Unit 1 Week 2

Off-label use

(effective for disease different from one involved in original testing)

hallucinations

(false sensory perceptions or perceptual experiences that do not really exist). Hallucinations can involve the five senses and bodily sensations. Auditory hallucinations (hearing voices) are the most common; visual hallucinations (seeing things that don't really exist) are the second most common. Initially, clients perceive hallucinations as real experiences, but later in the illness, they may recognize them as hallucinations.

•Black box warning

(serious or life-threatening side effects)

Psychological Screening Inventory (PSI)

103 true-false items; used to screen for the need for psychological help

Milton Clinical Multiaxial Inventory (MCMI) and MCMI-II (revised version)

175 true-false items; provides scores on various personality traits and personality disorders

Thematic apperception test (TAT)

20 stimulus cards with pictures; client tells a story about the picture; narrative interpretation discusses themes about mood state, conflict, quality of interpersonal relationships

Beck Depression Inventory (BDI)

21 items rated on scale of 0-3 to indicate the level of depression

MMPI-2

567 true-false items; provides scores on 20 primary scales

➔ WARNING - Droperidol, Thioridazine, and Mesoridazine

May lengthen the QT interval, leading to potentially life-threatening cardiac dysrhythmias or cardiac arrest.

➔ WARNING - Amphetamines

Potential for abuse is high. Administration for prolonged periods may lead to drug dependence.

lowering the dosage of the antipsychotic, changing to a different antipsychotic, administering anticholinergic medication

Treatment: of antipsychotic drugs

carbamazepine mood stabalizers

drowsiness, sedation, dry mouth, blurred vision. rashes orthostatic hypotension,

valproic acid mood stabilzer

drowsiness, sedation, dry mouth, blurred vision. weight gain, alopecia, hand tremor.

brain stem

includes the midbrain, pons, and medulla oblongata and the nuclei for cranial nerves III through XII. The medulla, located at the top of the spinal cord, contains vital centers for respiration and cardiovascular functions.

SSRIs,

venlafaxine, nefazodone, and bupropion: they carry no risk of lethal overdose in contrast to the cyclic compounds and the MAOIs. However, SSRIs are effective only for mild and moderate depression

Medulla oblongata:

vital centers for cardiac, respiratory function

tangenital thinking

wandering off the topic and never providing the information requested

•Broad affect:

displaying a full range of emotional expressions

Restricted affect:

displaying one type of expression, usually serious or somber

buspirone

dizziness, sedation, nausea, headache

Rorschach test

10 stimulus cards of ink blots; client describes perceptions of ink blots; narrative interpretation discusses areas such as coping styles, interpersonal attitudes, characteristics of ideation

Tennessee Self-Concept Scale (TSCS)

100 true-false items; provides information on 14 scales related to self-concept

Young adult (25-45 years of age)

Accept oneself. Stabilize self-image. Establish independence from parental home and financial independence. Establish a career or vocation. Form an intimate bond with another person. Build a congenial social and friendship group. Become an involved citizen. Establish and maintain a home.

Ego integrity vs. despair (maturity)

Accepting responsibility for oneself and life

Autonomy vs. shame and doubt (toddler)

Achieving a sense of control and free will

1.Tricyclic and the related cyclic antidepressants 2. Selective serotonin reuptake inhibitors (SSRIs) 3. MAO inhibitors (MAOIs) 4. Other antidepressants such as desvenlafaxine (Pristiq), venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone)

Antidepressants are divided into four groups:

Assessment of Suicide or Harm toward Others Suicide

Assessment Questions Ideation: "Are you thinking about killing yourself?" Plan: "Do you have a plan to kill yourself?" Method: "How do you plan to kill yourself?" Access: "How would you carry out this plan? Do you have access to the means to carry out the plan?" Where: "Where would you kill yourself?" When: "When do you plan to kill yourself?" Timing: "What day or time of day do you plan to kill yourself?"

Initiative vs. guilt (preschool)

Beginning to develop a conscience Learning to manage conflict and anxiety

Industry vs. inferiority (school age)

Building confidence in own abilities Taking pleasure in accomplishments

Haloperidol (Haldol) T, L, INJ Droperidol (Inapsine) INJ

Butyrophenones drugs

➔ WARNING - Carbamazepine

Can cause aplastic anemia and agranulocytosis at a rate five to eight times greater than the general population. Pretreatment hematologic baseline data should be obtained and monitored periodically throughout therapy to discover lowered WBC or platelet counts.

➔ WARNING - Valproic Acid and Its Derivatives

Can cause hepatic failure, resulting in fatality. Liver function tests should be performed before therapy and at frequent intervals thereafter, especially for the first 6 months. Can produce teratogenic effects such as neural tube defects (e.g., spina bifida). Can cause life-threatening pancreatitis in both children and adults. Can occur shortly after initiation or after years of therapy.

➔ WARNING - Pemoline

Can cause life-threatening liver failure, which can result in death or require liver transplantation in 4 weeks from the onset of symptoms. The physician should obtain written consent before the initiation of this drug.

➔ WARNING - Bupropion

Can cause seizures at a rate four times that of other antidepressants. The risk for seizures increases when doses exceed 450 mg/day (400 mg SR); dose increases are sudden or in large increments; the client has a history of seizures, cranial trauma, excessive use of or withdrawal from alcohol, or addiction to opiates, cocaine, or stimulants; the client uses over-the-counter (OTC) stimulants or anorectics; or the client has diabetes being treated with oral hypoglycemics or insulin.

WARNING - Lamotrigine

Can cause serious rashes requiring hospitalization, including Stevens-Johnson syndrome and, rarely, life-threatening toxic epidermal necrolysis. The risk for serious rashes is greater in children younger than 16 years.

liquid, tablet, chewable tablet forms.

Carbamazepine is available in - - - Dosages usually range from 800 to 1,200 mg/day; the extreme dosage range is 200 to 2,000 mg/day.

Drinking sugar-free fluids and eating sugar-free hard candy ease dry mouth. The client should avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. Methods to prevent or relieve constipation include exercising and increasing water and bulk-forming foods in the diet. Stool softeners are permissible, but the client should avoid laxatives. The use of sunscreen is recommended because photosensitivity can cause the client to sunburn easily. Clients should monitor the amount of sleepiness or drowsiness they feel. They should avoid driving and performing other potentially dangerous activities until their response times and reflexes seem normal. If the client forgets a dose of antipsychotic medication, he or she can take the missed dose if it is only 3 or 4 hours late. If the dose is more than 4 hours overdue or the next dose is due, the client can omit the forgotten dose.

Client Teaching antisychotics

Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety. Benzodiazepines strongly potentiate the effects of alcohol;

Client Teaching for antianxiety meds

Clients should take SSRIs first thing in the morning unless sedation is a problem; generally, paroxetine most often causes sedation. If the client forgets a dose of an SSRI, he or she can take it up to 8 hours after the missed dose. To minimize side effects, clients generally should take cyclic compounds at night in a single daily dose when possible. If the client forgets a dose of a cyclic compound, he or she should take it within 3 hours of the missed dose or omit the dose for that day. Clients should exercise caution when driving or performing activities requiring sharp, alert reflexes until sedative effects can be determined. Clients taking MAOIs need to be aware that a life-threatening hyperadrenergic crisis can occur if they do not observe certain dietary restrictions. They should receive a written list of foods to avoid while taking MAOIs. The nurse should make clients aware of the risk for serious or even fatal drug interactions when taking MAOIs and instruct them not to take any additional medication, including OTC preparations, without checking with the physician or pharmacist.

Client Teaching of antidepressants

For clients taking lithium and the anticonvulsants, monitoring blood levels periodically is important. The time of the last dose must be accurate so that plasma levels can be checked 12 hours after the last dose has been taken. Taking these medications with meals minimizes nausea. The client should not attempt to drive until dizziness, lethargy, fatigue, or blurred vision has subsided.

Client Teaching of mood stabilizers

Sentence completion test

Client completes a sentence from beginnings such as "I often wish," "Most people," and "When I was young."

Phenothiazines Chlorpromazine (Thorazine) T, L, INJ Perphenazine (Trilafon) T, L, INJ Fluphenazine (Prolixin) T, L, INJ Thioridazine (Mellaril) T, L Mesoridazine (Serentil) T, L, INJ Trifluoperazine (Stelazine) T, L, INJ Thioxanthene Thiothixene (Navane) C, L, INJ Butyrophenones Haloperidol (Haldol) T, L, INJ Droperidol (Inapsine) INJ Dibenzazepine Loxapine (Loxitane) C, L, INJ Dihydroindolone Molindone (Moban) T, L

Conventional or first-generation antipsychotics - - - - - -

Imipramine (Tofranil) T, C, INJ Desipramine (Norpramin) T, C Amitriptyline (Elavil) T, INJ Nortriptyline (Pamelor) C, L Doxepin (Sinequan) C, L Trimipramine (Surmontil) C Protriptyline (Vivactil) T Maprotiline (Ludiomil) T Mirtazapine (Remeron) T Amoxapine (Asendin) T Clomipramine (Anafranil) C, INJ

Cyclic compounds

Loxapine (Loxitane) C, L, INJ

Dibenzazepine drugs

Molindone (Moban) T, L

Dihydroindolone drugs

Amantadine (Symmetrel) Benztropine (Cogentin) Biperiden (Akineton) Diazepam (Valium) Diphenhydramine (Benadryl) Lorazepam (Ativan) Procyclidine (Kemadrin) Propranolol (Inderal) Trihexyphenidyl (Artane)

Drugs Used to Treat Extrapyramidal Side Effects

Generativity vs. stagnation (middle adult)

Establishing the next generation

➔ WARNING - Nefazodone

May cause rare but potentially life-threatening liver damage, which could lead to liver failure.

Norepinephrine (noradrenaline)

Excitatory Causes changes in attention, learning and memory, sleep and wakefulness, mood the most prevalent neurotransmitter in the nervous system, is located primarily in the brain stem and plays a role in changes in attention, learning and memory, sleep and wakefulness, and mood regulation. Norepinephrine and its derivative, epinephrine, are also known as noradrenaline and adrenaline, respectively. Excess norepinephrine has been implicated in several anxiety disorders; deficits may contribute to memory loss, social withdrawal, and depression. Some antidepressants block the reuptake of norepinephrine, while others inhibit MAO from metabolizing it. Epinephrine has limited distribution in the brain but controls the fight or flight response in the peripheral nervous system.

Dopamine

Excitatory Controls complex movements, motivation, cognition; regulates emotional response a neurotransmitter located primarily in the brain stem, has been found to be involved in the control of complex movements, motivation, cognition, and regulation of emotional responses. It is generally excitatory and is synthesized from tyrosine, a dietary amino acid. Dopamine is implicated in schizophrenia and other psychoses as well as in movement disorders such as Parkinson disease. Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity.

Epinephrine (adrenaline)

Excitatory Controls fight or flight response

Glutamate

Excitatory Results in neurotoxicity if levels are too high is an excitatory amino acid that can have major neurotoxic effects at high levels. It has been implicated in the brain damage caused by stroke, hypoglycemia, sustained hypoxia or ischemia, and some degenerative diseases such as Huntington or Alzheimer.

Acetylcholine

Excitatory or inhibitory Controls sleep and wakefulness cycle; signals muscles to become alert is a neurotransmitter found in the brain, spinal cord, and peripheral nervous system, particularly at the neuromuscular junction of skeletal muscle. It can be excitatory or inhibitory. It is synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep-wake cycle and to signal muscles to become active. Studies have shown that people with Alzheimer disease have decreased acetylcholine-secreting neurons, and people with myasthenia gravis (a muscular disorder in which impulses fail to pass the myoneural junction, which causes muscle weakness) have reduced acetylcholine receptors.

Middle adult (45-65 years of age)

Express love through more than sexual contacts. Maintain healthy life patterns. Develop sense of unity with mate. Help growing and grown children be responsible adults. Relinquish central role in lives of grown children. Accept children's mates and friends. Create a comfortable home. Be proud of accomplishments of self and mate/spouse. Reverse roles with aging parents. Achieve mature civic and social responsibility. Adjust to physical changes of middle age. Use leisure time creatively. Cherish old friends and make new ones.

Client Participation/Feedback Client's Health Status Client's Previous Experiences/Misconceptions about Health Care Client's Ability to Understand Nurse's Attitude and Approach

FACTORS INFLUENCING psychosocial ASSESSMENT

•Mature or aged cheeses or dishes made with cheese, such as lasagna or pizza. All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, and processed cheese slices. •Aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, meat extracts, and similar products. Make sure meat and chicken are fresh and have been properly refrigerated. •Italian broad beans (fava), bean curd (tofu), banana peel, overripe fruit, and avocado. •All tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including nonalcoholic beer) or 4 oz of wine per day. •Sauerkraut, soy sauce or soybean condiments, or marmite (concentrated yeast). •Yogurt, sour cream, peanuts, brewer's yeast, and monosodium glutamate (MSG).

Foods (Containing Tyramine) to Avoid When Taking Monoamine Oxidase Inhibitors

Intimacy vs. isolation (young adult)

Forming adult, loving relationships and meaningful attachment to others Being creative and productive

Identity vs. role diffusion (adolescence)

Formulating a sense of self and belonging

The nurse should conduct the psychosocial assessment in an environment that is comfortable, private, and safe for both the client and the nurse. If family members, friends, or caregivers have accompanied the client, the nurse should obtain their perceptions of the client's behavior and emotional state.

HOW TO CONDUCT THE psychosocial INTERVIEW

Age, Growth, and Development People with a younger age at onset have poorer outcomes, such as more negative signs (apathy, social isolation, and lack of volition) and less effective coping skills than do people with a later age at onset Genetics and Biologic Factors genetic links to several disorders. . Genetic makeup tremendously influences a person's response to illness and perhaps even to treatment Physical Health and Health Practices The healthier a person is, the better he or she can cope with stress or illness. Personal health practices, such as exercise, can influence the client's response to illness. Response to Drugs Biologic differences can affect a client's response to treatment, specifically to psychotropic drugs. Ethnic groups differ in the metabolism and efficacy of psychoactive compounds. Self-Efficacy Hardiness Resilience and Resourcefulness Spirituality

INDIVIDUAL FACTORS Affecting Response to Illness

Sense of Belonging Social Networks and Social Support Family Support

INTERPERSONAL FACTORS effecting response to illness

Communication Physical distance or space Social organization Time orientation Environmental control Biologic variations

Important Factors in Cultural Assessment

Serotonin

Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions is derived from tryptophan, a dietary amino acid. The function of serotonin is mostly inhibitory, and it is involved in the control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions. Serotonin plays an important role in anxiety, mood disorders, and schizophrenia. It has been found to contribute to the delusions, hallucinations, and withdrawn behavior seen in schizophrenia. Some antidepressants block serotonin reuptake, thus leaving it available longer in the synapse, which results in improved mood.

•The use of radioactive substances in PET and SPECT limits the number of times a person can undergo these tests. There is the risk that the client will have an allergic reaction to the substances. Some clients may find receiving intravenous doses of radioactive material frightening or unacceptable. •Imaging equipment is expensive to purchase and maintain, so availability can be limited. A PET camera costs about $2.5 million; a PET scanning facility may take up to $6 million to establish. •Some persons cannot tolerate these procedures because of fear or claustrophobia. •Researchers are finding that many of the changes in disorders such as schizophrenia are at the molecular and chemical levels and cannot be detected with current imaging techniques

Limitations of Brain Imaging Techniques - - - -

tablet, capsule, liquid, sustained-release forms; no parenteral forms are available.

Lithium is available in - - - - The effective dosage of lithium is determined by monitoring serum lithium levels and assessing the client's clinical response to the drug. Daily dosages generally range from 900 to 3,600 mg; more importantly, the serum lithium level should be about 1 mEq/L. Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic. The lithium level should be monitored every 2 to 3 days while the therapeutic dosage is being determined; then, it should be monitored weekly. When the client's condition is stable, the level may need to be checked once a month or less frequently.

Disulfiram inhibits the enzyme aldehyde dehydrogenase, which is involved in the metabolism of ethanol. Acetaldehyde levels are then increased from five to 10 times higher than normal, resulting in the disulfiram-alcohol reaction. This reaction is potentiated by decreased levels of epinephrine and norepinephrine in the sympathetic nervous system caused by inhibition of dopamine β-hydroxylase (Virani et al., 2017). Education is extremely important for the client taking disulfiram. Many common products such as shaving cream, aftershave lotion, cologne, deodorant, and OTC medications such as cough preparations contain alcohol; when used by the client taking disulfiram, these products can produce the same reaction as drinking alcohol. The client must read product labels carefully and select items that are alcohol free.

MOA od disulfiram

➔ WARNING - Clozapine

May cause agranulocytosis, a potentially life-threatening event. Clients who are being treated with clozapine must have a baseline WBC count and differential before initiation of treatment and a WBC count every week throughout treatment and for 4 weeks after discontinuation of clozapine.

Benzodiazepines mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain. Because GABA receptor channels selectively admit the anion chloride into neurons, activation of GABA receptors hyperpolarizes neurons and thus is inhibitory. Benzodiazepines produce their effects by binding to a specific site on the GABA receptor. Buspirone is believed to exert its anxiolytic effect by acting as a partial agonist at serotonin receptors, which decreases serotonin turnover (Stahl, 2017).The benzodiazepines vary in terms of their half-lives, the means by which they are metabolized, and their effectiveness

Mechanism of Action of Antianxiety drugs, or anxiolytic drugs,

Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within neuronal synapses; it acts directly on G-proteins and certain enzyme subsystems such as cyclic adenosine monophosphates and phosphatidylinositol. Lithium is considered a first-line agent in the treatment of bipolar disorder

Mechanism of Action of mood stabilizers

-Cause release of norepinephrine, dopamine, serotonin presynaptically -Direct agonist effects postsynaptically -Block reuptake of neurotransmitters Amphetamines and methylphenidate are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. They also block the reuptake of these neurotransmitters. Methylphenidate produces milder CNS stimulation than amphetamines; pemoline primarily affects dopamine and therefore has less effect on the sympathetic nervous system. It was originally thought that the use of methylphenidate and pemoline to treat ADHD in children produced the reverse effect of most stimulants—a calming or slowing of activity in the brain. However, this is not the case; the inhibitory centers in the brain are stimulated, so the child has greater abilities to filter out distractions and manage his or her own behavior. Atomoxetine helps block the reuptake of norepinephrine into neurons, thereby leaving more of the neurotransmitter in the synapse to help convey electrical impulses in the brain.

Mechanism of Action of stimulants

Phenelzine (Nardil) T Tranylcypromine (Parnate) T Isocarboxazid (Marplan) T

Monoamine oxidase inhibitors

-Genetics and Heredity -Stress and the Immune System (Psychoimmunology) -

NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS

Histamine

Neuromodulator Controls alertness, gastric secretions, cardiac stimulation, peripheral allergic responses role in mental illness is under investigation. It is involved in peripheral allergic responses, control of gastric secretions, cardiac stimulation, and alertness. Some psychotropic drugs block histamine, resulting in weight gain, sedation, and hypotension.

Neuropeptides

Neuromodulators Enhance, prolong, inhibit, or limit the effects of principal neurotransmitters

➔ WARNING - Disulfiram

Never give to a client in a state of alcohol intoxication or without the client's full knowledge. Instruct the client's relatives accordingly. •Drug interactions with phenytoin, isoniazid, warfarin, barbiturates, long-acting benzodiazepines •Client teaching: avoidance of alcohol, including common products that may contain it -Shaving cream, deodorant, OTC cough preparations

increase blood prolactin levels. Elevated prolactin may cause breast enlargement and tenderness in men and women; diminished libido, erectile and orgasmic dysfunction, and menstrual irregularities; and increased risk for breast cancer. It can also contribute to weight gain. Weight gain it is associated with increased appetite, binge eating, carbohydrate craving, food preference changes, and decreased satiety in some clients. Cardiac symptoms postural hypotension, palpitations, and tachycardia. Certain antipsychotic drugs, such as thioridazine (Mellaril), droperidol (Inapsine), and mesoridazine (Serentil), can also cause a lengthening of the QT interval.

Other Side Effects. of antipsychotics

Chlorpromazine (Thorazine) T, L, INJ Perphenazine (Trilafon) T, L, INJ Fluphenazine (Prolixin) T, L, INJ Thioridazine (Mellaril) T, L Mesoridazine (Serentil) T, L, INJ Trifluoperazine (Stelazine) T, L, INJ

Phenothiazines drugs

Older adult (65 years of age and older)

Prepare for retirement. Recognize the aging process and its limitations. Adjust to health changes. Decide where to live out remaining years. Continue warm relationship with mate/spouse. Adjust living standards to retirement income. Maintain maximum level of health. Care for oneself physically and emotionally. Maintain contact with children and relatives. Maintain interest in people outside the family. Find meaning in life after retirement. Adjust to the death of mate/spouse or other loved ones.

nefazodone (antidepressant)

Sedation Headaches Dry mouth nausea

Trazodone (Antidepressant)

Sedation Headaches priapism

Fluoxetine (Prozac) C, L Fluvoxamine (Luvox) T Paroxetine (Paxil) T Sertraline (Zoloft) T Citalopram (Celexa) T, L Escitalopram (Lexapro)

Selective serotonin reuptake inhibitors

Benzodiazepines

Side Effects physical dependence. Significant discontinuation symptoms CNS depression, drowsiness, sedation, poor coordination, impaired memory or clouded sensorium. next-day sedation or a hangover effect.

Dystonia

Side effect of antipsychotipc drugs. includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties. Dystonia is most likely to occur in the first week of treatment, in clients younger than 40 years, in males, and in those receiving high-potency drugs such as haloperidol and thiothixene.

pseudoparkinsonism,

Side effect of antipsychotipc drugs. is often referred to by the generic label of EPS. Symptoms resemble those of Parkinson disease and include a stiff, stooped posture; masklike facies; decreased arm swing; a shuffling, festinating gait (with small steps); cogwheel rigidity (ratchet-like movements of joints); drooling; tremor; bradycardia; and coarse pill-rolling movements of the thumb and fingers while at rest. Parkinsonism is treated by changing to an antipsychotic medication that has a lower incidence of EPS or by adding an oral anticholinergic agent or amantadine, which is a dopamine agonist that increases transmission of dopamine blocked by the antipsychotic drug.

Akathisia

Side effect of antipsychotipc drugs. is reported by the client as an intense need to move about. The client appears restless or anxious and agitated, often with a rigid posture or gait and a lack of spontaneous gestures. This feeling of internal restlessness and the inability to sit still or rest often leads clients to discontinue their antipsychotic medication. Akathisia can be treated by a change in antipsychotic medication or by the addition of an oral agent such as a beta-blocker, anticholinergic, or benzodiazepine.

Thiothixene (Navane) C, L, INJ

Thioxanthene drugs

➔ WARNING - Lithium

Toxicity is closely related to serum lithium levels and can occur at therapeutic doses. Facilities for serum lithium determinations are required to monitor therapy.

➔ WARNING - Methylphenidate

Use with caution in emotionally unstable clients such as those with alcohol or drug dependence because they may increase the dosage on their own. Chronic abuse can lead to marked tolerance and psychic dependence.

liquid, tablet, capsule forms

Valproic acid available in - - - dosages 1,000 to 1,500 mg/day; the extreme dosage range is 750 to 3,000 mg/day. Serum drug levels, obtained 12 hours after the last dose of the medication, are monitored for therapeutic levels of both these anticonvulsants.

Trust vs. mistrust (infant)

Viewing the world as safe and reliable Viewing relationships as nurturing, stable, and dependable

Labile

When the client exhibits unpredictable and rapid mood swings from depressed and crying to euphoria with no apparent stimuli, t

circumstantial thinking

a client eventually answers a question but only after giving excessive unnecessary detail

thought insertion

a delusional belief that others are putting ideas or thoughts into the client's head—that is, the ideas are not those of the client

thought withdrawal

a delusional belief that others are taking the client's thoughts away and the client is powerless to stop it

thought broadcasting

a delusional belief that others can hear or know what the client is thinking

delusion

a fixed false belief not based in reality

MAOIs

a low incidence of sedation and anticholinergic effects, they must be used with extreme caution for several reasons: •A life-threatening side effect, hypertensive crisis, may occur if the client ingests foods containing tyramine (an amino acid) while taking MAOIs. •Because of the risk of potentially fatal drug interactions, MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, meperidine (Demerol), CNS depressants, many antihypertensives, or general anesthetics. •MAOIs are potentially lethal in overdose and pose a potential risk in clients with depression who may be considering suicide.

Topiramate (Mood Stabilizer)

dizziness, sedation, weight loss (rather than gain), increased incidence of renal calculi

Psychoimmunology,

a relatively new field of study, examines the effect of psychosocial stressors on the body's immune system. A compromised immune system could contribute to thedevelopment of a variety of illnesses, particularly in populations already genetically at risk. When the inflammatory response is critically involved in illnesses such as multiple sclerosis or lupus erythematosus, mood dysregulation and even depression are common

Tardive Dyskinesia. Tardive dyskinesia (TD),

a syndrome of permanent involuntary movements, is most commonly caused by the long-term use of conventional antipsychotic drugs. The symptoms of TD include involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature. Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic. After it has developed, TD is irreversible, although decreasing or discontinuing antipsychotic medications can arrest its progression. Unfortunately, antipsychotic medications can mask the beginning symptoms of TD; that is, increased dosages of the antipsychotic medication cause the initial symptoms to disappear temporarily. As the symptoms of TD worsen, however, they "break through" the effect of the antipsychotic drug. The symptoms of TD include involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature. Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic. After it has developed, TD is irreversible, although decreasing or discontinuing antipsychotic medications can arrest its progression. Unfortunately, antipsychotic medications can mask the beginning symptoms of TD; that is, increased dosages of the antipsychotic medication cause the initial symptoms to disappear temporarily. As the symptoms of TD worsen, however, they "break through" the effect of the antipsychotic drug. Valbenazine has a dosage range of 40 to 80 mg daily, and deutetrabenazine ranges from 12 to 48 mg daily. Both drugs cause somnolence, QT prolongation, akathisia, and restlessness. Preventing TD is the primary goal when administering antipsychotics. This can be done by keeping maintenance dosages as low as possible, changing medications, and monitoring the client periodically for initial signs of TD using a standardized assessment tool such as the Abnormal Involuntary Movement Scale (

magnetic resonance imaging (MRI),

a type of body scan, an energy field is created with a huge magnet and radio waves. The energy field is converted to a visual image or scan. MRI produces more tissue detail and contrast than CT and can show blood flow patterns and tissue changes such as edema. It can also be used to measure the size and thickness of brain structures; persons with schizophrenia can have as much as 7% reduction in cortical thickness. The person undergoing an MRI must lie in a small, closed chamber and remain motionless during the procedure, which takes about 45 minutes. Those who feel claustrophobic or have increased anxiety may require sedation before the procedure. Clients with pacemakers or metal implants, such as heart valves or orthopedic devices, cannot undergo MRI.

Computed tomography (CT),

also called computed axial tomography, is a procedure in which a precise x-ray beam takes cross-sectional images (slices) layer by layer. A computer reconstructs the images on a monitor and also stores the images on magnetic tape or film. CT can visualize the brain's soft tissues, so it is used to diagnose primary tumors, metastases, and effusions and to determine the size of the ventricles of the brain. Some people with schizophrenia have been shown to have enlarged ventricles; this finding is associated with a poorer prognosis and marked negative symptoms (Fig. 2.5; see Chapter 16). The person undergoing CT must lie motionless on a stretcher-like table for about 20 to 40 minutes as the stretcher passes through a tunnel-like "ring" while the serial x-rays are taken.

Gamma-aminobutyric acid (γ-aminobutyric acid, or GABA),

an amino acid, is the major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than to provide a direct stimulus. Drugs that increase GABA function, such as benzodiazepines, are used to treat anxiety and to induce sleep.

stimulants

anorexia, weight loss, nausea, irritability. dizziness, dry mouth, blurred vision, palpitations. growth and weight suppression that occurs in some children. ("drug holidays" on weekends)

Benzodiazepines Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Flurazepam (Dalmane) Lorazepam (Ativan) Oxazepam (Serax) Temazepam (Restoril) Triazolam (Halcion) Nonbenzodiazepine Buspirone (BuSpar)

anti anxiety drugs

Side Effects of Cyclic Antidepressants

anticholinergic effects dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, blurred near vision. agitation, delirium, ileus orthostatic hypotension, sedation, weight gain, Tachycardia.

. Intelligence tests

are designed to evaluate the client's cognitive abilities and intellectual functioning. Personality tests reflect the client's personality in areas such as self-concept, impulse control, reality testing, and major defenses.

Social networks

are groups of people one knows and with whom one feels connected. Studies have found that having a social network can help reduce stress, diminish illness, and positively influence the ability to cope and adapt

The conventional, or first-generation, antipsychotic drugs

are potent antagonists (blockers) of D2, D3, and D4. This not only makes them effective in treating target symptoms but also produces many extrapyramidal side effects (discussion to follow) because of the blocking of the D2 receptors.

Antidepressant drugs

are primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression. Off-label uses of antidepressants include the treatment of chronic pain, migraine headaches, peripheral and diabetic neuropathies, sleep apnea, dermatologic disorders, panic disorder, and eating disorders. Although the mechanism of action is not completely understood, antidepressants somehow interact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite.

Neurotransmitters

are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitory). After neurotransmitters are released into the synapse and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be stored for later use (reuptake) or metabolized and inactivated by enzymes, primarily monoamine oxidase (MAO)

projective tests,

are unstructured and are usually conducted by the interview method. The stimuli for these tests, such as pictures or Rorschach's inkblots, are standard, but clients may respond with answers that vary widely. The evaluator analyzes the client's responses and gives a narrative result of the testing. Table 8.2 lists commonly used projective personality tests.

positron emission tomography (PET) and single-photon emission computed tomography (SPECT),

are used to examine the function of the brain. Radioactive substances are injected into the blood; the flow of those substances in the brain is monitored as the client performs cognitive activities as instructed by the operator. PET uses two photons simultaneously; SPECT uses a single photon. PET provides better resolution with sharper and clearer pictures and takes about 2 to 3 hours; SPECT takes 1 to 2 hours. PET and SPECT are used primarily for research, not for the diagnosis and treatment of clients with mental disorders

aAntianxiety drugs, or anxiolytic drugs,

are used to treat anxiety and anxiety disorders, insomnia, obsessive-compulsive disorder (OCD), depression, posttraumatic stress disorder, and alcohol withdrawal. Antianxiety drugs are among the most widely prescribed medications today.. Benzodiazepines have proved to be the most effective in relieving anxiety and are the drugs most frequently prescribed. Buspirone is a nonbenzodiazepine often used for the relief of anxiety and therefore is included in this section. Other drugs such as propranolol, clonidine (Catapres), and hydroxyzine (Vistaril) that may be used to relieve anxiety are much less effective and are not included in this discussion.

Mood-stabilizing drugs

are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Lithium is the most established mood stabilizer; some anticonvulsant drugs, particularly carbamazepine (Tegretol) and valproic acid (Depakote, Depakene), are effective mood stabilizers. Other anticonvulsants, such as gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal), and lamotrigine (Lamictal), are also used for mood stabilization. Occasionally, clonazepam (Klonopin) is also used to treat acute mania. Clonazepam is included in the discussion of antianxiety agents.

occipital lobes

assist in coordinating language generation and visual interpretation, such as depth perception.

Unnatural or personal beliefs

attribute the cause of illness to the active, purposeful intervention of an outside agent, spirit, or supernatural force or deity.

The third generation of antipsychotics,

called dopamine system stabilizers, is being developed. These drugs are thought to stabilize dopamine output; that is, they preserve or enhance dopaminergic transmission when it is too low and reduce it when it is too high. This results in control of symptoms without some of the side effects of other antipsychotic medications

serotonin syndrome (or serotonergic syndrome)

can result from taking an MAOI and an SSRI at the same time. It can also occur if the client takes one of these drugs too close to the end of therapy with the other. In other words, one drug must clear the person's system before initiation of therapy with the other. Symptoms include agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, and, in extreme reactions, even coma and death (Burchum & Rosenthal, 2018). These symptoms are similar to those seen with an SSRI overdose.

ideas of reference

client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning

frontal lobes

control the organization of thought, body movement, memories, emotions, and moral behavior. The integration of all this information regulates arousal, focuses attention, and enables problem-solving and decision-making. Abnormalities in the frontal lobes are associated with schizophrenia, attention-deficit/hyperactivity disorder (ADHD), dementia.

Side Effects of Monoamine Oxidase Inhibitors

daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, sexual dysfunction. ** potential for a life-threatening hypertensive crisis if the client ingests food that contains tyramine or takes sympathomimetic drugs. Because the enzyme MAO is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, causing severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness, and cardiac dysrhythmias***

Potency

describes the amount of the drug needed to achieve that maximum effect; low-potency drugs require higher dosages to achieve efficacy, while high-potency drugs achieve efficacy at lower dosages.

loose associations

disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts

Inappropriate affect:

displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances

flight of ideas

excessive amount and rate of speech composed of fragmented or unrelated ideas

word salad

flow of unconnected words that convey no meaning to the listener

Antipsychotic drugs,

formerly known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder. Off-label uses of antipsychotics include treatment of anxiety and insomnia; aggressive behavior; and delusions, hallucinations, and other disruptive behaviors that sometimes accompany Alzheimer disease. Antipsychotic drugs work by blocking receptors of the neurotransmitter dopamine.

Selective Serotonin Reuptake Inhibitors

have fewer side effects compared to the cyclic compounds. anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, sexual dysfunction diminished sexual drive or difficulty achieving an erection or orgasm. weight gain Less common side effects include sedation (particularly with paroxetine [Paxil]), sweating, diarrhea, hand tremor, Headaches.

Valproic acid and topiramate

increase the levels of the inhibitory neurotransmitter GABA. Both valproic acid and carbamazepine are thought to stabilize mood by inhibiting the kindling process. This can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures. In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures. It is suspected that this same kindling process may also occur in the development of full-blown mania with stimulation by more frequent minor episodes. This may explain why anticonvulsants are effective in the treatment and prevention of mania as well.

parietal lobes

interpret sensations of taste and touch and assist in spatial orientation. centers for the senses of smell and hearing and for memory and emotional expression.

Resourcefulness

involves using problem-solving abilities and believing that one can cope with adverse or novel situations. People develop resourcefulness through interactions with others, that is, through successfully coping with life experiences. Examples of resourcefulness include performing health-seeking behaviors, learning self-care, monitoring one's thoughts and feelings about stressful situations, and taking action to deal with stressful circumstances.

Self-efficacy

is a belief that personal abilities and efforts affect the events in one's life. A person who believes that his or her behavior makes a difference is more likely to take action. People with high self-efficacy set personal goals, are self-motivated, cope effectively with stress, and request support from others when needed. Four main ways to promote self efficacy include the following: Experience of success or mastery in overcoming obstacles •Social modeling (observing successful people instills the idea that one can also succeed) •Social persuasion (persuading people to believe in themselves)

Neuroleptic Malignant Syndrome. Neuroleptic malignant syndrome (NMS)

is a potentially fatal idiosyncratic reaction to an antipsychotic (or neuroleptic) drug. The major symptoms of NMS are rigidity; high fever; autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium; and elevated levels of enzymes, particularly creatine phosphokinase. Clients with NMS are usually confused and often mute; they may fluctuate from agitation to stupor. RISK Dehydration, poor nutrition, concurrent medical illness Treatment immediate discontinuance of all antipsychotic medications and the institution of supportive medical care to treat dehydration and hyperthermia until the client's physical condition stabilizes

Disulfiram

is a sensitizing agent that causes an adverse reaction when mixed with alcohol in the body. This agent's only use is as a deterrent to drinking alcohol in persons receiving treatment for alcoholism. It is useful for persons who are motivated to abstain from drinking and who are not impulsive. Five to 10 minutes after a person taking disulfiram ingests alcohol, symptoms begin to appear: facial and body flushing from vasodilation, a throbbing headache, sweating, dry mouth, nausea, vomiting, dizziness, and weakness. In severe cases, there may be chest pain, dyspnea, severe hypotension, confusion, and even death. Symptoms progress rapidly and last from 30 minutes to 2 hours. Because the liver metabolizes disulfiram, it is most effective in persons whose liver enzyme levels are within or close to normal range. Other side effects reported by persons taking disulfiram include fatigue, drowsiness, halitosis, tremor, and impotence. Disulfiram can also interfere with the metabolism of other drugs the client is taking, such as phenytoin (Dilantin), isoniazid, warfarin (Coumadin), barbiturates, and long-acting benzodiazepines such as diazepam and chlordiazepoxide.

limbic system

is an area of the brain located above the brain stem that includes the thalamus, hypothalamus, hippocampus, and amygdala (although some sources differ regarding the structures this system includes). The thalamus regulates activity, sensation, and emotion. The hypothalamus is involved in temperature regulation, appetite control, endocrine function, sexual drive, and impulsive behavior associated with feelings of anger, rage, or excitement. The hippocampus and amygdala are involved in emotional arousal and memory. Disturbances in the limbic system have been implicated in a variety of mental illnesses such as: the memory loss that accompanies dementia poorly controlled emotions and impulses seen with psychotic or manic behavior.

Resilience

is defined as having healthy responses to stressful circumstances or risky situations. This concept helps explain why one person reacts to a slightly stressful event with severe anxiety, while another person does not experience distress even when confronting a major disruption.

Social support

is emotional sustenance that comes from friends, family members, and even health care providers who help a person when a problem arises. It is different from social contact, which does not always provide emotional support. An example of social contact is the friendly talk that goes on at parties.

Cerebellum

is located below the cerebrum and is the center for coordination of movements and postural adjustments. It receives and integrates information from all areas of the body, such as the muscles, joints, organs, and other components of the CNS.

natural view

is rooted in a belief that natural conditions or forces, such as cold, heat, wind, or dampness, are responsible for the illness

Hardiness

is the ability to resist illness when under stress. First described by Kobasa (1979), hardiness has three components: 1.Commitment: active involvement in life activities 2.Control: ability to make appropriate decisions in life activities 3.Challenge: ability to perceive change as beneficial rather than just stressful

Insight

is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. The nurse can frequently infer insight from the client's ability to realistically describe the strengths and weaknesses of his or her behavior.

Half-life

is the time it takes for half of the drug to be removed from the bloodstream. Drugs with a shorter half-life may need to be given three or four times a day, but drugs with a longer half-life may be given once a day. The time that a drug needs to leave the body completely after it has been discontinued is about five times its half-life.

Self-concept

is the way one views oneself in terms of personal worth and dignity. To assess a client's self-concept, the nurse can ask the client to describe him or herself, what characteristics he or she likes, and what he or she would change. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image, which is also part of self-concept.

bupropion (antidepressant)

loss of appetite, nausea, agitation, and insomnia.

desvenlafaxine antidepressent

loss of appetite, nausea, agitation, and insomnia.

venlafaxine (antidepressant)

loss of appetite, nausea, agitation, and insomnia. dizziness, sweating, or sedation

•Waxy flexibility:

maintenance of posture or position over time even when it is awkward or uncomfortable

Personality tests

may be objective (constructed of true-or-false or multiple choice questions). Table 8.1 describes selected objective personality tests. The nurse compares the client's answers with standard answers or criteria and obtains a score or scores.

The major interaction is with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin. Both of these neurotransmitters are released throughout the brain and help regulate arousal, vigilance, attention, mood, sensory processing, and appetite. Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reuptake into presynaptic neurons. After reuptake, these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO. The SSRIs block the reuptake of serotonin, the cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and block serotonin to some degree, and the MAOIs interfere with enzyme metabolism. The cyclic compounds may take 4 to 6 weeks to be effective, MAOIs need 2 to 4 weeks for effectiveness, SSRIs may be effective in 2 to 3 weeks.

mechanism of action of MAOs

Mechanism of Action block receptors for the neurotransmitter dopamine;

mechanism of action of antipsychotics Dopamine receptors subcategories (D1, D2, D3, D4, and D5), D2, D3, and D4 have been associated with mental illness.

lithium therapy

mild nausea or diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste in the mouth, fatigue or lethargy. Weight gain acne are side effects that occur later in lithium therapy; both are distressing for clients. Toxic effects severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination.

Locus ceruleus:

norepinephrine-producing neurons (stress, anxiety, impulsive behavior)

Culturally competent

nursing care means being sensitive to issues related to culture, race, gender, sexual orientation, social class, economic situation, and other factors. Nurses and other health care providers must learn about other cultures and become skilled at providing care to people with cultural backgrounds that are different from their own. Finding out about another's cultural beliefs and practices and understanding their meanings are essential to providing holistic and meaningful care to the client.

Anticholinergic side effects

often occur with the use of antipsychotics and include orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory. These side effects usually decrease within 3 to 4 weeks but do not entirely remit. The client taking anticholinergic agents for EPSs may have increased problems with anticholinergic side effects. Using calorie-free beverages or hard candy may alleviate dry mouth, and stool softeners, adequate fluid intake, and the inclusion of grains and fruit in the diet may prevent constipation.

Other compounds Bupropion (Wellbutrin) T Venlafaxine (Effexor) T, C Desvenlafaxine (Pristiq) T Trazodone (Desyrel) T Nefazodone (Serzone) T Duloxetine (Cymbalta) C Vilazodone (Viibryd) T

other antidepressents

•Psychomotor retardation:

overall slowed movements

•Pons:

primary motor pathway

•A medication is selected based on its effect on the client's target symptoms such as delusional thinking, panic attacks, or hallucinations. The medication's effectiveness is evaluated largely by its ability to diminish or eliminate the target symptoms. •Many psychotropic drugs must be given in adequate dosages for some time before their full effects are realized. •The dosage of medication is often adjusted to the lowest effective dosage for the client. •As a rule, older adults require lower dosages of medications than do younger clients to experience therapeutic effects. •Psychotropic medications are often decreased gradually (tapering) rather than abruptly. •Follow-up care is essential to ensure compliance with the medication regimen, to make needed adjustments in dosage, and to manage side effects. •Compliance with the medication regimen is often enhanced when the regimen is as simple as possible in terms of both the number of medications prescribed and the number of daily doses.

principles that guide the use of medications to treat psychiatric disorders:

Judgment

refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Problems with judgment may be evidenced as the client describes recent behavior and activities that reflect a lack of reasonable care for self or others

Mood

refers to the client's pervasive and enduring emotional state. Affect is the outward expression of the client's emotional state.

Efficacy

refers to the maximal therapeutic effect that a drug can achieve.

Automatisms:

repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot

Midbrain:

reticular activating system (motor activity, sleep, consciousness, awareness) and extrapyramidal system

Mirtazapine (Antidepressant)

sedation.

Extrapyramidal Side Effects. Extrapyramidal symptoms (EPSs),

serious neurologic symptoms, are the major side effects of antipsychotic drugs. They include acute dystonia, pseudoparkinsonism, and akathisia. Blockade of D2 receptors in the midbrain region of the brain stem is responsible for the development of EPSs.

Blunted affect:

showing little or a slow-to-respond facial expression

•Flat affect:

showing no facial expression

Stimulant drugs,

specifically amphetamines, were first used to treat psychiatric disorders in the 1930s for their pronounced effects on CNS stimulation. In the past, they were used to treat depression and obesity, but those uses are uncommon in current practice. Dextroamphetamine (Dexedrine) has been widely abused to produce a high or to remain awake for long periods. Today, the primary use of stimulants is for ADHD in children and adolescents, residual attention-deficit disorder in adults, and narcolepsy (attacks of unwanted but irresistible daytime sleepiness that disrupt the person's life). The primary stimulant drugs used to treat ADHD are methylphenidate (Ritalin), amphetamine (Adderall), and dextroamphetamine (Dexedrine). Pemoline (Cylert) is infrequently used for ADHD because of the potential for liver problems.

Stimulants Methylphenidate (Ritalin) Sustained release (Ritalin-SR, Concerta, Metadate-CD) Transdermal patch (Daytrana) Dextroamphetamine (Dexedrine) Sustained release (Dexedrine-SR) Amphetamine (Adderall) Sustained release (Adderall-SR) Pemoline (Cylert) Selective norepinephrine reuptake inhibitor Atomoxetine (Strattera)

stimulants

thought blocking

stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea

Newer, atypical or second-generation antipsychotic drugs,

such as clozapine (Clozaril), are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects. In addition, second-generation antipsychotics inhibit the reuptake of serotonin, as do some of the antidepressants, increasing their effectiveness in treating the depressive aspects of schizophrenia

History

•Age •Developmental stage •Cultural considerations •Spiritual beliefs •Previous history

NATIVE AMERICANS

•Communication slow with many pauses -Rushing speaker or interrupting viewed negatively •Flexible orientation to time •Reluctance of family members to provide patient information (violation of patient's privacy) •Greeting via light-touch handshake, minimal direct eye contact •Patients typically quiet, stoic •Mental illness as due to ghosts, breaking taboos, or loss of harmony with environment •Medicine bag or healing objects (not to be removed or touched)

Abnormal Sensory Experiences or Misperceptions

•Concentration •Abstract thinking abilities

Thought Process and Content

•Content (what client is thinking) •Process (how client is thinking) •Clarity of ideas •Self-harm or suicide urges

Roles and Relationships

•Current roles •Satisfaction with roles •Success at roles •Significant relationships •Support systems

African Americans

•Different terms; patient preference for term important •Family support; maintenance of patient independence •Comfortable with public demonstration of affection; conversation possibly animated, loud •Handshake for greeting; direct eye contact shows interest and respect; silence possibly indicates lack of trust •Church important support; prayer for healing •View of mental illness as spiritual imbalance or punishment for sin •Use of folk remedies with Western medicine

Physiologic and Self-Care Considerations

•Eating habits •Sleep patterns •Health problems •Compliance with prescribed medications •Ability to perform the activities of daily living

Puerto Ricans

•Elders less direct eye contact; younger people prefer direct eye contact •Religious, spiritual practices important •Gratitude via homemade cooking -Refusal is an insult •Physical illness hereditary or punishment •Mental illness hereditary or due to suffering; highly stigmatized

Mood and Affect

•Expressed emotions •Facial expressions

Russians

•Formal greeting or handshake with direct eye contact; touching, embracing, kissing on cheek for close friends and family •Mental illness due to stress, moving to new environment •Ill persons on bed rest •Home remedies tried first; reluctant to take medications

Japanese Americans

•Formal greetings; light touching; minimal eye contact especially with authority figures •Self-disclosure unlikely; use of open-ended questions appropriate •Promptness important •Mental illness shameful; reluctance in seeking help •Mental illness due to evils spirits as punishment for bad behavior or failure to live good life

ARAB AMERICANS

•Greet with smile, direct eye contact, social comment about family or patient •Family as collective decision maker (father, eldest son, uncle, husband as family spokesperson) •Human concerns valued more than adhering to schedule •Mental illness due to fear, manipulation, God's will, or loss of country, family, or friends •Mental illness has stigma; treatment sought only when all other remedies fail

Vietnamese

•Greeting with smile, bow •Touch limited among older, traditional people •Head is sacred, feet profane •Avoidance of eye contact with authority figures, elders •Mental illness due to disharmony or punishment by ancestral spirits for past bad behavior •Ill person passive

Haitians

•Handshake as formal greeting •Polite but shy, especially with authority figures •Smile, nod even when not understanding •Mental illness not well accepted; due to supernatural causes •Home, folk remedies used first

Cambodians

•Handshake or slight bow with palms together, fingers pointed upward as greeting; no contact with person being greeted •Politeness highly valued; silence common; eye contact acceptable (lowering of eyes by women to be polite) •Inappropriate to touch head without permission •Family members included for decision making •Flexible orientation to time •Passive role when ill; mental illness due to war or brutalities

General Assessment and Motor Behavior

•Hygiene and grooming •Appropriate dress •Posture •Eye contact •Unusual movements or mannerisms •Speech

Judgment and Insight

•Judgment (interpretation of environment) •Decision-making ability •Insight (understanding one's own part in current situation)

South Asians

•Oral greetings, gestures; handshakes among men •Touching not common; feelings via eyes, facial expressions •Direct eye contact, loudness disrespectful •Silence indicates approval, acceptance, tolerance •Mental illness due to spells cast by enemies or evil spirits

Sensorium and Intellectual Processes

•Orientation •Confusion •Memory

Cubans

•Outgoing, animated in conversation •Direct eye contact as sign of respect or honesty •Extended family important •Mental illness inherited or caused by stress; stigma for family •Ill person submissive, helpless, dependent

Self-Concept

•Personal view of self •Description of physical self •Personal qualities or attributes

Chinese

•Shy in unfamiliar surroundings •Avoid eye contact with authority figures; silence respectful; asking questions a sign of disrespect •Time urgency not highly valued; respectful distance important •Eldest male may be family decision maker, spokesperson •Mental illness due to disharmony of emotions or evil spirits

Filipinos

•Smile (rather than handshake) for greeting •Animated facial expressions •Little direct eye contact with authority figures •Disagreement rarely voiced •Mental illness due to religious, mystical causes -Disruption in harmonious function of whole person, spiritual world •Ill person passive; eldest male as decision maker after conferring with family

Mexican Americans

•Touching prevalent among family; not always welcomed from strangers -Handshake acceptable as polite greeting •Avoidance of direct eye contact with authority figures •Silence often a sign of disagreement •Flexible time orientation •No clear separation of physical, mental illness -Due to imbalance between person and environment

Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk for death. Causes of death are varied, but most appear to be either cardiovascular or infectious in nature.

➔ WARNING - Atypical Antipsychotics