psych study guide

epidemiology of depression

A 12-month prevalence of major depression and persistent depressive disorder is approximately 6 and 2 percent.•Sex — Female: Male 2:1•Race — The lifetime prevalence of major depression for:• Whites was 18%• Caribbean blacks was 13% • African Americans was 10% •Age — Life time prevalence was significantly lower for older generations• >65 years old (10%)• Younger age groups (19%-23%)

medications fo bipolar

Agitation Individuals with bipolar disorder may be on multiple medications. For severe agitation, lithium (Eskalith, Lithobid) or valproate (Depakote) and a second-generation antipsychotic such as olanzapine (Zyprexa) or risperidone (Risperdal) are recommended. Individuals experiencing less severe symptoms may be given only one of these. There may be times when a benzodiazepine antianxiety agent can help reduce agitation or anxiety. Due to concern of dependency, use of benzodiazepines is usually short term until the mania subsides. The high-potency antianxiety benzodiazepines clonazepam (Klonopin) and lorazepam (Ativan) are useful in the treatment of acute mania. They may calm agitation and reduce insomnia, aggression, and panic. Mood Stabilization Mood stabilizers refer to classes of drugs used to treat symptoms associated with bipolar disorder. The original intent of the term "mood stabilizers" was to indicate that these drugs were effective in the treatment of both mania and depression. This is not precisely true. While all of the medications in this category are effective in treating mania, not all of them do as well in treating depression. Lithium The chemical name for lithium carbonate is LiCO3 , although you may see it abbreviated as Li + . Lithium (Eskalith, Lithobid) has Food and Drug Administration (FDA) approval for both acute mania and maintenance treatment. Onset of action is usually within 10 to 21 days. Because the onset of action is so slow, it is usually supplemented in the early phases of treatment by atypical antipsychotics, anticonvulsants, or antianxiety medications. The clinical benefits of lithium can be incredible. However, newer drugs have been introduced and approved that carry lower toxicity, have more favorable side effects, and require less frequent laboratory testing. The use of these newer drugs has resulted in a decline in lithium use. Lithium is particularly effective in reducing the following: • Elation, grandiosity, and expansiveness • Flight of ideas • Irritability and manipulation • Anxiety • Self-injurious behavior To a lesser extent, lithium controls the following: • Insomnia • Psychomotor agitation • Threatening or assaultive behavior • Distractibility • Hypersexuality • Paranoia Actress Patty Duke describes her response to lithium after years of alternating depression, elation, and bad choices (Moore, 2008): Lithium saved my life. After just a few weeks on the drug, death-based thoughts were no longer the first I had when I got up and last when I went to bed. The nightmare that had spanned 30 years was over. I'm not a Stepford wife; I still feel the exultation and sadness that any person feels. I'm just not required to feel them 10 times as long or as intensively as I used to. Therapeutic and toxic levels In the acute manic phase lithium is usually started at 600 to 1200 mg a day in two or three divided doses. It is then increased every few days by 300 mg a day with a maximum dose of 1800 mg a day. Many patients respond well to lower dosages during maintenance or prophylactic lithium therapy. There is a small window between the therapeutic and toxic levels of lithium. Lithium must reach therapeutic blood levels to be effective. This usually takes 7 to 14 days, or longer for some patients. Blood serum should reach a level of 0.6 to 1.2 mEq/L (Sadock et al., 2015). Lithium levels should not exceed 1.5 mEq/L to avoid serious toxicity. Table 13.4 details expected side effects of lithium, signs of lithium toxicity, and interventions for both. Lithium levels should be measured at least 5 days after beginning lithium therapy and after any dosage change, until the therapeutic level has been reached. Blood levels are determined every month. After 6 months to a year of stability, it is common to measure blood levels every 3 months. Blood should be drawn in the morning, 10 to 12 hours after the last dose of lithium is taken. For older adult patients, the principle of start low and go slow still applies. Box 13.1 outlines patient and family teaching regarding lithium therapy. Contraindications Before administering lithium, complete a baseline assessment of renal function and thyroid status, including levels of thyroxine and thyroid-stimulating hormone. Perform other clinical and laboratory assessments, including an electrocardiogram as needed, depending on the individual's physical condition. Lithium therapy is generally contraindicated in patients with cardiovascular disease, brain damage, renal disease, thyroid disease, or myasthenia gravis. Whenever possible, lithium is not given to women who are pregnant because it may harm the fetus. Lithium use is also contraindicated in mothers who are breast-feeding and in children younger than 12 years of age. Anticonvulsant Drugs Anticonvulsant drugs were developed to treat convulsions associated with epilepsy. They are commonly used to treat acute mania and bipolar maintenance. They are generally: • Superior for continuously cycling patients • More effective when there is no family history of bipolar disease • Effective at diminishing impulsive and aggressive behavior in some nonpsychotic patients • Helpful in cases of alcohol and benzodiazepine withdrawal • Beneficial in controlling mania (within 2 weeks) and depression (within 3 weeks or longer) Valproate Valproate (available as divalproex sodium [Depakote] and valproic acid [Depakene]) has surpassed lithium in treating acute mania. Valproate is also helpful in preventing future manic episodes. Although serious complications are rare, it is important to monitor liver function and platelet count periodically. Carbamazepine Carbamazepine (Tegretol, Equetro) is an alternative to lithium, valproate, or a second-generation antipsychotic. It seems to work better in patients with rapid cycling and in severely paranoid angry patients experiencing manias rather than in euphoric, overactive, overfriendly patients experiencing mania. It is also thought to be more effective in dysphoric patients experiencing manias. Liver enzymes should be monitored at least weekly for the first 8 weeks of treatment because the drug can increase levels of liver enzymes that can speed its own metabolism. In some instances, this can cause bone-marrow suppression and liver inflammation. Complete blood counts should also be drawn periodically since carbamazepine is known to cause leukopenia and aplastic anemia. Lamotrigine Lamotrigine (Lamictal) is an FDA-approved maintenance therapy medication. Patients usually tolerate lamotrigine well, but there is one serious but rare dermatological reaction: a potentially lifethreatening rash. Instruct patients to seek immediate medical attention if a rash appears although most are likely benign. Second-Generation Antipsychotics Many of the second-generation antipsychotics are approved for acute mania. In addition to showing sedative properties during the early phase of treatment (help with insomnia, anxiety, agitation), the second-generation antipsychotics seem to have mood-stabilizing properties. Most evidence supports the use of olanzapine (Zyprexa) or risperidone (Risperdal). This classification of drugs may bring about serious side effects. These serious side effects stem from a tendency toward weight gain that may lead to insulin resistance, diabetes, dyslipidemia, and cardiovascular impairment. Bipolar Depression Treatment of bipolar with a common antidepressant alone increases the risk of bringing on a manic episode (Viktorin et al., 2014). This risk vanishes when combining the antidepressant with a mood stabilizer. Specific medications are indicated for bipolar depression. The second-generation antipsychotics lurasidone (Latuda) and quetiapine (Seroquel) have FDA approval for the treatment of bipolar depression. Symbyax is another drug with approval for this type of depression. It is made up of the second-generation olanzapine (Zyprexa) and the selective serotonin reuptake inhibitor fluoxetine (Prozac). Table 13.5 identifies drugs with FDA approval for bipolar disorder. You may notice that your patient is taking a drug without specific FDA approval. This is called using the medication of -label meaning that they are not officially approved, but practitioners often prescribe them. Integrative Therapy A few generations ago, children resisted a nightly dose of cod liver oil that mothers swore by as constipation prevention. While the foul-tasting evil-smelling liquid undoubtedly helped win that particular battle, it may have had other benefits as well. Cod liver oil is rich in omega-3 fatty acids, which have drawn increasing attention as being important in mood regulation. Fish oil is the target of this attention. It contains two omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are important in CNS functioning. The interest in these particular fatty acids developed as research began to suggest that people who live in areas with low seafood consumption, especially cold water seafood, exhibited higher rates of depression and bipolar disorder. This led researchers to explore the influence of omega-3 fatty acids as protective for bipolar disorder. In 2012 Sarris and colleagues reviewed published research about omega-3 and its influence on mania and depression. They concluded that there is no evidence to support the use of omega-3 in treating mania. However, they found strong evidence that increasing the use of this fatty acid may improve bipolar depressive symptoms.

pathogenesis of depression

Biological Factors Genetic Twin studies consistently show that genetic factors play a role in the development of depressive disorders. The concordance rate for major depressive disorder among monozygotic (identical) twins is nearly 50%. That is, if one twin is affected, the second has about a 50% chance of being affected as well. It is likely that multiple genes are involved, each one having a small but substantial role in the development and severity of depression. For instance, certain genetic markers seem to be related to depression when accompanied by early childhood maltreatment or a history of stressful life events. In this case, there is no gene directly related to the development of the mood disorder. There is a genetic marker associated with depression in the context of stressful life events. One of the more important aspects of understanding the role of genetics in relation to mental illness such as major depression may be in pharmacological treatments. Understanding genetic influences on the role of the transport of certain neurotransmitters, such as serotonin, across synapses will make it much easier to prescribe effective medical treatment of depression based on individual genetic patterns. Biochemical The brain is a highly complex organ that contains billions of neurons. There is much evidence to support the concept that many CNS neurotransmitter abnormalities may cause clinical depression. These neurotransmitter abnormalities may be the result of genetic or environmental factors or other medical conditions, such as cerebral infarction, Parkinson's disease, hypothyroidism, acquired immunodeficiency syndrome (AIDS), or drug use. Two of the main neurotransmitters involved in mood are serotonin (5-hydroxytryptamine [5- HT]) and norepinephrine. Serotonin is an important regulator of sleep, appetite, and libido. Therefore, serotonin-circuit dysfunction can result in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability. Norepinephrine modulates attention and behavior. It is stimulated by stressful situations, which may result in overuse and a deficiency of norepinephrine. A deficiency, an imbalance as compared with other neurotransmitters, or an impaired ability to use available norepinephrine can result in apathy, reduced responsiveness, or slowed psychomotor activity. Research suggests that depression results from the dysregulation of a number of neurotransmitter systems beyond serotonin and norepinephrine. For example, glutamate is a common neurotransmitter that increases the ability of a nerve fiber to transmit information. A deficit in glutamate can interfere with normal neuron transmission in the areas of the brain that affect mood, attention, and cognition. Stressful life events, especially losses, seem to be a significant factor in the development of depression. Norepinephrine, serotonin, and acetylcholine play a role in stress regulation. When these neurotransmitters become overtaxed through stressful events, neurotransmitter depletion may occur. Research indicates that stress is associated with a reduction in neurogenesis, which is the ability of the brain to produce new brain cells. At this time, no single mechanism of depressant action has been found. The relationships among the serotonin, norepinephrine, dopamine, acetylcholine, gamma-aminobutyric acid (GABA), and glutamate systems are complex and need further assessment and study. However, treatment with medication that helps regulate these neurotransmitters has proved empirically successful in the treatment of many patients. Fig. 14.1 shows a positron emission tomographic (PET) scan of the brain of a woman with depression before and after taking medication. Refer to Chapter 3 for further discussion of brain imaging and depression. Hormonal The neuroendocrine characteristic most widely studied in relation to depression has been hyperactivity of the hypothalamic-pituitary-adrenal cortical axis. People with major depression have increased urine cortisol levels and elevated corticotrophin-releasing hormone. Dexamethasone, an exogenous steroid that suppresses cortisol, is used in the dexamethasone suppression test (DST) for depression. Results of this test are abnormal in about 50% of people with depression, which indicates hyperactivity of the hypothalamic-pituitary-adrenal cortical axis. Depression rates are almost equal for males and females in the years preceding puberty and in older adults. This has led to more research into the effect of hormones on depression in women (Ryan et al., 2012). Recent studies have found that estradiol, a form of estrogen, affects receptors sensitive to serotonin in the areas of the brain responsible for mood in rats. As the relationships between sex hormones such as estrogen in women and testosterone in males are better understood, more effective therapies may be developed. Inflammation Inflammation is the body's natural defense to physical injury. There is growing evidence that inflammation may be the result of psychological injury as well. Researchers have focused in on two important blood components related to inflammation, C-reactive protein and interleukin-6. In young females with a history of adversity, depression is accompanied by elevations in these blood components but not in children without a history of adversity (Miller & Cole, 2012). Adversity in life may compromise resilience and place children at risk for depression and other disorders. While we do not believe that inflammation causes depression, research indicates that it does play a role (Krishnadas & Cavanagh, 2012). Support for this belief includes that about a third of people with major depression have elevated inflammatory biomarkers in the absence of a physical illness. Also, people who have inflammatory diseases have an increased risk of major depression. Finally, people treated with cytokines to enhance immunity during cancer treatment develop major depression at a high rate. Diathesis-Stress Model The diathesis-stress model of depression takes into account the interplay between genetic and biological predisposition toward depression and life events. The physiological vulnerabilities such as genetic predispositions, biochemical makeup, and personality structure are referred to as a diathesis. The stress part of this model refers to the life events that impact individual vulnerabilities. This explains why two persons exposed to relatively similar events may respond differently. One person may demonstrate resilience and another may develop depression. Biochemically, the diathesis-stress model of depression is believed to work this way. Psychosocial stressors and interpersonal events trigger neurophysical and neurochemical changes in the brain. Early life trauma may result in long-term hyperactivity of the CNS corticotropin-releasing factor (CRF) and norepinephrine systems with a consequent neurotoxic effect on the hippocampus, which leads to overall neuronal loss. These changes could cause sensitization of the CRF circuits to even mild stress in adulthood, leading to an exaggerated stress response (Gillespie & Nemeroff, 2005) Psychological Factors Cognitive Theory In cognitive theory, the underlying assumption is that a person's thoughts will result in emotions. If a person looks at life in a positive way, the person will experience positive emotions, but negative interpretation of life events can result in sorrow, anger, and hopelessness. Cognitive theorists believe that people may acquire a psychological predisposition to depression due to early life experiences. These experiences contribute to negative, illogical, and irrational thought processes that may remain dormant until they are activated during times of stress (Beck & Rush, 1995). Beck found that people with depression process information in negative ways, and tend to ignore positive aspects of their lives. He believed that automatic, negative, repetitive, unintended, and notreadily-controllable thoughts perpetuate depression. Three assumptions constitute Beck's cognitive triad: 1. A negative, self-deprecating view of self 2. A pessimistic view of the world 3. The belief that negative reinforcement (or no validation for the self) will continue in the future

nursing process for depression

Diagnosis Major depressive disorder is a complex disorder, and patients have a variety of needs. Therefore, there are many applicable diagnoses. A high priority for the nurse is determining the risk of suicide, and the nursing diagnosis of risk for suicide is always considered. Refer to Chapter 25 for assessment guidelines and interventions for suicidal individuals. Outcomes Identification The recovery model emphasizes that healing is possible and attainable for individuals with psychiatric disorders, including depression. Recovery is attained through partnerships between patients and healthcare providers who focus on the patient's strengths. Treatment goals are mutually developed based on the patient's personal needs and values, and interventions are evidenced-based. The recovery model is consistent with the focus on patient-centered care and is a key component of safe quality healthcare. Major depressive disorder can be a recurrent and chronic illness. Care should be directed not only at resolution of the acute phase but also at long-term management. The nurse and the patient identify realistic outcome criteria and formulate concrete, measurable, short-term and long-term goals. Table 14.2 identifies signs and symptoms commonly experienced in depression, offers potential nursing diagnoses, and suggests outcomes. Planning The planning of care for patients with depression is geared toward the patient's phase of depression, particular symptoms, and personal goals. At all times students, nurses, and members of the healthcare team must be aware of the potential for suicide. Assessment of risk for self-harm (or harm to others) is ongoing. A combination of therapy (cognitive, behavioral, or interpersonal) and psychopharmacology is an effective approach to the treatment of depression across all age groups. Safety is always the highest priority. Implementation There are three phases in treatment and recovery from major depression: 1. The acute phase (6 to 12 weeks) is directed at reduction of depressive symptoms and restoration of psychosocial and work function. Hospitalization may be required, and medication or other biological treatments may be initiated. 2. The continuation phase (4 to 9 months) is directed at prevention of relapse through pharmacotherapy, education, and depression-specific psychotherapy. 3. The maintenance phase (1 year or more) of treatment is directed at prevention of further episodes of depression. Depending on the risk factors for relapse, medication may be phased out or continued. It is important to keep in mind that both the continuation and maintenance phases are geared toward maintaining the patient as a functional and contributing member of the community after recovery from the acute phase. Counseling and Communication Techniques Nurses often have difficulty communicating with patients without talking. However, some patients with depression are so withdrawn that they are unwilling or unable to speak and just sitting with them in silence may seem like a waste of time or be noticeably uncomfortable. As your anxiety increases, you may start daydreaming, feel bored, and believe that you should be doing something. It is important to be aware that this time can be meaningful, especially if you have a genuine interest in learning about and supporting the patient with depression. It is difficult to say when a withdrawn patient will be able to respond, but certain techniques are known to be useful in guiding effective nursing interventions. Some communication techniques to use with a severely withdrawn patient are listed in Table 14.3. Counseling guidelines for use with 518 patients with depression are offered in Table 14.4. Health Teaching and Health Promotion A basic premise of the recovery model of mental illness is that individuals exercise personal control of treatment based on individual goals. Within this model, health teaching is paramount because it allows patients to make informed choices. Health teaching points include: • Depression is an illness beyond a person's voluntary control. • Although it is beyond voluntary control, depression can be managed through medication and lifestyle. • Chronic illness management depends in large part on understanding personal signs and symptoms of relapse. • Illness management depends on understanding the role of medication and possible medication side effects. • Long-term management works best if the patient receives psychotherapy along with medication. • Identifying and coping with the stress of interpersonal relationships—whether they are familial, social, or occupational—are key to stable illness management. Including the family in discharge planning is also important. It helps the patient by: • Increasing the family's understanding and acceptance of the family member with depression during the aftercare period • Increasing the patient's use of aftercare facilities in the community • Contributing to higher overall adjustment in the patient after discharge Promotion of Self-Care Activities Nursing measures for improving physical well-being and promoting adequate self-care are essential. Some effective interventions targeting physical needs in depression are listed in Table 14.5. Nurses in the community can work with family members to encourage a family member with depression to perform and maintain self-care activities. Teamwork and Safety Safe quality inpatient care requires the skills of a well-coordinated team. Treating a patient with depression require the skills of nurses and prescribers. Other members of the team include mental health technicians, pharmacists, dietitians, social workers, and the patient's significant others. Safety becomes the most important issue facing a team that cares for people with depression who may be at high risk for suicide. Suicide precautions are usually instituted and include the removal of all harmful objects such as "sharps" (e.g., razors, scissors, and nail files), strangulation risks (e.g., belts), and medication that can be used to overdose. Some patients with severe depression may need to have someone check on them frequently, perhaps every 15 minutes, or even have 1:1 observation. A full discussion of inpatient safety measures is provided in Chapter 4. Biological Interventions Electroconvulsive Therapy Despite being a highly effective somatic (physical) treatment for psychiatric disorders, electroconvulsive therapy (ECT) has a bad reputation. This may be due, in part, to past practices of restraining a conscious individual while having a full-blown seizure induced. In fact, before paralytic drugs, more than 30% of ECT patients experienced compression fractures of the spine (Welch, 2016). Given the current sophistication of anesthetic and paralytic agents, ECT is actually not dramatic at all. Indications ECT is the most effective acute treatment for depression (Welch, 2016). Psychotic illnesses are the second most common indication for ECT. For drug-resistant patients with psychosis, a combination of ECT and antipsychotic medication has resulted in sustained improvement about 80% of the time. Depression associated with bipolar disorder remits in about 50% of the cases after ECT. While medication is generally the first line of treatment for ease of use, ECT may be a primary treatment in the following cases: • Severely malnourished, exhausted, and dehydrated due to lengthy depression (after rehydration) • ECT is often more safe than medications with certain medical conditions • Delusional depression • Previous medication trials have failed • Schizophrenia with catatonia Risk Factors Using ECT requires clinicians to weigh the risk of using this method versus the risk of suicide and diminished quality of life. Several conditions pose risks and require careful workup and management. Because the heart can be stressed at the onset of the seizure and for up to 10 minutes after, careful assessment and management in hypertension, congestive heart failure, cardiac arrhythmias, and other cardiac conditions is warranted (Welch, 2016). ECT also stresses the brain as a result of increased cerebral oxygen, blood flow, and intracranial pressure. Conditions such as brain tumors and subdural hematomas may increase the risk of using ECT. Procedure The procedure is explained to the patient, and informed consent is obtained if the patient is being treated voluntarily. For a patient treated involuntarily, permission may be obtained from the next of kin although in some states treatment must be court-ordered. The patient is usually given a general anesthetic to induce sleep and a muscle-paralyzing agent to prevent muscle distress and fractures. These medications have revolutionized the comfort and safety of ECT. Patients should have a pre-ECT workup including a chest x-ray, electrocardiogram, urinalysis, complete blood count, blood urea nitrogen, and an electrolyte panel. Benzodiazepines should be discontinued as they will interfere with the seizure process. An electroencephalogram (EEG) monitors brain waves, and an electrocardiogram (ECG) monitors cardiac responses. Brief seizures (30 to 60+ seconds) are deliberately induced by an electrical current (as brief as 1 second) transmitted through electrodes attached to one or both sides of the head (Fig. 14.3). To ensure that patients experience a seizure over the entire brain, a blood pressure cuff may be inflated on the lower arm or leg before administration of the paralytic agent. In that way, the convulsion can be visualized in the unparalyzed extremity. The usual course of ECT for a patient with depression is two or three treatments per week to a total of 6 to 12 treatments. Continuation ECT along with medication may help to decrease relapse rates. Adverse Reactions Patients wake about 15 minutes after the procedure. The patient is often confused and disoriented for several hours. The nurse and family may need to orient the patient frequently during the course of treatment. Most people experience what is called retrograde amnesia, which is a loss of memory of events leading up to and including the treatment itself. Transcranial Magnetic Stimulation Transcranial magnetic stimulation (TMS) is a noninvasive treatment modality. It uses MRIstrength magnetic pulses to stimulate focal areas of the cerebral cortex. Indications In 2008 the FDA approved the use of TMS for patients who have been unresponsive to other methods of treatment for depression. Some researchers suggest that TMS be used to enhance cognitive function in healthy, non-depressed individuals (Clark et al., 2013). Risk Factors The only absolute contraindication to this procedure is the presence of metal in the area of stimulation. Cochlear implants, brain stimulators, or medication pumps are examples of metals that could interfere with the procedures (Camprodon et al., 2016). Procedure Outpatient treatment with TMS takes about 30 minutes and is typically ordered for 5 days a week for 4 to 6 weeks. Patients are awake and alert during the procedure. An electromagnet is placed on the patient's scalp, and short, magnetic pulses pass into the prefrontal cortex of the brain (Fig. 14.4). These pulses are similar to those used by MRI scanners but are more focused. The pulses cause electrical charges to flow and induce neurons to fire or become active. During TMS, patients feel a slight tapping or knocking in the head, contraction of the scalp, and tightening of the jaws. Evaluation Because each patient presents differently, outcome evaluation will be tailored to each patient's unique presentation. Based on your evaluation, modification of nursing diagnoses, goals, and interventions is made. When suicidal ideation is present the following questions should be addressed: Are these thoughts still present? How frequently do they occur? Does the patient have a plan? Is the patient able to stop suicidal thoughts and formulate alternatives to suicidal thoughts? If the depression is severe and the patient has demonstrated psychotic features, the nurse will ask about auditory hallucinations and evaluate for signs of delusions. Basic self-care issues should be addressed. Is the patient taking in a sufficient number of calories and liquids? In an inpatient setting the nurse will also evaluate the patient's sleep pattern. Is the patient able to fall asleep? Stay asleep? Has the number of hours of sleep increased since admission? What about personal hygiene and grooming? Thought processes, self-esteem, and social interactions are evaluated because these areas are often problematic in people with depression. The nurse should assess self-esteem. How do you feel about yourself now as compared with when you were admitted? The nurse will evaluate negativity and if the patient is able to identify positive aspects of individual functioning

application of nursing process when providing care to patients with anxiety disorder

Assessment General Assessment People with anxiety and obsessive-compulsive disorders rarely need hospitalization unless they are suicidal or have compulsions that cause injury (e.g., cutting self, infected sores from picking). Most of these individuals are encountered incidentally in a variety of community settings. A common example is someone taken to an emergency department to rule out a heart attack when in fact the individual is experiencing a panic attack. It is essential to determine whether the anxiety is the primary problem, as in an anxiety disorder, or secondary to another source (medical condition or substance). Your assessment should be patient-centered to be helpful or meaningful. First and foremost is the recognition that the patient is the expert when it comes to his or her own illness. Elicit information about what has helped in the past. Identify expectations for the patient's personal participation in care and for the family or significant other's participation in care. Assess for specific cultural, ethnic, and social backgrounds that may impact the care that you and the patient plan. Objectively, there are a variety of scales available to measure anxiety and anxiety-related symptoms, and most are available online. The Yale-Brown Obsessive Compulsive Scale measures severity of compulsive behavior. The Hoarding Scale Self-Report measures hoarding; phobias are measured on the Fear Questionnaire; and panic symptoms are measured on the Panic Disorder Severity Scale. The Severity Measure for Generalized Anxiety Disorder in Adults is a popular tool for measuring anxiety (Fig. 15.2). High scores may indicate generalized anxiety disorder or panic disorder, although it is important to note that high anxiety scores may also be a symptom of major depressive disorder. Self-Assessment As a nurse working with an individual with an anxiety or obsessive-compulsive disorder, you may have feelings of frustration, especially if it seems that his or her symptoms are a matter of choice or under personal control. The rituals of the patient with obsessive-compulsive disorder may seriously slow your ability to complete certain nursing tasks within the usual time. How do you respond to a person with a phobia who acknowledges that the fear is exaggerated and unrealistic yet continues to engage in avoidant behavior? Behavioral change is often accomplished slowly. The recovery process is very different from what is seen in physical disorders such as an infection. After being given antibiotics, improvement may be seen in as little as 24 hours. Planning outcomes in small attainable steps can help prevent you from feeling overwhelmed by the patient's slow progress and help the patient gain a sense of control. Diagnosis The North American Nursing Diagnosis Association International (Herdman & Kamitsuru, 2014) provides many nursing diagnoses that can be considered for patients with anxiety and obsessivecompulsive disorders. The related-to component will vary with the individual patient. Outcomes Identification The Nursing Outcomes Classification (NOC) identifies desired outcomes for patients with anxietyrelated or obsessive-compulsive disorders (Moorhead et al., 2013). Outcomes are linked with signs and symptoms and nursing diagnoses in Table 15.8. Planning Whenever possible, the patient should be encouraged to participate actively in planning. By sharing decision making with the patient, you can increase the likelihood that the treatment regimen will be successful. Owning responsibility for health outcomes improves adherence. Shared planning is especially appropriate for someone with mild or moderate anxiety. When experiencing severe levels of anxiety, a patient may be unable to participate in planning, and the nurse may be required to take a more directive role. Implementation When working with patients with anxiety and obsessive-compulsive disorders, you must first determine what level of anxiety they are experiencing. A general framework for anxiety interventions can then be built on a solid foundation. Mild to Moderate Levels of Anxiety A person experiencing a mild to moderate level of anxiety is still able to solve problems; however, the ability to concentrate decreases as anxiety increases. A patient can be helped to focus and solve problems when you use specific nursing communication techniques such as asking open-ended questions, giving broad openings, and exploring and seeking clarification. Closing off topics of communication and bringing up irrelevant topics can increase a person's anxiety, making the nurse, not the patient, feel better. Reducing the patient's anxiety level and preventing escalation to more distressing levels can be aided by providing a calm presence, recognizing the anxious person's distress, and being willing to listen. Evaluation of effective past coping mechanisms is also useful. Often you can help the patient consider alternatives to problem situations and offer activities that may temporarily relieve feelings of inner tension. Table 15.9 identifies interventions useful in assisting people experiencing mild to moderate levels of anxiety. Severe to Panic Levels of Anxiety A person experiencing a severe to panic level of anxiety is unable to solve problems and may have a poor grasp of what is happening in the environment. Unproductive relief behaviors may take over, and the person may not be in control. Priority nursing interventions are to provide for the safety of the patient and others and to meet physical needs (e.g., fluids, rest) to prevent exhaustion. Anxiety-reduction measures may take the form of guiding the person to a quiet environment. The use of medications and restraints/seclusion may have to be considered. As always, both medications and restraints should be used only after other less-restrictive interventions have failed to decrease anxiety to safer levels. Because individuals experiencing severe to panic levels of anxiety are unable to solve problems, the techniques suggested for communicating with people with mild to moderate levels of anxiety are not as effective at more severe levels. Patients experiencing severe to panic anxiety levels are out of control, so they need to know they are safe from their own impulses. Firm, short, and simple statements are useful. Reinforcing commonalities in the environment and pointing out reality when there are distortions can also be useful interventions for severely anxious people. Table 15.10 suggests some basic nursing interventions for patients with severe to panic levels of anxiety. Anxiety management and reduction are primary concerns when working with patients who have anxiety and obsessive-compulsive disorders, but they may have a variety of other needs. When developing a plan of care, the psychiatric-mental health registered nurse can utilize the Psychiatric- Mental Health Nursing: Scope and Standards of Practice (American Nurses Association [ANA] et al., 2014). The Nursing Interventions Classification (NIC) offers pertinent interventions in the behavioral and safety domains (Bulechek et al., 2013). Refer to Box 15.1 for potential nursing interventions for patients experiencing anxiety. Guidelines for basic nursing interventions are: 1. Use counseling, milieu therapy, promotion of self-care activities, and psychobiological and health teaching interventions as appropriate. 2. Guide patients through slow, deep breathing exercises along with progressive muscle relaxation. 3. Identify community resources that can offer the patient specialized treatment proven to be highly effective for people with a variety of anxiety disorders. 4. Identify community support groups for people with specific anxiety disorders and their families. Counseling Basic-level psychiatric-mental health registered nurses use counseling to reduce anxiety, enhance coping and communication skills, and intervene in crises. When patients request or prefer to use integrative therapies, the nurse performs assessment and teaching as appropriate. Teamwork and Safety As mentioned earlier, most patients who demonstrate anxiety disorders and obsessive-compulsive disorders can be treated successfully as outpatients. Hospital admission is necessary only if severe anxiety or compulsive symptoms interfere with the individual's health or if the individual is suicidal. When hospitalization is necessary, the healthcare team can be especially effective by: • Collaborating to develop a multidisciplinary treatment plan to address goals, interventions, and outcomes that includes the patient's input. • Evaluating and refining the plan of care at regular intervals. • Documenting the plan and other essential communication electronically through an interactive and secure system. • Identifying specific members of the treatment team to be responsible for carrying out specific actions of the plan. • Maximizing safety through the provision of calm and consistent care. • Stressing the value of unconditional positive regard. • Maintaining a safe environment with an atmosphere of low-level stimulation. • Providing ongoing education and training for the team to recognize escalating or problematic behaviors. Promotion of Self-Care Activities 578 Respecting the patients' preferences for how involved they are in self-care, while recognizing that they may require more or less guidance depending on their level of ability, is a fine balance. Including the patient in care decisions is essential whenever possible. Patients with anxiety and obsessive-compulsive disorders are usually able to meet their own basic physical needs. Self-care activities that are most likely to be affected are discussed in the following sections. Nutrition and Fluid Intake Patients with high levels of anxiety are not focused on eating and drinking. Some phobic patients may be so afraid of germs that they cannot eat. In home settings, individuals who hoard may have created an environment that is so dysfunctional that normal intake may be impossible. Likewise, people who engage in ritualistic behaviors may be too involved with their rituals to take time to eat and drink. In general, nutritious diets with snacks should be provided. Adequate intake should be firmly encouraged, but power struggles should be avoided. Weighing patients frequently (e.g., three times a week) is useful in assessing nutrition. Personal Hygiene and Grooming Some patients with anxiety and obsessive-compulsive disorders are indecisive about bathing or about what clothing should be worn. For the latter, limiting choices to two outfits is helpful. In the event of severe indecisiveness, simply presenting the patient with the clothing to be worn may be necessary. You may also need to remain with the patient to give simple directions: "Put on your shirt. Now put on your slacks." Matter-of-fact support is effective in assisting patients to independently perform as much of a task as possible. Encourage patients to express thoughts and feelings about self-care. This communication can provide a basis for future health teaching or for ongoing dialogue about the patient's abilities. Some patients, especially those with obsessive-compulsive disorder and phobias, may be excessively neat and engage in time-consuming rituals associated with bathing and dressing. Hygiene, dressing, and grooming may take several hours. Maintenance of skin integrity may become a problem when the rituals involve excessive washing and skin becomes excoriated and infected. Assessment of skin integrity is also a concern for individuals who pull their hair or pick at their skin. Elimination Patients with severe obsessive-compulsive disorder may be so involved with the performance of rituals that they may suppress the urge to void and defecate. Urinary tract infections and constipation may result. Interventions may include creating a regular schedule for taking the patient to the bathroom. Sleep Patients experiencing anxiety and obsessive-compulsive disorders frequently have difficulty sleeping, particularly in falling asleep. Patients with generalized anxiety disorder often experience sleep disturbance from nightmares. Separation anxiety disorder may have such profound fears that sleep seems impossible. Patients may perform rituals to the exclusion of resting and sleeping, and physical exhaustion may occur. Teaching patients how to discover ways to promote sleep (e.g., warm bath, warm milk, and relaxing music) and monitoring sleep through a sleep record are useful interventions. Chapter 19 offers an in-depth discussion of sleep disturbances. Pharmacological Interventions Several classes of medications have been found to be effective in the treatment of anxiety disorders. Table 15.11 identifies medications approved by the US Food and Drug Administration (FDA) for the treatment of anxiety disorders. Refer to Chapter 3 for a more detailed explanation of the actions of psychotropic medications. Antidepressants SSRIs are considered the first line of defense in most anxiety and obsessive-compulsive-related disorders. These SSRIs include paroxetine (Paxil), fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Luvox), and sertraline (Zoloft). Some of these antidepressants exert more of an activating effect than others and may actually increase anxiety initially. Fluoxetine and sertraline tend to be the most activating. Paroxetine seems to have a more calming effect than the other SSRIs. Antidepressants have the secondary benefit of treating comorbid depressive disorders. Venlafaxine (Effexor) is a serotonin norepinephrine reuptake inhibitor (SNRI) that is quite successful in the treatment of several anxiety disorders. Another SNRI, duloxetine (Cymbalta), is effective in the treatment of generalized anxiety disorder. Monoamine oxidase inhibitors (MAOIs) are reserved for treatment-resistant conditions because of the risk of life-threatening hypertensive crisis if the patient does not follow dietary restrictions (patients cannot eat foods containing tyramine and must be given specific dietary instructions). The risk of hypertensive crisis also makes the use of MAOIs contraindicated in patients with comorbid substance use disorders. See Chapter 14 for a full discussion of antidepressants. Antianxiety Drugs Antianxiety drugs are often used to treat the somatic and psychological symptoms of anxiety disorders. When moderate or severe anxiety is reduced, patients are better able to participate in treatment of their underlying problems. Benzodiazepines are most commonly used because they have a quick onset of action. However, due to the potential for dependence, these medications should be used for short periods, only until other medications or treatments reduce symptoms. An important nursing intervention is to monitor for side effects of the benzodiazepines including sedation, ataxia, and decreased cognitive function. Paradoxical reactions—reactions that are the exact opposite of intended responses—sometimes occur. Symptoms such as anxiety, agitation, talkativeness, and loss of impulse control may occur when using this classification of medications. Benzodiazepines are not recommended for patients with a substance use disorder. They are not recommended for elderly patients due to risk of delirium, falls, and fractures. The decision to use benzodiazepines during pregnancy should be made by weighing the risk of fetal exposure versus the risk of untreated anxiety disorders (US Department of Health and Human Services, 2012). Benzodiazepine use shortly before delivery can result in a dystonia and muscle weakness in the newborn known as floppy infant syndrome. Withdrawal symptoms in the neonate have been known to occur. Prenatal benzodiazepine exposure increases the risk of oral cleft lip and palate, although the absolute risk increases by only 0.01%. The FDA warns against breastfeeding while taking these drugs since they pass into breast milk. Box 15.2 summarizes important information for patient teaching. Buspirone (BuSpar) is an alternative antianxiety medication that does not cause dependence, but 2 to 4 weeks are required for it to reach full effects. The drug may be used for long-term treatment and should be taken regularly. Side effects include dizziness, nausea, headache, nervousness, lightheadedness, and excitement. Buspirone is not recommended for individuals with impaired hepatic or renal function since in increased plasma levels and lengthened half-life may result. There is no direct evidence that this 581 medication poses a danger to the developing infant. The FDA recommends using the drug during pregnancy and breastfeeding only if clearly necessary. Other Classes of Medications Other classes of medications sometimes used to treat anxiety disorders include beta-blockers, antihistamines, anticonvulsants, and antipsychotics. These agents are often added if the first course of treatment is ineffective. Beta-blockers block the receptors that, when stimulated, cause the heart to beat faster. The beta-blockers reduce physical manifestations of anxiety by slowing the heart rate and reducing blushing and have been used to treat social anxiety disorder. Anticonvulsants have shown some benefit in the management of generalized anxiety disorder and social anxiety disorder. Gabapentin (Neurontin) and pregabalin (Lyrica), for example, are Antihistamines are a safe nonaddictive alternative to benzodiazepines to lower anxiety levels and again are helpful in treating patients with substance use problems. Antipsychotic medications are useful in treating more severe symptoms of anxiety disorders. There are no FDA-approved drugs for the treatment of the following disorders: separation anxiety, specific phobia, body dysmorphic, hoarding, trichotillomania, and excoriation. Despite the lack of approval, these conditions are often treated with antidepressants, antianxiety agents, and the other classes of medications previously described. Pharmacological Interventions in Children and Adolescents A few drugs are approved specifically for anxiety and obsessive-compulsive disorders in children and adolescents. The FDA approved the SNRI duloxetine (Cymbalta) in 2014 for children aged 7 to 17 years for generalized anxiety disorder. The FDA has approved four medications for use in children with obsessive-compulsive disorder. They are clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft). However, medications approved for other age groups are still prescribed off label. SSRIs are 582 being used for generalized anxiety disorder, panic disorder, and social anxiety disorder with good results. For children with obsessive-compulsive and related disorders, SSRIs are also often used. Psychobiological Interventions Besides medication, there are few biological interventions available to disrupt the course of the 583 anxiety and anxiety-related disorders. Surgery has been used in obsessive-compulsive disorder for those most severely affected. A Gamma Knife® creates irreversible damage known as lesions to certain areas of the brain, resulting in a disconnect of overactive circuits or regions. A relatively new reversible surgical treatment being used for obsessive-compulsive disorder is deep brain stimulation. This technique is considered a valid treatment (Alonso et al., 2015). Electrodes are surgically placed in the subthalamic nucleus of the brain. Then an implanted pulse generator in the chest activates a low-dose current for a specified period of time (several months in some cases). Researchers have reported a decrease of 35% on a measurement of obsessivecompulsive symptoms. Complementary and Integrative Therapy Chapter 35 identifies a number of complementary practices or integrative therapies that people use to cope with stress in their lives. Herbal therapy and dietary supplements are commonly used, yet they are not subject to the same rigorous testing as prescription medications. Also, herbs and dietary supplements may not be uniformly prepared or dosed, and there is no guarantee of bioequivalence of the active compound among preparations. Problems that can occur with the use of psychotropic herbs include toxic side effects and herb-drug interactions. Nurses and other healthcare providers should stay current regarding these popular products in order to assist their patients in making informed decisions. One example is kava, which is derived from the roots of Piper methysticum, a South American plant. Kava is used as a sedative with antianxiety effects. As an alternative to seeking professional care, people with anxiety disorders may try kava in the belief that herbs are safer than medications, but it has a dark side. In 2010 the FDA issued a warning regarding its risk of liver damage. Kava is known to dramatically inhibit the P450 liver enzyme necessary for the metabolism of many medications. This inhibition could result in liver failure, especially when taken along with alcohol or other medications such as central nervous system depressants (antianxiety agents fall into this category). Health Teaching Health teaching is a significant nursing intervention for patients with anxiety disorders. Patients may conceal symptoms for years before seeking treatment and often come to the attention of healthcare providers during a co-occurring problem. People with panic disorder and generalized anxiety disorder seem more motivated than those with other anxiety disorders to get treatment; most seek help during the first year of symptoms (Wang et al., 2005). Teaching about the specific disorder and available effective treatments is a major step toward improving the quality of life for those with anxiety disorders. Whether in a community or hospital setting, nurses can teach patients about signs and symptoms of anxiety disorders, presumed causes or risk factors (especially substance abuse), medications, the use of relaxation techniques, and the benefits of psychotherapy. Relaxation exercises for breathing or muscle groups are extremely useful in initiating a relaxation response. The relaxation response is the opposite of the stress response and results in a reduced heart rate and breathing and relaxed muscles. Refer to Chapter 10 for a description of different approaches to relaxation training. Advanced Practice Interventions Psychiatric-mental health advanced practice registered nurses use evidence-based cognitive treatment approaches. Behavioral approaches such as modeling, systematic desensitization, flooding, response prevention, and thought stopping are also useful with the anxiety and obsessivecompulsive disorders. Cognitive-behavioral therapies link both of these approaches. Cognitive Therapy Cognitive therapy is based on the belief that patients make errors in thinking that lead to mistaken negative beliefs about self and others. For example, "I have to be perfect or my boyfriend will not love me." Through a process called cognitive restructuring, the therapist helps the patient (1) identify automatic negative beliefs that cause anxiety, (2) explore the basis for these thoughts, (3) 584 reevaluate the situation realistically, and (4) replace negative self-talk with supportive ideas. Behavioral Therapy There are currently several forms of behavioral therapy, which involve teaching and physical practice of activities to decrease anxious or avoidant behavior: • Modeling: The therapist or significant other acts as a role model to demonstrate appropriate behavior in a feared situation, and then the patient imitates it. For example, the role model rides in an elevator with a claustrophobic patient. • Systematic desensitization: The patient is gradually introduced to a feared object or experience through a series of steps, from the least frightening to the most frightening (graduated exposure). The patient is taught to use a relaxation technique at each step when anxiety becomes overwhelming. For example, a patient with agoraphobia would start with opening the door to the house to go out on the steps and advance to attending a movie in a theater. The therapist may start with imagined situations in the office before moving on to in vivo (live) exposures. • Flooding: Unlike systematic desensitization, this method exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response. The patient learns through prolonged exposure that survival is possible and that anxiety diminishes spontaneously. For example, an obsessive patient who usually touches objects with a paper towel may be forced to touch objects with a bare hand for 1 hour. By the end of that period, the anxiety level is lower. • Response prevention: This method is used for compulsive behavior. The therapist does not allow the patient to perform the compulsive ritual (e.g., hand washing), and the patient learns that anxiety does subside even when the ritual is not completed. After trying this in the office, the patient learns to set time limits at home to gradually lengthen the time between rituals until the urge fades away. • Thought stopping: Through this technique a negative thought or obsession is interrupted. The patient may be instructed to say "Stop!" out loud when the idea comes to mind or to snap a rubber band worn on the wrist. This distraction briefly blocks the automatic undesirable thought and cues the patient to select an alternative, more positive idea. (After learning the exercise, the patient gives the command silently.) Cognitive-Behavioral Therapy Cognitive-behavioral therapy combines cognitive therapy with specific behavioral therapies to reduce the anxiety response. Cognitive-behavioral therapy includes cognitive restructuring, psychoeducation, breath restraining and muscle relaxation, teaching of self-monitoring for panic and other symptoms, and in vivo (real life) exposure to feared objects or situations. Evaluation Identified outcomes serve as the basis for evaluation. In general, evaluation of outcomes for patients with anxiety and obsessive-compulsive disorders deals with questions such as the following: • Is the patient experiencing a reduced level of anxiety? • Does the patient recognize symptoms as anxiety related? • Does the patient continue to display signs and symptoms such as obsessions, compulsions, phobias, worrying, or other symptoms of anxiety disorders? If still present, are they more or less frequent? More or less intense? • Is the patient able to use new behaviors to manage anxiety? • Does the patient adequately perform self-care activities? • Can the patient maintain satisfying interpersonal relations? • Is the patient able to assume usual roles?

signs and symptoms of depression

Assessment Tools Numerous standardized depression-screening tools that help assess the type and severity of depression are available. Common screening tools are the Beck Depression Inventory, the Hamilton Depression Scale, and the Geriatric Depression Scale. The Patient Health Questionnaire-9 (PHQ-9) is a short inventory that highlights predominant symptoms seen in depression. It is presented here because of its ease of use (Fig. 14.2) in primary care and community settings. Administering these tools at baseline and then again periodically allows clinicians to follow changes in the patient's symptoms and depression severity over time. Assessment of Suicide Potential The most dangerous aspect of major depressive disorder is a preoccupation with death. A patient may fantasize about her funeral or experience recurring dreams about death. Beyond these passive fantasies are thoughts of wanting to die. As a whole, all these nihilistic thoughts are referred to as suicidal ideation. These thoughts may be relatively mild and fleeting, or persistent and involve a plan. Suicidal ideation, especially those in which the patient has a plan and the means to carry the plan out, represents an emergency requiring immediate intervention (refer to Chapter 25). Suicidal thoughts are a major reason for hospitalization for patients with major depression. Patients diagnosed with major depressive disorder should always be evaluated for suicidal ideation. Risk for suicide is increased when depression is accompanied by hopelessness, substance use problems, a recent loss or separation, a history of past suicide attempts, and acute suicidal ideation. The following statements and questions help set the stage for assessing suicide potential: • "You said you are depressed. Tell me what that is like for you." • "When you feel depressed, what thoughts go through your mind?" • "Have you gone so far as to think about taking your own life? Do you have a plan?" • "Do you have the means to carry out your plan?" • "Is there anything that would prevent you from carrying out your plan?" Refer to Chapter 25 for a detailed discussion of suicide, critical risk factors, warning signs, and strategies for suicide prevention. Also see the Case Study and Nursing Care Plan Key Assessment Findings A depressed mood and anhedonia are the key symptoms in depression. Anxiety is also a common symptom in depression. When people experience a depressive episode, their thinking is slow, and their memory and concentration are usually negatively affected. They also dwell on and exaggerate their perceived faults and failures and are unable to focus on their strengths and successes. A person with major depression may experience delusions of being punished for committing bad deeds or being a terrible person. Feelings of worthlessness, hopelessness, guilt, anger, and helplessness are common. Depression and chronic pain are commonly seen together in primary care. Neurotransmitters for both problems are shared, as are nerve pathways, which can interact in a vicious cycle. Then there is the two-way interaction between pain and depression. Being in constant pain creates negative thinking overall and dampens brain chemistry, resulting in depression. On the other hand, depression magnifies pain and may also create a vulnerability to other physical problems. Areas to Assess Affect Affect is the outward representation of a person's internal state of being and is an objective finding based on the nurse's assessment. A person who has depression sees the world through gray-colored glasses. Posture is poor, and the patient may look older than the stated age. Facial expressions convey sadness and dejection, and the patient may have frequent bouts of weeping. Conversely, the patient may say that he or she feels numb or is unable to cry. Feelings of hopelessness and despair are readily reflected in the person's affect. For example, the patient may not make eye contact, may speak in a monotone, may show little or no facial expression (flat affect), and may make only yes or no responses. Frequent sighing is common. Thought Processes During a depressive episode, the person's ability to solve problems and think clearly is negatively affected. Judgment, or the ability to make reasonable decisions, is poor. This poor judgment leads to indecisiveness, which makes it difficult to make simple decisions such as what to wear or what to eat. The individual may claim that his mind is slowing down. Memory and concentration are poor. Patients might complain of intrusive negative thoughts. In extreme depression, a person may become mute. In cases of severe and profound depression, evidence of delusions (false thoughts) may also be present. An example of a delusional thought is, "I am responsible for Elvis Presley's death. I worked in a factory that made pill molds. Elvis died from an overdose. I deserve to die." Mood Mood is the patient's subjective experience of sustained emotions or feelings. Asking a person how he feels can assess a person's mood. Anhedonia (an "without" + hedone "pleasure" = inability to feel happy) refers to the absence of happiness or pleasure in aspects of life that once made them happy. Feelings Feelings frequently reported by those with depression include worthlessness, guilt, helplessness, hopelessness, and anger. Feelings of worthlessness range from feeling inadequate to having an unrealistically negative evaluation of self-worth. These feelings reflect the low self-esteem that is a painful partner to depression. Statements such as "I am no good" or "I'll never amount to anything" are common. Guilt is a nearly universal accompaniment to depression. A person may ruminate over present or past failings,"I was never a good parent," or "It's my fault that project at work failed." These thoughts tend to occur over and over again and are difficult for the patient to stop. These negative ruminations fill in the hours of lost sleep. Cognitive Changes Helplessness is demonstrated by a person's inability to solve problems in response to common concerns. In severe situations helplessness may be evidenced by the inability to carry out the simplest tasks (e.g., grooming, doing housework, working, caring for children) because they seem too difficult to accomplish. With feelings of helplessness come feelings of hopelessness, which are particularly correlated with suicidality. Even though most depressive episodes are time limited, people experiencing them believe things will never change. This feeling of utter hopelessness can lead people to view suicide as a way out of constant mental pain. Hopelessness includes the following attributes: • Negative expectations for the future • Loss of control over future outcomes • Passive acceptance of the futility of planning to achieve goals • Emotional negativism, as expressed in despair, despondency, or depression Anger and irritability are natural outcomes of profound feelings of helplessness. Anger in depression is often expressed inappropriately through hurtful verbal attacks, physical aggression toward others, or destruction of property, and anger may be directed toward the self in the form of suicidal or otherwise self-destructive behaviors (e.g., alcohol abuse, substance abuse, overeating, smoking). These behaviors often reinforce feelings of low self-esteem and worthlessness. Physical Behavior Most people with depression experience anergia, which refers to an abnormal lack of energy. Anergia may result in psychomotor retardation, in which movements are extremely slow, facial expressions are decreased, and gaze is fixed. The continuum of psychomotor retardation may range from slowed and difficult movements to complete inactivity and incontinence. Conversely, some patients experience psychomotor agitation, manifested in pacing, nail biting, finger tapping, or engaging in some other tension-relieving activity. Subjectively, patients commonly feel fidgety and unable to relax. Vegetative signs of depression refer to alterations in those activities necessary to support physical life and growth (e.g., eating, sleeping, elimination, and sex). Appetite changes vary in individuals experiencing depression. Appetite loss is common, and sometimes patients can lose up to 5% of their body weight in less than a month. Other patients find they eat more often and complain of weight gain. Change in sleep pattern is a cardinal sign of depression. Often, people experience insomnia, wake frequently, and have a total reduction in sleep, especially deep-stage sleep. Waking at 3 or 4 a.m. and then staying awake is common as is sleeping for short periods only. The light sleep of a person with depression tends to prolong the agony of depression over a 24-hour period. For some, sleep is increased (hypersomnia) and provides an escape from painful feelings. In any event, sleep is rarely restful or refreshing. Changes in bowel habits are common. Constipation is seen most frequently in patients with psychomotor retardation. Diarrhea occurs less frequently, often in conjunction with psychomotor agitation or anxiety. Sexual interest declines (loss of libido) during depression. Some men experience impotence, and a declining interest in sex often occurs among both men and women, which can further complicate marital and social relationships. Grooming, dressing, and personal hygiene may be markedly neglected. People who usually take pride in their appearance and dress may allow themselves to look shabby and unkempt. They may neglect to bathe, change clothes, or engage in other basic self-care activities. Age Considerations Assessment in Children and Adolescents As children grow and develop, they may display a wide range of moods and behavior, making it easy to overlook signs of depression. The core symptoms of depression in children and adolescents are the same as for adults, which are sadness and loss of pleasure. What differs is how these symptoms are displayed. For example, a very young child may cry, a school-age child might withdraw, and a teenager may become irritable in response to feeling sad or hopeless. Younger children may suddenly refuse to go to school while adolescents may engage in substance abuse or sexual promiscuity and be preoccupied with death or suicide. Assessment of Older Adults Because they are more likely to complain of physical illness than emotional concerns, depression might be overlooked. Older patients actually do have comorbid physical problems, and it is difficult to determine whether fatigue, pain, and weakness are the result of an illness or depression. The Geriatric Depression Scale is a 30-item tool that is both valid and reliable in screening for depression in the older adult (Sheikh & Yesavage, 1986). Its "yes" or "no" format makes this scale easier to administer with patients with cognitive deficits. It can be helpful in determining suicidality in this population. Self-Assessment Patients with depression often reject the advice, encouragement, and understanding of the nurse and others, and they often appear unresponsive to nursing interventions and resistant to change. When this occurs, the nurse may experience feelings of frustration, hopelessness, and annoyance. These problematic responses can be altered in the following ways: • Recognizing unrealistic expectations for yourself or the patient • Identifying feelings that the patient may be experiencing • Understanding the roles biology and genetics play in the precipitation and maintenance of a depressed mood As a student, your personal feelings should be recognized, named, and examined. You can discuss feelings with peers, staff, and faculty to separate personal feelings from those originating with the patient. Ultimately, supervision or peer support can increase your therapeutic potential and self-esteem while caring for individuals with depression. Previous suicidal attempts, putting affairs in order, giving away prized possessions, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness Risk for self-directed violence Risk for suicide Expresses feelings, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope Inef ective coping Identifies ineffective and effective coping, uses support system, uses new coping strategies, engages in personal actions to manage stressors effectively Dull/sad affect, no eye contact, preoccupation with own thoughts, seeks to be alone, uncommunicative, withdrawn, feels rejected and not good enough Social isolation Attends group meetings, interacts spontaneously with others, talks with the nurse in 1:1, demonstrates interest in engaging with family and others Feelings of helplessness, hopelessness, powerlessness Hopelessness Powerlessness Expresses hope for a positive future, believes that personal actions impact outcomes, demonstrates optimism and describes plans for the future Questioning meaning of life and existence, anger toward greater power, feeling abandoned, perceived suffering Spiritual distress Shares feelings of connectedness with self, others, and a higher power, identifies meaning and purpose in life Exaggerates negative feedback about self, excessive seeking of reassurance, guilt, indecisive and nonassertive behavior, poor eye contact, shame Chronic low selfesteem Identifies strengths, verbalizes self-acceptance, participates in groups, expresses a personal judgment of self-worth Vegetative signs of depression: grooming and hygiene deficiencies, significantly reduced appetite, changes in sleeping, eating, elimination, sexual patterns Self-care deficit (bathing, dressing) Insomnia Imbalanced nutrition: less than body requirements Constipation Sexual dysfuntion Increases baseline personal care each day, reports adequate sleep, eating and elimination normalize, returns to a normal level of physiologic activity

pathogenesis of bipolar

Biological Factors Genetics The lifetime prevalence for bipolar disorder is 3.9% (Kessler et al., 2005). However, the illness tends to run in families, and the lifetime risk for individuals with an affected parent is 15% to 30% greater (Fusar-Poli et al., 2012). The concordance rate among identical twins is around 70%. This means that if one twin has the disorder, 70% of the time the other one will too. Despite the high concordance rate in identical twins, it is uncommon for clinicians to find a positive family history for bipolar disorder (Kerner, 2014). This finding probably means that the disease is polygenic or that a number of genes contribute to its expression. Recent research suggests there may be an overlap between rare genetic variations linked to bipolar disorder and those implicated in schizophrenia and autism (Goes et al., 2016). Some evidence suggests that bipolar disorders are more prevalent in adults who had high intelligence quotients (IQs), particularly verbally, as children (Smith et al., 2015). People with bipolar disorders appear to achieve higher levels of education and higher occupational status than individuals with unipolar depression. Also, the proportion of patients with bipolar disorders among creative writers, artists, highly educated men and women, and professionals is higher than in the general population. Neurotransmitters Neurotransmitters such as norepinephrine, dopamine, and serotonin were the early focus for researchers who studied mania and depression. A simple explanation is that too few of these chemical messengers will result in depression, and an overabundance will bring about mania. However, proportions of neurotransmitters in relation to one another may be more important. Receptor site insensitivity could also be at the root of the problem; even if there is enough of a certain neurotransmitter, it is not getting to where it needs to go. Brain Structure and Function Structural neuroimaging techniques (e.g., computed tomography [CT] and magnetic resonance imaging [MRI]) provide still pictures of the scalp, skull, and brain. Structural imaging is useful in viewing bones, tissues, blood vessels, tumors, infection, damage, or bleeding. Functional neuroimaging techniques (e.g., positron emission tomography [PET], functional MRI [fMRI], and magnetoencephalography [MEG]) provide measures related to brain activity. Functional imaging reveals activity and chemistry by measuring the rate of blood flow, chemical activity, and electrical impulses in the brain during specific tasks. With bipolar disorder, functional imaging techniques reveal dysfunction in the prefrontal cortical region, the region associated with executive decision making, personality expression, and social behavior (Phillips & Schwartz, 2014). Dysfunction is also evident in the hippocampus, which is primarily associated with memory, and the amygdala, which is associated with memory, decision making, and emotion. Dysregulation in these areas results in the characteristic emotional lability, heightened reward sensitivity, and emotional dysregulation of bipolar disorder. These abnormalities may be due to gray matter loss in these areas. Neuroendocrine The hypothalamic-pituitary-thyroid-adrenal (HPTA) axis has been the object of significant research in bipolar disorder. In fact, hypothyroidism is one of the most common physical abnormalities associated with bipolar disorder. Typically, the thyroid dysfunction is not dramatic and the problem is often undetected. In both manic and depressive states peripheral inflammation is increased. This inflammation tends to decrease in between episodes (Maletic & Raison, 2014). These findings are consistent with changes in the HPTA axis, which are known to drive inflammatory activation. Environmental Factors Children who have a genetic and biological risk of developing bipolar disorder are most vulnerable in bad environments. Stressful family life and adverse life events may result in a more severe course of illness in these individuals. Stress is also a common trigger for mania and depression in adults. Psychological Factors With the advent of improved neuroimaging techniques and treatment advances, psychological theories are largely dismissed. Mania was once thought to be a defense against underlying anxiety and depression. Mania was also thought to help individuals tolerate loss or tragedy, such as the death of a loved one. Psychodynamic theorists believed that a faulty ego uses mania when it is overwhelmed by pleasurable impulses such as sex or feared impulses such as aggression. An overactive and critical superego is replaced with the euphoria of mania and has also been suggested as the cause.

nursing process for bipolar

Self-Assessment If you are around someone experiencing mania, you will probably feel uncomfortable. This discomfort may be brought on, in part, by the patient's decreased personal space and intrusive comments. You may find yourself feeling afraid, inadequate, or even angry. Understanding, acknowledging, and sharing these responses will enhance your professional ability to care for the patient. Collaborating with staff, your nursing faculty member, and sharing your experience with peers in post conference may be helpful. Diagnosis A primary consideration for a patient in acute mania is the prevention of exhaustion. Because of the patient's poor judgment, excessive and constant motor activity, probable dehydration, and difficulty evaluating reality, risk for injury is a likely and appropriate diagnosis. Table 13.2 lists signs, symptoms, potential nursing diagnoses, and outcomes for bipolar disorders. Outcomes Identification The primary outcome for an acute manic phase is injury prevention. For example, the patient will: • Be well hydrated. • Maintain stable cardiac status. • Maintain/obtain tissue integrity. • Get sufficient sleep and rest. • Demonstrate thought self-control with aid of staff or medication. • Make no attempt at self-harm. Planning During an acute manic phase, planning focuses on medically stabilizing the patient while maintaining safety, and the hospital is usually the safest environment for accomplishing this (see the Case Study and Nursing Care Plan). Nursing care is geared toward managing medications, decreasing physical activity, increasing food and fluid intake, ensuring at least 4 to 6 hours of sleep per night, and intervening so that self-care needs are met. Seclusion, restraint, or electroconvulsive therapy (ECT) may be considered during the acute phase. Implementation Patients with bipolar disorders are often ambivalent about treatment. Only 39% of people experiencing symptoms of bipolar disorder seek treatment within the first year, and the median delay of treatment is 6 years (Wang, 2005). Self-medicating through alcohol or substances complicates the clinical picture and contributes to treatment delay. Patients may minimize the destructive consequences of their behaviors or deny the seriousness of the disease, and some are reluctant to give up the increased energy, euphoria, and heightened sense of self-esteem of hypomania. Unfortunately, lack of adherence to mood-stabilizing medication is a major cause of relapse. Establishing a therapeutic alliance with the individual with bipolar disorder is crucial to support continued treatment. Depressive Episodes Depressive episodes of bipolar disorder have the same symptoms and risks as major depression (refer to Chapter 14) although they are often more intense. Hospitalization may be required if suicidal ideation, psychosis, or catatonia is present. Pharmacological treatment is impacted by concerns of bringing on a manic phase. A discussion of medication therapy is included in this chapter. Manic Episodes Hospitalization provides safety for a patient experiencing acute mania (bipolar I disorder), imposes external controls on destructive behaviors, and provides for medication stabilization. Staff members continuously set limits in a firm, nonthreatening, and neutral manner to prevent further escalation of mania and provide safe boundaries for the patient and others. There are unique approaches to communicating with and maintaining the safety of the patient during the hospitalization period. Table 13.3 lists interventions for individual experiencing mania Electroconvulsive Therapy Electroconvulsive therapy (ECT) is used to subdue severe manic behavior, especially in patients with treatment-resistant mania and patients with rapid cycling (i.e., those who experience four or more episodes of illness per year). ECT seems to be far more effective than drug-based therapy for treatment-resistant bipolar depression (Schoeyen et al., 2015). Depressive episodes—particularly those with severe, catatonic, or treatment-resistant depression—are an indication for this treatment. Teamwork and Safety Interprofessional staff work together to create a climate of teamwork and safety. This is essential for patients who are at risk of self-harm during a depressive phase or at risk for self-harm or other harm during the acute phase. The whole treatment team is trained to recognize changes that may lead to unsafe behavior. Frequent team meetings to plan strategies for dealing with challenging patient behaviors are essential. These meetings help to minimize staff splitting and may reduce feelings of anger, fear, and isolation. Limit setting (e.g., lights out after 11 p.m.) is the main theme in treating a person in a manic state. Seclusion and Restraint Control of hyperactivity during the acute phase almost always includes immediate treatment with an antipsychotic drug. When a patient is dangerously out of control, however, use of the seclusion room or restraints may be necessary. The use of seclusion or restraints is associated with complex therapeutic, ethical, and legal issues. Most state laws prohibit the use of unnecessary physical restraint or isolation. Unless it is an emergency, the use of seclusion and restraints requires the 483 patient's consent. Seclusion and restraint may be warranted when documented data collected by the nursing and medical staff reflect the following points: • Substantial risk of harm to others or self is clear. • The patient is unable to control actions. • Other measures have failed (e.g., setting limits beginning with verbal de-escalation or using chemical restraints). Most facilities have well-defined practices for treatment with seclusion and restraint, including a proper reporting procedure through the chain of command when a patient is to be secluded. For example, the use of seclusion and restraint is permitted only on the written order of an authorized care provider (e.g., physician, advanced practice nurse, or a physician assistant), which must be reviewed and rewritten every 24 hours. The order must include the type of restraint to be used. Only in an emergency may the charge nurse place a patient in seclusion or restraint; under these circumstances, a written order must be obtained within a specified period of time (15 to 30 minutes). Protocols identify specific nursing responsibilities such as how often to observe and document the patient's behavior (e.g., every 15 minutes), how often to offer the patient food and fluids (e.g., every 30 to 60 minutes), and how often the patient can use the restroom (e.g., every 1 to 2 hours). Caregivers should measure vital signs frequently (e.g., every 1 to 2 hours). Communication with a patient in seclusion is concrete, direct, and empathetic. Patients need reassurance that seclusion is only a temporary measure and that they will be returned to the unit when they demonstrate the ability to safely be around others. Restraints and seclusion are never for punishment or for the convenience of the staff. Refer to Chapter 6 for a more detailed discussion of the legal implications of seclusion and restraints. Support Groups Patients with bipolar disorder, as well as their friends and families, benefit from support groups such as those sponsored by the Depression and Bipolar Support Alliance (DBSA), the National Alliance for the Mentally Ill (NAMI), the National Mental Health Association, and the ManicDepressive Association. Health Teaching and Health Promotion Patients and families need information about bipolar illness, with particular emphasis on its chronic and highly recurrent nature. In addition, patients and families need to learn the warning signs and symptoms of impending episodes. For example, changes in sleep patterns are especially important because they usually precede, accompany, or precipitate mania. Even a single night of unexplainable sleep loss can be taken as an early warning of impending mania. Health teaching stresses the importance of establishing regularity in sleep patterns, meals, exercise, and other activities. Box 13.2 lists health-teaching guidelines for patients with bipolar disorder and their families. Most of the medications used to treat bipolar disorder may cause weight gain and other metabolic disturbances such as altered metabolism of lipids and glucose. These alterations increase the risk for diabetes, high blood pressure, dyslipidemia, cardiac problems, or all of these in combination (metabolic syndrome). Not only do these disturbances impair quality of life and life span, but they are also a major reason for nonadherence. Teaching aimed at weight reduction and management is essential to keeping patients physically healthy and emotionally stable. Recovery concepts are particularly important for patients with bipolar disorder who often have issues with adherence to treatment. The best method of addressing this problem is to follow a collaborative-care model in which responsibilities for treatment adherence are shared. In this model, patients are responsible for making it to appointments and openly communicating information, and the healthcare provider is responsible for keeping current on treatment methods and listening carefully as the patient shares perceptions. Through this sharing, treatment adherence becomes a self-managed responsibility. Advanced Practice Interventions Many psychiatric-mental health advanced practice registered nurses (PMH-APRNs) are able to diagnose and prescribe medications for treating bipolar disorder. In addition, they may use psychotherapy to help the patient cope more adaptively to stresses in the environment and decrease the risk of relapse. Specific approaches to psychotherapy include cognitive-behavioral therapy, interpersonal and social rhythm therapy, and family-focused therapy. Many patients have strained interpersonal relationships, marriage and family problems, academic and occupational problems, and legal or other social difficulties. Psychotherapy can help them work through these difficulties, decrease some of the psychic distress, and increase selfesteem. Psychotherapeutic treatments can also help patients improve their functioning between episodes and attempt to decrease the frequency of future episodes. Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is typically used as an adjunct to pharmacotherapy in many psychiatric disorders. It involves identifying maladaptive thoughts ("I am always going to be a loser") and behaviors ("I might as well drink") that may be barriers to a person's recovery and ongoing mood stability. CBT focuses on adherence to the medication regimen, early detection and intervention for manic or depressive episodes, stress and lifestyle management, and the treatment of depression and comorbid conditions. Some research demonstrates that patients treated with cognitive therapy are more likely to take their medications as prescribed than are patients who do not participate in therapy, and psychotherapy results in greater adherence to the lithium regimen. Interpersonal and Social Rhythm Therapy Depression and manic-type states impair a person's ability to interact with others. Even in between episodes, relationships have been so damaged it may seem impossible to correct the problems. The APRN can use a specialized approach, interpersonal and social rhythm therapy. This approach aimsto regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse. Psychoeducation is a major component of this therapy and includes symptom recognition, adherence with medication and sleep routines, stress management, and maintenance of social supports. Family-Focused Therapy Family-focused therapy helps improve communication among family members. During depressive and manic episodes, family life can become a challenge or even intolerable. Negative patterns of communicating develop and become part of the fabric of the family. APRNs can help people recognize and reduce negative expressed emotion and stressors that provoke episodes. Evaluation Outcome criteria often dictate the frequency of evaluation of short-term and intermediate indicators. Are the patient's vital signs stable? Is he or she well hydrated? Is the patient able to control personal behavior or respond to external controls? Is the patient able to sleep for 4 or 5 hours a night or take frequent short rest periods during the day? Does the family have a clear understanding of the patient's disease and need for medication? Do the patient and family know which community agencies may help them? After reassessing the outcomes and care plan, the plan is revised, if indicated. Longer-term outcomes include: • Adherence to the medication regimen • Resumption of functioning in the community • Achievement of stability in family, work, and social relationships and in mood • Improved coping skills for reducing stress.

negative vs positive symptoms of schizophrenia

Positive symptoms: The presence of something that should not be present. Positive symptoms include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech. 2. Negative symptoms: The absence of something that should be present. Negative symptoms include the inability to enjoy activities, social discomfort, or lack of goal-directed behavior

signs and symptoms of anxiety disrdes

Signs and Symptoms Nursing Diagnoses Outcomes Separation from significant other, concern that a panic attack will occur, exposure to phobic object or situation, presence of obsessive thoughts, fear of panic attacks, preoccupation with perceived physical flaws, apprehension about losing prized possessions, pulling hair or picking skin Anxiety (moderate, severe, panic) Monitors intensity of anxiety, uses relaxation techniques, decreases environmental stimuli as needed, controls anxiety response, maintains role performance Unable to attend social functions or take employment, anxiety interferes with the ability to work, avoidance behaviors (phobia, agoraphobia), inordinate time taken for obsession and compulsions Inef ective coping Identifies ineffective coping patterns, asks for assistance, seeks information about illness and treatment, identifies multiple coping strategies, modifies lifestyle as needed Exaggerated negative perception of physical appearance, ashamed of the appearance of the house due to hoarding activity, believes that others are disgusted with his appearance, embarrassment about the hair or skin condition Chronic low selfesteem Verbalizes self-acceptance, communicates openly, increases confidence, describes a positive sense of self-worth Skin excoriation related to rituals of excessive washing, excessive picking at the skin, or pulling hair out Selfmutilation Identifies feelings that lead to impulsive actions, practices selfrestraint of compulsive behaviors

psychiatric emergencies

crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility Managing Behavioral Crises Behavioral crises can lead to patient violence toward self or others and usually, but not always, escalate through fairly predictable stages. Staff members in most mental health facilities practice crisis prevention and management techniques. Training generally consists of a full-day course learning the skills to recognize and avoid crisis and de-escalate behavioral emergencies. Hands-on techniques, which are only used as a last resort, are also taught. At minimum, annual training is recommended to maintain competency. Some facilities have special teams of nurses, psychiatric technicians, mental health specialists, and other professionals who respond to psychiatric emergencies called codes. Each member of the team takes part in the team effort to defuse a crisis in its early stages. If preventive measures fail and imminent risk of harm to self or others persists, each member of the team participates in a rapid, organized plan to safely manage the situation. The nurse is most often this team's leader not only in organizing the plan but also in timing the actions and managing the concurrent administration of medications. Seclusion, restraint, and emergency medication are actions of last resort. The trend is to reduce or completely eliminate these practices whenever safely possible. The nurse can initiate such an 168 intervention in the absence of a physician in most places, but must secure a physician's order for restraint or seclusion within a specified time. Refer to Chapters 6 and 27 for further discussions and protocols for use of restraints and seclusion. The concept of trauma-informed care is a guiding principle for clinical interventions and unit philosophy and is addressed more comprehensively in Chapter 16.

anxiety disorder

Anxiety Anxiety is a universal human experience and is among the most basic of emotions. It can be defined as a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat. Fear is a reaction to a specific danger, whereas anxiety is a vague sense of dread related to an unspecified or unknown danger. However, the body reacts physiologically in similar ways to both anxiety and fear. Another important distinction between anxiety and fear is that anxiety affects us at a deeper level. It invades the central core of the personality and erodes feelings of self-esteem and personal worth. Normal anxiety is a healthy reaction necessary for survival. Without anxiety our ancestors would have had little motivation to run from the saber tooth tiger or hunt the mastodon. Anxiety provides the energy needed to carry out the tasks involved in living and striving toward goals. Anxiety motivates people to make and survive change. It prompts constructive behaviors, such as studying for an examination, being on time for a job interview, preparing for a presentation, and working toward a promotion. An understanding of the levels and defensive patterns used in response to anxiety is basic to psychiatric-mental health nursing care. This understanding is essential for assessing and planning interventions to lower a patient's level of anxiety (as well as one's own) effectively. With practice, you will become skilled at identifying levels of anxiety, understanding the defenses used to alleviate anxiety, and evaluating the possible stressors that contribute to increased levels of anxiety.

signs and symptoms of personality disorders

Cluster A: Eccentric Paranoid Schizoid Schizotypal Paranoid Personality Disorder Prevalence: 2% to 4% Characteristics May be apparent in childhood Social anxiety in childhood Jealous, controlling as adults Unwillingness to forgive and projection of feelings A pervasive mistrust and suspiciousness of others Suspects others are exploiting them. Doubts the loyalty of friends. Reluctant to confide in others. Feels attacked by others and reacts to this Suspects partner of unfaithfulness. Schizoid Personality Disorder Prevalence: Nearly 5% of population Characteristics Symptoms appear in childhood and adolescence Loners, poor academic performance Increased prevalence of disordered family life Avoid close relationships Depersonalization, detachment Restricted range of affect Few close friends Little sexual interest Schizotypal PersonalityDisorder Prevalence: Varies from 0.64 to 4.6% population Characteristics Severe social and interpersonal deficits Anxiety in social situations Rambling conversation Paranoia, suspiciousness, anxiety, distrust Brief, intermittent episodes of hallucination or delusion Can be made aware of their own odd beliefs May be vulnerable to involvement with cults or unusual religious/occult groups Cluster B (Erratic) Histrionic Narcissistic Antisocial Borderline Histrionic PersonalityDisorder Prevalence: Nearly 2% of population Characteristics Excitable, dramatic; often high functioning Bold external behaviors Uses physical appearance to draw attention to self Seductive or provocative Limited ability to develop meaningful relationships Attention-seeking, self-centered; low-frustration level Excessive emotions; may be provocative; smothering No insight into disorder or role in ruining relationships Narcissistic Personality Disorder Prevalence: For 0% to 6% Characteristics Feelings of entitlement, exaggerated self importance Lack of empathy; tendency to exploit others Weak self-esteem and hypersensitivity to criticism Constant need for admiration Less functional impairment than other personality disorders Sense of entitlement Arrogant and exploitative Lacks empathy Antisocial Personality Disorder Prevalence: 1.1% Characteristics pervasive pattern of disregard for and violation of the rights of others Repeated acts that are grounds for arrest Deceitful, impulsive, irritable and aggressive Antagonistic behaviors• Unfriendly, Unkind, Aggressive, intimidating Disinhibited behaviors• Impulsive behaviors, recklessness, substance use Profound lack of empathy Absence of remorse or guilt Borderline PersonalityDisorder Clinical picture Severe impairments in functioning Emotional lability Impulsivity Self-destructive behaviors Antagonism Splitting: Inability to view both positive and negative aspects of others as part of a whole Cluster C (Anxious) Avoidant Dependent Obsessive-compulsive Avoidant PersonalityDisorder Prevalence: 2.4% Characteristics Low self-esteem Shyness that increases with age Feelings of inferiority Reluctance to engage with new people Subject to depression, anxiety, and anger Preoccupied with rejection, humiliation, and failure Dependent PersonalityDisorder Prevalence: 0.5% Characteristics High need to be taken care of Submissiveness Fears of separation and abandonment Manipulating others to take responsibilities Intense anxiety when left alone even briefly Obsessive-Compulsive Personality Disorder Prevalence: 2% to 8% Characteristics Rigidity; inflexible standards for others and self Constant rehearsal of social responses Excessive goal-seeking that is self-defeating or relationship-defeating Strict standards interfere with project completion Unhealthy focus on perfection

signs and symptoms of bipolar

Individuals with bipolar disorder are often misdiagnosed or underdiagnosed. Early diagnosis and proper treatment can help people avoid: • Suicide attempts • Alcohol or substance abuse • Marital or work problems • Development of medical comorbidity Fig. 13.2 presents Altman's Self-Rating Mania Scale. The items in this scale are useful in capturing a picture of the patient's placement on the depression to mania continuum. Scores of 6 or higher suggest mania or hypomania and the need for further assessment and/or treatment. General Assessment Individuals with bipolar disorder tend to spend more time in a depressed state than in a manic state. For a complete discussion of nursing care for the depressive aspects of bipolar, refer to Chapter 14. In this chapter we will focus on nursing care for individuals experiencing mania. The characteristics of mania discussed in the following sections are (1) mood, (2) behavior, (3) thought processes and speech patterns, thought content, and (4) cognitive function. Mood People with mania are often described as having an expansive mood, which is defined as having an elevated and unrestrained emotional expressiveness. During this euphoria period, the patient may experience intense feelings of well-being, being "cheerful in a beautiful world," or is becoming "one with God." The overly joyous mood may seem out of proportion to what is going on, and cheerfulness may be inappropriate for the circumstances. 467 FIG. 13.2 Altman Self-Rating Mania Scale (ASRM). Reprinted from Altman, E.G., Hedeker, D., Peterson, J.L., Davis, J.M. (1997). The Altman Self-Rating Mania Scale. Biological Psychiatry 42, 948-955, with permission from Elsevier. People experiencing a manic state may laugh, joke, and talk in a continuous stream with uninhibited familiarity. They often demonstrate boundless enthusiasm, treat others with confidential friendliness, and incorporate everyone into their plans and activities. They know no strangers, and energy and self-confidence seem boundless. The euphoric mood associated with mania is unstable because this mood may change quickly to irritation and anger when the person is thwarted. The irritability and belligerence may be shortlived, or it may become the prominent feature of the manic phase of bipolar disorder. The following is a patient's description of the painful transition from hypomania to mania (Jamison, 1995): 468 At first when I'm high, it's tremendous...ideas are fast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things become intensely interesting. Sensuality is pervasive; the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria...you can do anything...but somewhere this changes... The fast ideas become too fast and there are far too many...overwhelming confusion replaces clarity...you stop keeping up with it—memory goes. Infectious humor ceases to amuse—your friends become frightened...everything now is against the grain...you are irritable, angry, frightened, uncontrollable, and trapped in the blackest caves of the mind—caves you never knew were there. It will never end. Madness carves its own reality. Behavior When people experience hypomania, they have voracious appetites for social engagement, spending, and activity, even indiscriminate sex. Constant activity and a reduced need for sleep prevent proper rest. Although short periods of sleep are possible, some patients may not sleep for several days in a row. This nonstop physical activity and the lack of sleep and food can lead to physical exhaustion and worsening of mania. The individuals may pursue elaborate schemes to get rich, famous, and powerful despite objections and realistic constraints. Sometimes the person will make excessive phone calls and emails, often to well-known and influential people. Being manic means being busy during all hours of the day and night, furthering grandiose plans and wild schemes. To the person experiencing mania, no aspirations are too high and no distances are too far. In the manic state, a person often gives away money, prized possessions, and expensive gifts. The person experiencing mania may throw lavish parties and visit expensive nightclubs and restaurants. While out, they may spend money freely on friends and strangers alike—"I'll buy the next round for everyone!" This excessive spending, use of credit cards, and high living continue even in the face of seriously depleted resources. The individual often needs intervention to prevent financial ruin. Distractibility is a hallmark symptom of mania. People with mania lose their focus and go from one activity or place to another. Many projects are started, but few, if any, are completed. Inactivity is impossible, even for the shortest period of time. Hyperactivity may range from mild constant motion to frenetic wild activity. Individuals experiencing mania may be manipulative, profane, faultfinding, and skilled at detecting and then exploiting others' vulnerabilities. They constantly push limits. These behaviors often alienate family, friends, employers, healthcare providers, and others. Choices of clothing often reflect the person's grandiose yet tenuous grasp of reality. Dress may be outlandish, bizarre, colorful, and noticeably inappropriate. Makeup may be gaudy and overdone. People often emerge from a manic state startled and confused by the shambles of their lives. The following description conveys one patient's experience (Jamison, 1995): Now there are only others' recollections of your behavior—your bizarre, frenetic, aimless behavior—at least mania has the grace to dim memories of itself...now it's over, but is it?...Incredible feelings to sort through...Who is being too polite? Who knows what? What did I do? Why? And most hauntingly, will it, when will it, happen again? Medication to take, to resist, to resent, to forget...but always to take. Credit cards revoked...explanations at work...bad checks and apologies overdue...memory flashes of vague men (what did I do?)...friendships gone, a marriage ruined. Thought Processes and Speech Patterns If a person is thinking clearly, he or she is able to communicate clearly and get to the point. Mania causes a person to experience disorganized thoughts and speech patterns. This disorganization is clearly evident in several specific ways. • Pressured speech is fast, ranging from rapid to frenetic that conveys an inappropriate sense of urgency. As the name implies, the speech is pressured—if normal speech is analogous to the flow of a garden hose, pressured speech is like the stream from a fire hose. This type of speech tends to be loud, rapid, and incoherent. Individuals may talk nonstop and usually have no interest in feedback or conversation. • Circumstantial speech is adding unnecessary details when communicating with others. Unlike some of the other verbal derailments, the person eventually gets to the point. I planned to have my oil changed today. When I got in my car, I noticed that the leather on the seat was dirty. The dog. We got a brown and white beagle because Jim insisted upon it. He's a barker. That's how things have gone since we got married in 1986 at a lovely church. I'll never forget the minister wore a green suit and dirty shoes... After I cleaned the seat I drove to the garage and four guys swarmed around the car and changed the oil. • Tangential speech is similar to circumstantial speech with one key difference. When people think tangentially, they lose the point that they were trying to make and never find it again. Awareness of losing the point is an indicator of severity of thought disturbance. "Sorry I'm so scattered, I've got a lot on my mind," indicates insight. The degree of tangentiality also helps identify how serious the thought disturbance is. Often, a common word connects sentences. 470 I did the laundry that day because it was Saturday. On Saturday I always watched Ninja Turtles on television. Have you seen those 60-inch televisions? Giants. I used to think of giants as I fell asleep and I thought that sleep activated them. • Loose associations represent the disordered way that a person is processing information. Thoughts are only loosely connected to each other in the person's conversation. For example, a patient may say, "The sky's the limit now that I have money, I took a flight you know from Kennedy, drinking beer is a belly full of bags." • Flight of ideas is a continuous flow of accelerated speech with abrupt changes from topic to topic. The speech is usually based on understandable associations or plays on words. At times, the attentive listener can keep up with the flow of words, even though direction changes from moment to moment. Speech is rapid, verbose, and circumstantial. When the condition is severe, speech may be disorganized and incoherent. The incessant talking often includes joking, puns, and teasing: How are you doing, kid, no kidding around, I'm going home...home sweet home...home is where the heart is, the heart of the matter is I want out and that ain't hay...hey, Doc...get me out of this place. Speech is not only profuse but also loud, bellowing, or even screaming. One can hear the force and energy behind the rapid words. As mania escalates, the flight of ideas may give way to clang associations. Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning: Cinema I and II, last row. Row, row, row your boat. Don't be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote. Thought Content The content of speech is often sexually explicit and ranges from grossly inappropriate to vulgar. Themes in the communication of the individual with mania may revolve around extraordinary sexual skill, brilliant business ability, or unparalleled artistic talents (e.g., writing, painting, and dancing). The person may actually have only average ability in these areas. Mania brings about disturbing ways of viewing others and the world. These distorted and generally false thoughts are called delusions. • Grandiose delusions are manifested by a highly inflated self-regard. It is apparent in both the ideas expressed and the person's behavior. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers. Religious ("I am the Messiah"), science fiction ("I was abducted"), and supernatural ("I am possessed by my dead father") themes are common in grandiose delusions. Sometimes it is difficult to distinguish fact from fiction ("I made an absolute fortune during the real estate crash of 2008"). • Persecutory delusions are also disturbingly common. For example, people may think that God is punishing them, that the FBI is spying on them, or that the mayor is harassing them. Sensory perceptions may become altered as the mania escalates, and hallucinations may occur. Rarely, patients may resort to violence in retaliation for this imagined persecution. Cognitive Function The onset of bipolar disorder is often preceded by comparatively high cognitive function. However, there is growing evidence that about one-third of patients with bipolar disorder display significant and persistent cognitive problems and difficulties in psychosocial areas. Cognitive deficits in bipolar disorder are milder but similar to those in patients with schizophrenia. Cognitive impairments are greater in bipolar I but are also present in bipolar II. The potential cognitive dysfunction among many people with bipolar disorder has specific clinical implications: • Cognitive function affects overall function. • Cognitive deficits correlate with a greater number of manic episodes, history of psychosis, chronicity of illness, and poor functional outcome. • Early diagnosis and treatment are crucial to prevent illness progression, cognitive deficits, and 471 poor outcome. • Medication selection should consider not only the efficacy of the drug in reducing mood symptoms but also the cognitive impact of the drug on the patient. Self-Assessment If you are around someone experiencing mania, you will probably feel uncomfortable. This discomfort may be brought on, in part, by the patient's decreased personal space and intrusive comments. You may find yourself feeling afraid, inadequate, or even angry. Understanding, acknowledging, and sharing these responses will enhance your professional ability to care for the patient. Collaborating with staff, your nursing faculty member, and sharing your experience with peers in post conference may be helpful.

Medications for depression

Pharmacological Interventions At the cellular level mood disorders are caused by problems with neurotransmitters. It follows that medications that alter brain chemistry are an important component in their treatment. Antidepressant therapy is an effective strategy for most cases of major depressive disorder, particularly in severe cases. A combination of psychotherapies and antidepressant therapy is superior to either psychotherapy or psychopharmacological treatment alone (Institute for Clinical Systems Improvement, 2016). Antidepressant Drugs Antidepressant drugs can positively impact poor self-concept, social withdrawal, vegetative signs of depression, and activity level. Target symptoms include the following: • Sleep disturbance • Appetite disturbance (decreased or increased) • Fatigue • Decreased sex drive • Psychomotor retardation or agitation • Diurnal variations in mood (often worse in the morning • Impaired concentration or forgetfulness • Anhedonia A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. If a patient is acutely suicidal, electroconvulsive therapy (discussed in detail later in this chapter) may be a reliable and effective alternative. The goal of antidepressant therapy is the complete remission of symptoms. Often, the first antidepressant prescribed is not the one that will ultimately bring about remission. Aggressive treatment helps in finding the proper treatment. An adequate trial for the treatment of depression is 3 months. Individuals experiencing their first depressive episode are maintained on antidepressants for 6 to 9 months after symptoms of depression remit. Some people may have multiple episodes of depression or may have a chronic form and benefit from indefinite antidepressant therapy. Genetic testing holds some promise in individualizing antidepressant therapy (Box 14.2). Antidepressants may precipitate a psychotic episode in a person with schizophrenia or a manic episode in a patient with bipolar disorder. Patients with bipolar disorder often receive a moodstabilizing drug along with an antidepressant. Choosing an antidepressant All antidepressants work to increase the availability of one or more of the neurotransmitters, serotonin, norepinephrine, and dopamine. All antidepressants have demonstrated similar efficacy in pharmaceutical trials. Each of the antidepressants has different adverse effects, costs, safety issues, and maintenance considerations. Selection of the appropriate antidepressant is based on the following considerations: • Symptom profile of the patient • Side-effect profile (e.g., sexual dysfunction, weight gain) • Ease of administration • History of past response • Safety and medical considerations • Genotyping (when available) Table 14.6 provides an overview of antidepressants used in the United States. Selective serotonin reuptake inhibitors The selective serotonin reuptake inhibitors (SSRIs) selectively block the neuronal uptake of serotonin (e.g., 5-HT, 5-HT1 receptors). This blockage increases the availability of serotonin in the synaptic cleft. Refer to Chapter 3 for a more detailed discussion of how the SSRIs work. SSRI antidepressant drugs have a relatively low side-effect profile compared with the older antidepressants (tricyclics—discussed later in this chapter). They do not create anticholinergic effects, dry mouth, blurred vision, or urinary retention, making it easier for patients to take these medications as prescribed. The SSRIs are effective in depression with anxiety features and depression with psychomotor agitation. Indications SSRIs are frequently the first-line treatment in depression. In addition to their use in treating depressive disorders, the SSRIs have been prescribed with success to treat some of the anxiety disorders—in particular obsessive-compulsive disorder and panic disorder. Fluoxetine has been found to be effective in treating some women who suffer from late-luteal-phase dysphoric disorder and bulimia nervosa. Common adverse reactions Agents that selectively enhance synaptic serotonin within the CNS may induce agitation, anxiety, sleep disturbance, tremor, sexual dysfunction (primarily anorgasmia), or tension headache. Autonomic reactions (e.g., dry mouth, sweating, weight change, mild nausea, and loose bowel movements) may also be experienced with the SSRIs. Potential toxic effects One rare and life-threatening event associated with SSRIs is serotonin syndrome. This syndrome is thought to be related to over-activation of the central serotonin receptors caused by either too high a dose or interaction with other drugs. The symptoms are many: abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental state (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change. Severe manifestations can induce hyperpyrexia (excessively high fever), cardiovascular shock, or death. The risk of this syndrome seems to be greatest when an SSRI is administered in combination with a second serotonin-enhancing agent, such as a monoamine oxidase inhibitor (MAOI). A patient should discontinue all SSRIs for 2 to 5 weeks before starting an MAOI. Box 14.3 lists the signs of serotonin syndrome and gives emergency treatment guidelines. Box 14.4 is a useful tool for patient and family teaching about the SSRIs. Serotonin norepinephrine reuptake inhibitors The serotonin norepinephrine reuptake inhibitors (SNRIs) inhibit the reuptake of both serotonin and norepinephrine. Pharmacological side effects are similar to the SSRIs, although the SSRIs may be tolerated better. The SNRIs are indicated for major depressive disorder. Other newer antidepressants Several other classifications of antidepressants have been introduced and have provided people with depression and prescribers with more options. The name of the classification describes the action of the antidepressants. They are the serotonin antagonists and reuptake inhibitors (SARIs), a norepinephrine dopamine reuptake inhibitor (NDRI), and a noradrenergic and specific serotonergic antidepressant (NaSSA). Chapter 3 provides more detail about these drug classifications. Tricyclic antidepressants The tricyclic antidepressants (TCAs) inhibit the reuptake of norepinephrine and serotonin by the presynaptic neurons in the CNS, increasing the amount of time norepinephrine and serotonin are available to the postsynaptic receptors. This increase in norepinephrine and serotonin in the brain is believed to be responsible for mood elevations. Indications The sedative effects of the TCAs are attributed to the blockade of histamine receptors. Patients must take therapeutic doses of TCAs for 10 to 14 days or longer before they begin to work. Full effects may not be seen for 4 to 8 weeks. An effect on some symptoms of depression, such as insomnia and anorexia, may be noted earlier. Choosing a TCA for a patient is based on what has worked for the patient or a family member in the past and the drug's adverse effects. A stimulating TCA, such as desipramine (Norpramin) or protriptyline (Vivactil), may be best for a patient who is lethargic and fatigued. If a more sedating effect is needed for agitation or restlessness, drugs such as amitriptyline and doxepin (Sinequan) may be more appropriate choices. Regardless of which TCA is given, the initial dose should always be low and increased gradually. Common adverse reactions The chemical structure of the TCAs closely resembles that of antipsychotic medications, and the anticholinergic actions are similar (e.g., dry mouth, blurred vision, tachycardia, constipation, urinary retention, and esophageal reflux). These side effects are more common and more severe in patients taking antidepressants. They usually are not serious and are often transitory, but urinary retention and severe constipation warrant immediate medical attention. Weight gain is also a common complaint among people taking TCAs. The α-adrenergic blockade of the TCAs can produce postural-orthostatic hypotension and tachycardia. Postural hypotension can lead to dizziness and increase the risk of falls. For this reason older patients on TCAs must be monitored carefully for dizziness and falls. Administering the total daily dose of TCA at night is beneficial for two reasons. First, most TCAs have sedative effects and thereby aid sleep. Second, the minor side effects occur while the individual is sleeping, which increases compliance with drug therapy. Potential toxic effects The most serious effects of the TCAs are cardiovascular: dysrhythmias, tachycardia, myocardial infarction, and heart block. Because the cardiac side effects are so serious, TCA use is considered a risk in older adults and patients with cardiac disease. Patients should have a thorough cardiac workup before beginning TCA therapy. Adverse drug interactions A few of the more common medications usually not given while TCAs are being used are MAOIs, phenothiazines, barbiturates, disulfiram (Antabuse), oral contraceptives (or other estrogen preparations), anticoagulants, some antihypertensives (clonidine, guanethidine, reserpine), benzodiazepines, and alcohol. A patient who is taking any of these medications along with a TCA should have medical clearance because some of the reactions can be fatal. Contraindications People who have recently had a myocardial infarction (or other cardiovascular problems), those with narrow-angle glaucoma or a history of seizures, and women who are pregnant should not be treated with TCAs except with extreme caution and careful monitoring. Patient and family teaching Areas for the nurse to discuss when teaching patients and their families about TCA therapy are presented in Box 14.5. Monoamine oxidase inhibitors The enzyme monoamine oxidase is responsible for inactivating, or breaking down, monoamine neurotransmitters in the brain such as norepinephrine, serotonin, dopamine, and tyramine. When a person takes an MAOI, fewer amines get inactivated, resulting in an increase of the mood-elevating neurotransmitters. The inability to break down tyramine sufficiently can result in a serious problem. Certain foods are quite rich in tyramine. Individuals who take MAOIs and eat these foods are at risk for a hypertensive crisis, which is severe high blood pressure that can lead to a cerebrovascular accident. People taking these drugs must reduce or eliminate their intake of foods and drugs that contain high amounts of tyramine (Table 14.7 and Box 14.6). Indications MAOIs are particularly effective for people with unconventional depression (characterized by mood reactivity, oversleeping, and overeating), as well as panic disorder, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and bulimia. MAOIs with FDA approval are phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). A transdermal patch, selegiline (EMSAM), does not require strict dietary restrictions. Common adverse reactions Some common and troublesome long-term side effects of the MAOIs are orthostatic hypotension, weight gain, edema, change in cardiac rate and rhythm, constipation, urinary hesitancy, sexual dysfunction, vertigo, overactivity, muscle twitching, hypomanic and manic behavior, insomnia, weakness, and fatigue. Potential toxic effects The most serious reaction to the MAOIs is an increase in blood pressure with the possible development of intracranial hemorrhage, hyperpyrexia, convulsions, coma, and death. Therefore routine monitoring of blood pressure, especially during the first 6 weeks of treatment, is necessary. Because many drugs, foods, and beverages can cause an increase in blood pressure in patients taking MAOIs, hypertensive crisis is a constant concern. The hypertensive crisis usually occurs within 15 to 90 minutes of ingestion of the contraindicated substance. Early symptoms include irritability, anxiety, flushing, sweating, and a severe headache. The patient then becomes anxious, restless, and develops a fever. Eventually the fever becomes severe, seizures ensue, and coma or death is possible. When a hypertensive crisis is suspected, immediate medical attention is crucial. If ingestion is recent, gastric lavage and charcoal may be helpful. Pyrexia is treated with hypothermic blankets or ice packs. Fluid therapy is essential, particularly with hyperthermia. A short-acting antihypertensive agent such as nitroprusside, nitroglycerine, or phentolamine may be used. Intravenous benzodiazepines are useful for agitation and seizure control. Contraindications The use of MAOIs may be contraindicated with each of the following: • Cerebrovascular disease • Hypertension and congestive heart failure • Liver disease • Consumption of foods containing tyramine, L-tryptophan, and dopamine (see Table 14.7) • Use of certain medications (see Box 14.6) • Recurrent or severe headaches • Surgery in the previous 10 to 14 days • Age younger than 16 years Use of antidepressants by pregnant women The risk of depression in pregnant women may be as high as 20% (Olivier et al., 2015). There is evidence that depression has a negative effect on birth outcomes. Preeclampsia, diabetes, and hypertension have all been associated with maternal depression. Low birth weight, preterm birth, and small size for gestational age have been noted effects in infants born to depressed mothers. We know that antidepressants cross the placenta. Treatment of severe depression, particularly with suicidal ideation, must weigh out the risks versus the benefits. Use of antidepressants by children and adolescents In 2004 FDA issued a black-box warning for all antidepressants. It alerted the public to an increased risk of suicidal thinking or attempts in children or adolescents taking antidepressants. Following the black-box warning, the number of prescriptions written for SSRIs for children, adolescents, and adults decreased (Friedman, 2014). Unfortunately, suicide attempts increased after the black-box warning was instituted. The risk for suicide is greater in children and adolescents with depression who do not take antidepressants. To minimize the risk of suicide in persons taking antidepressants, close monitoring by healthcare professionals and patient/caregiver education are essential. Chapter 25 has a more detailed discussion of suicide risk factors and warning signs. Use of antidepressants by older adults Polypharmacy and the normal metabolic processes of aging contribute to concerns about prescribing antidepressants for older adults. SSRIs are a first-line treatment for older adults, but this population has the potential for aggravated side effects. Starting doses are recommended to be half the lowest adult dose, with dose adjustments occurring no more frequently than every 7 days ("start low and go slow"). TCAs and MAOIs have side-effect profiles that are more dangerous for older adults, specifically cardiotoxicity with TCAs and hypotension with both classes. Any medication with a side effect of hypotension or sedation in older adults increases the risk of falls. Older adults should be cautioned against abrupt discontinuation of antidepressants because of the possibility of discontinuation syndrome, which causes anxiety, dysphoria, flulike symptoms, dizziness, excessive sweating, and insomnia.

application of nursing process when providing care to those with schizophrenia

Diagnosis Patients with schizophrenia have multiple distressing and often disabling symptoms. They require a multifaceted approach to care and treatment of both the patient and the family. Table 12.2 lists signs and symptoms and potential nursing diagnoses for a person with schizophrenia. Outcomes Identification Nursing Outcomes Classification (NOC; Moorhead et al., 2013) is one useful guide for developing outcomes. Outcomes should focus on illness knowledge, management, coping, and quality of life. Outcomes should be consistent with the recovery model (refer to Chapter 32), which stresses hope, living a full and productive life, and eventual recovery rather than focusing on controlling symptoms and adapting to disability. Desired outcomes vary with the phase of the illness. Phase I: Acute For the acute phase of schizophrenia, the overall goal is patient safety and stabilization. If the patient is a risk to self or others, initial outcome criteria address such safety issues (e.g., patient refrains from self-injury, hyponatremia is prevented). Another example of a desired outcome is a patient who consistently labels hallucinations as "not real—a symptom of an illness." Phase II: Stabilization Outcome criteria during phase II focus on patient understanding of the illness and treatment, achieving an optimal medication and psychosocial treatment regimen, and controlling and/or coping with symptoms and side effects. The outcomes target the negative and cognitive symptoms as these tend to respond less well to initial treatment than do positive symptoms and may reduce treatment success. Phase III: Maintenance Outcome criteria for phase III focus on maintaining and increasing symptom control and insight. Measures during the maintenance phase include adhering to treatment, preventing relapse, maintaining and increasing independence, and achieving a satisfactory quality of life. Planning Again, the planning of appropriate interventions is guided by the phase of the illness and the strengths and needs of the patient. Cultural considerations, available resources, and patient preferences influence planning. Phase I: Acute Hospitalization is indicated if the patient is considered a danger to self or others (e.g., refuses to eat or is too disorganized to function safely in the community). It may also be needed to clarify and confirm the diagnosis. Planning focuses on selecting the best strategies to ensure patient safety and control symptoms. Phase II: Stabilization and Phase III: Maintenance Planning during the stabilization and maintenance phases focuses on providing patient and family education, support, and skills training. Planning incorporates interpersonal, functional, coping, healthcare, shelter, educational and vocational strengths and needs, and addresses how and where these needs can best be met within the community. Relapse prevention efforts (Box 12.2) are vital. Each relapse of psychosis may increase residual dysfunction and deterioration and can contribute to despair, hopelessness, and suicide risk. Recognition of the early warning signs of relapse—such as reduced sleep, social withdrawal, and worsening concentration—followed by close monitoring and intensification of treatment is essential to minimize the duration of psychotic episodes and resulting disruption to the patient's life. Implementation Phase I: Acute Settings In general, during the acute phase of schizophrenia, 24-hour support is required to prevent harm to self or others. Hospitalization provides external structure and support (e.g., others guiding the patient's activities). As previously discussed, anosognosia is a symptom of schizophrenia that may impair a person's ability to recognize that he or she is ill. In this case, court-ordered hospitalization might be required. While a minority of patients require extended inpatient care (more than 1 month), the length of hospitalization or other intensive treatment during the acute phase is typically short (days to weeks), ending when acute symptoms have been stabilized. However, this does not necessarily take into account the extended time needed for full recovery from serious mental illness, making continued engagement and care in the community all the more important after discharge. Community-based services provide such care during the stabilization and maintenance phases. Interventions Structure within the therapeutic milieu provides a feeling of safety and security for patients who have been experiencing severe anxiety. Patients are monitored for suicide risk and intervene promptly to address risk factors such as despair or hopelessness and provide for the patient's safety (see Chapter 25). Virtually all people with psychotic disorders will be given pharmacological treatments to manage positive and negative symptoms. Medication response is monitored and side effects will be addressed. For example, fluid intake and weight can be assessed to identify polydipsia. Registered nurses provide support, psychoeducation, and guidance regarding the nature of the illness and its treatment. Psychoeducation promotes patient-centered care by helping the patient to recognize and self-manage symptoms such as anxiety, impaired concentration, social withdrawal, impaired rest or nutrition, impaired cognition, and hallucinations and delusions Working with an Aggressive Patient A small percentage of patients with schizophrenia, especially during the acute phase, may exhibit a risk for physical violence. Violence may be in response to hallucinations (especially command hallucinations), delusions, paranoia, and impaired judgment or impulse control. Interpersonal conflict, fear, desperation, and conflicts (e.g., about unit rules) also increase the risk of aggression. Assessment and periodic reassessment for risk of violence are essential. When the potential for violence exists, measures to protect the patient and others become a priority. Refer to Table 12.3 and Chapter 27 for more information on caring for the aggressive or potentially violent patient. Phase II: Stabilization and Phase III: Maintenance Effective long-term care of patients with schizophrenia relies on a four-pronged approach: 1. Medication 2. Treatment adherence 3. Relationships with trusted care providers and support people 4. Community-based therapeutic services All care is geared toward the patient's strengths, culture, personal preferences, and needs. Communication, continuity in care, and trusting relationships with care providers are essential for optimum recovery and relapse prevention. Postdischarge care typically includes group and individual psychotherapy and psychoeducation (e.g., social or coping skills), medication and case management, and structured activities such as day programs and recreational activities. Community mental health centers usually provide medication services, day treatment, case management, and 24/7 crisis and psychiatric emergency services. Community mental healthcare can also provide housing support, allied physical health services, employment programs. Peer-led services are available in most communities. These services include drop-in centers, sometimes called clubhouses, that offer socialization, activities, and sometimes employment opportunities. Hospital staff must be aware of such community services and ideally should directly connect patients and families with these resources before discharge. Support groups are also very helpful and patients and family members should be connected to these (e.g., the National Alliance on Mental Illness [NAMI, www.nami.org]). Nurses provide essential family psychoeducation about the illness and how best to help the patient. Education can be provided even if the patient does not provide consent if the family initiates the request and the information is provided in a way that does not divulge confidential health information about the patient. Alternately, the family can be connected to other resources for information. NAMI's "Family-to-Family" program educates families about severe mental illnesses and their treatment. Support and respite for caregivers are also important. A sample care plan can be found in the Case Study and Nursing Care Plan box. Additional nursing interventions often helpful in caring for individuals with schizophrenia are provided in Table 12.3. Teamwork and Safety A therapeutic milieu provides structure (a planned consistent routine) and external limits that create a sense of security. It is a physical and social environment that maximizes safety, opportunities for learning and practicing skills (such as conflict resolution, stress reduction, and symptom management techniques), and therapeutic activities (e.g., games that promote socialization, therapy groups that help develop insight or coping abilities) while minimizing undue stress and stimulation. Hospital alternatives (e.g., crisis centers, partial hospital programs) also provide a therapeutic milieu in a less-restrictive setting. Activities and Groups Participation in activities and groups appropriate to the patient's needs and abilities may decrease withdrawal, enhance motivation, modify unacceptable behaviors, improve understanding of the illness, facilitate support and feedback from staff and peers, and increase social competence and other skills. Drawing, poetry, journaling, and listening to music promote the recognition and expression of feelings. Self-esteem is enhanced via task completion and participation in activities for which there is a high likelihood of success. Recreational activities such as picnics and outings to stores or restaurants are not simply diversions; they teach and provide practice opportunities that improve constructive leisure skills (the ability to make meaningful and rewarding use of free time), increase social comfort, build interactional skills, promote independence, and improve boundaries. Outpatient programs can provide structure after discharge. Counseling and Communication Techniques Therapeutic communication techniques for patients with schizophrenia aim to build trust and reduce anxiety. Staff should remember that patients with schizophrenia may have memory and attentional impairment and require repetition and visual and verbal reminders to promote learning and task completion. People who think concretely also benefit from concrete examples during education (e.g., counting out the equivalent number of sugar cubes found in a bottle of cola to show its sugar content). Shorter (less than 30 minutes) but more frequent interactions may be less stimulating and better tolerated than fewer longer interactions. Intervening with Hallucinations When a patient is hallucinating, the nurse focuses on understanding the patient's experiences and responses. Suicidal or homicidal themes or commands necessitate appropriate safety measures. For example, if internal voices tell a patient that a peer plans to do harm, it may lead the patient to act aggressively against that person. In this case, close monitoring, helping the patient feel safe, and maintaining separation of the patient and potential victim would be indicated. Hallucinations are real to the person who is experiencing them and may be distracting during interactions. They can be supportive or terrifying, faint or loud, episodic or constant. They can be sounds or voices, and are sometimes attributed to specific sources (e.g., a parent or God). Nursing care includes calling the patient by name, speaking simply and loudly enough to be understood during auditory hallucinations, presenting in a supportive manner, maintaining eye contact, and redirecting the patient's focus to your conversation as needed (see Box 12.3 regarding helping patients experiencing hallucinations). Intervening with Delusions Impaired reality testing prevents self-correction of irrational thoughts that normally would be disregarded. When the nurse attempts to see the world through the patient's eyes, it becomes easier to understand the patient's delusion. For example: Patient: You people are all alike...all part of the FBI plot to destroy me. Nurse: It seems to you like people want to hurt you. That must be very frightening. I will not hurt you, and we can work together to help you feel safer. Here the nurse acknowledges the patient's experience and feelings, conveys empathy about the patient's fearfulness, provides reassurance about her intentions, avoids questioning the delusion itself, and focuses on helping the patient feel safer (addressing the underlying theme of fear). Focus on the delusion itself, the beliefs about the FBI, is not helpful. Focusing on fear, its causes, and what can help the patient feel more secure is therapeutic. Until reality testing improves it is never useful to try to prove that the delusion is incorrect. This can instead intensify the delusion and cause the patient to view staff as individuals who cannot be trusted. However, it is helpful to clarify misinterpretations of the environment and gently suggest, as tolerated, a more reality-based perspective. For example: Patient: I see the doctor is here. He wants to kill me. Nurse: It is true the doctor wants to see you as he talks with all patients about their treatment. Would you feel more comfortable if I stayed with you during your meeting? Focusing on activities and events occurring in the present keeps the focus on reality and provides opportunities to distinguish what is real. Work with the patient to find and promote helpful coping strategies. Box 12.4 provides strategies for working with patients experiencing delusions. Intervening with Associative Looseness Associative looseness is a reflection of idiosyncratic and disorganized thinking. Increased anxiety or overstimulation worsens cognitive disorganization. Guidelines for helping those with disorganized thinking include: • Do not pretend (or allow the patient to think) that you understand when you don't. • Place the difficulty in understanding on yourself, not on the patient. Example: "I'm having trouble following what you are saying," not "You're not making any sense." • Tell the patient what you do understand, and reinforce clear communication of needs, feelings, and thoughts when it occurs. • Look for recurring issues and themes in the patient's communications, and tie these to possible triggers. Example: "You've mentioned trouble with your brother several times, usually after your family has visited. Tell me about your brother and your visits with him." • Summarize or paraphrase the patient's communications to role model clearer communication and to give the patient a chance to correct anything you may have misunderstood. • Speak concisely, clearly, and concretely in sentences rather than paragraphs. Health Teaching and Health Promotion Ideally patients and family members or caregivers are included in teaching. Often home lives have been stressed by the illness. Significant others may have become critical, controlling, or intrusive. Lack of understanding of the disease and its symptoms can lead others to mistake symptoms such as apathy and poor hygiene as intentionally bad behavior. A warm, concerned, and supportive environment free of conflict and chaos promotes recovery. Teaching significant others how to recognize and respond helpfully to symptoms, and how to negotiate to achieve needed changes, is very important. Education should include the causes and nature of the illness, what to expect, how it is treated, ways to cope and control the illness, medications and side effects, helpful resources, and relapse prevention. This knowledge and skill helps the patient and family to become actively involved in managing symptoms and the illness. Including family members reduces family anxiety and distress and helps them reinforce the patient's and staff's efforts. Box 12.5 identifies patient and family teaching about schizophrenia. Additional nursing interventions for patients with schizophrenia are listed in Table 12.3

signs and symptoms of sud

Signs and Symptoms Nursing Diagnoses Outcomes Impulsiveness, loss of relationships and occupation due to focus on substances or gambling, legal problems, social isolation Risk for suicide Expresses feelings, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future Impairment from substances, overdose, withdrawal from substances, hallucinations, elevated temperature, pulse, respirations, agitation Risk for injury Remains free from injury Reports not feeling well rested, decreased ability to function, reports awakening multiple times Disturbed sleep pattern Minimal awakening, feels restored after sleep Substitutes substances for healthy foods, lack of appetite, aversion to food Nutrition: less than body requirements Maintains a nutrient intake to meet metabolic needs Increased appetite from cannabis use, dysfunctional eating pattern, weight 20% over ideal for height and frame, excessive intake in relation to metabolic need Nutrition: more than body requirements Maintains a nutrient intake to meet metabolic needs Inadequate environmental hygiene, inadequate personal hygiene, nonadherence to health activity Self-neglect Obtains stable health status, adheres to medication and treatment regimen Substance use or gambling, decreased use of social support, destructive behavior toward self and others, difficulty organizing information, inadequate problem-solving, poor concentration, reports inability to cope Inef ective coping Modifies lifestyle as needed to maintain sobriety, maintains abstinence from substances, engages in satisfying relationships Does not perceive danger of substance use or gambling, minimizes symptoms, refuses healthcare attention, unable to admit impact of disease on life pattern Inef ective denial Accepts responsibility for behavior, maintains abstinence from substances Substance use or gambling, lack of initiative, passivity, social isolation, reports seeing no alternatives or personal control, anger, sees no meaning in life Hopelessness Expresses feelings of self-worth, verbalizes sense of personal identity, expresses meaning in life, sets goals, believes that actions impact outcomes Substance use leads to vulnerability to decreased liver function Risk for impaired liver function Abstains from substance use Substance use edema, loss of appetite, fatigue, shortness of breath, decreased concentration, cough, decreased urine output, palpitations, irregular or rapid pulse Decreased cardiac output Abstains from substance use, cardiac pump supports systemic perfusion pressure Blaming, broken promises, chaos, denial of problems, enabling maintenance of substance use pattern, immaturity, inability to accept help or express feelings, loneliness, lying, manipulation, rationalization, refuses to get help social isolation, worthlessness, deterioration of family relationships Dysfunctional family processes Family members attain cohesion and emotional bonding

medications for schizphenia (antipsychotics and anticholinergics)

Antipsychotic medications, those used to treat psychotic disorders such as schizophrenia, first became available in the 1950s. Previously available medications provided sedation but did not reduce psychosis. Until the late 1960s, patients with schizophrenia usually spent months or years in 436 state or private hospitals, resulting in great emotional and financial costs to patients, families, and society. Antipsychotic drugs at last provided symptom control and allowed most patients to live and be treated in the community. Drugs used to treat psychotic disorders include: 1. First-generation antipsychotics (FGAs)—traditional dopamine (D2 receptor) antagonists, also known as typical antipsychotics or neuroleptics (e.g., haloperidol [Haldol]). 2. Second-generation antipsychotics (SGAs)—serotonin (5-HT2A receptor) and dopamine (D2 receptor) antagonists (e.g., clozapine [Clozaril]); other drugs are antagonist in areas of high dopamine activity, but agonists in areas of low dopamine activity (e.g., aripiprazole [Abilify]). The FGAs primarily affect positive symptoms (e.g., hallucinations and delusions) but have little effect on negative symptoms. Second-generation antipsychotics treat positive symptoms and can also help negative symptoms (e.g., asociality, blunted affect) though improvement in negative and cognitive symptoms is usually less. Second-generation drugs are generally an improvement on earlier drugs while reducing the overall burden of side effects. All antipsychotic agents usually take 2 to 6 weeks to achieve the desired effects. Patient-specific dosage adjustment is required to obtain an optimal balance between effectiveness and side effects. Treatment guidelines recommend monotherapy or the use of a single medication. After the failure of two monotherapy trials, a clozapine (Clozaril) monotherapy trial is warranted. Polypharmacy is avoided if at all possible. However, if clozapine results in failure or intolerance, an adjunctive antipsychotic may be used to improve the response of another. Antipsychotics are not addictive. However, they should be discontinued gradually to minimize a discontinuation syndrome that can include dizziness, nausea, tremors, insomnia, electric shock-like pains, and anxiety. Antipsychotics are unlikely to be lethal in overdose situations. A lesser-known risk of all antipsychotic medications, due to dopamine blockade or sedation, is impaired swallowing. This may cause drooling and risk of choking (Chen et al., 2015). Also, patients taking antipsychotics are at increased fall risk due to orthostatic (postural) hypotension, sedation, and gait impairment (Wynaden et al., 2015). Liquid or fast-dissolving forms, available for selected antipsychotics, can make it difficult for a person to cheek or palm his medicine (hide it in his cheek or palm and later dispose of it). See Table 12.3 for interventions to prevent cheeking and palming. Injectable Antipsychotics Some antipsychotics are available in short-acting injectable form, used primarily for treatment of agitation, behavioral emergencies such as assaultiveness, or when a patient refuses court-mandated oral antipsychotics. Side effects can be intensified and less easily managed when medication is administered directly into the system intramuscularly (IM). Some are available in long-acting injectable (LAI) formulations that only need to be administered every 2 to 4 weeks and in one case, every 3 months. Some require special administration protocols (Table 12.4). By requiring less frequent medication administration, adherence is improved and conflict about taking medications is reduced. The downside is lack of dosing flexibility and patients may feel like they have less control and are coerced. Additional information on antipsychotic medications can First-Generation Antipsychotics FGAs are used less in schizophrenia because of their minimal impact on negative symptoms and their generally higher level of side effects. However, they are as effective against positive symptoms as newer antipsychotics and are much less expensive than some SGAs. For patients untroubled by their side effects, FGAs remain an appropriate choice, especially when cost or metabolic syndrome (more common in SGA drugs and described later in this chapter) is a concern. First-generation antipsychotics are dopamine (D2) antagonists in both limbic and motor centers. Blockage of D2 receptors in motor areas causes extrapyramidal side effects (EPS) including: 1. Acute dystonia—Sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Acute dystonias can be frightening and painful, but unless they involve muscles affecting the airway, which is rare, they are not dangerous. However, they cause significant anxiety and should be treated promptly. 2. Akathisia—A motor restlessness that causes pacing, repetitive movements, or an inability to stay 437 still or remain in one place. It can be severe and distressing to patients. It can be mistaken for anxiety or agitation. Sometimes more of the drug that caused the akathisia is mistakenly given, which makes the side effect worse. A tardive form can persist despite treatment. TABLE 12.4 Long-Acting Injectable Antipsychotics From US Food and Drug Administration. (2016). FDA online label repository. Retrieved from http://labels.fda.gov/; Burchum, J., & Rosenthal, L. (2016) Lehne's pharmacology for nursing care (9th ed.). St. Louis, MO: Elsevier. 3. Pseudoparkinsonism—A temporary group of symptoms that looks like Parkinson's disease: tremor, reduced accessory movements (e.g., arms swinging when walking), gait impairment, reduced facial expressiveness (mask facies), and slowing of motor behavior (bradykinesia). Lowering dosages can minimize EPS, and EPS can be treated or prevented by using antipsychotics less prone to causing EPS. These unusual side effects may diminish with time. Oral antiparkinsonian drugs are also useful. However, these drugs have their own side effects because most are anticholinergic. Abuse of antiparkinsonian drugs is also a problem because they can cause an enjoyable altered sensorium. Trihexyphenidyl (Artane) is the most common drug in this category, but other anticholinergics drugs such as benztropine (Cogentin) are also used to get a high. Tardive dyskinesia is a persistent EPS side effect involving involuntary rhythmic movements. Tardive dyskinesia develops in 10% or more of patients, usually after prolonged treatment, and often persists even after the medication has been discontinued. This side effect usually begins in oral and facial muscles and progresses to include the fingers, toes, neck, trunk, or pelvis. More common in women, tardive dyskinesia varies from mild to severe and can be disfiguring or incapacitating. TABLE 12.5 Antipsychotic Drugs: Classification and Relative Side-Effect Profile 438 ∗ Doses listed are the therapeutic equivalent of 100 mg of oral chlorpromazine. † Incidence here refers to early extrapyramidal reactions (acute dystonia, parkinsonism, akathisia). The incidence of late reactions (tardive dyskinesia) is the same for all traditional antipsychotics. Data from Burchum, J., & Rosenthal, L. (2016). Lehne's pharmacology for nursing care (9th ed.). St. Louis, MO: Elsevier. The National Institute of Mental Health (NIMH) developed the Abnormal Involuntary Movement Scale (AIMS, Fig. 12.2), to identify and track involuntary movements. Using the AIMS is a key nursing role in treating this population. The FDA recently approved valbenazine capsules (Ingrezza) for the treatment of tardive dyskinesia in adults (FDA, 2017). Valbenazine is a selective vesicular monoamine transporter inhibitor that reduces the severity of abnormal involuntary movements in tardive dyskinesia. Adverse effects include sleepiness and QT prolongation. It is contraindicated with congenital long QT syndrome or with abnormal heartbeats associated with a prolonged QT interval. It should be used with caution for people who drive or operate heavy machinery or do other dangerous activities until it is known how the drug affects them. 439 440 FIG. 12.2 Abnormal Involuntary Movement Scale (AIMS). The first-generation antipsychotics cause anticholinergic (ACh) side effects by blocking muscarinic cholinergic receptors. Anticholinergic side effects include urinary retention, dilated pupils, constipation, reduced visual accommodation (blurred near vision), tachycardia, dry mucous membranes, reduced peristalsis (rarely, leading to paralytic ileus and risk of bowel obstruction), and cognitive impairment. Taking multiple medications with ACh side effects increases the risk of anticholinergic toxicity, covered later in this chapter. In general, FGAs have strong EPS potential or strong anticholinergic potential. That is, when one side effect is prominent, the other is not. Other Side Effects of FGAs Other side effects of FGAs include sedation, orthostatic (postural) hypotension, lowered seizure threshold (leading to seizures), photosensitivity, cataracts or other visual changes (with chlorpromazine [Thorazine] and thioridazine [Mellaril]), and increased release of prolactin (hyperprolactinemia), which can result in sexual dysfunction (impotence, anorgasmia, impaired ejaculation), galactorrhea (flow of fluid from the breasts), amenorrhea, and gynecomastia. Weight gain can be more than 50 pounds per year, causing significant psychological distress and increasing the risk of cardiovascular disorders and diabetes. Some side effects such as sedation occur initially but improve thereafter. Potentially dangerous side effects are infrequent but include anticholinergic toxicity, neuroleptic malignant syndrome, and prolongation of the QT interval, all discussed later in this section. Note that side effects that are not addressed increase the risk of nonadherence to treatment. Some have noted possible neurotoxicity in haloperidol and perhaps other FGAs as well, and haloperidol may cause a form of encephalopathy if combined with lithium carbonate (Nasrallah, 2013). Nursing care for common or potentially dangerous side effects is located in Table 12.6. Second-Generation Antipsychotics SGAs include drugs such as clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). They antagonize D2 receptors as do FGAs but also bind to serotonin receptors as well. They are often chosen as first-line antipsychotics because they 441 are equally effective for positive symptoms and also help negative symptoms. Side Effects of Second-Generation Antipsychotics Like FGAs, SGAs can cause sedation, sexual dysfunction, seizures, and increased mortality in elderly individuals with dementia. However, most SGAs are less likely to cause tardive dyskinesia or significant EPS. Although they have the same potential side effects as the FGAs, SGA side effects are usually fewer, milder, and better tolerated. When the first SGA, clozapine (Clozaril), was approved in 1989, it produced dramatic improvement in some patients whose disorder had been resistant to FGAs and helped improve negative symptoms as well. Unfortunately, clozapine causes agranulocytosis in 0.5% to 1% of those who take it. As a result, patients taking clozapine must have neutrophil monitoring (discussed later). Clozaril can also cause myocarditis and life-threatening bowel emergencies. Due to these serious problems, clozapine use declined in the United States and many clinicians reserve its use for patients who do not respond adequately to other antipsychotics. However, it is one of the few drugs that have Food and Drug Administration (FDA) approval for the treatment of suicidality in schizophrenias. TABLE 12.6 Side Effects of Antipsychotic Medication 442 Data from Burchum, J., & Rosenthal, L. (2016) Lehne's pharmacology for nursing care (9th ed.). St. Louis, MO: Elsevier. All SGAs carry a risk of metabolic syndrome, which includes weight gain (especially in the abdominal area), dyslipidemia, increased blood glucose, and insulin resistance. This metabolic syndrome is a significant concern and increases the risk of diabetes, certain cancers, hypertension, and cardiovascular disease, making its prevention an important role for nurses (see Table 12.6). Some SGAs also have antidepressant properties and are FDA approved for adjunctive use in the treatment of major depressive disorder. As with all antidepressants, they carry a theoretical risk of increased suicidality, particularly in adolescents. Other potentially dangerous SGA side effects include anticholinergic toxicity, neuroleptic malignant syndrome, and prolongation of the QT interval, all discussed later in this section. A subset of the SGAs is sometimes referred to as third-generation antipsychotics. These drugs are aripiprazole (Abilify), brexpiprazole (Rexulti), and cariprazine (Vraylar). They can be described as dopamine system stabilizers that act by reducing dopamine activity in some brain regions while increasing it in others. Aripiprazole and brexpiprazole act as D2 partial agonists (meaning they attach to the D2 receptor without fully activating it, reducing the effective level of dopamine activity). Cariprazine acts as a partial agonist more on D3 than D2 receptors, which may help improve cognitive symptoms. Additional information about antipsychotics can be found in Tables 12.4 and 12.5. Table 12.6 describes common antipsychotic side effects and related nursing care. Dangerous Antipsychotic Side Effects Nurses need to know about some rare, but serious and potentially fatal, effects of antipsychotic drugs including anticholinergic toxicity, neuroleptic malignant syndrome, and agranulocytosis. Nurses in psychiatry, primary care, and emergency services need to be aware of and monitor for the early signs and symptoms of these side effects. Patients and their families should be taught how to recognize and respond to dangerous side effects. More information and nursing care for these side effects is included in Table 12.6. Anticholinergic toxicity is a potentially life-threatening medical emergency caused by antipsychotics or other medications with anticholinergic effects including many antiparkinsonian drugs. Older adults and those on multiple anticholinergic drugs are at greatest risk. Symptoms include autonomic nervous system instability and delirium with altered mental status. Mental status changes can include hallucinations and may be mistaken for a worsening of the patient's psychosis, so people whose psychosis is inexplicably worsening should be immediately evaluated for possible anticholinergic toxicity. Neuroleptic malignant syndrome (NMS) occurs in about 0.2% to 1% of patients who have taken first-generation antipsychotics and is characterized by reduced consciousness and responsiveness, increased muscle tone (generalized muscular rigidity), and autonomic dysfunction. Although less likely, NMS can also occur with second-generation antipsychotics. Caused by excessive dopamine receptor blockade, NMS is a life-threatening medical emergency that is fatal in up to 10% of cases. It usually occurs early in therapy but has also occurred 20 years into treatment. Early detection, discontinuation of the antipsychotic, management of fluid balance, temperature 443 reduction, and monitoring for complications such as deep vein thrombosis and rhabdomyolysis (protein in the blood from muscle breakdown, which can cause organ failure) are essential. Agranulocytosis, while most associated with clozapine (Clozaril), is possible with most other antipsychotics as well. Neutropenia can also develop and can be fatal. Monitoring for neutropenia is done as part of the complete blood count through an absolute neutrophil count (ANC). Symptoms of agranulocytosis include signs of infection (e.g., fever, chills, sore throats) or increased susceptibility to infection. Some individuals have lower normal levels of ANC. It is referred to as benign ethnic neutropenia (BEN). Among these people are those from African descent (about 25% to 50%), some Middle Eastern groups, and other non-Caucasians with darker skin. They are not at greater risk for developing agranulocytosis but should have a baseline ANC before starting clozapine. Prolongation of the QT interval may contribute to sudden death of unknown origin that occasionally occurs in individuals with schizophrenia. SGAs quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) can prolong the QT interval. FGAs chlorpromazine (Thorazine), haloperidol (Haldol), and thioridazine (Mellaril) have also been implicated in this cardiac emergency. Electrocardiograms should evaluate all people for existing QT prolongation (which magnifies the risk from medication-related prolongation) before being started on any antipsychotic. Liver impairment may also occur during antipsychotic therapy, particularly with FGAs. SGAs also lead to serum enzyme elevations but rarely with injury or jaundice. Liver impairment usually occurs in the first weeks of therapy. This makes monitoring of liver function values essential. Signs of liver problems include yellowish skin and eyes, abdominal pain, ascites, vomiting, swelling in lower extremities, dark urine, pale or tar-colored stool, and easy bruising. The patient may complain of itchy skin, chronic fatigue, nausea, and a loss of appetite. Disorders co-occurring with schizophrenia should be actively treated. Depression is common in schizophrenia and is typically treated with antidepressants and other interventions (see Chapter 14). Antidepressants and mood-stabilizing agents may be needed for mood symptoms in schizoaffective disorder. Benzodiazepines (e.g., lorazepam [Ativan]) can reduce agitation and anxiety (which can worsen other symptoms and is quite common in schizophrenia) and can help lessen positive and negative symptoms.

side effects of antipsychotics (schizophrenia)

Antipsychotics are unlikely to be lethal in overdose situations. A lesser-known risk of all antipsychotic medications, due to dopamine blockade or sedation, is impaired swallowing. This may cause drooling and risk of choking (Chen et al., 2015). Also, patients taking antipsychotics are at increased fall risk due to orthostatic (postural) hypotension, sedation, and gait impairment First-generation antipsychotics are dopamine (D2) antagonists in both limbic and motor centers. Blockage of D2 receptors in motor areas causes extrapyramidal side effects (EPS) including: 1. Acute dystonia—Sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Acute dystonias can be frightening and painful, but unless they involve muscles affecting the airway, which is rare, they are not dangerous. However, they cause significant anxiety and should be treated promptly. 2. Akathisia—A motor restlessness that causes pacing, repetitive movements, or an inability to stay 437 still or remain in one place. It can be severe and distressing to patients. It can be mistaken for anxiety or agitation. Sometimes more of the drug that caused the akathisia is mistakenly given, which makes the side effect worse. A tardive form can persist despite treatment 3. Pseudoparkinsonism—A temporary group of symptoms that looks like Parkinson's disease: tremor, reduced accessory movements (e.g., arms swinging when walking), gait impairment, reduced facial expressiveness (mask facies), and slowing of motor behavior (bradykinesia). Lowering dosages can minimize EPS, and EPS can be treated or prevented by using antipsychotics less prone to causing EPS. These unusual side effects may diminish with time. Oral antiparkinsonian drugs are also useful. However, these drugs have their own side effects because most are anticholinergic. Antipsychotics Like FGAs, SGAs can cause sedation, sexual dysfunction, seizures, and increased mortality in elderly individuals with dementia. However, most SGAs are less likely to cause tardive dyskinesia or significant EPS. Although they have the same potential side effects as the FGAs, SGA side effects are usually fewer, milder, and better tolerated All SGAs carry a risk of metabolic syndrome, which includes weight gain (especially in the abdominal area), dyslipidemia, increased blood glucose, and insulin resistance. This metabolic syndrome is a significant concern and increases the risk of diabetes, certain cancers, hypertension, and cardiovascular disease, making its prevention an important role for nurses (see Table 12.6). Some SGAs also have antidepressant properties and are FDA approved for adjunctive use in the treatment of major depressive disorder. As with all antidepressants, they carry a theoretical risk of increased suicidality, particularly in adolescents. Other potentially dangerous SGA side effects include anticholinergic toxicity, neuroleptic malignant syndrome, and prolongation of the QT interval, all discussed later in this section. A subset of the SGAs is sometimes referred to as third-generation antipsychotics Dangerous Antipsychotic Side Effects Nurses need to know about some rare, but serious and potentially fatal, effects of antipsychotic drugs including anticholinergic toxicity, neuroleptic malignant syndrome, and agranulocytosis. Nurses in psychiatry, primary care, and emergency services need to be aware of and monitor for the early signs and symptoms of these side effects. Patients and their families should be taught how to recognize and respond to dangerous side effects. More information and nursing care for these side effects is included in Table 12.6. Anticholinergic toxicity is a potentially life-threatening medical emergency caused by antipsychotics or other medications with anticholinergic effects including many antiparkinsonian drugs. Older adults and those on multiple anticholinergic drugs are at greatest risk. Symptoms include autonomic nervous system instability and delirium with altered mental status. Mental status changes can include hallucinations and may be mistaken for a worsening of the patient's psychosis, so people whose psychosis is inexplicably worsening should be immediately evaluated for possible anticholinergic toxicity. Neuroleptic malignant syndrome (NMS) occurs in about 0.2% to 1% of patients who have taken first-generation antipsychotics and is characterized by reduced consciousness and responsiveness, increased muscle tone (generalized muscular rigidity), and autonomic dysfunction. Although less likely, NMS can also occur with second-generation antipsychotics. Caused by excessive dopamine receptor blockade, NMS is a life-threatening medical emergency that is fatal in up to 10% of cases. It usually occurs early in therapy but has also occurred 20 years into treatment. Early detection, discontinuation of the antipsychotic, management of fluid balance, temperature 443 reduction, and monitoring for complications such as deep vein thrombosis and rhabdomyolysis (protein in the blood from muscle breakdown, which can cause organ failure) are essential. Agranulocytosis, while most associated with clozapine (Clozaril), is possible with most other antipsychotics as well. Neutropenia can also develop and can be fatal. Monitoring for neutropenia is done as part of the complete blood count through an absolute neutrophil count (ANC). Symptoms of agranulocytosis include signs of infection (e.g., fever, chills, sore throats) or increased susceptibility to infection. Some individuals have lower normal levels of ANC. It is referred to as benign ethnic neutropenia (BEN). Among these people are those from African descent (about 25% to 50%), some Middle Eastern groups, and other non-Caucasians with darker skin. They are not at greater risk for developing agranulocytosis but should have a baseline ANC before starting clozapine. Prolongation of the QT interval may contribute to sudden death of unknown origin that occasionally occurs in individuals with schizophrenia. SGAs quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) can prolong the QT interval. FGAs chlorpromazine (Thorazine), haloperidol (Haldol), and thioridazine (Mellaril) have also been implicated in this cardiac emergency. Electrocardiograms should evaluate all people for existing QT prolongation (which magnifies the risk from medication-related prolongation) before being started on any antipsychotic. Liver impairment may also occur during antipsychotic therapy, particularly with FGAs. SGAs also lead to serum enzyme elevations but rarely with injury or jaundice. Liver impairment usually occurs in the first weeks of therapy. This makes monitoring of liver function values essential. Signs of liver problems include yellowish skin and eyes, abdominal pain, ascites, vomiting, swelling in lower extremities, dark urine, pale or tar-colored stool, and easy bruising. The patient may complain of itchy skin, chronic fatigue, nausea, and a loss of appetite. Disorders co-occurring with schizophrenia should be actively treated. Depression is common in schizophrenia and is typically treated with antidepressants and other interventions (see Chapter 14). Antidepressants and mood-stabilizing agents may be needed for mood symptoms in schizoaffective disorder. Benzodiazepines (e.g., lorazepam [Ativan]) can reduce agitation and anxiety (which can worsen other symptoms and is quite common in schizophrenia) and can help lessen positive and negative symptoms.

Epidemiology of Bipolar Disorder

Epidemiology Bipolar I and Bipolar II Disorders The lifetime risk, or the percentage of the population that will ever have a bipolar I or bipolar II disorder, is nearly 4% (Merikangas et al., 2012). Table 13.1 provides a snapshot of statistics regarding the bipolar disorders in adults and adolescents ages 13 to 18. Men and women have nearly equal rates of bipolar disorders, yet they respond somewhat differently to their condition. Men with a bipolar disorder are more likely to have legal problems and commit acts of violence. Women with a bipolar disorder are more likely to abuse alcohol, commit suicide, and develop thyroid disease. Women who experience a severe postpartum psychosis within 2 weeks of giving birth have a four times greater chance of subsequent conversion to bipolar disorder (Munk-Olsen et al., 2011). Giving birth may act as a trigger for the first symptoms of bipolar disorder. The precipitant may be hormonal changes and sleep deprivation.

signs and symptoms of schizophrenia

General Assessment Not all people with schizophrenia have the same symptoms, and some of the symptoms of schizophrenia are also found in other disorders. Fig. 12.1 describes the four main symptom categories in schizophrenia: 1. Positive symptoms: The presence of something that should not be present. Positive symptoms include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech. 2. Negative symptoms: The absence of something that should be present. Negative symptoms include the inability to enjoy activities, social discomfort, or lack of goal-directed behavior. 3. Cognitive symptoms: Subtle or obvious impairment in memory, attention, thinking (e.g., disorganized or irrational thoughts), judgment, or problem solving. 4. Affective symptoms: Symptoms involving emotions and their expression. 416 Positive Symptoms The positive symptoms usually appear early. Their dramatic nature captures our attention and is often what precipitates treatment. These symptoms are what most individuals associate with mental illness, making schizophrenia the classic "crazy" disorder. Positive symptoms include: Alterations in Reality Testing We all experience thoughts that are irrational or distorted, yet we can usually catch and correct the error by using reality testing. Reality testing is the automatic and unconscious process by which we determine what is and is not real. You might think you hear a voice but you see that no one is present. You conclude you are mistaken—it wasn't real. With impaired reality testing the person believes that hallucinations or delusions are real. Delusions are false beliefs held despite a lack evidence to support them. The most common delusions involve persecutory, grandiose, or religious ideas. Table 12.1 provides definitions and examples of types of delusions. Delusions can reflect underlying issues or needs (e.g., a person with poor self-esteem may believe he is Beethoven or God, possibly driven by a need to feel more beloved or powerful). FIG. 12.1 Four main symptom groups of schizophrenia. Just because someone has a mental illness does not mean that every story that sounds improbable is delusional. One patient repeatedly told the staff that the Mafia was out to kill him. The staff later learned that he had been selling drugs and had not paid his drug sources, and that drug dealers were trying to harm him. Alterations in Speech A striking positive symptom of schizophrenia spectrum disorders is the use of unusual speech patterns. One of the most common, associative looseness, or looseness of association, results from haphazard and illogical thinking where concentration is poor and individuals loosely associate their 417 thoughts. For example: "I need to get a Band-Aid. My friend was talking about AIDS. Friends talk about French fries but how can you trust the French?" A word salad, the most extreme form of associative looseness, is a jumble of words that is meaningless to the listener (e.g., "throat hoarse strength of policy highlighters on a boat reigning supreme"). Clang association is choosing words based on their sound rather than their meaning and often involves words that rhyme or have a similar beginning sound ("On the track...have a Big Mac" or "Click, clack, clutch, close"). TABLE 12.1 Types of Delusions ∗ Delusion Definition Example Persecutory Believing that one is being singled out for harm, or prevented from making progress, by others Shannon believes that her food is poisoned; therefore, she eats only prepackaged food. John believes co-workers plot to prevent his promotion. Referential A belief that events or circumstances that have no connection to you are somehow related to you Barbara believes that the birds sing songs to cheer her up. Andrea believes songs on the radio are chosen to send her a message. Grandiose Believing that one is a very powerful or important person Brianna believes she is a famous playwright. Erotomanic Believing that another person desires you romantically Although he barely knows her, Patty insists that Eric would marry her if only his current wife would stop interfering. Nihlistic The conviction that a major catastrophe will occur Larry gives away all his belongings since they won't be of any use when the comet hits. Somatic Believing that the body is changing in unusual ways Chris says her heart is dead and rotting away. Control Believing that another person, group of individuals, or external force controls thoughts, feelings, impulses, or behavior Brian covered his apartment walls with aluminum foil to block aliens' efforts to control his thoughts. ∗ A false belief held regardless of evidence to the contrary. Note that unusual beliefs that stem from one's culture or subculture are not considered delusions. Neologisms are words that have meaning for the patient but a different or nonexistent meaning to others. A person may use a known word differently than others understand it or can create a completely new word that others do not understand (e.g., "His mannerologies are poor"). Echolalia is the pathological repeating of another's words, occurring perhaps because the patient's thought processes are so impaired that he is unable to generate speech of his own. Nurse: Mary, come get your medication. Mary: Come get your medication. Other pathological speech patterns are: • Circumstantiality: Including unnecessary and often tedious details in conversation but eventually reaching the point. • Tangentiality: Wandering off topic or going off on tangents and never reaching the point. • Cognitive retardation: Generalized slowing of thinking, which is represented by delays in responding to questions or difficulty finishing thoughts. • Pressured speech: Urgent or intense speech; resists allowing comments from others. • Flight of ideas: Moving rapidly from one thought to the next, often making it difficult for others to follow the conversation. • Symbolic speech: Using symbols instead of direct communication. For example, a patient reports "demons are sticking needles in me" when what he means is that he is experiencing a sharp pain (symbolized by "needles"). • Thought blocking: A reduction or stoppage of thought. Interruption of thought by hallucinations can cause this. • Thought insertion: The uncomfortable belief that someone else has inserted thoughts into the brain. • Thought deletion: A belief that thoughts have been taken or are missing. Other positive symptoms manifested in disorders of thought include: • Magical thinking: Believing that thoughts or actions affect others. This is common and usually nonpathological in children (e.g., wearing pajamas inside out to make it snow, or because I was mad at him, he fell down). • Paranoia: An irrational fear, ranging from mild (wary, guarded) to profound (believing irrationally that another person intends to kill you). Fear may result in defensive actions, harming another person before that person can harm the patient. Alterations in perception Alterations in perception involve errors in how one interprets perceptions or perceives reality. The most common perceptual errors are hallucinations. Hallucinations occur when a person perceives a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking). Types of hallucination include: 418 • Auditory: Hearing voices or sounds • Visual: Seeing people or things • Olfactory: Smelling odors • Gustatory: Experiencing tastes • Tactile: Feeling bodily sensations (e.g., feeling an insect crawling on one's skin) Auditory hallucinations, the most common form in schizophrenia, are experienced by more than 60% of people with schizophrenia (Waters, 2014). They may be vague sounds or indistinct or clear "voices." Hallucinations seem to come from outside the person's head. Auditory processing areas of the brain are activated during these hallucinations just as they are when a genuine sound is heard. John Nash, the world-renowned mathematician with schizophrenia portrayed in the film A Beautiful Mind (2001), describes his hallucinations: I thought of the voices as...something a little dif erent from aliens. I thought of them more like angels... It's really my subconscious talking; it was really that, I know that now. Internal voices may be single or multiple, distinct or indistinct, and can be attributed to specific sources (e.g., God, a family member) or unrecognized. They may be supportive and pleasant or derogatory and frightening. They can be subtle and unobtrusive or intrusive and highly distressing. Hallucinations commenting on the person's behavior or conversing with the person are common. Indications that a person is hallucinating include tracking motions (turning one's head in the direction of the perceived sound), lips moving silently, talking as if to another when no one is present, and otherwise unexplained changes in affect (e.g., suddenly laughing without apparent reason). A person who hears voices struggles to understand the experience, sometimes developing related delusions to explain the voices (e.g., believing the voices are from God or due to a device implanted by the CIA). Patients may attempt to cope by drowning out auditory hallucinations with loud music or by competing with them by talking loudly, humming, or singing. Such auditory competition may, in fact, reduce hallucinations and serve as a recommended intervention. A command hallucination is a particularly disturbing symptom that directs the person to take an action. This type of hallucination must be monitored carefully because they may be dangerous, for example, telling a patient to "jump out the window" or "hit that nurse." Command hallucinations are often frightening and may be a warning flag for a psychiatric emergency. It is essential to assess what the patient hears, the ability to recognize the hallucination as "not real," and the patient's ability to resist any commands. Visual hallucinations are the second most common form in schizophrenia. They may involve distortion of visual stimuli or can be formed and realistic images. Seeing individuals and animals are most common. Olfactory, tactile, or gustatory hallucinations are unusual in mental illness. When present, other causes should be investigated. Other alterations in perception are: • Illusions: Misperceptions or misinterpretations of a real experience. For example, a man sees a coat on a shadowy coat rack and believes it is a bear. • Depersonalization: A feeling of being unreal or having lost identity. Body parts do not belong or the body has drastically changed (e.g., a patient may see the fingers as being smaller or not theirs). • Derealization: A feeling that the environment has changed (e.g., everything seems bigger or smaller or familiar surroundings seem somehow strange and unfamiliar). Alterations in Behavior Alterations in behavior involve changes in the speed of movement and behaviors that are illogical or inappropriate including: • Catatonia: A pronounced increase or decrease in the rate and amount of movement. Excessive motor activity is purposeless and accompanied by echolalia (repeating others' words) and echopraxia (mimicking others' movements). The most common form of catatonia is when the person moves little or not at all. Muscular rigidity, or catalepsy, may be so severe that the limbs remain in whatever position they are placed. Freezing in place may result in problems such as exhaustion, pneumonia, blood clotting, malnutrition, or dehydration. • Waxy flexibility: Maintaining a given posture inappropriately, usually seen in catatonia. For 419 example, when the nurse raises the arm, the patient continues to hold this position in a statue-like manner. • Motor retardation: A pronounced slowing of movement. • Motor agitation: Excited behavior such as running or pacing rapidly, often in response to internal or external stimuli. The agitation can put the patient at risk (e.g., exhaustion, running into traffic) or others at risk (being knocked down). • Stereotyped behaviors: Repetitive behaviors that do not serve a logical purpose. • Echopraxia: The mimicking of movements of another. • Negativism: A tendency to resist or oppose the requests or wishes of others. • Impaired impulse control: A reduced ability to resist one's impulses. Examples include interrupting in the group setting or throwing unwanted food on the floor. It can increase the risk of assault. • Gesturing or posturing: Assuming unusual and illogical expressions (often grimaces) or positions. • Boundary impairment: An impaired ability to sense where one's body or influence ends and another's begins. For example, a patient might stand too close to others or might drink another's beverage, believing that because it is near, it is theirs. Negative Symptoms Positive symptoms are so attention-getting, they make treatment seem more urgent than negative symptoms. Yet negative symptoms are serious problems for people with schizophrenia because they are the absence of essential human qualities. Treating negative symptoms is more difficult than treating positive symptoms. Negative symptoms include the following six symptoms that all start with the letter A: • Anhedonia (an = without + hedonia = pleasure): A reduced ability or inability to experience pleasure in everyday life. • Avolition (a = without + volition = making a decision): Loss of motivation; difficulty beginning and sustaining goal-directed activities; reduction in motivation or goal-directed behavior. • Asociality: Decreased desire for, or comfort during, social interaction. • Affective blunting: Reduced or constricted affect. • Apathy: A decreased interest in, or attention to, activities or beliefs that would otherwise be interesting or important. • Alogia: Reduction in speech, sometimes called poverty of speech. These symptoms can contribute to poor social functioning and social withdrawal. They can impede a person's ability to initiate and maintain conversations and relationships or succeed in school or work. Apathy and avolition result in deficits in basic activities such as maintaining adequate hygiene, grooming, and other activities of daily living Affect, an additional "A" word, is the external expression of a person's internal emotional state. In schizophrenia, affect may be diminished or not coincide with inner emotions. Some antipsychotics can also cause diminished affect. Affect in schizophrenia can usually be categorized in one of four ways: • Flat: Immobile or blank facial expression • Blunted: Reduced or minimal emotional response • Constricted: Reduced in range or intensity (e.g., shows sadness or anger but no other moods) • Inappropriate: Incongruent with the actual emotional state or situation (e.g., laughing in response to a tragedy) • Bizarre: Odd, illogical, inappropriate, or unfounded; includes grimacing Cognitive Symptoms Cognitive symptoms represent the third symptom group and are evident in most patients with schizophrenia. These impairments can lead to poor judgment and leave the patient less able to cope, learn, manage health, or succeed in school or work. Cognitive symptoms include the following. Concrete thinking is an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. For example, a nurse might ask what brought the patient to the hospital, and the patient answers "a cab" rather than explaining a suicide attempt. Interpreting proverbs can be used to assess abstract thought. An abstract interpretation of "The grass is always greener on the other side of the fence" is that it always seems we would be happier given other 420 circumstances. A concrete interpretation could be "That side gets more sun, so it's greener there." Concreteness reduces one's ability to understand and respond to concepts requiring abstract reasoning such as love or humor. Concreteness, especially when combined with an impaired ability to recognize variations in affect or tone of voice, can also make it difficult to recognize social cues such as sarcasm. For example, a patient who had forgotten his wallet asked a store clerk if he could pay later for a bag of chips. When the clerk sarcastically replied, "Oh sure, we let our customers pay whenever they want," the patient took this literally. The patient was distressed when police arrested him for theft despite his protests that he had permission not to pay. Impaired memory impacts short-term memory and the ability to learn. Repetition and verbal or visual cues may help the patient to learn and recall needed information (e.g., a picture of a toothbrush on the patient's wall as a reminder to brush his or her teeth). Impaired information processing can lead to problems such as delayed responses, misperceptions, or difficulty understanding others. Patients may lose the ability to screen out insignificant stimuli such as background sounds or objects in one's peripheral vision. This can lead to overstimulation. Impaired executive functioning includes difficulty with reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipation and planning, and inhibiting undesirable impulses or actions. Impaired executive functioning interferes with problem solving and can contribute to inappropriateness in social situations. Affective Symptoms Affective symptoms are those that involve the experience and expression of emotions. They are common and increase patients' suffering. Mood may be unstable, erratic, labile (changing rapidly and easily), or incongruent (not what would be expected for the circumstances). A serious affective change often seen in schizophrenia is depression. Depression may occur as part of a shared inflammatory reaction affecting the brain or may simply be a reaction to the stress and despair that can come from living with a chronic illness. Assessment for depression is crucial because it may indicate an impending relapse, further impair functioning, and increase risk of substance use disorders. Most importantly, depression puts people at increased suicide

opioid withdrawal symptoms of sud

Opioid withdrawal Withdrawal symptoms for opioids occur after a cessation of or reduction in heavy opioid use, or after an opioid antagonist has been administered. Symptoms of withdrawal include mood dysphoria, nausea, vomiting, diarrhea, muscle aches, fever, and insomnia. Other classic symptoms of withdrawal are lacrimation (watery eyes), rhinorrhea (runny nose), pupillary dilation, and yawning. The symptom of piloerection (bristling of hairs) or gooseflesh is the origin of the term cold turkey for the abstinence syndrome. Males may experience sweating and spontaneous ejaculations while awake. Morphine, heroin, and methadone withdrawal syndrome begins 6 to 8 hours after the last dose following a period of at least a week of use. It reaches intensity during the second or third day and then subsides during the next week. Meperidine (Demerol) withdrawal begins within 8 to 12 hours from abstinence and lasts about 5 days. See Box 22.1 for some of the signs and symptoms of intoxication and withdrawal.

appliation of nursing pocess when providing care to patients with sud

Application of the Nursing Process Screening Alcohol is a major contributing factor in: • Increased mortality and deaths • Morbidity and disease • Harm to others and injury • Increased economic loss and disabilities (SAMHSA, 2015b). Alcohol can be fatal as a result of its severe withdrawal symptoms. Screening is essential to intervene early and provide treatment for people with substance use disorders and for those at risk of developing these disorders. The Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. SBIRT identifies at-risk substance users for early intervention (SAMHSA, 2015) and consists of three major components: • Screening: A nurse or other healthcare professional in any healthcare setting assesses the severity of substance use and identifies the appropriate level of treatment. • Brief Intervention: A nurse or other healthcare professional focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. • Referral to Treatment: A nurse or other healthcare professional provides those identified as needing more extensive treatment with access to specialty care. A variety of other screening tools are available to assist healthcare practitioners in gaining important information on which to base plans of care. Additional screening tools are: • AUDIT (The Alcohol Use Disorders Identification Test) • CAGE (Questions: Have you felt you needed to cut down on your drinking? Are people annoyed by your drinking? Have you felt guilty about your drinking? Have you ever had a drink in the morning (eye-opener)? Score of 2 or more is significant, although a score of 1 requires further assessment. • CAGE-AID (Questions are the same as CAGE but refers to Adapted to Include Drugs.) • T-ACE (Tolerance, Annoyance, Cut down, Eye-opener) Formalized alcohol screening is as simple as using the Alcohol Use Disorders Identification Test (AUDIT) developed for the World Health Organization. AUDIT has been effective for decades and continues to be used today (Babor et al., 2001; Table 22.4). The clinician can administer this tool or the patient can self-report. During the screening process, instructions need to be clear and followed carefully. Nonjudgmental attitudes help with objectivity regardless of what the individual reveals. Several trends are important such as the appearance of progression or loss of control and whether or not tolerance or withdrawal is present. Once the screening process identifies a potential problem, a more complete assessment is warranted. Assessment An alcohol use assessment is part of a more comprehensive assessment that evaluates the individual holistically. Ideally, this assessment involves an addictions professional with specialized knowledge and skills to make a diagnosis. The assessment will include a clinical examination of background, pattern of substance use, and any mental health symptoms. The nurse will make special note of any history of trauma, a family history of substance use or mental health problems and any disabilities, as well as the individual's strengths and level of willingness to change. As a result of this assessment, the individual may be identified as having a substance-related disorder. Family Assessment Understanding the process of addiction from a holistic perspective requires careful attention to the family. Living with an individual who misuses alcohol or other substances is a source of stress and requires family system adjustments. Codependence is a cluster of behaviors originally identified through research involving the families of alcoholic patients. People who are codependent often exhibit overly responsible behavior—doing for others what others could just as well do for themselves. People who are codependent often define their self-worth in terms of caring for others to the exclusion of their own needs. Self-Assessment Alcohol use is self-inflicted. You should carefully assess personal thoughts, opinions, and feelings as the first step to remaining objective and establishing a therapeutic relationship with a person who misuses alcohol. Most of us have been impacted in some way by someone whose life has been torn apart by substance use. Recognizing and dealing with our responses by practicing introspection is essential to the provision of patient-centered care protected from bias or countertransference. You may be aware that registered nurses themselves might have personal substance use problems. For those nurses who become aware that they are engaging in risk-taking behaviors or that one of their colleagues may be experiencing difficulties, there are nonpunitive alternatives to discipline programs in the form of peer assistance. Many State Boards of Nursing have developed an alternative to discipline program to help impaired nurses. To determine if your state has this model, check with your state's Board of Nursing. Diagnosis Once the comprehensive substance use assessment has been completed in a thorough, objective manner, the data are analyzed and potential or actual problems and needs are identified. Clinical decision-making skills will be used to determine which of the identified problems requires a priority intervention. Outcomes Identification The goals for treatment planning arise from the preferred outcome for each problem. Outcome measures may include immediate detox and stabilization for individuals experiencing withdrawal, abstinence if individuals are actively drinking, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle for after discharge. Table 22.5 identifies signs and symptoms commonly experienced with substance use disorders, offer potential nursing diagnoses, and suggests outcomes. Planning The treatment plan will be developed based on the assessment and diagnoses. For treatment to be successful, a patient-centered approach includes the patient's goals. The plan should take into account the patient's ability to recognize the problem and readiness or motivation for change. Implementation Psychosocial Interventions Basic nursing interventions are useful in providing a supportive environment for managing substance use disorders. Promoting safety and sleep are essential first-line interventions. Also, patients with alcohol use disorder may have severely compromised nutritional status due to choosing substance over sustenance. Gradually reintroducing healthy food and hydration helps support body systems and neurological functioning. Support and encouragement for self-care (hygiene) will help improve self-esteem in individuals who may have long neglected themselves. The development of a therapeutic relationship sets the stage for exploring harmful thoughts, anxiety, hopelessness, and spiritual distress. An understanding of current coping skills along with identification of new skills provides tools to test in a safe setting. Assistance in goal setting helps a patient to see beyond the current situation and instills hope and direction. Psychobiological Interventions Pharmacological With the completion of the Human Genome Project and ongoing genetic research, it is only a matter of time before the nurse's responsibility will include not only review of laboratory data, but also a review of the patient's genetic profiles (Cheek et al., 2015). In addition to adding to the body of knowledge, this research will provide alternative options for treatment. Nurses administer medications and provide ongoing assessment of their efficacy and side effects after administration. Nurses need to monitor vital signs frequently since an increase in pulse, blood pressure, and body temperatures are clear signs of withdrawal. The goal is to keep the patient safe and comfortable and stay ahead of withdrawal so the patient does not suffer. Previously in the chapter we discussed medications used for other substances. Table 22.6 identifies medications used in the treatment of alcohol use disorder. Health Teaching and Health Promotion By 2020, substance use disorders and mental health disorders are predicted to surpass all physical diseases as the major causes of disability worldwide (SAMHSA, 2015c). If genetic vulnerability accounts for 40% to 60% of an individual's risk, prevention may be the best answer to the increasing problem of substance use and addiction (NIDA, 2014). Health teaching is a part of the school curriculum, and schools may offer classes on understanding addiction as a brain disorder, its risk factors, and ways to prevent or limit exposure to psychoactive substances. Promoting classes for developing healthy coping and stress management skills and activities for increasing selfconfidence and self-efficacy would also lower the risks for use of psychoactive substances. Social activities that increase supportive relationships reduce the impact of stressful life events and provide a venue for community activities that provide health education and promotion. Pay special attention to understanding the particular impact of trauma as a risk factor. Physical, sexual, or emotional abuse at any age; physical trauma from accidents; natural disasters; or acts of violence or war can all be predisposing factors for the use of psychoactive substances or processes. Advanced Practice Interventions Psychotherapy. Advanced practice nurses and other substance use and addiction treatment professionals use a number of psychotherapies. Cognitive behavioral therapy and motivational interviewing are commonly used evidence-based therapies. Destructive and negative thinking patterns play into the development of maladaptive behavioral patterns like substance use disorders. Cognitive behavioral therapy helps patients to explore thinking patterns so that the core belief system and any irrational core beliefs can be identified. Positive and negative consequences of alcohol use are explored. Patients learn to self-monitor their cravings and challenge these cravings realistically. Motivational interviewing is an approach based on the transtheoretical or stages of change theory. It has gained popularity in its use as a brief, long-term, and supplementary intervention, particularly in the treatment of substance use disorders. It uses a person-centered approach to strengthen motivation for change (Tan et al., 2015). The advanced practice nurse and patient usually meet for an hour at a time. Individuals may be at stage one, precontemplation, and need assistance in admitting there is a problem. If they have acknowledged the problem, contemplation, they may still not be ready to commit to addressing it. The goal of treatment is to assist in the development of awareness and a commitment. Preparation or getting ready, and action or changing take place in early treatment phases. The maintenance stage is the ongoing commitment to a recovery program. Without continuing action, the individual will likely return to previous behavior, relapse. Evaluation Evaluation occurs on several levels: assessing the effectiveness of the treatment plan, using objective data to check whether nursing actions addressed the patient's symptoms, and measuring the changes in the patient's behaviors for progress toward meeting stated goals. Problematic behaviors, patterns of expression, or perceptions may improve or only undergo change in small increments, requiring alterations in the action steps or even the goals of the treatment plan to meet the patient's needs. During the treatment experience, conduct ongoing evaluation of the process to ensure that any transference or countertransference is managed and that the goals and outcomes of treatment remain patient-centered. Evaluation will also make it possible to ensure that the patient acquires the necessary skills and competencies for continued reflection and maintenance of the new lifestyle identification.

pathogenesis of schizophrenia

Genetic Schizophrenia-spectrum disorders are inherited. About 80% of the risk of schizophrenia comes from genetic and epigenetic factors (factors such as toxins or psychological trauma that affect the expression of genes). Over 100 loci in the human genome are associated with an increased risk of schizophrenia (Castellani et al., 2015). Concordance rates (i.e., the percentage of a shared disorder in twins) are about 50% for identical twins and about 15% for fraternal twins. Evidence suggests that multiple genes on different chromosomes interact with one another in complex ways to create vulnerability for schizophrenia. Neurobiological Dopamine theory The first antipsychotic drugs, known as first-generation (typical) antipsychotics, (e.g., haloperidol and chlorpromazine), block the activity of dopamine-2 (D2) receptors in the brain and reduce symptoms such as hallucinations and delusions. Symptom reduction suggested that dopamine plays a significant role in psychosis. Amphetamines and cocaine can induce psychosis in people without schizophrenia and can also bring on the disorder. Almost any drug of abuse, particularly marijuana, can increase the risk of schizophrenia in biologically vulnerable individuals (Morgan et al., 2016). However, because medications that reduce dopamine activity do not alleviate all the symptoms of schizophrenia, it seems likely that other neurotransmitters or other factors are involved as well. Other neurochemical hypotheses Second-generation (atypical) antipsychotics block serotonin (5-hydroxytryptamine 2A, or 5-HT2A ) and dopamine, which suggests that serotonin may play a role in schizophrenia as well. Phencyclidine (PCP) induces a state that resembles schizophrenia. This observation led to interest in the N-methyl-D-aspartate (NMDA) receptor complex and the possible role of glutamate in the pathophysiology of schizophrenia. Glutamate, dopamine, and serotonin act synergistically in neurotransmission and thus glutamate may also play a role in causing psychosis (Andreou et al., 2015). Neurotransmission by another calming neurotransmitter, gamma-aminobutyric acid (GABA), is also impaired in schizophrenia (Frankle et al., 2015). Acetylcholine, active in the muscarinic system, may play a role in psychosis. Brain Structure Abnormalities It is possible that structural abnormalities cause disruption in communication within the brain. Structural differences may be due to errors in neurodevelopment or errors in the normal pruning of neuronal tissue that happens in late adolescence and early adulthood. Inflammation or neurotoxic effects from factors such as oxidative stress, infection, or autoimmune dysfunction may also alter the brain's structure (Sekar et al., 2016). Using brain imaging techniques—computed tomography (CT), magnetic resonance imaging 411 (MRI), functional MRI (fMRI), and positron emission tomography (PET)—researchers (Dean et al., 2016) demonstrated structural brain abnormalities including: • Reduced volume in the right anterior insula (may contribute to negative symptoms) • Reduced volume and changes in the shape of the hippocampus • Accelerated age-related decline in cortical thickness • Gray matter deficits in the dorsolateral prefrontal cortex area, thalamus, and anterior cingulate cortex, as well as in the frontotemporal, thalamocortical, and subcortical-limbic circuits • Reduced connectivity among various brain regions • Neuronal overgrowth in some areas, possibly due to inflammation or inadequate neural pruning • Widespread white matter abnormalities (e.g., in the corpus callosum) PET scans also show a lowered rate of blood flow and glucose metabolism in the prefrontal cortex. This executive functioning part of the brain governs planning, abstract thinking, social adjustment, and decision making. Fig. 3.5 in Chapter 3 shows a PET scan demonstrating reduced brain activity in the frontal lobe of a patient with schizophrenia. Such structural and functional changes may worsen as the disorder continues. Postmortem studies show a reduced volume of gray matter, especially in the temporal and frontal lobes. People with the most tissue loss had the worst symptoms. Psychological and Environmental Factors A number of biological, chemical, and environmental stressors are believed to combine with genetic vulnerabilities to produce schizophrenia. 412 Prenatal Stressors Infection during pregnancy increases the risk of mental illness in the child. Prenatal infections in the mother also increase the risk of infection in the child after birth, and those infections in the children also can make them more vulnerable to mental illness (Blomström et al., 2016). Other factors associated with an increased risk of schizophrenia include a father older than 35 at the child's 413 conception and a child's being born during late winter or early spring. Psychological Stressors Stress increases cortisol levels, impeding hypothalamic development and causing other changes that may precipitate the illness in vulnerable individuals. Schizophrenia often manifests at times of developmental and family stress such as beginning college or moving away from one's family. Social, psychological, and physical stressors may play a significant role in both the severity and course of the disorder and the person's quality of life. Other risk factors include childhood sexual abuse, exposure to social adversity (e.g., chronic poverty), migration to or growing up in a foreign culture, and exposure to psychological trauma or social defeat (Evans et al., 2015). These factors may cause structural changes in the brain via epigenetic changes to the genome. Even psychological trauma in a parent or grandparent may cause epigenetic changes that increase vulnerability, and this increased risk can be passed on to one's descendants. Environmental Stressors Environmental factors such as toxins, including the solvent tetrachloroethylene (used in dry cleaning, to line water pipes, and sometimes found in drinking water), are also believed to contribute to the development of schizophrenia in vulnerable people (Aschengrau et al., 2012). Living in urban areas or high-crime environments is also believed to increase the risk of schizophrenia (Haddad et al., 2015). Prognostic Considerations For most individuals symptoms improve with medications and psychosocial interventions. As a result, many people with schizophrenia experience a good quality of life and success within their families, occupations, and other roles. In many cases, schizophrenia does not respond fully to treatments, leaving mild to severe residual symptoms and varying degrees of dysfunction or disability. A minority of individuals requires repeated or lengthy inpatient care or institutionalization. Factors associated with a less positive prognosis include a slow onset (e.g., more than 2 to 3 years), younger age at onset, longer duration between first symptoms and first treatment, longer periods of untreated illness, and more negative symptoms. Reducing the frequency, intensity, and duration of relapse (when previously controlled symptoms return) is believed to improve the long-term prognosis

Epidemiology of Schizophrenia

The prevalence of childhood-onset schizophrenia is about 1 in 40,000 children. It affects individuals of all races and cultures equally. It is diagnosed more frequently in males (1.4:1) and among individuals growing up in urban areas (Haddad et al., 2015). Onset in males is usually between the ages of 15 and 25 years and is associated with poorer functioning and more structural abnormality in the brain. The onset tends to be somewhat later in women (ages 25 to 35 years), who tend to have a better prognosis and experience less structural changes in the brain.