N104 (Psych) – Intro to Mental Health, Process Recording, Anxiety, Crisis Intervention (Exam 1)

Mental health
– State of well-being in which each individual is able to realize their own potential, cope with the normal stresses of life, work productively and fruitfully and make a contribution to the community
– Provides an individual with the capacity for rational thinking, communication skills, learning, emotional growth, resilience and self-esteem
Mental illness
– Considered to be a clinically significant behavioral or psychological syndrome marked by the individual’s distress, disability or the risk of suffering disability or loss of freedom
– Refers to all mental disorders with definable diagnoses (thinking may be impaired, mood may be affected, behavioral alterations)
Coping
A conscious/unconscious attempt to manage stress and anxiety
Resilience
The ability to not only survive, but bounce back from traumatic experiences
Hildegarde Peplau
– Developed a framework for psychiatric nursing with an emphasis on the nurse -patient relationship
– In 1952, she wrote Interpersonal Relations in Nursing, the first nursing framework for psychiatric nursing practice
DSM
– A multiaxial manual that classifies mental disorders
– The DSM IV-TR focuses on research and clinical observation when constructing diagnostic categories for a discrete mental disorder
– Forces the diagnostician to consider a broad range of information to be made on each of five axes
Axis I (DSM)
– Refers to the collection of clinical manifestations that together constitute a particular disorder
– Includes all adult and child clinical disorders, all mental disorders (EXCEPT mental retardation and personality disorders)
Axis II (DSM)
– Refers to the Personality Disorders and Mental Retardation
– These disorders usually begin in childhood/adolescence and persist in a stable form into adult life
Axis III (DSM)
– Any general medical condition that needs to be taken into account when planning treatment
– Ex: HTN, CAD, hyperthyroidism
Axis IV (DSM)
– For reporting PSYCHOSOCIAL and environmental problems that may affect the diagnosis, treatment and prognosis of a mental disorder
– These include problems related to primary support group, social environment, education, occupation, housing, economics, access to health-care services, interaction with the legal system or crime, and other types of psychosocial and environmental problems
Axis V (DSM)
– called the Global Assessment of Functioning (GAF)
– This gives an indication of the person’s best level of psychological, social and occupational function during the preceding year
– Rated on a scale 1 to 100 where one indicates persistent danger of hurting self or others and 100 as superior functioning
Psychoanalytic Theory (Freud)
– Personality has 3 major components:
1.) Id – ‘Pleasure’ principle
2.) Ego – ‘Reality’ principle
3.) Superego – ‘Perfection’ principle
Topography of the Mind (Freud)
– All mental contents and operations are classified into 3 categories
1.) Conscious – All memories that are in an individual’s awareness
2.) Preconscious – All memories that may have been forgotten /or those memories which are not in present awareness, however with attention, can be readily recalled into consciousness
3.) Unconscious – All memories that an individual is unable to bring to awareness
Freud’s Stages of Personality Development
Birth to 18 months – Oral
– 18 months to 3 years – Anal
– 3 to 6 years – Phallic
– 6 to 12 years – Latency
– 12 to 20 years – Genital
Therapeutic Model
– Psychoanalysis to learn about unconscious thoughts
– Therapy is ‘not directed’ – free association and dream ‘analysis’
Ego Defense Mechanisms
– Strategies by the ego for protection against a threat to biological or psychological integrity, ward off anxiety by preventing conscious awareness of threatening feelings, UNCONSCIOUS level (except suppression)
– Deny, falsify or distort reality to make it less threatening
3 concepts of NPR (Nurse-Patient Relationship)
1.) Transference
2.) Counter-transference
3,) Resistance
Transference
– NPR concept
– A set of feelings and thoughts about significant others in the patient’s life that are transferred to the health care provider
Counter-transference
– NPR concept
– This involves the health care providers reactions to the patient
Resistance
– NPR concept
– All of the phenomena that interferes with and disrupts flow of feelings, memories and thoughts
– This is the patient’s ‘struggle’ against the anxiety associated with change and self -awareness
Erikson’s Psychosocial Theory
– Birth to 1 year: Trust vs Mistrust
– 1 to 3 years: Autonomy vs Shame and Doubt
– 3 to 6 years: Initiative vs Guilt
– 6 to 12 years: Industry vs Inferiority
-12 to 20 years: Identity vs Role Confusion
– 20 to 30 years: Intimacy vs Isolation
– 30 to 65 years: Generativity vs Stagnation
– 65 to death: Ego Integrity vs Despair
Therapeutic Model (Erikson)
– Analysis of the individual’s behavior pattern using Erikson’s framework
– Positive resolution of each stage important in order to move forward developmentally
Psychotherapy
– Based on the development of a trusting relationship between the patient and the health care provider for the purpose of exploring and modifying the patient’s behavior in a positive direction
– Therapy assists the patient to have a ‘positive’ outcome for each developmental stage
Sullivan’s Interpersonal Theory
– Individual behavior and personality development are the direct result of interpersonal relationships
– Development results from interpersonal relationships with others in maximizing satisfaction of needs while minimizing insecurity
Behavioral Theory (Pavlov, Watson)
– ‘Classical Conditioning’ – This is when involuntary behavior or reflexes can be conditioned to respond to neutral stimuli
– ‘Operant Conditioning’ – When voluntary behaviors are learned through consequences of reinforcement, either positive or negative
Therapeutic Model (Pavlov, Watson)
– Model provides a concrete method for modifying or replacing behaviors
– Treatment is concerned with patterns of behavior rather than inner motivations
– Behavior is learned via ‘conditioning’
– Maladaptive responses are replaced with adaptive behaviors
Biofeedback
A technique for gaining conscious control over unconscious body functions to achieve relaxation or the relief of stress -related physical symptoms
Behavior modification
Modify and change specific observable patterns of behavior via stimulus and response conditioning
Beck’s Cognitive Theory
– Cognitive appraisals of events lead to emotional response
– It is not the stimulus itself that causes the response, it is the individual’s evaluation of the stimulus
Therapeutic Model (Beck)
– Emphasizes the revision of a person’s maladaptive thought processes, perceptions and attitudes
– Negative and self -critical thinking causes depression
– Negative thought patterns are replaced with ‘rational’ ones
Humanistic Theory (Rogers, Maslow)
– These theories are concerned with the human potential for development, knowledge attainment, motivation and understanding
– Rogers developed a technique that emphasized the role of the patient in understanding their own problem; the role of the therapist as the facilitator rather than the director
4 elements of successful therapeutic relationships (Rogers)
1.) Reflection: allow idea coming from patient to flow freely
2.) Unconditional Positive Regard: warm and accepting atmosphere
3.) Empathy: ability to understand the patient by acknowledging what they are feeling and experiencing
4.) Authenticity: the ability to be open, genuine and honest in response to the patient
Maslow’s hierarchy of basic human needs
1.) Physiologic: Satisfy hunger, thirst
2.) Safety: Feel safe and secure
3.) Belonging and Love: Feeling of acceptance
4.) Esteem: To achieve, be competent
5.) Cognitive: To know, understand
6.) Aesthetic: To achieve order, beauty
7.) Self -Actualization: To find self -fulfillment and reach one’s potential
8.) Transcendence: To teach others to achieve self -actualization
Therapeutic Model (Maslow)
– Emphasis on human potential and patient’s strengths
– Meet ‘needs’ on lower levels of Maslow’s hierarchy before going on
– Psychotherapy
– Focus on NPR
Psychodynamic Nursing
– Peplau
– The ability to understand one’s own behavior, to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience
Peplau’s 6 nursing roles
1.) Resource person
2.) Counselor
3.) Teacher
4.) Leader
5.) Technical expert
6.) Surrogate
Peplau’s Stages of Personality Development (interpersonal theory)
– Infancy (learning how to count on others)
– Toddler (learning to delay satisfaction)
– Early childhood (identifying oneself)
– Late childhood (developing skills in participation)
Biogenic theories
These theories look at how genetic factors, neuroanatomy, neurophysiology and biologic rhythms relate to the cause, course and prognosis of mental disorders
Cerebrum (60% of brain with 2 cerebral hemispheres divided into 4 lobes)
1.) Frontal lobe: Higher -order thinking, abstract reasoning, decision making, speech and voluntary muscle movement
2.) Parietal lobe: Sensory function and proprioception (body position information)
3.) Occipital lobe: Visual function
4.) Temporal lobe: Judgment, memory, smell, sensory interpretation and understanding sound
Diencephalon (extends from the cerebrum and sits above the brainstem with 3 primary structures)
1.) Thalamus: receives and relays sensory information; plays a role in memory and in regulating mood
2.) Hypothalamus: controls body homeostasis; it regulates the autonomic nervous system, body temperature, appetite, water balance, biologic rhythms and drives as well as hormonal output of the anterior pituitary gland
3.) Limbic system: comprised of the limbic lobe and numerous structures functioning with it; limbic system is responsible for regulating emotional responses
Mesencephalon
– Part of the brain that integrates various reflexes
– Center for respiration and skeletal muscle tone
Pons
– Part of the brain that is the central connection of cranial nerves (V-VIII)
– Center for respiration and skeletal muscle tone
Medulla
– Part of the brain that is the vital center that regulates heart rate, blood pressure, respiration
– Reflex centers for swallowing, sneezing, coughing, and vomiting
– Cranial nerves IX – XII
Cerebeullum
– Involuntary movement
– Ex: muscle tone, coordination, posture, equilibrium
Neurotransmitters
– Chemical messengers of the nervous system that are manufactured in each neuron
– Stored in the axion terminals of the neuron
– An electrical impulse through the neuron stimulates the release of the neurotransmitter into the synaptic cleft – this determines whether another electrical impulse is generated
Reuptake
Process of neurotransmitters being stored for reuse
ACH
– Acetylcholine
– Major neurotransmitter of parasympathetic nervous system
– Controls muscles, memory and coordination, implicated in sleep, arousal, pain
– Changes in ACH levels are implicated with depression, Alzheimer’s, Parkinson’s disease
– Increased ACH (depression), decreased ACH (Alzheimer’s, Parkinson’s)
Dopamine
– Neurotransmitter that is derived from the amino acid, tyrosine
– Involved in regulation of movement and coordination, emotions, voluntary decision-making abilities, has influence on pituitary gland and inhibits release of prolactin
– Increased dopamine (mania and schizophrenia), decreased dopamine (Parkinson’s and depression)
GABA
– Gamma aminobutyric acid
– Inhibitory neurotransmitter
– Interrupts the progression of electrical impulse at the synaptic junction, producing a significant slow down of body activity
– Decreased GABA (anxiety disorders, movement disorders- Huntington’s), some epilepsies, mania)
Norepinephrine
– Catecholamine neutrotransmitter of sympathetic nervous system
– Associated with the fight or flight syndrome that occurs because of stress
– Changes implicated in regulation of modd (depression, bipoloar), anxiety, schizophrenia, cognition and perception, sleep, arousal)
Serotonin (5-HT)
– Derived from the dietary amino acid tryptohpan
– Implicated in sleep and arousal, libido, appetite, anxiety (increased), mood, aggression, and pain perception, depression (decreased)
Therapeutic Milieu
– Therapy focuses on ‘manipulation’ of the environment, physical and social, to effect positive change in the patient
– Therapeutic environment uses people, resources and events in the patient’s immediate environment to: Ensure safety, promote optimal functioning in the activities of daily living, develop or improve interpersonal skills, enhance the capacity to live independently outside the institutional setting
Group therapy
– Group: A gathering of two or more individuals
– Individuals share a common purpose
– Meets over a period of time
– Has face to face interactions
– Achieve an identifiable goal
Types of groups
1.) Task group: Function to solve a problem, make a decision and achieve a specific outcome
2.) Teaching group: Knowledge and information are conveyed to the individuals
3.) Supportive /Therapeutic group: To educate individuals to deal effectively with emotional stress in their lives
Phases of group development
– Phase I: Intial/orientation phase: Leaders and members work together to establish rules, importance of confidentiality and structure of the group
– Phase II: Middle/working phase: cohesiveness has been established, -productive work toward completion of the task, problem solving and decision making occur, differences and conflicts are confronted and resolved
– Phase III: Final/terminiation phase: Termination should be discussed in depth, a sense of loss that precipitates the grief process may be evident
Leadership styles
1.) Autocratic: Leader tries to persuade others that their ideas are superior, lack of input and creativity from members
2.) Democratic: Members are encouraged to participate fully, The group ‘decides’ what should be done – discusses alternatives, makes a selection and proceeds, The leader provides guidance and expertise as needed
3.) Laissez -Faire: This style allows individuals to do as they please – no guidance from the leader
Social relationship
– This is a relationship that is primarily initiated for the purpose of friendship, socialization, enjoyment, or accomplishing a task
– Initiated for the purpose of friendship, socialization, enjoyment or accomplishment of a task
– Mutual needs are met
Intimate relationship
– This occurs between two individuals who have an emotional commitment to each other
– Often a partnership, mutual needs are met and intimate desires and fantasies are shared
– Mutual needs are met
Therapeutic relationship
– This relationship focuses on the patient’s ideas, experiences and feelings
– Inherent in this relationship is the nurse’s focus on the significant personal issues introduced by the PATIENT during the interview
Elements of therapeutic relationship
1.) It is goal directed (Purposeful interactions include: establishing a time, place, and focus of the meeting, planning conditions for terminiation at the beginning of, as well as throughout the relationship)
2.) The roles and responsibilities should be clearly defined (nurse in the professional helper and facilitator, patient’s needs and problems are the focus of the relationship)
3.) Confidentiality (information is ONLY shared with professional staff who need to know, any time patient is going to be a danger to self or others – confidentiality is breached)
4.) Therapeutic behaviors (self-awareness of thoughts, feelings, and behaviors, empathetic listening)
Nurse-Patient Relationship
– Basis for all psychiatric treatment approaches
– Goal in this therapeutic alliance is to facilitate the individual’s growth by helping them address personal issues and concerns in order to handle unresolved problems constructively
Active listening
– Listening attentively and responding appropriately
– By giving the patient your undivided attention, you communicate that they are not alone, that someone is there to help them
SOLER
– S: Sit squarely, facing the patient or off to the side
– O: Observe an open posture, this indicated a willingness to listen
– L: Lean forward, toward the patient
– E: Establish eye contact – it shows that you are paying attention and that you are interested
– R: Relax, help ease tension, this takes the pressure off the patient and enhances open communication
Genuiness
– Demonstrate this via congruency between your verbal and non-verbal behavior
Helps to build trust
– Being genuine does not mean that you disclose personal information – just that you are focused on the patient
Unconditional Positive Respect
– This shows respect and acceptance
– Demonstrate this by: sitting and listening to the patient. validating the patients feelinngs: feelings are not right or wrong, they just are being non judgmental
Empathy
Ability to see things from the patient’s point of view and to communicate this understanding to the patient
Trustworthiness
– Means that you are responsible and dependable
– Ensure confidentiality
– You are consistent in your approach and response to the patient
Phases of a NPR
– Pre-interaction phase: Prepare for first encounter with patient, information gathering, examine own feelings
– Orientation (introductory) phase: create an environment for trust and rapport
– Working phase: therapeutic work of the relationship is accomplished during this phase
– Termination phase: may occur when progress has been made toward attainment of mutually set goals
Boundaries in the NPR
– Favoring one patient over another
– Keeping secrets with a patient
– Changing a style of dress when working with a particular patient
– ‘Swapping’ patient assignments to care for a particular patient
– Spending ‘free’ time with a patient
– Frequently thinking about the patient when away from work
– Sharing personal information or work concern with patient
– Receiving /giving gifts with a patient
– Continued contact after patient’s discharge
Ethics
Study of philosophical beliefs about what is considered right or wrong in a society
Bioethics
More specific term that refers to the ethical questions that arise in healthcare
Ethical dilemma
results when there is a conflict between two or more courses of action, each carrying with them favorable and unfavorable consequences
Restraints and seclusions
– The right from restraint or seclusion except in emergency
– Must have an MD order
– For adults age 18, new order every 4 hours
– For children age 9 to 17, new order every 2 hours
– For child less than age 9, new order every hour
– For adults over age 18, an in -person evaluation must be made within 4 hours
– For individuals under age 17, an in -person evaluation must be made within 2 hours
– Patients in seclusion or restraints need to be observed and assessed every 10 to 15 minutes
Commitment
– Voluntary (201): Patient makes direct application for treatment and may stay as long as deemed necessary, individual may ‘sign out’ of treatment facility at any time, however there is a policy to ‘give’ 72 hours notice, as long as patient is not harmful to self or others, they are discharged
– Involuntary (302): In emergency situations (where individual is dangerous to self or others), for observation and treatment; individual cannot make decisions for themselves, individual cannot take care of basic personal needs (gravely disabled), individual is admitted and must have a ‘hearing’ within 72 hours
Diagnostic evaluation
– Electroencephalogram (Measures brain activity – identifies dysrhythmias or suppression of brain rhythms)
– Computed Tomographic (CT) scan (Measures accuracy of brain structure to identify possible lesions, aneurysms or anatomical differences)
– Magnetic Resonance Imagining (MRI): Measures anatomical and biochemical status of various segments of the brain
– Positron Emission Tomography (PET): Measures specific brain functioning such as glucose metabolism, blood flow, oxygen utilization, neurotransmitter /receptor interaction
– Single Photon Emission Computed Tomography (SPECT): Measures various aspects of brain function as with PET
Psychiatric interview
– Different from therapeutic communication
– Purpose: to establish rapport with the patient, to obtain pertinent patient data which are characteristic patterns of their living and coping behaviors
Mental status exam
– This organizes observational data about all aspects of a patient’s mental functioning
– Useful to help identify acute psychotic features of the patient quickly and for distinguishing functional conditions from organic conditions
– Appearance, behavior, sensorium/intelligence, thought processes
Loose associations
– Rate/flow/speech
– Wide disconnections between thoughts which result in shifting from one topic to another in an incoherent fashion
Flight of ideas
Occurs when the patient moves quickly from one topic to another, however, there are connecting links
Blocking
This is a sudden, unexpected and complete cessation of spontaneous flow of speech
Circumstantially
This is a pattern of speech that is indirect and delayed in reaching the point
Tangentiality
This is a pattern of speech that strays from point to point and does not return
Mutism
The lack of speech even though the patient is aware of the examiner
Perservation
A pattern of repeating the same words or movements despite an effort to make new responses
Hallucination
A sensory perception in the absence of an actual external stimulus
Illusion
False perceptions based partially on external reality
Depersonalization
A feeling of unreality and alienation from oneself
Delusion
A false, fixed idea
Process recording
– Allows conversation to focus on specific issues and feelings the patient may have
– Being therapeutic does not focus on ‘giving advice’ or asking ‘why’ questions
– Learning tool, a verbatim written report of a verbal interaction with a patient, helps improve interpersonal communication techniques
– Major elements: patient’s nonverbal behavior, verbal behavior, nurses’ response/thoughts/feelings, therapeutic technique, analysis of the interaction
Stress
– Body’s arousal response to any demand, change, or perceived threat
– Stressor: external pressure that is brought to bear on the individual (real or perceived)
Anxiety
State of feeling apprehensive, uneasy, sense of uncertainty or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized
Fear
Reaction to a specific danger
Coping
Efforts to manage specific demands that are perceived as threatening
Physiological response stress theory (Hans Selye)
– Fight or flight syndrome, GAS (general adaptation syndrome)
– Has 3 stages: 1.) Alarm reaction phase, 2.) Stage of resistance, 3.) Stage of exhaustion
Alarm reaction phase
– The sympathetic nervous system prepares the body’s physiologic defense for fight or flight by stimulating the adrenal medulla to secrete epinephrine and norepinephrine; the adrenocortical hormones (aldosterone and cortisol) are secreted
– Increased HR, peripheral blood vessels constrict, bronchodilation, pupil dilation, liver releases glucose, PT time is shortened, sodium retained
Stage of resistance
– Few overt physical symptoms that occur in this stage compared to alarm stage
– Increased section of cortisone
– If adaptation does not occur, individual may move to stage of exhaustion
Stage of exhaustion
– All energy for adaptation has been expended
– Body no longer produce hormones as in alarm stage, organ damage begins
– In this stage, pt. usually becomes ill and may die if assistance from outside sources is not available
– Can be reversed by external sources of adaptive energy, such as medication, blood products or psychotherapy
Mild anxiety
– Increases motivation and alertness, sharpens the senses
– Increased hearing and increased assessment promotes learning and the ability to function
– Learning is enhanced
Moderate anxiety
– Perceptual field decreases
– Focus is on selected aspects of self and illness
– Attention span decreases
– Individual needs help with problem solving
Severe anxiety
– Can focus only on a single detail, disturbances in thought patterns
– Severely limited attention span
– Physical symptoms common
– Behavior aimed at relief of anxiety
Panic anxiety
– Distorted perceptions of environment; may have delusions or hallucinations
– Unable to focus on even one detail
– Unpredictable responses
– Random motor activity
Relief behaviors (anxiety)
1.) Interpersonal (involving 2 people: acting-out behaviors, somatizing, freezing to the spot, learning/problem solving)
2.) Intrapersonal (ego defense mechanisms)
Ego defense mechanisms
– Used by everyone to RELIEVE anxiety, protect the ego and PROTECT self-esteem
– These “ward” off anxiety by preventing conscious awareness of threatening feelings
– Operate on UNCONSCIOUS level (EXCEPT suppression)
– They deny, falsify, or distort reality to make it less threatening
– Adaptive: use of these to help lower anxiety
– Maladaptive: use of these can lead to distortion in reality and self-deception
Anxiety etiology
– Biologic theory: Increased levels of norepinephrine, decreased levels of serotonin, decreased levels of GABA (most significant offender in anxiety disorders), fight/flight responds excessively
– Genetic theory: 50-70% familial tendency
– Behavioral theory: learned
– Cognitive theory: pts. do not perceive the threat accurately and under-estimate their ability to cope
– Interpersonal theory: Emotional distress caused when early needs were unmet, anxiety is transmitted to infant from caregiver
Panic disorder
– Type of anxiety disorder
– Recurrent unexpected panic ‘attacks’
– Sudden onset of extreme apprehension/fear, usually associated with feelings of impending doom
– Normal function is suspended
– 2 types: Panic Disorder with Agoraphobia or Panic Disorder without Agoraphobia
Panic disorder clinical manifestations
– Attacks are accompanied with: palpitations, chest pain, nausea, breathing difficulties, feelings of choking, chills/hot flashes
– Occur intermittently, suddenly and not necessarily provoked by stress
– Attacks are extremely intense, last a matter of minutes, then subside, last 5 to 30 minutes
Phobias
– Type of anxiety disorder
– An irrational fear of an object or situation that persists although the person may recognize it as unreasonable
– Types: Agoraphobia, social phobia (excessive fear of situations in which person might do something embarassing, be looked at negatively, etc.), specific phobia
Agoraphobia
– Individual experiences a fear of being in places or in situations which escape might be difficult
– Pts avoid situations that might cause them panic
Obsessive-compulsive disorder
– Type of anxiety disorder
– Obsessions: thoughts, impulses or images that persist and recur, so that they cannot be dismissed from the mind
– Compulsions: ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety, these acts temporarily reduce anxiety
GAD
– Generalized anxiety disorder
– Excessive anxiety or worry about a number of issues
– Physical manifestations due to catecholamine’s being released include: chronic muscle fatigue, restlessness, trembling, chronic fatigue, vigilance
PTSD
– Post traumatic stress disorder
– Type of anxiety disorder
– Characterized by a repeated re- experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others, to which the individual responded with intense fear, helplessness or horror
3 major features of PTSD
1.) Re-experiencing trauma through dreams and waking thoughts (flashbacks are dissociative experiences during which the event is re-lived and the individual behaves as though experiencing the event at that time)
2.) Emotional numbing to other life events and relationships as evidenced by: feeling detached or estranged from others, feeling ’empty’ inside, feeling ‘turned off’ to others
3.) Symptoms of depression, poor concentration and other cognitive difficulties
Anxiety disorders assessment
– Complete physical assessment to rule out organic basis for anxiety
– Assess ability to develop satisfying relationships
– Psychological assessment
Anxiety disorders planning
– Involve patient
– Mild to moderate anxiety: assist with mutual goal setting
– Severe/panic anxiety: relieve immediate distress, stay with patient
– Feelings about the event are more important that the details of the event
Therapeutic modalities (anxiety)
1.) Psychotherapy
2.) Cognitive Restructuring
3.) Behavioral Techniques
4.) Relaxation Techniques
5.) Regular Physical exercises
6.) Modeling
7.) Pharmacology
Benzodiazepines
– Most commonly used antianxiety meds
– Anxiety disorders, acute alcohol withdrawal, skeletal disorders, insomnia, pre-operative sedation
– Should be discontinued gradually, should not be used for long-term use
– Should not be used concurrently with CNS depressants, alcohol, OTC meds
Benzodiazepines action and side effects
– Bind to GABA receptors and intensify the effect of GABA
– Drowsiness, lethargy, ataxia, confusion, blurred vision; paradoxical CNS stimulation, reduce REM sleep, orthostatic hypotension, bradycardia, syncope, respiratory depression, nausea, vomiting, diarrhea, hepatotoxicity
Benzodiazepines examples
– lorazepam (Ativan), clonazepam (Klonopin), chlordiazepoxide (Librium), oxazepam (Serax), diazepam (Valium), midazolam (Versed), alprazolam (Xanax)
– insomnia benzos: flurazepam (Dalmane), temazepam (Restoril), triazolam (Halicon)
– antihistamine benzos: atarax (hydroxyzine hydrochloride)
Symptoms of withdrawal
Difficulty concentrating, fatigue, insomnia, irritability, muscle aches, sweating, tremors, seizures
Antidote for benzo overdose
– Flumazenil (Romaxicon)
– Benzodiazepine antagonist (receptive blocker)
– Reverse the sedative effects of the benzos – but not reverse the respiratory depression
Non-benzodiazepine anxiolytics
– Buspar (Busprone)
– Reduces anxiety without having strong sedative -hypnotic properties, not a CNS depressant
– It is less likely to affect cognitive and motor performance
– It binds to serotonin and dopamine receptors in the brain
– It increases norepinephrine metabolism in the brain
– It is indicated for the management of anxiety
– Almost NO abuse potential
– Initial effects are experienced in 2-3 weeks, full effect 4-6 weeks
Misc agents used for anxiety disorders
– Antidepressants (tricyclics, SSRIs)
– Antihypertensives (beta blockers, propanolol-Inderal)
Barbituates
– Potent CNS depressant
– Produces all levels of CNS depression
– Inhibit transmission in the nervous system and increases the seizure threshold
– Therapeutic use: anticonvulsant activity and sedation
– Ex: butalbital compound (with acetaminophen and caffeine), phenobarbital (luminal), sodium pentathol, seconal
Somatoform disorders
– Presence of physical symptoms which suggest a general medical condition, but NO organic evidence of medical disorder
– Individuals can’t control the manifestations voluntarily and are not intentionally produced
– THESE DISORDERS CONVERT ANXIETY INTO PHYSICAL COMPLAINTS
Somatoform disorders etiology
– Implicated in serotonin and endorphin deficiency
– Faulty perception/incorrect assessment of body sensations
– May cause pt. to misperceive incoming stimuli
Somatization disorders
– Type of somatoform disorder
– Recurrent and multiple somatic complaints
– Manifestations are generally vague, impairment in social, occupational, and other areas of functioning
– Individual is self-absorbed; little concern for others
Hypochondriasis
– Type of somatoform disorder
– The non-delusional pre-occupation or fear of having a serious disease /illness
– Based on the individual’s mis-interpretation of bodily manifestations even though medical intervention and reassurance has been obtained
– Individuals see normal changes as life-threatening and real
– Ex: Bad headache must be a brain tumor
Pain disorder
– Type of somatoform disorder
– Predominant feature of this is pain in one or more anatomical sites
– Deserves clinical attention
– Impairs social or occupational functional
Body dysmorphic disorder
– Type of somatoform disorder
– Pre-occupation with an imagined defect in appearance in a normal appearing person
– Issue is not of body image, as much as it is a sense of self
Conversion disorder
– Type of somatoform disorder
– Presence of one or more manifestations that suggest the presence of a neurologic disorder
– This neurologic disorder cannot be explained by a known neurological or medical disorder or is a culturally bound symptom
– Despite the severity of the clinical manifestations, the individual usually displays a lack of concern called ‘LaBelle Indifference’
Dissociative disorder
Disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment
Depersonalization disorder
– Type of dissociative disorder
– Persistent or recurrent alteration in the perception of the self, to the extent that the sense of one’s own reality is temporarily lost; reality testing remains intact
– ‘Detached’ from their body, some experience derealization
Dissociative amnesia
– Type of dissociative disorder
– Inability to recall important personal information
– Onset is sudden, result of psychologically traumatic nature
– Localized amnesia: inability to recall all incidents associated with a traumatic event (few hours-days)
– Selective amnesia: inability to recall certain incidents associated with a traumatic event for a specified period of time
– Continuous amnesia: inability to recall events occurring after a specified time up to and including the present; individual cannot form new memories although they are alert and oriented
– Generalized amnesia: inability to recall anything that has happened in the past
– Systematized amnesia: inability to recall events which relate to a specific ‘category’ of information i.e. a particular person or event
Dissociative fugue
– Sudden, unexplained travel away from home or workplace accompanied by inability to remember one’s past, confusion about personal identity or the assumption of a new identity
– Natural disaster
Dissociative identity disorder
– Presence of two or more distinct personality states or identities
– The personality states take control of the person’s behavior
– ‘Core’ is the original person, the others are called ‘alters’
– Each personality state is experienced as if it has a distinct personal history self -image and identity
– Each alter has an intact ego
Dissociative identity disorder development
1.) Child has a terrifying event at a time when defenses are inadequate to handle the intense anxiety
2.) Child dissociates the event and the feelings associated with the event
3.) The dissociated part of the personality takes on an existence of its own becoming a ‘sub -personality’ or an ‘alter’
4.) The alter learns to ‘deal’ with feelings and emotions that would overwhelm the primary personality
Dissociative identity disorder signs
1.) Individual states that they have ‘spells’
2.) Individual ‘loses’ time’
3.) Memory ‘gaps’
4.) Physiologic changes may occur
5.) Generally, core is not aware of the alters
6.) Alters are generally aware of the core
7.) Alters are generally aware of the existence of each other – to some degree
DID therapeutic modalities
1.) Somatic therapies (anxiolytyics/antidepressants)
2.) Psychotherapy
3.) Behavior therapy
4.) Cognitive re-structuring
5.) Family therapy
6.) Hypnotherapy
7.) Narcotherapy
8.) In-patient treatment
Crisis
– A sudden event in one’s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem
– Problem solving skills decrease by level of anxiety and disequilibrium
Phases of crisis development
– Phase 1 – Individual exposed to precipitating stressor & uses previous problem-solving techniques
– Phase 2 – Anxiety increases when techniques don’t work
– Phase 3 – All internal & external resources rallied
– Phase 4 – Major tension & disorganization; possible breaking point
Classes of crises
1. Dispositional Crises
2. Crises of Anticipated Life Transitions
3. Crises Resulting from Traumatic Stress
4. Maturational / Developmental Crises
5. Crises Reflecting Psychopathology
6. Psychiatric Emergencies
Goals of crisis intervention
– Minimum therapeutic goal: psychological resolution of the individual’s immediate crisis and restoration to at least the level of functioning that existed before the crisis period
– Maximum goal: improvement in functioning above the pre-crisis level
Anger vs. aggression
– Difference between the two is intent
– Aggression refers to behavior that is INTENDED to inflict harm/destruction
Seclusion
Physical restraint whereby pt. is confined alone in a room from which he/she is unable to leave
Restraints
– Most restrictive form of care
– Any device or hold that restricts movement and mobility of patient against his/her will
Types of restraints
1.) Soft restraints: frequently used with elderly patients, often found in use on acute hospital floors
2.) Side rails
3.) Wheelchair seat belts
4.) Geri chair
5.) Posey vest restraint
6.) Mitt
7.) Body net
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