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Mental Health Test 3 [Monday 4/3/17]

Terms in this set (324)

Crisis precipitated by an unexpected external stressor over which the individual has little or no control and as a result of which he or she feels emotionally overwhelmed and defeated.
- EXAMPLE: Sally is a waitperson whose shift ended at midnight. Two weeks ago, while walking to her car in the deserted parking lot, she was abducted by two men with guns, taken to an abandoned building, and raped and beaten. Since that time, her physical wounds have nearly healed. However, Sally cannot be alone, is constantly fearful, relives the experience in flashbacks and dreams, and is unable to eat, sleep, or work at her job in the restaurant. Her friend offers to accompany her to the mental health clinic.

- Intervention: The nurse should offer Sally the opportunity to talk about the experience and to express her feelings about the trauma when she demonstrates readiness. The nurse should offer reassurance and support; discuss stages of grief and how rape may precipitate feelings of loss, including loss of control, loss of power, and loss of a sense of self-worth, triggering the grief response; identify support systems that can help Sally to resume her normal activities; and explore new methods of coping with emotions arising from a situation with which she has had no previous experience. These interventions should be conducted in an environment that is sensitive to the impact of trauma on a person's sense of self. All interventions should convey dignity, respect, and hopefulness and promote the client's empowerment to make choices in his or her care
A crisis that is influenced or triggered by preexisting psychopathology. Examples of psychopathology that may precipitate crises include personality disorders, anxiety disorders, bipolar disorder, and schizophrenia. (can get hospitalized)
- EXAMPLE: Sonja, age 29, was diagnosed with borderline personality disorder at age 18. This disorder is believed to be rooted in deep fear of abandonment. She has been in therapy on a weekly basis for 10 years, with several hospitalizations for suicide attempts during that time. She has had the same therapist for the past 6 years. This therapist told Sonja today that she is to be married in 1 month and will be moving across the country with her new husband. Sonja is distraught, stating that no one cares about her and that she would be better off dead. She is found wandering in and out of traffic on a busy expressway, oblivious to her surroundings. Police bring her to the emergency department of the hospital.

- Intervention: The initial goal is to reduce Sonja's anxiety. She requires that someone stay with her and reassure her of her safety and security. After the feelings of panic and anxiety have subsided, she should be encouraged to verbalize her feelings of abandonment. Regressive behaviors should be discouraged. Positive reinforcement should be given for independent activities and accomplishments.
- The primary therapist will need to pursue this issue of termination with Sonja and facilitate transfer of services to another therapist or treatment program. Hospitalization may be necessary to maintain patient safety.
Crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility for their behavior. Examples include acutely suicidal individuals, drug overdoses, reactions to hallucinogenic drugs, acute psychoses, uncontrollable anger, and alcohol intoxication. (can get hospitalized for it)
- EXAMPLE: Jennifer, age 14, had been dating Joe, the star high school football player, for 6 months. After the game on Friday night, Jennifer and Joe went to Jackie's house, where a number of high school students had gathered for an after-game party. No adults were present. About midnight, Joe told Jennifer that he did not want to date her anymore. Jennifer became hysterical, and Jackie was frightened by her behavior. She took Jennifer to her parent's bedroom and gave her a Valium from a bottle in her mother's medicine cabinet. She left Jennifer lying on her parent's bed and returned to the party downstairs. About an hour later, she returned to her parent's bedroom and found that Jennifer had removed the bottle of Valium from the cabinet and swallowed all of the tablets. Jennifer was unconscious and Jackie could not awaken her. An ambulance was called, and Jennifer was transported to the local hospital.

- Intervention: Emergency medical care, including monitoring vital signs, ensuring maintenance of adequate airway, and initiating gastric lavage and/or activated charcoal, is the priority in this case. Jennifer is a minor, so notifying the parents is essential as well. Inpatient hospitalization is justifiable to assure patient safety. Discussing feelings about self-esteem, rejection, and loss will help Jennifer explore more adaptive methods of dealing with stressful situations.
1. Remain calm when dealing with an angry client. - Anger expressed by the nurse will most likely incite increased anger in client.
2. Set verbal limits on behavior. Clearly delineate the consequences of inappropriate expression of anger, and always follow through. - Consistency in enforcing the consequences is essential if positive outcomes are to be achieved. Inconsistency creates confusion and encourages testing of limits.
3. Have client keep a diary of angry feelings, what triggered them, and how they were handled. - Journaling provides a more objective measure of the problem.
4. Avoid touching client when he or she becomes angry. - Client may view touch as threatening and could become violent.
5. Help client determine the true source of the anger. - Many times anger is being displaced onto a safer object or person. If resolution is to occur, the first step is to identify the source of the problem.
6. It may be constructive to ignore initial derogatory remarks by client. - Lack of feedback often extinguishes an undesirable behavior.
7. Help client find alternative ways to release tension, such as physical outlets, and more appropriate ways to express anger, such as seeking out staff when feelings emerge. - Client will likely need assistance to problem-solve more appropriate ways of behaving.
8. Role model appropriate ways to express anger assertively, such as, "I dislike being called names. I get angry when I hear you saying those things about me." - Role modeling is one of the strongest methods of learning.
1. Observe client for escalation of anger (called the prodromal syndrome): increased motor activity, pounding, slamming, tense posture, defiant affect, clenched teeth and fists, arguing, demanding, and challenging or threatening staff. - Violence may be prevented if risks are identified in time.
2. When these behaviors are observed, first ensure that sufficient staff are available to help with a potentially violent situation. Attempt to defuse the anger beginning with the least restrictive means. - The initial consideration must be having enough help to diffuse a potentially violent situation. Client rights must be honored, while preventing harm to client and others.
3. Techniques for dealing with aggression include: - Aggression control techniques promote safety and reduce risk of harm to client and others:
a. Talking down. Say, "John, you seem very angry. Let's go to your room and talk about it." (Ensure that client does not position self between door and nurse.) - Promotes a trusting relationship and may prevent client's anxiety from escalating.
b. Physical outlets. "Maybe it would help if you punched your pillow or the punching bag for a while" or "I'll stay here with you if you want." - Provides effective way for client to release tension associated with high levels of anger.
c. Medication. If agitation continues to escalate, offer client choice of taking medication voluntarily. If he or she refuses, reassess the situation to determine if harm to self or others is imminent. - Tranquilizing medication may calm client and prevent violence from escalating.
d. Call for assistance. Remove self and other clients from the immediate area. Call violence code, push "panic" button, call for assault team, or institute measures established by the institution. Sufficient staff to indicate a show of strength may be enough to de-escalate the situation, and client may agree to take the medication. - Client and staff safety are of primary concern. Many states, accrediting bodies, and/or facilities require that staff members working with hospitalized psychiatric patients be trained and/or certified in psychiatric emergency interventions to assure that the strategies used are in the best interest of staff and patient safety.
e. Seclusion or restraints. If client is not calmed by talking down or by medication, use of mechanical restraints and/or seclusion may be necessary. Be sure to have sufficient staff available to assist and appropriately deal with an out-of-control client. Follow protocol for restraints/seclusion established by the institution. Restraints should be used as a last resort, after all other interventions have been unsuccessful and client is clearly at risk of harm to self or others. - Clients who do not have internal control over their own behavior may require external controls, such as mechanical restraints, in order to prevent harm to self or others.
f. Observation and documentation. Hospital policy typically dictates the requirements for observation of client in restraints. Basic safety principles include that client in restraints should be observed throughout the period of restraint. Every 15 minutes, client should be monitored to ensure that circulation to extremities is not compromised (check temperature, color, pulses). Assist client with needs related to nutrition, hydration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. Document all observations. - Client well-being is a nursing priority.
g. Ongoing assessment. As agitation decreases, assess client's readiness for restraint removal or reduction. With assistance from other staff members, remove one restraint at a time, while assessing client's response. This measure minimizes the risk of injury to client and staff. - Gradual removal of the restraints allows for testing of client's self-control. Client and staff safety are of primary concern, as is assuring that the patient is offered the least restrictive treatment option effective in maintaining safety.
h. Debriefing. It is important when a client loses control for staff to follow-up with a discussion about the situation. This discussion should occur with client and among other staff. The staff should discuss factors that necessitated the crisis intervention, factors that contributed to the failure of less restrictive interventions, and staff's thoughts about the safety and effectiveness of the intervention.When client has regained control, a debriefing should occur in which client is encouraged to discuss thoughts about what contributed to the crisis situation and about staff interventions, and to explore strategies to avert a crisis situation in the future. It is also important to discuss the situation with other clients who witnessed the episode so they understand and process what happened. Some clients may fear that they could be at risk for experiencing a crisis or that they might be in danger when someone else's behavior becomes aggressive. - helps to process the impact of the intervention. Mutual feedback is shared; staff and client have an opportunity to process and learn from the event.
Use a reality-oriented approach. The focus of the problem is on the here and now.
Remain with the individual who is experiencing panic anxiety.
Establish a rapid working relationship by showing unconditional acceptance, by active listening, and by attending to immediate needs.
Discourage lengthy explanations or rationalizations of the situation; promote an atmosphere for verbalization of true feelings.
Set firm limits on aggressive, destructive behaviors. At high levels of anxiety, behavior is likely to be impulsive and regressive. Establish at the outset what is acceptable and what is not, and maintain consistency.
Clarify the problem that the individual is facing. The nurse does this by describing his or her perception of the problem and comparing it with the individual's perception of the problem.
Help the individual determine what he or she believes precipitated the crisis.
Acknowledge feelings of anger, guilt, helplessness, and powerlessness without judgment.
Guide the individual through a problem-solving process by which he or she may move in the direction of positive life change:
Help the individual confront the factors that are contributing to the experience of crisis.
Encourage the individual to discuss changes he or she would like to make. Jointly determine whether or not desired changes are realistic.
Encourage exploration of feelings about aspects that cannot be changed, and explore alternative ways of coping more adaptively in these situations.
Discuss alternative strategies for creating changes that are realistically possible.
Weigh benefits and consequences of each alternative.
- Assist the individual to select alternative coping strategies that will help alleviate future crisis situations.
- Identify external support systems and new social networks from which the individual may seek assistance in times of stress.
- CLINICAL PEARL Coping mechanisms are highly individual and the choice ultimately must be made by the client. The nurse may offer suggestions and provide guidance to help the client identify coping mechanisms that are realistic for him or her, and that can promote positive outcomes in a crisis situation
1. Determine degree of anxiety/fear present, associated behaviors (e.g., laughter, crying, calm or agitation, excited/hysterical behavior, expressions of disbelief and/or self-blame), and reality of perceived threat.
1. Clearly understanding client's perception is pivotal to providing appropriate assistance in overcoming the fear. Individual may be agitated or totally overwhelmed. Panic state increases risk for client's own safety as well as the safety of others in the environment.
2. Note degree of disorganization.
2. Client may be unable to handle activities of daily living or work requirements and may need more intensive intervention.
3. Create as quiet an area as possible. Maintain a calm, confident manner. Speak in even tone using short, simple sentences.
3. Decreases sense of confusion or overstimulation; enhances sense of safety. Helps client focus on what is said, and reduces transmission of anxiety.
4. Develop trusting relationship with client.
4. Trust is the basis of a therapeutic nurse-client relationship and enables them to work effectively together.
5. Identify whether incident has reactivated preexisting or coexisting situations (physical or psychological).
5. Concerns and psychological issues are recycled every time trauma is re-experienced, and they affect how client views the current situation.
6. Determine presence of physical symptoms (e.g., numbness, headache, tightness in chest, nausea, and pounding heart).
6. Physical problems need to be differentiated from anxiety symptoms so appropriate treatment can be given.
7. Identify psychological responses (e.g., anger, shock, acute anxiety, panic, confusion, denial). Record emotional changes.
7. Although these are normal responses at the time of the trauma, they will recycle repeatedly until they are dealt with adequately.
8. Discuss with client the perception of what is causing the anxiety.
8. Increases client's ability to connect symptoms to subjective feeling of anxiety, providing opportunity to gain insight/control and make desired changes.
9. Assist client to correct any distortions being experienced. Share perceptions with client.
9. Perceptions based on reality help to decrease fearfulness. How the nurse views the situation may help client to see it differently.
10. Explore with client or significant other the manner in which client has previously coped with anxiety-producing events.
10. May help client regain sense of control and recognize significance of trauma.
11. Engage client in learning new coping behaviors (e.g., progressive muscle relaxation, thought-stopping)
11. Replacing maladaptive behaviors can enhance ability to manage and deal with stress. Interrupting obsessive thinking allows client to use energy to address underlying anxiety, whereas continued rumination about the incident can retard recovery.
12. Encourage use of techniques to manage stress and vent emotions such as anger and hostility.
12. Reduces the likelihood of eruptions that can result in abusive behavior.
13. Give positive feedback when client demonstrates better ways to manage anxiety and is able to calmly and realistically appraise the situation.
13. Provides acknowledgment and reinforcement, encouraging use of new coping strategies. Enhances client's ability to deal with fearful feelings and gain control over situation, promoting future successes.
14. Administer medications as indicated: Antianxiety—diazepam, alprazolam, oxazepam. Antidepressants—fluoxetine, paroxetine, bupropion.
14. Antianxiety medication provides temporary relief of anxiety symptoms, enhancing ability to cope with situation. Antidepressants lift mood and help suppress intrusive thoughts and explosive anger.
1. Determine client's religious/spiritual orientation, current involvement, and presence of conflicts.
1. Provides baseline for planning care and accessing appropriate resources.
2. Establish environment that promotes free expression of feelings and concerns. Provide calm, peaceful setting when possible.
2. Promotes awareness and identification of feelings so they can be dealt with.
3. Listen to client's and significant others' expressions of anger, concern, alienation from God, belief that situation is a punishment for wrongdoing, and similar concerns.
3. It is helpful to understand client's and significant others' points of view and how they are questioning their faith in the face of tragedy.
4. Note sense of futility, feelings of hopelessness and helplessness, lack of motivation to help self.
4. These thoughts and feelings can result in client feeling paralyzed and unable to move forward to resolve the situation.
5. Listen to expressions of inability to find meaning in life and reason for living. Evaluate for suicidal ideation.
5. May indicate need for further intervention to prevent suicide attempt.
6. Determine support systems available to client.
6. Presence or lack of support systems can affect client's recovery.
7. Ask how you can be most helpful. Convey acceptance of client's spiritual beliefs and concerns.
7. Promotes trust and comfort, encouraging client to be open about sensitive matters.
8. Make time for nonjudgmental discussion of philosophic issues and questions about spiritual impact of current situation.
8. Helps client begin to look at basis for spiritual confusion. Note: There is a potential for care provider's belief system to interfere with client finding own way. Therefore, it is most beneficial to remain neutral and not espouse own beliefs.
9. Discuss difference between grief and guilt, and help client to identify and deal with each, assuming responsibility for own actions, expressing awareness of the consequences of acting out of false guilt.
9. Blaming self for what has happened impedes dealing with the grief process and needs to be discussed and dealt with.
10. Use therapeutic communication skills of reflection and active listening.
10. Helps client find own solutions to concerns.
11. Encourage client to experience meditation, prayer, and forgiveness. Provide information that anger with God is a normal part of the grieving process.
11. This can help to heal past and present pain.
12. Assist client to develop goals for dealing with life situation.
12. Enhances commitment to goal, optimizing outcomes and promoting sense of hope.
13. Identify and refer to resources that can be helpful, such as pastoral/parish nurse or religious counselor, crisis counselor, psychotherapy, Alcoholics Anonymous and/or Narcotics Anonymous.
13. Specific assistance may be helpful to recovery (e.g., relationship problems, substance abuse, suicidal ideation).
14. Encourage participation in support groups.
14. Discussing concerns and questions with others can help client resolve feelings.
1. Determine involvement in event (e.g., survivor, significant other, rescue/aid worker, health-care provider, family member).
1. All those concerned with a traumatic event are at risk for emotional trauma and have needs related to their involvement in the event. Note: Close involvement with victims affects individual responses and may prolong emotional suffering.
2. Evaluate current factors associated with the event, such as displacement from home due to illness/injury, natural disaster, or terrorist attack. Identify how client's past experiences may affect current situation.
2. Affects client's reaction to current event and is basis for planning care and identifying appropriate support systems and resources.
3. Listen for comments of taking on responsibility (e.g., "I should have been more careful or gone back to get her") - Statements such as these are indicators of "survivor's guilt" and blaming self for actions.
4. Identify client's current coping mechanisms. - Noting positive or negative coping skills provides direction for care.
5. Determine availability and usefulness of client's support systems, family, social contacts, and community resources.
5. Family and others close to client may also be at risk and require assistance to cope with the trauma.
6. Provide information about signs and symptoms of posttrauma response, especially if individual is involved in a high-risk occupation.
6. Awareness of these factors helps individual identify need for assistance when signs and symptoms occur.
7. Identify and discuss client's strengths as well as vulnerabilities.
7. Provides information to build on for coping with traumatic experience.
8. Evaluate individual's perceptions of events and personal significance (e.g., rescue worker trained to provide lifesaving assistance but recovering only dead bodies).
8. Events that trigger feelings of despair and hopelessness may be more difficult to deal with, and require long-term interventions.
9. Provide emotional and physical presence by sitting with client/significant other and offering solace. - Strengthens coping abilities.
10. Encourage expression of feelings. Note whether feelings expressed appear congruent with events experienced. - It is important to talk about the incident repeatedly. Incongruencies may indicate deeper conflict and can impede resolution.
11. Note presence of nightmares, reliving the incident, loss of appetite, irritability, numbness and crying, and family or relationship disruption. - These responses are normal in the early, post-incident time frame. If prolonged and persistent, they may indicate need for more intensive therapy.
12. Provide a calm, safe environment.
12. Helps client deal with the disruption in his or her life.
13. Encourage and assist client in learning stress-management techniques.
13. Promotes relaxation and helps individual exercise control over self and what has happened.
14. Recommend participation in debriefing sessions that may be provided following major disaster events.
14. Dealing with the stresses promptly may facilitate recovery from the event or prevent exacerbation.
15. Identify employment, community resource groups.
15. Provides opportunity for ongoing support to deal with recurrent feelings related to the trauma.
16. Administer medications as indicated, such as antipsychotics (e.g., chlorpromazine, haloperidol, olanzapine, or quetiapine) or carbamazepine (Tegretol).
16. Low doses of antipsychotics may be used for reduction of psychotic symptoms when loss of contact with reality occurs, usually for clients with especially disturbing flashbacks. Carbamazepine may be used to alleviate intrusive recollections or flashbacks, impulsivity, and violent behavior.
1. Evaluate community activities related to meeting collective needs within the community and between the community and the larger society. Note immediate needs, such as health care, food, shelter, funds.
1. Provides a baseline to determine community needs in relation to current concerns or threats.
2. Note community reports of functioning, including areas of weakness or conflict.
2. Provides a view of how the community sees these areas.
3. Identify effects of related factors on community activities.
3. In the face of a current threat, local or national, community resources need to be evaluated, updated, and given priority to meet the identified need.
4. Determine availability and use of resources. Identify unmet demands or needs of the community.
4. Information is necessary to identify what else is needed to meet the current situation.
5. Determine community strengths.
5. Promotes understanding of the ways in which the community is already meeting the identified needs.
6. Encourage community members and groups to engage in problem-solving activities.
6. Promotes a sense of working together to meet community needs.
7. Develop a plan jointly with the members of the community to address immediate needs.
7. Deals with deficits in support of identified goals.
8. Create plans managing interactions within the community and between the community and the larger society.
8. Meets collective needs when the concerns or threats are shared beyond a local community.
9. Make information accessible to the public. Provide channels for dissemination of information to the community as a whole (e.g., print media, radio and television reports and community bulletin boards, Internet sites, speaker's bureau, reports to committees, councils, advisory boards).
9. Readily available, accurate information can help citizens deal with the situation.
10. Make information available in different modalities and geared to differing educational levels and cultures of the community.
10. Using languages other than English and making written materials accessible to all members of the community promotes understanding.
11. Seek out and evaluate needs of underserved populations.
11. Homeless and those residing in lower income areas may have special requirements that need to be addressed with additional resources.
The term was coined in 1908 by the Swiss psychiatrist Eugen Bleuler, the word was derived from the Greek "skhizo" (split) and "phren" (mind)
- Schizophrenia is an imbalance of the brain which leads to altered thoughts. (chemical imbalance)!!!
- It is important to develop trusting relationships with clients. Accept, be calm, be reliable and honest in all communications!
- is probably not a homogeneous disease entity, DSM-5 supports this concept by describing schizophrenia as the schizophrenia spectrum, schizophrenia spectrum disorders may have several causative factors:
genetic predisposition,
biochemical dysfunction
physiological factors
psychosocial stress
- there is not now and probably never will be a single treatment that cures the disorder, instead, effective treatment requires a comprehensive, multidisciplinary effort, including pharmacotherapy and various forms of psychosocial care, such as living skills and social skills training, rehabilitation and recovery, and family therapy
- of all the mental illnesses that cause suffering in society, schizophrenia probably is responsible for lengthier hospitalizations, GREATER chaos in family life, more exorbitant costs to individuals and governments, and MORE fears than any other
- bc it is such an enormous threat to life and happiness and because its causes are an unsolved puzzle it has probably been studied more than any other mental disorder
- potential for suicide is a major concern among patients with schizophrenia
- about 1/3 of people with schizophrenia attempt suicide and about 1 in 10 die from the act
- perhaps NO psychological disorder is more crippling than schizophrenia.
- characteristically disturbances in:
thought processes
perception
affect
invariably result in a severe deterioration of social and occupational functioning
- lifetime prevalence of schizophrenia is about 1% in the general population
- symptoms generally appear in late adolescence or early adulthood, although they may occur in middle or late adult life
- symptoms that occur before age 17 suggest early-onset schizophrenia (EOS), and when symptoms occur before age 13, which is very rare, the condition is identified as very early-onset schizophrenia
- some studies have indicated that symptoms occur earlier in MEN than in women
- the pattern of development of schizophrenia may be viewed in four phases: premorbid, prodromal, active psychotic (schizophrenia), and residual.
- signs are differentiated from premorbid signs in that prodromal symptoms MORE clearly manifest as signs of the developing illness of schizophrenia
- begins with a change from premorbid functioning and extends until the onset of frank psychotic symptoms
- can be as brief as a few weeks or months, but most studies indicate that the average length of the prodromal phase is b/w 2-5 years
- the individual begins to show signs of significant deterioration in function
- 50% complain of depressive symptoms
- Social withdrawal is not uncommon, and signs of cognitive impairment may begin to emerge
- some adolescent pts develop sudden onset of OCD behavior (which can be misdiagnosed for normal behavior)
- recognition of the behaviors associated with the prodromal phase provides an opportunity for early intervention with a possibility for improvement in long-term outcomes
- current txt guidelines suggest therapeutic interventions that offer support with identified problems, cognitive therapies to minimize functional impairment, family interventions to improve coping, and involvement with the schools to reduce the possibility of failure
- some controversy exists as to the benefit of using pharmaceutical therapy during the prodromal phase; however, evidence supports that comprehensive treatment begun at the time of the first psychotic episode is associated with better outcomes

Deterioration in role functioning and social withdrawal
Substantial functional impairment
Sleep disturbance, anxiety, irritability
Depressed mood, poor concentration, fatigue
Perceptual abnormalities, ideas of reference (tv talking to them), and suspiciousness herald onset of psychosis
May be brief
Don't want to take a bath, etc
active phase of the disorder, psychotic symptoms are prominent
Diagnostic criteria for schizophrenia:
A. 2 (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avolition) [Impairment in work, social relations, and self-care]
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

- Specify if: First episode, currently in acute, partial, or full remission; Multiple episodes, currently in acute, partial or full remission; Continuous; Unspecified; With catatonia
- Specify current severity.
- abnormalities in the neurotransmitters norepinephrine, serotonin, acetylcholine, and gamma-aminobutyric acid and in the neuroregulators, such as prostaglandins and endorphins, have been suggested
- Excess of serotonin has been hypothesized to be responsible for both positive and negative symptoms of schizophrenia, and the effectiveness of medications such as clozapine (a strong serotonin antagonist) lends support to this hypothesis
- Recent research has implicated the neurotransmitter glutamate in the etiology of schizophrenia. The N-methyl-D-aspartate (NMDA) receptor is the receptor that is activated by the neurotransmitters glutamate and glycine. Psychopharmacological studies have shown that the drug class of glutamate antagonists (e.g., phencyclidine [PCP]; ketamine) can produce schizophrenic-like symptoms in individuals without the disorder (Hashimoto, 2006; Stahl, 2013). In one recent study, participants who were experiencing ketamine-induced schizophrenia-like psychotic symptoms were treated with a drug trial of a glycine transporter-1 inhibitor (D'Souza et al., 2012). This medication was shown to reduce the psychotic symptoms induced by the NMDA receptor antagonism of the ketamine, so it has been hoped that this drug may have benefits in the treatment of schizophrenia as well. So far, while there is evidence of a glutamate link in schizophrenia (Hu et al., 2014) more research is needed on the implications for treatment. Currently available conventional antipsychotic medications largely target the dopamine receptors in the brain. Newer, second-generation antipsychotics have strong affinity for serotonergic receptors. The glutamate model of schizophrenia suggests possibilities for new therapeutic target options, including NMDA agonists, glycine transport inhibitors, and metabotropic glutamate receptor agonists
The existence of prominent, nonbizarre delusions
is characterized by the presence of delusions that have been experienced by the individual for at least 1 month
If present at all, hallucinations are not prominent, and behavior is not bizarre.
The subtype of delusional disorder is based on the predominant delusional theme.
a specifier may be added to denote whether the delusions are considered bizarre (i.e., whether the thought is "clearly implausible, not understandable, and not derived from ordinary life experiences"

1. Erotomanic type. The individual believes that someone, usually of a higher status, is in love with him or her. Famous persons are often the subjects of erotomanic delusions. Sometimes the delusion is kept secret, but some individuals may follow, contact, or otherwise try to pursue the object of their delusion.
2. Grandiose type. Irrational ideas regarding own worth, talent, knowledge, or power. They may believe that they have a special relationship with a famous person or even assume the identity of a famous person (believing that the actual person is an imposter). Grandiose delusions of a religious nature may lead to assumption of the identity of a deity or religious leader.
3. Jealous type. Irrational idea that the person's sexual partner is unfaithful. The idea is irrational and without cause, but the individual with the delusion searches for evidence to justify the belief. The sexual partner is confronted (and sometimes physically attacked) regarding the imagined infidelity. The imagined "lover" of the sexual partner also may be the object of the attack. Attempts to restrict the autonomy of the sexual partner in an effort to stop the imagined infidelity are common.
4. Persecutory type. The most common type. The individual believes he or she is being malevolently treated in some way. Frequent themes include being plotted against, cheated or defrauded, followed and spied on, poisoned, or drugged. The individual may obsess about and exaggerate a slight rebuff (either real or imagined) until it becomes the focus of a delusional system. Repeated complaints may be directed at legal authorities, lack of satisfaction from which may result in violence toward the object of the delusion.
5. Somatic type. The individual has an irrational belief that he or she has some physical defect, disorder, or disease. believe they have some type of general medical condition.
6. Mixed Type. When the disorder is mixed, delusions are prominent, but NO single theme is predominant.
- delusions: false personal beliefs that are inconsistent with the person's intelligence or cultural background, the individual continues to have the belief in spite of obvious proof that it is false or irrational, are subdivided according to their content
1. Delusion of persecution: The individual feels threatened and believes that others intend harm or persecution toward him or her in some way (e.g., "The FBI has 'bugged' my room and intends to kill me"; "I can't take a shower in this bathroom; the nurses have put a camera in there so that they can watch everything I do").
2. Delusion of grandeur: The individual has an exaggerated feeling of importance, power, knowledge, or identity (e.g., "I am Jesus Christ").
3. Delusion of reference: All events within the environment are referred by the psychotic person to himself or herself (e.g., "Someone is trying to get a message to me through the articles in this magazine [or newspaper or TV program]; I must break the code so that I can receive the message"). Ideas of reference are less rigid than delusions of reference. An example of an idea of reference is irrationally assuming that, when in the presence of others, one is the object of their discussion or ridicule.
4. Delusion of control or influence: The individual believes certain objects or persons have control over his or her behavior (e.g., "The dentist put a filling in my tooth; I now receive transmissions through the filling that control what I think and do").
5. Somatic Delusion: The individual has a false idea about the functioning of his or her body (e.g., "I'm 70 years old, and I will be the oldest person ever to give birth. The doctor says I'm not pregnant, but I know I am").
6. Nihilistic delusion: The individual has a false idea that the self, a part of the self, others, or the world is nonexistent (e.g., "The world no longer exists"; "I have no heart").
- Paranoia Individuals with paranoia have extreme suspiciousness of others and of their actions or perceived intentions (e.g., "I won't eat this food. I know it has been poisoned").
- Magical Thinking With magical thinking, the person believes that his or her thoughts or behaviors have control over specific situations or people (e.g., the mother who believed if she scolded her son in any way, he would be taken away from her). Magical thinking is common in children (e.g., "It's raining; the sky is sad"; "It snowed last night because I wished very, very hard that it would").
1. Associative Looseness: Thinking is characterized by speech in which ideas shift from one unrelated subject to another. With associative looseness, the individual is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent (e.g., "We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere. No one needs a ticket to heaven. We have it all in our pockets").
2. Neologisms: The person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the individual (e.g., "She wanted to give me a ride in her new uniphorum").
3. Concrete Thinking: Concreteness, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking is very difficult. For example, the client with schizophrenia would have great difficulty describing the abstract meaning of sayings such as "I'm climbing the walls" or "It's raining cats and dogs."
4. Clang Associations: Choice of words is governed by sounds. Clang associations often take the form of rhyming. For instance, "It is very cold. I am cold and bold. The gold has been sold."
5. Word Salad: is a group of words that are put together randomly, without any logical connection (e.g., "Most forward action grows life double plays circle uniform").
6. Circumstantiality: individual delays in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met but only with numerous interruptions by the interviewer to keep the person on track of the topic being discussed.
7. Tangentiality: differs from circumstantiality in that the person never really gets to the point of the communication. Unrelated topics are introduced, and the focus of the original discussion is lost.
8. Mutism: is an individual's inability or refusal to speak.
9. Perseveration: The individual who exhibits perseveration persistently repeats the same word or idea in response to different questions.
1. Disturbed sensory perception - Impaired communication (inappropriate responses), disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in midsentence, tilts head to side as if to be listening
2. Disturbed thought processes
- Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others; inaccurate interpretation of the environment (#1 problem w/ schiz)
3. Social isolation - Withdrawal, sad dull affect, need-fear dilemma, preoccupation with own thoughts, expression of feelings of rejection or of aloneness imposed by others, uncommunicative, seeks to be alone
4. Risk for violence: Self-directed or other-directed - Risk factors: Aggressive body language (e.g., clenching fists and jaw, pacing, threatening stance); verbal aggression; catatonic excitement; command hallucinations; rage reactions; history of violence; overt aggressive acts; goal-directed destruction of objects in the environment; self-destructive behavior; active, aggressive suicidal acts
5. Impaired verbal communication - Loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing thoughts verbally, inappropriate verbalization, disordered unrealistic thinking!!!
6. Self-care deficit - Difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, and toileting
7. Disabled family coping - Neglectful care of client in regard to basic human needs or illness treatment, extreme denial or prolonged overconcern regarding client's illness, depression, hostility and aggression
8. Ineffective health maintenance - Inability to take responsibility for meeting basic health practices, history of lack of health-seeking behavior, lack of expressed interest in improving health behaviors, demonstrated lack of knowledge regarding basic health practices, anosognosia (lack of insight about illness)
9. Impaired home maintenance - Unsafe, unclean, disorderly home environment; household members express difficulty in maintaining their home in a safe and comfortable condition
1. Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping in midsentence). - Early intervention may prevent aggressive response to command hallucinations.
2. Avoid touching the client without warning him or her that you are about to do so. - Client may perceive touch as threatening and may respond in an aggressive manner.
3. An attitude of acceptance will encourage the client to share the content of the hallucination with you. - This is important to prevent possible injury to the client or others from command hallucinations.
4. Do not reinforce the hallucination. Use "the voices" instead of words like "they" that imply validation. Let client know that you do not share the perception. Say, "Even though I realize the voices are real to you, I do not hear any voices speaking." - It is important for the nurse to be honest, and the client must accept the perception as unreal before hallucinations can be eliminated.
5. Help the client understand the connection between increased anxiety and the presence of hallucinations. - If client can learn to interrupt escalating anxiety, hallucinations may be prevented.
6. Try to distract the client from the hallucination. - Involvement in interpersonal activities and explanation of the actual situation will help bring the client back to reality.
7. For some clients, auditory hallucinations persist after the acute psychotic episode has subsided. Listening to the radio or watching television helps distract some clients from attention to the voices. Others have benefited from an intervention called voice dismissal. With this technique, the client is taught to say loudly, "Go away!" or "Leave me alone!" in a conscious effort to dismiss the auditory perception. - These activities assist the client to exert some conscious control over the hallucination.
1. Convey acceptance of client's need for the false belief, but indicate that you do not share the belief. - Client must understand that you do not view the idea as real.
2. Do not argue or deny the belief. Use "reasonable doubt" as a therapeutic technique: "I understand that you believe this is true, but I personally find it hard to accept." - Arguing with the client or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded.
3. Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people. - Discussions that focus on the false ideas are purposeless and useless, and may even aggravate the psychosis.
4. If client is highly suspicious, the following interventions may be helpful: - To decrease client's suspiciousness:
a. Use same staff as much as possible; be honest and keep all promises. - Familiar staff and honesty promotes trust.
b. Avoid physical contact; warn client before touching to perform a procedure, such as taking a blood pressure - Suspicious clients often perceive touch as threatening and may respond in an aggressive or defensive manner.
c. Avoid laughing, whispering, or talking quietly where client can see but cannot hear what is being said. - Client may have ideas of reference and believe he or she is being talked about.
d. Provide canned food with can opener or serve food family style. - Suspicious clients may believe they are being poisoned and refuse to eat food from an individually prepared tray.
e. Mouth checks may be necessary following medication administration to verify whether the client is actually swallowing the pills. - Suspicious clients may believe they are being poisoned with their medication and attempt to discard the tablets or capsules.
f. Provide activities that encourage a one-to-one relationship with the nurse or therapist. - Competitive activities are very threatening to suspicious clients.
g. Maintain an assertive, matter-of-fact, yet genuine approach with suspicious clients. - Suspicious clients do not have the capacity to relate to, and therefore often feel threatened by a friendly or overly cheerful attitude.
1. Maintain low level of stimuli in client's environment (low lighting, few people, simple decor, low noise level). - Anxiety level rises in a stimulating environment. A suspicious, agitated client may perceive individuals as threatening.
2. Observe client's behavior frequently. Do this while carrying out routine activities. - Observation during routine activities avoids creating suspiciousness on the part of the client. Close observation is necessary so that intervention can occur if required to ensure client (and others') safety.
3. Remove all dangerous objects from client's environment. -Removal of dangerous objects prevents client, in an agitated, confused state, from using them to harm self or others.
4. Intervene at the first sign of increased anxiety, agitation or verbal or behavioral aggression. Offer empathetic response to the client's feelings: "You seem anxious (or frustrated or angry) about this situation. How can I help?" - Validation of the client's feelings conveys a caring attitude and offering assistance reinforces trust.
5. It is important to maintain a calm attitude toward the client. As the client's anxiety increases, offer some alternatives: participating in a physical activity (e.g., punching bag, physical exercise), talking about the situation, taking some antianxiety medication. - Offering alternatives to the client gives him or her a feeling of some control over the situation.
6. Have sufficient staff available to indicate a show of strength to the client if it becomes necessary. - This shows the client evidence of control over the situation and provides some physical security for staff.
7. If client is not calmed by "talking down" or by medication, use of mechanical restraints may be necessary. - The avenue of the "least restrictive alternative" must be selected when planning interventions for a violent client. Restraints should be used only as a last resort after all other interventions have been unsuccessful and the client is clearly at risk of harm to self or others.
8. If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow the protocol established by the institution. The Joint Commission requires that an in-person evaluation by a physician or other licensed independent practitioner (LIP) be conducted within 1 hour of the initiation of the restraint or seclusion. The physician or LIP must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents. - These interventions are necessary for the protection of client and staff.
9. The Joint Commission requires that the client in restraints be observed at least every 15 minutes to ensure that circulation to extremities is not compromised (check temperature, color, pulses); to assist the client with needs related to nutrition, hydration, and elimination; and to position the client so that comfort is facilitated and aspiration is prevented. Some institutions may require continuous one-to-one monitoring of restrained clients, particularly those who are highly agitated, and for whom there is a high risk of self- or accidental injury. - Client safety is a nursing priority.
10. As agitation decreases, assess the client's readiness for restraint removal or reduction. Remove one restraint at a time while assessing the client's response. - This minimizes the risk of injury to client and staff.
Use of role play to teach client appropriate eye contact, interpersonal skills, voice intonation, posture, and so on; aimed at improving relationship development
- aimed at improvement in social functioning

Social skills training is used to help clients manage struggles with interpersonal relationships and communication, which are often complicated by clients' inability to accurately perceive responses in others. Mueser, Bond, and Drake (2002) describe this training:
The basic premise of social skills training is that complex interpersonal skills involve the smooth integration of a combination of simpler behaviors, including nonverbal behaviors (e.g., facial expression, eye contact); paralinguistic features (e.g., voice loudness and affect); verbal content (i.e., the appropriateness of what is said); and interactive balance (e.g., response latency, amount of time talking). These specific skills can be systematically taught, and, through the process of shaping (i.e., rewarding successive approximations toward the target behavior), complex behavioral repertoires can be acquired.
Social dysfunction is a hallmark of schizophrenia. Impairment in interpersonal relations is included as part of the defining diagnostic criteria for schizophrenia in the DSM-5 (APA, 2013). Considerable attention is now being given to enhancement of social skills in these clients.
The educational procedure in social skills training focuses on role-play. A series of brief scenarios are selected. These should be typical of situations clients experience in their daily lives and be graduated in terms of level of difficulty. The health-care provider may serve as a role model for some behaviors. For example, "See how I sort of nod my head up and down and look at your face while you talk." This demonstration is followed by the client's role-playing. Immediate feedback is provided regarding the client's presentation. Only by countless repetitions does the response gradually become smooth and effortless.
Progress is geared toward the client's needs and limitations. The focus is on small units of behavior, and the training proceeds very gradually. Highly threatening issues are avoided, and emphasis is placed on functional skills that are relevant to activities of daily living. Milieu therapy, which focuses on the client's interaction within a social environment, may provide opportunities for social skills training.
Aimed at helping family members cope with long-term effects of the illness

Schizophrenia is an illness that can puzzle, disrupt, and sometimes tear apart families. Even when families appear to cope well, there is a notable impact on the mental and physical health of relatives when a family member has the illness.
The importance of the expanded role of family in the aftercare of relatives with schizophrenia has been recognized, thereby stimulating interest in family intervention programs designed to support the family system, prevent or delay relapse, and help to maintain the client in the community. These psychoeducational programs treat the family as a resource rather than a stressor, with the focus on concrete problem solving and specific helping behaviors for coping with stress. These programs recognize the biological basis for schizophrenia and the impact that stress has on the client's ability to function. By providing the family with information about the illness and suggestions for effective coping, psychoeducational programs reduce the likelihood of the client's relapse and the possible emergence of mental illness in previously nonaffected relatives.
Mueser and associates (2002) stated that although models of family intervention with schizophrenia differ in their characteristics and methods, effective treatment programs share a number of common features:
All programs are long term (usually 9 months to 2 years or more).
They all provide the client and family with information about the illness and its management.
They focus on improving adherence to prescribed medications.
They strive to decrease stress in the family and improve family functioning.

Asen (2002) suggested the following interventions with families of individuals with schizophrenia:
Forming a close alliance with the caregivers
Lowering the emotional intrafamily climate by reducing stress and burden on relatives
Increasing the ability of relatives to anticipate and solve problems
Reducing the expressions of anger and guilt by family members
Maintaining reasonable expectations for how the ill family member should perform
Encouraging relatives to set appropriate limits while maintaining some degree of separateness
Promoting desirable changes in the relatives' behaviors and belief systems

Family therapy typically consists of a brief program of family education about schizophrenia and a more extended program of family contact designed to reduce overt manifestations of conflict and to improve patterns of family communication and problem solving. The response to this type of therapy has been very dramatic. Studies have clearly revealed that a more positive outcome in the treatment of the client with schizophrenia can be achieved by including the family system in the program of care.
Assertive community treatment (ACT) is an evidence-based program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness such as schizophrenia.
- A case management-team approach that is individually tailored to teach clients basic living skills, help them work with community agencies, and assist clients in developing a social support network. Services are provided in the person's home, within the neighborhood, in local restaurants, parks, stores, or wherever assistance by the client is required.

- Some states use other terms for this type of treatment, such as mobile treatment teams (MTTs) and community support programs (CSPs). Assertive programs of treatment are individually tailored for each client, intended to be proactive, and include the teaching of basic living skills, helping clients work with community agencies, and assisting clients in developing a social support network. There is emphasis on vocational expectations, and supported work settings (i.e., sheltered workshops) are an important part of the treatment program. Other services include substance abuse treatment, psychoeducational programs, family support and education, mobile crisis intervention, and attention to health-care needs.
Responsibilities are shared by multiple team members, including psychiatrists, nurses, social workers, vocational rehabilitation therapists, and substance abuse counselors. Services are provided in the person's home, within the neighborhood, in local restaurants, parks, stores, or wherever assistance by the client is required. These services are available to the client 24 hours a day, 365 days a year, and this is considered a long-term intervention strategy.
ACT has been shown to reduce the number of hospitalizations and decrease costs of care for these clients. Although it has been called "paternalistic" and "coercive" by its critics, ACT has provided much-needed services to and improved quality of life for many clients who are unable to manage in a less-structured environment. One limitation is that treatment programs of this kind are time and labor intensive.
A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential
- research provides support for recovery as an OBTAINABLE objective for individuals with schizophrenia
- recovery from schizophrenia, in the sense of a state in which persons experience no difficulties associated with the illness, can occur but the modal outcome seems to be one in which difficulties linked to symptoms, social function, and work appear periodically but can be successfully confronted
- has been used primarily in caring for individuals with serious mental illness, such as schizophrenia and bipolar disorder, however concepts of the model are amenable to use with all individuals experiencing emotional conditions with which they require assistance and who have a desire to take control and manage their lives more independently.
- Weiden identifies 2 types of recovery with schizophrenia: functional and process
- Functional recovery focuses on the individual's level of functioning in such areas as relationships, work, independent living, and other kinds of life functioning, He or she may or may not be experiencing active symptoms of schizophrenia, recovery can also be considered as a process.
- With process recovery, there is no defined end point, but recovery is viewed as a process that continues throughout the individual's life and involves collaboration between the client and clinician.
- The individual identifies goals based on personal values or what he or she defines as giving meaning and purpose to life. The clinician and client work together to develop a treatment plan that is in alignment with the goals set forth by the client. In the process recovery model, the individual may still be experiencing symptoms.
- Patients do not have to be in remission, nor does remission automatically have to be a desired (or likely) goal when embarking on a recovery-oriented treatment plan.
- As long as the patient (and family) understands that a process recovery treatment plan is not to be confused with a promise of "cure" or even "remission," then one does not overpromise.
- The concept of recovery in schizophrenia remains controversial among clinicians, and many challenges lie ahead for continued study.
- Recovery models have similarities with ACT in that they both necessarily engage the support of multiple resources, but recovery models also highlight the dimension of active engagement and empowerment of the client in decision-making.
- Some argue that this approach is difficult to implement when the client lacks insight about his or her illness or the need for treatment. Further there is a lack of consistency in what constitutes "recovery," and many concepts exist. Still, the potential and hope is that, as these models become better studied and more clearly defined, they will provide a treatment approach that is comprehensive, protective, and supportive of patient-centered care.
a. Self-direction. Consumers lead, control, choose, and determine their own path of recovery.
b. Individualized and person-centered. Recovery is based on an individual's unique strengths, needs, preferences, experiences, and cultural background.
c. Empowerment. Individuals gain control of their own destiny and influence the organizational and societal structures in their lives.
d. Holistic. Recovery encompasses and individual's whole life, including mind, body, spirit, and community.
e. Nonlinear. Recovery is not a step-by-step process, but one based on continual growth, occasional setbacks, and learning from experience.
f. Strengths-based. Recovery builds on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of the individual, encouraging consumers to leave stymied life roles behind and engage in new life roles.
g. Peer support. Individuals provide each other with a sense of belonging, supportive relationships, values roles, and community.
h. Respect. Community, systems, and societal acceptance and appreciation of consumers are crucial in achieving recovery. Self-acceptance is particularly vital.
i. Responsibility. Consumers have a personal responsibility for their own self-care and journeys of recovery.
j. Hope. Recovery provides the essential motivating message of a better future-that people can and do overcome the barriers and obstacles that confront them.

The recovery model integrates services provided by professionals. services provided by consumers, and services provided in collaboration.
The RAISE approach to treatment for schizophrenia is based on a large National Institute of Mental Health (NIMH) initiative that began in 2008, and research findings published in 2015 demonstrated several benefits of this approach
- coordinated specialty care for first episode psychosis, With coordinated specialty care the young person experiencing first episode psychosis works with a team of specialists to create a personal treatment plan, combining recovery-oriented psychotherapy, low dose medication management, family education and support, case management, and work or education support.
- Coordinated specialty care emphasizes shared decision making, including family members when possible.
- incorporates many elements from other treatment approaches, including community treatment, recovery model approaches, family approaches, and comprehensive care models.
- It adds the dimension of early intervention at the first episode of psychosis.
- The research findings after 5 years of studying this approach look very promising for improving care to this population when intervention begins at the earliest onset of psychotic symptoms
- Findings have included greater adherence to treatment programs; greater improvement in symptoms, interpersonal relationships, and quality of life; more involvement in employment or educational pursuits; and less frequent hospitalizations for clients involved in RAISE than for clients involved in more traditional treatment approaches
- The hope for this approach to treatment is that, through early and comprehensive intervention, the long-term, debilitating consequences of schizophrenia can be averted or minimized.
- Chlorpromazine (Thorazine)
- Antipsychotic medications are also called neuroleptics and historically were referred to as major tranquilizers.
- Used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders!
- They are effective in the treatment of acute and chronic manifestations of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.
- Without drug treatment, an estimated 72% of individuals who have experienced a psychotic episode relapse within a year.
- This relapse rate can be reduced to about 23% with continuous medication administration
- The prognosis of schizophrenia has often been reported in a paradigm of thirds.
- One-third of the people achieve significant and lasting improvement.
- They may never experience another episode of psychosis following the initial occurrence
- One-third may achieve some improvement with intermittent relapses and residual disability
- Their occupational level may have decreased because of their illness, or they may be socially isolated
- Finally, one-third experience severe and permanent incapacity
- They often do not respond to medication and remain severely ill for much of their lives.
- Men have poorer outcomes than women do; women respond better to treatment with antipsychotic medications
- As mentioned earlier, the efficacy of antipsychotic medications is enhanced by adjunct psychosocial therapy.
- Because the psychotic manifestations of the illness subside with use of the drugs, clients are generally more cooperative with the psychosocial therapies.
- However, it takes several weeks for the antipsychotics to effectively treat positive symptoms, a fact that often leads to discontinuation of the medication.
- Clients and families need to be educated about the importance of waiting, often for several weeks, to determine whether the drug will be effective.
- These medications are classified as either "typical" (first-generation, conventional antipsychotics) or "atypical" (the newer, novel antipsychotics).
- Use caution when driving or operating dangerous machinery. Drowsiness and dizziness can occur.
- Not stop taking the drug abruptly after long-term use. To do so might produce withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia, tremulousness.
- Use sunblock lotion and wear protective clothing when spending time outdoors. Skin is more susceptible to sunburn, which can occur in as little as 30 minutes.
- Report weekly (if receiving clozapine therapy) to have blood levels drawn and to obtain a weekly supply of the drug.
- Immediately report to the physician the occurrence of any of the following symptoms: sore throat, fever, malaise, unusual bleeding, easy bruising, persistent nausea and vomiting, severe headache, rapid heart rate, difficulty urinating, muscle twitching, tremors, darkly colored urine, excessive urination, excessive thirst, excessive hunger, weakness, pale stools, yellow skin or eyes, muscular incoordination, or skin rash.
- Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.
- Take frequent sips of water, chew sugarless gum, or suck on hard candy, if dry mouth is a problem. Good oral care (frequent brushing, flossing) is very important.
- Consult the physician regarding smoking while on antipsychotic therapy. Smoking increases the metabolism of antipsychotics, requiring an adjustment in dosage to achieve a therapeutic effect
- Dress warmly in cold weather, and avoid extended exposure to very high or low temperatures. Body temperature is harder to maintain with this medication.
- Avoid drinking alcohol while on antipsychotic therapy. These drugs potentiate each other's effects.
- Avoid taking other medications (including over-the-counter products) without the physician's approval. Many medications contain substances that interact with antipsychotics in a way that may be harmful
- Be aware of possible risks of taking antipsychotics during pregnancy. Safe use during pregnancy has not been established. Antipsychotics are thought to readily cross the placental barrier; if so, a fetus could experience adverse effects of the drug. Inform the physician immediately if pregnancy occurs, is suspected, or is planned.
- Be aware of side effects of antipsychotic drugs. Refer to written materials furnished by health-care providers for safe self-administration.
- Continue to take the medication even if feeling well and as though it is not needed. Symptoms may return if medication is discontinued.
- Carry a card or other identification at all times describing medications being taken.
Sara, a 23-year-old single woman, has just been admitted to the psychiatric unit by her parents. They explain that over the past few months, she has become increasingly withdrawn. She stays in her room alone but lately has been heard talking and laughing to herself.
Sara left home for the first time at age 18 to attend college. She performed well during her first semester, but when she returned after Christmas, she began to accuse her roommate of stealing her possessions. She started writing to her parents that her roommate wanted to kill her and that her roommate was turning everyone against her. She said she feared for her life. She started missing classes and stayed in her bed most of the time. Sometimes she locked herself in her closet. Her parents took her home, and she was hospitalized and diagnosed with schizophrenia. Sara has since been maintained on antipsychotic medication while taking a few classes at the local community college.
Sara tells the admitting nurse that she quit taking her medication 4 weeks ago because the pharmacist who fills the prescriptions is plotting to have her killed. She believes he is trying to poison her. She says she got this information from a television message. As Sara speaks, the nurse notices that she sometimes stops in midsentence and listens; sometimes she cocks her head to the side and moves her lips as though she is talking.

1. From the assessment data, what would be the most immediate nursing concern in working with Sara?
2. What is the nursing diagnosis related to this concern?
3. What interventions must be accomplished before the nurse can be successful in working with Sara?
MDD is 1 of the leading causes of disability in the US
- In 2014, 6.6% of persons aged 18 or older (15.6 million persons) had at least one major depressive episode in the previous year
- lifetime prevalence of depression is about 17%, which makes it the most prevalent psychiatric disorder
- About 21% of women and 13% of men will become clinically depressed during their life.
1. Gender: Depression is more prevalent in WOMEN than men by about 2 to 1. The gender difference is less pronounced between ages 44 and 65, but after age 65, women again are more likely to be depressed than men.
2. Age: Depression is more common in young women than young men.
3. Social Class: There is an inverse relationship between social class and report of depressive symptoms
4. Race: No consistent relationship between race and affective disorder has been reported.
5. Marital Status: Single and divorced persons are more likely to experience depression than married persons or persons with a close interpersonal relationship.
- marriage has a positive effect on the psychological well-being of an individual (as compared to those who are single or do not have a close relationship with another person)
- Some of those studies have identified that age is an important variable in risk for depression among married and single individuals
- marital stress associated with increased risk for depression, suggesting that social stress may also be an important variable to consider
6. seasonality: Affective disorders are more prevalent in the spring and in the fall. Bipolar mainly
- Winter months - tends to bring on depression, probably from lack of sunlight
A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful) (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation)
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day!
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)!
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide!
B. The symptoms cause clinically significant distress or impairment in social, occupation, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.
NOTE: Criteria A, B, and C represent a major depressive episode.
NOTE: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Specify:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With peripartum onset
Specify if:
With pure dysthymic syndrome
With persistent major depressive episode
With intermittent major depressive episodes, with current episode
With intermittent major depressiveepisodes, without current episode
Specify if:
In partial remission
In full remission
Specify if:
Early onset (onset before age 21 years)
Late onset (onset at age 21 years or older)
Specify if:
Mild
Moderate
Severe
A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
B. 1 (or more) of the following symptoms must be present:
1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection)
2. Marked irritability or anger or increased interpersonal conflicts!!!
3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts!
4. Marked anxiety, tension, feelings of being keyed up or on edge!
C. 1 (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B.
1. Decreased interest in usual activities (e.g., work, school, friends, hobbies)
2. Subjective difficulty in concentration
3. Lethargy, easy fatigability, or marked lack of energy
4. Marked change in appetite; overeating; or specific food cravings
5. Hypersomnia or insomnia
6. A sense of being overwhelmed or out of control
7. Physical symptoms, such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," weight gain
Note: The symptoms in Criteria A, B, and C must have been met for most menstrual cycles that occurred in the preceding year.
D. The symptoms are associated with clinically significant distress or interferences with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities, decreased productivity, and efficiency at work, school or home).
E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
F. Criteria A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation).
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition (e.g., hyperthyroidism).
1. Biological theories
- Genetics - hereditary factor may be involved, genetic link suggested in many studies. A definitive mode of genetic transmission has yet to be demonstrated.
- Biochemical influences, Deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine has been implicated.
- Excessive cholinergic transmission may also be a factor
2. Neuroendocrine disturbances
- Possible failure within the hypothalamic-pituitary-adrenocortical axis
- Possible diminished release of thyroid-stimulating hormone
3. Physiological influences
- Medication side effects
- Neurological disorders
- Electrolyte disturbances: Excessive levels of Na, bicarb, or Ca can produce symptoms of depression, as can deficits in Mg and Na
- Hormonal disorders: imbalance of the hormones estrogen and progesterone has been implicated in the predisposition to PMDD
- Nutritional deficiencies (thiamine, B6, and B12)
- Other physiological conditions
4. Psychosocial Theories
- Psychoanalytical theory: a loss is internalized and becomes directed against the ego; once the loss had been incorporated into the self (ego), the hostile part of the ambivalence that had been felt for the lost object is then turned inward against the ego
- Learning theory "learned helplessness": the individual who experiences numerous failures learns to give up trying
- object loss theory: Experiences loss of significant other during the first 6 months of life, This absence of attachment, which may be either physical or emotional, leads to feelings of helplessness and despair that contribute to lifelong patterns of depression in response to loss, Early loss or trauma may predispose patient to lifelong periods of depression.
- Cognitive theory
- the transactional model of stress and adaptation
Not uncommon for the symptoms of depression to be manifested differently in childhood, and the picture changes with age:
1. Up to age 3!!!: feeding problems, tantrums, lack of playfulness and emotional expressiveness, failure to thrive, or delays in speech and gross motor development
2. From ages 3-5: accident proneness, phobias, aggressiveness, and excessive self-reproach for minor infractions, incidence among preschool children is estimated to be between 0.3-0.9%
3. From ages 6-8: may have vague physical complaints and display aggressive behavior, may cling to parents and avoid new people and challenges, they may lag behind their classmates in social skills and academic competence.
4. From ages 9-12: morbid thoughts and excessive worrying, may reason that they are depressed bc they have disappointed their parents in some way, may be lack of interest in playing with friends, incidence of depression among school-age children is estimated to be around 2-3%
- Other symptoms of childhood depression may include hyperactivity, delinquency, school problems, psychosomatic complaints, sleeping and eating disturbances, social isolation, delusional thinking, and suicidal thoughts or actions
- The APA has included a new diagnostic category in the Depressive Disorders chapter of the DSM-5. called Disruptive Mood Dysregulation Disorder
- in many there is a genetic predisposition toward the condition, which is then precipitated by a stressful situation, common precipitating factors include: physical or emotional detachment by the primary caregiver, parental separation or divorce, death of a loved one (person or pet), a move, academic failure, or physical illness. In any event, the common denominator is loss.
- focus of therapy with depressed children is to alleviate the child's symptoms and strengthen the child's coping and adaptive skills, with the hope of possibly preventing future psychological problems; untreated childhood depression may lead to subsequent problems in adolescence and adult life
- most children are treated on an outpatient basis, hospitalization of the depressed child usually occurs only if he or she is actively suicidal, when the home environment precludes adherence to a treatment regimen, or if the child needs to be separated from the home bc of psychosocial deprivation
- Parental and family therapy are commonly used to help the younger depressed child, recovery is facilitated by emotional support and guidance to family members, children >8 usually participate in family therapy
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation!!!
B. The temper outbursts are inconsistent with developmental level!
C. The temper outbursts occur, on average, 3 or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms of Criteria A-D.
F. Criteria A and D are present in at least 2 of 3 settings (i.e., at home, at school, with peers) and are severe in at least 1 of these!!!
G. The diagnosis should not be made for the 1st time before age 6 or after age 18 years.
H. By history or observation, the age at onset of Criteria A-E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.
J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).
NOTE: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.
Severe depression (also called major depressive disorder) is characterized by an intensification of the symptoms described for moderate depression (see Box 16-2). Symptoms at the severe level of depression include the following:
Affective: Feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect, appearing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure
Behavioral: Psychomotor retardation so severe that physical movement may literally come to a standstill, or psychomotor behavior manifested by rapid, agitated, purposeless movements; slumped posture; sitting in a curled-up position; walking slowly and rigidly; virtually nonexistent communication (when verbalizations do occur, they may reflect delusional thinking); no personal hygiene and grooming; social isolation is common, with virtually no inclination toward interaction with others
Cognitive: Prevalent delusional thinking, with delusions of persecution and somatic delusions being most common; confusion, indecisiveness, and an inability to concentrate; hallucinations reflecting misinterpretations of the environment; excessive self-deprecation, self-blame, and thoughts of suicide
NOTE: Because of the low energy level and slow thought processes, the individual may be unable to follow through on suicidal ideas. However, the desire is strong at this level.
Physiological: A general slowdown of the entire body, reflected in sluggish digestion, constipation, and urinary retention; amenorrhea; impotence; diminished libido; anorexia; weight loss; difficulty falling asleep and awakening very early in the morning; feeling worse early in the morning and somewhat better as the day progresses (as with moderate depression, this may reflect the diurnal variation in the level of neurotransmitters that affect mood and activity)
1. Risk for suicide - Depressed mood; feelings of hopelessness and worthlessness; anger turned inward in the self; misinterpretations of reality; suicidal ideation, plan, and available means
2. Complicated grieving - Depression, preoccupation with thoughts of loss, self-blame, grief avoidance, inappropriate expression of anger, decreased functioning in life roles
3. Low self-esteem - Expressions of helplessness, uselessness, guilt, and shame; hypersensitivity to slight or criticism; negative, pessimistic outlook; lack of eye contact; self-negating verbalizations
4. Powerlessness - Apathy, verbal expressions of having no control, dependence on others to fulfill needs
5. Spiritual distress - Expresses anger toward God, expresses lack of meaning in life, sudden changes in spiritual practices, refuses interactions with significant others or with spiritual leaders
6. Social isolation/Impaired social interaction - Withdrawn, uncommunicative, seeks to be alone, dysfunctional interaction with others, discomfort in social situations
7. Disturbed thought processes - Inappropriate thinking, confusion, difficulty concentrating, impaired problem-solving ability, inaccurate interpretation of environment, memory deficit
8. Imbalanced nutrition: Less than body requirements - Weight loss, poor muscle tone, pale conjunctiva and mucous membranes, poor skin turgor, weakness
9. Insomnia - Difficulty falling asleep, difficulty staying asleep, lack of energy, difficulty concentrating, verbal reports of not feeling well rested
10. Self-care deficit (hygiene, grooming) - Uncombed hair, disheveled clothing, offensive body odor
1. Ask client directly: "Have you thought about killing yourself?" or "Have you thought about harming yourself in any way? If so, what do you plan to do? Do you have the means to carry out this plan?"!!! (priority intervention) - The risk of suicide is greatly increased if the client has developed a plan and particularly if means exist for the client to execute the plan
2. Create a safe environment for the client. Remove all potentially harmful objects from client's access (sharp objects, straps, belts, ties, glass items, alcohol). Supervise closely during meals and medication administration. Perform room searches as deemed necessary. - Client safety is a nursing priority.
3. Formulate a short-term verbal or written contract that the client will not harm self during a specific time period. When the contract expires, make another. Repeat this process for as long as required. - Discussion of suicidal feelings with a trusted individual provides some relief to the client. A contract gets the subject out in the open and some of the responsibility for his or her safety is given to the client. An attitude of unconditional acceptance of the client as a worthwhile individual is conveyed.
4. Maintain close observation of the client. Depending on level of suicide precaution, provide one-to-one contact, constant visual observation, or every-15-minute checks. Place in room close to nurse's station; do not assign to private room. Accompany to off-unit activities if attendance is indicated. May need to accompany to bathroom. - Close observation is necessary to ensure that client does not harm self in any way. Being alert for suicidal and escape attempts facilitates being able to prevent or interrupt harmful behavior.
5. Maintain special care in administration of medications - Prevents saving up to overdose or discarding and not taking.
6. Make rounds at frequent, irregular intervals (especially at night, toward early morning, at change of shift, or other predictably busy times for staff)!!! - Prevents staff surveillance from becoming predictable. To be aware of client's location is important, especially when staff is busy, unavailable, or less observable.
7. Encourage client to express honest feelings, including anger. Provide hostility release if needed. Help the client to identify the true source of anger and to work on adaptive coping skills for use outside the treatment setting - Depression and suicidal behaviors may be viewed as anger turned inward on the self. If this anger can be verbalized in a nonthreatening environment, the client may eventually be able to resolve these feelings.
1. Determine the stage of grief in which the client is fixed. Identify behaviors associated with this stage - Accurate baseline assessment data are necessary to effectively plan care for the grieving client.
2. Develop a trusting relationship with the client. Show empathy, concern, and unconditional positive regard. Be honest and keep all promises. - Trust is the basis for a therapeutic relationship.
3. Convey an accepting attitude, and enable the client to express feelings openly. - An accepting attitude conveys to the client that you believe he or she is a worthwhile person. Trust is enhanced.
4. Encourage the client to express anger. Do not become defensive if the initial expression of anger is displaced on the nurse or therapist. Help the client explore angry feelings so that they may be directed toward the actual intended person or situation - Verbalization of feelings in a nonthreatening environment may help the client come to terms with unresolved issues.
5. Help the client to discharge pent-up anger through participation in large motor activities (e.g., brisk walks, jogging, physical exercises, volleyball, punching bag, exercise bike). - Physical exercise provides a safe and effective method for discharging pent-up tension!!!
6. Teach the normal stages of grief and behaviors associated with each stage. Help the client to understand that feelings such as guilt and anger toward the lost concept are appropriate and acceptable during the grief process and should be expressed rather than held inside. - Knowledge of acceptability of the feelings associated with normal grieving may help to relieve some of the guilt that these responses generate.
7. Encourage the client to review the relationship with the lost entity. With support and sensitivity, point out the reality of the situation in areas where misrepresentations are expressed - The client must give up an idealized perception and be able to accept both positive and negative aspects about the lost entity before the grief process is complete.
8. Communicate to the client that crying is acceptable. Use of touch may also be therapeutic. - Some cultures believe it is important to remain stoic and refrain from crying openly. Individuals from certain cultures are uncomfortable with touch. It is important to be aware of cultural influences before employing these interventions.
9. Encourage the client to reach out for spiritual support during this time in whatever form is desirable to him or her. Assess spiritual needs of the client (see Chapter 5) and assist as necessary in the fulfillment of those needs - Client may find comfort in religious rituals with which he or she is familiar.
1. Identify stressors in client's life that precipitated current crisis.
1. Important to identify causative or contributing factors in order to plan appropriate assistance.
2. Determine coping behaviors previously used and client's perception of effectiveness then and now.
2. A feeling of hope is engendered when the client recognizes personal strengths that have been helpful in the past.
3. Encourage client to explore and verbalize feelings and perceptions.
3. Identification of feelings underlying behaviors helps client to begin process of taking control of own life.
4. Provide expressions of hope to client in positive, low-key manner (e.g., "I know you feel you cannot go on, but I believe that things can get better for you. What you are feeling is temporary. It is okay if you don't see it just now. You are very important to the people who care about you").
4. Even though the client feels hopeless, it is helpful to hear positive expressions from others. The client's current state of mind may prevent him or her from identifying anything positive in life. It is important to accept the client's feelings nonjudgmentally and to affirm the individual's personal worth and value.
5. Help client identify areas of life situation that are under own control.
5. The client's emotional condition may interfere with ability to problem solve. Assistance may be required to perceive the benefits and consequences of available alternatives accurately.
6. Identify sources that client may use after discharge when crises occur or feelings of hopelessness and possible suicidal ideation prevail.
6. Client should be made aware of local suicide hotlines or other local support services from which he or she may seek assistance following discharge from the hospital. A concrete plan provides hope in the face of a crisis situation.
Group therapy forms an important dimension of multimodal treatment for the depressed client. Once an acute phase of the illness is passed, groups can provide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise out of having a serious affective disorder. The element of peer support provides a feeling of security, as troublesome or embarrassing issues are discussed and resolved. Some groups have other specific purposes, such as helping to monitor medication-related issues or serving as an avenue for promoting education related to the affective disorder and its treatment. Therapy groups help members gain a sense of perspective on their condition and tangibly encourage them to link up with others who have common problems. A sense of hope is conveyed when the individual is able to see that he or she is not alone or unique in experiencing affective illness
- Self-help groups offer another avenue of support for the depressed client. These groups are usually peer led and are not meant to substitute for or compete with professional therapy. They offer supplementary support that frequently enhances compliance with the medical regimen
- Examples of self-help groups are the Depression and Bipolar Support Alliance (DBSA), Depressives Anonymous, Recovery International, and GriefShare (grief recovery support group)
- Although self-help groups are not psychotherapy groups, they do provide important adjunctive support experiences, which often have therapeutic benefit for participants
In cognitive therapy, the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of mood disorders. In the cognitive model, depression is characterized by a triad of negative distortions related to expectations of the environment, self, and future. The environment and activities within it are viewed as unsatisfying, the self is unrealistically devalued, and the future is perceived as hopeless.
The general goals in cognitive therapy are to obtain symptom relief as quickly as possible, to assist the client in identifying dysfunctional patterns of thinking and behaving, and to guide the client to evidence and logic that effectively test the validity of the dysfunctional thinking. Therapy focuses on changing "automatic thoughts" that occur spontaneously and contribute to the distorted affect. Following are examples of automatic thoughts that may be common cognitive distortions in depression.
Personalizing: "I'm the only one who failed."
All or nothing: "I'm a complete failure."
Mind reading: "He thinks I'm foolish."
Discounting positives: "The other questions were so easy. Any dummy could have gotten them right."

The client is asked to describe evidence that both supports and disputes the automatic thought. The logic underlying the inferences is then reviewed with the client. Another technique involves evaluating what would most likely happen if the client's automatic thoughts were true. Implications of the consequences are then discussed.
Clients should not become discouraged if one technique seems not to be working. No single technique works with all clients. He or she should be reassured that any of a number of techniques may be used, and both the therapist and client may explore these possibilities.
Cognitive therapy has offered encouraging results in the treatment of depression. In fact, the results of several studies with depressed clients show that in some cases cognitive therapy may be equally or even more effective than antidepressant medication
1. Mortality
Studies indicate that the mortality rate from ECT is about 2 per 100,000 treatments (Marangell et al., 2003; Sadock et al., 2015). Although the occurrence is rare, the major cause of death with ECT is from cardiovascular complications (e.g., acute myocardial infarction or cerebrovascular accident)!!!, usually in individuals with previously compromised cardiac status. Assessment and management of cardiovascular disease prior to treatment is vital in the reduction of morbidity and mortality rates associated with ECT.
2. Permanent Memory Loss
Most individuals report no problems with their memory aside from the time immediately surrounding the ECT treatments. However, some clients have reported retrograde amnesia extending back to months before treatment. In rare instances, more extensive amnesia has occurred, resulting in memory gaps dating back years (Joska & Stein, 2008). Some clients have reported gaps in recollections of specific personal memories.
Sackeim and associates (2007) reported on the results of a longitudinal study of clinical and cognitive outcomes in patients with major depression treated with ECT at seven facilities in the New York City metropolitan area. Participants were evaluated shortly following the ECT course and 6 months later. Data revealed that cognitive deficits at the 6-month interval were directly related to type of electrode placement and electrical waveform used. Bilateral electrode placement resulted in more severe and persisting (as evaluated at the 6-month follow-up) retrograde amnesia than did unilateral placement. The extent of the amnesia was directly related to the number of ECT treatments received. The researchers also found that stimulation produced by sine wave (continuous) current resulted in greater short- and long-term deficits than that produced by short-pulse wave (intermittent) current.
3. Brain Damage
Brain damage from ECT remains a concern for those who continue to believe in its usefulness and efficacy as a treatment for depression. Critics of the procedure remain adamant in their belief that ECT always results in some degree of immediate brain damage (Frank, 2002). However, evidence is based largely on animal studies in which the subjects received excessive electrical dosages, and the seizures were unmodified by muscle paralysis and oxygenation (Abrams, 2002). Although this is an area for continuing study, there is NO evidence to substantiate that ECT produces any permanent changes in brain structure or functioning
Transcranial magnetic stimulation (TMS) is a procedure that is used to treat depression by stimulating nerve cells in the brain. TMS involves the use of very short pulses of magnetic energy to stimulate nerve cells at localized areas in the cerebral cortex, similar to the electrical activity observed with ECT. However, unlike ECT, the electrical waves generated by TMS do not result in generalized seizure activity (George, Taylor, & Short, 2013). The waves are passed through a coil placed on the scalp to areas of the brain involved in mood regulation. It is noninvasive and considered generally safe. A typical course of treatment is 40-minute sessions, three to five times a week for 4 to 6 weeks (Raposelli, 2015). Some clinicians believe that TMS holds a great deal of promise in the treatment of depression, whereas others remain skeptical. In rare instances, seizures have been triggered with the use of TMS therapy (Lanocha, 2010). In a study at King's College in London, researchers compared the efficacy of TMS with ECT in the treatment of severe depression (Eranti et al., 2007). They concluded that ECT was substantially more effective for the short-term treatment of depression, and they indicated the need for further intense clinical evaluation of TMS. One study (Connolly et al., 2012) identified that 24.7 percent of patients receiving TMS were in remission at 6 weeks. Effectiveness ratings for ECT have varied from 17 to 70 percent. While the effectiveness ratings may seem small or highly variable, both treatments provide an option for patients who are otherwise treatment resistant.
George and associates (2013) stated:
Since FDA approval, TMS has been generally safe and well tolerated with a low incidence of treatment discontinuation, and the therapeutic effects once obtained appear at least as durable as other antidepressant treatments. TMS also shows promise in several other psychiatric disorders, particularly treating acute and chronic pain. (p. 17)
More recently, researchers compared TMS to pharmacotherapy and found them both effective but identified TMS as more cost effective (Raposelli, 2015). Currently, not all insurance companies cover this treatment, so from the client's standpoint, this may be a more expensive alternative. Raposelli reports that up to 40 percent of patients with MDD do not respond to pharmacotherapy, so alternatives such as ECT and TMS may offer some hope of recovery for treatment-resistant conditions.
Between 15-25% of people with recurrent depressive disorder exhibit a seasonal pattern whereby symptoms are exacerbated during the winter months and subside during the spring and summer. The DSM-5 identifies this disorder as Major Depressive Disorder, Recurrent, With Seasonal Pattern. It has commonly been known as seasonal affective disorder (SAD). Bright light therapy has been suggested as a first-line treatment for winter "blues" and as an adjunct in chronic MDD or dysthymia with seasonal exacerbations (Karasu et al., 2006).
SAD is thought to be related to the presence of the hormone melatonin, which is produced by the pineal gland. Melatonin plays a role in the regulation of biological rhythms for sleep and activation. It is produced during the cycle of darkness and shuts off in the light of day. During the months of longer darkness hours, there is increased production of melatonin, which seems to trigger the symptoms of SAD in susceptible people.
Light therapy, or exposure to light, has been shown to be an effective treatment for SAD. The light therapy is administered by a 10,000-lux light box, which contains white fluorescent light tubes covered with a plastic screen that blocks ultraviolet rays. The individual sits in front of the box with the eyes open (although the client should not look directly into the light). Therapy usually begins with 10- to 15-minute sessions and gradually progresses to 30 to 45 minutes. The mechanism of action is believed to be related to retinal stimulation which triggers a reduction of melatonin and an increase in serotonin in the brain (Rodriguez, 2015). A recent study demonstrated benefits of bright light therapy in non-SADs as well (Lam et al., 2015). Some people notice improvement rapidly, within a few days, whereas others may take several weeks to feel better. Side effects appear to be dosage related and include headache, eyestrain, nausea, irritability, photophobia (eye sensitivity to light), insomnia (when light therapy is used late in the day), and (rarely) hypomania (Terman & Terman, 2005). Light therapy and antidepressants have shown comparable efficacy in studies of SAD treatment. One study compared the efficacy of light therapy for SAD to daily treatment with 20 mg of fluoxetine (Lam et al., 2006). The authors concluded that "light treatment showed earlier response onset and lower rate of some adverse events relative to fluoxetine, but there were no other significant differences in outcome between light therapy and antidepressant medication"
Continue to take the medication even though the symptoms have not subsided. The therapeutic effect may not be seen for as long as 4 weeks!!! If after this length of time no improvement is noted, the physician may prescribe a different medication.
Use caution when driving or operating dangerous machinery. Drowsiness and dizziness can occur. If these side effects become persistent or interfere with ADLs, the client should report them to the physician. Dosage adjustment may be necessary.
Not discontinue use of the drug abruptly! To do so might produce withdrawal symptoms, such as nausea, vertigo, insomnia, headache, malaise, nightmares, and return of symptoms for which the medication was prescribed.
Use sunblock lotion and wear protective clothing when spending time outdoors. The skin may be sensitive to sunburn.
Immediately report occurrence of any of the following symptoms to the physician: sore throat, fever, malaise, yellowish skin, unusual bleeding, easy bruising, persistent nausea/vomiting, severe headache, rapid heart rate, difficulty urinating, anorexia/weight loss, seizure activity, stiff or sore neck, and chest pain.
Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.
Take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth is a problem. Good oral care (frequent brushing, flossing) is very important.
Not consume the following foods or medications while taking MAOIs!!!: aged cheese, wine (especially Chianti), beer, chocolate, colas, coffee, tea, sour cream, smoked and processed meats, beef or chicken liver, canned figs, soy sauce, overripe and fermented foods, pickled herring, raisins, caviar, yogurt, yeast products, broad beans, cold remedies, diet pills. To do so could cause a life-threatening hypertensive crisis.
Avoid smoking while receiving tricyclic therapy. Smoking increases the metabolism of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect.
Avoid drinking alcohol while taking antidepressant therapy. These drugs potentiate the effects of each other.
Avoid use of other medications (including over-the-counter medications) without the physician's approval while receiving antidepressant therapy. Many medications contain substances that, in combination with antidepressant medication, could precipitate a life-threatening hypertensive crisis.
Notify physician immediately if inappropriate or prolonged penile erections occur while taking trazodone. If the erection persists longer than 1 hour, seek emergency department treatment. This condition is rare but has occurred in some men who have taken trazodone. If measures are not instituted immediately, impotence can result.
Not "double up" on medication if a dose of bupropion (Wellbutrin) is missed, unless advised to do so by the physician. Taking bupropion in divided doses will decrease the risk of seizures and other adverse effects.
Follow the correct procedure for applying the selegiline transdermal patch:
Apply to dry, intact skin on upper torso, upper thigh, or outer surface of upper arm.
Apply approximately same time each day to new spot on skin after removing and discarding old patch.
Wash hands thoroughly after applying the patch.
Avoid exposing application site to direct heat (e.g., heating pads, electric blankets, heat lamps, hot tub, or prolonged direct sunlight).
If patch falls off, apply new patch to a new site and resume previous schedule.
Be aware of possible risks of taking antidepressants during pregnancy. Safe use during pregnancy and lactation has not been fully established. These drugs are believed to readily cross the placental barrier; if so, the fetus could experience adverse effects of the drug. Inform the physician immediately if pregnancy occurs, is suspected, or is planned.
Be aware of the side effects of antidepressants. Refer to written materials furnished by health-care providers for safe self-administration.
Carry a card or other identification at all times describing the medications being taken.
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