Download Max and Adam - Scrubs

MAX
Setting:
Max is a 24 year old single male living in a rural area in south Auckland who has been referred
to the Early Psychosis Intervention Team by his general practitioner for assessment. Max’s
father identifies as Maori and the family has strong ties to the local marae. Max presents with
his parents for the assessment at the community mental health centre and is obviously
experiencing auditory hallucinations and his thinking is disorganised. The family have noticed a
change in Max’s behaviour over the past 9 months when he started struggling to continue with
his apprenticeship as a plumber and began spending long periods of time alone in his sleepout.
Currently he is not working and seems to have lost interest in completing his apprenticeship
and socialising with his friends. His family is struggling to cope with Max’s behaviour as he is
sometimes aggressive in manner and comes into the main house during the night swearing and
talking loudly about being followed by the devil.
Action point
A prodromal phase often precedes the first presentation of schizophrenia. Max may have been
experiencing this for the 9 months prior to this presentation.
Describe the prodromal phase and how this impacts on a client’s recovery.
Prodromal Phase – earliest manifestation of a psychotic disorder which often develops in early
adolescence:
-
Sleep/appetite disturbance
-
Marked unusual behavior
-
Feeling different to others (blunted or incongruent)
-
Speech difficult to follow
-
Marked pre occupation with unusual ideas
-
Ideas of reference things having special meaning
-
Persistent feeling of unreality
-
Changes in a way things appear, sound or smell
prodromal features in Schizophrenia are vague and not specific. Although when the illness
becomes severe it can be diagnosed and prodromal features can be identified.
722.724: 111A
Semester 1, 2011
During the interview Max becomes irritable and refuses to engage in the interview process. It
is clear that there is conflict between Max and his father who is obviously irritated by Max’s
behaviour and that his mother is frightened of Max’s aggressive behaviour. The psychiatrist and
a colleague continue to interview Max and you take the parents into another room to discuss
options for treatment which will include a discussion about the mental health act and
medication.
Action point
Educating clients and their families about the nature and process of the mental health act is an
important role for the mental health nurse.
The Mental Health (Compulsory Assessment and Treatment) Act 1992 defines the
circumstances in which a person may be required to undergo compulsory psychiatric
assessment and treatment. The Act aims to ensure that both vulnerable individuals and the
public are protected from harm with its rights of patients and proposed patients and aims to
protect those rights.
Under this act, the clients are entitled to:
• To have their culture respected
• To have an interpreter present
• To be supported by whanau or friends
• To have visitors and access to a phone
• The company of others
• Not to be video or audio taped
• Access to a District Inspector
• Full information on your status
• Receive appropriate health care
• To be informed of benefits of treatment
• To be informed of possible side effects
• To seek a second independent opinion
• To have access to legal advice
• To have a Judicial Review
The Summary of the Procedure for Assessment and Treatment under the Mental Health Act
1992:
•
Section 8A Application for assessment
722.724: 111A
Semester 1, 2011
•
•
•
•
•
•
Section 8B Medical certificate
Section 9 Notice to attend an assessment
Section 10 Certificate of preliminary assessment
Section 11 Further assessment and treatment (5 days)
Section 13 (2 weeks)
Section 15 (4 weeks)
Community Treatment Orders
• Section 29
Can last up to 6 months
Can be extended or made indefinite
Can be converted to an inpatient order
Must attend for treatment
Inpatient Orders
• Section 30
Provides for compulsory treatment
Lasts for up to six months
Can be extended or made indefinite
Can be converted to a community treatment order
• Section 31
Provides for conditional leave
Revoked if conditions not adhered to
Outline for Max’s parents, the criteria for a person to be under the Mental Health Act and give
the family an overview of how antipsychotic /anxiolytic medications are used in the
management of psychosis

Mental Disorder

Intermittent disorder – repeated or prolonged episodes of illness
- Severe consequences during phases of illness; such as severe
violence to self or others
- Early loss of insight during an episodes of illness, with a pattern
of failing to be able to take the necessary steps to halt the
development of illness
- Changeable insight = inability to maintain consistent decision
722.724: 111A
Semester 1, 2011

Degree of disorder – seriously diminishes the capacity of look after himself or herself i.e
failure to comply with meds (i.e. insulin); self neglect such as inattention to cooking and
high risk fire; a person in a manic state who overspends to such an extent that he or
she finds himself or herself bankrupt when symptoms of mania are no longer present
-
Poses a serious danger to the health or safety of that person or
others

Threshold for application for compulsory treatment

Abnormal state of mind

Disoders of volition and cognition (Volition: depression stupor; catatonic
excitement/withdrawal;passisivity;lack of motivation)

Head injury resulting to disturbance in behavior

Personality disorder

Substance abuse
Antipsychotics – previously referred to as major tranquilizers or neuroleptics are effective for
the treatment of a variety of psychotic symptoms. All available antipsychotics antagonize
dopamine (d2) receptors in vitro.
Max’s parents also ask you about the interview taking place in the other room. Describe your
response.
Privacy Act 1993
Action point
Describe what needs to be undertaken for a holistic assessment of Max in a first assessment
interview.
Psychiatric Assessment
The purpose of the psychiatric assessment is to develop an understanding of the person
presenting for help. It involves taking a basic psychiatric history and a mental status
assessment. The following information is required in conducting a comprehensive psychiatric
assessment:
1. Identifying Information
722.724: 111A
Semester 1, 2011
Includes; name, age, sex, present address, telephone number, languages spoken, general
practitioner, marital status, occupation and next of kin.
2. Reason for Referral
This should include;
Who has asked for the client to be seen and why
The nature of the problem
Events that led to this presentation
Any recent suicide attempts
Any recent episodes of self-harm
3. Presenting Problem and/or precipitating factors
Information needed include;
Specific symptoms that are present and their duration
Time relationships between the onset or exacerbation of symptoms and the presence of social
stressors/physical illness
Any disturbance in mood, appetite, sexual drive or sleep
Any treatments given by other doctors or specialists for this problem
The individual response to treatment
4. Mental Health/Medical/Drug History
Information required includes the number of admissions to mental health inpatient units,
number of episodes of self-harm, attempted suicide or occasions of assault, and an indication
of any mental health treatments received. This information is usually obtained from the client,
previous clinical notes, a letter from the doctor, or history provided by relatives or friends.
5. Psychosocial/Relationship History
This outlines circumstances that are significant for understanding current issues, and covers
many aspects of the individual’s life, such as relationships, family background, work or school
history and, possibility, developmental stages.
6. Determining Risk Factors
Several risk factors need to be assessed for each client;
Harm to others, harm to self, suicide, absconding, vulnerability to exploitation or abuse (sexual)
Vulnerability to exploitation or abuse (violence)
7. Assessment of Strengths
The focus on strengths of individuals and their opportunities rather than pathology creates
opportunity for growth. The strengths identified in this conceptual framework include the
individual’s interests, aspirations, skills, competencies and talents.
8. Mental State Examination (BATOMI)
A semi- structured interview used mainly as a screening tool to assess a person’s current
neurological and psychological status along several components. The exam involves
observations as well as an interview.
It involves;
Appearance and Behaviour
Speech, Mood and Affect
Form of Thought
722.724: 111A
Semester 1, 2011
Thought Content
Perception
Sensorium and Cognition
9. Physical Assessment
Involves past and present health status, physical functions (elimination, activitiy and execise,
sleep, appetite and nutrition, hydration, self-care), Laboratory results
20. Spiritual Assessment
It is important because it provides a deeper understanding of the client, their social setting and
the possible origins of the problem.
21. Cultural Assessment
Mental health nurses need to engage the client and the family so that appropriate care should
be given. In New Zealand, the principle of Cultural Safety is applied to provide quality care that
is also culturally sensitive to the patients.
22. Triage Assessment
Refers to the decision-making process that occurs when alternatives for acute care are being
considered
ADAM SMITH
Setting:
Agnes’s grandson Adam who is part Maori, has a history of schizophrenia and is currently in the
inpatient unit. Adam has a history of alcohol and drug abuse as well as schizophrenia. Agnes
asks about schizophrenia and what happens to someone in the short term in the inpatient
setting and in the long term and ask if alcohol and drug use would have caused her grandson to
develop schizophrenia.
Action point
What information are you going to pass on to Agnes?
Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people
throughout history.
People with the disorder may hear voices other people don't hear. They may believe other
people are reading their minds, controlling their thoughts, or plotting to harm them. This can
terrify people with the illness and make them withdrawn or extremely agitated.
722.724: 111A
Semester 1, 2011
People with schizophrenia may not make sense when they talk. They may sit for hours without
moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk
about what they are really thinking.
The symptoms of schizophrenia fall into three broad categories: positive symptoms, negative
symptoms, and cognitive symptoms
Positive symptoms
Positive symptoms are psychotic behaviors not seen in healthy people. People with positive
symptoms often "lose touch" with reality. These symptoms can come and go. Sometimes they
are severe and at other times hardly noticeable, depending on whether the individual is
receiving treatment. They include the following:
Hallucinations are things a person sees, hears, smells, or feels that no one else can see, hear,
smell, or feel. "Voices" are the most common type of hallucination in schizophrenia. Many
people with the disorder hear voices. The voices may talk to the person about his or her
behavior, order the person to do things, or warn the person of danger. Sometimes the voices
talk to each other. People with schizophrenia may hear voices for a long time before family and
friends notice the problem.
Other types of hallucinations include seeing people or objects that are not there, smelling odors
that no one else detects, and feeling things like invisible fingers touching their bodies when no
one is near.
Delusions are false beliefs that are not part of the person's culture and do not change. The
person believes delusions even after other people prove that the beliefs are not true or logical.
People with schizophrenia can have delusions that seem bizarre, such as believing that
neighbors can control their behavior with magnetic waves. They may also believe that people
on television are directing special messages to them, or that radio stations are broadcasting
their thoughts aloud to others. Sometimes they believe they are someone else, such as a
famous historical figure. They may have paranoid delusions and believe that others are trying to
harm them, such as by cheating, harassing, poisoning, spying on, or plotting against them or the
people they care about. These beliefs are called "delusions of persecution."
Thought disorders are unusual or dysfunctional ways of thinking. One form of thought disorder
is called "disorganized thinking." This is when a person has trouble organizing his or her
thoughts or connecting them logically. They may talk in a garbled way that is hard to
understand. Another form is called "thought blocking." This is when a person stops speaking
abruptly in the middle of a thought. When asked why he or she stopped talking, the person may
say that it felt as if the thought had been taken out of his or her head. Finally, a person with a
thought disorder might make up meaningless words, or "neologisms."
Movement disorders may appear as agitated body movements. A person with a movement
disorder may repeat certain motions over and over. In the other extreme, a person may
become catatonic. Catatonia is a state in which a person does not move and does not respond
722.724: 111A
Semester 1, 2011
to others. Catatonia is rare today, but it was more common when treatment for schizophrenia
was not available."Voices" are the most common type of hallucination in schizophrenia.
Negative symptoms
Negative symptoms are associated with disruptions to normal emotions and behaviors. These
symptoms are harder to recognize as part of the disorder and can be mistaken for depression
or other conditions. These symptoms include the following:
Flat affect
(a person's face does not move or he or she talks in a dull or monotonous voice)
Lack of pleasure in everyday life
Lack of ability to begin and sustain planned activities
Speaking little, even when forced to interact.
People with negative symptoms need help with everyday tasks. They often neglect basic
personal hygiene. This may make them seem lazy or unwilling to help themselves, but the
problems are symptoms caused by the schizophrenia.
Cognitive symptoms
Cognitive symptoms are subtle. Like negative symptoms, cognitive symptoms may be difficult
to recognize as part of the disorder. Often, they are detected only when other tests are
performed. Cognitive symptoms include the following:
Poor "executive functioning" (the ability to understand information and use it to make
decisions)
Trouble focusing or paying attention
Problems with "working memory" (the ability to use information immediately after learning it).
How is schizophrenia treated?
Because the causes of schizophrenia are still unknown, treatments focus on eliminating the
symptoms of the disease. Treatments include antipsychotic medications and various
psychosocial treatments.
Antipsychotic medications
clozapine (Clozaril) is an effective medication that treats psychotic symptoms, hallucinations,
and breaks with reality. But clozapine can sometimes cause a serious problem called
agranulocytosis, which is a loss of the white blood cells that help a person fight infection.
People who take clozapine must get their white blood cell counts checked every week or two.
This problem and the cost of blood tests make treatment with clozapine difficult for many
people. But clozapine is potentially helpful for people who do not respond to other
antipsychotic medications.
Other atypical antipsychotics were also developed. None cause agranulocytosis. Examples
include:
 Risperidone (Risperdal)
 Olanzapine (Zyprexa)
722.724: 111A
Semester 1, 2011




Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega).
When a doctor says it is okay to stop taking a medication, it should be gradually tapered off,
never stopped suddenly.
What are the side effects?
Some people have side effects when they start taking these medications. Most side effects go
away after a few days and often can be managed successfully. People who are taking
antipsychotics should not drive until they adjust to their new medication. Side effects of many
antipsychotics include:
 Drowsiness
 Dizziness when changing positions
 Blurred vision
 Rapid heartbeat
 Sensitivity to the sun
 Skin rashes
 Menstrual problems for women.
Atypical antipsychotic medications can cause major weight gain and changes in a person's
metabolism. This may increase a person's risk of getting diabetes and high cholesterol. A
person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while
taking an atypical antipsychotic medication.
Typical antipsychotic medications can cause side effects related to physical movement, such as:
 Rigidity
 Persistent muscle spasms
 Tremors
 Restlessness.
Long-term use of typical antipsychotic medications may lead to a condition called tardive
dyskinesia (TD). TD causes muscle movements a person can't control. The movements
commonly happen around the mouth. TD can range from mild to severe, and in some people
the problem cannot be cured. Sometimes people with TD recover partially or fully after they
stop taking the medication.
TD happens to fewer people who take the atypical antipsychotics, but some people may still get
TD. People who think that they might have TD should check with their doctor before stopping
their medication.
How are antipsychotics taken and how do people respond to them?
Antipsychotics are usually in pill or liquid form. Some anti-psychotics are shots that are given
once or twice a month.
Symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away
within days. Symptoms like delusions usually go away within a few weeks. After about six
weeks, many people will see a lot of improvement.
722.724: 111A
Semester 1, 2011
However, people respond in different ways to antipsychotic medications, and no one can tell
beforehand how a person will respond. Sometimes a person needs to try several medications
before finding the right one. Doctors and patients can work together to find the best
medication or medication combination, as well as the right dose.
Some people may have a relapse -- their symptoms come back or get worse. Usually, relapses
happen when people stop taking their medication, or when they only take it sometimes. Some
people stop taking the medication because they feel better or they may feel they don't need it
anymore. But no one should stop taking an antipsychotic medication without talking to his or
her doctor. When a doctor says it is okay to stop taking a medication, it should be gradually
tapered off, never stopped suddenly
Psychosocial treatments
Psychosocial treatments can help people with schizophrenia who are already stabilized on
antipsychotic medication. Psychosocial treatments help these patients deal with the everyday
challenges of the illness, such as difficulty with communication, self-care, work, and forming
and keeping relationships. Learning and using coping mechanisms to address these problems
allow people with schizophrenia to socialize and attend school and work.
Patients who receive regular psychosocial treatment also are more likely to keep taking their
medication, and they are less likely to have relapses or be hospitalized. A therapist can help
patients better understand and adjust to living with schizophrenia. The therapist can provide
education about the disorder, common symptoms or problems patients may experience, and
the importance of staying on medications.
Illness management skills. People with schizophrenia can take an active role in managing their
own illness. Once patients learn basic facts about schizophrenia and its treatment, they can
make informed decisions about their care. If they know how to watch for the early warning
signs of relapse and make a plan to respond, patients can learn to prevent relapses. Patients
can also use coping skills to deal with persistent symptoms.
Integrated treatment for co-occurring substance abuse. Substance abuse is the most common
co-occurring disorder in people with schizophrenia. But ordinary substance abuse treatment
programs usually do not address this population's special needs. When schizophrenia
treatment programs and drug treatment programs are used together, patients get better
results.
Rehabilitation. Rehabilitation emphasizes social and vocational training to help people with
schizophrenia function better in their communities. Because schizophrenia usually develops in
people during the critical career-forming years of life (ages 18 to 35), and because the disease
makes normal thinking and functioning difficult, most patients do not receive training in the
skills needed for a job.
Rehabilitation programs can include job counseling and training, money management
counseling, help in learning to use public transportation, and opportunities to practice
communication skills. Rehabilitation programs work well when they include both job training
722.724: 111A
Semester 1, 2011
and specific therapy designed to improve cognitive or thinking skills. Programs like this help
patients hold jobs, remember important details, and improve their functioning.
Family education. People with schizophrenia are often discharged from the hospital into the
care of their families. So it is important that family members know as much as possible about
the disease. With the help of a therapist, family members can learn coping strategies and
problem-solving skills. In this way the family can help make sure their loved one sticks with
treatment and stays on his or her medication. Families should learn where to find outpatient
and family services.
Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a type of psychotherapy
that focuses on thinking and behavior. CBT helps patients with symptoms that do not go away
even when they take medication. The therapist teaches people with schizophrenia how to test
the reality of their thoughts and perceptions, how to "not listen" to their voices, and how to
manage their symptoms overall. CBT can help reduce the severity of symptoms and reduce the
risk of relapse.
Self-help groups. Self-help groups for people with schizophrenia and their families are
becoming more common. Professional therapists usually are not involved, but group members
support and comfort each other. People in self-help groups know that others are facing the
same problems, which can help everyone feel less isolated. The networking that takes place in
self-help groups can also prompt families to work together to advocate for research and more
hospital and community treatment programs. Also, groups may be able to draw public
attention to the discrimination many people with mental illnesses face.
Short term in the inpatient setting
Principles of treatment for the first episode
Medication
Proper treatment of the first psychotic episode is of the utmost importance. Inadequate
management at this stage may foster the development of secondary
consequences which can snowball and lead to a substantial deterioration in long-term
outcome. For instance, lack of insight (ie unawareness of illness) is
a frequently encountered problem in schizophrenia. If the degree of insight is low after the first
episode, it can lead to reduced compliance to treatment, which
in turn can increase the relapse rate and worsen the long-term outcome. Likewise, residual
psychotic symptoms after the first episode may affect social and occupational functioning of
patients and indirectly predispose them to stressful experiences (eg relationship or
occupational problems). Difficulties like these
lead to relapses and a poor long-term outcome. Hence, the thorough and vigorous treatment of
the first episode is very important.
Maintenance therapy
One further issue is the length of maintenance therapy needed after a single episode of illness.
Existing data suggests that a number of patients may not suffer a
722.724: 111A
Semester 1, 2011
second episode even without maintenance treatment.44 Unfortunately, it is not yet possible to
identify those who will relapse and those who will not.28 As yet, data
from double-blind controlled studies that specifically address the optimal length of
maintenance therapy are not available.28,45 It appears, however, that continuing
medication after the first episode seems to reduce the relapse rate in the subsequent 12
months from approximately 70% to approximately 40%.46
Management of depressive symptoms and suicide risk
Depression is common in first-episode schizophrenic patients, with prospective studies
reporting rates of identifiable depressive syndrome of around 50% of
first episode patients. The actual rate of depressive symptoms detected varied considerably
between individual studies (from 20% to 80%), depending on
the rating instruments used. In most cases, depressive symptoms are worse at the time of the
acute episode and tend to subside as the psychosis comes under
control. If depressive symptoms persist, antidepressant therapy should be commenced. The risk
of suicide occurring is substantially increased in first-episode schizophrenia, especially among
male patients.
Psychosocial intervention
Apart from medication, psychosocial rehabilitation efforts are particularly important for
managing negative symptoms. Negative symptoms can be substantially
present in the first episode. Vigorous rehabilitation directed at these symptoms is particularly
important in minimising secondary disabilities. Competence in social skills is also important in
sustaining a social support network and is a crucial element in long-term management. A
further disability is the presence of
substantial neurocognitive deficits.By giving adequate medication treatment, some of these
deficits may improve with time, but the improvement takes
longer than does the improvement in symptoms. The efficacy of cognitive remediation
programmes in reducing neurocognitive deficits is still not established.
In general, it is known that a high level of expressed emotion among carers of schizophrenics is
predictive of more frequent relapses. Family behavioural therapy may be effective in modifying
the amount of expressed motion and the lower relapse rate in selected patients.
References:
Elder, R., Evans, K. & Nizette, D. (2009). Psychiatric and mental health nursing (2 nd ed.). Sydney:
Mosby.
Johannessen, J. O. (2001). Early recognition and intervention: The key to success in the
treatment of schizophrenia?. Dis Manage Health Outcomes, 9(6), 317-327.
722.724: 111A
Semester 1, 2011