Mental Health Nursing

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What are the causitive theories of Anorexia and Bulimia?: Neurobiological
Psychological and Sociocultural
Biopsychosocial
Family Theory
What is the neurobiological theory of Anorexia and Bulimia?: Anorexia and Bulimia is caused by an imbalance in Neurotransmitters (similar to mood disorders). Decreased levels impact satiety.
What role do endorphins play in the neurobiological causative theory of eating disorders?: Starvation is thought to cause the release of endorphins causing one to feel good while actually starving to death.
Is there a genetic predisposition to develop an eating disorder?: 57% concordance with zygotic twins.
What is the psychological and sociocultural causative theory of Anorexia and Bulimia?: Maladaptive response to the developmental taks of adolescence

Affective instability and poor impulse control

Cultural influences
What are two biopsychosocial theories of eating disorders?: Genetic vulnerability
Concurrent disorders
What does the family theory of eating disorders teach?: eating disorders are caused by unconscious intrapersonal and interpersonal conflicts in the family.
What type of family would a person with anorexia have under the family systems theory?: Enmeshed or overly rigid
What type of amily would a bulimic person have according to the family systems theory?: Disengaged or abivalent
What are three types of eating disorders?: Anorexia, Bulimia, and Binge-eating disorder
Define anorexia nervosa: a potentially life-threatening disorder characterized by extreme perfectionism, weight fear, significant weight loss, body image disturbances, strenuous exercising, peculiar food handling patterns, reductions in heart rate, blood pressure, metabolic rate, and the production of estrogen or testosterone.
What is the DSM-IV-TR criteria for anorexia?: 1. Refusal to maintain body weight
2. intense fear of gaining weight
3. disturbance in the way in which one's body image or shape is experienced
4. ammenorrhea in postmenarcheal females
What are the two types of anorexia nervosa?: Restricting type and binge-eating/purging type
What is the restrictive form of anorexia nervosa?: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior
What is the binge-eating/purging form of anorexia nervosa?: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior.
What is bulimia nervosa?: a disorder characterized by binge eating followed by purging
What is binge eating?: eating large quantities of food in a short period of time
What is purging?: self-induced vomiting and/or use of large doses of laxatives and diuretics
What is the DSM-IV-TR criteria for bulimia nervosa?: 1. recurrent episodes of binge eating
2. recurrent inappropriate conpensatory behavior in order to prevent weight gain
3. both 1 and 2 occur at least 2x a week for 3 months
4. self evaluation is unduly influenced by body shape and weight
5. the disturbance does not occur exclusively during episodes of anorexia nervosa
What are the two types of bulimia?: Purging type and nonpurging type
What is the purging type of bulimia?: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
What is the non-purging type of bulimia?: use of stric dieting, fasting, vigorous exercise, but does not regularly engage in purging
Characteristics of anorexia: denial of food related problems
turns away from food
rejection of femininity, not sexually involved
confident over mastery of food
dependency and social withdraw
pathological self-control
angelic child
egosyntonic behavior
Characteristics of bulimia: person sees eating pattern as abnormal
turns toward food
oriented towards traditional feminitity, sexually involved
afraid of food
independent; socially outgoing
difficulty with self-control
hellion child
egodystonic behavior
Define egosyntonic behavior: one's behavior is consistent with the perons beliefs
Define egodystonic behavior: A person's behavior is unacceptable to them because it is not compatible with their values or worldview
Define binge-eating disorder: repeated episodes of uncontrolled eating, sometimes called compulsive overating. Individuals are often obese
DSM-IV-TR criteria for binge-eating disorder: 1. recurrent episodes of binge eating
2. marked distress regarding binge eating
3. binge eating occurs on average at least 2 days a week for 6 months
4. no associated with purging
5. have 3 of the following: eating more rapidly, eating until feeling too full, eating when not hungry, eating alone out of embarassement, feeling disgusted with oneself b/c of overeating
Physical symptoms of anorexia: emanciated with sunken eyes and a skeletal appearance, lanugo growth on face, extremities, and trunk, bradycardia, hypotension, arrhythmias, delayed gastric motility, hypothyroid like state with dry skin, listlessness, and dry, falling out hair; peripheral edema; osteoporosis and increased risk of fracture
What will the labs for a person with anorexia look like?: leukopenia, anemia, low serum potassium, elevated blood urea nitrogen, high serum calcium levels indicate osteoporosis is occuring
Physical symptoms of bulimia: hoarseness, esophagitis, dental enamel erosion, enlarged parotid glands, abrasions or calluses on knucles, amenorrhea in 40% of cases, concentrated urine, decreased urine output, hypotension, elevated temperature, poor skin turgor, weakness, arrythmias
Lab test results for bulimics: low potassium, increased toxicity if using ipecac
What are some pharmacological treatments for eating disorders?: - Imipramine
- Prozac
- for severe problems use IV's, hyperal, appetite stimulation
**never use wellbutrin**
-acomplia - new med coming out
What therapy should be implemented in eating disorder clients?: help identify underlying fears, feelings, and any secondary gains they achieve from the behaviors. Help to develop alternative behaviors that are adaptive. Involve the family in treatment
What is the difference between REM and NON-REM sleep?: non-REM - quiet state
REM - most active dreaming, almost total paralysis, like waking state
Define cataplexy: sudden collapse of muscle tone in a person with a dyssomnia
What are circadian rhythm sleep disorders?: 24 hour sleep wake schedule is distrubed
What are examples of circadian rhythm sleep disorders?: Jet lag, shift work, delayed sleep hase, advanced sleep phase
What is somnambulism: sleep walking
What is there a deficit of, in terms of stages of sleep, for individuals with schizophrenia?: Reduced REM sleep and no REM rebound. Stage 4 sleep is limited
What disorder is related to melatonin level variation?: Seasonal affective disorder
What effect does acute alcohol intoxication have on sleep: increased sleepiness for 3-4 hours then fragmented sleep
What is RLS and who usually experiences it?: Restless leg syndrome is usually experienced by individuals greater than 60 years of age.
What is primary insomnia?: difficulty initiating or maintaining sleep, or nonrestorative sleep that lasts for at least a month and does not occur exclusively in association with another sleep disorder or mental disorder
What is primary hypersomnia?: prolonged sleep and excessive sleepiness so severe as to interfere with function which is not better explained by another sleep disorder or a mental disorder.
What are 3 breathing related sleep disorders?: sleep apnea r/t dementia
obstructive sleep apnea
central sleep apnea
What medication is currently being directly advertised to consumers for RLS: Requip
What do nurses need to work with individuals who have sexual disorders?: extensive background and experience
What is gender identity?: personal sense of being male or female related to genetic and environmental influences
What is an example of incongruence of gender identity and anatomical sex?: MTF - born physically male but are emtionally and psychologically female
This individual's life becomes unmanageable, they often lead a double life, there is often a progression to relieve pain: someone with a sexual addiction
What is flexibility in gender roles called?: androgyny
What is frotteurism: rubbing up against others for sexual gratification
What is pedohilia?: Adult sexually aroused by and engaging in sexual behavior with children
What is auterotic asphyxia?: a noncoercive but often fatal sexual behavior that is copulsive and unconventional
What are paraphilias?: sexual disorders that have a strong obsessive-compulsive behavioral component. Usually can be males that feel compelled to engage in hisparticular sexual behavior
What is hypoactive sexual desire disorder?: deficiency or absence of sexual fantasies and persistently low interest in sexual activity.
What can contribute to problems with sexual arousal?: fatigue, pain, meds, substance abuse, menopause, fear of intimacy, conflict, fear of losing control, anger
What is spectatoring?: detached appriasal of sexual performance or the body during a sexual act
What is the difference between transsexuals and cross dressers?: transexuals want to be a member of the opposite sex and cross-dressers simply dress that way
What is a fetish?: A fetish is a paraphilis that is characterized by an early association of a particular object or body part with a sexual arousal condition. The person begins to respond sexually to that stimulus.
What is autism?: abnormal development in social interaction, communication, and restricted involvement in activities and interests
What are some symptoms of autism?: - impaired nonverbal communication - lack of interest in shared activities - delay or lack of spoken languge - motor mannerisms - stereotyped, repetitive, or idosyncratic language - preoccupation with parts of objects - like structure - very anxious - aversion to being held
What is the etiology of autism?: Genetics
Structural brain and neurotransmitter abnormalities
Mre boys than girls
onset before 3 years
What is the treatment for autism?: - luvox and anafril
- behavioral and family therapy
- special diet
- educational approaches
Age of onset of schizophrenia in children: between 5-10 years of age
What is the etiology of schizophrenia in children: genetics and structural and functional brain changes
What are the signs and symtpoms of schizophrenia in children?: delusions, hallucinations, regressive behaviors, cognitive problems
Treatment of schizophrenia in children: atypical anti-psychotics
individual and fmaily therapy
behavior modifications
What is asperger's disorder?: Has some but not all of the features of autism. Children show same problems with social interaction adn restricte, repetitive behavior but there is no delay in language, cognitive development, in age appropriate self-help and adaptive kills, or in curiousity about the environment.
Symptoms of attention deficit disorder: 6 or more of the following:
1. doesn't give close attention to details
2. difficulty sustaining attention
3. does not listen when spoke to directly
4. doesn't follow instructions
5. doesn't like activities requiring a lot of mental effort
6. easily distracted by extraneious stimuli
7. forgetful in daily activities
Symptoms of attention deficit hyperactivity disorder: Six or more of the following
1. fidgets with hands or feet and squirms in chir
2. leave set in classroom
3. runs or climbs excessivly in inappropriate situations
4. can't play in quiet activities
5. described as driven by a motor
6. talks excessively
7. blurts out answers before question is done being asked
8. difficulty awaiting turn
9. interrupts or intrudes on others
Differences between ADHD and bipolar disorder in children: ADHD: gory dreams, slow and irritable in morning, excessive physical energy boosts, regression during anger, intentional destructiveness, family history positive, enjoys danger, dysphoric mood changes, treat with a stimulant

Bipolar disorder: no gory dreams, quick and fully charged in the morning, always on with excessive energy, less regression ssen during anger, accidental destructiveness, family history positive, oblivious to danger, no dysphoric mood changes, treat with mood stabilizers
What meds are given to treat ADHD: Ritalin (most common)
Concerta (longer acting)
Adderall (amphetamine mixture)
Cylert (not a true stimulant)
Straterra (non-stimulant)
Why are stimulants gien to children with ADHD: they have a idosyncratic effect, help inattentive and hyperactive peopel slow down and focus.
What are the short term side effects of ADHD meds?: weight loss
sleep disturbance
tics
what are some long term side effects of ADHD meds?: arrythmias
inhibit growth
What psychopathologies are unique to adolescents?: Oppositionaly defiant disorder
Conduct disorder
What the features of ODD and CD in adolescents?: challenging, severity and duration of symptoms defines illness according to DSMIV standards, pattern change from baseline, must differentiate between normal defiance and abnormal defiance
Define oppositional defiant disorder: recurrent and hostile pattern of behavior toward authority figures.

Most common in children 11+ years of age
Define conduct disorder: repetitive and resistent behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated
Criteria for diagnosing Oppositional defiant disorder: These four behaviors must last longer than 6 months:

1. negativisitic behavior
2. defiant behavior
3. disobedient behavior
4. hosilt behavior

Also: behavior must occur more frequently in this individual than others the same age and the person must have significant impairment in social, academic, or occupational functioning
Examples of behaviors exibited by persons with oppositional defiant disorder: - loss of temper
- arguing with adults
- actively defying
- refusing to comply with rules of adults
- deliberately annoying others
- blaming others for mistakes
- easily annoyed by others
- being angry
- being resentful
Symptoms of Conduct Disorder: - repetitive, persistent behavior
- rights of others are violated
- age apropriate societal norms are violated
- agressive conduct
- non agressive conduct
Examples of non agressive conduct in persons with CD: causes property damage or loss
deceitfulness
theft
serious violations of rules
Examples of agressive conduct in persons with CD: causes or threatens physical harm toward people or animals
Future prospect of persons with CD: - end up in legal system
- develop anti-social personality disorder
- substance abuse often develops
How should children and adolescents with CD or ODD be treated with medications: - adult meds at smaller doses
- long term effects are unknown
- research is showing protection of brain with antipsychotic meds in children
How should mental health nurses care for children and adolescents with psychopatholigies?: 1. screening
2. know developmental level of child
3. establish a connection with the child
4. set limits
5. educate on boundaries
6. be an authority figure
7. be consistent
8. make sure adult signs the child into the unit
9. family therapy
10. gather family history
Psychopathologies in older adults: Depression
Anxiety disorders
High rates of suicide
What might be a cause of depression in adults over the age of 65?: physical conditions that are difficult for their bodies to handle (asthma, CHF, chronic infection, anemia, rheumatoid arthritis, thyroid function problems)
What does dementia in older adults look like?: memory impairment, impaired ability to learn new information, short term memory is greatly impaired

Symptoms may come on gradually or abruptly
What are the symptoms of dementia in older adults: - aphraxia
- aphasia
- agnosia
- disturbance in executive functioning
What are the two types of demential in the elderly population: Early onset <65 years of age
Late onset >65 years of age
Define apraxia: Total or partial loss of the ability to perform coordinated movements or manipulate objects in the absence of motor or sensory impairment.
Define aphasia: Partial or total loss of the ability to articulate ideas or comprehend spoken or written language, resulting from damage to the brain caused by injury or disease.
Define agnosia: Loss of the ability to interpret sensory stimuli, such as sounds or images.
Compare and contrast dementia with psuedodementia: Dementia: family history, confabulate answers, disoriented to time and place, good at compensating, minimize impairment, LT memory intact, sundowners syndrome, cognitive then mood changes, behavior changes such as wandering and agitation, usually more gradual onset

Psuedodementia: no family history, depression may cause dementia, "i don't know answers", exaggerate impairment, LT and ST memory changes, early morning awakenings, rapid onset, mood change then dementia, usually no behavior change
What meds are used to treat elders with dementia: Namenda - for severe AD
Atypical anti-psychotics for agitation - abilify, geodon, risperadol
Antidepressant for dysphoria and agitation
vitamin E - to slow dementia
NSAIDS
Ginko biloba
What is anticholinergic syndrome?: Antipsychotics all possess anticholinergic side effects - they interfere with the normal transmission of nerve impulses.

Elderly people with this syndrome will look confused

Other meds that can cause this are benzodiazepines, anti-depressants, and antihistamines
What are some symptoms of anticholinergic syndrome: Skin flushing, dry mucous membranes, blurred vision, motor incoordination, confusion, agitation, hallucinations, delirium
What are the stages of loss?: Denial, anger, bargaining, depression, acceptance
What interventions can nurses use with care of elders with dementia and depression: - understand elders may act out feelings they can't express
- elders may become irritable with depression
- go elder's pace
-use simple, direct language
- use diagrams and signs
- start meds at small doses and increase slowly
- maintain optimal level of functioning
DSM-IV-TR criteria for Schizophrenia: -2 or more of the following symptoms every day for at least 1 month:
delusions
hallucination
dizorganized speech
disorganized behavior
negative symptoms
-social/occupational dysfunction
-duration
-r/o schizoaffective and mood disorder
-r/o substance/general medical condition
-relationship to pervasive developmental disorder
What are the positive symptoms of schizophrenia?: delusions
hallucinations
disorganized speech
catatonia
What are the negative symptoms of schizophrenia: affective flattening
alogia
avolition
anhedonia
Cognitive symptoms of schizoprenia: attention
memory
executive function
Mood symptoms of schizoprenia: dysphoria
Suicidal
hopelessness
What are delusions?: false personal beliefs
inconsistent with IQ
continue despite proof that they are not reality based
con be very bright and persuasive
you are unable to realize with these people
What are the common delusional themes: persecution - people are out to get them
grandeur - they can do anything
control of influence - ability to control others thougts
somatic - something is going on in their body
nihilistic - world is ending
What are hallucinations?: breaks from reality
What types of hallucinations exist?: Auditory - temporal lobe
Visual - occipital lobe
Tactile - parietal lobe
Olfactory - parietal lobe
Gustatory - parietal lobe
What are the stages of hallucinations?: comforting - help at first
condemning - become intrusive and negative
controlling - caustic and negative, commanding
conquering - eventually may kill person or another
What is disorganized speech?: speech is loose and incoherent, lack of goal directed actions, difficult to manage basic daily activities
What is Catatonia: - motor immobility
- waxy infelxibility
- purposeless motor activity
- mutism - won't be able to talk
- posturing
- echolalia - says last word over and over
- person slows down til they can't move anymore
What is affective flattening: blank or flat looks on their face all the time
What is alogia?: poverty of speech, don't initiate conversations
What is avolition?: Lack of attention of ability to finish things
What is anhedonia?: Lack of pleasure in activities they used to enjoy
What is dysphoria?: feeling sad or bad all the way to full blown depression
What are the four types of schizophrenia?: Disorganized
Catatonic
Paranoid
Undifferentiated
Describe disorganized schizophrenia: Sz that has disorganized thought as the most pronounced symptom
What is catatonic Sz?: the individual becomes immobilized with bursts of activity
What is paranoid Sz?: Sz with a strong paranoid or delusional process going on
what is Undifferentiated Sz?: Sz that has symptoms of all types of Sz and doesn't fit just one specifically
What are other forms of psychotic disorers?: Schizoaffective Disorder
Brief psychotic disorder
Delusional disorder
Shared psychotic disorder
Substance-induced psychotic disorder
What are some comorbities common with schizophrenia: uni or bipolar disorder
substance-dependence or addictions
anxiety disorders
personality disorders
What is the etiology of schizophrenia?: genetic influence

biochemical influences (too much dopamine)

Physiological influences

Environmental influences (toxins that peopel are exposed to, types of immunizations, stress people are in)

Transactional model (combination of all of the above)

Older theories (double blind communication or split personality)
What treatments are used for schizophrenia?: medications
long-term supportive therapy
group therapy
family support
milieu therapy
Treatment considerations for schizophrenic clients: 1. be supportive in nature, not intensive one to one psychotherapy
2. social skills oriented, focus on reintegration into the community
3. vocational rehabilitation - part time jobs
4. goal is to optimize level of functioning
Nursing interventions for schizophrenia: 1. safety
2. administer and monitor meds
3. clear communication and boundaries
4. anxiety reduction
5. decode delusion or hallucination themes
6. encourage reintegration into community
7. educate person and family
8. include and support family
5 points that are important to remember when interrupting hallucinations: 1. build a trusting relationship
2. look and listen for cues of hallucinations
3. ask if they are experiencing hallucinations
4. tell them you don't hear what they hear in a nonjudgmental manner
5. teach distraction methods
What are short-term anti-psychotic meds used for?: exacerbations of schizophrenia
actue mania
brief periods of loss of control
psychotic symptoms <3mo
What are long-term anti-psychotic meds used for?: schizophrenia
bipolar
paranoia
long lasting psychotic symptoms
What considerations should the nurse think about when selecting an anti-psychotic med for a person.: select according to side effect profile
start with a low dose
consider cost
non-addictive - don't want them addicted to psychotic agents
Characteristics of anti-psychotic meds: **metabolized in liver (20-40 hours)
**With paranoid patients - liquid concentrates or IM administration is important
**7up or diet 7up is universal mixer with meds
Types of anti-psychotics: High-potency/broad spectrum - wide range of side effects

Moderate potency

Low potency

Atypical - more dopamine specific, fewer side effects, very specific to dopamine

Dopamine system stabilizer - new and will be on market soon
Frequently seen antipsychotics: Risperdal (benzisoxazole derivative) - newest, longer acting, 500-650 per week

Abilify (dopamine stabilizer)

Geodon (benzisothiazolyl piperazine derivative)

Clozaril - 900-1000 per month
(dibenzodiazepines)
What are some different side effects seen with anti-psychotics: -anticholinergic
-orthostatic BP changes
-sedation
-weight gain
-increased photosensitivity
-decreased tolerance to alcohol and sedatives
-problems with sexual functioning
-agranulocytosis
-GI distress
-extrapyramidal side effects
Examples of extrapyramidal side effects: parkinsonism
dystonic reactions
akathisia
tardive dyskinesia
What are dystonic reactions?: abnormal tonic contractions of muscle groups

-trunk, neck, and face
-oculogyric crisis - eyes won't do what you want them to do
What is akathisia?: Motor restlessness perceived subjectively by the client and experienced as an urge to pace, an need to shift weight from one foot to another, or an inability to sit or stand still
What is tardive dyskinesia?: characterized by coordingated, arrythmic, involuntary movements (lip smaking, tongue protrusion, rocking, foot tapping)

can be reversible, risperadol can be helpful

atypicals cause less TD and Risperdal can reverse TD to some degree
What meds can be used to fight the effects of antipsychotic medications: Cogentin
Artane
Benadryl
Ativan (for dystonic reactions)
What tools can be used to assess tardive dyskinesia?: Measure with DISCUS scale
Abnormal involuntary movements scale (AIMS)
Use same tool over time
What is neuroleptic malignant syndrome?: a severe and potentially life-threatening side effect of all psychotropic medications.

It a result of dopamine blockade and is not an allergic or toxic reaction
What are symptoms of Neuroleptic malignant syndrome: fever
diaphoresis
muscle rigidity
increased CPK
increased heart rate and BP changes
change in sensorium-increase confusion results in delirium
What is the treatment for Neuroleptic malignant syndrome?: hold the antipsychotic and contact MD

Supportive care - safety and hydration

Dopamine agonist - Bromocriptine or symmetrel for sometimes meds do not help
What is the definition of severe and persistently mentally ill: severity = impairs one's ability to function socially, occupationally, ADL's, etc

duration = symptoms are pronounced nearly every day for 6 months to 2 years
Concerns for people with SPMI: - stigma
- parity in Kansas
- disability and the limited number of work hours
- self-determination

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