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CONCEPT TYPES/ SUBTYPES
Individuals experience a degree of anxiety that is so high that it interferes with personal, occupational, or social functioning. ANXIETY DISORDERS are the most common form of psychiatric Disorder in the USA.
PANIC DISORDER 1.The patient experiences recurrent panic attacks 2. Episodes typically last 15-30 minutes 3. Four or more of the following symptoms are present: -Palpitations, SOB, Choking or Smothering Sensation, Chest Pain, Nausea, Feelings of Depersonalization, Fear of Dying, Chills or Hot Flashes, Fear of going crazy, Decreased perceptual and cognitive abilities 4. Pt may experience Changes in Behavior and/or Persistent Worries about when the next attack will occur 5. May experience Agoraphobia due to fear of being in places where previous panic attacks occurred. *MAY BE CONFUSED WITH A HEART
ATTACK *DOES NOT NECESSARILY FOLLOWS AN STRESSFUL, IDENTIFIABLE EVENT
GENERALIZED ANXIETY DISORDER (GAD) 1. More than 6 months of uncontrollable, excessive, unrealistic worries (inadequacy in interpersonal relationships, job responsibilities, finances, health of family members, household chores, and lateness for appointments) 2. GAD causes significant impairment in one or more areas of functioning. 3. At least 3 of the following symptoms are present: -Fatigue -Restlessness -Inability to Concentrate -Irritability -Muscle Tension -Sleep Disturbances 4. Characterized by Remissions and exacerbations (no acute anxiety attack)
PHOBIAS 1. The client fears a specific object or situation to an unreasonable level. Phobias include: -SOCIAL PHOBIA -AGORAPHOBIA -SPECIFIC PHOBIAS: -Fear of specific objects (snakes, spiders, strangers) -Fear of specific experiences (flying, being in the dark, riding an elevator, being in an enclosed space)
OBSESSIVECOMPULSIVE DISORDER (OCD) 1. The client has intrusive thoughts of unrealistic obsessions and tries to control these thoughts with compulsive behaviors, which are repetitive – ritualistic-Clients who engage in constant ritualistic behaviors may have difficulty meeting self-care needs-If rituals include constant handwashing or cleaning, skin damage and infection may occur.
POST-TRAUMATIC STRESS DIRORDER (PTSD) 1. Exposure to a traumatic event causes intense fear, horror, flashbacks, feelings of detachment and foreboding, restricted affect, and impairment for longer than 1 month after the event. Symptoms may last for years. -ACUTE PTSD: Symptoms last less than 3 monthsCHRONIC PTSD: Symptoms last more than 3 months SYMPTOMS: -Recurrent, intrusive recollection of event -Dreams or images -Reliving through flashbacks, illusions, or hallucinations -Irritability, difficulty with concentration, sleep disturbances, avoidance of stimuli associated with trauma, inability to show feelings. (it differs from Acute Stress Disorder in that ASD occurs after exposure to a traumatic event, causing numbing, detachment and amnesia about the event for NOT MORE than 4 weeks following the event, with symptoms lasting from 2 days to 4 weeks)
1. Perform a thorough Physical and Neurological examination to help determine if anxiety is primary or is secondary to another psychiatric disorder, a medical condition, or substance use. 2. Assess Risk for Suicide 3. Perform psychosocial assessment (To help client identify the problem to be addressed by counseling (stressful marriage, recent loss, stressful job or school situation)
Assess coping mechanisms Use a standardized assessment scale, such as Hamilton Rating Scale for Anxiety. 1. Client uses coping mechanisms to prevent panic anxiety when stressful situations occur. 2. Client verbalizes acceptance of life situations over which he or she has no control 3. The client is able to recognize signs of anxiety and intervene to prevent panic levels 1. Ensure Safety In General, Interventions for Anxiety disorders attempt to: 2. Stay with the client and provide support (Provide reassurance, use therapeutic communication skills, use open-ended questions, encourage client to verbalize feelings) 1. Reduce Anxiety 3. Use relaxation breathing techniques as needed 2. Increase Self Esteem 4. Reduce environmental stimuli 3. Increase Reality Testing 5. Encourage physical activity like walking 4. Enhance Coping Mechanisms 6. Administer medications as prescribed (SSRIs, TCAs, MAOIs, Benzodiazepines (anxiolytics), Beta Blockers, 5. Instill Hope Mood stabilizers) 6. Relaxation Therapy 7. Instill hope (but avoid false reassurance) 8. Enhance Self Esteem by encouraging positive statements about self and discussion of past achievements. 9. Postpone teaching until acute anxiety subsides: clients with panic attack or severe anxiety are unable to 4. 5.
PANIC DISORDER: MEDICATIONS *SSRIs are First line for all anxiety Disorders except AAA (see bellow) *Benzodiazepines shouldn’t be used to treat GAD: this is a chronic disease and benzos should only be used for short periods of time, like in Acute Anxiety Attack (AAA) 1. 2. 3. 4. 5. 6. SSRIs Benzodiazepines TCAs MAOIs Beta Blockers Depakote (Valproic Acid)
GENERALIZED ANXIETY DISORDER (GAD) 1. 2. 3. 4. 5. SSRIs TCAS Buspirone (Buspar) SNRIs Depakote (Valproic Acid)
concentrate or learn. 10. Teach to limit nicotine and caffeine 11. Promote sleep with comfort measures PHOBIAS OBSESSIVECOMPULSIVE DISORDER (OCD) 1. 2. 3. 4. 5. SSRIs Benzodiazepine s Buspirone (Buspar) Beta Blockers Gabapentin (Neurontin)
POST-TRAUMATIC STRESS DISORDER (PTSD) 1. 2. 3. 4. 5. 6. 7. SSRIs TCAs Benzodiazepines SNRIs MAOIs Beta-Blockers Carbamazepine (Tegretol)
1. SSRIs (Especially
2. Luvox) TCAs (Especially Anafranil)
+ Cognitive-Behavioral Therapy
+ Cognitive-Behavioral Therapy *No Benzodiazepines
+ + Behavioral Therapy -Cognitive-Behavioral -Family -Group Therapy with survivors
+ Cognitive-Behavioral Therapy
Defense mechanisms: MISC Phobia: Displacement Compulsion: Undoing Obsession: Reaction-Formation/ Intellectualization PTSD: Isolation/ Repression
Nursing Diagnosis: -Risk for Suicide (=Risk for self-directed violence) -Risk for others-directed violence -Risk for injury to self or others -Anxiety (moderate, severe) -Ineffective role performance -Ineffective coping -Disturbed thought process -Disturbed Sleep Pattern -Self-care deficit
FOR ACUTE ANXIETY ATTACK (AAA) First Line of Treatment: Benzodiazepines (the only time this group is first line for anxiety disorders)
DEPRESSION TYPES/ SUBTYPES MAJOR DEPRESSIVE DISORDER (MDD) DYSTHYMIC DISORDER (DD) OR DYSTHYMIA
BIPOLAR DISORDER Bipolar disorders are mood disorders with recurrent episodes of depressionand mania. Phases vary depending on the type of bipolar disorder. • Bipolar disorders usually emerge in late adolescence/early adulthood, but can be diagnosed in the school-age as well. TYPES OF BIPOLAR DISORDERS: BIPOLAR I: At least 1 episode of Mania alternating w/ Major Depression. BIPOLAR II: Hypomanic episodes alternating w/ Major Depressive ones. CYCLOTHYMIA: At least 2 years of alternating episodes of Hypomanic Episodes alternating w/ Minor Depressive episodes (dysthymia) BEHAVIORS shown with Bipolar Disorders include: MANIA: Abnormally elevated mood, also described as expansive or irritable. HYPOMANIA: A less severe episode of mania that lasts at least 4 days accompanied by 3 or 4 symptoms of mania. MIXED EPISODE: A manic episode and an episode of major depression experienced by the client simultaneously. Marked impairment in functioning and may require admission to prevent self-harm or others-directed violence. RAPID CYCLING: Four or more episodes of acute mania within 1 year • ***BIPOLAR DISORDER IS ASSOCIATED WITH THE HIGHEST RATE OF SUICIDE OF ANY PSYCHIATRIC DISORDERS.
A single, recurrent, or chronic episode (s) of depression resulting in a significant change in the client’s normal functioning (social, occupational, self-care) accompanied by at least 5 specific symptoms. These symptoms must happen almost every day, last most of the day, and occur continuously for a minimum of 2 years.
A milder form of depression that usually has an early onset, such as childhood or adolescence (Chronic Depressed Mood) IT LASTS: More than 1 year (for Children and Adolescents) More than 2 years (For Adults) Contains at least 3 symptoms of depression, and may, later in life, become Major Depressive Disorder
• • • • • • FEATURES
Depressed Mood Insomnia/Hypersomnia Decreased ability to concentrate Anergia (Lack of Energy) Significant weight loss or gain (of more than 5% of body weight in 1 month) Indecissiveness Increase or Decrease in motor activity ****Suicidal Ideations ****
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Depressed Mood Insomnia/Hypersomnia Decreased ability to concentrate Anergia Decreased Self Esteem Feelings of Hopelessness and Despair Decreased/Increased Appetite
1. Severe enough to cause a marked impairment in
occupational activities, usual social activities, or relationships. OR 2. 3. Necessitates hospitalization to prevent harm to self or others, or there are psychotic features
1. Associated with an unequivocal change in
functioning that is uncharacteristic of the person when not symptomatic 2. The disturbance in mood and the change in functioning are observed by others Absence of marked impairment in social or occupational functioning. Hospitalization not indicated Symptoms are not due to direct physiological effects of substance (drug abuse, medication, alcohol) other medical condition (hyperthyroidism)
Anhedonia (Inability to feel pleasure in life) Specifiers (Features): • • • PSYCHOTIC FEATURES (Hallucinations, Delusions etc) POSTPARTUM ONSET (Begins within 4 weeks of childbirth, known as Postpartum Depression) SEASONAL FEATURES (SEASONAL AFFECTIVE DISORDER –SAD-) (Generally occurring in fall or winter, and remitting in Spring) CHRONIC FEATURES (Episode lasts over 2 years)
Specifiers (Features) • • • Early Onset (before 21 y/o) Late Onset (21 years or older) Atypical Features (Appetite changes, weight gain, Hypersomnia, extreme sensitivity to perceived interpersonal rejection)
3. Symptoms are not due to direct physiological effects of substance (drug abuse, medication, alcohol) other medical condition (hyperthyroidism) 4. 5.
ETIOLOGY & Risk Factors
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History of prior episodes of depression Family history of depression, especially first degree relatives History of Suicide attempts and/or family history of suicide Female Gender Age 40 years or younger Postpartum period Medical Illness Absence of Support System Negative, stressful life events Active alcohol or substance abuse
MAJOR DEPRESSIVE DISORDER DYSTHYMIC DISORDER (DD) OR DYSTHYMIA
BIOLOGICAL THEORIES: • Genetic Factors: Strong genetic component
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Neurobiological Factors: Neurotransmitters (NE,Dopamine and Serotonin) INCREASED: Mania DECREASED: Depression Neuroendocrine Factors: Hypothyroidism: Depressed mood and rapid-cycling
Neuroanatomical: Prefrontal cortex (PFC) and Medial Temporal Lobe (MTL) dysregulation SOCIOLOGICAL FINDINGS: More prevalence in the upper socioeconomic classes. Reason unclear; it seems people with BD achieve higher levels of education and higher occupational status than nonbipolar individuals PSYCHOLOGICAL INFLUENCES: There seems to exist an association between high expressed emotions and relapse. Abused children tend to reveal BD earlier in life than non abused ones.
ASSESSMENT + Additional Symptoms
• Assess Suicide Potential (applies also for Bipolar Disorder) Follow Algorithm “SAD PERSONS” (Sex _male- Age –25-44 or more 65-Depressed mood, Previous attempt(s), ETOH-alcohol-, Reality testing impaired, Social support (lack), Organized plan, No spouse, Sickness (severe or chronic) • Assess Risk factors for Depression Follow the algorithms “SIGECAPS” (Sleep disturbances, Interest –decreased-,Guilt, Energy -decreased-, Concentration –decreased-, Appetite –decreased/increased-, Psychomotor movements, Suicidal Ideation Other areas to assess: • Affect • Thought processes • Feelings • Guilt • Physical Behavior • Communication
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Labile moods Inappropriate and intrusive behavior Profane speech; crude sexual remarks Flight of ideas; may have clan associations (rhyming) Good humor turns into rage and hostility, especially when not getting his way or controls are set. Quick shifts in moods, hostile to docility Grandiose delusions Judgment extremely poor Decreased attention span and distractibility Restless, disorganized and chaotic behavior difficult to control; frequent outbursts and briefly assaultive when crossed Too busy for sex No time to eat or sleep. Too distracted and disorganized Severely hyperactive and restless. Can result in exhaustion and death. Same as Hypomanic with finances, but extreme
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Remains Safe Verbalizes hope for the future Identifies precursors of depression Reports improved mood Develops strategies to cope with stress and painful feelings
Talks and jokes incessantly (“life of the party”) Demands constant attention Treats everyone with familiarity; often crude. Sexual talk often inappropriate and obscene; proposes to strangers Flits from topic to topic Full of pep, humor, euphoria and sociability Inflated self confidence and enthusiasm. Many plan to become rich and famous Poor judgment; involved with schemes in which job, financial, o marriage is destroyed. High degree of involvement with the rich and famous; world-wide phone calls Decreased attention span, overactive Increased sexual appetite,; sexually irresponsible and indiscreet; illegitimate pregnancies, increased incidence of venereal diseases. Sex used for escape, not for relating. Voracious appetite, gobbles food, eats on the run May go without sleeping, unaware of fatigue Financially extravagant; buying sprees, gives money and gifts freely. Goes easily into debt. Wears extravagant, often inappropriate clothes and jewelry.
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FOR DEPRESSION: Safety!! Prevent Suicide!! Encourage to verbalize feelings Assist through grief process Increase Self Esteem and Reality Testing Decrease Anxiety Confront anger Administer medications & assess effects Teach coping mechanisms, disease process and medication regimen Ensure all basic needs are met Approach: caring, supportive, and firm Have patient sign “No Suicide Contract”: To take responsibility and make commitment.
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Exhibits no evidence of physical injury Has not harmed self or others Is not longer exhibiting signs of physical agitation Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status Accepts responsibility for own behaviors Does not manipulate others for gratification of own needs Interacts appropriately with others
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Safety in the environment!! One-to-one nurse-client relationship “No Suicide” contract Non-judgmental, accepting attitude Encourage verbalization of feelings Provide Hope Assist in meeting basic needs Provide diversional activity
Ensure safety in the environment Decrease Anxiety: use firm, calm approach, use short and concise explanations Remain neutral, Give simple step-by-step instructions Set limits and tell in concrete terms consequences of inappropriate behavior Firmly Redirect violent behavior (use distraction) Decrease environmental stimuli Structured solitary activities with staff High calorie, high protein “finger foods” snacks and drinks. Avoid caffeine. Provide frequent rest periods Administer and make sure pt takes prescribed medications When violent or extreme agitation use antipsychotics and seclusion Monitor lithium levels/observe s & s of toxicity
• • • • • • • MEDICATIONS/ TREATMENT MODALITIES 1. 2. 3. 4. SSRIs (First Line treatment) TCAs MAOIs ATYPICAL ANTIDEPRESSANTS
1. ANTIPSYCHOTICSs & BENZODIAZEPINES (Initially, used to calm manic symptoms until Lithium
therapeutic levels and full effects are achieved, in approx. 14 days)
PSYCHOLOGICAL TREATMENTS: • Individual Psychotherapy • Group Therapy
2. MOOD STABILIZERS (Lithium, Anticonvulsives)
• Family Therapy • Cognitive Therapy ORGANIC TREATMENTS: • ECT • PSYCHOPHARMACOLOGY • ALTERNATIVE OR COMPLEMENTARY THERAPY OTHER FACTS
1. Depression is the fourth leading cause of disability in the US. 2. Twice as common in women as in men 3. Suicides are more common in men than women
4. It is partially hereditable
• • • • •
Suicide Facts Most common method: firearm Most common sex: males Most common occupations: Physicians, dentists, nurses, Social workers Elderly attempt suicide less often, but have higher completion rate (more lethal methods) Suicide is more common in people with comorbidities (Major depression, bipolar disorder, schizophrenia, alcohol and substance abuse, borderline and antisocial personality disorders, panic disorder)
PERSONALITY DISORDERS (PDs) A personality disorder is an enduring pattern of inner experience and behavior that: 1. Deviates markedly from the expectations of one’s culture 2. Is pervasive, maladaptive and inflexible, 3. Has an onset in adolescent or early adulthood 4. Is stable over time and 5. Leads to distress or impairment ALL PERSONALITY DISORDERS have four common characteristics: -Inflexibility/maladaptive responses to stress -Disability in social and professional relationships -Tendency to provoke interpersonal conflict -Capacity to cause irritation or distress in others
CLUSTER A Odd or Excentric Traits
PARANOID SCHIZOID SCHIZOTYPAL ANTISOCIAL
CLUSTER B Dramatic, Emotional, or Erratic Traits
BORDERLINE HISTRIONIC NARCISSISTIC
CLUSTER C Anxious or Fearful Traits; Insecurity and Inadequacy
AVOIDANT DEPENDENT OBSSESIVECOMPULSIVE
Characterized by Characterized Characterized Characterized by Distrust And Emotional by Odd Beliefs, consistent Suspiciousness Detachment, leading to Disregard for Towards Others, disinterest in close interpersonal Others with based on the belief relationships, and difficulties, an exploitation and (unsupported by indifference to eccentric repeated unlawful evidence) that praise or criticism; appearance, and actions, deceit and others want to often magical failure to accept exploit, harm, or uncooperative. thinking or personal deceive the The person with perceptual responsibility. person. These this disorder does distortions that Previously called individuals are: not seek out or are not clear Psychopaths or -Hypervigilant enjoy close delusions or Sociopaths. There -Anticipate relationships. hallucinations. is a clear history of hostility These individuals conduct disorder in -May provoke may be able to childhood, and the hostile responses function in a individual show no by initiating a solitary remorse for hurting “counterattack” occupation. others. They -Demonstrate repeatedly: jealousy, Schizoid PD can -Neglect controlling be a precursor to responsibilities behaviors, and schizophrenia or -Tell lies unwillingness to delusional -Perform forgive. disorder. There is destructive or **Paranoid people increased illegal acts, without are difficult to prevalence of the developing any interview b/c they disorder in insight into are reluctant to families with predictable share information schizophrenia or consequences. about themselves. schizotypal PD. 1. Minnesota Multiphasic Personality Inventory (MMPI) 2. Full medical history to rule out medical causes 3. Psychosocial history : • Suicidal, homicidal, or aggressive thoughts. • Current use of medicines and illegal substances • History of current or abuse
Characterized by Instability of Affect, identity and Relationships; fear of abandonment, splitting behavior, manipulation, and impulsiveness; often tries selfmutilation and may be suicidal. Individuals w/ Borderline PD desperately seek relationships to avoid feelings of abandoned, but often drive others away b/c of their excessive demands, impulsive behavior, and their frequent use of splitting.
Characterized by Emotional Attention-Seeking Behavior, in which the person needs to be the center of attention; often seductive and flirtatious, the histrionic person is impulsive and melodramatic. Relationships do not last b/c their partner often feels smothered or reacts to the insensitivity of the histrionic person. The individual with histrionic PD has no insight into his role in breaking up relationships. In the treatment setting, the person demands “the best of everything” and can be very critical
Characterized by Arrogance, Grandiose Views of Self-Importance, the need for constant admiration along with a lack of empathy for others that strains most relationships; often sensitive to criticism. Underneath the surface of arrogance, narcissistics feel intense shame and fear that if they are “bad” they will be abandoned. They are afraid of their own mistakes, as well as the mistakes of others. May seek help, feeling that loved ones do not show enough appreciation of their special qualities.
Characterized by Social Inhibition and Avoidance of all situations that require interpersonal contact, despite wanting close relationships, due to extreme fear of rejection; often very anxious in social situations. Because in their social presentation they appear timid and with low selfesteem and poor self-care, they are often mistreated in groups. If they do develop relationships, they cling to their partners in a dependent way. They are seen in Tx for symptoms of anxiety.
Characterized by Extreme Dependency in a close Relationship with an urgent search to find a replacement when one relationship ends; the most frequently-seen personality disorder in the clinical setting. Individuals with Dependent PD have difficulty making independent decisions and are constantly seeking reassurance. Their submissiveness makes them vulnerable to abusive relationships. The have a deeply held conviction of personal incompetence that they cannot survive on their own.
Characterized by Perfectionism with a focus on orderliness and control .They become so preoccupied with details and rules that they may not be able to accomplish a given task. Persons with ObsessiveCompulsive PD feel genuine affection for friends and family, and don’t have insight about their own difficult behavior creating tension in their close relationships, in which the person tries to control the partner.
• • •
Legal history Ability to handle money
Current or past physical, sexual, or emotional abuse • Risk of harm of self and others The patient will be able to: • Use adaptive coping strategies to deal with conflict • Accept responsibilities for own actions/behaviors • Communicates needs appropriately • Demonstrate self-restrain of compulsive or impulsive behavior
*Usually not admitted for Personality Disorders. For a patient to be eligible for admission to the hospital, must have an AXIS I psychiatric diagnosis, plus the AXIS II Personality Disorder. *Realistically, behavior probably will not change significantly
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CLUSTER A Odd or Excentric Traits Objective, matter-of-fact approach Avoid being too “nice or friendly” Clear, simple, consistent verbal-non-verbal communication Give clear straightforward explanations Warn about changes, side effects etc Help identify feelings Assist with problem-solving Gradually involve in group situations but do not insist. Respect need for social isolation.
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CLUSTER B Dramatic, Emotional, or Erratic Traits Prevent self-harm. No harm contract. Set limits on inappropriate or manipulative behaviors Provide clear, consistent boundaries Assist examining consequences of behavior. Consistent approach by staff Do not rescue or reject Remain neutral, avoid engaging in power struggles or be coming defensive to patient’s comments Give recognition for goal achievement Explore feelings Teach problem solving and role model assertiveness Encourage and model concrete and descriptive communication Document behaviors and incidents objectively Encourage follow up treatment
CLUSTER C Anxious or Fearful Traits; Insecurity and Inadequacy • Caring consistent approach • Clear expectations for behavior • Expect patient to make decisions • Teach assertiveness • Encourage to identify positive attributes • Provide positive feedback for increased interactions in social situations • Teach stress management and relaxation techniques AGGRESSIVE BEHAVIOR ANGER CONTROL ASSISTANCE!! -Determine appropriate behavioral expectations for expressions of anger, given pt’s level of cognitive and physical functioning -Limit access to frustrating situations until pt is able to express anger in an adaptive manner -Encourage pt to seek assistance from nursing staff during periods of increasing tension -Monitor potential for inappropriate aggression and intervene before its expression -Assist pt in identifying source of anger -Prevent physical harm if anger is directed towards self or others -Provide physical outlets for expressions of anger or tension (e.g. pushing bag, sports, clay, journal writing)
MANIPULATIVE BEHAVIOR SET LIMITS!! -Discuss concerns about behavior with patient -identify undesirable behavior, and discuss with patient what is desirable behavior in a give situation or setting -Establish consequences for occurrence or nonoccurrence of desired behavior in a non punitive ad easily understood way -Refrain from arguing or bargaining with patient about established behavioral expectations and consequences -Modify behavioral expectations as needed based on reasonable changes in patient’s situations
IMPULSIVE BEHAVIOR IMPULSE CONTROL TRAINING!! -Assist pt to: Identify problem or situation that requires thoughtful action, and courses of possible actions, their costs or benefits -Teach pt to cue himself to “stop and think” before acting impulsively -Assist pt to evaluate the outcome of the chosen course or action -Provide positive reinforcement for successful outcomes (e.g. praise and rewards) -Provide opportunities for pt to practice problem solving in social and interpersonal situations outside the therapeutic environment
PSYCHOBIOLOGICAL INTERVENTIONS: Clients with Personality Disorders usually do not like taking medications unless it calms them down; they are fearful about taking something over which they have no control. They worry if they don’t have an adequate supply, but have difficulty organizing themselves to fill a prescription. Dependent on the chief complaint, psychotropic agents that are geared toward maintaining cognitive function and relieving symptoms may be used. These include: ANTIDEPRESSANTS, ANXIOLYTICS, ANTIPSYCHOTICS, or a combination of these. MILIEU THERAPY: When individuals with PDs are in hospital, partial hospitalization, or day treatment settings, Milieu Therapy is a significant part of treatment. The primary goal of Milieu Therapy is affect management in a group context. Community meetings, coping skills groups, and socializing groups are all helpful for these clients. CASE MANAGEMENT: CM is beneficial for clients who have PDs and are persistently and severely impaired. In Acute Care Facilities: CM focuses on obtaining pertinent history from current or previous providers, supporting integration with the family/significant other, and ensuring appropriate referrals to outpatient care. In long-term outpatient facilities, case management goals include reducing hospitalization by providing resources for crisis services and enhancing the social support system.
CONCEPT • • • Schizophrenia is a group of psychotic disorders that affect thinking, behavior, emotions, and the ability to perceive reality. The term “Psychosis” refers to the presence of hallucinations, delusions, or disorganized speech or catatonic behavior. The typical age at onset is late teens and early twenties, but schizophrenia has occurred in young children and may begin in later adulthood. PARANOID DISORGANIZED CATATONIC • Characterized by abnormal motor movements. There are two stages: the withdrawn stage and the excited stage. WITHDRAWN STAGE: o Psychomotor retardation; client may appear comatose. o Waxy Flexibility or stupor o Echolalia and/or Echopraxia o Client often has extreme self-care needs, such as for tube feeding due to inability to eat EXCITED STAGE: o Peculiar voluntary movement: Unusual posturing, Stereotyped movements, Prominent mannerisms, Prominent Grimaces o Excessive purposeless motor activity (agitation) o Self-care needs may predominate o Client may be a danger to self or others RESIDUAL UNDIFFERENTIATED (MIXED TYPE) Client has symptoms for schizophrenia, but does not meet criteria for any of the other types (no one clinical presentation dominates (e.g. paranoid, disorganized, catatonic) Any positive or negative symptoms may be present (has active-phase symptoms (does have hallucinations, delusions, and bizarre behaviors) Eccentric Psychotic features are extreme: o Fragmented delusions o Vague hallucinations o Bizarre, disorganized behavior o Disorientation, Incoherence
Characterized by suspicion toward others Dominant: Hallucinations and Delusions (positive symptoms) NO Disorganized speech, disorganized behavior, catatonia or inappropriate affect present. (No negative symptoms)
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Characterized by withdrawal from society and very inappropriate behaviors, such as poor hygiene, or muttering constantly to self. Frequently seen in the homeless population Dominant: Disorganized speech, disorganized behavior, and inappropriate affect. Marked regression Poor Reality Testing Poor social skills Inappropriate emotional responses Outbursts of laughter Silly behavior
Active-phase (positive) symptoms are not longer present (Delusions, hallucinations, disorganized speech and behaviors) However, the client has two or more “residual symptoms” (some negative symptoms) such as: o Marked social isolation or withdrawal o Impaired role function (wage earner, student, homemaker) o Anergia, Anhedonia, or Avolition o Alogia (speech problems) o Odd behavior, such as walking in a strange way o Impaired personal hygiene o Lack of initiative, interest or energy o Blunted or inappropriate affect
Diagnostic criteria: The four “A”s: 1. Affect: Refers to the outward manifestation of a person’s feelings or emotions. In Schizophrenia, clients may display flat, blunted affect. 2. Associative Looseness: Refers to haphazard and confused thinking that is manifested in jumbled and illogical speech and reasoning. The term “looseness of association” is also used 3. Autism: Refers to thinking that is not bound to reality, but reflects the private perceptual world of the individual. Delusions, hallucinations, and neologisms are examples of autistic thinking in persons with schizophrenia. (Also termed as “response to internal stimuli”) 4. Ambivalence: Refers to simultaneously holding two opposite emotions, attitudes, ideas, or wishes toward the same person, situation, or object. Schizophrenia is characterized by periods of exacerbations and remissions. Has three phases: o ACUTE PHASE: Periods of both positive and Negative symptoms o MAINTENANCE PHASE: Acute symptoms decrease in severity o STABILIZATION PHASE: Symptoms in remission
o Alterations in perception: Hallucinations: Sensory perceptions for which no external stimulus exists (auditory, visual,
CHARACTERISTIC DIMENSIONS OF SCHIZOPHRENIA (No single symptom is always present in all cases) olfactory, tactile), Personal Boundary Difficulties, Depersonalization, Derealization POSITIVE SYMPTOMS: These are the most easily identified symptoms
o Alterations in thinking:: Delusions: A false belief held and maintained as true, even with evidence to the contrary, concrete
thinking, thought broadcasting, thought insertion, thought withdrawal, delusions of being controlled)
o Alterations in speech: Associative looseness (Disorganized Speech), Neologisms, Echolalia, Clang Association, Word o
Salad. Alterations in behavior (Bizarre behavior): Extreme motor agitation, stereotyped behaviors, Automatic obedience, waxy flexibility, stupor, negativism) AFFECT: usually Blunted (narrow range of normal expression) or Flat (Facial expression never changes). ALOGIA: Poverty of thought or speech; client may sit with a visitor but may only mumble or respond vaguely to questions AVOLITION: Lack of motivation in activities and hygiene ANHEDONIA: Inability to find pleasure in life; the client is indifferent to things that often make others happy ANERGIA: Lack of energy, chronic fatigue Disordered thinking Poor problem-solving skills Poor decision-making skills Inattention; easily distracted (Difficulty concentrating to perform tasks) Impaired judgment Impaired memory Long-term memory loss Working Memory loss (such as inability to follow directions to find an address) Hopelessness Suicidal Ideation
NEGATIVE SYMPTOMS (THE FIVE “A”s): These symptoms are more difficult to treat successfully than positive symptoms
o o o o o o o o o o o
COGNITIVE SYMPTOMS: Problems with thinking make it very difficult for the client to live independently
ACTIVE PHASE: -Client safety and medical stabilization STABILIZATION PHASE: MAINTENANCE PHASE: -Target negative symptoms -Adherence to medication regimen -Anxiety Control -Understanding schizophrenia -Relapse prevention -Participation of client and family in psycho educational activities ACUTE PHASE: (Hospitalization, Client Safety, Stabilization Of Symptoms) 1. Administer antipsychotic medication as prescribed MAINTENANCE AND STABILIZATION PHASES: 2. Observe client behavior closely 3. Set limits on inappropriate behavior -Psychosocial education 4. Increase reality testing when delusional or hallucinating -Relapse prevention skills 5. Do not touch without warning 6. Offer foods that are not easily contaminated 7. Assist with ADLs as needed 8. Supportive counseling 9. Milieu Therapy 10. Family psycho education TYPICAL (CLASSIC) ANTISYCHOTICS (Treatment of positive symptoms) ATYPICAL ANTIPSYCHOTICS (Treatment of both positive and negative symptoms) o HALDOL (Haloperidol) o ZYPREXA (Olanzapine) o THORAZINE (Chlorpromazine) o RISPERDAL (Risperidone) o PROLIXIN (Fluphenazine) o SEROQUEL (Quetiapine) o GEODONE (Ziprasidone) o SERENTIL (Mesoridazine)
o TRILAFON (Pherphenazine) o MELLARIL (Thioridazine)
CLORAZIL (Clozpine) ABILIFY (Aripriprazole)
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