Mental Health Exam 3 Material

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Situational factors of addiction

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include peer influence, social norma, family influences, and social supports.

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Individual factors relating to addiction

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age, gender, ethnicity, and other demographic descriptors fall in to this category. The individual 's history of dug use, qualities of decision making, positive beliefs about the effects of drugs and the money to purchase them, the physiologic responses.

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environmental factors relating to addiction

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include and individuals access to and the cost of the desired substance, policies and policy enforcement, and the severity of the punishment for engaging in illegal activities.

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Telescoping

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Women begin problem drinking later in life than men (late 20s or early 30s) and they develop significant physical and psychosocial problems in a shorter period of time, often during their childbearing years.

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Substance abuse during pregnancy

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smoking leads to low birth weight, preterm delivery, and 10% of all infant deaths, an increased risk for congenital anomalies like narrowed airways and curtailed lung function, may exhibit hyperactivity.
Babies born to marijuana users were shorter, weighed less, and had smaller head sizes, and have also experienced difficulty concentrating as they got older.
Opioid uses leads to fetal damage as a result of genetic changes caused by them, they have elevated rates of intrauterine death, low birth weight, preterm deliver, and babies may experience withdrawal symptoms.
Alcohol use is the leading known cause of preventable birth defects and learning difficulties. They may be born with fetal alcohol syndrome

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Fetal alcohol symdrome (FAS)

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is characterized by growth retardation, central nervous system involvement that results in mental retardation and other learning difficulties, and facial and other abnormalities. Children many have a small head, small physical statues, mild-severe mental retardation, facial abnormalities, (flat bridge nose, absent philtrum, and epicanthal eye fold , an atrial or ventricular septal heart defect, synthadctyly, and disorders of the temporo-mandibular joint, hearing loss, and developmental delays. In school may have problems reading, spelling, and math, and increased risk for alcohol abuse and dependence.

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Adolescent factors for developing SUD

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age-under 17 to start are more likely to have an abuse problem

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Signs and symptoms of adolescent drug use and abuse

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bloodshot, red eyes; droopy eyelids; wearing sunglasses at inappropriate times; changes in sleep patter; unexplained periods of moodiness, depression, anxiety or irritability; decreased interaction and communication with family; loss of interest in precious hobbies sports, and so on; change in friends; will not introduce new friends; decline in academic performance, dropping grades, loss of motivation and interest in school activities; change in peer group; disappearance of money or items of value; use of eye drops and mouthwash; unfamiliar containers or locked boxes; money missing from the house.

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Prevention of Adolescent substance use and abuse

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ensure positive role modeling by parents and adults in teens world; reinforce the dangers of substance use, and teach positive behaviors; provide support in coping with the social pressure exerted by peers; establish limits, structure, and house rules for the teens behavior; help teen to anticipate pressures, and reinforce positive coping behaviors; engage the teen in life skills training programs which emphasize positive skills training, resistance training, and group support; monitor teens use of tv, computer, movies, and video games as this media may portray legal and illegal substance use as a part of daily life.

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Alcoholic blackouts (anterograde amnesia)

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occur in individuals who have consumed sufficient alcohol such that the substance interferes with the acquisition and storage of new memories in the hippocampus portion of the brain. Information is lost from memory within minutes of its occurrence.

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Alcohol abuse effect on neurologic system

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cellular damage and the loss of brain tissue have been documented. Some experience intense anxiety, psychoses, depressed mood, auditory hallucinations, or paranoia with intoxication. Be careful not to confuse an alcoholic delirium with dementia or with a worsening mental disorder. Wernicke-korsakoff syndrome involves neurologic abnormalities including inflammatory hemorrhagic degeneration of the brain. Marchaifava-Bignami disease involves atrophy of the corpus callosum and impaired cerebral blood flow.

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CAGE Test for alcoholism

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Have you ever felt that you out to CUT down on your drinking?
Have people ANNOYED you by criticizing your drinking?
Have you ever felt GUILTY about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (an EYE opener)?

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Assessment of signs of alcohol or drug use/dependence

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alcohol: jaundice, arcus senilis, acne rosacea, palmar erythema, enlarged liver, cigarette burns and stain on fingers; upper abdominal pain that results from the inflammation of the pancreas; decreased sensation in hands or feet as a result of peripheral neuropathy, positive stool guaic test for GI bleeding; hypertension, tremor, tachycardia.
DRUGS- cardiac arrhythmias, needle tracks, cellulitis, conjunctivitis, poor dentition, rapid weight loss, changes in pupil size, changes in nasal mucosa.

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Blood alcohol level 20-50 mg alcohol/dL blood (0.02-0.05)

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no legal consequences; some impaired coordination and potential changes in behavior

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Blood alcohol level 80-100 mg alcohol/dL blood (0.08-0.1)

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legal intoxication; impaired ability to drive, slurred speech, staggered gain, and impaired sensory function

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Blood Alcohol level 100-150 mg alcohol/dL blood (0.1-0.15)

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markedly uncoordinated balance and gross cognition and judgment distortions (over the legal limit)

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Blood alcohol level >200 mg alcohol/dL blood (0.2-0.3)

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Notable impairment in all sensory and motor functions

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Blood alcohol level >300 mg alcohol/dL blood (> or = 0.3)

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potential for cardiovascular and respiratory collapse; coma and death can occur if lifesaving measures are not initiated.

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Medication considerations for Alcohol Dependence

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Acamprosate calcium (Campral) for abstinence and disulfiram (Antabuse) as a deterrent to alcohol use and abuse.
Cyclic antidepressants may cause neurotoxicity
MOAI may cause delirium and psychosis with combination use
Acamprosate is not recommended for children
Herbal considerations-St. Johns wort may cause alcohol-like reactions

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Alcohol and opioid dependence medications information

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naltrexone (revia, trexan, vivitrol) to work as an adjunct in the treatment of alcohol dependence and opiate addiction by decreasing cravings.
Patient must be drug-free before beginning treatment.

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Medication fact for Opioid dependence

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buprenorphine/naloxone (Narcan, Suboxone) and levomethadul acetate (LAAM, ORLAAM).
Methadone is a substitute drug for narcotic analgesic dependence therapy and the treatment of severe pain.
Methadone has a high physical and psychologic dependence liability and withdrawal symptoms will occur with abrupt discontinuation.
Alcohol and other CNS depressants may increase CNS or respiratory depression and hypotension may cause fatal reactions with high doses.
MOAI may produce severe or sometimes fatal reaction; they should not be used together.
Children are more prone to experience paradoxic excitements. Naloxone and LAAM are not recom. for children under 16.
medication are not recommended for elderly adults.
Valerian, chamomile, kava kava, and poppy may increase CNS depression.

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Medication key facts-Nicotine Dependence.

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Buspropion (Zyban) and verenicline (Chantix) are used for smoking cessation

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Medication Key Facts for other drugs that may treat alcoholism

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diazepam (Valium), clonazepam (klonopin) for alcohol intoxication or withdrawal, and chordiazepoxide (librium) for alcohol withdrawal and anxiety.
Theses are contraindicated with acute alcohol intoxication ad acute angle-closure glaucoma.
Abrupt or too rapid withdrawal may result in pronounced restlessness, irritability, insomnia, and seizures.
Alcohol and CNS depressants increase CNS depression
these medications are not indicated for children who are younger than 6
Cowslip, kava kava, and valerian may increase CNS depression.

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Delirium

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an acute state of confusion, attention, and perceptions. Cognitive changes of delirium develop over a short period of time and are usually the result of a medical condition, substance abuse, or both. The cause of delirium is often unknown.

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Amnestic disorders

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impairments of memory that occur without delirium and dementia. A condition which the person has difficulty learning new information or with remembering previously learned information. May result from a general medical condition, substance use, or an unknown etiology.

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Alzheimer's Disease (AD)

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an irreversible and progressive disease that ultimately leads to death and is usually diagnosed after ruling out other etiologies. Factors contributing to late onset form are socioeconomic status; lifestyle choices; environmental factors; medical conditions and illnesses, including high blood pressure and dyslipidemia; medical treatment for these conditions.

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Dementia of the Alzheimer's Type DSM-IV-TR criteria

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development of multiple cognitive deficits manifest: memory impairment, aphasia, apraxia, agnosia, disturbance in executive functioning. The cognitive impairments cause significant impairment in social or occupational functioning and represent a significant decline rom a precious level of functioning. The course has a gradual onset and continuing cognitive decline. The cognitive deficits are not a result from other CNS conditions or other systematic conditions with are known to cause dementia, or substance induced conditions, the deficits do not occur during the course of delirium, and are not accounted for by another Axis 1 disorder.

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Aphasia

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deficit in language functioning. in severe forms may not speak at all

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apraxia

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person is unable to perform motor activities despite intact function.

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agnosia

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difficulties with object identification, usually common household items

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defense mechanisms used by those with early AD

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Denial, repression, projection, aggression, regression, or rationalization

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DSM-IV- TR Criteria for Amnestic Disorder

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development of memory impairment as manifested by impairment in the ability to learn new information or the inability to recall preciously learned information. 2-memory disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. 3- memory disturbance does not occur exclusively during the course of a delirium or demential. 4- evidence from history, physical exam, or lab findings that the disturbance is the direct physiologic consequence of a general medical condition. Transient-memory impairment lasts for 1 month or less
Chronic- memory impairment lasts for more than 1 month

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DSM-IV-TR for Delirium due to multiple etiologies

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A- disturbances of consciousness with reduced ability to focus, sustain, or shift attention. B- a change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia. C- The disturbance develops over a short period and tends to fluctuate during the course of the day. D- There is evidence from the history, physical examination or lab findings that delirium has more than one etiology

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Donepezil/Aricept

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a cholinesterase inhibit which is usually well tolerated and requires only once-per-day dosing. Enhances cholinergic function by the reversible inhibition of the hydrolysis of ACh by AChE and is effective when cholinergic neurons are intact, over time it may produce GI side effects, and as the degeneration of neurons progresses the effects of the drug lesson.

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Mental retardation/intellectual disability

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An Axis II disorder, an intelligence quotient below 70 that impairs the individual's social adaptation, and development in at least to

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Stage 1- (mild) Alzheimer's Disease

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recent memory loss, cognitive loss in the following areas: communication, calculation, recognition; anxiety and confusion; mild behavior problems, such as the inability to initiate and complete a task.

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stage 2- (moderate) Alzheimer's Disease

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Stage 1 symptoms increase, behavior problems increase, which may include the following: catastrophic reactions, sundowning 9confusion and irritation due to reduced stimulation and tiredness); perseveration (repetitive verbalizations or motions due to thought disturbances); aimless pacing, wandering, confusion, incontinence (mild), and hypertonia

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Stage 3- severe- Alzheimer's Disease

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Stage 2 symptoms increase, incontinence (total), choking, emaciation, total care required, progressive gait disturbances that lead to non-ambulatory status

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Interventions for Catastrophic reactions

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Reassure the patient that he or she is safe
Use positive & therapeutic behavioral interactions
Maintain the patient's personal space, do not touch the patient without asking his or her permission.
Eliminate or reduce all outside stimulation
Identify & remove the source of the problem or the patient.
Redirect the patient to a less demanding activity
Be patient & allow sufficient time for the patient to calm down which may take a few minutes or hours
If the nurse cannot stop or minimize the reaction-leave the client alone for a while in a quiet, safe place within view of staff or family. When readdressing the client act as if nothing has happened. Have one person address the patient, minimize hand gestures, and be aware of facial expressions. Speak in soft and nonthreatening voice while redirecting the conversation or task.

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Signs of Silent Aspiration (choking)

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watering eyes, reddening of the face, rhonchi on pulmonary auscultation, variable rates of respiration, grimacing, coughing, gagging, throat clearing, pocketing of food in the oral cavity

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Functional Incontinence

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loss of large amounts of urine that results from cognitive deficits that lead to not recognizing cues from the bladder, the inability to find a bathroom, or increasing apraxia

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Patient and Family Teaching Guidelines for Cognitive Disorders

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a strong professional and family support network is important for the caregiver who has to carry out exhausting tasks.
Psychiatric intervention for the caregiver will help him or her adjust and cope with difficulties that arise.
The caregiver needs the time and opportunity to mourn and complete the grieving process
Verbalizing concerns and feelings is important for coping
Action regarding finances need to be taken while the patient still retains the capacity to make decisions.

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Tacrine/Cognex

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he first cholinesterase inhibitor available. Rarely used now because it has potential for hepatic toxicity, and requires doses to be given 4 times a day, but some that have responded well may still take the medication, but have to watch for liver problems.

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Rivastigmine/ Exelon

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indicated for the treatment of mild to moderate AD and PD. It inhibits AChE selectively in the cortex and the hippocampus. Available as a tablet, oral solution, and a patch. Oral forms dose 2 times per day. good for those that did not respond well to other anticholinergic drugs or who are in later stages of AD. Side effects include nausea, vomiting, and dizziness.

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Galantamine/Razadyne

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the newest AChE which is also reversible. It is indicated for the tx of mild to moderate AD as it increases the availability of ACh. can decrease agitation and increase cognition. Immediate release forms 2 per day, extended release 1 time daily.

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Memantine/Namenda

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Indicated for moderate to severe AD and works by blocking the effects of excess glutamate. It requires once a day dosing.

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Vascular dementia (VaD)/multiinfarct dementia

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a change in cognition that is caused by the effects of one or more strokes on cognitive function. brain cannot be nourished due to occlusion or obstruction of small arteries or arterioles in the cerebral cortex. Sudden onset, and changes seem to be rapid and depending on the areas of the brain that are affected patient exhibit a patchy and uneven patter of deficits.

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Parkinson's disease (PD)

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a neurologic disorder that causes tremors, rigidity, bradykinesia, abnormalities of posture, a mask like facial expression and a shuffling gait. lewy body lesions are a sig of this disease.

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Frontotemporal Lobar Degeneration (FTLD)/frontotemperal dementia/ Pick's disease

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a group of degenerative disorders of nerve cells that usually affect the frontal and temporal lobes of the brain. Changes in personality occur early during the course of disease, social skills decline, emotions are dull and pt are unable to control impulses, and language abnormalities occur. Changes in behavior and personality are expected and include-socially inappropriate behavior, agitation, and apathy.

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Creutzfeldt-Jakob Disease (CJD)

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a rare condition that leads to dementia. prions cause a spongiform encephalopathy, and act as infective agents that cause cognitive losses, involuntary movements, and electroencephalogram changes. Develops around age 60. Begins onset with confusion, depression, and altered sensation and progresses to dementia, ataxia, palsy and sometimes cortical blindness. Initially problems with muscular coordination and visions as well as personality changes. most patients die within one year of dx.

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Huntington's Disease dementia

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a direct consequence of the disease which is the result of a single faulty autosomal-dominant gene on chromosome 4. progressive degeneration f cognition, emotion, and movement. Onset usually around 30-40 but as early as 4 and as late as 85. long course of 10-30 years, suicide is a common cause of death

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Progressive Supranuclear Palsy

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a degenerative process that is associated with frontotemporal lobar degeneration and it affects the nuclei of neurons. defined by presence of neorfibrillary tangles in neurons. Present with dementia, progressive paralysis of downward and vertical gaze, disarthria, ataxic gait, and bradykinesia. Men are more affected than women, and diminished cognition and personality changes are present but not as pronounced

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Down's Syndrome Dementia

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difficult to dx. Begins manifesting symptoms as memory loss.

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Reversible dementias

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majority are treatable if treatment is received before permanent damage occurs. Depression is often associated,and is seen among older adults that do not exhibit normal signs of depression.

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Mild Cognitive impairment (MCI)

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memory loss that does not interfere with activities of daily living.

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Amnestic Disorders

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a disturbance in learning and memory in an alert and responsive person. Result of either effects of a medical condition or the =r persisting effect of substance use/abuse or toxin exposure. Leading cuase is thiamine (vitamin B1) usually result of alcohol use.

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Characteristics of dementia

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spatial disorientation, poor judgment and disinhibition, poor insight, potential for violence, loss of motor skills, and possible mood and sleep disturbances.

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Alzheimer's disease progression

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starts with neurofibrillary tangles in the hippocampus (loss of memory), then temporoparietal regions deteriorate (produce cognitive deficits in learning, attention, judgment, orientation, and speech/language), then other areas of the brain may become involved.

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Multisensory Environments (MSEs)

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a controlled, safe,, and comfortable environment that is designed to provide a a multitude of sensory experiences for therapeutic benefit. It is non-directive and participants choose the activities they wish to participate. used in combination with behavioral therapy for moderate to sever dementia they provided a greater decrease in agitation, a decrease in apathy, and an increase in general independence.

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Therapeutic activity program

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is for persons with cognitive disorders and is specifically designed to meet individual needs and to prevent or lessen problematic behaviors caused by unmet needs with a goal to help keep person functioning at the highest level possible. They build on strengths for success with an attitude that of use it or lose it. May be a primary treatment for someone with demential and

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Adolescent depression and suicide

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main cause of suicide is undiagnosed depression, Make sure to screen for depression, drug/alcohol use, and conduct disorders. Risk increases with difficulty interacting with peers such as bullying, the breakup of a significant relationship, pregnancy, obesity, issues related to sexual orientation and feelings of isolation. High risk if problems within the family or isolation from the family. and with those who have had a peer commit suicide.

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Mnemonic for Warning signs of suicide

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Is Path Warm? Ideation, Substance Abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood Change

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Levels of Suicidal Behavior

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1. Suicidal Ideation: Direct/indirect thoughts or fantasies of suicide or self-injurious acts are expressed verbally or through writing or artwork without definite intent or action expressed. and may express symbolically.
2. Suicide threats- These are direct verbal or written expressions of intent to commit suicide but without action.
3. Suicide gestures- These self-directed actions result in no injury or minor injury by persons who neither intended to end their lies nor expected to die as a result. However, they were done in such a way that others interpret the act as suicidal in purpose.
4. Suicide attempts- These are serious self-directed actions that sometimes result in minor or major injury by persons who intend to end their lives or to seriously harm themselves. Gestures and attempts that are unsuccessful and of low lethality are sometimes called parasuicidal behavior.
5. Complete Suicide- the deaths of persons who end their lives by their own means with conscious intent to die are described as competed suicide. However, it is important to note that some suicides sometimes occur on the basis of the unconscious intent to die. (engage in high risk behaviors)

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Anomic suicide

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self-destruction by those who have become alienated from important relationships in their groups, especially as related to standard of living.
Example- suicides after stock market crash

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Egoistic suicides

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self-inflicted death of those who turn against their own conscience
Example- suicide of catholic after having an abortion which the religion forbids.

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Altruistic suicide

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self-inflicted deaths on the basis of obedience to a groups goals rather than reflecting the person's own best interest (suicide bombers)

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Fatalistic suicide

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deaths resulting from excessive regulation (prisoner hangs self to escape prolonged incarceration)

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Factors related to suicide

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Biologic FActors- the neurotransmitters-principally serotonin, dopamine, norepinephrine, and aminobutyric acid-are linked to emotional responses. Serotonin plays a major role in the regulation of mood, and it influences the occurrence of depression and suicidality. Genetic influences are evident; researchers believe they have found a specific gene that predisposes a person to suicide. Others have found that dimension of depression are correlated with alterations in specific brain structure.
Psychologic Factors- self-directed aggression, hopelessness, unresolved interpersonal conflicts, negativistic thinking patters, a reduction in positive reinforcement, difficulty with problem solving.
Sociologic Factors- Isolation and alienation from social groups, biopsychosocial.

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Consistent problems that exhibit before suicide

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1. Poor communication with treatment providers involved in the care of the patient.
2. Allowing the patient or relatives to control the therapy
3. Avoidance of discussion of issues related to sexuality
4. Ineffective or coercive actions that resulted from the therapist anxiety as opposed to the patient's clinical presentation.
5.Inability to recognize the meaning of the patients communication
6. untreated or under-treated symptoms such as anxiety or alcohol abuse.