Course Flashcards

Question

Depression and Grieving

Answer 1

People who experience a significant loss can exhibit feelings and behaviours similar to depression. They may cry, feel hopeless about the future, have disruptions in eating and sleeping, and lose pleasure in everyday activities. They may even experience a lack interest in caring for themselves and neglect normal hygiene. The rationale for avoiding a psy- chiatric diagnosis follows: 1. Normal mourning could be labelled pathological. 2. A psychiatric diagnosis could result in a lifelong label. 3. Unnecessary medications might be prescribed. Although controversial, a diagnosis of depression can now be given in the first 2 months following death of a loved one or other loss. The reason for the change is that grief, like other stressors, can result in depression. For some people, waiting 2 months for an official diagnosis of major depression may delay treatment and adversely affect prognosis.

Answer 2

Depression is the leading cause of disability in the world. The lifetime prevalence of a major depressive episode or the total number of adults in Canada who will experience the disorder within their lifetime is 11.3% The average age of MDD onset is between 15 and 45 years of age. Studies find that mood disorders are more common in women than men. MDD tends to have higher prevalence rates in lower-income or unemployed populations and unmarried or divorced people. Children and Adolescents: Children as young as 3 years of age have been diagnosed with depression; however, the prevalence is relatively low, with little difference be- tween boys and girls. Levels rise in the early teen years, more sharply among girls than boys. Older Persons: Although depression in older persons is common, it is NOT a normal result of aging. The risk for depression in the elderly increases as health deteriorates. About 1% to 5% of older persons who live in the community have depression. This statistic rises to 11.5% for hospitalized older persons and 13.5% for those requiring home care. Many older persons suffer from SUBSYNDROMAL depression in which they experience many, but not all, of the symptoms of a major depressive episode. These individuals have an increased risk of eventually developing major depression. Sometimes the psychomotor slowing and cognitive effects of depression lead others to believe that the older person is developing a neurocognitive disorder such as Alzheimer’s disease. This condition is referred to as pseudodementia, a problem that can be reversed when the underlying depression is treated and eliminated.

Answer 3

A depressive syndrome frequently accompanies other psychiatric dis- orders, such as anxiety disorders, schizophrenia, substance use, eating disorders, and schizoaffective disorder. People with anxiety disorders (e.g., panic disorder, generalized anxiety disorder, obsessive-compulsive disorder) commonly present with depression, as do people with per- sonality disorders (particularly borderline personality disorder), adjust- ment disorder, and brief depressive reactions.

Answer 4

Although many theories attempt to explain the cause of depression, many psychological, biological, and cultural variables make identification of any one cause difficult; furthermore, it is unlikely that there is a single cause of depression. The high variability in symptoms, response to treatment, and course of the illness support the supposition that depression results from a complex interaction of causes. For example, genetic predisposition to the illness combined with childhood stress may lead to significant changes in the central nervous system (CNS) that result in depression. Biological Factors (GENETIC): genetic factors play a role in the development of depressive disorders. The concordance rate for MDD among monozygotic (identical) twins is nearly 50%. That is, if one twin is affected, the second has about a 50% chance of being affected as well. or in- stance, certain genetic markers seem to be related to depression when accompanied by early childhood maltreatment or a history of stressful life events. In this case there is no gene directly related to the development of the mood disorder; however, there is a genetic marker associated with depression in the context of stressful life events. One of the more important aspects of understanding the role of ge- netics in relation to mental illness such as major depression may be in pharmacological treatments. Understanding genetic influences on the role of the transport of certain neurotransmitters, such as serotonin, across synapses will make it much easier to prescribe effective medical treatment of depression based on individual genetic patterns. Biochemical: The brain is a highly complex organ that contains billions of neurons. There is much evidence to support the concept that many CNS neurotransmitter abnormalities may cause clinical depression. Research suggests that depression results from the dysregulation of a number of neurotransmitter systems beyond serotonin and norepinephrine. Hormonal: The neuroendocrine characteristic most widely studied in relation to depression has been hyperactivity of the hypothalamic–pituitary– adrenal axis. People with major depression have increased urine cor- tisol levels and elevated levels of corticotrophin-releasing hormone. Dexamethasone, an exogenous steroid that suppresses cortisol, is used in the dexamethasone suppression test (DST) for depression. Results of this test are abnormal in about 50% of people with depression, which indicates hyperactivity of the hypothalamic–pituitary–adrenal axis. Inflammation: Inflammation is the body’s natural defence to physical injury. There is growing evidence that inflammation may be the result of psychological injury as well. Researchers have focused on two important blood com- ponents related to inflammation, C-reactive protein and interleukin-6. In young females with a history of adversity depression is accompanied by elevations in these blood components, but this elevation does not occur in children without a history of adversity. Adversity in life may compromise resilience and place children at risk for depression and other disorders. While we do not believe that inflammation causes depression, research indicates that it does play a role. Support for this belief includes the finding that about a third of people with major depression have elevated inflammatory biomarkers in the absence of a physical illness. Also, people who have inflammatory diseases have increased risk for major depression. Finally, people treated with cytokines to enhance immunity during cancer treatment develop major depression at a high rate. Diathesis–Stress Model: The diathesis–stress model of depression takes into account the inter- play of biology and life events in the development of depressive disorders. It is believed that psychosocial stressors and interpersonal events trigger neurophysical and neurochemical changes in the brain. Early life trauma may result in long-term hyperactivity of the CNS corticotropin-releasing factor (CRF), which releases the cortisol hormone, and norepinephrine systems, with a consequent neurotoxic effect on the hippocampus, which leads to overall neuronal loss. These changes could cause sensitization of the CRF circuits to even mild stress in adulthood, leading to an exaggerated stress response

Answer 5

Cognitive Theory: in cognitive theory the underlying assumption is that a person’s thoughts will result in emotions. If a person looks at their life in a posi- tive way, the person will experience positive emotions, but negative in- terpretation of life events can result in sorrow, anger, and hopelessness. Cognitive theorists believe that people may acquire a psychological predisposition to depression due to early life experiences. These experi- ences contribute to negative, illogical, and irrational thought processes that may remain dormant until they are activated during times of stress. Theorists found that people with depression process information in negative ways, even in the midst of positive factors. They believed that automatic, negative, repetitive, un- intended, and not readily controllable thoughts perpetuate depression. Three thoughts constitute Beck’s cognitive triad: 1. A negative, self-deprecating view of self 2. A pessimistic view of the world 3. The belief that negative reinforcement (or no validation for the self) will continue in the future Realizing that one has an ability to interpret life events in positive ways provides an element of control over emotions and, therefore, over depression. Learned Helplessness: An older but still plausible theory of depression is that of learned help- lessness. Seligman (1973) stated that although anxiety is the initial response to a stressful situation, it is replaced by depression if the person feels no control over the outcome of a situation. A person who believes that an undesired event is their fault and that nothing can be done to change it is prone to depression.

Answer 6

Two of the main neurotransmitters involved in mood are serotonin (5-hydroxytryptamine [5-HT]) and norepinephrine. Serotonin is an important regulator of sleep, appetite, and libido. Therefore serotonin circuit dysfunction can result in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability. Norepinephrine modulates attention and behaviour. It is stimulated by stressful situa- tions, which may result in overuse and a deficiency of norepinephrine. A deficiency, an imbalance as compared with other neurotransmitters, or an impaired ability to use available norepinephrine can result in apa- thy, reduced responsiveness, or slowed psychomotor activity. Research suggests that depression results from the dysregulation of a number of neurotransmitter systems beyond serotonin and norepi- nephrine. For example, glutamate is a common neurotransmitter that increases the ability of a nerve fibre to transmit information. A deficit in glutamate can interfere with normal neuron transmission in the ar- eas of the brain that affect mood, attention, and cognition. Stressful life events, especially losses, seem to be a significant fac- tor in the development of depression. Norepinephrine, serotonin, and acetylcholine play a role in stress regulation. When these neurotrans- mitters become overtaxed through stressful events, neurotransmitter depletion may occur. Research indicates that stress is associated with a reduction in neurogenesis, which is the ability of the brain to produce new brain cells. At this time, no single mechanism of depressant action has been found. The relationships among the serotonin, norepinephrine, dopa- mine, acetylcholine, gamma-aminobutyric acid (GABA), and glutamate systems are complex and need further assessment and study. However, treatment with medication that helps regulate these neurotransmitters has proven to be empirically successful in the treatment of many patients.

Answer 7

Female gender * Early childhood trauma * Stressful life events * Family history of depression, especially in first-degree relatives * High levels of neuroticism (a negative personality trait characterized by anxiety, fear, moodiness, worry, envy, frustration, jealousy, and loneliness) * Other disorders such as substance use, anxiety, and personality disorders * Chronic or disabling medical conditions

Answer 8

Assessment tools: Beck Depression Inventory: Hamilton Depression Rating Scale: asks about depressed mood, feelings of guilt, suicide, somatic symptoms (loss of appetite, heavy feelings in abd), general somatic symptoms (heaviness in limbs, back/ head), reproductive symptoms, illness anxiety, motor (slowness of thought and speech, decreased motor activity), work and activities, agitation Zung Self-Rating Depression Scale: Geriatric Depression Scale: The Patient Health Questionnaire–9 (PHQ-9), a short inventory that highlights predominant symptoms of depression, is presented here be- cause of its ease of use. Many clinicians also use the mnemonic SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal thoughts) to guide their assessment.

Answer 9

Suicidal ideation. The most dangerous aspect of MDD is a pre- occupation with death. A patient may fantasize about their funeral or experience recurring dreams about death. Beyond these passive fan- tasies are thoughts of wanting to die. As a whole, all of these nihilistic thoughts are referred to as suicidal ideation. Suicidal ideation, especially that in which the patient has a plan for suicide and the means to carry the plan out, represents an emergency requiring immediate intervention. Suicidal thoughts are a major reason for hospitalization for patients with major depression. Patients diagnosed with MDD should always be evaluated for suicidal ideation. Risk for suicide is increased when depression is accompanied by hopelessness, substance use problems, a recent loss or separation, a history of past suicide attempts, or acute suicidal ideation.

Answer 10

* You have said you are depressed. Tell me what that is like for you. * When you feel depressed, what thoughts go through your mind? * Have you gone so far as to think about taking your own life? * Do you have a suicide plan? * Do you have the means to carry out your plan? * Is there anything that would prevent you from carrying out your plan?

Answer 11

(loss of ability to experience joy or pleasure in living)

Answer 12

A depressed mood and anhedonia (loss of ability to experience joy or pleasure in living) are the key symptoms of depression. Almost 97% of people with depression have anhedonia. Anxiety, a common symptom in depression, is seen in about 60% to 90% of patients with depression. Psychomotor agitation may be evidenced by constant pacing and wringing of hands. The slowed movements of psychomotor retardation, however, are more common. Somatic complaints (e.g., headaches, malaise, backaches) are also common. Vegetative signs of depression, alterations in those activities necessary to support physical life and growth (e.g., change in bowel movements and eating habits, sleep distur- bances, lack of interest in sex), are universally present.

Answer 13

Affect is the outward presentation of a person’s internal state of being. It is reported as an objective finding based on the nurse’s assessment. A person who has depression sees the world through grey- coloured glasses. Posture is poor, and the patient may look older than their stated age. Facial expressions convey sadness and dejection, and the patient may have frequent bouts of weeping. Conversely, the patient may say that they are unable to cry. Feelings of worthlessness, guilt, anger, helplessness, hopelessness, and despair are readily reflected in the person’s affect. For example, the patient may not make eye contact, may speak in a monotone, may show little or no facial expression (flat affect), and may make only “yes” or “no” responses. Thought processes. During a depressive episode, the person’s abil- ity to solve problems and think clearly is negatively affected. Judgement is poor, and indecisiveness is common, largely because thinking is slow and memory and concentration are poor. People with depression also dwell on and exaggerate their perceived faults and failures and are un- able to focus on their strengths and successes. They may experience delusions of being punished for doing bad deeds or being a terrible person. Common statements of delusional thinking are “I have com- mitted unpardonable sins,” “God wants me dead,” and “I am wicked and should die.” Mood. Mood is the patient’s subjective experience of sustained emotions or feelings. People, when asked to describe their mood, will describe how they are feeling. Should a patient describe a feeling when asked about their mood, the clinician needs to follow up with a question asking about how long they have felt this way. Mood is about feel- ings that last over several days, weeks, or months. Feelings. Feelings frequently reported by those with depression include worthlessness, guilt, helplessness, hopelessness, and anger. Feelings of worthlessness range from feeling inadequate to having an unrealistically negative evaluation of self-worth. These feelings reflect the low self-esteem that is a painful partner to depression. Statements such as “I am no good” or “I’ll never amount to anything” are common. Anhedonia (an “without” + hedone “pleasure” = inability to feel happy) refers to the absence of happiness or pleasure in aspects of life that once made the patient happy. Guilt is a nearly universal accompaniment to depression. A person may ruminate over present or past failings: “I was never a good par- ent,” or “it’s my fault that project at work failed.” Cognitive changes. Helplessness is demonstrated by a person’s inability to solve problems in response to common concerns. In severe situations helplessness may be evidenced by the inability to carry out the simplest tasks (e.g., grooming, doing housework, working, caring for children) because they seem too difficult to accomplish. With feelings of helplessness come feelings of hopelessness, which are particularly correlated with suicidality. Even though most depressive episodes are time limited, people experiencing them believe that things will never change. This feeling of utter hopelessness can lead people to view suicide as a way out of constant mental pain. Hopelessness includes the following attributes: * Negative expectations for the future * Loss of control over future outcomes * Passive acceptance of the futility of planning to achieve goals * Emotional negativism, as expressed in despair, despondency, or de- pression Physical behaviour. Lethargy and fatigue may result in psychomotor retardation, in which movements are extremely slow, facial expres- sions are decreased, and the gaze is fixed. The continuum of psycho- motor retardation may range from slowed and difficult movements to complete inactivity and incontinence. Psychomotor agitation, in which patients constantly pace, bite their nails, smoke, tap their fingers, or engage in some other tension-relieving activity, may also be observed. At these times, patients commonly feel fidgety and unable to relax. Vegetative signs of depression refer to alterations in those activities necessary to support physical life and growth (e.g., eating, sleeping, elimination, sex). Appetite changes vary in individuals experiencing depression. Appetite loss is common, and sometimes patients can lose up to 5% of their body weight in less than a month. Other patients find they eat more often and complain of weight gain. Change in sleep pattern is a cardinal sign of depression. Often people experience insomnia, wake frequently, and have a total reduction in sleep, especially deep-stage sleep. Waking at 3 or 4 a.m. and then staying awake is common, as is sleeping for short periods only. For some, sleep is increased (hypersomnia) and provides an escape from painful feelings. Grooming, dressing, and personal hygiene may be markedly neglected. People who usually take pride in their appearance and dress may allow themselves to look shabby and unkempt. Sexual interest declines (loss of libido) during depression. Some men experience impotence, and a declining interest in sex often occurs among both men and women, which can further complicate marital and social relationships. Changes in bowel habits are common. Constipation is seen most frequently in patients with psychomotor retardation. Diarrhea occurs less frequently, often in conjunction with psychomotor agitation or anxiety. Communication. A person with depression may speak and comprehend very slowly. The lack of an immediate response by the patient to a remark does not necessarily mean the patient has not heard or chooses not to reply; the patient may need more time to comprehend what was said and then compose a reply. Religious beliefs and spirituality. Many studies have found a negative correlation between relational spiritual factors and depression. Specifically, it seems to be spiritual instability and a disappointment in a higher power that are predictors of depression. Encouraging a connection with religious or spiritual practices that have brought the pa- tient comfort in the past may be therapeutic.

Answer 14

is a strong feeling of displeasure or hostility. It is a natural outcome of profound feelings of helplessness. Anger in depression is often expressed inappropriately through hurtful verbal attacks, physical aggression toward others, or destruction of property, and anger may be directed toward the self in the form of suicidal or otherwise self- destructive behaviours (e.g., alcohol abuse, substance use, overeating, smoking). These behaviours often reinforce feelings of low self-esteem and worthlessness.

Answer 15

The core symptoms of depression in children and adolescents are the same as for adults, which are sadness and loss of pleasure. What differs is how these symptoms are displayed. For example, a very young child may cry, a school-aged child might withdraw, and a teenager may become irritable in response to feeling sad or hopeless. Younger children may suddenly refuse to go to school while adolescents may engage in substance use or sexual promiscuity and be preoccupied with death or suicide.

Answer 16

Because older persons are more likely to complain of physical illness than emotional concerns, depression might be overlooked. Older patients actually do have comorbid physical prob- lems, and it is difficult to determine whether fatigue, pain, and weakness are the result of an illness or depression. The Geriatric Depression Scale is a 30-item tool that is both valid and reliable in screening for depression in the older person.

Answer 17

Patients with depression often reject the advice, encouragement, and understanding of the nurse and others, and they often appear not to respond to nursing interventions and seem resistant to change. When this occurs, the nurse may experience feelings of frustration, hopeless- ness, and annoyance. These problematic responses can be altered in the following ways: * Recognizing any unrealistic expectations for yourself or the patient * Identifying feelings that originate with the patient * Understanding the roles that biology and genetics play in the pre- cipitation and maintenance of a depressed mood Realistic expecta- tions of self and the patient can decrease feelings of helplessness and increase a nurse’s self-esteem and therapeutic potential. You can discuss feelings of annoyance, hopelessness, and helplessness with peers and supervisors to separate personal feelings from those origi- nating with the patient. If personal feelings are not recognized, named, and examined, the nurse is likely to withdraw. People instinctively avoid situations and other people that arouse feelings of frustration, annoyance, or intimidation. If the nurse also has unresolved feelings of anger and depression, the complexity of the situation is compounded. There is no substitute for competent and sup- portive supervision to facilitate growth, both professionally and per sonally. Being supervised by a more experienced clinician and sharing with peers help minimize feelings of confusion, frustration, and isolation and can increase your therapeutic potential and self-esteem while you care for individuals with depression.

Answer 18

1.Always evaluate the patient’s risk for harm to self or others. Overt hostility is highly correlated with suicide. 2. Depression is a mood disorder that can be secondary to a host of medical or other psychiatric disorders, as well as to medications. A thorough medical and neurological examination helps determine if the depression is primary or secondary to another disorder. Essentially, evaluate whether: * The patient is psychotic * The patient has taken drugs or alcohol * Medical conditions are present * The patient has a history of a comorbid psychiatric syndrome (eating disorder, borderline or anxiety disorder) 3. Assess the patient’s past history of depression, what past treatments worked and did not work, and any events that may have triggered this epi- sode of depression. 4. Assess support systems, family, significant others, and the need for infor- mation and referrals.

Answer 19

Depression is a complex disorder, and individuals with depression have a variety of needs; therefore nursing diagnoses are many. How- ever, a high priority for the nurse is determining the risk for suicide, and the nursing diagnosis of Risk for suicide is always considered. Other key targets for nursing interventions are represented by the diagnoses of Hopelessness, Ineffective coping, Social isolation, Spiritual distress, and Self-care deficit (bathing, dressing, feeding, toileting).

Answer 20

Previous suicide attempts, putting affairs in order, giving away prized possessions, suicidal ideation (has plan, ability to carry it out), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness Risk for suicide Risk for self-mutilation Risk for self-harm ----------- Lack of judgement, memory difficulty, poor concentration, inaccurate interpretation of environment, negative ruminations, cognitive distortions Altered thought processes ------------ Difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope Ineffective coping Interrupted family processes Risk for impaired attachment Ineffective role performance -------------- Difficulty making decisions, poor concentration, inability to take action Decisional conflict --------------- Feelings of helplessness, hopelessness, powerlessness Hopelessness Powerlessness __________ Questioning the meaning of life and own existence, inability to participate in usual religious practices, conflict over spiritual beliefs, anger toward spiritual deity or religious representatives Spiritual distress Impaired religiosity Risk for impaired religiosity ___________ Feelings of worthlessness, poor self-image, negative sense of self, self-negating verbalizations, feeling of being a failure, expressions of shame or guilt, hypersensitivity to slights or criticism Chronic low self-esteem Situational low self-esteem ___________ Withdrawal, non-communicativeness, monosyllabic speech, avoidance of contact with others Impaired social interaction Social isolation Risk for loneliness ____________ Vegetative signs of depression: changes in sleeping, eating, grooming and hygiene, elimination, sexual patterns Self-care deficit (bathing, dressing, feeding, toileting) Imbalanced nutrition: less than body requirements Disturbed sleep pattern Constipation Sexual dysfunction

Answer 21

The Recovery Model: The recov- ery model emphasizes that individuals with mental illnesses, including depression, can learn to live with their disease. It is individuals who define who they are, not their diseases. Recovery is attained through partnership with health care providers who focus on the patient’s strengths. Treatment goals are mutually developed based on the patient’s personal needs and values, and interventions are evidence informed. The recovery model is consistent with the focus on patient-centred care, which is a key component of safe, quality health care. Remember that MDD can be a recurrent and chronic illness. Care should be directed not only at the resolution of the acute phase but also at long-term management.

Answer 22

The planning of care for patients with depression is geared toward the patient’s phase of depression, particular symptoms, and personal goals. At all times during the care of a person with depression, nurses and members of the health care team must be cognizant of the potential for suicide; therefore assessment of risk for self-harm (or harm to oth- ers) is ongoing. A combination of therapy (cognitive, behavioural, and interpersonal) and psychopharmacology is an effective approach to the treatment of depression across all age groups. Be aware that the vegetative signs of depression (e.g., changes in eating, sleeping, and sexual satisfaction), as well as changes in concentration, activity level, social interaction, care for personal appearance, and so on, often need targeting. The planning of care for a patient with depression is based on the individual’s symptoms and goals, and it at- tempts to encompass a variety of areas in the person’s life. Safety is always the highest priority.

Answer 23

There are three phases in the treatment of and recovery from major depression: 1. The acute phase (6 to 12 weeks) is directed at reduction of depres- sive symptoms and restoration of psychosocial and work function. Hospitalization may be required. 2. The continuation phase (4 to 9 months) is directed at prevention of relapse through pharmacotherapy, education, and depression- specific psychotherapy. 3. The maintenance phase (1 year or more) of treatment is directed at prevention of reoccurrences of depression. It is important to keep in mind that the primary goal of both the continuation and the maintenance phases is keeping the patient a func- tional and contributing member of the community after recovery from the acute phase.

Answer 24

Some patients with depression may be so withdrawn that they are un- willing or unable to speak. Nurses often experience some difficulty communicating with patients without talking; just sitting with them in silence may seem like a waste of time or be uncomfortable. As anxi- ety increases, the nurse may start daydreaming, feel bored, remember something that “must be done now,” and so on. It is important to be aware, however, that this time can be meaningful, especially for the nurse who has a genuine interest in learning about the patient with depression.

Answer 25

One basic premise of the recovery model of mental illness is that each person controls their own treatment based on individual goals. Within this model, health teaching is especially important because it allows patients to make informed choices. Health teaching is also an avenue for providing hope to the patient and should include the following in- formation: * Depression is an illness that is beyond a person’s voluntary control. * Although it is beyond voluntary control, depression can be managed through medication and lifestyle. * Illness management depends in large part on understanding personal signs and symptoms of relapse. * Illness management depends on understanding the role of medication and possible adverse effects of medication. * Long-term management is best assured if the patient undergoes psychotherapy along with taking medication. * Identifying and coping with the stress of interpersonal relationships, whether they are familial, social, or occupational, is a key to illness management. * Including the family in discharge planning is also important and helps the patient in the following ways: * Increases the family’s understanding and acceptance of the family member and helps family recognize the importance of medication adherence during the aftercare period. * Increases the patient’s use of aftercare facilities in the community. * Contributes to higher overall adjustment in the patient after discharge.

Answer 26

Depression self-control: Personal actions to minimize melancholy and maintain interest in life events Intermediate indicators: Reports improved mood Adheres to therapy schedule Takes medication as prescribed Follows treatment plan Short-term indicators: Monitors intensity of depression Identifies precursors of depression Plans strategies to reduce effects of precursors Reports changes in symptoms to health care provider

Answer 27

Intervention When a patient is mute, use the technique of making observations: “There are many new pictures on your wall.” “You are wearing your new shoes.” “You ate some of your breakfast.” Use simple, concrete words. Allow time for the patient to respond. Listen for covert messages and ask about suicide plans. Avoid platitudes such as “Things will look up,” “Everyone gets down once in a while,” or “Tomorrow will be better.” Rationale When a patient is not ready to talk, direct questions can raise the patient’s anxiety level and frustrate the nurse. Pointing to commonalities in the environment draws the patient into and reinforces reality. Slowed thinking and difficulty concentrating impair comprehension. Slowed thinking necessitates time to formulate a response. People often experience relief and a decrease in feelings of isolation when they share thoughts of suicide. Platitudes tend to minimize the patient’s feelings and can increase feelings of guilt and worthlessness, because the patient cannot “look up” or “snap out of it.”

Answer 28

Intervention Help the patient question underlying assumptions and beliefs and consider alternative explanations for problems. Work with the patient to identify cognitive distortions that encourage negative self-appraisal. For example: a. Overgeneralizations b. Self-blame c. Mind reading d. Discounting of positive attributes Encourage activities that can raise self-esteem. Identify need for (1) problem-solving skills, (2) coping skills, and (3) assertiveness skills. Encourage exercise, such as running or weight lifting. Encourage formation of supportive relationships, such as through sup- port groups, therapy, and peer support. Provide information referrals, when needed, for religious or spiritual information (e.g., readings, programs, tapes, community resources). Rationale Reconstructing a healthier and more hopeful attitude about the future can alter depressed mood. Cognitive distortions reinforce a negative, inaccurate perception of self and world. a. The patient takes one fact or event and makes a general rule out of it (“He always ...”; “I never...”). b. The patient consistently blames self for everything perceived as negative. c. The patient assumes others do not like them without any real evidence that assump- tions are correct. d. The patient focuses on the negative. Many people with depression, especially women, are not taught a range of problem-solv- ing and coping skills. Increasing social, family, and job skills can change negative self- assessment. Exercise can improve self-concept and potentially shift neurochemical balance. Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs. Spiritual and existential issues may be heightened during depressive episodes; many people find strength and comfort in spirituality or religion.

Answer 29

In addition to feelings of hopelessness, despair, and physical discomfort, signs of physical neglect may be apparent, in which case nursing measures for improving physical well-being and promoting adequate self-care are initiated.

Answer 30

Safe, quality inpatient care requires the skills of a well-coordinated team. Treating a patient with depression requires the skills of nurses and prescribers. Other members of the team include mental health technicians, pharmacists, dietitians, social workers, and the patient’s significant others. Safety becomes the most important issue facing a team that cares for people with depression who may be at high risk for suicide. Suicide pre- cautions are usually instituted and include the removal of all harmful ob- jects such as “sharps” (e.g., razors, scissors, nail files), strangulation risks (e.g., belts), and medication that can be used to overdose. Some patients with severe depression may need to have someone check on them frequently, perhaps every 15 minutes, or even have one-to-one observation.

Answer 31

Nutrition—Anorexia Offer small, high-calorie and high-protein snacks frequently throughout the day and evening. Low weight and poor nutrition render the patient susceptible to illness. Small, frequent snacks are more easily tolerated than large plates of food when the patient is anorexic. _____ Offer high-protein and high-calorie fluids frequently throughout the day and evening. These fluids prevent dehydration and can minimize constipation. ______ When possible, encourage family or friends to remain with the patient during meals. This strategy reinforces the idea that someone cares, can raise the patient’s self-esteem, and can serve as an incentive to eat. _______ Ask the patient which foods or drinks they like. Offer choices. Involve the dietitian. The patient is more likely to eat the foods provided. ______ Weigh the patient weekly and observe the patient’s eating patterns. Monitoring the patient’s status gives the information needed for revision of the intervention. ______ Sleep—Insomnia Provide periods of rest after activities. Fatigue can intensify feelings of depression. ______ Encourage the patient to get up and dress and to stay out of bed during the day. Minimizing sleep during the day increases the likelihood of sleep at night. ______ Encourage the use of relaxation measures in the evening (e.g., tepid bath, warm milk). These measures induce relaxation and sleep. ________ Reduce environmental and physical stimulants in the evening—provide decaffeinated coffee, soft lights, soft music, and quiet activities. Decreasing caffeine and epinephrine levels increases the possibility of sleep. ________ Self-Care Deficits Encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment, and so forth. Being clean and well groomed can temporarily increase self-esteem. _______ When appropriate, give step-by-step reminders such as “Wash the right side of your face; now the left.” Slowed thinking and difficulty concentrating make organizing simple tasks difficult. _________ Elimination—Constipation Monitor intake and output, especially bowel movements. Many patients with depression are constipated. If the condition is not checked, fecal impaction can occur. _________ Offer foods high in fibre, and provide periods of exercise. Roughage and exercise stimulate peristalsis and help evacuation of fecal material. ________ Encourage the intake of fluids. Fluids help prevent constipation. _________ Evaluate the need for laxatives and enemas. These measures prevent fecal impaction.

Answer 32

Antidepressant drugs can positively alter poor self-concept, degree of withdrawal, vegetative signs of depression, and activity level. Target symptoms include: * Sleep disturbance * Appetite disturbance (decreased or increased) * Fatigue * Decreased sex drive * Psychomotor retardation or agitation * Diurnal variations in mood (often worse in the morning) * Impaired concentration or forgetfulness * Anhedonia A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. If a patient is acutely suicidal, electro- convulsive therapy can be a reliable and effective alternative. The goal of antidepressant therapy is the complete remission of symptoms. Antidepressants may precipitate a psychotic episode in a person with schizophrenia or a manic episode in a patient with bipolar dis- order. Patients with bipolar disorder often receive a mood-stabilizing drug along with an antidepressant.

Answer 33

The imbalance of certain neurotransmitters (serotonin and norepinephrine) contributes to depression in certain parts of the brain. Prefrontal cortex: regulates role in executive functions and emotional control and memory. Limbic system: regulates activities such as emotions, physical and sexual drives, and the stress response, as well as processing, learning, and memory (amygdala, hypothalamus, hippocampus). Anterior cingulate cortex: regulates heart rate and blood pressure. Other functions include decision making, emotional regulation, error detection, preparation for tasks, and executive functions. Various Parts of the Brain Along the Noradrenergic Pathway; The axons of these neurons project upward through the forebrain to the cerebral cortex, the limbic system, the thalamus, and the hippocampus. Norepinephrine (NE) and the Noradrenergic System: plays a major role in mood and emotional behaviour as well as energy, drive, anxiety, focus, and metabolism. Norepinephrine- receptors (a1, a2, B1, B2); causes changes in mood, in attention and arousal, stimulate sympathetic branch of ANS for fight or flight in response to stress; [decreases- depression, increases- anxiety states, mania, schizoprenia] Various Parts of the Brain Along the Serotonergic Pathway The axons of serotonergic neurons originate in the raphe nuclei of the brainstem and project to the cerebral cortex, the limbic system, cerebellum, and spinal cord. Serotonin (5-HT) and the Serotonergic System: involved in the regulation of pain, depression, pleasure, anxiety, panic arousal, sleep cycle, carbohydrate craving, and premenstrual syndrome. Serotonin: receptors (5-HT); plays a role in sleep regulation, hunger, mood states, and pain perception, alters hormonal activity, play a role in agression and sexual behaviour, involved in alertness and inflammatory response, stimulates gastric secretion [decreases- depression, increases- anxiety states]

Answer 34

Medications for depression include the selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), serotonin antagonist and reuptake inhibitors (SARIs), norepinephrine–dopamine reuptake inhibitor (NDRI), noradrenergic and specific serotonergic antidepressants (NaSSAs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). They all work equally well and are chosen by their safety profile and side effects.* All have a delayed response, a discontinuation syndrome, and a Black Box Warning for suicide.

Answer 35

increase the availability of one or more of the neurotransmitters, serotonin, nor- epinephrine, or dopamine. Each of the antidepressants has different adverse ef- fects, costs, safety issues, and maintenance considerations. Selection of the appropriate antidepressant is based on the following considerations: * Adverse-effect profile (e.g., sexual dysfunction, weight gain) * Ease of administration * History of past response * Safety and medical considerations

Answer 36

Citalopram (Celexa) Fluoxetine (Prozac) Fluvoxamine (Luvox) P aroxetine (Paxil) Sertraline (Zoloft) Escitalopram (Cipralex) LINE/TINE/MINE/PRAM Blocks the reuptake of serotonin First-line treatment for major depression Some SSRIs activate and others sedate; choice depends on patient symptoms Risk of lethal overdose minimized with SSRIs AE: Agitation, insomnia, headache, nausea and vomiting, sexual dysfunction, hyponatremia, blurred vision, urinary retention Warning; Discontinuation syndrome— dizziness, insomnia, nervousness, irritability, nausea, and agitation—may occur with abrupt withdrawal (depending on half-life); taper slowly Contraindicated in people taking MAOIs Essentially, the SSRIs selectively block the neuronal uptake of serotonin (e.g., 5-HT, 5-HT1 receptors), which increases the availability of serotonin in the synaptic cleft. Because the SSRIs cause relatively few adverse effects and have low cardiotoxicity, they are less dangerous than older antidepressants when taken in overdose. Indications. The SSRIs have a broad base of clinical use. In addi- tion to their use in treating depressive disorders, the SSRIs have been prescribed with success to treat some anxiety disorders, in particular, obsessive-compulsive disorder and panic disorder. Fluoxetine has been found to be effective in treating some women who suffer from late luteal phase dysphoric disorder and bulimia nervosa. Common adverse reactions. Drugs that selectively enhance synap- tic serotonin within the CNS may induce agitation, anxiety, sleep dis- turbance, tremor, sexual dysfunction (primarily anorgasmia), or tension headache. **The effect of the SSRIs on sexual performance may be the most significant undesirable outcome reported by patients. Autonomic reactions (e.g., dry mouth, sweating, weight change, mild nausea, loose bowel movements) may also be experienced with the SSRIs. Potential toxic effects. One rare and life-threatening event associ- ated with SSRIs is serotonin syndrome. This syndrome is thought to be related to overactivation of the central serotonin receptors, caused by either too high a dose or interaction with other drugs, including non-prescription medication like St. John’s wort. Symptoms include abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental state (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change. Severe manifestations can induce hyperpyrexia (excessively high fever), car- diovascular shock, or death. The risk of this syndrome seems to be greatest when an SSRI is ad- ministered in combination with a second serotonin-enhancing agent, such as a monoamine oxidase inhibitor (MAOI).

Answer 37

Venlafaxine (Effexor) Duloxetine (Cymbalta) VD Blocks the reuptake of serotonin and norepinephrine Effexor is a popular next-step strategy after trying SSRIs Cymbalta has the advantage of decreasing neuropathic pain (similar to TCAs) AE: Hypertension (venlafaxine), nausea, insomnia, dry mouth, sweating, agitation, headache, sexual dysfunction Warning: Monitor blood pressure with Effexor, especially at higher doses and with a history of hypertension Hypertension may be particularly noted in the diastolic measurement Discontinuation syndrome (see SSRIs above) Contraindicated in people taking MAOIs The SNRIs inhibit the reuptake of both serotonin and norepinephrine. Pharmacological adverse effects are similar to those of the SSRIs, although the SSRIs may be tolerated better. The SNRIs are indicated for MDD.

Answer 38

Venlafaxine (Effexor XR) Duloxetine (Cymbalta) Blocks the reuptake of norepinephrine and enhances its transmission Antidepressant effects similar to SSRIs and TCAs Useful with severe depression and impaired social functioning AE Insomnia, sweating, dizziness, dry mouth, constipation, urinary hesitancy, tachycardia, decreased libido Warning Contraindicated in people taking MAOIs

Answer 39

Bupropion (Wellbutrin) Blocks the reuptake of norepinephrine and dopamine Not indicated for patients under 18 years of age Stimulant action may reduce appetite May increase sexual desire Used as an aid to QUIT SMOKING AE Agitation, insomnia, headache, nausea and vomiting, seizures (0.4%) Warning Contraindicated in people taking MAOIs High doses increase seizure risk, especially in people who are predisposed to seizures

Answer 40

Mirtazapine (Remeron) Blocks α1-adrenergic receptors that normally inhibit norepinephrine and serotonin Antidepressant effects equal SSRIs and may occur faster AE Weight gain, sedation, dizziness, headache; sexual dysfunction is rare Warning Drug-induced somnolence exaggerated by alcohol, benzodiazepines, and other CNS depressants Contraindicated in people taking MAOIs

Answer 41

Amitriptyline (Elavil) Clomipramine (Anafranil) Nortriptyline (Aventyl) Inhibits the reuptake of serotonin and norepinephrine (similar to SNRIs) Antagonizes adrenergic, histaminergic, and muscarinic receptors Therapeutic effects similar to SSRIs, but adverse effects are more prominent May work better in melancholic depression TCAs can worsen many cardiac and other medical conditions AE Antichollinergic effects Dry mouth, constipation, urinary retention, blurred vision, orthostatic hypotension, cardiac toxicity, sedation Warning Lethal in overdose Use cautiously in older persons and those with cardiac disorders, elevated intraocular pressure, urinary retention, hyperthyroidism, seizure disorders, or liver or kidney dysfunction Contraindicated in people taking MAOIs The TCAs inhibit the reuptake of nor- epinephrine and serotonin by the presynaptic neurons in the CNS, increasing the amount of time norepinephrine and serotonin are available to the postsynaptic receptors. This increase in norepineph- rine and serotonin in the brain is believed to be responsible for mood elevations. Indications. The sedative effects of the TCAs are attributed to the blockage of histamine receptors A stimulating TCA, such as desipramine (Desipramine), may be best for a patient who is lethargic and fatigued. If a more sedating ef- fect is needed for agitation or restlessness, drugs such as amitriptyline (Elavil) and doxepin (Sinequan) may be more appropriate choices. Re- gardless of which TCA is given, the initial dose should always be low and increased gradually. Common adverse reactions. The chemical structure of the TCAs closely resembles that of antipsychotic medications, and the anticholinergic actions are similar (e.g., dry mouth, blurred vision, tachycardia, constipation, urinary retention, esophageal reflux). These adverse effects are more common and more severe in patients taking antidepressants than in patients taking antipsychotic medica- tions. They usually are not serious and are often transitory, but uri- nary retention and severe constipation warrant immediate medical attention. Weight gain is also a common complaint among people taking TCAs. The α-adrenergic blockade of the TCAs can produce postural-or- thostatic hypotension and tachycardia. Postural hypotension can lead to dizziness and increase the risk for falls. Administering the total daily dose of TCA at night is beneficial for two reasons: (1) most TCAs have sedative effects and thereby aid sleep, and (2) the minor adverse effects occur while the individual is sleeping, which increases adherence to drug therapy. Potential toxic effects. The most serious effects of the TCAs are cardiovascular: dysrhythmias, tachycardia, myocardial infarction, and heart block have been reported. Because the cardiac adverse effects are so serious, TCA use is considered a risk in older persons and patients with cardiac disease. Adverse drug interactions. A few of the more common medi- cations usually not given while TCAs are being used are MAOIs, phenothiazines, barbiturates, disulfiram, oral contraceptives (or other estrogen preparations), anticoagulants, some antihyperten- sives, benzodiazepines, and alcohol. Contraindications. People who have recently had a myocardial infarction (or other cardiovascular problems), those with narrow-angle glaucoma or a history of seizures, and women who are pregnant should not be treated with TCAs, except with extreme caution and careful monitoring.

Answer 42

Phenelzine (Nardil) & Tranylcypromine (Parnate); Inhibits the enzyme monoamine oxidase, which normally breaks down neurotransmitters, including serotonin and norepinephrine Moclobemide (Manerix); Acts on serotonin, norepinephrine, and dopamine Efficacy similar to other antidepressants, but dietary restrictions and potential drug interactions make this drug type less desirable AE Insomnia, nausea, agitation, confusion Potential for hypertensive crisis or serotonin syndrome with concurrent use of other antidepressants Warning Contraindicated in people taking other antidepressants Tyramine-rich food could bring about a hypertensive crisis Many other drug interactions Monoamine oxidase inhibitors. The enzyme monoamine oxidase is responsible for inactivating, or breaking down, certain monoamine neurotransmitters in the brain, such as norepinephrine, serotonin, do- pamine, and tyramine. When a person ingests an MAOI, these amines do not get inactivated, and there is an increase of neurotransmitters available for synaptic release in the brain. The increase in norepinephrine, serotonin, and dopamine is the desired effect because it results in mood elevation. The increase in tyramine, on the other hand, poses a problem. When the level of tyramine increases, and it is not inactivated by monoamine oxidase, high blood pressure, hypertensive crisis, and eventually cerebrovascular accident can occur. Therefore people taking these drugs must reduce or eliminate their intake of foods and drugs that contain high amounts of tyramine. Because people with depression are often lethargic, confused, and apathetic, adherence to strict dietary limitations may not be realistic. That is why MAOIs, although highly effective, are not often given as a first-line treatment. Indications. MAOIs are particularly effective for people with atypical depression (characterized by mood reactivity, oversleeping, and overeating), along with panic disorder, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and bulimia. The MAOIs commonly used in Canada at pres- ent are phenelzine (Nardil) and tranylcypromine sulphate (Parnate). Common adverse reactions. Some common and troublesome long-term adverse effects of the MAOIs are orthostatic hypotension, weight gain, edema, change in cardiac rate and rhythm, constipation, urinary hesitancy, sexual dysfunction, vertigo, overactivity, muscle twitching, hypomanic and manic behaviour, insomnia, weakness, and fatigue. Potential toxic effects. The most serious reaction to the MAOIs is an increase in blood pressure, with the possible development of in- tracranial hemorrhage, hyperpyrexia, convulsions, coma, and death. Therefore routine monitoring of blood pressure, especially during the first 6 weeks of treatment, is necessary. Because many drugs, foods, and beverages can cause an increase in blood pressure in patients taking MAOIs, hypertensive crisis is a constant concern. The hypertensive crisis usually occurs within 15 to 90 minutes of ingestion of the contraindicated substance. Early symptoms include ir- ritability, anxiety, flushing, sweating, and a severe headache. The patient then becomes anxious, restless, and develops a fever. Eventually the fever becomes severe, seizures ensue, and coma or death is possible. When a hypertensive crisis is suspected, immediate medical atten- tion is crucial. If ingestion is recent, gastric lavage and charcoal may be helpful. Pyrexia is treated with hypothermic blankets or ice packs. Fluid therapy is essential, particularly with hyperthermia. A short- acting antihypertensive agent such as nitroprusside, nitroglycerine, or phentolamine may be used. Intravenous benzodiazepines are useful for agitation and seizure control. Contraindications. The use of MAOIs may be contraindicated with each of the following: * Cerebrovascular disease * Hypertension and congestive heart failure * Liver disease * Consumption of foods containing tyramine, tryptophan, and dopamine * Use of certain medications * Recurrent or severe headaches * Surgery in the previous 10 to 14 days * Age younger than 16 years

Answer 43

Symptoms * Hyperactivity or restlessness * Tachycardia → cardiovascular shock * Fever → hyperpyrexia * Elevated blood pressure * Altered mental states (delirium) * Irrationality, mood swings, hostility * Seizures → status epilepticus * Myoclonus, incoordination, tonic rigidity * Abdominal pain, diarrhea, bloating * Apnea → death Interventions * Remove offending agents * Initiate symptomatic treatment: * Serotonin receptor blockade with cyproheptadine, methysergide, propranolol * Cooling blankets, chlorpromazine for hyperthermia * Dantrolene, diazepam for muscle rigidity or rigours * Anticonvulsants * Artificial ventilation * Paralysis

Answer 44

The patient and family should be told that mood elevation may take from 7 to 28 days. Up to 6 to 8 weeks may be required for the full effect to be reached and for major depressive symptoms to subside. * The family should reinforce this information frequently to the family mem- ber with depression, who may have trouble remembering and may respond to ongoing reassurance. * The patient should be reassured that drowsiness, dizziness, and hypoten- sion usually subside after the first few weeks. * The patient should be cautioned to be careful when working around ma- chines, driving cars, and crossing streets because of possible altered re- flexes, drowsiness, or dizziness. * Alcohol can block the effects of antidepressants. The patient should be told to refrain from drinking. * If possible, the patient should take the full dose at bedtime to reduce the experience of adverse effects during the day. * If the bedtime dose (or the once-a-day dose) is missed, the patient should take the dose within 3 hours; otherwise, the patient should wait until the usual medi- cation time on the next day. The patient should not double the dose. * Suddenly stopping TCAs can cause nausea, altered heartbeat, nightmares, and cold sweats within 2 to 4 days. The patient should call the primary care provider or take one dose of the TCA until the primary care provider can be contacted.

Answer 45

Avocados, especially if over-ripe; fermented bean curd; fermented soybean; soybean paste Figs, especially if over-ripe; bananas, in large amounts Meats that are fermented, smoked, or otherwise aged; spoiled meats; liver, unless very fresh Fermented varieties; bologna, pepperoni, salami, others Dried or cured fish; fish that is fermented, smoked, or otherwise aged; spoiled fish Practically all cheeses Yeast extract (e.g., Marmite, Bovril) Some imported beers, Chianti wines Protein dietary supplements; soups (may contain protein extract); shrimp paste; soy sauce Drugs That Can Interact With Monoamine Oxidase Inhibitors (MAOIs) * Over-the-counter medications for colds, allergies, or congestion (any product containing ephedrine or phenylpropanolamine) * Tricyclic antidepressants (imipramine, amitriptyline) * Narcotics * Antihypertensives (methyldopa, spironolactone) * Amine precursors (levodopa, L-tryptophan) * Sedatives (alcohol, barbiturates, benzodiazepines) * General anesthetics * Stimulants (amphetamines, cocaine)

Answer 46

* Educate and provide details to the patient and family to avoid certain foods and all medications (especially cold remedies) unless prescribed by and discussed with the patient’s primary care provider * Give the patient a wallet card describing the MAOI regimen. * Instruct the patient to avoid Chinese restaurants (sherry, brewer’s yeast, and other contraindicated products may be used). * Advise the patient to go to the emergency department immediately if they have a severe headache. * Ideally, blood pressure should be monitored during the first 6 weeks of treatment (for both hypotensive and hypertensive effects). * After the MAOI is stopped, instruct the patient that dietary and drug restrictions should be maintained for 14 days.

Answer 47

There is evidence that depression has a negative effect on birth outcomes. Pre- eclampsia, diabetes, and hypertension have all been associated with maternal depression. Low birth weight, preterm birth, and small size for gestational age have been noted effects in infants born to maternal depression. It is known that antidepressants cross the placenta. Treat- ment of severe depression, particularly with suicidal ideation, must weigh out the risks versus the benefits.

Answer 48

AE Hypotension Insomnia Changes in cardiac rhythm Anorgasmia or sexual impotence Urinary hesitancy or constipation Weight gain Hypotension is a normal adverse effect of MAOIs. Orthostatic blood pressures should be taken—first lying down, then sitting or standing after 1–2 minutes. Hypotension may be a dangerous adverse effect, especially in older persons who may fall and sustain injuries as a result of dizziness from the blood pressure drop. Toxic effects Hypertensive crisis * Severe headache * Tachycardia, palpitations * Hypertension * Nausea and vomiting Patient should go to local emergency department immediately—blood pressure should be checked. One of the following may be given to lower blood pressure: * 5 mg intravenous phentolamine * Sublingual nifedipine to promote vasodilation Patients may be prescribed a 10 mg nifedipine capsule to carry in case of emergency.

Answer 49

In 2005 Health Canada issued a Black Box Warn- ing for all antidepressants, alerting the public to the increased risk for suicidal thinking or suicide attempts in children or adolescents under the age of 18 who are taking antidepressants. Following the Black Box Warning, the number of prescriptions written for SSRIs for children and young adults decreased, but the rates of suicide in those age groups actually increased. Dudley and colleagues concluded that the risk for suicide is greater in children and adolescents with depression who do not take antidepressants. To minimize the risk for suicide in people taking antidepressants, close monitoring by health care providers and patient and caregiver educa- tion are essential.

Answer 50

Polypharmacy and the normal process of aging contribute to concerns about prescribing antidepressants for older persons. SSRIs are a first-line treatment for older persons, but they have the potential for aggravated adverse ef- fects. Starting doses are recommended to be half the lowest adult dose, with dose adjustments occurring no more frequently than every 7 days. TCAs and MAOIs have adverse-effect profiles that are more dan- gerous for older persons, specifically cardiotoxicity with TCAs and hypotension with both classes. Any medication with an adverse effect of hypotension or sedation in older persons increases the risk for falls. Older persons should be cautioned against abrupt discontinuation of antidepressants because of the possibility of discontinuation syndrome, which causes anxiety, dysphoria, flulike symptoms, dizziness, excessive sweating, and insomnia.

Answer 51

(ECT) is a procedure in which electrical currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful Indications. ECT is an effective acute treatment for non-responsive depression. Psychotic illnesses are the second most common indication for ECT. For drug-resistant patients with psy- chosis, a combination of ECT and antipsychotic medication has resulted in sustained improvement about 80% of the time. Depression associated with bipolar disorder remits in about 50% of the cases after ECT. While medication is generally the first line of treatment, ECT may be a primary treatment in the following cases: * When a patient is experiencing intense suicidal ideation, and there is a need for a rapid, definitive response * When a patient is severely malnourished, exhausted, and dehydrated due to lengthy depression (after rehydration) * If previous medication trials have not successfully treated the illness * If the patient chooses * When there is marked agitation, marked vegetative symptoms, or catatonia * For major depression with psychotic features * In pregnant people * For people with rapid cycling mood swings (four or more in one year) ECT is not effective, however, in patients with dysthymia, atypical depression, personality disorders, drug dependence, or depression secondary to situational or social difficulties. Risk factors. Using ECT requires clinicians to weigh the risk of us- ing this method versus the risk of suicide, quality of life, and potential complications. Several conditions pose risks and require careful assess- ment and management. For example, because the heart can be stressed at the onset of the seizure and for up to 10 minutes after, careful as- sessment and management of hypertension, congestive heart failure, cardiac arrhythmias, and other cardiac conditions is warranted. ECT also stresses the brain as a result of increased cerebral oxygen, blood flow, and intracranial pressure. Conditions such as brain tumours and subdural hematomas may increase the risk of using ECT. Providers of care and patients need to weigh the risk of continued disability or potential suicide from depression against ECT treatment risks. Procedure. The usual course of ECT for a patient with depression is two or three treatments per week to a total of 6 to 12 treatments. The procedure is explained to the patient, and informed consent is obtained from the patient or the patient’s substitute decision maker. The patient is usually given a general anesthetic to induce sleep and a muscle-par- alyzing agent to prevent muscle distress and fractures. These medica- tions have revolutionized the comfort and safety of ECT. Patients should have a pre-ECT assessment, including a chest X- ray, electrocardiogram (ECG), urinalysis, complete blood count, blood urea nitrogen, and electrolyte panel. Benzodiazepines should be dis- continued, as they will interfere with the seizure process. An electroencephalogram (EEG) monitors brain waves, and an ECG monitors cardiac responses. Brief seizures (30 to 60-plus seconds) are deliberately induced by an electrical current (as brief as 1 second) transmitted through electrodes attached to one or both sides of the head. Adverse reactions. Patients wake about 15 minutes after the pro- cedure. The patient is often confused and disoriented for several hours. The nurse and family may need to orient the patient frequently during the course of treatment. Most people experience what is called retro- grade amnesia, which is a loss of memory of events leading up to and including the treatment itself.

Answer 52

(TMS) is a non-invasive treatment modality that uses magnetic resonance imaging (MRI)–strength mag- netic pulses to stimulate focal areas of the cerebral cortex (Figure 13.6). Indications. In 2002 Canada approved the use of TMS for patients who have been unresponsive to at least one antidepressant. Research- ers suggest that TMS be used to enhance cognitive function in healthy, non-depressed individuals. Risk factors. The only absolute contraindication to this procedure is the presence of metal in the area of stimulation. Cochlear implants, brain stimulators, or medication pumps are examples of metals that could interfere with the procedures Procedure. Outpatient treatment with TMS takes about 30 min- utes and is typically ordered for 5 days a week for 4 to 6 weeks. Pa- tients are awake and alert during the procedure. An electromagnet is placed on the patient’s scalp, and short, magnetic pulses pass into the prefrontal cortex of the brain. These pulses are similar to those used by MRI scanners but are more focused. The pulses cause electrical charges to flow and induce neurons to fire or become active. During TMS, patients feel a slight tapping or knocking in the head, contraction of the scalp, and tightening of the jaw. Potential adverse reactions. After the procedure, patients may ex- perience a headache and lightheadedness. No neurological deficits or memory problems have been noted. Seizures are a rare complication of TMS. Most of the common adverse effects of TMS are mild and include scalp tingling and discomfort at the administration site.

Answer 53

The use of vagus nerve stimulation (VNS) originated as a treatment for epilepsy. VNS is approved in Canada for treatment-resistant depression (TRD). Clinicians noted that while VNS decreased seizures, it also appeared to improve mood in a population that normally experiences increased rates of depression. The theory behind VNS relates to the action of the vagus nerve, the longest cranial nerve, which extends from the brainstem to organs in the neck, chest, and abdomen. Researchers believe that electrical stimulation of the vagus nerve results in boosting the level of neurotransmitters, thereby improving mood and also improving the action of antidepressants. Procedure. The surgery to implant VNS is typically an outpatient procedure. A pacemaker-like device is implanted surgically into the left chest wall. The device is connected to a thin, flexible wire that is threaded upward and wrapped around the vagus nerve on the left side of the neck. After surgery, an infrared magnetic wand is held against the chest while a personal computer or personal digital assistant is used to program the frequency of pulses. Pulses are usually delivered for 30 seconds, every 5 minutes, 24 hours a day. Antidepressant action usually occurs in several weeks. Non-surgical methods of VNS include deep diaphragmatic breath- ing, “om” chanting, and collecting saliva in your mouth and then sub- merging your tongue in the saliva pool. Potential adverse reactions. The implantation of VNS is a surgical procedure, carrying with it the risks inherent in any surgical procedure (e.g., pain, infection, sensitivity to anesthesia). Ad- verse effects of active VNS therapy are due to the position of the lead on the vagus nerve, which is close to the laryngeal and pharyngeal branches of the left vagus nerve. Voice alteration occurs in more than half of patients. Other adverse effects include neck pain, cough, paresthesia, and dyspnea, which tend to decrease with time. The device can be temporarily turned off at any time by placing a special magnet over the implant.

Answer 54

Nurses and nurse practitioners are qualified to provide counselling, so- cial skills training, and group therapy

Answer 55

CBT, interpersonal therapy (IPT), time-limited focused psychotherapy, and behavioural therapy all are considered especially effective in the treatment of mild to moderate depression. However, only CBT and IPT were shown to demonstrate superiority in the maintenance phase. CBT helps people change their negative thought patterns and behaviours, whereas IPT focuses on working through personal relationships that may contribute to depression.

Answer 56

Group therapy is a widespread modality for the treatment of depression; it increases the number of people who can receive treatment at a decreased cost per individual. Another advantage is that groups offer patients an opportunity to socialize and share common feelings and concerns, which decreases feelings of isolation, hopelessness, helplessness, and alienation. Therapy groups also provide a controlled environment in which patients can explore their patterns of interaction and response to others, which may contribute to or exac- erbate their depression.

Answer 57

Priority areas for further development and research are: * Improving screening for high-risk ages and groups, including: * Individuals in late adolescence and early adulthood * Women in reproductive years * Adults and older persons with medical problems (e.g., pain) * People with a family history of depression * Increasing education, particularly about the link between physical symptoms and depression * Integrating psychopharmacological treatment augmented with psy- chological and other non-pharmacological therapies * Inclusion of more self-care strategies, such as: * Promotion of sleep hygiene * Increase in exercise * Better overall health care

Answer 58

Outcomes relating to thought processes, self-esteem, and social interactions are frequently formulated, because these areas are often problematic in people with depression. Physical needs warrant nursing or medical attention. If a patient has lost weight because of anorexia, is the appetite returning? If the patient was constipated, are the bowels now functioning normally? If the pa- tient was suffering from insomnia, are they now sleeping 6 to 8 hours per night? If indicators have not been met, an analysis of the data, nurs- ing diagnoses, goals, and planned nursing interventions is made. The care plan is reassessed and reformulated as necessary.

Answer 59

Diagnosis The nurse evaluates Ms. Glessner’s strengths and weaknesses and decides to concentrate on two initial nursing diagnoses that seem to have the highest priority: 1. Risk for suicide related to separation from 2-year relationship, as evidenced by actual suicide attempt Outcomes Identification Patient refrains from attempting suicide. Planning Because Ms. Glessner is discharged after 48 hours, the issue of disturbance in self-esteem continues to be addressed in her therapy after discharge. Ms. Ward later reviews the goals for her work with Ms. Glessner in the community. Implementation Short-Term Goal 1. Patient expresses at least one reason to live, apparent by the second day of hospitalization. Intervention 1a. Observe patient every 15 minutes while she is suicidal. 1b.Remove all dangerous objects from patient. 1c. Obtain a “no self-harm” contract with patient for a specific period of time, to be renegotiated (Note: some provinces no longer use contracting). 1d.Spend regularly scheduled periods of time with patient throughout the day. 1e. Assist patient in evaluating both positive and negative aspects of her life. 1f. Encourage appropriate expression of angry feelings. 1g.Accept patient’s negativism. Rationale 1a, b. Patient safety is ensured. The risk for impulsive self-harmful behaviour is minimized. 1c. Contract may help patient gain a sense of control and a feeling of responsibility. 1d.This interaction reinforces that the patient is worthwhile and builds her experience in relating better to the nurse on a one-to-one basis. 1e. A person with depression is often unable to acknowledge any positive aspects of life unless they are pointed out by others. 1f. Providing for expression of pent-up hostility in a safe environment can reinforce more adaptive methods of releasing tension and may minimize need to act out self-directed anger. 1g.Acceptance enhances feelings of self-worth. Goal Met By the end of the second day, Ms. Glessner states that she really did not want to die; she just couldn’t stand the loneliness in her life. She states that she loves her sons and would never want to hurt them. Short term goal 2. Patient will identify two outside supports she can call on if she feels suicidal in the future. Intervention 2a. Explore usual coping behaviours. 2b.Assist patient in identifying members of her support system. 2c. Suggest a number of community- based support groups she might wish to discuss or visit (e.g., hotlines, support groups, women’s groups). 2d.Assist patient in identifying realistic alternatives she is willing to use. Rationale 1g.Acceptance enhances feelings of self-worth. 2a. Behaviours that need reinforcing and new coping skills that need to be introduced can be identified. 2b.Strengths and weaknesses in her available support systems can be evaluated. 2c. Patient needs to be aware of community supports to use them. 2d.Unless patient agrees with any plan, she will be unable or unwilling to follow through in a crisis. Goal Met By discharge, Ms. Glessner states that she is definitely going to try cognitive behavioural therapy. She also discusses joining a women’s support group that meets once a week in a neighbouring town. Evaluation During the course of her work with Ms. Ward, Ms. Glessner decides to go to some meetings of Parents Without Partners. She states that she is looking forward to getting back to work and feels much more hopeful about her life. She has also lost 1.5 kg while attending Weight Watchers. She states, “I need to get back into the world.” Although Ms. Glessner still has negative thoughts about herself, she admits to feeling more hopeful and better about herself, and she has learned important tools to deal with her negative thoughts.

Answer 60

* There are a number of subtypes of depression and depressive clinical phenomena. The two primary depressive disorders are major depres- sive disorder (MDD) and persistent depressive disorder (dysthymia). * The symptoms of major depression are usually severe enough to interfere with a person’s social or occupational functioning. A per- son with MDD may or may not have psychotic symptoms, and the symptoms usually exhibited during an episode of major depression are different from the characteristics of the normal personality pri- or to the onset of MDD. * The symptoms of persistent depressive disorder are often chronic (lasting at least 2 years) and are considered mild to moderate. Usu- ally, a person’s social or occupational functioning is not greatly im- paired. The symptoms in persistent depressive disorder are often congruent with the person’s usual pattern of functioning. * Many theories exist about the cause of depression. The most ac- cepted is biological (genetic and biochemical) factors; however, cognitive theory, learned helplessness theory, and the diathesis– stress theory help explain triggers to depression and maintenance of depressive thoughts and feelings. * Nursing assessment includes the evaluation of affect, thought pro- cesses (especially suicidal thoughts), mood, feelings, physical behav- iour, communication, and religious beliefs and spirituality. The nurse also must be aware of the symptoms that may mask depression. * Nursing diagnoses can be numerous. Individuals with depression are always evaluated for risk for suicide. Some other common nurs- ing diagnoses are Disturbed thought processes, Chronic low self-es- teem, Imbalanced nutrition, Constipation, Disturbed sleep pattern, Ineffective coping, and Interrupted family processes. * Working with people who have depression can evoke intense feel- ings of hopelessness and frustration in health care workers. Nurses must clarify expectations of themselves and their patients and sort personal feelings from those communicated by the patient via em- pathy. Peer supervision and individual supervision by an experi- enced nurse clinician, psychiatric social worker, or psychologist are useful in increasing therapeutic potential. * Interventions for patients who have depression involve several ap- proaches. Basic-level interventions include using specific principles of communication, planning activities of daily living, administering or participating in psychopharmacological therapy, maintaining a therapeutic environment, and teaching patients about the biochem- ical aspects of depression. * Advanced-practice interventions may include several short-term psychotherapies that are effective in the treatment of depression including interpersonal therapy (IPT), cognitive behavioural thera- py (CBT), skills training (assertiveness and social skills), and some forms of group therapy. * Depression is often overlooked in children, adolescents, and older persons because symptoms of depression are often mistaken for signs of normal development. * Children and adolescents with disruptive mood dysregulation dis- order had previously been diagnosed with bipolar disorder. Usually people with this disorder grow up and are diagnosed with MDD or an anxiety disorder. * Planning and interventions for patients with depression are based on the recovery model, which involves a therapeutic alliance with health care providers in order to achieve outcomes based on indi- vidual patient needs and values. * Evaluation is ongoing throughout the nursing process, and patients’ outcomes are compared with the stated outcome criteria and short- term and intermediate indicators. The care plan is revised when in- dicators are not being met.

Answer 61

an exaggerated euphoria or irritability

Answer 62

bipolar I, bipolar II, and cyclothymic disorder.

Answer 63

is marked by severe shifts in mood, energy, and in- ability to function. Periods of normal functioning may alternate with periods of illness (highs, lows, or a combination of both). Experience chronic interpersonal or occupational difficulties even during remission. Individuals with bipolar I disorder have experienced at least one manic episode. Mania is a period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy. These periods last at least 1 week for most of the day, every day. Symptoms of mania are so severe that this state is a psychiatric emergency. Manic episodes usually alternate with depression or a mixed state of anxiety and depression. Initially, individuals experiencing a manic episode feel euphoric and energized, they don’t sleep or eat, and they are in perpetual motion. They often take significant risks and engage in hazardous activities. As the mania intensifies, individuals may become psychotic and ex- perience hallucinations, delusions, and dramatically disturbed thoughts and behaviour. Hallucinations tend to be auditory, and individuals may begin to hear voices, sometimes the voice of God. They may believe that they are a person of extreme influence and power. The initial euphoria of mania gives way to agitation and irritabil- ity. Utter exhaustion eventually happens, and many people ultimately collapse into depression. Depression and the agitated state of mania is a dangerous combination that can lead to extreme behaviours such as violence or suicide. People may be at equal risk for developing anxiety as depression after an episode of mania. They may even experience a major depressive disorder and generalized anxiety disorder simultaneously after a manic event.

Answer 64

Individuals with bipolar II disorder have experienced at least one hypomanic episode and at least one major depressive episode.

Answer 65

Hypomania refers to a lower-level and less dramatic mania. However, this level of mania still causes significant issues in relationships and oc- cupational functioning. Like mania, hypomania is accompanied by ex- cessive activity and energy for at least 4 days and involves at least three of the behaviours listed under Criterion B in the Diagnostic and Statis- tical Manual of Mental Disorders, fifth edition (DSM-5). Unlike mania, psychosis is never present with hypomania. Psychotic symptoms may, however, accompany the depressive side of the disorder. Hospitaliza- tion is rare. However, the depressive symptoms can be quite profound and may put those who suffer from it at particular risk for suicide.

Answer 66

Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irrita- ble) are present to a significant degree and represent a noticeable change from usual behaviour: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrel- evant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non–goal-directed activity). 7. Excessive involvement in activities that have a high potential for pain- ful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C.The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D.The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. Hypomanic episode A. The mood change must be accompanied by persistently increased energy or activity levels. B. Same criteria as manic episode except: - shorter duration (may last only 4 days) - does not cause significant impairment (without psychotic features or requiring hospitalization) Depressive episode A. 5 or more of the following symptoms (at least one of which is 1 or 2) 1. depressed mood 2. diminished interest in activities 3. significant weight loss or gain 4. insomnia or hypersomnia 5. psychomotor agitation or retardation 6. fatigue/loss of energy 7. feelings of worthlessness or guilt 8. decreased concentration/indecisiveness 9. suicidal ideation/attempt Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syn- dromal level beyond the physiological effect of that treatment is suf- ficient evidence for a manic episode and, therefore, a bipolar I diagnosis. Note: Criteria A through D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

Answer 67

Cyclothymic disorder has symptoms of hypomania alternating with symptoms of mild to moderate depression for at least 2 years in adults and 1 year in children. Hypomanic and depressive symptoms do not meet the criteria for either bipolar II or major depression, yet the symptoms are disturbing enough to cause social and occupational impairment. As part of the spectrum of bipolar disorders, cyclothymic disorder may be difficult to distinguish from bipolar II disorder. Individuals with cyclothymic disorder tend to have irritable hypomanic episodes. Children with cyclothymic disorder experience irritability and sleep disturbance. Some people experience rapid cycling and may have at least four changes in mood episodes in a 12-month period.

Answer 68

Men and women have nearly equal rates of bipolar disorders, yet they respond somewhat differently to their conditions. Men with a bi- polar disorder are more likely to have legal problems and commit acts of violence. Women with a bipolar disorder are more likely to abuse alcohol, commit suicide, and develop thyroid disease. Women who experience a severe postpartum psychosis within 2 weeks of giving birth have a four times greater chance of subsequent conversion to bipolar disorder. Giving birth may act as a trigger for the first symptoms of bipolar disorder. The precipitant may be hormonal changes and sleep deprivation.

Answer 69

The existence of bipolar disorder in non-adults has been the subject of controversy. The most fundamental issue was that these children and adolescents did not usually go on to have bipolar disorder as adults. More commonly, they would eventually be diagnosed with major depression. Unfortunately, a bipolar diagnosis is a lifelong label, one that is stigmatized more than depression. This diagnosis also results in exposure to powerful medications during crucial growth periods. Bipolar disorder in adolescence, particularly late adolescence, is a serious problem. The prevalence rate in this age group mirrors that of adults. Researchers estimate that one in five young people with mania plus depression will attempt suicide. Also, these young people experience nearly 2 months per year of role impairment. This impairment has significant implications for individuals who are positioning themselves for a lifetime and a career, as well as developing relationship patterns.

Answer 70

Cyclothymic disorder usually begins in adolescence or early adult- hood. There is a 15% to 50% risk that an individual with this disor- der will subsequently develop bipolar I or bipolar II disorder. A major risk factor for developing cyclothymic disorder is having a first-degree relative, parent, sibling, or child, with bipolar I disorder.

Answer 71

Bipolar I Disorder About 75% of people with bipolar I disorder also experience an anxiety disorder. These individuals may experience panic attacks, social anxiety disorder, and specific phobias. A substance use disor- der is present in more than half of individuals with bipolar I, perhaps in an attempt to self-medicate or as a symptom related to increased risk taking. More than 50% of individuals have an alcohol use disorder, which in turn elevates the risk for suicide. Further complicating treatment is a higher than normal rate of seri- ous medical conditions. Migraines are more common. Metabolic syn- drome, a cluster of problems such as high blood pressure, high blood glucose, excess body fat around the waist, and abnormal cholesterol levels, may lead to pre-mature death due to heart disease, stroke, and diabetes. ----------- Bipolar II Disorder As with bipolar I, about 75% of individuals with bipolar II disorder have a comorbid anxiety disorder. Typically, the anxiety disorders come about before the hypomania and depressive symptoms. Substance use disorders are also common and affect about 37% of people with bipolar II. --------- Cyclothymic Disorder As with the bipolar disorders, substance use disorders are common with cyclothymic disorder. This may be due to efforts to self-medicate and sub- due the bipolar symptoms. Sleep disorders where people have difficulty going to sleep and staying asleep are often present in this disorder. Attention-deficit/hyperactivity disorder is more common among children with cyclothymic disorder.

Answer 72

Depressive episodes in bipolar disorder affect younger people, produce more episodes of illness, and require more frequent hospitalization. They are also characterized by higher rates of divorce and marital conflict. Theories of the development and onset of bipolar disorders focus on biological, psychological, and environmental factors.

Answer 73

Bipolar illnesses tend to run in families, and the lifetime risk for in- dividuals with an affected parent is 15% to 30% greater. The concordance rate among identical twins is around 70%. This means that if one twin has the disorder, 70% of the time the other one will, too. Despite the high concordance rate in identical twins, it is uncommon for clinicians to find a positive family history for bipolar disorder in these twins’ families. This finding probably means that the disease is polygenic or that a number of genes contribute to its expression. Some evidence suggests that bipolar disorders are more prevalent in adults who had high intelligence quotients (IQs), and who were particularly verbal, as children. People with bipolar disorders appear to achieve higher levels of education and higher occupational status than individuals with unipolar depression. Also, the proportion of patients with bipolar disorders among creative writers, artists, highly educated men and women, and professionals is higher than in the general population.

Answer 74

Neurotransmitters (norepinephrine, dopamine, and serotonin) have been studied since the 1960s as causal factors in mania and depression. One simple explanation is that having too few of these chemical messengers will result in depression and having an oversupply will cause mania. Receptor site insensitivity could also be at the root of the problem, even if there is enough of a certain neurotransmitter, it may not be going where it needs to go.

Answer 75

Structural neuroimaging techniques (e.g., computed tomography [CT] and magnetic resonance imaging [MRI]) provide still pictures of the scalp, skull, and brain. Structural imaging is useful in viewing bones, tissues, blood vessels, tumours, infection, damage, or bleeding. Func- tional neuroimaging techniques (e.g., positron emission tomography [PET], functional MRI [fMRI], and magnetoencephalography [MEG]) provide measures related to brain activity. Functional imaging reveals activity and chemistry by measuring the rate of blood flow, chemical activity, and electrical impulses in the brain during specific tasks. With bipolar disorder, functional imaging techniques reveal dys- function in the prefrontal cortical region, the region associated with executive decision making, personality expression, and social behaviour. Dysfunction is also evident in the hippo- campus, which is primarily associated with memory, and the amygdala, which is associated with memory, decision making, and emotion. Dysregulation in these areas results in the characteristic emotional lability, heightened reward sensitivity, and emotional dysregulation of bipolar disorder. These abnormalities may be due to grey matter loss in these areas.

Answer 76

The hypothalamic–pituitary–thyroid–adrenal (HPTA) axis has been the object of significant research in bipolar disorder. In fact, hypothy- roidism is one of the most common physical abnormalities associated with bipolar disorder. Typically, the thyroid dysfunction is not dramat- ic and the problem is often undetected. In both manic and depressive states peripheral inflammation is in- creased. This inflammation tends to decrease between episodes. Estrogen studies have shown that people with postpartum psychosis have very low levels of estrogen and improve after estrogen replacement therapy.

Answer 77

Bipolar disorder is a worldwide problem that generally affects all races and ethnic groups equally, but some evidence suggests that bipolar disorders may be more prevalent in upper socioeconomic classes. The exact reason for this finding is unclear; however, people with bipolar disorders appear to achieve higher levels of education and higher oc- cupational status than individuals with unipolar depression. The edu- cational levels of individuals with unipolar depressive disorders, on the other hand, appear to be no different from those of individuals with no symptoms of depression within the same socioeconomic class.

Answer 78

Individuals with bipolar disorder are often misdiagnosed or underdi- agnosed. Early diagnosis and proper treatment can help people avoid: * Suicide attempts * Alcohol or substance use * Marital or work problems * Development of medical comorbidity Individuals with bipolar disorder tend to spend more time in a de- pressed state than in a manic state. The characteristics of mania discussed in the following sections are (1) mood, (2) behaviour, (3) thought processes and speech patterns, and (4) cognitive function. Mood. The euphoric mood associated with mania is unstable. During euphoria, patients may state that they are experiencing an in- tense feeling of well-being, are “cheerful in a beautiful world,” or are becoming “one with God.” The overly joyous mood may seem out of proportion to what is going on, and cheerfulness may be inappropriate for the circumstances, considering that patients are full of energy with little or no sleep. Their mood may change quickly to irritation and anger when they are thwarted. The irritability and belligerence may be short-lived, or it may become the prominent feature of the manic phase of bipolar disorder. People experiencing a manic state may laugh, joke, and talk in a continuous stream, with uninhibited familiarity. They often demonstrate boundless enthusiasm, treat others with confidential friendliness, and incorporate everyone into their plans and activities. They know no strangers, and energy and self-confidence seem boundless. To people experiencing mania, no aspirations are too high, and no distances are too far, no boundaries exist to curtail them. Often during impulsive, intrusive, and demanding behaviours, they can become easily angered and show a shift in mood at anyone attempting to stop them or set limits. As the clinical course progresses from hypomania to mania, sociability and euphoria are replaced by a stage of hostility, irritability, and paranoia. Behaviour. When people experience hypomania, they have appe- tites for social engagement, spending, and activity, even indiscriminate sex. The increased activity and a reduced need for sleep prevent proper rest. Although short periods of sleep are possible, some patients may not sleep for several days in a row. This non-stop physical activity and the lack of sleep and food can lead to physical exhaustion and worsen- ing of mania. When in full-blown mania, a person constantly goes from one ac- tivity, place, or project to another. Many projects may be started, but few, if any, are completed. Inactivity is impossible, even for the short- est period of time. Hyperactivity may range from mild, constant mo- tion to frenetic, wild activity. Flowery and lengthy letters are written, and excessive phone calls are made. Individuals become involved in pleasurable activities that can have painful consequences, for example, spending large sums of money on frivolous items, giving money away indiscriminately, throwing lavish parties, visiting expensive night clubs and restaurants, or making foolish business investments that can leave an individual or family penniless. Sexual indiscretion can dissolve re- lationships and marriages and lead to sexually transmitted infections. Religious pre-occupation is a common symptom of mania. Individuals experiencing mania may be manipulative, profane, fault finding, and adept at exploiting others’ vulnerabilities. They constantly push limits. These behaviours often alienate family, friends, employers, health care providers, and others. Modes of dress often reflect the person’s grandiose yet tenuous grasp of reality. Dress may be described as outlandish, bizarre, colourful, and noticeably inappropriate. Makeup may be garish and overdone. People with mania are highly distractible. Concentration is poor, and individuals with mania go from one activity to another without completing anything. Judgement is poor. Impulsive marriages and divorces can take place. Thought processes and speech patterns. Flight of ideas is a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words. When the condition is severe, speech may be disorganized and incoherent. The incessant talking often includes joking, puns, and teasing: “How are you doing, kid? No kidding around, I’m going home ... home sweet home ... home is where the heart is, the heart of the matter is I want out, and that ain’t hay ... hey, Doc ... get me out of this place.” The content of speech is often sexually explicit and ranges from grossly inappropriate to vulgar. Themes in the communication of the individual with mania may revolve around extraordinary sexual prow- ess, brilliant business ability, or unparalleled artistic talents (e.g., writ- ing, painting, dancing). Speech is not only profuse but also loud, bellowing, or even scream- ing. One can hear the force and energy behind the rapid words. As mania escalates, flight of ideas may give way to clang associations. Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning: “Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.” Grandiosity (inflated self-regard) is apparent in both the ideas ex- pressed and the person’s behaviour. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe that they have great powers. Cognitive function. The onset of bipolar disorder is often preceded by comparatively high cognitive function. However, there is growing evidence that about one-third of patients with bipolar disorder display significant and persistent cognitive problems and difficulties in psychosocial areas. Cognitive deficits in bipolar disorder are milder but similar to those in patients with schizophrenia. Cognitive impairments are greater in bipolar I but are also present in bipolar II. The potential cognitive dysfunction among many people with bipo- lar disorder has specific clinical implications: * Cognitive function affects overall function. * Cognitive deficits correlate with a greater number of manic episodes, history of psychosis, chronicity of illness, and poor functional outcome. * Early diagnosis and treatment are crucial to prevent illness progres- sion, cognitive deficits, and poor outcome. * Medication selection should consider not only the efficacy of the drug in reducing mood symptoms but also the cognitive impact of the drug on the patient.

Answer 79

The person experiencing mania (who is often out of control and resists being controlled) can elicit numerous intense emotions in a nurse. The person may use humour, manipulation, power struggles, or demand- ing behaviour to prevent or minimize the staff ’s ability to set limits on and control dangerous behaviour. People with mania have the ability to “staff split,” or divide the staff into the “good guys” and the “bad guys”: “The nurse on the day shift is always late with my medication and never talks with me. You are the only one who seems to care.” This divisive tactic may pit one staff member or group against another, undermin- ing a unified front and consistent plan of care. Frequent team meetings to deal with the behaviours of the person and the nurses’ responses to these behaviours can help minimize staff splitting and feelings of anger and isolation. Limit setting (e.g., lights out after 2300 hours) is the main theme in treating a person with mania. Consistency among staff is im- perative if the limit setting is to be carried out effectively. The person can become aggressively demanding, which often trig- gers frustration, worry, and exasperation in health care providers. The behaviour of a person experiencing mania is often aimed at decreas- ing the effectiveness of staff control, which could be accomplished by staff members getting involved in power plays. For example, the person might taunt the staff by pointing out faults or oversights and drawing negative attention to one or more staff members. Usually this taunt- ing is done in a loud and disruptive manner, which provokes staff to become defensive and thereby escalates the environmental tension and the person’s degree of mania. If you are working with a person experiencing mania, you may find yourself feeling helplessness, confusion, or even anger. Understanding, acknowledging, and sharing these responses and counter-transference reactions will enhance your professional ability to care for the person and perhaps promote your personal development as well. Collaborating with the interprofessional team, accessing the supervision (as a nursing student) of your nursing faculty member, and sharing your experience with peers in post-conference may be helpful, perhaps essential.

Answer 80

Excessive and constant motor activity Poor judgement Lack of rest and sleep Poor nutritional intake (excessive or relentless mix of above behaviours can lead to cardiac collapse) Risk for injury Risk for self-neglect ---------------- Loud, profane, hostile, combative, aggressive, demanding behaviours Risk for other-directed violence Risk for self-directed violence Risk for suicide ---------------- Intrusive and taunting behaviours Inability to control behaviour Rage reaction Ineffective coping Self-neglect ------------------ Manipulative, angry, or hostile verbal and physical behaviours Impulsive speech and actions Property destruction or lashing out at others in a rage reaction Defensive coping Ineffective coping Ineffective impulse control ------------------ Racing thoughts, grandiosity, poor judgement Ineffective coping Ineffective impulse control ------------------ Giving away of valuables, neglect of family, impulsive major life changes (divorce, career changes) Interrupted family processes Caregiver role strain ------------------ Continuous pressured speech, jumping from topic to topic (flight of ideas) Impaired verbal communication ----------------- Constant motor activity, going from one person or event to another Annoyance or taunting of others, loud and crass speech Provocative behaviours Impaired social interaction Risk for ineffective relationships ---------------- Failure to eat, groom, bathe, or dress self because person is too distracted, agitated, and disorganized Imbalanced nutrition: less than body requirements Deficient fluid volume Self-care deficit (bathing, dressing, feeding, toileting) ------------- Inability to sleep because patient is too frantic and hyperactive (sleep deprivation can lead to exhaustion and death) Disturbed sleep pattern

Answer 81

1. Assess whether the person is a danger to self or others: * People experiencing mania can exhaust themselves to the point of death. * People experiencing mania may not eat or sleep, often for days at a time. * Poor impulse control may result in harm to others or self. * Uncontrolled spending may occur. 2. Assess the need for protection from uninhibited behaviours. External con- trol may be needed to protect the person from such things as bankruptcy because people experiencing mania may give away all of their money or possessions. 3. Assess the need for hospitalization to safeguard and stabilize the person. 4. Assess medical status. A thorough medical examination helps to determine whether mania is primary (a mood disorder, bipolar disorder or cyclothymia) or secondary to another condition. * Mania may be secondary to a general medical condition. * Mania may be substance induced (caused by use or abuse of a drug or substance or by toxin exposure). 5. Assess for any coexisting medical condition or other situation that warrants special intervention (e.g., substance use, anxiety disorder, legal or financial crises). 6. Assess the person’s and family’s understanding of bipolar disorder, knowl- edge of medications, and knowledge of support groups and organizations that provide information on bipolar disorder.

Answer 82

The acute phase occurs during an intense manic, hypomanic or depres- sive episode. The overall outcome of the acute phase is injury preven- tion. The person may be hospitalized during this phase. Outcomes in the acute phase reflect both physiological and psychiatric issues. For example, the patient will: * Be well hydrated * Maintain stable cardiac status * Maintain and obtain tissue integrity * Get sufficient sleep and rest * Demonstrate thought self-control * Make no attempt at self-harm

Answer 83

During this stage the presenting symptoms are being controlled but the individual’s mental health is still quite fragile. The continuation phase lasts for 4 to 9 months. Although the overall outcome of this phase is relapse prevention, many other outcomes must be accomplished to achieve relapse prevention. These outcomes include: * Psychoeducational classes for the patient and family related to: * Knowledge of disease process * Knowledge of medication * Consequences of substance addictions for predicting future re- lapse * Knowledge of early signs and symptoms of relapse * Support groups or therapy (cognitive behavioural, interpersonal) * Communication and problem-solving skills training

Answer 84

The overall outcomes for the maintenance phase continue to focus on prevention of relapse and limitation of the severity and duration of future episodes. Ad- ditional outcomes include: * Participation in learning interpersonal strategies related to work, interpersonal, and family problems * Participation in psychotherapy, group, or other ongoing supportive therapy modality

Answer 85

Planning care for an individual with bipolar disorder is usually geared to- ward the particular phase of mania the person is in (acute, continuation, or maintenance), as well as any other co-occurring issues identified in the assessment (e.g., risk for suicide, risk for violence to person or prop- erty, family crisis, legal crises, substance use, risk-taking behaviours)

Answer 86

During the acute phase, planning focuses on medically stabilizing the person while maintaining safety. Therefore the hospital is usually the safest environment for accomplishing this stabilization. Nursing care is geared toward managing medications, decreasing physical activity, increasing food and fluid intake, ensuring at least 4 to 6 hours of sleep per night, alleviating any bowel or bladder problems, and intervening to see that self-care needs are met. Some patients may require seclusion or even electroconvulsive therapy (ECT) to assist with stabilization.

Answer 87

During the continuation phase, planning focuses on maintaining ad- herence to the medication regimen and prevention of relapse. Inter- ventions are planned in accordance with the assessment data regarding the person’s interpersonal and stress-reduction skills, cognitive func- tioning, employment status, substance-related problems, and social support systems. During this time, psychoeducational teaching is nec- essary for the patient and family. The need for referrals to community programs, groups, and support for any co-occurring disorders or prob- lems (e.g., substance use, family problems, legal issues, financial crises) is evaluated. Evaluation of the need for communication skills training and prob- lem-solving skills training is also an important consideration.

Answer 88

During the maintenance phase, planning focuses on preventing relapse and limiting the severity and duration of future episodes.

Answer 89

Depressive episodes. Depressive episodes of bipolar disorder have the same symptoms and risks as those of major depression. Hospitalization may be required if suicidal ideation, psycho- sis, or catatonia is present. Pharmacological treatment is affected by concerns of bringing on a manic phase. Manic episodes Acute phase. Hospitalization provides safety for a person experiencing acute mania (bipolar I disorder), imposes external controls on destructive behaviours, and provides for medication stabilization. There are unique approaches to communicating with and maintaining the safety of the person during the hospitalization period. Staff members continuously set limits in a firm, non-threatening, and neutral manner to prevent further escalation of mania and provide safe boundaries for the person and others. Continuation phase. The continuation phase is crucial for patients and their families. The outcome for this phase is prevention of relapse, and community resources are chosen based on the needs of the person, the appropriateness of the referral, and the availability of resources. Medication adherence during this phase is perhaps the most important treatment outcome. Often, this follow-up is handled in a community mental health clinic. However, adherence to the medication regimen is also addressed in outpatient clinics and psychiatric home care visits. Maintenance phase. The goal of the maintenance phase is to pre- vent recurrence of an episode of bipolar disorder.

Answer 90

Communication Use firm and calm approach: “John, come with me. Please eat this sandwich.” Structure and control are provided for the person who is out of control. Feelings of security can result: “Someone is in control.” Use short and concise explanations or statements. Short attention span limits comprehension to small bits of information. Remain neutral; avoid power struggles and value judgements. Person can use inconsistencies and value judgements as justification for arguing and escalating mania. Be consistent in approach and expectations. Consistent limits and expectations minimize potential for person’s manipulation of staff. Have frequent staff meetings to plan consistent approaches and set agreed-on Consistency of all staff is needed to maintain controls and minimize manipulation by patient. With other staff, decide on limits, and communicate these with the person in simple, concrete terms with consequences. Example: “John, do not yell at or hit Peter. If you cannot control yourself, we will help you.” Or, “The seclusion room will help you feel less out of control and prevent harm to yourself and others.” Clear expectations help the person experience outside controls, as well as understand reasons for medication, seclusion, or restraints (if they are not able to control behaviours). Hear and act on legitimate complaints. Underlying feelings of helplessness are reduced, and acting-out behaviours are minimized. Firmly redirect energy into more appropriate and constructive channels. Distractibility is the nurse’s most effective tool with the person experiencing mania. --------- Structure in a Safe Milieu Maintain low level of stimuli in patient’s environment (e.g., away from bright Escalation of anxiety can be decreased. lights, loud noises, people). Provide structured solitary activities with nurse or aide. Structure provides security and focus. Provide frequent high-calorie fluids. Serious dehydration is prevented. Provide frequent rest periods. Exhaustion is prevented. Redirect violent behaviour. Physical exercise can decrease tension and provide focus. When warranted in acute mania, use phenothiazines and seclusion to minimize Exhaustion and death can result from dehydration, lack of sleep, and constant physical harm. physical activity. Observe for signs of lithium toxicity. There is a small margin of safety between therapeutic and toxic doses. Prevent person from giving away money and possessions. Hold valuables in Person’s “generosity” is a manic defence that is consistent with irrational, hospital safe until rational judgement returns. grandiose thinking. --------- Physiological Safety: Self-Care Needs Nutrition Monitor intake, output, and vital signs. Adequate fluid and caloric intake are ensured; development of dehydration and cardiac collapse are minimized. Offer frequent, high-calorie, protein drinks and finger foods (e.g., sandwiches, Constant fluid and calorie replacement are needed. Person may be too active to sit fruits, milkshakes). at meals. Finger foods allow “eating on the run.” Frequently remind person to eat. “Tom, finish your milkshake.” “Sally, eat this The person experiencing mania is unaware of bodily needs and is easily banana.” distracted. Needs supervision to eat. Sleep Encourage frequent rest periods during the day. Lack of sleep can lead to exhaustion and death. Keep person in areas of low stimulation. Relaxation is promoted, and manic behaviour is minimized. At night, provide warm baths, soothing music, and medication when indicated. Relaxation, rest, and sleep are promoted. Avoid giving person caffeine. Hygiene Supervise choice of clothes; minimize flamboyant and bizarre dress (e.g., garish The potential is decreased for ridicule, which lowers self-esteem and increases stripes or plaids and loud, unmatching colours). the need for manic defence. The person is helped to maintain dignity. Give simple, step-by-step reminders for hygiene and dress. “Here is your razor. Distractibility and poor concentration are countered through simple, concrete Here are your toothbrush and toothpaste.” instructions. Elimination Monitor bowel habits; offer fluids and foods that are high in fibre. Evaluate need Fecal impaction resulting from dehydration and decreased peristalsis is prevented. for laxative. Monitor input and output.

Answer 91

Lithium carbonate, valproic acid (Depakene), and several atypical antipsychotics continue to be first-line treatments for acute mania. For the management of bipolar depression, lithium, divalproex, lamotrigine (Lamictal), and quetiapine (Seroquel) are used for a monotherapy therapy approach. Olanzapine plus a selective serotonin reuptake inhibitor (SSRI) (except paroxetine), or lithium or valproic acid plus an SSRI or bupropion (Wellbutrin) are used as first- line options when combination therapy is required (Goldberg, 2019). Due to the concern of dependen- cy, use of benzodiazepines is usually short term until the mania sub- sides.

Answer 92

Mood stabilizers refer to classes of drugs used to treat symptoms as- sociated with bipolar disorder. Lithium carbonate. Lithium carbonate (LiCO3 or Li+) is effective in the treatment of bipolar I acute and recurrent manic and depressive epi- sodes. Onset of action is usually within 10 to 21 days. Because the onset of action is so slow, it is usually supplemented in the early phases of treatment by atypical antipsychotics, anticonvulsants, or antianxiety medications. The clinical benefits of lithium can be incredible. However, newer medications have been introduced and approved that carry lower tox- icity, have fewer adverse effects, and require less frequent laboratory testing. The use of these newer medications has resulted in a decline in lithium use. Assessment of renal function; determination of thyroid status, including lev- els of thyroxine and thyroid-stimulating hormone; and evaluation for dementia or neurological disorders, which presage a poor response to lithium. Other clinical and laboratory assessments, including an electrocardiogram, are performed as needed, depending on the individual’s physical condition. Lithium is particularly effective in reducing: * Elation, grandiosity, and expansiveness * Flight of ideas * Irritability and manipulation * Anxiety To a lesser extent, lithium controls: * Insomnia * Psychomotor agitation * Threatening or assaultive behaviour * Distractibility * Hypersexuality * Paranoia Therapeutic and toxic levels. There is a small window between the therapeutic and toxic levels of lithium. Lithium must reach therapeutic blood levels to be effective. This usually takes 7 to 14 days, or longer for some patients. Blood serum levels should reach 0.6 to 1.2 mEq/L. Lithium levels should not exceed 1.5 mEq/L to avoid serious toxicity. Lithium levels should be measured at least 5 days after beginning lithium therapy and after any dosage change, until the therapeutic level has been reached. Blood levels are determined every month. After 6 months to a year of stability, it is common to measure blood levels every 3 months. Blood should be drawn in the morning, 10 to 12 hours after the last dose of lithium is taken. Patient and family should be given careful instructions about (1) the pur- pose and requirements of lithium therapy, (2) its adverse effects, (3) its toxic effects and complications, and (4) situations in which the physician should be contacted. The patient and family should also be advised that suddenly stopping lithium can lead to relapse and recurrence of mania. People taking lithium need to know that two major long-term risks of lithium therapy are hypothyroidism and impairment of the kidneys’ ability to concentrate urine. Therefore a person receiving lithium therapy must have periodic follow-ups to assess THYROID and RENAL function. Taking lithium carries a high risk of hypercalcemia and hyperparathyroidism. Symptoms of hypercal-emia and hyperparathyroidism can include fatigue, depression, mental confusion, nausea, vomiting, excessive thirst, appetite loss, abdominal pain, frequent urination, muscle and joint aches, and muscle weakness. In the most serious situations, these conditions lead to coma and death. Contraindications. Lithium therapy is generally contraindicated in patients with cardiovascular disease, brain damage, renal disease, thyroid disease, or myasthenia gravis. Whenever possible, lithium is not given to people who are pregnant because it may harm the fetus.

Answer 93

The patient and the patient’s family should be given the following information, be encouraged to ask questions, and be given the material in written form as well. 1. Lithium treats your current emotional problem and also helps prevent relapse. Therefore it is important to continue taking the medication after the current episode is over. 2. Because therapeutic and toxic dosage ranges are so close, it is important to monitor lithium blood levels very closely, more frequently at first and then once every several months after that. 3. Lithium is not addictive. 4. It is important to eat a normal diet, with normal salt and fluid intake (1500 to 3000 mL or six 350-mL glasses of fluid). Lithium decreases sodium reabsorption in the kidneys, which could lead to a deficiency of sodium. A low sodium intake leads to a relative increase in lithium retention, which could produce toxicity. 5. You should stop taking lithium if you have excessive diarrhea, vomiting, or sweating. All of these symptoms can lead to dehydration. Dehydration can raise lithium levels in the blood to toxic levels. Inform your physician if you have any of these problems. 6. Do not take diuretics (water pills) while you are taking lithium. 7. Lithium is irritating to the lining of your stomach. Take lithium with meals. 8. It is important to have your kidneys and thyroid checked periodically, especially if you are taking lithium over a long period. Talk to your doctor about this follow-up. 9. Do not take any over-the-counter medicines without checking first with your doctor. 10. If you find that you are gaining a lot of weight, you may need to talk this change over with your doctor or dietitian. 11. Many self-help groups are available to provide support for people with bipolar disorder and their families. The local self-help group is (give name and telephone number). 12. You can find out more information by calling (give name and telephone number). 13. Keep a list of adverse effects and toxic effects handy, along with the name and number of a person to contact if these effects occur (see Table 14.4). 14. If lithium is to be discontinued, your dosage will be tapered gradually to minimize the risk of relapse.

Answer 94

In the 1980s researchers hypothesized that mood instability could be viewed much the same as epilepsy and that a chain reaction of sensitivity, or kindling, was responsible for the worsening of bipolar symptoms over time. This hypothesis led to the use of anticonvulsant drugs, such as carbamazepine (Tegretol), valproic acid (Depakene), and lamotrigine (Lamictal), as a treatment for mania that has been refractory to lithium therapy. They also proved useful in treating people who need rapid de-escalation and who do not respond to other treatment approaches. Anticonvulsant drugs are thought to be: * Superior for continuously cycling patients * More effective when there is no family history of bipolar disorder * Effective at dampening affective swings in schizoaffective patients * Effective at diminishing impulsive and aggressive behaviour in some non-psychotic patients * Helpful in cases of alcohol and benzodiazepine withdrawal * Beneficial in controlling mania (within 2 weeks) and depression (within 3 weeks or longer)

Answer 95

Divalproex sodium (Epival). Valproate (available as divalproex sodium [Epival] and valproic acid [Depakene]) has surpassed lithium in treating acute mania. Valproate is also helpful in preventing future manic episodes. Although serious complications are rare, it is important to monitor liver function and platelet count periodically. Divalproex doses can cause drowsiness and dizziness and increase thoughts of suicide; therefore mood, ideations, and behaviour should be monitored on a regular basis. Therapeutic serum levels that range from 50 to 100 mcg/ mL and 50 to 125 mcg/mL for mania should be monitored to prevent toxicity and overdose. Symptoms of cen- tral nervous system toxicity can include confusion, fatigue, dizziness, hallucinations, headache, and ataxia.

Answer 96

Some patients with treatment-resistant bipolar disorder improve after taking carbamazepine (Tegretol) and lithium, or carbamazepine and an antipsychotic. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients experiencing manias rather than in euphoric, overactive, overly friendly patients experiencing manias. It is thought to also be more effective in dysphoric patients experiencing manias. Liver enzymes should be monitored at least weekly for the first 8 weeks of treatment because the drug can increase levels of liver enzymes that can speed its own metabolism. In some instances this can cause bone marrow suppression and liver inflammation. Complete blood counts should also be done periodically since carbamazepine is known to cause leukopenia and aplastic anemia.

Answer 97

Lamotrigine (Lamictal) is a first-line treatment for bipolar depression and is approved for acute and maintenance therapy. Lamotrigine is generally well tolerated but has one serious, though rare, dermatological reaction: a potentially life-threatening rash. Patients should be instructed to seek immediate medical attention if a rash appears, although most are likely benign.

Answer 98

* Both valproic acid and carbamazepine may cause blood dyscrasias, hepatotoxicity, and teratogenicity. * Carbamazepine has also been linked to hyponatremia and serious dermatological adverse effects. * Valproic acid has been associated with polycystic ovary syndrome, weight gain, acute pancreatitis, and hyperammonemic encephalopathy. * The severe ADRs associated with lamotrigine are dermatological, namely Stevens–Johnson syndrome. * Drug interactions such as lamotrigine–valproic acid and carbam- azepine–hormonal contraceptives are also important to be aware of.

Answer 99

Antianxiety drugs. Diazepam (Valium), clonazepam (Rivotril), and lorazepam (Ativan) are antianxiety (anxiolytic) drugs useful in the treatment of acute mania in some patients who are resistant to other treatments. These drugs are also effective in managing the psychomo- tor agitation seen in mania. They should be avoided, however, in pa- tients with a history of substance use. Atypical antipsychotics. Many of the second-generation antipsychotics are approved for acute mania. In addition to showing sedative properties during the early phase of treatment (help with in- somnia, anxiety, agitation), the second-generation antipsychotics seem to have mood-stabilizing properties. Most evidence supports the use of olanzapine (Zyprexa) or risperidone (Risperdal). This classification of drugs may bring about serious adverse effects that stem from a tendency toward weight gain that may lead to insulin resistance, diabetes, dyslipidemia, and cardiovascular impairment. Electroconvulsive Therapy ECT is used to subdue severe manic behaviour, especially in patients with treatment-resistant mania and in those with rapid cycling (i.e., those who experience four or more episodes of illness per year). ECT seems to be far more effective than medication-based therapy for treatment-resistant bipolar depression. Depressive episodes, particularly those with severe, catatonic, or treatment resistant depression, are an indication for this treatment. Milieu Management Control of hyperactive behaviour during the acute phase almost always includes immediate treatment with an antipsychotic medication. How- ever, when a person is dangerously out of control, use of a seclusion room or restraints may also be required. A seclusion room provides comfort and relief to many patients who are unable to control their own behaviour.

Answer 100

Reduces overwhelming environmental stimuli * Protects a person from injuring themself or others, including staff * Prevents destruction of personal property or property of others Seclusion is warranted when documented data collected by the nursing and medical staff reflect the following points: * Substantial risk of harm to others or self is clear. * The person is unable to control their actions. * Problematic behaviour has been sustained (continues or escalates despite other measures). * Other measures have failed (e.g., setting limits beginning with ver- bal de-escalation or using chemical restraints). Milieu Management Control of hyperactive behaviour during the acute phase almost always includes immediate treatment with an antipsychotic medication. How- ever, when a person is dangerously out of control, use of a seclusion room or restraints may also be required. A seclusion room provides comfort and relief to many patients who are unable to control their own behaviour. Seclusion and observation levels and care protocols must be carefully adhered to as per individual hospital or employer policy. Seclusion protocols also identify specific nursing responsibilities, such as how often the patient’s behaviour is to be observed and documented (e.g., every 15 minutes), how often the patient is to be offered food and fluids (e.g., every 30 to 60 minutes), and how often the patient is to be toileted (e.g., every 1 to 2 hours). Medication is often administered to patients in seclusion; therefore vital signs should be measured frequently, as per hospital policy. Careful and precise documentation is a legal necessity. The nurse documents the following: * The behaviour leading up to the seclusion or restraint * The actions taken to provide the least restrictive alternative * The time the patient was placed in seclusion * Every 15 minutes, the patient’s behaviour, needs, nursing care, and vital signs * The time and type of medications given and their effects on the patient When a patient requires seclusion to prevent self-harm or violence toward others, it is ideal for one nurse on each shift to work with the patient on a continuous basis. Communication with a patient in se- clusion is concrete and direct but also empathic and limited to brief instructions. Patients need reassurance that seclusion is only a tem- porary measure and that they will be returned to the unit when their behaviour is more controlled and they demonstrate the ability to safely be around others. Frequent staff meetings regarding personal feelings are necessary to prevent using seclusion as a form of punishment or leaving a patient in seclusion for long periods of time without proper supervision. Restraints and seclusion are never to be used as punishment or for the convenience of the staff. Refer to Chapter 7 for a more detailed discussion of the legal implications of seclusion and restraints. Chapter 4 provides more information on milieu therapy.

Answer 101

Lithium carbonate Acute mania Maintenance Mood stabilizer Depression (off label) First-line treatment for bipolar depression Recommended for acute mania Treatment and prevention of manic episodes __________ Anticonvulsants Valproic acid (Depakene) Divalproex sodium (Epival) Carbamazepine (Tegretol) Lamotrigine (Lamictal) Gabapentin (Neurontin) and topiramate (Topamax) for acute mania depression (off label) Recommended for acute mania First-line maintenance treatment for bipolar disorder Recommended for maintenance treatment of bipolar disorder, mood-stabilizing effect First-line treatment for bipolar depression Recommended for maintenance treatment of bipolar disorder Recommended for maintenance treatment of bipolar disorder __________ Atypical Antipsychotics Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine fumarate (Seroquel) Risperidone (Risperdal) Ziprasidone (Zeldox) For mania, maintenance depression (off label)

Answer 102

Patients with bipolar disorder, as well as their friends and families, ben- efit from forming mutual support groups.

Answer 103

Emphasis on its chronic and highly recurrent nature. In ad- dition, patients and families need to be taught the warning signs and symptoms of impending episodes. For example, changes in sleep patterns are especially important because they usually precede, accompany, or precipitate mania. Health teach- ing stresses the importance of establishing regularity in sleep patterns, meals, exercise, and other activities. Most of the medications used to treat bipolar disorder may cause weight gain and other metabolic disturbances such as altered metabo- lism of lipids and glucose. These alterations increase the risk for diabe- tes, high blood pressure, dyslipidemia, cardiac problems, or all of these in combination (metabolic syndrome). Not only do these disturbances impair quality of life and lifespan, they are also a major reason for non- adherence. Teaching aimed at weight reduction and management is es- sential to keep patients physically healthy and emotionally stable. Recovery concepts are particularly important for patients with bi- polar disorder, who often have issues with adherence to treatment. The best method of addressing this problem is to follow a collaborative care model in which responsibilities for treatment adherence are shared. In this model patients are responsible for making it to appointments and openly communicating information, and the health care provider is responsible for keeping current on treatment methods and listening carefully as patients share perceptions. Through this sharing, treatment adherence becomes a self-managed responsibility. 1. Patients with bipolar disorder and their families need to know: * The chronic and episodic nature of bipolar disorder * The fact that bipolar disorder is long term. Treatment will require that one or more mood-stabilizing medications be taken for a long time * The expected side effects and toxic effects of the prescribed medication, as well as who to call and where to go in case of an adverse reaction * The signs and symptoms of relapse that may “come out of the blue” * The role of family members and others in preventing a full relapse * The phone numbers of emergency contact people, which should be kept in an easily accessed place 2. The use of alcohol, drugs of abuse, caffeine (particularly in energy drinks), and over-the-counter medications can cause a relapse. 3. Good sleep hygiene is critical to stability. Frequently, the early symptom of a manic episode is lack of sleep. In some cases, mania may be averted by the use of sleep medications. 4. Coping strategies are important for dealing with work, interpersonal, and family problems to lower stress, to enhance a sense of personal control, and to increase community functioning. 5. Group and individual therapy are valuable for gaining insight and skills in relapse prevention, providing social support, increasing coping skills in interpersonal relations, improving adherence to the medication regimen, reducing functional morbidity, and decreasing need for hospitalization.

Answer 104

Many patients have strained in- terpersonal relationships, marital and family problems, academic and occupational problems, and legal or other social difficulties. Psycho- therapy can help them work through these difficulties, decrease some of the psychic distress, and increase self-esteem. Psychotherapeutic treatments can also help patients improve their functioning between episodes and attempt to decrease the frequency of future episodes.

Answer 105

Cognitive behavioural therapy. CBT is typically used as an adjunct to pharmacotherapy in many psychiatric disorders. It involves iden- tifying maladaptive thoughts (“I am always going to be a loser”) and behaviours (“I might as well drink”) that may be barriers to a person’s recovery and ongoing mood stability. CBT focuses on adherence to the medication regimen, early de- tection and intervention for manic or depressive episodes, stress and lifestyle management, and the treatment of depression and comorbid conditions. Some research demonstrates that patients treated with cog- nitive therapy are more likely to take their medications as prescribed than are patients who do not participate in therapy, and psychotherapy results in greater adherence to the medication regimen. Interpersonal and social rhythm therapy. Depression and manic- type states impair a person’s ability to interact with others. Even in be- tween episodes, relationships have been so damaged it may seem im- possible to correct the problems. The advanced-practice nurses can use a specialized approach, interpersonal and social rhythm therapy. This approach aims to regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse. Psychoeducation is a major component of this therapy and includes symp- tom recognition, adherence with medication and sleep routines, stress management, and maintenance of social supports. Family-focused therapy. Family-focused therapy helps improve communication among family members. Negative patterns of communicating develop and become part of the fabric of the family. Advanced-practice nurses can help people recognize and reduce negative expressed emotion and stressors that provoke episodes.

Answer 106

Outcome criteria often dictate the frequency of evaluation of short- term and intermediate indicators. Are the person’s vital signs stable? Are they well hydrated? Is the person able to control personal behaviour or respond to external controls? Is the person able to sleep for 4 or 5 hours a night or take frequent, short rest periods during the day? Does the family have a clear understanding of the patient’s disorder and need for medication? Do the patient and family know which community agencies might help them? Were the data incorrect or insuf- ficient? Were nursing diagnoses inappropriate or outcomes unrealistic? Was intervention poorly planned? After the outcomes and care plan are reassessed, the plan is revised, if indicated. Longer-term outcomes include adherence to the medication regimen; resumption of functioning in the community; achievement of stability in family, work, and social relationships and in mood; and improved coping skills for reducing stress.

Answer 107

Diagnosis- 1. Risk for injury related to dehydration and faulty judgement, as evidenced by inability to meet own physiological needs and set limits on own behaviour Outcomes Identification Physical status will remain stable during manic phase. Short-Term Goal 1. Person will be well hydrated, as evidenced by good skin turgor and normal urinary output and specific gravity, within 24 hours. Intervention 1a. Give olanzapine (Zyprexa) intramuscularly immediately and as ordered. 1b.Check vital signs frequently (every 1–2 hours). 1c. Place person in private or quiet room (whenever possible). 1d.Stay with person and divert person away from stimulating situations. 1e. Offer high-calorie, high- protein drink (250 mL) every hour in quiet area. 1f. Frequently remind person to drink: “Take two more sips.” 1g.Offer finger food frequently, in quiet area. 1h.Maintain record of intake and output. 1i. Weigh person daily. Rationale 1a. Continuous physical activity and lack of fluids can eventually lead to cardiac collapse and death. 1b.Cardiac status is monitored. 1c. Environmental stimuli are reduced—escalation of mania and distractibility are minimized. 1d.Nurse’s presence provides support. Ability to interact with others is temporarily impaired. 1e. Proper hydration is mandatory for maintenance of cardiac status. 1f. Person’s concentration is poor; she is easily distracted. 1g.Person is unable to sit; snacks she can eat while pacing are more likely to be consumed. 1h.Such a record allows staff to make accurate nutritional assessment for person’s safety. 1i. Monitoring of nutritional status is necessary. Evaluation After 3 hours, person takes small amounts of fluid (60–120 mL per hour). After 5 hours, patient starts taking 250 mL per hour with a lot of reminding and encouragement. After 24 hours, urine specific gravity is within normal limits. ________ Goal 2 Person will sleep or rest 3 hours during the first night in the hospital with aid of medication and nursing interventions. 2a. Continue to direct person to areas of minimal activity. 2b.When possible, try to direct energy into productive and calming activities (e.g., pacing to slow, soft music; slow exercise; drawing alone; writing in quiet area). 2c. Encourage short rest periods throughout the day (e.g., 3–5 minutes every hour) when possible. 2d.Drinks such as coffee, tea, and colas should be decaffeinated only. 2e. Provide nursing measures at bedtime that promote sleep (e.g., warm milk, soft music). Rationale 2a. Lower levels of stimulation can decrease excitability. 2b.Directing patient to paced, non- stimulating activities can help minimize excitability. 2c. Person may be unaware of feelings of fatigue. Can collapse from exhaustion if hyperactivity continues without periods of rest. 2d.Caffeine is a central nervous system stimulant that inhibits needed rest or sleep. 2e. Such measures promote non- stimulating and relaxing mood. Evaluation Person is awake most of the first night. Sleeps for 2 hours from 0400 to 0600 hours. Person is able to rest on the second day for short periods and engage in quiet activities for short periods (5–10 minutes). ___________ Goal 3 Person’s blood pres- sure (BP) and pulse (P) will be within normal limits within 24 hours, with the aid of medication and nursing interventions. Intervention 3a. Continue to monitor BP and P frequently throughout the day (every 30 minutes). 3b. Keep staff informed, by verbal and written reports, of baseline vital signs and patient progress Rationale 3a. Physical condition is presently a great strain on patient’s heart. 3b. Alerting all staff regarding person’s status can increase medical intervention if a change in status occurs. Goal Met Baseline measures on unit are not obtained because of hyperactive behaviour. Information from family physician states that baseline BP is 130/90 mm Hg and baseline P is 88 beats per minute. BP at end of 24 hours is 130/70 mm Hg; P is 80 beats per minute.

Answer 108

* Bipolar I disorder is characterized by the presence or history of at least one manic episode, whereas bipolar II disorder is character- ized by the presence or history of at least one hypomanic episode. * Cyclothymia is a bipolar-related disorder with symptoms of hypo- mania and symptoms of mild to moderate depression. * Genetics plays a strong role in the risk for the bipolar disorders. * Neurotransmitter (norepinephrine, dopamine, serotonin) excess and imbalance are also related to bipolar mood swings, supporting the existence of neurobiological influences. Neuroendocrine and neuroanatomical findings provide strong evidence for biological influences. * Early detection of bipolar disorder can help diminish comorbid substance use, suicide, and decline in social and personal relation- ships and may help promote more positive outcomes. * Bipolar disorder often goes unrecognized. * The nurse assesses the person’s level of mood (hypomania, acute mania), behaviour, and thought processes and is alert to cognitive dysfunction. * Analyzing the objective and subjective data helps the nurse formu- late appropriate nursing diagnoses. Some of the nursing diagnoses appropriate for patients with mania are Risk for violence, Defensive coping, Ineffective coping, Disturbed thought processes, and Situation- al low self-esteem. * During the acute phase of mania, physical needs often take priority and demand nursing interventions. Therefore Deficient fluid vol- ume, Imbalanced nutrition, Imbalanced elimination, and Disturbed sleep pattern are usually addressed in the nursing plan. * The diagnosis of Interrupted family processes is vital. Support groups, psychoeducation, and guidance for the family can greatly affect the person’s adherence to the medication regimen. * Planning involves identifying the specific needs of the patient and family during the three phases of mania (acute, continuation, and maintenance). Can the patient benefit from communication skills training, improvement in coping skills, legal or financial counsel- ling, or further psychoeducation? What community resources does the person need at this time? * Health care workers, family, and friends often feel angry and frus- trated by the person’s disruptive behaviours. When these feelings are not examined and shared with others, the therapeutic potential of the staff is reduced, and feelings of confusion and helplessness remain. * Mood stabilizers are usually the first line of defence for bipolar dis- order and include lithium and several anticonvulsants. * Lithium is approved for treating acute mania and maintenance. Blood levels, kidney function, and thyroid function should be as- sessed regularly. * Most anticonvulsant drugs are approved for acute mania. Lamotrigine is approved for maintenance. * Antipsychotic medications, particularly the second-generation antipsychotics, are used for their sedating and mood-stabilizing properties. Screening for metabolic problems (e.g., diabetes) is es- sential in this population. * For some patients, ECT may be an appropriate medical treatment. * Patient and family teaching takes many forms and is most impor- tant in encouraging adherence to the medication regimen and re- ducing the risk of relapse. * Evaluation includes examining the effectiveness of the nursing in- terventions, changing the outcomes as needed, and reassessing the nursing diagnoses. Evaluation is an ongoing process and is part of each of the other steps in the nursing process.

Answer 109

is an individual’s characteristic patterns of relatively permanent thoughts, feelings, and behaviours that define the quality of experiences and relationships.

Answer 110

is a stable characteristic of a person, such as neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness.

Answer 111

is a way to describe a cluster of traits. For example, a person with an authoritarian personality has traits that relate to maintaining orderliness, command, and power. In contrast, a person’s character involves defining an individual’s integrity.

Answer 112

Individuals with personality disorders display significant challenges in self-identity or self-concept, they have problems with empathy and have difficulty establishing healthy, stable relationships. Individuals with personality disorders believe that the problems originate outside of themselves. They believe that if others behaved differently toward them or treated them differently, then all their problems would be solved. In the treatment of personality disorders, a key factor to success is that the person with the personality disorder recognizes and takes re- sponsibility for the contributions they make to their relational and so- cial difficulties. Treating personality disorders is difficult and complex, as people with these disorders have difficulty recognizing or owning the fact that their difficulties are problems of their personality. Thinking about personality as being made up of self-identity and self-concept is an important consideration when interacting with a person with a personality disorder. How they form opinions, and what actions they take, are influenced by how they see themselves in relation to the world. This impacts how the therapeutic relationship can be established and used. It is essential that the health- care team establish parameters to help staff deal with “splitting” behaviours.

Answer 113

Cluster A: Individuals with these disorders share characteristics of eccentric behaviours, such as social isolation and detachment. They may also display perception distortions, unusual levels of suspicious- ness, magical thinking, and cognitive impairment. * Paranoid personality disorder * Schizoid personality disorder * Schizotypal personality disorder Cluster B: People living with cluster B personality disorders show patterns of responding to life demands with dramatic, emotional, or erratic behaviour. Problems with impulse control, emotion processing and regulation, and interpersonal difficulties characterize this cluster of disorders. Insight into these issues is generally limited. To get their needs met, individuals with cluster B personality disorders may resort to behaviours that are considered desperate or entitled, including act- ing out, committing anti-social acts, or manipulating people and circumstances. * Borderline personality disorder (BPD) * Narcissistic personality disorder * Histrionic personality disorder * Anti-social personality disorder Cluster C: An individual with these types of personality disorders will demonstrate a consistent patterns of anxious and fearful behaviours, rigid patterns of social shyness, hypersensitivity, need for orderliness, and relationship dependency. * Avoidant personality disorder * Dependent personality disorder * Obsessive-compulsive personality disorder

Answer 114

The life- time prevalence of personality disorders is between 4% and 15% While narcissistic and schizotypal personal- ity disorders (STPDs) are relatively rare, borderline, avoidant, and obsessive-compulsive personality disorders have been established by meta-analyses (which pull together the best and most relevant research) to be common among both community and clinical popuations CULTURE has an influence on the rate of diagnosing personality disorders. For example, personality disorders are more often diag- nosed in high-income countries when compared to low to moderate- income countries

Answer 115

Personality disorders frequently co-occur with disorders of mood and eating, anxiety, and substance use. Personality disorders often amplify emotional dysregulation. The aging process has some effect on the prevalence of personality disorders. The dramatic, emotional, or erratic cluster B disorders may mute with age as individuals become less impulsive. This dampening may be due to a general tuning down of neurotransmitters. Other disorders such as obsessive-compulsive personality disorder or paranoid personality disorder may worsen with age, per- haps due to anxiety regarding declining sensory and cognitive capacity. Personality traits are amplified during the experience of a crisis and any illness; therefore it is pre-mature and not in the best interest of the individual for a personality disorder to be diagnosed during the ac- tive phase of another illness, especially a psychiatric episode or major stressful life event such as grief and loss or trauma.

Answer 116

a term that describes poorly modulated mood characterized by mood swings. Individuals with emotion regu- lation problems have ongoing difficulty managing painful emotions in ways that are healthy and effective.

Answer 117

Biological Factors Genetics: Individual children may perceive family experiences in unique ways and therefore respond differently from other family members. Children are also affected by forces outside the family that influence personality development. Neurobiology and Neurochemistry: Influences on the development of personality disorders probably incorporate a complex interaction of genetics, neurobiology, and neurochemistry. The chemical neurotransmitter theory proposes that certain neurotransmitters, including neurohormones, may regulate and influence temperament. Research in brain imaging has also revealed some differences in the size and function of specific structures of the brain in people with some personality disorders. Psychological Factors: Learning theory emphasizes that children develop maladaptive responses based on modelling of or reinforcement by important people in the child’s life. Cognitive theories emphasize the role of beliefs and assumptions in creating emotional and behavioural responses that influence one’s experiences within the family environment. Psychoanalytic theory focuses on the use of primitive defence mechanisms by individuals with personality disorders. Defence mechanisms such as repression, suppression, regression, undoing, and splitting have been identified as dominant. Environmental Factors: Childhood neglect and trauma have been established as risk factors for personality disorders. This association has been linked to possible neurotransmitter changes in response to early life stress and emotional reactivity. While the family environment is influential on development, there are other environmental factors besides upbringing that shape an individual’s personality.

Answer 118

This theory helps us understand how personality disorders emerge from the multi-faceted factors of biology and environment. Diathesis refers to genetic and biological vulnerabilities and includes personality traits and temperament. Temperament is our tendency to respond to challenges in predictable ways. Examples of descriptors of temperament may be laid back, referring to a calm temperament, or uptight, referring to an anxious temperament. In this model stress refers to immediate influences on personality such as the physical, social, psychological, and emotional environment. Stress also includes what happened in the past, such as growing up in one’s family with exposure to unique experiences and patterns of interaction. The diathesis–stress model proposes that, under conditions of stress, some people have maladaptive personal- ity development, resulting in the emergence of a personality disorder Genetic and biological traits are believed to influence the way an individual responds to the environment while, at the same time, the environment is thought to influence the expression of inherited traits. Many studies have suggested a strong correlation between trauma, neglect, and other dysfunctional family or social patterns of interaction and the development of personality disorders among individuals with particular personality traits and temperament. * STPD is a schizophrenia spectrum disorder and is genetically linked, meaning that there is a higher incidence of schizophrenia- related disorders in family members of people with STPD. * Anti-social personality disorder is genetically linked, and twin studies indicate a predisposition to this disorder. This predisposi- tion is set into motion by a childhood environment of inconsistent parenting, significant abuse, and extreme neglect. * BPD has traditionally been thought to develop as a result of early abandonment, which results in an unstable view of self and others. *Narcissistic personality disorder may be the result of childhood neglect and criticism. The child does not learn that other people can be a source of comfort and support. As an adult, the individual hides feelings of emptiness with an exterior of invulnerability and self-sufficiency. * Avoidant personality disorder has been linked with parental and peer rejection and criticism. * Obsessive-compulsive personality disorder may be related to ex- cessive parental criticism, control, and shame. The child responds to this negativity by trying to control their environment through perfectionism and orderliness.

Answer 119

is characterized by a long-standing dis- trust and suspiciousness of others based on the belief, which is unsupported by evidence, that others want to exploit, harm, or deceive the person. These individuals are hypervigilant (highly alet), anticipate hostility, and may provoke hostile responses by initiating a counterattack. The prevalence of paranoid personality disorder has been estimated at about 2% to 4%. Slightly more men than women are diagnosed with this disorder. Symptoms may be apparent in childhood or adolescence. Parents may notice that their child does not have friends and experiences social anxiety. Young people with this disorder are frequently teased due to their odd behaviour. As adults, relationships are difficult due to jealousy, controlling behaviours, and unwillingness to forgive. Projection is the dominant defence mechanism whereby people attribute their own unacknowledged feelings to others. For example, they may accuse their partner of being hypercritical when they themselves are attentively fault finding. Guidelines for Nursing Care * Considering the degree of mistrust, promises, appointments, and schedules should be strictly adhered to. * Being too nice or friendly may be met with suspicion. Instead, give clear and straightforward explanations of tests and procedures beforehand. * Use simple language and project a neutral but kind affect. * Limit setting is essential when threatening behaviours are present. Treatment Individuals with paranoid personality disorder tend to reject treatment. If they somehow end up in a psychiatric treatment setting, they may appear puzzled and obviously suspicious about why this is happening. Paranoid people are difficult to interview because they are reluctant to share information about themselves for fear that the information will be used against them. Psychotherapy is the first line of treatment for paranoid personality disorder. Individual therapy focuses on the development of a professional and trusting relationship. Due to fears, patients may behave in a threatening manner. Therapists should respond by setting limits and dealing with delusional accusations in a realistic manner without humiliating the patients. Group therapy is threatening to people with paranoid personality disorder. However, the group setting may be useful in improving social skills. Role-playing and group feedback can help reduce suspicious- ness. For example, if the patient says, “I think the therapist is singling me out,” other groups members may provide a reality check or describe similar feelings in the past. An anti-anxiety medication such as diazepam (Valium) may be used to reduce anxiety and agitation. More severe agitation and delusions may be treated with antipsychotic medi- cation such as haloperidol in small doses for brief periods of time to manage the mildly delusional thinking or severe agitation. The first- generation antipsychotic medication pimozide may be useful in reducing paranoid ideation.

Answer 120

People with schizoid personality disorder exhibit a lifelong pattern of social withdrawal. They are somewhat expressionless and operate with a restricted range of emotional expression. Others tend to view them as odd or eccentric due to their discomfort with social interaction. The prevalence rate may be nearly 5% of the population. Males are more often affected. Symptoms of schizoid personal- ity disorder appear in childhood and adolescence. These young people tend to be loners, do poorly in school, and are the objects of ridicule by their peers for their odd behaviour. There is increased prevalence of the disorder in families with a history of schizophrenia or STPD. Abnormalities in the dopaminergic systems may underlie this problem. Relationships are particularly affected due to the prominent feature of emotional detachment. People with this disorder do not seek out or enjoy close relationships. Neither approval nor rejection from others seems to have much effect. Friendships, dating, and sexual experiences are rare. If trust is established, the person may divulge numerous imaginary friends and fantasies. The patient may describe feelings of depersonalization or detachment from oneself and the world. Guidelines for Nursing Care * Nurses should avoid being too “nice” or “friendly.” * Do not try to increase socialization. * Patients may be open to discussing topics such as coping and anxiety. * Conduct a thorough assessment to identify symptoms the patient is reluctant to discuss. * Protect against ridicule from group members due to patient’s distinctive interests or ideas. Treatment Patients with schizoid personality disorder tend to be introspective. This trait may make them good, if distant, candidates for psychotherapy. As trust develops, these patients may describe a full fantasy life and fears, particularly of dependence. Psychotherapy can help improve sensitivity to others’ social cues. Group therapy may also be helpful, even though the patient may frequently be silent. Group therapy provides experience in practising interactions with and receiving feedback from others. Group members may become quite important to the person with schizoid personality disorder and may be the only form of socialization they have. Antidepressants such as bupropion (Wellbutrin) may help increase pleasure in life. Second-generation antipsychotics, such as risperidone or olanzapine (Zyprexa), are used to improve emotional expressiveness.

Answer 121

People with STPD do not blend in with the crowd. Their symptoms are strikingly strange and unusual. Magical thinking, odd beliefs, strange speech patterns, and inappropriate affect are hallmarks of this disorder. Estimates of the prevalence of STPD vary from 0.6% to 4.6%. It is more common in men than women. Like the other cluster A personality disorders, symptoms are evident in young people. People who have first-degree relatives with schizophrenia are at more risk for this disorder. Abnormalities in brain structure, physiology, chemistry, and functioning are similar to schizophrenia. For example, both disorders share reduced cortical volume. The Diagnostic and Statistical Manual of Mental Disorders, fifth edi- tion (DSM-5) (APA, 2013), identifies this problem as both a personality disorder and the first of the schizophrenia spectrum disorders. The ICD-10 (World Health Organization, 2016), used throughout the world, classifies schizotypal disorder along with schizophrenia and no longer lists schizotypal disorder as a personality disorder. Like schizoid personality disorder, individuals with STPD have severe social and interpersonal deficits. They experience extreme anxiety in social situations. Contributions to conversations tend to ramble, with lengthy, unclear, overly detailed, and abstract content. An additional feature of this disorder is paranoia. Individuals with STPD are overly suspicious and anxious. They tend to misinterpret the motivations of others as being out to get them and blame others for their social isolation. Odd beliefs (e.g., being overly superstitious) or magical thinking (e.g., “He caught a cold because I wished he would”) are also common. Psychotic symptoms seen in people with schizophrenia, such as hal- lucinations and delusions, may also exist with STPD, but to a lesser degree and only briefly. A major difference between this disorder and schizophrenia is that people with STPD CAN BE MADE AWARE of their suspiciousness, magical thinking, and odd beliefs. Schizophrenia is characterized by far stronger delusions. Guidelines for Nursing Care * Respect the patient’s need for social isolation. * Nurses should be aware of the patient’s suspiciousness and employ appropriate interventions. * Perform careful assessment as needed to uncover any other medical or psychological symptoms that may need intervention (e.g., suicidal thoughts). * Be aware that strange beliefs and activities, such as strange religious practices or peculiar thoughts, may be part of the patient’s life. Treatment The principles of psychotherapy used are similar to those for schizoid personality disorder. However, clinicians should be aware that these patients may also be actively involved in groups such as cults and unusual religious groups and engage in occult activities. While there is no specific medication for STPD, associated conditions may be treated. People with STPD seem to benefit from medications that help to control their symptoms. For example, antipsychotic medications for such symptoms as ideas of reference or illusions. Co- morbid symptoms related to depression and anxiety may be treated with antidepressants and anti-anxiety medications.

Answer 122

Neurobiology of Borderline Personality Disorder Borderline personality disorder (BPD) is a serious and disabling brain disorder marked by impulsivity and emotional dysregulation. Serotonin: Altered functioning of serotonin in the brain has been linked to depression, aggression, and difficulty in controlling destructive urges. The serotonin transporter gene 5-HTT is thought to have shorter alleles in BPD, which have been associated with lower levels of serotonin and increased impulsive aggression. Emotional dysregulation: Emotional responses that are poorly modulated (regulated) (e.g., angry outbursts, rage, marked fluctuation of mood, self-harm) and that can shift within seconds, minutes, or hours Brain imaging (functional magnetic resonance imaging) findings Pre-frontal cortex: In times of stress this part of the brain helps us regulate emotions and refrain from inappropriate actions. The pre-frontal cortex helps with reality testing and guides attention and thought. In people with BPD this part of the brain does not respond. Instead, there is an extreme perception and intensity of negative emotions. Limbic system/amygdala: In BPD parts of the emotional centre of the brain are overstimulated and take longer to return to normal. Also, certain neurotransmitters that act as constraints in normal circumstances may underfunction in BPD, leaving a person in a prolonged fight-or-flight response. ____________________ Medications Selective serotonin reuptake inhibitors, anticonvulsants, second-generation antipsy- chotics, lithium: Helps brain switch from sympathetic nervous system (arousal) to parasympathetic nervous system (relaxation mode) Dialectical behavioural therapy (DBT): Mindfulness, deep breathing, relaxation techniques- Helps dampen angry, impulsive, labile behaviour ___________________ There is evidence of dysfunction that accompanies the borderline trait of impulsivity. It may also contribute to the depression and aggression that commonly accompany this disorder. The serotonin transporter gene 5-HTT may have shorter alleles, which have been asso- ciated with lower levels of serotonin and increased impulsive aggression. [One of two or more versions of a genetic sequence at a particular region on a chromosome. An individual inherits two alleles for each gene, one from each parent.] Structural and functional magnetic resonance imaging have revealed abnormalities in the pre-frontal cortex and limbic regions. The frontal region is implicated in regulatory control processes, and the limbic region is essential for emotional processing. Limbic hyper-reactivity and diminished control by the frontal brain may explain poor emotion processing, impulsivity, and interpersonal disturbances. _______________ BPD is the most well known and dramatic of the personality disorders. BPD prevalence may be as high as 5.9% in the general population and be about 20% among people receiving inpatient psychiatric care The major features of this disorder are patterns of marked in- stability in emotion regulation, unstable interpersonal relationships, identity or self-image distortions, and unstable mood. These symptoms result in severe functional impairments, a high mortality rate (approximately 30%), and extensive use of health care services People with BPD seek out treatment for depression, anxiety, suicidal and self-harming behaviours, and other impulsive behaviours including substance use. Although hospitalization may decrease self-destructive risk for patients with BPD, it is not regarded as an effective long-term solution. BPD is around five times more common in first-degree biological relatives with the same disorder compared with the general population This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation _______ Mahler and colleagues (1975) believed that psychological problems are a result of the dis- ruption of the normal separation-individuation of the child from the mother. According to Mahler, an infant progresses from complete self- absorption with an inability to separate themself from the mother to a physically and psychologically differentiated toddler. Mahler em- phasized the role of the significant other (traditionally the mother) in providing a secure emotional base of support that promotes enough confidence for the child to separate. This support is achieved through a balance of holding (emotionally and physically) a child enough for the child to feel safe, while at the same time fostering and encouraging independence and natural exploration. Problems may arise in this separation-individuation process. If a toddler leaves their mother on the park bench and wanders off to the sandbox, ideally two things should happen. First, the child should be encouraged to go off into the world with smiles and reassurance: “Go on, honey, it’s safe to go away a little.” Second, the mother needs to be reliably present when the toddler returns, thereby reward- ing their efforts. Clearly, parents are not perfect and are sometimes distracted and short tempered. Mahler notes that raising healthy children does not require that parents never make mistakes and that “good enough parenting” will promote successful separation- individuation. Stages of this process are as follows: * Stage 1 (birth–1 month): Normal autism. The infant spends most of their time sleeping. * Stage 2 (1–5 months): Symbiosis. The infant perceives the mother- infant as a single fused entity. Infants gradually distinguish the in- ner world from the outer world. * Stage 3 (5–10 months): Differentiation. The infant recognizes dis- tinctness from the mother. Progressive neurological development and increased alertness draw the infant’s attention away from self to the outer world. * Stage 4 (11–18 months): Practising. The ability to walk and explore greatly expands the toddler’s sense of separateness. * Stage 5 (18–24 months): Rapprochement. Toddlers move away from their mothers and come back for emotional refuelling. Periods of helplessness and dependence alternate with the need for inde- pendence. * Stage 6 (2–5 years): Object constancy. When children compre- hend that objects (in this case, the object is the mother) are per- manent even when they are not in their presence, the individuation process is complete. Children who later develop BPD may have had this process dis- rupted.

Answer 123

One of the pathological personality traits seen in people with BPD is negative affect. This affect is characterized by emotional lability, that is, moods that alternate rapidly from one emotional extreme to another. Other characteristics of a negative affect include responding to situations with emotions that are out of proportion to the circumstances, pathological fear of separation, and intense sensitivity to perceived personal rejection. Other disruptive traits common in people with BPD are impulsivity and antagonism. Impulsivity is manifested in acting quickly in response to emotions without considering the con- sequences. This impulsivity results in damaged relationships and even suicide attempts. BPD is also characterized by feelings of antagonism, manifested in hostility, anger, and irritability in relationships. Physical violence toward intimate partners and non-intimate partners alike may oc- cur. Rarely, a homicide of family members or others occurs. Vio- lence is also manifested in destructive behaviours such as property damage. In addition, ineffective and harmful self-soothing habits, such as cutting, promiscuous sexual behaviour, and numbing with sub- stances, are common and may result in unintentional death. Chronic suicidal ideation is also a common feature of this disorder and in- fluences the likelihood of accidental death. A number of non-psychiatric diagnoses are also associated with BPD. They in- clude diabetes, high blood pressure, chronic back pain, fibromyalgia, and arthritis, and must be considered when determining treatment approaches. Splitting, the primary defence or coping style used by people with BPD, is the inability to incorporate positive and negative aspects of oneself or others into a whole image. This kind of dichotomous think- ing and coping behaviour is believed to be partly a result of the person’s failed experiences with adult personality integration and is likely influ- enced by exposure to earlier psychological, sexual, or physical trauma. For example, the individual may tend to idealize another person (e.g., friend, lover, health care provider) at the start of a new relationship, hoping that this person will meet all of their needs. However, at the first disappointment or frustration, the individual quickly shifts to devaluation, despising the other person. Guidelines for Nursing Care * A therapeutic relationship is essential with patients who have BPD because most of them have experienced failed relationships, includ- ing therapeutic alliances. * The therapeutic relationship often follows an initial hesitancy on the part of the patient, then an upward curve of idealization by the patient toward the caregiver. This idealization is invariably followed by a devaluation of the staff member when the patient is disappoint- ed by unmet, frequently impossible, expectations. * Conduct a thorough assessment of current or past physical, sexual, or emotional abuse and level of current risk for harm from self or others. * Clinical supervision and additional education are helpful and sup- portive to health care providers. * Awareness and monitoring of one’s own stress responses to patient behaviours facilitate more effective and therapeutic intervention, regardless of the therapeutic approach being used. * Evaluating treatment effectiveness in this patient population is difficult. Nurses may never know the real results of their interventions. Treatment People with BPD are usually admitted to psychiatric treatment pro- grams because of symptoms with comorbid disorders or dangerous behaviour. Emotions such as anxiety, rage, and depression and behav- iours such as withdrawal, paranoia, and manipulation are among the most frequent that health care workers must address. When patients blame and attack others, the nurse needs to understand the context of their complaints. These attacks originate from the feeling of being threatened. The more intense the complaints are, the greater the pa- tients’ fear of potential harm or loss is. Be aware of manipulative behav- iours such as flattery, seductiveness, and instilling guilt. Realistic outcomes are established for individuals with BPD based on the perspective that personality change occurs with one behavioural solution and one learned skill at a time. This can be expected to take a lot of time and repetition. In the acute care setting the focus is on the presenting problem, which may be depression or severe anxiety. Health care providers do not expect resolution of chronic behaviour problems during the hospital stay, but rather expect to be met with appropri- ate therapeutic feedback and incremental steps toward recovery in an outpatient setting. People with BPD are impulsive and may be suicidal, self-mutilating, aggressive, manipulative, and even psychotic during periods of stress. Provide clear and consistent boundaries and limits. Use straightforward communication. When behavioural problems emerge, calmly review the therapeutic goals. There are no approved medications for treating BPD. When medi- cations are used, their purposes are to maintain patients’ cognitive function, relieve symptoms, and improve quality of life. People with BPD often respond to antidepressants such as selective serotonin reup- take inhibitors (SSRIs), anti-convulsants, and lithium for mood and emotional dysregulation symptoms. Naltrexone, an opioid receptor antagonist, has been found to reduce self-injurious behaviours. Second-generation antipsychotics may control anger and brief psychosis. Community meetings, coping skills groups, and socializing groups are all helpful for these patients. They have the opportunity to interact with peers and staff to discuss goals and learn problem-solving skills. Common problems resulting from staff splitting can be mini- mized if the unit leaders hold weekly staff meetings in which staff members are allowed to express their feelings about conflicts with patients and each other. This process is often acted out in the treat- ment milieu and can interrupt the delivery of care. For example, a female patient may briefly idealize her male nurse on the inpatient unit, telling staff and patients alike that she is “the luckiest person because she has the best nurse in the hospital.” The rest of the team understands that this comment is an exaggeration. After days of her constant dramatic praise for the nurse and subtle insults to the rest of the staff, some members of the team may start to feel inadequate and resentful of the nurse. They begin to make critical remarks about minor events to prove that the nurse is not perfect.

Answer 124

Anti-social personality disorder is a pattern of disregard for, and vio- lation of, the rights of others. People with this disorder may be more commonly referred to as sociopaths. This diagnosis is reserved for adults, but symptoms are evident by the mid-teens. Symptoms tend to peak during the late teenage years and into the mid-twenties. By around 40 years of age, the symptoms may abate and improve even without treatment. The prevalence of anti-social personality disorder is between 0.2% and 3.3%. While the disorder is much more common in men, women may be underdiagnosed due to the traditional close association of this disorder with males. Anti-social personality disorder is genetically linked, and twin studies indicate a predisposition to this disorder. It is likely that the genetic predisposition for characteristics of anti-social personality disorder such as a lack of empathy may be set into motion by childhood maltreatment. Inconsistent parenting and discipline, significant abuse, and extreme neglect are associated with this disorder. Children reflect parental attitudes and behaviours in the absence of more prosocial inluences. Virtually all individuals who eventually develop this disorder have a history of impulse control and conduct problems as children and adolescents. The main pathological traits that characterize anti-social personality disorder are antagonistic behaviours such as being deceitful and ma- nipulative for personal gain or being hostile if needs are blocked. The disorder is also characterized by disinhibited behaviours such as high level of risk taking, disregard for responsibility, and impulsivity. Criminal misconduct and substance use are common in this population. People with this disorder are mostly concerned with gaining personal power or pleasure, and in relationships they focus on their own gratification to an extreme. They have little to no capacity for intimacy and will exploit others if it benefits them in relationships. One of the most disturbing qualities associated with anti-social personality dis- order is a profound lack of empathy, also known as callousness. This callousness results in a lack of concern about the feelings of others, the absence of remorse or guilt except when facing punishment, and a disregard for meeting school, family, and other obligations. These individuals tend to exhibit a shallow, unexpressive, and su- perficial affect. They may also be adept at portraying themselves as concerned and caring if these attributes help them to manipulate and exploit others. A person with anti-social personality disorder may be able to act witty and charming and be good at flattery and manipulating the emotions of others. Guidelines for Nursing Care * Nurses should be aware and monitor their responses to patient be- haviours to facilitate effective and therapeutic responses. * Conduct a thorough assessment of current life stressors, history of violent thoughts and behaviours (including suicidal ideation), and substance use. * Be aware that distrust, hostility, and a profound inability to connect with others will impair the usual process of developing a therapeu- tic relationship. * Evaluating treatment effectiveness in this patient population is difficult. Nurses may never know the real results of their interventions. Treatment In the context of anti-social personality disorder the role of the nurse will be to provide consistency, support, boundaries, and limits. Provid- ing realistic choices (e.g., selection of a particular group activity) may enhance adherence to treatment. People with anti-social personality disorder may be involuntarily admitted to psychiatric units for evalua- tion. With their freedom limited, they tend to be angry, manipulative, aggressive, and impulsive. Try to prevent or reduce untoward effects of manipulation (flattery, seductiveness, instilling of guilt). Set clear and realistic boundaries and consequences and ensure that all staff follow these limits. Carefully document behaviours and signs of manipula- tion. Be aware that anti-social patients can manipulate with feelings of guilt when they are not getting what they want. The safety of patients and staff is a prime consideration in work- ing with individuals in this population. To promote safety, the entire treatment team should follow a solid treatment plan that emphasizes realistic limits on specific behaviour, consistency in responses, and consequences for actions. Careful documentation of behaviours will aid in providing effective interventions and in promoting teamwork. Therapeutic communication techniques are valuable tools for work- ing with individuals with anti-social personality disorder. Simply being heard can defuse an emotionally charged situation. For example, the nurse can listen to a patient’s emotional complaints about the staff and the hospital without correcting errors, simply noting that the patient truly feels hurt. Showing empathy may also decrease aggressive out- bursts if the patient feels that staff members are trying to understand feelings of frustration. There are no approved medications for treating anti-social personality disorder. Medications are used to treat concurrent comorbid disorders. The advanced-practice psychiatric mental health registered nurse may care for individuals with this type of personality disorder in a variety of inpatient and community settings.

Answer 125

People with histrionic personality disorder are excitable and dramatic yet are often high functioning. They may be referred to in terms of be- ing a “drama queen” or “drama major.” Classic characteristics of this population include extraversion, flamboyancy, and colourful person- alities. Despite this bold exterior, those with histrionic personality dis- order tend to have limited ability to develop meaningful relationships. Histrionic personality disorder occurs at a rate of nearly 2% in community samples. In clinical settings it tends to be diagnosed more frequently in women than in men. Symptoms begin by early adulthood. Inborn character traits such as emotional expressiveness and egocentricity have also been identified as predisposing an individual to this disorder. This disorder is characterized by emotional attention-seeking be- haviours, including self-centredness, low frustration tolerance, and excessive emotionality. The person with histrionic personality disorder is often impulsive and may act flirtatiously or provocatively. Relation- ships do not last because the partner often feels smothered or reacts to the insensitivity of the histrionic person. The individual with histrionic personality disorder does not have insight into a personal role in break- ing up relationships. Guidelines for Nursing Care * Nursing care should reflect an understanding that seductive behav- iour is a response to distress. * Keep communication and interactions professional. * Patients may exaggerate symptoms and difficulty in functioning. * Encourage and model the use of concrete and descriptive rather than vague and impressionistic language. * Assist patients to clarify feelings because they often have difficulty identifying them. * Teach and role model assertiveness. * Assess for suicidal ideation. What was intended as a suicide gesture may inadvertently result in death. Treatment Individuals with histrionic personality disorder may be out of touch with their feelings. Psychotherapy may pro- mote clarification of inner feelings and appropriate expression. Group therapy may be useful in this population, although distracting symptoms may be disruptive to group functioning. There are no specific pharmacological treatments available for people with histrionic personality disorder. Medications such as antidepressants can be used for depressive symptoms. Anti-anxiety medications may be helpful in treating anxiety. Antipsychotics may be used if the patient exhibits derealization or illusions.

Answer 126

Narcissistic personality disorder is characterized by feelings of entitlement, an exaggerated belief in one’s own importance, and a lack of empathy. In reality, people with this disorder suffer from a weak self- esteem and hypersensitivity to criticism. Narcissistic personality dis- order is associated with less impairment in individual functioning and quality of life than the other personality-based disorders. The prevalence of narcissistic personality disorder ranges from 0% to about 6% in community samples. It tends to be more common in males than in females. There may be a familial tendency for this disorder, as parents with narcissism may attribute an unrealistic sense of talent, importance, and beauty to their children. These attributions put the children at higher risk for the disorder. People with narcissistic personality disorder come across as arrogant and as having an inflated view of their self-importance. The individual with this disorder has a need for constant admiration along with a lack of empathy for others, a factor that strains most relationships over time. They are very sensitive to rejection and criticism and can be disparaging to others. A sense of personal entitlement paired with a lack of social empathy may result in the exploitation of other people. Underneath the surface of arrogance, people with narcissistic personality disorder feel intense shame and have a fear of abandonment. In keeping with these descriptions the main pathological personality trait of narcissism is antagonism, represented by grandiosity and attention-seeking behaviours. Those with narcissistic personality disorder tend to tolerate rejection poorly. As a result, narcissistic individuals may seek help for depression or may seek to be validated by therapists and loved ones for their emotional pain of not being appreciated by others for their efforts or special qualities. Guidelines for Nursing Care * Nurses should remain neutral and recognize the source of narcis- sistic behaviour, shame and fear of abandonment. * Use the therapeutic nurse–patient relationship as an opportunity to practise engaging in meaningful interaction. * Avoid engaging in power struggles or becoming defensive in re- sponse to the patient’s disparaging remarks. * Role model empathy. Treatment Because individuals are not likely to seek help for their own problems, they are more likely to be involved in couples or fam- ily therapy than in individual treatment. In these family-oriented ap- proaches narcissistic individuals are likely to deflect suggestions that they contribute to family problems and will instead blame others. If a person with narcissistic personality disorder somehow seeks treatment, individual cognitive behavioural therapy is helpful in de- constructing faulty thinking. Group therapy can also assist the person in sharing with others, seeing their own qualities in others, and learn- ing empathy. There are no approved medications for treating narcissistic per- sonality disorder. Medications are used to treat concurrent comorbid disorders.

Answer 127

The main pathological personality traits associated with avoidant per- sonality disorder are low self-esteem related to functioning in social situations, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people. Some individuals with avoidant personality disorder can function in a protective environment. However, if their support system fails, they can suffer from depression, anxiety, and anger. They are especially sensitive to and pre- occupied with rejection, humiliation, and failure. They often avoid new interpersonal relationships or activities due to their fears of criticism or disapproval. Avoidant personality disorder occurs in approximately 2.4% of the population. It is found equally among men and women. Early symptoms of the disorder are often evident in infants and children. These symptoms include shyness and avoidance that, unlike common shyness, increases during adolescence and early adulthood. Guidelines for Nursing Care * Nurses should use a friendly, accepting, reassuring approach and remember that being pushed into social situations can cause ex- treme and severe anxiety for these patients. * Convey an attitude of acceptance toward patient fears. * Provide the patient with exercises to enhance new social skills, but use these with caution because any failure can increase feelings of poor self-worth. * Assertiveness training can assist the person to learn to express needs. Treatment Individual and group therapy is useful in processing anxiety-provoking symptoms and in planning methods to approach and handle anxiety- provoking situations. Psychotherapy focuses on trust and assertiveness training. Anti-anxiety medications can be helpful. Beta-adrenergic receptor antagonists (e.g., atenolol) help reduce autonomic nervous system hy- peractivity. Antidepressant medications, such as SSRIs like citalopram (Celexa) and serotonin–norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (Effexor), may reduce social anxiety. Serotonergic medications may help individuals with avoidant personalities feel less sensitive to rejection.

Answer 128

Dependent personality disorder is characterized by a pattern of sub- missive and clinging behaviour related to an overwhelming need to be cared for. This need results in intense fears of separation. Dependent personality disorder is fairly rare, with an estimated prevalence rate of about 0.5% May be the result of chronic physical illness or punishment for independent behaviour in childhood. The inherited trait of submissiveness may also be a factor. People with dependent personality disorder have a high need to be taken care of. This need can lead to patterns of submissiveness with fears of separation and abandonment by others. Because they lack con- fidence in their own ability or judgement, those with dependent per- sonality disorder may manipulate others to assume responsibility for such activities as finances or child rearing. This may create problems by leaving them more vulnerable to exploitation by others because of their passive and submissive nature. Feelings of insecurity about their self-agency and lack of self-confidence may interfere with attempts to become more independent. They may experience intense anxiety when left alone for even brief periods of time Guidelines for Nursing Care * Nurses can help the patient identify and address current stressors. * Be aware that strong counter-transference may develop because of the patient’s demands for extra time and crisis states. * The therapeutic nurse–patient relationship can provide a testing ground for increased assertiveness through role modelling and teaching of assertive skills. Treatment Psychotherapy is the treatment of choice for dependent personality disorder Cognitive behavioural therapy can help patients develop more healthy and accurate thinking by examin- ing and challenging automatic thoughts that result in fearful behaviour. This process can help in developing new perspectives and attitudes about the need for other people. There are no specific medications indicated for this disorder, but symptoms of depression and anxiety may be treated with the appropriate antidepressant and anti-anxiety medications. Panic attacks can be helped with the tricyclic antidepressant imipramine.

Answer 129

Obsessive-compulsive personality disorder is characterized by limited emotional expression, stubbornness, perseverance, and indecisiveness. Pre-occupation with orderliness, perfectionism, and control are the hallmarks of this disorder. Obsessive-compulsive personality disorder is one of the most prevalent personality disorders. The prevalence rate ranges from 2.1% to 7.9% It is more common in men than in women. Oldest siblings tend to be affected more often than subsequent siblings. Risk factors for this disorder include a background of harsh discipline and having a first- degree relative with this disorder. Obsessive-compulsive personality dis- order has been associated with increased relapse rates of depression and an increase in suicidal risks in people with co-occurring depression. The main pathological personality traits are rigidity and inflexible standards of self and others. People with obsessive-compulsive person- ality disorder rehearse over and over how they will respond in social situations. They persist in goal seeking long after it is necessary, even if it is self-defeating or relationship defeating. The pre-occupation often results in losing the major point of the activity. Projects are often in- complete due to overly strict standards. There is a difference between obsessive-compulsive disorder and obsessive-compulsive personality disorder. Obsessive-compulsive dis- order is characterized by obsessive thoughts and by repetition or ad- herence to rituals. Those with obsessive-compulsive disorder are aware that these thoughts and actions are unreasonable. Obsessive-compulsive personality disorder is characterized more by an unhealthy focus on perfectionism. Those with obsessive-compulsive personality disorder think that their actions are right and feel comfortable with such self-imposed systems of rules. Guidelines for Nursing Care * Nurses should guard against power struggles with these patients, as their need for control is very high. * Patients with this disorder have difficulty dealing with unexpected changes. * Provide structure, yet allow patients extra time to complete habitual behaviour. * Assist patients to identify ineffective coping and to develop effective coping techniques Treatment Typically, patients seek help for obsessive-compulsive personality dis- order, as they are aware of their own suffering. They may also seek treatment for anxiety or depression. The treatment course is often long and complicated. Both group therapy and behavioural therapy can be helpful, so that the person can learn new coping skills for their anxiety and see direct benefits for change from feedback within the group. Clomipramine (Anafranil) may help reduce the obsessions, anxiety, and depression associated with this disorder. Other serotonergic medi- cations such as fluoxetine (Prozac) may also be effective.

Answer 130

semistructured interview obtained by clinicians. These types of interviews have standard questions and a standard format for ask- ing the questions. These interviews go beyond asking the patient to self-report symptoms because individuals with personality disorders often lack insight into their behaviours and motivations and therefore have difficulty accurately describing themselves. One way to elicit more objective information is to ask the person if family members and col- leagues perceive them in a certain way. For example, “You said that you don’t think you’re emotionally distant. How would your wife describe you?” Cultural norms and expectations also need to be considered when evaluating the presence of a personality disorder. Personality dis- orders are often assessed through identifying pathology within one or more personality dimensions. The five main dimensions of personalities are (1) extraversion versus introversion, (2) antagonism versus adherence, (3) constraint versus impulsivity, (4) emotional dysregulation versus emotional stability, and (5) unconventionality versus closedness to experience. Open-ended or subjective interviews, which do not have standard questions or a standard question format, are more likely to result in biased and culturally based decisions about diagnosis and treatment delivery. Minnesota Multi-phasic Personality Inventory, are useful because they have built- in validity and reliability scales for the clinician to refer to when interpreting test results. Other more focused questionnaires and rating scales can be used to assess several symptoms. These include: * Feelings of emptiness * An inclination to engage in risky behaviours such as reckless driv- ing, unsafe sex, substance use, binge eating, gambling, or over- spending * Intense feelings of abandonment that result in paranoia or feeling spaced out * Idealization of others and becoming close quickly * A tendency toward anger, sarcasm, and bitterness * Self-mutilation and self-harm * Suicidal behaviours, gestures, or threats * Sudden shifts in self-evaluation that result in changing goals, values, and career focus * Extreme mood shifts that occur in a matter of hours or days * Intense, unstable romantic relationships * Feelings of insecurity * Rigidity * Perfectionism

Answer 131

Taking a full medical history can help determine if the problem is a psychiatric one, a non-psychiatric medical one, or both. Non-psychiatric illness should never be ruled out as the cause for problem behaviour until the data support this conclusion. Important issues in assessing for personality disorders include a history of suicidal or aggressive ide- ation or actions, current use of medications and illegal substances, abil- ity to handle money, and legal history.

Answer 132

Extraversion versus introversion Antagonism versus adherence Constraint versus impulsivity Emotional dysregulation versus emotional stability Unconventionality versus closedness to experience

Answer 133

Activity, aloofness, assertiveness, detachment, entitlement, excitement seeking, exhibitionism, exploratory excitability, extravagance, gregariousness, histrionic sexualization, intimacy problems, optimism, positive emotionality, restricted expression, schizoid orientation, shyness, sociability, social avoidance, social closeness, social potency, stimulus seeking, warmth, well-being

Answer 134

Adherence, aggression, agreeableness, alienation, altruism, attachment, callousness, compassion, conduct problems, dependency, diffidence, empathy, entitlement, helpfulness, insecure attachment, interpersonal disesteem, manipulativeness, mistrust, modesty, narcissism, passive oppositionality, psychopathy, pure-heartedness, rejection, sentimentality, social acceptance, social closeness, straightforwardness, submissiveness, suspiciousness, tender- mindedness, trust

Answer 135

Achievement striving, childishness, competence, compulsivity, conscientiousness, deliberation, disorderliness, dutifulness, eagerness of effort, harm avoidance, impulsivity, irresponsibility, obsessionality, order, perfectionism, propriety, resourcefulness, responsibility, risk taking, self-discipline, traditionalism, workaholism

Answer 136

Affective lability, alienation, angry hostility, anticipatory worry, anxiousness, dependency, depressiveness, dysphoria, emotional dysregulation, fear of uncertainty, hostility, hypochondriasis, identity problems, inferiority, introspection, irritability, negative affect, pessimism, self-acceptance, self-consciousness, self-harm, sensitivity, stress reaction, unhappiness, vulnerability, worthlessness

Answer 137

Absorption, dissociation, eccentric perceptions, eccentricity, openness to experience, perceptual cognitive distortion, rigidity, spiritual acceptance, thought disorder, transpersonal identification

Answer 138

Because enduring patterns of interpersonal difficulties are central to the problems faced by people diagnosed with personality disorders, it is un- derstandable that their relationship problems with their caregivers sur- face in the treatment milieu. Anticipating that people with personality disorders will likely have a disrupted, intense interpersonal experience with caregivers is helpful to the caregivers as they monitor their own personal stress responses. It is important to keep in mind that these dys- functional behaviours may really represent the person’s best efforts to cope because they lack the necessary skills to be effective in their lives. Planning It is often difficult to create a therapeutic relationship with individuals who have personality disorders because most of them have experienced failed relationships, including therapeutic alliances. Individuals with BPD or anti-social personality disorder will distrust relationships and demonstrate hostility toward others, thus making the establishment of a therapeutic relationship difficult. People with personality disorders require a sense of control over what is happening to them. Giving them realistic choices (e.g., selection of a particular group activity) may en- hance adherence to treatment. It is also important to plan individual patient treatment within the context of their family. Patients, families, and health care providers can access further information on person- ality disorders from the Internet; two reliable Canadian sites are the Canadian Mental Health Association (https://www.cmha.ca) and Here- toHelp (https://www.heretohelp.bc.ca). Refer to Table 19.4 for guide- lines for nursing care for the major clusters of personality disorders. Case Study and Nursing Care Plan 19.1 presents a person with BPD. Implementation People with BPD are impulsive (e.g., suicidal, self-mutilating), aggres- sive, manipulative, and even psychotic during periods of stress. Indi- viduals with anti-social personality disorder are often involuntarily admitted and are manipulative, aggressive, and impulsive. Refer to Boxes 19.1 to 19.3 for interventions to address these behaviours, based on the Nursing Interventions Classification (NIC) (Butcher et al., 2019). Finding an approach that works with people in the setting in which they are treated is important. Therapies such as dialectical behaviour therapy (DBT) and mindfulness-based therapies offer staff evidence- informed interventions, clinical structure, and formalized support for identifying best practices.

Answer 139

When people with personality disorders are admitted to hospital, it is usually because of symptoms of comorbid disorders, dangerous be- haviour, or court-ordered treatment. BPD and anti-social personality disorder both present a challenge for health care providers because the behaviours central to these disorders often cause disruption in psychiatric and medical-surgical settings. Emotions such as anxiety, rage, and depression and behaviours such as withdrawal, paranoia, and manipulation are among the most frequent concerns that health care workers must address. Outcomes Identification: Realistic outcomes are established for individuals with personality disorders based on the perspective that personality change occurs with one behavioural solution and one learned skill at a time. This change can be expected to take much time and repetition. In the acute care setting the focus is on the presenting problem, which may be depression or severe anxiety. Planning: People with personality disorders require a sense of control over what is happening to them. Giving them realistic choices (e.g., selection of a particular group activity) may en- hance adherence to treatment. It is also important to plan individual patient treatment within the context of their family. Implementation: People with BPD are impulsive (e.g., suicidal, self-mutilating), aggres- sive, manipulative, and even psychotic during periods of stress. Indi- viduals with anti-social personality disorder are often involuntarily admitted and are manipulative, aggressive, and impulsive.

Answer 140

1. Assess for suicidal or homicidal thoughts. If such thoughts are present, the person needs immediate attention. 2. Determine whether the person has a medical disorder or another psychi- atric disorder that may be responsible for the symptoms (especially a sub- stance use disorder). 3. View the assessment about personality functioning from within the per- son’s ethnic, cultural, and social background. 4. Ascertain whether the person experienced a recent important loss. Person- ality disorders are often exacerbated after the loss of significant supporting people or in a disruptive social situation. 5. Evaluate for a change in personality, in middle adulthood or later, that sig- nals the need for a thorough medical workup or assessment for an unrecognized substance use disorder.

Answer 141

When individuals with personality disorders are receiving treatment from a team of health professionals, milieu management is a significant part of treatment. Most individuals with personality disorders are admitted to hospital because of a risk to themselves or others. Patient and staff safety is a priority. When patients are actively involved in developing their treatment plans (e.g., being included in daily staff rounds to set goals and evaluate progress), they typically take more responsibility for themselves and the success of implementing the plan. Having limits and being con- fronted about negative behaviour are better accepted by the person if staff members first employ empathic mirroring (i.e., reflecting back to the person an understanding of the person’s distress without a value judgement). For example, the nurse can listen to a person’s emotional complaints about the staff and hospital without correcting any errors but simply noting that the person truly feels hurt. Showing empathy may also decrease aggressive outbursts if the person feels that staff members are trying to understand feelings of frustration. A final approach that is useful for people with BPD relates to the re- sponse to superficial self-destructive behaviours. Acting in accordance with unit policies, the nurse remains neutral and dresses the cutting wound in a matter-of-fact manner. Then the person is instructed to write down the sequence of events leading up to the injury, as well as the consequences, before staff will discuss the event. This cognitive exercise encourages the person to think independently about their own behaviour instead of merely ventilating feelings. It facilitates the discus- sion with staff about alternative actions.

Answer 142

There is no direct pharmacological treatment for personality disor- ders. However, people with personality disorders may be helped by a broad array of psychotropic medications, all geared toward maintain- ing cognitive function and relieving symptoms. Depending on the chief complaint, antidepressant, anxiolytic, or antipsychotic medication may be ordered for symptom relief and improved quality of life. * People with STPD seem to benefit from low-dose atypical antipsychotic medications for their psychotic-like symptoms and day-to-day functioning. * People with anti-social personality disorder respond to mood- stabilizing medications like lithium to help with aggression and impulsivity. * People with BPD often respond to anti-convulsant mood-stabiliz- ing medications, low-dose antipsychotic medications, and omega-3 supplementation for mood and emotion dysregulation symptoms. Naltrexone hydrochloride, an opioid receptor antagonist, has been found to reduce self-injuring behaviours. * People with avoidant personality disorder seem to respond positive- ly to medications similar to those used for anxiety disorders, such as SSRIs like citalopram (Celexa) and SNRIs such as duloxetine (Cym- balta).

Answer 143

Crisis, high levels of anxiety Ineffective coping Anxiety Self-mutilation __________ Anger and aggression; child, older adult, or spouse abuse Risk for other-directed violence Ineffective coping Impaired parenting Disabled family coping _________ Withdrawal Social isolation ____________ Paranoia Fear Disturbed sensory perception Disturbed thought processes Defensive coping __________ Depression Hopelessness Risk for suicide Self-mutilation Chronic low self-esteem Spiritual distress _____________ Difficulty in relationships, manipulation Ineffective coping Impaired social interaction Defensive coping Interrupted family processes Risk for loneliness ______________ Failure to keep medical appointments, late arrival for appointments, failure to follow prescribed medical procedure or medication regimen Ineffective therapeutic regimen management _____________ Non-adherence

Answer 144

Nursing Outcome and Definition: Social interaction skills: Personal behaviours that promote effective relationships Intermediate indicator: Uses conflict-resolution methods Short term indicators: Exhibits receptiveness Exhibits sensitivity to others Cooperates with others Uses assertive behaviours as appropriate Uses confrontation as appropriate ____________ Nursing outcome and definition: ersonal resiliency: Positive adaptation and function of an individual following significant adversity or crisis Intermediate indicators: Uses effective coping strategies Short term indicators: Expresses emotion Seeks emotional support Uses strategies to promote safety Takes responsibility for own actions Uses strategies to avoid violent situations Identifies available community resources Obtains needed support Self-initiates goal-directed behaviour Expresses belief in ability to perform action Expresses that performance will lead to desired outcome ___________ Nursing outcome and definition: Aggression self-control: Self-restraint of assaultive, combative, or destructive behaviours toward others Intermediate indicator: Communicates needs appropriately Identifies when frustrated Identifies when angry Short term indicators: Identifies responsibility to maintain control Identifies alternatives to aggression Identifies alternatives to verbal outbursts Vents negative feelings appropriately Refrains from striking or harming others _________________ Impulse self-control: Self-restraint of compulsive or impulsive behaviours -Controls impulses -Identifies harmful impulsive behaviours Identifies feelings that lead to impulsive actions Identifies consequences of impulsive actions to self or others Avoids high-risk environments and situations Seeks help when experiencing impulses

Answer 145

Case management is helpful for individuals with personality disorders who are persistently and severely impaired. Many have had multiple hospitalizations, have been unable to maintain work or personal rela- tionships, and are relatively alone in their attempts to care for them- selves. In the acute care setting case management focuses on three goals: to gather pertinent history from current or previous providers; to support reintegration with family or loved ones as appropriate; and to ensure appropriate referrals to outpatient care, including substance disorder treatment, if needed. In the long-term outpatient setting case- management objectives include reducing hospitalization by providing resources for crisis services and enhancing the social support system.

Answer 146

Characteristics: Manifestation of ideas of reference Cognitive and perceptual distortions Social ineptness Anxiety Odd and eccentric behaviours Nursing Guidelines: 1. Respect patient’s need for social isolation. 2. Be aware of patient’s suspiciousness, and employ appropriate interventions. 3. Perform careful diagnostic assessment as needed to uncover any other medical or psychological symptoms that may need intervention (e.g., suicidal thoughts). Suggested Therapies: Supportive psychotherapy Cognitive and behavioural measures Group therapy to try to improve social skills Low-dose antipsychotics and anti- depressants

Answer 147

Characteristic: Ability to seem normal Manipulative Exploitive of others Disparaging Impulsive (suicide, self-mutilation) Splitting (adoring then devaluing people) Grandiose Filled with rage Very sensitive to rejection, criticism Inability to experience empathy Nursing Guidlines: 1. Try to prevent or reduce untoward effects of manipulation (flattery, seductiveness, instilling of guilt): a. Set clear and realistic limits on specific behaviour. b. Ensure that limits are adhered to by all staff. c. Carefully document signs of manipula- tion or aggression. d. Document behaviours (give times, dates, circumstances). e. Provide clear boundaries and consequences. 2. Be aware that patients can instill guilt when they are not getting what they want. Guard against being manipulated through feelings of guilt. 3. Use clear and straightforward communi- cation. 4. When behavioural problems emerge, calmly review the therapeutic goals and boundaries of treatment. 5. Avoid rejecting or rescuing. 6. Assess for suicidal and self-mutilating behaviours, especially during times of stress. 7. Remain neutral; avoid engaging in power struggles or becoming defensive in response to the patient’s disparaging remarks. 8. Convey unassuming self-confidence. Suggested Therapies: ndividual psychotherapy Dialectical behaviour therapy Group therapy Pharmacotherapy for anxiety, depression Careful use of addictive medications (e.g., benzodiazepines) Anti-convulsants may help impulsive behaviour Antipsychotics to control anger and brief psychosis.

Answer 148

Characteristic Excessively anxious in social situations Hypersensitive to negative evaluation Desiring of social interaction Perfectionistic Has need for control Inflexible, rigid Pre-occupied with details Highly critical of self and others Nursing Guidlines 1. Being pushed into social situations can cause extreme and severe anxiety. 2. Guard against power struggles with patient. Need for control is very high. 3. A friendly, accepting, reassuring approach is the best way to treat patients. 4. The most common defence mechanisms are intellectualization, rationalization, reaction formation, isolation, and undoing. Suggested Therapies Supportive or insightful psychotherapy Group therapy Assertiveness training Anti-depressants Anti-anxiety medications Beta-adrenergic receptor antagonists help reduce autonomic nervous system hyperactivity

Answer 149

Definition of anger control assistance: Facilitation of the expression of anger in an adaptive, non-violent manner Activitiesa * Determine appropriate behavioural expectations for expression of anger, given person’s level of cognitive and physical functioning. * Limit access to frustrating situations until person is able to express anger in an adaptive manner. * Encourage person to seek assistance from nursing staff during periods of increasing tension. * Monitor potential for inappropriate aggression, and intervene before its expression. * Prevent physical harm if anger is directed at self or others (e.g., restraint and removal of potential weapons). * Provide physical outlets for expression of anger or tension (e.g., punching bag, sports, clay, journal writing). * Provide reassurance to person that nursing staff will intervene to prevent person from losing control. * Assist person in identifying source of anger. * Identify function that anger, frustration, and rage serve for person. * Identify consequences of inappropriate expression of anger.

Answer 150

Definition of limit setting: Establishing the parameters of desirable and acceptable personal behaviour Activities * Discuss concerns about behaviour with person. * Identify (with input when appropriate) undesirable personal behaviour. * Discuss with person, when appropriate, what desirable behaviour is in a given situation or setting. * Establish consequences (with person’s input when appropriate) for occur- rence or non-occurrence of desired behaviours. * Communicate established behavioural expectations and consequences to person in language that is easily understood and non-punitive. * Refrain from arguing or bargaining with person about established behav- ioural expectations and consequences. * Monitor person for occurrence or non-occurrence of desired behaviour. * Modify behavioural expectations and consequences, as needed, to accom- modate reasonable changes in person’s situation.

Answer 151

Psychotherapy. Advanced-practice nurses are highly involved in and are often the clinical leaders in providing individual and group psy- chotherapy using dialectical behaviour therapy. DBT is an evidence- informed therapy developed by Dr. Marsha Linehan to treat chroni- cally suicidal people with BPD. DBT is based on a biosocial theory that views the self-harming behaviour as a behaviour used to cope with or eliminate distress brought on by a negatively perceived environmental event, self-generated behaviours, and individual temperaments. There are three primary reasons why individuals use this means of coping: (1) low stress tolerance, (2) deficiencies in emotional regulation, and (3) self-harm is regarded as a reasonable means of problem solving. For example, if an individual is facing an intolerable and inescapable life problem, it would be only reasonable to think about suicide. DBT combines cognitive and behavioural techniques with mind- fulness, which emphasizes being aware of thoughts and actively shap- ing them. Interventions that are common to DBT and other behaviour therapies include cognitive restructuring, therapist reciprocal vulnera- bility, skills training, and reinforcement. Unique DBT interventions in- clude the use of emotional regulation and opposite action skills, dialec- tics, distress tolerance skills, higher degree of therapist self-disclosure, validation as an explicit therapist skill set, and microanalytic chain analysis. DBT encourages balance and synthesis of acceptance and change. The goals of DBT are to increase the person’s ability to manage distress and improve interpersonal effectiveness. Treatment focuses on behaviour targets, beginning with identification of and interventions for suicidal behaviours and then progressing to a focus on interrupting destructive behaviours. Finally, DBT addresses quality- of-life behaviours across a hierarchy of care. Optimally, DBT is delivered as a skills training group program combined with individual therapy with a DBT-trained therapist who may be a nurse, social worker, or psychologist.

Answer 152

Each therapeutic experience offers an opportunity for the person to ob- serve themself interacting with caregivers who consistently try to teach positive coping skills. Effectiveness can be measured by how success- fully the nurse is able to be genuine with the person, maintain a helpful posture, offer substantial instruction, and still maintain their own self care. Specific short-term outcomes may be accomplished, and overall, the person can be given the message of hope that quality of life can always be improved.

Answer 153

Diagnosis Annie formulates two initial nursing diagnoses that have the highest priority during this time: 1. Ineffective coping related to inadequate psychological resources, as evidenced by self-destructive behaviours Outcomes Identification 1. Person will consistently demonstrate the use of effective coping strategies. 2. Person will refrain from injuring self. Planning The initial plan is to maintain personal safety and to encourage verbalization of feelings and impulses instead of action. Implementation Annie’s plan of care is personalized as follows: Nursing diagnosis: Ineffective coping Outcome: Ada will consistently demonstrate the use of effective coping strategies. Short-Term Goal Ada will consistently demonstrate a decrease in stress as evidenced by talking about feelings with staff every day and an absence of acting-out behaviours. Intervention 1. Encourage verbalization of feelings, perceptions, and fears. 2. Support the use of appropriate defence mechanisms Rationale 1. Discussing and understanding the dynamics of frustration help reduce the frustration by helping the person take positive action. 2. Discussing and understanding the meaning of defences help reduce the potential for acting out. Goal Met Ada was able to experience problems and deal with them appropriately. Acting out was minimal or absent. Example: Ada had an appointment for a job interview. She wanted to stay in bed and avoid the interview, but instead she talked with the nurse about her fear of “growing up” and was able to get up and go to the interview. ---------------- Short-Term Goal Ada will consistently demonstrate that she will seek help when feeling the urge to injure herself, as evidenced by the absence of self-injurious behaviours and talking to staff about her troubling feelings on a daily basis. Intervention 1. Assist the person to identify situations and feelings that may prompt self-harm. 2. Instruct the person in coping strategies. 3. Provide ongoing surveillance of the person and environment. Rationale 1. Observing, describing, and analyzing thoughts and feelings reduce the potential for acting them out destructively. 2. Alternative behaviours are offered that can be more satisfying and growth promoting. 3. Times of increased anxiety, frustration, or anger without external controls could increase the probability of the person using self-mutilating behaviours Evaluation Goal Met Ada was able to experience troubling thoughts and feelings without self-mutilation. She stated, “I was mad at my therapist today and decided to cut my arms after the session. Instead, I told her I was angry, and together we figured out why.”

Answer 154

* All personality disorders share characteristics of inflexibility and difficulties in interpersonal relationships that impair social or oc- cupational functioning. * Personality disorders are most likely caused by a combination of biological and psychosocial factors. * People with personality disorders often enter psychiatric treatment because of distress from a comorbid major mental illness. * Nurses may experience intense emotional reactions to individuals with personality disorders and need to make use of clinical supervi- sion to maintain objectivity. * Despite the relatively fixed patterns of maladaptive behaviour, some individuals with personality disorders are able to change their be- haviours over time as a result of treatment.

Answer 155

Schizophrenia spectrum and other psychotic disorders are complex disorders that affect a person’s thinking, language, emotions, social be- haviour, and ability to perceive reality accurately. These disorders are characterized by psychosis, which refers to altered cognition, altered perception, and/or an impaired ability to determine what is or is not real (an ability known as reality testing). Psychosis itself is a symptom and not classified as a mental illness The most severe disorder defined by the presence of psychosis is schizophrenia Schizophrenia affects 1 in every 100 people in Canada, with 56% of people diagnosed being male and 44% being female “Schizophrenia is one of the most widely misunder- stood and feared illnesses in society. The lingering stigma and myths as- sociated with this illness often result in discrimination and, consequently, a reluctance to seek appropriate help” Negative attitudes toward people living with schizophrenia can interfere with recovery and impair their quality of life Overall, people who experience mental illness are much more likely to be victims of crime, hate, and discrimination then to be the perpetrators of them. Violence directed to oneself is a greater likelihood, with high levels of self-harm and suicide attempts reported in individuals with psychosis. Self-harm in these cases was associated with younger age of onset, female gender, comorbid depressive episode, comorbid alcohol abuse or dependence, current suicidality, awareness of illness, and low adherence to prescribed medication. Practices that concentrate on building trusting therapeutic relationships are practical ways to counter discrimination and promote recovery in the care of those experiencing psychosis and schizophrenia

Answer 156

Listen—Both nurses listened with compassion and genuineness. * Empathize—It is clear that both nurses were able to convey that they cared about understanding what Tammy was feeling. * Agree—Both nurses believed in Tammy, affirmed that she was in- deed worried and struggling. They supported her in her goals, never looking down on her or judging her but helping her on her own road to recovery. * Partner—Clearly, both nurses respected Tammy and worked with her as partners for recovery.

Answer 157

1. Delusions: Alterations in thought content (what a person thinks about). Delusions are false fixed beliefs that cannot be corrected by reasoning or evidence to the contrary. Beliefs maintained by one’s culture or subculture are not delusions. 2. Hallucinations: Perception of a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking). 3. Disorganized thinking: The loosening of associations, manifested as jumbled and illogical speech and impaired reasoning. 4. Abnormal motor behaviour: Alterations in behaviour, including bizarre and agitated behaviours (e.g., stilted, rigid demeanor; eccen- tric dress, grooming, and rituals). Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement. 5. Negative symptoms: The absence of something that should be present but is not, for example, the ability to make decisions or to follow through on a plan. Negative symptoms contribute to poor social functioning and social withdrawal. All those diagnosed with schizophrenia exhibit at least one psychotic symptom, such as delusions; hallucinations; or disorganized thinking, speech, or behaviour. The person experiences extreme difficulty with or an inability to function in family, social, or occupational realms and frequently neglects basic needs such as nutri- tion or hygiene. Over a period of 6 months, there may be times when the symptoms of psychosis are absent, and in their place the person may experience apathy or depression. It is important to note, the course of illness is unique in all individuals and each presentation may be different.

Answer 158

Alterations in thought content (what a person thinks about). Delusions are false fixed beliefs that cannot be corrected by reasoning or evidence to the contrary. Beliefs maintained by one’s culture or subculture are not delusions.

Answer 159

Perception of a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking).

Answer 160

The loosening of associations, manifested as jumbled and illogical speech and impaired reasoning.

Answer 161

Alterations in behaviour, including bizarre and agitated behaviours (e.g., stilted, rigid demeanor; eccen- tric dress, grooming, and rituals). Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement.

Answer 162

The absence of something that should be present but is not, for example, the ability to make decisions or to follow through on a plan. Negative symptoms contribute to poor social functioning and social withdrawal.

Answer 163

The lifetime prevalence of schizophrenia is 1% worldwide; anyone can develop schizophrenia, it affects people of all races and cultures. It is more common among persons growing up in urban areas. Onset in males is usually between the ages of 15 and 25 years and is associated with poorer functioning and more structural abnormality in the brain. The onset tends to be somewhat later in women (ages 25 to 35 years), who tend to have a better prognosis and experience fewer structural changes in the brain. People who are diagnosed later in life with schizophrenia often experience an earlier prodromal phase during which some milder symptoms of the disorder develop, often months or years before the disorder becomes fully apparent. Childhood schizophrenia, although rare, does exist, occurring in 1 out of 40 000 children. Early onset occurs more often in males and is associated with poor functioning before onset and increased levels of apathy. Individuals with a later onset are more likely to be female, have less structural brain abnormality, and have better outcomes.

Answer 164

Substance use disorders (particularly alcohol and marijuana related) have a greater prevalence for individuals living with schizophrenia and other psychotic disorders Approximately 21% of people living with schizophrenia are diagnosed with alcohol use disorder in their lifetime and 27% are diagnosed with cannabis use disorder. Cannabis and stimulant use in particular are associated with the development of symptoms of psychosis Nicotine use is reported in 60% to 90% of people living with schizophrenia Anxiety, depression, and suicide co-occur frequently in schizophrenia. Anxiety may be a response to symptoms (e.g., hallucinations) or circumstances (e.g., isolation, overstimulation) and may worsen schizo- phrenia symptoms and prognosis. (1) higher risk factors for many chronic dis- eases and some types of cancer; (2) the iatrogenic effects of some psy- chiatric medications; (3) higher rates of suicide, accidental, and violent death; and (4) disparities in health care access and use Barriers that are reported in the literature include illness symptoms, treatment effects, lack of support, and negative staff attitudes; incentives include peer and staff support, staff participation, reduction of symptoms, knowledge, and personal attributes

Answer 165

While there is not one specific cause of schizophrenia, the scientific consensus is that schizophrenia occurs when multiple inherited gene abnormalities combine with nongenetic factors (viral infections, birth injuries, pre-natal malnutrition) and are influenced by environmental and social factors. These alter the structures of the brain, affecting the brain’s neurotransmitter systems, injuring the brain directly, or doing all three. This effect is called the diathesis–stress model of schizophrenia. Biological Factors Genetic Factors About 80% of the risk of schizophrenia comes from genetic and epigenetic factors (factors such as toxins or psychological trauma that affect the expression of genes). More than 100 loci in the human genome are associated with an increased risk for schizophrenia. Having a first-degree relative with schizophrenia increases the risk to 10%. Further, a variability of expression of schizophrenia has been identified, and it depends on environmental factors; schizoaffective disorder and cluster A personality disorders are more common in relatives of people living with schizophrenia. Concordance rates (i.e., how often one twin will have the dis- order when the other twin has it) are about 50% for identical twins and about 15% for fraternal twins.

Answer 166

Dopamine theory. The dopamine theory of schizophrenia is de- rived from the study of the action of the first antipsychotic medications, collectively known as conventional (or first-generation) antipsychotic medication (e.g., haloperidol and chlorpromazine). These medications block the activity of dopamine D2 receptors in the brain, limiting the activity of dopamine and reducing some of the symptoms of schizophrenia. However, because the dopamine-blocking medications do not alleviate all symptoms of schizophrenia, it is recognized that other neurochemicals are involved in generating the symptoms of schizophrenia. Amphetamines, cocaine, methylphenidate (Ritalin), and levodopa increase the activity of dopamine in the brain and, in biologically susceptible people, may precipitate the onset of schizophrenia. If schizophrenia is already present, these substances may also exacerbate its symptoms. Almost any drug of abuse, particularly marijuana, can increase the risk for schizophrenia in biologically vulnerable individuals Other neurochemical hypotheses. A newer class of medications, collectively known as atypical (or second-generation) antipsychotic medications, block serotonin as well as dopamine, which suggests that serotonin may play a role in schizophrenia as well. A better under- standing of how atypical medications modulate the expression and targeting of 5-hydroxytryptamine 2A (5-HT2A) and its receptors would likely lead to a better understanding of schizophrenia. Researchers have long been aware that phenylcyclohexyl piperidine (PCP) induces a state closely resembling schizophrenia. This observation led to interest in the N-methyl-D-aspartate (NMDA) receptor complex and the possible role of glutamate in the pathophysiology of schizophrenia. Glutamate, dopamine, and serotonin act synergistically in neurotransmission, and thus glutamate may also play a role in causing psychosis Neurotransmission by another calming neurotransmitter, gamma-aminobutyric acid (GABA), is also impaired in schizophrenia. Kesby et al. (2018) suggest, “ex- cessive dopamine signalling in the associative striatum may directly lead to symptoms of psychosis by compromising the integration of cortical inputs” (p. 4).

Answer 167

Disruptions in communication pathways in the brain are thought to be severe in schizophrenia. Therefore it is conceivable that structural abnormalities cause disruption of the brain’s functioning. Structural differences may be due to errors in neurodevelopment or errors in the normal pruning of neuronal tissue that happens in late adolescence and early adulthood. Inflammation or neurotoxic effects from factors such as oxidative stress, infection, or autoimmune dysfunction may also alter the brain’s structure Using brain imaging techniques—computed tomography (CT), magnetic resonance imaging (MRI), functional MRI (fMRI), and positron emission tomography (PET)—researchers have demonstrated structural brain abnormalities, including: * Reduced volume in the right anterior insula (may contribute to negative symptoms) * Reduced volume and changes in the shape of the hippocampus * Accelerated age-related decline in cortical thickness * Grey matter deficits in the dorsolateral prefrontal cortex area, thala- mus, and anterior cingulate cortex, as well as in the frontotemporal, thalamocortical, and subcortical-limbic circuits * Reduced connectivity among various brain regions * Neuronal overgrowth in some areas, possibly due to inflammation or inadequate neural pruning * Widespread white matter abnormalities (e.g., in the corpus callosum) In addition, MRI and CT scans demonstrate lower brain volume and more cerebrospinal fluid in people living with schizophrenia. PET scans also show a lowered rate of blood flow and glucose metabolism in the frontal lobes, which govern planning, abstract thinking, social adjustment, and decision making, all of which are affected in schizophrenia. Postmortem studies on individuals with schizophrenia reveal a reduced volume of grey matter in the brain, especially in the temporal and frontal lobes; those with the most tissue loss had the worst symp- toms (e.g., hallucinations, delusions, bizarre thoughts, depression).

Answer 168

Pre-natal Stressors: A history of pregnancy or birth complications is associated with an in- creased risk for schizophrenia. According to Hodgins and Klein (2017), the abnormal neural development in schizophrenia begins in utero as environmental factors interact with specific genotypes (p. 90). Pre-natal risk factors include viral infection, poor nutrition, hypoxia or poor neural development, and exposure to toxins. Infection during pregnancy increases the risk for mental illness in the child. Pre-natal infections in the mother also increase the risk for infection in the child after birth, and those infections in the children also can make them more vulnerable to mental illness. Psychological trauma and increased stress during pregnancy can also contribute to the development of schizophrenia. Psychological Stressors Although there is no evidence that stress alone causes schizophrenia, psychological and physical stress increase cortisol levels, impeding hypothalamic development and causing other changes that may precipitate the illness in vulnerable individuals. Schizophrenia often manifests at times of developmental and social stress, such as beginning university or moving away from one’s family. Social, psychological, and physical stressors may also play a significant role in both the severity and course of the disorder and the person’s quality of life. Other risk factors include childhood sexual abuse, exposure to so- cial adversity (e.g., chronic poverty), migration to or growing up in a foreign culture, and exposure to psychological trauma or social defeat. Environmental Stressors: Environmental factors such as toxins, including the solvent tetrachlo- roethylene (used in dry cleaning and to line water pipes, and some- times found in drinking water), are also believed to contribute to the development of schizophrenia in vulnerable people. Environmental factors within broader social environments are also believed to contribute to the development of schizophrenia in vulner- able people. These include exposure to social adversity (e.g., living in chronic poverty) and migration to or growing up in a foreign culture.

Answer 169

Schizophreniform Disorder The features of schizophreniform disorder are similar to schizophrenia, but the total duration of the illness is less than 6 months. This disorder may or may not develop into schizophrenia. Brief Psychotic Disorder This disorder involves a sudden onset of psychosis or grossly disorganized or catatonic behaviour lasting less than 1 month. It is often precipitated by extreme stressors and is followed by a return to premorbid functioning. Schizoaffective Disorder Schizoaffective disorder is a subgroup of psychoses in which affective symp- toms and symptoms of schizophrenia are prominent simultaneously. The symptoms are not due to any substance use or to a medical condition and pres- ent with either bipolar or depressive affective symptoms alongside psychosis. Delusional Disorder Delusional disorder is characterized by nonbizarre delusions (i.e., situations that could occur in real life, such as being followed, being deceived by a spouse, or having a disease). The person’s ability to function is not mark- edly impaired nor is behaviour otherwise odd or psychotic. A related disorder, Capgras syndrome, involves a delusion about a significant other (e.g., family member, pet) being replaced by an imposter; this disorder may be a result of psychiatric or organic brain disease (Salvatore et al., 2014). Substance- or Medication-Induced Psychotic Disorder Psychosis may be induced by substances such as drugs of abuse, alcohol, or medications. Psychosis or Catatonia Associated With Another Medical Condition or Another Mental Disorder Psychoses may also be caused by a medical condition (delirium, neurological or metabolic conditions, hepatic or renal diseases, and many others) as well as by mental illness such as post-traumatic stress disorder (Alsawy et al., 2015) or depression, particularly with co-existing victimization from sexual violence or bullying (Nam et al., 2016). Medical conditions and substance use must always be ruled out before a diagnosis of schizophrenia or other psychotic disorder can be made.

Answer 170

The onset of symptoms or forewarning (prodromal) symptoms may appear a month to a year before the first psychotic break or full-blown manifestations of the illness; such symptoms represent a clear deterioration in previous functioning. The course of the disorder thereafter typically includes recurrent exacerbations separated by periods of reduced or dormant symptoms. Some people will have a single episode of schizophrenia without recurrences or have several episodes and none thereafter. Remission and recovery are increasingly common out- comes with early detection, appropriate treatment, and social support. In the prodromal phase complaints about anxiety, phobias, obses- sions, dissociative features, and compulsions may be noted. As anxiety increases, indications of a thought disorder become evident. Concen- tration, memory, and completion of school- or job-related work dete- riorate. Intrusive thoughts, “mind wandering,” and the need to devote more time to maintaining one’s thoughts are reported. The person may feel that something “strange” or “wrong” is hap- pening. Events are misinterpreted, and mystical or symbolic meanings may be given to ordinary events. For example, the person may think that certain colours have special powers or that a song on the radio is a message from a higher being. Reducing misunderstandings and fear of schizophrenia can reduce stigma and support individuals living with this illness

Answer 171

Phase I—Acute: Onset or exacerbation of florid, disruptive symp- toms (hallucinations, delusions, apathy, withdrawal) with resultant loss of functional abilities; increased care or hospitalization may be required. * Phase II—Stabilization: Symptoms are diminishing, and there is movement toward one’s previous level of functioning (baseline); day hospitalization or care in a residential crisis centre or a super- vised group home may be needed. * Phase III—Maintenance: The person is at or nearing baseline (or premorbid) functioning; symptoms are absent or diminished; level of functioning allows the person to live in the community. Ideally, recovery with few or no residual symptoms has occurred. Most people in this phase live in their own residences. Although this phase has been termed maintenance, current literature shows a trend toward reframing it with a greater emphasis on recovery.

Answer 172

An abrupt onset of symptoms is usually a favourable prognostic sign, and those with good premorbid social, sexual, and occupational functioning have a greater chance for a good remission or a complete recovery. Reducing the frequency, intensity, and duration of relapse (when previously controlled symptoms return) is believed to improve the long-term prognosis. While there is no cure for schizophrenia, schizophrenia is treatable. Successful treatment of schizophrenia requires an organized, recovery- oriented, mental health system with coordinated services. “in Canada, mental health services are delivered through provincially funded services. The or- ganization, funding and delivery of mental health services vary from province to province; there are no national standards for service delivery, although there is a National Strategy. In Canada, the Mental Health Strategy identifies supporting recovery as a core value for mental health services” (pp. 662–663). Early detection: Some clinicians suggest that there is an earlier prodromal (or pre- psychotic) phase, in which subtle symptoms or deficits associated with schizophrenia are present. Detection and treatment programs in most major Canadian cities aim to detect psychosis in the prodromal phase and prevent acute episodes of schizophrenia. Strategies of health promo- tion to improve outcomes, include reducing the duration of untreated psychosis, reducing delay in treatment, and providing early and appropriate interventions adapted for younger people (adolescents) and their families during the early course of the illness. Family involve- ment in early intervention has been found to be an important com- ponent of treatment, the most functional and adaptive family coping approaches being those that involve planning, seeking social support, positive reinterpretation, acceptance and turning to religion, and rare use of “avoidant” coping strategies (e.g., denial or disengagement, use of alcohol and non-prescription medications). A systematic review of family interventions for psychosis established that such interventions improved patient functioning and reduced the likelihood of relapse. Symptoms of psychosis were significantly reduced in the longer term; however, caregiver well-being did not sustain the same benefit over time.

Answer 173

Nursing assessment of people who have or may have a psychotic dis- order focuses largely on symptoms, coping, functioning, and safety. Assessment involves interviewing the person and observing behaviour and other outward manifestations of the disorder. It also should include mental status and spiritual assessments, cultural assessments, biologi- cal, psychological, social, and environmental elements. Medical records and history taken from other sources (e.g., family) Sound therapeutic communication skills, an understanding of the disorder and the ways in which the person may be experiencing the world, and the establishment of trust and a therapeutic nurse–patient relationship all strengthen the assessment. One effective approach to developing this trusting relationship for patients with psychosis is the LEAP approach. It consists of four steps: (1) listen—try to put yourself in the other person’s shoes to gain a clear idea of their experience; (2) empathize—seriously consider and empathize with the other person’s point of view; (3) agree—find common ground and identify facts you can both agree on; (4) partner— collaborate on accomplishing the agreed-upon goals. -------- During the Pre-psychotic Phase Experts believe that detection and treatment of symptoms that may warn of schizophrenia’s onset lessen the risk of developing the disorder or decrease the severity of the disorder if it does develop. Early and appropriate interventions can improve symptoms since one-third of all adults with schizophrenia have their onset before the age of 18. Experts believe that detection and treatment of symptoms that may warn of schizophrenia’s onset lessen the risk of developing the disorder or decrease the severity of the disorder if it does develop. Early and appropriate interventions can improve symptoms since one-third of all adults with schizophrenia have their onset before the age of 18. Therefore early assessment plays a key role in improving the prognosis for persons living with schizophrenia. This form of primary prevention involves monitoring those at high risk (e.g., children of parents diagnosed with schizophrenia) for symptoms such as abnormal social development and cognitive dysfunction. Intervening to reduce stressors (i.e., reduce or avoid exposure to triggers), enhancing social and coping skills (e.g., building resilience), and administering prophylactic antipsychotic medication may also be of benefit. Similarly, in people who have already developed the disorder, minimizing the onset and duration of relapses is believed to improve the prognosis. Research suggests that with each relapse of psychosis, there is an increase in residual dysfunction and deterioration. Recognition and personal tracking of the individual early warning signs of relapse, such as reduced sleep and concentration, are important to prevention of relapse. Limiting stress in work, relationships, and social or environmental domains, as well as enlisting the support of friends or loved ones and increasing the frequency of professional supports for monitoring and intensification of treatment, are essential. For this reason, for some, adherence to a medication regimen of antipsychotic medication can be more important than the risk of adverse effects because most adverse effects are reversible, whereas the consequences of relapse may not be. --------------- General Assessment Not all people living with schizophrenia have the same symptoms, and some of the symptoms of schizophrenia are also found in other disorders such as schizoaffective disorder, delusional disorder, brief psychotic dis- order, postpartum psychosis, and substance-induced psychotic disorder.

Answer 174

1. Positive symptoms: the presence of something that is not normally present 2. Negative symptoms: the absence of something that should be present but is not 3. Cognitive symptoms: abnormalities in how a person thinks 4. Affective symptoms: symptoms involving emotions and their expression

Answer 175

Positive symptoms usually appear early in the person’s illness and can precipitate hospitalization. These symptoms can cause misunderstanding, fear, and stigmatization. It is, important to reduce misunderstanding and fear, which can reduce stigma and support people living with schizophrenia. Positive symptoms usually respond to antipsychotic medication. Positive symptoms are associated with: * Acute onset * Normal premorbid functioning * Normal social functioning during remissions * Normal CT findings * Normal neuropsychological test results * Favourable response to antipsychotic medication The positive symptoms presented here are categorized as alterations in thinking, speech, perception, and behaviour.

Answer 176

All people experience occasional and mo- mentary errors in thinking (e.g., “Why are all these lights turning red when I’m already late? Someone must be trying to slow me down!”), but most can catch and correct the error by using intact reality testing— the ability to determine accurately whether an experience is based in reality. People with impaired reality testing, however, maintain the er- ror, which contributes to delusions, or alterations in thought content. A person experiencing delusions is convinced that what they believe to be real is real.

Answer 177

the ability to determine accurately whether an experience is based in reality.

Answer 178

Concrete thinking refers to an impaired ability to think abstractly. The person interprets statements literally. For example, the nurse might ask what brought the person to the hospital, and the person might answer, concretely, “a bus” (rather than explaining that they had been hearing voices). It is preferable to use the similarities test, which involves asking the person to explain how two things are similar—for example, an orange and an apple, a chair and a table, or a child and an adult. A description of physical characteristics (“apples and oranges are both round”) would be a concrete answer, whereas an abstract answer recognizes ideas such as classifications (“apples and oranges are fruit”). Concreteness reduces one’s ability to understand and address abstract concepts such as love or the pas- sage of time or to reality-test delusions or other symptoms. Educational strategies need to take into account a person’s ability to think abstractly.

Answer 179

Alterations in speech demonstrate difficul- ties with thought process (how a person thinks). Associations are the threads that tie one thought logically to another. In associative loose- ness these threads are interrupted or illogically connected; thinking becomes haphazard, illogical, and difficult to follow: Nurse: “Are you going to the picnic today?” Patient: “I’m not an elephant hunter; no tiger teeth for me.” At times, the nurse may be able to decipher or decode the patient’s messages and begin to understand the patient’s feelings and needs. Any exchange in which a person feels understood is useful. Therefore the nurse might respond to the patient in this way: Nurse: “Are you saying that you’re afraid to go out with the others today?” Patient: “Yeah, no tiger getting me today.” Sometimes it is not possible to understand the person’s meaning because their speech is too fragmented. For example: Patient: “I sang out for my mother ... for this to school I went. These little hills hop aboard, share the Christmas mice spread ... the elephant will be washed away.” If the nurse does not understand what the patient is saying, it is important that they let the patient know this. Clear messages, communication, trust, and honesty are a vital part of working effectively in psychiatric mental health nursing. An honest response lets the person know that the nurse does not understand, would like to understand, and can be trusted to be honest. Other alterations in speech that can make communication challenging are circumstantiality, tangentiality, neologisms, echolalia, clang association, and word salad:

Answer 180

refers to the inclusion of unnecessary and of- ten tedious details in one’s conversation (e.g., describing attending group therapy when asked how the day is).

Answer 181

is a departure from the main topic to talk about less important information; the patient goes off on tangents in a way that takes the conversation off-topic.

Answer 182

are made-up words (or idiosyncratic uses of existing words) that have meaning for the person but a different or nonexistent meaning to others (e.g., “I was going to tell him the mannerologies of his hospitality won’t do”). This eccentric use of words represents disorganized thinking and interferes with communication.

Answer 183

is the pathological repeating of another’s words and is often seen in catatonia. Nurse: “Rowan, come get your medication.” Rowan: “Come get your medication.”

Answer 184

is the choosing of words based on their sound rather than their meaning, often rhyming and sometimes having a similar beginning sound (e.g., “On the track, have a Big Mac,” “Click, clack, clutch, close”). Clanging may also be seen in neurological disorders.

Answer 185

is a jumble of words that is meaningless to the listener— and perhaps to the speaker as well—because of an extreme level of disorganization.

Answer 186

Alterations in perception are errors in one’s view of reality. The most common form of altered perception in psychosis are hallucinations, but depersonalization, derealization, and boundary impairment are sometimes experienced as well.

Answer 187

is a nonspecific feeling that a person has lost their identity and that the self is different or unreal. People may feel that body parts do not belong to them or may sense that their body has drastically changed. For example, a person may see their fingers as snakes or arms as rotting wood.

Answer 188

is the false perception that the environment has changed. For example, everything seems bigger or smaller, or familiar surroundings have become somehow strange and unfamiliar. Both depersonalization and derealization can be interpreted as loss of ego boundaries (sometimes called loose ego boundaries).

Answer 189

is an impaired ability to sense where one’s self ends and others’ selves begin. For example, a person might drink another’s beverage, believing that because it is in their vicin- ity, it is theirs.

Answer 190

result from perceiving a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking).

Answer 191

in that illusions are misperceptions or misinterpretations of a real experience; for example, a per- son sees their coat on a coat rack and believes it is a bear about to attack. They see something real but misinterprets what it is. Causes of hallucinations include psychiatric disorders, substance use, medications, organic disorders, hyperthermia, toxicity (e.g., digitalis), and other conditions. Hallucinations can involve any of the five body senses. Auditory hallucinations are sensory perceptions of hearing sounds without an external stimulus, which activates the auditory processing areas of the brain when they are heard by a person. People can describe voices as people familiar or unknown, single, or multiple. They may be perceived as supportive and pleasant or derogatory and frightening. Voices commenting on the person’s behaviour or conversing with the person are most common. A person who hears voices when no one is present often struggles to understand the experience, sometimes developing related delusions to explain the voices (e.g., the person may believe the voices are from a higher being, spirits, or deceased relatives).

Answer 192

are “voices” that direct the person to take an action. All hallucinations must be assessed and monitored carefully because the voices may command the person to hurt self or others. For example, voices might command a person to “use a weapon or method to harm themselves” or “use a weapon or method to harm someone else.” Command hallucinations are often terrifying and may herald a psychiatric emergency.

Answer 193

akin to resistance but may not be intentional. In active negativism the person does the opposite of what they are told to do; passive negativism is a failure to do what is requested.

Answer 194

a reduced ability to resist one’s impulses. Examples include performing socially inappropriate behaviours such as grabbing another’s cigarette, throwing food on the floor, and changing TV channels while others are watching.

Answer 195

the mimicking of the movements of another. It is also seen in catatonia.

Answer 196

Negative symptoms develop slowly and are those that most interfere with a person’s adjustment and ability to cope. They tend to be persistent and crippling because they render the per- son inert and unmotivated. Negative symptoms impede one’s ability to: * Initiate and maintain conversations and relationships * Obtain and maintain a job * Make decisions and follow through on plans * Maintain adequate hygiene and grooming Negative symptoms contribute to poor social withdrawal. During the acute phase, they are difficult to assess because positive symptoms (such as delusions and hallucinations) dominate.

Answer 197

In schizophrenia affect, the external manifestation of feeling or emotion that is manifested in facial expression, tone of voice, and body language, may not always coincide with inner emotions. Affect in schizophrenia can usually be categorized in one of four ways: * Flat—immobile or blank facial expression * Blunted—reduced or minimal emotional response * Inappropriate—emotional response incongruent with the tone or circumstances of the situation (e.g., a patient laughs when told a family member has died) * Bizarre—odd, illogical, emotional state that is grossly inappropriate or unfounded; especially prominent in disorganized schizophrenia and includes grimacing and giggling

Answer 198

Cognitive symptoms represent the third symptom group and are evident in most people living with schizophrenia. They include difficulty with attention, memory, information processing, cognitive flexibility, and executive functions (e.g., decision making, judgement, planning, problem solving). Cognitive symptoms include: Concrete thinking is an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. For example, a nurse might ask how the patient found the relaxation class, and the patient answers “by walking down the hall” rather than describing their experience of the class. An abstract interpretation of “The grass is always greener on the other side of the fence” is that it always seems we would be happier given other circumstances. A concrete interpretation could be “That side gets more sun, so it’s greener there.” Concreteness reduces one’s ability to understand and respond to concepts requiring abstract reasoning, such as love or humour. Concreteness, especially when combined with an impaired ability to recognize variations in affect or tone of voice, can also make it difficult to recognize social cues such as sarcasm. For example, a patient who had forgotten their wallet asked a store clerk if they could pay later for a bag of chips. When the clerk sarcastically re- plied, “Oh sure, we let our customers pay whenever they want,” the patient took this literally. The patient was distressed when they were arrested for theft despite their protests that they had permis- sion not to pay. * Impaired memory affects short-term memory and the ability to learn. Repetition and verbal or visual cues may help the patient to learn and recall needed information (e.g., a picture of a toothbrush on the patient’s wall and/or mirror as a reminder to brush their teeth). * Impaired information processing can lead to problems such as de- layed responses, misperceptions, or difficulty understanding others. Patients may lose the ability to screen out insignificant stimuli such as background sounds or objects in one’s peripheral vision. This can lead to overstimulation. * Impaired executive functioning includes difficulty with reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipation and planning, and inhibiting undesirable impulses or actions. Impaired executive functioning interferes with problem solving and can contribute to inappropriateness in social situations. These impairments have a considerable impact on longer-term functioning and can leave the person unable to manage personal health care, hold a job, initiate or maintain a support system, or live alone. Some psychosocial treatments, including cognitive behavioural therapy (CBT), cognitive remediation, social skills training, and computer assisted training programs, have shown therapeutic benefits and should be offered in conjunction with antipsychotic medications

Answer 199

Affective blunting: A reduction in the expression, range, and intensity of affect (in flat affect, no facial expression is present) Anergia: Lack of energy; passivity or lack of persistence at work or school; may also be a symptom of depression, so needs careful evaluation Anhedonia: Inability to experience pleasure in activities that usually produce it; result of profound emotional barrenness Avolition: Reduced motivation; inability to initiate tasks such as social contacts, grooming, and other activities of daily living (ADLs) Poverty of content of speech: While adequate in amount, speech conveys little information because of vagueness or superficiality Poverty of speech (alogia): Reduced amount of speech—responses range from brief to one-word answers

Answer 200

Auditory Hearing voices or sounds that do not exist in the environment Juan is alone in his room and is heard yelling. When staff arrive in his room, Juan tells them that he is hearing an angry voice. _____ Visual Seeing a person, object, animal, colours, or visual patterns that do not exist in the environment Antonia became frightened and screamed, “There are rats coming at me!” _______ Olfactory Smelling odours that do not exist in the environment Theresa “smells” their insides rotting. _________ Gustatory Tasting sensations that do not exist Simon will not eat his food because he “tastes” the poison they are putting in it. _________ Tactile Feeling strange sensations on the skin where no external objects stimulate such feelings; common in delirium tremens (DTs) Jack “feels” bugs on/under skin.

Answer 201

Affective symptoms, the fourth symptom group, are common and increase a person’s suffering. These involve the experience and expression of emotions. Mood may be unstable, erratic, labile (changing rapidly and easily), or incongruent (not what would be expected for the circumstances). A serious affective change often seen in schizophrenia is depression. Depression may occur as part of a shared inflammatory reaction affect- ing the brain or may simply be a reaction to the stress and despair that can come from living with a chronic illness. Assessment for depression is crucial because it may indicate an impending relapse, further im- pair functioning, and increase risk for substance use disorders. It may also be necessary to assess for a more prolonged and marked affective aspect of the illness, indicating schizoaffective disorder. Most importantly, depression puts people at increased risk for suicide.

Answer 202

The acutely ill per- son’s intensely anxious, lonely, dependent, and distrustful presentation evokes similarly intense, uncomfortable, and frightening emotions in others. The chronicity, repeated exacerbations, and slow response to treatment that many people experience can lead to feelings of helplessness and powerlessness in staff. Some behaviour (especially violent behaviour) can produce strong emotional responses (called counter- transference) such as fear or anger. It is important to set realistic, achievable goals; and to acknowledge and celebrate small steps/gains. Negative symptoms can be particularly slow to resolve. It may also take a long time to gain trust in the therapeutic relationship, so the nurse can expect the orientation phase of the helping relationship to be prolonged. Clinical mentoring is important for nurses. Without support and the opportunity and willingness to explore feelings with more experienced staff, the nurse is at risk to develop nontherapeutic behaviours and communication, denial, withdrawal, avoidance, and anger, most commonly. These behaviours and communications effect the patient’s progress and undermine the nurse’s self-esteem. Comments such as “I don’t see any hope” and “I feel like all I do is babysit people” are indications of unrecognized or unresolved counter-transference that, if left uncorrected, create hostility, negative therapeutic relationships, and interfere with both treatment and work satisfaction. Building personal resilience has been identified as an essential strategy for coping with work-related stress and responding to and overcoming experiences of workplace adversity. People living with schizophrenia may experience fear, self-stigma, or shame related to their mental illness, leading them to conceal some aspects of their experience. Negativism and alogia (reduced verbalization) can also limit the person’s responses. Many people living with schizophrenia can experience anosognosia, an inability to realize that they are ill, which is caused by the illness itself. The resulting lack of in- sight can make assessment (and treatment) challenging, delaying completion of a full assessment, and requiring additional skills on the part of the nurse.

Answer 203

Use empathic comments and observations to prompt the patient to provide information. Empathy conveys understanding and builds trust and rapport. Nurse: “It must be difficult to be admitted to a psychiatric unit. We are here to help and keep you safe.” Patient: “Yes ... it has been difficult, I am scared of being away from home, and I worry that people are going to harm me” Minimize questioning, especially closed-ended questioning. Seek data conversationally, using prompts and open-ended questions. Extended questioning can increase suspiciousness, whereas closed-ended questions elicit minimal information. Both become wearying and off-putting. “Could you please tell me more about ... ?” “Tell me what life has been like for you lately.” Use short, simple sentences and introduce only one idea at a time. Allow time for responses to questions. Long sentences or rambling questions can confuse a person who has difficulty processing auditory information or is actively hallucinating. Also, a person with alogia requires more time to respond to questions. Therapeutic: “Would you like to join us for a basketball game?” Nontherapeutic: “Would you like to join us for a basketball game? Sports can be very good for you, you know, and you seem very lonely, so it would help you a lot. I really hope you will come play a game.” Directly but supportively seek the needed information, explaining the reasons for the assessment. Being direct but supportive conveys genuineness, builds rapport, and helps reduce anxiety. “I have noticed that you are not participating in group therapy or socializing with your peers like you have been previously. Has something happened? I am here to support you.” Judiciously use indirect, supportive (therapeutic) confrontation. Seek other data to support (validate) the person’s report (obtain further history from third parties, past medical records, and other treatment providers when possible), preferably with the person’s permission. Blunt contradiction or premature confrontation increases resistance. Patients may be unable or unwilling to provide information fully and reliably. Validating their reports ensures the validity of the assessment. “I realize that admitting to hearing voices might be difficult to do. I notice you talking as if to others when no one is there.” “Your brother reports that he works at a factory. Is that your understanding?” Prioritize the data you seek, and avoid seeking nonessential data. Patients may have limited tolerance for the assessment interview and answer only a limited number of inquiries. Seeking nonessential information does not benefit the person or assessment. Patient: “Sometimes when I feel anxious, I take extra medication to fall asleep.” Nurse: (less therapeutic) “Why do you take extra medication?” Nurse: (more therapeutic) “Can you tell me more about taking extra medication when you are anxious.” (Paraphrasing prompts elaboration and confirmation or refutation of the comment.)

Answer 204

1. Assess for risk to self or others. 2. Assess for suicide risk (see Chapter 22). 3. Assess for command hallucinations (e.g., voices telling the patient to harm self or others). If present, ask the person: * Do you recognize the voices? 4. Do you believe the voices are real? Do you plan to follow the command? (A posi- tive response to any of these questions suggests an increased risk that the person will act on the commands). Assess for ability to ensure self-safety, addressing: * Adequacy of food and fluid intake * Hygiene and self-care * Handling of potentially hazardous activities, such as smoking and cooking * Ability to transport self safely * Impulse control and judgement * Appropriate dress for weather conditions. Assess whether the person abuses or is dependent on alcohol or substances. Assess the patient’s be- lief system. Is it fragmented or poorly organized? Is it systematized? Are the beliefs or content delusions? If yes, then ask: * Do you feel that you or your loved ones are being threatened or are in danger? * Do you feel the need to act against a person or organization to protect or avenge yourself or your loved ones? (A positive response to either of these questions suggests an increased risk of danger to others.) 5. Assess for the presence and severity of positive and negative symptoms. Complete a mental status examination, noting which symptoms are present, how they affect functioning, and how the patient is managing them. 6. Assess the patient’s insight, knowledge of the illness, relationships and support systems, other coping resources, and strengths. 7. Determine if the patient has had a medical workup. Are there any indica- tions of physical and/or medical problems that might mimic psychosis (e.g., digitalis or anticholinergic [ACh] toxicity, brain trauma, drug intoxication, delirium, fever)? 8. Assess for coexisting disorders: * Depression * Anxiety * Mood disorders * Substance use disorders or dependency * Medical disorders (especially brain trauma, toxicity, delirium, cardiovas- cular disease, obesity, and diabetes) 9. Assess medications the patient has been prescribed, whether and how the patient is taking the medications, and what factors (e.g., costs, mistrust of staff, adverse effects) are affecting adherence. 10. Assess the family’s knowledge of and response to the patient’s illness and its symptoms. Are family members overprotective? Hostile? Anxious? Are they familiar with family support groups and respite resources?

Answer 205

Positive Symptoms Hears voices that others do not (auditory hallucinations) Auditory perceptions -- Hears voices telling them to hurt self or others (command hallucinations) Self-directed violence Other-directed violence -- Delusions Thought processes -- Shows loose association of ideas (associative looseness) & Conversation is derailed by unnecessary and tedious details (circumstantiality) Thought processes Verbal communication --- Negative Symptoms Uncommunicative, withdrawn Expresses feelings of rejection or aloneness (lies in bed all day, positions back to door) Social isolation Social interaction Loneliness --- Talks about self as “bad” or “no good” Feels guilty because of “bad thoughts”; extremely sensitive to real or perceived slights Low self-esteem Self-directed violence -- Shows lack of energy (anergia) Shows lack of motivation (avolition), unable to initiate tasks (social contact, grooming, and other aspects of daily living) Ineffective coping Self-care (bathing, dressing, feeding, toileting) Constipation -- Other Families and significant others become confused or overwhelmed, lack knowledge about disorder or treatment, feel powerless in coping with the patient Family coping Caregiver role strain Health literacy -- Stops taking medication (because of anosognosia, adverse medication effects, medication costs, mistrust of staff), stops going to therapy, is not supported in treatment by significant others Decision-making

Answer 206

Outcomes should be consistent with the recovery model, which stresses hope, living a full and productive life, and eventual recovery rather than focusing on controlling symptoms and adapting to disability. Phase I—Acute During the acute phase, the overall goal is the person’s safety and medi- cal stabilization. Therefore if the person is at risk for violence to self or others, initial outcome criteria address safety issues (e.g., Person refrains from self-harm). Table 15.6 gives selected short-term and inter- mediate indicators for the outcome Distorted thought self-control. Phase II—Stabilization Outcome criteria during phase II focus on helping the patient adhere to treatment, become stabilized on medications, and control or cope with symptoms. The outcomes target the negative symptoms and may include ability to succeed in social, vocational, or self-care activities. Phase III—Maintenance Outcome criteria for phase III focus on maintaining achievement, pre- venting relapse, and achieving independence and a satisfactory quality of life.

Answer 207

The planning of appropriate interventions is guided by the phase of the illness and the strengths and needs of the patient. It is influenced by cultural considerations, available resources, and the patient’s prefer- ences. Phase I—Acute Hospitalization is indicated if the patient is considered a danger to self or others, refuses to eat or drink, or is too disorganized or otherwise impaired to function safely in the community without supervision. The planning process focuses on the best strategies to ensure the person’s safety and provide symptom stabilization. In addition, during the pa- tient’s hospitalization, this process includes discharge planning. In discharge planning the patient and interprofessional treatment team identify aftercare needs for follow-up and support. Discharge planning considers not only external factors, such as the person’s living arrangements, economic resources, social supports, and family rela- tionships, but also internal factors, such as resilience and repertoire of coping skills. Because relapse can be devastating to the person’s cir- cumstances (resulting in loss of employment, housing, and relation- ships) and worsen the long-term prognosis, vigorous efforts are made to connect the person and family with (and not simply refer them to) community resources that provide therapeutic programming and so- cial, financial, and other needed support. Phase II—Stabilization and Phase III—Maintenance Planning during the stabilization and maintenance phases includes providing individual and family education and skills training (psycho- social education). Relapse prevention skills are vital. Planning identifies interpersonal, coping, health care, and vocational needs and addresses how and where these needs can best be met within the community.

Answer 208

Distorted thought self-control: Maintains affect consistent with mood Recognizes that hallucinations or delusions are occurring ------ Self-restraint of disruptions in perception, thought processes, and thought content Intermediate Indicators -Interacts appropriately -Perceives environment and the ideas of others accurately -Exhibits logical thought flow patterns -Exhibits reality-based thinking -Exhibits appropriate thought content Short term indicator -Refrains from attending to and responding to hallucinations or delusions -Describes content of hallucinations or delusions -Reports decrease in hallucinations or delusions -Asks for validation of reality

Answer 209

Interventions are geared toward the phase of schizophrenia the person is experiencing. For example, during the acute phase, the clinical focus is on crisis intervention, medication for symptom stabilization, and safety. Interventions are often hospital based; however, people in the acute stage are increasingly being treated in the community. ---- Phase I—Acute Settings A number of factors affect the choice of treatment setting, including: * Level of care and restrictiveness needed to protect the person from harm to self or others * Person’s need for external structure and support * Person’s ability to cooperate with treatment * Need for a particular treatment available only in particular settings * Need for treatment of a coexisting medical condition * Availability of supportive others who can provide critical information and treatment history to staff and permit stabilization in less restrictive settings The use of less restrictive and more cost-effective alternatives to hospitalization that work for many people include: * Partial hospitalization: Patients sleep at home and attend treatment sessions (similar to what they would receive if admitted) during the day or evening. * Residential crisis centres: Patients who are unable to remain in the community but do not require full in-person services can be admit- ted (usually for 1 to 14 days) to receive increased supervision, guidance, and medication stabilization. * Group homes: Patients live in the community with a group of other people, sharing expenses and responsibilities. Staff are present in the house 24 hours a day, 7 days a week to provide supervision and therapeutic activities. * Day treatment programs: Patients reside in the community and attend structured programming during the day. Northern and rural communities, however, may not have local sup- port groups. It is critical for staff in these areas to review services that are available for patients and/or advocate for increased services. Other community resources include community mental health centres (usu- ally providing medication services, day treatment, access to 24-hour emergency services, psychotherapy, psychoeducation, and case man- agement); home health services; supported employment programs, of- fering services from job training to on-site coaches, who help people learn to succeed in the work environment, often via peer-led services (e.g., drop-in centres, sometimes called “clubhouses,” that offer social contact, constructive activities, and sometimes employment opportunities); family educational and skills groups (e.g., Schizophrenia Society of Canada’s “Strengthening Families Together” program); and respite care for caregivers. ---- Interventions Acute phase interventions include: * Psychiatric, medical, and neurological evaluation * Psychopharmacological treatment * Support, psychoeducation, and guidance * Supervision and limit setting in the milieu Due to a shortage of inpatient beds, there is pressure to keep the length of hospitalization short. This situation may create an ethical di- lemma for treatment teams, as short initial hospital stays have been found to be related to high rates of readmission and shorter intervals between hospitalizations. ----- Phase II—Stabilization and Phase III—Maintenance Effective long-term care of an individual with schizophrenia relies on a three-pronged approach: medication administration and adherence, nursing intervention, and community support. Family psychoeduca- tion, a key role of the nurse, is an essential intervention. All interven- tions and strategies are geared to the patient’s strengths, culture, per- sonal preferences, and needs. ------ Milieu Management Effective hospital care provides (1) protection from stressful or dis- ruptive environments and (2) structure. People in the acute phase of schizophrenia show greater improvement in a structured milieu rather than on an open unit that allows for increased stimulation. A therapeutic milieu is consciously designed to maximize safety, opportunities for learning skills, therapeutic activities, and access to resources. The milieu also provides guidance, supportive staff and peer contact, and opportunities for practicing conflict resolution, stress-reduction tecniques, and dealing with symptoms.

Answer 210

A small percentage of people living with schizophrenia, especially dur- ing the acute phase, may exhibit a risk for physical violence. Several in- terrelated risk factors, including demographics (i.e., age, marital status, gender) and social factors (i.e., homelessness, limited education, his- tory of maltreatment or criminality), presence of persecutory delusions or command hallucinations, comorbid antisocial personality patholo- gy, concurrent substance use, inadequate insight, treatment nonadherence, and physiological factors, increase the risk for violence in patients with psychosis. Nonadherence to treatment is a key risk factor predict- ing violence in patients with psychosis. ____ SAFETY TIP When the potential for violence exists, measures to protect the patient, staff, and others become the priority. _____ Interventions include assessing for risk, increasing staff supervision, reducing stimulation (e.g., noise, crowds), addressing paranoia and other contributing symptoms, providing constructive diversion and outlets for physical energy, teaching and practicing coping skills, implementing cognitive behavioural approaches (to correct unrealistic expectations or selectively extinguish aggression), de-escalating tension verbally, and, when necessary, using seclusion and chemical (i.e., medication) or physical restraints.

Answer 211

Participation in activities and groups appropriate to the patient’s level of functioning may decrease withdrawal, enhance motivation, modi- fy unacceptable behaviours, develop friendships, and increase social competence. Activities such as drawing, reading poetry, and listening to music may be used to focus conversation and promote the recog- nition and expression of feelings. Self-esteem is enhanced as patients experience successful task completion. Recreational activities such as picnics and outings to stores and restaurants are not simply diversions; they teach constructive leisure skills, increase social comfort, facili- tate growth in social concern and interactional skills, and enhance the ability to develop boundaries and set limits on self and others. After discharge, group therapy can provide necessary structure within the patient’s community milieu.

Answer 212

Nursing Care 1. Observe the patient for hallucinating cues such as eyes tracking an unheard speaker, garbled words under breath or talking to self, appearing distract- ed, suddenly stopping conversing as if interrupted, or intently watching a vacant area of the room. 2. Ask the patient about the content of the hallucinations and how they are reacting to it. Assess for command hallucinations and whether the halluci- nations are causing fear, distress, or upset for the patient. 3. Avoid referring to hallucinations as if they are real. Do not ask, “What are the voices saying to you?” Rather, ask, “What are you hearing?” 4. Be aware of and continue to assess for signs of anxiety, which may indicate that hallucinations are intensifying or that they are of a command type. 5. Do not negate the patient’s experience but offer your own perceptions and convey empathy. “I don’t hear the angry voices that you are hearing right now, they must be very frightening for you.” 6. Focus on reality-based “here-and-now” activities such as conversations or simple projects. “The voice you are hearing in your mind sounds very real, it is part of your illness, and it cannot harm you. You are safe. Focus on my voice and what you can see around you.” 7. Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accus- ing voices. 8. Promote and guide reality testing. If the patient has frightening hallucina- tions, guide them to scan the area to see if others are frightened; if they are not frightened, encourage the patient to consider that these might be hallucinations. 9. As the patient begins to develop insight, guide them to interpret the hal- lucinations as a symptom of the illness.

Answer 213

Therapeutic communication techniques for patients with schizophre- nia aim to lower the person’s anxiety, build trust, encourage clear com- munication, decrease defensiveness, encourage interaction, enhance self-esteem, and reinforce skills such as reality testing and assertive- ness. It is important to remember that people living with schizophrenia may have memory impairment and require repetition. They may also have limited tolerance for interaction, owing to the stimulation it cre- ates. Therefore shorter (<30 minutes) but more frequent interactions may be more therapeutic. Interventions for paranoia and other selected presentations are discussed later in this chapter.

Answer 214

When a patient is experiencing a hallucination, the nursing focus is on understanding the person’s experiences and responses. Suicidal or homicidal themes or commands necessitate appropriate safety mea- sures. For example, “voices” that tell a patient a particular individual plans to harm them may lead to aggressive actions against that person; one-to-one supervision of the patient or transfer of the potential victim to another unit is often essential. Hallucinations are real to the patient who is experiencing them and may be distracting during nurse–patient interactions. Call the person by name, speak simply but in a louder voice than usual, approach the person in a non-threatening and non-judgemental manner, maintain eye contact, and redirect the person’s focus to the conversation as needed

Answer 215

Delusions may be the patient’s attempts to understand confusion and distorted experiences. They reflect the misperception of one’s circum- stances, which go uncorrected in schizophrenia due to impaired real- ity testing. When, as a nurse, you attempt to see the world through the eyes of the patient, it is easier to understand their experience. For example: Patient: “You people are all alike ... all in on the RCMP plot to destroy me.” Nurse: “Quinn, I am a nurse, I am not going to harm you, you are safe with me. Thinking that people are plotting to destroy you must be very frightening.” In this example the nurse acknowledges the patient’s experience, conveys empathy about the patient’s fearfulness, and avoids focusing on the content of the delusion, but identifies the patient’s feelings so they can be explored, as tolerated. Note that talking about the feelings is helpful, but extended focus on delusional material is not. It is never useful to debate or attempt to dissuade the patient regard- ing the delusion. Doing so can intensify the patient’s retention of irra- tional beliefs and cause them to view you as rejecting or oppositional. However, it is helpful to clarify misinterpretations of the environment and gently suggest, as tolerated, a more reality-based perspective. For example: Patient: “I see the doctor is here; he is out to destroy me.” Nurse: “It is true the doctor is here. He does patient rounds every morning at 9:00 a.m. He will talk to you about how you are feeling and your treatment. Would you feel more comfortable talking to him in the day room?” Focusing on specific reality-based activities and events in the environment helps to minimize the focus on delusional thoughts. The more time the patient spends engaged in activities or with people, the more opportunities there are to receive feedback about and become comfort- able with reality.

Answer 216

Associative looseness often mirrors the person’s abnormal thoughts and reflects poorly organized thinking. An increase in associative looseness often indicates that the person is feeling increased anxiety or is overwhelmed by internal and external stimuli. The person’s speech may also produce confusion and frustration in the nurse. The follow- ing guidelines are useful for intervention with a patient whose speech is confused and disorganized: * Do not pretend you understand the patient’s words or meaning when you do not; tell the person you are having difficulty understanding. * Place the difficulty in understanding on yourself, not on the patient. Example: “I’m having trouble following what you are saying,” not “You’re not making any sense.” * Look for recurring topics and themes in the patient’s communica- tions, and tie these to events and timelines. Example: “You’ve men- tioned trouble with your family several times, usually after visits. Can you tell me about your family and your visits with them?” * Summarize or paraphrase the patient’s communications to role- model more effective ways of making their point and to give the person a chance to correct anything you may have misunderstood. * Reduce stimuli in the vicinity, and speak concisely, clearly, and con- cretely. * Tell the person what you do understand, and reinforce clear communication and accurate expression of needs, feelings, and thoughts.

Answer 217

* To build trust, be open, honest, and reliable. * Respond to suspicions in a matter of fact, empathic, supportive, and calm manner. * Ask the person to describe the delusions. Example: “Tell me more about someone trying to hurt you.” * Avoid debating the delusional content but interject doubt where appropri- ate. * Focus on the feelings that underlie or flow from the delusions. Example: “You seem to wish you could be more powerful” or “It must feel frightening to think others want to hurt you.” * Once it is understood and addressed, do not dwell further on the delusion. Instead, focus on more reality-based topics. If the person obsesses about delusions, set firm limits on the amount of time you will talk about them, and explain your reason for these limits. * Observe for events that trigger delusions. If possible, help the person find ways to reduce or manage them. * Validate a part of the delusion that is real. Example: “Yes, there was some- one at the nurses’ station, they were not speaking about you.”

Answer 218

Prevention and Stress Management * Avoid loud or stressful places or activities. * Avoid negative or critical people and seek out supportive people. * Learn assertive communication skills so you can tell others “no” if they pressure or upset you. * When faced with increased stress, slow and deepen your breathing. Count slowly from one to four as you inhale, hold the breath, and exhale. * Gently tense and then relax your muscles, one area of the body at a time, starting at your head (e.g., closing your eyes and then opening them, clenching your teeth and then relaxing your jaw) and working your way down to your hands and feet. * Discover other ways that help you manage stress (e.g., going for a walk, meditation, taking a hot bath, reading or listening to music, imagining your- self in a less stressful situation [sometimes called a mental vacation]). Distraction * Listening to music * Reading (aloud may help more) * Counting backwards from 100 * Watching television Interaction * Talking with another person * Group therapy * Cognitive behavioural therapy or dialectical behavioural therapy Activity * Walking * Cleaning the house * Having a relaxing bath * Playing the guitar or singing * Going to the gym (or any place you enjoy being, where others will be present) Talking to Yourself * Telling the voices or thoughts to go away * Telling yourself that the voices and thoughts are symptoms and not real * Telling yourself that no matter what you hear, voices can be safely ignored Social Action * Talking to a trusted friend or member of the family * Calling a help line/crisis line/ support line or going to a drop-in centre * Visiting a favourite place or a comfortable public place Physical Action * Taking as-needed medication as prescribed, or following up with physician to review medication * Meditation * Mindfulness

Answer 219

Education is an essential strategy and includes teaching the patient and family about illness, including possible causes, treatment plans, medications and medication adverse effects, coping strategies, what to expect, and prevention of relapse. Understanding these things helps the patient and family to recognize the impact of stress, enhances their understanding of the importance of treatment to a good outcome, en- courages involvement in (and support of) therapeutic activities, and identifies resources for consultation and ongoing support throughout the illness. Including family members in any strategies aimed at reducing symptoms of psychosis reduces family anxiety and distress and enables the family to reinforce the healthcare providers’ efforts. The family plays an important role in the stability of the patient. The patient who returns to a warm, concerned, and supportive environment is less like- ly to experience relapse. An environment in which people are critical or their involvement in the patient’s life is intrusive is associated with relapse and poorer outcomes. Lack of understanding of the disease and its symptoms can lead others to misinterpret the patient’s apathy and lack of drive as “laziness,” fostering a potential hostile response by family members, caregivers, or community. Thus, public education/health teaching about the symptoms of schizophrenia can reduce tensions in families, as well as in communities.

Answer 220

1. Learn all you can about the illness. * Attend psychoeducational and support groups. * Join the National Network for Mental Health (https://nnmh.ca/). * Contact your provincial/regional Schizophrenia Society. 2. Develop a relapse prevention plan. * Know the early warning signs of relapse (e.g., isolation, difficulty sleep- ing, troubling/intrusive thoughts). * Know who to call, what to do, and where to go when early signs of relapse appear. Make a list and keep it with you. * Understand that relapse is part of illness, not a sign of failure. 3. Take advantage of all psychoeducational tools. * Participate in family, group, and individual therapy. * Learn new ways to act and coping skills to help handle family, work, and social stress. Get information from your nurse, case manager, physician, self-help group, community mental health group, or hospital. * Have a documented plan, of what to do to cope during stressful times. * Recognize that everyone needs a place to address their fears and losses and to learn new ways of coping. 4. Adhere to treatment. * People who adhere to treatment that works for them do the best in cop- ing with the disorder. * Engaging in struggles over adherence does not help but tying adherence to the patient’s own goals does. (“Staying in treatment will help you keep your job and avoid trouble with the police.”) * Share any medication side effects or concerns (e.g., sexual problems, weight gain, “feeling funny”) with your nurse, case manager, physician, or social worker; most side effects can be helped. * Discontinuing medication treatment suddenly can be dangerous and symptoms can re-emerge. 5. Avoid alcohol and illicit substances; they can act on the brain and cause a relapse. 6. Keep in touch with supportive people—those with shared patient and fam- ily experiences and others. 7. Maintain healthy lifestyle and balance. * Taking care of one’s diet, health, and hygiene helps prevent medical illnesses. * Maintain a regular sleep pattern. * Keep active (hobbies, friends, groups, sports, job, special interests). * Nurture yourself, and practice stress-reduction activities daily. * Mindfulness

Answer 221

Mindfulness interventions are gaining popularity as a complementary and in- tegrative practice for people with a number of emotional and psychological concerns. Research illustrating how to adapt mindfulness groups for people with current psychosis has shown mindfulness for psychosis is both safe and therapeutic. These therapies employ elements of acceptance and compassion in addition to mindfulness. Research finds key benefits of mindfulness therapies included improved insight, medium to larger improvement in mood, trends toward improvement in quality of life, and significant improvements in positive and negative symp- toms of schizophrenia. No significant improvement in anxiety was found as a result of the mindfulness therapies. Certain therapies were examined to meet particular needs most effectively; for example, group mindfulness therapy for psychosis was found to improve clinical functioning and enhance mindful response to stressful thoughts. There is also reasonable evidence from one large trial that Internet-based, self-help mindfulness therapy effects moderate reductions in depressive symptoms and symptoms of obsessive-compulsive disorder in outpatients with psychosis.

Answer 222

Two groups of antipsychotic medications exist: conventional antipsychotic medications (traditional dopamine antagonists [dopa- mine D2 receptor antagonists]), also known as typical or first-generation antipsychotic medications, and atypical antipsychotic medications (serotonin–dopamine antagonists [5-HT2A receptor antagonists]), also known as second-generation antipsychotic medications. A “third generation” of medications (aripiprazole and brexpiprazole [Rexulti]) give hope for enhanced effectiveness and adverse-effect reduction. Other medications, such as anticonvulsants and antiparkinsoninal medications, are also used to augment antipsychotic medications. Antipsychotic medications are effective for most exacerbations of schizophrenia and for reduction or mitigation of relapse. Conventional antipsychotic medications primarily affect the positive symptoms of schizophrenia (e.g., hallucinations, delusions, disordered thinking). Atypical antipsychotic medications can improve negative symptoms (e.g., asociality, blunted affect, lack of motivation) as well. Evidence suggests medications should be trialed between 4 and 6 weeks for efficacy. It is not unusual for patients to be prescribed a combination of antipsychotic medications, sometimes both oral and depot (long- acting injectable [LAI]) or both typical and atypical. These individu- als may also be taking antiparkinson medications and other medica- tions to combat adverse effects. It is important in these cases to have the medication regimen carefully and regularly reviewed by both the physician and a pharmacist and to monitor closely for adverse effects. These patients would be at high risk for ACh toxicity, a potentially life- threatening situation.

Answer 223

they should be discontinued gradually to minimize a discontinuation syndrome that can include dizziness, nausea, tremors, insomnia, electric shock– like pains, and anxiety. Patients taking antipsychotic medications are at increased risk of falls due to orthostatic (postural) hypotension, sedation, and gait impairment

Answer 224

liquid or fast-dissolving forms, available for selected antipsychotic medications, can make it difficult for a patient to “cheek” or “palm” medication (hiding it in their cheek or placing in palm and later dispose of it). Some antipsychotic medications are also available in short-acting injectable form, used primarily for treatment of agitation, behavioural emergencies (imminent harm to self or others), or when patients refuse court-mandated oral antipsychotic medications. Adverse effects can be intensified and less easily managed when medication is administered directly into the system intramuscularly (IM). In addition, some medications are available in LAI formulations that need to be administered only every 2 to 4 weeks (some examples: aripiprazole [Abilify Maintena], paliperidone [Invega Sustenna], risperi- done [Risperdal Consta]) or, in one case, every 3 months (paliperidone [Invega Trinza]). These may be referred to as “depot” medications. Some require special administration protocols. By requiring less frequent medication administration, adherence is improved and conflict about taking medications is reduced. The downside is a lack of dosing flexibility, and patients may feel as if they have less control.

Answer 225

Atypical antipsychotic medication first emerged in the early 1990s with clozapine (Clozaril). When patients whose illness was previously treat- ment resistant were started on clozapine, they showed response rates between 30 and 60%. Unfortunately, clozap- ine produces agranulocytosis in 0.8% to 1% of those who take it and also increases the risk for seizures. Due to the risk for agranulocytosis, people taking clozapine must have weekly white blood cell counts for the first 6 months, then frequent monitoring thereafter, to obtain the medication. As a result of nonadherence, clozapine use is declining. Atypical medications are often discussed with patients as a potential first choice because they treat both the positive and the negative symp- toms of schizophrenia. Furthermore, they produce minimal to no extra- pyramidal side effects (EPSs) or tardive dyskinesia (TD) in most people, although these effects may still occur for some patients. Adverse effects tend to be significantly less, resulting in greater adherence to treatment. Atypical antipsychotic medications include risperidone (Risperdal), lurasidone (Latuda), olanzapine (Zyprexa), paliperidone (Invega), que- tiapine (Seroquel), ziprasidone (Zeldox). One significant disadvantage of the atypical medication, with the exception of ziprasidone and aripiprazole, is metabolic syndrome, which includes weight gain, dyslipidemia, and altered glucose metabolism, a significant concern due to increased risk for diabetes, hypertension, and atherosclerotic heart disease. An additional disadvantage of atypical antipsychotic medications is cost: they are more expensive than conventional antipsychotic medication.

Answer 226

These medications include aripiprazole (Abilify) and brexpiprazole (Rex- ulti). They can be described as dopamine system stabilizers that act by reducing dopamine activity in some brain regions while increasing it in others. Aripiprazole and brexpiprazole act as D2 partial agonists (meaning that they attach to the D2 receptor without fully activating it, reducing the effective level of dopamine activity).

Answer 227

Conventional antipsychotic medication are antagonists at the dopamine D2 receptor site in both the limbic and the motor centres. This blockage of dopamine D2 receptor sites in the motor areas causes extrapyramidal side effects, which include akathisia, acute dystonias, pseudoparkinsonism, and TD. The symptoms of EPS are debilitating, can interfere with social functioning and communication, motor tasks, and ADLs. EPS is often associated with poor quality of life and adherence to medication, which may result in disease relapse and rehospitalization. Other adverse reactions include ACh effects, orthostasis, photosensitivity, and lowered seizure threshold. Conventional antipsychotic medications are becoming less com- mon in the treatment of schizophrenia because of their minimal impact on negative symptoms and their adverse effects. However, conventional antipsychotic medications are effective in treating positive symptoms, are much less expensive than atypical medications, and come in a depot (long- acting) injectable form. (Note: Risperidone, an atypical antipsychotic med- ication, is also available in a depot form [Risperdal Consta].) For people who respond to them and can tolerate their adverse effects, conventional antipsychotic medications can remain an appropriate choice. The conventional antipsychotic medications are often divided into low-potency and high-potency medications on the basis of their ACh adverse effects, EPSs, and sedative profiles.

Answer 228

Low potency = high sedation + high ACh + low EPSs High potency = low sedation + low ACh + high EPSs

Answer 229

Conventional antipsychotic medication must be used cautiously in people with seizure disorders, as they can lower the seizure threshold. Three of the more common EPSs are acute dystonia (acute sustained contraction of muscles, usually of the head and neck), akathisia (psychomotor restlessness evident as pacing or fidgeting, sometimes pronounced and very distressing to patients), and pseudo-parkinsonism (a medication-induced, temporary constellation of symptoms associated with Parkinson’s disease: tremor, reduced accessory movements, impaired gait, and stiffening of muscles). EPSs can usually be minimized by lowering dosages of antipsychotic medications or adding antiparkinson medication, especially centrally acting ACh medications such as trihexyphenidyl and benztropine mesylate. Diphenhydramine hydrochloride (Benadryl) is also useful. Lorazepam, a benzodiazepine, may be helpful in reducing akathisia. Unfortunately, antiparkinson medications can cause significant ACh adverse effects and worsen the ACh adverse effects of conven- tional antipsychotic medication and other ACh medications. These adverse effects include ACh syndrome, which is seen in the peripheral nervous system (tachycardia, hyperthermia, hypertension, dry skin, urinary retention, functional ileus) and central nervous system (my- driasis, hallucinations, delirium, seizures, and, in some cases, coma) Other troubling adverse effects of conventional antipsychotic medications include sexual dysfunction, endocrine disturbances (e.g., galactorrhea), drooling, and tardive dyskinesia, dis- cussed next. Impotence and sexual dysfunction are occasionally re- ported (but frequently experienced) by men and may also necessitate a medication change.

Answer 230

is a persistent EPS that usually appears af- ter prolonged treatment and persists even after the medication has been discontinued. TD is evidenced by involuntary tonic muscular contrac- tions that typically involve the tongue, fingers, toes, neck, trunk, or pelvis. This potentially serious EPS is most frequently seen in women and older persons and affects up to 50% of individuals receiving long- term, high-dose therapy. TD varies from mild to moderate and can be disfiguring or incapacitating; a common presentation is a “guppy like” mouth movement sometimes accompanied by tongue protrusion. Its appearance can contribute to the stigmatization of people with mental illness and antipsychotic medications. Early symptoms of TD are fasciculations of the tongue (described as looking like a bag of worms) or constant smacking of the lips. These symptoms can progress into uncontrollable biting, chewing, or sucking motions; an open mouth; and lateral movements of the jaw. No reliable treatment exists for TD. The National Institute of Mental Health de- veloped the Abnormal Involuntary Movement Scale (AIMS), a 12-item clinician-rated scale to assess severity of dyskinesias (specifically, oro- facial movements and extremity and truncal movements) in patients taking neuroleptic medications. Additional items assess the overall se- verity, incapacitation, and the patient’s level of awareness of the movements, and distress associated with them. It examines facial, oral, extremity, and trunk movement.

Answer 231

Nurses need to know about some rare, but serious and potentially fatal, effects of antipsychotic medications, including neuroleptic malignant syndrome, agranulocytosis, liver impairment, and ACh-induced delirium.

Answer 232

occurs in about 0.2% to 1% of people who have taken conventional antipsychotic medications, although it can occur with atypical medication as well. Acute reduction in brain dopamine activity plays a role in its development. NMS is a life-threatening medical emergency and is fatal in about 10% of cases. It can occur any time during treatment. NMS is characterized by reduced consciousness, increased muscle tone (muscular rigidity), and autonomic dysfunction, including hyper- pyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. Treatment consists of early detection, discontinuation of the antipsychotic, management of fluid balance, temperature reduction, and monitoring for complications. Mild cases of NMS may be treated with benzodiazepines, vitamins E and B6, or bromocriptine

Answer 233

is a serious, potentially fatal, adverse effect. Liver impairment may also occur

Answer 234

is a potentially life-threatening adverse effect usually seen in older persons, although it can occur in younger people as well. It is also seen in patients taking multiple antipsychotic medications.

Answer 235

Antidepressants are recommended along with antipsychotic medication for the treatment of depression, which is common in schizophrenia. Antimanic (mood-stabilizing) medications have been helpful in enhancing the effectiveness of antipsychotic medication. Divalproex sodium/valproic acid (Epival, Depakene) are used during acute exacerbations of psychosis to hasten response to antipsychotic medication. Lamotrigine may be given along with clozapine to improve therapeutic effects. Augmentation with benzodiazepines (e.g., clonazepam) can reduce anxiety and agitation and contribute to improvement in positive and negative symptoms.

Answer 236

The following circumstances suggest a need to adjust or change the antipsychotic medication or add supplemental medications (e.g., lithi- um, carbamazepine, valproate): * Inadequate improvement in target symptoms despite an adequate trial of the medication * Persistence of dangerous or intolerable adverse effects

Answer 237

Dry mouth: Provide frequent sips of water, ice chips, and sugarless candy or gum; if severe, provide moisture spray (Important note: monitor patient’s fluid intake for potential water intoxication). Urinary retention and hesitancy: Check voiding Try warm towel on abdomen, and consider catheterization if no result. Review medication to ensure not a potential side effect. Constipation: Usually short term May use stool softener Ensure adequate fluid intake Increase fibre intake Use dietary laxatives (e.g., prune juice) Blurred vision: Usually abates in 1–2 weeks May require use of reading or magnifying glasses If intolerable, consider consult regarding change in medication Photosensitivity: Encourage person to wear sunglasses, sunscreen, and sun-blocking clothing Limit exposure to sunlight Dry eyes: Use artificial tears Inhibition of ejaculation or impotence in men: Consult prescriber: person may need alternative medication Anticholinergic-induced delirium: dry mucous membranes; reduced or absent peristalsis; mydriasis; nonreactive pupils; hot, dry, red skin; hyperpyrexia without diaphoresis; tachycardia; agitation; unstable vital signs; worsening of symptoms of psychosis; delirium; urinary retention; seizure; repetitive motor movements: Potentially life-threatening medical emergency Consult physician immediately Hold all medications Implement emergency cooling measures as ordered (cooling blanket, alcohol, or ice bath) Implement urinary catheterization as needed Administer benzodiazepines or other sedation as ordered Physostigmine may be ordered as a special access toxicology antidote. Pseudo-parkinsonism: mask-like facies, stiff and stooped posture, shuffling gait, drooling, tremor, “pill-rolling” phenomenon Onset: 5 hours–30 days: Consult physician, administer as needed antiparkinson medication (e.g., trihexyphenidyl or benztropine) Consult physician regarding medication change Provide towel or handkerchief to wipe excess saliva. Acute dystonic reactions: acute contractions of tongue, face, neck, and back (usually tongue and jaw first) Opisthotonos: tetanic heightening of entire body, head and belly up Oculogyric crisis: eyes locked upward Laryngeal dystonia: could threaten airway (rare) Cogwheel rigidity: stiffness and clicking in elbow joints felt by the examiner during passive range of motion (early indicator of acute dystonia) Onset: 1–5 days: Consult physician immediately Administer anti-parkinson medication as above—give IM for more rapid effect and because of swallowing difficulty Also consider diphenhydramine hydrochloride (Benadryl) 25–50 mg IM or IV Relief usually occurs in 5–15 minutes Prevent further dystonias with antiparkinson medication (see Table 15.8) Experience can be frightening, and person may fear choking Accompany to quiet area to provide comfort and support Assist person to understand the event and avert distortion or mistrust of medications Monitor airway Akathisia: motor inner-driven restlessness (e.g., tapping foot incessantly, rocking forward and backward in chair, shifting weight from side to side) Onset: 2 hours–60 days: Consult physician regarding possible medication change Give antiparkinson medication Tolerance to akathisia does not develop, but akathisia disappears when neuroleptic is discontinued Propranolol (Inderal), lorazepam (Ativan), or diazepam (Valium) may be used (Important note: In severe cases may cause great distress and contribute to potential suicidality, physician must be aware) Tardive dyskinesia (TD): Face: protruding and rolling tongue, blowing, smacking, licking, spastic facial distortion, smacking movements Limbs: Choreic: rapid, purposeless, and irregular movements Athetoid: slow, complex, and serpentine movements Trunk: neck and shoulder movements, dramatic hip jerks and rocking, twisting pelvic thrusts Onset: Months to years: No known treatment Discontinuing the medication rarely relieves symptoms Possibly 20% of people taking these medications for >2 years may develop TD Nurses and physicians should encourage people to be screened for TD at least every 3 months Onset may merit reconsideration of medications Changes in appearance may contribute to stigmatizing response Teach patient actions to conceal involuntary movements (purposeful muscle contraction overrides involuntary tardive movements) Hypotension and postural hypotension: Check blood pressure before giving medication: a systolic pressure of 80 mm Hg when standing is indication not to give the current dose Advise person to rise slowly to prevent dizziness and hold on to railings or furniture while rising to reduce falls Effect usually subsides when medication is stabilized in 1–2 weeks Elastic bandages may prevent pooling If any abnormal reading of blood pressure, consult physician immediately regarding medication change, volume expanders, or pressure medications Tachycardia: Always evaluate patients with existing cardiac problems before antipsychotic medications are administered Haloperidol (Haldol) is usually the preferred medication because of its low ACh effects Agranulocytosis (a rare occurrence, but a possibility the nurse should be aware of): symptoms include sore throat, fever, malaise, and mouth sores; any flulike symptoms should be carefully evaluated Onset: During the first 12 weeks of therapy, occurs suddenly: A potentially dangerous blood dyscrasia Blood work usually done every week for 6 months, then every 2 months Physician may order blood work to determine presence of leukopenia or agranulocytosis If test results are positive, the medication is discontinued, and reverse isolation may be initiated Mortality is high if the medication is not ceased and if treatment is not initiated Teach person to observe for signs of infection Cholestatic jaundice: rare, reversible, and usually benign if caught in time; prodromal symptoms are fever, malaise, nausea, and abdominal pain; jaundice appears 1 week later: Consult physician regarding possible medication change Bed rest and high-protein, high-carbohydrate diet if ordered Liver function tests should be performed every 6 months Neuroleptic malignant syndrome (NMS): rare, potentially fatal Severe extrapyramidal: severe muscle rigidity, oculogyric crisis, dysphasia, flexor-extensor posturing, cogwheeling Hyperpyrexia: elevated temperature (over 39°C or 103°F) Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence Delirium, stupor, coma Onset: variable, progresses rapidly over 2–3 days Risk factors: concomitant use of psychotropics, older age, female, presence of a mood disorder, and rapid dose titration (increase): Acute, life-threatening medical emergency Consult physician immediately Stop neuroleptic Transfer stat to medical unit Bromocriptine can relieve muscle rigidity and reduce fever Cool body to reduce fever (cooling blankets, alcohol, cool water, or ice bath as ordered) Maintain hydration with oral and IV fluids; correct electrolyte imbalance Arrhythmias should be treated Small doses of heparin may decrease possibility of pulmonary emboli Early detection increases patient’s chance of survival

Answer 238

Any intense and strongly defended irrational suspicion can be regarded as paranoia. Paranoia is evident, at least intermittently, in many people without psychotic disorders but is verified as irrational and discarded by the reality-testing process. This process fails in people experiencing paranoia concomitant with psychotic disorders. For them, paranoid ideas cannot be corrected by experiences or modified by facts or real- ity. Projection is the most common defence mechanism used in para- noia: when individuals with paranoia feel angry (or self-critical), they project the feeling onto others and believe that others are angry with (or harshly critical toward) them, as if to say, “I’m not angry—you are!” Schizophrenia with predominantly paranoid symptoms usually has a later age of onset (late twenties to thirties), develops rapidly in in- dividuals with good premorbid functioning, tends to be intermittent during the first 5 years of the illness, and, in some cases, is associated with a good outcome or complete recovery. People with paranoia are usually frightened and may behave defensively. The paranoia is often a defense against painful feelings of loneliness, despair, helplessness, and fear of abandonment. Useful nursing strategies are outlined in the following sections. Communication guidelines. People with paranoia can have difficulty trusting those around them, and may be guarded, tense, and/ or reserved. To ensure interpersonal distance, they may adopt a superior, aloof, hostile, or sarcastic attitude, disparaging and dwelling on the shortcomings of others to maintain their self-esteem. Although they may shun interpersonal contact, functional impairment other than paranoia may be minimal. These people frequently misinterpret the intent or actions of others, perceiving oversights as personal rejection. They also may personalize unrelated events (ideas of reference, or referentiality). For example, a patient might see a nurse talking to the psychiatrist and believe that the two are talking about them. During care, a patient suffering from paranoia may make offensive yet accurate criticisms of staff and unit policies. It is important that responses focus on reducing the patient’s anxiety and fear and not be defensive reactions or rejections of the patient. Staff conferences and clinical supervision help maintain objectivity and a therapeutic perspective about the patient’s motivation and behaviour, increasing professional effectiveness. Self-care needs. People with paranoia usually have stronger ego resources than do individuals in whom other symptoms predominate; this is particularly evident in occupational functioning and capacity for independent living. Grooming, dress, and self-care may not be problems and may, in fact, be meticulous. Nutrition, however, may be affected by a delusion, such as that the food is poisoned. Providing foods in commercially sealed packaging, for example, peanut butter and crackers or nutritional drinks in cartons, can improve nutrition. If people worry that others will harm them when they are asleep, they may be fearful of going to sleep, a problem that impairs restorative rest and warrants nursing intervention. Milieu needs. A person with paranoia may become physically aggressive in response to paranoid hallucinations or delusions. The per- son projects hostile drives onto others and then acts on these drives. cont’d. An environment that provides a sense of security and safety minimizes anxiety and environmental distortions. Activities that distract the patient from ruminating on paranoid themes also decrease anxiety.

Answer 239

The essential feature of catatonia is abnormal levels of motor behaviour, either extreme motor agitation or extreme motor retardation. Other as- sociated behaviours include posturing, waxy flexibility (described lat- er), stereotyped behaviour, muteness, extreme negativism or automatic obedience, echolalia, and echopraxia (discussed earlier in this chapter). The onset of catatonia is usually abrupt, and the prognosis favourable. With pharmacotherapy and improved individual management, severe catatonic symptoms are rarely seen today. Useful nursing strategies for intervening in catatonia are discussed in the following sections. Communication guidelines. People with catatonia can be so with- drawn they appear stuporous or comatose. They can be mute and may remain so for hours, days, or even weeks or months if untreated. Al- though such patients may not appear to pay attention to events going on around them, they are acutely aware of the environment and may accurately remember events at a later date. Developing skill and confi- dence in working with withdrawn patients takes practice. The person’s inability or refusal to cooperate or participate in activities challenges staff to work to remain objective and avert frustration and anger. Self-care needs. In extreme withdrawal a person may need to be hand- or tube-fed to maintain adequate nutritional status. Aspiration is a risk. Normal control over bladder and bowel functions may be inter- rupted, so the assessment and management of urinary or bowel reten- tion or incontinence is essential. When physical movements are mini- mal or absent, range-of-motion exercises can reduce muscular atrophy, calcium depletion, and contractures. Dressing and grooming usually require direct assistance. Milieu needs. The catatonic person’s appearance may range from decreased spontaneous movement to complete stupor. Waxy flexibility is often seen; for example, if the patient raises arms over the head, they may maintain that position for hours or longer. Caution is advised because, even after holding a single posture for long periods, the pa- tient may suddenly and without provocation show brief outbursts of gross motor activity in response to inner hallucinations, delusions, and changes in neurotransmitter levels.

Answer 240

Communication guidelines. During the excited stage of catatonia, the patient is in a state of greatly increased motor activity. They may talk or shout continually and incoherently, requiring the nurse’s com- munication to be clear, direct, and loud (enough to focus the patient’s attention on the nurse) and to reflect concern for the safety of the pa- tient and others. Self-careneeds. Apersonwhoisconstantlyandintenselyhyperac- tive can become completely exhausted and be at risk of death if medical attention is not available. Patients with co-existing medical conditions (e.g., congestive heart failure) are most at risk. Intramuscular adminis- tration of a sedating antipsychotic is often required to reduce psycho- motor agitation to a safer level. During heightened physical activity, the patient requires stimulation reduction and additional fluids, calories, and rest. It is not unusual for the agitated person to be destructive or aggressive to others in response to hallucinations or delusions or inner distress. Many of the concerns and interventions are the same as those for mania.

Answer 241

A person with disorganization may have marked associative looseness, grossly inappropriate affect, bizarre mannerisms, and incoherence of speech and may display extreme social withdrawal. Delusions and hallucinations are fragmentary and poorly organized. Behaviour may be considered odd, and a giggling or grimacing response to internal stimuli is common. Disorganization has an earlier age of onset (early to middle teens), often develops insidiously, is associated with poor premorbid function- ing and a significant family history of psychiatric disorders, and carries a poor prognosis. Often people reside in long-term care facilities and can live safely in the community only in a structured, well-supervised setting or with intensive follow-up such as a PACT (Program for As- sertive Community Treatment) service. Families of patients living at home need significant community support, respite care, and access to day hospital services. Unfortunately, individuals experiencing disor- ganization can experience housing instability, which further adds to stressors that contribute to psychosis and difficulties with access to mental health services as well as adherence to antipsychotic prescrip- tion (Rezansoff et al., 2016). See the Case Study and Nursing Care Plan for Disorganized Thinking on the Evolve website. Communication guidelines. People with disorganization experi- ence persistent and severe perceptual and communication problems. Communication should be concise, clear, and concrete. Tasks should be broken into discrete tasks that are performed one at a time. Repeat- ed refocusing may be needed to keep the patient on topic or to allow task completion. This repetition can be frustrating to the nurse and others, requiring special effort to identify and correct counter-transfer- ence and nontherapeutic responses. Self-care needs. In people with disorganization grooming is ne- glected; hair is often unkempt and matted, and clothes are unclean and often inappropriate for the weather (presenting a risk to self). Cognition, memory, and executive function are grossly impaired, and the person is frequently too disorganized to carry out simple ADLs. Areas of nurs- ing focus include encouraging optimal levels of functioning, preventing further regression, and offering alternatives for inappropriate behaviours whenever possible. Significant direct assistance for ADLs is also needed. Milieu needs. People with disorganization need assistance with their behaviour and social expectations. Creating a care plan is im- portant to assist patients with structure, initiation of ADLs, increased supervision, and offering alternatives for inappropriate behaviours. Equally important is modifying the care plan as the patient develops more organization in thoughts and behaviours. Nurses must provide for the patient’s privacy needs. A sense of safety and decreased stimula- tion is of utmost importance. Peer education about the disorder may reduce peer frustration and acting out.

Answer 242

Family Therapy Family therapy is a service usually delivered by healthcare providers with specific education in this area, including advanced-practice nurs- es, master’s-prepared social workers, and registered marriage and fam- ily therapists. The field of family therapy was originally developed as a treatment for schizophrenia. Families of people living with schizophre- nia, particularly direct caregivers, often endure considerable hardships while coping with the psychotic and residual symptoms of the illness. The patient and family may become isolated from other relatives, com- munities, and support systems. In fact, until the 1970s, families were often blamed for causing schizophrenia in the affected family member. Family education and family therapy improve the quality of life for the person living with schizophrenia and reduce the relapse rate for many. Programs that provide support, education, coping skills training, and so- cial network development are extremely effective. This psychoeducational approach brings educational and behavioural approaches into family treat- ment and does not blame families for illness. In family therapy sessions, fears, faulty communication patterns, and distortions are identified; problem solving skills are taught; healthier alternatives to conflict are explored; and guilt and anxiety can be lessened.

Answer 243

Evaluation is especially important in planning care for people who have psychotic disorders. Outcome expectations that are unrealistic discourage the patient and staff alike. It is critical for staff to remember that change is a process that occurs over time. For a person with schizo- phrenia, progress may occur erratically, and gains may be difficult to discern in the short term. Chronically ill people must be reassessed regularly so that new data can be considered and treatment adjusted when needed. Questions to be asked include: * Is the patient not progressing because a more important need is not being met? * Are the staff making the best use of the patient’s strengths and inter- ests to promote treatment and achieve desired outcomes? * Are any other possible interventions being overlooked? * Are new or better interventions/treatments available? * How is the patient responding to existing or recently changed medi- cations or other treatments? * Is the patient becoming discouraged, anxious, or depressed? * Is the patient participating in treatment? Are adverse medication effects controlled or troubling? * Is functioning improving or regressing? * What is the patient’s quality of life, and is it improving? * Is the family involved, supportive, and knowledgeable regarding the patient’s disorder and treatment? Active staff involvement and interest in the patient’s progress communicate concern and caring, help the patient to maximize progress, promote participation in treatment, and reduce staff feel- ings of helplessness and burnout. Input from the patient can offer valuable information about why a certain desired outcome has not occurred.

Answer 244

Diagnosis: 1. Disturbed thought processes related to alteration in neurological function, as evidenced by persecutory hallucinations and paranoia Outcomes Identification 1. Tom consistently refrains from acting on his “voices” and suspicions. 2. Tom consistently adheres to treatment regimen. Planning The nurse plans interventions that will (1) help Tom deal with his disturbing thoughts and (2) minimize drug use and adverse effects of medication to increase adherence and decrease the potential for relapse and violence. ------------------------- Implementation 1. Nursing diagnosis: Disturbed thought processes Outcome: Tom consistently refrains from acting on his “voices” and suspicions when they occur. Goal: 1. By the end of the first week, Tom will recognize the presence of hallucinations and identify one or more contributing factors, as evidenced by telling his nurse when they occur and what preceded them Intervention 1a. Meet with Tom each day for 30 minutes to establish trust and rapport. 1b.Explore those times when voices are most threatening and disturbing, noting the circumstances that precede them. 1c. Provide noncompetitive activities that focus on the here and now. Rationale 1a. Short, consistent meetings help decrease anxiety and establish trust. 1b.Identifying events that increase anxiety and trigger “voices” and then learning to manage triggers, hallucinations can be reduced. 1c. Increased time spent in reality- based activities decreases focus on hallucinations. Evaluation Goal Met By the end of the first week, Tom tells the nurse when he is experiencing hallucinations. ------------- 2. By the end of the first week, Tom will recognize hallucinations as “not real” and ascribe them to his illness. 2a. Explore content of hallucinations with Tom. 2b.Educate Tom about the nature of hallucinations and ways to determine if “voices” are real. 2a. Exploring hallucinations identifies suicidal or aggressive themes or command hallucinations. 2b.Education improves Tom’s reality testing and helps him begin to attribute his experiences to schizophrenia. Goal Met Tom identifies that the voices tell him he is a loser and he needs to be careful “because someone is after me.” He identifies that the voices are worse at nighttime. He notes that others do not seem to hear what he hears and also states that smoking marijuana produces very threatening voices. _____________ 3. By discharge, Tom will consistently report a decrease in hallucinations. 3. Explore with Tom possible actions that can minimize anxiety and reduce hallucinations, such as whistling or reading aloud 3. Such activities offer alternatives while anxiety level is relatively low. while anxiety level is relatively low. Rationale 1a. Such evaluation identifies medications and dosages that have increased therapeutic value and decreased adverse effects. 1b.Olanzapine causes no known sexual difficulties. 1c. This knowledge can give an increased sense of control over symptoms. 2. Being part of a group provides peer support and a chance to hear from others (further along in recovery) how medications can be helpful and adverse effects can be managed. The peer group can also offer suggestions for dealing with his loneliness and other problems. Evaluation Goal Met By the end of the first week, Tom tells the nurse when he is experiencing hallucinations. Goal Met Tom identifies that the voices tell him he is a loser and he needs to be careful “because someone is after me.” He identifies that the voices are worse at nighttime. He notes that others do not seem to hear what he hears and also states that smoking marijuana produces very threatening voices. Goal Met Tom states that he is hearing voices less often, and they are less threatening to him. Tom identifies that if he whistles or sings, he stays calm and can control the voices. __*****__ 2. Nursing diagnosis: Nonadherence to medication regimen Outcome: Tom consistently adheres to medication regimen. Short-Term Goal 1. By the end of week 1, Tom will discuss his concerns about medication with staff Intervention 1a. Evaluate medication response and adverse-effect issues. 1b.Initiate medication change to olanzapine (Zyprexa). Administer a large dose at bedtime to increase sleep and a small dose during the day to decrease fatigue. 1c. Educate Tom regarding adverse effects—how long they last and what actions can be taken. Rationale 1a. Such evaluation identifies medications and dosages that have increased therapeutic value and decreased adverse effects. 1b.Olanzapine causes no known sexual difficulties. 1c. This knowledge can give an increased sense of control over symptoms. Evaluation Goal Met Tom identifies the reasons for stopping his medication. He agrees to try olanzapine because he trusts staff’s assurances that the adverse effects will be reduced. Tom states that he sleeps better at night but is still tired during the day. _________ 2. By the end of week 2, Tom will describe two ways to reduce or cope with adverse effects and two ways the medications help him meet his goals (e.g., avoiding jail, reducing fear). 2. Connect Tom with the local Schizophrenia Society support group. 2. Being part of a group provides peer support and a chance to hear from others (further along in recovery) how medications can be helpful and adverse effects can be managed. The peer group can also offer suggestions for dealing with his loneliness and other problems. Goal Met Week 1: Tom attends meeting. Week 2: He speaks in the group about “not feeling good.” Several group members say they understand and try to help him figure out why he is not feeling good. Peers tell him how taking medication has helped them feel better. __________ Evaluation y discharge, Tom expresses hope that the medications will help him feel better and avoid problems like jail. He has a better understanding of his medications and what to do for adverse effects. He knows that marijuana increases his symptoms and explains that when he gets lonely, he now has ideas of things other than marijuana he can do to “feel good.” Tom continues with the support group and outpatient counselling, stating that his reason for doing so is “because Jodie really cared about me”; her empathy and caring made him want to get better and led him to trust what staff told him. He reports sleeping much better and says that he has more energy during the day.

Answer 245

* Schizophrenia is a complex disorder of the brain. It is not one dis- order but a group of disorders with overlapping symptoms and treatments. * Recovery is possible with early identification, new treatments, and adequate social supports. * The primary differences among subtypes involve the spectrum of symptoms that dominate their severity, the impairment in affect and cognition, and the impact on social and other areas of func- tioning. * Symptoms of psychosis are often more pronounced and obvious than are symptoms found in other disorders, making psychosis and schizophrenia more likely to be apparent to others and increasing the risk of stigmatization. * Neurochemical (catecholamines and serotonin), genetic, and neu- roanatomical findings help explain the symptoms of schizophre- nia. However, no one theory accounts fully for the complexities of schizophrenia. * There are four categories of symptoms of schizophrenia: positive, negative, cognitive, and affective. Symptoms vary considerably among people and fluctuate over time. * The positive symptoms of schizophrenia (e.g., hallucinations, delu- sions, associative looseness) are more pronounced and respond best to antipsychotic medication therapy. * The negative symptoms of schizophrenia (e.g., social withdrawal and dysfunction, lack of motivation, reduced affect) respond less well to antipsychotic therapy and tend to be more debilitating. * The degree of cognitive impairment (cognitive symptom) warrants careful assessment and active intervention to increase the patient’s ability to adapt, function, and maximize their quality of life. * Coexisting depression (affective symptom) must be identified and treated to reduce potential risk for suicide, substance use, nonad- herence, and relapse. * Some applicable nursing diagnoses include Disturbed sensory per- ception, Disturbed thought processes, Impaired communication, In- effective coping, Risk for self-directed or other-directed violence, and Impaired family coping. * Outcomes are chosen based on the type and phase of schizophrenia and the person’s individual needs, strengths, and level of function- ing. Short-term and intermediate indicators are also developed to better track the incremental progress typical of schizophrenia. * Interventions for people living with schizophrenia include trust build- ing, therapeutic communication techniques, support, assistance with self-care, promotion of independence, stress management, promo- tion of socialization, psychoeducation to promote understanding and adaptation, milieu management, cognitive behavioural interventions, cognitive enhancement or remediation techniques, and medication administration. * Because antipsychotic medications are essential in the care of people living with schizophrenia, the nurse must understand the properties, adverse and toxic effects, and dosages of conventional and atypical antipsychotic medication and other medications used to treat schizophrenia. The nurse helps the patient and family un- derstand and appreciate the importance of medication to recovery. * Schizophrenia can produce counter-transference responses in staff; clinical supervision and self-assessment help the nurse remain ob- jective and therapeutic. * Hope is closely tied to recovery; it is essential for nurses to hold hope for people living with schizophrenia.

Answer 246

is a universal human experience and is the most basic of emotions. It can be defined as a feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat. anxiety affects us at a deeper level: it invades the central core of the personal- ity and erodes feelings of self-esteem and personal worth.

Answer 247

is a reaction to a real or perceived specific danger.

Answer 248

is a healthy reaction necessary for survival. It provides us with energy to carry out everyday tasks and strive toward goals; motivates us to make and survive change; and prompts constructive behaviours, such as studying for an examination, being on time for a job interview, preparing for a presentation, and working toward making an individual change, such as a move, or advocating for social change, for instance, concerning what Usher and colleagues refer to as eco-anxiety

Answer 249

Hildegard Peplau had a profound role in shaping the specialty of psychiatric mental health nursing. She identified anxiety as one of the most important concepts and developed an anxiety model that consists of four levels: mild, moderate, severe, and panic. The boundaries between these levels are not distinct, and the behaviours and characteristics of individuals experi- encing anxiety can and often do overlap. Identification of a patient’s specific level of anxiety is essential because interventions are based on the degree of the anxiety.

Answer 250

Mild anxiety, which occurs in the normal experience of everyday liv- ing, allows an individual to perceive reality in sharp focus. A person experiencing a mild level of anxiety sees, hears, and grasps more information, and problem solving becomes more effective. Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension-relieving behaviours (e.g., nail biting, foot or finger tapping, fidgeting, wringing of hands). May have heightened perceptual field Is alert and can see, hear, and grasp what is happening in the environment Can identify things that are disturbing and are producing anxiety Able to work effectively toward a goal and examine alternatives Mild and moderate levels of anxiety can alert the person that something is wrong and can stimulate appropriate action. Slight discomfort Attention-seeking behaviours Restlessness, irritability, or impatience Mild tension-relieving behaviour (e.g., foot or finger tapping, lip chewing, fidgeting)

Answer 251

As anxiety increases, the perceptual field narrows, and some details are excluded from observation. The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out. While the person’s ability to think clearly is hampered, learning and problem solving can still take place, although not at an optimal level. Physical symptoms of moderate anxiety include tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency). Voice tremors and shaking may be noticed. Mild or moderate anxiety levels can be constructive because anxiety may signal that something in the person’s life needs attention or is dangerous. Has narrow perceptual field Grasps less of what is going on Can attend to more if pointed out by another (selective inattention) Able to solve problems but not at optimal ability Benefits from guidance of others Mild and moderate levels of anxiety can alert the person that something is wrong and can stimulate appropriate action. Voice tremors Change in voice pitch Difficulty concentrating Shakiness Repetitive questioning Somatic complaints (e.g., urinary frequency and urgency, headache, backache, insomnia) Increased respiration rate Increased pulse rate Increased muscle tension More extreme tension-relieving behaviour (e.g., pacing, banging hands on table)

Answer 252

The perceptual field of a person experiencing severe anxiety is greatly reduced. A person with severe anxiety may focus on one particular de- tail or many scattered details and has difficulty noticing their environment, even when it is pointed out by another. Learning and problem solving are not possible at this level, and the person may be dazed and confused. Behaviour becomes automatic (e.g., wringing hands, pacing) and is aimed at reducing or relieving anxiety. Somatic symptoms such as headache, nausea, dizziness, and insomnia often increase; trembling and a pounding heart are common; and the person may hyperventilate and experience a sense of impending doom or dread. Has greatly reduced perceptual field Focuses on details or one specific detail Attention is scattered May not be able to attend to events in environment even when pointed out by another Completely absorbed with self In severe to panic levels of anxiety, the environment is blocked out. It is as if these events are not occurring. Unable to see connections between events or details Has distorted perceptions Severe and panic levels prevent problem solving and discovery of effective solutions. Unproductive relief behaviours are called into play, thus perpetuating a vicious cycle. Feelings of dread Ineffective functioning Confusion Purposeless activity Sense of impending doom More intense somatic complaints (e.g., dizziness, nausea, headache, sleeplessness) Hyperventilation Tachycardia Withdrawal Loud and rapid speech Threats and demands

Answer 253

Panic, the most extreme level of anxiety, results in noticeably disturbed behaviour. Someone in a state of panic is unable to process what is going on in the environment and may lose touch with reality, even experiencing hallucinations, or false sensory perceptions (e.g., seeing people or objects not really there). Physical manifestations may include pacing, running, shouting, screaming, or withdrawal, and actions may become erratic, uncoordinated, and impulsive. These sorts of automatic behaviours are used to reduce or relieve anxiety, although such efforts may be ineffective. Acute panic may lead to exhaustion. Is unable to focus on the environment Experiences the utmost state of terror and emotional paralysis Feels he or she “ceases to exist” May have hallucinations or delusions that take the place of reality In severe to panic levels of anxiety, the environment is blocked out. It is as if these events are not occurring. May be mute or have extreme psychomotor agitation, leading to exhaustion Shows disorganized or irrational reasoning Severe and panic levels prevent problem solving and discovery of effective solutions. Unproductive relief behaviours are called into play, thus perpetuating a vicious cycle. Feeling of terror Immobility or severe hyperactivity, fight-or-flight or freeze Dilated pupils Unintelligible communication or inability to speak Severe shakiness Sleeplessness Severe withdrawal Hallucinations or delusions—likely out of touch with reality

Answer 254

Dysfunctional behaviour (e.g., compulsions, stress headaches, detachment) is a result of defence mechanisms (automatic coping styles that protect people from anxiety and maintain self-image by blocking feelings, conflicts, and memories). When behaviour is recognized as dysfunctional, nurses can initiate interventions to reduce anxiety. As anxiety decreases, dysfunctional behaviour will frequently decrease, although initially, as dysfunctional behaviour decreases, anxiety may actually increase until the individual learns to cognitively restructure thoughts. Therefore nurses must be available to help support alternative coping strategies as the individual learns to restructure their think- ing patterns. The adaptive use of defence mechanisms helps people lower their anxiety to achieve goals in acceptable ways. The excessive application of defence mechanisms, however, results in their maladaptive use and is particularly problematic when immature defences are called upon.

Answer 255

Stress (physical, social, psychological) can increase anxiety----which can cause a person to use defence mechanism, coping behaviours, spiritual, cultural, social supports----- can lead to effective mediation or decreased anxiety OR ineffective mediation (increased anxiety plus difficulty coping, extreme use of defences, or coping behaviours, exacerbation of psychotic symptoms, chronic anxiety

Answer 256

sublimation and altruism, which are always healthy coping mechanisms, all defence mechanisms can be used in both healthy and unhealthy ways.

Answer 257

* Acute stress disorder * Anxiety disorder not otherwise specified * Anxiety due to medical conditions *Depersonalization/derealization disorder * Generalized anxiety disorder (GAD) * OCD and related disorders * Panic disorders (PDs) * Phobias * PTSD * SSD * Substance-induced anxiety disorder

Answer 258

Fear is a response to an imminent threat. Anxiety is related to the perception of a future threat.

Answer 259

Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also effect significant behavioural changes lasting at least a month and ongoing worry about having other attacks. A panic attack is the sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom. The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is extremely limited, severe personality disorganization is evident, and misinterpretation of reality may occur. People experiencing panic attacks may believe that they are losing their minds or having a heart attack since the attacks are often accompanied by highly uncomfortable physical symptoms such as palpitations, chest pain, breathing difficulties, nausea, a choking feeling, chills, and hot flashes. Typically, panic attacks occur within 10 minutes “out of the blue” (i.e., suddenly, and not necessarily in response to stress), are extremely intense, last a matter of minutes, and then subside

Answer 260

When individuals actively avoid situations from which escape might be difficult or embarrassing or in which help might not be available if panic-like symptoms were to occur, they may be diagnosed with agoraphobia. Agoraphobia without a history of panic attacks occurs only rarely and early in the patient’s history. Situations that are commonly avoided by people with agora- phobia include being outside alone; waiting in line at a grocery store; travelling in a car, bus, or airplane; being on a bridge; riding in an elevator; or going to a movie theatre. These types of feared places are avoided in an effort to control anxiety. Avoidance behaviours, how- ever, can be debilitating and life constricting.

Answer 261

Altruism is dedicating oneself to meeting the needs of others as a means of diffusing potentially anxious situations. The use of altruism is always constructive.

Answer 262

Compensation is used to make up for perceived deficiencies and to cover up shortcomings related to these deficiencies to protect the conscious mind from recognizing them A shorter-than-average person becomes assertively verbal and excels in business. An individual drinks alcohol when self-esteem is low to temporarily diffuse discomfort.

Answer 263

Conversion is the unconscious transformation of anxiety into a physical symptom with no organic cause. Often the symptom functions to gain attention or to provide an excuse. A student is unable to take a final examination because of a terrible headache. A person becomes blind after seeing their spouse flirt with other people.

Answer 264

Denial involves escaping unpleasant, anxiety-causing thoughts, feelings, wishes, or needs by ignoring their existence. A person reacts to news of the death of a loved one by saying, “No, I don’t believe you. The doctor said they were fine.” A person whose spouse died 3 years earlier still keeps their clothes in the closet and talks about them in the present tense.

Answer 265

Displacement is the transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation. A patient criticizes a nurse after their family fails to visit. A child who is unable to acknowledge fear of their father becomes fearful of animals.

Answer 266

Dissociation is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. It may result in a separation between feeling and thought. Dissociation can also be manifested by compartmentalizing uncomfortable or unpleasant aspects of oneself. A nursing student is able to mentally separate themselves from the noisy environment in the gymnasium as they writes their final exam. As the result of an abusive childhood and the need to separate from its realities, a patient finds themselves perpetually in a world where they feel disconnected from reality. They feel like an outside observer to their thoughts, feelings, and body sensations.

Answer 267

Identification is attributing to oneself the characteristics of another person or group, which may be done consciously or unconsciously. An 8-year-old dresses up like their teacher and puts together a pretend classroom for their friends. A young child thinks a neighbourhood gang leader with money and drugs is someone to look up to.

Answer 268

Intellectualization is the process of analyzing events based on remote, cold facts (i.e., without passion), rather than incorporating feeling into the processing. Despite the fact that a patient has lost their farm to a tornado, they analyzes their options and leads their child to safety. A patient responds to the death of their spouse by focusing on the details of day care and operating the household, rather than processing the grief with their children.

Answer 269

Introjection is the process by which the outside world is incorporated or absorbed into a person’s view of the self. After their wife’s death, a patient has transient complaints of chest pains and difficulty breathing—the symptoms their wife had before she died. A patient whose parents overcriticized and belittled them as a child grows up thinking they are no good. They have taken on their parents’ evaluation of them as part of their self-image.

Answer 270

Projection refers to the unconscious rejection of emotionally unacceptable features and the transfer of them onto other people, objects, or situations. You can remember this defence through the childhood retort of “What you say is what you are.” A person who is unconsciously attracted to other people teases his partner about being attracted to other people. A patient who has repressed an attraction toward people of the same sex refuses to socialize. They have fears another same-sex person will make homosexual advances toward them.

Answer 271

Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener. An employee says, “I didn’t get the raise because the boss doesn’t like me.” A patient who thinks his child was the product of a suspected affair between his wife and best friend excuses his malicious treatment of the child by saying, “They are lazy and disobedient,” when that is not the case.

Answer 272

Reaction formation occurs when unacceptable feelings or behaviours are controlled and kept outside of awareness by developing the opposite behaviour or emotion. A patient in recovery from substance use disorder constantly preaches about the evils of drinking alcohol. A patient who has an unconscious hostility toward their child is overprotective and hovers over them to protect them from harm, interfering with their normal growth and development.

Answer 273

Regression is the reversion to an earlier, more primitive, and childlike pattern of behaviour that may or may not have been previously exhibited. A 4-year-old with a new baby sibling starts sucking their thumb and wanting a bottle. A patient who loses a promotion starts complaining to others, hands in sloppy work, misses appointments, and comes in late for meetings.

Answer 274

Repression is a first-line psychological defence against anxiety. It is the unconscious temporary or long-term exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. An individual forgets their partner’s birthday after a verbal disagreement. A patient is unable to enjoy sex after having pushed out of awareness a traumatic sexual incident from childhood.

Answer 275

Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Aspects of the self and of others tend to alternate between opposite poles—for example, either good, loving, worthy, and nurturing, or bad, hateful, destructive, rejecting, and worthless. A toddler views their parents as superhuman and wants to be like them. A 26-year-old patient has difficulty maintaining close relationships. Although they can initially find many positive qualities about new acquaintances, eventually they become disillusioned when the people they are attracted to, inevitably turn out to be flawed.

Answer 276

Sublimation is an unconscious process of substituting mature, constructive, and socially acceptable activity for immature, destructive, and unacceptable impulses. Often these impulses are sexual or aggressive. A patient who is angry with their boss writes a short story about a heroic character. The use of sublimation is always constructive.

Answer 277

Suppression is the conscious denial of a disturbing situation or feeling. An individual who is preparing to make an important speech later in the day is told by their partner that morning that they want a divorce. Although visibly upset, the patient puts the incident aside until after their speech, so they can give the matter their total concentration. A patient who feels a lump in their breast shortly before leaving for a 3-week vacation puts the information in the back of their mind until after returning from the vacation.

Answer 278

Undoing, most commonly seen in children, is atoning for an act or communication. After flirting with their assistant, a patient brings their spouse tickets to a concert they want to see. A patient with rigid, moralistic beliefs and repressed sexuality is driven to wash their hands to gain composure when around people they find attractive.

Answer 279

Intervention 1a. If hyperventilation occurs, encourage patient to take slow, deep breaths. Breathing with the patient may be helpful. 1b. Keep expectations minimal and simple. Rationale 1a. Focus is shifted away from distressing symptoms. Slow, deep breathing triggers a relaxation response. 1b. Anxiety limits ability to attend to complex tasks.

Answer 280

Intervention 2a. Help patient connect feelings before attack with onset of attack: “What were you thinking about just before the attack?” “Can you identify what you were feeling just before the attack?” 2b. Help patient recognize symptoms as resulting from anxi- ety, not from a catastrophic physical problem. Examples: Explain physical symptoms of anxiety. Discuss the fact that anxiety causes sensations similar to those of physical events, such as a heart attack. 2c. Identify effective therapies for panic episodes. 2d. Teach patient abdominal breathing. 2e. Teach patient to reframe anxiety by using positive self- talk, such as “I can control my anxiety.” 2f. Teach patient and family about any medication ordered for patient’s panic attacks. Rationale 2a. Physiological symptoms of anxiety usually appear first as the result of a stressor. They are immediately followed by automatic thoughts, such as “I’m dying” or “I’m going crazy,” which are distorted assessments. 2b. Factual information and alternative interpretations can help patient recognize distortions in thought. 2c. Cognitive behavioural treatment is highly effective. Antianxiety medication is appropriate. 2d. Breathing breaks the cycle of escalating symptoms of anxiety. 2e. Cognitive restructuring is an effective way to replace negative self-talk. 2f. Patient and family need to know what the medication can do, the adverse effects and toxic effects, and when to offer medication to the patient.

Answer 281

A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance or to actual avoidance of the object, activity, or situation despite the awareness and reassurance that it is not dangerous. Specific phobias, which are more intense, cause impaired daily functioning and last at least half a year. They are characterized by the experience of high levels of anxiety or fear in response to specific objects or situations, such as dogs, spiders, heights, storms, water, blood, closed spaces, tunnels, and bridges. Characteristically, phobic individuals experience overwhelming and crippling anxiety when faced with the object or situation provoking the phobia. Phobic people go to great lengths to avoid the feared object or situation. A phobic person may not be able to think about or visualize the object or situation without becoming severely anxious. The life of a phobic person becomes increasingly restricted as activities are given up in order to avoid the phobic object. All too frequently, complications ensue when peo- ple try to decrease anxiety through self-medication with alcohol or drugs.

Answer 282

also called social anxiety disorder (SAD), is characterized by severe anxiety or fear provoked by exposure to a social or performance situation (e.g., fear of being scrutinized, saying something that sounds foolish in public, not being able to answer questions in a classroom, eating in public, performing on stage). Fear of public speak- ing is the most common social phobia.

Answer 283

Generalized anxiety disorder is an anxiety reaction characterized by persistent and exaggerated apprehension and tension. Worry is the major concern in GAD. The individual’s beliefs about worry are then linked to beliefs about themself, such as having the inability to control anxiety and fear, that if they worry significantly about an upcoming issue it will be prevented, or that worrying is a valued part of their personal identity. The individual with GAD also displays many of the following symptoms: * Restlessness * Fatigue * Poor concentration * Irritability * Tension * Sleep disturbance Examples of concerns typical of GAD include inadequacy in interpersonal relationships, job responsibilities, finances, the health of family members, household chores, and lateness for appointments. Sleep disturbance is common because the individual pores over the day’s events and real or imagined mistakes, reviews past problems, and anticipates future difficulties. Decision making becomes difficult, owing to poor concentration and dread of making a mistake.

Answer 284

Intervention and Rationale 1a. Stay with patient. 1a. Conveys acceptance and ability to give help. 1b. Speak slowly and calmly. 1b. Conveys calm and promotes security. 1c. Use short, simple sentences. 1c. Promotes comprehension. 1d. Assure patient that you are in control and can assist them. 1d. Counters feeling of loss of control that accompanies severe anxiety. 1e. Give brief directions. 1e. Reduces indecision; conveys belief that patient can respond in a healthy manner. 1f. Decrease excessive stimuli; provide quiet environ- ment. 1f. Reduces need to focus on diverse stimuli; promotes ability to concentrate. 1g. After assessing level of anxiety, administer appro- priate dose of anxiolytic agent if warranted. 1g. Reduces anxiety and allows patient to use coping skills. 1h. Monitor and control own feelings. 1h. Avoids transmission of anxiety (which is transmis- sible); displays of negative emotion can cause patient anxiety.

Answer 285

Rationale and INtervention 2a. Encourage patient to discuss preceding events. 2a. Promotes future change through identification of stressors. 2b. Link patient’s behaviour to feelings. 2b. Promotes self-awareness. 2c. Teach cognitive therapy principles: * Anxiety is the result of a dysfunctional appraisal of a situation. * Anxiety is the result of automatic thinking. 2c. Provides a basis for behavioural change. 2d. Ask questions that clarify and dispute illogical think- ing: * “What evidence do you have?” * “Explain the logic in that.” * “Are you basing that conclusion on fact or feeling?” * “What’s the worst thing that could happen?” 2d. Helps promote accurate cognition.

Answer 286

3a. Have patient identify what has provided relief in the past. 3a. Provides awareness of self as individual with some ability to cope 3b. Have patient write assessment of strengths. 3b. Increases self-acceptance. 3c. Reframe situation in ways that are positive. 3c. Provides a new perspective and converts distorted thinking.

Answer 287

Substance-induced anxiety disorder is characterized by symptoms of anx- iety, panic attacks, obsessions, and compulsions that develop with the use of a substance or within a month of discontinuing use of the substance.

Answer 288

In anxiety due to a medical condition, the individual’s symptoms of anxiety are a direct physiological result of a medical condition, such as hyperthyroidism, pulmonary embolism, or cardiac dysrhythmias. Central nervous system involvement in COVID-19 and other viral infections is thought to contribute to anxiety.

Answer 289

Anxiety disorders are one of the most common forms of psychiatric dis- orders in Canada. In 2020 Mental Health Research Canada reported ap- proximately 17% of Canadians reported symptoms of an anxiety disorder in the previous 12 months Report from the Canadian Chronic Disease Surveillance System: Mood and Anxiety Disorders in Canada, 2016 indicates that the prevalence of these disorders is increasing in children and youth. The highest relative increase in prevalence was seen among those aged 5 to 10 years.

Answer 290

Clinicians and researchers have clearly demonstrated that anxiety disorders frequently co-occur with other psychiatric problems Anxiety-related disorders occur so frequently with depressive disor- ders that the treatments for both disorders are similar due to shared neuro- biology, symptom similarities, and abnormalities of emotional processing.

Answer 291

somatic symptoms may also cause anxiety, fear, and worry. This may occur in patients who are living with chronic diseases. For example, someone who has the fear of cancer reoccurrence or that they have a genetic disorder. Referred to as health anxiety. Health anxiety is experienced on a continuum from mild transient worries to severe and debilitating worry. There is no “normal” amount of worry that people with chronic illness experience. Worrying only becomes problematic when it interferes with a person’s day to day ability to function. SSD manifests itself through distress or a significant disruption in quality of life related to physical symptoms or health concerns that are disproportionate to the seriousness of the symptoms. Included in the most common symp- toms that prompt visits to primary care providers are chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain, and numbness. Health-related quality of life is fre- quently severely impaired, and patients appraise their body symptoms as unduly troublesome, threatening, or harmful, often fearing the worst about their health. Some patients feel that their medical assessment and treatment have been inadequate. Often the patient has a comorbid psychiatric disorder such as depression, anxiety, or a personality disorder.

Answer 292

are a complex spectrum of physical and emotional signs and symp- toms. Health care providers working in traditional medical settings are more likely to see individuals experiencing a psychiatric illness with predominantly somatic symptoms than are those working within a psychiatric setting. Individuals with these disorders will have physical symptoms and abnormal alterations in thoughts, feelings, and behaviours directly related to the physical symptoms experienced. There may, or may not be, a nonpsychiatric medical diagnosis made related solely to the physical symptoms. These illnesses are often misunderstood and mislabelled.

Answer 293

the expression of psychological stress through physical symptoms, can affect people of all ages and genders. Anxi- ety, depression, and trauma exert a powerful influence on the mind and may lead to a variety of clinical conditions, both mental and physical. When psychiatric disorders are present along with general medical conditions, increased health care costs and lengths of stay may result. They also can negatively affect outcomes and increase morbidity and mortality

Answer 294

* SSD * Illness anxiety disorder (previously hypochondriasis) * Conversion disorder (also called functional neurological symptom disorder) * Psychological factors affecting medical condition * Factitious disorder

Answer 295

Short-Term Goal 1. Patient will identify levels of anxiety in at least three situations and encounters with other patients and staff. Intervention 1. Develop a relationship with the patient that includes a mutually agreed-upon contract that details expected changes in behaviours. Rationale 1. A contract provides a concrete means to keep track of patient’s actions and enhances self-direction and independent actions. Evaluation After spending 3 weeks in the intensive outpatient mental health program, Cara developed a trusting relationship with one staff member and two patients. Short-Term Goal 2. Patient will seek support from staff and patients when feelings of anxiety become difficult to handle or physical symptoms increase. INTERVENTION 2. Educate the patient about 2. sharing feelings of loss with staff, friends, and family mem- bers. Rationale 2. Communication and expres- sion of feelings with family and friends help alters may also behave as individuals to alleviate stress and often provides a more supportive environment. Evaluation 2a. Ms. Silverthorn made several attempts to engage Cara in discussion of feel- ings, losses, and conflicts to no avail until she arranged for a family meet- ing with Cara, her daughters, and her former husband. Cara was able to ex- press her anxiety and occasional anger about the loss of her role as wife and the impending loss of her daughters when they attend university away from home. 2b.Cara also became more active in ex- pressing her grief, particularly in the assertiveness and anger-management classes, and actively sought out Ms. Silverthorn on three occasions to dis- cuss her feelings. Goal 3. Patient will make a list with contacts and phone numberswof community resources of interest to her and make plans to attend a community event within a week. Intervention 3. Identify available support systems. Rationale 3. Patients are more successful handling stressful life events if they have ad- equate support. Evaluation 3. Cara decided to take piano lessons and also enrolled in some of her town’s adult-education classes. Goal 4. Patient will remain free of injury throughout the hospitalization. Intervention 4. Assess for suicidal ideation. Rationale 4. Suicidal ideation may occur in response to depression or hopelessness over medical conditions. Evaluation 4. Cara made no attempts to self-injure while in the hospital.

Answer 296

Previously known as hypochondriasis, illness anxiety disorder results in the misinterpretation of physical sensations as evidence of a serious illness. Illness anxiety can be quite obsessive as thoughts about illness may be intrusive and hard to dismiss even when patients realize that their fears are unrealistic. People with this disorder experience extreme worry and fear about the possibility of having a disease. Even normal body changes, such as a change in heart rate or abdominal cramps, can be seen as red flags for serious illness and imminent death.

Answer 297

Conversion disorder (also known as functional neurological symptom disorder) manifests itself as neurological symptoms in the absence of a neurological diagnosis. Conversion disorder is marked by the presence of deficits in voluntary motor or sensory functions, including paralysis, blindness, movement disorder, gait disorder, numbness, paresthesia (tingling or burning sensations), loss of hearing, or seizures resembling epilepsy. Conversion disorder is attributed to the channelling of emotional conflicts or stressors into physical symptoms; however, some magnetic resonance imaging (MRI) studies suggest that patients with conversion disorder have an abnormal pattern of cerebral activation. Conversion disorder is a clinical problem that requires the appli- cation of multiple perspectives, namely, biological, psychological, and social, to fully understand the symptoms of individual patients. Experiences of childhood physical or sexual abuse are common among patients with conversion disorder, and comorbid psychiatric conditions include depression, anxiety, PTSD, other somatic disorders, and personality disorders. Patients with conversion disorder symptoms may be found to have “no neurological disorder” by the neurologist and “no psychiatric disorder” by the psychiatrist, thus adding to the complexity of treatment planning. While some patients become quite distressed about their symptoms, many show a lack of emotional concern about them (la belle indifférence). Imagine someone casually discussing sudden blindness.

Answer 298

Specific prevalence rates for SSD in the general population are un- known. Instead, the literature describes their occurrence in the population of individuals who seek medical care but do not have an underlying physiological cause for their symptoms. In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) the requirement for no underlying psychological cause for their symptoms was removed. As a result, there is very limited cur- rent information on the prevalence of this disorder based on the new diagnostic criteria.

Answer 299

A thorough psychosocial history is also required to confirm a SSD diagnosis, as well as any comorbid psychiatric disorders. People with this type of illness will also have a depressive, psychotic, or anxiety disorder. Both the medical and the mental health communities recognize the interrelationships between psychiatric and medical illnesses Selye’s description of the general adaptation syndrome and Cannon’s 1914 identification of the fight-or-flight response provided insight into the biological and molecular reactions to stressors in the sympathetic nervous system, the hypothalamic–pituitary–adrenocortical axis, and the immune system. Extensive studies have left little doubt that psychosocial stress affects the course and severity of illness. Psychological factors may present a risk for a medical disease, or they may magnify or adversely affect a nonpsychiatric medical condition. For example, researchers are consistently providing evidence demonstrating links between mental disorders and cardiovascular disease

Answer 300

At the pathological end of the continuum are obsessive-compulsive symptoms that typically involve issues of contamination, fear of losing control, need for symmetry, unwanted thoughts of a sexual nature, and recurrent feelings of doubt. Pathological obsessions or compulsions cause marked distress to individuals, who often feel humiliation and shame for these behaviours. The rituals are time consuming and in- terfere with normal routines, social activities, and relationships with others. Severe OCD consumes so much of the individual’s mental pro- cesses that the performance of cognitive tasks may be impaired.

Answer 301

are defined as thoughts, impulses, or images that persist and recur and cannot be dismissed from the mind. Obsessions often seem senseless to the individual who experiences them (ego-dystonic), and their presence causes severe anxiety. Common types of obsessions include losing control, harm, contamination, perfectionism, sexual, and religious. There are also common categories of compul- sions: washing and cleaning, checking, repeating, and mental com- pulsions. Obsessive-compulsive behaviour exists along a continuum. “Normal” individuals may experience mildly obsessive-compulsive be- haviour. For example, nearly everyone has had the experience of having a tune run persistently through the mind despite attempts to push it away. Many people have had nagging doubts as to whether a door is locked or not. These doubts may require people to go back to check the door once, but then they can carry on with their day. Compulsive superstitions such as touching a lucky charm or avoiding a black cat are not harmful, and mild compulsions about timeliness, orderliness, and reliability are, in fact, valued traits in Canadian society.

Answer 302

are ritualistic behaviours or thoughts an individual feels compelled to perform in an attempt to reduce anxiety. Performing the compulsive act temporarily reduces high levels of anxiety. Primary gain is achieved by compulsive rituals, but because the relief is only temporary, the compulsive act must be repeated again and again until it feels “just right”

Answer 303

Incidence: Rates higher in White males until age 60 years Risk factors: family history of cardiac disease, hypertension, increased serum lipid levels, obesity, sedentary lifestyle, cigarette smoking Psychosocial risk factors: stress, depression, loneliness High anxiety risk in patient with prior cardiac events Common Precipitating Factors: Sudden stress preceded by a period of losses, frustration, and disappointments (often resulting in myocardial infarction) Potential Holistic Therapies Used in Addition to Medical Management Relaxation training, stress management, group social support, and psychosocial intervention Support groups for type A personalities

Answer 304

Occurs in 12% of men, 6% of women (more prevalent in industrialized societies) Infection with H. pylori is associated with 95%–99% of peptic ulcers Both peptic and duodenal ulcers cluster in families, but separately from each other. Common Precipitating Factors Periods of social tension and increased life stress Losses Postmenopause Potential Holistic Therapies Used in Addition to Medical Management Biofeedback to alter gastric acidity Cognitive behavioural approaches to reduce stress (stress management)

Answer 305

Men: most common in lung, prostate, colon, and rectum Women: most common in breast, uterus, colon, and rectum Death rate higher in men than in women Genetic evidence suggesting dysfunction of cellular proliferation Familial patterns of breast cancer, colorectal cancer, stomach cancer, melanoma Prolonged and intensive stress Stressful life events (e.g., separation from or loss of significant other 2 years before diagnosis) Feelings of hopelessness, helplessness, and despair (depression) Relaxation (e.g., meditation, autogenic training, self- hypnosis) Visualization Psychological counselling Support groups Massage therapy Stress management

Answer 306

Occurs in 80% of population when under stress Begins at end of workday or early evening Associated with anxiety and depression Psychotherapy for chronic tension headaches Learning to cope or avoiding tension-creating situations or people Relaxation and stress- management techniques Cognitive restructuring techniques

Answer 307

Rates higher in males until age 60 years Risk factors: family history of cardiac disease and hypertension Life changes and traumatic life events Stressful job (e.g., air traffic controller) Behavioural feedback, stress reduction techniques, meditation, yoga, hypnosis Note: Pharmacological treatment considered primary for treatment of hypertension

Answer 308

OCD is the fourth most common psychiatric illness. Everyone on occasion will obsess about something. However, only 1 to 3% of people will spend more than an hour a day having obsessive thoughts. The typical age of onset is bimodal (10 years and 21 years) Males generally will have an earlier onset than females. Childhood OCD is diagnosed almost three times as frequently in boys than in girls. However, by adulthood OCD occurs with approximately equal frequency in women and men.

Answer 309

Other psychiatric conditions with common symptoms of rumination (mood disorder) and worry (anxiety disorder) commonly occur with OCD. Psychotic disorders may also occur, however; people with only OCD are able to recognize that their thoughts are irrational but that they cannot control them.

Answer 310

Losing control -Fear of acting on an impulse to harm oneself -Praying to prevent harm to oneself -Fear of violent or horrific images in one’s mind -Thinks about something else when horrific images come to mind -Praying to get rid of the images Harm -Fear of being responsible for something terrible happening -Checking that nothing terrible happened Checking that you did not make a mistake -Fear of harming others because of not being careful enough (e.g., dropping something on the ground will cause another person to fall and break an arm) -Praying to prevent harm to prevent terrible consequences. -Checking that you did not or will not harm others Perfectionism -Need for symmetry—concern about evenness -Rereading or rewriting -Putting things in order or arranging things until it “feels right” -Inability to decide whether to keep or discard things -Collecting items that results in significant clutter in the home (hoarding) Contamination -Environmental contaminants (radiation, oil, or lead) -Cleaning household items in a certain way to remove contaminants -Germs or viruses -Washing hands excessively Unwanted sexual thoughts -Forbidden or perverse sexual thoughts or images -Telling, asking, or confessing to get reassurance -Obsessions about aggressive sexual behaviour toward others -Avoiding situations that might trigger your obsessions Religious obsessions -Concern with offending God Praying to seek forgiveness -Repeatedly touching or kissing religious objects -Excessive concern with morality -Replaying interactions with others and repeatedly reviewing every remark to determine if you said anything wrong Other obsessions -Concern about getting a disease, such as cancer, colitis, or diabetes -Checking some parts of your physical condition or body -Superstitious ideas Repeating activities in “multiples” (e.g., doing a task three times because three is a “good,” “right,” or “safe” number)

Answer 311

Acute stress disorder occurs within 1 month of a highly traumatic event, such as those that precipitate PTSD. To be diagnosed with acute stress disorder, the individual must display at least three dissociative symptoms either during or after the traumatic event, including a sub- jective sense of numbing, detachment, or absence of emotional re- sponsiveness; a reduction in awareness of surroundings; derealization (a sense of unreality related to the environment); depersonalization (a sense of unreality or self-estrangement); or dissociative amnesia (loss of memory). By definition, acute stress disorder resolves within 4 weeks.

Answer 312

Post-traumatic stress disorder is included in a new chapter in the DSM-5 on trauma- and stressor-related disorders. PTSD is an acute emotional response to a traumatic event or situation involving severe environmental stress. The following is an introduction to how trauma and anxiety are related. The individual with PTSD persistently re-experiences a traumatic event that involved threatened or actual death or serious injury to self or others, and to which the person responded with intense fear, help- lessness, or horror. PTSD may present after any traumatic event that is outside the range of usual experience, such as military combat, de- tention as a prisoner of war, natural disasters (e.g., floods, tornadoes, earthquakes), human disasters (e.g., plane and train accidents), crime- related events (e.g., sexual abuse, bombing, assault, mugging, rape, be- ing taken hostage), or diagnosis of a life-threatening illness.

Answer 313

* Persistent re-experiencing of the trauma through recurrent intru- sive recollections of the event, dreams about the event, and flash- backs—dissociative experiences during which the event is relived (i.e., the person behaves as though they are experiencing the event in the present) * Persistent avoidance of stimuli associated with the trauma, causing the individual to avoid talking about the trauma or avoid activities, people, or places that rouse memories of the trauma * Persistent numbing of general responsiveness, as evidenced by the individual’s feeling empty inside or feeling disconnected from others * Persistent symptoms of increased arousal, as evidenced by irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response Difficulty with interpersonal, social, or occupational relationships nearly always accompanies PTSD, and trust is a common issue of con- cern. Child and spousal abuse may be associated with hypervigilance and irritability, and chemical abuse may begin as an attempt to self-medicate to relieve anxiety

Answer 314

Short-Term Goal 1. Patient will speak to staff whenever experiencing self-destructive thoughts. Intervention 1a. Administer medications with mouth checks. 1b. Provide ongoing surveillance of patient and environment. 1c. Agrees to safety plan, to talk with staff when experiencing suicidal ideation. 1d. Use direct, nonjudgemental approach in discussing suicide. 1e. Provide teaching about post-traumatic stress disorder. Rationale 1a. Addresses risk of hiding medications. 1b.Provides one-to-one monitoring for safety. 1c. Encourages increased self-control. 1d.Shows acceptance of patient’s situa- tion with respect. 1e. Offers reality of treatment. Evaluation Goal Met After 8 hours, patient agrees to safety plan every shift and starts to discuss feelings of self-harm. 2. Patient will express feel- ings by the third day of hospitalization. 2a. Interact with patient at regular inter- vals to convey caring and openness and to provide an opportunity to talk. 2b.Use silence and listening to encourage expression of feelings. 2c. Be open to expressions of loneliness and powerlessness. 2d.Share observations or thoughts about patient’s behaviour or response. 2a. Encourages development of trust. 2b. Shows positive expectation that pa- tient will respond. 2c. Allows patient to voice these uncom- fortable feelings. 2d.Directs attention to here-and-now treatment situation. Goal Met By second day, patient occasionally answers questions about feelings and admits to anger and grief. 3. Patient will express will to live by discharge from unit. 3a. Listen to expressions of grief. 3b.Encourage patient to identify own strengths and abilities. 3c. Explore with patient previous methods of dealing with life problems. 3d.Assist in identifying available support systems. 3e. Refer patient to spiritual advisor of his choice. 3a.Supports patient and communicates that such feelings are natural. 3b.Affirms patient’s worth and potential to survive. 3c. Reinforces patient’s past coping skills and ability to problem-solve now. 3d.Addresses fact that anxiety has narrowed patient’s perspective, distorting reality about loved ones. 3e. Allows patient opportunity to explore spiritual values and self-worth. Goal Met By fifth day, patient becomes tearful and states that he does not want to hurt his wife and daughter.

Answer 315

Dissociative disorders are a group of disorders precipitated by significant adverse experiences or traumas and resulting in the unconscious altering of mind–body connections. Dissociation is an unconscious defence mechanism that protects the individual against overwhelming anxiety and stress through an emotional separation; however, this separation results in disturbances in memory, consciousness, self-identity, and perception. Patients with dissociative disorders are able to assess a situation realistically, rather than for what they want it to be or fear that it might be. They do not have hallucinations or delusions (meaning that they have “intact reality testing”), but they may have flashbacks or see images that are triggered by current events that are related to the past trauma. Mild, fleeting dissociative experiences are relatively common to all of us; for example, we may be listening to someone and suddenly realize that we have not heard part or all of what was said. These common experiences are distinctly different from the processes of pathological dissociation. Pathological dissociation is involuntary and results in failure of control over one’s mental processes and the integration of conscious awareness. With pathological dissociation, pieces of a memory become fragmented. For example, normally, when people remember an experience, they can recall the people who were there, maybe a significant smell (like cooking turkey), maybe singing, and maybe an uncle who wore a bright red suit. However, when memories become fragmented, as in pathological dissociation, a person may re- call a sound or smell but not be able to link these sensations to the actual event, instead feeling as though there is something familiar about the smell or sound but not knowing why. If the pieces of memory are associated with a traumatic experience, the fragments can leave the person fearful, confused, or both. If the memory was very traumatic, the fragments may cause the person to re-enact, as well as re-experience, trauma without consciously knowing why. Symptoms of dissociation may be either positive or negative. Positive symptoms refer to unwanted additions to mental activity, such as flashbacks; negative symptoms refer to deficits, such as memory problems or the inability to sense or control different parts of the body. It is thought that dissociation decreases the immediate subjective distress of the trauma (a self-protective mechanism) and also continues to protect the individual from full awareness of the disturbing event. All of the dissociative disorders affect both the patient and the patient’s family. For example, people with depersonalization disorder are often fearful that others may perceive their appearance as distorted and may avoid being seen in public. If they exhibit consistently high levels of anxiety, the family is likely to find it difficult to keep relationships stable. By comparison, people who experience fugue states often function adequately in their new identities by choosing simple, undemanding occupations, and having few intimate social interactions. Patients with amnesia, in contrast to those with fugue, may be more dysfunctional. Their perplexity often renders them unable to work, and their memory loss impairs normal relationships. Families often direct considerable attention toward the patient but may exhibit concern over having to assume roles that were once assigned to the patient. Finally, patients with dissociative identity disorder (DID) often have both family and work problems. Families find it difficult to accept the seemingly erratic behaviours of the patient. Employers dislike the lost time that may occur when alternate identities are in control.

Answer 316

Depersonalization/derealization disorder may cause a person to feel mechanical, dreamy, or detached from the body. Some people suffer episodes of these problems that come and go, while others have episodes that begin with stressors and eventually become constant. People with this disorder may experience episodes of depersonalization or de- realization or both. When experiencing depersonalization, individuals feel as though they are observers of their own body or mental process- es—there is an internal feeling of disconnect. Similarly, with derealization, there is a recurring feeling that one’s surroundings are unreal or distant—an external or outside feeling of disconnect. These feelings are not consciously controlled by the patients with dissociative disorders and are reported to be very distressing to those who experience them.

Answer 317

Dissociative amnesia is marked by the inability to recall important autobiographical information, often of a traumatic or stressful nature, that is too pervasive to be explained by ordinary forgetfulness. While autobiographical memory is available (i.e., stored within the brain), the information is not accessible (i.e., the memory cannot be retrieved). When memories are stored, information about the situation (retrieval cues) is also stored. This additional information can be about the envi- ronment (smell, place, colour) or about a feeling (happy, sad, mad) or about an activity at the time (walking, crying, sitting, studying). Seeing or thinking about these retrieval cues helps us recall the memory. For example, have you ever got up from watching television and gone into the kitchen to do something but then forgotten what you were going to do once you got to the kitchen? But then you go back and sit down in front of the television and you remember? You have just accessed a memory using a retrieval cue. In contrast, a patient with generalized amnesia is unable to recall information about their entire lifetime. The generalized amnesia may be localized (the patient is unable to remember all events in a certain period) or selective (the patient is able to recall some but not all events in a certain period). For the person with generalized amnesia, the in- formation is neither available nor accessible, contrary to dissociative amnesia. A subtype of dissociative amnesia, also usually precipitated by a traumatic event, is dissociative fugue. This disorder is characterized by sudden, unexpected travel away from the customary locale and an in- ability to recall one’s identity and information about some or all of the past. The word fugue comes from the Latin word for flight. In rare cases, an individual with dissociative fugue assumes a whole new identity. During a fugue state (individuals are in a different location, unable to recall personal information about themselves or their past), individuals show no signs of illness and tend to lead rather simple lives, rarely call- ing attention to themselves. Only the memories tied to their identities are lost. If the person experiencing the fugue state knows how to drive, use the computer, make meals, and use a public transit system, they retain that knowledge. After a few weeks to a few months, the person may become confused about their identity or remember the former identity and then become amnesic for the time spent in the fugue state.

Answer 318

The essential feature of DID is the presence of two or more distinct personality states that alternately and recurrently take control of behaviour. It is believed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to the development of DID. Each alternate personality (alter), or subpersonality, has its own pattern of perceiving, relating to, and thinking about the self and the environment. Each alter is a complex unit with its own memories, behaviour patterns, and social relationships that dictate how the person acts when that personality is dominant. If the original or primary personality is religious and moralistic, the subpersonality or subpersonalities are often pleasure seeking and nonconforming. The alters may also behave as individuals of a different sex, race, or religion. DID appears to be associated with two dissociative identity states (alternate personalities): (1) a state in which the individual blocks ac- cess and responses to traumatic memories so as to be able to function daily and (2) a state fixated on traumatic memories. The primary personality, or host, is usually not aware of the subpersonalities and is perplexed by lost time and unexplained events. Experiences such as finding unfamiliar clothing in the closet, being called a different name by a stranger, and not having childhood memories are characteristic of DID. Subpersonalities are often aware of the existence of each other to some degree. Transition from one personality to another occurs during times of stress and may range from a dramatic to a barely noticeable event. Some patients experience the transition when awakening. Shifts may last from minutes to months, although shorter periods are more common.

Answer 319

Although mental health care providers in Canada believe that dissociative disorders are rare, depersonalization disorder prevalence rates range from about 1% to 3%, which is comparable to disorders such as schizophrenia, bipolar disorder, and OCD. More recently the international general population prevalence rates are estimated to be between 9% and 18%.

Answer 320

Psychiatric comorbidities are extremely common for people with dissociative disorders. Patients with dissociative disorders usually seek treatment for another problem such as anxiety, mood dysregulation, or substance use issues.

Answer 321

There is no longer any doubt that biological factors predispose some individuals to develop pathological emotional and mental states (e.g., generalized anxiety, phobias, panic attacks, dissociation, somatization). However, traumatic life events, psychological factors, and sociocultural factors are also etiologically significant for all the disorders identified in this chapter. Regardless of the age at which symptoms start, their purpose is to reduce disturbing feelings and protect the person from the effects of the trauma.

Answer 322

Numerous studies substantiate that anxiety disorders tend to cluster in families. Twin studies demonstrate the existence of a genetic component to anxiety disorders. First-degree biological relatives of those with OCD or phobias have a higher frequency of these disorders than exists in the general population, and relatives of people with a SSD are more likely to have persistent pain, depressive disorder, and alcohol dependence. Although genetic variability is thought to play a role in stress reactivity, dissociation is thought to be largely due to extreme stress or environmental factors.

Answer 323

Certain anatomical pathways in the midbrain (the limbic system) pro- vide the transmission structure for the electrical impulses that occur when anxiety-related responses are sent or received. Neurons release chemicals (neurotransmitters) that convey these messages. The neu- rochemicals that regulate anxiety-related disorders include epineph- rine, norepinephrine, dopamine, serotonin, gamma-aminobutyric acid (GABA), and endogenous opioids. Repeated trauma or stress not only alters the release of neurotransmitters but also changes the anatomy of the brain. Animal studies show that early, prolonged emotional detachment from the caretaker negatively affects the development of the limbic system, which is where traumatic memories are processed; therefore trauma negatively interferes with the normal development of the limbic system. Patients with PTSD have a malfunctioning hypothalamic–pituitary–adrenal system. Individuals with dissociative disorders have increased activation of the orbital frontal cortex, which inhibits activation of the amygdala and insular cortex as well as the hippocampal areas, where traumatic memories are stored. Any abnormality in the structure of the brain or the function of the neurotransmitters can lead to a misinterpretation of ordinary events. For example, the brain may misunderstand (or amplify the significance of) a stimulus, such as identifying a minor gas pain as a serious abdominal injury (somatization). The brain may also over-react in its analysis of the stimulus, deciding that the same minor gas pain is a sign of colon cancer (illness anxiety) and then hoping that death comes quickly.

Answer 324

Psychodynamic theories about the development of anxiety disorders centre on the idea that unconscious childhood conflicts are the basis for symptom development. Sigmund Freud suggested that anxiety results from the threatened breakthrough of repressed ideas or emotions from the unconscious into consciousness. Freud also suggested that the individual uses ego defence mechanisms to keep anxiety at manage- able levels. The use of defence mechanisms results in behaviour that is not wholly adaptive because of its rigidity and repetitive nature. Harry Stack Sullivan (1953) believed that anxiety is linked to the emotional distress caused when early needs go unmet or disapproval is experienced (interpersonal theory). He also suggested that anxiety is “contagious,” being transmitted to the infant from the mother or care- giver. Thus the anxiety experienced early in life becomes the prototype for anxiety experienced when unpleasant events occur later in life. Since the late nineteenth century, psychoanalytic theory has domi- nated medical thinking about conversion disorder. Nurses using this approach to guide treatment modalities frame the psychosomatic com- plaints of pain, illness, or loss of physical function within the context of the individual repressing a conflict or unwelcome experiences (usually of an aggressive or sexual nature) and that the transformation of anxiety into a physical symptom is symbolically related to the conflict. For example, in conversion disorder, conversion symptoms permit the individual to communicate a need for special treatment or consideration from others. There are two primary schools of thought that guide the treatment of illness anxiety disorder. The first has psychodynamic origins. Nurses using this perspective will view anger, aggression, or hostility as an expression of a need for help as a result of past losses or disappointments. Those nurses who work with a psychoanalytic worldview will see ill- ness anxiety as a defence against guilt or low self-esteem. Patients may themselves interpret their somatic symptoms as a form of punishment. Behavioural Theory Behavioural theories suggest that anxiety is a learned response to spe- cific environmental stimuli (classical conditioning). Anxiety may also be learnt through the modelling of parents or peers. For example, a mother who is fearful of thunder and lightning and hides in closets during storms may transmit her anxiety to her children, who adopt her behaviour into adulthood. Such individuals can unlearn this behaviour by observing others who react normally to a storm, perhaps by lighting candles and telling stories. Behaviourists suggest that people with somatic symptoms learn methods of communicating helplessness. These “helpless” behaviours are used to get their needs met. The symptoms become more intense when they are reinforced by attention from others. Behaviourists also identify potential secondary gains from many disorders. Secondary gains are those benefits derived from the symptoms alone; for exam- ple, in the sick role, the patient is not able to perform the usual fam- ily, work, and social functions and receives extra attention from loved ones. Other potential benefits include avoiding activities the individual considers distasteful, obtaining financial benefit, and gaining some ad- vantage in interpersonal relationships due to the symptom. Cognitive Theory Cognitive theorists believe that anxiety disorders are caused by distortions in an individual’s thoughts and perceptions. Because in- dividuals with such distortions may believe that any mistake will have catastrophic results, they experience acute anxiety. In contrast, patients with somatic symptoms focus on body sensations, misinterpret their meaning, and then become excessively alarmed by them. Learning Theory Dissociation is one of the most primitive ego defence mechanisms. The pattern of avoidance occurs when an individual deals with an un- pleasant event by consciously deciding not to think about it. The more anxiety provoking the event is, the greater is the need to avoid thinking about it. As the individual increasingly depends on this coping strategy, dissociation becomes easier, and it becomes more likely that this de- fence mechanism will be the individual’s predominant means of react- ing to stress. Thus learning theory suggests that dissociative disorders can be explained as learned methods for avoiding stress and anxiety.

Answer 325

The environmental factors related to a person developing an anxiety- related disorder are exposures to traumatic events, including any experience that is overwhelming to the person, such as a motor vehicle accident, combat experience, emotional or verbal abuse, incest, neglectful or abusive caregivers, and imprisonment. Experiencing adverse childhood events can result in lifelong problems, including PTSD, anxiety disorders, dissociative disorders, and somatic disorders. The Adverse Childhood Experiences (ACE) Study surveyed more than 16000 adults and discovered that childhood trauma exposure ac- counted for negative outcomes across a variety of diagnoses in later life, including multiple somatic symptoms of diabetes, heart disease, cancer, gastrointestinal conditions, and immune functioning.

Answer 326

Reliable data on the incidence of anxiety disorders are sparse, but sociocultural variation in symptoms of anxiety disorders has been noted. In some cultures most individuals express anxiety through somatic symptoms, whereas in other cultures, cognitive symptoms predominate. Panic attacks in Latin Americans and Northern Euro- peans often involve sensations of choking, smothering, numbness, or tingling, as well as fear of dying. In some other cultural groupspanic attacks involve fear of magic or witchcraft. Physical symp- toms are believed to result from the casting of spells. Spellbound individuals often seek the help of traditional healers in addition to modern medical staff. The medical health care provider may diag- nose a non–life-threatening SSD, whereas the traditional healer may offer an entirely different explanation and prognosis. The individual might not show improvement until the traditional healer removes the spell. The type and frequency of psychosomatic symptoms vary across cultures as well. The sensation of burning hands and feet, worms in the head, or ants under the skin is more common in Africa and southern Asia than in North America. Fainting is a symptom commonly associated with culture-specific religious and healing rituals. SSD, which is rarely seen in men in North America, is often report- ed in Greek and Puerto Rican men, suggesting that cultural customs permit these men to somatize as an acceptable approach to dealing with life stress. Somatization related to post-traumatic stress and depression was the most prevalent psychiatric symptom in North Korean defectors to South Korea. West Indians (Caribbean) attribute somatic symptoms to chronic overwork and the irregularity of daily living, citing symptoms such as dizziness, fatigue, joint pain, and muscle tension.

Answer 327

Up to 175 culture-bound syndromes have been identified. Culture- bound syndromes express distress about a range of personal and social problems in a culture and do not necessarily indicate psychopathology (e.g., heat in the head, heart-squeezed, bored). Some, such as trance, possession states, and fainting or seizure-like episodes, may in Western thinking be assessed as pathological (e.g., delusions or hallucinations) but are accepted expressions of distress in other cultures. In addition, cultural idioms of distress encompass explanatory mechanisms for behaviours or symptoms (e.g., evil eye, witchcraft, extreme emotion that upsets hot–cold balance). Rather than listing various culture-bound syndromes, the DSM-5 provides a cultural formulation interview guide to help mental health practitioners assess information about the cultural features of an indi- vidual’s mental health, history, and social context. Nurses need to show acceptance of and respect for culture-bound syndromes. However, showing acceptance and respect does not mean that the patient is not offered antipsychotics or other medications. Depending on the results of a thorough assessment, medication may be used to help alleviate a patient’s distress.

Answer 328

Understanding culture is not as easy as it sounds. Cultural safety begins with respect for others, humility, and self awareness. Ask yourself: what are my personal beliefs, values, and biases. We all have biases. Some that we are aware of and others to which we are blinded. * Think about the assumptions you make about your friends, peers, people you work with, and strangers. What assumptions do you make? * Be curious and open-minded about other cultures. Do some research; check out on-line resources, attend local food and cultural festivals, or maybe reach out and connect with an international pen pal. * Be open to cultural experiences.

Answer 329

People with anxiety disorders rarely need hospitalization unless they are in extreme distress, suicidal, or have compulsions that cause in- jury (e.g., cutting self, banging a body part). When assessing any pa- tient, it is essential that all aspects of patient safety are considered. Most patients prone to anxiety disorders are encountered in non– mental health settings. A common example is someone taken to an emergency department to rule out a heart attack when, in fact, the individual is experiencing a panic attack. It is essential for clinicians to determine whether the anxiety is secondary to another source (medical condition or substance) or is the primary problem, as in an anxiety disorder.

Answer 330

The Hamilton Anxiety Rating Scale is a popular tool for measuring anxiety. High scores may indicate GAD or PD, although it is important to note that high anxiety scores may also be a symptom of major depressive disorder. Keep in mind that although the Hamilton Anxiety Rating Scale highlights important areas in the assessment of anxiety, it is intended for use by experi- enced clinicians as a guide for planning care and not as a method of self-diagnosis. Goodman et al. (1989) developed the Yale-Brown Obsessive Compulsive Scale (YBOCS). The YBOCS has become the preferred measurement tool for OCD. It is important to note that the YBOCS is not a diagnostic tool. Rather, it is a scale used to gauge the severity and nature of OCD symptoms. Foa and colleagues (1998) developed the Obsessive- Compulsive Inventory (OCI) with the following subscales: washing, checking, doubting, ordering, obsessions, hoarding, and neutralizing. The Panic Disorder Severity Scale (PDSS) is a clinician-administered questionnaire developed to measure the severity of panic disorder and to monitor treatment outcome. The PDSS consists of seven items: panic frequency, distress during panic, panic-focused anticipatory anxiety, phobic avoidance of situations, phobic avoidance of physical sensations, impairment in work functioning, and impairment in social functioning. A useful assessment tool to understand the degree of somatization is the Patient Health Questionnaire–15 (PHQ), a somatic symptom severity scale for the purpose of diagnosis (Figure 12.2). The questionnaire inquires about 15 somatic symptoms (stomach pain, back pain, headache, chest pain, dizziness, fainting, palpitations, short- ness of breath, bowel complaints, nausea, fatigue, sleep problems, pain in joints or limbs, menstrual pain, and problems during sexual intercourse) that account for more than 90% of physical complaints reported in the primary care setting by asking patients to rate the severity of symptoms during the previous 4 weeks on a three-point scale (Korber et al., 2011). In addition, information should be sought about the patient’s ability to meet their own basic needs. Rest, com- fort, activity, and hygiene needs may be altered as a result of patient problems such as fatigue, weakness, insomnia, muscle tension, pain, and avoidance of diversional activities (hobbies). Safety and security needs may be threatened by patient experiences of blindness, deaf- ness, loss of balance, and anaesthesia of various parts of the body. During assessment, it is important to determine whether symptoms are under the patient’s voluntary control. Somatic symptoms are not under the individual’s voluntary control. Although the relationship between symptoms and interpersonal conflicts may be obvious to others, the patient is not aware of it. For a diagnosis of a dissociative dis- order to be made, other medical and neurological illnesses, substance use, and other coexisting (comorbid) psychiatric disorders must be ruled out as the cause of the patient’s symptoms. Specific information about identity, memory, consciousness, life events, mood, suicide risk, and the impact of the disorder on the patient and the family is im- portant to assess. The assessment should include objective data from physical examination, electroencephalography, imaging studies, and specific questions to identify dissociative symptoms. Assessment tools are important because a psychiatric interview will often miss the pres- ence of dissociation because the individual does not know what they do not know; that is, by definition, dissociative periods involve lapses of memory of which the person may not even be aware.

Answer 331

1. Ensure that a sound physical and neurological examination is performed to help determine whether the anxiety is primary or secondary to another psychiatric disorder, medical condition, or substance use. 2. Assess for substance use (i.e., prescription and nonprescription medication, alcohol consumption, nicotine and caffeine consumption). 3. Determine current level of anxiety (mild, moderate, severe, or panic). 4. Assess for potential for self-harm and suicide; people suffering from high levels of intractable anxiety may become desperate and attempt suicide. 5. Perform a psychosocial assessment. Always ask the person, “What is going on in your life that may be contributing to your anxiety?” The patient may identify a problem that should be addressed by counselling (e.g., stressful marriage, recent loss, stressful job or school situation). 6. Remember that culture can affect how anxiety is manifested.

Answer 332

1. Assess for nature, location, onset, characteristics, and duration of the symptom(s). 2. Assess the patient’s ability to meet basic needs. 3. Assess risks to the safety and security needs of the patient as a result of the symptom(s). 4. Determine whether the symptoms are under the patient’s voluntary control. 5. Identify any secondary gains the patient is experiencing from symptom(s). 6. Explore the patient’s cognitive style and ability to communicate feelings and needs. 7. Assess the type and amount of medication the patient is using.

Answer 333

1. Assess identity and memory. a. Assess for signs of dissociation. * Can you remember recent and past events? * Is your memory clear and complete or partial and fuzzy? * Are you aware of gaps in memory (e.g., lack of memory for events such as a graduation or a wedding)? * Do your memories place you with a family, in school, or in an occupa- tion? * Do you ever lose time or have blackouts? * Do you find yourself in places with no idea how you got there? b. Assess for a history of a similar episode in the past with benign out- comes. * Have you ever found yourself wearing clothes you cannot remember buying? * Have you ever had strange people greet and talk to you as though they were old friends? * Does your ability to engage in things such as athletics, artistic activi- ties, or mechanical tasks seem to change? * Do you have differing sets of memories about childhood? 2. Determine if there are comorbid medical conditions. * Have you sustained a recent injury, such as a concussion? * Do you have a history of epilepsy, especially temporal lobe epilepsy? 3. Establish whether the person suffered abuse, trauma, or loss as a child. 4. Evaluate mood and level of anxiety. 5. Identify support systems through a psychosocial assessment. 6. Identify relevant psychosocial distress issues by performing a basic psycho- social assessment. 7. Assess for safety of self and others.

Answer 334

Psychosocial factors are relevant to anxiety-related symptoms, and the way a patient thinks and feels can have a profound effect on recovery. For example, strong emotions such as fear, anger, sadness, confusion, and guilt can affect a patient’s physical, emotional, and spiritual recov- ery. Patients may feel overwhelmed and alone, and friends and family members may feel helpless and at a loss emotionally. Thus the nurse must complete a psychosocial assessment in tandem with a thorough physical workup and mental status examination (Table 12.10). Coping skills. Assessing how a patient has dealt with adversity in the past provides information about the availability of coping skills. Health care workers can also support the patient in gaining additional coping skills that may help them better manage. Spirituality and religion. Nurses and other health care workers are becoming increasingly aware of the role spirituality or religion plays in many patients’ lives and its importance as a source of peace. Sup- port from a priest, pastor, rabbi, imam, or other religious leader may be indicated, especially in a case of spiritual distress. Religious beliefs and practices are forces that can promote resilience. Practising healthy cop- ing depends on the capacity to create meaning from life experiences. Secondary gains. The nurse should try to identify secondary gains the patient may be receiving from the symptoms. If a patient derives personal benefit from the symptoms, giving up the symptoms is more difficult unless the patient can achieve the same benefits through healthier avenues, such as learning to communicate more adaptively and to connect with others; skills the clinician can help the patient learn. One approach to identifying the presence of secondary gains is to ask the patient questions such as: * What are you unable to do now that you used to be able to do? * How has this problem affected your life?

Answer 335

As a nurse working with an individual with an anxiety-related disorder, you may experience uncomfortable personal reactions. You may have feelings of frustration or anger while working with a patient, especially if the symptoms seem to be a matter of choice or under personal control. For example, the rituals of the patient with OCD may hinder Communicating with such patients can be difficult since patients with a phobia may acknowledge that the fear is exaggerated and unrealistic yet continue to practise avoidant behaviour, which may bewilder the nurse. It is natural for nurses to experience feelings of scepticism while caring for patients who are diagnosed with dissociative disorders. Be- lieving in the authenticity of the symptoms the patient is displaying can be difficult and feeling confused and bewildered by the presence of dissociative symptoms is not unusual. Some nurses even experience feelings of fascination and get caught up in the intrigue of caring for a patient with dissociative symptoms. Unlike the patient who just needs a dressing changed several times a week, the patient with an anxiety-related disorder requires “emo- tional bandaging” much more often, and behavioural change is often accomplished slowly. When rapid progress is not made, nurses can become impatient. Most people with dissociative disorders have ex- perienced a significant trauma or have been in relationships in which trust was betrayed. As a result, developing a therapeutic relationship with these patients can be a slower process than with patients who have other mental illnesses. Nurses may therefore feel inadequate and frustrated by their efforts. At the very least, they are likely to experi- ence increased tension and fatigue from mental strain. They may also feel anger or frustration and, as a consequence, may withdraw from the patient emotionally and physically. Such negative feelings are eas- ily transmitted to the patient, who then feels increasingly anxious and may also withdraw. Therefore patience, the ability to provide clear structure, and em- pathy are important assets when working with patients with anxiety and related disorders. Staging outcomes in small, attainable steps can help prevent the nurse from feeling overwhelmed by the patient’s slow progress and help the patient gain a sense of control. By having a clear understanding of the emotional pitfalls of working with patients who have anxiety and related disorders, a nurse is better prepared to minimize and avoid the guilt associated with strong nega- tive feelings. It is important, then, to examine your personal feelings so you can better understand their origin and respond objectively and constructively.

Answer 336

Many nursing diagnoses can be considered for patients experiencing anxiety and anxiety-related disorders. The “related to” component will vary with the individual patient.

Answer 337

The Nursing Outcomes Classification (NOC) identifies desired out- comes for patients with anxiety or anxiety-related disorders (Moor- head et al., 2018). Each outcome contains a definition and rating scale to measure the severity of the symptom or the frequency of the desired response. This rating scale enables you to evaluate outcomes in the nursing care plan. Some of the NOC-recommended outcomes related to anxiety include Anxiety self-control, Anxiety level, Stress level, Cop- ing, Social interaction skills, and Symptom control. Refer to Table 12.14 for examples of intermediate and short-term indicators related to NOC outcomes. Because shared decision making promotes goal attainment, patients should participate in identifying desired outcomes. Outcome criteria must be realistic and attainable. Structuring outcomes in small steps helps the patient and the nurse see concrete evidence of progress. The following are examples of possible outcomes for a patient with a SSD (Ackley et al., 2017): * Patient will exhibit sensitivity to self-needs and needs of others. * Patient will resume performance of work, family, and social role be- haviours. * Patient will identify ineffective coping patterns. * Patient will make realistic appraisal of strengths and weaknesses. * Patient will assertively verbalize feelings such as anger, shame, or guilt.

Answer 338

Planning for the delivery of specific nursing care is influenced by both the setting (community or inpatients) and the presenting problem. A top priority stated in the report Changing Directions, Changing Lives: The Mental Health Strategy for Canada (Mental Health Com- mission of Canada, 2012) is to identify and integrate mental health needs into primary care settings. Anxiety disorders are encountered in all health care settings. Nurses care for people with co-existing anxiety disorders in medical–surgical units, as well as in homes, day programs, and clinics. Patients with anxiety disorders usually do not require admission to inpatient psychiatric units, so planning for their care may involve selecting interventions that can be implemented in a community setting. Whenever possible, the patient should be encouraged to participate actively in planning. By including the patient in decision making, you in- crease the likelihood of positive outcomes. Shared planning is especially appropriate for someone with mild or moderate anxiety. When experi- encing severe levels of anxiety, a patient may be unable to participate in planning, and the nurse may be required to take a more directive role. One of the many advantages of integrating mental health services into primary health care settings is less stigmatization of treatment for mental illness and of people with mental health disorders. Because pri- mary health care services are not associated with any specific health conditions, this level of care seems far more “acceptable,” and therefore accessible, for most users and families. Many primary care centres have psychiatric mental health nurses as part of the regular treatment team, as these nurses can bring a strong perspective in terms of managing both physical and mental health needs in integrated care settings. Establishing a therapeutic relationship is the first step in delivering effective nursing care. The following strategies can be used to build an effective therapeutic relationship. 1. Provide frequent, brief, and regular office visits. 2. Avoid making disparaging comments such as “Your symptoms are all in your head.” 3. Set reasonable therapeutic goals such as maintaining function despite ongoing pain. A phase-oriented treatment model is recommended for individuals with a dissociative disorder for any setting and includes (International Society for the Study of Trauma and Dissociation, 2012): Phase 1: Establishing safety, stabilization, and symptom reduction Phase 2: Confronting, working through, and integrating traumatic memories Phase 3: Integrating identity and rehabilitating The nurse will most often encounter the patient in times of crisis (i.e., when the patient is suicidal or expressing homicidal behaviour), and in times of crisis the care plan will focus on Phase 1 strategies to ensure safety and crisis intervention. Basic nursing interventions should be implemented. Phases 2 and 3 are advanced interventions, so clinicians using these interventions require special training.

Answer 339

Concern that a panic attack will occur Exposure to phobic object or situation Presence of obsessive thoughts Recurrent memories of traumatic event Fear of panic attacks Anxiety (moderate, severe, panic) Fear ____ High levels of anxiety that interfere with the ability to work, disrupt relationships, and change ability to interact with others Avoidance behaviours (phobia, agoraphobia) Hypervigilance after a traumatic event Inordinate time taken for obsession and compulsions Inadequate coping Reduced diversional activity Social isolation Inadequate role performance _____ Difficulty with concentration Preoccupation with obsessive thoughts Disorganization associated with exposure to phobic object Inadequate health maintenance _______ Intrusive thoughts and memories of traumatic event Post-trauma syndrome _______ Excessive use of reason and logic associated with overcautiousness and fear of making a mistake Decisional conflict ________ Disruption in sleep related to intrusive thoughts, worrying, replaying of a traumatic event, hypervigilance, fear Insomnia Sleep deprivation Fatigue ______ Feelings of hopelessness, inability to control one’s life, low self-esteem related to inability to have some control in one’s life Hopelessness Chronic low self-esteem Spiritual distress _______ Inability to perform self-care related to rituals Self-care deficit ______ Skin excoriation related to rituals of excessive washing or excessive picking at the skin Reduced skin integrity ______ Inability to eat because of constant ritual performance Feeling of anxiety or excessive worrying that overrides appetite and the need to eat Imbalanced nutrition: less than body requirements _______ Excessive overeating to appease intense worrying or high anxiety levels Imbalanced nutrition: more than body requirements

Answer 340

Nursing Diagnoses Inability to meet occupational, family, or social responsibilities because of symptoms Inadequate coping ____ Inability to participate in usual community activities or friendships because of psychogenic symptoms Inadequate role performance Reduced social interaction _____ Dependence on pain relievers Powerlessness _____ Distortion of body functions and symptoms Disturbed body image ____ Presence of secondary gains by adoption of sick role Pain, acute or chronic _____ Inability to meet family role function and need for family to assume role function of the somatic individual Interrupted family processes Inadequate sexuality pattern ______ Assumption of some of the roles of the somatic parent by the children Inadequate parenting ______ Shifting of the sexual partner’s role to that of caregiver or parent and the patient’s role to that of recipient of care Risk for caregiver role strain ______ Feeling of inability to control symptoms or understand why they cannot find help Chronic low self-esteem ______ Development of negative self-evaluation related to losing body function, feeling useless, or not feeling valued by significant others Spiritual distress _______ Inability to take care of basic self-care needs related to conversion symptoms (paralysis, seizures, pain, fatigue) Inability to sleep due to psychogenic pain Self-care deficit Disturbed sleep pattern+++++

Answer 341

Amnesia or fugue related to a traumatic event Symptoms of depersonalization; feelings of unreality or body-image distortions Disturbed personal identity Disturbed body image ____ Alterations in consciousness, memory, or identity Use of substances related to dissociation Disorganization or dysfunction in usual patterns of behaviour (absence from work, withdrawal from relationships, changes in role function) Inadequate coping Inadequate role performance _____ Disturbances in memory and identity Interrupted family processes related to amnesia or erratic and changing behaviour Interrupted family processes Inadequate parenting _____ Feeling of being out of control of memory, behaviours, and awareness Inability to explain actions or behaviours when in altered state Anxiety Spiritual distress Potential for other- directed violence Potential for self- directed violence

Answer 342

When working with patients with anxiety disorders, you must first determine what level of distress they are experiencing. A general frame- work for anxiety interventions can then be built on a solid foundation of understanding. Mild to moderate levels of anxiety. A person experiencing a mild to moderate level of anxiety is still able to solve problems; however, the ability to concentrate decreases as anxiety increases. A patient can be helped to focus and solve problems when you use specific nursing com- munication techniques, such as asking open-ended questions, giving broad openings, and exploring and seeking clarification. Closing off topics of communication and bringing up irrelevant topics can increase a person’s anxiety, making the nurse, but not the patient, feel better. Reducing the patient’s anxiety level and preventing escalation to more distressing levels can be aided by providing a calm presence, recognizing the anxious person’s distress, and being willing to listen. Evaluation of effective past coping mechanisms is also useful. Often you can help the patient consider alternatives to problematic situations and offer activities that may temporarily relieve feelings of inner ten- sion. Table 12.15 identifies interventions useful in assisting people ex- periencing mild to moderate levels of anxiety. Severe to panic levels of anxiety. A person experiencing a severe to panic level of anxiety is unable to solve problems and may have a poor grasp of what is happening in the environment. Unproductive re- lief behaviours may take over, and the person may not be in control of their actions. Extreme regression and aimless running about are behav- ioural manifestations of a person’s intense psychic pain. Appropriate nursing interventions are to provide for the safety of the patient and others and to meet physical needs (e.g., fluids, rest) to prevent exhaustion. Anxiety reduction measures may take the form of removing the person to a quiet environment (seclusion room) with minimal stimulation and providing gross motor activities to drain some of the tension. The use of medications may have to be consid- ered, but both medications and a seclusion room should be used only after other more personal and less restrictive interventions have failed to decrease anxiety to safer levels. Although a patient’s communication may be scattered and disjointed, feeling understood can reduce anxiety and decrease the overwhelming sense of isolation. Because individuals experiencing severe to panic levels of anxiety are unable to solve problems, the techniques suggested for communi- cating with people with mild to moderate levels of anxiety may not be effective at more severe levels. These patients are out of control, so they need to know they are safe from their own impulses. Firm, short, and simple statements are useful. Reinforcing what is observable in the en- vironment (e.g., the door, the painting) and pointing out reality when there are distortions can also be useful interventions for severely anx- ious people. Table 12.16 suggests some basic nursing interventions for patients with severe to panic levels of anxiety. Anxiety management and reduction are primary concerns when working with patients who have anxiety disorders, but these patients may have a variety of other needs as well. When developing a plan of care, psychiatric mental health nurses can refer to the appropriate stan- dards of practice for their governing body. The Nursing Interventions Classification (NIC) offers pertinent interventions in the behavioural and safety domains (Butcher et al., 2019) (Box 12.1). The following are basic nursing interventions: 1. Identify community resources that can offer the patient special- ized, effective treatment. 2. Identify community support groups for people with specific anxiety disorders and their families. 3. Use counselling, milieu therapy, promotion of self-care activi- ties, and psychobiological and health teaching interventions as appropriate.

Answer 343

Intervention & Rationale Help the patient identify anxiety: “Are you comfortable right now?” It is important to validate observations with the patient, name the anxiety, and start to work with the patient to lower anxiety. Anticipate anxiety-provoking situations. Escalation of anxiety to a more disorganizing level is prevented. Use nonverbal language to demonstrate interest (e.g., lean forward, maintain eye contact, nod your head). Verbal and nonverbal messages should be consistent. The presence of an interested person provides a stabilizing focus. Encourage the patient to talk about their feelings and concerns. When concerns are stated aloud, problems can be discussed, and feelings of isolation decreased. Avoid closing off avenues of communication that are important for the patient. Focus on the patient’s concerns. When staff anxiety increases, changing the topic or offering advice is a common temptation, but this action isolates the patient. Ask questions to clarify what is being said: “I’m not sure what you mean. Give me an example.” Increased anxiety results in scattering of thoughts. Clarifying helps the patient identify thoughts and feelings. Help the patient identify thoughts or feelings before the onset of anxiety. “What were you thinking right before you started to feel anxious?” The patient is assisted in identifying thoughts and feelings, and problem solving is facilitated. Encourage problem solving with the patient.a Encouraging patients to explore alternatives increases sense of control and decreases anxiety. Assist in developing alternative solutions to a problem through role-play or modelling behaviours. The patient is encouraged to try out alternative behaviours and solutions. Explore behaviours that have worked to relieve anxiety in the past. The patient is encouraged to mobilize successful coping mechanisms and strengths. Provide outlets for working off excess energy (e.g., walking, playing Ping-Pong, dancing, exercising). Physical activity can provide relief of built-up tension, increase muscle tone, and increase endorphin levels.

Answer 344

Intervention & Rationale Maintain a calm manner. Anxiety is communicated interpersonally. The quiet calmness of the nurse can serve to calm the patient. The presence of anxiety can escalate anxiety in the patient. Always remain with the person experiencing an acute severe to panic level of anxiety. Alone with immense anxiety, a person feels abandoned. A caring face may be the patient’s only contact with reality when confusion becomes overwhelming. Minimize environmental stimuli. Move to a quieter setting and stay with the patient. A quieter setting helps minimize further escalation of anxiety. Use clear and simple statements and repetition. A person experiencing a severe to panic level of anxiety has difficulty concentrating and processing information. Use a low-pitched voice; speak slowly. A high-pitched voice can convey anxiety. A low pitch can decrease anxiety. Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present). Anxiety can be reduced by focusing on and validating what is going on in the environment. Listen for themes in communication. In severe to panic levels of anxiety, verbal communication themes may be the only indication of the patient’s thoughts or feelings. Attend to physical and safety needs (e.g., warmth, fluids, elimination, pain relief, family contact) when necessary. High levels of anxiety may obscure the patient’s awareness of physical needs. Because safety is an overall goal, physical limits may need to be set. Speak in a firm, authoritative voice: “You may not hit anyone here. If you can’t control yourself, we will help you.” A person who is out of control is often terrorized. Staff must offer the patient and others protection from destructive and self-destructive impulses. Provide opportunities for exercise (e.g., walk with nurse, punching bag, Ping- Pong game). Physical activity helps channel and dissipate tension and may temporarily lower anxiety. When a person is constantly moving or pacing, offer high-calorie fluids. Dehydration and exhaustion must be prevented. Assess need for medication or seclusion after other interventions have been tried but have not been successful. Exhaustion and physical harm to self and others must be prevented.

Answer 345

Definition of coping enhancement: Assistance provided to a patient in adapt- ing to perceived stressors, changes, or threats that interfere with meeting life demands and roles. Activitiesa * Provide an atmosphere of acceptance. * Encourage verbalization of feelings, perceptions, and fears. * Acknowledge the patient’s spiritual or cultural background. * Discourage decision making when the patient is under severe stress. Hope Inspiration Definition of hope inspiration: Enhancement of the belief in one’s capacity to initiate and sustain actions. Activitiesa * Assist the patient to identify areas of hope in life. * Demonstrate hope by recognizing the patient’s intrinsic worth and viewing the patient’s illness as only one facet of the individual. * Avoid masking the truth. * Help the patient expand the spiritual self. Self-Esteem Enhancement Definition of self-esteem enhancement: Assistance provided to a patient in in- creasing their personal judgement of self-worth. Activitiesa * Make positive statements about the patient. * Monitor frequency of self-negating verbalizations. * Explore previous achievements. * Explore reasons for self-criticism or guilt. Relaxation Therapy Definition of relaxation therapy: The use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety. Activitiesa * Demonstrate and practise the relaxation technique with the patient. * Provide written information about preparing and engaging in relaxation tech- niques. * Anticipate the need for the use of relaxation. * Evaluate and document the response to relaxation therapy.

Answer 346

People who have distressing symptoms are vulnerable to a variety of psy- chosocial stresses. How they cope with these stresses may make the dif- ference between living with an acceptable quality of life and experiencing despair, withdrawal, helplessness, hopelessness, and suicidal ideation. Nurses are in a position to assess and understand patients’ psychosocial stressors, identify needed coping skills, and teach stress-management techniques. Nurses can play an important role not only in managing pa- tients’ immediate care but also in helping patients improve their ability to cope and increase their quality of life during the course of their illness. Effective coping skills that can be taught are many and varied (e.g., assertiveness training, cognitive reframing, problem-solving skills, so- cial supports). A nurse is in a key position to assess, educate, or provide referrals to a patient to enable healthier ways of looking at and dealing with illness. Consider referring the patient for instruction in relaxation techniques such as reiki, meditation, guided imagery, breathing exer- cises, and others, or teach the patient some techniques yourself. Behav- ioural techniques, such as progressive muscle relaxation and biofeedback (which nurses can get special training to perform), are also useful. Re- laxation techniques, stress-management skills, and supportive education should be part of patient care, regardless of the comorbid conditions. The following interventions have all been shown to positively affect a patient’s recovery: * Educating the patient about specific treatments * Referring the patient to community support groups (or systems) * Teaching patients more effective coping skills that take into consid- eration patients’ values, preferences, and lifestyle * Focusing on a patient’s strengths and reinforcing coping skills that work (e.g., prayerfulness, participation in hobbies, relaxation techniques) To be successful, therapeutic interventions must address patient needs. The primary goal is to help patients identify ways to get their needs met without using harmful defence mechanisms or having path- ological behaviour reinforced. The secondary gains derived from ill- ness behaviours become less important to the patient when underlying needs can be met directly. Table 12.17 provides basic-level interventions for SSD. Reattribution treatment, an advanced nursing treatment approach also used with the treatment of somatization (Box 12.2), helps toward this goal.

Answer 347

Psychiatric mental health nurses use counselling to reduce anxiety, enhance coping and communication skills, and intervene in crises. From a behaviourist perspective, when appropriate, relaxation train- ing would occur during the counselling session. The training would include teaching relaxation exercises used to relax breathing or muscle groups. The relaxation response is the opposite of the stress response and results in a reduced heart rate, slower breathing, and relaxed muscles. Refer to Chapter 5 for a description of different approaches to relaxation training. When psychiatric mental health nurses begin to practise from a cognitive therapy perspective, they will help patients identify that what they think is linked with what they feel.

Answer 348

Health teaching is a significant nursing intervention for patients with anxiety disorders. Patients may conceal symptoms for years be- fore seeking treatment and often come to the attention of health care providers because of a co-occurring problem. Three out of every five individuals with an anxiety disorder do not consult a health care pro- vider about their disorder (Public Health Agency of Canada, 2016). And those who do often wait years before getting medical attention. Teaching about the specific disorder and available effective treat- ments is a major step toward improving the quality of life for those with anxiety disorders. Whether in a community or hospital setting, nurses can teach patients about signs and symptoms of anxiety disorders, pre- sumed causes or risk factors (especially substance use), medications, the use of relaxation techniques, and the benefits of psychotherapy. When patients request or prefer to use integrative therapies, the nurse performs assessment and teaching as appropriate. Some patients who somatize as a way of coping with anxiety may benefit from education about body functions. The type and depth of teaching is determined by the information the patient already under- stands. Others may know extensively about their physical body. In these situations, the teaching would focus on accurately assessing and interpreting the body’s responses to digestion, stress, fatigue, and ex- citement. Stress management and coping skills are important areas of health education for people with dissociative disorders. Normalizing experi- ences by explaining that symptoms are adaptive responses to past over- whelming events is important. Often the victim of childhood trauma feels as if they are a bad person and grows up with the false negative belief that the abuse was deserved punishment. Another important intervention strategy is to teach grounding techniques that help the person focus on the present and help to coun- ter dissociative symptoms. Examples of grounding techniques include stomping one’s feet on the ground, taking a shower, holding an ice cube, exercising, breathing deeply, counting beads, and touching fabric or upholstery on a chair. Patients can also be taught to keep a daily journal to increase their awareness of feelings and to identify triggers of their dissociative symptoms. If a patient has never written a journal, the nurse should suggest beginning with 5 to 10 minutes of daily writing.

Answer 349

Offer explanations and support during diagnostic testing. Reduces anxiety while ruling out organic illness. ___ After physical complaints have been investigated, avoid further reinforcement (e.g., do not take vital signs each time patient complains of palpitations). Directs focus away from physical symptoms. ___ Spend time with patient at times other than when patient summons nurse to voice physical complaint. Rewards non–illness-related behaviours and encourages repetition of desired behaviour. ___ Observe and record frequency and intensity of somatic symptoms. (Patient or family can give information.) Establishes a baseline and later enables evaluation of effectiveness of interventions. ___ Do not imply that symptoms are not real. Acknowledges that psychogenic symptoms are real to the patient. ___ Shift focus from somatic complaints to feelings or to neutral topics. Conveys interest in patient as a person rather than in patient’s symptoms; reduces need to gain attention via symptoms. ___ Assess secondary gains “physical illness” provides for patient (e.g., attention, increased dependency, distraction from another problem). Allows these needs to be met in healthier ways and thus minimizes secondary gains. ___ Use matter-of-fact approach to patient exhibiting resistance or covert anger. Avoids power struggles; demonstrates acceptance of anger and permits discussion of angry feelings. ___ Have patient direct all requests to primary nurse. Reduces manipulation. ____ Help patient look at effect of illness behaviour on others. Encourages insight; can help improve family relationships. ___ Show concern for patient while avoiding fostering dependency needs. Shows respect for patient’s feelings while minimizing secondary gains from “illness.” ___ Reinforce patient’s strengths and problem-solving abilities. Contributes to positive self-esteem; helps patient realize that needs can be met without resorting to somatic symptoms. ___ Teach assertive communication. Provides patient with a positive means of getting needs; reduces feelings of helplessness and need for manipulation _____ Teach patient stress-reduction techniques, such as meditation, relaxation, and mild physical exercise. Provides alternative coping strategies; reduces need for medication.

Answer 350

Ensure patient safety by providing safe, protected environment and frequent observation. Patient’s sense of bewilderment may lead to inattention to safety needs ___ Provide undemanding, simple routine. Reduces anxiety ____ Confirm identity of patient and orientation to time and place. Supports reality and promotes ego integrity ___ Encourage patient to do things for self and make decisions about routine tasks. Enhances self-esteem by reducing sense of powerlessness and reduces secondary gain associated with dependence ____ Assist with other decision making until memory returns. Lowers stress and prevents patient from having to live with the consequences of unwise decisions ____ Support patient during exploration of feelings surrounding the stressful event. Helps lower the defence of dissociation used by patient to block awareness of the stressful event ___ Do not flood patient with data regarding past events. Memory loss serves the purpose of preventing severe to panic levels of anxiety from overtaking and disorganizing the individual ____ Allow patient to progress at own pace as memory is recovered. Prevents undue anxiety and resistance ___ Provide support during disclosure of painful experiences. Do not force the patient to disclose. Can be healing, while minimizing feelings of isolation Forced disclosure can retraumatize the patient _____ Help patients see consequences of using dissociation to cope with stress. Increases insight and helps patient understand own role in choosing behaviours ____ Accept patient’s expression of negative feelings. Conveys permission to have negative or unacceptable feelings ____ Teach stress-reduction methods. Provides alternatives for anxiety relief ____ If patient does not remember significant others, work with involved parties to re-establish relationships. Helps patient experience satisfaction and relieves sense of isolation

Answer 351

As mentioned earlier, most patients with anxiety disorders can be treated successfully as outpatients. Hospital admission is necessary only if severe anxiety or symptoms interfere with the individual’s health or if the individual is suicidal. When hospitalization is nec- essary, providing a safe environment is fundamental. Other charac- teristics of a therapeutic milieu that can be especially helpful to the patient are: * Structuring the daily routine to offer physical safety and predict- ability, thus reducing anxiety over the unknown * Providing daily activities to promote sharing and cooperation * Providing therapeutic interactions, including one-on-one nursing care and behaviour contracts * Including the patient in decisions about their own care

Answer 352

Patients with anxiety disorders are usually able to meet their own basic physical needs. Individuals with a SSD may require more assistance with self-care activities due to the physical limitations of their illness. Self-care activities that are most likely to be affected are discussed in the following sections. Nutrition and fluid intake. Patients who engage in ritualistic behav- iours may be too involved with their rituals to take time to eat and drink. Some phobic patients may be so afraid of germs, they cannot eat. In general, nutritious diets with snacks should be provided. Adequate intake should be firmly encouraged, but a power struggle should be avoided. Weighing patients frequently (e.g., three times a week) is use- ful in assessing whether nutrition needs are being met. Personal hygiene and grooming. Some patients, especially those with OCD and phobias, may be excessively neat and engage in time- consuming rituals associated with bathing and dressing. Hygiene, dressing, and grooming may take several hours. Maintenance of skin integrity may become a problem when the rituals involve excessive washing and skin becomes excoriated and infected. Some patients are indecisive about bathing or about what clothing should be worn. For the latter, limiting choices to two outfits is help- ful. In the event of severe indecisiveness, simply presenting the patient with the clothing to be worn may be necessary. You may also need to remain with the patient to give simple directions: “Put on your shirt. Now put on your slacks.” Matter-of-fact support is effective in assist- ing patients to perform as much of a task as possible independently. Encourage patients to express thoughts and feelings about self-care. This communication can provide a basis for later health teaching or for ongoing dialogue about the patient’s abilities. Elimination. Patients with OCD may be so involved with the per- formance of rituals that they may suppress the urge to void and def- ecate, sometimes resulting in constipation or urinary tract infections. Interventions may include creating a regular schedule for taking the patient to the bathroom. Sleep. Patientsexperiencinganxietyfrequentlyhavedifficultysleep- ing. They may perform rituals to the exclusion of resting and sleeping, causing physical exhaustion. Those with GAD, PTSD, and acute stress disorder often experience sleep disturbance from nightmares. Teaching patients ways to promote sleep (e.g., warm bath, warm milk, relaxing music) and monitoring sleep through a sleep record are useful interven- tions.

Answer 353

Several classes of medications have been found to be effective in the treatment of anxiety disorders. The Drug Treatment box identifies medi- cations approved by Health Canada for the treatment of anxiety, as well as medications that do not have specific approval but are commonly used “off-label” for anxiety-related disorders. Researchers are currently investigating the effectiveness of medica- tions for the treatment of SSDs. Medication trials with antidepressants (including serotonin–norepinephrine reuptake inhibitors [SNRIs], such as venlafaxine [Effexor XR] and duloxetine [Cymbalta], and a norad- renergic and specific serotonergic antidepressant, such as mirtazapine [Remeron], have been effective in reducing the somatic symptoms, but further controlled trials are needed to determine the most effective antidepressants. Patients may also benefit from short-term use of antianxiety medication, which must be moni- tored carefully because of the risk for dependence. There are no specific medications used to treat patients with dissociative disorders, but medications are often prescribed for the presenting symptoms. In the acute care setting intravenous benzodiazepines may be used to decrease intense anxiety; subsequently, the nurse may wit- ness dramatic memory retrieval in patients with dissociative amnesia or fugue. Other medications sometimes prescribed are antidepressants, anxiolytics, and antipsychotics. As is the case whenever medications are prescribed, substance use disorders and potential suicidal risk must be assessed carefully prior to selecting a safe and appropriate medication.

Answer 354

Antidepressants prescribed for anxiety have the secondary benefit of treating comorbid depressive disorders. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for acute stress disorders and PTSD (Schatzberg, 2017). Some of the SSRIs, however, exert more of an “activating” effect than others and therefore may increase anxiety. Sertraline (Zoloft) and paroxetine (Paxil) seem to have a more calming effect than do other SSRIs. SSRIs are preferable to the tricyclic antidepressants (TCAs) because they have a more rapid onset of action and fewer problematic adverse effects. Monoamine oxidase inhibitors (MAOIs) are reserved for treat- ment-resistant conditions because of the risk for life-threatening hy- pertensive crisis in patients who do not follow dietary restrictions (e.g., to not eat foods containing tyramine). The risk for hypertensive crisis also makes the use of MAOIs contraindicated in patients with comor- bid substance use.

Answer 355

Antianxietydrugs(alsocalledanxiolytics)areof- ten used to treat the somatic and psychological symptoms of anxiety dis- orders (Schatzberg, 2017). When moderate or severe anxiety is reduced, patients are better able to participate in treatment of any underlying problems. Benzodiazepines are most commonly used because they have a quick onset of action. However, due to the potential for dependence, these medications ideally should be used for short periods, only until other medications or treatments reduce symptoms. An important nurs- ing intervention is to monitor for adverse effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. Benzodi- azepines are not recommended for patients with a known substance use problem and should not be given during pregnancy or lactation. Buspirone (BuSpar) is an alternative antianxiety medication that does not cause dependence, but 2 to 4 weeks are required for it to reach full effect. The drug may be used for long-term treatment and should be taken regularly.

Answer 356

Antianxiety Medications 1. Caution the patient: * Not to increase dose or frequency of ingestion without prior approval of doctor * That these medications reduce the ability to handle mechanical equip- ment (e.g., cars, machinery) * Not to drink alcoholic beverages or take other antianxiety drugs, be- cause depressant effects of both would be potentiated * To avoid drinking beverages containing caffeine, because they decrease the desired effects of the drug 2. Recommend that the patient taking benzodiazepines avoid becoming preg- nant because these drugs increase the risk of congenital anomalies. 3. Advise the patient not to breastfeed while taking benzodiazepines because these drugs are excreted in the milk and would have adverse effects on the infant. 4. Teach a patient who is taking monoamine oxidase inhibitors the details of a tyramine-restricted diet. 5. Teach the patient that: * Cessation of benzodiazepines after 3 to 4 months of daily use may cause withdrawal symptoms such as insomnia, irritability, nervousness, dry mouth, tremors, convulsions, and confusion. * Medications should be taken with or shortly after meals or snacks to reduce gastrointestinal discomfort. * Drug interactions can occur: antacids may delay absorption; cimetidine interferes with metabolism of benzodiazepines, causing increased se- dation; central nervous system depressants, such as alcohol and barbi- turates, cause increased sedation; serum phenytoin concentration may build up because of decreased metabolism.

Answer 357

Other classes of medications some- times used to treat anxiety disorders include beta blockers, antihista- mines, and anticonvulsants. These agents are often added if the first course of treatment is ineffective. Beta blockers block the nerves that stimulate the heart to beat faster and have been used to treat SAD. An- ticonvulsants have shown some benefit in the management of GAD, PD, PTSD, and SAD (Schatzberg, 2017). Antihistamines are a safe, nonaddictive alternative to benzodiazepines to lower anxiety levels, and again are helpful in treating patients with substance use problems. Another therapeutic strategy may come in a most unusual form: D-cycloserine, an antibiotic used to treat tuberculosis, has also been demonstrated to enhance learning. D-cycloserine binds with N-methyl-D- aspartate (NMDA) receptors in the amygdala, the area of the brain that mediates fears and phobic responses, and may help patients unlearn fear responses more quickly. Administering this drug to a patient un- dergoing cognitive behavioural therapy (CBT) actually promotes fear extinction, not just fear conditioning, in phobic individuals. It has also been useful when combined with extinction-based exposure therapy in the treatment of OCD and SAD (Rodrigues et al., 2014).

Answer 358

Chapter 35 identifies a number of complementary practices or integra- tive therapies that people use to cope with stress in their lives. Herbal and complementary therapy is popular in Canada; however, herbs and dietary supplements are not subject to the same rigorous testing as prescription medications. Also, herbs and dietary supplements are not required to be uniform, and there is no guaranteed bioequivalence of the active compound among preparations. Problems that can occur with the use of psychotropic herbs include toxic adverse effects and herb–drug interactions. Nurses and other health care providers do well to improve their knowledge of these products so that discussions with their patients provide informed and reliable information. The Integrative Therapy box discusses kava kava, an herb often used for its sedative and antianxiety effects. Kava kava is prepared from a South Pacific plant (Piper methysticum) and is marketed as an herbal sedative with antianxiety effects. Prior to seeking psy- chiatric treatment, patients with anxiety disorders may try kava kava in the belief that herbs are safer than medications, but it may have a darker side.

Answer 359

Advanced-practice nurses may use various types of psychotherapy or provide consultation to primary care providers who treat pa- tients with anxiety and related disorders. Because nursing has as a major focus viewing the patient in a holistic way, the advanced- practice nurse can lead the health care team in assessing each pa- tient’s unique biological, environmental, psychological, spiritual, and sociocultural needs to develop the most comprehensive, individual- ized plan of care to alleviate the distress of symptoms. Advanced- practice nurses build on basic nursing interventions and use more complex cognitive and behavioural treatment strategies, including modelling, systematic desensitization, flooding, response preven- tion, and thought stopping. Managing both psychiatric and physical symptoms can be a chal- lenge for general medical nurses. Psychiatric liaison nurses, a subspe- cialty of psychiatric mental health nursing initiated in the early 1960s, can bridge that gap. Usually, the psychiatric liaison nurse has a master’s degree and a background in psychiatric and medical–surgical nursing. they function as a consultant assisting other nurses in managing psy- chiatric symptoms and as a clinician working directly to help the pa- tient deal more effectively with physical and emotional problems. The psychiatric liaison nurse first meets with the nurse who initiated the consultation and then reviews the patient’s medical records, talks with the physicians, and interviews the patient. After the patient interview, the liaison nurse discusses the assessment and suggestions with the re- ferring nurse. If a psychiatric consultation is warranted, the psychiatric liaison nurse initiates the consultation by contacting the patient’s phy- sician. The liaison nurse will support general practice nurses to learn how to deliver more advanced intervention. A case conference is some- times needed to enhance communication and consistency in the care of a particular patient. Behavioural therapy. Beyond basic interventions, there are several forms of behavioural therapy currently used to decrease anxious or avoidant behaviour: * Modelling—The therapist or significant other acts as a role model to demonstrate appropriate behaviour in a feared situation, and then the patient imitates it. For example, the role model rides in an elevator with a claustrophobic patient. * Systematic desensitization—The patient is gradually introduced to a feared object or experience through a series of steps, from the least frightening to the most frightening (graduated exposure). The patient is taught to use a relaxation technique at each step when anxiety becomes overwhelming. For example, a patient with agora- phobia would start with opening the door to the house to go out on the steps and advance to attending a movie in a theatre. The thera- pist may start with imagined situations in the office before moving on to in vivo (real-life) exposures. * Flooding—Unlike systematic desensitization, flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response. The patient learns through pro- longed exposure that survival is possible and that anxiety dimin- ishes spontaneously. For example, an obsessive patient who usually touches objects with a paper towel may be forced to touch objects with a bare hand for 1 hour. By the end of that period, the anxiety level is lower. * Response prevention—Patients with compulsive behaviour are not allowed to perform the compulsive ritual (e.g., handwashing), and the patient learns that anxiety subsides even when the ritual is not completed. After trying this activity in the office, the patient learns to set time limits at home to gradually lengthen the time between rituals until the urge fades away. * Thought stopping—With this technique, a negative thought or ob- session is interrupted. The patient may be instructed to say “Stop!” out loud when the idea comes to mind or to snap a rubber band worn on the wrist. This distraction briefly blocks the automatic un- desirable thought and cues the patient to select an alternative, more positive idea. (After learning the exercise, the patient gives the com- mand silently.) Cognitive therapy. Advanced forms of cognitive therapy will build on the basic intervention of establishing that our thoughts have a link to our emotions. For example, “I have to be perfect or my boyfriend will not love me.” Through a process called cognitive restructuring, the therapist helps the patient to (1) identify automatic negative beliefs that cause anxiety, (2) explore the basis for these thoughts, (3) re-evaluate the situation realistically, and (4) replace negative self-talk with sup- portive ideas. Cognitive behavioural therapy. CBT is the most consistently supported treatment for the full spectrum of anxiety and related disorders. CBT combines cognitive therapy with specific behav- ioural therapies to reduce the anxiety responses and distress. CBT includes a combination of cognitive restructuring, psychoeduca- tion, breathing, muscle relaxation, teaching of self-monitoring for symptoms, and in vivo (real-life) exposure to feared objects or situ- ations. Refer to Chapter 4 for a more complete explanation of CBT. More information about CBT can be found in Chapters 4, 13, 16, 20, 27, and 33. Somatic therapy. Verbal and body psychotherapies are seen as complementary interventions. A specific type of somatic psycho- therapy, sensorimotor psychotherapy, combines talking therapy with body-centred interventions and movement to address the dissocia- tive symptoms inherent in trauma (Ogden & Fisher, 2015). This type of therapy is integrated into phase-oriented trauma treatment to fa- cilitate symptom reduction and stability, to integrate the traumatic memory, and to restore the person’s ability to stay in the present mo- ment. This therapy is based on the premise that the body, mind, emo- tions, and spirit are interrelated, and that a change at one level results in changes at the others. Being aware, focusing on the present, and recognizing touch as a means of communicating are some of the prin- ciples of this therapy. During psychotherapy sessions, the patient is asked to describe physical sensations they are experiencing. The goal is to safely disarm the pathological defence mechanism of dissocia- tion and replace it with other resources, especially body awareness and mindfulness.

Answer 360

Evaluation of patients with anxiety-related disorders is a simple process when measurable behavioural outcomes have been written clearly and realistically. Each NOC outcome has a built-in rating scale that helps the nurse measure improvement. In general, evaluation of outcomes for patients with anxiety disorders deals with questions such as: * Has patient safety been maintained? * Is the patient experiencing a reduced level of anxiety or distress? * Does the patient recognize symptoms as anxiety related? * Does the patient continue to display obsessions, compulsions, pho- bias, worrying, or other symptoms of anxiety disorders? If still pres- ent, are they more or less frequent? More or less intense? * Is the patient able to use newly learned behaviours to manage their symptoms? * Can the patient adequately perform self-care activities? * Can the patient maintain satisfying interpersonal relations? * Can the patient assume usual roles?

Answer 361

* Anxiety has an unknown or unrecognized source, whereas fear is a reaction to a specific threat. * Peplau operationally defined four levels of anxiety: mild, moder- ate, severe, and panic. The patient’s perceptual field, ability to learn, and physical and other characteristics are different at each level (see Table 12.1). * Defences against anxiety can be adaptive or maladaptive. Table 12.2 provides adaptive and maladaptive examples of the more common defence mechanisms. * Anxiety, somatic symptom, or dissociative disorders frequently co- occur with mood disorders or substance use and addictive disor- ders. * Research has identified genetic and biological factors in the etiology of anxiety and related disorders. * Psychological theories and cultural influences are also pertinent to the understanding of anxiety and related disorders. * People with anxiety disorders suffer from panic attacks, irrational fears, excessive worrying, uncontrollable rituals, or severe reactions to stress. * Dissociative disorders involve a disruption in consciousness with a significant impairment in memory, identity, or perceptions of self. * Nursing interventions include counselling, milieu therapy, promo- tion of self-care activities, psychobiological intervention, health teaching, and behavioural and cognitive behavioural therapies. * Because these patients may not seek psychiatric treatment, the nurse does not usually see them in the acute psychiatric setting, ex- cept during a period of crisis such as suicidal risk. * The nursing assessment is especially important to clarify the history and course of past symptoms, as well as to obtain a complete picture of the current physical and mental status. * Although these patients do respond to crisis intervention, they usu- ally require referral for longer-term treatment to attain sustained improvement in level of functioning.

Answer 362

Madness has always been part of humanity. In the early years it was associated with disease of the soul, demons, sins, and mood unbal- ance. Responsibilities for these individuals fell on families and com- munities. In extreme cases of disturbance the mad person sees themself excluded from society and becomes errant. Without being necessarily dangerous, they may disrupt public order or sometimes shows signs of violence. To protect them and the population, it was decided to isolate them by locking them in religious communities, prisons, and eventually hospitals Confinement in general hospitals was a European phenomenon in the fifteenth century. It accommodated the destitute, the old, the dying, and the mad. Treatments differed between quieter and more restless individuals. Cases of extreme agitation necessitated surveillance personnel and isolation rooms. At that time, the deviants were transferred to new establishments called asylums. Patients in these settings were often chained or caged, and cruelty or neglect was not uncommon. This type of treatment reflected the societal view that people with mental illness were bestial or less human in nature and therefore required discipline and were immune to human discomforts such as hunger or cold. Asylums, designed to be retreats from society, were built with the hope that, with early intervention and several months of rest, people with mental illness could be cured. In the late 1700s Philippe Pinel, a French physician, along with other humanitarians, began to advocate for more humane treatment of people with mental illness by literally removing the chains of the patients, talking to them, and providing a calmer, more soothing environment. Pinel and an- other reformer from England, William Tuke, described this use of social and psychological approaches to treatment as “moral treatment”. Critics such as French philosopher Michel Foucault argued that the asylum movement was little more than a shift from physical restraint to psychological and social control of people considered undesirable by societal norms. In Canada the country’s size, location, and history have played a sig- nificant part in how people with mental illness are treated. Indigenous peoples in Canada had a variety of approaches to caring for people with mental illness. Most were holistic, treating mind, body, and soul, and included sweat lodges, animistic charms, potlatch, and Sundance (Kirkmayer et al., 2000). In the sixteenth century colonial settlers from France and, later, England brought with them their own approaches to mental illness care. As in their European homelands, much of the responsibility of caring for people with mental illness fell on the family and the asylums established in the communities (Cellard & Thifault, 2006). Some Canadian religious orders, such as the Grey Nuns, were early providers of care for people with mental illness (Hardill, 2006). Those who could not be cared for in the community, however, often ended up in jails, where they received minimal shelter at best and abuse at worst (Moran, 1998). By the 1800s, migration to Canada increased, as did its urbanization. This relocation of families to cities from isolated settlements changed support systems and families’ ability to care for people with mental illness (Cellard & Thifault, 2006). In Europe the move to asylum care was well under way, and the Canadian colonies began to explore similar options. Founded by Marguerite d’Youville in 1737 in Montreal, the Sisters of Charity, formally known as the Grey Nuns, is a Canadian religious institute that has been involved in the care of the poor, the develop- ment of health care services, and the nursing education. They created the school of nursing at the Notre-Dame Hospital (1898) in Montreal that constituted rapidly of a network all over the country. They took a leading role in the advancement of nurses’ higher education with the establishment of the Institute of Marguerite d’Youville, affiliated with the University of Montreal, to offer the first French baccalaure- ate program (Paul, 1994). In 1893 the Quebec government entrusted the care and the custody of mentally ill persons of Saint-Michel- Archange asylum (Beauport) to the congregation. The increased de- mands for psychiatric care contributed to the development of these nursing speciality. The Grey Nuns were active in the psychiatric nurs- ing education by creating their own school of nursing inside the in- stitution in 1915 (Aubin, 2019). The deinstitutionalization movement and the disastrous reports issued by the different provinces in the 1960s raised the issues of overcrowding and poor quality of care in- side psychiatric institutions and forced the religious communities to withdraw from the administration of the psychiatric hospital, includ- ing the Grey Nuns. The poor life conditions of patients in custodial care caught the attention of many social reformers who, in the late nineteenth and early twentieth centuries, lobbied governments to create more hu- mane environments of care for people with mental illness. Among them was Dorothea Dix, a retired schoolteacher from New England who became the superintendent of nurses during the American Civil War. Dix was educated in the asylum reform movements in England while she was there recuperating from tuberculosis. In 1841 during an encounter at a Boston jail, Dix was shocked to witness the degrad- ing treatment of a woman with mental illness who was imprisoned there. Passionate about social reform, Dix began advocating for the improved treatment and public care of people with mental illness. She met with many politicians and even the Pope to push her agenda forward. Ultimately, she was influential in lobbying for the first pub- lic mental hospital in the United States and for reform in British and Canadian institutions. At that point, the asylums became peaceful and resourceful places focused on a therapeutic environment, until they became overcrowded.

Answer 363

The first asylum was created in Saint John, New Brunswick, in 1835 and became the Provincial Lunatic Asylum in 1848 (Wong, 2018). It housed patients with difficult conditions. Soon, more asylums were established in Upper and Lower Canada, the Maritime colonies, and Canada’s West. Despite the creation of asylums, early historical re- cords demonstrate that most families of people with a mental ill- ness maintained the care of those individuals themselves (Cellard & Thifault, 2006), so the asylums predominantly housed patients who were poor and had no family support. Many asylums were built in countrylike settings on large parcels of land that could provide op- portunity for occupational therapies such as farming. Toward the end of the nineteenth century, asylum care became more acceptable, and, with family support systems becoming diluted due to urban- ization and relocation, the inpatient population grew exponentially (Cellard & Thifault, 2006). Although the moral treatment era had moved psychiatric treatment toward more humane treatment, the lack of success in treating mental illnesses combined with increased admissions to asylums led to overcrowding and less than humane conditions in many asylums. In most settings a large population of people received only minimal custodial care: assistance with per- forming the basic daily necessities of life, such as dressing, eating, using a toilet, walking, and so on.

Answer 364

By the end of the nineteenth century, the new field of psychiatry was being challenged to provide a medical cure for mental illness. Since there were few medications available other than heavily alcohol-based sedatives, doctors used many experimental treatments, for example, leeching (using bloodsucking worms), spinning (tying the patient to a chair and spinning it for hours), hydrotherapy (forced baths), and insulin shock treatment (injections of large doses of insulin to pro- duce daily comas over several weeks). In the mid-twentieth century treatment choices expanded to include electroconvulsive therapy, and lobotomies, through which nerve fibres in the frontal lobe were severed. As treatments became more invasive, the need for patient monitoring beyond custodial care led many medical superin- tendents to recruit nurses to work in their institutions.

Answer 365

In Canada prior to the late 1800s, there were no nurses working in psy- chiatric settings; instead, asylums used predominantly male attendants to provide custodial care for patients. Changes in treatment approaches and the increased medicalization of psychiatry prompted a need for more specially trained providers, especially for female patients (Con- nor, 1996). In 1888 Rockwood Asylum in Kingston, Ontario, became the first psychiatric institution in Canada to open a training program for nurses (Kerrigan, 2011). The 2-year program was overseen by the asylum’s medical director and included one lecture a week combined with work experience training. The curriculum, taught by physicians, included courses in physiology, anatomy, nursing care of the sick, and nursing care of the insane (Legislature of the Province of Ontario, 1889). Consistent with societal beliefs of the time about women’s innate caring capacity, the training was offered only to females. This exclu- sion of males from the program hindered the recognition of the impor- tance of nursing knowledge and skills and lowered the status of male attendants at the time (Yonge et al., 2005). Both of these factors would greatly affect the future development of psychiatric mental health nurs- ing in Canada. Asylum-based training schools opened across Canada, and the training curriculum, similar to that of the hospital-based programs of generalist nurses, varied among institutions. Medical superintendents controlled the content and delivery of the programs, and hospital ad- ministrators highly valued the inexpensive labour provided by the fe- male workforce, so much so that their cross-training in other medical settings was discouraged so as to maintain staffing supplies (Tipliski, 2004). The asylum-based programs were founded heavily on a medi- cal model of training nurses to be obedient, orderly, and focused on the discipline of the inpatients (Cowles, 1916). Nursing duties at the beginning of the twentieth century often included extensive cleaning, serving meals, counting cutlery after meals, and assisting patients with hygiene activities, as well as administering treatments such as the long baths referred to as “hydrotherapy,” sedation with alcohol, and postop- erative care (Forchuk & Tweedell, 2001). Nurses also played a key role in the care of patients in the infirmary. The custodial environment of asylums did not promote a sense of professional knowledge for nurses and limited their ability to question the treatment approaches being offered at the time (Leishman, 2005).

Answer 366

In the early part of the twentieth century nurses’ lack of control over their own profession began to shift with changes to nursing education models and blossoming political advocacy by nursing groups across Canada, particularly with the formation of the Canadian National As- sociation of Trained Nurses in 1908. This early group expanded, and by 1926, each province had an affiliate group, and the organization was renamed the Canadian Nurses Association (CNA). The CNA provided a united voice for nurses and increased advocacy for control over nurs- ing by nurses (CNA, 2021a). At this time, nursing training programs still varied by institution, but many had long hours of hospital ward service taking precedence over instructional hours for students. The CNA’s mandate included the professionalization of nursing, so it began to advocate for standardization of nursing education (Tipliski, 2004). This was a politically loaded issue for several reasons: physicians want- ed control over nursing education, patriarchal society structures de- valued nursing knowledge, nursing skills were seen as natural women’s work, and hospitals relied on the economical service hours of nursing students (Anthony & Landeen, 2009). In 1927 the Canadian Medical Association and the CNA performed a joint study on the state of nursing education in Canada. The result, known as the “Weir Report,” was released in 1932 and concluded that drastic changes were needed in nursing education programs, including standard- ization of curriculum, work hours, and instructor training, and that care of people with mental illnesses needed to be integrated into all generalist pro- grams (Fleming, 1932). The uptake of the recommendations varied across Canada and even within regions. Since psychiatric hospitals and asylums had a harder time recruiting nurses, the idea of giving up their workforce so that students could complete an affiliation in general hospital settings was considered very costly. The medical superintendent psychiatrists were protective of their asylum-based training programs, which they felt devel- oped specialized skills compared to general nursing skills (Tipliski, 2004). They argued that a 3- to 6-month affiliation in psychiatry was too short to learn the skills required in their institutions. At the time, provincial legislation in the form of nursing acts was coming into existence and further formalizing the title and licensure of the registered nurse. There were provincial differences in government- legislated power over licensure and nursing education as well as vari- able interest in psychiatric training by provincial nursing associations (Tipliski, 2004). This, combined with the political influence of some medical superintendents from provincial psychiatric hospitals, led reg- istered nursing associations in Manitoba, Saskatchewan, Alberta, and British Columbia to be less inclusive of the psychiatric hospital–trained nurse than the associations in Eastern Canada were, which in turn led to the exclusion of registered nurse licensure for graduates of asylum pro- grams. This division of perspectives eventually resulted in a split between Western and Eastern Canada in training programs and the creation in the western provinces of the specialty-focused psychiatric nursing train- ing programs and the registered psychiatric nurse designation.

Answer 367

From the outset, the Registered Nurses’ Association of Ontario (RNAO) accepted the asylum-based programs for licensing of pro- spective nurses who were affiliated with a general hospital (Tipliski, 2004). It also represented nurses working in asylum settings, providing them with advocacy and nursing leadership (Tipliski, 2004). With the support of nurse leaders like Nettie Fiddler and the publication of the Weir Report, more generalist hospital programs began adding a psy- chiatry rotation to the curriculum. Also influential in the addition of a psychiatry rotation was the RNAO addressing the nursing shortage in psychiatric settings and the care concerns of mentally ill patients at the organization’s 1945 annual meeting (Tipliski, 2004). At this point, many psychiatric hospitals had large numbers of patients, inadequate staffing, and minimal enrollment of new students (Tipliski, 2004). The advocacy of nurse leaders, combined with the post–World War II men- tal hygiene movement, led to the addition of psychiatric nursing theory for all registered nurse education programs (Tipliski, 2004). Some asy- lum programs added training in general medical settings; however, by the 1950s, all of the psychiatric hospital training programs in Eastern Canada had closed. Nurses in psychiatric mental health were trained as generalist registered nurses with affiliations in psychiatry and the chance to specialize after graduation.

Answer 368

In the western provinces, where the population was much smaller and asylums were located in rural settings, recruiting an adequate la- bour force was a major concern. In the early 1900s British Columbia, Alberta, Saskatchewan, and Manitoba attempted different approaches to training nurses for psychiatric settings. Selkirk, Manitoba, opened the first asylum training school in Western Canada in 1920, followed closely by Brandon, Manitoba, in 1921 (Hicks, 2011). Manitoba imple- mented several combination programs between general hospitals and psychiatric hospitals, but similar attempts at other institutions in the western provinces failed due to lack of investment from administrators and nurse leadership groups and difficulty enticing nurses to remain in the psychiatric setting after their graduation (Hicks, 2011; Tipliski, 2004). In the 1930s Saskatchewan’s two provincial psychiatric hospitals began a training program for their attendants. Unlike in the rest of Canada, this training was offered to both male and female attendants and, upon completion, gave graduates the title “nursing attendant” (Ti- pliski, 2004). However, the specialized training did not bestow upon graduates any professional title or licensure, so several attendants lob- bied for the creation of the designation “psychiatric nurse.” The move- ment for the designation of the psychiatric nurse was supported by medical superintendents, unions, and politicians at the time, so despite opposition by provincial nursing leaders, the Registered Psychiatric Nurses Act was enacted in Saskatchewan in 1948 (Tipliski, 2004). This step toward professionalization of the role of the nurse in psychiatric hospitals was soon adopted by other western provinces. At the same time, the Saskatchewan Registered Nurses’ Association’s leader, Kath- ryn Ellis, was also trying to address the nursing shortage in mental hospitals by convincing provincial hospitals to become more involved in training, but she was unable to negotiate satisfactory psychiatric or general hospital affiliations (Hicks, 2011; Tipliski, 2004). Much of the professionalization movement was facilitated by the Canadian Council of Psychiatric Nurses (CCPN), an interprovincial organization of psychiatric nurses focused on increasing the stan- dards and recognition of psychiatric nurse training (Hicks, 2011). The CCPN, along with the efforts of provincial psychiatrists, was successful in advocating for the registered psychiatric nurse specialty designation across the western provinces; subsequently, British Columbia passed its Psychiatric Nurses Act in 1951, Alberta followed in 1955, and Mani- toba followed in 1960. To date, the separate designation has remained, although the CCPN evolved first into Registered Psychiatric Nurses of Canada (RPNC) and now is Registered Psychiatric Nurse Regulators of Canada (RPNRC). The organization has more than 5600 practising members (RPNRC, 2021), resulting in both registered nurses and reg- istered psychiatric nurses working in psychiatric mental health settings in the four western provinces and Yukon.

Answer 369

Psychiatric nursing continued to take place predominantly in hospi- tal settings until the 1960s. The discovery of new neuroleptics, such as chlorpromazine, assured a permanent recovery, or at least symptoms’ stabilization related to mental disorders. These new treatments allowed patients an early return home. The psychiatric deinstitutionalization movement, namely, the shift from caring for people with mental ill- ness in institutions to caring for them in communities, began not only in Canada but all over the world. Psychiatric nurses had to redefine their role and their professional identity within the health care team as the treatment of patients underwent this transition (Harrisson, 2017, p. 37). (See Chapter 3 for further discussion of deinstitutionalization.) The “pioneer” community mental health nurses set up many programs and frameworks for the delivery of psychiatric mental health care in the community (Boschma, 2012) and in acute psychiatric wards of gen- eral hospitals (Harrisson, 2017). The wide range of community-based mental health services that eventually developed (e.g., crisis manage- ment, consultation-liaison, primary care psychiatry, day clinics) cre- ated new settings and skill requirements for psychiatric mental health nurses. The ability to assess and monitor patients and their environ- ment changed nursing approaches toward mental health care. Assess- ment, autonomy, collaboration, crisis management, and resource find- ing became key skills for community-based nurses.

Answer 370

In 1919 the University of British Columbia (UBC) launched the first university-based program in nursing. The program was a “sandwich model,” with 3 years of hospital-based nursing sandwiched between the first and final years of university studies (Anthony & Landeen, 2009). At the time, the idea of a university program for nursing was consid- ered so risky that UBC refused to fund or administer the middle years of the program. A leader in nursing education at the time, E. Kathleen Russell at the University of Toronto, supported by the Rockefeller Foundation, set up one of the first university-based training programs in public health nursing, leadership, and education. This revolution- ary post-diploma certification program for registered nurses was at- tended internationally. Later, in 1928 Russell coordinated the first sole- ly university-based nursing program at the University of Toronto; in 1942 it began granting Bachelor of Science degrees in nursing (BScN) (University of Toronto, 2011). These university programs initiated a critical change in nursing education: for the first time, education for nurses was separated from and prioritized over their service in the hos- pitals (Anthony & Landeen, 2009). Despite this revolution in nursing education, nursing programs remained under the control of medical faculties until 1962, when the University of Montreal set up the first independent nursing faculty (Anthony & Landeen, 2009). Many other Canadian universities began to offer diploma programs in specialty areas such as public health. In the 1950s the University of Saskatchewan became the first to offer a 1-year post–registered nurse training diploma in advanced psychiatric nursing (University of Sas- katchewan, 2011). The inception of university education for nurses led to the growth and formalization of nursing knowledge. The University of Western Ontario launched Canada’s first graduate program in nurs- ing in 1959, and the first PhD program in nursing began at the Uni- versity of Alberta in 1991. The growth of graduate programs gave rise to increased research and theory in psychiatric nursing practice. The influence of nurse theorists such as American Hildegard Peplau, the first published nursing theorist since Florence Nightingale, contributed to the expansion of specialized nursing knowledge and related skills in the psychiatric mental health field. Much of Peplau’s work focused on the role of the nurse in therapeutic relationships and anxiety manage- ment. The growth of academic study in nursing, in turn, influenced nursing in the practice setting: the Hamilton Psychiatric Hospital be- came the first health care institution in Canada to employ a clinical nurse specialist (CNS) and to require theory-based nursing practice (Forchuk & Tweedell, 2001). Hildegard Peplau was born in 1909 in Reading, Pennsylvania. She graduated from Pottstown, Pennsylvania School of Nursing in 1931. She earned a Bachelor degree in Interpersonal Psychology in 1943 from Bennington College in Vermont. She served in the army as a nurse between 1943 and 1945. She was stationed in the School for Military Neuropsychiatry in the south of England and had the opportunity to work with William Menninger, psychiatric consultant of the US Army. After the war, she enrolled in the master program and completed her PhD (Smith, 2020). She conceptualized the process of the nurse–patient interaction, ad- vancing the idea that these interpersonal phenomena have a qualitative impact on patient outcome (Callaway, 2002; Peplau 1991). The devel- opment of a therapeutic relationship would allow a better understand- ing of the psychosocial behavioural problems of the patient rather than focusing on the mental illness diagnosis. “Her theory assists nurses to make sense of patients’ experience and behaviour related to their health and illness, including mental illness. The development of her theoretical work coincided with the transition of care for mentally ill patients to the community and to short-term units in general hospi- tals.” (Harrisson, 2017, p. 42). Peplau’s theory is now taught in nursing programs as part of general knowledge for nurses, and not only as part of the psychiatric curriculum (Senn, 2013). Currently, entry-to-practice mental health and addiction com- petencies for undergraduate nursing education in Canada have been established by the Canadian Association of Schools of Nursing and Ca- nadian Federation of Mental Health Nurses (CASN & CFMHN, 2015). The CFMHN (2016) recommends that the curricula of all undergradu- ate nursing programs in Canada include entry-to-practice mental health and addiction competencies in both theoretical knowledge and clinical practice. The CFMHN recommends delivering mental health and addiction core competencies through a designated (stand-alone) theory course and a dedicated clinical experience. Regardless of peda- gogical method, the obligatory outcome for undergraduate nurses is a strong knowledge base in mental health and addiction as outlined in the CFMHN practice standards (CFMHN, 2016). This body of core competency work and the nursing mandate to meet goals of key fo- cus areas of the national mental health strategy (Mental Health Com- mission of Canada, 2021) are enhanced by growing nursing research. Nursing research in mental health continues to expand through the works of nurse researchers such as Bernie Pauly, Cheryl Forchuk, Dave Holmes, Kristin Cleverley, Cheryl L. Pollard, Nicole Letourneau, and Kimberley Ryan-Nicholls. In Western Canada over the past 25 years, the shift to the role of the registered psychiatric nurse and the increased range of practice settings (i.e., away from inpatient facilities and into primary care and community-based clinics) have also brought about changes in educa- tional programs. Registered psychiatric nursing programs have ad- justed to ensure diversification of skills and knowledge base related to consumer-oriented primary health care and health promotion activities (Ryan-Nicholls, 2004). Registered psychiatric nurse train- ing continued to be diploma based across the western provinces until 1995, when Brandon University began its baccalaureate program in psychiatric mental health nursing. Registered Psychiatric Nurses of Canada issued a position statement in 2012 advocating for baccalau- reate degree entry to practice for registered psychiatric nurses due to the increasingly complex needs and roles of the registered psychiatric nurse (RPNC, 2012). The first graduate program in psychiatric nurs- ing for registered psychiatric nurses began at Brandon University in January 2011.

Answer 371

The division of Eastern and Western Canada in psychiatric nursing training and designation resulted in separate organizational groups. Although having multiple organizations has led to some duplication and fragmentation of a voice for nurses in psychiatric settings, the groups have also worked collaboratively toward common goals. Since 1995, the CNA has offered registered nurses certification in psychiat- ric mental health nursing (CNA, 2021b). Under the umbrella of the CNA and with consumer input, the Canadian Federation of Mental Health Nurses, an organization of registered nurses across Canada who specialize in psychiatric mental health nursing, established the standards of practice for psychiatric mental health nursing, now in a fourth edition (see https://www.cna-aiic.ca/en/nursing/advanced- nursing-practice). The 2014 Standards for Psychiatric Mental Health Nursing build on the Canadian Nurses Association Code of Ethics (CNA, 2017). Despite the separations in licensure and professional bodies, in workplaces in Western Canada, registered nurses and reg- istered psychiatric nurses work closely together in mental health set- tings and have many opportunities for collaboration and advocacy for the people they serve.

Answer 372

Advanced-practice nursing includes the roles of nurse practitioner and CNS (CNA, 2019). Each province has its own regulations guiding the licensing and scope of practice for APN. The CNS’s role has been well established in psychiatry since 1972, when Hamilton Psychiatric Hospital employed Pat Barry, a nurse with a graduate degree, to edu- cate staff and increase theoretical-based nursing practice (Forchuk & Tweedell, 2001). CNSs can provide psychotherapy and have worked as consultants, educators, and clinicians in inpatient and outpatient psychiatry throughout Canada. Nurse practitioners, on the other hand, work as consultants or collaborative team members and can diagnose, prescribe and manage medications, and provide psychotherapy. While the role of psychiatric nurse practitioner has been well established in the United States, where specialized graduate programs and advanced certification exams are offered, the role has remained virtually non- existent in Canada, likely because the nurse practitioner role itself is relatively new to Canada compared to the United States, where it has been well established and regulated since the 1970s. There has been a recent attempt in Canada to standardize the re- quirements for APN nationally through the use of exam certification. Currently, nurse practitioner certification falls under particular areas of specialization that are unique to certain provinces (Graduate Nurs- ing EDU, 2021) and include adult, primary care, pediatric, and neona- tal. All of these certifications are focused on physical health and mental health knowledge (CNA, 2021c). Further, differences in licensure for nurse practitioners exist among provinces due to hospital legislation and funding methodology for health care billing. Because of the strong need for psychiatric care throughout Canada and the lack of providers available, especially in rural areas, the role of the advanced-practice nurse in psychiatric mental health is expected to expand in the near future.

Answer 373

As its history has shown, the role of the nurse in psychiatric mental health care will continue to evolve and be influenced by societal trends. The change in the structure of health care delivery toward a primary health model and an integrative mental health care approach has led to new roles for nurses in psychiatric mental health, including shared- care roles in primary care and consultation-liaison psychiatry within the general hospital setting. The Association of Registered Nurses of Newfoundland and Labrador (2008) took some key steps in articulat- ing the range of competencies and role development required for com- munity mental health nursing in its 2008 policy paper Advancing the Role of the Psychiatric–Mental Health Nurse in the Community. These competencies and role development are in line with the CNA 2020 vi- sion statement, which has called for an increased role for nurses work- ing in integrative mental health care roles and primary care (Villeneuve & MacDonald, 2006). Career pathways for nurse practitioners who specifically work in mental health are lacking at this time in Canada. However, some provinces are rethinking this aspect in developing ad- vanced nursing training at a graduate level. For example, Quebec has offered a diploma in mental health to nurse practitioners since 2019 (OIIQ, 2019). The changes in public perception of mental illness and efforts toward addressing stigma are placing a new emphasis on men- tal health promotion and illness prevention in schools and workplace settings (Mental Health Commission of Canada, 2021). Evidence- informed approaches to treatment, for example, concurrent treatment for people with mental illnesses and addictions, harm reduction, and dialectical behavioural therapy for people with borderline personality disorder, have led to the creation of related nursing roles, education, and research.

Answer 374

* Early asylum care for people with mental illness predominantly fo- cused on containment and sometimes on punishment. * Philippe Pinel and William Tuke were eighteenth-century reform- ers who introduced the moral treatment era of psychiatry, which attempted to focus on providing peaceful, nurturing environments for people with mental illness. Their theories influenced the rural, farmlike settings of early Canadian asylums. * Nursing within asylums began in the late nineteenth century as a result of the increased medicalization of psychiatry. * Psychiatric mental health nursing development in Canada was heavily influenced by societal values toward gender and toward mental illness, by politics, and by psychiatric care approaches. * Early nursing roles in psychiatry were largely custodial until the introduction of new treatments such as electroconvulsive therapy, insulin shock therapy, and lobotomies. * The division between western provinces and eastern provinces in the creation of the registered psychiatric nurse designation was largely related to differences in nursing leadership power, advocacy, and labour supply issues. * The development of university-based programs in nursing in the 1920s was a key step in the professionalization of nursing and in the transition of nursing education from medical dominance to nursing-led knowledge development. * Psychiatric mental health nursing led the way in reinforcing theory-based nursing practice with the use of clinical nurse spe- cialists. * Registered nurses work within psychiatric mental health settings across Canada. * Registered psychiatric nurses work in psychiatric mental health set- tings in Manitoba, Saskatchewan, Alberta, British Columbia, and Yukon. * The deinstitutionalization of patients in favour of community- based treatment led to the development of new nursing roles in psychiatric mental health care, including community mental health, crisis management, consultation-liaison, and primary care psychiatry. * Advanced-practice nursing roles have had varied implementa- tion in Canada. The clinical nurse specialist role has been well established, whereas the nurse practitioner role has had limited development.

Answer 375

Anger is an emotion. Rage is a violent state of overwhelming anger. Aggression is behaviour and violence is extreme aggression. Anger is a normal, natural emotion that occurs on a continuum, from mild to severe: appropriate to inappropriate depending on the situation. It can be suppressed over periods of time or controlled in its release (emotional regulation). It does not always lead to violence. It can be triggered by someone else’s anger, illness, pain, or fear. Personal appraisals of self-worth and self-efficacy also factor into the anger response. Anger is sometimes a coping response to embarrassment, jealousy, or fear of rejection or replacement. Anger is not always expressed loudly or by facial expression. Sometimes in the heat of anger a person will suddenly become silent, actively listening and watching, processing it all. A sudden eruption of anger, even aggression, may follow. Anger can be functional when it prompts individuals to remove obstacles and barriers to achieving their goals but is also seen as an enhancer of creativity in, for example, problem solving, conflict resolution, and restructuring environments. In other words, anger can be a healthy way to draw attention to a matter of concern, elicit problem- solving, and collaboration. However, its expression comes with responsibility Proactive anger is present in social movements: petition-gathering, marches, media campaigns, and more. Anger that is used to oppress, embarrass, avoid, or achieve power over another is maladaptive and inappropriate but often used by people to cope. Anger can also be linked to resentment. Suppressed anger is a learned, protective response to fear, abuse, or oppression. Historical trauma often leads to suppressed anger. This arises from decades of political and societal oppression (Indigenous peoples of Canada) ----------------- Rage is an uncontrollable, violent state of anger and is quite uncom- mon. Once the person has begun expressing rage, they cannot think clearly or logically, and psychosocial or cognitive behavioural inter- ventions are not possible. Rage must dissipate on its own. An example is road rage, a dangerous aggressive response to extreme anger. Rage begins with a trigger that is usually spontaneous. Contributing factors may include age, gender, self-centredness, attention deficits, antisocial personality, and more at the time the incident occurs. Implications for Nursing: protective strategies are necessary both for the raging person and for those around them. _____________ Aggression is an intentional behaviour. The intent is to harm another person who does not want to be harmed. It does not include physical violence. Aggression is not the same as aggressive thought (anger leading to imagining acts of violence or revenge, for example). Under certain stressful or fearful conditions, negative emotions can ini- tiate aggressive thought, but action does not always follow. Aggression is often used interchangeably with the term violence. This is not accu- rate. The use of the term aggression is common in everyday speech but not necessarily used in the true clinical, psychosocial sense of the word. Here are two examples. A person can aggressively seek employment. No harm is intended to anyone. Aggressive treatment of a disease does not indicate intent to actually harm a patient. Aggression is not an emotion but it is a descriptor often used for one. Rarely does someone say, “I feel aggressive” but instead say “I am aggressive.” Instrumental aggression is that which is planned to achieve a goal of harm. Wanting what another person has and threatening and intimidating to get it is an example. Instrumental aggression is some- times necessary for self-protection or that of others, such as shouting to get someone to stop a dangerous action. Emotional aggression is that which lacks any degree of planning and is generally more impulsive. Relational aggression occurs when one party intends to harm the other in the relationship by socially isolating them, belittling, demean- ing, manipulating, controlling, and socially isolating them Reactive aggression may be the result of a sudden insult or danger to self. If this type of aggression is hostile in nature, it is violence. Workplace harassment is aggressive and often takes the form of discrimination. The intent is to ridicule and insult, to offend and intimidate. It is targeted. Verbal and non-verbal messages are used to convey this. Workers might find themselves being harassed by gender, ethnicity, minority status, age, ability, dress, and so forth. Workplace harassment (discriminatory behaviour) can lead to bullying (power over behaviour) and physical violence, but it does not always do so. Bullying is intentional and repetitive: it is aggression and it is on- going. It is predatory. Power and power imbalance are key factors. The bully exerts power over someone else, the victim. Bullying is predatory and often dispute related in nature. Bullies are not seeking resolution. Attempts to facilitate this can be challenging. The action can put the victim at even higher risk for retaliation. It is very important to distinguish bullying from interpersonal conflict. Sometimes accusations are made of bullying when in actuality that is not the case. Using accurate terminology is important when interventions are warranted. Bullying and interpersonal conflict are not the same, nor is their management. Cyberbullying is a behavioural subset of bullying. Like generic bul- lying, it is predatory aggression. It occurs through social media sites, computers, and cell phones. The intent is to cause psychological and social harm. Cyberbullying becomes physical violence when the bully intends a violent outcome, such as spurring the victim to self-harm or suicide. Cyberbullying can take the form of revenge porn. This is when intimate photos of a target are shared online without permission and accompanied by hostile and explicit commentary by a perpetrator. This is an aggressive act. The photos may be real or digitally altered; the intent is to demean, take revenge, punish, and cause severe psychological harm. Revenge porn becomes physical violence when the intent is to encourage or direct the target to physically self-harm. -------- Expressing Anger: To avoid bottling up anger and losing control of it at some point, it is healthy to express it. However, this comes with a very important responsibility not to harm or burden others with one’s own anger. Self-awareness and responsibility are necessary. Freedom from the feeling of anger is not about venting it on others or burdening or harming another but about voicing feelings and opening up for discussion with them. Teaching anger control assistance strategies or using cognitive behavioural therapeutic techniques for anger management can help. ________ Violence is a behaviour intended primarily, but not solely, to do physical harm to someone or something. Violence is aggression in its extreme form. An act can be planned or spontaneous. Violence can be used to dominate; to exert power and control over others; and to exact revenge. It can be used for correction or discipline by a parent, as in spanking a child. Note that this is not illegal in Canada. An act of excessive spanking is. The Criminal Code of Canada (2020b) includes violence under its definition of assault: physical or verbal. Here, violence includes psychological and emotional abuse, damage to property, suicide, and self-harm. States of high arousal, hyperexcitability, psychosis, and confusion are all possible antecedents to acts of violence, although some violence is clearly planned. Violence is almost always an objectionable act. Exceptions include the work of armed forces and police officers. In a best-case scenario violence can be used to defend. Used instrumentally, it can protect self and others. Physical restraints used in healthcare or policing are examples. At its worst, violence can be used in self-service to cause the maiming or death of another. Workplace violence may take many forms. In healthcare workplace violence refers to overt acts of aggression and violence by patients directed at hurting staff or others. It also includes staff-to-staff actions including belittling, lashing out, or social exclusion. Although not limited to these situations, Geoffrion et al. (2017) identify that Cana- dian bus drivers, police, and healthcare workers’ responses go beyond the physical ramifications and can lead to physical and mental health issues. Lateral workplace violence refers to psychologically violent acts that occur worker to worker. It is not uncommon in health care and in fact has been well studied in this field. Cultural relativism may be a contributing factor to why nursing seems so affected. Traditions and beliefs held by nurses about new nurses and vice versa, age cohorts, and hierarchies in nursing and the environment are also thought to contribute to this phenomenon. Workplace violence may also be perpetrated by a patient’s family member(s) or their visitors. In-group workplace violence also occurs. Dissatisfaction with an organization’s practices and policies, workplace constraints, poor communication or collaboration among the team, and incivility can all con- tribute to workplace stress and violence. Some workplace violence is caused by the defense mechanisms of suppression and projection. When individuals feel powerless, voiceless, disrespected, undervalued, or unable to implement change, they turn on others close at hand: others that are more vulnerable. _________ Physical violence ranges from physically pushing or hitting to rape or murder and all things in between. It can include the destruction of property, injury, and death of animals. Relational violence is also known as intimate partner violence or interpersonal violence. This includes a myriad of physical and psycho- logical harms to the victim, including the potential for murder. Collective violence is social, political, or economic. Violence is enacted by groups of people onto others. Examples are gang violence, dictatorships, and those like human traffickers, who prey on the disadvantaged and poor seeking work. It can include mob violence. ___________ Lateral Violence- Lateral violence is a form of psychological violence within a group itself. It includes acts of incivility (rudeness), bullying, harassment, scapegoating, withholding in- formation, gossiping, and refusing to help, to name a few. It can be overt or covert and the intention is to cause harm to someone. It happens in a toxic or oppressive work environment where there are real or perceived power imbalances, devaluation of workers’ contributions, and a sense that one’s integrity is challenged. When means of coping and adapting fail, moral distress can occur. At this juncture, psychological violence against others is potentiated. With no relief in sight, physical violence in the workplace may ensue. Lateral violence is also known as horizontal violence. the act of blaming a person or group for something bad that has happened or that someone else has done: the scapegoating of immigrants for the country's economic problems. __________-

Answer 376

incidents of anger, aggression, and violence are associated with the perpetrator experiencing an emotional reaction. These reactions occur in all areas of the healthcare system. A long-held stigmatizing belief among health care workers and the general public is that it is more dangerous to work in psychia- try that any other specialty area. Thomas (2016) has identified that the incidents of violent acts are similar in the emergency room, long-term care, general medicine, and psychiatry. To deal effectively with this and maintain the wellness of self and others, nurses need skills in managing violence pre-, during-, and post-incident. But first, they need knowledge. Understanding the contributing factors to workplace violence and the policies and practices are essential for protection of self and others.

Answer 377

The World Health Organization’s (2002) definition of violence identifies the likelihood that individuals, groups, or communities will be injured, killed, deprived, or suffer abnormal human or social development. The effects of violence in society today pose a major health concern. Victims and witnesses may experience anxiety, depression, suicide, or post-traumatic stress disorder and increased risk for medical issues such as cardiovascular disease. Other outcomes for victims can include substance use and physical and cognitive disabilities. Comorbidity Anger, aggression, and violence are natural phenomena. They can stand alone or coexist with multiple psychiatric and non-psychiatric disorders. Anger is a key diagnostic criterion in intermittent explosive disorder, oppositional defiant disorder, disruptive mood dysregulation disorder, borderline personality disorder, and bipolar disorder (refer to Chapter 27). Substance use, anxiety disorders, neurocognitive dis- orders, and personality disorders can be also factors in the expression of anger, aggression, and violence. Neurodevelopmental disorders, medical conditions, brain injury, medications, and pain are non-psychiatric conditions from which the healthcare practitioner needs to consider the patient’s experience of anger, aggression, and violence when making a diagnosis and developing a treatment plan. For those people with mental health disorders, additional assessment related to the content of hallucinations and delusions is needed. The risk of violence is enhanced when psychosis is accompanied by delusions of a persecutory nature. Patients with acute, severe mental illnesses who concurrently use substances are also at a greater risk for being a victim of violence than the general public. Disorders that include mood dysregulation hold the potential for impulsive, maladaptive expressions of anger, aggression, and violence

Answer 378

* Overcrowding * Provocative or controlling staff * Unclear rules and boundaries * Language or other communication barriers * Cultural barriers * Higher patient acuity * Staff inexperience * Long periods of waiting/queuing to get attention * Restricted movement—locked unit * Poor or limited food choices

Answer 379

Biological Factors Biologically, anger, aggression, and violence are associated with the corticolimbic areas of the brain. A biological predisposition to respond to life events with irritability, low frustration tolerance, and anger may be a function of neurological development or neurochemical changes due to brain tumours or brain injury. __________ Neurological Any neurological condition affecting areas of the brain that are involved with impulse control and emotion regulation can result in increased violence, severe behavioural disorders, and low levels of frustration tolerance. Temporal lobe dysfunction, violence, and aggression are correlated. Within the temporal lobes lies the amygdala, responsible for the regulation and perception of emotions. The lobes share some memory function with the limbic system. Memory of previous insult or assault is important in the cognitive appraisal of a threat and can play a determining role in the expression of anger. When there is damage to the frontal lobes of the brain, particularly a lesion in the frontal ventromedial area, the potential for aggression and violence is not uncommon. Prefrontal cortex damage is also implicated in aggressive behaviour as this structure is needed for judgement, reasoning, emotional and body reaction, and impulse control. Mild brain injury such as a concussion is extremely common. Dailey et al. (2018) found the integrity of the white matter in the area of the corpus callosum post-injury significantly to be correlated with greater aggression, particularly in the chronic phase of recovery. Traumatic brain injury can lead to anger, aggression, and violence in the acute, recovery, and rehabilitation stages. This is dependent on the amount of damage, the severity, and, most importantly, the centres of the brain involved, particularly the prefrontal and temporal cortices. Injuries in these areas also affected attitudes about aggression and violence Epilepsy is a neurological disorder. For years, aggression and vio- lence were thought to be symptoms. Understanding the true cause of the behaviour is essential to providing the most appropriate treatment. Aggression and violence are only factors for a minority of these patients. Violent outbursts occurring in the postictal phase of recovery are related to the adverse effects of certain antiepileptic medications, not the disease itself. The concurrent use of the beta-blocker pindolol can significantly decrease these episodes. ___________ Neurochemical The neurotransmitters serotonin, dopamine, gamma-aminobutyric acid (GABA), glutamate, and acetylcholine all have an impact on anger and aggression _________ Neurodevelopmental Mental health disorders, cognitive disabilities, and conduct disorders should be assessed when anger, aggression, and violence are factors in caring for children and adolescents. There are implications for individuals diagnosed with fetal alcohol spectrum disorder or neonatal abstinence syndrome. This history can be helpful in adult assessment and treatment as well.

Answer 380

The neurotransmitters serotonin, dopamine, gamma-aminobutyric acid (GABA), glutamate, and acetylcholine all have an impact on anger and aggression. Neurotransmitters stimulated in the alarm stage of the general adaptation syndrome can also trigger outbursts, particularly when the body is flooded with adrenalin and in the fight/flight mode (see Chapter 5). Dopamine too, has been linked to aggressive outbursts. There is some indication that this may be based on whether a reward–avoidance pro- cess is present during the dopamine transmission. Chester et al. (2016) found that individuals with low dopamine systems were more likely to seek external rewards through activities such as thrill-seeking, sub- stance use, and acts of risk and violence. The hormones adrenalin and testosterone play significant roles in the arousal of anger and subsequent excitability that can lead to aggression or violence. Fluctuating hormonal changes during pregnancy and menopause are examples. Steroid hormones can influence the ability to cope with or express anger, particularly in pubescent, adolescent, and young adult males who experience surges in testosterone. Research reveals that higher lev- els of testosterone combined with low levels of cortisol in males are positively associated with impulsivity and aggression. Thyroid dysfunction can also contribute to anger, aggression, and violence.

Answer 381

No one factor can be identified as the source of anger, aggression, or violence. All are at least to some extent, unique to the individual. Emotional intelligence, personality, and personal power are factors. Behavioural, cognitive, cognitive behavioural, and social learning theories offer insights into how anger, aggression, and violence manifest themselves.

Answer 382

perception is how we become aware of something. We perceive, then we interpret. The perception of emotions is called emotional intelligence and it plays a crucial role in the psychology of anger. Over time and with experience, a person develops a sense of how others are expressing emotions and learns to interpret these and respond accordingly. They also learn to imitate the emotions of others. Recognition accuracy is important to form appropriate responses. Misinterpretation of the emotions of others such as perceiving anger, insult, or rejection can arouse fear and an angry or aggressive response. Emotional intelligence and emotional regulation are issues present in cyberbullying, particularly among youth. Beck (1976) theorized that a perceived assault on areas of personal domain (e.g., values, moral code, self-esteem) can lead to anger (see Chapter 5). Implications for Nurs- ing: research shows that the development of emotional intelligence and teaching emotional regulation with young people can mitigate issues later in life. At any age, counsel- ling, individual or group psychotherapy, and psychoeducational programs are beneficial.

Answer 383

In general, personality is organized around a person’s characteristic traits, way of thinking, feeling, and doing. Personality traits combine to create personality type. Trait aggression is typical of persons with psychopathy, narcissism, and others lacking empathy. _____________ The theory of locus of control (LOC) was first introduced by Rotter (1966) and has proven significant in the field of mental health. Today, it is conceptualized as empowerment: personal power. LOC and self- efficacy are related. We all wish to exert and maintain control over our lives. Loss of same can lead to mental health problems and sometimes, critical incidences. ___________ An internal LOC exists when one has a sense of control over the external world. A person who believes that they have a strong, positive internal LOC believes that any rewards and successes that occur are the result of self-efficacy. Happiness and satisfaction are based on a positive internal LOC. Internal LOC works conjointly with problem-solving abilities and is more likely to produce better coping and successful outcomes. ____ A person with an external LOC is more likely to feel powerless and blame others for what occurs. This person sees themself as a victim of life or, at least, of the situation. When our personal power is threat- ened, we can experience psychological strain, even briefly, and that may precipitate an incident of anger, aggression, and violence. Con- sider that medication non-adherence, for example, may sometimes be an act of passive aggressiveness. Or consider the adult patient on a psychiatric unit who is held under the Mental Health Act and wants to leave or have various freedoms restored for those patients who are restrained and secluded. Loss of freedom and loss of personal power and control decreases a person’s aversion to risk, self- harm, or harming others. Implications for Nursing: interventions often reflect LOC theory as we strive to empower patients to manage their own care. This is also seen in non-violent crisis intervention; trying to allow as much personal control over a situation as deemed appropriate and safe.

Answer 384

Twentieth-century psychologists like B.F Skinner, I. Pavlov, and J. Watson studied how behaviour is connected to the mind by a stimulus-reward/ avoidance response. Behaviourist theory explains how rewards for acting with aggression and violence can have perceived re- wards of power, need gratification, and improved social status no mat- ter how fleeting these may be. Behaviourism is still one of the relevant theories used when exploring crime. Its tenets are also applicable to bullying, social anxiety disorder, eating disorders, and more. Implications for Nursing: behav- ioural approaches can be found when working with those with brain injury, cognitive deficits, intellectual disability, and some autism spec- trum disorders when anger, aggression, and violence are issues. These can include variations of behaviour modification and step program- ming. Aspects of behaviourism form part of cognitive behavioural treatment modalities.

Answer 385

Albert Ellis’s (1973) seminal works discussed irrational thinking. In this theory self is paramount and there is personal confusion about why others do not respond in ways one thinks they should. For example, a person who believes that they should be loved and accepted by absolutely everyone at all times is demonstrating irrational or faulty thinking. The irrationality here is the abiding belief in should and must. As a result, anger, hostile aggression, and violence are not uncommon behaviours, nor are suicide or self-harm. Acting out is a maladaptive attempt to deal with a perceived sense of rejection, devaluing, or disrespect and to deal with their inability to feel satisfied, loved, and accepted. Ellis (1990) believed that long- term suppression of anger may decrease the ability to deal effectively with new anger-provoking stimuli. Implications for Nursing: cogni- tive therapy examines the extremisms, faulty thinking, and personal belief systems and attempts to restore rational thinking. Cognitive behaviorism focuses on how thinking and behaving are intertwined and how reasoning and action may be faulty or based in false beliefs. Cutting edge theorists Beck, Emery, and Greenberg (2005) expanded Beck’s original theory by looking at dysfunctional anger. They found it was rooted in our predispositions, beliefs, memories, learning, and interpretations of self and others in relation to self. For example, self- appraisal of efficacy leads to confidence. This contributes to how we deal with all situations, including perceived threats. For example, a person predisposed to speaking their mind, seeking immediate need gratification, and having learned it is indeed possible to get this through anger and acting out exhibits dysfunctional anger to achieve goals. Sometimes it is successful and oft times it is not. Still, the behaviour is not extinguished, and this maladaptive anger/aggression response can continue for years until a crisis or desire to change oc- curs. Implications for Nursing: cognitive behaviour therapy includes not just working also restoring rational thinking but also developing and practicing positive changes in behaviour as well.

Answer 386

Social learning theory considers imitation, modelling, influence, asso- ciations, and rewards on behaviours. Bandura’s (1973) original social learning theory asserted that children learned aggression by imitating others and that people repeated behaviour that was rewarded. In other words, children exposed to violence often grow up to be aggressive and violent because that behaviour was originally imitated and subsequently rewarded. Using this reasoning, children who are disciplined or punished with disproportionate force and those exposed to violence on television, in music lyrics, images, and video games learn that violence is an option for resolving conflict and that those violent acts have no real negative consequences. Even so, benefits for angry, aggressive, and violent actions are often intermittent and short lived and, in that regard, are not satisfying or adaptive overall. Other variations of social learning theory have been applied to understanding gang violence and interpersonal violence, assessing the effects of violence in the media. Implications for Nursing: psychoeducational programs that focus on building empathy, cooperation, and respect are beneficial. Access to positive role-modelling in relation- ships, groups, and teams is therapeutic.

Answer 387

Social factors influencing responses of anger, aggression, or violence can also be external. The SDOH including parenting, poverty, educa- tion, health, and food affect one’s sense of safety and security. When basic needs are not met, that is, when the determinants are not met, fear, anger, resentment, a sense of injustice, etc., can all lead to aggres- sive and violent actions. Other important demographics include a history of violence, male gender, age 14 to 24 years, substance use, inadequate support system, and a history of prison time. A history of limited coping skills increases risk for using violence. Implications for Nursing: comprehensive social history-taking for the present and past are important. Engaging members of the interdisciplinary team for in-patient and/or community care are essential for a well-balanced approach to reaching the SDOH. Co-occurring counselling or group therapies for anger management may be indicated. In a multi-cultural context this difference in expression of anger provides a challenge to both nurses and patients. Language difficulties and culturally based acceptance of how anger is and can be expressed can easily confound a person’s abilities to experience and deal successfully with an anger-producing situation. In Western cultures the functionality of anger is acknowledged and accepted. The expression of anger is a way to protect rights, personal freedoms, and self-esteem. Anger is seen as a means to find clarity. In other cultures the expression of anger would be seen as inappropriate and disrespectful. Implications for Nursing: achieving a degree of cultural awareness and cultural knowledge is the first step to providing culturally sensitive and appropriate care even within the Western con- text of healthcare.

Answer 388

Historical trauma is a lived experience of the Inuit, First Nations, and Métis peoples in Canada. It stems from systemic, cultural, and spiritual oppression. For Indigenous people, lateral violence (internalized colonialism) refers to how suppression of the effects of colonialism, oppression, inter-generational trauma, and racism has found release in acts against each other: acts of in-group violence. Incidents can transpire between individuals, within a group, or be endemic in communities. It can exist between the various Indigenous peoples as well. This type of lateral violence is not connected to any one immediate triggering situation but rather to multiple factors over a very long period. These include voicelessness and powerlessness of individuals and populations.

Answer 389

A person’s history of violent behaviour is the most important indicator of risk for future incidents. Initial and ongoing assessment of the patient can reveal problems before they escalate to anger and aggression. These can include increased demandingness, irritability, frowning, redness of the face, pacing, twisting of the hands, or clenching and unclenching of the fists. The rate and volume of speech may be increased or may be slowed, pointed, and quiet. Any change in behaviour from what is typical for that patient must be noticed. The Risk Assessment Guide highlights various predictors and risk assessment criteria for aggression or violence. Assessment of the environmental stimuli that precede a patient’s agitation should be included. Once the assessment is complete, a nursing care plan (NCP) is developed. General assessment should also include history. For some, traumatic histories can impede a patient’s ability to self-soothe, resulting in negative coping responses and creating a vulnerability to coercive interventions by staff.

Answer 390

refers to care focused on the patient’s past experiences of violence or trauma and the role it currently plays in their lives. When a history of trauma is present, it is important for the nurs- ing team to be aware of this and to avoid any situations that may retrau- matize the patient. Consider the following examples: * A woman who was raped may be re-traumatized by being catheterized for a medical procedure years later. She lashes out in blind anger. * An Indigenous person who was starved and beaten in a residential school as a small child may be re-traumatized by the lights and sounds in the environment when hospitalized, especially at night, or may be triggered when meals are late or reflective of the types of food from that earlier traumatic time. He withdraws and is noncom- municative, staring and glaring, or abruptly throws his meal tray. * A Canadian veteran who was wounded and confined as a prisoner by the enemy years ago may be re-traumatized if confined to a hospital bed in traction. They may be verbally aggressive and even lash out physically in response to the situation.

Answer 391

Nurses may have their own histories of anger, aggression, and violence, and these experiences can influence their ability to intervene safely and effectively in a similar incident. It is essential to be aware of personal dynamics that may trigger non-therapeutic emotions and reactions with specific patients. Nurses should use self-reflection to identify any personal triggers such as certain words, tone of voice, or non-verbal communication. Finally, the nurse must assess situational factors (e.g., personal fatigue, insufficient staff on duty) that may decrease one’s normal ability to manage complex patient problems such as acting out. Self-assessment promotes calm responses to patient anger and poten- tial aggression. These responses are further supported by the creation of an environment that encourages staff to express feelings with each other, use humour, and develop a professional support system.

Answer 392

Initial Risk Assessment: History of aggressive behaviours Feelings of ... * Frustration, fear, anxiety, embarrassment, shame, or rejection * Irritability, hypersensitiv- ity to perceived criticism, or attempts by others to control Voicing ... * Lack of control over life or situation * Defiance * Need for support of anger from others Behaviours indicative of ... * Hyperactivity, impulsivity, or withdrawal * Confusion or delusions * Intoxication or other im- pairment * Sullenness or pacing Thinking.... * Rumination * Decreasing concentration Assaultive Stage—Risk Assessment History of limited coping skills increases risk for using violence Voicing ... * Verbal abuse (profanity, argumentative- ness, threats) * Loud voice; change of pitch; or very soft * Negative or hostile response in the con- text of limit setting by the nurse Thinking (cognition or decision making) ... * Narrowed field of perception; judgement * Diminishing ability to recognize the anger * Diminishing ability or desire to diffuse own anger * Inability to differentiate between asser- tiveness and aggressive expressions of anger * Plan, wish, or intent to harm and capacity or means to do so * Possession of a weapon or object that may be used as a weapon (fork, knife, rock) Behaviours ... * Hyperactivity most important predictor of imminent violence (pacing, restlessness) * Increasing anxiety and tension (clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self, short- ness of breath, sweating, and rapid pulse) * Intense or avoidant eye contact * Assault (hitting, punching, striking, throw- ing, intimidating, or threatening) * Voice, forcing others to strain to hear

Answer 393

A nursing diagnosis may identify maladaptive coping with anger, frustration, or any other emotion/situation that might trigger inappropriate behaviour by the at-risk patient. Or it might target low frustration tolerance and risk for aggression. The nursing diagnosis will be unique to the patient and set in the here and now.

Answer 394

Nursing outcomes (goals) will focus on anger management, emotional regulation, self-control, and safety for the patient. Concurrent or subsequent NCPs will need to address the pre– and post–acting out situations. Examples of goals might be that: incidents of angry, aggressive outbursts will be less frequent; the patient will seek out nurse for assistance early on when feelings of anger or agitation begin, to prevent escalation; and the patient will utilize anger control measures. Once identified, all outcomes require an evaluation date.

Answer 395

Planning interventions requires a sound assessment of history, present coping skills, and the patient’s willingness and capacity to learn alterna- tive and non-violent ways of handling angry feelings. In addition, the nurse needs to consider whether: * The situation calls for: * Psychoeducational approaches to teach the patient new skills for handling anger * Immediate intervention to prevent overt violence (e.g., de-escalation techniques, restraint or seclusion, medications) * The environment provides: * Privacy for the patient * Enough space for patients * A healthy balance between structured and quiet time * Adequate personnel to safely and effectively deal with potentially violent situations * Staff skills call for: * Education in verbal de-escalation techniques * Education about positive and consistent approaches to patients * Education for appropriate use of restraints

Answer 396

Ideally, intervention begins prior to any sign of escalation of anger. This intervention includes developing a trusting relationship with the pa- tient by having numerous brief, non-threatening, non-directive inter- actions to get to know the patient. In certain settings (e.g., crisis units, emergency departments) episodes of patient anger and aggression can be predicted; therefore education and practice of verbal and non-verbal interventions with patients and staff are essential. Cultural competency is an essential part of staff education.

Answer 397

A nurse can model appropriate responses and ways to cope with anger, teach a variety of methods to appropriately express anger, and educate patients regarding coping mechanisms, identification of personal triggers, de-escalation techniques, and self-soothing skills to manage emotions. Skilled nurses can lead anger management, coping, and emotion- al awareness/regulation groups. Skills include removing themselves from a situation or taking a personal time out. Working with patients to explore their own psychological and somatic responses to anger or anger-provoking stimuli enhances self-awareness related to personal triggers and facilitates learning about how to intervene and exert self- management skills during these stressful events. Once trust is established between the nurse and patient, the nurse may begin to challenge discrepancies in what that person believes, says, or does. Challenges or the therapeutic use of assertiveness skills to present a reality check for the person and lead them to circumspection are essential for growth. To use this skill, it is vitally important that the nurse moderate tone of voice, non-verbal behaviours, and so forth so as not to appear judge- mental or hostile in any way. The goal is to open communication and self-exploration in a non-threatening way.

Answer 398

A multi-disciplinary approach is important for a patient with behavioural issues. Consistency and planning are key to the patient’s success. Intervention strategies should be discussed during treatment team meetings and with the patient before implementation. The discharge plan may be composed of follow-up mental health care, anger management programs, and cognitive behavioural therapy.

Answer 399

Behaviours rarely occur in a vacuum. A thorough, proactive examina- tion of the environment is important when considering the potential for anger and aggression on a unit. It is hard to determine how the stimulation of any unit might affect someone whose anxiety is ex- tremely high or who is delusional or confused. Patient’s ability to cope with their acute illness is confounded by unfamiliar environments full of unfamiliar and often unpredictable fel- low patients. Frequent rounds on the unit are important as part of the ongoing assessment of the milieu and the patient’s response to it. Quiet rooms. If a patient is escalating but has enough self-control, a time-out in their room may be sufficient to enable the person to regain composure. Many inpatient psychiatric units, group homes, residential care facilities, and correctional centres offer a therapeutic quiet room. The room is partially lit and has relaxing music and comfortable fur- niture that promote feelings of security and safety. Individuals are free to avail themselves of this therapeutic space. However, in many institutions, quiet rooms are locked and used as seclusion rooms. The deci- sion to lock the door is based on the patient’s risk assessment and the discretion of the multi-disciplinary team. Staff safety. Staff should all know which colleague is working with a potentially violent patient, keep an eye on the interaction, and be pre- pared to intervene if the situation escalates. At that time, other patients should be moved away from the incident, and the environment around the specific patient should be free from any object that could be used as a weapon. On psychiatric units, policies and procedures for working as a team in a critical incident of violence (or potential for violence) are in place. All staff should become familiar with the protocols. Discuss- ing and rehearsing the protocols ensures confidence, safety, security, and trust. De-escalation techniques. As the nurse determines a patient’s emotional state, intervention begins. During this process, the nurse lis- tens to the patient’s story and acknowledges their needs. Summarizing what the patient has said demonstrates the nurse’s empathy, compas- sion, and acceptance of the patient. Acceptance of the patient does not indicate an acceptance of aggressive or violent behaviour. It is impor- tant to clearly and simply state expectations for the patient’s behaviour. In some situations the anger may not be resolved before the risk for violence arises. Approaching an angry patient can be unnerving or frightening. The goal is to facilitate the expression of anger in an adaptive, non-violent manner. When approaching the patient, the nurse will convey a calm, relaxed, open, non-threatening, and caring demeanour. The ability to maintain a calm exterior while feeling inner distress comes with experience. The nurse needs to pay attention to the environment. If the patient is in a state of low arousal, choose a quiet place to talk that is visible to other staff. This approach is most beneficial in helping a patient to regain control. If the patient is in a state of moderate arousal, pac- ing up and down a corridor together while the patient vents can be effective. The use of advanced communication skills to de-escalate the situation can help to dissipate pent-up energy fueled by the release of neurotransmitters and hormones. This technique is helpful when the patient is unable to use the flight response and may feel trapped. Personal space changes when the body and mind are in a height- ened state of arousal. Patients in the pre-assaultive stage need much more space. Do not crowd the patient in or attempt to touch them. Allow the patient enough personal space so that you are not perceived as intrusive, but not so much space that the patient cannot speak in a normal voice. Always stay about 30 cm (1 foot) farther than the patient can reach with their arms or legs. An agitated, angry, aggressive patient may invade the nurse’s space physically and with verbal abuse and profanity. This means of com- municating may be the only way the patient can express their feelings. As uncomfortable as this kind of communication may make someone feel, the nurse cannot take the patient’s words personally or respond in kind. During an escalating situation is not the time to forbid the patient to communicate in this way or to end the conversation because of the patient’s inappropriate word choices. Keeping the focus on the here and now and what needs to be done are priorities. The nurse should reflect that back in a calm tone during any barrage. The patient who is about to lose emotional control cannot be abandoned. For the protection of the patient and others, the nurse needs to remain engaged while a pre-planned crisis intervention begins to unfold. Even so, safety for the nurse is critical. Knowledge of crisis intervention techniques including staff safety plus the employer’s policies prior to such a situation is of the utmost importance. As escalation increases, the patient’s ability to process stimuli decreases. The nurse should keep their voice audible but at a lower volume than the patient’s. Eventually, the patient will match it and begin to listen more closely. The nurse will be sure to speak at an appropriate level and not whisper. Words must be chosen carefully, be spoken in short sentences, and be clear and concise, and the nurse must actively listen to the patient’s responses and concerns. The use of open-ended statements and questions elicits the patient’s thoughts. Punitive, threatening, accusatory, or challeng- ing statements are avoided completely. They can too easily overwhelm. Honest verbalization of the patient’s options encourages the individual to assume responsibility for choices made. During the pre-assaultive stage, it may be strategic to give two options, such as “Do you want to go to your room or to the quiet room for a while?” Do not give more than two options at any time, to avoid overloading the patient’s ability to process. Giving choice decreases the sense of pow- erlessness that often precipitates violence. This is quite appropriate in the anger stage, but not during the assaultive stage. In the pre-assaultive stage the patient’s lack of clarity in thinking and poor decision mak- ing become key elements in the intervention. Therefore open-ended questions create too much confusion. The nurse might say, “Some quiet time in your room might help now,” or “The quiet room is free.” Again, the nurse’s voice is calm and confident, with a tone that demonstrates that these statements to the patient are options, not directions. In the assaultive stage seclusion, restraint, or pharmacological means of de-escalation may be necessary to ensure the safety of patients and staff. These measures should be used only when other interven- tions have failed. Canadian care facilities are mandated by policies that dictate the use of the least restrictive means to care for patients when- ever possible. Nurses are also guided by position statements set out by their regulatory bodies. Engaging the angry or aggressive patient. rior to engaging an angry or aggressive patient, the team must ensure that sufficient staff members are available for support. As everyone prepares, confronta- tion with the patient should be avoided. The technique of immediacy is used instead. If security personnel are called to stand by, they should stay in the background until they are asked to assist. In a potentially volatile situation staff should not stand directly in front of the patient or in front of a doorway; this position could be interpreted as confrontational. Standing slightly off to the side is safer and more appropriate. The patient can be encouraged to have a seat. An angry person may sit. An aggressive person will not. If a patient’s behaviour begins to escalate, provide feedback: “You seem to be very angry.” This reflective statement allows exploration of the patient’s feelings and may lead to the early de-escalation of the situ- ation. If the patient validates this, invite them to sit down and talk about it using a closed-ended statement, “Let’s sit down and talk about it.” If any staff member believes that the aggression and violence are going to require additional help, a Code White can be called. Generally, the first staff member on the scene is the only person who should talk to the patient. That person takes the lead while other staff maintain an unobtrusive presence. They may be directed to call for additional help, prepare a seclusion room, gather restraints, or prepare to give medications.

Answer 400

* Intervene as early as possible; alert team * Assess for personal safety; quick environmental scan * Assess the patient and the situation for stressors and stress indicators * Focus on the patient; active listening and eye contact * Establish what the patient considers to be needed * Maintain calmness for self and patient * Use a calm, clear tone of voice; appropriate eye contact * Speak clearly and concisely; short sentences only * Maintain the patient’s self-esteem and dignity * Be factual * Remain honest; genuine, respectful * Maintain a large personal space * Stay in the here and now * Make the options clear SAFETY TIP Personal space changes when the body and mind are in a heightened state of arousal. Patients in the pre-assaultive stage need much more space. Do not crowd the patient in or attempt to touch them.

Answer 401

When a patient is showing increased signs of anxiety or agitation that may foreworn anger, aggression, or violence, it is appropriate to offer antianxiety or antipsychotic medication to alleviate symptoms. When used in conjunction with psychosocial interventions and de-escalation techniques, these medications may prevent violent acting out. How- ever, when dangerousness escalates and pharmacological restraint is needed, prn or stat medications are appropriate. Medications that are quick acting and easily administered in this type of situation (oral or intramuscular) are the best choices. Second-generation antipsychotics and benzodiazepines separately or in combination are commonly used. For patients who are psychotic, antipsychotic medication is the first priority. It is the nurse’s role to assess for appropriateness of prn medications. Many patients feel traumatized by the use of intramuscular injections; therefore the decision to use this route of administration needs to be determined by what is in the best interest of the patient and the speed with which effects of the medication are needed and what orders are available. Nurses must provide the patient with information about the medication, the reason it is being given, and potential adverse effects, even if the patient is out of control. The long-term treatment of anger, aggression, and violence is based on treating the underlying psychiatric disorder. Selective serotonin reuptake inhibitors (SSRIs), lithium, anticonvulsants, benzodiazepines, atypical antipsychotics, and beta-blockers are all used successfully for specific patient populations. Clozapine is generally the medication of choice for persistent aggression and hostility in refractory schizophrenia. For rage and severe, persistent agitation, anticonvulsants such as carbamazepine and gabapentin are often used. Anger and aggression related to autism spectrum disorders may be reduced through the use of psycho-stimulants, but caution should be used in adults. Lithium provides some control for irritability, agitation, and aggression for those with intellectual disabilities.

Answer 402

Combinations of fast-acting antipsychotics and antianxiety medica- tions: for moderate to severe, acute agitation; escalating violent behaviour Haloperidol + lorazepam (Ativan) + benztropine (Cogentin) Loxapine (Loxapac) + lorazepam (Ativan) + benztropine (Cogentin) _______________ Antianxiety medications (Benzodiazepines): for acute, mild to moderate agitation and anxiety; intoxicated or patients in acute withdrawal Lorazepam (Ativan) Diazepam (Valium) ______________ First-generation antipsychotics: for acute psychosis, agitation, aggres- sion, disturbed, unpredictable behaviours Haloperidol Chlorpromazine Loxapine (Loxapac) (Note: also indicated for acute mania) _______________ Second-generation antipsychotics: for acute psychosis, agitation, aggres- sion, unpredictable behaviours Risperidone Olanzapine (Zyprexa, Zyprexa Zydis) Zuclopenthixol acetate (Clopixol-Acuphase) Ziprasidone (Geodon) (Note: also indicated for acute mania) ________________ Antihistamine: for acute agitation Promethazine

Answer 403

Restraint is an intervention used to decrease the patient’s ability to harm themselves or others. It is only used if the patient presents a clear and present danger to self or others. Restraints of any type should be used only when alternatives fail to protect the patient and others from harm. 1. Environmental restraint: seclusion is an example of an environ- mental restraint. Movement is restricted to a defined area or locked room. The situation is temporary, the patient is alone, and there is no furniture or other amenities in the room. 2. Physical/mechanical restraints: any method whereby limbs or trunk are held down, that is, movement is restricted against the will of the patient (e.g., transfer belts, four-point restraints, Pinel or Posey restraints, locking geriatric chairs, strong sheets). In some jurisdictions, in an emergency situation, nurses are able to restrain prior to getting an order, for example, restraining a patient in the emergency room who is high on drugs or acutely psychotic and acting out. Nurses must be absolutely clear on their standards, rights, and obligations under their registration and other legisla- tion prior to attempting this. 3. Chemical restraints: also known as pharmacological restraint, is achieved through the use of medications, with the sole intent of managing behaviour. Comprehensive assessments of behaviours, patient’s needs, and safety must be taken into account first. Alternatives should be sought, particularly with the elderly or cognitively impaired. Many precautions need to be taken legally and ethically by the nursing staff regarding the use of chemical restraints. The rationale for the use of chemical restraint must be clearly articulated in all documentation.

Answer 404

Use of seclusion. Prior to seclusion, a patient must be assessed for contraindications including pregnancy, chronic obstructive pulmonary disorder, head or spinal injury, seizure disorder, abuse, history of surgery or fracture, morbid obesity, and sleep apnea. Seclusion results in the removal of external stimuli by placing the patient in a locked private room. A patient can only be secluded or restrained with an order from a psychiatrist or physician in accordance with a provincial or territorial mental health act or other policy. Staff work as a team when secluding a patient. The team leader briefly describes the rationale for seclusion and directs the team. One nurse prepares the seclusion room while others promote safety and privacy by clearing the area of onlookers, maintaining the patient’s pri- vacy and dignity. A nurse prepares prn or stat medication. Options are provided to the patient, including taking a time out, accepting medication orally, or walking with the nursing team into the seclusion room. When these options fail, the staff intervenes to physically restrain the patient and escort them into seclusion. The patient may be required to change into pyjamas and medication may be administered despite patient objections. One by one, team members back out of the room, locking the door behind them. Close or constant observation protocols are initiated per hospital policy. The patient remains in seclusion until assessed as being less at risk for harm to self or others. Reintegration to the unit after restraint or seclusion occurs when the patient is assessed as being able to handle increasing amounts of stimulation. Reintegration should be gradual. If the process proves to be too much for the patient and increased agitation results, the individual is returned to the seclusion room or another quiet area, or restraints are reapplied. Prior to release from restraint or seclusion, patients must be able to follow directions and control behaviours. With restraints, a structured reintegration is the best approach. Begin by removing one of the four-point restraints, then another, and so on. Close observation of the patient is essential as the restraints are removed and for several hours afterward. If the patient is unable to manage their behaviour, further seclusion or restraint may be nec- essary. Following seclusion of a patient, the treatment team should debrief the incident and when seclusion is discontinued, the nurse and patient should also debrief. Incidents that require the use of seclusion or restraints provoke anxiety for the staff and may trigger their stress responses. Skills in non-violent crisis intervention techniques are essential. Nurses should not be put into positions such as these without this additional training.

Answer 405

Indications for Use * To protect the patient from self-harm * To prevent the patient from assaulting others Legal Requirements * Multi-disciplinary involvement * Appropriate health care provider’s signature according to provincial and territorial law * Patient advocate or relative notification * Restraint or seclusion discontinuation as soon as possible Documentation Describes * Patient’s behaviour leading to restraint or seclusion * Nursing interventions used and the patient’s responses (including least re- strictive measures used prior to restraint or seclusion) * Evaluation of the interventions used and patient’s response Plan of Care for Restraint Use or Seclusion Implementation * Ongoing evaluations by nursing staff and appropriate health care providers * Method of reintegration into the unit milieu * Evidence of least restrictive measures used prior to restraint or seclusion * Critical Incident or Unusual Occurrence Report form completed Clinical Assessments * Patient’s mental state at time of restraint or seclusion (i.e., pre-assaultive, assaultive, post-assaultive) * Physical examination for medical problems possibly causing behaviour changes * Need for restraints or seclusion Observation and Ongoing Assessment * Staff in constant or close attendance * Written record completed every 15 minutes * Range of movement frequently assessed if limbs are restrained * Vital signs monitored * Circulation assessed: blood flow observed in hands or feet * Observation to ensure that restraint is not rubbing or causing friction on skin * Provision for nutrition, hydration, and elimination Release Procedure * Patient able to follow commands and stay in control * Termination of restraints or seclusion * Debriefing with patient

Answer 406

Caring for hospitalized patients who exhibit signs of anxiety begins with listen- ing to the patient’s story and helping the patient to identify immedi- ate goals. This kind of response can build rapport and reassure the patient. Mild anxiety can be moderated by the provision of comfort items before they are requested (beverage, deck of cards, access to TV). Interventions for anxiety might also include the use of distractions such as magazines, action comics, and video games. Generally, distrac- tions that are colourful and do not require sustained attention work best, although the choice of distraction varies according to the patient’s interests and abilities. Patients with a high level of baseline anxiety and limited coping skills are helped when their interactions with the treat- ment team are predictable. Visits by a chaplain or a volunteer may help by giving the patient more attention. Anxiety can also be minimized by reducing ambiguity. This strategy includes clear and concrete communication. An interaction providing clarity about what the nurse can and cannot do is most usefully ended by offering something within the nurse’s power to provide (i.e., leaving the patient with a “yes” or “I’ll see what I can do about that.”). When a patient is anxious, frustrated, angry, or fearful, pacing with the patient up and down the corridor can be a helpful strategy. Open communica- tion and active listening while walking together are therapeutic.

Answer 407

A patient loses autonomy and control when hospitalized. This can cause a great deal of stress and distress. When this stress is combined with the uncertainty of illness, a patient may respond in ways that are not usual for them. A careful nursing assessment, with history and informa- tion from family members/significant others, helps evaluate whether responses are normal coping methods for the patient. Spending one-to-one time with an overwhelmed patient is impor- tant to find a baseline to keep anxiety at a level that is manageable for them. Interventions for patients who generally have healthy cop- ing strategies involve finding ways to support these in this environ- ment or substitute similar means of dealing with the hospitalization. In stressful moments when the patient is struggling to cope or feeling overwhelmed, the nurse acknowledges the patient’s distress, validates how understandable this is under the circumstances, and indicates a willingness to support and collaborate around coping. Validation and genuine caring also include making an apology to the patient when appropriate to alleviate anxiety and ensure the patient knows they are cared for. For example, when a promised intervention (e.g., changing a dressing by a certain time) has not been achieved or acknowledging the patient’s response about the “horrible food” and assisting them in making tastier choices on the menu or asking if they would like to talk with the dietician are all helpful. All of these offer more autonomy to a person who is struggling to cope with the loss of personal power and control. Any angry patient may be unable to temper this emotion sufficiently to problem-solve with their nurses; others may be unable to communi- cate the source of their anger. Often the nurse, knowing the patient and the context of the anger, can make an accurate guess at what emotion is behind the anger and help name it for the patient using a closed state- ment of reflection. Pausing momentarily to let the patient think about this and answer is an important therapeutic technique. Doing so can lead to a sense of being understood and dissipation of the anger. This results in a calmer discussion of the event or issue.

Answer 408

Patients whose coping skills were marginal before hospitalization need a different set of interventions from those who have basically healthy ways of coping. They are poorly equipped to use alternatives when initial attempts to cope are unsuccessful or are found to be inappropriate. Such patients frequently manifest anxiety that moves quickly to anger and on to aggression. For some, anger and intimidation are primary coping strategies used to obtain short-term goals of control or mastery. For others, the anger occurs when their limited or primitive attempts at coping are unsuccessful, and alternatives are unknown. Fear, indignation, and arguing can be gratifying to many verbally abusive patients. For these patients, anger and violence are particular risks in inpatient settings. Marginal- ized coping may not be immediately apparent, and the nurse should watch for patterns and explore with the patient and their significant others. For patients with marginal coping skills, once anxiety is moderated, nursing interventions include teaching alternative behaviours and coping strategies. Implementing appropriate interventions can be difficult when the nurse is feeling threatened. Remaining matter-of-fact with patients who habitually use anger and intimidation can be difficult, as they are often skillful at making personal and pointed statements. It is important to remember that patients do not know their nurses personally and thus have no basis on which to make judgements. It can be helpful for nurses to discuss their thoughts and feelings with other staff members or with the critical incident debriefing team. 1. Leave the room as soon as the verbal abuse begins. Upon doing so, the patient is informed that the nurse will return in a specific amount of time (e.g., 20 minutes) if the situation is calmer. How- ever, if the nurse is in the middle of a procedure and cannot leave immediately, they can break off conversation and eye contact, com- pleting the procedure quickly and matter-of-factly before leaving the room. The nurse avoids chastising, threatening, or responding punitively to the patient. 2. Withdraw attention from the abuse. Withdrawal of attention to ver- bal or emotional abuse is successful only if a second intervention is also used. This step requires attending positively to, thus rein- forcing, non-abusive communication by the patient. Interventions can include discussing non–illness-related topics, responding to requests, and providing emotional support, particularly when the patient is calm and approachable. This technique is quite effective when used in conjunction with the third strategy. 3. Schedule routine interactions. Patients who are verbally abusive may respond best to the predictability of routine. Give the patient the schedule. Routine provides nursing attention that is not con- tingent on the patient’s behaviour; therefore it does not reinforce the abuse. Of course, the patient’s illness or injury may sometimes require nursing visits for assessment or intervention outside the scheduled contact times. These visits can be carried out in a calm, brief, matter-of-fact manner.

Answer 409

there is a potential for aggression and violence for hospitalized patients with chemical dependence. They may be highly anxious about being cut off from the substance on which they depend. They also may have well-founded concerns that any physical pain will be inadequately addressed (Cope- land, 2020). Many chemically dependent patients may see the source of their discomfort and anxiety as being outside themselves (i.e., external LOC) and therefore relief must come from an outside source (e.g., the nurse, medication). These patients exhibit severe frustration intoler- ance and can be quite verbally aggressive. Coping can include drug- seeking manipulative behaviours as well. Anger and aggression can also be used in an attempt to manipulate staff to achieve immediate need gratification, even on a small scale. The pro- vision of empathy, compassion, dignity, and an understanding of the patient’s lived experience with addiction helps the nurse and other staff determine a course of action. Most hospitals have a withdrawal protocol that ensures that patients do not go through with- drawal without medication. Medication administration for chemically dependent patients needs to be provided promptly and consistently to communicate to patients that nurses can be trusted. Other than at medication times, time spent interacting with the patient is impor- tant to build a respectful, trusting relationship as well. Precautionary measures may be in place on the hospital unit to limit certain visitors in order to protect the sobriety or withdrawal. The facility may also have maintenance protocols for chemically dependent patients. These should all be explained and, if warranted, repeated respectfully to these highly anxious patients.

Answer 410

On a psychiatric unit, the potential for hostile aggression and violence is most often demon- strated by those who are acutely psychotic, in a manic phase, substance dependent, or being held under the authority of a mental health act. In psychosis, cognitions are disturbed; misinterpretation of stimuli may occur and rational thoughts are skewed. Impulsivity may also be heightened and judgment impaired. Confusion, fear, paranoia, and mis- interpretation of reality can all contribute to acts of violence. Responses may have some connection to reality or be based in hallucinations and/ or delusions. Acting out with violence may be instrumental or reactive. For example, the psychotic patient may use violence to attempt to leave the unit for fear of being severely harmed or killed there. Implications for Nursing: a combination of an antipsychotic and a benzodiazepine are often given to help calm acutely psychotic patients and help with reducing thought distortions. Restraint or seclusion may be necessitated. O’Reilly et al. (2019) suggest a link between moral cognition and violent acts by patients in psychosis. Generally, moral cognitions include thoughts about justice, standards, and what a person believes to be right and proper. These can be rooted in religion, culture, or soci- ety. For example, using a moral cognition approach, a patient who has very strong beliefs about gender and sexuality may spontaneously violently act out to protect themself from the perceived risk of rape. There is a correlation between psychosis and violence, particularly in early psychosis. On top of that, the risk for violence by psychotic patients increases significantly when there is concurrent substance use. Together, cognitive distortions, lack of insight, and emotional instability are heightened. For risk assessment, this is another reason why nurses need to know what a patient’s delusions are and document them. Delu- sions can have triggers leading to violence.

Answer 411

Patients (or residents) with neurocognitive disorders are particularly at risk for acting aggressively, spontaneously, and dangerously. Risk factors may stem from delirium, dementia, or brain injury. Sometimes patients with dementia become frightened be- cause they are confused. They may become increasingly agitated and even more aggressive. Implications for Nursing: distraction techniques are often helpful to distract the person from focusing on something that is triggering this emotional response. When confusion is the cause, try to have the individual focus on one thing, particularly something fairly plain but that the patient likes is therapeutic. If this is unsuccessful, prn of an antianxiety medication may help. When suddenly and severely overwhelmed by the stimulus in the environment, a catastrophic reaction may happen. Extreme behaviours of screaming, swearing, punching, slapping, or banging are spontaneous and often quite violent. Implications for Nursing: to prevent this, adopting a calm and unhurried manner is the best approach at all times, as is reducing stimuli. Assessment of the patient will set the standard for whom multiple choices should not be given, because they, too, are overwhelming. Staff should never stand or stoop directly in front of patients with dementia but always stay slightly offside to avoid a sudden lashing out. A symbol or colour should appear on the patient/ resident’s chart to alert staff of the propensity for violence.

Answer 412

Evaluation of the NCP is essential for patients with a potential for an- ger, aggression, and violence. Evaluation provides information about the extent to which the interventions have achieved the outcomes. Re- sults of the interventions are evaluated, documented, and the NCP is revised.

Answer 413

* Angry emotions and aggressive, violent actions are difficult targets for nursing intervention, and knowledge plus self-awareness of per- sonal responses to these situations are essential. * Nurses benefit from an understanding of how to intervene with an angry, aggressive, or violent patient.

Answer 414

range from a mild wish to a compelling emotional need for the periodic or continuous use of a drug. Psychological dependence occurs when a drug becomes so important to an individual’s thoughts and actions that the person believes that they cannot manage without the substance. Psychoactive drugs also affect the peripheral nervous system (PNS), creating changes to core biological functioning.

Answer 415

which is a physiological state of cellular adaptation that arises when the CNS and PNS become habituated to a psychoactive agent such that the person physically needs the drug to function or to avoid the physical pain of withdrawal

Answer 416

biological, psychological, and social

Answer 417

do not have the biological element but only the psychological and social elements. Examples of compulsive behaviours that are labelled by some as addictive behaviours, even in the academic literature, are exercising, gaming, gambling, Internet use, pornography viewing, shopping, smartphone use, studying, and work.

Answer 418

No Contact: Prior to a person coming into contact with a psychoactive agent, there is no use and thus no risk. In this stage the individual does not use any psychoactive substances. Just as someone can be predisposed to substance use due to biological (genetic), psychological, or social factors, one’s personal disposition or social environment may dissuade the use of certain substances or behaviours. Precence of protective factors. Experimentation: Individuals begin to experiment with drugs for a range of biological, psychological, or social reasons, such as to feel the effects of different substances; to fit in with peers; to reduce the anxiety of intimacy; and to escape from issues of stress, violence, trauma, and oppression. Integrated Use: Some people may use a substance to enhance an already pleasurable and ongoing experience and therefore consider their use to be a social habit, integrated into their lives and not creating any biological, psychological, or social issues. This can include a glass of wine with dinner or using cannabis before going to sleep. This integrated use of a substance in a socially and culturally accepted manner has few negative consequences. Excessive Use: The misuse or excessive use of a substance results in problems for users and often for those associated with them. People who misuse drugs may experience lapses in memory; experience conflict in their personal, school, or vocational relationships because of impairment; or engage in acts they would not consider when not under the influence of a psychoactive substance. Treatment intervention becomes appropriate when a person has reached this degree of psychoactive drug consumption. Addiction: At the stage of addiction, a person has reached the state where they are physically and psychologically dependent. The person has lost the abil- ity to choose to use, and the drug becomes the central organizing principle of the person’s life. With regular use of a psychoactive substance, a person develops tolerance. Tolerance is a physiological experience that occurs when a person’s reaction to a substance decreases with repeated administrations of the same dose. At this point, if the person attempts to stop using the substance, they may experience symptoms of withdrawal, which entails cravings for the substance of misuse that are accompanied by decreased physical and emotional health. Withdrawal also produces physiological changes as the blood and tissue concentrations of a drug decrease after heavy and prolonged use of a substance.

Answer 419

stimulant, cocaine

Answer 420

The complex combination of both substance use and a mental health condition. This incorporates the entire range of mental health issues from post-traumatic stress to mood disorders to psychosis, for example, an individual dependent upon alcohol with depression or misusing cannabis with schizophrenia.

Answer 421

is pharmacologically unique, giving it the ability to affect all or- gan systems, particularly the CNS, resulting in disorders such as Wernicke’s encephalopathy and Korsakoff ’s syndrome when there is chronic use.

Answer 422

is an acute and reversible condition, whereas Korsakoff ’s syndrome is a chronic condition with a recovery rate of only about 20%. The pathophysiological connection be- tween the two problems is a thiamine deficiency, which may be caused by poor nutrition associated with alcohol use or by the malabsorption of nutrients.

Answer 423

altered gait, vestibular dysfunction, confusion, and several ocular motility abnormalities (horizontal nystagmus, lateral orbital palsy, and gaze palsy). These eye-focused signs are bilateral but not necessarily symmetrical. Sluggish reaction to light and anisocoria (unequal pupil size) are also symptoms.

Answer 424

the more severe and chronic version of Wernicke's

Answer 425

Wernicke’s encephalopathy responds rapidly to large doses of intravenous thiamine two to three times daily for 1 to 2 weeks. Treatment of Korsakoff’s syndrome is also thiamine for 3 to 12 months. Most patients with Korsakoff ’s syndrome never fully recover, al- though cognitive improvement may occur with thiamine and nutritional support.

Answer 426

use also produces esophagitis, gastritis, pancreatitis, alcoholic hepatitis, and cirrhosis of the liver and is associated with tuberculosis, cancer, all types of accidents, suicide, and homicide.

Answer 427

can have negative consequences for the fetus and result in fetal alcohol spectrum disorder (FASD), which is a lifelong issue affecting cognitive ability. FASD is the umbrella term for several different diagnoses, which include fetal alcohol syndrome (FAS), partial FAS, alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBDs). Women who are planning a pregnancy or are already pregnant are strongly advised to abstain from drinking any alcohol. Alcohol exposure during pregnancy is related to decreased placental weight and a smaller placenta-to-birthweight ratio. Alcohol exposure is also associated with an increased risk of placental hemorrhage. Consuming alcohol during pregnancy can cause brain damage to the developing infant, leading to a range of developmental, cognitive, and behavioural problems that can appear at any time during child- hood. People with FASD often have difficulty in a broad range of areas, including coordination, emotional control, socialization, academic achievement, and maintaining employment. Children born with FAS have restricted growth, facial abnormalities, and learning and behavioural disorders that may be severe and lifelong. FAS can lead to is- sues with learning, memory, attention span, communication, vision, or hearing, as well as interpersonal relationship difficulties. Children diagnosed with FAS are easily overstimulated and slow to settle, have difficulties understanding personal boundaries, and have issues with information processing, abstract thinking, and executive function.

Answer 428

have a range of intellectual disabilities and problems with behaviour and learning. They typically do poorly in school and have difficulties with math, memory, attention, and judgment and exhibit poor impulse control. Individuals with an ARBD might have a range of physical problems, typically with the heart, kidneys, or bones, and often have hearing issues as well

Answer 429

Those who use intravenous drugs have a higher incidence of infections and associated problems from infection, including hepatitis and human immunodeficiency virus (HIV), cellulitis, and sclerosing of veins. Those who use intranasal substances may be prone to sinusitis and perforated nasal septum. Smoking substances increases the likelihood of respiratory problems and saliva or airborne infections if sharing pipes, cigarettes, or e-cigarettes.

Answer 430

use, misuse, and physical and psychological dependence and also by certain patterns of behaviour: (1) loss of control of substance consumption, (2) continued substance use despite associated problems, and (3) cravings and a tendency to lapse and relapse after efforts to change behaviour. The reason a person may experience a substance use disorder relates to the inter- section of biological, psychological, and social factors. Biological Factors: neuronal response mechanisms and their adaptive changes through an array of techniques rang- ing from in vitro molecular methods to brain imaging procedures in conscious subjects actively performing a range of behavioural tasks. This research has demonstrated that brain structures do change over time due to exposure to psychoactive drugs until they reach a threshold, at which point the primary symptom of dependence occurs, making it difficult to stop excessive drug use without professional assistance. The brain continually attempts to keep the body at or return the body to a point of balance or homeostasis, and in doing so it will adapt to the prolonged or excessive presence of drugs by making changes in brain cells and neural pathways. When people administer a psychoactive drug, it activates the same reinforcement system in the brain that is normally activated by food, water, and sex, sometimes to a lesser extent but sometimes to a far greater degree. Biological theories have examined the role of the limbic system, particularly the amygdala, the part of the brain responsible for emotions such as fear and anxiety, as being crucial to this process, and the effect of reinforcement of dopamine receptors in the mesolimbic system that originate in the ventral teg- mental area and terminate in the nucleus accumbens. All of these reinforcers share one physiological effect, that is, increased amounts of dopamine being released in the brain either directly or indirectly through other neurotransmitters being activated. During this process, prominent physical changes occur in areas of the brain that are critical to judgement, decision making, learning and memory, and behavioural control. Neurobiological research focuses on four primary areas: * Drug actions on intracellular signaling systems that mediate cell responses * Synaptic plasticity in the course of chronic drug exposure * The role of dopaminergic and other components of the human reward system * Genetic factors that will be examined as a distinct theoretical construct Regardless of which neurobiological theory you favour, scientists now know that psychoactive drugs affect specific neurotransmitters and areas of the brain. Neurotransmitters are chemical signaling molecules in the brain that are used to relay, amplify, and modulate signals between neurons and can be grouped into three categories: * Monoamines, including acetylcholine, norepinephrine, dopamine, histamine, and serotonin * Peptides and hormones, including endorphins, cortisone, and nitric oxide * Amino acids, including gamma-aminobutyric acid (GABA) and glutamate

Answer 431

All of the approximately 100 identified neurotransmitters that carry chemical information between cells follow the same chemical trans- mission pathway. However, they can act in different ways on this path- way. First, a neurotransmitter is released from the sending neuron into the synaptic cleft from a storage vesicle located in the axon terminal. The neurotransmitter then diffuses (travels) across the synaptic cleft. On the receiving neuron, there are specialized receptor areas that are designed to receive one type of neurotransmitter and bind with it. As more and more binding occurs, an electrical signal begins to form in the receiving neuron, and when a sufficient amount of the neurotransmitter is bound, an internal electrical charge is generated and the mes- sage is sent forward, following the same pattern of transmission. Once the charge is generated, the neurotransmitter may be broken down by enzymes in the cleft and thus deactivated or actively transported back to its point of origin, the axon terminal of the sending neuron

Answer 432

* Blocking the reuptake of a neurotransmitter back into the axon terminal, allowing more of the neurotransmitter to be available for binding, thus enhancing the message (cocaine) * Pushing more neurotransmitters out of the storage vesicles into the synaptic cleft, increasing the opportunity for binding and thus enhancing the message (amphetamines) * Enhancing the binding to the neurotransmitters to further enhance binding to the receptor site to enhance the message (diazepam) * Blocking the enzyme from breaking down the drug in the synap- tic cleft, allowing more neurotransmitters to bind to their receptors to enhance the message (monoamine oxidase inhibitors [MAOIs], which are antidepressants, such as phenelzine [Nardil] and tranylcypromine [Parnate]) * Mimicking neurotransmitters and binding directly to receptor sites, but not allowing a message to be transmitted (naloxone). The main systems that seem to be involved in substance use are the endorphin, catecholamine (especially dopamine), serotonin, endocannabinoid, and GABA systems. Cocaine, amphetamines, and lesser stimulants increase levels of norepinephrine, serotonin, and dopamine.

Answer 433

Opioid drugs act on endorphin receptors with a secondary effect on dopamine. Alcohol and other CNS depressants will act on GABA receptors and, as a result, increase the bioavailability of glutamate, norepinephrine, and dopamine. Hallucinogens act to varying degrees on serotonin, whereas cannabis acts on endocannabinoids

Answer 434

Among the earliest investigations into why people became addicted to substances were learning theories that studied stimuli that give plea- sure, relief, or excitement and how reliably and quickly these effects could be produced. Fundamental to this perspective is the belief that people will repeat any behaviour that brings them some kind of plea- sure or reward and will discontinue any behaviour that brings them discomfort or punishment. If a drug brings pleasure or relief in a stressful situation, reduces anxiety or fear, or provides status or popularity in an insecure or lonely situation, its use will become a repeated behaviour. Tolerance is also an important process and is associated with habituation. Habituation is seen through reduced responses to a drug either because of prior exposure to the substance or because of the presentation of environmental stimuli that in the past have reliably predicted the presence of the drug. Under specific circumstances, people who are dependent on opioids have been observed to respond to the mere anticipation of drug effects, to an injection of saline or to an opioid injected while an antagonist is present, as if they had actually administered the drug. Extinction also plays a role and is the pro- cess whereby the link between the previously established behaviours of drug seeking and drug using is weakened until a point is reached when the behaviour no longer has any reinforcing benefit or purpose. This is what the treatment process attempts to accomplish in terminating an individual’s misuse of a psychoactive agent.

Answer 435

Human personality traits have been grouped into five categories: extraversion, agreeableness, conscientiousness, emotional stability, and openness to experience. Of these five, it is the extraversion trait that has been most closely associated with excessive substance use, particularly the attribute of impulsivity. However, the idea of a person having an al- coholic personality had been extremely popular well before the development of the five personality dimensions and contributed to the rise in the popularity of personality tests for those with addiction issues in the mid-twentieth century. The literature generally sides with the view that personality does not predict illness, with research continuing in this area and attempting to determine if those with certain personality characteristics become drug misusers or if drug use creates a specific type of personality.

Answer 436

* Seeking sensuous satisfaction * Conflicts among the components of the self * Fixation in the infantile past Freud stated that alcoholism may be due to the inability to successfully resolve issues among the three components of the self: the id or instinctual striving for at times pleasure and at other times pain relief, the superego or conscience, and the ego or coping component of the person. Failure of the ego to resolve issues between conscience and ba- sic instincts can lead to maladaptive coping responses, including the use of psychoactive drugs.

Answer 437

The core idea of attachment theory is that pri- mary caregivers who are available and responsive to an infant’s needs allow the child to develop a sense of security, which some label as love, enabling the child to explore their environment in a confident manner, knowing that they are protected. Children who are securely attached as infants tend to develop stronger self-esteem and are more sociable and self-reliant as they grow older. They generally become independent and have good school performance, which establishes a foundation for successful adulthood interactions. Individuals who are more securely attached in childhood tend to have good self-esteem, positive romantic relationships, and the ability to self-disclose to others. Attachment the- ory views addiction as an attempt to fill the empty space left by the lack of a secure attachment due to deprivation during childhood, including painful, rejecting, or shaming relationships. Excessive drug use, then, is seen as an individual’s attempt to self-repair psychological deficits and fill an emptiness from childhood.

Answer 438

Culture is a set of thoughts shared by members of a social unit that include common understandings, patterns of beliefs, and expectations. Cultural guidelines are generally unwritten rules of conduct and direction for acceptable behaviours and actions that reflect the morals, norms, and values of a specific group. Cultural theory begins with this premise in attempting to describe and explain the process of drug use in relation to societal norms. Sociocultural factors express the social relationships, politics, and environments beyond individual psychological environments, and thus sociocultural theories attempt to explain differences in the incidence of substance use in various groups. Socio- cultural theorists support the demystification of substance use and the study of drugs within an integrated life model. As early as 1943, Horton asserted that the primary function of alcohol in a culture was to reduce anxiety. Thus substance use would be more prevalent in societies in which anxiety abounds and few alternatives to drinking alcohol and using drugs as tension-releasers exist. These societies would also ex- hibit the highest rates of intoxication. Culture influences alcohol and other socially accepted psychoactive drug use in three distinct ways: * By the degree to which they operate to bring about the acute need for adjustment of inner tensions such as guilt, suppression, aggression, conflict, and sexual tension in their members * By the attitudes toward drinking that they produce in the members seen in information exchange, including advertising * By the degree to which the culture provides substitute means of satisfaction beyond substance use in the form of positive alternative lifestyle options

Answer 439

Assessment of chemical impairment, substance use, misuse, dependence, tolerance, and withdrawal is becoming more complex because of the increase in polydrug misuse, co-occurring psychiatric disorders, and comorbid physical illnesses, including HIV and hepatitis C infections, dementia, and encephalopathy. Also, changes in the diagnostic criteria for substance use and substance-induced disorders lead to changes in practice. Depending on the context of the assessment, acute care, critical care unit, community clinic, or street engaged, different practice guidelines need to be considered. Regardless of the setting, the assessment of the safety of the patient and others is always the priority. Sensitivity to cultural and contextual concerns of patients and families is also important in assessing, interpreting symptoms, making diagnoses, providing clinical care, and designing prevention strategies. Steps to follow in assessment include (1) level of acute intoxication, (2) history and past substance use, (3) medical history, (4) psychiatric history, and (5) psychosocial assessment. General nurs- ing assessment can be augmented with specific substance use assessment and addiction screening, family assessment, and assessment of readiness for change in preparation for interventions.

Answer 440

Acute intoxication and history of substance use are critical aspects of assessment. Although acute intoxication may or may not be obvious, it is crucial for intoxication to be ascertained to ensure an accurate clinical picture and to prevent possible drug interactions or misdiagnoses. Intracranial hematomas, subdural hematomas, and other conditions can go unnoticed if symptoms of acute alcohol intoxication and with- drawal are not distinguished from the symptoms of a brain injury. Therefore neurological signs such as pupil size, equality, and reaction to light need to be assessed, especially in comatose patients suspected of having traumatic injuries. In addition, questions pertaining to alcohol misuse should be asked as part of the assessment of any trauma. Blood alcohol level (BAL), a measurement of the percentage of alcohol in the bloodstream, tested through urinalysis and breath screening de- vices, can be useful for acute assessment purposes. Assessment strategies must include collection of data pertaining to both patterns of substance use and psychiatric impairment. Un- explained exacerbations of psychiatric disorders may be due to acute substance use or to dependence. Substance use can go undetected in patients with depression, anxiety, mania, or suicidal ideation unless a thorough history is taken. Similarly, the understanding and treatment of people with substance use disorders are enhanced by inquiries about symptoms of depression and anxiety.

Answer 441

1. Have you felt you ought to Cut down on your drinking, substance use, or behaviour? 2. Have people Annoyed you by criticizing your drinking, substance use, or behaviour? 3. Have you felt Guilty about your drinking, substance use, or behaviour? 4. Have you had a drink (or used another substance or behaviour) first thing in the morning to steady your nerves or get yourself going for the day (an Eye-opener)?

Answer 442

Central nervous system depressants. CNS depressant drugs include alcohol, sedative hypnotics (benzodiazepines, Z-drugs, and barbiturates), and inhalants. Withdrawal reactions from alcohol and other CNS depressants are the most problematic and are associated with severe morbidity and mortality, unlike withdrawal from other psychoactive agents (Csiernik, 2019). The syndrome for alcohol withdrawal is the same as that for the entire class of CNS depressant drugs; therefore alcohol is used in this discussion as the prototype as it will be the most commonly observed. Alcohol withdrawal, if uncomplicated, is typically complete within 5 to 7 days. Symptoms of withdrawal, however, continue for a longer period and are more severe for older than younger patients; as well, psycho- logical craving can last for months and even years. Withdrawal may be delayed, however, when another CNS depressant is the main drug of choice or when the patient is withdrawing from a combination of alcohol and other CNS depressants. Multiple drug and alcohol dependencies can result in simultaneous withdrawal syndromes that present a complicated clinical picture among polydrug users and may pose ad- ditional problems for safe withdrawal.

Answer 443

Alcohol poisoning is a state of toxicity that can result when an individual has consumed large amounts of alcohol either quickly or over time. It can produce death from aspiration of emesis or a shutdown of body systems due to severe CNS depression. Signs of alcohol poisoning include an inability to rouse the individual, severe dehydration, cool or clammy skin, respirations less than 10 per minute, cyanosis of the gums or under the fingernails, and emesis while semiconscious or unconscious.

Answer 444

The early signs of alcohol withdrawal, a physical reaction to the cessation or reduction of alcohol (ethanol) intake, can develop within a few hours of the last intake. Symptoms peak after 24 to 48 hours and then rapidly and dramatically disappear unless the withdrawal progresses to alcohol withdrawal delirium. The severity of withdrawal tends to be dose related, with heavier drinkers experiencing more severe symptoms. Withdrawal severity is also related to age, with those over 65 years of age typically experiencing more severe symptoms. During withdrawal, the patient may appear hyperalert, manifest jerky movements and irritability, startle easily, and experience subjective distress often described as “shaking inside.” Grand mal seizures may appear 7 to 48 hours after cessation of alcohol intake, particularly in people with a history of seizures. Careful assessment, including this history and any other risk factors, followed by appropriate medical and nursing interventions, can prevent the more serious withdrawal reaction of delirium. A competent, supportive manner on the part of the nurse can al- lay anxiety and provide a sense of security. Consistently and frequently orienting the patient to time and place may be necessary. Encouraging family or close friends, one at a time, to remain with the patient in quiet surroundings can also help to increase orientation and minimize confusion and anxiety. During withdrawal, some patients may experience illusions, which can be both disorientating and terrifying. Illusions are misinterpreta- tions, usually of a threatening nature, of objects in the environment due to excess activation of the CNS by the drug. For example, a person may think that spots on the wallpaper are blood-sucking ants. How- ever, illusions can be clarified to reduce the patient’s terror: “See, they are not ants; they are just part of the wallpaper pattern.” Some patients withdrawing from alcohol may be argumentative, hostile, or demand- ing due to the difficult physical experiences but also because of deep- seated anxiety. The nurse can relieve some of these feelings by demon- strating a non-judgmental attitude, validating the experiences of the patient, maintaining a positive affect and encouragement for efforts at recovery. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) provides an efficient, objective means of assessing alcohol withdrawal to prevent under- or overtreating patients with benzodiaz- epines

Answer 445

Alcohol is the only drug for which exact ob- jective measures of intoxication (BAL) currently exist. The relationship between BAL and behaviour in a non-tolerant individual is illustrated in Table 18.4. Assessing the patient’s behaviour can assist the nurse in (1) ascertaining whether the person accurately reported recent drink- ing and (2) determining the level of intoxication and possible tolerance, s patient behaviours may indicate greater or lesser levels of tolerance. As tolerance develops, a discrepancy is seen between the BAL and ex- pected behaviour: a person with tolerance to alcohol may have a high BAL but minimal signs of impairment. Alternatively, a person who is highly sensitive to alcohol or compromised medically may have a low BAL but demonstrate a high level of intoxication. Alcohol content varies from product to product; nevertheless, a drink is a drink is a drink, with 1.5 ounces of liquor (40% alcohol), a 12-ounce bottle of beer (5% alcohol), and a 5-ounce glass of table wine (12% alcohol) all containing the same amount of ethanol and be- ing considered a standard drink. Thus all affect human physiology in a consistent manner as measured by blood alcohol content, although there are distinct differences between men and women (Table 18.5). Differences in effects from person to person produced by beverage alcohol do not generally result from the type of drink consumed but rather from the person’s size, previous drinking experiences, and rate of consumption. A person’s feelings and activities and the presence of other people also play a role in the way the alcohol affects behaviour.

Answer 446

DTs), is a medical emergency that can result in death in 20% of untreated patients. It is an altered level of consciousness that presents with seizures following acute alcohol withdrawal. Death is usually due to cardiopathy, cirrhosis, or other comorbidities requiring mechanical ventilation (Foertsch et al., 2019). The state of delirium usually peaks 48 to 72 hours after cessation or reduction of intake, although it can peak later, and lasts 2 to 3 days. Features of alcohol withdrawal delirium include the following: * Autonomic hyperactivity (tachycardia, diaphoresis, elevated blood pressure) * Severe disturbance in sensorium (disorientation, clouding of con- sciousness) * Perceptual disturbances (visual or tactile hallucinations) * Fluctuating levels of consciousness (ranging from hyperexcitability to lethargy) * Delusions * Anxiety and agitated behaviours * Fever (38°C to 39°C) * Insomnia * Anorexia If these symptoms are observed, immediate medical attention, including ongoing assessment and supervised treatment, is warranted.

Answer 447

A distinct CNS depressant subgroup is inhalants, which include volatile gases, substances that exist in a gaseous form at body temperature, refrigerants, solvents, general anaesthetics, and pro- pellants. Except for nitrous oxide, more commonly known as laughing gas, and related aliphatic nitrates, all inhalants are hydrocarbons. The misuse of these collective substances has been labelled volatile sub- stance use. As this is typically one of the first drugs misused by adolescents, particularly Indigenous youth, it is a significant public health concern. In addition, long-term exposure to solvents in the workplace has also been linked to a range of health issues in older persons, par- ticularly dementia. It is generally believed that solvents alter CNS functioning through one of three means: altering the structure of lipid membranes by impairing ion channels, altering enzymes that bind to the brain’s membrane, or producing toxic metabolites These substances not only have depressant effects but also can pro- duce minor hallucinogenic effects on the CNS. As solvents are inhaled, entry into the brain is extremely quick and the onset of effects is virtu- ally immediate, producing feelings of relaxation and warmth within 8 to 15 seconds and with effects generally lasting for several hours. This class of psychoactive drugs has a significant misuse liability. The initial mood-enhancement effect is typically characterized by lightheadedness, exhilaration, fantasy images, and excitation. Negative effects include nausea, increased salivation, sneezing and coughing, loss of co- ordination, depressed reflexes, and sensitivity to light, along with skin irritation and burns around the mouth and nose. In some users feelings of invincibility may lead to reckless, dangerous, violent, or erratic behaviour. Physical effects include pallor, thirst, weight loss, nosebleeds, bloodshot eyes, and sores on the nose and mouth. Chronic use creates a range of medical problems, including damage to the cardiovascular, pulmonary, renal, and hepatic systems as well as to cognitive functioning

Answer 448

Opioids are a distinct family of CNS depressants that includes codeine, fentanyl, heroin, meperidine, methadone, and oxycontin (Box 18.2). An opioid is a derivative or synthetic that affects the CNS and the PNS. Medically, it is used primarily as an analgesic (pain masker). Consistent use causes tolerance and severe, physically painful withdrawal symptoms. Table 18.7 lists signs and symptoms of intoxication, overdose, withdrawal, and possible treatments. Distinct phases are experienced when injecting an opioid such as heroin. The initial rush that occurs almost immediately is frequently characterized in terms of feelings of sexual arousal and as being superior to sexual intimacy. This initial euphoric phase is characterized physiologically by facial flushing and a deepening of the voice. The second, more prolonged, phase entails a sense of extreme well-being as an intense endorphin reaction is occurring in the brain. This phase can extend for several hours. The third phase reflects the fact that opioids are CNS depressants and is characterized by a range of responses, from lethargy to virtual unconsciousness. The fourth phase occurs when the heroin is nearly fully metabolized and the person who has used the substance begins to seek additional heroin in order to avoid the painful withdrawal process.

Answer 449

Cocaine is a naturally occurring stimulant extracted from the leaf of the coca bush, whereas crack is an alkalinized form of coca administrated via inhalation. When smoked, crack alters the CNS in as little as 6 to 10 seconds, producing a short sense of euphoria, followed by a crash, and then a period of deep depression as the body works to return to homeostasis that reinforces the drug-using behaviour. Cocaine works by blocking the reuptake of norepinephrine, dopa- mine, and serotonin, causing an imbalance of neurotransmitters that, when the drug is metabolized, results in physical withdrawal symptoms including depression, lethargy, anxiety, insomnia, sweating and chills, and a renewed craving for the drug (Cunningham et al., 2020). There are three distinct phases of withdrawal from cocaine: 1. The first phase, the crash phase, can last up to 4 days. Those who use cocaine report depression, anergia, and an acute onset of agitated depression. Craving for the drug peaks during this phase, as do anxi- ety and paranoia. Inpatient care to prevent access to further doses of the drug is helpful during the first and second phases of withdrawal. 2. During the second phase, the user feels a prolonged sense of dysphoria and anhedonia, a lack of motivation, and intense cravings for the drug. This phase can last up to 10 weeks. Lapse and relapse is most likely during the second phase of withdrawal. 3. The third phase is characterized by intermittent craving and can last indefinitely.

Answer 450

This family of drugs includes cocaine hydrochloride as well as crack, amphetamines including crys- tal meth, caffeine, and nicotine. CNS stimulants are drugs that increase the activity of both the CNS and the PNS primarily through the direct activation of dopamine. Mood enhancement occurs because of these changes as well as increased activity of serotonin and norepinephrine. Upon initial ingestion, there is euphoria, followed by excitement and then agitation. Higher doses produce irritability, violent behaviour, spasms, convulsions, and, in infrequent and extreme cases, death. More common and frequent short-term effects include enhanced concentration, increased vigilance, increased blood pressure, increased strength, reduced fatigue, reduced appetite, and feelings of power. While all stimulants increase alertness, as a family, they exhibit considerable differences in the nature of their effects and in their relative potencies. Table 18.9 outlines the physical and psychological effects of intoxication from amphetamines and other psychostimulants, possible life-threatening results of overdose, and emergency measures for both overdose and withdrawal. Upon the abrupt discontinuation of drug administration, abstinence symptoms observed include fatigue, severe mood depression, lethargy, and irritability; these are commonly referred to as the “crash,” which can also include abdominal and muscle cramps, dehydration, and a general apathy. However, unlike with depressants, there is generally no risk for fatal withdrawal, although when someone who has ingested a stimulant experiences chest pain, has an irregular pulse, or has a history of heart trouble, the person should immediately be taken to an emergency department.

Answer 451

Amphetamines are chemi- cally related to the naturally occurring catecholamine neurotransmitter and work by increasing synaptic levels of dopamine, serotonin (5-HT), and norepinephrine. They are used to raise energy levels and reduce both appetite and the need for sleep, as well as to provide feelings of clear-headedness and power. Norepinephrine is responsible for meth- amphetamine’s alerting, anorectic, locomotor, and sympathomimetic effects; dopamine also stimulates locomotor effects but, in excess, can produce psychosis and perception disturbances; and changes to sero- tonin (5-HT) are responsible for the delusions and psychosis associated with the use of amphetamines. Methamphetamine’s effects are similar to those of cocaine, but its onset is slower and the duration is longer

Answer 452

Phar- macologically, bath salts are most closely related to khat, a plant that grows and is used widely in the Horn of Africa region. Its psychoac- tive property is derived from the same source, cathinone, though the synthetic version is much more potent. Although cathinone was synthesized by pharmaceutical companies in the late twentieth cen- tury, its derivatives did not become broadly used within the drug trade until the beginning of the twenty-first century. It also shares some pharmacological similarity with MDMA (ecstasy) but with less hallu- cinogenic and more stimulant properties closer to the effects of meth- amphetamine. In a study of the rewarding and reinforcing effects of methylenedioxypyrovalerone (MDPV) rats showed self-administration patterns and escalation of drug intake nearly identical to those seen with methamphetamine (Colon-Perez et al., 2016). This drug can be administered orally, across mucous membranes, or via inhalation or injection. The energizing and often agitating effects occur because of increased levels of dopamine, which also increase a user’s heart rate and blood pressure. The surge in dopamine creates feelings of euphoria, increased physical activity, heightened sexual in- terest, a lack of hunger and thirst, muscle spasms, sleeplessness, and, when sleep does occur, disrupted dream cycles. Behavioural effects in- clude erratic behaviour, teeth grinding, a lack of recall of how much of the substance has been consumed, panic attacks, anxiety, agitation, severe paranoia, hallucinations, psychosis, self-harm, and behaviour that can be aggressive, violent, and in extreme cases move beyond suicidal ideation to suicidal actions. Overdose is possible due to heart and blood vessel problems because of a lack of any type of regulation of this drug.

Answer 453

Caffeine is the most used psychoactive drug not only in Canada but across the world. It is found in coffee, tea, energy drinks, and soft drinks. Caffeine blocks the actions of adenosine, an inhibi- tory neurotransmitter, by binding to its receptor and preventing post- binding changes from taking place, which leads to increased firing of dopaminergic neurons, particularly in the nucleus accumbens. Due to its ability to constrict cerebral blood vessels, caffeine is used in combi- nation with other drugs to combat migraine and other cerebrovascular headaches associated with high blood pressure. However, contrary to popular belief, caffeine is not effective in ameliorating headaches due to other causes, and in some instances it may even exacerbate pain. In other medical uses caffeine is employed to counteract certain symp- toms, such as respiratory depression, associated with CNS depressant poisoning. It is also used: * As a respiratory stimulant in babies who have had apnea episodes (periods when spontaneous breathing ceases) * As an emergency bronchodilator in asthmatic children * As a substitute for methylphenidate for children with attention- deficit/hyperactivity disorder * As an antifungal agent in the treatment of skin disorders * As an aid in fertility, because of its ability to enhance sperm mobility * As a mild stimulant for an assortment of medical problems When taken in moderate amounts, caffeine can produce stimulant effects on the CNS similar to those of small doses of amphetamines. These can include mild mood elevation; feelings of enhanced energy; an increased alertness and reduced performance deficit due to bore- dom or fatigue; postponement of feelings of fatigue and the need for sleep; and a decrease in hand steadiness, suggesting impaired fine motor performance. Small doses of caffeine can also increase motor activity, alter sleep patterns (including delaying the onset of sleep), di- minish sleep time, and reduce the depth of sleep (including altering rapid eye movement sleep patterns) while also increasing respiration, blood pressure, and metabolism. However, with the increasing use of dietary supplements, caffeine pills, and energy drinks containing far more caffeine than coffee, tea, or cola, there has been an increase in hospitalizations involving the drug and in overdoses leading to death

Answer 454

Nicotine, in combination with its agent of delivery, to- bacco, is the leading cause of premature death from any psychoactive agent in Canada and in the world. Nicotine has a pale-yellow colour and an oily consistency. It turns brown on contact with air, and doses of 60 mg can be fatal, while amounts as low as 4 mg can produce severe illness. Tobacco smoke comprises some 500 compounds, including tar, ammonia, acetaldehyde, acetone, benzene, toluene, benzo(a)pyrene, dimethylnitrosamine, methylethylnitrosamine, naphthalene, carbon monoxide, and carbon dioxide. This drug is thought to affect the brain reward system by increas- ing dopamine concentrations through interaction with nicotine ace- tylcholine receptors. Since nicotine is a CNS stimulant, it increases heart rate, pulse rate, and blood pressure; depresses the spinal reflex; reduces muscle tone; decreases skin temperature; increases acid in the stomach; reduces urine formation; precipitates a loss of appetite; in- creases adrenaline production; and stimulates, then reduces, brain and nervous system activity. In non-smokers small doses, even less than one cigarette, may produce an unpleasant reaction that includes cough- ing, nausea, vomiting, dizziness, abdominal discomfort, weakness, and flushing (Csiernik, 2019). Nicotine crosses the placenta, and women who smoke during preg- nancy tend to have babies smaller in body weight, height, and head circumference and are more likely to give birth prematurely. Cigarette smoking during pregnancy also increases the risk of sudden infant death syndrome, whereas exposure to second-hand smoke during pregnancy increases the risk of infant stillbirth, congenital malforma- tions, low birth weight, and respiratory illnesses. Newborns exposed in utero to nicotine are more irritable and have poorer attention than un- exposed infants, and they exhibit increased muscle tension, increased tremors and startle responses, and deficient speech processing (Lee et al., 2018; Reece et al., 2018).

Answer 455

Cannabis sativa is a member of the hemp family of plants, with one major distinction: it contains delta-9-tetrahydrocan- nabinol (THC). This is the psychoactive ingredient found in the resin secreted from the flowering tops and leaves of the female cannabis plant. While this substance has historically been classified as part of the hallucinogen family of drugs, THC also produces depressant ef- fects and is the only hallucinogen that produces physical dependency; thus it is a fully addicting agent. Cannabis is generally smoked, but it also can be ingested orally, typically in baked goods or other sweets such as chocolates or jelly candies. Desired effects include euphoria, detachment, and relaxation. Other effects include talkativeness, slowed perception of time, inappropriate hilarity, heightened sensitivity to ex- ternal stimuli, and anxiety or paranoia. Long-term use of cannabis can result in lethargy, anhedonia, difficulty concentrating, amotivational syndrome, and memory impairment. Medical cannabis is used in response to a broad range of issues, in- cluding fighting antibiotic-resistant infections, as an antiemetic, control- ling chemotherapy-induced nausea, reduction of intraocular pressure in glaucoma, appetite stimulation in acquired immunodeficiency syn- drome (AIDS) wasting syndrome, muscle spasms associated with spinal cord injury, and multiple sclerosis, and to decrease seizures caused by some forms of epilepsy. Cannabis can also help alleviate gastrointestinal disorders, symptoms of Tourette’s syndrome, depression, anxiety, and post-traumatic stress disorder; can decrease chronic pain and the pain from fibromyalgia; and can aid insomnia (Csiernik, 2019). Canada was among the first nations to prohibit the use of cannabis and now has be- come one of the first to legalize its use. Bill C-45, The Cannabis Act, along with its companion legislation Bill C-46, An Act to Amend the Criminal Code, was passed by the House of Commons of Canada in late Novem- ber 2017 with Royal Assent on June 21, 2018. The Cannabis Act created a formal legal framework for controlling the production, distribution, sale and possession of cannabis with three stated goals: * to keep cannabis out of the hands of youth * to eliminate the illegal market of cannabis sales * to protect public health and safety by allowing adults access to legal cannabis with known and stated THC levels Each individual of legal age is allowed to possess up to 30 g of dried cannabis or equivalent in non-dried form in public, to share up to 30 g of legal cannabis with other adults, and to buy dried or fresh cannabis and cannabis oil from a provincially licensed retailer. Individuals are also allowed to grow up to four cannabis plants per residence for personal use and to make their own homemade prod- ucts using dried cannabis.

Answer 456

Hallucinogens are distinct psychoactive agents in that they do not primarily produce euphoria but rather disrupt the CNS and PNS, producing a disconnect between the physical world and the user’s perception of the physical world. Effects can include distor- tion in space and time, hallucinations, delusions, both paranoid and grandiose, and synesthesia, which is a blurring and intermingling of the senses, such as smelling a colour or tasting a feeling. Table 18.11 outlines the signs and symptoms of hallucinogen intoxication and overdose. Hallucinogens, excluding cannabis, are divided into three groups. Indolealkylamines, such as LSD and psilocybin, have no secondary psychoactive effects. Phenylethylamines, such as mescaline and jimson weed, have structural similarities to amphetamines, producing second- ary stimulant effects on the body. Dissociative anaesthetics, psychoac- tive drugs such as PCP and ketamine that are members of the arylcy- clohexylamine family, possess depressant properties along with their hallucinatory effects. A hallucinogen that has received extensive public attention is MDMA (3,4-methylenedioxymethamphetamine), referred to as ecstasy, molly, Adam, yaba, and XTC. Related hallucinogens with stimulant properties include MDA (methylenedioxyamphetamine), the “love drug,” and MDE (3,4-methylenedioxyethamphetamine), whose slang name is “Eve.” MDMA causes a significant release of the neurotransmitters serotonin, dopamine, and norepinephrine. The brain’s saturation with these neurotransmitters causes those who use MDMA to exhibit major empathy toward others; reduces inhibitions; elicits introspection; and results in an outpouring of good feelings about others, the current environment, and the world. The release of serotonin also intensely sharpens the senses of those using the substance. Those using MDMA may be hyperactive and have inexhaustible en- ergy (dancing all night long), dilated pupils with impaired reaction to light, elevated temperature, elevated pulse, elevated blood pressure, di- aphoresis, dystonia, and bruxism (grinding of the teeth). Other symp- toms of stimulant use, such as tachycardia, mydriasis (dilation of the pupils), tremors, arrhythmias, parkinsonism, esophoria (eyes turning inward), serotonin syndrome, and severe hyponatremia, may also pres- ent with MDMA use. Those using MDMA must drink a large quantity of water during use to prevent dehydration and hyperthermia, which have contributed to occasional deaths. After the effects of MDMA wear off, the person using the substance commonly goes through a period of depression, referred to as “suicide Tuesdays.” This affective state is caused by a depletion of serotonin, levels of which do not return to normal within the CNS for at least 3 to 4 days. Two distinct pharmacological processes are most closely associated with this family of drugs. The first process is tachyphylaxis, the rapid reduction in the effect produced by the substance, regardless of how much of the drug is consumed. Essentially, this is total tolerance that occurs in a short period of time, such that there is no physical with- drawal to the drug. If a drug is taken for a consecutive number of days, after 3 or 4 days, no psychoactive effects of any type are perceived. The secondary effects of hallucinogens such as MDMA or ketamine can still be perceived even when the primary hallucinogenic effect is not. The second process is a flashback, or hallucinogen persisting percep- tual disorder (HPPD). These are transitory recurrences of perceptual disturbance that can be caused by a person’s earlier hallucinogenic drug use but occur after the fact, when the person is in a drug-free state. Flashbacks can be experienced as pleasant but most often entail recur- rences of frightening images, visual distortions, time expansion, loss of ego boundaries, and intense emotions.

Answer 457

To offer support and motivation toward recovery, a nurse must begin by examining their own attitudes, feelings, and beliefs about addiction and persons with addiction issues. Such reflection often means that nurses must examine their own substance use and the substance use of others in their lives, particularly their partners and family members, which is a potentially difficult task. A history of substance use in a nurse’s own family can interfere with the helping relationship and contribute to counter-transference (see Chapter 9). The negative or positive experiences a nurse has had with family members or others with addiction issues can influence interpersonal interactions with patients and affect treatment outcomes. Therefore attending to personal feelings that arise when working with people experiencing addiction issues is vital, as are ongoing self-reflection and supervision that encourages reflection on the nurse’s responses as well as the patients’. Nurses who do not attend to, and work through, expected negative feelings that arise while providing care are more likely to engage in power struggles with patients, resulting in an ineffective therapeutic process, and are more likely to suffer from vicarious trauma

Answer 458

Distinct psychological characteristics are associated with substance use, often arising from trauma or oppression, including hopelessness, low self-esteem, anxiety, and depression. People who use substances often feel threatened on many levels in their interactions with nurses in formal hospital and treatment set- tings. First, they are concerned about being rejected because not all nurses are willing to care for people with addiction issues. In fact, many patients have reported experiences of rejection in past encounters with nursing personnel. Second, people who use substances may be anxious about giv- ing up the substance they believe they need to survive; this relates to psychological dependency. Third, people with addiction issues often are concerned about failing at recovery, as addiction is a chronic, re- lapsing condition. In fact, relapse is one of the criteria for diagnosing an addiction. Most individuals with an addiction have tried to become abstinent at least once and often several times before experiencing re- lapse. As a result, many become discouraged about their chances of ever succeeding. Such feelings of discouragement and a high level of hopelessness can act as substantive barriers to recovery and contribute to the risk of suicide. Concerns about failure or potential relapse on the path of recovery can threaten the person’s sense of security and sense of self, increasing anxiety levels. To protect against these feelings, the person with an addiction may establish self-defensive responses, including defence mechanisms such as projection or rationalization, or thought processes such as all-or-none thinking, selective attention, or conflict minimization and avoidance. Typically, the person is un- able to give up these maladaptive coping styles until more positive and functional skills are learned.

Answer 459

They took the idea of motivation and made it into an active counselling skill. Rather than being located ex- clusively within the patient, they expressed the idea that motivation was an interpersonal, interactional process within which the probabil- ity existed for behaviours to lead to positive outcomes. Prochaska and DiClemente identified six specific steps necessary for any type of radi- cal change to occur, which represented a natural process of change that could be adapted by nurses to assist any patient in moving forward. Pre-contemplation. In the first stage of the model it is recognized that an individual will be resistant to change and typically has no in- tention of altering behaviour in the near future; there is typically no or little recognition from the patient’s perspective that any type of prob- lem exists. This idea has historically been called denial. Critical to the entire premise of the Transtheoretical Model of Change (TTM) is the replacement of the long-standing idea that patients are in denial regarding their addiction with the concept of pre-contemplation. Prochaska and DiClemente (1984) reconceptualized the idea of denial to frame it so that patients are not viewed as willfully deceiv- ing themselves and others and in the process destroying themselves or their families; instead, these individuals are considered to be truly unaware of the impact of their behaviour and the effect it has on those around them. People with substance use disorders are often ambiva- lent about changing their harmful behaviour regarding alcohol or other drug use. They may continue their drug use for a range of rea- sons, such as being attracted to a particular lifestyle, wanting to be in- cluded in a peer group, coping with life’s daily stresses, or responding to trauma and oppression in their lives. When the destructive effect of these behaviours becomes obvious, they are then faced with the reality of giving up most of the people, places, and things they have come to enjoy and with which they may strongly identify. Without a clear picture of the future, these individuals are typically reluctant to engage in any type of change process. Thus considerable effort is required by the individual with a substance use disorder, their fam- ily members, friends, and helping professionals to become willing to make a commitment to change. Approaches to supporting the patient at this stage include: * Validating the lack of readiness * Encouraging re-evaluation of current behaviour * Encouraging self-exploration rather than immediate action * Explaining and personalizing the risk Contemplation. In the second stage, contemplation, patients be- come aware that they are stuck in a situation and must decide whether they wish to change or remain where they are at. Nurses support pa- tients in gaining an understanding of the consequences of their drug use but do not force the patient to make a commitment to change. The nurse helps to balance in the patient’s mind the delicate equilibrium between the desire to change and the fear of changing and the associ- ated unknown consequences. Nurses need to reflect this ambivalence to help patients be able to move forward to the next stage while rec- ognizing and acknowledging the fear associated with change. Nurses also need to be open to the fact that some patients will drop out at this highly stressful stage, and thus a willingness to work with the patient in the future must be presented, again, once the person is ready and able to move forward. Supportive approaches include: * Encouraging evaluation of the pros and cons of behaviour change * Re-evaluating group image through group activities * Identifying and promoting new, positive-outcome expectations Preparation. The third stage, preparation, also known as the de- termination stage, involves some commitment from the patient that changing the drug-using behaviour is being considered along with the anticipation of what this future action may look like and what actions need to occur. However, the nurse needs to be aware that a significant level of ambivalence may still exist to the idea and process of actual change. During the preparation phase, probing, reviewing consequenc- es, and self-evaluation are areas of work to perform with the patient, and a specific time frame is established for when the patient agrees to begin changing existing practices and actions, with a maximum target of 1 month. Supportive approaches at this phase include: * Encouraging the evaluation of the pros and cons of behaviour change * Identifying and promoting new positive-outcome expectations * Encouraging realistic, practical, and small initial steps * Offering referrals to and support of action-oriented programs such as smoking cessation Action. The fourth stage is when the work and behavioural change begin, with a heavy emphasis on problem solving and prob- lem-solving skills. However, action also entails changing awareness, emotions, self-image, and thinking. Support of positive decisions and positive reinforcement dominate this stage of moving forward by the patient. Emphasis is on the positive: what patients are doing rather than what they are not (i.e., not using drugs). Supportive approaches include: * Helping the patient with restructuring cues and triggers and solidi- fying social support * Enhancing self-efficacy for dealing with obstacles * Helping to guard against feelings of loss and frustration, especially if a lapse occurs Maintenance/adaption. The fifth stage, maintenance/adaption, focuses on supporting and consolidating the gains made during the action stage and on avoiding lapses or a more significant relapse. Social skills training underscores this stage of continued change. This is the skills practice phase of the TTM during which patients are less tempted to lapse and become increasingly confident that they can continue their changed behaviour. Approaches to use include: * Planning for follow-up support * Reinforcing internal rewards * Discussing strategies for coping with triggers and relapse * Generalizing positive behaviours into more situations Evaluation/termination. The final stage of the TTM has the patient move past problem solving with a focus on relapse prevention and dealing with the reality of abstinence and sobriety. During this phase, patients assess their strengths and areas that may be problematic in the future as they develop a relapse prevention plan that can be undertaken on their own and begin once a lapse occurs. Supportive approaches that are particularly helpful to assist the patient and family include: * Evaluating triggers for relapse * Reassessing motivation and barriers to change * Planning and rehearsing new and stronger coping strategies.

Answer 460

Closely associated with the TTM, and integral to its success, is the idea of motivational interviewing (MI), initially conceptualized by William Miller (1983). MI is a brief, patient-centred, directive method for enhancing change in intrinsic motivation by exploring and resolving patient ambivalence using the ideas of empathy, attribution, cognitive dissonance, and self-efficacy. In MI motivation is conceptualized not as a personality trait but as an interpersonal process. The model de-emphasizes labelling, replacing confrontation with empathy, and places a much greater emphasis on individual responsibility and internal attribution for change. It has become a foundation practice approach in community-based addiction counselling approaches across Canada. Cognitive dissonance is a core technique in the MI approach. It is created by contrasting the ongoing problem behaviour of a patient with salient awareness of the behaviour’s negative consequences. Empathic processes, motivation, and objective assessment feedback are used to channel this dissonance toward a behaviour change, being cognizant of and avoiding the typical patient barriers of low self-esteem, low self-efficacy, and pre-contemplation. MI is a strength-based counsel- ling style in which the nurse works with the patient rather than doing things for or to the patient. The focus is to look for natural motivating issues within a patient’s life or the patient’s system. The nurse needs to anticipate and respond to a patient’s genuine hesitation and insecurity to engage in a fundamentally life-altering change in behaviour because simply giving patients advice to change is typically unrewarding and ineffective. MI is non-confrontational in nature and acknowledges the fact that creating conflict, rather than ambivalence, in the therapeutic relationship is counterproductive and is more likely to create patient re- sistance than patient change. MI seeks to increase a patient’s awareness of their problematic behaviour along with unrecognized strengths and opportunities for change. Miller and Rollnick (2002) established eight steps for the MI process: establishing rapport, setting the agenda, as- sessing readiness to change, sharpening focus, identifying ambivalence, eliciting self-motivating statements, handling resistance, and shifting focus and transition (Box 18.3).

Answer 461

Formulation of appropriate nursing diagnoses depends on accurate assessment and screening. Whereas the criteria for medical diagnosis emphasize patterns of use and physical symptoms, nursing diagnoses identify how dependence on substances interferes with a person’s abil- ity to deal with the activities and demands of daily living. Nursing diag- noses for patients with psychoactive substance use disorders are many and varied because of the range of physical and psychological effects of drug misuse or dependence on people using these substances, as well as on their families. Concurrent disorders also need to be directly addressed. Potential nursing diagnoses for people with substance use disorders are listed in Table 18.12. Outcomes Identification Nursing Outcomes Classification (NOC) categories (Moorhead et al., 2018) for outcome criteria for patients with substance use disorders can be divided into withdrawal, initial and active treatment, and health maintenance. When the patient has a concurrent disorder, the nurse will also develop nursing outcomes for that mental health disorder. Specific NOC outcomes and examples of patient goals follow. Withdrawal Fluid balance: Patient’s blood pressure will not be compromised. Neurological status: Consciousness: Patient will have no seizure activity. Distorted thought self-control: Patient will consistently describe the content of hallucinations. Initial and Active Treatment Risk control: Substance use: Patient will consistently demonstrate a commitment to substance use control strategies. Risk control: Substance use: Patient will consistently acknowledge per- sonal consequences associated with substance use. Substance addiction consequences: Patient will demonstrate no diffi- culty supporting themselves financially. Health Maintenance Knowledge: Substance use control: Patient will describe actions to pre- vent and manage relapses in substance use. Family coping: Family will consistently demonstrate care for the needs of all family members. Planning Planning care requires attention to the patient’s social status, income, ethnic background, faith or religion, sex, sexual orientation, age, sub- stance use history, and current condition. Planning must also address the patient’s major psychological, social, and medical problems, as well as the substance-using behaviour. The involvement of appropriate fam- ily members is also essential whenever possible. Unfortunately, a person’s social status and social relations often de- teriorate as a result of addiction. Job demotion or loss of employment, with resultant reduced or non-existent income, may occur. Meeting ba- sic needs for food, shelter, and clothing is affected. Marriage and other close interpersonal relationships often deteriorate, and the patient is then left alone and isolated. A lack of interpersonal and social supports is a complicating factor in treatment planning for people experiencing addiction. Case Study and Nursing Care Plan 18.2 presents a discus- sion of a patient with concurrent alcohol dependence and depression. Implementation The aim of treatment is self-responsibility and motivation, not ad- herence to an imposed program. A major challenge is improving treatment effectiveness by matching subtypes of patients to specific types of treatment. Although those experiencing substance-related disorders may share some characteristics and dynamics, significant differences exist with regard to physiological, psychological, and sociocultural processes for all individuals. As with most complex issues and illnesses, the best solutions are the ones that can be read- ily implemented and sustained. Proposing abstinence as a treatment goal is safest for those with more than one substance use disorder. Abstinence is strongly relat- ed to good work adjustment, positive health status, comfortable in- terpersonal relationships, and general social stability, though it may also often be too great a commitment for many patients with long- term drug use. Often the choice of treatment approach depends on the patient’s needs, treatment goals, motivation, and personal cir- cumstances, including family needs and financial resources. Out- patient programs work best for people with substance use disorders who are employed and have an active social support system or those opting for a harm reduction approach. Individuals who have little to no support and structure in their daily lives may do better in inpatient or longer-term residential programs focused exclusively upon abstinence goals. Beyond personal concerns and choice of treatment, neuropsycho- logical deficits have been associated with long-term alcohol misuse and may affect treatment choices or potential benefits. Such deficits have been found in abstract reasoning ability, ability to use feed- back in learning new concepts, attention and concentration spans, cognitive flexibility, and subtle memory functions. These cognitive impairments undoubtedly have an impact on the process of treat- ment for alcohol or another substance use. At all levels of practice, the nurse can play an important role in the intervention process by recognizing the signs of substance use in both the patient and the family and by being familiar with the resources available to help with the problem.

Answer 462

Alcohol. Antidipsotropics are drugs that were traditionally pre- scribed to create an adverse physical reaction when the individ- ual consumed alcohol intended to deter further drinking. The two prominent drugs in this category are disulfiram (tetraethylthiuram disulphide) and citrated calcium carbimide. When an antidipso- tropic interacts with alcohol, a person’s face and neck become warm and flushed, and the individual can experience dizziness, a pound- ing heart, a throbbing head, and nausea, essentially an exaggerated hangover effect. The severity of the reaction varies; the more alco- hol consumed, the more severe the reaction. If a person continues to consume alcohol, the person can experience escalating unpleasant and dangerous symptoms such as vomiting, tachycardia, hyperventi- lation, shortness of breath, hypotension, and in severe instances ar- rhythmias, unconsciousness, and even myocardial infarction, which explains, in part, why these drugs are no longer commonly used (Csi- ernik, 2019). Acamprosate is a newer, less toxic pharmacological option for responding to alcohol dependency. Taken orally three times a day, the drug ameliorates the symptoms of alcohol withdrawal and aids in limiting reactions to drink-related cues. Acamprosate makes con- suming alcohol less pleasurable, with a goal of stopping lapses from becoming relapses. Acamprosate also has far fewer side effects than antidipsotropics. It is thought to stabilize the chemical balance in the CNS that is disrupted by both alcohol and benzodiazepine with- drawal, though the exact mechanism of action remains uncertain. The American Psychiatric Association (2018) recommends the use of acamprosate with individuals who have moderate to severe alco- hol-related issues who have a goal of reducing alcohol consumption or becoming abstinent. Antabuse is now only recommended when patients specifically request it as part of their treatment regimen, with both acamprosate and naltrexone (see next) having better outcomes with fewer risks. Naltrexone is an opioid antagonist that had been demonstrated to have some success in decreasing cravings for alcohol. Antagonists are drugs that block the effects of other pharmacologically similar psycho- active agents by occupying the same receptor sites in the brain. Antago- nists extinguish the behavioural aspects of drug use for when they are administered ahead of the psychoactive agent, the individual obtains no positive reinforcement from the psychoactive drug. However, as with antidipsotropics, the effectiveness of this method of intervention rests solely with the dependent person’s willingness to take the drug. As well, there is always a risk of overdose when using these drugs as dependent persons attempt to overcome the antagonistic effect by in- creasing the amount of psychoactive drug they consume. When using naltrexone, which is marketed under the name ReVia, the pleasurable effects some people experience when they drink are diminished or do not occur. As well, there is no experience of nausea such as with the use of antidipsotropics. However, unlike its interaction with heroin, fentanyl, and other opioids, naltrexone does not prevent one from becoming impaired or intoxicated with the use of alcohol, as alcohol does not attach itself to only one type of receptor site in the brain as do opioids. When naltrexone is present in the brain, alcohol cannot stimulate the release of dopamine. The use of ReVia has been demonstrated to reduce the frequency and intensity of drinking, to re- duce the risk of relapse to heavy drinking, and to increase the percent- age of days abstinent. However, this drug does not discriminate and when it is being used, it decreases the release of dopamine regardless of the activity (Froehlich et al., 2019). Baclofen is an orally administered muscle relaxant primarily used to prevent muscle spasms resulting from neurological conditions. It was also found to aid alcohol-dependent persons in maintaining ab- stinence and is well tolerated, even in cases of lapse. Effectiveness in producing abstinence appears to be dose dependent; an Ameri- can study of 30 mg a day did not produce significant abstinence, whereas a German study administering three doses of 90 mg, up to 270 mg/day did. However, even in the German study, one-quarter of participants dropped out due to lapses and only half of the partici- pants maintained abstinence throughout the entire study. Individuals taking Baclofen are found to have greater rates of abstinence com- pared to those not receiving any type of pharmacological assistance, though it does not consistently decrease episodes of heavy drinking, craving, anxiety, or depression (Rose & Jones, 2018). Topiramate is a non-benzodiazepine anticonvulsant medication. Preliminary clinical trials have demonstrated that its use decreases alcohol’s reinforcement of the CNS, leading to a decrease in alcohol consumption (Johnson et al., 2007). Topiramate appears to antagonize alcohol-rewarding effects by inhibiting dopamine release while also enhancing the inhibitory function of GABA, which in turn antagonizes glutamate receptors, further inhibiting dopamine release. Side effects of topiramate include an increased likelihood of cognitive dysfunction and numbness, tingling, dizziness, taste abnormalities, and decreased the major limitation of topiramate is that tolerance seemingly builds rapidly to its effects (American Psychiatric Association, 2018). Opioids. Drug dependence that involves heroin and other opioid drugs is a chronic, relapsing condition with a generally unfavourable prognosis. The outstanding characteristic elements include an over- powering drive to continue to administer the drug and to obtain it by any means for pleasure or to avoid the extreme discomfort of with- drawal. The basic premise for opioid substitution therapy is that ap- propriate drug substitutes suppress withdrawal symptoms, reducing the use of illicit and higher-risk opioids. The two primary substances employed in opioid substitution therapy are methadone and Suboxone, both of which are themselves opioids. These alternative opioids, both of which are administered orally, do not produce the same euphoria as other opioids and are safer as they are given in standardized doses with no impurities and do not have to be taken as frequently. The use of methadone and Suboxone eliminates withdrawal though the drugs need to be taken every day because if a person misses a dose, the indi- vidual will experience the same physically painful withdrawal effects as from any other opioid. Methadone is currently the most widely used pharmacotherapeutic medication for maintenance treatment, with a history dating back to the Vietnam War era (Dole & Nyswander, 1965). The World Health Organization considers it an essential medication for global health as it effectively reduces illicit drug use, treats opioid use disorder, and re- tains individuals in treatment, even if they do remain physically depen- dent upon this opioid. Among methadone’s pharmacological strengths is that, unlike morphine, it is highly effective when administered orally and it is metabolized and excreted slowly, making it therapeutically ef- fective for up to 24 hours. However, tolerance and withdrawal do occur in methadone users, though their development is much slower than with other opioids. Without other forms of intervention, chronic users eventually become both psychologically and physically dependent on methadone. Methadone’s side effects include weight gain due to low- ered metabolism, dental issues due to decreased salivation, constipa- tion, numbness in extremities, sedation, and, for some, hallucinations when initially prescribed the drug. Long-term use will also create sex- ual dysfunction due to decreased testosterone levels in males, as occurs with chronic use of any opioid (Csiernik, 2019). The major alternative to methadone is Suboxone, which is com- prised of the partial μ-opioid receptor agonist buprenorphine in combination with the opioid antagonist naloxone in a 4:1 ratio. Bu- prenorphine, derived from thebaine, is a partial opioid agonist, pro- ducing less sedation than methadone, which is a full opioid agonist. The effects of buprenorphine peak 1 to 4 hours after the initial dose with adverse effects are similar to other opioids: nausea, vomiting, and constipation. Naloxone is a true antagonist with a chemical structure similar to oxymorphone. However, it produces neither pain relief nor any type of psychoactive effects. When taken orally, it produces no dis- cernable effects; however, if naloxone is crushed, dissolved, or injected, it produces severe opioid withdrawal effects almost immediately. As a result, naloxone has several therapeutic uses not only in combina- tion with buprenorphine in Suboxone but also as a means of reversing the opioid-induced respiratory depression, sedation, and hypotension that is commonly observed in cases of opioid overdose. Naloxone can begin working in as little as 30 seconds after administration though it has a far shorter half-life than the vast majority of opioids: 30 to 90 minutes (Kerensky & Walley, 2017; McDonald et al., 2017). A recent study in the United Kingdom found that Suboxone users suffered fewer poisonings and had a lower risk of mortality than did methadone users, though on average, the period of usage was shorter for Suboxone than for methadone (Hickman et al., 2018). Nicotine. Nicotine replacement therapy has become a prominent pharmacological treatment approach for those wishing to stop smok- ing tobacco products with several administration options (Table 18.13). In each of these approaches one form of nicotine is simply being re- placed by another, though all the other harmful side effects of smoking are eliminated, except with electronic cigarettes (e-cigarettes), where it is reduced. E-cigarettes have the look and feel of cigarettes but do not burn tobacco. Instead, e-cigarettes use a battery and an electronic device to produce a warm vapour from a cartridge containing nico- tine, often propylene glycol, and some flavouring additive. Cartridges can be refilled with different flavours and nicotine concentrations. E-cigarettes still contain some carcinogens (including nitrosamines), toxic chemicals (such as diethylene glycol), and tobacco-specific com- ponents that are harmful to humans. E-cigarettes deliver nicotine to the blood more rapidly than nicotine inhalers but less rapidly than cigarettes. As a result, the effect of the e-cigarette on nicotine craving is similar to that of the nicotine inhaler but less than that of cigarettes. This has led researchers to conclude that e-cigarette use leads to de- creased tobacco consumption among existing smokers (McKeganey et al., 2019). The issues of course have not been this reduction, which is a positive harm reduction approach, but rather the number of new vapers this method of nicotine administration has created, primarily adolescents and young adults. E-cigarettes are a safer nicotine delivery mechanism but still not a totally safe option. Individuals who have moved to vaping rather than smoking are still consuming nicotine, with a variety of health issues associated with this administration option, from minor mouth and throat irritation to airway obstruction, increased cardiovascular risks, and lung damage (Ghosh et al., 2019). While carcinogens remain in the product, the overall health effects are less than smoking a cigarette, though here again, as with cigarettes and cigars, vapour in the air con- tains harmful irritants, though it is not yet known if these are as prob- lematic as second-hand smoke. For individuals addicted to tobacco, completely substituting e-cigarettes for combustible tobacco cigarettes reduces their users’ exposure to thousands of toxicants and carcinogens present in traditional tobacco cigarettes (Koval et al., 2018). E-cigarettes can be an aid in both reducing and totally stopping the use of tobacco products (Manzoli et al., 2017) with the potential to decrease tobacco- related deaths (Levy et al., 2018). Preliminary studies have indicated that the use of e-cigarettes is more effective in promoting smoking cessation than the other nicotine-replacement options summarized in Table 18.13 (Hajek et al., 2019). However, this benefit has been under- mined by the direct targeting of the product to non-smokers, primarily adolescents, creating a group of new nicotine users who otherwise may never have used this drug. Benzodiazepines (sedative-hypnotics). Benzodiazepines with long half-lives (clonazepam) are used to assist persons to withdraw from dependencies on benzodiazepines with short half-lives (Xanax). A typical five-step intervention model incorporating benzodiazepine drug substitution with ongoing counselling would consist of the fol- lowing: 1. For 2 weeks, patients monitor and record their daily drug consump- tion. 2. Eight one-on-one therapy sessions follow at a rate of one per week. 3. Gradual reduction of drug use begins by switching to drugs with longer half-lives. 4. Ongoing supportive care and reassurance continues until the cessa- tion of any drug use. 5. A 1-year follow-up period commences, using a support group model (Ashton, 2013). Stimulants. No medications have yet been proven effective in pharmacologically treating addiction to either cocaine or metham- phetamine. Ritalin has been used in an attempt to improve brain function among those addicted to cocaine, while both D-amphet- amine and methylphenidate are being used to treat heavy amphet- amine users, with some limited success. When given disulfiram for the treatment of their alcoholism, individuals who misused both co- caine and alcohol also reduced their cocaine use from 2.5 days per week to less than once per week. As well, modafinil, a mild stimulant used to treat chronic fatigue, has been found to have some value in treating those physically dependent on crack. While several clini- cal trials have found those using modafinil to be far more likely to become abstinent, the vast majority (over three quarters in the ex- perimental group) did lapse or relapse during the study period (Chan et al., 2019; Singh et al., 2016). Implementation at Primary, Secondary, and Tertiary Levels of Prevention Primary prevention. Prevention models in health care are classi- fied as primary, secondary, or tertiary. In terms of substance use and addiction prevention primary approaches are those efforts focused on reducing the demand for a substance as well as stopping the occur- rence of alcohol or drug use or misuse. Examples include implementing healthy public policy, offering health education related to addiction, taxing and health-related warning labelling of licit products such as cigarettes and alcohol, and promoting educational campaigns such as addiction and mental health in the workplace. Secondary prevention. Secondary prevention seeks to limit further health deterioration and social harm from the use of, misuse of, depen- dence on, and addiction to psychoactive substances. Examples include programs of early recognition, awareness campaigns, relapse preven- tion, community support approaches, and strategies for safe prescrib- ing guidelines. The most prominent and most controversial among secondary prevention approaches is harm reduction. Harm reduction. Harm reduction refers to a range of programs, policies, and interventions designed to reduce or minimize the adverse consequences associated with drug use, such as overdose, infections, and spread of communicable diseases. Officially one of the four pillars of Canada’s drug plan, the approach involves any strategy or behaviour that an individual uses to reduce the potential harm that may exist for them. Harm reduction is more than just a programming approach, it is also a philosophy, and seven prominent values that shape harm reduc- tion programming are highlighted here: 1. All humans have intrinsic value. 2. All humans have the right to comprehensive, non-judgmental med- ical and social services. 3. Licit and illicit drugs are neither good nor bad. 4. Psychoactive drug users are sufficiently competent to make choices regarding their use of drugs. 5. Outcomes are in the hands of the substance user. 6. Options are to be provided in a non-judgmental, non-coercive manner (Denis-Lalonde et al., 2019). Needle exchange programs. Needle exchange programs allow in- jection drug users (IDUs) to trade used syringes for new, sterile sy- ringes and related injection equipment, although in recent years many of these fixed and mobile outreach programs have also begun to offer crack pipes and straws for cocaine use. Needle exchange is a harm re- duction strategy that arose as a direct result of the blood-borne infec- tions of HIV, hepatitis C virus, and hepatitis B virus that were an unin- tended outcome of injection drug use. However, this is not only a form of intervention for IDUs but also part of a broader public health model, as funding for these initiatives occurs so as to limit the transfer of these diseases into the general populace. Opioid substitution therapy: methadone treatment and methadone maintenance/Suboxone treatment and Suboxone maintenance. Both methadone/Suboxone maintenance (MM/ SM) and methadone/Suboxone treatment (MT/ST) consist of an individual administering a sufficient dose of the alternative opioid on a daily basis to eliminate opioid withdrawal symptoms. The basic premise of opioid substitution therapy is that methadone or Suboxone administered daily by mouth is effective in the suppres- sion of withdrawal symptoms and in the reduction of the use of illicit opioids. MM/SM involves determining a correct dose for each individual and providing regular health care and treatment for other addiction issues, while MT/ST programs also entail the provision of counselling and support, mental health services, health promotion, and disease prevention and education, along with advocacy and links to community-based supports and ser- vices such as housing. Heroin-assisted treatment (HAT). Some individuals do not re- spond well to methadone or Suboxone, as it may not ease the physical or psychological pain of withdrawal, it may not negate the craving, or an individual may have a negative reaction to the synthetic nature of the drug. Historically, these individuals either endured a cold turkey withdrawal or more typically went back to using street opioids. By re- turning to use, they again put themselves at risk for life-threatening health issues, including drug overdose, blood-borne viral infections, and endocarditis, as well as the violence that accompanies illicit drug transactions. One controversial alternative is heroin-assisted treat- ment (HAT). Under a HAT protocol, street opioid users are prescribed pharmaceutical quality heroin, which is injected in safe, clean special- ized medical clinics. Service users typically attend up to two to three times per day to self-inject their dose of heroin. Average heroin dosage ranges from 400 and 600 mg/day, with supervised consumption ad- ministered on average at around 150 to 300 mg/dose. Clinical staff can also supplement this further with a small 20- to 60-mg oral methadone dose as needed. Methadone administration is prevalent as a means to prevent withdrawal between the administrations of heroin which has a far shorter half-life. The heroin-assisted programs are usually sup- ported by access to psychological support in the form of counseling and group work, as well as general social welfare support from social services (Hill, 2016). The overall value of HAT remains inconclusive, in part due to a lack of multiple outcomes studies. Existing research suggests that the major- ity of dependent users seeking treatment can use either methadone or Suboxone and these options should be offered first. However, HAT can be considered as a secondary option for those who fail to make signifi- cant progress with the standard options. Research completed on HAT programs found that program participants demonstrated improved: * Use of structured drug treatment programs * Physical and psychological health outcomes * Social integration including improved capacity for work, better liv- ing conditions, and debt management * Pro-social behaviours highlighted by a significant reduction in of- fending-related activity (Hill, 2016). Supervised consumption sites (SCS). Supervised consump- tion sites (SCSs) began as supervised (or safe) injection sites (SISs) in Canada. These clinics were designed to provide IDUs with clean needles and sterilized works to inject their drugs in a safer manner. SISs that have evolved to SCSs provide individuals with a healthier environment in which to inject, inhale, intranasally, or orally con- sume drugs while also providing related health and social services, all in one location. While the first Canadian site opened in Lethbridge, Alberta, in 2017, Switzerland, Germany, and the Netherlands ad- opted the concept of safe injection rooms during the 1970s, again as a general public health initiative. However, since then, the strategy demonstrated a decrease in new HIV and HCV infections and re- duced the number of overdose-related deaths while providing access to primary and emergency health care for a traditionally oppressed population. After the opening of a new site, once the public backlash has subsided, there is generally a decrease in public nuisance issues related to drug use, including public injecting, discarded syringes, and injection-related litter (Rowe & Rapp, 2017). SCSs offer a safe place where drug-dependent individuals can ad- minister drugs under the supervision of trained multi-disciplinary health and social services staff who can provide education regarding safer use practices, as well as respond appropriately in the event of an overdose. Each SCS varies in the way it operates. However, in general, individuals bring pre-obtained drugs to the site, are provided with ster- ile equipment to use, and consume their drugs with nurses and other trained staff nearby. Typically, needles, syringes, candles, sterile water, paper towels, cotton balls, cookers/spoons, ties, alcohol swabs, filters, ascorbic acid, and bandages are available in the injection-specific areas. SCSs allow substance users to have their privacy while also offering the comfort of knowing that trained medical staff are available to re- spond in case of an emergency. SCSs do not allow the sharing of drugs or equipment and prohibit assisted injection. SCSs lead to a reduction in syringe sharing among users, which also reduces the spread of dis- eases and infections. SCSs attempt to protect and promote the health of drug users by employing a non-judgmental, person-centered approach rooted in a harm-reduction philosophy (Rowe & Rapp, 2017). As with other forms of harm reduction, SCSs benefit a hard-to- reach population by offering services with minimal barriers to access and avoidance of interactions with the criminal justice system. Con- tact with these hard-to-reach persons can lead to important social and health referrals and treatment opportunities, which ultimately result in positive social and community opportunities. The introduction of SCSs has contributed to individual improvements in health, social function- ing, and stabilization, along with a decreased number of overdoses and pre-mature deaths (Kennedy et al., 2019). The Registered Nursing Association of Ontario has now prepared a set of best practice guide- lines to assist in the development of this important community-based service (https://rnao.ca/sites/rnao-ca/files/bpg/Implementing_super- vised_injection_services.pdf ). Controlled drinking. Controlled drinking is an adapted behav- ioural technique used with persons experiencing low levels of alco- hol misuse. Assessment of the patient’s level of alcohol dependence is necessary to determine if a goal of controlled drinking is feasible. This approach proposes that training in drinking skills is required to teach alcohol misusers to drink in a non-abusive manner as an alternative to abstinence as part of a more broad-based treatment program. The first step in controlled drinking is determining whether a person is us- ing alcohol excessively or is alcohol dependent. This is accomplished by imposing a 2- to 3-week period of abstinence. If the person can go without drinking, they are moved into the next phase. Those who can- not abstain during this baseline period generally do not qualify for a controlled drinking treatment program. In the program itself patients are provided with a set of goals and rules to help them control their alcohol intake. A common drinking goal of a set number of standard drinks per week is established, with numerous limitations. For a young, healthy male approximately 6 feet tall and weighing 180 pounds, the following regimen might be applied: * No more than two standard drinks per day (one for women) * No more than one drink per hour * Sip drinks and avoid carbonated beverages * Drink only on a full stomach * Two days per week must be set aside on which no alcohol is con- sumed * Limit weekly intake to 14 standard drinks per week (7 for women). Low-risk, or reduced, drinking is achievable for some individuals as they undergo treatment for alcohol dependence. Individuals with lower dependence severity, less baseline drinking, fewer negative mood symptoms and fewer heavy drinkers in their social networks have a higher probability of achieving low-risk drinking during treatment. Reduced drinking may be a viable alternative for those who do not have alcohol-related physical damage and who have not experienced any se- rious personal, financial, legal, or employment problems as a result of their alcohol misuse. However, controlled drinking training is not an alternative for those who are physically and psychologically dependent on alcohol or on any other psychoactive substance (Witkiewitz et al., 2017). Managed alcohol programs (MAPs). The primary purpose of managed alcohol programs (MAPs) is to offer continuing health and housing services for individuals who have a history of homelessness and alcohol misuse along with chronic health issues and are in many cases deemed to be near the end of their lives. The aim is to provide humane treatment and reduce harm to the patients by eliminating the need to binge drink and to drink non-beverage alcohol products. Nurs- ing, medical, and rehabilitation care are provided along with a regular, limited amount of alcohol. MAPs’ goal is to provide their residents with permanent rather than transient housing, and in this way it falls into the Housing First philosophy. Some MAPs offer private rooms, though the standard is shared accommodation, with all programs being staffed 24 hours per day. Care plans are individualized and typically include a recreational component. The overall goal is to improve the quality of life of patients while allowing them to live in a respectful, supportive environment. General strategies for relapse prevention are cognitive and behavioural: recognizing and learning how to avoid or cope with threats to recovery, changing lifestyle, learning how to participate in activities without drugs, and securing help from other people or from social support services. In Canada MAPs are almost exclusively used by men. Relapse prevention and aftercare. Long-term recovery is not a straight line but is preceded by periods of flux and discontinuity before change is stabilized. These periods can last longer than the length of time the individual was actually in treatment initially. This reality has placed increasing importance and emphasis upon follow-up, aftercare, or, as it has become more prominently known, relapse prevention. Relapse, which is a return to previous drug use patterns, poses a fundamental barrier to the treatment of addiction. It is distinct from lapse, which is a singular or short-term use of drugs that is viewed as a learning opportu- nity around a specific event or trigger (Kougiali et al., 2017). Depending on the definition one uses for recovery, statistics indi- cate that upwards of 90% of individuals have the potential to relapse. Historically, relapse had been attributed to factors such as cravings or withdrawal symptoms arising due to the disease of addiction. However, relapse is a complicated, multi-faceted process rather than a discrete event and is now generally considered not a failure but rather a setback. Thus aftercare needs to be a continuation of work initiated during the initial treatment regimen, with a focus on resettling and reintegrating individuals back into society. The goal is to provide continuous encour- agement, support, and additional services as needed following a patient’s completion of a treatment plan. Preventing relapse or minimizing its extent is a necessity for successful, long-term change (Csiernik, 2021). The contemporary approach to relapse prevention also rejects the idea of a person being either successfully abstinent or failing and be- ing a drug misuser. Rather, the transition is viewed as a process where lapses are not end points but learning opportunities. If a lapse becomes a relapse, it is still only a temporary setback, which is not unique to the individual but a common part of the process toward the end goal of abstinence. It is simply another learning opportunity, which, when resolved, becomes part of the person’s behavioural repertoire. The pri- mary goals of treatment are functional analysis, determining triggers and consequences of use, and skill building. Relapse prevention as an intervention is a tertiary strategy, in- tended to reduce the likelihood and severity of relapse following the cessation or reduction of problematic substance use. Cognitive- behavioural principles guide contemporary evidence-informed re- lapse prevention models (Figure 18.5). Marlatt and Witkiewitz’s (2005) model views relapse as a complex, circular process in which various factors interact, creating the opportunity for the person to return to regular drug use. Thus the key becomes to assist patients in recognizing and quickly addressing high-risk situations in their lives. There are two sets of variables that need to be considered. The first are called tonic factors and are constants in a person’s life while the second group, phasic, are transient influences in a person’s life. Tonic processes include personality, genetic and familial risk factors, drug sensitivity, metabolism, neurotransmitter levels, and the effects produced by physical withdrawal. Tonic processes also include cogni- tive factors that show relative stability over time, such as drug-related outcome expectancies, a person’s degree of self-efficacy, and personal beliefs about one’s ability to remain abstinent. Tonic processes provide a baseline of risk, but it is typically phasic responses that produce the relapse event. Phasic processes can be both cognitive and affective, including urges/cravings often triggered by an event or mood, both negative (distress) or positive (eustress). A minimally acceptable af- tercare program would involve a monthly contact for 1 year, with the provision that the patient can contact the relapse prevention worker whenever needed. Box 18.4 outlines relapse prevention strategies that are of value in a nursing environment. Alcoholics Anonymous (AA) and related 12-step groups are a self-help format that also serves as an ongoing relapse prevention support system. While AA is the most prominent and well-known form of mutual aid, it is not the best fit for all, especially women with trauma histories. As such, it is valuable to familiarize yourself with a range of options such as Women for Sobri- ety (WFS), SMART Recovery, the Secular Organization for Sobriety (SOS), Rational Recovery (RR), Moderation Management (MM), and Refuge Recovery.

Answer 463

is the prototype for all addiction-related mutual aid self-help programs. Beginning with two members in 1935, it has grown into a global movement premised on 12 steps to recov- ery (Box 18.5). These programs offer properly matched individuals a behavioural, cognitive, and dynamic structure to assist in maintaining their abstinence. Three basic concepts are fundamental to all 12-step programs: 1. Individuals with an addiction are powerless over their addiction, which is no longer conceptualized as a moral failing but rather as a disease, and their lives are unmanageable because of their addiction. 2. Although individuals with an addiction are not responsible for their disease, they are responsible for their recovery. 3. Individuals can no longer blame people, places, and things for their addiction; they must face their problems and their feelings and do so in conjunction with a Higher Power. Before referring any patient to any mutual aid group, a nurse should attend an open meeting to learn what occurs there and how the fellowship functions in order to facilitate a proper referral. While AA and related groups such as Narcotics Anonymous and Cocaine Anonymous are welcoming resources, they are not a good fit for all patients, and mismatched individuals can be discouraged from seek- ing professional treatment if they do not find AA of value to them. Self-help groups for the patient and family or friends. Counsel- ling and support should be encouraged for all family and friends of a person experiencing problems with alcohol, other substance use, or addictions.

Answer 464

Tertiary prevention is concerned with lim- iting and reducing complications and dysfunction related to the ex- perience of addiction. Effective care, treatment, and rehabilitation programs and services are characteristic of tertiary prevention ap- proaches. Specialized addiction detoxification programs, recovery programs, and concurrent disorder programs are examples of tertia- ry-level services. Assessment and referral. Once an individual has been identified as having a substance use issue, the depth and breadth of the situa- tion needs to be determined. Assessment and referral agencies provide services that use specific instruments and processes to determine the major issues as well as the strengths and supports of the person with a substance issue. These agencies develop individualized plans for as- sistance, which may entail referral to other organizations for more in- tensive or residential treatment. A standardized assessment procedure can take anywhere from 2 to 3 hours to complete, typically including a history of the use of alcohol and other drugs, including the age of onset, duration, patterns, consequences of use, use of alcohol and drugs by family members, and types of and responses to previous treatment initiatives. It is also recommended that assessments determine a pa- tient’s physical health, environmental supports (including partner and family), accommodation, employment (if employed), school status (if attending school), leisure activities, legal problems, sexual orientation, gender identification, and any history of sexual or other physical abuse or trauma. It is also essential to initially assess the level and intensity of withdrawal management and stabilization services required. Withdrawal management services: daytox and detox. Withdraw- al management or detoxification services are often a first step in the treatment process. This entails total abstinence from not only the drug of misuse but also often all other drugs, including, in some facilities, to- bacco. The detoxification process should be of sufficient length to allow all of the psychoactive drugs to be eliminated by the body. A patient’s safety is the first priority of all withdrawal management staff, though once an individual becomes more stable, staff also typically offer social and environmental support during the stay, including referrals to mu- tual aid groups. Daytox programs provide support and programming during the day, while detox programs have a residential component that lasts 3 to 7 days depending upon the province and the drug. Community-based (outpatient) treatment. This is treatment pro- vided on a non-residential basis, usually in regularly scheduled sessions of 1 to 2 hours per week but sometimes two times per week. Treatment may entail individual and/or group sessions to explore all aspects of the person’s substance use and related problems. Sessions offer information and strategies to assist each individual in their recovery process. This is the least intense and intrusive treatment intervention option, primarily offered by non-medical, community-based counselling agencies. Ap- propriate matches for this service include patients who: Are free of any significant medical problem Are self-motivated Have a support system in place, including family, friends, or work Live within easy access to the facility Have not yet had their personal or work life extensively affected by their substance use Day treatment. This is a more intensive, structured non-residen- tial treatment, typically provided 5 days per week or alternatively 4 or 5 evenings per week for 3 to 4 hours per session. Treatment involves group activities ranging from formal group treatment sessions to ed- ucation groups to recreational activities. As patients are at home on weekends, evenings, and days, the home environment must be stable, with support from family and friends. This treatment option allows the social aspect of addiction to be acknowledged and addressed early in the treatment process. Day treatment is appropriate for individuals who are able to maintain social competence despite their dependency. Concurrent disorder programs. Another specialized form of community-based counselling entails work done by agencies whose patients have both an addiction and a mental health issue. Services offered by institutional and community-based psychologists, psychia- trists, social workers, and nurses have long been a part of the extended continuum of care, but traditionally these helping professionals dealt with either the mental health issue or the addiction issue alone, rarely the two together. Concurrent disorder programs move beyond work- ing only with the addiction issue and provide counselling that also ad- dresses issues such as anxiety, depression, loneliness, suicidal ideation and attempts, paranoia, and violent behaviours. Whether these behav- iours are primary or secondary to the use of psychoactive agents is no longer an issue; rather, the mental health problems are categorized as coexisting with the drug misuse and vice versa, and thus intervention focuses on both. The Reis Typology (Box 18.6) is used to determine the best service for a patient with a concurrent disorder (Sinha et al., 2019). Short-termresidentialtreatment. Theseprogramsrunfor18to28 days, can be sex specific or co-ed, and offer a wide variety of services, including medical evaluation, assessment of the extent of the drug de- pendency, detoxification in some facilities, individual and group counsel- ling, drug education, spiritual guidance, family involvement, vocational guidance, and even employer involvement. Recovery homes. For many struggling with ongoing issues in their recovery, the ability to avoid a relapse is often jeopardized by untenable housing or unsupportive living environments. Recovery residences, also called social model recovery or sober living houses, are designed to provide safe and supportive housing to help individuals initiate and sustain recovery primarily through peer-to-peer interactions guided by staff who themselves have recovery histories. They are sex-specific, residential programs in which the goal is to provide a safe, supportive, therapeutic program of addiction education and life skills counselling. They provide an array of services to individuals with addiction prob- lems within a structured environment either before or after the person has attended a withdrawal management program or has received more intensive treatment through the auspices of a short-term residential program. One issue that is highlighted among recovery homes, but pertains to all addiction residential programming, is that there are cur- rently more facilities and more beds for men than for women. Alternative living environment. For many people with a sub- stance use problem, the environment they live in is counterproductive to their successful treatment and recovery. These people may have un- stable home lives or no support from family and friends who them- selves may also be regular substance users. Others come into treatment having no real home at all, having no role models for healthy living, or needing to relearn or learn socialization skills. Alternative living envi- ronments or therapeutic communities provide a protective living envi- ronment for people whose substance use is not an isolated problem but a major disruption of their entire life. These programs help in setting limits and defining behaviour while satisfying daily needs and desires in a quasi-home setting. Relationships that develop provide a basis on which the members can build the learning or relearning of living with others. Real-life issues of daily existence take precedence at these facili- ties, the premise being that people best learn about how to sustain and manage the stresses of daily living and relationships while experiencing actual everyday life (rather than an isolated bubble, no matter how safe that may seem). Many alternative living settings are affiliated with a religious order, the most prominent being the Salvation Army. Addictionsupportivehousing(ASH). Addictionsupportivehousing (ASH) programs are another component of the treatment continuum that recognizes the importance of safe and sustainable housing in the recovery process. This resource is part of the Housing First initiative and, while still limited, it provides longer support in a therapeutic environment than do short-term residential programs or recovery homes. The goal is to encour- age program participants to develop long-term skills that are necessary to maintain one’s own residence but without necessarily demanding absti- nence in order to be housed. By providing housing supports, ideally in conjunction with but not contingent on addiction treatment, service pro- viders can increase the probability that someone who is marginally housed or homeless will follow through with addiction treatment. Onen’tó:kon Healing Lodge: an Indigenous treatment ap- proach. TheOnen’tó:konHealingLodgesituatedintheMohawkcom- munity of Kanehsatake is one of a network of specialized Indigenous treatment programs in Canada. The 6-week residential program takes a cultural perspective on treatment, including talking and healing circles. Not only is the chemical dependency addressed, but the specific issues that the individual identifies, such as anger; resentment; grief; physi- cal, emotional, and sexual abuse; and low self-esteem, are addressed as well. Talking circles are a variant of group therapy where a person speaks about the issues that are causing pain. The other members of the circle provide individual feedback and confront behaviours that are not helpful in the individual’s recovery program. However, healing circles are conducted without confrontation unless an individual behaves in a manner that is disruptive. Nurses and addiction in the workplace. The issue of nurses de- veloping an addiction is not as taboo a topic as in the past, helped in part by the dramatization of this issue in media such as Nurse Jackie (2009 to 2015). However, fear of disciplinary action up to and includ- ing job loss still prevents nurses in the real world from either seeking help for themselves or from reporting a colleague or friend. Supporting the treatment and recovery of a fellow nurse experiencing an addiction can be challenging, but the situation is not uncommon, nor is being supportive impossible. The choices for action are varied, and the only choice that is clearly wrong is doing nothing. Without intervention or treatment, the problems associated with addiction escalate, including systemic and institutionalized problems such as over-work, workplace bullying, and the potential for not only self-harm but also patient harm

Answer 465

Favourable treatment outcome is judged by increased use of harm reduction strategies, fewer lapses and relapses, increased lengths of time of abstinence (if not following a harm reduction approach), ac- ceptable occupational functioning, improved family relationships, and ultimately the ability to sustain healthy relationships and behaviour. Although continuous monitoring and evaluation increase the chances for prolonged success, it must be stated that no single approach has been found to be universally successful in the treatment of those mis- using psychoactive substances. Research is conclusive, however, that intervention is superior to no treatment. Given that addiction is a biopsychosocial phenomenon, an inte- grated approach of several types of helping modalities will be more successful than recourse to any one alone. Two things are certain: that the treatment used must be tailored to meet the specific needs of each individual and that no patient should be forced into a particular type of rehabilitation merely because of the nurse’s convenience or prejudicial choice. Critical factors to always consider are: The patient choosing to enter treatment with an expectation of be- ing helped to change their behaviour, thus having a motivation to change The credibility of the technique being used to both the nurse and the patient Consistent application of an empirically proven technique The ability to create optimism for a successful outcome The ability to create a foundation so that change may occur The nurse’s discretion, flexibility, and emotional support The ability of the nurse to create a supportive environment The choice of harm reduction or abstinence

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