- Panic is associated with dread and terror and a sense of

impending doom.
Anxiety - The personality is disorganized.
Description - The individual is unable to communicate or function
- A normal response to stress effectively.
- It is a subjective experience that includes feelings of - Increased motor activity occurs.
apprehension, uneasiness, uncertainty, or dread. Interventions:
- Occurs as a result of a threat that may be misperceived or - Recognize the anxiety.
misinterpreted or of a threat to identity or self-esteem. - Establish trust.
- Anxiety may result when values are threatened or preceding new - Protect the client.
experiences. - Do not criticize coping mechanisms.
Types of anxiety - Do not force the client into situations that provoke anxiety.
- Normal: A healthy type of anxiety - Modify the environment by setting limits or limiting interaction
- Acute: Precipitated by imminent loss or change that threatens with others.
one’s sense of security - Provide creative outlets.
- Chronic: Anxiety that persists as a characteristic response to daily - Monitor for signs of impending destructive behavior.
activities - Promote relaxation techniques, such as breathing exercises or
Levels of anxiety guided imagery.
o Mild - Monitor vital signs, and administer antianxiety medications as
- Mild anxiety is associated with the tension of everyday life. prescribed
- The individual is alert. Interventions: Mild to moderate levels
- The perceptual field is increased. - Help the client identify the anxiety.
- Mild anxiety can be motivating, produce growth, enhance - Encourage the client to talk about feelings and concerns.
creativity, and increase learning. - Help the client identify thoughts and feelings that occurred before
o Moderate the onset of anxiety.
- The focus is on immediate concerns. - Encourage problem solving.
- Moderate anxiety narrows the perceptual field. - Encourage gross motor exercise.
- Selective inattentiveness occurs. Interventions: Severe to panic levels
- Learning and problem solving still occur. - Reduce the anxiety quickly.
o Severe - Use a calm manner.
- Severe anxiety is a feeling that something bad is about to - Always remain with the client.
happen. - Minimize environmental stimuli.
- A significant narrowing in the perceptual field occurs. - Provide clear, simple statements.
- Focus is on minute or scattered details. - Use a low-pitched voice.
- All behavior is aimed at relieving the anxiety. - Attend to the physical needs of the client.
- Learning and problem solving are impossible. - Provide gross motor activity.
- The individual needs direction to focus. - Administer antianxiety medications as prescribed.
o Panic Generalized Anxiety Disorder
Description - Assist the client to change the unrealistic thoughts to more
- Generalized anxiety disorder is an unrealistic anxiety about realistic thoughts.
everyday worries that persists over time and is not associated - Use cognitive restructuring to replace distorted thinking.
with another psychiatric or medical disorder. - Administer antianxiety medications if prescribed.
Assessment Posttraumatic Stress Disorder
- Restlessness and inability to relax - Description: After experiencing a psychologically traumatic event,
- Episodes of trembling and shakiness the individual is prone to reexperience the event and have
- Chronic muscular tension recurrent and intrusive dreams or flashbacks.
- Dizziness Stressors
- Inability to concentrate - Natural disaster
- Chronic fatigue and sleep problems - Terrorist attack
- Inability to recognize the connection between the anxiety and - Combat experiences
physical symptoms - Accidents
- Client is focused on the physical discomfort. - Rape
1. Panic disorder - Crime or violence
Description - Sexual, physical, and emotional abuse
- Panic disorder produces a sudden onset of feelings of intense - Reexperiencing the event as flashbacks
apprehension and dread. Assessment
- The cause usually cannot be identified. - Emotional numbness
- Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 - Detachment
minutes occur. - Depression
Assessment - Anxiety
- Choking sensation - Sleep disturbances and nightmares
- Labored breathing - Flashbacks of event
- Pounding heart - Hypervigilance
- Chest pain - Guilt about surviving the event
- Dizziness - Poor concentration and avoidance of activities that trigger the
- Nausea memory of the event
- Blurred vision Interventions
- Numbness or tingling of the extremities - Be nonjudgmental and supportive.
- Sense of unreality and helplessness - Assure client that his or her feelings and behaviors are normal
- Fear of being trapped reactions.
- Fear of dying - Assist client to recognize the association between his or her
Interventions feelings and behaviors and the trauma experience.
- Remain with the client. - Encourage client to express his or her feelings; provide individual
- Attend to physical symptoms. therapy that addresses loss of control or anger issues.
- Assist the client to identify the thoughts that aroused the anxiety - Assist client to develop adaptive coping mechanisms and to use
and identify the basis for these thoughts. relaxation techniques.
 - Encourage use of support groups. o Obsessions: Preoccupation with persistently intrusive thoughts
- Facilitate a progressive review of the trauma experience. and ideas
- Encourage client to establish and reestablish relationships. o Compulsions
- Inform client that hypnotherapy or systematic desensitization - A compulsion is the performance of rituals or repetitive
may be used as a form of treatment. behaviors designed to prevent some event, divert
Phobias unacceptable thoughts, and decrease anxiety.
Description - Obsessions and compulsions often occur together and can
- Irrational fear of an object or situation that persists, although the disrupt normal daily activities.
person may recognize it as unreasonable - Anxiety occurs when one resists obsessions or compulsions
- Associated with panic-level anxiety if the object, situation, or and from being powerless to resist the thoughts or rituals.
activity cannot be avoided - Obsessive thoughts can involve issues of violence, aggression,
- Defense mechanisms commonly used include repression and sexual behavior, orderliness, or religion and uncontrollably
displacement. can interrupt conscious thoughts and the ability to function.
Types o Compulsive behavior patterns (behaviors or rituals)
- Acrophobia: Fear of heights o Compulsive behavior patterns decrease the anxiety.
- Agoraphobia: Fear of open spaces - The patterns are associated with the obsessive thoughts.
- Astraphobia: Fear of electrical storms - The patterns neutralize the thought.
- Claustrophobia: Fear of closed spaces - During stressful times, the ritualistic behavior increases.
- Hematophobia: Fear of blood - Defense mechanisms include repression, displacement, and
- Hydrophobia: Fear of water undoing.
- Monophobia: Fear of being alone Intervention
- Mysophobia: Fear of dirt or germs - Ensure that basic needs (food, rest, grooming) are met.
- Nyctophobia: Fear of darkness - Identify situations that precipitate compulsive behavior;
- Pyrophobia: Fear of fires encourage the client to verbalize concerns and feelings.
- Social Phobia: Fear of situations in which one might be - Be empathetic toward the client and aware of his or her need to
embarrassed or criticized; fear of making a fool of oneself perform the compulsive behavior.
- Xenophobia: Fear of strangers - Do not interrupt compulsive behaviors unless they jeopardize
- Zoophobia: Fear of animals the safety of the client or others (provide for client safety
Interventions related to the behavior).
- Identify the basis of the anxiety. - Allow time for the client to perform the compulsive behavior but
- Allow the client to verbalize feelings about the anxiety-producing set limits on behaviors that may interfere with the client’s
object or situation; frequently talking about the feared object is physical well-being to protect the client from physical harm.
the first step in the desensitization process. - Implement a schedule for the client that distracts from the
- Teach relaxation techniques, such as breathing exercises, muscle behaviors (structure simple activities, games, or tasks for the
relaxation exercises, and visualization of pleasant situations. client).
- Promote desensitization by gradually introducing the individual to - Establish a written contract that assists the client to decrease
the feared object or situation in small doses. the frequency of compulsive behaviors gradually.
Obsessive-Compulsive Disorder - Recognize and reinforce positive nonritualistic behaviors.
Somatoform Disorders
Description
- Somatoform disorders are characterized by persistent worry or
complaints regarding physical illness without supportive physical
findings.
- The client focuses on the physical signs and symptoms and is
unable to control the signs and symptoms.
- The physical signs and symptoms increase with psychosocial
stressors.
- The anxiety is redirected into a somatic concern.
- The client may unconsciously use somatization for secondary
gains, such as increased attention and decreased responsibilities.
1. Conversion disorder
Description
- The sudden onset of a physical symptom or a deficit
suggesting loss of or altered body function related to
psychological conflict or a neurological disorder.
- Conversion disorder is an expression of a psychological
conflict or need.
- The most common conversion symptoms are blindness,
deafness, paralysis, and the inability to talk.
- Conversion disorder has no organic cause.
- Symptoms are beyond the conscious control of the client
and are directly related to conflict.
- The development of physical symptoms reduces anxiety.
Assessment
- Rule out a physiological cause for symptoms or deficits.
- “La belle indifference”: Unconcerned with symptoms
- Physical limitation or disability
- Feelings of guilt, anxiety, or frustration
- Low self-esteem and feelings of inadequacy
- Unexpressed anger or conflict
- Secondary gain
2. Hypochondriasis
Description
- Preoccupation with fears of having a serious disease
- No evidence of physical illness exists.
- Hypochondriasis significantly impairs social and
occupational functioning.
Assessment
- Preoccupation with physical functioning
- Frequent somatic complaints
- Complaints of fatigue and insomnia
- Anxiety
- Difficulty expressing feelings
- Extensive use of home remedies or nonprescription
medications
- Repeatedly visiting a health care provider despite repeated
reassurance and normal test results
- Secondary gain
Somatization disorder
Description
- The client has multiple physical complaints involving numerous
body systems.
- The cause of these complaints is presumed to be psychological
Assessment
- Physical complaints of pain; denial of emotional problems; and
signs of anxiety, fear, and low self-esteem may be present.
- Secondary gain
Interventions
- Obtain a nursing history and assess for physical problems.
- Explore the needs being met by the physical symptoms with the
client.
- Assist the client to identify alternative ways of meeting needs.
- Assist the client to relate feelings and conflicts to the physical
symptoms.
- Convey understanding that the physical symptoms are real to the
client.
- Assure the client that physical illness has been ruled out.
- Explore the source of anxiety and stimulate verbalization of
anxiety.
- Encourage the use of relaxation techniques as the anxiety
increases.
- Use a pain assessment scale if the client complains of pain and
implement pain reduction measures as required.
 - Report and assess any new physical complaint. - Localized: The client blocks out all memories about a
- Encourage diversional activities. specified period.
- Provide positive feedback. - Selective: The client recalls some but not all memories
- Assist the client in recognizing his or her own feelings and about a specified period.
emotions. - Generalized: The client has a loss of all memory about
- Administer antianxiety medications if prescribed. past life.
Dissociative Disorder 3. Dissociative fugue
Description Description
- Dissociative disorder is a disruption in integrative functions of - The client assumes a new identity in a new environment.
memory, consciousness, or identity. - The disorder may occur suddenly.
- Dissociative disorder is associated with exposure to an extremely Assessment
traumatic event. - The client may drift from place to place.
1. Dissociative identity disorder (DID), formally called multiple personality - The client develops few social relationships.
disorder - When the fugue lifts, the client returns home and is
Description unable to recall the fugue state.
- Two or more fully developed, distinct, and unique 4. Depersonalization disorder
personalities exist within the client. Description: An altered self-perception in which one’s own reality
- The host is the primary personality, and the other is temporarily lost or changed
personalities are referred to as alters. Assessment
- Alter personalities may take full control of the client, one - Feelings of detachment
at a time, and may or may not be aware of each other. - Intact reality testing
- The alters may be aware of the host, but the host is not Interventions
usually aware of the alters. - Develop a trusting relationship with the client.
Assessment - Encourage verbal expression of painful experiences,
- The client may have an inability to recall important anxieties, and concerns.
information (unrelated to ordinary forgetfulness). - Explore methods of coping.
- Transition from one personality to the other is related to - Identify sources of conflict.
stress or a traumatic event and is sudden. - Focus on the client’s strengths and skills.
- Dissociation is used as a method of distancing and - Orient the client.
defending one’s self from anxiety and traumatizing - Provide nondemanding simple routines.
experiences. - Allow the client to progress at his or her own pace.
2. Dissociative amnesia - Implement stress reduction techniques.
Description - Plan for individual, group, or family psychotherapy to
- Inability to recall important personal information integrate dissociated aspects of personality or memory
because it provokes anxiety and to expand self-awareness.
- Memory impairment may range from partial to almost Mood Disorders
complete. 1. Bipolar disorder
Assessment
- Bipolar disorder is characterized by episodes of mania and - Pressured and/or clanging speech
depression with periods of normal mood and activity in between. - Restlessness
- The medication of choice has traditionally been lithium carbonate, - Sexually promiscuous
which can be toxic and requires regular monitoring of serum - Urgent motor activity
lithium levels to help o Depression
- keep the medication’s therapeutic index level appropriate; a - Increased or decreased appetite
stable intake of adequate dietary sodium and fluid (2 to 3 L daily) - Decrease in activities of daily living
must be maintained to avoid toxicity. - Decreased emotion and physical activity
- Other medications such as valproic acid (Depakote) or - Easily fatigued
carbamazepine (Tegretol) may be prescribed both to reduce the - Inability to make decisions
symptoms of acute bipolar manic episodes and for maintenance - Poor concentration
therapy; lamotrigine (Lamictal) may be recommended for - Internalizing hostility
maintenance therapy. - Introverted personality
- Antianxiety agents may be prescribed to assist in managing the - Social isolation and withdrawn from groups
psychomotor agitation characteristic of mania; these medications - Lack of energy
should be avoided in clients with a history of substance abuse. - Lack of initiative
- Atypical antipsychotic medications such as olanzapine (Zyprexa), - Lack of self-confidence and low self-esteem
aripiprazole (Abilify), and risperidone (Risperdal) may be - Lack of sexual interest
prescribed for both their sedative and mood-stabilizing effects. - Psychomotor retardation
o Mania - Suicidal thinking
- Becomes angry quickly Interventions for mania
- Delusional self-confidence o Aggressive Behavior
- Constantly pushing limits, manipulating, and finding fault - Assist client in identifying feelings of frustration and
- Euphoric with intense feelings of well-being aggression.
- Demonstrates little or no inhibition - Encourage client to talk out instead of acting out
- Distracted by environmental stimuli feelings of frustration.
- Extroverted personality - Assist client in identifying precipitating events or
- Flight of ideas situations that lead to aggressive behavior.
- Grandiose and persecutory delusions - Describe the consequences of the behavior on self and
- High and unstable affect others.
- Significant decrease in appetite - Assist in identifying previous coping mechanisms.
- Inability to eat or sleep because of involvement in more - Assist client in problem-solving techniques to cope with
important things frustration or aggression
- Unlimited energy o Deescalation Techniques
- Inappropriate affect - Maintain safety for client, other clients, and self.
- Dress that is inappropriately bizarre, loud, and/or colorful - Maintain large personal space and use a nonaggressive
- Make-up is colorful and overdone posture.
- Initiation of activity
 - Use a calm approach and communicate with a calm,
clear tone of voice (be assertive, not aggressive).
- Determine what client considers to be his or her need.
- Avoid verbal struggles.
- Provide client with clear options that deal with client’s
behavior.
- Assist client with problem-solving and decision-making
regarding options.
o Manipulative Behavior
- Set clear, consistent, realistic, and enforceable limits,
and communicate expected behaviors.
- Be clear about consequences associated with exceeding
set limits and follow through with consequences in a
nonpunitive manner, if necessary.
- Discuss client’s behavior in a nonjudgmental and
nonthreatening manner.
- Avoid power struggles with client (avoid arguing with
client).
- Assist client in developing means of setting limits on
own behavior.
 Remove hazardous objects from the environment
(this should be done for all clients).
 Assess the client closely for fatigue.
 Monitor the client’s sleep patterns; use comfort
measures to promote sleep.
 Provide frequent rest periods.
 Provide a private room if possible.
 Encourage the client to ventilate feelings.
 Use calm, slow interactions.
 Help the client focus on one topic during the
conversation.
 Ignore or distract the client from grandiose thinking.
 Present reality to the client.
 Do not argue with the client.
 Limit group activities and assess the client’s
tolerance level; solitary activities may be necessary.
 Provide high-calorie finger foods and fluids.
 Supervise the client’s choice of clothing.
 Reduce environmental stimuli.
 Set limits on inappropriate behaviors.
 Provide physical activities and outlets for tension.
 Avoid competitive games.
 Provide gross motor activities such as walking.
 Provide structured activities or one-to-one activities
with the nurse.
 Provide simple and direct explanations for routine
procedures.
 Supervise the administration of medication;
administer a hypnotic or sedative medication as
prescribed.
 Seclusion may be considered if hyperactive behavior
is dangerous due to altered sensory perceptions.
Depression
Description
- Depression affects feelings, thoughts, and behaviors.
- It can occur after a loss, including loss of self-esteem, the end of a
significant relationship, the death of a loved one, or a traumatic
event.
- The loss is followed by grief and mourning; if this process does not
resolve, depression results.
- Depression may be mild, moderate, or severe.
- Treatment includes counseling, antidepressant medication, and
electroconvulsive therapy (ECT).
1. Mild depression
- Mild depression is triggered by an external event and follows
the normal grief reaction.
- Mild depression lasts less than 2 weeks.
- Feeling sad
- Feeling let down or disappointed
- Mild alterations in sleep patterns
- Feeling less alert
- Irritability
- Disinterested in spending time with others
- Increased or decreased appetite
- Increased use of alcohol or drugs
2. Moderate depression
 - Moderate depression persists over time. - Diurnal variation: The person may feel better at a certain time
- The person experiences a sense of change and often seeks of the day.
help. - Delusions and hallucinations
- Despondent and gloomy Interventions
- Dejected o Risk for Harm
- Low self-esteem - Assess for homicidal and suicidal ideation.
- Helplessness and powerlessness - Provide safety from suicidal actions (be certain that there
- May experience intense anxiety and anger are no harmful objects in the environment).
- Diurnal variation: The person may feel better at a certain time - Do not leave the client alone for extended periods.
of the day. - If the client has a suicidal plan, place on one-to-one
- Slow thought processes and difficulty in concentrating supervision.
- Rumination: Persistent thinking about and discussion of a - Form a “no-suicide contract” with the client.
particular subject o Activities
- Negative thinking and suicidal thoughts - Use gentle encouragement to participate in activities of daily
- Sleep disturbances living and unit therapies.
- Social withdrawal - Do not push decision-making or the making of complex
- Anorexia, weight loss, and fatigue choices or decisions that the client is not ready for.
- Somatic complaints - Provide achievable activities in which client can achieve
- Menstrual changes success (focus on strengths).
- Increased use of alcohol or drugs - Begin client with one-to-one activities.
3. Severe depression - Provide activities for easy mastery to increase self-esteem
- Intense and pervasive and help in alleviating guilt feelings and that do not require a
- Despair and hopelessness great deal of concentration (simple card games, drawing).
- Guilt and worthlessness - Engage in gross motor activities (walking).
- Flat affect - Eventually bring the client into small group activities and
- May show agitation and pace about then large groups.
- Poor posture and unkempt appearance o Nutrition
- Decreased speech - Monitor nutritional intake and weight. Offer small, high-
- Self-destructive thoughts; however, the person may lack calorie, high-protein snacks and fluids throughout the day.
energy to act on the thought. - Stay with the client during meals.
- Social withdrawal o Hygiene Care
- Poor concentration and overwhelmed by simple tasks - Monitor for general hygiene and self-care deficits; deficits
- Severe psychomotor retardation may indicate worsening depression.
- Anorexia and considerable weight loss - Assist with activities of daily living.
- Constipation and urinary retention o Sleep Patterns
- Lack of sexual interest - Monitor sleep patterns.
- Terminal insomnia - Decrease environmental stimuli at bedtime.
- Spend time with the client before bedtime.
 o Altered Thought Processes
- Remind client of times when he or she felt better and was
successful.
- Spend time with client to convey the client’s worth and
value.
- Encourage the client to discuss losses or changes in the life
situation.
- Encourage the client to express sadness or anger and allow
adequate time for verbal responses.
- Respond to anger therapeutically.
Electroconvulsive Therapy (ECT)
Description
- ECT is an effective treatment for depression (not a cure); an
electrical current is delivered through electrodes attached to the
temples that cause a brief seizure within the brain; outward
movement is usually a slight movement of hands, feet, or a toe
because premedication is given to relax the muscles.
- The usual course is 6 to 12 treatments given 2 or 3 times per
week; maintenance ECT once a month may help decrease the
relapse rate for a client with recurrent depression.
- ECT is not always effective in clients with dysthymic depression,
depression and personality disorders, drug dependence, or
depression secondary to situational or social difficulties.
- At-risk clients include clients with recent myocardial infarction,
brain attack (stroke), or intracranial mass lesions.
Uses
- When antidepressant medications have no effect
- When there is a need for a rapid definitive response, such as
when a client is suicidal or homicidal
- When the client is in extreme agitation or stupor
- When the risks of other treatments outweigh the risk of ECT
- When the client has a history of poor medication response, a
history of good ECT response, or both
- When the client prefers ECT as a treatment
Preprocedure
- Explain the procedure to the client.
- Encourage the client to discuss feelings, including myths regarding
ECT.
- Teach the client and family what to expect.
- Informed consent must be obtained when voluntary clients are
being treated.
- For involuntary clients, when informed consent cannot be
obtained, permission may be obtained from the next of kin,
although in some states the permission for ECT must be obtained
from the court.
- Maintain NPO status after midnight or at least 4 hours before
treatment as prescribed.
- Baseline vital signs are taken.
- The client is requested to void.
- Hairpins, contact lenses, and dentures are removed.
- Administer preprocedure medication as prescribed.
During the procedure
- Place a blood pressure cuff on one of the client’s arms.
- As the intravenous line is inserted, electroencephalographic and
electrocardiographic electrodes are attached.
- A pulse oximeter is placed on the client’s finger.
- Blood pressure is monitored throughout the treatment.
- Medications administered may include a short-acting anesthetic
and
- a muscle relaxant.
- Throughout the procedure, 100% oxygen by mask via positive
pressure is administered.
- An airway or bite-block is placed to prevent biting the tongue.
- An electrical stimulus is administered; a brief seizure occurs.
- Hairpins, contact lenses, and dentures are removed.
- Administer preprocedure medication as prescribed
Postprocedure
- The client is transported to a recovery room with the blood
pressure cuff and oximeter in place, where oxygen, suction, and
other emergency equipment are available.
- When the client is awake, talk to the client and take vital signs.
- The client may be confused; provide frequent orientation (brief,
distinct, and simple) and reassurance.
- The client returns to the nursing unit when at least a 90% oxygen
saturation level is maintained, vital signs are stable, and mental
status is satisfactory.
 - Assess the gag reflex before giving the client fluids, food, or
medication.
Potential side effects
- Major side effects include confusion, disorientation, and short-
term memory loss.
- The client may be confused and disoriented on awakening.
- Memory deficits may occur, but memory usually recovers
completely, although some clients have memory loss lasting 6
months.
Schizophrenia
Description
- Schizophrenia is a group of mental disorders characterized by
psychotic features (hallucinations and delusions), disordered
thought processes, and disrupted interpersonal relationships.
- Disturbances in affect, mood, behavior, and thought processes
occur.
Assessment
o Physical characteristics
- Unkempt appearance
- Body image distortions
- May be preoccupied with somatic complaints
- May neglect hygiene, eating, sleeping, and elimination
o Motor activity
o Description: Abnormal motor behavior or activity
displayed by mentally ill client that occurs as a result of a
psychiatric disorder
o Types
 Echolalia: Repeating the speech of another
person
 Echopraxia: Repeating the movements of
another person
 Waxy Flexibility: Having one’s arms or legs
placed in a certain position and holding that
same position for hours
- Catatonic posturing: Holding bizarre
postures for long periods
- Catatonic excitement: Moving excitedly,
with no environmental stimuli present
- Possible total immobilization
- Inability to respond to commands or
responding only to commands
- Waxy flexibility
- Repetitive or stereotyped movements
- Motor activity that may be increased, as
evidenced by agitation, pacing, inability to
sleep, loss of appetite and weight, and
impulsiveness
- Possible inability to initiate activity (anergia)
o Emotional characteristics
- Mistrust
- View of the world as threatening and unsafe
- Affect blunted, flat, or inappropriate
- May display feelings of ambivalence, helplessness, anxiety,
anger, guilt, or depression in response to hallucinations or
delusions or as a result of grief related to losses imposed by
the illness
o Compulsive rituals: Constant repetitive activity performed as an
attempt to solve conflicting feelings
o Overcompliance: Attempt to deny responsibility for any action by
doing only what another person instructs exactly
o Affective disturbances
o Flat or incongruent affect or inappropriate affect
 Altered thought processes
 Abnormal thought process
1. Abnormal thought process
Description: Abnormal thought processes displayed by mentally ill client
that occur as a result of a psychiatric disorder
Types
o Circumstantiality: Before getting to the point or answering a
question, client gets caught up in countless details and
explanations
o Confabulation: Filling a memory gap with detailed fantasy
believed by the teller; the purpose of confabulation is to maintain
self-esteem; seen in organic conditions such as Korsakoff’s
psychosis
 o Flight of Ideas: Constant flow of speech in which client jumps from
one topic to another in rapid succession; a connection between
topics exists, although it is sometimes difficult to identify; seen in
manic state
o Looseness of Association: Haphazard, illogical, and confused
thinking and interrupted connections in thought; seen mostly in
schizophrenic disorders
o Neologisms: Client makes up words that have meaning only for
the individual; often part of a delusional system
o Thought Blocking: Sudden cessation of a thought in the middle of
a sentence; client is unable to continue the train of thought;
often, sudden new thoughts come up unrelated to the topic
o Word Salad: Mixture of words and phrases that has no meaning
- Impaired reality testing
- Fragmentation of thoughts
- Thought blocking
- Loose associations
- Echolalia
- Distorted perception of the environment
- Neologisms
- Magical thinking
- Inability to conceptualize meaning in words or thoughts
- Inability to organize facts logically
- Delusions associated with thought processes or content
2. Types of delusions
Description
- A false belief held to be true, even when there is evidence to
the contrary
o Grandeur: False belief that one is a powerful and
important person
o Jealousy: False belief that one’s partner or mate is
going out with other persons
o Persecution: Thought that one is being singled out
for harm by others
Interventions
- Ask client to describe the delusion.
- Be open and honest in interactions to reduce suspiciousness.
- Focus conversation on reality-based topics, rather than on the
delusion.
- Encourage client to express feelings and focus on feelings that
the delusions generate.
- If client obsesses on the delusion, set firm limits on the amount
of time for talking about the delusion.
- Do not argue with client or try to convince client that the
delusions are false.
- Validate if part of the delusion is real.
o Loss of reference, in which the client believes that
certain events, situations, or interactions are related
directly to self
o Delusions of persecution, in which the client believes
that he or she is being harassed, threatened, or
persecuted by some powerful force
o Delusions of grandeur, in which the client attaches
special significance to self in relation to others or the
universe and has an exaggerated sense of self that has
no basis in reality
o Somatic delusions, in which the client believes that his
or her body is changing or responding in an unusual
way, which has no basis in reality
3. Perceptual distortions
Description
- Sense perception (occurs with one of the five senses) for which no
external stimuli exist; can have an organic or functional cause
- Illusions, which may be brief experiences with a misinterpretation
or misperception of reality
- Hallucinations (five senses) with no basis in reality
Types
o Auditory: Hearing voices when none are present
o Gustatory: Experiencing taste in the absence of stimuli
o Olfactory: Smelling smells that do not exist
o Tactile: Feeling touch sensations in the absence of stimuli
o Visual: Seeing things that are not there
Interventions
- Ask client directly about hallucination.
 - Avoid reacting to hallucination as if it were real. - Automatic obedience
- Decrease stimuli or move client to another area. - Stereotyped or repetitive behavior
- Do not negate client’s experience. 2. Disorganized schizophrenia
- Focus on reality-based topics. - Extreme social withdrawal
- Attempt to engage client’s attention through a concrete activity. - Disorganized speech or behavior
- Respond verbally to anything real that client talks about. - Flat or inappropriate affect
- Avoid touching client. - Silliness unrelated to speech
- Monitor for signs of increasing anxiety or agitation, which may - Stereotyped behaviors
indicate that hallucinations are increasing. - Grimacing mannerisms
4. Language and communication disturbances - Inability to perform activities of daily living
o Clang Association: Repetition of words or phrases that are 3. Paranoid schizophrenia
similar in sound but in no other way - Suspiciousness
o Echolalia: Repetition of words or phrases heard from another - Hostility
person - Delusions
o Mutism: Absence of verbal speech - Auditory hallucinations
o Neologism: A newly devised word that has special meaning only - Anxiety and anger
to the client - Aloofness
o Pressured Speech: Speaking as if the words are being forced out - Persecutory themes
quickly - Violence
o Verbigeration: Purposeless repetition of words or phrases 4. Residual schizophrenia
o Word Salad: Form of speech in which words or phrases are - Diagnosed as schizophrenic in the past
connected meaninglessly - Time limited between attacks, but may last for many years
- Related to disorders in thought process - The client exhibits considerable social isolation and
- Inability to organize language withdrawal and impaired role functioning.
- Difficulty communicating clearly 5. Undifferentiated schizophrenia
- Inappropriate responses to a situation - Undifferentiated schizophrenia does not meet the criteria for
- A single word or phrase may represent the whole meaning of catatonic, disorganized, or paranoid, schizophrenia.
the conversation such that the client may feel that he or she - Delusions and hallucinations
has communicated adequately. - Disorganized speech
- Development of a private language - Disorganized or catatonic behavior
Types of schizophrenia - Flat affect
1. Catatonic schizophrenia - Social withdrawal
- Psychomotor disturbances Interventions
- Immobility - Assess client’s physical needs.
- Stupor - Set limits on client’s behavior when it interferes with others and
- Waxy flexibility becomes disruptive.
- Excessive purposeless motor activity - Maintain a safe environment.
- Echolalia
- Initiate one-on-one interaction and progress to small groups as Interventions: Active hallucinations
tolerated. - Monitor for hallucination cues and assess content of
- Spend time with client, even if client is unable to respond. hallucinations.
- Monitor for altered thought processes. - Intervene with one-on-one contact.
- Maintain ego boundaries and avoid touching client. - Decrease stimuli or move the client to another area.
- Limit the time of interaction with client. - Avoid conveying to the client that others also are experiencing the
- Avoid an overly warm approach; a neutral approach is less hallucination.
threatening. - Respond verbally to anything real that the client talks about.
- Do not make promises to client that cannot be kept. - Avoid touching the client.
- Establish daily routines. - Encourage the client to express feelings.
- Assist client to improve grooming and accept responsibility for - During a hallucination, attempt to engage the client’s attention
personal care. through a concrete activity.
- Sit with client in silence if necessary. - Accept and do not joke about or judge the client’s behavior.
- Provide brief, frequent contact with client. - Provide easy activities and a structured environment with routine
- Tell client when you are leaving. activities of daily living.
- Tell client when you do not understand. - Monitor for signs of increasing fear, anxiety, or agitation.
- Do not “go along” with client’s delusions or hallucinations. - Decrease stimuli as needed.
- Provide simple concrete activities, such as puzzles or word - Administer medications as prescribed.
games. Interventions: Delusions
- Reorient client as necessary. - Interact based on reality.
- Help client establish what is real and unreal. - Encourage the client to express feelings.
- Stay with client if he or she is frightened. - Do not dispute the client or try to convince the client that
- Speak to client in a simple, direct, and concise manner. delusions are false.
- Reassure client that the environment is safe. - Initiate activities on a one-on-one basis.
- Remove client from group situations if client’s behavior is too - Alter hospital routines as necessary, such as using canned or
bizarre, disturbing, or dangerous to others. packaged food or food from home.
- Set realistic goals. - Recognize accomplishments and provide positive feedback for
- Initially, do not offer choices to client, and gradually assist client successes.
in making his or her own decisions. Paranoid Disorders
- Use canned or packaged food, especially with a paranoid Description
schizophrenic client - Paranoid disorder is a concrete, pervasive delusional system
- Provide a radio or tape player at night for insomnia. characterized by persecutory and grandiose beliefs.
- Explain to client everything that is being done. - The client exhibits suspiciousness and mistrust of others.
- Set limits on client’s behavior if client is unable to do so. - The client often is viewed by others as hostile, stubborn, and
- Decrease excessive stimuli in the environment. defensive.
- Monitor for suicide risk. Behaviors
- Assist client to use alternative means to express feelings, such as - Suspicious and mistrustful
through music or art therapy or writing. - Emotionally distant
 - Distortion of reality - Before the onset, the client becomes cold, withdrawn,
- Poor insight and poor judgments distrustful, resentful, argumentative, sarcastic, and
- Hypervigilance defiant
- Low self-esteem - Bizarre, numerous, and changeable delusions occur
- Highly sensitive, difficulty in admitting own error, and taking pride - Delusions become less logical as the client becomes
in being correct more disorganized
- Hypercritical and intolerant of others - Persecutory hallucinations occur
- Hostile, aggressive, and quarrelsome - Psychotic state ensues
- Evasive - All symptoms of schizophrenia are present
- Concrete thinking Interventions
Delusions - Assess for suicide risk.
- Delusions serve a purpose in establishing identity and self-esteem. - Diminish suspicious behavior.
- The client may have grandiose and persecutory delusions. - Avoid direct eye contact.
- Process of delusion includes denial, projection, and - Establish a trusting relationship.
rationalization. - Promote increased self-esteem.
- As trust in others increases, the need for delusions decreases. - Remain calm, nonthreatening, and nonjudgmental.
Types of paranoid disorders - Provide continuity of care.
1. Paranoid personality disorder (see Section XIII,C,3) - Respond honestly to client.
- Suspicious - Assess for suicide risk.
- Nonpsychotic - Diminish suspicious behavior.
- No hallucinations or delusions - Avoid direct eye contact.
- No symptoms of schizophrenia - Establish a trusting relationship.
2. Paranoia-induced state - Promote increased self-esteem.
- Abrupt onset in response to stress; subsides when stress - Remain calm, nonthreatening, and nonjudgmental.
decreases - Provide continuity of care.
- No hallucinations, but experiences paranoid delusions - Respond honestly to client.
- May be sensitive and suspicious before the development of - Follow through on commitments made to client.
delusions - Acknowledge client’s feelings, but tell client that you do not
- No symptoms of schizophrenia share his or her interpretation of an event.
3. Paranoia - Provide a daily schedule of activities.
- Exhibits an organized delusional system - Assist client to identify diversionary activities.
- No hallucinations - Gradually introduce client to groups.
- Reserved and sensitive before onset - Refocus conversation to reality-based topics.
- Psychotic state - Use role playing to help client identify thoughts and feelings.
- No symptoms of schizophrenia - Provide positive reinforcement for successes.
4. Paranoid schizophrenia - Do not argue with delusions.
- Use concrete, specific words.
- Do not be secretive with client.
 - Do not whisper in client’s presence. 6. Impaired self-perception: Distorted self-perception and
- Assure client that he or she will be safe. experience of self-hate or self-idealization
- Involve client in noncompetitive tasks. 7. Impaired thought processes
- Provide client with the opportunity to complete small tasks. - Concrete or diffuse thinking
- Monitor eating, drinking, sleeping, and elimination patterns. - Difficulty concentrating
- Limit physical contact. - Impaired memory
- Monitor for agitation, and decrease stimuli as needed. 8. Impaired stimulus barrier
Personality Disorders - Inability to regulate incoming sensory stimuli
Description - Increased excitability
- Personality disorders include various inflexible maladaptive - Excessive response to noise and light
behavior patterns or traits that may impair functioning and - Poor attention span
relationships. - Agitated
- The client usually remains in touch with reality and typically has a - Insomnia
lack of insight into his or her behavior. Cluster A personality disorder types include the odd, eccentric types—
- Stress exacerbates manifestations of the personality disorder. schizoid, schizotypal, and paranoid.
- In severe cases, the personality disorder may deteriorate to a 1. Schizoid personality disorder is characterized by an inability
psychotic state. to form warm, close social relationships.
Characteristics - Social detachment and lack of close relationships
1. Poor impulse control - Interest in solitary activities
- Acting out to manage internal pain - Aloof and indifferent
- Forms of acting out include physical and verbal attacks, such - Restricted expression of emotions
as yelling and swearing, and self-injurious behaviors, such as - Lack of interest in others
cutting own skin, banging the head, punching self, 2. Schizotypal personality disorder is characterized by the
manipulation, substance abuse, promiscuous sexual display of abnormal or highly unusual thoughts, perceptions,
behaviors, and suicide attempts. speech, and behavior patterns.
- The client may be preoccupied with such things as self, - Suspicious
religion, or sex. - Paranoia
2. Mood characteristics - Magical thinking
- May experience abandonment and depression - Odd thinking and speech
- Moods may include rage, guilt, fear, and emptiness. - Relationship deficits
3. Impaired judgment 3. Paranoid personality disorder is characterized by
- Difficulty with problem-solving suspiciousness and mistrust of others (paranoia).
- Inability to perceive the consequences of behavior - May be suspicious and distrusting
4. Impaired reality testing: Distortion of reality and often projection - May be argumentative
of own feelings onto others - May be hostile, aloof
5. Impaired object relations: Rigid and inflexible, with difficulty in - May be rigid, critical, and controlling of others
intimate relationships - May have thoughts of grandiosity
Cluster B personality disorders include the overemotional, erratic types—
histrionic, narcissistic, antisocial, and borderline.
1. Histrionic personality disorder is characterized by overly dramatic
and intensely expressive behavior.
- Lively and dramatic and enjoys being the center of attention
- Has poor and shallow interpersonal relations
- May be sexually seductive or provocative
- Dramatizes his or her life and may appear theatrical
- Overly concerned with appearance
- Easily bored
2. Narcissistic personality disorder is characterized by an increased
sense of self-importance and preoccupation with fantasies and
unlimited success.
- Need for admiration and inflation of accomplishments
- Overestimation of abilities and underestimation of
contributions of others
- Lack of empathy and sensitivity to needs of others
3. Antisocial personality disorder comprises a pattern of
irresponsible and antisocial behavior, selfishness, an inability to
maintain lasting relationships, poor sexual adjustment, a failure to
accept social norms, and a tendency toward irritability and
aggressiveness.
- Perceives the world as hostile
- Superficial charm, yet can become hostile
- No shame or guilt
- Self-centered
- Unreliable
- Easily bored
- Poor work history
- Inability to tolerate frustration
- View others as objects to be manipulated
- Poor judgment
- Impulsive
4. Borderline personality disorder is characterized by instability in
interpersonal relationships, unstable mood and self-image, and
impulsive and unpredictable behavior.
- Unclear identity
- Unstable and intense
- Extreme shifts in mood
- Easily angered
- Easily bored
- Argumentative
- Depression
- Self-destructive behavior
- Manipulation
- Inability to tolerate anxiety
- Chronic feelings of emptiness and fear of being alone
- Splitting—sees others as all good or all bad; creates conflict
between individuals by playing one person against another
Cluster C personality disorders include the anxious, fearful types of
personality disorders—obsessive-compulsive personality, avoidant, and
dependent.
1. Obsessive-compulsive personality disorder is characterized by
difficulty expressing warm and tender emotions, perfectionism,
stubbornness, the need to control others, and a devotion to work.
- Overly conscientious
- Inflexible and preoccupied with details and rules
- Extremely devoted to work to the exclusion of leisure
activities and friendships
- Miserly and stubborn
- Hoarding behavior
- Engages in rituals
2. Avoidant personality disorder is characterized by social
withdrawal and extreme sensitivity to potential rejection.
- Feelings of inadequacy
- Hypersensitive to reactions of others and poor reaction to
criticism
- Social isolation
- Lack of support system
3. Dependent personality disorder is characterized by an intense lack
of self-confidence, low self-esteem, and inability to function
independently, such that the individual passively allows others to
make decisions and assume responsibility for major areas in the
person’s life; the dependent client has great difficulty making
decisions.
General interventions for a client with a personality disorder
 1. Maintain safety against self-destructive behaviors.
2. Allow the client to make choices and be as independent as
possible.
3. Encourage the client to discuss feelings rather than act them out.
4. Provide consistency in response to the client’s acting-out
behaviors.
5. Discuss expectations and responsibilities with the client.
6. Discuss the consequences that will follow certain behaviors.
7. Inform the client that harm to self, others, and property is
unacceptable.
8. Identify splitting behavior.
9. Assist the client to deal directly with anger.
10. Develop a written safety or behavioral contract with the client.
11. Encourage the client to keep a journal recording daily feelings.
12. Encourage the client to participate in group activities, and praise
nonmanipulative behavior.
13. Set and maintain limits to decrease manipulative behavior.
14. Remove the client from group situations in which attention-
seeking behaviors occur.
15. Provide realistic praise for positive behaviors in social situations.
Cognitive Impairment Disorders
1. Autism: See Chapter 45.
2. Attention-deficit/hyperactivity disorder
3. Dementia and Alzheimer’s disease
A. Dementia
- Dementia is a syndrome with progressive deterioration in
intellectual functioning secondary to structural or
functional changes.
- Long-term and short-term memory loss occur, with
impairment in judgment, abstract thinking, problem-
solving ability, and behavior.
- Dementia results in a self-care deficit.
- Dementia-like symptoms can be a result of physiological
conditions and such conditions must be ruled out
initially.
- The most common type of dementia is Alzheimer’s
disease.
B. Alzheimer’s disease
o Agnosia: Failure to recognize or identify familiar objects
despite intact sensory function
o Amnesia: Loss of memory caused by brain
degeneration
o Aphasia: Language disturbance in understanding and
expressing spoken words
o Apraxia: Inability to perform motor activities, despite
intact motor function
- Alzheimer’s disease is an irreversible form of
senile dementia caused by nerve cell
deterioration.
- Individuals with Alzheimer’s disease experience
cognitive deterioration and progressive loss of
ability to carry out activities of daily living.
- The client experiences a steady decline in physical
and mental functioning and usually requires long-
term care in a specialized facility in the final stages
of the illness.
- Stages and major characteristic of Alzheimer’s
diseases
 Stage 1 (mild): forgetfulness
 Stage 2 (moderate): confusion
 Stage 3 (moderate to severe): ambulatory
dementia
 Stage 4 (late): end stage.
Interventions
- Identify and reinforce retained skills.
- Provide continuity of care.
- Orient the client to the environment.
- Furnish the environment with familiar possessions.
- Acknowledge the client’s feelings.
- Assist the client and family members to manage memory deficits
and behavior changes.
- Encourage family members to express feelings about caregiving.
- Provide the caregiver with support and identify the resources and
support groups available.
- Monitor the client’s activities of daily living.
- Remind the client how to perform self-care activities.
- Help the client maintain independence. - Reduce hot water heater temperature.
- Provide the client with consistent routines. 7. Altered thought processes
- Provide the client with exercise, such as walking with an escort. - Call the client by name.
- Avoid activities that tax the memory. - Orient the client frequently.
- Allow the client plenty of time to complete a task. - Use familiar objects in the room.
- Use constant encouragement with the client with a simple step- - Place a calendar and clock in a visible place.
by-step approach. - Maintain familiar routines.
- Provide the client with activities that distract and occupy time, - Allow the client to reminisce.
such as listening to music, coloring, and watching television. - Make tasks simple.
- Provide the client with mental stimulation with simple games or - Allow time for the client to complete a task.
activities. - Provide positive reinforcement for positive behaviors.
4. Wandering 8. Altered sleep patterns
- Provide the client with a safe environment. - Allow the client to wander in a safe place until he or she
- Prevent unsafe wandering. becomes tired.
- Provide the client with close supervision. - Prevent shadows in the room by using indirect light.
- Close and secure doors. - Avoid the use of hypnotics because they cause confusion and
- Use identification bracelets and electronic surveillance. aggravate the sundown effect.
- Sundown syndrome (sundowning) is characterized by a 9. Agitation
pronounced increase in symptoms and problem behaviors in - Assess the precipitant of the agitation.
the evening. - Reassure the client.
- Providing a safe environment is a priority in the care of a - Remove items that can be hazardous when the client is
client with Alzheimer’s disease. agitated.
5. Communication - Approach the client slowly and calmly from the front, and
- Adapt to the communication level of the client. speak, gesture, and move slowly.
- Use a firm volume and a low-pitched voice to communicate. - Remove the client to a less stressful environment; decrease
- Stand directly in front of the client and maintain eye contact. excess stimuli.
- Call the client by name and identify self; wait for a response. - Use touch gently.
- Use a calm and reassuring voice. - Do not argue with or force the client to do something.
- Use pantomime gestures if the client is unable to understand Psychosexual Alterations
spoken words. Sexuality
- Speak slowly and clearly, using short words and simple - One’s sense of being a sexual individual
sentences. - Includes how one looks, behaves, and relates to others
- Ask only one question at a time and give one direction at a Sexual expression
time. o Bisexuality: Sexual attraction to and activity with both genders
- Repeat questions if necessary, but do not rephrase. o Heterosexuality: Male-female sexual relationships
6. Impaired judgment o Homosexuality: Sexual attraction to a member of the same
- Remove throw rugs, toxic substances, and dangerous gender
electrical appliances from the environment.
 o Transvestism: Obsession with wearing clothing of the opposite
gender
Alterations in sexual behavior
- Transsexualism: Feeling that one’s gender is inappropriate and
desiring to acquire sexual characteristics of the opposite gender
- Exhibitionism: Sexual urges and fantasies that result in exposure
of genitals to strangers to bring sexual gratification or arousal
- Fetishism: Using nonliving objects for sexual gratification
- Pedophilia: Desiring sexual activity with a child younger than 13
years of age
- Sexual masochism: Sexual gratification that involves receiving pain
- Sexual sadism: Sexual gratification that involves inflicting pain
- Voyeurism: Sexual gratification through observing others
disrobing or engaging in sexual activity
- Zoophilia: Intense sexual arousal or desire for sexual contact with
animals
- Frotteurism: Intense sexual arousal or desire when rubbing
against a nonconsenting person
Interventions
- Assess sexual history, history of trauma or abuse, and
precipitating event for the sexual disorder.
- Encourage the client to explore personal beliefs.
- Provide a nonjudgmental attitude.
- Ensure the client does not present a harm to self or others.
- Provide supportive psychotherapy.