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NUR 114 1

Exam #1 Study Guide


https://quizlet.com/55329439/mh-exam-2-flash-cards/ - Practice Questions

Legal and Ethical Issues in Psychiatric Nursing

Diagnostic & Statistical Manual of Mental Health Disorders (DSM-5)


- Provides guidelines for identifying diagnosis of mental illness
- Helps physicians plan and evaluate treatment
- Must have certain symptoms to be diagnosed with a certain condition

Axis I - Signs and symptoms of any disorder


Axis II - Personality disorders and Intellectual disability (mental retardation)
- Disorder that will not get better, Life long
Axis III - General medical condition
- Ex. DM, CHF, COPD, etc...
Axis IV - Psychosocial, environmental and occupational problems
- Ex. Family life?, Where do they work?, Homeless?, Smoker?
Axis V - Global Assessment of Functioning (GAF)
- Best level of functioning for an individual
- Rated: 1 - 100
- Normal: 75 - 100
- Mid level: 50 - if pt has a score of 49 there is something going on. Ex. death, loss of job, etc...
- Psych pt’s: Below 35
Bioethics
Autonomy - Right to make own decisions
- Ex. Refuse treatment or medications
Beneficence - Actions to promote good, moral obligation to act for the benefit of others
- Ex. Spending extra time with the pt
Fidelity - Faithfulness to obligations, duties, or observances. “to do no harm.”
- Ex. Maintaining expertise in nursing skills
Justice - Fairness, equal treatment for all
Veracity - Telling the truth, providing honest and full disclosure to patients
- Ex. Explaining all the side effects to a medication prescribed

Mental Health Laws


Psych pt’s have all the same rights as everyone else. These rights include Civil rights:
- Right to vote
- Driver’s license
- Right to purchase
- Right to enter contracts
- Right to press charges - if nurse mistreats them.
- Right to human care - healthcare needs must be met.
- Includes: dental (toothaches,cavities,) freedom of religion (church services) social
interactions (always make sure pt’s are in a therapeutic environment that
promotes them to get better) exercise and recreation
- Nurses responsibility to make sure pt is not bored
- Right to refuse treatment/medications

Specific Rights
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- Client consent
- * MUST have
- Verbal or Implied
- Implied - Ex. Pt holds out hand for medication and puts pills in mouth
- Anything without consent is forced
- Communication
- Visitors, Mail, Telephone calls - Need Code
- No code, cannot give any information!!!
- Freedom from harm
- Nurses responsibility
- Freedom from harm from other pt’s, sharp objects/utensils, etc...
- Dignity and Respect
- Confidentiality
- Must ask pt if you can be there nurse before looking at pt’s chart
- ANA asserts the duty of the nurse to protect confidential pt information
- RNs legal duty to maintain pt’s confidentiality
- No conversations
- No information without signed consent
- No picture or recordings
- Participation in plan of care
- *Best way
- Explain and involve pt, get them to comply

Admission, Commitment, & Discharge


- Due Process in Civil Commitment
- Writ of habeas corpus (protection from unlawful detention)
- Pt’s can challenge commitments using a writ of habeas corpus
- A “formal written order” to “free the person”
- Have 3 days to comply. Gets another doctor to come up with plan to treat
and release pt at same time.
- Least restrictive alternative doctrine
- Least restrictive drastic means to be taken to achieve a purpose
- Must try the least restriction measure 1st to achieve purpose
- Ex. Talk to pt before giving medication (Chemical restraint)

Psychiatric Hospital Admission


- Voluntary admission - By choice
- Involuntary admission - Without choice
- Types: Judicial (court), Administrative (magistrate), Agency (hospital)
- A well-defined psychiatric problem must be established. Based on the current
illness classifications in the DSM-5
- The presenting illness should be of such a nature that it causes an immediate crisis
situation or that other less restrictive alternative are inadequate or unavailable
- There should be a reasonable expectation that the hospitalization and treatment
will improve the presenting problems

Voluntary Admission
- Admitted by patient or guardian
- through a written application to the facility
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- Right to demand release
- have the right to demand and obtain release
- May need written release notice to facility
- Pt submits written release notice to the facility staff. Who reevaluate the pt’s
condition for possible conversion to involuntary status according to criteria
established by stat law
- Written statement is looked at within 24 hours. Can take up too 72 hours. No
guarantee of release

Involuntary Admission
- No consent is given
- Desperately needs treatment
- Risk of harm to self or others
- Cannot meet basic needs
- Have rights still too...
- Medications - information about, refusal
- Unnecessary restraints - least restrictive
- Informed consent - to request and refuse treatment
- A specific number of physicians must certify that a pt’s mental health status
justifies detention and treatment

Types of Involuntary Admission


- Emergency
- Specified period of time. On average 1-10 days
- Purpose: To prevent dangerous behavior that is likely to cause harm to self or
others
- Common in the homeless
- Police, MD’s authorize
- Observational/Temporary
- Longer duration than emergency
- Purpose: To provide observation, diagnosis and treatment for those with a mental
illness or pose a danger to themselves or others
- A guardian, family member, or physician may apply for
- Certification by 2 or more physicians, judicial or administrative review, and an
order is often required
- Long-term/Formal
- 60 - 180 days, but may be for an undetermined period of time
- Purpose: To provide extended care and treatment of the mentally ill
- Committed through medical certification, judicial or administrative action
- Outpatient
- Attached to receiving goods or services (usually provided by social welfare
agencies, disability benefits and housing)
- Preventative measures, allowing a court oder before the onset of a psychiatric
crisis
- Pt must participate in treatment and may face inpatient admission if he/she does
not participate in treatment

Discharge
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- Depends on the pt’s admission status
- Informal or Voluntary admission
- Pt’s have the right to request and receive release
- Conditional release
- Enables the treating MD to order continued treatment on an outpatient basis if the pt needs warrant
further care
- Usually requires treatment for a specified period of time ti determine the pt’s adherence with
medications, ability to meet basic needs and reintegrate into the community
- Unconditional discharge
- Termination of pt / hospital relationship
- Patient cannot be at harm to self or others
- Against Medical Advice (AMA)
- When treatment seems beneficial, but there is no compelling reason to seek an involuntary
continuance of stay. Pt’s may be released AMA.
- Only way to keep is if pt is a danger to themselves or others

Seclusion & Restraints


* Least restrictive/shortest duration doctrine
- #1 - Verbal interventions
- Enlisting the cooperation of patients
- Always talk to patient first, before taking any drastic measure
- #2 - Medications
- Considered if verbal interventions fail
- Seclusion and Restraints
- When all other methods have failed
- In an emergency, a nurse may pace a pt in seclusion or restraints and then obtain a written or verbal
order as soon as possible, thereafter
- Permitted when:
- MD order
- Time limited - 2-4 hours
- Pt observed and needs are met q15min
- Food, fluids, bathroom, ROM
- Orders reauthorized in 24 hours
- Document q15-30min
- Behavior leading to restraint or seclusion
- Time pt is place in and taken out
- Observations made
- Needs provided
Exceptions to Confidentiality
- Duty to warn and protect third parties
- NC nurses must warn if threats are made by a patient
- Must assess and predict the pt’s danger of violence toward another
- Identify the specific individual(s) being threatened
- Take appropriate action to protect identified individuals
- Required to report
- Willfully do not report = Guilty of a misdemeanor

Child and Elder Abuse


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- Required to report cases of suspected abuse
- Make a report in good faith - immune from civil liability
- Apply to depend adults (18-64 years of age who’s physical or mental limitations
restrict their ability to carry out normal activities or to protect themselves) when the RN
has actual knowledge that a person has been a victim of physical abuse

Tort Law - Civil wrongs for which money damages can be collected
Battery
- Physical violence
Protection of Clients
Defamation of Character
- Any communication written or spoken that harms someones reputation
False Imprisonment
Assault
- Threat of harm

Unintentional Torts Intentional Torts


- Suicide risk - Careless / Reckless
- Restraints - Absence of consent
- Miscommunication - Threatening force / harm
- Medication error - Bodily contact
- Sexual misconduct - False imprisonment
- Privacy violation - Improper use of restraints
- Defamation

Unintentional tort
- Equal less jail time may only be a fine.
Intentional tort
- Equal jail time.
- Intentional torts include battery, assault, and false imprisonment
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Suicide
Suicide
Define - Intentional act of killing oneself
- Suicide attempt - is inflicted life threatening attempt on one’s life which did not lead
to death
- Suicidal ideation - is thinking about self harm
- Physician assisted suicide - Not legal in NC
Requirements:
- No psychosis or mental illness
- 2 physicians must agree upon
- Prognosis of 6 months to live
- Bipolar disorders emerge between childhood and 50 years of age, with most cases
manifesting between 15 and 19 years of age.
Statistics - Third leading cause of death among adults 15-24 years old
- Second cause in ages 25-34
- One in 5 deaths of veterans r/t PTSD
- 90% of people who die by suicide suffer from a mental condition

Risk Factors - Co-morbidity with a Mental Health Disorders


- Depression
- Anxiety
- Substance abuse
- Schizophrenia
- Eating
- Bipolar
- Personality
- Firearms in house
- Family Hx of abuse
- Violence
- Male - tend to be more aggressive and hold feelings in

Societal Risk Factors - “Lack of Support”


- Negative / Stressful life event
- Divorced
- Bereavement (Grief)
- Childless
- Live alone
- Unemployed
- Economic troubles

Biological - Low serotonin levels r/t depressed mood


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Clinical - Signs of chronic self destructive behavior
Manifestations - Participation in dangerous behaviors
- Participate in at least 2 or more reckless behaviors
Ex. Base jumping, Racing cars
- Suicidal comments
Covert or Overt statements

Covert Statements - statements leading to suicide.


- Must listen carefully
- Ex. “It’s okay, now. Soon everything will be fine”
“Everything is looking pretty grim”
“I won’t be a problem much longer”

Overt Statements - obvious suicidal statements


- Ex. “There is just no reason for me to go on living”
“Life just isn’t worth living anymore”
Assessment Preform suicide assessment
- #1 - Directly ask the question “Are you thinking of harming or killing yourself?”
- #2 - Assess presence of plan and intent of plan
- #3 - Details of plan, how do they plan to accomplish suicide?
- #4 - Assess access to plan, do they have means to accomplish plan
- #5 - Establish pt contract for safety

- Do they have thoughts of being with deceased family members?


- Preoccupation with death?

Assessment tools: SAD PERSONS SCALE


- To determine depression tendencies
Score
0-5 : Safe for discharge
6-8 : Talk with the patient, outpatient
greater than 8 : Hospitalization
Looks at: Sex, Age, Depression, Previous suicide attempts, Excessive substance use, Rational
thinking loss, Separated, Organized or serious attempt, No social supports, Stated future
intent
Nursing Diagnosis - Risk for suicide
- Risk for self injury
- Ineffective coping
- Hopelessness
- Social isolation
- Spiritual distress
Planning/ Short-term
Outcome - Family stay with patient overnight
- Keep follow-up visits with therapist

Long-term
- Minimize destructive behaviors
- Increase problem solving skills
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Implementation - Initiate one on one
- Document observations q15min
- Remove all potentially dangerous items
- Maintain safe environment
- Do not assign to private room and always keep door open
- Limit time at risk patients spend alone
- Involve significant others in treatment
- Medications
- CBT
- Problem solving skills
- Therapeutic communication
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Mood Disorders: Bipolar Spectrum Disorders
Bipolar Spectrum Disorders
Define - Bipolar Spectrum Disorders are the sixth leading cause of death in pt’s with mental
health disorders
- Bipolar disorders are chronic, recurrent, and life-threatening; Require lifetime
monitoring
- Characterized by two opposite poles: Depression and Mania
- Periods of normal functioning may alternate with periods of illness
Unipolar - Effect more women
- Insomnia - Difficulty falling asleep or waking repeatedly at night
- Appetite loss
- Depression
- Agitation
- Pacing
- Episodes last longer
Bipolar - Men and women effected equally
- Earlier onset - Teenage years
- Generally takes 10 years to dx
- Hyper-insomnia - Excessive tiredness and difficult morning waking, sleep a lot
- Binge eating
- Cravings - Crave carbohydrates (Ex. Sweets, pastas)
- Have weight fluctuations
- Psychomotor retardation
- At risk of substance abuse and suicide
- Have a tendency to have a dual/mixed diagnosis - Ex. Drug use -> At risk for
infection, STI/HIV, Cardiovascular disorder, Endocrine issues (DM, Tumors)
- Patients must take medications daily and understand the importance of taking
medications
Bipolar I Behavior
- 1 episode of Mania with major depression

Additional Symptoms
- May or may not have psychosis

Prevalence
- Men and women equally
Bipolar II Behavior
- Depressive episodes alternating with hypomania

Additional Symptoms
- Euphoria
- Suicide

Prevalence
- Men and women equally
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Cyclothymic Behavior
- Hypomania alternating with minor depression (lasting 2 years)

Additional Symptoms
- Irritability with hypomania

Prevalence
- Begins in adolescence or early adulthood
- 50% will subsequently develop Bipolar I or II disorder
Rapid Cycling Behavior
- 4 mood changes in 12 months

Additional Symptoms
- Decreased GAF score
- High reoccurrence
- Resistance to treatment

Prevalence
- Reported more cases in women
Mixed Episodes - A mixture of hypomania or just mania plus depression
- Highest risk of suicide
Prevalence and - Begin between childhood and 50 years old
Co-morbidities of - BP I and BP II occur equally in men and women
Bipolar Spectrum - 76% have a co-morbid disorder
Disorders - Co-morbid disorders include: Anxiety, Behavioral, Substance abuse
- Substance abuse will have rapid cycling or mixed dysphoria (highs and lows of
emotions)
- Medical co-morbidities worsen the prognosis and increase suicide
- Medical co-morbidities include: Cardiovascular issues, Metabolic dx (DM), HIV
Neurobiology - First generation relative may have schizophrenia
- Interactions between neurotransmitters and hormones: Serotonin, norepinephrine
and dopamine
- Bipolar Mania: Decreased Serotonin and Dopamine, Increased Norepinephrine
- Depression: Decreased Norepinephrine
- Hypothalamic-pituitary-thyroid-adrenal axis (HPA) regulate the stress response and
is involved in maintaining homeostasis - causing increased cortisol levels - which cause
mood swings
- MRI image of the brain showed brain atrophy and volume reduction
- Stressful events can trigger symptoms of bipolar disorders
Characteristics of - Underlying depression
Acute Mania - Significant and persistent problems
- Difficulties in psychosocial areas: Environment, Occupational and Relationships
- Flight of ideas: Speech - Rapid, loud, vulgar
- Grandiosity - Idea of extreme self-importance “I’m the best!”
- Poor judgement
- Suicidal thoughts or plans
- Clang association - Rhyming without regard to meaning. “Bang, clang, shebang”
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Hypomanina - Functioning
- Sleep less than 6 hours per night
- Increased sex drive
- Life of the party
- Flight of ideas
- Peppy, humor and sociable
- Enthusiastic
- Self-confidence
- Overactive
- Easily distracted
- Big appetite
- May not sleep
- Spend lots of money
Acute Mania - Demanding of time
- Intrusive
- Crude sexual remarks
- Flight of ideas
- May use clang association
- Humor turns to hostility
- Grandiose
- Short attention span
- Restless
- Disorganized
- Outburst/Tantrums
- Too busy for: Sex, Food, Sleep
Delirious Mania - Out of touch with reality
- Uses clang association
- Destructive
- Aggressive
- May hallucinate
- Dangerous state
- Hyperactive motor activity
- No sex
- Cannot eat or sleep
- Too disorganized
Assess for Danger - Suicidal thoughts/plans
to Self or Others - Intrusive behavior - In acute mania
- Delusions of grandeur - Think they are or know famous people
- Self-care needs - Unable to preform? - At risk for infection, malnutrition,
dehydration (Ex. Cannot eat, dress self or clean after self)
- Assess for medical status, co-existing medical conditions
Nursing Diagnosis - Risk for injury
- Risk for violence: Self or Others - Acute Mania
- Imbalance Nutrition - Acute and Delirious Mania
- Ineffective impulse control
- Impaired social interactions
- Disturbed sleep - Need at least 6 hours of sleep
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Outcome Criteria Phase I: Acute Mania - 24 hours
- Prevent physical and psychological injury
- Ex. “Pt will make no attempt at self harm”

Phase II: Continuation of treatment - 2-6 months


- Relapse prevention
- Medication compliance
- Ex. Pt and family will attend support groups

Phase III: Maintenance treatment


- Preventing relapse
- Limiting severity and duration of future episodes
- Ex. Medication compliance, learning intrapersonal strategies
Planning Phase I: Acute Mania
- Maintain safety
- Medication stabilization
- Self-Care

Phase II: Continuation Phase (Assessment data)


- Maintain medication and regimen compliance
- Psycho-education teaching - Priority for pt and family
- Counseling

Phase III: Maintenance phase (begins at 6 months)


- Preventing relapse
- Support groups
- Revaluation
Implementation: Manic Patient
Nurses - Manipulative
assessment of - Splitting - attempt to distract staff and loosen limits. Ex. Pt turns staff members
the patient against one another
- Aggressively demanding

Staff Member Actions


- Set limits consistently
- Frequent staff meetings (daily) to communicate with one another and reestablish
limit setting staff responses.

- Patients may use humor, manipulation, power struggles, or demanding behavior to


prevent or minimize the staff’s ability to set limits or control dangerous behaviors.
Communication - Use firm, calm approach
with the Manic - Use short and concise explanations - Short attention spans
Patient - Remain neutral: Avoid power struggles - pt will use any inconsistencies to argue
and escalate mania
- Be consistent in approach and expectations
- Firmly redirect energy into more appropriate areas - Distracting the patient is the
nurse’s most effective tool to use during the patient’s manic phase
- Can ask the pt to rephrase, ask pt to repeat slowly to help clarify what was said.
Allowing the pt to realize how bizarre the behavior sounds
- Do not play into delusions. “I do not see that.” Bring them back to reality
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Implementation Phase I: Acute Mania
- Control destructive behavior- Supervise choice of clothing, Give step-by-step
reminders for hygiene and dress
- Medical stabilization
- Establish communication
- Milieu therapy
- Pharmacological therapy - Vital to a safe physical and mental level of functioning
- ECT - Only for delirium states
- Nutrition - Offer frequent high-calorie protein drinks and finger foods Ex.Sandwich,
fruit and milkshake

Phase II: Continuation Phase


- Prevention relapse
- Appropriate community resources
- Medication compliance
- Psycho-education

Phase III: Maintenance Phase


- CBT - helps pt’s accept illness and need for medical treatment, decrease rate of
relapse and number of hospital admissions
- Interpersonal and social rhythm therapy (IPSRT) - idea that problems in
interpersonal relationships and disruptions in daily routines contribute to the
reoccurrence of manic and depressive episodes
- Family focused therapy (FFT)
- Support Groups - Benefit from forming mutual support groups
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Pharmacology Lithium Carbonate (LiCO3)
- Normal Blood levels - 0.4 -1.3 mEq/L
- Acts as a mood stabilizer
- Monitor labs biweekly, weekly, then monthly until therapeutic levels are reached
- Therapeutic levels in 7-21 days (May take up too 3 weeks to become effective)
- Encourage fluids 1500-3000 mL/day
- Do not d/c abruptly - Leads to relapse and reoccurrence of mania
- Monitor for risks of hypothyroidism and renal function - impairs kidneys ability to
concentrate urine
- Monitor for changes in moods
- Normal dose 300-900 mg BID or TID
- Narrow therapeutic window
- Effective in treatment of mania and depressive episodes and in the prevention of
recurrent episodes
- Lithium and divaiproex (Depakpote) are first-line mood stabilizing agents
- Initially in treatment of acute mania an antipsychotic or benzodiazepine can help
calm the symptoms until lithium reached therapeutic levels
- When taking monitor intake of salt

When taking Lithium observe the pt for motor tremors, orthostatic hypotension, Advise pt
to avoid caffeinated food and beverage and to take with meals to decrease gastric acid
- Polyuria - common side effect when taking for the first time

Antiepileptic or Anticonvulsant Medications


- Lamotrigine (Lamictal) - Potentially life-threatening rash, seek immediate
attention
- Caramazepine (Tegretol) - Rapid cyclers, severe paranoia, anger pt’s, mixed
bipolar disorder
- Both stop seizures
- Divalproex (Depakote) - Need to check blood levels. Sometimes taken for life
- Gabapentin (Neurontin)
- Topiramate (Topamax) - For manic pt’s who desire weight loss

- Tetratogenic to fetus
- Monitor Liver function tests
- Infants, elderly, children may require decreased dose
- Start low, go slow - always applies to the elderly. often monitor q3-4days

Anxiolytics or Benzodiazepines
- Given early to control behavior, Calms patients
- Dangerous to the elderly or substance abusers

- Clonazepam (Klonopin)
- Lorazepam (Ativan)

Antipsychotics
- 2nd generation
- Work to treat anxiety, agitation, and psychosis

- Olanzapine (Zyprexa)
- Quetiapine (Seroquel) - Helps with sleep
- Ziprasidone Hcl (Geodon) - Helps with aggresion
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To Treat Mania Antipsychotics
until Lithium - Slow speech
becomes - Inhibit aggression
Effective - Decrease psychomotor activity

Benzodiazepine (Clonazepam and Lorazepam) to prevent:


- Exhaustion
- Coronary collapse
- Death

Lithium: Early - Call MD, medication should be withheld, measure blood lithium levels and re-
Signs of Toxicity evaluate the dose
- Anything that can deplete hydration levels ; check blood lithium levels. Ex.
Diarrhea, Vomiting, Polyuria, Thirst, etc..
- The most
common - Blood levels should not exceed 1.5 mEq/L
adverse effects
Signs and Symptoms:
to Lithium are:
- Nausea
Nausea, - Vomiting
Diarrhea, - Diarrhea
Tremor, and - Thirst
Lethargy - Polyuria (Increased urine output)
- Slurred speech
- Muscle weakness
Lithium: - Blood levels 1.5-2.0 mEq/L
Advanced Toxicity Signs and Symptoms:
- Course hand tremors
- Severe GI upset
- Confusion
- Muscle hyper-irritability
- ECG changes
- Incoordination
Lithium: Severe - Blood levels 2.0-2.5 mEq/L
Toxicity Signs and Symptoms:
- Ataxia (lack of voluntary coordination of muscle movement)
- Know - Serious EKG changes
known antidote - Blurred vision
for Lithium - Clonic movements
poisoning - Large output of diute urine - signals renal damage
- Seizures
- Stupor
- Severe hypotension
- Coma/Death
Lithium: - Cardiovascular disease
Contradictions - Brain damage
- Renal disease
- Thyroid disease
- Myasthenia gravis - muscle weakness and fatigue
- Pregnancy
- Breastfeeeding
- Children younger than 12 years of age
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Patient and - Effects of treatment
Family Teaching - Need to monitor blood levels
for Lithium - Side effects
Therapy - Toxic effects
- Effects of OTC medications
- When to call the MD
ECT - - Only for severe manic behavior
Electroconvulsive - Rapid cycling
Therapy - Paranoid, destructive features
- Acutely suicidal behavior
Interventions/ - CBT used with pharmacotherapy after mania subsides
Evaluations - Family therapy - Focused on communication within the family, teaches
communication skills, prepares the entire family for relapses episodes
- Effect of interventions and outcomes
- Revise plan of care as needed
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Mood Disorders: Depression

Depression
Define Mood
- Sustained objective state of how one feels subjectively (pt’s words)
- How a person feels over time
- Able to observe emotions
- Judge based off the way you saw the pt the first time to now
Affect
- External manifestation of feelings or emotions, tone, voice, or body language
- Communicated outwardly of what the individual is feelings
- Inner feelings projected outward
- At the moment

Descriptors
Mood Affect
- Agitated - Angry
- Disturbed - Inappropriate
- Humorous - Joy/Sad/Tearful
- Relaxed - Appropriate

Depression
- Effects all races, ages, and genders
- Most common mental health issue
- Women 70% more likely
- The base of depression is anxiety
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Mood Disorders Major Depressive Disorder (MDD)
- Depression without manic symptoms
- Pt’s are hospitalized

Subtypes
Dysthymic Disorder (DD)
- Chronic form of depression
- Not generally hospitalized unless having suicidal thoughts
- Lasts for at least 2 years

Mixed anxiety depression


- Most common psychiatric presentations

Situational Depression
- Individual is unable to adjust to or cope with a particular stressor

Bipolar Disorder
- Mania
- Depression

Postpartum Depression
- Can begin anytime within the first year after childbirth
- Characterized by: mood swings, feeling sad, anxious, overwhelmed, crying spells, lose
appetite or trouble sleeping
MDD and DD - Sadness
have in common - Despair
- Emptiness
- Anhedonia (No pleasure in life)
- Low self-esteem
- Social withdrawal
- Apathy (Lack of feeling emotion, interest, concern)
- Irritability
- Suicidal ideation - Vary between MDD and DD
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Assessing Health History
Alteration in - Disease processes
Mood and Affect - Medications
- Hx alterations
- Family history
- Co-Morbidities?

Co-morbidity with depression may lead too:


- Increased suicide risk
- Symptoms exasperated
- Decreased social functioning
- Decreased responsiveness to treatment
- Increase relapse rate

70% of depression accompanies a medical condition


Children have been diagnosed with depression as young as 3 years old

Psychological Status
- Mood
- Affect
- Coping skills - Hopelessness/Powerlessness
- Cognition - How the pt is processing information Ex. Slow speech
- Concentration
- Appetite
- Sleep - Disturbed sleep patterns and Fatigue
Major Depressive - Lasts 9 months
Disorder - Affects children, teenagers, adults and the elderly
(MDD) - Pt’s suffer from mental, social, occupational disability without manic features
- Hospitalized
- Accompanies other mental disorders
- Mixed anxiety/Depression
- Excessive sleeping
- Crying/ Irritability
- Suicidal ideation
- Decreased appetite
- May complain of pain that does not seem to have a physical cause Ex.Headache
- Vegetative signs = no appetite, loss of sexual drive, crying spells, trouble thinking
Dysthymia - Chronic depression
Disorder - Lasts at least 2 or more years
(DD) - Onset: Early childhood to early adulthood
- Decrease functions at work - able to work just not at optimal levels
- Eat too much or not enough
- Energy loss
- Low self-esteem
- Negative thinking
- Hyper-insomnia
- No hospitalization unless having suicidal thoughts
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Prevalence - Girls at higher risk than boys
- High reoccurrence rate
- Family hx increases chances
- Early treatment and CBT, first 12 weeks assist in remission
- Older adults at risk
- Suicidal risks increase with age
- Medical conditions mask dx
- Tricyclic / Antidepressant medications to treat the elderly is controversial. Due to risk
for: Falls, Stroke, and/or Seizures
Neurobiology Neurotransmitters
- Serotonin - important regulator of sleep, appetite and libido
- Norepinephrine - decreased level may cause angeria (lack of energy), anhedohia (no
pleasure in life), decreased concentration and libido
- Dopamine - disrupted in depression
- GABA
- Acetylcholine

- Serotonin and Norepinephrine are involved in the perception of pain


Theory Aaron Beck
- Proposed people acquire a mental predisposition to depression through early life
experiences contributing to negative, irrational thoughts that may reman dormant until they
are activated during times of stress.
Therapies - CBT and Medication(s) work best to treat depression
- CBT - modifies negative thinking
- Interpersonal therapy (IPT) - emphasis on current pt response to others including
relationships
- Mindfulness based cognitive therapy (MBCT) - used for relapse pt’s. A combination of
CBT and stress reduction
- Group therapy
- Social skills training - includes assertiveness training, negotiation and resolving conflict

Risk Factors - Prior episodes of depression


- Family Hx
- Female
- 40 years old or younger
- Absence of social support
- Secondary to substance abuse
- Medial illness
- Grief
- Mental stressors
- Hx of sexual abuse
Clinical Key Symptoms
Manifestations - Anxiety - Seen in about 60-90% of depressed pt’s
- Anhedonia - No pleasure in life
- Vegetative signs = No appetite, loss of sexual drive, crying spells, trouble thinking
- Depressed mood - Feelings of worthlessness, guilt, hopelessness, anger and irritability
- Somatic complaints - C/O headache
- Psychomotor agitation/retardation - May range from slow to difficult movements to
complete an activity
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Physical Changes - Crying
- Flat affect
- Look older
- Poor posture
- Poor eye-contact
- Sighing
- Monotoned voice
- Disheveled appearance
- Poor grooming
- Appetite changes - Anorexia or overeating (overeating common in DD)
- Insomnia
- Constipation/Diarrhea
- Loss of libido
- Psychomotor agitation/retardation - May range from slow to difficult movements to
complete an activity

Mood and Affect


- Lethargic
- Anxious
- Loss of energy
- Anger
- Hopeless
- Suicidal gestures
- Psychomotor gestures - Smoking, Fidgeting, Nail biting, Finger taping, Pacing
Cognitive - Inability to solve problems
- Poor judgment
- Indecisiveness
- Poor memory
- Poor Concentration
- Delusional thinking
- Very negative hard for them to focus on strength
- Require extra time to respond to questions - Talk slowly to them
- Be direct when giving praise - Do not understand “You look good”
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Therapeutic - Exercise 30 mins / q 3 days - Encourage pt’s to walk to halls for 30 mins
Management - Saint Johns Wort and SAME - acts as an antidepressant
- Vitamin B - Maintain neurotransmitters
- Melatonin - Sleep
- Omega 3 Fatty Acid - Improve Cardiovascular health

- Animal therapy, Music therapy and Message therapy - Help to decrease depression

Milieu Therapy
- Assess pt’s risk for suicide
- Maintain safe environment
- Support pt’s
- Encourage attending group
- Ensure right medications

Psychotherapy
- CBT
- Interpersonal
- Mindfulness-based cognitive therapy
- Group - Increases social skills and allows pt’s to share
- Pharmacological

- Social training skills - Assertiveness - Increases self-esteem


Pharmacology - MD looks at side effects, cost, response time, depression symptoms and medical
conditions when prescribing
- Provide pt teaching for all antidepressants
- Do not d/c suddenly
- Therapeutic effects are not immediate
- Avoid alcohol and driving
- Notify MD of any thoughts of suicide
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Selective - Action - slow the re-uptake of serotonin, makes serotonin available
Serotonin Re- - Primary use: relieve depression
uptake Inhibitors - Used more than TCAs
(SSRI’s) - Cost more
- Lower incident of anti-cholinergic effects (dry mouth, blurred vision) Increases pt’s
- #1 compliance
treatment for - Take 1-3 weeks to take effect
anxiety - Relieves obsessive compulsive thinking

- Must ask
- Used for major depressive disorders
“Are you having
- Anxiety
suicidal - Obsessive/Compulsive
thoughts?” - Panic
- Phobias
- St. Johns - PTSD
Wort can cause
Serotonin - Citalopram (Celexa)
Syndrome - Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)

Side Effects:
- Decreased libido
- Weight changes (Generally weight gain)
- Sexual dysfunction
Why pt’s are less compliant to take
- S/E’s also include: Nausea, Headache, Anxiety, Insomnia

Adverse Reactions
- Serotonin syndrome (SES) - occur when SSRI’s taken with an MAOI or taking 2 SSRI’s
together
- Restlessness - Generally due to the lack of O2
- Elevated B/P
- Delirium
- Hostile
- Seizures
- Abdominal pain
- Diarrhea
- Fever, Shock, Death

Paoxetine (Paxil) - Half-life of 5 weeks


- Must wait 5 weeks before starting new medication
- Decrease dose in older adults
- Low cardiac toxic effects
- Black box warning - can increase suicidal thoughts in teenagers and need to monitor
when medications are changed or when starting
- The good typically outweighs the risks
Serotonin - D/C for 5 weeks
syndrome (SES) - Anticonvulsants (IV Dilantin) - Only IV and given for depression r/t seizures
- Occur when 2 SSRI’s are taken together or an SSRI is taken with an MAOI
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Atypical - Inhibit re-uptake of serotonin and affect the activity of NE and DA
Antidepressants - Primary use: Major depression, reactive depression (occur a lot) and anxiety
(SNRI’s) - Can lower seizure threshold
- Should not be used with an MAOI or used within 14 days after d/c of MAOI
- Antivirals taken with an Atypical can lead to kidney toxicity

- Bupropion (Wellbutrin) - multi-function help with depression and to quit smoking


- Nefazodone (Serzone)
- Venlafaxine (Effexor)
- Buspirone (BuSpar)

Buspirone - Works well on anxiety, has anti-depression factor


(BuSpar) - Takes 2 weeks to work
- No immediate effects
- Given as a maintenance
Tricyclic - Inhibit re-uptake to NE and 5HT
Antidepressants - Old
(TCAs) - Inexpensive
- Treats major depression
- Response takes 10-14 days or longer; up to 3 weeks
- Increase interest in mood and daily living
- Decrease insomnia
- Always provide written information to pt’s regarding TCAs
- Many given at night to help pt’s sleep
- If taking large dose concerned with overdose
- Pregnancy class D
- Decreased dose in the elderly to reduce side effects - “go low, go slow”

Side Effects
- Orthostatic hypotension
- Sedation
- Dry mouth
- Constipation
- urinary retention
- Blurred vision
- Tachycardia

- Amitriptyline (Elavil) - Esp. given at night


- Doxepin (Sinequan)
- Imipramine (Tofranil)
- Nortiptyline (Pamelor)
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Monoamine - Inactivates NE, DA, 5HT in CNS, increases levels
Oxidase - Equally effective ad TCAs to treat depression but have risk for hypertensive crisis from
Inhibitors food and drug interaction
(MAOIs) - Used last when nothing else works
- Must monitor B/P frequently
- Must watch diet - NO foods with Tyramine
- NO drugs containing Tyramine - OTC meds for colds, allergies or congestion
- Last chance; prescribed when TCA’s or Atypical’s fail
- Used for mild, reactive, atypical depression
- Should not be taken with TCA’s
- Contraindicated in pt’s with co-morbid substance abuse

Adverse Effects:
- Orthostatic hypotension
- Headache
- Insomnia
- Diarrhea

Hypertensive crisis
- Occurs when MAOI is used with other antidepressants and foods containing tyramine
Symptoms:
- Stiff neck
- Nausea
- Flushing
- Palpitations
- Occipital headaches

- Transdermal patch can be used without diet restrictions. Known as Selequilene (STS)
patch = 6 mg
- Patch dose greater than 9 mg must follow diet - NO tyramine

- St. Johns Wort - May lead to palpitations, MI, Hypertensive crisis


- Ginsing - May lead to manic episodes
- Brewer’s yeast - Raise B/P

- Phenelzine (Nardil)
- Isocarboxazid (Marplan)
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Foods containing Fruits
Tyramine - Avocado
- Bananas
- No - Raisins
guacamole, soy - Papaya
sauce, - Figs
chocolate, yeast
bread, - Soy sauce (Avoid Chinese Restaurants)
beer/wine, no
organ meats, Dairy Products
processed Aged cheese
meats, no Sour cream
coffee (NO Yogurt
caffeine)
Alcohol - Wine and Beer (Esp. Red Wine)
- Know
fruits Yeasts - Yeast bread

Meats
- Liver
- Pickled meats
- Pepperoni
- Salami
- Sausage
- Bologna
- Hot dogs

- Chocolate
- Pickles
- Caffeine
- Coffee
Electroconvulsive - Given 2-3 times per week to equal up to 12 treatments
therapy - Then on maintenance ECT - Every month
(ECT) - For psychosis attached to depression you may have to utilize ECT
- Must have consent
- Short-term memory loss - Assess upon return to unit - Can last up too 2-3 weeks
- NO important decisions should be made at this time
- Immediately check ABC’s after procedure and ensure the body is functioning: Bowel
sounds? Gag reflex present?
- Monitor heart rate for dysrhythmias
- Catatonic/Vegetative states receive ECT
- Produces a seizure in the brain

- Succinylcholine (Anectine) is given as muscle relaxant, causes paralyzed chest


muscles causing breathing compromised
- O2 is given during and after procedure
- Check: ABC’s plus body functions are priority
- Short-term memory assessment after returning to the unit
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Mental Status Looks at...
Exam - Appearance
- Behavior
- Speech
- Mood
- Affect
- Thought process/content
- Perceptual disturbances
- Orientation
- Judgment/Insight
Nursing Diagnosis - Risk for suicide - Always #1 when talking about depression
- Risk for disturbed identity - Could be r/t thought process
- Powerlessness / Hopelessness
- Low self-esteem
- Spiritual distress
Planning / - Plan expected behavioral outcomes
Outcomes - Remains safe (#1 priority)
- Reports hope for future - Want pt to verbalize
- Identifies causes of depression
- Reports improved mood
- Plans strategies to reduce effects of depression

- Planning must be specific to signs and symptoms


Interventions - Communication
- Counseling techniques for suicidal pt
- Encourage self-care activities - Direst praise and assist - Encourage attendance and
participation to group therapies - Ex. Pt may need help bathing or dressing
- Assess effects of medications
- Health teaching - include: community resourced, suicidal assessment scales
- Speak slow and allow the pt time to answer
- Assist the pt to preform any task they may need help with
- Obtain suicide contract - Make sure your pt is willing to make a NO suicide contract -
Can be verbal or written as long as the pt knows to come to nurse when having suicidal
thoughts or tendencies and agrees

Hamilton Assessment Scale Guidelines...


0-7 : Normal
8-13: Mild
14-18: Moderate
19-22: Severe
23+:Very severe depression

SAD scale - “Do you have a tendency to have depression?”


0-5: Safe for discharge
6-8: Talk with someone, outpatient
Greater than 8: Hospital

Suicide/Self-harm Assessment Tool


0-3: No precautions
4-9: Moderate - q15min observation/assessment
10 or more: High risk precautions - Need one on one
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Stress and Coping: Obsessive Compulsive Disorder (OCD)


Obsessive Compulsive Disorder
Define - Anxiety - Feeling apprehension, uneasiness
- Fear - Reaction to a specific danger
- Anger - Emotional feeling of animosity or strong displeasure
- Depression - Extreme feeling of sadness, despair, lack of worth or emptiness

OCD patients are rigid in thought and inflexible


OCD unconsciously controlling unpleasant thoughts or feelings
OCD attempting to resist compulsion. Should assess for increased anxiety
Levels of Anxiety Mild Anxiety - Typically the type student experience when taking a test
- Heightened perception
- Restless
- Irritable

Moderate Anxiety
- Narrow perception
- Difficulties concentrating
- Increases P, RR, muscle tension

Mild and Moderate Anxiety Interventions


- Ask open ended questions
- Seeking clarification - “Am I hearing?”
- Calm presence
- Listen to the patient

Severe Anxiety
- Focused on one detail
- Distorted
- Confusion
- N&V
- Tachy
- Dizziness
- Speech loud, rapid, demanding

Panic Anxiety
- Unable to focus on environment
- Mute
- Psychomotor agitation
- Irrational reasoning
- Terror
- Immobility
- Dilated pupils
- Sleeplessness
- Delusions

Severe and Panic Anxiety Interventions


- See to physical needs
- Pt safety
- Encourage fluids
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Defense - Protect us from painful or anxiety provoking feelings and memories
Mechanisms - Lower anxiety
- Unconscious
- Adaptive/Maladaptive or Healthy/Unhealthy
Healthy Defense - Altruism - Emotional conflicts and stressors are addressed by meeting the needs of
Mechanisms other, self sacrificing behavior.
Ex. Volunteering as a coach, get nothing out of it but are helping kids

- Sublimation - Unacceptable strong sexual or aggressive impulses unconsciously are


substituted for constructive and socially acceptable activity.
Ex. Rooted in sexual or aggressive behaviors, redirects self

- Suppression - Conscious denial of a disturbing situation or feeling. Rationalization for


a situation
Intermediate - Repression - “Block Out” - Exclusion of unpleasant or unwanted experiences,
Defenses emotions from conscious awareness. First defense to anxiety. Used the most.

- Displacement - Transfer emotions associated with a particular person, object,


situation. Displacement of energy generally to feel less threatened by.

- Reaction Formation - “Over Compensation” - Unacceptable behavior or feelings are


kept out of awareness by developing the opposite behavior or emotion
Ex. My dad said never become a boy scout, now I am a boy scout

- Somatization - Unconsciously transforming anxiety into a physical symptom, has no


organic cause
Ex. Spouse says “I am leaving you” Wife starts to dry hive in response or
During PR you start moving foot because you are nervous

- Undoing - Compensates for an act or statements such as giving a gift to undo an


argument
Ex. After abusing husband send his wife flowers

- Rationalization - justifying illogical or unreasonable ideas, actions or feelings by


developing acceptable explanations that satisfy the teller as well as the listener.
- Not a sensible idea, Hope to make self and listener happy
Ex. “Everyone cheats so why shouldn’t I?”
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Immature - Passive Aggressive - Dealing with emotional conflicts or stressors by indirectly and
Defenses unassertively expressing aggression
- Bottom line on top you are nice underneath it all, your nasty
- The worst - Acting like everything is okay on the outside
Ex. Due for raise. Boss passes you up. You act like everything is okay. Turn in
work late and did not do best

- Dissociation - Disruption in the function of consciousness and memory.


- Passed out or mentally dissociated
Ex. Thrown from car cannot remember anything prior to accident, can
remember after

- idealization - Emotional conflicts or stressors are addressed by attributing exaggerated


positive qualities to others
- Sometimes people overvalue a person and later they are disappointed
Ex. Idealize man with fancy car and clothes to find out he sells drugs causing
disappointment

- Splitting - Inability to integrate the positive and negative qualities of oneself or others
into cohesive image.
- Person believes they are only good or only bad. Do not understand they can be both.

- Projection - UNconsciously rejecting, unacceptable personal features and attributing


them to other people, objects, or situations. Form of blaming
Ex. Person does not like you says your a cheater, do so because they are
the cheater

- Denial - Escaping unpleasant realities by ignoring their existence


Obsessive- - Obsessions - Thoughts cannot be diminished
Compulsive Ex. Constantly washing hands, Checkin the stove
Disorder
(OCD) - Compulsions - Ritualistic behaviors, can be thoughts
Ex. “Did I check the stove?” Until they look they will not feel at ease
- Generally know it it silly but cannot help themselves

- Begins in adolescent years


- Responsive to SSRIs - Drug of choice
- One TCA drug - Anafanil Clompramine - Works to treat OCD and is effective
OCD Risk Factors - Family Hx - Strong link between 1st degree realatives
- Major life stressor
- OCD is an anxiety disorder
- Response to stress
- Not hospitalization unless they have excessive thoughts of suicide
- Goal in hospital is to reduce the time spent preforming ritual act
- Time no spent on ritual, nurse should direct pt’s thoughts to group or other activities
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Clinical - Aggressive, sexual, religious, and checking
Manifestations - Some pts think some degree of violence will occur if they do not complete their act
- Symmetry and ordering
- Cleaning
- Hoarding - Cannot throw away anything. Usually associated with death or violence.
Safety issue - fire risk, unsafe living conditions, falls/trips are common, being elderly doubles
the hazards

Therapeutic Cognitive Behavioral Therapy


Management - Modeling - Mimic ideal behaviors
- Systematic Desensitization - Gradually expose pt fear or situation until they are
anxiety free
- Response Prevention - Therapist helps to prevent impulse by gradually limiting time
spent between impulsive acts
- Thought Stopping - Wearing a rubber band around wrist, popping it when having a
negative thought

Anxiolytics - Treat anxiety and insomnia


- Include benzodiazepines
- Benzodiazepines are more effective that barbiturates
- Fewer side effects
- Less dangerous with overdosing
- Long-term use causes dependence and tolerance

- Alprazolam (Xanax)
- Clonazepam (Klonopin)
- Lorazepam (Ativan)
- Buspirone (BuSpar) - Not addictive, Ideal for substance users, Good for anxiety
disorders: PTSD, OCD, and Phobias. Takes 2-3 weeks to work.
- Phenobarbitals - Sedative, not good for addictive behaviors

- Benzodiazepines given for primary anxiety for a short time to relieve acute cases of
anxiety.
- Biggest danger with taking Benzodiazepines = Drug Dependency
Flumazenil - Antidote to any kind of Benzodiazepines
(Romazicon)

Benzodiazepines Side Effects:


- Sedation
- Headache
- Dry mouth
- Blurred vision
- Do NOT give with Alcohol
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Nursing Process - Assessment for self harm
- What caused the problem - Ask pt “What were you thinking before preforming ritual
act?”
- Cultures and Beliefs

Diagnosis
- Anxiety
- Ineffective coping
- Social Isolation - Do they have time in-between ritual? (Always washing hands in room
no time for socialization) Nurse should encourage pt to “dry hands and come outside” “Are
you feeling anxious this morning?”
- Self care deficit - Preoccupied with ritual cannot care for self
- Impaired Skin Integrity - R/T constant washing of hands

Outcomes should be Short-term


- Reflect pt’s values
- Be culturally appropriate
- Measurable goals
- Include a time estimate

Planning
- Involve pt in planning process
- Offer the pt choices
- Allow pt to set goals
- #1 to enhance compliance
- Implement CBT therapy: Modeling, Systemic desensitization, Response prevention,
and Thought stopping
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Personality Disorders

Personality Disorders
Define - Personality - Style a person adopts to deal with world. Remains the
same , cannot change
- Complex and challenging behaviors to deal with

A lot of the time they have co-morbidities such as: (Coexist with everything)
- Anxiety
- Depression
- Substance abuse
- Eating d/o
- Medical condition

- Personalities are deeply ingrained, cannot change


- Conditioned by your environment

Personality Disorders - Axis II Diagnosis


- When seemingly normal traits lead to the point of dysfunction
- Pattern of inner experience and behavior that deviates from the
expectation of the individual’s culture
- Inflexible
- Onset adolescence to early adulthood
- Causes distress and decreased social functioning
Common Traits of - Avoidance and fear of rejection
Personality - Blurring boundary lines
Disorders - Insensitive to others
- Demanding and fault finding
- Inability to trust
- Passive aggressive traits
- Invoke interpersonal conflict
- Usually violence is involved
- No insight to what is right or wrong
- Chronic low self-esteem
- Inflexible to stress
- Disability in working and loving
- Can “get under your skin”
- Lack of social restraint

Risk factor
- Chronic trauma/abuse
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Categories of Group A.
Personality - Remember the word PASS
Disorders - When you see these individuals you want to walk right pass them
- Odd behavior
- Patients - Paranoid
can have 2 at - Schizoid
the same time - Scizotypal

Group B.
- Drama queens, Emotional or Erratic
- Inappropriate, disruptive behaviors
- Antisocial
- Borderline
- Histrionic
- Narcissistic

Group C.
- “Scaredy Cats”
- Anxious, Fearful, Insecure
- Avoidant
- Dependent
- OCD
- Passive-Aggressive

Group A: Odd - Preoccupied with unjustified doubts


Paranoid - Reluctant to confide in others
- Reads hidden meanings
- Perceives attacks on themselves
- Do not trust anyone
- Exploit the week
- *Sarcastic and Argumentative
- When caring for you only want to offer the truth

Group A: Odd - Detached from social relationships


Schizoid - Early adulthood
- Does not want or enjoy relationships
- Enjoys solitary activities
- Little interest in sex
- Does not want friends
- Takes night jobs
- Prefers non-human interaction Ex. Books
- Must respect their need for alone time
- Pts do not want you to be funny, don’t process humor
- Rarely get upset or angry
- Smart
- Isolate themselves
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Group A: Odd - Begins in early adulthood
Schizotypal - Awkward in social situations
- Ideas of reference - Focus on one person or they are the focus of
- Unusual perceptions - Think they can control others with their minds
- Don’t smile
- No eye contact
- Want friends but relationships cause anxiety
- Negative self-judgment
- Do well with one on one therapy
Group B: Drama - Belittle and devalue
Borderline - Frequent mood changes
- Self mutilation
- Suicide prone
- Aimed at attention seeking
- Do not see good and bad they cannot coexist
- Act anyway to get their way
- Based on anxiety
- Cuts/Burns - Monitor for infection but do not draw extra attention too
Group B: Drama - Dis-social, Psychopath
Antisocial - Entitlement
- Lie
- Con
- Impulsive
- Irritable
- Aggressive - Fight a lot
- Reckless disagreed for self and others
- Manipulation is key
- Typically hospitalized to escape the law
- Fail at: sustaining a job, developing stable relationships, obeying laws
- Feel as if they are not responsible for their actions : “They deserved it”
Group B: Drama - Grandiose
Narcissistic - Preoccupied with fantasies
- Believes they are “Unique”
- Arrogant
- Entitled
- Feed on attention, underneath fragile
- Do not succeed in group therapy
- Lack empathy for others
- May think they know more than the doctors
- Believes others are envious or Envy others
- “All about themselves”
Group B: Drama - Uncomfortable when not the center of attention
Histrionic - Often seductive
- Jump into relationships too quickly
- Will cry or stay in room to pout to get their way
- Will storm out of group
- Benefit from assertiveness training and modeling
- Easily influenced by others
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OCD Personality - Perfectionist
Disorder - Do not bend rules
- Do want to be liked but fear to much contact with people
- Brown nose authority - “Flatter boss:
Group C: Anxious - Low self-worth
Avoidant - High levels of anxiety
- Awkward and uncomfortable socially
- Timid, withdrawn, or cold
- Speech slow, frequent hesitations
- Lonely
- View others as critical, betraying, humiliating
- Hospital plan is - slowly encourage in environment, slowly ease into
group therapy, by the end of hospitalization goal for pt to attend at least 1
group session
- Need assertiveness training to decrease fearfulness/anxiety
- Many have social phobias
Group C: Anxious - Excessive care needs
Dependent - Submissive
- Want to gain acceptance
- Only assertive when defending the person they depend on
- Benefit from assertiveness training and modeling
- Plan - Assertive therapy, Family meeting - abuse present?
Group C: Anxious - Verbally aggressive and hostile
Passive- - Manipulation
Aggressive - Wronged, may seek retribution
- Express feelings indirectly
- Work is procrastinated
- Uses blame
- Feels unappreciated
- If attends group, accept them to destroy group
- DM - Reaction formation
Assessment - Use of DM
- Inappropriate behaviors
- Difficult to dx
- Full medical problems
- Assess suicidal thoughts
- Medications - Help identify medical co-morbidness
- Life pattern = “always been this way”
- Recent loss
Goals - Rotate staff to decrease manipulation
- Give positive reinforcement
- Sould be - Explore feelings of fear
long-term - Work on one goal at a time
- Firm yet supportive approach
- Offer realistic choices to enhance pt’s sense of self control
- Limit setting and consistency are essential with pt’s who are
manipulative
- Team meetings to establish limit setting activities
- Decrease stimuli - Esp. Group B
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Limit Setting - 1. Identify behaviors and discuss behaviors
- 2. Jointly discuss appropriate behaviors
- 3. Jointly establish consequences when violates
- 4. Implement consequences when appropriate

Alcohol Use Screening: CAGE


 C | Cut back: Has anyone ever suggested that you cut back on drinking?
 A | Annoyed: Has anyone ever expressed being annoyed at your drinking habits?
 G | Guilt: Do you ever feel guilty about your drinking?
 E | Eye opener: Do you ever feel the urge to have a morning drink (referred to as
an “eye opener”)?
 S | Shakes: Do you ever experience “The Shakes” when you don’t have a drink?
(More common in the morning)
Altered Mental Status: DIM TOP (as in his head ain’t right!)
 D | Drugs: Prescription, illicit, accidental overdose, and toxicity of unknown origin
 I | Infections: Meningitis, encephalitis, sepsis, urinary tract infections, and others
 M | Metabolic: Hypoglycemia, hyponatremia, and other imbalances
 T | Trauma: Head, c-spine, and blood loss
 O | Oxygen deficit: CNS hypoxia, metabolic
 P | Psychological: Diagnosis of exclusion
Bipolar Disorder Manic Episode Signs: DIG FAST
 D | Distractibility
 I | Indiscretion, impatience, and irritability
 G | Grandiosity
 F | Flight of ideas and energy
 A | Activity increase
 S | Sleep deficit/Sexually hypoactive
 T | Talkative- excessively
Depression Assessment Signs: CAPS
 C | Concentration impaired or decreased
 A | Appetite changes
 P | Psychomotor function decreased
 S | Suicidal ideations and sleep disturbances
Depression: Assessment Findings | SIGN
 S | Sleep disturbances
 I | Interest decreased
 G | Guilty feelings
 N | No energy
Generalized Anxiety Disorder: Worry WARTS
 W: Wound up
 W: Worn-out
 A: Absentmindedness
 R: Restless
 T: Touchy (as in increased emotional sensitivity)
 S: Sleepless
Major Depressive Disorder: SIG E CAPS
 S | Suicidal thoughts
 I | Interests decreased
 G | Guilt
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 E | Energy decreased
 C | Concentration decreased
 A | Appetite disturbance
 P | Psychomotor changes
 S | Sleep disturbances
OARS: Motivational Interviewing
 O | Open-ended questions
 A | Affirmations
 R | Reflections
 S | Summaries
Psych Assessment: Always Send Mail Through Post Office
 A | Appearance
 S | Speech
 M | Mood and Memory
 T | Thoughts
 P | Perception
 O | Orientation
Schizophrenia: Primary Symptoms | 4 A’s
1. A | Affect
2. A | Ambivalence
3. A | Associative looseness
4. A | Autism (autistic-like behavior; including limited affection/difficulty making
interpersonal connections with others)
Suicide Attempt Warning Signs: IS PATH WARM?
 I: Ideation
 S: Substance abuse
 P: Purposelessness
 A: Anxiety
 T: Trapped
 H: Hopelessness
 W: Withdrawal
 A: Anger
 R: Recklessness
 M: Mood Changes