies for dealing with ...........

4 major dimensions of recovery

•Health- living in a physically and emotionally healthy way •Home - a stable and safe place to live •Purpose- meaningful daily activities such as job; school; volunteerism; family caretaking or creative endeavors. Independence, income, resources to participate in society •Community- relationships and social networks that provide support, friendship, love and hope.

Clues that you are working with a nurse addicted to substances

•High absenteeism if the chemical abused is found outside of work •Low absenteeism if the chemical abused is found at the workplace •Poor concentration •Difficulty meeting deadlines •Inappropriate responses •Poor memory recall -All clues vary depending on the substance abused There are professional treatment facilities just for Nurses and other health professionals. Peer Assistance programs. -Care must be taken when confronting a chemically impaired nurse. Hostility can result. Take careful, objective notes of your observations. -State boards of nursing have passed diversionary laws, Cases are decided on an individual basis. To get your nursing license reinstated is a process devised by each state board of nursing.

4 main constructs of psychological recovery model

•Hope •Responsibility •Self and identity •Meaning and purpose

Dynamics nurse/client relationship according to Hildegard Peplau

•Human to human relationship- more than just nurse/client •-Beliefs •-Attitudes •-Values •Therapeutic use of self- ability to use one's own personality consciously and in full awareness in an attempt to establish relatedness and structure nursing interventions Most important part is termination

Suicide epidemiology

•IN 2014, over 42,000 people died by suicide (AFSP, 2016) •Suicide- 2nd leading cause of death among young americans aged 10-34 years •Many more attempt suicide than die by suicide 12:1 •Suicide is on the rise during 2000-2014 •Suicide has increased in our military population since 2010 and 2011 (22/day) •High rates of suicide among youth on indian reservations

SAFE-T: suicide assessment five step evaluation and triage

•Identify risk factors •Identify protective factors •-Note these can be enhanced •Conduct suicide inquiry •-Evaluate suicidal thoughts, plans, behavior, and intent •Determine risk level and intervention •-Choose appropriate interventions to address and reduce level of risk •Document --Record assessment of risk, rationale, intervention, and follow-up

Importance of self-awareness

•Knowing oneself is important in a Nurse/Client relationship •Who AM I assignment •Gaining self awareness •-Values clarification •-Can change throughout the lifetime

Common cognitive errors or automatic thought -magnification

•Magnification—exaggerating the negative significance of an event

Indications for ECT therapy

•Major Depression- esp the client with refractory depression or those with psychotic symptoms, catatonia, psychomotor retardation and neurovegetative changes (disturbances in sleep, appetite, or energy) •Mania—usually those clients who do not respond to lithium, or life is threatened by self •Schizophrenia—For those in acute schizophrenia states. Not for those who have chronic schizophrenia •Also for those with marked positive symptoms; in catatonic states; or depressed affect •Other conditions— •-Episodic psychosis •-Atypical psychosis -•OCD -•Delirium •-Parkinson's disease

Communication with clients with schizophrenia -older adult clients

•Recognize that the client may require amplification. •Minimize distractions, and face the client when speaking. •Allow plenty of time for the client to respond. •When impaired communication is assessed, ask for input from caregivers or family to determine the extent of the deficits and how best to communicate.

Recovery model guiding principles

•Recovery emerges from hope •Recovery is person-driven •Recovery occurs via many pathways •Recovery is holistic •Recovery is supported by peers and allies •Recovery is supported through relationship and social networks •Recovery is culturally based and influenced •Recovery is support by addressing trauma •Recovery involves individual, family, and community strengths and responsibility •***Recovery is based on respect Hope is internalized and fostered by peers, families.... Support recovery and resilience Highly personalized and nonlinear Holistic- an individual's whole life Trauma- supports must be trauma-informed to foster safety

onset of schizophrenia

•Males- Adolescence to early adulthood (15-25 yrsold) •Females- later than males (25-35 yrsold) •Usually not diagnosed after the age of 45 yrsold. •Child-onset schizophrenia is growing You may have seen the 20/20 program where Diane Sawyer, news reporter for ABC, interviews and follows a family with a schizophrenic 7 yogirl who is schizophrenic and both parents had to quit their jobs and have separate apartments for their baby boy's safety. Oprah even visited with the girl. This girl had many delusions and many where different cats who all had distinct personalities and distinct names. One was called "300" and that cat or delusion was particularly violent- or caused the girl to be violent. Psychotic Disorders: Identifying Risk Factors of Schizophrenia in Young Adult Clients ● Schizophrenia spectrum and other psychotic disorders affect thinking, behavior, emotions, and the ability to perceive reality. ● Schizophrenia probably results from a combination of genetic, neurobiological, and nongenetic(injury at birth, viral infection, and nutritional) factors. ● the typical age at onset is late teens and early 20s, but schizophrenia has occurred in young children and may begin in later adulthood. ● a diagnosis of schizophrenia should not be made for children until after age 7 to rule out attention de cit hyperactivity disorder (ADHD) with violent tendencies.

condition of client with schizophrenia

•May be seriously impaired; unable to care for self •Some can be violent if they have delusions •The violence usually is directed at family member and usually takes place at home. •Attempt suicide more than others (suicidal ideation is present in 40-55% of those with schizophrenia •Potential for suicide is a major concern •Approximately 10% (especially young males) die of suicide.

Common cognitive errors or automatic thought -minimization

•Minimization—Undervaluing the positive significance of an event

Stages of psychological recovery model

•Moratorium- Despair and Confusion •Awareness- Possibility for recovery exists •Preparation- client prepares to begin the work of recovery •Rebuilding- Working towards the goals •Growth- the personal growth achieved in the final stages of recovery. Also understanding that growth is a continual process

Risks associated with ECT

•Mortality •-O.002%/treatment or 0.01% for each client •-Although rare, the major cause of death with ECT is from cardiovascular complications •Memory Loss •-Can be 4 hrsto 10 hrs -•Most clients return to their cognitive baselines after 6 months •-Persistent memory loss is often associated with clients who have seen little improvement in their depression from ECT therapy •Brain Damage •-Still a concern by critics •-No evidence supports this

Specific nursing interventions for ECT

•NPO for 6-8 hrs •Approximately one hour before ECT: •-vital signs, remove dentures, eyeglasses, jewelry, and hairpins •-Have client void, change into gown •Approximately 30 minutes before ECT: •-Pre-treatment medications (Atropine sulfate or Glycopyrollate/Robinul)-decrease secretions/prevent aspiration •-Blood pressure cuff on lower leg inflated to just above systolic pressure—so as to better observe the seizure activity in the toe •During ECT : •-Place the airway bite block •-Electrodes bilaterally or unilaterally as ordered •-Monitor airway •Post ECT recovery: •-Post procedure vital signs, document recovery

Alcohol use disorder

•Neolithic age around 6400 B.C. •66.6% of Americans 12 yrsand older report as drinkers of alcohol •6.4% of Americans met criteria for alcohol use disorder (SAMHSA, 2015) •Third largest drug problem in the US (prescription drugs and marijuana are first and second largest drug problem) (SAMHSA, 2015)

Countertransference

•Nurse's emotional or behavioral response to the client in which the nurse transfers past feelings or experiences onto the client •Can be unresolved feelings from the nurse's past •(i.e.) Nurse has difficulty setting limits on the client because the client reminds the nurse of a favorite niece •(i.e.) The Nurse is very rude to the client because the client looks a lot like a sibling that the nurse does not like

schizophrenia interventions

•Offer the use of self in development of therapeutic relationship •Use of silence •Set time for interactions with the client •Encourage reality orientation (while realizing the hallucinations and delusions are real to client) •Assist with feeding, dressing, and other cares as necessary •Remove harmful objects •Contract with the client to let you know when she/he is anxious to prevent loss of control •Administer antipsychotic medication

Schizophrenia therapy

•Once a client is stabilized on antipsychotic medications •Helps with communication, self-care, work, and forming and keeping relationships •Learning and using coping mechanisms •Watching for early warning sign of the disease •Family education •CBT The goal is helping the person with schizophrenia still attend work or school.

Opioid use disorder

•Opioids exert a sedative and analgesic effect •Mainly used for pain relief •Popular because they desensitize a client to both psychological and physiological pain and induce a sense of euphoria

Uses of CBT

•Originally developed for use with depressed clients •Panic disorder •Generalized anxiety disorder (GAD) •Social phobias •Obsessive Compulsive Disorder (OCD) •PTSD •Eating disorders •Substance use disorder •Personalitydisors •Schizophrenia •Bipolar I and II •Somatic symptom disorder

Common cognitive errors or automatic thought -overgeneralization

•Overgeneralization (Absolutist thinking)- Sweeping conclusions on the basis of one incident

positive symptoms of schizophrenia (alterations in:)

•Perceptions (hallucinations and delusions) •Thinking (delusions, paranoia and disorganized thought) •Emotions (agitation and emotional dyscontrol) •Language (Associative looseness, poverty of speech) •Movement (agitated/catatonic) Positive symptoms- tend to reflect an excess or distortion of normal functions. They are associated with disturbances of the mesolimbic doamminergicsystem. Symptoms occur suddenly. Normal CT findings. Positive symptoms are active and include alterations in Perceptions, thinking, emotions, language.

Recovery

•Process of movement toward improvement in health and quality of life •Process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (SAMHSA, 2012) •Basic concept of recovery is to allow clients primary control over decisions about their own care (NASW, 2006)

TMS treatment risk

•Seizures- rare •Mania -rare •Headache or scalp irritation are more common •Remission may not be as long as ECT •-2012 study found that at 6 month follow up: •--24.7% of TMS clients were still in remission •--17-70% of ECT clients were still in remission

Common cognitive errors or automatic thought -selective abstraction

•Selective abstraction—Conclusion based only on a selected portion of the evidence

Communication with clients with schizophrenia -children

•Simple, straightforward language. •Be aware of own nonverbal messages, as children are sensitive to nonverbal communication. •Enhance communication by being at the child's eye level. •Incorporate play in interactions.

Predisposing factors to substance-related disorders sociocultural

•Social learning •Conditioning •Cultural and ethnic influences

Other substances abused

•Stimulants •Opioids •Prescription Drugs •Inhalants •Hallucinogens •Sedative, hypnotic or anxiolytic use disorder

Transcranial magnetic stimulation (TMS)

•Stimulation of nerve cells in the brain •Very short pulses of magnetic energy directed at localized areas of the brain •Similar to ECT but no generalized seizure activity induced •Non-invasive

age and suicide

•Suicide risk and age are positively correlated among men •Highest rates of suicide are among 45-64 yrs of age and over 85 yrs old •Adolescents- Suicide is the third leading cause of death in this population for many years, jumping to the second leading cause of death in year 2013 where it remains. •Children- •--They are actively talking about it. Social media? •--Ages 5-11 yrs old lose 33/year to suicide (suffocation and hanging) •--Ages 3-7 yrs old show 11 % suicidal ideation

Electroconvulsive therapy

•The induction of a grand mal (generalized) seizure through the application of electrical current to the brain •Electrodes are placed bilaterally or unilaterally on the right side •Why the right side? Because the right hemisphere of the brain is involved in sustaining depressed mood •Most clients require 6-12 treatments, but some require as many as 20. •Provided as inpatient or outpatient basis

Automatic thought

•Thoughts that occur rapidly in response to a situation and without rationale analysis •Often negative •Based on erroneous logic/ "cognitive errors"

Transference

•Unconscious displacement or transfer to the nurse feelings formed toward a person from his or her past •Can be triggered by something the nurse is wearing or something the nurse is doing •Can interfere with the nurse/client relationship when the feelings are "anger" or "hostility" Can't tell it's happening Feelings drawing from a source from long ago

Mindfulness meditation

•Used for mental health symptoms or basic relaxation •Focus on the present •Keeps the client from focusing on stressful events of the future •Deep breathing, meditation postures and techniques •Client goal driven—they set the goals -Great with clients suffering from anxiety, schizophrenia, personality disorder, substance use disorders, and neurocognitive disorders such as dementia -Must have the right healing environment -Best as an individual therapy, but some group mindfulness therapies with clients who have similar goals can be successful

Motivational interviewing

•Useful in the assessment and intervention steps with a client abusing substances •Skills include: empathy, validation, open-ended questions, and reflection to explore the client's motivation, strengths, and readiness for change •Empowers the client to become an active partner in treatment goals while exploring reasons for resistance to behavior change

antipsychotic medications

•Valuable but they do not cure schizophrenia •20% of clients have complete remission with first generation antipsychotics •While some effect on the negative symptoms, these symptoms remain socially incapacitating •These medications have a range of significant adverse side effects •With the exception of clozapine, there is still no evidence that any one neuroleptic is more effective than others. •New neurolepticsincrease the risk of heart disease and must be used cautiously long term. (Risperodal, Zyprexa, Seroquel, Geodon, Abilify, Invega) Haldol, Thorazine, Trilafon, and prolixin—1950's . "Thetypicals" Newer Medications for schizophrenia: "The Atypicals" Clozipine Risperdal Zyprexa Seroquel Goedon Abilify Invega Saphris Anti psychotic -around since the 1950's. The older ones are Haldol, Thorazine, trilafon, andprolixin. "The typicals". They inhibit the dopamine-mediated transmission of neural impulses at the synapses. Clozapine came about in the 1990's and we are all soooo happy. It is very effective. Clozapine treats psychotic symptoms, hallucinations and breaks with reality. The only downside to clozapine is it can cause agranulocytosis—loss of WBC's. Risperdal (Risperidone)—many lawsuits out now as it is causing gynecomastia in men ; Zyprexa(Olanzapine); Seroquel (Quetiapine); Geodon (Zipreasidone);Abilify(Aripiprazole); Invega(Paliperidone). These atypical antipsychotics are thought to be more potent antagonists of the Serotonin 5 hydroxytryptamine type 2 receptors. (5HT 2A)

TMS: inform your provider if:

•You're pregnant or thinking of becoming pregnant. •You have any metal or implanted medical devices in your body. Due to the strong magnetic field produced during rTMS, the procedure is not recommended for some people who have the following devices: -•Aneurysm clips or coils •-Stents •-Implanted stimulators •-Implanted vagus nerve or deep brain stimulators •-Implanted electrical devices, such as pacemakers or medication pumps •-Electrodes for monitoring brain activity •-Cochlear implants for hearing •-Any magnetic implants •-Bullet fragments •-Any other metal device or object implanted in your body