NCMB 419 RCE

Psychotic Medications

• Typical vs. Atypical Antipsychotics:

  • Typical (First-Generation / Conventional): Potent Dopamine $D_2$ receptor antagonists. Primarily target positive symptoms of psychosis (e.g., delusions, hallucinations, disorganized speech and behavior). Associated with a high incidence of Extrapyramidal Side Effects (EPS) and Tardive Dyskinesia (TD). Examples include Chlorpromazine, Haloperidol, Fluphenazine, and Thioridazine.

  • Atypical (Second-Generation): Weak $D<em>2$ receptor blockers that also block Serotonin ($5 ext{-HT}</em>{2 ext{A}}$) receptors. Target both positive and negative symptoms (e.g., anhedonia, avolition, alogia, affective flattening, asociality). Lower incidence of EPS and TD, but carry a higher risk of metabolic side effects (e.g., weight gain, dyslipidemia, diabetes mellitus). Examples include Clozapine, Risperidone, Olanzapine, Quetiapine, and Ziprasidone.

  • Dopamine System Stabilizers (Third-Generation): Partial agonists at $D_2$ receptors (e.g., Aripiprazole).

• Indications across Psychotic Spectrum Disorders:

  • Schizophrenia & Schizoaffective Disorder: Primary maintenance and acute stabilization.

  • Schizotypal Personality Disorder: Utilized at low doses to manage cognitive-perceptual distortions, transient psychotic episodes, or severe social anxiety.

• Adverse Effects & Emergency Management:

  • Acute Dystonia: Severe muscle spasms of the head and neck, torticollis, and oculogyric crisis, with a risk of laryngospasm. Treated with Diphenhydramine ($25 - 50\,\text{mg}$ IM/IV) or Benztropine ($1 - 2\,\text{mg}$ IM/IV).

  • Pseudoparkinsonism: Shuffling gait, mask-like facies, muscle rigidity, tremors, and drooling. Treated with anticholinergics (Benztropine, Trihexyphenidyl) or Amantadine ($100\,\text{mg}$ BID).

  • Akathisia: Intense motor restlessness, pacing, and inability to sit still. Treated with beta-blockers (Propranolol), benzodiazepines, or anticholinergics.

  • Tardive Dyskinesia (TD): Late-onset, often irreversible involuntary movements (lip smacking, tongue protrusion, choreiform movements). Monitored using the Abnormal Involuntary Movement Scale (AIMS). Managed by dose reduction, switching to Clozapine, or administering Valbenazine or Deutetrabenazine.

  • Neuroleptic Malignant Syndrome (NMS): Life-threatening reaction characterized by hyperpyrexia ($102 - 105^\circ\text{F}$), lead-pipe muscle rigidity, autonomic instability (labile BP, tachycardia $>130\,\text{bpm}$, tachypnea $>25\,\text{rpm}$), diaphoresis, and elevated CPK. Managed by immediate discontinuation of antipsychotics, ICU admission, IV hydration, cooling measures, and administration of Bromocriptine or Dantrolene.

  • Agranulocytosis: Severe neutropenia (Absolute Neutrophil Count [ANC] $< 500/\mu\text{L}$ or WBC $< 2000/\mu\text{L}$), particularly associated with Clozapine. Requires strict FDA REMS monitoring (weekly ANC for the first $6\,\text{months}$, biweekly for the next $6\,\text{months}$, then monthly).

• Nursing Responsibilities:

  • Perform baseline and periodic AIMS evaluations every $3 - 6\,\text{months}$.

  • Educate patients on orthostatic hypotension precautions (rising slowly from sitting or lying positions).

  • Monitor ANC and WBC counts prior to dispensing Clozapine.

  • Manage anticholinergic effects: encourage fluid/fiber intake for constipation, sugar-free hard candy for dry mouth, and assess bladder distention for urinary retention.

Mood Stabilizers for Bipolar Disorder and Major Depression

• Lithium Carbonate:

  • Mechanism: Alters sodium transport in nerve and muscle cells; accelerates destruction of catecholamines; regulates serotonin and norepinephrine.

  • Therapeutic Ranges:

  • Acute Mania: $0.8 - 1.5\,\text{mEq/L}$

  • Maintenance: $0.5 - 1.2\,\text{mEq/L}$

  • Toxic Level: $> 1.5\,\text{mEq/L}$

  • Toxicity Manifestations:

  • $1.5 - 2.0\,\text{mEq/L}$ (Mild-Moderate): Severe diarrhea, vomiting, drowsiness, muscle weakness, coarse hand tremors, and lack of coordination.

  • $2.0 - 3.0\,\text{mEq/L}$ (Moderate-Severe): Ataxia, giddiness, blurred vision, tinnitus, slurred speech, hyperreflexia, and muscle fasciculations.

  • $> 3.0\,\text{mEq/L}$ (Severe/Fatal): Complex seizures, cardiac arrhythmias, hypotension, peripheral vascular collapse, coma, and renal failure.

  • Nursing Considerations: Maintain fluid intake of at least $2 - 3\,\text{L/day}$ and normal dietary sodium ($2\,\text{g/day}$); monitor serum levels every $2 - 3\,\text{days}$ initially, then every $1 - 3\,\text{months}$; evaluate thyroid function (TSH) and renal function (BUN/creatinine) periodically.

• Anticonvulsant Mood Stabilizers:

  • Valproic Acid / Divalproex (Depakote): Therapeutic serum level $50 - 125\,\mu\text{g/mL}$. Requires monitoring of liver function tests (LFTs) due to risk of hepatotoxicity, serum ammonia (hyperammonemia), and platelet count (thrombocytopenia).

  • Carbamazepine (Tegretol): Therapeutic serum level $4 - 12\,\mu\text{g/mL}$. Risk of agranulocytosis and aplastic anemia; requires baseline and regular complete blood counts (CBC).

  • Lamotrigine (Lamictal): Preferred for bipolar depression. Main safety concern is severe dermatologic reaction (Stevens-Johnson Syndrome); requires slow dose titration.

  • Topiramate (Topamax) & Gabapentin (Neurontin): Adjunctive mood stabilization and anxiety management.

Antidepressants and Associated Nursing Responsibilities

• Selective Serotonin Reuptake Inhibitors (SSRIs):

  • Examples: Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram.

  • Features: First-line therapy due to low toxicity in overdose and minimal anticholinergic/cardiovascular effects.

  • Side Effects: Nausea, sexual dysfunction, agitation, insomnia, hyponatremia.

  • Serotonin Syndrome: Triggered by combining serotonergic agents or insufficient washout. Symptoms include agitation, confusion, diaphoresis, hyperreflexia, myoclonus, tremors, autonomic instability, and hyperthermia.

• Tricyclic Antidepressants (TCAs):

  • Examples: Amitriptyline, Imipramine, Desipramine, Nortriptyline.

  • Features: Block reuptake of norepinephrine and serotonin.

  • Side Effects: Severe anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention), sedation, orthostatic hypotension, weight gain.

  • TCA Overdose: Lethal in overdose; causes severe cardiotoxicity (QRS widening, arrhythmias), seizures, coma, and respiratory depression.

• Monoamine Oxidase Inhibitors (MAOIs):

  • Examples: Phenelzine, Tranylcypromine, Isocarboxazid.

  • Tyramine Reaction: Ingestion of tyramine-rich foods (aged cheeses, cured/smoked meats, red wine, draft beer, fermented products) while on MAOIs causes massive norepinephrine release and Hypertensive Crisis (severe occipital headache, palpitations, neck stiffness, N/V, BP escalation).

  • Washout Period: Requires a $14\text{-day}$ washout period when switching between MAOIs and other antidepressants ($5 - 6\,\text{weeks}$ for Fluoxetine).

• Atypical Antidepressants & SNRIs:

  • SNRIs: Venlafaxine, Duloxetine.

  • Bupropion: Inhibits norepinephrine/dopamine reuptake; lowers seizure threshold (contraindicated in eating disorders and seizure history).

  • Esketamine: NMDA receptor antagonist nasal spray for treatment-resistant depression; administered in certified clinics under $2\text{-hour}$ observation due to dissociation and sedation risks.

• Nursing Responsibilities:

  • Educate patients on therapeutic lag time ($2 - 6\,\text{weeks}$ for full efficacy).

  • Monitor closely for increased suicidal ideation during the initial phase of therapy as energy levels improve before mood elevates.

  • Provide strict dietary guidance regarding tyramine restrictions for MAOIs.

Health-Care Delivery System and mhGAP

• Three-Tier Mental Health Delivery System (Philippines):

  • Primary Care: First point of contact in outpatient settings, community health centers, and barangay health stations. Focuses on screening, basic treatment, and mental health promotion.

  • Secondary Care: Referrals to psychologists, psychiatrists, and specialized outpatient clinics. Includes diagnostic assessment, specialized counseling, and psychotropic medication management.

  • Tertiary Care: Specialized psychiatric institutions (e.g., National Center for Mental Health - NCMH) providing acute inpatient, long-term residential, and complex clinical care.

• Mental Health Gap Action Program (mhGAP):

  • Origin: Launched by the World Health Organization (WHO) in $2008$ to scale up services for mental, neurological, and substance use (MNS) disorders in low- and middle-income settings.

  • Core Purpose: Trains non-specialized healthcare providers (general physicians, nurses, community health workers) to assess, manage, and follow up MNS conditions using clinical decision algorithms.

  • Local Integration: Collaborative efforts between WHO, Department of Health (DOH), and local government units (LGUs). The municipality of Leon is recognized as a pioneer in community-based mhGAP implementation.

Anxiety and Stress Reduction Management

• General Adaptation Syndrome (Hans Selye):

  • Alarm Reaction Stage: Stressor triggers hypothalamus to signal adrenal glands to release epinephrine and norepinephrine; liver converts glycogen to glucose.

  • Resistance Stage: Blood shunted to skeletal muscles and brain, lungs expand, heart rate increases. Body attempts to adapt; if successful, systemic responses abate.

  • Exhaustion Stage: Depletion of physical and emotional reserves due to chronic unmanaged stress, leading to organ vulnerability and systemic collapse.

• Transactional Model of Stress and Coping (Lazarus):

  • Primary Appraisal: Evaluation of event as irrelevant, benign-positive, or stressful (threat, harm/loss, challenge).

  • Secondary Appraisal: Assessment of available coping resources (internal willpower vs. external supports).

  • Problem-Focused Coping: Direct action when situation is perceived as controllable.

  • Emotion-Focused Coping: Managing emotional distress when situation is uncontrollable.

• Stress Reduction Techniques:

  • Progressive muscle relaxation, deep breathing exercises, guided imagery, isometric exercises, positive self-talk, and assertiveness training using "I" statements.

Mental Status Examination (MSE) – Assessment Techniques

• Appearance & General Behavior: Dress, hygiene, grooming, posture, eye contact, motor activity (psychomotor agitation vs. retardation, tics, tremors).

• Speech: Rate, volume, tone, fluency, latency of response.

• Mood & Affect:

  • Mood: Subjective emotional state reported by the client (e.g., euthymic, dysphoric, euphoric, anxious).

  • Affect: Objective outward expression of emotion (e.g., flat, blunted, inappropriate, labile, restricted).

• Thought Process (Form):

  • Circumstantiality: Excessive detail before reaching the point.

  • Tangentiality: Wandering off-topic and never answering the question.

  • Loose Associations: Unconnected, fragmented speech jumping between unrelated ideas.

  • Flight of Ideas: Continuous, rapid speech with rapid shifting between topics.

  • Word Salad: Jumble of disconnected, meaningless words.

  • Clang Association: Speech guided by rhyming rather than meaning.

  • Neologisms: Invented words meaningless to others.

  • Thought Blocking: Sudden involuntary interruption in speech mid-sentence.

  • Perseveration: Persistent repetition of words or phrases despite changing stimuli.

• Thought Content:

  • Delusions: Fixed false beliefs (persecutory, grandiose, somatic, referential, nihilistic, thought broadcasting, insertion, withdrawal).

  • Obsessions: Intrusive unwanted thoughts.

  • Suicidal / Homicidal Ideation: Assessment of lethality risk matrix (Ideation, Plan, Method, Access, Timing, Venue).

• Perception:

  • Hallucinations: False sensory perceptions without external stimulus (auditory, visual, olfactory, gustatory, tactile).

  • Illusions: Misinterpretation of real sensory stimuli.

  • Depersonalization / Derealization: Detachment from self or environment.

• Sensorium & Cognition: Orientation to person, place, time, situation; memory (recent and remote); concentration and abstract thinking.

• Insight & Judgment: Understanding of illness and ability to make logical, safe decisions.

Therapeutic Communication: Verbal and Non-Verbal Communication

• Communication Dimensions:

  • Verbal: Words used, tone, pace, intonation, clarity, simplicity.

  • Non-Verbal: Body language, gestures, facial expressions, eye contact, posture.

  • Congruence: Alignment between verbal message and non-verbal cues.

• Proxemics (Spatial Zones):

  • Intimate Zone: $0 - 18\,\text{inches}$ (physical contact, whispering).

  • Personal Zone: $18 - 36\,\text{inches}$ (conversational distance between acquaintances).

  • Social Zone: $4 - 12\,\text{feet}$ (group or business interactions).

  • Public Zone: $12 - 25\,\text{feet}$ (speaker addressing an audience).

• Therapeutic Techniques:

  • Accepting: Indicating reception ("Yes, I follow what you are saying").

  • Broad Openings: Allowing client initiative ("Where would you like to begin?").

  • Exploring: Delving deeper into an idea or experience.

  • Focusing: Concentrating on a single key point.

  • Offering Self: Making oneself available unconditionally.

  • Presenting Reality: Offering a calm, factual perspective without arguing.

  • Reflecting: Directing actions, thoughts, or feelings back to the client.

  • Restating: Repeating the main idea in similar words.

  • Silence: Pausing purposefully to allow thought organization.

  • Summarizing: Reviewing main highlights of the conversation.

• Non-Therapeutic Barriers:

  • Advising, Agreeing/Disagreeing, Belittling expressed feelings, Challenging, Defending, Giving Approval/Disapproval, Probing, False Reassurance, Requesting an Explanation ("Why" questions).

Defense Mechanisms

• Adaptive / Mature Mechanisms:

  • Sublimation: Rechanneling unacceptable drives into socially constructive activities.

  • Compensation: Overachieving in one area to offset real or perceived deficits in another.

  • Anticipation: Planning ahead for realistic future stressors.

  • Humor: Emphasizing amusing aspects of a stressful situation.

• Narcissistic Mechanisms:

  • Denial: Refusal to acknowledge painful reality.

  • Projection: Attributing unacceptable personal thoughts, motives, or deeds onto others.

• Immature Mechanisms:

  • Conversion: Transforming emotional conflicts into physical sensorimotor symptoms.

  • Regression: Reverting to an earlier developmental stage under stress.

  • Identification: Modeling behavior after an admired figure.

  • Introjection: Incorporating another person's values into one's own self-structure.

  • Intellectualization: Excessively analyzing events logically to detach from painful emotions.

  • Suppression: Conscious, voluntary exclusion of unwanted thoughts from awareness.

  • Isolation: Separating memory of an event from its accompanying emotional reaction.

• Neurotic Mechanisms:

  • Displacement: Transferring emotional reactions from a threatening target to a less threatening one.

  • Dissociation: Temporarily altering consciousness or identity to escape trauma.

  • Rationalization: Formulating logical excuses to justify unacceptable behaviors or feelings.

  • Reaction Formation: Exhibiting behaviors or attitudes opposite to true internal feelings.

  • Repression: Involuntary, unconscious blocking of painful memories or thoughts.

  • Undoing: Engaging in behavior to symbolically negate or make up for a previous unacceptable act.

DSM-5 Criteria for Thought Processes in Schizophrenia and Other Psychoses

• Diagnostic Criteria for Schizophrenia:

  • Two or more active-phase symptoms present for a significant portion of time during a $1\text{-month}$ period (at least one must be 1, 2, or 3):

  1. Delusions

  2. Hallucinations

  3. Disorganized speech (e.g., frequent derailment, loose associations, incoherence)

  4. Grossly disorganized or catatonic behavior

  5. Negative symptoms (e.g., diminished emotional expression, avolition)

  • Social or occupational dysfunction markedly below premorbid levels.

  • Continuous signs of disturbance persist for at least $6\,\text{months}$ (including at least $1\text{-month}$ of active-phase symptoms).

• Related Psychotic Disorders:

  • Schizoaffective Disorder: Uninterrupted period of illness during which there is a major mood episode (depressive or manic) concurrent with Criterion A of schizophrenia, alongside delusions or hallucinations for at least $2\,\text{weeks}$ in the absence of a major mood episode.

  • Schizophreniform Disorder: Identical symptoms to schizophrenia lasting at least $1\,\text{month}$ but less than $6\,\text{months}$.

  • Brief Psychotic Disorder: Sudden onset of psychotic symptoms lasting at least $1\,\text{day}$ but less than $1\,\text{month}$, with full return to premorbid functioning.

  • Delusional Disorder: Presence of one or more non-bizarre or bizarre delusions for at least $1\,\text{month}$ without meeting Criterion A for schizophrenia or significant functional impairment outside the delusion.

Anxiety Disorders

• Levels of Anxiety:

  • Mild: Heightened awareness, expanded perceptual field, energetic, optimal for learning.

  • Moderate: Narrowed perceptual field, selective inattention, muscle tension, GI discomfort, manageable with redirection.

  • Severe: Perceptual field greatly reduced to scattered details, dread, inability to learn or problem-solve, physiological arousal (tachycardia, diaphoresis).

  • Panic: Perceptual field collapsed to self, loss of rational thought, potential hallucinations/delusions, immobility or aimless running.

• Specific Disorders:

  • Panic Disorder: Recurrent unexpected panic attacks followed by at least $1\,\text{month}$ of persistent concern or behavioral change.

  • Agoraphobia: Marked fear/anxiety regarding being in places where escape might be difficult or help unavailable.

  • Specific Phobias: Irrational fear of a specific object or situation (natural environment, blood-injection-injury, situational, animal).

  • Social Anxiety Disorder (Social Phobia): Severe anxiety provoked by social or performance situations due to fear of scrutiny or embarrassment.

  • Generalized Anxiety Disorder (GAD): Excessive, uncontrollable worry about multiple everyday issues occurring at least $50\%$ of the time for at least $6\,\text{months}$.

  • Selective Mutism: Persistent failure to speak in specific social situations where expected, despite speaking in other settings.

Mood Disorders

• Major Depressive Disorder (MDD): Depressed mood or anhedonia for at least $2\,\text{weeks}$ accompanied by at least four additional symptoms (weight changes, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue, worthlessness/guilt, impaired concentration, suicidal ideation).

• Bipolar Disorders:

  • Bipolar I Disorder: Characterized by at least one manic episode (elevated/irritable mood, grandiosity, decreased need for sleep, flight of ideas, pressured speech, risky behavior lasting at least $1\,\text{week}$).

  • Bipolar II Disorder: Characterized by at least one major depressive episode and at least one hypomanic episode (milder mania lasting at least $4\,\text{days}$ without psychotic symptoms or severe impairment).

  • Cyclothymic Disorder: Chronic mood instability lasting at least $2\,\text{years}$ ($1\,\text{year}$ in children) with numerous hypomanic and depressive periods not meeting full diagnostic thresholds.

• Other Related Mood Disorders:

  • Persistent Depressive Disorder (Dysthymia): Chronic depressed mood for at least $2\,\text{years}$.

  • Disruptive Mood Dysregulation Disorder (DMDD): Severe, recurrent temper outbursts out of proportion to situation in children under age 10$.

  • Postpartum Depression & Psychosis: Depressive onset within 4\,\text{weeks} of delivery; psychosis represents a psychiatric emergency.

  • Seasonal Affective Disorder (SAD): Depressive episodes recurring seasonally (commonly winter-onset treated with light therapy).

Personality Disorders

• Cluster A (Odd / Eccentric):

  • Paranoid: Distrust, pervasive suspiciousness, projection of blame.

  • Schizoid: Detachment from social relationships, restricted affect, preference for solitude.

  • Schizotypal: Acute interpersonal discomfort, cognitive/perceptual distortions, magical thinking, odd speech.

• Cluster B (Dramatic / Emotional / Erratic):

  • Antisocial: Disregard for and violation of rights of others, deceitfulness, impulsivity, lack of remorse/empathy.

  • Borderline: Instability in interpersonal relationships, self-image, and affect; marked impulsivity, fear of abandonment, nonsuicidal self-injury, splitting.

  • Histrionic: Excessive emotionality and attention-seeking behavior, theatricality, suggestibility.

  • Narcissistic: Grandiosity, need for admiration, entitlement, lack of empathy.

• Cluster C (Anxious / Fearful):

  • Avoidant: Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation or rejection.

  • Dependent: Submissive and clinging behavior, excessive need to be taken care of, fear of separation.

  • Obsessive-Compulsive Personality Disorder (OCPD): Preoccupation with orderliness, perfectionism, and mental/interpersonal control at the expense of flexibility and efficiency.

Cognitive Disorders (Dementia and Alzheimer's)

• Delirium vs. Dementia:

  • Delirium: Acute onset, fluctuating course, altered level of consciousness, clouded sensorium, impaired attention, reversible; secondary to medical conditions, toxicity, or withdrawal.

  • Dementia: Gradual onset, progressive and irreversible decline in cognitive function, clear sensorium until terminal stages.

• Diagnostic Terminology in Dementia:

  • Aphasia: Deterioration of language function.

  • Apraxia: Loss of ability to execute purposeful motor activities despite intact motor function.

  • Agnosia: Inability to recognize or identify objects despite intact sensory function.

  • Anomia: Difficulty recalling names of objects.

  • Confabulation: Fabricating stories to fill memory gaps.

• Types of Dementia:

  • Alzheimer's Disease: Cerebral cortical atrophy, amyloid plaques, neurofibrillary tangles.

  • Vascular Dementia: Stepwise cognitive decline due to cerebrovascular lesions.

  • Pick's Disease (Frontotemporal Dementia): Early loss of social inhibitions, personality changes, language abnormalities.

  • Parkinson's & Huntington's Dementia: Subcortical dementias associated with motor disturbances (chorea, rigidity).

Eating Disorders: Bulimia and Anorexia Nervosa

• Anorexia Nervosa:

  • Features: Refusal to maintain minimally normal body weight (< 85\%$expected), intense fear of gaining weight, disturbed body image, amenorrhea.</p></li><li><p><em>Subtypes:</em> Restricting type (fasting, exercise) vs. Binge-eating/purging type.</p></li><li><p><em>Ego Dynamics:</em> Ego-syntonic (client views behavior as desirable/acceptable).</p></li><li><p><em>Medical Risks:</em> Severe bradycardia, hypotension, electrolyte imbalance, lanugo, osteoporosis.</p></li></ul></li><li><p><strong>Bulimia Nervosa:</strong></p><ul><li><p><em>Features:</em> Recurrent binge eating followed by inappropriate compensatory behaviors (self-induced vomiting, laxative/diuretic misuse) at least once/week for$3\,\text{months}. Body weight typically near or within normal range.

  • Ego Dynamics: Ego-dystonic (client feels intense shame, guilt, distress).

  • Medical Risks: Perimylolysis (enamel erosion), parotid gland enlargement, hypokalemia, metabolic alkalosis.

• Related Feeding & Eating Disorders:

  • Binge Eating Disorder (BED): Binge episodes without compensatory purging.

  • Pica: Ingestion of non-nutritive, non-food substances.

  • Avoidant/Restrictive Food Intake Disorder (ARFID): Restrictive eating leading to nutritional deficiency without body image disturbance.

Paraphilic Disorders

• DSM-5 Paraphilias:

  • Sexual Masochism: Arousal from being humiliated, beaten, bound, or made to suffer.

  • Sexual Sadism: Arousal from inflicting physical or psychological suffering on another.

  • Exhibitionism: Arousal from exposing genitals to unsuspecting non-consenting individuals.

  • Fetishism: Arousal involving non-living objects or non-genital body parts.

  • Frotteurism: Arousal from touching or rubbing against non-consenting persons.

  • Pedophilia: Sexual urges or activity involving prepubescent children.

  • Transvestic Disorder: Cross-dressing causing significant distress or impairment.

  • Voyeurism: Arousal from observing unsuspecting nude or engaging persons.

• Management:

  • Cognitive Behavioral Therapy (relapse prevention, trigger identification), social skills training, and pharmacotherapy (SSRIs to decrease obsessive urges, anti-androgens/hormonal therapy).

Treatment Modalities in Psychiatric-Mental Health Care: Somatic Therapies

• Electroconvulsive Therapy (ECT):

  • Indications: Severe treatment-resistant depression, acute catatonia, severe mania, active suicidal ideation requiring rapid response.

  • Procedure: Delivered under general anesthesia and short-acting muscle relaxants (Succinylcholine); induces controlled generalized seizure (30 - 60\,\text{seconds}$). Course consists of$6 - 15$sessions ($3\times\text{per week}$$).

  • Nursing Care: NPO after midnight, void prior to procedure, monitor vital signs and airway post-procedure, reorient patient.

  • Side Effects: Brief confusion, transient retrograde and anterograde amnesia, headache, muscle soreness.

• Other Somatic Therapies:

  • Transcranial Magnetic Stimulation (TMS): Non-invasive pulsed magnetic stimulation to prefrontal cortex for treatment-resistant depression.

  • Vagus Nerve Stimulation (VNS) & Deep Brain Stimulation (DBS): Surgical neurostimulation for treatment-refractory mood conditions.

Psychotherapies & Specialized Therapies

• Core Psychotherapies:

  • Individual Therapy:

  • Cognitive Behavioral Therapy (CBT): Focuses on identifying and modifying cognitive distortions and maladaptive behaviors.

  • Dialectical Behavior Therapy (DBT): Specialized CBT combining mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (first-line for Borderline Personality Disorder).

  • Interpersonal Therapy (IPT): Focuses on resolving interpersonal disputes, grief, role transitions, and deficits.

  • Group Therapy:

  • Provides peer feedback, universality, installation of hope, and social learning in a safe, structured setting.

  • Family Therapy:

  • Addresses family communication patterns, boundary setting, and reduces Expressed Emotion (EE) to lower relapse rates in schizophrenia and mood disorders.

• Specialized Therapies:

  • Play Therapy: Utilized in pediatric care to allow children to express feelings, resolve trauma, and build coping strategies symbolically through play.

  • Gestalt Therapy: Focuses on immediate self-awareness, personal responsibility, and integrating unresolved feelings in the "here and now."

  • Client-Centered (Person-Centered) Therapy (Carl Rogers): Non-directive approach grounded in unconditional positive regard, congruence, and empathetic understanding to foster personal growth.