Session 12: PTSD, and Neurocognitive disorders
- Having a traumatic event of any kind can lead to PTSD symptoms
- Almost 1 out of 10 people one month after 9/11 had symptoms of PTSD
- In PTSD there are recurring symptoms of the stressor that has occurred.
- The stress needs to be processed or else it will run on a continuous loop that will not allow the person to be free from the stressor.
- Ted talk about PTSD
- Thalamus, amygdala and hippocampus – emotional response to the experience
- Overactive amygdala can cause increased sympathetic response and PTSD symptoms.
- Cortisol – the stress hormone, longer exposure times allow the stress to have a higher reaction in this patient ie. a kindling effect the more stress there is.
- Norepinephrine – high levels in PTSD
- Coping skills are aimed at bringing them back to baseline levels of functioning
- Exposure therapy is allowing the person to deal with the trauma in a safe more manageable place.
- EMDR – is therapy using patterned eye movement thought to mimic REM sleep eye movement and this helps some people separate the trauma from the physical response that is elicited from the trauma memory.
- Medications –
- SSRI – fluoxetine, Paroxetine, Sertraline
- Alpha agonist – Prazosin, Clonidine
- Compassion fatigue – decrease ion compassion over time due to repeated secondary trauma
- Common in healthcare workers
- Adjustment disorder – precipitated by a traumatic or stressful event. Less intense than PTSD
- Acute stress disorder – PTSD symptoms that last for one month only
- Dissociative disorders – commonly occur with a history of trauma. Unconscious defence mechanisms, where the patient dissociates with consciousness. (out of body experience)
- Fugue state – amnestic state of personality
- Dissociative Identity Disorder – presence of more than one personality state. Each personality perceives, relates and thinks in a specific unique way.
Neurocognitive disorders In the Elderly
- Common Mental disorders in the elderly
- Confusion – from withdrawal, illness, dementia, delirium
- s/s to be aware of:
- Short attention, irritable
- Benzodiazepines are not recommended to patients with any confusion s/s because it may exacerbate them.
- In anxiety disorders sleep initiation is an issue, with depression it is sleep fragmentation.
- Confabulation – filling in details of a story that are not true to connect to a scenario that they do not remember.
- Creating stories relating to factual events
- 15% of the elderly commit suicide
- Dementia – impairment of intellectual functioning affecting memory and cognition
- Primary caused by alzheimer’s Disease.
- Anticholinergics have a high chance of a person experiencing dementia
- Can also be very flushed, and have poor secretions.
- Alzheimer’s disease – 4th leading cause of death
- Progressive decrease in cognitive functioning
- Risk Increases with age, head trauma, and lower education level
- Medications –
- Namenda (Memantine – blocks excess glutamate
- Exelon (rivastigmine – Cholinesterase inhibitor
- Aricept (donepezil) – Cholinesterase inhibitor, stops breakdown of Acetylcholine. Fewer side effects then exelon.
Session: 11 Personality Disorders
Cluster A: Odd or eccentric – Paranoid, Schizoid, Schizotypal
- Paranoid – distrusting to the people around them
- Schizoid – detachment from relationships
- Schizotypal – Deficits in social and personal skills as well cognitive distortions and eccentricities.
Cluster B: Dramatic or erratic – Antisocial, borderline, Histrionic,
- Borderline personality disorder – can have self injurious behaviors, lack of sense of self, emotionally unstable.
- Narcissistic personality disorder: (Bernie Madoff) wants to be seen as a hero for people.
- Histrionic personality disorder: needs to be in the center of attention, (housewives series on bravo)
- Antisocial – Ted Bundy, criminal lack of remorse or regard, and can be charming.
Cluster C: Anxious or fearful – Avoidant, Dependent, Obsessive compulsive
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive-compulsive personality disorder – different than OCD, rigidity to routine to the extreme.
Somatic and fictitious symptom disorder
Disorders with a base in anxiety that present as real disease processes.
Illness anxiety disorder – always think there is some thing else. Have a lot of tests do to rule out causes but they always think there is something else
Conversion disorder – neurological disorders that results in a deficit of motor or sensory function.
- pseudo seizures , paralysis, blindness, paresthesias, loss of sensation.
Factitious Disorders (formerly munchausen’s disorder)
- Faking symptoms or inflict injury to self for secondary gain.
- They want to be in the role of a sick person
- About 1% of the population
- This disorder “imposed on another” – giving their child a disease to have the child in the role of the sick person.
- Malingering – is to fake an illness for a gain of some sort, personal or otherwise
Session: 10 Eating disorders
Hypothalamus signals hunger and satiation
- Regulation of the person’s appetite
Anorexia nervosa – usually in females ages in 12-30 y.o. And the prevalence is about 1%
- Restrict eating
- Medical complications
- Cardiac arrhythmias, seizures, poor enamel, amenorrhea, constipation,
Bulimia nervosa – more chronic than anorexia. Prevalence ½% in males and three times that in females.
- Cannot control eating or how much you eat.
- Purging, laxatives, enemas, or diuretics
- Purging weekly for at least three months
- Generally normal weight to slightly over weight
- Medical complications: bradycardia, electrolyte imbalances, russell’s sign which is calloused knuckles on the hands, stomach pain, dehydration, and poor dentition.
Binge eating disorder – similar to bulimia but do not purge
- Extreme overeating from feelings of worthless self.
- Genetic component is not proven but is hypothesised
- Serotonin release occurs with eating almost any food. People with anorexia will feel anxious instead when feeling full.
- May start development at a very early age and delay the development of the ego.
- Cognitive-behavioral theory – learned behaviour based on the positive reinforcement for loss of weight.
Obesity – over 30 BMI
- Increases mortality
- Overweight americans are about 65% of the population
- Not classified as an eating disorder
- Contraindicated meds
- Bupropion (wellbutrin) – lowers seizure threshold which increases risk when the patient is already at a high risk.
- Caution psychostimulants
- Meds to use: there are no medications specific for an eating disorder
- Use medications that target anxiety and depression ie. SSRI’s,
- Medication for people with binge eating disorder: reduction of appetite
- Topiramate (topamax)
- Fluoxetine (Prozac)
- Phentermine or topiramate (Osymia) – may have paresthesias, tingling in the periphery.
Session 9: Schizophrenia
About one percent of the population suffers from this disease
Strong genetic link
More common in men
- s/s positive: delusions, hallucinations, disorganized, speech
- s/s negative: not connecting socially, decreased expression
- Less intense than schizophrenia
- 2 or more s/s for more than a month
- This is the diagnosis before full blown schizophrenia
- 2 or more s/s for more than 6 months
- Premorbid phase
- Shy, withdrawn, a- or anti social behaviour
- Prodromal phase
- Acute phase
- Decline in functioning
- Increase in thoughts and behaviour that are overwhelming
- Stabilization phase
- Decrease in symptoms
- Increase socialization
- Needs medication
- Maintenance phase
- Try to get back to previous level of functioning
- Medications may decrease in this phase
- Family support and community is crucial
- Auditory is most common,
- Visual, tactile, olfactory, gustatory (taste)
Positive hallucination are added effects, and negative hallucinations are things that they stop doing like social activities and coping mechanisms
- Reduction of normal cognitive level
- Memory attention, and thinking,
- This could be independent of other cognitive functions.
Alterations in behaviour and catalonia
- Negativism – the person does not react to stimulus even when painful
- excessive motor activity without purpose
Risk factors of schizophrenia
- Stresses in prenatal period – lack of food to starvation, influenza and other infections
- Strong genetic connection
Risk factors for suicide
- Male, not adherent to medications, impulsive, psychosis, and multiple hospitalizations
- First gen: (mostly treats positive s/s) Haloperidol, Chlorpromazine, THiothixene, fluphenazine
- EPS that are severe – dystonia, akathisia
- This can lead to parkinson’s like permanent movements
- Second gen: treat the negative s/s as well.
- Clozapine – great drug, but at risk for agranulocytosis
- Ziprasidone -done – take with meal to increase absorption.
Nicotine – interacts with CYP450 enzyme so that the medication may be need to be reduced if the person smokes les cigarettes per day. clozapine and zyprexa
Session 7 Substance Abuse Disorders
NIAAA is a group that tracks statistics about alcohol use
Chronic alcohol use is a CNS depressant, this can lead to increasing depression symptoms in a patient that is chronically using alcohol
AUD – alcohol use disorder. (mild, Moderate, Sever)
- A cluster of cognitive behavioral, and physiological symptoms indicating that the individual continues use even though there are issues arising in the person’s life related to drinking.
- Criteria groups:
- Impaired control
- Social impairment
- Risky use
- Severity is defined by how many criteria that the person is completing
- If a person starts drinking before 15 there is a 50% higher chance to develope AUD
- DUI – BAC 0.08 g/dl
- DWAI – BAC 0.05 g/dl
- UUD – underage drunk driving
- Implied consent for breathalyzer in colorado and if you refuze there is a 1 year suspension of licence.
Medications to help a person to stop drinking (9% of patients with AUD get one of these meds)
- Disulfiram, Antabuse – discovered on accident and causes person to feel sick with alcohol. It also has a long half life about 2 weeks but a person can drink after 3 days or so. The patient who is required to take this drug may need to take it in front of a healthcare worker 3 times a week for their probation
- Disulfiram reaction – flushing increased HR, SOB, Nausea and VOM. Side Effects – drowsiness headache, hepatotoxic.
- Naltrexone – do not feel the good effects of alcohol
- Acamprosate (campral)
- Vivitrol – month long injection of naltrexone
- Topamax – not yet approved for alcohol. Decreases cravings of alcohol.
- Now commonly used for seizures and migraines
Alcohol withdrawal syndrome
- N/V, tremors, kindling effect (each time the person goes through withdrawal it get worse.), diaphoresis, high BP HR and temp, seizures,
- CIWA score
- Can be deadly!
- Getting a alcohol history is important and is needed to treat the patient.
- TREATMENT –
- CIWA Q4h
- Vitals – B1 often in a “banana bag”
- Pharm: Short acting benzodiazepines (lorazepam Ativan, alprazolam Xanax)
Opiates – from poppy plant. morphine, heroin, oxycodone
- Opioids – synthetic opiates
- Withdrawal can last 72-96 hours and is not usually deadly.
- OD s/s: excessive CNS depression, respiratory depression, pinpoint pupils
- Noxalone (Narcan) – is the opiate overdose med to stop symptoms but the H/L is shorter than the heroine H/L so there may need multiple doses.
- Methadone clinics are used to take a person off of a street drug and hopefully wean them off of opiates in general.
- Cocaine, and crack cocaine.
- No pharmacological interventions for cocaine use
- Extremely addictive,
- High may last for days
- Can have “meth mouth” where teeth fall out
- Adolescence and cannabis, can affect attention, memory, and IQ. This may not improve after succession of use of the drug
- “Spice” – called an alternative to cannabis, but there are intense side effects: agitation, vomiting, heart attacks, strokes, brain damage, psychosis.
- The leading preventable cause of disease, disability, and death in the US.
- Contribute to 443,000 deaths year.
- Higher prevalence in the schizophrenia population.
- Treatments to stop smoking: nicotine replacement, Bupropion, Varenicline tartrate
Nurses and substances
- Alcohol use is similar to the general population
- Prescription drugs is higher in professionals almost 7% of population
- A nurse is required to report suspected use by other healthcare workers.
Session 6 Depressive disorder
- Persistence of symptoms for at least 2 weeks
- Anhedonia, Sleep issues, Changes in appetite, Feeling like there is a Grey cloud over you all the time (hopelessness), suicidal thoughts, concentration issues, change in physical activity.
- It is the leading cause of disability in the United States.
- 6% of adults experience a major depressive episode, and it can be the only time in their life that this happens.
- Children can get depression.
- Biological factors
- There are genetic components
- Biochemical imbalances of serotonin and norepinephrine
- HPT axis changes, this will decrease thyroid function and therefore the production of T hormones decreasing energy and metabolism.
- Cognitive theory – thoughts are greater than emotions
- Cognitive Triad: Negative view of self, pessimistic view of self, and negative occurrences
- Nursing assessment of Depressive disorder
- Affect, thought process, mood, feelings, physical, behaviour, communication, spirituality.
- Nursing diagnosis
- Risk for suicide, hopelessness, ineffective coping, self care deficit,
- Antidepressants – (do not give to a patient that has bipolar because it will make the maina worse).
- SSRI’s are the first drug that is usually prescribed.
- There is a low side effect profile
- May take 4-6 weeks to be effective
- Serotonin syndrome if the med reaches toxic levels.
- Fever, increased HR, seizure, coma, death,
- Tricyclic antidepressants –
- Block histamine, and will make the patient tired
- Anticholinergic effects
- 8 weeks to see effect
- Low Therapeutic index, high chance for MI and other heart issues.
- Neurotransmitter changes
- Interactions with tyrosine (aged cheese, red wine)
- Hypertensive crisis if toxic
- Persistent Depressive Disorder (Dysthymis D/O)
- Chronic depression for at least 2 years
- Non medical interventions
- Transcranial magnetic stimulation (TMS)
- ECT – medical induced seizures to shock the brain to generate different pathways that are different then the depressive ones that already exist.
- Premenstrual Dysphoric disorder
- Depressive symptoms that occur 1 week prior to menses
- Serotonin meds for this, a small increase in the dose for that week before the period can be very helpful.
- Disruptive Mood Dysregulation disorder
- Ages 6-18
- Outbursts, tantrums, fights, poor school performance
- R/O medical conditions before diagnosis
- Non-Pharmacologic treatments for Depressive disorders
- Electroconvulsive therapy
- Transcranial magnetic stimulation (Brainsway Deep TMS treatment for depression) not very invasive.
- Vagus stim
- Light therapy
- St. John’s wort
- Grief – when someone is dealing with loss
- can turn into depression if not dealt with
- Should try to treat without meds.
- Freud psychoanalytic theory
- Subjective, objective, overt and covert statements, assessment tools,
- Scale SAD PERSONS – Sex, age, Depression, previous attempt, ethanol, Rational thought loss, social support, organized plan, No spouse, sickness.
- Command hallucinations are hallucinations that tell the person what to do.
- Rare and can be very overwhelming and disturbing
- Protective factors – support group, though process
- Asking the questions:
- Have you thought about suicide? This is ideation
- Hove they ever thought though how they would do it?
- How would they do it and when did they last think about it?
- Hard and specific questions need to be asked to help the patient, and your own assessment.
Psychiatric pediatric emergency
- Safety is the highest priority
- RNs will manage the techs to a 1:1 ratio with the children
- Try not to use restraints
- The patients are searched for items that can harm themselves, as well as things like cell phones
- The patients change into maroon scrubs for identification.
- M-1 Form a 72 hour hold that requires the hospital to hold the patient for three days and the person cannot leave.
- This also applies to medication that may need to be used to sedate or calm the patient.
- The family may be the source of the issue and you may need to focus and support the parents as well.
- Motivational interviewing is huge in this field.