Review exam i 2

The DSM-IV-TR
Multiaxial System p 13-15
 Axis I: Mental disorder that is the focus of
treatment
 Axis II: Personality disorders and mental
retardation
 Axis III: General medical disorder relevant
to the mental disorder in axis I
 Axis IV: Psychosocial and environmental
problems
 Axis V: Global Assessment of Functioning
(GAF)

2

 Stem: Unresolved issues in childhood
 Levels of awareness
◦ Conscious
◦ Preconscious
◦ Unconscious

Freud's Psychoanalytic Theory

3

 Personality structure
◦ Id
Pleasure principle
Reflex action
Primary process
◦ Ego
Problem solver
Reality tester
◦ Superego
Moral component

Continued
4

 Defense mechanisms and anxiety
◦ Operate on unconscious level
◦ Deny, falsify, or distort reality to make it
less threatening

Continued
5

 Attentive listening
 Transference and countertransference
 Therapy: psychoanalysis (lengthy) , free
association, dream analysis, focuses on
here and now
 Brief psychotherapy

Freudian Theory and Nursing
6

 Eight stages of development
◦ Personality continues to develop through old
age
 Failures at one stage can be rectified at
another stage
 Table p 29

Erikson's Ego Theory
7

 Rational-Emotive Behavior Therapy (Ellis)
◦ Perception influences thoughts which influence
behavior
◦ Aims to eradicate irrational beliefs
◦ Recognize thoughts that are not accurate
 Cognitive-Behavioral Therapy (Beck)
◦ Test distorted beliefs and change way of
thinking; reduce symptoms
◦ Automatic thoughts, cognitive distortions
◦ Table p 36

Cognitive Theories
8

 GABA is an inhibitory (calming)
neurotransmitter in the CNS
 Benzodiazepines (potentiate GABA)
◦ Diazepam (Valium)
◦ Clonazepam (Klonopin)
◦ Alprazolam (Xanax)
◦ Lorazepam (Ativan)

Antianxiety and Hypnotic Drugs
9

◦ Flurazepam (Dalmane)
◦ Temazepam (Restoril)
◦ Triazolam (Halcion)
◦ Estazolam (ProSom)
◦ Quazepam (Doral)
◦ Patient teaching: Avoid heavy
machinery, limit use due to tolerance and
dependence, do not mix with alcohol or other
depressants

Continued
10

 Short-Acting Sedative-Hypnotic Sleep Agents
(“Z-hypnotics”)
◦ Zolpidem (Ambien)
◦ Zaleplon (Sonata)
◦ Eszopiclone (Lunesta)
◦ Patient teaching: Quick action – take
immediately before retiring, short half-
lives, may cause bad taste upon awakening

Continued
11

 Melatonin Receptor Agonist
(Melatonin is a hormone secreted by the
pineal gland that regulates circadian
rhythm)
◦ Ramelteon (Rozerem) – low abuse potential,
not restricted to short-term use
◦ Buspirone (BuSpar) – not a CNS depressant,
less potential for addiction

Continued
12

Antidepressant Drugs

 Typical or standard antidepressants
◦ Tricyclic antidepressants (TCAs) block
the reuptake of norepinephrine and
serotonin
◦ Amitriptyline (Elavil)
◦ Imipramine (Tofranil)
◦ Nortriptyline (Pamelor)
◦ Cause anticholinergic side
effects, sedation, drowsiness, and
can cause death

13

 Selective serotonin reuptake inhibitors
(SSRIs)
◦ Fluoxetine (Prozac)
◦ Sertraline (Zoloft)
◦ Paroxetine (Paxil)
◦ Citalopram (Celexa)
◦ Escitalopram (Lexapro)
◦ Fluvoxamine (Luvox)
◦ Less lethal, no anticholinergic SE or
sedation, cause apathy, low libido, n/v
Continued
14

 Serotonin-Norepinephrine Reuptake
Inhibitors (SNRIs)
◦ Venlafaxine (Effexor)
◦ Duloxetine (Cymbalta)
◦ Can cause hypertension and lower seizure
threshold

Continued
15

 Serotonin-Norepinephrine Disinhibitors
(SNDIs)
◦ Mirtazapine (Remeron)
◦ Has antiemetic properties also. Causes
sedation and weight gain (good for anorexics)

Continued
16

 Monoamine oxidase inhibitors (MAOIs)
 (Monoamine oxidase is the enzyme that
metabolizes norepinephrine. To inhibit it allows a
consistent level of norepi at the synapse.)
◦ Phenelzine (Nardil)
◦ Tranylcypromine (Parnate)
◦ Selegiline (ENSAM)
◦ Seldom used due to dietary restriction of
tyramine (with drug causes hypertensive crisis)
Must avoid aged cheeses, pickles, smoked fish,
wine

Continued
17

 Bupropion (Wellbutrin, Zyban)
◦ Can cause seizures, weight loss, and
sexual dysfunction
 Trazodone (Desyrel)
◦ Can cause priapism; given at night due to
sedation

Other Antidepressant Drugs
18

Mood Stabilizers
 Lithium (reduces overactivity of neurons
in brain)
◦ Dosing based on serum drug levels
(monitored q week)
◦ Serum level should be 1.0 mEq/L
◦ Less than 0.5 mEq/L is subtherapeutic
◦ More than 1.5 mEq/L is toxic
◦ Greater than 3.0 mEq/L requires
dialysis stat

19

 Common side effects
◦ Mild nausea, diarrhea, anorexia
◦ Fine hand tremor
◦ Polydipsia and polyuria
◦ Metallic taste in mouth
◦ Weight gain
◦ Acne

Lithium
20

 Toxic side effects
◦ Severe diarrhea
◦ Vomiting
◦ Drowsiness
◦ Muscle weakness
◦ Lack of coordination
◦ Can lead to renal failure and death

Lithium
21

Anticonvulsant drugs

◦ Valproate (Depakote, Depakene)
 Causes wt gain, sedation, thrombocytopenia,
liver & renal problems
 Requires bloodwork (CBC & liver) before
starting and periodically while on meds
◦ Carbamazepine (Tegretol)
 Same SE as above plus anticholinergic SE and
rash
 Requires ongoing labs to monitor CBC, liver
function and drug level (below 12 mcg/mL)

22

◦ Lamotrigine (Lamictal)
 Watch for Stevens-Johnson Syndrome
◦ Gabapentin (Neurontin)
◦ Topiramate (Topamax)
 Can cause blindness, weight loss, kidney stones
◦ Oxcarbazepine (Trileptal)

Anticonvulsants (mania)
23

 First-Generation or Conventional
Antipsychotic Drugs
◦ Phenothiazines
◦ Thioxanthenes
◦ Butyrophenones
 Strong antagonists (blocking agents)
◦ Bind to D2 receptors
◦ Block attachment of dopamine
◦ Reduce dopaminergic transmission

Antipsychotic Drugs
24

Antipsychotics
 Treats positive symptoms of schizophrenia
(delusions, hallucinations)
 Side effects include extrapyramidal
symptoms
(parkisonism, akinesia, akathisia, dyskinesi
a, and tardive dyskinesia)
 Monitor SE with Simpson scale (for acute
SE) or Abnormal Involuntary Movement
(AIMS)
 Treat with benztropine
(Cogentin), trihexyphenidyl
(Artane), diphenhydramine (Benadryl)
 Depot form
25

 Binds to dopamine receptors in the limbic
system
◦ Decreased motor side effects and EPS
◦ Increases the risk of metabolic syndrome with
wt gain, hyperglycemia and increased
triglycerides. (Can cause insulin resistance)
Can cause sedation
◦ Clozaril causes agranulocytosis and requires
weekly CBCs to get meds

Atypical Antipsychotics
(Second-Generation)
26

Atypical Antipsychotics
Continued
 Clozapine (Clozaril)
 Risperidone (Risperdal)
 Olanzapine (Zyprexa)
 Ziprasidone (Geodon)
 Aripiprazole (Abilify)
 Paliperidone (Invega)
 Review p 70

27

Other Drugs
 For Attention Deficit Hyperactivity Disorder
(ADHD) – Psychostimulants
 Block reuptake of norepinephrine and
release monoamines that act as agonists
at adrenergic receptor sites-
sympathomimetics.
 SE include decreased appetite, wt loss,
growth suppression

28

Psychostimulants
◦ Methylphenidate (Ritalin) – do not take
after 4 p.m.; monitor weight
 Concerta
 Daytrana
◦ Dextroamphetamine (Adderall)
◦ Methamphetamine – (Desoxyn)
◦ Dexmethylphenidate (Focalin)
◦ Lisdexamfetamine (Vyvanse)
◦ Atomoxetine hydrochloride (Strattera)
 Nonstimulant – 24 hour dosing

29

 For Alzheimer's Disease
 cholinesterase inhibitors
◦ Tacrine (Cognex)
 hepatotoxic
◦ Donepezil (Aricept)
◦ Revastigmine (Exelon)
◦ Galantamine (Reminyl)
◦ Memantine (Namenda) – works as glutamate
antagonist

Other Drugs

30

 Admissions reserved for
◦ Suicidal
◦ Homicidal or
◦ Unable to care for basic needs (thus
endangering self)
◦ Outpatient therapy is ineffective

Inpatient Psychiatric Care
31

Inpatient Psychiatric Care

 Admission options
◦ Direct admission
◦ Hospital emergency department
 Criteria to justify admissions
◦ Danger to self or others or unable to
care for basic needs
 Voluntary or involuntary

32

 Hospitalized patients retain their rights as
citizens. They have the right to:
◦ Vote
◦ Receive, forfeit or deny a driver’s license
◦ Make purchases and enter contraction
relationships (unless incompetent)
◦ Press charges against another person
◦ Humane care and treatment (least
restrictive)
◦ Due process

Patient Rights
33

 They have the right to:
◦ Religious freedom and practice
◦ Social interaction
◦ Exercise and participate in recreational
opportunities
◦ Refuse treatment
◦ Informed consent
◦ Freedom from seclusion and restraint
◦ Confidentiality

Patient Rights
34

 Exceptions to the rule
◦ Duty to warn and protect third parties
◦ Child and elder abuse reporting statutes

Confidentiality
35

 Review nonverbal communication patterns
on p 105 for cultural variances

 Assess general appearance
◦ Dress, hygiene, grooming
◦ Appropriate for age? Setting? Weather?
◦ Is the person disheveled? Unkempt?
◦ Does the person appear their stated age?
◦ How is the person’s posture? Eye contact?
Facial expressions?

Mental Status Exam
37

 Assess motor behavior
◦ Automatisms
◦ Psychomotor retardation
◦ Waxy flexibility
◦ Speech (Do they clang? Do they create
neologisms?)

MSE
38

 Assess mood and affect
◦ Mood – emotional state
◦ Affect – outward expression of mood
◦ Look for consistency between verbal and
nonverbal communication
◦ Ask patient to rate his mood on a scale of 1-10

MSE
39

◦ Is affect blunted?
◦ Is affect flat?
◦ Does patient have an inappropriate affect?
◦ Is affect restricted?
◦ Is affect labile?

MSE
40

 Assess thought process and content
◦ Can patient stay on track with thoughts?
◦ What is the content of patient’s thoughts?
◦ Listen for themes
◦ Assess if patient makes sense? Are ideas
related? Do they flow logically so you can
follow the conversation?

MSE
41

◦ Circumstantial thinking
◦ Delusions – FALSE FIXED BELIEFS (i.e.
grandiose, poverty, somatic, religious,
persecution)
◦ Flight of ideas
◦ Ideas of reference
◦ Loose associations
◦ Tangential thinking

MSE
42

◦ Thought blocking
◦ Thought broadcasting
◦ Thought insertion
◦ Thought withdrawal
◦ Word salad

MSE
43

 Assess for suicidality
 Assess sensorium
◦ Oriented x 3
◦ Memory
◦ Ability to concentrate

MSE
44

 Assess for sensory-perceptual alterations
◦ Hallucinations – FALSE SENSORY PERCEPTIONS
(i.e. auditory, visual, tactile, etc.)

MSE
45

 Assess insight
 Assess self-concept
 Assess coping
 Assess relationships
 Assess judgment
◦ Use situational questions

MSE
46

 Assess for neurovegetative changes
◦ Changes in eating or sleeping habits
◦ Weight gained or lost
◦ Hours slept per night

MSE
47

 Needs of patient identified and explored
 Clear boundaries established
 Problem-solving approaches taken
 New coping skills developed
 Behavioral change encouraged
 Nurses needs are met outside of the
relationship

Therapeutic Relationships
48

 Transference – patient unconsciously
displaces onto individual in current life
emotions and behaviors from childhood
that originated in relationships with
significant others
◦ Transference intensified with person in
authority in current life

Blurring of Roles
49

 Countertransference – nurse displaces
feelings related to people in nurse’s past
onto patient
◦ Patient’s transference to nurse often results in
countertransference in nurse
◦ Common sign of countertransference in nurse is
overidentification with the patient

Blurring of Roles
Continued
50

 Orientation phase

 Working phase

 Termination phase

Peplau’s Model of Nurse-Patient
Relationship
51

 Tools for enhancing communication
◦ Using silence
◦ Active listening
◦ Listening with empathy
◦ p 181-185

Therapeutic Communication
Techniques
52

 Paraphrasing
 Restating
 Reflecting
 Exploring

Clarifying Techniques
53

 Open-ended questions

 Closed-ended questions

Asking Questions and Eliciting
Patient Responses
54

 Excessive questioning
 Giving approval or disapproval
 Giving advice
 Asking “why” questions

Nontherapeutic Communication
Techniques
55

Autism
 More common in males; more severe in girls
 Cause may be related to immunizations
 Present by early childhood (age 3)
 Little eye contact, few facial expressions, doesn’t
communicate verbally or with gestures, doesn’t
relate to peers or parents, lacks spontaneous
enjoyment, cannot engage in make believe with
toys.
 May exhibit hand flapping, body twisting, head
banging
 Autism may improve if language skills improve
 Traits persist into adulthood

56

 Short term care: decrease child’s level of
anxiety (private room, touch as little as
possible, minimize time in
room, encourage parents to stay, bring in
familiar objects from home, keep
communication brief and
concrete, maintain a predictable schedule
as close to home as possible)

Autism (cont)
57

 Long term care: encourage social
interactions, foster development of
communication skills, encourage
development of self control, provide
opportunities for development of
psychomotor skills.

Autism (cont.)
58

Attention Deficit Hyperactivity
Disorder and Disruptive
Behavior Disorders
 Attention deficit hyperactivity disorder
◦ Inattention
◦ Overactivity
◦ Impulsivity
 Oppositional defiant disorder
 Conduct disorder
◦ Childhood onset and adolescent onset

59

 Fidgets constantly
 Makes excessive noise
 Normal environmental noises are
distracting
 Cannot listen to directions or complete
tasks
 Blurts out answers before questions are
completed

Symptoms
60

 Hurried, careless mistakes in schoolwork
 Loses or forgets homework assignments
 Fails to follow directions
 Peers may ostracize
 Temper tantrums especially when young

Symptoms (cont)
61

Outcomes Identification
 Remains safe
 Demonstrates effective coping
methods
 Develops friendships with peers

Attention Deficit Hyperactivity
Disorder
Continued
62

 Help parents cope
 Teach parents: structure, limits, &
consistency are key
 Provide consistent rewards and
consequences for behavior
 Offer consistent praise
 Use time-out

Strategies
63

 Give verbal reprimands
 Issue daily report card for behavior
 Use a point system for positive and
negative behaviors
 Teach coping skills (Stop & Think)
 Teach social skills
 Don’t talk about symptoms or illness in
front of child or child will see self as sick

64

 Role play ways to cope with stressful
events
 Have child discuss and examine
consequences of his/her behavior

65

 Structure, limits and consistency
 Daily schedule
 Limit setting
 Behavioral contracts
 Time out or loss of privileges
 Tough love
 Individual therapy for child; family therapy

Treatment for
Oppositional/Defiant Disorder and
Conduct Disorder
66

 Depression is often just seen as misbehavior or
irritability
 Anhedonia is losing interest in things that once
child was passionate about
 Children & adolescents will give away prized
possessions when suicidal
 Copy cat suicides are common; quick
intervention needs to occur following a suicide
 Bipolar disorder is hard to differentiate from
ADHD

Mood disorders
67

 Anxiety is part of normal development
 Anxiety is a problem when:
◦ An individual fails to move beyond the fears
associated with a particular problem
◦ It interferes with normal functioning over an
extended period of time
 Two anxiety disorders of children and
adolescents:
◦ Separation anxiety disorder
◦ Posttraumatic stress disorder

Anxiety Disorders
68

Separation Anxiety Disorder and
Posttraumatic Stress Disorder
Continued
Implementation
 Protect child from panic levels of anxiety.
 Provide emotional support to help child
progress developmentally.
 Increase child's self-esteem and feelings of
competence.
 Help child accept and work through traumatic
event.
 Teach coping skills.
 Cognitive therapy
◦ Focused on underlying fears and concerns
69

 Results: hypothalamus triggers adrenal
glands to release adrenalin which
increases SNS activity (e.g. tachycardia,
tachypnea, hypertension, dilated pupils,
blood shunted away from GI and GU tracts
to muscles); hypothalamus causes adrenal
cortex to release steroids to increase
muscle endurance/stamina and mobilizes
glucose in bloodstream, but also inhibits
reproduction, growth and immunity.
Endorphins are released to reduce
sensitivity to pain/injury.

70

 Interaction between nervous system and
immune system during alarm phase of
GAS

 Negatively affects body’s ability to
produce protective factors

Immune Stress Responses
71

 Stress Busters Box 11-1
 Jacobson – Progressive muscle relaxation
 Benson’s relaxation techniques
 Meditation
 Guided imagery
 Breathing exercises

Behavior Stress-Management
Techniques
72

 Cognitive reframing
 Mindfulness
 Journaling
 Humor

Cognitive Approaches to
Stress Management
73

 Mild anxiety
 Moderate anxiety
 Severe anxiety
 Panic

Levels of Anxiety
74

 Defense mechanisms (p 215-217)
◦ Automatic coping styles
◦ Protect people from anxiety
◦ Maintain self-image by blocking
 feelings
 conflicts and
 memories
◦ Can be healthy or unhealthy

Defenses Against Anxiety
75

 Specific phobias p 220

 Social phobia or social anxiety disorder
(SAD)

Phobias
76

 Obsessions
◦ Thoughts, impulses, or images that persist and
recur, so that they cannot be dismissed from the
mind
 Compulsions
◦ Ritualistic behaviors an individual feels driven to
perform in an attempt to reduce anxiety

Obsessive-Compulsive Disorder
(OCD) p 221
77

 Flashbacks
 Avoidance of stimuli associated
with trauma
 Experience of persistent numbing
of responses
 Persistent symptoms of increased arousal

Posttraumatic Stress Disorder
(PTSD)
78

Basic Level
Nursing Interventions
 Do not set limits on rituals at first
 Teach relaxation exercises and practice them
 Explore coping behaviors that have worked in
the past
 Decrease environmental stimuli
 Channel anxiety into physical activity
 Communicate with firm, short, simple
statements and repetition
 Remain calm; stay with patient with severe
anxiety

79

 Promote self-care activities
 Reinforce reality
 Attend to physical needs (limit caffeine)
 Later, set limits on rituals while helping
patient use relaxation (i.e. postpone
performance of ritual by 5 minutes, then
10 minutes, while using relaxation)
 Pharmacological interventions
 Health teaching

80

Advanced Practice
Interventions
 Cognitive therapy
◦ Cognitive restructuring
◦ Cognitive behavioral therapy
 Reframing
 Decatastrophizing
 Assertiveness training

81

Other
Interventions
 Visual imagery
 Change of pace or scenery
 Exercise
 Music
 Massage (effleurage)
 Meditation, prayer
 Therapeutic touch
 Hypnosis

82

 Behavioral therapy
◦ Relaxation training
◦ Modeling
◦ Systematic desensitization
◦ Flooding
◦ Response prevention
◦ Thought stopping

83

 Medications
◦ Antianxiety (anxiolytics)
◦ Antidepressants (SSRIs)
◦ Antihistamines
◦ Beta blockers
◦ Anticonvulsants
 Herbal and complementary practices
◦ Kava kava

84

Cluster A Personality Disorders
 Eccentric and odd behavior
 Unusual levels of suspiciousness
 Magical thinking
 Cognitive impairment
 Examples
◦ Paranoid PD p 436
◦ Schizoid PD p 436
◦ Schizotypal PD p 436

85

Cluster B Personality Disorders

• Dramatic, emotional, erratic
behavior
• Problems with impulse control
• Examples
– Antisocial PD p 437
– Borderline PD p 437
– Histrionic PD p 439
– Narcissistic PD p 439
86

Cluster C Personality Disorders
 Anxious or fearful behavior
 Rigid patterns of social shyness
 Examples
◦ Avoidant PD p 440
◦ Dependent PD p 441
◦ Obsessive-compulsive PD p 441

87

Interventions
 Basic level interventions
◦ Milieu management
(structure, limits, confrontation and
consistency) Watch for splitting
◦ Pharmacological interventions
◦ Case management
◦ Limit setting
◦ Interventions for aggressive behavior
◦ Interventions for impulsive behavior

88

Somatoform Disorders
 Physical symptoms suggest a physical
disorder for which there is no
demonstrable base

 Strong presumption that symptoms
linked to psychobiological factors

89

Somatoform Disorders
 Somatization disorder
 Undifferentiated somatoform disorder
 Conversion disorder
 Pain disorder
 Hypochondriasis
 Body dysmorphic disorder
 Somatoform disorder not otherwise
specified

90

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