An emotional response to frustration of desires, threat to one's needs (emotional or physical), or a challenge
Anger
Action or behavior that results in verbal or physical attack
Aggression
In the hospital, violence is most frequent in
Psychiatric unitsEmergency departmentsGeriatric units
Behavior Theory vs Social Learning Theory
BT: Learned responseSLT: Imitating others
Involuntary confinement alone in a room that the patient is physically prevented from leaving
Seclusion
Any manual method, physical or mechanical device, material, or equipment that restricts freedom of movement
Restraints
__________ disorders are leading cause of disability in the United States
Depressive
People with co-occurring ____1_____ medical problems, (e.g., hypertension, backache, diabetes, heart problems, arthritis) are at a higher risk for __2___ than those in the general population.
1) Chronic 2) Depression
Dysthymia
Chronic, mild depression (2.5% of population over lifetime)
Depressive Syndrome
-Episodic, moderate-severe depression. -Frequently accompanies other psychiatric disorders (E.g. Anxiety)
Children as young as ____ years of age have been diagnosed with depression.
3
Major Depressive Disorder: May occur in up to __(1)__% of preadolescentsAmong adolescents is often associated with ___(2)___ abuse and ____(3)____ behavior.
1) 18%2) Substance abuse3) Antisocial behavior
Bipolar I vs Bipolar II
Bipolar I - Mania (Abnormal behavior during elevated mood, more severe, possible hallucinations and/or delusionsBipolar II - Hypomania (Distinctly elevated mood from baseline, but NOT abnormal, less severe, not usually associated with other psychotic symptoms)
Cyclothymia: Usually begins in ___(1)___ or early ___2___.
1) Adolescence 2) Adulthood
Cyclothymia
Milder symptoms than those that occur in full-blown bipolar II.(Think less depressiveness and hypomania)
Depressive Disorders Models of Causation: Diathesis Stress vs Biological Model
Diathesis Stress: Environmental and Genetics play a roleBiological Model: Genetic/Biochemical/Hormonal factors play a role
Is there more or less brain activity (than that of a non-depressed person) in a depressed individual?
Less, especially in the prefrontal cortex.
Persistent Depressive Disorder
Dysthymia
Disruptive mood dysregulation disorder
Usually, children who exhibit severe and frequent temper tantrums that interfere with their ability to function at home, in school or with their friends.
Mood Screening and Tracking Tools (Bob Decker Hardly Does Manly Duties)
Beck Depression InventoryHamilton Depression ScaleMood Disorder Questionairre
Assessment of Suicide Potential- Areas to Assess
-Mood-Anhedonia (inability to experience pleasure)-Anergia (lack of energy) -Anxiety-Feelings of: Worthlessness, guilt, helplessness, and hopelessness Anger and irritability
Mood Disorder Assessment Continued
AffectThought processesMoodFeelingsPhysical behaviorCommunicationReligious beliefs and spirituality
Individuals with depression are always evaluated for the risk of _______.
Suicide
Common Nursing Diagnoses r/t Mood Disorders
Disturbed thought processes Chronic low self-esteem Imbalanced nutrition Constipation Disturbed sleep pattern Ineffective coping Spiritual distress Disabled family coping
Nursing Process: Implementation (3) Phases [for pt's w/ Mood Disorders]
1) Acute Phase (6-12wks)2) Continuation Phase (4-9 months)3) Maintenance Phase (1 year or more)
Advanced Practice Interventions
CBT (Cognitive Behavioral Therapy)IPT (Interpersonal Therapy)Time-Limited Focused PsychotherapyBehavior Therapy
CBT? (Congnitive Behavior Therapy) What is it? Goal?
Thoughts and feelings play a fundamental role in our behavior.Goal of cognitive behavior therapy is to teach patients that while they cannot control every aspect of the world around them, they can take control of how they interpret and deal with things in their environment.
IPT (Interpersonal Therapy)
Short-term therapy used to treat mild to moderate depression. Focuses on addressing interpersonal issues, role transitions, and improving quality and/or quantity of an individual's personal relationships.
Behavior Therapy
Used to treat a variety of mood and anxiety disorders. Focuses on reducing and eliminating destructive behaviors and replacing them with positive coping skills.
Target Symptoms of Pharmacologic Therapy____1____disturbance_____2____ disturbance (decreased or increased)Increased ___3___Decreased ___4__ __4______5___ retardation or agitationDiurnal variations in __6__ (often worse in the morning)Impaired ____7____ __8___ (loss of ability to experience joy or pleasure)
1) Sleep2) Appetite3) Fatigue4) Sex Drive5) Psychomotor6) Mood7) Concentration8) Anhedonia
Antidepressants: SSRIs
Inhibit Serotonin ReuptakeFirst-Line TherapyWatch for adverse reactions and potential toxic effectsWarning: Serotonin Syndrome -Too much serotonin in the body Can be fatalGreatest risk when SSRI is given in combination with MAOIs.
Antidepressants: Correlated with increased ____1____ behavior in certain age groups. Close observation recommended for worsening ___2____, __3___ thoughts, and for __4___.
1) Suicidal 2) Depression3) Suicidal4) Mania
Tricyclic antidepressants (TCAs)
Start Low, Go Slow" Inhibited Reuptake of Serotonin and Norepinephrine Usually continued indefinitely Significant Cardiovascular EffectsContraindicated During PregnancyLots of Drug Interactions (Contraceptives, Benzos, Alcohol, Nicotine)Sedating Effect
MAIOs
Not 1st Line TreatmentAtypical or Several Anxiety/Depression DisordersSimilar SEs to TriCycs Drug Reaction - Elevation in BP and Severe Headaches(No Sudafed, Tyramine-containing foods [beer, wine, cheese, processed foods/meats])Could cause hypertensive crisis, seizures, strokes)
Atypical Antidepressants
Wellbutrin (works on Dopamine)- ADHD, Smoking Cessation [Has fewer sexual side effects]Trazodone (Strong Sedative)[Helps with sleep, not very effective as antidepressant because of sedating effects](Ex. Wellbutrin, Remeron, Trazodone)
Electroconvulsive therapy (ECT) is indicated if the:
-Patient is suicidal or homicidal.-Agitation or stupor is extreme.-Life-threatening illness is a result of the refusal of foods or fluids.-History includes a poor drug response or a good ECT response.-Standard medical treatment has no effect.
Types of depression for which ECT is most helpful:
-Major depression with psychotic symptoms -Life-threatening psychiatric conditions (e.g., self-harm) -Treatment-resistant (TR) depression -Refractory to other treatments
A nearly continuous flow of rapid speech that jumps from topic to topic, usually based on discernible associations, distractions, or plays on words, but in severe cases so rapid as to be disorganized and incoherent.
Flight of Ideas
Groupings of words based on their sounds, generally rhyming or partially rhyming, without necessarily having any logical reason to be put together.
Clang Associations
An exaggerated sense of one's importance, power, knowledge or identity. Often having religious overtones.
Grandiosity
Assessment Guidelines: Bipolar Disorder
Danger to self or othersNeed for protection from uninhibited behaviorsNeed for hospitalizationMedical statusCoexisting medical conditionsFamily's understanding
Bipolar Disorder: OutcomesAcute PhaseContinuation PhaseMaintenance Phase
Acute - Prevent InjuryContinuation - Relapse PreventionMaintenance - Limit severity/duration of future episodes
Pharmacological Interventions: Bipolar Disorder (Lithium)1) Therapeutic Blood Level2) Maintenance Blood Level3) Toxic Blood Level
1) 0.8-1.4 mEq/L2) 0.4-1.3 mEq/L3) 1.5 mEq/L and ^
Anticonvulsant Drugs
Valproate (Depakote)Carbamazepine (Tegretol)Lamotrigine (Lamictal)
Antianxiety Drugs
Clonazepam (Klonopin)Lorazepam (Ativan)Atypical Antipsychotics for Anxiety: Olanzapine (Zyprexa)Risperidone (Risperdal)
-Extremely overwhelming anxiety in real or perceived life-threatening situation.-Recurrent episodes and worry about recurring episodes-Physical and Cognitive Symptoms
Panic Disorder
History of Panic Disorder in past 12 months related to higher rates of ____1____ attempts and ideation.
Suicide
Marked fear or anxiety about two (or more) of the following five situations: 1) Using public transportation 2) Being in open spaces 3) Being in enclosed places 4) Standing in line or being in a crowd.5) Being outside of the home alone.
Agoraphobia
Persistent fear of clearly discernible, circumscribed objects or situations leading to avoidance behaviors
Specific Phobias
Thought pattern restructuring
Cognitive Behavior Therapy
Exposing the client to the most fear-inducing stimuli immediately for prolonged periods of time
Flooding
Similar to Flooding, but through imagery. Usually more anxiety-provoking situations are brought forth by the therapist
Implosive Therapy
Exposing client to specific stimuli that gradually increases in its fear-inducing-ness
Systematic Desensitization
Broad term r/t to therapy aimed at exposing client to the fear-inducing stimulus
Exposure therapy
Focus on the self. A feeling of watching oneself act, while having no control over a situation, in which a person feels he has changed, and the world has become vague, dreamlike, less real, or lacking in significance.
Depersonalization
Focus on outside world. An alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional vividness, and depth.
Derealization
Inability to recall important personal information, often of traumatic or stressful nature.
Dissociative Amnesia
One or more episodes of sudden, unexpected, but purposeful travel from home during which people cannot remember some or all of their past life, including who they are (their identity). When in this state, people disappear from their usual routine and may assume a new identity, forgetting all or some of their usual life. Usually, these states last only hours or days, then resolve on their own.
Dissociative Fugue
Presence of two or more distinct personality states; each alternate personality (alter) has own pattern of perceiving, relating to and thinking about the self and environment.
Dissociative Identity Disorder
Alprazolam, Clonazepam, Diazepam, Lorazepam1) Category 2) Nursing Implications
1) Benzodiazepines2) Tolerance occurs, Short-term relief of severe or panic levels of anxiety
Fluoxetine, Paraxetine, Fluvoxamine, Citalaopram, Escatilopram1) Category2) Nursing Implications
1) SSRIs2) Blocks re-uptake of Serotonin, considered first line treatment. May take 1-3 weeks to be effective; Be aware of Serotonin Syndrome
Clomipramine, Imipramine, Desipramine, Amitriptyline1) Category2) Nursing Implications
1) Tricyclics2) Cardiac Effects, Contraindicated during pregnancy
Propranolol1) Category2) Nursing Implications
1) Beta Blocker2) Reduces Blood Pressure, helps control the physical effects of anxiety
Is used to make up for perceived deficiencies and cover up shortcomings related to these deficiencies to protect the conscious mind from recognizing them.
Compensation
Is the unconscious transformation of anxiety into a physical symptom with no organic cause. Often the symptom functions to gain attention or as an excuse.
Conversion
Involves escaping unpleasant, anxiety-causing thoughts, feelings, wishes, or needs by ignoring their existence.
Denial
Is the transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation.
Displacement
Is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. It may result in a separation between feeling and thought. This can also manifest itself in compartmentalizing uncomfortable or unpleasant aspects of oneself.
Dissociation
Is attributing to oneself the characteristics of another person or group. This may be done consciously or unconsciously.
Identification
Is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing.
Intellectualization
Is the process by which the outside world is incorporated or absorbed into a person's view of the self.
Introjection
Refers to the unconscious rejection of emotionally unacceptable features and attributing them to other people, objects, or situations. You can remember this defense through the childhood retort of "What you say is what you are.
Projection
Consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener.
Rationalization
Is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.
Reaction Formation
Is reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been previously exhibited.
Regression
Is a first-line psychological defense against anxiety. It is the temporary or long-term exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. This happens at an unconscious level.
Repression
Is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Aspects of the self and of others tend to alternate between opposite poles; for example, either good, loving, worthy, and nurturing, or bad, hateful, destructive, rejecting, and worthless.
Splitting
Is an unconscious process of substituting mature, constructive, and socially acceptable activity for immature, destructive, and unacceptable impulses. Often these impulses are sexual or aggressive.
Sublimation
Is the conscious denial of a disturbing situation or feeling. For example, Jessica has been studying for the state board examination for a week solid. She says, "I won't worry about paying my rent until after my exam tomorrow.
Suppression
Is most commonly seen in children. It is when a person makes up for an act or communication.
Undoing
A shorter-than-average man becomes assertively verbal and excels in business. vsAn individual drinks alcohol when self-esteem is low to temporarily diffuse discomfort.
Compensation
A student is unable to take a final examination because of a terrible headache. vsA man becomes blind after seeing his wife flirt with other men.
Conversion
A man reacts to news of the death of a loved one by saying, "No, I don't believe you. The doctor said he was fine." vsA woman whose husband died 3 years earlier still keeps his clothes in the closet and talks about him in the present tense.
Denial
A patient criticizes a nurse after his family fails to visit. vsA child who is unable to acknowledge fear of his father becomes fearful of animals.
Displacement
An art student is able to mentally separate herself from the noisy environment as she becomes absorbed in her work. vsAs the result of an abusive childhood and the need to separate from its realities, a woman finds herself perpetually in a world where she feels disconnected from reality.
Dissociation
An 8-year-old girl dresses up like her teacher and puts together a pretend classroom for her friends. vsA young boy thinks a neighborhood pimp with money and drugs is someone to look up to.
Identification
Despite the fact that a man has lost his farm to a tornado, he analyzes his options and leads his child to safety. vsA man responds to the death of his wife by focusing on the details of day care and operating the household, rather than processing the grief with his children.
Intellectualization
After his wife's death, a man has transient complaints of chest pains and difficulty breathing—the symptoms his wife had before she died. vsA young child whose parents were overcritical and belittling grows up thinking that she is no good. She has taken on her parents' evaluation of her as part of her self-image.
Introjection
A man who is unconsciously attracted to other women teases his wife about flirting. vsA woman who has repressed an attraction toward other women refuses to socialize. She fears another woman will make homosexual advances toward her.
Projection
An employee says, "I didn't get the raise because the boss doesn't like me." vsA man who thinks his son was fathered by another man excuses his malicious treatment of the boy by saying, "He is lazy and disobedient," when that is not the case.
Rationalization
A recovering alcoholic constantly preaches about the evils of drinking. vsA woman who has an unconscious hostility toward her daughter is overprotective and hovers over her to protect her from harm, interfering with her normal growth and development.
Reaction Formation
A 4-year-old boy with a new baby brother starts sucking his thumb and wanting a bottle. vsA man who loses a promotion starts complaining to others, hands in sloppy work, misses appointments, and comes in late for meetings.
Regression
A man forgets his wife's birthday after a marital fight. vsA woman is unable to enjoy sex after having pushed out of awareness a traumatic sexual incident from childhood.
Repression
A toddler views her parents as superhuman and wants to be like them. vsA 26-year-old woman has difficulty maintaining close relationships. Despite the fact that she can initially find many positive qualities about new acquaintances, eventually she becomes disillusioned when they turn out to be flawed.
Splitting
A woman who is angry with her boss writes a short story about a heroic woman. vsThe use of __________ is always constructive.
Sublimation
A businessman who is preparing to make an important speech later in the day is told by his wife that morning that she wants a divorce. Although visibly upset, he puts the incident aside until after his speech, when he can give the matter his total concentration. vsA woman who feels a lump in her breast shortly before leaving for a 3-week vacation puts the information in the back of her mind until after returning from her vacation.
Suppression
After flirting with her male secretary, a woman brings her husband tickets to a concert he wants to see. vsA man with rigid, moralistic beliefs and repressed sexuality is driven to wash his hands to gain composure when around attractive women.
Undoing
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
Generalized Anxiety Disorder
Recurrent unexpected severe anxiety attacks. Characterized by an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.
Panic Disorder (Panic attack being described)
Marked fear or anxiety about two (or more) of the following five situations:A. Using public transportation (e.g., automobiles, buses, trains, ships, planes).B. Being in open spaces (e.g., parking lots, marketplaces, bridges).C. Being in enclosed places (e.g., shops, theaters, cinemas).D. Standing in line or being in a crowd.E. Being outside of the home alone.
Agoraphobia
Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
Specific Phobia
Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.&Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
Obsessive Compulsive Disorder (OCD)
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
Body Dysmorphic Disorder
Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:A. Directly experiencing the traumatic event(s).B. Witnessing, in person, the event(s) as it occurred to others.C. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.D. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
Acute Distress Disorder (Short-Term) PTSD (Long-Term)
Are a type of process or coping that results in automatic psychological responses exhibited as a means of protecting the individual against anxiety
Defense Mechanisms
Person: Suggested that anxiety results from the threatened breakthrough of repressed ideas or emotions, and ego defense mechanisms keep anxiety at manageable levels.
Sigmund Freud
Person: Believed that anxiety is linked to emotional distress caused when early needs go unmet or disapproval is experienced. He also stated that anxiety is "contagious," being transmitted to an infant from mother or caregiver.
Harry Stack Sullivan
Group: Suggest that anxiety is a learned response to specific environmental stimuli.
Behaviorists
Group: Believe anxiety disorders are caused by distortions in an individual's thoughts and perceptions.
Cognitive Theorists
Model of Anxiety: Theories regarding the causes of anxiety disorders, such as the GABA (gamma-aminobutyric acid)-benzodiazepine theory, where GABA slows neural transmission, and the stress response of the hypothalamus-pituitary-adrenal system is abnormal in patients with posttraumatic stress disorder (PTSD).
Neuropsychiatric or Biological Models of Anxiety
Of or relating to the body, especially as distinct from the mind.
Somatic
-Distressing symptoms-Maladaptive response -No significant physical findings and medical diagnosis-Suffering is authentic -High level of functional impairment
Somatic Symptom Disorder
Misinterpretation of physical sensationsOver-concerned for health and preoccupied with symptomsExtreme worry and fear Course of illness chronic and relapsing
Illness Anxiety Disorder
Neurological symptoms in the absence of a neurological diagnosis [Common symptoms—paralysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, or episodes resembling epilepsy]
Conversion Disorder
Artificially, deliberately, and dramatically fabricate symptoms or self-inflict injuryGoal of assuming a sick role
Factitious disorder
Common Nursing Diagnosis for Somatic Disorders
Ineffective Coping
Theory of Why Dissociation Happens: With exposure to __1__, individuals respond with a severe disruption of ___2___.
1) Trauma2) Consciousness
Theory of Why Dissociation Happens: Dissociation is an unconscious __1__ __1___ that protects a person from overwhelming anxiety through an ____2____ separation.
1) Defense Mechanism2) Emotional
Theory of Why Dissociation Happens: The emotional ___1____ results in ___2____ in memory, consciousness, self-identity and perception
1) Separation2) Disturbances
Limbic System Involvement: Animal studies reveal that early prolonged ___1____ from caregivers ___2____ affects limbic system development.
1) Detachment 2) Negatively
__1_____ memories are processes in the limbic system.
Traumatic
3. People who have Dissociative Disorders have increased activation of the __1__, __2__ , and __3__ areas.
1) Amygdala2) Insular cortex3) Hippocampal
Dissociative Identity Disorder: Assessment
Assess ability to identify the self, memory, mood, and suicide risk.
Side Effects Associated with Benzodiazepines
Drowsiness, lack of energy Clumsiness, slow reflexes Slurred speech Confusion and disorientation Depression Dizziness, lightheadedness Impaired thinking and judgment Memory loss, forgetfulness Nausea, stomach upset Blurred or double vision
Adverse Effects Associated with Benzodiazepines
Paradoxical Effects (opposite of SEs)Increasing ToleranceAbuse/AddictionWithdrawal Effects
A persistent difficulty discarding or parting with possessions because of a perceived need to save them
Hoarding Disorder (r/t OCD)
An impulse disorder characterized by the compulsive urge to pull out one's hair, leading to noticeable hair loss and balding, distress, and social or functional impairment.
Trichotillomania (r/t OCD)
An impulse control disorder characterized by the repeated urge to pick at one's own skin, often to the extent that damage is caused.
Excoriation Disorder
___1___ experience anxiety disorders more often than ___2___
1) Women2) Men
Anxiety: Most common condition of __1____.
1) Adolescents
Anxiety: Highly associated with ________
Depression
What is the ACE Study?
ACEs study is one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being.
What were the findings of the ACE Study?
-Adverse childhood experiences were strongly associated with addiction later in life, and higher likelihood of suicide-Childhood abuse was underreported because the brain protects individuals from trauma
More findings of the ACE Study:
2x more likely to be smokers7x more likely to be alcoholics 10x more likely to use street drugs12x more likely to attempt suicide
Selective, bidirectional relationship with another individual
Attachment
Brain Regions Affected By Trauma: (3)
AmygdalaHippocampusPrefrontal Cortex
Linked to emotions and aggression. The ________ functions to control fear responses, the secretion of hormones, arousal and the formation of emotional memories.
Amygdala
Liked to Short-Term ----> Long-term memory transfer, spatial memory (ability to navigate), emotion regulation.
Hippocampus
Involved in planning a person's response to complex and difficult problems. Decision-making area.
Prefrontal Cortex
Traumatic stress is associated with increased __1___ and __2____ responses to subsequent stressors.
1) Cortisol2) Norepinephrine
Principles of Psychological First Aid (PFA)include: (SECCF)
SAFETY - developing/identifying a physically safe environment EFFICACY - maximizing an individual's ability to care for self, family and othersCALMNESS - teaching and encouraging relaxation and calming skills (as wellas maintenance of natural body rhythms such as sleep, food, exercise)CONNECTEDNESS - facilitating links to family and other social supportsFOSTERING Hope and Optimism
Common Self and Worldview after Trauma
• Self: Shame and guilt, low self-esteem • Worldview: Fearful
Polyvagal Theory
The Autonomic nervous system is not limited to fight or flight, but actually consists of fight-flight-freeze.
The vagus nerve sends and receives information via two major vagus nerves, __1__ and __2__ , with two branches, __3__and __4__.
1) Ventral2) Dorsal3) Myelinated4) Unmyelinated
__1__ __1__ vagal responses are activated during pleasant.situations. In this state the __2__ vagal responses are normal.
1) Myelinated ventral vagal2) Ventral
__1__ ___1___ vagal responses are activated when theperson perceives a threat (fight or flight).
Unmyelinated ventral vagal
The third response is the __1___ __1___ response which results inheart and respiratory slowing (freeze).
1) Dorsal vagal
Polyvagal Theory: (Term)Referring to activity of the vagus nerve in relation to heart rate.
Vagal tone
Polyvagal Theory: (Term)Study of evolutionary relationships b/w groups of organisms.
Phylogeny
When is ECT contraindicated?
w/ Increased Intracranial Pressure
Nerve associated with parasympathetic system, specifically r/t to heart and GI tract function.
Vagus Nerve