Mental Health Test 3 [Monday 4/3/17]

*Give an example of an SSRI*

*fluoxetine (Prozac)*, celexa, *sertraline (Zoloft)*

*Catatonic Schizophrenia* (from her outline)

- Catatonic stupor: extreme psychomotor retardation, the individual is usually mute, posturing is common - Catatonic excitement: extreme psychomotor agitation, purposeless movements that must be curtailed to prevent injury to the client or others. - Catatonic features may be associated with other psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder. - symptoms of catatonic disorder include: Stupor and muscle rigidity or excessive purposeless motor activity Waxy flexibility negativism echolalia echopraxia mutism

MDD

- Feelings of total despair and hopelessness - Physical movement may come to a standstill - Feels at their worst early in the AM and somewhat better as the day progresses

Outcome Criteria The following criteria may be used for measurement of outcomes in the care of the client with schizophrenia. *!!!The Client*

1. Demonstrates an ability to relate satisfactorily with others. 2. Recognizes distortions of reality. 3. Has not harmed self or others. 4. Perceives self realistically. 5. Demonstrates the ability to perceive the environment correctly. 6. Maintains anxiety at a manageable level. 7. Relinquishes the need for delusions and hallucinations. 8. Demonstrates the ability to trust others. 9. Uses appropriate verbal communication in interactions with others. 10. Performs self-care activities independently.

*Alterations in which of the neurotransmitters are most closely associated with depression?*

1. Norepinephrine 2. Serotonin

waxy flexibility

A condition by which the individual with schizophrenia passively yields all movable parts of the body to any efforts made at placing them in certain positions.

*BOX 15-2 Positive and Negative Symptoms of Schizophrenia - Negative Symptoms!!!*

AFFECT 1. Inappropriate affect 2. Bland or flat affect 3. Apathy VOLITION 1. Inability to initiate goal-directed activity 2. Emotional ambivalence 3. Deteriorated appearance INTERPERSONAL FUNCTIONING AND RELATIONSHIP TO THE EXTERNAL WORLD 1. Impaired social interaction 2. Social isolation 3. Anosognosia PSYCHOMOTOR BEHAVIOR 1. Anergia 2. Waxy flexibility 3 Posturing 4. Pacing and rocking ASSOCIATED FEATURES 1. Anhedonia 2. Regression

What was the 1st atypical antipsychotic to be developed? Why is it not considered a 1st line treatment for schizophrenia?

Clozapine (Clozaril) was the 1st atypical antipsychotic to be developed. It is not considered 1st-line treatment bc of serious side-effects, such as *agranulocytosis, seizures, and hypersalivation!!!*

Ambivalence

Coexistence of opposite emotions toward the same object person or situation example cannot decide whether to have tea or coffee for lunch

TABLE 15-1 Substances That May Cause Psychotic Disorders

DRUGS OF ABUSE Alcohol Amphetamines and related substances Cannabis Cocaine Hallucinogens Inhalants Opioids Phencyclidine and related substances Sedatives, hypnotics, and anxiolytics MEDICATIONS Anesthetics and analgesics Anticholinergic agents Anticonvulsants Antidepressant medication Antihistamines Antihypertensive agents Cardiovascular medications Antimicrobial medications Antineoplastic medications Antiparkinsonian agents Corticosteroids Disulfiram Gastrointestinal medications Muscle relaxants Nonsteroidal anti-inflammatory agents TOXINS Anticholinesterase Organophosphate insecticides Nerve gases Carbon dioxide Carbon monoxide Volatile substances (e.g., fuel, paint, gasoline, toluene)

Mutism

Does not talk.

*avolition*

Lack of motivation, inability to initiate task

*alogia*

Lack of speech due to poverty of thought, lack of energy, or slowed processing

inappropriate affect

Laughs when told that his or her mother has just died.

Sociocultural Factors (Environmental Influences)

Many studies have attempted to link schizophrenia to social class - Epidemiological statistics have shown that greater numbers of individuals from the *lower socioeconomic classes experience symptoms associated with schizophrenia than do those from the higher socioeconomic groups* - Explanations for this occurrence include the conditions associated with living in poverty, such as congested housing accommodations, *inadequate nutrition*, absence of prenatal care, few resources for dealing with stressful situations, and feelings of hopelessness for changing one's *lifestyle of poverty* - An alternative view is the downward drift hypothesis, which suggests that because of the characteristic symptoms of the disorder, individuals with schizophrenia have difficulty maintaining gainful employment and *"drift down" to a lower socioeconomic level (or fail to rise out of a lower socioeconomic group)* - *Proponents of this view consider poor social conditions to be a consequence rather than a cause of schizophrenia*

*anergia*

Passivity, lack of energy

A client with depression has just been prescribed the antidepressant phenelzine (Nardil). She says to the nurse, "The doctor says I will need to watch my diet while I'm on this medication. What foods should I avoid?" Which of the following is the correct response by the nurse? a. Blue cheese, red wine, raisins b. Black beans, garlic, pears c. Pork, shellfish, egg yolks d. Milk, peanuts, tomatoes

a. *Blue cheese, red wine, raisins*

The physician orders sertraline (Zoloft) 50 mg PO bid for Margaret, a 68-year-old woman with Major Depressive Disorder. After 3 days of taking the medication, Margaret says to the nurse, "I don't think this medicine is doing any good. I don't feel a bit better." What is the most appropriate response by the nurse? a. "Cheer up, Margaret. You have so much to be happy about." b. "Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms." c. "I'll report that to the physician, Margaret. Maybe he will order something different." d. "Try not to dwell on your symptoms, Margaret. Why don't you join the others down in the dayroom?"

b. "Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms."

A client whose husband died 6 months ago is diagnosed with Major Depressive Disorder. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? a. "Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b. "I can understand how you must feel." c. "Those feelings are a normal part of the grief response." d. "Just think about the good times that you had while he was alive."

c. "Those feelings are a normal part of the grief response."

A client who has been taking chlorpromazine (Thorazine) for several months presents in the emergency department with EPS of restlessness, drooling, and tremors. What medication will the nurse expect the physician to order? a. Paroxetine (Paxil) b. Carbamazepine (Tegretol) c. Benztropine (Cogentin) d. Lorazepam (Ativan)

c. *Benztropine (Cogentin)* Benztropine is an anticholinergic medication that blocks cholinergic activity in the central nervous system, which is responsible for EPS. *Anticholinergics are the drugs of choice to treat extrapyramidal symptoms associated with antipsychotic medications.*

A client recently admitted to the hospital reports to the nurse, "I don't understand why I was brought here. I was simply hanging out in my apartment, and the police said I had to come with them." This is an example of what symptom of schizophrenia? a. Delusions of reference b. Loose association c. Anosognosia d. Auditory hallucinations

c. Anosognosia

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing which of the following? a. Somatic delusions b. Catatonic stupor c. Auditory hallucinations d. Pseudoparkinsonism

c. Auditory hallucinations

Jenny reported to the high school nurse that her mother drinks too much. She is drunk every afternoon when Jenny gets home from school. Jenny is afraid to invite friends over because of her mother's behavior. What is this type of crisis called? a. Crisis resulting from traumatic stress b. Maturational or developmental crisis c. Dispositional crisis d. Crisis reflecting psychopathology

c. Dispositional crisis

Margaret, age 68, is a widow of 6 months. Since her husband died, her sister reports that Margaret has become socially withdrawn, has lost weight, and does little more each day than visit the cemetery where her husband was buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with a diagnosis of Major Depressive Disorder. Which of the following is the priority nursing diagnosis for Margaret? a. Imbalanced nutrition: less than body requirements b. Complicated grieving c. Risk for suicide d. Social isolation

c. Risk for suicide

Substance-Induced Depressive Disorder

considered to be the direct result of physiological effects of a substance. 1 Ex: cocaine, alcohol 2 Happens w/ withdrawals or while they're on the substance - The symptoms associated with a substance- or medication-induced depressive disorder are considered to be the direct result of physiological effects of a substance (e.g., a drug of abuse, a medication, or toxin exposure). This disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The depressed mood is associated with intoxication or withdrawal from substances such as alcohol, amphetamines, cocaine, hallucinogens, opioids, phencyclidine-like substances, sedatives, hypnotics, or anxiolytics. The symptoms meet the full criteria for a relevant depressive disorder. A number of medications have been known to evoke mood symptoms. Classifications include anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antiulcer agents, cardiac medications, oral contraceptives, psychotropic medications, muscle relaxants, steroids, and sulfonamides. Some specific examples are included in the discussion of predisposing factors to depressive disorders.

Education for the client who is taking MAOIs should include which of the following? a. Fluid and sodium replacement when appropriate, frequent drug blood levels, signs and symptoms of toxicity b. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2 to 4 weeks c. Short-term use, possible tolerance to beneficial effects, careful tapering of the drug at end of treatment d. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification

d. *Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification*

The most appropriate nursing intervention with Marie (from question 9) would be to a. Refer her to her family physician for a complete physical examination. b. Suggest she seek outside employment now that her children have left home. c. Identify convenient support systems for times when she is feeling particularly despondent. d. Begin grief work and assist her to recognize areas of self-worth separate and apart from her children.

d. Begin grief work and assist her to recognize areas of self-worth separate and apart from her children.

*Substance- and Medication-Induced Psychotic Disorder!!!*

The *prominent hallucinations and delusions associated with substance-induced or medication-induced disorder are found to be directly attributable to substance intoxication or withdrawal or after exposure to a medication or toxin* - this diagnosis is made when the symptoms are more excessive and more severe than those usually associated with the intoxication or withdrawal syndrome - The medical hx, physical exam, or lab findings provide evidence that the appearance of the symptoms occurred in association with a substance intoxication or withdrawal or exposure to a medication or toxin - Catatonic features also may be associated with this disorder

seasonal pattern

The DSM-5 uses this to describe and specify any depressive disorder that occurs at "characteristic times of the year" o most commonly, the episodes occur in *fall or winter* but in some cases clients have recurrent summer episodes. o Authors of 1 large study report that prevalence rates of depression with seasonal patterns have varied from 1% to 12%, but in their study of 5549 patients from primary care settings, there was no evidence of seasonal patterns for major depressive disorder o In another study found that a small but significant peak in depression symptoms occurred in winter months, but over 20 years of following those clients, the winter seasonal pattern was not stable. o Seasonal affective disorder continues to be popularly referred to as a separate condition, although the DSM-5 does not list it as a distinct diagnosis. o The reported benefits of light therapy may support a seasonal cause for depression during winter months when there may be less exposure to natural sunlight, but more research is needed to determine a causal relationship.

*Anhedonia*

The INABILITY to experience or even imagine any pleasant emotion.

Word Salad

"Get by for anyone just to answer fortune cookies."

Hal says to the nurse, "We must choose to take a ride. All alone we slip and slide. Now it's time to take a bride." How would the nurse respond appropriately to this statement by Hal?

"I don't understand what you are saying, Hal. What message do you want to give me? Might you be telling me that you are lonely?" (Seeking clarification; attempting to translate words into feelings)

Hal, a patient on the psychiatric unit, has a diagnosis of schizophrenia. He lives in a halfway house, where last evening he began yelling that "aliens were on the way to take over our bodies! The message is coming through loud and clear!" The residence supervisor became frightened and called 911. As Hal was being admitted to the psychiatric unit, he told the nurse, "I'm special! I get messages from a higher being! We are in for big trouble!" How would the nurse respond appropriately to this statement by Hal?

"I know that you believe what you are saying is true, but I find it very hard to accept." (Voicing doubt) "Please understand that you are safe here." (Reassurance of safety)

A client you have been working with for several days approaches you with apparent signs of agitation and yells in a loud voice, "I want out of this hospital right now! You don't listen to a thing I say, and my doctor just wants my money!" How will you respond?

"I'll try to help you to the best of my ability. Please tell me what is upsetting you." Establish rapport, convey respect, and assess precipitating events.

Persecutory Delusion

"If the FBI finds me here, I'll never get out alive."

magical thinking

"We can't close the drapes, for if we do, the sun won't shine."

neologism

"When I get out of the hospital I'm going to buy me a sprongle."

delusion of grandeur

"When I speak, presidents and kings listen."

Client and Family Education Related to Antipsychotics The client receiving antipsychotic medication should:

- Use caution when driving or operating dangerous machinery. Drowsiness and dizziness can occur. - *Not stop taking the drug abruptly after long-term use. To do so might produce withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia, tremulousness.* - *Use sunblock lotion and wear protective clothing when spending time outdoors. Skin is more susceptible to sunburn, which can occur in as little as 30 minutes.* - *Report weekly (if receiving clozapine therapy) to have blood levels drawn and to obtain a weekly supply of the drug.* - Immediately report to the physician the occurrence of any of the following symptoms: sore throat, *fever*, malaise, unusual bleeding, easy bruising, persistent nausea and vomiting, severe headache, rapid heart rate, difficulty urinating, muscle twitching, tremors, darkly colored urine, excessive urination, excessive thirst, excessive hunger, weakness, pale stools, yellow skin or eyes, muscular incoordination, or skin rash. - *Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.* - Take frequent sips of water, chew sugarless gum, or suck on hard candy, if dry mouth is a problem. Good oral care (frequent brushing, flossing) is very important. - Consult the physician regarding smoking while on antipsychotic therapy. Smoking increases the metabolism of antipsychotics, requiring an adjustment in dosage to achieve a therapeutic effect - Dress warmly in cold weather, and avoid extended exposure to very high or low temperatures. Body temperature is harder to maintain with this medication. - *Avoid drinking alcohol while on antipsychotic therapy. These drugs potentiate each other's effects.* - *Avoid taking other medications (including over-the-counter products) without the physician's approval. Many medications contain substances that interact with antipsychotics in a way that may be harmful* - *Be aware of possible risks of taking antipsychotics during pregnancy. Safe use during pregnancy has not been established. Antipsychotics are thought to readily cross the placental barrier; if so, a fetus could experience adverse effects of the drug. Inform the physician immediately if pregnancy occurs, is suspected, or is planned.* - Be aware of side effects of antipsychotic drugs. Refer to written materials furnished by health-care providers for safe self-administration. - Continue to take the medication even if feeling well and as though it is not needed. Symptoms may return if medication is discontinued. - Carry a card or other identification at all times describing medications being taken.

NURSING DIAGNOSIS: RISK FOR VIOLENCE: SELF-DIRECTED OR OTHER-DIRECTED RISK FACTORS: Extreme suspiciousness, panic anxiety, catatonic excitement, rage reactions, command hallucinations, overt and aggressive acts, goal-directed destruction of objects in the environment, self-destructive behavior or active aggressive suicidal acts OUTCOME CRITERIA Short-Term Goals - Within [a specified time], client will recognize signs of increasing anxiety and agitation and report to staff (or other care provider) for assistance with intervention. - Client will not harm self or others. Long-Term Goal - Client will not harm self or others.

1. Maintain low level of stimuli in client's environment (low lighting, few people, simple decor, low noise level). - Anxiety level rises in a stimulating environment. A suspicious, agitated client may perceive individuals as threatening. 2. *Observe client's behavior frequently. Do this while carrying out routine activities. - Observation during routine activities avoids creating suspiciousness on the part of the client. Close observation is necessary so that intervention can occur if required to ensure client (and others') safety.* 3. Remove all dangerous objects from client's environment. -Removal of dangerous objects prevents client, in an agitated, confused state, from using them to harm self or others. 4. Intervene at the first sign of increased anxiety, agitation or verbal or behavioral aggression. Offer empathetic response to the client's feelings: "You seem anxious (or frustrated or angry) about this situation. How can I help?" - Validation of the client's feelings conveys a caring attitude and offering assistance reinforces trust. 5. *It is important to maintain a calm attitude toward the client. As the client's anxiety increases, offer some alternatives: participating in a physical activity (e.g., punching bag, physical exercise), talking about the situation, taking some antianxiety medication. - Offering alternatives to the client gives him or her a feeling of some control over the situation.* 6. *Have sufficient staff available to indicate a show of strength to the client if it becomes necessary. - This shows the client evidence of control over the situation and provides some physical security for staff.* 7. If client is not calmed by "talking down" or by medication, use of mechanical restraints may be necessary. - The avenue of the "least restrictive alternative" must be selected when planning interventions for a violent client. Restraints should be used only as a last resort after all other interventions have been unsuccessful and the client is clearly at risk of harm to self or others. 8. If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow the protocol established by the institution. The Joint Commission requires that an in-person evaluation by a physician or other licensed independent practitioner (LIP) be conducted within 1 hour of the initiation of the restraint or seclusion. The physician or LIP must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents. - These interventions are necessary for the protection of client and staff. 9. The Joint Commission requires that the client in restraints be observed at least every 15 minutes to ensure that circulation to extremities is not compromised (check temperature, color, pulses); to assist the client with needs related to nutrition, hydration, and elimination; and to position the client so that comfort is facilitated and aspiration is prevented. Some institutions may require continuous one-to-one monitoring of restrained clients, particularly those who are highly agitated, and for whom there is a high risk of self- or accidental injury. - Client safety is a nursing priority. 10. As agitation decreases, assess the client's readiness for restraint removal or reduction. Remove one restraint at a time while assessing the client's response. - This minimizes the risk of injury to client and staff.

*Shared Psychotic Disorder (also called folie`a deux.)*

A delusional system develops in a 2nd person as a result of a close relationship with another person who already has a psychotic disorder with prominent delusions.

Dysthymia

A depressive neurosis. The symptoms are similar to, if somewhat milder than, those ascribed to major depressive disorder. There is no loss of contact with reality.

premenstrual dysphoric disorder

A disorder that is characterized by depressed mood, anxiety, mood swings, and decreased interest in activities during the week prior to menses and subsiding shortly after the onset of menstruation.

word salad

A group of words that are put together in a random fashion without any logical connection.

She seemed to experience a total lack of energy for usual activities of daily living.

Anergia This demonstrates a negative symptom of schizophrenia called anergia. It is a lack of energy, passivity, lack of persistence at work or school.

She sits alone, talking and laughing to herself.

Autism A positive symptom, bizarre behavior for a social setting.

Psychological Treatments Behavior Therapy

Chief drawback has been inability to generalize to community setting after client has been discharged from treatment. Behavior modification has a history of qualified success in reducing the frequency of bizarre, disturbing, and deviant behaviors and increasing appropriate behaviors. Features that have led to the most positive results include the following: Clearly defining goals and how they will be measured Attaching positive, negative, and aversive reinforcements to adaptive and maladaptive behavior Using simple, concrete instructions and prompts to elicit the desired behavior Behavior therapy can be a powerful treatment tool for helping clients change undesirable behaviors. In the treatment setting, the health-care provider can use praise and other positive reinforcements to help the client with schizophrenia reduce the frequency of maladaptive or deviant behaviors. A limitation of this type of therapy is the inability of some individuals with schizophrenia to generalize what they have learned from the treatment setting to the community setting.

postpartum depression

Depression that occurs during the postpartum period. It may be related to hormonal changes, tryptophan metabolism, or alterations in membrane transport during the early postpartum period. Other predisposing factors may also be influential.

"I don't know why anyone would want to bother taking care of me. I really have nothing left to live for." How would the nurse respond appropriately to this statement by Carrie?

Direct questions assessing suicide potential: "Are you or have you been thinking about harming yourself? Do you have a plan for doing so? Have you ever acted on that plan?" Demonstrations of genuine concern and caring: "I care about you. I will stay here with you." Expressions of empathy: "It must be frightening to feel so all alone. But you are not alone. There are many people who care about you, and I am one of those people."

The nurse notices that each time she wipes her mouth with her napkin at dinner, Sandra does the same.

Echopraxia This is an example of Echopraxia, mimicking the movements of another person, also seen in catatonia.

Gynecomastia

Enlargement of the breasts in men may be a side effect of some antipsychotic medications.

psychomotor retardation

Extreme slowdown of physical movements. Posture slumps speech is slowed digestion becomes sluggish Common in severe depression.

MONOAMINE OXIDASE INHIBITORS

Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline Transdermal System (Emsam) - *avoid foods containing tyramine, CANNOT BE TAKE W/ OTHER ANTIDEPRESSANTS*

reaction formation

Jane hates her mother who ignored her when growing up Jane tell everyone I have a wonderful mother whom I love very much

waxy flexibility

Keeps arm in position nurse left it after taking blood pressure. Assumes this position for hours

Religiosity

Kneels to pray in front of water fountain; prays during group therapy and during other group activities.

Perseveration

Persistent repetition of the same word or idea in response to different questions.

preservation

Persistently repeats the same word or idea in response to different questions

paranoia

Refuses to eat food that comes on tray, stating, "They are trying to poison me."

Sometimes she would not even get up to go the bathroom, instead soiling herself in an infantile manner.

Regression This demonstrates a negative symptom of schizophrenia: lack of hygiene.

*Schizophreniform Disorder* (From her outline)

Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but <6 months

Phase IV: Residual Phase

Schizophrenia is characterized by periods of *remission and exacerbation* - phase usually follows an active phase of the illness (symptoms described in Phase III). - symptoms of the acute stage are either absent or no longer prominent. - Negative symptoms may remain, and flat affect and impairment in role functioning are common - Residual impairment often increases between episodes of active psychosis. Symptoms similar to those of the prodromal phase. Flat affect and impairment in role functioning are prominent. Goal: get them on medicine so you have remission and not exacerbation Even if s/s are not prominent they have negative symptoms: no joy from anything, no energy, sad

*Describe behaviors common to preschool children following a traumatic event.*

Separation anxiety regressive behaviors nightmares possibly can either be hyperactive or withdrawan

Medications Used With ECT

Several medications are associated with ECT. A pretreatment medication, such as atropine sulfate or glycopyrrolate (Robinul), is administered intramuscularly approximately 30 minutes before the treatment. Either of these medications may be ordered to decrease secretions (to prevent aspiration) and counteract the effects of vagal stimulation (bradycardia) induced by the ECT. In the treatment room, the anesthesiologist administers intravenously a *short-acting anesthetic*, such as *propofol (Diprivan) or etomidate (Amidate)*. A *muscle relaxant, usually succinylcholine chloride (Anectine)*, is given intravenously to *prevent severe muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones*. Because succinylcholine *paralyzes respiratory muscles as well, the client is oxygenated with pure oxygen during and after the treatment, except for the brief interval of electrical stimulation, until spontaneous respirations return.*

*Psychotic Disorder Due to Another Medical Condition!!!*

The essential features of this disorder are *prominent hallucinations and delusions that can be directly attributed to another medical condition* - *diagnosis is NOT made if the symptoms occur during the course of a delirium* - number of medical conditions that can cause psychotic symptoms - Medical conditions such as CNS infections hypo- or hyper-thyroidism migraine headaches renal disease

associative looseness

Thinking is characterized by speech in which ideas shift from one unrelated subject to another "I'm going to the circus. Jesus is God. The police are playing for keeps."

What is the goal of cognitive therapy with depressed clients? a. Identify and change dysfunctional patterns of thinking. b. Resolve the symptoms and initiate or restore adaptive family functioning. c. Alter the neurotransmitters that are creating the depressed mood. d. Provide feedback from peers who are having similar experiences.

a. *Identify and change dysfunctional patterns of thinking.*

Which of the following is the primary goal in working with an actively psychotic, suspicious client? a. Promote interaction with others. b. Decrease his anxiety and increase trust. c. Improve his relationship with his parents. d. Encourage participation in therapy activities.

b. Decrease his anxiety and increase trust.

To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented? a. Reinforce the perceptual distortions until the client develops new defenses. b. Provide an unstructured environment. c. Avoid making connections between anxiety-producing situations and hallucinations. d. Distract the client's attention.

d. Distract the client's attention. The nurse should first empathize with the client by focusing on feelings generated by the hallucination, present objective reality, and then distract or redirect the client to reality-based activities. I understand that you think the Devil is talking to him but he's not. Do you want to go play dominos or take a walk or eat lunch?

*mood (also called affect)*

is a pervasive and sustained emotion that may have a major influence on a person's perception of the world. Examples: depression, joy, elation, anger, and anxiety - affect: the external, observable emotional reaction associated with an experience. - flat affect: someone who lacks emotional expression and is often seen in severely depressed clients

A client needs to be advised

it may take 3-4 weeks for TCA to take effects

"I can read your mind, you know."

magical thinking This is an example of hallucination, sandra is perceiving a sensory experience, but no external stimuli exists, she thinks she can read minds.

Gender socialization

the construction of gender stereotypes, promotes typical female characteristics, such as helplessness, passivity, and emotionality, which are associated with depression some studies have suggested that "masculine" characteristics are associated with higher self-esteem and less depression

*Give an example of an MAOI*

*Phenelzine (Nardil)* & parnate

concrete thinking

Literal interpretations of the environment, inability to think in the abstract

Transient depression

- Feeling of the "blues" in response to everyday disappointments

Describe some common side effects for tricyclic antidepressants. List nursing implications.

1) blurred vision: Instruct not to drive until vision is clear 2) *constipation*: Eat foods high in fiber; increase fluid intake if not contraindicated; encourage exercise 3) urinary retention: instruct to report hesitancy or inability to urinate. Monitor Intake and Output. Try running water or pouring water over the perineal area to stimulate urination 4) *orthostatic hypotension*: Instruct to rise slowly. Monitor BP. Avoid long hot showers or tub baths 5) Weight gain: increase activity and teach on reduced-calorie intake 6) photosensitivity: teach importance of wearing sunblock, protective clothing, and sunglasses 7. sedation (request order to administer PC) 8. *dry mouth* 9. decreased seizure threshold (closely observe pt, esp. w/ hx of seizures)

*BOX 16-2 Diagnostic Criteria for Major Depressive Disorder!*

A. 5 (or more) of the following symptoms *have been present during the same 2-week period and represent a change from previous functioning*; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful) (Note: In children and adolescents, can be irritable mood.) 2. *Markedly diminished interest or pleasure in all*, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6. *Fatigue or loss of energy nearly every day!* 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. *Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)!* 9. *Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide!* B. The symptoms cause clinically significant distress or impairment in social, occupation, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. NOTE: Criteria A, B, and C represent a major depressive episode. NOTE: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. Specify: With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern

associative looseness (loose associations)

a thinking process characterized by speech in which ideas shift from one unrelated subject to another. The individual is unaware that the topics are unconnected.

*BOX 15-2 Positive and Negative Symptoms of Schizophrenia - Positive Symptoms!!!*

CONTENT OF THOUGHT 1. Delusions 2. Religiosity 3. Paranoia 4. Magical thinking FORM OF THOUGHT 1. Associative looseness 2. Neologisms 3. Concrete thinking 4. Clang associations 5. Word salad 6. Circumstantiality 7. Tangentiality 8. Mutism 9. Perseveration PERCEPTION 1. Hallucinations 2. Illusions SENSE OF SELF 1. Echolalia 2. Echopraxia 3. Identification and Imitation 4. Depersonalization

Client and Family Education Related to Antidepressants The Client Should:

Continue to take the medication even though the symptoms have not subsided. *The therapeutic effect may not be seen for as long as 4 weeks!!!* If after this length of time no improvement is noted, the physician may prescribe a different medication. Use caution when driving or operating dangerous machinery. *Drowsiness and dizziness* can occur. If these side effects become persistent or interfere with ADLs, the client should report them to the physician. Dosage adjustment may be necessary. *Not discontinue use of the drug abruptly!* To do so might produce withdrawal symptoms, such as nausea, vertigo, insomnia, headache, malaise, nightmares, and return of symptoms for which the medication was prescribed. *Use sunblock lotion and wear protective clothing* when spending time outdoors. The skin may be sensitive to sunburn. Immediately report occurrence of any of the following symptoms to the physician: sore throat, fever, malaise, yellowish skin, unusual bleeding, easy bruising, persistent nausea/vomiting, severe headache, rapid heart rate, difficulty urinating, anorexia/weight loss, seizure activity, stiff or sore neck, and chest pain. Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure. *Take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth is a problem*. Good oral care (frequent brushing, flossing) is very important. *Not consume the following foods or medications while taking MAOIs!!!*: aged cheese, wine (especially Chianti), beer, chocolate, colas, coffee, tea, sour cream, smoked and processed meats, beef or chicken liver, canned figs, soy sauce, overripe and fermented foods, pickled herring, raisins, caviar, yogurt, yeast products, broad beans, cold remedies, diet pills. To do so could cause a life-threatening hypertensive crisis. Avoid smoking while receiving tricyclic therapy. Smoking increases the metabolism of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect. *Avoid drinking alcohol while taking antidepressant therapy*. These drugs potentiate the effects of each other. *Avoid use of other medications* (including over-the-counter medications) without the physician's approval while receiving antidepressant therapy. Many medications contain substances that, in combination with antidepressant medication, could precipitate a life-threatening hypertensive crisis. Notify physician immediately if inappropriate or prolonged penile erections occur while taking trazodone. If the erection persists longer than 1 hour, seek emergency department treatment. This condition is rare but has occurred in some men who have taken trazodone. If measures are not instituted immediately, impotence can result. Not "double up" on medication if a dose of bupropion (Wellbutrin) is missed, unless advised to do so by the physician. Taking bupropion in divided doses will decrease the risk of seizures and other adverse effects. Follow the correct procedure for applying the selegiline transdermal patch: Apply to dry, intact skin on upper torso, upper thigh, or outer surface of upper arm. Apply approximately same time each day to new spot on skin after removing and discarding old patch. Wash hands thoroughly after applying the patch. Avoid exposing application site to direct heat (e.g., heating pads, electric blankets, heat lamps, hot tub, or prolonged direct sunlight). If patch falls off, apply new patch to a new site and resume previous schedule. *Be aware of possible risks of taking antidepressants during pregnancy*. Safe use during pregnancy and lactation has not been fully established. These drugs are believed to readily cross the placental barrier; if so, the fetus could experience adverse effects of the drug. Inform the physician immediately if pregnancy occurs, is suspected, or is planned. Be aware of the side effects of antidepressants. Refer to written materials furnished by health-care providers for safe self-administration. Carry a card or other identification at all times describing the medications being taken.

To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented? A) Reinforce the perceptual distortions until the client develops new defenses B) Provide an unstructured environment C) Avoid making connections between anxiety-producing situations and hallucinations D) Distract the client's attention

D) Distract the client's attention The nurse should first empathize with the client by focusing on feelings generated by the hallucination, present objective reality, and then distract or redirect the client to reality-based activities.

At one point she hears a laugh track on TV and states, "They're laughing at me. I know they are."

Delusion of reference This is an example of an alteration in thinking which occurs with everyone to some extent, however, people with schizophrenia are unable to correct this thinking with reasoning and become fixated with the delusion.

illusions

Misperception of a real external stimuli

Twenty-four-year-old Harriet was informed that her husband was killed in an industrial accident at the plant where he works. An hour later, she was found walking down a busy highway saying, "I'm looking for my lucky rabbit's foot. Everything will be okay if I can just find my lucky rabbit's foot."

a. Psychiatric emergency i. Will be in hospital

Sally is admitted to the hospital with Major Depressive Disorder and repeatedly makes negative statements about herself. Which of the following interventions is identified as an approach that promotes positive self-esteem in the patient? Select all that apply. a. Teach assertive communication skills. b. Make observations to Sally when she completes a goal or task. c. Instruct Sally that you will not talk with her unless she stops talking negatively about herself. d. Offer to spend time with Sally using a nonjudgmental, accepting approach.

a. Teach assertive communication skills. b. Make observations to Sally when she completes a goal or task. d. Offer to spend time with Sally using a nonjudgmental, accepting approach.

Tony, age 21, has been diagnosed with schizophrenia. He has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. What is the initial nursing intervention for Tony? a. Give him an injection of Thorazine. b. Ensure a safe environment for him and others. c. Place him in restraints. d. Order him a nutritious diet.

b. Ensure a safe environment for him and others.

The client hears the word "match." The client replies, "A match. I like matches. They are the light of the world. God will light the world. Let your light so shine." Which communication pattern does the nurse identify? a. Word salad b. Clang association c. Loose association d. Ideas of reference

c. Loose association Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question represents this communication pattern.

What is the mechanism of action by which antidepressant meds achieve the desired effect (regardless of the different physiological processes by which this action is accomplished)?

increase the concentration/levels of *norepinephrine, serotonin*, and/or dopamine in the body

MDD

characterized by depressed mood or loss of interest or pleasure in - nursing diagnosis R/T depressed mood - *symptoms have been present for at least 2 weeks* - No history of manic behavior, that would be bipolar NOT MDD - Cannot be attributed to use of substances or another medical condition - CNS depressants can cause people to be depressed including - the diagnosis of MDD is specified according to whether it is a single episode (the individual's first encounter with a major depressive episode) or recurrent (the individual has a history of previous major depressive episodes) - *Fatigue or loss of energy everyday* - *Diminished ability to think or concentrate every day!*

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid, 2 mg benztropine PO bid prn. Because benztropine was ordered on a prn basis, which of the following assessments by the nurse would convey a need for this medication? a. The client's level of agitation increases. b. The client complains of a sore throat. c. The client's skin has a yellowish cast. d. The client develops muscle spasms.

d. The client develops muscle spasms.

Which of the following is the primary focus of family therapy for clients with schizophrenia and their families? a. To discuss concrete problem-solving and adaptive behaviors for coping with stress b. To introduce the family to others with the same problem c. To keep the client and family in touch with the health-care system d. To promote family interaction and increase understanding of the illness

d. To promote family interaction and increase understanding of the illness

Light Therapy

*Between 15-25% of people with recurrent depressive disorder exhibit a seasonal pattern whereby symptoms are exacerbated during the winter months and subside during the spring and summer*. The DSM-5 identifies this disorder as Major Depressive Disorder, Recurrent, With Seasonal Pattern. It has commonly been known as seasonal affective disorder (SAD). Bright light therapy has been suggested as a first-line treatment for winter "blues" and as an adjunct in chronic MDD or dysthymia with seasonal exacerbations (Karasu et al., 2006). *SAD is thought to be related to the presence of the hormone melatonin*, which is produced by the pineal gland. Melatonin plays a role in the regulation of biological rhythms for sleep and activation. It is produced during the cycle of darkness and shuts off in the light of day. During the months of longer darkness hours, there is increased production of melatonin, which seems to trigger the symptoms of SAD in susceptible people. Light therapy, or exposure to light, has been shown to be an effective treatment for SAD. The light therapy is administered by a 10,000-lux light box, which contains white fluorescent light tubes covered with a plastic screen that blocks ultraviolet rays. The individual sits in front of the box with the eyes open (although the client should not look directly into the light). Therapy usually begins with 10- to 15-minute sessions and gradually progresses to 30 to 45 minutes. The mechanism of action is believed to be related to retinal stimulation which *triggers a reduction of melatonin and an increase in serotonin in the brain* (Rodriguez, 2015). A recent study demonstrated benefits of bright light therapy in non-SADs as well (Lam et al., 2015). Some people notice improvement rapidly, within a few days, whereas others may take several weeks to feel better. Side effects appear to be dosage related and include headache, eyestrain, nausea, irritability, photophobia (eye sensitivity to light), insomnia (when light therapy is used late in the day), and (rarely) hypomania (Terman & Terman, 2005). Light therapy and antidepressants have shown comparable efficacy in studies of SAD treatment. One study compared the efficacy of light therapy for SAD to daily treatment with 20 mg of fluoxetine (Lam et al., 2006). The authors concluded that "light treatment showed earlier response onset and lower rate of some adverse events relative to fluoxetine, but there were no other significant differences in outcome between light therapy and antidepressant medication"

Treatment Modalities for Depression Electroconvulsive Therapy

*Electroconvulsive therapy (ECT) is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain*. ECT is effective with clients who are acutely suicidal and in the treatment of severe depression, particularly in those clients who are also experiencing psychotic symptoms and those with psychomotor retardation and neurovegetative changes, such as disturbances in sleep, appetite, and energy. *It is often considered for treatment only after a trial of therapy with antidepressant medication has proved ineffective.*

Evaluation of Care for the Depressed Client In the final step of the nursing process, a reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. Evaluation of the nursing actions for the depressed client may be facilitated by gathering information using the following types of questions:

*Has self-harm to the individual been avoided?* *Have suicidal ideations subsided?* Does the individual know where to seek assistance outside the hospital when suicidal thoughts occur? Has the client discussed the recent loss with staff and family members? Is he or she able to verbalize feelings and behaviors associated with each stage of the grieving process and recognize own position in the process? Have obsession with and idealization of the lost object subsided? Is anger toward the lost object expressed appropriately? Does the client set realistic goals for self? Is he or she able to verbalize positive aspects about self, past accomplishments, and future prospects, including a desire to live? Can the client identify areas of life situation over which he or she has control? Is the client able to participate in usual religious practices and feel satisfaction and support from them? Is the client seeking out interaction with others in an appropriate manner? Does the client maintain reality orientation with no evidence of delusional thinking? Is he or she able to concentrate and make decisions concerning own self-care? Is the client selecting and consuming foods sufficiently high in nutrients and calories to maintain weight and nutritional status? Does the client sleep without difficulty and wake feeling rested? Does the client show pride in appearance by attending to personal hygiene and grooming? Have somatic complaints subsided?

Treatment Modalities for Depression Individual Psychotherapy

*Research has documented both the importance of close, satisfactory attachments in the prevention of depression* and the role of disrupted attachments in the development of depression - With this concept in mind, interpersonal psychotherapy focuses on the client's current interpersonal relations - *Interpersonal psychotherapy with the depressed person proceeds through 3 phases.*

*Brief Psychotic Disorder!!!* (from her outline)

*Sudden onset of psychotic symptoms* that *may or may not be preceded by a severe psychosocial stressor* - Symptoms last *< 1 month*, and the individual *returns to the full premorbid level of functioning* - The individual experiences emotional turmoil or overwhelming perplexity or confusion - Evidence of impaired reality testing may include incoherent speech, delusions, hallucinations, bizarre behavior, and disorientation - Individuals with preexisting personality disorders (most commonly, histrionic, narcissistic, paranoid, schizotypal, and borderline personality disorders) appear to be susceptible to brief psychotic disorder - Catatonic features also may be associated with this disorder

ECT Side Effects

*The most common side effects of ECT are temporary memory loss and confusion*(like 1-2 days after). Critics of the therapy argue that these changes represent irreversible brain damage. Proponents insist they are temporary and reversible. Black and Andreasen (2014) have stated: Because ECT disrupts new memories that have not been incorporated into long-term memory stores, ECT can cause anterograde and retrograde amnesia that is most dense around the time of treatment. The anterograde component usually clears quickly, but the retrograde amnesia can extend back to months before treatment. It is unclear if the memory loss is due to the ECT or to ongoing depressive symptoms. (p. 550) The controversy continues regarding the choice of unilateral versus bilateral ECT. Studies have shown that unilateral placement of the electrodes decreases the amount of memory disturbance. However, *unilateral ECT often requires a greater number of treatments to match the efficacy of bilateral ECT in the relief of depression*

Transcranial Magnetic Stimulation

*Transcranial magnetic stimulation (TMS) is a procedure that is used to treat depression by stimulating nerve cells in the brain*. TMS involves the use of *very short pulses of magnetic energy to stimulate nerve cells at localized areas in the cerebral cortex, similar to the electrical activity observed with ECT*. However, unlike ECT, the electrical waves generated by TMS do not result in generalized seizure activity (George, Taylor, & Short, 2013). The waves are passed through a coil placed on the scalp to areas of the brain involved in mood regulation. It is noninvasive and considered generally safe. A typical course of treatment is 40-minute sessions, three to five times a week for 4 to 6 weeks (Raposelli, 2015). Some clinicians believe that TMS holds a great deal of promise in the treatment of depression, whereas others remain skeptical. In rare instances, seizures have been triggered with the use of TMS therapy (Lanocha, 2010). In a study at King's College in London, researchers compared the efficacy of TMS with ECT in the treatment of severe depression (Eranti et al., 2007). They concluded that ECT was substantially more effective for the short-term treatment of depression, and they indicated the need for further intense clinical evaluation of TMS. One study (Connolly et al., 2012) identified that 24.7 percent of patients receiving TMS were in remission at 6 weeks. Effectiveness ratings for ECT have varied from 17 to 70 percent. While the effectiveness ratings may seem small or highly variable, both treatments provide an option for patients who are otherwise treatment resistant. George and associates (2013) stated: Since FDA approval, TMS has been generally safe and well tolerated with a low incidence of treatment discontinuation, and the therapeutic effects once obtained appear at least as durable as other antidepressant treatments. TMS also shows promise in several other psychiatric disorders, particularly treating acute and chronic pain. (p. 17) More recently, researchers compared TMS to pharmacotherapy and found them both effective but identified TMS as more cost effective (Raposelli, 2015). Currently, not all insurance companies cover this treatment, so from the client's standpoint, this may be a more expensive alternative. Raposelli reports that up to 40 percent of patients with MDD do not respond to pharmacotherapy, so alternatives such as ECT and TMS may offer some hope of recovery for treatment-resistant conditions.

Vagal Nerve Stimulation and Deep Brain Stimulation

*Vagal nerve stimulation (VNS)*, while it was being studied in the treatment of epilepsy, was found to improve the client's mood. This treatment involves implanting an electronic device in the skin to stimulate the vagus nerve. The mechanism of action is not known, but preliminary studies have shown that many patients with chronic recurrent depression improved when treated with VNS (Sadock et al., 2015). Trials are ongoing to determine its effectiveness. A more novel approach, a form of psychosurgery, is *deep brain stimulation (DBS)*. In this procedure, as in VNS, an electrode is implanted with the intent of stimulating brain function. However, this procedure, unlike VNS, is a deep implant that requires craniotomy. DBS has been well studied to determine its safety and effectiveness for other conditions, and controlled trials are ongoing. Currently, DBS is reserved for patients with severe, incapacitating depression or obsessive compulsive disorder who have not responded to any other more conservative treatments

A client is admitted with a diagnosis of brief psychotic disorder, with catatonic features. Which symptoms are associated with the catatonic specifier? a. Strong ego boundaries and abstract thinking b. Ataxia and akinesia c. Stupor, muscle rigidity, and negativism d. Substance abuse and cachexia

*c. Stupor, muscle rigidity, and negativism* Symptoms associated with the catatonic specifier include stupor and muscle rigidity or excessive, purposeless motor activity. Waxy flexibility, negativism, echolalia, and echopraxia are also common behaviors.

*Schizophreniform Disorder!*

*essential features are identical to those of schizophrenia, with the exception that the DURATION, including prodromal, active, and residual phases, is at least 1 month but <6 months* - If the diagnosis is made while the individual is still symptomatic but has been so for <6 months, it is qualified as "provisional." - The diagnosis is changed to schizophrenia if the clinical picture persists >6 months - is thought to have a good prognosis if the: 1. individual's affect is not blunted or flat 2. if there is a rapid onset of psychotic symptoms from the time the unusual behavior is noticed 3. if the premorbid social and occupational functioning was satisfactory - Catatonic features also may be associated with this disorder

positive symptoms and communication

- *By discharge, you want the client to identify events that increase anxiety and illicit hallucinations.* - Patient: "The voices, i.e. devil are telling me I'm going to hell." Nurse: "I'm sure the voices sound scary. The devil is not talking to you. This is part of your illness. (Reassure the patient) - Risperidone (Risperdal) is given for the positive symptoms (somatic delusion, gustatory (sense of taste) hallucination, clang associations) - With command hallucinations: voices tell you to kill, the president etc. NSG Dx: Risk for violence directed toward others. - Patient may isolate self, be accusatory/yelling and hearing voices. - *Would you warn the others? YES* - *Paranoid delusions, neologisms, and echolalia are positive symptoms.*

Developmental Implications - Postpartum Depression

- *of women who give birth, approximately 50-85% experience the blues following delivery, the incidence of moderate depression is 10-20%, severe, or psychotic, depression occurs rarely, in about 1 or 2 out of 1000 postpartum women!!!* - May last for a few weeks to several months; the symptoms usually begin w/i 48 hrs of delivery, peak at about 3-5 days, and last approximately 2 weeks - Associated with hormonal changes, tryptophan metabolism. - Treatments include antidepressants and psychosocial therapies - Symptoms include *fatigue, irritability, loss of appetite, sleep disturbances, loss of libido*, and *concern about inability to care for infant* - *Risks of suicide and infanticide should not be overlooked!!!*

Developmental Implications - Senescence

- Bereavement overload - High percentage of suicides among the elderly - the aging individual's adaptive coping strategies may be seriously challenged by major stressors, such as financial problems, physical illness, changes in bodily functioning, and an increasing awareness of approaching death - the problem is often intensified by the numerous losses individuals experience during this period in life, such as spouse, friends, children, home, and independence - symptoms of depression often confused with symptoms of NCD - txt includes antidepressant medication, ECT, and psychosocial therapies - ECT is an important alternative for treatment of major depression in the elderly, especially considering the problematic side effects of antidepressants in this population

Organic Treatment Psychopharmacology

- Chlorpromazine (Thorazine) - *Antipsychotic* medications are also called neuroleptics and historically were referred to as major tranquilizers. - *Used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders!* - They are effective in the treatment of acute and chronic manifestations of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms. - Without drug treatment, an estimated 72% of individuals who have experienced a psychotic episode relapse within a year. - This relapse rate can be reduced to about 23% with continuous medication administration - The prognosis of schizophrenia has often been reported in a paradigm of thirds. - One-third of the people achieve significant and lasting improvement. - They may never experience another episode of psychosis following the initial occurrence - One-third may achieve some improvement with intermittent relapses and residual disability - Their occupational level may have decreased because of their illness, or they may be socially isolated - Finally, one-third experience severe and permanent incapacity - They often do not respond to medication and remain severely ill for much of their lives. - Men have poorer outcomes than women do; women respond better to treatment with antipsychotic medications - As mentioned earlier, the efficacy of antipsychotic medications is enhanced by adjunct psychosocial therapy. - Because the psychotic manifestations of the illness subside with use of the drugs, clients are generally more cooperative with the psychosocial therapies. - However, it takes several weeks for the antipsychotics to effectively treat positive symptoms, a fact that often leads to discontinuation of the medication. - Clients and families need to be educated about the importance of waiting, often for several weeks, to determine whether the drug will be effective. - These medications are classified as either "typical" (first-generation, conventional antipsychotics) or "atypical" (the newer, novel antipsychotics).

Premenstrual Dysphoric Disorder

- Depressed Mood - Anxiety - Mood swings - Decreased interest in activities - Symptoms begin during week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses. - The essential features of premenstrual dysphoric disorder include markedly depressed mood, excessive anxiety, mood swings, and decreased interest in activities during the week prior to menses, improving shortly after the onset of menstruation, and becoming minimal or absent in the week postmenses

Developmental Implications - Adolescence

- Depression may be even harder to recognize in an adolescent than in a younger child. - Feelings of sadness, loneliness, anxiety, and hopelessness associated with depression may be perceived as the normal emotional stresses of growing up. - Symptoms include anger, aggressiveness, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, apathy - *Best clue that differentiates depression from normal stormy adolescent behavior: A visible manifestation of behavioral change that lasts for several weeks!!! - Most common precipitant to adolescent suicide: perception of abandonment by parents or close peer relationship - Treatment of the depressed adolescent is often conducted on an outpatient basis - Treat with 1. Supportive psychosocial intervention 2. Antidepressant medication (all antidepressants carry an FDA black box warning for increased risk of suicidality in children and adolescents). *Fluoxetine (Prozac)* has been approved by the FDA to treat depressions in children and adolescents.

Psychological Factors

- Early conceptualizations of schizophrenia focused on family relationship factors as major influences in the development of the illness, probably in light of the conspicuous absence of information related to a biological connection. These early theories implicated poor parent-child relationships and dysfunctional family systems as the cause of schizophrenia, but they *no longer hold any credibility* - Researchers now focus their studies in terms of schizophrenia as a *brain disorder* - Even though family relationships are not involved in the etiology of the illness, the symptoms in schizophrenia can contribute to significant disruption in communication and relationships among family members, so psychosocial factors should always be part of a comprehensive assessment

Dysthymic disorder

- Gloomy and pessimistic outlook - Feels at their best early in the AM and continually feels worse as the day progresses - Able to carry out thoughts of self-destructive behavior

What is the most potentially life-threatening adverse effect of MAOIs? List symptoms to be aware of with this. How can it be prevented?

- HTN Crisis - Really elevated BP fever sweating palpitations N&V muscle rigidity/nuchal severe occipital HA chest pain coma - Avoid foods and OTC meds with a high content of Tyramine, such as: aged cheese red wines avocados figs anchovies bean curd/fermented beans broad beans yeast liver processed meats (sausages) cold medications pickled herring...

Dysthymic Disorder

- Sad or "down in the dumps" - No evidence of psychotic symptoms - If they have a period of psychosis, it's MDD if not its dysthymic disorder - Essential feature is a chronically depressed mood for: Most of the day More days than not *At LEAST 2 years* - Low energy or fatigue - Feelings of hopelessness - Won't be hospitalized they will be treated output basis - Characteristics of dysthymia are similar to, if somewhat milder than, those ascribed to MDD. Individuals with this mood disturbance describe their mood as sad or "down in the dumps." There is no evidence of psychotic symptoms. The essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for most of the day, more days than not, for at least 2 years (1 year for children and adolescents). The diagnosis is identified as early onset (occurring before age 21 years) or late onset (occurring at age 21 years or older).

Positive Symptoms - Content of Thought

- delusions: *false personal beliefs* that are inconsistent with the person's intelligence or cultural background, the individual continues to have the belief in spite of obvious proof that it is false or irrational, are subdivided according to their content 1. Delusion of persecution: The individual feels threatened and believes that others intend harm or persecution toward him or her in some way (e.g., "The FBI has 'bugged' my room and intends to kill me"; "I can't take a shower in this bathroom; the nurses have put a camera in there so that they can watch everything I do"). 2. Delusion of grandeur: The individual has an exaggerated feeling of importance, power, knowledge, or identity (e.g., "I am Jesus Christ"). 3. *Delusion of reference*: All events within the environment are referred by the psychotic person to himself or herself (e.g., "Someone is trying to get a message to me through the articles in this magazine [or newspaper or TV program]; I must break the code so that I can receive the message"). Ideas of reference are less rigid than delusions of reference. An example of an idea of reference is irrationally assuming that, when in the presence of others, one is the object of their discussion or ridicule. 4. Delusion of control or influence: The individual believes certain objects or persons have control over his or her behavior (e.g., "The dentist put a filling in my tooth; I now receive transmissions through the filling that control what I think and do"). 5. Somatic Delusion: The individual has a false idea about the functioning of his or her body (e.g., "I'm 70 years old, and I will be the oldest person ever to give birth. The doctor says I'm not pregnant, but I know I am"). 6. Nihilistic delusion: The individual has a false idea that the self, a part of the self, others, or the world is nonexistent (e.g., "The world no longer exists"; "I have no heart"). - *Paranoia* Individuals with paranoia have extreme suspiciousness of others and of their actions or perceived intentions (e.g., "I won't eat this food. I know it has been poisoned"). - Magical Thinking With magical thinking, the person believes that his or her thoughts or behaviors have control over specific situations or people (e.g., the mother who believed if she scolded her son in any way, he would be taken away from her). Magical thinking is common in children (e.g., "It's raining; the sky is sad"; "It snowed last night because I wished very, very hard that it would").

Types of Schizophrenia and Other Psychotic Disorders The DSM-5 (APA, 2013) identifies a spectrum of psychotic disorders that are organized to reflect a gradient of psychopathology from least to most severe. Degree of severity is determined by the level, number, and duration of psychotic signs and symptoms. Several of the disorders may carry the additional specification of With Catatonic Features, the criteria for which are presented in Box 15-1. The disorders to which this specifier may be applied include brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder. It also may be applied to neurodevelopmental disorder, major depressive disorder, and bipolar disorders I and II (APA, 2013). The DSM-5 initiates the spectrum of disorders with Schizotypal Personality Disorder. For purposes of this textbook, this disorder is presented in Chapter 23, "Personality Disorders."

...

Predisposing Factors to Depression (the etiology of depression is unclear) [won't ask specifics just know sub-topics] 1-4

1. *Biological theories* - Genetics - hereditary factor may be involved, genetic link suggested in many studies. A definitive mode of genetic transmission has yet to be demonstrated. - Biochemical influences, Deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine has been implicated. - Excessive cholinergic transmission may also be a factor 2. *Neuroendocrine disturbances* - Possible failure within the hypothalamic-pituitary-adrenocortical axis - Possible diminished release of thyroid-stimulating hormone 3. *Physiological influences* - Medication side effects - Neurological disorders - Electrolyte disturbances: Excessive levels of Na, bicarb, or Ca can produce symptoms of depression, as can deficits in Mg and Na - Hormonal disorders: imbalance of the hormones estrogen and progesterone has been implicated in the predisposition to PMDD - Nutritional deficiencies (thiamine, B6, and B12) - Other physiological conditions 4. *Psychosocial Theories* - Psychoanalytical theory: a loss is internalized and becomes directed against the ego; once the loss had been incorporated into the self (ego), the hostile part of the ambivalence that had been felt for the lost object is then turned inward against the ego - Learning theory "learned helplessness": the individual who experiences numerous failures learns to give up trying - object loss theory: Experiences loss of significant other during the *first 6 months of life*, *This absence of attachment, which may be either physical or emotional, leads to feelings of helplessness and despair that contribute to lifelong patterns of depression in response to loss*, Early loss or trauma may predispose patient to lifelong periods of depression. - *Cognitive theory* - the transactional model of stress and adaptation

NURSING DIAGNOSIS: *COMPLICATED GRIEVING* RELATED TO: *Real or perceived loss, bereavement overload* EVIDENCED BY: Denial of loss, inappropriate expression of anger, idealization of or obsession with lost object, inability to carry out activities of daily living OUTCOME CRITERIA Short-Term Goals - Client will express anger about the loss. - Client will verbalize behaviors associated with normal grieving. Long-Term Goal - Client will be able to recognize his or her own position in the grief process, while progressing at own pace toward resolution.

1. *Determine the stage of grief in which the client is fixed. Identify behaviors associated with this stage* - Accurate baseline assessment data are necessary to effectively plan care for the grieving client. 2. *Develop a trusting relationship with the client*. Show empathy, concern, and unconditional positive regard. Be honest and keep all promises. - Trust is the basis for a therapeutic relationship. 3. *Convey an accepting attitude*, and enable the client to express feelings openly. - An accepting attitude conveys to the client that you believe he or she is a worthwhile person. Trust is enhanced. 4. *Encourage the client to express anger*. Do not become defensive if the initial expression of anger is displaced on the nurse or therapist. Help the client explore angry feelings so that they may be directed toward the actual intended person or situation - Verbalization of feelings in a nonthreatening environment may help the client come to terms with unresolved issues. 5. *Help the client to discharge pent-up anger through participation in large motor activities* (e.g., brisk walks, jogging, physical exercises, volleyball, punching bag, exercise bike). - *Physical exercise provides a safe and effective method for discharging pent-up tension!!!* 6. Teach the normal stages of grief and behaviors associated with each stage. Help the client to understand that feelings such as guilt and anger toward the lost concept are appropriate and acceptable during the grief process and should be expressed rather than held inside. - Knowledge of acceptability of the feelings associated with normal grieving may help to relieve some of the guilt that these responses generate. 7. Encourage the client to review the relationship with the lost entity. With support and sensitivity, point out the reality of the situation in areas where misrepresentations are expressed - The client must give up an idealized perception and be able to accept both positive and negative aspects about the lost entity before the grief process is complete. 8. Communicate to the client that crying is acceptable. Use of touch may also be therapeutic. - Some cultures believe it is important to remain stoic and refrain from crying openly. Individuals from certain cultures are uncomfortable with touch. It is important to be aware of cultural influences before employing these interventions. 9. *Encourage the client to reach out for spiritual support during this time in whatever form is desirable to him or her*. Assess spiritual needs of the client (see Chapter 5) and assist as necessary in the fulfillment of those needs - Client may find comfort in religious rituals with which he or she is familiar.

NURSING DIAGNOSIS: DISTURBED SENSORY PERCEPTION: AUDITORY/VISUAL RELATED TO: Panic anxiety, extreme loneliness and withdrawal into the self EVIDENCED BY: Inappropriate responses, disordered thought sequencing, rapid mood swings, poor concentration, disorientation OUTCOME CRITERIA Short-Term Goal - Client will discuss content of hallucinations with nurse or therapist within 1 week. Long-Term Goals - Client will be able to define and test reality, reducing or eliminating the occurrence of hallucinations. (This goal may not be realistic for the individual with severe and persistent illness who has experienced auditory hallucinations for many years.) A more realistic goal may be: - Client will verbalize understanding that the voices are a result of his or her illness and demonstrate ways to interrupt the hallucination.

1. *Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping in midsentence). - Early intervention may prevent aggressive response to command hallucinations.* 2. Avoid touching the client without warning him or her that you are about to do so. - Client may perceive touch as threatening and may respond in an aggressive manner. 3. An attitude of acceptance will encourage the client to share the content of the hallucination with you. - This is important to prevent possible injury to the client or others from command hallucinations. 4. Do not reinforce the hallucination. Use "the voices" instead of words like "they" that imply validation. Let client know that you do not share the perception. Say, "Even though I realize the voices are real to you, I do not hear any voices speaking." - It is important for the nurse to be honest, and the client must accept the perception as unreal before hallucinations can be eliminated. 5. *Help the client understand the connection between increased anxiety and the presence of hallucinations. - If client can learn to interrupt escalating anxiety, hallucinations may be prevented.* 6. *Try to distract the client from the hallucination. - Involvement in interpersonal activities and explanation of the actual situation will help bring the client back to reality.* 7. For some clients, auditory hallucinations persist after the acute psychotic episode has subsided. Listening to the radio or watching television helps distract some clients from attention to the voices. Others have benefited from an intervention called voice dismissal. With this technique, the client is taught to say loudly, "Go away!" or "Leave me alone!" in a conscious effort to dismiss the auditory perception. - These activities assist the client to exert some conscious control over the hallucination.

Sara, a 23-year-old single woman, has just been admitted to the psychiatric unit by her parents. They explain that over the past few months, she has become increasingly withdrawn. She stays in her room alone but lately has been heard talking and laughing to herself. Sara left home for the first time at age 18 to attend college. She performed well during her first semester, but when she returned after Christmas, she began to accuse her roommate of stealing her possessions. She started writing to her parents that her roommate wanted to kill her and that her roommate was turning everyone against her. She said she feared for her life. She started missing classes and stayed in her bed most of the time. Sometimes she locked herself in her closet. Her parents took her home, and she was hospitalized and diagnosed with schizophrenia. Sara has since been maintained on antipsychotic medication while taking a few classes at the local community college. Sara tells the admitting nurse that she quit taking her medication 4 weeks ago because the pharmacist who fills the prescriptions is plotting to have her killed. She believes he is trying to poison her. She says she got this information from a television message. As Sara speaks, the nurse notices that she sometimes stops in midsentence and listens; sometimes she cocks her head to the side and moves her lips as though she is talking. 1. From the assessment data, what would be the most immediate nursing concern in working with Sara? 2. What is the nursing diagnosis related to this concern? 3. What interventions must be accomplished before the nurse can be successful in working with Sara?

1. *Possible command hallucinations.* 2. *Disturbed sensory perception: auditory.* 3. *Decrease Sara's anxiety and establish trust!*

*TABLE 16-1 Assigning Nursing Diagnoses to Behaviors Commonly Associated With Depression!* BEHAVIORS & NURSING DIAGNOSES

1. *Risk for suicide* - Depressed mood; feelings of hopelessness and worthlessness; anger turned inward in the self; misinterpretations of reality; suicidal ideation, plan, and available means 2. *Complicated grieving* - Depression, preoccupation with thoughts of loss, self-blame, grief avoidance, inappropriate expression of anger, decreased functioning in life roles 3. *Low self-esteem* - Expressions of helplessness, uselessness, guilt, and shame; hypersensitivity to slight or criticism; negative, pessimistic outlook; lack of eye contact; self-negating verbalizations 4. *Powerlessness* - Apathy, verbal expressions of having no control, dependence on others to fulfill needs 5. *Spiritual distress* - Expresses anger toward God, expresses lack of meaning in life, sudden changes in spiritual practices, refuses interactions with significant others or with spiritual leaders 6. *Social isolation/Impaired social interaction* - Withdrawn, uncommunicative, seeks to be alone, dysfunctional interaction with others, discomfort in social situations 7. *Disturbed thought processes* - Inappropriate thinking, confusion, difficulty concentrating, impaired problem-solving ability, inaccurate interpretation of environment, memory deficit 8. *Imbalanced nutrition: Less than body requirements* - Weight loss, poor muscle tone, pale conjunctiva and mucous membranes, poor skin turgor, weakness 9. *Insomnia* - Difficulty falling asleep, difficulty staying asleep, lack of energy, difficulty concentrating, verbal reports of not feeling well rested 10. *Self-care deficit* (hygiene, grooming) - Uncombed hair, disheveled clothing, offensive body odor

*TABLE 15-2 General Medical Conditions That May Cause Psychotic Symptoms!!!*

1. Acute intermittent porphyria 2. Cerebrovascular disease 3. CNS infections 4. CNS trauma 5. Deafness 6. Fluid or electrolyte imbalances 7. Hepatic disease 8. Herpes encephalitis 9. Huntington's disease 10. Hypoadrenocorticism 11. Hypo- or hyperparathyroidism 12. Hypo- or hyperthyroidism 13. Metabolic conditions (e.g., hypoxia; hypercarbia; hypoglycemia) 14. Migraine headache 15. Neoplasms 16. Neurosyphilis 17. Normal pressure hydrocephalus 18. Renal disease 19. SLE 20. Temporal lobe epilepsy 21. *Vitamin deficiency (e.g., B12)* 22. Wilson's disease

Psychomotor Behavior - Negative Symptoms

1. Anergia is a deficiency of energy. The individual with schizophrenia may lack sufficient energy to carry out activities of daily living or to interact with others. 2. Waxy Flexibility Waxy flexibility describes a condition in which the client with schizophrenia allows body parts to be placed in bizarre or uncomfortable positions. Once placed in position, the arm, leg, or head remains in that position for long periods, regardless of how uncomfortable it is for the client. For example, the nurse may position the client's arm in an outward position to take a blood pressure measurement. When the cuff is removed, the client may maintain the arm in the position in which it was placed to take the reading. 3. Posturing This symptom is manifested by the voluntary assumption of inappropriate or bizarre postures. 4. Pacing and Rocking Pacing back and forth and body rocking (a slow, rhythmic, backward-and-forward swaying of the trunk from the hips, usually while sitting) are common psychomotor behaviors of the client with schizophrenia.

Associated Features - Negative Symptoms

1. Anhedonia is the inability to experience pleasure. This is a particularly distressing symptom that compels some clients to attempt suicide. 2. Regression is the retreat to an earlier level of development. Regression, a primary defense mechanism of schizophrenia, is a dysfunctional attempt to reduce anxiety. It provides the basis for many of the behaviors associated with schizophrenia.

Form of Thought - Positive Symptoms

1. Associative Looseness: Thinking is characterized by speech in which ideas shift from one unrelated subject to another. With associative looseness, the individual is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent (e.g., "We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere. No one needs a ticket to heaven. We have it all in our pockets"). 2. *Neologisms*: The person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the individual (e.g., "She wanted to give me a ride in her new uniphorum"). 3. Concrete Thinking: Concreteness, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking is very difficult. For example, the client with schizophrenia would have great difficulty describing the abstract meaning of sayings such as "I'm climbing the walls" or "It's raining cats and dogs." 4. Clang Associations: Choice of words is governed by sounds. Clang associations often take the form of rhyming. For instance, "It is very cold. I am cold and bold. The gold has been sold." 5. Word Salad: is a group of words that are put together randomly, without any logical connection (e.g., "Most forward action grows life double plays circle uniform"). 6. Circumstantiality: individual delays in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met but only with numerous interruptions by the interviewer to keep the person on track of the topic being discussed. 7. Tangentiality: differs from circumstantiality in that the person never really gets to the point of the communication. Unrelated topics are introduced, and the focus of the original discussion is lost. 8. Mutism: is an individual's inability or refusal to speak. 9. Perseveration: The individual who exhibits perseveration persistently repeats the same word or idea in response to different questions.

NURSING DIAGNOSIS: IMPAIRED VERBAL COMMUNICATION RELATED TO: Panic anxiety, regression, withdrawal, disordered, unrealistic thinking EVIDENCED BY: Loose association of ideas, neologisms, word salad, clang association, echolalia, verbalizations that reflect concrete thinking, poor eye contact Short-Term Goal - Client will demonstrate the ability to remain on one topic, using appropriate, intermittent eye contact for 5 minutes with the nurse or therapist. Long-Term Goal - By time of discharge from treatment, the client will demonstrate ability to carry on a verbal communication in a socially acceptable manner with health-care providers and peers.

1. Attempt to decode incomprehensible communication patterns. Seek validation and clarification by stating, "Is it that you mean . . .?" or "I don't understand what you mean by that. Would you please explain it to me?" - These techniques reveal how the client is being perceived by others, while the responsibility for not understanding is accepted by the nurse. 2. Maintain staff assignments as consistently as possible. - *This facilitates trust and understanding between client and nurse.* 3. The technique of verbalizing the implied is used with the client who is mute (unable or unwilling to speak). Example: "That must have been a very difficult time for you when your mother left. You must have felt very alone." - This approach conveys empathy and may encourage the client to disclose painful issues. 4. Anticipate and fulfill client's needs until functional communication pattern returns. - Client safety and comfort are nursing priorities. 5. *Orient client to reality as required. Call the client by name. Validate those aspects of communication that help differentiate between what is real and not real. - These techniques may facilitate restoration of functional communication patterns in the client.* 6. Explanations must be provided at the client's level of comprehension. Example: "Pick up the spoon, scoop some mashed potatoes into it, and put it in your mouth." - Because concrete thinking prevails, abstract phrases and clichés must be avoided, as they are likely to be misinterpreted.

NURSING DIAGNOSIS: *SPIRITUAL DISTRESS* (VERY common w/ depression) RELATED TO: *Dysfunctional grieving over loss of valued object* EVIDENCED BY: *Anger toward God, questioning meaning of own existence, inability to participate in usual religious practices* OUTCOME CRITERIA Short-Term Goals - Client will identify meaning and purpose in life, moving forward with hope for the future. Long Term Goal - Client will express achievement of support and personal satisfaction from spiritual practices.

1. Be accepting and nonjudgmental when client expresses anger and bitterness toward God. Stay with client. 1. The nurse's presence and nonjudgmental attitude increase the client's feelings of self-worth and promote trust in the relationship. 2. Encourage client to ventilate feelings related to meaning of own existence in the face of current loss. 2. Client may believe he or she cannot go on living without the lost entity. Catharsis can provide relief and put life back into realistic perspective. 3. Encourage client as part of grief work to reach out to previous religious practices for support. Encourage client to discuss these practices and how they provided support in the past. 3. Client may find comfort in religious rituals with which he or she is familiar. 4. Reassure client that he or she is not alone when feeling inadequate in the search for life's answers. 4. Validation of client's feelings and the assurance that others share them offers reassurance and an affirmation of acceptability. 5. Contact spiritual leader of client's choice, if he or she requests. 5. These individuals serve to provide relief from spiritual distress and often can do so when other support persons cannot.

NURSING DIAGNOSIS: *LOW SELF-ESTEEM* RELATED TO: *Learned helplessness, feelings of abandonment by significant other, impaired cognition fostering negative view of self* EVIDENCED BY: Expressions of worthlessness, hypersensitivity to slights or criticism, negative and pessimistic outlook OUTCOME CRITERIA Short-Term Goals: - Client will verbalize areas he or she likes about self. - Client will attempt new activities without fear of failure. Long-Term Goal - By time of discharge from treatment, client will exhibit increased feelings of self-worth as evidenced by verbal expression of positive aspects of self, past accomplishments, and future prospects.

1. Be accepting of client and spend time with him or her even though pessimism and negativism may seem objectionable. Focus on strengths and accomplishments and minimize limitations and failures. - Interventions that focus on the positive contribute toward feelings of self-worth. 2. *Promote attendance in therapy groups that offer client simple methods of accomplishment*. Encourage client to be as independent as possible - Success and independence promote feelings of self-worth. 3. *Encourage client to recognize areas of change and provide assistance toward this effort* - Client will need assistance with problem-solving. 4. Teach assertiveness techniques: the ability to recognize the differences among passive, assertive, and aggressive behaviors, and the importance of respecting the human rights of others while protecting one's own basic human rights. - Self-esteem is enhanced by the ability to interact with others in an assertive manner. 5. *Teach effective communication techniques, such as the use of "I" messages (e.g., "I feel hurt when you say those things")* - "I" statements help to avoid making judgmental statements.

Nursing interventions for the depressed client are aimed at maintaining pt safety

1. Be direct (Ask client directly "Are you thinking about harming yourself....) 2. Maintain close observation at irregular intervals a. Encourage verbalization of honest feelings 3. Remove all potentially harmful objects from client's access. 4. Assisting patient through grief process a. Develop a trusting relationship with the client. b. Encourage the client to express emotions. c. Communicate that crying is acceptable. 5. Promoting increase in self-esteem a. Be accepting of the client b. Encourage the client to recognize areas of change 6. Encouraging patient self-control and control over life situation a. Encourage client to take responsibility. b. Help the client set goals. c. Help the client identify areas of their life that they can and cannot control. 7. Helping patient to reach out for spiritual support of choice 8. Assistance in confronting anger that has been turned inward 9. Ensuring that needs related to nutrition, elimination, activity, rest, and personal hygiene are met. 10. *A simple structured daily schedule with limited choices of activities. Provide a daily structured program, encourage patient to participate. (Depressed patients need structure)!!!* 11. *Identify recent accomplishments (depressed patients have low self-esteem and feelings of worthlessness)* a. *Restate things like "you've been feeling really hopeless"!* b. *Keep the convo going!*

NURSING DIAGNOSIS: DISTURBED THOUGHT PROCESSES RELATED TO: Inability to trust, panic anxiety, possible hereditary or biochemical factors EVIDENCED BY: Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others OUTCOME CRITERIA Short-Term Goal - By the end of 2 weeks, client will recognize and verbalize that false ideas occur at times of increased anxiety. Long-Term Goals - By time of discharge from treatment, client's verbalizations will reflect reality-based thinking with no evidence of delusional ideation. - By time of discharge from treatment, the client will be able to differentiate between delusional thinking and reality.

1. Convey acceptance of client's need for the false belief, but indicate that you do not share the belief. - Client must understand that you do not view the idea as real. 2. *Do not argue or deny the belief. Use "reasonable doubt" as a therapeutic technique: "I understand that you believe this is true, but I personally find it hard to accept." - Arguing with the client or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded.* 3. *Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people. - Discussions that focus on the false ideas are purposeless and useless, and may even aggravate the psychosis.* 4. If client is highly suspicious, the following interventions may be helpful: - To decrease client's suspiciousness: a. Use same staff as much as possible; be honest and keep all promises. - Familiar staff and honesty promotes trust. b. Avoid physical contact; warn client before touching to perform a procedure, such as taking a blood pressure - Suspicious clients often perceive touch as threatening and may respond in an aggressive or defensive manner. c. Avoid laughing, whispering, or talking quietly where client can see but cannot hear what is being said. - Client may have ideas of reference and believe he or she is being talked about. d. Provide canned food with can opener or serve food family style. - Suspicious clients may believe they are being poisoned and refuse to eat food from an individually prepared tray. e. Mouth checks may be necessary following medication administration to verify whether the client is actually swallowing the pills. - Suspicious clients may believe they are being poisoned with their medication and attempt to discard the tablets or capsules. f. Provide activities that encourage a one-to-one relationship with the nurse or therapist. - Competitive activities are very threatening to suspicious clients. g. Maintain an assertive, matter-of-fact, yet genuine approach with suspicious clients. - Suspicious clients do not have the capacity to relate to, and therefore often feel threatened by a friendly or overly cheerful attitude.

NURSING DIAGNOSIS: SOCIAL ISOLATION RELATED TO: Inability to trust, panic anxiety, weak ego development, delusional thinking, regression EVIDENCED BY: Withdrawal, sad, dull affect, need-fear dilemma, preoccupation with own thoughts, expression of feelings of rejection or of aloneness imposed by others OUTCOME CRITERIA Short-Term Goal - Client will willingly attend therapy activities accompanied by trusted staff member within 1 week. Long-Term Goal - Client will voluntarily spend time with other clients and staff members in group therapeutic activities.

1. Convey an accepting attitude by making brief, frequent contacts. 1. An accepting attitude increases feelings of self-worth and facilitates trust. 2. Show unconditional positive regard. 2. This conveys a belief in the client as a worthwhile human being. 3. Offer to be with client during group activities that he or she finds frightening or difficult. 3. The presence of a trusted individual provides emotional security for the client. 4. Give recognition and positive reinforcement for client's voluntary interactions with others. 4. Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors.

TABLE 15-3 Assigning Nursing Diagnoses to Behaviors Commonly Associated With Psychotic Disorders BEHAVIORS NURSING DIAGNOSES Diagnosis and Outcome Identification

1. Disturbed sensory perception - Impaired communication (inappropriate responses), disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in midsentence, tilts head to side as if to be listening 2. *Disturbed thought processes* - Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others; inaccurate interpretation of the environment (#1 problem w/ schiz) 3. Social isolation - Withdrawal, sad dull affect, need-fear dilemma, preoccupation with own thoughts, expression of feelings of rejection or of aloneness imposed by others, uncommunicative, seeks to be alone 4. *Risk for violence: Self-directed or other-directed* - Risk factors: Aggressive body language (e.g., clenching fists and jaw, pacing, threatening stance); verbal aggression; catatonic excitement; *command hallucinations*; *rage reactions*; history of violence; overt aggressive acts; goal-directed destruction of objects in the environment; self-destructive behavior; active, aggressive suicidal acts 5. Impaired verbal communication - Loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing thoughts verbally, inappropriate verbalization, *disordered unrealistic thinking!!!* 6. Self-care deficit - Difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, and toileting 7. Disabled family coping - Neglectful care of client in regard to basic human needs or illness treatment, extreme denial or prolonged overconcern regarding client's illness, depression, hostility and aggression 8. Ineffective health maintenance - Inability to take responsibility for meeting basic health practices, history of lack of health-seeking behavior, lack of expressed interest in improving health behaviors, demonstrated lack of knowledge regarding basic health practices, anosognosia (lack of insight about illness) 9. Impaired home maintenance - Unsafe, unclean, disorderly home environment; household members express difficulty in maintaining their home in a safe and comfortable condition

NURSING DIAGNOSIS: *POWERLESSNESS* RELATED TO: *Dysfunctional grieving process, lifestyle of helplessness* EVIDENCED BY: Feelings of lack of control over life situation, overdependence on others to fulfill needs OUTCOME CRITERIA Short-Term Goals - Client will participate in decision-making regarding own care within 5 days. Long-Term Goal - Client will be able to effectively problem-solve ways to take control of his or her life situation by time of discharge from treatment, thereby decreasing feelings of powerlessness.

1. Encourage client to take as much responsibility as possible for own self-care practices. Examples: a. Include client in setting the goals of care he or she wishes to achieve. b. Allow client to establish own schedule for self-care activities. c. Provide client with privacy as need is determined. d. *Provide positive feedback for decisions made*. Respect client's right to make those decisions independently, and refrain from attempting to influence him or her toward those that may seem more logical. - Providing client with choices will increase his or her feelings of control. 2. Help client set realistic goals. - Realistic goals will avoid setting client up for failure and reinforcing feelings of powerlessness. 3. Help client identify areas of life situation that he or she can control - Client's emotional condition interferes with his or her ability to solve problems. Assistance is required to perceive the benefits and consequences of available alternatives accurately. 4. *Help client identify areas of life situation that are not within his or her ability to control!* Encourage verbalization of feelings related to this inability - Verbalization of unresolved issues may help client accept what cannot be changed.

Perception - Positive Symptoms

1. Hallucinations, or false sensory perceptions not associated with real external stimuli: may involve any of the 5 senses. Types of hallucinations include the following: - Auditory: Auditory hallucinations are false perceptions of sound. Most commonly they are of voices, but the individual may report clicks, rushing noises, music, and other noises. Command hallucinations may place the individual or others in a potentially dangerous situation. "Voices" that issue commands for violence to self or others may or may not be heeded by the psychotic person. Auditory hallucinations are the most common type in psychiatric disorders. - Visual: These hallucinations are false visual perceptions. They may consist of formed images, such as of people, or of unformed images, such as flashes of light. - Tactile: Tactile hallucinations are false perceptions of the sense of touch, often of something on or under the skin. One specific tactile hallucination is formication, the sensation that something is crawling on or under the skin. - Gustatory: This type of hallucination is a false perception of taste. Most commonly, gustatory hallucinations are described as unpleasant tastes. - Olfactory: Olfactory hallucinations are false perceptions of the sense of smell. 2. Illusions: are misperceptions or misinterpretations of real external stimuli.

NURSING DIAGNOSIS: *HOPELESSNESS* (NOT on NANDA anymore) RELATED TO: *Absence of support systems and perception of worthlessness* EVIDENCED BY: *Verbal cues (despondent content, "I can't"); decreased affect; lack of initiative; suicidal ideas or attempts* OUTCOME CRITERIA Short-Term Goals - Client will express acceptance of life and situations over which he or she has no control. Long-Term Goal - Client will verbalize a measure of hope for the future by identifying reachable goals and ways to achieve them.

1. Identify stressors in client's life that precipitated current crisis. 1. Important to identify causative or contributing factors in order to plan appropriate assistance. 2. Determine coping behaviors previously used and client's perception of effectiveness then and now. 2. A feeling of hope is engendered when the client recognizes personal strengths that have been helpful in the past. 3. Encourage client to explore and verbalize feelings and perceptions. 3. Identification of feelings underlying behaviors helps client to begin process of taking control of own life. 4. Provide expressions of hope to client in positive, low-key manner (e.g., "I know you feel you cannot go on, but I believe that things can get better for you. What you are feeling is temporary. It is okay if you don't see it just now. You are very important to the people who care about you"). 4. Even though the client feels hopeless, it is helpful to hear positive expressions from others. The client's current state of mind may prevent him or her from identifying anything positive in life. It is important to accept the client's feelings nonjudgmentally and to affirm the individual's personal worth and value. 5. Help client identify areas of life situation that are under own control. 5. The client's emotional condition may interfere with ability to problem solve. Assistance may be required to perceive the benefits and consequences of available alternatives accurately. 6. Identify sources that client may use after discharge when crises occur or feelings of hopelessness and possible suicidal ideation prevail. 6. Client should be made aware of local suicide hotlines or other local support services from which he or she may seek assistance following discharge from the hospital. A concrete plan provides hope in the face of a crisis situation.

Risks Associated with ECT

1. Mortality Studies indicate that the mortality rate from ECT is about 2 per 100,000 treatments (Marangell et al., 2003; Sadock et al., 2015). Although the occurrence is rare, the major cause of death with ECT is from *cardiovascular complications (e.g., acute myocardial infarction or cerebrovascular accident)!!!*, usually in individuals with previously compromised cardiac status. Assessment and management of cardiovascular disease prior to treatment is vital in the reduction of morbidity and mortality rates associated with ECT. 2. Permanent Memory Loss Most individuals report no problems with their memory aside from the time immediately surrounding the ECT treatments. However, some clients have reported retrograde amnesia extending back to months before treatment. In rare instances, more extensive amnesia has occurred, resulting in memory gaps dating back years (Joska & Stein, 2008). Some clients have reported gaps in recollections of specific personal memories. Sackeim and associates (2007) reported on the results of a longitudinal study of clinical and cognitive outcomes in patients with major depression treated with ECT at seven facilities in the New York City metropolitan area. Participants were evaluated shortly following the ECT course and 6 months later. Data revealed that cognitive deficits at the 6-month interval were directly related to type of electrode placement and electrical waveform used. *Bilateral electrode placement* resulted in more severe and persisting (as evaluated at the 6-month follow-up) retrograde amnesia than did *unilateral placement*. The extent of the amnesia was directly related to the number of ECT treatments received. The researchers also found that stimulation produced by sine wave (continuous) current resulted in greater short- and long-term deficits than that produced by short-pulse wave (intermittent) current. 3. Brain Damage Brain damage from ECT remains a concern for those who continue to believe in its usefulness and efficacy as a treatment for depression. Critics of the procedure remain adamant in their belief that ECT always results in some degree of immediate brain damage (Frank, 2002). However, evidence is based largely on animal studies in which the subjects received excessive electrical dosages, and the seizures were unmodified by muscle paralysis and oxygenation (Abrams, 2002). *Although this is an area for continuing study, there is NO evidence to substantiate that ECT produces any permanent changes in brain structure or functioning*

NURSING DIAGNOSIS: SELF-CARE DEFICIT RELATED TO: Withdrawal, regression, panic anxiety, perceptual or cognitive impairment, inability to trust EVIDENCED BY: Difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, toileting OUTCOME CRITERIA Short-Term Goal - Client will verbalize a desire to perform activities of daily living (ADLs) by end of 1 week. Long-Term Goal - Client will be able to perform ADLs in an independent manner and demonstrate a willingness to do so by time of discharge from treatment.

1. Provide assistance with self-care needs as required. Some clients who are severely withdrawn may require total care. 1. Client safety and comfort are nursing priorities. 2. Encourage client to perform as many activities as possible independently. Provide positive reinforcement for independent accomplishments. 2. Independent accomplishment and positive reinforcement enhance self-esteem and promote repetition of desirable behaviors. 3. Use concrete communication to show client what is expected. Provide step-by-step instructions for assistance in performing ADLs. Example: "Take your pajamas off and put them in the drawer. Take your shirt and pants from the closet and put them on. Comb your hair and brush your teeth." 3. Because concrete thinking prevails, explanations must be provided at the client's concrete level of comprehension. 4. Creative approaches may need to be taken with the client who is not eating, such as allowing client to open own canned or packaged foods; family-style serving may also be an option. 4. These techniques may be helpful with the client who is paranoid and may be suspicious that he or she is being poisoned with food or medication. 5. If toileting needs are not being met, establish a structured schedule for the client. 5. A structured schedule will help the client establish a pattern so that he or she can develop a habit of toileting independently.

Social Treatments The Recovery Model

A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential - research provides support for recovery as an OBTAINABLE objective for individuals with schizophrenia - recovery from schizophrenia, in the sense of a state in which persons experience no difficulties associated with the illness, can occur but the modal outcome seems to be one in which difficulties linked to symptoms, social function, and work appear periodically but can be successfully confronted - has been used primarily in caring for individuals with serious mental illness, such as schizophrenia and bipolar disorder, however concepts of the model are amenable to use with all individuals experiencing emotional conditions with which they require assistance and who have a desire to take control and manage their lives more independently. - Weiden identifies 2 types of recovery with schizophrenia: functional and process - Functional recovery focuses on the individual's level of functioning in such areas as relationships, work, independent living, and other kinds of life functioning, He or she may or may not be experiencing active symptoms of schizophrenia, recovery can also be considered as a process. - With process recovery, there is no defined end point, but recovery is viewed as a process that continues throughout the individual's life and involves collaboration between the client and clinician. - The individual identifies goals based on personal values or what he or she defines as giving meaning and purpose to life. The clinician and client work together to develop a treatment plan that is in alignment with the goals set forth by the client. In the process recovery model, the individual may still be experiencing symptoms. - Patients do not have to be in remission, nor does remission automatically have to be a desired (or likely) goal when embarking on a recovery-oriented treatment plan. - As long as the patient (and family) understands that a process recovery treatment plan is not to be confused with a promise of "cure" or even "remission," then one does not overpromise. - The concept of recovery in schizophrenia remains controversial among clinicians, and many challenges lie ahead for continued study. - Recovery models have similarities with ACT in that they both necessarily engage the support of multiple resources, but recovery models also highlight the dimension of active engagement and empowerment of the client in decision-making. - Some argue that this approach is difficult to implement when the client lacks insight about his or her illness or the need for treatment. Further there is a lack of consistency in what constitutes "recovery," and many concepts exist. Still, the potential and hope is that, as these models become better studied and more clearly defined, they will provide a treatment approach that is comprehensive, protective, and supportive of patient-centered care.

*medication side effects*

A number of drugs, either alone or in combination with other medications, can produce a depressive syndrome. - *Most common among these drugs are those that have a direct effect on the central nervous system* - Examples of these include the anxiolytics, antipsychotics, sedative-hypnotics (including barbiturates and opioids), and anticonvulsant mood stabilizers - *Many drugs that are used to treat general medical conditions have also been associated with inducing depression*, and several are listed here: Antibacterial, antifungal, and antiviral agents Antihypertensives and statins (including beta blockers and calcium blockers) Antineoplastics (including vincristine and zidovudine) Dermatologics (including Accutane and finasteride) Hormones (including contraceptives) Respiratory agents (leukotriene inhibitors) Steroids Smoking cessation agents (varenicline)

melancholia

A severe form of major depressive episode. Symptoms are exaggerated, and interest or pleasure in virtually all activities is lost. - A clearly nondivine point of view regarding depression was held by the Greek medical community from the 5th century BC through the 3rd century AD and represented the thinking of Hippocrates, Celsus, and Galen, among others. - They strongly rejected the idea of divine origin and considered the brain as the seat of all emotional states. - *Hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain.* - During the Renaissance, several new theories evolved. Depression was viewed by some as being the result of obstruction of vital air circulation, excessive brooding, or helpless situations beyond the client's control. Depression was reflected in major literary works of the time, including Shakespeare's King Lear, Macbeth, and Hamlet.

*BOX 16-5 Diagnostic Criteria for Disruptive Mood Dysregulation Disorder*

A. *Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation!!!* B. *The temper outbursts are inconsistent with developmental level!* C. The temper outbursts occur, on average, 3 or more times per week. D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms of Criteria A-D. F. *Criteria A and D are present in at least 2 of 3 settings (i.e., at home, at school, with peers) and are severe in at least 1 of these!!!* G. The diagnosis should not be made for the 1st time before age 6 or after age 18 years. H. By history or observation, the age at onset of Criteria A-E is before 10 years. I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). NOTE: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned. K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

*BOX 16-3 Diagnostic Criteria for PERSISTENT Depressive Disorder (Dysthymia)!*

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year. B. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. D. Criteria for a major depressive disorder may be continuously present for 2 years. E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With peripartum onset Specify if: With pure dysthymic syndrome With persistent major depressive episode With intermittent major depressive episodes, with current episode With intermittent major depressiveepisodes, without current episode Specify if: In partial remission In full remission Specify if: *Early onset (onset before age 21 years)* *Late onset (onset at age 21 years or older)* Specify if: Mild Moderate Severe

BOX 16-4 Diagnostic Criteria for Premenstrual Dysphoric Disorder

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. B. 1 (or more) of the following symptoms must be present: 1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) 2. *Marked irritability or anger or increased interpersonal conflicts!!!* 3. *Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts!* 4. *Marked anxiety, tension, feelings of being keyed up or on edge!* C. 1 (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B. 1. Decreased interest in usual activities (e.g., work, school, friends, hobbies) 2. Subjective difficulty in concentration 3. Lethargy, easy fatigability, or marked lack of energy 4. Marked change in appetite; overeating; or specific food cravings 5. Hypersomnia or insomnia 6. A sense of being overwhelmed or out of control 7. Physical symptoms, such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," weight gain Note: The symptoms in Criteria A, B, and C must have been met for most menstrual cycles that occurred in the preceding year. D. The symptoms are associated with clinically significant distress or interferences with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities, decreased productivity, and efficiency at work, school or home). E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders). F. Criteria A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation). G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition (e.g., hyperthyroidism).

Social Treatments Family Therapy

Aimed at helping family members cope with long-term effects of the illness Schizophrenia is an illness that can puzzle, disrupt, and sometimes tear apart families. Even when families appear to cope well, there is a notable impact on the mental and physical health of relatives when a family member has the illness. The importance of the expanded role of family in the aftercare of relatives with schizophrenia has been recognized, thereby stimulating interest in family intervention programs designed to support the family system, prevent or delay relapse, and help to maintain the client in the community. These psychoeducational programs treat the family as a resource rather than a stressor, with the focus on concrete problem solving and specific helping behaviors for coping with stress. These programs recognize the biological basis for schizophrenia and the impact that stress has on the client's ability to function. By providing the family with information about the illness and suggestions for effective coping, psychoeducational programs reduce the likelihood of the client's relapse and the possible emergence of mental illness in previously nonaffected relatives. Mueser and associates (2002) stated that although models of family intervention with schizophrenia differ in their characteristics and methods, effective treatment programs share a number of common features: All programs are long term (usually 9 months to 2 years or more). They all provide the client and family with information about the illness and its management. They focus on improving adherence to prescribed medications. They strive to decrease stress in the family and improve family functioning. Asen (2002) suggested the following interventions with families of individuals with schizophrenia: Forming a close alliance with the caregivers Lowering the emotional intrafamily climate by reducing stress and burden on relatives Increasing the ability of relatives to anticipate and solve problems Reducing the expressions of anger and guilt by family members Maintaining reasonable expectations for how the ill family member should perform Encouraging relatives to set appropriate limits while maintaining some degree of separateness Promoting desirable changes in the relatives' behaviors and belief systems Family therapy typically consists of a brief program of family education about schizophrenia and a more extended program of family contact designed to reduce overt manifestations of conflict and to improve patterns of family communication and problem solving. The response to this type of therapy has been very dramatic. Studies have clearly revealed that a more positive outcome in the treatment of the client with schizophrenia can be achieved by including the family system in the program of care.

Psychopharmacology

Antidepressant medication is generally considered first-line treatment for severe clinical depression, but antidepressants are also used in the treatment of other depressive disorders. These include tricyclic, tetracyclic, and heterocyclic antidepressants; monoamine oxidase inhibitors (MAOIs); *SSRIs (sertraline (Zoloft) and fluoxetine (Prozac))*; SNRIs; and SSRI/SNRI combination drugs - it is important to highlight that antidepressant medication can be lethal in overdose, so depressed, suicidal patients must be observed closely and suicide risk assessed frequently in the use of this treatment modality. - CLINICAL PEARL All antidepressants carry an FDA black-box warning for increased risk of suicidality in children and adolescents. - *CLINICAL PEARL As antidepressant drugs take effect and mood begins to lift, the individual may have increased energy with which to implement a suicide plan. Suicide potential often increases as level of depression decreases. The nurse should be particularly alert to sudden lifts in mood.*

On the unit Sandra appears disinterested in everything around her.

Apathy This is a cognitive symptom ie: Difficulties attending to and processing of information around her. This shows a positive symptom (ie, bizarre behavior)

Social Treatments Assertive Community Treatment Don't have to know much about PACT

Assertive community treatment (ACT) is an evidence-based program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness such as schizophrenia. - A case management-team approach that is individually tailored to teach clients basic living skills, help them work with community agencies, and assist clients in developing a social support network. Services are provided in the person's home, within the neighborhood, in local restaurants, parks, stores, or wherever assistance by the client is required. - Some states use other terms for this type of treatment, such as mobile treatment teams (MTTs) and community support programs (CSPs). Assertive programs of treatment are individually tailored for each client, intended to be proactive, and include the teaching of basic living skills, helping clients work with community agencies, and assisting clients in developing a social support network. There is emphasis on vocational expectations, and supported work settings (i.e., sheltered workshops) are an important part of the treatment program. Other services include substance abuse treatment, psychoeducational programs, family support and education, mobile crisis intervention, and attention to health-care needs. Responsibilities are shared by multiple team members, including psychiatrists, nurses, social workers, vocational rehabilitation therapists, and substance abuse counselors. Services are provided in the person's home, within the neighborhood, in local restaurants, parks, stores, or wherever assistance by the client is required. These services are available to the client 24 hours a day, 365 days a year, and this is considered a long-term intervention strategy. ACT has been shown to reduce the number of hospitalizations and decrease costs of care for these clients. Although it has been called "paternalistic" and "coercive" by its critics, ACT has provided much-needed services to and improved quality of life for many clients who are unable to manage in a less-structured environment. One limitation is that treatment programs of this kind are time and labor intensive.

Moderate Depression

Dysthymia (also called persistent depressive disorder) is an example of moderate depression and represents a more problematic disturbance that, according to the DSM-5, is characterized by symptoms that are enduring for at least 2 years (APA, 2013). Symptoms associated with this disorder include the following: Affective: *Feelings of sadness*, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities Behavioral: Sluggish physical movements (i.e., psychomotor retardation); slumped posture; slowed speech; limited verbalizations, possibly consisting of ruminations about life's failures or regrets; social isolation with a focus on the self; increased use of substances possible; self-destructive behavior possible; decreased interest in personal hygiene and grooming Cognitive: Slowed thinking processes; *difficulty concentrating and directing attention*; obsessive and repetitive thoughts, generally portraying pessimism and negativism; verbalizations and behavior reflecting suicidal ideation. Physiological: *Anorexia or overeating; insomnia or hypersomnia; sleep disturbances*; amenorrhea; decreased libido; headaches; backaches; chest pain; abdominal pain; low energy level; fatigue and listlessness; *feeling best early in the morning and continually worse as the day progresses* (this may be related to the diurnal variation in the level of neurotransmitters that affect mood and level of activity)

Treatment Modalities for Depression Group Therapy

Group therapy forms an *important dimension of multimodal treatment for the depressed client*. Once an acute phase of the illness is passed, groups can provide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise out of having a serious affective disorder. The element of *peer support provides a feeling of security*, as troublesome or embarrassing issues are discussed and resolved. Some groups have other specific purposes, such as helping to monitor medication-related issues or serving as an avenue for promoting education related to the affective disorder and its treatment. Therapy groups help members gain a sense of perspective on their condition and tangibly encourage them to link up with others who have common problems. A sense of hope is conveyed when the individual is able to see that he or she is not alone or unique in experiencing affective illness - *Self-help groups* offer another avenue of support for the depressed client. These groups are usually peer led and are not meant to substitute for or compete with professional therapy. They offer supplementary support that frequently enhances compliance with the medical regimen - Examples of self-help groups are the *Depression and Bipolar Support Alliance (DBSA), Depressives Anonymous, Recovery International, and GriefShare (grief recovery support group)* - Although self-help groups are not psychotherapy groups, *they do provide important adjunctive support experiences, which often have therapeutic benefit for participants*

Evaluation In the final step of the nursing process, a reassessment is conducted in order to determine if the nursing actions have been successful in achieving the objectives of care. Evaluation of the nursing actions for the client with exacerbation of schizophrenic psychosis may be facilitated by gathering information utilizing the following types of questions:

Has the client established trust with at least one staff member? Is the anxiety level maintained at a manageable level? Is delusional thinking still prevalent? Is hallucinogenic activity evident? Does the client share content of hallucinations, particularly if commands are heard? Is the client able to interrupt escalating anxiety with adaptive coping mechanisms? Is the client easily agitated? Is the client able to interact with others appropriately? Does the client voluntarily attend therapy activities? Is verbal communication comprehensible? Is the client compliant with medication? Does the client verbalize the importance of taking medication regularly and on a long-term basis? Does he or she verbalize understanding of possible side effects and when to seek assistance from the physician? Does the client spend time with others rather than isolating self? Is the client able to carry out all activities of daily living independently? Is the client able to verbalize resources from which he or she may seek assistance outside the hospital? Does the family have information regarding support groups in which they may participate and from which they may seek assistance in dealing with their family member who is ill? If the client lives alone, does he or she have a source for assistance with home maintenance and health management?

Treatment Modalities for Depression Cognitive Therapy

In cognitive therapy, the individual is taught to control *thought distortions* that are considered to be a factor in the development and maintenance of mood disorders. In the cognitive model, *depression is characterized by a triad of negative distortions related to expectations of the environment, self, and future*. The environment and activities within it are viewed as unsatisfying, the self is unrealistically devalued, and the *future is perceived as hopeless*. The general goals in cognitive therapy are to obtain symptom relief as quickly as possible, to *assist the client in identifying dysfunctional patterns of thinking and behaving*, and to guide the client to evidence and logic that effectively test the validity of the dysfunctional thinking. Therapy focuses on changing "automatic thoughts" that occur spontaneously and contribute to the distorted affect. Following are examples of automatic thoughts that may be common cognitive distortions in depression. Personalizing: "I'm the only one who failed." All or nothing: "I'm a complete failure." Mind reading: "He thinks I'm foolish." Discounting positives: "The other questions were so easy. Any dummy could have gotten them right." The client is asked to describe evidence that both supports and disputes the automatic thought. The logic underlying the inferences is then reviewed with the client. Another technique involves evaluating what would most likely happen if the client's automatic thoughts were true. Implications of the consequences are then discussed. Clients should not become discouraged if one technique seems not to be working. No single technique works with all clients. He or she should be reassured that any of a number of techniques may be used, and both the therapist and client may explore these possibilities. Cognitive therapy has offered encouraging results in the treatment of depression. In fact, the results of several studies with depressed clients show that in some cases cognitive therapy may be equally or even more effective than antidepressant medication

epidemiology of MDD

MDD is *1 of the leading causes of disability in the US* - In 2014, 6.6% of persons aged 18 or older (15.6 million persons) had at least one major depressive episode in the previous year - lifetime prevalence of depression is *about 17%, which makes it the most prevalent psychiatric disorder* - About 21% of women and 13% of men will become clinically depressed during their life. 1. Gender: Depression is more prevalent in WOMEN than men by about 2 to 1. The gender difference is less pronounced between ages 44 and 65, but after age 65, women again are more likely to be depressed than men. 2. Age: Depression is more common in young women than young men. 3. Social Class: There is an inverse relationship between social class and report of depressive symptoms 4. Race: No consistent relationship between race and affective disorder has been reported. 5. Marital Status: Single and divorced persons are more likely to experience depression than married persons or persons with a close interpersonal relationship. - marriage has a positive effect on the psychological well-being of an individual *(as compared to those who are single or do not have a close relationship with another person)* - Some of those studies have identified that *age* is an important variable in risk for depression among married and single individuals - marital stress associated with increased risk for depression, suggesting that social stress may also be an important variable to consider 6. seasonality: Affective disorders are more prevalent in the *spring and in the fall*. Bipolar mainly - Winter months - tends to bring on depression, probably from lack of sunlight

Developmental Implications - Childhood

Not uncommon for the symptoms of depression to be manifested differently in childhood, and the picture changes with age: 1. *Up to age 3!!!*: *feeding problems, tantrums, lack of playfulness and emotional expressiveness*, failure to thrive, or delays in speech and gross motor development 2. *From ages 3-5*: *accident proneness, phobias, aggressiveness, and excessive self-reproach for minor infractions*, incidence among preschool children is estimated to be between 0.3-0.9% 3. *From ages 6-8*: may have *vague physical complaints and display aggressive behavior*, may cling to parents and avoid new people and challenges, they may lag behind their classmates in social skills and academic competence. 4. *From ages 9-12*: *morbid thoughts and excessive worrying*, may reason that they are depressed bc they have disappointed their parents in some way, may be lack of interest in playing with friends, incidence of depression among school-age children is estimated to be around 2-3% - Other symptoms of childhood depression may include hyperactivity, delinquency, school problems, psychosomatic complaints, sleeping and eating disturbances, social isolation, delusional thinking, and suicidal thoughts or actions - The APA has included a new diagnostic category in the Depressive Disorders chapter of the DSM-5. called Disruptive Mood Dysregulation Disorder - in many there is a genetic predisposition toward the condition, which is then *precipitated by a stressful situation*, common precipitating factors include: physical or emotional detachment by the primary caregiver, parental separation or divorce, death of a loved one (person or pet), a move, academic failure, or physical illness. *In any event, the common denominator is loss.* - *focus of therapy with depressed children is to alleviate the child's symptoms and strengthen the child's coping and adaptive skills*, with the hope of possibly preventing future psychological problems; untreated childhood depression may lead to subsequent problems in adolescence and adult life - most children are treated on an outpatient basis, hospitalization of the depressed child usually occurs only if he or she is actively suicidal, when the home environment precludes adherence to a treatment regimen, or if the child needs to be separated from the home bc of psychosocial deprivation - *Parental and family therapy* are commonly used to help the younger depressed child, recovery is facilitated by emotional support and guidance to family members, children >8 usually participate in family therapy

Severe Depression

Severe depression (also called major depressive disorder) is characterized by an intensification of the symptoms described for moderate depression (see Box 16-2). Symptoms at the severe level of depression include the following: Affective: *Feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect*, appearing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure Behavioral: Psychomotor retardation so severe that physical movement may literally come to a standstill, or psychomotor behavior manifested by rapid, agitated, purposeless movements; slumped posture; sitting in a curled-up position; walking slowly and rigidly; virtually nonexistent communication (when verbalizations do occur, they may reflect delusional thinking); no personal hygiene and grooming; social isolation is common, with virtually no inclination toward interaction with others Cognitive: Prevalent delusional thinking, with delusions of persecution and somatic delusions being most common; confusion, indecisiveness, and an inability to concentrate; hallucinations reflecting misinterpretations of the environment; excessive self-deprecation, self-blame, and thoughts of suicide NOTE: Because of the low energy level and slow thought processes, the individual may be unable to follow through on suicidal ideas. However, the desire is strong at this level. Physiological: *A general slowdown of the entire body*, reflected in sluggish digestion, constipation, and urinary retention; amenorrhea; impotence; diminished libido; anorexia; weight loss; difficulty falling asleep and awakening very early in the morning; *feeling worse early in the morning and somewhat better as the day progresses* (as with moderate depression, this may reflect the diurnal variation in the level of neurotransmitters that affect mood and activity)

Psychological Treatments Group Therapy

Some success if occurring over the long-term course of the illness; less successful in acute, short-term treatment - for individuals with schizophrenia has been shown to be effective, particularly with outpatients and when combined with drug treatment. - for persons with schizophrenia generally focuses on real-life plans, problems, and relationships. Some investigators doubt that dynamic interpretation and insight therapy are valuable for typical patients with schizophrenia. But group therapy is effective in reducing social isolation, increasing the sense of cohesiveness, and improving reality testing for patients with schizophrenia. - in inpatient settings is less productive. - Inpatient treatment usually occurs when symptomatology and social disorganization are at their most intense. - At this time, the least amount of stimuli possible is most beneficial for the client. - Because group therapy can be intensive and highly stimulating, it may be counterproductive early in treatment. - for schizophrenia has been most useful over the long-term course of the illness. - The social interaction, sense of cohesiveness, identification, and reality testing achieved within the group setting have proven to be highly therapeutic processes for these clients. - Groups that offer a supportive environment appear to be more helpful to clients with schizophrenia than those that follow a more confrontational approach.

Hallucination

Stops talking in mid-sentence, tilts head to side, and listens to something. False sensory perceptions not associated with real external stimuli. Can be out auditory, visual olfactory gustatory or tactile. 90 percent of schizophrenics experience hallucinations. Auditory most common

*Psychotic Disorder Due to a General Medical Condition*

Symptoms of this disorder include prominent hallucinations and delusions that can be directly attributed to a general medical condition Hypothyroidism, hyper, vitamin b12 deficiency, etc.

Social Treatments RAISE (Recovery After an Initial Schizophrenia Episode)

The RAISE approach to treatment for schizophrenia is based on a large National Institute of Mental Health (NIMH) initiative that began in 2008, and research findings published in 2015 demonstrated several benefits of this approach - coordinated specialty care for first episode psychosis, With coordinated specialty care the young person experiencing first episode psychosis works with a team of specialists to create a personal treatment plan, combining recovery-oriented psychotherapy, low dose medication management, family education and support, case management, and work or education support. - Coordinated specialty care emphasizes shared decision making, including family members when possible. - incorporates many elements from other treatment approaches, including community treatment, recovery model approaches, family approaches, and comprehensive care models. - It adds the dimension of early intervention at the first episode of psychosis. - The research findings after 5 years of studying this approach look very promising for improving care to this population when intervention begins at the earliest onset of psychotic symptoms - Findings have included greater adherence to treatment programs; greater improvement in symptoms, interpersonal relationships, and quality of life; more involvement in employment or educational pursuits; and less frequent hospitalizations for clients involved in RAISE than for clients involved in more traditional treatment approaches - The hope for this approach to treatment is that, through early and comprehensive intervention, the long-term, debilitating consequences of schizophrenia can be averted or minimized.

ECT Mechanism of Action

The exact mechanism by which ECT effects a therapeutic response is *unknown*. Several theories exist, but the one to which the most credibility has been given is the biochemical theory. *A number of researchers have demonstrated that electrical stimulation results in significant increases in the circulating levels of several neurotransmitters*. These neurotransmitters include serotonin, norepinephrine, and dopamine, the same biogenic amines that are affected by antidepressant drugs. Additional evidence suggests that ECT may also result in increases in glutamate and GABA. The results of studies relating to the mechanism underlying the effectiveness of ECT are still ongoing and continue to be controversial.

*Delusional Disorder* (From book) Subtypes of delusional disorders include erotomanic, grandiose, jealous, persecutory, somatic, and mixed.

The existence of prominent, nonbizarre delusions is characterized by the presence of delusions that have been experienced by the individual for at least 1 month If present at all, hallucinations are not prominent, and behavior is not bizarre. The subtype of delusional disorder is based on the predominant delusional theme. a specifier may be added to denote whether the delusions are considered bizarre (i.e., whether the thought is "clearly implausible, not understandable, and not derived from ordinary life experiences" 1. Erotomanic type. The individual believes that someone, usually of a higher status, is in love with him or her. Famous persons are often the subjects of erotomanic delusions. Sometimes the delusion is kept secret, but some individuals may follow, contact, or otherwise try to pursue the object of their delusion. 2. Grandiose type. Irrational ideas regarding own worth, talent, knowledge, or power. They may believe that they have a special relationship with a famous person or even assume the identity of a famous person (believing that the actual person is an imposter). Grandiose delusions of a religious nature may lead to assumption of the identity of a deity or religious leader. 3. Jealous type. Irrational idea that the person's sexual partner is unfaithful. The idea is irrational and without cause, but the individual with the delusion searches for evidence to justify the belief. The sexual partner is confronted (and sometimes physically attacked) regarding the imagined infidelity. The imagined "lover" of the sexual partner also may be the object of the attack. Attempts to restrict the autonomy of the sexual partner in an effort to stop the imagined infidelity are common. 4. *Persecutory type*. The most common type. The individual believes he or she is being malevolently treated in some way. Frequent themes include being plotted against, cheated or defrauded, followed and spied on, poisoned, or drugged. The individual may obsess about and exaggerate a slight rebuff (either real or imagined) until it becomes the focus of a delusional system. Repeated complaints may be directed at legal authorities, lack of satisfaction from which may result in violence toward the object of the delusion. 5. Somatic type. The individual has an irrational belief that he or she has some physical defect, disorder, or disease. believe they have some type of general medical condition. 6. Mixed Type. When the disorder is mixed, delusions are prominent, but NO single theme is predominant.

The nurse notices that Hal is sitting off to himself in a corner of the dayroom. He appears to be talking to himself and tilts his head to the side as if listening to something. How would the nurse intervene with Hal in this situation?

The nurse should slowly and carefully approach Hal so that he is not startled by his or her presence. "Hal, are you hearing the voices again? What do you hear the voices saying to you?" *(Encouraging description of perceptions. This type of information may help to protect the client and others from potential violence associated with command hallucinations.)* "I know the voices seem real to you, but I do not hear any voices speaking." (Presenting reality)

*Substance-Induced Psychotic Disorder*

The presence of prominent hallucinations and delusions that are judged to be directly attributable to the physiological effects of a substance. Problem is that even just 1 time becomes permanent

Psychological Treatments Social Skills Training

Use of role play to teach client appropriate eye contact, interpersonal skills, voice intonation, posture, and so on; aimed at improving relationship development - aimed at improvement in social functioning Social skills training is used to help clients manage struggles with interpersonal relationships and communication, which are often complicated by clients' inability to accurately perceive responses in others. Mueser, Bond, and Drake (2002) describe this training: The basic premise of social skills training is that complex interpersonal skills involve the smooth integration of a combination of simpler behaviors, including nonverbal behaviors (e.g., facial expression, eye contact); paralinguistic features (e.g., voice loudness and affect); verbal content (i.e., the appropriateness of what is said); and interactive balance (e.g., response latency, amount of time talking). These specific skills can be systematically taught, and, through the process of shaping (i.e., rewarding successive approximations toward the target behavior), complex behavioral repertoires can be acquired. Social dysfunction is a hallmark of schizophrenia. Impairment in interpersonal relations is included as part of the defining diagnostic criteria for schizophrenia in the DSM-5 (APA, 2013). Considerable attention is now being given to enhancement of social skills in these clients. The educational procedure in social skills training focuses on role-play. A series of brief scenarios are selected. These should be typical of situations clients experience in their daily lives and be graduated in terms of level of difficulty. The health-care provider may serve as a role model for some behaviors. For example, "See how I sort of nod my head up and down and look at your face while you talk." This demonstration is followed by the client's role-playing. Immediate feedback is provided regarding the client's presentation. Only by countless repetitions does the response gradually become smooth and effortless. Progress is geared toward the client's needs and limitations. The focus is on small units of behavior, and the training proceeds very gradually. Highly threatening issues are avoided, and emphasis is placed on functional skills that are relevant to activities of daily living. Milieu therapy, which focuses on the client's interaction within a social environment, may provide opportunities for social skills training.

A client, diagnosed with paranoid schizophrenia, states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? a. "I find that hard to believe." b. "What would make you think such a thing?" c. "I know your roommate. He would do no such thing." d. "I can see why you feel that way."

a. "I find that hard to believe." This client is experiencing a persecutory delusion. This nursing response is an example of "voicing doubt," which expresses uncertainty as to the reality of the client's perceptions. This is an appropriate therapeutic communication technique in dealing with clients who are experiencing delusional thinking.

Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Clint's belief is an example of which of the following? a. Delusion of persecution b. Delusion of reference c. Delusion of control or influence d. Delusion of grandeur

a. Delusion of persecution

Recent research on the RAISE approach to treatment of schizophrenia incorporates which of the following elements as important to improving outcomes? Select all that apply. a. Early intervention at the first episode of psychosis b. Support for employment and/or educational pursuits c. Rapid, high-dose loading with antipsychotic medication d. Court-ordered sanctions for treatment e. Recovery-focused psychotherapy

a. Early intervention at the first episode of psychosis b. Support for employment and/or educational pursuits e. Recovery-focused psychotherapy

A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? a. Identify with the person speaking b. Imitate the nurse's movements c. Alleviate alogia d. Alleviate avolition

a. Identify with the person speaking Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking.

Components of the recovery model include:

a. Self-direction. Consumers lead, control, choose, and determine their own path of recovery. b. Individualized and person-centered. Recovery is based on an individual's unique strengths, needs, preferences, experiences, and cultural background. c. Empowerment. Individuals gain control of their own destiny and influence the organizational and societal structures in their lives. d. Holistic. Recovery encompasses and individual's whole life, including mind, body, spirit, and community. e. Nonlinear. Recovery is not a step-by-step process, but one based on continual growth, occasional setbacks, and learning from experience. f. Strengths-based. Recovery builds on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of the individual, encouraging consumers to leave stymied life roles behind and engage in new life roles. g. Peer support. Individuals provide each other with a sense of belonging, supportive relationships, values roles, and community. h. Respect. Community, systems, and societal acceptance and appreciation of consumers are crucial in achieving recovery. Self-acceptance is particularly vital. i. Responsibility. Consumers have a personal responsibility for their own self-care and journeys of recovery. j. Hope. Recovery provides the essential motivating message of a better future-that people can and do overcome the barriers and obstacles that confront them. The recovery model integrates services provided by professionals. services provided by consumers, and services provided in collaboration.

A client has just been admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder. Which of the following behavioral manifestations might the nurse expect to assess? Select all that apply. a. Slumped posture b. Delusional thinking c. Feelings of despair d. Feels best early in the morning and worse as the day progresses e. Anorexia

a. Slumped posture b. Delusional thinking c. Feelings of despair e. Anorexia

Depressive Disorder Due to Another Medical Condition

attributable to the direct physiological effects of a general medical condition. 1 Ex: *brain tumor* pressing on frontal lobe of brain, which has a lot to do w/ our emotions, so that location can affect mood and cause personality changes 2 Ex: *stroke* to the brain, area becomes necrotic, causes personality changes This disorder is characterized by symptoms associated with a major depressive episode that are the direct physiological consequence of another medical condition (APA, 2013). The depression causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Types of physiological influences are included in the discussion on predisposing factors to depression.

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes these behaviors as a symptom of the client's illness. What is the most appropriate nursing intervention for this symptom? a. Ask the client to describe his physical symptoms. b. Ask the client to describe what he is hearing. c. Administer a dose of benztropine. d. Call the physician for additional orders.

b. Ask the client to describe what he is hearing.

In teaching a client about his antidepressant medication, fluoxetine, which of the following would the nurse include? Select all that apply. a. Don't eat chocolate while taking this medication. b. Keep taking this medication, even if you don't feel it is helping. It sometimes takes a while to take effect. c. Don't take this medication with the migraine drugs "triptans." d. Go to the lab each week to have your blood drawn for therapeutic level of this drug. e. This drug causes a high degree of sedation, so take it just before bedtime.

b. Keep taking this medication, even if you don't feel it is helping. It sometimes takes a while to take effect. c. Don't take this medication with the migraine drugs "triptans."

When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use first? a. Provide large motor activities to relieve the client's pent-up tension. b. Administer a dose of prn chlorpromazine to keep the client calm. c. Call for sufficient help to control the situation safely. d. Convey to the client that his behavior is unacceptable and will not be permitted.

c. Call for sufficient help to control the situation safely.

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid, 2 mg benztropine PO bid prn. Why is chlorpromazine ordered? a. To reduce extrapyramidal symptoms b. To prevent neuroleptic malignant syndrome c. To decrease psychotic symptoms d. To induce sleep

c. To decrease psychotic symptoms

"I have spent my whole life taking care of others. Now someone else has to take care of me. I feel so useless." How would the nurse respond appropriately to this statement by Carrie?

"You feel sad because you can no longer do the things that you used to do ... the things that made you feel good about yourself." (Statement that focuses on feelings)

Carrie, age 75, is a patient on the psychiatric unit with a diagnosis of Major Depressive Disorder. She says to the nurse, "I never knew my life would end up like this. I've lost my husband, all my friends, and my home." How would the nurse respond appropriately to this statement by Carrie?

"You have had a lot of losses. You are feeling very much alone right now." (Verbalizing the implied)

TRICYCLICS

*Amitriptyline (Elavil) - txt for depression and pain* Amoxapine Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin Imipramine (Tofranil) Nortriptyline (Aventyl; Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil)

you don't need medicine." Shortly afterward, she became totally despondent, taking no pleasure in activities she had always found enjoyable.

*Anhedonia* taking no pleasure in activities that used to be enjoyable is a negative symptom of Schizophrenia, Sandra lacks motivation and has Anhedonia (the inability to experience pleasure)

All antidepressants carry a black-box warning. What is it?

*Antidepressants can increase the risk/level of suicidality in children and adolescents*

HETEROCYCLICS

*Bupropion (Wellbutrin) - smoking cessation too* Maprotiline Mirtazapine (Remeron) Nefazodone‡ Trazodone

An alteration in which of the following neurotransmitters is most closely associated w/ the symptoms of schizophrenia?

*Dopamine*

Sandra's mother reports that Sandra stopped taking her medicine about a month ago, stating, "When you don't have a brain,

*Nihilistic delusion* This is a somatic delusional thought, thinking a body part doesn't work anymore

*assessing risk factors!!!*

*Prevention is the key issue in management of aggressive or violent behavior* * 3 factors are important considerations in identifying extent of risks* 1. *Past hx of violence (more likely to be violent again)* 2. *Client Diagnosis* 3. *Current behaviors*: are predictive of impending violence, prodromal syndrome - *Past history of violence is widely recognized as a major risk factor for violence in a treatment setting!* - Also highly correlated with assaultive behavior is diagnosis, Diagnoses that have a strong association with either self-directed or other-directed violence are: schizophrenia, MDD, BD, and *substance use disorders*, in addition to mental illness, compounds the increased risk of violence, NCD and antisocial, borderline, and intermittent explosive personality disorders have also been associated with a risk for violent behavior - The successful management of violence is predicated on an understanding of the dynamics of violence. - A patient's threatening behavior is commonly an overreaction to feelings of impotence, helplessness, and perceived or actual humiliation - *Aggression rarely occurs suddenly and unexpectedly*

Why do we give cogentin?

*Restlessness and muscle rigidity*

What is schizoaffective disorder?

*The individual w/ this manifests symptoms of both schizophrenia and a mood disorder (either depression or mania).*

Depression in adolescence is very hard to differentiate from the normal stormy behavior associated with adolescence. What is the best clue for determining a problem with depression in adolescence?

*When there is a visible manifestation of behavioral change that lasts for several weeks*

*Stressful Life Events* (Environmental Influences) Studies have been conducted in an effort to determine whether psychotic episodes may be precipitated by stressful life events

- There is NO scientific evidence to indicate that stress causes schizophrenia - it is very probable; however, that stress may contribute to the severity and course of the illness - It is known that extreme stress can precipitate psychotic episodes - Stress may indeed precipitate symptoms in an individual who possesses a genetic vulnerability to schizophrenia - Stressful life events also may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse.

Action of antipsychotics

- Typical antipsychotics work by blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. They also demonstrate varying affinity for cholinergic, alpha1-adrenergic, and histaminic receptors. Antipsychotic effects may also be related to inhibition of dopamine-mediated transmission of neural impulses at the synapses. - Atypical antipsychotics are weaker dopamine receptor antagonists than the conventional antipsychotics but are more potent antagonists of the serotonin (5-hydroxytryptamine) type 2A (5-HT2A) receptors. They also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors.

NURSING DIAGNOSIS: *RISK FOR SUICIDE* RELATED TO: *Depressed mood, feelings of hopelessness and worthlessness, anger turned inward on the self, misinterpretations of reality!* OUTCOME CRITERIA Short-Term Goal - Client will seek out staff when feeling urge to harm self. - Client will make short-term verbal (or written) contract with nurse not to harm self. - Client will not harm self. Long-Term Goal: - Client will not harm self.

1. *Ask client directly: "Have you thought about killing yourself?" or "Have you thought about harming yourself in any way? If so, what do you plan to do? Do you have the means to carry out this plan?"!!! (priority intervention)* - *The risk of suicide is greatly increased if the client has developed a plan and particularly if means exist for the client to execute the plan* 2. Create a safe environment for the client. Remove all potentially harmful objects from client's access (sharp objects, straps, belts, ties, glass items, alcohol). Supervise closely during meals and medication administration. Perform room searches as deemed necessary. - *Client safety is a nursing priority.* 3. Formulate a short-term verbal or written contract that the client will not harm self during a specific time period. When the contract expires, make another. Repeat this process for as long as required. - Discussion of suicidal feelings with a trusted individual provides some relief to the client. A contract gets the subject out in the open and some of the responsibility for his or her safety is given to the client. An attitude of unconditional acceptance of the client as a worthwhile individual is conveyed. 4. Maintain close observation of the client. Depending on level of suicide precaution, provide one-to-one contact, constant visual observation, or *every-15-minute checks*. Place in room close to nurse's station; do not assign to private room. Accompany to off-unit activities if attendance is indicated. May need to accompany to bathroom. - Close observation is necessary to ensure that client does not harm self in any way. Being alert for suicidal and escape attempts facilitates being able to prevent or interrupt harmful behavior. 5. Maintain special care in administration of medications - Prevents saving up to overdose or discarding and not taking. 6. *Make rounds at frequent, irregular intervals (especially at night, toward early morning, at change of shift, or other predictably busy times for staff)!!!* - Prevents staff surveillance from becoming predictable. To be aware of client's location is important, especially when staff is busy, unavailable, or less observable. 7. Encourage client to express honest feelings, including anger. Provide hostility release if needed. Help the client to identify the true source of anger and to work on adaptive coping skills for use outside the treatment setting - Depression and suicidal behaviors may be viewed as anger turned inward on the self. If this anger can be verbalized in a nonthreatening environment, the client may eventually be able to resolve these feelings.

Extrapyramidal symptoms (EPS) includes

1. *Pseudoparkinsonism*: Stiff stooped posture, tremors, shuffling gait, rolling of tongue on inside of mouth, mask-like facies 2. *Akinesia*: impaired body movement 3. *Akathisia*: Rocking while standing or sitting, Restlessness, urge to move 4. *Dystonia*: Sustained muscle contractions cause twisting and repetitive movements 5. *Oculogyric crisis*: Spasmodic movement (usually upward) of the eyeballs into a fixed position that persists for many minutes or for hours - *Antiparkinsonian agents: Used to counteract the extrapyramidal symptoms associated with some antipsychotic medications.* - Mellaril is contraindicated if allergic to penicillin; Cross sensitivity among phenothiazines (compazine etc).

*rehabilitation!!!* GMSS

1. Group Therapy 2. Medication Management 3. Supportive Family Therapy 4. Social Skills Retraining

Physical Conditions (Physiological Factors) Some studies have reported a link between schizophrenia and:

1. epilepsy (particularly temporal lobe) 2. *Huntington's disease* 3. birth trauma 4. head injury in adulthood 5. alcohol abuse 6. cerebral tumor (particularly in the limbic system) 7. cerebrovascular accidents 8. SLE 9. myxedema 10. parkinsonism 11. *Wilson's disease (excess copper in system that damages the liver)* 12. various hormonal deficiencies

Disaster

A natural or man-made occurrence that overwhelms the resources of an individual or community and increases the need for emergency evacuation and medical services. - Disaster Nursing - A common feature of disasters is that they overwhelm local resources and threaten the function and safety of the community. - Disasters leave victims with a damaged sense of safety and well-being and varying amounts of *emotional trauma* - Be caring, creative and flexible, and use *active listening!* (Be kind, the person is in emotional pain)

*psychosis*

A severe mental condition in which there is disorganization of the personality, deterioration in social functioning, and loss of contact with or distortion of reality. There may be evidence of hallucinations and delusional thinking. Psychosis can occur w/ or w/o the presence of organic impairment

depersonalization

A state in which the individual ceases to perceive the reality of the self or the environment. The patient feels that his or her body is unreal, is changing or is dissolving or that he or she is outside of the body.

cognitive therapy

A type of therapy in which the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of emotional disorders.

extrapyramidal symptoms (EPS):

A variety of responses that originate outside the pyramidal tracts and in the basal ganglion of the brain. Symptoms may include tremors, chorea, dystonia, akinesia, akathisia, and others. May occur as a side effect of some antipsychotic medications.

Autism

A withdrawal inward into one's own fantasy world.

ideas of reference

A woman might believe people were laughing at her when in fact they were laughing at a joke someone told

A client, diagnosed with paranoid schizophrenia, states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? A) "I find that hard to believe." B) "What would make you think such a thing?" C) "I know your roommate. He would do no such thing." D) "I can see why you feel that way."

A) "I find that hard to believe." This client is experiencing a persecutory delusion. This nursing response is an example of "voicing doubt," which expresses uncertainty as to the reality of the client's perceptions. This is an appropriate therapeutic communication technique in dealing with clients who are experiencing delusional thinking

Negative Symptoms - Affect

Affect describes the behavior associated with an individual's feeling state or emotional tone. 1. Inappropriate affect, is inappropriate when the individual's emotional tone is incongruent with the circumstances (e.g., a young woman who laughs when told of the death of her mother). 2. Bland or Flat Affect Affect is described as bland when the emotional tone is very weak. The individual with flat affect appears to be void of emotional tone (or overt expression of feelings). 3. Apathy The client with schizophrenia often demonstrates an indifference to or disinterest in the environment. The bland or flat affect is a manifestation of the emotional apathy.

*Dispositional crisis*

An acute response to an external situational stressor. - *EXAMPLE*: Nancy and Ted have been married for 3 years and have a 1-year-old daughter. Ted has been having difficulty with his boss at work. Twice during the past 6 months he has exploded in anger at home and become abusive with Nancy. Last night he became angry that dinner was not ready when he expected. He grabbed the baby from Nancy and tossed her, screaming, into her crib. He hit and punched Nancy until she feared for her life. This morning when he left for work, she took the baby and went to the emergency department of the city hospital, not knowing what else to do. - Intervention: Physical care of wounds and screening for domestic violence issues should be conducted in the emergency department. The mental health counselor can provide support and guidance in terms of presenting alternatives to her. The emergency nurse should encourage and empower Nancy to clarify her needs and issues so that referrals for agency assistance can be made.

*depression*

An alteration in mood that is expressed by feelings of sadness, despair, and pessimism. There is a loss of interest in usual activities, and somatic symptoms may be evident. Changes in appetite, sleep patterns, and cognition are common. - Depression is the oldest and still one of the most frequently diagnosed psychiatric illnesses - Transient symptoms are normal, healthy responses to everyday disappointments in life. - An occasional bout with the "blues," a feeling of sadness or downheartedness, is common among healthy people and considered to be a normal response to everyday disappointments in life. - These episodes are short-lived as the individual adapts to the loss, change, or failure (real or perceived) that has been experienced. - Pathological depression occurs when adaptation is ineffective and the symptoms are significant enough to impair functioning

*List of side effects of antipsychotics* [from PPT slide]

Anticholinergic effects Nausea; gastrointestinal upset Skin rash Sedation Orthostatic hypotension Photosensitivity Hormonal effects Electrocardiogram changes Hypersalivation Weight gain Hyperglycemia/diabetes Increased risk of mortality in elderly clients with dementia Reduction in seizure threshold *Agranulocytosis - Clozaril (monitor WBC)!* EPS: Restlessness, involuntary movements, uncontrollable speech Tardive dyskinesia (Irreversable): Uncontrollable tongue movements; stiff neck, difficulty swallowing: D'C antipsychotic meds NMS: Muscle rigidity, tachycardia, temp 105 (high): D'C antipsychotics; Give Dantrolene (Dantrium) Fatal

Indications of antipsychotics

Antipsychotic medications are used in the treatment of schizophrenia and other psychotic disorders. - Selected agents are used in the treatment of bipolar mania (olanzapine, aripiprazole, chlorpromazine, quetiapine, risperidone, asenapine, ziprasidone).

*FIGURE 10-1 Chinese symbol for crisis.*

Bateman and Peternelj-Taylor (1998) stated: Outside Western culture, a crisis is often viewed as a time for *movement and growth* The Chinese symbol for crisis consists of the characters for *Danger AND Opportunity* When a crisis is viewed as an opportunity for growth, those involved are much MORE capable of resolving related issues and MORE able to move toward positive changes. When the crisis experience is overwhelming because of its scope and nature or when there has not been adequate preparation for the necessary changes, the dangers seem paramount and overshadow any potential growth. The *results are maladaptive coping and dysfunctional behavior*

*Undifferentiated Schizophrenia* (from her outline)

Bizarre behavior that does not meet the criteria outlined for the other types of schizophrenia. Delusions and hallucinations ARE prominent.

She stayed in her room, sitting on the bed moving back and forth in a slow, rhythmic fashion.

Body rocking The rocking in a rhythmic fashion is a repetitive behavior, bizarre behaviors (i.e. positive symptom)

A client is admitted with a diagnosis of schizoaffective disorder. Which symptoms are characteristic of this diagnosis? A) Strong ego boundaries and abstract thinking B) Ataxia (inability to coordinate muscle activity) and akinesia C) Altered mood and thought disturbances D) Substance abuse and cachexia

C) Altered mood and thought disturbances The characteristic symptoms of schizoaffective disorder are a combination of alterations in mood (mania or depression) and thought.

A pt has been diagnosed w/ MDD. Fluoxetine prescribed. Teaching:

Can have chocolate Don't discontinue abruptly - Can result in nausea, vertigo, insomnia, HA, malaise, nightmares, and return of s/s Will make you more prone to sunburn EPS is what you worry about w/ it

*Catatonic Disorder Due to Another Medical Condition!!!!!!!!!!!*

Catatonic disorder is identified by the *symptoms*(on the catonia flash card) - This diagnosis is made when the symptomatology is evidenced from medical hx, physical exam, or lab findings to be directly attributable to the physiological consequences of another medical condition - Types of medical conditions that have been associated with catatonic disorder include: 1. metabolic disorders (e.g., hepatic encephalopathy, hypo- and hyperthyroidism, hypo- and hyperadrenalism, and vitamin B12 deficiency) 2. neurological conditions (e.g., epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis)

*Paranoid Schizophrenia* (from her outline)

Characterized by paranoid delusions. Client may be: 1. argumentative 2. hostile 3. aggressive a. *INTERVENE IMMEDIATELY* b. Bizarre behavior c. Neologisms

Clang association

Choice of words is governed by sounds. Ex. "Test, test, this is a test. I do not jest; we get no rest."

*Disorganized Schizophrenia* (from her outline)

Chronic variety with flat or inappropriate affect. Silliness and incongruous giggling is common. Behavior is bizarre, and social interaction is impaired.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

Citalopram (Celexa) *Escitalopram (Lexapro)* Fluoxetine (Prozac; Serafem) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Vilazodone (Viibryd) (also acts as a partial serotonergic agonist) Vortioxetine (Brintellix)

How do delusions differ from hallucinations?

Delusions are false personal beliefs, usually irrational, and held by the individual regardless that proof exists to the contrary. Hallucinations are false sensory perceptions that can be experienced through any of the 5 senses (auditory, visual, tactile, gustatory, olfactory).

Sandra is assigned to a room and oriented to the unit. At 5:00PM, the nurse says to Sandra, "Sandra it's time for dinner." Sandra responds, "time for dinner; time for dinner; time for dinner."

Echolalia This is an example of Echolalia- the pathological repeating of another persons words, a positive symptom of Schizophrenia, often seen with catatonia.

social skills training

Educational opportunities through role play for the person with schizophrenia to learn appropriate social interaction skills and functional skills that are relevant to daily living.

*Delusions*

False personal beliefs NOT consistent with a person's intelligence or cultural background. The individual continues to have the belief in SPITE of obvious proof that it is false and/or irrational.

delusions

False personal beliefs not consistent with a person's intelligent or cultural background. example I have a microchip in my brain which transmits my thoughts to the CIA

Hallucinations

False sensory perceptions not associated with real external stimuli. Hallucinations may involve any of the five senses.

Volition - Negative Symptoms

Impaired volition has to do with the inability to initiate goal-directed activity. In the individual with schizophrenia, this may take the form of inadequate interest, motivation, or ability to choose a logical course of action in a given situation. 1. Emotional Ambivalence Ambivalence in the client with schizophrenia refers to the coexistence of opposite emotions toward the same object, person, or situation. These opposing emotions may interfere with the person's ability to make even a very simple decision (e.g., whether to have coffee or tea with lunch). Underlying the ambivalence is the difficulty the client with schizophrenia has in fulfilling a satisfying human relationship. This difficulty is based on the need-fear dilemma—the simultaneous need for and fear of intimacy. 2. Deteriorated Appearance Personal grooming and self-care activities may be neglected. The client with schizophrenia may appear disheveled and untidy and may need to be reminded of the need for personal hygiene.

Interpersonal Functioning and Relationship to the External World - Negative Symptoms

Impairment in social functioning may be reflected in social isolation, emotional detachment, and lack of regard for social convention. 1. Impaired Social Interaction Some clients with acute schizophrenia cling to others and intrude on the personal space of others, exhibiting behaviors that are not socially and culturally acceptable. 2. Social Isolation Individuals with schizophrenia sometimes focus inward on themselves to the exclusion of the external environment. 3. Lack of Insight Some individuals lack awareness of there being any illness or disorder even when symptoms appear obvious to others. The term for this is anosognosia. The DSM-5 identifies this symptom as the "most common predictor of nonadherence to treatment, and it predicts higher relapse rates, increased number of involuntary treatments, poorer psychosocial functioning, aggression, and poorer course of illness"

regression

In response to stressful situation, begins to suck thumb and soils clothing.

Circumstantiality

In speaking, the delay of an individual to reach the point of a communication, owing to unnecessary and tedious details.

*anhedonia*

Inability to experience pleasure

*Treatment for schizophrenia includes what?!!!* [Random question from Jett in class]

Individual, group therapy and social skills

Behaviors of depression often change with the diurnal variation in the level of neurotransmitters. Describe the difference in this phenomenon between moderate and severe depression.

Individuals w/ moderate depression feel better early in the morning and continually worse as the day progresses. Those w/ severe depression feel worse early in the morning and somewhat better as the day progresses.

Psychological Treatments Individual Psychotherapy

Long-term therapeutic approach; difficult because of client's impairment in interpersonal functioning - Individual recovery-oriented psychotherapy and cognitive therapies are evidence-based interventions in the treatment of the client with schizophrenia, but these therapies should be adjunct to a multifaceted team approach. - The primary focus in all cases must reflect efforts to decrease anxiety and increase trust. - Establishing a relationship is often particularly difficult because the individual with schizophrenia is desperately lonely yet defends against closeness and trust. - He or she is likely to respond to attempts at closeness with suspiciousness, anxiety, aggression, or regression. - Successful intervention may be achieved with honesty, simple directness, and a manner that respects the client's privacy and human dignity. - Exaggerated warmth and professions of friendship are likely to be met with confusion and suspicion. - Once a therapeutic interpersonal relationship has been established, reality orientation is maintained through exploration of the client's behavior in relationships. - Education is provided to help the client identify sources of real or perceived danger and ways of reacting appropriately. - Methods for improving interpersonal communication, emotional expression, and frustration tolerance are attempted.

Client and Family Education *The role of client teacher is important in the psychiatric area, as it is in all areas of nursing* BOX 16-7 Topics for Client and Family Education Related to Depression

NATURE OF THE ILLNESS Stages of grief and symptoms associated with each stage. *What is depression?* *Why do people get depressed?* *What are the symptoms of depression?* MANAGEMENT OF THE ILLNESS Medication management Nuisance side effects Side effects to report to physician Importance of taking regularly Length of time to take effect Diet (related to MAOIs) Assertiveness techniques *Stress-management techniques!!!* *Ways to increase self-esteem* *ECT (last resort)* *Support Services* Suicide hotline Support groups Legal/financial assistance

BOX 15-4 Topics for Client and Family Education Related to Schizophrenia Topics for discussion with the client and family include the nature of the illness, including what to expect as the illness progresses ways for the family to respond; management of the illness, including appropriate medication management, when to contact the health provider, and daily living skills training.

NATURE OF THE ILLNESS What to expect as the illness progresses Symptoms associated with the illness Ways for family to respond to behaviors associated with the illness MANAGEMENT OF THE ILLNESS Connection of exacerbation of symptoms to times of stress Appropriate medication management Side effects of medications Importance of not stopping medications When to contact health-care provider Relaxation techniques Social skills training Daily living skills training SUPPORT SERVICES Financial assistance Legal assistance Caregiver support groups Respite care Home health care

*Neologism*

New words that an individual invents that are meaningless to others, but have symbolic meaning to the psychotic PERSON.

"I know you are possessed by the devil." During her initial interview, she is very guarded and suspicious of the nurse

Paranoia This demonstrates positive symptom , paranoia (i.e. persecutory)

Viral Infection (Physiological Factors)

Sadock and colleagues (2015) report that epidemiological data indicate a high incidence of schizophrenia after prenatal exposure to influenza. They stated: Other data supporting a viral hypothesis are an increased number of physical anomalies at birth, an increased rate of pregnancy and birth complications, seasonality of birth consistent with viral infection, geographical clusters of adult cases, and seasonality of hospitalizations. (p. 305) The effect of autoimmune antibodies in the brain is being studied within the field of psychoneuroimmunology and suggests that these may be responsible for the development of at least some schizophrenias following infection from a neurotoxic virus.

*Schizoaffective Disorder* (from her outline)

Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders, either mania or depression. *Social skills may be an issue; teach how to make eye contact when communicating*

Sense of Self - Positive Symptoms

Sense of self describes the uniqueness and individuality a person feels. Because of extremely weak ego boundaries, the individual with schizophrenia lacks this feeling of uniqueness and experiences a great deal of confusion regarding his or her identity. 1.*Echolalia* The client with schizophrenia may repeat words that he or she hears, which is called echolalia. This is an attempt to identify with the person speaking (e.g., the nurse says, "John, it's time for lunch." The client may respond, "It's time for lunch, it's time for lunch" or sometimes, "Lunch, lunch, lunch, lunch"). 2. Echopraxia The client who exhibits echopraxia may purposelessly imitate movements made by others. 3. Identification and Imitation Identification, which occurs on an unconscious level, and imitation, which occurs on a conscious level, are ego defense mechanisms used by individuals with schizophrenia and reflect their confusion regarding self-identity. Because they have difficulty knowing where their ego boundaries end and another person's begins, their behavior often takes on the form of that which they see in the other person. 4. Depersonalization The unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (e.g., feeling that one's extremities have changed in size; or a sense of seeing oneself from a distance)

Cannabis and Genetic Vulnerability (Environmental Influences)

Studies of genetic vulnerability for schizophrenia have linked certain genes (COMT and ATK1) to increased risk for psychosis and particularly for adolescents with this *genetic vulnerability* who use cannabinoids - Both cannabis and synthetic cannabinoids can induce many schizophrenia-like symptoms, and in individuals with a preexisting psychosis, cannabinoids can exacerbate symptoms - More importantly, the increased risk for psychotic disorders such as schizophrenia with cannabis use suggests the influence of lifestyle factors in the expression of genes and points to the possibility of multiple factors playing a role in the causality of this illness.

Mild Depression

Symptoms at the mild level of depression are like those associated with uncomplicated grieving. Alterations at the mild level include the following: Affective: Denial of feelings, *anger, anxiety*, guilt, helplessness, hopelessness, sadness, despondency Behavioral: Tearfulness, regression, restlessness, agitation, withdrawal Cognitive: Preoccupation with the loss, self-blame, ambivalence, blaming others Physiological: *Anorexia or overeating, insomnia or hypersomnia*, headache, backache, chest pain, or other symptoms associated with the loss of a significant other

Transient Depression

Symptoms at this level of the continuum are not necessarily dysfunctional; in fact, they may be considered part of the broad range of typical human emotional responses that accompany everyday disappointments in life. Transient depression subsides quickly, and the individual is able to refocus on other goals and achievements. Alterations include the following: Affective: *Sadness, dejection, feeling downhearted, having the blues* Behavioral: Some crying possible Cognitive: Some difficulty getting mind off of one's disappointment Physiological: Feeling tired and listless

*Side Effects of antipsychotics*

The effects of these medications are related to blockage of a number of receptors for which they exhibit various degrees of affinity. - Blockage of the dopamine receptors is thought to be responsible for controlling positive symptoms of schizophrenia - *Dopamine blockage also results in extrapyramidal symptoms (EPS) and prolactin elevation (galactorrhea; gynecomastia)* - Cholinergic blockade causes anticholinergic side effects (dry mouth, blurred vision, constipation, urinary retention, tachycardia) - Blockage of the alpha1-adrenergic receptors produces dizziness, orthostatic hypotension, tremors, and reflex tachycardia - Histamine blockade is associated with weight gain and sedation

Theoretical Integration

The etiology of schizophrenia remains unclear. - No single theory or hypothesis has been postulated that substantiates a clear-cut explanation for the disease. - It seems the more research that is conducted, the more evidence is compiled to support the concept of multiple causation in the development of schizophrenia. - The most current theory is that schizophrenia *is a biologically based disease, the onset of which is influenced by factors within the environment (either internal or external)*

Tangentiality

The inability to get to the point of a story. The speaker introduces many unrelated topics, until the original topic of discussion is lost.

Biochemical Factors (Biological Factors)

The oldest and most thoroughly explored biological theory in the explanation of schizophrenia attributes a pathogenic role to *abnormal brain biochemistry* - Notions of a "chemical disturbance" as an explanation for insanity were suggested by some theorists as early as the mid-19th century.

For what must the nurse be on the alert with the client who is receiving antidepressant meds?

The risk for suicide increases as the level of depression decreases, *a sudden lift in mood may indicate suicidal intention*

As the nurse, when would you expect the client to begin showing signs of symptomatic relief after the initiation of antidepressant therapy?

Therapeutic effects can take as long as four weeks Depending on medication, from *1-4 weeks*

*Residual Schizophrenia* (from her outline)

This category is used with the individual who has a history of at least 1 previous episode of schizophrenia with prominent psychotic symptoms occurs in an individual who has a chronic form of the disease and is the stage that follows an acute episode

Anatomical Abnormalities (Physiological Factors)

With the use of neuroimaging technologies, structural brain abnormalities have been observed in individuals with schizophrenia. Ventricular enlargement is the most consistent finding; however, some reductions in gray matter are also reported. Magnetic resonance imaging (MRI) has revealed reduced symmetry in several lobes of the brain and reductions in size of structures within the limbic system of clients with schizophrenia. Postmortem studies provide considerable evidence of abnormalities in the prefrontal cortex, and people who have had prefrontal lobotomies are reported to manifest with many symptoms common to schizophrenia

Individuals in crisis need to develop more adaptive coping strategies. How does the nurse provide assistance with this process?

a. Assessment b. Plan interventions c. Evaluate d. Goals ADOPIE

Ted was transferred on his job to a distant city. His wife, Jane, had never lived away from her family before. She became despondent, living only for daily phone calls to her relatives back in their hometown.

a. Crisis of anticipated life transition - Because of lack of control

*Give an example of a tricyclic antidepressant (TCA)*

anafranil & doxepin, *amitriptyline (Elavil)*

The most appropriate crisis intervention with Amanda (from question 3) would be to a. Encourage her to recognize how lucky she is to be alive. b. Discuss stages of grief and feelings associated with each. c. Identify community resources that can help Amanda. d. Suggest that she find a place to live that provides a storm shelter.

b. Discuss stages of grief and feelings associated with each.

Andrew, a New York City firefighter, and his entire unit responded to the terrorist attacks at the World Trade Center. Working as a team, he and his best friend, Carlo, entered the area together. Carlo was killed when the building collapsed. Andrew was injured but survived. Since that time, Andrew has had frequent nightmares and anxiety attacks. He says to the mental health worker, "I don't know why Carlo had to die and I didn't!" This statement by Andrew suggests that he is experiencing a. Spiritual distress. b. Night terrors. c. Survivor's guilt. d. Suicidal ideation.

c. Survivor's guilt.

Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Which of the following is the most appropriate response by the nurse? a. "That's ridiculous, Clint. No one is going to hurt you." b. "The CIA isn't interested in people like you, Clint." c. "Why do you think the CIA wants to kill you?" d. "I know you believe that, Clint, but it's really hard for me to believe."

d. "I know you believe that, Clint, but it's really hard for me to believe."

Crises occur when an individual a. Is exposed to a precipitating stressor. b. Perceives a stressor to be threatening. c. Has no support systems. d. Experiences a stressor and perceives coping strategies to be ineffective.

d. Experiences a stressor and perceives coping strategies to be ineffective.

Schizoaffective Disorder

manifested by s/s of schizophrenia, along with a strong element of symptomatology associated with the mood disorders (depression or mania) - The client may appear depressed, with psychomotor retardation and suicidal ideation, or symptoms may include euphoria, grandiosity, and hyperactivity - The decisive factor in the diagnosis of schizoaffective disorder is the presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episode - However, prominent mood disorder symptoms must be evident for a majority of the time - The prognosis for schizoaffective disorder is generally *better than that for other schizophrenic disorders but worse than that for mood disorders alone* - Catatonic features also may be associated with this disorder.

*cognitive theory*

theory suggesting that the primary disturbance in depression is cognitive rather than affective - The underlying cause of the depression is cognitive distortions that result in *negative, defeated attitudes.* - 3 cognitive distortions that they believe serve as the basis for depression: 1. Negative expectations of the environment 2. Negative expectations of the self 3. Negative expectations of the future - These cognitive distortions arise out of a defect in cognitive development, and the individual feels inadequate, worthless, and rejected by others, Outlook for the future is one of *pessimism and hopelessness.* - Cognitive theorists believe that *depression is the product of negative thinking* - This is in contrast to the suggestions by other theorists that negative thinking occurs when an individual is depressed - focuses on helping the individual to alter mood by changing the way he or she thinks - the individual is taught to control negative thought distortions that lead to *pessimism, lethargy, procrastination, indecisiveness, and low self-esteem.*

*Anger can be identified by a cluster of behaviors that include:*

1. *Anxious, tense, angry facial expression (affect)!!!* 2. *Clenched fists (stay arms length away)* 3. Low-pitched voice 4. Yelling and shouting - common 5. Intense (or no) eye contact (will stare you down) 6. Easily offended 7. Defensive response to criticism 8. Passive-aggressive behavior 9. Flushed face 10. Lack of control or over controlled emotions 11. Intense discomfort, continuous state of tension individuals need assistance to recognize their true feelings and to understand that *anger is a perfectly acceptable emotion when it is expressed appropriately*

Illusion

A misperception of a real external stimulus.

clang association

A pattern of speech in which the choice of words is governed by sounds. Clang associations often take the form of rhyming.

magical thinking

A primitive form of thinking in which an individual believes that thinking about a possible occurrence can make it happen.

Echolalia

The parrot-like repetition, by an individual with loose ego boundaries, of the words spoken by another

Shelley enters the emergency room accompanied by a friend who reports that Shelley was raped after leaving a college campus party the night before. Shelley is staring off into space, exhibits a closed posture, and is mumbling inaudibly. How will you introduce yourself and begin to intervene in this crisis situation?

"Hi Shelley, my name is Mrs. Smith, and I am a registered nurse here to help you. I'm so glad you came in to seek help. I'd like to ask you some questions about the events you've experienced. Alright?" Convey respect, reassurance of help, and empower the client to be involved in decision making.

Thomas was secluded and restrained after punching another patient on the inpatient psychiatric unit. The next day he asks you what happened last night, stating he doesn't remember, and says he wants to know why he was arrested and tied up like an animal. What will you communicate to Thomas about the prior events and the crisis intervention process?

"Thomas, last evening you became very upset, stating you thought the FBI was trying to kill you, and you struck another patient." (Giving information) "Do you remember any of those events?" (Assessing the patient's perception and memory) "Restraint is an intervention that we only use when other efforts have failed to protect your safety and the safety of others." (Giving information) "Let's talk about what you think would be helpful in preventing that from happening again." (Formulating a plan, empowering the client to be involved in problem solving)

What is the goal of crisis intervention?

*Restore the person to their pre-crisis level of functioning (minimum at the least) and enhance growth*

Two employees lost their jobs. One employee re-evaluates his career goals, and starts his job search. The other employee is hospitalized with suicidal ideation. Which of the following factors would have been influential in the development of the second employee's crisis? (Which of the following factors would be MOST influential) a. The individual's birth order b. The presence of support systems c. A lack of adequate coping skills d. The time of year in which the event occurred

*c. A lack of adequate coping skills* Presence of a support system is important but coping skills is MOST IMPORTANT

Which of the following is the desired outcome of working with an individual who has witnessed a traumatic event and is now experiencing panic anxiety? a. The individual will experience no anxiety. b. The individual will demonstrate hope for the future. c. The individual will identify that anxiety is at a manageable level. d. The individual will verbalize acceptance of self as worthy.

*c. The individual will identify that anxiety is at a manageable level.*

For the past 3 days, a student has skipped classes, cried constantly, experienced panic attacks, and is now exhibiting difficulty with short-term memory. In her assessment of this student, what crucial information should the nurse initially obtain PRIOR to planning interventions? a. The student's available support system b. The student's usual ability to cope with stress c. The student's access to community resources d. The student's description of the precipitating stressor

*d. The student's description of the precipitating stressor* Its most important to assess the precipitating stressor that led to the crisis

Intervention with Andrew (from question 12) would include a. Encouraging expression of feelings. b. Antianxiety medications. c. Participation in a support group. d. a and c. e. All of the above.

*e. All of the above*

Other Biochemical Hypotheses - various other biochemicals have been implicated in the predisposition to schizophrenia

- *abnormalities in the neurotransmitters norepinephrine, serotonin, acetylcholine, and gamma-aminobutyric acid and in the neuroregulators, such as prostaglandins and endorphins, have been suggested* - *Excess of serotonin has been hypothesized to be responsible for both positive and negative symptoms of schizophrenia, and the effectiveness of medications such as clozapine (a strong serotonin antagonist) lends support to this hypothesis* - Recent research has implicated the neurotransmitter glutamate in the etiology of schizophrenia. The N-methyl-D-aspartate (NMDA) receptor is the receptor that is activated by the neurotransmitters glutamate and glycine. Psychopharmacological studies have shown that the drug class of glutamate antagonists (e.g., phencyclidine [PCP]; ketamine) can produce schizophrenic-like symptoms in individuals without the disorder (Hashimoto, 2006; Stahl, 2013). In one recent study, participants who were experiencing ketamine-induced schizophrenia-like psychotic symptoms were treated with a drug trial of a glycine transporter-1 inhibitor (D'Souza et al., 2012). This medication was shown to reduce the psychotic symptoms induced by the NMDA receptor antagonism of the ketamine, so it has been hoped that this drug may have benefits in the treatment of schizophrenia as well. So far, while there is evidence of a glutamate link in schizophrenia (Hu et al., 2014) more research is needed on the implications for treatment. Currently available conventional antipsychotic medications largely target the dopamine receptors in the brain. Newer, second-generation antipsychotics have strong affinity for serotonergic receptors. The glutamate model of schizophrenia suggests possibilities for new therapeutic target options, including NMDA agonists, glycine transport inhibitors, and metabotropic glutamate receptor agonists

Evaluation consists of reassessment to determine if the nursing interventions have been successful in achieving the objectives of care. The following type of information may be gathered to determine the success of working with a client exhibiting inappropriate expression of anger.

- Is the client now able to recognize when he or she is angry? - Can the client take responsibility for these feelings and keep them in check without losing control? - Does the client seek out staff to talk about feelings when they occur? - Is the client able to transfer tension generated by the anger into constructive activities? - Has harm to the client and others been avoided? - Is the client able to solve problems adaptively without undue frustration and without becoming violent?

*phases in the development of a crisis*

- Phase 1. *The individual is exposed to a Precipitating Stressor*. Anxiety increases; previous problem-solving techniques are employed. - Phase 2. *When previous problem-solving techniques do NOT relieve the stressor, Anxiety increases further*. The individual begins to feel a great deal of discomfort at this point. Coping techniques that have worked in the past are attempted, only to create feelings of helplessness when they are not successful. Feelings of confusion and disorganization prevail. - Phase 3. *ALL possible resources, both internal and external, are called on to resolve the problem and relieve the discomfort*. The individual may try to view the problem from a different perspective or even to overlook certain aspects of it. New problem-solving techniques may be used, and if effectual, resolution may occur at this phase, with the individual returning to a higher, a lower, or the previous level of precrisis functioning. - Phase 4. *If resolution does not occur in previous phases, "the tension mounts beyond a further threshold or its burden increases over time to a Breaking Point. Major disorganization of the individual with drastic results often occurs"*. Anxiety may reach panic levels. Cognitive functions are disordered, emotions are *labile*, and behavior may reflect the presence of psychotic thinking.

Phase I: The Premorbid Phase

- Premorbid signs are those that occur before there is clear evidence of illness and may include distinctive personality traits or behaviors. - Premorbid personality and behavioral measurements that have been noted include being very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating antisocial behavior. - In the typical, but not invariable, premorbid history of schizophrenia, patients had schizoid or schizotypal personalities characterized as quiet, passive, and introverted; as children, they had few friends - Preschizophrenic adolescents may have no close friends and no dates and may avoid team sports. They may enjoy [solitary activities] to the exclusion of social activities. Social maladjustment Antagonistic thoughts and behavior Shy and withdrawn with normal functioning Poor peer relationships Doing poorly in school Antisocial behavior (maybe)

BOX 10-1 The Brøset Violence Checklist

- Score: (Score 1 point for each behavior observed. At a score of ≥2, begin de-escalation techniques.) - Behaviors: Confusion Irritability Boisterousness Physical threats Verbal threats Attacks on objects Total Score : - *De-escalation techniques!*: 1. Calm voice 2. Helpful attitude 3. *Identify consequences (must carry through w/, use as few words as possible, simple words!)* 4. Open hands and nonthreatening posture 5. Allow phone call 6. Offer food or drink 7. Decrease waiting times and request refusals 8. *Distract with a more positive activity (e.g., soft music or a quiet room)* 9. Walk outdoors or fresh air 10. Reduction in demands 11. Group participation 12. Relaxation techniques 13. Express concern 14. Reduce stimulation and loud noise 15. Verbal redirection and limit setting 16. Time out, quiet time, open seclusion 17. *Offer prn medication (if they as for it give it but don't make it 1st intervention)* - If de-escalation techniques fail: 1. Suggest prn medications 2. Time out or *unlocked seclusion*, which can progress to locked seclusion if all other de-escalation strategies and less restrictive measures have been unsuccessful (*seclusion is LAST resort*)

Phase II: The Prodromal Phase

- signs are differentiated from premorbid signs in that prodromal symptoms MORE clearly manifest as signs of the developing illness of schizophrenia - begins with a change from premorbid functioning and extends until the onset of frank psychotic symptoms - *can be as brief as a few weeks or months, but most studies indicate that the average length of the prodromal phase is b/w 2-5 years* - the individual begins to show signs of *significant deterioration in function* - 50% complain of depressive symptoms - *Social withdrawal is not uncommon, and signs of cognitive impairment may begin to emerge* - *some adolescent pts develop sudden onset of OCD behavior* (which can be misdiagnosed for normal behavior) - recognition of the behaviors associated with the prodromal phase provides an opportunity for early intervention with a possibility for improvement in long-term outcomes - current txt guidelines suggest therapeutic interventions that offer support with identified problems, cognitive therapies to minimize functional impairment, family interventions to improve coping, and involvement with the schools to reduce the possibility of failure - some controversy exists as to the benefit of using pharmaceutical therapy during the prodromal phase; however, evidence supports that comprehensive treatment begun at the time of the first psychotic episode is associated with better outcomes Deterioration in role functioning and social withdrawal Substantial functional impairment Sleep disturbance, anxiety, *irritability* Depressed mood, poor concentration, fatigue Perceptual abnormalities, ideas of reference (tv talking to them), and suspiciousness herald onset of psychosis May be brief Don't want to take a bath, etc

NURSING DIAGNOSIS: RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE RELATED TO: History of violence, inadequate management of anger, posttrauma stress OUTCOME CRITERIA: *Client does not harm self or others.* Client verbalizes anger rather than hit others. Nursing interventions:

1. *Observe client for escalation of anger (called the prodromal syndrome): increased motor activity, pounding, slamming, tense posture, defiant affect, clenched teeth and fists, arguing, demanding, and challenging or threatening staff.* - Violence may be prevented if risks are identified in time. 2. When these behaviors are observed, first ensure that sufficient staff are available to help with a potentially violent situation. Attempt to defuse the anger beginning with the least restrictive means. - The initial consideration must be having enough help to diffuse a potentially violent situation. Client rights must be honored, while preventing harm to client and others. 3. Techniques for dealing with aggression include: - Aggression control techniques promote safety and reduce risk of harm to client and others: a. *Talking down. Say, "John, you seem very angry. Let's go to your room and talk about it." (Ensure that client does not position self between door and nurse.) - Promotes a trusting relationship and may prevent client's anxiety from escalating.* b. *Physical outlets*. "Maybe it would help if you punched your pillow or the punching bag for a while" or "I'll stay here with you if you want." - Provides effective way for client to release tension associated with high levels of anger. c. *Medication*. If agitation continues to escalate, offer client choice of taking medication voluntarily. If he or she refuses, reassess the situation to determine if harm to self or others is imminent. - Tranquilizing medication may calm client and prevent violence from escalating. d. *Call for assistance*. Remove self and other clients from the immediate area. Call violence code, push "panic" button, call for assault team, or institute measures established by the institution. Sufficient staff to indicate a show of strength may be enough to de-escalate the situation, and client may agree to take the medication. - Client and staff safety are of primary concern. Many states, accrediting bodies, and/or facilities require that staff members working with hospitalized psychiatric patients be trained and/or certified in psychiatric emergency interventions to assure that the strategies used are in the best interest of staff and patient safety. e. *Seclusion or restraints. If client is not calmed by talking down or by medication, use of mechanical restraints and/or seclusion may be necessary. Be sure to have sufficient staff available to assist and appropriately deal with an out-of-control client. Follow protocol for restraints/seclusion established by the institution. Restraints should be used as a last resort, after all other interventions have been unsuccessful and client is clearly at risk of harm to self or others. - Clients who do not have internal control over their own behavior may require external controls, such as mechanical restraints, in order to prevent harm to self or others.* f. *Observation and documentation*. Hospital policy typically dictates the requirements for observation of client in restraints. Basic safety principles include that client in restraints should be observed throughout the period of restraint. Every 15 minutes, client should be monitored to ensure that circulation to extremities is not compromised (check temperature, color, pulses). Assist client with needs related to nutrition, hydration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. Document all observations. - Client well-being is a nursing priority. g. *Ongoing assessment*. As agitation decreases, assess client's readiness for restraint removal or reduction. With assistance from other staff members, remove one restraint at a time, while assessing client's response. This measure minimizes the risk of injury to client and staff. - Gradual removal of the restraints allows for testing of client's self-control. Client and staff safety are of primary concern, as is assuring that the patient is offered the least restrictive treatment option effective in maintaining safety. h. *Debriefing*. It is important when a client loses control for staff to follow-up with a discussion about the situation. This discussion should occur with client and among other staff. The staff should discuss factors that necessitated the crisis intervention, factors that contributed to the failure of less restrictive interventions, and staff's thoughts about the safety and effectiveness of the intervention.When client has regained control, a debriefing should occur in which client is encouraged to discuss thoughts about what contributed to the crisis situation and about staff interventions, and to explore strategies to avert a crisis situation in the future. It is also important to discuss the situation with other clients who witnessed the episode so they understand and process what happened. Some clients may fear that they could be at risk for experiencing a crisis or that they might be in danger when someone else's behavior becomes aggressive. - helps to process the impact of the intervention. Mutual feedback is shared; staff and client have an opportunity to process and learn from the event.

The *premorbid behavior* of an individual with schizophrenia can be viewed in 4 phases. PPSR

1. *Phase I. The Premorbid Phase.* Marked by normal functioning, although events can occur that contribute to the development of the subsequent illness. Personality and behavioral measurements include being very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating antisocial behavior. 2. *Phase II. The Prodromal Phase.* In this phase, which lasts from a few weeks to a few years, there is deterioration in role functioning and social withdrawal. Substantial functional impairment can occur, with nonspecific symptoms such as sleep disturbance, anxiety, irritability, depressed mood, poor concentration, and fatigue. Perceptual abnormalities, ideas of reference, and suspiciousness develop late in this phase and may herald the imminent onset of psychosis. 3. *Phase III. Schizophrenia (Active Psychotic).* In the active phase of the disorder, psychotic symptoms are prominent. These include delusions, hallucinations, and impairment in work, social relations, and self-care. 4. *Phase IV. Residual Phase.* Symptoms similar to the prodromal phase, with flat affect and impairment in role functioning being prominent.

NURSING DIAGNOSIS: INEFFECTIVE COPING RELATED TO: (Possible) negative role modeling; dysfunctional family system EVIDENCED BY: Yelling, name calling, hitting others, and temper tantrums as expressions of anger *OUTCOME CRITERIA: Client recognizes anger in self and takes responsibility before losing control.* Nursing interventions:

1. *Remain calm when dealing with an angry client.* - *Anger expressed by the nurse will most likely incite increased anger in client.* 2. Set verbal limits on behavior. Clearly delineate the consequences of inappropriate expression of anger, and always follow through. - Consistency in enforcing the consequences is essential if positive outcomes are to be achieved. Inconsistency creates confusion and encourages testing of limits. 3. Have client keep a diary of angry feelings, what triggered them, and how they were handled. - Journaling provides a more objective measure of the problem. 4. *Avoid touching client when he or she becomes angry.* - Client may view touch as threatening and could become violent. 5. Help client determine the true source of the anger. - Many times anger is being displaced onto a safer object or person. If resolution is to occur, the first step is to identify the source of the problem. 6. It may be constructive to ignore initial derogatory remarks by client. - Lack of feedback often extinguishes an undesirable behavior. 7. Help client find alternative ways to release tension, such as physical outlets, and more appropriate ways to express anger, such as seeking out staff when feelings emerge. - Client will likely need assistance to problem-solve more appropriate ways of behaving. 8. *Role model appropriate ways to express anger assertively, such as, "I dislike being called names. I get angry when I hear you saying those things about me."* - Role modeling is one of the strongest methods of learning.

*The paradigm set forth by Aguilera suggests that whether or not an individual experiences a crisis in response to a stressful situation depends on the following three factors:*

1. *The individual's Perception of the event.* If the event is perceived realistically, the individual is more likely to draw upon adequate resources to restore equilibrium. If the perception of the event is distorted, attempts at problem-solving are likely to be ineffective, and equilibrium is not restored. 2. *The availability of situational Supports*. Aguilera stated, "Situational supports are those persons who are available in the environment and who can be depended on to help solve the problem". Without adequate situational supports during a stressful situation, an individual is most likely to feel overwhelmed and alone. 3. *The availability of adequate Coping Mechanisms*. When a stressful situation occurs, individuals draw upon behavioral strategies that have been successful for them in the past. If these coping strategies work, a crisis may be diverted. If not, disequilibrium may continue and tension and anxiety increase.

characteristics of a crisis

1. Crisis occurs in *ALL individuals* at 1 time or another and is NOT necessarily equated with psychopathology. 2. Crises are precipitated by specific identifiable events. 3. Crises are personal by nature. What may be considered a crisis situation by 1 individual may not be so for another. 4. Crises are *acute, NOT chronic*, and will be resolved in one way or another w/i a brief period. 5. A crisis situation contains the potential for psychological *growth or deterioration!*

NURSING DIAGNOSIS: SPIRITUAL DISTRESS RELATED TO: Physical or psychological stress; energy-consuming anxiety; loss(es), intense suffering; separation from religious or cultural ties; challenged belief and value system EVIDENCED BY: Expressions of concern about disaster and the meaning of life and death or belief systems; inner conflict about current loss of normality and effects of the disaster; anger directed at deity; engaging in self-blame; seeking spiritual assistance OUTCOME CRITERIA: Client expresses beliefs and values about spiritual issues.

1. Determine client's religious/spiritual orientation, current involvement, and presence of conflicts. 1. Provides baseline for planning care and accessing appropriate resources. 2. Establish environment that promotes free expression of feelings and concerns. Provide calm, peaceful setting when possible. 2. Promotes awareness and identification of feelings so they can be dealt with. 3. Listen to client's and significant others' expressions of anger, concern, alienation from God, belief that situation is a punishment for wrongdoing, and similar concerns. 3. It is helpful to understand client's and significant others' points of view and how they are questioning their faith in the face of tragedy. 4. Note sense of futility, feelings of hopelessness and helplessness, lack of motivation to help self. 4. These thoughts and feelings can result in client feeling paralyzed and unable to move forward to resolve the situation. 5. Listen to expressions of inability to find meaning in life and reason for living. Evaluate for suicidal ideation. 5. May indicate need for further intervention to prevent suicide attempt. 6. Determine support systems available to client. 6. Presence or lack of support systems can affect client's recovery. 7. Ask how you can be most helpful. Convey acceptance of client's spiritual beliefs and concerns. 7. Promotes trust and comfort, encouraging client to be open about sensitive matters. 8. Make time for nonjudgmental discussion of philosophic issues and questions about spiritual impact of current situation. 8. Helps client begin to look at basis for spiritual confusion. Note: There is a potential for care provider's belief system to interfere with client finding own way. Therefore, it is most beneficial to remain neutral and not espouse own beliefs. 9. Discuss difference between grief and guilt, and help client to identify and deal with each, assuming responsibility for own actions, expressing awareness of the consequences of acting out of false guilt. 9. Blaming self for what has happened impedes dealing with the grief process and needs to be discussed and dealt with. 10. Use therapeutic communication skills of reflection and active listening. 10. Helps client find own solutions to concerns. 11. Encourage client to experience meditation, prayer, and forgiveness. Provide information that anger with God is a normal part of the grieving process. 11. This can help to heal past and present pain. 12. Assist client to develop goals for dealing with life situation. 12. Enhances commitment to goal, optimizing outcomes and promoting sense of hope. 13. Identify and refer to resources that can be helpful, such as pastoral/parish nurse or religious counselor, crisis counselor, psychotherapy, Alcoholics Anonymous and/or Narcotics Anonymous. 13. Specific assistance may be helpful to recovery (e.g., relationship problems, substance abuse, suicidal ideation). 14. Encourage participation in support groups. 14. Discussing concerns and questions with others can help client resolve feelings.

NURSING DIAGNOSIS: ANXIETY (PANIC)/FEAR RELATED TO: Real or perceived threat to physical well-being; threat of death; situational crisis; exposure to toxins; unmet needs EVIDENCED BY: Persistent feelings of apprehension and uneasiness; sense of impending doom; impaired functioning; verbal expressions of having no control or influence over situation, outcome, or self-care; sympathetic stimulation; extraneous physical movements OUTCOME CRITERIA: *Client demonstrates that anxiety is at a manageable level. Client demonstrates use of positive coping mechanisms to manage anxiety.*

1. Determine degree of anxiety/fear present, associated behaviors (e.g., laughter, crying, calm or agitation, excited/hysterical behavior, expressions of disbelief and/or self-blame), and reality of perceived threat. 1. Clearly understanding client's perception is pivotal to providing appropriate assistance in overcoming the fear. Individual may be agitated or totally overwhelmed. Panic state increases risk for client's own safety as well as the safety of others in the environment. 2. Note degree of disorganization. 2. Client may be unable to handle activities of daily living or work requirements and may need more intensive intervention. 3. Create as quiet an area as possible. Maintain a calm, confident manner. Speak in even tone using short, simple sentences. 3. Decreases sense of confusion or overstimulation; enhances sense of safety. Helps client focus on what is said, and reduces transmission of anxiety. 4. Develop trusting relationship with client. 4. Trust is the basis of a therapeutic nurse-client relationship and enables them to work effectively together. 5. Identify whether incident has reactivated preexisting or coexisting situations (physical or psychological). 5. Concerns and psychological issues are recycled every time trauma is re-experienced, and they affect how client views the current situation. 6. Determine presence of physical symptoms (e.g., numbness, headache, tightness in chest, nausea, and pounding heart). 6. Physical problems need to be differentiated from anxiety symptoms so appropriate treatment can be given. 7. Identify psychological responses (e.g., anger, shock, acute anxiety, panic, confusion, denial). Record emotional changes. 7. Although these are normal responses at the time of the trauma, they will recycle repeatedly until they are dealt with adequately. 8. Discuss with client the perception of what is causing the anxiety. 8. Increases client's ability to connect symptoms to subjective feeling of anxiety, providing opportunity to gain insight/control and make desired changes. 9. Assist client to correct any distortions being experienced. Share perceptions with client. 9. Perceptions based on reality help to decrease fearfulness. How the nurse views the situation may help client to see it differently. 10. Explore with client or significant other the manner in which client has previously coped with anxiety-producing events. 10. May help client regain sense of control and recognize significance of trauma. 11. Engage client in learning new coping behaviors (e.g., progressive muscle relaxation, thought-stopping) 11. Replacing maladaptive behaviors can enhance ability to manage and deal with stress. Interrupting obsessive thinking allows client to use energy to address underlying anxiety, whereas continued rumination about the incident can retard recovery. 12. Encourage use of techniques to manage stress and vent emotions such as anger and hostility. 12. Reduces the likelihood of eruptions that can result in abusive behavior. 13. Give positive feedback when client demonstrates better ways to manage anxiety and is able to calmly and realistically appraise the situation. 13. Provides acknowledgment and reinforcement, encouraging use of new coping strategies. Enhances client's ability to deal with fearful feelings and gain control over situation, promoting future successes. 14. Administer medications as indicated: Antianxiety—diazepam, alprazolam, oxazepam. Antidepressants—fluoxetine, paroxetine, bupropion. 14. Antianxiety medication provides temporary relief of anxiety symptoms, enhancing ability to cope with situation. Antidepressants lift mood and help suppress intrusive thoughts and explosive anger.

NURSING DIAGNOSIS: RISK FOR POST-TRAUMA SYNDROME RELATED TO: Events outside the range of usual human experience; serious threat or injury to self or loved ones; witnessing horrors or tragic events; exaggerated sense of responsibility; survivor's guilt or role in the event; inadequate social support OUTCOME CRITERIA: Client demonstrates ability to deal with emotional reactions in an individually appropriate manner. NURSING INTERVENTIONS

1. Determine involvement in event (e.g., survivor, significant other, rescue/aid worker, health-care provider, family member). 1. All those concerned with a traumatic event are at risk for emotional trauma and have needs related to their involvement in the event. Note: Close involvement with victims affects individual responses and may prolong emotional suffering. 2. Evaluate current factors associated with the event, such as displacement from home due to illness/injury, natural disaster, or terrorist attack. Identify how client's past experiences may affect current situation. 2. Affects client's reaction to current event and is basis for planning care and identifying appropriate support systems and resources. 3. *Listen for comments of taking on responsibility (e.g., "I should have been more careful or gone back to get her") - Statements such as these are indicators of "survivor's guilt" and blaming self for actions.* 4. *Identify client's current coping mechanisms. - Noting positive or negative coping skills provides direction for care.* 5. Determine availability and usefulness of client's support systems, family, social contacts, and community resources. 5. Family and others close to client may also be at risk and require assistance to cope with the trauma. 6. Provide information about signs and symptoms of posttrauma response, especially if individual is involved in a high-risk occupation. 6. Awareness of these factors helps individual identify need for assistance when signs and symptoms occur. 7. Identify and discuss client's strengths as well as vulnerabilities. 7. Provides information to build on for coping with traumatic experience. 8. Evaluate individual's perceptions of events and personal significance (e.g., rescue worker trained to provide lifesaving assistance but recovering only dead bodies). 8. Events that trigger feelings of despair and hopelessness may be more difficult to deal with, and require long-term interventions. 9. *Provide emotional and physical presence by sitting with client/significant other and offering solace. - Strengthens coping abilities.* 10. *Encourage expression of feelings. Note whether feelings expressed appear congruent with events experienced. - It is important to talk about the incident repeatedly. Incongruencies may indicate deeper conflict and can impede resolution.* 11. *Note presence of nightmares, reliving the incident, loss of appetite, irritability, numbness and crying, and family or relationship disruption. - These responses are normal in the early, post-incident time frame. If prolonged and persistent, they may indicate need for more intensive therapy.* 12. Provide a calm, safe environment. 12. Helps client deal with the disruption in his or her life. 13. Encourage and assist client in learning stress-management techniques. 13. Promotes relaxation and helps individual exercise control over self and what has happened. 14. Recommend participation in debriefing sessions that may be provided following major disaster events. 14. Dealing with the stresses promptly may facilitate recovery from the event or prevent exacerbation. 15. Identify employment, community resource groups. 15. Provides opportunity for ongoing support to deal with recurrent feelings related to the trauma. 16. Administer medications as indicated, such as antipsychotics (e.g., chlorpromazine, haloperidol, olanzapine, or quetiapine) or carbamazepine (Tegretol). 16. Low doses of antipsychotics may be used for reduction of psychotic symptoms when loss of contact with reality occurs, usually for clients with especially disturbing flashbacks. Carbamazepine may be used to alleviate intrusive recollections or flashbacks, impulsivity, and violent behavior.

NURSING DIAGNOSIS: INEFFECTIVE COMMUNITY COPING RELATED TO: Natural or man-made disasters (earthquakes, tornados, floods, reemerging infectious agents, terrorist activity); ineffective or nonexistent community systems (e.g., lack of or inadequate emergency medical system, transportation system, or disaster planning systems) EVIDENCED BY: Deficits of community participation; community does not meet its own expectations; expressed vulnerability; community powerlessness; stressors perceived as excessive; excessive community conflicts; high illness rates OUTCOME CRITERIA: Client demonstrates an increase in activities to improve community functioning. NURSING INTERVENTIONS

1. Evaluate community activities related to meeting collective needs within the community and between the community and the larger society. Note immediate needs, such as health care, food, shelter, funds. 1. Provides a baseline to determine community needs in relation to current concerns or threats. 2. Note community reports of functioning, including areas of weakness or conflict. 2. Provides a view of how the community sees these areas. 3. Identify effects of related factors on community activities. 3. In the face of a current threat, local or national, community resources need to be evaluated, updated, and given priority to meet the identified need. 4. Determine availability and use of resources. Identify unmet demands or needs of the community. 4. Information is necessary to identify what else is needed to meet the current situation. 5. Determine community strengths. 5. Promotes understanding of the ways in which the community is already meeting the identified needs. 6. Encourage community members and groups to engage in problem-solving activities. 6. Promotes a sense of working together to meet community needs. 7. Develop a plan jointly with the members of the community to address immediate needs. 7. Deals with deficits in support of identified goals. 8. Create plans managing interactions within the community and between the community and the larger society. 8. Meets collective needs when the concerns or threats are shared beyond a local community. 9. Make information accessible to the public. Provide channels for dissemination of information to the community as a whole (e.g., print media, radio and television reports and community bulletin boards, Internet sites, speaker's bureau, reports to committees, councils, advisory boards). 9. Readily available, accurate information can help citizens deal with the situation. 10. Make information available in different modalities and geared to differing educational levels and cultures of the community. 10. Using languages other than English and making written materials accessible to all members of the community promotes understanding. 11. Seek out and evaluate needs of underserved populations. 11. Homeless and those residing in lower income areas may have special requirements that need to be addressed with additional resources.

nursing interventions

1. Limit setting A. Explain exactly which behavior is inappropriate B. Explain why the behavior is inappropriate C. Give reasonable choices and consequences D. Allow time 2. Enforce consequences A. Patient teaching for after situation is over. B. *Encourage "I" statements to express feelings* C. Example: "I feel angry when I have to attend group therapy because...." 3. New coping skills must be taught (when patient expresses readiness to learn) A. "Let's explore methods to help you stop and think before taking action." 4. *Client teaching can occur when the client understands he/she lost control and acted inappropriately (after the event). Client must be rational at time of teaching. Teach the "Stop Strategy" and other strategies for controlling one's own anxiety and out of control behavior. Example: "Next time you feel like hitting, think STOP! (can visualize a stop sign). Take deep breaths. Count to 10."*

Aggression may be evidenced in many behaviors, including (but not limited to) the following defining characteristics:

1. Pacing, restlessness (let them pace bc they're anxious and sitting will increase anxiety) 2. Threatening body language 3. Verbal or physical threats 4. Loud voice, shouting, use of obscenities, argumentativeness 5. Threats of homicide or suicide 6. Increased agitation, with overreaction to environmental stimuli 7. Panic anxiety, leading to misinterpretation of the environment 8. Disturbed thought processes 9. Suspiciousness and defensive posturing 10. Angry mood, often disproportionate to the situation 11. Destruction of property 12. Acts of physical harm toward another person

Name the three factors that determine whether or not a person experiences a crisis in response to a stressful situation.

1. Perception of event 2. Availability of support 3. Coping mechanisms

Goal of intervention is protections and safety (number 1 thing is to get all other pts away/safe, 1 person at least needs to be watching the other pts)

1. Restraints and/or seclusion is used only as a last resort, after all other interventions have been unsuccessful, and the client is clearly at risk of harm to self or others. 2. What is the purpose of seclusion? (safety to self and others) 3. What is the client outcome for seclusion? (client verbalizes insight about his behavior, must make it a learning opportunity) 4. FOLLOW the policies of the institution where you are employed 5. *The Joint Commission requires that an in-person evaluation by physician or other licensed practitioner (LIP) be conducted w/i 1 hour of the initiation of the restraint or seclusion.* 6. Staff debriefing - important to occur within 24 hours of an incident. Debriefing helps diminish the emotional impact of the intervention. Mutual feedback is shared and staff has an opportunity to process and learn.

Factors contributing to the intensity of a crisis:

1. The suddenness of the onset of the crises 2. How strong the person's sense of identity is (people w/ a strong sense of identity tend to do better) 3. Availability of support systems 4. The severity of a crisis 5. Person's relationship with God. 6. Whether the person has unresolved issued from the past

*prodromal syndrome!!!*

A Syndrome of Symptoms that often PRECEDE the onset of aggressive or violent behavior. These symptoms include anxiety and tension, verbal abuse and profanity, and increasing hyperactivity. - These escalating behaviors usually do not occur in stages but most often overlap and sometimes occur simultaneously. - Behaviors associated with this prodromal stage include rigid posture; clenched fists and jaws; grim, *defiant affect*; talking in a rapid, raised voice; arguing and demanding; using profanity and threatening verbalizations; agitation and pacing; and pounding and slamming. - MOST assaultive behavior is preceded by a period of *increasing hyperactivity* - *Behaviors associated with this should be considered emergent and demand immediate attention!* - Keen observation skills and background knowledge for accurate assessment are critical factors in predicting potential for violent behavior. - The Brøset Violence Checklist (BVC) is a quick, simple, and reliable checklist that can be used as a risk assessment for potential violence. - Testing has shown 63% accuracy for prediction of violence at a score of 2 or above

*Crisis reflecting psychopathology!!!*

A crisis that is influenced or triggered by preexisting psychopathology. Examples of psychopathology that may precipitate crises include personality disorders, anxiety disorders, bipolar disorder, and schizophrenia. (can get hospitalized) - *EXAMPLE*: Sonja, age 29, was diagnosed with borderline personality disorder at age 18. This disorder is believed to be rooted in deep fear of abandonment. She has been in therapy on a weekly basis for 10 years, with several hospitalizations for suicide attempts during that time. She has had the same therapist for the past 6 years. This therapist told Sonja today that she is to be married in 1 month and will be moving across the country with her new husband. Sonja is distraught, stating that no one cares about her and that she would be better off dead. She is found wandering in and out of traffic on a busy expressway, oblivious to her surroundings. Police bring her to the emergency department of the hospital. - Intervention: The initial goal is to reduce Sonja's anxiety. She requires that someone stay with her and reassure her of her safety and security. After the feelings of panic and anxiety have subsided, she should be encouraged to verbalize her feelings of abandonment. Regressive behaviors should be discouraged. Positive reinforcement should be given for independent activities and accomplishments. - The primary therapist will need to pursue this issue of termination with Sonja and facilitate transfer of services to another therapist or treatment program. Hospitalization may be necessary to maintain patient safety.

neuroleptic malignant syndrome (NMS):

A rare but potentially fatal complication of treatment with neuroleptic drugs. Symptoms include severe muscle rigidity, high fever, tachycardia, fluctuations in BP, diaphoresis, and rapid deterioration of mental status to stupor and coma.

*Anosognosia*

A symptom of some mental illnesses, such as schizophrenia, in which the individual is manifesting overt symptoms of illness but is UNAWARE of the presence of symptoms/unaware that there is anything wrong.

Paranoia

A term that implies extreme suspiciousness. In schizophrenia, paranoia is characterized by *persecutory delusions and hallucinations of a threatening nature*

Catatonia - BOX 15-1 Diagnostic Criteria for Catatonia Specifier

A type of psychological disturbance that is typified by stupor or excitement. STUPOR is characterized by extreme psychomotor retardation, mutism, negativism, and posturing EXCITEMENT, by psychomotor agitation, in which the movements are frenzied and purposeless. Catatonic symptoms may be associated with other mental or physical disorders. *The clinical picture is dominated by 3 (or more) of the following symptoms:* Stupor (i.e., no psychomotor activity; not actively related to environment) Catalepsy (i.e., passive induction of a posture held against gravity) Waxy flexibility (i.e., slight, even resistance to positioning by examiner) Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]) Negativism (i.e., opposition or no response to instructions or external stimuli) Posturing (i.e., spontaneous and active maintenance of a posture against gravity) Mannerism (i.e., odd, circumstantial caricature of normal actions) Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements) Agitation, not influenced by external stimuli Grimacing Echolalia (i.e., mimicking another's speech) Echopraxia (i.e., mimicking another's movements)

crisis intervention

An EMERGENCY type of assistance in which the intervener becomes a part of the individual's life situation. - The focus is to provide guidance and support to help mobilize the resources needed to resolve the crisis and restore or generate an improvement in previous level of functioning. - Usually lasts no longer than 6-8 weeks. - *Is a thinking, directive, problem-solving approach that focuses only on the client's immediate problems. All behavior is being aimed at keeping the individual's anxiety at a MANAGEABLE level!!!* - Must be supportive and nonjudgmental, client can have a lot of problems but we are ONLY focusing on CURRENT crisis - Minimum therapeutic goal of crisis intervention: psychological resolution of the individual's immediate crisis and *restoration to at least the level of functioning that existed before the crisis period* - Maximum goal: improvement in functioning above the pre-crisis level

Echopraxia

An individual with loose ego boundaries attempting to identify with another person by imitating movements that the other person makes.

Phase 1. Assessment In this phase, the nurse gathers information regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help. A nurse in crisis intervention might perform some of the following assessments:

Ask the individual to describe the event that precipitated this crisis. - *"Tell me what happened." Determine when it occurred. Assess the individual's mental and physical status. Determine if the individual has experienced this stressor before. If so, what method of coping was used? Have these methods been tried this time? If previous coping methods were tried, what was the result? If new coping methods were tried, what was the result? Assess suicide or homicide potential, plan, and means. *Assess the adequacy of support systems!!!* *Determine level of precrisis functioning. Assess the usual coping methods, available support systems, and ability to problem solve!!! "Describe to me what your life was like before this happened"* Assess the individual's perception of personal strengths and limitations. Assess the individual's use of substances. - Information from the comprehensive assessment is then analyzed, and appropriate nursing diagnoses reflecting the immediacy of the crisis situation are identified. Some nursing diagnoses that may be relevant include the following: coping Anxiety (severe to panic) Disturbed thought processes (has been resigned from the NANDA-I list of approved diagnoses but is used for purposes of this textbook) Risk for self- or other-directed violence Rape-trauma syndrome Posttrauma syndrome Fear

*Maturational/developmental crisis*

Crises that occur in response to failed attempts to master developmental tasks associated with transitions in the life cycle. - *EXAMPLE*: Jill and Calvin have been married for 2 years, and their firstborn child is 4 months old. Jill's mother was recently diagnosed with cancer, and the prognosis is unclear. Over the past 3 weeks Jill has become increasingly anxious and disorganized. She has been calling the nurse practitioner 10 to 15 times each day with new fears that she is not addressing her child's health needs. Jill has been screaming at Calvin that he is never there when she needs help with the baby and states she is thinking of dropping their child off at the children's services agency because she believes they are both unable to be effective parents. She agrees to see a counselor at Calvin's insistence. - Intervention: The primary intervention is to help Jill with anxiety reduction. When individuals have intense anxiety, their ability to gain insight about contributing factors and explore options for behavior change is impaired. The safety of their child should also be carefully assessed. Referrals and guidance in parenting skills may also lessen the anxiety associated with this new developmental phase. Anxiety and grief related to Jill's mother's illness could also be explored as a possible contributing factor. In general, the interventions should be directed at helping Jill develop skills needed to master the developmental tasks of new parenthood.

*Crisis resulting from traumatic stress*

Crisis precipitated by an unexpected external stressor over which the individual has little or no control and as a result of which he or she feels emotionally overwhelmed and defeated. - *EXAMPLE*: Sally is a waitperson whose shift ended at midnight. Two weeks ago, while walking to her car in the deserted parking lot, she was abducted by two men with guns, taken to an abandoned building, and raped and beaten. Since that time, her physical wounds have nearly healed. However, Sally cannot be alone, is constantly fearful, relives the experience in flashbacks and dreams, and is unable to eat, sleep, or work at her job in the restaurant. Her friend offers to accompany her to the mental health clinic. - Intervention: The nurse should offer Sally the opportunity to talk about the experience and to express her feelings about the trauma when she demonstrates readiness. The nurse should offer *reassurance and support*; discuss stages of grief and how rape may precipitate feelings of loss, including loss of control, loss of power, and loss of a sense of self-worth, triggering the grief response; identify support systems that can help Sally to resume her normal activities; and explore new methods of coping with emotions arising from a situation with which she has had no previous experience. These interventions should be conducted in an environment that is sensitive to the impact of trauma on a person's sense of self. All interventions should convey dignity, respect, and hopefulness and promote the client's empowerment to make choices in his or her care

*Psychiatric emergencies!!!*

Crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility for their behavior. Examples include acutely suicidal individuals, drug overdoses, reactions to hallucinogenic drugs, acute psychoses, uncontrollable anger, and alcohol intoxication. (can get hospitalized for it) - *EXAMPLE*: Jennifer, age 14, had been dating Joe, the star high school football player, for 6 months. After the game on Friday night, Jennifer and Joe went to Jackie's house, where a number of high school students had gathered for an after-game party. No adults were present. About midnight, Joe told Jennifer that he did not want to date her anymore. Jennifer became hysterical, and Jackie was frightened by her behavior. She took Jennifer to her parent's bedroom and gave her a Valium from a bottle in her mother's medicine cabinet. She left Jennifer lying on her parent's bed and returned to the party downstairs. About an hour later, she returned to her parent's bedroom and found that Jennifer had removed the bottle of Valium from the cabinet and swallowed all of the tablets. Jennifer was unconscious and Jackie could not awaken her. An ambulance was called, and Jennifer was transported to the local hospital. - Intervention: Emergency medical care, including monitoring vital signs, ensuring maintenance of adequate airway, and initiating gastric lavage and/or activated charcoal, is the priority in this case. Jennifer is a minor, so notifying the parents is essential as well. Inpatient hospitalization is justifiable to assure patient safety. Discussing feelings about self-esteem, rejection, and loss will help Jennifer explore more adaptive methods of dealing with stressful situations.

Evaluation In the final step of the nursing process, a reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. Evaluation of the nursing actions for the client who has experienced a traumatic event may be facilitated by gathering information utilizing the following types of questions.

Has the client escaped serious injury, or have injuries been resolved? Have infections been prevented or resolved? Is the client able to maintain anxiety at a manageable level? Does he or she demonstrate appropriate problem-solving skills? Is the client able to discuss his or her beliefs about spiritual issues? Does the client demonstrate the ability to deal with emotional reactions in an individually appropriate manner? Does he or she verbalize a subsiding of the physical manifestations (e.g., pain, nightmares, flashbacks, fatigue) associated with the traumatic event? Has there been recognition of factors affecting the community's ability to meet its own demands or needs? Has there been a demonstration of increased activities to improve community functioning? Has a plan been established and put in place to deal with future contingencies?

Phase 4. Evaluation of Crisis Resolution and Anticipatory Planning To evaluate the outcome of crisis intervention, a reassessment is made to determine if the stated objective was achieved:

Have positive behavioral changes occurred? Has the individual developed more adaptive coping strategies? Have they been effective? Has the individual grown from the experience by gaining insight into his or her responses to crisis situations? Does the individual believe that he or she could respond with healthy adaptation in future stressful situations to prevent crisis development? Can the individual describe a plan of action for dealing with stressors similar to the one that precipitated this crisis? During the evaluation period, the nurse and client summarize what has occurred during the intervention. They review what the individual has learned and "anticipate" how he or she will respond in the future. A determination is made regarding follow-up therapy; if needed, the nurse provides referral information.

Phase 2. Planning of Therapeutic Intervention

In the planning phase of crisis intervention, the nurse selects the appropriate nursing actions for the identified nursing diagnoses. In planning the interventions, the type of crisis, as well as the individual's strengths, desired choices, and available resources for support, are taken into consideration. Goals are established for crisis resolution and a return to, or increase in, the precrisis level of functioning.

assessment disaster nursing

Individuals respond to traumatic events in many ways. *Grieving is a natural response following any loss, and it may be more extreme if the disaster is directly experienced or witnessed.* The emotional effects of loss and disruption may show up immediately or may appear weeks or months later. Psychological and behavioral responses common in adults following trauma and disaster include *anger; disbelief; sadness; anxiety; fear; irritability; arousal; numbing; sleep disturbance; and increases in alcohol, caffeine, and tobacco use!!!* Preschool children commonly experience *separation anxiety, regressive behaviors, nightmares, and hyperactive or withdrawn behaviors* Older children may have *difficulty concentrating, somatic complaints, sleep disturbances, and concerns about safety* Adolescents' responses are often similar to those of adults!

Nursing Diagnoses and Outcome Identification Disaster Nursing

Information from the assessment is analyzed, and appropriate nursing diagnoses reflecting the immediacy of the situation are identified. Some nursing diagnoses that may be relevant include the following: Risk for injury (trauma, suffocation, poisoning) Risk for infection Anxiety (panic) Fear Spiritual distress Risk for posttrauma syndrome Ineffective community coping - The following criteria may be used for measurement of outcomes in the care of the client having experienced a traumatic event. Timelines are individually determined. 1. Demonstrates behaviors necessary to protect self from further injury. 2. Identifies interventions to prevent/reduce risk of infection. 3. Is free of infection and/or physical injury. 4. *Maintains anxiety at a manageable level!!!!* 5. Expresses beliefs and values about spiritual issues. 6. Demonstrates ability to deal with emotional reactions in an individually appropriate manner. 7. Demonstrates an increase in activities to improve community functioning.

*Crisis of anticipated life transition*

Normal life-cycle transitions that may be anticipated but over which the individual may feel a lack of control. - *EXAMPLE*: College student J.T. is placed on probationary status because of low grades this semester. His wife had a baby and had to quit her job. He increased his working hours from part time to full time to compensate and therefore had little time for studies. He presents himself to the student-health nurse practitioner and describes numerous vague physical complaints. - Intervention: Physical examination should be performed* (physical symptoms could be caused by depression)* and ventilation of feelings encouraged. Reassurance and support should be provided as needed. J.T. should be referred to services that can provide financial and other types of needed assistance. Problematic areas should be identified and approaches to change discussed. - Reassurance and guidance are so important for the pt

Prognosis

Outcomes in schizophrenia are difficult to predict, but *a complete return to full premorbid functioning is NOT common* - several factors have been associated with a more positive outcome: 1. good premorbid functioning 2. LATER age at onset 3. FEMALE gender 4. ABRUPT onset of symptoms with obvious precipitating factor (as opposed to gradual, insidious onset of symptoms) 5. associated mood disturbance 6. rapid resolution of active-phase symptoms 7. *minimal residual symptoms* 8. *absence of structural brain abnormalities* 9. *normal neurological functioning* 10. *NO family history of schizophrenia* 11. *family history of mood disorder*

Crisis

Psychological disequilibrium in a person who confronts a hazardous circumstance that constitutes an important problem that he or she can neither escape nor solve with usual problem-solving resources. - a *sudden event* in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem - Any stressful situation can precipitate a crisis - Crisis intervention requires *problem-solving skills* that are often diminished by the level of anxiety. - Assistance with problem solving during the crisis period preserves *self-esteem* and promotes *growth* with resolution

Genetics (biological factors)

The body of evidence for genetic vulnerability to schizophrenia is growing - Studies show that relatives of individuals with schizophrenia have a much higher probability of developing the disease than does the general population - *whereas the lifetime risk for developing schizophrenia is about 1% in most population studies, the siblings of an identified client have a 10% risk of developing schizophrenia, and offspring with one parent who has schizophrenia have a 5-6% chance of developing the disorder* - how schizophrenia is inherited is uncertain, *NO* definitive biological marker has as yet been found, studies are ongoing to determine which genes are important in the vulnerability to schizophrenia and whether one or many genes are implicated - some individuals have a strong genetic link to the illness, whereas others may have only a weak genetic basis, this theory gives further credence to the notion of multiple causations - in studies of *twins*, the rate of schizophrenia is 4-5 times greater among monozygotic (identical) twins than dizygotic (fraternal) twins and approximately 50 times that of the general population - Identical twins reared apart have the same rate of development of the illness as do those reared together - bc in about 1/2 of the cases only 1 of a pair of identical twins develops schizophrenia, genetic makeup alone cannot account for the development of this disease

*schizophrenia*

The term was coined in 1908 by the Swiss psychiatrist Eugen Bleuler, the word was derived from the Greek "skhizo" (split) and "phren" (mind) - *Schizophrenia is an imbalance of the brain which leads to altered thoughts. (chemical imbalance)!!!* - *It is important to develop trusting relationships with clients. Accept, be calm, be reliable and honest in all communications!* - is probably not a homogeneous disease entity, DSM-5 supports this concept by describing schizophrenia as the schizophrenia spectrum, schizophrenia spectrum disorders may have several causative factors: genetic predisposition, biochemical dysfunction physiological factors psychosocial stress - there is not now and probably never will be a single treatment that cures the disorder, instead, effective treatment requires a comprehensive, multidisciplinary effort, including pharmacotherapy and various forms of psychosocial care, such as *living skills and social skills training, rehabilitation and recovery, and family therapy* - of all the mental illnesses that cause suffering in society, schizophrenia probably is responsible for *lengthier hospitalizations, GREATER chaos in family life, more exorbitant costs to individuals and governments, and MORE fears than any other* - bc it is such an enormous threat to life and happiness and because its causes are an unsolved puzzle it has probably been studied more than any other mental disorder - potential for suicide is a major concern among patients with schizophrenia - *about 1/3 of people with schizophrenia attempt suicide and about 1 in 10 die from the act* - perhaps NO psychological disorder is more crippling than schizophrenia. - characteristically disturbances in: thought processes perception affect invariably result in a severe deterioration of social and occupational functioning - lifetime prevalence of schizophrenia is about 1% in the general population - symptoms generally appear in late adolescence or early adulthood, although they may occur in middle or late adult life - symptoms that occur before age 17 suggest early-onset schizophrenia (EOS), and when symptoms occur before age 13, which is very rare, the condition is identified as very early-onset schizophrenia - some studies have indicated that symptoms occur earlier in MEN than in women - the pattern of development of schizophrenia may be viewed in four phases: premorbid, prodromal, active psychotic (schizophrenia), and residual.

Phase 3. Intervention During phase 3, the actions that were identified in phase 2 are implemented. The following interventions are the focus of nursing in crisis intervention:

Use a reality-oriented approach. The focus of the problem is on the here and now. Remain with the individual who is experiencing panic anxiety. Establish a rapid working relationship by showing unconditional acceptance, by active listening, and by attending to immediate needs. Discourage lengthy explanations or rationalizations of the situation; promote an atmosphere for verbalization of true feelings. Set firm limits on aggressive, destructive behaviors. At high levels of anxiety, behavior is likely to be impulsive and regressive. Establish at the outset what is acceptable and what is not, and maintain consistency. Clarify the problem that the individual is facing. The nurse does this by describing his or her perception of the problem and comparing it with the individual's perception of the problem. Help the individual determine what he or she believes precipitated the crisis. Acknowledge feelings of anger, guilt, helplessness, and powerlessness without judgment. Guide the individual through a problem-solving process by which he or she may move in the direction of positive life change: Help the individual confront the factors that are contributing to the experience of crisis. Encourage the individual to discuss changes he or she would like to make. Jointly determine whether or not desired changes are realistic. *Encourage exploration of feelings about aspects that cannot be changed, and explore alternative ways of coping more adaptively in these situations.* Discuss alternative strategies for creating changes that are realistically possible. Weigh benefits and consequences of each alternative. - Assist the individual to select alternative coping strategies that will help alleviate future crisis situations. - Identify external support systems and new social networks from which the individual may seek assistance in times of stress. - CLINICAL PEARL *Coping mechanisms are highly individual and the choice ultimately must be made by the client. The nurse may offer suggestions and provide guidance to help the client identify coping mechanisms that are realistic for him or her, and that can promote positive outcomes in a crisis situation*

Linda had a history of obsessive-compulsive disorder. She was phobic about germs and washed her hands many times every day. Last night, after a party, she had sex with a fellow college student she barely knew. Today, she is extremely anxious and keeps repeating that she knows she has AIDS. Her roommate cannot get her to come out of the shower.

a. Crisis reflecting psychopathology i. Preexisting psychopathology made worse ii. Stress makes things worse iii. Will be in hospital

Amanda's mobile home was destroyed by a tornado. Amanda received only minor injuries but is experiencing disabling anxiety in the aftermath of the event. What is this type of crisis called? a. Crisis resulting from traumatic stress b. Maturational or developmental crisis c. Dispositional crisis d. Crisis of anticipated life transitions

a. Crisis resulting from traumatic stress

Frank was very proud of his home. He had saved for many years and built it himself virtually from the ground up. Last night, while he and his wife were visiting in a nearby town, a tornado ripped through his neighborhood and totally destroyed the home. Frank is devastated and for more than a week has sat and stared into space, barely eating and rarely speaking.

a. Crisis resulting from traumatic stress i. Feel no control and emotionally underwhelmed

Carrie knew when she married Matt that he had a drinking problem, but she believed he would change. Last night, after becoming intoxicated, Matt beat Carrie until she was unconscious. When she regained consciousness, he was gone. She took a taxi to the emergency department of the local hospital.

a. Dispositional crisis

The most appropriate nursing intervention with Jenny (from question 5) would be to a. Make arrangements for her to start attending Alateen meetings. b. Help her identify the positive things in her life and recognize that her situation could be a lot worse than it is. c. Teach her about the effects of alcohol on the body and that it can be hereditary. d. Refer her to a psychiatrist for private therapy to learn to deal with her home situation.

a. Make arrangements for her to start attending Alateen meetings.

At age 13, Sue was raped by her uncle. The abuse continued for several years. He threatened to kill her mother if she told. Sue is 23 years old now and recently became engaged. She has never had an intimate relationship and experiences panic attacks at the thought of her wedding night.

a. Maturational or developmental crisis i. Situations that trigger emotions r/t unresolved conflict in past ii. Underlying developmental issues

*Phase III: Schizophrenia*

active phase of the disorder, psychotic symptoms are prominent Diagnostic criteria for schizophrenia: A. 2 (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. *Delusions* 2. *Hallucinations* 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. *Negative symptoms (i.e., diminished emotional expression or avolition)* [Impairment in work, social relations, and self-care] B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). - Specify if: First episode, currently in acute, partial, or full remission; Multiple episodes, currently in acute, partial or full remission; Continuous; Unspecified; With catatonia - Specify current severity.

Marie, age 56, is the mother of five children. Her youngest child, who had been living at home and attending the local college, recently graduated and accepted a job in another state. Marie has never worked outside the home and has devoted her life to satisfying the needs of her husband and children. Since the departure of her last child from home, Marie has become increasingly despondent. Her husband is very concerned and takes her to the local mental health center. What is this type of crisis called? a. Dispositional crisis b. Crisis of anticipated life transitions c. Psychiatric emergency d. Crisis resulting from traumatic stress

b. Crisis of anticipated life transitions

The most appropriate nursing intervention with Ginger (from question 7) would be to a. Suggest she move to a college closer to home. b. Work with Ginger on unresolved dependency issues. c. Help her find someone in the college town from whom she could seek assistance rather than calling her mother regularly. d. Recommend that the college physician prescribe an antianxiety medication for Ginger.

b. Work with Ginger on unresolved dependency issues.

Which of the following is a correct assumption regarding the concept of crisis? a. Crises occur only in individuals with psychopathology. b. The stressful event that precipitates crisis is seldom identifiable. c. A crisis situation contains the potential for psychological growth or deterioration. d. Crises are chronic situations that recur many times during an individual's life.

c. A crisis situation contains the potential for psychological growth or deterioration.

aggression

can arise from a number of feeling states, including anger, anxiety, guilt, frustration, or suspiciousness. Aggressive behaviors can be classified as 1. *mild (e.g., sarcasm)* 2. *moderate (e.g., slamming doors)* 3. *severe (e.g., threats of physical violence against others)* 4. *extreme (e.g., physical acts of violence against others)* - in contrast to anger, aggression is almost always goal directed and has the aim of harm to a specific person or object - Aggression is one of the negative outcomes that may emerge from general arousal and anger - *Intent* is a requisite in the definition of aggression, It refers to *behavior that is intended to inflict harm or destruction.* - Accidents that lead to unintentional harm or destruction are NOT considered aggression. - Aggression is 1 way individuals express anger - Can cause damage with words, fists, or weapons but it is almost always designed to *punish.*

Ginger, age 19 and an only child, left 3 months ago to attend a college of her choice 500 miles away from her parents. It is Ginger's first time away from home. She has difficulty making decisions and will not undertake anything new without first consulting her mother. They talk on the phone almost every day. Ginger has recently started having anxiety attacks. She consults the nurse practitioner in the student health center. What is this type of crisis called? a. Crisis resulting from traumatic stress b. Dispositional crisis c. Psychiatric emergency d. Maturational or developmental crisis

d. Maturational or developmental crisis

*anger*

is a normal healthy emotion that when handled appropriately, can provide an individual with a positive force to solve problems and make decisions concerning life situations. - becomes a problem when: 1. *denied or buried, can precipitate a number of physical problems* 2. *turned inward ,can result in depression and low self-esteem!!!* 3. suppressed, may turn into resentment - *anger is a stage of the grieving process*

Traumatic bereavement

is recognized as posing special challenges to survivors. While the death of loved ones is always painful, an unexpected and violent death can be more difficult to assimilate. Family members may develop intrusive images of the death based on information gleaned from authorities or the media. Witnessing or learning of violence to a loved one also increases vulnerability to psychiatric disorders. The knowledge that one has been exposed to toxins is a potent traumatic stressor... and the focus of much concern in the medical community preparing for responses to terrorist attacks using biological, chemical, or nuclear agents

The Dopamine Hypothesis (Biological Factors)

suggests that schizophrenia (or schizophrenia-like symptoms) may be caused by an *excess of dopamine-dependent neuronal activity in the brain* - This excess activity may be related to increased production or release of the substance at nerve terminals, increased receptor sensitivity, too many dopamine receptors, or a combination of these mechanisms - pharmacological support for this hypothesis exists - Amphetamines, which increase levels of dopamine, induce psychotomimetic symptoms - the antipsychotics (e.g., chlorpromazine or haloperidol) lower brain levels of dopamine by blocking dopamine receptors, thus reducing the schizophrenic symptoms, including those induced by amphetamines - postmortem studies of brains of individuals who had schizophrenia have revealed a significant increase in the average number of dopamine receptors in approximately 2/3s of the brains studied - This finding suggests that an increased dopamine response may not be important in all individuals with schizophrenia - Clients with positive symptoms (e.g., delusions and hallucinations) respond with GREATER efficacy to dopamine-reducing drugs than do clients with negative symptoms (e.g., apathy, poverty of ideas, and loss of drive) - positive symptoms of schizophrenia may be related to increased numbers of dopamine receptors in the brain and respond to antipsychotic drugs that block these receptors