Mental Health Final Exam Study Guide

1 Mental Health Final Exam Diagnostic Classes of Substance Abuse Intoxication: use of a substance that results in maladaptive behavior Withdrawal syndrome: refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases Detoxification: the process of safely withdrawing from a substance Substance abuse: drug is used outside the medical or social norm despite negative consequences Substance dependence: problem associated with addiction Alcoholism First episode of intoxication → continuing problems with alcohol → first blackout → continued drinking → development of tolerance → tolerance break → continued drinking → functioning becoming affected → periods of abstinence/temporary controlled drinking → escalation of alcohol intake → more problems → subsequent crisis → continuation of cycle Related disorders: gambling, caffeine and tobacco additions CNS depressant: relaxation/loss of inhibitions 1. Slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment 2. Aggressive behavior or display inappropriate sexual behavior; the person who is intoxicated may experience a blackout Treatment of an alcohol overdose: gastric lavage or dialysis to remove the drug and support of respiratory and cardiovascular functioning in an intensive care unit Symptoms of withdrawal 1. Onset within 4 to 12 hours after cessation or marked reduction of alcohol intake; peaking on second day; complete in about 5 days 2. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium (DTs) 3. Benzodiazepines for safe withdrawal Substance Abuse Treatment Concept: medical illnesses, chronic, progressive, characterized by remissions and relapses Treatment models: Hazelden Clinic model and 12-step program of Alcoholics Anonymous Individual, group counseling Treatment settings Pharmacologic treatment: safe withdrawal; prevent relapse Medications help manage withdrawal or cravings, but is not a specific treatment for substance abuse 2 Alcohol Intoxication and Overdose An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression This combination can cause aspiration pneumonia or pulmonary obstruction Alcohol-induced hypotension: can lead to cardiovascular shock and death Treatment: similar to that for any central nervous system depressant—gastric lavage or dialysis to remove the drug, and support of respiratory and cardiovascular functioning in an intensive care unit The administration of central nervous system stimulants is contraindicated Physiological Effects of Alcoholism/Long Term (Box 19.1) Cardiac myopathy Wernicke encephalopathy: an acute neurological condition characterized by a clinical triad of ophthalmoparesis with nystagmus, ataxia, and confusion Korsakoff psychosis: a late complication of persistent Wernicke encephalopathy and results in memory deficits, confusion, and behavioral changes Pancreatitis Esophagitis Hepatitis Cirrhosis Leukopenia Thrombocytopenia Ascites Alcohol Withdrawal and Detoxification Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms: coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremens Alcohol withdrawal usually peaks on the second day and is over in about 5 days; withdrawal may take 1 to 2 weeks Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms Total scores less than 8 indicate mild withdrawal, scores from 8 to 15 indicate moderate withdrawal (marked arousal), and scores greater than 15 indicate severe withdrawal (Clinical Institute Withdrawal Assessment of Alcohol Scale) Disulfiram (Antabuse) 3 Use: aversion therapy for alcoholism Never give to a patient that is intoxicated or without their consent Mechanism of action: inhibition of enzyme involved with alcohol metabolism Adverse reaction with alcohol ingestion Side effects: fatigue, drowsiness, halitosis, tremor, impotence Drug interactions: with phenytoin, isoniazid, warfarin, barbiturates, long-acting benzodiazepines Client teaching: avoidance of alcohol, including common products that may contain it (will cause same symptoms if the client has taken it with alcohol) 1) Shaving cream, deodorant, OTC cough preparations, vanilla extract Elder Considerations Approximately 30% to 60% of elders in treatment began drinking abusively after age 60 Risk factors for late-onset substance include chronic illness that causes pain, long-term use of prescription medication (sedative-hypnotics, anxiolytics), life stress, loss, social isolation, grief, depression, and an abundance of discretionary time and money Physical problems associated with substance abuse develop more quickly in elders Types of Therapy Groups Psychotherapy Group: the goal of a psychotherapy group is for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group 1) Open groups are ongoing and run indefinitely, allowing members to join or leave the group as they need to 2) Closed groups are structured to keep the same members in the group for a specified number of sessions Family Therapy: the goals include understanding how family dynamics contribute to the client’s psychopathology, mobilizing the family’s inherent strengths and functional resources, restructuring maladaptive family behavioral styles, and strengthening family problem-solving behavior Family Education: the curriculum focuses on schizophrenia, bipolar disorder, clinical depression, panic disorder, and obsessive–compulsive disorder Education Groups: the goal is to provide information to members on a specific issue—for instance, stress management, medication management, or assertiveness training Support Groups: are organized to help members who share a common problem cope with it Self-Help Groups: members share a common experience, but the group is not a formal or structured therapy group (no identifiable leader) Therapeutic Techniques (Table 6.1) 4 Accepting—indicating reception Broad openings—allowing the client to take the initiative in introducing the topic Consensual validation—searching for mutual understanding, for accord in the meaning of the words Encouraging comparison—asking that similarities and differences be noted Reflecting—directing client actions, thoughts, and feelings back to client Restating—repeating the main idea expressed Exploring—delving further into a subject or an idea Silence—absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking Voicing doubt—expressing uncertainty about the reality of the client’s perceptions Nontherapeutic Techniques (Table 6.2) Advising—telling the client what to do Challenging—demanding proof from the client Agreeing—indicating accord with the client Introducing an unrelated topic—changing the subject Disagreeing—opposing the client’s ideas Giving approval—sanctioning the client’s behavior or ideas Reassuring—indicating there is no reason for anxiety or other feelings of discomfort Avoiding Nontherapeutic Communication These responses cut off communication and make it more difficult for the interaction to continue Responses such as “everything will work out” or “maybe tomorrow will be a better day” may be intended to comfort the client, but instead may impede the communication process Asking “why” questions (in an effort to gain information) may be perceived as criticism by the client, conveying a negative judgment from the nurse Overt cues are clear, direct statements of intent, such as “I want to die.” The message is clear that the client is thinking of suicide or self-harm Covert cues are vague or indirect messages that need interpretation and exploration—for example, if a client says, “Nothing can help me.” Components of Therapeutic Relationship Trust 5 1) Will build when the client is confident in the nurse and when the nurse establishes integrity and reliability 2) Behaviors such as caring, interest, understanding, consistency, honesty, promise keeping, listening 3) Congruence: occurs when words and actions match Genuine Interest 1) When the nurse is comfortable with him or herself, aware of his or her strengths and limitations, and clearly focused, the client perceives a genuine person showing genuine interest 2) Self-comfort, self-awareness of strengths and limitations, clear focus Empathy 1) Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client 2) Client and nurse giving “gift of self” (client feeling safe enough to share feeling and the nurse listening to understand) 3) Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings 4) Acceptance (no judgments; set boundaries) 5) Positive regard (unconditional nonjudgmental attitude) Nonverbal Communication Skills (more accurate, 2/3 of communication) 6 Facial movements connect with words to illustrate meaning; this connection demonstrates the speaker’s internal dialogue 1) An expressive face portrays the person’s moment-by-moment thoughts, feelings, and needs. These expressions may be evident even when the person does not want to reveal his or her emotions 2) An impassive face is frozen into an emotionless deadpan expression similar to a mask 3) A confusing facial expression is one that is the opposite of what the person wants to convey. A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing facial expression Body language (e.g., gestures, postures, movements, and body positions) is a nonverbal form of communication Closed body positions, such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting A better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle This open posture demonstrates unconditional positive regard, trust, care, and acceptance Vocal cues are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender’s message The use of extraneous words with long, tedious descriptions is called circumstantiality; it can indicate the client is confused about what is important or is a poor historian Eye contact, looking into the other person’s eyes during communication, is used to assess the other person and the environment and to indicate whose turn it is to speak; it increases during listening but decreases while speaking Silence or long pauses in communication may indicate many different things. The client may be depressed and struggling to find the energy to talk. Sometimes, pauses indicate the client is thoughtfully considering the question before responding Categories of Mood Disorders (pg. 285) 7 The primary mood disorders are major depressive disorder and bipolar disorder (formerly called manic-depressive illness) A major depressive episode lasts at least 2 weeks, during which the person experiences a depressed mood or loss of pleasure in nearly all activities About 20% have delusions and hallucinations; this combination is referred to as psychotic depression Bipolar disorder is diagnosed when a person’s mood fluctuates to extremes of mania and/or depression, as described previously Mania: a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable (typically last 1 week or more) 1. Mania episode = inflated self-esteem, “pleasure driven” = high rate of consequences Pressured speech: unrelenting, rapid, often loud talking without pauses Hypomania: a period of abnormally and persistently elevated, expansive, or irritable mood and some other milder symptoms of mania Difference between Mania and Hypomania 1. Hypomanic episodes do not impair the person’s ability to function (in fact, he or she may be quite productive), and there are no psychotic features (delusions and hallucinations) Rapid Cycling: a mixed episode is diagnosed when the person experiences both mania and depression nearly every day for at least 1 week Major depressive disorder: lasts at least 2 weeks Bipolar I disorder: one or more manic or mixed episodes usually accompanied by major depressive episodes Bipolar II disorder: one or more major depressive episodes accompanied by at least one hypomanic episode Anticonvulsants Used as Mood Stabilizers (Table 17.6) 8 Generic (Trade) Name Side Effects Carbamazepine (Tegretol) Dizziness, hypotension, ataxia, sedation, blurred vision, leukopenia, and rashes Divalproex (Depakote) Ataxia, drowsiness, weakness, fatigue, menstrual changes, dyspepsia, nausea, vomiting, weight gain, and hair loss Lamotrigine (Lamictal) Nursing Implications Assist client in rising slowly from sitting position Report rashes to physician Provide rest periods Administer with food Establish balanced nutrition Assist client in rising slowly from sitting Dizziness, hypotension, ataxia, coordination, sedation, position headache, weakness, fatigue, menstrual changes, sore throat, flu-like symptoms, blurred or double vision, nausea, Provide rest periods vomiting, and rashes Administer with food Report rashes to physician Bipolar Disorder (pg. 305) Bipolar disorder: involves extreme mood swings from episodes of mania to episodes of depression They have poor judgment and rapid thoughts, actions, and speech If a person’s first episode of bipolar illness is a depressed phase, he or she might be diagnosed with major depression; a diagnosis of bipolar disorder may not be made until the person experiences a manic episode Manic episodes begin suddenly, last from a few weeks to several months Manic episodes typically begin suddenly with rapid escalation of symptoms over a few days, and they last from a few weeks to several months The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem, sleeplessness, pressured speech, flight of ideas, reduced ability to filter extraneous stimuli, distractibility, increased activities with increased energy, and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments Treatment for Bipolar (Lifelong Tx) (pg. 306) 9 Antimanic agent = Lithium: a salt contained in the human body; it is similar to gold, copper, magnesium, manganese, and other trace elements Lithium’s action peaks in 30 minutes to 4 hours for regular forms and in 4 to 6 hours for the slow-release form It crosses the blood–brain barrier and placenta and is distributed in sweat and breast milk Lithium use during pregnancy is not recommended because it can lead to first-trimester developmental abnormalities Onset of action is 5 to 14 days; with this lag period, antipsychotic or antidepressant agents are used carefully in combination with lithium to reduce symptoms in acutely manic or acutely depressed clients The half-life of lithium is 20 to 27 hours Anticonvulsant drugs: several anticonvulsants traditionally used to treat seizure disorders have proved helpful in stabilizing the moods of people with bipolar illness Psychotherapy useful in mildly depressive or normal portion of bipolar cycle (not manic stages) Mood-Stabilizing Drugs Lithium, some anticonvulsants (carbamazepine, valproic acid; gabapentin, topiramate, oxcarbazepine, and lamotrigine) Use: treatment of bipolar disorders Mechanism of Action 1) Normalize reuptake of certain neurotransmitters (lithium) 2) Increase levels of GABA (valproic acid, topiramate) 3) Kindling process (valproic acid, carbamazepine) = manages small episodes Side Effects of Mood-Stabilizing Drugs Lithium: nausea, diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste, fatigue, lethargy; weight gain, acne (later in therapy) 1) Toxicity: severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination Carbamazepine and valproic acid: drowsiness, sedation, dry mouth, blurred vision Carbamazepine: rash, orthostatic hypotension (aplastic anemia and agranulocytosis) Valproic acid: weight gain, alopecia, hand tremor (monitored for hepatic failure) Topiramate: dizziness, sedation, weight loss Client Teaching (Mood-Stabilizing Drugs) Periodic monitoring of blood levels = 12 hours after last dose Drug with meals Safety measures (waiting to drive until dizziness, lethargy, fatigue or blurred vision goes away) 10 Warning Lamotrigine: can cause serious rashes requiring hospitalization, including Stevens-Johnson syndrome and, rarely, life-threatening toxic epidermal necrolysis. The risk for serious rashes is greater in children younger than 16 year Lithium: toxicity is closely related to serum lithium levels and can occur at therapeutic doses. The serum lithium level should be about 1 mEq/L. Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic Valproic Acid/Derivatives: can cause hepatic failure, resulting in fatality. Liver function tests should be performed before therapy and at frequent intervals thereafter, especially for the first 6 months. Can produce teratogenic effects such as neural tube defects (e.g., spina bifida). Can cause life-threatening pancreatitis in both children and adults. Can occur shortly after initiation or after years of therapy Carbamazepine: can cause aplastic anemia and agranulocytosis at a rate five to eight times greater than the general population. Pretreatment hematologic baseline data should be obtained and monitored periodically throughout therapy to discover lowered WBC or platelet count Mood Disorders (pg. 285) Everyone occasionally feels sad, low, and tired, with the desire to stay in bed and shut out the world These episodes are often accompanied by anergia (lack of energy), exhaustion, agitation, noise intolerance, and slow thinking processes, all of which make decisions difficult At the other end of the mood spectrum are episodes of exaggeratedly energetic behavior In an elated mood, stamina for work, family, and social events is untiring. This feeling of being “on top of the world” also recedes in a few days to a euthymic mood (average affect and activity) Mood disorders, also called affective disorders, are pervasive alterations in emotions that are manifested by depression, mania or both Most common psychiatric diagnosis associated with suicide 1. Depression being one of the most important risk factors for suicide Antidepressants Use: major depressive illness, anxiety disorders, depressed phase of bipolar disorder, psychotic depression Off-label use: chronic pain, migraines, peripheral and diabetic neuropathy, sleep apnea, dermatologic disorders, panic and eating disorders Mechanism of action: interact with monoamine neurotransmitter systems, especially norepinephrine and serotonin Preferred drugs for clients at high risk for suicide 11 Groups of Antidepressants Tricyclic and related cycle antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRIs) 1) Typically not fatal for OD, used for medium to moderate depression MAO inhibitors (MAOIs) Others (venlafaxine, bupropion, duloxetine, trazodone, nefazodone) Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro) Monoamine Oxidase Inhibitors (MAOIs) Phenelzine (Nardil), Tranylcypromine (Parnate), Isocarboxazid (Marplan) Cyclic Compounds Imipramine (Tofranil), Desipramine (Norpramin), Amitriptyline (Elavil), Nortriptyline (Pamelor), Doxepin (Sinequan), Trimipramine (Surmontil), Protriptyline (Vivactil), Maprotiline (Ludiomil), Mirtazapine (Remeron), Amoxapine (Asendin), Clomipramine (Anafranil) Other Compounds Bupropion (Wellbutrin), Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Trazodone (Desyrel), Nefazodone (Serzone), Duloxetine (Cymbalta), Vilazodone (Viibryd) “S-S-S” (SSRI’s Adverse Effects) Stomach upset Sexual dysfunction Serotonin syndrome SSRI Drugs – “Effective for Sadness, Panic & Compulsions" Effective = Escitalopram For- Fluoxetine = Fluvoxamine Sadness = Sertraline Panic = Paroxetine 12 Compulsions = Citalopram Antidepressant Side Effects SSRIs (fewer side effects than most) 1) Anxiety, agitation, akathisia, nausea, insomnia, sexual dysfunction 2) Weight gain 3) Sweating and continued sedation indicate a need for change in medication TCAs (block reuptake of norepinephrine) 1) Anticholinergic effects 2) Orthostatic hypotension, sedation, weight gain, tachycardia 3) Sexual dysfunction 4) Weight gain and sexual disfunction will contribute to non-compliance MAOIs 1) Daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, sexual dysfunction 2) Hypertensive crisis (with foods containing tyramine) i. Aged cheese, aged meat, tap beers, yogurt, sour cream, peanuts, soy sauce, sauerkraut, and over ripped fruit Other Agents 1) Sedation, headache (nefazodone, trazodone) 2) Loss of appetite, nausea, agitation, insomnia (bupropion, venlafaxine) 3) Priapism: persistent/painful erection (trazodone) Drug Interactions (Antidepressants) Serotonin Syndrome 1) Results from taking MAOI + SSRI (at the same time) 2) Agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia 3) Coma, death (extreme reactions) 4) One drug must be fully cleared from a person’s system before starting a new therapy MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, meperidine (Demerol), CNS depressants, many antihypertensives, or general anesthetics Preferred Drugs for Clients at High Risk for Suicide SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose in contrast to the cyclic compounds and the MAOIs SSRIs are effective only for mild and moderate depression 13 Client Teaching (Antidepressants) Time of dosage 1) SSRI first thing in morning 2) TCAs at night Actions for missed dose 1) SSRI up to 8 hours after missed dose 2) TCAs within 3 hours of missed dose Safety measures 1) Driving/operating heavy machinery = drowsy Dietary restrictions 1) Foods containing tyramine “ SIG” Sleep disturbances Interest decreased Guilty feelings Depression assessment: monitor for signs and symptoms in clients that may be at risk for depression “DIG FAST” (Manic attack = signs and symptoms) Distractibility Indiscretion Grandiosity Flight of ideas Activity increase Sleep deficit Talkative "IS PATH WARM" (Suicide Attempt Warning Signs) Ideation Substance abuse Purposelessness Anxiety Trapped Hopelessness Withdrawal Anger Recklessness Mood changes 14 Ch. 12 Definitions – Abuse and Violence Abuse: treat (a person or an animal) with cruelty or violence, especially regularly or repeatedly Child abuse: the intentional injury of a child Cycle of violence: a typical pattern in domestic battering: violence; honeymoon or remorseful period; tension building; and, finally, violence; this pattern continually repeats itself throughout the relationship Date rape (acquaintance rape): sexual assault that may occur on a first date, on a ride home from a party or when the two people have known each other for some time Elder abuse: the maltreatment of older adults by family members or caretakers Family violence: encompasses domestic or partner battering; neglect and physical, emotional, or sexual abuse of children; elder abuse; and marital rape Intergenerational transmission process: explains that patterns of violence are perpetuated from one generation to the next through role modeling and social learning Intimate partner violence: the mistreatment, misuse, or abuse of one person by another in the context of a close, personal, or committed relationship Neglect: malicious or ignorant withholding of physical, emotional, or educational necessities for the child’s well-being Ostracism: exclusion from a society or group Physical abuse: ranges from shoving and pushing to severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, and even homicide Psychological abuse (emotional abuse): includes name calling, belittling, screaming, yelling, destroying property, and making threats as well as subtler forms such as refusing to speak to or ignoring the victim Rape: a crime of violence, domination, and humiliation of the victim expressed through sexual means Restraining order: legal order of protection obtained to prohibit contact between a victim and a perpetrator of abuse Sexual abuse: involves sexual acts performed by an adult on a child younger than 18 years Sodomy: anal intercourse Stalking: repeated and persistent attempts to impose unwanted communication or contact on another person Child Abuse Intentional injury to a child 1. Physical abuse or injuries 2. Neglect or failure to prevent harm 3. Failure to provide adequate physical or emotional care or supervision 4. Abandonment 5. Sexual assault or intrusion 6. Overt torture or maiming 15 Clinical Picture of Child Abuse Minimal parenting knowledge, skills Emotionally immature, needy, incapable of meeting own needs View children as property Cycle of family violence: adults raising children in same way they were raised (adults as victims of abuse frequently abuse their own children) Types of Child Abuse Sexual abuse: involves sexual acts performed by an adult on a child younger than 18 years 1. Incest, rape, and sodomy performed directly by the person or with an object, oral– genital contact, and acts of molestation such as rubbing, fondling, or exposing the adult’s genitals 2. A second type of sexual abuse involves exploitation, such as making, promoting, or selling pornography involving minors, and coercion of minors to participate in obscene acts Neglect: malicious or ignorant withholding of physical, emotional, or educational necessities for the child’s well-being 1. Child abuse by neglect is the most prevalent type of maltreatment and includes refusal to seek health care or delay doing so; abandonment; inadequate supervision; reckless disregard for the child’s safety; punitive, exploitive, or abusive emotional treatment; spousal abuse in the child’s presence; giving the child permission to be truant; or failing to enroll the child in school Psychological abuse (emotional abuse): includes verbal assaults, such as blaming, screaming, name-calling, and using sarcasm; constant family discord characterized by fighting, yelling, and chaos Warning Signs of Abused/Neglected Children Serious injuries such as fractures, burns, or lacerations with no reported history of trauma Delay in seeking treatment for a significant injury Child or parent giving a history inconsistent with severity of injury, such as a baby with contrecoup injuries to the brain (shaken baby syndrome) that the parents claim happened when the infant rolled off the sofa Inconsistencies or changes in the child’s history during the evaluation by either the child or the adult Unusual injuries for the child’s age and level of development, such as a fractured femur in a 2month-old or a dislocated shoulder in a 2-year-old High incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising of rectum or vagina Evidence of old injuries not reported, such as scars, fractures not treated, and multiple bruises that parent/caregiver cannot explain adequately 16 Treatment and Intervention of Child Abuse Child safety, well-being a priority Psychiatric evaluation/possible long-term therapy/play therapy (for very young child) Family therapy if reuniting feasible Psychiatric or substance abuse for parents Foster care (short or long term) Elder Abuse Elder abuse: the maltreatment of older adults by family members or others in a caregiver role 1. Physical, sexual, psychological abuse, or neglect 2. Self-neglect 3. Financial exploitation 4. Denial of adequate medical treatment 60-65% are women, 10% of population over age 65 Bullying has also been identified in senior living facilities between residents People who abuse elders almost always in caretaker role or elders depend on them in some way Elders often reluctant to report abuse due to fear of alternative (nursing home) Clinical picture: variable depending on type of abuse Potential Indicators of Elder Abuse (Box 12.4) Physical Abuse Indicators 1. Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations Psychosocial Abuse Indicators 1. Change in elder’s general mood or usual behavior; isolated from previous friends/family Material Abuse Indicators 1. Unpaid bills; standard of living below the elder’s mean Neglect Indicators 1. Poor personal hygiene; lack of needed medications or therapies Indicators of Self-Neglect 1. Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills Warning Indicators from Caregiver 1. The elder is not given an opportunity to speak for self, have visitors, or see anyone without the presence of the caregiver 17 Treatment and Intervention of Elder Abuse Caregiver stress relief Additional resources Possible removal of elder or caregiver Characteristics of Violent Families Family violence encompasses spouse battering; neglect and physical, emotional, or sexual abuse of children; elder abuse; and marital rape Common characteristics regardless of type of abuse (4) 1. Social isolation: members of these families keep to themselves and usually do not invite others into the home or tell anyone what is happening; abusers often threaten victims with even greater harm if they reveal the secret 2. Abuse of power, control: the abuser exerts not only physical power but also economic and social control; perception of any indication, real or imagined, of victim independence or disobedience, violence usually escalates 3. Alcohol, other drug abuse: alcohol does not cause the person to be abusive; rather, an abusive person is also likely to use alcohol or other drugs 4. Intergenerational transmission process: shows that patterns of violence are perpetuated from one generation to the next through role modeling and social learning; suggests that family violence is a learned pattern of behavior (not always present but a risk factor when we are assessing) Intimate Partner Violence (IPV) Intimate Partner Violence is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship The abuse can be emotional or psychological, physical, sexual, or a combination (which is common) 1. Psychological abuse (emotional abuse): includes name-calling, belittling, screaming, yelling, destroying property, and making threats as well as subtler forms, such as refusing to speak to or ignoring the victim 2. Physical abuse: ranges from shoving and pushing to severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, and even homicide 3. Sexual abuse: includes assaults during sexual relations such as biting nipples, pulling hair, slapping and hitting, and rape Pregnant women experience an increase in violence during pregnancy 18 Domestic violence occurs in same-sex relationships with the same statistical frequency as in heterosexual relationships Clinical Picture of IPV Abuser’s view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem-solving and social skills Increasing violence, abuse with any signs of independence (getting a job) Victim commonly dependent; viewed as unable to function without husband Cycle of Abuse and Violence Is another reason often cited for why women have difficulty leaving abusive relationships Violent episode → honeymoon phase → tension-building → violent episode While the cycle of violence is the most common pattern of IPV, it does not apply to all situations As violence continues, honeymoon phase gets smaller and smaller Many survivors report only one or two elements of the cycle There may be only periodic episodes of violent behavior with no subsequent honeymoon period or no observable period of increasing tension Screening/Assessment: SAFE (Box 12.2) Stress/safety Afraid/ abused Friends/family Emergency plan IPV may be suspected if a client exhibits unexplained bruising, broken bones, sexual assault, or a psychological/emotional trauma Stalking is a crime of intimidation in which perpetrators harass and terrorize their victims through behavior that causes fear or substantial emotional distress Don’ts of Working with Victims of Partner Abuse (Table12.1) Don’t tell the victim what to do Don’t express disgust, disbelief, or anger Don’t disclose client communications without the client’s consent Don’t preach, moralize, or imply that you doubt the client Don’t minimize the impact of violence Don’t express outrage with the perpetrator Don’t imply that the client is responsible for the abuse Don’t recommend couples’ counseling Don’t direct the client to leave the relationship 19 Don’t take charge and do everything for the client Treatment and Interventions for IPV Laws related to domestic violence; arrest 1. Sometimes after police have been called to the scene, the abuser is allowed to remain at home after talking with police and calming down 2. If an arrest is made, sometimes the abuser is held only for a few hours or overnight Restraining order/civil orders of protection 1. Restraining order: provides only limited protection 2. Civil orders of protection: are more effective in preventing future violence when linked with other interventions such as advocacy counseling, shelter, or talking with health care providers Shelters 1. Shelters are crowded; some have waiting lists, and the relief they provide is temporary Individual psychotherapy/counseling, group therapy, support and self-help groups Treatment for anxiety/depression Ch. 16 Definitions – Schizophrenia Abnormal Involuntary Movement Scale (AIMS): tool used to screen for symptoms of movement disorders (side effects of neuroleptic medications) Alogia: a lack of any real meaning or substance in what the client say Anhedonia: having no pleasure or joy in life; losing any sense of pleasure from activities formerly enjoyed Catatonia: psychomotor disturbance, either motionless or excessive motor Command hallucinations: disturbed auditory sensory perceptions demanding that the client take action, often to harm self or others, and are considered dangerous; often referred to as “voices” Dystonic reactions: extrapyramidal side effect to antipsychotic medication; includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties Echolalia: repetition or imitation of what someone else says; echoing what is heard Echopraxia: imitation of the movements and gestures of someone an individual is observing Latency of response: refers to hesitation before the client responds to questions Neuroleptics: antipsychotic medications Polydipsia: excessive water intake Psychosis: cluster of symptoms including delusions, hallucinations, and grossly disordered thinking and behavior 20 Schizophrenia Distorted and bizarre thoughts, perceptions, emotions, movements, behavior Usually diagnosed in late adolescence or early adulthood The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women Medication may control the positive symptoms, but frequently, the negative symptoms persist after positive symptoms have abated Schizoaffective disorder is diagnosed when the client has a mixture of psychotic and mood symptoms Often, second-generation antipsychotics are the best first choice for treatment; mood stabilizers or an antidepressant may be added if needed Positive Symptoms of Schizophrenia (Box 16.1) Positive or Hard Symptoms (elevated perspective) 1. Delusions: fixed false beliefs that have no basis in reality a) Grandeur delusions: false belief that one is powerful, association with a famous person b) Jealousy delusions: false belief that one’s partner is going out with other persons c) Paranoid delusions: thoughts that one is being singled out/aimed at for harm by others 2. Hallucinations: false sensory perceptions or perceptual experiences that do not exist in reality a) Auditory (hearing) b) Gustatory (taste) c) Olfactory (smell) d) Tactile (touch) e) Visual (sight) 3. Ambivalence: holding seemingly contradictory beliefs or feelings about the same person, event, or situation 4. Associative looseness: fragmented or poorly related thoughts and ideas 5. Echopraxia: imitation of the movements and gestures of another person whom the client is observing 6. Flight of ideas: continuous flow of verbalization in which the person jumps rapidly from one topic to another 21 7. Ideas of reference: false impressions that external events have special meaning for the person 8. Perseveration: persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic 9. Bizarre behavior: outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior Negative Symptoms of Schizophrenia (Box 16.1) Negative or Soft Symptoms (decreased perspective) 1. Flat affect: absence of any facial expression that would indicate emotions or mood 2. Avolition or lack of volition: absence of will, ambition, or drive to take action or accomplish tasks 3. Alogia: tendency to speak little or to convey little substance of meaning (poverty of content) 4. Anhedonia: feeling no joy or pleasure from life or any activities or relationships 5. Apathy: feelings of indifference toward people, activities, and events 6. Asociality: social withdrawal, few or no relationships, lack of closeness 7. Blunted affect: restricted range of emotional feeling, tone, or mood 8. Catatonia: psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance 9. Inattention: inability to concentrate or focus on a topic or activity, regardless of its importance Clinical Course Onset: abrupt or insidious; most with slow, gradual development of signs, symptoms Diagnosis usually with more actively positive symptoms of psychosis Immediate course: two patterns 1. Ongoing psychosis, never fully recovering 2. Episodes of psychotic symptoms alternating with episodes of relatively complete recovery Long-term course: intensity of psychosis diminishes with age; most with difficulty functioning; few with ability to live fully independent lives Related Disorders Schizophreniformdisorder: the client exhibits an acute, reactive psychosis for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia Catatonia: catatonia is characterized by marked psychomotor disturbance, either excessive motor activity or virtual immobility and motionlessness 22 Delusional disorder: the client has one or more nonbizarre delusions—that is, the focus of the delusion is believable. The delusion may be persecutory, erotomanic, grandiose, jealous, or somatic in content Brief psychotic disorder: the client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which lasts from 1 day to 1 month; may or may not have an identifiable stressor or may follow childbirth Shared psychotic disorder (folie à deux): two people share a similar delusion Schizotypal personality disorder: this involves odd, eccentric behaviors, including transient psychotic symptoms; approximately 20% of persons with this personality disorder will eventually be diagnosed with schizophrenia Etiology Biologic theories 1. Genetic factors (partial inheritance) 2. Neuroanatomic and neurochemical factors (less brain tissue and cerebrospinal fluid; dopamine excess and serotonin modulation of dopamine or excess) 3. Immunovirological factors (viral exposure; cytokines) Researchers focusing on infections in pregnant women as a possible origin 1. After influenza epidemics 2. Respiratory ailments Symptoms of Schizophrenia Explained by A Beautiful Mind (2001) Delusions of Grandeur = most often, the early warning signs of schizophrenia aren’t noticed but mistook as Genius acts Reduced daily activities = feeling low in daily activities, neglecting one’s own hygiene, and withdrawal from the social world are few negative signs of schizophrenia Suspiciousness = makes them believe that they are in danger of harm from someone relentlessly Hallucinations = the sufferers of schizophrenia often see or hear things that aren’t real Self-harm = people with schizophrenia are often prone to self-harm rather than hurting others Lack of insight = a failure to recognize the need for treatment; are unaware of their illness and consequences Recovery = research shows that family support is vital for recovery Cultural Considerations Bouffée délirante is a syndrome found in West Africa and Haiti, characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement Ghost sickness is preoccupation with death and the deceased frequently observed among members of some Native American tribes Jikoshu-kyofu is a condition characterized by a fear of offending others by emitting foul body odor 23 Locura refers to a chronic psychosis experienced by Latinos in the United States and Latin America Qi-gong psychotic reaction is an acute, time-limited episode characterized by dissociative, paranoid, or other psychotic symptoms that occur after participating in the Chinese folk healthenhancing practice of qi-gong Zar, an experience of spirits possessing a person, is seen in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies Psychopharmacology Treatment Conventional antipsychotics (dopamine antagonists; see Table 16.1) 1. Targeting positive symptoms 2. No observable effect on negative symptoms Atypical antipsychotics (dopamine, serotonin antagonists) 1. Diminish positive symptoms 2. Lessen negative symptoms Psychopharmacology: Maintenance Therapy Six antipsychotics available in depot injection forms (LAIs) 1. Fluphenazine in decanoate and enanthate (sesame oil) 2. Haloperidol in decanoate (sesame oil) 3. Risperidone 4. Paliperidone 5. Olanzapine 6. Aripiprazole Effects vary in length of time; eliminate need for daily oral antipsychotic medication 1. The effects of the medications last 2 to 4 weeks, eliminating the need for daily oral antipsychotic medication 2. The duration of action is 7 to 28 days for fluphenazine and 4 weeks for haloperidol Not used for acute episodes Psychopharmacology: Neurological Side Effects *KNOW THIS* Extrapyramidal side effects 1. Acute dystonic reactions: appear early in the course of treatment and are characterized by spasms in discrete muscle groups, such as the neck muscles (torticollis) or eye muscles (oculogyric crisis); diphenhydramine (Benadryl) given either intramuscularly or intravenously, or benztropine (Cogentin) given intramuscularly 24 2. Akathisia: characterized by restless movement, pacing, inability to remain still, and the client’s report of inner restlessness; beta-blockers such as propranolol, benzodiazepines 3. Parkinsonism: includes a shuffling gait, masklike facies, muscle stiffness (continuous) or cogwheeling rigidity (ratchet-like movements of joints), drooling, and akinesia (slowness and difficulty initiating movement); benztropine (Cogentin) Tardive dyskinesia: a late-appearing side effect of antipsychotic medications, is characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet; clozapine (Clozaril) Seizures: clozapine has an incidence of 5% compared to other medications which is closer to 1% Neuroleptic malignant syndrome: medical emergency, treat the symptoms; baseline of WBCs; Psychopharmacology: Nonneurological Side Effects Weight gain, sedation, photosensitivity (second-generation agents, except ziprasidone) Anticholinergic symptoms = can’t pee, see, spit, shit Orthostatic hypotension Agranulocytosis (clozapine) = WBC count Psychosocial Treatment Individual, group therapies 1. Supportive, medication management, use of community supports Social skills training 1. Cognitive adaptation training 2. Cognitive enhancement therapy (CET) Family therapy Family education Assessment for Schizophrenia History: previous history with schizophrenia; previous suicidal ideation; current support system; patient’s perception of current situation General appearance, motor behavior, speech (see Box 16.3) Mood, affect (flat, blunted; anhedonia) Thought process, content (thought blocking, broadcasting, withdrawal, or insertion) Delusions (see Box 16.4) Sensorium, intellectual processes (hallucinations [auditory, visual, olfactory, tactile, gustatory, cenesthetic, kinesthetic, command]; depersonalization) Judgment, insight (usually impaired) Self-concept (loss of ego boundaries; ideas of reference) Roles, relationships (social isolation) 25 Physiologic, self-care (inattention to hygiene and grooming; failure to recognize sensations; polydipsia) Unusual Speech Patterns of Clients with Schizophrenia (Box 16.3) Clang associations: ideas that are related to one another based on sound or rhyming rather than meaning Example: “I will take a pill if I go up the hill but not if my name is Jill, I don’t want to kill.” Neologisms: words invented by the client Example: “I’m afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?” Verbigeration: the stereotyped repetition of words or phrases that may or may not have meaning to the listener Example: “I want to go home, go home, go home, go home.” Echolalia: the client’s imitation or repetition of what the nurse says. Example: Nurse: “Can you tell me how you’re feeling?” Client: “Can you tell me how you’re feeling, how you’re feeling?” Stilted language: use of words or phrases that are flowery, excessive, and pompous. Example: “Would you be so kind, as a representative of Florence Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?” Perseveration: the persistent adherence to a single idea or topic and verbal repetition of a sentence, phrase, or word, even when another person attempts to change the topic. Example: Nurse: “How have you been sleeping lately?” Client: “I think people have been following me.” Nurse: “Where do you live?” Client: “At my place people have been following me.” Nurse: “What do you like to do in your free time?” Client: “Nothing because people are following me.” Word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener Example: “Corn, potatoes, jump up, play games, grass, cupboard.” 26 Types of Delusions (Box 16.4) Persecutory/paranoid delusions: involve the client’s belief that “others” are planning to harm him or her or are spying, following, ridiculing, or belittling the client in some way. Sometimes the client cannot define who these “others” are Examples: The client may think that food has been poisoned or that rooms are bugged with listening devices. Sometimes the “persecutor” is the government, FBI, or another powerful organization. Occasionally, specific individuals, even family members, may be named as the persecutor Grandiose delusions: characterized by the client’s claim to association with famous people or celebrities, or the client’s belief that he or she is famous or capable of great feats. Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming to be the daughter of the president of the United States, or he or she may claim to have found a cure for cancer Religious delusions: often center around the second coming of Christ or another significant religious figure or prophet. These religious delusions appear suddenly as part of the client’s psychosis and are not part of his or her religious faith or that of others. Examples: The client claims to be the Messiah or some prophet sent from God and believes that God communicates directly to him or her or that he or she has a special religious mission in life or special religious powers Somatic delusions: generally vague and unrealistic beliefs about the client’s health or bodily functions. Factual information or diagnostic testing does not change these beliefs. Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain Sexual delusions: involve the client’s belief that his or her sexual behavior is known to others; that the client is a rapist, prostitute, or pedophile or is pregnant; or that his or her excessive masturbation has led to insanity Nihilistic delusions: the client’s belief that his or her organs aren’t functioning or are rotting away, or that some body part or feature is horribly disfigured or misshapen. Referential delusions: ideas of reference involve the client’s belief that television broadcasts, music, or newspaper articles have special meaning for him or her 27 Examples: The client may report that the president was speaking directly to him on a news broadcast or that special messages are sent through newspaper articles Data Analysis/Nursing Diagnoses Risk for other-directed violence Risk for suicide Disturbed sensory perception Disturbed personal identity Impaired verbal communication Outcome Identification Focus on safety of patient and others Stabilize patient’s thought process Reality orientation Interventions Safety of patient, others Therapeutic relationship; therapeutic communication Interventions for delusional thoughts (focus on reality; no confrontation or reinforcement) Interventions for hallucinations Management of socially inappropriate behavior Patient, family education 1. Signs, symptoms of relapse (lack thereof) 2. Self-care, nutrition 3. Social skills 4. Medication management Elder Considerations Late onset: after age 45 Psychotic symptoms later in life usually associated with depression or dementia, not schizophrenia Variety of long-term outcomes for elderly 1. Approximately one fourth experiencing dementia, resulting in steady, deteriorating health decline 2. Approximately one fourth experiencing reduction in positive symptoms 3. Remainder mostly unchanged 28 Community-Based Care Housing with family or independently Assertive community treatment (ACT) Behavioral home health care Community support programs Case management services Mental Health Promotion Goal of psychiatric rehabilitation: patient recovery Accurate identification of those at risk Early intervention 1. Improved prodromal symptoms 2. Prevention of social stagnation or decline 3. Prevention or delay of progression to psychosis Self-Awareness Issues Challenge when the patient suspicious or mistrustful or nurse frightened Frustration if the patient noncompliant Need not to take patient’s success or failure personally Patient’s strengths, time out of hospital as focus No nurse has all the answers Points to Consider When Working with Clients with Schizophrenia Remember that although these clients often suffer numerous relapses and return for repeated hospital stays, they do return to living and functioning in the community Focusing on the amount of time the client is outside the hospital setting may help decrease the frustration that can result when working with clients with a chronic illness Visualize the client not at his or her worst, but as he or she gets better and symptoms become less severe Remember that the client’s remarks are not directed at you personally but are a byproduct of the disordered and confused thinking that schizophrenia causes 29 Discuss these issues with a more experienced nurse for suggestions on how to deal with your feelings and actions toward these clients; you are not expected to have all the answers Key Points for Schizophrenia Schizophrenia is a chronic illness requiring long-term management strategies and coping skills. It is a disease of the brain, a clinical syndrome characterized a person’s thoughts, perceptions, emotions, movements, and behaviors The effects of schizophrenia on the client may be profound, including all aspects of the client’s life: social interactions, emotional health, and ability to work and function in the community Schizophrenia is conceptualized in terms of positive signs such as delusions, hallucinations, and disordered thought processes as well as negative signs such as social isolation, apathy, anhedonia, and lack of motivation and volition The clinical picture, prognosis, and outcomes for clients with schizophrenia vary widely. Therefore, it is important that each client is carefully and individually assessed with appropriate needs and interventions determined Careful assessment of each client as an individual is essential to planning an effective plan of care Families of clients with schizophrenia may experience fear, embarrassment, and guilt in response to their family member’s illness. Families must be educated about the disorder, the course of the disorder, and how it can be controlled Failure to comply with treatment and the medication regimen and the use of alcohol and other drugs are associated with poorer outcomes in the treatment of schizophrenia For clients with psychotic symptoms, key nursing interventions include helping to protect the client’s safety and right to privacy and dignity, dealing with socially inappropriate behaviors in a nonjudgmental and matter-of-fact manner, helping present and maintain reality for the client by frequent contact and communication, and ensuring appropriate medication administration For the client whose condition is stabilized with medication, key nursing interventions include continuing to offer a supportive, nonconfrontational approach, maintaining the therapeutic relationship by establishing trust and trying to clarify the client’s feelings and statements when 30 speech and thoughts are disorganized or confused, helping to develop social skills by modeling and practicing, and helping to educate the client and family about schizophrenia and the importance of maintaining a therapeutic regimen and other self-care habits Self-awareness issues for the nurse working with clients with schizophrenia include dealing with psychotic symptoms, fear for personal safety, and frustration as a result of relapses and repeated hospital admissions Ch. 11 Definitions – Anger, Hostility, and Aggression Acting out: an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings Anger: results when a person is frustrated, hurt, or afraid Catharsis: release or alleviation of anger; engaging in aggressive but safe activities such as hitting a punching bag or yelling Crisis phase: during an emotional and physical crisis, the client loses control Escalation phase: the client’s responses represent escalating behaviors that indicate movement toward a loss of control Hostility: also called verbal aggression, is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior Impulse control: the ability to delay gratification Physical aggression: behavior in which a person attacks or injures another person or destroys property Postcrisis phase: the client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents Recovery phase: the client regains physical and emotional control Triggering phase: an event or circumstances in the environment initiates the client’s response, which is often anger or hostility Anger Normal human emotion; anger, or angry feelings, are not bad or wrong Handled appropriately, a positive force for resolving conflicts, solving problems, making decisions Body physically energized for self-defense (“fight-or-flight” response) 31 Expression inappropriate or suppressed: negative force 1. Physical or emotional problems; interference with relationships 2. Possible hostility, aggression Catharsis: alleviate or increase feeling of anger Related Disorders and Anger, Hostility, or Aggression Paranoid delusions Auditory hallucinations Dementia, delirium, head injuries Intoxication with alcohol or other drugs Antisocial, borderline personality disorders Depression Intermittent explosive disorder Acting-out behaviors Etiology of Hostility and Aggression Neurobiological theories 1. Possible role of neurotransmitters: decreased serotonin; increased dopamine, norepinephrine 2. Structural damage to limbic system; damage to frontal or temporal lobes Psychosocial theories 1. Failure to develop impulse control 2. Inability to delay gratification Cultural Considerations Hwa-Byung: culture-bound syndrome that literally translates as anger syndrome or fire illness, attributed to the suppression of anger Bouffee delirante: condition observed in West Africa and Haiti, is characterized by sudden outbursts of agitated and aggressive behavior, marked confusion, and psychomotor excitement Amok: a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects; seen only in men Treatment Lithium: bipolar and conduct disorders; mental retardation Carbamazepine or valproate: dementia, psychosis, personality disorders Atypical antipsychotics: clozapine, risperidone, and olanzapine: dementia, brain injury, mental retardation, personality disorders Benzodiazepines: irritability and agitation in older adults with dementia Haloperidol and lorazepam: decrease agitation or aggression and psychotic symptoms 32 Interventions Most effective, least restrictive when implemented early in cycle of aggression Environmental management 1. Planned activities; informal discussions 2. Scheduled one-to-one interactions (letting patients know what to expect) 3. Assistance with problem solving or conflict resolution to avoid expression of anger 4. Safety of other patients TABLE 11.1 Five-Phase Aggression Cycle Phase Definition Signs, Symptoms, and Behaviors An event or circumstances in the environment Restlessness, anxiety, irritability, pacing, muscle tension, initiates the client’s response, which is rapid breathing, perspiration, loud voice, anger often anger or hostility. Pale or flushed face, yelling, swearing, agitation, The client’s responses represent escalating threatening, demanding, clenched fists, threatening behaviors that indicate movement toward a Escalation gestures, hostility, loss of ability to solve the problem loss of control. or think clearly Loss of emotional and physical control, throwing During an emotional and physical crisis, the Crisis objects, kicking, hitting, spitting, biting, scratching, client loses control. shrieking, screaming, inability to communicate clearly Lowering of voice; decreased muscle tension; clearer, The client regains physical and emotional Recovery control. more rational communication; physical relaxation The client attempts reconciliation with others and returns to the level of functioning Remorse; apologies; crying; quiet, withdrawn behavior Postcrisis before the aggressive incident and its antecedents. Triggering Managing Aggression in Triggering Phase Approach in nonthreatening, calm manner Convey empathy; listening Encourage verbal expression of feelings Suggest patient go to a quieter area (offer time-out) Use PRN medications Suggest physical activity such as walking Managing Aggression in Escalation Phase Take control; provide directions in firm, calm voice 33 Direct patient to room or quiet area for time-out Offer medication again Let patient know aggression is unacceptable; nurse or staff will help maintain/regain control If ineffective, obtain help from other staff (show of force) Managing Aggression in Crisis Phase Inform patient that behavior is out of control, and staff is taking control to provide safety and prevent injury Use of restraint or seclusion only if necessary Managing Aggression in Recovery Phase Talk about situation or trigger Help patient relax or sleep Explore alternatives to aggressive behavior Provide documentation of any injuries Debrief staff Managing Aggression in Postcrisis Phase Remove patient from any restraint or seclusion to rejoin milieu Calmly discuss behavior (no lecturing or chastising); allow patient to return to activities, groups, and so forth Focus on appropriate expression of feelings, resolution of problems or conflicts in nonaggressive manner Restraints Physical safety of the client = the priority Have not touched anyone or anything Show of force 1. 4-6 trained staff enter room to begin to reduce behavior to show that if they cannot control themselves; group Show force to allow them time to help bring pt down to prevent having to place restraints Wil often start to listen and stop behavior Time frame for assessment after restraints = within 1 hour 1. Harmful to self, others, or property 2. Do not have to ask for order prior to placing them into restraints 3. Dr has 1 hour to assess the need for the restraints 4. Assess every 4 hours after implemented 34 Ch. 22 Definitions – Neurodevelopmental Disorders Attention-deficit/hyperactivity disorder (ADHD): characterized by inattentiveness, overactivity, and impulsiveness. ADHD is a common disorder, especially in boys, and probably accounts for more child mental health referrals than any other single disorder Autism spectrum disorder (ASD): diagnosis that includes disorders previously categorized as different types of a pervasive developmental disorder (PDD), characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, and restricted stereotypical behavioral patterns Encopresis: the repeated passage of feces into inappropriate places such as clothing or the floor by a child who is at least 4 years of age either chronologically or developmentally Enuresis: the repeated voiding of urine during the day or at night into clothing or bed by a child at least 5 years of age either chronologically or developmentally Sluggish cognitive tempo (SCT): a syndrome that is not a DSM-5 diagnosis; includes daydreaming, trouble focusing and paying attention, mental fogginess, staring, sleepiness, little interest in physical activity, and slowness in finishing tasks Stereotyped motor behavior: such as hand flapping, body twisting, or head banging Therapeutic play: play techniques are used to understand the child’s thoughts and feelings and to promote communication Tic: a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization Tourette disorder: involves multiple motor tics and one or more vocal tics, which occur many times a day for more than 1 year Autism Spectrum Disorders Pervasive, usually severe impairment of reciprocal social interaction skills, communication deviance, restricted stereotypical behavioral patterns 1. Autism (classic autism) 2. Rett’s disorder 3. Childhood disintegrative disorder 4. Asperger’s disorder 35 Behaviors Common with ASD Not responding to own name by 1 year (appears not to hear) Doesn’t show interest by pointing to objects or people by 14 months of age Doesn’t play pretend games by 18 months of age Avoids eye contact Prefers to be alone Delayed speech and language skills Obsessive interests (gets stuck on an idea) Upset by minor changes in routine Repeats words or phrases over and over Autism Spectrum – Related Disorders Tic disorders Learning disorders Motor skill disorders Communication disorders Elimination disorders Tic Disorders Rapid, sudden, recurrent, nonrhythmic stereotyped motor movement or vocalization Treatment with atypical antipsychotics (olanzapine or risperidone) Tourette’s disorder: multiple motor tics; one or more vocal tics Chronic motor or tic disorder: either motor or vocal tics; not both Transient tic disorder: may involve single or multiple vocal or motor tics, but the occurrences last no longer than 12 months Learning Disorder Achievement in reading, mathematics, written expression below expected for child’s age, formal education, level of intelligence Interference with academic achievement, life activities, development of self-esteem, social skills Early identification, intervention, coexisting problems associated with better outcomes Communication Disorder Communication deficit severe enough to hinder development, academic achievement, or ADLs, including socialization Types 36 1. Expressive language disorder: the impairment to verbally communicate, including sign language = birth or traumatic brain injury 2. Mixed receptive–expressive language disorder: problem of expressive language and understanding the meaning of the word in sentences = birth or traumatic brain injury 3. Phonologic disorder: problem with articulation = hereditary 4. Stuttering disorder: disturbance in fluency and time pattering in speech = hereditary Communication disorders may be mild to sever Speech therapy to improve communication skills Elimination Disorders Encopresis: defecating in or into inappropriate places (child at least age 4) 1. Involuntary encopresis: usually associated with constipation that occurs for psychological, not medical, reasons 2. Intentional encopresis: often associated with oppositional defiant disorder (ODD) or conduct disorder Enuresis: repeated urination during day or night in clothes or bed after age 5 1. Most often involuntary 2. Intentional enuresis associated with disruptive behavior disorder 3. Can be treated effectively with imipramine (Tofranil), an antidepressant with a side effect of urinary retention Motor Disorders Developmental coordination disorder 1. Marked impairment in coordination severe enough to interfere with academic achievement or ADLs 2. Often coexisting with communication disorder 3. Not made if the diagnosis is part of a general medical condition, such as cerebral palsy or muscular dystrophy Adaptive physical education, sensory integration to foster normal growth, development Stereotypic movement disorder 1. Characterized by rhythmic, repetitive behaviors 2. Self-inflicted injuries are common, and the pain is not a deterrent to the behavior Attention Deficit Hyperactivity Disorder (ADHD) Inattentiveness, overactivity, impulsiveness; persistent pattern of inattention and/or hyperactivity and impulsivity 37 Often diagnosed when child starts school Fidgeting, noisy, disruptive, unable to complete tasks, failure to follow directions, blurting out answers, lost or forgotten homework Etiology 1. Cause unknown: possible cortical-arousal, information-processing, maturational abnormalities in the brain 2. Other theories: environmental toxins, prenatal influences, heredity/genetic link, damage to brain structure and functions 3. Having a first-degree relative with ADHD increases the risk of the disorder by four to five times more than that of the general population 4. There seems to be a genetic link for ADHD that is most likely associated with abnormalities in catecholamine and, possibly, serotonin metabolism Strategies with Attention Deficit Hyperactivity Disorder (ADHD) Home and school strategies 1. Behavioral strategies 2. Environmental strategies 3. Parental education a) Rewards and consequences, consistent praise, time-out, verbal reprimands b) Daily report cards, point systems Therapeutic play: play techniques are used to understand the child’s thoughts and feelings and to promote communication; creative play Medications for Attention Deficit Hyperactivity Disorder (ADHD) Stimulants: methylphenidate (Ritalin), amphetamine compound (Adderall), lisdexamfetamine (Vyvance) Antidepressants = second choice Nonstimulant (SNRI): atomoxetine (Strattera), at least 6 years old Antihypertensives: clonidine (Kapvay), guanfacine (Intuniv) Methylphenidate is effective in 70% to 80% of children with ADHD; it reduces hyperactivity, impulsivity, and mood lability and helps the child pay attention more appropriately Dextroamphetamine (Dexedrine) and pemoline (Cylert) are other stimulants used to treat ADHD The most common side effects of these drugs are insomnia, loss of appetite , and weight loss or failure to gain weight = drug holiday Methylphenidate, dextroamphetamine, and amphetamine compounds are also available in a sustained-release form taken once daily; this eliminates the need for additional doses when the child is at school Nursing Interventions for ADHD 38 Ensuring the child’s safety and that of others Stop unsafe behavior Provide close supervision Give clear directions about acceptable and unacceptable behavior Improved role performance Give positive feedback for meeting expectations Manage the environment (e.g., provide a quiet place free of distractions for task completion) Simplifying instructions/directions Break complex tasks into small steps Structured daily routine Establish a daily schedule Minimize changes Allow breaks Ch. 23 Definitions – Disruptive Behavior Disorders Callous and unemotional traits: little empathy for others, do not feel “bad” or guilty or show remorse for their behavior, have shallow or superficial emotions, and are unconcerned about poor performance at school or home Conduct disorder: characterized by persistent behavior that violates societal norms, rules, laws, and the rights of others Disruptive behavior: disorders include problems with the person’s ability to regulate his or her own emotions or behaviors Externalizing behavior: behavior Intermittent explosive disorder (IED): involves repeated episodes of impulsive, aggressive, violent behavior, and angry verbal outbursts, usually lasting less than 30 minutes Internalizing behavior: self-regulation of emotion Oppositional defiant disorder (ODD): consists of an enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations; expected at 2 to 3 years of age Disruptive Behavior Disorders Characterized by persistent patterns of behavior that involve people and/or property 1. Anger 2. Hostility 3. Aggression Some practitioners view oppositional defiant disorder and conduct disorder as a continuum that also includes antisocial personality disorder Others view oppositional defiant disorder as a milder form of conduct disorder Intermittent explosive disorder is often viewed as an impulse control disorder Types of Behavior Disorders 39 Intermittent explosive disorder (IED) Oppositional defiant disorder (ODD) Conduct disorder Related disorders: 1. Kleptomania: impulsive, repetitive theft of items not needed by the person 2. Pyromania: repeated, intentional fire-setting TABLE 23.1 Acceptable Characteristics and Abnormal Behavior in Adolescence Acceptable Abnormal Inconsistent and unpredictable behavior Eagerness for peer approval Competitive in play Erratic work–leisure patterns Critical of self and others Highly ambivalent toward parents Anxiety about lost parental nurturing Fears, anxiety, and guilt about sex, health, and education Defiant, negative, or depressed behavior Frequent hypochondriacal complaints Learning irregular or deficient Poor personal relationships with peers Inability to postpone gratification Unwillingness to assume greater autonomy Acts of delinquency, ritualism, obsessions Verbal aggression to parents Strong moral and ethical perceptions Sexual aberrations Inability to work or socialize Occasional psychosomatic complaints Intermittent Explosive Disorder (IED) Viewed as an impulse control disorder Involves aggression toward people and property Age of onset: adolescence to young adulthood, but only diagnosed after 18 years of age Repeated episodes of impulsive, aggressive, violent behavior and angry verbal outbursts Episodes last less than 30 minutes May involve physical injury to others, destruction of property, or injury to self May feel guilty and remorseful after the outburst but not able to refrain from future outbursts Occurs more frequently in males (adolescence and young adults) 1. Many have a comorbid psychiatric disorder: 2. Substance abuse 3. Attention deficient hyperactivity disorder (ADHD) 4. Oppositional defiant disorder (ODD) 40 5. Depression 6. Conduct disorder 7. Anxiety disorder Often related to childhood trauma, neglect, or maltreatment Etiology 1. Neurotransmitter imbalance (serotonin) 2. Plasma tryptophan depletion 3. Frontal lobe dysfunction Treatment for IED Psychopharmacology 1. Fluoxetine (Prozac) 2. Lithium 3. Anticonvulsant mood stabilizers: valproic acid (Depakote), phenytoin (Dilantin), topiramate (Topamax), and oxcarbazepine (Trileptal 4. SSRI antidepressants: reduce aggressive tendencies = serotonin linked Even with medication, outbursts aren’t eliminated 1. Cognitive–behavior therapy 2. Anger management 3. Relaxation techniques 4. Avoidance of alcohol and illicit drug use Oppositional Defiant Disorder (ODD) An enduring pattern of uncooperative, defiant, disobedient, and hostile behavior toward authority figures without major antisocial violations Typically behavior begins in adolescence 25% develop conduct disorder; 10% diagnosed with antisocial personality disorder as adults Dysfunction in: 1. Social 2. Academic 3. Work Impaired problem solving ↓ Attention, ↓ flexibility of thinking and decision making Occurs more frequently in males (with an ↑ in female occurrence over past few years) Children with oppositional defiant disorder have lower self-concept Lack confidence in social situations Little insight into consequences of behavior Early onset of ODD is associated with ↑ risk of developing conduct disorder (30%) Etiology 41 1. Genetics 2. Temperament 3. Adverse social conditions Treatment in ODD Parental training models of behavioral interventions 1. Parents learn to ignore maladaptive behaviors 2. Positive behaviors are rewarded Individual therapy with behavioral focus Treatment of any psychiatric comorbidities (ADHD, anxiety, psychosis) Treatment in ODD Parental training models of behavioral interventions 1. Parents learn to ignore maladaptive behaviors 2. Positive behaviors are rewarded Individual therapy with behavioral focus Treatment of any psychiatric comorbidities (ADHD, anxiety, psychosis) Conduct Disorder (Levels) The childhood-onset type involves symptoms before 10 years of age, including physical aggression toward others and disturbed peer relationships; adolescent onset = after 10 years Mild: the child has some conduct problems that cause relatively minor harm to others 1. Examples: lying, truancy, minor shoplifting, and staying out late without permission Moderate: The number of conduct problems increases as does the amount of harm to others 1. Examples: vandalism, conning others, running away from home, verbal bullying and intimidation, drinking alcohol, and sexual promiscuity Severe: The person has many conduct problems that cause considerable harm to others 1. Examples: forced sex, cruelty to animals, physical fights, cruelty to peers, use of a weapon, burglary, robbery, and violation of previous parole or probation requirements Related problems: externalizing and internalizing behaviors Risk factors/protective factors: poor family functioning, marital discord, poor parenting, and a family history of substance abuse and psychiatric problems are all associated with the development of conduct disorder Treatment: early intervention/prevention; parenting education, social skills training, family therapy, individual therapy, medications (in conjunction with treatment) Externalizing Behaviors 42 Lying, cheating at school, swearing, truancy, vandalism, setting fires, bragging, screaming, inappropriate attention-seeking, arguing, threatening, demanding, relentless teasing, and anger outbursts Internalizing Behaviors (Self-Regulation of Emotions) Prefers to be alone, withdraws, sulks, won’t talk, secretive, overly shy, stares in lieu of verbal response, physically underactive, somatic aches and pains, dizziness, nausea, vomiting, stomach problems, fatigue, lethargy, lonely, guilt feelings, nervous, crying spells, feels worthless, unloved Conduct Disorder and Nursing Process Application – Assessment History: disturbed peer relationships, aggression toward people or animals, destruction of property, deceitfulness, theft, truancy, running away, staying out all night General appearance/motor behavior: typical for age group; may be extreme Mood/affect : quiet, reluctant to talk; openly hostile, angry; disrespectful Thought processes, content Sensorium, intellectual processes Judgment/insight: limited; rule breaking Self-concept: tough appearance; low self-esteem Roles/relationships: disruptive, possibly violent Physiologic, self-care Conduct Disorder and Nursing Process Application – Interventions and Outcomes Interventions 1. Decreasing violence/increasing compliance with treatment a) Limit setting with consistent enforcement b) Behavioral contracting; time-out 2. Improving coping skills, self-esteem 3. Promoting social interaction 4. Providing patient, family education Outcomes 1. No injury to others or damage to property 2. Participate in effective problem solving and coping 3. Use age-appropriate and acceptable behavior when interacting with others 4. Verbalize age-appropriate statements about self Self-Awareness Issues (CD) 43 Recognize own beliefs about parenting and how they differ from others Focus on patient’s and family’s strengths, not just problems/support family Try to have positive impact on patient even when disability is severe Recognize feelings associated with working with patients with anger, violence, and aggression issues Anxiety (pg. 222) Anxiety: a vague feeling of dread or apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms Fear: feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person Anxiety disorders: comprise a group of conditions that share a key feature of excessive anxiety with ensuing behavioral, emotional, cognitive, and physiological responses Stress: the wear and tear that life causes on the body; each person handles stress differently (one person can thrive in a situation that creates great distress for another) General adaptation syndrome = physiological aspects of stress 1. Alarm reaction stage: stress stimulates the body to send messages from the hypothalamus to the glands (such as the adrenal gland, to send out adrenaline and norepinephrine for fuel) and organs (such as the liver, to reconvert glycogen stores to glucose for food) to prepare for potential defense needs 2. Resistance stage: the digestive system reduces function to shunt blood to areas needed for defense; the lungs take in more air, and the heart beats faster and harder so that it can circulate this highly oxygenated and highly nourished blood to the muscles to defend the body by fight, flight, or freeze behaviors (adapting = relaxation of systems) 3. Exhaustion stage: occurs when the person has responded negatively to anxiety and stress; body stores are depleted or the emotional components are not resolved, resulting in continual arousal of the physiological responses and little reserve capacity Levels of Anxiety (pg. 223) Mild anxiety: a sensation that something is different and warrants special attention Moderate anxiety: the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated (can still process information) Severe anxiety: trouble thinking and reasoning; tightened muscles; increased vital signs; restless, irritable, angry 44 Panic: fight or flight, or freeze response; increased vital signs; dilated pupils; cognitive processes focusing on defense Mild Anxiety (Table 14.1) Psychological Response 1. Sharpened senses 2. Increased motivation 3. Effective problem-solving and learning 4. Irritability Physiological Response 1. Restlessness and difficulty sleeping 2. Fidgeting 3. “Butterflies in the belly” 4. Hypersensitivity to noise Mild anxiety is beneficial for teaching, as anxiety increases it becomes more difficult to teach Moderate Anxiety (Table 14.1) Psychological Response 1. Perceptual field narrowed to immediate task 2. Selectively attentive 3. Cannot connect thoughts or events independently 4. Increased use of automatisms Physiological Response 1. Muscle tension 2. Diaphoresis 3. Pounding pulse 4. Headache 5. Dry mouth 6. High voice pitch 7. Faster rate of speech 45 8. GI upset 9. Frequent urination Severe Anxiety (Table 14.1) Psychological Response 1. Perceptual field reduced to one detail or scattered details 2. Cannot complete tasks 3. Cannot solve problems or learn effectively 4. Behavior geared toward anxiety relief and is usually ineffective (can lead to ritualistic) 5. Doesn’t respond to redirection 6. Feels awe, dread, or horror 7. Cries Physiological Response 1. Severe headache 2. Nausea, vomiting, diarrhea 3. Trembling 4. Rigid stance 5. Vertigo 6. Pale 7. Chest pain with tachycardia (think they’re having a heart attack) Panic Anxiety (Table 14.1) Psychological Response 1. Perceptual field reduced to focus on self 2. Cannot process any environmental stimuli (danger in harming self or others) 3. Distorted perceptions 4. Loss of rational thought 5. Doesn’t recognize potential danger 46 6. Can’t communicate verbally 7. Possible delusions and hallucination 8. May be suicidal Physiological Response 1. May bolt and run or totally immobile and mute 2. Dilated pupils 3. Increased blood pressure and pulse 4. Flight, fight, or freeze in place Working with Anxious Patients (pg. 225) Self-awareness of anxiety level Assessment of person’s anxiety level 1. Mild anxiety is an asset to the client and requires no direct intervention 2. With moderate anxiety, the nurse must be certain that the client is following what the nurse is saying 3. When anxiety becomes severe, the client can no longer pay attention or take in information 4. During panic anxiety, the person’s safety is the primary concern Use of short, simple, easy-to-understand sentences Lower person’s anxiety level to moderate or mild before proceeding Anxiolytic Drugs (Table 14.2) Benzodiazepines Side effects: Dizziness, clumsiness, sedation, headache, fatigue, sexual dysfunction, blurred vision, dry throat and mouth, constipation, high potential for abuse and dependence 1. Diazepam (Valium) 2. Alprazolam (Xanax) 3. Chlordiazepoxide (Librium) 4. Lorazepam (Ativan) 5. Clonazepam (Klonopin) 6. Oxazepam (Serax) Nonbenzodiazepines 47 Side effects: Dizziness, restlessness, agitation, drowsiness, headache, weakness, nausea, vomiting, paradoxical excitement or euphoria 1. Buspirone (BuSpar) 2. Meprobamate (Miltown, Equanil) Nursing Implications for Benzodiazepines (Table 14.2) Avoid other CNS depressants, such as antihistamines and alcohol Avoid caffeine Take care with potentially hazardous activities, such as driving Rise slowly from lying or sitting position Use sugar-free beverages or hard candy Drink adequate fluids Take only as prescribed = PRN/4 to 6 weeks Do not stop taking the drug abruptly (taper) Nursing Implications for Nonbenzodiazepines (Table 14.2) Rise slowly from sitting position Take care with potentially hazardous activities, such as driving Take with food Report persistent restlessness, agitation, excitement, or euphoria to physician Anxiety Disorders (pg. 225) Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but becomes chronic and permeates major portions of the person’s life, resulting in maladaptive behaviors and emotional disability 1. Agoraphobia with or without panic disorder 2. Panic disorder (most common) 3. Specific phobia 4. Social phobia 5. Generalized anxiety disorder (GAD) Related Disorders (pg. 228) Selective mutism: diagnosed in children when they fail to speak in social situations even though they are able to speak Anxiety disorder due to another medical condition: diagnosed when the prominent symptoms of anxiety are judged to result directly from a physiological condition 48 Substance/medication-induced anxiety disorder: anxiety directly caused by drug abuse, a medication, or exposure to a toxin Separation anxiety disorder: excessive anxiety concerning separation from home or from persons, parents, or caregivers to whom the client is attached Incidence: nearly one in four adults in the United States is affected, and the magnitude of anxiety disorders in young people is similar Prevalence: anxiety disorders are more prevalent in women, people younger than 45 years of age, people who are divorced or separated, and people of lower socioeconomic status Cultural Considerations (pg. 229) Each culture has rules for expressing and dealing with anxiety The nurse should be aware of cultural differences and be careful not to stereotype a client One intense anxiety reaction is koro, or a man’s profound fear that his penis will retract into the abdomen and he will then die In women, koro is the fear that the vulva and nipples will disappear Susto is diagnosed in some Hispanic clients during cases of high anxiety, sadness, agitation, weight loss, weakness, and heart rate changes Treatment for Anxiety Disorders (pg. 229) Combination of medications, therapy (best outcome) Medications: anxiolytics; antidepressants Cognitive–behavioral therapy 1. Positive reframing: turning negative messages into positive ones a) “I can stand this. This is just anxiety. It will go away” 2. Decatastrophizing making more realistic appraisal of situation a) “What is the worst thing that could happen?” 3. Assertiveness training: learn to negotiate interpersonal situations/foster self-assurance a) “I feel angry when you turn your back while I’m talking” Drugs used to Treat Anxiety Disorders (Table 14.3) Generic (Trade) Drug Name Alprazolam (Xanax) Buspirone (BuSpar) Clorazepate (Tranxene) Chlordiazepoxide (Librium) Classification Benzodiazepine Nonbenzodiazepine anxiolytic Benzodiazepine Benzodiazepine Used to Treat Anxiety, panic disorder, social phobia, agoraphobia Anxiety, social phobia, GAD Anxiety Anxiety 49 Clonazepam (Klonopin) Clonidine (Catapres) Diazepam (Valium) Fluoxetine (Prozac) Benzodiazepine Beta-blocker Benzodiazepine SSRI antidepressant Hydroxyzine (Vistaril, Atarax) Antihistamine Imipramine (Tofranil) Tricyclic antidepressant Meprobamate (Miltown, Nonbenzodiazepine Equanil) anxiolytic Oxazepam (Serax) Benzodiazepine Paroxetine (Paxil) SSRI antidepressant Propranolol (Inderal) Alpha-adrenergic agonist Sertraline (Zoloft) SSRI antidepressant Anxiety, panic disorder Anxiety, panic disorder Anxiety, panic disorder Panic disorder, GAD Anxiety Anxiety, panic disorder, agoraphobia Anxiety Anxiety Social phobia, GAD Anxiety, panic disorder, GAD Panic disorder, social phobia, GAD Elder Considerations (pg. 230) Late-life anxiety disorders 1. Phobias = agoraphobia and GAD are most common 2. Often associated with another condition, such as depression, dementia, physical illness, or medication toxicity or withdrawal SSRIs as treatment of choice for anxiety disorders in the elderly 1. Started on lower dose because anxiety symptoms can worsen if dose is too high Mental Health Promotion (pg. 231) Anxiety as warning of not dealing with stress effectively “Positive events” can be stressful as well Managing the effects of stress and anxiety in one's life is important to being healthy The goal is effective management of stress and anxiety, not the total elimination of anxiety While medication is important to relieve excessive anxiety, it does not solve or eliminate the problem entirely Panic Disorder (pg. 231) Panic disorder is composed of discrete episodes of panic attacks, that is, 15 to 30 minutes of rapid, intense, escalating anxiety in which the person experiences great emotional fear as well as physiological discomfort 50 1. Discrete episodes of panic; no stimulus for panic response Diagnosis: when the person has recurrent, unexpected panic attacks followed by at least 1 month of persistent concern or worry about future attacks or their meaning or a significant behavioral change related to them Avoidance behavior: the person becomes homebound or stays in a limited area near home, such as on the block or within town limits (Boston Bombing) Agoraphobia: “fear of the marketplace” or fear of being outside Primary gain: the relief of anxiety achieved by performing the specific anxiety-driven behavior, such as staying in the house to avoid the anxiety of leaving a safe place Secondary gain: the attention received from others as a result of these behaviors 1. For instance, the person with agoraphobia may receive attention and caring concern from family members who also assume all the responsibilities of family life outside the home (become enablers) Increased risk for suicidality Treatment for Panic Disorder (pg. 232) Cognitive behavioral techniques 1. Deep breathing, relaxation Benzodiazepines, SSRIs, tricyclic antidepressants, antihypertensives (clonidine, propranolol) Generalized Anxiety Disorder (pg. 237) A person with GAD worries excessively and feels highly anxious at least 50% of the time for 6 months or more (chronic) Three or more of the following symptoms 1. Uneasiness 2. Irritability 3. Muscle tension 4. Fatigue 5. Difficulty thinking 6. Sleep alterations Buspirone (BuSpar) and SSRI or (serotonin–norepinephrine reuptake inhibitor antidepressants) are the most effective treatments Phobias (pg. 235) Phobia: an illogical, intense, and persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning 1. Phobias usually do not result from past negative experiences 2. Develop anticipatory anxiety and engage in avoidance behaviors Three Categories 51 1. Agoraphobia: fear of being outside 2. Specific phobia: an irrational fear of a particular object or a situation 3. Social phobia: anxiety provoked by certain social or performance situations; severely anxious to the point of panic or incapacitation = social anxiety disorder (SAD) Specific Phobia Subcategories 1. Natural environmental phobias: fear of storms, water, heights, or other natural phenomena 2. Blood–injection phobias: fear of seeing one’s own or others’ blood, traumatic injury, or an invasive medical procedure such as an injection 3. Situational phobias: fear of being in a specific situation such as on a bridge or in a tunnel, elevator, small room, hospital, or airplane 4. Animal phobia: fear of animals or insects (usually a specific type; often, this fear develops in childhood and can continue through adulthood in both men and women; cats and dogs are the most common phobic objects) 5. Other types of specific phobias: fear of getting lost while driving if not able to make all right (and no left) turns to get to one’s destination (I do this all the time) A person may have one or several social phobias; the latter is known as generalized social phobia Specific phobias that persist into adulthood are lifelong 80% of the time Treatment for Phobias (pg. 237) Behavioral therapists initially focus on teaching what anxiety is, helping the client identify anxiety responses, teaching relaxation techniques, setting goals, discussing methods to achieve those goals, and helping the client visualize phobic situations Systematic (serial) desensitization: the therapist progressively exposes the client to the threatening object in a safe setting until the client’s anxiety decrease Positive reframing: turning negative messages into positive messages Assertiveness training: helps the person take more control over life situations Flooding: a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety Rights of Clients and Related Issues (pg. 141) Clients receiving mental health care retain all civil rights afforded to all people except the right to leave the hospital in the case of involuntary commitment They have the right to refuse treatment, to send and receive sealed mail, and to have or refuse visitor Any restrictions (mail, visitors, clothing) must be made for a verifiable, documented reason 52 1. A suicidal client may not be permitted to keep a belt, shoelaces, or scissors because he or she may use these items for self-harm 2. A client who becomes aggressive after having a particular visitor may have that person restricted from visiting for a period of time 3. A client making threatening phone calls to others outside the hospital may be permitted only supervised phone calls until his or her condition improves Involuntary Hospitalization (pg. 142) Most clients are admitted to inpatient settings on a voluntary basis, which means they are willing to seek treatment and agree to be hospitalized = civil commitment Persons held without consent presenting with imminent danger to self or others 1. Proven at hearing if person is to be committed Detention in facility for 48 to 72 hours on emergency basis; hearing to determine possible commitment to facility Release from the Hospital (pg. 142) Voluntary hospitalization: right to request discharge at any time 1. Release unless danger to self or others; if such danger present, then commitment proceedings instituted; patient no longer dangerous = discharged from hospital Mandatory Outpatient Treatment (pg. 142) Legally assisted or mandatory outpatient treatment is the requirement that clients continue to participate in treatment on an involuntary basis after their release from the hospital into the community 1. Conditional release or outpatient commitment 2. Continued participation in treatment on involuntary basis after release from hospital into community This may involve taking prescribed medication, keeping appointments with health care providers for follow-up, and attending specific treatment programs or groups The four states that do not have assisted outpatient treatment are Connecticut, Maryland, Massachusetts, and Tennessee Least Restrictive Environment (pg. 143) Right to treatment in least restrictive environment appropriate to meet patient’s needs Free of restraint or seclusion unless necessary 53 Central philosophy to deinstitutionalization of large state hospitals, move to community-based care and services Restraint: application of physical force to person without permission 1. Human restraint: occurs when staff members physically control the client and move him or her to a seclusion room 2. Mechanical restraints: devices, usually ankle and wrist restraints, fastened to the bed frame to curtail the client’s physical aggression, such as hitting, kicking, and hair pulling Seclusion: involuntary confinement in specially constructed, locked room equipped with security window or camera for direct visual monitoring (only for shortest time necessary) Short-term use of restraints and seclusion 1. Face-to-face evaluation in 1 hour, every 8 hours (every 4 hours for children) 2. Physician’s order every 4 hours (every 2 hours for children) 3. Documented assessment by nurse every 1 to 2 hours 4. Close supervision of patient 5. Debriefing session within 24 hours after release from seclusion or restraint Conservatorship and Guardianship (pg. 143) Legal guardianship; separate from civil commitment for hospitalization 1. Grave disability 2. Incompetency 3. Inability to provide self with food, clothing, shelter 4. Inability to act in own best interests Consent to be obtained from legal guardian who speaks for patient Confidentiality (pg. 144) The protection and privacy of personal health information is regulated by the federal government through the Health Insurance Portability and Accountability Act (HIPAA) of 1996 Civil (fines) and criminal (prison sentences) penalties for violation of patient privacy Duty to warn third parties: exception to patient confidentiality 1. These laws vary from state to state; some states impose a mandatory duty to warn, others have laws stating the clinician “may” warn 2. Still other states base decisions on case law, and some states have no statutory or case law to cover warning a third party 3. If a case were litigated in a state with no laws, the judge or jury could make a decision on a case-by-case basis Duty to Warn Third Parties (pg. 145, Box 9.2) Basis decisions on the following 54 1. 2. 3. 4. 5. 6. Is the client dangerous to others? Is the danger the result of serious mental illness? Is the danger serious? Are the means to carry out the threat available? Is the danger targeted at identifiable victims? Is the victim accessible? Ethical Issues (pg. 146) Ethics: branch of philosophy dealing with values of human conduct (rightness and wrongness of actions) and goodness or badness of motives and ends of such actions Utilitarianism: theory that bases decisions on greatest good for greatest number Deontology: decisions based on whether action is morally right or wrong, with no regard for consequences Autonomy: right to self-determination, independence Beneficence: duty to benefit others or promote good Nonmaleficence: requirement to do no harm Justice: fairness Veracity: honesty, truthfulness Fidelity: obligation to honor commitments, contracts Torts (pg. 146) Tort: wrongful act resulting in injury, loss, damage Unintentional torts 1. Negligence: an unintentional tort that involves causing harm by failing to do what a reasonable and prudent person would do in similar circumstance 2. Malpractice: is a type of negligence that refers specifically to professionals such as nurses and physicians For a malpractice suit to be successful, that is, for the nurse, physician, or hospital or agency to be liable, the client or family needs to prove four elements 1. Duty: a legally recognized relationship (physician to client, nurse to client) existed; acting in capacity 2. Breach of duty: the nurse (or physician) failed to conform to standards of care, thereby breaching or failing the existing duty; unreasonable 3. Injury or damage: the client suffered some type of loss, damage, or injury. 55 4. Causation: the breach of duty was the direct cause of the loss, damage, or injury. In other words, the loss, damage, or injury would not have occurred if the nurse had acted in a reasonable, prudent manner Intentional torts (voluntary) 1. Assault: involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority 2. Battery: involves harmful or unwarranted contact with a client; actual harm or injury may or may not have occurred 3. False imprisonment: unjustifiable detention of a client, such as the inappropriate use of restraint or seclusion Proving liability for an intentional tort involves three elements 1. The act was willful and voluntary on the part of the defendant (nurse) 2. The nurse intended to bring about consequences or injury to the person (client) 3. The act was a substantial factor in causing injury or consequence Delirium Has a quick onset with a brief duration The LOC will be impaired and fluctuate Short-term memory will be impaired Speech may be slurred and the thought process will temporarily be disturbed Mood will be anxious, irritable, and weeping Dementia Onset is gradual and the duration is progressively deteriorating LOC is not affected Short and long-term memory will be impaired and then completely destroyed Speech will be normal at the start and then progressive to aphasia The person can suffer from paranoia, hallucination and illusions At first depressed and then angry outburst in later stages TABLE 24.1 Comparison of Delirium and Dementia Indicator Delirium Dementia Onset Duration Rapid Brief (hours to days) Gradual and insidious Progressive deterioration 56 Level of consciousness Memory Impaired, fluctuates Not affected Short-term memory impaired Short- and then long-term memory impaired, eventually destroyed May be slurred, rambling, Normal in early stage, progressive aphasia in later stage pressured, irrelevant Thought processes Temporarily disorganized Impaired thinking, eventual loss of thinking abilities Often absent, but can have paranoia, hallucinations, Visual or tactile hallucinations, Perception delusions illusions Anxious, fearful if hallucinating; Depressed and anxious in early stage, labile mood, restless Mood weeping, irritable pacing, angry outbursts in later stages Speech DSM-5 Diagnostic Criteria: Obsessive Compulsive Disorder (OCD) (pg. 243) Obsessions Are Defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced at some time during the disturbance as intrusive and unwanted and that in most individuals cause marked anxiety or distress 2. The individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action (by performing a compulsion) Compulsions Are Defined by (1) and (2): 1. Repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive Note: young children may not be able to articulate the aims of these behaviors or mental acts Obsessive–Compulsive Disorder (pg. 241) Classified as an anxiety disorder, but with unique manifestations in the way patients attempt to decrease or control their anxiety The spectrum approach includes repetitive behaviors of various types Self-soothing behaviors 1. Trichotillomania: involves recurrent, irresistible urges to pull out body hair 2. Dermatillomania: characterized by repeated picking at one's own skin which results in skin lesions and causes significant disruption in one's life (Excoriation disorder) 3. Onychophagia: excessive nail-biting Reward-seeking behaviors 1. Hoarding: persistent difficulty discarding or parting with possessions, regardless of their actual value 2. Kleptomania: recurrent inability to resist urges to steal items that you generally don't really need and that usually have little value 57 3. Pyromania: an obsessive desire to set fire to things 4. Oniomania: an obsessive or uncontrollable urge to buy things Disorders of body appearance or function 1. Body dysmorphic disorder (BDD): obsessive focus on a perceived flaw in appearance; can be minor or imagined 2. Body identity integrity disorder (BIID): feeling alienated from a part of the body to the extent of seeking amputation of the identified body part Obsessions: recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses Compulsions: ritualistic or repetitive behaviors that a person carries out continuously in an attempt to decrease anxiety Treatment for OCD (pg. 244) Combination of medications and therapy Medications 1. First line: SSRIs (fluvoxamine = Luvox, sertraline = Zoloft) 2. Second line: SNRI (venlafaxine = Effexor) 3. Treatment-resistant OCD: second-generation antipsychotics (risperidone = Risperdal, quetiapine = Seroquel, olanzapine = Zyprexa) Behavior therapy 1. Cognitive behavioral therapy: treatment focuses on examining the relationships between thoughts, feelings, and behaviors 2. Exposure therapy: deliberately confronting situation and stimuli that one usually tries to avoid 3. Response prevention: delay or avoid performing the rituals; learn to tolerate the thoughts and anxiety Best Practice: OCD Treatment Cognitive Behavioral Therapy (CBT) that encompasses exposure and response prevention may be the first-line best practice in the treatment of OCD 1. Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft) (SSRIs) and behavioral therapy (first line) 2. Venlafaxine (Effexor), Duloxetine (Cymbalta) (SSNRI) (second line) 3. Risperidone (Risperdal), Olanzapine (Zyprexa) (Second Gen/treatment resistant) (third line) Treatment can be delivered in a variety of settings, and initially, the results seem to be enduring The next step is to implement this combination therapy with different age groups, in various settings, and using different delivery methods to determine whether the enduring positive results will continue under the varying circumstance 58 Etiology of OCD and Related Disorders (pg. 242) Diagnosis: only when these thoughts, images, and impulses consume the person or he or she is compelled to act out the behaviors to a point at which they interfere with personal, social, and occupational functions 1. “A man who can no longer work because he spends most of his day aligning and realigning all items in his apartment” 2. “A woman who feels compelled to wash her hands after touching any object or person” Cognitive model (based on Aaron Beck’s work with focus on cognitive–behavioral therapy) 1. Focuses on childhood and environmental experiences of growing up Heredity Theory 1. Complex network of several genes may contribute to the genetic risk for OCD Self-Awareness Issues (OCD) (pg. 251) Need to understand how and why OCD behaviors work OCD is a chronic condition involving bizarre thoughts/behaviors OCD treatment is dependent upon meds, daily structure, and long-term behavior therapy Avoid trying to “fix” patient’s problem Points to consider when working with OCD and related disorders 1. When clients experience severe symptoms of OCD, they are usually not able to change their patterns of thinking and behavior without treatment and assistance from professionals 2. As with any chronic illness, clients with OCD will have stressful periods that may increase symptoms and necessitate professional support and assistance 3. It is not beneficial to tell the client that his or her thoughts and rituals interfere with life or that the ritual actions really have no lasting effect on anxiety—he or she already knows that Ch. 13 Definitions – Trauma and Stressor-Related Disorders Acute stress disorder: diagnosis is appropriate when symptoms appear within the first month after the trauma and do not persist longer than 4 weeks Adaptive disclosure: combat-specific therapy for veterans with posttraumatic stress disorder (PTSD); eight sessions designed to help identify unhelpful beliefs about the trauma and find ways to move forward Adjustment disorder: a group of symptoms, such as stress, feeling sad, or hopeless, and physical symptoms that occur following a stressful life event; the reaction is stronger than would-be expected for the event that occurred Depersonalization: feelings of being disconnected from himself or herself; the client feels detached from his or her behavior Derealization: client senses that events are not real, when, in fact, they are 59 Disinhibited social engagement disorder (DSED): also referred to as Disinhibited Attachment Disorder, in which a child may actively approach and interact with unfamiliar adults Dissociation: a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory Dissociative disorders: these disorders have the essential feature of a disruption in the usually integrated functions of consciousness, memory, identity, or environmental perception; they include amnesia, fugue, and dissociative identity disorder Exposure therapy: behavioral technique that involves having the client deliberately confront the situations and stimuli that he or she is trying to avoid Grounding techniques: helpful to use with the client who is dissociating or experiencing a flashback; grounding techniques remind the client that he or she is in the present, as an adult, and is safe Hyperarousal: symptoms that arise from high levels of anxiety, including insomnia, irritability, anger outbursts, watchfulness, suspiciousness, and distrustfulness; often seen with PTSD Posttraumatic stress disorder (PTSD): a disturbing pattern of behavior demonstrated by someone who has experienced a traumatic event; for example, a natural disaster, a combat, or an assault; begins 3 months or more following the trauma Reactive attachment disorder (RAD): a condition in which an infant or young child does not form a secure, healthy emotional bond with his or her primary caretakers (parental figures); children with RAD often have trouble managing their emotions; they struggle to form meaningful connections with other people Repressed memories: memories that are buried deeply in the subconscious mind or repressed because they are too painful for the victim to acknowledge; often relate to childhood abuse Survivor: view of the client as a survivor of trauma or abuse rather than as a victim; helps to refocus client’s view of himself or herself as being strong enough to survive the ordeal, which is a more empowering image than seeing oneself as a victim Trauma/Stress-Induced Disturbed Patterns of Behavior (Posttraumatic stress disorder—PTSD) Intense memories of the trauma Dreams/nightmares Flashbacks Intense, recurrent, intrusive thoughts Emotional numbing Increased irritability Hyperarousal Three Major Elements of PTSD 60 Experiencing the trauma leads to 1. Dreams or intrusive, recurrent thoughts of the trauma 2. Emotional numbing (feeling detached from others) 3. Hyperarousal (being on guard, irritable) Acute Stress Disorder Versus PTSD Acute stress disorder = event occurred <3 months PTSD = event occurred >3 months PTSD is chronic in nature with periods of exacerbation during increased stress PTSD can lead to other psychiatric disorders such as depression, anxiety, and substance abuse Related Disorders Adjustment disorder 1. Financial, relationship, and work-related stressors are the most common events 2. Outpatient counseling or therapy is the most common and successful treatment 3. Symptoms develop within a month, lasting no more than 6 months Acute stress disorder 1. Occurs after a traumatic event and is characterized by reexperiencing, avoidance, and hyperarousal that occur from 3 days to 4 weeks following a trauma 2. It can be a precursor to PTSD 3. Cognitive–behavioral therapy (CBT) involving exposure and anxiety management can help prevent the progression to PTSD Reactive attachment disorder (RAD) 1. The child with RAD exhibits minimal social and emotional responses to others, lacks a positive effect, and may be sad, irritable, or afraid for no apparent reason Disinhibited social engagement disorder (DSED)/Disinhibited Attachment Disorder (DAD) 1. The child with DSED exhibits unselective socialization, allowing or tolerating social interaction with caregivers and strangers alike Risk Factors for PTSD PTSD can occur in children, adults, and older adults 1. Directly involved in the traumatic event 2. Experiences of physical injury 3. Loss of loved one(s) 4. Lack of social supports 5. Pervious psychiatric history or personality factors PTSD is a disorder associated with event exposure, rather than personal characteristics, especially with the adult population Adolescents are more likely to develop PTSD than are children or adults 61 Treatment for PTSD Psychotherapy (individual or group) 1. Therapy on an outpatient basis is the indicated treatment for PTSD Medications (antidepressants, anxiolytics, sleep aids) 1. Studies show that selective serotonin reuptake inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor antidepressants are most effective, followed by second-generation antipsychotic, such as risperidone 2. Evidence is lacking for the efficacy of benzodiazepines, though they are widely used in clinical practice Self-help groups 1. Offer support and a safe place to share feelings Exposure therapy 1. A treatment approach designed to combat the avoidance behavior that occurs with PTSD, help the client face troubling thoughts and feelings, and regain a measure of control over his or her thoughts and feelings 2. Prolonged exposure therapy has been particularly effective for both active military personnel and veterans Relaxation techniques Adaptive disclosure 1. A specialized CBT approach developed by the military to offer an intense, specific, shortterm therapy for active-duty military personnel with PTSD 2. It incorporates exposure therapy as well as the empty chair technique, in which the participant says whatever he or she needs to say to anyone, alive or dead Cognitive processing therapy 1. Involves structured sessions that focus on examining beliefs that are erroneous or interfere with daily life, such as guilt and self-blame Mental health promotion 1. One of the most effective ways of avoiding pathologic responses to trauma is effectively dealing with the trauma soon after it occurs Ch. 18 Definitions – Personality Disorders Antisocial personality disorder: characterized by a pervasive pattern of disregard for and violation of the rights of others and with the central characteristics of deceit and manipulation Avoidant personality disorder: characterized by a pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation Borderline personality disorder (BPD): pervasive and enduring pattern of unstable interpersonal relationships, self-image, and affect; marked impulsivity; frequent self-mutilation behavior Character: consists of concepts about the self and the external world Cognitive restructuring: therapy that focuses on changing the way one thinks about or interprets one’s self, relationships, and/or environment 62 Confrontation: technique designed to highlight the incongruence between a person’s verbalizations and actual behavior; used to manage manipulative or deceptive behavior Dependent personality disorder: characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation Depressive behavior: characterized by a pervasive pattern of depressive cognitions and behaviors in various contexts Dysphoric: mood that involves unhappiness, restlessness, and malaise Histrionic personality disorder: characterized by a pervasive pattern of excessive emotionality and attention seeking Limit setting: an effective technique that involves three steps: stating the behavioral limit (describing the unacceptable behavior), identifying the consequences if the limit is exceeded, and identifying the expected or desired behavior Narcissistic personality disorder: characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy Nonsuicidal self-injury: intentional physical damage to the body, such as cutting or burning; results from self-harm urges or thoughts; injury is not an attempt at suicide No-self-harm contract: a client promises to not engage in self-harm and to report to the nurse when he or she is losing control Obsessive–compulsive personality disorder: characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency Paranoid personality disorder: characterized by pervasive mistrust and suspiciousness of others Passive-aggressive behavior: characterized by a negative attitude and a pervasive pattern of passive resistance to demands for adequate social and occupational performance Personality: an ingrained, enduring pattern of behaving and relating to self, others, and the environment; includes perceptions, attitudes, and emotions Personality disorders: diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress Ch. 18 Definitions Cont. Positive self-talk: a cognitive–behavioral technique in which the client changes thinking about the self from negative to positive Schizoid personality disorder: characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings Schizotypal personality disorder: characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities Temperament: refers to the biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion Thought stopping: a cognitive–behavioral technique to alter the process of negative or selfcritical thought patterns 63 Time-out: retreat to a neutral place to give the opportunity to regain self-control Personality Disorders: Cluster A Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder Personality Disorders: Cluster B Borderline personality disorder Antisocial personality disorder Narcissistic personality disorder Histrionic personality disorder Personality Disorders: Cluster C Obsessive personality disorder Avoidant personality disorder Dependent personality disorder Related Personality Disorders and Behaviors Depressive behavior: characterized by a pervasive pattern of depressive cognitions and behaviors in various contexts; it occurs more often in people with relatives who have major depressive disorders (seek treatment for their distress) Passive-aggressive behavior: characterized by a negative attitude and a pervasive pattern of passive resistance to demands for adequate social and occupational performance; these clients may appear cooperative, even ingratiating, or sullen and withdrawn, depending on the circumstances (easily upset or offended) Treatment Psychopharmacology (symptom focused) 1. Cognitive–perceptual distortions 2. Affective symptoms and mood dysregulation 3. Aggression and behavioral dysfunction 4. Anxiety (see Table 18.1) Group, individual therapies 1. Cognitive–behavioral therapy (cognitive restructuring techniques) 2. Dialectical behavior therapy (borderline personality disorder) (see Table 18.2) 64 TABLE 18.2 Summary of Symptoms and Nursing Interventions for Personality Disorders and Behaviors Personality Disorder Symptoms/Characteristics Paranoid Mistrust and suspicions of others; guarded, restricted affect Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive– compulsive Nursing Interventions Serious, straightforward approach; teach client to validate ideas before taking action; involve client in treatment planning Detached from social relationships; restricted Improve client’s functioning in the community; affect; involved with things more than assist client in finding case manager people Acute discomfort in relationships; cognitive or Develop self-care skills; improve community perceptual distortions; eccentric behavior functioning; social skills training Limit setting; confrontation; teach client to solve Disregard for rights of others, rules, and laws problems effectively and manage emotions of anger or frustration Promote safety; help client to cope and control Unstable relationships, self-image, and affect; emotions; cognitive restructuring techniques; impulsivity; self-mutilation structure time; teach social skills Teach social skills; provide factual feedback about Excessive emotionality and attention seeking behavior Matter-of-fact approach; gain cooperation with Grandiose; lack of empathy; need for needed treatment; teach client any needed selfadmiration care skills Support and reassurance; cognitive restructuring Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation techniques; promote self-esteem Foster client’s self-reliance and autonomy; teach Submissive and clinging behavior; excessive problem-solving and decision-making skills; need to be taken care of cognitive restructuring techniques Encourage negotiation with others; assist client in Preoccupation with orderliness, perfectionism, making timely decisions and complete work; and control cognitive restructuring techniques Paranoid Personality Disorder (Cluster A) Characterized by pervasive mistrust and suspiciousness of others Clinical picture: pervasive mistrust/suspiciousness; use of projection; conflict with authority Nursing interventions: formal, business-like approach; involvement in plan of care; idea validation before action Example: Mel Gibson from Conspiracy Theory (locks on everything) Schizotypal Personality Disorder (Cluster A) 65 Characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities Clinical picture: social and interpersonal deficits; behavioral eccentricities; cognitive or perceptual distortions; odd appearance; inability to respond to normal social cues Nursing interventions: self-care, social skills, community functioning Example: Willy Wonka, magical thinking Schizoid Personality Disorder (Cluster A) Characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings Clinical picture: social detachment; restricted emotions; intellectual Nursing interventions: improved functioning in community Example: fantasy life (can distinguish real from fantasy) Antisocial Personality Disorder (Cluster B) Characterized by a pervasive pattern of disregard for and violation of the rights of others—and by the central characteristics of deceit and manipulation Clinical picture: deceit/manipulation, false emotions; no empathy, narrowed view of world, poor judgment; no insight, relationships as serving own needs, egocentric, but actually selfshallow and empty Nursing interventions: therapeutic relationship; responsible behavior (limit setting, confrontation), problem solving; control of emotions (timeout), enhancing role performance Example: my sister’s ex-boyfriend Borderline Personality Disorder (Cluster B) Clinical picture: unstable interpersonal relationships, self-image, and affect; marked impulsivity, wide range of behavior, appearance, dysphoric mood, polarized extreme thinking (splitting); dissociation, impaired judgment; safety not a concern, threats of self-harm, social isolation Nursing interventions: safety (no self-harm contract), therapeutic relationship (structured, with limit setting), strict adherence to boundaries, communication skills; coping, emotion control, reshape thinking patterns (cognitive restructuring, thought stopping, positive self-talk, decatastrophizing), structuring of daily activities 66 Example: think about the movie “Split” Histrionic Personality Disorder (Cluster B) Characterized by a pervasive pattern of excessive emotionality and attention seeking Clinical picture: excessive emotionality and attention seeking; insincerity; center of attention; exaggeration of relationships Nursing interventions: feedback about social interactions; social skills training through roleplaying; exploration of strengths, assets Example: “Mean Girls” Narcissistic Personality Disorder (Cluster B) Characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy Clinical picture: grandiosity; need for admiration; lack of empathy; arrogant or haughty attitude; superior view; fragile, vulnerable self-esteem; ambitious Nursing interventions: self-awareness skills to avoid anger and frustration; matter-of-fact approach; limit setting Example: “Wolf of Wallstreet” Avoidance Personality Disorder (Cluster C) Characterized by a pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation Clinical picture: social discomfort; low self-esteem; hypersensitivity to negative evaluation Nursing interventions: self-affirmations; positive self-talk; support and reassurance; reframing/decatastrophizing; social skills training Example: “The Queen” Dependent Personality Disorder (Cluster C) Characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation Clinical picture: need to be taken care of; submissive; clinging Nursing interventions: expression of feelings; autonomy/self-reliance; cognitive restructuring; problem solving 67 Example: “Bob” Obsessive Personality Disorder (Cluster C) Characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency Clinical picture: perfectionism; formal, serious; orderliness a priority; problems with decision making, judgments; low self-esteem; harsh self-evaluations Nursing interventions: different perspective view; cognitive restructuring; risk taking Example: Monica from Friends Passive-Aggressive Personality Behavior (Other) Characterized by a negative attitude and a pervasive pattern of passive resistance to demands for adequate social and occupational performance Clinical picture: negative attitude, passive resistance to demands for adequate social and occupational performance; blaming of others Nursing interventions: identification and expression of feelings Example: Pam from The Office Antipsychotic Drugs Formerly known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorders Conventional (Thorazine, Prolixin, thioridazine, haloperidol, loxapine) Second generation (clozapine, risperidone, zyprexa) Third generation (dopamine system stabilizers; Abilify) Use: Delusions, hallucinations as seen in schizophrenia, schizoaffective disorder, and manic bipolar Off-label uses: anxiety, insomnia, aggressive behavior and symptoms r/t Alzheimer’s Mechanism of action: block dopamine receptors First Generation (Antipsychotics) Phenothiazines Chlorpromazine (Thorazine) Perphenazine (Trilafon) 68 Fluphenazine (Prolixin) Thioridazine (Malaria) Mesoridazine (Serentil) Trifluoperazine (Stelazine) Thioxanthene Thiothixene (Navane) Butyrophenones Haloperidol (Haldol) Droperidol (Inapsine) Dibenzazepine Loxapine (Loxitane) Dihydroindolone Molindone (Moban) Second Generation/Atypical (Antipsychotics) Clozapine (Clozaril) Fazaclo (clozapine) Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Paliperidone (Invega) Iloperidone (Fanapt) Asenapine (Saphris) Lurasidone (Latuda Third Generation (Antipsychotics) Aripiprazole (Abilify) Cariprazine (Vraylar) Brexpiprazole (Rexulti) Warning Atypical Antipsychotics: Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk for death; causes of death are varied, but most appear to be either cardiovascular or infectious in nature 69 Geodon (Ziprasidone): Contraindicated in patients with a known history of QT prolongation, recent myocardial infarction, or uncompensated heart failure, it should not be used with other QT-prolonging drugs Droperidol, Thioridazine, and Mesoridazine: May lengthen the QT interval, leading to potentially life-threatening cardiac dysrhythmias or cardiac arrest Clozapine: May cause agranulocytosis, a potentially life-threatening event. Clients who are being treated with clozapine must have a baseline WBC count and differential before initiation of treatment and a WBC count every week throughout treatment and for 4 weeks after discontinuation of clozapine Ch. 21 Definitions – Somatic Symptom Illness Conversion disorder: sometimes called conversion reaction; involves unexplained, usually sudden deficits in sensory or motor function related to an emotional conflict the client experiences but does not handle directly Cyberchondria: excessive or repeated online searches for health-related information that is distressing or anxiety-provoking for the person Disease conviction: preoccupation with the fear that one has a serious disease Disease phobia: preoccupation with the fear that one will get a serious disease Emotion-focused coping strategies: techniques to assist clients to relax and reduce feelings of stress Fabricated or induced illness: factitious disorders characterized by physical symptoms that are feigned or inflicted on one’s self or another person for the sole purpose of gaining attention or other emotional benefits; also called factitious disorder, imposed on self or others Factitious disorder, imposed on self or others: a mental disorder in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created the symptoms Functional somatic syndrome: medically unexplained illness (MUS) Hypochondriasis: illness anxiety disorder Hysteria: refers to multiple, recurrent physical complaints with no organic basis Illness anxiety disorder: preoccupation with the fear that one has a serious disease or will get a serious disease; also called hypochondriasis Internalization: keeping stress, anxiety, or frustration inside rather than expressing them outwardly La belle indifférence: a seeming lack of concern or distress; a key feature of conversion disorder Malingering: the intentional production of false or grossly exaggerated physical or psychological symptoms Ch. 21 Definitions Cont. Medically unexplained symptoms: Physical symptoms and limitations of function that have no medical diagnosis to explain their existence 70 Munchausen syndrome: a factitious disorder where the person intentionally causes injury or physical symptoms to self to gain attention and sympathy from health care providers, family, and other Munchausen syndrome by proxy: when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a hero for “saving” the victim Pain disorder: has the primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance Psychosomatic: caused or aggravated by a mental factor such as internal conflict or stress Somatic symptom disorder: characterized by multiple, recurrent physical symptoms in a variety of bodily systems that have no organic or medical basis; also called somatization disorder Somatization: the transference of mental experiences and states into bodily symptoms Somatic Symptom Illness Psychosomatic: connection between mind (psyche) and body (soma) Hysteria: multiple physical complaints with no organic basis 1. Proposal by Freud that people can convert unexpressed emotions into physical symptoms Somatization: transference of mental experiences, states into body symptoms Three central features 1. Physical complaints suggest major medical illness but have no demonstrable organic basis 2. Psychological factors and conflicts seem important in initiating, exacerbating, maintaining symptoms 3. Symptoms or magnified health concerns are not under patient’s conscious control Types of Somatic Symptom Illnesses Somatic symptom illness: multiple physical symptoms—combination of pain, GI, sexual, pseudoneurologic symptoms Conversion disorder: unexplained sensory or motor deficits associated with psychological factors; typically involves significant functional impairment; “la belle indifference” Pain disorder: pain unrelieved by analgesics; psychological factors influencing onset, severity, exacerbation, maintenance Illness anxiety disorder (hypochondriasis): disease conviction or disease phobia Onset and Clinical Course Symptoms usually onset in adolescence or early adulthood All either chronic or recurrent 71 Patients go from one physician or clinic to another, or see multiple providers at once, to obtain relief of symptoms Related Disorders Malingering: intentional false or grossly exaggerated symptoms; external incentives as motivation Factitious disorder: intentional symptoms to gain attention (Munchausen’s syndrome = imposed upon self) 1. Munchausen’s syndrome by proxy = imposed upon others Malingering and factitious disorders: willful control of symptoms; somatic symptom illnesses— no voluntary control over symptoms Etiology Psychosocial theories 1. Internalization 2. Primary gains: direct external benefits of being sick provide relief of anxiety, conflict, distress 3. Secondary gains: person receives internal or personal benefits from others because one is sick Treatment Symptom management, improvement in quality of life Antidepressants for accompanying depression: SSRIs Pain clinic referral for disorder Involvement in therapy groups Antidepressants Used to Treat Somatic Symptom Illnesses Drug Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Usual Dose (mg/day) 20–60 20–60 50–200 Defense Mechanisms Table 3.1 Nursing Considerations Monitor for rash, hives, insomnia, headache, anxiety, drowsiness, nausea, loss of appetite; avoid alcohol Monitor for nausea, loss of appetite, dizziness, dry mouth, somnolence or insomnia, sweating, sexual dysfunction; avoid alcohol Monitor for nausea, loss of appetite, diarrhea, headache, insomnia, sexual dysfunction; avoid alcohol 72 Compensation: overachievement in one area to offset real or perceived deficiencies in another area Conversion: expression of an emotional conflict through the development of a physical symptom, usually sensorimotor in nature Denial: failure to acknowledge an unbearable condition; failure to admit the reality of a situation or how one enables the problem to continue Displacement: ventilation of intense feelings toward persons less threatening than the one who aroused those feelings Dissociation: dealing with emotional conflict by a temporary alteration in consciousness or identity Fixation: immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage Identification: modeling actions and opinions of influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal Intellectualization: separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions Introjection: accepting another person’s attitudes, beliefs, and values as one’s own Projection: unconscious blaming of unacceptable inclinations or thoughts on an external object Rationalization: excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect Reaction formation: acting the opposite of what one thinks or feels Regression: moving back to a previous developmental stage to feel safe or have needs met Repression: excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness Resistance: overt or covert antagonism toward remembering or processing anxiety-producing information Sublimation: substituting a socially acceptable activity for an impulse that is unacceptable Substitution: replacing the desired gratification with one that is more readily available Suppression: conscious exclusion of unacceptable thoughts and feelings from conscious awareness Undoing: exhibiting acceptable behavior to make up for or negate unacceptable behavior Maslow’s Hierarchy of Needs (Humanistic Theory) 73 Humanism focuses on a person’s positive qualities, his or her capacity to change (human potential), and the promotion of self-esteem The most basic needs - the physiologic needs of food, water, sleep, shelter, sexual expression, and freedom from pain - must be met first The second level involves safety and security needs, which include protection, security, and freedom from harm or threatened deprivation The third level is love and belonging needs, which include enduring intimacy, friendship, and acceptance The fourth level involves esteem needs, which include the need for self-respect and esteem from others The highest level is self-actualization, the need for beauty, truth, and justice Rogers’ Client Centered Therapy (Humanistic Theory) Client-centered therapy focuses on the role of the client, rather than the therapist, as the key to the healing process Unconditional positive regard: a nonjudgmental caring for the client that is not dependent on the client’s behavior Genuineness: realness or congruence between what the therapist feels and what he or she says to the client Empathetic understanding: in which the therapist senses the feelings and personal meaning from the client and communicates this understanding to the client Psychoanalytic Theories: Sigmund Freud Id: reflects basic or innate desires 1) Pleasure seeking behaviors, aggression, sexual impulses Ego: balancing force between the Id and Superego; 4th to 5th month of life 1) Mature and adaptive behaviors = success Superego: reflects moral and ethical concepts, values and social conventions (opposite of Id); 3 to 6 yrs Levels of awareness 1) Conscious: emotions a person is aware of 2) Preconscious: thoughts and emotions that are not currently in the persons awareness 3) Unconscious: thoughts and feeling that motivate a person and they are not aware of it 4) Subconscious: slip of the tongue that emerge into conversation Psychosexual stages of development 1) Oral: birth-18 mnths, Id is present, tension and gratification is the mouth 2) Anal: 18-36 mnths, toilet training 3) Phallic/oedipal: 3-5 yrs, stimulation and excitement is a focus (masturbation) 4) Latency: 5-11/13 yrs, social activities, superego, final stage of psychosexual development. 5) Genital: 11-13 yrs begins a puberty and captures true intimacy Ch. 1 PowerPoint Questions