b.Blood shunted away from digestive tract and kidneys to more essential organs-results in dry mouth.
c.corticosteroids produced and digestion decreased
d.endorphins released-reduces sensitivity to pain and injury
GAS
Resistance/Adaptation stage S&S
pituitary stops secreting but sx persist
This is the stage where stressors are successfully overcome but if not continues to next stage.
GAS
Exhaustion stage
Resources are depleted, the stress may become chronic.
Psychological and physiological responses.
Neurotransmitter that plays a role in mood, sleep, sexuality, appetite, and metabolism-
Serotonin
Distress
a negative draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue.
ex.death, work demands, financial overload
Eustress
positive beneficial energy that motivates and results in feelings of happiness, hopefulness, and purposeful movement.
ex. vacation, birth of baby, buying a new car
psychoneuroimmunology
studies that provide evidence that stress can induce changes in the immune system
Life-changing events questionnaire
way of quantifying stress over the last year
highest is death of child or spouse
Positive Stress Responses
Problem solving
Using social support
Reframing
Negative Stress Response
Avoidance
Self-blame
Wishful thinking
Most effective method to reduce stress-
Cognitive behavioral methods
Progressive Muscle Relaxation (PMR)
Tensing groups of muscles (beginning with feet and ending with face) for 8 sec and suddenly releasing them
Benson's Relaxation Technique
allows pt to switch from fight or flight to relaxation
Using a word that reflects your belief system like love
sit with eyes closed
deep breathing and say word
do this for 10 to 20 minutes
Meditation
works by training the mind to develop greater calm. works by creating a hypometabolic state of quieting the SNS
Guided imagery
process of envisioning images that are both calming and health enhancing
sometimes use auditory recordings
breathing exercises
diaphragmatic breathing
Other forms of stress reduction:
physical exercise, biofeedback, journaling, humor
Mindfulness
form of meditation where one observes and monitors the content of consciousness and recognizes thoughts as just thoughts- focuses on here and now
thinking of negative situations as positive
Most basic emotion
Anticipation of future threat
Anxiety
Reaction to a real or perceived imminent specific threat
Fear
Normal anxiety
a healthy reaction for survival
provides energy to carry out tasks involved in living and striving towards goals
Determines whether anxiety will help or hinder level of functioning-
the degree of anxiety experienced along with the ability to perceive it accurately and channel it appropriately
Acute Anxiety
crisis threatens sense of security
Chronic anxiety
long term anxiety
Levels of anxiety
Occurs in normal experience of everyday living.
See, hear, and grasp more info; problem-solving more effective
slight discomfort, restlessness, irritability, mild tension-relieving behaviors like nail biting
Mild anxiety
Anxiety Levels See, hear, and grasp less info and may demonstrate selective attention
problem-solving ability reduced
tension, pounding heart, increased HR AND RR, perspiration, GI discomfort, HA, urinary urgency.
Moderate anxiety
Anxiety Levels greatly decreased perceptual field, attention scattered. Can't focus on whole picture, completely self-focused, unable to learn or problem-solve, appear dazed. Behavior focused on reducing anxiety.
Sx increase such as: HA, nausea, dizziness, insomnia, trembling and pounding heart,
True hyperventilation, true tachycardia, sense of dread or impending doom.
Severe Anxiety
Anxiety Levels
Markedly disturbed behavior, can't process what's going on in env, lose touch with reality, may have hallucinations or delusions, can have erratic behavior.
automatic behaviors used to reduce anxiety
Panic
Interventions Mild to Moderate Anxiety:
communication techniques
calm behavior
willingness to listen
Interventions for severe to panic:
Safety-1st concern
Communication
restraints and seclusion as last resort
Coping mechanisms that are always healthy-
sublimation and altruism
Determines whether defense mechanisms are adaptive or maladaptive-
frequency, intensity, and duration
Meeting the needs of others. Get gratification vicariously. working out emotional conflict by helping others.
Altruism
An appropriate thing to an inappropriate thing.
ex. Dave Lively-Organ donation
a woman who is angry with her boss writes a short story about a heroic woman
Sublimation
Conscious denial of disturbing situation or feeling
Suppression
A man who is preparing to make a speech is told by his wife that he wants a divorce. he puts this aside until after the speech
Adaptive use of suppression
a woman who feels a lump in her breast puts the info in the back of her mind
maladaptive use of suppression
Trying to make up for an inadequacy. Frustration in one area exceeding in another.
Compensation
a person drinks alcohol when self-esteem is low to temporarily diffuse discomfort
maladaptive use of compensation
short man becomes assertively verbal and excels in business
adaptive use of compensation
Unconscious identification with another person
outside world is incorporated into a person's view of self
Introjection
after a wife's death a man has transient complaints of chest pain and difficulty breathing-the sx his wife had before dying
adaptive introjection
a child who's parents are overcritical and belittling thinks she is not good enough.
maladapative introjection
attributing characteristics of another person or group to self. can be conscious or unconscious
Identification
a child dresses up like her teacher and plays school
adaptive identification
a young boy thinks a neighborhood drug dealer is someone to look up to
maladaptive identification
1st line of psychological defense against anxiety
cornerstone of defense
Repression
Unconscious blocking of painful feelings or episode.
Repression
a woman is unable to enjoy sex after a traumatic sexual incident from childhood
maladaptive use of repression
a man forgets his wife's bday after a marital fight
adaptive use of repression
placing emotions associated with one person or situation onto another person or situation that is nonthreatening
displacement
want to choke Heaton but go home and yell at husband
displacement
a patient criticizes a nurse after his family fails to visit
adaptive use of displacement
a child who is unable to acknowledge fear of his father becomes fearful of animals
maladaptive use of displacement
Unexplainable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion
Reaction formation
crush on boss but keep them aloof
reaction formation
a recovering alcoholic constantly preaches about the evils of drink.
adaptive use of reaction formation
a woman with unconscious hostility towards her daughter is overprotective and hovers over her to protect her from harm, interfering with normal growth and development
maladaptive use of reaction formation
method of coping with psychological issues by developing physical sx with no organic cause
Somatization
Tries to undo harm that he or she feels that they have done
Undoing
man calls his wife fat and later buys her flowers
adaptive use of undoing
a man with rigid moralistic beliefs and repressed sexuality is driven to wash his hands to gain composure when around attractive women
maladaptive use of undoing
reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been previously exhibited
Regression
a man who loses a promotion starts complaining to others, hands in sloppy work, misses appointments, and comes in late for meetings
maladaptive use of regression
a 4 year old with a new baby brother starts sucking his thumb and wanting a bottle
adaptive use of regression
Justifying illogical or unreasonable ideas by developing acceptable reasons that satisfy the teller as well as the listener
Rationalization
an employee says, "I didn't get the raise because the boss doesn't like me"
adaptive use of rationalization
a man who thinks his son was fathered by another man excuses his malicious treatment of the boy by saying, "he's lazy and disobedient", when this is not the case
maladaptive use of rationalization
person doesn't like feelings so projects them on someone else
blame
Projection
a man who is unconsciously attracted to other women teases his wife about flirting
adaptive use of projection
a woman who has repressed feelings of attraction to other women won't socialize. she feels other women will make homosexual advances towards her.
maladaptive projection
escaping unpleasant anxiety-causing thoughts, feelings, wishes, or needs by ignoring their existence.
Denial
dx of cancer but says will be ok
seen a lot with substance abuse
adaptive use of denial
a woman whose husband died 3 years ago still keeps his clothes in the closet and talks about him in the present tense
maladaptive use of denial
process in which events are analyzed based on facts and without passion, rather than incorporating feelings into the processing
intellectualization
despite the fact that a man lost his farm in a tornado, he analyzes his options and leads his family to safety
adaptive use of intellectualization
a man responds to the death of his wife by focusing on the day to day care and operating the household, rather than processing grief with his children
maladaptive use of intellectualization
Most common form of psychiatric disorder
anxiety
characteristics of which disorder?
person is rigid, inflexible in actions or beliefs, repetitive behavior; a lot of behaviors ineffective for coping
anxiety disorder
Anxiety disorders include:
Panic disorders
Phobias
OCD
GAD
PTSD
Acute stress disorder
Substance-induced anxiety disorder
Anxiety due to medical conditions
Anxiety Disorders NOS
Which theorist and theory?
Anxiety caused by repressed ideas going to conscious defense mechanism to keep anxiety at manageable level
Freud/Psychodynamic theory
What theorist and theory?
emotional distress caused when early needs go unmet or disapproval is experienced.
-unmet needs can be transferred from mother to infant
Sullivan/ interpersonal theory
What theory?
anxiety is a learned response and can be unlearned
ex. mother that is fearful of storms hides in a closet and transmits her anxiety to her children
Learning theories/behavioral theories
What theory?
anxiety disorders are caused by perceptual problems (the way we see things)
Cognitive theories
T or F
Hamilton scale is used to diagnose anxiety
False- used for planning care/ targets behaviors and helps achieve outcome measures. can indicate anxiety but not dx because anxiety level could be caused by something else.
What disorder?
recurrent attacks- palpitations, chest pain, breathing difficulties, nausea, feeling of chocking, chills, hot flashes.
Panic disorder
Panic attack can be with or without agoraphobia.
agoraphobia is-
intense, excessive anxiety or fear of being in places or situations form which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurs.
avoid places to try and control anxiety
persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance
phobia
fear of specific object or situation such as water, spiders
specific phobia
anxiety or fear provoked by social situation or performance situation/ fear of being judged by others
public speaking is the most common
social phobia
what disorder?
worry is the cardinal symptom-lasts 6 months or longer; sx-restlessness, fatigue, poor concentration, irritability, tension, sleep disturbance
- worry about day's events and real or imagined mistakes. reviews past problems and anticipates future problems.
common worries are: relationships, finances, health, chores
General Anxiety Disorder (GAS)
thoughts, impulses, or images that persist or recur; cannot be dismissed from the mind
obsessions
ritualistic behaviors that are performed to decrease anxiety
compulsions
what disorder?
preoccupied with rules, regulations, orderliness, neatness, details and the achievement of perfection.
-can interfere with every aspect of their life/ time consuming and unreasonable
OCD
What disorder?
characterized by re-experiencing of a highly traumatic event that involved threatened death or serious injury to self or others.
-sx last longer than 1 month
-onset usually within 3 months of event but can happen at any time
PTSD
what disorder?
occurs within 1 month of traumatic event and resolves within 4 wks.
At least three of these sx:
sense of numbing
detachment
absence of emotional responsiveness, reduction in awareness of surroundings
derealization, depersonalization, dissociative amnesia
Acute stress disorder
Benefit of benzodiazepines
Disadvantage of benzo
Fast acting
High potential for abuse-short-term use only
SE of Benzodiazapines
sedation, ataxia, decreased cognitive function
Benzo's increase levels of these drugs:
Dilantin
Coumadin
Lanoxin
drugs that increase benzo levels:
Prozac
Tagamet
Low-dose estrogens
Antabuse
INH
Nonbenzo used for anxiety. does not produce sedation, memory impairment, had decreased abuse potential and does not require gradual tapering
Buspar (Buspirone)
first line drug tx for acute stress disorder and PTSD
SSRI
drug used to treat panic attacks
TCA
drug for tx of resistance anxiety disorders (when have tried everything else)
MAOI
Drug used for managing social anxiety or substance dependence-detoxing?
anticonvulsants- tegretol, Neurontin, depakote
safe/ nonadictive drugs used for lowering anxiety
antihistamines-atarx and vistaril
other drugs used for anxiety
beta-blockers-inderal
DSM criteria for major depressive disorder
persistently sad mood lasting 2 wks or longer
poor concentration
sleep disturbance
anhedonia
anergia
*no hx of manic or hypomanic episodes
sx of depression
guilt, helplessness, hopelessness, feel down all the time, lethargy, appetite loss or gain, thing about death, depressed almost every day all day
What type of MDD?
very severe form, presence of delusions regarding guilt or punishment, acquiring a disease and possible hallucinations-mostly auditory
ex)delusion- god put snakes in my stomach and told me not to eat
MDD with psychotic features
What type of MDD?
onset before or after birth. psychotic features are common
MDD with peripartum onset
What type of MDD?
characterized by anergia, hypersomnia, overeating, weight gain, craving for carbs, responds to light therapy
MDD with SAD
What type of MDD?
nonresponsiveness, extreme psychomotor retardation, withdrawal, negativity
MDD with catatonic features
What type of MDD?
severe form of depression not attributed to env stressors, characterized by severe apathy, weight loss, profound guilt, sx worse in am, early morning waking, suicidal ideation
MDD with melancholic features
Catatonic features
stupor-
no response to external stimuli
catatonic features
catalepsy-
musc rigidity, limbs remain in whatever position they are placed
Catatonic features
echolalia-
parrot like repetition of a word or phrase someone else said
echo
Catatonic features
echopraxia-
repetitive immitations of movements from another pt.
ex. chief in One Flew Over
praxia-practice
Neurotransmitters involved in depression
norepinephrine and serotonin
Cognitive theory of depression
psychological predisposition to depression through early life experiences. depressed people of negative perceptions
assessment findings in depressed pts:
anergia-
lack of energy or passivity
assessment findings in depressed pt:
psychomotor agitation-
pacing or wringing hands, biting nails, pacing
assessment findings in depressed pts:
psychomotor retardation-
slowed movements or complete inactivity
*more common than psychomotor agitation
assessment findings in depressed pts:
vegetative signs-
alterations in activities that are necessary to support life-eating, drinking, sleeping
assessment findings in depressed pts:
anxiety-
60-90% pts have anxiety
ECT TX for depression
how many treatments and how often?
6-12 treatments every other day for 2 to 3 weeks
Transcranial magnetic stimulation (TMS)
what is it and how many tx and how long is each?
contraindications-
noninvasive tx that uses MRI strength magnetic pulses that stimulate focal areas of the cerebral cortex.
-contraindicated if metal plate in head
-for 30 min, 5 days a week
SE of TMS-
HA, tenderness in areas where probes attached
indications tms-
for pts with depression that are unresponsive to other treatments
Light therapy-
resembles sunlight
30 minutes a day
TX good for SAD
most effective natural way to increase serotonin
Light therapy
implant device that sends pulses to increase levels of neurotransmitters
what disorder?
characterized by chronic mild depression; present for most of the day, more days than not -lasting at least 2 years.
Dysthymic Disorder
Difference between MDD and Dysthymic disorder
Severity and duration
dysthymic disorder is less sever and lasts longer
1st line antidepressant
SSRI
Antiderpessants work by:
altering poor self-concept
positively alter degree of withdrawal
positively alter vegetative signs
given to achieve remission and prevent relapse
when do you evaluate pts on antidepressants?
total time on therapy-
after 2wks at 6wks then every 3 months
6-9 months
SSRI'S-
Prozac
Paxil
Lexapro
Zoloft
Luvox
Celexa
Central Serotonin Syndrome Sx-
abd pain, D, sweating, fever, tachycardia, elevated blood pressure, altered mental status (delirium), myoclonus (musc spasms), increased motor activity, irritability, hostility, and mood changes.
severe- hyperpyrexia, cv shock, and death
cause of serotonin syndrome-
overreaction of central serotonin receptors either from too high of a dose or interaction w/ other drug esp MAOI. dc 2 to 5 wks b4 taking MAOI
SE SSRI-
insomnia, nervousness, med reactions -digoxin and Coumadin, sexual dysfunction, dysuria, anorexia, weight loss
TCA's
Elavil
Tofranil
Anafranil
Sinequan
Vivactil k
pts on SSRI need
Liver and renal fx tests
caution w/otc meds
report increased depression or suicidal thoughts
report rash or hives could be serious se
TCA'S begin working in
reach full effect in
10-14 days
4-8 weeks
SE TCA's
anticholinergic, weight gain, orthostatic hypotension, tachycardia.
serious- dysrhythmias, heart block
NDRI-
Wellbutrin
advantages ndri's wellbutrin
used smoking cessation, sexual dysfunction rare, usually no weight gain, stimulant, antianxiety properties
disadvantages ndri's wellbutrin
3-4 wks before any benefit
in high doses can cause seizures
Usual dose Wellbutrin
50-300 mg
SNRI
Effexor, Cymbalta
usual dose Effexor SNRI
75-225 MG a day
SNRI used for pts-
chronic resistant depression
Disadvantages Effexor SNRI
somnolence dry mouth, dizziness, increased BP
advantages SNRI
low potential drug interaction
MEd given to decrease neuropathic pain
Abilify
SE Abilify
response-
N, dry mouth, dercreased appetite, fatigue
1-4 wks
Drug used as last resort or atypical depression
MAOI'S
Nardil, Parnate, Emsam
Most serious SE of MAOI's
hypertensive crisis
sx hypertensive crisis
HA, stiff neck, palpitations, increase or decrease in HR (often associated with chest pain), N, V, pyrexia.
Unsafe foods MAOI's
avocados, bean curd, soybean paste, fermented soybean, fig, bananas in large amounts, fermented meats, liver, sausages, dried cured or fermented fish, most cheeses, yeast extract, wines and some imported beers, protein supplements, shrimp paste, soy sauce. also caffeine , ginseng fava beans,chocolate, otc meds
adverse reactions MAOI
Hypotension
sedation, weakness, fatigue
insomnia
cardiac rhythm changes
musc cramps
sexual dysfunction
urinary hesitancy or constipation
weight gain
types of bipolar
mix of manic and depressive episodes; psychosis my be present
bipolar I
types of bipolar
mix of hypomanic (tends to be euphoric)and depressive episodes; no psychosis
bipolar II
hypomanic alternates with minor depressive episodes (at least 2 yrs in duration)
cyclothymia
4 or more mood episodes in a 12 month period
rapid cycling
mania
excessive excitement
delirious mania
out of touch with reality
concurrent mania
manic and depressed
disorder with highest rate of suicide
bipolar
median age of onset for bipolar
20 years
bipolar one is more prevalent in males or females
male
bipolar II more prevalent in male or female
female
Sx of bipolar manic phase
unstable euphoria, irritable, trust everyone, loud, share info with all, spend lots of money, behavior can escalate to violence, odd dress, no sleep, may not eat, if hypomanic- veracious appetite, poor judgment, decreased attention span
bipolar sx
flight of ideas
moving from one topic to the next
bipolar sx
clang association
stringing together words because they rhyme
bipolar sx
grandiosity
exaggerated sense of self-worth and accomplishments
acute phase bipolar focus is
prevention of injury- basic needs met and self control
continuation phase bipolar focus is
relapse prevention - therapy, education for family and pt , communication and problem-solving skills
bipolar maintenance phase focus is
prevention of relapse and limitation of severity and duration of future episodes- interpersonal skills, therapy , group and support groups
First line drugs for bipolar
Lithium and anticonvulsants
How long for Lithium to reach therapeutic level
7-14 days
therapeutic lithium level
0.8 to 1.4 meq/L
maintenance level Lithium
0.6-1.2 meq/L
toxic level Lithium
> 1.5 meq/L
purpose of lithium therapy
tx of recurrent manic and depressive episides / works to eliminate manic sx/ best bipolar I
Long-term effects Lithium
hypothyroidism and impairment of kidney's ability to concentrate urine
signs lithium toxicity
early and advanced and severe sx
N/V/D, thirst, polyuria, lethargy, slurred speech, musc weakness, and fine hand tremor
coarse hand tremor, persistent gi upset, mental confusion, musc hyperirritability, eeg changes, incoordination, sedation
ataxia, confusion, blurred vision, large amounts dilute urine, clonic movements, seizure, stupor, sever hypotension, coma, death
Lithium and alcohol
alcohol causes dehydration which increases lithium level
anticonvulsants for bipolar
1st line
Lamotrigine (Lamictal)
sx to watch for with Lamictal
rash-steven Johnson syndrome
HA and dizziness
per day dose Lamictal
500-1500 mg/day
anticonvulsant used for rapid cycling and severe paranoid/angry manics
(Tegretol) Carbamazepine
maintenance anticonvulsant for lithium nonresponders
Depakote (valproic acid)
dose Depakote
500-100 mg/day
antipsychotic that is better tolerated and works better than Lithium for preventing relapse in bipolar
Zyprexa
Why use antipsychotics in bipolar?
have a sedative property , help relieve insomnia, anxiety, and agitation
mood stabilizing properties
antipsychotic for anxiety sx of bipolar
seroquel
syndrome characterized by delusions, hallucinations, disorganized speech, disorganized catatonic behavior, psychotic syx more pronounced than other disorders
affects language, emotions, behavior, perceptions of reality
Schizophrenia
polydipsia
compulsive drinking of 4-10 L of water a day.
sx in schizophrenia
comorbid conditions of schizophrenia
anxiety, depression, substance abuse in 50% of pts, nicotine, suicide common
Phases of Schizophrenia
Acute
onset of sx (hallucinations, delusions, apathy, withdrawal), loss of fx
Phases schizophrenia
Stabilization
acute sx are less severe; returning to baseline
Phases schizophrenia
Maintenance Phase
pt at or nearing baseline ; sx absent or greatly diminished
Positive sx schizophrenia
Delusions-
false, fixed beliefs that cannot be changed
ex. I'm being poisoned
Other Positive sx schizophrenia
Ideas of reference
Persecution
Grandiosity
Delusions of being controlled
Positive sx of schizophrenia
thought withdrawal
thoughts being removed, usually by specific person or agency
Positive sx schizophrenia
Neologisms
made up words that have a meaning to pt
Positive sx schizophrenia
thought broadcasting
believe other people can hear what they are thinking
Positive sx schizophrenia
concrete thinking
think literally only; what brought you hear? a cab
Positive sx schizophrenia
associative looseness
disordered thought process. response not logical to what ask
Positive sx schizophrenia
echolalia
parrot like repetition
Positive sx schizophrenia
word salad
using real words but putting together in a way that doesn't make sense
Positive sx schizophrenia
clang association
rhyming words ; doesn't make sense
Positive sx schizophrenia
hallucinations -
personal boundary difficulties
sensory perception where there is no external stimulus
Positive sx schizophrenia
extreme motor agitation
leads to fatigue- excited behavior such as running or pacing rapidly
Positive sx schizophrenia
stereotyped behaviors
motor patterns that have become mechanical/purposeless
