PSYCHIATRIC NURSING Psychiatric treatment approaches

1. PSYCHIATRIC NURSINGPsychiatric treatment approaches Dr. Naiema Gaber El-sayed

2. Learning Objectives • Determine the components of Psychiatric treatment approaches. • Discuss the mechanism of action of each modality • Explain the nursing role in each modality

3. Therapeutic Approaches • Psychopharmacology • Therapeutic Groups • Intervention with Families • Mileu Therapy • Relaxation Therapy • Assertiveness Therapy • Promoting Self-Esteem 8. Cognitive Therapy 9. Behavioral Therapy 10. Nutritional therapy 11. Electroconvulsive Therapy 12. Complementary Therapy 13. Client Education

4. I- Psychopharmacology • Antipsychotic drugs • Antidepressants • Mood stabilizers • Anxiolytic drugs • Sedative-Hypnotic Agents • Psychostimulants • Cognitive Enhancers and treatment for Alzheimer's diseases • Drugs for substances abuse disorders

5. PSYCHOPHARMACOLOGY 1-ANTI-PSYCHOTIC DRUGS Antipsychotic agents are effective for treating nearly every medical and psychiatric condition where psychotic symptoms or aggression are present. They are currently used routinely in the management of psychosis and/or agitation associated with psychotic diorders Examples : 1- First degenerations as Haldol an Loxitane) 2-Second degeneration as: Clozaril and Zyprexa)

6. 2- ANTIDEPRESSANTS • indications for antidepressants including panic disorder (PD), obsessive–compulsive disorder(OCD), bulimia and posttraumatic stress disorder (PTSD). • Many of these illnesses respond best to combination treatment modalities that include medication and various forms of psychotherapy.

7. Example lo Antidepressant • Monoamine Oxides' Inhibitors as Trazodone, • Serotonin Reuptake Inhibitors as Duloxetine SIDE EFFECTS • Once the choice of an antidepressant has been made, the main goal is to maximize therapeutic effects and minimize side effect

8. 3- MOOD STABILIZERS(ANTI-MANIC DRUGS) Mood stabilizers fall into three families: (1) lithiumIs used for manic phase of manic-depressive illness and refractory depression (2) anti-epileptic drugs (anticonvulsants) (3) second-generation antipsychotics.

9. 4- ANXIOLYTIC DRUGS Drugs used in treatment of anxiety and anxiety disorder. • Barbiturates and meprobamate were some of the first agents shown to be effective in decreasing anxiety, but were addictive in overdose. • Along with medication interventions, psycho-education and psycho therapeutic interventions are often part of treatment anxiety disorders.

10. 5- SEDATIVE–HYPNOTICAGENTS • Medications used to control the condition could cause insomnia. Insomnia is common disabling medical and psychiatric conditions • Benzodiazepines is an example of hypnotics. The risk for abuse and physiological dependence are the least likely complications

11. 6- PSYCHOSTIMULANTS • The term Psychostimulants refers to the ability of these compounds to increase CNS activity in some but not all brain regions. • The Psychostimulants methylphenidate, amphetamines, and atomoxetine reduce the core symptoms of childhood attention deficit/ hyperactivity disorder

12. 7- COGNITIVE ENHANCERS AND TREATMENTS FOR ALZHEIMER’S DISEASE • The Choline Inhibitors (ChIs ) are approved for the treatment of mild to moderate Alzheimer’s disease. • Memantine is currently the only agent approved for the treatment of moderate to severe Alzheimer’s disease

13. 8- DRUGS FOR TREATING SUBSTANCE ABUSE DISORDERS • Disorders of substance abuse are one of the commonest of psychiatric illnesses. They often complicate other psychiatric disorders together with their complications. • Examples of abuse substances are: Alcohol Intoxication, Sedative–Hypnotic Intoxication, Opiate Intoxication, Cocaine and Amphetamine Intoxication.

14. 10- ANTIANXIETY DRUGS • Are also known as anxiolytics; • Classified into: a. Benzodiazepines as Valium, Ativan, b. Sedative-Hypnotics as Barbiturates

15. The role of the nurse in Psycho-pharmachology therapy • Carry out the treatment on prescriptive time • Monitoring the patient’s condition to detect the effect of the drug on health status • Reassure that symptoms will decrease in 2 - 4 weeks • Increase fiber and fluid diet. • Assess for adverse drug reactions. • Assess for suicide potential. • Detect signs of early drug toxicity: as Vomiting – Diarrhea and Drowsiness, Muscular weakness, Lack of coordination, Polyuria

16. II-Therapeutic Groups Therapeutic groups Focus is on group relations, interactions between group members, and the consideration of a selected issue. Functions of a Group • Socialization. • Support. • Task completion. • Camaraderie. • Informational. • Normative. • Empowerment. • Governance.

17. Types of Therapeutic Groups • Task groups.to accomplish a specific outcome. • Teaching groups. to convey knowledge and information to a number of individuals. • Supportive/therapeutic groups. to prevent possible future upsets by teaching effective ways of dealing with emotional stress. • Self-help groups:composed of individuals with a similar problem Serve to reduce the possibilities of further emotional distress leading to pathology and necessary treatment. May or may not have a professional leader. Run by members, and leadership often rotates from member to member

18. Therapeutic groups vs. group therapy • Group therapyhas a sound theoretical base, and leaders generally have advanced degrees in psychology, social work, nursing, or medicine. • Therapeutic groupsare based to a lesser extent on theory. Focus is on group relations, interactions between group members, and the consideration of a selected issue. • Leaders of both types of groups must be knowledgeable about group process (the way in which group members interact with each other) as well as group content (the topic or issue being discussed in the group).

19. The Role of the Nurse in Group Therapy • Guidelines set forth by the American Nurses Association specify that nurses who serve as group psychotherapists should have a minimum of a master’s degree in psychiatric nursing.

20. Curative Factors of Groups • Instillation of hope. • Universality. • Imparting of information. • Altruism. • Corrective recapitulation of the primary family group. • Development of socializing techniques. • Imitative behavior. • Interpersonal learning. • Group cohesiveness. • Catharsis. • Existential factors.

21. Phases of Group Development Initial or Orientation Phase • Leader and members work together to establish rules and goals for the group. • Leader promotes trust and ensures that rules do not interfere with fulfillment of the goals. • Members are superficial and overly polite. Trust has not yet been established. Middle or Working Phase • Productive work toward completion of the task is undertaken. • Leader role diminishes and becomes more one of facilitator. • Trust has been established between the members, and cohesiveness exists. • Conflict is managed by the group members themselves. Final or Termination Phase • A sense of loss, precipitating the grief process, may be experienced by group members. • The leader encourages the group members to discuss these feelings of loss and to reminisce about the accomplishments of the group. • Feelings of abandonment may be experienced by some members. Grief for previous losses may be triggered.

22. III-Family Therapy The family defined: “A family is who they say they are.”(Wright & Leahy, 2000) Types of Families • Biological family of procreation • Nuclear family (incorporates one or more members of the extended family) • Sole-parent family • Stepfamily • Communal family • Homosexual couple or family

23. Family Functioning • Boyer and Jeffrey describe six elements on which families are assessed to be either functional or dysfunctional. 1. Communication 2. Self-concept Reinforcement 3. Family Members’ Expectations 4. Handling Differences 5. Family Interactional Patterns 6. Family Climate

24. IV-Milieu Therapy The Therapeutic Community • Milieu therapy, or therapeutic community, is defined as “a scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual.”

25. Role of the Nurse • Through use of the nursing process, nurses manage the therapeutic environment on a 24-hour basis. • Nurses have the responsibility for ensuring that the client’s physiological and psychological needs are met. • Nurses are also responsible for • Medication administration • Development of a one-to-one relationship • Setting limits on unacceptable behavior • Client education

26. V- Relaxation Therapy • Deep breathing exercises • Progressive relaxation • Modified (or passive) progressive relaxation • Meditation • Mental imagery • Biofeedback • Physical exercise

27. VI- Assertiveness Training • Honestyis basic to assertive behavior and is expressed in a manner that promotes self-respect and respect for others. • Basic Human Rights

28. Four Common Response Patterns • Nonassertive behavior • Assertive behavior • Aggressive behavior. • Passive-aggressive behavior.

29. Techniques that Promote Assertive Behavior • Standing up for one’s basic human rights • Assuming responsibility for own statements • Responding as a “broken record”– persistently repeating in a calm voice what is wanted • Agreeing assertively – assertively accepting negative aspects about oneself; admitting where an error has been made • Inquiring assertively – seeking additional information about critical statements

30. Shifting from content to process – changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction • Clouding/fogging – concurring with the critic’s argument without becoming defensive and without agreeing to change • Defusing – putting off further discussion with an angry individual until he or she is calmer • Responding assertivelywith irony

31. Nurses Role • Education • Thought-Stopping Techniques

32. VII- Promoting Self-Esteem • Self-concept : is the cognitive or thinking component of the self, and generally refers to learned beliefs, attitudes, and opinions that each person holds to be true about his or her personal existence. • Self-concept consists of : 1-The physical self, or body image, 2-personal identity 3-Self-esteem

33. Boundaries • Physical boundariesinclude physical closeness, touching, eye contact, privacy, and pollution. • Touching someone who does not want to be touched is an example of an invasion of a physical boundary. • Psychological boundariesinclude beliefs, feelings, needs, interests, confidences, individual differences, and spirituality. • Being criticized for doing something differently from others is an example of an invasion of a psychological boundary.

34. Boundary pliancy –Boundaries can be rigid, flexible, or enmeshed • Rigid boundaries occur when people have a very narrow perspective on life. They perceive that things must be one way and refuse to change for any reason. • Flexible boundaries occur when people are able to let go of their boundaries as appropriate. Healthy boundaries are flexible. • Enmeshed boundaries occur when two people’s boundaries are so blended together that neither can be sure where one stops and the other begins. An individual with an enmeshed boundary is unable to differentiate his or her wants and needs from those of the other person.

35. VIII- Behavior Therapy • A behavior is considered to be maladaptive when it: - Is age-inappropriate - Interferes with adaptive functioning - Is misunderstood by cultural inappropriateness • The behavioral approach to therapy is that people have become what they are through learning processes or through the interaction of the environment • The basic assumption is that problematic behaviors occur when there has been inadequate learning

36. Techniques for Modifying Client Behavior • Shaping. • Modeling. • Premack principle. • Extinction. • Contingency contracting. • Token economy. • Time out. • Reciprocal inhibition. • Overt sensitization. • Covert sensitization. • Systematic desensitization. • Flooding.

37. Role of the Nurse

38. IX- Cognitive Therapy • The foundation on which cognitive therapy is established can be identified by the statement, “Men are disturbed not by things but by the views which they take of them.”

39. Indications for Cognitive Therapy • Depression • Panic disorder • Generalized anxiety disorder • Social phobia • Obsessive-compulsive disorder • Posttraumatic stress disorder • Substance abuse • Personality disorders • Schizophrenia • Couple’s problems • Bipolar disorder • Hypochondriasis • Somatoform disorder • Eating disorders

40. Automatic thoughts – thoughts that occur rapidly in response to a situation and without rational analysis; sometimes called cognitive errors • Some examples are: • Arbitrary inference • Overgeneralization • Dichotomous thinking • Selective abstraction • Magnification • Minimization • Catastrophic thinking • Personalization

41. Basic Concepts • “The general thrust of cognitive therapy is that emotional responses are largely dependent on cognitive appraisals of the significance of environmental cues.” (Wright, Beck, & Thase, 2003)

42. X- Complementary Therapies • The connection between mind and body is well recognized. • Traditional medicine practiced in the United States is based on scientific methodology and is known as allopathic medicine. • Practices that differ from the usual traditional practices are known as alternative medicine.

43. The Office of Alternative Medicine was established by the National Institutes of Health in 1991 to study nontraditional therapies and to evaluate their usefulness and effectiveness. The name has been changed to the National Center for Complementary and Alternative Medicine. • Increasing numbers of third-party payers are bowing to public pressure and including alternative therapies in their coverage. • Some clinicians view these therapies not as alternatives but as complementary therapies in partnership with traditional medicine

44. Complementary medicine is viewed as holistic health care, which deals not only with the physical perspective but also with the emotional and spiritual components of the individual. • Most complementary therapies are not founded on scientific principles, but they have been shown to be effective in the treatment of certain disorders and merit further examination as a viable component of holistic health care.

45. Types of Complementary Therapies • Herbal Medicine • Acupressure and Acupuncture • Diet and Nutrition • Chiropractic Medicine • Therapeutic Touch • Massage • Yoga • Pet Therapy • Aromatherapy • Hypnosis • Meditation • Guided imaging • others

46. XI- Client Education • Client education has been defined as “the process of influencing behavior, producing the changes in knowledge, attitudes, and skills necessary to maintain or improve health. It is a holistic process with the goal of changing a patient’s behavior to benefit his or her health status.” (Rankin, Stallings, & London, 2005) • Standard Ve of the ANA Standards of Psychiatric-Mental Health Nursing Practice pertains to “Health Teaching.” • Health teaching is required by the nurse practice acts and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

47. Nursing • Assessment • Nursing Diagnosis • Outcome Identification • Planning/Implementation • Evaluation • Documentation of Client Education

48. XII- ELECTROCONVULSIVE THERAPY • An electrical current (70-150 v) passes thru electrodes applied to the patient’s temple to induce a generalized tonic-clonic seizure (or Grand Mal) and unconsciousness; • Is use when other traditional therapies failed; • Length of application: 0.5 - 2 secs; • Length of seizure: 30 - 60 secs; • The cumulative effect of ECT is approx 220 - 250 secs. • Used to treat patients with depression, bipolar disorders, manic, and psychotic symptoms; • The exact action of ECT remains unknown;

49. Nursing Interventions: • Obtain an informed consent from the patient, family, or legal representative of the patient; • Teach the family and the patient about the treatment and what to expect like: • Short-term memory loss – resolve after 4-8 weeks; • Disorientation • Confusion • Respiratory depression • NPO post-midnight to prevent aspiration and vomiting; at least 8 hrs. • Remove all prostheses including hairpins and dentures;

50. Administer all preop meds as indicated like: • AtSO4– to decrease oral and nasal secretions*; • Succinylcholine – muscle relaxant; • Short-acting barbiturates* • Does not affect seizure threshold • Ex. Methohexital • Vital signs must be monitored before and after the procedures; • Tongue guard is inserted to prevent tongue injury during seizure; • Monitor heart rate and rhythm, blood pressure, and EEG;