Mental Health N4615 Module II Flashcards
(134 cards)
1
Q
What is Schizophenia Spectrum?
A
It, and other psychotic disorders are those that distrub the fundamental ability to deteremine what is real or what is not.
2
Q
All people who have Schizophrenia, have at least one of the following psychotic symptoms
A
hallucinatioins
delusions
and / or disorganized speech
3
Q
What is the epidemiology of Schizophrenia
(when does it normally occur)
A
usually presents in late teens / early twenties.
4
Q
What are the prodromal signs of schizophrenia
A
they are the initial signs indicating that a pt. might be leading toward a schizophrenic break
Withdrawal
misinterpreting
poor concentration
preoccupation with religion
5
Q
What is early on-set Schizophrenia
A
(18 to 25) occurs more often in males
associated w/poor functioning before onset & more structural brain damage
6
Q
What is later on-set Schizophrenia
A
(25 to 35) more likely to be female
less structural brain damage
better outcomes
7
Q
What are some of the comorbidities associated w/ Schizophrenia
A
1) Substance abuse disorders - nearly 50% (sucide)
2) Nicotine dependence 70% - 90%
3) Anxiety, depression
4) Physical Health Illnesses
5) Polydipsia - can lead to fatal water intoxication (20% have insatiable thirst) may be due to medications
8
Q
What is the etiology of Schizophrenia
A
scientific consesus is that Schizophrenia occurs due to multiple inherited genetic abnormalities combined with nongenetic factors.
called the diathesis-stress model of Schizophrenia
9
Q
What are some of the genetic factors for Schizophrenia
A
Increased levels of dopamine (1st generations treat)
Increased levels of serotonin (2nd generation meds treat)
glutamate - which is a major neurotransmitter during neuronmaturation
Brain Structure Abnormalities - reduced volume of “grey matter” (temporal / frontal lobes) — more hallucinations.
10
Q
What are some of the psychological / environmental
factors associated w/ Schizophrenia
A
1) prenatal stressors (poor nutrition & hypoxia)
2) psychological stressors (stress w/ incr cortisol level which imped hypothalamic development)
3) environmental stressors (toxins, ie. solvent tetrochoroethylene in dry cleaning)
all increase chances w/ those vulnerable to Schizophrenia
11
Q
Schizophrenia def.
A
The most severe form of Schizphenia Spectrum
It is a potentially devastating brain disorder that affects a person’s thinking, language, emotions, social behavior, and ability to perceive reality accurately.
12
Q
What are the Phases of Schizophrenia
A
Phase I - Acute
Phase II - Stabilization
Phase III - Maintenance
13
Q
Def. Phase I - Schizophrenia
A
Acute
onset or exacerbation of distruptive symptoms (ie. hallucinations, delusions, apathy w/draw)
w/ loss of functional abilities - increased care or hospitalization may be required.
14
Q
Def. Phase II - Schizophrenia
A
Stabilization
symptoms are diminishing, and there is movement towards one’s previous level of functioning (baseline)
15
Q
Def. Phase III - Schizophrenia
A
Maintenence
pt. is at or near baseline functioning
symptoms are absent or significantly decreased.
16
Q
What are the 4 main symptom groups of Schizophrenia
A
Positive symptoms
Negative symptoms
Affective Symptoms
Congnitive Symptoms
17
Q
What are postive symptoms of Schizophrenia
associated w/acute onset
A
The presence of something that is not normally present
hallucinations
delusions
disorganized speech
bizarre behavior
will generally respond to medication
18
Q
What are negative symptoms of Schizophrenia
A
absence of something that should be present
- Poverty of thought (interest in hygiene)
- Avolition (loss of motivation / energy or drive)
- Blunted affect (minimal emotional response)
- Alogia (poverty of speech)
- Anhedonia (loss of joy in something previously enjoyed)
- Anergia (lack of energy)
more presistent / crippling b/c they reduce motivation & limit social & vocational success
19
Q
What are cogntitive symptoms of Schizophrenia
A
often subtle changes in memory, behavior, attention or thinking
ie. impaired executive functioning (ability to set priorities or make decisions)
20
Q
What are affective symptoms of Schizophrenia
A
symptoms involving emotions and their expression
dysphoria (dissatisfaction w/ life)
suicidality
hopelessness
21
Q
Positive symptoms are broken down into
what four categories
A
alterations in
1) thought
2) speech
3) perception &
4) behavior
22
Q
What is “concrete thinking”
A
refers to the impaired ability to think abstractly
ie. When you ask a pt. what brought them to the hospital — they would say “ a cab”
Concreteness reduces one’s ability to understand and address abstract concepts such as love or the passage of time.
23
Q
What is “clang association”
A
choosing words based on their sound rather then their meaning
ie. rhyming “on the track… have a Big Mac”
24
Q
What is “word salad” (schizohasia)
A
jumbled words that are meaningless to the listener and possible to the speaker
ie. “red chair out town board”
25
What are **Neologisms**?
_made-up words_ that have meaning to the pt. but a different or nonexistent meaning to others
26
What are **Echolalia**
pathological _repeating_ of anothers words
ie. **Nurse**...Mary, come get your medication
**Mary**...come get your medication
27
What is **Depersonalizaiton**
feeling that one is somehow _different or unreal_ or has lost his / her identity
may feel body parts don't belong to them.
28
What is **Derealization**
a _false perception_ that the _environment has changed_ - surroundings seem strange and unfamilar
29
What is **associative looseness**
refers to _jumbled thoughts_ inchoherently expressed to the listener.
30
**Illusion** is def as
A false belief about a perception
Based on a **real perception** (sight, sound, taste or feeling) that is **misinterpreted**
ex. the person actually sees something but believes they see something else
31
**Hallucinations** are def as
Perceptions involving the **senses** (sight, sound, odor, taste or feeling on the skin)
The body's ability to detect things in the environment that are not detected by others.
32
Hallucinations vs. Illusions
both are **perceptions**
**Hallucinations** involve perceiving a _sensory experience_ for which *no external stimulus* exist
**Illusions** are misperceptions or misinterpretations of a real experience (*external stimulus*); a false belief about a perception
ie. pts see the coat rack, but believes it is a bear
33
What are the types of **hallucinations**
experienced by 60% of pts. with Schizophrenia
**Auditory:** hearing voices or sounds
**Visual:** seeing persons or things
**Olfactory:** smelling odors
**Gustatory:** experiencing taste
**Tactile:** feeling bodily sensations
ex. I see; I hear; I taste; I smell; I feel
34
What are the worst types of hallucinations
**Command hallucinations**
those that _direct pts to take action_. voices may command the pt. to hurt themselves or others.
35
What is the MOST EFFECTIVE intervention for hallucinaitons?
Medications
RN-patient relationship
Reduce environmental stimuli
Increase internal stimuli (exercise) - tell the hallucinations to go away...listen to my voice or music
36
What is "**Catatonia**"
pronounced decrease in the rate and amount of movement
Generally pts. may move little if at all
37
What is **Echopraxia**
mimicking the movements of another
38
What is **Anosognosia**
inability to realize they are ill (caused by the illness itself)
The resulting **lack of insight** can make assessment / treatment challenging.
39
What does the "**recovery model**" stress
stresses hope, living a full and productive life, and eventually *recovery* **rather than** focusing on *controlling* symptoms and *adapting* to the disability
40
What is the overall **goal** for the **acute phase**
patient safety and stabilization
41
What **goals** does **phase II** (stabilization) focus on
helping the pt _understand_ the illness and treatment, become _stabilized_ on medications, and be able to _control or cope_ with symptoms.
42
What **goals** does **phase III** (maintenance) focus on
_adhering_ to medication, _preventing_ relapse, and achieving _independence_ and a satisfactory quality of life.
43
What is "**waxy flexiblity**"
the ability to hold distorted postures for extended periods of time.
44
What are some of the signs of a potential **relapse in schizophrenia**
feeling tense
difficultly concentrating
**trouble sleeping**
increased w/drawal
**increased bizarre or magical thinking**
Relapse can occur even w/ medication compliance
45
**Delusions** are def. as
false fixed **beliefs** that cannot be corrected by reasoning. Pt will agree w/ RN about facts but disagree w/ interpretation.
75% of those w/ schizophrenia experience these
**persecutory**
**gradiose** or
those involving **religious** or **hypochondriacal** ideas
ex. I think; I believe; I interpret; My opinion
46
Delusion vs. Illusion
A **delusion** (false belief) does not change w/ the use of logic.
An **illusion** (false belief about a perception) can often change once a person is given evidence that the belief is not true.
47
Delusions may be **bizarre** or **non-bizarre**
**Bizarre** type are _unreal_ and _impossible_ beliefs
i. e. Pt believes body organs replaced in absence of scars
i. e. Pt believes they are another animal (not human)
48
**Non-bizarre** types of **delusions**
- Delusions of control
- Ideas of reference
- Persecution
- Grandeur
- Somatic
- Erotomanic
- Jealousy
49
Def. of **control delusions**
Believing that another person, group of people, or external force controls thoughts, feelings, impulses, or behavior
i.e. Pt covers his apartment walls w/ aluminum foil to block government efforts to control his thoughts
50
Def. of **ideas of reference**
Giving personal significance to unrealated or trivial events; perceiving events as relating to you when they are not
i.e. Pt believes that birds sing when she walks down the street just for her.
51
Def. of **persecution delusions**
Believing that one is being singled out for harm by others; this belief often takes the form of a plot by people in power.
i.e. Pt believes the Secret Service was planning to kill him by poisoning his food; therefore, he would eat only prepackaged food.
52
Def. of **grandeur delusions**
Believing that one is a very powerful or important person
i.e. Pt believed he was a famous playwright and tennis pro
53
Def. of **somatic delusions**
Believing that the body is changing in unusual ways (i.e. rotting inside)
i.e. Pt said his heart had stopped and was rotting away.
54
Def. of **erotomanic delusions**
Believing that another person desires you romantically.
i.e. Although he barely knew her, Patti insisted that Eric would marry her if only his current wife would stop interfering.
55
Def. of **jealousy delusions**
Believing that one's mate is unfaithful
i.e. Pt wrongly accused her spouse of going out w other women. Her proof was that he twice came home from work late (even though his boss explained that everyone had worked late).
56
What is **paranoia**?
An unrealistic fear of harm
57
What is the HIGHEST PRIORITY intervention for delusional thinking?
* Reinforce **reality** for the pt.
* Establish a relationship or milieu that promotes **trust**
* Give **meds on time** (do not be late w/ prescribed meds)
58
Characteristics of **psychotic thinking**
* Limited ability to focus when lots of things are happening
* Concrete thought
* black/white thinking
* right/wrong judgments
* relationship w/ objects
* ambiguous boundaries btwn reality & fantasy
* ambiguous boundaries btwn self & others
59
**Psychosis** key points
* psychosis is frightening to the pt - **provide safety**
* use **kindness & respect**
* pts experiencing psychosis NEED an **anchor to reality**
60
Hierarchy of needs for **psychosis intervention**
Priorities will change depending on the situation and context (use critical thinking)
- Physical integrity
- Establishing trust
- Preventing inappropriate behavior
- Treating symptoms: hallucinations/delusions
- Enhancing compliance w/ treatment
- Reinforcing reality
61
What neurotransmitter is targeted by traditional **antipsychotics**?
**Dopamine**
Traditional _antipsychotics block_ excessive dopamine, an excitatory neurotransmitter, so that symptoms r/t psychosis are reduced.
62
Typical (1st generation) Antipsychotic info
Reduce **positive symptoms** of psychosis
Blocks **Dopamine**
Uses: quick hallucination remission (delusions take longer to respond); out-of-control aggression; acute manic episodes
Safe, highly effective, very affordable
Poor compliance d/t bothersome SEs (i.e. **EPS**)
63
Common Typical (1st generation) Antipsychotics
Chlorprom**_azine_** (Thorazine)
Fluphen**_azine_** (Prolixin)
Prochlorper**_azine_** (Compazine)
Haloperidol (Haldol)
64
What are common side effects of Haldol (Haloperidol)?
* Sedation
* Muscle stiffness
* **Akathisia**
* alters effectiveness of exogenous insulin
Antipsychotics often produce sedation & EPS effects (i.e. stiffness, gait disturbance). The pt might describe the medication as making them feel like a "robot".
65
2nd generation Atypical antipsychotics
* targets both **positive & negative symptoms** of schizophrenia
* block *dopamine* & *serotonin*
* high incidence of **significant weight gain**, **diabetes**, & **hyperlipidemia** w/ use
* low incidence of tardive dyskinesia
* produces drowsiness (sedates w/o causing confusion; can use for severe anxiety instead of benzodiazapines)
* may cause constipation
Ex. Latuda (Lurasidone); Zyperxa (Olanzapine)
66
3rd generation Atypical antipsychotics
* effective against both **positive & negative** symptoms of schizophrenia
* block *dopamine* & *serotonin*
* causes little / _no_ weight gain
* causes _no_ increase in glucose, cholesterol, or triglycerides
**Good choice for pts w/ obesity &/or heart disease**
Ex. Abilify (Aripiprazole)
67
Common Atypical (2nd & 3rd generation) Antipsychotics
Aripiprazole (Abilify)
**Cloz**_apine_** (Clozaril)** - risk of ***Agranulocytosis***
Lurasi**_done_** (Latuda)
Olanz**_apine_** (Zyprexa) - ***significant wt gain***
Quenti**_apine_** (Seroquel)
**Risperi**_done_** (Risperdal)**
Ziprasi_done_ (Geodon) - ***prolonged QT interval***
68
Side effects of antipsychotics
Fewer overall SEs w/ Atypical antipsychotics
**iSHADE**
**i**mpotence
**S**edation, seizures (reduce seizure threshold)
**H**ypotension, orthostatic
**A**kathisia (inability to sit still)
**D**ermatological effects (risk of severe sun burn)
**E**xtrapyramidal rxns (acute dystonias, rigidity, tremor, tachycardia)
69
Extrapyridamidal Side Effects (**EPS**)
***movement disorders*** resulting from effects of antipsychotics on extrapyramidal motor system (primarily **Typcial** antipsychotics)
_4 types of EPS reactions_:
* acute dystonia
* pseudo-parkinsonism
* akathisia\*
* tardive dyskinesia
\*most common EPS
70
## Footnote
**Acute Dystonia**
EPS rxn characterized by severe spasm of muscles of tongue, face, neck, or back
**Torticollis** (head turned & arched) & **oculogyric crisis** (upward deviation of eyes) occurs
rxn develops w/in **1st few wks** of drug therapy; possibily w/in **hrs of 1st dose**
Requires rapid intervention if intense rxn
**Anticholinergics** used for initial trmt
71
## Footnote
**Psuedo-Parkinsonism**
**Mild EPS rxn** characterized by bradykinesia, mask-like facies, drooling, tremor, rigidity, shuffling gait, cog wheeling, & stooped posture
Rxn develops **w/in 1st month** of drug therapy
Treat w/ central acting **anticholinergics** (i.e. benztropine (Cogentin), diphenhydramine)
Must AVOID use of Levadopa (promotes activation of dopamine; will induce psychosis)
72
## Footnote
**Akathisia**
**Serious & troublesome** EPS rxn characterized by pacing & squirming (uncontrollable need to be in motion); profound sense of restlessness
Rxn develops **w/in 1st 2 months** of drug therapy
Most common reason for non-compliance w/ meds
Trmt is **beta blockers & benzodiazapines** (does not respond to anticholinergics)
Only "cure" is to stop taking antipsychotic
73
## Footnote
**Tardive Dyskinesia**
**Serious & troublesome** EPS rxn characterized by abnormal muscle movements (i.e. slow, worm-like movements of the tongue, tongue flicking, lip smacking, pursing lips, grimacing)
Movements become constant; exhausting for the pt
Occurs late in antipsychotic drug therapy; 1 in 5 pts
**Only trmt is to stop taking antipsychotic**; maybe irreversible
**Prevention** is best approach; antipsychotics s/b used in lowest effective dose & for shortest time required; AIMS test every 3 mo. if long term use
74
## Footnote
**Acute Dystonic Reaction**
**Acute & dangerous** EPS rxn
Acute dystonia that becomes **life-threatening d/t involvement of the throat muscules**
**Inability to swallow** & **respiratory distress**
**Emergent** use of **anticholinergics** necessary
75
What medication is used to provide immediate relief to a pt. experiencing a **dystonic reaction**?
Dystonic reactions are emergencies & require intervention (can be caused by antipsychotics)
**Diphendhydramine** (Benadryl) IM or IV
or
**Benztropine** (Cogentin) IM or IV
IV response is 5 mins; IM response is 15 - 20 mins
Other anticholingerics may be used
76
Neuroleptic Malignant Syndrome (**NMS**)
**Acute & dangerous** EPS rxn; life-threatening **medical emergency**; transfer to ICU
NMS symptoms: **FEVER**
* **F**ever, sudden & high (1050+)
* **E**ncephalopathy
* **V**ital signs unstable (dysrhythmias, BP fluctations)
* **E**levated enzymes (CK)
* **R**igidity of muscles
Death can result from respiratory failure, cardiovascular collapse, or dysrhythmias
Tmt is immediate w/drawal of antipsychotic, supportive measures & drug therapy
77
The Bipolar Spectrum
Bipolar disorder mood cycling:
Mania
Hypomania
Normal mood
Mild depression
Major depression
78
Manic episode
mnemonic
MANIC EPISODE
**M**ood swings
**A**ctive, agressive behavior
**N**othing is wrong (denial)
**I**mpulsive, intrusive behavior
**C**an't sit still, can't stop talk
**E**uphoric mood
**P**oor judgement, provocative behavior
**I**ncreased sexual interest
**S**ubstance (stimulant) abuse
**O**mnipotent feelings
**D**ecreased need for sleep
**E**ndless energy
79
Rapid stabilization of the manic pt
Antipsychotics & benzodiazapines
Typical "cocktail" given in psych ER:
Haldol 5 - 10 mg w/ Avtivan 2 mg
80
Bipolar disorder medications
**Lithium** (used for mood stabilization)
**Anticonvulsants** (used for mood stabilizaiton)
* Depakote (valproate)
* Tegretol (carbamazepine)
* Lamictal (lamotrigine)
**Antipsychotics** (used for acute manic phase)
* Seroquel (quetiapine)
* Zyprexa (olanzapine)
* Geodon (ziprasidone)
* Ambilify (aripiprazole)
* Risperdal (resperidone)
* Haldol (haloperidol)
81
Antidepressants and Mania
Use very cautiously w/ bipolar pts
*All* antidepressants **induce mania** in bipolar pts
If pt is bipolar, antidepressants should always be used **in conjuction w/ a mood stabilizer**.
82
What are the 3 types of
bipolar disorder
Bipolar I
Bipolar II
Cyclothymic disorder
83
**Bipolar I** disorder is def. as
mood disorder that is characterized by **at least one-week long manic episode** that results in excessive activity and energy
84
The presence of **three** of the following behaviors **constitues** mania:
**E**xtreme drive & energy
**I**nflated sence of self-importance
**D**rastically reduced sleep requirements
**E**xcessive talking combined w/ pressured speech
**P**ersonal feeling of racing thoughts
**D**istraction by environmental events
**U**nusually obsessed with and overfocused on goals
**P**urposeless arousal and movement
**D**angerous activities (ie. indiscriminate spending, reckless sexual encounters, or risky investments)
85
**Bipolar II** disorder is def. as
**low-level mania** alternated with **profound depression**
this is called **hypomania**...unlike mania, psychosis is generally never present.
86
**Cyclothymic** disorder is def. as
symptoms of **hypomania alternate with** symptoms of **mild to moderate depression** for at least **two years** in *adults* & **one year** in *children*.
87
What are the **3 phases** associated with **bipolar disorders**
**Acute** Phase
**Continuation** Phase
**Maintenence** Phase
88
What is the primary outcome in the **acute phase** of bipolar disorders
The primary goal is
**injury prevention**
outcomes in the acute phase reflect both physiological and psychiatric issues
89
the primary outcome in the **continuation phase** of bipolar disorders is:
can last for 4 - 9 months
overall outcome is **_relapse prevention_**, but consist of
**Psycheducational classes** for the pt. & family to:
**a)** understand the disease process
**b)** medication knowledge
**c)** knowledge of the early warning signs of replapse
90
the primary outcome in the **maintenence phase** of bipolar disorder is:
continuing to focus of **relapse prevention** & **limiting** the severity and duration of **future episodes**.
91
**Personality disorders** characteristic's
defined
Pts with personailty disorders are **inflexible** & deomonstrate **maladaptive** responses to stress
- they are unable to develop true intimacy with others
- unable to develop trusting relationships.
**"Impaired soical interaction"**
92
What are the 10 Personality disorders according to the American Psychiatric Association (APA)
1) Avoidant 2) Antisocial
3) Borderline 4) Dependent
5) Histrionic 6) Narsicistic
7) Paranoid 8) Obsessive-complusive
9) Shizioid 10) Schizotypical
93
What are the **Cluster "A"** personality disorders?
Cluster "A" = odd or eccentric
* Paranoid
* Schizoid
* Schizotypal
94
What are the **Cluster "B"** personality disorders?
Cluster "B" = dramatic, emotional, erratic
* Antisocial
* Borderline
* Histrionic
* Narcissistic
95
What are the **Cluster "C"** personality disorders?
Cluster "C" = anxious, fearful
* Avoidant
* Dependent
* Obsessive-Compulsive
96
**Paranoid** personality disorder
characterized by a longstanding _distrust & suspiciousness_ of others based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive them.
* difficult to treat b/c they distrust everyone
* have a need for _space & reassurance_
* are _hypervigilant_
**Projection** is the dominant defense mechanism; they blame others for their shortcomings.
97
**Schizoid** personality disorder
exhibits a _poor ability to function_ in their lives...Relationships are particularly affected due to their prominent feature of **emotional detachment**.
**need for soical isolation**
Individuals _do not seek out or enjoy close relationships_. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization.
98
**Schizotypal** personality disorder
more common in men then women.
**It is the 1st of the schizophrenia spectrum.**
severe *social* and *interpersonal* deficits.
These individuals experience extreme anxiety in social settings & conversations tend to _ramble_ w/ lengthy, unclear & overly detailed content.
**eccentricity, odd or unusual beliefs** (magical thinking)
prefer periods of _solitude_
99
**Histrionic** personality disorder
characterized by emotinal **attention-seeking** behaviors & **melodramatic**, including self-centeredness, low frustration tolerance, & **excessive emotionality**
demonstrates poor verbal boundaries
- In general, those with this disorder do not believe they need psychiatric help.
- **flirtatious** - overly intense attachment w/ the opposite sex; _provocative_.
- **Psychotherapy** is the txmt of choice.
100
**Narcissistic** personality disorder
comes across as **arrogant** & w/ an inflated view of thier own self-importance **(grandiose self-importance)**.
_needs constant admiration_
_lack of empathy_ for others
pathological traits include: antagonism, represented by _grandiosity_ and _attention-seeking behaviors_.
txmt includes **cognitive-behavioral therapy**, family & group therapy.
101
**Avoidant** personality disorder
main traits are _low self-esteem_ associated w/ feelings of _inferiority_ compared to peers.
**timid, socially uncomfortable**
they tend to avoid engaging in new or unfamilar activities involving new people d/t _fear of criticism or rejection_
102
**Dependent** personality disorder
people with this disorder have a high _need to be taken care of_, which can lead to patterns of submissiveness with fears of separation & abandonment by others.
_urgently seek relationships_
have a _constant need for reassurance_
_lack self-confidence_
**Psychotherapy** is the txmt of choice
103
**Obsessive-Complusive** personality disorder
the _most prevalent disorder_ in the general community - associated w/ the highest burden of medical cost.
main traits include: **rigidity & inflexible standards** of self & others --- along with persistence of goals long after they are necessary.
They will typically rehearse over & over for situations where they will deal with others.
_perfectionists_ (interferes w/ task completion)
**SSRI's & prozac** may help.
104
**Anti-social** personatily disorder
most studied & researched personality disorder
- **concerned with personal pleasure & power**; does not conform to social norms
**-** characterized by **decietfulness, impulsiveness, aggressiveness, disregard for others, lack of remorse, & manipulation.**
usually presents w/ _depression_ or because of the consequences of their behaviors, not because they care about the effects of their actions on others
Txmt w/_one caregiver_ is preferred to avoid having the manipulative nature play one staff against another.
105
**Borderline** personality disorder
has the central characteristic of _instability_ in affect, identity, & relationships
desperately seek relationships to avoid feeling _abandoned_, but often drive others away with **excessive demands, impulsive behavior, or uncontrolled anger**.
chronic feelings of **emptiness**
assess for suicidal & self-mutilating behaviors, especially during times of stress...**Risk for self-directed violence.**
teach pt to _identify triggers_ & _positive coping_
The frequent use of the defense of **splitting** strains personal relationships & creates turmoil in health care settings.
106
What is **Splitting**
involves loving a person, then hating the person b/c the pt. is unable to recognize that an individual can have both positive and negative qualities.
**black & white thinking**
**defense mechanism** often used with BPD
107
Which medication is the drug of choice for **safe alcohol w/drawals**
## Footnote
**Benxodiazepines**
108
Which medicaton is used in the treatment of both **alcohol and opiod addiction**
**Naltrexone (ReVia) -** it is an opiod antagonist that blocks the action of opiods & reduces alcohol cravings.
109
Types of **Antidepressants**
* **SSRIs**
* **SNRIs**
* **TCAs**
* **MAIOs**
110
**SSRI** info
**First-line** approach for trmt of depression
Increases **Serotonin** levels in brain
Uses: Major Depressive Disorder, anxiety disorders, panic disorders & OCD
Mood responds gradually (over 2 wks)
Do NOT STOP taking ABRUPTLY
111
Common **SSRIs**
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
112
SSRI side effects mnemonic
**BAD SSRI**
**B**ody wieght increase **S**eritonin Syndrome
**A**nxiety **S**timulation of the CNS
**D**izziness **R**eproductive dysfuntion
**I**nsomnia
113
## Footnote
**Serotonin Syndrome**
Toxicity resulting from SSRI use w/ other meds that increases serotonin
Manifestions: **HARM**
**H**yperthermia
**A**utonomic instability (delirium)
**R**igidity
**M**yoclonus
- Be alert for sweating & diarrhea
- Late sign is apnea & death
114
Serotonin Syndrome interventions
Stop SSRI
Administer serotonin-receptor blocker
Cooling blankets or meds to reduce fever
Benzodiazepines for seizures & muscle rigidity
Anticonvulsants for seizures
Ventillation support for apnea
115
SNRI info
Increases **Serotonin** & **Norepinephrine** levels in brain
Treats both **chronic neuropathic pain** _&_ **depression**
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Common **SNRIs**
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
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SNRI side effects mnemonic
**BAD SNRI**
**B**ody wieght increase **S**uicidal thoughts
**A**nxiety **N**ausea / vomiting
**D**izziness **R**eproductive dysfuntion
**I**nsomnia
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TCA info
Boosts **Norepinephrine**
Uses: _adjunctive therapy_ to treat chronic neuropathic _pain_ & _anxiety_ disorders; used only when other antidepressants fail or need to be boosted
**SEs** much more **bothersome** than SSRI class; results in nonadherence
Effects are **slow to work**
Do **NOT stop** taking **abruptly**
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Common **TCAs**
Amitriptyline (Elavil)
Clomipramine (Anafranil) - ***risk for glacoma***
Imipramine (Tofranil)
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Tricyclic antidepressant (TCA)
side effects mnemonic
**TCAS**
**T**hrombocytopenia (low platelets)
**C**ardiac (arrythmia, MI, stroke)
**A**nticholinergic effects (tachycardia, urinary retention dry mouth, etc)
**S**eizures
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TCA overdose
TCA toxicity / overdose can be **fatal**
Signs associated w/ toxicity:
* altered LOC / delirium
* arrhythmias: VTach, VFib, prolonged QRS, QT & PR intervals
* vomiting
* fever
* coma
* hypoventilation from CNS depression
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MAOI info
Rarely used d/t danger they present when combined w/ certain pharmaceuticals & foods
Uses: _Atypical depressio_n (oversleeping & overeating); _adjunctive med_ for anxiety disorders & bulemia
**Monitor BP**
**AVOID tyramine**, alcohol, & yeast
Do NOT take w/ oral decongestant
Dietary & med restrictions to stay in place 2 wks after MAIO stopped
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Common **MAOIs**
Phenelizine (Nardil)
Isocaroxzid (Marplan)
Tranylcyproine (Parnate)
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MAOI side effects mnemonic
**HAHA**
**H**ypotension, orthostatic
**A**nticholinergic effects
**H**ypertensive crisis (avoid tyramine foods)
**A**nxiety, agitation, anorexia
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MAOI toxicity
Toxicity can occur when MAOIs are combined w/ certain foods & medications resulting in **Hypertensive Crisis** & **death**
MAOIs prevent the break down of tyramine & certain meds; results in significant vasoconstriction
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Tyramine containing foods
Aged & fermented foods:
* *All* hard cheese (use caution w/ Italian & Mexican foods)
* pickled or smoked meats
* olives, pickles, sauerkraut
* soy sauce (avoid Asian foods)
* ripe alvocados
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Bupropion (Wellbutrin)
"Other" antidepressant
Boosts **Norepinephrine** & **Dopamine**
**Only antipressant w/out unpleasant sexual SEs**
Lowers seizure threshold
Not very effective w/ anxiety or pain
Effective in treating **nicotine** addiction & **ADHD**
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Anxiolytic info
2 types: Benzodiazipines & Non-benzodiazipines
_Benzodiazepines_:
* target **GABA**
* uses: sedative effect for anxiety; anticonvulsant effect for seizures (Klonopin); prevention of seizures induced by alcohol w/drawal (Librium)
* lead to **physical & psychological dependence**
* **short term** use only (1-2 wks)
* do NOT discontinue abruptly
* when combined **w/ alcohol** can result in **overdose & death** by respiratory suppression
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Common Anxiolytics
_Benzodiazapines_:
* Aloprazolam (Xanax)
* Lorazepam (Ativan)
* Chlordiazepoxide (Librium) - use for severe DTs
* Diazepam (Valium)
* Clonazepam (Klonopin) - effective anticonvulsant
_Non-benzodiazapines_:
* Buspirone (BuSpar)
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Buspirone (BuSpar)
Does _not_ result in tolerace or addicition
Targets **Serotonin** & **Dopamine**
Does _not_ have rapid onset of action
Takes **up to 2 wks** to be effective
Must be taken **daily**; not for PRN use
**AVOID** drinking **grapefruit juice**
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Antimania meds (mood stabilizers)
**_Lithium_**
**_Anticonvulsants_**: treat/prevent mood episodes in Bipolar by slowing neuron firing & mood cycling
* Valproate / Valproic acid (Depakote)
* Carbamazepine (Tegretol)
* Lamotrigine (Lamictal) - risk of **SJS** (severe rash)
* Clonazepam (Klonopin) - anxiolytic/benzodiazepine effective for seizures
**Depakote** & **Tegretol** require blood levels to be monitored for therapeutic effect; periodic monitoring of liver enzymes & CBC
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Lithium info
* Lithium is a salt; regulated by body like sodium
* Be very alert for SUDDEN DROPS in sodium
* Lowering of dietary sodium intake, use of diuretics, excessive sweating or vomiting can have drastic effect on lithium; if Sodium goes DOWN, Lithium goes UP
* Narrow therapeutic index (0.6 - 1.2)
* 3 wks to reach therapeutic level; not for quick control of mania
* Teach strict adherence to dosing regimen
* Fluid intake 1-2qt/day & maintain normal salt intake
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Acute Lithium Toxicity symptoms
mnemonic
**CAN HAM SUCS**
**C**onfusion
**A**n increase of urine & thirst
**N**ausea
**H**and tremors (coarse)
**A**taxia (uncoordinated arm & leg movements)
**M**uscle twitches
**S**eizures
**U**ncontrollable eye movements
**C**oma
**S**lurred speech
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Medications for treatment of Alcohol Abuse
**Naltrexone hydrochloride (ReVia, Vivitrol)**
**Disulfiram (Antabuse)**
* causes unpleasant effects when alcohol is consumed; negative reinforcer
* AVOID foods/products containing alcohol (cough syrup, mouthwash, cooking wine)
* extremely poor compliance; does not reduce alcohol cravings
**Acamprosate (Campral)**
* eliminated thru kidneys; pts w/ kidney disease at risk for adverse rxns
* eases discomfort of w/drawal & prevents cravings
* stimulates GABA
