DIAGNOSTIC CRITERIA
WEEK 7
Mood Disorders
● Also referred to as an affective disorder
● DSM 5 – Bipolar and Other Related
Disorders
● Mood disorder is a broad term used to
include all the different types of depressive
and bipolar disorders, both of which affect
the individual’s mood and major functioning.
(OES function of individual)
● Mood may range from extremely low
(depressed) to extremely high (mania).
Types of Mood Disorders in the DSM 5
Classification
Unipolar Disorder (one mood only)
1. Major depressive disorder (MDD)
2. Persistent depressive disorder (PDD)
3. Disruptive mood dysregulation disorder
(DMDD)
4. Seasonal Affective Disorder (SAD)
5. Psychotic Depression
6. Peripartum/Postpartum Depression
7. Premenstrual Dysphoric Disorder (PMDD)
8. 'Situational' Depression
9. Atypical Depression
10. Melancholic Depression
Bipolar Disorder (two moods) – mania and
depression
1. Bipolar 1 Disorder
2. Bipolar 2 Disorder
3. Cyclothymic
DEPRESSION
The persistent feeling of sadness and emptiness
“THE LOW”
DEPRESSIVE DISORDERS
1. MAJOR DEPRESSIVE
DISORDER
● Also referred to as the
MAJOR
DEPRESSION or
CLINICAL
DEPRESSION
● It involves periods of extreme sadness,
accompanied by a variety of physical,
cognitive, and emotional symptoms
● Symptoms present at least 2 weeks almost
everyday
● Cause significant distress or severely
impaired major functioning.
DSM 5 DIAGNOSTIC CRITERIA
● Five of the following symptoms are
present during the 2-week period and a
change from previous functioning
- one of the symptoms is either (1)
depressed mood or (2) loss of interest or
pleasure.
1. Depressed mood nearly every day
e.g., feeling sad, empty, or hopeless, appears
tearful, irritable mood.
2. Markedly diminished interest or pleasure in
all
3. Weight loss when not dieting or weight gain
⬆️ ⬇️
e.g., a change of more than 5% of body weight in a
month, or or in appetite
4. Insomnia or hypersomnia Fatigue or loss of
energy
5. Psychomotor agitation or retardation
6. Feelings of worthlessness or excessive or
inappropriate guilt
7. Diminished ability to think or concentrate, or
indecisiveness(either by subjective account
or as observed by others).
8. thoughts of death (not just fear of dying),
suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for
committing suicide.
● The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.
● .The episode is not attributable to the
physiological effects of a substance (e.g., a
drug of abuse, a medication) or another
medical condition.
● The occurrence of the major depressive
episode is not better explained by
schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional
disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic
disorders.
● . There has never been a manic episode or
a hypomanic episode.
SYMPTOMS DEPRESSIVE DISORDER
(IF PoWeR is gone) – NO energy, (anergia), no
motivation (avolition), no pleasure (anhedonia),
no social interest (asocial)
● I - Insomnia/ Hypersomnia
● F - Feeling Hopeless, empty, sad,
worthlessness, (low self- esteem/delusion of
self-deprecation)
● P- Poverty of Ideas/uncommunicative
- Psychomotor Retardation
- Poor concentration & indecisiveness
● W-Weight loss (decreased appetite)
- Weight gain (Increased appetite)
● R- Recurrent thought of death (suicidal
ideation)
2. PERSISTENT DEPRESSIVE DISORDER
(DYSTHYMIA)
● Symptoms are less severe than major
depressive disorders but are still debilitating
● Symptoms of depression may lasts for 2
years or longer and maybe present most of
the time for most days of the week.
SYMPTOMS:
● Change in appetite or
● weight
● Insomnia/Hypersomnia
● Lack of energy or fatigue
● Low self-esteem
● Difficulty with concentrating or making
decisions
● feeling of hopelessness
TREATMENT:
● Psychotherapy
● Medication – antidepressants
● Combination of both
3. DISRUPTIVE MOOD DYSREGULATION
DISORDER
● DMDD It is used to categorize children up to
18 years of age who exhibit frequent
episodes of extreme temper outbursts,
extreme irritability and hyperactivity, but
without the manic episodes typical of bipolar
disorder.
DIAGNOSTIC CRITERIA
● Severe temper outbursts (verbal or
behavioral), on average, three or more
times per week
● Chronically irritable or angry mood most
of the day, nearly every day
● Trouble functioning due to irritability in
more than one place (at home, at school,
and with peers)
DIAGNOSIS
● Diagnosed between the ages of 6 and 10.
● Symptoms should be steady for 12 or more
months.
TREATMENT
● Medications.
● Cognitive behavioral therapy (CBT)
4. SEASONAL AFFECTIVE DISORDER
● Also known as SAD, SEASONAL
DEPRESSION or WINTER DEPRESSION.
● SAD is considered to be a sub-type of
major depressive disorder (MDD) – Major
Depressive Disorder with Seasonal
Pattern.
● Happens during fall or winter for the past 2
years. It typically goes away in the spring
and summer.
● Begins at any age, but it typically starts
between ages 18 and 30
SYMPTOMS
● Symptoms are similar to major depression
but can vary from mild to severe
TREATMENT:
● Medication - Antidepressants
● Light therapy (15-30 min/day) - special
light therapy box which mimics natural
sunlight
5. PSYCHOTIC DEPRESSION
● It is a sub-type of major depressive disorder
(MDD) - Major Depressive Disorder with
Psychotic Symptoms.
● People with psychotic depression have the
symptoms of major depression along with
"psychotic" symptoms, such as:
- Hallucination (Paranoia)
- Delusions the hallucinations and delusions
tend to focus on themes of hopelessness
and failure.
- Disorganized or disordered thinking.
TREATMENT:
- Medication - a combination of
antidepressant and antipsychotic drugs
- ECT may also be an option.
6. PERIPARTUM POSTPARTUM DEPRESSION
(PPD)
PERIPARTUM DEPRESSION
● Refers to a major depressive episode that
occurs during pregnancy or after childbirth,
POSTPARTUM DEPRESSION
● Refers to an episode of major depression
that begins within the first 4 weeks after
delivery.
● Major depressive disorder w/ peripartum
onset
● A woman may feel irritable, indecisive,
anxious, and sudden mood swings during
pregnancy or after childbirth
TREATMENT:
● Antidepressant drugs
● Counseling
FACTORS THAT INCREASE A WOMAN’S RISK
OF PPD
● Prenatal anxiety
● History of previous depression
● Maternity blues
● Recent stressful life events
● Inadequate social supports
● Poor marital relationship
● Low self-esteem
● Child care stress
● Difficult infant temperament
● Single mother
● Unwanted pregnancy
● Low socioeconomic status
7. PREMENSTRUAL DYSPHORIC DISORDER
(PMDD)
● Women with PMDD have depression and
other symptoms in the week before the
onset of menstruation, followed by the
resolution of these symptoms at the start of
their menstrual period.
● Cause of PMDD is unknown but most likely
caused by hormonal imbalances during
menstrual cycle that affects mood regulation
8. SITUATIONAL DEPRESSION
● Also known as "STRESS RESPONSE
SYNDROME or REACTIVE
DEPRESSION“
● Situational depression is a natural
response to a traumatic or stressful event.
Recovery is possible once the person
recovers from the difficult life situation
● Characterized by depressed mood when
someone is having trouble managing a
stressful event in life such as:
○ Relationship or marital problems
○ Situational changes
○ Financial instability
○ Life-or-death experiences
○ Death of a loved one or sickness
○ Social issues at school or work
● Previous life experiences
○ Gone through considerable stress
during childhood
○ Existing mental health problems
○ Several difficult life circumstances
occurring at the same time
● Situational depression is a natural
response to a traumatic or stressful event.
Recovery is possible once the person
recovers from the difficult life situation
9. ATYPICAL DEPRESSION
● Atypical depression can be a "specifier" for
either major depression or persistent
depressive disorder.
● In atypical depression, a positive event can
temporarily improve the depressed mood
● It is usually characterized by:
○ Increased appetite or weight gain
○ Sleeping more than usual
○ Marked fatigue or weakness
○ Oversensitive to criticism and
rejection
● People with atypical depression have often
experienced depression first during their
teenage years.
10. MELANCHOLIC DEPRESSION
● It is a form of major depressive disorder
(MDD) which presents with melancholic
features.
● Melancholicdepression isa sub-type of
major depressive disorder (MDD) - “Major
depressive disorder with melancholic
features.”
● People with melancholic depression may
also experience symptoms of major
depressive disorder
TREATMENT
1. PSYCHOPHARMACOLOGY
● Antidepressant drugs
● Antimanic drugs
● Mood stabilizer drugs
● Antianxiety drugs
2. ELECTRO CONVULSIVE THERAPY
3. ANTIDEPRESSANT DRUGS
● Tricyclic antidepressant drugs (TCA)
○ Ex: Amitriptyline (Elavil), Imipramine
(Tofranil), clomipramine (Anafranil)
● Selective serotonin reuptake inhibitor
(SSRI)
○ Ex: Citaloram (Celexa), Sertraline (
Zoloft), Fluoxetine (Prozac),
Fluvoxamine (Luvox)
● Monoamine oxidase inhibitor (MAOI)
○ Ex: Phenelzine (Nardil)
● Serotonin-norepinephrine reuptake inhibitor
(SNRI)
○ Ex: Venlafaxine (Effexor)
● Norepinephrine – dopamine reuptake
inhibitor (NDRI)
○ Ex: Bupropion (Wellbutrin)
4. INTERPERSONAL THERAPY
● Help client establish a successful
relationship
● Help client learn to trust others
5. BEHAVIORAL THERAPY
● Reinforcing behavioral change through
positive feedback and decreasing negative
interactions
● Focus on improving social & coping skills
6. COGNITIVE THERAPY
● Changing negative thinking into positive
thinking
BEHAVIORS THAT CAN MASK DEPRESSION
1. CHILDREN
● cranky behavior, hyperactivity, school
phobia (didaskaleinophobia), learning
disorders, failing grades, antisocial
behaviors
2. ADOLESCENCE
● substance abuses, joining gangs, engage in
risky behavior, overeating, sleepiness,
underachiever, drop outs, cranky behavior
3. ADULTS
● substance abuse, eating
4. OLDER ADULTS
● argumentative, disorders, compulsive
behavior cranky behavior, somatic ailments,
(gambling, workaholics), other behavioral
changes hypochondriasis
TOOL FOR SUICIDE ASSESSMENT
SAMPLE SCORING
– Mr. John Cruz, male, 58
year old is grieving over the
death of his wife due to car
accident 2 months ago. To
cope with his depression, he
drown his sorrow with
excessive use of alcohol.
Since the death of his wife,
Mr. Cruz is alone at home
since his 3 children are all
married and have their own
life, “Ayaw kong abalahin
sila” as verbalized by Mr. Cruz. He began to loss
interest with his ADL and fails to go to work that
makes things worse because of financial
constraints
BEHAVIORAL CLUES OF IMPENDING SUICIDE
WHICH
- W - Withdraws social activities and plans
- H - Has death plan/ Leaves a note,
Finalizes business or personal affairs. Gives
away valuable possessions
- I - Improved mood 10 – 14 days after taking
antidepressant drug
- C - Change in patient’s behavior
- H - He/she makes direct or indirect
statements (“I may not be around then”), (“I
will not be needing it where I am going”)

SAD PERSONS’ SCALE SUICIDE IN ADOLESCENCE

- S – Sex
- A – Age – <19 and >45 USED PILL
- D – Depression (good indicator) - U - Used of drugs
- P – Previous attempt - S - Social problems with peers
- E – Ethanol or other substance use - E - Emotional isolation
- R – Rational thinking is loss - D - Dysfunctional family interaction
- S – Social support is lacking - Depression
- O – Organized plan - P - Poor judgment/ poor impulse control
- N – No spouse - I - Immature coping skills
- S – Sickness - L - Low self-esteem
` - L - Lack of self-integration & identity
SCORING IN SPS
● 0–5: safe to SUICIDE IN ADULT
discharge 6–8:
psychiatric COLDS
consultation - C – Crisis in the past or upcoming two
● 8–11: hospital weeks (29%)
admission - Criminal legal problems (9%)
- O - Occupational and financial problems
(16%)
- L - Loss of significant relationships (42%)
- Loss of housing (4%)
- D - Drug addiction and alcoholism (28%)
- S – Sickness or physical health problems
(22%)
 BIPOLAR DISORDERS
SUICIDE IN ELDERLY
● The exaggerated euphoric feeling “THE
PERCIeVeD
HIGH”
- P – Passive suicide (refusing to eat, drink,
● formerly called MANIC-DEPRESSIVE
cooperate with care)
DISORDER or MANIC-DEPRESSION
- E – Exhaustion
DISORDER
- R – Retirement
● It is a mental health condition that causes
- C – Chronic medical condition
extreme mood swings that include
- I – Incidence of suicide increases with age
emotional highs (mania or hypomania) and
- V – View self as useless (desperate,
lows (depression).
frustrated)
● When depressed, the person may feel sad
- D – dependent
or hopeless and lose interest or pleasure in
most activities.
PSYCHIATRIC CONDITIONS WITH HIGH
● When manic or hypomanic, the person may
INCIDENCE OF SUICIDE
feel euphoric, energetic or unusually
MAD PERSON
hyperactive.
- M – Major depression
● These mood swings can interfere in their
- A – Alcoholism
everyday living.
- D – Drug addiction
● Symptoms can vary from person to person,
- P – Panic disorder & other personality
and symptoms may vary over time.
disorders
● Diagnosed during adolescence or early 20s
- E – Eating disorders (Anorexia nervosa)
but can occur at any age.
- R-
- S – Schizophrenia
DIFFERENCE BETWEEN HYPOMANIA
- O – Obsessive-compulsive disorder
● Hypomania - mood state or energy level is
- N – Any type of depression
elevated above normal, but not so extreme
as to cause impairment in daily life.
● Mania - is more severe than hypomania and
causes more noticeable problems at work,
school and social activities, as well as
relationship difficulties.
● Mania may also trigger a break from reality
(psychosis) and require hospitalization.

DIAGNOSTIC CRITERIA FOR MANIA &

HYPOMANIA
● HYPOMANIA - 3 symptoms for four days
● MANIA- one week or more.

iS FADED social behavior is impaired

- S - Sleep need decreases
- F - Flight of ideas/ hyperproductive
speech/racing thoughts
- A - Appetite is not lost but unable to focus
- D- Distractibility
- E - Extreme energy/ Hyperactivity -
Excessive buying, impulsive sexual
relationship & business investments (painful
consequences)
- D - Delusion of grandeur /increase self--
esteem)

TREATMENT FOR BIPOLAR DISORDERS

1. MEDICATION
● Lithium
● Mood stabilizer
- Olanzapine-Fluoxetine combination
● Anticonvulsant
 - Ex: Lamotrigine, Divalproex sodium,
BIPOLAR I BIPOLAR II CYCLOTHYMI
Valproic acid
DISORDER DISORDER A
● Atypical antipsychotic
- Ex: Seroquel, Risperidone, Latuda, Vraylar - Have a - At least 1 - Cyclical
(CBT) manic or hypomanic mood swings
mixed episode but of numerous
2. PSYCHOTHERAPY episode of never had a hypomania
- Cognitive Behavioral Therapy patient’s mania and manic episode alternating
mood swings under control hypomania - Have a major with mild
- Interpersonal and Social Rhythm Therapy - Have a depressive depression
(IPSRT) major episode
- Family Therapy depressive
episode
TYPES OF BIPOLAR DISORDERS:
1. BIPOLAR I DISORDER
● Also known as "MANIC-DEPRESSIVE
4. SUBSTANCE INDUCED MOOD DISORDER
DISORDER” or “MANIC DEPRESSION”
● Depressive disorder that is caused by using
● Formerly called Bipolar Disorder, Type I.
alcohol, drugs, or medications.
● It is characterized by distinct period of
● To be diagnosed, there should be evidence
abnormally and persistently elevated or
from the history, physical examination, or
irritable mood at least 1 week and present
laboratory findings that the symptoms
most of the day, nearly every day
developed during or within a month after
● In some cases, mania may trigger a break
substance intoxication or withdrawal, or
from reality (psychosis), thus can be severe
medication use
and dangerous
● The symptoms cause clinically significant
● When in the depressed phase, symptoms
distress or impairment of functioning
are similar with major depression that can
last weeks or months, but rarely longer than
one year.
2. BIPOLAR II DISORDER
● Formerly called Bipolar Disorder, Type II
● It is characterized by at least one major
depressive episode and at least one
hypomanic episode, but never had a manic
episode.
● An individual with bipolar II disorder can be
depressed for longer periods, which can
EXAMPLE OF SUBSTANCE-INDUCED
cause significant impairment
DEPRESSION:
● People with bipolar II disorder frequently
● Alcohol-induced depressive disorder
have other mental illnesses such as an
● Inhalant-induced depressive disorder
anxiety disorder or substance use disorder
● Opioid-induced depressive disorder
● Sedative-induced depressive disorder
3. CYCLOTHYMIC DISORDER
● Hypnotic-induced depressive disorder
● Also known as CYCLOTHYMIA
● Anxiolytic-induced depressive disorder
● It is a milder form of bipolar disorder
● Amphetamine-induced depressive disorder
● It is characterized by cyclical mood swings
● UNKNOWN SUBSTANCE-INDUCED
of numerous hypomania and mild
DEPRESSIVE DISORDER
depression with a duration of 2 years in
adult and 1 year in children and
EXAMPLE OF MEDICATION- INDUCED
adolescence.
DEPRESSION:
● The high and low are not severe enough to
● Steroid-induced depressive disorder
qualify as either mania or major depression
● L-dopa-induced depressive disorder
● Has increased risk of developing full- blown
● Antibiotic-induced depressive disorder
bipolar disorder
● Central nervous system drug- induced
depressive disorder
● Dermatological agent-induced depressive
disorder
 ● Chemotherapeutic drug-induced depressive
disorder
● Immunological agent-induced depressive
disorder
5. “UNSPECIFIED” BIPOLAR DISORDER
● Formerly called NOS (NOT OTHERWISE
SPECIFIED) MOOD DISORDER
● Symptoms do not meet the criteria for one
of the other types but people still have
significant, abnormal changes in mood.
● People who present with an unclear pattern
will have to be diagnosed as:
- “unspecified” bipolar disorder
- “unspecified” depressive disorder
THEORIES OF ETIOLOGY IN MOOD
DISORDERS
● Biologic factors
- Genetic factor
- Neurochemical factors
● Psychodynamic factors
- Freud
- Meyer
- Bibring
- Horney
- Jacobson
- Beck
● Societal factors
● Environmental factors
GENETIC FACTORS
● Person with bipolar disorder, first- degree
relatives (parents, children, siblings) are
more likely to have a mood
● Studies of twins
- identical twin -occurrence is 40%.
- fraternal twin - occurrence in both is 5%.
NEUROCHEMICAL FACTORS
● A link between neurotransmitters and mood
disorders exists because drugs that alter
these transmitters also relieve mood
disorders.
● A low or high level of a specific
neurotransmitter such as serotonin,
norepinephrine, or dopamine is involved.
● Other studies have found evidence that a
change in the sensitivity of the receptors on
nerve cells may be the cause of mood
disorders.
KINDLING PROCESS
● Norepinephrine levels may be deficient in
depression and increased in mania.
● This catecholamine energizes the body to
mobilize during stress and inhibits kindling.
● The kindling hypothesis posited that initial
episodes of mood disorders are likely
triggered by major life events (stressors).
● Anticonvulsants inhibit kindling; this may
explain their efficacy in the treatment of
bipolar disorder
PSYCHODYNAMIC THEORIES
● Most psychoanalytical theories of mania
view manic episodes as a “defense” against
underlying depression
● Sigmund Freud - attributed depression as
anger turned inward related to either a real
or perceived loss.
● Grete Bibring believed that one’s ego (or
self) aspired to be ideal and that to be loved
and worthy, one must achieve these high
standards.
- Ex. Good, kind, loving, superior, or strong.
Depression results when, in reality, the
person was not able to achieve these ideals
all the time.
● Edith Jacobson theorized that negative
self-views give rise to negative thoughts.
Negative self- constructions and low
self-esteem may result to depression.
● Adolf Meyer viewed depression as a faulty
reaction to a distressing life experience
● Karen Horney believed that children raised
by rejecting or unloving parents were prone
to feelings of insecurity, loneliness, and
helplessness making them susceptible to
depression.
● Aaron Beck saw depression as a result
from specific cognitive distortions in
susceptible people. Early experiences
shaped distorted ways of thinking about
one’s self, the world, and the future.
- Ex: One failure is applied to future
aspiration
- If one experience is negative, then all
similar experiences will be negative
NURSING PROCESS
MENTAL STATUS EXAMINATION
A T OM I C
- A– Appearance and behavior
- T– Thoughts
- O– Orientation
- M– Memory
- I– Intellectual functions
- C – Cognitive functions
ASSESSMENT JUDGMENT AND INSIGHT

ROLES AND RELATIONSHIPS

GENERAL APPEARANCE AND MOTOR
BEHAVIOR

PHYSIOLOGIC AND SELF-CARE

CONSIDERATIONS
MOOD AND AFFECT

COMMON NURSING DIAGNOSIS

THOUGHT PROCESS AND CONTENT
DEPRESSION
ORIENTATION, SENSORIUM INTELLECTUAL
AND PROCESSES
● Risk for self-directed violence
● Risk for suicide
● Imbalanced Nutrition: Less Than Body
Requirements
● Ineffective Coping
● Hopelessness
● Anxiety
● Ineffective Role Performance
● Self Care Deficit
● Chronic Low Self Esteem
● Disturbed Sleep Pattern
● Impaired Social Interaction
● Disturbed thought process
● Impaired sensory perception

MANIA & HYPOMANIA

● Risk for other –directed violence
● Risk for Injury
● Imbalanced Nutrition: Less Than Body
Requirements
● Ineffective Coping
● Ineffective Role Performance
● Chronic Low Self Esteem
 ● Disturbed Sleep Pattern PLANNING
● Impaired Social Interaction ● Short term goal
● Disturbed thought process - After 2 days of nursing intervention, the
● Impaired sensory perception client will follow step by step instructions for
dressing, bathing and grooming
PATIENT’S OUTCOME ● Long term goal
- After 2 weeks of nursing intervention the
DEPRESSION client will participate in self-care at optimal
● Not injure himself or herself level with supervision and guidance
● Independently carry out ADLs EVALUATION
● Establish a balance of rest, sleep and After 2 weeks of nursing interventions:
activity ● Patient’s ability to put on her dress with
● Establish a balance of adequate nutrition, little supervision
hydration, and elimination ● Patient followed steps in taking a bath with
● Evaluate self attributes realistically little supervision.
● Socialize with staff, peers, family, and ● Patient dried herself alone after bathing
friends ● Patient properly combed her hair alone.
● Return to occupation or school activities
● Comply with treatment regimen NURSING INTERVENTIONS
● Verbalize recurrence of symptoms
DEPRESSION MANIA
● Refrain from hurting self
1. PHYSIOLOGIC 1. PHYSIOLOGIC
MANIA & HYPOMANIA NEEDS NEEDS
● Not injure himself or herself - Provide adequate - Provide adequate
● Independently carry out ADLs nutrition and hydration -
nutrition and hydration
● Establish a balance of rest, sleep and Prevent exhaustion
- Assess body weight - Encourage rest
activity by - Prevent constipation > short naps
● Establish a balance of adequate nutrition, - Increase activities and > medication PRN
hydration, and elimination exercise
● Participate in self-care activities - Promote personal 2. LIMIT SETTING
● Engage in socially appropriate, reality- hygiene - Provide client a clear
based interaction understanding of what
2. FEELING is and isn’t acceptable
● Evaluate self attributes realistically
EXPRESSION behavior and what the
● Verbalize knowledge of his or her illness or consequences of their
- Let client expresses
treatment actions will be.
his/her feelings

3. ENVIRONMENT 3. ENVIRONMENT
SELF CARE DEFICIT - Stimulating - non-stimulating -
- Safety (remove safety (remove excess
objects) furniture) - provide
ASSESSMENT
- institute suicide productive diversional
Subjective activity
precaution:
Objective Cues > 1:1 ratio
● Dirty clothing > 24 hrs. observation
● Foul breath > No-suicide contract
● Foul body odor
● Long dirty finger 4. ACTIVITIES 4. ACTIVITIES
- Repetitive, menial - Gross physical
nails
task Ex: folding laundry activities Ex: brisk
● Uncombed hair walking
– NOTE: Promote
● Unkempt hair completion of activity
● Presence of hair lice by providing enough
● Presence of tartar or plaque time and assisting
client when necessary
NURSING DIAGNOSIS
5. ATTITUDE 5. ATTITUDE
- Self-care deficit: bathing, dressing, THERAPY
THERAPY
grooming, related to disturbed sensory - Matter of fact (setting
- Kind firmness (ADL
perception as manifested by poor personal and therapy limit, follow rules and
hygiene participation - regulations
Watchfulness (24hr
observation or 1:1.
QUIZ 8
MOOD AND BIPOLAR DISORDERS
1. The nurse observes that a client with bipolar
disorder is pacing in the hall, talking loudly and
rapidly, and using elaborate hand gestures. The
nurse concludes that the client is demonstrating
which of the following?
A. Psychomotor agitation
B. Aggression
C. Anger
D. Anxiety
2. Which of the following is most often associated
with the symptoms of depression?
A. An unresolved parental conflict.
B. A problem with sexual identity
C. A hormonal imbalance
D. A sense of real or imagined loss.
3. Which of the following should the nurse include
in planning care for patient who is depressed?
A. Give only one activity a day, so fatigue will
be reduced.
B. Wait until the client indicates a willingness to
participate before providing any activities
C. Let the client choose what he wants to do
each day.
D. Prepare a schedule of activities for the client
to follow each day.
4. A client with bipolar disorder begins taking
lithium carbonate (lithium), 300 mg four times a
day. After 3 days of therapy, the client says, “My
hands are shaking.” The best response by the
nurse is
A. “Fine motor tremors are an early effect of
lithium therapy that usually subsides in a
few weeks.”
B. “It is nothing to worry about unless it
continues for the next month.”
C. “You can expect tremors with lithium. You
seem very concerned about such a small
tremor.”
D. “Tremors can be an early sign of toxicity, but
we’ll keep monitoring your lithium level to
make sure you’re okay.”
5. he nurse observes that a client with depression
sat at a table with two other clients during lunch.
The best feedback the nurse could give the client
is:
A. “Do you feel better after talking with others
during lunch?”
B. “I see you were sitting with others at lunch
today.”
C. “You must feel much better than you were a
few days ago.”
D. “I’m so happy to see you interacting with
other clients.”
6. Which of the following typifies the speech of a
person in the acute phase of mania?
A. Mutism
B. Psychomotor retardation
C. Hesitant
D. Flight of ideas
7. A depressed client says to the nurse, “You are
the best nurse I’ve ever met. I want you to
remember me.” What is an appropriate response by
the nurse?
A. “I suspect you want something from me.
What is it?”
B. “You probably say that to all your nurses.”
C. “Are you thinking of suicide?”
D. “Thank you. I think you are special too.”
8. A client with mania begins dancing around the
day room. When she twirled her skirt in front of the
male clients, it was obvious she had no underpants
on. The nurse distracts her and takes her to her
room to put on underpants. The nurse acted as she
did to:
A. Minimize the client’s embarrassment about
her present behavior.
B. Teach her about proper attire and hygiene.
C. Avoid embarrassing the male clients who
are watching.
D. Keep her from dancing with other clients.
9. Which of the following would not be appropriate
questions for the nurse to ask when assessing the
depressed client?
A. “What kinds of things are pleasurable for
you?”
B. “What are your expectation of yourself?”
C. “Don’t you know that it is morally wrong to
think of suicide?”
D. “What are your expectation of yourself?” c.
“What kinds of things are pleasurable for
you?” b. “Don’t you know that it is morally
wrong to think of suicide?” d. “How do you
cope with anger?”
10. Which of the following would be the most
appropriate goal for a nursing diagnosis of
“ineffective individual coping related to feelings of
hopelessness and anger”?
A. The client will demonstrate cheerful affect.
B. The client will voice no complaints
C. The client will deny feelings of
hopelessness and anger.
D. The client will share feelings with nurse and
others.
11. Which of the following actions would be least 17. A depressed 70 year old woman says to the
effective in helping a depressed client cope with nurse, “I’m really not worth all the time it takes for
painful feelings? you to help me,” What is the best response for the
A. Focus on the positive aspects of life. nurse to make?
B. Encourage the client to share feelings. A. “Soon you will be able to start doing more
C. Help the client to identify feelings. for yourself, so it won’t take so much of my
D. Provide reality orientation, and encourage time.”
realistic expectations of self. B. “you should not think of yourself that way.”
C. “ I don’t have anything else I have to do
12. When a depressed client becomes angry, three right now.”
of the following nursing actions are appropriate. D. “Even though you feel that way, I am here to
A. Use simple, direct explanations and help you. I think it is worthwhile.”
open-ended questions.
B. Encourage client to verbalize feelings and 18. What are the most common types of side
concerns. effects from SSRIs?
C. Make plans with client for physical activity A. Dizziness, drowsiness, and dry mouth
and exercise. B. convulsions and respiratory difficulties
D. Offer medication to calm the client. C. diarrhea and weight gain
D. jaundice and agranulocytosis
13. A 49 year old homemaker, was recently
admitted to the psychiatric unit because of anxiety 19. Cognitive restructuring techniques include all
and suicidal behavior. Her adult life has always the following except
been centered on her family and home. She had A. decatastrophizing
expressed feelings of hopelessness and somatic B. positive self talk
complaints before hospitalization. Mrs. Pinky C. Refraning
presents the typical symptoms of which of the D. relaxation
following?
A. Bipolar 1 disorder 20. Transient psychotic symptoms that occur with
B. Substance abuse borderline personality disorder are most likely
C. Schizophrenia. treated with which of the following?
D. Major depressive disorder A. anti-convulsant mood stabilizers
B. antipsychotics
14. Which of the following is the most important C. benzodiazepines
nursing action for a severely depressed client? D. lithium
A. Institute suicide precautions
B. Reassure the client that the physical ANS:
complaints are imaginary. 1. A
C. Encourage her interest in her family. 2. A
D. Monitor her food intake. 3. D
4. A
15. A potential suicide is most likely to be 5. B
committed when: 6. D
A. At the point of her deepest depression 7. C
B. Just before discharge 8. A
C. When the depression begins to lift 9. D
D. Immediately after admission 10. D

16. A depressed 28 year old woman is slow about

getting herself dressed and ready for breakfast. More questions:
What should the nurse do?
A. Tell her she will not get breakfast if she
arrives late
B. Permit her to take as much time as she
wishes.
C. Serve her breakfast in her room
D. Help her to get dressed and get to breakfast
- https://www.coursehero.com/file/166674486/quiz
-317pdf/
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t-3-flash-cards/
- https://quizlet.com/216030230/mental-health-qui
z-3-ch-17-flash-cards/
- https://quizlet.com/272916572/chapter-17-questi
on-flash-cards/
 WEEK 8 Symptoms:
- A – Amenorrhea for at least 3 consecutive
EATING
cycles
DISORDERS - N – No organic factor accounts for weight
loss
- O – Obviously thin but feels fat
● Characterized by alteration - R – Refusal to maintain body weight
in eating pattern and - E – Emotional expression is restrained
disturbance in body image - X – Symptoms of depression and social
that interferes with withdrawal are present
relationship and - I – Intense fear of gaining weight.
occupational functioning. - A – Always think of food and food related
activities
POTENTIAL SIGNS OF AN
EATING DISORDERS Preoccupation of food related activities
● Grocery shopping
● Collecting recipe or cookbooks
● Counting calories
● Creating fat free meals
Unusual ritualistic food behaviors:
● Refusing to eat around others
● Cutting food into small pieces
● Not allowing food to touch their lips

SUBTYPES OF ANOREXIA NERVOSA

1. Restricting subtype
- Weight loss is through
fasting, dieting and
excessive exercise
2. Binge-purging subtype
TYPES OF EATING DISORDERS
- Weight loss is through
1. Anorexia Nervosa (AN)
induce vomiting, use of
2. Bulimia Nervosa (BN)
laxatives, diuretics and
3. Binge Eating Disorder (BED)
enema
4. Other Specified Feeding and Eating
Disorder (OSFED
BULIMIA NERVOSA
5. Pica
● an eating disorder
6. Rumination Disorder
characterized by recurrent
7. Avoidant/Restrictive Food Intake Disorder
episodes of binge eating
(ARFID)
at least twice a week for 3
8. Unspecified Feeding or Eating Disorder
months.
(UFED)
Symptoms:
9. Other related disorders:
- B – Binge eating
● Muscle Dysmorphia
- U – Under strict dieting or
● Orthorexia Nervosa (ON)
vigorous exercise
- L – Lack control over
ANOREXIA NERVOSA
eating
● Life-threatening eating
- I – Induced vomiting
disorder characterized
- M – Moth-eaten appearance teeth
by body weight 85% less
- I – Increase and persistent concern of body
than the expected or
- A – Abuse of diuretics and laxatives
normal body weight.
DISTINGUISHING FEATURES
MEDICAL COMPLICATION (WEIGHT LOSS) OTHER RELATED DISORDERS
CARDIAC
● Hypotension
● Bradycardia
● Loss of cardiac muscle muscle
Cardiac arrhythmias
●
DERMATOLOGIC BINGE EATING DISORDERS
Dry, cracking skin due to dehydration, lanugo, ● BED is a severe,
edema, and acrocyanosis (blue hands and feet) life-threatening but
HEMATOLOGIC treatable eating
Leukopenia, anemia, thrombocytopenia, disorder
hypercholesterolemia, and characterized by
hypercarotenemiaMETABOLIC recurrent episodes of
- Hypothyroidism (lack of energy, weakness, eating large
intolerance to cold, and bradycardia) – quantities of food
Hypoglycemia often very quickly and
MUSCULOSKELETAL to the point of
● Loss of muscle mass, loss of fat, discomfort.
osteoporosis, and pathologic fractures ● BED is one of the newest eating disorders
GASTROINTESTINAL formally recognized in the DSM-5
● Delayed gastric emptying, bloating, ● It is the most common eating disorder in the
constipation, abdominal pain, gas, and United States.
diarrhea RUMINATION DISORDER
REPRODUCTIVE ● Rumination syndrome is a
● Amenorrhea condition in which people
NEUROPSYCHIATRIC repeatedly and
● sleep disturbances, depression,mild unintentionally spit up
organic mental symptoms, and sleep (regurgitate) undigested or
disturbances partially digested food from
OTHERS the stomach, rechew it,
● Electrolyte imbalances and then either re-swallow
● Elevated BUN it or spit it out.
● Hypertrophy of salivary gland ● It can occur in children, teens and adults.
Rumination syndrome is more likely to occur
MEDICAL COMPLICATION (PURGING) in people with anxiety, depression or other
psychiatric disorders.
DENTAL AVOIDANT RESTRICTIVE EATING DISORDER
● Erosion of dental enamel (perimyolysis), ● Also known as
particularly front teeth Avoidant Restrictive
GASTROINTESTINAL Food Intake Disorder
● Salivary gland and pancreas inflammation (ARFID) and is
and enlargement, esophageal and gastric previously known as
erosion or rupture, dysfunctional bowel, and feeding disorder
superior mesenteric artery syndrome ● It is a serious mental
METABOLIC health condition that
● Electrolyte abnormalities causes the individual to
● Hypokalemia restrict food intake by volume and/or
● Metabolic alkalosis variety.
● Hypochloremic alkalosis ● This avoidance may be based on
● Hypomagnesemia appearance, smell, taste, texture, brand,
● Elevated BUN presentation, fear of adverse
NEUROPSYCHIATRIC consequences, lack of interest in food, or a
● Seizures (related to large fluid shifts and past negative experience with the food, to a
electrolyte disturbances), mild neuropathy, point that may lead to nutritional
fatigue, weakness, and mild organic mental deficiencies, failure to thrive, or other
symptoms negative health outcomes.
 ● The fixation is not caused by a concern for
body appearance or in an attempt to lose
weight.
PICA
● Characterized by
ingestion of
nonnutritive
substances or objects.
● Includes sand, paper,
crayons, leaves, etc.
● Result to malnutrition
● Complications:
intestinal obstruction and infections, lead
poisoning
ORTHOREXIA
● involves an unhealthy obsession with
healthy eating, mostly revolves around
food quality, not quantity
BIGOREXIA
● when someone, usually a man, worries that
their body is too small and weak and tries to
eat only foods that they believe will build
bigger muscles.
DIABULIMIA
● eating disorder in a person with type I
diabetes, wherein the person purposefully
restricts insulin in order to lose weight.
OTHER SPECIFIED FEEDING OR EATING
DISORDERS
● OSFED previously known as Eating
Disorder Not Otherwise Specified (EDNOS)
● OSFED is a serious, life-threatening but
treatable eating disorder.
● The category was developed to encompass
those individuals who did not meet strict
diagnostic criteria for anorexia nervosa or
bulimia nervosa but still had a significant
eating disorder.
ETIOLOGY
● BIOLOGIC FACTORS
● GENETIC FACTORS
- Tend to run in families with eating disorders
- History of mood or anxiety disorders
- Genetic vulnerability result from a
personality type
● NEUROSTRUCTURAL FACTORS
- Hypothalamus dysfunction
● Deficit in lateral hypothalamus
- decrease desire in eating (Anorexia)
● Disruption of ventromedial hypothalamus
- leads to excessive eating, weight gain and
decreased responsiveness to the satiety
(Bulimia)
● NEUROCHEMICAL CHANGES
- Decrease level of norepinephrine have
linked to decrease appetite seen in anorexia
- Increased level of serotonin have linked with
increased satiety seen in bulimia
- low platelet levels of monoamine oxidase
have been found in bulimia, and binging and
purging subtype of anorexia
● SOCIOCULTURAL FACTORS
- Advertisements, magazines, and movies
that feature thin models reinforce the
cultural belief that slimness is attractive.
- Pressure from peers, parents and coaches
● DEVELOPMENTAL FACTORS
- Failure to develop autonomy
- Failure to establish unique identity
- Poor role modeling
● FAMILY DYSFUNCTION
- Response to family conflict and problems
- Childhood adversities:
> Sexual abuse
> Parental maltreatment
> Rejection
> Excessive paternal control
> Over protectiveness
> Failure to develop satisfying
relationship with peers
NURSING PROCESS
ASSESSMENT: HISTORY TAKING
ANOREXIA
● Perfectionist with above average
intelligence
● Goal oriented
● Dependable
● Seeking approval
● Parents describe client as being “good” and
“causing no trouble”
BULIMIA
● Pleasing to others and avoiding conflicts
● Has history of impulsive behavior such as
substance abuse and shoplifting
● History of anxiety, depression and
personality disorders
GENERAL APPEARANCE and BEHAVIOR
ANOREXIA
● Appears slow, fatigued and emaciated
● Slow to respond to questions
● Often wear loose fitting clothes regardless
of weather to keep them warm and to hide
body weight
BULIMIA
● With normal or near normal body weight
● Normal physical appearance
● Appears open and willing to talk
MOOD AND AFFECT – NURSING DIAGNOSIS
ANOREXIA ● Anxiety
- Usually sad, anxious and worried ● Disturbed body image
- Seldom smile and serious most of the time ● Ineffective coping
BULIMIA ● Chronic low self-esteem
- Normal mood and affect – PLANNING
- May express intense guilt, shame and ● Client will demonstrate reduced anxiety
embarrassment when discussing bingeing ● Client will verbalize acceptance of body
and purging image with stable body weight
● Client will demonstrate non-food related
THOUGHT PROCESS AND CONTENT coping mechanism
ANOREXIA ● Increase self-esteem
- Have paranoid ideas about their family,
friends and health care professionals NURSING INTERVENTION
BULIMIA and ANOREXIA 1. Help client identify emotions and develop a
- Preoccupied with dieting, food and food non-food related coping strategies
related behavior ● Help client identify and express feeling.
- Body image disturbance ● Alexithymia difficulty expressing feeling
● Self-monitoring using a journal to raise
ROLES AND RELATIONSHIPS clients’ awareness about behavior and help
ANOREXIA them regain a sense of control
- Withdraw from peers and pay little attention ● Manage emotions through relaxationand
to friendship distraction techniques
- Failure at school which is in contrast to
previously successful academic 2. Help client deal with body image issues
achievement ● Recognize benefits of a normal or near
BULIMIA normal body weight
- Feels great shame about their bingeing and ● Identify personal strength, interest and
purging behaviors talents to broadened clients’ perception of
- Time spent buying and eating food and themselves
purging interfere clients’ role performance ● Increased self esteem

NURSING DIAGNOSIS 3. Provide health education

● NURSING DIAGNOSIS
- Imbalance nutrition: less/more than body
requirement
● PLANNING
- Client will establish adequate nutritional
eating pattern
NURSING INTERVENTION
1. Establish nutritional eating pattern
● Set specific time for meals
● Sit with the client during meals and snacks
● Observe client ff. meals and snacks (1- 2
hours)
● Weight client daily in uniform clothing and
time
● Provide positive reinforcement
● Offer liquid protein supplement if unable to
complete required calories
2. Adhere to treatment program guidelines
regarding restrictions
- No food substitutions
- No energy drinks
- Prevent hoarding, hiding or discarding foods
- Refrain exercise
● PSYCHOSOCIAL DOMAIN
CLIENT:
● Basic nutritional needs
● Harmful effects of restrictive dieting and
purging
● Benefits of normal body weight.
● Acceptance of healthy body image
FAMILY AND FRIENDS
● Provide emotional support
● Become informed about eating disorders
● Express concern about client’s health.
● Avoid talking about weight, food intake and
calories
● Encourage client to seek professional help.
EVALUATION
1. Demonstrate alternative methods of dealing
with stress
2. Demonstrate more satisfying relationships
3. Develop a positive self – concept
4. Find new ways of effective coping
5. Acceptance of a healthy body image
6. Maintain a normal body weight
TREATMENT FOR ANOREXIA
1. Medical management
 ● focuses on weight restoration, nutritional
rehabilitation, rehydration and correction of
electrolyte imbalances.
2. PSYCHOPHARMACOLOGY
● Cyproheptadine ( Periactin)
● Amitriptyline ( Elavil)
● Olanzapine (Zyprexa)
● Flouxetine (Prozac)
3. PSYCHOTHERAPY
● Family therapy - Individual therapy

TREATMENT FOR BULIMIA

1. COGNITIVE-BEHAVIORAL
THERAPY
● strategies designed to change the client’s
thinking (cognition) and action (behavior)
2. PSYCHOPHARMACOLOGY
● TCA - Desipramine (Norpramin)
- Imipramine (Tofranil)
● SSRI - Fluoxetine (Prozac)
- Sertraline (Zolo
QUIZ 9
EATING DISORDERS
1. A 15-year-old girl is assessed in the emergency
department and admitted to the hospital after she
fainted at school. She is more than 25% below the
normal weight for her height. She is thought to have
anorexia nervosa. During physical assessment, if
the client has anorexia nervosa, the nurse is most
likely to find?
A. Club-shaped fingertips.
B. Bruises over her upper torso.
C. Hyperactive bowel sound.
D. Growth of fine body hair
2. Which of the following is a common finding in a
client who purges by vomiting?
A. Lanugo
B. Edema
C. Hyperlipidemia
D. Dental caries
3. Which of the following criteria would indicate
improvement in an outpatient who has anorexia
nervosa?
A. The patient reports putting “thin” clothes on
display in her room as a reminder to
maintain proper weight
B. The patient identifies the relationship
between emotions and eating behaviors
C. The patient avoids contact with her
dysfunctional family
D. The patient develops a plan to control
negative feelings
4. A female patient, 16, is assessed with
amenorrhea, constipation, and bradycadia. She
expresses a distorted body image and fear of being
fat. These are signs and symptoms of
A. Cushing’s syndrome
B. Anorexia nervosa
C. Bulimic syndrome
D. Conversion disorder
5. The nurse is monitoring a patient diagnosed with
anorexia nervosa. In addition to monitoring the
patient’s eating. The nurse should do which of the
following after meals?
A. Tell the patient to lie down for 2 hours after
eating
B. Prevent the patient from using the bathroom
for hour after eating
C. Encourage the patient to go for a walk to get
some exercise
D. Instruct the patient to get plenty of exercise
6. A teenager is being evaluated for an eating
disorder. Which finding would suggest anorexia
nervosa?
A. Guilt and shame about eating patterns
B. Lack of knowledge about food and nutrition
C. Refusal to talk about food-related topics
D. Unrealistic perception of body size
7. The primary objective in the treatment of
anorexia is to
A. Help patient to select food she likes
B. Decrease anxiety to stimulate appetite
C. Cure her anorexia condition and eat
D. Enable the patient to gain weight
8. It is an eating disorder that occurs most often
during the first year of life characterized by
regurgitation and re-chewing of food?
A. Rumination Disorder
B. Feeding Disorder
C. Anorexia Nervosa
D. Pica
9. Amenorrhea is commonly observe in which of
the following eating disorders.
A. Anorexia nervosa
B. Bulimia Nervosa
C. Pica
D. All of the above
10. The nurse notes there are some very obvious
differences between anorexia and bulimia. The
nurse recognizes the following are characteristic of
bulimia ЕХСЕРТ:
A. The bulimic knows there is a problem with
her eating habits
B. The bulimic is of average weight or just a bit
overweight.
C. The bulimic has amenorrhea for several
months.
D. The bulimic has recurrent episodes of binge
eating followed by purging
11. A patient who has a history of bulimia is brought
to the ER with a BP of 76/50mm Hg, a heart rate of
48 beats per minute, lethargy and poor skin turgor.
The priority nursing diagnosis for this patient is:
A. Fluid volume deficit related to laxative
abuse
B. Knowledge deficit related to maladaptive
coping skills
C. Alteration in nutrition: less than body
requirements, related to binging and purging
D. Self-esteem disturbance related to distorted
body image
12. The nurse is evaluating the progress of a client
with bulimia. Which of the following behaviors
would indicate that the client is making positive
progress?
A. The client spends time resting in her room
after meals
 B. The client identifies healthy ways of coping 18. Treating clients with anorexia nervosa with a
with anxiety selective serotonin reuptake inhibitor
C. The client can identify calorie content for antidepressant such as fluoxetine (Prozac) may
each meal present which problem?
D. The client verbalizes knowledge of former A. Clients object to the side effect of weight
eating pattern as unhealthy gain.
B. Fluoxetine can cause appetite suppression
13. A client with bulimia is learning to use the and weight loss.
technique of self-monitoring. Which of the following C. Fluoxetine can cause clients to become
interventions by the nurse would be most beneficial giddy and silly.
for the client? D. Clients with anorexia get no benefit from
A. Teach the client about nutrition content and fluoxetine.
calories of various foods
B. Assist the client to make out daily meal 19. The nurse is working with a client with anorexia
plans for one week nervosa. Even though the client has been eating all
C. Encourage the client to ignore feeling and her meals and snacks, her weight has remained
impulses related to food unchanged for 1 week. Which intervention is
D. Ask the client to write about all feelings and indicated?
experiences related to food A. Supervise the client closely for 2 hours after
meals and snacks.
14. Which statement is true concerning bulimia B. Increase the daily caloric intake from 1,500
nervosa? to 2,000 calories.
A. This is an exclusively female disorder C. Increase the client's fluid intake.
B. The age onset is older than that of a person D. Request an order from the physician for
with anorexia nervosa fluoxetine.
C. Bulimics are actually underweight before the
onset of the illness 20. Which is not a goal for treating the severely
D. There is an intense fear of foods that malnourished client with anorexia nervosa?
produce weight gain A. Correction of body image disturbance
B. .Correction of electrolyte imbalances
15. The nurse is caring for a bulimic patient and an C. Nutritional rehabilitation
anorectic patient. What cognitive characteristics D. Weight restoration
would be similar for both of these patients?
A. Relaxed personality, but preoccupied with
food
B. No similarities ANS:
C. Perfectionism, preoccupation with food 1. B
D. Preoccupation with body image 2. D
3. B
16. This eating disorder was developed to 4. B
encompass those individuals who did not meet 5. B
strict diagnostic criteria for anorexia nervosa or 6. D
bulimia nervosa but still had a significant eating 7. D
disorder. 8. A
A. BED (Binge Eating Disorder) 9. A
B. OSFED (Other Specified Feeding or Eating 10. C
Disorder) 11. C
C. NES (Night Eating Disorder) 12. B
D. ARFID (Avoidant Restrictive Food Intake 13. D
Disorder) 14. B
15. D
17. Which of the following is a common finding in a 16. B
client who purges by vomiting? 17. D
A. Osteoporosis 18. B
B. acrocyanosis 19. A
C. hyperlipidemia 20. A
D. perimylolysis
 WEEK 9
ANXIETY DISORDERS,
PHOBIAS, OBSESSIVE
-COMPULSIVE
ANXIETY
● Is a unpleasant feeling of apprehension. It is
an emotional response to unknown, and
non-specific danger or threat.
● Anxiety motivates a person to take action, to
solve a problem or to resolve a crisis.
Considered normal when it is appropriate to
the situation and abnormal when it is
excessive, chronic and results in impairment
in the individual’s major functioning.
FEAR
● Fear is an unpleasant, often strong emotion
caused by expectation or awareness of
danger.
Incidence
● Highest prevalence rate of all mental
disorders in the US for both children and
adults. Nearly one in four adults is affected
and the magnitude in young people is
similar.
● It is more prevalent in women, people
younger than 45 y/o, people who are
divorce or separated and those with low
socio economic status.
● The onset and clinical course is variable
depending on the specific disorder.
Hans Selye’s response to stress
1. Alarm Reaction
● Stress stimulate/signal hypothalamus to
send messages to the glands (adrenal
gland) to send out adrenaline and
norepinephrine for fuel and organs (liver) to
convert glycogen to glucose for body’s
defenses
2. Resistance
● Digestive system reduces function to shunt
blood to areas needed for defense
● Lungs to take in more oxygen
● Heart beats faster and harder so that it can
circulate this highly oxygenated blood to the
muscles to defend the body by fight, flight or
freeze
Note: If the person adapts to the stress, the body
responses relax and the body gland, organ and
systemic response abate
3. Exhaustion Stage
● If the person has responded negatively to
anxiety and stress; body sores are depleted
or the emotional components are not
resolved, resulting in continual arousal of
the physiologic responses and little reserve
capacity
● Anatomic nervous system responses to fear
and anxiety generate the involuntary
activities of the body that are involved in
self-preservation
● Sympathetic nerve fibers increases
● Parasympathetic nerve fibers decreases
UNDERLYING CAUSE OF ANXIETY
Biologic Factor
1. Genetic
● anxiety may have an inherited component
because 1st degree relatives of clients’ with
anxiety have higher rates of developing
anxiety
2. Neurochemical
● GABA - functions as the body’s natural
anti-anxiety agent by reducing cell
excitability. It reduces anxiety.
● Norepinephrine – excites cellular function
thus increases anxiety. It can be seen in
panic disorder, GAD, PTSD
● Serotonin – Panic Disorder, GAD, OCD
Psychodynamic Factor (Theories)
1. Psychoanalytic /Intrapsychic Theory
● defense mechanisms are cognitive
distortions that a person uses unconsciously
to maintain a sense of being in control of a
situation to lessen discomfort to deal with
stress
● Conflict between the ID and the Superego
2. Interpersonal Theory
● The higher the level of anxiety, the lower the
ability of the individual to communicate and
solve problems and the greater chance for
anxiety to develop.
3. Behavioral Theory
● Anxiety is learned through experience but
can be change or unlearn through new
experiences
 ● Theorists believed that people can modify
maladaptive behaviors without gaining
insight into the cause of the anxiety

]
LEVELS OF ANXIETY

PERCEPTION MILD MODERATE SEVERE PANIC

Increased/ decreased/ Distorted Disorganized
widens narrowed, selective perception
inattention

Behavioral - Alert/aware - Difficulty in - Can’t reason - Immobilization

changes - Energetic concentration abstractly hysterical
- Attention - Easily distracted - Can’t make - mute
Increased - Attention span decision disorganized
decreased pacing - Can’t solve - thinking
a problem irrational
- Judgment is reasoning
impaired - feeling
- Confused and overwhelmed and
disoriented out of control.
- Difficulty - suicidal
focusing even with out of contact
assistance with reality
(Hallucination/
Delusion)

Physiological - Slight - Clammy hands - Increased BP, - Same w/ severe

changes discomfort - Diaphoresis RR, CR anxiety but to a
- Restlessness - Muscle tension - Chest pain greater degree
- GI butterflies - GI distress - Severe - DOB/
- Difficulty - Headache headache Hyperventilation
sleeping - Dry mouth - Nausea/
- Frequent Vomiting
urination - Diarrhea
- Tremors
- Dilated pupils

Coping - Adaptive - Palliative Use of - Maladaptive - Dysfunctional

Tasked or any defense Excessive defense Defense
defense mechanism mechanisms mechanisms fail
oriented available

Nursing - Allow to - Refocus - Reduce anxiety. - Provide safety.

management verbalize attention - Relaxation - Reduce
- Focus on - Supervise client technique environmental
problem in solving - Reduce stimuli.
solving problems and environmental - Continuously
- Engage in learning new stimuli. talk with the
goal directed Things - Stay or walk with person.
activities - Speak in short, person who is - Use touch
simple and easy Upset. judiciously.
to understand - Listen attentively. - Remain with
sentence. - Administer the person (Panic
- Administer oral intramuscular can last from 5
anxiolytic anxiolytics –30 minutes)
ANXIETY RELATED DISORDERS Types of Specific Phobia
Anxiety disorders across the lifespan
Acrophobia- height Mysophobia -
Panic Disorder Ailurophobia- cats contamination or
● characterized by a sudden onset of intense Algophobia- pain germs
apprehension or terror that lasts for 15 - 30 Nyctophobia - nights/
Androphobia- man
dark
min. Astraphobia- storms places
● After the attack, it is followed by 1 month of Belonophobia- Ochlophobia - crowds
one or more of the ff. symptoms. needles Opidiophobia - snakes
○ Persistent concern of having another Brontophobia - Pathophobia - disease
attack thunder Phonophobia - loud
○ Feeling of “Going crazy”, losing Claustrophobia- noises
control, or having heart attack Photophobia - light
enclosed
Pyrophobia- fire
○ Significant change in behavior places Taphophobia- being
Cynophobia- dogs buried
Types of Panic Disorder Entomophobia- alive
● Panic disorder with agoraphobia insects Topophobia- stage
● Panic disorder without agoraphobia Genophobia - dirt fright
Pointers to remember in Panic Disorder Hematophobia- blood Xenophobia- fear of
● Review breathing control and relaxation strangers
Kakorrhaphobia -
Zoophobia- animals
techniques failure
● Discuss positive coping strategies Microphobia - germs
● Encourage regular exercise.
● Emphasize the importance of maintaining
prescribed medication and regular follow up.
● Describe management techniques such as Generalized Anxiety Disorder
creating “to do” lists with realistic estimated ● Generalized Anxiety Disorder is
deadlines characterized by non- specific, excessive
● Stress the importance of maintaining and uncontrollable which may last over days
contact with community and participating in for 6 months
supportive organizations. ● Individual w/ GAD typically anticipate
disasters and overly concern about
Phobias everyday matters such as:
● characterized by specific or irrational fear. - Health issues
Defense mechanisms used by patient with - Death
phobia are displacement, repression and - Money
projection - Family problem
Types: - Work difficulties
● Agoraphobia- fear of open spaces, fear of
being alone in public places Treatment and Management for Panic Disorder,
● Social Phobia - avoidance of social Phobia and Generalized Anxiety Disorders
situations because of fear of being Biological Domain
humiliated or embarrassed
● Specific Phobia - persistent irrational fear 1. Relaxation techniques
other than mentioned above ● Isometric exercise
- Natural environmental phobias –fear of ● Progressive muscle relaxation
water, storm.heights or any other natural
phenomena 2. Divert attention by increasing physical
- Blood-injection phobias activities to release energy
- Situational phobias- fear of being in a ● Stationary bicycling.
specific situation such as on a tunnel, ● Avoid situations that will provoke anxiety
bridge, elevator, small room hospital or 3. Teach client about medications as part of the
airplane. treatment plan.
- Animal phobias- fear of animal or insects ● Panic
(usually a specific type; often this fear - SSRI (Prozac and Zoloft)
develop in childhood and can continue - SNRI (Effexor )
through adulthood in both men and women. - Benzodiazepine (Xanax, Klonopin and
- Other type of specific phobia- example; Valium)
fear of getting lost while driving ● GAD
 - Non-benzodiazepine (BusPar) Be aware of your own Anxiety is
- Antidepressants feelings and level of communicated
- SNRI (Effexor-Venlafaxine) discomfort interpersonally. Being
- SSRI (Paxil-Paroxetine) with an anxious client
can raise you anxiety
- TCA (Tofranil (Imipramine)
level
● Phobia Teach the client to use Using relaxation
- Benzodiazepine (Xanax) relaxation techniques techniques can give the
- Non-benzodiazepine (BuSpar) independently. client confidence in
- SSRI (Paxil & Zoloft having control over
anxiety.
Management Help the client see that The client may feel that
mild anxiety can be a all anxiety is bad and
1. Distraction techniques
positive catalyst for not useful.
● Performing simple repetitive activities change and does not
● Rubber band, counting objects, counting need to be avoided.
backward from 100 by threes. Encourage the client to The client's anxiety
2. Positive self-talk identify and pursue may have prevented
3. Exposure therapy relationships, personal him or her from
● Systemic desensitization interests, hobbies, or engaging in
recreational activities relationships or
● Gradual exposure to the feared object
that may appeal to the activities recently, but
● Implosive therapy/Flooding technique client. these can be helpful in
● Abrupt exposure to the feared object. The building confidence
goal is to rid the client’s phobia in one or and having a focus on
two sessions something other than
4. Cognitive behavioral therapy anxiety.
● Cognitive restructuring Encourage the client to Supportive resources
identify supportive can assist the client in
● Breathing training
resources in the the ongoing
● Psychoeducation community or on the management of his or
internet. her anxiety and
Nursing interventions for Anxiety decrease social
isolation.
Nursing Interventions Rationale
Remain with the client The client's safety is a
at all times when levelspriority. A highly anxious Selective Mutism
of anxiety are high client should not be left
(severe or panic) alone; his or her anxiety ● Failure to speak in
will escalate.
particular
Move the client to a Anxious behavior can be
quiet area with minimal escalated by external situations, such as
or decreased stimuli stimuli. In a large area, the classroom,
such as a small room or the client can feel lost where he is
seclusion area. and panicky, but a expected to speak
smaller room can but is unable to do
enhance a sense of so. However, he may be able to talk while at
security
home.
PRN medications may Medication may be Diagnostic criteria:
be indicated for high necessary to decrease ● Talkative at home with his family, but
levels of anxiety, anxiety to a level at changes his speaking to words with one
delusions, disorganized which the client can feel syllable and utters or gestures in order to
thoughts, and so forth. safe. communicate.
Remain calm in your The client will feel more ● A health professional must eliminate the
approach to the client. secure if you are calm possibility that the child is unable to speak
and if the client feels you
the Language or does not have the
are in control of the
situation. knowledge about something he’s asked
Use short, simple, and The client's ability to about.
clear statements. deal with abstractions or ● The condition must be present for a
complexity is impaired minimum of a month.
Avoid asking or forcing The client may not make ● A determination will be made if the
the client to make sound decisions or may condition is causing a negative impact on
choices be unable make
school and other activities.
decisions or solve
problems.
 ● The health professional must rule out other Assess and monitor the Limiting noise and other
disorders, including stuttering or the lack of client's sleep patterns, stimuli will encourage
verbal communication during a psychotic and prepare him or her rest and sleep. Comfort
disorder. for bedtime by measures and sleep
decreasing stimuli and medications will
● He is extremely attached to parents.
providing comfort enhance the client's
● He is extremely shy. measures or ability to relax and
● The child does not have contact with other medication. sleep.
individuals (social isolation). You may need to allow The client's thoughts or
Treatment extra time, or the client ritualistic behaviors may
● Cognitive Behavioral Therapy may help the may need to be verbally interfere with or
child identify the thoughts that make him directed to accomplish lengthen the time
activities of daily living necessary to perform
anxious as they relate to the behavior.
(personal hygiene, tasks.
● Medication: antidepressants and antianxiety preparation for sleep,
medications and so forth).
Encourage the client to Gradually reducing the
Obsessive-Compulsive Disorders try to gradually frequency of
decrease the frequency compulsive behaviors
● characterized by of compulsive will diminish the client's
behaviors. Work with anxiety and encourage
repetitive
the client to identify a success.
thoughts baseline frequency and
(obsession) and keep a record of the
actions decrease
(compulsion) As the client's anxiety The client may need to
Common obsession: decreases and as a learn ways to manage
- Violence, power trust relationship builds, anxiety so that he or
talk with the client about she can deal with it
- Wealth, sex
his or her thoughts and directly. This will
- Cleanliness, contaminations behavior and the client's increase the client's
Common compulsion: feelings about them. confidence in managing
- Checking, counting Help the client identify anxiety and other
- Handwashing, touching alternative methods for feelings.
- Arranging, cleaning dealing with anxiety
Nursing Management: Convey honest interest Your presence and
in and concern for the interest in the client
● Teach client about medications as part of
client. Do not flatter or convey your
the treatment plan. be otherwise dishonest. acceptance of the
- P - Psychopharmacology: Benzodiazepine client. Clients do not
(Xanax), Non- benzodiazepine (BuSpar), benefit from flattery or
TCA (Anafranil and Klonopin), SSRI (Paxil- undue praise, but
Prozac/Zoloft – Luvox) genuine praise that the
- A - Allow client time to perform rituals client has earned can
foster self-esteem.
- C - Convey acceptance of the client, despite
Provide opportunities The client may be
ritualistic behavior for the client to limited in his or her
- E - Encourage expression of feelings. participate in activities ability to deal with
- D - Diversional therapy - Encourage limit that are easily complex activities or in
setting on ritualistic behaviors as part of the accomplished or relating to others.
treatment plan enjoyed by the client; Activities that the client
● Keep a journal – Assist client in listing all of support the client for can accomplish and
participation. enjoy can enhance
the objects and places that triggers anxiety
self-esteem.
as part of exposure- response prevention Teach the client social The client may feel
program skills, such as embarrassed by his or
Nursing Interventions appropriate her OCD behaviors and
conversation topics and may have had limited
Nursing Interventions Rationale active listening. social contact. He or
Encourage him or her to she may have limited
Observe the client's The client may be practice these skills with social skills and
eating, drinking, and unaware of physical staff members and confidence, which may
elimination patterns, needs or may ignore other clients, and give contribute to the client's
and assist the client as feelings of hunger, the client feedback anxiety.
necessary. thirst, or the urge to regarding interactions.
delegate, and so forth. Teach the client and The client and family or
family or significant significant others may
others about the client's have little or no ● People with Hoarding Disorder have rooms
illness, treatment, or knowledge about these. that are stacked full with items; hallways are
medications, if any. difficult to pass through because of the
Encourage the client to Clients often experience amount of clutter, and sinks and tables
participate in follow-up long-term difficulties in
unusable.
therapy, if indicated. dealing with obsessive
Help the client identify thoughts. ● They may come to the attention of
supportive resources in authorities because of health and safety
the community or on the concerns of their homes. Hoarders are not
internet. comfortable inviting guests over and guests
do not feel comfortable in the hoarder’s
Body Dysmorphic Disorder chaos.
Symptoms
● Body dysmorphic ● Unable to discard possessions.
disorder is a mental ● Severe anxiety over the idea of discarding
health disorder in possessions.
which an individual ● Limited living space in the home
can't stop thinking ● Floor and counter space within common
about one or more areas of the home (such as the kitchen and
perceived defects or living room) are seen as storage space.
flaws in his/her appearance - a flaw that ● Isolation
appears minor or can't be seen by others. ● Loneliness
However, he/she may feel so embarrassed, ● Depression
ashamed and anxious that he/she may ● Fear or embarrassment of having visitors in
avoid many social situations. the home
Symptoms ● Withdrawn
● Intensely focus on appearance and body ● Disorganized
image ● Indecisive about where to put things
● Repeatedly checking the mirror, grooming Treatment
or seeking reassurance from others ● People with hoarding disorder are not
sometimes for many hours each day. always aware of the seriousness of their
● Significant distress and impaired the problems and only go for treatment when
individual’s ability to function in his/her daily pressured by family or are at risk of being
life. convicted from their home. Since hoarding
● Seek out numerous cosmetic procedures to can create safety and health risks, harm
try to "fix" the perceived flaw. Afterward, you reduction may be a focus of treatment.
may feel temporary satisfaction or a ● Psychotherapy
reduction in your distress, but often the - Group cognitive-behavioral therapy has
anxiety returns and you may resume shown to decrease hoarding symptoms
searching for other perceived flaw. - Talk therapy address the cognitive and
Treatment emotional challenges with hoarding
● Cognitive behavioral therapy behaviors
● Medication to reduce level of anxiety ● Medications are used to relieve symptoms
of depression and anxiety
Hoarding Disorder
Trichotillomania
● Hoarding disorder is
a mental disorder ● Trichotillomania is
characterized by an impulse control
excessively save psychiatric disorder
items and the idea within the group of
of discarding items conditions known
causes extreme as body-focused
stress. repetitive behaviors
● Hoarders cannot bear to depart from any of (BFRBs). Such conditions are characterized
their belongings, which results in excessive by self-grooming through pulling, picking,
clutter to an extent that impairs functioning scraping or biting the hair, nails or skin,
and may create health and safety risks. often causing self- damage. (The TLC
● Hoarding disorder is more than collecting a Foundation for Body-Focused Repetitive
little clutter. Behaviors 2018)
Symptoms.
● Constant pulling or twisting hair
● Bald patches or hair loss
● Uneven hair appearance
● Denial of the hair pulling
● Obstructed bowels if the hair is consumed
● Tension before hair is pulled and relief or
gratification after
● Other self-injury behaviors
● Poor self-image
● Feeling sad, depressed or anxious
● Habit reversal training is coupled with
awareness training to focus attention on the
picking behavior
● Competing response training teaches
patients to execute a different motor
response Example: making a fist, in
situations that usually trigger skin-picking
● Acceptance and commitment therapy
● Cognitive behavioral therapy
● Use of protective clothing that covers
picked-at areas of skin for developmentally

Treatment TRAUMATIC AND STRESSOR

● Psychotherapy – Cognitive-behavioral
therapy helps patient to develop techniques RELATED DISORDERS
to reverse the habit and substitute unhelpful
behaviors. Post-traumatic Stress Disorder
● Using a fidget toy or squeezing a stress ball ● Post-traumatic Stress Disorder is a mental
● Relieving stress by taking a hot bath health condition characterized by
● Breathing deeply until the urge has re-experiencing extreme traumatic events /
subsided stressors through flashbacks and nightmare
● Tensing the arm to form a fist causing extreme level of anxiety. Patients
● Keeping hair cut short or wearing a with
tightly-fitting hat ● PTSD usually use voidance or dissociation
● Exercising as defense mechanisms.
● Repeating a phrase out loud until the urge
has passed Symptoms
Medication 1. Persistently re-experiencing the events:
● Fluoxetine (Prozac) ● Thoughts/perceptions
● Sertraline (Zoloft) ● Flashbacks
● Fluvoxamine (Luvox) ● Illusions/hallucinations
● Paroxetine (Paxil) ● Nightmares
● Clomipramine (Anafranil) 2. Increased arousal:
● Valproate (Depakote) ● Startling behavior
● Lithium (Lithobid, Eskalith) ● Difficulty falling/staying asleep
3. Avoidance of stimuli associated with trauma:
Excoriation Disorder ● Avoidance of thoughts, feelings,
conversations
● also known as ● Avoidance of people, places, activities
dermatillomania, is ● Dissociation
a disorder of ● Depersonalization/derealization
impulse control
characterized by the Categories that may cause PTSD
urge to pick at the ● Natural disasters (e.g. earthquake, flood,
skin, even to the hurricane, tornadoes,
extent that damage ● Accidental man-made disasters (e.g., car
is caused. crashes, industrial accidents, airplane
● It is analogous to trichotillomania, the urge Crashes, nuclear plant accidents)
to pull one’s own hair, but has now been ● Intentional man-made disasters (e.g. war,
anglicized to hair-pulling disorder. rape, smuggling, robbery, assault military
● Both are classified with the Combat, physical abuse, bullying)
obsessive-compulsive disorders, but some
analogies have been suggested to Nursing Interventions
substance use disorders. ● Promote client safety
● Discuss self-harm thoughts
Treatment and management ● Help client to cope with stress and emotions
● Behavioral treatments are helpful to ● Use grounding techniques to help client who
patients with and without psychological is dissociating or experiencing flashbacks
disabilities. ● Distraction techniques
 - Physical exercise
- Listening to music
- Talking with others
- Engaging in a hobby
● Make a list of activities and provide
materials close at hand
- Books/Listen to a tape/Draw a picture
● Help client promote self esteem
- Refer client as “survivor” and not a “victim”
● Make a list of people and activities in the
community for client to contact when he/she
needs help
- Local crisis hotline
- Local support group (Ex: DSWD, NGO)
Acute Stress Disorder
● Acute stress disorder as the development of
specific fear behaviors that last from 3 days
to 1 month after a traumatic event.
● These symptoms always occur after the
patient has experienced or witnessed death
or threat of death, serious injury or sexual
assault.
Contributing factors resulting to ASD:
● Physical attack,
● Physical abuse
● Mugging,
● Active combat,
● Sexual violence,
● Natural disaster
● Serious accidents.
● Hearing or witnessing a violent or accidental
trauma of a loved one,
● Repeated exposure to traumatic events
Symptoms
● Experience intrusive thoughts or memories
of the traumatic event.
● Distressing dreams about the trauma
● General sleep disturbances are also
common.
● Flashbacks or distress when exposed to
triggers of the traumatic event.
● “Block out” or be unable to remember parts
or the entire traumatic event.
● Avoidance of external reminders, such as
places or people related to the traumatic
event.
● Negative mood. They may feel depressed,
anxious, angry or guilty and unable to feel
happy.
● Unrealistic feelings or beliefs about the
event. (E.g. believing that a plane crash
could have been prevented had the patient
done something differently).
● Hypervigilance,
● Problems with concentration
● Exaggerated startle response are also
common.
● Physical symptoms, such as headaches,
dizziness and sensitivity to light or sound
may occur, even without injury
Treatment
The primary goal of ASD is to prevent the disorder
from developing into PSTD.
1. Debriefing or crisis therapy to promote a
sense of safety after a trauma
● Calm the victim,
● Promote a sense of self-efficacy,
● Encourage community or victim
connectedness
● Instill a sense of hope. Debriefing can be
done in a variety of ways. When an entire
community is affected by a catastrophe,
such as a school shooting or natural
disaster,
2. Group therapy
3. Individual therapy to help victims of trauma
share their personal narrative related To the
traumatic event and quickly develop coping
skills
4. Acceptance and commitment therapy to
promote the use of mindfulness to accept
the traumatic event.
5. Stress management and reduction
techniques to prevent PTSD from
developing at a later time.
● thought stopping,
● Relaxation breathing,
● Assertiveness training
● Behavior rehearsal
● Psycho-education (Simpson and Moriarty,
2013).
ADJUSTMENT DISORDERS
● When stressful times in life from expected
or unexpected events cause an individual to
be confused, lost (disoriented), and
prevents him from going on with normal,
everyday life.
● Some of the instances that may cause an
individual stress include losing a job and not
knowing how to pay the mortgage on the
house, having been cheated on by a spouse
or being the victim of a sexual assault.
Stressors That May Cause Adjustment
Disorders
1. Stressors can be a single event, such as:
● Divorce or break-up of a relationship.
● Being fired from a job.
2. There may be multiple stressors, including:
● Difficulties with a business and marital
problems.
3. Stressors may be recurrent, such as:
● Business crises that occur in the
“off-season.”
● Unfulfilling sexual relationships.
4. Continuous stressors can include:
● Continuous painful illness that increases
disability.
● Residing in a crime-filled community.
5. Some stressors can affect an entire family or
community, such as:
● A natural disaster.
● Terrorism.
6. Some of the stressors can accompany
specific developmental events, such as:
● Getting married.
● Going to school.
● Becoming a parent.
● Leaving the parents’ home.
● Re-entering the parents’ home after being
away (such as having been at college, after
a marriage or relationship breakup, or loss
of a job).
● Failure to succeed in a career.
● Retirement.
Symptoms
● Worry
● Angry or disruptive behavior
● Insomnia
● Loss of self-esteem
● Sadness
● Difficulty concentrating
● Anxiety
● Feeling as if trapped and have no other
options
● Hopelessness
● Feeling isolated
Children and adolescents
● Irritable
● Depressed
● Poor sleep
● Poor grades and performance in school
Treatment
● Adjustment Disorder rarely extends beyond
six months, there may be some lasting
feeling that happens beyond that time
frame. Those are normal and are usually
not serious enough to require additional
treatment.
● Psychotherapy is usually the best choice.
for Adjustment Disorder, because the
disorder is seen as temporary and a
somewhat normal reaction to a stressful
event. The therapist works with the
individual to find new behaviors and ideas
and helps him to be able to deal more
effectively with the problem. In addition, the
therapist helps the individual find a clearer
understanding of the issue/s. The treatment
will often stress the significance of
● Social support in the individual’s life. If
there’s an issue with stress, therapy may
also include
● Relaxation training techniques.
● Family therapy for a child and adolescent
patients
- Family is used a family as a scapegoat
(blaming that individual).
- Family education about the disorder and
gain knowledge of its seriousness of the
condition
● Couples therapy is used when the disorder
is negatively affecting a marriage or
romantic relationship
ATTACHMENT DISORDERS
1. Reactive Attachment Disorder (RAD)
● An attachment disorder describes a
problematic pattern of developmentally
inappropriate moods, social behaviors, and
relationships due to a failure in forming
normal healthy attachments with primary
care givers in early childhood.
● A child who experiences neglect, abuse, or
separation during the critical stages of
development of first three years of life is at
risk of developing an attachment disorder.
2. Disinhibited Social Engagement Disorder
(DSED)
● The absence of normal fear or discretion
when approaching strangers. The child is
unusually comfortable talking to, touching,
and leaving a location with an adult
stranger.
● These behaviors are not the result of
attention problems or other issues that
might be associated with impulsive
behavior.
● The DSM-5 explains that a background of
severe social neglect is a diagnostic
requirement
● Because young infants are unable to form
selective attachments, disinhibited social
engagement disorder is not diagnosed in
children younger than nine months old.
● Development of disinhibited social
engagement disorder usually occurs during
the first two years of life
Diagnosing RAD and DSED
● RAD is diagnosed when a child’s social
relations are inhibited and, as a result,
he/she fails to engage in social interactions
in a manner appropriate to his/her
developmental age. The child may exercise
avoidance, hyper-vigilance or resistance to
social contact. The child may also avoid
social reciprocity, fail to seek comfort when
upset, become overly attached to one adult,
 and refuse to acknowledge a caregiver.
Links have been shown between future
behavioral, and relationship problems.
● DSED is diagnosed when a child is
excessively social with strangers and does
not engage in selective attachments. A child
with DSED will indiscriminately engage in
social behavior.
Symptoms RAD:
● The first indications of RAD or DSED are a
child’s abnormal social interactions. The
child may avoid initiating social interaction
or responding to social stimuli even from
family members and other intimates.
Alternatively, under DSED he/she may
indiscriminately seek excessive social
interaction with strangers.
● Failure to develop normally
● Poor hygiene
● Underdevelopment of motor coordination
and a pattern of
● Bewildered, unfocused, and
under-stimulated appearance
● Blank expression, with eyes lacking the
usual luster and joy
● Fails to respond appropriately to
interpersonal exchanges
Symptoms DSED:
● Excessive social interaction with unknown
persons
● Readiness to give hugs to anyone who
approaches and to go with that person if
asked
● Willingness to approach a complete
stranger for comfort or food, to be picked
up, or to receive a toy
● The disorder must be present for 12
months. Under DSM-V, if the symptoms of
both RAD and
● DSED are present at high levels, the
disorder is specified as severe
Reactive Attachment Disorder Therapy
1. Behavioral therapies to identify the triggers
underlying the disassociation, as well as
model and reinforce healthy adaptive
behavior.
2. Trauma-focused cognitive behavioral
therapy (TF-CBT) to treat underlying
attachment disruptions and promotes
emotion regulation, producing positive
therapeutic outcomes.
3. Emotion regulation to ensure a safe and
supportive environment to teach, model and
regulate emotion.
4. Integrative play therapy (IPT) and social
learning provide creative channels through
which children can learn social behavior and
explore the underlying causes of their
detachment disorder.
5. Cognitive-behavioral therapy (CBT) is often
applied simultaneously with IPT.
Disinhibited Social Engagement Disorder
Therapy and Treatment
1. Play therapy offers an opportunity to create
attachments that did not occur during early
infancy
2. Creative arts therapy uses painting,
drawing, dance, music and theatrical
activities as a means of carrying out
interactive and experiential activities. Both
play therapy and creative arts therapy is
that both approaches can be done
non-verbally. This is important because
young children are not always willing to able
to verbally discuss trauma, thoughts, and
feelings
3. Social Therapy. Children, teens, and adults
experience relationships through hugging,
touching, storytelling, and eating together
SOMATIC SYMPTOMS DISORDER
AND RELATED DISORDERS
SOMATIC SYMPTOMS DISORDER
● Characterized by an intense focus on
physical (somatic) symptoms that causes
significant distress and/or interferes with
daily functioning.
Diagnostic criteria:
1. One or more somatic symptoms that are
distressing or result in significant disruption
of daily life.
2. Excessive thoughts, feelings, or behaviors
related to the somatic symptoms or
associated health concerns as manifested
by at least one of the following:
● Disproportionate and persistent thoughts
about the seriousness of one’s symptoms.
● Persistently high level of anxiety about
health or symptoms.
● Excessive time and energy devoted to these
symptoms or health concerns.
3. Although any one somatic symptom may
not be continuously present, the state of
being symptomatic is persistent (typically
more than 6 months).
Treatment
● Cognitive behavior therapy
● Mindfulness-based therapy are effective for
the treatment of somatic symptom disorder.
 ● Medicines: Amitriptyline, Selective serotonin
reuptake inhibitors,
MALINGERING DISORDER
● Producing false medical symptoms or
exaggerating existing symptoms in hopes
of being rewarded in some way.
● It is a medical diagnosis, but not a
psychological condition.
Eg:
- Pretend to be injured so they can collect an
insurance settlement or obtain prescription
medication.
- Exaggerate mental health symptoms to
avoid criminal convictions.
Specific examples:
● Putting makeup on face to create a black
eye
● Adding contaminants to a urine sample to
change its chemistry
● Placing a thermometer near a lamp or in hot
water to increase its temperature
Symptoms:
– someone suddenly starts having physical or
psychological symptoms while:
● Being involved with a civil or criminal legal
action
● Facing the possibility of military combat duty
● Not cooperating with a doctor’s examination
or recommendations
● Describing symptoms as being much more
intense than what a doctor’s exam reveals
Causes:
● Malingering is not caused by any physical
factors.
● Result of someone’s desire to gain a reward
or avoid something. It is often accompanied
by real mood and personality disorders,
such as antisocial personality disorder or
major depressive disorder.
Management:
● Cognitive Behavioral Therapy
● Assertiveness training
● Therapist-Patient Relationship.
- Confrontation. Indirectly confront the client
that objective findings do not meet the
physician's objective criteria for diagnosis.
Allow the person the opportunity to her save
face
CONVERSION DISORDER
● Also known as functional neurological
symptom disorder, occurs when a person
experiences neurological symptoms not
attributable to any medical condition.
● The symptoms are real and not imaginary,
and they can affect motor functions and
senses.
Risk factors:
● Neurological disease, a movement disorder,
or a mental health condition.
● Family member has a functional
neurological disorder
● Experienced physical or sexual abuse as a
child or any other trauma in life.
● Women are also more likely to receive a
diagnosis of conversion disorder than men
are.
Symptoms:
– Symptoms triggered by physically or
psychologically traumatic events or by stress, but
not necessarily.
● Difficulty walking
● Loss of balance
● Body tremors
● Weakness or paralysis
● Hearing difficulty
● Vision problems or blindness
● Loss of sensation
● Trouble swallowing
● Seizures or shaking episodes
● Unresponsiveness
Diagnostic criteria DSM 5:
● Altered voluntary motor or sensory function.
● Clinical findings provide evidence of
incompatibility between the symptom and
recognized neurological or medical
conditions.
● The symptom or deficit is not better
explained by another medical or mental
disorder.
● The symptom or deficit causes clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning or warrants medical evaluation.
FACTITIOUS DISORDER
● Person acts as if he or
she has a physical or
mental illness. People with
factitious disorder
deliberately create or
exaggerate symptoms of
an illness.
● They have an inner need
to be seen as ill or injured. It is considered a
mental illness because it is associated with
severe emotional difficulties and stressful
situations.
● Most patients with factitious disorder have
histories of abuse, trauma, family
dysfunction, social isolation, early chronic
medical illness, or professional experience
in healthcare (training in nursing, health aid
work, etc.).
Types of factitious disorder
1. Factitious disorder imposed on self
● Falsifying of psychological or physical signs
or symptoms, as described above.
Eg: Mimicking behavior that is typical of a mental
illness, such as schizophrenia. The person may
appear confused, make absurd statements,
and report hallucinations (the experience of sensing
things that are not there; for example, hearing
voices).
2. Factitious disorder imposed on another
● People with this disorder produce or
fabricate symptoms of illness in others
under their care: children, elderly adults,
disabled persons, or pets.
● Often occurs in mothers who intentionally
harm their children in order to receive
attention. The diagnosis is not given to the
victim, but rather to the perpetrator.
Warning signs
● Dramatic but inconsistent medical history
● Unclear symptoms that are not controllable,
become more severe, or change once
treatment has begun
● Predictable relapses following improvement
in the condition
● Extensive knowledge of hospitals and/or
medical terminology, as well as the textbook
descriptions of illness
● Presence of many surgical scars
● Appearance of new or additional symptoms
following negative test results
● Presence of symptoms only when the
patient is alone or not being observed
● Willingness or eagerness to have medical
tests, operations, or other procedures
● History of seeking treatment at many
hospitals, clinics, and doctors’ offices,
possibly even in different cities
● Reluctance by the patient to allow
healthcare professionals to meet with or talk
to family members, friends, and prior
healthcare providers
● Refusal of psychiatric or psychological
evaluation
● Forecasting negative medical outcomes
despite no evidence of this
● Sabotaging discharge plans or suddenly
becoming more ill as one is about to be
discharged from the hospital setting
Symptoms
● Lie about or mimic symptoms
● Hurt themselves to bring on symptoms
● Alter diagnostic tests (such as
contaminating a urine sample or tampering
with a wound to prevent healing)
● Be willing to undergo painful or risky tests
and operations in order to obtain the
sympathy and special attention given to
people who are truly medically ill
Diagnostic criteria DSM 5:
1. Factitious Disorder Imposed on Self
● Falsification of physical or psychological
signs or symptoms, or induction of injury or
disease, associated with identified
deception.
● The individual presents himself or herself to
others as ill, impaired, or injured.
● The deceptive behavior is evident even in
the absence of obvious external rewards.
● The behavior is not better explained by
another mental disorder, such as delusional
disorder or another psychotic disorder.
2. Factitious Disorder Imposed on another
● Falsification of physical or psychological
signs or symptoms, or induction of injury or
disease, in another, associated with
identified deception.
● The individual presents another individual
(victim) to others as ill, impaired, or injured.
● The deceptive behavior is evident even in
the absence of obvious external rewards.
● The behavior is not better explained by
another mental disorder, such as delusional
disorder or another psychotic disorder.
ILLNESS ANXIETY DISORDER
● Previously called hypochondriasis, a term
that has been abandoned because of its
pejorative connotation) most commonly
begins during early adulthood and appears
to occur equally among men and women.
● The patient's fears may derive from
misinterpreting non- pathologic physical
symptoms or normal bodily functions (e.g.,
borborygmi, abdominal bloating and crampy
discomfort, awareness of heartbeat,
sweating).
● The course of the disorder is often chronic,
fluctuating in some, steady in others and
some patients recover.
Symptoms:
● Preoccupied with the idea that they are or
might become ill
● Preoccupied that their illness anxiety
impairs social and occupational functioning
or causes significant distress.
● May or may not have physical symptoms,
but if they do, their concern is more about
the possible implications of the symptoms
than the symptoms themselves.
● Repeatedly examine themselves (e.g.,
looking at their throat in a mirror, checking
their skin for lesions).
 ● Easily alarmed by new somatic sensations.
● Visit physicians frequently (care-seeking
type); others rarely seek medical care
(care-avoidant type).
Diagnosis criteria:
● The patient is preoccupied with having or
acquiring a serious illness
● The patient has no or minimal somatic
symptoms.
● The patient is highly anxious about health
and easily alarmed about personal health
issues.
● The patient repeatedly checks health status
or maladaptive avoids doctor appointments
and hospitals.
● The patient has been preoccupied with
illness for ≥ 6 months, although the specific
illness feared may change during that
period.
● Symptoms are not better accounted for by
depression or another mental disorder.
● Patients who have significant somatic
symptoms and are primarily concerned
about the symptoms themselves are
diagnosed with somatic symptom disorder.
Treatment
● Serotonin reuptake inhibitors
● Cognitive-behavioral therapy
PSEUDOCYESIS
● A false belief of being pregnant that is
associated with objective signs and reported
symptoms of pregnancy. It is a rare, but
debilitating somatic disorder in which a
woman presents with outward signs of
pregnancy, although she is not truly gravid.
● Commonly, women of lower socioeconomic
status, limited access to health care, and
feeling under significant stress to conceive
are most at risk for this disorder.
● Although depression is a frequent
comorbidity alongside pseudocyesis,
endocrinologic disorders have been
documented that mimic sign of polycystic
ovary syndrome.
● This complex array of concerns requires an
understanding of similar differentials and
treatment options
Treatment
● Psychotherapy
● Medication if co-morbid with depression or
anxiety
Dissociative Disorders
● Involve problems with memory, identity,
emotion, perception, behavior and sense of
self.
● Dissociative symptoms can potentially
disrupt every area of mental functioning.
● Examples of dissociative symptoms include
the experience of detachment or feeling as
if one is outside one’s body, and loss of
memory or amnesia. Dissociative disorders
are frequently associated with previous
experience of trauma.
Types:
1. Dissociative identity disorder
2. Dissociative amnesia
3. Depersonalization/derealization disorder
● Dissociation is a disconnection between a
person’s thoughts, memories, feelings,
actions or sense of who he or she is.
Everyone has experienced this normal
process.
● Examples of mild, common dissociation
include daydreaming, highway hypnosis or
“getting lost” in a book or movie, all of which
involve “losing touch” with awareness of
one’s immediate surroundings. During a
traumatic experience such as an accident,
disaster or crime victimization, dissociation
can help a person tolerate what might
otherwise be too difficult to bear. In
situations like these, a person may
dissociate the memory of the place,
circumstances or feelings about of the
overwhelming event, mentally escaping
from the fear, pain and horror. This may
make it difficult to later remember the details
of the experience, as reported by many
disaster and accident survivors.
Dissociative identity disorder
● Associated with overwhelming experiences,
traumatic events and/or abuse that occurred
in childhood.
 ● Dissociative identity disorder was previously
referred to as multiple personality disorder.
Symptoms/Criteria:
● The existence of two or more distinct
identities (or “personality states”). The
distinct identities are accompanied by
changes in behavior, memory and thinking.
The signs and symptoms may be observed
by others or reported by the individual.
● Ongoing gaps in memory about everyday
events, personal information and/or past
traumatic events.
● The symptoms cause significant distress or
problems in social, occupational or other
areas of functioning.
● The disturbance must not be a normal part
of a broadly accepted cultural or religious
practice. As noted in the DSM-51, in many
cultures around the world, experiences of
being possessed are a normal part of
spiritual practice and are not dissociative
disorders.
Treatment
● Psychotherapy. Therapy can help people
gain control over the dissociative process
and symptoms.
● Cognitive behavioral therapy
● Dialectical behavioral therapy.
● Hypnosis
● Medication may be helpful in treating related
conditions or symptoms, such as the use of
antidepressants to treat symptoms of
depression
Dissociative amnesia
● A condition in which a person cannot
remember important information about his
or her life.
● This forgetting may be limited to certain
specific areas (thematic), or may include
much of the person’s life history and/or
identity (general). In some rare cases called
dissociative fugue, the person may forget
most or all of his personal information
(name, personal history, friends), and may
sometimes even travel to a different location
and adopt a completely new identity.
● In all cases of dissociative amnesia, the
person has a much greater memory loss
than would be expected in the course of
normal forgetting.
Types:
1. Localized
● Memory loss affects specific areas of
knowledge or parts of a person’s life, such
as a certain period during childhood, or
anything about a friend or coworker. Often
the memory loss focuses on a specific
trauma. For example, a crime victim may
have no memory of being robbed at
gunpoint but can recall details from the rest
of that day.
2. Generalized
● Memory loss affects major parts of a
person’s life and/or identity, such as a young
woman being unable to recognize her
name, job, family, and friends.
3. Fugue
● With dissociative fugue, the person has
generalized amnesia and adopts a new
identity. For example, one middle manager
was passed over for promotion. He did not
come home from work and was reported as
missing by his family. He was found a week
later, 600 miles away, living under a different
name, working as a short-order cook. When
found by the police, he could not recognize
any family member, friend, or coworker, and
he could not say who he was or explain his
lack of identification.
Treatment
1. Psychotherapy
● Psychotherapy, sometimes called “talk
therapy,” is the main treatment for
dissociative disorders. This is a broad term
that includes several forms of therapy.
2. Cognitive-behavioral therapy:
● This form of psychotherapy focuses on
changing harmful thinking patterns, feelings,
and behaviors.
3. Eye movement desensitization and
reprocessing:
● This technique is designed to treat people
who have continuing nightmares,
flashbacks, and other symptoms of post-
traumatic stress disorder (PTSD).
4. Dialectic-behavior therapy:
● This form of psychotherapy is for people
with severe personality disturbances (which
can include dissociative symptoms), and
often takes place after the person has
suffered abuse or trauma.
5. Family therapy:
● This helps teach the family about the
disorder and helps family members
recognize if the patient’s symptoms come
back.
6. Creative therapies (for example, art therapy,
and music therapy):
 ● These therapies allow patients to explore ● Family therapy
and express their thoughts, feelings, and ● Creative therapies
experiences in a safe and creative ● Meditation and relaxation techniques
environment. ● Clinical hypnosis
7. Meditation and relaxation techniques: ● Antidepressant or anti-anxiety medications.
● These help people better handle their
dissociative symptoms and become more
aware of their internal states.

8. Clinical hypnosis:
● This is a treatment that uses intense
relaxation, concentration, and focused
attention to achieve a different state of
consciousness, and allows people to
explore thoughts, feelings, and memories
they may have hidden from their conscious
minds.
9. Medication:
● There is no medication to treat dissociative
disorders. However, people with dissociative
disorders, especially those with depression
and/or anxiety, may benefit from treatment
with antidepressant or anti-anxiety
medications.

Depersonalization/Derealization disorder
● Depersonalization/derealization disorder is
the feeling of being detached from one’s
thoughts, feelings, and body
(depersonalization), and/or disconnected
from one’s surrounding environment
(derealization).
● It involves disruptions or breakdowns of
memory, consciousness or awareness,
identity and/or perception— mental
functions that normally work smoothly.
When one or more of these functions is
disrupted, dissociative symptoms can result.
These symptoms can interfere with a
person’s general functioning, both in their
personal life and at work.
● People with this disorder do not lose contact
with reality. They realize that their odd
perceptions are not real. Depersonalization
and/or derealization also might be
symptoms of other disorders, including brain
diseases and seizure disorders.
● The goal of treatment is to address all
stressors associated with the onset of the
disorder. The best treatment approach
depends on the individual, the nature of any
identifiable triggers, and the severity of the
symptoms.
Treatment:
● Psychotherapy
● Cognitive-behavioral therapy
● Eye movement desensitization and
reprocessing (EMDR)
● Dialectic-behavior therapy (DBT)
QUIZ 10
ANXIETY DISORDERS
1. Which of the following approaches would the
nurse expect to include in the plan of care for a
client with antisocial personality disorder who has a
history of stealing and jail time?
A. Assisting the client with understanding right
from wrong.
B. Helping the client develop a conscience
C. Teaching the client consequences of her
actions.
D. Using strategies to help the client become
passive
2. What is a likely symptom of an anxiety disorder?
A. Eating excessive amounts of sweet foods
B. Exercising several times at the gym in a
single day
C. Struggling to get out of bed in the morning
D. Worrying about being judged by others
3. A client often jumps when spoken to and
complains of feeling uneasy. She says, "It's as
though something bad is going to happen." Which
of the following actions would be most beneficial to
the client?
A. Demonstrating technical competency
B. Leaving her alone
C. Conveying optimistic verbalization
D. Reducing environmental stimulation
4. Which of the following points would the nurse
include when teaching a client about panic
disorder?
A. Maintaining self-control will decrease
symptoms of panic.
B. Symptoms of a panic attack are time limited
and will abate
C. Medication should be taken when
symptoms start.
D. Staying in the house will eliminate panic
attacks.
5. A week ago, a landslide destroyed the client's
home and seriously injured her husband. The client
has been walking around the hospital in a daze
without any outward display of emotions. She tells
the nurse she feels like she's going crazy.
Which of the following actions would the nurse use
initially?
A. Explain the effect of stress on the mind and
body
B. Acknowledgment the unfairness of the
client's situations
C. Reassure the client that her symptoms are
temporary
D. Reassure the client that her feelings are
typical reactions to serious trauma
6. Aia is about to take the local board exam when
she experiences nauseous, palpitation, rapid
breathing, and profuse sweating. What was she
suffering from?
A. Phobia
B. Panic Disorder
C. Post-Traumatic Stress Disorder
D. General Anxiety Disorder
7. The client with a fear of eating in public places or
in front of other people has finished eating lunch in
the dining areas in the nurse's presence. Which of
the following statements by the nurse would
reinforce the client's positive actions?
A. "It wasn't so hard now. Wasn't"
B. 'You must have been hungry today"
C. 'It's a sign of progress to eat in the dining
area
D. 'At super, i hope to see you eat with a group
of people*
8. What anxiety disorder is developed in response
to an unexpected emotional or physical trauma that
could not be controlled?
A. Panic Disorder
B. Phobia
C. General Anxiety Disorder
D. Post-Traumatic Stress Disorder
9. The nurse must recognize the obsessive
compulsive rituals are an attempt to:
A. Control others
B. Reduce anxiety
C. increase self-esteem
D. Express anxiety
10. A client with Acute Stress Disorder states to the
nurse, "I keep having horrible nightmares about the
car accident that killed my daughter, I shouldn't
have taken her with me to the store". Which of the
following responses by the nurse would be most
therapeutic?
A. "Stop blaming yourself, It's only hurting you"
B. "The accident just happened and could not
have been predicted
C. "Don't keep torturing yourself with such
horrible thoughts'"
D. "Let's talk about something that is a bit more
pleasant"
11. Which of the following medical diagnosis is
appropriate when an individual experiences
persistent worry about everyday challenges out of
proportion to the perceived threat that can last at
least 6 months to years.
A. Agoraphobia
B. Acute stress disorder
C. Generalized anxiety disorder
 D. Panic Disorder A. Allow the client to describe the event and
listen empathetically
12. The nurse must recognize the obsessive B. Tell the client that the event was not as bad
compulsive rituals are an attempt to: as he remembers it
A. Express anxiety C. Encourage the client to share his
B. Increase self-esteem experience in the therapeutic group meeting
C. Reduce anxiety D. Change the subject because the topic is
D. Control others clearly upsetting the client

13. When planning the care of a patient who has 19. Ms. Cory is experiencing a severe level of
post-traumatic stress disorder, a nurse should anxiety. Which of the following statements
include which of the following outcomes? concerning the concept of anxiety is not true?
A. The patient will work through conflicting A. Anxiety on any level is a destructive force
emotions about the trauma and thus moves the individual to change
B. The patient will intellectualize about the B. Anxiety is multidimensional concept and is
traumatic experience. manifested as a somatic, experiential, and
C. The patient will demonstrate a normal interpersonal phenomenon
range of moods. C. Anxiety is an energy and as such cannot be
D. The patient will be able to use stress observed directly
management techniques D. Anxiety occurs as the result of a threat to
person's self hood, self-esteem, or identity
14. Which of the following observations would be
most definitive when assessing a patient with 20. Which of the following client statements would
post-traumatic stress disorder? indicate the need for additional teaching about
A. Flashbacks benzodiazepine?
B. Depression A. "I can't stop taking the drug anytime I want"
C. Aggression B. "Valium will help my tight muscles feel
D. Substance abuse better®
C. "I can't drink alcohol while taking Diazepam
15. The nurse is caring for a 39-year-old man with a (Valium)"
generalized anxiety disorder. In assisting the client D. "Valium can make me drowsy, so I shouldn't
to be less anxious, which of the following nursing drive for a while"
actions would be most appropriate?
A. Administering major tranquilizing drugs ANS:
B. Maintaining calm and supportive manner 1. C
while interacting 2. D
C. Encouraging the client to cry 3. D
D. Beginning intensive psychotherapy 4. B
5. D
16. The nurse is caring for a 35-year-old woman 6. B
with agoraphobia. Which of the following behaviors 7. C
would the nurse expect to observe in the client? 8. D
A. The client is afraid of talking to other people 9. B
B. The client is afraid of fire 10. B
C. The client is afraid of pain 11. C
D. The client is afraid to leave her home 12. C
13. A
17. In implementing treatment for a client with a 14. B
phobic disorder, nursing actions include: 15. B
A. Administering lithium 16. D
B. Systemic desensitization 17. B
C. Insight-oriented 18. A
D. Crisis intervention 19. D
20. C
18. Nurse Moly is caring for a client admitted 1 MORE QUESTIONS:
week ago with a diagnosis of PTSD. https://quizlet.com/54923584/nclex-mood-disorders
Today he begins to describe the traumatic event -anxiety-abuse-flash-cards/
that occurred in his life 6 months ago. The best https://quizlet.com/71857444/anxiety-lippincott-flas
response by the nurse would be to: h-cards/
 WEEK 9 PART 2
PERSONALITY
DISORDERS
PERSONALITY DISORDERS
● Spectrum of maladaptive traits that produce
or influence considerable psychological and
emotional disturbance and impair
relationships.
● Results when a person develops inflexible,
maladaptive behavior, which interfere with
occupational functioning.
● Diagnosed during ADULTHOOD.
General Personality Disorder DSM V(5)
● An enduring pattern of inner experience and
DSM V (5) behavior that deviates markedly
from the expectations of the individual’s
culture. This pattern is manifested in two or
more of the following areas:
1. Cognition
2. Affectivity
3. Interpersonal relationship
4. Impulse control
● The enduring pattern in inflexible and DSM
V (5) pervasive across a broad range of
personal and social situations.
● The enduring pattern leads to clinically
significant distress or impairment in social,
occupational or other important areas of
functioning.
Theoretical Framework of personality disorders
includes:
A. Biologic Factors
● Genetic factor. Personality develops in
response to inherited characteristics
(temperament). These are engrained by 2
–3 years of age.
● Neurochemical factors-Imbalances of
serotonin, norepinephrine and dopamine
● Autonomic nervous system-Hypothalamus
hypometabolism. According to Kerberg,
pain activates the punishing center of the
hypothalamus.
- Ex: A child whose orientation to the world is
based on hurting tend to cope by using
greater amount of aggression. It is this
excessive aggressions that powers the
development of borderline,
passive-aggressive, histrionic and
narcissistic personality disorders.
● Hormonal Factor-Aggressive behavior
-increased levels of androgens-Impulsive
behavior -increased level of estrogen and
testosterone –Pleasure seeking individual
B. Psychodynamic Factors
● Personality develops in response to
environmental influences (character) or
personality traits. Character consists of
concepts about self and the external world.
When fully developed, these character traits
define a mature personality.
3 Major character traits
1. Self-directedness
2. Cooperativeness
3. Self-transcendenic
CLUSTER A — odd, eccentric, mistrust,
suspicious, loner, isolated
PARANOID PERSONALITY DISORDER
● Characterized by a pervasive DISTRUST
and SUSPICIOUSNESS
● Always suspicious of others, extreme
mistrust and suspiciousness, isolates self,
very private and secretive, uses projective.
DSM
A. A pervasive distrust and suspicious of
others such that they are interpreted as
malevolent, beginning by early adulthood
and present in a variety of contexts, as
indicated by four or more of the following:
1. Suspects, without sufficient basis, that
others are exploiting, harming, or deceiving
him or her.
2. Is preoccupied with unjustified doubts about
the loyalty or trustworthiness of friends or
associates.
3. Is reluctant to confide in others because of
unwarranted fear that the information will be
used maliciously against him or her.
4. Reads hidden demeaning or threatening
meanings into benign remarks or events
5. Persistently bears grudges.
6. Perceives attacks on his or her character or
reputation that are not apparent to others
and is quick to react angrily.
7. Has recurrent suspicious without
justification, regarding fidelity of spouse or
sexual partner.
B. Does not occur exclusively during the course of
schizophrenia, a bipolar or depressive disorder with
psychotic features, or another psychotic disorder
and is not attributable to the psychological effects
of another medical condition.
PSYCHOTHERAPY
● Individual therapy
● Group therapy
● Attitude therapy: PASSIVE FRIENDLINESS
● Cognitive-Behavioral
MEDICAL MANAGEMENT
● Anxiolytics
● Anti depressants: SSRIS and TCAs
● Atypical Neuroleptics
NURSING MANAGEMENT
● Know that the building the therapeutic
relationship is difficult.
● Respect personal space.
To gain the clients trust, the nurse should:
● Talk with professionalism; avoid joking.
● Avoid making indirect statements.
● Clarify everything that discussed and do not
leave any query unanswered.
● Keep all appointments and maintain
consistency in approach.
● Not argue with, challenge, reject or disagree
with the patient's paranoid ideations. Use
supportive confrontation whenever
necessary.
● When late, apologize rather than rationalize.
● Avoid inquiring too deeply into the client’s
history, unless directly relevant to treatment.
Gain patient’s compliance to treatment and
teach coping skills:
● Teach the client to validate ideas first before
making conclusions.
● Involve the client in establishing objectives
for the treatment plan.
SCHIZOID PERSONALITY DISORDER
● Characterized by pervasive pattern of
SOCIAL DETACHMENT and a
RESTRICTED RANGE of EMOTIONAL
EXPRESSIONS.
● Prefers to be alone, solitary, isolated, lacks
friends, old fashioned.
DSM
A. A pervasive pattern of detachment from
social relationships and a restricted range of
emotions in interpersonal settings,
beginning by early adulthood and present in
a variety of contexts, as indicated by four or
more of the following:
1. Neither desires nor enjoys close
relationships, including being part of a
family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual
experiences with another person.
4. Takes pleasure in few, if any, activities. V
5. Lacks close friends or confidants other than
first- degree relatives.
6. Appears indifferent to the praise or criticism
of to others.
7. Shows emotional coldness, detachment, or
flattened affectivity.
B. Does not occur exclusively during the course of
schizophrenia.
PSYCHOTHERAPY
● Individual therapy
● Group therapy
● Attitude therapy: KIND FIRMNESS
● Role play
● Cognitive- Behavioral therapy
MEDICAL
● Antidepressant: SSNRIs MANAGEMENT
–Bupropion (wellbutrin)
● Atypical Neuroleptics
NURSING MANAGEMENT
● Note that these people never seek
treatment for they think its very intrusive.
● Develop feelings of security; stability and
support is the key areas of concerns
● Possible sources if disappointments in the
relationships should be avoided.
● Nurse should initiate.
- Acknowledge the need of the client for
personal distance.
- Show respect for his private thoughts
- Ask to participate in activities where
socialization is a a minimum, and later
advance.
● Social skills training:
- Use the therapeutic relationship to allow the
client try out new coping skills and to learn
that social attachment to others need not to
be great source of fear of rejection when the
person has the appropriate social skill.
- Motivate the client to increase his ability to
relate to and communicate with other
SCHIZOTYPAL PERSONALITY DISORDER
● Characterized by a pervasive pattern of
SOCIAL & INTERPERSONAL
RELATIONS. Socially isolated, reserved
and distant.
● Psychotic manifestations are already
apparent.
DSM
A. A pervasive pattern of social and
interpersonal deficits marked by acute
discomfort with, and reduced capacity for,
 close relationships as well as by cognitive or CLUSTER B - DRAMATIC, EMOTIONAL,
perceptual distortions and electricity of
ERRATIC
behavior, beginning by early adulthood and
present in a variety of contexts, as indicated
ANTISOCIAL PERSONALITY DISORDER
by five or more of the following:
● Characterized by pervasive pattern of
DSM
disregard for the rights of other people that
1. Ideas of reference (excluding delusions of
often manifests as HOSTILITY and/or
reference).
AGGRESSION. Central features include
2. Odd beliefs or magical thinking that
DECEIT and MANIPULATION.
influences behavior and is inconsistent with
● Habitually breaks law, low self-esteem and
sub cultural norms.
lack of sense of guilt
3. Unusual perceptual experiences, including
bodily illusions.
DSM
4. Odd thinking and speech.
A. A pervasive pattern of disregard for violation
5. Suspiciousness or paranoid ideation.
of the rights of others. Occurring since age
6. Inappropriate or constricted affect.
15 years, as indicated by three or more of
7. Behavior or appearance that is odd,
the following:
eccentric or peculiar.
8. Lack of close friends or confidants other
1. .Failure to conform to social norms with
than first-degree relatives.
respect to lawful behaviors, as indicated by
9. Excessive social anxiety that does not
repeatedly performing acts that are grounds
diminish with familiarity and tends to be
for arrest.
associated with paranoid fears rather than
2. Deceitfulness, as indicated by repeated
negative judgments' about self.
lying, use of aliases, or conning others for
B. Does not exclusively occur during the course of
personal profit or pleasure
schizophrenia.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated
PSYCHOTHERAPY
by repeated physical fights or assaults.
● Cognitive- Behavioral Therapy
5. Reckless disregard for safety of self or
others.
MEDICAL MANAGEMENT
6. Consistent irresponsibility, as indicated to
● Anxiolytics
repeated failure to sustain consistent work
● Antidepressants: SSRI’s and TCA’s
behavior or honor financial obligations.
● Atypical Neuroleptics
7. Lack of remorse, as indicated by being
indifferent to or rationalizing having hurt,
NURSING MANAGEMENT
mistreated, or stolen from another.
● Rarely seek treatment because of the
B. The individual is at least age 18 years .
necessary personal contact they have to
C. There is evidence of conduct disorder with onset
endure and watch out for bizarre description
before age 15 years.
of their disease.
D. The occurrence of anti social behavior is not
● Apply the interventions for a client with
exclusively during the course of schizophrenia or
paranoid personality.
bipolar disorder.
● Know that the client’s discomfort when
around people is not likely to change;
PSYCHOTHERAPY
therefore help the client establish a
● Individual therapy
satisfying solitary existence wherein the
● Group therapy
patient can function well.
● Attitude therapy: NO DEMAND, MATTER
● Focus in improving self- care skills;
OF FACT
establish a routine to follow.
● Cognitive- Behavioral therapy

MEDICAL MANAGEMENT
● Anti-depressants: SSRI;s and TCA’s

NURSING MANAGEMENT
● Be alert in the clients’ ACTING OUT
behavior. Help the patient to identify the
connection of feelings and behavior. •Avoid
moralizing and judging the patients’
 behaviors, thoughts and feelings. Instead
provide a healthier outlet and constructive
expression of anger and inadequacy to
decrease impulsivity and acting out.
● Point the effects of his behavior on other
people.
● Never threaten the patient in an effort to
elicit acceptable behavior.
● Avoid arguments and taking sides on
authority issues.
● Observe clear limit setting:
1. The staff should present a united front.
2. Do not accept gifts and favors.
3. Always verify what the client says.
4. Confront patient for manipulative behaviors.
5. Execute contract regarding acceptable
behaviors and rewards for it and
unacceptable behaviors and the
consequences for it.
6. Be consistent, firm, and matter of fact when
implementing limit setting.
7. Reinforce behaviors that foster sensitivity.
8. Provide model for mature and appropriate
behaviors. MANAGEMENT
9. Holding client responsible for his actions.
10. Enhance coping skills by:
- Teaching client problem solving skills when
confronted with difficult situations.
- Teach to address problematic areas of his
life, drug dependence, alcoholism,
unemployment, marital and family problems
- Use supportive confrontation for
manipulative and deceptive behavior by
pointing out specific problematic behavior in
a non-accusatory and matter of fact.
BORDERLINE PERSONALITY DISORDER
● Fears separation, INTENSE and
UNSTABLE emotions and moods,
hypochondriacal, suicidal, impulsive
behaviors.
DSM
● A pervasive pattern of instability of
interpersonal relationships, self- image and
affects and marked impulsivity, beginning by
early adulthood and present in a variety of
contexts, as indicated by five or more of the
following:
1. Frantic efforts to avoid real or imagined
abandonment.
2. A pattern of unstable and intense
interpersonal relationships characterized by
alternating between extremes of idealization
and devaluation.
3. Identity disturbance: markedly and
persistently unstable self-image or sense of
self.
4. Impulsivity in at least two areas that are
potentially self- damaging
5. Recurrent suicidal behavior, gestures, or
threats or self- mutilating behavior.
6. Affective instability due to markedly
reactivity of mood.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger of difficulty
controlling anger.
9. Transient, stress-related paranoid ideation
or severe dissociative symptoms.
PSYCHOTHERAPY
● Individual therapy
● Dialectical therapy
● Attitude therapy: MATTER OF FACT.
MEDICAL
● Antidepressant: SSRI’s and TCA’s
● Atypical Neuroleptics
● Anticonvulsants
● Opiate-receptor antagonist (Naltrexone)
● Caution Anxiolytics!
NURSING MANAGEMENT
● Recognize characteristics of manipulation:
- Uses bargains, threats, demands or
intimation to get own way.
- Shows ability to identify and use other
people’s weaknesses for own benefit.
- Makes continuous, unrealistic demands.
- Pretends to be helpless and sorry for
behavior.
- Lies to gain sympathy of staff or other
clients.
- Acts out even when given acceptable
behavior alternatives
- Keeps all relationships on a superficial level.
- Uses flattery, charm and excessive
compliments to have needs met.
- Exploits the generosity of others.
- Identifies with staff or authority figure and
acts as if he/she is not incarcerated.
- Finds a way around the unit rules and
expectations.
- Uses sensuality to gain control over others.
● Interventions for manipulative behavior:
- Set clear and realistic limit with appropriate
consequences.
- Confront client about manipulative behavior.
Do not try to out-manipulate-client is a
master at it.
- Reinforce adaptive behavior through
positive feedback and realistic praise.
- Do not be influenced by client’s charming
ways- directed toward manipulating the
nurse.
- Do not be intimidated by client’s behavior.
- Clearly and consistently communicate care
plans and client’s behavior to other staff.
- Accept no flattery, gifts or favors.
 - Strengthen the therapeutic relationship.
● Protect patient from suicidal and
self-destructive tendencies:
- Know that clients may commit suicide to
convey their distress in a concrete way.
- Execute contract for the client to contact the
nurse, therapist, social supports or
emergency attention when suicidal urge
occurs and before engaging in
sel-destructive behaviors.
- Keep environment safe.
- If manipulation occurs.
- Provide care to self-inflicted wounds in a
matter of fact manner.
● Help improve adaptive skills:
- Finding meaningful work or creative outlets
and to form interpersonal relationships to
lessen suicidal tendency.
● Provide alternative ways in expressing
anger and hostility.
HISTRIONIC PERSONALITY DISORDER
● Characterized by a pattern of EXCESSIVE
EMOTIONALITY and ATTENTION
SEEKING BEHAVIOR.
● Overly concerned about physical
appearance, extrovert, loud, usually wears
heavy make up and bright colored clothes.
DSM
● A pervasive pattern in excessive
emotionality and attention seeking,
beginning by early adulthood and present in
a variety of contexts, as indicated by five or
more of the following:
1. Is uncomfortable in situations in which he or
she is not the center of attention.
2. Interaction with others is often characterized
by inappropriate sexually seductive or
provocative behavior.
3. Displays rapidly shifting and shallow
expressions of emotions.
4. Consistently uses phVysical appearance to
draw attention to self.
5. Has a style of speech that is excessively
impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and
exaggerated expressions of emotion.
7. Is suggestible.
8. Considers relationships to be more intimate
than they actually are.
PSYCHOTHERAPY
● Individual therapy
● Caution group therapy and family therapy
● Attitude therapy: MATTER OF FACT
● Cognitive-behavioral therapy
NURSING MANAGEMENT
● Consistent limit setting.
● Assess for current life situations and
exploring solutions in a matter of fact
approach.
● To overcome the patients’ exaggeration:
- Take a skeptical stance to help the patient
objectivity.
- Guide discussions with the patient by
following reasonable line of reasoning to its
logical conclusions.
- Help the patient examine and clarify
- Help patient examine interactions and
social.
- Situations from an objective viewpoint while
not rejecting and criticizing patient’s
opinions and presenting alternative
explanations.
- Explore, present and encourage patient to
try new behaviors.
● Increase patient’s self-esteem by exploring
personal strengths and showing confidence
on patient’s abilities.
● Modeling socially acceptable behavior.
● Protect patient from self-destructive
NARCISSISTIC PERSONALITY DISORDER
● Significant problems with their
SELF-WORTH stemming from a powerful
sense of entitlement.
● Believes that they are VERY SPECIAL,
needs and demands for special treatment,
attention and care.
● Believes they have special powers or
uniquely talented, disregard and disrespect
the worth of those people around them.
DSM
● A pervasive pattern of grandiosity, need for
admiration, and lack of empathy, beginning
by early adulthood and present in a variety
of contexts, as indicated by five or more of
the following:
1. Has a grandiose send of self- importance
2. Is preoccupied with fantasies of unlimited
success, power, brilliance, beauty or ideal
love.
3. Believes that he or she is “special” and
unique and can only be understood by, or
should associate with, other special or high
status people.
4. Requires excessive admiration. 5. Has
sense of entitlement.
PSYCHOTHERAPY
● Individual therapy
● Group therapy
● Family therapy
● Attitude therapy: MATTER OF FACT
● Cognitive- Behavioral therapy
MEDICAL MANAGEMENT
● *NO DRUG is usually prescribed.
● Anti-depressant: SSRI’s and TCA’s
NURSING MANAGEMENT
● Know that the client may be very resistant
on the early phase of the therapeutic
relationship.
● Should always validate what the client says
for self-reports are unreliable.
● To reconstitute an intact self-image, the
nurse should:
- Provide initial support by conveying a
feeling of respect and acknowledgement of
self-importance.
- Step-by-step, confront the patient’s
- Providing empathy with the hurt that the
patient experiences when confronted with
his behavior.
● The nurse should maintain self-awareness
and objectivity so as not to internalize and
be put-off by the patient’s rude and critical
verbalizations and behavior.
● It is important for the nurse to :
- Set limits and provide a role model of
acceptable
CLUSTER C - PERVADED BY ANXIETY AND
FEAR
AVOIDANT PERSONALITY DISORDER
● Characterized by pervasive pattern of social
inhibition, feelings of inadequacy,
hypersensitivity to negative evaluation.
Fears rejection, remains aloof in a
relationship, feels very inferior.
DSM
● A pervasive pattern of social inhibition,
feelings of inadequacy, and hypersensitivity
to negative evaluation, beginning by early
adulthood and present in a variety of
contexts, as indicated by five or more of the
following:
1. Avoids occupational activities that involve
significant interpersonal contact because of
fears of criticism, disapproval or rejection.
2. Is unwilling to get involved with people
unless certain of being liked.
3. Shows restraint within intimate relationships
because of the fear of being shamed or
ridiculed.
4. Is inhibited in new interpersonal situations
because of feelings of inadequacy.
5. .Views self as socially inept, personally
unappealing, or inferior to others.
6. Is unusually reluctant to take personal risks
or to engage in any new activities because
they may prove embarrassing.
PSYCHOTHERAPY
● Individual therapy
● Cognitive- Behavioral therapy
MEDICAL MANAGEMENT
● ***NO DRUG is usually prescribed.
● Anti-depressants: SSRI’s and TCA’s
NURSING MANAGEMENT
● Be aware the client trusts few people only.
● Enhance the patient’s self-esteem.
● Aid in improving social interaction and later
increase confidence in interpersonal
relationships.
● Slowly desensitize with criticism.
● Inform him that changes are constant.
DEPENDENT PERSONALITY DISORDER
● An incessant demand for attention from
others, lacks self confidence, lacks self-
worth, cannot live independently, needs
constant reassurance and advice, strong
NEED to be taken cared of.
DSM
● A pervasive and excessive need to be taken
care of that leads to submissive and clinging
behavior and fears of separation, beginning
by early adulthood and present in a variety
of contexts, as indicated by five or more of
the following:
1. Has difficulty making everyday decisions
without an excessive amount of advice and
reassurance from others.
2. Needs others to assume responsibility for
most major areas of his or her life.
3. Has difficulty expressing V disagreements
with others because of fear of loss of
support or approval.
4. Has difficulty initiating projects or doing
things on his or her own.
5. Goes to excessive lengths to obtain
nurturance and support from others, to the
point of volunteering to do things that are
unpleasant.
6. Feels uncomfortable or helpless when alone
because of exaggerated fears of being
unable to care for himself/herself.
7. Urgently seeks another relationship as a
source of care and support when a close
relationship ends.
8. Is unrealistically preoccupied with fears of
being left to take care of himself or herself.
PSYCHOTHERAPY
● Individual therapy
● Cognitive-Behavioral therapy (exposure and
response prevention)
● Attitude therapy: MATTER OF FACT
● Self-help groups
MEDICAL
● Anxiolytics: BENZODIAZEPINES PSYCHOTHERAPY
● Antidepressants: SSRI’s, TCA’s and MAOI’s ● Individual therapy
NURSING MANAGEMENT ● Caution group therapy
● Offer persistent, consistent, flexible care- ● Cognitive-Behavioral therapy
take direct approach to gain trust. ● Attitude therapy: MATTER OF FACT
● Give client AUTONOMY as much as MEDICAL
possible; give options to choose. ● ***NO DRUG is usually prescribed.
● Verify client’s approval before proceeding. ● Anxiolytics
● LIMIT STAFF: few, consistent, easy to trust ● Antidepressants: SSRI’s and TCA’s
with sense of security. NURSING MANAGEMENT
● Encourage to verbalize feelings and the ● Set mutual goals.
plan that he/she has in order to solve the ● Provide choices to maintain autonomy.
plight’ strengthen available coping ● Allow time to complete rituals.
mechanisms.
● Dismiss somatic complaints, without organic Other Related Personality Disorder
basis MATTER OF FACTLY.
PASSIVE AGGRESSIVE PERSONALITY
OBSESSIVE-COMPULSIVE PERSONALITY
DISORDER
DISORDER
● Excessively devoted to working flexible and
DSM
rigid. and productivity, perfectionist,
● Passive-Aggressive (Negativistic)
Personality Disorder will be represented and
DSM
diagnosed by a combination of core
● A pervasive pattern of preoccupation with
impairment in personality functioning and
orderliness, perfectionism, and mental and
specific pathological personality traits,
interpersonal control, at the expense of
rather than as a specific type.
flexibility, openness, and efficiency,
beginning by early adulthood and present in
Passive behavior includes:
a variety of contexts, as indicated by five or
VALE
more of the following:
- V–View future negatively (believe that
1. Is preoccupied with details, rules, lists,
nothing good ever last)
order, organization, or schedules to the
- A–Ambivalent and indecisive
extent that the major point of the activity is
- L–Low self-confidence despite the bravado
lost.
shown
2. Shows perfectionism that interferes with
- E–Excessive dependence
task completion or to work with others
unless
Aggressive behavior includes:
3. Is excessively devoted to work and
FAMES
productivity to the exclusions of leisure
- F–Fault finder
activities and friendships.
- A–Anticipate difficulties and
4. Is over conscientious, scrupulous and
disappointments where none exist
inflexible about matters of morality, ethics or
- M–May blame others fortheir own feelings
values.
and misfortune –May report feeling cheated,
5. Is unable to discard worn-out or worthless
victimized, exploited misunderstood or
objects even when they have no
unappreciated
sentimental value.
- E–Easily upset and offended
6. Is reluctant to delegate tasks they submit to
- S–Shows resistance through procrastination
exactly his or her way of doing things.
and stubbornness
7. Adopts a miserly spending style toward both
self and others; money is viewed as
NURSING MANAGEMENT
something to be hoarded for future
- Help client to identify feelings and express
catastrophes.
them directly
8. Shows rigidity and stubbornness.
- Assertiveness
- Training Role play
QUIZ
PERSONALITY DISORDERS
1. Which of the following approaches would the
nurse expect to include in the plan of care for a
client with antisocial personality disorder who has a
history of stealing and jail time?
A. Using strategies to help the client become
passive
B. Helping the client develop a conscience
C. Assisting the client with understanding right
from wrong.
D. Teaching the client consequences of her
actions. .
2. A client with borderline personality disorder is
complaining to other clients about not being
allowed by the staff to keep food in her room.
Which of the following interventions would be most
appropriate?
A. Ignoring the client’s behavior
B. Reprimanding the client
C. Setting limits on the behavior
D. Allowing the snack to be kept in her room. .
3. A client with antisocial personality disorder has a
potential for evidence and aggressive behavior.
Which of the following client outcomes to be
accomplished in the short term would be most
appropriate for the nurse to include in the plan of
care?
A. Discuss feelings of anger with staff.
B. Use humor when expressing anger
C. Use the indirect behavior to express anger.
D. Ask the nurse for medication when upset
4. When planning care for a client with schizotypal
personality disorder, which of the following would
help the client become involved with others?
A. Attending an activity with the nurse
B. Participating solely in group activities
C. Leading a sing a-along in the afternoon
D. Being involved with primarily one to one
activities
5. The client with borderline personality disorder
who is to be discharged soon threatened to ‘do
something’ to herself if discharged. Which of the
following actions by the nurse would be most
important?
A. Request an immediate extension for the
client.
B. Ask a family member to stay with the client
at home temporarily.
C. Discuss the meaning of the client’s
statement with her.
D. Ignore the client’s statement because it’s a
sign of manipulation
6. The client with narcissistic personality disorder
tells the nurse he can get an executive position with
the best company around anytime he wants. The
history reveals that the client, whose highest level
of education completed is high school, has held
only a series of short-term part-time jobs for the
past 2 years. The nurse interprets the client
statement to be an example of which of the
following
A. Intellectualization
B. Grandiose delusion
C. Grandiose of self-importance
D. Sense of entitlement
7. Which symptoms support a diagnosis of
borderline personality disorder?
A. Suspiciousness, hypervigilance, and
emotional coldness
B. Insensitivity to others, sexual acting out, and
violence
C. Flat affect, social withdrawal, and unusual
dress
D. Lack of self-esteem, clinging and impulsive
behavior, and self-mutilating behavior
8. The nurse is talking with a client who has been
diagnosed with histrionic personality disorder about
how to social during activities without being
seductive. The nurse would focus the discussion on
which of the following area:
A. Explaining the negative reactions of others
toward his behavior
B. Suggesting she apologize to others for his
behavior.
C. Discussing his relationship with his mother.
D. Asking him to explain reasons for his
seductive behavior
9. A client with antisocial personality, when asked
about his family, states “I’ve been married 4 times.
Three of those marriages were ‘shotgun’ wedding. I
never really loved my wives. I didn’t know much of
my three children. I’ve lost track on them” One
reason that a person with such disorder may marry
repeatedly or get into trouble with legal authorities
is:
A. They are mentally retardate
B. They do not learn from their experiences
C. They are too psychotic to understand what’s
going on
D. They usually don’t care
10. A 23 year old unmarried man, is demanded by
the courts for psychiatric treatment. He has a police
record dating to his early teenage years that
includes delinquency, running away, auto theft,
vandalism, and other infractions. He dropped out of
school at age 16 and has been living on his own
since then. His history suggests maladaptive
coping, which is associated with which type of A. “I don’t want you to wash your hands often
personality disorder? anymore”
A. Antisocial B. “The doctor wrote an order that you are to
B. Narcissistic stop washing your hands so often.”
C. Obsessive-compulsive C. “If you continue to wash your hands so
D. Borderline frequently, the skin on your hands will break
down,”
11. A primary focus of treatment plan for client with D. “You may wash your hands before the group
antisocial personality is to help him: therapy meeting if you wish, but not during
A. Choose a stable career or occupation group therapy.”
B. Establish mature relationships with women
C. Express feelings of remorse about past 17. An individual who is with histrionic personality is
behaviors characterized by:
D. Recognize and observe limits when A. Keeping self the center of attention and
interacting with others dramatic expression of feeling
B. Marked dependency and difficulty making
12. Which ego defense mechanisms are most decisions
prominently used in obsessive-compulsive C. Grandiose feeling of self-importance, beauty
disorders and power
A. Displacement and undoing D. Magical thinking and paranoid ideation
B. Introjection and projection
C. Rationalization and repression 18. The nurse is caring for a patient who’s sarcastic
D. Compensation and isolation and critical and often expresses feelings that are
the opposite of what he’s actually feeling. This
13. Client with an antisocial disorder may not profit patient is exhibiting which type of behavior?
by psychotherapy because they? A. Passive-aggressive
A. Have difficulty relating meaningfully B. Borderline
B. Are too psychotic to cooperate C. Histrionic
C. Do not have the intelligence to profit from D. Narcissistic
therapy 19. A client with compulsive personality
D. Will not accept the therapy characteristics usually exhibits specific symptoms
that are typical of this particular disorder. Which of
14. Your client states, “I work for the government, the following traits would be most identifiable as
and I am so important in my office that the other compulsive personality disorder?
people will not be able to work without me.” This is A. Indecisive but a high achiever
characteristic of: B. Poor interpersonal relationships
A. A histrionic personality disorder C. Cold, rigid, and excessive perfectionism
B. An antisocial personality disorder D. Lack of adaptability
C. A narcissistic personality disorder 20. Personality disorders are identified in the DSM
D. A multiple personality disorder IV in clusters. The nurse would expect a client with
a Cluster A personality disorder to exhibit behaviors
15. A patient with antisocial personality has been that are:
“borrowing” money, cigarettes, and clothing without A. Odd and eccentric
returning the items or reciprocating the favor. The B. Dramatic and erratic
best way to approach Ben about this reported C. Hostile and impulsive
behavior is to: D. Anxious and fearful
A. Confront the client on a one-to-one basis
B. Limit the client's interactions with other
patients by restricting him to his room KEY:
C. Ask the patients to confront Ben in a 1. D 11. D 19. C
community meeting 2. C 12. A 20. A
D. Say nothing to him and have staff members 3. A 13. A
observe him for such behaviors. 4. D 14. C
5. C 15. A
16. Which is an example of limit setting as an 6. C 16. D
effective nursing intervention in ritualistic hand 7. D 17. A
washing behavior? 8. A 18. A
9. B
10. A
 WEEK 10
NEURODEVELOPMENTAL INTELLECTUAL AND DEVELOPMENTAL
DISORDERS in INFANTS, DISABILITIES (IDDs)
● Intellectual disability
CHILDREN and disorder or general learning
ADOLESCENCE disability
● Formerly known as mental
retardation
NEURODEVELOPMENTAL DISORDERS
● Characterized by
● Disorders first diagnosed in infancy or
below-average intelligence or mental ability
childhood
and a lack of skills necessary for day-to-day
● Impairments of the growth and development
living.
of the brain or the central nervous system.
● Has limitations in two areas.
● Affects emotion, learning ability,
○ Intellectual functioning.
self-control and memory which unfolds as
○ Adaptive behaviors.
an individual develops and grows.
DSM
CATEGORIES OF NEURODEVELOPMENTAL
● DSM 5 - severity is defined by the ability to
DISORDERS
meet the demands of daily life, as compared
– The DSM 5 categories includes:
with peers.
● Intellectual disability disorders (IDD)
● DSM IV-TR - severity is defined by IQ test.
● Autism spectrum disorders (ASD)
● IQ TEST is use to measure human
● Attention deficit hyperactivity disorder
intelligence
(ADHD)
● Intellectual Disability is defined by an IQ
● Motor disorders
under 70
● Communication disorders
● The average IQ is 100, with the majority of
● Specific learning disorders
people scoring between 85 and 115.
● Elimination disorders
SCORING:
● 70 below – intellectually disabled
WHAT CAUSES NEURODEVELOPMENTAL
● 70- 79 – borderline/ deficiency intelligence
DISORDERS?
● 80 – 89 – dullness
● GENETIC FACTORS : such as genetic
● 90 – 109 – average or normal intellect
mutations and metabolic conditions during
● 110-119 – superior intelligence
conception.
● 120 – 140 – very superior intelligence
● PRENATAL FACTORS : such as nutritional
● 140 & above – genius or almost genius
deficiencies and maternal infections during
pregnancy.
● PERINATAL FACTORS : such as those due
to complications that arise during labor,
typically a lack of oxygen (hypoxia).
● POSTNATAL FACTORS: such as traumatic
brain injury, infections like meningitis or
exposure to environmental toxins after birth.
● SOCIAL FACTORS: Deprivation from social
and emotional care causes severe delays in
TREATMENT AND MANAGEMENT FOR ID
brain and cognitive development.
Primary goals of treatment:
● to develop the child's potential to the fullest
DIAGNOSING NEURODEVELOPMENTAL
● to allow them to participate in as many
DISORDERS
aspects of their social and community life as
— The neurodevelopmental examination provides
possible
information about how a child is learning, growing,
● Treat the underlying cause of ID
and developing over time.
- Ex: phenylketonuria - restricting
● Developmental tests
phenylalanine in the diet
● Neurologic examination
● Treat comorbid physical and mental
● Brain imaging
disorders with the aim of improving the
● Physical examination
patient's functioning and life skills.
● LABORATORY TESTS are procedures in
● Behavioral and cognitive intervention
which samples of blood, urine and other
○ special education
bodily fluid or tissues is examined to get
○ psychosocial supports
information about a child’s health

GLOBAL DEVELOPMENTAL DELAY
● It is an intellectual developmental disorder
characterized by significant delay in two or
more developmental domain.
● Diagnosed when children are less than 5
year old
● 6 main areas of development in which kids
can have delays
- Language or speech
- Vision
- Gross motor and fine motor skills
- Thinking and cognitive skills
- Social and emotional skills
- Daily skills
UNSPECIFIED INTELLECTUAL DISABILITY
● It is characterized by the
presence of associated sensory
of physical impairments, such
as blindness or prelingual
deafness; locomotor disability;
or presence of severe
behavioral problem or
comorbidity with mental disorder.
● This category should only be used in
exceptional circumstances and requires
reassessment after a period of time
● This category is reserved for children over
the age of 5 years
AUTISM SPECTRUM DISORDER
● Autism spectrum disorder is previously
categorized as one of the different types of
pervasive developmental disorders which
previously includes:
- Autistic Disorder
- Rett’s Disorder
- Childhood Disintegrative Disorder
- Asperger’s Disorder
- PDD not otherwise specified
● In DSM 5, previous PDDs such as Rett
disorder, childhood disintegrative disorder,
and Asperger disorder are now viewed on a
continuum of autism spectrum
AUTISM SPECTRUM DISORDER (ASD)
● Formerly known as mindblindness.
● It is a developmental disability
characterized by significant impairment in
social, communication and behavior
● Onset: identified usually by 12 months and
not later than 3 years old
● Incidence: 5x more prevalent in boys than in
girls
● Characteristic: impairment of reciprocal
interaction skills
● Etiology: Unknown but could be genetic or
mechanical trauma of the birth process
itself.
SIGNS AND SYMPTOMS OF AUTISM
– Each child with autism may have slightly different
symptoms.
● DIFFICULTY WITH SOCIAL
INTERACTIONS
- Unaffectionate
- Prefer to be alone
- Inappropriate attachments to objects
- Lack of interest in the environment
- Inappropriate laughing or giggling
- Upset by minor changes in routine
- Avoid eye contact
● DIFFICULTY WITH COMMUNICATION
- Difficulty in expressing needs
- Unrelated responses to questions
- Delayed or does not develop language
(echolalia)
- May not use language to communicate
instead may use gestures
- Produce abnormal intonation pronoun
reversal
● STEREOTYPE BEHAVIOR
SPAN
- S - Sustained repetitive motor movements
○ spin objects or self
○ Rocking
○ hand or finger flapping
○ body twisting
- P - Prefer sameness
○ preoccupied usually with lights,
moving objects or parts of objects
- A - Apparent insensitivity to pain
- N - No real fear of dangers
HOW IS AUTISM DIAGNOSED?
— For the first two years of life, the child should be
checked for the following:
developmental deficits:
● 12 months: No babbling, pointing, or
gesturing/ not responding to own name
● 14 months: not showing interest by pointing
to object or people
● 18 months: No single word spoken/ doesn’t
play pretend games
 ● 24 months: No two-words spoken, just ASPERGER’S SYNDROME
repeating words or sounds of others ● AS is considered to be on the mild end of
● 3 – 4 months: no eye contact the autism spectrum.
● Loss of any language or social skills at any ● Children with AS exhibit 4 primary
age symptoms:
1. Obsessive focus on a narrow topic of
HOW IS ASD TREATED? interest.
1. Reduce behavioral symptoms 2. Having difficulty with social interaction
● Reduce temper tantrums, aggressiveness, 3. Engaging in repetitive behavior
self-injury, hyperactivity and stereotyped 4. Focusing on rules and routines
behaviors ● Incidence: common among boys
- Haloperidol (Haldol) ● Onset: appears to have a later onset
- Risperidone (Risperdal) ● Some people with AS are classified as
● Diminish self-injury, hyperactivity and high-functioning.
obsessive behaviors ● High-functioning autism means they don’t
- Catapres (Clonidine) have delayed language skills and cognitive
- Anafranil (Clomipramine) development that is typical of many people
2. Promote learning and development with ASDs.
● Behavior change programs. ● Often, individuals diagnosed with AS have
- These programs teach social , movement, normal or above normal intelligence and are
and cognitive skills. They can help a child frequently able to be educated in
change behavioral problems. mainstream classrooms and hold jobs.
● Special education programs. ● AS cannot be cured. Early diagnosis and
- These focus on social skills, speech, intervention can help a child make social
language, self-care, and job skills. connections, achieve their potential, and
3. Family therapy: lead a productive life.
● Parental education
SAVANT SYNDROME
● rare condition
RETT DISORDER ● When an individual with multiple cognitive
● Rett syndrome is a rare genetic neurological disabilities has extraordinary proficiency in
and developmental disorder that affects the one isolated skill
way the brain develops, causing a
progressive loss of motor skills and speech CHILDHOOD DISINTEGRATIVE DISORDER
● Incidence: Common in girls ● Also called Heller’s Syndrome or Dementia
● Children with Rett disorder develop normally Infantialis
for the first 6 to 18 months of age, and then ● A rare condition characterized by late onset
lose skills they previously had — such as of developmental delays (or severe and
the ability to crawl, walk, communicate or sudden reversal) in language, social
use their hands. function and motor skills
● marked regression in multiple areas of
RETT DISORDER AUTISM functions after at least 2 years of normal
growth and development
Common in girls Common in boys
● Incidence: common in boys
Loss of previously Delayed/ inappropriate
● Cause: Unknown
acquired language language development
Loss of hand function Preserved hand function
Ataxia is common Ataxia is rare
Seizure is common Seizure is not common
Microcephaly Normal/ large head
Delayed physical growth Normal physical growth
& function and function
ATTENTION DEFICIT TREATMENT FOR ADHD
HYPERACTIVITY DISORDER
1. PSYCHOPHARMACOLOGY
Stimulants
ADHD
- use to reduce hyperactivity, inattentiveness,
● ADHD is a neurodevelopmental disorder
impulsivity and lability of mood
characterized by inattention, or excessive
CARDS
activity and impulsivity, which are otherwise
● C – Cylert (Pemoline)
not appropriate for a child's age
- Last drug to be prescribed due to its
● Incidence: Common among boys
hepatotoxicity (liver damage)
● Onset: Before age 6–12years
● A – Adderall (Amphetamine)
● Diagnosis: Usually identified and diagnosed
- SE: addictive
when the child begins pre-school
● R – Ritalin (Methylphenidine)
● Characterized by:
- SE: have a high potential for abuse and
- H - Hyperactivity
dependence
- I – Inattentiveness
● D – Dexedrine (Dextroamphetamine)
- D – Distractibility and impulsivity
- SE: insomnia, loss of appetite, weight loss,
irritability & increase self-injury during the
SIGNS & SYMPTOMS OF ADHD
highest dose week
● A – Academic performance is poor
Non-stimulant drugs
● D – Development of family and peer
● S – Strattera (Dapoxetine)
relationship is restrained
- help to increase the ability to pay attention,
○ Disruptive and intrusive at home
concentrate, stay focused, and stop
which causes friction with siblings
fidgeting
and parents
- an antidepressant (selective norepinephrine
● H – Hyperactive and impulsive behavior
reuptake inhibitor) approved in 2002
○ Inability to sit still
- SE: loss of appetite. N/V, fatigability,
○ Fidgets
abdominal distress
○ talks excessively
○ run or climbs excessively
2. PSYCHOTHERAPY AND PSYCHOSOCIAL
○ often on the go
INTERVENTIONS
○ blurts out answers/interrupts
● Behavioral therapy
conversation
- aims to help the child change his/her
● D – Difficulty sustaining attention and
behavior
concentration
● Cognitive behavioral
○ misses details
- therapy aims to teach the child mindfulness
○ Doesn’t seem to listen
techniques to improve focus and
○ Easily distracted
concentration.
○ Often forgetful in daily activities
● Specific behavioral
○ Often losses necessary things
- classroom management interventions aims
○ severe – 2 to 3 seconds and mild – 2
to help the child manage his/her symptoms
to 3 minutes
and improve his/her functioning at school
○ Makes careless mistakes in school
and with peers.
works
● Support groups
○ Has difficulty with organization
- aims connect with others who have similar
○ Avoids task requiring mental effort
problems and concerns
Causes:
● Parenting education
● Both genetic and environmental factors
- Family and marital therapy aims to help
Diagnostic method:
family members and spouses find better
● Based on symptoms after other possible
ways to handle disruptive behaviors, to
causes were ruled out
encourage behavior changes, and improve
Treatment:
interactions with the patient.
● Medication, behavioral interventions,
- Parenting skills training aims to teach
special education and parental education
parents the skills needed to encourage and
reward positive behaviors in their children.
 CAUSES OF ADHD
● Brain anatomy and function. A lower level
of activity in the parts of the brain that
control attention and activity level may be
associated with ADHD.
● Genes and heredity. ADHD frequently runs
in families.
● Prematurity increases the risk of
developing ADHD.
● Prenatal exposures, such as alcohol or
nicotine from smoking, increase the risk of
developing ADHD.
● Toxins in the environment may lead to
ADHD in rare cases.
NURSING INTERVENTIONS FOR ADHD
1. Ensure safety of client and that of others
● Stop unsafe behavior
● Provide close supervision
● Give clear directions about acceptable and
unacceptable behavior
2. Improved role performance
● Give positive feedback for meeting
expectations
● Manage the environment (ex: provide a
quiet place free of distractions for task
completion
3. Simplifying instructions/directions
● Get child’s full attention
● Break complex tasks into small steps
● Allow break
4. Structured daily routine
● Establish a daily schedule
● Minimize changes
5. Client/family education and support
● Listen to parent’s feelings and frustrations
MOTOR DISORDERS
DSM 5 classification of Motor Disorders
includes:
1. Developmental Coordination Disorder
2. Stereotypic Movement Disorder
3. Tic Disorder
● Provisional Tic Disorder
● Persistent (Chronic) Motor or Vocal Tic
Disorder
● Tourette’s Disorder
● Other Specified Tic Disorder
● Unspecified Tic Disorder
1. DEVELOPMENTAL COORDINATION
DISORDER
● Also known as motor skills disorder,
motor coordination disorder or motor
dyspraxia
● It is diagnosed when motor skills problems
significantly interfere with academic
achievement or activities of daily living.
● Onset: may be first identified when the child
is a preschooler or kindergartner
● Impairment can be extremely disabling both
in academic settings (school) as well as in
everyday life due to impairment of
functioning
SIGNS AND SYMPTOMS
● Children with this disorder have variable
symptoms, depending on the age of
diagnosis
● Young infants may present with non-specific
findings, such as hypotonia (floppy baby) or
hypertonia (rigid baby).
● Older infants may be delayed in their ability
to sit, stand or walk.
● Toddlers may have difficulty feeding
themselves.
● Older children may have a hard time
learning to hold a pencil, and tend to knock
over drinking glasses more often than
expected.
● As children with this disorder age, they often
avoid physical activities, especially those
requiring complex motor behaviors
TREATMENT
● Multimodal treatment that involves
occupational therapy and physical therapy
to improve their motor skills
● Special gym activities at school to promote
hand-eye coordination, motor development
and improve specific skills.
● Medical treatment which includes screening
and management for potential comorbid
conditions such as:
- Speech and language disorders
- Tourette's syndrome
- ADHD
- Mood disorders
- Psychosis
- Autism spectrum disorders
- Developmental disabilities
- Learning disorders.
2. STEREOTYPE MOVEMENT DISORDER.
● Characteristics: repetitive, purposeless
movements that is non-functional thus
interfere with the normal daily activities or
may results in self-injury.
● Stereotypic movements may include:
- Body rocking
- Biting fingernails
- Biting oneself
- Twirling self
- Twirling objects
- thumb sucking
- teeth grinding
- nose picking
 - breath holding ● Characteristic: Rapid, recurrent,
- air swallowing uncontrollable movements or vocal outburst
● Onset: First seen within the first three years (but not both)
of life ● Affect less than 1% of children and may be
related to a more complex tic disorder called
CAUSES Tourette's disorder.
● Cause: Unknown To be diagnosed, a person must:
● Genetic factor ● Have one or more motor tics or vocal tics
● Social isolation may lead to self-stimulation but not both.
in the form of stereotypic movements ● have tics that occur many times a day
● Environmental stress, such as difficulty in nearly every day or on and off throughout a
school or at home period of more than a year.
● Due to certain medications ● have tics that start before age 18 years.
● Head injury ● have symptoms that are not due to taking
medicine or having other medical conditions
TREATMENT OF STEREOTYPE MOVEMENT that can cause tics
DISORDER ● not have been diagnosed with Tourette
● Behavioral strategies - to reduce repetitive syndrome
movements and minimize the risk for
self-harm. TOURETTE’S DISORDER
● Differential Reinforcement is a therapy to Diagnostic criteria:
modify the child’s behavior through positive ● Have two or more motor tics and at least
reinforcement one vocal tic although they might not always
● Medical treatment - focus on screening and happen at the same time.
managing potential comorbid conditions ● Have had tics for at least a year. The tics
can occur many times a day (usually in
3. TIC DISORDERS bouts) nearly every day, or off and on.
● Tic disorder is characterized by a sudden, ● Have tics that begin before age 18 years.
rapid, recurrent, non-rhythmic, stereotyped ● Have symptoms that are not due to taking
motor movement or vocalization medicines or having other medical condition
● Example of (Ex: seizures, Huntington disease or
motor tics post-viral encephalitis
- Blinking ● Onset: between ages 2 and 15, with the
- neck jerking average being around 6 years of age.
- Grimacing ● Incidence: Males are about 3-4 x more
- Coughing likely than females
- shoulder shrugging Treatment:
● Example of vocal tics ● Psychotherapy- to improve school, work or
- clearing of the throat social life
- Grunting ● Medication: clonidine, neuroleptics,
- Sniffing ● Treat comorbid disorders
- snorting ● Deep brain stimulation

PROVISIONAL TIC DISORDER Common motor tics seen in Tourette syndrome

● Previously known as TRANSIENT TIC
DISORDER
Simple tics Complex tics
● Characterized by single or multiple vocal or
motor tics, but for no longer than 12 months Eye blinking Touching or smelling
● Have tics that start before age 18 years. objects
● Provisional tics go away by themselves in Head jerking Repeating observed
less than a year. However, some may get movements
worse with anxiety, tiredness, and some Shoulder shrugging Stepping in a certain
medications. pattern
● Affects up to 10 % of children during the Eye darting Obscene gesturing
early school years.
Nose twitching Bending or twisting
PERSISTENT TICS DISORDER Mouth movements Hopping
● Also known as CHRONIC MOTOR OR
VOCAL TIC DISORDER
Common vocal tics seen in Tourette syndrome
Simple tics Complex tics
Grunting Repeating one's own
words or phrases
Coughing Repeating others' words
or phrases
Throat clearing Using vulgar, obscene or
swear words
Barking
COMMUNICATION DISORDERS
COMMUNICATION DISORDERS
● Communication disorders involve persistent
problems related to language and speech.
Language competence involves two main
elements
1. PRODUCTION - ability to encode one's
ideas into language forms and symbols.
2. COMPREHENSION - ability to understand
meanings that others have expressed using
language.
● Speech refers to production of sounds
produced orally.
TYPES OF COMMUNICATION DISORDERS
— DSM 5 Classification of Communication
disorders includes:
1. Language disorder
2. Speech sound disorder
3. Childhood-onset fluency disorder
4. Social (pragmatic) communication disorder,
LANGUAGE DISORDER
● Previously known as expressive and mixed
receptive-expressive language disorders
● involves deficits in language production or
comprehension causing limited vocabulary
and an inability to form sentences or have a
conversation
● Onset: Symptoms first appear in the early
developmental period when children begin
to learn and use language
● Cause: genetic and could be associated
with other neurodevelopmental disorders
● Treatment: Speech and language therapy
and Psychotherapy
SPEECH SOUND DISORDER
● Previously known as PHONOLOGICAL
DISORDER
● Characterized by persistent difficulty
producing words or sounds correctly
● Onset: Symptoms begin early in life
● Cause: Unknown but could be genetic
● Treatment: Speech and language therapy.
CHILDHOOD-ONSET FLUENCY DISORDER
● Previously known as stuttering
● It is a disturbance of fluency and patterning
of speech with sound and syllable repetition
● Onset: between the ages of 2 and 7, with
80 to 90 percent of cases developing by age
6.
● Symptoms can be exacerbated by stress,
anxiety, or feeling self-conscious
● Cause: Unknown
● Treatment: Speech and language therapy
and CBT
SOCIAL COMMUNICATION DISORDER
● It is a new condition described in DSM 5
● Also called pragmatic communication
● Characterized by persistent difficulties in the
social uses of verbal and nonverbal
communication
● Symptoms: problems in understanding and
using language for social purposes
● Cause: Unknown
● Treatment: Speech-language therapy to
promote social communication skills
SPECIFIC LEARNING DISORDER
● Also referred to as LEARNING DISORDER
or LEARNING DISABILITY,
● It is characterized by problems in one of
three areas, reading, writing and math,
which are foundational to one’s ability to
learn.
● Onset: begins during school-age
● Cause: Unknown
● Treatment: Special education in school and
CBT
Diagnostic criteria:
– The child have difficulties in at least one of the
following areas for at least six months despite
targeted help:
● Difficulty reading
● Difficulty understanding the meaning of
what is being read
● Difficulty with spelling
● Difficulty with written expression
● Difficulty understanding number concepts,
number facts or calculation
● Difficulty with mathematical reasoning
ELIMINATION DISORDERS NURSING PROCESS FOR CHILDREN
WITH NEURODEVELOPMENTAL
ELIMINATION DISORDERS DISORDERS
● Characterized by
inappropriate elimination of
NURSING DIAGNOSIS SAMPLE
urine or feces
● Risk for injury
● Onset: usually first
● Impaired verbal communication
diagnosed in childhood or
● Impaired social interaction
adolescence.
● Impaired physical mobility
● Self care deficit
ENURESIS
● Ineffective impulse control
● Commonly known as BEDWETTING.
● Impaired bladder elimination
● Characterized by repeated voiding of urine
● Constipation
into inappropriate places
● Bowel incontinence
● NOCTURNAL ENURESIS - bedwetting at
night, is the most common type of
NURSING CARE FOR CHILDREN WITH
elimination disorder.
PSYCHIATRIC DISORDERS
● DIURNAL ENURESIS
daytime wetting
Ensuring the child’s safety
Diagnosed: when the child
● Stop unsafe behavior.
is 5 years or older
● Provide close supervision.
● Cause: Medical
● Give clear directions about acceptable and
conditions, stress, developmental delays
unacceptable behavior.
● Treatment: Urine alarm, bladder training
Improved role performance
and reward
● Give positive feedback for meeting
expectations.
ENCOPRESIS
● Manage the environment by provide a quiet
● Also known as stool soiling or fecal
place free of distractions for task completion
incontinence
Simplifying instructions/directions
● Characterized by repeated passage of feces
● Get child’s full attention
into inappropriate places
● Break complex tasks into small steps.
● Diagnosed: children ages
● Allow breaks.
4 and older who have
● Step by step instructions
already been toilet trained.
Structured daily routine
● Incidence: affects boys
● Establish a daily schedule.
more than girls
● Minimize changes.
● Cause: chronic
Client/family education
constipation
● Educate family members about the
● Treatment: Manage constipation, behavior
disorders and on the medications the child
modification
is taking.
● Offer emotional support
TREATMENT FOR ELIMINATION DISORDERS
● Arrange for family counseling to help
parents better understand the disorder. This
also assist them with their coping
mechanisms.
● Provide referrals for early intervention and
special education programs to increase
child’s capacity to learn, communicate, and
relate to others.
NURSING CARE TIPS FOR CHILDREN WITH ● Help the child accept responsibility for
AUTISM SPECTRUM DISORDER behavior rather than blaming others,
● Choose words carefully when speaking to becoming defensive, and wanting revenge.
verbal autistic child because they are likely ● Use role-playing so he can practice ways of
to interpret words concretely. handling stress and gain skill and
● Advise parents to have close, face-to-face confidence in managing difficult situations.
contact with child to promote ● Instruct patients on how to deal with child’s
communication. demands. This might include learning how
● Maintain a regular and predictable daily to
routine to prevent outbursts. Prepare child
for changes of routine.
● Educate parents on behaviors that signal
tantrums such as increased hand flapping.
Emphasize the importance of intervening
and anticipating needs before a tantrum
occurs.
● Advise patients on ways to provide a safe
environment for the child (e.g. installing
locks and gates).
● Educate family members on the
medications (e.g. stimulants, selective
serotonin reuptake inhibitors, lithium, etc.)
the child is taking.
● Offer emotional support and information to
parents.
● Arrange for family counseling to help
parents better understand the disorder. This
also assist them with their coping
mechanisms.
● Provide referrals for early intervention,
home care assistance, and support groups,
as needed. Early intervention and special
education programs increase child’s
capacity to learn, communicate, and relate
to others. This also reduce the severity and
frequency of disruptive behaviors. Special
schools for behavior modification is alright
but educational mainstreaming is preferred.

NURSING CARE TIPS FOR CHILDREN WITH

ADHD
● Establish a trusting relationship with child
and family by conveying your acceptance.
● Provide clear behavioral guidelines,
including consequences for disruptive and
manipulative behavior.
● Talk to the child about making acceptable
choices.
● Teach child on effective problem-solving
skills, and have him or her demonstrate
them in return.
● Identify abusive communication (e.g.
threats, sarcasm, and disparaging
comments). Encourage child to stop using
them.
● Teach child on constructive methods of
releasing negative feelings to express anger
appropriately.
 WEEK 11 ● HYPOYGLYCEMIA
- low blood sugar can lead to temporary
NEUROCOGNITIVE
impairment in memory. In most cases,
DISORDERS memory should improve back to normal
soon after the sugar levels return to normal.
● HYPERGLYCEMIA
NEUROCOGNITIVE DISORDERS - high blood sugar has been linked with
● Formerly called COGNITIVE DISORDER longer term effects on memory
● It occurs when there is impairments or ● GENERAL MEDICAL CONDITION
disruptions in cognitive functions that - Seizures
interferes with normal functioning of an - Head trauma/injuries (closed and
individual. penetrating)
- Brain tumors
MEDICAL ASSESSMENT AND DIAGNOSTIC - Brain inflammation
PROCEDURES - Hypoxia/Anoxia
● Medical history - Multiple Sclerosis
● Physical exam - ECT
● Neurological tests - Neurotoxins
● Laboratory screening tests ● SUBSTANCE-INDUCED PERSISTING
● Brain scans AMNESTIC DISORDER
- CT scan - Ingestion of a substance.
- MRI - Benzodiazepines and other
- PET sedative-hypnotics
- SPECT - Over the counter medications
(antihistamines, cough syrups)
TYPES OF NEUROCOGNITIVE DISORDERS - Specific substance should be recorded
● DSM IV-TR when coding (i.e., cocaine-induced
● ADD + C persisting amnestic disorder).
○ Amnestic Disorder - Can code as “unknown” substance-
○ Delirium induced
○ Dementia ● TRAUMA OR STRESS
○ Cognitive disorders - Severe psychological trauma or stress can
● DSM 5 cause DISSOCIATIVE
● DMM DISORDERS/DISSOCIATIVE AMNESIA.
○ Delirium - Formerly known as PSYCHOGENIC
○ Major Neurocognitive Disorder AMNESIA
(Dementia) - Example: being the victim of a violent crime,
○ Mild Neurocognitive Disorder rape
- With this condition, the mind rejects
1. AMNESTIC DISORDER thoughts, feelings, or information that are
● Amnestic disorder can also be simply called too overwhelmed to handle.
AMNESIA Types of dissociative disorder
● Characterized by disturbance in memory ● Dissociative amnesia
that can be temporary or permanent. ● Dissociative identity disorder
● It can be caused by damage to areas of the ● Dissociative fugue
brain that are vital for memory processing.
○ Left brain hemisphere DISSOCIATIVE AMNESIA CAN ALSO BE
○ Hippocampus CLASSIFIED AS:
○ Cerebral cortex ● Localized amnesia
- No memory of a specific traumatic event
CAUSES OF AMNESTIC DISORDERS that took place
● ALCOHOL ABUSE ● Selective amnesia
- Short-term alcohol use can cause - Remember only selective part/s of events
BLACKOUT. This is a temporary form of that occurred in a defined period of time
anterograde amnesia. ● Generalized amnesia
● Long-term alcoholism can cause - Complete amnesia for one’s whole life
WERNICKE- KORSAKOFF SYNDROME
(ALCOHOL DEMENTIA).
 TYPES OF MEMORY IMPAIRMENT ● DTs usually lasts for 2 to 3 days, but
symptoms may linger for as long as a week.
1. ANTEROGRADE AMNESIA ● About 5% of people in alcohol withdrawal
● Is forgetting recent memories or inability to get DTs. If untreated, delirium tremens can
form new memories. cause a heart attack, stroke, and death.
● Can be temporary:
- Ex: blackout caused by too much alcohol. SYMPTOMS OF ALCOHOL WITHDRAWAL
● Can be permanent: ● 3 – 24 hrs. after the last drink – called
- Ex: One can experience it if the “The SHAKES” or “Mild Tremors”
hippocampus is damaged because - S – sweating
hippocampus plays an important role in - H – hypertension, and increased pulse and
forming memories. heart rate
- A – anxiety, confusion, agitation
2. RETROGRADE AMNESIA - K–none
● Is forgetting further events or inability to - E - excessive vomiting/ nausea
recall existing or, previously made - S – seizures/ tremors / startled behavior
memories. ● 36 – 72 hrs. after the last drink – results to
● Affect recently formed memories first. “DELIRIUM TREMENS” - hallucination (48
Older memories, such as memories from hours)
childhood, are usually affected more slowly.
Diseases such as dementia cause gradual 3. DEMENTIA
retrograde amnesia.
MAJOR NEUROCOGNITIVE DISORDER
WERNICKE-KORSAKOFF SYNDROME ● previously called DEMENTIA
● Also known as ALCOHOL DEMENTIA ● It is a condition in which higher brain
● It is a set of neurological conditions that functions are impaired as a result of
result from THIAMINE (Vitamin B1) neuronal damage.
DEFICIENCY. ● It is characterized by impairments in
● Wernicke's syndrome/encephalopathy memory, speech, reasoning, intellectual
represents the "acute" phase function, and/or spatial-temporal
● Korsakoff's syndrome represents the awareness.
"chronic" phase.
MILD NEUROCOGNITIVE IMPAIRMENT (MCI)
● Describe deficits that are more severe than
2. DELIRIUM are seen with normal aging but are
● Characterized by serious disturbance in insufficient to warrant a diagnosis of
mental abilities that results in confused dementia
thinking and reduced awareness of the ● Nevertheless, patients with MCI have an
environment. increased risk (approximately 10% per year)
● The disturbance of awareness tends to of developing dementia
develop over hours to days, and typically
fluctuates in the course of the day, often DIFFERENCE OF MAJOR & MILD
worsening in the evening. NEUROCOGNITIVE DISORDER
MAJOR MILD
CAUSES OF DELIRIUM NEUROCOGNITIVE NEUROCOGNITIVE
● Medical condition DISORDER IMPAIRMENT
● Substance intoxication 1.There is significant 1.There is modest
● Substance withdrawal (delirium tremens) decline in a cognitive cognitive decline in a
● Exposure to neurotoxins function as assessed by cognitive function as
● Combination of these factors a clinician, reported by assessed by a clinician,
significant person, etc. reported by significant
DELIRIUM TREMENS person, etc.
● Also known as ALCOHOL WITHDRAWAL 2. Cognitive deficits 2. Cognitive deficits do
DELIRIUM (AWD), interfere with daily not interfere with capacity
activities for independence in daily
● A severe type of withdrawal from alcohol. activities
● Symptoms appear 2 to 4 days after the last
3. Cognitive deficits do 3. Cognitive deficits do
drink, But some symptoms may not show up not occur not occur
until up to 10 days after giving up alcohol. exclusively in the context exclusively in the context
of a delirium of a delirium
4. The cognitive deficits 4. The cognitive deficits B. CREUTZFELDT-JACOB DISEASE (CJD)
are not better explained are not better explained - also known as subacute spongiform
by another mental by another mental encephalopathy or neurocognitive disorder
disorders disorders due to PRION DISEASE
- Early symptoms include memory problems,
FACTORS that CAUSES DELIRIUM and behavioral changes, poor coordination, and
DEMENTIA visual disturbances.
- Later symptoms include dementia,
DELIRIUM involuntary movements, blindness,
● PHYSIOLOGICAL AND METABOLIC weakness, and coma.
CONDITIONS - About 70% of people die within a year of
HE iS BRAVE diagnosis. - Onset- 40-60.
- H- Hypoxemia 3. SUBSTANCE-INDUCED DEMENTIA
- E- Electrolyte imbalance - dementia is related to the persistent or
- iS- Sleep disturbances prolong use of:
- B- Brain tumor - Alcohol
- R- Renal/Hepatic failure - Inhalants, sedatives, hypnotics and
- A- Any head injury anxiolytics
- V- Vitamin deficiency - Medication such as anticonvulsants.
- E- Exposure to noxious substances (paints, - Toxins such as lead, mercury, carbon
solvents, insecticides) monoxide insecticides, and industrial
● INFECTIONS solvents.
Systemic PUS 4. DEMENTIA DUE TO HEAD TRAUMA
- P – Pneumonia - A head trauma is any sort of injury to the
- U – UTI brain, skull, or scalp. Common head injuries
- S – Sepsis include concussions, skull fractures, and
Cerebral HEMS scalp wounds.
- H – HIV - A traumatic brain injury (TBI) can increase
- E – Encephalitis the risk of dementia by 80 percent, even 15
- M – Meningitis years after an accident.
- S – Syphilis - A concussion or other traumatic brain injury
● DRUG RELATED (TBI) can increase the risk of developing
Drug Withdrawal HAS dementia even 30 years later, according to
- H – Hypnotics a 2018 study.
- A – Anticholinergics 5. DEMENTIA DUE TO GENETIC FACTOR
- S – Sedatives ● HUNTINGTON’S DISEASE
Drug Intoxication LASH - an inherited, dominant gene disease that
- L – Lithium involves cerebral atrophy and enlargement
- A – Anticholinergics of the brain ventricles.
- S – Sedative characterized by:
- H – Hypnotics - choreiform movements (facial contortions,
twisting, turning and tongue movements),
DEMENTIA - personality changes, memory loss,
1. MEDICAL CONDITIONS: - decreased intellectual functioning and other
- Fluid and electrolyte imbalances signs of dementia
- Cardiopulmonary insufficiency - Symptoms can develop at any time, but
- Endocrine disorders they often first appear when people are in
- Renal/hepatic failure their 30s or 40s.
- Vascular Diseases - If the condition develops before age 20, it's
● VASCULAR DEMENTIA called juvenile Huntington's disease.
- CT/MRI shows multiple vascular lesions of 6. DEMENTIA DUE TO DECREASE
the cerebral cortex and sub-cortical METABOLISMS AND FUNCTIONS IN THE BRAIN
Structures resulting to decrease Blood
supply to the brain ALZHEIMER’S DISEASE
2. INFECTIOUS DISEASE ● progressive mental deterioration due to
A. HIV INFECTION neurofibrillary tangles and senile plaques
- Characterized by mild sensory impairment deposit in the nerve cells
to gross memory and cognitive deficits to ● It is the most common cause of premature
severe muscle dysfunction senility that can occur in middle or old age.
 ● Onset is insidious followed by rapid
changes in functioning characterized by:
a. Increase decline in functioning: loss of
speech and motor function
b. Profound personality and behavioral
changes:
- delusion
- Hallucination
- paranoia
- inattention to hygiene, etc.
● Late onset (after 65 years old) average
duration of 8-10 years
DIAGNOSING ALZHEIMER’S DISEASE
● CT, MRI, PET, SPECT Scans show atrophy
of cerebral neurons, senile plaque deposits
and fibrillary tangle resulting to enlargement
of the 3rd and 4th ventricles of the brain.
EPIDEMIOLOGY
● In 2020, as many as 5.8 million Americans
were living with Alzheimer’s disease.
● Younger people may get Alzheimer’s
disease, but it is less common.
● The number of people living with the
disease doubles every 5 years beyond age
65.
● This number is projected to nearly triple to
14 million people by 2060.1
● Symptoms of the disease can first appear
after age 60, and the risk increases with
age.
PARKINSON’S DISEASE
● Due to loss of dopaminergic neuron in the
substantia nigra
● Characterized by impaired movements such
as tremor, rigidity, motor slowing,
bradykinesia, postural instability.
● Other symptoms include impaired cognitive
functions, memory and executive
functioning.
PICK’S DISEASE
● degenerative brain disease that affects the
frontal and temporal lobes resulting to
clinical picture similar to Alzheimer’s
disease.
● This disease is one of many types of
dementias known as frontotemporal
dementia (FTD) caused by frontotemporal
lobar degeneration (FTLD).
● Early manifestations includes loss of social
skills and inhibitions, emotional blunting and
language abnormalities
● Later manifestations includes difficulty with
language, behavior, thinking, judgment, and
memory and personality changes.
● Onset is commonly seen in adults aged 50-
60; death occurs 2 -5 years.
LEWY BODY DEMENTIA
● "Lewy body disease is one of the most
common causes of Dementia in the elderly.
● Lewy body disease exists either in pure
form or in conjunction with other brain
changes, including those typically seen in
Alzheimer's disease and Parkinson's
disease thus hard to diagnose because
these diseases have similar symptoms.
● Scientists think that Lewy body disease
might be related to these diseases, or that
they sometimes happen together.
● The disease usually begins between the
ages of 50 and 85 and gets worse over
time.
● The disease has no cure thus treatment
focuses on drugs that help reduce
symptoms."
STAGES OF DEMENTIA
STAGE I - MILD
● last 2 – 4 years
● Losses objects frequently
● Difficulty finding words
● Forgetfulness
● Occupational & social setting is less
enjoyable
STAGE II - MODERATE
● may last several years
● confusion is apparent
● oriented to date & pla
● progressive memory loss
● requires assistance to perform tasks
because the client losses ability to live
independently
● inability to recall information (address,
numbers)
STAGE III - SEVERE
● nursing home care or hospital facility is
needed
Personality changes
● anger, irritability, loss of inhibitions,
hypersexualities, vulgarities
● loss of memory as manifested by aphasia,
anomia, agnosia, apraxia, etc
● wanders at night and difficulty to go back
home (get lost) due to memory loss and
confusion, Even name of spouse and
children can’t recall
● requires assistance for ADL
 NURSING PROCESS cannot perceive underestimate risks
DELIRIUM DEMENTIA potentially harmful and unrealistically
situations) appraise their
HISTORY - medical illness, - medical and drug
abilities resulting to
prescribed history
high risk for injury)
medications, - mental status
alcohol, illicit drugs, examination can ROLE & - clients are unlikely ROLE
OTC. provide information RELATIONSHI to fulfill their roles - work performance
- Perform 4AT about the client’s PS during the course is greatly affected
cognitive abilities of delirium however because of memory
they may regain and cognitive deficits
MOTOR Hyperkinetic APRAXIA – loss of
delirium their previous level RELATIONSHIP
BEHAVIOR ability to perform - results to “Role
- hyperactive, of functioning
purposeful activities reversal”
motor restlessness despite intact motor
Hypokinetic abilities SELF-CONCE clients may feel - Client may be angry
delirium - neglect personal PT guilt, shame and or frustrated with
- sluggish and hygiene humiliated and this themselves for
lethargic may result to long- misplacing objects or
Mixed delirium term problems with forgetting important
- fluctuating self- concept, if things OR angry to
behavior delirium has others for taking their
L - Loud, rapid and APHASIA- inability resulted from things
SPEECH
scream alcohol, illicit drug - Client may be
to understand and
I - incoherent, use or overuse of depressed for getting
express language
irrelevant prescribed old and losing their
ECHOLALIA –
P - perseveres on a repetition of the medications functioning
single topics and words PHYSIOLOGIC Sleep Disturbances N - Nap during the
confabulate of others and SELF- - daytime day and wander at
- pressured speech PALILALIA – CARE sleepiness night (sleep pattern
involuntary repetition CONSIDERATI - nighttime agitation disturbance)
of words, syllables, ON Eating and I - ignore internal
phrases or sounds elimination cues,hunger or thirst
slurred speech and disturbances C – can’t bath, dress
total loss of language - ignore or fail to and groom
function during the perceive internal themselves
late stage body cues such as E - experience bowel
hunger, thirst, and and bladder
THOUGHT - disorganized L - loss of cognitive elimination incontinence and
PROCESS and thought process functions
difficulty cleaning
CONTENT - thought content is Ex: inability to solve
themselves after
fragmented and problems, take
elimination
illogical actions and perform
- delusions tasks such as
believing that their planning, budgeting, DELIRIUM DEMENTIA
altered sensory decision making, - is characterized by - is characterized by co
perceptions are sequencing, disturbance of deficits primarily memory
real monitoring or stop consciousness and impairment develops
complex behavior cognitive abilities that gradually
I - impaired abstract develops rapidly over a short
thinking period of time.
D - delusions of
iS – Sensorium is clouded - Sensorium is clear
persecution as
- altered level of - forgetfulness (primary
dementia progresses
consciousness (primary sign)
INTELLECTUA Cannot focus, AGNOSIA – inability sign) - Impairment of attention
L sustain or shift to recognize objects - inability to think clearly and only in severe stage
PROCESSES attention effectively and person concentrate dementia
ANOMIA – inability - confusion, impaired
- Loss of recent to remember names attention
and remote of everyday objects
R – Reversible usually cause - Irreversible/Some
memory - attention and
by general medical reversible. Usually caused
concentration is
conditions, medications by neurologic or other
impaired
intoxication or withdrawal, medical conditions
Loss of recent
etc.
memory then remote
memory A – Acute onset (rapid onset - Gradual/ Progressive.
and short duration), Duration: years to years
JUDGMENT - impaired - impaired judgment
Duration: days to weeks
judgment (client (they may
P – Perception & thought - Perception is impaired bathroom if client - checking and
process is impaired H- H- Hallucination (V) does not make changing pads
hallucination (V & T) I - illusion requests frequently to avoid
I- Illusion P – Paranoia 4. Encourage some infection
D - Delusion – Prognosis is (persecutory delusion) exercise during 4. Encourage mild
good - Prognosis is poor day like sitting, physical activities
walking in hall, or such as walking
I – Involve young and old - Involve older adult other activities
- Inappropriate , slow and or elderly people client can manage
frequently incoherent speech
- Struggle to find the
appropriate word
DELIRIUM Manage client’s 1. Provide structured
D – Disorientation to time - Orientation to person,
- Acute confusion, environment and
(date) and place though time and place then
confusion disturbed routine
sometimes variable deteriorate at the later
- Disturbed thought process - Provide familiar
stage
sensory and surrounding and
S – Sundowning – - Sundowning – symptoms perception misconceptions routine to help
symptoms always almost worse at night - Disturbed 1. Approach client eliminate confusion
worse at night thought calmly and speak and promote role
processes in a clear low voice performance
and use simple 2. Promote social
NURSING DIAGNOSIS & INTERVENTIONS DEMENTIA words interaction
- Ineffective 2. Allow adequate - staying socially
DIAGNOSIS DELIRIUM DEMENTIA role time for client to engaged with friends
Risk for injury Promote client’s Promote client’s performance comprehend and and family has been
safety safety - Impaired respond shown to boost self
1. Teach client to 1. Offer self and social 3. Allow client to esteem
request assistance support in interaction make decision 3. Provide emotional
for activities performance - Impaired when able support
(getting out of bed, of ADL and preserve verbal 4, Provide orienting - show acceptance,
going to the client’s dignity communicatio cues such as be kind and
bathroom) 2. Avoid n calling client by respectful
2. Provide close environmental - Impaired name, placing - convey
supervision to triggers such as memory calendar and clock reassurance by
ensure safety strangers, or in the client’s approaching
during performance changes in daily room, introducing client in a calm and
of ADL routine to prevent self when supportive manner
3. Respond anxiety and talking - use supportive
promptly to client’s suspicion which may 5. Use supportive touch when
call for lead to agitation or touch if appropriate appropriate
assistance erratic behavior that 6. Reduce 4. Promote
compromise safety. environmental interaction and
stimulation such as involvement
noises, tv, radio, - Plan activities
Promote sleep, visitors, etc. to according to client’s
- Disturbed Promote adequate
proper nutrition, reduce client’s interest and abilities
sleep pattern sleep, proper
Hydration, confusion - Reminisce with
- Risk for fluid nutrition, hydration,
7. Provide well
volume deficit elimination, and elimination and client about the past
activities lighted environment - If client is
- Risk for hygiene , and activity
to minimize nonverbal, remain
imbalance
1. Monitor sleep environmental alert to
nutrition: less 1. Monitor sleep
pattern. misperceptions nonverbal cues
than body pattern
- Discourage (illusions) - Employ techniques
requirements - Daily physical
daytime napping activity helps client of distraction, time
to help sleep at to sleep at night away,going along
night 2. Monitor food and and reframing to
2. Monitor fluid and fluid intake, calm clients who are
food intake. - Provide assistance agitated, suspicious
- Provide prompts to eat and drink or confused
assistance to adequate amounts of
eat and drink food and fluids DISTRACTION – rechanneling client’s attention
adequate amounts 3. Monitor elimination and energy to a more neutral topic.
of food and fluids pattern
TIME AWAY – leaving the client for a short period
3. Monitor - Remind client to
elimination pattern. urinate; - provide and then returning to them to re-engage in
- Provide periodic pads or diapers as interaction
assistance to needed;
 GOING ALONG – providing emotional reassurance - VALPROIC ACID (Depakote)
to clients without correcting their misperception or - CARBAMAZEPINE (Tegretol
delusion 3. CHOLINESTERASE INHIBITOR
Ex: “There’s no need to worry; the children are just ● Slow the progression of dementia
fine” ● Cholinesterase inhibitors, also called
REFRAMING - offering explanations for events or acetylcholinesterase inhibitors, block the
situations normal breakdown of acetylcholine.
Ex: “The lady has many problems, and she yells ● Acetylcholine is the main neurotransmitter
sometimes because she’s frustrated found in the body and functions in both
peripheral and central nervous system
OUTCOME CARE
● C - COGNEX (Tacrine)
DELIRIUM DEMENTIA - 40-160 mg orally/day divided into 4 doses
• The client will be: - monitor liver enzymes for hepatotoxic
The client will be:
• Free of injury. effects
• Free of injury.
• Demonstrate increased • Maintain an adequate - monitor for flu-like symptoms
orientation and reality balance of ● A - ARICEPT (Donepezil
contact. activity and rest. - 5 -10 mg orally/day
• Maintain an adequate • Maintain adequate - monitor for nausea, diarrhea and insomnia
balance of activity and nutrition and fluid
- Test stole periodically for GI bleeding
rest. balance.
• Maximize his/her level of ● R - REMINYL (Galantamine)
• Maintain adequate
nutrition and fluid balance. functioning - 16-32 mg orally/day divided into 2 dose
• Return to his or her - monitor for nausea, vomiting, loss of
optimal level of appetite, dizziness and syncope
functioning ● E - EXELON (Rivastigmine)
• Client and caregivers or - 3 – 12 mg orally/day divided into 2 doses
family must - monitor for nausea, vomiting, abdominal
understand health care
pain and loss of appetite
practices to avoid
recurrence.

TREATMENT: DELIRIUM
1. The primary treatment for delirium is to
identify and to treat any casual or
contributing medical conditions
2. Antipsychotic drug
- Haloperidol (Haldol) 0.5-1 mg to decrease
agitation
3. Sedatives and benzodiazepines should be
avoided because they may worsen delirium
except for alcohol withdrawal (Valium,
Ativan, Librium)

TREATMENT: DEMENTIA
1. Identify and treat the underlying cause
Ex: Vascular dementia – change diet, exercise,
control of hypertension or diabetes
2. PSYCHOPHARMACOLOGY
● Antidepressants – for depressive symptoms
● Antipsychotics – to manage symptoms of
hallucinations, delusion & paranoia
- HALOPERIDOL (Haldol)
- OLANZAPINE (Zyprexia)
- RISPERIDONE (Risperdal)
- QUETIAPINE (Seroquel)
● Mood stabilizer to stabilize affective lability
and to diminish aggressive outburst
- LITHIUM CARBONATE
QUIZ 10 Neurocognitive Disorders
1.A client who was brought to the emergency room
by ambulance begins to trash about on the
stretcher, slapping the sheets and yelling. "Go away
bugs, go away!" Assessment reveals disorientation,
a blood pressure of 189/75 mm Hg, and a pulse of
86 bmp. The friend who accompanied the client to
the hospital states, "he was drinking a lot when I
say him 4 days ago and asked me for money to get
liquor, but l didn't have any cash to give him."
Based on an analysis of these findings, the nurse
suspects that the client is experiencing which of the
following?
A. delirium
B. dementia
C. alcohol withdrawal
D. amnesia
6.Mr Roy, a 65 years old man with a diagnosis of
dementia stage Il, is admitted to the health care
facilty unit. Mr Roy's food intake is only marginally
adequate, in part because of his inability to sit at
the table and concentrate for the length of time
necessary to eat the meal. Which approach would
be most likely to ensure a nutritionally adequate
intake?
A. Offer small amounts of food whenever he
appears ready to eat.
B. Order 6 small, nutritionally balanced meals
C. Feed Mr. Roy in the time of his choice
D. Order a full liquid diet that will take him less
time to eat

2.When a client experiencing alcohol withdrawal

the client rashes in bed and yells. "Go away bugs,
go away," the nurse would expect to classify this
behavior as reflective of which of the following
nursing diagnoses?
A. Disturbed Thought Processes
B. Ineffective Coping
C. Disturbed Sensory Perception
D. Risk of injury

3.The nurse is teaching a family caregiver how to

help a client with early dementia complete activities
of daily living (ADL's). Which information should be
included in the teaching?
A. Tell the client that the ADLs must be
finished by 9am
B. Perform ADL's for the client
C. Give the client ample time to perform the
ADLs as independently as possible
D. Have the client plan a schedule for ADLs

4.When working with a client who has dementia,

the primary intervention by the nurse is to ensure
that the client:
A. Is offered dietary choices to stimulate
appetite
B. Remains in a safe and secure environment
to prevent injury
C. Discusses feelings of fear and loss to
prevent low self-esteem and anxiety
D. Meets other clients with dementia to prevent
social isolation

5.A condition known as the acute phase of delirium

dementia that result from Thiamine (Vitamin B1)
Deficiency?
A. Lewy body disease
B. Korsakoff's syndrome
C. Vascular Dementia
D. Wernicke's syndrome