Evidence-Based Practice in Psychiatric Nursing and Mental Health Care, Exams of Molecular biology

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WEEK 1: CHAP 1, 2, 3

Depression

• one of the leading disease burdens in the middle and high income countries such as the US, By 2030, it is projected to be the leading burden worldwide
• In the US, 1 in 4 adults or 43.4 million people have at least one diagnosable mental disorder in any given year Cultural competence
• Set of academic and interpersonal skills that are respectful of and responsive to the health beliefs, health care practices, and cultural and linguistic needs of diverse patients to bring about positive health care outcomes
• Linguistic competence -capacity to communicate effectively and convey information that is easily understood by diverse audiences and address the health literacy needs of the patients and their families an important part of cultural competence
• Understands and appreciates cultural differences in health care practices and similarities within, among, and between groups
• Valuing patients’ cultural beliefs and recognizing the need to bridge language barriers are essential behaviors Hildegard E. Peplau
• Conceptualized nursing practice as independent of physicians
• Published the landmark work Interpersonal Relations in Nursing o Introduced psychiatric-mental health nursing practice as independent of physicians
• Also contributed to educational programs for psychiatric nursing, developing a specialty training program in psychiatric nursing -- the first graduate nursing program -- in 1994 at Rutgers University Recovery Model
• A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential
• Recovery-oriented treatment is based on the belief that mental illness and emotional disturbances are treatable and that recovery is an expectation o Person with a mental health problem develops a partnership with a clinician to manage the illness, strengthen coping abilities, and build resilience for life’s changes
• 4 dimensions that support recovery o Health -managing disease and living in a physically and emotionally healthy way o Home -safe and stable place to live o Purpose -meaningful daily activities and independence, resources, and income o Community -relationships and social networks
• Not an orderly, predictable path in w/c the individual progresses step by step. Rather, each individual's makeup and experiences will direct that person’s progression; setbacks are to be expected Families living in poverty are under tremendous financial and emotional stress, which may trigger or exacerbate mental problems.
• They become trapped in a downward economic spiral as tension and stress mount Chapter 1 Evidence-Based Practice -standard of care in psychiatric nursing and mental health care
• Problem solving approach to clinical decision making that involves conscientious use of the best available evidence (including a systematic search for and critical appraisal of the most relevant evidence to answer a clinical question) with one’s own clinical expertise and pt values and preferences to improve outcomes for individuals, groups, communities, and systems Asylum - “safe haven” that was considered the best option for treatment when neurobiologic science are not advanced enough to offer reasonable tx approaches Moral treatment -use of kindness, compassion, and a pleasant environment during the moral treatment period (1790-1900) Institutionalization -forced confinement of individuals for long periods of time in large facilities, became the primary rx for more than 50 years
• Outcomes were consistently negative (pts were isolated from their families, untrained attendants who had little understanding of mental illnesses were responsible for care, w/c was often cruel and inhumane, women were often institutionalized at the convenience of their fathers or husbands) Freud’s contribution
• Freudian model: normal development occurred in stages, with the first three o oral (infant experiencing the world through symbolic oral ingestion ) o anal(toddlers develop a sense of autonomy through withholding) o genital (a beginning sense of sexuality emerges within the framework of oedipal relationship)

• Mental illnesses were categorized either as o psychosis (severe) -impaired daily functioning because of breaks in contact w/ reality o neurosis (less severe) -often distressed about their problems
• Intensive psychoanalysis -therapy focused on repairing the trauma of the original psychological injury; Freudian tx of choice Psychopharmacology -revolutionized the tx of people with mental illness
• Barbiturates (amobarbital sodium), chlorpromazine, phenothiazines
• The meds calmed the pts and reduced some of the symptoms Deinstitutionalization -release of those confined to mental institutions for long periods of time into the community for tx, support, and rehabilitation, become a national movement
• Considered a failure 2 main findings for the mental illness tx by Mental Health: A report of the Surgeon General (1999)
• The efficacy of mental health treatments is well documented
• A range of treatments exists for most mental disorders Healthy people 2020 overarching goals:
• Attain high quality, longer lives free of preventable disease, disability, injury, and premature death
• Achieve health equity, eliminate disparities, and improve the health of all groups
• Create social and physical environments that promote good health for all
• Promote healthy development and healthy behaviors across every stage of life Chapter 2 Mental health -a state of well-being in w/c the individual realizes his or her own abilities, can cope with life’s normal stresses, can work productively and fruitfully, and can make a contribution to society (World Health Organization) Wellness -purposeful process of individual growth, integration of experience, and meaningful connection with others, reflecting personally valued goals and strengths and resulting in being well and living values Mental disorders -clinically significant disturbances in cognition, emotion regulation, or behaviors that reflect a dysfunction in the psychological, biological, or developmental processes underlying mental dysfunction; usually associated with distress or imparied functioning
• A syndrome -set of symptoms that cluster together that may have multiple causes and may represent several different disease states that have not yet been identified Epidemiology -study of patterns of disease distribution and determinants of health within populations, contributes to the overall understanding of the mental health status of population groups, or aggregates, and associated factors DSM-5 Diagnostic and Statistical Manual of Mental Disorders 5 -contains subtypes and other specifiers that further classify disorders
• There are no absolute boundaries separating one disorder from another, and disorders often have different manifestations at different points in time Cultural syndromes -represent a specific pattern of symptoms that occur within a specific cultural group or community (ataque de nervios and susto) Stigma -mark of shame, disgrace, disapproval, that results in an individual being shunned or rejected by others
• Types: public stigma (“marked” as mentally ill) , self-stigma, and label avoidance Chapter 3 Acculturation -socialization process by which minority groups learn and adopt selective aspects of the dominant culture Cultural identity -set of cultural beliefs with which one looks for standards of behavior Culture -not only a way of life, but also the totality of learned, socially transmitted beliefs, and behaviors that emerge from its members’ interpersonal transactions -The DSM-5 differentiates cultural idiom of distress, a commonly used term or phrase that describes the suffering within a cultural group from cultural explanations, perceived causes for symptoms Spirituality -develops overtime, and is dynamic, conscious process characterized by two movements of transcendence (going beyond the limits of ordinary experiences): either deep within the self od beyond the self Religiousness -participation in a community of people who gather around common ways of worshipping WEEK 2: CHAP 6, 7, 8 Ch 6) Ethics
• Standards for ethical behaviors for professional nurses are set by national professional organizations such as the ANA.
• There are several ethical principles to consider when providing psychiatric nursing care, including autonomy, beneficence, justice, nonmaleficence, paternalism, veracity, and fidelity. o Autonomy , each person has the fundamental right of self-determination

o Beneficence , the health care provider uses knowledge of science and incorporates the art of caring to develop an environment in which individuals achieve their maximal health care potential. ▪ Can conflict when patient wants to stop taking meds (autonomy), and nurse urges patient to continue (beneficence) o Justice is the duty to treat all fairly, distributing the risks and benefits equally. ▪ Justice becomes an issue in mental health when a segment of a population does not have access to health care. Basic goods should be distributed, so that the least advantaged members of society are benefited. o Nonmaleficence is the duty to cause no harm, both individual and for all. o Paternalism is the belief that knowledge and education authorize professionals to make decisions for the good of the patient. ▪ Mandatory use of seat belts and motorcycle helmets. ▪ This principle can be in direct conflict with the mental health recovery belief of self-determinism o Veracity is the duty to tell the truth. ▪ Patients may ask questions when the truth is unknown. For example, if I take my medication, will the voices go away? o Fidelity is faithfulness to obligations and duties. It is keeping promises. ▪ Fidelity is important in establishing trusting relationships. Mental Health Laws: Civil Rights & Due Process (ppt)

• Civil rights: people with mental illness are guaranteed the same rights under federal/state laws as any other citizen o Due process in civil commitment: courts have recognized involuntary commitment to a mental hospital is “massive curtailment of liberty” requiring due process protection, including: ▪ Writ of habeas corpus: procedural mechanism used to challenge unlawful detention ▪ Least restrictive alternative doctrine: mandates least drastic means be taken to achieve specific purpose Mental Health Laws: Admission to the Hospital
• Voluntary: sought by patient or guardian o Patients have right to demand and obtain release o Many states require patient submit written release notice to staff
• Involuntary admission (commitment): made without patient’s consent o Necessary when person is danger to self or others, and/or unable to meet basic needs as result of psychiatric condition
• Emergency involuntary hospitalization o Commitment for specified period (1-10 days) to prevent dangerous behavior to self/others
• Observational or temporary involuntary hospitalization o Longer duration than emergency commitment o Purpose: observation, diagnosis, and treatment for mental illness for patients posing danger to self/others Patient’s Rights
• Right to treatment: requires that medical and psychiatric care and treatment be provided to everyone admitted to public hospital
• Right to refuse treatment: w/hold or w/draw consent for tx at any time o Issue of right to refuse psychotropic drugs has been debated in courts with no clear direction yet forthcoming
• Right to informed consent: based on right to self-determination o Informed consent must be obtained by physician or other health care professional to perform treatment or procedure o Presence of psychosis does not preclude this right Issue of Legal Competence
• All patients must be considered legally competent until they have been declared incompetent through legal proceeding o Determination made by courts o If found incompetent, court-appointed legal guardian, who is then responsible for giving or refusing consent
• Implied consent o Many procedures nurse performs has element of implied consent (e.g., giving medications) o Some institutions require informed consent for every medication given
• All patients must be considered legally competent until they have been declared incompetent through legal proceeding o Determination made by courts o If found incompetent, court-appointed legal guardian, who is then responsible for giving or refusing consent
• Implied consent o Many procedures nurse performs has element of implied consent (e.g., giving medications) o Some institutions require informed consent for every medication given

Rights Regarding Restraint & Seclusion

• Doctrine of least restrictive means of restraint for shortest time always the rule
• Legislation provides strict guidelines for use o When behavior is physically harmful to patient/others o When least restrictive measures are insufficient o When decrease in sensory overstimulation (seclusion only is needed) o When patient anticipates that controlled environment would be helpful and requests seclusion
• Recent legislative changes have further restricted use of these means and some facilities have instituted “restraint free” policies Patient Confidentiality
• Ethical considerations o Confidentiality is right of all patients o ANA Code of Ethics for Nurses (2001) asserts duty of nurse to protect confidentiality of patients
• Legal considerations o Health Insurance Portability and Accountability Act (HIPAA), 2003 ▪ Health information may not be released without patient’s consent, except to those people for whom it is necessary in order to implement the tx plan
• Exceptions o Duty to Warn and Protect Third Parties ▪ Tarasoff v. Regents of University of California (1974) ruled that psychotherapist has duty to warn patient’s potential victim of harm o Most states have similar laws regarding duty to warn 3rd parties of life threats o Staff nurse reports threats by patient to the treatment team Each domain has an independent knowledge and treatment focus but interacts and is mutually interdependent with the other domains.
• Biologic domain : biologic activity related to other health problems; functional health patterns such as exercise, sleep, and adequate nutrition to mental health conditions. o Neurobiologic theories also serve as a basis for understanding and administering pharmacologic agents
• Psychological domain : contains the theoretical basis of the psychological processes—thoughts, feelings, and behavior (intrapersonal dynamics) that influence one’s emotion, cognition, and behavior o Neurobiologic changes in mental disorders, symptoms are psychological: manic behavior is caused by dysfunction in the brain, there are no laboratory tests to confirm a diagnosis, only a pattern of behavior o Nursing interventions are behavioral, such as cognitive approaches, behavior therapy, and patient education ▪ Understanding own and their patients’ intrapersonal dynamics and motivation is critical in developing a therapeutic relationship
• Social domain : includes theories that account for the influence of social forces encompassing the patient, family, and community within cultural settings. o Psychiatric disorders are not caused by social factors, but their manifestations and treatment can be significantly affected by the society in which the patient lives. ▪ Family support can actually improve treatment outcomes ▪ Community forces, including cultural and ethnic groups within larger communities, shape the patient’s manifestation of disorders, response to treatment, and overall view of mental illness. Ch 6) Questions

1. A 19-year-old patient with schizophrenia announces that he and a 47-year-old patient with bipolar disorder will be married the following week. They ask the nurse to witness the wedding. Discuss which ethical principles may be in conflict.
2. Compare the ethical concepts of autonomy and beneficence. Focus on the difference between legal consequences and ethical dilemmas.
3. Compare the variety of patients for whom psychiatric–mental health nurses care. Factors to be considered are age, health problems, and social aspects.
4. Visit the ANA’s website for a description of the psychiatric–mental health nurse’s certification credentials. Compare the basic level functions of a psychiatric nurse with those of the advanced practice psychiatric nurse.
5. Explain the biopsychosocial framework and apply it to the following three clinical examples:
6. A first-time father is extremely depressed after the birth of his child, who is perfectly healthy.
7. A child is unable to sleep at night because of terrifying nightmares.
8. An older woman is resentful of moving into a senior citizens residence even though the decision was hers.

b. Discuss the purposes of the following organizations in promoting quality mental health care and supporting nursing practice. Visit the organizations’ websites for more information.

1. American Nurses Association
2. American Psychiatric Nurses Association
3. International Society of Psychiatric–Mental Health Nurses
4. International Nurses Society on Addictions Ch 7) Psychosocial Theories

• The traditional psychodynamic framework helped form the basis of early nursing interpersonal interventions, → therapeutic relationships & the use of such concepts as transference, countertransference, empathy, and object relations.
• Behavioral theories often used in strategies that help patients change behavior & thinking.
• Sociocultural theories remain important in understanding and interacting with patients as members of families and cultures. Psychodynamic Theories (ppt)
• Psychoanalytic models o Freud o Study of unconscious, personality development, object relations & identification, anxiety & defense mechanisms, sexuality, psychoanalysis, transference & countertransference ▪ Transference is the displacement of thoughts, feelings, and behaviors originally associated with significant others from childhood onto a person in a current therapeutic relationship ▪ For example, a woman’s feelings toward her parents as a child may be directed toward the therapist. If a woman were unconsciously angry with her parents, she may feel unexplainable anger and hostility toward her therapist. ▪ Countertransference , on the other hand, is defined as the direction of all of the therapist’s feelings and attitudes toward the patient. ▪ Countertransference becomes a problem when these feelings and perceptions are based on other interpersonal experiences. ▪ For example, a patient may remind a nurse of a beloved grandmother. Instead of therapeutically interacting with the patient from an objective perspective, the nurse feels an unexplained attachment to her and treats the patient as if she were the nurse’s grandmother. The nurse misses important assessment and intervention data.
• Neo-Freudian models o Carl Jung : extroverted vs. introverted personalities o Harry Stack Sullivan: interpersonal forces ▪ Importance of human relationships ▪ People develop their personality w/in a social context ▪ w/o other people, humans would have no personality ▪ Interpersonal relations as the basis for human development & behavior ▪ Development rests on the individual’s ability to establish intimacy w/another person ▪ Anxiety can interfere w/satisfying interpersonal relations ▪ He believed that the health or sickness of one’s personality is determined by the characteristic patterns in which one deals with other people. ▪ For example, one man is passive aggressive to everyone who contradicts him. This maladaptive behavior began when he was unable to express his disagreement to his parents. Health depends on managing the constantly changing physical, social, and interpersonal environment as well as past and current life experiences ▪ Influenced Peplau
• Humanistic theories o Carl Rogers: client-centered therapy ▪ Empathy, unconditional positive regard (a nonjudgemental caring for the client) , genuineness o Fritz Perls: Gestalt therapy - anxiety resulting from inability to express natural biologic & psychological desires; repression → anxiety o Maslow’s Hierarchy of Needs : ranging from basic food, shelter, & warmth to high-level requirement for self- actualization Applicability to Nursing: Psychodynamic Theories
• Interpersonal relationships (Harry Stack Sullivan)
• Defense mechanisms (Freud): coping styles that protect a person from unwanted anxiety
• Transference & countertransference (Freud)

• Internal objects (Freud): the psychological attachment to another person or object. o He believed that the choice of a sexual partner in adulthood and the nature of that relationship depended on the quality of the child’s object relationships during the early formative years (e.g. 1st love object is the mother) →Therapeutic interpersonal relationship: core of PMH nursing intervention Cognitive-Behavioral Theories (ppt)
• Stimulus–response theories o Pavlovian theory: classical conditioning - unconditioned stimulus (not dependent on previous training) elicits an unconditioned (i.e. specific) response (aka salivating); teach dog to associate bell (conditioned stimulus) w/meat (unconditioned stimulus) o John B. Watson: behaviorism - a learning theory that only focuses on objectively observable behaviors and discounts any independent activities of the mind
• Reinforcement theories o Edward L. Thorndike: “stamping in” (reinforcement of positive behavior) - became dominant view in American learning theory o B. F. Skinner: operant conditioning - focus is on the consequence of the behavioral response, not a specific stimulus. If a behavior is reinforced/rewarded with success, praise, money, etc., the behavior will probably be repeated
• Cognitive theories o Albert Bandura: social cognitive theory; self-efficacy - a person’s sense of his or her ability to deal effectively with the environment; influence how people feel, think, motivate themselves, and behave. The stronger the self- efficacy, the higher the goals people set for themselves and the firmer their commitment to them o Aaron Beck: thinking and feeling; cognitions - verbal or pictorial events in the stream of consciousness; important in depression tx (patients improve when they began viewing themselves & situations in a positive light; incorrectly interpret life situations, judge themselves too harshly, & jump to inaccurate neg. conclusions) Applicability to Nursing: Cognitive-Behavioral Theories
• Patient education interventions
• Changing an entrenched habit
• Privilege systems and token economies Developmental Theories
• Erik Erikson: psychosocial development (vs. Freud-intrapsychic experiences); 8 stages o Identity and adolescence ▪ When adolescence begins, childhood ways are given up, and bodily changes occur. An identity is formed.
• Jean Piaget: learning in children (see Table 7.5)

o Assess. of concrete thinking is typical w/schizophrenia; unable to think abstractly

• Carol Gilligan: gender differentiation o Attachment w/in relationships is the important factor for successful development o Compared m & f personality development; highlighted differences
• Jean Baker Miller: sense of connection o Connections (mutually responsive & enhancing relationships) lead to mutual engagement (attention), empathy, and empowerment o Disconnections (lack of mutually responsive & enhancing relationships) occur when don’t receive any response from others ▪ The most serious types of disconnection arise from the lack of response that occurs after abuse or attacks. Marcia’s Identity Status Theory (1996) is based on Erikson’s notions of psychosocial development, particularly the stage of identity versus role confusion.
• The model involves four statuses of identity development, based on two dimensions; commitment and exploration.
• The four cells of the model are identity diffusion (low commitment and exploration), foreclosure (high commitment but low exploration), moratorium (low commitment and high exploration) and identity achievement (high commitment and exploration).

Social Theories

• Sociocultural perspectives: o Mead: culture and gender - anthropologist; child rearing in various cultures o Leininger: transcultural (sunrise model) - holistic, congruent, and beneficent ▪ Nursing care in one culture is different from another because definitions of health, illness, and care are culturally defined; goal: discover culturally based care Nursing Theories (Social)
• Orem’s Self-care: schizophrenia r/t maintaining self-care
• Peplau: developing relationship w/patient Interpersonal Relations Models
• Hildegard Peplau: the power of empathy o Empathic linkage: the ability to feel in oneself the feelings experienced by another ▪ Anxiety or panic most common ▪ Anger, disgust & envy can also be communicated nonverbally o Self-system: drawn from Sullivan, self as an “antianxiety system” and a product of socialization; self proceeds through personal development that is always open to revision but tends toward stability ▪ For example, in parent–child relationships, patterns of approval, disapproval, and indifference are used by children to define themselves. o Anxiety: energy that arises when expectations that are present are not met ▪ If not recognized, cont. to rise & escalate toward panic ▪ Cues: defensive or “relief behaviors” i.e. yelling, swearing → generated by unmet security need ▪ Severe anxiety interferes with learning. Mild anxiety is useful for learning. ▪ Levels of Anxiety ▪ Mild: awareness heightens ▪ Moderate: awareness narrows ▪ Severe: focused narrow awareness ▪ Panic: unable to function Ch7) Questions

1. Discuss the similarities and differences among Freud’s ideas and those of the neo-Freudians, including Jung, Adler, Horney, and Sullivan.
2. Compare and contrast the basic ideas of psychodynamic and behavioral theories.
3. Compare and differentiate classic conditioning from operant conditioning.
4. Define the following terms and discuss their applicability to psychiatric– mental health nursing: classical conditioning, operant conditioning, positive reinforcement, and negative reinforcement.
5. List the major developmental theorists and their main ideas.
6. Discuss the cognitive therapy approaches to mental disorders and how they can be used in psychiatric–mental health nursing practice.
7. Define formal and informal support systems. How does the concept of social distance relate to these two systems?
8. Compare and contrast the basic ideas of the nursing theorists. Ch 8) Biologic Foundations

• Neuroscientists now view behavior and cognitive function as a result of complex interactions within the CNS and its plasticity, or its ability to adapt and change in both structure and function.
• Each hemisphere of the brain is divided into four lobes: the frontal lobe, which controls motor speech function, personality, and working memory—often called the executive functions that govern one’s ability to plan and initiate action; the parietal

lobe, which controls the sensory functions; the temporal lobe, which contains the primary auditory and olfactory areas; and the occipital lobe, which controls visual integration of information.

• The structures of the limbic system are integrally involved in memory and emotional behavior. Dysfunction of the limbic system has been linked with major mental disorders, including schizophrenia, depression, and anxiety disorders. o Basic emotions, needs, drives, and instinct begin and are modulated in the limbic system. Hate, love, anger, aggression, and caring are basic emotions that originate within the limbic system & Memory
• Neurons communicate with each other through synaptic transmission.
• Neurotransmitters excite or inhibit a response at the receptor sites and have been linked to certain mental disorders. These neurotransmitters include ACh, DA, NE, SE, GABA, and glutamate. o Neurotransmitters are small molecules that directly and indirectly control the opening or closing of ion channels. ▪ Excitatory neurotransmitters reduce the membrane potential and enhance the transmission of the signal between neurons. ▪ Inhibitory have the opposite effect and slow down nerve impulses. Cholinergic & Bioamines ACh •^ Primary^ cholinergic^ neurotransmitter;^ greatest^ [^ ]^ in^ PNS
• Excitatory
• Higher intellectual functioning & memory
• Decreased: Alzheimer, Down syndrome DA • (biogenic amines: DA, NE, EPI, SE)
• Excitatory
• Cognition, motor & neuroendocrine fxn
• “Feel good” reward pathways, euphoria
• Action, emotion, motivation, attention
• Increased: Schizophrenia
• Decreased: Parkinsons SE • Appetite, sleep, mood, hallucinations, pain perception, vomiting
• Decreased during REM (muscles relaxed)
• Hormone secretion, sexual behavior, thermo & CV regulation
• Melatonin derived from SE (produced by pineal gland); sleep, aging, mood changes NE •^ Learning,^ memory,^ reward^ systems,^ sleep/wake^ cycle
• Fights or flight (anxiety)
• Decreased: depression
• Increased: manic Histamine (AA) •^ If^ blocked,^ SE:^ sedation,^ weight^ gain,^ hypotension GABA •^ Inhibition^ (fast)^ →^ seizures,^ agitation,^ anxiety^ control

• Decrease: seizure
• Dysregulation: anxiety disorders Glycine •^ Inhibitory Glutamate •^ Excitatory,^ most^ widely^ distributed
• Chronic malfunctioning of glutamate system: HTN, Parkinson, Alzheimer, ALS, AIDS-related dementia, vascular dementia
• Decrease: schizophrenia Neuropeptides •^ Opioid:^ endorphins,^ enkephalins,^ dynorphins^ (endocrine^ fxn^ &^ pain^ suppression)
• Nonopioid: Substance P, somatostatin (pain transmission & endocrine fxn) Major DA pathway beginning in substantia nigra → basal ganglia (striatum) influences: extrapyramidal motor system (voluntary motor system & allows involuntary motor mvmts Ch 8) Questions

1. A woman who has experienced a “ministroke” continues to regain lost cognitive function months after the stroke. Her husband takes this as evidence that she never had a stroke. How would you approach patient teaching and counseling for this couple to help them understand this occurrence if the stroke did damage to her brain?
2. Your patient has “impaired executive functioning.” Consider what would be a reasonable follow-up schedule for this patient for counseling sessions. Would it be reasonable to schedule visits at 1:00 PM weekly? Is the patient able to keep to this schedule? Why or why not? What would be the best schedule?
3. Mr. S is unable to sleep after watching an upsetting documentary. Identify the neurotransmitter activity that may be interfering with sleep. (Hint: fight or flight.)
4. Describe what behavioral symptoms or problems may be present in a patient with dysfunction of the following brain area:
5. Basal ganglia
6. Hippocampus
7. Limbic system
8. Thalamus
9. Hypothalamus
10. Frontal lobe b. Compare and contrast the functions of the sympathetic and parasympathetic nervous systems. c. Discuss the steps in synaptic transmission, beginning with the action potential and ending with how the neurotransmitter no longer communicates its message to the receiving neuron. d. Examine how a receptor’s usual response to a neurotransmitter might change. e. Compare the roles of dopamine and Ach in the CNS. f. Explain how dopamine, norepinephrine, and serotonin all contribute to endocrine system regulation. Suggest some other transmitters that may affect endocrine function. g. Discuss how the fields of PNI and chronobiology overlap. h. Compare the methods used to find biologic markers of psychiatric disorders reviewed in this chapter. Consider the potential risks and benefits to the patient.

WEEK 3: CHAP 9, 11, 12, 14

Ch. 11: Psychopharmacology, Dietary Supplements and Biologic Interventions Pharmacodynamics: Where Drugs Act

• Receptors: specific proteins intended to response to a chemical normally present in blood or tissues.
• Selectivity: the ability of a drug to be specific for a particular receptor.
• Affinity: the degree of attraction or strength of the bond between the drug and its biological target.
• Intrinsic Activity: a drug’s ability to interact with a given receptor, or the ability to produce a response after it becomes attached to the receptor. Clinical Concepts
• Efficacy: the ability of a drug to produce a response and is considered when a drug is selected.
• Potency: refers to the dose of drug required to produce a specific effect.
• Desensitization: a rapid decrease in drug effects that may develop in a few minutes of exposure to a drug.
• Tolerance: a gradual decrease in the action of a drug at a given dose or concentration in the blood.
• Toxicity: generally, refers to the point at which concentrations of the drug in the bloodstream are high enough to become harmful or poisonous to the body.
• Therapeutic Index: the ratio of the maximum nontoxic dose to the minimum effective dose. *Table 11.5 (pg. 351): Antipsychotic Medications *Table 11.8 (pg. 361): Antidepressant Medications *Table 11.11 (pg. 366): Antianxiety and Sedative- Hypnotic Medications Major Psychopharmacologic Drug Classes Drug Class Indications/MOA Pharmacokinetics Side Effects, Adverse Reactions, Toxicity Antipsychotic Medications Risperidone - Atypical Antipsychotic ✓** Schizophrenia ✓ Mania ✓ Autism ✓ Symptoms of Psychosis (hallucinations, delusions, bizarre behavior, disorganized thinking, and agitation) ✓ Reduce aggressiveness, and inappropriate behavior associated with psychosis ✓ Haloperidol & Pimozide  Tourette syndrome ✓ Chlorpromazine  antiemetics for postoperative intractable hiccoughs - ORAL: Rate of absorption complicated by: food, antacids, co- administration of anticholinergics  slow gastric motility. - IM produces greater bioavailability. - Most antipsychotics are subject to the effects of other drugs that induce or inhibit the CYP system. - Long Acting Forms: administered by injection once every 2 weeks – 3 months. ▪ Cardiovascular Effects: o Orthostatic hypotension o Prolongation of the QT interval (can lead to irregular heart rhythms) ▪ Anticholinergic Effects o Dry mouth, slow gastric motility, constipation, urinary hesitancy/retention, etc. ▪ Weight Gain o Clozapine, Olanzapine can cause weight gain of up to 20 lb. within 1 year o Ziprasidone, Aripiprazole, Lurasidone associated with little to NO weight gain ▪ Diabetes o ALL ATYPICAL ▪ Sexual Side Effects o T Prolactin  Breast enlargement o  Sexual Drive o Amenorrhea o Menstrual irregularities

*The atypical antipsychotic meds differ from typical b/c they block serotonin receptors more potently than the dopamine receptors. o T growth for pre-existing cancers ▪ Blood Disorders o Clozapine agranulocytosis ▪ Neuroleptic Malignant Syndrome: characterized by rigidity and high fever ▪ Other: o Photosensitivity o Pigmentary deposits o May lower seizure threshold ▪ Medication Related Movements (ACUTE): o Commonly caused by TYPICAL o Acute Extrapyramidal Symptoms: abnormal movements that include dystonia, pseudo parkinsonism, and akathisia. Occurs when there is an imbalance of acetylcholine, dopamine and GABA in the basal ganglia as a result of blocking dopamine o Dystonia: impaired muscle tone, generally the first EPS to occur, usually within a few days. Acetylcholine is overactive because dopamine is blocked. Characterized by involuntary muscle spasms that lead to abnormal posture (esp. head and neck). ▪ First: thick tongue, tight jaw, stiff neck  protruding tongue, oculogyric eyes (eyes rolled up in the head), torticollis (muscle stiffens in the neck), laryngopharyngeal constriction ▪ Severe symptoms where intercostal muscles produce significant breathing difficulty. ▪ Treatment: anticholinergic agents (inhibit acetylcholine & restore balance of neurotransmitters) o Pseudo parkinsonism: presentation is identical to Parkinson’s Disease. Activity of dopamine is blocked. ▪ Older patients are at greatest risk ▪ Symptoms (classic triad): rigidity, slowed movements (akinesia), tremor. ALSO, mask0like facies, loss of facial expression, a  ability to initiate movements, hypersalivation ▪ Usually, first 30 days of treatment ▪ Treatment: anticholinergic medication o Akathisia: characterized by an inability to sit still or restlessness ▪ More common in middle-aged patients ▪ Person will pace, rock while sitting or standing, march in place, cross and uncross legs. ▪ Subjective experience: anxiety, jitteriness, inability to relax, inability to communicate ▪ Difficult to treat, does not respond to anticholinergic medications ▪ Treatment to reduce symptoms: beta adrenergic blockers,

anticholinergics, antihistamines, low-dose antianxiety agents (limited success). ▪ Medication Related Movements (CHRONIC): o Chronic Syndromes: develop from long-term use of antipsychotics, IRREVERSIBLE o Tardive Dyskinesia: irregular, repetitive involuntary movements of the mouth, face, and tongue including chewing, tongue protrusion, lip smacking, puckering of the lips, rapid eye blinking, abnormal finger movements ▪ Occur after 6 months of treatment (or when the medication is reduced or withdrawn) ▪ Any movement disorder that persists after discontinuation of antipsychotic medication has been described as tardive dyskinesia ▪ The risk for experiencing tardive dyskinesia T with age ▪ Treatment: Valbenzine, dietary precursors of acetylcholine (lecithin, vitamin E supplements) o Preventative Measures: use of atypical antipsychotics, lowest possible dose of typical medication, minimize PRN meds, monitor high-risk individuals for symptoms Mood Stabilizers (Antimanic Medications) ✓ Stabilize mood swings (particularly those of mania in bipolar disorders) ✓ LITHIUM: the oldest, & gold standard of treatment for acute mania and maintenance of bipolar disorders ✓ Other: anticonvulsants, CCBs, adrenergic blocking agents, atypical antipsychotics Lithium: indicated for symptoms of mania characterized by rapid speech, flight of ideas, irritability, grandiose thinking, impulsiveness, agitation

• Has mild
  • Orally (capsule), tablets, liquid
  • May be taken with food (does not impair absorption)
  • Almost entirely excreted by the kidneys
  • In conditions that cause sodium depletion, the kidneys attempt to conserve sodium (b/c lithium is a salt, kidneys retain lithium as well  T blood levels & potential toxicity) SIGNIFICANTLY increasing sodium intake causes lithium levels to fall
  • Therapeutic Index: 0.8-1.4 mEq/L. ▪ Mild: o Excessive thirst, unpleasant metallic tastes (treatment: sugarless throat lozenges) o Frequent urination, fine head tremor, drowsiness, diarrhea, weight gain (20% of individuals) o Nausea minimized by taking w/ food or by slow- release preparation (however slow-release may T diarrhea). o Muscle weakness, restlessness, headache, acne, rashes, exacerbation of psoriasis ▪ Early signs of lithium toxicity: o Side effects become numerous and severe o Diarrhea, vomiting, drowsiness, muscular weakness, coordination o *Lithium should be withheld and the prescriber consulted ▪ Must monitor creatinine concentration (could affect kidneys), thyroid hormones (alter thyroid function 6-18 months, T TSH), CBC every 6 months during maintenance therapy to help assess the occurrence of potential adverse reactions. ▪ CI for pregnancy b/c associated with birth defects (esp. during 1 st^ semester). ▪ CI for breast feeding women.

antidepressant effects so it is used in treating depressive episodes of bipolar illness

• Augmentation in pts experiencing major depression that has only partially responded to antidepressants alone
• Helpful in  impulsivity and aggression - *Constantly have blood drawn 12 hours after last dose and before they take their first dose of medication MOA of Lithium
• Enhance serotonergic transmission
• T synthesis of norepinephrine
• Block postsynaptic dopamine
• Actively transported across cell membranes (altering sodium transport in both nerve & muscle cells) **Anticonvulsants
• Valproate (valproic acid, Depakote)
• Carbamazepine (Equetro)**
• Lamotrigine (Lamictal)** ✓ Bipolar disorder, considered “mood stabilizers” ✓ All approved for the treatment of bipolar disorder, mania, or mixed episodes ✓ Basically, their effects on ion channels  reduce repetitive firing of action potentials in the nerves, most directly  manic symptoms
• Valproic acid is rapidly absorbed; food appears to slow absorption but does not lower bioavailability of the drug.
• These medications easily cross into the CNS, move into placenta and associated with T risk for birth defects
• Metabolized by CYP450 system
• One of the Carbamazepine ▪ Most common side effects: o Dizziness, drowsiness, tremor, visual disturbance, nausea and vomiting o Minimized by initiating treatment in low doses o Giving w/ food may  nausea ▪ Rare: o Aplastic anemia, agranulocytosis, severe rash, rare cardiac problems, SIADH caused by hyponatremia Valproic Acid ▪ Side effects: o GI disturbances, tremor, lethargy o Weight loss, o Alopecia (Treatment: Zinc & Selenium) o Monitor UO & T fluid consumption **Lamotrigine****

metabolites of carbamazepine is potentially toxic (DON’T take w/ erythromycin, verapamil, cimetidine) ▪ Side Effects: o Benign skin rash, sedation, blurred or double vision, dizziness, nausea, vomiting, other GI symptoms ▪ Rare: o Life-threatening rashes (2-8 weeks of treatment); highest risk in children Hepatic injury (T in liver enzymes) with carbamazepine & valproic acid Antidepressant Medications: General Overview ✓ Depression ✓ Anxiety Disorders ✓ Eating Disorders ✓ Other mental health states SSRIs, SNRIs, Norepinephrine Dopamine Reuptake Inhibitors, A2 Antagonists, Other, TCAs, MAOIs

• Should not be discontinued abruptly, discontinuance requires slow tapering
• “Boxed Warning” for increased risk of suicidal behavior in children, adolescents, and young adults Serotonin syndrome: can occur if there is an overactivity of serotonin or an impairment of the serotonin metabolism
• Symptoms: mental status changes (hallucinations, agitation, coma),
• autonomic instability (tachycardia, hyperthermia, changes in BP
• Neuromuscular problems (hyperreflexia, incoordination)
• GI disturbance (nausea, vomiting, diarrhea) Treatment: discontinuation of medication & symptom management Selective Serotonin Reuptake Inhibitors (SSRIs) ✓ Serotonergic system is associated with mood, emotion, sleep and appetite and is implicated in the control of numerous emotional, physical, and behavioral functions ✓  serotonergic neurotransmission has been proposed to play a key role in depression ✓ Inhibit the reuptake of serotonin by blocking its transport into the presynaptic neuron which in turn T the concentration of synaptic serotonin ▪ Common Side Effects: o Headache, anxiety, insomnia, transient nausea, vomiting, diarrhea o Sedation, esp. w/ Paroxetine, high doses of Fluoxetine. o ^ side effects & … sexual dysfunction, sedation, diastolic and T perspiration tend to be dose dependent o Constipation, dry mouth, tremors, blurred vision, asthenia/muscle weakness o Sexual dysfunction: erectile and ejaculation disturbances, anorgasmia Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) ✓ Decreased activity of the norepinephrine is also associated with depression and anxiety disorders ✓ Prevent the reuptake of both serotonin & norepinephrine ▪ Common Side Effects: o Similar to SSRIs o T in BP (nurses should monitor BP esp. pts w/ high BP) Venlafaxine: has little effect on acetylcholine & histamine  only MILD sedation & anticholinergic symptoms Nefazodone: dry mouth, nausea, dizziness, muscle weakness, constipation, and tremor. Unlikely to cause sexual disturbance. Has “boxed warning” for hepatic failure (CI for pts. w/ acute liver disease). Norepinephrine Dopamine Reuptake Inhibitors Bupropion (Wellbutrin, Zyban) inhibits reuptake of norepinephrine, serotonin, and dopamine. o Wellbutrin: depression o Zyban: nicotine addiction ▪ Bupropion has chemical structure unlike other antidepressants & somewhat resembles a few of the psychostimulants. ▪ Bupropion’s activating effects may be experienced as agitation or anxiety by some pts.

▪ Others experience insomnia & appetite suppression. ▪ Some individuals  psychosis, hallucinations, delusions. ▪ CI for people with seizure disorders or at risk for seizures. ▪ Lower incidence of sexual dysfunction Alpha 2 Antagonists Mirtazapine ✓ Boosts norepinephrine or noradrenaline & serotonin by blocking a 2 adrenergic presynaptic receptors on a serotonin receptor ✓ Histamine receptor is also blocked  sedative effect ✓ Indicated for depression ✓ Side effects: sedation (lower doses), dizziness, weight gain, dry mouth, constipation, change in urinary functioning Other Trazadone ✓ Blocks 2A receptor potently and blocks the serotonin reuptake pump less potently ✓ Indicated for depression, used off-label for insomnia and anxiety ✓ Sedation is common side effect ✓ Other side effects: weight gain, nausea, vomiting, constipation, dizziness, fatigue, incoordination, tremor Tricyclic Antidepressants (TCAs)

• Depression
• [Has more serious side effects & higher lethal potential]
• Act on norepinephrine and serotonin reuptake systems - Highly bound to plasma proteins which make the association between blood levels & clinical effects difficult - Most common: o Sedation, orthostatic hypotension, anticholinergic effects - Other: o Tremor, restlessness, insomnia, N/V, confusion, pedal edema, headache seizures, blood dycrasias *Potential for cardiotoxicity: may precipitate HF, Mis, Arrhythmias, Stroke Antidepressants that block the dopamine (D2) receptor, such as amoxapine have produced symptoms of NMS. Mild forms of EPS and endocrine changes, including galactorrhea, and amenorrhea may develop. **Monoamine Oxidase Inhibitors (MAOIs)
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
• Isocarboxazid (Marplan)
• Selegiline (Emsam)
• transdermal patch**
• MAO: an enzyme that breaks down the biogenic amine neurotransmitter serotonin, norepinephrine, and others
• By inhibiting this enzyme, serotonin & norepinephrine activity is increased in the synapse
• Main problem is: interaction with tyramine & certain medications that can result in a hypertensive crisis
• The enzyme monoamine is important in the breakdown of dietary amines (tyramine). When the enzyme is inhibited, tyramine, a
• Most common: o Dizziness, headache, insomnia, dry mouth, blurred vision, constipation, nausea, peripheral edema, urinary hesitancy, muscle weakness, forgetfulness, weight gain o Older pts. Especially sensitive to orthostatic hypotension o Sexual dysfunction:  libido, impotence, anorgasmia

precursor for dopamine increases in the nerve cells. Tyramine has a vasopressor action that induces hypertension  severe headache, palpitations, neck stiffness & soreness, N/V, sweating, htn, stroke,  death.

• Don’t take w/ food that contain tyramine, diet pills, cold remedies Antianxiety and Sedative- Hypnotic Medications: Overview ✓ Sometimes called anxiolytics **Benzodiazepines
• Alprazolam (Xanax)
• Lorazepam (Ativan)
• Diazepam (Valium
• Chlordiazepoxide (Librium)
• Flurazepam (Dalmane)
• Triazolam (Halcion)**
• Enhance the effects of the inhibitory neurotransmitter GABA
• Oxazepam (Serax) and Lorazepam (Ativan) are often preferred for pts. With liver disease and for older pts. Because of their short half lives
• Highly lipid soluble and highly protein bound ▪ Most common: o Sedative & CNS depression effects o Drowsiness, intellectual impairment, memory impairment, ataxia, reduced motor coordination ▪ Alcohol increases all of these symptoms and potentiates CNS depression ▪ IV benzos often cause phlebitis and thrombosis ▪ Psychological dependence occur when medications are used for longer period ▪ Gradual tapering for discontinued use after long-term treatment ▪ Individual reactions to benzos appear to be associated with sensitivity to their effects ▪ Toxicity develops in overdose or accumulation of the drug in the body from liver dysfunction or disease: s/s: CNS depression, ataxia, confusion, delirium, agitation, hypotension, diminished reflexes, lethargy
• • •

To be continued pg. 367 • • • Other Biologic Treatments Therapy Description Electroconvulsive Therapy • Seizures have been known to produce improvement in some psychiatric symptoms.

• One of the most effective treatments for severe depression but has been used for other disorders including mania, schizophrenia (when other treatments have failed)
• With ECT, a brief electrical current is passed through the brain to produce generalized seizures lasting 25-150 seconds; a short- acting anesthetic & a muscle relaxant are given before induction of current.
• Induction of seizure is necessary to produce. BP & ECG monitored; 2-3x a week for a total of 6-12 treatments
• After symptoms improved  antidepressant medication may be used to prevent relapse.
• The number and frequency vary depending on the individual’s response.
• ECT is known to downregulate B-adrenergic receptors in the same way as antidepressant medications. However, unlike antidepressant therapy, ECT produces an upregulation of serotonin.
• ADE: brief episodes of hypo/hypertension, brady/tachycardia, minor arrythmias.
• Aftereffects: headache, nausea, muscle pain
• Memory loss is the most troublesome of long-term effect of ECT
• CI: T ICP, recent MI, CVA, retinal detachment, pheochromocytoma, high risk for complication from anesthesia
• Need consent, explanation of procedure Light Therapy (Phototherapy)
• Human circadian rhythms are set by time clues inside and outside the body. One of the most powerful of these body patterns is the cycle of daylight and darkness.
• Disturbance of normal body patterns or circadian rhythms  depression in certain individuals
• Individuals more depressed in winter months when there is less light  s/s differ from classic depression: fatigue, T need for sleep, T appetite and weight gain
• Light therapy involves exposing the pt. to an artificial light source during winter months to relieve seasonal depression; artificial light helps shift the patient’s circadian rhythm to an earlier time
• Morning phototherapy > evening or morning and evening phototherapy session
• ADE: eye strain, headaches, insomnia
• Rare: episode of mania Transcranial Magnetic Stimulation
• Noninvasive, painless method to stimulate the cerebral cortex
• Undergirding this procedure is the hypothesis that a time varying magnetic field will induce an electric field, which, in brain tissue, activates inhibitory and excitatory neurons, thereby modulating neuroplasticity in the brain.
• The rTMS stimulation of the brain’s prefrontal cortex may help some depressed pts in the same way as ECT but without its side effects
• ADE: mild headaches Vagus Nerve Stimulation •^ VNS^ sends^ electrical^ impulses^ to^ the^ brain^ to^ improve^ depression.
• Vagus nerve has traditionally been considered a parasympathetic efferent nerve that was responsible only for regulating autonomic

functions such as HR and gastric tone, BUT it has now been confirmed that is also carries sensory info to the brain from dif parts of the body.

• Vagus nerve stimulation connections change levels of several neurotransmitters implicated in the development of major depression, including serotonin, norepinephrine, GABA, and glutamate in the same way that antidepressant medications produce their therapeutic effect.
• Approved for the adjunctive treatment of severe depression for adults who are unresponsive to four or more adequate antidepressant treatments.
• Pts must be seen regularly for assessment of mood states and suicidality. Ch. 12 Cognitive Interventions in Psychiatric Nursing Cognition: can be defined as an internal process of perception, memory, and judgement through which an understanding of self and the world is developed. Development of Cognitive Therapies Cognitive Behavioral Therapy
• CBT is a highly structured psychotherapeutic method used to alter distorted beliefs and problem behaviors by identifying and replacing negative inaccurate thoughts and changing the rewards for behaviors.
• In CBT, the relationship between thoughts, feelings and behavior is examined and identified. CBT operates on the following assumptions: o People are disturbed not by an event but by the perception of that event. o Whenever and however a belief develops, the individual believes it. o Work and practice can modify beliefs that create difficulties in living.
• By changing the dysfunctional thinking, a person can alter their emotional reaction to a situation and reinterpret the meaning of an event.
• The goal of CBT is to restructure how a person perceives events in his or her life to facilitate behavioral and emotional change.
• Intervention Framework In CBT, the therapist helps the patient identify the underlying belief and then they: o Explore the evidence that supports or refutes the belief about the event o Identify alternative explanations for the event o Examine the real implications if the belief is true (e.g. What is the worst thing that could happen?) Cognitive Processes pg. 388- 389

1. Cognitive Triad: includes thoughts about oneself, the world and the future.
2. Cognitive Distortions: automatic thoughts; generated by organizing distorted information and/or inaccurate interpretation of a situation. a. Cognitive distortions or “twisted thinking” occur in a variety of ways such as overgeneralization (asserting that something general is always true about an event, situation or people), personalizing (applying a general statement to oneself, catastrophizing (viewing or talking about an event as worse than it actually was, and selective abstraction (selectively abstracting negative information from stressful events.
3. Schemas: are the individual’s life rules that act as a sieve or filter. They allow only information compatible with the internal picture of self and the world to be brought to the person’s awareness. Schemas are an accumulation of learning and experience from the individual’s genetic makeup, family and school environments, peer relationships, and society as a whole. Rational Emotive Behavior Therapy

- REBT is a psychotherapeutic approach that proposes that unrealistic and irrational beliefs cause many emotional problems. It is a form of CBT with a primary emphasis on changing irrational beliefs that cause emotional distress into thoughts that are more reasonable and rational. - REBT is based on the assumption that people are born with the potential to be rational (self-constructive) and irrational (self-defeating). - A: Activating event that triggers automatic thoughts and emotions - B: beliefs that underlie the thoughts and emotions - C: consequences of this automatic process - D: dispute or challenge unreasonable expectations - E: effective outlook developed by disputing or challenging negative belief systems - Intervention Framework: REBT uses role-playing, assertation training, desensitization, humor, operant conditioning, suggestion, support and other interventions. Solution-Focused Brief Therapy

• SFBT focuses on solutions rather than problems. This approach does not challenge the existence of problems but proposes that problems are best understood in relation to their solutions. Solution-focused therapy assists the client in exploring life without the problem.
• Deemphasis on the patient’s “problems” or symptoms, and an emphasis on what is functional and healthful.
• Interventions: the therapist takes a position of curiosity in learning about the patient, as opposed to an expert to whom the person has come to be helped. This curiosity is manifested in the questions and techniques that are integral to this approach and enable the development of realistic goals at each sessions. Questions used in eliciting the “problem” seek very specific information. o Interventions in SFBT focus on achievement of specific, concrete and achievable goals developed in collaboration between therapist and patient. Ch. 14 Family Assessments and Interventions A family is a group of people connected emotionally, or by blood, or in both ways that has developed patterns of interaction and relationships. Family is the support system for a psychiatric patient. Family Mental Health
• A family becomes dysfunctional when interactions, decisions, or behaviors interfere with the positive development of the family and its individual members. Effects of Mental Illness on Family Functioning
• Providing support. People with mental illness have difficulty maintaining nonfamilial support networks and may rely exclusively on their families.
• Providing information. Families often have complete and continuous information about care and treatment over the years.
• Monitoring services. Families observe the progress of their relative and report concerns to those in charge of care.
• Advocating for services. Family groups advocate for money for residential care services. Comprehensive Family Assessment
• A comprehensive family assessment is the collection of all relevant data related to family health, psychological well-being and social functioning to identify problems for which the nurse can generate nursing diagnoses.
• The assessment consists of face-to-face interview with family members and can be conducted during several sessions.
• Relationship Building: develop a relationship with a family. Developing relationship takes times, so nurses may have to meet on several occasions. o Positive relationship  nurses must establish credibility with the family & address its immediate intervention needs. o Cultural competence, professional image o First needs (shelter or food) should be met before discussion about medication regimen
• Genograms: facilitate taking the family history – multigenerational schematic depiction of biologic, legal and emotional relationships from generation to generation. o Includes age, dates of marriage/death, geographic location of each member. o Useful in understanding family history, composition, relationships & illnesses.

Transition Times: transition times are the addition, subtraction, or change in status of family members. During transitions, family stresses are more likely to cause symptoms or dysfunction. Significant family events such as the death of a family member or the introduction of a new member, also affect the family’s ability to function. During transitions, families may seek help from the mental health system.

WEEK 4: CHAP 15, 16, 17

Chapter 15: Mental Health Promotion for Children and Adolescents

- Resilience : some children at risk for psychopathology attain good mental health, maintain hope, and achieve healthy outcomes - Protective factors : characteristics that reduce the probability that a child will develop a disorder (e.g. 2 parent hh) CHILDHOOD AND ADOLESCENT MENTAL HEALTH

• Children more likely to be mentally healthy if they have good physical health, positive social development, an easy temperament, and secure attachment through emotional bonds formed between them and their parents at an early age o Easy temperament → can adapt to change without intense emotional reaction o Secure attachment → reduces fear of rejection COMMON PROBLEMS IN CHILDHOOD
• Loss (death of grandparents, parental divorce, death of a pet, loss of friends) → learning to mourn can → renewed appreciation of the precious value of life and close relationships Death and Grief
• Children who experience major losses are at risk for mental health problems, particularly if natural grieving process is impeded
• Children’s response to loss reflects their developmental level o Not until about 7 y/o can most children understand the permanence of death o Invincibility fable : adolescents view themselves in egocentric way, as unique and invulnerable to consequences experienced by others (ex: believe they are immune to dangerous situations- unprotected sex, fast driving, drug abuse) Loss and Preschool-Aged Children
• Pre-school aged child may react more to the parents’ distress about a death than to the death itself
• Best approach: explain honestly that the person has died and is not coming back, elicit the child’s understanding and questions about what has happened, and then repeat this process continually as the child gradually begins to grasp the reality of the situation Loss and School-Aged Children
• School-aged children understand the permanence of death more clearly than preschoolers, but may still struggle to articulate their feelings -- may express their grief through somatic complaints, regression, behavior problems, withdrawal, even anger toward parents
• Parents should provide grieving children w/ support; nurturance; continuity; and the opportunity to remember the lost person in concrete ways through photographs, stories, and other family activities Loss and Adolescents
• Adolescents in the formal operation stage (ability to use abstract reasoning to conceptualize and solve problems) can better understand death as an abstract concept
• Some are reluctant to express thoughts and feelings about death for fear of being viewed as childish
• Some assume a parental role in the family, denying their own needs Separation and Divorce - Parental separation and divorce change the family structure, usually resulting in a substantial reduction in the contact that children have w/ one of their parents - Children of divorce are at ↑ risk for emotional, behavioral, and academic problems - Response to the loss that divorce imposes varies depending on child’s temperament, parents’ interventions, and level of stress/change/conflict surrounding divorce - First 2-3 year after breakup tend to be most difficult o Typical childhood reactions: confusion, guilt, depression, regression, somatic symptoms, acting-out behaviors, fantasies parents will reunite, fear of losing the custodial parent, alignment w/ one parent against the other o Stepfamilies develop → renewed risk for problems - Protective factors against emotional problems in children of divorce and remarriage include: o Structured home and school environment w/ reasonable and consistent limit setting & warm, supportive relationship w/ stepparents, regular and predictable visitations, reduction of conflict btwn parents, continuance of usual routines, reasonable and consistent limit setting, family counseling - Helpful interventions : education re: child’s reactions; promotion of regular & predictable visitation; ****important to make it clear to children that the divorce was not caused by them** Sibling Relationships**

- Research shows that sibling relationships significantly influence personality development - Positive sibling relationships can be protective factors against development of psychopathology - Nurses should emphasize that minimizing sibling rivalry & maximizing cooperative behavior will benefit their children’s social and emotional development throughout life - Sibling rivalry begins w/ birth of 2nd child -- parents should recognize anger reactions of 1st child are natural and allow child to express feelings, (+) and (-), about baby while reassuring that he/she has a special place in the family - Some sibling rivalry is natural and inevitable o Intense rivalry and conflict between siblings → behavior problems in children o Positive temperament and effect, supportive coparenting can buffer against negative outcomes o Differential treatment of children can exacerbate sibling rivalry - Children w/ siblings who have psychological disorders are also at ↑ risk for mental health problems Bullying

• Repeated, deliberate attempts to harm someone, usually unprovoked o Boys more likely to use physical aggression (bigger boys pick on smaller, weaker ones) o Girls more likely to use relational aggression (disrupting peer relationships by excluding or manipulating others and spreading rumors)
• Children who have insecure attachments; who have distant or authoritarian parents; and who have been physically, sexually, or verbally abused are at risk for becoming bullies
• Victims of bullies often suffer from low self-esteem & relationship difficulties, even into adulthood
• Immediate intervention: Should involve coordinated effort by school, parents, bullies, and victims o The most effective programs involve educating and changing the climate in the whole school Physical Illness - Hospitalization and intrusive medical procedures are acutely traumatic for most children - Likelihood of lasting psychological problems resulting from physical illness depends on child’s developmental level and previous coping mechanisms, the family’s level of functioning before and after the illness, and the nature and severity of illness - Vulnerable child syndrome : family perceives child as fragile despite current good health, causing them to be overprotective; one possible outcome - Common childhood reactions: regressions, somatic complaints that mask attempts at emotional expression, and depression - Nurses must maintain a collaborative approach in working with parents of physically ill children o Teaching parents how to care for their children’s medical problems and reinforcing their successes in doing so will help - Children with chronic health conditions are significantly more likely to experience psychiatric symptoms than are their healthy peers o Conditions that affect CNS → likely to result in psychiatric difficulties o Inactivity and lack of sensory stimulation from hospitalization or bed rest may contribute to neurologic deficits and developmental delays o Children who view themselves as different or defective will experience low self-esteem and be more at risk for depression, anxiety, and behavior problems. Adolescent Risk-Taking Behaviors - Biologic changes (e.g., onset of puberty, height and weight changes, hormonal changes), psychological changes (increased ability for abstract thinking), and social changes (dating, driving, increased autonomy) are all significant. - Unevenness in adolescent brain development, specifically in the amygdala, may contribute to difficulties with impulse control or the ability to “think twice” before acting (Steinberg, 2013). - Many adolescents experiment with risk-taking behaviors, such as smoking, using alcohol and drugs, having unprotected sex, engaging in truancy or delinquent behaviors, and running away from home. Although most youths eventually become more responsible, some develop harmful behavior patterns and addictions that endanger their mental and physical health. One recent trend is self-mutilation or cutting by adolescents who use this as a cry for help or a tension release. - Adolescents whose psychiatric problems have already developed are particularly vulnerable to engaging in risky behaviors b/c they have limited coping skills, may attempt to self-medicate, and may feel increased pressure to fit in w/ other teens
• Approaches to mental health promotion: o 1) intervening at peer group level through education programs, alternative recreational activities, peer counseling o 2) Training in values clarification, problem-solving, social skills, and assertiveness (gives them skills to cope w/ situations in which they are pressured) o 3) Program that uses team efforts by teachers, parents, community leaders, and role models -- help at-risk youth by building self-esteem, setting positive examples, and working to involve the youth in community activities RISK FACTORS FOR CHILDHOOD PSYCHOPATHOLOGY

Poverty and Homelessness

- Children living in poverty may be more vulnerable to crime, drug abuse, gang activity, and teenage pregnancy because they may view their options as limited → may have increased need to maintain a tough image and struggle more for a sense of control of their environment; increased risk for physical health problems, mental health problems, educational underachievement - Preventive nursing interventions for disadvantaged families involves simply forming an alliance that conveys respect and willingness to work as an advocate to help patients gain access to resources - Additional risks arise from homelessness → may result from loss of shelter for entire fam, running away, or being thrown out of homes - Homeless youths → increased risk for physical health problems, mental health problems (inc. social development; depression, anxiety, disruptive behavior disorders) and educational underachievement o Many homeless youths have been physically and/or sexually abused → elevated rates of mental disorders ****IMPLICATIONS FOR NURSING:** Nurses and other health care workers are often on the front lines of screening efforts and should assess risk and protective factors among youth as they enter and move between out-of-home placements. Particular attention should be paid to the history and impact of physical and sexual abuse and suicidality. Youth in out-of-home placements may continue to idealize their parents despite the trauma that they may have faced at their hands. This need to remain attached to their parents should be supported since the emotional bond and perception of parental caring may be a protective factor for their mental health. Other research has demonstrated that programs promoting school connectedness increase the mental health of youth, and the current study underscores how these programs may be of particular benefit to youth in out-of-home placements. **Child Abuse and Neglect

• Includes any actions that endanger or impair a child’s physical, psychological, or emotional health and development
• Risk factors** : high levels of family stress, drug or alcohol abuse, stepparent or parental BF or GF who is unstable or unloving toward child, lack of social support for the parents - Young children & children w/ history of prematurity or medical/emotional problems are at high risk bc place great demands on parents - Children who have been maltreated are more likely to enter aggressive relationships, abuse drugs or alcohol to numb emotions, develop eating disorders, become depressed, engage in self-destructive behavior - To minimize damaging the nurse–family relationship, experts recommend that nurses report abuse in the presence of the parents, preferably with the parent initiating the telephone call. - Preventing child abuse and neglect occurs with any intervention that supports the parents with physical, financial, mental health, and medical resources that will reduce stress within the family system - A major protective factor against psychopathology stemming from abuse and neglect is the establishment of a supportive relationship with at least one adult who can provide empathy, consistency, and possibly, a corrective experience **Substance-Abusing Families
• Codependency movement** : emphasizes the effects of addiction on family members - Groups such as Adult children of alcoholics (ACOA) and Al-Anon -- increased attention to effects of parental substance abuse - Biologic factors affecting children include: fetal alcohol syndrome, nutritional deficits, neuropsychiatric dysfunction
• Children of those who abuse substances are at high risk for both substance abuse and behavior disorders o Other factors related to addiction (family stress, violence, divorce, dysfunction, and other concurrent parental psychiatric disorders) are also important in increasing this risk - Even for children who do not experience significant psychopathology, the experience of growing up in a substance-abusing family can lead to a poor self-concept when children feel responsible for their parents’ behavior, become isolated, and learn to mistrust their own perceptions because the family denies the reality of the addiction. **Out-of-Home Placement
• Family preservation** : involves supporting and educating the family in order to secure attachment btwn children and parents and to preserve the family unit and prevent the removal of children from their homes - The adjustment to an out-of-home placement can be viewed through the conceptual framework of Bowlby’s stages of coping with parental separation. o Child initially responds to separation from parents with protest → state of despair → detachment if the child and new parent can’t manage to form an emotional bond

- Typical coping styles seen in children exposed to multiple placements: detachment, diffuse rage, chronic depression, antisocial behavior, low self-esteem, and chronic dependency or exaggerated demands for nurturing and support → these symptoms can devlop into attachment disorders that can be difficult to treat INTERVENTION APPROACHES

• Selected interventions should allow maximal autonomy for the child and family; keep the family unit intact, if possible; and provide the appropriate level of care to meet the needs of the child and family
• Should view parents as partners
• Interdisciplinary approaches are ideal → nurse = coordinator, case manager, advocate in order to implement a comprehensive biopsychosocial plan of intervention
• Early Intervention Programs- Offer regular home visits, support, education, and concrete services to those in need; w/ support and eucation, parents are empowered to respond more effectively to their children
• Psychoeducational programs- teach parents and children basic coping skills for dealing with various stressors; focus on normalization (teaching fams normal behaviors and expected responses) & provide w/ info about typical child dev and reactions → families feel less isolated and know what to expect
• Social Skills training- involves instruction, feedback, support, and practice w/ learning behaviors that help children interact more effectively w/ peers and adults; useful for youth who have low self-esteem/ aggressive behavior who are high risk for substance abuse
• Bibliotherapy- empower families to learn and develop coping mechanisms on their own (books, pamphlets) o By providing concrete info and advice, these reading materials help to reduce anxiety by pointing out common reactions to the various stressors, so that families do not feel alone **Chapter 16: Mental Health Promotion for Young and Middle-Aged Adults YOUNG AND MIDDLE-AGED ADULTHOOD MENTAL HEALTH
• Sandwich generation** : middle-aged parents are often already caring for their own parents, with its responsibilities toward the elder generation above and two generations of children below them COMMON CHALLENGES IN ADULTHOOD
• Significant life events in young & middle-aged adulthood: leaving primary home for first time, getting married (or not), taking on new caregiving responsibilities, breadwinning role, unemployment can be a major life challenge Changes in Family Structure
• Normal developmental events (marriage, having kids) can also lead to mental distress, physical problems, social alienation
• Widowed, divorced, or separated adults are more likely to experience serious psychological distress than married adults o Rates of separation or divorce are at least 2x as high for those w/ almost any psychiatric disorder as for those w/o Caring for Others - Informal caregivers - unpaid individuals who provide care; largest source of long-term care services in the US - Caregivers are under considerable stress and often neglect their physical and mental health needs o Also report higher levels of loneliness, anxiety and depressive symptoms and other mental health problems o Altered physical and mental health reduces quality, satisfaction, and ability to cope w/ daily caregiving stresses Unemployment
• Employment serves as a source of economic, social, and emotional stability and self-esteem
• High risk groups for low wages and unemployment: African American, Hispanics, single mothers
• Within the cohort of unemployed workers, there are twice as many ppl w/ mental disorders o Of those w/ mental illness who are working, many are underemployed MENTAL DISORDERS IN YOUNG AND MIDDLE-AGED ADULTS
• Great majority of ppl experience their 1st diagnostic symptoms of mental illness during late adolescence or early adulthood o Highest rates of mental disorder occur among young adults
• Changes in the biologic, psychological, and social domains can create a matrix of stress that may foster mental disorder o Fewer than ½ of those w/ mental disorders receive any kind of tx from mental health professionals RiSK FACTORS FOR YOUNG AND MIDDLE-AGED ADULT PSYCHOPATHOLOGY
• Specific risk factors can contribute to poor mental health and influence the development of a mental disorder o Risk factors don’t cause disorder & arent symptoms but are factors that influence likelihood that symptoms will appear
• Gender, age, unemployment, lower education risk = risk factors associated w/ mental illness Biologic Risk Factors