chapter 8 & 9

Psychoanalysis

- is a form of therapy that originated from the theories of Sigmund Freud. In psychoanalysis, the focus is on the cause of the problem, which is buried somewhere in the unconscious. The therapist tries to get the patient to review his or her past in an effort to determine where the problem began.

Antianxiety Agents (Anxiolytics/ Minor Tranquilizers)

-Action: Antianxiety agents depress activities of the cerebral cortex -Uses: Antianxiety agents decrease the effects of stress, anxiety, and mild depression. They can be used preoperatively to enhance sedation. -Side Effects: The use of antianxiety agents can cause physical and psychological dependence. Other side effects include drowsiness, lethargy, fainting, postural hypotension, nausea, and vomiting. If discontinued abruptly, severe side effects, including nausea, hypotension, and fatal grand mal seizures, can occur anywhere from 12 hours to 2 weeks after the drug is stopped

Antiparkinson Agents (Anticholinergics)

-Action: Antiparkinson agents inhibit the action of ace - tylcholine. Acetylcholine increases as dopamine decreases at its receptor sites (the cholinergic effect). When the amount of acetylcholine available to interact with dopamine is decreased, there is a better balance between the two neurochemicals, and the symptoms of parkinsonism decrease. -Uses: Antiparkinson agents help decrease the effects of drug-induced and non-drug-induced symptoms of parkinsonism that often occur with antipsychotics. -Side Effects: Blurred vision, dry mouth, dizziness, drowsiness, confusion, tachycardia, urinary retention, constipation, and changes in blood pressure. -Contraindications: Patients with known hypersensitivity should not use these medications. People with glaucoma, myasthenia gravis, peptic ulcers, prostatic hypertrophy, or urine retention should not take these medications. These agents should be avoided in children under the age of 12 years and used with caution with the elderly.

Monoamine Oxidase Inhibitors (MAOIs)

-Action: Monoamine oxidase inhibitors (MAOIs) prevent the metabolism of neurotransmitters by an enzyme, monoamine oxidase. Too much monoamine oxidase can lead to destructive, psychotic behaviors. -Uses: MAOIs are generally used for patients with varied types of depression, who have not been helped by other antidepressants. -Side Effects: Postural hypotension, photosensitivity (sunburn potential), headache, dizziness, memory impairment, tremors, fatigue, insomnia, weight gain, and sexual dysfunction are possible. -Contraindications: MAOI medications should be given carefully to patients who have asthma, congestive heart failure, cerebrovascular disease, glaucoma, hypertension, schizophrenia, alcoholism, liver or kidney disorders, or severe headaches, as well as to those who are over 60 years old or who are pregnant. -Nursing Considerations: Teach patients to avoid and provide them with a list of foods containing the amino acid tyramine, a precursor of norepinephrine, while taking these medications

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

-Action: These drugs increase the availability of serotonin and norepinephrine, which are decreased in the brains of depressed individuals -Commonly Used SNRI Agents: nefazodone (Serzone), venlafaxine (Effexor), duloxetine (Cymbalta)

Selective Serotonin Reuptake Inhibitors (SSRIs) (Bicyclic Antidepressants)

-Action: These drugs increase the availability of serotonin, which is decreased in the brains of depressed individuals. -Uses: Treatment of depression, anxiety, obsessive disorders, impulse control disorders. -Side Effects: Potential for increased suicidal tendencies, sedation, dry mouth, agitation, postural hypotension, headache, arthralgia, dizziness, insomnia, confusion, and tremors. -contradictions: People using monoamine oxidase inhibitors (MAOIs) or who are within 14 days of discontinuing MAOIs should not use these medications. People using certain herbal preparations including but not limited to St. John's wort, ginseng, brewer's yeast, vitamin B6, and ginkgo biloba should not use SSRIs without consulting their health-care provider. -Nursing Considerations: Serotonin syndrome, which includes altered mental status, restlessness, tachycardia, and labile blood pressure, can occur with abrupt discontinuation as well as when SSRIs are combined with some other medications. Hard, sugarless candy or saliva substitute can be used to treat dry mouth.

Tricyclic Antidepressants

-Action: These drugs increase the level of serotonin and norepinephrine, thereby increasing the ability of the nerve cells to pass information to each other. Patients with depressive disorders generally have decreased amounts of these two neurochemicals. -Uses: Treatment of symptoms of depression, including (but not limited to) sleep disturbances, sexual function disturbances, changes in appetite, and cognitive changes. -Side Effects: Sedation, lethargy, dry mouth, constipation, tachycardia, postural hypotension, urine retention, blurred vision, weight gain, and changes in blood glucose are possible. -Contraindications: Women who are pregnant or breastfeeding and individuals with kidney disease, liver disease, or a recent myocardial infarction should not take these medications. Anyone who has asthma, seizure disorders, schizophrenia, benign prostatic hypertrophy (BPH), or alcoholism should use tricyclic antidepressants with extreme caution

Biofeedback

-Biofeedback is a training program designed to develop one's ability to control the autonomic nervous system. -widely accepted in the West because of its use of scientific measuring devices and proven techniques. -The primary purpose of biofeedback training is to teach patients to be aware of tension within the body and to respond with relaxation. -series of 1-hour sessions, sometimes spaced 1 week apart -obtain a deep level of relaxation as a means to control a light, buzzer, image, or a video game, to which he or she is attached by electrodes and cables. The machine is then gradually adjusted to greater sensitivity, and the patient learns improved control. When training is completed, all the patient needs to do to obtain relaxation and symptom resolution at any time or place is to recall the particular thought and feeling that worked in the clinic

The EPS include:

-Drug-induced parkinsonism (pseudoparkinsonism) -Akathisia -Dystonia -Tardive dyskinesia (TD)

psychopharmacology

-First, medications control symptoms, helping the patient to feel more comfortable emotionally. -Second, the medications are usually used with some other type of therapy -The patient is generally more receptive to, and more able to focus on, therapy if the appropriate medications are also used.

MILIEU

-In mental health, this therapeutic environment is called a milieu, or therapeutic milieu -The milieu is the setting that provides safety and where stress is minimized during the patient's stay. Milieu therapy is intended to combine social and the therapeutic environments, creating the opportunity for a therapeutic interaction between the nurse and patient. The milieu must be comfortable and safe. Patients need to feel accepted while learning new behaviors

Antimanic Agents (Mood Stabilizing Agents)

-Lithium carbonate was the drug of choice for treatment and management of bipolar mania for many years. In recent years, several other antimanic agents have become treatment options. Other medications being used as mood stabilizers include some anticonvulsants and calcium channel blockers

Milton H. Erickson

-Milton H. Erickson (1901-1980) was one of the best-known figures in the development of hypnosis for modern therapeutic purposes. As a child, Erickson had polio, which left him partially paralyzed. He had little strength in his arms and upper body and used a wheelchair. In addition, he had dyslexia, tone-deafness, color-blindness, and heart problems.

MIND, BODY, AND BELIEF

-The mind represents the cognitive, emotional, and logical responses that make people individual human beings. The mind is clearly more than just the brain, the sum of its cells, chemicals, electrical activity, and connections -a person's beliefs will determine the success of a given treatment. This can be plainly seen when a placebo medication is given and is effective in relieving symptoms like severe pain even though the placebo contains no actual medication.

Lithium Carbonate

-Uses: Lithium is used for the manic phase of bipolar disorder and sometimes for other depressive or schizoaffective disorder -Nursing Considerations: • Lithium crosses the placenta and is excreted in breast milk, so women of childbearing years need to be counseled by their health-care provider regarding the effects of this drug before they become pregnant. • Adequate fluid and sodium intake are essential. Patients should not decrease their dietary intake of salt (unless instructed to do so by the health-care provider) and should be taught to inform the physician immediately if they are ill. • Hard, sugarless candy can be helpful to decrease dry mouth and thirst, but consult your health-care provide

Massage, Energy, and Touch

-Western variations of massage include Swedish, which was developed in the early nineteenth century and is the type most Americans are familiar with. It is characterized by long, smooth strokes that go toward the heart. -Rolfing is a therapy designed to realign the body with gravity through fascial manipulation, a vigorous form of bodywork that is finding increasing acceptance. Eastern massage traditions have followed a different path. -Shiatsu is a Japanese form of acupressure that uses pressure from the fingers to free energy flow. Reflexology is also based upon the belief that energy pathways and zones cross the body, connecting vital organs and body parts. Reflexologists use massage of the feet to act upon these pathways, unblocking and renewing the energy flow. -Therapeutic touch also deserves mention. Reiki is representative of methods of touch healing that are often associated with massage. Reiki is a term that means "universal life energy" and refers to the process whereby this energy is drawn along the body's meridians.

Complementary and alternative medicine (CAM)

-alternative medicines replace those of conventional/Western medicine, whereas -complementary medicine methods are used together with conventional treatments -integrative medicine- provides the best of both worlds -An alternative practice, for example, would be to use an herbal preparation to combat depression instead of a prescription medication ordered by a health care provider. -A complementary treatment might consist of using biofeedback to reduce the symptoms of anxiety associated with mental illness while the patient continues to participate in psychotherapy and take antianxiety medications. **Both approaches address a key concept in alternative and complementary medicine: the mind- body connection.**

Rational-Emotive Therapy (RET)

-best-known cognitive therapies. -Dr. Ellis's theory is based on an A-B-C format: • A is the activating event, or the subject of the faulty thinking. • B is the belief system a person has adopted about the activating event. • C is the consequence to continuing the belief system. -When behavior was thought to be related to an emotional disturbance, Ellis added to the A-B-C format: • D is disputing against beliefs appearing irrational • E is effective emotions and behaviors about the activating event, which is "A"

Hypnosis

-hypnosis was thought to be quackery and presented in stage shows in which people did things such as cluck like chickens, which served as entertainment. -However, hypnotherapy, as professional therapists prefer to call it, is useful for certain patients in certain instances. It is not a magic solution to problems. It takes practice on the part of the patient. It can, however, be a very effective tool for unlocking the unconscious or for searching further into what has been repressed.

Neuroleptic malignant syndrome (NMS)

-is an uncommon but potentially fatal reaction to treatment with some antipsychotic medications -Symptoms include muscle rigidity, hyperpyrexia, fluctuations in blood pressure, and altered level of consciousness. -Some antipsychotics, such as clozapine (Clozaril), are known to cause serious blood dyscrasias and require regular monitoring of blood counts. -Contraindications: Antipsychotics should be used carefully in patients who are hypersensitive to medications or who have brain damage or blood dyscrasias

Hypnotherapy

-is one of the most controversial complementary and alternative treatment modalities. Hypnosis is a means for entering an altered state of consciousness, and in this state, using visualization and suggestion to bring about desired changes in behavior and thinking. Called a trance, this state of focused attention is one people enter every day. The English language even contains references to this common experience of "zoning out." Trance is not sleep, but rather a state of mind wherein a person is less aware of what is going on around him or her and instead is very focused on an internal experience, like a memory or an imagined event.

Aromatherapy

-may well be one of the oldest methods used to treat illness in human beings. -aromatherapy provides treatment by both the direct pharmacological effects of aromatic plant substances and the indirect effects of certain smells on mood and affect. Applied in salves or ointments, used in incense, reduced to essential oils for topical application, or even ingested, these substances often appeal to patients who are seeking a "natural" and cost-effective approach to healing. People's response to the sense of smell has strong significance in their lives. People associate certain aromas with certain situations, conditions, and emotional states. Many individuals are able to relive particularly strong memories when exposed to an aroma that was present when the remembered event occurred. For example, the fragrance of baking cookies or apple pie reminds some people of being at home

Cognitive ability

-the ability to think rationally and to process those thoughts -Cognitive means "of, relating to, or involving conscious intellectual activity (such as thinking, reasoning, or remembering)"

Free Association

-the patient says whatever comes to mind in response to a word that is given by the therapist. For example, the therapist might say mother or blue, and the patient would give a response, also typically one word, to each of the words the therapist says.

goals of psychotherapy:

1. Decrease the patient's emotional discomfort. 2. Increase the patient's social functioning. 3. Increase the patient's ability to behave or perform in a manner appropriate to the situation -therapeutic relationships, open and honest venting of feelings and thoughts, allowing the patient to practice new coping skills, helping the patient to gain insight into the problem, and using consistency in the team approach to the patient's care and treatment. Positive reinforcement of progress is encouraged. Some therapies may be focused on gaining insight into the reasons for current behavior, and others are more focused on changing specific behaviors.

8. In order for psychotherapy to be effective, it is necessary to do all of the following except: 1. Encourage the patient to repress feelings. 2. Reinforce appropriate behavior. 3. Establish a therapeutic patient-staff relationship. 4. Assist patient to gain insight into problem.

1. Encourage the patient to repress feelings.

3. When traditional medicine is combined with less traditional methods, it is called: 1. Integrative medicine 2. Alternative medicine 3. Hypnotherapy 4. Biofeedback

1. Integrative medicine

8. Which of the following is false about trance? 1. It is an altered state of consciousness, just like sleep. 2. Humans move in and out of trance states during the day. 3. It is a state of relaxed awareness. 4. Trance is a common experience, even if you are not aware of it.

1. It is an altered state of consciousness, just like sleep.

7. Mr. Douglas wants to know more about massage therapy. Which one of the following is not a massage modality? 1. Reiki 2. Trigger point 3. Rolfing 4. Swedish

1. Reiki

9. Your patient, Mrs. L, is on your unit for bowel resection. She is exhibiting signs of nervousness and anxiety, which she attributes to the upcoming surgery. You note from her record that she has a history of ethyl alcohol (ETOH) abuse. Which of the following classifications of drugs would be potentially addictive for her? 1. Lithium salts 2. Antianxiety drugs 3. Antipsychotic drugs 4. Anticholinergics

2. Antianxiety drugs

1. Which of the following is not a behavior noted in the crisis phase? 1. Denial 2. Feeling of well-being 3. Use of projection 4. Rationalization

2. Feeling of well-being

7. The goals of crisis intervention include all of the following except: 1. Safety 2. Increasing anxiety 3. Taking care of the precipitating event 4. Return to pre-crisis or better level of functioning

2. Increasing anxiety

4. Which of the following is false regarding ECT? 1. It is used to treat depression and schizophrenia. 2. It is used to stop convulsive seizures. 3. Fatigue and disorientation are immediate side effects. 4. Memory will gradually return

2. It is used to stop convulsive seizures.

10. Which of the following should be avoided when communicating with a mentally ill patient? 1. Having an expectation that the patient will get better 2. Making the presupposition that the patient will not improve 3. Taking the time to convey respect for the patient 4. Demonstrating through your expression and posture that you are listening

2. Making the presupposition that the patient will not improve

5. Mrs. Lucas is telling you about her ideas for curing her depression by taking an herbal medication. She is convinced that because St. John's wort is a natural product, it is better for her than her prescription therapy. You should: 1. Quickly get the drug handbook and show her she is wrong. 2. Remain open and supportive. 3. Point out to her that herbal therapy is contraindicated. 4. Suggest some available brands for her to use.

2. Remain open and supportive.

9. Which of the following statements indicates a visual channel preference for information? 1. "That really feels good! My gut feeling is that it will work!" 2. "It sounds good to me; this idea is worth paying attention to." 3. "I can see the solution, and clearly it will work." 4. "I smell a rat. I think the whole thing stinks."

3. "I can see the solution, and clearly it will work."

3. A therapeutic environment (milieu) is best defined as: 1. An environment in which a patient is under a 72-hour hold 2. An environment that is locked and supervised 3. An environment that is structured to decrease stress and encourage learning new behavior 4. An environment that is designed to be homelike for persons who are hospitalized for life

3. An environment that is structured to decrease stress and encourage learning new behavior

10. James is a 13-year-old who has been transferred to your medical-surgical unit after being stabilized in the ED. He slit both wrists and took an overdose of his bupropion (Wellbutrin). You know medications such as Wellbutrin: 1. Are antidepressants and should have stopped his suicidal impulse 2. Have no particular nursing considerations for children and adolescents 3. Are antidepressants and may have an increase in the suicidal ideation for children and adolescents 4. Are not effective as antidepressants for children or adolescents

3. Are antidepressants and may have an increase in the suicidal ideation for children and adolescents

1. Alternative therapy modalities are used: 1. Infrequently, as they have no value to patients today 2. In combination with conventional therapies 3. In place of conventional therapies 4. Only when there is no hope for recovery

3. In place of conventional therapies

6. Avoiding such foods as bananas, cheese, and yogurt should be emphasized to patients who are taking: 1. Fluoxetine (Prozac) 2. Lithium 3. MAOIs 4. Tricyclic antidepressants

3. MAOIs

2. One of the first statements a nurse might make to a person who has been abused might be: 1. "Why didn't you leave the first time you were attacked?" 2. "Do you want to prosecute or not?" 3. "What do you think made that person hit you?" 4. "You're safe here. I would like to help you."

4. "You're safe here. I would like to help you."

2. A treatment modality used with conventional medical therapies is: 1. A medical approach 2. An alternative approach 3. A holistic approach 4. A complementary approach

4. A complementary approach

6. Of the following, which are either complementary or alternative modalities? 1. ECT, Reiki, rolfing 2. Hypnotherapy, shiatsu, antianxiety medications 3. NLP, psychotherapy, SAM-e 4. Aromatherapy, biofeedback, massage

4. Aromatherapy, biofeedback, massage

4. The mechanism that describes thoughts and expectations affecting health is: 1. A complementary therapy 2. A misconception that is dangerous to the patient 3. An integrated therapy 4. The mind-body connection

4. The mind-body connection

5. Psychopharmacology (psychotropic drug therapy) is used: 1. As a cure for mental illness 2. Only to control violent behavior 3. To alter the pain receptors in the brain 4. To decrease symptoms and facilitate other therapies

4. To decrease symptoms and facilitate other therapies

Typical antipsychotic

Action: Typical antipsychotic agents act on the central nervous system (CNS). Their main action is to block the dopamine receptors. Dopamine is a neurochemical that the human body contains naturally. -if it is overproduced it can cause someone to exhibit psychotic behavior. -Atypical antipsychotic agents block both serotonin (another neurochemical) and dopamine. Uses: Antipsychotics are used to treat psychotic behavior in schizophrenia and other disorders that may include violent or potentially violent behavior. -Typical antipsychotic agents treat the positive symptoms of schizophrenia, such as hallucinations, delusions, and suspiciousness. -Atypical antipsychotic agents reduce the negative symptoms of schizophrenia, such as flat affect, social withdrawal, and difficulty with abstract thinking. Side Effects: Antipsychotics have unpleasant side effects. people are sometimes reluctant to take these medications because of the side effects and would rather be ill. -A few of these side effects are photosensitivity (especially with chlorpromazine [Thorazine]), darkening of the skin from increased pigmentation, anticholinergic effects such as dry mouth, and a group of side effects called extrapyramidal symptoms (EPS). There is less risk of EPS with the atypical agents, but early observation and reporting of any possible

Foods containing tyramine include:

Aged cheese (cheddar, Swiss, provolone, blue cheese, parmesan) • Avocados (guacamole) • Yogurt, sour cream • Chicken and beef livers, pickled herring, corned beef • Bean pods • Bananas, raisins, and figs • Smoked and processed meat (salami, pepperoni, and bologna) • Yeast supplements • Chocolate • Meat tenderizers (MSG), soy sauce • Beer, red wines, and caffeine

Catharsis

Catharsis is the "elimination of a complex (problem) by bringing it to consciousness and affording it expression". In psychoanalysis, the therapist helps the patient see the root of the problem and then, by talking or expressing feelings, allows the patient to learn to evacuate this problem from the psyche. This can take place in conjunction with other forms of psychotherapy

Counseling

Counseling "addresses the emotional, social, work, school, and physical health concerns people may have at different stages in their lives, focusing on typical life stresses and more severe issues with which people may struggle as individuals and as a part of families, groups, and organizations"

Crisis Intervention

Crisis can happen at any time to anyone. It can involve one's child, the next-door neighbor, or a patient. Crisis is defined in several ways. In the health fields, a crisis is a sudden, unexpected event in a person's life that drastically changes his or her routine. Crisis has been defined as a state in which the body is out of homeostasis. It is thought of as a situation in which a person may "lose control of feelings and thoughts, thus experiencing an extreme state of emotional turmoil"

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT), or electroshock therapy as it is sometimes still called, is a form of treatment that can be frightening to some patients. ECT delivers a small electrical charge to the brain that creates a change in nerve impulses. ECT is an alternative treatment for certain mental disorders when nothing else works. -ECT has a few side effects that can be fairly unpleasant. The patient may feel confused and forgetful immediately after the treatment.

Group Therapy

Group therapy is a very broad topic. Groups are formed for many reasons; they can be ongoing or short-term, depending on the needs of the patients or the type of disorder. Group therapy can include formal psychotherapy groups where patients meet with a therapist regularly as part of their treatment. Self-help programs are also a form of group therapy. For example, Alcoholics Anonymous (AA) and similar 12-step groups are well-established, ongoing groups.

Pastoral or Cultural Counseling

Some people prefer to obtain assistance, guidance, or counseling from their church or spiritual leaders. Sessions are often free or on a "freewill" or "ability to pay" status. The person who provides therapy in this time or circumstance may or may not be trained in traditional mental health theories and modalities.

Stimulants

Stimulants are readily available over the counter as well as by prescription. Nonprescription stimulants include OTC diet preparations and pills to prevent sleep; tobacco products; and caffeinated beverages such as coffee, energy drinks, and soda. -Amphetamines are one type of stimulant. Amphetamines can be abused, and they have many street names, including "uppers," "speed," and "bennies." Stimulants are widely available, powerful, and potentially dangerous drugs -Nursing Considerations: • Tolerance and physical and psychological dependence can occur with CNS stimulants, especially with long-term use. • Monitor for suicide potential.

. Drug-induced parkinsonism (pseudoparkinsonism)

Symptoms appear 1 to 8 weeks after the patient begins the medication. The major symptom is akinesia (muscle weakness), shuffling gait, drooling, fatigue, mask-like facial expression, tremors, and muscle rigidity

Dystonia

Symptoms appear 1 to 8 weeks after the patient starts taking the medication. Symptoms manifest as bizarre distortions or involuntary movements of any muscle group. Tongue, eyes, face, neck (torticollis), or any larger muscle mass can become tightened into an unnatural position or have irregular spastic movements

Akathisia

Symptoms appear 2 to 10 weeks after the patient starts taking the medication. Symptoms are agitation and motor restlessness, and they seem to appear more frequently in women. The reason for this is currently unknown, but it may be due to hormonal interaction with the medication

Tardive dyskinesia (TD)

Symptoms appear within 1 to 8 weeks after the patient starts taking the medication. The frequently seen manifestations are rhythmic, involuntary movements that look like chewing, sucking, or licking motions. Frowning and blinking constantly are also common. TD is irreversible

Legal Considerations in Crisis Intervention

Voluntary treatment happens when the patient gives informed consent to be hospitalized or to accept some formal treatment program. Informed consent means that the patient has been made aware of his or her behaviors, the implications of the behaviors, and the expected effects of treatment. Informed consent can be oral, nonverbal, or written. Implied consent allows people who are unconscious to be treated in such a way as to preserve life. If the patient is an adult of legal age who is considered to be competent in the eyes of the law (or an adolescent who has acquired legal emancipation), this patient can also sign himself or herself out of the hospital or facility at any time. Involuntary commitment varies somewhat from state to state. Many states have the capability to place a "hold" on the patient, usually for 48 to 72 hours. During this time, the patient is confined to the treatment setting.

Commonly Used Tetracyclic Antidepressant Agents

maprotiline (Ludiomil), bupropion (Wellbutrin, Zyban), mirtazapine (Remeron), trazodone (Desyrel)