all right guys uh it's dr marquez here we are going to be doing a quick recap of some significant areas that i think will be important for you to ensure you have familiarity with as well as a basic understanding regarding some important concepts regarding psychoanalysis mental health overall psychotropic perspectives of medication management and different diagnosis that are commonly and often seen in mental health so first uh chapter i want you guys to take a look at it incorporates the biological basis for understanding psychiatric disorders and treatments i'm going to kind of skip ahead and go to areas that are important you will be expected to know the actions of neurons particularly understanding the perspectives of how neuronal activity occurs looking at the synaptic changes that occur regarding messages being sent and altering particular areas of functioning as it relates to disturbances or dysregulation in a certain neurotransmitter um the neurotransmitters that we're going to look at specifically are going to be norepinephrine serotonin dopamine glutamate and gaba one that isn't mentioned here but is also important for you to know is acetylcholine um because it does have a significant effect on a mental health disorder but again it's a little bit controversial to have under mental health but acetylcholine and the dysregulation of civil coding have a lot to do with things like dementia and organic brain syndrome so that one isn't mentioned here but that is also an important neuron that you need to be aware of as far as this mechanism of action the big one here all of them are important because they have certain aspects that affect a individual's mental health but serotonin is often related to quite a few disturbances and we'll talk about that as we move forward but you do need to know norepinephrine serotonin which is also known sorry norepinephrine which is also known as the um the uh fight-or-flight response um you'll see it often uh discussed as um uh when we look at the other aspects of norepinephrine uh you'll see that there are medications like serotonin norepinepta reaptic inhibitors that are often interchangeable because utilized with uh serotonin norepinephrine and serotonin have a lot to do with things like stress and anxiety so uh and so you're gonna see norepinephrine also interchangeably used with endorphins as well okay all right um we're gonna talk about medications just do a quick recap of medications so um your benzodiazepines um the pam sisters are often what we acclimate or what we associate with the pams um valium clonopin xanax and anivans diazepam clonazepam alphazolan and lorazepam are all benzos it is important to remember that they are to be utilized in a short-term basis unfortunately people do use them on a longer term basis than what's um recommended when you look at some of these medications do be conscientious that they are highly addictive people can become dependent on them and you can also start to become tolerant to the medications as well medications used from a injectable perspective that you're going to see for patients that have panic disorders or severe anxiety in particular in the hospital if you have a patient show with a panic attack um they're often going to be given out of them because adamant can be given iv or im the rest xanax clonazepim um and diazepam are po as well uh so the lorazepam is usually your medication given in the hospital and it's usually given iv for panic disorders again there's a variety of benzos that can be prescribed all of them are considered control substances so it is important to educate patients about not taking these medications with other medications or other substances that can cause respiratory depression particularly alcohol or other illicit substances these are some other hypnotic drugs of fluency fluorazepam demazepam trasoline misadozulum and uh quasipam and i don't use that much to that one too much too much to mass pam's often used in the hospital it's also known as restoral to help patients sleep when they're in a foreign environment um so restaurant is often used for sleep-wake disorders or insomnia as a result of environmental stimuli again all of these are highly addictive so it is important that you educate the patients about not taking these with other substances such as alcohol or drugs and maintaining short-term use of it these are your hypnotic drugs or what we call the z hypnotics they would be zolpidim zeloplan and um a cyclopene which is lunesta so it's ambient sonata all of these medications are prescribed for sleep-like disorders particularly insomnia again you patients can become dependent and they can become addicted to the medication so you want to use it cautiously and educate the patient about taking it sparingly not taking it every night um really it is used for severe insomnia so some of your melatonin receptor agonists rose around cylinder and boost i've talked about buspirone before bispro is actually a really good medication to utilize for chronic anxiety agitation and anxiety irritability uh it is non-addictive in nature so the anxiety medications if you're going to prescribe something for more of a chronic issue associated with those symptoms boost bone would be a more appropriate medication to prescribe your antidepressant drugs your tcas or tricyclic antidepressants like amitriptyline or dropdoline and imapramine or pamelar elabel and tophenyl all of these medications um can and have been used in the past for treatment of depression and anxiety don't use them quite as much as we used to just because the tendency with side effects of these medications is much higher so we try to utilize medications that don't have as much of a tendency to have side effects number one side effect with using tcas is going to be gastro well actually all psychotropic medications number one side effect is gastrointestinal irritability uh so um constipation nausea reflux patients will complain about cramping as well tcas also can have a significant sexual side effect too amitriptyline can help with sleep weight disorders as well so we do use it at night too as well as uh amitriptyline and the maparovin can also actually help with migraine disorder or severe headaches or as prophylaxis for headaches uh your ssris are your number one go-to medication regarding uh an antidepressant utilized for depression and anxiety um these medications are most often prescribed because of the side effects being much less with the use of an ssri so this is your go-to medication philosophies virtually peroxidine citalopram scattalopine and fluoxamine these are all medications that would be more appropriate to use initially versus jumping to a tca we usually will try a couple different ssris before we put a patient on the tca just because we're concerned about the potential for side effects so always go to an ssri before you try a different type of antidepressant snris like memphaxy and desmonoflaxine and diloxatine they can be utilized as well because they are serotonin norepinephrine reuptake inhibitor the big one with this one is that they have a lot of dual um combinations as far as what their um directive is for meaning what they're what we use them for specifically deloxating like cymbalta is used a lot in pain management because it also works on the gaba receptors as well so it can help with pain control it's not pain medication but it can help alleviate some experiences with pain so patients have depression or anxiety but also have accompanying physical pain we can prescribe deloxating mental vaccine good medication uh does have a tendency to cause uh significant weight gain a lot of patients who use it before say it works great but they have a tendency to gain weight on the medication as well pristiq uh good medication too has a little bit longer acting effect with it um but uh it's a significant potential for sexual side effects with snris um the serotonin norepinephrine disc inhibitor is mirtazapine or remron merge hazamine is used for patients that have significant sleep like disorders or insomnia so it's utilized for patients that have a dual modality with depression and insomnia patients take it at night it has a significant side effect of making the patient drowsy or sleepy so it is taken in the evening to help with a sleep-like disorder as well uh malis like uh azoc epoxide um phenylazine selegne and travels like colopramine parnate and some nardo and marplen all of these medications uh of all the medications regarding uh prescribe prescribing um in order of what has the least amount of side effects maoi should probably go third in line of utilization because it can have some significant gi side effects with it there's also certain foods that are contraindicated to utilize with malis so you want to stay away from your terramine um derived foods so that would be like your aged cheeses red wine grapefruit so it does have a certain types of cured meats as well so that it does have some contraindications of a certain foods just some of your other antidepressants the program wellbutrin or xyben is used oftentimes for patients who also have a smoking disorder so patients who are desiring to cease their smoking habit uh bupropan is used well with that you can parape propion as well with ssris you have a fairly significant um cohabitation positive effect for the patient so you're going to see a lot of these medications uh co-utilized with other types of ssris trazadone is helpful for insomnia too mood stabilizers are used for patients with a bipolar disorder or mood disorder first medication you see is lithium lithium is the go-to medication for uh patients that have bipolar disorder is the most significant um uh lasting effect regarding addressing patients with uh bipolar disorder so it is usually the go-to medication you do need to know the therapeutic uh range for lithium uh 0.5 to 1.2 um there's a couple like the book has a little bit of a different level associated with some of the other literature out there um and the significant component to look at with lithium is that anything over a 1.5 can be toxic in nature so it's got a very short therapeutic index um some other drugs that we use for stabilization are going to be like your depakote carbomezapine lamotrigine gabapentin to perimate and oxycarbzepine again these are usually your go-to drugs if lithium the patient isn't being compliant to utilization of lithium like having their blood draws uh checked uh periodically to ensure that the patient doesn't become toxic on the medication we usually want to do a baseline lithium level on the patient and then check them again in six weeks and three months and then thereafter every three months for the first year and unless the patient is having any kind of significant side effects associated with uh utilization of lithium you can usually do maintenance every three to six months thereafter as long as there aren't any changes into the dosage antipsychotic drugs are classified as fgas or first generation antipsychotics they are the conventional typical centered antipsychotic drug that bind to the d2 receptors they block attachment of dopamine and they reduce the dopaminergic transmission um so we use these for patients that have schizophrenia some smi's or serious mental illnesses but the antipsychotic drugs are fairly significant in not just their utilization as far as compliance is concerned for them to be um as effective as possible but their side effects can be significant and this is a lot of the reason why we can't get patients to stay on them their antagonists have receptors for acetylcholine norepinephrine and histamines but the significant side effects are associated with weight gain and sedation when i say awaken i talk about significant weight gain 30 pounds or more so it can be really disheartening for the patient if they already have low self-esteem to then gain significant amount of weight your sdas are your atypical antipsychotic drugs produce fewer extra parietal side effects they target both negative and positive symptoms you do need to know negative and positive symptoms remember what i told you guys memorize what your negative symptoms are and if you do that then everything else would be all your positive symptoms would be fairly easy to remember just because there's not as many symptoms associated they're often chosen as first line treatment because of the lack of side effects associated and then you've got when we look at sga's we look at dopamine and serotonin blockers associated with those these are samples of sgas second generations most often you're going to see respiratory catio pain used a labs means a good drug and so is the prostate but those are the ones that you talk about the significant side effect with weight gain also polydipsia dry mouth uh patients that um will complain of feeling really sedated and sleepy on these medications uh palo paranone is a good medication it can be used on a long-term basis because it can be prescribed as an injectable as well so it lasts a patient like a month while they're on it um and it does have to be administered by a nurse and has to be administered in the office so we can actually watch the patient afterwards for any type of uh side effects and lastly your error purposel or ability which is a dopamine stabilizer it's probably most effective of all the medications but it's also extremely costly very expensive and you have to basically prove to most insurance companies that you've tried everything else before they'll approve you to go on their purposeful or abilify other drugs we use medications for adhd it's adhd is a disorder that's usually associated with a childhood onset or adolescent onset but it can manifest into adulthood as well medications are used for that are going to be stimulants stimulants i'd like some of your other control substances have to be washed very carefully unfortunately the use of these medications on the streets when cut with junk from the streets can and then cooked can result in meth on the street so we want to be very conscientious of how it's prescribed there is high misutilization of stimulants prescribed for adhd uh methylphenidate dextron cytomeans atomoxetine in turnip and caffeine are some of the samples of this medication for alzheimer's disease you're looking at medications that help with dysregulation of acetylcholine for alzheimer's you're going to look at attack grain dinepazole which is most often the medication that's prescribed glutamine ribestomine and laventine momentum is also used do understand all these medications are used uh hopefully to slow the progression of the disease but they are not cured by any means that's the goal is just to help with the progression of organic brain syndromes some herbal medications we want to be conscientious of our medications they can get over the counter such as st john's wort which has an anticoagulation effect um long-term effects of herbal medications depending on what they are you can see nerve damage kidney damage or liver damage just depends on what the patient is taking over the counter and what type of mix they're putting together and there are possibilities of other adverse chemical reactions one of the big ones that we look at right now is the utilization of thc or cannabis um and it really you know if you're put a patient an antidepressant and they're using thc or cannabis for assistance with their anxiety you're basically countering the effect of an antidepressant when you're utilizing thc which is depressant so it may potentially help with anxiety but it's not going to do much for your depression um okay a person has a decrease in circulating oh you guys can go and read that i just wanted to kind of go with those components with you guys okay i'm gonna pause for a second we'll get to the next piece so give it a sec all right so let's take a look at legal and ethical guidelines for safe practice i'm gonna skip ahead kind of give you some [Music] components of legal areas that you need to be aware of the different types of admission procedures associated with admissions into a formal setting um specifically looking at hospital admission so an informal admission is when the patient themselves seeks to be admitted because of either a threat to self or threat to others suicidal or homicidal ideation a voluntary admission is when it's stopped by the patient or guardian um a temporary admission is when the person is confused or demented or they're so ill that he or she needs emergency admission remember there are three reasons to admit a patient to the hospital for a psychiatric disorder and that's going to be a threat to cell threat to others or gravely disabled greatly disabled can be a patient who has advanced dementia or is unable to do basic care for themselves eating sleeping bathing because they're so cognitively impaired that they cannot do these functions independently we don't usually keep patients that are demented um unless they are legitimately trying to hurt themselves or hurt somebody else but the goal is to really try and place them so that they can be in a safe environment because it's more their inability to function independently so usually those patients we try to transfer out of a acute care hospital that deals with psychiatric emergencies and find them something a little bit more stable and involuntary admissions without a patient's consent uh and again this can be as a means of assessment that's been done in involuntary admission is um indicated for that patient long-term involuntary admission needs medical certification judicial review and administrative action so you can't just put a patient into the hospital and say you're going to be here for 30 days we know that there are certain wic guidelines um that we'll look at right now in order for a patient to be admitted in what types of admission it's deemed involuntary outpatient admission is also a perspective to look at discharge procedures you can have a conditional unconditional or an ama discharge conditional release is often used for patients that have alcohol abuse disorder or some type of drug addiction and they're mandated after released from the hospital to attend like a 12-step meeting where they have to go to so many aaa meetings um or they're going to be released to a family member or a guardian so they're not released without any uh or they're released with restrictions unconditional releases basically no restrictions the patient is independent to be able to release to be home and a release against medical advice where the may patient may not have been deemed to be um threat to self or threat to others but maybe they have it has indicated that they should be in another facility or they should go with family we can still release them but against medical advice would mean that they're going against what is being advised for them patients rights under the law right to treatment right to refuse treatment and right to inform consent it is considered battery if you do something to a patient they do not give you consent so it does that does that mean if a patient is in a mental health facility they don't get the same rights as any other citizen or any other patient okay they have the right to involuntary commitment surrounding and voluntary commitment and psychiatric advance directives rights regarding restraint and seclusion rights to confidentiality what they don't have a right to is a private room um be nice if everybody could get one but that is not a right uh hipaa confidential confidentiality after death confidentiality of professional communication and so forth is also intact for the patient we there are a few exceptions to the rule we talked about the um [Music] the duty to warn as providers if the patient has deemed to you that they're going to hurt someone or they have a plan or intent to cause harm to another person as well as child and elder abuse too much okay let's go to the next thing all right guys so let's go ahead and take a look at the wic document i want you to be aware of okay everybody needs to know these all right these are your welfare and institution codes utilized uh for admission purposes and to understand what type of admission the patient is going to be um admitted into or what the what the rationale would be so if you look at a wic 5150 most of you should be aware of this this is also known as a 72-hour hold it is defined as detention and mentally disordered person for evaluation and treatment for a period of 72 hours for persons alleged to meet the legal criteria of being endangered itself or others are greatly disabled due to a mental health disorder okay if the patient is admitted uh and we deem that the patient has to be overseen a minimum of 72 hours as a hold will be maintained if the patient um is deemed to need to go beyond the 72 hours then we're going to look potentially at a wick 5250 which is certification for attention treatment for a period of 14 days the person's alleged to meet the legal criteria of being a dangerous offer others are gravely disabled due to mental health disorder a wic 5260 is additional intensive treatment for a suicidal person of a suicidal person so we've already done the patient is has a suicidal tendencies or intention certifications for an additional period of 14 days beyond a 52-50 the first 14 days to persons who are allegedly imminently suicidal due to a mental health disorder a wick 5270.15 it's also known as a 30-day hold and this is additional treatment intensive treatment um for an additional period of 30 days beyond the wick 5250. so you see that we went from a 15 52 50 which is 14 days to additional 30 days so um you can go from a 50 to 50 to a 50 to 70 15 for persons who are greatly disabled and so forth and then your wic 5300 is known as 180 day post cert which is the procedure for imminently dangerous dangerous persons for a period of 180 days beyond a wick 5250 which is your initial 14 day hold for persons who allegedly made a serious threat or substantial physical harm or tempted or inflicted physical harm on another due to mental disorder so do know these they are important for you to be aware of because you do need to know the legal statutes associated with these types of admissions as well okay okay on this slide i have one particular slide i really need you guys all to know and that is your mechanisms of action associated with your uh neurotransmitter and the neurotransmitter function so let me take a look at i want to say i believe it is oh there it is uh slide number seven on the neurotransmitter slides um know this chart you have to know it this is your these are your neurotransmitters and their function so if i ask you specifically the momentum is utilized for patients with alzheimer's disorder what neurotransmitter is most associated uh what disregard the dysregulation of what neurotransmitter is associated with alzheimer's disorder you would need to know acetylcholine and glutamate those are your two most dominant neurotransmitters associated with that disorder i may say a patient has a history of um alcohol abuse disorder or of ingestion of illicit substances or some type of compulsive disorder associated with drugs or alcohol you'll need to know that the two that you're looking at specifically would be dopamine dysregulation of dopamine as well as um norepinephrine um you for for the most part when you look at that type of thing we'd want to see that you know um issues associated with pleasure and reward feelings or dysregulation associated with dopamine has a lot to do with those types of disorders and then the pleasurable feelings that come with them as well so it would be both of the neurotransmitters involved in which one is most predominantly involved so this is what you want you guys to memorize this slide number seven is super important so please please know this one i guarantee you're going to get questions about this slide okay so do make sure you go over that and you're going to have more than one neurotransmitter associated with most of your disorders um for instance stress anxiety depression are going to involve serotonin and endorphins or norepinephrine uh to some extent you may also see some issues associated with if a patient has like aggressive angry or you know has irritability associated with their anxiety you may also see some uh gaba mixed in there i'm not going to get as specific as that if i'm going to use that type of a scenario but you do need to know what neuron transmitters would be desperately disregulated when you look at these types of issues okay all right so now that one okay this is chapter eight um i skipped ahead to therapeutic relationships chapter 8 really focuses on the establishment of the therapeutic relationship with the patient the important thing to remember about therapeutic relationships and mental health is that honestly this is very one-sided this is not about us as the nurse it's about the patient and whereas in a regular or normal relationship it's reciprocal in nature you ask a question someone responds they ask you a question similar to what you have asked so that you have that opportunity to really delve into both sides of a conversation and this is not to say that your responses to patients need to be monosyllabic or cold in nature but the establishment of therapeutic relationship really depends on you allowing yourself to be there for the patient and making them the focus of the relationship the needs of the patient are identified and explored it doesn't say needs of the patient and nurse are identified explored this is about the patient clear boundaries are established um this is not a friendship this is not a relationship that's going to lead to you having coffee or dinner one night it's about you being there for the patient from a professional perspective and offering stuff you want to take a problem problem-solving approach to this develop coping skills and help the patient develop their coping skills and change the behaviors you can never make a patient change who they are but you can help them identify behaviors that are affecting them negatively um some of the areas i want you to ensure is that you understand the blurring of boundaries can occur and the reason is is that information is shared that is very personal in nature and when a patient sharing that type of information they start to create a bond with you but when this relationship slips into a social context or when the nurse needs are met at the expense of the patient's needs then these boundaries have been blurred um when we look at the concept of blurring of roles one of the main um um components to look at are two um two issues that need to be addressed and that's the issue of transference this is when a patient unconsciously and inappropriately displaces onto the nurse feelings of the behavior and behaviors related to significant figures in the patient's past transference intensified in relationships of authority so the patient looks at you and then you remind them of a friend or a wife or a husband or a significant other and because of that that that component of them looking to you as someone they relate to also gives you more authority in the relationship so you have to be careful with that because it can it can lead to some significant um negative outcomes counter transference on the other side is really when it's the nurse that displaces feelings related to people and the nurses pass on to the patient so this is the nurse projecting onto the patient patient's transference to the nurse often results in counter transference so it's this blurring between both the the patient and the nurse and common sense of counter transference in the nurse is over identification with the patient saying things oh like i know how you feel or i've been through that experience before or i have a brother who has experienced the same thing again remembering this is not about us this is about the patient so no um transference and counter transference because those are two main topics that you need to be conscientious of okay okay this is chapter 10 this looks at the stress response um some of the theoretical ideas behind stress response have to do with um concepts developed by dr walter cannon he looked at the fight-or-flight response the run to it or went away from that response this is really the body's perception of protecting itself it prepares for a situation that individual perceives as a threat to their survival new research indicates that men and women have different neuronal responses to stress we know that neuronally we're going to be looking at serotonin and norepinephrine as two of the major neurotransmitters associated with stress um solay looked at the jazz or the general adaptation syndrome you've got three stages to stress which are the alarm or the acute stress stage resistance or adaptation and then exhaustion stage psychological reactions were developed by lazarus and these are two concepts you need to know distress and eustress eustress is positive it means that it's protective in nature it means that if you were to go to a corner and there was a lot of traffic and your eustress is protective in nature because it's stressing you to the perspective that you don't want to put yourself in danger by putting yourself out in traffic so it protects you from doing things that potentially are dangerous to yourself or could cause harm to yourself so eustress is not a bad thing distress can be a negative component of a mental health reaction if it causes you to not be able to function if it's so if the distress becomes so life-altering that you can't get out of bed you can't get up to brush your teeth you're so stressed about your environment around you that you're unable to engage in your regular activities so that would be considered a negative response we know that neuronal stress transmittance transmission involves serotonin synthesis becoming more active so we may see more active dysregulation in the neuronal transmission of serotonin this can impair receptor sites and brain's ability to use serotonin um let's see anything else it can be physical and psychological in nature meaning stress can have a physical manifestation on your body sometimes you call it a somatic issue like when you're having mental health issues and you have physical response to mental health issue extreme stress or severe stress can can cause the patient to become panicked as well so we the concept between inner reliability of stress and anxiety are very close in relation so depending on how bad it is you can have a physical response to it as well um some of the things to help with manage stress through relaxation techniques are like deep breathing progressive muscle relaxation relaxation response meditation guided imagery things that you can do environmentally exercise is really really good for stress it just creates natural endorphins in the body as well okay um [Music] okay that's it all right let's look at schizophrenia and schizophrenia spectrum disorders um it really doesn't have any it's important to remember that it doesn't have any specific rationale associated with race social status or culture it can affect anybody and it does not differentiate between race culture social status or culture so it crosses the spectrum so the comorbidities are substance abuse disorders anxiety depression suicide physical health or illness issues with poly dipsy have been thirsty a lot as well um the there are patients that are genetically predisposed to schizophrenia if there is a history in the family neurobiologically the dopamine theory uh looks at how the transmission or the dysregulation of transmission of dopamine can be associated with positive symptoms of schizophrenia so not necessarily positive and negative but it's a really factor that's associated with positive symptoms so the theory is that you're going to see the dysregulation of dopamine as a result from a neurobiological perspective the three neurotransmitters associated with schizophrenia are going to be dopamine glutamate and serotonin so dysregulation of all three of those neurotransmitters are linked to schizophrenia and that would be your other neurochemical hypotheses um some of the psychological environmental factors some of these you know we look at the data associated with them and following these from a long-term perspective a little bit harder with prenatal stressors wise but uh psychological environmental stressors are uh indicated to exacerbating the disorder we're going to look at the phases of schizophrenia the acute phase which is when it initially occurs and i often see this in early um in late teens um 18 to 21 and the thought process is you know a lot of times they can learn how to compensate when they're home they learn how to deal with the issue they learn to work around it they're in the familiar environment and then when you send them off to college or you send them off after high school on their own or whatever the case may be they're no longer in this situation or in this environment that they're comfortable or they can manipulate because they've learned how to do it so uh the first acute onset often happens between the ages of 18 and 21 uh so when the person arrives to college or is that on their own phase two has to do with stabilization this is when the symptoms begin to diminish the movement toward previous level of functioning is uh started so similar patients on medications the patient's seeing a therapist the patient is more stabilized because they've been on a routine that addresses their plan of care more appropriately and then maintenance is really looking at an at or near baseline functioning so what they were previous to their mental breakdown or the issues associated with the acute exacerbation uh let's take a look at the positive symptoms of the negative so here's all your positive symptoms delusions which are false fixed beliefs ideas concrete thinking inability to think abstractly alterations and speaks associated with looseness like clang associations word solid neologisms echolalium these are all of your positive symptoms so here's what i tell you to do memorize your negative symptoms because they all have to do with affect um and this would be like a flat affect blunted inappropriate even bizarre if you memorize your negative symptoms everything else is pretty much going to be positive and that can range from everything from catatonia to modern retardation to motor agitation uh so um know your that your negative symptoms for sure because then everything else is pretty much going to be positive symptoms i know it sort of has like a strange connotation because you would think it would be good to hear a positive it just means that you're having these particular symptoms so do be conscientious of that you got to check for potential depression because there's a high rate of comorbidity with it patient with schizophrenia says there are worms under my skin eating the hair follicles how would you classify these symptoms if we go back to our positive symptoms it's actually hallucination auditory command visual um dot insertion dot uh deletion flight of ideas see if they have anything um let's see i'm gonna see um trying to see if there's something specific well it would be delusional in nature i do remember the hallmark of schizophrenia is aleutians and uh being uh delusional as well there are three types of hallucinations auditory command visual there's others as well tactile olfactory but these are the ones that you're going to see most often associated with schizophrenia tactile hallucinations are usually associated with patients that have um you can't see them schizophrenia but they're not as predominant as they are with patients that have some type of drug abuse disorder um so auditory about 80 of the time a patient who has uh schizophrenia is going to have auditory types of hallucinations the next would be a command individual the one thing information tells you if they're seeing things or they're hearing things the important thing to ask is are those things telling you to do something are they telling you to hurt yourself or hurt other people those would be considered command because the hallucinations are actually telling them to do something okay so those are some important aspects to remember memorize your negatives everything else is pretty much going to be positive okay so let's look at adhd um again we talked about a little bit in the beginning adhd is usually recognized in in elementary school sometimes in middle school but for the most part you'll start to see issues associated with attention concentration inattention focus memory all those types of symptoms associated with adhd usually in grammar school around the age of seven uh it usually appears in truly early childhood but it can appear a little bit later especially if the kid has not been diagnosed signs and symptoms of adhd typically occur about the age of seven can be difficult to distinguish between adhd and normal kid behavior is this just you know a child that's very excitable and um you know somewhat the class clown just wants attention versus someone who really can't focus or concentrate or has difficulty in completing tasks there are um it's very it's known in various cultures western countries probably have more uh association with them because we test for it more often um [Music] so about a seven percent average in children uh as far as uh seeing this disorder occur anywhere from three to seven percent the um subtypes of adhd are classified by the six by six by six rules which are adhd combined type which is the most common type of scene it's usually when there's six or more symptoms of inattention and six or more symptoms of hyperactivity slash impulsivity have persisted for at least six months so again the six by six by six rule most children adolescents with this disorder have a combined type this is adhd predominantly inattentive type basically the same thing except that you have fewer than six symptoms of the hyperactivity and impulsivity occur however in attention um you have six or more symptoms of inattention that occur and again this has to be six months same thing with the predominantly hyperactive type you're gonna see less symptoms of inattention but more so with symptoms of hyperactivity and impulsivity so you want to identify the six by six five or six rule and again we put it for six months specifically to see you know from a range perspective how long has this uh child been having issues with this we don't want to do it from an acute basis maybe the kids very excitable at some point maybe they like somebody in their class maybe they just want to be attention but it's not transient in nature this type of behavior really needs to be maladapted and inconsistent with developmental level if you've got an eight-year-old who's used to sitting in there you've got a classroom of kids and you know 28 year olds are sitting there at their desk coloring and every day you have to fight with a child because they're never in their desk they're never doing what they're supposed to be doing you know they're taking their shoes off they're running around the classroom they're playing with you know audio visual equipment so it's inconsistent with their developmental level um here are your diagnostic criteria within attention so if you're doing the six by six by six rule and it's prominent uh predominant in attention then you'd have to have six of these diagnostic criteria um and less so with the hyperactivity impulsivity and vice versa as well do know the different factors associated with those uh it can be distinct difficult to distinguish between symptoms of adhd from age-appropriate behaviors and active children kids like to run around and be noisy versus kids who really are having a you know really significant issue in functioning at school we use medication-wise we do use um [Music] we're going to use stimulant well i did want to mention the two neurotransmitters associated with dysregulation with this disorder are going to be dopamine and norepinephrine remember we're talking about memory inattention focus so all those things are challenged in this particular disorder so again all right uh remember dopamine and norepinephrine are your two neurotransmitters associated with this disorder okay so let's talk about autism autism is characterized by a umbrella term associated with the term pervasive developmental disorder there's a few different disorders that fall under this generalized term but um autism itself is categorized as a pdd it is characterized by difficulties in social interaction verbal and non-verbal communication repetition in behaviors intellectual disabilities and difficulties with motor coordination and attention some of the aspects regarding demographics wise um about 1 in 110 american children have autism this is about a 600 increase over the past two decades not there's not a lot of substantiation as to why other than um we do know that there is some um there is some impact associated with uh mothers have babies over the age of 35 so advanced maternal age has been linked there is no linkage between vaccinations for a while there was a rumor that was really being mongered by celebrities and unfortunately gained some traction but autism is not caused by vaccinations in particular mmr uh mmr has was the vaccination that was pointed out potentially having a link between symptoms of autism this has been debunked there is no research to substantiate that claim so if you get asked a question about it is not true it is not a there is no evidence to support that claim um signs and symptoms impairment and social interactions impairment and communication and again looking at restricted repetition and stereotype patterns of behavior you know the rocking back and forth the pill rolling the repetition of sounds the echolalia so all of these types of symptoms um can accompany autism there is autism is put on a spectrum as well it can be fairly pervasive um have some significant um issues associated with symptomology and then on the spectrum it can be not as pervasive as well there are a lot of functional people that have autism for a significant amount of time it was also coined as workers syndrome we don't use that anymore we just say that the patient is on the spectrum because there's a wide variation between how pervasive the disorder can be so you can function on autism and it can go all the way to being highly non-functional as well depending on how many symptoms are present and how how pervasive the issue is the biological signs in large portions of the autistic brain are often seen abnormal genes can be identified including ones that may alter brain architecture genes can interact with environmental factors and the major brains areas implicated autism are the cerebellum cerebral cortex temporal lobe in the amygdala neurobiology perspectives it's commonly believed to be caused by widespread abnormalities in brain structure and function that occur prenatally and in early life neural trajectory is altered by cell migration formation of neuronal networks neurotransmitter systems failing to perform optimally and communication between neurons may be impaired there's not one that's specifically i mean you can look at you know movement disorder you can look at um stereotypical behavior so associated with dopamine but then you also have um issues associated with mood um so it this is more neurobiologically associated with formation of or misformation of neural networks as a result of widespread abnormalities in brain structure so it's more anatomically based as well from a functional perspective can be related to excess brain overgrowth during the first two years and then the regionally specific areas of the brain start to become affected we usually don't see symptoms occur until about second or third year of life when higher level functioning like language complex social interaction that requires integrational complexity to emerge um so usually we're not going to see a lot of the symptoms associated with autism until like the second or third year of life when more like i said high level functioning occurs um this again is because it affects so many components of the brain it is considered a whole brain integration deficit so versus um neurologically um affecting the neurotransmitters because it has so much more to do with the brain the function of the brain as it relates to components of the brain not being having pervasive issues with development or over development or underdevelopment it's again more anatomical in nature and neurobiological in nature if we look at the amygdala larger amygdala and autistic children in adolescence adults amygdala appears to be the same size or smaller larger amygdala means increased anxiety poor social skills and communication processing distinguishing faces understanding sensory stimuli and social stimuli there really are no specific tests for autism it is identified in the dsm criteria it's more of a rule out type of diagnosis so they do various testing to see what issues may be present in this child again there's no cure for autism uh early intervention is important things like ot pt sensory integration therapy uh some of the health considerations these children do have a tendency to have gi issues leaky gut food allergies it is often suggested to put a child on a gluten-free carbohydrate limited type of diet as well so staying away from complex sugars and that's pretty much it for that okay we'll keep going this is bipolar disorder covered in chapter 13. bipolar disorder is characterized by periods of significant depression and periods of mania a manic episode is a period of abnormally and persistently elevated expansive or irritable mood during the period of new disturbance at least three of the following symptoms have persisted for if the mood is only irritable and have been persistent to a significant degree these include inflated self-esteem decreased need for sleep more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing so racing thoughts is you also have to have an increase of energy that needs to be one of the hallmarks of the disorder so that has to be one of the symptoms that have persisted okay uh distractibility increasing goal directed activity or psychomotor agitation as well as excessive involvement and pleasurable activities that have high potential for painful consequences like buying sprees sexual indiscretions foolish business investments and this happens usually when the patient is having a manic episode mood disturbances sufficiently are severe enough to cause marked impairment and occupational functioning using usual our usual social activities as it relates to relating to other people and no time during the disturbance have there been delusions or hallucinations for at least for as long as two weeks in the absence of prominent mood symptoms so this is not a hallucination or delusional type of disorder however because a lack of sleep is one of the characteristics that you may see the patient can have a reaction to their lack of sleep so once they kind of hit that wall where they have to sleep they may become delusional because they've been sleep deprived but it's not a delusion or hallucination as a result of the during that particular period of time that they're having a manic episode it's not superimposed on schizophrenia or delusional disorder or other psychotic disorder it's usually because there's physiological effects of a substance or a general medical disorder that it cannot be due to so if a person is having a manic episode it cannot be as a result of ingestion of a listed substance presentation of bipolar disorder will present with a manic episode depression and a mix of the both of them um there are two types of bipolar disorder type one is manic mixed episode including a major depressive episode and type two which is a hypomatic episode a major depressive disorder now hypomanic just basically means that it's not to the same degree as a full manic episode a lot of times people can have actually bipolar 2 disorder and function at work and so forth where they have some some characteristics of a manic episode but not nearly as acute not nearly as um extreme so they can be much more functional these are the prevalence components of it angelons it's usually late adolescence or early adulthood sometimes it can happen after age 50 but late onset is more common in type two so the patient may have been living with it for a really long time and not really recognized or had a hypomanic episode until they're later after the age of 50. um we look at neurological secondary causes of mania like non-dominant frontal cpa non-dominant frontal tumors huntington's disease and multiple sclerosis not to be confused with actual bipolar disorder these are neurological issues that can occur that can have very similar um monetizations that look like a manic episode but it's not categorized as bipolar 2 because there's an actual physiological reason um we talked about treatment earlier your go-to medication for mood disorders lithium but there are other um anti-seizure medications that are also used like carbon mesopine vaporic acid and sometimes we do use um lamotrigine as well episodes can last an acute episode can last anywhere from five weeks to uh nine weeks with depression the mix can be up to 14 weeks now obviously you can't live in a manic episode for that long so manic episodes are going to be much more brief versus depressed episodes um let's see we're going to talk i'm not really talking about psychothermic disorder it's just a variation of bipolar disorder um but most psychological disorders now are just characterized as a form of bpd as well um know that um you're wanting to see if there's anything else in you too oh yeah obviously you want to be aware that the neurotransmitter involves bipolar disorder is going to be serotonin dysregulation of serotonin okay all right okay let's go into chapter 14 major depressive disorder some components associated with major depressive disorder is that depression can occur throughout a lifetime it can be as a result of a significant life altering event but to truly be diagnosed with mdd or major depressive disorder this mood has to last for a minimum of two weeks um so you have to see the disorder occur for two weeks or longer with symptoms that include anything from anhedonia right to express that to you and i don't care uh fatigue sleep deprivation changes in appetite either eating too much or too little feelings of hopelessness or worthlessness persistent thoughts of death or suicide and inability to concentrate or make decisions and as well as changes in physical activity some of the disrupt the depressive disorders that are classified as some types of mdd would be like disruptive mood dysregulation disorder dysthymic disorder that's just kind of always being sad or blue um premenstrual dysphoric disorder having to do with hormonal changes that can occur as a result of the female menstrual cycle substance abuse depressive disorder that's either as a result of being on an illicit substance for a significant time or being off a significant time from the substance and then craving it and then being depressed as a result of not having it and then depressive disorder associated with another medical condition um particular neurobiological disorders like cv like cvas or parkinson's or ms those types of neurological disorders it's the leading cause of disability in the us don't forget that's the number one reason why people go on disability in stress anxiety and depression the sad triad um there are genetic factors i've actually been able to identify a um a gene it's called httpi1 i want to say anyway you don't need to know that but it's kind of interesting they have been able to identify the actual an actual genetic gene that is passed down um and so there is a genetic predisposition bio biochemical stressful life events can bring on depression again it has to last two weeks for longer for it to be considered a depressive episode if it's as a result of a stressful life event that as well alterations in hormonal regulation and slim inflammation as always and that's the stress model which is the nature nurture concept um psychological factors uh cognitive theory is you know there's a a degree of uh changes in the cognition of what's occurring and it has a direct effect on the patient's ability to perceive life events from a perspective that they feel that life is hopeless and helpless learn helplessness is being unable to get out of that phase of feeling sad or depressed and you've learned how to cope with it by this process of helplessness and as far as being able to actually address what the underlying issue is all sorts of assessment tools you'll see things like the hads or the das or the um what do they use a lot i mean it's the hads a lot um phq9 there's all sorts of tools used out there um for assessment depending on what unit you're in sometimes like in the emergency department they'll use hospital um and depression scale hospital anxiety depression scale the heads in emergency rooms areas to assess are affect thought processes mood feelings physical behavior communication and religious beliefs and spirituality age consideration children and adults can have can both have depression and it can be significant in older adults as they deal with loss and changes in their ability to function independently some of the things you want to be conscientious of is that you have to ask the questions you do have to ask if the patient has considered hurting themselves or hurting others because of the fact that if you don't ask the question you're not going to get the answer and if there are reasons to intervene it is our nursing responsibility to ensure that we've asked the questions and that we've elicited a response and how to address it appropriately okay um the phases uh acute phase of uh treatment is like a six to twelve week period continuation phase four to nine months then maintenance phase one year or more uh very important to be conscientious of the fact that this should be addressed through a dual modality through both therapeutic means and medication means in order to achieve the best outcome for the patient so we know about uh if the patient uses a dull modality of medications and therapeutic treatment their chances of successfully being treated for depressive disorders about 85 percent ssris are your first line therapy we need to know what the indications are if there's any potentiality for adverse reactions and talk to patients about potential toxic side effects such as serotonin syndrome where there's an overabundance of serotonin it's not breaking down fast enough and the patient can have a reaction to the medication most often it's going to manifest like in a rash and uh it is definitely important to intervene quickly if the patient has a serotonin syndrome am i going to go with this psychopharmacology because we kind of went over that at the beginning okay we're going to look at anxiety and ocd related disorders anxiety is normal it really stems from apprehension uneasiness uncertainty or dread from a real or perceived threat now the reason it's normal is because a real uh or perceived threat can potentially also be real in nature can have a substantiation behind it however if the anxiety becomes so pervasive and it's not responding to appropriately to the situation where it becomes so all-intensive or so pervasive that it's difficult to function that's when anxiety no longer is classified as a normative response because you're not reacting to it appropriately fear is a reaction specific danger and normal anxiety is necessary for survival because it it taps into that fight or flight response to ensure that our safety is there but again anxiety that's not normal in relation where you're unable to function you're so apprehensive and so scared and so uneasy and you dread things that are really not as acute or concerning as you're perceiving then it's going to affect your ability to function which again was what we're trying to achieve anxiety is classified into four separate sections mild moderate severe and panic um treatment wise really we all the medications can be used for anxiety as well um in order to address anxiety the go to is always therapeutic so we want to actually start the patient on therapeutic means before we start them on medications get them incorporated into seeing a therapist and then start treating them with medications but what happens is if you start treating therapeutically secondary to medication management patients well can potentially misuse their medications like anxiety medications for severe anxiety or panic attacks like your benzos and really we want to get to the root of what's causing the anxiety and that's best achieved through talk therapy so make sure the patient is incorporated in therapeutic means um some of the things there are different types separation anxiety disorders developmentally inappropriate level of concern or being away from a significant other when you're a kid it's okay to have separation anxiety disorder appreciate if you're a little one baby two or three years old but if you're still doing it at 18 or 19 years old with a family member or your wife or husband or significant other then there's cause for concern panic disorder or panic attacks will have a physical manifestation associated so racing heart sweating um pallor patient may have tachypnea as well it often mimics looking like a cardiac event um agoraphobia is excessive fear about places or situations from which they can a person can't escape and these are often what we call the shut-in person doesn't leave their home because they're uncomfortable going anywhere that's foreign to them social anxiety disorders severe anxiety or fear provide but provoked by exposure to a social performance situation and gad which is what most patients with anxiety are classified as has to occur for uh you know for a significant amount of time like meaning that it lasts months um so you know it's important to identify what kind of anxiety they have but most people fall under general anxiety disorder from a treatment perspective and it's just gotta last you know significant amount of months there's not a particular number associated um these are some other issues why patient my anxiety like substance induced anxiety disorder and anxiety due to medical condition when we look at obsessive-compulsive disorders we're looking at thoughts and pulses or images that persist and recursively it cannot be dismissed from the mind and compulsions this is where you've got ritualistic behaviors individuals driven to perform an attempt to reduce anxiety it's like turning the doorknob ten times checking the door ten times before you leave not stepping up cracks on the floor just like these ritualistic kind of odd and peculiar behaviors but they help to lessen the amount of anxiety because there's some sense of control these are other ocd related diagnoses body dysmorphic disorder is often characterized by patients that have pervasive plastic surgery or cosmetic surgeries where they're always wanting more regarding how they actually see their body so they will continue to do plastic surgery till they find that ideal body type but the problem is they're constantly chasing what that body type looks like so they're never really satisfied reporting disorders hair pulling tryptophilia and skin picking disorders are also manifestations of compulsive disorders um okay anything counseling important don't forget that antidepressants anxiolytics and other classifications and medications um there's differentness of behavioral therapies that we can use like cognitive behavioral therapy which is very successful in ptsd behavioral therapy like relaxation training modeling [Music] systematic desensitization cbt and so forth okay we're gonna do start with uh edos let's take a look at these last two areas okay we're gonna look at anorexia and bulimia specifically uh is characterized by a refusal to maintain a minimally minimally normal body weight however bulimia is characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviors like self-induced vomiting misuse of laxatives diuretics fasting or excessive exercise um this also has to do with the disturbance in the perception of the body shape and weight and it's an essential feature of both anorexia and bulimia with anorexias again refusal to maintain body weight at or above a minimally normal weight for age and height so it's height versus weight um the weight loss leads to maintenance of body weight less than 85 percent of that expected of of that expected or failure to make expected weight gain during a period of growth leading to body weight less than 85 percent again of that which is expected it's characterized by intense fear of gaining weight or becoming fat and even though the patient is underweight um it's disturbance in the way one's body weight and shape are experienced um denial of the seriousness of the low body weight um in post-monarchal females amenorrhea can occur in the absence of at least three cycles of menstrual cycles so we see this a lot with athletes as well and those who have to maintain a specific body structure like gymnasts or ice skaters um you're gonna often see depressed mood social withdrawal irritability insomnia and diminished interest in sex you can meet the symptomatic requirements for major depressive disorder which is secondary but it's almost always a co-diagnose associated with anorexia um and it can also be a manifestation associated with things that are you know the physical sensation of starving as well um let's see some of the symptoms you're gonna also see things like constipation abdominal pain and tolerance to cold lack of fatty tissue lethargy excessive excess energy so they get like these spurts of excess energy and then emaciation just being severely underweight and then bulimia on the other hand is characterized by recurrent episodes of binge eating an episode of binge eating is characterized both by um eating in a discrete period of time julian within any kind of two-hour period and you just eat these mass amounts of food and then um the sense of lack of control over eating during this episode that it makes them feel like they can't stop eating or control how much and then their compensatory behavior is to then vomit or take laxatives sometimes they'll do enemas as well diuretics and other types of medications fasting or excess exercise binge eating compensatory behaviors both occur on an average at least twice a week for about three months so there's criteria associated with um how often the occurrences happen self-evaluation is unduly influenced by shape and weight however most people with bulimia just you know they don't show signs of under being underweight um in fact most of the time they look at normal body weight and sometimes a little bit above body weight um typically within the normal weight range some may be like i said slightly overweight between binges individuals typically restrict their total calories consumption avoid foods they perceive to be fattening while binge eating food types can be high in carbohydrates and like cakes ice creams sugars things like that there is purging and non-purging type too so non-purging would be like the excess exercise okay [Music] all right okay guys i think that's pretty much it for sharing with you guys there's a couple other things on the um study guide i need you guys to go over as well but those are going to be most of the topics we're going to be covering for the final uh there are 50 questions and six bonus questions on that um so the final will be graded until um or won't completely be graded until after you've completed the test okay hope this helps a little bit good luck talk to you later see you in a couple days bye