PSYCHIATRIC MENTAL HEALTH NURSING

CHAPTER I: CONCEPTS AND c. Working Phase

PRINCIPLES OF NURSING ® Problem-solving are done
• Psychiatric Mental Health Nursing ® SICO
® A specialized area of nursing practice, d. Termination Phase
employing theories of human behavior as its ® Must be done gradually
science and purposeful use of self as its art. ® Identify FRAT: (must be done
• Psychodynamic by the nurse and the client)
® Psychological aspect of human behavior Feelings
• Psychopathology Roles
Actions
® Study of mental disorders and unusual or
Thoughts
maladaptive behaviors
o Biologic Basis ® Grand socialization –
o Psychodynamic Basis heightened state of the reality
® 1990: Decade of the brain
*What is our goal in establishment of the nurse-
® Genetic and environmental influences
patient relationship?
Þ FOR THE PATIENT TO HAVE A
Therapeutic Tools of Psychiatric Mental
POSITIVE CHANGE or CORRECTIVE
Health Nursing PATIENT EXPERINCE
• “Tools of the Trade”
1. Therapeutic Use of Self *Resistance can be found in all of the phases. What
- Ability of a nurse to use his or her is the most common thing found in all forms of
personality consciously and in full resistance?
awareness in an attempt to establish Þ SILENCE
relatedness and to structure nursing
intervention.
COMMUNICATION AS A PROCESS
- Four Elements:
• Communication
a. Self-awareness: ability to recognize
genuine feelings in relation to the ® Is an exchange of my world of meanings with
environment; rites of passage your world of meanings
b. Self-disclosure: expressing of one’s ® It is a dynamic, on-going process
feelings; revelation ® Is a start to form relationship
c. Empathy: entering into the person’s ® Validate a patient’s feelings or experience
life situation by perceiving his current
condition/problem § Two Modes of Communication:
d. Respect: accept a patient as a person a. Verbal: Spoken and written words;
but reject the maladaptive behavior used 7% at all times
2. Therapeutic Skills b. Non-verbal:
- Communication Skills 1. Kinesis or Body cues: 55%
- Observation Skills: ability to detect slight 1.1 Facial Expression: two parts
changes in things; sensitivity to recognize of the face that are least
changes susceptible to control – (1)
- Reporting/Recording Skills: an official eyes and (2) corner of the
account of things done mouth.
3. Therapeutic Nurse – Patient Relationship 1.2 Eye Contact
- Is a brief planned goal-focused between 1.3 Gestures: expressing a
the nurse and the client subconscious feeling through
- Usually for 2 weeks actions
- A mutual learning process 2. Paralanguage or Paraverbal or
- It is a responsibility to meet the client’s Paralinguistic cues or vocal cues:
need as perceived by the client. 2.1 Voice Quality:
- In terms of the boundaries of the o Tone of voice
relationship, there is TIME 2.2 Non-language Vocalization:
BOUNDARY, MATERIAL o Crying
BOUNDARY o Sobbing or moaning
o Phases of Nurse-Patient Relationship: 3. Proxemics
a. Pre-meditation Phase 3.1 Territoriality: permanent
® Primary Task space that a person prevents
b. Orientation Phase from intrusion
® To know the reason behind 3.2 Personal Space: temporary
patient’s admission. space that a person prevents
® Gathering demographic data, from intrusion
places, time, and duration § Four Tones
a. Intimate distance (6-8 in.)
® FEED
1
sanchez, s.a.c
 b. Personal distance (1 ½ - 4
ft); known as Comfort
Zone (Hall)
c. Social distance (4-12 ft);
known as Consultative
distance or Business
distance
d. Public distance (12ft or
more)
4. Touch
® most personal of the non-
verbal messages
5. Cultural articles
® hair, clothing, fragrance,
eyeglasses, beard, moustache
• Therapeutic Communication
Þ Purposeful use of dialogue to bring about the
client’s insight, control of symptoms and
promotes healing.
§ Interactive Verbal and Non-verbal
strategies that focus on the needs of
patients facilitate a goal directed patient-
centered communication process.
§ Involves active listening, understanding
the client, promoting insight and
clarification.
§ REMEMBER:
Safety
Encourage expressions of feelings
Assist in solving problems
§ Active listening includes the Five Aspects
of Physical Attending which are:
a. Face to face contact
b. Open posture
c. Maintain eye contact
d. Occasionally lean forward
e. Relatively relax posture
• Non-Therapeutic Responses or Questions
a. “Don’t worry” questions – lacks empathy
b. “Why” question – seeking for reasons, asking
explanations; subjective, conclusive,
threatening, judgmental; places client in a
defensive side (VERY WRONG)
c. Exploratory questions – deep proving; avoid
HOW and WHY
d. Close-ended questions
e. Advising
f. Giving approval – other patients might feel
rejected; the focus of the statement is not the
patient, but the nurse
g. Rejecting
h. Disapproval
i. Agreeing
j. Disagreeing
k. Arguing
l. Challenging
m. Testing – mental status examination – check
patients’ orientation, place, or time;
*The nurse ORIENTS, not examine.
n. Defending
o. Requesting an explanation
p. Indicating the existence of an external source
q. Belittling feelings expressed
r. Using denial
s. Interpreting
t. Introducing an unrelated topic
sanchez, s.a.c
• Therapeutic Responses or Questions
a. Empathetic listening
b. Broad openings
c. Offering general leads (Exploring)
d. Restating: repeating the main idea or main
theme of the patient; echolalia
e. Reflecting – learn from reflecting from
experiences; to go back to one’s feeling and
thoughts; has two types:
§ Reflecting content: fresher, newer, and
fewer words; paraphrasing
§ Reflecting feeling: similar to validation
f. Clarification – encourage client to express
feeling accurately, specifically, and
explicitly.
g. Focusing – can be into circumstantiality,
though an answer can be given; tangentiality,
no answer is given
h. Encourage comparison
i. Using silence
j. Accepting
k. Exploring
l. Offering self
m. Confronting – giving a client feedback that
there is a congruence between verbal and
non-verbal
n. Giving a correct information
o. Seeking Information
p. Presenting reality
q. Voicing out doubts
r. Suggesting Collaboration – empowers the
patient; “perhaps you and I can determine the
source of your anxiety”
s. Encouraging expression
t. Giving recognition
u. Making observation – “I notice that you are
trying”
v. Summarizing – telling what’s important
w. Encouraging formulation of a plan
CHAPTER II: PSYCHODYNAMICS
• Health
® A state of complete physical, mental, and
social well-being and not merely the absence
of disease or infirmity
® There is no health without mental health
• Mental Health
® A state of well-being in which the individual
realizes his or her own abilities, can cope with
the normal stresses of life, can work
productively and fruitfully and is able to
make a contribution to his or her community.
® Is the ability to:
o Meet and handle problems
o Make choices and decisions
o Find satisfaction accepting tasks to carry
on without undue independence on others
o Contribute one’s share in life
o Enjoy
o Be able to love and be loved
• Principles to achieve optimum Mental Health
Nutrition/No to drugs and alcohol
Exercise
2
 Water/Writing
Sunshine/Stress Reduction/Self-care/Support
Talk/Time Management
Air/Act of kindness
Rest and Relaxation
Trust
• Personality
® Sum total of one’s physical, emotional,
social, intellectual, and spiritual well-being
® Enduring patterns of perceiving relating to
and thinking about the environment and
oneself.
§ Two Portions of Personality:
1. Body or Soma – tangible, measurable
2. Mind or Psyche – intangible,
unmeasurable
§ Three Levels of Consciousness:
1. Conscious – functions when a person is
awake
2. Subconscious/Preconscious – safeguards
conscious activities
® compares to the watchman of the
mind
® partly forgotten, partly remembered
3. Unconscious – motivates a person
® Selects what needs to remember
o Methods of Recalling the
Unconscious:
a. Hypnosis by Anton Mesmer
b. Psychoanalysis by Sigmund
Freud
1. Free Association – orientation
phase of the relationship;
word (jokes), dreams,
Freudian slip (pen or tongue),
forgetting important names
and numbers
2. Transference – the experience
of having an intense negative
or positive feeling towards a
person in the present, but this
could be intended towards a
significant person from the
past.
3. Countertransference – if the
feeling of the nurse is
transferred to the client
4. Catharsis – unloading or
venting
§ Defense Mechanism
o Psychological ways of resolving a
problem/conflict
o Use by the ego unconsciously to
reduce anxiety
o Three Psychic Forces:
a. Id – demon in us
b. Ego – human in us
c. Superego – angel in us
1. Identification – ego defense or mental
mechanism through which an
individual, in varying degree, makes
himself or herself like someone else;
he identifies with another person
2. Condensation – fusion of two or more
ideals into one
sanchez, s.a.c
3. Introjection – a higher level of
condensation; occurs when a person
internalizes the ideas or voices of
other people
4. Projection – taking your own
unacceptable qualities or feelings and
ascribing them to other people.
5. Denial – ignoring the reality of a
situation to avoid anxiety.
6. Rationalization – apparent logical
reasons are given to justify behavior
that is motivated by unconscious
instinctual impulses.
7. Intellectualization – involves a person
using reason and logic to avoid
uncomfortable or anxiety-provoking
emotions
8. Suppression – consciously choosing
to block ideas or impulses that are
undesirable, as opposed to repression,
a subconscious process
9. Repression – subconsciously
blocking ideas or impulses that are
undesirable
10. Dissociation – emotional problem is
transformed into psychological
11. Conversion – when mental problems
are turned into physical symptoms;
hysterical fainting
12. Undoing – a reverse reenactment of a
particular act; guilt feelings are
involved; DM of obsessive-
compulsive disorder (OCD)
13. Reaction Formation – primary
defense mechanism in bipolar during
the manic episode
14. Displacement – transferring feeling to
safer object, person, or situation
15. Substitution – individual replaces an
unattainable or unacceptable goal,
emotion, or motive with one that is
attainable or acceptable
16. Sublimation – socially unacceptable
impulses or idealizations are
transformed into socially acceptable
actions or behavior, possibly resulting
in a long-term conversion of the
initial impulse
17. Altruism – doing good for others
without expecting anything in re;
genuine desire
18. Compensation – emphasizing assets
to fill up inadequacies
19. Symbolization – is a mental shortcut
wherein a person attaches meanings
to shape, colors, and objects
20. Withdrawal – it is pathologically
isolating self from others; momentary
withdrawal is effective
21. Fantasy – dwelling into one’s
imagination
§ Coping Mechanism
o Can be constructive and destructive
3
 STRESS
Þ Wear and tear on the body
Þ Any positive or negative occurrence or any
emotion requiring a response
Þ A person has adaptive energy to respond to
any stressor
• General Adaptation Syndrome (GAS)
Þ Specific, predictable, physiologic,
psychosocial responses to stress
§ Three Stages:
1. Stage I: Alarm Reaction
® Mobilization of the body’s defensive
forces and activation of the fight or flight
mechanisms
o Psychosocial Responses: increase
levels of alertness and task-oriented,
defense-oriented inefficient, or
maladaptive behavior may occur
2. Stage II: Resistance
® Optimal adaptation of stress within the
person’s capabilities
o Psychosocial Responses: increase and
intensified use of coping
mechanisms; tendency to rely on
defense-oriented behavior
3. Stage III: Exhaustion
® Loss of ability to resist stress because of
depletion of body resources
o Psychosocial Responses:
a. Defense-oriented behavior
become exaggerated
b. Disorganization of thinking and
personality
c. Sensory stimuli may be
misperceived with appearance of
illusion
d. Reality contact may be reduced
with appearance of elusions or
hallucination
e. If exposure to the stressor
continues stupor or violence may
occurs
• Stress Assumptions
Þ Stress produces physiological and
psychosocial responses
Þ Inadequate handling of stress can lead to
physical or mental illness
• Goals or Approaches to Stress
a. Developing effective coping mechanisms
b. Reduction of body tensions
c. Increasing resources and social support
d. Stress management
ANXIETY
Þ Inner state that stress produces
Þ Fear of the unknown
Þ Vague sense of impending doom
Þ SNS stimulation and manifestation
Þ Stressor that precipitates anxiety is whatever
the individual perceives as a danger, a loss, or
a threat to his safety and security
sanchez, s.a.c
• General Etiology of Anxiety
1. Psychodynamic Theory
® Ego develops defenses to help individuals
to control or cope with anxiety. The need
to cope stems from the conflicts between
the id and the superego – early conflicts
are repressed – later life – person
experiences conflict again – defenses fail
– ANXIETY
2. Interpersonal Theory
® Sullivan interpersonal conflict
3. Biologic Theory
4. Otto Rank Birth Trauma Theory
® Everyone was born to be anxious
• Levels of Anxiety
a. Mild – +
® Increase attention and motivation; total
focus on the situation; no need to use
defense mechanisms; NORMAL
(widened perceptual field)
® Use adaptive mechanisms-like logical
reasoning and problem-solving
b. Moderate – ++
® Narrow perception; decreased attention,
selective inattention, problem-solving
and learning are possible with effort or
assistance
® Use of palliative coping mechanisms;
increasing VS
c. Severe – +++
® Scattered focus; psychologically painful;
mental block, use defense mechanisms
and maladaptive coping mechanisms
® (+) Hyperventilation
® Greatly reduced perceptual field
® No learning, no decision making
® PROD the client: Giving of instructions
d. Panic – ++++
® Personality disorganization; shouting
*Stay with the client, give meds as
ordered
® Out of contact with reality
® Wild and desperate behaviors
® Use of dysfunctional coping mechanism
*Priority: SAFETY
CRISIS
Þ Krinein
Þ Hazard, risky event
Þ Psychological time wherein a person handles
a stress when he finds his old, usual coping
ways to be ineffective
Þ Normal duration to handle a crisis 4-6 weeks
• Crisis Worker should be Active and Directive:
a. + resolution ® with a support system ®
identified problem ® learning opportunity
b. (-) resolution ® without a support system ®
sets in the pre-conscious ® physical or mental
illness
§ May be minor event ® series of stressor ®
severe disorganization ® lack of usual
resources; failure of individual’s coping
mechanism ® CRISIS
• Stages of Crisis
4
 a. STAGE I:
Loss, danger threat ® anxiety ® coping
mechanism ® anxiety not reduced
b. STAGE II:
Anxiety increases ® coping mechanisms
decrease ® person feels pressured and
unable to respond
c. STAGE III: Anxiety continuous to escalate
Person uses every means available to bring
anxiety level and situation under control ®
anxiety uncontrolled
d. STAGE IV:
Anxiety or panic ® depression or psychosis
• Nursing Process in Crisis
1. Assessment
® Immediate precipitant
2. Analysis
a. Ineffective coping – coping mechanisms
are no longer effective
b. Anxiety
c. Risk for Suicide
d. Situational low self-esteem
3. Intervention
® Safety
® Never attack client’s defenses
® Gently encourage client’s positive coping
a. Intervene during the crisis:
o The person is generally receptive to
help
o It takes less time and more effective
o To prevent the development of
dysfunctional coping pattern
o Flexible strategies ® Feelings ®
Extreme rage ® Cognition ®
Consequences
WHO – DOH MENTAL HEALTH
PSYCHOSOCIAL SUPPORT SERVICES
1. Psychosocial First Aid/Band-aid
® First 24 hours of crisis
2. Psychosocial Processing
® A crisis worker’s tool wherein a victim
will become a victor by providing
psychological relief
® Critical Incident Stress Debriefing – a
one shot deal; nonspecialized
therapeutic strategy
a. Introduction: introduce neutral
environment, what is to be done
or expected
b. Facts and Feelings: what has
happened
c. Reactions: could be cognitive,
emotional, physical,
behavioral;
*Assure the client that he/she is a
normal person having a normal
reaction to an abnormal
situation*
d. Identify Coping Styles
e. Assist the person into the
Contingency Plan: formulating a
plan
® Multiple Intervention
sanchez, s.a.c
3. Psychosocial Processing for Children
® Since most children do not have an ability
to use language in expressing feelings,
crisis workers tend to use Color Your Life
Technique (CYLT)
CHAPTER III:
PSYCHOPATHOLOGY
ANXIETY DISORDERS
Þ Excessive fear and anxiety and related
behavioral disturbance for more than 6
months
Þ Usually seen in the medical setting
a. Fear – emotional response to real or
perceived imminent threat or immediate
danger
b. Anxiety – anticipation of future
threat/danger
Anxiety Fear
Free-floating and attached to Specific
specific object or situation
Chronic, subjective feeling Acute
Unconscious Conscious
• Types and Assessment
1. Separation Anxiety Disorder
® Fearful or anxious about separation
from attachment figures to a degree
that is developmentally inappropriate
2. Selective Mutism
® Consistent failure to speak in social
situations in which there is an
expectation to speak even though the
individual speaks in other situations
3. Specific Phobia
® Fearful or anxious about or avoidant
of subjects or situation
® Fear or anxiety of leaving the mother
4. Social Anxiety Disorder (Social Phobia)
® Fearful or anxious about or avoidant
of social interaction and situation that
involved the possibility of being
scrutinized.
5. Panic Disorder
® Recurrent unexpected panic attacks
and is persistently concerned or
worried about having more panic
attacks
o Panic Attacks
a. Abrupt surges of intense fear or
discomfort that reach a peak
within minutes accompanied by
or
physical and/or cognitive
symptoms
b. Can be expected or unexpected
6. Agoraphobia
® Fearful or anxious about two or more
of the following situations: using
public transportation; being in open
space; being in enclosed places;
standing in line or being in a crowd;
5
 or being outside of the home alone in
other situations
® House bound syndrome
7. Generalized Anxiety Disorder
® Persistent and excessive anxiety and
worry about various domains
§ Analysis:
a. Biological Bases – genetics transmission,
decrease GABA
b. Psychodynamic Bases – environmental
factors; repression and displacement
§ NANDA Nursing Diagnosis:
a. Anxiety
b. Self-esteem Disturbance
§ Interventions
a. Recognize the anxiety
b. Establish trust
c. Safety
d. Do not criticize coping mechanisms
e. Do not force to go to situations that
provoke anxiety
f. Environmental modification by setting
limits or limiting interactions with others
g. Provide creative outlets
h. Monitor for signs of impending
destructive behavior
i. Relaxation exercises
j. Monitor vital signs and administer
prescribed anxiolytics
§ Psychopharmacotherapy
a. Anxiolytics
o Benzodiazepines – Alprazolam
(XANAX)
® Take on short term basis because it
causes dependence
® Taper the dose gradually to avoid
convulsion, headache tremor,
vomiting, cramping and sweating
® No to alcohol
® No to caffeine
Side effects
• Drowsiness
• Hypotension
• Confusion
• Headache
• Incontinence
b. Anti-depressant
® A companion of anxiety is
depression. An anxious client
eventually becomes depress because
of the incapacitating effect of anxiety
OBSESSIVE COMPULSIVE AND
RELATED DISORDERS
1. Obsessive Compulsive Disorder
® Presence of obsession, compulsion or
both causing dysfunction
2. Body Dysmorphic Disorders
® Preoccupation with perceived defects or
flaws in physical appearance that are not
observable or appear only sight to others
and by repetitive behaviors or mental acts
(comparing one’s appearance with that of
other people) in response to the
appearance concern
sanchez, s.a.c
3. Hoarding Disorder
® Persistent difficulty discarding or parting
with possessions, regardless of their
actual value, as a result of a strong
perceived need to save the items and to
distress associated with discarding them.
4. Trichotillomania (Hair pulling disorder)
® Recurrent pulling out of one’s hair
resulting in hair loss and repeated
attempts to decrease or stop pulling hair
5. Excoriation (Skin picking) Disorder
(Dermotillomania)
® Recurrent picking of one’s skin resulting
in skin lesions and repeated attempts to
decrease or stop skin picking
§ Analysis:
a. Biologic Bases
o Genetic transmission
o Serotonin transmission
b. Psychodynamic Bases
o Anal phase – anal habit training –
rigid
o Undoing – defense mechanism
§ NANDA Nursing Diagnosis
a. Anxiety
b. Fear
c. Ineffective Coping
§ Interventions
a. Ensure that basic needs of food, rest and
grooming are met
b. Provide time to perform rituals
c. Supportive confrontation (­ awareness of
ritual)
d. Explain expectations, routines, and
changes
e. Empathy
f. Assist with connecting behaviors and
feelings
g. Structure simple activities, games, or task
h. Reinforce and recognize non-ritualistic
behaviors
§ Psychopharmacotherapy
a. Anti-depressants
TRAUMA AND STRESSOR RELATED
DISORDERS
Þ Individuals’ exposure to a traumatic or
stressful event leads to psychological distress
like:
o A hedonic and dysphoric symptoms
o Angry and aggressive symptoms
o Dissociative symptoms – rather than
anxiety or fear-based
1. Reactive Attachment Disorder
® Absent or underdeveloped attachment
between the child and the caregiver
® Depressive symptoms and withdrawn
behavior
® Common etiology is social neglect.
Evident before age 5 years.
Developmental age of at least 9
months.
2. Disinhibited Social Engagement
® Culturally inappropriate, overly familiar
behavior with strangers
6
 ® Common etiology: social neglect
® Developmental age of at least 9 months
3. Posttraumatic Stress Disorder
® Priority: SAFETY (due to guilt feelings)
® Considerations:
a. Stay with client/know whereabouts
b. Verbalization of feelings
a. Criteria A: Exposure
® Exposure to actual or threatened
death, serious injury or sexual
violence
b. Criteria B: Intrusion
® Intrusion symptoms beginning after
the traumatic event
® Intrusive – distressing memories of
the traumatic event are expressed
® Recurrent distressing dreams
® *Dissociative reactions (flashback) or
Nightmares
® Intense or prolonged psychological
distress
c. Criteria C: Persistent Avoidant
d. Stimuli associated with the traumatic
event Criteria D: Negative Alteration
® In cognition and mood associated
with the traumatic event like inability
to remember an important aspect of
the traumatic event
o Duration: More than 1 month with
dysfunctions
4. Acute Stress Reaction
® Criteria:
a. Intrusion Symptoms
b. Negative Mood
c. Dissociative Symptoms
d. Avoidance Symptoms
e. Arousal Symptoms
o Duration: 3 days to 1 month with
dysfunctions
5. Adjustment Disorder
® Development of emotional or behavioral
symptoms in response to an identifiable
stressor occurring within 3 months of the
onset of stressor
® Presence of PTSD criteria A only
(Exposure)
§ Analysis:
a. Biological Bases – genetic transmission
o Increased noradrenergic and
dopaminergic system activity and
decreased serotonergic activity
b. Psychodynamic Bases
o Exposure to a traumatic event
o Temperamental and environmental
o Repression ® Dissociation
§ NANDA Nursing Diagnosis
a. Ineffective Coping
§ Interventions
a. Be nonjudgmental and honest; empathy
and support; acknowledge any unfairness
or injustices related to trauma
b. Assure that their feelings and behaviors
are typical reactions to serious trauma
c. Help patients to recognize the
connections between the trauma
sanchez, s.a.c
experience and their current feelings,
behaviors, and problems.
d. Encourage safe verbalization of feelings
especially anger
e. Encourage adaptive coping strategies,
exercise, relaxation techniques and sleep
promoting strategies
f. Facilitate progressive review of the
trauma and its consequences
g. Encourage patient to establish or
reestablish relationships
§ Psychotherapeutic Strategy
a. Covert rehearsal
§ Psychopharmacotherapy
a. Antidepressant
DISSOCIATIVE DISORDERS
Þ Disruption of and/or discontinuity in the
normal integration of consciousness,
memory, identity, emotion, perception, body
representation, motor control and behavior
Þ Etiology: Frequently found in the aftermath
of trauma
1. Depersonalization/derealization Disorder
® Clinically significant persistent or
recurrent depersonalization and/or
derealization with intact reality testing.
® Feeling = not of oneself
2. Dissociative Fugue
® Inability to recall history of travel
3. Dissociative Amnesia
® Inability to recall autobiographical
information that is inconsistent with
normal forgetting
® Memory loss
® Selective (specific aspect of an event)
® Generalized (identity and life history)
4. Dissociative Identity Disorder
® Presence or two or more distinct
personalities (multiple personality) states
or an experience of possession and
recurrent episodes of amnesia
® Aware or unaware personalities
§ Analysis:
a. Psychodynamic Bases
Repression ® dissociation (walling or
splitting of some areas of personality or
extreme stress) ® emotional stability
§ NANDA Nursing Diagnosis:
a. Sensory Perception Disturbances
b. Sleep Pattern Disturbance
c. Social Interaction Impaired
d. Social Isolation
e. Altered Thought Process
f. Violence potential for self-directed or
directed to others
§ Interventions
a. Trust and support
b. Rule out organic cause
c. Gather data regarding feelings, conflicts
or situations experienced prior to amnesia
or fugue
d. Safety
e. Treatment goal: ultimately integrate the
personalities or memories, if possible so
7
 they can survive or coexist in the original
personality
§ Psychopharmacotherapy
a. Antidepressant – Prozac
SOMATIC SYMPTOM AND RELATED
DISORDERS
Þ Common feature: the prominence of somatic
symptoms associated with significant distress
or impairment
Þ Experiencing bodily signs and symptoms
because of a desire to lift up anxiety
1. Somatic Symptoms Disorder (Somatization
Disorder)
® Excessive thoughts, feelings or behavior
related to the multiple, recurrent,
distressing somatic symptoms (usually
pain) causing dysfunctions for more than
6 months
® Doctor’s shoppers/hopping
® Suicide risk
2. Illness Anxiety Disorder (Hypochondriasis)
® Preoccupation with having or acquiring a
serious illness for at least 6 months
® Extensive worries about health but no or
minimal somatic symptoms
3. Body Dysmorphic Disorders
® Preoccupation of having physical defect
4. Pain Disorder
5. Conversion Disorder (Functional
Neurological Symptoms Disorder)
® Altered voluntary motor or sensory
functions causing clinically significant
distress; e.g., blindness, paralysis,
paresis
® With disability to comparable medical
disease
® TEMPORARY
® Resolution: ACCEPTANCE OF EVENT
® La Belle Indifference (Unilateral
Neglect)
6. Psychological Factors Affecting Other
Medical Conditions
® Psychological or behavioral factors
adversely affect the medical conditions
such as denial of symptoms or poor
adherence to medical recommendation
(e.g., anxiety – exacerbating asthma,
diabetes, cancer, migraine, irritable
bowel syndrome)
7. Factitious Disorder
® Falsification of physical or psychological
signs and symptoms or induction of
injury or disease associated with
identified deception
§ Analysis
a. Biological Basis
® Genetic
b. Psychodynamic Bases
® Stressful life events, developmental
learning, personality, and socio-
cultural factors
§ Defense Mechanisms:
a. Repression
sanchez, s.a.c
b. Denial
§ NANDA Nursing Diagnosis
a. Pain, chronic
b. Post-trauma response
c. Powerlessness
d. Role Performance Altered
e. Interrupted Family Process
f. Impaired Adjustment
§ Interventions
a. Matter of fact, caring approach for
physical symptoms
b. Allow verbalization of feelings and ask to
describe feelings
c. Assist with developing more appropriate
ways to verbalize feelings and needs
d. Positive reinforcement to increase non-
complaining behavior. Set limits by
withdrawing attention from patients when
they focus on physical complaints.
e. Be consistent and have all requests
directed to primary nurse providing care
f. Diversionary activities through
recreational games
g. Do not push awareness of or insight into,
conflicts or behavior
FEEDING AND EATING DISORDERS
Þ Persistent disturbance or eating related
behavior that results in the altered
consumption or absorption of food causing
dysfunctions
1. Pica
® Eating or nonnutritive, non-food
substance for more than 1 month
2. Rumination Disorder
® Repeated regurgitation of food at least 1
month
3. Avoidant/Restrictive Food Intake
® Persistent failure to meet appropriate
nutritional and/or energy needs
4. Anorexia Nervosa
® Persistent energy intake restrictions;
intense fear of gaining weight or of
becoming fat or persistent behavior that
interferes with weight gain and a
disturbance in self-perceived weight or
shape
5. Bulimia Nervosa
® Recurrent episodes of binge and
inappropriate compensatory behaviors to
prevent weight gain
® Self-evaluation that is unduly influenced
by body shape and weight
® Binge eating and purge cycle at least once
a week for 3 months
§ Analysis
a. Biological
® Increase serotonin activity ® food
restrictions
b. Sociocultural Factors
c. Family Factors
d. Cognitive and Behavioral Factors
e. Psychodynamics
8
 ® Regression to a prepubertal state;
attempt to reduce the control of an
over controlling maternal figure
§ NANDA Nursing Diagnosis
a. Altered Nutrition
b. Powerlessness
c. Fluid Volume Deficit
d. Ineffective Individual Coping
e. Disturbance in Body Image
§ Interventions
a. Monitor intake, output, and activity
b. Weigh daily
c. Observe signs of purging
d. Plan for dietitian to meet with patients to
discuss information nutrition and healthy
diet
e. Monitor electrolyte status
f. Empathy
MOOD DISORDER
Þ Prominent feature is the client’s mood
Þ Mood is the inner state of the mind that is
expressed through feelings, emotions, or
affect
® Affect is the external response to
varied state of mood;
measurable/quantifiable
§ Two Extremes of Emotion:
a. Too little – despair and lethargy
b. Too much – vehement energy of mania
DEPRESSIVE DISORDERS
Þ Presence of sad, empty, or irritable mood
accompanied by somatic and cognitive
changes that lead to dysfunctions.
§ Triad of Depression
7. Feelings of worthlessness and
excessive guilt
8. Inability to think, concentrate, decide,
and remember (pseudodementia,
false dementia – down cast head;
drooping facial expression) (true
dementia – apathetic)
9. Recurrent thought of death, suicidal
ideation, suicidal attempt or with or
without specific plan to commit
suicide
Grief Process Major Depressive Disorder
Predominant affect is feeling of Persistent depressed mood and
emptiness and loss inability to anticipate
happiness or pleasure
Dysphoria is likely to ¯ in Dysphoria is more persistent
intensity over days to weeks and and not tied to specific
occurs in waves tend to be thoughts or preoccupation
associated with thoughts and
reminders of the decreased
Pain of grief may be Pervasive unhappiness and
accompanied by positive misery
emotions and humor
Thought content features a Self-critical and pessimism
preoccupation with thoughts and
memories of the deceased
Self-esteem is preserved Feelings of self-worthlessness
and self-loathing
If self-derogatory ideation is Worthlessness
present, it typically involves
perceived feelings
Thoughts are about death and Thought of ending one’s life
dying are generally focused on because of worthlessness and
the deceased and possibly about the pain of depression
“joining” the deceased

2. Persistent Depressive Disorder (Dysthymia)

® Depressed mood for most of the day, for
more days than not for at least 2 years and
1 year for children and adolescence
Grief Process Depression ® Mood is irritable
Normal loss Pathological: Abnormal, 3. Premenstrual Dysphoric Disorder
imagine loss
® Lability, irritability, dysphoria and
Symbolic
Harmonious relationship Ambivalent relationship (may
anxiety symptoms that occur repeatedly
result to guilt feelings) during the premenstrual phase of the
Exogenous Endogenous (chemical cycle and remit around the onset of
imbalance) menses or shortly thereafter
Shorter Prolonged 4. Disruptive Mood Dysregulation Disorder
Spontaneously recall Self-blaming ® Severe, chronic, persistently irritable or
negative and positive angry mood in between the severe temper
experiences with the loss
outburst that is present 3 or more times
per week for at least 1 year and noticeable
1. Major Depressive Disorder by others in the child’s environment
¨ Criteria:
® Client between 6 years old to 18 years old
1. Depressed mood most of the day
5. Unspecified Depressive Disorder
2. Markedly diminished interest or
® With peripartum onset – the full criteria
pleasure
of major depressive episode are not met
3. ¯ in appetite ® weight loss, ¯ sexual
® Onset of mood symptoms occur during
libido
pregnancy and 4 weeks after delivery
4. Hypersomnia or insomnia
§ Analysis
5. Psychomotor retardation or
a. Biological Bases
retardation
o Hypofunction of the hypothalamus
6. Fatigue or loss of energy
9
sanchez, s.a.c
 o ¯ serotonin, dopamine, and
norepinephrine
o Dysregulation of acetylcholine and
GABA
o Genetics
o Circadian Rhythm changes
b. Psychodynamics Bases
o Psychological Theories
1. Adverse life experiences
2. Loss, stress, intrapsychic conflict
o Psychoanalytical Theory
1. Repression, denial, introjection,
magical thinking
2. Strong superego ® internalized
hostility ® turned inward ®
SUICIDE
o Cognitive Theory
1. All stressful situations are
negative
§ NANDA Nursing Diagnosis
a. Risk for suicide
b. Dysfunctional Grieving
c. Self-esteem Disturbance
d. Hopelessness
e. Powerlessness
§ Interventions
1. Risk for Harm
a. Significant others
b. Self
2. Activities
a. Achievable activities so that they
experience success;
b. Walk with patient ® small group
activities ® large group
3. Nutrition
4. Hygiene Care
5. Sleep Pattern
6. Altered Thought Process
§ Psychopharmacotherapy
a. Tricyclic Anti-depressants (TCAS)
® S/E: orthostatic hypotension, urinary
retention, constipation, manic states,
cardiac arrhythmia
b. Monoamine Oxidase Inhibitors (MAOIs)
® Avoid tyramine-rich food ®
hypertensive crisis (initial symptom –
occipital headache)
c. Selective Serotonin Reuptake Inhibitors
® Fluoxetine – Prozac
® S/E: ¯ sexual libido, impotence,
nausea and vomiting, tremors
¨ Key Points in administering
Antidepressants
1. Most antidepressant have a lag time
of 1-4 weeks after the full clinical
effect occurs ® they have more
energy to carry out suicide
2. Watch out for hoarding of medicines
TCAs and Lithium carbonate can be
toxic
3. Observe for early signs of toxicity
BIPOLAR AND RELATED DISORDERS
sanchez, s.a.c
1. Bipolar Disorder I
® May have been precede by manic episode
(at least 1 week) and may be followed by
hypomania (at least 4 days) or major
depressive episode (at least 2 weeks),
severe to cause marked impairment and
hospitalization to prevent harm to self and
others or there are psychotic symptoms
¨ Criteria for Manic Episode
o Inflated self-esteem or grandiosity
o ¯ need for sleep (feels rested after
only 3 hours of sleep)
o More talkative that usual or pressure
to keep talking
o Flight of ideas or thought racing
o Distractibility
o ­ in goal-directed activity (socially at
work or school) or psychomotor
agitation (non-goal directed activity)
o Excessive involvement in activities
with painful consequences
o Elevated, expansive or irritable mood
– ­ norepinephrine ® DEATH
§ Severe to cause dysfunctions and
hospitalization
¨ Criteria for Hypomanic Episode
o At least 4 days present
2. Bipolar II
® One or more major
3. Cyclothymic Disorder
® Chronic (at least 2 years for adult or 1
year in children or adolescent) fluctuating
mood disturbance of numerous periods of
hypomanic symptoms and periods of
depressive symptoms
§ Analysis
a. Biological Bases
o Genetic
o ¯ Serotonin, ¯ acetylcholine, ¯
dopamine
o ­ norepinephrine
b. Psychodynamic Bases
o Defense mechanisms – denial and
reaction formation
o Faulty family dynamics
§ NANDA Nursing Diagnosis
a. Injury, Potential for
b. Sleep Pattern Disturbances
c. Risk for Suicide
§ Interventions
1. Safety
Simplify environment by reducing
Stimuli
Serve foods in the run
Set limits
2. Matter-of-fact
3. Homogenous grouping
§ Psychopharmacotherapy
1. Lithium Carbonate
o Starting dose 600 mg TID
maintenance 900-1200 mg/day and
maintenance level of 0.6-1.2 mEq/L;
therapeutic level can be reached 7-10
days after
o ¯ Sodium, ­ Lithium carbonate –
Lithium toxicity or hyponatremia
10
 o ­ Sodium, ¯ Lithium carbonate – no
therapeutic level
*3-6 grams of sodium and 3-4 liters of
water – to get therapeutic level
2. Carbamazepine
o Anti-convulsant
o With mood stabilizing qualities
3. Valproic Acid
o Anti-convulsant
o With mood stabilizing qualities
4. Atypical neuroleptics
PERSONALITY DISORDERS
• Schizophrenia Spectrum and Other Related
Disorders
Þ Worst among the mental disorders
Þ A group of disorder that is characterized by a
disturbance in thoughts (autism, idea of
reference coming from a stimulus, associated
looseness, delusion = no stimulus), feelings
(apathy and ambivalence), behavior
(regression and withdrawal), and perception
(auditory hallucination, visual hallucination
is rare) for >6 months
§ Clinical Types
o Schizophrenia Paranoid Type
® One or more delusion ® aggression
® most dangerous
® Hallucinations are fixed
® Grandiose delusion
® Frequent, command hallucinations
® Extreme withdrawal
® Suspiciousness
® Hypercritical and sarcastic
® Unfounded jealousy (projection)
³ Distance: not nearer than 4 feet
³ Gradual movements
³ Never whisper in their presence
³ Never hold complicated instruments
in their presence
³ Do not touch the patient, unless
consent is given
³ NO TO GROUP THERAPY but
encourage SOLITARY ACTIVITY
(close concentration removes client’s
delusion)
³ Serve foods in sealed containers
³ Let the patient be the first to get the
food tray
o S. Catatonic Disorganized Type
a. Catatonic Stuporous Phase
® Automatism (waxy flexibility),
negativism (catalepsy)
b. Catatonic Excitement Phase
sanchez, s.a.c
® Repetitive, impulsive activities
without stimulus
o S. Hebephrenic Type
® Regressed behaviors (dancing
without music, eating feces and
secretions, silly giggles)
® Somatic delusions (pregnancy, pain)
o S. Undifferentiated Type
® No prominent symptoms
® Hallucinations varies
o S. Residual Type
® No more positive symptoms –
presence of unusual thoughts and
behavior
Hallucination
Associated looseness
Delusion
® Presence of negative symptoms –
absence of what should be
Avolition: absence of a voluntary
activity
Alogia: absence of words
Akinesia: absence of movement
Apathy: absence of feelings
Anhedonia: absence of pleasure
1. Schizotypal (Personality Disorder)
® Under psychotic disorders but discussed
in personality disorder
2. Delusional Disorder
® Presence of one or more delusions that
persist for at least 1 month; functioning
not markedly impaired and behavior is
not obviously bizarre or odd
o Subtype: can be
a. Erotomaniac type – another person is
in live with the individual
3. Brief Psychotic Disorder
® Sudden onset of at least one of the
positive psychotic symptoms
(hallucinations, delusion, disorganized
speech; incoherent) or grossly abnormal
psychomotor behavior including
catatonia
o Duration: at least 1 day to less than a
month
4. Schizophreniform Disorder
® At least one of these: hallucination,
disorganized speech, delusion
® Grossly disorganized or catatonic
behavior
® Negative symptoms at least a month but
less than 6 months
5. Schizophrenia
® At least one of these must be 1, 2, and
3
§ Analysis
a. Biological Bases (Nature)
® Genetic, increased dopamine in
dopamine receptor sites; decreased
cortical blood flow particularly in the
pre-formal
b. Psychodynamics Bases (Nurture)
1. Developmental Theories
o Freud: poor ego boundaries;
fragile ego and arrested
psychosexual development
11
 o Erickson: trust vs mistrust crucial
to later interpersonal relationship
o Sullivan absence of warm,
nurturing attention during the
early year blocks the expression
in the later years
2. Family Theories
o Vulnerability – Stress Model
§ NANDA Nursing Diagnosis
1. Altered Thought Process
2. Sensory Perceptual Alteration
3. Impaired Verbal Interaction
4. Impaired Social Interaction
§ Interventions
a. Generalized Principles
o Be calm when talking with patient
o Accept patients as they are but do not
accept all behaviors
o Keep promises
o Be honest
b. Basic Interventions
o Do not reinforce hallucination or
delusion
o Orient to person, place, and time
o Do not touch without warning
o Avoid whispering and laughing in
their presence
o Reinforce positive behaviors
o Avoid competitive activities
o Do not embarrass
o For withdrawn, start with one-on-one
interaction
o Allow verbalization of feelings
o Help identify stressor that may
precipitate hallucination or delusions
o Focus on real people and real events
§ Psychopharmacotherapy
® Neuroleptics or antipsychotics
® Desired effects are sedation, emotional
quieting, psychomotor slowing
1. Typical or traditional neuroleptics
a. Chlorpromazine
® ¯ potency
® SE: more of anticholinergic effects
b. Haloperidol
® ­ potency
® SE: more of EPS; dystonia (robot-
like; threatening on the part of the
client, difficulty in talking and
swallowing ® choking, protrusion of
the tongue), akathisia (motor
restlessness, apathetic = ¯ dose),
parkinsonism (pill rolling
movement), tardive dyskinesia (give
meds and refer; involuntary
movement and irreversible)
2. Atypical or Novel Neuroleptics
a. Clozapine
® SE: Agranulocytosis (blood exam
weekly for 18 weeks and monthly
thereafter; fever, sore throat, and gum
bleeding), few EPS and good for
treatment resistant
b. Risperidone
sanchez, s.a.c
® AE: Neuroleptic Malignant (presence
of uncontrollable fever; all VS are
elevated; muscular rigidity)
c. Olanzapine
SUBSTANCE RELATED DISORDERS
• Two Types:
a. Substance Used
Þ Cognitive behavioral and physiological
symptoms indicating that the individual
continues using the substance despite
significant substance related problems
Þ Applied in all substances except caffeine
1. Abuse – ingesting nonmedically
prescribed substances causing family,
societal, legal, and occupational problems
¨ Criteria:
o Craving; Impaired Control –
subjective desire for the substance
o Social Impairment – no longer being
sociable
o Risky Use
o Withdrawal symptoms – the physical
need for the substance
o Compulsion – the psychological need
for the substance
o Tolerance – gradual increase of the
dose to get its desired result
® 2-3 bots = 0.10%-0.15% BALC
¨ Alcohol
³ CNS depressant ® inhibits center ®
uninhibition (ataraxia) ® heightened
spirit ® euphoria ® lowering of
superego forces ® *wears off*
SHAME AND GUILT
³ Physical consequences:
o Hangover – 4-6 hours;
accumulation of HCl and
acetaldehyde in the blood
o Blackout – anterograde amnesia
o Acute alcohol withdrawal – 1-2
days after a heavy drinking;
symptoms of hangover is present,
mild tremors, Rhum fits, and
tactile hallucination
o Delirium – due to alcohol
(delirium tremens); no food ®
nonstop ® when stopped, occurs
2-3 days after drinking ® fatal ®
may die of CEREBRAL
EDEMA; visual hallucinations
2. Dependence
b. Substance Induced
Þ Cognitive behavioral and physiological
symptoms contribute to the continued use
despite significant substance related
problems
1. Intoxication
2. Withdrawal
§ Encompass 1o separate classes of drugs
a. Alcohol
b. Caffeine
c. Cannabis
d. Hallucinogens
12
 e. Inhalants a. Constricted pupils
f. Opioids b. Decrease respiration
g. Sedatives, hypnotics and anxiolytics c. Drowsiness
h. Stimulants d. Euphoria
i. Tobacco e. Hypotension
j. Other unknown substances f. Memory impairment and judgment
• Drug Dependency g. Psychomotor retardation
A. CNS Depressants h. Slurred speech
® Alcohol, sedatives, hypnotics like o Overdose
benzodiazepines and barbiturates ® Respiratory depression, shock, coma,
o Barbiturates: seizures and DEATH
a. Oral dosage: 1 gram (serious ® Treatment: Naloxone
poisoning), 2-10 grams (fatal) o Withdrawal
b. Avoid other CNS depressants like Diarrhea, diaphoresis
alcohol Anxiety and irritability
® Must be given in small doses Cold or flu-like symptoms
® Sudden withdrawal will cause Abdominal cramps
acute psychosis Nausea and vomiting
o Intoxication o Treatment
® Drowsiness, hypotension, a. Methadone or tapering dosage
impairment of memory, attention, b. Clonidine (Catapres) reduce
judgment and social or occupational withdrawal discomfort
functioning, incoordination and D. Hallucinogens
unsteady gait, irritability and slurred o Natural – Cannabis Sativa
speech o Synthetic – LSD, Ecstasy
o Withdrawal o Intoxication
® Nausea and vomiting, tachycardia, ® Terrifying psychosis-like reaction,
diaphoresis, irritability, tremors, hallucinations, depersonalization,
insomnia, and seizures anxiety, confusion, paranoid
o Treatment reactions, (frank psychosis – bad trip)
® Lower dose gradually Good trip (psychedelic and euphoric
o Sudden withdrawal ® DEATH effects)
B. CNS Stimulant o Overdose
® Amphetamines, cocaine, crack ® Psychosis, brain damage and DEATH
o Intoxications o Treatment
Tachycardia a. ¯ environmental stimuli and
Euphoria anxiolytics
Evident weight loss E. Inhalants
Potential for violence o Hydrocarbon solvents
Pupillary dilatation ® Gasoline and glue, aerosol
Paranoid, delusion, hallucination propellants and anesthetics, butane,
Psychomotor retardation or agitation paint-thinner, paint and wax remover
Insomnia and nail polish remover
Impairment of judgment and social or o Intoxication
occupational functioning a. Enhancement of sexual pleasure
Nausea and vomiting b. Euphoria
o Over dosage c. Excitation followed by drowsiness,
® Respiratory distress, ataxia, lightheadedness, disinhibition and
hyperpyrexia, seizures, coma, stroke, agitation
myocardial infarction, DEATH d. Giggling and laughter
® Treatment: Antipsychotics and o Overdose
management of associated effects ® Damage to the nervous system
o Withdrawal o Side effects
Fatigue ® Mouth ulcers; gastrointestinal
Anxiety problems, anorexia, confusion,
Apathy headache, and ataxia
Disorientation o Treatment
Insomnia a. Supportive
Increase appetite F. Caffeine Intoxication
Craving ® High dosage in excess of 250mg;
o Treatment restlessness, nervousness, excitement,
a. Antidepressant insomnia, flushed face, diuresis,
C. Opioids gastrointestinal disturbance, muscle
o Narcotics, codeine, morphine twitching, rambling flow of thoughts and
(methadone), heroin, Demerol, opium speech, tachycardia or cardiac
o Intoxication
13
sanchez, s.a.c
 arrhythmia, inexhaustibility and 1. Delirium
psychomotor agitation; dysfunctions ® Disturbance of attention or awareness
o Withdrawal accompanied by a change in baseline
a. Within 24 hours – headache; marked cognition
fatigue or drowsiness, dysphoric 2. Major or mild neurocognitive disorders
mood, depressed mood, irritability, and their etiological subtypes (NCD due
difficulty in concentrating, and flu- to Alzheimer’s disease, vascular NCD)
like symptoms a. Major NCD – cognitive deficit
G. Non-substance Related Disorders interferes with independence in
1. Gambling Disorders everyday activities. Decline from a
® Persistent and recurrent problematic previously attained level of
gambling behavior leading to functioning
clinically significant impairment or b. Mild NCD – cognitive deficits do not
distress in a 12-month period interfere with capacity for
§ Biological Bases independence; modest cognitive
a. Genetics decline from a previous level of
b. Activation of the brain reward performance
system ® impairs brain
inhibitory mechanism
§ Psychodynamics Delirium Major and Mild NCD
a. Strong oral tendencies • Few hours to 1 month • More than 1 month
§ Defense Mechanisms: (usually 1 week)
a. Denial • Acute temporary, • Gradual in onset progressive
reversible in course
b. Rationalization
• Assessment • Assessment
c. Projection Acute confusion and Chronic confusion
d. Minimization anxiety Confabulation
§ NANDA Nursing Dx Sleep-wake disturbance Amnesia
a. Ineffective Coping Irritability Agnosia
b. Family Processes Altered Disturbance in Aphasia
c. Risk for Violence attention/awareness Apraxia
§ Interventions Extreme restlessness Apathy
• Analysis: Risk and • Analysis
1. Safety
Prognostic Factors a. Environmental – traumatic
2. Care during the acute phase a. Environmental – brain injury
® Thiamine (vehicle for glucose) functional impairment, b. Genetic and physiological
*Alcohol interferes Thiamine with immobility, history of 1. Age
absorption falls, low levels of 2. Down’s syndrome
® Magnesium sulfate activity, use of
*For seizure prevention psychoactive drugs
b. Genetic and
3. Alcohol-free environment physiological
4. Matter-of-fact • NANDA Nursing Dx • Nursing Dx
*Firmly consistent, objective, and a. Acute confusion a. Chronic confusion
nonjudgmental b. Sensory Perceptual b. Thought Process
5. Detoxify Alteration Alteration
6. Resocialization • Highest Priority – maintain • Highest Priority – maintain
• Nursing Intervention for all Substance life optimal level of functioning
Related Disorders a. Remove the cause a. Well-lit rooms
b. Manage the symptoms b. Non-slippery floors
1. Confrontational strategies judiciously through c. Safety devices
2. Tough love nursing care and • Feelings – family – educate
3. Point out consequences of behavior environmental • Flexible activities
4. Non-judgmental attitude manipulation • Reality orientation – mild
® Matter-of-fact c. Emotional support impairment
5. Life style change d. Physical comfort • Reminiscence Therapy –
6. Education severe impairment
7. Self-help group • Life Review Therapy
• Clocks, calendars with big
numbers
• Concrete short directions
NEUROCOGNITIVE DISORDERS • Care self
Þ Primary clinical deficit is cognitive functions • Community
Þ Acquired rather than developmental • Consistent caregiver and
³ Cognitive domains: environment
Perception
Orientation 3. Major NCD due to another medical
Reasoning condition
Memory
Attention
³ Classification PERSONALITY DISORDERS (APA)
14
sanchez, s.a.c
 Þ No behavioral symptoms (no hallucination, d. Point out consequences of
delusions, etc.) behavior
Þ Enduring pattern of inner experience and e. Group them with the same
behavior that deviates markedly from the diagnosis
expectations of the individual’s culture, is 2. Borderline PD
pervasive and inflexible, has an onset in ® Instability in interpersonal relationships,
adolescence or early adulthood, is stable self-image, and effect and marked
overtime and leads to distress or impairment impulsivity
• Cluster A Personality Disorder (Odd or o Analysis
Eccentric) a. Biological Bases
1. Paranoid Personality Disorder ® Inadequate regulation of
® Distrust and suspiciousness such that serotonin, dopamine, etc.
others motives are malevolent b. Psychodynamic Bases
2. Schizoid Personality Disorder ® Environmental Factors: traumatic
® Hermit-life lifestyle home environment
® Detachment from social relationships and ® Stress-related events trigger
restricted range of emotional expression vulnerable temperament remind
3. Schizotypal Personality Disorder earlier trauma
® Acute discomfort in close relationships, ® DM: Splitting: views self and
cognitive or perceptual distortions and others as either all good and bad
eccentric of behavior ® Recurrent self-minimum – cry for
o Analysis help, expression of intense anger,
a. Biological Bases block emotional pain, reality
• Genetics testing
b. Psychodynamic Bases o Nursing Dx
• Oral Phase – under gratified a. High risk for self-mutilation
• Stressful environment b. Ineffective Coping
o Nursing Dx o Interventions
a. Altered Family Process a. Empathy
b. Defensive Coping b. Safety
c. Impaired Verbal Communication c. Assist in finding acceptable ways to
o Interventions express anger and rage
a. Trust – being honest, non-intrusive d. No self-harm contract to decrease
b. No to group therapy self-harm and suicide
• Cluster B e. Journaling
Þ Dramatic, emotional, erratic f. Consistency
1. Anti-social PD g. Limit setting, supportive
confrontation to manipulative
® Disregard for and violation of the rights
behavior
of others
o Analysis h. Offer superficial solutions to their
problem = “safer” and less frustrating
a. Biological Bases
for then nurse
• Genetic
3. Histrionic PD
• Physiological - ­ norepinephrine to
® Excessive emotionality and attention
prepare their body for flight or fight
seeking
b. Psychodynamic Bases
o Analysis
• Anal Phase – lax ® poor impulse a. Psychodynamic Bases
control
• Mother negates the child’s inner
• Unstable family pattern feelings
• Inconsistent family pattern • Child turns to father for nurturance
• Low frustration tolerance • Father responds to the child’s
o Nursing Dx dramatic/emotional behavior
a. Defensive Coping o Interventions
b. High risk for violence: Self-directed a. Positive reinforcement like praise for
or directed at others unselfish or other centered-behavior
o Interventions 4. Narcissistic PD
® Keys in working with them: ® Grandiosity, need for admiration and lack
Consistency by the nursing staff and of empathy
accountability by the client o Analysis
a. Long term treatment in a
® Parents fail to mirror what is
therapeutic milieu for lasting
appropriate or inappropriate back to
changes to occur
the child
b. Set firm limits
o Interventions
c. Consistent in confronting
a. Supportive confrontation
behavior and enforcing rules and
b. Limit setting and consistency
policies
• Cluster C – Anxious and Fearful
15
sanchez, s.a.c
 1. Avoidant PD
® Social inhibition, feeling of inadequacy
and hyper sensitivity to negative
evaluation
o Analysis
® Few genetic, biological, and
psychological studies have been
conducted
o Interventions
a. Allow verbalization of feelings
b. Assertion and social skills training
c. Stress reduction or relaxation
techniques
2. Dependent PD
® Submissive and clinging behaviors
related to an excessive need to be taken
care of.
o Analysis
® Psychosocial Theories – culture
o Interventions
a. Manage anxiety
b. Assertiveness training
3. Obsessive Compulsive PD
® Preoccupation with orderliness,
perfectionism, and control
o Analysis
® Biological – genetics
® Psychosocial Theories – culture
® Psychodynamics – Anal phase (rigid)
o Interventions
a. Support in exploring feelings
b. Confront – procrastination and
intellectualization
c. Teach client to understand that it is
alright to make mistakes
NEURODEVELOPMENTAL DISORDER
Þ Often before the child enters grade school
and characterized by developmental deficits
that produce impairments of personal, social,
academic, or occupational functioning
1. Intellectual Disability
® A disorder with onset during the
developmental period that includes both
intellectual and adaptive functioning deficits
in conceptual, social, and practical domains
® IQ: ¯ 65-75 (70+5)
o Analysis
a. Biological
³ Genetics, intrauterine environment –
alcohol, drugs, toxins, teratogens
³ Perinatal – variety of labor and
delivery related events leading to
neonatal encephalopathy
³ Post-natal – hypoxic ischemic injury,
traumatic brain injury, infections,
seizure disorder, intoxications (lead
mercury)
b. Psychodynamics
³ Severe and chronic deprivations
o Nursing Dx
a. Risk for injury
b. Family pattern disturbances
o Interventions
a. Safety
sanchez, s.a.c
b. Meaningful relationship
c. Family therapy
d. Nutritional needs
e. Opportunities to explore environment
f. Empathy
g. Play therapy
2. Communication Disorder
® Deficits in language, speech, and
communication
3. Autism Spectrum Disorder
® The child has no interpersonal skills
® Common among males
® Persistent impairment in reciprocal social
communications and social interaction and
restricted, repetitive patterns of behavior
interest of activities
® Age of onset: 12-24 months – others are
earlier than 12 months of symptoms are
severe
® Pica is present, no eye contact and interest in
inanimate, bright spinning objects
® Presents a lack of interest in social interaction
– 1st year of life
® Some may experience developmental
plateaus or regression with a gradual or
relatively rapid deterioration in social
behavior or use of language often during the
first 2 years of life – red flag.
o Analysis
a. Biological
³ Genetic, advanced parental age, low
birth weight, fetal exposure to
valproate
b. Psychodynamics
³ Environmental
o Nursing Dx
a. Risk for injury
b. Family pattern disturbances
o Interventions
a. Protective care
b. Firm and consistent
c. Love and belongingness
d. Reality orientation
e. Facilitate optimal ability
f. Family therapy
g. Nutritional needs
4. Attention Deficit Hyperactivity Disorder
(ADHD)
® Persistent pattern of inattention, and/or
hyperactivity, impulsivity that interferes with
functioning or developmental for more than 6
months
® Symptoms present before age 12 in two or
more settings (e.g., home, school, work);
with friends or relatives; in other activities
o Analysis
a. Biological
³ Mild dysfunction of the frontal lobe –
responsible for planning,
concentration and motor regulation
³ Genetics and physiological
³ Brain damage
³ Hypersensitivity to good additives
³ Perinatal insult
³ Lead poisoning
b. Psychodynamics
16
 ³ Severe and chronic deprivations ® Recurrent daytime naps or lapses into sleep
³ Born to parents with mental illness occurs daily but must occur at a minimum of
and alcoholism 3x week for 3 months
³ Urban dwellers ® It produces cataplexy (loss of muscle tone)
³ Unpredictable family situation o Analysis
o Interventions a. Biological
® Improve the child’s ability to “STOP, ³ Genetic; physiological; head trauma
LOOK, and LISTEN” before acting b. Psychodynamics
a. Social skills training ³ Temperamental; environmental –
³ Role playing – for children streptococcal throat infection or
³ Psychodrama – for adults winter infections
b. Problem-solving skills training 4. Breathing – related Disorders
c. Parent training on: ® Obstructive sleep apnea/hypopnea
³ Self-awareness enhancement a. Apnea – total absence of airflow
³ Creative stress reduction techniques b. Hypopnea – reduction in airflow
³ Clear limits concerning unwanted
behavior
³ Positive reinforcement (praise and DISRUPTIVE IMPULSE CONTROL AND
tangible rewards) for desired CONDUCT DISORDERS
behaviors Þ Poorly controlled behaviors that violate the
³ Mild punishment like time-out rights of others or that violate major societal
*not recommended since it provokes norms.
the feelings of the child • Types
o Psychopharmacotherapy 1. Oppositional Defiant Disorder
a. Methylphenidate (Ritalin) – mild CNS ® A pattern of angry/irritable mood,
stimulant; it will stimulate the frontal argumentative/defiant behavior and
lobe, improving concentration vindictiveness for at least 6 months
Side Effects Nursing Considerations o Analysis
Loss of appetite Give immediately before a. Biological
or with meals
³ Abnormalities in the pre-frontal
Insomnia Give 4 hours before sleep
Loss of weight Monitor body weight
cortex and amygdala
Mood lability, tics, Prevent from injury b. Psychodynamics
abnormal movements ³ Temperamental: increase levels
Overfocused on details Supervise of emotional reactivity
b. Atomoxetine – Strattera (non-CNS ³ Poor frustration tolerance
stimulant); ³ Environmental: harsh, neglectful
inconsistent child rearing
practices
SLEEP – WAKE DISORDERS 2. Conduct Disorder
1. Insomnia Disorder ® Repetitive and persistent pattern of
o Analysis behavior in which the basic rights of
a. Precipitating events others or major age-appropriate societal
³ Severe stress (separation) Chronic norms or rules are violated in the past 12
daily stress months; at least one of the following are
b. Perpetuating factors present in the past 6 months
³ Poor sleep habits, irregular sleep ³ Aggression to people and animals
scheduling, fear of not sleeping ³ Destruction to property
c. Temperamental ³ Deceitful or theft
³ Anxiety or worry prone personality, ³ Serious violations of rules
cognitive styles, increase arousal ® Begins before age 13 and with
predisposition, and increase tendency clinically significant impairment
to repress o Analysis
d. Environmental a. Biological
³ Noise, light, high or low temperature ³ Genetics – increase in children
2. Hypersomnolence Disorder with biological or adoptive
® excessive quantity of sleep (>9 hours/day that parents or a sibling with conduct
is nonrestorative or unrefreshing) and disorder
difficulty being fully awake after abrupt ³ Family history of mental illness
awakening ³ Structural and functional
® accompanied by recurrent periods of sleep or differences in frontal-temporal
lapses within the same day; with significant limbic connections
distress or impairment in functioning b. Psychodynamics
3. Narcolepsy ³ Environmental: family – parental
rejection and neglect; inconsistent
child rearing practice; harsh
17
sanchez, s.a.c
 discipline; physical and sexual 9. Be certain that expectations are within the
abuse; early institutional living child’s developmental parameters
frequent changes of caregivers; 10. Clearly outline consequences for
association with delinquent peer unacceptable behavior, and follow through
group on their implementation
³ Temperamental: under control
infant temperament, low verbal
IQ
o Treatment
a. Psychopharmacotherapy
³ Mood stabilizers
³ Methylphenidate
b. Psychosocial Method
³ Therapeutic Play
³ Family therapy
³ Individual Therapy – provision of
vehicle for the safe acting out of
feelings like role playing, games,
journals
3. Intermittent Explosive Disorder
® Impulsive (anger-based) aggressive
outbursts with rapid onset and typically
little or no prodromal period lasting for
less than 30 minutes
® Commonly occur in response to minor
provocation by a close intimate or
associate
4. Pyromania
® Multiple episodes of deliberate and
purposeful fire setting with affective
arousal before setting fire
® Experience pleasure, or gratification
when setting fir, witnessing its effect or
participating in its aftermath
5. Kleptomania
® Recurrent stealing things which have
little or no value
® Sense of tension immediately before the
theft ® pleasure gratification or relief
while stealing
o Nursing Dx
a. Anxiety
b. Impaired social interaction
c. Ineffective coping
d. Risk for violence
e. Self-esteem disturbance

Helping Children who Exhibit Disruptive

Behavior
1. Praise accomplishments through touch,
verbal affection, or small rewards such as
stickers or stars on an activity calendar
2. Model desirable traits, such as sharing and
honesty
3. Acknowledge positive or desirable behaviors
4. Correct unacceptable or undesirable
behaviors immediately and calmly
5. Communicate that the behavior, not the child,
is unacceptable
6. Have the child help determine acceptable
behavior parameters
7. Explain expectations in clear terms
8. Ensure that the child understands
expectations by asking the child to repeat
instructions

18
sanchez, s.a.c