INTERACTION OF BODY AND MINDCHAPTER 67 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with Psychobiologic Disorders

BRAIN STRUCTURES

LIMBIC SYSTEM Controls Emotions and memory Includes:

Thalamas – modulates movement, sensation, behavior, and emotions

Hypothalamus – controls the autonomic nervous system

RECEPTORS Found on the surface of cells throughout

body and brain Function: Sense and pick up chemical

messengers in extracellular fluid

Chemical messenger: Specific key; Natural or synthetic; Neurotransmitters

You hold the key

To my receptor

NEUROTRANSMITTERS Endogenous chemical messengers

Synthesized in the neurons Stored in the vesicles of the Axons Bind momentarily to receptors on postsynaptic

neurons

Broken down Reuptake Diluted

NEUROTRANSMITTERS Serotonin (5-HT)

Imbalances: depression, eating disorders, sleep disturbances, Obsessive–compulsive disorder

Dopamine (DA) Excess: disorganized thought patterns, Schizophrenia Deficient: Parkinson’s disease, impaired judgment

Norepinephrine (NE) Excess: Neurodegenerative diseases Deficient: depression

Acetylcholine (ACH) Gamma-aminobutyric acid (GABA) Glutamate (GT)

NEUROPEPTIDES Separate type of neurotransmitter Substance P

Transmits sensation of pain Endorphins

Interrupt transmission of substance P. Promote feeling of well-being (morphine-like)

Neurohormones Endocrine System

Receptors for neurotransmitters are found throughout CNS, endocrine, and immune systems

Mind and emotions can affect physical well being

Physical well-being can affect the mind and emotions

PSYCHOBIOLOGIC ILLNESS Biologic Factors

Neurotransmitters

Psychological Factors Forces that shape behavior

Intrapersonal Development Conflicts within oneself

Freud Interpersonal Interaction

Consequences of social development Relationships, Interactions, Social Systems

Erikson, Stack-Sullivan Learning

Positive and Negative reinforcement Skinner

ASSESSMENT FINDINGS Signs and Symptoms

Affect relationships, interfere with responsibilities American Psychiatric Association DSM-IV-TR

Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision)

Classifies psychiatric disorders Psychological Tests

MMPI, MMPI-A, Beck, DAP, WAT, TAT, Rorschach Diagnostic Findings

CT, MRI, EEG, PET, QEEG, Brain mapping Mental Status Examination

MENTAL STATUS EXAMINATION

Physical appearance Orientation Attention and concentration Short-term and long-term memory Movement and coordination Speech problems Mood Intellectual performance Perception Insight Judgment Thought content

MENTAL STATUS EXAMINATION

What is the year? What is today date? In what city are we in? Spell globe backward Repeat the following sentence: “A rolling

stone gathers no moss.” Write a sentence of your own choice.

Evaluate the sentence. Does it have a subject, verb, object?

MEDICAL AND NURSING MANAGEMENT Determined by the disorder Drug therapy

Correcting the underlining biochemical abnormality

Psychotherapy Talk therapy

Freudian Cognitive therapy

Changing the patterns of thought Self help books

Behavioral therapy Behavior modification

Pavlov

PSYCHOSOMATIC FUNCTION

Role of Stress on Health Stress implicated in development or

exacerbation of Autoimmune disorders Thyroid conditions Heart disease Diabetes Chronic pain Functional and inflammatory disorders of the GI

system Anorexia nervosa OCD And on and on and on…

STRESS

Eustress Maintaining a healthy balance Just right amount of stress

Distress Ill-timed unrelieved

General Adaptation Syndrome

STRESS RESPONSE Physiologic

Autonomic Nervous System Sympathetic

Norepinephrine Fight or flight

Parasympathetic Frozen with fear

Psychologic Coping Mechanisms

Temporarily avoid the emotional effects of a stressful situation Used correctly they maintain psychological equilibrium Overuse causes dysfunction

Hardiness

PSYCHOSOMATIC ILLNESSES

Psyche = MindSoma = Body

“Pertaining to the mind-body relationship”

Also known as stress-related disorders These are actual medical conditions

associated or aggravated by stress Most illnesses have psychosomatic

components

BIOLOGIC FACTORS Stress affects the immune system

The brain sends messages directing the immune system’s actions Immunopeptides

Cytokines Function as neurotransmitters

Immune Cells Secrete neurochemicals

Nerve cells Connect the immune system to the brain

PSYCHOLOGICAL FACTORS Anger

Suppressing Anger Compromised immune system

Excessive Expression of Anger Heart disease

Dependence Fear of rejection/abandonment Heplessness Powerless

Increase illness Ambivalence

Unresolved conflicts Affect immune systme

ASSESSMENT FINDINGS

Signs and Symptoms Stress-prone

Diagnostic Findings Rule out other conditions

MEDICAL AND NURSING MANAGEMENT Stress Management Techniques

Relaxation techniques Coping strategies Anger management Assertiveness training

Support Groups referral

Nutrition Depending on individual

THE PLACEBO EFFECT Healing or improvement that takes place

because the individual believes a treatment will be effective

Observed during research trials We can not use placebos in practice

CARING FOR CLIENTS WITH ANXIETY DISORDERSCHAPTER 68 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with Psychobiologic Disorders

ANXIETY AND FEAR

Anxiety A vague uneasy feeling, the cause of which is not readily

identifiable. Evoked when a person anticipates nonspecific danger

Fear A feeling of terror in response to someone or

something specific that a person perceives as dangerous or threatening

LEVELS OF ANXIETY Mild

Attention and sensory perception increased, reality intact, person feels in control. HR, BP, RR slightly increased, perspiration noticeable. Good for learning.

Moderate Concentration slightly impaired, learning takes more

effort, irritable, may feel inadequate. Hand or leg tremors, voice changes

Severe Cannot concentrate or stay focused, person feels

discomfort and incompetent. Palpitations, hyper-ventilation, limited communication

Panic Thoughts fragmented, learning not possible, feel helpless,

speech incoherent, dyspnea, tremors, diaphoresis

ANXIETY Anxiety disorders sometimes have familial

patterns Symptom manifestations caused when

norepinephrine floods the limbic system Biochemical changes brought on by the ANS

trigger physical arousal in cortex and neuroendocrine pathways

Biochemical mechanismsDysregulation of gamma-aminobutyric (GABA)

Depletion of serotonin

ANXIETY DISORDERS

Psychobiologic illness that results from activation of the autonomic nervous system

Tends to be chronic Appears without logical explanation Sometimes leads to other psychobiologic

conditions Depression Substance abuse Binge eating disorder Compulsive eating

GENERALIZED ANXIETY DISORDER

Chronic worrying on a daily basis for 6 months or more.

Usually more than one focus of worry

Usually out of proportion with reality

Signs and symptoms of anxiety accompany client’s distress

PANIC DISORDER

Abrupt onset of physical symptoms Intense apprehension, tachycardia, palpitations, chest

pain, smothering, choking sensations, hyperventilation, lightheadedness, feeling of impending doom, fear of fainting, dying, losing control, or going insane

Lasts minutes to less than an hour then subsides Often referred to as attacks, interrupt daily activities

First instinct is to escape to safety Unexplained fight from work, school, etc

Learn to avoid events that trigger attacks Can lead to phobias

Agoraphobia-fear of experiencing a panic attack in public

PHOBIC DISORDER

Person manifests an exaggerated fear Insects, animals, heights, flying, enclosed

spaces, etc

Social Phobia Common phobia Client afraid they will be embarrassed or

criticized

POST TRAUMATIC STRESS DISORDER

Delayed anxiety response 3 months or more

after an emotionally traumatic experience. Must be extraordinarily severe to cause PTSD Involve actual or threatened death or injury to

self or others Produce fear, helplessness, or horror

Psychic Numbing Initially avoid dealing with the tragedy and

detaches from the situation Flashbacks

Memories or recurrent nightmares in which the client feels as if they are reliving the event.

OBSESSIVE COMPULSIVE DISORDER

Performance of an anxiety-relieving ritual (compulsion) that relieves a disturbing, persistent thought (obsession).

Anxiety escalates if ritual is stopped, interrupted, altered, or forbidden.

Clients recognize their thoughts and behaviors are absurd, but they are helpless to stop independently.

May lead to problems in social relationships, failure in school, or loss of employment

ASSESSMENT FINDINGS Most Clients seek treatment for physical

signs and symptoms Palpitations Increased BP, HR, RR Chronic fatigue Headaches Sleep disturbances

Some will seek treatment due to unrealistic worries, flashbacks, performing rituals

NURSING CARE Building Trust

Be available and attentive Avoid leaving anxious clients alone

Restoring Comfort Providing relief. Asking client to suggest methods that

may be personally comforting Modifying Communication

Avoid interrupting anxious clients Reduce distracting stimuli Verbalize client’s right to privacy You may offer a referral to a health professional such

as a psychologist or social worker Respect your client’s right not to discuss their

anxieties and fears if they choose not to

NURSING CARE

Adjusting Teaching Limited attention and concentration Provide simple and repeated directions Determine level of comprehension Reductions in sensory stimulation Avoid expecting the client to show a great deal of self-reliance

Helping Problem-Solve Step-by-step problem-solving process Talking helps to process information and explore methods for

dealing with problems Avoid giving advise or influencing decisions Advocate on the client’s behalf

Ensuring safety Remain calm and reduce anxiety One nurse interaction Unstable client-avoid getting physically close

MEDICAL MANAGEMENT Drug Therapy

Reduce or block levels of norepinephrine Normalize levels of serotonin Avoid caffiene

Benzodiazepines Xanax, Ativan, Valium May lead to drug dependence Abrupt discontinuation can lead to withdrawal symptoms

Nonbenzodiazepines Buspar, Paxil, Luvox

beta-adrenergic blockers Inderal, Tenormin, Lopressor

central-acting sympatholytics Catapres, Aldomet, Wytensin

MEDICAL MANAGEMENT Cognitive Therapy

Alter irrational thinking, correct faulty belief systems, and replace negative self-statements with positive ones

Behavioral Therapy Extinguish undesirable responses by learning

other adaptive techniques Desensitization-AKA exposure therapy

CARING FOR CLIENTS WITH MOOD DISORDERSCHAPTER 69TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with Psychobiologic Disorders

MOOD CONTINUUM AND MOOD DISORDERS Mood

Overall feeling state. Continuum with extremes of emotions

MAJOR DEPRESSION

MOOD DISORDERS Affect

Nonverbal behavior that communicates feelings Euthymic

Normal moods Manic

Frenzied state of euphoria Depressed

A persistent sad mood

MAJOR DEPRESSION

Reactive (Secondary Depression) Attributed to a situation, usually self-limiting

Major Depression Sad mood with no obvious relationship to events

MAJOR DEPRESSION

Genetics Prevalent among close blood relatives

Neuorotransmitter dysregulation Imbalance of Serotonin, Norepinephrine,

Dopamine Neuroendocrine Imbalance

Changes in hormone levels (Cortisol, Thyroid) Influence of the hypothalamus

MAJOR DEPRESSION Signs and symptoms

Persistent sad mood Physiologic changes Cognitive changes SAD IMAGES

Diagnostic Findings 5-HIAA Blood levels of neurotransmittters Clinical presentation CT, MRI, PET R/O thyroid, brain tumor, etoh/sedative use,

withdrawal, hypoxia, side effects

MAJOR DEPRESSION Tricyclic antidepressants

block reuptake of serotonin and norepinephrine Monoamine oxidase inhibitors (MAOIs)

Block enzyme that breaks down monoamines Selective Serotonin reuptake inhibitors

Block reuptake of serotonin and some norepinnephrine

Serotonin norepinephrine reuptake inhibitors Block reuptake of serotonin, norepinephrine and

reduces sensitivity to glutamate Atypical antidepressant drugs

Buproprion, maprotiline

MAJOR DEPRESSION Serotonin Syndrome

Excessive serotonin in the blood Multiple classes of antidepressants Not enough weaning time Other serotonergic agonists combined with

antidepressant therapies

Treatment Temporarily withhold antidepressants

MAJOR DEPRESSION Psychotherapy

Psychodynamic Cognitive Behavioral

Electroconvulsive Therapy Electric stimulus to one or both temporal regions,

produce brief seizure Vagus Nerve Stimulation Deep Brain Stimulation Transcranial Magnetic Stimulation

SEASONAL AFFECTIVE DISORDER Pathophysiology, Etiology

Prevalence: Winter months only; States north of 40 to 50 degrees of latitude

Primitive biologic response; Triggered by photoperiods; Melatonin

Assessment Findings: Bimodal depression; Cycles with the seasonsWinter: Sleepy, fatigued, lethargic; Irritable

Unable to concentrate; Suicidal; Increased craving for carbohydrates; Poor social interaction

SEASONAL AFFECTIVE DISORDER

SEASONAL AFFECTIVE DISORDER

• Assessment Findings: Spring– Lifting of spirits; Feeling energetic and

motivated; Hyperactive; Euphoria; Remains until late fall

Medical Management Phototherapy: Use of artificial light Move to sunny location

Nursing Management

BIPOLAR DISORDER Pathophysiology, Etiology: Cycling between

depression, euthymia, and euphoriaExtremes in monoamine levels; Genetic

predisposition Assessment Findings: Signs and Symptoms

Depressive phase: Similar to major depression

Manic phase: Hyperactivity; Exaggerated self-importance; Anger; Aggressiveness; Impaired judgment; Reckless behavior; No sleep; Rapid thinking; Racing speech Psychotic features

BIPOLAR DISORDER Diagnostic Findings

Gene mappingHistory

Pattern of emotional ‘highs’ and ‘lows’Family member with bipolar disorderSubstance abuse

BIPOLAR DISORDER Medical Management

Anticonvulsants: Enhance GABA actionCarbamazepine (Tegretol)

Acute mania; Decreases mood swings among rapid cyclers; Risk for infection

Valproic acid derivatives: Depakote Enhance GABA activity; Used with lithium for long-term management

Unsafe during pregnancy; Side effects- GI symptoms, sedation, and ataxia

BIPOLAR DISORDER Medical Management

Lithium: Mood equalization; Regulates activity between neurotransmitters and receptor sitesDisadvantages: Ineffective for some; Time lag; Narrow safety range; Side effectsPeriodic lab tests; Lithium toxicity Maintain adequate ingestion of salts

Nursing Management

CARING FOR CLIENTS WITH EATING DISORDERSCHAPTER 70 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with Psychobiologic Disorders

EATING DISORDERS Normal Eating: In response to hunger;

Ceases with satiety Eating Disorder: Outside range of normal;

Accompanied by anxiety, guilt; Result in physiologic imbalances, medical complicationsAnorexia nervosaBulimia nervosaBinge eatingCompulsive overeating

ANOREXIA NERVOSA Obsession for thinness achieved via self-

starvation12 – 18 y.o. females: 1 of 200Males less likely to develop, report

Two TypesSevere restriction of caloric intakeBulimarexia

ANOREXIA NERVOSA Pathophysiology, Etiology: Unknown

Neurotransmitter role; Complications Assessment Findings: Signs and Symptoms

Appear skeleton-like; Significantly less weight than similar builds; Lanugo; Hypotensive; Irregular bradycardia; Menstruation absence; Wear bulky clothes

Diagnostic Findings: BMI (Healthy: 18.5–24.9)

ANOREXIA NERVOSA Medical Management: Goal – normal eating

patternsNutritional therapy: Nourishing meals;

Supplements; IV fluids, electrolytes; Tube feedings; TPN

Drug therapy: Antidepressants; Antipsychotic; Supplements; Stool softeners

Psychotherapy: Promote compliance with weight gain regimen; Family counseling

Nursing Management

BULIMIA NERVOSA Minimum of two binges per week, followed

with behaviors to prevent weight gain; Lasting at least six monthsBinging then purgingBinging then fasting

Pathophysiology, Etiology: Potential neurotransmitter, neurohormone connectionConsume 3500 – 11,500 calories ≤ 2 hoursComplications

BULIMIA NERVOSA Assessment Findings: Signs and Symptoms

Significant weight fluctuation; Hoarseness; Inflammation of esophagus, oral pharnyx; Calluses: Back of hands, fingers; Tooth enamel erosion; Swollen parotid glands

Diagnostics Findings: Clinical findings, history of binging/purging; Radiograph; Blood labs

Medical Management: Drug therapy (antidepressants); Individual and group therapy; Behavior modification

Nursing Management

BINGE EATING DISORDER, COMPULSIVE OVEREATING Binge Eating Disorder: Inability to control

overeating plus guilty feeling; No compensating behaviors to prevent weight gain

Compulsive Overeating: Eating in absence of hunger or full feeling

Pathophysiology, Etiology: Unknown; Potential neurotransmitter, neurohormone connection; Coping mechanism; Complications

Assessment Findings: Overweight; Eat in absence of hunger; Preference for high-sugar, high-fat foods

BINGE EATING DISORDER, COMPULSIVE OVEREATING Diagnostics Findings: BMI ≥ 30; Elevated

blood sugar, cholesterol, serum lipids Medical Management

Weight reduction: Reasonable goal of 10% - 20% weight loss

Psychotherapy, self-help support groupsShort-term drug therapy (antidepressants)

Nursing Management

CARING FOR CLIENTS WITH CHEMICAL DEPENDENCECHAPTER 71 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with Psychobiologic Disorders

CARING FOR CLIENTS WITH DEMENTIA AND THOUGHT DISORDERSCHAPTER 72 TIMBY/SMITH: INTRODUCTORY MEDICAL-SURGICAL NURSING, 10/ECaring for Clients with Psychobiologic Disorders