Exam #2 Anxiety/OCD

20% - Anxiety / OCD 20% - Bipolar Disorders 30% - Depressive Disorders 25% - Schizophrenia Spectrum Disorders Anxiety/OCD -​ most common of all mental illnesses in the United States, affecting 18.1 percent of the population each year Why? -​ There is a genetic component…the way you think about things can be internally damaged, also can be environmental, developmental, psychological -​ Neurotransmitters: Chemical IMBALANCE…serotonin, norepinephrine, and GABA…shown as a true cause (give meds to counteract the imbalance + fix it) Reaction of the body to stress…general adaptation syndrome 1. Alarm reaction stage. During this stage, the responses of the fight-or-flight syndrome are initiated. 2. Stage of resistance. The individual uses the physiological responses of the first stage as a defense in an attempt to adapt to the stressor. If adaptation occurs, the third stage is prevented or delayed. Physiological symptoms may disappear. 3. Stage of exhaustion. This stage occurs when there is a prolonged exposure to the stressor to which the body has become adjusted. The adaptive energy is depleted, and the individual can no longer draw from the resources for adaptation described in the first two stages. Anxiety is on a spectrum… Between moderate + severe someone is d/x with a mental illness​ Are patients who suffer from anxiety at risk for suicide?: YES! They want the anxiety to stop…they do NOT want to feel like this…no one wants to live in a high state of anxiety with a threat of it becoming a paniced state Types of Anxiety Disorders: 1.​ Panic Disorder: will have a panic attack (lasts a min or longer periods of time depends on the person) -​ To be a panic attack need (FOUR or more of these) →palpitations, SOB, may have a choking or smothering sensation, chest pain, nausea, a sense that they’re 2.​ 3.​ 4.​ 5.​ 6.​ dying or going insane, no control, hot flashes/chills, a feeling of need being part of self -- depersonalization) -​ NOT always in a state of panic but intervals for this pt -​ Pt might experience behavior changes between these episodes due to being worried about next attack… (on edge) -​ H/x typically a genetic link, could be because of child/sexual abuse, parental smoking -​ They have more negative outlook or more focus on negative emotions (common lead to S+S of depression) Generalized Anxiety Disorder (GAD): most common…what is thought of when they say “I have anxiety” persistent, unrealistic/excessive worry…more days than not over a 6 mon period of time -​ Signs + Symptoms: restless (look), on the edge or keyed up, easily fatigued, difficulty concentrating…mind goes blank, prone to irritability, somatic (physical) manifestations of muscle tensions -​ NEED to rule out a physiological cause prior to d/x….need to also rule out caffeine intake…can mimic GAD…also rule out hyperthyroidism can mimic GAD -​ Onset→can begin in childhood but not common after the age of 20…see avoidance activities (see that there is a negative outcome in activity will not do it, mentally prepare prior to going to an activity….trying to limit the amount of feelings they’re going to have) -​ CAN enter a panic level anxiety -​ Depressive symptoms common….GAD is chronic → WON’T go away Trichotillomania: hair pulling disorder…pull it out of head till bald/bruising/bleeding…cause by increased obsession with tension in head they get released from this obsession -​ Paired with GAD often…can use this to relieve GAD Phobias: irrational fear of an object or situation (fear of something external to you) Ex: fear of heights, spiders, flying, -​ Agoraphobia: fear of going outside + social situations…fear of being vulnerable→if something happens they feel they can’t escape the situation -​ Onset: 20-30’s can persist for many years -​ Pt will NOT go there cause it will increase level of anxiety -​ Flooding is most often used for phobias Social anxiety disorder: fear of a situation when you might do something embarrassing or you might be looked at weird by others Obsessive Compulsive Disorder (OCD): considered an anxiety state//obsession of compulsion or actions (obsession of a current thought these are INTENSE + IRRATIONAL…they know it's irrational but can't stop!!) -​ Compulsions (repetitive realistic behaviors) that individual has to do…by doing them it reduces their anxiety -​ Ask them: “are there things that you do to make yourself comfortable”, “can you not get thoughts out of your head” -​ It can get severe enough where it causes so much distress in them that it impairs them socially + with their jobs become non-functional….they NEED help 7.​ Body Dysmorphic Disorder (BDD): considered an anxiety state -​ Characterized by: exaggerated belief that your body is deformed or defective in a specific way…grossly excessive…obsessive thoughts//NOT delusion…patient is fully aware that this obsession is completely irrational -​ Depression comes with BDD Ex: someone who does multiple cosmetic surgeries…look worse drives obsession more 8.​ Separation Anxiety Disorder: excessive anxiety when separated with person you are fond of…fear that something bad will happen to them -​ Can have chest pain, sweating, rapid pulse Rating scale for anxiety Hamilton Anxiety rating scale…widely used in clinical setting…results in somatic anxiety symptoms (more symptoms you have the higher score…anxiety level) -​ Mild, moderate, severe Nursing Interventions: depends on level of anxiety pt is experiencing -​ MOST IMPORTANT→ provide safety for the pt + staff (calm, quiet environment) -​ When in a panicked state all you need to do is keep them safe…you can NOT talk to them…but NEVER leave the pt (always remain with the patient + provide reassurance) -​ Postpone education until acute anxiety attack subsides…WILL NOT listen/take it in -​ Approach trauma informed care…be sensitive + recognize that they consider this a trauma -​ Provide a suicide risk assessment -​ Create a structured environment to keep them focused -​ See if they have any comorbidities + see if anything is causing this -​ Use relaxation techniques: deep breathing, focus on something Treatment Modalities: -​ Individual Psychotherapy -​ CBT (change the way I think) -​ Behavior therapy Ex: flooding: for phobias Psychopharmacology Selective Serotonin Reuptake Inhibitors (SSRI) Fluoxetine (Prozac) Paroxetine (Pazil) Seratraline (Zolof) First line treatment for anxiety!!! -​ Can increase risk for suicide especially on admission of therapy! (more energy) -​ -​ -​ -​ -​ -​ Can take 4 weeks to see effects in therapeutic period + where seeing side effects Contraindicated: Warfarin: increased levels of bleeding…amplifies effect (DO NOT ever prescribe together)///St. John’s Worth…NEVER take with any antidepressant (will bring on serotonin syndrome if also taking an antidepressant) Side effects: sleep disturbances, headache, sexual dysfunction, weight gain, restlessness Preferred over tricyclic due to less side effects Reduce BDD symptoms -- fluoxetine! Higher dose for OCD SNRI: take these if SSRI not effective as well (both first line) Venlafaxine (Fexor) Duloxetine (Symbolic) -​ Can increase BP…messing with noepinephrine levels…monitor BP -​ Complication: headache, nausea, agitation, anxiety, dry mouth, hyponatremia, w/t loss, sexual dysfunction, and sleep disturbances -​ Can take up to 4 weeks to achieve therapeutic effects Atypical anxiolytic/nonbarbiturate anxiolytic Buspirone: used for long-term treatment of anxiety…used if SSRI not working; affects dopamine receptors -​ Takes 4 weeks to work -​ Contraindicated: St John’s wort, MAOIs (hypertensive crisis), pregnancies -​ Complications: CNS effects Benzodiazepines Lorazepam (Ativan), Clonazepam, Chlordiazepoxide (Librium) -​ Has sleepiness effect: effects GABA receptors -​ Should only use PRN…during exacerbation period that you use benzo to put your anxiety level down…NEVER used to treat anxiety around the clock (addictive) -​ Contraindicated: alcohol (if you take these do NOT have alcohol: increases sleepiness so much that you can have respiratory depression) -​ Pregnancies contraindicated Antihypertensives are powerful + have powerful effects severe manifestations of anxiety like palpitations, sweating, increased HR, effective only in acute settings -take only as needed -used sparingly + situational…ex: testing -Ex: propranolol, clonidine Antihistamine: alternative for mild states of anxiety + restlessness + can be for sleep -Hydroxyzine: Vistaril Tricyclics -- side effects* Schizophrenia Spectrum Disorders Schizophrenia (schiz=split) (phren=mind) Current interpretation: Of all the disorders schizophrenia is responsible for the longest hospitalizations, it is more taxing for the families, people are more fearful of these individuals, life expectancy is 25 yrs younger than the rest of the population, risk for suicide is huge concern (20-40%)...only (5%) are able to due to problem with their cognition, don’t understand this disorder still Need two or more of these to d/x→ Need delusions and or hallucinations and or disorganized speech for at least one month or longer, may present with disorganized behavior or catatonic, and display negative symptoms -​ Affects thinking, the way people speak, affects emotions, the way they communicate and think in society, they do not see society the way everyone else does…affects how they function..early treatment may help with long term outcome Comorbidites: typical for them to have multiple other things at same time: anxiety, depression, substance use disorder (part of them wants them to go away…common to use substances), physical illnesses (not taking care of self), polydipsia, suicide Course of disorder: -More acute cycles a patient has that worse prognosis they have -Much slower than bipolar disorders phases Phase 1: Premorbid phase → not sure what is happening with pt withdrawing from friends, not liking what they do, school + work performance get affected, express unusual suspicions -if you can catch them at this point can potentially prevent onset… difficult to catch though -to catch early→ friends + family help or they speak up that something has changed go get screening Phase 2: Prodromal Phase → 2-5 years//see signs of developing schizophrenia, during this phase show signs of significant deterioration in function (50% will have depressive symptoms) Phase 3: Active Psychotic phase → will deteriorate so much where they enter this phase triggered by a stressful life event (train on tracks can not stop it) -Need hospitalization…get treatment Phase 4: Residual Phase→ how this disorder presents in the person…many types can present different in each individual, know how they look/know what it is, understand where their disability is not, how far are we able to get them back to the premorbid phase -during this phase positive symptoms are significantly reduced in this phase…still can present with negative Four Main Symptom Groups: 1.​ Positive: Exaggerated symptoms that the patient is experiencing -​ Delusions (false beliefs that are not based in reality ex: everytime that the person is scratching their eyebrow a person is making a signal about them/they think they’re the best trained artist of all time)...not able to process that this isn’t true…they believe it -​ Hallucinations (sense of seen, hearing, smelling, or feeling things that do not exist (all the senses)...to them this is normal it is actually there Ex: smell blood, see things on the wall, see 7 people in band uniforms, hear someone talking, but do not hear them 2.​ Negative: Reduced or lack of ability to function normally…any see a person neglecting their personal hygiene, lack of emotions, no eye contact, flat affect, monotone, withdrawn from social activities -push the pt forward in phases…withdrawn become small (like depression) 3.​ Cognitive: disorganized thinking/slow, difficult to understand, tend to have poor memories, can’t concentrate, can’t express thoughts well..can’t put the pieces together (no critical thinking) 4.​ Affective: may be present in a person not always → depression, anxiety, irritability, and sometimes aggression Alterations in speech: 1.​ Loose association: ideas shift from one unrelated subject to another -​ Ex: loose of stream of consciousness doesn’t make sense 2.​ Neologisms:newly invented words that are meaningless to others but have symbolic meaning to the individual -​ Ex: wanted to give me a ride in her uniforum 3.​ Clang association: the choice of words is governed by sounds, often taking the form of rhyming -​ Ex: it is very cold, the cold is gold, the gold is very sold 4.​ Word Salad: a group of words that appear to be put together randomly, without any logical connection -​ Ex: random string of words together 5.​ Echolalia: repetition of another person's words -​ Ex: Bob sit down, bob come here 6.​ Echopraxia: mimicking the movements of another -Ex: you lean, they lean, you stand/they stand Alterations in behavior: -​ Bizarre behavior -​ Extreme motor agitation -​ Pacing + rocking -​ Waxy flexibility -​ Stupor -​ Negativism -​ Automatic -​ Regression to child-like behavior Nursing interventions: Lower the pt anxiety, encourage pt participation (with stuff on unit + with other people) Antipsychotic medications: help stabilize the pt + don’t allow them to go back to the acute phase no cure…alleviate the symptoms, make sure they’re compliant 1st generation: address the positive symptoms they’re for, psychosis Chlorpromazine (thorazine) Haloperidol (haldol) Thiothizene (Navane) -​ Side effects: Extrapyramidal symptoms (akathisia(restlessness + need for movement), acute dystonia (involuntary muscle movement of legs, face, neck), pseudoparkinsonism ( they look like parkinsins) → if have shuffling gate take Benztropine, tardive dyskinesia (abnormal movements of the mouth, trunk), neuroleptic malignant syndrome (S+S→ fever, muscle rigidity, tachycardia), agranulocytosis (low WBC…reduced ability to fight infection), need blood work done often -​ Treatment of extrapyramidal symptoms: Use benztropine mesylate (Cogentin), amantadine hydrochloride (Symmetrel) to control parkinson symptoms…once the symptoms present they never go away 2nd generation (atypical): target positive + negative symptoms…more commonly used because of less side effects // PINE AND DONE! **Aripiprazole (Abilify) clozapine (Clozaril) **WBCCCC/ AGNAYCOCTOSIS EVEN THO ITS TYPE 2 (also adverse affects are heart failure, myocarditis, and PE) paliperidone (Invega) quetiapine (Seroquel) risperidone (Risperdal) ziprasidone (Geodon) **Ends in done -​ Side effects: risk is extremely low…but super expensive//metabolic syndrome (w/t gain, dyslipidemia, altered glucose, HTN, heart disease, diabetes), dry mouth, insomnia, drowsiness Long-acting meds: help with pt’s struggling with compliance…for long term…comes in 1st + 2nd (exact same side effects)....once a month Schizophrenia goals: help people stay employed + maintain independence a possible, relapse prevention Psychotic disorders 1.​ Delusional Disorder: the pt experiences delusions for at least 1 month, behavior is not besare…if they hallucinate it is not seen in presentation…but they do not, as soon as they begin to have disorganized behavior they can be upgraded into schizo 2.​ Brief Psychotic Disorder: sudden onset of psychotic symptoms typically precipitated by psychosocial stressor…symptoms usually can last one day but do not precede one month return to regular function -can experience incoherent speech, delusions, hallucination, bizarre behavior, complete disorientation -can look like they have schizo but is not schizo, this a brief disorder -have other risk factors that bring them into this psychotic disorder…need to be hospitalized 3.​ Schizophreniform Disorder: identical to schizo…lasts for about a month but not more than 6 months, if they present beyond 6 months then they move into schizophrenia disorder 4.​ Schizoaffective Disorder: (type of schizophrenia + bipolar) has all S + S of schizophrenia, but is also having all the symptoms of a bipolar pt (manic and or depression is found), difficult to treat pt, have a poor prognosis compared to a mood disorder…but better than a schizophrenia patient alone -Pt who has the best outcome with treatment are the mood disorders, then schizoaffective, then schizophrenia Psychosis: can happen with a lot of disorders…is a severe acute mental condition (disorganization of personality of person, deterioration in pt to act socially, and impairment in the individuals reality, may have delusional thinking not with reality, when in psychosis can not reason with these people…need to stabilize them to allow them to process what you’re thinking) Bipolar Disorder Mood disorder with recurrent episodes of depression + mania Bipolar 1 vs Bipolar 2 type 1 has at least one episode of mania alternating with major depression, mania requires hospitilization and medication, goal of therapy is to flatten the wave, reduce intensity of the episodes type 2 has one or more HYPO manic episodes alternating with major depression, mania isnt as high much lesser degree, mania does not put them in the hospital-their depression will put them in the hospital they have very low low's. These people do not have episodes of mania Bipolar 1: one episode mania + alternating with depression -​ -​ mania: need hospitalization hit peak, goal of therapy is the reduce the cycle and flatten it out (goal is up and down, minimize up and down), their depression can go low too but not as frequent as bipolar 2//will be a type one for life Once you hit the bottom you start climbing up then mania begins, start to feel normal, become psychotic need hospitalization Bipolar 2: has one or more hypomania episodes alternating with major depression -​ the mania is not as high, still get manic, still display some of these but to a much less degree, there mania does NOT put them in the hospital…what puts them in the hospital is their depression (their lows are LOW…very low) -​ If a person has more than one cycles in one yr they’re considered a rapid cycler….can be very resistant to treatment Expected Findings: -​ Mania looks like→ Same but the more severe it is the more manic you’re as you increase in mania you will see that they have euphoria, highly agitated, rapid talking, flight of ideas running in their head, make poor decisions, think they’re more than they’re, they’re manic can spend a lot of money, engage in risk behaviors, so excited they can’t sleep, move around a lot, very active can not sit still, may even at high states display delusions, have hallucinations, hallmark have no idea they’re manic…they deny it Agaitiona, irritability, increased talking, impulsive, poor judgement, risky behavior, decreased sleep, delusions, hallucinations, denial of illness -​ Depressive: flat blunted labile affect, lack of energy, anhedonia (lack of interest), psychomotor retardation Lithium motherfucker Can be used in type 1 or 2 Need to remain in a therapeutic level need to get blood drawn all the time!!! -​ Target range for acute mania (hospital): 1-1.5 -​ In the community(maintenance) 0.6-1.2 Dosing is based on what gets you to that level 10-12 hrs after their last dose…take blood Low sodium, eat health foods, avoid junk, avoid caffeine Lithium needs sodium…do not have too much fluids pushes out the sodium -​ Early signs of toxic: muscle weakness, diarrhea, vomiting, confusion, a little sedated >2: we see tremors, confusion, extreme polyuria, ringing in ears, gitterness, jerky movements, seizures, hypertension, and severe will be delirium coma, CV collapse + death -​ Treat this: Need to reduce the dose, promote excretion, hydrate pt -​ Contra: on lithium do not breastfeed -​ Levels >2.5 you begin having lithium side effects…as you take it it will decrease over time (headache, decreased memory, diarrhea, nausea, blotting, leukocytosis, tremors) -​ Hydrate, promote excretion, and STOP THE MED Anticonvulsant Drugs: use if lithium doesnt work -​ Valproate + Carb(Tegretol: causes blood dyscrasias (altered blood counts), plt/wbc/rbc, VAL: keep an eye on liver levels also can affect plt -​ Carb(Tegretol + Lamictal: high risk for SJS Anxiolytics and Atypical Antipsychotics: -​ Takes 7-10 days to see therapeutic we may want to use ajavents -​ When they take effect may take them off antipsychotics…wait for lithium to work Treatments: -​ TMS: used in persons with depression or depression with bipolar as well or drug resistant can go through TMS where they place magnets at point around the head + crease a field that is, without causing a seizure… when can’t do ECT -​ Sit in the chair do not need sedation, 6-8 weeks TMS) used for depression, when ECT is not an option and your drug resistant, magnets are placed in strategic points and create a field, the thought is that it reset the electrical activity of the brain without causing a seizure , TMS you do every day for 6-8 weeks can do this awake dont need to be sedated or anything, ECT you come in like 2-3 times spaced out quite a bit ECT: Very powerful form of treatment, need a history of poor response to medications…to induce a seizure, given during anesthesia, electrodes placed on pt head//can cause a pt to have seizure disorder/memory loss -​ Last resort….kick starts brain -​ Cardiac: contra -​ When coming out of ECT might have short term memory response -​ Make sure gag reflex comes back -​ Can cause seizures They have to have a history of poor drug response, we do not just jump to this -any cardiac condition is a contraindication for this -moderately sedated -Likely to have some short term memory loss, may or may not return, may be very tired after, don't give patient water right after this, check for the gag reflex