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Chapter 33

Therapeutic Groups

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Characteristics That Influence a Group

Size Defined purpose

Degree of similarity among members


Rules Boundaries Content (what is said in the group) Process (underlying dynamics among group members)

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Therapeutic Factors Common to All Groups


Instillation of hope

Universality
Imparting of information Altruism Corrective recapitulation of primary family group Development of socializing techniques Imitative behavior Interpersonal learning Group cohesiveness Catharsis Existential resolution
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Phases of Group Development

Orientation phase Working phase Termination phase

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Group Member Roles

Task roles Maintenance roles Individual roles

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Group Leadership Responsibilities

Initiating Maintaining Terminating

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Styles of Leadership

Autocratic leader
Democratic leader Laissez-faire leader

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Basic Level Registered Nurse (Cont.)

Symptom-management groups Stress-management groups

Therapeutic community meeting groups


Support and self-help groups

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Dealing with Challenging Member Behaviors

Monopolizing member Complaining member who rejects help Demoralizing member Silent member

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Chapter 34
Family Interventions

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Characteristics of Family Function

Ability to provide for safety of members Quality of resources and support systems Underlying issues Cultural concerns Developmental needs

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Characteristics of Family Function (Cont.)

Patterns of behavior and interaction Responses to stressors

Ability to interact with support services


Parenting skill Relationships and interactions Overall flexibility or resilience

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Types of Families

Nuclear family Single parent family Unmarried biological or adoptive family Blended family Cohabitating family

Extended family

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Family Functions

Management Boundaries
Clear

Diffuse or enmeshed
Rigid or disengaged

Communication Emotional-supportive

Socialization

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Overview of Family Therapy

Insight-oriented family therapy


Focuses on developing increased self, other, and family awareness among family members

Behavioral family therapy


Focuses on changing behaviors of family members to influence overall patterns of family interactions

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Concepts Central to Family Therapy

Identified patient Family triangles

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Nursing Process

Diagnosis

Implementation
Counseling and communication techniques
Nonjudgmental manner promotes open and flexible communication Perspective of each family member is elicited and heard

Pharmacological interventions

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Outcomes Identification
Reduce dysfunctional behavior of individual family members and resolve or reduce conflicts Mobilize family resources, encourage adaptive family problem-solving behaviors, improve familys communication skills, heighten awareness and sensitivity to other family members emotional needs

Strengthen familys ability to cope with major life stressors and traumatic events, including chronic physical or psychiatric illness
Improve integration of family system into societal system

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Chapter 10
Understanding and Managing Responses to Stress

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Introduction

Definition of stress Stress responses and psychiatric disorders The interface between stress and all health alterations

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Early Stress-Response Theories

Fight-or-flight response
Body prepares for situation that individual perceives as threat to survival New research indicates that men and women have different neural responses to stress

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Stress Responses

Neurotransmitter Stress Response Serotonin synthesis more active May impair serotonin receptor sites and brains ability to use serotonin Immune Stress Response Interaction between nervous system and immune system during alarm phase of GAS

Negatively affects bodys ability to produce protective factors

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Mediators of the Stress Response

Stressors
Physical Psychological

Perception Individual temperament Social support


Support groups

Culture
Spirituality and religious beliefs

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Managing Stress Through Relaxation Techniques


Deep breathing exercises Progressive muscle relaxation Relaxation response Meditation Guided imagery

Biofeedback
Physical exercise Cognitive reframing

Journaling
Humor
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Chapter 15
Anxiety and ObsessiveCompulsive Related Disorders

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Anxiety

Anxiety Apprehension, uneasiness, uncertainty, or dread from real or perceived threat Fear Reaction to specific danger Normal anxiety Necessary for survival Levels of Anxiety

Mild anxiety
Moderate anxiety Severe anxiety Panic

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Defenses Against Anxiety

Defense mechanisms
Automatic coping styles
Protect people from anxiety Maintain self-image by blocking
Feelings

Conflicts
Memories

Can be healthy or unhealthy

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Clinical Picture

Separation anxiety disorder


Developmentally inappropriate levels of concern over being away from a significant other

Panic disorder
Panic attacks

Agoraphobia
Excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing

Specific phobias

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Clinical Picture (Cont.)

Social anxiety disorder


Severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others

Generalized anxiety disorder


Excessive worry that lasts for months

Other anxiety disorders


Substance-induced anxiety disorder Anxiety due to a medical condition

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Obsessive-Compulsive Disorders

Obsessions
Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind

Compulsions
Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety

Obsessive-compulsive disorder Body dysmorphic disorder Hoarding disorder

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Anxiety Disorders

Epidemiology Comorbidity Etiology


Biological
Genetics

Neurobiological

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Application of the Nursing Process

Assessment
General assessment of symptoms

Self-assessment
Assessment guidelines: anxiety and obsessive-compulsive disorders

Nursing diagnosis Outcomes identification

Planning

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Application of the Nursing Process (Cont.)


Implementation

Mild to moderate levels of anxiety Severe to panic levels of anxiety


Counseling Teamwork and safety Promotion of self-care activities

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Implementation

Pharmacological interventions
Antidepressants Anti-anxiety drugs Other classes

Psychobiological interventions Integrative therapy Health teaching

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Other Interventions

Cognitive therapy Behavioral therapy


Relaxation training Modeling Systematic desensitization Flooding Response prevention Thought stopping

Cognitive-behavioral therapy
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Chapter 26
Crisis and Disaster

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Crisis
Profound disruption of normal psychological homeostasis Normal coping mechanisms fail Results in inability to function as usual Acute and time-limited Type of Crisis

Maturational
New developmental stage is reached Old coping skills no longer effective Leads to increased tension and anxiety

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Types of Crisis (Cont.)

Situational
Arise from events that are
Extraordinary External Often unanticipated

Adventitious
Unplanned and accidental
Natural disaster National disaster Crime of violence

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Outcomes of Crisis

Depend on
Realistic perception of the event Adequate situational supports
Crisis intervention

Adequate coping mechanisms

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Phases of Crisis Phase 1

Conflict or problem

Self-concept threatened
Increased anxiety Use of problem-solving techniques and defense mechanisms Resolve conflict or problem Reduce anxiety

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Phases of Crisis Phase 2

Defense mechanisms fail Threat persists Anxiety increases Feelings of extreme discomfort Functioning disorganized Trial-and-error attempt to solve problem and restore normal balance

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Phases of Crisis Phase 3

Trial-and-error attempts fail Anxiety can escalate to severe level or panic Automatic relief behaviors mobilized (i.e., withdrawal and flight)

Some form of resolution may be devised (i.e., compromising needs or redefining situation)

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Phases of Crisis Phase 4

Problem is unsolved and coping skills are ineffective Overwhelming anxiety

Possible serious personality disorganization, depression, confusion, violence against others, or suicidal behavior

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Application of the Nursing Process


Assessment
General assessment Assessment of perception of precipitating event Assessment of situational supports Assessment of personal coping skills Self assessment Ineffective coping

Outcomes identification

Implementation
Basic level
Patient safety Anxiety reduction
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Nursing Process (Cont.)

Crisis intervention
Primary care Secondary care Tertiary care

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Chapter 17
Somatic Symptom Disorders

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Clinical Picture

Somatic symptom disorder (SSD)


Illness anxiety disorder (previously hypochondriasis) Conversion disorder Psychological factors affecting medical condition

Factitious disorder

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Somatic Symptom Disorder

Distressing symptoms Maladaptive response Without significant physical findings and medical diagnosis Suffering is authentic High level of functional impairment

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Illness Anxiety Disorder

Misinterpretation of physical sensations Overconcerned for health and preoccupied with symptoms Extreme worry and fear

Course of illness chronic and relapsing

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Conversion Disorder

Neurological symptoms in the absence of a neurological diagnosis


Presence of deficits in voluntary motor or sensory functions Common symptomsparalysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, or episodes resembling epilepsy La belle indiffrence versus distress

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Application of the Nursing Process

Assessment
Psychosocial factors Coping skills

Spirituality and religion


Secondary gains Cognitive style Ability to communicate feelings and emotional needs

Dependence on medication
Self-assessment

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Application of the Nursing Process


Nursing diagnosis
Ineffective coping

Outcomes identification Interventions


Psychosocial interventions
Promotion of self-care activities Assertiveness training

Psychobiological interventions
Pharmacological interventions

Health teaching and health promotion

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Factitious Disorders

Artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury Goal of assuming a sick role Malingering

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Chapter 12
Schizophrenia and Schizophrenia Spectrum Disorders

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Schizophrenia
Epidemiology Lifetime prevalence of schizophrenia is 1% worldwide No difference related to
Race

Social status
Culture Comorbidity

Substance abuse disorders


Nicotine dependence

Anxiety, depression, and suicide Physical health or illness

Polydipsia
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Etiology
Biological factors
Genetics

Neurobiological
Dopamine theory Other neurochemical hypotheses

Brain structure abnormalities Psychological and environmental factors


Prenatal stressors Psychological stressors Environmental stressors

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Course of the Disorder

Prodromal Responses to treatment

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Phases of Schizophrenia

Phase I Acute
Onset or exacerbation of symptoms

Phase II Stabilization
Symptoms diminishing Movement toward previous level of functioning

Phase III Maintenance


At or near baseline functioning

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Assessment

During the prepsychotic phase General assessment


Positive symptoms
Negative symptoms Cognitive symptoms Affective symptoms

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Positive Symptoms

Alterations in thinking
Delusions False, fixed beliefs Concrete thinking Inability to think abstractly

Alterations in speech Associative looseness


Clang associations Word salad Neologisms Echolalia

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Positive Symptoms (Cont.)


Other disorders of thought or speech
Religiosity

Magical thinking
Paranoia Circumstantiality Tangentiality

Cognitive retardation
Alogia, or poverty of speech Flight of ideas Thought blocking

Thought insertion
Thought deletion

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Positive Symptoms (Cont.)

Alterations in perception
Depersonalization Derealization Hallucinations
Auditory
Command Visual

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Positive Symptoms (Cont.)


Alterations in Behavior

Catatonia Motor retardation Motor agitation

Echopraxia Negativism

Impaired impulse control


Gesturing or posturing Boundary impairment

Stereotyped behaviors
Waxy flexibility

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Negative Symptoms

Affect
Flat
Blunted Inappropriate Bizarre

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Cognitive Symptoms

Difficulty with
Attention Memory Information processing Cognitive flexibility Executive functions

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Affective Symptoms

Assessment for depression is crucial


May herald impending relapse
Increases substance abuse Increases suicide risk Further impairs functioning

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Outcomes Identification
Phase I Acute
Patient safety and medical stabilization

Phase II Stabilization
Help patient understand illness and treatment Stabilize medications Control or cope with symptoms

Phase III Maintenance


Maintain achievement Prevent relapse Achieve independence, satisfactory quality of life

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Planning

Phase I Acute
Best strategies to ensure patient safety and provide symptom stabilization

Phase II Stabilization Phase III Maintenance


Provide patient and family education Relapse prevention skills are vital

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Interventions

Acute Phase
Psychiatric, medical, and neurological evaluation
Psychopharmacological treatment Support, psychoeducation, and guidance Supervision and limit setting in the milieu

Monitor fluid intake

Stabilization and Maintenance Phases


Medication administration/adherence Relationships with trusted care providers

Community-based therapeutic services

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Interventions Counseling and communication techniques


Hallucinations Delusions Associative looseness Health teaching and health promotion

Psychobiological Interventions
Antipsychotic medications
First-generation Second-generation Third-generation

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First-Generation Antipsychotics
Dopamine antagonists (D2 receptor antagonists)

Target positive symptoms of schizophrenia


Advantage
Less expensive than second generation

Disadvantages
Extrapyramidal side effects (EPS)
Anticholinergic side effects Tardive dyskinesia Weight gain, sexual dysfunction, endocrine disturbances

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Second-Generation Antipsychotics

Treat both positive and negative symptoms

Minimal to no extrapyramidal side effects (EPS) or tardive dyskinesia


Disadvantage tendency to cause significant weight gain

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Third-Generation Antipsychotic

Aripiprazole (Abilify)

Dopamine system stabilizer


Improves positive and negative symptoms and cognitive function
Little risk of EPS or tardive dyskinesia

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Potentially Dangerous Responses to Antipsychotics


Anticholinergic toxicity Neuroleptic malignant syndrome (NMS) Agranulocytosis

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Adjuncts to Antipsychotic Drug Therapy

Antidepressants Mood stabilizing agents

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Other Interventions

Individual and group therapy Psychoeducation

Medication prescription and monitoring


Basic health assessment Cognitive remediation Family therapy

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