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Psychopathology, Etiology, and Psychodynamics
1. Disturbances in Thought Content/ Processes:
Schizophrenia and other Psychosis
CONTENT THOUGHT DISORDER
• is a thought disturbance in which a person experiences
multiple, fragmented delusions, typically a feature of:
→ schizophrenia and some other mental disorders
which include obsessive-compulsive disorder and
mania.
SCHIZOPHRENIA
Psychopathology of Schizophrenia
• In the late 1800s,
EMIL KRAEPLIN 15 described the course of the disorder
he called dementia praecox because of its early onset
and notable changes in an individual's cognitive
functioning
• In the late 1900s,
EUGEN BLEULER renamed the disorder
SCHIZOPHRENIA, meaning SPLIT MINDS, and began to
determine that there was not just one type of
schizophrenia but rather a group of schizophrenia
• More recently,
KURT SCHNEIDER differentiated behaviors associated
with schizophrenia as "FIRST RANK" symptoms such as
HALLUCINATIONS and DELUSIONS and 2nd rank
symptoms, i.e, all other experiences and behaviors
associated with the disorder (Boyd, et.al. 2023)
ETIOLOGY OF SCHIZOPHRENIA
• The exact causes of schizophrenia are UNKNOWN
Research suggests a combination of:
• Physical, Genetic, psychological and environmental
factors can make a person more likely to develop the
condition.
• Some people may be prone to schizophrenia, and a
stressful or emotional life event might trigger a
psychotic episode.
EXPERTS THINK SCHIZOPHRENIA IS CAUSED BY
SEVERAL FACTORS
1. Genes And Environment
• Scientists have long known that schizophrenia runs
in families.
The illness occurs in
→ 1 percent of the general population, but it occurs in
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→ 10 percent of people who have a first-degree relative
with the disorder, such as a parent, brother, or
sister.
• People who have second-degree relatives (aunts,
uncles, grandparents, or cousins) with the disease
also develop schizophrenia more often than the
general population.
• The risk is highest for an identical twin of a person with
schizophrenia. He or she has a 40 to 65 percent
chance of developing the disorder.
• Many environmental factors may be involved, such as
exposure to
→ viruses or malnutrition before birth,
→ problems during birth,
→ and other not yet known psychosocial factors.
2. Psychodynamic Theory
• Poor care giving that leads to psychic alterations
(Freud & Bleuler )
• Loss of ego boundaries
• Double bind communication pattern within a poor
family relationships
3. Neurobiological Theory
• Changes within the brain ( prefrontal, limbic, and basal
ganglia ) affecting language and memory
• Imbalance in neuro-transmitters dopamine,
norepinephrine, serotonin, acetylcholine, and gamma-
aminobutyric acid ( GABA )
3 INESCAPABLE “ FACTS “ ABOUT SCHIZOPHRENIA
( WEINBERGER, 1987 )
1) AGE AT ONSET: It is almost always during late
adolescence (15-22 y/o) or early adulthood (20-40
y/o) [ Female = 25-34 Male = 15-24 ]
2) ROLE OF STRESS : Onset and relapse are almost
always related to stress.
3) EFFICACY OF DOPAMINE ANTAGONISTS : Drugs
that block dopamine receptors are therapeutic
CHARACTERISTICS OF SCHIZOPHRENIA
1. PERCEPTION – ( hallucinations )
2. THOUGHT PROCESS – (thought derailment)
3. REALITY TESTING – (delusions )
4. FEELING – (flat or in appropriate affect )
5. BEHAVIOR – (social withdrawal )
6. ATTENTION - (inability to concentrate)
7. MOTIVATION - (cannot initiate or persist in goal
directed activities)
TYPICAL GENDER- BASED DIFFERENCES
SCHIZOPHRENIA
• Age of onset in men is typically 4 to 6 years earlier than
it is in women
• Men have a more severe course
• Women have more positive symptoms (hallucinations)
• Estrogen modulates dopamine function and
presumably plays a protective role for women
• Women are more compliant with medication
• Women tend to have lower blood levels and longer half-
lives of medications
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PRENATAL AND PERINATAL EVENTS ASSOCIATED TYPES OF SCHIZOPHRENIA

WITH SCHIZOPHRENIA 1. CATATONIC (Kahbaun)
1. Maternal Influenza • marked catatonic state or stupor (waxy flexibility),
2. Obstetrical complication unresponsive to environment, rigid posture, mutism,
3. Prenatal exposure to lead (extreme negativism), purposeless motor activity,
4. Maternal starvation echolalia (repeat words), echopraxia (mimics actions
5. Perinatal exposure to cats (viral zoonosis) of others)
toxoplasma gondi - alter behavior and
neurotransmitter function TREATMENT
6. Birth during later winter or early spring (low sunlight • ECT and benzodiazepines (such as diazepam or
exposure/vitamin D deficiency) lorazepam) for catatonic schizophrenia
• Avoiding conventional antipsychotic drugs (they may
EPIDEMIOLOGY OF SCHIZOPHRENIA worsen catatonic symptoms).
→ 1% of the total population develops schizophrenia • Investigating atypical antipsychotic drugs to treat
→ 95% suffer a lifetime catatonic schizophrenia (requires further evaluation).
→ 50% experience serious side effects from
medications (pseudoparkinsonism) NURSING INTERVENTIONS
→ 10% kill themselves 1. Spend time with the patient
2. Remember that, despite appearances, the patient is
BLEULER'S 4 A's of SCHIZOPHRENIA acutely aware of his environment
1. Affective disturbance: inappropriate, blunted or 3. Emphasize reality
flattened affect 4. Verbalize for the patient the message that his
2. Autism: pre occupation with the self, with little behavior seems to convey, encourage him to do the
concern for external reality same
3. Associative looseness - the stringing together of 5. Tell the patient directly, specifically, and concisely
unrelated topics what needs to be done; don't give him choice
4. Ambivalence - simultaneous opposite feelings 6. Assess for signs and symptoms of physical illness;
7. Remember that if he's in bizarre posture, he may be
POSITIVE SYMPTOMS OF SCHIZOPHRENIA at risk for pressure ulcers or decreased circulation.
• Abnormal thoughts 8. Encourage to ambulate every 2 hours. During
• Agitation periods of hyperactivity, try to prevent him from
• Bizarre behavior experiencing physical exhaustion and injury.
• Delusions 9. As appropriate, meet his needs for adequate food,
• Excitement fluid, exercise, and elimination; follow orders with
• Feelings of persecution respect to nutrition, urinary catheterization, and
enema use.
• Grandiosity
10. Stay alert for violent outbursts;
• Hallucinations
• Hostility 2. DISORGANIZED (Hebephrenia)
• Illusions • Confusion
• Insomnia • Loose association
• Suspiciousness • Disorganized speech / behavior
• affective disturbances
NEGATIVE SYMPTOMS OF SCHIZOPHRENIA
• regression
• Alogia (poverty of speech, or a reduction in the
amount of speech.
TREATMENT
• Anergia (abnormal lack of energy. ) 1. Treatments described for other types of
• Asocial behavior schizophrenia
• Attention deficits 2. Antipsychotic drugs and psychotherapy
• Avolition (general lack of drive, or motivation to
pursue meaningful goals 3. PARANOID (Kraepelin - adds the term paranoia)
• Blunted affect • systematic persecutory delusions
• Communication difficulties • auditory hallucinations
• Difficulty with abstractions • delusion of grandeur
• Passive social withdrawal • anger violence
• Poor grooming and hygiene
• Poor rapport TREATMENT
• Poverty of speech 1. Antipsychotic drug therapy
2. Psychosocial therapies and rehabilitation, including
group and individual psychotherapy

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NURSING INTERVENTION DELUSIONS

1. Build trust, and be honest and dependable, do not DO DON’T
threaten or make promises you cannot fulfill 1. Explain all procedures 1. Touch without warning
2. Be aware that brief patient contacts may be most 2. Provide personal 2. Whisper or laugh in the
useful initially space presence of the client
3. When the patient is newly admitted, minimize his 3. Maintain eye contact 3. Argue and disprove
contact with the staff 4. Provide consistency delusions
4. Do not touch the patient without telling him first (cornerstone of trust ) 4. Reinforce delusions
exactly what you are going to be doing and before 5. Set realistic goals 5. Present logical
obtaining his permission to touch him argument
5. Approach him in a calm, unhurried manner
6. Avoid crowding him physically, or psychologically; he HALLUCINATION
may strike out to protect himself. DO DON’T
7. Respond neutrally to his condescending remarks; do 1. Decrease 1. Participate in the
not let him put you on the defensive, and do not take environmental stimuli hallucination process
his remarks personally. 2. Identify contributory
8. If he tells you to leave him alone, do leave-but make factors
sure you return soon. Set limits firmly without anger, 3. Monitor command
avoid a punitive attitude. hallucination
9. Be flexible, giving the patient as much control as 4. Be alert to nonverbal
possible stimulation
10. Consider postponing procedures that require physical 5. Present reality
contact with hospital personnel if the patient
becomes suspicious or agitated.
11. If the patient has auditory hallucinations, explore the KEY OBJECTIVES FOR TREATING PERSONS WITH
content of the hallucinations (what voices are saying SCHIZOPHRENIA
to him, whether he thinks he must do what they 1. Work with family
command) tell him you do not hear voices, but you 2. Treat depression
know they are real to him. 3. Minimize stressful interactions
4. Treat substance abuse
4. UNDIFFERENTIATED 5. Avoid lengthy, intense verbal interactions
• pronounced delusions - hallucinations - confusion -
disorganized thinking

5. RESIDUAL SCHIZOPHRENIA
• characterized by at least one previous, though not a
current, episode, social withdrawal, flat affect and
looseness of associations.
• no symptoms, but signs of illness still exist

BASIC NURSING INTERVENTIONS

AGITATION
DO DON’T
1. Remove cause of 1. Display anger,
agitation frustration,
2. Eliminate stimulants discouragement
3. Set limits 2. Criticize
4. Monitor physical 3. Argue
discomforts
5. Administer drugs as
ordered

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ANXIETY DISORDERS PANIC

• recurring feelings of excessive nervousness, worry, → intense anxiety, maybe a response to a life
or fear (often triggered by a particular situation) that threatening situation
impact one's ability to function on a daily basis. → complete inability to focus
→ disintegrated ability to cope; physiologic symptoms
ANXIETY from fight or flight response
→ Is an uncomfortable feeling of apprehension or dread
that occurs in response to internal or external stimuli. GOALS OF NURSING MANAGEMENT
→ It can result in physical, emotional, cognitive and • To be supportive and protective
behavioral symptoms • Decrease environmental stimuli
• Stay with the client and use a quiet voice
FEAR • Assist in relaxation and breathing
→ Feeling afraid or threatened by a clearly identifiable,
external stimulus that represents danger to the COPING WITH ANXIETY
person 1. ADAPTIVE • Solves the problem which is
causing the anxiety so, it is
LEVELS OF ANXIETY decreased
1. MILD ANXIETY
• Patient is objective, rational
ooccurs in the normal experience of everyday living
and productive
• ability to perceive is brought into sharper focus 2. PALLIATIVE • Temporarily decreases the
• one sees, hears, and grasps more information anxiety but does not solve
• problem solving becomes more effective the problem, so returns the
anxiety eventually
SYMPTOMS • Temporary relief shows the
• Discomfort, restlessness, irritability patient returns to problem
• Fidgeting, nail biting, foot and finger tapping solving
3. MALADAPTIVE • Unsuccessful attempts to
GOALS OF NURSING MANAGEMENT decrease the anxiety
• Peplau says “anxiety is the first step to problem solving“ without attempting to solve
• Use cognitive strategies the problem
• Stress management education • The anxiety still remains
• problem solving approach 4. DYSFUNCTIONAL • This is not successful in
reducing anxiety or solving
2. MODERATE ANXIETY the problem.
• the disturbing feeling that something is definitely • Even minimal functioning
wrong, the person becomes nervous or agitated becomes difficult, and new
• difficulty staying attentive and being able to learn problems begin to develop
• focus on central concerns
ANXIETY REDUCING TECHNIQUES AND
GOALS OF NURSING MANAGEMENT INTERVENTIONS
• Reduce anxiety by helping client to understand its → COGNITIVE TECHNIQUES - A technique which
cause and by identifying a way of controlling it assesses the client’s belief systems and challenges (
• Use relaxation techniques with aim to alter ) distorted or negative thoughts and
• Encourage verbalization of feelings self-defeating behavior, through internal dialogue or
• Teach coping strategies self – talk
• Use problem solving approach
→ SYSTEMATIC DESENSITIZATION - Slowly and
3. SEVERE ANXIETY progressively exposing clients to situations that
• an increased level of anxiety when more primitive evoke anxiety and teaching them to maintain
survival skills take over, defensive responses ensue relaxation to neutralize response
and cognitive skills decrease significantly the person o BEHAVIORAL THERAPY
has trouble thinking and reasoning. - Behavior therapists help clients think about
• Sympathetic nervous system activated psychological problems as learned behaviors that can
be changed without searching for hidden meaning or
GOALS OF NURSING MANAGEMENT unconscious causes.
• help the client channel anxiety and to lower it to a - E.g. client is suffering from anxiety therapist doesn't
moderate or mild level focus on MEANING of anxiety, but help client identify
• encourage physical activity ( structured task/exercise) learning principles that have created & maintained it

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ANXIETY RELATED DISORDERS
TO UNDERSTAND RELATED ANXIETY DISORDER it is
crucial to understand :
• What is anxiety
• Where it comes from
• Why is it difficult to manage
• How individual normally cope with it
TYPES
A. GENERALIZED ANXIETY DISORDER
• Generalized anxiety disorder produces FEAR,
WORRY, and a constant feeling of being
overwhelmed.
• It is characterized by persistent, excessive, and
unrealistic worry about everyday things.
• This worry could be multifocal such as finance,
family, health, and the future.
THE ICD-10 CRITERIA FOR GAD:
→ A period of at least 6 months with prominent
tension, worry and feelings of apprehension, about
everyday events and problems
→ At least 4 of the symptoms are present, one of
which must be from:
1) palpitations or pounding heart, sweating,
trembling or shaking, dry mouth
2) Difficulty breathing; feeling of choking; chest
pain or discomfort; nausea or abdominal
distress; feeling dizzy; faint or light-headed;
feeling that objects are unreal (derealization)
or that one’s self is distant or “ not really here ‘
(depersonalization) fear of losing control,
going crazy, or passing out.
ETIOLOGY
BIOLOGIC
• Genetics
• Dysfunctional GABA – anti-anxiety agent – reduces
cell excitability, thus decreasing the rate of neuronal
firing. – benzodiazepine, norepinephrine, serotonin,
neuropeptides, glutamate systems
• Cognitive impairment
PSYCHODYNAMIC
• Psychoanalytic - Use of defense mechanisms
• Interpersonal - Anxiety is generated from problems
in interpersonal relationships
• Behavioral - Anxiety is learned through experiences
B. PANIC DISORDER
• is characterized by panic attacks that recur at
unpredictable times with intense apprehension, fear
and terror.
DIAGNOSTIC CRITERIA (ICD-10)
recurrent panic attacks, that are consistently associated
with a specific situation or object, and often occurring
spontaneously (e.i, episodes are unpredictable)
→ Autonomic arousal
1. Palpitations or pounding heart ; or heart rate
2. Sweating
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3. Trembling or shaking
4. Dry mouth (not due to medication or dehydration)
→ Symptoms concerning chest and abdomen:
1. Difficulty breathing
2. Feeling of choking
3. Chest pain or discomfort
4. Nausea or abdominal distress
→ Symptoms concerning brain and mind:
1. Feeling dizzy, unsteady, faint or light headed
2. Feelings that objects are unreal
3. Fear of losing control, going crazy, or passing out
4. Fear of dying
→ General Symptoms:
1. Hot flushes or cold chills
2. Numbness or tingling sensations
The severity of panic disorder can also be specified
based on the frequency of panic attacks
C. OBSESSIVE-COMPULSIVE DISORDER
CHARACTERIZED BY :
• OBSESSIONS - which is a recurring thought that
cannot be dismissed from consciousness,
sometimes trivial or ridiculous, often morbid or
fearful and always distressing and anxiety – provoking
• COMPULSION - an uncontrollable, persistent urge to
perform certain acts or behaviors to relieve an
otherwise unbearable tension
D. PHOBIC DISORDER
• A phobia is a persistent and irrational fear of a
specific object, activity or situation that results in a
compelling desire to avoid the dreaded object or
situation.
• The fear is recognized by the person as excessive or
unreasonable in proportion to the actual danger.
3 MAIN TYPES OF PHOBIAS:
AGORAPHOBIA - is the fear of being alone or in public
places from which escape might be difficult or in which
help might not be available.
SOCIAL PHOBIA - is the fear of situations that may be
humiliating or embarrassing, extreme fear of performing
or speaking in public, making complaints, or eating in
front of the trauma.
SIMPLE PHOBIA - is the fear of specific things,
Eg. Animals, Heights, Darkness, etc.
E. POST TRAUMATIC STRESS DISORDER (PTSD)
• Is characterized by the re-experiencing of an extremely
traumatic event, avoidance of stimuli associated with
the event, numbing of responsiveness
• Reflects an origin in combat situations, a generalized
numbing of responsiveness followed by cognitive or
somatic symptoms, such as irritability, anxiety,
aggressiveness and depression
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MEDICATIONS FOR TREATING ANXIETY DISORDERS A. SOMATIZATION DISORDER

→ BENZODIAZEPINES - Increase the level of GABA, • Recurrent and multiple somatic complaints of
which decreases stimulation of the limbic system, several years duration and seemingly without
thereby decreasing anxiety; physiologic causes.
• aprazolam (Xanax) • Usually begins before 30 years of age
• chlordiazepoxide (Librium) • Has a chronic course
• clonazepam (Klonopin) • Often accompanied by anxiety and depressed mood
• lorazepam(Ativan)
B. CONVERSION DISORDER
→ AZAPIRONES - Act on serotonin receptors, causing • Clients report loss or alteration of physical function,
presynaptic neurons to release less serotonin, thus which suggests a physical disorder, but is in fact
decreasing anxiety related to the expression of a psychologic conflict
• Ebuspirone (BuSpar) • Characterized by LA BELLE INDIFFERENCE - the
seeming lack of concern with having a fairly dramatic
→ TRICYLIC ANTIDEPRESSANTS - Block reuptake of symptom, such as being unable to walk or move a
neurotransmitters (serotonin and norepinephrine), limb.
thus allowing increased levels at synapse)
• Clomipramine ( Anafranil) C. SOMATOFORM PAIN DISORDER
• Imipramine ( Tofranil) • Clients experience pain in the absence of physiologic
findings and the presence of possible psychological
→ SELECTIVE SEROTONIN REUPTAKE factors
INHIBITOR (SSRI) - Selectively block serotonin
reuptake at synapse, thereby increasing serotonin D. HYPOCHONDRIASIS
levels • Preoccupation with the fear of belief that they have a
• Fluoxetine ( Prozac) serious disease, which on physical evaluation is not
• Fluvoxamine (Luvoc) present
• Paroxwtine (Paxil)
E. BODY DYSMORPHIC DISORDER
• sertraline ( Zoloft)
• Preoccupation with some imagined defect in physical
appearance, which is out of proportion to any actual
→ OTHER ANTIDEPRESSANTS - affect serotonin
abnormality
reuptake and norepinephrine and dopamine levels
• Venlafaxine ( Effexor)
OTHER RELATED DISORDERS
→ MALINGERING - a conscious effort to stimulate or feign
→ MAO INHIBITORS - Inhibit the action of enzyme
the symptoms of an illness to avoid unpleasant
monoamine oxidase (MAO) which brings down
situation. - no real physical symptoms or grossly
serotonin levels
exaggerate minor symptoms.
• Phenelzine (Nardil)
→ FACTITIOUS DISORDER - occurs when the person
intentionally produces or feign physical or
→ BETA BLOCKERS - Induce peripheral beta-adrenergic
psychological symptoms solely to gain attention
blockade, therefore reducing the physiologic effects of
• MUNCHAUSEN SYNDROME - common term for
anxiety
factitious disorder
• atenolol (Tenormin)
• MUNCHAUSEN SYNDROME BY PROXY - occurs
• Propanolol (Inderal) when a person inflicts illness or injury on
someone else to gain the attention of emergency
SOMATOFORM DISORDER
personnel or to be a “ HERO “ for saving the
• Characterized by complaints of physical symptoms victim.
that cannot be explained by known physical
mechanisms INTERVENTIONS
• There may be a loss or change in physical function Treatment involves medication and therapy
• The symptoms are not under the individual’s voluntary → COGNITIVE BEHAVIORAL THERAPY
control • Positive reframing – turning negative messages into
• The individual uses multiple prescribed and over-the- positive messages.
counter-medications → DECATASTROPHIZING
• Denial of physiological distress and resistance to • Uses thought stopping and distraction techniques to
psychiatric treatment by the individual is also common jolt from focusing on negative thoughts.
• ie ; snapping a rubber band worn on the wrist -
TYPES OF SOMATOFORM DISORDER shouting
→ SOMATIZATION – is defined as the transference of
mental experiences and states into bodily symptoms

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→ ASSERTIVENESS TRAINING
• is based on the principle that we all have a right
to express our thoughts, feelings, and needs to
others, as long as we do so in a respectful way

NURSING DIAGNOSIS
→ Impaired Judgment
→ Sleep Pattern Disturbance
→ Alteration in Comfort
→ Chronic Low Self Esteem
→ Disturbed Body Image
→ Ineffective Coping
→ Disturbed Body Image
→ Social Isolation

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MOOD DISORDERS
• are a group of psychiatric diagnoses characterized
by disturbances in emotional and behavioral
response patterns.
• The patterns range from elation and agitation to
extreme depression with a serious potential for
suicide.
• Patients with mood disorders may exhibit various
abnormalities in affect.
FLAT AFFECT - complete or almost absence of outward
emotional expression
LABILE AFFECT - rapid and easily changing affective
expression that is unrelated to external events or stimuli
ETIOLOGY
GENETICS
• Major depression is transmitted in first degree
relatives
BIOLOGICAL
• Such as deficiencies or abnormalities in the brain/s
neurotransmitters, namely:
→ norepinephrine ,acetylcholine, serotonin ,
dopamine
PSYCHOLOGICAL FACTORS
• Cognitive theory - suggests that people who suffer
from depression process information in a
characteristically negative way
• Behavioral theory – (specifically, the learned
helplessness) posits that a person’s helplessness and
depression develop from his/her experiences with
negatively perceived events
• Psychoanalytic theory - maintains that depression
results from a harsh superego (“ the conscience “ of
the unconsciousness mind) and feelings of loss and
aggression
NEUROENDOCRINE INFLUENCES
• Increased cortisol secretion
PSYCHODYNAMIC THEORY
• Freud – self depreciation
• Bibring – ideals not achieve
• Jacobson – powerless ego
• Meyer – reaction to distressing life experiences
• Horney – children with rejecting and unloving parents
TYPES OF MOOD DISORDERS
1. BIPOLAR DISORDER
(MANIC-DEPRESSIVE DISORDER)
• Marked by severe, frequent, pathologic mood swings.
• The patient experiences extreme highs (Mania or
hypomania) alternating with extreme lows
(depression)
HYPOMANIA
• is an expansive, elevated or agitated mood that
resembles mania.
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• It is less intense than mania and lacks psychotic
symptoms
• Periods of normal mood are interspersed between
the highs and lows
• Severe episodes of mania or depression can
sometimes involve psychotic symptoms
CLASSIFYING BIPOLAR DISORDERS
→ BIPOLAR I DISORDER
• Is the classic and most severe form of bipolar
disorder.
• It is characterized by manic episodes or mixed
episodes
→ BIPOLAR II DISORDER
• Characterized by milder episodes of
hypomania that alternate with depressive
episodes
SIGNS AND SYMPTOMS OF BIPOLAR DISORDER
MANIC PHASE
• expansive, grandiose, or hyper irritable mood
• increased, psychomotor activity such as agitation,
pacing, or hand wringing
• excessive social extroversion
• rapid speech with frequent topic changes
• decreased need for sleep and food
• impulsivity - Impaired judgment
DEPRESSIVE PHASE
• Low self-esteem
• Overwhelming inertia
• Feelings of hopelessness and apathy
• Difficulty concentrating or thinking clearly
• Psychomotor retardation
• Anhedonia (decreased attention to and enjoyment
from previously pleasurable activities)
• Suicidal ideation
PHARMACOLOGIC TREATMENT
1. LITHIUM (eskalith)
→ Highly effective in both preventing and relieving
manic episodes
→ Non-sedating
→ Prevents recurrence of depressive episodes but
ineffective for treatment of acute depression
→ Decreases the risk of suicide
→ Therapeutic range : 0.5- 1.5 mEq/L
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Lethal if > 3 mEq/L ( needs hemodialysis) 2. CYCLOTHYMIC DISORDER

Indicated for bipolar disorder • characterized by short periods of mild depression
Therapeutic range – 0.6 – 1.2 mEq/L alternating with short periods of hypomania;
Hyponatremia → toxicity interspersed between the depressive and manic
Increase excretion w/ mannitol and diamox episodes, brief periods of normal mood occur.
Uncoordination and coarse hand tremors – early signs of • odd, eccentric or suspicious personality
toxicity • dramatic, erratic, or antisocial personality features
Metallic taste and fine hand tremors – normal • inability to maintain enthusiasm for new projects
• pattern of pulling close and then pushing away in
GUIDELINES FOR PATIENTS RECEIVING LITHIUM interpersonal relationships
 Blood levels should be checked 8 to 12 hours after the • abrupt changes in personality from cheerful,
1st dose, 2 to 3 times weekly for the 1st month , then confident, and energetic to sad, blue or mean
weekly to monthly during maintenance therapy.
 Instruct the client to maintain fluid intake of 10 to 13 SIGNS AND SYMPTOMS OF HYPOMANIA
glasses / day • Insomnia
 Teach the client that increasing salt intake may • Hyperactivity and physical restlessness
increase lithium excretion • Irritability or aggressiveness
 Teach the client and his/her family to watch for • Grandiosity or inflated self-esteem
evidence of lithium toxicity • Increased productivity, creativity
 Advise the client to take lithium with food or after
meals SIGNS AND SYMPTOMS OF DEPRESSIVE PHASE
 Caution the client against driving or operating • Insomnia or hypersomnia
dangerous equipment. • Feelings of inadequacy
• Decreased productivity
SIGNS AND SYMPTOMS OF LITHIUM TOXICITY • Social withdrawal
 Thirst • Loss of libido or interest in pleasurable activities
 Abdominal cramps • Lethargy
 Frequent urination • Suicidal ideation
 Diarrhea
 Vomiting TREATMENT OPTIONS FOR CYCLOTHYMIC DISORDER
 Drowsiness → Lithium
 Unsteadiness → Carbamazepine
 Muscle weakness → Valproic acid
 Ataxia → Individual psychotherapy
 Tremors → Couple or family therapy

2. CARBAMAZEPINE (Tegretol) 3. DYSTHYMIC DISORDER

→ This drug is useful in treating mania • also called dysthymia, this refers to a mild
→ used to manage and treat epilepsy, trigeminal depression that lasts at least 2 years in adults or 1
neuralgia and acute manic and mixed episodes in year in children
bipolar I disorder
PSYCHOLOGICAL SYMPTOMS
3. VALPROIC ACID (Depakote - anticonvulsant) • Persistently sad, anxious or empty mood
→ This drug is given to patients who cannot tolerate • Excessive crying
lithium • Increased feeling of guilt, helplessness, or
→ Frequent blood testing is needed to determine hopelessness
therapeutic levels
PHYSIOLOGICAL SYMPTOMS
4. ANTIDEPRESSANTS • Weight / appetite
→ These are usually prescribed to augment a mood • Sleep difficulties
• Reduced energy level
stabilizer
→ These must be used cautiously, as they may
TREATMENT OPTIONS FOR CYCLOTHYMIC DISORDER
trigger a manic
→ Short term psychotherapy
→ Behavioral therapy
→ Group therapy
→ Antidepressants such as SSRI’s and TCA’s
especially for patients who exhibits pessimism

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4. MAJOR DEPRESSIVE DISORDER TREATMENT

(UNIPOLAR MAJOR DEPRESSION)
• Refers to a syndrome of persistently sad mood lasting
for 2 weeks or longer.
• Feelings of sadness go beyond – and last longer than
“ normal” sadness or grief
• Suicide - is the most serious complication.
→ Suicidal ideation can occur if feelings of
worthlessness, guilt, and hopelessness are
overwhelming that the person no longer considers
life worth living.
SIGNS AND SYMPTOMS
• Feelings of sadness
• Increased or decreased appetite
• Sleep disturbance
• Disinterest in sex
• Difficulty concentrating or thinking clearly
• Easy distractibility
• Indecisiveness
• Low self-esteem
• Poor coping
• Constipation
• Suicidal thoughts
SUBTYPES OF MAJOR DEPRESSIVE DISORDER
1. MELANCHOLIC FEATURES
 the client experiences either anhedonia in
relation to all activities or lack of mood reactivity
to usually pleasurable activities.
 the client usually wakes up early in the morning,
feeling worst during this time, and feels
excessively guilty
2. ATYPICAL FEATURES
 clients exhibits mood reactivity (ability to
respond to positive environmental stimuli),
increased levels of anxiety, changes in appetite
and sleep, and increased sensitivity to
interpersonal rejection.
3. PSYCHOTIC FEATURES
 clients depression is accompanied by delusions
and hallucinations.
 he theme of the psychotic symptoms is usually
mood congruent with depression
1. PHARMACOTHERAPY TREATMENT
SSRI - Selective Serotonin Reuptake Inhibitor
Mechanism of Action
→ widely used type of antidepressant mainly
prescribed to treat depression, particularly
persistent or severe cases,
→ represents the latest advancement in
pharmacotherapy
→ inhibit serotonin reuptake
→ e.g. flouxetine (Prozac), paroxetine (Paxil);
sertraline (Zoloft) fluvoxamine (Luvox)
TCA – Tricyclic Antidepressants
→ second line agent
→ inhibits the reuptake of NE, serotonin into
→ the nerve terminal resulting to increase NT at the
synapse producing a significant antidepressant
effect
→ e.g. imipramine HCl (Tofranil), desipramine HCl
(Pertofrane), bupropion (Wellbutrin), amoxapine
(Asendin), amiptriptyline HCl (Elavil),
clomipramine (Anafranil)
MAOI – Monoamine Oxidase Inhibitors
→ 3rd major class agent
→ prevent the metabolism of NT
→ used less frequently because less effective
→ must be given for a long period before they are
beneficial
→ toxic, with longer duration of action
→ may cause severe adverse reactions
→ e.g. Isocarboxazid (Marplan), phenelzine sulfate
(Nardil), tranylcypromine sulfate (Parnate)

NURSING INTERVENTIONS
1. Assess for suicidal potential
2. encourage verbalization of feelings
3. Provide quite environment
4. Encourage food intake
5. Use silence, broad opening, focus on the clients
verbal and non-verbal behaviors
6. Present reality ATYPICAL ANTIDEPRESSANT
7. Assist with self-care → alternatives or second-line therapy
8. Reduce environmental stimuli
→ trazodone (Desyrel), reboxetine (Edronax, Vestro),
maprotiline (Ludiomil)
Side Effects:
1. Drowsiness/Somnolence
2. Dry mouth
3. Dizziness
4. GI upset
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NURSING RESPONSIBILITIES
1. Monitor v/s to detect potential adverse effects (e.g.
Hypotension, HPN, arrhythmias)
2. Establish safety precautions if CNS changes occurs
3. Administer medication with food to decrease GI
effects
4. Monitor liver and hepatic function tests in client with
history of liver and kidney impairment

MAOI = AVOID FOOD RICH IN TYRAMINE TO PREVENT

HYPERTENSIVE CRISIS (obtain BP and monitor!)
→ Elevated BP
→ Headache
→ Nausea and vomiting
→ Blurring vision
→ Nape pain
→ Dizziness

2. ELECTROCONVULSIVE THERAPY
• ECT is a psychiatric treatment that involves the use of
electrical currents to stimulate the brain.
• The treatment is typically reserved for severe cases of
mental illness, such as treatment-resistant
depression or bipolar disorder.
• ECT is performed under anesthesia and muscle
relaxants to minimize discomfort
• The procedure is closely monitored for potential side
effects or complications.
• ECT produces dramatic improvements in many
psychiatric symptoms, especially depression, who
do not respond to antidepressants or those who
experience intolerable side effects

→ Methohexital ( Brevital ) - general anesthetic

agent given prior to ECT
→ Succinycholine ( Anectine ) – skeletal muscle
relaxant IV administration before ECT

SIDE EFFECT OF ECT: short term memory loss

o Believes that shock stimulates brain chemistry to

correct the chemical imbalance of depression.
o Barbaric due to its unfavorable side effects
o 6 minimum-15maximum treatments ( 3x a week)

PREPARATION:
• NPO post-midnight
• remove nail polish
• void before the procedure
• IV line is started
• anesthetics and relaxants are administered

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PERSONALITY DISORDERS CURRENT RESEARCH

"these disorders are the toughest to treat"
PERSONALITY
• is a complex pattern of characteristics, largely
outside of the person's awareness, which
compromise the individual's distinctive pattern of
perceiving, feeling, thinking, coping and behaving
• an integration of the conscious and unconscious
• Effects of societal changes
• Stressful environment
• Negative childhood experiences
DIAGNOSIS
• is based on abnormally inflexible behavior patterns of
long duration traced to adolescence or early adulthood
that deviates from acceptable cultural norms.

CATEGORIES/CLUSTERS CATEGORIES/CLUSTERS
CLUSTER A – Odd or Eccentric Behaviors
• Paranoid CLUSTER A - PARANOID
• Schizoid SIGNS AND SYMPTOMS
• Schizotypal → Mistrust and suspicious of others
→ Guarded
CLUSTER B – Dramatic / Emotional /Erratic → Blunted affect
• Borderline → Humorless
• Histrionic → Rigid
• Antisocial → Hypersensitive to other people's motives
• Narcissistic → Transient psychotic symptoms might be
precipitated by extreme stress
CLUSTER C – Anxious and Fearful
• Avoidant NURSING DIAGNOSIS
• Dependent o Potential loss of control
• Obsessive-Compulsive o Potential for violence
DOMINANT PERSONALITIES NURSING INTERVENTION
ID EGO SUPEREGO
1. Serious, straightforward, honest, professional
→ Mania → Schizophrenia → Obsessive approach
→ Antisocial Compulsive
2. Offer persistent, consistent, and flexible care
→ Narcissistic → Eating Disorder
3. Supportive, non-judgmental
4. Establish a therapeutic relationship
ETIOLOGY 5. Use humor cautiously
HISTORICALLY 6. Avoid challenging the patient's paranoid beliefs
• is it “BAD GENES” or “BAD ENVIRONMENT”? 7. Avoid situations that threaten the patient's autonomy
• the main etiologic factors are heritably heightened
affect states: UNIQUE CAUSES
→ Excessive fear ▪ Some evidence has suggested that paranoid disorder
→ Anger tend to occur in biologic relatives of identified patients
→ Detachment with schizophrenia and is diagnosed more often in
• adverse environmental factors men than in women.
→ Substandard parenting
→ Childhood psychological trauma CLUSTER A - SCHIZOID
SIGNS AND SYMPTOMS
CONTEMPORARY VIEWS → Detached from social relationships
Historically: EXACT CAUSE : UNKNOWN → Involved with things more than people
Psychological in origin based on: → Hermits or loners - shyness and introversion
→ Problems experienced in childhood growth and → Do not initiate spontaneous conversation
development disturbances → Solitary activities are more gratifying
→ Reactions to childhood experiences → Functional at work if they work in isolation
→ Family - deficient mother-child relationship,
unresponsiveness, overprotectiveness NURSING INTERVENTION
→ Environmental factors 1. Focus initially on building trust
2. Identification and appropriate verbal expression of
CURRENT BIOLOGIC RESEARCH feelings
• Biologic factors are not totally responsible 3. Slowly involving the patient in milieu and group
• Social environment & Psychological vulnerability activities
strongly influence the individual 4. Increase social skills
5. Respect the patient's need for privacy

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CLUSTER A - SCHIZOTYPAL UNIQUE CAUSES

SIGNS AND SYMPTOMS
→ appear similar to patient with mild schizophrenia
→ problems in thinking, perceiving, communicating
→ sensitive to the behaviors of others especially
rejection and anger
Most prevalent and unchangeable criteria:
o Paranoid ideations
o Ideas of reference
o Odd beliefs
NURSING INTERVENTION
1. Offering support, kindness and gentle suggestions
2. Improve interpersonal relationships, social skills and
appropriate behaviors
3. Vocational counseling and assistance with job
placement increase the patient's opportunity for
success.
UNIQUE CAUSES
▪ Viewed as part of SCHIZOPHRENIA SPECTRUM
▪ Family member with schizophrenia are at increased risk
for developing schizotypal personality disorder
PSYCHOTHERAPEUTIC MANAGEMENT
Nurse Patient Relationship
→ Task centers on dealing with trust issues
→ professional demeanor coupled with honesty and
non-intrusiveness will assist to develop some trust
MULTIFACTORAL:
▪ heredity/ genetics
▪ environmental factors - chaotic home
▪ childhood experiences- neglect of feelings /
needs/abuse
▪ hyperresponsiveness to stress
▪ neurologic and biochemical dysfunction
ESSENTIAL RESEARCH
▪ The relationship between sexual, physical and
emotional abuse during childhood and a diagnosis of
BPD during childhood is well established, but the
interpretation of this relationship is a matter of ongoing
controversy.
TREATMENT
1. DIALECTICAL BEHAVIOR THERAPY (DBT)
• Gask et.al, 2013
• is evidence-based comprehensive treatment
modality that helps patients with BPD who have
problems regulating emotions and who are
suicidal.
• an outpatient model that requires patient to meet
weekly in individual psychotherapy and skills
training groups.
2. MENTALIZATION-BASED TREATMENT
• Fonagy & Bateman, 2008
• Posits that BPD arises because of disorganized
infant-caregiver attachment which results in
people being unable to “ mentalize” (understands
the thoughts and emotions, thoughts and
intentions of others)

Benefits:
• Reduced suicidal behavior
• Improvement in hospitalizations and social
CLUSTER B - BORDERLINE (BPD) functioning
SIGNS AND SYMPTOMS
→ Emotional dysregulation 3. SCHEMA THERAPY
→ Anger • Jacob & Arnts, 2013
1. Focus on processing of aversive childhood
→ Impulsivity
memories and experiences
→ Unstable relationship
2. Use of “experiential” techniques such as
→ Identity or self-image disturbance
imagery rescripting - change the negative
→ Abandonment fears emotions that are associated with aversive
→ Self mutilation memories from childhood
→ Suicidality 3. Therapeutic relationship as a form of “limited
→ Most commonly treated, triggering high mental reparenting” – therapist assumes patient’s
health center utilization parent when recreating aversive childhood
experiences
NURSING INTERVENTION 4. “Schema mode” – helps a patient to understand
1. require hospitalization when they are in crisis or exhibit the cause of their current problems (eg.
self-injurious or suicidal behaviors Abandoned child )
2. take responsibility for him/her
3. avoid sympathetic, nurturing responses 4. TRANSFERENCE FOCUSED THERAPY
4. avoid defensiveness and arguing • identify and resolve internal representations of the
5. respect the patient's personal space self and others that contradict each other (my
6. set appropriate expectations for social interaction. husband is the BEST person, my husband is a
7. If taking medication - monitor "cheeking" or hoarding MORON)

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• it is presumed that your feelings about important UNIQUE CAUSES

people in your life, such as your parents or siblings,
are transferred to the therapist
5. COGNITIVE ANALYTIC THERAPY "TALK THERAPY"
• It is based on the idea that our early life
experiences influence the way we relate to other
people and how we treat ourselves.
• help patient recognize and then change the beliefs
and ways of thinking that are contradictory,
confusing and distressing
CRITICAL THINKING QUESTION:
A 22 year old woman is admitted to the unit with BPD and
self-injurious behaviors. What are the nurse’s priorities in
caring for this patient ? [Patient’s safety]
▪ Arrested emotional development because the parents
fail to mirror that which is appropriate or inappropriate
back to the child
▪ The child develops without any feedback about his or
her behavior
PSYCHOTHERAPEUTIC MANAGEMENT
NURSE - PATIENT RELATIONSHIP
• decrease the constant recitation of self-importance
and grandiosity
• the nurse must mirror what the patient sounds like,
esp. if contradictions exists
• supportive confrontation
• limit setting, remain non-judgmental
• avoid defensiveness and arguing

PSYCHOTERAPEUTIC MANAGEMENT CLUSTER C - DEPENDENT

NURSE – PATIENT RELATIONSHIP
• Use of empathy by the nurse while maintaining clear
boundaries is important
• Nurse should emphasize to be a health care
professional
• Acknowledge patient pain, offers support
• Empowers and work with patient to understand,
control and change dysfunctional behavior.
CLUSTER B - HISTRIONIC
SIGNS AND SYMPTOMS
→ self-indulgent, vain, demanding, dependent,
inconsiderate
→ dramatizes events and draws attention to self
→ prone to manipulative threats and gestures
→ behavior is silly, colorful, frivolous, seductive
→ overly dramatic and reactive and responds intensely.
→ engages in attention-seeking, self-dramatization and
irrational outbursts of emotion
→ uses sexual expression to manipulate and control
others in his/her relationships
→ DISSOCIATION — is a common defense to avoid
feelings
SIGNS AND SYMPTOMS
→ Submissive and clinging behavior
→ Excessive need to be taken cared of
PSYCHOTHERAPEUTIC MANAGEMENT
NURSE - PATIENT RELATIONSHIP
• Foster client's self-reliance and autonomy
• Teach problem solving and decision-making skills
• Cognitive restructuring techniques
UNIQUE CAUSES
▪ PSYCHOSOCIAL THEORIES cultures dictate that
women should maintain a dependent role
PROPOSED PERSONALITY DISORDER - DEPRESSIVE
SIGNS AND SYMPTOMS
• Patterns of depressive cognitions and behaviors in a
variety of contexts
NURSING INTERVENTION
1. Assess self-harm risk
2. Provide factual feedback
3. Promote self esteem
4. Increase involvement in activities
5. Cognitive restructuring techniques

PROPOSED PERSONALITY DISORDER

- PASSIVE AGRESSIVE
SIGNS AND SYMPTOMS
→ Patterns of negative attitudes and passive resistance
to demands for adequate performance in social and
occupational situations

NURSING INTERVENTION
1. Help client to identify feelings and express them
CLUSTER B - NARCISSISTIC directly
SIGNS AND SYMPTOMS 2. Assist client to examine own feelings and behavior
→ Grandiose sense of self importance realistically
→ Pre occupation with fantasies of unlimited success,
money, power, beauty, brilliance, etc. PSYCHOPHARMACOLOGY
→ Lack of empathy Pharmacologic treatments of clients with personality
→ Need for attention and admiration disorders focuses on the client's symptoms rather than
→ Indifference or overreaction to criticism the particular subtypes.

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Treatment: SYMPTOMATIC
→ CLUSTER A – antidepressants and low dose
antipsychotic agents
→ CLUSTER B – Anticonvulsants, mood stabilizing
agent and MAOI'S - for marked mood reactivity,
impulsivity and rejection
→ CLUSTER C – may benefit from anxiolytic agents

POSSIBLE NURSING DIAGNOSIS

o Ineffective individual coping
o Altered role performance
o Impaired social interaction
o Risk for violence directed to others

GENERAL GUIDELINES IN MANAGEMENT POSSIBLE

• Promote client safety at all times
• Set limits to the client's socially unacceptable
behaviors
• Help the client cope with the problem and control
his/her emotions
• Help client enhance his/her social skills
• Help the client enhance his/her role performance

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2. Client typically undergoes a comprehensive
COGNITIVE DISORDERS diagnostic assessment, and physiologic symptoms
DELIRIUM (acute confusion) are readily treated
• Disturbed consciousness and changes in
cognition that develop over a short period of time; OBJECTIVES OF CARE
onset is acute and symptoms occur rapidly. 1. Identification of immediate care
2. correction of the underlying cause
SYMPTOMS 3. Symptom management
Consciousness 4. Supportive and safety measures
• clouded; reduced clarity
Memory DEMENTIA
• impaired • characterized by confusion, memory loss and
Orientation disorientation, occurs mostly among the elderly
• disoriented
Course SYMPTOMS
• abrupt (short period of hours to days) Consciousness
• fluctuates during the course of the day • not clouded
• reversible and temporary Memory
Cognition • impaired
• abrupt (short period of hours to days) Orientation
• fluctuates during the course of the day • may be
• reversible and temporary disoriented
Course
TYPES • insidious, slow
1. DELIRIUM DUE TO GENERAL MEDICAL CONDITION and progressive
→ Acute or chronic illness • does not fluctuate
→ Hormonal and nutritional factors
→ Sensory impairments ALZHEIMER’S DISEASE
→ Various medications as well as surgical procedures RESEARCH ON THE CAUSES OF ALZHEIMER’S
DISEASE AND OTHER DEMENTIAS
Etiologies of Delirium o genetic factors, neurotransmitters, inflammation
General Medical Conditions o factors that influence programmed cell death in the
• HIV/AIDS brain
• Orthopedic procedures (50%) o the roles of tau, beta amyloid and the associated
• Infectious (UTI, Pneumonia, Sepsis) neurofibrillary tangles and plaques in AD
• Metabolic derangement
• Cancer (PLE, brain mets-L, B, M) Since many dementias and other neurodegenerative
• Impaction, constipation, dehydration diseases have been linked to abnormal clumps of
proteins in cells, researchers are trying to learn how these
2. SUBSTANCE-INDUCED DELIRIUM AND SUBSTANCE clumps develop, how they affect cells, and how the
WITHDRAWAL DELIRIUM clumping can be prevented.
→ The clients history, physical examination and
diagnostic study findings indicate the delirium is Insulin resistance is common in people with AD, but it is
associated with substance use not clear whether the insulin resistance contributes to
the development of the disease or if it is merely a side
3. DELIRIUM DUE TO MULTIPLE ETIOLOGIES effect.
→ Several medical conditions or combination of
substance use and medical conditions are evident COGNITION
CHARACTERIZED BY 4 A'S
CAUSES 1. AMNESIA - memory loss
1. Advanced age 2. AGNOSIA - inability to recognize familiar objects or
2. Pre-exiting illness persons
3. Infection and / or electrolyte and metabolic 3. APHASIA - language dysfunction (receptive,
imbalance expressive, global)
4. Bone fractures 4. APRAXIA - impaired ability to perform purposeful
5. Brain damage or dementia movements despite intact motor functions

MANAGEMENT PHYSIOLOGY
1. Treatment usually occurs in acute care medical- • progressive brain disorder that causes a gradual and
surgical setting irreversible decline in memory, language skills,
perception of time and space, and, eventually, the
ability to care for oneself.

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• your brain floats in a bath of cerebrospinal fluid. This
fluid also fills large open structures, called
VENTRICLES, which lie deep inside your brain. The
fluid-filled ventricles help keep the brain buoyant
and cushioned.
MANAGEMENT
ROUTINE
• provide safe, therapeutic and consistent environment
• speak in clear, low pitch voice
• daily routine
REPEAT
• provide information (time, place, person, situation)
REINFORCE
• use environmental cues to stimulate memory
(calendar, clock, signs)
CHARACTERISTICS
JUDGEMENT
AFFECT
MEMORY
COGNITION
ORIENTATION
STAGES
1. FORGETFULNESS - short term memory losses
2. CONFUSION - progressive memory decline,
disorientation, depression and confabulation
3. AMBULATORY DEMENTIA - functional loses,
language problems, loss of reasoning, depression,
and wandering behavior
4. END STAGE - no recognition, very little purposeful
activities, immobile, and does not swallow and chew
(patient is already aphasic, bedfast, non-verbal,
confined on bed, feeding thru NGT)
COURSE OF THE DISEASE
→ 2- 20 years
→ With sundowner's syndrome
• confusion and disorientation becomes
noticeable in the late afternoon and evening.
• the closer to evening and "sundown," the more
confused and agitated the client becomes.
TIPS IN CARING FOR PATIENT WITH ALZHEIMER’S
• Provide basic human needs and safety
• Listen to what the person is NOT saying
• Encourage periodic rest periods and sleep
• Assist in activities of daily living
• Sing and dance as necessary
• Engage in reminiscing activities
• Call person by name and introduce self
• Actively involve clients in activities & simple decision
making
• Redirect inappropriate behavior like anger
• Exaggerate facial expression and gesture when
communicating face to face
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CARE MEDICATIONS
(not to treat, just slows down progression of disease)
• Cognex (donepecil)
• Aricept (tacrine)
• Reminyl (galantamine)
• Exelon (rivastagmine)
Several studies have found a reduced risk of dementia in
people who take cholesterol-lowering drugs called
statins. However, it is not yet clear if the apparent effect
is due to the drugs or to other factors.
• Ex. Levostatin, Simvastatin
A clinical trial called the Vitamins to Slow Alzheimer’s
Disease (VITAL) study is testing whether high doses of
three common B vitamins (Folic acid, B12, B6) can
reduce homocysteine levels and slow the rate of
cognitive decline in AD.
PRESCRIPTION MEDICATIONS
1. Donepezil
2. Rivastigmine
3. Galantamine
→ help improve memory function during the earlier
stages
4. Memantine HCL
→ is used when dementia has advanced to moderate or
severe stages.
5. Anti-psychotic drugs
• haloperidol
• risperidone
→ are used to minimize the agitation and bell with
dementia, and cholinesterase inhibitors are used to
treat hallucinations. Most of these medications have
serious side effects so they must be administered
under the guidance of a physician.
NUTRITIONAL SUPPLEMENTS
1. Phosphatidylserine 100 mg 3x a day may increase
levels of brain chemicals associated with memory.
2. Vitamin E together with prescription medication
Aricept slowed the cognitive decline of Alzheimer's
patients.
3. Zinc (30 to 50 mg) daily dose may help improve
memory function
4. L-arginine 1.6 g daily for three-month dose of may
help vascular dementia by increasing blood flow to
the brain.
HERBS
Herbs have been used to treat disease for centuries, and
studies have shown that some can aid in the treatment of
dementia.
1. Ginkgo 40 to 50 mg doses are taken three times daily
shows promise in treating early stages of the disease
2. Lemon balm (Melissa officinalis) also may be
helpful.
3. Huperzine A - Chinese studies indicated that 200
mcg twice daily may improve memory in both
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Herbs can trigger side effects and can have a negative

interaction with other herbs, supplements or medication.
As with supplements and prescription medications, no
herbs should be taken without a doctor's approval.

OTHER TREATMENTS
Except for the treatable types listed above, there is no
cure to this illness, although scientists are progressing in
making a type of medication that will slow down the
process.

COGNITIVE AND BEHAVIORAL INTERVENTIONS

(may also be appropriate)
• Educating and providing emotional support to the
caregiver is of importance as well.

OFF LABEL
AMYLOID DEPOSIT INHIBITORS
→ Minocycline and Clioquinoline, antibiotics,
may help reduce amyloid deposits in the brains of
persons with Alzheimer disease.

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EATING DISORDERS
• any of a range of mental conditions in which there
is a persistent disturbance of eating behavior and
impairment of physical or mental health.
THE DIET-BINGE-PURGE DISORDER
BULIMIA
BULIMIA NERVOSA
Bulimia is an eating disorder characterized by binge-
eating followed by inducement of vomiting.
Binge - Purge Cycle
Usual onset : 15-24 years old
Laxative, diet pills and diuretic abuse
Ipecac abuse (root of a plant)
Menses irregular
Increased peristalsis, rectal bleeding & constipation
Afraid of losing control over eating
ANOREXIA NERVOSA
→ Fear of Obesity
→ Feels Fat When Thin
→ Loss of At Least 25% of Original Body Weight
→ Refusal To Maintain Minimal Body Weight
→ Amenorrhea
• The opposite of bulimia, anorexia nervosa is another
eating disorder in which the patient refuses to eat
anything at all.
• Just like in bulimia, an anorexic patient views herself as
a very fat person when in fact she is actually too thin for
her body built.
• Disorder with an insidious (slowly) onset that often
affects adolescent girls.
Normal weight (common) or overweight
Episodes: 2x /week in 3 months
Russell's sign ( reddened knuckles)
Vomiting (self-induced)
Overly concerned with body shape and weight
Salivary Glands, enlarged (parotid)
Afraid of becoming fat
NURSING DIAGNOSIS
o Alterations in health maintenance.
o Altered nutrition: Less than body requirements.
o Altered nutrition: More than body requirements
o Anxiety
o Body image disturbance
o Ineffective family coping; compromised
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o Ineffective Individual Coping
o Self-esteem disturbance
SIGNS AND SYMPTOMS
7. Refuses to eat
8. Plays with food and eats only very small amounts
9. Perceives body or body part as being fat even though
thin
10. Dry skin, fine downy body hair
11. Absent menses
12. Hypothermia, hypotension and bradycardia
TYPES
→ Restricting - weight loss by dieting, fasting and
excessive exercise.
→ Binge eating or purging - uses self-induced
vomiting, abuses laxatives, diuretics or enema.
APPROACHES TO CLIENTS WITH EATING DISORDERS
1) Small frequent feedings
2) Monitor intake and output, and bowel functions
3) Monitor weight gain and lab results (electrolytes,
urine, BUN)
4) Encourage expression of feelings
→ Set realistic expectations of self
→ Encourage participation in activities
→ Stay with client during meal time, and at least one
hour after eating (Bulimia)
→ Accompany to bathroom (if self-induced vomiting is
expected)
DON'Ts:
• Don't indicate feelings of shock, disbelief or disgust
at eating disorders
• Don't confront and judge hostilities and anger,
should they occur
• Don't discuss and explain food, diet, or body (unless
these are linked with feelings)
• Don't compare clients behavior and appearance
with others
• Don't allow long meal times ( set - 30 minute
mealtime.
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SEXUAL DISORDERS FROTTEURISM

PARAPHILIA • Sexual pleasure derived from touching or rubbing one's
• is a condition in which the sexual instinct is genitals against a nonconsenting individual's thighs or
expressed in ways that are socially prohibited or buttocks
unacceptable or are biologically undesirable (APA, • They also attempt to fondle the person's breasts or
2000) genitals.
• recurrent, intense sexual fantasies / urges • Usually occurs in a crowded place in which escape into
involving nonhuman object, suttering or the crowd is possible.
humiliation of oneself or others or children or non-
consenting persons. SEXUAL MASOCHISM
• sexual pleasure derived from being humiliated,
PEDOPHILIA beaten, or otherwise made to suffer.
• Involves recurrent intense sexual urges and sexually • some sexually masochistic individuals enjoy being
arousing fantasies involving sexual activity with urinated or defecated on and might play prostitutes to
children. do so
• The individual acts on the urges or is distressed by • HYPOXYPHILIA is the act of enhancing sexual arousal
them (APA, 2000) by strangulation or some other oxygen-depleting
activity.
→ Victims - younger than 13 years old
→ Pedophile - 16 years or older and at least 5 years SEXUAL SADISM
older than the victim • sexual pleasure derived from inflicting psychological
or physical suffering on another
PEDOPHILIC BEHAVIOR CAN BE EXPRESSED FOR: • partners can be consenting or masochistic
o opposite-sex children
o same sex-children SADISTIC BEHAVIOR INCLUDE:
o both o Spanking o Beating o Torturing
o Whipping o Burning o Killing
Pedophilia also can be limited to incest o Pinching o Restraining

TYPICAL PEDOPHILIC BEHAVIOR VOYEURISM

1. Fondling (stroke or caress lovingly or erotically) • sexual pleasure derived from observing unsuspecting
2. Inappropriate touching people who are naked or undressing or who are
3. Masturbating in a child's presence engaged in sexual activity,
4. Penetration of the mouth, anus, and or vagina • commonly referred to as Peeping Tom
• the voyeur might masturbate during peeping or after
INCEST returning home.
→ is pedophilia with child and adolescent relatives and
involves relationships by blood, marriage PSYCHOSEXUAL DYSFUNCTIONS
(stepparents), or live-in partners. HYPOACTIVE SEXUAL DESIRE
→ is traumatic to children because they are victimized → deficient or absent sexual fantasy or desire
by someone they depend on and trust and are unable
to escape their victimizer. SEXUAL AVERSION DISORDER
→ avoidance of genital sexual contact with sexual
EXHIBITIONISM partner
• Sexual pleasure derived from exposing one's genitals
to an unsuspecting stranger. FEMALE SEXUAL AROUSAL DISORDER
• The stereotypical offender is a young man in a raincoat → partial or complete failure to attain or maintain
who flashes women while walking down the street. lubrication with lack of subjective sense of sexual
• No other sexual activity is attempted excitement and pleasure
• The exhibitionist is stimulated by the effect of shocking
the victim MALE ERECTILE DISORDER
→ partial or complete failure to attain or maintain
FETISHISM erection until completion of sexual act with lack of
• Sexual pleasure derived from animate objects subjective sense of sexual excitement and pleasure
COMMON FETISH LESS COMMON FETISH (common in patients with DM)
OBJECTS: OBJECTS:
o Bras, Underpants o Urine-soaked INHIBITED FEMALE ORGASM
o Stockings, Shoes o Feces-smeared items → delay in orgasm following a normal sexual
→ They often masturbate while holding or rubbing these excitement phase, although may experience orgasm
items during non-coital stimulation

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INHIBITED MALE ORGASM

→ delay in orgasm following a normal sexual
excitement phase, with possible orgasm with other
stimulation like masturbation

PREMATURE EJACULATION
→ ejaculation with minimal sexual stimulation or
before, upon or shortly after penetration, and before
the person wishes it

DYSPAREUNIA
→ general pain before, during or after sexual
intercourse

VAGINISMUS
→ involuntary spam of musculature of the outer third of
the vagina that interferes with coitus.

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SUBSTANCE RELATED DISORDERS Adoption studies

DRUGS make people feel good. If they don't stop using → 4x increased risk it biological parents alcoholic even
drugs when their life starts to fall apart, this is because if adoptive parents not alcoholic
they are SELFISH & WEAK.
ADDICTION
SUBSTANCE ABUSE • A state in which the organism engages in compulsive
• chronic disorder characterized by the use of mind behavior
altering chemicals that cause an impairment in • behavior is reinforcing (pleasurable or rewarding)
functioning of the person. • loss of control in limiting intake
• DANGEROUS DRUGS ACT (RA 6425 OF 1972)
TOLERANCE
- Follows ingestion • A state in which the organism no longer responds to a
INTOXICATION
- Reversible drug
12 months, impairment in 1 • a higher dose is required to achieve the same effect
- Fail obligations
- Hazardous activities DEPENDENCE
ABUSE
- Recurrent • A state in which the organism functions normally only
- Continue despite social in the presence of a drug
problems • manifested as physical disturbance when drug is
12 months, impairment with 3 removed (withdrawal)
- Tolerance
DEPENDENCE - Withdrawal SHABU
- Obsession (Methamphetamine Hydrochloride)
- Preoccupation SHORT TERM LONG TERM
o loss of appetite o a full-blown psychosis
COMMONLY ABUSED SUBSTANCES o euphoria, elation or schizophrenia
Alcohol Inhalant o inability to sleep o paranoia
o tension, anxiety
Amphetamines Nicotine
o irritability
Caffeine Betel Nut o loss of self-control
Cannabis Phencyclidine o irrational behavior
Cocaine, Opioid Sedative/Hypnotic/Anxiolytic
Hallucinogen Anabolic-Androgenic Steroids MARIJUANA
INTERMEDIATE LONG TERM
WITHDRAWAL SYNDROME o hallucinations/ o renal damage, heart
(Alcohol, Sedatives/Hypnotics/Anxiolytics, Opioids) Illusions disease, stroke
o bloodshot eye, REM o psychiatric
STAGE 1 (MINOR WITHDRAWAL) o faster heart rate, and consequences
• Restlessness, anxiety, insomnia, agitation, tremor, pulse rate o severe irritation of
tachycardia, low-grade fever, diaphoresis, elevated BP o dry mouth and throat nasal passage
o forgetfulness/inability
STAGE 2 (MAJOR WITHDRAWAL) to think
• Minor audio/visual hallucination, body tremor, o "food trip" & sleepiness
vomiting o disorientation

STAGE 3 (DELIRIUM TREMENS) ECSTASY

• T>37.8 C, disorientation, confusion, memory loss SHORT TERM LONG TERM
o fatigue and perhaps o same with users of
WITHDRAWAL SEIZURES depressed after the synthetic stimulants
• Alcohol - 12-48 hrs after last drink drug is stopped o brain and liver damage
• Barbiturate- 72 hrs after last take o restless, anxious and
• BZD -1 wk after last take with pronounce visual
& auditory
1A. GENETICS - FAMILIAL o hallucinations at large
Children of alcoholics doses
→ 3-4x increased risk o nausea & vomiting
o increased blood
Twin studies pressure and heart
→ 60% monozygotic rate
→ 39% dizygotic

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INHALANTS
→ Volatile chemical substances that contain psycho-
active (mind/mood altering) vapors to produce a
state of intoxication.
→ e.g. Glue and adhesive cement / rugby / super glue /
thinner
STIMULANTS
a.k.a. "uppers"
→ excite the central nervous system, in which Increase
alertness, alleviate fatigue, reduce hunger and
provide a feeling of well being
→ ex: Cocaine / amphetamine

BANGKOK PILLS IMMEDIATE EFFECTS:

→ The US Bureau of Food and Drugs discovered the • Dilated pupils
assorted pills (Bangkok Pills) to contain ephedrine, • Involuntary muscle twitching
phentermine and fenfluramine. • A sense of well being
→ Its sale in the United States was declared illegal • Feels energetic/alert
recently due to degree of casualty and affectation to • Less hunger & slurred speech
its users. • Increased blood pressure, heart rate, respiratory rate,
body temperature.
SIDE EFFECTS:
o dry mouth, suppressed appetite, nervous and dizzy, DEPRESSANTS
insomnia, restless, and anxious increased heart rate a.k.a. "downers" or "barbs"
and blood pressure, irritability, vomiting, irregular → the term most often is used to refer to drugs that
heart rate and constipation reduce the activity of the central nervous system.
IMMEDIATE WITHDRAWAL
KETAMINE EFFECTS SYNDROME
→ Fine and white crystalline powder, it can be liquid or LARGE DOSES: o psychosis
tablets or in capsule form. slurred speech, staggering, o restless
→ STREET NAME: K, Special K, Super K, Kit-Kat, Ket, poor judgment, slow body o sleeplessness
Vitamin K, K-hole, Bump oh K, Honey Oil K, Bump movement, uncertain reflexes o irritability/ anxiety
Bottle. SMALL DOSES: calmness & o stuffy/ runny nose
relaxation o lung damage
ILL- effects OVERDOSE: o confusion
o has disoriented behavior, impaired judgment, has unconsciousness/ death o slurred speech
hallucinations & impaired coordination, Violent & out-
of-body feeling, State of euphoria HALLUCINOGENS
a.k.a. "psychedelics"
BENZODIAZEPINES → synthetic psychoactive drugs that produce marked
→ Increases the efficiency of GABA (a neurotransmitter distortions of the senses and changes in perception
that slows or calms things down), thus causing IMMEDIATE LONG TERM
greater inhibition or calming. o hallucinations / o psychiatric
illusions consequences
LONG TERM USE: o appetite loss o renal damage, heart
o over sedation, impaired blood pressure regulation and o faster heart beat and disease, stroke
balance control, cognitive impairment, memory loss, pulse rate o severe irritation of nasal
pseudo dementia, nocturnal urinary incontinence, o blurred vision passage.
worsening sleep, respiratory problems, dependency o bloodshot eye, REM
and drug interaction o dry mouth & throat
o inability to think
NICOTINE o disoriented; anxious
→ is the most important active ingredients which is a
very toxic or poisonous substance. ALCOHOL
SHORT TERM LONG TERM → Before treatment or recovery, most people with
o stained teeth and o sickness alcoholism deny that they have a drinking problem.
fingers o heart attack
o stimulated central o cancer Other signs of alcoholism and alcohol abuse include:
nervous system o bronchitis and • Drinking alone or in secret
o increase heart rate, emphysema • Being unable to limit the amount of alcohol
breathing rate & blood o ulcers & infertility • Not remembering conversations or commitments,
pressure sometimes referred to as "blacking out"
• Making a ritual of having drinks before, with or after
dinner and becoming annoyed when this ritual is
disturbed or questioned
• Losing interest in activities and hobbies that used to
bring pleasure

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• Feeling a need or compulsion to drink EFFECTS ON THE BODY
• Irritability when your usual drinking time nears, • Wernicke's Encephalopathy represents the most
especially if alcohol isn't available serious form of thiamine deficiency in alcoholics
• Note: if thiamine replacement therapy is not
DRUGS
HEART
EYES
SYMPTOMS OF undertaken quickly, DEATH will occur.
RATE OVERDOSE
Agitation,
Methamphetamine Dilated increased body
Increased
Amphetamine pupils temperature,
hallucination
Psychosis,
Marijuana Elevate Red eyes
coma, death
Bad breath,
yellow teeth,
Constricted
Nicotine Rapid cancer in
pupils
mouth and
neck
Short term
memory loss,
Dilated
Alcohol Decreased loss of body
pupils
coordination, Ophthalmoplegia – paralysis of eye muscles
slurred speech
Sweating,
Blurred KORSAKOFF'S PSYCHOSIS
Ecstasy Increased nausea,
vision
cramps → identified by a syndrome of :
• confusion
NURSING RESPONSIBILITIES • loss of recent memory
• Detoxification • confabulation in alcoholics
• Prevent suicide → frequently encountered in clients recovering from
• Prevent convulsion Wernicke's encephalopathy
• Correct fluid & electrolyte imbalance → NOTE: sometimes two disorders are usually
• Nutritional status considered together and are called: Wernicke's-
• Safe environment Korsakoff syndrome
• Recovery phase → TREATMENT - parenteral or oral thiamine
• Rehab - becomes productive replacement
• Prevents relapse after detox
TREATMENT
ALCOHOL DETOX PROTOCOL A. Psychological and Social Interventions
Here is a flow of care needed for patients being treated for 1) Motivational counseling (Latest)
alcohol intoxication. • express empathy through reflective listening
→ Usually, a patient intoxicated with alcohol needs 3 • avoid argument / direct confrontation
drugs - magnesium, multivitamin and thiamine • roll of resistance
injections • support self-efficacy
→ Knowing when to administer these drugs as ordered • develop discrepancy between patients' goals or
by the doctor is essential in responding quickly during values and their current behavior
emergency situations. 2) cognitive behavior approaches
3) social skills learning
ALCOHOL DETOX PROTOCOL 4) behavioral contracting
↓ 5) family counselling
Thiamine injections, Multivitamins, Magnesium 6) self help
↓
Alcohol causes you to diurese, Mg is excreted through DISULFIRAM (ANTABUSE) – Aldehyde Dehydrogenase
kidneys, Patient is losing Mg, Needs Magnesium Inhibitor
↓ → a form of aversion therapy, an alcohol deterrent, an
Patient is not eating well, Not getting enough vitamins, adjunct treatment for selected clients with chronic
Needs Multivitamins alcoholism
↓ → inhibits hepatic enzymes from normal metabolic
Patient is not eating well, Vitamin deficiency = think breakdown of alcohol resulting in high levels of
nerves, Thiamine = Vitamin B1, Corrects heart problems, acetaldehyde, leading to disulfiram alcohol reaction
Needs Thiamine Injections (flushing, throbbing headache, copious vomiting,
tachycardia, hypotension, blurred vision, to death
THIAMINE DEFICIENCY may be one of the critical factors → client should abstain from alcohol at least 12 H's
in the development of the amnesia and dementia before initial dose
associated with chronic alcohol abuse. → alcohol reaction may continue up to 14 days after
discontinuing disulfiram

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CHILDHOOD DISORDERS
PERVASIVE DEVELOPMENTAL DISORDERS OF
CHILDHOOD
AUTISM SPECTRUM DISORDER (ASD)
→ Autism, also known as autism spectrum disorder or
ASD, is a developmental condition that leads to
communication, social, and behavioral challenges.
→ occur in 17 per 10,000 children
→ start before age 3 and are four to five times more
common in boys.
AUTISTIC DISORDER (severe form)
is characterized by
• communication problems
• significant inability to form social relationships
• repetitive, purposeless behavior (e.g. spinning, self-
injury, etc.)
• subnormal intelligence in 25-75% of children.
• However, others have savant skills like exceptional
memory or calculation skills.
ASPERGER DISORDER (mild form)
is characterized by
• normal cognitive development with little or no
language delay but with impaired conversational
skills
• therefore, children with Asperger disorder have
significant problems forming relationships.
• they also have repetitive behaviors and intense
interest in obscure objects
RISPERIDONE (RISPERDAL) & ARIPIPRAZOLE (ABILIFY)
• are the only drugs approved by the FDA for children
with autism spectrum disorder.
RISPERIDONE can be prescribed for children between 5
and 16 years old to help with irritability and aggression.
ARIPIPRAZOLE can be prescribed for children between 6
and 17 years old.
METHYLPHENIDATE
(Ritalin, Concerta, Delmosart, Equasym, Medikinet.)
• may improve hyperactivity in children with ASD in the
short term, although there was no evidence that
methylphenidate improves or worsens ASD
symptoms.
• some children cannot tolerate the medication's side
effects.
ETIOLOGIES
→ cerebral dysfunction
→ perinatal complications
→ genetic component
→ immunologic compatibility between mother-fetus
→ SMALLER AMYGDALA AND HIPPOCAMPUS
→ FEWER PURKINJE CELLS IN THE CEREBELLUM
• less circulating oxytocin (Some autistic people have
genetic variants in the oxytocin receptor, a protein to
which oxytocin binds to carry out its functions. The
compiled by: 元美安
exact relationship between oxytocin and autism is not
clear, though)
OTHER PERVASIVE DEVELOPMENTAL DISORDERS
RETT DISORDER
• is characterized by diminished social, verbal, and
cognitive development after four years of normal
functioning.
• this only occurs among girls
• stereotyped movements like handwringing is usually
seen
CHILDHOOD DISINTEGRATIVE DISORDER
→ involves diminished social, verbal, and cognitive
function after two years of functioning.
→ This also presents with mental retardation.
NURSING CARE TIPS FOR CHILDREN WITH PERVASIVE
DEVELOPMENTAL DISORDERS
1. Choose words carefully when speaking to verbal
autistic child because they are likely to interpret
words concretely.
2. Advise parents to have close, face-to-face contact
with child to promote communication
3. Maintain a regular and predictable daily routine to
prevent outbursts, prepare child for changes of
routine
4. Educate parents on behaviors that signal tantrums
such as increased hand flapping. Emphasize the
importance of intervening and anticipating needs
before a tantrum occurs.
5. Advise patients on ways to provide a safe
environment for the child (e.g. installing locks and
gates).
6. Educate family members on the medications (e.g.
stimulants, selective serotonin reuptake inhibitors,
lithium, etc.) the child is taking.
7. Offer emotional support and information to parents.
8. Arrange for family counseling to help parents better
understand the disorder. This also assist them with
their coping mechanisms.
9. 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.
ADHD (Attention Deficit/ Hyperactivity Disorder)
• are characterized by inappropriate behaviors which
lead to problems in social relationships and school
performance.
• presents itself before age seven and is characterized
by: Hyperactivity, Impulsiveness, Inattention, and
carelessness.
• Children with ADHD have high propensity for
accidents.
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• They also have history of excessive crying and
irregular sleep patterns in infancy.
• Upon reaching adolescence, hyperactivity is the first
sign to disappear. However, most children show
remission
by adulthood.
RITALIN is used to treat (ADHD) in children and adults.
However, it is not usually recommended for children
younger than 6 years old. It helps people with ADHD pay
attention to tasks.
DISRUPTIVE BEHAVIOR DISORDERS
CONDUCT DISORDER
• usually begins in ages 6-10 and would not show
symptoms prior to age 10.
• this is best exemplified by child's behavior that grossly
violates social norms (e.g, animal torture, stealing,
truancy).
• they have high risk for criminal behaviors, antisocial
personality disorder and substance abuse in
adulthood
NURSING CARE TIPS FOR CHILDREN WITH
ADHD AND CONDUCT DISORDERS:
1. Establish a trusting relationship with child and family
by conveying your acceptance.
2. Provide clear behavioral guidelines, including
consequences for disruptive and manipulative
behavior.
3. Talk to the child about making acceptable choices.
4. Teach child on effective problem-solving skills, and
have him or her demonstrate them in return.
5. Identify abusive communication (e.g. threats,
sarcasm, and disparaging comments).
6. Encourage child to stop using them.
7. Teach child on constructive methods of releasing
negative feelings to express anger appropriately.
8. Help the child accept responsibility for behavior
rather than blaming others, becoming defensive, and
wanting revenge.
9. Use role-playing so he can practice ways of handling
stress and gain skill and confidence in managing
difficult situations.
10. Instruct patients on how to deal with child's
demands. This might include learning how to
reinforce appropriate behaviors. Ways to bond more
strongly with the child should be encouraged.

OPPOSITIONAL DEFIANT DISORDER (ODD)

• usually begins at age 8 is characterized by defiant and
negative behaviors (e.g. anger) that do not violate
social norms.
• children with this disorder are usually seen as
argumentative and resentful especially towards
authority figures.
• most children develop conduct disorder in adulthood
and cases of remission is high.

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DOMESTIC VIOLENCE RED FLAGS OF CHILD ABUSE

• Includes not only family members but persons not
related by blood and affinity, who live in the same
domicile or constitute a household
• RA 9262 - act defining VAW, their children, and
penalties
• RA 7610 - Special Protection of Child Against Child
Abuse, Exploitation and Discrimination
FAMILY VIOLENCE
consist of several forms of abuses:
→ Physical, Verbal, Economic, Emotional, Sexual
→ 98 % are women, with an average of 23 years old
1. Unexplained bruises and wets on any part
2. Bruises of different stages
3. Injuries reflecting shape of article used
4. Unexplained burns
5. Rope burns on arms, legs and neck
6. Injuries inconsistent with information
7. Immersion burns with distinct boundary line
8. Unexplained laceration or fracture
NOTE: CALL THE APPROPRIATE AUTHORITIES IF THERE
IS SUSPICION OR SIGNS OF CHILD ABUSE PRESENT.
Child's safety is priority.

VIOLENCE AGAINST WOMEN (VAW) On the question of recovery - yes, it's absolutely possible
• any act of gender based violence that results in or is to recover from the effect of incest and child sexual
likely to result in physical, sexual or psychological abuse. The effects of abuse can be damaging but they
harm or suffering to women, including threats of such don't have to be permanent. Recovery begins with the
act, coercion, or arbitrary deprivation of liberty, survivor acknowledging that they were abused, that their
whether occurring in public or private life (Declaration life is affected by what happened, and deciding to do
against VAW, 1992) something about it.
• Victims experience violence repeatedly at varying
periods of time, in the hands of the same or different
household members
• Father - is the most frequent abuser
• The most common perpetrators are male spouses or
partners (> ½ of abuses )

THE CYCLE WILL GO ON UNLESS...

....the man takes responsibility for the behavior and
genuinely changes
.....Or the woman leaves the violent situation and / or
takes legal steps to halt the violence and abuse

INTERVIEWING ABUSE VICTIMS

• Approach: sensitive questioning
• Ask relevant questions and avoid asking "WHY"
• Soften the effect of sensitive questions by stating the
reasons for asking such questions
• Be careful in using words such as "ALLEGED" RAPE
within the survivor's hearing
• Should be done in a private room with only
appropriate personnel present

PHYSICAL EXAMINATION AND COLLECTION

• Give brief concrete explanation of what is going to
happen
• Determine what the survivor wants
• Do not ask to undress or climb up the stirrups before
the procedure
• Provide privacy and be gentle throughout the
examination
• If the doctor does the examination, the nurse must be
present

CHILD ABUSE
Clinging excessively or unresponsive to parent or adult
Has tendency to be fearful of physical contact
Inconsistent history and injury
Lack of reaction to frightening events
During care, cooperative

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