NR320: Mental Health: Exam 2 / NR 320 Exam 2 Study Guide: Mental Health: Chamberlain College of Nursing

NR320: Mental Health: Exam 2 / NR 320 Exam 2 Study Guide: Mental Health Chapter 26: Psychotic Disorders • Psychosis: serious psychiatric disorder in which there is gross disorganization of the personality, a marked disturbance in reality testing and impairment of interpersonal functioning and relationship to the external world o It severely impairs the lives of the individual, their families and the community at large o Types of Psychosis:  1st type Dx: childhood – very rare  2nd type Dx: psychotic break/event: often happens late teens/early 20s – first year of college  3rd type Dx: up to age 50 – one day they hear a voice • Subtypes of Psychosis: o Psychosis is a term used for a group of related disorders:  Schizophreniform Disorder: same s/s but lasts 1-6 months if it lasts longer than that then it is changed to schizophrenia  Can happen from blunt trauma  Schizoaffective Disorder: schizophrenic behaviors but with a strong element of mood disorders either depression or mania  Most often depression  Substance Abuse Psychosis: induced and directly r/t substances  The Schizophrenias: 5 subtypes • Theories o Genetics: inherited sometimes skips generations o Neurobiological factors: norepinephrine, serotonin, GABA, abnormalities that are biologically based  Brain chemistry, brain activity different in a person with schizophrenia o Neuroanatomical factors:  Brain-imaging techniques validate differences in structure of brain  Lower brain volume  Atrophy in frontal lobe • Schizophrenia:a psychotic disorder in which the individual experiences such phenomena as delusions, hallucinations, disorganized speech or behavior o Chronic condition o Treatable but not curable • 5 Types of Schizophrenia o Schizophrenia: Paranoid  Person is intensely suspicious toward others  Guarded, tense and/or aloof  Paranoid ideas cannot be corrected by experiences, facts or reality  Defense mechanisms used is to disparage others, projection or hostility  Ideas of references: misinterprets messages of others or gives a private meaning to the message o Schizophrenia: Catatonic  Rare  Essential feature: abnormal motor behavior  Catatonic Excitement: extreme agitation  S/S eyes glazed over, disengaged, dull yet agitated  Catatonic Stupor: extreme psychomotor retardation, experiences such an anxiety that they become so disconnected that brain & body literally becomes disconnected, not responding at all (even if falling)  S/S not perceiving anything outside self at all  Other Behaviors:  Posturing: holding arms/legs rigid for long periods  Waxy flexibility: when placed in awkward position, holds position for long time (like a barbie doll)  Echolalia: repetition of words of another person (imitating words)  Echopraxia: mimicking movement of another person (not on purpose) o Schizophrenia: Disorganized  Often not helped or recognized  Most regressed and socially impaired of all types  Large numbers of homeless population  Characterized by:  Looseness of associations  Bizarre mannerisms  Incoherent speech  Fragmented and poorly organized hallucinations/delusions  Frequent giggling or grimacing in response to internal stimuli o Schizophrenia: Undifferentiated and Residual  Undifferentiated (NOS = not otherwise specified)  Active signs of disorder present, but individual does not meet criteria for other types o Schizophrenia: Residual  Active-phase symptoms no longer present, evidence of residual symptoms: lack of initiative, social withdrawal, inability to work/study, vague speech, magical thinking • Course of Disease: Schizophrenia o Prodromal Stage: s/s that precede that acute fully manifested s/s  Social w/d, deterioration in fx, perceptual disturbances, magical thinking, depressive mood & peculiar behavior  Can occur up to 2 years prior to the psychotic break  Often missed or dismissed for acting out o Active Stage: psychotic symptoms are prominent  Positive symptoms (flagrant): delusions, hallucinations, disorganized speech, disorganized behaviors  Negative symptoms (subtle): less intensity of emotional expression or flat affect, isolative, anhedonia (lack of feeling pleasure)  Distorted cognitive symptoms o Maintenance Stage:  Acute symptoms decrease in severity, especially positive symptoms but do not go away altogether  Symptoms are in remission • Common Symptoms of Schizophrenia: Positive Symptoms (flagrant) o Delusions: false, fixed beliefs that cannot be corrected by reasoning  persecutory, grandiose, somatic, control, religious, paranoid, and/or magical o Hallucinations: sensory perceptions for which no external stimulus exists  auditory, visual, tactile, gustatory (taste), olfactory o Psychotic Components  Associative looseness: thinking is haphazard, illogical and confused  Neologisms: made-up words that have a symbolic meaning to the individual  Clang association: meaningless rhyming or words. Rhyming is more important than the words  Word Salad: jumble of words together making no sense o Positive symptoms are highly responsive to medications  1st generation meds: Haldol (great a muffling positive symptoms, not so good with negative symptoms)  2nd generation meds: help with negative symptoms • Common Symptoms of Schizophrenia: Negative Symptoms (subtle) o Not as responsive to medication therapy o Affect motivation and more dangerous than the positive symptoms o Impaired desire to initiate activity o Symptoms may include:  Flat affect: no emotional displayed  Inappropriate affect: emotional response incongruent to situation  Blunted affect: minimal emotional response  Bizarre affect: grimacing, giggling, mumbling  Apathy: impassivity, suppression of emotions  Anhedonia: lack of feeling pleasure in anything in life o Poor social functioning o Symptoms interfere with functioning o Abnormal cognitive impairment - difficulty with attention, memory and execution function • Assessment Guidelines o Review medical workup to rule out medical cause and use of abusive substances o Assess for command hallucinations (voices telling patient to harm self or others) o Determine pts belief system (delusions, paranoid beliefs) • Communication Guidelines o Dealing with Hallucinations &Delusions  Approach pt in nonthreatening and nonjudgmental manner  Identify feelings pt is experiencing  Clarify reality of pts experience  Avoid arguing/attempt to reason with pt who is delusional  Distract pts attention from hallucination/delusional belief o Compassion & Empathy  Be honest and consistent  Avoid talking, laughing, whispering when pt cannot hear what is being said  Talking about pts feelings is helpful - talking about the delusion is not • Treatment for Schizophrenia o Milieu Therapy o Structured routine o Group therapy o Supervised activities o Individual counseling o Psychotherapy o Family Therapy o CBT o Psychopharmacology • Treatment for Schizophrenia: Antipsychotic Medications o Used to alleviate symptoms, not curative  When pts discontinue medications, psychotic symptoms/relapse occurs  Each relapse leads to longer recovery time and possibility that pt will become unresponsive to medications o Types of Antipsychotic Medications  Conventional (1st generation): target the positive symptoms  Atypical (2nd generation): diminish some negative symptoms • Book Resources: Chapter 26 (psychotic disorders) PG 522: Medical Conditions That May Cause Psychotic Symptoms PG 523: Substances That May Cause Psychotic Disorders PG 524: Positive and Negative Symptoms PG 528: Nursing Dx Chapter 29: Anxiety & Anxiety Disorders • Anxiety & Fear o Fear: reaction to specific danger – an acute response that goes away when the stressor is removed o Anxiety: feeling of apprehension, uneasiness, uncertainty, or dread whose actual source is unknown or unrecognized  Deeper experience as the apprehension stays in response to feeling…. • Levels of Anxiety o Mild  Prepares an individual for action:  Sharpens senses  Increases motivation for productivity  Increases perceptual field  Results in heightened awareness  Learning is enhanced and problem solving becomes more effective  Manifested by restlessness, irritability, tension relieving behaviors: biting nails  PG 17-19: Anxiety Levels and Characteristics o Moderate  Perceptual field narrows, less alert to events occurring in the environment  Ability to concentrate decreases which hinders productivity  Learning can still take place but is hampered  Manifested by:  Increased heart rate  Perspiration  Mild somatic symptoms  Greatly helped by the supportive presence of another o Severe  Greatly reduced perceptual field – attention span is extremely limited  Learning and problem solving not possible  Manifested by:  Erratic, uncoordinated and impulsive behavior  Physical Symptoms:  Pounding heart, sweating, headaches, insomnia, confusion  Many somatic complaints including hyperventilation and sense of impending doom o Panic  Not able to process anything and may lose touch with reality  Markedly disturbed behavior occurs – may have hallucinations or delusions  Manifested by:  Confusion, shouting, screaming, withdrawal, feeling of terror  Physical behaviors may be erratic and impulsive • Defense Mechanisms o Help protect people from painful awareness of feelings and memories that can cause overwhelming anxiety o **PG 19-22: Ego Defense Mechanisms** o Healthy  Altruism: meeting the needs of others which gives self-gratification  Sublimation: rechanneling of drives or impulses that are unacceptable into activities that are more tolerable or constructive  Humor: supports positive feelings in self and others  Suppression: conscious denial or a stressor until it can be better dealt with o Intermediate  Repression: exclusion of unpleasant ideas, emotions or unwanted experiences from awareness – blocking it out  Displacement: transfer of emotions from one target to another that is considered less threatening or neutral - EX) boss yells at you, you go home and start a fight with your spouse  Reaction Formation: prevention of unacceptable thoughts or behaviors from being expressed by exaggerating opposite thoughts or behaviors - EX) soldier who is a coward  Undoing: exhibiting a behavior that symbolically undoes a previous action or experience that one finds intolerable - EX) man has fight with his wife and buys her flowers to make u  Rationalization: justifying illogical or unreasonable feelings or behaviors essentially self-deception - EX) making excuses  Somatization: physical symptoms of anxiety with no organic cause - EX) headaches  Regression: reverting to an earlier level of development and the comfort measures associated with it such as crying or sucking thumb o Immature  Passive aggressive: indirectly or unassertively expressing aggression toward others, sabotaging  Acting-out behaviors: physical aggression toward self or others  Dissociation: going inside oneself or disengaging from reality - EX) multiple personalities  Devaluation: minimizing other’s efforts making themselves look good - EX) bully  Idealization: overvaluing someone else which sets them up for failure  Projection: transferring personal undesirable feelings onto someone else – scapegoating, passing the blame - EX) person values punctuality is late and blames her secretary for not reminding her  Denial: refusal to acknowledge the existence of a problem or the feelings associated with it - EX) abuse or rape victims • Theories o Anxiety disorders are the most common of all psychiatric illnesses and result in undesirable functional impairment and distress o Learning & Behavioral Theory  It is believed that anxiety is a learned response from modeling from parents and/or models o Biological Theory  Differences in the brain of those with anxiety and those who don’t  GABA not producing • Panic Disorders o Panic Attack: a sudden overwhelming feeling of terror or impending doom  Onset is unpredictable and can include physical symptoms: palpitations, sweating, chest pain, nausea  GABA not being produced by amygdala - SLEEPING  Fear of losing one’s mind or having a heart attack  Agoraphobia: fear of being in places or situations in which escape is difficult in the event that a panic attack should occur o Panic Disorder: characterized by the recurrent panic attacks and agoraphobia • Phobias: persistent, irrational fear of specific objects, activities or situations o Types of Phobias:  Specific: response to specific objects – animals, natural environments like public transportation, tunnels, elevators  Social: result of exposure to social situations or required performance where person might do something embarrassing or be evaluated negatively by others • Obsessive-Compulsive Disorder o Obsession: recurrent unwanted thoughts that are severe enough to be time consuming or cause marked distress or significant impairment o Compulsion: unwanted repetitive behavior patterns such as counting, washing hands that are intended to reduce anxiety and alleviate obsessive thoughts • Generalized Anxiety Disorder (GAD) o Characterized by unrealistic and excessive anxiety and worry o Common Symptoms with GAD:  Restlessness  Fatigue  Poor concentration  Irritability  Tension and sleep disturbances o Worry is out of proportion with the true effect of the events or situation o The symptoms must have occurred more days than not for at least 6 months o Causes significant impairment in functioning • Posttraumatic Stress Disorder (PTSD) o Development of symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity of self and/or others o Re-experiencing highly traumatic event o Characterized by:  Recurrent nightmares or flashbacks  Feeling of dread or doom  Numbing of responsiveness (feeling empty)  Persistent symptoms of increased arousal  Irritability, difficulty sleeping/concentrating, exaggerated startle response, hyper vigilance, avoidance • Nursing Process and Treatment o Treatment:  Individual Psychotherapy  CBT  Desensitization Therapy (phobias)  Psychopharmacology (anti-anxiety drugs) • Book Resources: Chapter 29 (anxiety) PG 638: Diagnostic Criteria for Agoraphobia PG 639: Diagnostic Criteria for Social Phobia PG 641: Diagnostic Criteria for Specific Phobia PG 643: Diagnostic Criteria for OCD PG 646: Diagnostic Criteria PG 650-651: Nursing Dx Chapter 24: Cognitive Disorders • Definitions Cognition: mental operations that relate to logic, awareness, intellect, memory language and reasoning powers Cognitive disorder: significant deficit in cognition or memory representing a change from a previous level of functioning • Cognitive Disorders Classified in DSM-IV-TR o Delirium o Dementia o Amnestic disorder o Cognitive disorder not otherwise specified (NOS) • Delirium: disturbance of consciousness and a change in cognition that develops over a short period of time o Acute – lasts only a short time (time limited) o Symptoms of Delirium:  Disturbances in attention span  Easily distractible  Disorganized thinking  Rambling, incoherent speech  Impaired reasoning ability  Disorientation to time, place and person o Characteristics of Delirium:  Delirium always exists secondary to another medical condition or substance use  When treated complete recovery should occur  Occurs more often in older adults which may be r/t medication changes  Causes:  Surgery  Drugs  UTI  Pneumonia  cerebral-vascular disease  congestive heart failure  Safety issues become a priority b/c the pt may misperceive the environment with hallucinations or illusions  Medical monitoring also is priority as the pt may have a physiologic response  Communication Guidelines:  Keep distractions to minimum  Always identify self  Speak slowly, with short, simple words/phrases  Reinforce reality when pt is delusional or having illusions  Use reality orientation tools: large clocks, calendars, well-lit room, family pictures • Amnesia o Amnestic disorders: inability to retain or recall past experiences despite normal attention span & full alertness  Characterized by loss of both short term and long term memory  Differs from dementia as there is no impairment in abstract thinking or judgment  Amnestic disorders are always secondary to underlying causes such as medical conditions or substance abuse o Dementia: progressive deterioration in intellectual functioning, judgment, memory, ability to problem solve, and learning new skills despite being in a state of full alertness  Usually irreversible  Two kinds of Dementia:  Primary dementia is the sign itself that there is organic brain disease such as Alzheimer’s disease  Secondary dementia is r/t another disease such as HIV  Symptoms of Dementia:  Impairment of abstract thinking, judgment and impulse control  Agnosia: loss of sensory ability to recognize objects  Aphasia: loss of language ability  Apraxia: loss of purposeful movement  Short term memory loss then long term  Disturbances in executive functioning  Social skills change  Personality changes  Defense Behaviors: Dementia  Defensive behaviors in early dementia  Denial: attempt to hide memory deficits  Confabulation: making up of stories to preserve self-esteem when person doesn’t remember  Avoidance of questions • Alzheimer’s Disease o The most common type of dementia o Brain damage begins long before symptoms appear o Average life span after diagnosis is about 10 years o Early: onset AD is rare, seems to be inherited and occurs prior to age 65 o Late: onset AD does not seem to have any obvious inheritance pattern and occurs after age 65 • Theory for Alzheimer’s Disease o Etiology: acetylcholine alterations o Genetics • Diagnosis of Alzheimer’s Disease o Important to rule out other causations:  Depression  Neurological  Medical problems  Effect of medications  Nutritional deficits  Fluid and electrolyte imbalances o No definitive test for AD o Studies such as PET and MRI can diagnose cerebral atrophy o Mental status questionnaires (mini-mental status exam) increase early detection • Stages of Alzheimer’s Disease o Stage 1: mild  Characterized by short-term memory loss, forgetfulness, awareness of problem, depression, difficulty of learning o Stage 2: moderate  Progressive memory loss, declines in instrumental activities of daily living, social w/d from social activities, confabulation, lability (unpredictable moods) o Stage 3: moderate to severe  Loss of ADLs, difficulty communicating, wandering, sundowning, institutional care usually needed o Stage 4: end stage  Family recognition disappears  Forgets how to eat, swallow and chew  Mobility problems  Institutional care needed  Death can occur from infection or choking • Treatment: Alzheimer’s Disease o No one definitive treatment or cure o Focus on making experience less traumatic for the individual through:  Safety measures  Cognitive stimulation  Psychopharmacology  Validation therapy  Reminiscence therapy  Medication therapy • Book Resources: Chapter 24 (cognitive disorders) PG 430: Factors that may cause delirium and/or dementia PG 432-434: Mental Status Exam for Dementia PG 436: Nursing Dx Chapter 36: Abuse, Neglect and Rape • Abuse: an act of misuse, deceit or exploitation, wrong or improper use of or action toward another resulting in injury, damage, maltreatment or corruption - The maltreatment of one person by another • Theories r/t Abuse o Societal &Cultural Factors that seem to exist when family abuse is high:  Poverty or unemployment  Low tolerance for frustration  View of women in some subcultures as “property” o Learned Theory – Role Modeling:  Proposes that a child who watches abuse or is abused learns that violence is the acceptable reaction to stress o Other Theories:  Biochemical: dopamine, serotonin, limbic system, norepinephrine differences suggest disorder for aggression  Genetics: runs in families may skip generations o Psychological Factors:  Substance abuse  Low self-esteem: will “choose” victims  Will usually abuse someone who is vulnerable to him/her  Will not hit bosses or authority  History of impulsive behavior: usually immature  Self-centered, lacks compassion for others • Characteristics of the Victim o Battered partner:  Usually have low self-esteem  Often accept blame for abuser’s actions  Are often cut off from support systems  Live in terror of next abusive event  Feelings of powerlessness  Become afraid not only for self but also children  Common for social isolation to occur • Characteristics of the Batterer o Batterer  Violence is a learned behavior  Low self-esteem, poor impulse control, and limited tolerance for frustration as well as lack of control  Lack of guilt and unconcern about behavior  Extremely possessive, pathologically jealous, believe in male supremacy  Strives to keep the victim dependent on the individual • Cycle of Violence o Tension-building phase  Abuser becomes edgy, verbally abusive  Victim feels tense, afraid, like “walking on eggs” o Serious battering phase  Abuser becomes unbearable; violence occurs  Victim may try to cover up the injury or may look for help o Honeymoon phase  Abuser displays loving behavior, makes promise to change  Victim becomes trusting, hoping for change • Child Abuse o A crime that involves both physical and long lasting emotional ramification o High number of perpetrators that have suffered abuse as children themselves o Usually manifested as physical, emotional, sexual or neglect o Nursing Process: Planning & Implementation  Planning  When child abuse is suspected, nurse is legally responsible for reporting to appropriate child protective agencyMandated reporter • Intimate Partner Violence (IPV) o An abusive relationship is about instilling fear and wanting to have power and control in relationship o Anger is one way to achieve control o Usually exhibited as physical, sexual or psychological violence o Age 17 and up o Consequences of Intimate Partner Violence  IPV has severe, long reaching effects  Children become vulnerable to feelings of responsibility, guilt, emotional distress, behavioral regression, somatic complaints, post-traumatic disorders, substance abuse  Children from violent homes most likely will model this behavior  Partners tend to seek out same type of relationships o Assessment Guidelines:  Questions to Ask  Have you been hit, kicked, punched or otherwise hurt by someone within the past year? If so, who?  Do you feel safe in your current relationship?  Are your children being hurt by anyone?  Nursing Process: Planning & Implementation  Planning: Ensure that victim has a basic safety plan, including how to get out of the house, movement to safe location, bags packed with necessities, code word to use for help  Implementation: Ensure patient receives medical treatment, is interviewed in private, and understands legal rights • Elder Abuse o Abuser is often a relative who is in the caretaker role and experiencing exhaustion, substance abuse, economic stress or themselves a victim of family abuse o Usually exhibited as physical, emotional, sexual, financial and neglect o Assessment Guidelines  Determine if elder:  Fears being alone with caregiver  Have signs of obvious malnutrition  Have bedsores or skin lesions  Is in need of medical/dental care  Reports abuse or neglect  Behaves in passive, withdrawn or emotionless manner o Response to Interventions  The elderly population may resist intervention to their abuse due to:  Fear of retaliation  Embarrassment  Protection of the perpetrator  Unwillingness to take legal action o Guidelines for Intervention for Elder Abuse  Check state law regarding elder abuse – state mandated reporting  Involve adult protective services  Meet with other family members and others to identify stressors  If no family members, notify other community agencies that may help abuser and elder  Encourage abuser’s use of counseling  Often under reported and treatment resistance • Concept of Sexual Assault and Battery o Sexual assault: not a sexual act but an act of violence, it involves a desire to humiliate, defile & dominate victim  Results in devastating, severe, and long-term trauma  Encompasses crimes of rape, date rape, acquaintance rape, marital rape, intimate partner violence, molestation or incest, and sexual assault of older adults o Legal definitions of sexual assault vary among states o In general, sexual assault includes use of force or any nonconsensual contact involving breasts, genitals, or anus with or without penetration o Sexual Assault – Victim  Occurs with all age groups, genders, cultures and socioeconomic backgrounds  “Wrong place wrong time”  They all experience powerlessness and sense of violation o Sexual Assault: Perpetrator  Biological factors:  Alterations in limbic system, neurotransmitters and temporal lobe that suggest aggression disorder  Psychosocial factors:  History of being sexually assaulted as child  Impulsive and hostile toward women  Association with sexually aggressive peers  Childhood as “mother dominated” o Assessment Guidelines  Sexual Assault Nurse Examiner (SANE)  Use direct but compassionate questions like “has anyone forced you into sex that you did not want to participate in?”  Use institutional protocol for evidence collection (rape kits)  Consent forms are essential (right to refuse treatment)  Diagnosis &Outcomes Identification  Nursing Dx: Rape-trauma syndrome: is a variant of PTSD  Acute phase: shock, numbness, disbelief, confusion, restlessness  Difficulty making…  Planning & Communication  Planning: Nurse plans to approach victim in nonjudgmental and empathic manner  Implementation for sexual assault:  Maintain confidentiality  Listen and let patient talk, stressing patient did right thing to save his/her life  Long-term: return to previous level of functioning • Book Resources: Chapter 36 (abuse, neglect, rape) PG 860: Cycle of Battering Chapter 37: Mental Health Settings • The Model of Public Health o Primary care: attempts made to avoid hospitalization or crisis outbreak  These attempts include:  Assisting individuals to increase their ability to cope with stress  Targeting and diminishing harmful stresses within the environment o Secondary care: occurs during hospitalization and focuses on:  Recognition of symptoms  Provision of care  Applying of the Nursing Process o Tertiary care: intention is to assist pts with severe and persistent mental illness (SPMI) live as high quality life as they are capable of living  This is accomplished by:  Preventing complications of the illness  Promoting rehabilitation to reach maximum level of independence • Psychiatric Care Settings o Economic forces, scientific advances and advocacy movements have been instrumental in shifting psychiatric care from the hospital setting to community based settings o Psychiatric nurse roles have adapted to the needs of population in order to ensure quality & consistent services o Two nursing roles for psychiatric community help are:  Psychiatric RN  Psychiatric APN • Case Management o Case managers link the service system to the consumer and coordinate services to achieve successful community living for the individual o Role requires a mental health trained professional who can work independently and has a strong demeanor to work with difficult patients • Accessing the System o Anytime an individual has to access mental health services a comprehensive assessment will be done to determine the least restrictive environment that the pt needs to achieve the greatest independence and personal freedom o Time spent to complete a comprehensive assessment which includes collecting data for all 5 axes can be 4-6 hours o Problems in Accessing Mental Health Care  Stigma: negative labeling, bias or prejudice against the MI population, which often prevents MI from seeking help  Disorders themselves sometimes can interfere with seeking treatment b/c of belief that one does not have a problem  Mental health symptoms can also be confused with medical problems o Types of Services  Inpatient hospitalization  Outpatient services  Residential facilities  Psychiatric home health care  Case management  Pediatric care  Geriatric care  Veteran’s services  Forensic settings (criminal insane)  Substance abuse treatment (MISA) • Inpatient Hospitalization o 24 hours structured safe environment used only when an individual has presented a danger to self and others o Goal has changed from acute illness stage-remission mode requiring longer length of stays to crisis stage-stabilization mode requiring shorter lengths of stays o Provides a therapeutic community milieu, crisis intervention, psychopharmacology, therapy and discharge planning • Outpatient Care Settings o Partial hospitalization (PHP): goal is to prevent hospitalization or ease the transition from hospitalization to community living  Meets in a hospital setting for about 4-6 hours a day then goes home at night o Intensive Outpatient Programs (IOPs): structured intense programming utilizing individualized goals and objectives  Meets in hospital or clinic setting for about 4-5 hours a week  Focus for both programs is providing specific treatment like medication management and education, groups, individual and family therapy o Community Residential Facilities: long term care placements for treatment resistant or homeless mentally ill individuals  Structured short or long term living environments where the individuals are provided with varying levels of supervision and support  Can be more secure environments or independent living arrangements • Independent Community Services o Home health care is provided in the home settings for those who are unable to leave their homes such as elderly or physically disabled o Care is provided by nurses who are adept at doing comprehensive assessments and case management • Self Help Options o Self-help groups allow individuals to talk about their issues and relieve feelings of isolation while receiving support and advice from peers who are experiencing similar problems  Examples: AA, grief groups o Advocacy groups allow pts and family members to join together to shape delivery of mental health care  Example: NAMI (national alliance for mental illness) Chapter 18: Suicidal Thoughts & Behaviors • Definitions Suicide: act of intentionally ending one’s own life Suicide attempt: includes all willful, self-inflicted life-threatening attempts that have not led to death Suicidal ideation: thoughts of inflicting death on self Suicidal threat: an indirect or direct verbal or non-verbal warning of self-inflicted death • Suicide is not a diagnosis or disorder it is a behavior • Risk Factors: Suicide o There are some commonalities among people who attempt or complete suicides  They exhibit poor problem solving skills, impulsive, lead troubled lives, and experience hopelessness  Gender  Women have more suicide attempts and use less violent means  Men have more suicide completions and use more violent means  Psychosis (especially presence of command hallucinations)  Feelings of hopelessness, helplessness, worthlessness  Presence of a plan, weapon, previous suicide attempt  Family history of suicide, violence, abuse  Chronic physical illness • Theories o Psychological: hopelessness, shame, guilt  Victims of suicide suffer unbearable psychological pain, isolation, and perception that death is the only solution o Neurochemical: studies show a deficiency of serotonin o Cultural/Societal: poverty, divorce, separation, bereavement, homelessness, negative life events with poor social support • Assessment Guidelines: Suicide o Recognize verbal clues such as: “I can’t take it anymore” or “I wish I were dead”  Suicide threats need to be taken seriously, including overt and covert statements o Recognize behavioral clues such as: giving away possessions, writing farewell notes, making one’s will, putting affairs in order, sudden improvement after being depressed or withdrawn, neglecting personal hygiene o Assess precipitating events and risks o Assess suicide history • Communication: Suicide o Assess suicide plan, including intent, lethality, availability of means, any injury suffered o Determine support systems; include community supports if person will be managed on outpatient basis o Always convey that the crisis is temporary, pain can be survived, help is available and “You are not alone” o Always ask: “Are you thinking about killing yourself?” • Help for Survivors of Suicide o Postvention for survivors initiated 24 to 72 hours after death o Survivors often feel they are “going crazy”  Need to know these feelings are normal o Anger toward person who committed suicide normal and needs to be discussed o PTSD is common in survivors o Self-help groups useful as well as counseling • Book Resources: Chapter 18 (suicide) PG 307-308: Facts/Fables about Suicide PG 311: Risk and Protective Factors PG 317-318: Sources for Information for Suicide Chapter 27: Mood Disorder – Depression • Definitions Mood: prolonged emotional state that influences a person’s perception of the environment Depression: alteration in mood that is expressed by profound sadness, despair, pessimism, hopelessness, helplessness and worthlessness. It is a clinical illness that is severe, maladaptive and incapacitating Mania: alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, accelerated thinking and speaking • Concepts of Mood Disorders o Chronic, recurring, life-threatening illness o Individuals experience impairments in interpersonal and occupational functioning even during remission o Associated with highest lifetime suicide rate among psychiatric disorders o A biological disorder for which psychopharmacology is effective • Depression o An alteration in mood expressed by feelings of sadness, pessimism and despair o Depression ranges from mild to severe with or without psychotic features. Can begin at any age but usually begins in the mid-twenties o If left untreated episodes can last 6-24 months o Co-morbidities occur with at least 40% of the depressed population – substance abuse, medical illness, pain • Theories o Genetics o Biological: imbalance of neurotransmitters o Bio-anatomical: ventrical enlargement, atrophy and sulcal widening o Loss and trauma o Learned helplessness, hopelessness, lack of control over stress o Self-esteem issues • Major Depressive Disorder (MDD) o Impaired social and occupational functioning that has existed for at least two weeks o Manifested by emotional, cognitive, physical and behavioral symptoms o Symptoms are usually more severe and represent and interference in functioning o History of one or more major depressive episodes and no history of mania o DSM-IV-TR diagnosis can include specifiers:  Psychotic features  Catatonic features  Melancholic features  Postpartum onset  Seasonal affective disorder (SAD)  Chronic single episode, recurrent, mild moderate or severe  Depressed mood most of the day nearly every day o Common Symptoms: MDD  Emotional and Cognitive symptoms: MDD  depressed mood  feelings of worthlessness and guilt  anhedonia  hopelessness  decreased concentration  recurrent thoughts of death/suicide  Physical symptoms: MDD  weight gain or loss  insomnia or hypersomnia  increased or decreased motor activity  anergia  constipation  fatigue • Dysthymic Disorder: DD o Characterized by chronic depressive syndrome usually present for most of the day, more days than not, for at least a 2-year period o Not usually severe enough for hospitalization unless person becomes suicidal o Onset is usually early childhood, teenage years, or early adulthood and are at risk for developing MDD o Assessment Guidelines:  Evaluate patient for suicidal ideation by assessing feelings of worthlessness, hopelessness, helplessness, guilt, anger or irritability  Determine presence of other medical conditions contributing to depression  Current support system  Recent triggering events (death of a loved one) o Planning & Implementation:  Priority is suicide prevention  Patient and family education about symptoms of depression, treatment and medication  This is a legitimate medical illness over which the patient has no voluntary control • Communication Guidelines for Depression o Understand that patient may need more time to reply to communication o Silence/sitting with patient can be therapeutic o Allow time for patient to respond o Avoid platitudes “Everything will be OK” o Listen carefully for covert messages and question directly about suicide • Book Resources: Chapter 27 (depression) PG 559: Diagnostic Criteria for MDD PG 560: Diagnostic Criteria for DD PG 572: Nursing Dx Chapter 28: Mood Disorder – Bipolar • Definitions Mania: an alteration in mood expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation and accelerated thinking and speaking Hypomania: a milder form of mania usually not severe enough for hospitalization and it does not include psychotic features • Types of Bipolar Disorders o Bipolar I  Experience a full syndrome of mania mixed with a mild depressive episode  Psychosis may accompany manic episode o Bipolar II  Major depression alternating with hypomanic episodes  Not accompanied by psychosis  Does not meet the criteria for mania • Theories r/t Bipolar Disorder o Genetics o Biochemical: neurotransmitters imbalances when they go up associated with mania when they go down associated with depression o Neurobiological: differences in the brain anatomy o Prevalence of Bipolar Disorder:  More prevalent in higher socioeconomic classes  Higher rates noted among creative writers, artists and highly educated men and women • Common Symptoms: Bipolar o Physical:  nonstop activity  minimal food intake  little or no sleep Can lead to exhaustion and even death o Mood symptoms:  unstable euphoric mood  intense feeling of well-being  mood may change to irritation and anger o Behavioral symptoms:  excessive hyperactivity  involved in pleasurable activities with painful consequences  sexual indiscretion  excessive spending of money  mode of dress/makeup may be outlandish, bizarre o Cognitive symptoms:  poor concentration  problems with verbal memory  sustained attention and executive functioning (may persist even in remission)  flight of ideas: continuous flow of accelerated speech with abrupt changes from topic to topic  clang associations: stringing together of words because of rhyming sounds  delusions: usually of grandiosity or persecutory • Assessment Guidelines: Bipolar o Determine if patient is dangerous to self or others o Presence of physical exhaustion o Poor impulse control o Uncontrolled spending of money o Determine medical symptoms o Dehydration, infections o Poor self-care o Hospitalization will be necessary • Communication Guidelines for Mania o Use firm, calm approach o Use short, concise statements o Remain neutral; avoid power struggles o Be consistent o Hear and act on legitimate complaints o Firmly redirect energy into appropriate channels • Treatment for Depression and/or Mania o Milieu therapy o Somatic therapy:  ECT (Electroconvulsive therapy - Tx for 3 days a week for 6 weeks – cannot stop mid therapy – very effective) o Group therapy o Family therapy o Psychotherapy:  CBT (restructuring negative thoughts) o Psychopharmacology:  mood stabilizers, antidepressants o Integrative therapy: light therapy o Holistic therapy:  St. John’s Wort (herbal supplement that relieves depression – same chemical make-up as SSRIs – cannot be mixed with MAOIs)  Exercise • Book Resources: Chapter 28 (bipolar) PG 598: Diagnostic Criteria for Mania PG 605: Nursing Dx for Mania