Substance Abuse: Opioid Abuse

Opioid is a chemical substance that has a morphine-like action in the body. It is use mostly for pain relief. Opioid works by binding to opioid receptors in the central nervous system and the gastrointestinal tract. The receptors in these two organ systems mediate both the beneficial effects, and the undesirable side effects.

Classes of opioids:

1. natural opiates, alkaloids contained in the resin of the opium poppy including morphine, codeine and thebaine, but not papaverine and noscapine which have a different mechanism of action;
2. semi-synthetic opiates, created from the natural opioids, such as hydromorphone, hydrocodone, oxycodone, oxymorphone, desomorphine, diacetylmorphine (Heroin), nicomorphine, dipropanoylmorphine, benzylmorphine and ethylmorphine;
3. fully synthetic opioids, such as fentanyl, pethidine, methadone, tramadol and propoxyphene;
4. endogenous opioid peptides, produced naturally in the body, such as endorphins, enkephalins, dynorphins, and endomorphins.

Effect of Substance:
Temporary sense of well being, drowsiness, poor coordination, light-headedness, impaired thought processes, memory difficulty, confusion

Effect of Withdrawal:

Anxiety, gastrointestinal distress, nausea, insomnia, muscle pain, fever and chills, runny nose and eyes, sweating, tachypnea, coma, pintpoint pupils

Treatment:

• Detoxification
• Drugs: Opiate antagonis naloxone (Narcan) IV in emergency situation.
• In morphine and heroin addicts can use methadone daily to stabilize patient.
• In other opioid addicts, slowly taper the abused opioid.
• Psychotherapy
• Halfway houses
• Day or night hospitalization
• Twelve-step support groups

Nursing Intervention:

• Maintain airway
• Maintain safety
• Do not leave patient unattended because of risk of lapsing into coma quickly
• Monitor and assess for pulmonary edema
• Monitor vital sign and neurologic status and report to physician any abnormal redings
• Provide a quiet environment
• Encourage patient to express fears and anxiety

Substance Abuse: Nicotine Abuse

Nicotine is the drug in tobacco leaves. It a poisonous volatile alkaloid derived from tobacco (Nicotiana spp.) and responsible for many of the effects of tobacco. It first stimulates (small doses), then depresses (large doses) at autonomic ganglia and myoneural junctions.

Nicotine in inhaled tobacco smoke or in smokeless tobacco applied to buccal or nasal mucosa enters the circulation within seconds, causing an increase in heart rate, ventricular stroke volume, and myocardial oxygen consumption, as well as euphoria, heightened alertness, and a sense of relaxation. Nicotine use is powerfully addictive, readily leading to habituation, tolerance, and dependency. Withdrawal from nicotine causes restlessness, irritability, anxiety, difficulty concentrating, and craving for nicotine. Addiction to nicotine is the reason for most tobacco use and is thus directly responsible for the resulting morbidity and mortality.

Nicotine: Tobacco smoking, chewing, and dipping.


Effect of Substance:
Mild euphoria, feeling of relaxation, anorexia, hypertension, tachycardia

Effect of Withdrawal:
Restlessness, irritability, difficulty in concentrating, depression, insomnia, increased appetite, weight gain

Treatment:

• Detoxification
• Drugs: nicotine gum, nicotine nasal sprays, and nicotine patches.
• Behavior therapy
• Psychotherapy
• Support groups

Nursing Intervention:

• Maintain safety
• Monitor vital sign and neurologic status and report to physician if any abnormal readings
• Provide support to patient, family, and significant others
• Encourage patient to express fears and anxiety

Substance Abuse: Methamphetamines

Methamphetamine is a member of the family of phenylethylamines. Methamphetamine acts as a dopaminergic and adrenergic reuptake inhibitor and in high concentrations as a monamine oxidase inhibitor (MAOI). Since it stimulates the mesolimbic reward pathway, causing euphoria and excitement, it is prone to abuse and addiction.

Methamphetamines: amphetamine (Benzedrine), dextroamphetamine (Dexedrine), MDMA (Ecstasy), methylphenidate (Ritalin)

Effect of Substance:
Increased attention, increased activity, decreased fatigue, decreased appetite, euphoria, hyperthermia, tachycardia

Effect of Withdrawal:

Insomnia, restlessness, irritability, panic, paranoia, confusion, homicidal behavior, depression with suicidal ideation, hallucination, vomiting, nausea, chills

Treatment:

• Detoxification
• Drugs: small doses of diazepam IV or haloperidol to combat CNS hyperactivity
• Treat seizure with benzodiazepines
• Activated charcoal for overdose
• Behavior therapy
• Psychotherapy
• Halfway houses
• Day or night hospitalization
• Twelve-step support groups

Nursing Intervention:

• Maintain airway
• Maintain safety
• Monitor for suicide attempts
• Calm, cool, and quiet environment
• Monitor vital signs and neurologic status and report to physician if any abnormal readings
• Encourage patient to express fears and anxiety

Substance Abuse: Cocaine Abuse

Cocaine is a crystalline alkaloid obtained from the leaves of Erythroxylon coca (family Erythroxylaceae) and other species of Erythroxylon, or by synthesis from ecgonine or its derivatives.

Cocaine is a potent central nervous system stimulant, vasoconstrictor, and topical anesthetic, widely abused as a euphoriant and associated with the risk of severe adverse physical and mental effects.

Cocaine: cocaine hydrochlororide (sniffed) free-base cocaine (smoked), crack cocaine (small rocks that are smoked), cocaine that may be injected intravenously

Effect of Substance:

Euphoria, risk taking behavior, feeling of confidence, anorexia, inappropriate sexual behavior, tachycardia, tachypnea, nervousness, hypertension, dilated pupil, agitation, fever, inability to concentrate.

Effect of Withdrawal:
Psychosis, delusion, hallucinations, paranoia, depression, ideas of persecution, aggressiveness, tremor, hypervigilance, insomnia, fatigue, muscle pain, nausea, vomiting, general malaise, suicidal ideation

Treatment:
Detoxification
Drugs: antidepressant, antipsychotic
Charcoal to treat ingested cocaine
Behavior therapy
Psychotherapy
Halfway houses
Day or night hospitalization
Twelve-step support groups

Nursing Intervention:
Maintain and ensure the airway and ventilation
Maintain safety
Monitor and assess patient for using of alcohol and benzodiazepine
Control seizure
Treat hyperthermia
Monitor cardiovascular status
Quiet environment
Encourage patient to express fears and anxiety

Substance Abuse: Benzodiazeipnes

The benzodiazepines are a class of psychoactive drugs with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties, which are mediated by slowing down the central nervous system. The drugs are useful in treating anxiety, insomnia, agitation, seizures, and muscle spasms, as well as alcohol withdrawal. Using of benzodiazepines in long term can cause physical dependence.

Types of Benzodiazepines are Diazepam (Valium) and Lorazepam (Ativan)

Effect of Substance:
Sleepiness and deep sleep, poor coordination, slurred speech, falling, poor thought processes, memory difficulty, weak comprehension, poor judgment, mood swings, constricted pupils, nystagmus, and tachypnea.

Effect of Withdrawal:

Anxiety, rage, insomnia, panic attacks, depression, night-mares, nausea, constipation, diarrhea, shaking, muscle pain, sweating, tachycardia, paresthesia, seizure, and death if combine with alcohol.

Treatment:

• Detoxification
• Drugs: antagonist fumezenil (Romazicon), slowly taper the abused benzodiazepine.
• Behavior therapy
• Psychotherapy
• Halfway houses
• Day or night hospitalization
• Twelve-step support group

Nursing Intervention:

• Maintain safety
• Monitor vital sign and neurologic status and notify physician if abnormal readings
• Monitor for alcohol abuse
• Monitor for dysrhythmias
• Encourage patient to express fears and anxiety, Provide a quiet environment
• Implement seizure precaution

Substance Abuse: Barbiturate

Barbiturates are a group of drugs known as sedative-hypnotics, which generally describes their sleep-inducing and anxiety-decreasing effects.

Person uses barbiturates as abused mostly to reduce anxiety, decrease inhibitions, and treat unwanted effects of illicit drugs. Barbiturates can be extremely dangerous because the correct dose is difficult to predict. Barbiturates are also addictive and can cause a life-threatening withdrawal syndrome.

There are many different kind of barbiturate: Amobarbital (Amytal), pentobarbital (Nembutal), Secobarbital (Seconal), Phenobarbital, and Tuinal

Effect of Subtance:
Sluggish coordination, emotional lability, faulty judgment, aggressiveness, nystagmus, strabismus, diplopia, decreased reflexes, ataxic gait, bradycardia, respiratory depression, stupor, decreased tendon reflexes.


Effect of Withdrawal:
Irritability, anxiety, tachycardia, tachypnea, nausea, tremors, muscle pain, confusion, hallucination, seizures, insomnia, vivid dreaming, coma, death.

Treatment:

• Detoxification
• Drugs: slowly taper the abused barbiturate, sodium bicarbonate (promotes excreation of barbiturates, and activated charcoal for overdose.
• Behavior therapy
• Psychotherapy
• Halfway houses
• Day or night hospitalization
• Twelve-step support groups

Nursing Intervention:

• Maintain airway
• Maintain client safety
• Monitor for alcohol abuse
• Monitor vital signs and neurologic status and notify physician if any abnormal readings
• Orient client to place, person, and time
• Provide a quiet environment with a light switched on
• Control combative behavior
• Encourage patient to express fears and anxiety
• Implement seizures precautions

Substance Abuse: Alcohol Abuse

Alcohol abuse is a psychiatric diagnosis describing the use of alcoholic beverages despite negative consequences. Alcohol abuse is different from alcohol dependence means by the lack of symptoms such as tolerance and withdrawal.

Effect of Substance:
Drunkenness, drowsiness, behavioral changes, poor judgment, coordination difficulty, slurred speech, inappropriate sexual behavior, aggression, memory problems, nystagmus, poor attention span, stupor, coma.

Effect of Withdrawal:
Altered consciousness, agitation, aggressiveness, anxiety, fear, confusion, delusions, disorientation, hallucinations, insomnia, blackouts, profuse sweating, acute psychosis, tachycardia, hypertension, tachypnea, anorexia, nausea, grand mall seizure, abdominal cramps, tremors, and vomiting.

Treatment:

• Detoxification
• Drugs: benzodiazepines, anti-seizure dugs.
• Behavior therapy
• Psychotherapy
• Halfway houses
• Day or night hospitalization
• Twelve-step support groups

Nursing Intervention:

• Maintain client safety
• Orient patient to place, person, and time
• Monitor vital signs and neurologic status, and notify physician if any abnormal value.
• Quiet environment with a light on
• Record intake and output
• Encourage patient to express fears and anxiety

Schizophrenia 1: Definition, Signs, and Symptoms

Schizophrenia is a group of mental disorders characterized by abnormalities in perception, content of thought, and thought processes (hallucinations and delusions) and by extensive withdrawal of interest from other people and the outside world, with excessive focusing on one's own mental life.

Schizophrenia is the most prevalent psychosis, affecting some 2 million Americans. The annual cost of the disease to the U.S. economy is estimated at $65 billion, of which $46 billion reflects lost productivity of patients and their caregivers

The term of schizophrenia was coined by Bleuler, synonymous with and replacing dementia praecox. This disorder disturbances in affect, mood, behavior, and though process.

Signs and Symptoms of Schizophrenia:

POSITIVE SYMPTOMS

• Excess or distortion of normal functions
• Delusions (persecutory or grandiose)
• Conceptual disorganization
• Hallucinations (visual, auditory, or other sensory mode)
• Excitement or agitation
• Hostility or aggressive behavior
• Suspiciousness, ideas of reference
• Pressurized speech
• Bizarre dress or behavior
• Possible suicidal tendencies

NEGATIVE SYMPTOMS

• Diminution or loss of normal functions
• Anergia (lack of energy)
• Anhedonia (loss of pleasure or interest)
• Emotional withdrawal
• Poor eye contact (avoidant)
• Blunted affect or affective flattening
• Avolition (passive, apathetic, social withdrawal)
• Difficulty in abstract thinking
• Alogia (lack of spontaneity and flow of conversation)
• Dysfunctional relationship with others

DISORGANIZED SYMPTOMS

• Cognitive defects/confusion
• Incoherent speech
• Disorganized speech
• Repetitive rhythmic gestures (such as walking in circles or pacing)
• Attention deficits

Diagnostic Characteristics:

• Evidence of two or more of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms
• Above symptoms present for a major portion of the time during a 1-month period
• Significant impairment in work or interpersonal relations, or self-care below the level of previous function
• Demonstration of problems continuously for at least a 6-month interval
• Symptoms unrelated to schizoaffective disorder and mood disorder with psychotic symptoms and not the result of a substance-related disorder or medical condition

Continued to Schizophrenia 2

Bipolar Disorder

Bipolar disorder is an affective disorder characterized by the occurrence of alternating periods of euphoria (mania) and depression.

Signs and Symptoms Of Mania:

• Becomes angry quickly.
• Distracted by environmental stimuli.
• Extroverted personality
• Flights of idea
• Delusional self-confidence.
• Grandiose and persecutory delusions
• Inability to eat or sleep.
• High and unstable affect.
• Inappropriate dress.
• Inappropriate affect.
• Initiation of activity
• Restlessness
• Pressured speech
• Sexually promiscuous
• Unlimited energy
• Urgent motor activity
• Significant decrease in appetite

Signs and Symptoms Of Depression:

• Decreased emotion and physical activity
• Decrease in activities of daily living
• Easily fatigue
• Inability to make decisions
• Introverted personality
• Internalizing hostility
• Lack of initiative
• Lack of energy
• Lack of self-confidence
• Lack of sexual interest
• Withdrawn from groups

Interventions for maniac patients:

• Remove hazardous objects from the environment
• Assess the client closely for fatigue
• Promote sleep
• Provide rest periods
• Provide private room
• Hypnotic or sedative medication as prescribed
• Encourage the patient to ventilate feeling
• Calm and slow interaction
• Encourage patient to focus on one topic during conversation
• Ignore and distract patient from grandiose thinking
• Present reality to patient
• Do not argue with patient
• Provide high-calorie finger foods and fluids
• Reduce environmental stimuli
• Set limits on inappropriate behaviors
• Provide physical activities and outlets for tension
• Avoid competitive games
• Provide gross motor activities such as walking and writing
• Provide structured activities with nurse
• Provide simple and direct explanations for routine procedures
• Supervise the administration of medication

Deal With Aggressive Behavior Patients:

• Assist patient to identify feeling of frustration and aggression
• Encourage patient to talk out instead of acting out
• Assist patient in identifying precipitating events or situations lead to aggressive behavior
• Describe the consequences of the behavior on self and others
• Assist in identifying previous coping mechanism
• Assist in problem solving techniques.

Deal With De-escalation Techniques:

• Maintain safety for the patient, others and self
• Maintain a large personal space and use non-aggressive posture
• Calm in approaching and communicating
• Clear tone of voice, be assertive not aggressive
• Avoid verbal struggles
• Assist the patient with problem-solving and decision making
• Provide the patient with clear option

Deal With Manipulative Behaviors:

• Set clear, consistent, realistic and enforceable limits
• Communicate the expected behaviors
• Be clear with the consequences associated with exceeding limits
• Discuss the patient’s behavior in non-judgmental and non-threatening manner
• Avoid power struggles with the patients

Dissociative Disorder

Dissociative disorder is a group of mental disorders characterized by disturbances in the functions of identity, memory, consciousness, or perception of the environment. It is associated with exposure to an extremely traumatic event.

Dissociative disorder includes dissociative amnesia, dissociative fugue, dissociative identity (multiple personality) disorder, and depersonalization disorder.

Dissociative Amnesia
Dissociative amnesia is the inability to recall important personal information because it is anxiety provoking. Memory impairment may be partial or almost complete.
There are three types of dissociative disorder:

1. Localized: block out all memories about specific period.
2. Selective: recalls some but not all memories about a specific period.
3. Generalized: loss of all memory about past life.

Dissociative Fugue

Dissociative fugue is a disorder in which client assumes a new identity in a new environment. It may be suddenly. The client may drift from place to place and develops few social relationships.

Dissociative Identity (Multiple Personality)
Two or more fully developed distinct and unique personalities exist within the person and may take full control of the client one at a time. This disorder is used as a method of distancing and defending self from anxiety and traumatic experiences. The transition from one personality to the other is related to stress and is sudden.

Depersonalization Disorder
Depersonalization disorder is an altered self perception in which client’s reality is temporally lost or changed. The client will have feelings of detachment and intact reality testing.

Specific Intervention for Dissociative Disorder Client:

• Develop a trust with the client.
• Encourage verbal expression of anxiety and concerns.
• Encourage client to explore methods of coping.
• Orient the client and identity sources of conflicts.
• Focus on the client’s strengths and skills.
• Use stress reduction techniques.
• Allow the client to progress at his or her own pace.
• Plan for individual, group, and family psychotherapy.

Somatoform Disorders

Somatoform disorders are group of disorders in which physical symptoms suggesting physical disorders for which there are no demonstrable organic findings or known physiologic mechanisms. There is a strong presumption that the symptoms are linked to psychological factors. The client focuses on the physical signs and symptoms and is unable to control the signs and symptoms. The signs and symptoms increase with psychosocial stressors.

There are three types of somatoform disorders: conversion disorder, hypchondriasis, and somatization disorder.

Conversion Disorder
Conversion disorder is a mental disorder in which an unconscious emotion conflict is expressed as an alteration or loss of physical functioning without any organic causes. The most common conversion symptoms are blindness, deafness, paralysis, and the inability to talk.


Clients with conversion disorder will have physical limitation or disability, feeling of guilt, anxiety, or frustration, low self esteem, feeling of inadequacy, unexpressed anger or conflict, and secondary gain.

Hypochondriasis
Hypochondriasis is a delusion that one is suffering from some disease for which no physical basis is evident. Hypochondriasis can cause impaired social and occupational functioning.

Clients with hypochondriasis will have frequent somatic function, complaints of fatigue and insomnia, preoccupation with physical function, anxiety, difficulty expressing feelings, extensive use of remedies or nonprescription medications, repeatedly visiting doctors, and secondary gain.

Somatization Disorder
Somatization disorder is a mental disorder characterized by complicated medical history and multiple physical complains involving multiple body systems without any organic basis. Somatization disorder can result from anxiety, fear, depression, worry or repressed anger. The client may use somatization for secondary gains such as increased attention or decreased responsibilities.

Clients with somatization disorder will have physical complaints of pain, signs of anxiety, fear and low self esteem, psychosocial symptoms, and secondary gains.

Specific Interventions for somatiform disorders:

• Assess nursing history and physical problems
• Do not reinforce the sick role and discourage verbalization about physical symptoms.
• Allow specific time period to discuss physical complaints.
• Assist client to identify alternative ways of meeting needs.
• Convey understanding that the physical symptoms are real to the client and assure that physical illness has been ruled out.
• Explore the source of anxiety and encourage verbalization of anxiety.
• Use relaxation techniques as the anxiety increases.
• Encourage diversional activities to decrease the focus on self.
• Report and assess any new physical complaint.
• Positive feedback for accomplishments.
• Establish a written contract with the client.
• Administer anti-anxiety medication as prescribed.

Obsessive Compulsive Disorder

Obsessive compulsive disorder is a type of anxiety disorder whose essential feature is recurrent obsession, persistent, intrusive ideas, thoughts, impulses or images, or compulsion. Compulsion means repetitive, purposeful and intentional behaviors performed in response to an obsession. The person may have both obsession and compulsions that can disrupt normal activities. An example of this disorder is excessive and repeated hand washing to ward off infection.

A person act compulsive behavior patterns can decrease the anxiety that associated with the obsessive thoughts and during stressful time, the ritualistic behavior will be increased. Most of the patient with obsessive compulsive disorder has variety of defense mechanism include repression, displacement, and undoing.


Cause of obsessive compulsive disorder was rare. Some reports have linked obsessive compulsive disorder to head injury and infections and about 20% of those with this disorder have motor tics related to tourette syndrome.

Intervention:

• Try to identify the situation that precipitates the behavior.
• Do not interrupt the compulsive behavior.
• Allow time for the patient to perform the compulsive rituals.
• Keep the client safety
• Make a schedule for patient that can distracts from the ritual.
• Set limit on the ritual.
• Encourage the patient to verbalize concerns.
• Establish the written contract that can assist to decrease the frequency of compulsive behavior.

Phobias

Phobia is an irrational fear of an object or situation that persist although the person may recognize it as unreasonable. It is associated with panic level anxiety if the object, situation, or activity cannot be avoided. The word of phobia is used as a combining form in many term expressing the object that inspires the fears.

Types of Phobias:

1. Acrophobia : fear of heights
2. Agoraphobia : Fear of open spaces
3. Astraphobia : Fear of electrical storms
4. Claustrophobia : Fear of closed spaces
5. Hematophobia : Fear of blood
6. Hydrophobia : Fear of water
7. Monophobia : Fear of being alone
8. Mysophobia : Fear of dirt or germs
9. Nyctophobia : Fear of darkness
10. Pyrophobia : Fear of fire
11. Social Phobia : fear of situation in which one might be embarrassed or criticized
12. Xenophobia : Fear of strangers
13. Zoophobia : Fear of animals.

How to care patient with phobias:

• Identify the basic of the anxiety
• Stay with the patient when the anxiety is high
• Encourage patient to verbalize feeling
• Desensitization : gradually introducing the patient to the feared object or situation in small doses
• Using relaxation techniques such as breathing, muscle relaxation, exercises, and visualization or pleasant situation.
• Try not to force the client to have contact with the phobic object or situation.

Model of Care: Group Therapy

There are three stages of group development: Initial stage, working stage, and termination stage. Each stage has specific character.

Initial Stage:

• This is the first stage in which the members become acquainted with each other and search for similarity between themselves.
• Trusting communication is important in this stage.
• Structuring of group norms, roles and responsibilities are taking place in this stage.

Working Stage:

• This is the second stage in which the real work of the group is accomplished.
• Member are familiar with each other, the group leader and the group roles.
• Members feel free to approach their problems and to attempt to solve their problems.

Termination Stage:

• In this stage, the group evaluates the experience and explores member’s feeling and impending separation.
• The leader provides an opportunity for members who have difficulty with termination to learn to deal more realistically with this human experiences.

There are eight model of group therapy:

1. Psychoanalytical Group Therapy

• The therapist holds a main position and each client in the group has a relationship with the therapist.
• Communication is focused on three level, unconscious, semiconscious, and conscious information.

2. Transactional Analysis

• The three ego of individual are examined in transactional analysis groups.
• The individuals in the group will communicate from the proper ego states for the situation and the responses of other.

3. Rational Emotive Therapy

• In this method, the therapist designs activities to eliminate the irrational ideas of the members.

4. Rogerian Therapy

• This therapy helps the members express their feeling toward one another during group sessions.

5. Gestalt Therapy

• This gestalt therapy emphasizes self expression, self exploration, and self awareness in the present time, and focusing on everyday problems and try to solve them.

6. Interpersonal Group Therapy

• This therapy promotes the individual’s comfort with others in the group then transfers to other relationship.

7. Self-help or Support Group Therapy

• This therapy is based on the premise that persons who have experienced a similar problem are able to help others who have the same problem.
• It also prevents the individual member from feeling lonely and isolated.
• There are so many self-help or support groups: adult children of alcoholic, al-alon, alcoholic anonymous, co-dependent anonymous, gamblers anonymous, narcotics anonymous, over-eaters anonymous, bereavement, etc.

8. Family Therapy

• This therapy assists the family members to identify and express their thoughts and feeling, define family roles and rules, try new, more productive styles of relating and restore strength to the family.

Model of Care: Cognitive Therapy

Cognitive therapy is an active, directive, time-limited , structured approach that is designed to identify reality testing and correct distorted conceptualization and the dysfunctional belief underlying these cognition.

The therapist tries to help the client to think and act more realistically and adaptively so it can reduce the psychological problem.

Model of Care: Behavior Modification

Behavior Modification is the systematic use of principles of conditioning and learning, especially operant or instrumental conditioning, to teach certain skills or to extinguish undesirable behaviors, attitudes, or phobias. There are types of behavior modification: behavior therapy, self-control therapy, desensitization, aversion therapy, modeling therapy, and operant conditioning.

Behavior Therapy:
Behavior therapy is an approach to bring about behavioral change. It includes a group of diversified approaches for dealing with maladaptive behavior.


Self-Control Therapy:
Self control therapy is a combination of cognitive and behavioral approaches. It is useful to deal with stress. The basic of this concept is that talking to oneself can direct and control action more effectively.

Desensitization:
Desensitization is the reduction of intense reactions to a stimulus by repeated exposure to the stimulus in a weaker and milder form. The exposure is increased until the fear of the object or situation is ceased.

Aversion Therapy:
Aversion therapy is also a technique to change behavior in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort. This conditioning is intended to cause the patient to associate the stimulus with unpleasant sensations in order to stop the specific behavior.

Modeling Therapy:
In this therapy, the therapist acts as a role model for a specified behavior, and the client learns through imitation.

Operant Conditioning:
Operant conditioning is the use of consequences to modify the occurrence and form of behavior. It deals with the modification of "voluntary behavior". Reinforcement and punishment are the for this therapy.

Model of Care: Psychotherapy

Psychotherapy is treatment of emotional, behavioral, personality, and psychiatric disorders based primarily upon verbal or nonverbal communication and interventions with the patient, in contrast to treatments utilizing chemical and physical measures. Verbal means communication. Non verbal techniques include silence, body language, facial expressions, and respect for personal space.

There are three levels of psychotherapy:

1. Supportive therapy
2. Reeducative therapy
3. Reconstructive therapy

Supportive Therapy:
In supportive therapy, the client is allowed to express feelings, explore alternatives and make decision.


Reeducative Therapy:
Reeducative therapy will include a short-term psychotherapy, reality therapy, cognitive restructuring, and behavior modification, and involves learning new ways of perceiving and behaving. Reeducative therapy requires a longer period than supportive therapy.

Reconstructive Therapy:
Reconstructive therapy includes deep psychotherapy or psychoanalysis and may require 2 to 5 years of therapy or more, focusing on all aspects of the client’s life. The positive outcomes of reconstructive therapy will be a greater understanding of self and others, more emotional freedom, and the development of potential abilities.

Anxiety Disorder Classification (part-2)

Post-Traumatic Stress Disorder (PTSD)
This stress disorder occurs after experiencing a psychologically traumatic event outside the range of usual experience such as rape, combat, bombings, kidnapping. The person with posttraumatic stress disorder re-experiences the event through recurrent dreams and flashbacks.

Person with post-traumatic stress disorder may commonly uses emotional numbness, detachment, and estrangement to defend against anxiety. Sleep disturbance, hypervigilance, guilt about surviving, poor concentration, and avoidance of activities that trigger memory of the event are the most symptom with post-traumatic stress disorder.

Phobias
Phobia is irrational fear of an object or situation that persists, although the person may recognize it as unreasonable. Sever anxiety will be occurred if the object, situation, or activity cannot be avoided



Types of Phobias include:

• Agoraphobia: Fear of being alone in open or public places where escape might be difficult; may not leave home
• Social phobia: Fear of situations in which one might be seen and embarrassed or criticized; fear of eating in public, public speaking, or performing
• Specific phobia: Fear of a single object, activity, or situation (eg, snakes, closed spaces, and flying)

Substance-induced anxiety disorder

A substance-induced anxiety disorder is sub-typed or categorized based on whether the prominent feature is generalized anxiety, panic attacks, obsessive-compulsive symptoms, or phobia symptoms. Drug use is related to this disorder.

Symptoms substance-induced anxiety disorder will develop within 1 month of substance intoxication or withdrawal and significant distress of impairment in social and occupational functional will be occurred.

Anxiety Disorder Classification (part-1)

Acute Stress Disorder

Client with acute stress disorder will develop three or more of these dissociative symptoms:

• Subjective sense of numbing
• No emotional responsiveness
• Feeling dazed
• Depersonalization
• Derealization
• Amnesia

Duration of acute stress disorder would be 2 days to 4 weeks.


Generalized Anxiety Disorder

Client with generalized anxiety disorder will develop three off the four categories:

• Autonomic hyperactivity: palpitations, sweating, cold clammy, urinary frequency, pallor or flushing, lump in throat, rapid respiration, and tachycardia.
• Motor tension: restlessness, trembling, inability to relax, fatigue.
• Apprehensiveness: dread, worry, fear, insomnia, rumination, and inconcentrate.
• Hypervigilance: felling edgy and distractibility.

These symptoms persist for at least 6 months.


Obsessive-Compulsive Disorder

Obsession is preoccupation with persistent intrusive thoughts. Compulsion is repeated perfomance of rituals designed to prevent some anxiety. Client with Obsessive-Compulsive Disorder with have obsession symptoms, compulsion symptoms, or both.

The client will be in anxiety condition if obsessions or compulsions are resisted and from feeling powerless to resist the thoughts or rituals.


Panic Disorder

Panic disorder means the recurrent unexpected anxiety attacks. It happens suddenly with intense apprehension and dread.
Client with panic disorder will develop at least four of the following symptoms:

• Dyspnea
• Dizziness
• Chest discomfort
• Hot or cold flashes
• Tingling of hands or feet
• Feeling of unreality
• Palpitation
• Syncope
• Diaphoresis
• Trembling
• Fear of losing control, going crazy or dying

Anxiety Related Disorder

Anxiety-related disorders are the most common of all psychiatric disorders. Client with these disorder will experience physiologic, cognitive, and behavioral symptoms.

Physiologic manifestations are related to the fight and flight response that result in cardiovascular, respiratory, neuromuscular, and gastrointestinal stimulation. The cognitive symptoms are apprehension, uneasiness, an uncertainty. Behavioral symptoms are irritability, restlesnes, pacing, crying, and sighing, tension and nervousness.

Classification

As defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR), anxiety-related disorders are include those listed here.


Anxiety Disorders:

• Panic disorder without agoraphobia
• Panic disorder with agoraphobia
• Agoraphobia without history of panic disorder
• Specific phobia
• Social phobia
• Obsessive-compulsive disorder (OCD)
• Posttraumatic stress disorder (PTSD)
• Acute stress disorder
• Generalized anxiety disorder
• Anxiety disorder due to a general medical condition
• Substance-induced anxiety disorder
• Anxiety disorder not otherwise specified

Dissociative Disorders

• Dissociative amnesia
• Dissociative fugue
• Dissociative identity disorder
• Depersonalization disorder
• Dissociative disorder not otherwise specified

Model Of Care: Milieu Therapy

Milieu therapy is an treatment environment in which everyday events and interactions are therapeutically designed for the purpose of enhancing social skills and building confidence. It provides a safe environment adapted to the client’s needs, comport, and freedom of expression.

Milieu therapy is staffed by persons trained to provide support, and all members contribute to the planning and functioning of setting. All members are viewed as significant and valuable members of community.

Focus of milieu therapy:

• Positive physical, social and environmental manipulation to effect a positive changes.
• Group and social interaction.
• Client’s rights.
• Using community meeting, activity groups, social skills groups, and physical exercise programs.

Mental Health Admission and Client Rights

There are two types of admission and discharge in Mental Health Care :

Voluntary Admission

• Client agree to accept treatment
• Civil rights are retained fully by the client and the client is free to sign out of the hospital
• The client has the right to demand and receive release
• Any client of lawful age may apply in writing for admission to the hospital

Involuntary Admission

• Client who has legal capacity to consent to mental health treatment refuses to do so and is detained involuntarily for treatment by the state
• It is necessary when a client is mentally ill and is a danger to self or other and need of psychiatric treatment and physical care
• The client who involuntary admitted to mental health care can be categorized for evaluation and emergency care, certification for observation and treatment, or extended and indeterminate commitment.
• This client does not lose his or her right of informed consent

The client who is admitted to mental health care (voluntary or involuntary) will have “client right” to :

• Accessible health care
• Courteous and individualized health care
• Coordination and continuity of health care
• Get the information about the qualifications, names, and titles of personal giving care
• Privacy and confidentiality
• Refuse observation by those not directly involved in care
• Informed consent
• Treatment
• Information about diagnosis, prognosis, and treatment
• Information on the charges of services
• Communicate with people outside the hospital through correspondence, telephone, and personal visits
• Be employed
• Religious freedom
• Execute wills
• Retains in licenses, privileges, or permits established by law
• Treatment in the least restrictive setting
• Not to be subjected to unnecessary restraints

Therapeutic Communication in Nursing

Therapeutic Communication is a important thing in delivering a care for patient, as well as part of nursing skills to achieves nursing goal as part of nursing care plan. Communication is defined as a process of generating and transmitting meaning and it includes verbal and non verbal communication. Successful communication includes appropriateness, efficiency, flexibility, and feedback.

Element of Communication:

• Sender: originator of information
• Message: information being transmitted
• Receiver: recipient of information
• Channel: mode of communication
• Feedback: return response
• Context: the setting of communication

There is five steps in therapeutic communication :

1. Assessment, how to gather information
2. Diagnose
3. Planning and setting goals
4. Implementation
5. Evaluation

Before or during intervention, as a nurse should :

• Consider factors which influence effective verbal communication
• Use special communication aids as needed
• Use planned therapeutic communication techniques
• Avoid nontherapeutic techniques

Therapeutic Communication Techniques:

• Encouraging formulation of a plan of action
• Clarifying and validating
• Focusing and refocusing
• Give information and presenting reality
• Listening
• Maintain neutral responses
• Maintain silence
• Provide acknowledgment and feedback
• Provide nonverbal encouragement
• Restating
• Reflecting
• Share perceptions
• Use broad opening and open-ended question
• Summarizing

Nontherapeutic Communication Techniques:

• Be defensive or challenging the client
• Ask the client “why”
• Change the subjects
• Give advice or approval or disapproval
• Make value judgment
• Make stereotypical comments
• Place the client’s feeling on hold
• Provide false reassurance

Nurse - Client Relationship

Nurse – Client relationship is essential in nursing practice. The basic element of the relationship between nurse and client depends on the interaction of thought, feeling, and action of each person. The patient will experience better health when all their needs are fully considered in the relationship (Peplau, Interpersonal Relation 9).

Nurse establishes and maintains this relationship by nursing knowledge and skills, as well as applying caring attitudes and behaviors. This nurse – client relationship is based on trust, respect, empathy and professional intimacy.

There are principles in establishing nurse – client relationship :

• Care for the client in holistic manner
• Maintain genuineness, respect, empathy and concreteness
• Assess religious and spiritual practice of patient
• Assess cultural beliefs and values
• Honest and open communication
• Encourage expression of the client’s feeling
• Established in appropriate limits
• Help the client to develop resources

PHASE OF THERAPEUTIC NURSE-CLIENT RELATIONSHIP


Preinteraction phase. It begins before the nurse’s first contact with client, self exploration about his or her values and feeling for caring for the client

Orientation Phase. In this phase, the nurse establish boundaries, acceptance, ant trust with client, identify the expectation and assess the anxiety in the client. Goals are defined with the client in this phase, as well as preparing the client for termination or separation of relationship.
Working Phase. Nurse promotes an attitude of acceptance and assist the client to express feelings by using the constructive coping mechanisms, and increase the client’s independence.

Termination or Separation Phase. This is the end of all phase in which the nurse prepares the client for termination and separation on initial contact and evaluate progress and achievement of goals. Nurse encourage the client to discuss the feeling about termination and never promise the client that the relationship will be continued. This is times to refer and transfer the client to other available support systems.

Coping and Defense Mechanism in Psychiatry

Coping Mechanism involves any effort to decrease the stress response. It can be constructive or destructive, task oriented, or defense oriented, regulating the response to protect oneself. If destructive coping mechanism is happened, it often cause a mental health disorder because the person avoids the problem or stress that causes the disorder. And neurotic or psychotic behaviors can result when coping mechanism become destructive.

Defense mechanism is coping mechanism of the ego that attempts to protect the person from feelings of inadequacy and worthlessness.

Practically a Nurse should have a knowledge of Coping Mechanism or Defense Mechanism in caring of psychiatry client whether in primary psychiatry health care of secondary psychiatry health care.

Knowing of Coping or Defense Mechanism also will be a key point in preparing of NCLEX or CGFNS test. Some question in NCLEX - CGFNS will ask coping - defense mechanism as a comprehensive client care.

Here are types of defense mechanism :

COMPENSATION
Putting fort extra effort to achieve in areas where one has a real or imagined dificiency.

CONVERSION
It is a expression of emotional conflicts or stress through physical symptoms

DENIAL
Keep anxiety-producing realities out of conscious awareness

DIPLACEMENT
Transfers an emotion from the original to a different idea. Feeling toward one person are directed to another who is less threatening

DISSOCIATION
The blocking off of an anxiety event or period of time from the conscious mind

FANTASY
Escapes stress by focusing on unreal mental images in which his or her wishes are fulfilled

FIXATION
Never advancing to the next level of emotional development and organization.

IDENTIFICATION
Pattern himself or herself after another person

INSULATION
Withdrawing into passivity and becoming inaccessible so as to avoid further threating situation

INTELLECTUALIZATION
Deals with problem or stress on an intellectual basis to avoid discomfort of emotions

INTROJECTION
The person incorporates the traits or values of another into self

ISOLATION
The person block feeling associated with an unpleasant experience or stress

PROJECTION
The person displaces own undesirable actions or feeling to another person

RATIONALIZATION
Attempt to make unacceptable feeling, emotion or behavior by justifying the behavior

REACTION FORMATION
The person act in a way that is the opposite of her or his actual feelings

REGRESSION
Returning to an earlier developmental stage to express an impulse to deal with reality

REPRESSION
Unconsciously inhibits an idea or desire

SUBLIMATION
Replacement of an unacceptable need, attitude, or emotion with one more socially acceptable

SUBSTITUTION
The replacement of a valued unacceptable object with an object that is more acceptable to the ego

SUPRESSION
Consciously inhibits or forgetting of unacceptable or painful thoughts or idea or desire

SYMBOLIZATION
Consciously using an idea or object to represent another actual event or object

UNDOING or RESTITUTION
Attempts to engage behavior that is considered to be opposite of a previous unacceptable thought or feeling

Mental Health & Illness

DSM-IV-TR: Mental Illness/Disorder is defined as a clinically significant behavioral or psychological syndrome or pattern associated with distress or disability......with increased risk of death, pain, disability and is not a reasonable (expectable) response to a particular situation (APA 2000).

On the other hand Mental Health is defined as a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and cope with adversity. (US Surgeon General Report, Dec 1999).



There are six major categories of positive mental health (Marie Jahoda in 1958) :

1. Attitudes of individual toward self
2. Presence of growth and development, or actualization
3. Personality integration
4. Autonomy and independence
5. Perception of reality
6. Environmental mastery

The health person will accepts the self, self-reliant, and self-confident.