• family history of suicide
• family hx of child maltreatment
• previous suicide attempt(s)
• hx of mental disorder, particularly depression
• hx of alcohol and substance abuse
• feelings of hopelessness
• impulsive or aggressive tendencies
• cultural and religious beliefs
• local epidemics of suicides
• isolation
• barriers to accessing mental health treatment
• loss
• physical illness
• easy access to lethal methods
• unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts.

• prevention of relapse
• promoting communication
• promoting adherence to treatment
• assisting with grooming and hygiene
• promoting organized behavior
• promoting social interaction and activity
• promoting social skills and activities
• promoting reality-based perceptions
• intervening with delusions
• promoting family understanding and involvement
• promoting community contacts

Signs and symptoms anxiety disorder

Physiologic, Psychological, Cognitive Assessments

Physiologic assessment

• how often do you experience heart palpitations?
• do you have difficulty breathing?
• do you experience muscle tightness?
• how often do you experience changes in ladder or bowel fxn?
• how do your symptoms affect your sleep?

Psychological assessment

• do you feel sad and/or hopeless?
• how often do you lose your temper?
• Do you enjoy being with other people?
• How often do you criticize yourself?

Cognitive assessment

• Do you think about the same things over and over?
• Do you frequently have trouble concentrating on important activities?
• how often do you worry about the past or future?
• Do you still enjoy activities that were pleasurable for you in the past?

• use a quiet, calm approach
• observe the client’s verbal and nonverbal behavior
• encourage the client to verbalize feelings
• teach relaxation techniques when the client’s anxiety is at a mild level
• encourage the client to use relaxation techniques as needed

Recurrent attacks of severe anxiety not originally associated with a stimulus but may result in anticipatory fear and object attachment

1. symptoms may mimic life-threatening physical illness (heart attack, choking to death)
2. may be accompanied by agoraphobia (fear of public places, fear of being alone or in a public place where you can’t escape or get help)
3. first seen in adolescence and more often in women.

pervasive, persistent, exaggerated anxiety of at least 6 month’s duration without phobias, panic attacks, obsessions, or compulsions

1. need to rule out physical conditions such as hyperthyroidism and cushing’s disease.
2. client has little impairment of fxning, but may self-medicate with alcohol or drugs to control anxiety

a stressor followed by recurrent re-experiencing of the trauma

1. Categories:
1. acute: <3mo
2. chronic: >6months
3. Delayed onset: not seen until 6mo later
2. zoloft is effective for treating symptoms
3. often complain of feeling empty inside
4. may become psychotic

recurrent somatic complaints for which there is no organic evidence

• conversion disorder
• pain disorder
• hypochondriasis
• body dysmorphic disorder
• somatization disorder

unconscious psychological conflict is converted into physical symptoms; e.g. paralysis, pseudo seizures, sudden blindness, pseudo pregnancies etc.

Patients gain something form having a conversion disorder

• Primary gain: the psychologic conflict or need is kept out of conscious awareness
• Secondary gain: the symptoms help clients avoid distressing activity while still getting support

(undifferentiated somatoform disorder)-- 6 months of multiple physical symptoms in multiple body systems with no organic base. Most often treated with the nursing intervention of neutrality and setting limits on the amount of time devoted to discussing symptoms. Individuals experience symptoms; e.g. pain. They are not faking or exaggerating symptoms and they are not seeking attention

• Somatoform disorders
• factitious disorders
• malingering

• consciously producing symptoms, both physical and psychological.
• Psychological need to assume sick role
• deliberately hurting themselves.
• no secondary gain

faking symptoms

external incentive/secondary gain

Benzodiazepines

Nonbenzodiazepines

potentiate the neurotransmitter GABA, producing muscle relaxation

• Xanax (alprazolam)
• Ativan (lorazepam)
• Klonopin (clonazepam)
• Valium (diazepam)
• Dalmane (flurazepam)
• Restoril (temazepam)

1. Amnesia
2. Paradoxical reaction: excitement, confusion, agitation
3. Drowsiness, fatigue, ataxia, lightheadedness
4. risk for falls
5. withdrawal syndrome

buspar

lunesta

ambien

sonata

Nonbenzodiazepine

No abuse/dependence potential

non-sedating

not use for "as needed" use

takes 2-3 weeks to see effects

no issues with drug interactions with other CNS drugs

• anxiety
• insomnia
• irritability
• fatigue
• nausea
• depression
• ataxia
• blurred vision

1.  lack of insight (clients view their problems as separate from themselves)
2. external responses to stress- they try to change the environment rahter than changing themselves
3. failure to accept consequences for own behavior
4. all experience painful feelings

Odd and eccentric behaviors

1. Paranoid
2. Schizoid
3. Schizotypal

Dramatic/Emotional

1. Borderline Personality Disorder
2. Histrionic Personality Disorder
3. Antisocial Personality Disorder
4. Narcissistic Personality Disorder

These often co-occur with mood disorders, alcohol and drug abuse, or dependence and somatization disorders

Anxious/Fearful

1. Avoidant PD
2. Dependent PD
3. Obsessive-compulsive PD
4. Passive-agressive PD

Paranoid Personality Disorder

(characteristics and Cluster)

Cluster A

Characteristics:

1. suspiciousness and mistrust
2. rigidity
3. hypervigilace/guarded behavior
4. distortions of reality
5. projection
6. restricted and labile affect
7. exclusion or joining in cult-like groups
8. bears grudges and quick to counterattack

Schizoid and Schizotypal PD

(cluster and characteristics)

Cluster A

Characteristics

1. social isolation
2. blunted affective response
3. detached from relationships
4. prefer solitary activities

Borderline PD

(characteristics and cluster)

Cluster B

1. Unstable interpersonal realtinships and intense fear of abandonment
2. Manipulation of others
3. intense attachments
4. explosive separations
5. superficial relationships and chameleon-like behavior
6. intense anger
7. identity diffusion about goals and values in life and around areas such as gender identity
8. splitting-cannot unify "good and bad"
9. affective instability
10. impulsivity
11. marked instability in relationships, mood and self image

Histrionic PD

(characteristics and Cluster)

Cluster B

1. dramatic, exhibitionistic, and egocentric responses
2. dysfunctional interpersonal relationships
3. provocative and seductive in sexual expression
4. dysphoric mood
5. cognitive alterations
6. impaired health patterns (somatic and dissociative disorders are common to unconsciously call attention to them)
7. excessive emotionality and attention seeking

Narcissistic PD

(characteristics and cluster)

Cluster B

1. grandiosity
2. mirroring
3. exhibitionism
4. labile affective response
5. dysfunctional interpersonal relationships
6. promiscuity in sexual expression
7. feel entitled to special privileges

Avoidant PD

(characteristics and cluster)

Cluster C

1. pattern of social withdrawal along with a sense of inadequacy and fear of rejection
2. hypersensitive to rejection
3. devalue own achievements
4. serious, humorless, and shy
5. do not readily express feelings

Dependent PD

(characteristics and cluster)

Cluster C

1. pervasive, excessive, and unrealistic need to be cared for
2. fear of seaparation
3. lack of self-confidence and initiative
4. inability to make decisions
5. inability to function independently
6. clinging and demanding behaviors

Obsessive Compulsive PD

(characteristics and cluster)

Cluster C

1. excessive dedication to work and perfectionism at the expense of pleasure. this perfectionism is linked to fear and anxiety and an excessive need for order
2. rigid and stubborn rule following with need for order
3. self-critical
4. procrastination and passive-agressive behaviors
5. potential for depression especially later in life
6. no spontaneity
7. poor ability to tolerate mistakes (theirs or others)
8. difficulty expressing feelings openly

1. On-going communication with colleagues
2. Clear, concise, and consistent limit-setting (it is most effective to tell clients the reasons for the rules and they are expected to follow them
3. Teach client relaxation and to ask directly for what is needed
4. if complaining that their assigned staff is ignoring them, tell them to speak directly with staff involved, don't triangulate

1. Maintain safe environment. Safety is a big concern for staff and patients, especially for cluster B.
2. develop behavioral contracts (especially no harm contracts)

1. confront client's illogical perception of others
2. start with 1:1 interaction and move slowly to groups
3. assertiveness training. Teach healthy ways to meet needs. Not demanding things out of a sense of entitlement, but through assertive communications
4. use role-playing and group process

1. maintain a physically and psyhcologically safe milieu
2. initiate no-harm contracts
3. be alert to the potential for suicide

1. maintain a safe milieu
2. teach client to differentiate between anger and aggression and to appreciate other's needs
3. use limit setting and assertiveness training. Tell them the reasons for the rules and tell them they are expected to follow the rules
4. avoid personalizing client's aggression

1. use cognitive behavioral techniques, journaling, exercise, and relaxation skills
2. identify client's strengths
3. provide unconditional positive regard

1. Repression
2. suppression
3. dissociation
4. identification
5. introjection
6. projection
7. denial
8. fantasy
9. rationalization
10. reaction formation
11. displacement
12. intellectualization

blocking out painful or anxiety-inducing events or feelings

example: a manager tells an employee he may have to fire him. On the way home, the employee shops for a new car.

Discharging pent-up feelings on people less dangerous than those who initially aroused the emotion

example: a student who has received a low grade on a term paper blows up at his girlfriend when she asks about his grade

handling emotional conflicts, or internal or external stressors, by a temporary alteration of consciousness or identity

example: a woman has amnesia for the events surrounding a fatal car crash when she was the speeding driver

symbolic satisfaction of wishes through nonrational thought.

example: a student struggling through grad school thinks about a prestigious, high-paying jobs she wants

unconscious assumption of similarity between oneself and another.

example: after a hospitalization for minor surgery, a girl decides to become a nurse.

Separating an emotion from an idea or thought because the emotional reaction is too painful to be acknowledged.

example: a man learns he has cancer. He studies the physiology and treatment of cancer without experiencing any emotion.

acceptance of another's values and opinions as one's own

example: a woman who prefers a simple lifestyle assumes the materialistic, prestige-oriented values of her husband.

attributing one's own unacceptable feelings and thoughts onto others.

example: a man who is quite critical of others thinkgs that people are joking about his appearance

falsification of experience through the construction of logical or socially approved explanations of behavior

example: a man cheats on his income tax return and tells himself that it's alright because everyone does it.

unacceptable feelings disguised by repression of the real feeling and by reinforcement of the opposite feeling.

example: a woman who dislikes her mother in law is always very nice to her.

unconsciously keeping unacceptable feelings out of awareness

example: a man is jealous of a good friend's success but is unaware of his feelings

Consciously keeping unacceptable feelings and thoughts out of awareness.

example: a student taking an exam is upset about an argumetn with her boyfriend but puts it out of her mind so she can finish the test.

• adult and child clinical disorders
• conditions that are not attributable to a mental disorder that are a focus of clinical attention
• additional codes
• clinically significant behaviors or psychological syndrom or pattern that occurs.

• personality disorders
• mental retardation
• NO diagnosis
• maladaptive personality traits

• General medical conditions
• record of physical disorders and med conditions
• lack of information = "deferred"

• psychosocial and environmental problems that may affect the diagnosis and treatment of mental disorders

• Global assessment of functioning (GAF score)

Moodswings

Active, Agressive

"Nothing is Wrong" (Denial)

Irritable, impulsive, intrusive behavior

Can't Sit Still

Euphoric mood

Poor judgment; provocative behavior

Increased Sexual interest

Substance abuse

Omnipotent Feelings

Decreased Need for sleep

Endless Energy

• Monitor lithium levels in blood
• assess for signals of exacerbation of symptoms
• maintains normal sodium and water intake
• not recommended for those with impaired renal fxn, sodium restricted diets, or those with congestive heart failure
• Lithium toxicity= blood value >1.5
• Narrow therapeutic range (0.6-1.2)

MDD:

SIGECAPS

Sleep (increased or decreased)

Interest (diminished interest or pleasure in activities)

Guilt and worthlessness

Energy (decreased)

Concentration (impaired)

Appetite (increased or decreased)

Psychomotor changes (retardation or agitiation)

Suicide

consists of one or more manic mixed episodes, and the course of illness can be accompanied by major depressive episodes

Consists of one or more major depressive episode accompanied by at least one hypomanic episode.

characterized by an abnormal and persistently elevated, expansive, or irritable mood lasting at least one week, significantly impairing social or occupational functioning, and generally requiring hospitalization.

must also be accompanied by at least 3 additional symptoms such as:

• grandiosity
• decreased need for sleep
• pressure of sleep
• flight of ideas
• distractibility
• increased involvement in goal-directed activities
• psychomotor agitation

less extreme form of mania that is not severe enough to markedly impair functioning or require hospitalization. People feel wonderful and "on top of the world" and do not recognize changes in themselves. No psychotic features

• Clients suffering for at least 2 years from "chronic, fluctuating mood disturbances involving numerous periods of hypmanic symptoms and numerous periods of depressive symptoms.
• must be free of severe symptoms that qualify for the diagnosis of manic disorder or MDD.
• individuals are often considered moody, unpredictable or tempermental.

• TCAs
• SSRIs
• SNRIs
• NRIs
• trazodone/desyrel
• mirtazapine/remeron
• MAOI
• nefazodone/serzone

• headaches
• nausea
• anxiety
• insomnia
• dizziness
• tremor
• sweating
• dry mouth
• decreased appetite
• sexual dysfunction (esp in men)

• fluoxetine (prozac)
• paroxetine (paxil)
• sertraline (zoloft)
• cialopram (celexa)
• fluvoxamine (luvox)
• escitalopram (lexapro)

• sleepiness (Helpful for insomnia)
• weight gain
• seizures
• hypotension
• heart conduction defects
• blurred vision
• constipation
• urinary hesitancy
• sexual dysfunction

• high rates of noncompliance
• highly fatal in overdose situations
• interacts with other CNS drugs

• currently the only antidepressant without serotonin activity; it acts as a norepinephrine and dopamine reuptake inhibitor
• no weight gain or sexual dysfunction
• improves energy and concentration
• low fatality in overdose
• watch for seizures with hx of bulimia

• insomnia
• agitation
• seizures
• tremors
• dry mouth
• constipation

Venlafaxine (Effexor)

Desvenlafaxine (Pristiq)

• SNRI
• side effects: overall well tolerated with minimal hypotension or weight gain; may elevate BP

• SNRI
• treats depression, peripheral neuropathy and fibromyalgia
• expensive
• side effects: anticholinergic, plus decreased appetite, fatigue, sweating, and erectile dysfunction

• not a reuptake inhibitor
• acts to increase norepi and serotonin release
• fewer problems with sexual dysfunction
• side effects: sedation, weight gain, constipation

• isocarboxazid (Marplan)
• Phenelzine (Nardil)
• tranylcypromine (parnate)
• emsam patch

1. hallucinations
2. delusions
3. disorganized speech and thoughts
4. disorganized behaviors

• flat affect
• alogia
• avolition
• anhedonia
• apathy

• antipsychotic medications with psychosocial approaches
• clinical and family monitoring for prodromal symptoms
• group therapy
• community treatment
• cognitive-behavioral therapy
• social skills training

• haldol
• prolixin
• loxitane
• thorazine

• clozaril
• risperdal
• geodon

• EPS/movement disorders
• acute dystonic rxns or muscle spasms
• parkinsonian reactions
• akathisias
• tardive dyskinesia
• neuroleptics malignant syndrome

Side effect of Antipsychotics

• of mouth and torso lasting from min to hrs
• occurs with high potentcy antipsychotics (haldol, prolixin, navane, stelazine)

treat with benadryl and cogentin

occurs within five days of starting meds

side effect of Antipsychotics

• mask-like facial expression
• shuffling gait
• drooling
• finger and hand tremors
• cogwheel rigidity

occurs 5-30 days after start

treat with IM cogentin or Artane

Side effect of Antipsychotic

• motor restlessness
• agitation-- irresistible urge to move lower extremities

occur within 5wks of treatment

Antipsychotic Adverse Reaction

• results from long term use of antipsychotics
• 20-30% people affected
• facial twitches
• small tongue tremors
• abnormal jaw mvmnts
• thrusting and rolling of tongue
• lip licking and smacking
• chewing and sucking mvmnts
• difficulty swallowing

Adverse Reaction of Antipsychotics

• severe muscle rigidity/spasms
• altered consciousness
• catatonia
• stupor
• high fever
• increased respirations
• diaphoresis
• urinary retention or incontinence
• tachycardia

Atypical Antipsychotic

lactation in men and women

atypical antipsychotic

can create heart palpitations due to elongation of QT interval so baseline and periodic EKGs are necessary

Atypical antipsychotic

• can precipitate life threatening agranulocytosis (requires regular blood draws to check WBC)
• increased risk for seizures
• side effects: sedation, weight gain, hypersalivation
• Last resort