A compilation of notes that are mostly direct copies of Mr. Michael Jimenez’s handouts on the lecture held on January 26, 2025. I take no credit in any of the material presented.
Anatomy and Physiology
- Cerebrum: the cerebrum is the largest part of the brain and is responsible for a wide range of higher cognitive functions. It is divided into four lobes: frontal, temporal, parietal, and occipital.
- Frontal Lobe: this area is primarily associated with executive functions, such as decision-making, planning, problem-solving, and impulse control. It also plays a role in motor function and personality.
- Temporal Lobe: the temporal lobe is involved in auditory processing, language comprehension, memory formation (particularly the hippocampus within the temporal lobe), and emotion regulation.
- Parietal Lobe: this lobe is responsible for processing sensory information from various modalities, including touch, pain, temperature, and spatial orientation. It plays a crucial role in body awareness and spatial perception.
- Occipital Lobe: the occipital lobe is primarily responsible for visual processing and perception. It interprets visual information received from the eyes.
Neurotransmitters and Mental Health
- Depression: Depression is often associated with imbalances in neurotransmitters such as serotonin, norepinephrine. Low levels of serotonin are particularly linked to depressive symptoms. Antidepressant medications like SSRIs (Selective Serotonin Reuptake Inhibitors) work by increasing serotonin levels in the brain.
- Mania (Bipolar Disorder): In bipolar disorder, there is a shift between depressive and manic episodes. During manic episodes, there may be an excess of norepinephrine and dopamine, contributing to elevated mood, increased energy, and impulsivity. Medications like mood stabilizers aim to balance these neurotransmitters.
- Schizophrenia: Schizophrenia is associated with dysregulation of several neurotransmitters, mainly dopamine. Excessive dopamine activity in certain brain areas is thought to contribute to positive symptoms (hallucinations, delusions), while decreased glutamate activity may be linked to negative symptoms (social withdrawal, cognitive deficits). Antipsychotic medications target dopamine receptors to alleviate symptoms.
- Anxiety: Anxiety disorders are often linked to imbalances in neurotransmitters like gamma-aminobutyric acid (GABA), serotonin, and norepinephrine. Reduced GABA activity can lead to increased anxiety, while fluctuations in serotonin and norepinephrine can affect mood and arousal. Medications such as benzodiazepines and SSRIs are commonly used to treat anxiety disorders by modulating these neurotransmitters.
Note
It’s important to note that while neurotransmitter imbalances are associated with these mental health conditions, they are not the sole cause. Genetics, environmental factors, brain structure, and psychological factors also play significant roles in the development and course of these disorders. Treatment typically involves a combination of therapy and medication to address both the biological and psychological aspects of these conditions.
Mental Health
The World Health Organization defined health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. Mental health, however, is defined as a state of well-being wherein an individual recognizes their own potential (able to become productive) and is able to cope with normal stress (able to overcome obstacles). Prosperity in both aspects will allow an individual to work and live productively.
There are many factors affecting mental health. These include the:
- Individual: an individual’s personal biological, genetic, and neurochemical make-up.
- Interpersonal: an individual’s social connections
- Sociocultural: external conditions that the individual resides in, which can place stressors on the individual such as social norms, social stigmas, cultural expectations, etc.
Psychoanalytic Theory
Sigmund Freud’s (the father of psychoanalysis) psychoanalytic theory, a cornerstone of the field of psychology, seeks to provide insight into the intricacies of human behavior and mental processes. At its core, this theory revolves around the tripartite structure of the human psyche, comprising the id, ego, and superego. These components engage in dynamic interactions that significantly influence an individual’s personality and behavior. Let’s delve into these components with a more technical perspective and provide examples to illustrate their functioning:
- Id: the id represents the most primitive and instinctual aspect of the psyche. It operates on the pleasure principle, relentlessly pursuing immediate gratification of basic needs and desires such as hunger or thirst.
- Ego: the ego serves as the rational and conscious part of the psyche, emerging in response to the demands of the external world. It adheres to the reality principle, striving to satisfy the id’s desires in a socially acceptable manner while considering the potential consequences. It is the arbiter between the Id and the Superego.
- Superego: the superego functions as the moral and ethical compass of the psyche. It embodies internalized rules and values, often influenced by societal and parental expectations. It enforces moral and ethical standards and can induce feelings of guilt or shame when actions violate these standards.
These components frequently engage in conflicts, resulting in psychological tensions and impacting an individual’s thoughts, feelings, and behaviors:
- Conflict between the Id and Ego: the ego must navigate a fine balance between fulfilling the immediate desires of the id and recognizing the constraints of the external world.
- Conflict between the Id and Superego: the id’s pursuit of pleasure may collide with the moral values dictated by the superego, leading to inner turmoil.
- Conflict between the Ego and Superego: the ego’s responsibility includes reconciling the demands of the superego with the realities of the external world, which can create internal strife when societal expectations diverge from personal desires.
- Id Dominance results in conditions such as mania, antisocial personality disorder, and narcissistic personality disorder.
- Superego Dominance results in conditions such as obsessive-compulsive disorder and anorexia nervosa.
- Damaged Ego may result in the loss of basis in reality, producing disorder such as schizophrenia.
While Freud’s psychoanalytic theory has encountered both praise and criticism, and some of its concepts have evolved over time, the id, ego, and superego framework remains an invaluable tool for comprehending the intricate mechanisms of the human mind and the complexities inherent in human behavior.
Defense Mechanisms
Defense mechanisms are psychological strategies that individuals unconsciously use to cope with emotional discomfort, anxiety, and stress. These mechanisms operate on an unconscious level and help protect the ego from overwhelming feelings or thoughts that may be too difficult to deal with directly.
- Denial: Refusing to accept reality or the truth to avoid facing a painful situation. For instance, a person with a drinking problem might insist they don’t have an issue despite evidence to the contrary.
- Projection: Attributing one’s own undesirable feelings, thoughts, or traits to others. An individual who is competitive and sees winning as crucial may accuse others of being overly competitive.
- Rationalization: Creating logical explanations or justifications for behaviors or situations to make them appear less threatening. Someone passed over for a promotion might say they didn’t want it anyway.
- Regression: Reverting to behaviors and patterns of earlier stages of development as a way to cope with stress. An adult under stress might start biting their nails, a habit from childhood.
- Displacement: Redirecting emotions, usually anger, onto a safer target. If frustrated by a boss, someone might take out their anger on their family.
- Sublimation: Channeling unacceptable impulses into more socially acceptable outlets. An individual with aggressive tendencies might become a competitive athlete to channel their aggression constructively.
- Repression: Pushing distressing thoughts or memories out of conscious awareness. Someone might have no memory of a car accident due to repression.
- Reaction Formation: Expressing the opposite of one’s true feelings as a way to manage uncomfortable emotions. Someone disliking a coworker might be overly friendly.
- Intellectualization: Dealing with emotions by focusing excessively on facts, logic, and intellectual aspects of a situation. Faced with loss, someone might research grief instead of experiencing their emotions.
- Undoing: Engaging in actions to counteract a previous undesirable action. Someone berating their partner might later buy them gifts as a way of compensating.
- Dissociation: Separating oneself from reality or a situation to avoid distressing emotions. This can result in feeling disconnected or observing experiences from a distance. For example, a person who experienced a traumatic event might feel detached as a way to cope.
- Identification: Taking on characteristics of someone else to reduce anxiety. A person might imitate traits of those they admire to feel more secure.
- Introjection: Incorporating external beliefs into one’s identity without critically evaluating them. Someone might internalize a parent’s strong political beliefs without questioning them.
- Conversion: Converting emotional distress into physical symptoms without medical basis. This can manifest as paralysis or other sensory deficits. For instance, intense anxiety might lead to temporary leg paralysis.
- Compensation: Overachieving in one area to compensate for perceived deficiencies in another. Someone lacking athletic ability might excel in academics.
- Substitution: Replacing an unattainable goal with a more attainable one. Someone unable to pursue a dream career might focus on building a fulfilling personal life.
- Suppression: Consciously pushing distressing thoughts, emotions, or memories out of awareness. A student might consciously suppress thoughts about an upcoming exam to avoid feeling anxious.
Anxiety Disorder
Anxiety is a natural response to stress or a perceived threat, characterized by feelings of tension, worry, and physical symptoms such as increased heart rate and rapid breathing. It can range from mild to panic levels, each with distinct characteristics and management strategies.
| Level | Definition | Behavior |
|---|---|---|
| Mild | Normal response to daily stress that enhances focus and problem-solving. Signs: Restlessness, slight irritability, and improved motivation. | No medical interventions are needed. Encourage verbalization of feelings and relaxation techniques. |
| Moderate | Narrowed focus on the stressor, with difficulty concentrating on other stimuli. Signs: Increased breathing rate, selective inattention, muscle tension, and a sense of unease. | Non-pharmacological interventions like grounding techniques and deep breathing. PRN medications may be considered if anxiety disrupts functioning. |
| Severe | Overwhelming anxiety leading to significant impairment in focus and functioning. Signs: Hyperventilation, trembling, rapid speech, and an inability to focus on anything but the stressor. | Reduce stimuli, ensure safety, use simple instructions, and stay with the patient for reassurance. |
| Panic | Intense and overwhelming anxiety, often accompanied by physical symptoms like hyperventilation and chest tightness. Signs: extreme fear, irrational behavior, inability to communicate or focus. Physical symptoms such as hyperventilation (rapid breathing), dizziness, palpitations, and a sense of impending doom. Possible Respiratory Alkalosis: Hyperventilation can cause low levels of carbon dioxide in the blood, leading to symptoms such as tingling in the hands and feet, lightheadedness, or faintness. | Immediate Intervention: Encourage the patient to breathe into a brown paper bag. This helps increase carbon dioxide levels and counteracts respiratory alkalosis. Grounding techniques (e.g., focus on the five senses). Provide reassurance: “You are safe; focus on your breathing.” Avoid teaching or asking the patient to make decisions during this phase. |
Nursing Diagnoses related to Anxiety
Diagnosis Factors Ineffective Individual Coping Related to Inability to effectively manage stress; Evidenced by Verbalizations of worry, physical symptoms of anxiety, or avoidance behaviors Powerlessness Related to Feelings of lack of control, often seen in patients with compulsive behaviors or rituals; Evidenced by Repeated rituals, expressions of frustration, or helplessness.
Nursing Management
Goals
- Patient will demonstrate reduced physical symptoms of anxiety (e.g., normalized breathing and heart rate) within 15-30 minutes of intervention.
- Patient will verbalize feelings and identify at least one coping strategy by the end of the shift.
- Mild Anxiety: encourage verbalization of thoughts and feelings.
- Teach relaxation techniques (e.g., deep breathing, mindfulness).
- Moderate Anxiety: provide calm and clear communication.
- Use grounding exercises (e.g., focusing on present sensory input).
- Engage the patient in guided relaxation techniques.
- Severe Anxiety: reduce environmental stimuli (e.g., quiet, dimly lit space).
- Stay with the patient and provide reassurance.
- Use short and simple instructions, focusing on immediate needs.
- Panic Anxiety (with Hyperventilation and Respiratory Alkalosis): stay with the patient and ensure their safety.
- Encourage controlled breathing (e.g., slow inhalation through the nose and exhalation through pursed lips).
- If hyperventilation persists, have the patient breathe into a brown paper bag to rebalance carbon dioxide levels and manage respiratory alkalosis.
- Use grounding techniques to reorient the patient.
Assess Reduction in Anxiety:
- Has the patient’s breathing and heart rate normalized?
- Are physical symptoms such as tingling or dizziness resolved?
- Can the patient verbalize feelings and engage in problem-solving?
- Is the patient able to use relaxation techniques independently?
Determine Next Steps:
- If symptoms persist, reassess interventions and consider further medical or psychological support
Bipolar Disorder
A disorder characterized by episodes of mania and depression.
- Appearance: the use of heavy make-up and (possibly inappropriate to weather/situation) colorful, flamboyant clothing.
- Behavior: mania will appear as hyperactivity and irritability. They may act seductive.
- Communication: individuals are talkative, possibly explicit or inappropriate, and loud.
Lithium Therapy
Lithium, often in the form of lithium sodium, is a common antimanic medication used in psychiatric patients. It is one of the few medications that require close monitoring due to its narrow therapeutic window. Regular monitoring of lithium levels is essential. The therapeutic range is typically between 0.6 to 1.2 mEq/L. Blood levels should be checked 5 days after starting treatment or after any dose change, then every 2-3 months. Monitor for symptoms of lithium toxicity if levels exceed 1.5 mEq/L. Educate the patient about the importance of regular blood level checks. Adjust the lithium dose based on serum levels and clinical response.
Kidney Function Tests
Lithium can affect renal function, necessitating periodic kidney function tests (e.g. Crea and BUN).
- Identify any signs of renal impairment. Schedule regular monitoring of kidney function. Educate the patient about the importance of kidney function tests.
- Monitor trends in renal function tests and adjust lithium therapy as needed.
| Side Effects | Pathophysiology | Management |
|---|---|---|
| Polyuria | Lithium being excreted through the renal system draws more fluids towards itself. | Monitor fluid balance. Increase hydration up to 3 L per day. |
| Diarrhea | Lithium in the gastrointestinal system pulls fluids towards itself, decreasing stool bulk. | Monitor fluid and electrolyte balance. Increase hydration up to 3 L per day. |