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NURS603 Mental Health Nursing Practice 2021

Contents Ways of understanding mental health and illness 3-4 Anxiety disorders 5-9 Generalized anxiety disorder 6 Social anxiety disorder 7 Panic attacks 7 Panic disorder 7 Mood disorders 10-16 Depression 10 Bipolar disorder 14 Personality disorders 17-22 Cluster B: 17 Antisocial personality disorder 18 Borderline personality disorder 18 Narcissistic personality disorder 20 Cluster C: 20 Avoidant personality disorder 20 Dependent personality disorder 21 Obsessive compulsive personality disorder 21 Paranoid personality disorder 22 Psychosis 23-33 Medications 29 Therapeutic alliance, engagement and assessment 34-39 Ethics and law in mental health 40-46 The Mental Health Act 1972 42 Nuffield dementia ethics 45 Recovery, exclusion and stigma 47-50 Forensic mental health 51-52 Co-existing conditions 53-54 Risk assessment of violence to others 55-57

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Ways of understanding mental health and illness Biopsychosocial approach: - Western approach - Interdisciplinary - Biological, psychological and sociological understanding together provides a rounder picture - It's necessary to consider the person from all three perspectives - Know what the person thinks about their experience and what is happening to them. This is about a therapeutic relationship and assessment skill Diagnostic statistic manual V The DSM is historically and culturally located e.g. the reflection of the cultural and social aspects of the time. Psychiatric medications - Antipsychotics - Anxiolytics - Anti-depressants - Hypnotics and sedatives - Mood stabilizers - Anti-dementia drugs The problem with the biomedical approach in mental health covers all aspects of the approach. The aetiology of the disease is unknown. There is not a definite disease pattern and shifting diagnosis as the disease progresses. Medications are given based off unproven hypothesis. The timeline, pattern and prognosis of the recovery is unknown. Psychological interventions Talking therapies: - Cognitive behavioural therapy - Administered by psychologists - Nurses use a brief CBT approach - Basis is challenging thoughts to change behaviour - Aims to interrupt and question responses - Special types for dementia and psychosis e.g. “I can’t talk on zoom”. What’s the belief that sits underneath this, then find a solution to it. Dialectic behavioural therapy Often used to when people have difficulties relating to others and want to contain impulses – effective with people with complex trauma. Skills based: - Mindfulness 3

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Distress tolerance Emotional intelligence Interpersonal skills

Social determinants of health Your health is pre-determined by the environment in which you grew up in and your opportunities in life. Poverty = ill health of all long term conditions including mental health problems. Lifting out of poverty is best response – therefore changes to social conditions such as homelessness, adequate food, access to health, community participation and belonging, education and employment. How can you expect someone to get better if they have poor living conditions.  Dementia is linked to social determinants. Recovery Mental health commission definition – living well in the presence or absence of symptoms. C – connectedness (family, friends, whanau) H – hope (rebuilding – change is inevitable) I – identity (personal journey, own sense of self) M – making sense of the experience and material resources E – empowerment Common elements of recovery services: - Peer support - Non-clinical orientation - Person led - Navigating challenges - Co-produced

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Anxiety disorders What is anxiety? - Cognitive and physiological (ANS) reactions that lead to anxiety driven behaviours (flight/fight/freeze). - Anxiety is protective - In many everyday situations anxiety is appropriate and reasonable. - Anxiety disorder is o Intense o Persistent o Debilitating - People with anxiety tend to o Misinterpret ambiguous information as threatening o Selectively attend to threatening information, disregarding alternative neutral interpretations. Anxiety symptoms: - Shortness of breath - Shaking - Palpitations - Sweating/diaphoresis - Tachycardia - Sense of choking - Nausea/abdominal discomfort - Numbness - Dizziness/unsteady - Hot flushes/chills - Difficulty concentrating - Social withdrawal - Reassurance seeking. Neuroanatomy of anxiety - Different types of anxiety disorders yield different neuroimaging patterns - Thalamus receives sensory information - Amygdala consistently identified as being hyperactive in anxiety - Sympathetic nervous system arousal (from sensory systems e.g. smell) The initial processes of a stress response are contained within the hypothalamus. Incoming sensory information is sent directly to the amygdala for a rapid preparatory response. At the same time, information is processed against stored memories in the hippocampus. This process allows us to ascertain the level of risk and prepare for further physiological and behavioural responses. The sympathetic nervous system is activated, and a cascade of hormonal signalling responses work to 5

stimulate action on the body's systems such as the cardiovascular system to ensure we are ready to respond to potential danger through our fight or flight response. The system responsible for these responses is the hypothalamic–pituitary–adrenal axis, or HPA axis Anxiety disorders: - Generalized anxiety disorder (GAD) - Panic disorder - Specific phobia - Social anxiety disorder (social phobia) - Agoraphobia - Separation anxiety disorder, selective mutism Disorders that feature anxiety: - Some personality disorders e.g. borderline PD, avoidant PD - Obsessive compulsive disorder - Eating disorders - Trauma or stressor related disorders. Origins of anxiety disorders - Genetic and other biological o Shared genetic diathesis (genetic vulnerability) across anxiety disorders and possibly depression o High co-morbidity between anxiety and depression o Temperament – shyness, inhibition - Parent and parent/child interaction - Modelling and other learning influence - Life events – traumatic events can cause a change in world view - Cognitive factors – the way we filter something o Catastrophic misinterpretation of stimuli that provokes anxiety for the person o E.g. overestimation of threat and underestimation of ability to cope. - Environment we grow up in Avoidance is at the heart of maintaining anxiety Avoidance prevents learning of an alternative interpretation or experience may be true. Avoidance of physical sensations in a panic disorder. Social situations in a social disorder. Specific items in specific phobia. Avoidance of problem solving in GAD. Find a structured way to think through the possible outcomes.

Generalized anxiety disorder (GAD) Excessive and difficult to control anxiety and worry: - Restlessness or feeling keyed up on edge - Being easily fatigued (high levels of cortisol and low levels of adrenaline) 6

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Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (trouble falling asleep, staying asleep or restless unsatisfying sleep)

Age related manifestations of GAD: As we get older our physiological systems stop working as well so more prone to GAD. Old people worry more about money and health etc. Exacerbation of medical conditions when high levels of anxiety. Anxiety increases if routine is disturbed. Sleep disturbances common. Avoidance behaviour common in everyday life. Children have more comorbid disorders. Concerned about school, sports or other performance and punctuality. Worry about catastrophic events. Overly conforming, perfectionistic and re-doing tasks. Excessive reassurance seeking.

Social anxiety disorder Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. The individual fears that their anxiety symptoms will be obvious and negatively evaluated (e.g. humiliation) and will lead to rejection or offend others. 75% will develop the disorder between the age of 8 and 15. Onset often after a stressful or humiliating event. Adult onset is rare. Adolescents show a broad pattern of fear and avoidance.

Panic attacks An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of the following symptoms occur: - Palpitations, pounding heart or racing heart. - Sweating - Trembling or shaking - Sensations of shortness of breath or smothering - Feelings of choking - Chest pain or discomfort - Nausea or abdominal distress - Feeling dizzy, lightheaded, faint or unsteady - Chills or heat sensations - Paraesthesia (numbness or tingling) - Derealization (feelings of unreality) or depersonalization (being detached from oneself) - Fear of losing control or going crazy - Fear of dying. A catastrophic misinterpretation of symptoms. Aetiology of panic attacks may be due to medical conditions: hyperventilation syndrome, hypoglycemia, hyperthyroidism, mitral valve prolapse, emphysema and cardiac disease. Short term triggers include personal loss, life changes and stimulant or recreational drugs.

Panic disorder 7

Panic disorder is recurrent, unexpected panic attacks. Followed by at least one month of persistent concern about their recurrence and their consequences OR by a significant change in the persons behaviour following the panic attack. Cognitive model of panic attacks: - Autonomic nervous system response is fear to the trigger - May not be an identifiable trigger, rather the experience of bodily sensations from the ANS response. - The catastrophic misinterpretation of the body sensation is what keeps the panic attacks going. Physiology - Increase in respiratory rate (hyperventilation) o Decrease in CO2 in blood causes increase in heart rate o Perceptual changes o Vasoconstriction - Habitual shallow breathing - Providing an alternative explanation to the catastrophic misinterpretation of the sensations in a panic attack can decrease the intensity and frequency - Distraction from sensations is a way to break the cycle Nursing interventions: - I understand you are scared right now but you are having a panic attack - Slow down your breathing - Focus on something outside of your body e.g. count the ceiling tiles. - You may be overestimating the threat due to past experiences Interventions for anxiety disorders - Increasing coping skills o Look for areas of strength o Evidence of ability to cope in difficult situations o Teach relaxation and anxiety reducing techniques -

Decreasing appraisal of threat o Build evidence that the worst won’t happen o Increase tolerance of physical sensations o Change the meaning of their observations

Cognitive behavioural therapy for anxiety Understand the relationship between thoughts, body sensations, behaviour and the emotion of anxiety. Understand how avoidance maintains anxiety. Aim is to decrease avoidance to increase engagement with the feared stimuli, to learn that it is not harmful. Must experience some anxiety to 8

learn how to tolerate it and become aware that it decreases (anxiolytic medications interfere with this a negate the effect of therapy). People having CBT for panic get no additional benefit taking anxiolytics AND have a worse outcome compared to those who have only had CBT and no medication. After the study, the medication group went back to original level of anxiety while the CBT group remained well. Research has shown that benzodiazepine use in panic disorder is detrimental. Coping and relaxation skills - Abdominal breathing - Progressive muscle relaxation - Visualization - Meditation - Guided imagery - Yoga - Calming music

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Mood disorders Depression Definition of depressive episode: - Depressive mood most of the day, nearly every day, as indicated by either a subjective report or observation perceived by others. - Reduced pleasure in almost all activities (anhedonia). - Significant (5% in a month) weight loss or gain without dieting. - Insomnia or fatigue nearly every day. - Psychomotor agitation or retardation observable by others. - Reduced ability to concentrate or think. Recurrent thoughts of death or suicide – can be just the thought of death. - Feelings of worthlessness or inappropriate guilt that may approach near delusional. - Genetic vulnerability and environmental factors. Monoamine hypothesis Decreased levels of monoamines noradrenaline and serotonin are associated with depression. However, cause and effect not established. Rate of synthesis of serotonin in depressed people may be explained by: - Lowering serotonin synthesis may result in depression - Depression mat result in lowering in serotonin synthesis - A third factor may both lower serotonin synthesis and trigger depression Noradrenaline/norepinephrine - Noradrenaline pathways innervate the limbic system (emotion regulation) - Differences in noradrenaline systems observed in depressed vs. healthy controls - Enhanced noradrenaline functioning is a protective factor against stress induced depression in mice - Depletion of noradrenaline results in return of depressive symptoms following treatment with noradrenaline based drugs - Therapeutic agents which increase noradrenaline activity are effective as antidepressants. Antidepressant medications are designed to increase monoamine transmission by inhibiting neuronal reuptake (SSRI’s) or inhibiting monoamine degradation (MOAI’s). But, although SSRIs show immediate effect of increasing available monoamines, the clinical effect takes weeks. Acute increases in the amount of synaptic monoamines induced by antidepressants produce secondary neuroplastic changes that are on a longer timescale. Brain Derived Neurotrophic Factor (BDNF) Supports the survival of existing neurons and encourages growth and differentiation of new neurons and synapses. Is upregulated by antidepressants and downregulated by stress. BDNF dysfunction may adversely affect monoamine systems through the loss of either neurons or synapses. Monoamines modulate the production of cortisol and as excessive cortisol is causing damage to he HPA axis. Lack of BDNF within the hippocampus is thought to be one reason for cellular death in 10

the hippocampus during stress. This may be occurring in the background when starting to take SSRI’s. Stress HPA axis may be overactive: - Hypersecretion of cortisol in depression is well established - 50% of depressed people have elevated cortisol levels - Chronic stress linked to damage to HPA axis and hippocampus. Episodic stress – cumulative, discrete episodes. Any undesirable event that has personal meaning and significance. Losses greater risk for precipitating depression, particularly interpersonal loss. Chronic stress – marital discord, financial hardship, disability. Neuroendocrine regulation Hypothalamus regulates the neuroendocrine axes and receives multiple neuronal inputs that use neurotransmitters. Neuroendocrine axes that are implicated in mood disorders are: - Adrenal axis o Hypersecretion of cortisol in depression is well established o 50% of depressed people have elevated cortisol levels - Thyroid axis o 5-10% of depressed people have a thyroid disorder o Presently studies are correlational - Growth hormone axis o Depressed patients show a blunted sleep induced stimulation of growth hormone release o Exact cause and effect future avenue for research Other Biological Abnormalities Sleep: - Initial and terminal insomnia, multiple wakening, hypersomnia classic symptoms of - depression - Decreased need for sleep is a sign of mania - Depressed peoples’ sleep EEG’s show abnormalities o Delayed sleep onset o Shortened period between sleep onset and REM stage o Longer first REM period o Abnormal delta sleep - Sleep deprivation can lead to transient clinical improvement in mood – circadian rhythm dysregulation Post-mortem and neuroimaging studies have reported reductions in grey- matter volume and glial density in the prefrontal cortex and the hippocampus (cognitive aspects of depression).

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Psychological Factors Cognitive theory: - Event itself does not cause depression-rather the persons interpretation of the meaning of the event and their ability to cope determines whether or not they develop depression. - View of self = ____, world = unfair, _____ = hopeless. - Beliefs are formed in childhood from early experiences, and become activated by a triggering event e.g. failing an exam or a relationship breakup. - A person’s thoughts and beliefs influence their emotions and behaviour; therefore by modifying and challenging thoughts, and changing behaviour, a person’s emotional experiences can improve. Interpersonal theory: - Lack of meaningful social relationships - Loss of social support - Bereavement - Changes in interpersonal roles (e.g. transitioning from being in a relationship to single, leaving home) Behaviours: - Withdrawal from activities previously meaningful or enjoyable - Withdrawal then further increases feelings of worthlessness, allows for rumination, and becomes self-perpetuating - Self-destructive behaviours o Alcohol and drugs – feel good at the time but, negative effects long term o Self-harm - Try and find a way to make them do their enjoyable activities again.

Treatments for Depression - Psychotherapy

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o Cognitive Behavioural Therapy (CBT) identifies ___ (cognitions) and behaviours that contribute to depression, and helps the client to change their thoughts and behaviour to resolve their depression Pharmacotherapy o Antidepressant medications e.g SSRI’s & SNRI’s ECT

Efficacy of Treatments for Depression Meta-analysis of research with patients who have moderate depression found the following: - Psychotherapy (no type identified) and medication show ______ outcomes at termination of treatment BUT, treatment gains for psychotherapy are _______ once treatment has been stopped. For patients with dysthymia, medication was more effective than therapy. - Cognitive Behavioural Therapy (CBT) is _____to medication, and superior to wait list control, placebo, and no treatment. - Antidepressants are barely- if at all, better than placebos for patients with mild depression. - NICE guidelines recommend psychotherapy for patients with mild-moderate depression, and that medication should only be prescribed to people who have moderate or severe depression.

Lifespan considerations: older adults - Age related brain changes - Psychosocial adversity - Withdrawal from activities - Dementia often follows depression with cognitive impairments

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Depressed older adults 4 times more likely to die within 4 months of a MI than those without. Suicide 2x more frequent than the general population If suicidal thoughts present in older adults they are more likely to complete suicide than younger adults

Bipolar disorder Definition of depressive episode: As above for depression Definition of manic episode: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal directed activity or energy lasting at least one week and present most of the day nearly every day or any duration if hospitalization is necessary. Three or more of the below symptoms: - Inflated self-esteem or grandiosity. - Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). - More talkative than usual or pressure to keep talking. - Flight of ideas or subjective experience that thoughts are racing. - Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. - Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal- directed activity). - Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). - Marked impairment in social or occupational functioning. Definition of hypo...