NCM 117: Long Exam 2: Anxiety & Anxiety Disorders Topic Outline

NCM 117: Long Exam 2
ANXIETY & ANXIETY DISORDERS ➔ Adaptive use of defense mechanisms helps people lower
anxiety to achieve goals in acceptable ways.
TOPIC OUTLINE
➔ Maladaptive use of defense mechanisms occurs when
1. Anxiety one or several are used in excess, particularly in the
2. Levels of anxiety overuse of immature defenses.
a. Mild anxiety
b. Moderate anxiety ANXIETY DISORDERS
c. Severe anxiety
1. Separation anxiety disorder
d. Panic
3. Anxiety disorders 2. Panic disorder
a. Separation anxiety disorder 3. Agoraphobia
b. Panic disorder 4. Specific Phobia
c. Agoraphobia 5. Social anxiety disorder
d. Specific Phobia 6. Generalized anxiety disorder
e. Social anxiety disorder
f. Generalized anxiety disorder
SEPARATION ANXIETY DISORDER
➔ Separation anxiety is a normal part of infant development
ANXIETY ➔ It begins around 8 months of age, peaks around 18
➔ Is a universal human experience and is the most basic of months and begins to decline after that.
emotions. ➔ People with separation anxiety disorder exhibit
➔ It can be defined as the feeling of apprehension, developmentally inappropriate levels of concern over
uneasiness, uncertainty, or dread resulting from a real or being away from significant other
perceived threat. ➔ There may also be fear that something terrible will
➔ Fear is a reaction to a specific danger, whereas anxiety is happen to the other person and that it will result in
a vague sense of dread related to an unspecified or permanent separation.
unknown danger. ➔ Anxiety starts from here because they always have that
constant fear that something terrible will happen and will
LEVELS OF ANXIETY cause permanent separation.
(1) MILD ANXIETY ➔ Adult separation anxiety disorder include characteristics
➔ Occurs in the normal experience of everyday living and such as:
allows an individual to perceive reality in sharp focus. ● harm
● Avoidance
(2) MODERATE ANXIETY ● Worry
➔ The person sees, hears, and grasps less information and ● Shyness
may demonstrate selective attention, in which only ● Uncertainty
certain things in the environment are seen or heard ● Fatigability, and
unless they are pointed out. ● Lack of self-direction
➔ Ability to think is hampered, but learning and problem
solving can still take place although not an optimal level. PANIC DISORDER
➔ Panic attacks are the key feature of this disorder, it is a
(3) SEVERE ANXIETY sudden onset of extreme apprehension or fear, usually
➔ Focuses on one particular detail or many scattered details associated with feelings of impending doom
and have difficulty noticing what is going on in the ➔ Normal functioning is usually suspended, the perceptual
environment, even when another points out. field is severely limited, and misinterpretation of reality
➔ Learning and problem solving are not possible at this may occur
level. ➔ Unpredictability is a key aspect of panic disorder in
children and adolescents.
(4) PANIC
➔ Is the most extreme level of anxiety, with marked AGORAPHOBIA
disturbed behavior, unable to process what is going on in ➔ Is intense, excessive anxiety or fear about being in places
the environment and may lose touch with reality. or situations from which escape might be difficult or
➔ Behaviors in this level include embarrassing or in which help might not be available.
● pacing, ➔ The feared places are avoided in an effort to control
● running, anxiety.
● Shouting, ➔ Example situations that are commonly avoided by
● screaming, or patients with agoraphobia:
● Withdrawal. ● Being alone
● Being alone at home
DEFENSES AGAINST ANXIETY ● Travelling a car, bus, plane
➔ Defense mechanisms are automatic coping styles that ● Being on a bridge
protect people from anxiety and maintain self-image by ● Riding on an elevator
blocking feelings, conflicts, and memories. ➔ These situations are made more tolerable with a friend
BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 1

➔ Avoidance behaviors can be debilitating: ➔ Putting things off (not sure, clarify pls 11:29) and
● Father with agoraphobia-> unable to leave home avoidance are key symptoms and may result in lateness
and prevents him from seeing his child’s highschool or absence from school or employment and overall,
graduation social isolation.
● Business woman-> prevents her from attending ➔ Sleep disturbance is common because the individual
distant business conferences. worries about the day’s events and will imagine mistakes,
reviews past problems, and anticipates future difficulties.
SPECIFIC PHOBIAS ➔ Fatigue is also a noticeable side effect of sleep
➔ Is a persistent, irrational fear of a specific object, activity, deprivation.
or situation that leads to a desire for avoidance, or actual
avoidance of the object, activity, or situation. OTHER ANXIETY DISORDERS
➔ Common phobias include: ➔ Substance-induced anxiety disorder
● Acrophobia- heights ● Is characterized by symptoms of anxiety, panic
● Agoraphobia- open spaces attacks, obsessions and compulsions that develop
● Claustrophobia- closed spaces with the use of a substance (e.g alcohol, cocaine,
● Hematophobia- blood heroin, hallucinogens)
● Hydrophobia- water ➔ Anxiety due to a medical condition
● Nyctophobia- dark
● Pyrophobia- fire
● Xenophobia- strangers
SOCIAL ANXIETY DISORDER

➔ Also called social phobias
➔ Is characterized by severe anxiety or fear provoked by
exposure to a social or a performance situation that
could be evaluated negatively by others
➔ People with social phobias avoid social situations.
➔ If unable to avoid them-> endure this situations with
intense anxiety and emotional distress
➔ Small children with this disorder may be mute, nervous,
and hide behind their parents.
➔ Older children and adolescents may be paralyzed by fear
of speaking in class or interacting with other children.
➔ The worry of saying the wrong thing or being criticized
immobilizes them.
➔ Conversely, younger people may act out to compensate
for this fear, making an accurate diagnosis more difficult.
➔ This anxiety often results in physical complaints to avoid
social situations, particularly school.
➔ Fear of public speaking is the most common
manifestation of social anxiety disorder.
➔ Famous singers affected by this disorder (terrified they
may forget the words in songs and scripts)
● Barbara Streisand
● Laurence Olivier
GENERALIZED ANXIETY DISORDER

➔ The key pathological feature of generalized anxiety
disorder is excessive worry
➔ Persons with generalized anxiety disorder anticipate
disaster and are restless, irritable, and experience muscle
tension. Decision making is difficult due to poor
concentration and dread of making a mistake.
➔ Common worries:
● Inadequacy in interpersonal relationships
● Job responsibilities
● Finances
● Health of family members
➔ Because of this worry, huge amounts of time are spent in
preparing for activities

IMPULSE CONTROL DISORDERS ➔ The aggression can be verbal or physical and targeted
toward other persons, animals, property, or even
TOPIC OUTLINE
themselves.
1. Impulse control disorders ➔ The pattern usually goes from being upset to being
2. Oppositional defiant disorder remorseful.
3. Intermittent explosive disorder ● Tension and arousal based on some environmental
4. Conduct disorder stimuli
5. Application of the Nursing Process
○ While driving, naay ni cut off nga
a. Assessment
b. Signs and symptoms, Nursing Diagnoses, motorcycle kalit sa imong lane.
Outcome ● Explosive behavior
c. Implementation ○ Mutry ka ug overtake ug balik, imong
i. General interventions apason ang ni cut off sa imo lane
ii. Pharmacologic Interventions ● Experience a sense of relief
iii. Health Teaching and Promotion ○ Imo na maapas balik then naa naka in front.
iv. Advanced Practice Interventions
● Feelings of remorse, regret, and embarrassment over
d. Evaluation
the aggressive behavior.
○ Maka realize ang person ‘why’d I do that’
IMPULSE CONTROL DISORDERS (char englishings)
➔ People with impulse control disorders seem like children ➔ This disorder can impede on a person’s functioning by
whose parents cannot control them or adults who simply leading to problems with interpersonal relationships and
do not choose to control their behavior. occupational difficulties, and can lead to criminal
➔ Impulsive and exhibit aggressive behaviors and emotions problems as well.
➔ Problems relating to others in socially acceptable ways
result in a lack of healthy relationships, leaving the CONDUCT DISORDER
individual isolated and the family devastated ➔ Is a persistent pattern of behavior in which the rights of
➔ Risk factors: others are violated and societal norms or rules are
● Genetics disregarded
● Neurobiological- gray matter is less dense in the left ➔ Behavior is usually abnormally aggressive and can
prefrontal cortex in young patients with oppositional frequently lead to destruction of property or physical
defiant disorder injury
● Psychological ➔ Persons with this disorder initiate physical fights and
● Environmental bully others, and they may steal or use a weapon to
intimidate or hurt others.
OPPOSITIONAL DEFIANT DISORDER ➔ Coercion into activity against the will of others, including
➔ Is a primarily childhood disorder, characterized by a sexual activity, is characteristic of this disorder. These
repeated and persistent pattern of having an angry and behaviors are enduring patterns and continue over a
vindictive behavior period of 6 months and beyond.
➔ Angry mood can manifest as losing one’s temper or ➔ People affected by this disorder may have a normal
becoming easily annoyed by others. intelligence, but they tend to skip class or disrupt school
➔ A defiant behavior can be demonstrated through arguing so much that they fall behind and may be expelled or
with adults and refusing to compu with adults’ requests drop out.
or rules. ➔ Complications associated with conduct disorder include:
➔ Vindictiveness is defined as spiteful, malicious behavior ● Academic failure
and a particularly chilling aspect of this disorder. This ● School suspensions and dropouts
quality increases the chances that revenge will be sought ● Juvenile delinquency
in response to real or imagined slights. ● Drug and alcohol abuse and dependency
➔ People with this disorder shows a pattern of deliberately ● Juvenile court involvement
annoying people and blaming others for his or her ➔ In adults, characteristics include:
mistakes or misbehavior ● Aggression
➔ This disorder impairs the child’s entire life and makes it ● Destruction of property
extremely difficult for him or her to attend school, to ● Stealing
have friends, or be a functioning member of the family. ● Deceitfulness
➔ Is often predictive of emotional disorders in young ● Criminal behavior
adulthood. ● Family problems
➔ Two subtypes:
INTERMITTENT EXPLOSIVE DISORDER ● Child-onset conduct disorder-
➔ Is a pattern of behavioral outbursts in adults 18 years and ○ Occurs prior to age 10 years old and is
older characterized by an inability to control aggressive found mainly in males who are physically
impulses progressive, have poor peer relationships,
show little concern for others and lack of
feelings of guilt and remorse

○ Hallmarks of these disorders include limited ● Explore how the child or adolescent can exercise
frustration tolerance, irritability, and temper control and take responsibility, problem solve for
outbursts. situations that occur and plan to handle things
● Adolescent onset differently in the future. Assess barriers and
○ No symptoms are present prior to age 10. motivation to change, and potential rewards to
○ Male to female ratio is not high as for the engage patients.
childhood-onset type, including more girls ➔ Assessment for Intermittent Explosive Disorder
become aggressive during this period of ● Assess the history, frequency, and triggers for violent
development outbursts
● Both can occur in mild, moderate, or severe forms ● Identify times in which the patient was able to
➔ Predisposing factors: maintain control despite being in a situation in which
● ADHD the patient might normally lose control of emotions.
● Oppositional child behaviors ● Explore actual and potential sources of support at
● Parental rejection home and socially
● Inconsistent parents with harsh discipline ● Assess for substance use (past and present)
● Early institutional living ➔ Assessment for Conduct Disorder
● Chaotic home life ● Assess the seriousness, types, and initiation of
● Large family size disruptive behavior and how it has been managed
● Absent or alcohol father ● Assess anxiety, aggression and anger levels,
● Antisocial and drug-dependent family members motivation, and the ability to control impulses.
● Association with delinquent peers ● Assess moral development, problem solving, belief
➔ There is a subset of people with conduct disorder who system, and spirituality for the ability to understand
are also referred to as being callous and unemotional the impact of hurtful behavior on others, to
● Callousness is characterized by a lack of empathy, empathize with others, and to feel remorse
such as disregarding and being unconcerned about ● Assess the ability to form a therapeutic relationship
the feelings of others, having a lack of remorse or and engage in honest and committed therapeutic
guilt except when facing punishment, and being work leading to observable behavioral change
unconcerned about meeting school and family ● Assess for substance use (past and present)
obligations.
● Unemotional traits include a shallow, unexpressive SIGNS AND SYMPTOMS, NURSING DIAGNOSES AND
and superficial affect OUTCOMES
➔ Two disorders related to impulse control disorders. ➔ History of suicide attempts, aggression and impulsivity,
● Pyromania- repeated deliberate fire setting. The conflictual interpersonal relationships; states, ‘’If I have
person experiences pleasure or relief when setting a to stay here, I’m going to kill myself.’’
fire ➔ Risk for suicide:
● Kleptomania- repeated failure to resist urges to steal ● Expresses feelings
objects not needed for personal use or monetary ● Verbalizes suicidal ideas
value. ● Refrains from suicide attempts
● Plans for the future
APPLICATION OF THE NURSING PROCESS ➔ Body posture, rigid, clenches fists and jaw, paces, invades
ASSESSMENT the personal space of others, history of cruelty to
➔ Assess for suicide risk: animals, fire setting, and frequent fights, history of
● Past suicidal thoughts, threats, or attempts childhood abuse and witnessed family violence’ states,
● Existence of a plan, lethality of the plan, and ‘’That wimp of a roommate better stay out of my way.’’
accessibility of the methods for carrying out the plan ➔ Risk for other-directed violence
● Feelings of hopelessness, changes in level of energy ● Identifies harmful impulsive behaviors
● Circumstances, state of mind, and motivation ● Controls impulses
● Viewpoints about suicide and death ● Refrains from aggressive acts
● Depression and other moods or feelings ● Identifies social support
● History of impulsivity, poor judgment, or decreased ➔ Hostile laughter, projects responsibility for behavior onto
decision making others, grandiosity, difficulty establish relationships
● Drug or alcohol use ➔ Defensive coping related to impulse-control problems
● Prescribed medications and any recent adherence ● Identifies ineffective and effective coping
issues ● Identifies and uses support system
● An assessment of protective factors and coping skills ● Uses new coping strategies
➔ Assessment for Oppositional Defiant Disorder ➔ Rejection of child or hostility toward the child; unsafe
● Identify issues that result in power struggles and home environment, abuse and/or neglectful; disturbed
triggers for outbursts relationship between parent/caregiver and the child
● Assess the child’s or adolescent’s view of his/her ➔ Impaired parenting
behavior and its impact on others ● Parent/caregiver participates in the therapeutic
program

● Learns appropriate parenting skills patterns of negative interactions, ineffective harsh
punishments, emotionally charged command and
IMPLEMENTATION comments, and poor modeling of appropriate
GENERAL INTERVENTIONS behaviors
➔ Promote a climate of safety for the patient and for others ● This treatment target the parents rather than the
➔ Establish a rapport with the patient child and focuses attention on reinforcement of
➔ Set limits and expectations positive and prosocial behavior, and on brief,
➔ Consistently follow through with consequences of negative consequences of bad behavior
rule-breaking ➔ Multisystemic Therapy- is the most expensive; an
➔ Provide structure and boundaries intensive family and community-based program that
➔ Provide activities and opportunities for achievement of takes into consideration all of the environments of violent
goals to promote a sense of purpose juvenile offenders
➔ Seclusion and Restraint
PHARMACOLOGICAL INTERVENTIONS ➔ Teamwork and safety
➔ Intermittent explosive disorder- fluoxetine (Prozac), ● Using non threatening body posture and a flat
lithium, clozapine (Clozaril) and haloperidol (Haldol) neutral tone of voice
➔ Conduct disorder- risperidone (Risperidal), olanzapine, ● Using matter-of-fact, easy to understand words
Seroquel, and ziprasidone ● Avoid personal terms such as I and you, when setting
➔ Take note: anti-anxiety medication should be avoided a limit
since they may reduce inhibitions and self-control ● Consistently setting limits
HEALTH TEACHING AND HEALTH PROMOTION EVALUATION

➔ Explore the impact of the child’s behaviors on family life ➔ Patients on inpatient units demonstrate increased levels
and of the other member’s behavior on the child of self-regulation and ability to interact appropriately
➔ Assist the immediate and extended family to access with others.
available and supportive individuals and systems ➔ In outpatient and community setting, patients will
➔ Discuss how to make a safe environment, especially in progress incrementally from aggressive and impulsive
regard to weapons and drugs; attempt to talk separately behavior and move on to considering the rights of others
to members whenever possible and behaviors that are in control
➔ Discuss realistic behavioral goals and how to set them;
problem solve potential problems
➔ Teach behavior modification techniques
➔ Give support and encouragement as parents learn to
apply new techniques
➔ Provide education about medications
➔ Refer parents or caregivers to a local self-help group
➔ Advocate with the educational system if
special-education services are needed
Advanced Practice Interventions

➔ Overall goal are to help patients maintain control of their
thoughts and behaviors; and assist families to function
more adaptively
➔ Cognitive behavioral therapy- a talk therapy that focuses
on a patient’s feelings, thought, and behaviors
➔ Psychodynamic Psychotherapy- focuses on underlying
feelings and motivations and explores conscious and
unconscious thought processes
➔ Dialectical Behavioral Therapy- a specific kind of CBT
that has a focus on impulse control
➔ Parent-Child Interaction Therapy- advanced practice
nurses sit behind one-way mirrors and coach parents
through an ear audio device while they interact with their
children
● Suggests strategies that reinforce positive behavior
in the child or adolescent
➔ Parent Management Training- is an evidence-based
treatment for children aged 2 to 14 with mild to severe
behavioral problems
● Parents of children with oppositional defiant
disorder and conduct disorder tend to engage in

OBSESSIVE-COMPULSIVE DISORDERS (OCD) BODY DYSMORPHIC DISORDER
➔ Characterized by preoccupation with perceived flaws in
TOPIC OUTLINE
one’s physical appearance that are not noticeable to
1. Obsessive-compulsive disorder others
2. Body dysmorphic disorder ➔ The perceived thoughts leads the individual to feel ugly,
3. Hoarding disorder unattractive, abnormal, or deformed.
4. Trichotillomania (hair pulling) ➔ Repeated behavior (e.g. checking the mirror, excessive
5. Excoriation
surgery) in response to their concerns
6. Psychotherapeutic management
a. Nurse-patient relationship ➔ Preoccupations are intrusive, unwanted, and difficult to
b. Psychopharmacology control.
c. Milieu Management
HOARDING DISORDER
OBSESSIVE-COMPULSIVE DISORDER ➔ Characterized by persistent difficulties parting with
➔ Characterized by the presence of obsessions or possessions, regardless of their actual value.
compulsions or both. ➔ Difficulty is due to the stress associated with discarding,
➔ Obsession: recurrent and persistent thoughts, ideas, selling, recycling, or throwing them away.
impulses, or images that are experienced as intrusive and ➔ Results in accumulation of possessions that congest and
unwanted. clutter living areas.
● Obsessions are the things that are going about inside ➔ The main motivation for hoarding is related to the
the mind. In order to relive/express it out, the perceived value of the items or strong sentimental
individual needs to act something to reduce the attachment to them (American Psychiatric Association,
anxiety towards these intrusive and unwanted 2013)
thoughts.
➔ Compulsions: or rituals are repetitive behaviors or TRICHOTILLOMANIA (HAIR PULLING)
mental acts the individual feels driven to perform, such ➔ Characterized by recurrent pulling out of one’s hair,
as washing hands, checking, counting or repeating words. resulting in hair loss in various regions of the body (scalp,
The aim is to reduce the anxiety triggered by the eyebrows, eyelids, axillary, facial, pubic)
obsessions ● Using tweezers, bare hands
➔ It can significantly interfere with the patient’s normal ➔ Repeated attempts are unsuccessful leading to significant
routine and is so time-consuming that they interfere with distress such as embarrassment, feeling of loss of control,
occupational and social functioning. and shame
➔ Example:
● Frequent washing of hands EXCORIATION
● Checking, counting or repeating words
➔ Characterized by recurrent picking at one’s own skin,

resulting in skin lesions (face, arms, and hands)
➔ Preceded by a feeling of boredom or anxiety and results
in a sense of relief, pleasure, or gratification.
➔ Target areas are:
● Healthy skin
● Pimples
● Calluses
● Scabs
● Lesions
PSYCHOTHERAPEUTIC MANAGEMENT
NURSE-PATIENT RELATIONSHIP
➔ The nurse focuses on teaching and helping patients
develop adaptive coping behaviors to deal with anxiety

➔ Patients need to learn to substitute positive,
anxiety-reducing behaviors for obsessions and rituals
➔ Reinforce non ritualistic behaviors
➔ Ensure basic needs of food, rest, and grooming are met
➔ Provide patients with time to perform rituals
➔ Explain expectations, routines, and changes
➔ Be empathic toward patients and be aware of their need
to perform rituals
➔ Assist patients with connecting behaviors and feelings
➔ Structure simple activities, games, and tasks for patients
➔ Reinforce and recognize positive non ritualistic behaviors
PSYCHOPHARMACOLOGY
➔ SSRIs such as Fluoxetine (Prozac), Sertraline (Zoloft),
Fluvoxamine (Luvox) and Paroxetine (Paxil) are effective
in treating OCD.
➔ Higher treatment dosage of SSRIs than patients with
depression
➔ response usually are 2-4 weeks.
MILIEU MANAGEMENT
➔ Relaxation exercises, stress management, recreational or
social skills, CBT, problem solving, and communication or
assertiveness training groups
➔ CBT (Cognitive Behavioral Therapy): technique called
“thought stopping” can also be used. When an intrusive
thought occurs, the patient says “stop” and snaps a
rubber band on the wrist or substitutes an adaptive
behavior, such as deep breathing, for the ritual. .

TRAUMA, STRESSOR-RELATED & DISSOCIATIVE DISORDERS ➔ Observation-interaction part of mental health
assessment begins with a semi-structured interview in
TOPIC OUTLINE
which the nurse asks the young person about the home
1. Traumatic events environment, parents, and siblings; and about the school
2. Trauma-related disorders in children environment, teachers, and peers.
a. Post-traumatic stress disorder (PTSD) in ➔ Play activities such as games, drawings, and puppets are
children used for younger children who cannot respond to direct
b. Reactive attachment disorder
approach.
c. Disinhibited social engagement disorder
3. Trauma-related disorders in adults ➔ Initial interview is key to observing interactions among
4. Acute Stress Disorder the child, caregiver, and siblings (if available) and to
5. Adjustment Disorder building trust and rapport.
6. Dissociative Disorders ➔ Essential symptom assessment data:
7. Depersonalization/ Derealization Disorder ● Uncontrollable rage
● Somatic symptoms
TRAUMATIC EVENTS ○ Headache or stomach aches
➔ Traumatic life events are associated with a wide range of ● Nightmares, night terrors, traumatic reenactments
psychiatric and other medical disorders. ● Difficulty concentrating
➔ Are not always as extraordinary as war and may be as ● Forgetfulness
common as interpersonal trauma, sexual abuse, physical ➔ Developmental assessment should also be done to
abuse, sever neglect, emotional abuse, repeated provide information about the child or adolescent’s
abandonment or suddent and traumatic loss. maturational level.
TRAUMA-RELATED DISORDERS IN CHILDREN Diagnosis

POST-TRAUMATIC STRESS DISORDER (PTSD) IN CHILDREN ➔ Risk for impaired parent/child attachment
➔ May manifest in preschool children as reduction in play, It is defined as the risk for disruption of the interactive
repetitive play that includes aspects of the traumatic process between the parent or significant other and child
event, social withdrawal, and negative emotions such as that fosters the development of a protective and
fear, guilt, anger, horror, sadness, shame, or confusion. nurturing relationship
➔ Often there is irritability, aggressive or self-destructive ● Anxiety associated with the parent role
behavior, sleep disturbances, problems concentrating ● Ill infant/child who is unable to effectively initiate
and hypervigilance. parental contact due to altered behavioral
➔ Children may also suffer relationship trauma from a organization
grossly inadequate caregiving environment which results ● Inability of parents to meet personal needs
to: ● Parental conflict due to altered behavior
● Reactive Attachment Disorder ● Substance abuse
○ Severe emotional inhibition ● separation
● Disinhibited Social Engagement Disorder ➔ Risk for delayed development
○ Indiscriminately social behaviors Defined as the risk for delay of 25% or more in one or
more of the areas of the social or self-regulatory behavior
REACTIVE ATTACHMENT DISORDER or in cognitive, language, gross or fine motor skills
➔ Children suffering this have a constant pattern of ● Substance abuse
inhibited, emotionally withdrawn behavior, and the ● Failure to thrive
child rarely directs attachment behaviors toward any ● Unstable home
adult caregivers. ● Unwanted pregnancy
➔ Is caused by a lack of bonding experience with a primary ● Poverty
caregiver by the age of 8 months.
Outcome Identification
DISINHIBITED SOCIAL ENGAGEMENT DISORDER ➔ An overall attachment outcome would be for the parent
➔ Children demonstrate no normal fear of strangers, seem and infant/child to demonstrate an enduring
unfazed in response to separation from a primary affectionate bond.
caregiver ➔ In regard to development, general outcomes would
➔ Usually willing to go off with people who are unknown pertain to meeting age-appropriate milestones.
to them.
Implementation
Assessment ➔ Staged Model of Treatment
➔ Is an ongoing process throughout treatment ● Stage 1
➔ Methods of collecting data include interviewing, ○ Providing safety and stabilization through
screening, testing (neurological, psychological, creating a safe, predictable environment;
intelligence), observing and interacting with the child or ○ stopping self-destructive behaviors;
adolescent. ○ providing education about trauma and its
effects.

● Stage 2 ● Anxiety has been reduced, and stress is handled
○ Reducing arousal and regulating emotion adaptively
through symptom reduction and memory ● Emotions and behavior are appropriate for the
work through reducing arousal; situation
○ finding comfort from others: ● The child achieves normal developmental milestones
○ tolerating affect; for his or her chronological age.
○ integrating disavowed emotions and ● The child is able to seek out adults for nurturance
accepting ambivalence; and help when needed.
○ overcoming avoidance;
○ Improving attention and decreasing TRAUMA-RELATED DISORDERS IN ADULTS
dissociation; ➔ PTSD in Adults
○ working with memories; ● Is characterized by persistent re-experiencing of a
○ transforming memories highly traumatic event that involves actual or
● Stage 3 threatened death or serious injury to self or others,
○ Developmental skills catch up though to which the individual responded with intense fear,
enhancing problem-solving skills; helplessness or horror.
○ nurturing self-awareness: social skills ● PTSD may occur after any traumatic event that is
training; outside the range of usual experience.
○ developing a value system. ➔ Major Features
● Re-experiencing of the trauma though recurrent
Intervention intrusive recollections of the event, dreams about
➔ Establish trust and safety in the therapeutic relationship the event, and flashbacks (dissociative experiences
➔ Use developmentally appropriate language to explore during which the event is relived, and the person
feelings behaves as though he or she is experiencing the
➔ Teach relaxation techniques before trauma exploration to event at that time)
restore a sense of control over thoughts and feelings ● Avoidance of stimuli associated with the trauma,
➔ Help the child to identify and cope with feelings through causing the individual to avoid talking about the
the use of art and play to promote expression event or avoid activities, people, or places that
➔ Involve the parents or appropriate caretakers in 1:1s arouse memories of the trauma, accompanied by
unless they are the cause of the trauma feelings of detachment, emptiness and numbing
➔ Assist parents in resolving their own emotional distress ● Persistent symptoms of increased arousal, as
about the trauma evidenced by irritability, difficulty sleeping, difficulty
➔ Coordinate with social work for protections as indicated. concentrating, hypervigilance, or exaggerated startle
➔ Advanced Practice response
● Cognitive-Behavioral Therapy ● Alterations in mood, such as chronic depression
○ Psychoeducation ➔ Comorbidities for adults with PTSD include:
○ Behavioral modification ● Depression
○ Cognitive therapy ● Anxiety disorders
○ Exposure Therapy ● Sleep disorders
○ Stress management ● Dissociative disorders
● Eye Movement Desensitization Reprocessing
(EMDR) -innovative evidence-based therapy used to Assessment
treat children and adults ➔ Screening tools such as Primary Care PTSD Screen and
○ Processes traumatic memories through a PTSD Checklist
specific eight-phase protocol that allows the ➔ Additional history about the time of onset, frequency,
person to think about the traumatic event while course, severity, level of distress, and degree of
attending to other stimulation, such as eye functional impairment.
movements, audio tones or tapping. ➔ Suicidal or violent ideations, family and social supports,
● Pharmacology insomnia, social withdrawal.
○ Best when combined with another treatment
such as EMDR and CBT Diagnosis
○ Medications that target specific symptoms or ➔ Anxiety (moderate, severe, panic)
comorbidities such as ADHD or depression can ➔ Ineffective coping
enhance the child or adolescent's potential for ➔ Social isolation
growth and may make a real difference in a ➔ Insomnia
family's ability to cope and quality of life. ➔ Sleep deprivation
➔ Hopelessness
Evaluation ➔ Chronic low self-esteem
➔ Treatment is effective when: ➔ Self-care deficit
● The child's safety has been maintained

Outcome Identification ➔ To be diagnosed with AsD, individual must display eight
➔ The person is able to manage anxiety as demonstrated by of the following 14 symptoms either during or after the
use of relaxation techniques, adequate sleep, and ability traumatic event including:
to maintain role or work requirements ● Subjective sense on numbing
➔ Enhanced self-esteem as demonstrated by maintenance ● Derealization ( a sense of unreality related to the
of grooming/hygiene, maintenance of eye contact, environment)
positive statements about self, and acceptance of ● Inability to remember at least one important aspect
self-limitations of the event
➔ Enhanced ability to cope as demonstrated by decrease in ● Intrusive distressing memories of the event
physical symptoms, ability to ask for help, and seeks ● Recurrent distressing dreams
information about treatment ● Feeling as if the event is recurring
● Intense prolonged distress or physiological reactivity
Implementation ● Avoidance of thoughts or feelings about the event
➔ Stage model of treatment previously described for ● Sleep Disturbances
children is the standard for trauma treatment for adults ● Hypervigilance
as well. ● Irritable, angry, or aggressive behavior
➔ Psychoeducation ● Exaggerated startle response
● Initial education should include reassurance that ● Agitation or restlessness
reactions to trauma are common and that these ➔ What is the difference between Acute Stress Disorder and
reactions do not indicate personal failure or PTSD? The most significant difference between ASD and
weakness. PTSD is the onset and duration of symptoms.
● Teach on strategies to improve coping, enhanced ● The effects of Acute Stress Disorder is present
self-care, facilitate recognition of problems, immediately and lasts up to a month
instructions on relaxation techniques and avoidance ● While PTSD symptoms presents slower and lasts
of caffeine and alcohol. longer up to several years if not treated
➔ Pharmacology
● SSRI Diagnosis
○ Fluoxetine (Prozac) ➔ Post Trauma Syndrome
○ Paroxetine (Paxil) ● Aggression
○ Sertraline (Zoloft) ● Headaches
● Serotonin-Norepinephrine Reuptake Inhibitors ● Intrusive dreams
(SNRIs) ● Irritability
○ Venlafaxine (Effexor)- to decrease anxiety and ● Anxiety
depressive symptoms Related to:
● Tricyclic Antidepressants-may be prescribed when ● Serious automobile accident
SSRIs are SNRIs are not tolerated or does not work ● Serious injury to loved one
○ Mitaprazine (Remeron) ● Disaster
➔ Advanced Practice ● Abuse
● Eye Movement Desensitization Reprocessing (EMDR)
● Cognitive restructuring Outcome Identification
➔ Desired Outcomes:
Evaluation ● General outcomes may relate to aggression.
➔ Treatment is effective when: ● The patient will be able to practice self-restraint of
● The patient recognizes symptoms as related to the assaultive, combative, or destructive behaviors
trauma toward others.
● The patient is able to use newly learned strategies to ● For anxiety, a general outcome may be that the
manage anxiety patient's anxiety level be maintained at a level of
● The patient experiences no flashbacks or intrusive mild to moderate.
thoughts about the traumatic event
● The patient is able to sleep without nightmares. Implementation
● The patient can assume usual roles and maintain ➔ Establishing therapeutic relationship with the patient
satisfying interpersonal relationships. ➔ Helping the person to problem solve
➔ Connecting the person to supports such as family and
ACUTE STRESS DISORDER friends
➔ Another disorder related to trauma is the Acute Stress ➔ Educating about ASD
Disorder. ➔ Coordination of care through collaboration with others
➔ Acute stress disorder may develop after exposure to a ➔ Ensuring and maintaining safety
highly traumatic event, such as those listed in the prior ➔ Monitoring response and/or adherence to treatment
section on PTSD. ➔ Advanced Practice
● Cognitive-Behavioral Therapy
● Eye Movement Desensitization Reprocessing (EMDR)

● The focus is on oneself. It is an extremely
Evaluation uncomfortable feeling of being an observer of one’s
➔ Same as PTSD own body or mental processes
➔ Derealization
ADJUSTMENT DISORDER ● The focus is on the outside world. It is the recurring
➔ Considered milder forms of PTSD and ASD. feeling that one’s surroundings are unreal or distant.
➔ The event - including retirement, chronic illness, or a
break-up-may not be as severe and may not be Dissociative Amnesia
considered a traumatic event. ➔ Marked by the inability to recall important personal
➔ May be diagnosed immediately within 3 months of information, often of a traumatic or stressful nature; this
exposure. lack of memory is too pervasive to be explained by
➔ Hallmarks of AD are COGNITIVE, EMOTIONAL, and ordinary forgetfulness.
BEHAVIORAL symptoms that negatively impact ➔ Autobiographical memory is available but is not
functioning. Responses to the stressful event may include accessible. (In contrast, a patient with generalized
combinations of depression, anxiety, and conduct amnesia is unable to recall information about his or her
disturbances. entire lifetime.
➔ Treatment of adjustment disorder is not uniform due to
the lack of specificity of the problem; practitioners tend Dissociative fugue
not to recognize this disorder. ➔ A subtype of dissociative amnesia, is characterized by
➔ Symptoms are generally treated with antidepressants. sudden, unexpected travel away from the customary
locale and inability to recall one’s identity and
DISSOCIATIVE DISORDERS information about some or all of the past.
➔ Dissociative disorders occur after significant adverse ➔ The person assumes a whole new identity, and usually is
experiences/ traumas, and individuals respond to stress precipitated by a traumatic event.
with a severe interruption of consciousness.
➔ Dissociation is an unconscious defense mechanism that Dissociative Identity Disorder
protects the individual against overwhelming anxiety ➔ Essential feature is the presence of 2 or more distinct
though an emotional separation; however, this personality states that recurrently take control of
separation results in disturbances of memory, behavior, called alter (alternate personality).
consciousness, self-identity and perception. ➔ Each alter has its own pattern of perceiving, relating to,
➔ Positive symptoms refer to unwanted additions to and thinking about the self and the environment.
mental activity such as flashbacks. ➔ At Least 2 dissociative Identity states/ alter:
➔ Negative symptoms refer to deficits such as memory ● 1st- functions on a daily basis, blocks access and
problems or the ability to sense or control different parts responses to traumatic life events.
of the body. ● 2nd- fixated on traumatic memories.
➔ Dissociative disorders include: ➔ Each alter is a complex unit with its own memories,
● Depersonalization/ derealization disorder behavioral patterns, and social relationships that dictate
● Dissociative amnesia how the person acts when that personality is dominant.
● Dissociative Identity Disorder ➔ Transition from one personality to another (switching)
occurs during times of stress and may range from a
Etiology of Dissociative Disorders dramatic to a barely noticeable event.
➔ Childhood physical, sexual or emotional abuse and other ➔ Shifts may last from minutes to months, although shorter
traumatic life events are associated with adults periods are more common.
experiencing dissociative symptoms.
➔ Dissociative symptoms, “mind-flight”, actually reduce Assessment
disturbing feelings and protect the person from full ➔ For a diagnosis of dissociative disorder to be made,
awareness of the trauma. medical and neurological illnesses, substance use, and
➔ Biological Factors: other coexisting psychiatric disorders must be ruled out
● Genetic variability as the cause of the patient's symptoms.
● Neurobiological- research suggests that the limbic ➔ Assessment tools used:
system is involved in development of dissociative ● Dissociative Experience Scale (DES)
disorders. ● The Somatoform Questionnaire (SDQ)
➔ Psychological Factors: ● Dissociative Disorders Interview Schedule (DDIS)
● Primitive ego defense mechanism is dissociation. ➔ Assessment tools are important because a psychiatric
➔ Environmental Factors: interview will often miss the presence of dissociation.
● Dissociative disorders are responses to acute Specific information about identity, memory,
overwhelming trauma (MVA, combat, emotional/ consciousness, life events, mood, suicide risk, and the
verbal abuse) impact of the disorder on the patient and the family are
important dimensions to assess.
DEPERSONALIZATION/DEREALIZATION DISORDER ➔ Nurse should consider the following when assessing
➔ Depersonalization memory:

● Can the patient remember recent and past events?
explain actions or strategies, maintains
● Is the patient’s memory clear and complete or partial behaviors when in role performance, and
and fuzzy? altered state. relationships.
● Is the patient aware of gaps in memory, such as lack
of memory for events such as graduation, or Planning
wedding? ➔ Planning includes 3 phases:
● Do the patient’s memories place the self with a ● Phase 1- Establishing safety, stabilization, and
family, in school, or in an occupation? (Patients with symptom reduction
amnesia and fugue may be disoriented with regard ● Phase 2- Confronting, working through, and
to time and place as well as person.) integrating traumatic memories
● Does the patient ever lose time or have blackouts? ● Phase 3- Identity integration and rehabilitation
● Does the patient ever find herself or himself in
places with no idea how she or he got there? Implementation
➔ For History: If dissociative identity disorder is suspected, ➔ Psychoeducation
pertinent questions include the following: ● Patients with dissociative disorders need to be
● Have you ever found yourself wearing clothes you educated about their illness and given ongoing
cannot remember buying? instruction about coping skills and stress
● Have you ever had strange people greet and talk to management.
you as though they were old friends? ● Teaching grounding techniques that bring the
● Does your ability to engage in things such as person’s awareness to noticing real things in the
athletics, artistic activities, or mechanical tasks seem present helps to counter dissociative episodes.
to change? ● Examples of Grounding Techniques:
● Do you have differing sets of memories about ○ Stomping one’s feet on the ground
childhood? ○ Taking a shower
➔ Mood- is the individual depressed, anxious, or ○ Holding an Ice cube
unconcerned? ○ Exercising
➔ Impact on Patient and Family- fugue states usually ○ Deep breathing
function adequately in the new identities, patients with ○ Counting beads
amnesia may be more dysfunctional. Patients with DID ○ Encourage daily journals
often have both family and work problems. ➔ Pharmacologic Intervention
➔ Suicide Risk ● No specific medications for patients with dissociative
➔ Guidelines for assessment of a patient with a dissociative disorders, but appropriate medications are often
disorder include: prescribed for the hyperarousal and intrusive
● Assess for a history of self-harm symptoms that accompany PTSD and dissociation.
● Evaluate level of anxiety and signs of dissociation ● Include:
● Identify support systems through a psychosocial ○ Antidepressant,
assessment. ○ anxiolytics, and
○ Antipsychotics
Signs and Symptoms, Diagnoses, and Outcomes ➔ Advanced Practice Interventions
Signs and Symptoms Diagnosis Desired Outcomes ● CBT
● Psychodynamic psychotherapy
Amnesia or fugue Disturbed Verbalizes a clear ● Exposure therapy
related to a traumatic Personal sense of personal ● Modified EMDR (Eye Movement Desensitization and
event; symptoms of Identity identity, perceives the
depersonalization; Reprocessing)
environment
feelings of unreality ● Hypnotherapy
and/ or body image accurately, performs
● Neurofeedback
distortions. social roles well.
● Ego state Therapies
Alterations in Ineffective role Performs family, ● Somatic Therapies- based on the premise that the
consciousness, performance parental, intimate, body, mind, emotions, and spirit are interrelated,
memory, or identity, community, and work and a change at one level results in changes in the
abuse of substances, roles adequately;
disorganization or reports comfort with others. Awareness, focusing on the present, and
dysfunction in usual role expectations. recognizing touch as means of communicating are
patterns of behavior some of the principles of this therapy.
(absence from work,
withdrawal from
relationships, changes Evaluation
in role function) ➔ Evaluation is positive when:
● Patient safety has been maintained.
Feeling of being out of Anxiety self- Monitors intensity of
control of memory, control anxiety, eliminates
● Anxiety has been reduced, and the patients has
behaviors, and precursors of anxiety, returned to a functional state
awareness; inability to uses effective coping

● Integration of the fragmented memories has
occurred
● New coping strategies have permitted the patient to
function at a better level
● Stress is handled adaptively, without the use of
dissociation

SOMATIC SYMPTOMS AND RELATED DISORDERS ➔ Similar to Somatic Symptom Disorder, medical evaluation
fails to identify a serious medical condition.
TOPIC OUTLINE
➔ Regardless of medical reassurances anxiety is not
1. Somatic Symptom Disorder alleviated and may be heightened.
2. Illness Anxiety Disorder ➔ Anxiety is our main point here, it’s not much more on
3. Conversion Disorder (Functional Neurologic bodily symptoms but there is increased anxiety in
Disorder) response to a belief that there is a serious undiagnosed
4. Factitious Disorder
illness.
➔ Example: A person may fear that the normal sounds of
SOMATIC SYMPTOMS AND RELATED DISORDERS digestion, sweating or a mark on the skin may be
➔ It is important to know that somatic symptoms and indicators of life-threatening disease.
related disorders can also be called as “somatoform ➔ This is more inclined on patient’s anxiety, in response to
disorders” Which comes from the root word “somato” to whatever he sees or feel inside his body that is actually
which means body. normal.
➔ Major Characteristic: ➔ The main issue here is the anxiety of your patient,
● Patients have physical symptoms for which there is despite the reassurance that the medical diagnosis, the
no known organic cause or physiologic mechanism. laboratory work are not reflective of an actual disease.
➔ Common feature: This is how somatic symptom disorder and illness anxiety
● Distressing somatic symptoms associated with disorder differs.
abnormal thoughts, feelings, behaviors in response
to these symptoms. CONVERSION DISORDER (FUNCTIONAL NEUROLOGIC
● That is why it is categorized a disorder under DISORDER)
psychiatric mental health nursing because of the ➔ Major Feature: A deficit or alteration in voluntary motor
associated abnormal thoughts, feelings, and or sensory function that mimics a neurologic or medical
behaviors in response to these symptoms manifested condition.
by the body. ➔ One concrete example of this would be your patient is
presenting “pill rolling” symptoms, “ants on pants”, and
SOMATIC SYMPTOM DISORDER bradykinesia, rigidity and a lot of involuntary movements
➔ Previously known as Hypochondriasis. that is similar to Parkinson's disease. No matter how the
➔ Make sure that when you hear the term doctor evaluates the patient, in terms of laboratories,
“hypochondriasis” you link it with the new term “somatic imaging etc. it doesn’t show that he has parkinson's
symptom disorder”. It is much known as hypochondriasis disease. That is why it is called conversion disorder
than somatic symptom disorder, that is why it is being because it mimics a neurologic condition. Not just
included. neurologic but also medical conditions that affects the
➔ Patients have multiple, recurrent, significant somatic motor and sensory function of the patient.
symptoms with no evidence of medical explanation. ➔ Typically associated with psychological or physical stress
➔ No matter what fact you present to the patients objective or trauma.
results such as: laboratory results, CT scan, MRI, or any ➔ Individuals have spontaneous attacks of severe physical
other imaging or any other tests, still there is a recurrent disability despite a lack of medical evidence.
or multiple thoughts or belief that there is a serious ➔ Most common motor symptoms:
illness because of misinterpretation of physical ● Paralysis
symptoms. ● Tremor
➔ The patients are not in control of their symptoms, which ● Gait Abnormalities
are unconscious and involuntary. They express conflicts ● Abnormal limb posturing
through bodily symptoms (primarily pain). Sakit na walay ➔ Frequent sensory symptoms:
hinungdan. ● Altered/absent skin sensations
➔ Repetition of medical consults seeking medical dx and ttt ● Blindness
even though they have been told that there is no known ● Inability to hear
physiologic or organic evidences to explain their ➔ Other symptoms:
symptoms or disability. ● Aphonia ( loss of speech/voice )
➔ Patients with somatic symptom disorder, they also ● Dysphonia ( difficulty in speaking )
experience “doctor shopping” or “doctor hopping”. They ● Globus ( lump in the throat )
keep on having medical appointments with a lot of ➔ Dissociative Symptoms:
doctors because they have this belief within themselves ● Depersonalization
that they have something serious inside their body that ● Derealization
the doctor failed to diagnose. ● Amnesia
➔ Symptoms may be persistent or transient. It may stick
ILLNESS ANXIETY DISORDER with the patient for life, until the patient dies or transient
➔ Excessive preoccupation with having or acquiring a mulabay lang or passing lang without any explanation as
serious undiagnosed illness. to how the sings and symptoms disappear.

➔ La belle indifference - express little concern or anxiety ➔ Do not push awareness of or insight into conflicts or
about the distressing symptoms. For the patient, the problems. Thereby, they will know what to expect.
gravity of what he or she is manifesting is not that much.
FACTITIOUS DISORDER ➔ Explain to them the mechanism or course of their
➔ Characterized by falsification of medical of psychological disorder
signs and symptoms in oneself or others
➔ Impose harm on themselves or others by misinterpreting, Psychopharmacology
exaggerating, fabricating, inducing, simulating or causing ➔ Medication for pain should be used temporarily and
s/s of illness or injury in the absence of obvious external sparingly.
rewards ➔ SSRIs to decrease sensitivity to bodily sensations, anxiety
➔ Factitious disorder imposed on self (previously and depression
Munchausen syndrome). Gi revise; update sa research. It
is usually appreciated when the person or patient does Milieu Management
self-mutilation, mo induce siya ug fever or even ➔ Relaxation exercise
hemorrhage sa iyang kaugalingon, mga seizures or even ➔ Meditation
hypoglycemia (pataka lang ug inject ug insulin sa iyang ➔ CBT
self) ➔ Physical therapy might be indicated to prevent muscle
➔ Factitious disorder imposed on others (previously atrophy with conversion disorder (Miller, 2005)
Munchausen syndrome by proxy). Ma appreciate rani ➔ Family therapy is helpful when family conflict is present
with cases kaning mga abusive parents, to be specific kay ➔ Because patients with somatoform disorders are usually
abusive mothers, presenting their children in the overused of medical care, some hospitals and clinics
emergency department with various wounds with provide group interventions as part of medical care;
different healing stages. Maka huna huna ka sa imong focusing on psychosocial needs, not on physical needs.
self na, ‘’Okay I am the nurse and this is obviously one
sign of abuse. It is also my duty to warn or report to the
authorities about the suspicion that I have in my mind
according to my assessment.’’
➔ When you take the medical history of the patient,
sometimes it doesn’t make sense. Makaingon ang mama
nga kaning mga wounds kay ‘’chicken pox’’, 3 weeks to 1
month ago unya wa gihapon na ayo. It doesn’t make
sense based on your studies; chickenpox doesn’t last 1
month.
➔ No believable reasons; lack of healing; contradictory
consistent symptoms or lab test results; person is lying;
person resist getting information from previous medical
records, other healthcare professionals and family
members
➔ Fakes symptoms for the purpose of the sick role
➔ Example: injecting insulin, or injecting fecal material to
produce and abscess or to induce sepsis
➔ Malingering- pretend or exaggerate incapacity or illness
to avoid duty or study or school; has obvious external
rewards
PSYCHOTHERAPEUTIC MANAGEMENT
Nurse-Patient Relationship
➔ Focus is to improve a patient's overall levels of
functioning by helping them develop adaptive coping
behaviors.
➔ Allow to verbalize feelings appropriately
➔ If not done before, PE and lab workup is done to assess
patients thoroughly
➔ Use a matter-of-fact caring approach
➔ Ask patients how they are feeling
➔ Use positive reinforcement and set limits by withdrawing
attention from patients when they focus on physical
complaints or make unreasonable demands
➔ Be consistent with patients
➔ Use diversion by including patients in milieu activities and
recreational games

EATING DISORDERS ● Participate on rigid exercise program, hyperactive,
highly anxious, and unable to relax
TOPIC OUTLINE
2. Vomit-Purgers
1. Anorexia Nervosa ● More often overweight before the eating disorders
2. Bulimia Nervosa begins
3. Binge-eating disorders ● Prone to dangerous methods of weight reduction
(e.g. introduction of vomiting or excessive use of
ANOREXIA NERVOSA laxatives and diuretics)
➔ DSM 5 Criteria ○ Dangerous because they use risky weight
● Core feature: a restriction of caloric intake relative to reduction techniques. The medications also
body requirements, which leads to a significantly low (laxatives and diuretics) are just OTC drugs.
body weight ● Typically eat normally in social institutions
● Intense fear of gaining weight or becoming fat ● Post meal, they retreat to the nearest bathroom and
● Disturbance in the way in which one’s body weight purge on the consumed food but not as excessive as
or shape is experienced, undue influence of body bulimics
weight or shape on self-evaluation, or persistent lack ● Dental problems are common
of recognition of the seriousness of the current low ○ Gastric juices/acids causes erosion of the
body weight enamel/esophageal linings
● They do not see themselves as having problems with ● Weight tends to fluctuate
regards to their body weight.
OBJECTIVE SIGNS
INTERESTING FACTS ➔ Most observable sign is deliberate weight loss in an
➔ Women account for approximately 90% of reported cases effort to control weight through changing eating
of anorexia nervosa, although anorexia in men appears to behaviors
be increasing (Cohane & Pope, 2001) ➔ V/s: hypotension, bradycardia, hypothermia
➔ Onset caries from preadolescence (12 to 13 years old) to ● Hypothermia is common because the body of the
early adulthood (McDonald, 2009) patient has less fat. Therefore, it cannot preserve
➔ 6%-20% die as a result of their illness, usually through body heat noh. So dili maka preserve ug body heat
starvation or suicide and as a compensating mechanism of the body, it
➔ Anorexia nervosa is associated with a higher suicide rate will allow itself to grow hairs (lanugo). Most
than most other psychiatric disorders (Pompli et al., observable sa trunk part sa ato patient (back part),
2004) diri dapit sa scapular area and here sa nape area. It
could also grow along sa arms sa patient.
CHARACTERISTICS ➔ Skin is dry; appearance of lanugo
➔ People with AN have an intense fear of gaining weight or ➔ Constipation due to slower abdominal peristalsis
of becoming overweight combined with decreased intake of food fuels the use of
➔ Focus on NOT gaining weight, despite their low weight laxatives, leading to dehydration and giving the anorectic
(APA, 2013) a false sense of decreased weight
➔ They generally DO NOT lose their appetites, instead ➔ Dehydration can lead to irreversible renal damage
suppress them in an effort to remain thin or getting ● Due to excessive use of laxatives and diuretics. This
thinner can damage the kidneys.
➔ Disturbance in the way they view their weight/shape; ➔ Osteopenia and Osteoporosis might develop because of
these two factors are the most IMPORTANT influence on prolonged amenorrhea and malnutrition (Lock and
people with anorexia’s sense of worth. Fitzpatrick, 2019)
➔ Denial that they are dangerously thin and that their ● 90% of AN patients are women. These are most
condition is problematic. common because of hormonal imbalances brought
➔ Amenorrhea is no longer a diagnostic criterion for about by lack of nutrition
anorexia nervosa (APA, 2013), however data support that ➔ Alterations in the size of the cardiac chambers and
menstrual difficulties/irregularities may occur in the decreased myocardial O2 uptake which can lead to
disease life-threatening cardiac arrhythmias.
➔ They believe they are the nutrition authorities in the
2 GROUPS household and attempt to control meals.
1. Restricters ➔ Might engage in bizarre behavior regarding food and
● Views losing weight as more probable if they simply eating such as hoarding food or preparing elaborate
eat less and avoid social situations in which they are meals for others but not eating the food they prepare.
expected to eat ➔ Refeeding Syndrome can occur causing cardiovascular,
● Avoid family and friends and withdraw to their neurologic and hematologic complications and death.
rooms ● Refeeding syndrome occurs when there is rapid
● Commonly competitive, compulsive, and obsessive reintroduction of nutrition into a severely
about their ADLs malnourished person (pasensya di ko na talaga
marinig si miss chz haha) This includes valuable

symptoms of muscle weakness, diarrhea, vomiting, Famous Celebrities with Anorexia:
hypotension, arrhythmias, and even respiratory (di ● Nicole Richie
najerd madungerg si miss pasensyerrrr ganito lang ● Keira Knightley
akoe huhuhahaha), which can lead to death ● Lindsay Lohan
● Pitting edema can occur ● Victoria Beckham
● Refeeding must be done slowly and under close
supervision to avoid serious problems. BULIMIA NERVOSA
➔ DSM-5 Criteria
SUBJECTIVE SYMPTOMS ● Recurring episodes of binge-eating characterized by
➔ The fear of gaining weight might be triggered by an both following:
offhand comment by a friend or relative. 1. Eating in a discrete period of time, an amount
● “Hala nanambok lagi ka?” — Come on guys, it’s 2022 of food that is larger than what most individuals
charaught. #NoToBodyshaming would eat in a similar period of time under
➔ They try to combat helplessness by controlling what similar circumstances- for example in a straight
they can control – how much food they eat and their 2-hour period (because commonly 2 hours ra
weight man gyud ning bulimia)- they would spend the
➔ Depression, irritability, social withdrawal, lessened sex entire 2 hours just eating large bulky foods
drive, and obsessional symptoms continuously until mahuman na siya
➔ It is believed that bizarre behaviors might be the result 2. A sense of lack of control over eating during the
of starvation and often diminish with weight gain, but if episode
they do not, the patient might have a comorbid condition ● Recurrent inappropriate compensatory behavior in
such as OCD, major depression, substance abuse or order to prevent weight gain
personality disorder (Ro et al., 2005) ● Binge-eating and inappropriate compensatory
behavior occur on average at least once a week × 3
ETIOLOGY months
➔ Biologic Factors ● Self-evaluation is unduly influenced by body shape
● Increased serotonin levels and weight
● Disturbances in the serotonin system contribute to ● The disturbance does not occur exclusively during
vulnerability for restricted eating, behavioral episodes of anorexia nervosa- usually bulimia
inhibition, and a bias toward anxiety and error nervosa occurs after the patient has anorexia. The
prediction patient can have anorexia first and then bulimia right
● If SSRIs are used to treat AN, they should not be after. Bulimia typically occurs but not all the time.
started until weight restoration has been But when bulimia occurs to certain individuals who
achieved-never use this if the patient is still in the already have a certain individuals who already have
perilous side of gaining weight, establish the eating disorders, it usually comes second to anorexia.
physiologic needs of the patient first before we tend They have anorexia first then later on bulimia.
to go with SSRIs because they are also closely related
to depression and suicide. INTERESTING FACTS
➔ Sociocultural Factors ➔ Begins in adolescence or early adult life, primarily in
● A culture of thinness-especially in the western world women- just like your AN
where they tend to equate beauty with thinness ➔ The usual course of the disorder is chronic and
● Societal standard of beauty through computer intermittent over many years- so mu anam na siyag ka
imaging technology which encourage dieting, a gamay over the years
major predisposing factor to both anorexia and ➔ Onset is usually between the ages 15 to 24 years old
bulimia ➔ The disease might develop after AN or after a period of
● American culture: thin beauty ideal = approval by dieting
others
➔ Family factors BEHAVIOR AND CHARACTERISTICS
● Emotional restraint, enmeshed relationships, rigid ➔ Bulimia literally means to have an insatiable appetite-so
organization in the family, tight control of child dili makuntento, dili ma satisfy sa cravings for food-and is
behavior by parents and avoidance of conflict used interchangeably with with binge eating or bingeing
➔ Psychodynamic Factors ➔ Dieting predisposes the individual to binge eating, and
● AN might be related to an early history of sexual purging develops as a means of compensating for calories
abuse ingested during the binge in an attempt to prevent
● The drive for thinness might be an attempt to reduce weight gain- here in bulimia grabe kaayo ni sila mu purge.
the control of an over controlling maternal figure Grabe kaayo mu stimulate ug vomiting of AKA pure
● Some researchers suggested that anorexia involves a ➔ The individual continues the restrictive eating during the
regression to a prepubertal state, so that the disorder, which precipitates binge eating and then
adolescent does not mature physically or purging, perpetuating the cycle- so almost ang uban ani
emotionally they feel a sense of hopelessness because they tend to
promise to themselves na “okay this will be my last binge

eating and then right after I will do diet again” and then
later on they will not be able to fulfill their promise from
their own to their own which then the cycle repeats.
➔ After a binge, patients promise themselves to adhere to a
strict diet and vow never to binge again, only to return to
this behavior because they find themselves addicted to
the high they experience when bingeing.
➔ Overeating vs binge eating
OBJECTIVE SIGNS ➔ Russel’s sign- callusing of the knuckles of the fingers used
➔ Most common food ingested is a high-calorie, to induce vomiting
high-carbohydrate "snack" food easily ingested in a short
period- burgers, doughnuts, finger food like fries. They
tend to see it as a snack but it is already a meal for
normal people, the amount of food.
➔ Pancreatitis is reported to pt with bulimia
SUBJECTIVE SYMPTOMS
➔ Most have normal body weight
➔ Loss of control of eating causes them great anxiety and
shame; express a fear of becoming fat
➔ Most binges occur during the evening or at night (so no ➔ Pre-binge: feals week, anxious, lonely, bored, or
one can see them or may even hop from resto to resto) uncontrollably craving for food
● para lang gyud sila maobserbaran sa uban nga tao ➔ During binge: either continued anxiety or relief from
mag tago ni sila they bring food inside their rooms tension
and go from restaurant to restaurant so that walay ➔ Post-binge: anxiety is replaced with guilt. If not relieved,
maka pansin nila over a long period of time nga sige patients feel angry, agitated, and might become
silag kaon-kaon depressed
➔ Rapid eating during the binge with calories more than ➔ Relationship between depression and bulimia might be
recommended daily allowance one in which one causes the other
● Bulimic episode ends when: ➔ Some patients eat a marker food
○ begin to induce vomiting ● Marker is mao ni ilang permi i eat. Usually bright
○ physically exhausted (mag numb na ang colors like hotdog
jaw) ➔ Self induce vomiting by use of:
○ suffer from painful abdominal distention ● Finger,
○ interrupted by others (“magtawag kog ● Toothbrush,
pulis, dugay lagi kaayu ka muundang diha”) ● utensils down their throats
○ run out of food ➔ Over time, vomiting becomes easier and might require
➔ Dehydration, hyponatremia, hypochloremia, only slight abdominal pressure or no physical
hypokalemia, and metabolic alkalosis and acidosis manipulation at the end of the binge
➔ Laxatives can lead to reflex constipation. And both ➔ Other compensatory behaviors: neglect of insulin
laxatives and diuretics are associated with rebound requirements by patients with DM (Poirier, 2001)
edema
● Just like what I said earlier, just like your anorexia ETIOLOGY
nervosa, there is a rapid shifting of our electrolytes. ➔ Biologic factors
Pwede na sha makacreate ug rebound edema, ● Lowered serotonin activity
usually pitting edema sa ankles. ● Decreased cognitive abilities and inefficient
➔ Dilation of the stomach prefrontal self-regulatory function
➔ Irritation of the GI tract ● Treatment of SSRI Fluoxetine (Proxac) appears to be
➔ Menstrual irregularities helpful
➔ Enlarged salivary glands (Parotid glands) ➔ Sociocultural Factors
➔ Erosion of dental enamel ● Similar with AN
● This is most common among purgers ➔ Family Factors

● Similar with AN PSYCHOPHARMACOLOGY
● Family conflict, disorganized, lacking in nurturance, ➔ No medication is approved specifically for AN at present
and not being cohesive ➔ Medication mgt of anxiety, depression, somatic
➔ Cognitive and behavioral Factors disturbances might assist in the ttt
● Distorted and negative cognitions about self and ➔ Small amount of anxiolytics might help patient in eating
body premeals during refeeding
➔ Psychodynamic Factors ➔ Olanzapine (Zyprexa) promotes weight gain with some
● Bingeing and purging appear to be seen in patients success
who numbs in pain resulting from abuse, neglect, ➔ SSRIs in bulimic pts when psychotherapy alone does not
trauma, and strong feelings respond
● Binge eating and purging behavior is thought to
express the ambivalence they feel towards MILIEU MANAGEMENT
themselves. ➔ Provide a warm and nurturing environment
○ Worthy of nurturing they lack, they binge ➔ Closely observe pts
○ Unworthy of nurturing, they purge ➔ Encourage the pt to approach a team member if feeling
the need to purge
PSYCHOTHERAPEUTIC MANAGEMENT ➔ Involve the patient’s family in ttt
➔ Initial treatment goal: medical stabilization ➔ Respond with consistency
➔ Secondary treatment goal: Psychotherapy ➔ Encourage participation in art, recreation and other
➔ Primary objective for Anorexia Nervosa: therapies
1. Increase weight to at least 90% of the average body ➔ Encourage pts’ attendance to group sessions
weight for the patient’s height ➔ Recommend follow-up psychotherapeutic groups and
2. Helping patients establish appropriate eating support groups
behavior
3. Increasing self-esteem, so patients do not need to FAMOUS ICONS WITH BULIMIA
attain the perfection that they believe thinness ➔ Russel Brand
provides ➔ Princess Diana
➔ Primary Objectives for Bulimia Nervosa (similar with AN ➔ Elton John
but focus on stabilizing weight gain without purging) ➔ Demi Lovato
➔ IV lines and feeding tubes must be readily available
➔ Refeeding and weight restoration must be done slowly BINGE-EATING DISORDER
➔ Multidisciplinary approach: ➔ (BED) is a condition that does not meet the diagnostic
● Physician criteria for inclusion in DSM 5
● Dietitian ➔ Shares many criteria of bulimia but without the regular
● Nurse compensation of excess intake through purging, laxatives,
● Psychotherapist fasting or overexercise
➔ Tend to more overweight
NURSE-PATIENT RELATIONSHIP ➔ Similar to bulimia, onset is later than anorexia
➔ For AN, pts, the nurse may be perceived as an enemy not
an ally
➔ BN pts are more likely to want help, which is their
greatest strength
➔ Monitor daily caloric intake
➔ Monitor activity level and observe for signs of purging or
other compensatory behaviors
➔ Weight patient daily
➔ Promote decision making concerning issues other than
food
➔ Promote positive self-concept and perception of the
body; identify positive qualities
➔ Convey warmth and sincerity
➔ Be honest
➔ Plan for a dietitian meet with pt and families
➔ Set appropriate behavioral limits
➔ Teach patients about their disorders and collaborate with
them
➔ Model and teach appropriate social skills
➔ Identify non-weight-related interests of the patient
➔ Initiate behavior modification program
➔ Encourage use of therapies or support groups

SLEEP-WAKE DISORDERS NON-RAPID EYE MOVEMENT (NREM)
➔ Is divided into 3 stages:
TOPIC OUTLINE
● Stage 1 (N1)- is a brief transition between
1. Sleep wakefulness and sleep and comprises between
2. Sleep disorders 2%-5% of total sleep time. The time it takes to fall to
a. Hypersomnolence Disorders sleep is referred to as sleep latency.
b. Narcolepsy/Hypocretin deficiency ○ Body temperature declines and muscles
c. Breathing-related Sleep Disorders
relax.
d. Circadian Rhythm Sleep Disorders
e. Disorders of Arousal ○ Slow rolling eye movements are common.
f. Nightmare Disorder ○ Easily arousable.
g. Rapid Eye Movement Sleep Behavior ● Stage 2 (N2)- sleep occupies 45%-55% of total sleep
Disorder (RSBD) time
h. Restless Leg Syndrome ○ Heart rate and respiratory rate decline.
i. Substance-Induced Sleep Disorder ○ Arousal from stage 2 sleep requires more
j. Insomnia Disorder
stimuli than stage 1
3. Application of the Nursing Process
● Stage 3 (N3)- a.k.a slow wave sleep or delta sleep. Is
relatively short and constitutes only about 13%-23%
SLEEP of total sleep time.
➔ Is a dynamic neurological process that involves complex ○ It is characterized by further reduction of
interaction between the CNS and the environment. heart rate, respiratory rate, blood pressure,
➔ National Sleep Foundation (NSF) recommends that the and response to stimuli.
average adult get 7 to 9 hours of sleep each night. ○ Is considered “restorative sleep”, as it is a
time of reduced sympathetic activity.
CONSEQUENCES OF SLEEP LOSS
➔ The major consequences of acute or chronic curtailment RAPID EYE MOVEMENT (REM)
is excessive sleepiness. ➔ REM sleep comprises 20%-25% of total sleep time.
● Is a subjective report of difficulty staying awake that ➔ Is characterized by reduction and absence of skeletal
is serious enough to impart social and vocational muscle tone (muscle atonia), bursts of rapid eye
functioning and increase the risk for accident or movement, myoclonic twitches of the facial and limb
injury. muscles, reports of dreaming and autonomic nervous
● Causes: system variability.
○ Self-imposed sleep restriction
○ Disruption of the normal sleep cycle SLEEP PATTERN
○ Underlying sleep disorders ➔ Sleep architecture changes over the lifespan
○ Medications ➔ Infants sleep 16-18 hours a day, and usually starts with
○ Alcohol and substance abuse REM.
○ Medical and psychiatric disorders ➔ The percentage of REM sleep decreases to 20%-25% by
➔ Neurocognitive symptoms of chronic sleep deprivation age 3 and stays relatively constant throughout old age.
that mimic psychiatric symptoms:
● Poor general health REGULATION OF SLEEP
● Mood disturbance ➔ Sleep drive- one that promotes sleep (homeostatic
● Increase pain syndromes/perception process)
● Impaired cognitive function ➔ Circadian drive- one that promotes wakefulness
● Memory disturbance (circadian process)
● Reduction in measures of overall quality of life
FUNCTIONS OF SLEEP
NORMAL SLEEP CYCLE ➔ Brain tissue restoration
➔ Sleep is measured through an EEG ➔ Body restoration (thru NREM sleep)
(Electroencephalogram) and consists of two distinct ➔ Energy conservation
physiological states: ➔ Memory reinforcement and consolidation (REM sleep)
● Non-rapid eye movement (NREM) ➔ Regulation of immune function, metabolism, and
● Rapid eye movement (REM) regulation of certain hormones
➔ In an adult, sleep normally begins with NREM sleep, ➔ Thermoregulation
predominating the first had of the sleep period and REM
sleep predominating during the second half. SLEEP REQUIREMENTS
➔ Sleep architecture- is the structural organization of ➔ The amount of sleep required is the amount necessary to
NREM and REM sleep. feel fully awake and able to sustain normal levels of
➔ Irregular cycling, absent sleep stages and sleep performance during the periods of wakefulness and is
fragmentation are associated with many psychiatric known as the basal sleep requirement.
disorders, sleep disorders and medication effects. ● Average- 7-8 hours
● Long sleepers- 10 hours or more

● Short sleepers- less than 5 hours ● Hypnagogic hallucination- may be auditory, visual,
and tactile and occur at sleep onset.
SLEEP TESTING ● Sleep paralysis- is inability to move or speak during
➔ Is often indicated for patients complaining of sleep the transition from sleep to wakefulness.
disturbance or excessive sleepiness that impairs social ● Patients generally feel refreshed upon awakening but
and vocational functioning. within 2 or 3 hours begin to feel sleepy again.
➔ Polysomnography ➔ Additional symptoms include:
● Is the most common sleep test and is used to ● Disturbed nighttime sleep with multiple
diagnose and evaluate patients with sleep-related middle-of-the-night awakenings and automatic
breathing disorders and nocturnal seizure disorders. behaviors characterized by memory lapses.
➔ Multiple Sleep Latency Test (MSLT) ➔ Treatment is through lifestyle modification and
● Is a daytime nap test used to objectively measure long-acting stimulants
sleepiness in a sleep-conducive setting. Indicated in
patients suspected of having narcolepsy. BREATHING-RELATED SLEEP DISORDERS
➔ Maintenance of Wakefulness Test (MWT) ➔ Characterized by episodes of upper airway collapse and
● Evaluated a patient’s ability to remain awake in a obstruction that results in sleep fragmentation.
situation conducive to sleep and is used to document ➔ Most common is sleep-apnea hypopnea syndrome
adequate alertness in individuals with careers for (OSAHA)
which sleepiness would pose a risk to public safety. ➔ Patients with obstructive sleep apnea are not able to
➔ Actigraphy sleep and breathe at the same time.
● Involves using a wristwatch-type device that records ➔ Symptoms include:
body movement over a period of time and is helpful ● Loud, disruptive snoring
in evaluating sleep patterns and sleep duration. It is ● Witnessed apnea episodes
used in patients with circadian rhythm disorders or ● Excessive daytime sleepiness
insomnia. ➔ Obesity is an important risk factor for obstructive apnea
➔ Treatment is with CPAP (continuous positive airway
SLEEP DISORDERS pressure) therapy
HYPERSOMNOLENCE DISORDERS ➔ Central Sleep Apnea
➔ Are associated with excessive daytime sleepiness and ● Is the cessation of respiration during the sleep
have a prevalence of more than 15% in the general without associated ventilatory effort and is caused
population. by instability of the respiratory control system
➔ Usual complaints for patients with Hypersomnolence ● Central sleep apnea is seen in older individuals,
disorder: those with advanced cardiac or pulmonary disease,
● Recurrent periods of sleep or unintended lapses into or those with neurological disorders.
sleep ➔ Sleep-related Hypoventilation
● Frequent napping ● Is associated with sustained oxygen desaturation
● A prolonged main sleep period of greater than 9 during sleep in the absence of apnea or respiratory
hours events and is seen in individuals with morbid obesity,
● Non-refreshing, non-restorative sleep regardless of lung parenchymal disease or pulmonary vascular
amount of time slept pathology.
● Difficulty with full alertness during the wake period
➔ Excessive sleepiness significantly impairs social and CIRCADIAN RHYTHM SLEEP DISORDERS
vocational functioning by impacting the person’s ability ➔ Occurs when there is a misalignment between the timing
to participate and enjoy relationships and function in the of the individual’s normal circadian rhythm and external
workplace. factors that affect the timing or duration of sleep.
➔ Cognitive impairment is common as is an increased risk ➔ Diagnosis is determined by clinical evaluation, sleep
for accident or injury associated with the sleepiness. diaries, and actigraphy.
➔ Treatment focuses on maintaining sleep-wake cycle ➔ Treatment is with lifestyle management strategies aimed
➔ Pharmacotherapy includes: at adapting to or modifying the required sleep schedule.
● long-acting amphetamine-based stimulants such as ➔ Which profession usually has this circadian rhythm sleep
○ methylphenidate, and disorder? Nurses because of shifting schedules.
● non-amphetamine-based stimulants such as
○ Modafinil. DISORDERS OF AROUSAL
➔ Refers to the unusual or undesirable behaviors of sleep
NARCOLEPSY/HYPOCRETIN DEFICIENCY that occur during sleep-wake transitions or during certain
➔ Classic symptoms: stages of sleep.
● Irresistible attacks of refreshing sleep ➔ Sleepwalking (somnambulism)
● Cataplexy- brief episodes of bilateral loss of muscle ● consists of a sequence of complex behaviors that
tone with maintained consciousness. Usually begin in the first third of the night during NREM
happens along with a strong emotion such as anger, sleep and usually progress (without full
frustration, or laughter.

consciousness or later memory) to leaving the bed ● Precipitating- external factors that trigger insomnia
and walking about. ● Perpetuating- sleep practices and attributes that
➔ Polysomnography may be done to rule out the possibility maintain sleep complaints
of underlying disorder of sleep fragmentation.
➔ Treatment: APPLICATION OF NURSING PROCESS
● Instructing the patient about safety measures ASSESSMENT
● Benzodiazepines (when risk for injury is likely) ➔ Assess for sleep patterns
➔ Confusional arousals consist of mental confusion or ● Insomnia
confused behavior during or following arousal from slow ○ Do you have difficulty with falling asleep,
wave sleep but also upon attempted awakening from staying asleep, or early-morning
sleep in the morning. awakenings?
● Treatment is focused on lifestyle management and ○ Do you feel refreshed and restored in the
safety measures morning?
○ Have you noticed any problems with you
NIGHTMARE DISORDER energy, mood, concentration, or work
➔ Is characterized by long, frightening dreams from which quality as a result of your sleep problem?
people awaken scared. Occurs usually during REM sleep. ● Hypersomnia
➔ Diagnosis is by clinical evaluation. Polysomnography is ○ Obstructive sleep apnea hypopnea
sometimes done. syndrome: Have you ever been told that you
➔ Treatment includes hypnotic therapy and lifestyle snore or that it looks as if you stop
modification breathing in you sleep?
○ RLS (Restless Leg Syndrome): Do you have
RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER (RSBD) an unpleasant or uncomfortable sensation
➔ Is characterized by absence of muscle atonia during sleep in your legs that prevents you from sleeping
➔ Patients display elaborate motor activity associated with or wakes you up from sleep and makes you
dream mentation. These patients are actually acting out want to move?
their dreams. ○ Narcolepsy: Do you have episodes of
➔ Diagnosis is determined by clinical evaluation and sleepiness you cannot control? Have you
polysomnography with video recording. experienced episodes where you were
➔ Treatment focuses on patient and sleep partner safety. unable to move as you were about to fall
● Intermediate-acting benzodiazepines may be used. asleep or wake up? Unexplained muscle
weakness following a strong emotion
RESTLESS LEG SYNDROME (RLS) (cataplexy)? Have you ever seen or heard
➔ Is characterized by an unpleasant, uncomfortable something that you knew was not real as
sensation in the legs accompanied by an urge to move. you were falling asleep or waking up from
➔ Treatment includes lifestyle modification and sleep (hypnogogic hallucination)?
pharmacotherapy (dopamine agonists such as ○ Primary hypersomnia: Do you every feel
pramipexole and ropinirole). unrested even after an extended sleep
period?
SUBSTANCE-INDUCED SLEEP DISORDER ● Arousal
➔ Sleep disturbance caused by intake of substances such as: ○ Have you ever been told that you have done
● Alcohol- which decreased deep sleep anything unusual in you sleep, such as
● Nicotine- makes the patient wake in response to walking or talking?
mild withdrawal symptoms during sleep (Somnambulism/somniloquy)
● Caffeine- promotes wakefulness ○ Have you ever been told that you act out
your dreams? (REM sleep behavior
INSOMNIA DISORDER disorder)
➔ Patients with insomnia disorder report dissatisfaction ○ Have you been troubled by nightmares or
with sleep quality and report difficulty with sleep disturbing dreams?
initiation, sleep maintenance, early awakening with ● Circadian Rhythm
difficulty returning to sleep, or nonrefreshing non ○ Is your desired sleep schedule in conflict
restorative sleep with your social and vocational goals?
➔ Symptoms must be present at least 3 times per week for ○ What is your preferred sleep schedule?
a period of at least 3 months despite adequate sleep
opportunity DIAGNOSIS
➔ Insomnia is best understood as a state of constant ➔ Insomnia: A disruption in amount and quality of sleep
hyperarousal that involves biological, psychological, and that impairs function
social factors ➔ Sleep deprivation: Prolonged periods of time without
➔ 3P model of Insomnia sleep
● Predisposing- individual factors that create a ➔ Disturbed sleep pattern: Changes in sleep routines thaT
vulnerability cause impairment in social or vocational functioning

➔ Readiness for enhanced sleep: A pattern of natural,
periodic suspension of consciousness that provides
adequate rest, sustains a desired lifestyle, and can be
strengthened.z
OUTCOME IDENTIFICATION
➔ SLEEP
➔ REST
➔ RISK CONTROL
➔ PERSONAL WELL-BEING
PLANNING
➔ Role of nurse is generally to conduct full assessment,
provide support to the patient and family while the
appropriate interventions are determined, and teach the
patient and family strategies that may improve sleep.
IMPLEMENTATION
➔ Counseling
● Begins during assessment. The nurse's questions and
responses provide support to the patient and family
as well as assurance that the sleep problems are
amenable to treatment.
➔ Health Teaching and Health Promotion
● Relaxation techniques such as meditation, guided
imagery, progressive muscle relaxation,
controlled-breathing exercises.
● Modifying poor sleep habits.
➔ Pharmacological Interventions
● Provide education about the benefits of a particular
drug, the side effects, untoward effects, and the fact
that medications are usually prescribed for no more
than 2 weeks.
➔ Advanced Practice Interventions-
● Sleep hygiene - conditions and practices that
promote continuous and effective sleep
● Behavioral therapy
● Hypnotic therapy
● Cognitive-behavioral therapy for insomnia (CBT-I)
➔ Advanced Practice Interventions
● Stimulus control:
○ Go to bed only when sleepy
○ Use the bed or bedroom only for sleep and
intimacy (no TV, reading, stand-by or using your
phone)
○ Get out of bed if unable to sleep and engage in a
quiet-time activity such as reading or crossword
puzzles
○ Maintain a regular sleep/wake schedule
○ Avoid daytime napping.
EVALUATION
➔ Is based on whether or not the patient experiences
improved sleep quality as evidenced by decreased sleep
latency, fewer nighttime awakenings, a shorter time to
get back to sleep after awakening, and improvement in
daytime symptoms of sleepiness.
➔ Evaluation is accomplished through patient reports and
patient maintenance of a sleep diary.

SEXUAL DISORDERS ➔ Often a combination of psychogenic and physiologic
factors
TOPIC OUTLINE
➔ The duration of symptoms within the disorder should be
1. Sexual disorder at least 6 months to be considered dysfunctional and a
2. Sexual dysfunction disorder
a. Sexual desire Disorders
b. Sexual arousal Disordes ETIOLOGIC FACTORS
c. Orgasm Disorders
PHYSICAL/BIOLOGIC FACTORS
d. Sexual Pain Disorders
e. Paraphilias ➔ Testosterone stimulates sexual desire in males and
3. Therapeutic interventions females
➔ Stress reduce secual interest and arousal
➔ Medications:
SEXUAL DISORDER
● Antidepressants
➔ Sexual needs are basic human needs
● antiHPN and
● According to Abraham Maslow, sex belongs to the
● Hormonal ttt
base part of the triangle, the physiologic needs.
➔ Substance use disorders
➔ Sexuality is essential to the well-being of individuals and
of couples
PSYCHOLOGICAL/EMOTIONAL FACTORS
➔ Sexual activities are considered abnormal only if they are
➔ Anxiety, stress, depression
directed toward anyone or anything other than
➔ Positive and negative perception of one’s own body
consenting adults or are performed under unusual
image affect sexual interest and function.
circumstances
➔ Phases of human sexual activity:
CULTURAL FACTORS
1. Phase 1: Desire
➔ Sexual myths influence attitudes towards sex
○ Characterized by: sexual fantasies and desire to
● Myth: dili mangihi after sexual encounter
have sexual activity.
➔ Many religions place restrictions on sexual behavior that
2. Phase 2: Excitement
is other than procreative; however many religions
○ Combination of stimulation
advocate for a happy and vital sexual relationship, albeit
○ Physiologic signs and symptoms: penile
generally inside the context of marriage.
erection, vaginal lubrication.
● Ang uban religions, they want to really encourage
○ Usually lasts several minutes to hours
couples to get married first before having or
3. Phase 3: Orgasm
engaging in sexual activity. And other religions they
○ There is already peaking of sexual pleasure with
wanted that after marriage, immediately mag
release of sexual tension and the rhythmic
consummate.
contraction of perineal muscle and pelvic
reproductive organs
RELATIONAL FACTORS
○ Usually lasts 3-15 seconds
➔ Problems within the relationships: finances and family
4. Phase 4: Resolution
stress
○ There is disgorgement of blood in the genitalia
➔ Couples often have poor and ineffective communication
which brings the body back from the resting
regarding their sexual likes and dislikes- kaning mga
state
couples pud usahay gyud they need to be open in
○ If orgasm occurs, resolution is rapid and is
communication with their boyfriend, girlfriend, live-in
characterized by subjective sense of
partner, wife or husband about the things that they like
well-being->general relaxation and muscular
especially in their intimate moments dapat kung mu
relaxation. Usually kapoyon inig kahuman
ingon ang girl na “I’m not comfortable in this position.
○ If no orgasm, resolution may take 2-6 hours
Can we just try another position” or “I’m not in the mood
and may be associated with irritability and
of doing, it can we just sleep tonight and do it again
discomfort
sometime where we both are relaxed and in the mood”
○ Refractory period: in men, in which they can’t
Dapat open communication is key.
be stimulated any further to orgasm. So it takes
➔ Differences in sexual drives and interest complicate their
much longer time for them to be stimulated
interest- Basin ag sexual drive ni mister dili mao ag sexual
once again.
drive ni misis. Dapat congruent sila duha. Dapat
➔ DSM 5 Categories:
congruent.
1. Sexual dysfunctions
➔ Couples often do not discuss what they do/ do not enjoy
2. Paraphilias
sexually or share their feelings about the experience- It is
3. Gender Dysphoria
also healthy among couples, among husband and wife to
talk about the experience after they have done it. “I feel
SEXUAL DYSFUNCTIONS
good about doing this because of this and that.” “I do not
➔ Inhibition or interference with the desire, excitement,
feel good because you keep doing this when I am
orgasm, or resolution phases of the sexual response cycle
uncomfortable and I kept on saying to stop it but you
➔ Can be lifelong or acquired

didn't listen, you kept doing it and it hurt me.” So dapat D. Sexual Pain Disorders (Dyspareunia)
communication gyud noh, communication is really key. ➔ Genito-pelvic pain / Penetration disorder -experience
pain or anticipate pain with vaginal penetration-wala pa
TYPES gali naka penetrate ang male, nag anticipate na siya na
A. Sexual Desire Disorders sakit mao na nga kuan siya it’s more inclined on painful
➔ Deficient, absent or extreme aversion to and avoidance sensations
of sexual activity- Avoidance- mag likay or dili siya ➔ Vaginismus- involuntary muscle constriction of the outer
ganahan or wala jud siyay interest about sexual activity 3rd of the vagina that interferes with penile insertion and
● Male Hypoactive Sexual Desire Disorder- have little intercourse- so mao kuno ni ang chika before about John
or no response in sexual fantasies or activities and Lloyd Cruz ug Shainah kay ni constrict or nag muscle
have hypoactive sexual desires- no matter gi unsa constriction na kuno ag vagina wala na mi release ag
siya pag tempt or flirt sa babay, the male has penis. Because it does happen in real life. What was
hypoactive sexual desire so wala siyay any interest in passed down to us was there was a farmer mga
doing or engaging in such activity. mountainous area. Didto sil nag sex sa iya mistress.
Because Vaginismus also happens in extreme anxiety.
B. Sexual Arousal Disorders Grabe kaayo nimo ug kabalaka. Ug dili nimo partner
➔ Partial or complete failure to achieve a physiologic or grabe ka ka stress or hypervigilant kaayo ka sa imong
psychologic (subjective) response to sexual activity surroundings ug naay maka kita ninyo. So kaning babay
● Erectile Disorder- cannot obtain/ maintain an pwede kaayo ni siya magka Vaginismus under these
erection sufficient for sexual activity- How can the circumstances. So kadto nga couple na nag intercourse in
penis penetrate the vaginal canal if in the very first a kubo in the middle of the field kanang rice field so naa
place, it is not erect, so dili kaayo siya ka sulod sa silay sexual encounter adto and later on wala na sila ka
vaginal canal and penetrate itself. separate. So they had to shout and get help and to be
● Female Sexual Interest/ Arousal Disorder-have little transported to the nearest hospital to be injected with a
or no response in sexual fantasies or activities- it muscle relaxant. The cause kuno adto kay vaginismus.
used to be sexsual desire disorder however naa nay
mga studied and upgrades. Sometimes we cannot THERAPEUTIC INTERVENTIONS
really delineate sexual desire from sexual arousal ➔ First, treat underlying physiologic cause if present-
really so pwede ra na siya Female Sexual Interest/ Example if ang cause sa atong erectile dysfunction kay
Arousal Disorder can be under desire or arousal. chainsmoking kay, of course, we have to treat that we do
-Mura ni siyag opposite sa Male Hypoactive Sexual not give medications immediately. Because what if it can
Desire Disorder kani pang laki, kani karon pang baye. be treated without medications. It can just be treated
with abstinence or reduction of smoking
C. Orgasm Disorders ➔ Psychologic-based interventions: sexual counseling for
➔ Delay in or absence of orgasm, premature ejaculation- client and partner
● Ejaculation Disorder ➔ To develop arousal response and orgasmic capacity, sex
○ Delayed Ejaculation therapists may teach their clients masturbatory training
○ Premature Ejaculation: a man reaches orgasm exercises- so if it is already out of our scopes as nurses we
within 1 minute of vaginal penetration and can always refer and tap our multi-disciplinary healthcare
before he wishes it, frustrating both himself and team. Such as our sex therapists. We can ask help from
his partner- pwede 1 minute or less mi ejaculate them through referral to improve arousal response and
the dayon ang male or bisan unta dili pa siya orgasmic capacity of our patient.
gusto mu ejaculate siya there is premature ➔ Relation-based interventions -what if it is not really
ejaculation which can be very frustrating to both about erectile dysfunction or female disorders, it's just
partners the male and the female or even for the really about the relationships. If there is infidelity,
male. Usahay mu ingon siya “Okay, I'm not as unfaithfulness, or close communication so fix that first
effective as a man can be because I have before going further. Assist client with enhancing
reached ejaculation before a minute or less, mu self-esteem related to sexuality, encourage positive
affect sad na sa iyang self-concept. self-talk and affirmations and body image exercises
● Female Orgasmic Disorders- delay or absence of ➔ Vacuum constriction device for males for treatment of
orgasm & a reduction in the intensity of orgasmic impotence- there are a lot of devices under it but this is
sensations- Simply, gamay iyang sense of pleasure the general term.
after reaching the orgasm phase. Dili kaayo ingon ➔ Pharmacologic Therapy
nga when we reach orgasim phase naa man tay ● Sildenafil, Tadalafil, Alprostadil for erectile
gitawag na climax noh? Wala ka reach ana ang dysfunction (Viagra & Cialis)
female because there is a delay or absence or even ● Anxiolytics for ttt vaginismus, basically vaginismus is
reduced iyang intensity or iyang sensation diha na grounded on anxiety and stress
stage. ● Genital Pain Disorders: Topical lidocaine and
Gabapentin
➔ Hormonal Treatments

● Exogenous testosterone to improve male sexual 10. Teach how to support/ promoter erection. Teach side
desire and possibly sexual function in general effects of erectile agents.
● Testosterone replacement for women ( Less sexual 11. Teach couples to schedule their sexual experiences for
desire/ arousal for women) manually agreed upon times. (Not appropriate time if
➔ Surgical Interventions one is anxious, tired, stressed, and not in the mood or has
- Semi Rigid or inflatable penile prosthesis ( For male a lot of problems.)
who has impotence. It is up to the patient if he wants
semi rigid or inflatable penile prosthesis) E. Paraphilias
➔ Intense and persistent sexual interest in anything other
Principles of Sexual Asessment than a physically normal and mature consenting adults,
We have to focus and give emphasis on how to assess and the may be directed toward an abnormal activity or target.
proper way to assess it because sexual assessment is not The target can be inanimate objects. The target may not
trivial. We have to dig deeper if the problem really lies on the be human beings. As well as non-inanimate objects.
sexual pattern of the patient. ➔ To be considered a paraphilic disorder, a paraphilia must
1. Examine your own feelings, attitudes, and level of have a negative consequences, such as distress or
understanding and comfort before beginning impaired functioning, or harm to client or others
assessment. ( If you yourself as a nurse are not very much ➔ Recurrent or intense behavior that continues for at least
comfortable in doing the assessment because you have 6 months. Kaning mga paraphilia’s class pwede sad ni
preconceived notions, any biases, or recent experiences siya na directed to non-human objects and it can also be
before your duty then might as well not engage yourself any infliction of pain to self or partner, children or any
in the assessment. You can delegate the task to other non-consenting individuals.
nurses. It is really important to assess yourself before ➔ Exhibitionistic Behavior
examining others. ● Recurrent, intense sexually arousing fantasies, urges or
2. Ensure private and quiet space, ample time, and behaviors involving exposing one's genitals to
unhurried attitude for the assessment. (This is unsuspecting strangers.
something sensitive so we need to set a conducive ● So ma arouse ang certain individual if magpakita sha
environment for you and the patient to talk privately and saiyaang genitals. This is most commonly found among
to have a quiet space for the patient to express his/ her males. Sa Ramos one time, personal experience a long
sexual needs and sexual problems.) sa china bank, I saw a red car (it’s a good thing I was
3. Do not ask questions about sexuality first ( Be sensitive walking with my friends) clear ang tint ato nga car,
and slow with your assessment. Ask for general when we walked pass sa China bank, nag park lang
information first to get general ideas.) siya didto. Intentionally nag move siya or make
4. Begin questioning about sexuality with the least anything to catch our attention, when we looked at him
sensitive areas, and then move to areas of greater through the window sa passenger seat, mao to nag
sensitivity.( Start with , “Sir, kanusa man nahitabo na start siyag masturbate, then after na kuyawan na
nakahibaw ka sa pakig hilawas?”) dayon mi. Then later naka realize nami that he was an
5. Open and nonjudgmental attitude. Be professional and a exhibitionist. It’s not only when it’s face to face but it
matter-of-fact about information that is asked or can be cyber sex.
obtained. ➔ Fetishistic Disorder
6. Maintain eye contact and a relaxed and interested ● Recurrent, intense sexually arousing fantasies, urges or
manner. (Eye contact is important because it ensures behaviors using non-sexual or nonliving objects. So
trust and that the patient can lean to you on private example, ma arouse and individual maka kita sa
matters. Intimacy, relationships, and sexual topics are sapatos nga size nine or shiny black shoes nga shoes.
private. Let's give them the impression that we are the ● Partialism: refers to fetishes specifically involving
‘uban tao’ that can help them solve problems.) nonsexual parts of the body. Makakita kag finger/ hand
7. Use language that is professional that will be nga ugaton kaayo murag ma arouse na ang person
understood by the client being interviewed. (Always ana. For a person with fetishistic disorder ma arouse
make sure to use professional words, engage in sentences rajud sha maka kita ug arm or elbow or even ankle.
that you will be regarded as professional. Do not say ➔ Frotteuristic Disorder
words such as ‘gibirahan, gi torjak’. This is the most ● Recurrent, intense sexually arousing fantasies, urges or
significant time where you can inject appropriate sexual behaviors involving touching and rubbing against a
terms and words, especially in children. Remind children nonconsenting person. Naa gyud tay mga legal basis
to use the exact terms. Term in it as ‘penis’ ‘vagina’ ani, kaning pataka lang ug hikap or pang rub sa
Example: Abused female child (Children still have buko-buko, arms or wherever the patient does not or
difficulty with thought processes where they can the person being rubbed off does not consent. So of
misinterpret ‘flower’ as a generalized term.) course it needs consent.
Nurse: “Gihikap imong flower?” ➔ Pedophilic Disorder
8. Tone of voice and manners reflect trust. ● Recurrent, intense sexually arousing fantasies, urges or
9. Accept that the problem is real to the client regardless behaviors that involve sexual activity with a child or
of age. children generally 13 yo or younger.

● The person is at least 16 yo and at least 5 years older
than the child or children involved. GENERAL NURSING CARE OF CLIENTS WITH SEXUAL AND
➔ Sexual Masochism Disorder GENDER DYSPHORIA DISORDERS
● Recurrent, intensc scxually arousing fantasics, urges or ➔ Reflect on own sexual values and customs
behaviors involving the act of being humiliated, beaten, ➔ Accept an individual as a person in emotional pain
restrained, or otherwise made to suffer. Ma arouse siya ➔ Create a safe, nonjudgmental environment that permits
kung ipa suffer or ipa-sakitan. open communication
➔ Sexual Sadism Disorder ➔ Begin with a less sensitive topic and move gradually to
● Recurrent, intense sexually arousing fantasies, urges or more personal issues
behaviors involving acts in which the psychological or ➔ Avoid punitive or judgmental remarks or responses;
physical suffering of the victim is sexually exciting to maintain a matter-of-fact manner
the person. 50 shades of grey. If maka cause siyag pain ➔ Provide for privacy and protect individual from others
saiya partner diha siya ma arouse kung mang sakit ➔ Set limits on sexual acting out behavior
siya. Ang masochistic kay diha siya ma arouse kung ➔ Report suspected child or elder abuse to appropriate
masakitan siya, maka feel siyag pain. protective service agencies
➔ Transvestic Disorder
● Recurrent, intense sexually arousing fantasies, urges or PSYCHOTHERAPEUTIC MANAGEMENT
behaviors involving cross-dressing or dressing as the Nurse-Patient Relationship
opposite sex. ➔ For victims of perpetrator nurses deal with:
➔ Voyeuristic Disorder ● Physical dimensions: anorexia, insomnia, and weight
● Act of observing an unsuspecting person who is naked, loss
in the process of disrobing, or engaging in sexual ● Emotional dimensions: guilt, helplessness, shame
activity. and relief about getting caught
➔ Incest ➔ Appropriate collaboration with other health team
● Is pedophilia with child and adolescent relatives and members: social workers and chaplains
involves relationships by blood marriage (stepparents) ➔ Nurses are legally obligated to report suspected and
or live-in partners. actual cases of abuse
Other paraphilias not otherwise specified: Psychopharmacology

➔ Telephone scatalogia- obscene phone call; sexting ➔ Antiandrogen medication- to lower testosterone levels of
➔ Necrophilia- sexual pleasures involving corpses men with paraphilia
➔ Zoophilia- sexual pleasures involving animals (having sex ➔ Medroxyprogesterone (Provera) and Leuprolide acetate
with animals) (LPA, Lupron)- decrease LH therefore decrease
➔ Coprophilia- sexual pleasures involving fecal matter testosterone
➔ Klismaphilia- sexual pleasures involving enemas (Concept ➔ SSRIs
of enema where they love the sensation of their rectums
being filled with liquid) Milieu Management
➔ Urophilia- sexual pleasures involving urine ➔ Self-esteem, assertiveness, anger management, social
relationship skills, sex education, stress mangagement
GENDER DYSPHORIA ➔ Self-help groups: sex-addicts anonymous
➔ Strong, persistent preference for living as a person of the ➔ CBT
opposite sex
➔ In adults involves feelings of incongruence between one’s
assigned or biologic sex and one’s gender identity
➔ Preoccupation of getting rid of the primary and
secondary sex characteristics
➔ Might desire hormones and surgery to become opposite
gender
➔ Sexual identity- refers to the biological indicators of
male and female such as sex chromosomes, sex
hormones, and genetalia
➔ Gender- refers to a lived role in public of either a man or
a woman
➔ Gender identity- refers to how an individual identifies
himself or herself as male or female and is a facet of
social identity
➔ Sexual Orientation- described the object of a person’s
sexual impulses
● Heterosexual (opposite sex), homosexual (same sex),
bisexual (both sexes)

WEEK 10.A: ANXIETY AND ANXIETY DISORDERS • Unpredictability is key aspect of panic disorder in children and
ANXIETY adolescents.
• Is a universal human experience and is the most basic of 3. Agoraphobia
emotions • Is intense, excessive anxiety or fear about being in places or
• It can be defined as the feeling of apprehension, uneasiness, situations from which escape might be difficult or embarrassing
uncertainty, or dread resulting from a real or perceived threat. or in which help might not be available
• Fear is a reaction to a specific danger, whereas anxiety is a vague • The feared places are avoided in an effort to control anxiety
sense of dread related to an unspecified or unknown danger. • Example situations that are commonly avoided by patients with
LEVELS OF ANXIETY agoraphobia:
1. Mild Anxiety o Being alone at home, travelling in a car/ bus, plane
• Occurs in the normal experience of everyday living and allows an o Being on a bridge
individual to perceive reality in sharp focus. o Riding an elevator
2. Moderate Anxiety • These situations can be made tolerable with an addition of a
• The person sees, hears, and grasps less information and may friend.
demonstrate selective inattention, in which only certain things • Avoidance behaviors can be debilitating considering the effect
in the environment are seen or heard unless they are pointed because agoraphobia renders them unable to be at home and
out. prevents them from social interactions.
• Ability to think is hampered but learning and problems solving 4. Specific phobia
can still take place although not an optimal level. • Is a persistent, irrational fear of a specific object, activity, or
3. Severe anxiety situation that leads to a desire for avoidance, or actual avoidance
• Focuses on one particular detail or many scattered details and of the object, activity or situation.
have difficulty noticing what is going on in the environment, Common phobias
even when another points it out. Acrophobia Heights
• Learning and problem solving are not possible at this level. Agoraphobia Open spaces
4. Panic Claustrophobia Closed spaces
• It is the most extreme level of anxiety, with marked disturbed Hematophobia Blood
behavior, unable to process what is going on in the environment Hydrophobia Water
and may lose touch with reality. Nyctophobia Dark
• Behaviors in this level include pacing, running, shouting, Pyrophobia Fire
screaming, or withdrawal Xenophobia Strangers
Defenses against Anxiety 5. Social anxiety disorder
• Defense mechanisms are automatic coping styles that protect • Also called social phobias, is characterized by severe anxiety or
people from anxiety and maintain self-image by blocking fear provoked by exposure to a social or a performance situation
feelings, conflicts, and memories. that could be evaluated negatively by others.
• Adaptive use of defense mechanisms helps people lower anxiety • People with social phobias avoid social situations.
to achieve goals in acceptable ways, maladaptive use of defense • Small children with this disorder may be mute, nervous, or hide
mechanisms occurs when one or several are used in excess, behind their parents.
particularly in the overuse of immature defenses. • Older children may be paralyzed by fear of speaking in class or
interacting with other children. They worry of saying the wrong
ANXIETY DISORDERS thing or being criticized.
1. Separation anxiety disorder
• Younger people may act out to compensate for this fear, making
• Separation anxiety is a normal part of infant development; it an accurate diagnosis more clear.
begins around 8 months of age, peaks around 18 months, and
• This anxiety results to physical complaints to avoid social
begins to decline after that.
situations, particularly school.
• People with separation anxiety disorder exhibit developmentally
• Fear of public speaking – Most common manifestation of social
inappropriate levels of concern over being away from a
anxiety disorder.
significant other.
• Even singers and actors have stage fright
• There may also be fear that something terrible will happen to the
6. Generalized Anxiety Disorder
other person and that it will result in permanent separation.
• The key pathological feature of generalized anxiety disorder is
• Adult separation anxiety disorder includes characteristics such
excessive worry.
as:
• Persons with generalized anxiety disorder anticipate disaster
o Harm avoidance
and are restless, irritable, and experience muscle tension.
o Worry
• Decision making is difficult due to poor concentration and dread
o Shyness
of making a mistake.
o Uncertainty
• Common worries:
o Fatigability
o Inadequacy in interpersonal relationship
o Lack of self-direction
o Job responsibilities
2. Panic disorder
o Finances
• Panic attacks are the key feature of this disorder, it is a sudden
o Health of family members
onset of extreme apprehension or fear, usually associated with
• These worries use a lot of time spent in preparing for things.
feelings of impending doom.
• Putting things off avoidance of these may result to lateness of
• Normal functioning is usually suspended, the perceptual field is
absence in school or employment, and overall social isolation.
severely limited, and misinterpretation of reality may occur.
1
• Sleep disturbance is common because an individual worries • Is a persistent pattern of behavior in which the rights of others
about the day’s events and feel more imagined mistakes for are violated, and societal norms or rules are disregarded.
these problems. • Behavior is usually abnormally aggressive and can be frequently
Other Anxiety Disorders led to destruction of property or physical injury.
Substance-induced Anxiety disorder • Persons with this disorder initiate physical fights and bully
• Is characterized by symptoms of anxiety, panic attacks, others, and they may steal or use a weapon to intimidate or hurt
obsessions and compulsions that develop with the use of a others.
substance (e.g. alcohol, cocaine, heroin, hallucinogens) • Coercion into activity against the will of others, including sexual
Anxiety due to a medical condition activity, is characteristic of this disorder. These behaviors are
*NURSING PROCESS for anxiety is the same with OCD. enduring patterns and continue over a period of 6 months and
beyond.
10.B: IMPULSE CONTROL DISORDERS • People affected by this disorder may have a normal intelligence,
• People with impulse control disorders seem like children whose but they tend to skip a class or disrupt school so much that they
parents cannot control them or adults who simply do not choose fall behind and may be expelled or drop out.
to control their behavior. Complications:
• Impulsive and exhibit aggressive behaviors and emotions. • Complications associated with conduct disorder include:
• Problems relating to others in socially acceptable ways result in o Academic failure
a lack of healthy relationships, leaving the individual isolated and o School suspensions and dropouts
the family devastated. o Juvenile delinquency
Risk Factors: o Drug and alcohol abuse and dependency
• Genetics o Juvenile court involvement
• Neurobiological – gray matter is less dense in the left prefrontal • In adults, characteristics include:
cortex in young patients with oppositional defiant disorder. o Aggression
• Psychological o Destruction of property
• Environmental o Stealing
OPPOSITIONAL DEFIANT DISORDER o Deceitfulness
• Is a primarily childhood disorder, characterized by a repeated o Criminal behavior
and persistent pattern of having an angry and vindictive o Family problems – very common in this disorder
behavior. • Two subtypes:
• Angry mood can manifest as losing one’s temper or becoming o Child-onset
easily annoyed by others. o Adolescent onset
• A defiant behavior can be demonstrated through arguing with Both can occur in mild, moderate, or severe forms
adults and refusing to comply with adults’ requests or rules. • Predisposing factors include:
• Vindictiveness is defined as spiteful, malicious behavior and a o ADHD
particularly chilling aspect of this disorder. This quality increases o Oppositional child behaviors
the chances that revenge will be sought in response to real or o Parental rejection
imagined slights. o Inconsistent parenting with harsh discipline
• People with this disorder shows a pattern of deliberately o Early institutional living
annoying people and blaming others for his or her mistakes or o Chaotic home life
misbehavior. o Large family size – can cause or lead to parental rejection
• This disorder impairs the child’s entire life and make it extremely or lesser time to involve with their children
difficult for him or her to attend school, to have friends, or be a o Absent or alcoholic father
functioning member of the family. o Antisocial and drug-dependent family members
• Is often predictive of emotional disorders in young adulthood. o Association with delinquent peers
INTERMITTENT EXPLOSIVE DISORDER • Childhood onset conduct disorder
• Is a pattern of behavioral outbursts in adults 18 years and older o Occurs prior to age 10 years old and is found mainly in
characterized by an inability to control aggressive impulses males who are physically aggressive, have poor peer
• The aggression can be verbal or physical and targeted toward relationships, show little concern for others and lack
other persons, animals, property, or even themselves. feelings of guilt or remorse.
o Hallmarks of these disorder include limited frustrations
• The pattern usually goes from being upset to being remorseful.
tolerance, irritability, and temper outbursts.
o Tension and arousal based on some environmental stimuli
– you were driving and a motorcycle cuts you off • Adolescent onset conduct disorder
o Explosive behavior – because you got cut off, you try to o No symptoms are present prior to age 10
overtake the motorcycle and chase him o Male to female ratio is not as high as for the childhood-
o Experience a sense of relief – since you chased him, you onset type, including more girls become aggressive during
caught up to him this period of development
o Feelings of remorse, regret, and embarrassment over the • There is a subset of people with conduct disorder who are also
aggressive behavior. – you realized “why did I do that, it’s referred to as being callous and unemotional.
not worth it” o Callousness is characterized by a lack of empathy, such as
• This disorder can impede on a person’s functioning by leading to disregarding and being unconcerned about the feeling of
problems with interpersonal relationships and occupational others, having a lack of remorse or guilt except when
difficulties and can lead to criminal problems as well. facing punishment, and being unconcerned about meeting
CONDUCT DISORDER school and family obligations.
2
o Unemotional traits include a shallow, unexpressive and SIGNS AND SYMPTOMS, NURSING DIAGNOSES, OUTCOMES
superficial affect. S/S DIAGNOSIS OUTCOME
• Two disorders related to impulse control disorders: Hx of suicide attempts, Risk for suicide • Refrains from
o Pyromania – repeated deliberate fire setting. The person aggression and • Expresses suicide attempts
experiences pleasure or relief when setting a fire. impulsivity, conflictual feelings • Plans for the
o Kleptomania - repeated failure to resist urges to steal interpersonal • Verbalizes future
objects not needed for personal use or monetary value. relationships; suicidal
APPLICATION OF THE NURSING PROCESS states “If I have to stay ideas
ASSESSMENT here, I’m going to kill
• Assess for suicide risk: myself.”
o Past suicidal thoughts, threats or attempts Body posture rigid, Risk for other- • Identifies
o Existence of a plan, lethality of the plan, and accessibility clenches fists and jaw, directed harmful
of the methods for carrying out the plan paces, invades the violence impulsive
o Feelings of hopelessness, changes in level of energy personal space of behaviors
o Circumstances, state of mind, and motivation others, history of • Controls
o Viewpoints about suicide and death cruelty to animals, impulses
o Depression and other moods or feelings frequent fights, history • Refrains from
o History of impulsivity, poor judgement, or decreased of childhood abuse and aggressive acts
decision making witnessed family • Identifies social
o Drug or alcohol use violence; states “That support
o Prescribed medication and any recent adherence issues wimp of a roommate
o An assessment of protective factors and coping skills better stay out of my
• Oppositional Defiant Disorder way.”
o Identify issues that result in power struggles and triggers Hostile laughter, Defensive • Identifies
for outbursts projects responsibility coping r/t ineffective and
o Assess the child’s or adolescent’s view of his/her behavior for behavior onto impulse- effective coping
and its impact on others others, grandiosity, control • Identifies and
o Explore how the child or adolescent can exercise control difficulty establishing problems uses support
and take responsibility, problem solve for situations that relationships system
occur and plan to handle things differently in the future. • Uses new coping
▪ Assess barriers and motivation to change and strategies
potential rewards to engage patient Rejection of child or Impaired • Parent/caregiver
• Intermittent Explosive Disorder hostility toward the parenting participates in
o Assess the history, frequency, and triggers for violent child; unsafe home the therapeutic
outburst environment, abusive program
o Identify times in which the patient was able to maintain and/or neglectful; • Learns
control despite being in a situation in which the patient disturbed relationship appropriate
might normally lose control of emotions between parenting skills
o Explore actual and potential sources of support at home parent/caregiver and
and socially the child
o Assess for substance use (past and present)
• Conduct Disorder IMPLEMENTATION
o Assess the seriousness, types, and initiation of disruptive General interventions include:
behavior and how it has been managed • Promote a climate of safety for the patient and for others
o Assess anxiety, aggression and anger levels, motivation, • Establish a rapport with the patient
and the ability to control impulses • Set limits and expectations
o Assess moral development, problem solving, belief • Consistently follow through with consequences of rule-breaking
system, and spirituality for the ability to understand the • Provide structure and boundaries
impact of hurtful behavior on others, to empathize with
• Provide activities and opportunities for achievement of goals to
others, and to feel remorse
promote a sense of purpose
o Assess the ability to form a therapeutic relationship and
Pharmacological interventions
engage in honest and committed therapeutic work leading
Intermittent explosive • fluoxetine (Prozac),
to observable behavioral change
disorder • lithium,
o Assess for substance use (past and present)
• clozapine (Clozaril),
• and haloperidol (Haldol)
Conduct disorder • risperidone (Risperidol),
• olanzapine,
• Seroquel,
• and ziprasidone
*Take note that antianxiety medications must be avoided since they
reduce inhibitions and self-control
3
Health teaching and health promotion EVALUATION
• Explore the impact of the child’s behaviors on family life and of • Patients on in patient units demonstrate increased levels of self-
the other member’s behavior on the child regulation and ability to interact appropriately with others
• Assist the immediate and extended family to access available • In outpatient and community setting, patients will progress
and supportive individuals and systems incrementally from aggressive and impulsive behavior and move
• Discuss how to make home a safe environment, especially in on to considering the rights of others and behaviors that are in
regard to weapons and drugs, attempt to talk separately to control
members whenever possible
• Discuss realistic behavioral goals and how to set them; problem 11.A: OCD
solve potential problems 1. Obsessive-Compulsive Disorders
• Teach behavior modification techniques • Characterized by the presence of obsessions or compulsions or
• Give support and encouragements as parents learn to apply new both
techniques • OBSESSION: recurrent and persistent thoughts, ideas, impulses,
• Provide education about medications or images that are experienced as intrusive and unwanted;
• Refer parents or caregivers to a local self-help group • COMPULSIONS: or rituals; are repetitive behaviors or mental
• Advocate with the educational system if special education acts the individual feels driven to perform such as washing
services are needed hands, checking, counting, or repeating words. The aim is to
Advanced Practice Interventions reduce the anxiety triggered by the obsessions.
• Overall goal is to help patients maintain control of their thoughts • Obsession is basically the things going about inside your mind; in
and behaviors; and assist families to function more adaptively order to relieve and express it, the individual needs to act
o Cognitive behavioral therapy – a talk therapy that focuses something out to reduce their anxiety towards intrusive and
on a patient’s feelings, thoughts, and behaviors unwanted thoughts
o Psychodynamic Psychotherapy – focuses on underlying o Ex. Frequently washing of hands – they do this to comply
feelings and motivations and explores conscious and with their obsessions because it keeps on disturbing them
unconscious thought processes if they don’t address it
o Dialectical behavioral therapy – a specific kind of CBT that o The problem is they keep on repeating the actions (cycle)
has a focus on impulse control even though they have already addressed their obsessions
o Parent-child interaction therapy – advanced practice nurses through the compulsions
sit behind one-way mirrors and coach parents through an • It can significantly interfere with the patient’s normal routine
ear audio device while they interact with their children and so time-consuming that they interfere with occupational
▪ Suggest strategies that reinforce positive behavior in and social functioning.
the child or adolescent
o Parent management training
▪ Is an evidence-based treatment for children aged 2-14
with mild to severe behavioral problems
▪ Parents of children with oppositional defiant disorder
and conduct disorder tend to engage in patterns of
negative interactions, ineffective harsh punishments,
emotionally charged command and comments, and
poor modeling of appropriate behaviors
▪ This treatment targets the parents rather that the child
and focuses attention on reinforcement of positive
and prosocial behavior, and on brief, negative
consequences of bad behavior.
o Multisystemic therapy
▪ Most extensive type
▪ Is an intensive family and community-based program
that takes into consideration all of the environments
of violent juvenile offenders
o Seclusion and Restraint – whenever necessary
o Teamwork and safety
▪ Using nonthreatening body posture and a flat neutral
• The obsession of the valet is classifying things by color – if he
tone of voice
leaves the car park the way it was (top photo), it is something
▪ Using matter-of-fact, easy to understand words
that will constantly disturb him and cause anxiety
▪ Avoid personal terms such as I and you, when setting
a limit
▪ Consistently setting limits
4
• OCD with washing of hands – they think that there are germs, • Reinforce and recognize positive nonritualistic behaviors – to let
bacteria, or any microorganisms in their hands. Having those them forget of their rituals
thoughts in their mind, they keep on washing their hands despite Psychopharmacology
already having dry skin from it • SSRIs such as Fluoxetine (Prozac), Sertraline (Zoloft),
2. Body Dysmorphic Disorder Fluvoxamine (Luvox), and Paroxetine (Paxil) are effective in
• Characterized by a preoccupation with perceived flaws in one’s treating OCD
physical appearance that are not noticeable to others • Higher ttt dosage of SSRIs than patients with depression
o So conscious with their appearance • Response usually occurs at 2-4 weeks
• The perceived thoughts leads the individual to feel ugly,
unattractive, abnormal, or deformed Milieu Management
• Repeated behaviors (e.g. checking the mirror, excessive surgery, • Relaxation exercises, stress management, recreational or social
or even excessive makeup) in response to their concerns skills, CBT, problem solving, and communication or assertiveness
• Preoccupations are intrusive, unwanted and difficult to control training groups – decrease anxiety
3. Hoarding Disorder • CBT: technique called “thought stopping” can also be used
• Characterized by persistent difficulties parting with possessions, o When an intrusive thought occurs, the px says “stop” and
regardless of their actual value snaps a rubber band on the wrist or substitutes an adaptive
• Difficulty is due to the stress associated with discarding, selling, behavior, such as deep breathing for the ritual
recycling, or throwing them away
• Results in accumulation of possessions that congest and clutter 11.B: TRAUMA, STRESSOR-RELATED AND DISSOCIATIVE DISORDERS
living areas • Traumatic events are associated with a wide range of psychiatric
o To the point that they will have a hard time occupying their and other medical disorders.
own house; they will lie in fetal position to make room for • Are not always as extraordinary as war and may be as common
their other belongings as interpersonal trauma, sexual abuse, physical abuse, severe
• The main motivation for hoarding is related to the perceived neglect, emotional abuse, repeated abandonment or sudden
value of the items or strong sentimental attachment to them and traumatic loss.
(American Psychiatric Association, 2013). A. Trauma-Related Disorders in Children: PTSD in Children
4. Trichotillomania (Hair Pulling) • May manifest in preschool children as reduction in play,
• Characterized by recurrent pulling out of one’s hair, resulting in repetitive play that includes aspects of the
hair loss in various regions of the body (scalp, eyebrows, eyelids, traumatic event, social withdrawal, and
axillary, facial, pubic). Through the use of tweezers or bare hands negative emotions such as fear, guilt, anger,
• Repeated attempts are unsuccessful leading to significant horror, sadness, shame or confusion.
distress such as embarrassment, feeling of loss of control and • Often there is irritability, aggressive or self-destructive behavior,
shame sleep disturbances, problems concentrating and hypervigilance.
5. Excoriation • Children may also suffer relationship trauma from a grossly
• Characterized by recurrent picking at inadequate caregiving environment which results to:
one’s own skin, resulting in skin lesions o Reactive Attachment Disorder (Severely emotional
(face, arms, and hands) inhibition)
o Conscious picking of one’s own o Disinhibited Social Engagement Disorder
healthy skin, acne scars, warts, or (indiscriminately social behaviors)
skin tags 1. Reactive Attachment Disorder
• Preceded by feeling of boredom or anxiety and results in sense • Children suffering this have a constant pattern of inhibited,
of relief, pleasure or gratification emotionally withdrawn behavior, and the child rarely directs
• Target areas are healthy skin, pimples, calluses, scabs, cuticles, attachment behaviors toward any adult caregivers.
or lesions • Is caused by a lack of bonding experiences with a primary
PSYCHOTHERAPEUTIC MANAGEMENT caregiver by the age of 8 months.
Nurse-Patient Relationship 2. Disinhibited Social Engagement Disorder
• The nurse focuses on teaching and helping patients develop • Children demonstrate no normal fear of strangers, seem unfazed
adaptive coping behaviors to deal with anxiety – plan of care is in response to separation from a primary caregiver.
structured • Usually willing to go off with people who are unknown to them.
• Patients need to learn to substitute positive, anxiety-reducing Assessment:
behaviors for obsessions and rituals • Is an ongoing process throughout treatment
• Reinforce nonritualistic behaviors • Methods of collecting data include interviewing, screening,
o Substitute other behaviors so they won’t have to do their testing (neurological, psychological, intelligence), observing and
compulsions (washing of hands, picking of skin) to minimize interacting with the child or adolescent.
ritualistic behaviors • Observation-interaction part of mental health assessment
• Ensure basic needs of food, rest, and grooming are met begins with a semi-structured interview in which the nurse ask
• Provide patients with time to perform rituals (but always limit) the young person about the home environment, parents, and
• Explain expectations, routine, and changes siblings; and about the school environment, teachers and peers.
• Be empathetic towards patients and be aware of their need to • Play activities such as games, drawings, and puppets are used for
perform rituals younger children who cannot respond to direct approach.
• Assist patients with connecting behaviors and feelings • Initial interview is key to observing interactions among the child,
• Structure simple activities, games, and tasks for patients caregiver, and siblings (if available) and to building trust and
rapport.
5
• Essential symptom assessment data • Involve the parents or appropriate caretakers in 1:1s unless they
o Uncontrollable rage are the cause of the trauma
o Somatic symptoms such as headache, or stomachaches • Assist parents in resolving their own emotional distress about
o Nightmares, night terrors, traumatic reenactments the trauma.
o Difficulty concentrating • Coordinate with social work for protections as indicated.
o Forgetfulness Interventions (Advanced Practice)
• Developmental assessment should also be done to provide • Cognitive – Behavioral Therapy
information about the child or adolescent’s maturational level. o Psychoeducation
o Behavior modification
o Cognitive therapy
Diagnosis o Exposure therapy
Risk for Impaired Parent/Child Attachment o Stress management
• It is defined as the risk for disruption of the interactive process • Eye Movement Desensitization Reprocessing
between the parent or significant other and child that fosters the o Process traumatic memories through a specific eight -
development of a protective and nurture reciprocal relationship. phase protocol that allows the person to think about the
It is usually related to: traumatic event while attending to other stimulation, such
o Anxiety associated with the parent role as eye movements, audio tones or tapping.
o Ill infant/child who is unable to effectively initiate Interventions (Pharmacology)
parenteral contact due to altered behavioral • Best when combined with another treatment such as EMDR or
organization CBT.
o Inability of parents to meet personal needs • Medications that target specific symptoms such or comorbidities
o Parenteral conflict due to altered behavior such as ADHD or depression can enhance the child or
o Substance abuse adolescent’s potential for growth and may make a real
o Separation difference in a family’s ability to cope and quality of life.
Risk of Delayed Development Evaluation
• Defined as the risk of delay of 25% or more in one or more of the • Treatment is effective when:
areas social or self-regulatory behavior or in cognitive, language, o The child’s safety has been maintained
gross and fine motor skills. Related to: o Anxiety has been reduced, and stress is handled
o Substance abuse adaptively
o Failure to thrive o Emotions and behavior are appropriate for the
o Unstable home situation
o Unwanted pregnancy o The child achieves normal developmental milestones
o Poverty for his or her chronological age.
Outcome Identification o The child is able to seek out adults for nurturance and
• An overall attachment outcome would be for the parent and help when needed.
infant/child to demonstrate an enduring affectionate bond. B. Traumatic-Related Disorders in Adults: PTSD in Adults
• In regard to development, general outcomes would pertain to • Is characterized by persistent re-experiencing of a highly
meeting age-appropriate milestone. traumatic event that involves actual or threatened death or
Implementation serious injury to self or others, to which the individual responded
• Staged Model of Treatment. We have 3 stages: with intense fear, helplessness or horror.
Stage 1 • PTSD may occur after any traumatic event that is outside the
• Providing safety and stabilization through creating a safe, range of usual experience.
predictable environment; stopping self-destructive behaviors; Major features of PTSD
providing education about trauma and its effects. 1. Re-experiencing of the trauma through recurrent intrusive
Stage 2 recollections of the event, dreams about the event, and
• Reducing arousal and regulating emotion through symptom flashbacks (dissociative experiences during which the event is
reduction and memory work through reducing arousal; finding relieved, and the person behaves as though he or she is
comfort from others; tolerating affect; integrating disavowed experiencing the event at that time.)
emotions and accepting ambivalence; overcoming avoidance; 2. Avoidance of stimuli associated with the trauma, causing the
improving attention and decreasing dissociation; working with individual talking about the event or avoid activities, people, or
memories; and transforming memories. places that arouse memories of the trauma, accompanied by
Stage 3 feelings of detachment, emptiness and numbing.
• Development skills catch up through enhancing problem-solving 3. Persistent symptoms of increased arousal, as evidenced by
skills; nurturing self-awareness; social skills training; and irritability, difficulty sleeping, difficulty concentrating,
developing a value system. hypervigilance, or exaggerated startle response.
Interventions: 4. Alterations in mood, such as chronic depression.
• Establish trust and safety in the therapeutic relationship • Comorbidities for Adults with PTSD include:
• Use of developmentally appropriate language to explore feelings o Depression
• Teach relaxation techniques before trauma exploration to o Anxiety disorders
restore a sense of control over thoughts and feelings. o Sleep disorders
• Help the child to identify and cope with feelings through the use o Dissociative disorders
of art and play to promote expression Assessment
• Screening tools such as Primary Care PTSD Screen and PTSD
Checklist
6
• Additional history about the time of onset, frequency, • To be diagnosed with ASD, individual must display eight of the
course, severity, level of distress, and degree of functional following 14 symptoms either (8) during or after the traumatic
impairment. event including:
• Suicidal or violent ideations, family and social supports, o Subjective sense of numbing
insomnia, social withdrawal. o Derealization (a sense of unreality related to the
Diagnosis environment)
• Anxiety (moderate, severe, panic) o Inability to remember at least one important aspect of the
• Ineffective coping event
• Social isolation o Intrusive distressing dreams
• Insomnia o Feelings as if the event is recurring
• Sleep deprivation o Intense prolonged distress or physiological reactivity
• Hopelessness o Avoidance of thoughts or feelings about the event
• Chronic low self-esteem o Sleep disturbances
• Self-care deficit o Hypervigilance
Outcome Identification o Irritable, angry or aggressive behavior
o Exaggerated startle response
• The person is able to manage anxiety as demonstrated by use of
o Agitation or restlessness
relaxation techniques, adequate sleep, and ability to maintain
role or work requirements. • Difference of ASD and PTSD: onset and duration of symptoms.
The effects of ASD are present immediately and last up to a
• Enhanced self-esteem as demonstrated by maintenance of
month while PTSD present slower and lasts longer up to several
grooming/hygiene, maintenance of eye contact, positive
years.
statements about self, and acceptance of self-limitations.
Diagnosis
• Enhanced ability to cope as demonstrated by decrease in
• Post trauma Syndrome
physical symptoms, ability to ask for help, and seeks information
o Aggression
about treatment.
o Headaches
Implementation
o Intrusive dreams
• Stage model of treatment previously described for children is the
o Irritability
standard for trauma treatment for adults as well.
o Anxiety
Psychoeducation
• Related to:
• Initial education should include reassurance that reactions to
o Serious automobile accident
trauma are common and that these reactions do not indicate
o Serious injury to loved one
personal failure or weakness
o Disaster
• Teach on strategies to improve coping, enhanced self-0care,
o Abuse
facilitate recognition of problems, instructions on relaxation
Outcome Identification
techniques and avoidance of caffeine and alcohol.
• General outcome may relate to aggression
Pharmacology
• The patient will be able to practice self-restraint of assaultive,
• SSRI
combative, or destructive behaviors toward others.
o Fluoxetine (Prozac)
• For anxiety, a general outcome may be that the patient’s anxiety
o Paroxetine (Paxil)
level be maintained from mild to moderate
o Sertraline (Zoloft)
Implementation
• Serotonin-Norepinephrine RI (reuptake inhibitors)
• Establishing therapeutic relationship with the patient
o Venlafaxine (Effexor) – This is to decrease anxiety and
present symptoms • Helping the person to problem solve
• TCA • Connecting the person to supports such as family and friends
▪ Mirtazapine (Remeron) – This may be prescribed when • Educating about ASD
SSRIs are not tolerated • Coordination of care through collaboration with others
• Implementation (Advanced Practice) • Ensuring and maintaining safety
o EMDR • Monitoring response and/or adherence to treatment
o Cognitive restructuring • Implementation (Advanced Practice)
Evaluation o CBT
• Treatment is effective when: o EMDR
o The patient recognizes symptoms as related to the trauma Evaluation
o The patient is able to use newly learned strategies to • Same as PTSD
manage anxiety 2. Adjustment Disorder
o The patient experiences no flashbacks or intrusive • Considered milder forms of PTSD and ASD
thoughts about the traumatic event • The event – including retirement, chronic illness, or a break-up –
o The patient is able to sleep adequately without nightmares may not be as severe and may not be considered a traumatic
o The patient can assume usual roles and maintains event
satisfying interpersonal relationships. • May be diagnosed immediately or within 3 months of exposure
1. Acute Stress Disorder (ASD) • Hallmarks of AD are COGNITIVE, EMOTIONAL, AND BEHAVIORAL
• May develop after exposure to a highly traumatic event, such as symptoms that negatively impact functioning. Responses to the
those listed in the prior section on PTSD stressful event may include combinations of depression, anxiety
and conduct disturbances.
7
• Treatment of adjustment disorder is not uniform due to the lack • Essential feature is the presence of 2 or more distinct personality
of specificity of the problem; practitioners tend not to recognize states that recurrently take control of behavior, called alter
this disorder (alternative personality).
• Symptoms are generally treated with antidepressants • Each alter has its own pattern of perceiving, relating to, and
C. DISSOCIATIVE DISORDERS thinking about the self and environment.
• Dissociative disorders occur after significant adverse • At least 2 dissociative identity states:
experiences/traumas, and individuals respond to stress with a o 1st alter– functions on daily basis, blocks access and
severe interruption of consciousness. responses to traumatic life events
• Dissociation is an unconscious defense mechanism that protects o 2nd alter – fixated on traumatic memories.
the individual against overwhelming anxiety through an • Each alter is a complex unit with its own memories, behavioral
emotional separation; however, this separation results in patterns, and social relationships that dictate how the person
disturbances in memory, consciousness, self-identity and acts when that personality is dominant
perception. • Transition from one personality to another (switching) occurs
• Positive symptoms refer to unwanted additions to mental during times of stress and may range from a dramatic to a barely
activity such as flashbacks noticeable event
• Negative symptoms refer to deficits such as memory problems • Shifts may last from minutes to months, although shorter
or the ability to sense or control different parts of the body. periods are more common
• Dissociative Disorders include: Assessment
o Depersonalization/derealization disorder • For a diagnosis of dissociative disorder to be made, medical and
o Dissociative amnesia neurological illnesses, substance use, and other coexisting
o Dissociating identity disorder psychiatric disorders must be ruled out as the cause of the
Etiology patient’s symptoms
• Childhood physical, sexual or emotional abuse and other • Assessment tools used:
traumatic life events are associated with adults experiencing o Dissociative Experience Scale (DES)
dissociative symptoms o The Somatoform Questionnaire (SDQ)
• Dissociative symptoms, “mind-flight”, actually reduce disturbing o Dissociative Disorders Interview Schedule (DDIS)
feelings and protect the person from full awareness of the • Assessment tools are important because a psychiatric interview
trauma. will often miss the presence of dissociation.
• Biological Factors: o Specific information about identity, memory,
o Genetic variability consciousness, life events, mood, suicide risk, and the
o Neurobiological – research suggests that limbic system is impact of the disorder on the patient and the family are
involved in development of dissociative disorders important dimensions to assess.
• Psychological Factors: • Nurse should consider the ff. when assessing memory:
o Primitive ego defense mechanism is dissociation. o Can the patient remember recent and past events?
• Environmental Factors: o Is the patient’s memory clear and complete or partial and
o Dissociative disorders are responses to acute overwhelming fuzzy?
trauma (MVA, combat, emotional/verbal abuse…) o Is the patient aware of gaps in memory, such as lack of
1. Depersonalization/Derealization Disorder memory for events such as graduation or wedding?
• Depersonalization o Do the patient’s memories place the self with a family, in
o The focus is on oneself. It is an extremely school, or in an occupation?
uncomfortable feeling of being an observer of one’s ▪ Patients with amnesia and fugue may be disoriented
own body or mental processes, with regard to time and place as well as person
• Derealization o Does the patient ever lose time or have blackouts?
o The focus is on the outside world. It is the recurring o Does the patient ever find herself or himself in places with
feeling that one’s surroundings are unreal or distant. no idea how she or he got there?
2. Dissociative Amnesia • For history, if DID is suspected, pertinent questions include the
• Is marked by the inability to recall important personal following:
information, often of a traumatic or stressful nature; this lack of o Have you ever found yourself wearing clothes you cannot
memory is too pervasive to be explained by ordinary remember buying?
forgetfulness o Have you ever had strange persons greet and talk to you as
• Autobiographical memory is available but is not accessible. (in though they were old friends?
contrast, a patient with generalized amnesia is unable to recall o Does your ability to engage in things such as athletics,
information about his or her entire lifetime.) artistic activities, or mechanical tasks seem to change?
• Dissociative fugue o Do you have differing sets of memories about childhood?
o A subtype of dissociative amnesia and is characterized by • Mood
sudden, unexpected travel away from the customary locale o Is the individual depressed, anxious, or unconcerned?
and inability to recall one’s identity and information about • Impact on patient and family
some or all of the past. o Fugue states usually function adequately in the new
o Assumes a whole new identity, and usually is precipitated by identities, patients with amnesia may be more
a traumatic event. dysfunctional.
3. Dissociative Identity Disorder o Patients with DID often have both family and work
problems
• Suicide risk
8
• Guidelines for Assessment of a Px with a dissociative disorder o EMDR – Eye Movement Desensitization and Reprocessing
include: • Hypnotherapy
o Assess for a history of self-harm • Neurofeedback
o Evaluate level of anxiety and signs of dissociation • Ego state therapies
o Identify support systems through a psychosocial • Somatic therapies
assessment o Based on the premise that the body, mind, emotions, and
Signs and Symptoms, Diagnoses, Outcomes spirit are interrelated, and a change at one level results in
• S/S: Amnesia or fugue r/t a traumatic event changes in others.
o Symptoms of depersonalization; feelings of unreality o Awareness, focusing on the present, and recognizing touch
and/or body image distortions as means of communicating are some of the principles of
o Diagnosis: Disturbed personal identity this therapy
o Outcomes: Verbalizes clear sense of personal identity, Evaluation
perceives environment accurately, performs social roles Evaluation is positive when:
well • Patient safety has been maintained
• S/S: Alterations in consciousness, memory, or identity, abuse of • Anxiety has been reduced and the patient has returned to a
substances, disorganization or dysfunction in usual patterns of functional state
behavior (absence from work, withdrawal from relationships, • Integration of the fragmented memories has occurred
changes in role function) • New coping strategies have permitted the patient to function at
o Diagnosis: Ineffective role performance a better level
o Outcomes: Performs family, parental, intimate, • Stress is handled adaptively, without the use of dissociation
community, and work roles adequately; reports comfort
with role expectations 11.C: SOMATIC SYMPTOMS AND RELATED DISORDERS
• S/S: Feeling of being out of control of memory, behaviors, and • Can also be called somatoform disorders
awareness; inability to explain actions or behaviors when in • Somato which means “body”, and symptoms that are
altered state manifested by the body
o Diagnosis: Anxiety self-control • It is characterized under the disorder in psychiatric health
o Outcomes: Monitors intensity of anxiety, eliminates nursing because it is associated of feelings and behaviors in
precursors of anxiety, uses effective coping strategies, response to these symptoms manifested by the body.
maintains role performance and relationships Major Characteristic:
Planning • Patients have physical symptoms for which there is no known
Planning includes 3 phases: organic cause of physiologic mechanism.
• Phase 1 – Establishing safety, stabilization, and symptom Common feature:
reduction • Distressing somatic symptoms associated with abnormal
• Phase 2 – Confronting, working through, and integrating thoughts, feelings, behaviors in response to these symptoms
traumatic memories 1. Somatic Symptom Disorder (Hypochondriasis)
• Phase 3 – Identity integration and rehabilitation • Previously known as hypochondriasis
Implementation • Patients have multiple, recurrent, significant somatic symptoms
Psychoeducation with no evidence of medical explanation. This belief is due to
• Px with dissociative disorders need to be educated about their misinterpretation of physical symptoms.
illness and given ongoing instruction about coping skills and • Patients are not in control of their symptoms, which are
stress management unconscious and involuntary. They express conflicts through
• Teaching grounding techniques that bring the person’s bodily symptoms (primarily pain).
awareness to noticing real things in the present helps to counter • Repetition of medical consults seeking medical diagnosis and
dissociative episodes treatment even though they have been told that there is no
• Example of grounding techniques: known physiologic or organic evidence to explain their
o Stomping one’s feet on the ground symptoms or disability.
o Taking a shower • Most common symptom they present: pain (Sakit ng way
o Holding an ice cube hinungdan)
o Exercising
• These patients also experience doctor hopping. They keep
o Deep breathing
having appointment with a lot of doctors because they have a
o Counting beads
belief that they have something serious in their body that the
o Encourage daily journals
doctor failed to diagnose.
Pharmacologic Intervention
2. Illness Anxiety Disorder
• No specific medications for patients with dissociative disorders,
• Excessive preoccupation with having or acquiring a serious
but appropriate medications are often prescribed for the
undiagnosed illness
hyperarousal and intrusive symptoms that accompany PTSD and
• Similar to somatic symptoms disorder, medical evaluation fails
dissociation
to identify a serious medical condition
• Include: antidepressant, anxiolytics, and antipsychotics
• Regardless of medical assurances, anxiety is not alleviated and
Advanced Practice Interventions
may even be heightened
• CBT
• Example: a person may fear that the normal sounds of digestion,
• Psychodynamic psychotherapy
sweating or a mark on the skin may be indicators of life-
• Exposure therapy threatening disease.
• Modified EMDR • Main point: more on anxiety, not physical symptoms
9
3. Conversion Disorder (Functional Neurologic Disorder) • Allow to verbalize feelings appropriately
• Major feature: a deficit or alternation in voluntary motor or • If not done before, PE and lab workup is done to assess patients
sensory function that mimics a neurologic or medical condition thoroughly
without medical evidence. • Use a matter-of-fact caring approach
• Example: patient is experiencing bradykinesia that is similar to • Ask patients how they are feeling
Parkinson’s disease. no matter how many tests done by the • Use positive reinforcement and set limits by withdrawing
doctor, it doesn’t’ show Parkinson’s disease. attention from patients when they focus on physical complaints
• Risk factor: Typically associated with psychological or physical or make unreasonable demands.(limit-setting)
stress or trauma. • Be firm yet kind to patients.
• Physical stress and Trauma: Most common factor that cause • Be consistent with patients
psychiatric and medical diseases. • Use diversion by including patients in milieu activities and
• Individuals have spontaneous attacks of severe physical recreational games
disability despite lack of medical evidence. • Do not push awareness of or insight into conflicts or problems
• Explain course of the disorder so they know what to expect and
SYMPTOMS cope.
Most common • Paralysis Psychopharmacology
motor symptoms: • Tremor • Medication for pain should be used temporarily and sparingly
• Gait abnormalities • SSRIs to decrease sensitivity to bodily sensations, anxiety and
• Abnormal limb posturing depression
Frequent sensory • Altered/ absent skin sensations, Milieu Management
symptoms: • Blindness • Relaxation exercise
• Medication
• Or inability to hear
• CBT
Other symptoms: • Aphonia (loss of speech/ voice) • Physical therapy might be indicated to prevent muscle atrophy
• Dysphonia (difficulty in speaking) with conversion disorder (there are motor disorders associated
• Globus (lump in the throat) with conversion disorder) (Miller, 2005).
• Family therapy is helpful when family conflict is present
Dissociative • Depersonalization
• Because patients with somatoform disorders are usually over
symptoms • Derealization
users of medical care, some hospitals and clinics provide group
• Amnesia
interventions as part of medical care; focusing on psychosocial
*Symptoms may be persistent (stick with the patient for life) or needs, not on physical needs.
transient (passing symptoms)
• La belle indifference: express little concern or anxiety about the 12: EATING DISORDERS
distressing symptoms 1. ANOREXIA NERVOSA
4. Factitious Disorder DSM 5 CRITERIA
• Characterized by falsification of medical or psychological signs • Core feature: a restriction of caloric intake relative to body
and symptoms in oneself or others. requirements, which leads to a significantly low body weight.
• Impose harm on themselves or others by misinterpreting, • Intense fear of gaining weight or becoming fat.
exaggerating, fabricating, inducing, stimulating, or causing signs • Disturbance in the way in which one’s body weight or shape is
and symptoms of illness or injury in the ABSENCE of obvious experienced, undue influence of body weight or shape on self-
external rewards. evaluation, or persistent lack of recognition of the seriousness of
o Factitious disorder imposed on self (previously the current low body weight.
Munchausen Syndrome)
Interesting Facts:
▪ Example: injecting insulin or injecting fecal
• Women account for approximately 90% of reported cases of
material to produce an abscess or to induce
anorexia nervosa, although anorexia in men appears to be
sepsis.
increasing (Cohane & Pope, 2001).
o Factitious disorder imposed on others (previously
• unset varies from preadolescence (12 to 13 years old) to early
Munchausen syndrome by proxy)
adulthood (McDonald, 2009)
▪ Abusive mothers presenting their children
• 6% to 20% die as a result of their illness, usually through
with wounds of different healing stages
starvation or suicide.
(signs of abuse)
• Anorexia nervosa is associated with a higher suicide rate than
• Fakes symptoms for the purpose of the sick role
most other psychiatric disorders (Pompli et al., 2004)
Factitious disorder vs. malingering
Characteristics:
• Malingering: pretend or exaggerate incapacity or illness to avoid
duty, study, or school. Malingering has OBVIOUS external • People with anorexia nervosa have an intense fear of gaining
REWARDS. weight or of becoming overweight
• Factitious: without gains. • Focus on not gaining weight, despite their low weight (APA,
2013)
• Malingering: with gains.
PSYCHOTHERAPEUTIC MANAGEMENT o 2 most important features for AN – body weight and
Nurse-patient relationship shape
• They generally do not lose their appetites, instead suppress
• Focus is to improve patient’s overall levels of functioning by
them in an effort to remain thin or getting thinner. They
helping them develop adaptive coping behaviors. Distract them
purposely suppress their appetite, they count their calories and
from thinking about it.
know these in every serving of food.
10
• Disturbance in the way they view their weight/ shape; these two • Variable symptoms – muscle weakness, diarrhea, vomiting,
factors are the most important influence on people with hypotension. It can occur causing cardiovascular, neurologic and
anorexia's sense of worth. They equate their self-worth in their hematologic complications and death.
body weight or shape. o Pitting edema can occur
• Denial that they are dangerously thin and that their condition is o Refeeding must be done slowly and under close
problematic. They do not see it as a problem or deny it as a supervision to avoid serious problems
problem. Subjective Symptoms
• In DSM 5, amenorrhea is no longer a diagnostic criterion for • The fear of gaining weight might be triggered by an offhand
anorexia nervosa (APA, 2013), however data support that comment by a friend or relative
menstrual difficulties/ irregularities may occur in the disease. • They try to combat helplessness by controlling what they can
TWO GROUPS control—how much food they eat and their weight
a. Restricters • Depression, irritability, social withdrawal, lessened sex drive,
• Views losing weight as more probable if they simply eat less and and obsessional symptoms
avoid social situations in which they are expected to eat • It is believed that bizarre behaviors might be the result of
• Avoid family and friends and withdraw to their rooms starvation and often diminish with weight gain, but if they do
• Commonly competitive, compulsive and obsessive about their not, the pt might have a comorbid condition such as OCD, major
activities of daily living depression, substance abuse or personality disorder (Ro et al.
• Participate on rigid exercise program, hyperactive, highly 2005)
anxious and unable to relax Etiology
b. Vomit-Purgers • Biologic Factors
• More often overweight before the eating disorders begin o Increased serotonin levels
• Prone to dangerous methods of weight reduction (e.g. o Disturbances in the serotonin system contribute to
introduction of vomiting or excessive use of laxative and vulnerability for restricted eating, behavioral inhibition, and
diuretics). They overuse these weight reduction strategies. a bias toward anxiety and error prediction
• Typically eat normally in social situations o if SSRIs are used to treat AN, they should not be started until
• Post meal, they retreat to the nearest bathroom and purge on weight restoration has been achieved
the consumed food but not as excessive as bulimics. • Sociocultural Factors
• Dental problems are common caused by stomach acids. Stomach o A culture of thinness
lining and enamel may also erode. o Societal standard of beauty through computer imaging
• Weight tends to fluctuate. technology which encourage dieting, a major predisposing
• Bulimia nervosa is much more excessive than vomit-purgers factor to both anorexia and bulimia
o Along with purging, we inspect the mouth and GI tract o American culture: thin beauty ideal = approval by
and gastric juices which can cause dental problems like others
erosion of enamel and esophageal lining • Family factors
Objective Signs o Emotional restraint, enmeshed relationships, rigid
• Most observable sign is deliberate weight loss in an effort to organization in the family, tight control of child behavior by
control weight through changing eating behaviors parents and avoidance of conflict
o Scapular and knee area especially • Psychodynamic Factors
• Vital signs: hypotension, bradycardia, hypothermia (Everything o AN might be related to an early history of sexual abuse
is low). Hypothermia is common because the body does not have o The drive for thinness might be an attempt to reduce the
fat to preserve heat. As a compensating mechanism, the body control of an overcontrolling maternal figure
will allow itself to grow hair all over the body. o Some researchers suggested that anorexia involves a
• Skin is dry (because of the use of laxatives); appearance of regression to a prepubertal state, so that the adolescent
lanugo (observable in the back part, trunk, scapular area, and does not mature physically or emotionally
nape. It can also grow in arms) Famous Celebrities with Anorexia
• Constipation due to slower abdominal peristalsis combined with
decreased intake of food fuels the use of laxatives, leading to
dehydration and giving the anorectic a false sense of decreased
weight.
• Dehydration can lead to irreversible renal damage
• Nicole Richie
• Osteopenia and osteoporosis might develop because of
• Keira Knightley
prolonged amenorrhea and malnutrition (Lock and Fitzpatrick,
• Lindsay Lohan
2019)
• Victoria Beckham
• Alterations In the size of the cardiac chambers and decrease
2. BULIMIA NERVOSA
myocardial oxygen uptake which can lead to life threatening
DSM 5 Criteria
cardiac arrhythmias.
• Recurring episodes of binge-eating characterized by both ff:
• They believe they are the nutrition authorities in the household
o Eating in a discrete period of time an amount of food that is
and attempts to control meals
larger than what most individuals would eat in a similar
• Might engage in bizarre behavior regarding food and eating such
period of time under similar circumstances
as hoarding food or preparing elaborate meals for others but not
▪ In 2 hours, they would spend it eating large, bulky
eating the food they prepare.
foods continuously until they are done
• Refeeding syndrome – rapid introduction of nutrition into a
o A sense of lack of control over eating during the episode
severely malnourished person.
11
• Recurrent inappropriate compensatory behavior in order to • Relationship between depression and bulimia might be one in
prevent weight gain which one causes the other
• Binge-eating and inappropriate compensatory behavior occur on • Some pts eat a marker food
average at least once a week x 3 months o The first food they eat, usually bright colored (e.g. hotdog)
• Self-evaluation is unduly influenced by body shape and weight o As soon as they purge, they won’t stop until they see their
• The disturbance does not occur exclusively during episodes of marker food in their vomit
anorexia nervosa o “This is the first food that I ate so this should be the last
o Bulimia is usually secondary to AN food that will come out so I can assure to myself that
Interesting Facts everything is thrown up.”
• Begins in adolescence or early adult life, primarily in women o Wrong notion scientifically because our food mixes in the
• The usual course of the disorder is chronic and intermittent stomach so we cannot determine if the marker food is the
over many years last food in the stomach
• Onset is usually between the ages 15 to 24 years old • Self-induced vomiting by use of:
• The disease might develop after AN or after a period of dieting o Finger,
Behaviors and Characteristics o Toothbrush, and
• Bulimia literally means to have an insatiable appetite and is used o Utensils down their throats
interchangeably with binge eating or bingeing • Over time, vomiting becomes easier and might require only
• Dieting predisposes the individual to binge eating and purging slight abdominal pressure or no physical manipulation at the end
develops as a means of compensating for calories ingested of the binge
during the binge in an attempt to prevent weight gain • Other compensatory behavior:
o Purging – stimulating vomiting o Neglect of insulin requirements by pts with DM (Poirier,
• The individual continues the restrictive eating during the 2001)
disorder, which precipitates binge eating and then purging, Etiology
perpetuating the cycle • Biologic Factors
• After a binge, patients promise themselves to adhere to a strict o Lowered serotonin activity
diet and vow never to binge again, only to return to this behavior o Decreased cognitive abilities and inefficient prefrontal self-
because they find themselves addicted to the high, they regulatory function
experience when bingeing o Treatment of SSRI Fluoxetine (Prozac) appears to be helpful
• Overeating vs. binge eating • Sociocultural Factors
Objective Signs o Similar with AN
• Most common food ingested is a high-calorie, high-carbohydrate • Family Factors
“snack” food easily ingested in a short period o Family conflict, disorganized, lacking nurturance and not
• Most binges occur during the evening or at night (so no one can being cohesive
see them or may even hop from resto to resto) • Cognitive and Behavioral Factors
o Distorted and negative cognitions about self and body
• Rapid eating during the binge with calories more than
recommended daily allowance • Psychodynamic Factors
o Bingeing and purging appear to be seen in pts who numbs
• Bulimic episode ends when:
o Begin to induce vomiting the pain resulting from abuse, neglect, trauma, and strong
o Physically exhausted feelings
o Suffer from painful abdominal distention o Binge eating and purging behavior is thought to express the
o Interrupted by others ambivalence they feel towards themselves
o Run out of food o Worthy of nurturing they lack, they binge
o Unworthy of nurturing, they purge
• Dehydration, hyponatremia, hypochloremia, hypokalemia, and
Psychotherapeutic Management:
metabolic alkalosis and acidosis
• Initial Treatment Goal: Medical Stabilization
• Laxatives can lead to reflex constipation. And both laxatives and
• Secondary ttt goal: Psychotherapy
diuretics are associated with rebound edema
• Primary Objectives for Anorexia Nervosa
• Dilation of the stomach
o Increase weight to at least 90% of the
• Irritation of GI tract
average body weight for the patient’s height
• Menstrual irregularities
o Helping patients reestablish appropriate
• Enlarged salivary gland (parotid)
eating behavior
• Erosion of dental enamel
o Increasing self-esteem, so patients do not
• Russel’s sign – callusing of the knuckles of the fingers used to need to attain the perfection that they believe thinness
induce vomiting provides.
• Pancreatitis in reported to patient with bulimia • Primary Objectives for Bulimia Nervosa: (similar with AN but
Subjective Symptoms focus on stabilizing weight gain without purging)
• Most have normal body weight o we know that in bulimia nervosa, the patient’s body weight
• Loss of control of eating causes them great anxiety and shame; is usually abnormal range, but their primary problem is the
express a fear of becoming fat purging part, so we are to stabilize patient for utmost and
• Pre-binge: feels week, anxious, lonely, bored, or uncontrollably right patients’ behavior.
craving for food • IV lines and feeding tubes must be readily available
• During binge: either continued anxiety or relief from tension • Refeeding and weight restoration must be done slowly – prevent
• Post-binge: anxiety is replaced with guilt. If not relieved, pts feel complications of refeeding syndrome
angry, agitated, and might become depressed
12
• Multidisciplinary approach: physician, dietitian, nurse,
psychotherapist
ff. interventions that are expected…
• For AN pts, the nurse may be perceived as an enemy not an ally
o Nurses as we are, it is expected of us to care and • Russel Brand
nurture and to nourish, so basically, we need to go
• Princess Diana
back to our physiologic needs. Patients should have an
• Elton John
improve weight etc., but its not the same set of goals
• Demi Lovato
that they establish for themselves. So instead, they do
not want to gain weight
3. BINGE-EATING disorder (BED)
o Ex. Patient does not want to gain weight, while the
• (BED) is a condition that does not meet the diagnostic criteria for
nurse wants patient to gain weight. They are not on
inclusion in DSM 5
the same page, so probably we are seen as enemies.
o Although it shares a lot of criteria with bulimia, there
o So we nurses must be ready in times when we face this
is no regular compensation of excess intake through
type of patients, and usually patient like these are
purging, laxatives, fasting or over exercise.
manipulative.
o There is no purging, they do not vomit, they only do
• BN pts are more likely to want to help, which is their greatest
the binge eating part, therefore they only kept on
strength
intaking (input), and there is no output. So, it is
o Their ability to submit themselves for help
expected for them to be overweight.
• Monitor daily caloric intake
• Shares many criteria of bulimia but without the regular
• Monitor activity level and observe for signs of purging or other
compensation of excess intake through purging laxatives, fasting
compensatory behaviors
or over exercise
• Weight patient daily
• Tend to more overweight
• Promote decision making concerning issues other than food
• Similar to bulimia, onset is later than anorexia
• Promote positive self-concept and perceptions of the body;
o Early adulthood to young adulthood and late
identify positive qualities
adulthood
• Convey warmth and sincerity
• Listen emphatically 13: SLEEP-WAKE DISORDERS
• Be honest SLEEP
• Plan for a dietitian meet with patient and families • Is a Dynamic neurological process that involves complex
• Set appropriate behavioral limits interaction between the CNS and the environment.
• Teach patients about their disorders and collaborate with them • National Sleep Foundation (NSF) recommends that the average
• Model and teach appropriate social skills adult gets 7 to 9 hours of sleep each night
• Identify non-weight related interests of the patient Consequences of Sleep Loss
• Initiate behavior modification program • The major consequence of acute or chronic curtailment is
• Encourage use of therapies or support groups excessive sleepiness.
Psychopharmacology o It is a subjective report of difficulty staying awake that is
• No medication is approved specifically for AN at present serious enough to impact social and vocational functioning
• Medication management of safety, depression, somatic and increase the risk for accident or injury.
disturbances might assist in the treatment Causes
• Small amount of anxiolytics might help patient in eating premeal • Self-imposed sleep restriction
during refeeding (first physiologic step in gaining weight) • Disruption of the normal sleep cycle
• Olanzapine (Zyprexa) promotes weight gain with some success • Underlying sleep disorders
• SSRIs in bulimic patients when psychotherapy alone does not • Medications
respond • Alcohol and substance use
Milieu Management • Medical and psychiatric disorders
• Provide a warm and nurturing environment Neurocognitive symptoms of chronic sleep deprivation that mimic
• Closely observe patients psychiatric symptoms:
• Encourage the patient to approach a team member if feeling the • Poor general health
need to purge • Mood disturbance
• Involve the patient’s family in treatment • Increase pain syndromes/ perception
• Respond with consistency • Impaired cognitive function
• Encourage participation in art, recreation, and other therapies • Memory disturbance
• Encourage patients’ attendance to group sessions • Reduction in measures of overall quality of life
• Recommend follow-up psychotherapeutic groups and support Normal Sleep Cycle
groups • Sleep is measured through an EEG and consists of two distinct
Famous Icons with Bulimia physiological states:
o Non-rapid eye movement (NREM)
o Rapid eye movement (REM)
Non-Rapid Eye Movement (NREM)
• Is divided into 3 stages:
Stage 1 (N1)
13
• Is A brief transition between wakefulness and sleep and • The percentage of REM sleep decreases to 20%-25% by age 3 and
comprise just between 2% to 5% of total sleep time. stays relatively constant throughout old age.
• The time it takes to fall to sleep is referred to as sleep latency. Regulation of Sleep
• Body temperature declines and muscles relax. • Sleep drive – one that promotes sleep (homeostatic process)
• Slow, rolling eye movements are common. • Circadian Drive – one that promotes wakefulness (Circadian
• Easily arousable. process)
Stage 2 (N2) Function of Sleep
• Sleep occupies 45% to 55% of total sleep time, heart rate, • Brain tissue restoration
respiratory rate decline. • Body restoration through NREM sleep)
• Arousal from stage two sleep requires more stimuli than stage 1. • Energy conservation
Stage 3 (N3) • Memory reinforcement and consolidation (REM sleep)
• Also known as wave sleep or delta sleep. • Regulation of immune functions, metabolism, and regulation of
• Is relatively short and constitutes only about 13% to 23% of total certain hormones
sleep time. • Thermoregulation
• It is characterized by further reduction of heart rate, respiratory Sleep Requirements
rate, blood pressure and response to stimuli. • The amount of sleep required is the amount necessary to feel
• Is considered “Restorative sleep”, as it is a time of reduced fully awake and able to sustain normal levels of performance
sympathetic activity. during the periods of wakefulness and is known as the basal
Rapid Eye Movement (REM) sleep requirement.
• REM sleep comprises of 20% to 25% of total sleep time. o Average = 7-8 hours
• Is characterized by reduction and absence of skeletal muscle o Long sleepers = 10 hours or more
tone (muscle atonia), bursts of rapid eye movement, myoclonic o Short sleepers = less than 5 hours
twitches of the facial and limb muscles, reports of dreaming and Sleep Testing
autonomic nervous system variability. • Sleep testing is often indicated for patients complaining of sleep
o Atonia in REM is a protective mechanism to prevent the disturbance or excessive sleepiness that impairs social and
acting out of nightmares and dreams vocational functioning.
Polysomnography
• Is the most common sleep test and is used to diagnose and
evaluate patients with sleep-related breathing disorders and
nocturnal seizure disorders.
Multiple Sleep Latency Test (MSLT)
• Is a daytime nap test used to objectively measure sleepiness in a
sleep-conducive setting. Indicated in patient’s suspected of
having narcolepsy.
Maintenance of Wakefulness Test (MWT)
• Evaluates a patient’s ability to remain awake in a situation
conducive to sleep and is used to document adequate alertness
in individuals with careers for which sleepiness would pose a risk
to public safety.
Actigraphy
• Involves using a wristwatch-type device that records body
movement over a period of time and is helpful in evaluating
sleep patterns and sleep duration.
• It is used in patients with circadian rhythm disorders and
insomnia.
SLEEP DISORDERS
1. HYPERSOMNOLENCE DISORDERS
• Are associated with excessive daytime sleepiness and have a
prevalence or more than 15% in the general population
• Usual complaints for patients with Hypersomnolence Disorder:
o Recurrent periods of sleep or unintended lapses into sleep
• In adults, sleep normally begins with NREM sleep, predominating o Frequent napping
the first half of the sleep period and REM sleep predominating o A prolonged main sleep period of greater than 9 hours
the second half. • Usual complaints for patients with Hypersomnolence disorder:
• Sleep architecture – is the structural organization of NREM and o Non-refreshing, non-restorative sleep regardless of amount
REM sleep. of time slept
• Irregular cycling, absent sleep stages and sleep fragmentation o Difficulty with full alertness during the wake period
are associated with many psychiatric disorders, sleep disorders • Excessive sleepiness significantly impairs social and vocational
and medication effects. functioning by impacting the person’s ability to participate and
Sleep Pattern enjoy relationships and function in the workplace
• Sleep architecture changes over the lifespan. • Cognitive impairment is common as is an increased risk for
• Infants sleep 16-18 hours a day, starts with REM accident or injury associated with the sleepiness
14
• Treatment focuses on maintaining sleep-wake cycle • Refers to the unusual or undesirable behaviors of sleep that
• Pharmacotherapy include long-acting amphetamine-based occur during sleep-wake transitions or during certain stages of
stimulants such as methylphenidate, and non-amphetamine sleep
based stimulants such as modafinil. Sleepwalking (somnambulism),
• Consists of a sequence of complex behaviors that begin in the
2. NACROLEPSY / HYPOCRETIN DEFICIENCY first third of the night during NREM sleep and usually progress
Classic Symptoms (without full consciousness or later memory) to leaving the bed
• Irresistible attacks of refreshing sleep and walking about
• Cataplexy – brief episodes of bilateral loss of muscle tone with • Polysomnography may be done to rule out the possibility of
maintained consciousness. underlying disorder or sleep fragmentation
o Usually happens along with a strong emotion such as anger, • Treatment
frustration, or laughter o Instructing patient and family about safety measures
• Hypnagogic hallucinations – may be auditory, visual, and tactile o Benzodiazepines (when injury is likely)
and occur at sleep onset Confusional arousals
• Sleep paralysis – is inability to move or speak during the • Consist of mental confusion or confused behavior during or
transition from sleep to wakefulness following arousal from slow wave sleep but also upon attempted
• Patients generally feel refreshed upon awakening but within 2 or awakening from sleep in the morning
3 hours begin to feel sleepy again • Treatment is focused on lifestyle management and safety
• Additional symptoms include: measures
o Disturbed nighttime sleep with multiple middle-of-the- 6. NIGHTMARE DISORDER
night awakenings and automatic behaviors characterized by • Is characterized by long, frightening dreams from which people
memory lapses awaken scared
• Treatment is through lifestyle modification and long-acting • Occurs usually during REM sleep
stimulants • Diagnosis is by clinical evaluation
o Polysomnography is sometimes done
• Treatment includes hypnotic therapy and lifestyle modification
3. BREATHING-RELATED SLEEP DISORDERS 7. RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER (RSBD)
• Characterized by episodes of upper airway collapse and • Is characterized by absence of muscle atonia during sleep
obstruction that result in sleep fragmentation • Patients displays elaborate motor activity associated with dream
• Most common is sleep-apnea hypopnea syndrome (OSAHA) mentation
• Patients with obstructive sleep apnea are not able to sleep and o These patients are actually acting out their dreams
breathe at the same time • Diagnosis is determined by clinical evaluation and
Symptoms polysomnography with video recording
o Loud, disruptive snoring • Treatment focuses on patient and sleep partner safety
o Witnessed apnea episodes o Intermediate-acting benzodiazepines may be used
o Excessive daytime sleepiness 8. RESTLESS LEG SYNDROME
• Obesity is an important risk factor for obstructive sleep apnea • Is characterized by an unpleasant, uncomfortable sensation in
• Treatment is with CPAP (continuous positive airway pressure) the legs accompanied by an urge to move
therapy • Treatment includes lifestyle modification and pharmacotherapy
Central Sleep Apnea (dopamine agonists such as pramipexole and ropinirole)
• Is the cessation of respiration during the sleep without 9. SUBSTANCE-INDUCED SLEEP DISORDER
associated ventilatory effort and is caused by instability of the • Sleep disturbance caused by intake of substances such as:
respiratory control system o Alcohol – which decreases deep sleep
• Central sleep apnea is seen in older individuals, those with o Nicotine – makes the patient wake in response to mild
advanced cardiac or pulmonary disease, or those with neurologic withdrawal symptoms during sleep
disorders o Caffeine – promotes wakefulness
Sleep-related Hypoventilation 10. INSOMIA DISORDER
• Is associated with sustained oxygen desaturation during sleep in • Patients with insomnia disorder report dissatisfaction with sleep
the absence of apnea or respiratory events quality and report difficulty with sleep initiation, sleep
• Is seen in individuals with morbid obesity, lung parenchymal maintenance, early awakening with difficulty to sleep, or non-
disease, or pulmonary vascular pathology refreshing nonrestorative sleep.
4. CIRCADIAN RHYTHM SLEEP DISORDER • Symptoms must be present at least 3 times per week for a period
• Occurs when there is a misalignment between the timing of the of at least 3 months despite adequate sleep opportunity.
individual’s normal circadian rhythm and external factors that • Insomnia is best understood as a state of constant hyperarousal
affect the timing or duration of sleep that involves biological, psychological and social factors.
• Very common among nurses; we are going on shifting schedules • 3 P model of Insomnia
so our normal circadian rhythm is affected o Predisposing – individual factors that create a vulnerability
• Diagnosis is determined by clinical evaluation, sleep diaries, and o Precipitating – external factors that trigger insomnia
actigraphy o Perpetuating – sleep practices and attributes that maintain
• Treatment is with lifestyle management strategies aimed at sleep complaint
adapting to or modifying the requires sleep schedule APPLICATION OF NURSING PROCESS
5. DISORDERS OF AROUSAL Assess for sleep patterns:
15
• Insomnia o Relaxation techniques such as meditation, guided imagery,
o Do you have difficulty with falling asleep, staying asleep, or progressive muscle relaxation, controlled-breathing
early-morning awakenings? exercises.
o Do you feel refreshed and restored in the morning? o Modifying poor sleep habits.
o Have you noticed any problems with your energy, mood, • Pharmacological Interventions
concentration, or work quality as a result of your sleep o Provide education about the benefits of a particular drug, the
problem? side effects, untoward effects, and the fact that medications
• Hypersomnia are usually prescribed for no more than 2 weeks.
o Obstructive sleep apnea hypopnea syndrome: Have you • Advanced Practice Interventions
ever been told that you snore or that it looks as if you stop o Sleep hygiene – conditions and practices that promote
breathing in your sleep? continuous and effective sleep.
o RLS: Do you have an unpleasant or uncomfortable o Behavioral therapy
sensation in your legs that prevents you from sleeping or o Hypnotic therapy
wakes you up from sleep and makes you want to move? o Cognitive-behavioral therapy for insomnia (CBT-I)
o Narcolepsy: Do you have episodes of sleepiness you cannot o Stimulus control:
control? Have you experienced episodes where you were ▪ Go to bed only when sleepy
unable to move as you were about to fall asleep or wake ▪ Use the bed or bedroom only for sleep and intimacy (no
up? Unexplained muscle weakness following a strong TV, no reading)
emotion (cataplexy)? Have you ever seen or heard ▪ Get out of bed if unable to sleep and engage in a quiet-
something that you knew was not real as you were falling time activity such as reading or crossword puzzles.
asleep or waking up from sleep (hypnogogic hallucination)? ▪ Maintain a regular sleep/wake schedule
o Primary hypersomnia: Do you ever feel unrested even after ▪ Avoid daytime napping
an extended sleep period? Evaluation:
• Arousal • Is based on whether or not the patient experiences improved
o Have you ever been told that you have done anything sleep quality as evidenced by decreased sleep latency, fewer
unusual in your sleep, such as walking or talking nighttime awakenings, a shorter time to get back to sleep after
(Somnambulism/somniloquy)? awakening, and improvement in daytime symptoms of
o Have you ever been told that you act out your dreams (REM sleepiness.
sleep behavior disorder)? • Evaluation is accomplished through patient report and patient
o Have you been troubled by nightmares or disturbing maintenance of a sleep diary.
dreams? 14: SEXUAL DISORDERS
• Cardiac Rhythm
o Is your desired sleep schedule in conflict with your social Sexual Disorders
and vocational goals? • Sexual needs are basic human needs
o What is your preferred sleep schedule? • Sexuality is essential to the well-being of individuals and of
Diagnosis: couples
• Insomnia: A disruption in amount and quality of sleep that • Sexual activities are considered abnormal only if they are
impairs function directed toward anyone or anything other than consenting
• Sleep deprivation: Prolonged periods of time without sleep adults or are performed under unusual circumstances
• Disturbed sleep pattern: Changes in sleep routines that cause • DSM5 Categories
impairment in social or vocational functioning. a) Sexual Dysfunctions
• Readiness for enhanced sleep: A pattern of natural, periodic b) Paraphilias
suspension of consciousness that provides adequate rest, c) Gender Dysphoria
sustains a desired lifestyle, and can be strengthened.
Outcome Identification: 1. SEXUAL DYSFUNCTIONS
• Sleep - Inhibition or interferences with the desire, excitements, orgasm
• Rest or resolution phases of the sexual response cycle
• Risk control - Can be lifelong or acquired
• Personal well-being - Often a combination of psychogenic and physiologic factors
Planning - The duration of symptoms within the disorders should be at least
• Role of nurse is generally to conduct full assessment, provide 6 months to be considered dysfunctional and a disorder
support to the patient and family while the appropriate
interventions are determined, and teach the patient and family Etiologic Factors:
strategies that may improve sleep. A. Physical / Biologic Factors
Implementation: - Testosterone stimulates sexual desire in males and females
• Counseling - Stress reduce sexual interest and arousal
o Begins during assessment. The nurse’s questions and - Medications: antidepressants, antiHPN and hormonal ttt
responses provide support to the patient and family as well - Substance use disorders
as assurance that the sleep problems are amenable to
treatment. B. Psychologic/Emotional factors
• Health Teaching and Health Promotion - Anxiety, stress, depression
- Positive and negative perception of one’s own body image affect
sexual interest and function
16
C. Cultural Factors
- Sexual myths influence attitudes towards sex Hormonal treatments:
- Many religions place restrictions on sexual behavior that is other • Exogenous testosterone to improve male sexual desire and
than procreative; however many religions advocate for a happy possible sexual function in general
and vital sexual relationship, albeit generally inside the context • Testosterone replacement for women
of marriage
Surgical interventions:
D. Relational Factors • Semirigid of inflatable penile prosthesis
- Problems within the relationships: finances and family stress
- Couples often have poor and ineffective communication Principles of Sexual Assessment
regarding their sexual likes and dislikes • Examine own feelings, attitudes, and level of understanding and
- Differences in sexual drives and interest complicate their interest comfort before beginning assessment
- Couples often do not discuss what they do / do not enjoy sexually • Ensure private and quiet space, ample time, and unhurried
or share their feelings about the experience attitude for the assessment
• Do not ask questions about sexuality first
Types • Begin questioning about sexuality with the least sensitive areas,
1. Sexual Desire Disorders: deficient, absent or extreme aversion and then move to areas of greater sensitivity
to and avoidance of sexual activity • Open and nonjudgmental attitude. Be professional and a matter
- Male Hypoactive Sexual Desire Disorder – have little or no of fact about information that is asked or obtained
response in sexual fantasies or activities and have hypoactive • Maintain eye contact and a relaxed and interested manner
sexual desires
• Use language that is professional but that will be understood by
the client being interviewed
2. Sexual Arousal Disorders: partial or complete failure to achieve
• Tone of the voice and manners reflect trust
a physiologic or psychologic (subjective) response to sexual
• Accept that the problem is real to client regardless of age
activity
• Teach how to support/promote erection. Teach side effects of
- Erectile Disorder – cannot obtain / maintain and erection
erectile agents
sufficient for sexual activity
- Female Sexual Interest / Arousal Disorder – have little or no • Teach couples to schedule their sexual experiences for mutually
response in sexual fantasies or activities agreed upon times
3. Orgasm Disorders: delay in or absence of orgasm, premature 2. PARAPHILIAS

ejaculation • Intense and persistent sexual interest in anything other than a
- Ejaculation disorders physically normal and mature consenting adults, may be
A. Delayed Ejaculation directed toward an abnormal activity or target.
B. Premature Ejaculation: a man reaches orgasm within 1 • To be considered a paraphilic disorder, a paraphilia must have a
minute of vaginal penetration and before he wishes, negative consequence, such as distress or impaired functioning,
frustrating both himself and his partner or harm to client or others.
- Female Orgasmic Disorders • Recurrent or intense behavior that continues for at least 6
o Delay or absence of orgasm and a reduction in the months.
intensity of orgasmic sensations Exhibitionistic Behavior
• Recurrent, intense sexually arousing fantasies, urges or
4. Sexual Pain Disorders (Dyspareunia) behaviors involving exposing one's genitals to unsuspecting
- Genito-pelvic pain / Penetration disorder – experience pain or strangers.
anticipate pain with vaginal penetration Fetishistic Disorder
- Vaginismus – involuntary muscle constriction of the outer 3rd of • Recurrent, intense sexually arousing fantasies, urges or
the vagina that interferes with penile insertion and intercourse behaviors using non-sexual or nonliving objects.
• Partialism: Refers to fetishes specifically involving
Therapeutic Interventions nonsexual parts of the body.
- First, treat underlying physiologic cause if present Frotteuristic Disorder
- Psychologic-based interventions: sexual counseling for client and • Recurrent, intense sexually arousing fantasies, urges or
partner behaviors involving touching and rubbing against a
- To develop arousal response and orgasmic capacity, sex nonconsenting person
therapists may teach their clients masturbatory training Pedophilic Disorder
exercises • Recurrent, intense sexually arousing fantasies, urges or
- Relation-based interventions behaviors that involve sexual activity with a child or children
- Assist client with enhancing self-talk and affirmations and body generally 13 years old or younger.
image exercises • The person is at least 16 years old and at least 5 years older
- Vacuum constriction device for males for treatment of than the child or children involved.
impotence Sexual Masochism Disorder
• Recurrent, intense sexually arousing fantasies, urges or
Pharmacologic therapy: behaviors involving the act of being humiliated, beaten,
• Sildenafil, Tadalafil, Alprodastil for erectile dysfunction restrained, or otherwise made to suffer.
• Anxiolytics for ttt of vaginismus Sexual Sadism Disorder
• Genital Pain Disorders: Topical Lidocaine and Gabapentin
17
• Recurrent, intense sexually arousing fantasies, urges or • Emotional dimensions: guilt, helplessness, shame, and relief
behaviors involving acts in which the psychological or about getting caught
physical suffering of the victim is sexually exciting to the • Appropriate collaboration with other health team members:
person. social workers and chaplains
Transvestic Disorder • Nurses are legally obligated to report suspected and actual cases
• Recurrent, intense sexually arousing fantasies, urges or of abuse
behaviors involving cross-dressing or dressing as the
opposite sex. Psychopharmacology
Voyeuristic Disorder • Antiandrogen medication - To lower testosterone levels of men
• Act of observing an unsuspecting person who is naked, in with paraphilia
the process of disrobing, or engaging in sexual activity. • Medroxyprogesterone (Provera) and Leuprolide acetate (LPA,
Incest Lupron) - Decrease LH therefore decrease testosterone
• Is pedophilia with child and adolescent relatives and • SSRIs
involves relationships by blood, marriage (stepparents) or
live-in partners. Milieu Management
Other paraphilias not otherwise specified: • Self-esteem, assertiveness, anger mgt, social relationship skills,
• Telephone scatalogia - Obscene phone calls (e.g. sexting) sex education, stress management
• Necrophilia - Sexual pleasures involving corpses • Self-help groups: Sex-addicts anonymous
• Zoophilia - Sexual pleasures involving animals • CBT
• Coprophilia - Sexual pleasures involving fecal matter
• Klismaphilia - Sexual pleasures involving enemas
• Urophilia - Sexual pleasures involving urine
3. GENDER DYSPHORIA
• Strong, persistent preference for living as a person of the
opposite sex.
• In adults involves feelings of incongruence between one's
assigned or biologic sex and one's gender identity.
• Preoccupation of getting rid of the primary and secondary
sex characteristics.
• Might desire hormones and surgery to become opposite
gender.
Definition of Terms
1. Sexual identity - Refers to the biological indicators of male and
female such as sex chromosomes, sex hormones, and genitalia.
2. Gender - Refers to a lived role in public of either a man or
woman.
3. Gender identity - Refers to how an individual identifies himself
or herself as male or female and is a facet of social identity.
4. Sexual orientation - describes the object of a person sexual
impulses
a. Heterosexual (opposite sex), homosexual (same sex),
bisexual (both sexes)
General Nursing Care of Clients with Sexual and Gender Dysphoria

Disorders
• Reflect on own sexual values and customs
• Accept an individual as a person in emotional pain
• Create a safe, nonjudgmental envt that permits open
communication
• Begin with a less sensitive topic and move gradually to more
personal issues
• Avoid punitive or judgmental remarks or responses; maintain a
matter-of-fact manner
• Provide for privacy and protect individual from others
• Set limits on sexual acting out behavior
• Report suspected child or elder abuse to appropriate protective
service agencies
Psychotherapeutic Management
• For victims of perpetrators nurses deal with:
• Physical dimensions: anorexia, insomnia and weight loss
18
Short Quiz 5
1.
Which of the following substances is a natural hormone produced by the
pineal gland that induces sleep?
(1 Point)
D. Pemoline
C. Methylphenidate
A. Amphetamine
B. Melatonin
2.
A patient with obstructive sleep apnea (OSA) is being discharged. What
patient statement indicates the need for further teaching?
(1 Point)
c. “I will try the oral appliance that the doctor suggested.”
a. “I hope to lose some weight.”
b. “My antidepressants seem to be helping.”
d. “A glass of wine at bedtime will help relax my airways.”

3.
The nurse observes a distorted thinking pattern in a teenage patient
diagnosed with an eating disorder. Which statement characterizes
personalization by the patient?
(1 Point)
a. “I’ve got to be thin to get a good job.”
d. “My whole family will be disgraced if I don’t get into a good college.”
b. “There is no such thing as a healthy carbohydrate.”
c. “My mother and dad fight all the time because I’m fat.”
4.
A patient with obstructive sleep apnea (OSA) is being discharged. What

patient statement indicates the need for further teaching?
(1 Point)
c. “I will try the oral appliance that the doctor suggested.”
a. “I hope to lose some weight.”
d. “A glass of wine at bedtime will help relax my airways.”
b. “My antidepressants seem to be helping.”

5.
Which of the following interventions is the initial treatment goal for clients
with eating disorders?
(1 Point)
Helping patients reestablish appropriate eating behavior
Increase weight to at least 90% of the average body weight for the patient's height
Increasing self-esteem, so patients do not need to attain the perfection that they believe
thinness provides
Medical stabilization
6.
Which outcome is appropriate for an adult patient recently diagnosed with
primary insomnia?
(1 Point)
a. Demonstrate an understanding of the cerebral stimulants prescribed.

b. Recognize that the prescribed flurazepam (Dalmane) can be used for up to 2 months.
d. Recognize physical and psychosocial stressors that exacerbate the sleep disturbance.
c. Demonstrate the proper use of continuous positive airway pressure (CPAP)

ventilation.
7.
Which patient statement demonstrates the expected emotional response to
bingeing?
(1 Point)
b. “Everyone indulges in bingeing some times.”
a. “I know it’s bad but I can’t help bingeing.”
d. “Bingeing isn’t bad if I do it only when I’m stressed.”
c. “After I binge I feel happy for a little while.”

8.
A 14-year-old patient newly admitted to the eating disorders unit refuses to
eat meals and angrily shouts at the nurse, “You can’t make me eat! I’ll do
whatever I want to do.” Which nursing intervention demonstrates an
understanding of the priority safety issue for this anorexic patient?
(1 Point)
a. Placing the patient’s favorite low calorie beverages in open view
c. Unlocking the patient’s bathroom only at specific times during the day
b. Assigning a staff member to one-on-one observation of the patient
d. Explaining to the patient that they will be required to keep an eating journal
9.
Which intervention will best assess a narcoleptic patient for a commonly
recognized comorbid psychiatric disorder?
(1 Point)
a. Observing for signs of self-mutilation
d. Asking, “Do you rely on alcohol to function socially?”
c. Asking, “Do you consider yourself to be depressed?”
b. Observing the patient for ritualistic behaviors

10.
The following are the characteristics of Bulimia nervosa except:
(1 Point)
Erosion of dental enamel
Irritation of the GI tract
Enlarged cervical lymph nodes
Menstrual irregularities
11.
A nurse working the night shift in a pediatric unit observes a 10-year-old
male patient walking the hallway in a sleep state. The child is unaware of
his environment and doesn't recall the incident in the morning. Which sleep
disorder would the nurse expect?
(1 Point)
b. Cataplexy
c. Restless leg syndrome
d. Somnambulism
a. Bruxism
12.
The nurse is caring for a patient who is being treated for comorbid eating
and affective disorders. For which medication would the nurse expect to
prepare a patient teaching plan?
(1 Point)
c. Lorazepam (Ativan)
a. Fluoxetine (Prozac)
d. Lithium
b. Diazepam (Valium)
13.
A client's altered body image is evidenced by claims of feeling fat, even
though the client is emaciated. Which is the appropriate outcome criterion
for this clients problem?
(1 Point)
B. The client will cease strenuous exercise programs.
C. The client will perceive personal ideal body weight and shape as normal.
D. The client will not express a preoccupation with food.
A. The client will consume adequate calories to sustain normal weight.

14.
In regulation of sleep, it is the one that promotes wakefulness.
(1 Point)
None of the above
Homeostatic process
Circadian process
15.
Which statement indicates to the nurse that a patient requires additional
education regarding appropriate sleep hygiene?
(1 Point)
c. “Exercising before bed will make me good and tired.”
b. “Relaxing music may help relax me for sleep.”
a. “I will try to avoid daytime napping.”
d. “I need to cut back on my four daily cups of coffee.”

16.
Which assessment observation would not support a diagnosis of
narcolepsy?
(1 Point)
d. Patient reports, “When I get sleepy I actually see things that aren’t really there.”
c. Patient reports “needing to drink pots of coffee to stay awake at work.”
b. Sleep study shows evidence of sleep paralysis.
a. Sleep study reports excessive, loud snoring.

17.
This is a callusing of the knuckles of the fingers used to induce vomiting.
(1 Point)
Romberg sign
Russell's sign
Rocker's sign
Rutor sign
18.
Which of the following is not an objective sign of anorexia nervosa?
(1 Point)
presence of lanugo
140/90mmHg
36.3C per axilla
58bpm
19.
A nurse is discussing with an older female patient the factors that affect
sleep. What fact does the nurse teach her?
(1 Point)
b. Using alcohol moderately promotes a deep sleep.
d. Exercising decreases REM and NREM sleep.
c. Aging decreases the amount of REM sleep a person experiences.
a. Drinking a cup of regular tea at night induces sleep.

20.
Nurse Even is doing health teaching to an at risk client. Which of the
following he includes is true?
(1 Point)
Bulimia nervosa is an eating disorder characterized by a sense of lack of control over

purging
Anorexia nervosa occurs most often in males
Bulimia nervosa often develop before anorexia nervosa or a period of dieting
Anorexia nervosa might be related to early history of sexual abuse

Short Quiz 4
1.This is defined as an excessive preoccupation with having or acquiring a serious
undiagnosed illness
(1/1 Point)
Hypochondriasis
Illness Anxiety disorder
Factitious disorder
Malingering
2.This is defined as a deficit or alteration in voluntary motor or sensory function that mimics
a neurologic or medical condition
(1/1 Point)
Functional Neurologic disorder
Munchausen syndrome
Malingering
Factitious disorder
3.Which nursing diagnosis should be investigated for clients with conversion disorder?
(0/1 Point)
Disturbed personal identity
Delayed growth and development
Deficient fluid volume
Self-care deficit
4.Dissociative identity disorder is characterized by
(1/1 Point)
the inability to recall important information
sudden unexpected travel away from home and inability to remember the past
recurring feelings of detachment from one's body or mental processes
the existence of two or more subpersonalities, each with its own patterns of thinking
5.Which statement about somatoform and dissociative disorders is true?
(1/1 Point)
Nurses perceive clients with these disorders as easy to care for.
Clients lack awareness of the relations among symptoms, anxiety, and conflicts
No relation exists between these disorders and early childhood loss or trauma.
An organic basis exists for each group of disorders.
6.(Blank) is characterized by pretending or exaggerating incapacity or illness for obvious
external rewards such as avoidance of work or duty.
(1/1 Point)
Illness anxiety disorder
Factitious disorder
La belle indifference
Malingering
7.This somatoform disorder is described as a deficit or alternation in voluntary motor or
sensory function that mimics a neurologic or medical condition.
(0/1 Point)
Hypochondriasis
Munchausen syndrome
Conversion disorder
La belle indifference
8.Which of the following is not a symptom of conversion disorder?
(0/1 Point)
Anosmia
Paralysis
Hypotension
Aphonia
9.Which of the following assessment findings might indicate Factitious disorder?
(1/1 Point)
There are contradictory of inconsistent symptoms or lab test results
There is a lack of healing for no apparent reason, despite appropriate treatment
The person's medical history doesn't make sense
All of the above
10.This is characterized by recurrent pulling out of one's hair, resulting in hair loss in various
regions of the body (scalp, eyebrows, eyelids, axillary, facial, pubic)
(1/1 Point)
None of the above
Somnambulism
Trichotillomania
Excoriation
11.Which of the following statements are correct regarding obsessive-compulsive disorder
(OCD)? Select all that apply.
(0/1 Point)
Schizophrenia often occurs comorbidly with OCD
OCD patients often have difficulty sleeping
Obsessions are repetitive thoughts, whereas compulsions are ritualistic behaviors
Patients diagnosed with OCD are at higher risk for suicide than patient with depression
OCD symptoms can start as early as 3 years of age
There is a tool to measure compulsive behaviors.
12.A variety of medications are used in the treatment of severe anxiety disorders. Which
class of medication used to treat anxiety is potentially addictive?
(1/1 Point)
Anti-histamines
Buspirone
Selective serotonin reuptake inhibitors
Beta-blockers
Benzodiazepines
13.You are caring for Mae, a 29-year-old who has been diagnosed with dissociative identity
disorder. She was recently hospitalized after coming to the emergency room with deep cuts
on her arms with no memory of how this occurred. The priority nursing intervention for Mae
is.
(0/1 Point)
Refer for integrative therapy
Assist in recovering memories of abuse
Maintain 1:1 observation
Teach coping skills and stress-management strategies
14.You are caring for Dylan, an 8-year-old boy who has been diagnosed with reactive
attachment disorder. Which of the following nursing outcomes would be the most
appropriate to achieve?
(0/1 Point)
Writes or draws feelings in a journal
Increases ability to self-control and decreases impulsive behaviors
Expresses complex thoughts
Avoids situations that trigger conflicts
15.Andi is a 21-year-old college student who was sexually assaulted at a party. She was seen
in the local emergency department and referred for counseling after being diagnosed
having acute stress disorder. Which of the following treatment modalities would you expect
to see used in therapy with Andi?
(0/1 Point)
Cognitive-behavioral therapy
Aversion therapy
Short-term classical analysis therapy
Stress-reduction therapy

NCM 117: Long Exam 2: Anxiety & Anxiety Disorders Topic Outline

Uploaded by

Copyright:

Available Formats

You might also like

NCM 117: Long Exam 2: Anxiety & Anxiety Disorders Topic Outline

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NCM 117: Long Exam 2: Anxiety & Anxiety Disorders Topic Outline

Uploaded by

Copyright:

Available Formats

NCM 117: Long Exam 2

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 1

SOCIAL ANXIETY DISORDER

GENERALIZED ANXIETY DISORDER

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 2

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 3

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 4

HEALTH TEACHING AND HEALTH PROMOTION EVALUATION

Advanced Practice Interventions

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 5

➔ Characterized by recurrent picking at one’s own skin,

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 6

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 7

TRAUMA-RELATED DISORDERS IN CHILDREN Diagnosis

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 8

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 9

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 10

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 11

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 12

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 13

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 14

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 15

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 16

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 17

➔ Pancreatitis is reported to pt with bulimia

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 18

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 19

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 20

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 21

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 22

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 23

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 24

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 25

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 26

Other paraphilias not otherwise specified: Psychopharmacology

BAYO, BOLLOZOS, CABERTE, CARITAN, MAMACOS, SAVIOR 27

3. Orgasm Disorders: delay in or absence of orgasm, premature 2. PARAPHILIAS

General Nursing Care of Clients with Sexual and Gender Dysphoria

c. “I will try the oral appliance that the doctor suggested.”

a. “I hope to lose some weight.”

b. “My antidepressants seem to be helping.”

d. “A glass of wine at bedtime will help relax my airways.”

a. “I’ve got to be thin to get a good job.”

A patient with obstructive sleep apnea (OSA) is being discharged. What

c. “I will try the oral appliance that the doctor suggested.”

a. “I hope to lose some weight.”

d. “A glass of wine at bedtime will help relax my airways.”

b. “My antidepressants seem to be helping.”

Helping patients reestablish appropriate eating behavior

a. Demonstrate an understanding of the cerebral stimulants prescribed.

c. Demonstrate the proper use of continuous positive airway pressure (CPAP)

b. “Everyone indulges in bingeing some times.”

a. “I know it’s bad but I can’t help bingeing.”

d. “Bingeing isn’t bad if I do it only when I’m stressed.”

c. “After I binge I feel happy for a little while.”

a. Placing the patient’s favorite low calorie beverages in open view

b. Assigning a staff member to one-on-one observation of the patient