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Avoidance of difficult realities by ignoring or refusing to recognize them, or minimizing the impact or effect something wil have on their life.
Denial/minimization
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Attributing one’s own thoughts or impulses to another person.
Projecting
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Feelings, emotions and conflicts are expressed behaviorally, rather than through language.
Acting out
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Excessive reasoning of logic used to avoid painful emotions.
Intellectualization
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Offering a socially acceptable or apparently logical explanation to justify or make acceptable otherwise unacceptable impulses, feelings, behaviors and motives.
Rationalization
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Voluntary psychiatric hospitalization.
Person signs themselves into the hospital and must give 72 hours notice of intent to leave.
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Involuntary psychiatric hospitalization.
2 physicians determine that a person meets criteria and can be hospitalized without consent.
-
Emergency petition for psych evaluation.
Person can be taken to ED for evaluation.
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What is Transference?
An unconscious response of patients in which they experience feelings and attitudes toward the nurse that were originally associated with significant figures in their lives- may be positive or negative
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What is Counter transference?
An emotional response of the nurse that is generated by the patient’s qualities that stimulate emotions based on their own personal experience that results in behavior based that is not appropriate to the therapeutic relationship
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Psychiatric medication that is extremely addicting.
Benzodiazepines
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Length of time by which an involuntary hospitalized patient must have a hearing.
10 days
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Axis I Diagnosis
Psychiatric Clinical Disorders
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Axis II Diagnosis
Personality disorders, mental retardation
-
Axis III Diagnosis
Medical conditions
-
Axis IV Diagnosis
Psychosocial and environmental problems
-
Axis V Diagnosis
Global Assessment of Functioning (GAF)
-
-
What Axis is Schizophrenia?
Axis I
-
What Axis is poly-substance abuse?
Axis I
-
What Axis is obsessive compulsive personality disorder?
Axis II
-
What Axis is alcohol and drug dependence?
Axis I
-
What Axis is eating disorder?
Axis I
-
How old does a person have to be to be diagnosed with a personality disorder?
At least 18 years old
-
-
What GAF score is assigned to out of control behavior or danger to themselves?
0-30
-
What GAF score is assigned to in control, serious problems?
31-70
-
What GAF score is assigned to average or above average function?
71-100
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Best predictor of suicide?
Previous attempt
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Parts of the Mental Status Exam.
- Appearance/Behavior
- Orientation/LOC
- Cognitive functioning
- Mood/Affect
- Speech
- Thought Processes and content
- Perception
- Insight/judgment
-
Tool used to assess cognitive functioning.
Mini Mental Status Exam
-
Difference between Mood and Affect.
- Mood is what the patient tells you
- Affect is what you observe
-
What may waxing and waning of LOC indicate?
Delerium
-
Four areas of memory?
- Immediate recall
- Short-term
- Long-term
- Remote
-
Five elements of speech assessment.
- Quantity
- Volume/tone
- Rate
- Rhythm
- Impairments
-
Loosening of Associations (LOA)
Lack of connectedness in thoughts and ideas with sudden illogical shifts in topic without any relation to the preceding topic.
-
Tangential
Gets off topic very easily and ends up on a totally different topic though it may have had some relation to the original topic.
-
Circumstantial
Difficulty getting to the point because of lengthy unnecessary detail about the topic.
- Flight of Ideas
- Rapid thoughts that are often fragmented and shifting topics.
-
Perseveration
Excessive focus on a topic, activity, or idea which interferes with all interactions and activities.
-
Delusions
FIXED FALSE BELIEFS that are outside of the norms for the patient’s social, cultural or religious background. They often have a theme and can be classified as paranoid, religious, grandiose, somatic or erotomanic.
-
Thought broadcasting
The belief that others can read their mind or hear their thoughts.
-
Thought insertion
The belief that others are putting thoughts in their head.
-
Ideas of influence
The belief that someone/something is controlling their behavior.
-
Hallucinations
False sensory experiences. It’s not really there.
-
Illusions
Misperceptions or misrepresentations of real external sensory stimuli. It’s there but it’s not what you perceive it to be.
-
Hallucinations often seen with brain tumors.
Gustatory and olfactory
-
Hallucinations often seen in schizophrenics.
Auditory
-
Insight
Ability to understand cause and effect, especially concerning one’s own actions
-
Judgment
Ability to make accurate analysis of a situation and choose appropriate actions
-
Anosognosia
Person is unaware of their disability. Common in right hemisphere strokes.
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Location of Broca’s area.
Left hemisphere, back of fronal lobe.
-
Location of Wernicke’s area.
Most people have it on left in temporal lobe.
-
Location in brain where executive function occurs.
Pre-frontal cortex
-
Function in Precentral Gyrus
Primary motor area
-
Function of Prefrontal cortex
- Executive function
- higher cognition
- working memor
- personality
-
What is Executive Function?
Planning, organizing, and carrying out complex behavior
-
Functional areas of Parietal Lobe
- Postcentral Gyrus = Primary sensory cortex
- Touch, pain, temperature, proprioception
-
Functional areas of Temporal Lobe:
- Primary auditory cortex
- Wernicke’s area
-
Connects left and right brain.
Corpus callosum
-
Relay station for most information going into the brain
Thalamus
-
Regulates blood pressure, body temperature and sex hormones.
Hypothalamus
-
Regulates heartbeat and other visceral functions, and processes the emotion fear
Amygdala
-
Helps establish long term memory in regions of the cerebral cortex.
Hippocampus
-
Control of breathing, heartbeat, circulation and digestion.
Pons, Medulla
-
Control system for movement and cognitive function.
Basal ganglia
-
Bradykinesia, hyperkinesia, and hypokinesia all suggest disease of, or damage to…
Basal ganglia
-
Neurotransmitter that regulates arousal, concentration, learning and memory, mood, stress response
Norepinephrine (NE)
-
Neurotransmitter that regulates stress response
Epinephrine (E)
-
Neurotransmitter that regulates arousal, concentration, learning and memory, mood, stress response
Dopamine (DA)
-
Neurotransmitter that regulates mood, appetite, eating behavior, sleep, depression and anxiety
Serotonin (5-HT)
-
Neurotransmitter that regulates sleep/wake
Melatonin
-
Percentage of psychiatric illness that is explained by genetics?
No more than 50-70%
-
What is the Diathesis Stress Model?
Genetic vulnerability + stressor → expression of psychiatric disorder
-
What is Serotonin syndrome?
- hyperserotonergic state
- Hyperreflexia, myoclonic jerking, confusion, autonomic dysfunction, muscle rigidity, ataxia
-
What is a potentially lethal side effect of antipsychotics?
Neuroleptic malignant syndrome
-
S/S of neuroleptic malignant syndrome.
Fever, tachycardia, sweating, muscle rigidity, tremor, incontinence, stupor
-
Special considerations regarding children and medication.
Have greater hepatic capacity and glomerular filtration rates, may be less able to store medication in body fat. Shorter half-life.
-
Special considerations regarding the elderly and medication.
- GI disease may decrease absorption
- Slower metabolism increases toxicity risk
- May have greater sensitivity to psychotropics
- Multiple medication interaction
- More susceptible to adverse effects
-
Common side effects of Tricyclic Antidepressants
- Arrhythmia
- Orthostatic hypotension
-
Atypical antipsychotics increase mortality among elderly patients with these conditions…
dementia and psychosis
-
Most psychotropics are this pregnancy category
Category C, some are Category D (anticonvulsants).
-
Psychotropics that pass through breast milk.
All of them.
-
How cholinesterase inhibitors work.
Decrease metabolism of ACh by cholinesterase
-
How Monoamine Oxidase Inhibitors work.
Decrease metabolism of transmitters by MOA
-
How antipsychotic drugs work.
Block dopamine from binding with receptors
-
How atypical antipsychotics and some antidepressants work.
Block specific serotonin receptor families
-
How benzodiazepines work.
Enhance the effects of GABA at the receptor
-
Receptor sensitivity changes
Receptor becomes more or less responsive
-
Reuptake inhibition:
Leaves more neurotransmitter in synapse
-
Five key concepts of recovery.
- •HOPE
- •PERSONAL RESPONSIBILITY
- •EDUCATION
- •SELF-ADVOCACY
- •SUPPORT
-
Ragin’s Four Stages of Recovery
- •HOPE
- •EMPOWERMENT
- •SELF – RESPONSIBILITY
- •A MEANINGFUL ROLE IN LIFE
-
10 Fundamental Components of Recovery
- Self direction
- Individualized & Person-centered
- Empowerment
- Holistic
- Non-linear
- Strenghts-based
- Peer support
- Respect
- Responsibility
- Hope
-
What is a more important criterion of recovery than being symptom free?
Psychosocial functioning
-
Personal process of recovery.
The process of positive adaptation to the illness and living a satisfying life (patient’s role)
-
Treatment process of recovery
The external conditions that can facilitate personal recovery (practitioner’s role)
-
Recovery oriented services are reimburseable by…
Medical assistance. Not medicare.
-
Biggest barrier to recovery according to 1999 Surgeon General’s Report on Mental Health.
Stigma
-
Percent of homeless population in US that suffers from some form of severe mental illness.
20-25%
-
Percent of Americans that are severely mentally ill.
6%
-
Third largest cause of homelessness for single adults.
Mental illness
-
What population is overrepresented in the US’s homeless population?
African American Men
-
How many years shorter is the life expectancy of a schizophrenic?
10-20 years
-
Percent of schizophrenics that attempt suicide? Succeed?
-
What changes brain development of a fetus that may increase vulnerability to schizophrenia?
- Alcohol
- Drugs
- Poor nutrition
- Stress
- Viruses
-
Percentage of patients with schizophrenia have a co-occurring substance abuse disorder (alcohol/cannabis).
Nearly 50%
-
What neurobiological findings in schizophrenia can be seen with a PET scan?
- Decreased blood flow to frontal lobes
- Decreased size of thalamus
- Increased activity of basal ganglia
-
What is the dysregulation hypothesis related to schizophrenia?
There are overactive dopamine pathways to the mesolimbic areas of the brain and underactive pathways to the mesocortical areas and there is an imbalance between serotonin and dopamine neurotransmitter systems.
-
Schizophrenia diagnosis criteria according to the DSM IV-TR:
- At least two of the following signs/symptoms present for at least 6 months:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized/catatonic behavior
- Negative symptoms
-
What is schizophreniform disorder?
Meets criteria for schizophrenia and episode lasts at least one month but less than 6 months.
-
Positive symptoms of schizophrenia.
- Delusions
- Hallucinations
- Thought disorder
- Disorganized speech
- Bizarre behavior
- Inappropriate affect
-
Negative symptoms of schizophrenia
- Flat affect
- Alogia
- Avolition/apathy
- Anhedonia/associality
- Attention deficit
-
Cognitive symptoms of schizophrenia.
- Attention
- Memory
- Executive Functions impaired
-
Mood symptoms of schizophrenia.
- Dysphoria
- Suicidality
- Hopelessness
-
Social/occupational dysfunction in schizophrenia.
- Work/activity
- Interpersonal relationships
- Self-care
- Mortality/morbidity
-
Types of delusions:
- Paranoid
- Persecutory
- Somatic
- Nihilistic
- Grandiose
- Religious
-
Schneiderian 1st Ranks Symptoms:
- Thought broadcasting
- Thought insertion
- Thought withdrawal
- Ideas/delusions of reference
-
Positive symptoms of Schizophrenia
- Hallucinations
- Delusions
- Disorganized thoughts
- Other odd/unusual behaviors
-
Some examples of disorganized thoughts:
- Loosening of associations
- Echolalia
- Concrete thinking
- Neologisms
- Clang associations
-
Negative syptoms of Schizophrenia
- Flat affect
- Alogia (poverty of speech)
- Avolition
- Anhedonia
-
Cognitive Symptoms of Schizophrenia
- Poor attention span
- Memory
- Executive function impairment
-
Effect of nicotine/smoking on schizophrenics
It is hypothesized that nicotine may help with cognitive functioning and negative symptoms.
-
Mood symptoms with schizophrenia
- Dysphoria
- Hopelessness
- Suicidality
-
High risk times for suicide in schizophrenics.
- 1. Periods when they are very psychotic and out of touch with reality.
- 2. Periods when they are very depressed
- 3. In the first 6-9 months after they have started first taking meds
-
Features of paranoid schizophrenia.
Pre-occupation with 1 or more delusions or frequent auditory hallucinations. No disorganized thoughts
-
Features of disorganized schizophrenia.
- Disorganized speech
- Disorganized behavior
- Flat of inappropriate affect
- Does not meet criteria for catatonic schizophrenia
-
Features of catatonic schizophrenia.
- At least two of the following:
- 1.motor immobility
- 2.excessive motor activity
- 3.extreme negativism or mutism
- 4.peculiarities of voluntary movement
-
Feature of undifferentiated schizophrenia.
Symptoms meeting general criteria are present byt criteria for other types are not met.
-
Features of residual schizophrenia.
Criteria for schizophrenia are not met, nor are those for any other subtype.
-
Risk factors for poor outcome in people with schizophrenia.
- Early onset
- Insidious onset
- Poor premorbid adjustment
- Inappropriate affective response:
- Enlarged cerebral ventricles
- Reduced blinking rates
- Poor response to meds
-
Criteria for schizoaffective disorder:
Has signs/symptoms of BOTH schizophrenia and a mood disorder and the mood and psychotics symptoms are concurrent.
-
Criteria for delusional disorder:
- Non-bizarre delusions at least 1 month
- No symptoms characteristics of schizophrenia
- May function well
-
Criteria for Brief psychotic disorder
Psychotic symptoms for more than 1 day and less than 1 month
-
How do typical antipsychotics work?
Block dopamine (D2) receptors
-
Indications for typical antipsychotics:
- Psycosis
- Manic excitation
- Severe agitation
- Tourette’s
-
Effect of typical antipsychotics on positive and negative symptoms:
- Decrease positive symptoms
- Can worsen negative symptoms
-
How long it takes for an antipsychotic medication to take effect…
7-10 days
-
Time it takes for typical antipsychotic to take full therapeutic effect….
4-6 weeks
-
Difference in side effects between high and low potency typical antipsychotics:
- High potency = greater risk of EPS, less sedation and anticholinergic effect
- Low potency = greater sedation and anticholinergic effect, lower risk of EPS
-
Common adverse effects of typical antipsychotics:
- orthostatic hypotension
- Anticholinergic symptoms
- Increased prolactin
-
Treatment for EPS from typical antipsychotics
Anticholinergic agents (cogentin and artane)
-
Extrapyramidal symptoms
- Muscle stiffness
- Cogwheel rigidity
- Shuffling gait
- Stooped posture
- Drooling
- Slow resting tremor
-
Treatment for acute dystonic reaction:
- Anticholinergics (cogentane and artane)
- Antihistamines (Benadryl)
-
Symptoms of Neuroleptic malignant syndrome:
- Motor/behavioral: muscular rigidity, dystonia, akinesia, mutism, obtundation, agitation
- Autonomic: hyperpyrexia, sweating, increased pulse and BP
-
Treatment of neuroleptic malignant syndrome:
- Immediate discontinuation of dopamine receptor antagonist
- Medical support to cool patient
- Monitor vitals, electrolytes, fluid balance, renal output
-
How atypical antipsychotics (SDAs) work:
- Block serotonin(5HT) and dopamine(DA) at the post-synaptic receptors
- Low risk of EPS and improves negative symptoms
-
Time before psychotic symptoms improve with atypical antipsychotics…
1 week
-
Time until full therapeutic effect on behavior takes effect with atypical antipsychotics (SDAs)…
4-12 weeks
-
Common side effects of SDAs:
- Weight gain
- Metabolic syndrome
- Insulin resistance/type II DM
- Sedation
-
More serious side effects associated with SDAs:
- Agranulocytosis
- EPS (lower risk)
- Mild-moderate prolonged QT interval (Geodon)
- Increased prolactin (Risperdal)
-
Adverse effects associated with Clozaril:
- Increased risk for diabetes and dyslipidemia
- Increased salivation
- Sweating
- Agranulocytosis
- Seizures
- Hyperglycemia with ketoacidosis
- Pulmonary embolism
- Myocarditis
- Neuroleptic malignant syndrome
-
Relationship between serotonin, dopamine and schizophrenia….
- Decrease in serotonin causes negative symptoms: Depression, decreased energy
- Increase in dopamine causes positive symptoms: Hallucinations, delusions, altered thinking/behavior/perceiving
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