Education as psychiatric intervention: the cognitive-behavioral context.

1. The cognitive behavioral treatment context is essentially an educational function that focuses on eliciting changes in attitude and judgment, values, methods of cognitive processing, correction of distorted thinking, re-examination of internalized core assumptions, and subsequently, behavior. 2. The behavioral framework presumes that behavior is learned and can be unlearned or relearned, and that psychiatric disorders are severely complicated by maladaptive and dysfunctional attempts to compensate. 3. The cognitive models involve validation, remotivation, resocialization, reality testing through increasing coping and problem solving abilities, and increasing self esteem and a sense of personal control.

Integration and synthesis. Cognitive behavioral therapies within the biological paradigm.

1. In today's managed care environments, where more emphasis is placed on cost-effective management of patients, the role of medications along with psychotherapy is becoming an accepted standard for psychiatric care. 2. Blind acceptance of the biological model tends to trivialize cognitive behavioral and psychoeducational interventions and casts doubt on the outcome of rehabilitation and retraining. 3. For complete and comprehensive care of patients, psychiatric nursing should embrace both biological and behavioral paradigms and view them as complementary rather than competitive.

Understanding vicarious traumatization.

1. Close and prolonged work with victims of trauma and abuse can have serious psychological consequences for professionals. 2. The consequences to professionals can include development of anxiety, depression, intrusive thoughts, alienation, dissociative episodes, feeling of helplessness, paranoia, hypervigilance, and disrupted personal relationships. 3. The concepts of cognitive processing models and investigation into memory dynamics can offer understanding of vicarious traumatization, and may help define preventive measures and treatment options for this condition.

The placebogenic phenomenon: art in psychiatric nursing.

1. Nearly half of all orders for psychotropic medications are written "as needed" (PRN); therefore, the nurse must assume a vital function in the assessment, use, and evaluation of medication. 2. Placebo agents are known to have an effectiveness rate between 30% and 50%. Nurses and other health professionals severely underestimate the magnitude of this effect. 3. The patient's perception of the medication experience, beliefs, degree of trust, expectation, and the psychosocial context in which medications are used, contribute to agent effectiveness. 4. The nurse's personal beliefs, nonverbal cues, anticipation, and interpersonal style can influence effectiveness of agents in relieving symptoms; likewise, by understanding and increasing various interpersonal skills, professionals can enhance effectiveness of psychotropic agents.

The undertreatment of anxiety: overcoming the confusion and stigma.

1. The patient, the nurse, and organizational variables all interact in a dynamic and complex manner, which all have an impact on decisions about intervention. 2. The numbers and variety of agents ordered as PRN indicate the responsibility for treatment placed by physicians on nurses and their reliance on appropriate and accurate nursing assessment. 3. Much of the stigma surrounding symptoms of anxiety and their treatment is based not only on the nature of the illness, but on the perceptions and beliefs concerning the use of anti-anxiety agents.

Nonneuroleptic etiologies of extrapyramidal symptoms.

Antipsychotic or neuroleptic medications are known to produce various extrapyramidal symptoms as common side effects. Extrapyramidal symptoms may present clinically as acute dystonic reactions, tardive dyskinesia, akinesia, Parkinsonism, akathisia, and neuroleptic malignant syndrome. Dopamine blockade or depletion in the basal ganglia produces these symptoms. Not as widely known or understood is that extrapyramidal symptoms can also occur as side effects from a variety of nonantipsychotic agents, namely certain antidepressants, antiemetics, lithium, and, rarely, some anticonvulsants and oral contraceptive agents. These symptoms mimic the naturally occurring, idiopathic pathologies of the extrapyramidal system and basal ganglia disease. Clinicians must be able to recognize these symptoms as side effects, distinguish extrapyramidal symptoms from psychiatric symptoms and, assess the possible nonantipsychotic causes of extrapyramidal symptoms, particularly in nonpsychiatric settings.

Neuroleptic malignant syndrome: liability in nursing practice.

In the summer of 1991, the malpractice case Reyes v Houston International Hospital et al was settled for an amount in excess of $600,000. The case involved the psychiatric treatment received by Marjorie Reyes, a 27-year-old Latin-American mother of three, who was admitted to a psychiatric unit in late October 1986 with a diagnosis of atypical psychosis. Malpractice was charged because her treatment failed to meet any reasonably expected outcome for atypical psychosis. In fact, Reyes developed neuroleptic malignant syndrome (NMS) as a direct result of the antipsychotic medications she was administered. Her treatment outcome was nearly fatal and caused permanent, serious neurological disabilities. The litigation implicated the nursing care delivered in a psychiatric setting. This unfortunate situation illustrates general principles of legal liability in nursing practice as well as offers a unique opportunity to review NMS and to examine the specific implications for the assessment and evaluation of the side effects of antipsychotic medications. Additionally, methods of behavioral control, specifically as they relate to concepts concerning the use of medications, the importance of documentation, and the manner in which nurses plan care, were also addressed in the case. It is important for professionals to be familiar with general legal concepts and liabilities, the potential of the development of this serious side effect, and how clinical decisions regarding the administration of both routine and as-needed medications may incur legal accountability.

Extrapyramidal symptoms are serious side-effects of antipsychotic and other drugs.

Antipsychotic medications commonly produce extrapyramidal symptoms as side effects. The extrapyramidal symptoms include acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome. Extrapyramidal symptoms are caused by dopamine blockade or depletion in the basal ganglia; this lack of dopamine often mimics idiopathic pathologies of the extrapyramidal system. Less recognized is that extrapyramidal symptoms are also associated with certain non-antipsychotic agents, including some antidepressants, lithium, various anticonvulsants, antiemetics and, rarely, oral-contraceptive agents. Extrapyramidal symptoms caused by these agents are indistinguishable from neuroleptic-induced extrapyramidal symptoms. Clinicians must be able to recognize these side effects and be able to determine the antipsychotic-induced and non-antipsychotic causes of extrapyramidal symptoms.

Assaultive behavior: know the risks.

1. Violence in our society is an increasing national concern, and violence in health-care settings reflects this trend. Assaultive episodes continue to increase in health-care settings due to various cultural, sociological, and political factors. 2. Present administrative and educational solutions to the problems of assault have failed to decrease the incidence and, in fact, may contribute to the increasing number of assaultive episodes. 3. Psychiatric staff can reduce incidence of assault by recognizing the risk factors and designing styles and interventions with these factors in mind. 4. Risks most often associated with assault are history of assault, diagnosis of dementia or organic brain disorder, intoxication from drugs or alcohol, and from the characteristics of the milieu and treatment itself.

PTSD and the Vietnam veteran: the battle for treatment.

1. Patients with post-traumatic stress disorder (PTSD) often encounter treatment that is complicated by professional bias, personal issues, countertransference, and pathological staff dynamics. 2. Treatment is further complicated by diagnostic confusion, the dual diagnoses of substance abuse or depression, and symptoms that mimic personality disorders or psychosis. 3. The special circumstances of the Vietnam conflict that contributed to the susceptibility and etiology of PTSD are the individual characteristics of those who served, the special nature of the war itself and the military strategies used, and the psychosocial and cultural milieu in which it occurred.

Assaultive behavior. Does provocation begin in the front office?

1. Provocation is an important risk predictor because these issues can be recognized, assessed, and appropriate interventions can be implemented to reduce the associated risks. It is only by the reduction of such "non-fixed" risk factors that any reduction of assaults can be accomplished. 2. Involuntary admission, patients with dementia or organic brain disorder, physical or verbal limits, staff attitude, denial of the possibility of assaults, and the educational level and clinical experience of the staff may help provoke an assaultive episode. 3. An important step is assessing the assault to identify provocation due to certain medical causes, and to document the extent of degeneration in patients with dementia or organic brain disorder. Medical intervention would be indicated and would appropriately address the causes of some violent episodes.

Akathisia. When treatment creates a problem.

1. Akathisia is a state of restlessness and motor agitation, which includes subjective feelings of inner tension, emotional unease, anxiety, a constant need to move, restless motor activity, and an inability to tolerate inactivity or rest. 2. Akathisia is often unrecognized or misdiagnosed as agitation or anxiety of psychiatric origin; this often leads to inappropriate increases in the antipsychotic dosage, which then potentiates its severity, or to the misuse of antianxiety agents, which masks symptoms. 3. Akathisia can be easy to recognize by simple clinical observation of the patient's behaviors, especially if the symptoms worsen after increases in antipsychotic dosages or the frequent use of as needed medications. Assessment must also include the patient's own report.

Risk management for extrapyramidal symptoms.

Extrapyramidal symptoms (EPS), the side effects of antipsychotic medications, have become the focus of much attention from clinical researchers, the courts, consumer groups, and even the U.S. Congress. The major clinical manifestations of EPS, the etiology, symptoms, and treatments are reviewed. The literature identified risk factors for EPS--those specific to the patient, to the particular antipsychotic agent used, and to the nature of the ongoing treatment for EPS. By quantifying these factors, weighting them according to the known risks, a risk management tool is developed for use in predicting which patients are at higher risks for EPS, in evaluating treatment, and in assessing the responses of patients to changes in their condition and to the subsequent adjustments in treatment. The risk management tool provides guidelines for the continual evaluation of these changes, with the goal of minimizing the risks for EPS.

Fixed-bed uncoated charcoal hemoperfusion in the treatment of intoxications: animal and patient studies.

We examined the efficacy of a new, fixed-bed, uncoated charcoal device in experimentally intoxicated dogs and in drug-intoxicated as well as chemically poisoned patients. In the animal studies, 4 h of hemoperfusion resulted in a significant decrease in the blood level of phenobarbital, salicylate, pentobarbital and glutethimide. The drug clearances varied between 97 +/- 10 and 129 +/- 6 ml/min. However, the total amount of drug removed was higher for phenobarbital and salicylate which have a small apparent volume of distribution (AVD) than for pentobarbital and glutethimide which have an AVD greater than total body water. We next treated 14 patients suffering from a wide variety of intoxications. Patients intoxicated with phenobarbital, methsuximide, chlordane and Amanita muscaria all showed a significant improvement in their clinical status. Patients intoxicated with ethchlorvynol, glutethimide, methaqualone, podophyllin and fluoroacetamide did not improve. Charcoal hemoperfusion may be useful in patients poisoned with drugs characterized by an AVD smaller than total body water. No major complications were encountered during the hemoperfusions.