TREATMENT MODALITIES

REMOTIVATION THERAPY
TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS STEPS : climate of acceptance creating bridge to reality sharing the world we live in appreciation of works of the world climate of appreciation

MUSIC THERAPY
Involves use of music to facilitate expression of feelings, relaxation and outlet of tension

PLAY THERAPY
enables patient to experience intense emotion in a safe environment with the use of play children express themselves more easily in play. revealing as reflection of childs situation in the family provide toys and materials facilitate interaction observe and help child resolve problems through play

Group therapy
Treatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others IDEAL 8 10 MEMBERS

MILIEU THERAPY
Consists of treatment by means of controlled modification of the patients environment to facilitate positive behavioral change Increase patients
Awareness of feelings Sense of responsibility and Help return to community

clients plan social and group interaction token programs , open wards and self medication are done

FAMILY THERAPY
A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN INTERACTIONAL SYSTEM PROBLEM IS A FAMILY PROBLEM focus on sick members behavior as source of trouble / symptom serve a function for the family members develop sense of identity points out function of the sick member for the rest of the family

PSYCHOANALYTIC
focuses on the exploration of the unconscious, to facilitate identification of the patients defenses ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO Becomes aware of unconscious thoughts and feelings to understand anxiety and defenses

HYPNOTHERAPY
Various methods and techniques to induce a trance state where patient becomes submissive to instructions

BEHAVIOR MODIFICATION
Application of learning principles in order to change maladaptive behavior Believes that psychological problems are a result of learning Everything learned can be unlearned

BEHAVIOR MODIFICATION
OPERANT CONDITIONING
Use of rewards to reinforce positive behavior Perceived and self-reinforcement becomes more important than external reinforcement

DESENSITIZATION
Slow adjustment or exposure to feared objects (phobias) Periodic exposure until undesirable behavior disappears or lessens

AVERSION THERAPY
An example of behavior modification Painful stimulus is introduced to bring about an avoidance of another stimulus End view: behavioral change

OTHER THERAPIES
HUMOR THERAPY
To facilitate expression and enhance interaction

ACTIVITY THERAPY
Group interaction while working on a task together

 EMOTIONAL PROBLEM IS AN ILLNESS cause may be inherited or chemical in origin FOCUS OF TREATMENT IS MEDICATIONS AND ECT

BIOLOGICAL/ MEDICAL THEORY

BIOLOGICAL THERAPY
ELECTROCONVULSIVE THERAPY
Artificial induction of a grand mal seizure by passing a controlled electrical current through electrodes applied to one or both temples mechanism of action unclear voltage: 70 150 volts Duration: 0.5 2.0 seconds 6 to 12 treatments intervals of 48 hours

indicators of effectiveness occurrence of generalized tonic clonic seizures

 indications depression , mania and catatonic schizophrenia s/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec) NPO prior Contraindications
Fever, pregnancy Inc ICP, fracture retinal detachment TB with hemoptysis cardiac d/o

consent needed Reorient after, supportive care

 medications given :
Atropine sulfate: decrease secretions Succinylcholine (Anectine): promote muscle relaxation Methohexital Sodium ( Brevital ): serves as an anesthetic agent

common complications:
loss of memory headache apnea fracture respiratory depression

Psychopharmacologic Therapy

Anti-anxiety drugs
For: Delirium, anti-anxiety, insomnia ACTION: Increases GABA (gamma amino butyric acid) USES: Major use to reduce anxiety; also induce sedation, relax muscles, inhibit convulsion; Used in neuroses, psychosomatic disorders, functional psychiatric disorders. DO NOT modify psychotic behavior. Most commonly prescribed drugs in medicine Greatest harm: When combined with ALCOHOL

Benzodiazepines
Indications
Anxiety Sedation/sleep Muscle spasm Seizure disorder Alcohol withdrawal syndromes

Benzodiazepines

Anti-anxiety drugs
Generic
Alprazolam Chlordiazepoxide Clorazepate Diazepam Lorazepam Oxazepam Busipirone

Trade name
Xanax Librium Tranxene Valium Ativan Serax BuSpar

Benzodiazepines

Side effects
Drowsiness/ sedation Ataxia Feelings of detachment Increase irritability and hostility Anterograde amnesia Increased appetite & weight gain Nausea Headache, confusion

Benzodiazepines

Anti-depressants
Indications
Depression Bipolar depression Panic disorder Bulimia Obsessive-compulsive d/o

Possibly
Attention deficit/Hyperactivity d/o Post Traumatic Stress D/o Conduct d/o

Anti-depressants

Tricyclic (TCA)
Generic
Amitriptyline Imipramine Trimipramine Nortriptyline Trazodone Bupropion

Trade name
Elavil Tofranil Surmontil Pamelor Desyrel Wellbutrin

Anti-depressants

Side effects
Orthostatic hypertension Anticholinergic effect
Dry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/ retention, tachycardia, agitation, delirium, exacerbation of glaucoma

Neurologic effects
sedation, psychomotor slowing, poor concentration, fatigue, ataxia, tremors

Decrease libido and sexual performance

Anti-depressants

Monoamine Oxidase inhibitors

Generic
Isocarboxazid Phenelzine Tranylcypromine

Trade name
Marplan Nardil Parnate

Anti-depressants

Side effects
Postural lightheadedness Constipation Delay ejaculation or orgasm Muscle twitching Drowsiness Dry mouth

Anti-depressants

Dietary restrictions
Cheese, esp. aged and matured Fermented or aged protein Pickled or smoked fish Beer, red wine, sherry; liquor & cognac Yeast Fava or broad beans Beef or chicken liver Spoiled/ overripe fruits; banana peel yogurt

Anti-depressants

Hypertensive Crisis
Signs
Sudden elevation of BP Explosive headache, occipital may radiate frontally Head & face flushed Palpitations, chest pain Sweating, fever Nausea, vomiting Dilated pupils, photophobia Intracranial bleeding

Anti-depressants

 Treatment
Hold next MAO dose Dont let pt. lie down IM chlorpromazine 100 mg Fever: manage by external cooling techniques

Anti-depressants

Serotonin Reuptake Inhibitors

Generic
Fluoxetine Sertraline Paroxetine Venlafaxine

Trade name
Prozac Zoloft Paxil Effexor

Anti-depressants

Side effects
Nausea Diarrhea Insomnia Dry mouth Nervousness Headache Male sexual dysfunction Drowsiness Dizziness Sweating

Anti-depressants

MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM

For: (Mood disorder Disorder) specifically Mania (Bipolar

USES: Elevate mood when client is depressed; dampen mood when client is in manic; used in acute manic, bipolar prophylaxis; ACTS by reducing adrenergic neurotransmitter levels in cerebral tissue through alteration of sodium transport affects a shift in intraneural metabolism of NOREPINEPHRINE

Action: hyperactivity and balance or stabilize the mood Effect: 1 wk.

Mood stabilizing drugs

Indications
Acute mania Bipolar prophylaxis

Possibly
Bulimia Alcohol abuse Aggressive behavior schizoaffective

Mood stabilizing

 Mode of action
Normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine and dopamine Reduces the release of norepinephrine thru competition with calcium Effects intracellularly

Lag period: 7-10 to 14 days

Mood stabilizing

Lithium carbonate
Trade names

Eskalith Lithotabs Lithane Lithonate MOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport in nerves and muscle cells

Prelithium workup
Urinalysis (BUN and creatinine) ECG, FBC, CBC

Mood stabilizing

Side effects
Early
Nausea and diarrhea Anorexia Fine hand tremor (propranolol) Thirst, Polydipsia (dec. crea, inc. albumin) Metallic taste Fatigue Lethargy

Late
Weight gain acne

Mood stabilizing

Contraindications
Brain damage/ CV disease Epilepsy Elderly/ debilitated Thyroid and renal disease Severe dehydration Pregnancy (1st trimester) Can augment the effects of antidepressants

Mood stabilizing

Nursing considerations
Therapeutic serum level: 0.5 1.2 meq/L Maintenance level: 0.6 -1.2 meq/L Toxic
Mild to moderate: 1.5 to 2 meq/L Moderate to severe: 2 2.5 meq/L Needs dialysis: 3 meq and above

Early signs of toxicity

Lethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria, polydipsia, metallic taste, fatigue

Late signs of toxicity

Ataxia, giddiness, tinnitus, blurred vision, polyuria

Mood stabilizing

Nursing considerations
Lithium levels should be checked q 2-3 mos Serum drawn in the AM, 12H after last dose Common causes of inc. levels
Dec. Na intake Diuretic therapy Dec. renal functioning F&E loss Medical illness Overdose NSAIDS

Mood stabilizing

Nursing considerations
Diet: adequate Na+ and fluid
3g NaCl/ day 6-8 glasses of H2O

No caffeine No driving: wait for clinical effect

Mood stabilizing

 Moderately severe toxicity

Management

Osmotic diuresis: urea/ mannitol Aminophylline & PLR IV Adequate NaCl Peritoneal/ hemodialysis

Severe toxicity
Assess hx quickly Hold next lithium dose Check BP, rectal T, RR, LOC, support O2 Obtain labs ECG Emetic, NGT lavage Hydrate: 5-6L/day c PLR; FBC-CDU

Mood stabilizing

Other drugs
Carbamazepine (Tegretol)
Side effects
Dizziness Ataxia Clumsiness Sedation Dysarthria Diplopia Nausea & GI upset

Preparation: liq, tab, chewable tab

Mood stabilizing

Nursing considerations
Assess drug levels q 3-4 days Monitor salt and fluid intake Avoid alcohol and non-prescription drugs Refer dec. in UO Dont stop abruptly C/I: pregnancy Take with meals

Mood stabilizing

Other drugs
Valproic acid (Depakote, Depakene)
Side effects
Nausea Hepatoxicity Neurotoxicity Hematological toxicity Pancreatitis

Prep: tab, cap, sprinkles

MOA: inc. levels of GABA; inhibits the kindling process or snoball-like effect seen in mania & seizures

Mood stabilizing

Nursing considerations
Therapeutic level: 50 100 ug/mL Dose: 1, 000 1,500 mg/day Monitor serum levels 12H after last dose Toxic effects
Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination Renal failure, coma, death

Mood stabilizing

ANTIPSYCHOTICS
Another word: Neuroleptic / Major Tranquilizers USES: Schizophrenia, acute mania, depression and organic conditions; Non-psychiatric cases: Nausea and vomiting, pre-anesthesia, intractable hiccups. Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the negative symptom such as ambivalence.

Action: delusion, hallucinations, looseness of association to decrease levels of dopamine in the substantia nigra

Anti-psychotic drugs
Indications
Psychotic symptoms of schizophrenia, acute mania and depression Gilles de Tourette disorder Treatment-resistant bipolar disorder Huntingtons disease and other movement disorder

Possibly
Paranoid Childhood psychoses

Anti-psychotic

 MOA: block receptors of dopamine (D2, D3, D4) If unresponsive after 6 weeks of therapy, another class is tried General considerations
Calms without producing impairment of sleep High therapeutic index Non addicting, no tolerance Avoided in pregnancy

Anti-psychotic

TYPICAL: High Potency

Fluphenazine (Prolixin) Haloperidol (Haldol) Thiothexene (Navane) Trifluoperazine (Stelazine)

Anti-psychotic

Moderate Potency
Loxapine (Loxitane) Molindone (Moban) Perphenazine (Trilafon)

Anti-psychotic

Low Potency
Chlopromazine (Thorazine) Chlorprothixene (Taractan) Mesoridazine (Serentil) Thioridazine (Mellaril)

Anti-psychotic

ATYPICAL
Clozapine (Clozaril) Resperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Sertindole (Serlect) Ziprasidone (Zeldox)

Anti-psychotic

Contraindications
CNS depression: brain damage, excess alcohol/ narcotics Parkinsons disease Allergy Blood dyscrasias Acute narrow angle glaucoma BPH

Anti-psychotic

Side effects
Hypotension Sedation Dermal and ocular syndrome Neuroleptic malignant syndrome Anticholinergic syndrome Movement syndrome (Extrapyramidal Syndrome) Atropine psychosis Agranulocytosis Seizures

Anti-psychotic

Neuroleptic Malignant Syndrome

A potentially fatal, idiosyncratic reaction to an antipsychotic drug 10-20% mortality rate Sx:
rigidity, high fever, autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or mute, fluctuate from agitation to stupor

Occurs in the first 2 weeks of therapy Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med illness

Anti-psychotic

Movement Syndromes
Akathisia Dystonia Tardive dyskinesia Bradykinesia Parkinsonism

Anti-psychotic

 Atropine psychosis (geriatrics)

Hyperactivity, agitation, confusion, flushed skin, sluggish reactive pupils TTT: IM physostigmine

Other s/e

Agranulocytosis (Clozapine)
Occurs 3-8 wks after Medical emergency s/s: fever, malaise, sore throat, leukopenia TTT: d/c, reverse iso, antibiotics

Seizures (Clozapine)
Occurs in 5% of patients; TTT: D/c drug

Anti-psychotic

Anticholinergics
Benztropine (Cogentin) Trihexyphenidyl (Artane) Biperiden (Akineton) Procyclidine (Kemadrin)
Not withdrawn abruptly Provide cool environment

Anti-psychotic

ANTIPARKINSONIAN MEDICATIONS
Adjunct to anti-psychotic agents to balance dopamine/ acetylcholine in the brain s/e: glaucoma, tachycardia, HPN, cardiac dx, asthma, duodenal ulcer A/e: blurred vision, photosensitivity, drowsiness, orthostatic hypotension, CHF, hallucinations

 COMMON DRUGS:
Trihexyphenidyl (Artane) benztropine (Cogentin) Biperiden (Cogentin) Selegiline (Eldepryl) Pergolide (Permax)

ANTIHISTAMINE
Diphenhydramine HCl (BENADRYL)

DOPAMINE RELEASING AGENT

Amantadine (SYMMETREL)

 Nursing considerations
Best taken after meals Avoid driving Check BP Alcohol increases sedative effects Avoid sudden position change Drug is not withdrawn abruptly

PSYCHIATRIC DISORDERS

DELIRIUM
The medical dx term that describes an organic mental disorder characterized by a cluster of cognitive impairments with an acute onset with a specific precipitating factor. Sx: diminished awareness of the environment, disturbances in psychomotor activity and sleepwake cycle. COGNITIVE: the mental process characterized by knowing, thinking, and judging.

COGNITIVE DISSONANCE: arises when 2 opposing beliefs exists at the same time. COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that might include errors of logic, mistakes in reasoning, or individualized view of the world that do not reflect reality. Term: confusion = cognitive impairment

COGNITIVE DISORDERS

DEMENTIA
The medical dx term that describes an organic mental d/o characterized by a cluster of cognitive impairments of generally gradual onset and irreversible without identifiable precipitating stressors. Types:
VASCULAR or MULTI-INFARCT VASCULAR WITH ALZHEIMERS DSE AD: most common DEMENTIA WITH LEWY BODIES: 2nd most common; neurofilament material PARKINSONIAN DEMENTIA AIDS DEMENTIA COMPLEX

COGNITIVE DISORDERS

 FRONTAL LOBE DEMENTIA or PICKS DSE: cytoplasmic collections; 3rd most common; loss of expressive language & comprehension CREUTZFELDT-JAKOB DSE: prion (proteinaceous infectious particles) = spongy brain; related to TSE & BSE in mad cow dse CORTICOBASAL DEGENERATION or HUNTINGTONS DSE/CHOREA: jerky movts SUPRANUCLEAR PALSY: clumping of protein tau = slow movt, weak eye movt (esp. downward), impaired walking COGNITIVE DISORDERS &balance

 Reversible Causes:
Subdural hematoma Tumor (meningioma) Cerebral vasculitis Hydrocephalus

Terms: disorientation, memory loss (sensory, primary, secondary, tertiary, working memory), confabulation, confusion Disturbing behaviors
Aggressive psychomotor Nonaggressive psychomotor Verbally aggressive Passive Functionally impaired: loss of ability to do self-care
COGNITIVE DISORDERS

DELIRIUM
Rapid onset w/ wide fluctuations Hyperalert to difficult to arouse LOC Fluctuating affect Disoriented, confused Attention & sleep disturbed Memory impaired Disordered reasoning

vs.

DEMENTIA

Gradual, chronic with continuous decline Normal LOC Labile affect Disoriented, confused Attention intact, sleep usually normal Memory impaired Disordered reasoning & calculation
COGNITIVE DISORDERS

DELIRIUM

vs.

DEMENTIA
Disorganized, rich in content, delusional, paranoid No change in perception Poor judgment No insight Consistently poor & progressively worsens in MSE
COGNITIVE DISORDERS

Incoherent, confused, delusional, stereotyped Illusions, hallucinations Poor judgment Insight may be present in lucid moment Poor but variable in MSE

 Most common type of dementia Stages:

ALZHEIMERS DEMENTIA

MILD: impaired memory, insidious loses in ADL, subtle personality changes, socially normal MODERATE: obvious memory loss, overt ADL impairment, prominent behavioral difficulties, variable social skills, supervision needed SEVERE: fragmented memory, no recognition of familiar people, assistance needed with basic ADL, fewer troublesome behaviors, reduced mobility (4 As)
COGNITIVE DISORDERS

Symptoms
AGNOSIA: Difficulty recognizing wellknown objects APHASIA: Difficulty in finding the right word APRAXIA: Inability or difficulty in performing a purposeful organized task or similar skilled activities AMNESIA: Significant memory impairment in the absence of clouded consciousness or other cognitive symptoms
COGNITIVE DISORDERS