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498 terms

Mental Health Final

(norepinephrine + dopamine re-uptake inhibitor)
acetylcholinesterase inhibitors
Donepezil (Aricept)

Galantamine (Razadyne)

Tacrine (Cognex)

Rivastigmine (Exalon)

used to treat dementia

Cloraze-pate (Tranxene)

Triazolam (Halcion)
Oxcarbazepine (Trileptil)

Lamotrigine (Lamictal)

Topirimate (Topamax)

Gabapentin (Neurontin)
atypical antipsychotics and mood stabilizers
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
Zuclopenthixol Decanoate (Clopixol Depot)

how powerful?
Intermediate Potency
Fluphenazine Decanoate (Modecate)

how powerful?
High Potency
Flupenthixol Decanoate (Fluanxol)

how powerful?
High Potency
-twisting and repetitive movements or abnormal postures
drug induced; tremor either fine or course, drumming of fingers against the thumb; stiffness
Cogentin treat what EPS side effect? (2)
dysonia and parkinsonism
Artane treats what eps side effect?
Kemadrin treats what eps side effect?
panic disorder symptoms
paresthesia (is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect)
Milleu therapy
is an approach that uses the total environment (i.e. a hospital unit) to provide a therapeutic community. Personal responsibility for one's self and others is encouraged in a safe and caring community setting.
behavioral symptoms of anxiety
are inhibited, postural collapse,
cognitive symptoms of anxiety
are either sensory-perceptual, such as feeling dazed, objects blurred or seem in the distance, or the environment seems different or unreal,
physical symptoms of anxiety
increased reflexes, startle reaction, flushed or pale face, diarrhea
criteria of major depressive episode
a) Presence of ≥5 symptoms for at least 2 week period, and represent a change from previous functioning. One of the symptoms should be either 1- depressed mood or 2- loss of interest or pleasure (anhedonia). These symptoms are:
major depressive disorder
Major Depression Disorder diagnosis requires 2 or more of the previous episodes in 2 consecutive months. Some authors found that 5 out of 9 diagnostic criteria are required for diagnosis without the necessity of the depressed mood and anhedonia to be among them (Zimmerman et al., 2006).
MDD epidemiology and risk factors
Highest rate of onset occurs in young adult age group
manic depression epidemiology
Mean age of onset = 21-30yrs old

Main sign in children is intense rage

Older adults w/ mania have more abnormalities and cognitive impairments than younger patients

Increased incidence in mania in women (50+) and men (80-90+)

Bipolar II disorder 5% greater in women than men
suicide ideation epidemology
Most common in adolescents
Milder but more chronic form of MDD
symptons of dysthmia
Depressed mood for at least 2 years
serotonin and NERI
• Inhibit serotonin and NE reuptake

• Another first-line treatment for major depressive disorder
NE and Dopamine reuptake inhibitor
• Inhibit NE and dopamine reuptake

• Alternative use: smoking cessation
TCA function
In other words, the drug increases the amount of serotonin and norepinephrine available in the brain.
skills for care
information about the illness, treatments, symptom recognition and management, monitoring and rehabilitative strategies.
family cohesion
those suffering mental illness do better living at home.

A family that is taught to moderate their emotional responses to the illness can reduce relapse.

Family functioning may be strengthened by working together to problem solve and set coping strategies in plae.
respite care
the role of the caregiver can lead to extreme burn-out, and place higher levels of stress on family functioning. Retaining appropriate care for the mentally ill member can help relieve stress on the caregiver. If the family member is in the position where their care is priority, and lifelong, it is recommended to find a caregiver willing to take on that role if the present one is unable or dies.
problem focused coping
Problem focused coping is aimed at the actual stressor and its physical impact where the goal is to remove or reduce the physical impact. (i.e.) stressor= loud tv preventing studying and coping= asking neighbour to turn down the tv. The neighbour turns the tv down and the student resumes studying. The student will likely repeat this behaviour the next time as it successfully and physically removed the problem.
acute care vs community care mental health
Community care for a patient with a major depressive disorder offers a less intensive means of helping patients improve their health and wellbeing. Community care measures offer services to those who do not need inpatient services in order to manage their conditions. Examples of community care include mental health walk-in clinics, support groups, counsellor/psychiatrist visits, and community mental health centers.

In the mental health milieu acute inpatient care is generally reserved for acutely ill patients who due to a mental illness meet one or more of the following criteria: high risk for harming themselves, high risk for harming others, or possess an inability to meet one's own basic needs.
axis 2
Personality Disorders

Mental Retardation
axis 4
Psychosocial and Environmental Problems
General Medical Conditions that may Produce Psychosis (a break with reality)
Thyroid (thryoid regulates our metabolism but if someone is hyperthyroidism can lead to depression,

lupus causes psychosis
why 2nd generation antipsychotics over first gen antipsychotics
Treat negative symptoms

Improve cognition

Less prolactin elevation
atypical antipsychotic side effects
Weight gain (Olanzapine)

Insulin resistance and diabetes (Clozapine, Olanzapine)

Hyperprolactinemia (Risperidone)

Sialorrhea (Clozapine)

Sedation (Clozapine, Olanzapine, Quetiapine)

Rare parkinsonism and akathisia at higher doses (Risperidone, Ziprasidone)

Rare seizures (Clozapine)
Clozapine and olanzapine side effect
Weight gain (Clozapine, Olanzapine)

Insulin resistance and diabetes (Clozapine, Olanzapine
Risperidone side effect
Hyper-prolacti-nemia (abnormally high prolactin in blood)
clozapine side effect
Sialorrhea (excessive secretion of saliva)

Rare seizures (Clozapine)
Clozapine, Olanzapine and Quetia-pine side effect
Risperidone and Ziprasidone side effects
Rare parkinsonism and akathisia at higher doses
con of using second gen over 1st gen antipsychotics?
Higher for second-generation antipsychotics but deemed worth the price due to reduced hospitalization time and improved client quality of life.
Types of acute treatment
1st or 2nd generation Antipsychotics


PRN use of injectable, quick-acting agents
-Haloperidol + Lorazepam
-Zuclopenthixol Acetate (Acuphase)
types of maintenance treatment
2nd generation Antipsychotics

Depot Neuroleptics or Risperidone Consta

Mood Stabilizers

tricyclics side effects
Cardiac arrhythmias
Very toxic in overdose
Anticholinergic +++
MAOI side effects
Stimulation (anxiety, insomnia, etc)
Hypertensive crisis (tyramine foods)
Toxic in overdose
SSRI side effects
Gastrointestinal distress: hypermotility, loose BMs. Risk for NMS.
Sexual Dysfunction: delay or inhibition of orgasm, erectile dysfunciton, reduced libido.
Serotonin syndrome: fast onset, tremors, diarrhea, pyrexia, twitches, shivering.
Much safer in overdose.
mood stabilizers function
Used to treat Bipolar Affective Disorder
(Manic Depression)
Oldest psychiatric drug still in use

"Narrow therapeutic window"

60-80% response in "classic BPD"
lithium side effects
Stomach discomfort, g.i. hypermotility
Excessive thirst and urination
Weight gain, tremor
Weakness, dizziness, confusion
lithium interaction

how many? Nursing consideration?
Many drugs
Always monitor for toxicity

Rapid cyclers and lithium failure

"Narrow therapeutic window"
carba-zepine side effects and interactions
Drowsiness, dizziness
Decreased white blood cells
Skin rash

Interactions- Many
valproic acid
Classic BPD and rapid cyclers
valproic acid side effects
Weight gain, menstrual changes, pancreatitis
Hair loss
anxiety/sleep meds
-enhance the actions of GABA
increase synaptic dopamine and/or norepinephrine
Atomoxetine (Strattera)
non-stimulant; increases synaptic dopamine & norepinephrine
Memantine (Ebixa, Namenda)
blocks effects of glutamate
meds for dementia
Memantine (Ebixa, Namenda)
Medications for Attention Deficit (Hyperactivity) Disorder

Atomoxetine (Strattera)- non-stimulant; increases synaptic dopamine & norepinephrine

Antidepressants (bupropion, imipramine, nortriptyline)
Anxiety/Sleep Medications
Trazodone (Desyrel)
Diphenhydramine (Nytol, etc)
Zaleplon (Starnoc)
Mood Stabilizers are..
some atypical antipsychotics are mood stabilizers
mood stabilizers and antipsychotics
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
ways to behaviorally cope with mild anxiety
ways to behaviorally cope with moderate anxiety
Compensation - when somebody got a perceived deficiency

Denial (most common)

Displacement - my boss yells at me at work, then I yell at my own kids

Identification - I buzz my face just like my dad

Projection - I walk in here in a bad mood then I yell at u

Rationalization - I have to get blind drunk cuz of the horrible class I have to endure

Regression -

Repression -when somebody can't remember something

Undoing -
Psycho-physiological responses to moderate anxiety
CHD (coronary heart disease)
Sexual dysfunction

Conversion disorder (a condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation)

Dissociative ID (multiple personality disorder)


Fugue ( is a rare psychiatric disorder characterized by reversible amnesia for personal identity, including the memories, personality and other identifying characteristics of individuality
can be roughly divided into two halves or hemispheres. For most people, one hemisphere is dominant, whereas about 5 percent of individuals have mixed dominance. Each hemisphere controls functioning mainly on the opposite side of the body. The left hemisphere, dominant in about 95 percent of people, controls functions mainly on the right side of the body. The right hemisphere provides input into receptive nonverbal communication, spatial orientation and recognition; intonation of speech and aspects of music; facial recognition and facial expression of emotion; and nonverbal learning and memory in general, the left hemisphere is more involved with verbal language function, including areas for both receptive and expressive speech control. In addition, the left hemisphere provides strong contributions to temporal order and sequencing, numeric symbols and verbal learning and memory.
o b/w nerve fibers are synapses. Between one fiber to the next ,communication occurs with the neurotransmitters. Neurotransmitters are metabolized by various enzmes
cerebral cortex
o abstracting thinking and decision making
o part of the brain we can see
o frontal lobes of the cortex - higher order thinking and good judgment
o impairment here; get them drunk and observe their social judgment.
limbic system
• Basic emotions (rage), needs, drives and instinct begin and are modulated in the limbic system
• Roles in memory and learning
• Seat of emotions.
• Composed of hippocampus, thalamus, hypothalamus, amygdala and limbic midbrain nuclei.
basal ganglia
• Involved with motor funcitons and association in both the learning and the programming of behavior or activities that are repetitive and, done over time, become automatic.
• Has to do with muscles and movts
• Damage to portions of these nuclei may procduce changes in posture or muscle tone. May also produce abnormal mvts, such as twitches or tremors.
• Subdivisions: putamen, globus pallidus, and caudate.
• Basic human activities, such as sleep-rest patterns, body temp, and physical drives such as hunger and sex (basic sexual arousal and sexual behavior), are controlled by another part of the limbic system that rests deep within the brain and is called the hypothalamus.
• Dysfunction of this structure, whether from disorders or as a consequence of the adverse effect of drugs used to treat mental illness, produces common psychiatric symptoms, such as appetite and sleep problems.
• Dysfunction of this structure, produces common psychiatric symptoms, such as appetite and sleep problems.
• Secretes neuro hormones such as ADH
substantia nigra
manufacture dopamine which plays a major role in muscle mvt.
looks at how psychosocial factors affect our immune system. There are great connects not well understand between SN endocrine sytem, etc
• proposed role in learning and memory, attributing value in reward systems; fluctuates in sleep and wakefulness

• has effects on our moods and our bp. Antidepressant effects

• very widespread throughout the cortex, thalamus, cerebellum, brain stem and spinal cord.

• Basal forebrain, thalamus, hypothalamus, brain stem and spinal cord.
• Striatum, limbic system and cerebral cortex. Pituitary
• Involved in involuntary motor mvts. Some role in mood states, pleasure components in reward systems, and complex behavior such as judgment, reasoning and insight.
• Very widespread through the cortex, thalamus, cerebellum, brain stem, and spinal cord

• Proposed role in the control of appetite, sleep, mood states, hallucinations, pain perception, and vomiting, activity levels. Antidepressant effects
• Diffuse throughout the cortex, hippocampus. Peripheral NS.
• Important role in learning and memory.
• Some role in wakefulness and basic attention.
• Peripherally activates` muscles and is the major neurochemical in the autonomic system.
• Found in cells and projections throughout the CNS, especially in intrinsic feedback loops and interneurons of the cerebrum

• Also in the extrapyramidal motor system and cerebellum

• Fast inhibitory response postsynaptic ally (calms NS), inhibits the excitability of the neurons and therefore contributes to seizure, agitation and anxiety control. Antianxiety muscle relaxant, hypnotic effects, anticonvulsant. Affected by antianxiety meds.
• Suppresses pain, modulates mood and stress. Relaxant and analgesic.
• Likely involvement in reward systems and addiction
anxiety disorders
• The most common of the psychiatric illnesses treated by health care providers.
• A brief electrical current is passed through the brain to produce generalized seizures lasting 25 to 2 min and 30 sec

• A short acting anaesthetic and a muscle relaxant are given before induction of current

• A brief pulse stimulus, administered unilaterally on the non-dominant side of the head is associated with less confusion after ECT.

• Some individuals require bilateral treatment for the effective resolution of depressive symptoms

• Induction of a seizure is necessary to produce positive treatment outcomes.

• the lowest possible electrical stimulus necessary to produce seizure activity is used

• Blood pressure and ECG are monitored during the procedure. The procedure is repeated two or three times per week.

• ECT is most effective in treating severe depression, mania and schizophrenia when other treatments have failed. Also used for severe forms of depression, delusions and paranoia.

• After symptoms improve antidepressants are given to prevent relapse

• ECT causes rapid improvement in depressive symptoms, the exact mechanism remains unclear
ECT function
• ECT produces an up-regulation in serotonin, especially 5-HT, also an increased influx of calcium and effects on second messenger systems
ECT side effects
• Adverse Effects are: hypotension, hypertension, bradycardia, tachycardia, minor arrhythmias

• After Effects are: headache, nausea, muscle pain

• Cognitive side effects are: after seizure disorientation, short term retrograde amnesia, retrograde memory loss

• ECT is contraindicated for patients with increased intracranial pressure, recent MI, recent CVA
Risk factors associate with self-harm, and attempted and successful suicide
age: The incidence of suicide increases with age. However, recently the incidence in young adult men up to 45 years of age has been increasing

gender: Suicide is approximately three times higher in men across all ages
Self-harm has a higher incidence among females, especially those aged 25 years and under.

race: Suicide and self-harm have a higher incidence among Caucasians

marital status: Suicide has a higher incidence among divorced, single or widowed individuals

living circumstances: Suicide and self-harm have a higher incidence among those living alone or homeless

unemployed status: Suicide and self-harm have a higher incidence among the unemployed

Occupation: Suicide has a higher incidence among certain professions, for example farmers, dentists, and doctors, possibly associated with accessibility of methods.

episodes of loss or bereavement: Suicide has a higher incidence among those experiencing recent losses, for example loss of job, partner, health due to illness, especially diagnosis of chronic or terminal illness such as HIV, hepatitis C virus or cancer

Season Variation: Suicide has a higher incidence during spring (except for prison populations where the incidence increases in autumn)

regional variation: Suicide has a higher incidence in rural regions

deliberate self-harm: Suicide and self-harm risk is greater if there is a previous or current history of such behavior

Mental Illness: Suicide has a higher incidence in patient with current episodes, receiving treatment or an inpatient with previous 12 months (that is, recent discharge)

social support history: Suicide and self-harm have a higher incidence among those with poor social support networks

substance abuse: Suicide and self-harm have a higher incidence among patients with a history of substance misuse

forensic history: Suicide and self-harm have a higher incidence where there is a history of violent crime

biological factors: Suicide risk is greater where there is a family history of suicide
giving broad statements

Giving broad openings
• Introducing an idea and letting the client respond
• Nurse: trust means....CT: that someone will keep you safe.
• Purpose: used when helping client explore feelings or gain insight.
reflecting feelings

Reflecting feelings
• Redirection the idea back to the client.
• CT: Should I go home for the weekend? Nurse: should you go home for the weekend?
• Purpose: used when client is asking for the nurse's approval or judgment. Use of reflection helps nurse maintain a nonjudgmental approach.

why is it prohibited during therapeutic communication?
• Problem: nurse solves the client's problem, which may not be the appropriate solution and encourages dependency on the nurse.
• If advice doesn't work out, trust in relationship is broken and nurse is blamed.

why is it prohibited during therapeutic communication?
• Agreeing with a particular viewpoint of a client
• CT: Abortions are sinful. Nurse: I agree.
• Problem: Client is denied opportunity to change one's view now that the nurse agrees

why is it prohibited during therapeutic communication?
• Tell a client that everything will be ok.
• CT: everyone thinks I'm bad. Nurse: you are a good person.
• Problem: nurse makes a statement that may not be true. Client is blocked form exploring feelings.

is it good or bad?
Self-disclosure can be used in very specific situations, but self-disclosure is not the first intervention to consider. In prioritizing interventions, active listening is one of the first to use.
boundary violations
• Be professional
• Don't have sex with client.
• Don't be friends with client.
• Time
• Place and space
• Money
• Gifts and services
• Clothing
• Language
• Self-disclosure
• Post-discharge
• Physical contact
principles of therapeutic communication
1) The client should be the main focus of the interaction.
2) A professional attitude sets the tone of the therapeutic relationship
3) Use self-disclosure cautiously and only when the disclosure has a therapeutic purpose.
4) Avoid social relationships with clients.
5) Maintain client confidentiality.
6) Assess client's intellectual competence to determine the level of understanding.
7) Implement interventions from a theoretic base.
8) Maintain a nonjudgmental attitude. Avoid making judgments about the client's behavior and giving advice. By the time the client sees the nurse, he or she has had plenty of advice.
9) Guide the client to reinterpret his or her experiences rationally/
10) Track the client's verbal interaction through the use of clarifying statements. Avoid changing the subject unless the content change is in the client's best interest.
therapeutic relationships are characterized by
Therapeutic relationships are characterized by:
• • Trust
• • Professionalism
• • Mutual respect
• • Caring
• • Empathy
• • Genuineness
• • Unconditional positive regard

This relationships is:
• One-way
• Focused on improving the health of the patient.
• Whereas with a social relationship, it's a mutual benefit.
• Nurse is in power position and at the same time, the nurse is trying to give power to patient by giving that patient more autonomy
• Patient is vulnerable.
• Therapeutic relationships are intentional
• Relationship is short-term
orientation phase
• Definition: when you make the connection with the person, about their life situation, about why they come for help

• Goal: 1) to build trust and rapport and 2) to get some initial info

• Tuning in- focus on what the patient is saying; maintain eye contact. Start a conversation. Do not ask questions right away

• Active listening - listening to what the person is saying

• Respond with empathy - to communicate with them that you understand what they said.

• Checking understanding - use interpretation or summarize what you heard back
o It's ok to ask both close-ended and open-ended questions

• Probing - probe for more details

• Summarizing - summarize back the message and then patient says "yes, you got it" then you understand what they're saying

• Challenging
• negotiating
o is an unconscious response in which the patient experiences feelings and attitudes (of inappropriate intensity) toward the nurse that were originally associated with other significant figures in his or her life. Transference reduces self-awareness by allowing the patient to maintain an inaccurate view of the world.
o Client uses transference to examine problems.
o During the phase, client is psychologically vulnerable and emotionally dependent on the nurse.
o is a therapeutic impasse created by the nurse's specific emotional response to the qualities of the patient. This response is inappropriate to the content and context of the therapeutic relationship and inappropriate in the degree of intensity of emotion.

o The nurse needs to recognize countertransference and prevent it from eroding professional boundaries.
factors that facilitate effective interviewing
o If you intend to make notes, inform others of this at the beginning of the interview. Keep your notes brief; most of the attentional resources should be focused on interaction
o Maintain an open body posture and actively attend to the encounter.
• Avoid jargon
o Repeatedly check with participants to ensure that they understand what you are saying.
• Being with a less sensitive topic and move toward sensitive issues as rapport develops.
• Leave some time at the end of the encounter for closure and future planning.
o Monitor the available time
"SAD CHILDREN" - Framework for Suicide Assessment
S - Support System. Does indiv have support system?

A - Alcohol and Drug Use. Substance use may intensify the individual¡¦s mood and increase the risk of suicide

D - depression. The single best predictor of suicidal thinking is the presence of a mood disorder, including mania.

C - communication. Is the individual able to verbalize feelings? With whom?

H - hostility. Is the individual angry? How is anger expressed? (i.e. internalized or expressed outwardly)

I - impulsivity. Impulsivity when combined with method of high lethality indicates significant risk

L - lethality. What means has the individual chosen? Especially lethal methods include weapons, jumping, hanging, toxic medication. Is there a plan to avoid being discovered or rescued?

D - demography.

R - reaction of evaluator. Are you worried about the client? Do you feel depressed listening to the client?

E - Events. Severe life events often precede a suicide attempt such as: losses (significant others; marriage; job; past lifestyles) or conflicts (in relationships; making decisions)

N - No hope. Expressions of hopelessness
Asking a patient "Do you feel like killing yourself?" will
put ideas into his or her head and lead to suicide attempt.

Children and adolescents with anxiety disorders
have higher rates of suicidal behavior, early parenthood, drug and alcohol dependence, and educational underachievement later in life.
psychodynamic theory about anxiety disorder
. The kid may begin with a neurophysiologic vulnerability that predisposes one to fearfulness.

This fearfulness is enhanced by parental behavior in some way, which results in disturbed parent-child relationships and causes the child to feel conflict about dependence and independence (separating from parent), self-doubt and confusion regarding self-identity, and personal control.
interpersonal theory of anxiety disorder
Loss or disapproval of relationships leads to anxiety disorder
biochemistry evidence about OCD
• Pharmacologic evidence that serotonin plays a role in OCD

• Dysfunction in GABA and other neurotransmitters.
panic attacks
discrete period of intense fear with 4 or more of the following symptoms that develop abruptly and reach a peak within 10 minutes.
panic attack symptoms (some of them)
o Chest pain
o Depersonalization (feeling detached from oneself)
o Numbness or tingling sensations
can lead to avoidance behaviors

frequently occurs with panic disorder/
generalized anxiety disorder

characterized by long-standing excessive worry and anxiety (apprehensive expectation) often over uncontrollable events. Ex: what if? Indiv with this disorder experience excessive worry and anxiety almost daily for extended periods.
GAD symptoms
• Patients with GAD often have mood symptoms, from mild depressive symptoms, such as dysphoria (restlessness, unwell), to comorbid, major depressive disorder.

• They are also highly somatic, with complaints of multiple clusters of physical symptoms, including muscle aches, soreness, and GI ailments. In addition to physical complaints, patients with GAD often experience poor sleep habits, irritability, trembling, twitching, poor concentration, and an exaggerated startle response.
social phobia

what neurotransmitter is it linked to?
• Linked to a number of key neurotransmitter systems. Recent evidence links low dopamine receptor binding to social anxiety disorder
fear of strangers
fear of night or dark places
re-experience the event through distressing images, thoughts or perceptions and may have reoccurring nightmares. In addition, the patient may experience flashbacks and exhibit extreme stress upon exposure to an event or image that resembles the traumatic event (e.g. fireworks may bring back memories of war). Generally outside the norm of human experience.
avoidance (PTSD)
• Avoidance: patients will avoid discussing the event altogether or avoid ppl and places that remind them of the traumatic event
heightened arousal (PTSD)
Increased arousal: evidenced by difficulty sleeping, irritability, poor concentration, exaggerated startle response, or hypervigilance.
risk factors of PTSD
o Prior diagnosis of depression
o Prior diagnosis of acute stress disorder
o Duration and intensity of trauma involved
o Environmental issues
o Coping style
o Low self-esteem
biofeedback (anxiety)
to monitor and display your physiological activity to expand your awareness and increase control of your body.

Person hooked up to a screen that will let them know when certain brain waves are occurring.
systematic desensitization (anxiety)
• Exposes the patient to a hierarchy of feared situations that the patient has rated from least to most feared.
• The patient is taught to use muscle relaxation as levels of anxiety increase through multisituaaqtional exposure
• Planning and implementing exposure therapy needs special training, because of the multitude of outpatients in treatment for agoraphobia, exposure therapy would be a useful tool for home health psychiatric nurses.
flooding (anxiety)
• Desensitizing is done by presenting feared objects or situations repeatedly, without session breaks, until the anxiety dissipates.
cognitive restructuring function
Its goal is to alter the patient's immediate, dysfunctional appraisal of a situation and perception of long0ternm consequences.
cognitive restructuring steps
-monitor thoughts & feelings:
o Taught to monitor automatic thoughts
o Then to recognize the connection between thoughts, emotional response and behaviors.

-question the evidence: am I drawing the right conclusion
o The distorted thoughts are examined and tested by for-or-against evidence presented by the therapist, which helps the patient to realistically assess the likelihood that the feared event will happen if the compulsive behavior is not performed.

-examine alternatives and perspectives
-de-catastrophizing: is the plain going to crash? Slim chance

-re-framing: How the event can be looked at positvley

o Taught to interrupt obsessional thoughts by saying "Stop!" either aloud or subvocally. This activity interrupts and delays the uncontrollable spiral of obsessional thoughts.
learning new behavior (anxiety disorder)

shaping:learning new behavior one step at a time.

token economy: Clients are rewarded with tokens for selected desired behaviors. They can use these tokens to purchase meals, leave the unit, watch tv, or wear street clothes.

role playing: i'll play you and you play my mother-inlaw

social skills training: Involves instruction, feedback, support and practice with learning behaviors that help children to interact more effectively with peers and adults. ex: toastmasters

aversion therapy

contingency contracting
aversion therapy
a form of psychological treatment in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort. This conditioning is intended to cause the patient to associate the stimulus with unpleasant sensations in order to stop the specific behavior.
o for example: placing unpleasant-tasting substances on the fingernails to discourage nail-chewing
contingency contracting
o A contract is a written document that the nurse and client develop. The document clearly states acceptable and unacceptable behaviors, consequences and rewards, and the role of both the client and nurse in preventing and managing anxiety
o Having a what if plan.
• A pervasive and sustained emotion that colors one's perception of the world and how one function in it; emotional state that influences personality and life functioning.

• Normal mood variations, such as sadness, euphoria and anxiety, are time limited and are not associated with significant functional impairment. The normal range of mood or affect varies considerably both within and between cultures.
inappropriate affect
discordant affective expression accompany the content of speech or ideation. Ex: smile at a sad event
reactive affect
varies normally to any situation. Ex: When I talk of something of concern, I would frown.
labile affect
varied, rapid and abrupt shifts in affective expression. Up and down expressions Ex: laughing to angry in seconds. You see it in mania.
restricted or constricted affect
mildly reduced in the range and intensity of emotional expression. Ex: when everyone is laughing loudly, and you hardly respond....just chuckle.
where does the suppression of emotions fit in the continuum of emotional responses
where does delayed grief reaction fit in the continuum of emotional responses
right to the middle.
-Most maladaptive mood states are characterized by their:
1) intensity: how depressed is somebody?
2) pervasiveness
3) persistance: how long does it last?
4) interference with normal functioning
pathological grief
occurs when grief does not run its normal course. Gotta go through the grief, not around it. You can't schedule it. Ex: can schedule childbirth.
endocrine predisposing factors to mood disorders
-disinhibition of hypothalamic-pituitary-adrenal (HPA) and h-p-thyroid (HPT) axes:
• sometimes there's a problem b/w the target and the pituitary gland.

-cortisol hypersecretion.
• Result in chronic stress, which might lead to neurotoxin in brain thus leading to dementia.

DST: dex-metha-soad Suppression Test.
• Last indicator of depression. Cortisol secretion may not be reduced by the hypothalamus, or there may be no change at all after receiving the synthetic cortisol. In healthy individuals cortisol levels drop at first, but then return to normal as the hypothalamus compensates for the dexamethasone in the blood.
if you have subsequent reoccurrences (episodes) of depression, each one can be worse than the last. That means it can be brought on by weaker forces (causes), will have more severe symptoms, and be harder to treat (need more meds and time). In fact, at some point, it will come on without any push
psychodynamic theory of depression
• Ascribes the cause of depression to an early lack of love, care, warmth, and protection and resultant anger, guilt helplessness, and fear regarding the loss of love.
• This ensuing conflict b/w wanting to be loved and fear of rejection produces pathologic self-punitiveness (aggression and anger turned inward), self-rejection, low self-esteem and depressive symptoms.
depression range of severity
-range of severity: anywhere from a mild sadness to a complete incapacitation with psychotic features (ex: I caused the death of thousands of African ppl, and it's my fault).
depression female/male ratio
self-limiting aspect for untreated depression
4-6 months duration; sometimes a person have a single episode or have chronic depression.
an estimated of cases will seek help, be diagnosed, and obtain appropriate treatment
dysthmic disorder
depressed mood for most days for at least 2 years and two or more of the following symptoms:
Cyclothymic Disorder
• Periods of hypomanic episodes and depressive episodes that don't meet full criteria for a major depressive epidsode.
behaviors associated with depression
-change from previous functioning: " He's just not himself"
o Anhedonia: inability to experience pleasure
-expression of mood:
o Come across as sadness; or negative passivity (pessimism)
o Irritability: "aww I have to do it again?"
o Withdrawal: less involved with people than before
o Pessissm: nothing's going to turn out well.
o Sometimes crying.
o Looks overstressed
o Easily overwhelmed. Ex: give them a task, and they'll say "can't u do that."

-free floating anxiety

-diurnal variation:
o Depressions gets worse in te morning and gets a bit better by evening.
o Ruminating: thinking the same thing over and over again.

somatic or vegetative (biological) s&s:
o Constipation
o Loss of appetite
o Various aches and pains
o Lack of lipido is a big one
o Feelings of weakness in the body which are quite real for them. Ex: do I have to walk in hallway again. We just did that yesterday.
o Catatonia: immobile state. Inability to make a small decision. Ex: ok, lets side down but no I gotta stand up.
-may occur alone or also in people with hx of depressive episodes
milder form of mania
mobile crisis intervention team
provides a highly responsive community crisis to individuals who are experiencing a mental health crisis by the provision of a trained police-mental health team who can assess needs
and ensure connection to appropriate services.

• Focused on:
o De-escalation
o Stabilization
Control of precipitating symptoms via meds, behavioural interventions and agency coordination
o Symptom reduction
o Prevention of relapse
• Usually in place to divert patients from inpatient hospitalization
what is crisis intervention?
o Provision of emergency psych care to aid in returning clients to adaptive level of functioning and prevent negative effects of psychological trauma
o Principles
Early intervention (Crisis intervention services)
Stabilization (prevent worsening)
Facilitating understanding
Focusing on problem solving
Encourage self-reliance
what is bipolar disorder divided into?
• Bipolar disorder is divided into: Bipolar I, Bipolar II and cyclothymic disorder
what occurs during a manic episode?
• During a manic episode
o there may be a manifestation of expansive mood- in which the person shows an inappropriate lack of restraint in expressing feelings and frequently will over evaluate their own importance.
o individual may being quite irritable, being easily annoyed and provoked with anger particularly when they wish to be challenged or thwarted.
o inc. in energy that can be described as hyperactive
o requiring less sleep to feel rested
o may remain awake for long periods of time at night and may wake up several times a night where they are full of energy
o inc. motor activity and agitation
o may engage in spree overspending or even reckless sexual encounters, drug and alcohol abuse and other high risk actives (eg driving fast)
o overly talkative
o thoughts may become disorganized and seem to skip rapidly among un-related topics= FLIGHT OF IDEAS
diagnostic criteria of manic depression
3 to 7 of the follow symptoms must be present (in addition to depressive episodes and manic episodes)
o These include: inflated self esteem or grandiosity, dec. need for sleep, being more talkative or having pressured speech, flight to ideas or racing thoughts, distractibility, inc. in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences.
• Depression must be differentiated from grief reactions, medication side effects and medical illnesses
what is comorbidity in Cindy's case?
indicates that there is the presence of one or more disorder/diseases. It is identified that medical comorbidities in a patient with bipolar disorder is a significant issue because it complicates the diagnosis as well as the management of the illness and may have a negative impact on the patents outcomes. The two most common comorbidities are anxiety disorders and substance abuse. Individuals with comorbid anxiety disorders tend to experience a more sever course and a history of substance abuse further complicates the course of illness and creates a poorer treatment compliance
differential diagnosis
In 1972, attempted suicide was removed from the provisions of the Criminal Code, but remains a criminal act. Is there another possible cause?

In this case we know that when diagnosing the individual with Bipolar Disorder that we need to make sure that we have differentiated it from grief, medical illnesses and medication side effects. I think the importance of doing this type of diagnosis in part lies in the fact that we are dealing with a young girl; a 15 year old where some of her responses can be due to other things such as puberty. Also it is important to take on this type of diagnosis because being identified as having bipolar disorder does have an impact on the individual's life as well as the lives around them.
Global Assessment of Functioning
This tallies behaviors related to school, peers, activity level, mood, speech, family relationships, behavioral problems, self-care skills, and self-concept. GAF scale is from 0 to 100 the lower the score the higher the level of impairment.
suicide epidemiology
• Suicide is the leading cause of death in Aboriginals up to the age of 44 years;

• Most common means are: hanging (39%), poisoning (26%), and firearms (22%) (Statistics Canada, 2006);

• The most predictive factor is previous attempt, and the most protective is being married with dependent children;

• In 1972, attempted suicide was removed from the provisions of the Criminal Code, but remains a criminal act.
Crisis intervention vs psychotherapy
Crisis intervention: "A specialized short-term (often no longer than 6 hours) goal-directed therapy designed to assist patients in an immediate manner, after which they are usually transferred to an inpatient unit or an intensive outpatient setting." (Austin and Boyd)

"A psychotherapeutic technique directed at counseling at the time of an acute life crisis and limited in aim to helping resolve the crisis." (Stegman)
Psychotherapy: "Treatment of emotional, behavioural, personality, and psychiatric disorders based primarily on verbal or nonverbal communication and interventions with the patient, in contrast to treatments using chemical and physical measures." (Stegman)
characteristics of high suicide risk
risk/protective factor: Psychiatric diagnoses with severe symptoms, or acute precipitating event;
protective factors not relevant.

suicidality: Potentially lethal suicide attempt or
persistent ideation with strong intent or
suicide rehearsal
characteristics of moderate suicide risk
Multiple risk factors, few protective factors

Suicidal ideation with plan, but no intent
or behavior
characteristics of low suicide risk
Modifiable risk factors, strong protective Factor

Thoughts of death, no plan, intent or behavior
Cindy and social stigmas
Cindy has a challenging road ahead of her. She has just moved to a new school and has likely created a bad first impression. Studies have shown that teachers can be both supportive and unsupportive of students with mental health illnesses and that they have a huge impact on the success of students being able to manage their illnesses and succeed in school. As Cindy's nurse, it will be important to help Cindy develop strategies to deal with these issues in addition to provide encouragement that she does not have to be defined and controlled by her illness. The nurse will also need to work with Cindy's mom and family, providing education about the importance of treating Cindy like everyone else. Cindy's family needs to be supportive, in a way that focuses on her strengths and not her weaknesses.
Bipolar I
MD + one or more manic episodes (never full mania)
bipolar II
periods of MD + at least one episode of hypomania
disorganized schizophrenia
Obvious personality disorganization marked by incoherence and a flat, silly affect. Other common features are making faces, odd mannerisms, preoccupation with bodily complaints and wanting to be left alone.

As a rule, hallucinations and delusions are less pronounced, although there may be some evidence of these symptoms.

These people may have significant impairments in their ability to maintain the activities of daily living. Even the more routine tasks, such as dressing, bathing or brushing teeth, can be significantly impaired or lost.

may appear emotionally unstable, or their emotions may not seem appropriate to the context of the situation. They may fail to show ordinary emotional responses in situations that evoke such responses in healthy people. Mental health professionals refer to this particular symptom as blunted or flat affect. Additionally, these people may have an inappropriately jocular or giddy appearance, as in the case of a patient who chuckles inappropriately through a funeral service or other solemn occasion.

significant impairment in their ability to communicate effectively. At times, their speech can become virtually incomprehensible, due to disorganized thinking. In such cases, speech is characterized by problems with the utilization and ordering of words in conversational sentences, rather than with difficulties of enunciation or articulation.
catatonic type
Marked disturbance in physical activity, either a long period of immobility in a strange position or uncontrollable excitement.

involve disturbances in movement. Affected people may exhibit a dramatic reduction in activity, to the point that voluntary movement stops, as in catatonic stupor. Alternatively, activity can dramatically increase, a state known as catatonic excitement.

Actions that appear relatively purposeless but are repetitively performed, also known as stereotypic behavior, may occur, often to the exclusion of involvement in any productive activity.

They may maintain a pose in which someone places them, sometimes for extended periods of time. This symptom sometimes is referred to as waxy flexibility. Some patients show considerable physical strength in resistance to repositioning attempts, even though they appear to be uncomfortable to most people.

Affected people may voluntarily assume unusual body positions, or manifest unusual facial contortions or limb movements. This set of symptoms sometimes is confused with another disorder called tardive dyskinesia, which mimics some of these same, odd behaviors. Other symptoms associated with the catatonic subtype include an almost parrot-like repeating of what another person is saying (echolalia) or mimicking the movements of another person (echopraxia). Echolalia and echopraxia also are seen in Tourette's Syndrome.
paranoid type
Belief that others are plotting against them and persecuting them. May exhibit unreasonable jealousy or think they are unusually powerful and important.

Since there may be no observable features, the evaluation requires sufferers to be somewhat open to discussing their thoughts. If there is a significant degree of suspiciousness or paranoia present, people may be very reluctant to discuss these issues with a stranger.
undifferentiated type
Psychotic symptoms that cannot be found in the above categories. Symptoms from more than one category.

The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures.
Residual type
Symptoms of schizophrenia which remain after an active episode.

This subtype is diagnosed when the patient no longer displays prominent symptoms. In such cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations, delusions or idiosyncratic behaviors may still be present, but their manifestations are significantly diminished in comparison to the acute phase of the illness.
can people successfully manage schizophrenia?
there are different subtypes of schizophrenia, one patient can be diagnosed with different subtypes over the course of his illness. Also, note that "People having a higher level of functioning before the start of their illness typically have a better outcome" example: in the movie "the beautiful mind" the professor struggles w/ his illness life long. How would this apply to Adam since he has problems in school (grade 10).
adam's auditory and visual hallucinations
Hallucinations- can be defined as perceptual experiences that can occur wthout actual sensory stimuli.

He states he has often experiences hallucinations although he rarely tells anyone that he is experiencing these. He describes hearing his own voice in his head saying negative things about him, and sees aliens at the side of his bed

threatening him. He also describes having seen an angel with long beautiful hair standing at his bed. Adam's mother states that she has observed body changes in Adam where he will stand frozen in one position for long periods of time and will not respond to requests to move nor will he verbalize during these periods.
ambivalence in schizophrnia
is a common negative symptom in which one has diametrically opposing feelings towards issues that are seemingly minute to most people such as dressing or combing one's hair that they are unable to make decisions in regards to these matters.
+ symptoms of schizophrenia
are characterized by an excess or distortion of normal functions including delusions or hallucinations.
- symptoms of schizophrenia
are a reflection of a lessening or loss of normal functions including restriction or flattening of in both the range and intensity of emotion, reduced fluency and productivity of thought and speech (alogia), withdrawal, inability to initiate and persist in goal-driven activity and anhedonia.
neurocognitive impairment (schizophrenia)

what is it characterized by?
Neurocognitive impairment characterized by impaired short of long term memory, attention, verbal fluency, executive functioning, and working memory may all be affected. It is important to note that any of these can be affected with or without the presence of positive symptoms. Also long term memory and intellectual functioning are not necessarily affected.
suicide rate in schizophrenics
Depression as it relates to schizophrenia is important for the following reasons: 1) it may be evidence that diagnosis of a mood disorder is more appropriate (but the two can coexist as well) 2) Depression is not unusual in all stages of the disorder and should be taken seriously. 3) A suicide rate among schizophrenics of 10% is higher than that of the general population. In particular periods of untreated psychosis or treatment with older typical antipsychotics have been associated with higher suicide attempts.

Suicide prevention. 20-50% of patients will have a suicide attempt due to schizophrenia and 10% attempt suicide due to corresponding depression.
main nursing interventions for adam
Main nursing interventions address the biologic domain: promotion of self-care, activity, exercise, nutrition, thermoregulation and fluid balance interventions. Monitor for EPS symptoms from pharmacology treatment and the nurse must be familiar with these drugs. For the psychological: interventions should focus on enhancing cognitive function and maintaining the nurse/patient relationship. Social: patient and family education is critical
what behavioral changes associated with schizophrenia are evident in the adam scenario?
What behavioural changes associated with schizophrenia are evident in the scenario? He is demonstrating social isolation and withdrawing from activities, poor social skills, and difficulty communicating with others. He is suicidal. He describes being unable to talk to girls, having inappropriate social behaviour, being unfocused, not being interested in anything and having hallucinations. He remains frozen for long periods of time and will not respond
adam scenario nursing diagnoses
1. Risk for suicide related to suicide attempt, adolescent schizophrenia, symptoms of withdrawal, decreased motivation for activities and self-care, impaired judgement, and fear of prognosis.
2. Social Isolation related to withdrawal from social activities, lack of motivation, poor social skills and difficulties communicating with others, evidenced by his mother's reports of these things.
3. Self-care deficit related to decreased motivation to care for himself and increased forgetfulness, evidenced by his mother's reports on his behaviour.
what is it like to undergo a CT scan for a schizophrenic patient?
A contrast dye may need to be injected which could cause some pain and may have side effects like an odd taste. The patient also must lie still for close to 30 minutes. If the patient cannot lie still they may require pillows, straps, and medication.
Adam's tourettes
Adam is currently in grade 10. His grades were above average until grade 7, when he started to have facial and body tics. Adam's symptoms were mild and did not interfere with his school or social activities. Adam also exhibits poor social skills and has difficulty communicating with others. Adam has not finished Grade 10 studies as he has been unable to continue attending high school.
It is a neurological disorder characterized by multiple repetitive, stereotyped, involuntary movements and vocalizations called tics. For the diagnosis of TS, 2 motor and at least one vocal tics X 1 year. No tic-free period of >3months, and should not be caused by drugs or general medical conditions. TS is noticed first in childhood (onset between the ages of 3 and 9 years). May occur in all ethnic groups, and M:F is 3-6:1. Although TS can be a chronic condition with symptoms lasting a lifetime, most people with the condition experience their worst tic symptoms in their early teens, with improvement occurring in the late teens and continuing into adulthood. Incidence rate is 1-10 per 1000 school aged children.
Tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups (e.g. eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking).

Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds.

Complex tics are distinct, coordinated patterns of movements involving several muscle groups.
Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug.
Behavioral treatments for tourettes
Behavioral treatments such as awareness training and competing response training can also be used to reduce tics. Cognitive Behavioral Intervention for Tics, or CBIT, showed that training to voluntarily move in response to a premonitory urge can reduce tic symptoms. Other behavioral therapies, such as biofeedback or supportive therapy, have not been shown to reduce tic symptoms. However, supportive therapy can help a person with TS better cope with the disorder and deal with the secondary social and emotional problems that sometimes occur.
prognosis of tourettes
Genetic counseling of individuals with TS should include a full review of all potentially hereditary conditions in the family.
Prognosis: Although there is no cure for TS, the condition in many individuals improves in the late teens and early 20s. As a result, some may actually become symptom-free or no longer need medication for tic suppression. Although the disorder is generally lifelong and chronic, it is not a degenerative condition. Individuals with TS have a normal life expectancy. TS does not impair intelligence. Although tic symptoms tend to decrease with age, it is possible that neurobehavioral disorders such as ADHD, OCD, depression, generalized anxiety, panic attacks, and mood swings can persist and cause impairment in adult life.

Unfortunately, there is no one medication that is helpful to all people with TS, nor does any medication completely eliminate symptoms. In addition, all medications have side effects. Many neuroleptic side effects can be managed by initiating treatment slowly and reducing the dose when side effects occur. Effective medications are also available to treat some of the associated neurobehavioral disorders that can occur in patients with TS.
social stigma in adam's scenario
mental illness is usually blamed on the parent and that the compassion of the public was even more decreased in cases where a parent was blamed. The public was more apt to withhold help in this case too. So in Adam's case with their being a history of mental illness in the family, the social support from family and friends is apt to be little to none.
milieu management in adam scenario
o In terms of milieu management- this is a technique that has been found to be helpful in managing the environment in inpatient settings. It is said that arranging the treatment environment to maximize recovery is crucial to the rehabilitation of the patient.
common generic root of dementia drugs
generic name ending in -mine
common generic root of benzodiazepam
generic name ending in -lam and -pam
treat acute manic episode (psychosis)

treats seizures so it's also an anticonvulsant
used to treat EPS such as akathisia

and hypertension
typical antipsychotic generic root
atypical antipsychotic generic root


what does it do?
is a 2nd gen drug used to treat schizophrenia, bipolar mania and mixed manic/depressive episodes (as sole or adjunctive therapy) and as adjunctive (add-on) therapy for major depressive disorder.

what does it do?
a 2nd gen drug used to treat psychosis in schizophrenia and episodes of mania in bipolar disorder.

lethal side effect?
cardiotoxicity, which limits their use in the elderly.

may worsen preexisting cardiac conduction problems and should be used cautiously in patients who have other cardiac problems.

Occasionally, they may precipitate HF, MI, arrhythmia, and stroke.
tyramine containing food
aged cheese

processed meat or improperly stored meat

fava or broad bean pods, banana peel,

tap beer

yeast extracts, sauerkraut and soy sauce and other soy bean condiments.
MAOI and tyramine
block the breakdown of tyramin, a trace amin with vasoconstrictor properties.

Increased levels of tyramine ca cause severe headaches and high bp, stroke and in rare instances, death,
serotonin syndrome
mental status changes,


ataxia (a neurological sign consisting of lack of voluntarycoordination of muscle movements, as in walking.),

myoclonus (is a brief, involuntary twitching of a muscle or a group of muscles),

hyperreflexia (overactive or overresponsive reflexes. Examples of this can include twitching or spastic tendencies),



increased sweating

and diarrhea.
when are side effects from lithium relatively mild?
at lower therapeutic blood levels.
what happens when blood levels of lithium increase? What are the symptoms?

What is the nursing consideration?
side effects of it become many and become severe

severe diarrhea, vomiting,


muscular weakness

lack of corrdination

nursing consideration: should be withheld. Lithium toxicity can easily be resolved in 24-48 hours by discontinuing the med, but haemodialysis may be needed in severe situations
how does lithium affect thryoid, parathryoid and kidneys?
hypothryoidism and high TSH

hopparathyroidism which increases parathryoid hormone levels and calcium
since carbamazepine has a narrow therapeutic window, what are the nursing considerations? What are the side effects associated with the narrow therapeutic window of this drug?
blood dyscrasisa are associated carbamaziepine, inclduing agranulocytosis and leucopenia and aplastic anaemia.

Patients should be advised to report fever, sore throat, rash, petechiae or bruising imeddiately.

In additon, advise patients of the importance of completing routine blood tests thorughout threatment.
tolerance and dependance and benzodiazepams
because tolerance develops to most of the CNS depressant effects, indivs who wish to experience the feeling of intoxication from these meds may be tempted to increase their own dosage.

psychological dependance is more likely to occur when using these meds for a longer period,
abrupt withdrawal symptoms of benzodiazepams
rebound insomnia or anxiety

increased sweating
increased sensitivity to light
abdominal discomfort or pain
elevations in systolic bp

gradual tapering is recommended for discontinuing use of benzodiazepines after long-term treatment
guidelines for minitoring and administering antidepressant meds
obsere patient for cheeking or saving meds for a later suicide attempt.

monitor vital signs: obtain baseline data before the initiationof meds

monitor periodically liver and thyroid function tests, blood chemistry and CBC as appropriate and compare with baseline values
interventions for psychological effects of depressoin
cogntive therapy - successful in reducing depressive symptoms during acute phase of major depression

behavior therapy - effective in cute treatment of patients with mild to moderately severe depression especially when combined with pharmacotherapy.

interpersonal therapy
interventions for relieving biological effects of manic depression
1) rest - sleep hygiene is a priority but may be unrealistic until meds take effect. Limiting stimuli may help too.

2) adequate hydration and nutrition - snacks and high-energy foods should be provided that can be eaten while moving. Alcohol should be avoided.

3) re-establishment of physical well-being
social interventions for manic depression
if possible, a private room is ideal because patients with manic depression tend to irritate others, who quickly tire of the intrusiveness.
biological interventions for schizophrenia
1) prompt, safe and informed administration of antipsychotic mefds

2) attention to self-care needs- developing a daily schedule of routine activiites can help the patient structure the day. Most patients actually know how to perform self-care actvitiies but are not motivated to carry them out consistently.

3) patient`s ability to maintain hygiene and adequate nutrition are important
speech (MSE)
usually described in terms of rate, volume, and characteristics -
o rate: rapid or slow
o volume: loud or soft
o amount: paucity, muteness, pressure of speech
o characteristics: stuttering, slurring, unusual accents
motor activity (MSE)
physical movement
o level of activity: lethargic, tense, restless, agitated
o type of activity: tics, grimaces, or tremors
o unusual gesture or mannerisms, compulsions
interaction during interview (MSE)
description of how the patient relates to the nurse during the interview
o is the patient hostile, uncooperative, irritable, guarded, apathetic, defensive, suspicious
o NOTE - guard against over-interpreting or misinterpreting behavior because of social or cultural differences.
affect (MSE)
The patient's apparent emotional tone
o Described in terms of :
o Range (eg: smiles, seriousness, interest, sadness, etc., as compared to one unchanging mood)
o Duration
o Intensity
o Appropriateness (eg: doesn't smile when discussing suicide attempt)
perceptions (MSE)
Two major types of perceptual problems
o Hallucinations - false sensory impressions or experiences
o Illusions - false perceptions or false responses to sensory stimulus
o Five sensory modalities for hallucinations
o Auditory (most common), visual, tactile, gustatory, olfactory. Command hallucinations tell the person to do something, eg., hit that person!
thought content (MSE)
Specific meaning expressed in patientfs communication
o Delusions . false fixed beliefs firmly maintained even though not shared by others and contradicted by social reality. (It is not appropriate to ask, \Do you have delusions?..consider why! A better question might be \Have you had recent occasions when other people have not agreed with things you believe?)
o Religiose, somatic, grandiose, paranoid (eg: \I am a prophet sent to save the world.)
o Thought broadcasting . onefs thoughts being aired to the outside world
o Thought insertion . thoughts placed into onefs mind by outside influence
o Depersonalization . feeling of having lost self identity
o Hypochondriasis . somatic over-concern (eg: belief that one is physically ill despite lack of signs)
o Ideas of reference . incorrect interpretation of casual incidents and external events as having direct personal reference (eg: those two people across the street talking must be discussing me)
o Magical thinking . belief that thinking equates with doing, characterized by lack of realistic relationship between cause and effect (\step on a crackc.)
o Nihilistic ideas . thoughts of nonexistence and hopelessness
o Obsession . an idea, emotion, or impulse that repetitively and insistently forces itself into consciousness
o Phobia . morbid fear associated with extreme anxiety
thought process (MSE)
The ¢whow¡ü of patient expression
o Observed through speech ¡V patterns or forms of verbalization
„X Circumstantial ¡V thought and speech associated with excessive and unnecessary detail that is usually relevant to a question, and an answer is ultimately given
„X Flight of ideas ¡V over-productive speech characterized by rapid shifting from one topic to another and fragmenting ideas
„X Looseness of Association ¡V lack of a logical relationship between thoughts and ideas that renders speech and thought inexact, vague, diffuse and unfocused.
„X Neologisms ¡V new word or words created by the patient, often a blend of other words (eg: a ¢wdeathilating¡ü machine)
„X Perseveration ¡V involuntary, excessive continuation or repetition of a single response, idea or activity; may apply to speech or movement
„X Tangential ¡V similar to circumstantial but the person never returns to the central point and never answers the original question
„X Thought blocking ¡V sudden stopping in the train of thought or in the middle of sentence
„X Word salad ¡V series of words that seem to totally unrelated
memory (MSE)
Ability to recall past experiences
o Remote memory - recall of events, information and people from the distant past
o Recent memory - recall of events, etc. from the past week or so
o Immediate memory - recall of information or data to which a person was just exposed - repeat a series of numbers either forward or backward within a 10 second interval
level of concentration and calculation (MSE)
The patient's ability to pay attention during the course of the interview and the ability to do simple math (eg., multiply 8x9)
o Note the level of distractibility
o Ask the patient to do the following:
o Count from 1 to 20 rapidly
o Serially subtract 7 from 100 (eg: 100, 93, 86, 79, etc.)
information and intelligence (MSE)
Assess last grade level of school completed, general knowledge and use of vocabulary
o Assess level of literacy
o Ability to conceptualize and abstract can be tested by having the patient explain a series of proverbs (eg: \A stitch in time saves nine.; \Still waters run deep., \A bird in the hand is worth two in the bush.)
judgment (MSE)
o Involves making decisions that are constructive and adaptive ¡V requires ability to understand the facts and draw conclusions from relationships
o Exploring patient involvement in activities, relationships, vocational choices
o Present hypothetical situations for evaluation:
„X What would you do if you found a stamped addressed envelope lying on the ground?
„X What would you do if you entered your home and smelled gas?
insight (MSE)
o Patient's understanding of the nature of the problem or illness.
gary and identity diffusion
Adolescent experiences have a great influence to adult personality (Marcia, 1994). Gary is involved in incidents of fighting with other students and biting his classmates, as well as stealing from his peers, parents and sibling and shoplifting. When confronted with his behavior, Gary denies any responsibility, makes excuses or blames it on someone else. He fails to show any remorse for having broken the law or for physically or emotionally hurting others. Gary's adolescent experiences have a great likelihood of influencing his adult personality.
is a complex pattern of characteristics that are

largely outside a person's own awareness that

compose an individual's pattern of perceiving, feeling, thinking, coping, and behaving. Personality emerges from complex interactions including biological dispositions, psychological experiences and environmental situations.
personality traits
are prominent aspects of personality that are exhibited in a range of important social and personal contacts.
personality disorder

what 4 characteristics that PD have in common?
the following common features exist among all personality disorders: "to be maladaptive, an extreme trait should also be 1) inflexible, 2) pervasive, 3) long lasting, and 4) culturally decontextualized and it should lead to clinically significant distress or functional impairment."
severity of personality disorder have 3 characteristics. What are they?
Three criteria tenuous stability, adaptive inflexibility, and the tendency to become trapped are measures of the severity of PDs.

Tenuous stability refers to fragile personality patterns that lack resiliency.

Adaptive inflexibility is a rigidity of interactions with others, achievement of goals and coping with stress.

The tendency to be trapped refers to rigid and inflexible behaviour patterns that create dilemmas, provoke new predicaments, and set into motion self-defeating sequences with others.
cluster A personality disorder

what are the following types?
are known as Odd-Eccentric and include the following three types:

1) Paranoid PD
2) Schizoid PD
3) Schizotypal personality disorder
paranoid personality disorder
(suspicious pattern)- characterized by a mistrust of others and the desire to avoid relationships where one is not in control or loses power.
schizoid PD
(Asocial pattern)- patients with this condition are expressively impassive and interpersonally unengaged. They often cannot experience the joyful and pleasurable aspects of life and can appear introverted and emotionally detached.
schizotypal PD
(eccentric pattern)-characterized by a pattern of social and interpersonal deficits. They often had odd beliefs about the world that are inconsistent with cultural norms.
cluster B personality disorder
disorders are known as dramatic-emotional disorders. Those diagnosed with these conditions show great degrees of impulsivity and emotionality The following are types of Cluster B disorders :
cluster b PD types
1) Borderline Personality Disorder (BPD)

2) Antisocial Personality Disorder (APD)

3) Histrionic Personality Disorder (gregarious pattern)-

4) Narcissistic Personality Disorder (egotistic pattern)-
histronic PD
Individuals with this disorder and lively and dramatic, often drawing attention to themselves. They often express an insatiable need for attention and approval from others.
narcississtic PD
These individuals are often grandiose, have a need for admiration and lack empathy. Beginning in childhood, these individuals often believe they are superior, special or unique and believe that others should recognize them in this way.
cluster C PD

what are they divided into?
anxious-fearful disorders. Those diagnosed with these conditions have a predominant sense of anxiety and fearfulness. The following are the types of Cluster C disorders:

1) Avoidant Personality Disorder
2) Dependent Personality Disorder
3) Obsessive Compulsive Disorder (conforming pattern)-
avoidant PD
(withdrawn pattern)- is characterized by avoiding social situations in which there is interpersonal contact with others. This avoidance is purposeful so as to avoid criticism and inadequacy in relation to others.
dependent PD
(submissive pattern)- people with this disorder cling to others to keep them close. This need for closeness can be so great that they will do anything to maintain closeness including being submissive and disregarding their own self.
obsessive compulsive PD
(conforming pattern)- This form of OCD is distinguished from OCD under Axis I as those with the Axis I disorder often use obsessive thoughts and compulsions when anxious but less so when anxiety is decreased. This form of OCD manifests itself in an overall sense of rigidity, perfectionism and control. Those with the disorder attempt to maintain order by careful attention to rules, trivial details, procedures and lists.
dilemma of being a forensic nurse?
Forensic nurses must have a strong nursing identity in order to maintain their professional authority and responsibility, w/o succumbing to the temptation to align themselves w/ the correctional staff. Forensic nurses are nurses, not prison guards. On the other hand, it's important to keep oneself safe and avoid violations of boundaries and manipulation. There are power differentiations in both situations. Forensic nurses should be extra cautious walking between the lines.
gary and youth criminal justice act
Gary is 18, which means that he is no longer under the Youth Criminal Justice Act. His previous sentences had been light because he was a youth, however now that he is 18, he would potentially face much more severe consequences if he is found guilty. If however, the defence is able to make a case that he was suffering from a mental illness when he stole the car, he may be found not criminally responsible. However, his history with the justice system will may causes him to receive a harsher sentence.
conduct disorder
Conduct disorder is characterized by serious violations of social norms including aggressive behaviour, destruction of property and cruelty to animals. They frequently lie to achieve short term goals, skip school, run away from home, and possibly engage in petty larceny or mugging.
key characteristics of borderline PD in Gary
unstable interpersonal relationships - Gary Brown has a poor relationship with his parents. Has few friends and very poor relationship with his brother.

cognitive dysfunction - The way he describes his parents could show extremes "my father is a dictator and my mother bows to whatever he says when hes there and then does whatever she wants when he is away."

Impulsivity - "In trouble" since early years in elementary school. Involved in fights with other students and biting his classmates. Stealing from peers, parents, siblings and shoplifting. His mother states "he has a cruel streak and often teases his brother to the extreme....had to give away their pet dog due to Gary's cruelty towards the animal"
key characteristics of borderline PD
Affective Instability Identity Disturbances - Rapid of extreme shift in mood. Lacks aspects of personal identity or when personal identity is poorly developed

unstable interpersonal relationships - Extreme fear of abandonment, history of unstable, insecure attachments

cognitive dysfunction - They evaluate experiences, people, and objects in terms of mutually exclusive categories (ie. good or bad, success or failure, trustworthy or deceitful)
Also client shows dissociation in which thoughts and ideas can be split off from consciousness.

impaired problem solving - Failure to engage in active problem solving, usually solicit help from others. Rarely takes suggestions

impulsivity - Difficulty delaying gratification or thinking through the consequences before acting on their feelings, their actions are often unpredictable. Ex. gambling, spending money, unsafe sex practices, substance

self-injurious behaviors - Suicide attempts or parasuicidal behaviors
Compulsive self injurious behaviors
Repetitive Self mutilation
borderline PD epidemiology
• in general population ranges from 0.3% to 2.0%, median rate of 1.6%
• in clinical population is most frequently diagnosed personality disorder
• prevalence ranges 11%-70% with median 31%
• More than 77% of individuals with diagnoses of BPD are young women
risk factors of bpd
• physical abuse and sexual abuse appear to be significant risk factors
• 55%-80% of individuals with BPD have reported a history of childhood sexual abuse and or physical abuse
• other studies cite parental loss and separation
dialectic group therapy
• is a biosocial approach to treatment that combines numerous cognitive and behavior therapy strategies
• therapists and coaches must work with clients as partners and be willing to focus on many interconnected behaviors and not a single diagnosis
• client actively participates in formulating treatment goals by collecting data about their own behaviors, identifying treatment targets in individual therapy, working with the therapist in changing these target behaviors
• core treatment procedures include problem solving, exposure techniques, skill training, contingency management
• Skill groups are integral part of DBT
• skill groups are taught in group settings in which members practice emotional regulation, interpersonal effectiveness, core mindfulness skills, and distress tolerance
• emotional regulation is taught to manage intense labile moods.
• Patient is taught interpersonal effectiveness skills
• taught mindfulness skills similar to meditation skills, used to improve observation, to focus the mind and awareness on the current moment
• distress tolerance skills involve helping the individual tolerate and accept distress as part of normal life
• DBT is the most researched , requires total staff commitment and reinforcement
• DBT is most incorporated into a long term outpatient treatment approach because the greatest effectiveness occurs when skills are reinforced over time
o Self-denial = Refusal to satisfy one's own desires
Diagnostic characteristics of Antisocial personality disorder
• Disregard for and violation of rights of others
• Failure to conform to social norms with respect to lawful behaviors
• Deceitfulness
• Impulsivity or failure to plan ahead
• Irritability and aggressiveness
• Disregard for safety of self and others
• Consistent irresponsibility
• Lack of remorse
Behavioural findings of Antisocial personality disorder
• Lacking empathy
• Callous, cynical, contemptuous of feelings, rights and suffering of others
• Inflated and arrogant self-appraisal
• Excessively opinionated, self-assured, or cocky
• Superficial charm, Glib, impressive verbal ability
• Irresponsible and exploitative in sexual relationships
• Dysphoria, complaints of tension, inability to tolerate boredom, depressed mood
antisocial vs asocial
Antisocial is being hostile or harmful to organized society marked by behavior deviating sharply from the social norm, while asocial behaviour is a personal refusal to interact with other people for example because of shame or guilt.
Gary and stress
Gary is suffering from multiple conditions which could be a physical and psychological stressors in Gary's life. On top of this Gary is having trouble dealing with his parents, brother and peers at school making it very likely that he also has the added stress of lack of support from his social group. These stressors together have the potential to cause an imbalance in Gary's life between his resources and the demands placed on them.
community programs and gary
Gary is 18 and is now legally considered an adult. There are programs in place in Alberta for both adult and youth offenders to help them re-integrate into the community. These programs offer rehabilitation and may help people like Gary learn to cope with the stressors of life in a more appropriate fashion.
millieu therapy
"structured environment with rules that are consistently applied to clients who are responsible for their own behaviour" (p. 613). Target and correct dysfunctional social patterns demonstrated on the unit. Set limits.
crisis def'n
An experience of being confronted by a stress in which the individual is unable to
characteristics of a crisis
Stimulus is beyond the person's usual experience
Previously developed coping mechanisms are ineffective
Anxiety, tension and disorganization ensue
maturational crisis def'n and example
Involves normal life transitions that evoke changes in individuals self-perception, role,
status and integrity. ex: leaving home for first time.
situational crisis def'n and example
Involves an external event that disturbs the individual's equilibrium (loss, change) and
threatens consistency between self-behaviors and values or beliefs. e.g. death of a loved one (loss) leads to person feeling isolated and alone.
adventitious crisis def'n and example
Crisis of disaster - unplanned and accidental; may result from natural disaster, national
disaster (war, riot) or crime of violence (rape)
difference between maturational and situational crisis
The event leading to the situational crisis is usually unanticipated. Consequently, situational crises have the potential to disrupt equilibrium unexpectedly. A maturational crisis involves life cycle changes or normal transitions of human development; therefore, they are foreseeable.
factors determining response
Individual's perception of event
Past experiences in coping with stress
Established coping strategies
Availability of support persons
goals of treatment for those with experienced a crisis
The client will:
o Remain safe from self-harm
o Identify specific problem
o Verbalize feelings related to the stress
o Analyze the event/problem and express perceptions of event
o Identify and seek help from support systems
o Explore alternatives for coping with the crisis
o Participate in choosing an action plan
o Implement the action plan
o Experience less anxiety and tension
o Verbalize enhanced self-esteem
Robert's 7-stage crisis intervention model
stage 1: conduct crisis and bio-psycho-social assessment (including lethality measures)

stage 2: establish rapport and rapidly establish relationship

stage 3: identifiy dimensions of presenting problems (including the last straw of crisis precipitants

stage 4: explore feelings and emotions (including active listening and validatoin)

stage 5: generate and explore alternatives (untapped resources and coping skills)

stage 6: develop and formulate an action plan

stage 7: follow-up plan and agreement
stage 1: conduct crisis and biopsychosocial assessment (including lethality assessment)
billy has experienced major losses, that his behavior is suggestive acute mourning and/or depression; that he is at high risk for self-harm; and that his aunt, who is his primary social support, has exhausted her resources for dealing with situation. the nurse tells Theresa that she and a colleague are on their way to talk with bill and that they will be bringing police assistance in case the individual is in imminent danger to himself or herself or someone else.
Stage 3: identify dimensions of presenting problem
crisis team learn that billy has not done anything to harm himself. He is experiencing a great deal of emotional pain for which he has few words, has lost his sense of meaning in life and has only a vague plan of shooting himself. He does not have immediate access to a firearm. In his conversation with Don (policeman), Billy acknowledges that the loss of his parents was devastating, but it was his brother's death that caused his world to crash apart
Stage 4: explore feelings and emotions
don encoruages Billy to talk about his experience and offers him words for the things he is feeling,. Eventually, Billy agrees to include his aunt and Joanne in the conversation.
stage 5: generate and explore alternatives
Billy, Theresa, Don and Joanne sit around the kitchen table with cups of tea discussing the supports available to the family.
Stage 6: develop a plan
theresa states that praying to the Creator everyday and speaking to a local elder help her to get through many difficult times. Billy says that he will pray with her every day, signs a written safety contract, and agrees to see an intake worker at the mental health centre for an assesment tmr. The safety contract specifies a number of things that Billy will do if he begins to feel overwhelmed again, including praying, talking to Theresa, and calling the crisis line.
Stage 7: follow-up plan
Joanne calls Theresea the next afternoon and learns that she and Billy had spent the afternoon talking and praying together. He had eaten breakfast ans showered this morning before attending his appointment at the mental health centre. The intake worker referred Billy to a men's grief support group and was going to speak with the student counselling service at his college to arrange one to one counselling.
Police were called when Sandra (paranoid schizo) began wandering through a local park and screaming at everyone, "I know you are possessed by the devil." During her initial interview, she is very guarded and suspicious of the nurse (1). "I can read your mind, you know." (2)
1) paranoia

2) delusions of grandeur
Sandra is assigned to a room and oriented to the unit. At 5:00 PM, the nurse says to Sandra, "Sandra, it's time for dinner." Sandra responds, "Time for dinner, time for dinner, time for dinner." (3) The nurse notices that each time she wipes her mouth with her napkin at dinner, Sandra does the same. (4)
3) echolalia (automatic repetition of vocalizations made by another person)

4) imitation
Sandra's mother reports that Sandra stopped taking her medicine
about a month ago, stating, "When you don't have a brain, (5) you don't need brain medicine." Shortly afterward, she became totally despondent, taking no pleasure in activities she had always found enjoyable. (6). She stayed in her room, sitting on her bed, moving back and forth in a slow, rhythmic fashion. (7) Sometimes she would not even get up to go to the bathroom, instead soiling herself in an infantile manner. (8)
5) nihislic delusions

6) anhedonia

7) body rocking

8) regression
She seemed to experience a total lack of energy for usual activities of daily living. (9) On the unit, Sandra appears disinterested in everything around her. (10) She sits alone, talking and laughing to herself. (11) At one point, she hears a laugh track on TV and states, "They're laughing at me. I know they are." (12
9) anergia (condition of lethargy or lack of physical activity)

10) apathy

11) autism

12) delusions of reference
Barriers to Successful Intervention For Delusions
Becoming anxious and avoiding the person
Reinforcing the delusion
Attempting to prove that the delusion is wrong.
Setting unrealistic goals
Becoming incorporated into the delusional system (may be unavoidable)
Being inconsistent in intervention
Seeing the delusion first and the person second.
Strategies for Working with Individuals Experiencing Delusions
Place the delusion in time frame and identify triggers
Identify triggers that may be related to stress or anxiety
If delusions are linked to anxiety, teach anxiety management skills.
Assess the intensity, frequency, and duration of the delusion
Fixed delusions, endured over time, may have to be temporarily avoided to prevent them from becoming stumbling blocks in the relationship
Listen quietly until there is no need to discuss the delusion
Identify emotional components of the delusion
Respond to the underlying feelings rather than the illogical nature of the delusion
Encourage discussion of fears, anxiety, and anger that are generated by the delusion
Observe for evidence of concrete thinking
Determine whether the individual takes you literally
Determine whether you and the individual are using language in the same way.
Observe for the ability to accurately use cause and effect reasoning
Can the individual make logical predictions based on past experiences?
Is the individual able to conceptualize time?
Is the individual able to access and use meaningfully his or her recent and long-term memory?
Distinguish between the description of the experience and the facts of the situation
Identify false beliefs about real situations.
Promote the individual's ability to reality test.
Avoid arguing about the content, but interject doubt where appropriate.
Validate if part of the delusion is real.
Once an individual describes the delusion, do not dwell on it. Rather, focus conversation on more reality based topics
If the individual obsesses on delusions, set firm limits on the amount of time you will devote to talking about them.
Promote distraction as a way to stop focusing on the delusion
Promote activities that require attention to physical skills
Recognize and reinforce healthy positive aspects of the personality.
Strategies for Working with Individuals Experiencing Hallucinations
Establish a trusting interpersonal relationship
If the nurse is anxious or frightened the individual will be anxious or frightened.
Be patient, show acceptance, and use active listening skills
Assess for symptoms of hallucinations including duration, intensity, and frequency
Observe for behavioral clues that indicate the presence of hallucinations.
Observe for clues that identify the level of intensity and duration of the hallucination
If asked, point out simply that you are not experiencing the same stimuli
Respond by letting the individual know what is actually happening in the environment
Do not argue with the individual about differences in perceptions
When a hallucination occurs, do not leave the person alone
Suggest and reinforce the use of interpersonal relationships as a symptom management technique
Encourage the patient to talk to someone trusted who will give supportive and corrective feedback
Help the individual in mobilizing social supports
Help the individual describe and compare current and past hallucinations
Determine whether the individual's hallucinations have a pattern
Encourage the individual to remember when hallucinations first began
Pay attention to the content of the hallucination; it may provide clues for predicting behavior
Be especially alert for command hallucinations that may compel the individual to act in a certain, probably unpredictable way
Encourage the individual to describe past and present thoughts, feelings, and actions as they relate to hallucinations
Help the individual identify needs that may be reflected in the content of the hallucination
Identify needs that may trigger hallucinations, eg., loneliness, fear
Focus on the individual's unmet needs and discuss the relationship between them and the presence of hallucinations
Determine the impact of the individual's symptoms on activities of daily living
Provide feedback regarding the individual's general coping responses and activities of daily living
Help the individual recognize symptoms, symptom triggers, and symptom management techniques
expressions of anger
o Suppression- Keep anger in and don't express it. Maybe deny it.
o Expression- Perhaps attack or blame.
o Discussion- Talk about the concern directly with the person(s) involved.
assertiveness theory
o Non-assertive or submissive- Consider the rights of others but not your own.
o Assertive- Consider the rights of others and your own.
o Aggressive- Consider your own rights but not those of others.
An affective state experienced as the motivation to act in ways that warn, intimidate, or attack those who are
perceived as challenging or threatening. It occurs when there is a threat, delay, thwarting of a goal, or conflict between goals (Savard, p. 84).
Selected Models of Anger, Aggression, and Violence
o Psychoanalytical: Anger is instinctual; it is a programmed-in human response to perceived threats.
o Behavioural: Anger results when goals are blocked. Anger and aggression develop more strongly if they receive positive reinforcement, especially early in life.

o Cognitive: Judgements, self-esteem, and expectations influence anger. Thoughts, feelings, and behaviour are affected as a unit; some negative emotions may arise from distorted beliefs.

o Sociocultural: Society is competitive; some people have status higher than others; power differentials exist in gender relations.

o Interactional: People having argumentative or coercive interactional styles are more likely to be aggressive.
implications for the nurse in regards to anger
o People often believe that their view is the only correct one.
o Having a mental health problem does not automatically signify that a person will be violent. However, some of the characteristics of a mental disorder (eg. paranoia, agitation, disorientation, hallucinations) may predispose a person to aggressive behaviours.
o The experience of mental illness and hospitalization may lead to feelings of humiliation and lack of control; hospitals are often perceived as bureaucratic places staffed with authoritarian employees.
o Nurses' perceptions influence their responses to client behaviours; these nurses often identifythe client's illness as the cause of an aggressive incident, while clients are more likely to see the problem as stemming from the nurse's communication style.
o Some individuals believe that they have no control over their angry behaviour. However, it has been shown that when in the presence of physically stronger people, these individuals will control their behaviour. Therefore, there is the expectation that everyone can control their angry behaviour to some degree.
o Environment or milieu conditions (noise, crowding, understaffing) play a big part in how potentially aggressive situations unfold.
People at highest risk for aggression toward are those who:
o Have a previous history of violent behaviour (the strongest predictor).
o Have experienced a recent humiliation such as arrest, fight, disagreement with an authority figure, hospitalization, relationship breakup, public embarrassment.
o Have antisocial attitudes (eg. "looking out for #1" "winning through intimidation," believe that "people are objects to be manipulated, people and authority cannot be trusted").
o Are under the influence of a substance such as alcohol or cocaine.
o Come from life circumstances of frequent violence or abuse.
o Suffer from certain mental disorders such as schizophrenia (delusions, paranoia); childhood conduct disorder, antisocial or borderline personality disorders (poor impulse control); mania (irritability); dementia (confusion) and brain injury (impulsivity).
Situations that may provoke a violent incident:
o The nurse imposes a limit on a client such as refusing them permission to leave the nursing unit.
o The client has recently been disappointed or given bad news, for example notification of being certified under the Mental Health Act; that an expected visitor will not be coming; that it is not possible to see the doctor immediately; that medications have been changed; that it is not permitted to have a cigarette right now; something bad has happened to a significant other.
o Being irritated by other clients on the nursing unit.
o Unceasing environmental noise (eg, other client, maintenance equipment).
o Being asked to wait for something, especially if the reason is not apparent.
Nurses need to keep the following principles in mind in regards to preventing violence in patients:
In hospital, nursing is the profession responsible for management of the milieu, ie. the nursing unit environment.
o The nurse needs to "stay in the frontal cortex" , which mean maintaining objectivity by monitoring and controlling their own emotions; knowing their temperament, personal triggers, and current mental state; keeping in mind the other person's viewpoint; being aware how they might be perceived by others; setting goals and staying on course with them.
o The nurse must not take the situation or negative communication from the client personally—this is part of maintaining one's boundaries.
o Everyone needs to be skilled at self-soothing in times of stress, for example taking quiet time away from the situation, positive self-talk, relaxation and deep breathing exercises. This ability to self-soothe may be precisely what a client who is behaving aggressively may lack.
o Compared to clients in their care, nurses typically have more resources (eg, social power, education, clinical experience, institutional support, objectivity, knowledge and understanding of psychiatric illness).
o The goal in effectively managing aggressive behaviour is to create a culture of early prevention with a focus on least restrictive intervention
o Safety of the client and the staff is the prime objective.
o It is useful to keep in mind that aggression results from a person's feeling helpless and fragile. We are reacting to the client's expression of unmet needs rather than simply anger.
o Successful management of aggressive behaviour often involves negotiating competing demands. The nurse must consider how they can best accommodate a client's wishes or preferences, while at the same time ensuring safety of other people and property. Nurses must also think about what choices they can realistically offer.

Three variables: What.s happening? Is safety an issue? Why now?
o Authoritarian approaches will ultimately fail.
o Introduce yourself to the client if you haven.t previously. Address the client by name.
o Stand at a 450 angle to the client- this suggests facing an obstacle together rather than ¡°squaring off¡± face-to-face like two boxers. Keep some extra distance between you and the client.
o Speak in a calm voice. Listen more and talk less.
o Do not touch the client.
o Do not reject or fulfill requests immediately before getting all the facts and considering alternatives.
o Avoid a debate or a power struggle.
o Create an expectation of self-control at the onset of contact with the agitated client.
o As much as possible, allow the individual to exercise choice.
o At times, a PRN medication may be offered (by mouth or injection) to help the individual settle
o Show some awareness of the patient.s perspective.this is the use of empathy, eg. ¡°I can understand how you might feel disappointed that you can.t go outside right at this moment to have your cigarette.¡±
o Focus the situation by using closed-ended, rather than open-ended questions. Do not ask too many questions (remember that from the Therapeutic Communication lab?).
o Focus on moving toward a solution by asking ¡°What can I do to help you at this moment?¡± or ¡°What do you need right now?¡±
o Personal safety involves: not working in isolation; placing yourself physically where you can quickly exit (eg. between the client and the door of a room, or better yet, outside the room); not wearing potentially dangerous items like chains or large earrings; keeping potential weapons like knives or scissors safely stored; wearing appropriate shoes and clothing that allow movement.
o If you start feeling uncomfortable or in .over your head¡±, or if the client appears about to move in and attack, leave (run) immediately. This is not the time to worry about looking weak or foolish.
o The following is for information only: If the situation does not resolve despite verbal intervention, the team will likely to plan the next step, which may include injectable PRN medication. The client may be physically restrained by a team of four staff members (who move together to immobilize a limb) and then placed in a seclusion room for as brief a period as possible. While in seclusion, the individual is under constant observation (through a [very strong] glass window) by a staff member. Following the client.s release from seclusion, the nurse should approach the client to debrief the situation, focusing on how the client was feeling at the time and how the situation might be resolved better in the future.
personality style
collection of traits that define a particular type of personality. Not as severe or dysfunctional as full blown personality disorder.
paranoid PD characteristics
-Paranoid PD
• skeptical and suspicious
• frequently hostile
• hold grudges and unwilling to forgive
• look deeper than the situation really is.
• Doesn`t trust anyone - quick to react and counterattack to perceived insults-possible pathologic jealousy with recurrent suspiciousness about fidelity of spouse or sexual partner
• Concern that other people have hidden motives
• Expectation that they will be exploited by others
• Comorbid with other disordersÉ
characteristics of schizoid PD
Schizoid PD
• split off from others
• indifferent to social relationships
• very, reclusive often seen as cold
• very little interest in intimacy and sexuality
• "things are much more than ppl" and not in a manipulating way.
• Restricted range for emotional expression
• Preference for alone time
• Indifferent to ppl`s opinions
• Not occurring exclusively during course of another psychiatric disorder
characteristics of schizotypal PD
• Strong predisposition toward schizo but not quite there yet
• Very odd or eccentric
• Very superstitious or magical thinker
• In their own world. E.g. dresses in a style of the 1700s
• Suspiciousness or paranoid ideation
• Stiff, inappropriate or constricted interactions
• Few close friends
• Anxiety in social situation, especially unfamilari ones; no decrease in anxiety with increasing familiarity
• Not occurring exclusively during course of another psychiatric disorder
characteristics of avoidant personality
• Social discomfort
• An inferior selfimage; very insecure
• Avoid any kind of risk getting in a relationship because of the fear of rejection. Lack of willingness for involvement unless certainty of being liked.
• Inhibition in new interpersonal situations
characteristics of dependent PD
• Need to be taken care of
• Submissive and clingy
• Fall apart
• Very often tie themselves to a dominant person in the relationship.
• Go to any lengths to stay in a relationship
• Can come across as very wimpy.
• Often sabotage autonomy; responsibility for major areas of life assumed by others. Depends on others to make decisions.
characteristics of OC PD
• Perfectionalism, rigidity, control, orderliness
• Preoccupation with small detail
• Critical, stingy, hoarding (don't share), workaholic, stubborn
• Moralizing; everybody needs to work as hard as I do.
• Nobody can stand OCPD ppl
• Frequently believe that the place can't run without them
• Can`t work with ppl; can`t deligate.
• Task completion interfered with because of perfectionism
• Excludes friends and leisure due to work and productivity
• Overly conscientious, scrupulous and inflexible about morality, ethics or values.
• Difficulty discarding worn-out or worthless objects
chloral hydrate
helps you sleep
helps you sleep
helps you sleep
treats anxiety
treats anxiety
helps you sleep
helps you sleep
characteristics of Narcissistic PD
• Self-centerness and self-absorption
• Inability to empathize with others
• exploitation and taking advantage of others
• Envious of others and think others should be envious of him/her
• Primma donna or a movie star
• They feel that they are special
• Have sense of entitlement
characteristics of histrionic PD
• Theatrical or dramatic
• Attention-seeking
• Emotional
• Frequently have a seductive side to them. Dress the part.
• Drama queen
• Seen it more in females than males
• View relationships as more intimate than they really are
antisocial PD
Antisocial: against society
• Vandalism
• Impaired driving
• Selling drugs
• Passing gas in an elevator
• Psychopath and sociopath in past; but correct expression is antisocial PD
• Lack of responsibility
• Disregard for the rights of others
• Lack of remorse
• Problem with authority
• Impulsiveness and easily bored
• Frequently this person charming - ingratiating - they butter u up because they want something form you. Very manipulative.
• Very good at using projection, and blaming and rationalization. They minimize very well. I only drink a case of beer per day and more ppl drink more than that.
• Make excellent mercenary soldiers, CIA, spies
• Irritatbility and aggressiveness
• Consistent irresponsibility (e.g. work)
• Occurring since 15 years of age
• At least 18 years of age
• Evidence of conduct disorder with onset before 15 years of age.
• Not exclusive during the course of schizophrenia or manic episode
asocial meaning
-Asocial: without social, schizophrenic (if I'm not feeling good, I don't care to talk)
characteristics of borderline PD
• Affective instability: melts down at a drop of the hat (angry)
• Poor emotional control
• Impulsivity
• Self-destructive behavior - cutting
• From one bad relationship to another. Pattern of unstable and intense interpersonal relationships
• Getting in bad, bad situations
• Chronic fear of abandonment - clinging and distancing. "I hateyou, please stay"
• Inability to be alone and the pathological need to be in a relationship no matter the cost.
• Loose boundaries
• Unstable self-image
• Recurrent suicidal behavior.
• Chronic feelings of emptiness
• Transient-stress-related paranoid ideation. Beginning by early adulthood and presenting in a variety of contexts.
co-morbidities and dual diagnosis of antisocial PD
• Frequent depression, ADHD, and shizo
• Sometimes even psychotic breaks
• Very often substance use disorder - alcoholism in antisocial and borderline
Dialectic Behavior Therapy (DBT)
• is a biosocial approach to treatment that combines numerous cognitive and behavior therapy strategies
• therapists and coaches must work with clients as partners and be willing to focus on many interconnected behaviors and not a single diagnosis
• client actively participates in formulating treatment goals by collecting data about their own behaviors, identifying treatment targets in individual therapy, working with the therapist in changing these target behaviors
• core treatment procedures include problem solving, exposure techniques, skill training, contingency management
• Skill groups are integral part of DBT
• skill groups are taught in group settings in which members practice emotional regulation, interpersonal effectiveness, core mindfulness skills, and distress tolerance
• emotional regulation is taught to manage intense labile moods.
• Patient is taught interpersonal effectiveness skills
• taught mindfulness skills similar to meditation skills, used to improve observation, to focus the mind and awareness on the current moment
• distress tolerance skills involve helping the individual tolerate and accept distress as part of normal life
• DBT is the most researched , requires total staff commitment and reinforcement
• DBT is most incorporated into a long term outpatient treatment approach because the greatest effectiveness occurs when skills are reinforced over time
a "breaking with reality" characterized by hallucinations, delusions (first-rank symptoms) and disorganized thoughts, feelings, and behaviour.
is a state of apparent unresponsiveness to external stimuli in a person who is apparently awake.q
carrying out purposeful mvt such as getting dressed
imitating others actions
schizophrenia behavior

-grimacing: tardive dyskinesia is more mvt

-eye movements: staring, abnormal eye contact

-apraxia: carrying out purposeful mvt such as getting dressed

-echo-praxia: imitating others actions.

mannerisms/stereotyped movements: repeatedly pull or twist their hair.
stereotyped mvts
repeatedly pull or twist their hair.
paranoid schizophrenia
being suspicious, thinking people are out to get u (persecutory),
• trust is major issue for this person.
• Some of them are high functioning: good hygiene, etc
• Often act threatened and behave superiorly ,
schizophreniform d/o:
over one month yet less than 6 months.
schizoaffective disorder
shows signs equal of schizophrenia and a mood disorder (could be manic or depressive)
delusional disorder
person is intact mentally but has a particular delusions like maybe something like this person is in love with me.
brief psychotic disorder
more than a day but less than a month
shared psychotic disorder
where two people share a psychosis. Both are psychotic; are in enmeshed (overly familiar) relationships and share a delusion. E.g. still phone your mom to talk about day to day decisions.
psychosis attributable to substance ("drug-induced")
cocaine is classic one. Causes paranoid psychosis.
what does antisocial PD and passive agressive behavior have in common?
-poor boundaries: are symptoms of antisocial and passive aggressive behavior.
what is the short term treatment for phobias?
are considered a learned response to anxiety that can be unlearned with interventions such as behavior modification. Psychoanalytic oriented therapy and group therapy may also be effective in reduction of anxiety but they are long-term approaches that may need years of therapy.
Compensation: unconsciously attempting to emphasize a strong point in an attempt to make up for a perceived weakness is engaging in compensation. people overachieve in one area to compensate for failures in another

For example, individuals with poor family lives may direct their energy into excelling above and beyond what is required at work.
an SSRI that is prescribed to treat depressive disorders
how does depression normally manifest for children and adults?
For Adolescents, depression typically manifests as social withdrawal and oppositional behavior. For adults, it often produces hoplessness and helplessness.
is something like schizophrenia acceptable in some cultures?
some religions and cultures may accept particular epxeirences, including seeing vision and hearing voices, as complete normlay even though these manifestastions may meet the criteria for a psychotic episode.
what happens when you alprazolam with alcohol
it will increase the depressant effects of the drug, causing harmful sedation
name one dangerous side effect of clozapine
A dangerous side effect of clozapine is blood dyscrasias (agranulycytosis?). Symptoms of blood dyscrasia, including sore throat, fever general malaise, and unusual bleed, need to be taught to the client. Weekly WBC counts are often order when a client is started on clozapine.
Don, a client with schizophrenia, is taking trifluoperazine, and he begins to exhibit restlessness, severe extrapyramidal symptoms, a high temperature, and diaphoresis (excessive sweating).

1)have him stop taking the med immediately
2) tell the doctor about what's happening to Don
Trifluoperazine is neuroleptic agent, so it should be immediately discontinue when the patient is expereincing NMS. Because this is a potentially fatal condition, medical treatment and assessment should be initiated.
is the drug of choice for ppl with manic depression and has an antimanic effectiveness in 78% of ppl. Lithium lowers the intensity, freq, and duration of manic and depressive episodes. Blood levels need to be monitored for therapeutic levels during the acute phase and during longer term maintenance. Other treatments that could be expected for patients during mania include sedatives or antipsychotics. Read up on lithium!
When communicating with a client experiencing paranoid thought distortions, the nurse should use which guiding principle?
1) Use a logical and persistent approach.
2) Encourage the ventilation of anger and frustration.
3) Express doubt and don't argue
Answer: Express doubt and do not argue.
Paranoid clients develop delusional system to defend against anxiety. It is best to insert doubt but not argue with the client because refuting and arguing with the delusion would just add to the anxiety of the client. Encouraging venting of frustration would not address the thought distortion, and a logical, persistent approach would not be a match with the distorted thinking.
The most appropriate activity to suggest for a client who is experiencing anxiety is:
1) Competitive sports
2) Trivia pursuits
3) Daily walks
4) Bingo
Answer: daily walks; allows the client to expend energy and establish a trust neutral relationship with the nurse. The others are too stimulating that insert competition and added anxiety to the situation. Motivation and anxiety are related.
Physical exercise is an effective relaxation technique that nurses can recommend for clients with anxiety because it:
1) Stresses and strengthens the cardio system
2) Decreases the metabolic rate
3) Decreases levels of norepinephrine in the brain
4) Provides a natural outlet for the release of muscle tension.
Answer: 4; Clients experiencing anxiety often experience the stress response, which creates considerable muscle tension. Physical exercise allows for a relation of this tension, which lowers the experience of stress for anxious clients.
Read up on stress and anxiety.
what kind of parenting style is implemented for children who have conduct disorder?
Issues of inconsistent limit setting and very harsh discipline are often typical of families with children who have conduct disorder. High expectations and parental overinvolvement are more characteristic of anxiety disorders. Being an only child is not correlated in any way with conduct disorder.
difference between relaxation technique and sleeping pills for promoting sleep in clients with anxiety
Relaxation technique can all help the client gain control over anxiety in a way that promotes sleep. These exercises help produce a physiologic response opposite to that produces by stress. Providing sleeping will would provide short-term relief from the sleeplessness but would not promote healthy sleeping patterns.
To incorporate (characteristics of a person or object) into one's own psyche unconsciously.

Stephanie's parents generally have a passive and easygoing style of communication with Stephanie and others. Stephanie rarely expresses her feelings and remains passive in her care and life decisions (unconsciously ingrained passiveness that she got from parents).
mirroring vs reframing
Mirroring: when the nurse mirrors behavior for client to see as feedback.

Reframing is feeding back to the client an alternative way tf looking at the client's statement.
Which of the following traits is most common among suicidal clients?
1) Remorse
2) Anger
3) Psychosis
4) Ambivalence
Answer 4: the struggle b/w self-survival and self-destruction sets up an inherent ambivalence in clients who are suicidal. Often these doubts are expressed by clients who attempt suicide and later attempt to get rescued or saved.anger and remorse amy be present in ppl who experience depression but are not universally present in those with suicidal ideation. Similarly, indivs with psychosis may or may not experience suicidal ideation.
autistic fantasy
excessive daydream as a substitute for human relationships, more effective action, or problem solving. Ex: young man sits in his room all day and dreams about being a rock star (e.g. daydreaming) instead of attending a baseball game with his friends (e.g. replacing human relationship, more effective action or problem solving).
E.g. a child is mad at her mom for leaving for the day, but says she is really mad at the sitter for serving her food she doesn`t like (channel anger from mom to sitter because it's less threatening).
An adult relates severe sexual abuse experienced as a child, but does it without feeling. She says that the experience was as if she were outside her body watching the abuse (detachment from body or reality)
help-rejecting complaint
a college student asks a teacher for help after receiving a bad grade on a test (asks for help or complains). Every suggestion the teacher has is rejected by the student (student rejects the help).
an adults falls in love and fails to see the negative qualities in the other person (exaggerates the positive).
after rejection in a love relationship (feelings of rejection), the rejected explain about the relationship dynamics to a friend (use abstract thinking or generalizes to cope with rejection).
isolation of affect
the indiv loses touch with the feelings (separation of feelings from...) associated with a rape while remaining aware of the details (...ideas
an indiv tell a friend about personal expertise in the stock market (expressing special expertise) and the ability (expressing special abilities and acting superiorly) to predict the best stocks.
a child is very angry at a parent (child feels anger), but accuses the parent (attributing her anger to another and is aware of it) of being angry.
projective identification
a child is mad at a parent (child feels anger) and accuses said parent of being angry (attributing that anger to another), who in turn becomes angry at the child, but may be unsure of why (child causes the feeling in mother that is first mistakenly believed to be there, making it hard to clarify who did what to whom first). The child then feels justified at being angry with parent (child feels justified of accusation).
a man is rejected by gf, but explains to his friends that her leaving was best because she was beneath him socially and would not be liked by his family (trying to conceal feelings of rejection with self-serving incorrect explanations of why they broke up).
reaction formation
a wife finds out about her husband`s affair and tells her friends that she thinks his affairs are appropriate (said she is happy about affair...). She truly does not feel, on a conscious level, any anger or hurt (...when she truly feels anger and hurt deep down)
A women doesn`t remember the experience of being raped in basement (experience, thoughts, or wishes is unconscious but...), but does feel anxious when going into that house (feeling remains conscious).
an indiv notices an irritation at his friend's late arrival (observes feelings, thoughts, motivation and behavior and...) and decides to tell the friend of the irritation (responds to them appropriately).
splitting self
one friend is wonderful and another former friend, who was at one time viewed at being perfect, is now believed to be an evil person (compartmentalizing opposite affect states and failing to integrate the positive and negative qualities of the self and others)
an adolescent boy is very mad with his parents (channeling anger from parents...). On the football field, he tackles someone very forcefully ( socially acceptable behavior).

This is different from displacement. Sublimation emphasizes on what is socially acceptable).
a student is anxiously awaiting test results, but goes to a movie to stop thinking about it (intentionally watches movie to avoid thinking about something).
a man has sexual fantasies about his wife`s sister (unacceptable thoughts, feelings or actions). He takes his wife away for a romantic weekend (behaves in a way that negates or makes amends for said sexual fantasies about wife`s sister).

Advantage of transference: Therapist uses transference as a tool to help the patient understand emotional problems and their origin.

Disadvantage of countertransference; Feelings and perceptions caused by countertransference may interfere with the therapists' ability to understand the patient.
substance use and panic disorder
Indiv with panic disorder use alcohol or CNS depressants to self-mediate anxiety symptoms, and the withdrawal symptoms may produce symptoms of panic.
disadvantages of st. john's wort
o Sedative effects of it may impede attention and concnetratoin.
• Older age has been associated with a favorable resonse to ECT. Because depression can increase mortality risk in elderly people, in particular, and some elderly patients do not respond well to meds, effective treatment is especially important for this age group.
physical symptoms of anxiety
parasympathetic cardiovascular
-actual fainting
-decreased bp
decreased pulse rate

-strained face
-generalized weakness

-hold and cold spells

-loss of appetite
-revulsion toward food
-abdominal discomfort

parasympathetic GI
-abdominal pain

-dilated pupils

parasympathetic urinary tract
-pressure to pee
-increased frequency of urination
involuntary admission
nclude dangerousness to oneself or others, unwillingness to seek treatment, and serious and acute mental illness. The man threatening to kill is wife meets these criteria.
A withdrawal inward into one's own fantasy world.
Does not talk (refuse or unable)
persecutory delusion
If the FBI finds me here, I'll never get out alive."
word salad
(jumble of words)
Kneels to pray in front of water fountain (becomes preoccupied with religious ideas); prays during group therapy and during other group activities (defense mechanism used to provide stability and structure ti disorganized thoughts and behavior)
associative looseness.
"I'm going to the circus. Jesus is God. The police are playing for keeps" (ideas shift fro one unrelated subject to another)
inappropriate affect
Laughs when told that his or her mother had just died.
FRANGITUDES or truthiness
clang association
j)_"Test, test, this is a test. I do not jest; we get no rest." (words that rhyme in a nonsensical pattern)
waxy flexibility
Keeps arm in position the nurse left it in after taking blood pressure. Assumed this position for hours (a psychomotor symptom of catatonic schizophrenia which leads to a decreased response to stimuli and a tendency to remain in an immobile posture)
delusions of grandeur
When I speak, presidents and kings listen." (exaggerated feeling of importance or power)
concrete thinking
psychotic person has difficulty thinking on the abstract level and may use literal translations.
delusional disorder
characterized by presence of one or more nonbizarre delusions that last for at least 1 month. Hallucinatory activity is not prominent. Apart from the delusions, behavior and functioning are not impaired.

Divided into:
jealous type
erotomanic type
somatic type
grandiose type
jealous delusional disorder
delusions that one's sexual partner is unfaithful
erotomanic type
delusions that another person of higher status is in love with him or her.
somatic type
delusions that the person has some physical defect, disorder, or disease
Anorexia nervosa
• Person has a fear of obesity

• Occurs predominantly females 12 to 30 years.

• Without intervention, death from starvation can occur.
symptoms of anorexia
o Morbid fear of obesity, even when in an emaciated condition.
o Reports "not being hungry." Although it is thought that the actual feelings of hunger do not stop until late in the disorder.
o Preoccupation with food. Thinks and talks about food at great length. Prepares enormous amounts of food for friends and family members but refuses to eat any of it.
o Amenorrhea is common (absence of a menstrual period in a woman of reproductive age), often appearing even before noticeable weight loss has occurred
o Delayed psychosexual dev't.
o Compulsive behavior (excessive handwashing) may be present
o Extensive exercising is common.
o Feelings of depression and anxiety often accompany this disorder.
o May engage in binge-and purge syndrome from time to time.
bulimia nervosa
• Often called Binge and purge syndrome
• Characterized by extreme overeating, followed by self-induced vomiting and abuse of laxatives and diuretics.
• Occurs predominantly in females and begins in adolescence or early adult life.
symptoms of bulimia
o Binges are often done quietly and in secret, and the person may consume thousands of calories in one episode.
o After a binge has begun, there is often an inability to stop eating.
o Following the binge, the person engages in inappropriate measures to avoid gaining weight (e.g. vomiting, use of laxatives, diuretics, enemas, fasting, extreme exercising)
o Binge may be viewed as pleasurable at first but are followed by intense self-criticism and depression.
o Often within normal weight range, some a few punts underweight, some a few pounds overweight.
o Display undue concern with sexual attractiveness and how they will appear to others.
o Binges often alternate with periods of normal eating and fasting.
o Continuous vomiting may lead problems with dehydration and electrolyte imbalance.
o vomit may contribute to erosion of tooth enamel.
predisposing factors to anorexia
• genetics
o more common among sisters and moms of those with the disorder than among the general pop
o mood disorders, anorexia nervosa and bulimia nervosa and substances disorders are likely to be among first degree biological relatives of those with eating disorders.
• Neuroendocrine abnormalities
o There is some speculation regarding the primary hypothalamic dysfunction in anorexia nervosa, such as an elevated cerebrospinal fluid cortisol levels and a possible impairment of dopaminergic regulation in those with anorexia.
• Neurochemical influences
o Speculation that those with bulimia may be associated with low levels of serotonin and norepinephrine. Some studies have found high levels of endogenous opioids in the spinal fluid of clients with anorexia, promoting the speculation that these chemicals may contribute to denial of hunger.
• Psychodynamic theory
o Reflect a developmental arrest in the very early years of childhood caused by disturbances in mom-infant interactions.
o Trust, autonomy, and separation-individuation go unfulfilled, and the individual remains in the dependent position.
o Problem is compounded when the mom responds to the child's physical and emotional needs with food.
• Family dynamics
o Consist of a passive father, a domineering mom, and an overly dependent child
o High value is placed on perfectionism in this family, and the child feels he or she must satisfy these standards. Parental criticism promotes an increase in obsessive and perfectionistic behavior on the part of the kid, who continues to seek love, approval and recognition.
o In adolescence, this distorted eating patterns may represent a rebellion against the parents, viewed by child as a means of gaining and remaining in control
• Body mass index = weight (kg) /height (m)2
• Norma weight is 20 to 24.9
• Overweight is 25 to 29.9 (US dietary guidelines for Americans) or 30.0 (WHO)
physiological factors of obesity
o Overeating and/or obesity has also been linked to lesions in the appeptite and satiety centers of the hypothalamus, hypothyroidism, and decreased insulin production in diabetes mellitus, and increased cortisone production in Cushing's disease
complications of eating disorders
• From starvation to weight loss
o Musculoskeletal
Loss of muscle mass, loss of fat
o Metabolic
o Cardiac
Low HR, low bp, loss of cardiac muscle, small heart cardiac arrhythmias including atrial and ventricular premature contractions, prolonged QT interval, ventricular tachycardia, sudden death
o GI
Delayed gastric emptying, bloating, constipation, abdominal pain, gas diarrhea
o Reproductive
Amenorrhea, low levels of luteinizing hormone and FSH, irregular periods
o Dermatolgic
Dry, cracking skin and brittle nails due to dehydration, lanugo (fine baby-like hair over body), edema, acrocyanosis (bluish hand and feet); hair thinning
o Hematologic
Leukopenia, anemia, thrombocytopenia, high blood cholesterol, hypercarotenemia (excessive carotene in the blood, often with yellowing of the skin), abnormal taste sensation (possible zinc deficiency)
o Neuropsychiatric
Decreased total brain volume, increase brain ventricular size, neurologic deficits in cognitive processing new info
Apathetic depression, sleep disturbances, fatigue
• Related to purging
o Metabolic
Electrolyte abnormalities, particular low potassium levels, hypochloremic alkalosis (due to loss of gastric acid); low magnesium levels, increased blood urea nitrogen
o GI
Salivary gland and pancreatic inflammation and enlargement with increase in serum amylase; esophageal and gastric erosion (esophagitis) rupture; dysfunctional bowel with haustral dilation; superior mesenteric artery syndrome (compression of the third, or transverse, portion of the duodenum between the aorta and the superior mesenteric artery. This results in chronic, intermittent, or acute complete or partial duodenal obstruction)
o DentAL
o Neuropsychiatric
Seizures (related to electrolytes disturbances and large fluid shifts), mild neuropathies, fatigue, weakness
o Cardiac
Ipecac cardiomyopathy arrhythmias
residual schizophrenia
• Behavior is eccentric but psychotic symptoms, if present at all, are not prominent.
• Social withdrawal and inappropriate affect are characteristic
• The patient has a history of at least one episode of schizophrenia in which psychotic symptoms were prominent.
schizoaffective disorder
• Refers to behaviors characteristic of schizophrenia, in addition to those indicative of disorders of mood, such as depression or mania
schizophreniform disorder
• Identical to those of schizophrenia, with the exception that the duration of at least 1 month but less than 6 months.
• The diagnosis is term provisional if a diagnosis must be made prior to recovery.
Delusional disorder
• Presence of one or more nonbizarre delusions that last for at least 1 month.
• Hallucinatory activity is not prominent
• Behavior and functioning are not impaired
types of delusional disorder
o Persecutory type
Delusions that one is being malevolently treated in some way
o Jealous type
o Erotomanic type
Delusions that another person of higher status is in love with him or her
o Somatic type
Delusions that the person has some physical defect, disorder or disease
o Grandiose type
Delusions of inflated worth, power, knowledge, special identity, or special relationship to a deity or famous person.
shared psychotic disorder
• Delusional system develops in the context of a close relationship with another person who already has a psychotic disorder with prominent delusions.
Psychotic disorder due to a general medical condition
o Neurologic conditions (Huntington`s disease)
o Endocrine conditions (hyper or hypothyroidism)
o Metabolic conditions (hypoxia)
o Autoimmune disorders (lupus)
Predisposing factors of schizophrenia
• Histological changes
o Birth defect in hippocampus region of brain and related to an influenza virus encountered by the mom during the second trimester of pregnancy.
• Dopamine hypothesis
o Schizophrenia may be caused by an excess of dopamine-dependent neuronal activity in the brain.
• Anatomical abnormalities
o Ventricular enlargement is the most consistent finding;
o Sulci enlargement and cerebellar atrophy are also reported.
symptoms of schizophrenia
• Emotional ambivalence
o Powerful feelings of love, hate, and fear produce much conflict within the individual. Each emotion tends to balance the other until an emotional neutralization occurs, and the individual experiences apathy or indifference.
• Associative looseness
o Disorganized thoughts and verbalizations of the psychotic person. Ideas shift from one unrelated subject to another. When the condition is severe, speech may be incoherent.
• Circumstantiality
o Refers to a psychotic person's delay in reaching the point of a communication because of unnecessary and tedious details.
• Perseveration
o Individual with psychosis may persistently repeat the same word or idea in response to different questions.
dysthmic disorder
• No evidence of psychotic symptoms.
• The characteristics are similar to, if somewhat milder than, those ascribed than major depression.
chronic depression
• Current episode of depressed mood has been evident continuously for at least the past two years
seasonal depression
• Depressive symptoms during the fall or winter months.
• The diagnosis is made when the number of seasonal depressive episodes more than outnumbers the non-seasonal depressive episodes that have occurred over the individual's lifetime.
postpartum depression
• Symptoms of major depression occur within 4 weeks postpartum.
Predisposing factors to depression
• Genetic
o 1.5 to 3 times more common among first-degree relatives of individuals with the disorder than among the general pop.
• Biochemical
o Deficient in norepinephrine ,dopamine and serotonin
• Neuroendocrine disturbances
o Elevated levels of serum cortisol and decreased levels of TSH have been associated with depressed mod in some ppl.
• Other
o Medication side effects
o Other physiological conditions like nutritional deficient, electrolyte disturbances, hormonal disturbances etc
• Psychoanalytic
o Melancholia occurs after the loss of a loved object, either actually by death or emotionally by rejection, or the loss of some other abstraction of value to the individual.
• Object loss theory
o Suggest that depressive illness occurs as a result of having been abandoned by, or otherwise separated from, a significant other during the first 6 months of life. Because during this period the mom represents the child's main source of security, she is the object. This includes physical and emotional loss.
symptoms of depression
• Psychotic features such as hallucinations and delusions may be evident, reflecting misinterpretations of the environment
• Urinary retention is possible
• At the less severe level (dysthymic disorder), individuals tend to feel their best early in the morning, then continually feel worse as the day progresses. It is thought to be related to the circadian rhythm of the hormones and their effect on the body.
bipolar disorder
• Experiencing or has experienced, a full syndrome of manic or mixed symptoms (when the symptom presentation includes rapidly alternating moods of sadness, irritability and euphoria accompanied by symptoms associated with both depression and mania).

• The client may also have experienced episodes of depression
bipolar II disorder
• Characterized by recurrent bouts of major depression with the episodic occurrence of hypomania.
• Never experienced a full syndrome of manic or mixed symptoms.
Cyclothymic disorder
• Absence of psychotic features
Predisposing factors to bipolar disorder
• Genetics
o If both parents both have the disorder, the risk is two to three times as great.
o Appears to be equally common in men and women.
• Biochemical
o Higher levels of dopamine and norepinephrine in a manic episode.
o Increased intracellular sodium and calcium
These electrolyte imbalances may be related to abnormalities in cellular membrane function in bipolar disorder.
• Neuroanatomical factors
o Right-sided lesions in the limbic system, temporobasal areas, basal ganglia, and thalamus have been shown to induce secondary mania
o Enlarged their ventricles and subcortical white matter and periventricular hyperintensities in ppl with bipolar disorder.
• Medications
o Antidepressants, high doses of anticonvulsants, steroids, and amphetamines.
o Pressured speech that is very forceful and strong.

indicative of a symptom of bipolar disorder
continuum of care
• A range of services developed and organized to address the variety of needs individuals have as they age. This concept recognizes and considers the availability and extent of short-term and long-term care systems and services in the community and in institutional settings
• Goal of care: to provide treatment that allows the patient to achieve the highest level of functioning in the least restrictive environment.
intensive care management
• Targeted for adults with serious mental illnesses or kids with serious emotional disturbances.
• Managers of such cases have 24 hour availability, frequency of contact, proactive outreach, community-based practice and fewer caseloads.
assertive community treatment
• Assertive outreach
• Continuous, around the clock, time-unlimited, individual support to people with serious mental illness services that are mainly provided in the community as opposed to office based
• Provision of flexible support specifically tailored to meet the needs of each individual
• Involvement of consumers and their families in all aspects of service delivery, including design, implementation, monitoring and evaluation
• Provision of programs to service special needs groups such as those with dual disorders
rehab model
• Focuses on improving living skills, is individually tailored top patient needs, and provides continuous interpersonal support
personal strengths model
• Focuses on patient strengths and identifies or develops community resources and environments where patients can achieve success.
clubhouse model
• Form of psychosocial rehab that aims to reintegrate a person with mental illness into the community.
• All members of society can be productive; every human aspires to achieve gainful employment; humans require social contacts; and programs are incomplete if they offer recreational, social and vocational opportunities but neglect housing needs.
virtue ethics
character of the moral agent. Some virtues: honesty, courage, compassion, practical wisdom
• A nurse in an emerg may restrain a patient without the necessary physician's order, to protect the patient from harming himself. To stand aside as a confused, acutely ill person injures himself may be correct according to rules or policy, but it does not seem ethical
• Duty based. Some acts are wrong in themselves. Universality: do not treat others as a means to an end.
• For instance, individuals should not be used as research subjects unless they understand what will happen and agree to it. Nor should we, according to Kantian ethics, place individuals at risk in research by depriving them of the best known treatment in order to carry out a placebo-controlled study, even though this would provide the most valid evidence.
• Consequence based. Actions are right if they promote the best outcome (happiness, pleasure, satisfaction) for the most people.
• Covertly putting antipsychotic med in an acutely ill person's food, for instance, might be regarded as ethically acceptable for instance, might be regarded as ethically acceptable in a special circumstance when such action causes the least suffering to the ill person. A Kantian would never approve, and, despite ethical justification from a utilarian perspective, such an act can result in disciplinary or legal action.
ethics of care
• Care based: connection/responsibility for others. Emotional responsiveness.
relational ethics
• Ethical action involves relationships. Context matters; emotion accepted. Dialogue is supported. Aims for the fitting response.
feminist ethics
• Addresses power inequities, dominance, and oppression
human rights ethics
• Rights based (negative and positive); every person is entitled to certain basic rights.
moral dilemma
• A conflict in which one feels a moral obligation to act but must choose b/w incompatible alternatives
moral distress
• Occurs when one is unable to act on one's moral choices because of internal or external constraints.
• The anger, frustration or anguish experienced when one is unable to fulfill one's ethical obligations as one believes one should.
• Sources of nurses' moral distress include harm to patients (pain, suffering); treatment of patients as objects; effects of cost containment; policy constraints; and inadequate staffing. For many PMH nurses, lack of time to engage with patients (including suicidal patients) appears to be common sources of distress.
predisposing factors to anxiety disorders
• Biochemical: increased levels of norepinephrine have been noted in panic and GADs. Abnormal elevations of blood lactate have also been noted in clients with panic disorder. Decreased levels of serotonin have been implicated in the cause of OCD.
somatization disorder
• Somatization disorder is a long-term (chronic) condition in which a person has physical symptoms that involve more than one part of the body, but no physical cause can be found.
• The pain and other symptoms people with this disorder feel are real, and are not created or faked on purpose (malingering).
• Onset of the disorder is often in adolescence or early adulthood and is more common in women than in men.
• Often runs a fluctuating course, with periods of remission and exacerbation.
pain disorder
• The pain is like that of a physical disorder, but no physical cause is found. The pain is thought to be due to psychological problems.
• The pain that people with this disorder feel is real. It is not created or faked on purpose (malingering).
• Hypochondria is a belief that physical symptoms are signs of a serious illness, even when there is no medical evidence to support the presence of an illness.
• Often have a long history of "doctor shopping" and are convinced that they are not receiving the proper care.
• People with hypochondria are overly focused on their physical health. They have an unrealistic fear of having a serious disease.
conversion disorder
• Conversion disorder is a condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation.
• Conversion disorder symptoms may occur because of a psychological conflict.
• Most common conversion symptoms are those that suggest neurological disease such as paralysis, aphonia, seizures, coordination disturbance, akinesia, dyskinesia, blindness, tunnel vision, anosmia, anesthesia and paresthesia.
body dysmorphic disorder
Body dysmorphic disorder
• a type of mental illness, a somatoform disorder, wherein the affected person is concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of their physical features
• involve imagined or slight flaws of the face or head, such as thinning hair, acne, wrinkles, scars, vascular markings, facial swelling or asymmetry or excessive facial hair
predisposing factors to somatoform disorders
• biochemical: decreased levels of serotonin and endorphins may play a role in the cause of pain disorder.
Symptoms and signs of somatoform disorders
• any physical symptom for which there is no organic basis but for which evidence exists fo the implication of psychological factors.

• Depressed mood is common
• Loss or alteration in physical functioning, with no organic basis. Examples include the following:
• La belle indifference - a relative lack of concern regarding the severity of the symptoms just described
• Doctor shopping
• Excessive use of analgesics
• Requests for surgery
• Assumption of an invalid role
• Impairment in social or occupational functioning because of preoccupation with physical complaints
• Psychosexual dysfunction (impotence, dyspareunia [painful coitus], sexual indifference)
• Excessive dysmenorrhea
• Excessive preoccupation with physical defect that is out of proportion to the actual condition
types of first gen antipsychotics
Zuclopenthixol (Clopixol)
Loxapine (Loxapac)
Flupenthixol (Fluanxol)
Haloperidol (Haldol)
types of depots
Zuclopenthixol Decanoate (Clopixol Depot) -
Haloperidol Decanoate (Haldol LA)
Fluphenazine Decanoate (Modecate)
Flupenthixol Decanoate (Fluanxol)
Risperidone Microspheres (Consta) -2nd -generation
Paliperidone (Sustenna) -2nd -generation
types of 2nd gen antipsychotics
CLOZAPINE (Clozaril)
types of tricylics
Amitriptyline (Elavil)
Imipramine (Tofranil)
Desipramine (Norpramine)
Clomipramine (Anafranil) *SSRI pharmacology
types of MAOIs
Phenelzine (Nardil)
Tranylcypromine (Parnate)
types of SSRIs
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
All antidepressants increase the activity of 1 or more of the following:
1. Serotonin
2. Norepinephrine
3. Dopamine
type of reversible inhibitors of MAO-A (RIMA)
Manerix (generic name)
type of serotonin + norepinephrine re-uptake inhibitor (SNRI)
Effexor (generic name)
Cymbalta (generic name)
types of norepinephrine + dopamine re-uptake inhibitor (NDRI)
Wellbutrin, (generic name)
Zyban (generic name)
type of norepinephrine + specific serotonin antidepressant (NaSSA)
Remeron (generic name)

what does it do
treats depression, GAD, anxiety disorders, panic disorder
SNRI (effexor and cymbalta side effects
dry mouth nausea
asthenia (weakness)
dilated pupils (venlaxine)
increased risk of suicidality in kids and adolescents
discontinuation syndrome. Abrupt withdrawal may result in symptoms such as nausea, vomiting, nervousness, dizziness, headache, insomnia, nightmares, paresthesias, and a return of symptoms for which the med was prescribed. A gradual reduction in dosage is recommended.
NDRI (wellbutrin and zyban) side effects
dry mouth
blurred vision
sedation; dizziness
high HR
excessive sweating
anorexia; weight loss
increased risk of suicidality in kids and adolescents

what does it treat?
depression, SAD and ADHD
ADHD and smoking cessation
NaSSA (remeron) side effects
dry mouth
increased appetite
weight gain
increases in cholsterol and triglyceride levels.

what does it treat?

what does it treat?
diabetic peripheral neuropathic pain
tricyclic side effects
Drowsiness; Dizziness
Tachycardia; Cardiac arrhythmias
Very toxic in overdose; blood dyscrasias
Anticholinergic +++
Increased risk of suicidality in children and adolescents
MAOI side effects
Stimulation (anxiety, insomnia, etc)
Hypertensive crisis (tyramine foods)
Toxic in overdose
Anticholinergic effects
Weight gain
Site reactions (itching, irritation)
Increased risk of suicidality
SSRI side effects
Sexual dysfunctiom
Somnolence (state of near sleep)

Serotonin syndrome: diarrhea, cramping, high HR, labile bp, diaphoresis, fever, tremor, shivering, restlessness, confusion, disorientation, mania, myoclonus (brief, involuntary twitching of a muscle or a group of muscles), hypperreflexia (overactive reflexes), ataxia (lack of voluntary coordination of muscle movements), seizures, cardiovascular shock and death.
Much safer in overdose.
lithium side effects
Excessive thirst and urination
Weight gain, tremor
Weakness, dizziness, confusion
Dry mouth, thirst
Indigestion, nausea, anorexia
Fine hand tremors
Hypotension, arrhythmias, (ECG) changes
Polyuria, glycosuria
weight gain
lithium interactions
Many drugs
Always monitor for neurotoxicity (neurotoxicity may occur with concurrent use of lithium and high-potency antipsychotics or calcium channel blockers)
carbamazepine side effects
drowsiness, ataxia
Nausea, vomiting
Blood dyscrasias
cabamazepine interactions
valproic acid side effects
nausea and vomiting
Weight gain, menstrual changes
prolonged bleeding time (bruising), pancreatitis
Hair loss
benzodiazepam side effects
Drowsiness; dizziness, lethargy
Nausea and vomiting
Dry mouth
Blurred vision
Hypotension, tachycardia, palpitations
Paradoxical excitation
types of psychostimulants
Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)

Dexmethylphenidate (Focalin)

Amphetamine-Dextroamphetamine (Adderall)

Dextro-amphetamine (Dexedrine, Dextrostat)

Lisdex-amfetamine (Vyvanse)
ADHD med side effects
• Overstimulation
• Restlessness
• Dizziness
• Insomnia
• Headache
• Palpitations
• Tachycardia
• Elevation of bp
• Anorexia
• Weight loss
• Dry mouth
• Tolerance
• New or worsened psychiatric symptoms
• Physical and psychological dependence
• Suppression of growth in children (with long-term use)
aboriginal mental health
o Many aboriginal people are raised to believe the body is affected by four elements made up of the spiritual, emotional,, mental and physical.
o The traditional aboriginal healing system encompasses a holistic view of manifestations of illness in an individual. There is little evidence of a clear distinction between what science would call somatic disorders and disorders of the psyche. The mind, body, and spirit are seen as an integrated whole.
o Notions of sanity and insanity and of personality disorders are not restricted defined, as in the case of the biomedical tradition.
aboriginal mental health vs western health
o The western approach, in contrast, separates the body from the mind and spirit, and the emphasis is on disease and treatment.

o It has been argued that psychiatric researchers, focussed on a biologic model of mental disorders, tend to ignore cultural factors.
aboriginal mental health issues
o It is necessary to recognize the historical, socioeconomic, and political circumstances of aboriginal people in Canada in order to understand the mental health problems or disorders of a person from this culture because they may be related to factors that have historically confronted them.
colonialism of aboriginals
o Colonialism is the institutionalized political domination of one nation over another. There is direct political admin by the colonial power, control of all economic relationships, and a systematic attempt to transform the culture.
o Before confederation and up through Government of Canada toward First Nations was a colonial one. Government policy was to canadianize aboriginal people and assimilate them into the majority culture. Part of making native peoples into Canadians was to convert them to Christianity: government and several churches and religious orders cooperated to run residential schools.
aboriginal vs western view of mental illness and religion
Aboriginal culture advocates that spiritual needs as important as hunger and thirst. Getting in touch with one's own spirituality is identified as a key to recovery or healing. To most aboriginal people, the concept of spirituality refers to a sense of direction: it is not a religion but a way of life.

• Western medicine and psychiatry are premised on the belief that mental illness is caused by biologic and experiential events; many other cultures ascribe a metaphysical or spiritual cause as well.
poverty and mental illness
• The chances of becoming poor are greater if someone is mentally ill. Three percent of Canadians suffer from severe and chronic mental disorders that can cause serious functional limitations and social and economic impairment.
• Still, many people with mental illness hold down well-paid jobs. A key factor for many of these people is a strong support network of family and friends.
gap in life expectancy b/w First Nations and Canadians
• The gap in life expectancy b/w first Nations individuals and other Canadians is 7 years.
• Approximinately, half of the children in our aboriginal communities live in poverty.
Why do First Nations individuals tend to drop out of mental health services provided by the dominant culture
• There is a tendency for First Nations individuals not to use the mental health services provided by the dominant culture. If services are accessed, approximately 50 percent drop out, and for many, treatments are not effective, partly because mental health services ignore the unique cultural identities, histories and sociopolitical contexts of the everyday lives of Aboriginal peoples.
the use of electronic info and communication technologies to support health care services over distance. It ranges from the retrieval of lab results or other health records posted on a network to the assessment of a person by a psychiatrist trough videoconferencing.
rights of person with mental illness
• Right to medical care
• Right to be treated with humanity and respect
• Equal protection right
• Right to be cared for in the community
• Right to provide informed consent before receiving any treatment
• Right to privacy
• Freedom of communication
• Freedom of religion
• Right to voluntary admission
• Right to judicial guarantees
mental health act
is a law that gives certain powers, and sets the conditions (including time limits) for those powers, to stipulated health care professionals and designated institutions regarding the admission and treatment of individuals with a mental disorder.
mandatory outpatient treatment
involves legal provisions requiring people with a mental illness to comply with a treatment plan while living in the community.
community treatment order
a type of MOT, existing in saskatchewan, and Ontario, that are often initiated by a doctor. People who do not meet involuntary admission criteria and who are not necessarily in a hospital at the time of the CTO can be required to comply with the stipulated treatment.
Involuntary Admission Criteria in Provincial and Territorial Mental Health Acts
• Is not suitable as a voluntary inpatient: a person who is willing and capable of consenting to a voluntary admission cannot be admitted with a involuntary status anywhere in Canada.
• Meets the definition of mental disorder: the person must have a mental disorder. In many, but not all, of the jurisdictions, it is specified that the disorder must seriously impair the person's functioning.
• Meets the criteria for harm: in most jurisdictions, this is not limited to serious bodily harm; nonbodily harms are acceptable. The criterion of danger stipulated in some acts, however, has been interpreted by the courts to mean bodily harm.
• Likely to suffer substantial mental or physical deterioration: this is included in some provinces (BC, Sask, Manitoba, and ON) as an alternative to the harm criterion.
• In need of psychiatric treatment: this is a criterion in BC, Sask and Onatario. It is possible in order jurisdictions to commit a person with a mental disorder who is dangerous, but for whom there is no treatment for the purpose of preventative detention.
• Refusal of treatment: by the person after admission: this is allowed in some jurisdictions but not others. In some jurisdictions, a refusal can be overruled in the person's best interests.
• Review and appeal procedures: regarding the validity of involuntary hospitalization: these are found in all jurisdictions.
impulse control disorders
a set of psychiatric disorders including intermittent explosive disorder, kleptomania, pathological gambling, pyromania (fire-starting), and three body-focused repetitive or compulsive behaviors of trichotillomania (a compulsion to pull one's hair out).

Impulsivity, the key feature of these disorders, can be thought of as seeking a small, short term gain; in the case of these behaviours, this gain is at the expense of a large and long term loss.

Seldom do these individuals know why they do what they do or why it pleasurable.
intermittent explosive disorder
a behavioral disorder characterized by extreme expressions of anger, often to the point of violence, that are disproportionate to the situation at hand, resulting in serious assaultive acts or destruction of property

Some clients report changes in sensorium, such as confusion, during an episode or amnesia for events that occurred during an episode.,

symptoms often appear suddenly without apparent provocation and terminate abruptly, lasting only min to a few hours, followed by feelings of genuine remorse and self-reproach about the behavior/
is the failure to refrain from the urge to steal items, not for reasons of personal use or financial increase.

Often the stolen items are given away, discarded, returned, or kept and hidden.

The person with kleptomania steals purely for the sake of stealing and for the sense of relief and gratification that follows an episode.
pathological gambling
Pathological gambling is being unable to resist impulses to gamble, which can lead to severe personal or social consequences.

the preoccupation with gambling, and the impulse to gamble, intensifies when the individual is under stress.

many pathological gamblers exhibit characteristics associated with narcissism and grandiosity and often have difficulties with intimacy, empathy, and trust.
in more extreme circumstances can be an impulse control disorder to deliberately start fires to relieve tension or for gratification or relief.

Even though some people with pyromania may take precautions to avoid apprehension, many are totally indifferent to the consequences of their behavior.
pathological gambling
classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment, and in some cases one may even consume the hair. the Impulse is preceded by an increasing sense of tension, and the person experiences a sense of release from pulling out hair.
predisposing factors to impulse control disorders
genetics: a familial tendency appears to be a factor in some cases of intermittent explosive disorder and pathological gambling.

physical factors: brain trauma or dysfunction and mental retardation have also been implicated in the predisposition to impulse control disorders.

family dynamics: Various dysfunctional family patterns have been suggested as contributors in the predisposition to impulse control disorders. These include the following: child abuse or neglect, parental rejection or abandonment, harsh or inconsistent discipline, emotional deprivation, parental substance abuse, parental unpredictability
signs and symptoms of impulse control disorders
sudden inability to control violent, aggressive impulses

aggressive behavior accompanied by confusion or amnesia.

feelings of remorse following aggressive behavior

inability to resist impulses to steal

increasing tension before committing the theft, followed by pleasure or relief during and following the act.

sometimes discards, returns, or hides stolen items.

inability to resist impulses to gamble

preoccupation with ways to get money with which to gamble.

increasing tension that is relieved only by placing a bet

hair-pulling may be accompanied by other types of self-mutilation (e.g. head-banging, biting, scratching)
substance-related disorders
made of two groups: the substance-use disorders (dependence and abuse) and the substance
substance use
maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of the substance.

Symptoms include:use of substances in physically harmful circumstances
impaired role performance (school, work or home)
repeated encounters with the legal system for substance-related conduct
experiencing personal problems related to substance use.
substance dependence
defined as chronic requirement.

depend on substances is identified by the appearance of unpleasant effects characteristics of a withdrawal syndrome when a drug is discontinued. Dependence on substances can also be associated with tolerance, in which there is a need for increasingly larger or more frequent doses of a substance to get the desired effects originally produced by a lower dose. The person who is dependent on substances continues to increase the amount consumed to get the desired effect and to relieve or avoid withdrawal symptoms.
substance intoxication
stimulation, excitement, or stupefaction caused by a chemical substance

is reversible
medical use for alcohol
an antidote for methanol consumption
medical use as analgesics, cough supressants, and antidiarrheals.
CNS depressants
medical use as antianxiety agents, sedatives, hypnotics, anticonvulsants, and anesthetics. They depress the action of the CNS, resulting in an overall calming, relaxing effect on the individual. At higher dosages they can induce sleep.
CNS stimulants
medical use in the treatment of hyperkinesia (excessive abnormal movements, excessive normal movements, or a combination of both), narcolepsy (excessive sleepiness and sleep attacks)and weight control
the treatment of chronic alcoholism and intractable pain (e.g. terminal malignant disease, phantom limb sensations).

at this time there is no real evidence of the safety and efficacy of the drug in humans.
produce state of relaxation characterized by a feeling of extreme well-being.

Large doses produce hallucination.

pot is used to treat nausea and vomiting related to antineoplastic chemotherapy.
generally act as a CNS depressant

effects are relatively brief, lasting from several min to a few hours, depending on the specific substance amount consumed.

e.g. fuels, paint thinners, aerosol propellants
predisposing factors for substance-related disorders
kids of alcoholics are 3 times more likely than that of other kids to become alcoholics.

biohemica reason: alcohol may produce morphine-like substances in brain that are responsible for alcohol addiction. This occurs when the products of alcohol metabolism react with biological active amines.

psychodynamic: overactive superego; turn to alcohol to diminish anxiety and increase feelings of power and self-worth

social learning theory of alcoholism: parents who drink serve as role-models for kids
signs of alcohol abuse.
Repeatedly neglecting your responsibilities at home, work, or school because of your drinking. For example, performing poorly at work, flunking classes, neglecting your kids, or skipping out on commitments because you're hung over.

Using alcohol in situations where it's physically dangerous, such as drinking and driving, operating machinery while intoxicated, or mixing alcohol with prescription medication against doctor's orders.

Experiencing repeated legal problems on account of your drinking. For example, getting arrested for driving under the influence or for drunk and disorderly conduct.

Continuing to drink even though your alcohol use is causing problems in your relationships.
Getting drunk with your buddies, for example, even though you know your wife will be very upset, or fighting with your family because they dislike how you act when you drink.

Drinking as a way to relax or de-stress. Many drinking problems start when people use alcohol to self-soothe and relieve stress.

Getting drunk after every stressful day, for example, or reaching for a bottle every time you have an argument with your spouse or boss.
signs and symptoms of alcohol withdrawal
occurs within 4-12 hours of cessation of, or reduction in, heavy and prolonged alcohol use.

without aggressive intervention, the person may progress to alcohol withdrawal delirium about the second or 3rd day following stoppage of, or reduction in prolonged, heavy alcohol use.

Anxiety or jumpiness
Shakiness or trembling
Nausea and vomiting
Loss of appetite
transient hallucinations or illusions
high HR
alcohol intoxication
legal def'n of alcohol intoxication for blood alcohol concentration of .08 to .10 g/dL

nontolerant individuals with blood alcohol concentrations greater than 300 mg/dL are at risk for respiratory failure, coma and death.
amphetamine dependence / abuse
appetite suppressant

taken for initial feeling of wellbeing and confidence

chronic daily use often results in an increase in dosage over time to produce the desired effect

typically taken orally, IV, or by nasal inhalation

episodic use often takes the form of binges, followed by an intense and unpleasant "crash" in which the individual experiences anxiety, irritability and feelings of fatigue and depression

continued use appears to be related to a "craving" for the substance, rather than to prevention or alleviation of withdrawal symptoms
amphetamine intoxication
begins with high feeling, then euphoria with enhanced vigor, gregariousness, hyperactivity, restlessness, hypervigilance, interpersonal sensitivity, talkativeness, anxiety, tension, alertness, grandiosity, stereotypical and repetitive behavior anger, fighting and impaired judgement

physical signs and symptoms:
high HR
low HR
pupil dilation
high BP
lower BP
sweating or chills
nausea or vomiting
psychomotor retardation or agitation
musclar weakness
respiratory depression
chest pain
cardiac arrhythmais,
amphetamine withdrawal symptoms
Physically, amphetamines withdrawal symptoms can include excessive hunger as the appetite recovers from long-term suppression, and extreme fatigue as sleep cycles become disrupted by bouts of insomnia and oversleeping. Physical signs of amphetamines withdrawal can also include lack of coordination, shaking, seizures and overheating due to dehydration from continued use. Amphetamine withdrawal symptoms in the body can even affect the heart, causing tachycardia (rapid heartbeat), arrhythmia (irregular heartbeat) or even cardiac arrest in severe cases.