607 Psych communication

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Group: a number of people coming together, sharing a purpose, interest, or concern, and staying together long enough for development of a network of relationships.
* used to work through issues of intimacy, differentiation and individuation
Common Group Phenomena: -group acceptance
-reality testing
-universality(individual -problem is not unique)
-ventilation
-learning
-altruism(putting another's needs before your own)
-transference(projection onto group leader)
-interactions
3 Phases of Group (Peplau): 1.orientation - leader sets up atmosphere of respect, confidentiality & trust. Getting comfortable.
2. working phase - keep group focused, support members, encourages honest expression but prevents attacks.
3. terminator - acknowledge each members' contribution and purpose for separation.
Roles of Group Members: -opinion giver
-opinion seeker
-information giver
-information seeker
-initiator-proposes new ideas on how to reach goal
-elaborator-expands on another's ideas and works out specific scenarios
-coordinator-brings ideas together
-orienter-keeps group focus on goals, questions direction of group
-critic-examines solutions against standards and goals
-clarifier
-recorder
summarizer
What benefits can group therapy offer?: Instilling hope in the demoralized
develop social skills
develop interpersonal learning
Terms Central to Group Work: -group content
-group process
-confrontation
-covert content
-dynamics
-feedback
-hidden agenda
-cohesiveness
-conflict
-close group
-open group
-sub group
-milieu therapy
-behavior modification
Group Content: all that's said in group
Group Process: movement that reflects the struggle between meeting an individual need and group goal. Includes body language.
Confrontation: bring buried conflicts into open.
Covert Content: deeper meaning of messages or of what is happening
Dynamics: ebb and flow of pwer/energy in group.
Feedback: letting members know how they affect each other.
Hidden Agenda: individual, leader, or subgroup's goals at cross-purposes to group goals.
Cohesiveness: bond with members; sense of id.
Conflict: disagreement - pos/neg
Closed Group: no new members added when others leave.
Open Group: new members are added.
Sub Group: more loyalty to each other than to the larger group.
Milieu Therapy: a comfortable, secure environment created for the patient on individual basis

Ex: quiet & dim lights for mania
Behavior Modification: changing specific observable, dysfunctional patterns of behavior by stimulus/response conditioning.
Protocol: description of actual nursing care involved in group
-objectives, methods, organization
Pschoeducational Groups: Medication Groups: concrete, here & now subject, teaching clients about meds, answer questions, prepare cleint for self-management of med.
Psychoeducational Groups: Sexuality Groups: AIDS, STDs, safe sex, sexual dysfunction related to drug therapy.
Therapeutic Milieu Groups: Goal is to increase client self esteem, decrease social isolation, encourage appropriate social behaviors, educate clients in basic living skills.
Therapeutic Milieu Groups: Recreational Group: teamwork, learning how to spend leisure time, increase self esteem by completing a project, nostalgia groups.
Therapeutic Milieu Groups: Physical Activity Groups: exercise
Therapeutic Milieu Groups: Creative Arts Groups: withdrawn clients get in touch with feelings through books, poems, music, and dance.
Therapeutic Milieu Groups: Social Skills Groups: cooking, adls, grooming, client government groups. Give staff a chance to assess client on life skills.
Time-Limited Therapy Groups: a closed group, short duration. Used to fit an inpatient setting with rapid turnover.
Cognitive Behavior Groups: short term, problem oriented, deal with here & now. To alter maladaptive response by modeling and reinforcing new behaviors.
Cognitive Behavior Group Therapy: This therapy is useful for dealing with client's negative thoughts, distortions, and attitudes.
Behavioral group therapy: Used to eliminate undesireable behaviors, such as phobias.
Phobia: a marked and persisten fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.
Compulsion: a repetitive behavior that takes up a significant part of the day that the person feels driven to perform (handwashing).
systematic desensitization: client gradually approaches the feared object or situation while in a relaxed state.
flooding: saturating the client with anxiety-producing stimulus without allowing the client to escape (anxiety should start to subside within 20 minutes).
self-help (support) groups: A group in which people who have experienced a problem help others deal with the same problem.
-demonstrate to members they are not alone with their problem (ex. AA - 12 steps)
Person who monopolizes the group: person with compulsive speech - an attempt to deal with anxiety.

intervention: ask the group why they let the person talk so much to make them mad, so they will get that person to stop
Person who complains but rejects group: brings problems to group, thinks they're insurmountable. Mistrusts authority.

intervention: aggree w/client, be detached, help recognize patter of behavior
Person who demoralizes others: people who are self-centered, lack empathy, highly depressive, angry, refuse to take personal responsbility.

intervention: listen to content being avoided. Empathize in matter of fact manner.
silent person: quiet and observing, waiting till its safe

intervention: be patient, supportive, draw patient into discussion
Inpatient groups: 1.orientation
2.spatial boundaries
3.start/end session on time
4.encourage clients to stay but don't lock the door
5.be directive & decisive
6.maintain group safety
Outpatient groups: clients are often not prepared for what will happen in group or who will be there

General goal setting is helpful
DSM-IV: Axis I: Clinical disorders
other conditions that may be a focus of clinical attention

Ex: Major Depression
DSM-IV: Axis II: Personality Disorders
Mental Retardation

Ex: Dependent personality disorder
DSM-IV: Axis III: General Medical Conditions

Ex: Diabetes
DSM-IV: Axis IV: Psychosocial and environmental problems

Ex: Divorce 3 months ago
DSM-IV: Axis V: Global assessment of functioning

Ex: 31 yrs old, unable to work or respond to family and friends
Global Assessment of Functioning Scale: Less than 50 usually require hospitalization
First Generation Antipsychotics: phenothiazines, thioxanthenes, butyrophenones

Ex:
Chlorpromazine HCl (Thorazine)
Thioridazine (Mellaril)
Fluphenazine HCl (Prolixin)least sedative
Thiothixene (Navane)
Haloperidol (Haldol) q 1 month
Side Effects of 1st Generation Antipsychotics: Dopamine Blocker - movement defects (extrpyrimidal symptoms), gynocomastia, galactorrhea-amenorrhea

Muscarinic Blocker -blurred vision, dry mouth, constipation, urinary hesitancy

Alpha1 antag. - orthostatic hypotension, failure to ejaculate
Atypical Antipsychotics (novel antipsychotic agents): Clozapine (Clozaril) Risperidone (Risperdal) Quetiapine (Seraquel Olanzapine (Zyprexa)
Loxapine (Loxitane)
Ziprasidone (Geodon)
Aripiprazole (Abilify)

Treat Neg & Pos symptoms
Few or No EPS

SE: headache, somnolence, dizziness, weight gain, agranulocytosis
Clozapine requires...: weekly WBC count
Mood Stabilizers: Lithium
Antiepileptics
Antidepressants
Lithium: Side Effects: altered electrical activity, disturbed fluid balance

lowest therapeutic index of all psychiatric drugs
Antiepileptic Drugs: Tegretol
Depakote
Klonopin

Reduce firing rate of high-frequency brain neurons.

Effective for the manic bipolar client.
Antidepressant Drugs: increase the synaptic levels of norepinephrine, serotonin, or both.

Tricyclic
SSRIs
MAOIs
Atypical
Tricyclics: block reuptake of norepi and serotonin

SE: drowsy, blurred vision, dry mouth, tachycard., constip.
Ex: Elavil
SSRIs: obsessive compulsive disorder
MOAIs: blocks destruction of monoamines, by inhibiting action of MAO, an enzyme which destroys monoamines.

Ex: Nardil

SE: prevents degradation of Tyranine, cause life-threat. HTN (so avoid wine, cheese)
Atypical Antidepressants: Ex: Trazodone (priapism), Effexor (nausea, dizzy, impotence), Remeron (weight gain), Wellbutrin (headache, insomnia, nausea, restless)
Anti-anxiety/anxiolytics: Increase GABA

Benzodiazepines
BuSpar
Benzodiazepine: antianxiety

Ex: Halcion, Ativan, Xanax

hypnotic

used in alcohol withdrawal
BuSpar: reduces anxiety
not as sedative-hypnotic
better tolerated than benzodiazepines

prevents negative feedback and allows more serotonin to be released
imipramine: for panic attack
sertaline: social phobias
ADD/ADHD: short attention span, impulsivity, overactivity

Ritalin
Amphetamines (Adderall)
Alzheimers: anticholinesterase drugs

Cogex
Aricept

SE: Liver damage
Psychosis: the inability to distinguish reality from imagination
Schizophrenia: onset? affects? course? NTs?: onset: late teens, early 20s
affects: thinking, language, emotions, social behavior, perception of reality
course: recurrent acute exacerbations of psychosis
NTs: increased dopamine
increased serotonin

some genetic contribution
structural brain abnormalities
Schizophrenia: Comorbidity: Substance abuse
nicotine dependence
depressive symptoms
anxiety disorders
Schizophrenia: Positive Symptoms: 1.hallucinations
2.delusions
3.disorganized speech
4.bizarre behavior
5.looseness of association

*reflect an excess or distortion of normal functions, including delusions and hallucinations
Schizophrenia: Negative Symptoms: 1.poverty of speech
2.blunted affect
3.poverty of thought (alogia)
4.loss of motivation (avolition)
5.inability to experience pleasure (anhedonia)
6.social withdrawal
7.apathy
8.poor grooming
9. attentional impairment

*reflect a lessening or loss of normal function: flattened emotions, thought, & speech, lack of motivation
Schizophrenia: Content of Thought: Delusions:
1.religious
2.ideas of reference
3.persecution
4.grandeur
5.somatic
6.Thought - broadcasting, insertion, withdrawal, being controlled
Schizophrenia: Forms of Thought: 1.Neologisms
2.Concrete Thinking
3.Clang Association
4.Word Salad
5.Tangientiality
6.Mutism
7.Perseveration
Schizophrenia: Forms of Thought Neologisms: made up words with special meanings for the person only
Schizophrenia: Forms of Thought Clang Association: rhyming of words, often in a forecful manner
Schizophrenia: Forms of Thought Word Salad: mixture of meaningless phrases
Schizophrenia: Forms of Thought Tangentiality: digress readily from one topic to another
Schizophrenia: Forms of Thought Mutism: absence of speech
Schizophrenia: Forms of Thought Perseveration: uncontrollabe repetition of word, phrase or gesture
Assessment: Acute Stage of Schizophrenia: psychiatric, medical, neurological
Intervention:Phase I: 1.Acute pharmacological treatment
2.supportive and directive communication
3.limit setting
Intervention:Phase II & III: 1.client/family teaching
2.medication teaching/side effect management
3.cognitive/social skills enhancements. Milieu Tx.
4.ID signs of relapse
5.attention to deficit in self-care, social and work functioning
What are Extrapyrimidal Side Effects?: pseudoparkinsonism
dystonia
akathisia
tardive dyskinesia
EPS: Pseduoparkinsonism: stiffening of muscles in face, body, neck, legs
EPS: dystonia: muscle cramps of head and neck
EPS: akathisia: internal and external restless pacing and fidgeting
EPS: tardive dyskinesia: appears after prolonged Tx
serious, nonreversible
-involuntary tonic muscle spasms of tongue, fingers, toes, neck, trunk, pelvis
Neuroleptic Malignant Syndrome (NMS): Rare, may be fatal
From acute reduction in brain dopamine
Can begin after 1st week of Tx, symptoms progress rapidly

Hyperthermia, muscular rigidity, altered consciousness, autonomic dysfunction
AIMS: Abnormal Involuntary Movement Scale
Antidyskinetics: Benztropine (Cogentin)
trihexphenidyl (Artane)
Diphenhydramine (Benadryl)

*Anticholinergic Side effects
Side Effects of Antipsychotics: 1.sedation
2.ortho. hypertension
3.alteration of sexual function
4.increased appetite
5.decreased tolerance to drugs/alcohol
Schizophrenia: Social Interventions: 1.promote economic stability
2.decrease family/caregiver stress
3.provide family education
4.maintain housing
5.increase social contact
Schizophrenia: Family Burden: 1.housing
2.food & laundry
3.transportation
4.medication mgmt.
5.money and money mgmt.
6.companionship/recreation
7.crisis intervention
8.mediation with police
Schizophrenia: Family Emotional Burden: 1.grief
2.fear
3.guilt
4.anger
5.mourning without end
Schizophrenia: Relapse prevention: 1.maintain regular sleep pattern
2.reduce alcohol, drugs, caffeine
3.KIT w/supportive friends/family
4.keep active
5.daily routine/weekly schedule
6.med. compliance
Schizophrenia: Symptom Mgmt. Skills Hallucination: 1.be open, honest, direct, reliable
2.be matter of fact
3.ask pt to describe
4.avoid arguing/interject doubt
5.focus on reality/set limits
6.triggers
7.validate part of delusion if it is real
Schizophrenia: Specific Intervetions: 1.Mileu Tx
2.Partial hospitalization
3.Day Tx programs
4.Group homes
5.Group work
6.Individual counseling
7.supervised activities

*prevention of relapse is more important than risk of side effects - most SE are reversible, but consequences of relapse may be irreversible.
Alteration in Mood: Depression: Prevalence: more women than men
familial
pattern of recurrence
onset at 18-24
increasing a younger and older ages
less than 25% receive Tx
Alteration in Mood: Bipolar: Prevalence: less than 1%
men & women equal
familial
cyclical
onset: late 20's
Symptoms of Depression: Experienced Uniquely
"depressed mood"
tearful, crying, anxiety, worry, fear
Somatic:
headaches, lethargy, fatigue, GI Sx, aches, sleep distur., appetite, decreased concentration, sexual dysfunction, ammenorrhea, vertigo
Dx of Depression: 1.depressed mood for more than 2 weeks
2.sleep distub.
3.appetite disturb.
4.poor concentration/indecisive
5.feeling guilty or worthless
6recurrent thoughts of death
7.psychomotor agitation/retardation
fatigue
8.loss of pleasure - anhedonia
Subgroups of Depression: By Symptom By Intensity: By Symptom
-psychotic - somatic delusions
-melancholic
-atypical
-seasonal
-post-partum/menopausal/midlife

By Intensity
mild
moderate
severe
Depression can be comorbid with...: anxiety
Bipolar I: Dx: -at least one manic episode
-Sx disrupt functioning
-at least one major depressive episode
-chracterized by mood swings
-4 or more episodes a year - rapid cycler
Bipolar II: Dx: cycling 2x a year (q 6 mos.)
Mania: -mood elevated, expansive, irritable
-may be delusional - grandeur
-motor activity increased
-speech pressured
hypersexual - inappropriately
poor judgment - excessive spending, substance abuse, risk sexual behavior
Hypomania: premania
feelings of ease, power, well-being, omnipotence, euphoria, sensuality, seduction

(followed by mania)
Bipolar Disorder in Children: -more rapid mood swings
-mania presents more often as irritability, angry outbursts, and tantrums
-mixed symptoms common
-difficult to diagnose
-more likely in children whose parents have bipolar
Myths of Schizophrenia: -patients are violent
-family caused it
-split-personality
-stupid
-only treat the positive symptoms

*housing is a huge issue

*Nurses need to look for S&S of tardive dyskinesia (EPS Sx)
Comorbity with Bipolar: -substance abuse (29% w/bipolar are addicts)
-53% w/addiction have mental illness
-Anxiety Disorders
With Depressive Disorders...: there is a familial (although not genetic) link

not r/t traumatic life even
(PTSD is not depression)
Psychodynamic Theory: loss theory
significant loss in childhood predisposes to depression
anger turned inward - loss of object of ambivalence; anger is misdirected & accompanied by guilt
(theories are not validated)
Receptor Sensitivity Theory: change in NT receptor activity results in the development of a mood disorder
-over sensitive NE autoreceptors decrease amount of NE secreted into the synapse - result is depression
Receptor Sensitivity Theory: Serotonin: -low in mood disorders
SSRI's decrease amount of serotonin reabsorbed
-increase available serotonin
-decreased Sx of depression
Cognitive Theory: (Beck)
experience of depression is due to cognitive distorions
-thoughts 1st, feelings 2nd
-silent assumptions are formed in childhood - often irrational
-NEGATIVE world view
Depression: Focused Assessment: Clinical Interview
-Hx of dep., bipolar, suicide attempts
-mood changes
cognitive, behavioral, social schanges

Physical Assessment

Assessment Scales
-Beck, Zung

Suicide Assessment
Depression: Assessment: Suicide Risk: IMPORTANT
Are you going to hurt yourself?
How are you feeling today?
Is this the first time?
How many times before?
What was it like, what do you do to feel better?
Does anyone in your family have depression?
Depression: Nursing Diagnosis: Risk For:
1.Injury/Suicide
2.Safety and Health
3.Impaired Self-care Patterns
4.Impaired though processes
5.impaired selft concept
6.social isolation
Depression: DSM-IV compared to NANDA: DSM-IV/NANDA
Depressed mood / hoplessness
Dec. Interest / Ineffective Coping
Wt.loss,gain / altered nutrition
insomnia / sleep disturbance
suicide / violence -risk to self
Mania: DSM-IV compared to NANDA: DSM-IV / NANDA
grandiosity / dist. self-esteem
pressured speech / impaired communication
flight of ideas / altered thought processes
poor judgment / ineffective coping
Outcomes: general: decrease Sx
restore function
increase quality of life
reduce incidence of relapse and occurrence of symptoms
Depression: Outcomes: -no self-harm (CONTRACT)
-realistic goals
-takes social risks
-able to focus attention
-inc. frequency of positive self-statements
-balanced diet
apprpriate hygeine
5-8 hours sleep per night
Mania: Outcomes: -verbalize understanding of illness
-verbalize decrease in hallucinations and delusions
-no manipulation of staff
-accepts limits and responsibility for behavior
-appropriate social interaction
-5-8 hours sleep per night
appropriate hygeine
-appropriate diet

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