Note
Studied by 52 people
exam 2 mental health
Chapter_017
Somatization and Related Disorders
Page 5: Somatization
Definition: Expression of stress through physical symptoms.
Symptoms often represent psychological and emotional distress.
Commonly expressed in place of anxiety, depression, or irritability.
Factors: Multifactorial interplay of biological, cognitive, psychological, and social factors.
Page 6: Cultural Considerations
Cultural Variability: Type and frequency of somatic symptoms vary across cultures.
In some cultures, physical symptoms may be attributed to spells.
U.S. Immigrant Population: Primary care visits often linked to responses to traumatic events.
Page 7: Four Primary Disorders
Somatic Symptom Disorder is characterized by focus on somatic (physical) symptoms such as pain or fatigue, to point of excessive concern, preoccupation, and fear
Illness Anxiety Disorder- extreme worry and fear about the possibility of having a disease
Conversion Disorder marked by presence of deficits in voluntary motor or sensory functions
Cognitive Factors Affecting Medical Condition
Factitious Disorder
Definition: A mental disorder where a person deliberately produces or exaggerates symptoms of illness for attention or sympathy.
Types:
Factitious Disorder Imposed on Self: Individuals fake their own illness.
Factitious Disorder Imposed on Another: Individuals fabricate illness in someone else (often a child).
Symptoms:
Vague or inconsistent medical history.
Frequent hospital visits.
Eagerness for medical procedures.
Causes: Often linked to emotional issues, past trauma, or a desire for attention.
Treatment: Focuses on psychotherapy and addressing underlying psychological issues.
n
Page 8: Disorders Under Conscious Control
Factitious Disorder -
Malingering-
Page 10: Somatic Symptom Disorder
Characteristics:
One or more distressing symptoms.
Excessive thoughts, anxiety, and behaviors regarding symptoms or health concerns.
Symptoms occur without significant physical findings or medical diagnosis.
Authentic suffering with high levels of functional impairment.
ASSESSMENT OF PT
SEE IF THE PT DEPENDENCE ON MEDICATION
Page 11: Somatic Symptom Disorder (Cont.)
Epidemiology: Prevalence among adults is about 5%-7%.
PREDOMINANCE IN WOMEN. Young women ages 16-25
Comorbidity: Often coexists with anxiety disorders and major depressive disorders.
Risk Factors: biological
environmental
Page 12: Guidelines for Nursing Care
Develop a strong therapeutic relationship.
Educate about manifestations of somatic symptom disorder.
Provide consistent reassurance.
Support and educate the family when possible and include them in education regarding the disorder
develop strong therapeutic relationship provide education regarding manifestations of somatic symptom disorder
Page 14: Somatic Symptom Disorder (Cont.)
Treatment Modalities:
Offer support.
Avoid unnecessary diagnostics.
Consider hypnotherapy and CBT in conjunction with medication.
MEDICATION COMMONLY PRESCRIBED FOR SOMATIC DISORDER = ANXIOLYTIC
Page 15: Illness Anxiety Disorder
Definition: Fear and preoccupation with having or acquiring serious illness for at least 6 months.
Somatic symptoms are absent or mild.
Involves frequent self-scanning and excessive health-related behaviors.
Page 16: Illness Anxiety Disorder (Cont.)
Epidemiology
1 to 2 yrs prevalence of illness anxiety disorder has been estimated about 1.3 to 10 %
Comorbidity:
anxiety disorders- generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, depressive disorder
Risk Factors:
Environmental history of adverse childhood experiences, such as abuse or illness, may predispose adults to these disorder cognitive factors.
anger, aggression or hostility that had its sources in past losses or disappointment may be expressed as a need for help and concern from others
Treatment Modalities:
Pharmacotherapy nonstreroidal pain relief, laxatives, and complementary medicines, SSRI ECT, CBT/iCBT.
Page 17: Guidelines for Nursing Care
Develop a therapeutic relationship.
Allow time for discussing illness concerns while favoring education.
Reassure that psychiatric care will supplement medical care.
Encourage socialization to combat loneliness.
Page 18: Conversion Disorder or functional neurological disorder
Definition: Neurological symptoms without a neurological diagnosis. marked by presence of deficits in voluntary motor or sensory functions
Conversion is attributed to channeling of emotional conflicts or stressors into physical symptoms
Symptoms include paralysis, blindness, movement disorders, and episodes resembling epilepsy.
"La belle indifférence" versus distress. so someone discussing themselves experiencing sudden blindness
Page 19: Conversion Disorder (Cont.)
Epidemiology and Comorbidity:
Risk Factors: Biological, physiological, neurobiological, environmental, and cognitive factors.
Biological
physiological- ppl who actually have a neurological disease with symptoms similar to those originating from the conversion symptoms are at higher risk neurobiological- conversion disorder may have a biological basis. hypometabolism can lead to impaired hemispheric communication.
Cognitive symptoms permit the person to communicate a need for special treatment or consideration from others. don’t treat them with special care
environmental factors conversion symptoms purely biological factors and to psychosocial and traumatic factors like child abuse and family dysfunction
Page 20: Guidelines for Nursing Care
Develop a therapeutic relationship.
Avoid direct confrontation of symptoms.
Provide reassurance and support.
Encourage socialization and explore adaptive coping mechanisms.
Page 21: Conversion Disorder (Cont.)
Treatment Modalities:
Body-oriented psychological therapy (BOPT).
Dialectical-behavior therapy (DBT).
Psychodrama and physical therapy.
Page 22: Cognitive Factors Affecting Medical Condition
Cognitive factors can increase risk for medical diseases and interfere with treatment. Associated Conditions: Depression/MMD linked to cardiovascular diseases higher in man
cancer men mostly
Page 23: Cognitive Factors Affecting Medical Condition (Cont.)
Epidemiology and Risk Factors:
Environmental factors. loneliness and weak interpersonal connections are associated with negative health outcomes high levels of loneliness are associated with exaggerated BP and inflammatory reactivity to acute stress adverse childhood experiences have been shown to contribute to more negative health outcomes in adulthood
Treatment Modalities: Focus on treating anxiety, depression, and loneliness, as they are identified as risk factors for multiple illnesses, particularly those related to cardiovascular disease
Page 24: Guidelines for Nursing Care
Develop a therapeutic relationship.
Teach the importance of positive affective responses.
Assess adverse childhood experiences regularly.
Focus on connections to family and community to prevent loneliness.
Page 29: Assessment
Assessment Guidelines:
Medical history
Psychosocial factors.
Nutrition, fluid balance, and elimination needs.
Coping skills assessing how pt has dealt with adversity in past provides information. “ can you tell me how you dealt with this in the past” spirituality and religion communication- they are able to describe their physical symptoms, they frequently don’t verbalize feelings, especially those related to anger, guilt, and dependence
self-assessment- its helpful to remember that symptom the pt is experiencing feels real, even though the objective data may not support it.
Page 30: Nursing Diagnoses
Difficulty coping Anxiety.
Risk for loneliness.
Powerlessness and hopelessness.
Chronic low self-esteem.
Impaired socialization and family process.
Risk for suicide.
Page 31: Outcomes Identification
Shared decision-making and patient participation.
Set realistic and attainable outcome criteria.
Focus on small steps for visible progress. small goals is key
Page 32: Implementation
Establish an integrated model of care.
Build a therapeutic relationship and provide patient education.
Offer psychosocial support and coping skills.
Promote self-care activities and assertiveness training.
Page 33: Six Key Elements for Effective Treatment
Provide continuity of care.
Avoid unnecessary procedures.
Conduct frequent, brief, and regular visits.
Always perform a physical exam.
Avoid disparaging comments.
Set reasonable therapeutic goals.
Page 34: Evaluation
Based on clear, realistic, measurable outcomes.
Goals often reported as partially met.
Patients may report continuing somatic symptoms but less concern about them. focus on the pt not there symptoms
Page 35: Treatment Modalities
Psychological therapies, particularly CBT.
Coping strategies to prevent somatization.
Page 37: Factitious Disorder or munchausen syndrome
Definition: Deliberately fabricating symptoms or self-inflicting injury to assume a sick role.
Characterized by compulsivity and deception. contrived illness may be physical or psychiatric
Page 38: Types of Factitious Disorder
Factitious disorder imposed on self.
pt don’t want healthcare workers to talk to family and friends about there condition.
once admitted they request specific treatment and interventions negative test results are often common with new symptoms. pt may become angry and accuse the staff of maltreatment
Factitious disorder imposed on another-caregiver deliberately falsifies illness in a vulnerable person
they do it to receive attention, excitement, insurance money etc
Page 39: Factitious Disorder (Cont.)
Epidemiology and
Comorbidity: pts may describe symptoms of depression, dissociation, conversion and psychoses.
also have high IQ and substance use, borderline personality
Risk Factors:
Biological
brain dysfunction cognitive factors.
Nursing Care and Treatment Modalities: Focus on CBT addressing childhood trauma.
Page 40: Malingering
Definition: Conscious fabrication or exaggeration of symptoms for secondary gain or avoid something undesired such as to obtain prescription medication. Common in men who have been abused and neglected in childhood (e.g., insurance). associated with antisocial, narcissistic, and borderline personality disorders
CH 15 PPT
Anxiety Disorders Overview
Page 2: Understanding Anxiety
Anxiety Defined
Apprehension, uneasiness, uncertainty, or dread from real or perceived threats.
Fear vs. Anxiety
Fear is a reaction to specific danger.
Normal Anxiety
Necessary for survival.
Page 3: Levels of Anxiety
Mild Anxiety
Sharpens focus, grasps more information, and improves problem-solving. occurs in normal experience of everyday living
Moderate Anxiety
Selective inattention; sympathetic nervous system activation; problem-solving becomes difficult.
Severe Anxiety
The only goal is to reduce anxiety.
learning and problem solving are not possible person might be dazed and confused.
Characterized by feelings of falling apart and impending doom, impaired cognition, severe somatic symptoms such as headache and pounding heart.
Page 4: Panic
Characteristics of Panic
Extreme anxiety, disturbed behavior, no focus, disorganized or irrational reasoning, potential loss of touch with reality. physical behavior may become erratic, uncoordinated and impulsive.
Page 7: Defenses Against Anxiety
Defense Mechanisms
Automatic coping styles that protect individuals from anxiety.
Can block feelings, conflicts, and memories.
Can be adaptive (healthy) or maladaptive (unhealthy).
Importance of recognizing personal defense mechanisms.
Page 9: Separation Anxiety Disorder
Definition
Developmentally inappropriate concern over being away from a significant other. begins around 8 months of age, peak at 18 months
Symptoms
Harm avoidance, worry, shyness, uncertainty, lack of self-direction.
adult symptoms include harm avoidance, worry, shyness, uncertainty, lack of self-direction, which manifest in physical symptoms such as gastrointestinal disturbance and headaches
environmatl stresses like lose of relative or pet
Page 10: Types of Anxiety Disorders
Specific Phobias Is a persistent irrational fear of specific object, activity, or situation that lead to avoidance
Social Anxiety Disorder
Severe anxiety or fear in social or performance situations evaluated negatively by others.
Page 11: Panic Disorder and Agoraphobia
Panic Disorder
Characterized by panic attacks and severe terror.
Agoraphobia
Excessive anxiety or fear about being in places or situations where escape might be difficult or embarrassing.
Page 12: Generalized Anxiety Disorder
Definition
Excessive worry lasting for months.
Symptoms
Excessive preparation time, lateness, avoidance, sleep issues, fatigue.
Excessive is characterized by symptomatology that lasts 6 months or longer.
Page 13: Other Anxiety Disorders
Examples
Selective mutism is a condition where kids don’t speak owing to fears of negative responses or evalutions. comfortable around immediate family
, substance-induced anxiety disorder is characterized by symptoms of anxiety, panic attacks, obsessions, and compulsions that develops with use of substance
anxiety due to a medical condition symptoms of anxiety are direct physiological results of medical condition like cardiac dysrthmia. MAKE SURE TO REASSESS THE PT VITALS
Page 14: Obsessive-Compulsive Disorders
Obsessions
Persistent thoughts, impulses, or images causing severe anxiety.
Compulsions
Ritualistic behaviors performed to reduce anxiety. temporary relief of anxiety
Page 15: Obsessive-Compulsive Disorder (OCD)
Symptoms
Daily occurrence, issues related to sexuality, violence, contamination, illness, or death.
Feelings of shame and embarrassment; rituals may interfere with daily living.
Sexual and physical abuse in childhood or trauma increases the risk of this disorder. Genetics are strongly associated with this disorder. First-degree relatives have TWICE the risk
Page 16: Other Compulsive Disorders
Examples
Body dysmorphic disorder, hoarding disorder, trichotillomania (hair pulling), excoriation disorder (skin picking).
other compulsive disorders substance induced obsessive-compulsive- obession and compulsions that develop with use of substance substance like amphetamines, coaine, levodopa, dopamine, heavy metals, 2nd gen antipsychotics
Page 17: Factors Contributing to Anxiety Disorders
Biological Factors
Familial and genetic relationships, abnormalities in the amygdala and limbic system pathways.
Psychological Factors
Unconscious childhood conflicts, unmet needs, learned responses, thought distortions.
Page 18: Application of the Nursing Process
Assessment
General assessment of symptoms, ruling out physical complaints, current anxiety levels, and self-harm risk.
Page 19: Nursing Interventions
Interventions for Anxiety Levels
Counseling, teamwork, safety, promotion of self-care activities, and medications.
Response prevention is a technique by which the pt is prevented from engaging in the compulsive ritual. A form of behavior therapy, response prevention is never undertaken without physician approval
Page 20: Pharmacological Interventions
Antidepressants
SSRIs (e.g., Sertraline, Paroxetine) for calming effects and comorbid depressive disorders.
SNRIs (e.g., Venlafaxine, Duloxetine). SNRI DULOXETINE IS FDA APPROVED FOR ANXIETY TREATMENT FOR KIDS
MAOIs for treatment-resistant conditions.
must avoid tyramine,and substance abuse
Page 21: Anti-Anxiety Medications
Benzodiazepines
Quick action but risk of dependence; caution with sedation and cognitive function.
Avoid use with alcohol, caffeine, and during pregnancy take with meals
Page 22: Other Drug Classes and Integrative Therapy
Additional Medications
Beta blockers, antihistamines, anticonvulsants, antipsychotics as alternatives.
Cognitive Therapy
Cognitive restructuring, identifying negative beliefs, and replacing negative selftalk.
Page 23: Pharmacological Interventions for Children and Adolescents
Approved Medications
SNRI (Duloxetine) for GAD; various SSRIs for OCD.
FDA approved clomipramine (anafraill), fluoxetine (prozac), Fluvoxamine (luvox), sertraline (zoloft)
Page 24: Behavioral Therapy Interventions
Types of Therapy
Relaxation training, modeling, systematic desensitization, flooding, response prevention
EGO DEFENSE MECHANISMS
REPRESSION- excludes unwanted or unpleasant experiences, emotions, or ideas from conscious awareness
DENIAL- invokes escaping reality by ignoring it’s existence
REACTION FORMATION- keeps unacceptable feelings or behaviors out of awareness by developing the opposite behavior or emotion
CHAPTER 11
Note on Psychiatric Disorders in Children and Adolescents
Page 2: Introduction
Prevalence of Psychiatric Disorders
75% of adults diagnosed with psychiatric disorders were first diagnosed between ages 11 and 18.
Challenges in Diagnosis
Disruption to normal childhood development patterns.
Difficulty in diagnosing younger individuals because of limited language skills and cognitive and emotional development also kids undergo more rapid psychological, neurological, and physiological changes
/
Lack of services and premature termination of treatment.
Page 3: Risk Factors
Biological Factors
Genetic predispositions.
Neurobiological influences- declining number of synapse, changes in relative vol and activity level. myelination of brian fibers increases the speed of information processing, improves the conduction speed of nerve impulses, and enables faster reactions to occur
Psychological Factors
Temperament traits- refers to overall mood, attitude, and behavior that a child habitually uses to cope with the demands and expectations of the environment.
Page 4: Behavioral Traits of Temperament
Common Traits
Shyness.
Aggressiveness.
Rebelliousness.
may increase risk for substance use problems
Page 5: Etiology
Psychological Factors
Resilience in children.
adaptability to change in the environment ability to form nurturing relationships with other adults when the parent is not available ability to distance self form emotional choas social intelligence good problem-solving skills ability to perceive a long term future
Environmental Factors
Parental modeling of behavior.
Cultural Influences Shaping Worldview
risk factors that correlate with child psychiatric disorders severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and fostercare placement adverse childhood experiences include abuse ( emotional, physical, sexual), neglet, household challenges such as mental illness, spousal abuse and substance use
/
Page 8: Assessing Development and Functioning
Assessment Data developmental assessment psychomotor skills language skills cognitive skills interpersonal and social skills mental status assessment general appearance
activity levels
coordination and motor function affect, speech, manner or relating
Page 9: General Interventions for Children and Adolescents
Therapeutic Approaches
Play Therapy- is an intervention that allows kids to express feelings such as anxiety, self-doubt, and fear through the natural use of play.
Bibliotherapy- involves using literature to help the child express feelings in a supportive environment, gain insight, into feeling and behavior and learn new ways to cope with difficult situations.
Expressive Art Therapy- use of art provides a nonverbal means of expressing difficult or confusing emotions
Journaling- teenagers . is a tanigble way of recording and viewing emotions and may be a way yo begin dialogue
Music Therapy- music can be used to improve physical, psychological
Page 11: General Interventions for Children and Adolescents
Family Interventions
Importance of family involvement.
Psychopharmacology
Medication management.
Teamwork and Safety
Collaborative care approach.
Page 12: General Interventions
Disruptive Behavior Management
Principle of least restrictive intervention.
Techniques: Time-out, Quiet room, Seclusion, and restraint.
Page 13: General Interventions for Children and Adolescents
Group Therapy
Benefits of peer support.
Cognitive Behavioral Therapy (CBT)
Focus on changing negative thought patterns.
Page 14: Neurodevelopmental Disorders
Communication Disorders
Speech disorders (e.g., stuttering), speech sound disorder , childhood-onset fluency
Language disorders (e.g., inability to understand or use language contextually).
Social communication disorder.
Page 15: Motor Disorders
Developmental Coordination Disorder Impairment in motor skill development coordination below the child’s development age problems interfering with academic achievement or activities of daily living symptoms- delayed sitting or walking or difficulty jumping or performing tasks such as tying shoelaces
Page 16: Motor Disorders
Stereotypic Movement Disorder
Repetitive, purposeless movements. Priority intervention focuses on child safety. behavioral therapy includes habit-reversal techniques such as folding the arms when the urge to hand-wave begins.
naltrexone an opioid receptor antagonist, may block euphoric response from these behaviors, thereby reducing their occurrence
Tourette’s Disorder
Characterized by motor and verbal tics, including coprolalia in 10% of cases.
Page 17: Tourette’s Disorder Medications
Medication Options
Conventional 1st gen antipsychotics (Haloperidol, Pimozide).
Atypical second antipsychotics Aripiprazole (abillify) Clonidine for anxiety and ADHD. anti-anxiety drug clonazepam (klonopin) is used as a supplement to other med
Botox injections ( botulinum)calms muscles
Alpha 2-adrenergic agonist
Page 18: Learning Disorders
Types of Learning Disorders Dyslexia (reading difficulties).
Dyscalculia (math difficulties).
Dysgraphia (written expression issues).
screening for learning disorder is essential at early intervention
Page 19: Intellectual Development Disorder
Deficits intellectual functioning deficits in reasoning, problem solving, planning social functioning impaired communication
daily functioning practical aspects of daily life are impacted by a deficit in managing age- appropriate activities of daily living
Page 20: Autism Spectrum Disorder
Characteristics
Neurobiological and developmental disability.
Autism affects the normal development of the brain in social relatedness, including communication, nonverbal behavior, and age-appropriate interaction.
Other behaviors include stereotypical repetitive speech, obsessive focus on specific objects, over adherence to routines or rituals, hyper- or hypo reactivity to sensory input, and extreme resistance to change
Symptoms appear within the first three years of life.
High risk for abuse. symptoms- deficits in social relatedness, manifests disturbance indeveloping and maintaining relationship
Page 21: Autism Spectrum Disorder: Application of the Nursing Process
Implementation Strategies
Identify the patient. children
Utilize psychobiological interventions.
Incorporate multiple therapies and psychosocial interventions.
Use of unconventional antipsychotics and SSRIs may improve mood and reduce anxiety, which provides pt with higher degree of tolerance treatment plans include behavior management with a reward system
Page 22: Attention Deficit Hyperactivity Disorder (ADHD)
Core Symptoms
Inappropriate levels of inattention, impulsiveness, and hyperactivity.attention problems and hyperactivity contribute to LOW FRUSTRATION TOLERANCE, TEMPER OUTBURST, LABILE MOODS, POOR SCHOOL PERFORMANCE, PEER REJECTION,AND LOW SELF ESTEEM
Page 23: ADHD Assessment
Assessment Focus
Level of physical activity, attention span, talkativeness, and social skills.
ADHD puts kids at risks for injury due to hyperactivity
Consideration of comorbid conditions.
Page 24: ADHD Interventions
Therapeutic Approaches
Short inpatient stays if self-harm is present.
Correcting faulty personality development.
Individual, group, and family therapy.
Cognitive-Behavioral therapy.
Page 25: ADHD Medications
Medication Types
Psycho stimulants (e.g., Methylphenidate, Amphetamine). mainstay of treatment, dose-dependent effect, low dose stimulates aggressive behaviors, moderate to high dose suppressess agressions
Antidepressants SNRI (e.g., Atomoxetine).
amphetamine dexmethylphenide dextroamphetamine lisdexamfetamine dimesylate
methamphetamine methylphenidate HCL
Page 26: ADHD Medications
Additional Medications
Antipsychotics for violent behavior and hyperactivity. Lithium reduces aggressive behavior anticonvulsants (e.g., Clonidine) for aggression.
IDD IS characterized by severe deficits in 3 major areas of functioning:intellectual,social,and managing daily life. These kids demonstrate difficulty with self care with almost any social interaction
CH 12 PPT
Note on Schizophrenia and Related
Disorders
Page 2: Types of Psychotic Disorders
Delusional Disorder: delusions( false thoughts or beliefs) last 1 month or longer. can include; grandiose, persecutory, somatic, and referential themes.
Brief Psychotic Disorder- sudden onset of at least- hallucination, disorganized speech, catatonic ( severely decreased motor activity). symptoms last longer than 1 day but no longer than 1 month.
Schizophreniform Disorder- last less than 6 months. some ppl with this disorder return to their pervious level of functioning, whereas other develop a persistent or recurrent psychosis.
Schizoaffective Disorder- is a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms such as depression, mania, and a milder form of mania.
Substance Induced Psychotic Disorder- drugs, alcohol, meds or toxins can induce delusions or hallucination. delusion and hallucination can cause delirium, neurological diseases, hepatic or renal failure.
Schizophrenia- delevops gradually and insidiously. 15-25 years of age. prodrmal phase when milder symptoms occur often months or years before the full disorder manifests. ppl may experience diminished school performance and cognitive ability.
Psychosis
Altered Cognition
Altered Perception
Altered Reality Testing
Page 3: Prevalence of Schizophrenia
Lifetime Prevalence: 1% worldwide No Differences:
Race
Social status
Culture
Page 4: Substance Abuse and Health Risks
Substance Abuse Disorders: Occurs in 50% of patients. it is associated with poorer treatment adherence and prognosis and with increased relapse, violence and suicide.
Nicotine Dependence: 60% of patients, Mental Health Risks:
Anxiety, depression, and suicide- suicide attempts are more common 3 yrs after diagnosis especially after discharge after 1st episode of schizopherenia
10% suicide rate (5X normal population) Physical Health Risks:
Premature death rate is 3.5X greater. pts die more than 20 yrs prematurely with cardiovascular diseases and metabolic syndrome.
May receive less attentive care due to poverty, stigma, impaired ability to express their needs, or stereotyping.
Polydipsia: is the compulsive drinking of fluids. this causes the sodium levels to decrease, causing hyponatremia. 20% of patients experience insatiable thirst, leading to hyponatremia. symptoms of hyponatremia- confusion, delirium, hallucination, worsening psychotic symptoms. antipsychotic meds that cause dry mouth, and compulsive behavior.
hyponatremia should be considered when there is a sudden increase in psychotic symptoms ( fluctuating vital signs, disorientation, restlessness)
Page 5: Diathesis-Stress Model
Biological Factors:
Genetics:
1st degree relative increases risk by 10%
Concordance rates: Fraternal twins 15%, Identical twins 50%
Page 6: Neurobiological Factors
Dopamine Theory:
1st antipsychotics (e.g., Haloperidol, Chlorpromazine), block the activity of D2 receptors in the brain and reduce symptoms like hallucination and delusion. Second-generation antipsychotics block serotonin and dopamine amphetamine and cocaine enhances dopamine activity and induces psychosis or precipitates schizophrenia. phencyclidine induces a state that resembles schizophrenia.
Page 7: Brain Structure Abnormalities
Key Findings:
Small, oddly shaped hippocampus
Decline in cortical thickness with age
Gray matter deficits
Reduced connectivity and white matter abnormalities
Triggers: Drugs that increase dopamine activity, prenatal stress, psychological stress
Page 8: Phases of Schizophrenia
Prodromal Phase: Symptoms appear before onset, indicating deterioration. acute symptoms vary, from mild to many disabling. such hallucinations, delusions, apathy, social withdrawal, diminished affect, anhedonia, disorganized behavior, impaired judgement.
Chronic Nature: Not curable, but symptoms can be managed with medications and psychosocial interventions. Positive symptoms; include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts or speech.
negative symptoms; include the inability to enjoy activities (anhedonia), social discomfort or lack of goal-directed behavior cognitive symptoms include subtle or obvious impairment in memory, attention, thinking
affective symptoms involves emotions and their expression
Page 9: Phases of Treatment
Phase I – Acute: Onset of severe symptoms, may require inpatient care
Phase II – Stabilization: Symptoms diminish, outpatient care begins
Phase III – Maintenance: Near baseline functioning, risk of relapse if medications are stopped. Planning is geared towards client and family education and skills training that will help maintain the optimal functioning of schizophrenia individuals in the community
Page 10: General Assessment of Symptoms
Positive Symptoms (+): Hallucinations, delusions, bizarre behavior- usually appear early. reality testing is the automatic and unconscious process by which we determine what is and is not real.
Negative Symptoms (-): blunted affect, alogia ( poverty of thought,) Lost of motivation ( avolition), inability to experience pleasure or joy ( anhedonia)
Cognitive Symptoms: Changes in memory, attention, thinking. impaired judgement and memory
Affective Symptoms: emotional expression changes. ( dysphoria, suicidality, hopelessness)
Page 12: Alterations in Reality Testing
Delusions: False, fixed beliefs experienced by 75% of patients
Types: Persecutory- believing that one is being singled out for harm or prevented from making progress by other. grandiose—believing that one is powerful or important person religious-
Page 13: Alterations in Speech
Types:
Associative looseness—looseness of association results from haphazard and illogical thinking where concentration is poor and thoughts are only loosely connected.
Clang associations- is choosing words based on their sound rather than their meaning and often involves words that rhyme or have a similar beginning sound.
Word salad (schizophasia) is a jumble of words that is meaningless to the listener.
Neologisms are words that have meaning for the patient but nonexistent meaning to others. making up fake words
Echolalia- pathological repetition of another’s word. repeating everything you are saying to them
Page 16: Alterations in Perception
Hallucinations: perceives a sensory experience for which no external sources exist.
Auditory (60% of patients)
Visual (rare in schizophrenia) second most common. involves distortion of visual stimuli or may be formed and realistic images.
Command Hallucinations: Can indicate psychiatric emergencies pts may try to cope by drowning out auditory hallucinations with loud music or by talking loudly, or humming. this serves as a recommended intervention.
illusions- misinterpretations of real experience depersonalization- a feeling of being unreal or having lost an element of ones person or identity
derealization- a feeling that the environment has changed
alterations in behavior
1. catatonic: a pronounced increase or decrease in the rate and amount of movement.
muscular rigidity or catalepsy.
2. motor retardation- a pronounced slowing of movement
3. motor agitation- excited behavior such as running or pacing rapidly often in response to internal or external stimuli
4. stereotyped behavior- repetitive behaviors that don’t serve a logical purpose
5. echopraxia: mimicking of movement of another
6. Negativism: a tendency to resist or oppose the requests or wishes of other
7. impaired impulse control- reduced ability to resist ones impulse
8. gesturing or posturing- assuming unusual and illogical expressions ( often grimaces) posture, or position
9. boundary impairment- an impaired ability to sense where ones body or influence ends and another begins
Page 20: Negative Symptoms
Key Symptoms:
Anhedonia- ( an= without + hedonia = pleasure)- a reduced ability or the inability to experience pleasure.
Affective blunting- reduced or constricted affect
Avolition- reduced motivation or goal directed behavior difficulty beginning and sustaining goal directed activites
Apathy- decreased interest in activities or beliefs that would otherwise be interesting or important or little attention to them
Asociality- decreased desire for social interaction or discomfort during it; social withdraw
Alogia- reduction in speech, sometimes called poverty speech affect can be categorized in one 0f 4
1. flat- immobile or blank facial expression
2. blunted- reduced or minimal emotional response
3. constricted- reduced in range or intensity ( shows sadness or anger but no other moods)
4. inappropriate- laughing in response to tragedy
5. bizzare- odd, illogical, inappropriate or unfounded; includes grimacing cognitive symptoms- represent the 3rd symptom group and are evident in most pts with schizophrenia. can lead to poor judgment concrete thinking is an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner.
memory- impairment primarily affects short term memory and the ability to learn impaired executive functioning- includes difficulty with reasoning setting priorities comparing options placing things in logical order or groups, anticipating and planning and inhibiting undersirable impulses or actions impaired information processing can lead to problems such as delayed responses, misperceptions or difficulty understanding others.
anosognosia- the inability to realize one is ill. could lead to pts resist or stop treatment a serious affective change often seen in schizopherina is comorbid major depressive disorder.
Page 23: Importance of Depression Assessment
Mood Variability: Can indicate impending relapse
Increased Risks: Substance abuse and suicide
assessment guideline
1. ensure that the pt has had a medical workup
2. assess for indication of medical problems that might mimic psychosis
3. assess for substance use disorder
4. complete MSE, including insight, reality testing, judgment, cognitive abilities, knowledge of the illness, relationships and support system
5. assess for hallucinations
6. assess for delusions
7. assess for suicide risk
8. assess activities of daily living
9. assess medication regiman
10. assess the family knowledge of and response to the illness and its symptoms
Page 26: Treatment Phases
Phase I – Acute: Focus on safety and stabilization
Phase II – Stabilization: Understanding illness and treatment
Phase III – Maintenance: Prevent relapse and achieve quality of life
Page 28: Working with Aggressive Patients
Priority Interventions: Protect from violent behavior, increase supervision, and address paranoia. violence may be in response to hallucinations, delusions, paranoia, impaired judgment
Page 30: Counseling Techniques for Hallucinations
Approach: Understand the patient’s experience, use simple language, maintain eye contact, acknowledge feelings use of therapeutic communication helps build trust and reduce anxiety.
calling the pt by name, speaking simply and loudly enough to be understood during hallucination, conveying support, maintaining eye contact and redirecting the pts focus to the conversation with the nurse as needed
helping pt who are delusional
1. build trust being open, honest, genuine and reliable
2. respond to suspicion in a matter-of-fact empathic supportive, and calm manner
3. ask the pt to describe beliefs. tell me more about someone trying to hurt you.
4. never debate the delusional content
5. validate if part of the delusion is real
6. don’t dwell excessively on the delusion. instead refocus on reality based topics
Page 32: Antipsychotic Medications
First-Generation: Best for positive symptoms, block dopamine. examples include; haloperidol ( haldol), chlorpromazine ( thorazine). help reduce hallucination and delusions
Second-Generation: Effective for both positive and negative symptoms. example; clozapine ( clozaril) and risperidone (risperdal), olanzapine ( zyprexa), quetiapine ( seroquel), ziprasidone (geodon). clozapine causes severe neutropenia monitor wbc count. they can cause sedation, sexual dysfunction, seizures, and increased mortality in older adults with dementia. all second gen meds carry risk of metabolic syndrome, which includes weight gain ( abdomen area) dyslipidemia, and increased blood glucose.
Third-Generation: Aripiprazole (Abilify) improves cognitive function
extrapyramidal side effect
1. acute dystonia- a sudden sustained contraction of 1 or several muscle groups usually head and neck. monitor and assure open airway
2. akathisia- a motor restlessness that cause pacing and or an inability to stay still or remain in one place. relaxation exercises and antiparkinsonian agent
3. pseudoparkinsonism- temporary symptoms resemble Parkinson. tremors, and gait impairment.
4. tardive dyskinesia a persistent EPS involving involuntary rhythmic movements. this more common with 1st gen antipsychotics usually after prolonged use. teach pt ways to conceal involuntary movements such as holding ones hand with the other. Is not always reversible with discontinuation of the meditation and has no proven cure
anticholinergic side effects
1. urinary retention
2. dilated pupils
3. constipation
4. reduced visual accommodation (blurred near vision)
5. tachycardia
6. dry mucous membrane
7. reduced peristalsis
8. cognitive impairment
Page 39: Serious Side Effects
Anticholinergic Toxicity: Life-threatening, especially in the elderly. caused by taking multiple meds with anticholinergic side effects. hold all medication and consult the prescriber immediately. implement cooling measures
Neuroleptic Malignant Syndrome (NMS): Life-threatening condition from excessive dopamine blockage. it is characterized by reduced consciousness and responsiveness and increased muscle tone and autonomic dysfunction.
other 1st gen meds side effects include; sedation, orthostatic hypotension, lowered seizure threshold,
liver impairment may also occur during antipsychotic therapy especially with 1st gen agents. liver impairment occurs during the first week of therapy. liver problems include jaundice, abdominal pain, ascites, vomiting, lower body edema, pale skin.
Page 41: Additional Medications
Antidepressants and Mood Stabilizers: Enhance antipsychotic effectiveness
Benzodiazepines: Reduce anxiety and agitation, improve symptoms
This note summarizes key points regarding schizophrenia, its symptoms, treatment phases, and medication management, providing
Ch 4 PPT
Outpatient Psychiatric Mental Health Care
Page 2: Role of Primary Care Providers
First Recognition of Mental Health Issues
Primary care providers often identify uncomplicated, common mental illnesses.
Support for Patients
Strategies needed to assist these patients effectively.
Page 3: Specialty Psychiatric Care
Complex Cases
Specialty providers handle complicated and severe psychiatric illnesses. this providers include psychologists, psychiatrists, psychiatric mental health advanced rn, social worker, counselors
Patient-Centered Care
Focus on comprehensive psychiatric care.
Emphasizes respect and autonomy of patients.
Integration of Services
Combines primary care and behavioral health to reduce stigma.
Page 4: Community Mental Health Clinics
Accessibility
Services available for uninsured individuals.
Types of Services
Emergency services, routine care for adults and children, long-term follow-up, psychosocial rehabilitation, and psychiatric case management.
Page 5: Psychiatric Home Care
Admission Criteria
homebound status of PT- means pt can’t leave the house independently due to physical or mental condition psychiatric diagnosis- needs of skills of psychiatric nurses—Medicare allows 2 groups of healthcare providers to be involved in psychiatric home care under the care of a physician with a treatment plan - a psychiatric rn provides evaluation, therapy, and teaching.
Benefits
Continuity of care and therapeutic relationships.
Challenges include boundary issues.
Aims to decrease levels of depression and anxiety.
Page 6: Assertive Community Treatment (ACT)
Intensive Case Management
Designed for patients with persistent symptoms and repeated hospitalizations.
Goal is to work intensely with the client in the community to prevent rehospitalization
Mobile Treatment Teams
Multidisciplinary teams provide care in various environments. the teams are on call 24 hours a day
Long-Term Engagement
Teams may work with the same patient for years, focusing on creative problemsolving.
Page 7: Partial Hospitalization Programs (PHPs)
Intensive Short-Term Treatment
Involves 5-6 hours of individual and group psychotherapy daily.
PHP is for clients who may need a “step down” environment from inpatient status or for those who are being diverted from hospitalization with intensive, short term care from which they can RETURN HOME EACH DAY.
Goals of Treatment
Focus on symptom improvement, safety, education, and coping strategies.
Multidisciplinary Approach
Available through referrals, aiming to reduce hospitalizations.
Page 8: Other Outpatient Venues
Diverse Care Options
Includes dual-diagnosis programs, telephone crisis counseling, outreach, and telepsychiatry.
telepsychiatry goal include
1. treating ppl in remote areas
2. reducing emergency department visits
3. reducing delays in care
4. improving continuity of care and follow-ups
5. eliminating transportation barriers
6. reducing the barrier of stigma
Page 9: Goals for Community Care
Individualized Care
Provide necessary care in the least restrictive environment.
Preventative Focus
Aims to prevent decompensation and rehospitalization.
Patient-Centered Approach
Care is negotiated rather than imposed.
Page 10: Psychiatric Case Management
Coordination of Services
Involves professional assessment, care planning, implementation, and regular review.
Advocacy
Ensures that patient needs are met effectively.
Page 11: Emergency Care and Crisis Stabilization
emergency care primary care is to perform triage and stabilization. triage refers to determining the severity of the problem and the urgency of a response
Comprehensive Emergency Services
Triage and stabilization in emergency departments.
full service with full-time staff
Mobile Crisis Teams
Provide crisis stabilization and observation units.
hospital-based consultant model: triage and stabilize, refer to a specialist, and discharge or transfer is
possible.
prevention in outpatient care
1. primary prevention occurs before any problem manifests and seeks to reduce the incidence or rate of new cases. may prevent or delay the onset of symptoms in genetically or otherwise predisposed individuals. provide coping strategies and psychosocial support.
2. Secondary prevention is aimed at reducing the prevalence of psychiatric disorders. Early identification of problems, screening, and prompt and effective treatment are hallmarks of this level.
3. Tertiary prevention is the treatment of disease with a focus on preventing the progression to a severe course, disability, or even death. closely related to rehabilitation, which aims to prevent or restore functional ability
Page 12: Inpatient Psychiatric Care
Admission Criteria
Reserved for individuals who are suicidal, homicidal, or extremely disabled.
Short-Term Acute Care
Focus on those unable to care for basic needs or protect themselves.
elopement leaving before being discharged
Page 13: Therapeutic Milieu
Environment and Activities
The physical surroundings and social interactions foster independence and responsibility.
Skill Development
Aims to improve social skills, communication, self-worth, and social competence
milieu refers to surrounding the physical environment
managing behavior crises
behavioral crises can lead to pt violence toward self or others and usually but not always escalate through fairly predictable stages.
hands-on techniques which are only used as a last resort also seclusion, restraint, and emergency med are actions of last resort.
safety - safe environment is essential component of any inpatient setting. for pt with active suicidal thoughts continuous in-person observation is essential because even checking on the pt every 15 minutes may not prevent a suicide that takes only several minutes.
Managed care goal is directed by a case manager is to provide coordination of all health services with an emphasis on preventive care. While appropriate interventions,( arranging for the client to have a screening for prostate cancer)
Ch 9 PPT
Therapeutic Communication Techniques (Page 2)
Tools for Enhancing Communication
Using Silence: Allows space for reflection and thought.
Active Listening: Engaging fully with the speaker to understand their message.
Listening with Empathy: Understanding and sharing the feelings of the speaker.
Clarifying Techniques (Page 3)
Methods to Clarify Communication
Paraphrasing: Restating what the speaker has said in your own words.
Restating: Repeating the speaker's message to confirm understanding.
Reflecting: Mirroring the speaker's emotions or thoughts.
Exploring: Asking for more information to gain deeper understanding.
Projective Questions: Encouraging the speaker to project their feelings or thoughts.
Presumption Questions: Asking questions based on assumptions to clarify.
Asking Questions and Eliciting Patient Responses (Page 4)
Types of Questions
Open-ended Questions: Encourage detailed responses (e.g., "How do you feel about that?").
Closed-ended Questions: Elicit short, specific answers (e.g., "Did you take your medication?").
Nontherapeutic Communication Techniques (Page 5)
Techniques to Avoid
Excessive Questioning: Can overwhelm the patient and hinder communication.
Giving Approval or Disapproval: May lead to judgment and inhibit openness.
Giving Advice: Can undermine the patient's autonomy.
Asking “Why” Questions: May come off as accusatory or confrontational.
Attending Behaviors (Page 6)
Non-verbal Communication
Eye Contact: Shows attentiveness and respect.
Body Language: Conveys openness and engagement.
Vocal Quality: Tone and pitch can affect the message's reception.
Verbal Tracking: Following the speaker's narrative to maintain focus.
telehealth technologies include video conferencing, the internet, phone consultation and counseling. mobile medical applications as tools to monitor, diagnose, treat, and communicate with patients
proxemics refers to the significance of the physical distance between individuals.
Case Scenario: Nurse-Parent Interaction (Page 7)
Scenario Overview: A nurse is approached by a mother seeking reassurance about her child's condition.
Best Response:
D. “I understand you’re concerned. Let’s discuss what concerns you specifically.”
This response acknowledges the mother's feelings and invites a discussion.
Example of Non-therapeutic Response (Page 8)
Client Statement: “I was so upset about my sister ignoring my pain when I broke my leg.”
Nurse Response: “When are you going to your next diabetes education program?” This response fails to address the client's emotional concern.
Asking for Relationship Details (Page 9)
Client Statement: “I met Joe at the dance last month.”
Best Nurse Response: C. “Tell me about you and Joe.”
This encourages the client to elaborate on their relationship.
Examples of Therapeutic Communication Responses (Page 10)
Responses to Select:
D. “Tell me more about your discharge plans.”
F. “What might you do the next time you’re feeling angry?”
Responses to Avoid:
A. “Don’t worry-everybody has a bad day occasionally.”
B. “I don’t think your mother will appreciate that behavior.”
C. “Let’s talk about something else.”
E. “That sounds like a great idea.”