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2014 T1 Mental Health Exam notes Mental Health nursing, aetiology and pharmacology Mental Health: State of wellbeing which every individual realizes their own potential, can cope with stress of life, work productively and fruitfully and is able to make a contribution to community. a positive concept...

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HNN222 2014 T1

HNN222 Mental Health Exam notes Mental Health nursing, aetiology and pharmacology Mental Health: State of wellbeing which every individual realizes their own potential, can cope with stress of life, work productively and fruitfully and is able to make a contribution to community.  ‘Mental wellbeing’ – a positive concept. Refers to resilience and good functioning, also incorporates flourishing, happiness and getting the most out of life Mental illness: A clinically recognizable set of symptoms related to mood, thought, cognition and behaviour that is associated with distress and interferes with normal functioning.  A diagnosed clinical condition Therapeutic relationship: Purposeful, goal driven relationship between nurse and pt, aiming to support the patient in their recovery.  Elements: Trust, respect, empathy, collaboration, listening, communication. How does therapeutic relationship and communication contribute to person centered care?  Focus on individual needs, respect pt choices/beliefs/goals, tailored to individual

Personality disorder: A diagnosis that occurs when manifestations of personality in an individual start to interfere negatively with the individuals life.  Maladaptive personality  Abnormal behaviour pattern is enduring, long standing  Effects personal and social situations Borderline Personality Disorder:  Terrified of abandonment  Experiences intense + unstable moods – rapid changes  Forms intense and unstable relationships  Disturbance of identity  Impulsive, self destructive behaviors – abuse, sex, spending, eating  Recurrent suicidal behaviour  Chronic feelings of emptiness and paranoia  Anger  Self image Potential nursing management issues:  Unpredictable behaviour- can lead to harm of nurse  Maintaining boundaries  Keeping pt/other staff/self safe  May suicide watch Antisocial personality disorder:  No regard for right and wrong and often disregard the rights, wishes and feelings of others  Tend to antagonize, manipulate or treat others harshly – showing no guilt or remorse  Persistent lying  Using charm or wit to manipulate others for personal gain

HNN222 2014 T1 Aetiology of mental illness:  Biological, psychological, environmental Biological aetiological theories for mental illness:  Genetics = increased predisposition  Biochemistry – neurotransmitter theory  Brain structure abnormalities  Endocrine system dysfunction (thyroid)

Psychotropic medications: Psychotropic: psychiatric medicines that alter chemical levels of the brain = impact mood + behaviour  Antipsychotics, antidepressants, mood stabilizers, ADHD drugs, anti anxiety NEUROTRANSMITTERS: Dopamine: Related to psychosis (schizophrenia) Serotonin: Mood disorders (Depression)

Antidepressants    

SSRI (selective serotonin reuptake inhibitors) Atypical Tricyclic (TCA) MAOIs (Monoamine oxidase inhibitors)

SSRI’s Increase serotonin by inhibiting its reuptake into pre-synaptic cell, increasing levels of serotonin in the synaptic cleft available to bind to postsynaptic receptor.  Block the uptake of serotonin back into brain cells = increase amount of serotonin available in the brain for transmitting signals. This increase in improves symptoms of depression Examples:  Citalopram  Fluoxetine (Prozac)  Sertaline (Zoloft) Side effects:  Nausea  Insomnia  Dizziness  Weight loss/gain  Anxiety + restlessness  Decreased sex drive  Dry mouth  Fatigue Atypical:  Reuptake inhibitors  Include serotonin and norepinephrine reuptake inhibitors (SNRIs, NDRIs, NRIs)  Alter chemical messages (neurotransmitters) used to communicate between cells Examples: Bupropion, Mirtazapine Side effects:  Fatigue

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Weight gain Nausea Headache Insomnia Blurred vision

Tricyclic:  Inhibit the reuptake (absorption) of serotonin or norepinephrine (=more available in brain). Helping brain cells send and receive messages= boosts mood.  More side effects than other antiD’s  Mostly been replaced due to side effects Examples:  Desipramine (Norpramin)  Doxepin Side effects:  Dry mouth  Blurred vision  Constipation  Urinary retention  Drowsiness  Increased appetite = weight gain  Decreased sex drive MAOIs Inhibits the activity of monoamine oxidase (enzyme)=preventing the breakdown of monomine neurotransmitters and increase the availability in synaptic cleft  Reduces the breakdown of neurotransmitters norepinephrine, serotonin and dopamine = improve brain cell communication  First type of antiD invented, mostly been replaced due to MAOIs side effects  Typically requires diet restrictions  Can be used to treat other conditions e.g. Parkinsons Examples:  Phenelzine (nardil)  Selegiline (Emsam) Side effects:  Dizziness or lightheadedness  Insomnia  Weight gain  Headaches  Sexual problems  Nausea  Diarrhea or constipation

Antipsychotics (neuroleptic) Used to treat: Psychosis, schizophrenia, mania Typical: 1st generation  Act on dopamine levels (dopamine antagonists) – block dopamine receptors  Reduce positive symptoms of schizophrenia Atypical: 2nd generation (newer)

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Act on dopamine and serotonin levels – block Reduce positive and negative schizophrenic symptoms Without the EPSE’s (extrapyramidal side effects) – effect the extrapyramidal motor system (same system responsible for the movement disorders of Parkinson’s – can give antiparkinsonian meds to counteract the epse’s

Typical Examples:  Chlorpromazine (Largactil)  Halaperidol Side effects:  Effects on CNS (EPSE’s: o Acute dystonic reaction (painful muscle spasms in head, back and torso) o Seizures o Akathisia: restlessness, leg aches, person cannot stay still o Tardive dyskinesia – uncontrolled movement of persons mouth, tongue  Other: o Dry mouth, blurred vision, urinary retention o Weight gain, diminished libido o Sedation

Atypical  Quetiapine (seroquel)  Rispiridone  Olanzapine  Clozapine (last resort)  Weight gain – main one  Constipation  Dizziness  Insomnia  Headache  Drowsiness  Dry mouth

Clozapine:  Regulations around it  Treatment of schizophrenia in pts as a last resort  Atypical  Blocks dopamine receptors in brain = preventing excess activity of dopamine  Side effects: o Drowsiness o Increased HR, Salivation o Headache, tremor o Fever

Antianxioytics – anti anxiety Anxiety disorders – involve neurotransmitters serotonin, noradrenalin and dopamine  Benzodiazepines and non-benzodiazepines Benzodiazepines: Commonly prescribed for short term relief of severe anxiety. Can assist with sleep  Inhibit neurotransmitter GABA  Depressant drug – slow down activity on CNS and messages travelling between brain and body  Used a lot for prn meds  High withdrawal symptoms Side effect Nursing intervention Drowsiness – lack of energy Encourage appropriate activity but warn against those such as driving Dizziness/lightheadedness Observe and take steps to prevent falls Feeling detached Encourage socialization Dependency Encourage short term use, educate to avoid other drugs e.g. alcohol  Slurred speech

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Depression Memory loss/ forgetfulness Nausea Blurred vision

Examples: (most things ending in PAM)  Diazepam (Valium)  Alprazopam –( Xanax)

Biopsychosocial model: Biological, psychological and social factors contributing to mental health and illness. Biological:  Physical health  Medications  Alcohol/drug use  Sexual health  Genetics  Disability Psychological:  Thoughts  Coping skills  Mental status  Self concept/esteem Social:  Occupation  School/work  Family/friends  Social isolation/connection  Cultural CASE STUDY: Read the following and develop and brief care plan based on the principles of the Biopsychosocial framework Jenni is a 23 year old woman who arrived at ED with a friend after falling over and sustaining a deep laceration to her arm. On arrival she appeared to be intoxicated, distressed and tearful. On examination she admitted to use ketamine and alcohol at a club, but added she does not usually use drugs, but the past month she has been ‘out of control’ since breaking up with her BF. She describes feeling depressed, unable to work, poor appetite and sleep for the past 2 weeks. BIO: Medication, harm minimization, referral drug/alcohol service Psycho: Support, reassurance, mental health assessment, counseling Social: referral to social support, employment assistance, youth mental health services

Recovery:   

Not about absence of illness – about managing symptoms and living with them Individual journey + goals Family/carer involvement

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Legality of mental health: Mental health act:  Only in public system (takes voluntary and involuntary) AIMS:  Provides care, treatment and protection of mentally ill people who do no consent to treatment  Facilitate the provision of treatment + care  Protects the pts rights  Ensure the best possible treatment in the least restrictive environment Section 8 criteria: 1. Appears mentally ill 2. At risk to self or others 3. Requires immediate treatment 4. Unable or refuses consent to treatment 5. Treatment in the least restrictive environment (a hospital) MUST fit all criteria Section 9 criteria ( request and recommendation)  Anyone over 18 can make a request for someone to see a psychiatrist  Must be recommended by a psychiatrist Section 18: pts rights  Dignity, respect, visitors, 2nd opinion Seclusion:  Small white room  Little/ no stimuli (mattress, sheets, pillow)  When an individual is at risk to themselves or others Restraint:  Risk of harming self/ others  Medications (depot)  Risk of damaging property Seclusion + restraint:  Must have good rational to why restraining – nurse can do it  Let psychiatrist know why  Whilst restrained :visual obs every 15 mins, reviewed every 4hrs by medical officer to make sure they are physically able to be restrained CTO – community treatment order:  Order requiring person to obtain treatment for mental illness while not detained in a mental health facility  Must specify the duration of order  May specify where the person must live  A psychiatrist can make a CTO for a person who is subject to an ITO if they are satisfied that: o Criteria for section 8 apply (criteria for involuntary treatment) o The treatment required can be obtained through a CTO Strengths and weakness of ITO:

HNN222 2014 T1 Strengths  Prevent death and harm to pt + others  Pt receives treatment and recovery plans = increased quality of life  Positive impact on families  Family members/carers get support when caring for loved one with MI  Must specify: o Treatment plan o Regularity of treatment o Location o Additional services to be supplied  Can be revoked at any time  CBT, group therapy ect can minimize use of coercive treatment

Weaknesses  Higher rates of relapse after treatment  Can cause pt to feel humiliated, lack of control and devalued  Seclusion and restraints can impact negatively on pts

Mental health assessment: Assessment: systematic collection and interpretation of Biopsychosocial info or data to determine current and past health, functional status and human responses to mental health problems, both actual and potential Purpose:  Diagnose  Treatment Forming a rapport with pt:  Risk assessment  Trust  Interventions  Empathy Setting: Formal assessment:  Privacy  Quiet  Comfortable  Uninterrupted  Saftey Safety considerations:  Violent behaviour  Exacerbating anxiety/agitation levels in pt Genogram: Family history in pictures

Mental state examination (MSE) PAMSGOTJIMI + R  To find the mental state of person  Must be followed by physical examination

P

Components Perception

A

Affect

  

Non-judgemental Compassion Open minded

Key communication skills for conducting a psychiatric interview:  Clear voice  Eye contact  Posture  Non judgmental  Open ended qns  Appear friendly and open to talk to  Respectful Barriers in communication:  Social/culture/religion of pt  Age  Gender  Disabilities  Signs and symptoms

Description Inquire about all sensory info: visual, auditory, olfactory (smell), gustatory (taste), tactile (feel) How they present to you

Examples  Hallucinations  Delusions Type: eythymic (normal)

   M

Mood

S

Speech

G

General appearance

O T

Orientation Thoughts

Objective Whether congruent/appropriate to situation/mood Reactivity

What they are saying about their mood ‘I am feeling depressed’  1-10 scale  Quiet (paranoid, depressed)  Loud/fast (anxious, agitated, manic)  Slurred speech (alcohol/drug use)  Disheveled (washed, clothing state)  Groomed  Posture  Clothes - appropriate for situation/weather To time/place?  What are they telling you?  Delusions? – are they in reality ?

HNN222 2014 T1 Dysphoric (depressed, irritable, angry) Euphoric: elevated Congruent: does it match the mood? Appropriate: to situation Flat, blunt, restricted  Euphoric, euthymic Depressed, grieving, fearful, irritable, angry,  Rate: rapid/slow  Tone  Rate  Apparent age, race, build, hairstyle + colour  Physical abnormalities – scars, tattoos  

J I

Judgment Insight

M

Memory

I R

Intelligence Risk

Rapid thinking Slow or hesitant .g. depression Spontaneous or only when qnd Thought blocking (schizo) Right from wrong, consequence of actions Are they aware of their mental illness and the impacts Immediate?



‘flight of ideas’ – going from one thing to another quickly Thought disordered, poverty of ideas, loose associations Delusions of reference, control, grandeur, thought blocking

 Denial  Intellectual insight Ask pt to repeat 6 figures after examiner says them Different types of memory

Harm to self/others, homicide, financial, ADLS, falls risk

Physical examination:  General obs: HR, RR, BP, temp  Tremor, sweating etc  Urinalysis, height, weight, skin condition  CVS, RS, GI, CNS exams

Risk assessment: Process of weighing up all info attained in the assessment, with focus on known risk factors to determine overall risk of pt (low, m, high, severe), which can be used for care plan.  Suicide, self harm, violence, absconding, significant mental deterioration, loss of social standing, economic loss, falls, accidental injury Suicide risk assessment:  Thoughts  Plans  Intent  Means Risk factors for suicide (get 1 point per risk factor) SADPERSONS

HNN222 2014 T1 S A D P E R S O N S    

Sex (males 1 pt) Age (between 15-65) Depression Previous attempts Ethanol use - alcohol Rational thought loss (irrational) Social support (lack of) Organized plan No spouse Sickness (illness) eg. Diabetes 0-2: send home 3-4: Closely follow up 5-6 strongly consider hospitalization 7+: hospitalize

Psychosis: ‘psyche’ = mind/soul ‘osis’ abnormal condition Diagnostic features:  Impaired (different) reality  Delusions  Hallucinations Delusion: Firm, fixed belief that is not based in reality – not shared by others and doesn’t respond to reason Hallucination: Sensory perception in the absence of external stimuli – hearing voices

Psychotic disorders: Mental illnesses that cause severe disturbances in thinking, perceiving, feeling and behaving.  Schizophrenia  Bipolar disorder (mania)  Psychotic depression  Schizoaffective disorder  Delusional disorder  Substance induced psychotic disorder Psychotic episode: The onset of symptoms or exacerbation of symptoms in which the person’s current mental state loses rational though and/or loss of ability to accurately interpret the environment.  Disturbance of thinking, perceiving and behaving Early intervention Aims:  Reduce delays in treatment by: o Promoting early detection o Collaborate engagement in community  Optimize assessment and diagnosis by: o Biopsychosocial assessment  Maximize recovery by: o Providing Biopsychosocial treatment o Focus on person as a whole

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Prevent relapse by: o Ensure assertive follow up o Psycho education o Support systems

Symptoms of psychosis:  Unable to think clearly  Poor judgment + reasoning  Behave inappropriately  Can’t understand difference between reality and imagination  Delusions and hallucinations Person with psychosis may feel:  Anxious or stressed  Scared  Confused  Angry  Hard to concentrate  Start to avoid certain people, places or situations

Schizophrenia:  Psychotic disorder characterized by disturbances of thinking, delusions and disorganized behaviour  Associated with an over activity of dopamine and may lead to hallucinations and delusions  Many people hear or see things not there, have odd beliefs, speak/behave in a disorganized way Aetiology: Biological theories:  Neuroanatomical abnormalities: o Reason for psychological disturbances is in neurological structure of brain  Genetic predisposition Biochemical theories:  Dopamine hypothesis: o Chemicals responsible for the transmission of nerve impulses across the synapse may be responsible for development of schizop. o Abnormal amount or action of dopamine Diathesis – stress model o Stress leads to schizo. Criteria: Individuals must have 2 of the following symptoms present during a period of 1 month (DSM 4) 1. Delusions 2. Hallucinations 3. Disorganized (incoherent or erratic) speech patterns 4. Behavioral disturbances 5. Negative symptoms (blunting of affect or avolition) Subtypes:  Paranoid: o Paranoid delusions + unfounded suspiciousness o Hallucinations o Ideas of reference – thinking that messages through tv, radio are specifically for them o E.g. neighbor is a spy, spying on them, then think that they have a special purpose e.g. a god  Catatonic:

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o Severe and debilitating disorganization of motor movements Disorganized: o Disorganized, purposeless, non-constructive behaviour o Often described as ‘silly’ and inappropriate in behaviour and appearance Undifferentiated: o Doesn’t fit into one category

Symptom Content of thought:  Delusion 

Ideas of reference

Thought disorder  Thought broadcasting  Loose associations  Incoherence Perceptual disturbances  

Auditory hallucinations Other hallucinations

Affect  Emotional blunting  Anhedonia  Incongruent Psychomotor behaviors  Catatonia

Description Fixed false belief that is inconsistent with ones cultural, social or religious beliefs which cannot be reasoned with logic Belief that insignificant or incidental object or event has special significance or meaning to that individual e.g. person on TV is talking to the person specifically Feeling that ones thought are being read or thoughts are being inserted into ones mind Ideas that fail to follow one another with logical flow and sequence, shifting from one topic to another Verbal rambling in which recognition of any verbal content is impossible

 The hearing of voices coming from outside the persons head  Comment on or command certain behaviors Can involve other sensors Being ‘flat’, voice is monotone Loss of feelings of pleasure previously associated with favored activities A mismatch between the persons thoughts a emotions e.g. person may say they are feeling depressed and low but be laughing and smiling Person may appear unconscious – so preoccupied in thoughts

Positive symptoms:  In addition to normal experiences  Reflect confusion in the brain  Hallucinations +delusions Negative symptoms:  Loss/deterioration of normal functioning  Anhedonia + blunted affect Case study: 18 y/o at ED, reported screaming by her neighbours, appears frightened, suspicio...