• One or more major depressive episodes, characterized be either a depressed mood or loss of interest/pleasure in nearly all activities for at least 2 weeks.

• 4 of 7 additional symptoms must be present...disruption in:
  
  • sleep
  • appetite
  • weight
  • concentration
  • energy
  • psychomotor agitation or retardation
  • excessive guilt or feelings of worthlessness
  • suicidal ideation

Somatic symptom disorder (SSD)

• Person intentionally causes illness for the purpose of becoming a patient
• Covertly injure themselves as to "trick" physicians of the illness
• main idea: they act sick for physicians attention

• excitatory & primary cholinergic neurotransmitter
• higher intellectual functioning (learning), memory, attention
• found throughout the cerebral cortex and limbic system

• regulates sleep-rest patterns, body temperature, hunger, and sex drive
• hypothalamus malfunction is notable in schizophrenia (ie. wearing jackets when it's hot outside)
• pituitary + hypothalamus: temp regulation, BP, hunger, thirst, GI motility and secretion 

• refusing to acknowledge some painful aspect of external reality or subjective experience that would be apparent to others 
• example: teenager's best friend moves away, but says he does not feel sad
• substance abusers may deny that they have a problem

• a person who dissociates is making him or herself "disappear"... a sense of leaving one's body and observing what is happening to them from the outside.
• protects them from the impact of trauma

• derealization - feelings of depersonalization, as if the environment is strange or unreal.
• disengagement - "spacing out"
• alterations in body perception
• emotional numbing
• out-of-body experiences
• amnesia about abuse-related experiences

• a psychologic theory of the etiology of OCD
• an act performed with the goal of preventing the consequences of a thought or impulse
• example from the internet: you impulsively cut people off while walking to a door and end up holding the door open for them

• unconsciously forgetting or blocking unwanted thoughts, feelings, or impulses
• individuals might use repression to become unconscious of past trauma
• example: woman does not remember being rapes in the basement but does feel anxious when entering the house

• concealing the true motivations for one's own thoughts, actions, or feelings through using self-serving and incorrect explanations
• example: a man is rejected by hid girlfriend but explains to his friends that her leaving the house was for the best because she was below him socially
• a negative consequence of this is being out of touch with the reality of situations

• substituting behaviors, thoughts, or feelings that are opposed to one's own unacceptable thoughts or feelings
• usually occurs with repression
• example: wife finds out her husbands is having an affair and she tells her friends that she thinks affairs are totally acceptable to protect herself from feelings of hurt

• excessive use of abstract thinking or making generalizations to control or minimize disturbing feelings
• example: after a relationship, the rejected person explains the relationship dynamics to a friend.
• good because it looks at situations from a distant and objective standpoint, not so good because it interferes with the processing of one's feelings

• falsely attributing to another one's own unacceptable feelings, impulses, or thoughts
• example: a child is very angry at his parents but accuses his parents of being angry

• patient is the primary focus
• professional attitudes set the tone
• cautious self-disclosure
• avoid social relationships with patients
• maintain patient confidentiality
• assess patients intellectual competence to determine level of understanding
• implement interventions from a theoretic base
• nonjudgemental attitude
• don't give advice
• guide patient to reinterpret their experience
• track patient's verbal interaction by using clarifying statements
• avoid changing the subject unless it's in the patient's best interest

• the providers emotional reaction to the patient based on personal unconscious needs and conflicts
• one of Freud's psychodynamic models
• main idea: provider is directing personal feelings onto patient
• example: a patient reminds the nurse of her grandmother, this takes away from the nurse treating her objectively, nurse may miss important assessment details
• important for the nurse to recognize countertransference as to avoid eroding professional boundaries
• working phase

• when the nurse tries to bring the conversation back to the question at hand
• example: can we continue to talk about your dad?

• nurse tests a patients abstract reasoning by giving the patient a proverb to interpret
• examples:
  • people in glass houses shouldn't throw stones
  • a rolling stone gathers no moss
  • a penny saved is a penny earned

• selective serotonin uptake inhibitors (name tells the MOA)
• fewer side effects than most other antidepressants
• common side effects:
  • nausea
  • insomnia 
  • sexual dysfunction
• examples:
  • citalopram (celexa)
  • sertraline (zoloft) 
• used for:
  • depression, anxiety, panic, aggression, anorexia, OCD

• serotonin norepinephrine reuptake inhibitors
• side effects:
  • hypertension (w/ high doses)
  • photosensitivity
  • decreased appetite
  • others are similar to SSRIs (sexual dysfunction, insomnia)
• used for:
  • depression & anxiety
• example:
  • venlafaxine (effexor)

• monamine oxidase inhibitors
• MOA:
  
  • inhibit the enzyme that breaks down serotonin and norepinephrine
• examples:
  • phenelzine (nardil)
  • tranylcypromine (parnate)
  • isocarboxazid (marplan)
  • selegiline (emsam)
• side effects:
  • hypertensive crisis (when mixed with tyramine-rich foods)
    • sudden pounding headache
    • racing pulse
    • flushing
    • stiff neck
    • chest pain
    • n/v
    • profuse sweating

• GHB 
• club drug - colorless, tasteless, odorless
• originally used to treat insomnia
• produces euphoric, sedative effects
• anterograde amnesia
• "date rape" drug
• not legal in the USA

• TCAs have a very narrow therapeutic range
• 3-5 times the recommended dose = lethal
• >1 gram = toxic
• do not prescribe to suicidal patients because they can easily overdose

• safety is priority
• 3 priorities:
  • connecting the patient to people who instill hope
  • restring emotional stability
  • ensuring safety (visualizing emotional safe spaces for the patient to go)

• when a person has a generalized feelings of frustration, being disgusted with life, feels demoralized, and hopeless lasting over 6 months
• may state that they cannot recall a time when they did not feel anxious
• insidious onset
  
  • may complain of being a chronic worrier
  • may worry about their job, finances, health of family members, or simple matter like chores
• may have somatic complaints, sleep disturbances, exaggerated startle response
• nursing interventions:
  • teach relaxation techniques
  • med teaching (if on anti anxiety medication)
  • sleep hygiene
  • time management

• persistent fear of social performance situations in which embarrassment may occur
• may be r/t low dopamine receptor binding
• tend to evaluate themselves poorly and magnify their weaknesses
• SSRIs are used to treat SAD
• common fears:
  • public speaking
  • eating in front of people
  • being stared at
  • writing in front of others

• an extreme form of anxiety often experience when an individual is places in a real or perceived life-threatening situation
• characterized by recurrent panic attacks and fear of returning panic attacks
• nursing interventions:
  • if the patient is in a mild to moderate phase, try to have them assume responsibility and teach coping mechanisms
• medication
  
  • benzodiazepines 
  • SSRI
  • beta blocker (for autonomic symptoms)
• panic attacks
  • can last 10-30 min
  • 1st one is usually associated with an identifiable cause

• amygdala
• hippocampus
• thalamus
• midbrain
• pons
• medulla
• cerebellum

• fuels fight-or-flight response
• effects: CV, respiratory, GI

• central autonomic and emotional control system
• regulates anxiety-related physiologic and behavioral responses

• inhibitory (most abundant inhibitory NT in brain)
• reduces anxiety
• causes sedation
• raises seizure threshold

• fear of being in open spaces or using public transportation
• leads to avoidance behaviors
• person may become afraid to leave their home and only leave when necessary (like taking kids to school)
• treatment
  • implosive therapy - therapist present anxiety-provoking material and vividly describes an anxiety-inducing scenario to the patient

• intrusive symptoms
  • avoidance of people and places that remind of the traumatic event
  • nightmares & flashbacks

• negative mood & cognitions
  • difficulty experiencing positive moods like love and happiness
• hyperarousal
  • aggressive, reckless, or self-destructive behavior
• sleep disturbance or hypervigilance

• SSRIs
  • fluoxetine (prozac)
  • fluvoxamine
  • paroxetine (Paxil)
  • sertraline (zoloft)
  • s/e:
    • sedation, somnolence, insomnia, h/a, sexual dysfunction
• clomipramine (a TCA)
  • suicidality is a main s/e
  • increased risk for seizures

• and TCA used to treat OCD
• s/e:
  • suicide ideation, seizures orthostatic hypotension, syncope, CV stuff, arrive dyskinesia, anticholinergic

• when severe emotional distress or unconscious conflict is expressed through physical symptoms
• commonly associated symptoms:
  • impaired coordination
  • aphonia (inability to produce sound)
  • sensation og lump in throat
  • note: lab findings will reveal no underlying pathology
• nursing care:
  • treat the symptoms are real because they are very real to the patient

• disregard and violation of the rights of others since the age of 15
• diagnosis is given to 18 y/o who believe that society's rules do not apply to them
• sometimes called psychopath or sociopathy
• tendency toward criminal behavior
• associated with substance abuse, however, the two are different

• magical beliefs, similar to delusions
• perceptual aberrations (interpreting insignificant events as personally relevent)
• odd in appearance & behavior
• unkempt appearance, avoidant, avoids eye contact 

• different from OCD in that OCD persons tend to ruminate in obsessive thoughts or compulsive behaviors when stressed (goes away when not stressed)
• OCPD persons do not demonstrate obsessions and compulsions, but will be preoccupied with orderliness, perfectionism, and control
• OCPD = perfectionists
• they will be obsessed with rules and work and be uncomfortable with leisure time

• introverted, reclusive, distant, aloof, emotionally detached
• life-long loners
• difficulty forming relationships
• may become close with animals rather than people
• nursing interventions:
  • social skill training
  • balance social engagement
  • may be difficult to form a therapeutic relationship

• treatment is often not sought until an ultimatum is made (marriage, job, children, etc)
• goal is to develop a sense of nurture and empathy in them
• the have a tendency to mistrust treatment staff and may embellish parts of their psych history
• can be verbally and physically abusive - protecting other patients and staff is important
• won't assume responsibility for their actions and will blame
• nurse must protect her/himself from manipulation since they are charming
• want to provide a structured environment

• intentionally producing symptoms of illness with hopes of attaining a specific goal (like missing work, getting disability, etc)

• a disorder characterized by abnormal or unusual behavior of the nervous system during sleep
• characterized by specific sleep stages or sleep-wake cycles
• non-rapid eye movement (NREM) disorders - sleep arousal, sleepwalking, sleep terrors; usually occurs in the 1st third of the sleep cycle
• rapid eye movement (REM) disorder - nightmare disorder, 

• mood stabilizer for depressive disorder
• drug class: anti epileptic
• requires a dose titrate
• rash (think Stevens-Johnson), hypersensitivity, and blood dycrasias are the most serious side effects

• life-threatening side effect from antipsychotic meds (risperidone, clozapine)
• can develop 3-9 days after antipsychotic treatment
• early signs:
  
  • low-grade fever, achy, elevated BP, diaphoresis
• late signs:
  • rigidity, autonomic changes, hyperthermia
• treatment:
  • dopamine agonists (bromocriptine), muscled relaxants (dantroline)
  • always monitor temp

• happens when SSRIs are combined with certain medication (MAOIs, TCAs)
• cause is excess intrasynaptic serotonin
• mental status changes, myoclonus, ataxia, hyperreflexia
• treat by discontinuing the drug & providing supportive care (IV fluids, antipyretics, cooling blankets)

• EPS characterized by the inability to sit still
• s/e of antipsychotic
• sometimes misdiagnosed for agitation (important to differentiate the 2)
• could be a reason is non-med compliant
• can use beta-blockers to treat

• anti-alcoholic treatment
• blocks the oxidation of alcohol, accumulating concentrations 5-10x higher than normal
• used to enforce sobriety
• if taken with alcohol:
  • flushing, throbbing headache, vertigo, respiratory difficulty, lots of vomiting.
• severe reactions:
  • arrhythmia, CV collapse, CHF, unconsciousness 
• reaction occurs in the presence of any alcohol
• not a cure, but an adjunct therapy for recovering alcoholics seeking new coping skills

• used for opioid detoxification
• minimizes the side effects of withdrawal by giving the person a tapering dose of methadone, a strong opioid, that helps wean them off
• does not produce the subjective high
• usually a 21 day course

• 1st gen antipsychotic
• thick oil-based med - keep that in mind for IM injection
• can be used to treat schizophrenia and Tourette's
• side effects:
  • seizures, tremors, jerky movements, twitching muscles, confusion, hyperproleacteremia

• atypical antipsychotic
• can cause metabolic syndrome & neuroleptic malignant syndrome
• treatment uses:
  • schizophrenia
  • short-term acute mania
  • irritability a/w autism
• side effects:
  • EPS
  • weight gain
  • agitation & anxiety
  • GI upset
  • insomnia
  • dementia-related psychosis

• originally used for heroine abuse, but now used for alcohol dependence
• block opioid receptors
• daily dose pill & monthly injection
• effect:
  • reduces cravings
  • maintain abstinence
  • interferes w? the tendency to want to drink more

• 2nd generation antipsychotic
• treatment uses:
  • schizophrenia (decreases hallucinations and increases concentration)
  • bipolar
  • depression
• allergic reaction:
  • itching, hives, swelling, mouth tingling, chest tightness, trouble breathing
• adverse effects:
  • lightheadedness, dizziness, fainting, clumsiness, seizures, vision changes

• smoke cessation
• reduces the rewarding effect and craving of nicotine
• prevents nicotine from accessing the ACh receptor associated with dependence
• can cause depression
• benefits outweigh side effects for most

• nonbenzodiazepine
• controls anxiety symptoms (no effect on panic disorders or OCD)
• does not depress the CNS or cause withdrawal
• used to treat GAD
• blocks serotonin receptors at both pre and post synaptic site
• highly protein bound (replaces digoxin - can cause toxicity)
• caution with liver and kidney disease
• side effects:
  • dizziness
  • drowsiness
  • excitement
  • HA
  • not adequately studies in older adults and pregnant women

• reduce environmental stimuli
• assess/guide patient through questions to find out why they had a panic attack
• stay with the patient
• reassure the patient that it will pass and they are safe
• clear, concise communication
• encourage the patient to talk
• debrief with the client about their feelings about the experience

• genetic factors (brain function/structure abnormalities)
• early neuro problems
• stressful life events
• environmental factors (having an older father, toxoplasmosis, prenatal famine, lifetime cannabis use, OB complications, urban rearing, winter/spring birth)

• importance of emotional connection
• instilling hope
• discouraging suicide ideation, rumination, and self-harming behaviors
• salf-validation
• emotional distress management
• finding alternative to suicidal behavior
• crisis management plan
• reestablishing social network
• info about underlying psych disorders and treatment

• imbalance between ACh and dopamine
• ACh is more dominant
• GABA & serotonin also play a role

• dementia
  • slow onset
  • not a symptom
  • characterized by cognitive impairments
  • can be: cortical (AD), subcortical (localized effects), or vascular (more sudden, result of TIA)
  • anticholinergic drugs increased cognitive impairments
• delirium
  • acute cognitive impairment w/ an underlying cause (infection, substance, etc)
  • quick onset
  • problems wit orientation
  • many of the same symptoms as dementia, but the main thing is cause and onset is different 

• lack on interest in completing ADLs
• negative symptom of schizophrenia

• atypical antipsychotics
• risperidone, apriprazole

• difficulty expressing emotion
• associated with somatic symptom disorder
• preoccupation with external events