Concepts Basic to Psychosocial Nursing - mental illness was a product of sin & witchcraft;

jailed, placed in asylums & considered outcasts

Psychiatric Nursing
-person who understands other people’s feelings, 2. Middle ages
motivations, thoughts, insights,etc. -”advent of psychoanalysis”
- self-awareness strengths, limitations, dreams - non biologic theories explained etiologies or
-case of clients concerning rehabilitation psychiatric disorders
-focus on case and rehabilitation of those identified of - "advent of psychoanalysis" Freud 1880
mental illness -invention of tranquilizer chair
- condition is already there : rehabilitation
- care of clients with mental & psychosocial disorders; *Extinction
promote rehabilitation - Freud
- Advent of psychoanalysis
Mental Health Nursing
-care of clients focusing on the well and at risk Benjamin Rush
population to provide immediate interventions - Invented tranquilizer chair:believe
-condition is not yet diagnosed and at risk : preventive people should be treated with kindness
-Preventive care on the well and at risk population to and compassion
provide immediate interventions - Gyrantor: head starter
- Father of american psych
Mental Health
-expression of our emotions and signifies a successful Phillipe Pimel
adaptation to a range of demands - Advocate of human treatment
-emotional, psychological and social well-being or on - Hospital director
absence of a mental disorder
-state of well-being in which the individual realizes William Tuke
his/her own abilities can cope with the normal - Retreat homes
stresses of his life, can work productively and fruitfully - Avoid seclusions
and is able to make a contribution to his/her community - stopped seclusion, made homes for
clients

Franz Anton Mesmer

- “Mesmerism”
- Similar to hypnosis
- mesmerism & hypnotism

Mental Illness Hildegard Peplau

-result of distress, poor coping or biological alterations - How to socialize, communicate, treat
affecting social functioning - IPR Theory (interpersonal relationships
-mental disorder/illness is a psychological or behavioral theory) r/t care of patients
pattern associated with distress or disability that occurs in - Pioneer for nursing in psychiatry
an individual and is not part of normal development of
asruse (di ko kasabot) Dorothy Dix
-Includes disorders that affect mood, behavior & thinking - Asylums
such as depression, schizophrenia, anxiety disorders & - Milieu therapy
addictive disorders - Environment conducive to clients
-Result of distress, poor coping or biologic alterations - opened 3rd state asylums
affecting social functioning

History
1. Early ages
-sin, treated like animals 1950’s
-restoration
 ● Antipsychotic drugs : 1st drug therapy - Coping with stress, flexible and can
-chloropromazine (thorazine) experience failure without thinking of it as
-Lithium (antimanic drugs) a failure
● Drugs and electric shock cures
Adaptive Patterns of Behavior
After 10 years: 1. Working it out
2. Seeking comfort
1. Monoamine oxidase inhibitor 3. Avoidance withdrawal
4. Intense expansion of feeling
antidepressants 5. Privately thinking it through

2. Haloperidol Basic Characteristics of Good Mental Health

1. Courage
3. Tricyclic antidepressants
a. Being willing to take action in the fact of
perceived danger
4. Benzodiazepines (antianxiety)
2. Integrity
Present Community Psychiatry a. Involves concept of matching words and
deeds
- To reintegrate clients 3. Tenacity
a. Individual is able to focus on a selected
-- Community awareness, involvement & research about task without allowing
psychiatric condition distractions/procrastination to interrupt or
delay
Positive mental Health = self 4. Inspiration to others
5. Awareness
Criteria for Positive Mental Health a. Comes with the capacity for change
(Elements of Mental Health)
Contributing Factors of Mental Illness (Filipino
1. Self-governance Society)
- Person acts independently, dependently 1. Biological Influences
or interdependent without losing a. Prenatal, perinatal or neonatal events
autonomy b. Physical health status, nutrition, history of
- Decide for yourself injuries, neuroanatomy
2. Psychological Factors
2. Progress towards growth/ self-realization a. Interactions with parents, siblings, peers
- Willingness to move forwards max. and others with the environment,
Capabilities intelligence quotient, self-concept,
creative
3. Tolerance of uncertainty/ perception of b. Growth & developmental, coping
unknowing mechanism, intelligence & emotional
- Facing uncertainty of life and certainty of quotient, self-concept, parenting styles
death with faith and hope (uncertain) (immediate environment)
- Perceiving the uncertain 3. Sociocultural Factors (external)
a. Family stability, ethnicity, housing, child
4. Reality orientation rearing patterns, economic levels,
- Distinguishing facts from fantasy religion, values & beliefs and safety &
culture
5. Mastery of Environment b. Environment, social & family structures,
-person is competent, effective and creative in cultural practices, values & beliefs
influencing his environment
-coping and adapt

6. Stress Management
Personality Theories
A. Sigmund Freud - PSYCHOANALYSIS (Father of
Psychoanalysis)
I. Exploring the unknown “unconscious”
a. Conscious - things you are aware of
b. Preconscious - something you dig deeper
c. Unconscious
- no easily accessible;unseen
- behavior are caused by thoughts, ideas and
wishes
-immune system of the mind
-Freudian slip of the tongue
II. Putting things down “repression”
- Works as the mind’s immune system threats to:
● Self-esteem
● Comfort
● Pleasure
- Awareness of these threats produce anxiety
- Unconscious protects us from anxiety
- By the unconscious
- Keep disturbing thoughts from
becoming conscious
III. Dreams and Slips
- Unconscious thoughts express themselves in a
distinguished form
- Dream analysis and psychoanalysis
- Best place for clues
- suppressed
- 8. Regression
IV. Mental Protection / Defense Mechanisms
- Defense mechanisms: products of repressions
1. Rationalization
a. - justify something to make it
right
Ex. Not telling the truth as you
don’t want to hurt her
2. Projection
- put feelings onto another
-projecting oneself to another; transfer
what you feel to someone else
-Ex. Saying she hates me, instead of
expressing what is really felt which is “i
hate her”
3. Sublimation
- channeling something unacceptable to
something socially acceptable
-Make something socially acceptable
-Displace emotions into a constructive
-Ex. writing songs, playing a sport to
relieve anger
4.Reaction formation
- making your reaction acceptable
-Therapeutic
-Ex. Instead of saying she’s
fat, you tell her to exercise;
-“plastic”
5. Intellectualization
- separating emotions of a painful event
from the facts; acknowledging facts and
not emotions
-back of scientific basis
>Suppression - conscious >Repression -
unconscious
Ex. insecurities, ambitions, manglibak
6. Displacement
- place anger on someone related to
problem
-ex: dog= less threatening object
- Ma damay ang smaller
7. Denial
- pretending that the problem does not
exist
- habit to relieve anxiety and anger.
- goes back to something
- ex: nail biting, thumb sucking, bed
wetting
V. Structures of Personality
1. ID
- acts with basic INSTINCTS (, inborn dispositions
and animalistic urges; schizophrenic)
- Initiate desires, pleasure seeking, aggression and
social impulse
- OPERATES IN PLEASURE & INSTINCTS​;
avoids painful things schizophrenia
- Playful side
2. SUPER EGO
- Moral ideas learned with the family
- Pride or guilt
- Moral, ethical values and parental
- Mature, care
- Bipolar and depression
 -Solitary play
3. EGO
- Partly conscious and partly unconscious 2. Toddler(1.5-3 yrs)
- Operates regarding to reality principles - Autonomy vs shame and doubt
- Attempts to help ID get what it wants by judging - Act independently
the differences of real and imaginary - Parallel play
- Mature adaptive behavior
- BALANCE 3. Pre-schooler (3-6 yrs)
- Between id & superego - Initiative vs guilt
- satisfy needs according through reality; operated - Self esteem start to develop
according to REALITY - Take action
- “An eye for an eye, a tooth for a tooth” - Associative play

4. School age (6-12 yrs)

VI. Psychosexual Stages - Industry vs inferiority
- Ready to learn new things
- Failure: being no good
1. Oral - Competitive play
a. - Erogenous zone: mouth
b. - 0-18 months 5. Adolescent (12-18 yrs)
c. - Smoke, bad words, nail biting, - Identity vs role confusion
thumb sucking - Think abstractly, conceptualize Identity
d. weaning - Phallic
2. Anal
a. - Erogenous zone: anus 6. Young adult (19-40 yrs)
b. - 18-36 months - Intimacy vs isolation
c. - Control - Develop intimacy
d. - “Retention & expulsion” - Sexually, socially & emotionally
e. - Messy or OCD
f. Potty training 7. Middle adult (45-65 yrs)
g. - Generativity vs Stagnation
3. Phallic - Leave a mark on the world
a. - Identification - Find purpose; concern for people & contribute to
b. - 3-6 years old generation
c. - Electra complex (favor dad) - Failure: selfishness & self absorbed
d. - Oedipus complex (mum)
4. Latency 8. Older adult (65 yrs and above)
a. - Repression of all interests, - Ego Integrity vs despair
socialization, school - Reflection & preparation
b. - 6-puberty (12/14 yo)
5. Genitals C.Harry Sullivan
a. - Sexual reawakening - Self Systems Theory
b. - Puberty-onwards - Personality development in childhood
c. - Adults affection & love reinforcement
d. - settlement - defined personality as behavior that can be
observed than interpersonal relationship
I. Parataxical Integration
- Mutual conditions of intimacy coexiteal
B. Erik Erikson with parataxic distortions
- PSYCHOSOCIAL THEORY - reciprocally reactive to seductions ,
hostile comments, manipulations,
1. Infant (0-18 mos) judgments of inaccuracies
-Trust vs mistrust - Existence of which entails reciprocally
-Needs are met or not reactive
 - “Ping-pong” or “you get me, I get you
3. Needs that move -difficult, dominating,
back”
against others and unkind
II. Paradoxical Distortions
need to control others -Hostility & need to
- Inclinations to show perceptions of others
control others
based on fantasy:
a. Perfect match
b. Soul mate
c. forever

D. Carl Gustav Jung F. Alfred Adler

- Collective unconscious known collectively in the - Individual Psychology
world - Industrial psychology
- Unconscious common to mankind as a whole not - Inferior complex
from experience - Striking for superiority in compensation for feeling
- Shared by everyone: inferior
A.person - Focus on who you want to be in the future
B.anima- men; moodiness, intuition - Conscious care of personality
Animus- women; aggression, veracity I. Self Ideals
C. shadow- parts of a person they don't like - represents the ideal type of person we
- Archetypes, universal primordial want
- Anima animus persona of shadow
- Powerful archetype PERSONA; public personality II. Superiority
- SHADOW; animalistic - we seek to actualize our self ideals
- ANIMA; Feminine archetype for men
- ANIMUS; Masculine archetype for women III. Lifestyles
- all lifestyles are normal; sometimes we
E. Karen Horney are unprepared, unrealistic
- Theory of Basic Neurosis
- Stress (Anxiety & Obsessive Behavior) IV. Inferiority
- Basic neurosis - defective inferiority
- Neurotic needs - only triggers if it is important for striving
- Striking for superiority in compensation for feeling for superiority (money, strengths)
inferior
- Conscious care of personality Standards of Professional Performance
● Inferiority complex
● Goals
● Self- ideals

Neurotic needs

1.Needs that move -needy, clingy

you towards others -seek affirmation and
and seeking acceptance
affirmation and
acceptance

2.Needs that move

you away from others -Create hostility &
and hostility and antisocial behavior
antisocial behavior cold, indifferent, aloof
 Patients Bill of Rights Roles & Functions of a Community Mental Health
1. Appropriate treatment =supportive and least Nurse
restrictive
2. Treatment with written plan ​ ● Primary Role
3. Reasonable explanation ​ - Prevent mental disorders
4. Refuse treatment ​ - Reduce identified cases:
5. Not to participate in experimentation 1. Health promotion (banners)
6. Seclusion or restraint 2. Health protection (bicycle
7. Humane treatment lane)
8. Confidentiality of medical records 3. Disease prevention
9. Access medical records (immunization, exercise)
10. Use of telephone,personal mail,visitors ​ Examples:
11. Be informed of their rights ​ ○ Self-awareness
​ ○ Stress reduction technique
- ​ ○ Nutrient supplementation
​ ○ Family development sessions
● Common lawsuits ​ ○ Education towards positive mental
1. Breach of confidentiality health
2. Defamation of character ​ ○ Promote bonding
- Libel (publishing)
- Slander (verbal,social media) ​ ● Secondary Role
3. Invasion of privacy ​ - interventions, identifying mental health
4. Assault problems
-threatening ​ - Early & reduce the duration &
5. Battery prevalence of illness
-manifest assault ​ Examples:
-physical contact ​ ○ MSE (mental status exam)
6. False imprisonment ​ ○ Prenatal
- use of restraints ​ ○ Crisis intervention
a. Restraints ​ ○ Counselling
- Physical belts ​ ○ Drug test
- Chemical restraints
drugs=sedatives ​ ● Tertiary Role
- medications ie: sedatives) - Rehabilitation
devices that are used to restrain - Minimize residual effects
extremities
- Never to be used as a Examples
punishment or consequence
- Set of physical activities or ​ ○ Self help groups
​ ○ Vocational rehab
chemical devices,restrain
​ ○ Drug rehab
activities if behavior is out of ​ ○ Social Skill training therapy
control or risks physical safety ​ ○ Support groups

b. Seclusion Clinical Nursing Practice

- Confine client into a room alone
- Minimally furnished (promotes Assessment
clients comfort and safety)
- Need physician order - Gather data, mental status exam

Diagnosis

Planning

1. Milieu Management
 a. Behavioral therapy
b. Family therapy Adaptive patterns of behavior
c. Environmental manipulation ● Collection of conceptual, social and practical skills
learned by people to enable them to function in
2. Psychopharmacology their everyday lives
● Includes real life skills (grooming, getting
a. Anxiolytics
dressed, avoiding danger, safe food handling,
b. Psychotropics
following school rules, managing money,
3. Nurse-Client Relationship cleaning, making friends, ability to work, practice
a.Therapeutic communications & relationship social skills and take personal responsibility
● “Making a choice to solve a problem”
- IPR & care provider ● Balance mental perspective
● A person who does not have an adaptive pattern
Interventions of behavior (maladaptive pattern of
behavior) would withdraw
Evaluation ○ Result to passive aggressiveness, self
harm, anger, substance abuse
Standards of Professional Performance
○ Maladaptive daydreaming
● Ethics ■ Caught up in fantasy and no
longer in touch in reality
● Research

● Resource utilization Components/ factors that influence mental health

- Important ingredient for an individual to have
● Quality of practice stable and functioning in its optimum level
- Goal: Achieve balance: not too much sa
● Education, Collegiality, leadership
mga factors
● Professional practice of evaluation 1. Autonomy and independence
- Considers the opinions and wishes of
● Collaboration others but does not allow them to dictate
decisions and behavior
DISCUSSION - Being independent

Mental health 2. Maximization of one’s potential

- Health Definition: WHO definition
- Health is not physical
- Mental health:
- State of emotional, psychological
and social wellness evidenced by
satisfying interpersonal
relationships, effective behavior
and coping
- Way you feel, think and act
- Is not always being away with
reality
- As important as physical health
- Includes emotional, psychological
and social well-being
Mental Illness
- Result of distress, poor coping or biologic
alterations affecting social function
- The person is oriented toward growth
and self-actualization. He or she is not
content with the status quo and
continually strives to grow as a person.
- To achieve optimal growth is to
dream
- Try to risk
- The catch is we can’t hope too
much
- We get frustrated but don’t get
into darkness and loneliness =
bounce back sis
3. Tolerance of life’s uncertainties
- Person can face the challenges of day to
day living with hope and a positive
 outlook despite not knowing what lies
ahead
- Related to maximation
- We don’t know what will happen
in the future
- Ration to uncertainties = adapt
successfully or not
4. Self - esteem
- The person has a realistic awareness of
his or her abilities and limitations.
- Persons dignity
- Knowing who you are
- One factor on how we view
ourselves
- Rooted on his or her limitations
and abilities = balance is
achieved then stability of mental
health
5. Mastery of the environment
- Person can deal with the influence the
environment in a capable, competent and
creative manner
6. Reality orientation
- Person can distinguish the real world
from a dream, fact from fantasy and act
accordingly
- The more involved you are in
fantasy the more difficult it is to
get back in reality.
- The more in touch you are with
reality, you won’t get crazy
7. Stress Management
- The person can tolerate life stresses,
appropriately handle anxiety or grief, and
experience failure without devastation.
He or she uses support from family and
friends to cope with crises, knowing that
the stress will not last forever.
- Important to know your coping
and defense mechanisms
- Learn to process your own issues
and listen to yourself
- Stress is one of the many things
certain in life and stress
management is an important
factor of mental health.
- A support system will help
master all stresses.
APA defines mental disorder or mental illness as a
clinically significant behavioral or psychological syndrome
or pattern that occurs in an individual and that is
associated with present distress (painful symptom) or
disability (impairment in one or more important areas of
functioning) or with a significantly increased risk of
suffering death, pain, disability or an important loss of
freedom
General criteria to diagnose mental disorders
include:
1. Dissatisfaction with one’s characteristic, abilities
and accomplishments
2. Ineffective or satisfying relationships
3. Dissatisfaction with one’s place in the world
4. Ineffective coping
- CRETIERIAS MUST BE must pervasive and
prevalent before you can diagnose yourself to
have mental disorders
- Common denominator: ineffectiveness and
inadequacy is so prevalent that it affects your
functioning
- DSM-IV-TR
- describes all mental disorders, outlining
specific diagnostic criteria for each based
on clinical experiences and research
- All mental health clinicians who diagnose
psychiatric disorders use the DSM-IV-ITR
Purpose of DSM-IV TR (a guide for clinicians):
- To provide a standardized nomenclature
and language for all mental health
professionals
- To present defining characteristics or
symptoms that differentiate specific
diagnoses
- To assist in identifying the underlying
causes of disorders
- If you know the cause, you can
treat
Factors influencing a person’s mental illness:
1. Individual factors:
- Biologic makeup
 - Naay kaliwat mental disorder, in
the future kay naay possibility
maka experience sad ana
- Sense of harmony in life
- Vitality
- Ability to find meaning in life
- Emotional resilience or hardiness
- Flexibility emotionally
- Ex: if smthg does not go your
way, how do you react??
- Spirituality
- Big factor
- Positive identity
- How do you view yourself
2. Interpersonal Factors
- Effective communication
- Talking and listening dapat
- If you cannot communicate, you
can go to out of touch of reality
- Ability to help others and intimacy
- Relationships are important like
the support system
- Balance of separateness and connection
3. Sociocultural factors
- Include a sense of community
- access to adequate resources
- Intolerance of violence
- Support of diversity among people.
Mental Health Nurse
- Focuses on rehabilitation and ways to
minimize residual effects for people who have
encountered mental health problems.
- Ex. social skills training, vocational
rehabilitations, self-help groups
- Focuses on interventions that identify mental
health problem ealy and reduce the duration
and prevalence of mental illness
- A mental health nurse help identify
triggers that causes relapse of specific
conditions
- Okay ra di isud mental facility basta
imanage properly
- Focuses on preventing mental disorders and
reducing identified cases of psychiatric
disorders and disabilities within a population
● Roles of the nurse in the Therapeutic
Relationship (Peplau)
1. Stranger
- Kanang mo smile sa client
2. Surrogate
- Substitute for another as a
parent or a friend or sibling
- Not social or intimate relationship
- Therapeutic relationship ONLY :P
(beginning with a goal and have
an end)
- Build a relationship with a client
and don’t be afraid
- Relationship will cause client to
thrive
- Constantly emphasize regulations
by the facility
- Therapeutic professional rel.-
nurse have a say bc you are in
authority
3. Caregiver
- Help client meet psychosocial
need
- Need to do physical care, employ
touch but do in discretion
(PANANGHID)
- Implementation in problem
solving
- Consider boundaries and have
limits
4. Advocate
- You speak for in behalf of your
client, support client in what
decision he/she makes
- If suicidal di mu support
- Ensure privacy and dignity
(drapes)
- Promote informed consent
- Ensure safety from abuse from
other healthcare
- Be observant to other
members of healthcare team and
report if nay bati
5. Leader
- Offer direction to the client and
the group
- Facilitate the client, tell the client
to take a bath, accompany them
6. Counselor
- advising is non therapeutic
 - walk them through their own - Help their mind think na bisan
emotions and let them see how gubot atleast napay nipabilin na
things are hapsay
- - Help them look at their perspective
7. Resource person ● Psychobiologic Interventions
- Answers questions from client - treatments, medications affect
- Be a source of good information neurochemical
8. Teacher ● Health Teaching
- Health teaching - Promotion of mental health
- Inherent in most aspects of client ● Case Management
care ● Health Promotion and maintenance
- Once a nurse, you’ll always be a
teacher
- Feel confident about knowledge
she has and knows her
limitations
- Equip yourself with new
information

CLINICAL NURSING PRACTICE (ADOPIE)

- standards of psychiatric mental health care:

Assessment
- Core of management
- Get from client when in lucid interval Evaluation
Diagnosis - to know if effective imo interventions
- NANDA - Human being is dynamic and open system
- Analyze data gathered and determine diagnosis - Continuous
Outcome identification - evaluation since if it is not working = improvise
- What do you intend to achieve at the end of the
interaction Standards of professional performance
- Depend on the data you have collected 1. Quality of care
- Help come up with a plan of care - Dapat best jud, if di best why give?
Planning 2. Performance appraisal
- prescribed interventions to attain - Evaluates his or her nursing practice
Implementation - Evaluate oneself if the care you are given
- Implement ang plan what is in the protocol
● Milieu therapy 3. Education
- Important sa mental health - Maintain acquire nursing practice
- Provide a conducive - Be updated to new informations
environment for them to 4. Collegiality
strive emotionally, - Professional development of colleagues
mentally, physically, - Care to community and facility she
socially belongs
5. Ethics
● Self-care activities - In everything you do, put ethics
- Kung baho kaayo, sige kag mug 6. Collaboration
ot - No man is an island
- You are not alone in working to better
the client
 - Work with the healthcare team
7. Research
- Very important part
- What might be effective before, will no
longer be effective now
8. Resource utilization
- Planning client carre
LEGAL CONSIDERATIONS
- Clients receiving mental health care retain all civil
rights afforded to all people except the right to
leave the hospital in the care of involuntary
commitment.
- A client is admitted by protest, wala right
to refuse treatment bc most probably
mag combative or not in his or her mind
- Involuntary committed: clients will
have limited rights
- Voluntary committed : has right to
refuse anything and to leave hospital
the moment you want
- They have the right to refuse treatment, to send
and to receive sealed mail or to refuse visitors
Patients bill of rights
- Any restrictions (mail, visitors, clothing) must be
made by a court of physicians order for a
verifiable documented reasons
- Any restrictions not ordered by the doctor
can be a source of legal liability
- Clients have a right to treatment in the least
restrictive environment appropriate to meet their
needs.
- central to the deinstitutionalization
movement. It means that a client does
not have to be hospitalized if he or she
can be treated in an outpatient setting or
a group home
- client must be free of restraint or
seclusion unless it is necessary
- Restraints
- a set of physical and chemical devices that
are used to restrain the extremities of an
individual whose behavior is out of control and
poses an inherent risk to physical safety. Never
to be used as a punishment or for the
convenience of staff
-physical restraints or visitors
- Seclusions is another type of physical restraint
in which the client is confined in a room from
which he or she is unable to leave
- The room is minimally furnished
In the event of an emergency, restraints or seclusion may
be initiated without an physicians’ order
As soon as possible, but no longer that 1 hour after the
initiation of restraints or seclusions, a qualified staff
member must notify the physician about the individual's
physical and psychological condition and obtain a verbal
or written for the restraint or seclusion
Orders for restraints or seclusion must be reissued by a
physician every 4 hours for adults age 18 and older every
2 hours for children and adolescents ages 9 to 17, and
every hour for children younger than 9 years
An in person evaluation of the individual must be made
by the physician within 4 hours of the initiation of
restraints or seclusion of an adult age 18 or older and
within 2 hours for children and adolescents ages 17 and
younger.
Minimum times for in person reevaluations nby a
physician include 8 hours for individuals ages 18 y.o and
older and 4 hours for indiv 17 below
If an individual is no longer in restraints or
seclusion when an original verbal order expires, the
physician must conduct an in-person evaluation within 24
hours of initiation of the intervention. If ,No need pwede
ra tangtangon.
Nurses are responsible for providing safe, competent,
legal and ethical care to clients and families. Nurses are
expected to meets standards of care, meaning the care
that they provide to clients meets set expectations and is
what any nurse in a similar situation would do.
TORTS
● Wrongful act that results in injury, loss or damage
● May be either unintentional or intentional
○ Unintentional torts
■ Negligence- an unintentional tort
that involves causing harm by
failing to do what a reasonable
and prudent person would do in
similar circumstances
 ■ Malpractice- a type of negligence
that refers specifically to
professionals such as nurses and
physicians.
- Care should be properly
- Meet the set expectations a prudence should do
to avoid liabilities
- Unintentional torts- based on negligence “nag
tinanga”
- Negligence-general worl
- Malpractice-if done by professionals (nurse and
doctor)
Clients or families can file malpractice lawsuits in any
case of injury, loss or death. For a malpractice suit to be
successful:
● Duty: a legally recognized relationship, i.e.
physician to client, nurse to client, existed. The
nurse had a duty to the client, meaning that the
nurse was acting in the capacity of a nurse.
● Breach of duty: the nurse or physician failed to
conform to standards of care, thereby breaching
or failing the existing duty. The nurse did not act
as a reasonable, prudent nurse would have acted
in similar circumstances.
● Injury or damage : the client suffered some types
of loss, damage or injury.
● Causation: the breach of duty was the direct
cause of the loss, damage or injury. In other
words, the loss, damage or injury would not have
occurred if the nurse had acted in a reasonable,
prudent manner.
- No law criminalizes malpractice here in the
Philippines but does not mean we should appear
lenient BUT there is a law criminalizes negligence
- Absent in these elements dapat present tanan,
this case would no hold in matter
- Duty: meet expected standards of care
- Breach of duty: nurse DID NOT ACT as
reasonable nurse
- Injury or damage
- Causation: breach of duty is the cause to
injury
- Ex: some patient fakes their name
- Nurses: know your patients
properly if di nimo makuha kay
help from other caregiver to
avoid giving the wrong
medication
- 4 ELEMENTS SHOULD BE PRESENT TO
BE HELD LIABLE
- Common scenarios: suicide kay the nurse
did not do their obligations
(presumptions)
Intentional torts
- Are voluntary acts that result in harm to the
client
● Assault: involves any action that causes
a person to fear being touched in a way
that is offensive, insulting or physically
injurious without consent
● Battery: involves harmful or
unwarranted contact with a client; actual
harm or injury may or may not have
occured
● False imprisonment: unjustifiable
detention of a client such as
inappropriate use of restraint or seclusion
- INTENTIONAL TORTS:
- Touch is not always therapeutic so you
need to have consent
- Battery and false imprisonment:
- EX: Client is combative and
needs to be restraint or
secluded. Daoat order by
physician para di ka ma held
liable
- IF there is damage and loss to the client,
you can held be liable
3 ELEMENTS OF INTENTIONAL TORTS
- The act was done voluntarily
- Act was substantial factor
- The nurse intended to bring consequences or
injury to the person (client)
Nurses can minimize the risk of lawsuits through safe,
competent nursing care and descriptive, accurate
documentation
STEPS TO AVOID LIABILITY
● Practice within the scope of state laws and nurse
practice act
● Collaborate with colleagues to determine the best
course of action
 ● Use established practice standards to guide
decisions and actions
● Always put the client;s rights and welfare first
● Develop effective interpersonal relationships with
clients and families
● Accurately and thoroughly document all
assessment data, treatments, interventions, and
evaluation of client’s response to care.
- Update yourself with present laws to avoid
lawsuits
- Knowledge wise
- Accurate documentation: reason ngano gi train ta
to not erasures and superimpositions kay one of
your defense if naay mo complain against you
kay gi accurately and descriptively document
nimo such as suidice
- To minimize lawsuits
- STEPS TO AVOID LIABILITY:
- Don't hesitate to ask to avoid any risk of
negligence act
- 3rd:
- Dont based on instincts or kung
unsa naandan sa balay
- Based your care from evidenced
based researches
- SAFE COMPETENT ETHICAL AND
LEGAL
- 4TH
- Primary responsibilities is
towards your client
ETHICAL ISSUES
- Ethics is a branch of philosophy that deals with
values of human conduct related to the rightness
or wrongness of actions and to the goodness and
badness of the motives and ends of such actions.
ETHICAL THEORIES:
● Utilitarianism- bases decisions on the greatest
good for the greatest number. Decisions based on
utilitarianism consider which action would
produce the greatest benefit for the most people.
● Deontology- decisions should be based on
whether or not an action is morally right with no
regard for the result or consequences.
- UTILITARIANISM:
- The most ethical decision is the decision
will benefit the greatest good to the
greatest number
- “END JUSTIFIES THE MEANS”
- Rightness and wrongness of the decision
depends on the outcome dapat maka
benefit tanan
- DEONTOLOGY:
- Opposite sa utilitarianism
- Regardless whether the outcome is good
or bad or wala naka benefit tanan basta
sakto imoha gi buhat
- MEANS: MORAL
PRINCIPLE USED AS GUIDES FOR DECISIONS MAKING
IN DEONTOLOGY
● Autonomy- person’s right to self-determination
and independence
● Beneficence- one’s duty to benefit or to promote
good for others
● Nonmaleficence- to do no harm to others either
intentionally or unintentionally
● Justice- fairness, treat all people fairly and
equally without regard for social or economic
status, race, sex, marital status, religion, ethinicty
or cultural beliefs
● Veracity- duty to be honest or truthful
● Fidelity- obligation to honor commitments and
contracts
AUTONOMY:
- Even if your client is admitted in the mental
institution, naa gihapon sil arights
- Choose for himself
- Right to refuse treatment but maybe overridden
by utilitarianism when they already poses danger
to others
JUSTICE
- Do not show favoritism
- Fair
- You can be friends but there should be
demarcation line
- Be guided by the boundaries of the therapeutic
relationships
- One phone call a day then hatagan nimo ug
passes sa uban
- Injustice act
- Don't be manipulated by your client
VERACITY
- To tell the truth or lie (dilemma)
- Not be applied when chika2 lang
- Ex: your client is joking na nag harm sha
to others but your should not apply
veracity
 - Do not divulge any informations
FIDELITY
- Stay true to your contract bahala kapoy na
- Stay committed to your profession
- Stay loyal
All these principles have meaning in healthcare. The
nurse respects the client’s autonomy through patients
right, informed consent
ETHICAL DILEMMA
- A situation in which ethical principles conflict or
when there is no clear course of action in a given
situation.
- no one ans in ethical dilemma
- No sanction ethical dilemma but ma conscieca ka
- Look into your values
- SELF AWARENESS IS IMPORTANT to know you
limitations and in deciding your ethical dilemma
- Scenarios:
- Not taking meds
- Deontology: autonomy
- BUT THIS CLIENT SIGE REFUSE
MEDICATION and has now become
combative
- Utilitarianism or deontology
(BENEFICENCE)
- TO DETERMINE RIGHT THINGS
TO HIMSELF
- Initial reaction: separate client
and inform the psychiatrist and
ask PRN order for a drug to let
the client calm down
- Seclusion will be last
resort and follow
protocols
- If no PRN order, call the
psychiatrist so you'll be given an
order (ex. tranquilizer)
- If refusing for a long time, secure
ahead of time for medication to
calm him/her
- Client has already built rapport with
nurse, asks to add on FB
- DEONTOLOGY: FIDELITY
- NI GAWAS NA SHA RON NYA ADD si
christa sa FB
- Act in private capacity
- Dilemma as a private indiv
and decide in your capacity
- Friends in FB already but client is
readmitted and his nurse again or people
you know will be your patient
- FIDELITY: STAY WITHIN THE
BOUNDS
- JUSTICE: FAIRNESS
SELF AWARENESS
- OBLIGATED AND is a MUST TO ATTEND TO
SELF AWARENESS
- Examine the things you stand for
- Johari window
- Picture scenarios before it happens
POINTS TO CONSIDER WHEN CONFRONTING ETHICAL
DILEMMAS
- Talk to colleagues or seek professional
supervision
- Spend time thinking about ethical issues and
determine what your values and beliefs are
regarding situations before they occur.
- Be willing to discuss ethical concerns with
colleagues or managers. Being silent is condoning
the behavior.
- Talk to colleagues and not keep it
yourself
- Think about possible ethical scenarios
and how will you respond to it para di ka
ma shock
- Be silent is condoning the behavior
- Things to anticipate:
- Client will be intimate to you
- Remind client to
maintain professional
relationship and no touch
unless if necessary or
with consent
- Remind client with clear
limits while playing each
other’s roles: client and
nurse
 2. Patient centered
Concept 2 Therapeutic Intervention
3. Primary prevention
Standards of Psychiatric Mental Health Clinical Nursing
Practice 4. Treatment

Standards 5. Rehabilitation ➔
- Care is adapted to unique needs
- authoritative statements in nursing to describe
RESPONSIBILITIES in which the nurse is accountable for 1. Self Awareness
standards of professional performance -Understanding of self
- Framework for the evaluation of practice -nurses use aspects of personality, experiences,
- Provides direction for practice values, feelings, behavior, intelligence, needs, skills,
adaptation styles, communication techniques &
Standards of Professional Performance perception to establish therapeutic relation with
clients (grow, heal, change)
● Quality of care -therapeutic use of self as a tool to help client
● Performance appraisal A. change, grow , heal
● Education B. Achieve adequate & ​satisfactory adaptation​with
● Collegiality the self & environment
● Ethics
● Collaboration
● Research
● Research utilization 2. Nurse-Client Relationship
- Series of interaction between the nurse and client,
Psychiatric Nursing Process Goals where the nurse assists the client to achieve a
positive behavioral change
1. Goal directed (action that facilitates health) - Accepts clients’ feelings of insecurity & anxiety
(cornerstone)
Nursing Process - Understanding clients irrational feelings, system
activity
A​ssessment - Active listening
- ongoing assessment -Therapeutic nurse cares through following
- initial client assessment standards of the Nursing Process & Nursing Practice
- assess Mental status assessment (continue because new -to achieve a positive behavioral change of nursing
problems may arise) care relationship: goal oriented focused on client
needs, planned, time limited, professional
D​iagnosis
- identification of problems​based on conclusion of dynamics ~in trusting patients with maladaptive behaviors,
evident in verbalization & behaviors pharmacologic regimen is the golden standard
- based on the nervous system
O​utcome identification ~​Nervous system is affected (medications are important for
- specifies an adaptive behavior​to replace one that's maladaptive behaviors)
dysfunctional ~Capital “c: = Compliance
- Specific​behavior (identify non acceptable behavior &
change to an acceptable behavior)
- more realistic: write a lot of strengths, abilities or positive
qualities (but do not make problems on your own)

P​lanning & ​Intervention

- NCP, progress notes, shift records

E​valuation
- client progress, discharge summaries
- Process recordings Conceptual framework (above)

Paradigm of Therapeutic Psychiatric Management

1. Facilitates health promotion (care is adopted to clients

unique needs)
 - other TASK: determine why one is admitted, build rapport,
3. Psychotherapeutic management​model of care (Koldjeski establish therapeutic environment, assessment
1979)
C. Working Phase
i. INTERACTIVE THERAPY
- longest & most productive phase
​ - crisis intervention, individual psychotherapy, group -M​ AJOR TASK: identification for action & resolution of
therapy, psychotherapy, couples OR family therapy, patients problem
psychoanalysis, hypnotherapy, attitude therapy, - other TASK: planning & implementation, develop positive
creative therapy, behavior modification coping behavior, exploring
​ - To achieve a positive behavioral change
D. Termination Phase
b. Milieu Therapy
- gradual weaning process
i. ALTERNATIVE THERAPY - feelings of anxiety, fear and loss
- recognizd in orientation phase
- behavior modification, desensitization, sensory stimulation - MAJOR TASK: assist the client to review what was
therapy, adjunctive management therapy, remotivation learned and transfer that learning to his relationship
with others.
c. Psychopharmacology When to terminate:
● Accomplished goals
● Psychotropic drugs ● Client is emotionally stable
● Other Somatic therapies like: ● Client exhibits greater independence
○ ECT
○ BRAIN THERAPY Nurse-Client Relationship
○ INSULIN SHOCK THERAPY
- Series of interaction between the nurse & the client in
Compliance is important which the nurse assists the client to achieve a positive
behavioral change
Base of ▲ - Introduced by Hildegard Peplau
- “Interpersonal Relationship in Nursing”
Base or foundation of therapy Treats underlying
psychological conditions with client to create effective Characteristics of Nurse-Client Relationship
nurse-patient relationship Somatic therapies
- goal directed
- ECT (electro convulsive therapy), brain surgery, insulin - focus on needs of patient
shock therapy - planned
- time limited
Drugs / Psychotropics - professional

- Interpersonal relationships in nursing Elements of Nurse-Client Relationship

Phases of Nurse-Client Relationship ● T​rust

● R​apport
A. Pre-interaction Phase ● U​nconditional positive regard
● S​etting limits
- When nurse is assigned to a client ● T​herapeutic communication
- begins when nurse is assigned to patients
- MAJOR TASK: develop self-awareness Hildegard Peplau
- other TASK: data gathering, plan for first interaction
- inform the patient of termination; there is an end to an - Introduced the concept of nurse-client relationship
interaction to promote independence
D. Termination Phase
B. Orientation Phase
- gradual weaning process
- begins when nurse & client interact for the first time - involves feeling of anxiety, fear & loss - recognized in the
- parameters are set orientation phase
- nurse knows about the patient/ begins to
know about the patients
- MAJOR TASK: develop a mutually acceptable contract
-M​ AJOR TASK: assist patient in reviewing what they -Preoccupied with crisis and can’t do ADL
learned and transfer his learnings to his relationship anymore
with others - No longer in touch with reality
4. Attempts to reorganize
Whent to terminate: - Mobilizes person’s coping mechanisms

CRISIS INTERVENTIONS:

Crisis Intervention ● Entering the life situations of individual, family, group

and community to:
- an interruption of equilibrium ○ Help mobilize resources
- crisis= coping is ineffective to meet the demand of a ○ Decrease effects of crisis producing stress
situation ● GOAL: help clients obtain OLOF
- examples: moving to environment, breakups, injury, loss of
a loved one, gender identity, family problems, floods,
disaster
- Can be serious or manageable PRIMARY ROLES OF NURSE IN CRISIS INTERVENTION:
- A way of entering into a life situation of an individual, family,
group or community to: ● Active - nurse does it
● Mobilize their resources ● Directive - client does it
● Decrease effects of crisis inducing stress ● Supportive - nurse pushes client to do it
Goal​: to enable client to develop optimal level of functioning
Primary role​of nurse in CI

TYPES OF CRISIS: BALANCING FACTORS:

1. Maturation/ developmental crisis ● Realistic perception of event

- Expected, predictable, internally moved
- No relation to psychosexual stage
2. situational/ accidental crisis
- Unexpected, sudden, unpredictable,
externally moved
- Car accidents, loss of a job, death of a loved
one, severe mental illness
3. social/ adventitious crisis
- Act of nature
- Earthquakes, floods, fire
● Adequate coping mechanism
● Adequate situational support
- if you don't have all the 3 then crisis can be tackled but
there is a degree/ duration of resolution
- 3/3= resolution time is faster
CRISIS METHODS

1. Crisis group: self-awareness group, short-term, 4-6

sessions, support
CHARACTERISTICS OF CRISIS STATE 2. Family crisis: weeks for children and adolescents
3. Suicide prevention and CI counselling centers:
- Highly individualized telephone hotlines 24 hours
- Up to the patient if he can cope 4. Mental health CI services- hospital related services
- If 2 siblings lost their father, pain felt will not
be the same
- 4-6 weeks (problematic if>6 weeks)
- Person affected becomes passive and submissive Common Problems affecting NCR
- Affects a person's support system
1. Transference

- Development of an emotional attitude of the patient either​

PHASES OF CRISIS: positive or negative towards the nurse
Example: client looks up to the nurse as a mother
1. Denial figure
- Individual initial reaction; why me?
2. Increased tension 2. Countertransference
- Recognizes crisis but continues ADL
3. Disorganization ​ - Transference as ​experienced by the nurse
​ - Bias may happen
 Example: nurse remembers the client similar ●
to someone they know
- According to Sigmund freud, personality consist of: ●

​ ● Id​- the primitive instincts and energies underlying Types of Crisis

all psychic activities (child)
​ ● Ego​- conscious part which controls thoughts and ● Active, Directive & Supportive
behavior (self)
​ ● Superego​- the conscience (parent) ○ the nurse works with and assist the client together with the
​ - During childhood, development occurs in 5 significant others
psychosexual stages (Oral, Anal, Phallic, Latency,
Genitals) ○ Active - difficult technique
​ - Deviation in behavior result from unsuccessful task
accomplishment during early developmental stages Maturational/Developmental crisis

○○ ​ ○ expected, predictable, internally motivated

​ ○ ex. growth, parenthood, pregnancy
interruption in the steady state or equilibrium of a person, Situational/Accidental crisis
family or group ​ ○ unexpected, unpredictable, externally motivated
​ ○ Ex. Car accident, job loss, death
Occurs when an individual's coping mechanism is ineffective Adventitious/Social crisis
to meet the demands of situation ​ ○ due to acts of nature

1. Cope well Balancing factors

2. Fail to cope
(can be resolved if majority 2⁄3 is present)
- Must be present to recover from crisis 1. Realistic
perception of the event
Eric Lindemann 2. Adequate coping mechanism
3. Adequate situational support
- Father of crisis theory
Crisis Modes/ Methods
● Psychoanalysis ● ● Crisis group
○ use of group processes, short term
● Sigmund freud: Father of Psychoanalytic Theory 4-6 sessions, provide support &
personality consists of encouragement ● Family crisis counseling
○ ID ○ entire family, last 6 week (children & adolescents)
■ Primitive extinct and energies
underlying all psychic activities ​ ● Suicide prevention and CI counselling centers
○ EGO ○ 24 hrs telephone hotline
■ Conscious part, controlling thoughts ​ ● Mental health CI services
and behaviors ○ community mental health center, outreach
○ SUPEREGO programs, mobile crisis units to service, homebound
■ Conscience geriatrics
● Deviations of behavior due to unsuccessful task
accomplishments during earlier developmental
stages Behavior Modification
● Residuals of personality
● Behavior is motivated by anxiety which is the - based on testing one hypothesis which may lead to
cornerstone of psychopathology another which must also be tested
● Understanding psychosexual stages of childhood,
provides framework for nurses to understand adult ​ - Therapies can use several techniques
behaviors The therapist will use ​5 step approach:
1. Assess for signs of symptoms of
highly individualized behavioral dysfunction using direct
Lasts for 4-6 weeks (more than depression) observation (eg. suicidal ideations)
Person affected becomes submissive and passive 2. Discuss treatment goals with the client
Affects a person's support system focusing on specific behaviors that needs
changing
Individual Theories
 3. Alter that conditions that either promote or
minimize these behaviors
4. Alters the environment to effect changes in
behavior (Milieu)
5. Observe, document and analyze any
continue the treatment or develop alternative options.
Several Techniques to change behavior:
- May overlap
1. Systematic desensitization
- learns ​relaxation techniques​and new
behaviors to reduce anxiety
- Learns to tolerate increasing amounts of
anxiety
- induce anxiety progressively
2. Graded exposure
- Gradually makes contact​with source of
anxiety
- learns anxiety producing object is harmless
- eventually anxiety is tolerable or no longer
present
- Object will no longer arouse anxiety
3. Social skills training
- Rewards for social behaviors
- Group role playing remodelling to teach
social skills
- Client completes homework assignments
before sessions to practice and reinforce
desirable behaviors
- consequences before exhibiting undesirable
behavior
4. Aversion therapy
- unpleasant and undesired stimuli are given
simultaneously so client associated the
underside stimulus ​to the unpleasant one
thus discontinuing the obsessed undesirable
behavior
- Eg. alcohol
5. Thought stopping
- learns to stop saying such thoughts by
saying “Stop” and then focusing attention
achieving calmness and muscle relaxation
- Help client break the habit of fear inducing
anticipatory thoughts by focusing attention
on achieving calmness and muscle
relaxation
- Ex: doesn't want to go on duty but tells
themselves that absence=extension, so
goes on duty
6. Flooding
- therapist ​rewards the client only for social
behavior
- Aka “Implosion/Implosive therapy” rapid
relief from phobias
- direct exposure to anxiety producing
situation
- Use group role playing, work assignments &
modeling to teach social skills
- However it assumes that:
1. Anxiety & panic cant persist
2. Confrontation helps clients
overcome
7. Response prevention
- child learns to tolerate noxious stimuli
- Therapist ask clients to​hesitate briefly before
responding to noxious stimuli
- Client is rewarded for delaying for the
- characteristic response
- Clients learns to tolerate noxious stimuli w/o
restoring the characteristics of maladaptive behavior
8. Token economy
- provides a ​token for doing acceptable behavior
exhibited
- Client learns acceptable behavior overtime
- Give a list of desirable behaviors to a stimulus with
consequences of maladaptive behaviors
- Awards for desirable behaviors
- Learns accepted behavior overtime
9. Thought twitching
- Replace fear with competent self-instructions
- Entertain positive things rather than unpleasant ones
- substitute positive thoughts for fear inducing ones
- behavioral changes that occur & either acceptable
behaviors to a stimulus
Various Therapies:
1. Individual psychotherapy
- therapist establishes a relationship in an a attempt to
understand client intrapsychic conflicts
- Therapist sits on a chair and listens to a
client ventilating their thoughts and feelings
in a reclining chair and process the thought
after
- Major Techniques:
1. Supportive therapy
- strengthens client inner
defenses
2. Analytic psychotherapy
- uses dream interpretation,
free association and
transference distortions to
uncover intra psychic
conflicts
*Psychotherapy
- best for stress-related problems
- Capacity to engage and work through treatment process
(long term therapy)
- most effective when clients problem is stress related

- An approach where clients emotional conflicts are 6. Play therapy

addressed through a psychological means
- enables the client to experience intense emotional
2. Group therapy in a safe environment with the use of play
- Environment must suit particular play
- based on the premises that group influence is - Safe environment
powerful vehicle for structuring and reinforcing
behavior 7. Attitude therapy
- 4-10 clients experiencing same emotional problems
- Emphasizes the examination of interpersonal - “there is no such a thing as hopelessly ill mental
relationship ​guided by a psychotherapist clients” Dr. Falsom
- Includes sensory stimulation & remotivatio aims to - Kinds of attitude therapy:
alter relationships within the family and change the 1. Kind firmness
problematic behavior of one or more members a. dependent client, depressed​
- May be short or long term clients who are encouraged to work
- Useful in treating addictions and refused, therapist is firm
- Similar to peer pressure 2. Active friendliness
- “Homogenous group” have similar situations a. avoidant personality,
- schizophrenia pt,schizoid, socially
withdrawn
3.Psychodrama (creative therapy) b. Therapist: Give them a reason to
want to be active and not withdraw
- structured and controlled dramatization​of client’s 3. Passive friendliness
problems a. Paranoid
- Goal: dramatize emotional problems b. people that have distrust with
others
4.Hypnotherapy c. Therapist needs to make it very
obvious they are always available
- Guided hypnosis or trance-like focus and d. Pick an activity for them to engage
concentration achieved with the help of a clinical in that they will be immediately
hypnotherapist successful in
- Various methods for transfer state where becomes 4. No demand
submissive to instructions a. Violent
- Not effective if client has strong mind b. When they get out of control the
therapist does nothing but just
come back to them later
5. Matter of act
5.Milieu Therapy a. anti social, narcissistic, manipulative
b. Therapist has to state and stick to
- Managing the environment to effect a positive what they say and NOT deviate
behavioral change from what they say
- refers to environment that facilitates psychological c.
restoration and maintains physical integrity 6. Watchfulness
- Use of total environment a. suicidal
- therapeutic modality which involves various methods 7. Indulgence
and techniques to induce a​trance state a. severely depressed
- - Patient becomes submissive to instruction
- Elements to create therapeutic Mileu: Dr. Bruno 8 Alternative and complementary therapy
bettelheim, 1948
1. Safety=free from danger - Alternative medicine
2. Structure= “lagda”, rules and regulations, - includes therapies used in place of
schedule conventional treatment such as
3. Norms= expectations of behavior (privacy, homeopathic medicine
nonviolence, acceptance) a. Complementary therapy
4. Firm setting= clear and enforceable - Used with conventional practices
limitation of behavior - Homeopathic + naturopathic
5. Balance= dependence and independence b. Complementary medicine
- Used WITH conventional practices
- St. Johns for depression
 -Nutrition therapy, yoga, taichi, medication, ● memory loss
acupuncture, remedial massage ● Apnea
- Energy Biofield Therapies ● Headache
​ - intended to affect energy fields believed to ● Fracture
penetrate the body such therapeutic touch
​ - Traditional Chinese herbal medicine NSG RESPONSIBILITIES:
​ ❖ Biologically based therapies - uses substances
found in nature such as herbs, food and vitamins - Client teaching
​ ❖ Manipulative body based - manipulation or - NPO (4HRS)
movement of one or more parts of the body - Voiding
(therapeutic massage and chiropractic massage) - Remove jewelry and dentures
​ ❖ Reiki - universal life healing (Japanese) - General anesthesia
- Void before procedure
9. Family therapy - Signed informed consent
- Inform use of anesthesia
- conventional treatment - Loose fitting clothing
- Homeopathic and naturopathic medicine in western - Safety
culture
- E.g: POST ECT
- Nutritional therapy
- tai chi restorative physical exercises, - Vital signs q 15mins for 1 hour
acupuncture, remedial massage - Main effect: mild forgetfulness & severe confusion
- Mind body intervention - Reorient to time, date & place
- meditation, prayer
- mental healing INSULIN SHOCK THERAPY

10. Creative therapy - 10-20 units of regular insulin until hypoglycemic

- Art, psychodrama, music, dance, play
​ -
11. Somatic therapies​(psychopharmacology)
- Goes into the body
- Electroconvulsive therapy
- unilateral or bilateral electrodes are applied
to clients temples to pass approximately
70-150 volts of electricity​at about 0.5- 2
seconds through the brain, to ​endure grand
mal seizure
- 6-12 treatments are necessary to produce a
therapeutic effect
- Effective seizure induced: interval of 48
hours for each treatment is necessary
- Tonic- clonic=seizure
- They are in danger of malnutrition
- Needs signed informed consent
Indications:
- severe depression with no response to
antidepressants
- Mania
- Catatonic schizophrenia
shock
- Warmth should be provided
AFTER: encourage to eat, assist to the shower and
observe for 24 hours
PSYCHOPHARMACOLOGY
- Important for treating many mental illnesses
- Psychotropic agents refers to drugs really used
- Adjunct medicine is used with psychotropic agents
- “Corollary” of the same function
Principles of psychopharmacology:
(guides the use of medications)
1. Effect on target symptom
2. Adequate dosage for sufficient time
3. Lowest dose needed for maintenance
4. Lowest dose for elderly
5. Tapering rather than abrupt cessation to
avoid rebound or withdrawal
6. Follow up care
7. Simplify the regimen for increase
compliance

Meds given prior to ECT: 1. Antipsychotics/ Neuroleptics

- Common use: schizophrenia
● Atropine sulfate​- decrease secretions - Ex: haloperidol
● Anectine / Succin ​- promote muscle relaxation
● Methohexital sodium (Brevital) -​anesthetic TYPES:
Common complications:
 a. Conventional- traditional (increase S/E) 2. Selective Serotonin Reuptake Inhibitor (SSRI)
- Increase risk EPS - Ex: fluoxetine (prozac), citalopram (celexa)
- Dopamine blocket 3. Monoamine oxidase inhibitor
b. Atypical - serotonin - Ex: phenelzine
- Dopamine blocker - Report headache - hypertensive crises
c. New generation - Avoid tyramine food (avocado, banana,
● decrease delusions, hallucinations and looseness of chicken, soy sauce)
association - 2 to 3 wks for effect
● Take after meals
● Report if sore throat and avoid exposure to sunlight C. Antimanic/Mood stabilizer

NEURO - Increase fluid to 3L/day

- Sodium intake to 3g/day
● Assess for akathisia “ants in pants” - Avoid increase perspiration
● Observe for tardive dyskinesia - Check bp, hypo
○ Tongue twitch, lip smacking - Check HR, arrhythmias
● CBC for leukopenia - more prone to infection - Monitor for lithium toxicity (antidote- mannitol)
● Assess for pseudoparkinsonism - shuffling gait,
hypersalivation, tremors in hands and feet Reduces mood swings
● Monitor temp
Example: lithium carbonate
Neuroleptic Malignant Syndrome
- 10 to 14 days before effect
● Acute dystonic syndrome - Supplements
● Assess for acute dystonic nons: decrease/loss of - MDT= multidrug therapy (adjunct) for best
expected muscle tone therapeutic effect
● Dry mouth: ice chips - Antipsychotic given for 1st 2wks
● photosensitivity - sunblock, sunglasses - Manage acute mania until lithium tons
- Range: 0.5 - 1.5 meq/L ; 0.6 - 1.2 mcg/L lithium
Adjunct Meds level

1. Antiparkinsonism (w/ antipsychotic) 1. Anticonvulsant

2. Anticonvulsants (antimanic) - decrease mood swings
and manic activity - Adjunct to antimanic
3. Antihistamines - Decrease hypersensitivity
- Control convulsions
- Monitor dry mouth, constipation, urinary retention,
blurry vision
A. Antiparkinsonism
D. Anti Anxiety/ Anxiolytics/ Hypnosedative/ Minor
Types: Tranquilizer

1. Dopaminergic drugs - Anxiety disorder (ex: Diazepam (valium), alprazolam

● Amantadine, levodopa, carbidopa (xanax))
2. Anticholinergic drugs - Muscle relaxant, decrease anxiety and increase
● Trihexyphenidyl sleep
- No alcohol, driving and caffeine
Interventions: - Incompatible with other drugs or toxic effect

● Muscles becomes stiff, pill rolling tremors E. Stimulant

● Best taken after meals
● Avoid driving (d/f blurred vision)
● Check BP may cause hypotension
B. Antidepressant/ Mood Elevator
1. Tricyclic Antidepressants (TCA)
- Ex: imipramine
- To increase appetite and sleep
- Effects 2-3 weeks later
- Attention deficit hyperactivity disorder
- ADHD, residual, ADD in adults, narcolepsy
- Release of NTS: interaction with serotonin and
dopamine to enhance it
- Ex: dopamine
- Dextroamphetamine (adderall): dependence
- s/s nausea, anorexia, irritability
- Patient teaching: no caffeine, no sugar, no chocolate
CULTURAL (wa ko kasabot unsay sumpay kamoy adjust
pls)

● Ethnic background influences some response to

psychotropic meds: may affect compliance
● Ex: upororemmision of symptoms, stop taking drugs
(filipino)
● Ex: african american: rapid dependence, response,
and increase risk for S/E
● Asians: slow metabolism, low doses
● Hispanics: low dose of antidepressant
● Asians and african american: decrease lithium

SELF (wako kasabot unsay sumpay)

● Mental illness as having remissions and

exacerbations like physical illness -------------------------------
● Remaining open to new ideas that may lead to future
breakthroughs Insulin shock therapy
● Patch Adams (?????)
● Understand that meds noncompliance is often part - induction of hypoglycemia shock at
of illness.. Kayat anig agi oi wa jud ko kasabot
muscles

- Starts with a dose at 10-20 units of regular

insulin

- Increase daily by 5-10 units (until

hypoglycemia shock is induced)

Nursing responsibilities​​after 1. eat after

2. Assist to shower and put on clothes 3. Monitor for 24hrs

4. Prevent falling temperature

5. Prepare IVF glucose solution

● Forgetfulness and Confusion

Responsibilities:

- important in the treatment of many mental illnesses

6. explain

7. Take vital signs

1. NPO at least 4 hrs

● Psychotropic agents
● Adjunct medication​( meds given addition to another) ​ ○ PISA Syndrome
​ ○ Neuroleptic malignant syndrome
● Supplements ​ ○ Tardive dyskinesia
Atypical
Principles of psychopharmacology:

(guides the use of medications)

○○
8. Effect on target symptom
9. Adequate dosage for sufficient time Weight gain Agranulocytosis - clozaril
10. Lowest dose needed for maintenance
11. Lowest dose for elderly ■ Prone to infection
12. Tapering rather than abrupt cessation to
avoid rebound or withdrawal
13. Follow up care
14. Simplify the regimen for increase 1. Antipsychotic / Neuroleptic / Major
compliance
​ - Common indication​: schizophrenia Tranquilizers
​ - Purpose:
- decrease delusions, hallucinations and looseness Responsibilities:
of association
Side Effects:
3. Monitor elevated temp and muscle rigidity & hypotension
(neuroleptic malignant syndrome) ● Typical ○

4. Assess for akathisia (motor restlessness) & intense need ○○

to move
○○○
5. Assess for tardive dyskinesia (tongue twitching, lip
smacking, involuntary movement) Haloperidol (Halool) Fluphenazine

6. Check CBC for leukopenia Chlorpromazine (Thorazine)

7. Assess for pseudoparkinson - ●

extrapyramidal symptoms (tremors, ●

shuffling Dopaminergic Drugs

8. Assess for acute dystonic reactions ​ ○ Amantadine (Symmetrel)

​ ○ Levodopa - Carbidopa
(intermittent / sustained spasmodic (Sinemet)
Anticholinergic
involuntary contractions) ​ ○ Trinex Pyridyl
​ ○ Biperiden - Hydrochloride
9. Ice chips, mint for dry mouth ​ ○ Benztropine Mesylate
​ ○ Benadryl
10. Photosensitivity - sunscreen, sunglasses Adjunct meds: Dopaminergic drugs

3 types: 2.

● Conventional Considerations:

● ​ ● Compliance
​ ● Decrease sugar and caloric intake
​ ○ Extrapyramidal side effects ​ ● Clotazil
​ ○ Pseudoparkinsonism Antiparkinson agent
​ ○ Dystonia ​ ● Adjunct Medication
​ ○ Akathisia ​ ● given with all psychotropic agents
​ ○ Anticholinergic effects
 ​ ● Muscles become less shift, ● Anorexia
decreases pill rolling tremors
2 Types: ● Polyurea ● Fatigue

Responsibilities:

○ Examples: ○ ● mannitol (diuretic) given at toxicity

○ ● Monitor lithium toxicity (0.6 - 1.2 mEq/L) ● Increase sodium

intake (3g/day) + fluid
traditional with side effects dopamine blocker
intake (3L/day)
More s/e
● Avoid activities that increase perspiration ● antipsychotic is
● Atypical administered during 1st 2

○ less SE weeks to manage the acute symptoms of

○ dopamine and serotonin blocker ● New generation mania anti lithium takes effect

Adjunct medications: ● Check BP for hypotension

1. Antiparkinsonism (w/ antipsychotic) 2. Anticonvulsant ● Monitor HR (causes cardiac arrhythmias) ● Reduce mood
(Antimanic) swings

● Typical (More S/E) ● Takes 10-14 days before therapeutic effect ● Monitor
nausea, anorexia, abdominal

cramps, vomiting
● Atypical (Less S/E)
Normal serum level:

● 0.5 - 1.5mEq/L ● 0.6 - 1.2 mEq/L

○○
5. Anxiolytics/ hypo sedative/ anti anxiety/
Clozapine (Ilozazol) Olanzapine (Zyprexa)
Minor Tranquilizers

● for anxiety
1. Best taken after meals
2. Report sore throat and avoid sun exposure ● Given as a muscle relaxant ● Avoid alcohol/ caffeine

Motor retardation ● Given before meals - food in stomach delays absorption

Rigidity ● Driving precaution

Hypersalivation ● ● Administer separately -

● Anticholinergic incompatible with any drug

Example: ● Examples:

● Lithium carbonate ○ Diazepam

Side Effects: ○ Oxazepam

● Abdominal Cramps ● Nausea ○ Alprazolam (Xanax)

● Diarrhea ● Side Effects:

 ​ ○ tolerance / dependence ​ ● Indication​: bipolar disorder
​ ○ Drowsiness ​ ● Decreases the release of epinephrine
​ ○ Sedation
​ ○ Poor concentration 1. 2.
​ ○ Impaired memory
​ ○ Clouded sensorium
6. Anticonvulsants
​ ○ (adjuncts to mood stabilizers) 7. Antidepressants / mood elevator
​ ○ Control convulsions, seizures,
tremors A. TCA-tricyclicantidepressants
​ ○ Decreases hyperactivity
Examples: ​ ● given after meals
​ ○ Valproate ​ ● Therapeutic effects become
​ ○ Carbamazepine evident after 2-3 weeks of
​ ○ Lamotrigine intake
Responsibilities: ​ ● For increase appetite and
Increase fluid intake adequate sleep
Monitor for dry mouth, constipation, distention, blurry ​ ● Example:​Imipramine
of vision, urinary distention (Torranil) and amitriptyline (Elavil)
B. SSRI(selectiveserotonin reuptake inhibitor)
Responsibilities: ​ ○ Example​: Fluoxetine (Prozac), Citalopram
(Celexia), Flusoxamine (Lurox)
​ ● muscle becomes stiff ​ ○ Side Effects:
​ ● Decrease rolling tremors ■ Anxiety
​ ● Do not drive (Drug causes blurring ■ Agitation
of visions) ■ Akathisia
​ ● Best after meals ■ Nausea
​ ● Check BP (may cause hypotension) ■ Insomnia
C. MAOIs(monoamineoxidase inhibitor)
3. Stimulant drugs
● report headache
​ ○ Causes release of neurotransmitters
​ ○ indication​: ADHD attention deficit hyperactivity ○ hypertensive crisis
disorder, Residual PDD, Narcolepsy
​ ○ Examples: ​ ● Avoid tyramine containing food (avocado, banana,
cheddar, soy sauce, preserved food)
​ ● Takes 2-3 weeks before effects
​ ● 2-3 weeks interval to shift to another
■■■ antidepressants
​ ● Check vital signs
○ SE: ​ ● Monitor and record

■ ● Examples:​Isocarboxazid, Tranylcypromine, Phenelzine

methylphenidate (ritalin) Palmolein Dextroamphetamine

● Cough and colds medication

anorexia, weight loss,

nausea, irritability

○ Patient teaching:

■ avoid caffeine, sugar,

chocolate
■ Take after meal
■ Long term use can cause DISCUSSION NOTES :
dependency
4. Antimanic / Mood stabilizer Nurse client relationship
 - A series of interaction between the nurse and the
patient in which the nurse assists the patient to
achieve a positive behavioral change
- Hildergard peplau -introduced the concept of NPR in
her book
Characteristics of Nurse-Client Relationship
- goal directed
- focus on needs of patient
- planned
- time limited
- professional
- springboard
- Nurse acts as a catalyst
- Nurse assist the patient to achieve a positive
behavioral change
- Focus on the needs of the patient
Basic elements of a therapeutic np relationst
● Trust
● Rapport
● Unconditional positive regard
● Setting limits
● Therapeutic communication
- Rules needs to be followed
Common Problem Encountered while in a N-P
Relationship
● Transference
-development of an emotional attitude of the client
either positive or negative towards the nurse
- Not deliberate, automatic and unconscious
way na mu relate and client sa nurse
- Ex. adult client has a relationship before
admission, same age gf sa nurse, so ang
client mo show transference the nurse like
sexual inclinations
- Displaces his emotions and attitude from his
past towards his nurse
● Countertransference
- transference as experienced by the nurse
- The nurse who displaces his thought of his
past relationship of his patient
- Opposite
- Nursing displacing her emotions towards the
client
Ex: nurse is a mother, her patient is a
adolescent then reacts in a way that he
would react in her adolescent child, ma
controlling sha, acting a mother instead a
nurse
- What should u do as a nurse? Do
self awareness, talk to your
supervisor regarding your feelings
and thoughts
- If not enough if self awareness ra,
talk to colleagues
- FIRST : Resolve on own
- Second- talk to colleague
- Third - talk to supervisor
Individual Therapies
1. Psychoanalysis
● Psychoanalytic theory supports the notion that all
human behavior is caused and can be explained
(deterministic theory)
● Freud concluded that many of the problems resulted
from childhood trauma or failure to complete tasks of
psychosexual development. The repressed, unmet
needs, unresolved conflicts and sexual feelings as
well as traumatic events is the one causing
“hysterical” or neurotic behaviors
● Psychopathology results when a person has
difficulty making the transition from one stage to the
next, or when a person remains stalled at a
particular stage or regresses to an earlier stage
● Focuses on discovering the causes of the client’s
unconscious and repressed thoughts, feelings and
conflicts believed to cause anxiety and helping the
client to gain insight into and resolve these conflicts
and anxieties
- Supports the notion that all human behavior is
caused and can be explained
- Unresolved conflicts and unmet needs
- Psychoanalysis is still practiced today but on a very
limited basis. Analysis is lengthy with weekly or more
frequent sessions for several years. It is costly and
not covered by conventional health insurance
programs; thus, it has become known as “ therapy
for the wealthy”
- Here in the philippines (1000 per hour)
- Impractical and expensive that is why it is not
commonly used
- It resulted from childhood trauma- repressed needs
- Repressed emotions that is the source of internal
conflicts that will manifest to disturbing behavior
- Psychopathology
- 3 component personality: anxiety arises if
there is a conflict between the 3
- Anxiety:ID achieve full pressure clashed with
super ego
- Unresolved sexual conducts: disturbing
behaviors occur
- Focus ni freud: SEXUAL NEEDS AND
LIBIDO
- The root all of its theories: fixation in your
sexual desires
- FOCUSES ON PHALLIC STAGE
- Freud focuses on the consciousness of an
individual
- conscious:
- Preconscious: thought that can be recalled
 - Unconscious: feelings that motivate a
person even though she does not remember
them
- Repressed due to painful
experiences
- This unconscious part of ourselves
will come out as a slip of the tongue
“freudian slip”
- Freudian slip is the manifestation of
the mind
- Freud believe that much of what we
do is from our subconscious belief
- In reality, we it in our mind be we
are not aware of it bc is may have
caused us trauma in the past
METHODS:
1. DREAM ANALYSIS
● A primary method used in psychoanalysis involves
discussing a client’s dreams to discover their true
meaning and significance
● Dream:
○ Products our subconscious
○ Unmet needs and issues
○ have meaning
○ Yourself telling yourself something
2. FREE ASSOCIATION
● Another method used to gain access to
subconscious thoughts and feelings
● the therapist tries to uncover the client’s true
thoughts and feelings by saying a word and asking
the client to respond quickly with the first thing that
comes to mind
● What comes of the mind or first thing you said:
repressed feelings
● Subconscious
●
HYPNOTHERAPY
- This form of therapy is considered alternative
medicine with the purpose of utilizing one’s mind to
help reduce or alleviate a variety of issues such as
psychological distress, phobias, and unhealthy or
dangerous habits ( ex. Smoking and drinking).
- The aim of hypnotherapy is to create a positive
change in an individual while he/she is in a stage of
unconsciousness or slumber (sleep).
- Destructive
- referred to as guided hypnosis, is a form of
psychotherapy that uses relaxation, extreme
concentration and intense attention to achieve a
heightened state of consciousness or mindfulness.
In other words, it places the individual into a “trance”
or altered state of awareness
- Placed in a trance
- Suggest things to you
alternative medicine
1. Suggestion Therapy
- Research indicates that suggestion therapy may
encourage positive and healthy behaviors like
self-motivation and self- confidence.
- This method may help clients or patients uncover the
psychological root of a problem pisting giatay
- -relies on an individual’s ability to respond to
suggestions and guidance from the hypnotherapist
or psychologist, while he/she is in a “trance like” or
altered state
- -commonly used
- Introduces new ideas (coping and cognitive skills)
2. ANALYSIS IN HYPNOTHERAPY
● “REGRESSION THERAPY” is more exploratory in
nature. In fact, the main goal of the analysis is to
determine the root cause, issue, disorder, and or
symptom of an individual’s distress.
● to control or stop unwanted or unhealthy behaviors
like smoking, gambling, nail biting and excessive
eating
-research : indicates that suggestion therapy may encourage
positive and healthy behaviors like self-motivation and
self-confidence
-may help clients or patients “uncover” the psychological root
of a problem or symptom, for instance the root of one’s
social anxiety , depression, and or past trauma
- important to understand that feeling or memories
associated with trauma tend to “hide” in one’s unconscious
memory so that the individual doesn’t remember (on a
conscious level) the trauma he /she experienced
- going back to traumatic stage in your life then embraced it
May be done standing alone or done with medication
- Digging deep into unconscious mind
- Going back to developmental yeats
What is analysis in hypnotherapy
● Analysis, on the other hand, has proven extremely
effective for “digging deep’ into the subconscious
mind to retrieve repressed memories or past
traumas - all of which could be causing
psychological distress, mental health conditions, and
or problematic behaviors
● Maybe done stand alone or with medications
● This method also referred to as a “regression
therapy'' is more exploratory in nature. In fact, the
main goal of the analysis is to determine the root
cause, issue, disorder, and/or symptoms of an
individual distress
● This method is not meant to cure or directly change
an individual's behavior. Rather, the goal is to
determine the main cause of the individual’s
distress and treat it through psychotherapy.
● During analysis a psychologist first hypnotizes the
individual by putting him/her into a relaxed state.
Then, he/she helps this indiv explore past events in
life. The goal is to probe the individual's unconscious
memories of said events, so he/she can move past
them
 ● Not meant to cure or directly “change” an individual's
behavior. Rather, the goal is to determine the main
cause of the individual’s distress and treat it through
psychotherapy
Crisis Intervention
- Crisis:
- is a turning point in an individual’s life that
produces an overwhelming emotional
responses
- Know the factors when handling the client
- Self limiting (4-6 weeks)
- 1st Go back to pre crisis level - function
normally
- 2nd Or not, form new adaptive skills
- 3rd level- negative outcome; lower than
pre-crisis level, develop maladaptive
behaviors results to mental disorder
- may go back to pre crisis level or the client
will be able to form new adaptive, social and
coping skills and she would function in a
higher level and these two outcomes are
positive
- behavior and directing the person’s behavior
- Individual experiences a crisis when they confront
some life circumstances or stressors that they
cannot effectively manage through use of their
customary coping skills
- Coping skills can’t cope
Stages of crisis
● The person is exposed to a stressor, experience
anxuey, and tries to cope in a customary fashion
○ Use old or usual coping mechanism
● Anxiety increases when customary coping skills are
ineffective
○ Customary coping skills does not work
anymore
● The person makes all possible efforts to deal with
the stressor including attempts at new methods of
coping and
○ Try new coping skills
● When coping attempts fail, the person experiences
disequilibrium and significant distress
○ breakdown!!!! (breakdown)
3 Categories of Crisis
1. Maturational crisis
-developmental crisis
-predictable events in the normal course of life
-leaving home for the first time, getting married,
having a baby, beginning a career, going to college
2. Adventitious crisis
- Sometimes called social crisis
Incluse natural disasters like lfloods, earthquakes
hurricanes, war terrorits attacks rits and violent
crimes such as rape or murder.
3. Situational crisis Crisis
-Are unanticipated or sudden events that threaten
the indiv integrity such as death of a loved one, loss
of job and physical or emotional illness in the indiv
family member
- Pandemic
- CRISIS IS NOT NECESSARILY NEGATIVE -
Factors that influence whether or not an individual
experiences a crisis:
1. Individuals perception of the event
2. Availability of emotional supports
3. Availability of adequate coping mechanism
TWO CATEGORIES OF CRISIS INTERVENTION
● Authoritative interventions
○ Are designed to assess the person’s health
status and promote problem-solving such as
offering the person new information,
knowledge or meaning; raising the person’s
self awareness by providing feedback about
by offering suggestions or courses of action.
● Facilitative Interventions
○ Aim at dealing with the person's needs for
empathetic understanding such as
encouraging the person to identify and
discuss feelings, serving as a sounding
board for the person, and affirming the
person's self worth
- Techniques and strategies that include the
balance of these
- Use both of the categories
Goal of Crisis Intervention
1. To decrease the emotional stress and protect the
crisis victim from additional stress
2. To assist the victim in organizing and mobilizing
resources or support system to meet unique need
and reach a solution for the particular situation that
precipitated the crisis
3. To mitigate the individuals adverse reaction to the
immediate crisis and facilitate his coping and
planning by assisting him in identifying and
assessing supports and coping skills
4. To normalize reactions to the crises and assess the
individuals capacities and need for further support
and referral
Treatment Modalities or crisis intervention:
- To facilitate client in crisis to get out of it either going
to pre crisis level or functioning
1. Individual Psychotherapy
● Method of bringing about change in a person by
exploring his or her feelings attitudes , thinking and
behavior
 ● Involves a one-to-one relationship between the
therapist and the client
● Relationship between the client and the therapiPst
proceeds through stages similar to those of the
nurse-client relationship: introduction, working, and
termination
● Selecting a therapist is extremely important in terms
of successful outcomes for the client
● Client must select a therapist whose theoretical
beliefs and style of therapy are congruent with the
client’s needs and expectations of therapy
● Find a therapist na same mo ug POV
● Find another buang
● Choosing the therapist is the key
● One on one
● Goal oriented
2. Group therapy
● Clients participate in sessions with a group of people
● Members share a common purpose
● Expected to contribute to the group to benefit others
and receive benefit from others in return
● Same coping skills
● Being a member of a group allows client to learn
new ways of looking at a problem or ways of coping
or solving problems and also helps him or her to
learn important interpersonal skills
● Results:
-gaining new information or learning
-gaining new inspiration or hope
-interacting with others
-feeling acceptance and belonging
-becomingaware that one is not alone an that others
share the same problems
-gaining insight into one’s problems and behaviors
and how they affect others
-giving of oneself for the benefit of others (altruism)
● Client will realize he or she is not only one
experiencing the crisis
● Client learns new info with other members
Therapy groups: different purposes, degrees of
formality and structure
2.1 Psychotherapy groups
● Goals : members to learn about their behavior and
to make positive changes in their behavior by
interacting and communicating with others as a
member of a group
● Group techniques and processes are used to help
group members learn about their behavior with other
people and how it relates to core personality traits.
● Members learn that they have responsibilities to
others and help other members achieve their goals
● Formal in structure with 1-2 group leader or the
entire group is to establish the rules for the group
● Rules: confidentiality, punctuality, attendance and
social contact between members outside of group
times
● Open group : freely join
● Closed : join and finish
● More structured
● Designated leader-facilitate
● Cannot freely talk about anything
● Members are not transformed into support groups
● Cannot become friends outside session
● Very particular with confidentiality
● Not exchange number with each other
● First name basis
● Decides on how degree they can contact each other
● Limit social contacts
2.2 Family therapy
● client and his or her family members participate
● Goal: understanding how family dynamics
contribute to the clients psychopathology,
mobilizing the family's inherent strengths and
functional resources, restructuring maladaptive
family behavioral styles and strengthening family
problem solving behaviors
● Can be used to assess and treat various psychiatric
disorders
● Allowing the fam participate
● other fam may have maladaptive behavioral styles
which contributed to the client
● Not talking about will be talk about
● Issues and concerns will be addressed
● Can also be used to addressed other fam members
disorders
2.3 Support Group
● Organized to help members who share a common
problems cope with it
● Provide a safe place for group members to express
their feelings of frustration, boredom or unhappiness
● Discuss common problems and potential solutions
● Tend to be open groups in which members can join
or leave as their needs dictate
● Common support groups are for cancer or stroke
victims, persons with AIDS and family members bla
blabla
● Not so formal
● Okay ra magka friends at the end of the session
● Becomes their extended family
3M: MALADAPTIVE BEHAVIOR PATTERN WITH
CHILDREN AND ADOLESCENTS
1. Terms: (Sa pdf ni)
Mental retardation (p. 948)
● A term often used in a disparaging manner to bully
or ridicule individuals with impaired cognitive
abilities.
● Intellectual disability is the correct diagnostic term
for what was once called mental retardation.
● The essential feature of intellectual disability is
below-average intellectual functioning (intelligence
quotient [IQ] <70) accompanied by significant
limitations in areas of adaptive functioning such as
communication skills, self-care, home living, social
or interpersonal skills, use of community resources,
self-direction, academic skills, work, leisure, and
health and safety.
● The degree of disability is based on IQ and
cognitive functioning, often categorized as mild,
moderate, severe, or profound (King, Toth, DeLacy,
& Doherty, 2017).
Fear (p. 1121)
● Feeling afraid or threatened by a clearly identifiable
external stimulus that represents danger to the
person.
Anxiety (p. 517)
● Vague feeling of dread or apprehension
● fIt is a response to external or internal stimuli that
can have behavioral, emotional, cognitive, and
physical symptoms
● Unavoidable in life and can serve many positive
functions such as motivating the person to take
action to solve a problem or to resolve a crisis
● Normal when it is appropriate to the situation and
dissipates when the situation has been resolved.
● Anxiety disorders:
○ Group of conditions that share a key
feature of excessive anxiety with ensuing
behavioral, emotional, cognitive, and
physiological responses
Manifestations:
○ Panic without reason, unwarranted fear of
objects or life conditions, or unexplainable
or overwhelming worry.
○ Distress over time
○ Impairs their daily routines, social lives, and
occupational functioning
○ Anxiety is distinguished from fear
Autism (p. 949 & 1112)
● Autism spectrum disorder is a neurodevelopmental
disorder first seen in childhood, conceptualized
across a continuum with symptoms varying from
mild to severe; may include communication deficits,
problems building social relationships,
overdependence on routines, and high level of
sensitivity to the environment.
● Autism spectrum disorder (ASD), formerly called
autistic disorder, or just autism, is almost five times
more prevalent in boys than in girls, and it is usually
identified by 18 months and no later than 3 years of
age.
● Children with ASD have persistent deficits in
communication and social interaction accompanied
by restricted, stereotyped patterns of behavior and
interests/activities.
● These children may display little eye contact with
and make few facial expressions toward others;
they use limited gestures to communicate. They
can have limited capacity to relate to peers or
parents. They may lack spontaneous enjoyment,
express no moods or emotional affect, and may not
engage in play or make-believe with toys.
● There can be little intelligible speech.
● These children engage in stereotyped motor
behaviors, such as hand flapping, body twisting, or
head banging. These behaviors and difficulties are
less prominent on the milder end of the autism
spectrum and more pronounced on the severe end
(Volkmar, Klin, Schultz, & State, 2017).
Hyperkinesis (wala sa book)
● Hyperactivity (hyperkinesis) - Restless, aggressive,
often destructive activity; prominent in manic state.
(From the book “Psychiatric Nursing” by Keltner,
Bostrom, & McGuinness 6th ed)
● A disorder of children marked by hyperactivity and
inability to concentrate. (From Google)
2. Maladaptive Patterns
A. Mental Retardation (p. 949)
● The essential feature of intellectual disability is
below-average intellectual functioning (intelligence
quotient [IQ] <70) accompanied by significant
limitations in areas of adaptive functioning
● The causes of intellectual disability include
hereditary conditions such as Tay–Sachs disease
or fragile X chromosome syndrome; early
alterations in embryonic development, such as
trisomy 21 or maternal alcohol intake, which cause
fetal alcohol syndrome; pregnancy or perinatal
problems such as fetal malnutrition, hypoxia,
infections, and trauma; medical conditions of
infancy such as infection or lead poisoning; and
environmental influences such as deprivation of
nurturing or stimulation. In addition, the cause is
sometimes unknown or not yet discovered.
● Children with mild-to-moderate intellectual disability
usually receive treatment in their homes and
communities and make periodic visits to physicians.
● Those with more severe intellectual disabilities may
require residential placement or day care services.
B. Learning Disorders (Kaye) page 953 in Videbeck PDF
- reading disorders
- Mathematics disorders
- Disorder of written expression
❏ Learning disorder
→ is diagnosed when a child’s achievement in
reading, mathematics, or written expression is
below that expected for age, formal education, and
intelligence. Learning problems interfere with
academic achievement and life activities requiring
reading, math, or writing.
→ (page 980 in PDF) include categories for
substandard achievement in reading, mathematics,
and written expression. They are treated through
special education in schools.
❏ Reading and written expression disorders
→ are usually identified in the first grade;
❏ Math disorder
→ may go undetected until the child reaches fifth
grade.
❏ Low self-esteem and poor social skills are common
in children with learning disorders.
C. Communication disorders (Den)
● Communication is the process that people use to
exchange information. Messages are
simultaneously sent and received on two levels:
verbally through the use of words and nonverbally
by behaviors that accompany the words (Wasajja,
2018). (PAGE 93 IN BOOK; PAGE 236 IN PDF)
● Communication disorders involve deficits in
language, speech, and communication and are
diagnosed when deficits are sufficient to hinder
development, academic achievement or activities of
daily living, including socialization. (page 422 of
hard copy, page 954 in pdf)
● Communication disorders may be mild to severe.
Difficulties that persist into adulthood are related
most closely to the severity of the disorder. Speech
and language therapists work with children who
have communication disorders to improve their
communication skills and to teach parents to
continue speech therapy activities at home. (page
422 of hard copy, page 954 in pdf)
- expressive language
● WALA SA VIDEBECK :(
(ANOTHER BOOK SOURCE: VARCOLIS’)
● Expressive language disorder
- results in difficulty in finding the right
words and forming clear sentences. The
child demonstrates difficulty learning words
or an inability to speak in complete
coherent sentences.
- These disorders range from mild to severe
and tend to show up prior to the age of 4
(National Institute on Deafness and Other
Communication Disorders, 2015).
- Mixed receptive and expressive disorder
● WALA SA VIDEBECK :(
(FROM ANOTHER BOOK SOURCE; VARCOLIS’)
● Receptive language disorder
- Where children experience difficulty
understanding or are unable to follow
directions.
- Some children have a mixed
receptive-expressive mixture of both
problems and can neither understand
others nor communicate properly.
- These disorders range from mild to severe
and tend to show up prior to the age of 4
(National Institute on Deafness and Other
Communication Disorders, 2015).
● a communication disorder in which both the
receptive and expressive areas of communication
may be affected in any degree, from mild to severe.
Children with this disorder have difficulty
understanding words and sentences. (GOOGLE
DEFINITION)
D. Phonologic disorder (422 in book; page 594 in pdf)
(Rikka)
● Also known as speech sound disorder
● Is the difficulty or inability to produce intelligible
speech, which precludes effective verbal
communication
● involves problems with articulation (forming sounds
that are part of speech)
E. Stuttering (422 in book; page 594 in pdf) (Rikka)
● A disturbance of fluency and patterning of speech
with sound and syllable repetition.
= both Phonologic disorder and stuttering run in families
and occur more frequently in boys than in girls
= treated by speech and language therapists
F. Pervasive Developmental disorder (Sandra)
- autism
● Autism spectrum disorder (ASD) is the DSM-5
(Diagnostic and Statistical Manual of Mental
Disorders, fifth edition) diagnosis that includes
disorders previously categorized as different types
of a pervasive developmental disorder (PDD),
characterized by pervasive and usually severe
impairment of reciprocal social interaction skills,
communication deviance, and restricted
stereotypical behavioral patterns.
● Almost five times more prevalent in boys than in
girls, and it is usually identified by 18 months and
no later than 3 years of age.
● The behaviors and difficulties experienced vary
along the continuum from mild to severe.
● Children with ASD have persistent deficits in
communication and social interaction accompanied
by restricted, stereotyped patterns of behavior and
interests/activities.
● These children may display little eye contact with
and make few facial expressions toward others;
they use limited gestures to communicate. They
can have limited capacity to relate to peers or
parents.
● They may lack spontaneous enjoyment, express no
moods or emotional affect, and may not engage in
play or make-believe with toys. There can be little
intelligible speech.
● These children engage in stereotyped motor
behaviors, such as hand flapping, body twisting, or
head banging.
● Eighty percent of cases of autism are early onset,
with developmental delays starting in infancy.
● The other 20% of children with autism have
seemingly normal growth and development until 2
or 3 years of age, when developmental regression
or loss of abilities begins.
● Autism tends to improve, in some cases
substantially, as children start to acquire and use
language to communicate with others. If behavior
deteriorates in adolescence, it may reflect the
effects of hormonal changes or the difficulty
meeting increasingly complex social demands.
● The goals of treatment of children with autism are
to reduce behavioral symptoms (e.g., stereotyped
motor behaviors) and to promote learning and
development, particularly the acquisition of
language skills.
● Comprehensive and individualized treatment,
including special education and language therapy,
as well as cognitive behavioral therapy for anxiety
and agitation, is associated with more favorable
outcomes.
● Pharmacologic treatment with antipsychotics, such
as haloperidol (Haldol), risperidone (Risperdal),
aripiprazole (Abilify), or combinations of
antipsychotic medications, may be effective for
specific target symptoms such as temper tantrums,
aggressiveness, self-injury, hyperactivity, and
stereotyped behaviors. Other medications, such as
naltrexone (ReVia), clomipramine (Anafranil),
clonidine (Catapres), and stimulants to diminish
self-injury and hyperactive and obsessive
behaviors, have had varied but unremarkable
results. There are no medications approved for the
treatment of ASD itself.
- Rett’s disorder (wala sa book)
● Rett syndrome is a rare genetic neurological
disorder that occurs almost exclusively in girls and
leads to severe impairments, affecting nearly every
aspect of the child’s life: their ability to speak, walk,
eat, and even breathe easily.
● The hallmark of Rett syndrome is near constant
repetitive hand movements.
● Rett syndrome is usually recognized in children
between 6 to 18 months as they begin to miss
developmental milestones or lose abilities they had
gained.
● Rett syndrome is caused by mutations on the X
chromosome on a gene called MECP2. There are
more than 900 different mutations found on the
MECP2 gene.
● Most of these mutations are found in eight different
“hot spots.”
Symptoms
● Loss of speech
● Loss of purposeful use of hands
● Involuntary hand movements such as handwashing
● Loss of mobility or gait disturbances
● Loss of muscle tone
● Seizures or Rett “episodes”
● Scoliosis
● Breathing issues
● Sleep disturbances
● Slowed rate of growth for head, feet and hands
- Asperger’s disorders (wala sa book)
● Today, Asperger's syndrome is technically no
longer a diagnosis on its own. It is now part of a
broader category called autism spectrum disorder
(ASD).
● Many professionals felt Asperger’s syndrome was
simply a milder form of autism and used the term
“high-functioning autism” to describe these
individuals.
● What distinguishes Asperger’s Disorder from
classic autism are its less severe symptoms and
the absence of language delays. Children with
Asperger’s Disorder may be only mildly affected,
and they frequently have good language and
cognitive skills. To the untrained observer, a child
with Asperger’s Disorder may just seem like a
neurotypical child behaving differently.
● there is no speech delay in Asperger’s
● Speech patterns may be unusual, lack inflection or
have a rhythmic nature, or may be formal, but too
loud or high-pitched.
 ● a person with Asperger’s Disorder cannot have a
“clinically significant” cognitive delay, and most
possess average to above-average intelligence.
G. Attention deficit and disruptive behavior disorder
(Dats)
Attention deficit/hyperactivity disorder PAGE 422 in
book, 995 in pdf
● is characterized by inattentiveness, overactivity,
and impulsiveness
● a common disorder, especially in boys, and
probably accounts for more child mental health
referrals than any other single disorder.
● The essential feature of ADHD is a persistent
pattern of inattention and/or hyperactivity and
impulsivity more common than generally observed
in children of the same age.
● A key feature of ADHD is the consistency of the
child’s behavior—every day, in almost all situations,
and with almost all caregivers, the child
demonstrates the problematic behaviors.
Onset and Clinical Course
● usually identified and diagnosed when the child
begins preschool or school, though many parents
report problems from a much younger age
ADHD (Child)
● often fussy and temperamental and have poor
sleeping patterns
● Toddlers may be described as “always on the go”
and “into everything,” at times dismantling toys and
cribs
● Children who are ADHD cannot tolerate sedentary
activities such as listening to stories
● Normal environmental noises, such as someone
coughing, distract the child.
● He or she cannot listen to directions or complete
tasks. The child interrupts and blurts out answers
before questions are completed.
● Academic performance suffers because the child
makes hurried, careless mistakes in schoolwork,
often loses or forgets homework assignments, and
fails to follow direction
● Forming positive peer relationships is difficult
because the child cannot play cooperatively or take
turns and constantly interrupts others.
ADHD (adult)
● ADHD continues to have problems in adolescence.
● Typical impulsive behaviors include cutting class,
getting speeding tickets, failing to maintain
interpersonal relationships, and adopting risk-taking
behaviors, such as using drugs or alcohol,
engaging in sexual promiscuity, fighting, and
violating curfew
● The secondary complications of ADHD, such as low
self-esteem and peer rejection, continue to pose
serious problems.
● Previously, it was believed that children outgrow
ADHD, but it is now known that ADHD can persist
into adulthood.
Etiology
● Although much research has taken place, the
definitive causes of ADHD remain unknown. There
may be cortical-arousal, information-processing, or
maturational abnormalities in the brain.
● Combined factors, such as environmental toxins,
prenatal influences, heredity, and damage to brain
structure and functions, are likely responsible.
● Prenatal exposure to alcohol, tobacco, and lead
and severe malnutrition in early childhood increase
the likelihood of ADHD.
● Brain images of people with ADHD suggest
decreased metabolism in the frontal lobes, which
are essential for attention, impulse control,
organization, and sustained goal-directed activity.
● also shown decreased blood perfusion of the frontal
cortex in children with ADHD and frontal cortical
atrophy in young adults with a history of childhood
ADHD.
● There seems to be a genetic link for ADHD that is
most likely associated with abnormalities in
catecholamine and, possibly, serotonin metabolism.
Risk Factor
● include family history of ADHD; male relatives with
antisocial personality disorder or alcoholism; female
relatives with somatization disorder; lower
socioeconomic status; male gender; marital or
family discord, including divorce, neglect, abuse, or
parental deprivation; low birth weight; and various
kinds of brain insult
Treatment
● No one treatment has been found to be effective for
ADHD; this gives rise to many different approaches
such as sugar-controlled diets and megavitamin
therapy.
● Parents need to know that any treatment heralded
as the cure for ADHD is probably too good to be
true.
● ADHD is chronic; goals of treatment involve
managing symptoms, reducing hyperactivity and
impulsivity, and increasing the child’s attention so
that he or she can grow and develop normally.
 ● The most effective treatment combines
pharmacotherapy with behavioral, psychosocial,
and educational interventions.
Psychopharmacology of ADHD
● The most common medications are
methylphenidate (Ritalin) and an amphetamine
compound (Adderall).
● Methylphenidate is effective in 70% to 80% of
children with ADHD; it reduces hyperactivity,
impulsivity, and mood lability and helps the child
pay attention more appropriately.
● Dextroamphetamine (Dexedrine) and pemoline
(Cylert) are other stimulants used to treat ADHD.
● Most common side effects of these drugs are
insomnia, loss of appetite, and weight loss or failure
to gain weight.
● Giving stimulants during daytime hours usually
effectively combats insomnia.
● Eating a good breakfast with the morning dose and
substantial nutritious snacks late in the day and at
bedtime helps the child maintain an adequate
dietary intake.
● When stimulant medications are not effective or
their side effects are intolerable, antidepressants
are the second choice for treatment
● Atomoxetine (Strattera) is the only non-stimulant
drug specifically developed and tested by the U.S.
Food and Drug Administration for the treatment of
ADHD.
○ It is an antidepressant, specifically a
selective norepinephrine reuptake inhibitor.
○ The most common side effects in children
during clinical trials were decreased
appetite, nausea, vomiting, tiredness, and
upset stomach.
○ In adults, side effects were similar to those
of other antidepressants, including
insomnia, dry mouth, urinary retention,
decreased appetite, nausea, vomiting,
dizziness, and sexual side effects.
○ atomoxetine can cause liver damage, so
individuals taking the drug need to have
liver function tests periodically
Strategies for Home and School
● providing consistent rewards and consequences for
behavior, offering consistent praise, using time-out,
and giving verbal reprimands. Additional strategies
are issuing daily report cards for behavior and using
point systems for positive and negative behavior.
● In therapeutic play, play techniques are used to
understand the child’s thoughts and feelings and to
promote communication. This should not be
confused with play therapy, a psychoanalytic
technique used by psychiatrists.
● Dramatic play is acting out an anxiety-producing
situation such as allowing the child to be a doctor or
use a stethoscope or other equipment to take care
of a patient (a doll).
● Play techniques to release energy could include
pounding pegs, running, or working with modeling
clay.
● Creative play techniques can help children to
express themselves; for example, by drawing
pictures of themselves, their family, and peers.
● These techniques are especially useful when
children are unable or unwilling express themselves
verbally
Conduct behavior PAGE 441 in book, 992 in pdf
● Conduct disorder is characterized by persistent
behavior that violates societal norms, rules, laws,
and the rights of others.
● These children and adolescents have significantly
impaired abilities to function in social, academic, or
occupational areas.
● Symptoms are clustered in four areas:
○ aggression to people and animals,
○ destruction of property,
○ deceitfulness and theft, and
○ serious violation of rules.
● Children with conduct disorder often exhibit callous
and unemotional traits, similar to those seen in
adults with antisocial personality disorder.
● They have little empathy for others, do not feel
“bad” or guilty or show remorse for their behavior,
have shallow or superficial emotions, and are
unconcerned about poor performance at school or
home.
● These children have low self-esteem, poor
frustration tolerance, and temper outbursts.
● Conduct disorder is frequently associated with early
onset of sexual behavior, drinking, smoking, use of
illegal substances, and other reckless or risky
behaviors.
Onset and Clinical Course
● Two subtypes of conduct disorder are based on
age at onset.
● The childhood onset type involves symptoms
before 10 years of age, including physical
aggression toward others and disturbed peer
relationships.
● These children are more likely to have persistent
conduct disorder and develop antisocial personality
disorder as adults.
● Adolescent-onset type is defined by no behaviors
of conduct disorder until after 10 years of age.
 ● These adolescents are less likely to be aggressive,
and they have more normal peer relationships.
They are less likely to have persistent conduct
disorder or antisocial personality disorder as adults.
● Behaviors associated with conduct disorders fall
into categories of aggression, destruction,
deceit/theft, and rule violation, but they can vary
in intensity. They are often described as mild,
moderate, or severe.
○ Mild: The child has some conduct problems
that cause relatively minor harm to others.
Examples include repeated lying, truancy,
minor shoplifting, and staying out late
without permission.
○ Moderate: The number of conduct
problems increases as does the amount of
harm to others. Examples include
vandalism, conning others, running away
from home, verbal bullying and intimidation,
drinking alcohol, and sexual promiscuity.
○ Severe: The person has many conduct
problems that cause considerable harm to
others. Examples include forced sex,
cruelty to animals, physical fights, cruelty to
peers, use of a weapon, burglary, robbery,
and violation of previous parole or
probation requirements.
● The course of conduct disorder is variable.
● People with the adolescent onset type or mild
problems can achieve adequate social relationships
and academic or occupational success as adults.
● Those with the childhood-onset type or more
severe problem behaviors are more likely to
develop antisocial personality disorder as adults.
● Even those who do not have antisocial personality
disorder may lead troubled lives with difficult
interpersonal relationships, unhealthy lifestyles, and
an inability to support themselves.
Etiology
● Researchers generally accept that genetic
vulnerability, environmental adversity, and factors
such as poor coping interact to cause the disorder.
● Risk factors include poor parenting, low academic
achievement, poor peer relationships, and low
self-esteem; protective factors include resilience,
family support, positive peer relationships, and
good health
● The disorder is more common in children who have
a sibling with conduct disorder or a parent with
antisocial personality disorder, substance abuse,
mood disorder, schizophrenia, or ADHD.
● A lack of reactivity of the autonomic nervous
system has been found in children with conduct
disorder
● The abnormality may cause more aggression in
social relationships as a result of decreased normal
avoidance or social inhibitions.
● Poor family functioning, marital discord, poor
parenting, and a family history of substance abuse
and psychiatric problems are all associated with the
development of conduct disorder.
● The specific parenting patterns considered
ineffective are inconsistent parental responses to
the child’s demands and giving into demands as the
child’s behavior escalates.
● Exposure to violence in the media and community
is a contributing factor for the child at risk in other
areas
○ Socioeconomic disadvantages, such as
inadequate housing,crowded conditions,
and poverty, also increase the likelihood of
conduct disorder in at-risk children.
● Academic underachievement, learning disabilities,
hyperactivity, and problems with attention span are
all associated with conduct disorder.
● Children with conduct disorder have difficulty
functioning in social situations. They lack the
abilities to respond appropriately to others and to
negotiate conflict, and they lose the ability to
restrain themselves when emotionally stressed.
● They are often accepted only by peers with similar
problem
Treatment
● Dramatic interventions, such as “boot camp” or
incarceration, have not proved effective and may
even worsen the situation.
● Treatment must be geared toward the client’s
developmental age; no one treatment is suitable for
all ages.
● Preschool programs, such as Head Start, result in
lower rates of delinquent behavior and conduct
disorder through use of parental education about
normal growth and development, stimulation for the
child, and parental support during crises.
● For school-aged children with conduct disorder, the
child, family, and school environment are the focus
of treatment.
○ Techniques include parenting education,
social skills training to improve peer
relationships, and attempts to improve
academic performance and increase the
child’s ability to comply with demands from
authority figures.
○ Family therapy is considered to be
essential for children in this age group
● Adolescents rely less on their parents and more on
peers, so treatment for this age group includes
individual therapy.
 ● Many adolescent clients have some involvement
with the legal system as a result of criminal
behavior, and consequently, they may have
restrictions on their freedom.
● Use of alcohol and other drugs plays a more
significant role for this age group; any treatment
plan must address this issue.
● The most promising treatment approach includes
keeping the client in his or her environment with
family and individual therapies.
● The plan usually includes conflict resolution, anger
management, and teaching social skills.
● Medications alone have little effect, but may be
used in conjunction with treatment for specific
symptoms.
○ For example, the client who presents a
clear danger to others (physical
aggression)
○ may be prescribed an antipsychotic
medication, such as risperidone
(Risperdal).
○ Clients with labile moods may benefit from
lithium or another mood stabilizer such as
carbamazepine (Tegretol) or valproic acid
(Depakote)
Oppositional defiant disorder PAGE 449 in book, 988 in
pdf
● Oppositional defiant disorder (ODD) consists of
an enduring pattern of uncooperative, defiant,
disobedient, and hostile behavior toward authority
figures without major antisocial violations.
● A certain level of oppositional behavior is common
in children and adolescents; indeed, it is almost
expected at some phases such as 2 to 3 years of
age and in early adolescence.
● ODD is diagnosed only when behaviors are more
frequent and intense than in unaffected peers and
cause dysfunction in social, academic, or work
situations.
● The disruptive, defiant behaviors usually begin at
home with parents or parental figures and are more
intense in this setting than settings outside the
home.
● Most authorities believe that genes, temperament,
and adverse social conditions interact to create
ODD.
● Children with ODD have lower self concept and
lack competence in social situations.
● Children with ODD have limited abilities to make
associations between their behavior and
consequences of behavior—both negative and
positive, indicative of a reduced sensitivity to
reward and punishment.
○ Therefore, learning appropriate behavior
and learning to refrain from inappropriate
obehavior are impaired.
● They also exhibit impaired problem-solving abilities
and deficiencies in attention, flexibility of thinking,
and decision-making. All of these problems are also
present in children diagnosed with conduct disorder
—to an even greater degree.
● Prognosis for ODD varies by age of onset,
symptom severity, and the presence of comorbid
psychiatric disorders.
Interventions for conduct disorder
● include decreasing violent behavior, increasing
compliance, improving coping skills and
self-esteem, promoting social interaction, and
educating and supporting parents.
● Treatment for ODD is based on parent
management training models of behavioral
interventions.
● Treatment goals for ODD involve learning
appropriate behavior and refraining from
inappropriate behavior
● These programs are based on the idea that ODD
problem behaviors are learned and inadvertently
reinforced in the home and school.
● Adolescent children benefit from interventions that
use enhancement of personal strengths to improve
behavioral and social functioning.
● Older children may also benefit from individual
therapy in addition to the behavioral program.
● There is little evidence that medications help ODD
behaviors; however, successful pharmacologic
treatment of comorbid disorders such as ADHD
may also decrease the severity of ODD symptoms.
● The two major challenges for parents and
caregivers are managing the adolescent’s
aggressive, defiant, and deceitful behaviors, and
interacting frequently with multiple service providers
and agencies.
H. Feeding and eating disorder (Page 862)
Introduction
- Eating is part of everyday life. It is necessary for
survival, but it is also a social activity and part of
many happy occasions
- Anorexia nervosa and bulimia nervosa, the two
most common eating disorders found in the mental
health setting
- Of clients with eating disorders, 90% are females.
Anorexia begins between the ages of 14 and 18
years, and bulimia begins around age 18 or 19
Overview of Eating Disorders
 - In the late 1800s, doctors in England and France
described young women who used self starvation to
avoid obesity
- It was not until the 1960s, however, that anorexia
nervosa was established as a mental disorder
- Bulimia nervosa was first described as a distinct
syndrome in 1979
- Eating disorders can be viewed on a continuum,
with clients with anorexia eating too little or
starving themselves, clients with bulimia eating
chaotically, and clients with obesity eating too
much
- There is much overlap among the eating disorders;
30% to 35% of normal-weight people with bulimia
have a history of anorexia nervosa and low body
weight, and about 50% of people with anorexia
nervosa exhibit the compensatory behaviors seen
in bulimic behavior, such as purging and
excessive exercise
- The distinguishing features of anorexia include an
earlier age at onset and below-normal body weight;
the person fails to recognize the eating behavior as
a problem
- Clients with bulimia have a later age at onset and
near-normal body weight. They are usually
ashamed and embarrassed by the eating behavior
- Although fewer men than women suffer from eating
disorders, the number of men with anorexia or
bulimia may be much higher than previously
believed, many of whom are athletes
- Men are less likely to seek treatment
- The prevalence of both eating disorders is
estimated to be 2% to 4% of the general population
in the United States.
- A majority of the general population is dissatisfied
with body image and preoccupied with weight and
dieting at some point in their lives
Etiology
- A specific cause for eating disorders is unknown.
Initially, dieting may be the stimulus that leads to
their development.
- Biologic vulnerability, developmental problems, and
family and social influences can turn dieting into an
eating disorder
- Psychological and physiological reinforcement of
maladaptive eating behaviors sustains the cycle
Risk factors for Eating Disorders:
Biologic Factors
- Studies of anorexia nervosa and bulimia nervosa
have shown that these disorders tend to run in
families
- Genetic vulnerability might also result from a
particular personality type or a general susceptibility
to psychiatric disorders or, it may directly involve a
dysfunction of the hypothalamus
- A family history of mood or anxiety disorders (e.g.,
obsessive–compulsive disorder) places a person at
risk for an eating disorder
- Disruptions of the nuclei of the hypothalamus may
produce many of the symptoms of eating disorders
- Two sets of nuclei are particularly important in
many aspects of hunger and satiety (satisfaction of
appetite)—the lateral hypothalamus and the
ventromedial hypothalamus
- Deficits in the lateral hypothalamus result in
decreased eating and decreased responses to
sensory stimuli that are important to eating
- Disruption of the ventromedial hypothalamus
leads to excessive eating, weight gain, and
decreased responsiveness to the satiety effects of
glucose, which are behaviors seen in bulimia
- Many neurochemical changes accompany eating
disorders
Example: norepinephrine levels rise
normally in response to eating, allowing the
body to metabolize and use nutrients
Norepinephrine levels do not rise during
starvation, however, because few nutrients
are available to metabolize. Therefore, low
norepinephrine levels are seen in clients
during periods of restricted food intake.
Also, low epinephrine levels are related to
the decreased heart rate and blood
pressure seen in clients with anorexia.
Increased levels of the neurotransmitter
serotonin and its precursor tryptophan have
been linked with increased satiety. Low
levels of serotonin as well as low platelet
 levels of monoamine oxidase have been
found in clients with bulimia and the binge
and purge subtype of anorexia nervosa
(Call et al., 2017); this may explain binging
behavior. The positive response of some
clients with bulimia to the treatment with
SSRI antidepressants supports the idea
that serotonin levels at the synapse may be
low in these clients.
Developmental Factors
- Two essential tasks of adolescence are the struggle
to develop autonomy and the establishment of a
unique identity
- Autonomy, or exerting control over oneself and the
environment, may be difficult in families that are
overprotective or in which enmeshment (lack of
clear role boundaries) exists
- Such families do not support members’ efforts to
gain independence, and teenagers may feel as
though they have little or no control over their lives.
These teens begin to control their eating through
severe dieting and thus gain control over their
weight
- Losing weight becomes reinforcing; by continuing to
lose, these clients exert control over one aspect of
their lives
- Adolescent girls who express body dissatisfaction
are most likely to experience adverse outcomes,
such as emotional eating, binge eating, abnormal
attitudes about eating and weight, low self-esteem,
stress, and depression
- Characteristics of those who developed an eating
disorder included disturbed eating habits; disturbed
attitudes toward food; eating in secret;
preoccupation with food, eating, shape, or weight;
fear of losing control over eating; and wanting to
have a completely empty stomach
- The need to develop a unique identity, or a sense of
who one is as a person, is another essential task of
adolescence. It coincides with the onset of puberty,
which initiates many emotional and physiological
changes
- Self-doubt and confusion can result if the
adolescent does not measure up to the person she
or he wants to be
- Advertisements, magazines, television, and movies
that feature thin models reinforce the cultural belief
that slimness is attractive
- Excessive dieting and weight loss may be the way
an adolescent chooses to achieve this ideal
- Body image is how a person perceives his or her
body, that is, a mental self-image. For most people,
body image is consistent with how others view
them.
- For people with anorexia nervosa, however, body
image differs greatly from the perception of others.
They perceive themselves as fat, unattractive, and
undesirable even when they are severely
underweight and malnourished
- Body image disturbance occurs when there is an
extreme discrepancy between one’s body image
and the perceptions of others and extreme
dissatisfaction with one’s body image
Family Influences
- Girls growing up amid family problems and abuse
are at higher risk for both anorexia and bulimia
- Disordered eating is a common response to family
discord
- Girls growing up in families without emotional
support may try to escape their negative emotions.
They may place an intense focus outward on
something concrete—physical appearance
- Disordered eating becomes a distraction from
emotions
- Childhood adversity has been identified as a
significant risk factor in the development of
problems with eating or weight in adolescence or
early adulthood
- Adversity is defined as physical neglect, sexual
abuse, or parental maltreatment that includes little
care, affection, and empathy as well as excessive
paternal control, unfriendliness, or
overprotectiveness.
Sociocultural Factors
- Media fuels the image of the “ideal woman” as thin
- This culture equates beauty, desirability, and,
ultimately, happiness with being thin, toned, and
physically fit
- Adolescents often idealize actresses and models as
having the perfect “look” or body, even though
many of these celebrities are underweight or use
ways to appear thinner than they are
- Books, magazines, dietary supplements, exercise
equipment, plastic surgery advertisements, and
weight loss programs abound;
- Western culture considers being overweight a sign
of laziness, lack of self-control, or indifference; it
equates pursuit of the “perfect” body with beauty,
desirability, success, and willpower
- Thus, many women speak of being “good” when
they stick to a diet and “bad” when they eat
desserts or snacks
- Pressure from others may also contribute to eating
disorders
- Pressure from coaches, parents, and peers and the
emphasis placed on body form in sports such as
gymnastics, ballet, and wrestling can promote
eating disorders in athletes
 - Parental concern over a girl’s weight and teasing
from parents or peers reinforces a girl’s body
dissatisfaction and her need to diet or control eating
in some way
- Studies indicate that bullying and peer harassment
are also related to an increase in disordered eating
habits for both bullies and victims.
Categories of Eating Disorders
A. Anorexia nervosa
- life-threatening eating disorder characterized by the
client’s restriction of nutritional intake necessary to maintain
a minimally normal body weight
- intense fear of gaining weight or becoming fat, significantly
disturbed perception of the shape or size of the body, and
steadfast inability or refusal to acknowledge the
seriousness of the problem or even that one exists.
-body weight that is less than the minimum expected weight
considering age, height, and overall physical health
Physical Problems of Anorexia Nervosa
● Amenorrhea
● Constipation
● Overly sensitive to cold, lanugo hair on body
● Loss of body fat
● Muscle atrophy
● Hair loss
● Dry skin
● Dental caries
● Pedal edema
● Bradycardia, arrhythmias
● Orthostasis
● Enlarged parotid glands and hypothermia
● Electrolyte imbalance (i.e., hyponatremia,
hypokalemia)
- Clients with anorexia nervosa can be classified into two
subgroups depending on how they control their weight.
Clients with the restricting subtype lose weight primarily
through dieting, fasting, or excessive exercising. Those with
the binge eating and purging subtype engage regularly in
binge eating followed by purging.
Binge eating: consuming a large amount of food (far greater
than most people eat at one time) in a discrete period of
usually 2 hours or less
Purging: involves compensatory behaviors designed to
eliminate food by means of self-induced vomiting or misuse
of laxatives, enemas, and diuretics. Some clients with
anorexia do not binge but still engage in purging behaviors
after ingesting small amounts of food.
- The term “anorexia” is actually a misnomer; these clients
do not lose their appetites. They still experience hunger but
ignore it and also ignore the signs of physical weakness
and fatigue
- they often believe that if they eat anything, they will not be
able to stop eating and will become fat.
- often preoccupied with food-related activities, such as
grocery shopping, collecting recipes or cookbooks, counting
calories, creating fat-free meals, and cooking family meals
- May also engage in unusual or ritualistic food behaviors
such as refusing to eat around others, cutting food into
minute pieces, or not allowing the food they eat to touch
their lips. These behaviors increase their sense of control
- Excessive exercise is common
Onset and Clinical Course
● begins 14-18 years
● In the early stages, clients often deny having a
negative body image or anxiety regarding their
appearance.
● Profound sense of emptiness is common
● As the illness progresses, depression and lability in
mood become more apparent. As dieting and
compulsive behaviors increase, clients isolate
themselves.
● Can lead to basic mistrust and paranoia.
● Clients may believe their peers are jealous of their
weight loss and may believe that family and health
care professionals are trying to make them “fat and
ugly.”
● six times more likely to die from medical conditions
and suicide
● Clients with the lowest body weights and longest
durations of illness tended to relapse most often
and have the poorest outcomes.
● Clients who abuse laxatives are at a higher risk for
medical complications.
● Medical Complications of Eating Disorder
Treatment and Prognosis
● Difficult to treat because they are often resistant,
appear uninterested, and deny their problems.
● Treatment settings include inpatient specialty eating
disorder units, partial hospitalization or day
treatment programs, and outpatient therapy. The
choice of setting depends on the severity of the
illness, such as weight loss, physical symptoms,
duration of binging and purging, drive for thinness,
body dissatisfaction, and comorbid psychiatric
conditions.
● Major life-threatening complications that indicate
the need for hospital admission include severe fluid,
electrolyte, and metabolic imbalances;
 cardiovascular complications; severe weight loss
and its consequences; and risk for suicide.
● Short hospital stays are most effective for clients
who are amenable to weight gain and who gain
weight rapidly while hospitalized. Longer inpatient
stays are required for those who gain weight more
slowly and are more resistant to gaining additional
weight.
● OPD for those clients who have been ill for fewer
than 6 months, are not binging and purging, and
have parents supportive in family therapy
● Cognitive–behavioral therapy (CBT) can also be
effective in preventing relapse and improving
overall outcomes.
Medical Management
● Focuses on weight restoration, nutritional
rehabilitation, rehydration, and correction of
electrolyte imbalances. Clients receive nutritionally
balanced meals and snacks that gradually increase
caloric intake to a normal level for size, age, and
activity.
● Severely malnourished clients may require total
parenteral nutrition, tube feedings, or
hyperalimentation to receive adequate nutritional
intake.
● Access to a bathroom is supervised to prevent
purging as clients begin to eat more food. Weight
gain and adequate food intake are most often the
criteria for determining the effectiveness of
treatment.
Psychopharmacology
● Amitriptyline (Elavil) and the antihistamine
cyproheptadine (Periactin) in high doses (up to 28
mg/day) can promote weight gain
● Olanzapine (Zyprexa) for antipsychotic effect (on
bizarre body image distortions) and associated
weight gain
● Fluoxetine (Prozac) has some effectiveness in
preventing relapse in clients whose weight has
been partially or completely restored (close
monitoring because weight loss can be a side
effect)
Psychotherapy
Family therapy
● may be beneficial for families of clients younger
than 18 years. Family therapy is also useful to help
members be effective participants in the client’s
treatment. Family-based early intervention can
prevent future exacerbation of anorexia when
families are able to participate in an effective
manner. However, in a dysfunctional family,
significant improvements in family functioning may
take 2 years or more.
Individual therapy
● May be indicated in some circumstances; for
example, if the family cannot participate in family
therapy, if the client is older or separated from the
nuclear family, or if the client has individual issues
requiring psychotherapy.
● Therapy that focuses on the client’s particular
issues and circumstances, such as coping skills,
self- esteem, self-acceptance, interpersonal
relationships, and assertiveness, can improve
overall functioning and life satisfaction.
● CBT, long used with clients with bulimia, has been
adapted for adolescents with anorexia nervosa and
used successfully for initial treatment as well as
relapse prevention.
● Enhanced cognitive–behavioral therapy (CBT-E)
has been even more successful than CBT. In
addition to addressing the body image disturbance
and dissatisfaction, CBT-E addresses
perfectionism, mood intolerance, low self- esteem,
and interpersonal difficulties
B. Bulimia nervosa
● often simply called bulimia
● an eating disorder characterized by recurrent
episodes of binge eating followed by inappropriate
compensatory behaviors to avoid weight gain, such
as purging, fasting, or excessively exercising.
● The amount of food consumed during a binge
episode is much larger than a person would
normally eat.
● Between binges, the client may eat low-calorie
foods or fast. Binging or purging episodes are often
precipitated by strong emotions and followed by
guilt, remorse, shame, or self-contempt.
● weight of clients with bulimia is usually in the
normal range, though some clients are overweight
or underweight
● Recurrent vomiting destroys tooth enamel, and
incidence of dental caries and ragged or chipped
teeth increases in these clients. Dentists are often
the first health care professionals to identify clients
with bulimia.
● Clients with bulimia may also exhibit high
impulsivity, sensation seeking, novelty seeking, and
traits associated with borderline personality
disorder.
Onset and Clinical Course
● Usually begins in late adolescence or early
adulthood; 18 or 19 years is the typical age of
onset.
● Binge eating frequently begins during or after
dieting.
● Between binging and purging episodes, clients may
eat restrictively, choosing salads and other
low-calorie foods. This restrictive eating effectively
sets them up for the next episode of binging and
purging, and the cycle continues.
● Aware that their eating behavior is pathologic, and
they go to great lengths to hide it from others. (store
food in secret locations or drive from one fast food
 to another ordering normal amount but stopping at
six places for 1-2 hours)
● Clients with bulimia had 45% full recovery, while
23% remained chronically ill (Call et al., 2017).
One-third of fully recovered clients relapse.
● Clients with a comorbid personality disorder tend to
have poorer outcomes than those without. The
death rate from bulimia is estimated at 3% or less.
● Outpatient basis
● Hospital admission is indicated if binging and
purging behaviors are out of control and the client’s
medical status is compromised.
● Most clients with bulimia have near-normal weight,
which reduces the concern about severe
malnutrition, a factor in clients with anorexia
nervosa.
Treatment and Prognosis
A. Cognitive-Behavioural Therapy
● most effective
● requires detailed manual to guide treatment
● Strategies designed to change the client’s thinking
(cognition) and actions (behavior) about food focus
on interrupting the cycle of dieting, binging, and
purging and altering dysfunctional thoughts and
beliefs about food, weight, body image, and overall
self-concept.
● Web-based CBT, including face time with a
therapist, has been effective as well as traditionally
delivered CBT. Smartphone applications (apps) for
eating disorder self-management are acceptable
B. Psychopharmacology
● Desipramine (Norpramin), imipramine (Tofranil),
amitriptyline (Elavil), nortriptyline (Pamelor),
phenelzine (Nardil), and fluoxetine (Prozac), were
prescribed in the same dosages used to treat
depression
● Antidepressants were more effective than were the
placebos in reducing binge eating. They also
improved mood and reduced preoccupation with
shape and weight; however, most of the positive
results were short term. It may be that the primary
contribution of medications is treating the comorbid
disorders frequently seen with bulimia.
Related Disorders
A. Binge eating disorder
- characterized by recurrent episodes of
binge eating; no regular use of
inappropriate compensatory behaviors,
such as purging or excessive exercise or
abuse of laxatives; guilt, shame, and
disgust about eating behaviors; and
marked psychological distress.
- >35, common in men, overweight
B. Night eating syndrome
- characterized by morning anorexia,
evening hyperphagia (consuming 50% of
daily calories after the last evening meal),
and nighttime awakenings (at least once a
night) to consume snacks. It is associated
with life stress, low self-esteem, anxiety,
depression, and adverse reactions to
weight loss
- obese, SSRI
C. Eating or feeding disorders in childhood include
pica, which is persistent ingestion of nonfood
substances, and rumination, or repeated
regurgitation of food that is then rechewed,
reswallowed, or spit out. Both of these disorders
are more common in persons with intellectual
disability.
D. Orthorexia nervosa
- Sometimes called orthorexia, is an
obsession with proper or healthful eating. It
is not formally recognized in the Diagnostic
and Statistical Manual of Mental Disorders,
fifth edition, but some believe it is on the
rise and may constitute a separate
diagnosis. Others believe it is a type of
anorexia or a form of
obsessive–compulsive disorder.
Additional info:
● Comorbid psychiatric disorders are common in
clients with anorexia nervosa and bulimia nervosa.
Mood disorders, anxiety disorders, and substance
abuse/dependence are frequently seen in clients
with eating disorders.
● Depression and OCD are common
● Both anorexia and bulimia are characterized by
perfectionism, obsessive–compulsiveness,
neuroticism, negative emotionality, harm avoidance,
low self-directedness, low cooperativeness, and
traits associated with avoidant personality disorder.
● Often linked to a history of sexual abuse, especially
if the abuse occurred before puberty
● Childhood neglect, both physical and emotional, is
also associated with eating disorders
-pica
-rumination disorder
I. Tic Disorders (Ella)
● A tic is a sudden, rapid, recurrent, nonrhythmic,
stereotyped motor movement or vocalization.
● Tics can be suppressed but not indefinitely
● Stress exacerbates tics, which diminish during
sleep and when the person is engaged in an
absorbing activity.
● Common simple motor tics:
○ blinking, jerking the neck, shrugging the
shoulders, grimacing, and coughing.
● Common simple vocal tics:
 ○ clearing the throat, grunting, sniffing,
snorting, and barking
● Complex vocal tics
○ repeating words or phrases out of context,
coprolalia (use of socially unacceptable
words, frequently obscene), palilalia
(repeating one’s own sounds or words),
and echolalia (repeating the last-heard
sound, word, or phrase)
● Complex motor tics
○ facial gestures, jumping, or touching or
smelling an object.
● Tic disorders tend to run in families
● Abnormal transmission of the neurotransmitter
dopamine is thought to play a part in tic disorders
● Tic disorders are usually treated with risperidone
(Risperdal) or olanzapine (Zyprexa), which are
atypical antipsychotics
● It is important for clients with tic disorders to get
plenty of rest and to manage stress because fatigue
and stress increase symptoms
-tourette’s disorder
● involves multiple motor tics and one or more vocal
tics, which occur many times a day for more than 1
year
● The complexity and severity of the tics change over
time, and the person experiences almost all the
possible tics described previously during his or her
lifetime
● The person has significant impairment in academic,
social, or occupational areas and feels ashamed
and self-conscious
● rare disorder (4 or 5 in 10,000) is more common in
boys and is usually identified by 7 years of age
● Some people have lifelong problems; others have
no symptoms after early adulthood
-Chronic Motor or tic disorder
● Chronic motor or vocal tic differs from Tourette
disorder in that either the motor or the vocal tic is
seen, but not both
J. Elimination Disorders (Christa) page 422
-transient tic disorder
● Transient tic disorder may involve single or multiple
vocal or motor tics, but the occurrences last no
longer than 12 month
-Motor Skills Disorder
● essential feature of developmental coordination
disorder is impaired coordination severe enough to
interfere with academic achievement or activities of
daily living
● This diagnosis is not made if the problem with
motor coordination is part of a general medical
condition, such as cerebral palsy or muscular
dystrophy
● becomes evident as a child attempts to crawl or
walk or as an older child tries to dress
independently or manipulate toys such as building
blocks.
● Developmental coordination disorder often coexists
with a communication disorder
● Its course is variable; sometimes lack of
coordination persists into adulthood
● Schools provide adaptive physical education and
sensory integration programs to treat motor skills
disorder
● Adaptive physical education programs emphasize
inclusion of movement games such as kicking a
football or soccer bal
● Sensory integration programs are specific physical
therapies prescribed to target improvement in areas
where the child has difficulties.
○ For example, a child with tactile
defensiveness (discomfort at being touched
by another person) might be involved in
touching and rubbing skin surfaces
● Stereotypic movement disorder is characterized by
rhythmic, repetitive behaviors, such as hand
waving, rocking, head banging, and biting, that
appears to have no purpose
○ Self-inflicted injuries are common, and the
pain is not a deterrent to the behavior
○ Onset is prior to age 3 years and usually
persists into adolescence.
○ It is more common in individuals with
intellectual disability
○ Comorbid disorders, such as anxiety,
ADHD, OCD, and tics/Tourette syndrome,
are common and often cause more
functional impairment than the stereotypic
behavior
- elimination disorders depends on the ff:
- limitations on the child’s social activities
- effects on self-esteem
- degree of social ostracism by peers
- anger, punishment, and rejection on the
part of parents or caregivers
- common in boys
- Nursing management:
- behavioral approaches:
- pad with a warning bell, and to positive
reinforcement for continence
- Medical management:
 - psychological treatment
- may improve the elimination
disorder
- indication: children with a disruptive
behavior disorder
- - lengthy and elaborate
Encopresis (4 y.o)
- repeated passage of feces in INAPPROPRIATE places:
- clothing
- floor
- by at least 4 y.o (chronologically or developmentally)
- persist with intermittent exacerbations for years
- rarely chronic
- involuntary BUT can be intentional
- Involuntary encopresis
- associated constipation
-psychological, not medical, reasons.
- Intentional encopresis
- associated with oppositional defiant
disorder (ODD) or conduct disorder
Enuresis (5 y.o)
- repeated voiding of urine during the day or at
night into clothing or bed
- By at least 5 y.o (chronologically or
developmentally)
- Involuntary:
- disruptive behavior disorder
- children with enuresis (GENETICS)
- 75% have a first-degree relative who has
had the disorder
- no coexisting mental disorder
- continent by adolescence
- 1% persist into adulthood.
- PHARMACOLOGIC MGMT:
- imipramine (Tofranil)
- antidepressant
- side effect: urinary retention.
K. Sleep disorders (Nasnin) page 484
Parasomnias
● abnormal behavioral or psychological events
associated with sleep, specific sleep stages, or
sleep– wake transition.
● involve activation of physiological systems:
-autonomic nervous system
- motor system
-cognitive processes
Nightmare disorder
● Repeated occurrence of frightening dreams
● lead to waking from sleep.
● dreams
-provoking anxiety or terror
● trouble returning to sleep
● experience significant distress
● lack of sleep
● no widely accepted treatment.
Sleep terror disorder
● Repeated occurrence of abrupt awakenings from
sleep associated with a panicky scream or cry
● confused and upset upon awakening
● no memory of a dream either at the time of
awakening or in the morning
● difficult to fully awaken or console the child
● go away in adolescence.
Sleepwalking disorder
● Repeated episodes of complex motor behavior
initiated during sleep
● getting out of bed and walking around
● appear disoriented and confused
● may be violent.
● return to bed on their own or can be guided back to
bed.
● Occurs most : ages of 4 and 8 years,
● End : adolescence
● No treatment is required
L. Other disorders (Princess)
Separation Anxiety
(p. 530)
- Separation anxiety disorder is excessive anxiety
concerning separation from home or from persons,
parents, or caregivers to whom the client is
attached. It occurs when it is no longer
developmentally appropriate and before 18 years of
age.
- Treatment for anxiety disorders usually involves
medication and therapy.
- Drugs used to treat anxiety disorder: (p.533)
 • Limit intake of caffeine and alcohol.
• Get enough rest and sleep.
• Set realistic goals and expectations, and find an activity
that is personally meaningful.
• Learn stress management techniques, such as relaxation,
guided imagery, and meditation; practice them as part of
your daily routine.

For people with anxiety disorders, it is important to

emphasize that the goal is effective management of stress
and anxiety, not the total elimination of anxiety

Selective autism (Mutism)

- to interact at school or with extended family.
- Decatastrophizing involves the therapist’s use of
questions to more realistically appraise the situation.
- The client uses thought-stopping and
distraction techniques to jolt him or herself
from focusing on negative thoughts.
- Splashing the face with cold water,
snapping a rubber band worn on the wrist,
or shouting are all techniques that can
break the cycle of negative thoughts.
- The therapist may ask, “What is the worst
thing that could happen? Is that likely?
Could you survive that? Is that as bad as
you imagine?”
- Assertiveness training helps the person take more
control over life situations.
- These techniques help the person negotiate
interpersonal situations and foster self-assurance
- They involve using “I” statements to identify
feelings and to communicate concerns or needs to
others.
- Examples include “I feel angry when you turn your
back while I’m talking,” “I want to have 5 minutes of
your time for an uninterrupted conversation about
something important,” and “I would like to have
about 30 minutes in the evening to relax without
interruption.”
Tips for managing stress include the following:
• Keep a positive attitude and believe in yourself.
• Accept there are events you cannot control.
• Communicate assertively with others: Talk about your
feelings to others, and express your feelings through
laughing, crying, and so forth.
• Learn to relax.
• Exercise regularly.
• Eat well-balanced meals.
(p. 529)
- Selective mutism is diagnosed in children when
they fail to speak in social situations even though
they are able to speak.
- They may speak freely at home with parents but fail
- Lack of speech interferes with social
communication and school performance. There is a
high level of social anxiety in these situations
- SAME MANAGEMENT SA SEPARATION
ANXIETY BC ANXIETY DISORDER SAD NI SYA
Reactive Attachment Disorder
(p. 485)
- Reactive attachment disorder (RAD) and
disinhibited social engagement disorder (DSED)
occur before the age of 5 in response to the trauma
of child abuse or neglect, called grossly pathogenic
care.
- The child shows disturbed inappropriate social
relatedness in most situations.
- Rather than seeking comfort from a select group of
caregivers to whom the child is emotionally
attached, the child with RAD exhibits minimal social
and emotional responses to others, lacks a positive
effect, and may be sad, irritable, or afraid for no
apparent reason.
Stereotypic Movement Disorder
(p.954)
- Motor skill disorder
- Stereotypic movement disorder is characterized by
rhythmic, repetitive behaviors, such as hand
waving, rocking, head banging, and biting, that
appears to have no purpose.
- Self-inflicted injuries are common, and the pain is
not a deterrent to the behavior. Onset is prior to age
3 years and usually persists into adolescence.
- It is more common in individuals with intellectual
disability. Comorbid disorders, such as anxiety,
ADHD, OCD, and tics/Tourette syndrome, are
 common and often cause more functional Anxiety
impairment than the stereotypic behavior (Doyle, - An emotion characterized by the feelings of tension,
2017). worried thoughts and physical changes
Autism
Programs for motor skill disorder: - Most severe developmental disability
- Schools provide adaptive physical education and - Appearing within first three years of life
sensory integration programs to treat motor skills - Involves impairments in social interaction - such as
disorder. being aware of other peoples feelings
- Adaptive physical education programs emphasize - Pervasive developmental disorder
inclusion of movement games such as kicking a Hyperkinesis
football or soccer ball. - A condition especially of childhood characterized by
- Sensory integration programs are specific physical hyperactivity
therapies prescribed to target improvement in areas - ADHD
where the child has difficulties. Specific Learning Disorders (SLD’s)
- For example, a child with tactile defensiveness - a developmental disorder that begins by school age
(discomfort at being touched by another person) - Persists into adulthood; more common in males
might be involved in touching and rubbing skin - Involves ongoing problems learning key academic
surfaces. skills, including reading, writing and math
Problems:
Discussion ● Lower academic achievement
Mental retardation ● Lower self-esteem
- Intellectual disability (Intellectual ● Higher rates of dropping out of school
Developmental Disorder) is the new term ● Higher psychological distress
- Places greater emphasis on adaptive skills and ● Poor overall mental health
environmental support needs ● Higher rates of unemployment
- Severity is now defined by the ability to meet the To receive diagnosis, must not be due to:
demands of daily life, as compared to peers ● Intellectual disabilities
- Categorized as mild, moderate, severe or profound ○ Not because you are not given the chance
- A condition with an onset in the developmental to learn
period of life ● External factors
- Originates before the age of 18 ○ Economic or environmental disadvantages
Etiologic factors; or lack of instruction
● Genetic ● Vision or hearing problems or neurologic condition
● Developmental ○ E.g. pediatric stroke or motor disorders
● Acquired syndrome ● Limited english language proficiency
Fear Diagnosis is based on:
- Is a powerful and primitive human emotion - Observation
- It alerts us to the presence of danger - Interviews
Two stages: - History of the learning difficulties
1. Biochemical = universal response - School reports
2. Emotional = highly individualized response - Standardized tests
Phobia - Educational and psychological assessments
- An intense and irrational fear of a specified object
or situation
Four categories:
1. Natural
- Example is lightning
2. Mutilation
- Fear of a part of your body being
impaired
3. Animal
- Fear of animals
4. Situational
- Example fear of being in a public
place

PRERECORDED : Part 1
Anorexia Nervosa
● Eating disorder characterized by an abnormally low
body weight, intense fear of gaining weight and
distorted perception of weight
● High value on controlling their weight
● Engage in extreme efforts to tend to significantly
interfere with their lives
● Slow onset : early adolescence (14-16 y/o)
● may be chronic
● Less common than bulimia n. : mostly females
● Significant weight loss is noted
● Men suffer less
● May suffer with other mental disorders
● May develop bulimia n. Or mental illness
● Poor prognosis may be d/t:
- initial lower minimum weight, purging, later age of
onset
● More life threatening THAN bulimia
● Characterized Distorted body image and intense
fear of becoming fat ----- individual refuses to
maintain a normal weight
● Engage in severe and restricted dieting
● Control calorie intake by vomiting after eating or
misusing laxatives, diuretics ,diet aids or enemas,
exercising excessively
● No matter how much effort, they still think they are
fat
● About self perception : emotional and psychological
● Think they will be accepted more and they have
control over their lives more
● Equate thinness with self-worth or success
● Diagnostic characteristics
- Refusal to maintain body weight
- Intense fear of gaining weight
- Disturbance in way person experiences
body shape or weight
- Undue influence of b.w. Or shape on self
evaluation or denial of seriousness of
current low body weight
- Absence of at least 3 consecutive
menstrual cycles (in post menarchal
females) due to poor nutritional intake
- No food at all
Target symptoms :
● Depressive s/s:
- Depressed mood
- Social withdrawal
- Insomnia
- Etc.
● Obsessive-compulsive features related and
unrelated to food
-obsessing over specific thoughts and acting on
their obsession
-not feel at peace until they act on what they
excessively thought of
-perfectionists
-strict regimen in maintaining or losing weight
-thinness equate to perfection
● Preoccupation with thought of food
● Concerns about eating in public
● Feelings of effectiveness
● Strong need to control one’s environment
● Inflexible thinking
● Limited social spontaneity and overly restrained
initiative and emotional expression
● Physical symptoms (related to starvation s/s)
-thin appearance
-related to starvation the symptoms
-show fatigue and dizziness and fainting
-discoloration in the finger
-oxygen deprivation due to lack of hematocrit and
hemoglobin in the blood due to inadequate food
-thin hair and hair fall
-hair characteristic : soft downy hair covering the
body
-amenorrhea
Physical findings:
● Complaints: constipation, abdominal pain
○ metabolism is affected
● Cold intolerance
○ due to thyroid is affected
● Lethargy and excess energy
● Emaciation
○ Starving and not eating right
● Sig. hypotension, hypothermia , dry skin
● Bradycardia
● Hypertrophy of salivary and parotid glands
○ Attributed to bulimia nervosa
○ Clients with bulimia nervosa also suffer
from binge eating and purging cycle to try
to control their weight.
○ Continually purging after binge eating may
affect their salivary and parotid glands
● Dental enamel erosion
○ Purging out induces the food in the
stomach which is already acidic.
○ When food reaches the mouth and it is
acidic it touches the teeth and from there it
causes erosion.
 ● scars/ calluses on hand dorsum
○ Because they tend to induce vomiting so
the food will not store in the body and not
weight gain
○ Purging causes wounds and then later on
scars on hand dorsum
LAB FINDINGS OF ANOREXIA NERVOSA
● Leukopenia and mild anemia
○ If not picking low caloric they are not eating
at all
○ If they are eating something they get rid of
what they eat
○ So basically nothing is absorbed in the
bloodstream and different tissues to be
nourished
● Elevated BUN
○ Enzyme which measures functionality of
kidney
○ In long run, clients with anorexia nervosa
will have elevated BUN
○ Kidneys get overwhelmed by
undernourishment, it gets damaged
● Hypercholesterolemia
● Elevated liver function tests
● Electrolyte imbalances
○ Attributed to the vomiting episodes induced
of client to get rid of the caloric intake
● Decreases T3 and T4
○ Hormones in thyroid
○ Decreased t3 and t4 wherein client
experiences metabolic problems such as
cold intolerance
● Low estrogen
○ Low estrogen = amenorrhea
● Sinus bradycardia
● Metabolic encephalopathy
● Reduced resting energy expenditure
○ Causes fatigability
● Increased ventricular/brain ratio 2 to starvation
- Client is obsessed with thinness which equates to
perfection
- Mental problem with causes negative effect to the
physical body of the client
PSYCHOLOGICAL CHARACTERISTICS OF ANOREXIA
NERVOSA
● Decreased interoceptive awareness (ex.hunger)
○ Because they don't eat normally and
restrict themselves on a very restrictive and
constrictive diet they tend to not be aware
of being hungry anymore
● Sexuality conflict/fears
○ Less interest in sex
● Maturity fears
● Ritualistic behaviors
○ Attributed to OC features
○ Attributed to being perfectionist
- in anorexia, aside physical characteristics together with it,
it cause some psychological and behavioral symptoms
- behavioral symptoms:
- restrictive dieting
- self induced vomiting
- excessive use and misuse of laxatives to get rid of
calories
- binging
- purging cycle
- psychological manifestations:
- being preoccupied with food and notwithstanding
with preoccupation with food that they prepared
food for everybody but they don’t eat
- like the idea of food but they don’t eat because
they don’t want to get fat.
- frequently skipping meals
- denial of hunger due to decreased interoceptive
awareness
-clients eat on low caloric food only and
obsessed on calorie counting
- satiety part of the brain is affected
- spitting food after chewing because they just want
to taste food
- not wanting to eat in public because lesser
opportunity to induce vomiting after eating
- frequent checking of mirror for perceived loss
- excessing complaining of being fat after checking
in mirror and pointing the body which has fats and
needs to be trimmed down
- excessive layers of clothing to hide fats
- social withdrawal
- irritable
- show signs of insomnia
TYPES OF ANOREXIA NERVOSA
● Restricting type
○ Not regularly engaged in binge-eating/
purging
○ There is adherence to a very strict diet
regimen
○ Client restricts his or her eating habits
○ Eats only a little amount
○ Restrict calories and does not go beyond
specific calories a day
● Binge eating and purging type
○ Regular engagement in both behaviors
○ Eats a lot then right after eating, purges
or induced self-vomiting
■ Both binge eating and purging
■ Misuse laxatives and enemas

COMORBIDITIES OF ANOREXIA NERVOSA
○ Depression-common=suicide
■ Depressed clients dont usually eat
■ They restrict themselves from
eating because they dont have
enough strength to eat
○ Anxiety disorder and mood disorder
■ Because they try to lessen their
anxiety by restricting their food
consumption because it feels like
they have control over something
over a situation
○ OCD-predate dx.of anorexia by 5 years
■ OCD=obsessive compulsive
disorder or obsessive compulsive
personality
■ Has an obsession over a specific
concept or idea so they want to try
to act on it
■ Perfectionist characteristic so being
like that they want to stick to a
certain diet regimen or attain a
specific weight
■ They also has a goal: to be fit due
to they perfectionist personality
○ Alcohol and substance abuse
○ Self-injury, suicidal thoughts or suicide
attempts
■ Related to depression
*Treat anorexia to treat these comorbidities
- KEY: Treat first anorexia nervosa or
restrictive restrictive eating to treat these
comorbidities
- RATIONALE: not eating well may
not have a positive effect response
when you treat right away the
comorbidities
- Ex: Schizophrenia: study shows:
low glucose- cause
- Not eating well can affect our
mental capacity
- CHALLENGE FOR THE CLINICIAN: if
anorexia nervosa is primarily brought by
any of these mental disorder
ETIOLOGY OR CAUSE OF ANOREXIA NERVOSA (3)
1. Biologic-genetic
- Familial predisposition
- Some Genetic traits can be the cause
- Ex: Genetic tendency toward
perfectionism towards sensitivity
and perseverance (biologic cause)
- If you are sensitive of people telling
about your weight so it affects you
mentally
- Ex: Parent Carpenters
- She developed anorexia
nervosa because someone
commented she is fat
- Moral lesson:do not
comment on someone's
weight
- Sensitivity +perfectionism
- Three genetic tendency to cause
anorexia: these traits can be
trace in your genes
1. Perfection
2. Sensitivity
3. Perseverance
- Upbringing is intertwined with
genetics
2. Social/environmental
a. Idealization of thinness (media)
- eX: Karen Carpenter
- Media equates thinness to
attractiveness
- But being thin does not
mean you are attractive
- tHINNESS=GAUGE OF
SUCCESS
- Closely intertwined with
biological cause
- being perfectionist,
- Can be
trace in the
genetics
b. Pursuit of thinness
c. Enmeshment with family
d. Overprotective family
3. Psychological
a. OC personality
- Obsessive compulsive personality
- client tends to be perfectionist on
what she wants to achieve. Like
the previous example mentality
niya kay fitness is equivalent to
success and optimum self
production
b. High levels of anxiety
- Not to eat for the purpose of not
increasing their anxiety
Anorexia Nervosa- Research
Barbie & Ken Dolls
● Implications to Nursing:
- Findings of study can be used to assist
parent in choosing appropriate models for
dolls for children
 - Be careful in using specific aids to
the client or when you will have a
child of your own be careful on who
you set forth as an example
because it will form the minds of
the children and think that if you
always idealize a body shape or
body weight they will think that
specific idealization is equitable to
perfection and if its thinness clients
or children may want to achieve
that specific goal to try to belong
- Provides a basis for helping those with
EDS understand the effect of
environmental cues in an ideal body type at
a young age
Risk factors (Anorexia Nervosa)
● Genetic
○ Those with a first degree relative who had
the disorder have a much higher risk of
anorexia
● Dieting and Starvation
○ Starvation and weight loss may change the
way the brain works in vulnerable
individuals which may perpetuate restrictive
eating behaviors and make it difficult to
return to normal eating habits
■ They don't feel anymore hunger
cos na rewire ila brain
○ Starving in anorexia nervosa the
manifestation are clearly similar with
starvation
○ Starvation affects the brain and influences
mood changes rigidity in thinking, anxiety
and reduction in appetite
○ Changes in the brain programing
○ They dont feel hunger
● Transitions
○ Changes that bring emotional stress and
increase the risk of anorexia
■ Sometimes we react to change
differently and so because of these
specific transitions like for example
change of place of domicile
because you want to pursue a
specific education like nursing.
There's a change in the ppl
surrounding you lets say gikan na
leyte larga ka cebu to study nursing
and together with other loss like
breakup, death, etc can cause
stress and risk for anorexia
nervosa
Goals of Care
● Nutritional rehabilitation
○ Treat first the restrictive dieting or the very
strict eating habit. It has to be treated first
because even if you treat for example
depression, the client is treated with
medication for depression, if her mind or
thought about thinness, if her mind is not
restructured about the idea of thinness she
will still continue eating and together with it
she will always feel inadequate and even if
given a medication for depression it will still
go back because again the root of it all is
not addressed which is for clients with
anorexia it is not just about food, it is about
self image and self worth
○ First address nutritional problems so that
you can effectively address other problems
like psychological or emotional
● Resolving conflicts on:
○ Image disturbance
○ Maturity fears
○ Role conflicts
● Increasing effective coping
● Assisting family with healthy functioning and
communication
○ There may be a need to include the family
in the therapy so that it can be talked about
the roots like genetic tendency and it may
not be attributed as to what specific gene
but then again it may be attributed to
genetic tendency
Treatment
● Restore weight through refeeding (medical unit)
○ Clients with anorexia nervosa this disorder
may show other comorbidities but then do
not treat them first, treat the restrictive
dieting which causes initiation or signs
observation and then after that go to the
emotional or psychological aspects
○ Always treat first the client not eating
anything meaning let her be healthy first, so
that when she will be healthy and she will
eat properly her mind as well will be
properly oxygenated and then from there
the other therapies she can actually come
up with better judgement
● Family therapy - begins while client is hospitalized
● Acute phase: impaired concentration of client to
verbal therapy
○ Art therapy
○ Psychodrama
● SSRIs
○ Not recommended
 ○ Low CHON stores = inability of med to oxidation which ultimately
metabolize causes weight loss
○ May cause weight loss - Preventing excessive
○ Clients who are also depressive are not weight loss
given SSRIs because it has low protein - Monitor 1H after meals for purging
stores and a client with anorexia nervosa - Weigh daily
has already low protein so if they take - Preferably in the morning
SSRIs they will not be able to metabolize (no meals)
the drugs so it will be ineffective and will - Client should be wearing
cause more weight loss the same clothing apparel
● Antidepressants- for comorbidity - Monitor V/S and electrolytes
● Clients are suspicious and mistrustful of care - Praise
providers= “make them fat” - Positive reinforcement,
○ Build therapeutic relationship established in praise but do not sugarcoat
trust because client may be suspicious and - Praise according to facts
distrustful of caregivers and they might - Do not overdo as it may
think of you as you want to make them give false hope
fatter - Make them feel good but
● Clients are irritable and impatient d/t starvation not at the point of lying
○ Let the client eat so that they can have - If they realize it is a lie,
better judgement they will feel bad about it
and cause them to go back
Therapeutic relationship to their usual adaptive
● Firm, accepting approach pattern
● Provide rationales for interventions II. Disturbed Body Image
○ To mitigate their being suspicious and (distorted body image on which they see
distrustful and make them understand why themselves as fat even if they are thin)
you want to make them eat because if you - Explore and clarify feeling towards
won't explain these things to them they body
might think that you just want them to be fat - Maintain a nonjudgmental
● Power Struggles over eating: nurse should think of approach
own feelings of frustration and need of control - Stay within the limits or
○ Put yourself in the clients shoes because boundaries of the
we may tend to be fixated on reaching the therapeutic relationship
goal but then again we have to understand - Make them open up on
that the process of reaching it has the what’s causing these
same importance as obtaining it behaviors and why they
Care Plan think the way they do
I. Imbalanced Nutrition: less than body - Engage in talk therapy
requirements - You’ll be able to draw out
- Primary nsg problem why they do not eat or
- Encourage verbalization have a restrictive diet,
- Monitor meals and snacks which causes bad or
- To check if client is eating negative effect on the body
as prescribed, really taking - Assist in identifying positive
it in and not bridging it out physical characteristics
- May show signs of bulimia - To see positive side of
nervosa things
- Don not substitute other foods for - Health Education
food on tray - Normal physical growth
- Limit caffeine = 1 cup coffee/soda - Role of fat in body
daily protection
- Black coffee increases - Grooming for a more
metabolism and causes fat attractive look
Intervention Summary ● Trust
● Biologic ● Realistic goal setting
1. Assess and monitor somatic s/s ● Resources
- Physical manifestations which are - Enroll them to a support group in order for
attributed to weight loss below their them to know they are not alone
bmi
2. Weigh OD
3. Record all intake 2nd video
4. Supervise bathroom if purging BULIMIA NERVOSA
- Check if not inducing vomit - Commonly known as bulimia
5. Est. normal sleep routine - serious , life threatening eating disorder (anorexia
6. Antidepressant has more life threatening than bulimia)
7. Monitor exercise - Clients mays secretly binge, eat in large amounts
- May engage in excessive exercise of food with loss of control and tend to lose
to lose weight calories right after in an unhealthy way
● Social - Newly identified disorder
1. Supportive but firm - Usual treatment: outpatient therapy
- Within the therapeutic relationship - Has better outcomes that AN and has lower
boundary mortality rates
2. Include family - Binge on high caloric food
- One cause is genetics
3. Suggest resources for information CHARACTERISTICS
4. Assist with discharge plans Binge eating
● Psychological - Rapid, episodic, impulsive, and uncontrollable
1. Est. trust ingestion of a large amount of food during a short
2. Diary period of time, 1-2 hours
- To jot down emotions - “Dietary restraint” - precipitate the next binge
- To write out negative mental - No sweets, fats, etc
regurgitations - Described as a way to explain the rel. With
- To avoid client punishing oneself dieting and binge eating
- Help client identify negative and - Must be resolved to prevent future binge
maladaptive thoughts eating
- Awareness is key - Right after binge eating, they tend to feel
- Help them correct their guilty about it
maladaptive disorders - Feel guilty so they restrict themselves and
3. Correct cognitive distortions then engage again in another binge cycle
4. Dance therapies/enc. Movement (binge eating-purging cycle) or binge-purge
5. Assist with realistic goal setting cycle
6. Educate - Undoing to try away with their guilt
Additional:
- Anorexia nervosa show very low weight compared SYMPTOMS
to bulimia - Being preoccupied with your body shape and
- With bulimia, it would range from normal to weight
overweight - Clients want to achieve a certain body
Psychoeducation Checklist weight but they don’t have low weight just
● Psychopharmacologic agents like in AN
● Nutrition and eating patterns - Living in fear of gaining weight (they try to purge
● Effect of restrictive eating or dieting after eating to get rid of calories)
● Weight monitoring - Repeated episodes of eating abnormally large
● Safety and comfort measures amounts of food in one sitting
● Avoidance of triggers - Feeling a loss of control during bingeing - unable to
○ Risk factor of anorexia nervosa is control or stop eating
transitions which will trigger anxiety and - Forcing yourself to vomit or exercising too much to
would result to restricted regimen keep from gaining weight after bingeing
● Self-monitoring techniques
 - Using laxatives, diuretics, or enemas after eating
when they’re not needed (to get rid of calories they
took in)
- Fasting, restricting calories or avoiding certain
foods between binges
- Using dietary supplements or herbal products
excessively for weight loss
- Clients with bulimia nervosa don't really achieve
very low weight, they either have normal weight or
slightly overweight
- Difference with anorexia nervosa:
- Binge eat and does not have a really low
wight (normal or overweight)
- Binge-purge cycle
- Eat alot---> vomit
RED FLAGS (they say this)
● Constantly worrying or complaining about being fat
● Having a distorted, excessively negative body
image
- Continually negates and talks bad about
themselves, specifically about weight.
● Repeatedly eating unusually large quantities
especially foods they normally avoid
- Ex. cakes, meat, or foods high in calories
- Finish food in a very short period of time
and eat in large amounts.
● Strict dieting or fasting
● Not wanting to eat in public or infront of others
- Does not want to eat in public, because it
will lessen the chance of purging after
binge eating.
● Going to the bathroom right after eating, during
meals or for long periods of time
● Exercising too much
● Having sores, scars, or calluses on the knuckles or
hands
● Having damages teeth and gums
- Stomach contents are highly acidic that it
damages gums and teeth after vomiting
● Changing weight
- It’s like engaging in a yo-yo diet. Binge
eating to restrictive eating. Dietary restraint
will trigger another binge eating.
● Swelling in the hands and feet
● Facial and cheek swelling from enlarged glands
-You can encourage them to seek help but do not force
them
- they’re happy they whatever, they feel
RISK FACTORS:
● Biology. People with first-degree relatives (siblings,
parents or children) with an eating disorder may be
more likely to develop an eating disorder,
suggesting a possible genetic link. Being
overweight as a child or teen may increase the risk.
- Tendencies of being perfectionist, showing
perseveration and for being sensitive
● Psychological and emotional issues.
Psychological and emotional problems, such as
depression, anxiety disorders or substance use
disorders are closely linked with eating disorders.
People with bulimia may feel negatively about
themselves. In some cases, traumatic events and
environmental stress may be contributing factors.
- Societal expectations
- Thinness = attractiveness/success
- They fall short in controlling the external
stressors
- Try to control themselves internally, and
form maladaptive behaviors.
- People with depression may engage in
maladaptive behaviors because they are
depressed, and some neurochemical
imbalance, the way they think and
judgement is affected.
- People with anxiety disorders will tend to
manage their anxiety by managing or
controlling what they eat which will
ultimately have an effect in themselves that
they will feel worthy.
● Dieting. People who diet are at higher risk of
developing eating disorders. Many people with
bulimia severely restrict calories between binge
episodes, which may trigger an urge to again binge
eat and then purge. Other triggers for bingeing can
include stress, poor body self-image, food and
boredom.
- You feel like you’ve used all other possible
methods of trying to lose weight and yet
you’re not achieving the results that you
want. Sometimes, a client who is obsessed
with dieting will engage in peace behavior
so that the person can lower her weight
even more or she can get her weight a
much lower .
- It can also be attributed with stress.
Because according to studies, the more
stress an individual is, the more he or she
engages into some eating sprees for
episodes and to try to cope up with stress.
- There are some individuals for emotional
eaters. If they’re stressed they eat, if
bored, happy, sad lonely they eat. These
individuals and these unreasonable
patterns which is attributed to dieting
includes causes as a risk factor for
developing Bulimia Nervosa.
 - Those time with poor body self image
because these eating disorders are not just
about food. It is about something deeper
which is something internal, emotional,
psychological and something found
mentally.
- In other words, when we know all these,
then we know if we’re aware, we can better
have control over it with ourselves and of
course other people.
Physical Findings in Bulimia Nervosa
● Loss of dental enamel
- Due to erosion of dental enamel because
you purge your tooth bridges
- Induce yourself in vomiting. When you
vomit, those materials are not completely
digested, mixed with hydrochloric acid. So
these acidic materials will go to your mouth
and touch your teeth causing dental
enamel erosion and loss.
● Chipped, ragged, or moth-eaten appearance
● Increased incidence of dental caries
- Because they usually eat foods that are
high caloric like sweets and because of
their oral hygiene.
● Scars on dorsum of hand (from manually inducing
vomiting)
● Cardiac and skeletal myopathies (from use of syrup
of ipecac. ’vomiting’)
- Because when they try to induce vomiting
and to effectively do that, a manual
induction of vomiting with the use of their
hands. If there will be a failure of vomiting,
then they will use other alternatives for
methods which is the use of syrup ipecac. It
is a substance that can induce vomiting.
That will actually in the long run can cause
cardiac and skeletal myopathies.
● Menstrual irregularities
- Because they’re deprived with specific nutrients,
vitamins and minerals and their tissues are not
properly nourished and since their tissues are not
properly nourished then it will cause a negative
effect in their reproductive health and cause
menstrual irregularities.
● Laxative dependence
- These manifestations will be seen in clients
who are diagnosed chronically with bulimia
nervosa.
- The client can no longer defecate without
the use of laxative so that will cause other
physical problems.
- Bulimia is a mental disorder and yet it
affects your physical health.
- Another living example or manifestation
that mental health cannot be overlooked or
rushed off, because if you don’t take good
care of your mental health, it will bring
down to your all aspects of your life such as
physical but also emotional, psychological
occupation. It will affect your relationship,
your judgement, the way you decide, the
way you live your life which also ultimately
affect the quality of your life. If it affects
your quality of life, it will affect not just work
but also society in general.
● Esophageal tears
- It occurs because of constant purging
episodes and is attributed by continuous
passage of highly acidic materials from
your stomach.
Lab Findings of Bulimia Nervosa
● Fluid & electrolyte abnormalities
- Because the client purges, so clients may
show electrolyte imbalances and elicit
physical manifestations.
● Metabolic alkalosis - vomiting
● Metabolic acidosis - diarrhea
● Mildly elevated serum amylase levels
- Because the constant purging episodes.
RECAP FOR 2ND VID
Psychoeducation Checklist : Bulimia
● Psychopharmacologic agents
- Just like you anorexia nervosa, your
Bulimia may be associated with other
comorbidities like depression, anxiety and
more, substance abuse, suicidal thoughts.
With those medications, treating those
specific comorbidities will also help and
antidepressants may be given the doctor’s
order.
● Binge-purge cycle and effects on body
- Should be taught to the client. Health
teaching is important
● Nutrition and eating patterns
- Include health teaching about proper
hydration because remember your client,
due to constant purging, your client will
experience hydration problems and
metabolic disorders.
● Hydration
 - Hydrate your client for doctors’ order it - BED is one of the newest eating disorders
means water may not be sufficient because formally recognized in the DSM-5.
of the metabolic acidosis and metabolic - Then: subtype of EDNOS Eating Disorder
alkalosis caused by vomiting and diarrhea None Other Specified
so, there may be a need to give specific - Now: OSFED Otherwise Specified Feeding
electrolytes like potassium, sodium that will or Eating Disorder
be administered. *The change is important insurance companies will
● Avoidance of cues not cover eating disorder treatment without a DSM
● Cognitive distortions diagnosis
- By completing behavioral therapy. It is a BINGE EATING DISORDER (BED) Criteria
therapy where there is an attempt to try - Binge-eating
changing the client’s perspective or how by - Large amount in short period of time
engaging into a talk therapy. Either - Sense of loss of control during binge
one-on-one therapy or group therapy, - Distress-binge
where the client is allowed to express - Eating until uncomfortably full
his/her feelings and emotions so that the - Feelings of guilt and depression
therapist can explore as to the very root - NO PURGING
cause of the disorder. If the disorder is - Lower “dietary restraint” and higher in
pinpointed, then, the being aware the client weight (not many are obese)
has better chances of doing something Research
about it and coping. - SHAPIRA, GOLDSMITH, & McElroy, 2000
● Limit Setting - CBT - not effective in BED but in B.N.
- To know the boundaries of therapeutic (Bulimia Nervosa)
relationship - Meds = reduces binges: (needs further
● Assertiveness studies) already given to patients
● Resources - Sertraline
● Self-monitoring & behavioral interventions - Topiramate (for epilepsy)
● Realistic goal setting - Also reduces appetite
- Bulik, et.al., 1998
3rd video - Women with bulimia: binged without
BINGE EATING DISORDER (BED) purging years before developing B.N.
- From the name itself, you can say here that the - Started as young as 10 y/o
client experiences episodes of binge eating as
regards to bulimia nervosa wherein there is a binge
eating purging cycle and then from there, is a
dietary restriction wherein the client does not eat
anything and restricts in eating high-caloric food
and would rather resort to not eating sweets or
high-fat food, and then from that dietary restraint, it
will then trigger another binge-eating purging
episode or cycle
- It’s just binge eating, wherein the client engages in
an uncontrollably eating spree in a short period of
time
- Severe, life-threatening but TREATABLE just like
bulimia nervosa and anorexia nervosa
- It is the most common eating disorder in the United
States.
- APA, 2000
- Still in research stage
- For inclusion in DSM-IV-TR
- 3%-4% of population
- 10%-30% of obese individuals have BED
BED-Then & Now
PICA
- An eating disorder that involves eating items that
are not typically thought of as food and that do not
contain significant nutritional value
- e.g. hair, dirt, and paint chips ice? or even
soap
- Common in children and pregnant women
Warning Signs and Symptoms
- The persistent eating, over a period of at least one
month
- Substances that are not food and do not
provide nutritional value
- Not part of culturally supported or socially
normative practice
- e.g., some cultures promote eating
clay as part of a medicinal practice
- Subs. ingested tend to vary with age and
availability
- Paper, soap, cloth, hair, string,
wool, soil, chalk, talcum powder,
paint, gum, metal, pebbles,
charcoal, ash clay, starch or ice.
- Children under 2 y/o of age should not be
diagnosed with pica since they typically put
anything and everything in their mouth because
they are in the oral stage, because it is part of their
developmental stage
Risk Factors
- Associated with impaired functioning
- e.g., intellectual disability, autism spectrum
disorder (austistic disorder, rett syndrome
and aspergers), schizophrenia
- Iron-deficiency anemia and malnutrition
- Most common causes of pica
- Followed by pregnancy
Diagnostic (Dx) Tests
- No laboratory tests that can help diagnose with
PICA however, it can be categorized by the clinician
with unraveling the clinical history of the mind
asking for medical history
- Diagnosis is made from a clinical history of the
client
- Dx accompanies by tests for:
- Anemia
- Potential intestinal blockages
- Toxic side effects of substances consumed
- Ex: lead in patient, bacteria or
parasites from dirt
- There’s no specific diagnostic test that can
specifically diagnose however there are some
diagnosis which may indirectly identify what specific
particles are eaten and then can deduce that the
client is really eating substances that doesn't have
any nutritional value because it will be show that
the client already developed anemia, for example or
potential intestinal blockages or other toxic side
effects because of what the client ate that are not
food or doesn't have any nutritional value
Treatment
- First-line treatment: testing for mineral or nutrient
deficiencies
- then finding out what mineral or nutrient
deficiencies are lacking or absent then the doctor or
clinician can actually give supplements to try to
address that
- Behavioral interventions
- Involve trying to find out or exploring the very
reason why the client engages in such behavior
which is associated with intellectual disabilities or
autism spectrum disorder or mental illness like
schizophrenia
- Then if we’ll be able to/ clinician will be able to find
that out then a more specific and tailored fit
behavioral interventions will be given to client
- Aversion therapy
- Client will be put in specific programs to make sure
that the client will avoid those specific materials that
he/she specifically seeks to eat
- Scientists in the autism community:
- Redirecting the person’s attention away
from the desired object
- Rewards system
RUMINATION DISORDER
- Regular regurgitation of food that occurs for at least
one month
- Regurgitated food may be re-chewed, re-swallowed
or spit out
- Typically, when someone regurgitates their food,
they don’t appear to be making an effort, nor do
they appear to be stressed, upset or disgusted
- The client regurgitates the food that’s already in the
stomach is propelled back from the stomach to their
esophagus then finally to the mouth and there it’s
either rechewed, swallowed back or spit out
Etiology
- Primarily occurs in infants
- Also more common in people with mental
retardation/ intellectual disability
- Often in males
 - People who have A.N. or B.N may begin to
ruminate only in adult life
- 20% of people with bulimia may ruminate
Symptoms
- The person often appears to take pleasure in the
act = “MERYCISM”
= client feels pleasure/ comfortable about the idea
of rechewing, re-swallowing or not spitting it out
right after the food is propelled from the stomach
going back to the oral cavity
- Foul or sour odor of breath
= breath is foul because it’s been regurgitated from
the stomach and it has a sour odor because of the
HCl / hydrochloric acid mixed with the food
- INFANTS:: attempts to bring up food
● Putting fingers in the mouth, sucking on the
tongue, and arching the back
● The cheeks expand and appear puffed
when food is brought up
● Some infants, especially those who have
just begun ruminating, will expel most or all
of the regurgitated food from their mouths
● It is often mistaken for normal infant
vomiting
Diagnosis (Dx) Criteria
DSM-IV-TR:
- Three (3) general criteria:
- Person’s behavior of deliberately bringing
up and rechewing food must have lasted
for at least a month
- Regurgitation and rechewing must happen
after a period of time in which the person
didn’t ruminate
- Rumination can’t result from a medical
condition such as esophageal reflux
= in addition, the manual specified that the rumination can’t
be associated with anorexia or bulimia
= if there is anorexia or bulimia then it’s not rumination
disorder
= if there’s been bringing up and rechewing of food and it
didn’t last for a month then there’s no rumination disorder
Diagnostic (Dx) Tests
- High resolution Esophageal Manometry
= confirm the diagnosis
= provides an image of the disordered function for
use in biofeedback
= during biofeedback, the imaging can help the
patient’s diaphragmatic breathing skills to
counteract regurgitation
- Esophagogastroduodenoscopy
= to rule out any obstruction
= to rule out presence of GERD in order for
rumination disorder to be diagnosed
- Gastric emptying
= determines how long it takes food containing a
marker to empty stomach
= can measure how long it takes food to travel
through your small intestine and colon
- SIngle-photon emission computerized
tomography (SPECT) of the stomach
= a type of nuclear imaging test which means it
uses a radioactive substance and a special camera
to create 3-D pictures which will then help in
identifying or checking the gastric emptying ability
of the client
Reminder from miss:
“It doesn’t really follow if you’re thin, you’re pretty, or if
you’re fat, you’re pretty. It’s not about your weight, whether
you’re pretty, beautiful, or not rather it is about how you
conceive yourself, it is about how you value yourself. We
can always look into that through self-awareness.”
Treatment
- Parent education
- Breathing exercises
- Breathing properly will stop the food from
regurgitating
- May give meals - person with MR
- Habit reversal
- Child learns to prevent rumination habit by
replacing it with deep breathing techniques
9 TRUTHS OF EDs-by many authors
1. Many people with eating disorders may look
healthy, but are extremely ill
2. Families are not to blame
3. An eating disorder diagnosis is a health crisis that
disrupts personal and family functioning
4. Eating disorders are not choices, but serious
biologically influenced illnesses
5. Eating disorders affects all people
6. Eating disorders carry an increased risk for both
suicide and medical complications
7. Genes and environment play important roles in the
development of eating disorders
8. Genes alone do not predict who will develop eating
disorders
9. Full recovery from an eating disorder is possible.
Early detection and intervention are important
FAMILY & FRIENDS: How can they help
● SHow concern; suggest in seeking professional
help
● Refused pro’s help: Encourage to reach out to an
adult (teacher, school nurse, counselor)
● Try talking about things other than food, weight,
counting calories, and exercise
● Avoid making comments on appearance
● Do not force the person to eat
 ● Offer support but change is within the client himself - Temporary or transient blocking of
● Read and educate self on these EDs the airway. This will deprive the
brain with oxygen
Prevention Strategies - Occurs: dozen times of
Parents Education sleep interactions that may
● Real vs. ideal weight give rise to sleepwalking
● Influence of attitudes, behaviors, teasing - Who Frequently bed wets
● Ways to increase self- esteem - Bed wetting: related to stress
● Role of media - Because stress causes disruption
● s/s of sleep and increase propensity
● Interventions of obesity for sleepwalking
● Boys at risk also - Has fever
● Observe for rituals - Common cause
● Supervision of eating & exercise - Because of increase number of
illness driven arousals during the
Children education night
● Peer pressure ( eating & weight) - Ill patient are delirious
● Menses, puberty,normal weight gain - They create scenarios that
● Strategies for obesity may increase tendency of
● Ways To develop/improve self-esteem sleepwalking
● Body image traps: media, retail clothing - Stressed
● Adapting & coping with problems - Related to bed wetting
● Reporting friends with s/s - Unfamiliar surroundings
● SAF - Cause: stress
-screening risk factors - Medication
-assessment for tx - Sedation medication/ sedatives
-Folllow- up for relapse - Push people in a type if
sleep that can increase
chances of having
PART 4 sleepwalking episodes
SLEEP DISORDERS - Alcohol
- Drinking alcohol in the evening
SLEEP WALKING - This can create instability
● “Somnambulism” in the persons sleep
● Form of parasomnia stages and heightens risk
- sleep disorder that causes abnormal behavior for sleepwalking
while sleeping - May be difficult to awaken the individual and will
- behavior : occur at a transition in sleep probably not remember sleepwalking incident (diff
- travels between the border of sleep and part of the house or outside)
wakefulness - Usually outgrow overtime
● More common in children (3-7 years old and peaks - Very curable
at 8-12 y/o) BEHAVIORS that may be manifested: s/s: (Complex
● CAUSES: Behaviors)
- Genetics - Most obvious: walking
- Familial predisposition - May quietly walk toward a light or to the
- Sleep deprived parent’s bedroom
- due to more time spent in deep - Sitting up in bed and looking around
sleep after a period of sleep - Walking around the room or house
deprivation. - Leaving the house (opening door/window)
- With sleep apnea - Sleep talking and sleep terrors (Screaming)
- Disorder - Urinating in closets: inappropriate behavior
- Airway gets block which causes - Very dangerous: get out of the house and drive the
short lapses of breath during sleep car
- May be at risk for danger

DIAGNOSIS (Sleepwalking)
- Physical exam.
The doctor may do a physical exam to identify any
conditions that may be confused with sleepwalking,
such as nighttime seizures, other sleep disorders or
panic attacks.
- Should rule out any possible causes
because maybe mistaken as a different
condition that's why PE is needed
- Discussion of your symptoms.
Unless you live alone and are unaware of your
sleepwalking, you'll likely be told by others that you
sleepwalk. If your sleep partner comes with you to
the appointment, your doctor may ask him or her
whether you appear to sleepwalk. Your doctor may
also ask you and your partner to fill out a
questionnaire about your sleep behaviors. Tell your
doctor if you have a family history of sleepwalking.
- Dig deep into the client's physical, mental,
familial history.
- Partner should be called upon and provide
information
- Nocturnal sleep study (polysomnography).
In some cases, your doctor may recommend an
overnight study in a sleep lab. Sensors placed on
your body will record and monitor your brain waves,
the oxygen level in your blood, heart rate and
breathing, as well as eye and leg movements while
you sleep. You may be videotaped to document
your behavior during sleep cycles.
- Use of electroencephalogram; overnight
Client’s who sleepwalk are at risk for danger.
What to do: WAKE THEM UP
- Safety first
- Gently guide the child back to bed
- Gently wake up the child (dont shout)
- Will prevent another episode occurring
- If child sleepwalks at the same time every
night, wake them up for a short time (15-30
mins) before the sleepwalk
- DON'Ts:
- Do not shout or startle the child
- Do not try to physically restrain
(except in very severe cases)
● There has been speculations that in sleepwalking
the individual actually lives up or embodies or
exemplifies what is going on in his or her dream.
○ But this is a myth
○ While you are sleepwalking, it occurs in the
deep sleep cycle specifically in the NREM
cycle
○ NREM is engaged in hormonal releases to
allow the body to recuperate and it is not a
part of the sleep cycle which causes you to
have long vivid dreams
○ It is in the REM cycle where dreams are
made and elicited and dreams tend to be
vivid.
○ In sleepwalking, this usually occurs during
the NREM cycle and in NREM there are no
dreams yet
TREATMENT FOR SLEEPWALKING
● Medications
○ Topiramate, antidepressants, dopamine
antagonists, melatonin, levodopa,
benzodiazepines (clonazepam)
○ Check these medications, these are either
mood stabilizers, antidepressants or
muscle relaxants or sedatives.
○ Sleepwalking may be attributed to stress,
or other anxiety or depressive disorders so
giving these medications will help treat the
condition
● Scheduled awakenings
○ Wake up the child about 15-30 minutes
before they spontaneously wake up. It may
help minimize behaviors that follow a
certain pattern.
= or before the usual time they sleepwalk
○ Sleep hygiene: includes different practices
and habits that are necessary to have a
good nighttime sleep quality and full
daytime alertness.
● Cognitive behavioral therapy
○ Psychotherapy, relaxation therapy,
hypnosis = methods
○ As what was mentioned earlier since your
sleepwalking may be attributed to some
mental health concerns like stress and
anxiety so the cognitive behavioral therapy
thus is a common parasomnia treatment
○ CBT is similar to a talk therapy wherein
there’s face to face counselling wherein the
client is asked about his thoughts and his
experiences and feelings regarding
situations which may have brought these
sleepwalking incidents
○ Common method
● Safe sleep environment
○ You create an environment which is safe
for the client who sleepwalks
○ Avoid bunk beds
 = because if the client sleeps at the upper
part of the bunk bed then the client will
need to walk down from that bunk bed
going to the floor out of the room and in II. SLEEP TERRORS & NIGHTMARES
that way the client will be at risk for falls or For of parasomnia
even accidents
○ Remove any sharp or breakable objects
SLEEP NIGHTMARES
from the area near the bed TERRORS
○ Install gates on stairways
= so that the client will be hindered or if not Definition “Night Terrors” “Scary dreams”
will be awakened at the time that he/ she (Part of normal
will pass by the gates installed on stairways development)
○ Lock the doors and windows, place the
Incidence -frequently - More common
mattress on the floor and sleep with extra regresses in children
padding around - PEAK
= so that accidents and falls will be adolescence incidence: 3-6
prevented - PEAK y/o
● Consultation with pediatrician or psychiatrist incidence: 5-7
○ If symptoms persist until adolescence y/o
○ Done to find out if there are other
Risk Factors - Familial history -PTSD-associate
underlying mental disorders that is - Increased d with recurrent
associated with sleepwalking arousals from nightmares
Sleep Hygiene sleep (e.g., OSA, - Family conflict,
● Limiting daytime naps GERD) parental anxiety
● Avoiding stimulants & heavy or rich foods, fatty or “I’m afraid”
fried meals, spicy dishes, citrus fruits, and - Effective
stalling
carbonated drinks especially before going to bed,
tactic or
as much as possible cut caffeinated beverages a way to
when it’s already afternoon so that when night time avoid
comes, it will be easier for the client to sleep bedtime
● Exercising but not before sleeping because
exercising wil cause surge of energy then disrupts Triggers - STRESSORS: - STRESSORS:
fever, sleep toilet training,
sleep
deprivation moving..
● Ensuring adequate exposure to natural light - MEDS: because client is
○ Maintains a healthy sleep-wake cycle stimulants. boltingput in a
● Establishing a regular relaxing bedtime routine Sedatives, tremendous
○ Taking warm shower or bath, reading a antihistamines stress
book, or light stretches - MEDS:
○ Avoid emotionally upsetting conversations antidepressants,
antihistamines
and activities before attempting to sleep
encourage client to drink milk before Sleep Stage - Occurs in the - Occurs during
sleeping first few hours of light, REM (2nd
● Maintaining a pleasant sleep environment sleep (approx. half of sleep)
○ Comfortable mattress and pillows & cool 15-90 mins. Of - Length varies
bedroom falling asleep);
deep, non -
○ Turn lights off or adjust them when possible
REM
○ Blackout curtains, eyeshades, ear plugs, - Frequency &
humidifiers, fans severity varies
 - These can be use as topics during CBT

Parent teaching if a child is scared to sleep:

SLEEP TERRORS & NIGHTMARES
ESSENTIAL TO LESSEN ANXIETY OF THE CHILD
Sleep Terrors Nightmares ● Listen and understand
● Reassurance “REALISTIC”
Event description - Bolting upright, - Child awakes ● Communicate the idea of safety over and over
open eyes, look completely again
frightened or - May involve ● Teach coping skills
agitated anger, fear,
- Screaming, disgust, sadness, ● “Being Brave” and thinking positive thoughts
thrashing of anxiety ● Have fun in the dark
limbs, panic - May have ● Be creative
- Can usually fall difficulty falling ● “Monster spray” pet, bedside fish tank
asleep asleep afterwards ● Security object-GIVING PILLOW to help the child
afterwards sleep
- May sleepwalk,
● Nightlight
mumble
○ Leaving the bedroom door open
Memory of Event - Usually none or - Can vividly ● Avoid scary television shows
forgotten remember ● Relaxation training
○ Relaxing scene, such as lying on the beach
Response to - Cannot be - Can frequently ○ Music
Parents comforted be comforted ● Discuss child’s fears during the day
- Doesn’t know
● Set limits
parents are there
- To Prevent child’s “being scared” behavior
Management - Do not disturb - Gently lay child from being reinforced
child and be near back to bed and
- Provide safety promote usual ● Have child stay in his bed
- relaxation (stroking - Find out for himself that he really is safe
L-5-hydroxytrypt the hair or back) to
● Check on child every 5-10 minutes
ophan (better calm the child
than placebo) - Talk about it: ● Star system
- Child may be daytime only -earn stars for being brave
given milk to - Do not use:
induce sleeping “looking for
- Childproof monsters with a OTHER DISORDERS
house: flashlight”
1. SEPARATION ANXIETY
sleepwalking - Hypnotherapy,
- Prepare CBT ● Excessive fear or anxiety about separation from
caretakers for home or an attachment figure
these episodes ● Normal stage of development for infants and
for them to toddlers
substitute parent ○ Most children outgrow: by about 3 years of
if not there age
○ Most children 3 y.o of age are fit for
excessive fear anxiety away from home
Childrens different fears at different developmental ● Can also occur for adolescents and adults
stages: ○ No longer known as separation but fear in
● Toddlers abandonment
-Parental separation ○ Term adults: fear of abandonment
○ Common in individuals with common
● Preschoolers family ties
-monsters and other imaginary creatures ● This term is common in children
● Tend to come in families that are close
● School Age ● Now categorized as an anxiety disorder
-fear of death or being hurt by more realistic ● Can be present at all stages of life
dangers (burglars or a natural disaster) ● Younger gen would cause this as sepanx
 ● In order for this to become a disorder: it should be
pervasive/naa there all throughout your life
● CAUSES OF SEPARATION ANXIETY:
○ Life stress
■ resettlement
○ Genetics
■ If you have a family member with
this, most likely you will be the
same
● RISK FACTORS OF SEPARATION ANXIETY:
○ Family history
○ Environmental issues
○ Life stresses or loss that result in
separation
■ Change of home, change of status
○ Certain temperaments
■ Personality types which causes
someone to be more melancholic
than others, feel more deeply,
sensitive
■ More susceptible to separation
anxiety
■ Those types that are depressive,
do not open up, keep to
themselves, the quiet ones
■ Disorder: has to be pervasive, in all
aspects of life
■ Introverted
■ Sensitive person
○ Environmental Issues
■ Leads to life stresses or loss of
someone
SYMPTOMS
(There has to be 3 or more symptoms)
● Separation from home or major attachment figures
● Repeated complaints of physical symptoms
(headaches, stomachaches, nausea, vomiting)
○ Seen during separation anxiety disorder
● Repeated nightmares involving the theme of
separation
● Losing or about possible harm, befalling, major
attachment figures
● Untoward event (e.g. getting lost or being
kidnapped)
● Persistent reluctance or refusal to go to school or
elsewhere
● Fearful or reluctant to be alone
● Persistent reluctance or refusal to go to sleep
*prevailing symptom: persistent and reuccurent fear of
attachment from figures
● Duration last for 4 weeks for children and
adolescent and typically 6 months or more in
adults
● Onset: Before age 18 years
○ But may be present in all stages in life
● Disturbance causes clinically significant distress or
impairment
○ This makes it even hard for client
INTERVENTIONS
● Coping and support
○ Practice goodbyes
■ To major attachment figures
○ Encourage client to socially acceptable
coping and adaptive skills
○ Offer client support
■ Make client recall on support
system she has
■ If support not available, encourage
to form new support system
■ Saying goodbye is room for client
to grow and be independent
- Teaching proper adaptive coping skills
- Constant use of defense
mechanism will not let the client
grow
- Form adaptive coping skills
- Offer client support through recall his
support systems
-
● Cognitive Behavioral Therapy (CBT) or Talk
Therapy
- Explore thoughts and feelings of client on
separation
- Perspectives are changed in several
sessions
- Perspective are change (several sessions)
○ To face and manage fears
○ Talk therapy or psychological counseling
○ Client will have face 2 face with therapist
○ Therapist explore emotions and feelings of
client i hopes that it will be corrected
● Antidepressants (SSRIs)
○ Older children and adults
○ Not a mainstay treatment but only manage
symptoms of anxiety
○ Rationale for antidepressant: High levels of
anxiety leads to depression
○
2. SELECTIVE MUTISM
● Inability to speak and communicate but selective
● Now classified as anxiety disorder
● More than 90% of children also have social phobia
or social anxiety
 - Selective individuals: inability to speak
- Able to communicate: he/she trust or warm-up
- Unfamiliar people- selective mutism
- learn to progress verbal communications and feel
● Diagnosed mostly at 3-8 years old
● Consistent failure to speak in specific social (e.g at
school)
● Duration of the disturbance is at least 1 month
● Disturbance interferes with education or
occupational achievement or with social
communication
● Now classified as an anxiety diroder
● More than 90% of children also have social phobia
or social anxiety
- Anxiety disorder-lack or rapport or trust
- SOCIAL EVENTS
- If at home: Can communicate
- if party: cannot communicate
- cause: anxiety
- at least 1 month: to be diagnosed as selective
mutism
- Has social phobia
MANIFESTATIONS
● Most are at the extreme end of the spectrum for
timidity and shyness
● Unable to speak and communicate
● May stand motionless with fear
● May freeze, be expressionless, unemotional and
may be socially isolated
● May be able to speak to a select few or whisper
○ selected few: warm up with or fam
members because the child is comfortable
CAUSES
● Children with inhibited temperaments
● Decreased threshold of excitability
● Amygdala -almond shapes
● Set off a series of reactions that will help
individuals protect themselves
● Amygdala receives signals of potential danger
● Fearful scenario
○ Birthday parties, school, family gatherings
- Introverted personality
- Decrease threshold: shyness
- Temperament: controlled by amygdala
- Allow the child to see bdays as fearful
scenario
- Then amygdala sees it as fear
- Protection of selves: selective mutism
- Protective mechanism
Upon consultation
- Children do not progress communitavely without
learning coping skills . Simply lowering anxiety is not
enough to enable the child to begin engaging socially,
comfortable
- Skills must be taught
- - To grow: teach adaptive coping skills
- o Train child socially to respond
- Lower anxiety plus teaching child to react in a
friendly manner if they need to talk in bdays
CAUTION
Treatment approaches based on discipline and forcing a
child to speak are inappropriate and will only heighten
anxiety and negatively reinforce mute behavior.
- Do not use authoritative
- To build rapport
INTERVENTIONS
● Social communication Anxiety therapy (S-CAT)
○ Includes development of an individualized
treatment plan that focuses on the whole
child and incorporates a team approach
● Behavioral therapy: positive reinforcement and
desensitization
○ Are the primary behavior treatments
○ Positive reinforcement
○ § Praise child
○ § Give rewards when they are able to
mingle with other children
○ desensitization
○ · immerse child in the scenario
○
● Play therapy, psychotherapy (talk therapy) and
other psychological approaches
● Cognitive Behavioral Therapy
○ Talk therapy in psychotherapy form
● Self-esteem boosters
○ Reward system when a child will not show
any signs of anxiety in usual situations
where he/she shows anxiety.
● Frequent socialization
○ BRING HER TO PARTS WHERE THERE
ARE PEOPLE BUT NOT TO CROWDS
○ § Bringing child to mall to talk to others
○
● School involvement
● Family involvement and parental acceptance
○ Child can’t try to manage own inabilities
and capacities
○ In family therapy, the reason for anxiety will
be found out and the family will know how
to manage
● Meds:
 ○ SSRI ● Consistent pattern of emotionally withdrawn
■ Prozac, paxil, celexa, luvox, zoloft behavior towards caregivers
are very effective in anxiety ● Persistent social and emotional problems
disorders ○ Can be seen in clients with ASD or eating
■ Effexor XR and Buspar- chemical disorders
balance ○ Include minimal responsiveness to others,
no positive response to interactions, or
3. REACTIVE ATTACHMENT unexplained irritability, sadness or
● Occurs when a child has fearfulness during interactions with
○ Unmet changs in caregiver caregivers
○ Unmet emotional needs ● Persistent lack of having emotional needs for
○ unmet physical needs comfort
● And reacts with confused attachment to caregiver ● No diagnosis of ASD
or no “stranger danger” (Healthy fear (not irrational, ● Autistic syndrome shall be ruled out
natural) ○ Has a thinline with ASD

● But child does not have a developmental delay,
such as mental retardation, or pervasive
development disorder
● Infant or young child has no healthy attachment
with parents or caregivers
○ No stable environment
● Remains uncertain whether it occurs in children
older than 5 years
● May display callous, emotional traits
○ Cruelty towards people or animals
● Can start in infancy
○ Child does not feel safe during her infant
stage
- Cannot differentiate strangers
o Cannot have healthy fear towards
stranger
- Rare but serious
o Early interventions is a must
- No healthy attachments to parents or
caregivers
o No stable trusting environment
growing up
SYMPTOMS
● No interest in playing peekaboo or other interactive
games
● Unexplained withdrawal, fear, sadness, irritability
● Sad and listless appearance
● Failure to smile
● Not seeking comfort or showing no repsonse when
comfort is given
● Watching others closely but not engaging in social
interaction
● Failing to ask for support or assistance
● Failure to reach out when picked up
DIAGNOSIS
GOALS AND INTERVENTIONS
● Goals of treatment are to help ensure that the child:
○ Has a safe and stable living situation
○ Develops positive interactions and
strengthens attachment with parents and
caregivers
● Psychological counseling
● Parent or caregiver counseling and education
● Learning positive child and caregiver interactions
● Creating a stable and nurturing environment
○ Develop a stable living situation
■ At infancy stage, physical and
emotional needs must be met (cry)
○ Help address this order
PARENT EDUCATION
● Take classes or volunteer with children
○ · Will help parents address well to the
child
○
● Be actively engaged with child
○ Lost of playing, talking, making eye contact
and smiling
○ Employing touch
● Interpet baby's cues
○ An infant can’t talk but communicates the
discomfort by crying (hungry or needs
immediate attention)
○ Build trust by making a structured and
nurturing environment
● Provide warm, nurturing interactions
○ Emotional interaction will be developed
between child and parent
● Offer both verbal and nonverbal responses
○ Touch, facial expressions and tone of voice
■ Child can’t understand words but
read nonverbal responses or cues
■ Can tell whether you are angry
 4. STEREOTYPIC MOVEMENT
● Common in boys
● Each child - signature behavior
○ DIFFERENT S/S FROM ONE CHILD TO
ANOTHER
● Typically developing children- can usually be
suppressed OR END UP LESSENING OVER TIME
● Person makes repetitive, purposeless movement
(HAND WAVING, BODY ROCKING OR HEAD
BANGING)
● Movement interfere with normal activity or may
cause bodily harm

CAUSES:
● Unknown
● Stress, frustration, boredom
● Stimulant drugs
○ Cocaine and amphetamines
■ Picking , hand wringing, head
tics,lip biting
● Head injuries
○ May be a permanent effect
○ Cause seizures

EXAMS AND TESTS

● Rule out others including:
- Autism
- Chorea disorders
- Tourette syndrome or other tic disorder
- Obsessive compulsive disorder
SYMPTOMS
● Biting self
● Nail biting
● hand shaking or waving
● Head banging
● Hitting own body
● Mouthing of objects
● Rocking

TREATMENT:
● Foci: cause, specific symptoms, persons age
○ Safe environment
■ Employ safety measures to avoid
falls
○ Behavioral techniques and psychotherapy
○ Antidepressants
○ Have been used in some cases

1. PSYCHOLOGICAL DISORDERS
AND TERMS
Terms:
● Anxiety
Anxiety is a vague feeling of dread or
apprehension; it is a response to external
or internal stimuli that can have
behavioral, emotional, cognitive, and
physical symptoms.
● Stress
Stress is the wear and tear that life
causes on the body (Selye, 1956).
It occurs when a person has
difficulty dealing with life situations,
problems, and goals.
● Fear
● Lucid interval (wala book; google)
- is the period of time between
regaining consciousness after
a short period of
unconsciousness, resulting
from a head injury and
deteriorating after the onset of
neurologic signs and
symptoms caused by that
injury
● Primary gain
- the relief of anxiety achieved
by performing the specific
anxiety-driven behavior; the
direct internal benefits that
being sick provides, such as
relief of anxiety, conflict, or
distress
● Secondary gain
- the external benefits received
from others because one is
sick, such as attention from
family members, comfort
measures, and being excused
from usual responsibilities or
tasks
Anxiety disorders:
Phobia
Panic disorder
Obsessive-Compulsive Disorder
Generalized Anxiety disorder
- A person with GAD worries
excessively and feels highly anxious at
least 50% of the time for 6 months or
more.
- Unable to control this focus on worry,
the person has three or more of the
following symptoms: uneasiness,
irritability, muscle tension, fatigue,
difficulty thinking, and sleep
alterations.
- The quality of life is diminished greatly
in older adults with GAD
➔ Points to Consider When Working with
Clients with Anxiety and Anxiety
Disorders
◆ Remember that everyone
occasionally suffers from
stress and anxiety that can
interfere with daily life and
work.
◆ Avoid falling into the pitfall of
trying to “fix” the client’s
problems.
◆ Discuss any uncomfortable
feelings with a more
experienced nurse for
suggestions on how to deal
with your feelings toward
these clients.
◆ Remember to practice
techniques to manage stress
and anxiety in your own life.
Treatment
- Treatment for anxiety disorders
usually involves medication and
therapy. This combination produces
better results than either one alone
- Cognitive–behavioral therapy (CBT) is
used successfully to treat anxiety
disorders.
- Positive reframing means turning
negative messages into positive
messages. The therapist teaches the
client to create positive messages for
use during panic episodes. For
example, instead of thinking, “My heart
is pounding. I think I’m going to die,”
 the client thinks, “I can stand this. This
is just anxiety
- Decatastrophizing involves the
therapist’s use of questions to more
realistically appraise the situation. The
therapist may ask, “What is the worst
thing that could happen? Is that likely?
Could you survive that? Is that as bad
as you imagine?” The client uses
thought-stopping and distraction
techniques to jolt him or herself from
focusing on negative thoughts.
Splashing the face with cold water,
snapping a rubber band worn on the
wrist, or shouting are all techniques
that can break the cycle of negative
thoughts.
- Assertiveness training helps the
person take more control over life
situations. These techniques help the
person negotiate interpersonal
situations and foster self-assurance.
They involve using “I” statements to
identify feelings and to communicate
concerns or needs to others
- Drugs for anxiety:
Acute stress disorder
- occurs after a traumatic event and is
characterized by reexperiencing,
avoidance, and hyperarousal that
occur from 3 days to 4 weeks following
a trauma
- It can be a precursor to PTSD
- Stress immediately after an event is
acute stress disorder, while PTSD is
delayed in onset. Some individuals will
report “having PTSD” but are
self-diagnosed
- Intense traumatic events that disrupt
peoples’ lives can lead to an acute
stress disorder from 2 days to 4 weeks
following the trauma
- diagnosis is appropriate when
symptoms appear within the first
month after the trauma and do not
persist longer than 4 weeks
- Traumatic stressors can cause a
short, acute stress reaction or, if
unresolved, may occur later as PTSD
Treatment
- Cognitive–behavioral therapy (CBT)
involving exposure and anxiety
management can help prevent the
progression to PTSD
- Counseling or therapy, individually or
in groups, for people with acute stress
- disorder may prevent progression to
PTSD.
-
Post-traumatic stress disorder
- a disturbing pattern of behavior
demonstrated by someone who has
experienced, witnessed, or been
confronted with a traumatic event such
as a natural disaster, combat, or an
assault
- A person with PTSD was exposed to
an event that posed actual or
threatened death or serious injury and
responded with intense fear,
helplessness, or terror
- In PTSD, the symptoms occur 3
months or more after the trauma,
which distinguishes PTSD from acute
stress disorder, which may have
similar types of symptoms but lasts 3
days up to 1 month
➔ Life Events Checklist that is used to
screen individuals with a history of exposure to
some type of trauma
 ➔ Four subcategories of symptoms for
PTSD
- reexperiencing the trauma through
dreams or recurrent and intrusive
thoughts
- avoidance
- negative cognition or thoughts
- being on guard, or hyperarousal
- A PTSD person persistently re experiences
the trauma through memories, dreams,
flashbacks, or reactions to external cues about
the event and therefore avoids stimuli
associated with the trauma
- The victim feels a numbing of general
responsiveness and shows persistent signs of
increased arousal such as insomnia,
hyperarousal or hypervigilance, irritability, or
angry outbursts. He or she reports losing a
sense of connection and control over his or
her life.
➔ PTSD Checklist that details many of
the symptoms people experience
- PTSD can occur at any age, including during
childhood. Estimates are that up to 60% of
people at risk, such as combat veterans and
victims of violence and natural disasters,
develop PTSD
- Complete recovery occurs within 3
months for about 50% of people
- The severity and duration of the trauma and
the proximity of the person to the event are the
most important factors affecting the likelihood
of developing PTSD
- One-fourth of all victims of physical assault
develop PTSD. Victims of rape have one of the
highest rates of PTSD at approximately 70%
Treatment
- Therapy on an outpatient basis is
- the indicated treatment for PTSD
- Counseling or therapy, individually or
in groups, for people with acute stress
disorder may prevent progression to
PTSD.
- There are some medications that may
also contribute to successful
resolution, especially when targeting
specific issues, such as insomnia. A
combination of both therapies
produces the best results
- Inpatient treatment is not indicated for
clients with PTSD; however, in times
of severe crisis, short inpatient stays
may be necessary. This usually occurs
when the client is suicidal or is being
 overwhelmed by reexperiencing
events, such as flashbacks
- The choice of therapy can depend on
the type of trauma, as well as the
choice to seek formal individual or
group counseling. Self-help groups
offer support and a safe place to share
feelings
- Exposure therapy is a treatment
approach designed to combat the
avoidance behavior that occurs with
PTSD, help the client face troubling
thoughts and feelings, and regain a
measure of control over his or her
thoughts and feelings
- Adaptive disclosure is a specialized
CBT approach developed by the
military to offer an intense, specific,
short-term therapy for active-duty
military personnel with PTSD
- Cognitive processing therapy has
been used successfully with rape
survivors with PTSD as well as
combat veterans.
- Medications may be used for clients
with PTSD to deal with symptoms
such as insomnia, anxiety, or
hyperarousal.
2. ANXIETY RELATED DISORDERS
(Kim Isa)
Introduction
- Anxiety is a vague feeling of dread or
apprehension; it is a response to
external or internal stimuli that can
have behavioral, emotional, cognitive,
and physical symptoms.
- Anxiety is distinguished from fear,
which is feeling afraid or threatened by
a clearly identifiable external stimulus
that represents danger to the person.
- Anxiety is unavoidable in life and can
serve many positive functions such as
motivating the person to take action to
solve a problem or to resolve a crisis.
It is considered normal when it is
appropriate to the situation and
dissipates when the situation has been
resolved
- Anxiety disorders comprise a group of
conditions that share a key feature of
excessive anxiety with ensuing
behavioral, emotional, cognitive, and
physiological responses.
- Clients suffering from anxiety
disorders can demonstrate unusual
behaviors such as panic without
reason, unwarranted fear of objects or
life conditions, or unexplainable or
overwhelming worry.
- They experience significant distress
over time, and the disorder
significantly impairs their daily
routines, social lives, and occupational
functioning.
Anxiety as Response to Stress
- Stress is the wear and tear that life
causes on the body (Selye, 1956). It
occurs when a person has difficulty
dealing with life situations, problems,
and goals.
- Each person handles stress
differently; one person can thrive in a
situation that creates great distress for
another. Hans Selye (1956, 1974), an
endocrinologist, identified three stages
of reaction to stress:
1. In the alarm reaction stage, stress
stimulates the body to send messages
from the hypothalamus to the glands
(such as the adrenal gland, to send
out adrenaline and norepinephrine for
fuel) and organs (such as the liver, to
reconvert glycogen stores to glucose
for food) to prepare for potential
defense needs.
2. In the resistance stage, the digestive
system reduces function to shunt
blood to areas needed for defense.
The lungs take in more air, and the
heart beats faster and harder so that it
can circulate this highly oxygenated
and highly nourished blood to the
muscles to defend the body by fight,
flight, or freeze behaviors. If the
person adapts to the stress, the body
responses relax, and the gland, organ,
and systemic responses abate.
3. The exhaustion stage occurs when
the person has responded negatively
to anxiety and stress; body stores are
depleted or the emotional components
are not resolved, resulting in continual
 arousal of the physiological responses
on self immobile and
and little reserve capacity. -Cannot process mute
Levels of Anxiety any -Dilated pupils
environmental Increased
stimuli blood
Anxiety Psychological Physiologic
Level response response
-Distorted pressure and
perceptions pulse
Mild -Wide -Restlessness -Loss of rational -Flight, fight,
perceptual field -Fidgeting GI thought or freeze
-Sharpened “butterflies” -Doesn’t
senses -Difficulty recognize
-Increased sleeping potential danger
motivation -Hypersensitiv -Can’t
-Effective ity to noise communicate
problem-solving verbally
-Increased -Possible
learning ability delusions and
Irritability hallucination
-May be suicidal
Moderat -Perceptual field -Muscle
e narrowed to tension Levels of Anxiety
immediate task -Diaphoresis
- Mild anxiety is a sensation that
-Selectively -Pounding
attentive pulse something is different and warrants
-Cannot connect -Headache special attention. Sensory stimulation
thoughts or -Dry mouth increases and helps the person focus
events -High voice attention to learn, solve problems,
independently pitch think, act, feel, and protect him or
Increased use of -Faster rate of herself. Mild anxiety often motivates
automatisms speech
people to make changes or engage in
-GI upset
-Frequent goal-directed activity.
urination - For example, it helps students
focus on studying for an
Severe -Perceptual field -Severe examination.
reduced to one headache - Moderate anxiety is the disturbing
detail or -Nausea,
feeling that something is definitely
scattered vomiting, and
-Cannot diarrhea wrong; the person becomes nervous
complete tasks -Trembling or agitated. In moderate anxiety, the
-Cannot solve -Rigid stance person can still process information,
problems or -Vertigo solve problems, and learn new things
learn effectively -Pale with assistance from others. He or she
-Behavior -Tachycardia has difficulty concentrating
geared toward -Chest pain
independently but can be redirected to
anxiety relief
and is usually the topic.
ineffective - For example, the nurse might
-Doesn’t be giving preoperative
respond to instructions to a client who is
redirection anxious about the upcoming
-Feels awe, surgical procedure. As the
dread, or horror
nurse is teaching, the client’s
-Cries
-Ritualistic attention wanders, but the
behavior nurse can regain the client’s
attention and direct him or her
Panic -Perceptual field -May bolt and back to the task at hand.
reduced to focus run or totally
 - As the person progresses to severe
anxiety and panic, more primitive
survival skills take over, defensive
responses ensue, and cognitive skills
decrease significantly.
- A person with severe anxiety has
trouble thinking and reasoning.
Muscles tighten, and vital signs
increase. The person paces; is
restless, irritable, and angry; or uses
other similar emotional–psychomotor
means to release tension. In panic, the
emotional–psychomotor realm
predominates with accompanying
fight, flight, or freeze responses.
Adrenaline surge greatly increases
vital signs. Pupils enlarge to let in
more light, and the only cognitive
process focuses on the person’s
defense.
Types of anxiety disorders include the
following:
• Agoraphobia
• Panic disorder
• Specific phobia
• Social anxiety disorder (social phobia)
• Generalized anxiety disorder (GAD)
Panic Disorder
- is composed of discrete episodes of
panic attacks, that is, 15 to 30 minutes
of rapid, intense, escalating anxiety in
which the person experiences great
emotional fear as well as physiological
discomfort.
During a panic attack, the person has
overwhelmingly intense anxiety and displays
four or more of the following symptoms:
palpitations, sweating, tremors, shortness of
breath, sense of suffocation, chest pain,
nausea, abdominal distress, dizziness,
paresthesias, chills, or hot flashes
- is diagnosed when the person has
recurrent, unexpected panic attacks
followed by at least 1 month of
persistent concern or worry about
future attacks or their meaning or a
significant behavioral change related
to them
Clinical Course
- peaks in late adolescence and the
mid-30s
- The memory of the panic attack,
coupled with the fear of having more,
can lead to avoidance behavior. In
some cases, the person becomes
homebound or stays in a limited area
near home, such as on the block or
within town limits. This behavior is
known as agoraphobia (“fear of the
marketplace” or fear of being outside).
- Some people with agoraphobia fear
stepping outside the front door
because a panic attack may occur as
soon as they leave the house. Others
can leave the house but feel safe from
the anticipatory fear of having a panic
attack only within a limited area.
- Agoraphobia can also occur alone
without panic attacks. The behavior
patterns of people with agoraphobia
clearly demonstrate the concepts of
primary and secondary gain
associated with many anxiety
disorders.
- Primary gain is the relief of anxiety
achieved by performing the specific
anxiety-driven behavior, such as
staying in the house to avoid the
anxiety of leaving a safe place.
- Secondary gain is the attention
received from others as a result of
these behaviors.
Treatment
- Panic disorder is treated with CBTs,
deep breathing and relaxation, and
medications such as benzodiazepines,
SSRI antidepressants, tricyclic
antidepressants, and
antihypertensives such as clonidine
(Catapres) and propranolol (Inderal).
Nursing Diagnoses
● Risk for injury
● Anxiety
● Situational low self-esteem (panic
attacks)
● Ineffective coping
● Powerlessness
● Ineffective role performance
● Disturbed sleep pattern
Intervention
Promoting Safety and Comfort
 - nurse’s first concern is to provide a
safe environment and to ensure the
client’s privacy
- If the environment is overstimulating,
the client should move to a less
stimulating place.
- A quiet place reduces anxiety and
provides privacy for the client.
- The nurse remains with the client to
help calm him or her down and to
assess client behaviors and concerns.
- After getting the client’s attention, the
nurse uses a soothing, calm voice and
gives brief directions to assure the
client that he or she is safe.
Using Therapeutic Communication
- rapport between the nurse and the
client is important.
- Communication should be simple and
calm because the client with severe
anxiety cannot pay attention to lengthy
messages and may pace to release
energy.
- The nurse can walk with the client who
feels unable to sit and talk.
- The nurse should carefully evaluate
the use of touch because clients with
high anxiety may interpret touch by a
stranger as a threat and pull away
abruptly.
- As the client’s anxiety diminishes,
cognition begins to return.
- When anxiety has subsided to a
manageable level, the nurse uses
open-ended communication
techniques to discuss the experience
Managing Anxiety
- The nurse can teach the client
relaxation techniques to use when he
or she is experiencing stress or
anxiety.
- Deep breathing is simple; anyone can
do it.
- Guided imagery and progressive
relaxation are methods to relax taut
muscles.
- Guided imagery involves imagining a
safe, enjoyable place to relax. In
progressive relaxation, the person
progressively tightens, holds, and then
relaxes muscle groups while letting
tension flow from the body through
rhythmic breathing.
- Cognitive restructuring techniques
may also help the client manage his or
her anxiety response.
Nursing Interventions
● Provide a safe environment and
ensure the client’s privacy during a
panic attack.
● Remain with the client during a panic
attack.
● Help the client focus on deep
breathing.
● Talk to the client in a calm, reassuring
voice.
● Teach the client to use relaxation
techniques.
● Help the client use cognitive
restructuring techniques.
● Engage the client to explore how to
decrease stressors and anxiety
provoking situations.
Phobia
- is an illogical, intense, and persistent
fear of a specific object or a social
situation that causes extreme distress
and interferes with normal functioning.
- Phobias usually do not result from
past negative experiences. In fact, the
person may never have had contact
with the object of the phobia.
- People with phobias have a reaction
that is out of proportion to the situation
or circumstance.
- Some individuals may even recognize
that their fear is unusual and irrational
but still feel powerless to stop it
Three Categories of Phobia
1. Agoraphobia
2. Specific phobia, which is an irrational
fear of a particular object or a situation
3. Social anxiety or phobia, which is
anxiety provoked by certain social or
performance situations
Specific Phobias:
1. Natural environmental phobias: fear
of storms, water, heights, or other
natural phenomena
2. Blood–injection phobias: fear of
seeing one’s own or others’ blood,
 traumatic injury, or an invasive medical
procedure such as an injection
3. Situational phobias: fear of being in
a specific situation such as on a bridge
or in a tunnel, elevator, small room,
hospital, or airplane
4. Animal phobia: fear of animals or
insects (usually a specific type; often,
this fear develops in childhood and
can continue through adulthood in
both men and women; cats and dogs
are the most common phobic objects)
5. Other types of specific phobias: for
example, fear of getting lost while
driving if not able to make all right (and
no left) turns to get to one’s
destination
Social Phobia
- also known as social anxiety disorder,
the person becomes severely anxious
to the point of panic or incapacitation
when confronting situations involving
people. Examples include making a
speech, attending a social
engagement alone, interacting with the
opposite sex or with strangers, and
making complaints
- The fear is rooted in low self-esteem
and concern about others’ judgments.
- The person fears looking socially
inept, appearing anxious, or doing
something embarrassing such as
burping or spilling food.
- Other social phobias include fear of
eating in public, using public
bathrooms, writing in public, or
becoming the center of attention.
- A person may have one or several
social phobias; the latter is known as
generalized social phobia
Onset and Clinical Course
- Specific phobias usually occur in
childhood or adolescence.
- In some cases, merely thinking about
or handling a plastic model of the
dreaded object can create fear.
- Specific phobias that persist into
adulthood are lifelong 80% of the time.
- The peak age of onset for social
phobia is middle adolescence; it
sometimes emerges in a person who
was shy as a child.
- The course of social phobia is often
continuous, though the disorder may
become less severe during adulthood.
Treatment
- Behavioral therapy works well
- Behavioral therapists initially focus on
teaching what anxiety is, helping the
client identify anxiety responses,
teaching relaxation techniques, setting
goals, discussing methods to achieve
those goals, and helping the client
visualize phobic situations.
- Therapies that help the client develop
self-esteem and self-control are
common and include positive
reframing and assertiveness training
- One behavioral therapy often used to
treat phobias is systematic (serial)
desensitization, in which the therapist
progressively exposes the client to the
threatening object in a safe setting
until the client’s anxiety decreases.
During each exposure, the complexity
and intensity of exposure gradually
increase, but the client’s anxiety
decreases. The reduced anxiety
serves as a positive reinforcement
until the anxiety is ultimately
eliminated.
For example, for the client who fears flying, the
therapist would encourage the client to hold a
small model airplane while talking about his or
her experiences; later, the client would hold a
larger model airplane and talk about flying.
Even later, exposures might include walking
past an airport, sitting in a parked airplane,
and, finally, taking a short ride in a plane. Each
session’s challenge is based on the success
achieved in previous sessions
- Flooding is a form of rapid
desensitization in which a behavioral
therapist confronts the client with the
phobic object (either a picture or the
actual object) until it no longer
produces anxiety.
- Because the client’s worst fear
has been realized and the
client did not die, there is little
reason to fear the situation
anymore.
- The goal is to rid the client of
the phobia in one or two
 sessions. This method is
highly anxiety producing and
should be conducted only by a
trained psychotherapist under
controlled circumstances and
with the client’s consent
Generalized Anxiety Disorder
- A person with GAD worries
excessively and feels highly anxious at
least 50% of the time for 6 months or
more.
- Unable to control this focus on worry,
the person has three or more of the
following symptoms: uneasiness,
irritability, muscle tension, fatigue,
difficulty thinking, and sleep
alterations.
- The quality of life is diminished greatly
in older adults with GAD. Buspirone
(BuSpar) and SSRI
serotonin–norepinephrine reuptake
inhibitor antidepressants are the most
effective treatments
3. PERSONALITY DISORDERS
- Nasnin, ella, dats
PARANOID PERSONALITY DISORDER
Clinical Picture
● characterized by pervasive mistrust
and suspiciousness of others
● interpret others’ actions as potentially
harmful.
● periods of stress
- may develop transient
psychotic symptoms.
● Incidence is estimated at 2% to 4% of
the general population
● common in males
● lifelong problems living and working
with others
s/s
● appear aloof and withdrawn and
considerable physical distance from
the nurse
- necessary for their protection
● appear guarded or hypervigilant
● survey the room and its contents
- look behind furniture or doors
● appear alert to any impending danger.
● May choose to sit near the door to
have ready access to an exit, or with
their backs against the wall to prevent
anyone from sneaking up behind
them.
● restricted affect
● unable to demonstrate warmth or
empathic emotional responses such
as “You look nice today” or “I’m sorry
you’re having a bad day.”
● Mood may be labile, quickly changing
or from quietly suspicious to angry or
hostile.
● Sarcastic responses for no apparent
reason.
● constant mistrust and suspicion that
clients feel toward others and the
environment distorts thoughts, thought
processing, and content.
● see malevolence in the actions of
others where none exists.
● spend disproportionate time examining
and analyzing the behavior and
motives of others to discover hidden
and threatening meanings
● often feel attacked by others
● devise elaborate plans or fantasies for
protection.
● use the defense mechanism of
projection
- blaming other people,
institutions, or events for their
own difficulties.
- common for such clients to
blame the government for
personal problems.
- For example, the client who
gets a parking ticket says it is
part of a plot by the police to
drive him out of the
neighborhood. He may
engage in fantasies of
retribution or devise elaborate
 and sometimes violent plans ● characterized by a pervasive pattern
to get even. of detachment from social
● potential danger. relationships and a restricted range of
● Common : Conflict with authority emotional expression in interpersonal
figures on the job settings.
● resent being given directions from a ● affect 5% of the general population
supervisor. ● more common in males
● Paranoia may extend to feelings of ● avoid treatment as much as they avoid
being singled out for menial tasks, other relationships, unless their life
treated as stupid, or more closely circumstances change significantly.
monitored than other employees.
s/s
Nursing Interventions
● display a constricted affect and little, if
● remember that these clients take any, emotion.
everything seriously and are ● aloof and indifferent
particularly sensitive to the reactions ● appearing emotionally cold
and motivations of others. ● uncaring, or unfeeling.
● approach clients in a formal, ● no leisure or pleasurable activities
businesslike manner - they rarely experience
● refrain from social chit-chat or jokes. enjoyment.
● Being on time ● under stress or adverse
● keeping commitments circumstances, their response appears
● straightforward passive and disinterested.
● involve them in formulating their care ● difficulty experiencing and expressing
plan emotions, particularly anger or
● asks what the client would like to aggression
accomplish in concrete terms, such as ● do not report feeling distressed about
minimizing problems at work or getting this lack of emotion----more
along with others. distressing to family members.
● Clients are more likely to engage in ● rich and extensive fantasy
the therapeutic process if they believe life-----reluctant to reveal that
they have something to gain. information to the nurse or anyone
● helping clients validate ideas before else.
taking action ● ideal relationships that occur in the
- requires the ability to trust and client’s fantasies are rewarding and
listen to one person gratifying
- Rationale : clients can avoid - stark contrast to real-life
problems if they can refrain experiences.
from taking action until they - includes someone the client
have validated their ideas with has met only briefly.
another person. - can distinguish fantasies from
- helps prevent clients from reality,
acting on paranoid ideas or - no disordered or delusional
beliefs. thought processes are
- assists them to starting to evident.
base decisions and actions on ● Clients generally are accomplished
reality, rather than distorted intellectually and often involved with
ideas or perceptions. computers or electronics for work or to
pass their time.
SCHIZOID PERSONALITY DISORDER ● spend long hours solving puzzles or
mathematical problems----- see these
Clinical Picture
 pursuits as useful or productive rather
than fun.
● indecisive and lack future goals or
direction.
● See no need for planning and have no
aspirations.
● little opportunity to exercise judgment
or decision-making because they
rarely engage in these activities.
● Insight might be described as impaired
● do not see their situation as a
problem
● fail to understand why their lack of
emotion or social involvement troubles
others.
● self-absorbed and loners in almost all
aspects of daily life.
● Decline when engage with other
people
● indifferent to praise or criticism
● relatively unaffected by the emotions
or opinions of others.
● experience dissociation from or no
bodily or sensory pleasures.
● For example, the client has little
reaction to beautiful scenery, a sunset,
or a walk on the beach.
● pervasive lack of desire for
involvement with others in all aspects
of life.
● do not have or desire friends, rarely
date or marry
● little or no sexual contact.
● some connection with a first- degree
relative, often a parent.
● Clients may remain in the parental
home well into adulthood if they can
maintain adequate separation and
distance from other family members.
● few social skills
● oblivious to the social cues or
overtures of others
● do not engage in social conversation.
Nursing Interventions
● focus : improved functioning in the
community
● needs housing or a change in living
circumstances
- the nurse can make referrals
to social services or
appropriate local agencies for
assistance.
- help agency personnel find
suitable housing that
accommodates the client’s
desire and need for solitude.
- For example, the client with a
schizoid personality disorder
would function best in a board
and care facility, which
provides meals and laundry
service but requires little
social interaction. Facilities
designed to promote
socialization through group
activities would be less
desirable.
● If the client has an identified family
member as his or her primary
relationship, the nurse must ascertain
whether that person can continue in
that role.
- If the person cannot, the client
may need to establish at least
a working relationship with a
case manager in the
community.
- case manager can then help
the client obtain services and
health care, manage finances,
and so on.
- The client has a greater
chance of success if he or she
can relate his or her needs to
one person (as opposed to
neglecting important areas of
daily life).
SCHIZOTYPAL PERSONALITY DISORDER
Clinical Picture
● characterized by a pervasive pattern
of social and interpersonal deficits
● marked by acute discomfort with and
reduced capacity for close
relationships as well as by cognitive or
perceptual distortions and behavioral
eccentricities.
● Incidence about 3% of the population
● common in men
 ● experience transient psychotic extrasensory perception and
episodes in response to extreme clairvoyance.
stress. ● clients may express ideas that indicate
● may develop schizophrenia!!! paranoid thinking and suspiciousness,
usually about the motives of other
s/s people
● anxiety around other people,
● odd appearance that causes others to especially those who are unfamiliar.
notice them. - does not improve with time or
● unkempt and disheveled repeated exposures
● clothes are often ill-fitting, do not - anxiety may intensify
match, and may be stained or dirty. - from the belief that strangers
● wander aimlessly cannot be trusted.
● preoccupied with some environmental - Clients do not view their
detail. anxiety as a problem that
● Speech is coherent, but may be arises from a threatened
loose, digressive, or vague. sense of self.
● provide unsatisfactory answers to ● Interpersonal relationships
questions troublesome
● unable to specify or to describe ● only one significant
information clearly. relationship(usually with a first-degree
● use words incorrectly----speech sound relative)
bizarre. ● may remain in their parents’ home well
into the adult years.
For example, in response to a question about ● limited capacity for close relationships,
sleeping habits, the client might respond, even though they may be unhappy
“Sleep is slow, the REMs don’t flow.” being alone.
● cannot respond to normal social cues
● restricted range of emotions ● cannot engage in superficial
● lack the ability to experience and to conversation.
express a full range of emotions such ● skills that could be useful in a
as anger, happiness, and pleasure. vocational setting
● Affect flat and sometimes silly or ● not often successful in employment
inappropriate. without support or assistance.
● Cognitive distortions ● Mistrust of others, bizarre thinking
- ideas of reference and ideas, and unkempt appearance
❖ involve the client’s can make it difficult for these clients to
belief that events get and to keep jobs.
have special meaning
for him or her Nursing Interventions
❖ not firmly fixed and
delusional ● focus : development of self-care and
- magical thinking social skills and improved functioning
❖ normal in small in the community.
children ● nurse encourages clients to establish
❖ he or she has special a daily routine for hygiene and
powers grooming
❖ thinking about - important since it does not
something, he or she depend on the client to decide
can make it happen when hygiene and grooming
- odd or unfounded beliefs, tasks are necessary.
- preoccupation with - useful for clients to have an
parapsychology, including appearance that is not bizarre
 or disheveled because stares
or comments from others can
increase discomfort.
● nurse must help them function in the
community with minimal discomfort.
● ask clients to prepare a list of people
in the community with whom they must
have contact, such as a landlord, store
clerk, or pharmacist.
● nurse can then role-play interactions
that clients would have with each of
these people
- allows clients to practice
making clear and logical
requests to obtain services or
to conduct personal business.
● Because face-to-face contact is more
uncomfortable, clients may be able to
make written requests or to use the
telephone for business.
● Social skills training may help clients
talk clearly with others and to reduce
bizarre conversations.
● identify one person with whom clients
can discuss unusual or bizarre beliefs,
such as a social worker or a family
member
● clients may be able to refrain from
these conversations with people who
might react negatively.
Antisocial personality disorder
● - characterized by a pervasive pattern
of disregard for and violation of the
rights of others—and by the central
characteristics of deceit and
manipulation
○ pattern has also been referred
to as psychopathy, sociopathy,
or dyssocial personality
disorder
● - occurs in about 3% of general
population
● 30% in clinical settings, and is three to
four times more common in men than
in women
● - prison populations- about 75% are
diagnosed with antisocial personality
disorder
● - tend to peak in the 20s and diminish
significantly after 45 years of age in
many individuals
● Clients are skillful at deceiving others
○ Check and validate
information from other
sources.
● Onset is in childhood or adolescence
○ formal diagnosis is not made
until the client is 18 years old
● Childhood histories of enuresis,
sleepwalking, and syntonic acts of
cruelty are characteristic predictors
● In adolescents, clients may have
engaged in lying, truancy, sexual
promiscuity, cigarette smoking,
substance use, and illegal activities
that brought them into contact with
police
● Families have high rates of
depression, substance abuse,
antisocial personality disorder, poverty,
and divorce
● Erratic, neglectful, harsh, or even
abusive parenting frequently marks
the childhoods of these clients.
● Appearance is usually normal
○ may be quite engaging and
even charming
● They may exhibit signs of mild or
moderate anxiety, especially if another
person or agency arranged the
assessment.
● Often display false emotions chosen to
suit the occasion or to work to their
advantage.
● These clients cannot empathize with
the feelings of others, which enables
them to exploit others without guilt.
● Feel remorse only if they are caught
breaking the law or exploiting
someone.
● Do not experience disordered
thoughts, but their views of the world
are narrow and distorted
● They view the world as cold and
hostile and therefore rationalize their
behavior.
● “It’s a dog-eat-dog world” represent
their viewpoint
 ○ believe they are only taking
care of themselves because
no one else will
● Oriented, have no sensory–perceptual
alterations, and have average or
above-average IQs
● Exercise poor judgment for various
reasons
● Pay no attention to the legality of their
actions and do not consider morals or
ethics when making decisions
● Behavior is determined primarily by
what they want, and they perceive
their needs as immediate. In addition
to seeking immediate gratification,
these clients are impulsive
○ impulsivity ranges from simple
failure to use normal caution
to extreme thrill-seeking
behaviors such as driving
recklessly
● lack insight and almost never see their
actions as the cause of their problems.
○ always someone else’s fault;
some external source is
responsible for their situation
or behavior.
● appear confident, self-assured, and
accomplished, perhaps even flip or
arrogant
● feel fearless, disregard their own
vulnerability, and usually believe they
cannot be caught in lies, deceit, or
illegal actions
● may be described as egocentric, but
actually the self is quite shallow and
empty
● devoid of personal emotion
● appraise their own strengths and
weaknesses.
● manipulate and exploit those around
them
● view relationships as serving their
needs and pursue others only for
personal gain
● never think about the repercussions of
their actions to others
● often involved in many relationships,
sometimes simultaneously
● may marry and have children
○ they cannot sustain long-term
commitments
● usually unsuccessful as spouses and
parents and leave others abandoned
and disappointed
● obtain employment readily with their
adept use of superficial social skills,
but over time, their work history is poor
● Problems may result from
absenteeism, theft, or embezzlement,
or they may quit simply out of
boredom
● generally do not seek treatment
voluntarily unless they perceive some
personal gain from doing so
● Nursing diagnoses for antisocial
disorder:
○ Ineffective coping
○ Ineffective role performance
○ Risk for other-directed
violence
OUTCOME IDENTIFICATION OF
ANTISOCIAL PERSONALITY DISORDER
● treatment focus is often behavioral
change
● treatment is unlikely to affect the
client’s insight or view of the world and
others
○ possible to make changes in
behavior
INTERVENTION OF ANTISOCIAL
PERSONALITY DISORDER
Forming a Therapeutic Relationship and
Promoting Responsible Behavior
● must provide structure in the therapeutic
relationship, identify acceptable and
expected behaviors, and be consistent in
those expectations
● He or she must minimize attempts by these
clients to manipulate and control the
relationship
● Limit setting is an effective technique that
involves three steps:
○ Stating the behavioral limit
○ Identifying the consequences
if the limit is exceeded
○ Identifying the expected or
desired behavior
● Consistent limit setting in a matter-of-fact
nonjudgmental manner is crucial to
success.
● The nurse should not become angry or
respond to the client harshly or punitively
● Confrontation is another technique
designed to manage manipulative or
deceptive behavior
● The nurse points out a client’s problematic
behavior while remaining neutral and
matter-of-fact
○ avoids accusing the client
● Use confrontation to keep clients focused
on the topic and in the present
● Nurse can focus on the behavior itself
rather than on attempts by clients to justify
it
Helping Client Solve Problems and Control
Emotions
● Teach problem-solving skills and help
clients practice them
○ identifying the problem,
exploring alternative solutions
and related consequences,
choosing and implementing an
alternative, and evaluating the
results
● Although these clients have the
cognitive ability to solve problems,
they need to learn a step-by-step
approach to deal with them
● Help the client discuss the various
options and choose one so that he or
she can go back to work
● Managing emotions, especially anger
and frustration, can be a major
problem
● When clients are calm and not upset,
the nurse can encourage them to
identify sources of frustration, how
they respond to it, and the
consequences
● nurse assists clients in anticipating
stressful situations and to learn ways
to avoid negative future consequences
● Taking a time-out or leaving the area
and going to a neutral place to regain
internal control is often a helpful
strategy
○ help clients to avoid impulsive
reactions and angry outbursts
in emotionally charged
situations, regain control of
emotions, and engage in
constructive problem-solving
NURSING INTERVENTIONS FOR
ANTISOCIAL PERSONALITY DISORDER
● Promoting responsible behavior
● Limit setting
○ State the limit
○ Identify the consequences of
exceeding the limit
○ Identify the expected or
acceptable behavior
● Consistent adherence to rules and
treatment plan
● Confrontation
○ Point out the problem
behavior
○ Keep the client focused on
him or herself
○ Help clients solve problems
and control emotions
● Effective problem-solving skills
● Decreased impulsivity
● Expressing negative emotions such as
anger or frustration
● Taking a time-out from stressful
situations
● Enhancing role performance
● Identifying barriers to role fulfillment
● Decreasing or eliminating use of drugs
and alcohol
ENHANCING ROLE PERFORMANCE
● nurse helps clients to identify specific
problems at work or home that are
barriers to success in fulfilling roles
● Assessing use of alcohol and other
drugs is essential when examining role
performance because many clients
use or abuse these substances
● These clients tend to blame others for
their failures and difficulties, and the
nurse must redirect them to examine
the source of their problems
realistically
● Referrals to vocational or job
programs may be indicated
CLIENT AND FAMILY EDUCATION OF
ANTISOCIAL PERSONALITY DISORDER
● Avoiding use of alcohol and other
drugs
● Appropriate social skills
● Effective problem-solving skills
 ● Managing emotions such as anger
and frustration
● Taking a time-out to avoid stressful
situations
Borderline personality disorder
● characterized by a pervasive pattern
of unstable interpersonal relationships,
self-image, and affect as well as
marked impulsivity
● 2% to 3% of the general population
has BPD
○ five times more common in
those with a first-degree
relative with the diagnosis
● Most common personality disorder
found in clinical settings
● Three times more common in women
than in men
● Under stress, transient psychotic
symptoms are common
● 8% and 10% of people with this
diagnosis commit suicide, and many
more suffer permanent damage from
self-mutilation injuries, such as cutting
or burning
● Up to three-quarters of clients with
BPD engage in deliberate self-harm,
sometimes called nonsuicidal
self-injury
● Recurrent self-mutilation is a cry for
help, an expression of intense anger
or helplessness, or a form of
self-punishment
○ Resulting physical pain is also
a means to block emotional
pain
● Clients who engage in self-mutilation
do so to reinforce that they are still
alive; they seek to experience physical
pain in the face of emotional numbing
● Working with these clients can be
frustrating
○ Cling and ask help for 1
minute and then become
angry, act out and reject all
offers of help in ht next minute
● Attempt to manipulate staff to gain
immediate gratification of needs and,
at times, sabotage their own treatment
plans by purposely failing to do what
they have agreed.
● Labile mood, unpredictability, and
diverse behaviors can make it seem
as if the staff is always “back to square
one” with them
APPLICATION OF THE NURSING
PROCESS: BORDERLINE PERSONALITY
DISORDER
● report disturbed early relationships
with their parents that often begin at
18 to 30 months of age
● early attempts by these clients to
achieve developmental independence
were met with punitive responses from
parents or threats of withdrawal of
parental support and approval
● 50% have experienced childhood
sexual abuse; others have
experienced physical and verbal
abuse and parental alcoholism
● tend to use transitional objects (e.g.,
teddy bears, pillows, blankets, and
dolls) extensively; this may continue
into adulthood
○ Transitional objects are often
similar to favorite items from
childhood that the client used
for comfort or security
● Experience a wide range of
dysfunction from severe to mild
● Initial behavior and presentation may
vary widely depending on a client’s
present status
● When dysfunction is severe, clients
may appear disheveled and may be
unable to sit still, or they may display
labile emotions
● Initial appearance and motor behavior
may seem normal
● Pervasive mood is dysphoric
○ unhappiness, restlessness,
and malaise. Clients often
report intense loneliness,
boredom, frustration, and
feeling “empty.”
● Rarely experience periods of
satisfaction or well-being
● Although there is a pervasive
depressed affect, it is unstable and
erratic
● Become irritable, even hostile or
sarcastic, and complain of episodes of
panic anxiety
● They experience intense emotions
such as anger and rage but rarely
express them productively or usefully
● usually hypersensitive to others’
emotions, which can easily trigger
reactions
● Minor changes may precipitate a
severe emotional crisis, for example,
when an appointment must be
changed from one day to the next
● Experience major emotional trauma
when their therapists take vacations.
● Thinking about oneself and others is
often polarized and extreme, which is
sometimes referred to as splitting
● Tend to adore and idealize other
people even after a brief acquaintance
but then quickly devalue them if these
others do not meet their expectations
in some way
● Have excessive and chronic fears of
abandonment even in normal
situations; this reflects their
intolerance of being alone
● May also engage in obsessive
rumination about almost anything,
regardless of the issue’s relative
importance
● may experience dissociative episodes
(periods of wakefulness when they are
unaware of their actions)
● Self-harm behaviors often occur
during these dissociative episodes,
though, at other times, clients may be
fully aware of injuring themselves
● Under extreme stress, clients may
develop transient psychotic symptoms
such as delusions or hallucinations
● Intellectual capacities are intact, and
clients are fully oriented to reality
● The exception is transient psychotic
symptoms; during such episodes,
reports of auditory hallucinations
encouraging or demanding self-harm
are most common
○ symptoms usually abate when
the stress is relieved
● Many clients also report flashbacks of
previous abuse or trauma
● These experiences are consistent with
posttraumatic stress disorder, which is
common in clients with BPD
● frequently report behaviors consistent
with impaired judgment and lack of
care and concern for safety, such as
gambling, shoplifting, and reckless
driving.
● make decisions impulsively on the
basis of emotions rather than facts
● have difficulty accepting responsibility
for meeting needs outside a
relationship
● see life’s problems and failures as a
result of others’ shortcomings
○ others are always to blame,
insight is limited
● A typical reaction to a problem is “I
wouldn’t have gotten into this mess if
so-and-so had been there
● have an unstable view of themselves
that shifts dramatically and suddenly
● appear needy and dependent one
moment and angry, hostile, and
rejecting the next
● Sudden changes in opinions and plans
about career, sexual identity, values,
and types of friends are common
● view themselves as inherently bad or
evil and often report feeling as if they
don’t really exist at all
● Suicidal threats, gestures, and
attempts are common. Self-harm and
mutilation, such as cutting, punching,
or burning, are common
○ must be taken seriously
because these clients are at
increased risk for completed
suicide
○ cause much pain and often
require extensive treatment
○ result in massive scarring or
permanent disability such as
paralysis or loss of mobility
from injury to nerves, tendons,
and other essential structures
● hate being alone, but their erratic,
labile, and sometimes dangerous
behaviors often isolate them
● Relationships are unstable, stormy,
and intense; the cycle repeats itself
continually
 ● have extreme fears of abandonment
and difficulty believing a relationship
still exists once the person is away
from them
● engage in many desperate behaviors,
even suicide attempts, to gain or
maintain relationships. Feelings for
others are often distorted, erratic, and
inappropriate
● may view someone they have met
only once or twice as their best and
only friend or the “love of my life
○ If not reciprocated, may feel
rejected, become hostile, and
declare him or her to be their
enemy
○ these situations precipitate
self-mutilating behavior;
occasionally, clients may
attempt to harm others
physically
● history of poor school and work
performance because of constantly
changing career goals and shifts in
identity or aspirations, preoccupation
with maintaining relationships, and
fear of real or perceived abandonment
● lack the concentration and self
discipline to follow through on
sometimes mundane tasks associated
with work or school.
● may engage in binging (excessive
overeating) and purging (self-induced
vomiting), substance abuse,
unprotected sex, or reckless behavior
such as driving while intoxicated. They
usually have difficulty sleeping
NURSING DIAGNOSIS FOR BORDERLINE
PERSONALITY DISORDER
● Risk for suicide
● Risk for self-mutilation
● Risk for other-directed violence
● Ineffective coping
● Social isolation
OUTCOME IDENTIFICATION FOR
BORDERLINE PERSONALITY DISORDER
• The client will be safe and free from
significant injury.
• The client will not harm others or destroy
property.
• The client will demonstrate increased control
of impulsive behavior.
• The client will take appropriate steps to meet
his or her own needs.
• The client will demonstrate problem-solving
skills.
• The client will verbalize greater satisfaction
with relationships
INTERVENTIONS OF BORDERLINE
PERSONALITY DISORDER
● often involved in long-term
psychotherapy to address issues of
family dysfunction and abuse
● nurse is most likely to have contact
with these clients during crises, when
they are exhibiting self-harm behaviors
or transient psychotic symptoms
● Brief hospitalizations are often used to
manage these difficulties and to
stabilize the client’s condition.
Promoting clients’ safety
● physical safety is always a priority
● seriously consider suicidal ideation
with the presence of a plan, access to
means for enacting the plan, and
self-harm behaviors and institute
appropriate interventions
● often experience chronic suicidality or
ongoing intermittent ideas of suicide
over months or years
● Helping clients avoid self-injury can be
difficult when antecedent conditions
vary greatly
● nurse must remain nonjudgmental
when discussing about self-harm
urges
● encourage clients to enter into a
no-self-harm contract, in which the
client promises not to engage in
self-harm and to report to the nurse
when he or she is losing control
○ no-self-harm contract is not a
promise to the nurse but the
client’s promise to him or
herself to be safe
○ not legally binding, such a
contract is thought to be
beneficial to the client’s
treatment by promoting
self-responsibility and
 encouraging dialogue
between client and nurse
● avoids sensational aspects of the
injury; the focus is on identifying mood
and affect, level of agitation and
distress, and circumstances
surrounding the incident. In this way,
clients can begin to identify trigger
situations, moods, or emotions that
precede self-harm and to use more
effective coping skills to deal with the
trigger issues
● Lecturing or chastising clients is
punitive and has no positive effect on
self-harm behaviors. Deflecting
attention from the actual physical act
is usually desirable
Promoting the therapeutic relationship
● provide structure and limit setting in
the therapeutic relationship
● Clinical setting, seeing the client for
scheduled appointments of a
predetermined length rather than
whenever the client appears and
demands the nurse’s immediate
attention
● Hospital setting, plan to spend a
specific amount of time with the client
working on issues or coping strategies
rather than giving the client exclusive
access when he or she has had an
outburst.
● Limit setting and confrontation
techniques, described earlier, are also
helpful
NURSING INTERVENTIONS FOR
BORDERLINE PERSONALITY DISORDER
● Promoting client’s safety
○ No-self-harm contract
○ Safe expression of feelings
and emotions
● Helping client to cope and control
emotions
○ Identifying feelings
○ Journal entries
○ Moderating emotional
responses
○ Decreasing impulsivity
○ Delaying gratification
● Cognitive restructuring techniques
○ Thought stopping
○ Decatastrophizing
● Structuring time
● Teaching social skills
● Teaching effective communication
skills
● Entering therapeutic relationship
○ Limit setting
○ Confrontation
Establishing boundaries in relationships
● difficulty maintaining satisfying
interpersonal relationship
● Personal boundaries are unclear, and
clients often have unrealistic
expectations
● Erratic patterns of thinking and
behaving often alienate them from
others
○ true for both professional and
personal relationships
● Clients can easily misinterpret the
nurse’s genuine interest and caring as
a personal friendship, and the nurse
may feel flattered by a client’s
compliments
● a nurse must be quite clear about
establishing the boundaries of the
therapeutic relationship to ensure that
neither the client’s nor the nurse’s
boundaries are violated.
Helping clients to cope and to control emotions
● Clients often react to situations with
extreme emotional responses without
actually recognizing their feelings
○ nurse can help clients identify
their feelings and learn to
tolerate them without
exaggerated responses such
as destruction of property or
self-harm
● Keeping a journal often helps clients
gain awareness of feelings
● The nurse can review journal entries
as a basis for discussion.
● Another aspect of emotional regulation
is decreasing impulsivity and learning
to delay gratification
● When clients have an immediate
desire or request, they must learn that
 it is unreasonable to expect it to be
granted without delay
● Clients can use distraction such as
taking a walk or listening to music to
deal with the delay, or they can think
about ways to meet needs themselves
● Clients can write in their journals about
their feelings when gratification is
delayed
Reshaping thinking patterns
● clients view everything, people and
situations, in extremes—totally good
or totally bad
● Cognitive restructuring is a technique
useful in changing patterns of thinking
by helping clients recognize negative
thoughts and feelings and replacing
them with positive patterns of thinking
● The client then learns to replace
recurrent negative thoughts of
worthlessness with more positive
thinking
● Decatastrophizing is a technique that
involves learning to assess situations
realistically rather than always
assuming a catastrophe will happen
● Client must consider other points of
view and actually think about the
situation; in time, his or her thinking
may become less rigid and inflexible
Structuring the clients’ daily activities
● Feelings of chronic boredom and
emptiness, fear of abandonment, and
intolerance of being alone are
common problems
● Minimizing unstructured time by
planning activities can help clients
manage time alone
● Clients can make a written schedule
that includes appointments, shopping,
reading the paper, and going for a
walk
● more likely to follow the plan if it is in
written form
● help clients plan ahead to spend time
with others instead of frantically calling
others when in distress
● The written schedule also allows the
nurse to help clients engage in more
healthful behaviors, such as
exercising, planning meals, and
cooking nutritious food
CLIENT AND FAMILY EDUCATION FOR
BORDERLINE PERSONALITY DISORDER
● Teaching social skills
○ Maintaining personal
boundaries
○ Realistic expectations of
relationships
● Teaching time structuring
○ Making a written schedule of
activities
○ Making a list of solitary
activities to combat boredom
● Teaching self-management through
cognitive restructuring
○ Decatastrophizing situation
○ Thought stopping
○ Positive self-talk
● Using assertiveness techniques, such
as “I” statements
● Using distraction, such as walking or
listening to music
Histrionic personality disorder
● pervasive pattern of excessive
emotionality and attention seeking
● 1% to 3% of the general population
but in as much as 10% to 15% of
inpatient populations.
● Clients often seek assistance for
depression, unexplained physical
problems, and difficulties with
relationships
● clients do not see how their own
behavior has an impact on their
current difficulties
● diagnosed more frequently in females
than in males
● tendency of these clients to
exaggerate the closeness of
relationships or to dramatize relatively
minor occurrences can result in
unreliable data
● Speech is usually colorful and
theatrical, full of superlative adjectives
○ It becomes apparent,
however, that though colorful
and entertaining, descriptions
are vague and lack detail.
● Overall appearance is normal,
although clients may overdress (e.g.,
wear an evening dress and high heels
for a clinical interview)
● concerned with impressing others with
their appearance and spend inordinate
time, energy, and money to this end.
● Dress and flirtatious behavior are not
limited to social situations or
relationships, but also occur in
occupational and professional settings
● emotionally expressive, gregarious,
and effusive
● exaggerate emotions inappropriately
● Expressed emotions, though colorful,
are insincere and shallow; this is
readily apparent to others, but not to
clients
● experience rapid shifts in moods and
emotions and may be laughing
uproariously one moment and sobbing
the next
○ displays of emotion may seem
phony or forced to observers
● self absorbed and focus most of their
thinking on themselves with little or no
thought about the needs of others
● highly suggestible and will agree with
almost anyone to get attention
● express strong opinions firmly, but
because they base them on little
evidence or facts, the opinions often
shift under the influence of someone
they are trying to impress
● uncomfortable when they are not the
center of attention and go to great
lengths to gain that status
● use their physical appearance and
dress to gain attention
● fish for compliments in unsubtle ways,
fabricate unbelievable stories, or
create public scenes to attract
attention
○ may even faint, become ill, or
fall to the floor
● brighten considerably when given
attention after some of these
behaviors; this leaves others feeling
they have been used
● comment or statement that could be
interpreted as uncomplimentary or
unflattering may produce a strong
response such as a temper tantrum or
crying outburst
● tend to exaggerate the intimacy of
relationships
● may embarrass family members or
friends by flamboyant and
inappropriate public behavior such as
hugging and kissing someone who
has just been introduced or sobbing
uncontrollably over a minor incident
● may ignore old friends if someone new
and interesting has been introduced
● have relationships often describe
being used, manipulated, or exploited
shamelessly
● may have a wide variety of vague
physical complaints or relate
exaggerated versions of physical
illness
○ usually involve the attention
the client received (or failed to
receive) rather than any
particular physiological
concern
NURSING INTERVENTION FOR HISTRIONIC
PERSONALITY DISORDER
● gives clients feedback about their
social interactions with others,
including manner of dress and
nonverbal behavior
○ Feedback should focus on
appropriate alternatives, not
merely criticism
● discuss social situations to explore
clients’ perceptions of others’
reactions and behavior
● Teaching social skills and role-playing
those skills in a safe, nonthreatening
environment can help clients gain
confidence in their ability to interact
socially
● nurse must be specific in describing
and modeling social skills, including
establishing eye contact, engaging in
active listening, and respecting
personal space
○ helps to outline topics of
discussion appropriate for
casual acquaintances, closer
friends or family, and the
nurse only
 ● It is important to explore personal
strengths and assets and to give
specific feedback about positive
characteristics
● Encouraging clients to use assertive
communication, such as “I”
statements, may promote self-esteem
and help them get their needs met
more appropriately.
● The nurse must convey genuine
confidence in the client’s abilities.
Narcissistic personality disorder
● characterized by a pervasive pattern
of grandiosity (in fantasy or behavior),
need for admiration, and lack of
empathy
● 1% to 6% of the general population
● 50% to 75% are men
● Narcissistic traits are common in
adolescence and do not necessarily
indicate that a personality disorder will
develop in adulthood
● Narcissistic traits are common in
adolescence and do not necessarily
indicate that a personality disorder will
develop in adulthood
● may display an arrogant or haughty
attitude
● lack the ability to recognize or
empathize with the feelings of others
● may express envy and begrudge
others any recognition or material
success because they believe it
rightfully should be theirs
● Clients tend to disparage, belittle, or
discount the feelings of others
● May express their grandiosity overtly,
or they may quietly expect to be
recognized for their perceived
greatness
● often preoccupied with fantasies of
unlimited success, power, brilliance,
beauty, or ideal love
○ These fantasies reinforce their
sense of superiority
● ruminate about long-overdue
admiration and privilege and compare
themselves favorably with famous or
privileged people
● Thought processing is intact, but
insight is limited or poor
● Clients believe themselves to be
superior and special
● Underlying self-esteem is almost
always fragile and vulnerable
● hypersensitive to criticism and need
constant attention and admiration
● often display a sense of entitlement
(unrealistic expectation of special
treatment or automatic compliance
with wishes)
● may believe that only special or
privileged people can appreciate their
unique qualities or are worthy of their
friendship
● expect special treatment from others
and are often puzzled or even angry
when they do not receive it
● often form and exploit relationships to
elevate their own status
● assume total concern from others
about their welfare
● discuss their own concerns in lengthy
detail with no regard for the needs and
feelings of others
● become impatient or contemptuous of
those who discuss their own needs
and concerns
● may experience some success
because they are ambitious and
confident
● Difficulties are common, however,
because they have trouble working
with others (whom they consider to be
inferior) and have limited ability to
accept criticism or feedback
● likely to believe they are underpaid
and underappreciated or should have
a higher position of authority even
though they are not qualified
NURSING INTERVENTIONS FOR
NARCISSISTIC PERSONALITY DISORDER
● Clients with narcissistic personality
disorder can present one of the
greatest challenges to the nurse
● nurse must use self-awareness skills
to avoid the anger and frustration that
these clients’ behavior and attitude
can engender
● Clients may be rude and arrogant,
unwilling to wait, and harsh and critical
of the nurse
 ○ nurse must not internalize
such criticism or take it
personally
● The goal is to gain the cooperation of
these clients with other treatment as
indicated
● Nurse teaches about comorbid
medical or psychiatric conditions,
medication regimen, and any needed
self-care skills in a matter-of fact
manner.
● he or she sets limits on rude or
verbally abusive behavior and explains
his or her expectations of the client.
Avoidant personality disorder
● is characterized by a pervasive pattern
of social discomfort and reticence, low
self-esteem, and hypersensitivity to
negative evaluation.
● It occurs in 2% to 3% of the general
population.
● It is equally common in men and
women. Clients are good candidates
for individual psychotherapy
● These clients are likely to report being
overly inhibited as children and that
they often avoid unfamiliar situations
and people with an intensity beyond
that expected for their developmental
stage.
● This inhibition, which may have
continued throughout upbringing,
contributes to low self-esteem and
social alienation.
● Clients are apt to be anxious and may
fidget in chairs and make poor eye
contact with the nurse. They may be
reluctant to ask questions or to make
requests.
Characteristics:
○ They may appear sad as well
as anxious. They describe
being shy, fearful, socially
awkward, and easily
devastated by real or
perceived criticism.
○ Their usual response to these
feelings is to become more
reticent and withdrawn.
Clients with avoidant
personality disorder have low
self-esteem.
○ They are hypersensitive to
negative evaluation from
others and readily believe
themselves to be inferior.
Clients are reluctant to do
anything perceived as risky,
which for them is almost
anything.
○ They are fearful and
convinced they will make a
mistake, be humiliated, or
embarrass themselves and
others. Because they are
unusually fearful of rejection,
criticism, shame, or
disapproval, they tend to avoid
situations or relationships that
may result in these feelings.
○ They usually strongly desire
social acceptance and human
companionship; they wish for
closeness and intimacy but
fear possible rejection and
humiliation.
○ These fears hinder
socialization, which makes
clients seem awkward and
socially inept and reinforces
their beliefs about themselves.
○ They may need excessive
reassurance of guaranteed
acceptance before they are
willing to risk forming a
relationship.
● Clients may report some success in
occupational roles because they are
so eager to please or to win a
supervisor’s approval. Shyness,
awkwardness, or fear of failure,
however, may prevent them from
seeking jobs that might be more
suitable, challenging, or rewarding.
○ For example, a client may
reject a promotion and
continue to remain in an
entry-level position for years,
even though he or she is well
qualified to advance.
Nursing Interventions
● These clients require much support
and reassurance from the nurse. In
the non threatening context of the
relationship, the nurse can help them
explore positive self-aspects, positive
responses from others, and possible
reasons for self-criticism. Helping
clients practice self-affirmations and
positive self-talk may be useful in
promoting self-esteem.
● Other cognitive restructuring
techniques such as reframing and
decatastrophizing (described
previously) can enhance self-worth.
● The nurse can teach social skills and
help clients practice them in the safety
of the nurse–client relationship.
● Although these clients have many
social fears, those are often
counterbalanced by their desire for
meaningful social contact and
relationships. The nurse must be
careful and patient with clients and not
expect them to implement social skills
too rapidly.
Dependent personality disorder
● is characterized by a pervasive and
excessive need to be taken care of,
which leads to submissive and clinging
behavior and fears of separation.
● These behaviors are designed to elicit
caretaking from others.
● This disorder occurs in about 1% of
the population and is three times more
common in females than males.
● It runs in families and is more common
in the youngest child.
● People with dependent personality
disorder may seek treatment for
anxious, depressed, or somatic
symptoms
● Clients are frequently anxious and
may be mildly uncomfortable. They
are often pessimistic and self-critical;
other people hurt their feelings easily.
● They commonly report feeling
unhappy or depressed; this is
associated most likely with the actual
or threatened loss of support from
another.
● They are excessively preoccupied with
unrealistic fears of being left alone to
care for themselves.
● They believe they would fail on their
own, so keeping or finding a
relationship occupies much of their
time.
● They have tremendous difficulty
making decisions, no matter how
minor.
● They seek advice and repeated
reassurances about all types of
decisions, from what to wear to what
type of job to pursue. Although they
can make judgments and decisions,
they lack the confidence to do so
● Clients perceive themselves as unable
to function outside a relationship with
someone who can tell them what to
do.
● They are uncomfortable and feel
helpless when alone, even if the
current relationship is intact.
● They have difficulty initiating projects
or completing simple daily tasks
independently.
● They believe they need someone else
to assume responsibility for them, a
belief that far exceeds what is age or
situation appropriate.
● They may even fear gaining
competence because doing so would
mean an eventual loss of support from
the person on whom they depend.
● They may do almost anything to
sustain a relationship, even one of
poor quality.
● This includes doing unpleasant tasks,
going places they dislike, or, in
extreme cases, tolerating abuse.
● Clients are reluctant to express
disagreement for fear of losing the
other person’s support or approval;
they may even consent to activities
that are wrong or illegal to avoid that
loss.
● When these clients do experience the
end of a relationship, they urgently
and desperately seek another. The
unspoken motto seems to be “Any
relationship is better than no
relationship at all.”

Nursing Interventions
● The nurse must help clients express
feelings of grief and loss over the end
of a relationship while fostering
autonomy and self-reliance.
● Helping clients identify their strengths
and needs is more helpful than
encouraging the overwhelming belief
that “I can’t do anything alone!”
Cognitive restructuring techniques
such as reframing and
decatastrophizing may be beneficial.
● Clients may need assistance in daily
functioning if they have little or no past
success in this area.
○ Included are such things as
planning menus, doing the
weekly shopping, budgeting
money, balancing a They were expected to be good and
checkbook, and paying bills.
Careful assessment to
determine areas of need is
essential.
● Depending on the client’s abilities and
limitations, referral to agencies for
services or assistance may be
indicated.
● the nurse may also need to teach
problem-solving and decision-making
and help clients apply them to daily
life.
● He or she must refrain from giving
advice about problems or making
decisions for clients, even though
clients may ask the nurse to do so.
● The nurse can help the client explore
problems, serve as a sounding board
for discussion of alternatives, and
provide support and positive feedback
for the client’s efforts in these areas.
Obsessive- compulsive personality
disorder
● is characterized by a pervasive pattern
of preoccupation with perfectionism,
mental and interpersonal control, and
orderliness at the expense of flexibility,
openness, and efficiency.
● It is one of the most prevalent
personality disorders, occurring in
about 2% to 8% of the population,
affecting twice as many men as
women.
● Incidence is higher in oldest children
and people in professions involving
facts, figures, or methodical focus on
detail.
● These people often seek treatment
because they recognize that their life
is pleasureless or they are
experiencing problems with work or
relationships.
● Clients frequently benefit from
individual therapy.
● The demeanor of these clients is
formal and serious, and they answer
questions with precision and much
detail.
● They often report feeling the need to
be perfect beginning in childhood.
do the right thing to win parental
approval.
● Expressing emotions or asserting
independence was probably met with
harsh disapproval and emotional
consequences.
● Emotional range is usually quite
constricted. They have difficulty
expressing emotions, and any
emotions they do express are rigid,
stiff, and formal, lacking spontaneity.
● Clients can be stubborn and reluctant
to relinquish control, which makes it
difficult for them to be vulnerable to
others by expressing feelings.
● Affect is also restricted; they usually
appear anxious and fretful or stiff and
reluctant to reveal underlying
emotions.
● Clients are preoccupied with
orderliness and try to maintain it in all
areas of life. They strive for perfection
as though it were attainable and are
preoccupied with details, rules, lists,
and schedules to the point of often
missing “the big picture.”
● They become absorbed in their own
perspective, believe they are right, and
do not listen carefully to others
because they have already dismissed
what is being said.
● Clients check and recheck the details
of any project or activity; often, they
never complete the project because of
“trying to get it right.”
● They have problems with judgment
and decision making—specifically,
actually reaching a decision. They
consider and reconsider alternatives,
and the desire for perfection prevents
a decision from being reached.
● Clients interpret rules or guidelines
literally and cannot be flexible or
modify decisions based on
circumstances.
● They prefer written rules for each and
every activity at work.
● Insight is limited, and they are often
oblivious that their behavior annoys or
frustrates others. If confronted with
this annoyance, these clients are
stunned, unable to believe others
``don't want me to do a good job.”
● These clients have low self-esteem
and are always harsh, critical, and
judgmental of themselves; they
believe that they “could have done
better” regardless of how well the job
has been done.
● Praise and reassurance do not change
this belief. Clients are burdened by
extremely high and unattainable
standards and expectations. Although
no one could live up to these
expectations, they feel guilty and
worthless for being unable to achieve
them.
● They tend to evaluate self and others
solely on the basis of deeds or actions
without regard for personal qualities.
● These clients have much difficulty in
relationships, few friends, and little
social life. They do not express warm
or tender feelings to others; attempts
to do so are stiff and formal and may
sound insincere.
○ For example, if a significant
other expresses love and
affection, a client’s response
might be “The feeling is
mutual.”
● Marital and parent–child relationships
are often difficult because these
clients can be harsh and unrelenting.
○ For example, most clients are
frugal, do not give gifts or
want to discard old items, and
insist that those around them
do the same. Shopping for
something new to wear may
seem frivolous and wasteful.
● Clients cannot tolerate lack of control
and hence may organize family
outings to the point that no one enjoys
them. These behaviors can cause
daily strife and discord in family life.
● At work, clients may experience some
success, particularly in fields where
precision and attention to detail are
desirable. They may miss deadlines,
however, while trying to achieve
perfection or may fail to make needed
decisions while searching for more
data.
● They fail to make timely decisions
because of continually striving for
perfection.
● They have difficulty working
collaboratively, preferring to do it
themselves so that it is done
“correctly.” If clients do accept help
from others, they may give such
detailed instructions and watch the
other person so closely that coworkers
are insulted, annoyed, and refuse to
work with them.
● Given this excessive need for routine
and control, new situations and
compromise are also difficult.
Nursing Interventions
● Nurses may be able to help clients
view decision-making and completion
of projects from a different
perspective. Rather than striving for
the goal of perfection, clients can set a
goal of completing the project or
making the decision by a specified
deadline.
● Helping clients accept or tolerate
less-than perfect work or decisions
made on time may alleviate some
difficulties at work or home. Clients
 may benefit from cognitive
restructuring techniques. The nurse
can ask, “What is the worst that could
happen?” or “How might your boss (or
your wife) see this situation?” These
questions may challenge some rigid
and inflexible thinking.
● Encouraging clients to take risks, such
as letting someone else plan a family
activity, may improve relationships.
● Practicing negotiation with family or
friends may also help clients relinquish
some of their need for control.
MENTAL HEALTH PROMOTION
● The treatment of individuals with a
personality disorder often focuses on
mood stabilization, decreasing
impulsivity, and developing social and
relationship skills.
● In addition, clients perceive unmet
needs in a variety of areas, such as
self-care (keeping clean and tidy),
sexual expression (dissatisfaction with
sex life), budgeting (managing daily
finances), psychotic symptoms, and
psychological distress. Typically,
psychotic symptoms and
psychological distress are often the
only areas addressed by health care
providers.
● Perhaps dealing with those other
areas in the treatment of a client might
result in a greater sense of well-being
and improved health.
● Children who have a greater number
of “protective factors” are less likely to
develop antisocial behavior as adults.
○ These protective factors
include school commitment or
importance of school, positive
peer relationships, parent or
peer disapproval of antisocial
behavior, functional family
relationship, and effective
parenting skills.
● Interestingly, the study found that
children at risk for abuse and those
not at risk were less likely to have
antisocial behavior as adults if these
protective factors were present in their
environment.
● Children lacking these protective
factors are much more likely to
develop antisocial behavior as adults.
Points to Consider When Working with
Clients with Personality Disorders
● Talking to colleagues about feelings of
frustration will help you deal with your
emotional responses so you can be
more effective with clients.
● Clear, frequent communication with
other health care providers can help
diminish the client’s manipulation.
● Do not take undue flattery or harsh
criticism personally; it is a result of the
client’s personality disorder.
● Set realistic goals, and remember that
behavior changes in clients with
personality disorders take a long time.
Progress can be slow.
4. PSYCHOBIOLOGICAL DISORDERS
- Christa, Har, Jeanne, Khay,
Rikka
•Mood disorders-rikka
MAJOR DEPRESSIVE DISORDER
- typically involves 2 or more
weeks of a sad mood or lack of
interest in life activities with at
least four other symptoms of
depression such as:
- Anhedonia
- Changes in weight, sleep,
energy, concentration,
decision making,
self-esteem, and goals
- twice as common in women and
has a 1.5 to 3 times greater
incidence in first-degree relatives
than in the general population
- Incidence of depression
decreases with age in WOMEN
and increases with age in MEN
- Single and divorced people have
the highest incidence
 - Depression in prepubertal BOYS - Researchers believe that levels
and GIRLS occurs at an equal of neurotransmitters, especially
rate NOREPINEPHRINE and
ONSET AND CLINICAL COURSE SEROTONIN are decreased in
- An untreated episode of depression
depression can last 6 to 24 - Usually, presynaptic neurons
months before remitting release these neurotransmitters
- Fifty to sixty percent of people to allow them to enter synapses
who have one episode of and link with postsynaptic
depression will have another receptors
- After a second episode of DEPRESSION results if:
depression, there is a 70% - too few neurotransmitters are
chance of recurrence released
- Depressive symptoms can vary - neurotransmitters linger too
from mild to severe briefly in synapses
- The degree of depression is - the releasing presynaptic
comparable with the person’s neurons reabsorb them too
sense of helplessness and quickly
hopelessness - conditions in synapses do not
- Some people with severe support linkage with postsynaptic
depression (9%) have psychotic receptors
features - the number of postsynaptic
TREATMENT AND PROGNOSIS receptors has decreased
Psychopharmacology GOAL: increase the efficacy of available
- Major categories of neurotransmitters and the absorption by
antidepressants include: postsynaptic receptors
- cyclic antidepressants - To do so, ANTIDEPRESSANTS
- monoamine oxidase establish a blockade for the
inhibitors (MAOIs) reuptake of norepinephrine and
- selective serotonin serotonin into their specific nerve
reuptake inhibitors terminals
(SSRIs) - This permits them to linger longer
- atypical antidepressants. in synapses and to be more
- The choice of which available to postsynaptic
antidepressant to use is based receptors
on the client’s: - ANTIDEPRESSANTS also
- Symptoms increase the sensitivity of the
- Age postsynaptic receptor sites
- physical health needs ACUTE DEPRESSION W/ PSYCHOTIC
- drugs that have or have FEATURES:
not worked in the past or - an ANTIPSYCHOTIC is used in
that have worked for a combination with an
blood relative with antidepressant
depression - ANTIPSYCHOTIC treats the
- other medications that the psychotic features
client is taking
 - several weeks into treatment, the
client is reassessed to determine
whether the antipsychotic can be
withdrawn and the
antidepressant maintained.
● Evidence is increasing that
ANTIDEPRESSANT THERAPY
should continue for longer than
the 3 to 6 months originally
believed necessary
● Fewer relapses occur in people
with depression who receive 18
to 24 months of
ANTIDEPRESSANT THERAPY
● As a rule, the dosage of
ANTIDEPRESSANTS should be
tapered before being
discontinued
A. Selective Serotonin Reuptake
Inhibitors (SSRIs)
- newest category of
antidepressants
- effective for most clients
- action is specific to serotonin
reuptake inhibition
- produce few sedating,
anticholinergic, & cardiovascular
side effects, which make them
safer for use in older adults
- Because of their low side effects
and relative safety, people using
SSRIs are more apt to be
compliant with the treatment
regimen than clients using more
troublesome medications
EFFECTS:
● Insomnia decreases in 3 to 4
days
● appetite returns to a more normal
state in 5 to 7 days
● energy returns in 4 to 7 days. In 7
to 10 days, mood, concen-
tration, and interest in life
improve
Fluoxetine (Prozac)
- produces a slightly higher rate of
mild agitation and weight loss but
less somnolence
- has a half-life of more than 7
days, which differs from the
25-hour half-life of other SSRIs
B. Cyclic Antidepressants
- Tricyclics, introduced for the
treatment of depression in the
mid-1950s, are the oldest
antidepressants
- They relieve symptoms of
hopelessness, helplessness,
anhedonia, inappropriate guilt,
suicidal ideation, and daily mood
variations (cranky in the morning
and better in the evening)
- Other indications include panic
disorder, obsessive–compulsive
disorder, and eating disorders
- Each drug has a different degree
of efficacy in blocking the activity
of norepinephrine and serotonin
or increasing the sensitivity of
postsynaptic receptor sites
- Tricyclic and heterocyclic
antidepressants have a lag
period of 10 to 14 days before
reaching a serum level that
begins to alter symptoms; they
take 6 weeks to reach full
effect
- Because they have a long serum
half-life, there is a lag period of 1
to 4 weeks before steady plasma
levels are reached and the
client’s symptoms begin to
decrease
- They cost less primarily because
they have been around longer
and generic forms are available
- Tricyclic antidepressants are
CONTRAINDICATED in:
- severe impairment of liver
function
 - myocardial infarction - neuroleptic malignant
(acute recovery phase) syndrome
- They can’t be given concurrently - It can create tolerance in 1 to 3
with MAOIs months
- Because of their anticholinergic - It increases appetite and causes
side effects, tricyclic weight gain and cravings for
antidepressants must be used sweets
cautiously in clients who have: Maprotiline (Ludiomil)
- Glaucoma - carries a risk for:
- benign prostatic - seizures (especially in
hypertrophy heavy drinkers)
- urinary retention or - severe constipation
obstruction - urinary retention
- diabetes mellitus - Stomatitis
- Hyperthyroidism - other side effects; this
- cardiovascular disease leads to poor compliance
- renal impairment - The drug is started and
- respiratory disorders withdrawn gradually
- Overdosage of tricyclic - CNS depressants can increase
antidepressants occurs over the effects of this drug
several days and results in: D. Atypical Antidepressants
- Confusion - used when the client has an
- Agitation inadequate response to or side
- Hallucinations effects from SSRIs
- Hyperpyrexia - include:
- increased reflexes ● venlafaxine (Effexor)
- Seizures, coma, and = blocks the reuptake of
cardiovascular toxicity can occur serotonin, norepinephrine, and
with ensuing tachycardia, dopamine (weakly)
decreased output, depressed ● duloxetine (Cymbalta)
contractility, and atrioventricular = selectively blocks both
block serotonin and norepinephrine
- Because many older adults have ● bupropion (Well-butrin)
concomitant health problems, = modestly inhibits the reuptake
cyclic antidepressants are used of norepinephrine, weakly inhibits
less often in the geriatric the reuptake of dopamine, and
population than newer types of has no effects on serotonin
antidepressants that have fewer = marketed as Zyban for smoking
side effects and less drug cessation
interactions. ● nefazodone (Serzone)
C. Tetracyclic Antidepressants = inhibits the reuptake of
Amoxapine (Asendin) serotonin and norepinephrine
- may cause: and has few side effects
- extrapyramidal symptoms = half-life is 4 hours
- tardive dyskinesia = used in clients with liver and
kidney disease
 = increases the action of certain
benzodiazepines (alprazolam,
estazolam, and triazolam) and
the H2 blocker terfenadine
● mirtazapine (Remeron)
= inhibits the reuptake of
serotonin and norepinephrine
= has few sexual side effects
= however, its use comes with a
higher incidence of weight gain,
sedation, and anticholinergic side
effects
E. Monoamine Oxidase Inhibitors
(MAOIs)
- used infrequently because of
potentially fatal side effects and
interactions with numerous
drugs, both prescription and
over-the-counter preparations
- The most serious side effect is
HYPERTENSIVE CRISIS
HYPERTENSIVE CRISIS
- a life-threatening condition that
can result when a client taking
MAOIs ingests
tyramine-containing foods and
fluids or other medications
- Symptoms are:
● Occipital headache
● Hypertension
● Nausea
● Vomiting
● Chills
● Sweating
● Restlessness
● Nuchal rigidity
● Dilated pupils
● Fever
● Motor agitation
- These can lead to hyperpyrexia,
cerebral hemorrhage, and death.
- The MAOI–tyramine interaction
produces symptoms within 20 to
60 minutes after ingestion.
- For hypertensive crisis, transient
antihypertensive agents, such
as phentolamine mesylate, are
given to dilate blood vessels and
decrease vascular resistance
- There is a 2- to 4-week lag period
before MAOIs reach therapeutic
levels
- Because of the lag period,
adequate washout periods of 5
to 6 weeks are recommended
between the times that the MAOI
is discontinued and another class
of antidepressant is started
OTHER MEDICAL TREATMENTS &
PSYCHOTHERAPY
Electroconvulsive Therapy (ECT)
- Psychiatrists may use
electroconvulsive therapy (ECT)
to treat depression in select
groups, such as clients who:
- don’t respond to
antidepressants
- experience intolerable
side effects at therapeutic
doses (particularly true for
older adults)
- pregnant women can
safely have ECT with no
harm to the fetus
- Clients who are actively
suicidal may be given
ECT if there is concern for
their safety while waiting
weeks for the full effects
of antidepressant
medication
- involves application of
electrodes to the head of the
client to deliver an electrical
impulse to the brain and this
causes a seizure
- It is believed that the SHOCK
stimulates brain chemistry to
correct the chemical imbalance
of depression
- Historically, clients did not receive
any anesthetic or other
 medication before ECT, and they - Electrodes are placed on the
had full blown grand mal seizures client’s head:
that often resulted in injuries - one on either side
ranging from biting the tongue to (bilateral)
breaking bones - both on one side
- ECT fell into disfavor for a period (unilateral)
and was seen as “barbaric.” - The electrical stimulation is
- Today, although ECT is delivered, which causes seizure
administered in a safe and activity in the brain that is
humane way with almost no monitored by an
injuries, there are still critics of electroencephalogram/EEG
the treatment. - The client receives oxygen and is
- Clients usually receive a series of assisted to breathe with an Ambu
6 to 15 treatments scheduled bag
thrice a week - He or she generally begins to
- Generally, a minimum of six waken after a few minutes
treatments are needed to see - Vital signs are monitored, and the
sustained improvement in client is assessed for the return
depressive symptoms and of a gag reflex
maximum benefit is achieved - After ECT treatment, the client
in 12 to 15 treatments may be mildly confused or briefly
- Preparation of a client for ECT is disoriented
similar to preparation for any - He or she is very tired and often
outpatient minor surgical has a headache
procedure: - The symptoms are just like those
- Client receives nothing by of anyone who has had a grand
mouth (or, is NPO) after mal seizure
midnight - In addition, the client will have
- removes any fingernail some short-term memory
polish impairment
- voids just before the - After a treatment, the client may
procedure eat as soon as he or she is
- An IV line is started for the hungry and usually sleeps for a
administration of period
medication - Headaches are treated
- Initially, the client receives a symptomatically
short-acting anesthetic so he or - UNILATERAL ECT results in less
she is not awake during the memory loss for the client, but
procedure more treatments may be needed
- Next, he/she receives a muscle to see sustained improvement
relaxant/paralytic, usually - BILATERAL ECT results in more
succinylcholine, which relaxes all rapid improvement but with
muscles to reduce greatly the increased short-term memory
outward signs of the seizure loss
(e.g., clonic–tonic muscle
contractions)
 - The literature continues to be
divided about the effectiveness of
ECT
- Some studies report that ECT is
as effective as medication for
depression, whereas other
studies report only short-term
improvement
- Likewise, some studies report
that memory loss side effects of
ECT are short lived, whereas
others report they are serious
and long term
- ECT is also used for relapse
prevention in depression
- Clients may continue to receive
treatments, such as one per
month, to maintain their mood
improvement
- Often, clients are given
antidepressant therapy after ECT
to prevent relapse
- Studies have found maintenance
ECT to be effective in relapse
prevention
Psychotherapy
- A combination of psychotherapy
and medications is considered
the most effective treatment for
depressive disorders
- There is no one specific type of
therapy that is better for the
treatment of depression
- The GOALS of combined
therapy:
- symptom remission
- psychosocial restoration
- prevention of relapse or
recurrence
- reduced secondary
consequences such as
marital discord
occupational difficulties
- increasing treatment
compliance
A. Interpersonal therapy
- focuses on difficulties in
relationships, such as grief
reactions, role disputes, and role
transitions
- For example, a person who, as a
child, never learned how to make
and trust a friend outside the
family structure has difficulty
establishing friendships as an
adult. Interpersonal therapy helps
the person to find ways to
accomplish this developmental
task
B. Behavior therapy
- seeks to increase the frequency
of the client’s positively
reinforcing interactions with the
environment and to decrease
negative interactions
- It also may focus on improving
social skills.
C. Cognitive therapy
- focuses on how the person thinks
about the self, others, and the
future and interprets his or her
experiences
- This model focuses on the
person’s distorted thinking,
which, in turn, influences
feelings, behavior, and functional
abilities
Investigational Treatments
- Other treatments for depression
are being tested
- These include:
- transcranial magnetic
stimulation (TMS)
- magnetic seizure therapy
- deep brain stimulation
- vagal nerve stimulation
- TMS is the closest to approval for
or clinical use
- These novel brain-stimulation
techniques seem to be safe, but
their efficacy in relieving
 depression needs to
established
APPLICATION OF THE NURSING
PROCESS: DEPRESSION (p. 290)
ASSESSMENT
HISTORY
- The nurse can collect
assessment data from the client
and family or significant others,
previous chart information, and
others involved in the support or
care
- It may take several short periods
to complete the assessment
because clients who are severely
depressed feel exhausted and
overwhelmed
- It can take time for them to
process the question asked and
to formulate a response
- It is important that the nurse does
not try to rush clients because
doing so leads to frustration and
incomplete assessment data.
- To assess the client’s perception
of the problem, the nurse asks
about behavioral changes:
- when they started
- what was happening
- when they began
- their duration
- what the client has tried to
do about them
- Assessing the history is important
to determine any previous
episodes of depression,
treatment, and client’s response
to treatment
- The nurse also asks about family
history of mood disorders,
suicide, or attempted suicide
GENERAL APPEARANCE & MOTOR
BEHAVIOR
- Many people with depression
look sad
- sometimes they just look ill
be -The POSTURE often is
slouched with head down &
they make minimal eye contact
- They have PSYCHOMOTOR
RETARDATION (slow body
movements, slow cognitive
processing, and slow verbal
interaction)
- Responses to questions may be
minimal, with only one or two
words
- Latency of response is seen
when clients take up to 30
seconds to respond to a question
- They may answer some
questions with “I don’t know”
because they are simply too
fatigued and overwhelmed to
think of an answer or respond in
any detail
- Clients also may exhibit signs of
agitation or anxiety such as
wringing their hands and having
difficulty sitting still
- These clients are said to have
psychomotor agitation (increased
body movements and thoughts),
which includes pacing,
accelerated thinking, and
argumentativeness
MOOD AND AFFECT
- Clients with depression may
describe themselves as
hopeless, helpless, down, or
anxious
- They also may say they are a
burden on others or are a failure
at life, or they may make other
similar statements
- They are easily frustrated, are
angry with themselves, and can
be angry with others
- They experience anhedonia,
losing any sense of pleasure
from activities they formerly
enjoyed
 -Clients may be apathetic, that is,
not caring about self, activities, or
much of anything
- Their affect is sad or depressed
or may be flat with no emotional
expressions
- Typically, depressed clients sit
alone, staring into space or lost in
thought
- When addressed, they interact
minimally with a few words or a
gesture
- They are overwhelmed by noise
and people who might make
demands on them, so they
withdraw from the stimulation of
interaction with others
THOUGHT PROCESS AND CONTENT
- Clients with depression
experience slowed thinking
processes: their thinking seems
to occur in slow motion
- With severe depression, they
may not respond verbally to
questions
- Clients tend to be negative and
pessimistic in their thinking, that
is, they believe that they will
always feel this bad, things will
never get any better, and nothing
will help
- Clients make self-deprecating
remarks, criticizing themselves
harshly and focusing only on
failures or negative attributes
- They tend to ruminate, which is
repeatedly going over the same
thoughts
- Those who experience psychotic
symptoms have delusions
- they often believe they are
responsible for all the tragedies
and miseries in the world.
- Often clients with depression
have thoughts of dying or
committing suicide
- It is important to assess suicidal
ideation by asking about it
directly
- The nurse may ask, “Are you
thinking about suicide?” or “What
suicidal thoughts are you
having?” Most clients readily
admit to suicidal thinking
SENSORIUM AND INTELLECTUAL
PROCESS
- Some clients with depression are
oriented to person, time, and
place
- others experience difficulty with
orientation, especially if they
experience psychotic symptoms
or are withdrawn from their
environment
- Assessing general knowledge is
difficult because of their limited
ability to respond to questions
- Memory impairment is common
- Clients have extreme difficulty
concentrating or paying attention
- If psychotic, clients may hear
degrading and belittling voices or
they may even have command
hallucinations that order them to
commit suicide
JUDGEMENT AND INSIGHT
- Clients with depression
experience impaired judgment
because they cannot use their
cognitive abilities to solve
problems or to make decisions
- They often cannot make
decisions or choices because of
their extreme apathy or their
negative belief that it “doesn’t
matter anyway.”
- Insight may be intact, especially if
clients have been depressed
previously
- Others have very limited insight
and are totally unaware of their
 behavior, feelings, or even their
illness
SELF-CONCEPT
- Sense of self-esteem is greatly
reduced
- Clients often use phrases such
as “good for nothing” or “just
worthless” to describe
themselves
- They feel guilty about not being
able to function and often
personalize events or take
responsibility for incidents over
which they have no control
- They believe that others would
be better off without them, a
belief which leads to suicidal
thoughts
ROLES AND RELATIONSHIPS
- Clients with depression have
difficulty fulfilling roles and
responsibilities
- The more severe the depression,
the greater the difficulty
- They have problems going to
work or school; when there, they
seem unable to carry out their
responsibilities
- The same is true with family
responsibilities
- Clients are less able to cook,
clean, or care for children
- In addition to the inability to fulfill
roles, clients become even more
convinced of their
“worthlessness” for being unable
to meet life responsibilities
- Depression can cause great
strain in relationships
- Family members who have
limited knowledge about
depression may believe clients
should “just get on with it.”
- Clients often avoid family and
social relationships because they
feel overwhelmed, experience no
pleasure from interactions, and
feel unworthy
- As clients withdraw from
relationships, the strain increases
PHYSIOLOGIC & SELF-CARE
CONSIDERATIONS
- Clients with depression often
experience pronounced weight
loss because of lack of appetite
or disinterest in eating
- Sleep disturbances are common:
● either clients can’t sleep,
or they feel exhausted and
unrefreshed no matter
how much time they
spend in bed
- They lose interest in sexual
activities, and men often
experience impotence
- Some clients neglect personal
hygiene because they lack the
interest or energy
- Constipation commonly results
from decreased food and fluid
intake as well as from inactivity
- If fluid intake is severely limited,
clients also may be dehydrated
DEPRESSION RATING SCALES
- Clients complete some rating
scales for depression; mental
health professionals administer
others
- These assessment tools, along
with evaluation of behavior,
thought processes, history, family
history, and situational factors,
help to create a diagnostic
picture
A. SELF-RATING SCALES
- Self-rating scales of depressive
symptoms include:
- Zung Self-Rating
Depression Scale
- Beck Depression
Inventory
 - Self-rating scales are used for person is slow or agitated, sleeps
case finding in the general public too much or too little, or eats too
and may be used over the course much or too little
of treatment to determine - Examples of outcomes for a
improvement from the client’s client with the psychomotor
perspective retardation form of depression
B. HAMILTON RATING SCALE include the following:
- The Hamilton Rating Scale for ● The client will not injure
Depression is a clinician-rated himself or herself.
depression scale used like a ● The client will
clinical interview independently carry out
- The clinician rates the range of activities of daily living
the client’s behaviors such as (showering, changing
depressed mood, guilt, suicide, clothing, grooming)
and insomnia ● The client will establish a
- There is also a section to score balance of rest, sleep, and
diurnal variations, activity
depersonalization (sense of ● The client will establish a
unreality about the self), paranoid balance of adequate
symptoms, and obsessions nutrition, hydration, and
DATA ANALYSIS elimination
- The nurse analyzes assessment ● The client will evaluate
data to determine priorities and to self-attributes realistically
establish a plan of care ● The client will socialize
- Nursing diagnoses commonly with staff, peers, and
established for the client with family/friends
depression include the following: ● The client will return to
● Risk for Suicide occupation or school
● Imbalanced Nutrition: activities
Less Than Body ● The client will comply with
Requirements antidepressant regimen
● Anxiety ● The client will verbalize
● Ineffective Coping symptoms of a recurrence
● Hopelessness INTERVENTION
● Ineffective Role A. PROVIDING FOR SAFETY
Performance - The first priority is to determine
● Self-Care Deficit whether a client with depression
● Chronic Low Self-Esteem is suicidal
● Disturbed Sleep Pattern - If a client has suicidal ideation or
● Impaired Social hears voices commanding him or
Interaction her to commit suicide, measures
OUTCOME IDENTIFICATION to provide a safe environment are
- Outcomes for clients with necessary
depression relate to how the - If the client has a suicide plan,
depression is manifested—for the nurse asks additional
instance, whether or not the
 questions to determine the
lethality of the intent and plan
- The nurse reports this
information to the treatment team
- Health care personnel follow
hospital or agency policies and
procedures for instituting suicide
precautions (e.g., removal of
harmful items, increased supervi-
sion)
B. PROMOTING A THERAPEUTIC
RELATIONSHIP
- It is important to have meaningful
contact with clients who have
depression and to begin a
therapeutic relationship
regardless of the state of
depression
- Some clients are quite open in
describing their feelings of
sadness, hopelessness,
helplessness, or agitation
- Clients may be unable to sustain
a long interaction, so several
shorter visits help the nurse to
assess status and to establish a
therapeutic relationship
- The nurse may find it difficult to
interact with these clients
because of empathy with such
sadness and depression
- The nurse also may feel unable
to “do anything” for clients with
limited responses
- Clients with psychomotor
retardation (slow speech, slow
movement, slow thought
processes) are very
noncommunicative or may even
be mute
- The nurse can sit with such
clients for a few minutes at
intervals throughout the day
- The nurse’s presence conveys
genuine interest and caring
- It is not necessary for the nurse
to talk to clients the entire time;
rather, silence can convey that
clients are worthwhile even if
they are not interacting
“My name is Sheila. I’m your nurse
today. I’m going to sit with you for a few
minutes. If you need anything, or if you
would like to talk,
please tell me.”
- After time has elapsed, the nurse
would say the following:
“I’m going now. I will be back in an hour
to see you again.”
- It is also important that the nurse
avoids being overly cheerful or
trying to “cheer up” clients
- It is impossible to coax or to
humor clients out of their
depression
- In fact, an overly cheerful
approach may make clients feel
worse or convey a lack of
understanding of their despair
C. PROMOTING ACTIVITIES OF
DAILY LIVING & PHYSICAL CARE
- The ability to perform daily
activities is related to the level of
psychomotor retardation
- To assess ability to perform
activities of daily living
independently, the nurse first
asks the client to perform the
global task. For example,
“Martin, it’s time to get dressed.”
(global task)
- If a client cannot respond to the
global request, the nurse breaks
the task into smaller segments
- Clients with depression can
become overwhelmed easily with
a task that has several steps
- The nurse can use success in
small, concrete steps as a basis
to increase self-esteem and to
 build competency for a slightly
more complex task the next time
- If clients cannot choose between
articles of clothing, the nurse
selects the clothing and directs
clients to put them on. For
example,
“Here are your gray slacks. Put
them on.”
- This still allows clients to
participate in dressing
- If this is what clients are capable
of doing at this point, this activity
will reduce dependence on staff
- This request is concrete, and if
clients cannot do this, the nurse
has information about the level of
psychomotor retardation
- If a client cannot put on slacks,
the nurse assists by saying,
“Let me help you with your
slacks, Martin.”
- The nurse helps clients to dress
only when they cannot perform
any of the above steps
- This allows clients to do as much
as possible for themselves and to
avoid becoming dependent on
the staff
- The nurse can carry out this
same process with clients when
they eat, take a shower, and
perform routine self-care
activities
- Because abilities change over
time, the nurse must assess
them on an ongoing basis
- This continual assessment takes
more time than simply helping
clients to dress
- Nevertheless, it promotes
independence and provides
dynamic assessment data about
psychomotor abilities
- Often, clients decline to engage
in activities because they are too
fatigued or have no interest
- The nurse can validate these
feelings yet still promote
participation. For example,
“I know you feel like staying in
bed, but it is time to get up for
breakfast.”
- Often, clients may want to stay in
bed until they “feel like getting
up” or engaging in activities of
daily living
- The nurse can let clients know
they must become more active to
feel better rather than waiting
passively for improvement. It may
be helpful to avoid asking
“yes-or- no” questions
- Instead of asking, “Do you want
to get up now?” the nurse would
say, “It is time to get up now.”
- Reestablishing balanced nutrition
can be challenging when clients
have no appetite or don’t feel like
eating
- The nurse can explain that
beginning to eat helps stimulate
appetite
- Food offered frequently and in
small amounts can prevent
overwhelming clients with a large
meal that they feel unable to eat
- Sitting quietly with clients during
meals can promote eating
- Monitoring food and fluid intake
may be necessary until clients
are consuming adequate
amounts.
- Promoting sleep may include the
short-term use of a sedative or
giving medication in the evening
if drowsiness or sedation is a
side effect
- It is also important to encourage
clients to remain out of bed and
 active during the day to facilitate
sleeping at night
- It is important to monitor the
number of hours clients sleep as
well as whether they feel
refreshed on awakening
D. USING THERAPEUTIC
COMMUNICATION
- Clients with depression are often
overwhelmed by the intensity of
their emotions
- Talking about these feelings can
be beneficial
- Initially, the nurse encourages
clients to describe in detail how
they are feeling
- Sharing the burden with another
person can provide some relief
- At these times, the nurse can
listen attentively, encourage
clients, and validate the intensity
of their experience
- For example,
Nurse: “How are you feeling today?”
(broad opening)
Client: “I feel so awful . . . terrible.”
Nurse: “Tell me more. What is that like
for you?” (using a general lead;
encouraging
description)
Client: “I don’t feel like myself. I don’t
know what to do.” Nurse: “That must be
frightening.” (validating)
- It is important at this point that
the nurse doesn’t attempt to “fix”
the client’s difficulties or offer
clichés such as “Things will get
better” or “But you know your
family really needs you.”
- Although the nurse may have
good intentions, remarks of this
type belittle the client’s feelings or
make the client feel more guilty
and worthless.
- As clients begin to improve, the
nurse can help them to learn or
rediscover more effective coping
strategies such as talking to
friends, spending leisure time to
relax, taking positive steps to
deal with stressors, and so forth
- Improved coping skills may not
prevent depression but may
assist clients to deal with the
effects of depression more
effectively
E. MANAGING MEDICATIONS
- The increased activity and
improved mood that
antidepressants produce can
provide the energy for suicidal
clients to carry out the act
- Thus, the nurse must assess
suicide risk even when clients are
receiving antidepressants
- It is also important to ensure that
clients ingest the medication and
are not saving it in attempt to
commit suicide
- As clients become ready for
discharge, careful assessment of
suicide potential is important
because they will have a supply
of antidepressant medication at
home
- SSRIs are rarely fatal in
overdose, but cyclic and MAOI
antidepressants are potentially
fatal
- Prescriptions may need to be
limited to only a 1-week supply at
a time if concerns linger about
overdose
- An important component of client
care is management of side
effects
- The nurse must make careful
observations and ask clients
pertinent questions to determine
how they are tolerating
medications
 - Clients and family must learn
how to manage the medication
regimen because clients may
need to take these medications
for months, years, or even a
lifetime
- Education promotes compliance
- Clients must know how often they
need to return for monitoring and
diagnostic tests
F. PROVIDING CLIENT AND FAMILY
TEACHING
- Teaching clients and family about
depression is important
- They must understand that
depression is an illness, not a
lack of willpower or motivation
- Learning about the beginning
symptoms of relapse may assist
clients to seek treatment early
and avoid a lengthy recurrence
- Clients and family should know
that treatment outcomes are best
when psychotherapy and
antidepressants are combined
- Psychotherapy helps clients to
explore anger, dependence, guilt,
hopelessness, helplessness,
object loss, interpersonal issues,
and irrational beliefs
- The GOAL is to reverse negative
views of the future, improve
self-image, and help clients gain
competence and self-mastery
- The nurse can help clients to find
a therapist through mental health
centers in specific communities
- SUPPORT GROUP
PARTICIPATION also helps some
clients and their families
- Clients can receive support and
encouragement from others who
struggle with depression, and
family members can offer support
to one another
- The National Alliance for the
Mentally Ill is an organization that
can help clients and families
connect with local support groups
EVALUATION
- Evaluation of the plan of care is
based on achievement of
individual client outcomes
- It is essential that clients feel safe
and do not experience
uncontrollable urges to commit
suicide
- Participation in therapy and
medication compliance produce
more favorable outcomes for
clients with depression
- Being able to identify signs of
relapse and to seek treatment
immediately can significantly
decrease the severity of a
depressive episode
BIPOLAR DISORDER
- involves extreme mood swings
from episodes of mania to
episodes of depression
- was formerly known as
manic-depressive illness
- During manic phases, clients are
euphoric, grandiose, energetic,
and sleepless
- They have poor judgment and
rapid thoughts, actions, and
speech
- During depressed phases, mood,
behavior, and thoughts are the
same as in people diagnosed
with major depression
- In fact, if a person’s first episode
of bipolar illness is a depressed
phase, he or she might be
diagnosed with major depression
- a diagnosis of bipolar disorder
may not be made until the person
experiences a manic episode
- To increase awareness about
bipolar disorder, health care
 professionals can use tools such
as the Mood Disorder
Questionnaire
- Bipolar disorder ranks second
only to major depression as a
cause of worldwide disability
- The lifetime risk for bipolar
disorder is at least 1.2%, with a
risk of completed suicide for 15%
- Young men early in the course of
their illness are at highest risk for
suicide, especially those with a
history of suicide attempts or
alcohol abuse as well as those
recently discharged from the
hospital
- Whereas a person with major
depression slowly slides into
depression that can last for 6
months to 2 years, the person
with bipolar disorder cycles
between depression and normal
behavior (bipolar depressed) or
mania and normal behavior
(bipolar manic)
- A person with bipolar mixed
episodes alternates between
major depressive and manic
episodes interspersed with
periods of normal behavior
- Each mood may last for weeks or
months before the pattern begins
to descend or ascend once again
- Bipolar disorder occurs almost
equally among men and women
- It is more common in highly
educated people
- Because some people with
bipolar illness deny their mania,
prevalence rates may actually be
higher than reported
ONSET AND CLINICAL COURSE
- The mean age for a first manic
episode is the early 20s, but
some people experience onset in
adolescence, whereas others
start experiencing symptoms
when they are older than 50
- Currently, debate exists about
whether or not some children
diagnosed with attention deficit
hyperactivity disorder actually
have a very early onset of bipolar
disorder
- Manic episodes typically begin
suddenly, with rapid escalation of
symptoms over a few days, and
they last from a few weeks to
several months
- They tend to be briefer and to
end more suddenly than
depressive episodes
- Adolescents are more likely to
have psychotic manifestations
- The DIAGNOSIS of a manic
episode or mania requires at
least 1 week of unusual and
incessantly heightened,
grandiose, or agitated mood in
addition to three or more of the
following symptoms:
● exaggerated self-esteem
● sleeplessness
● pressured speech
● flight of ideas
● reduced ability to filter
extraneous stimuli
distractibility
● increased activities with
increased energy
● multiple, grandiose,
high-risk activities
involving poor judgment
and severe
consequences, such as
spending sprees, sex with
strangers, and impulsive
investments
- Clients often do not understand
how their illness affects others
- They may stop taking
medications because they like
 the euphoria and feel burdened - Once believed to be helpful for
by the side effects, blood tests, bipolar mania only, investigators
and physicians’ visits needed to quickly realized that lithium also
maintain treatment could partially or completely mute
- Family members are concerned the cycling toward bipolar
and exhausted by their loved depression
ones’ behaviors - The response rate in acute mania
- they often stay up late at night for to lithium therapy is 70% to 80%
fear the manic person may do - In addition to treating the range
something impulsive and of bipolar behaviors, lithium also
dangerous can stabilize bipolar disorder by
TREATMENT reducing the degree and
Psychopharmacology frequency of cycling or
- Treatment for bipolar disorder eliminating manic episodes
involves a lifetime regimen of - Lithium not only competes for salt
medications: receptor sites but also affects
- either an antimanic agent calcium, potassium, and
called lithium magnesium ions as well as
- anticonvulsant meds used glucose metabolism
as mood stabilizers - Its mechanism of action is
- This is the only psychiatric unknown, but it is thought to work
disorder in which medications in the synapses to hasten
can prevent acute cycles of destruction of catecholamines
bipolar behavior (dopamine, norepinephrine),
- Once thought to help reduce inhibit neurotransmitter release,
manic behavior only, lithium and and decrease the sensitivity of
these anticonvulsants also postsynaptic receptors
protect against the effects of - Lithium’s action peaks in 30
bipolar depressive cycles minutes to 4 hours for regular
- If a client in the acute stage of forms and in 4 to 6 hours for the
mania or depression exhibits slow-release form
psychosis (disordered thinking - It crosses the blood–brain barrier
as seen with delusions, and placenta and is distributed in
hallucinations, and illusions), an sweat and breast milk
ANTIPSYCHOTIC AGENT is - Lithium use during pregnancy is
administered in addition to the not recommended because it
bipolar medications can lead to first-trimester
- Some clients keep taking both developmental abnormalities.
bipolar medications and - Onset of action is 5 to 14 days;
antipsychotics with this lag period, antipsychotic
A. LITHIUM or antidepressant agents are
- A salt contained in the human used carefully in combination
body with lithium to reduce symptoms
- similar to gold, copper, in acutely manic or acutely
magnesium, manganese, and depressed clients
other trace elements
 - The half-life of lithium is 20 to 27
hours
B. ANTICONVULSANT DRUGS
- Lithium is effective in about 75%
of people with bipolar illness
- The rest do not respond or have
difficulty taking lithium because of
side effects, problems with the
treatment regimen, drug
interactions, or medical
conditions such as renal disease
that contraindicate use of lithium
- Several anticonvulsants
traditionally used to treat seizure
disorders have proved helpful in
stabilizing the moods of people
with bipolar illness
- These drugs are categorized as
miscellaneous anticonvulsants
- Their mechanism of action is
largely unknown, but they may
raise the brain’s threshold for
dealing with stimulation which
prevents the person from being
bombarded with external and
internal stimuli
Carbamazepine (Tegretol)
- which had been used for grand
mal and temporal lobe epilepsy
as well as for trigeminal neuralgia
- was the first anticonvulsant found
to have mood-stabilizing
properties, but the threat of
agranulocytosis was of great
concern
- Clients taking carbamazepine
need to have drug serum levels
checked regularly to monitor for
toxicity and to determine whether
the drug has reached therapeutic
levels, which are generally 4 to
12 μg/ mL
- Baseline and periodic laboratory
testing must also be done to
monitor for suppression of white
blood cells
Valproic acid (Depakote)
- also known as divalproex sodium
or sodium valproate
- an anticonvulsant used for simple
absence and mixed seizures,
migraine prophylaxis, and mania
- The mechanism of action is
unclear
- Therapeutic levels are monitored
periodically to remain at 50 to
125 μg/mL, as are baseline and
ongoing liver function tests,
including serum ammonia levels
and platelet and bleeding times
Gabapentin (Neurontin), lamotrigine
(Lamictal), and topiramate (Topamax)
- are other anticonvulsants
sometimes used as mood
stabilizers, but they are used less
frequently than valproic acid
- Value ranges for therapeutic
levels are not established
Clonazepam (Klonopin)
- is an anticonvulsant and a
benzodiazepine (a schedule IV
controlled substance)
- used in simple absence and
minor motor seizures, panic
disorder, and bipolar disorder
- Physiologic dependence can
develop with long-term use
- This drug may be used in lithium
or other mood stabilizers but is
not used alone to manage bipolar
disorder
Psychotherapy
- can be useful in the mildly
depressive or normal portion of
the bipolar cycle
- It is not useful during acute manic
stages because the person’s
attention span is brief and he or
she can gain little insight during
times of accelerated
psychomotor activity
 - Psychotherapy combined with
medication can reduce the risk
for suicide and injury, provide
support to the client and family,
and help the client to accept the
diagnosis and treatment plan
APPLICATION OF THE NURSING
PROCESS: BIPOLAR DISORDER
ASSESSMENT
HISTORY
- Taking a history with a client in
the manic phase often proves
difficult
- The client may jump from subject
to subject, which makes it difficult
for the nurse to follow
- Obtaining data in several short
sessions, as well as talking to
family members, may
necessary
- The nurse can obtain much
information, however,
watching and listening
GENERAL APPEARANCE
MOTOR BEHAVIOR
- Clients with mania experience
psychomotor agitation and seem
to be in perpetual motion
- sitting still is difficult
- This continual movement has
many ramifications:
- clients can become
exhausted or injure
themselves
- In the manic phase, the client
may wear clothes that reflect the
elevated mood:
- brightly colored
- Flamboyant
- Attention-getting
- perhaps sexually
suggestive
- a woman in the manic phase may
wear a lot of jewelry and hair
ornaments, or her makeup may
be garish and heavy
-male client may wear a tight and
revealing muscle shirt or go
bare-chested
- Clients experiencing a manic
episode think, move, and talk fast
- Pressured speech, one of the
hallmark symptoms, is evidenced
by unrelentingly rapid and often
loud speech without pauses
- Those with pressured speech
interrupt and cannot listen to
others
- They ignore verbal and nonverbal
cues indicating that others wish
to speak, and they continue with
constant intelligible or
unintelligible speech, turning from
one listener to another or
be speaking to no one at all
- If interrupted, clients with mania
often start over from the
by beginning
MOOD AND AFFECT
AND - Mania is reflected in periods of
euphoria, exuberant activity,
grandiosity, and false sense of
well-being
- Projection of an all-knowing and
all-powerful image may be an
unconscious defense against
underlying low self-esteem
- Some clients manifest mania with
an angry, verbally aggressive
tone and are sarcastic and
irritable, especially when others
set limits on their behavior
- Clients’ mood is quite labile, and
they may alternate between
periods of loud laughter and
episodes of tears
THOUGHT PROCESS & CONTENT
- Cognitive ability or thinking is
confused and jumbled with
thoughts racing one after
another, which is often referred to
as flight of ideas
- Clients cannot connect concepts,
and they jump from one subject
to another
- Circumstantiality and tangentiality
also characterize thinking
- At times, clients may be unable
to communicate thoughts or
needs in ways that others
understand
- These clients start many projects
at one time but cannot carry any
to completion
- There is little true planning, but
clients talk nonstop about plans
and projects to anyone and
everyone, insisting on the
importance of accomplishing
these activities
- Sometimes they try to enlist help
from others in one or more
activities
- They do not consider risks or
personal experience, abilities, or
resources
- Clients start these activities as
they occur in their thought
processes
- Examples of these multiple
activities are going on shopping
sprees, using credit cards
excessively while unemployed
and broke, starting several
business ventures at once,
having promiscuous sex,
gambling, taking impulsive trips,
embarking on illegal endeavors,
making risky investments, talking
with multiple people, and
speeding
- Some clients experience
psychotic features during mania
- they express grandiose delusions
involving importance, fame,
privilege, and wealth
- Some may claim to be the
president, a famous movie star,
or even God or a prophet.
SENSORIUM AND INTELLECTUAL
PROCESSES
- Clients may be oriented to
person and place but rarely to
time
- Intellectual functioning, such as
fund of knowledge, is difficult to
assess during the manic phase
- Clients may claim to have many
abilities they do not possess
- The ability to concentrate or to
pay attention is grossly impaired
- Again, if a client is psychotic, he
or she may experience
hallucinations
JUDGEMENT AND INSIGHT
- People in the manic phase are
easily angered and irritated and
strike back at what they perceive
as censorship by others because
they impose no restrictions on
themselves
- They are impulsive and rarely
think before acting or speaking,
which makes their judgment poor
- Insight is limited because they
believe they are “fine” and have
no problems
- They blame any difficulties on
others
SELF-CONCEPT
- Clients with mania often have
exaggerated self-esteem
- they believe they can accomplish
anything
- They rarely discuss their
self-concept realistically
- Nevertheless, a false sense of
well-being masks difficulties with
chronic low self-esteem
ROLES AND RELATIONSHIPS
- Clients in the manic phase rarely
can fulfill role responsibilities
 - They have trouble at work or - They may be on the brink of
school (if they are even physical exhaustion but are
attending) and are too distracted unwilling or unable to stop, rest,
and hyperactive to pay attention or sleep
to children or activities of daily - They often ignore personal
living hygiene as “boring” when they
- Although they may begin many have “more important things” to
tasks or projects, they complete do
few - Clients may throw away
- These clients have a great need possessions or destroy valued
to socialize but little items
understanding of their excessive, - They may even physically injure
overpowering, and themselves and tend to ignore or
confrontational social interactions be unaware of health needs that
- Their need for socialization often can worsen
leads to promiscuity DATA ANALYSIS
- Clients invade the intimate space - The nurse analyzes assessment
and personal business of others data to determine priorities and to
- Arguments result when others establish a plan of care
feel threatened by such boundary - Nursing diagnoses commonly
invasions established for clients in the
- Although the usual mood of manic phase are as follows:
manic people is elation, emotions ● Risk for Other-Directed
are unstable and can fluctuate Violence
(labile emotions) readily between ● Risk for Injury
euphoria and hostility ● Imbalanced Nutrition:
- Clients with mania can become Less Than Body
hostile to others whom they Requirements
perceive as standing in way of ● Ineffective Coping
desired goals ● Noncompliance
- They can’t postpone or delay ● Ineffective Role
gratification Performance
- For example, a manic client tells ● Self-Care Deficit
his wife, “You are the most ● Chronic Low Self-Esteem
wonderful woman in the world. ● Disturbed Sleep Pattern
Give me $50 so I can buy you a OUTCOME IDENTIFICATION
ticket to the opera.” When she - Examples of outcomes
refuses, he snarls and accuses appropriate to mania are as
her of being cheap and selfish follows:
and may even strike her ● The client will not injure
PHYSIOLOGIC & SELF-CARE self or others
CONSIDERATIONS ● The client will establish a
- Clients with mania can go days balance of rest, sleep, and
without sleep or food and not activity
even realize they are hungry or
tired
 ● The client will establish
adequate nutrition,
hydration, and elimination
● The client will participate
in self-care activities.
● The client will evaluate
personal qualities
realistically
● The client will engage in
socially appropriate,
reality-based interaction.
● The client will verbalize
knowledge of his or her
illness and treatment.
INTERVENTION
A. PROVIDING FOR SAFETY
- Because of the safety risks that
clients in the manic phase take,
safety plays a primary role in
care, followed by issues related
to self-esteem and socialization.
- A primary nursing responsibility is
to provide a safe environment for
clients and others
- The nurse assesses clients
directly for suicidal ideation and
plans or thoughts of hurting
others
- In addition, clients in the manic
phase have little insight into their
anger and agitation and how their
behaviors affect others
- They often intrude into others’
space, take others’ belongings
without permission, or appear
aggressive in approaching others
- This behavior can threaten or
anger people who then retaliate
- It is important to monitor the
clients’ whereabouts and
behaviors frequently
- The nurse also should tell clients
that staff members will help them
control their behavior if clients
cannot do so alone
- For clients who feel out of
control, the nurse must establish
external controls empathetically
and nonjudgmentally
- These external controls provide
long-term comfort to clients,
although their initial response
may be aggression
- People in the manic phase have
labile emotions
- it is not unusual for them to strike
staff members who have set
limits in a way clients dislike
- These clients physically and
psychologically invade
boundaries
- It is necessary to set limits when
they cannot set limits on
themselves. For example, the
nurse might say,
“John, you are too close to my face.
Please stand back 2 feet.”
Or
“It is unacceptable to hug other clients.
You may talk to others, but do not touch
them.”
- When setting limits, it is important
to clearly identify the
unacceptable behavior and the
expected, appropriate behavior
- All staff must consistently set and
enforce limits for those limits to
be effective
NURSING INTERVENTIONS for Mania
● Provide for client’s physical
safety and those around.
● Set limits on client’s behavior
when needed.
● Remind the client to respect
distances between self and
others.
● Use short, simple sentences to
communicate.
● Clarify the meaning of the client's
communication.
 ● Frequently provide finger foods
that are high in calories and
protein.
● Promote rest and sleep.
● Protect the client’s dignity when
inappropriate behavior occurs.
● Channel client’s need for
movement into socially
acceptable motor activities.
B. MEETING PHYSIOLOGIC NEEDS
- Clients with mania may get very
little rest or sleep, even if they
are on the brink of physical
exhaustion
- Medication may be helpful,
though clients may resist taking it
- Decreasing environmental
stimulation may assist clients to
relax
- The nurse provides a quiet
environment without noise,
television, or other distractions
- Establishing a bedtime routine,
such as a tepid bath, may help
clients to calm down enough to
rest.
- Nutrition is another area of
concern
- Manic clients may be too “busy”
to sit down and eat, or they may
have such poor concentration
that they fail to stay interested in
food for very long
- “Finger foods” or things clients
can eat while moving around are
the best options to improve
nutrition
- Such foods also should be as
high in calories and protein as
possible
- For example, celery and carrots
are finger foods, but they supply
little nutrition
- Sandwiches, protein bars, and
fortified shakes are better
choices
- Clients with mania also benefit
from food that is easy to eat
without much preparation
- Meat that must be cut into bite
sizes or plates of spaghetti are
not likely to be successful options
- Having snacks available between
meals, so clients can eat
whenever possible, is also useful.
- The nurse needs to monitor food
and fluid intake and hours of
sleep until clients routinely meet
these needs without difficulty
- Observing and supervising
clients at meal times are also
important to prevent clients from
taking food from others.
C. PROVIDING THERAPEUTIC
COMMUNICATION
- Clients with mania have short
attention spans, so the nurse
uses clear, simple sentences
when communicating
- They may not be able to handle a
lot of information at once, so the
nurse breaks information into
many small segments
- It helps to ask clients to repeat
brief messages to ensure they
have heard and incorporated
them
- Clients may need to undergo
baseline and follow-up laboratory
tests
- A brief explanation of the
purpose of each test allays
anxiety
- The nurse gives printed
information to reinforce verbal
messages, especially those
related to rules, schedules, civil
rights, treatment, staff names,
and client education.
- The speech of manic clients may
be pressured: rapid,
 circumstantial, rhyming, noisy, or
intrusive with flights of ideas
- Such disordered speech
indicates thought processes that
are flooded with thoughts, ideas,
and impulses
- The nurse must keep channels of
communication open with clients,
regardless of speech patterns.
The nurse can say,
“Please speak more slowly. I’m having
trouble following you.”
- This puts the responsibility for the
communication difficulty on the
nurse rather than on the client
- This nurse patiently and
frequently repeats this request
during conversation because
clients will return to rapid speech.
- Clients in the manic phase often
use pronouns when referring to
people, making it difficult for
listeners to understand who is
being discussed and when the
conversation has moved to a new
subject
- While clients are agi- tatedly
talking, they usually are thinking
and moving just as quickly, so it
is a challenge for the nurse to
follow a coherent story
- The nurse can ask clients to
identify each person, place, or
thing being discussed.
- When speech includes flight of
ideas, the nurse can ask clients
to explain the relationship
between topics—for example,
“What happened then?”
OR
“Was that before or after you got
married?”
- The nurse also assesses and
documents the coherence of
messages.
- Clients with pressured speech
rarely let others speak
- Instead, they talk nonstop until
they run out of steam or just
stand there looking at the other
person before moving away
- Those with pressured speech do
not respond to others’ verbal or
nonverbal signals that indicate a
desire to speak
- The nurse avoids becoming
involved in power struggles over
who will dominate the
conversation
- Instead, the nurse may talk to
clients away from others so there
is no “competition” for the nurse’s
attention
- The nurse also sets limits
regarding taking turns speaking
and listening as well as giving
attention to others when they
need it
- Clients with mania cannot have
all requests granted immediately
even though that may be their
desire.
D. PROMOTING APPROPRIATE
BEHAVIORS
- These clients need to be
protected from their pursuit of
socially unacceptable and risky
behaviors
- The nurse can direct their need
for movement into socially
acceptable, large motor activities
such as arranging chairs for a
community meeting or walking
- In acute mania, clients lose the
ability to control their behavior
and engage in risky activities
- Because acutely manic clients
feel extraordinarily powerful, they
place few restrictions on
themselves
 - They act out impulsive thoughts,
have inflated and grandiose
perceptions of their abilities, are
demanding, and need immediate
gratification
- This can affect their physical,
social, occupational, or financial
safety as well as that of others
- Clients may make purchases that
exceed their ability to pay
- They may give away money or
jewelry or other possessions
- The nurse may need to monitor a
client’s access to such items until
his or her behavior is less
impulsive
- In an acute manic episode,
clients also may lose sexual
inhibitions, resulting in
provocative and risky behaviors
- Clothing may be flashy or
revealing, or clients may undress
in public areas
- They may engage in unprotected
sex with virtual strangers
- Clients may ask staff members or
other clients (of the same or
opposite sex) for sex, graphically
describe sexual acts, or display
their genitals
- The nurse handles such behavior
in a matter-of-fact,
nonjudgmental manner. For
example,
“Mary, let’s go to your room and find a
sweater.”
- It is important to treat clients with
dignity and respect despite their
inappropriate behavior
- It is not helpful to “scold” or
chastise them
- they are not children engaging in
willful misbehavior
- In the manic phase, clients
cannot understand personal
boundaries, so it is the staff’s role
to keep clients in view for
intervention as necessary
- For example, a staff member who
sees a client invading the
intimate space of others can say,
“Jeffrey, I’d appreciate your help in
setting up a circle of chairs in the group
therapy room.”
- This large motor activity distracts
Jeffrey from his inappropriate
behavior, appeals to his need for
heightened physical activity, is
noncompetitive, and is socially
acceptable
- The staff’s vigilant redirection to a
more socially appropriate activity
protects clients from the hazards
of unprotected sex and reduces
embarrassment over such
behaviors when they return to
normal behavior.
E. MANAGING MEDICATIONS
- Lithium is not metabolized;
rather, it is reabsorbed by the
proximal tubule and excreted in
the urine
- Periodic serum lithium levels are
used to monitor the client’s safety
and to ensure that the dose given
has increased the serum lithium
level to a treatment level or
reduced it to a maintenance level
- There is a narrow range of safety
among maintenance levels (0.5
to 1 mEq/L), treatment levels (0.8
to 1.5 mEq/L), and toxic levels
(1.5 mEq/L and above)
- It is important to assess for signs
of toxicity and to ensure that
clients and their families have
this information before discharge
- Older adults can have symptoms
of toxicity at lower serum levels.
- Lithium is potentially fatal in
overdose.
- Clients should drink adequate
water (approximately 2 L/day)
and continue with the usual
amount of dietary table salt
- Having too much salt in the diet
because of unusually salty foods
or the ingestion of salt-containing
antacids can reduce receptor
availability for lithium and
increase lithium excretion, so the
lithium level will be too low
- If there is too much water, lithium
is diluted and the lithium level will
be too low to be therapeutic
- Drinking too little water or losing
fluid through excessive sweating,
vomiting, or diarrhea increases
the lithium level, which may result
in toxicity
- Monitoring daily weights and the
balance between intake and
output and checking for
dependent edema can be helpful
in monitoring fluid balance
- The physician should be
contacted if the client has
diarrhea, fever, flu, or any
condition that leads to
dehydration.
- Thyroid function tests usually are
ordered as a baseline and every
6 months during treatment with
lithium
- In 6 to 18 months, one third of
clients taking lithium have an
increased level of
thyroid-stimulating hormone,
which can cause anxiety, labile
emotions, and sleeping difficulties
- Decreased levels are implicated
in fatigue and depression.
- Because most lithium is excreted
in the urine, baseline and
periodic assessments of renal
status are necessary to assess
renal function
- The reduced renal function in
older adults necessitates lower
doses
- Lithium is contraindicated in
people with compromised renal
function or urinary retention and
those taking low-salt diets or
diuretics
- Lithium also is contraindicated in
people with brain or
cardiovascular damage.
F. PROVIDING CLIENT AND FAMILY
TEACHING
- Educating clients about the
dangers of risky behavior is
necessary
- however, clients with acute mania
largely fail to heed such teaching
because they have little patience
or capacity to listen, understand,
and see the relevance of this
information
- Clients with euphoria may not
see why the behavior is a
problem because they believe
they can do anything without
impunity
- As they begin to cycle toward
normalcy, however, risky
behavior lessens, and they
become ready and able for
teaching.
- Manic clients start many tasks,
create many goals, and try to
carry them out all at once
- The result is that they cannot
complete any
- They move readily between
these goals while sometimes
obsessing about the importance
of one over another, but the goals
can quickly change
- Clients may invest in a business
in which they have no knowledge
or experience, go on spending
sprees, impulsively travel, speed,
 make new “best friends,” and
take the center of attention in any
group
- They are egocentric and have
little concern for others except as
listeners, sexual partners, or the
means to achieve one of their
poorly conceived goals.
- Education about the cause of
bipolar disorder, medication
management, ways to deal with
behaviors, and potential
problems that manic people can
encounter is important for family
members
- Education:
- reduces the guilt, blame,
and shame that
accompany mental illness
- increases client safety
- enlarges the support
system for clients and the
family members
- promotes compliance.
- Education takes the “mystery” out
of treatment for mental illness by
providing a proactive view: this is
what we know, this is what can
be done, and this is what you can
do to help.
- Family members often say they
know clients have stopped taking
their medication when, for
example, clients become more
argumentative, talk about buying
expensive items that they cannot
afford, hotly deny anything is
wrong, or demonstrate any other
signs of escalating mania.
- People sometimes need
permission to act on their
observations, so a family
education session is an
appropriate place to give this
permission and to set up
interventions for various
behaviors.
- Clients should learn to adhere to
the established dosage of lithium
and not to omit doses or change
dosage intervals; unprescribed
dosage alterations interfere with
maintenance of serum lithium
levels.
- Clients should know about the
many drugs that interact with
lithium and should tell each
physician they consult that they
are taking lithium.
- When a client taking lithium
seems to have increased manic
behavior, lithium levels should be
checked to determine whether
there is lithium toxicity.
- Periodic monitoring of serum
lithium levels is necessary to
ensure the safety and adequacy
of the treatment regimen.
- Persistent thirst and diluted urine
can indicate the need to call a
physician and have the serum
lithium level checked to see if the
dosage needs to be reduced.
- Clients and family members
should know the symptoms of
lithium toxicity and interventions
to take, including backup plans if
the physician is not immediately
available
- The nurse should give these in
writing and explain them to
clients and family
EVALUATION
- Evaluation of the treatment of
bipolar disorder includes but is
not limited to the following:
● Safety issues
● Comparison of mood and
affect between start of
treatment and present
 ● Adherence to treatment - Intimate partner violence
regimen of medication and (IPV) : 14% homicides
psychotherapy - Deaths:
● Changes in client’s - 70%-females
- 30 %-males
perception of quality of life
- Alcohol and other drug abuse
● Achievement of specific
- Alcoholism
goals of treatment - associated with family
including new coping violence
methods - does not imply a
• Schizophrenia and other Psychotic cause-and-effect
Disorders - relationship
•Cognitive Disorders (Organic Brain - Alcohol does
Disorders) - not cause the
- Delirium person to be
abusive;
- Dementia
rather, an
- Alzheimer’s Disease
abusive
•Psychiatric emergencies-christa person is also
likely to use
● Family Violence alcohol or
other drugs.
CHARACTERISTICS OF VIOLENT
- make violent behavior
FAMILIES
more intense or
frequent
- Social isolation
- factor in acquaintance
- do not invite others into the
rape or date rape
home or tell anyone what is
- flunitrazepam (Rohypnol)
happening
- Illegal drug
- abusers threaten victims with
- Causes abuse
even greater harm if they
- Intergenerational transmission
reveal the secret
process
- Abuse of power and control
- Patterns of violence moves
- abusive family member
from one generation to the
- holds a position of
next through role modeling
power and control
and social learning
over the victim (child,
- Ex: children who witness
spouse, or elderly
violence between their
parent).
parents learn that violence is
- only family member
a way to resolve conflict and
who makes decisions,
is an integral part of a close
spends money, or
relationship.
spends time outside
the home with other
people.
- belittles and blames - FAMILY VIOLENCE: COMPONENT:
the victim, often using - spouse battering
threats and emotional - neglect and physical
manipulation - emotional, or sexual
abuse of children
 - elder abuse
- marital rape
- Occurs: home
- most dangerous place
for victims.
INTIMATE PARTNER VIOLENCE
- mistreatment or misuse of one person
by another in the context of an
emotionally intimate relationship
- Categories:
- Psychological abuse
(emotional abuse)
- Name-calling
- Belittling
- Screaming
- Yelling
- destroying property
- making threats
- refusing to speak to
or ignoring the victim
- Physical abuse
- shoving and pushing
to severe battering
- choking
- broken limbs and ribs
- internal bleeding
- brain damage
- Homicide
- Sexual abuse
- biting nipples
- pulling hair
- Slapping
- Hitting
- rape
- violence during pregnancy
- adverse outcomes:
- Miscarriag
- Stillbirth
- Cause:
- Jealousy
- Possessiveness
- Insecurity
- lessened physical and
emotional availability
of the pregnant
woman
- same-sex battering
- sodomy (anal intercourse)
- Crime
- Batterer additional
weapon against the
victim:
- threat of revealing the
partner’s
homosexuality to
friends, family,
employers, or the
community.
- Clinical Picture
- abusive husband
often believes his wife
belongs to him (like
property) and
becomes increasingly
violent and abusive if
she shows any sign of
independence, such
as getting a job or
threatening to leave
- emotionally immature,
needy, irrationally
jealous, and
possessive.
- jealous of his wife’s
attention to their own
children or may beat
both his children and
his wife
- sense of power and
control:
- bullying and
physically
punishing the
family,
- violent behavior is
often rewarding and
boosts his
self-esteem.
- Dependency
- trait most
commonly
found in
abused wives
who stay with
their
husbands.
- she perceives
herself as
 unable to - Tension-buildi
function ng phase
without her - argu
husband. ments
- national statistics ,
show that women stony
have a much greater silenc
chance of being e, or
murdered when compl
leaving an abusive aints
relationship than if from
they stay. the
- Cycle of Abuse and husba
Violence nd
- another reason often - anoth
cited for why women er
have difficulty leaving violen
abusive relationships t
- most common pattern episo
of IPV but does not de
apply to all situations.
- Some are only
periodic episodes of
violent behavior with
no subsequent
honeymoon period or
no observable period
of increasing tension.
- Cycle:
- initial episode
of battering or -
violence - Honeymoon period:
- Honeymoon - last weeks or even months,
period:abuser causing the woman to believe
expressing that the relationship has
regret, improved and her husband’s
apologizing, behavior has changed
and promising - Assessment
it will never - identify abused women in
happen again. various settings.
He professes - most abused women
his love for do not seek direct
his wife and help for the problem,
may even - generalist nurse is not
engage in expected to deal with
romantic this complicated
behavior problem alone. He or
(e.g., buying she can, however,
gifts and make referrals and
flowers). contact appropriate
 health care
professionals
experienced in
working with abused
women
- DONT’S
- Don’t tell the victim
what to do.
- Don’t express disgust,
disbelief, or anger.
Don’t disclose client
communications
- without the client’s
consent.
- Don’t preach,
moralize, or imply that
you
- doubt the client.
- Don’t minimize the
impact of violence.
Don’t express outrage - ask everyone whether they
with the perpetrator.
Don’t imply that the
client is responsible
for
- the abuse.
- Don’t recommend
couples’ counseling.
Don’t direct the client
to leave the
- relationship. Don't - Questions to ask:
Take Charge And Do
Everything For The
- Client
- DOS
- Do believe the victim.
- Do ensure and
maintain the client’s
confidentiality. Do
listen, affirm, and say,
“I am sorry you have
been
- hurt.”
- Do express, “I’m
concerned for your
safety.”
- Do tell the victim,
“You have a right to
be safe and
- respected.”
- Do say, “The abuse is
not your fault.”
- Do recommend a
support group or
individual
- counseling.
- Do identify community
resources, and
encourage the
- client to develop a
safety plan.
- Do offer to help the
client contact a
shelter, the police,
- or other resources. Do
Accept And Respect
The Victim's Decision.
Do encourage
development of a
safety plan.
are safe at home or in their
relationship
- When nurse asks only
people seen as “likely
victims,” he or she will
be stereotyping and
may well miss
someone who really
needs help.
- Do you feel safe in
your relationships?
- Are you concerned for
your safety?
- Are family or friends
concerned for your
safety?
- Are your children (if
any) safe?
- Do you ever feel
threatened?
- If you felt threatened
or unsafe, is there
someone you can
call? Night
or day?
- Do you have a safe
place to go if you
need to?
 - Do you have a plan if the abuser from approaching
suddenly your or contacting her.
situation becomes - provides only limited
unsafe? protection.
- Note: - Civil orders of protection
- initial - more effective in preventing
questions are future violence when linked
designed to with other interventions such
detect abuse. as advocacy counseling,
- ask the latter shelter, or talking with health
questions if care providers
warranted. - Battered women’s shelters
- sk these - provide temporary housing
questions and food for abused women
when the and their children when they
woman is decide to leave the abusive
alone relationship
- nurse can - Individual psychotherapy or
paraphrase or counseling, group therapy, or
edit the support and self-help groups
questions as - can help abused women deal
needed for with their trauma and begin to
any given build new, healthier
situation. relationships.
- Treatment and Intervention - Note:
- police to make arrests in cases - Stalking
of domestic violence; - repeated and
- after police have been called persistent attempts to
to the scene impose unwanted
- abuser is allowed to communication or
remain at home after contact on another
talking with police and person, is a problem
calming down.
- arrest is made CHILD ABUSE
- abuser is held only for
a few hours or - maltreatment
overnight - intentional injury of a child.
- abuser retaliates upon - Examples:
release: - physical abuse or injuries
- women have a - neglect or failure to prevent
legitimate fear of harm
calling the police. - failure to provide adequate
- Studies have shown that arresting the physical or emotional care or
batterer may reduce short-term supervision
violence but may increase long-term - Abandonment
violence - sexual assault or intrusion
- restraining order (protection - overt torture or maiming
order) - Adults with a history of childhood
- Obtain from her country of sexual abuse are at a higher risk for
residence that legally prohibits depression, suicide attempts, marital
 problems, marriage to an alcoholic, participate in
smoking, alcohol abuse, chronic pain, obscene acts.
and medically unexplained symptoms - Neglect
- Types of Child Abuse - malicious or
- Physical abuse ignorant
- Unreasonable severe withholding of
corporal punishment physical,
or unjustifiable emotional, or
punishment such as educational
hitting an infant for necessities for
crying or soiling his or the child’s
her diaper well-being
- Intentional, deliberate - Child abuse by neglect
assaults: - most prevalent type of
- Burning maltreatment
- Biting - Ex:r
- Cutting - refusal to seek health
- Poking care
- twisting limbs - Abandonment
- scalding with hot - inadequate
water supervision
- Sexual abuse - reckless disregard for
- sexual acts performed the child’s safety
by an adult on a child - Punitive
younger than 18 - exploitive, or abusive
years. emotional treatment
- single incident or - spousal abuse in the
multiple episodes over child’s presence
a protracted period - giving the child
- Ex: permission to be
- Incest truant; or failing to
- Rape and sodomy enroll the child in
performed directly by school
the person or with an - Psychological abuse (emotional
object, oral–genital abuse)
contact - verbal assaults
- acts of molestation - accompanies other types of
such as rubbing, abuse (physical or sexual
fondling, or exposing abuse).
the adult’s genitals. - Ex:
- Second type: - Blaming
exploitation - screaming,
- Making and name-calling
promoting or - using sarcasm
selling - constant family
pornography discord characterized
involving by fighting, yelling,
minors chaos and emotional
- coercion of deprivation or
minors to
 withholding of
affection, nurturing,
- normal experiences
that engender
acceptance, love,
security, and
self-worth.
Clinical Picture
- Parents who abuse their children often
have minimal parenting knowledge
and skills
- not understand or know what their
children need, or they may be angry
or frustrated because they are
emotionally or financially unequipped
to meet those needs
- Parents who abuse their children often
are emotionally immature, needy, and
incapable of meeting their own needs
much less those of a child
- As in spousal abuse, the abuser
frequently views his or her children as
property belonging to the abusing
parent
- abuser does not consider the children
people with rights and feelings
- When the parent’s unrealistic
expectations are not met, he or she
often reverts to using the same
methods his or her parents used.
- Adults who were victims of abuse as
children frequently abuse their own
children
Assessment
- detection and accurate identification
- First step
- Nsg mgmt:
- reporting suspected child
abuse with accurate and
thorough documentation of
assessment data.
- Child Protective Services,
Children and Family Services,
or the Department of Health.
- Burns or scalds may have an
identifiable shape, such as cigarette
marks, or may have a “stocking and
glove” distribution, indicating scalding.
- parent of an infant with a severe skull
fracture may report that he or she
“rolled off the couch,” even though
the child is too young to do so or the
injury is much too severe for such a
shortfall
- Bruises may have familiar,
recognizable shapes such as belt
buckles or teeth marks.
- Warning signs of abused/ neglected
child:
- Serious injuries such as
fractures, burns, or lacerations
with no reported history of
trauma
- Delay in seeking treatment for
a significant injury
- Child or parent giving a
history inconsistent with
severity of injury,
such as a baby with
contrecoup injuries to the
brain (shaken baby syndrome)
that the parents claim
happened when the infant
rolled off the sofa
- Inconsistencies or changes in
the child’s history during the
evaluation by either the child
or the adult
- Unusual injuries for the child’s
age and level of development,
such as a fractured femur in a
2-month-old or a dislocated
shoulder in a 2- year-old
- High incidence of urinary tract
infections; bruised, red, or
swollen genitalia; tears or
bruising of rectum or vagina
- Evidence of old injuries not
reported, such as scars,
fractures not treated, and
multiple bruises that
parent/caregiver cannot
explain adequately
- Children who have been sexually
abused may have urinary tract
infections; bruised, red, or swollen
 genitalia; tears of the rectum or - Family therapy
vagina; and bruising. - indicated if
- Key: recognize when the child’s reuniting the
behavior is outside what is normally family is
expected for his or her age and feasible
developmental stage. - short-term or
- unexplained behavior, from refusal to long-term foster care
eat to aggressive behavior with peers, services
may indicate abuse. - child is
- Treatment and Intervention unlikely to
- ensure the child’s safety and return home
well-being.
- 1st part of treatment ELDER ABUSE
for child abuse or
neglect: - maltreatment of older adults by family
- removing the child members or others in a caregiver role.
from the home, - Categories:
- relationship of trust between - Physical
the therapist and the child is - sexual abuse
crucial to help the child deal - Psychological abuse
with the trauma of abuse - Neglect
- Long-term treatment - Self-neglect
- psychiatry, social - financial exploitation
work, and psychology - denial of adequate medical
- Therapy for very young child treatment
- play therapy - Perpetrators of the abuse are most
- draws or acts likely living with the victim and/or
out situations related to the victim as well as having
with puppets legal or psychological problems
or dolls rather themselves
than talks - Abuse is more likely when the elder
about what has multiple chronic mental and
has happened physical health problems and when he
or his or her or she is dependent on others for
feelings. food, medical care, and various
- Social service activities of daily living
agencies - spousal abuse
- determining - elder abuse occur when one
whether older spouse is taking care of
returning the another.
child to the - happens over many years
parental after a disability renders the
home is abused spouse unable to care
possible for him or herself.
based on - Abuser adult child: son or daughter
whether - psychiatric disorder or a problem with
parents can substance abuse may aggravate abuse
show benefit of elders.
from - Bullying
treatment
 - identified in senior living
facilities
- Verbal and social bullying
- Most common
Clinical Picture
- victim may have bruises or fractures
- may lack needed eyeglasses or
hearing aids
- may be denied food, fluids, or
medications
- may be restrained in a bed or chair.
- abuser may use the victim’s financial
resources for his or her own pleasure,
while the elder cannot afford food or
medications
- withhold medical care from an elder
with acute or chronic illness.
- Self-neglect
- elder’s failure to care for him
or herself.
Assessment
- Careful assessment of elderly persons
and their caregiving relationships
- essential in detecting elder
abuse
- nurse should suspect abuse if injuries
have been hidden or untreated or are
incompatible with the explanation
provided. Such injuries can include
cuts, lacerations, puncture wounds,
bruises, welts, or burns.
- burns can be cigarette burns,
scaldings, acid or caustic burns, or
friction burns of the wrists or ankles
caused from being restrained by
ropes, clothing, or chains.
- Signs of physical neglect: pervasive
smell of urine or feces, dirt, rashes,
sores, lice, or inadequate clothing.
Dehydration or malnourishment not
linked with a specific illness also
strongly indicates abuse.
- self-neglect to be diagnosed, the elder
must be evaluated as unable to
manage day-to-day life and take care
of him or herself.
-
Possible indicators of elder abuse:
Physical Abuse Indicators
● Frequent, unexplained injuries
accompanied by a habit of seeking
medical assistance from various
locations
● Reluctance to seek medical treatment
for injuries or denial of their existence
● Disorientation or grogginess indicating
misuse of medications
● Fear or edginess in the presence of
family member or caregiver
Psychosocial Abuse Indicators
● Change in elder’s general
mood or usual behavior
● Isolated from previous friends
or family
● Sudden lack of contact from
other people outside the
elder’s home
● Helplessness
● Hesitance to talk openly
● Anger or agitation
● Withdrawal or depression
● hesitant to talk openly to the
nurse or who is fearful,
withdrawn, depressed, and
helpless.
● The elder may also exhibit
anger or agitation for no
apparent reason. He or she
may deny any problems, even
when the facts indicate
otherwise.
Material Abuse Indicators
● Unpaid bills
● Standard of living below the elder’s
means
● Sudden sale or disposal of the elder’s
property/possessions
● Unusual or inappropriate activity in
bank accounts
 ● Signatures on checks that differ from
the elder’s
● Recent changes in will or power of
attorney when the elder is not
capable of making those decisions
● Missing valuable belongings that are
not just misplaced
● Lack of television, clothes, or personal
items that are easily affordable
● Unusual concern by the caregiver over
the expense of the elder’s
treatment when it is not the
caregiver’s money being spent
Neglect Indicators
● Poor personal hygiene
● Lack of needed medications or
therapies
● Dirt, fecal or urine smell, or other
health hazards in the elder’s living
environment
● Rashes, sores, or lice on the elder
● The elder has an untreated medical
condition or is malnourished or
dehydrated not related to a known
illness
● Inadequate material items, such as
clothing, blankets, furniture, and
television
Indicators of Self-Neglect
● Inability to manage personal finances,
such as hoarding, squandering, or
giving away money while not paying
bills
● Inability to manage activities of daily
living, such as personal care,
shopping, or housework
● Wandering, refusing needed medical
attention, isolation, and substance use
● Failure to keep needed medical
appointments
● Confusion, memory loss, and
unresponsiveness
● Lack of toilet facilities, or living
quarters infested with animals or
vermin
Warning Indicators From Caregiver
- The elder is not given an opportunity
to speak for self, have visitors, or see
anyone without the presence of the
caregiver
- Attitudes of indifference or anger
toward the elder
- Blaming the elder for his or her illness
or limitations
- Defensiveness
- Conflicting accounts of elder’s abilities,
problems, and so forth
self-neglect indicators
- inability to manage money (hoarding
or squandering while failing to pay
bills)
- inability to perform activities of daily
living (personal care, shopping, food
preparation, and cleaning), and
changes in intellectual function
(confusion, disorientation,
inappropriate responses, and memory
loss and isolation).
- Other indicators of self-neglect include
- signs of malnutrition or dehydration,
rashes or sores on the body, an odor
of urine or feces, or failure to keep
necessary medical appointments
Treatment and Intervention
- Relieving the caregiver’s stress and
providing additional resources may
help correct the abusive situation and
leave the caregiving relationship
intact.
- removal of the elder or caregiver is
necessary.
- access to the victim’s financial
resources
● Sexual Assault (Rape)
○ Rape
■ perpetration of an act
of sexual intercourse
 with a person against ■ underacknowledged
his or her will and and underreported
without her consent, crime
whether that will is ■ gay partners or
overcome by force, strangers
fear of force, drugs, ■ Prevalent: prisons
or intoxicants. ○ Dynamics of Rape
■ crime of violence and ■ Men:
humiliation of the ● 50%- 30 and
victim expressed older;
through sexual ● 50% - 30 and
means. older
■ incapable of ● 34%- alcohol
exercising rational ● 75%
judgment because of - arrest
mental deficiency or ed
because he or she is rapist
younger than the age s
of consent (which - rape is not a sexual crime but
varies among states rather the perpetrator’s
from 14 to 18 years exertion of power, control,
○ crime of rape infliction of pain, or
■ slight penetration of punishment for perceived
the outer vulva or wrongs.
rectum - Feminist theory
■ full erection and - women have
ejaculation are not historically served as
necessary objects of aggression,
○ Sodomy (sexual assault) dating back to when
■ Forced acts of oral sex women (and children)
and anal penetration were legally the
○ date rape (acquaintance property of men.
rape) - 1982
■ first date, on a ride - first time, a married
home from a party, or man was convicted of
when the two people raping his wife,
have known each signaling the end of
other for some time the notion that sexual
■ college campuses intercourse could not
■ rate of serious be denied in the
injuries: increases context of marriage.
with increased - attempts to resist or fight
consumption of - attacker succeed
alcohol by either the - fighting and yelling result in
victim or the more severe physical injuries
perpetrator. or even death.
○ underreported crime - Degree of submission is
○ any age: 15 months to 82 higher
years
○ Male rape
 - attacker has a permitted
weapon such as a gun immediately.
or knife - How to assess:
- Severe physical and - asks the victim to
psychological trauma describe what
- Related medical problems happens
- acute injury, sexually - ask needed questions
transmitted diseases, gently and with care
pregnancy, and - If victim
lingering medical cannot
complaints. describe what
happened
Common Myths about rape: - physician or a
specially trained
- Rape is about having sex. sexual assault nurse
- When a woman submits to rape, she examiner
really wants it to happen. - Responsible
- Women who dress provocatively are to collect
asking for rape. physical
- Some women like rough sex but later evidence
call it rape. using rape
- Once a man is aroused by a woman, kits and rape
he cannot stop his actions. protocols
- Walking alone at night is an invitation
for rape. Treatment and Intervention
- Rape cannot happen between persons
who are married. - providing emotional support to the
- Rape is exciting for some women. victim
- Rape occurs only between - allow the victim to proceed at his or
heterosexual couples. her own pace and not rush through
- If a woman has an orgasm, it can’t be any interview or examination
rape. procedures.
- Rape usually happens between - Let the victim sign inform consent
strangers. before any photographs or hair and
- Rape is a crime of passion. nail samples are taken for future
- Rape happens spontaneously. evidence.
- Offer prophylactic treatment for
Assessment sexually transmitted diseases
- Encourage HIV testing at specified
- physical examination intervals because seroconversion to
- Before the victim has positive status does not occur
showered, brushed teeth, immediately
douched, changed clothes, or - Encourage victim to engage in
had anything to drink safe-sex practices until the results of
- To preserve possible HIV testing are available
evidence - Offer ethinyl estradiol and norgestrel
- no report of oral sex (Ovral) to prevent pregnancy
- rinsing the mouth or - Rape crisis centers, advocacy groups,
drinking fluids can be and other local resources
 - provide a counselor or
volunteer to be with the victim
from the emergency
department through
longer-term follow-up.
- provides emotional support
- advocate for the victim
- Therapy:
- supportive
- Focus:
- restoring the victim’s
sense of control
- relieving feelings of
helplessness
- Dependencyand
obsession with the
assault that frequently
follow rape
- regaining trust
- improving daily
functioning
- finding adequate
social support; and
dealing with feelings
of guilt, shame, and
anger.
- Group therapy
- effective treatment.
- 1 year or more
- survivors of rape to regain
previous levels of functioning
- Ways to give much control back to the
victim (victims decision):
- allowing him or her to make
decisions such as who to call,
what to do next, what he or
she would like done, and so
on
- victim’s decision about whether or not
to file charges and testify against the
perpetrator
- Rape treatment centers: emergency
services that coordinate psychiatric,
gynecologic, and physical trauma
services
- most helpful to the victim.
- Education about rape and the needs
of victims is ongoing requirement for
health care professionals, law
enforcement officers, and the general
public.
- Victims of rape fare best when they
receive immediate support and can
express fear and rage to family
members, nurses, physicians, and law
enforcement officials who believe
them.
- Warning signs of relationship violence
or dating violence
- expressing negativity about
women
- acting tough
- engaging in heavy drinking
- exhibiting jealousy
- making belittling comments
- expressing anger
- using intimidation.
- Emotionally abuses you
(insults, makes belittling
comments, or acts sulky or
angry when you initiate an
idea or activity)
- Tells you with whom you may
be friends or how you should
dress, or tries to control other
elements of your life
- Talks negatively about women
in general
- Gets jealous for no reason
- Drinks heavily, uses drugs, or
tries to get you drunk
- Acts in an intimidating way by
invading your personal space
such as
standing too close or touching
you when you don’t want that
- Cannot handle sexual or
emotional frustration without
becoming angry
- Does not view you as an
equal: sees self as smarter or
socially superior
- Guards masculinity by acting
tough
- Is angry or threatening to the
point that you have changed
your life or
yourself so you won’t anger
him
 - Goes through extreme highs sexual response cycle or by pain
and lows: is kind one minute, associated with sexual intercourse.
cruel the - may be caused by psychological
next factors alone or a combination of
- Berates you for not getting psychological factors and a medical
drunk or high, or not wanting condition.
to have sex
- Is physically aggressive,
Sexual desire disorders
grabbing and holding you, or
- involve a disruption in the desire
pushing and
phase of the sexual response cycle.
shoving
● Hypoactive sexual desire
disorder
- characterized by a
deficiency or absence
of sexual fantasies
and a lack of desire
for sexual activity that
causes marked
distress or
interpersonal difficulty.
a
● Sexual aversion disorder
● Special Populations - involves aversion to
and active avoidance
- Chemically Impaired
of genital sexual
- Substance Abuse contact with a sexual
- Substance Dependence partner that causes
marked distress or
● Sexual disorders - Har interpersonal difficulty.
(pp. 1102-1105) pdf The individual reports
anxiety, fear, or
Wa ko kita interventions ani sa book ;(
disgust when
confronted by a
Sexual response cycle
sexual opportunity
- consists of desire, excitement,
with a partner.
orgasm, and resolution

There are three general groups of sexual and

Sexual Arousal Disorders
gender problems:
- Are a disruption of the excitement
- Sexual dysfunctions (desire, arousal,
phase of the sexual response cycle.
orgasm, pain, and dysfunction due to
● Female sexual arousal
a medical condition)
disorder
- Paraphilias (exhibitionism, fetishism,
- Persistent or recurrent
frotteurism, pedophilia, masochism,
inability to attain
sadism, transvestic fetishism, and
1102or to maintain,
voyeurism), and
until completion of the
- Gender dysphoria
sexual activity, an
adequate
SEXUAL DYSFUNCTIONS
lubrication–swelling
- Sexual dysfunction is characterized by
response of sexual
a disturbance in the processes of the
excitement, which
 causes marked
distress or Sexual Pain Disorders
interpersonal difficulty.
● Male erectile disorder
- Persistent or recurrent
inability to attain or
maintain, until
completion of the
sexual activity, an
adequate erection,
which causes marked
distress or
interpersonal difficulty
Orgasmic disorders
- are disruptions of the orgasm
phase of the sexual response
cycle.
● Female orgasmic disorders
- Persistent or recurrent
delay in, or absence
of, orgasm following a
normal sexual
excitement phase,
which causes marked
distress or
interpersonal difficulty.
● Male orgasmic disorder
- Persistent or recurrent
delay in, or absence Sexual dysfunction due to a general
of, orgasm following a medical condition
normal sexual
excitement phase,
which causes marked
distress or
interpersonal difficulty.
● Premature ejaculation
- Persistent or recurrent
onset of orgasm and
ejaculation with
minimal sexual
stimulation before, on,
or shortly after
penetration and Substance-induced sexual dysfunction
before the person
wishes it, causing
marked distress or
interpersonal difficulty.
- Involve pain associated with sexual
activity
● Dyspareunia
- Genital pain associated with
sexual intercourse causing
marked distress or
interpersonal difficulties.
- It can occur in both males and
females, and symptoms range
from mild discomfort to sharp
pain.
● Vaginismus
- Persistent or recurrent
involuntary contractions of the
perineal muscles surrounding
the outer third of the vagina
when vaginal penetration with
penis, finger, tampon, or
speculum is attempted,
causing marked distress or
interpersonal difficulties.
- The contraction may range
from mild (tightness and mild
discomfort) to severe
(preventing penetration).
- is the presence of clinically significant
sexual dysfunction that is exclusively
due to the physiological effects of a
medical condition.
- It can include pain with intercourse,
hypoactive sexual desire, erectile
dysfunction, orgasmic problems, or
other problems as previously
described.
- The individual experiences marked
distress or interpersonal difficulty
related to the symptoms.
- is clinically significant sexual
dysfunction resulting in marked
distress or interpersonal difficulty
caused by the direct physiological
 effects of a substance (drug of abuse,
medication, or toxin).
- It may involve impaired arousal,
impaired orgasm, or sexual pain
PARAPHILIAS
- Paraphilias are recurrent, intensely
sexually arousing fantasies, sexual
urges, or behaviors generally
involving:
(1) nonhuman objects
(2) the suffering or humiliation of
oneself or partner, or
(3) children or other nonconsenting
persons.
- For pedophilia, voyeurism,
exhibitionism, and frotteurism, the
diagnosis is made if the person has
acted on these urges or if the urges or
fantasies cause marked distress or
interpersonal difficulty.
- For sexual sadism, the diagnosis is
made if the person has acted on these
urges with a nonconsenting person or
if the urges, fantasies, or behaviors
cause marked distress or
interpersonal difficulty.
- For the remaining paraphilias, the
diagnosis is made if the behavior,
sexual urges, or fantasies cause
clinically significant distress or
impairment in social, occupational, or
other important areas of functioning.
● Exhibitionism
- exposure of the genitals to a
stranger, sometimes involving
masturbation; usually occurs
before age 18 and is less
severe after age 40.
● Fetishism
- use of nonliving objects (the
fetish) to obtain sexual
excitement and/or achieve
orgasm.
- Common fetishes include
women’s underwear, bras,
lingerie, shoes, or other
apparel.
- The person might masturbate
while holding or rubbing the
object.
- It begins by adolescence and
tends to be chronic.
● Frotteurism
- touching and rubbing against
a nonconsenting person,
usually in a crowded place
from which the person with
frotteurism can make a quick
escape, such as public
transportation, a shopping
mall, or a crowded sidewalk.
- The individual rubs his
genitals against the victim’s
thighs and buttocks or fondles
breasts or genitalia with the
hands.
- Acts of frottage occur most
often between the ages of 15
and 25; frequency declines
after that.
● Pedophilia
- sexual activity with a
prepubescent child (generally
13 years or younger) by
someone at least 16 years old
and 5 years older than the
child.
- It can include an individual
undressing the child and
looking at the child; exposing
himself or herself;
masturbating in the presence
of the child; touching and
fondling the child; fellatio;
cunnilingus; or penetration of
the child’s vagina, anus, or
mouth with the individual’s
fingers or penis or with foreign
objects, with varying amounts
of force.
- Contact may involve the
individual’s own children,
stepchildren or relatives, or
1104strangers.
- Many individuals with
pedophilia do not experience
distress about their fantasies,
urges, or behaviors.
● Sexual masochism
 - Recurrent, intensely sexually birth, usually anatomical and called
arousing fantasies, sexual natal.
urges, or behaviors involving - The incongruence is accompanied by
the act of being humiliated, the persistent discomfort of his or her
beaten, bound, or otherwise assigned sex or a sense of
made to suffer. inappropriateness in the gender role of
- Some individuals act on that assigned sex.
masochistic urges by - The person experiences clinically
themselves, others with a significant distress or impairment in
partner. social, occupational, or other important
● Sexual sadism areas of functioning.
- Recurrent, intensely sexually - In boys, there is a preoccupation with
arousing fantasies, sexual traditionally feminine activities, a
urges, or behaviors involving preference for dressing in girls’ or
acts in which the women’s clothing, and an expressed
psychological or physical desire to be a girl or grow up to be a
suffering of the victim is woman.
sexually arousing to the - Girls may resist parental attempts to
person. have them wear dresses or other
- It can involve domination feminine attire, wear boys’ clothing,
(caging the victim or forcing have short hair, ask to be called by a
victim to crawl, beg, plead), boys name, and express the desire to
restraint, spanking, beating, grow a penis and grow up to be a
electrical shock, rape, cutting, man.
and, in severe cases, torture
and death.
- Victims may be consenting
(those with sexual
masochism) or
nonconsenting.
● Voyeurism
- recurrent, intensely sexually
arousing fantasies, sexual
urges, or behaviors involving
the act of observing an
unsuspecting person who is
naked, in the process of
undressing, or engaging in
sexual activity.
- Voyeurism usually begins
before age 15, is chronic, and PRE REC (8.5 MINS EACH)
may involve masturbation FIRST VIDEO: DISSOCIATIVE
during the voyeuristic DISORDER PART 1
behavior.
DISSOCIATIVE DISORDERS:
Gender Dysphoria
● Dissociative amnesia
- Gender dysphoria is diagnosed when
● Dissociative fugue
an individual has a strong and
● Dissociative identity disorder
persistent sense of incongruence
● Depersonalization disorder
between experienced or expressed
gender and the gender assigned at
Dissociation
- Is a defense against trauma that helps
persons remove themselves from
trauma as it occurs and delays the
working through of the trauma
- Dissociation as a defense
mechanism is ultimately
performed to protect self from
hurtful or damaging or very
traumatizing experience. so
he is or she removes himself
from that specific trauma by
using dissocatiociation so he
can protect himself from that
experience
- avoids that specific
experience or situations
- Patients have lost sense of having one
consciousness
- avoids that specific
experience or situations
- Avoidance response
- Some aspect of cognition or
experience becomes inaccessible to
consciousness
- Avoidance response
- Some types of dissociation
are harmless and common
(losing track of time )
- We go through that most of
the time (track of time)
- Disoriented
- Lose track of the date
- Ask spontaneously of your
age and answers
spontaneously (not
dissociation)
- Dissociation as a defense
mechanism i am bringing up is
the kind in which is
subconsciously removes a
person from the specific
experience so that he or she
protect from pain that has
brought him or her
- Sudden disruption in the continuity of
- Consciousness
- Emotions
- Motivation
- Memory
- Identity
Defenses (Frequently used in all
dissociative disorders:)
- Repression
- Disturbing impulses are
blocked from consciousness
- Denial
- External reality is ignored
- Client here pretends
not to occur for the
purpose of protecting
himself from hurtful
experience
- Dissociation
- Separation and independent
functioning of 1 group of
mental process from others
(mental contents exists in
parallel consciousness)
- Client
compartmentalized
subconsciously
forgetting that
specific experience
DISSOCIATIVE AMNESIA
- Most common type of dissociative
disorder
- The main feature is loss of memory,
usually of important recent events that
is not due to organic mental disorder
and is too great to be explained by
ordinary forgetfulness or fatigue
- Not the usual amnesia or
forgetfulness of the
experience because
sometimes we tend to forget
or lose track of time especially
when we are too stressed
- This kind of amnesia is too
great to be explained as
ordinary forgetful fullness
- The amnesia is usually centered on
traumatic events such as accidents or
unexpected bereavements and is
usually partial and selective
- Not cause by head injuries or physical
damage to the brain, it is amnesia
which is psychological cause
- Ex: a client experience
forgetfulness or a loss of
memory and if the therapist
will try to review clients history
 and their is a previous head
injury occur to the client which
may cause the amnesia (not
dissociative amnesia)
- Dissociative amnesia is not
organic in nature (not caused
by physical neurologic
disorder) rather it is caused by
a psychological reason or
conflict
- It can occur as part of a number of
other mental health conditions
including post traumatic disorder and
acute stress disorder, dissociative
identity disorder, somatoform disorder
and anxiety disorder in any of those
case it would not be classed as a
separate disorder
- If the client experiences
dissociative amnesia or
amnesia in general and yet it
is because any of these
disorders then it is not
classified dissociative
amnesia
- Ex: a client which is also going
through tremendous amount
of stress because of that the
client forget things then it is
not anymore known as
dissociative amnesia rather
amnesia is deemed to a
disease
- It can last for between a few days to a
few years but is typically less than a
week. The period of time cannot be
remembered can range from minutes
to decades
Key Characteristics:
- The inability to recall important
autobiographical information that:
- Should be successfully stored
in memory
- Should be ordinarily would be
readily remembered
- Normally would know your
autibio information or personal
infor (name, address, age,
birthdate)
- If there is inability to recall or if
there's loss of memory on
specific information that
should naturally be stored in
our memory and should
ordinarily be remembered like
those information that they’ve
mentioned earlier then it may
be because the client in
experiencing dissociative
amnesia and most importantly
it can be said that it is really
dissociative amnesia if it is not
caused by any neurological or
physical or organic causes
-
- Dissociative amnesia is more likely
in people with
- A history of multi adverse
childhood experience
(physical or sexual abuse)
- People who have experienced
interpersonal violence
(domestic violence or physical
assaults)
- Risk increases with the
severity frequency and
violence of the trauma
- More likely in people
with history or multiple
adverse childhood
experiences
especially if they
include physical or
sexual abuse for
example domestic
violence or physical
assaultand
- the risk increases with
the severity,
frequency and
violence of trauma
because remember in
dissociative amnesia
it's not organic or
physical in nature, it is
due to psychological
conflicts or causes
3 three Major type of Dissociative Amnesia
1. Localized amnesia
 ● Failure to recall events during
a specific period of time
2. Selective Amnesia
● Some, but not all, events can
be recalled during a period of
time only part of a traumatic
event may be remembered
e.g months/years of intense
combat or child abuse
3. Generalized Amnesia
● Complete amnesia for one’s
life history. May forget their
identity. Sudden onset. Rare
● Most severe type
● 7 onset
● Client may also lose semantic
knowledge or the previous
knowledge they have about
the world
● May also forget procedural
knowledge or those well
learned skills example if
student nurse and client nga
naay dissociative amnesia
he/she does not have any
recollection of how nursing
procedures or even nursing is
practiced
● Only partially aware of their gaps and
memory and since because its due to
psychological conflicts or reason or its
not because of any neurological or
organic in nature then the memory
loss is reversible
○ The client can regain or
recover from the moment that
the dissociative amnesia
subsides
DSM-5 Diagnostic Criteria for Dissociative
Amnesia
1. An inability to recall important
autobiographic information, usually of
a traumatic or stressful nature, that is
inconsistent with ordinary forgetting
- It is not your usual
forgetfulness in our day to day
living
- Forgetting autobiographical
information which we are
supposed to remember like
name
2. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning
3. The disturbance is not attributable to
the physiological effects of a
substance or a neurological or other
medical condition
4. The disturbance is not better
explained by dissociative identity
disorder, posttraumatic stress disorder,
acute stress disorder, somatic
symptom disorder, or major or mild
neurocognitive disorder
- In other words a client with
dissociative amnesia is in
itself experiencing
forgetfulness that is not
associated or related to any
other mental causes or illness
so it stands alone
Treatment
● Spontaneous recovery
- May just heal in his or her own
● Hypnosis
- Therapist will put the client in
a trance like state and there
the client will be asked to
recall that specific
traumatizing event which may
have triggered the amnesia
- And to remember and access
those repressed memories
and control some of the
problematic behaviors which
accompanied the repressed
memory
● Drug assisted interview thiopental
(pentothal) / sodium amobarbital
(amytal) or IV benzos
- May give this drug to hasten
the trance like state and allow
access to the clients
repressed memories
● Psychotherapy
- Also known as talk therapy
and its designed to work on
the repressed memories
which caused amnesia. Bring
back to traumatizing event
and process the client on
how she/he feels and try to
recall or identify specific
skills may it be adaptive or
coping skills to address
situation
Dissociative Fugue
● A fugue occurs when there is a
sudden and unexpected travel away
from home or work in combination with
amnesia or a person’s past, and either
identity confusion or assumption of a
new identity
- The assumption of new
identity comes along with the
amnesia that the client
experiences because the
client with dissociative fugue
will not be able to recall or
even know his/her identity
which will force or compel
him/her to assume a new
identity
● The amnesia is typically associated
with confusion about one’s identity,
and presentation of a new identity
may occur
● Dissociative fugue has all the
features of dissociative amnesia,
plus purposeful travel beyond the
usual everyday range
- Cannot recall autobiographical
information which should be
easily recalled
- Cannot recall own identity so
they assumes a new identity
- Travel to other part of the
country, travel beyond the
usual normal or range of
activities
● Although there is amnesia for the
period of the fugue, the patient’s
behavior during this time may appear
completely normal to independent
observers
● Beyond the client’s usual range of
activities
● Client may appear completely normal
to an observer though there’s amnesia
Fugue
- Rare, sex and age of onset variable
- Spontaneous, rapid recovery
- Recurrences are rare
- Common after wars/disaster,
emotional stress, heavy alcohol
abuse, medical causes-epilepsy, head
trauma
- Can last months-brief if due to medical
cause
Treatment (same with dissociative amnesia)
- Spontaneous recovery
- Hypnosis (maybe done alone or be
with ubos)
- Drug assisted interviews
- Psychotherapy (expressive supportive
psychodynamic therapy for healthy
adjustment to stressor)
Dissociative Identity Disorder
- Previously known as multiple
personality disorder; taught to be
coping mechanism
- Dissociates oneself from a
traumatic or painful event to
embrace subconscious self
- Dissociates oneself to a
traumatic/painful circumstance
- Caused by severe trauma during early
childhood, extreme repetitive sexual
emotional abuse
- Presence of 2 or more distinct
identities or personality states (each
with its own pattern of relating to the
environment and self)
- Shows Unpredictable and
frightening behavior
- At least 2 states recurrently take
control of the person's behavior
- Inability to recall important personal
information that is too extensive to be
explained by ordinary forgetfulness
Forgetfulness not due to substances
(alcohol) or organic cause but caused
by assumption of new identity
-amnesia is present assumption of a
 new identity which triggered by a
traumatic experience-
DID
- Most severe and chronic dissociative
d/o
- Original personality(host personality)
is generally amnestic of and unaware
of the other personalities or outer
egoes (downside)
- But other alter egos maybe aware of
certain aspects of other personalities
- Each may have their own set of
memories name and description, age,
sex and race
- May have diff physiologic
characteristics: diff eyeglass
prescriptions
- Psychometric testing: diff IQ scoring or
diff psychiatric disorders: mood or
personality disorders
- Alter egos are a total diff. Personality
from the host
- Alter ego is just part of the person’s
personality but can not integrate all
other personalities
- Outer egos of the same range form
cliques or gang up to the host
personality
- Not limited to a person, may have alter
egos of animals (ex: dog-bark)
- Totally different personality or total
opposite from original or host
personality to cope with traumatic
event
- “Book cibil”
- Outer personality is part of the host
personality
- Cannot integrate all personalities
- Difference with a normal
person
- Same person but cannot integrate
personality
S/S
- Reports of time distortions, lapses and
discontinuities (host person may not
remember bec. Other personality took
over)
- Being told of behavioral episodes by
others that are not recommended by
pt
- Being recognized by others or called
by another name the pt does not
recognize
- Notable changes in pt’s behavior
reported by a reliable observer; or pt
may call him/herself by a diff name or
refer to him in the the 3rd person, use
of “we” during interview
- Client may experience mood swings
as the client assumes different alter
egos or personalities
- Client feels depressed if the host
personality cannot recall what or she
did when he or she was in that state
- The personalities of the different alter
egos which are of the same range will
form one click. Those that are the
opposite, will form another click.
- These clicks of different alter egos
may get along with one another or not.
- The click egoes will sabotage the host
personality
- In reality, it will appear like there is
someone who’s monologuing, talking
to herself, and then assume
assumptions of different personalities
- As the different alter egos and
personalities vary in their
manifestations and appearance and
even vital statistics, you can also
expect they also have different voices.
- While they talk with one another, it’s
just one person but different voices
emerge.
- If what personality experience or they
feel they will show that
- Ex: feeling child personality,
client manifest child v/s
- Discovery of writings, drawing etc. or
objects (identification cards, clothing)
among the patients belonging that are
not recognized by the patient or
cannot be accounted for
- Headaches
- Hearing voices originating from within
and not separate
- History of witnessing a death or
trauma or severe emotional, sexual, or
 physical abuse as a child (incest
usually before 5yrs), poor support
- This specific disorder is caused by
trauma
- Sudden transition from one personality
to another
- Unlimited number of personalities (as
the treatment or therapy continues,
there are instances where other
personalities will actually show up)
- Each distinct personality dominates
the person’s behavior and thinking
when it is present
- Not very rare as previously thought -
5% psych patients
- Common among adolescent/young
adults and those with 1st degree
relatives
- Female > male (more common in
female)
- Difficult to diagnose, incomplete
recovery (difficult to diagnose because
this masks other mental illnesses)
The DSM-5 provides the ff criteria to diagnose
dissociative identity disorder: FIVE
- Two or more distinct identities or
personality states are present, each
with its own relatively enduring pattern
of perceiving, relating to, and thinking
about the environment and self.
- Amnesia must occur, defined as gaps
in the recall of everyday events,
important personal information, and/or
traumatic events.
(Because it is actually another
personality or alter ego that assumed
that specific period because the host
personality have already succeeded
due to the traumatic event again, so
the person must be distressed by the
disorder or have trouble functioning in
one or more major life areas. This is a
pervasive statement because a client
may experience any of these
manifestations and relate to a lot of
manifestations as long as it does not
interfere with your occupational,
personal, or your social functioning
then it is not a disorder, if it’s otherwise
the it’s a disorder.)
- The person must be distressed by the
disorder or have trouble functioning in
one or more major life areas because
of the disorder.
- The disturbance is not part of normal
cultural or religious practices.
- The symptoms cannot be due to the
direct physiological effects of a
substance (such as blackouts or
chaotic behavior during alcohol
intoxication) or a general medical
condition (such as complex partial
seizures).
(So it’s not organic or physical in
nature rather the client will just switch
to another alter ego personality and it
can be attributed to his/her traumatic
experiences in the past.)
PSYCHODYNAMICS
● Severe psychological and
physical abuse (mostly
sexual) in childhood leads to a
profound need to distance
oneself from horror and pain.
(For them, the answer is
subconscious dissociation.
When the client does
something beyond their
control, not at their will, it is
because they can no longer
stand the pain or the hurtful
experience that they literally
shut themselves off from that
scene so when they do that
it’s not conscious.)
● This leads to an unconscious
splitting off of different aspects
of the original personality, with
each personality, expressing a
necessary emotion or
state(rage, sexuality,
competence, playfulness) that
the original personality dare
not express
● OUTER EGOS-
PERSONALITIES THAT CAN
BETTER COPE THE
TRAUMATIC EVENT OR TO
PROTECT THE SELF
DID (DISSOCIATIVE IDENTITY DISORDER)
NO CURE, only long term treatment IF THE
PATIENT STAYS COMMITED because other
egos may arise unless client go through
extensive therapy
(The alter egos are
personalities that can better
cope with the traumatic
experience, so for example,
the weal sibyl can no longer
take on the abuses of her
physical abuse of the mother,
this specific alter ego or
personality emerges to
combat the abuses of her
mom. Since that specific
personality can stand up for
herself against her mother
then self is protected so you
can see the dynamics. So that
happens during DID)
● During abuse, the child attempts to
protect him/herself from trauma by
dissociating from the terrifying acts
who could not be subject to abuse or
who is not experiencing abuse
● In children the symptoms are not
attributable to imaginary playmates or
other fantasy play
● The dissociative selves become a long
term, ingrained method of self
protection from emotional threats.
(In other words, everytime that the
client with DID experiences a similar
traumatic experience subconsciously
shuts herself off and then allows the
emergence of another personality that
can cope with this emotional threat.)
- INDIVIDUAL PSYCHOTHERAPY
(hypnosis) (useful) but can be with
other therapy
DID - Steps in Therapy
- Establish strong therapeutic alliance
and a safe atmosphere
- Have consistency, clear
communication
- Set boundaries with most readily
reached personalities and agreements
not to abandon therapy
- Hx (history) gathering from the
different alters and understanding their
reasons for creation and
persistence-their problems, concerns
and how they function
- Responding to all alters in the same
way
- Pacing therapy to avoid
re-traumatizing patient as buried
trauma resurfaces
- Facilitate integrating the personalities
into one by pressing for collaboration
and cooperation among the alters
- Teaching new coping skills
---------------------------------------------
- Establish strong therapeutic alliance
and a safe atmosphere
-
= in that book, there was a time
wherein the therapist reached an
impasse with sibil, the host personality
and the other alter egos. In other
words, they’ve reached a point in the
therapy where it seemed that there is
no other way to proceed like there’s
nothing to talk about anymore and the
therapist felt that she has to really get
inside the head and the mind of sibil
and get those other alter egos talking
but the other alter egos are no longer
responding. So what the therapist did
was in their usual client-therapist
relationship and they just stay in one
office or clinic rather and they talk in a
sofa, but since they reached an
impasse and the therapist can no
longer reach the core of sibil so what
the therapist did is that she brought
sibil to ride a plane they were like tall
grasses and all that. Sibil, the host’s
personality, already likes the therapist
but the other alter egos actually talk
among themselves and said i really
like this therapist because she really
cares for us aka sibil so why dont we
tell the therapist about the other alter
egos so that was the beginning of a
new alliance which created a more
established and safe atmosphere for
the other alter egos to talk about the
presence of other alter egos. Other
alter egos who are of the same
 personality range can form cliques and
then some cliques would actually get
along with each other. So that’s what
happened. So specific alter egos
actually wanted to help sibil and
because they like the therapist, they
opened up to the therapist about sibil
= for a therapy to be effective, there
has to be a very strong therapeutic
alliance and safe atmosphere. You
can’t expect the host personality or
even the alter egos to open up and for
it to be built, there has to be
consistency and clear communication
= there has to be profound trust and
care for the client
= in fact in that book, sibil cried to her
therapist and told the therapist that
she can no longer finance the therapy
because it’s too expensive so the
therapist cared for sibil and thought of
it as a challenge because in that
specific scenario, they’ve already
attained some accomplishments and
built a trusting relationship which
causes the alter egos to open up to
the therapist so she felt that if they
stop now, the other alter egos will not
be integrated with the host personality
so she really went an extra mile for
sibi and extended help beyond the
formalities of therapy
= in the later part of this disorder,
initially there has to be psychotherapy
of the client herself or himself but
there may be a need to involve the
families to allow support for the client
- Have consistency, clear
communication
- Set boundaries with most readily
reached personalities and agreements
not to abandon therapy
- Hx (history) gathering from the
different alters and understanding their
reasons for creation and
persistence-their problems, concerns
and how they function
= the therapist would really need to
interview each alters and allow the
different alter egos and personalities
to open up so that the therapist can
find out the reason why these
personalities emerge and by finding
out why these personalities emerge
then the therapist will be able to know
how to integrate these personalities to
the host personality because although
these alter egos may be totally
different or opposite from the
personality of the host ego, we must
put in mind that it’s one and the same
person
= the only reason why it’s not
integrated is because the client’s
traumatic experience. There’s no
foundation to glue to put together and
allow adhesiveness of the person’s
different personalities into one
- Responding to all alters in the same
way
= there has to be dedication as a
therapist
- Pacing therapy to avoid
re-traumatizing pt. as buried trauma
resurfaces
- Facilitate integrating the personalities
into one by pressing for collaboration
and cooperation among the alters
= this is what the therapist did in sibil
with the use of hypnotic therapy or
hypnosis, guided hypnosis
= different personalities have different
ages and even have different sexes so
the therapist with the use of hypnosis
allows the integration of other alter
egos
= in the later part of the book sibil,
another alter ego, a boy emerged and
the reason for that is because sibil is
always left with her mother and her
father goes to work, and sometimes
the father is busy so there are some
things that would be easier for a guy to
do like any activity that has to do with
carpentry which is a task usually done
by guys
= since sibil can't expect her mother to
do it for her and her dad isn’t around
to do it, she has to do it herself and for
her to do that, she takes on or
assimilates an alter ego personality
that is a boy who can do the task
- Teaching new coping skills
Treatment
 ● Treat co-morbid disorders because it
is likely that a client diagnosed with
DID will also experience depression
because of existential crisis, with a
bad childhood or bad past. The client
may also have suicidal tendencies.
They may also show mood swings,
sleep disorders, anxiety, panic attacks,
phobias. They may engage into
alcohol or drug abuse to cope.
Treatment includes treating the other
comorbid disorders
● Intense insight-oriented
psychotherapy-attempt to integrate
split personalities into one whole
because although the personalities
may differ, it is actually part of who a
person really is. It’s not just cohesively
integrated to the host personality
because of very poor foundation and
poor support
● Help pt understand that original
reasons for dissociation
(overwhelming rage, fear & confusion
secondary to abuse) no longer exist
● Specific traits can be expressed by
one whole person without the self
being destroyed You can have a lot of
different personalities, but it doesn’t
mean that it’s not you. It may come out
at will or it may come out at the
situation you are in. Nonetheless,
even if it’s different from your usual or
default personality, it is still you
Most treatments involve:
● Empathic and supportive therapist
● Integration of alters into one fully
functioning individual
● Improvement of coping skills because
the client here subconsciously
dissociates and shuts herself off and
assumes another alter ego or
personality when he/she experiences
traumatic or stressful experiences. In
order for the client to not assume
another alter ego in order to shut
herself off and dissociate, the client,
the host personality should be able to
cope to the stresses, and for him/her
to do that, she should have an
improved adaptive and coping skills so
that she will not dissociate when she is
encountering a stressful situation.
They also say that DID isn’t curable
because if it’s deeply ingrained in a
person’s personality, without specific
commitment to adhere to therapy
sessions and to make use of the skills
being taught in the therapy, then it’s
really impossible to manage the
situation, but Sybil’s story is a success
story, so who knows right
● To emphasize, for treatment you have
your psychotherapy or talk therapy. It
is designed through whatever
triggered and triggers the DID. The
goal of psychotherapy is to integrate
the severed personality into one
consolidated personality that can
control the triggers that’s why it’s very
important that the client has an
improved coping and adaptive skills.
Initially, it may involve just the client
and the therapist, but later on it may
involve the family members in the
therapy.
Psychodynamic approach adds:
● Overcome repression
● Use of hypnosis
○ Age regression In the book,
the therapist actually brings
the alter egos/personalities
together on the same age and
then finally, they will integrate
○ May actually worsen
symptoms There is no formal
evidence-based guidelines to
treat it, so all these treatments
are based on case reports.
They still remain to be
controversial until now so
some may actually worsen
symptoms.
Adjunctive therapy is a therapy that may be
used with other therapies. Therapies like
psychotherapy or hypnotherapy. Example of
adjunctive therapy is for a client diagnosed
with dissociative identity disorder is your art or
movement therapy, which have shown to help
people connect with parts of their mind that
they have shut off to cope with the trauma
With DID, there’s no established medication
treatments. Although the clinicial or the
therapist can use Thiopental or other hypnotic
drugs just to assist them to hasten the client’s B. During the episode, reality testing
arrival to a trance state, but then those remains intact
hypnotic drugs are not actually standing - Derealization disorder does
orders, they’re only given when hypnosis not experience
therapy is conducted. The client may be given hallucination, delusion or
an antidepressant but that is not for the illusion
purpose of treating dissociative identity - The client here is not
disorder. They may be given for the purpose of psychotic. The client's reality
treating other comorbidities wherein a client testing remains intact however
with DID may also experience depression, so the client experiences a
in other words, there is really no medication for condition wherein he/she feels
DID. The psychologically-based like he/she is having an
approaches, the psychotherapy, outside of the body
hypnotherapy and other adjunctive therapy experience, like she sees
are actually the mainstay of treatment of herself
dissociative identity disorder. C. Causes significant distress or
impairment in social, occupational
Goal of psychotherapy or talk therapy: to fused functioning
separate personality traits to one consolidated - The very definition of this
trait to control triggers so it is important the disorder
client has good coping skills D. Not due to another mental disorder
disorder, dissociative disorder,
Psychotherapy plus family therapy substances
- The feeling of being detached
Hypnotherapy: help access repressed is not because the client is
memories, control problematic behaviors diagnosed of schizophrenia
which accompanies DID. Integrate all different because if the client is
personality into one diagnosed with schizophrenia,
and then he feels detached
Adjunctive therapy:therapy that may be used because we can not say that
with other therapies she is has depersonalization
Art therapy: ave shown to help people and at the same time
connect with parts of their mind that they have schizophrenia, rather in that
shut off to cope with the trauma scenario you can only say that
the client is schizophrenic and
NO meds experiencing
depersonalization, not the
Thiopental or other hypnotic drugs disorder but
-to assist them depersonalization.
-given during hypnosis therapy only - For example, it can only be a
Antidepressant dissociative amnesia, if the
- Treat other comorbidities amnesia is not caused by any
- physical or organic reasons, it
DSM-5 Criteria: is always psychological. Same
Depersonalization/Derealization Disorder with depersonalization
A. Persistent or recurrent experiences of disorder, it is not caused by
feeling detached from and as if one is any mental disorder nor it is
an outside observer of, one’s mental caused by any dissociative
processes or body disorder and of course it
- Like for example feeling like should not be caused by any
one is in a dream drugs like hallucinogens since
it can cause the client to
 experience an out of the body ○ World has become unreal
activity and it should not be ■ World appears
caused by any of that for it to strange, peculiar,
be diagnosed by foreign, dream-like
depersonalization or ■ Objects appear at
derealization disorder. times strangely
- diminished in size at
DEPERSONALIZATION/ DEREALIZATION times flat
DISORDER -Perception of
● Perception of self is altered self and the
○ Triggered by stress or environment is altered
traumatic event ■ Incapable of
○ No disturbance in memory experiencing
■ Client experiences no emotions
memory loss - Tend to be
■ Does not appear to apathetic
be forgetful ■ Feeling as if they
○ No psychosis or loss of were dead, lifeless,
memory mere automatons (or
○ Often comorbid with anxiety, robot)
depression ■ Experiences of
○ Typical onset in adolescence unreality of
○ Chronic course surroundings
● Symptoms are not explained by ○ Symptoms are persistent or
substances, another dissociative recurrent
disorder, another psychological ○ Reality testing remains intact
disorder, or a medical condition. ○ Symptoms are not explained
○ Out of the body experience by substance, another
perse without any other dissociative disorder.
mental disorder
○ If it is associated with other ● Phenomenon of depersonalization/
mental disorder then it is not derealization disorder:
depersonalization rather it is ○ Doubling - clients feel
that disorder which is the consciousness is outside the
diagnosis of that disorder that body, a few feet overhead
is the main reason the client ○ Hemi-depersonalization - half
experiences of the body is unreal or does
● Experiences of depersonalization or not exist.
detachment from one’s mental ○ Double orientation - clients
processes as if one is in a dream believe they are in 2 places at
○ Unusual sensory experiences the same time.
■ Limbs feel deformed
or enlarged PATIENTS ARE VERY AWARE OF THEIR
■ Voice sounds different DISTURBED SENSE OF CONSCIOUSNESS
or distant AND YET IT IS BEYOND THEIR CONTROL
○ Feelings of detachment or - Triggered by stress or traumatic
disconnection experience
■ Watching self from
outside Treatment of depersonalization or
■ Floating above one’s derealization disorder
body
● Or experiences of derealization
 ● Treat anxiety with anxiolytics, - Neurological symptoms that
supportive and insight oriented cannot be explained by
therapy medical disease or culturally
● As anxiety is reduced, episodes of sanctioned behavior
depersonalization will decrease as ● Malingering
well. - Intentionally faking
psychological or somatic
For the other treatments, the treatment that I symptoms to gain from those
have mentioned earlier with regards to how symptoms
dissociative identity disorder is dealt with then ● Factitious Disorder
the therapist may also use the same as he or - Falsification of psychological
she sees fit . The treatments that may work or physical symptoms, without
with DID may also work for depersonalization evidence of gains from those
or derealization disorder. symptoms

THIRD VIDEO: SOMATIC ● Criteria for Somatic Symptom Disorder

SYMPTOM-RELATED DISORDER ○ At least one somatic symptom
that is distressing or disrupts
daily life
○ Excessive thoughts, feelings,
● Previously known as Somatoform
or behavior related to somatic
Disorders,
symptoms or health concerns
● now reclassified as Somatic
as indicated by at least one of
Symptom-Related Disorders by the
the following:
DSM-5.
■ Health related anxiety
● All these disorders are brought about
■ Disproportionate
by Psychological conflicts.
concerns about the
DIAGNOSES OF SOMATIC
medical seriousness
SYMPTOM-RELATED DISORDERS
of symptoms
● Somatic Symptom Disorder
■ Excessive time and
- Excessive thought, distress,
energy devoted to
and behavior related to
health concerns
somatic symptoms
○ Lasts for a duration of at least
- Comes from the root word
6 months
“soma” which means body.
○ Specify: Predominant
There are excessive concerns
These manifestations may stretch
of this disorder about physical
widely as aspects that may affect a
symptoms or health. To the
client’s life to a point of interfering with
point of having physical
client’s personal, social, or
symptoms that cannot be
occupational functioning
explained with organic or
physical reasons, which are
● Criteria for Illness Anxiety Disorder
brought by psychological
○ Preoccupation with high level
conflicts, or traumatic,
of anxiety about having or
unresolved issues.
acquiring a serious disease
-
○ Excessive behaviors
● Illness Anxiety Disorder
(checking for serious illness,
- Unwarranted fears about a
seeking reassurance) or
serious illness in the absence
maladaptive avoidance- goes
of any significant somatic
to different doctors or avoids
symptoms
medical care because
● Conversion Disorder
experiencing serious disease
 ○ No more than mild somatic
symptoms are present
○ Not explained by other
psychological disorders
○ Preoccupation lasts at least 6
months
● Manifestation of Conversion
Disorder
○ Sensory or motor function
impaired but no known
neurological cause
■ Vision impairment or
tunnel vision
■ Partial or complete
paralysis of arms or
legs
■ Seizures or
coordination problems
■ Aphonia
● Whispered
speech
■ Anosmia
● Loss of smell
The client will feel these manifestations yet
there are no organic or physical evidence of
why they are feeling the way they do,
ultimately due to psychological costs
● Hippocrates
○ Believed disorder only
occured in women
○ Attributed it to a
wandering uterus
■ Originally
known as
hysteria
■ Greek word
for uterus
● Freud
○ Coined the term
conversion (new term)
○ Anxiety and conflict
converted into
physical symptoms
○ Famous case of Anna
O.
After Frued’s philosophy, the word hysteria
became obsolete and was later changed or
referred to as conversion, as in anxiety and
conflict converted into physical symptoms. In
other words the client does not have any
physical illness at all, rather psychologically
believe they do, caused by unresolved
conflicts which were anxiety and emotional
mental turmoils, which are then manifested
through physical symptoms.
DSM-5 Criteria for Conversion Disorder
● One or more symptoms affecting
voluntary motor or sensory function
● The symptoms are incompatible with
recognized medical disorders (more
psychological in Nature)
● Symptoms cause significant distress
or functional impairment or warrant
medical evaluation
● Onset typically adolescence or early
adulthood
- Often follows life stress
● Prevalence less than 1%
-More common in women than in Men
● Often comorbid with:
-Other somatic symptom disorders
-Major depressive disorder
-Substance use disorders
DSM 5-CRITERIA: FACTITIOUS DISORDER
● Fabrication or induction of physical or
psychological symptoms, injury,or
disease
● Deceptive behavior is present in the
absence of obvious external rewards
● Behavior is not explained by another
psychological disorder
● In factitious Disorder on self, the
person presents himself or herself to
others as ill, impaired or injured
● In factitious disorder imposed on
another, the person fabricated or
induce symptoms in another person
and then presents that person to
others as ill, impaired or injured
Etiology of Somatic Symptoms Disorders:
Neurological Factor (ALL 5 CONDITIONS)
● No support for genetic influence
-Concordance rates in MZ twin pairs
do not differ from DZ twin pairs
-may or may not occur
● Why are some people more aware
and distressed by bodily sensation
 -Anterior insula anterior cingulate
hyperactive
(located in complex cognitive
[ex: empathy, impulse control, emotion
and decision making)---purpose
-hyperactive
-Somatic symptoms influenced by
emotions and stress
Etiology of somatic symptoms disorder
cognitive behavioral factors
Two important cognitive variables:
● attention to bodily sensations
-automatic focus on physical health
cues
-over attention
Very conscious bodily movements or
sensations
● attributions interpretations of those
sensations
-overreact with overly negative
interpretations
Two important consequences
● sick role limits healthy life alternatives
● health seeking behaviour reinforced by
attention or sympathy
- Psychological defense
mechanism
- Visual information of client
from the eye is being
processed unconsciously
- Do not know that they are
visually processing things
Etiology of Somatic Symptoms Disorders:
Social and Cultural Factors
● Decrease in incidence of conversion
disorders since last half of 19th
century
- Higher incidence may have
been due to more repressed
sexual attitudes or low
tolerance for anxiety
symptoms
● More prevalent
-in rural areas (countryside or
province)
-in individuals of lower SES (socio
economic society)
-in non-western cultures

Examples: malingering your practices disorder Treatment of Somatic Symptoms Disorders

they would show the specific symptoms to get ● Few controlled treatment outcome
secondary gains which is the assumption of studies
the sick role wherein they will no longer be - No evidenced based
excuse of their responsibilities and not be held guidelines
accountable. - Just relies on anecdotes or
Secondary gain which is attention or sympathy case report
that they get because of course if you assume ● Cognitive behavioral treatment
the sick role, attention and affection will be - Identify and change triggering
gained. emotions
- Change cognitions about
Primary - excused from responsibilities symptoms
Secondary- reinforced attention for sympathy - Replace sick role behaviors
with more appropriate social
interactions
- Done through:
Etiology of Conversion Disorder: - Talk therapy
Psychodynamic Perspective - Individual therapy
● Unconscious psychological factor - Make positive adaptive and
cause coping skills and the client will
● blindsight change for his or her thought
- Not consciously aware of regarding the symptoms
visual input Antidepressants
- Failure to be explicitly aware - Tofranil
of sensory information
 - Effective even at low dosages that do
not alleviate depressive symptoms
- Use some anti-depressants
specifically you’re tougher
now and given in low dosages
that may not alleviate only
depressive symptoms
because the client here is not
really depressed just to
manage their anxiety behavior
anxious behavior rather and to
better make them susceptible
to the therapies that they will
then engage themselves
BPD Results on the individuals demonstration
of at least Five our a possible nine behaviors:
● Frantic efforts to avoid abandonment
● Unstable and intense rela
● Identity disturbance
● Impulsivity in areas such as sexuality,
spending; or reckless driving
● Recurrent suicidal behavior
● Affective instability
● Chronic feelings of emptiness
● Difficulty controlling anger
● Occasional feelings of paranoia or
dissociative symptoms
- Concerned with their physical
appearance, try to draw attention to
themselves; behavior seems ludicrous
- Flirtatious and seductive
- Demand reassurance and
praise
- Need for gratification
- Easily influenced by others
and lack analytical ability
- Tend to form superficial
relationships
- Feeling bestfriend tanan tao
lol
Narcissistic Personality Disorder
- Unrealistic sense of self-importance
and lack of sensitivity to other people’s
needs
- Lack of empathy and need for
admiration
-

Splitting: a defense, as being all good or

bad, usually resulting in disturbed
interpersonal relationships.

Emotional dysregulation:
- Lack of awareness, understanding, or
acceptance of emotions
- Inability to control the intensity or
duration of emotions
- Unwillingness to experience emotional
distress as an aspect of pursuing
goals
- Inability to engage in goal directed
behaviors when experiencing distress

Histrionic Personality Disorder

- Attention seeking behavior
- Exaggerated emotional reactions,
approaching theatrically
- Extreme pleasure as the center of
attention and makes sure this happens
 START: 00:00 - complete or almost complete absence of outward
NASNIN emotional expression
-
3. Restricted
Mood Disorders - reduction in the intensity of outward emotional
- Disturbances in regulation of mood, behavior and affect expression
that go beyond the normal fluctuations that most people 4. Inappropriate
experience - affect that does not match the situation or the
content of verbalized message
-May cause somatic (physical) symptoms that may be - Example naa ga joke, siya ni hilak or nag frown
mistaken of physical illness 5. Labile
- May neglect self-care because of lowered motivation and - rapid and easily changing affective expression
energy levels that’s unrelated to extend event or stimuli
- May alter family and social relationships, leading to - Mood swings
frustrations anger and guilt; consequently, the patient may - Easily changes from one to another
be the victim or perpetrator of abuse (does not follow all - Happy to sad again
time)
- Viewed as social or moral problems rather than medical CAUSES:
health problems that are appropriate to discuss with 1. Genetics
healthcare providers ● play a major roles in mood disorders
- Seriously depressed may be at risk of suicide ● Major depressive disorder and bipolar disorders
-- still in touch with reality and primary unlike occur much more often in first degree relatives
schizophrenia where they show manifestation of than they do no in general population
hallucination and illusions ● Familial predisposition
-bipolar --- show schizo-affective features (mood disorder ● Great chance if first degree
and signs of schizophrenia ) ● Unfair disadvantage
- primary concern: something wrong with their mood
-mood swings--- natural 2. Biological
- disturbance which go beyond mood swings ● focuses on deficiencies and abnormalities in the
-affects the affect brain’s chemical messengers --- neurotransmitters
- such as norepinephrine, serotonin, dopamine and
acetylcholine
Classification ● the effectiveness of drug therapy that affects
1. Bipolar disorder neurotransmitter levels support the theory that
2. Cyclothymic disorder mood disorders have biological roots
3. Dysthymic disorder ● Drugs given balanced the chemical messenger
4. Major depressive disorder abnormalities/deficient

Clients may exhibit various abnormalities in affect 3. Psychological Theories

(outward expression of emotion attached to ideas, ● Cognitive theory
including but not limited to facial expression and vocal - suggests that people who suffer from
modulation) depression process information in a
characteristically negative way
Affect - Each individual have different
1. Blunted way of processing things or
- severe reduction in the intensity of outward emotions or situations
emotional expression - We have different perspectives
- Below what is the normal expect expression then it has been shown that
- Example: really funny and everyone laughs hard clients who have diagnosed with
but client just smile a bit lower than normal depression tend to be pessimistic
expression elicited and tend to look at things in a
2. Flat- negative lens rather than positive
 when something does not go their
way. Always a bad thing for them
if it does not go in there away
- As long as it affects their
emotions in such a way that they
will have negative feelings they
will process it as negative
- Patients view themselves and the world in
a negative way
- Believe in their cognitive distortions will
continue in the future
- These clients who can’t see a silver lining
in this bad situation are the one prone to
depression
● Behavioral theory
- explain mood disorders in terms of learned
helplessness and depression develop from his
experiences with negatively perceived events
(such as loved one’s death or a job loss)
- depression develop from his experiences with
negatively perceived events
- example: client naturally happy suddenly a loved
one died, major authority attached to her/him
because of that they have already viewed in a
negative manner.
● Psychoanalytic theory
- depression results from a harsh superego (the
“consciences” of the unconscious mind) and
feeling loss of aggressions
- Freud (Id, Ego, Superego)
- Ego decides what will prevail whether id or
superego
- What ego decides, superego will see it as harsh
- their mood is affected.
***susceptibility to depression later in life if a child
experiences early losses
-Individuals who are unforgiving taking
themselves in a high standard, when they make
mistakes, they have this harsh superego that will
make them overthink guilty
***loss interpreted by child as a form of rejection
and sign he is unworthy if love
***feelings pushed out of awareness and turned
inside (against himself ) resulting in depression
-continous voice that he is not good enough (from
harsh superego who wants things to be perfect
and straight)
-harsh superego - continually bother the
individuals
END (1530 NASNIN)
START (1531 ELLA)
Bipolar disorder
- Also called manic depressive disorders
- Severe frequent pathologic mood swings
- It is not just ordinary mood swings
- Patient experiences highs (mania or hypomania)
alternating with extreme lows (depression);
interspersed between highs and lows are periods
of normal mood
- Hypomania then madepress
nasad then in between those
periods interspersed highs and
lows in a normal mood
- Mood swing usually occurs across the patient’s
lifespan, with symptom-free periods between
episodes
- Clients with bipolar look normal
you will never even see them act
it out until you see them be in
their manic mood at the same
time in their depressive mood but
their highs are really high and
their low are bad as well to the
point that they may not be able to
get out of their bed because they
are so depressed
- These clients unlike
schizophrenia, they do not show
delusions or hallucinations. They
do not even have problems with
their motor behaviors or display
catatonia for example. Basically,
they are just normal, it is just that
- Variations in the highs and lows can occur (for
instance, some people experience only acute
episodes of mania or hypomania with severe
depression)
- Men and women are affected equally
- Women likely to have more depressive episodes;
men: more manic episodes
- Onset usually occurs between ages 20-30 years
old
- Symptoms sometimes appearing in late childhood
or early adolescence
- It may appear as early as late childhood
or early adolescence but may not be
readily diagnosed as it may be likened to
a physical illness.
- In bipolar, there is mania which is characterized
by 1 week of incessantly heightened episodes of
elation, grandiose, or agitated mood with 3 or
more of the following:
- Euphoria agitation or irritability
- Hyperexcitability
- Rapid thought and speech
- Flight of ideas
- Exaggerated sexuality and self-esteem
- Decreased sleep
- In severe bipolar disorder they may show
schizoaffective disorders like
- Delusions and hallucinations
- Not like that all the time for clients
with bipolar only those with
severe and showing with
schizoaffective features
- Multiple grandiose
- High risk activities involving poor
judgement and severe consequences.
- I remember before when I was
assigned in sotto their behavioral
sciences, their psychiatric ward. I
have talked to one with bipolar
disorders in their normal mood
and they would say that if i ask
tem do you know the reason that
you are here? Then they will say
kanang yes mam. They are
diagnosed with bipolar disorder
and what they do is for that
specific individual, she would
always sing in karaoke ba whole
day until kadlawn gipangbato na
gud siya ug silingan if badlungon
masuko, she becomes irritable.
Ofcourse, that client has been in
and out of the psychiatric ward
and from there gipadala nlng jud
siya ngadto kay wa man jud siyay
undang and she can’t sleep. Kay
di siya katud so mag videoke
siya, and in videoke she will sing
her heart out in a very loud voice
in the middle of the night that is
how usually clients with manic
episodes portray.
- Impulsive behavior during manic episode
have far-reaching emotional, physical and
social consequences
- Divorce, child abuse, joblessness,
accidents, physical
decompensation and bankruptcy
- It may affect the
relationship already
because they would
engage in irrational
patterns of behavior or
they will just go on a
shopping spree and max
out their credit card and
buy the same design of
dress but different shirt or
color. Some individuals
do that.
- Other individuals in manic
disorder while they are
mnia they will go on
shopping spree buying
just whatever they want
and sometimes it will
come in one episode and
in other episodes mu palit
napud siya more or less
the same and it is out of
control. These clients use
credit cards not thinking
the repercussions of
paying it and lead the
client to joblessness and
bankruptcy
- Some Instances mania
clients will be extremely
harsh to their child which
may lead to abuse
- Promiscuity- STD, unwanted
pregnancies
- Other instance with
bipolar disorder exhibiting
mania will engage in sex
spree
- sEx with anyone
- Pataka ug have sex with
someone that is why they
may get STD or
unwanted preganacies
for women
- Hyperactivity and sleep
disturbances- exhaustion, poor
nutrition and dehydration
- Whent hey are too
hyperactive they do not
 eat anymore so provide
them finger foods
- Suicide- may occur impulsively
during either manic or depressive
episode
- If they get overwhelmed
by their situation they
may think of getting their
own life.
- Hypomania expansive, elevated or
agitated mood that resembles mania but
is less intense and lacks psychotic
symptoms
- Without proper treatment, hypomania may
progress to severe mania or change in
depression
- Severe episodes of mania or depression
can sometimes involve psychotic
symptoms
- Hallucinations
- Delusions
- May result in misdiagnosis of
schizophrenia
BIPOLAR 1
- classic and most severe form
- Characterized by manic episodes or mixed
episodes (with symptoms of both mania and
depression) that alternate with major depressive
episodes
- Occurrence of depressive phase immediately
before and after manic phase; may also be
separated from manic phase by months or years
- It depends but when client is in manic
phase the client is hyperactive, high levels
of irritability, always going around all over
the place but then when client shift to
depressed period that is the time the
client will only be seen in the room with
typical signs of depression
BIPOLAR II
- milder episodes of hypomania that alternate with
depressive episodes
CYCLOTHYMIC DISORDER
- History of numerous hypomanic episodes
intermingled with numerous depressive episodes
that don’t meet criteria for major depressive
episodes
RAPID CYCLING BIPOLAR DISORDER
- Variant form of the disease
- Affects up to 20% of all patients diagnosed with
bipolar disorder (mostly women)
- Characterized by four or more distinct episodes of
depression, mania, hypomania, or mixed stated
occurring within a 12-month period: periods of
normal mood are typically brief (sometimes
absent)
- Tends to develop later in the course of illness
- Generally, the more rapid the cycling the more
numerous the mood swings
- In some patients. Multiple illness episodes within
a single week; in some ultra rapid cyclers, several
mood swings in a single day.
- Ingon ana ka daghan mood swings nya
kapoyan na sila. These clients when they
go back to normal mood and then from
normal mood madepress that is when
they will think ing’ani diay ko noh? The
inconvenience that i have caused. So
they really need help and there should be
no stigma to it.
- Experts believe that any bipolar patient can switch
to a rapid cycling pattern but most return to their
normal bipolar pattern in time.
- Causes of Rapid Cycling Bipolar Disorder
- Precise cause unknown; genetic,
biochemical and psychological factors
probably play a role
- Genetic component strongly suggested by
twin, family studies
- Genetic predisposition play a
primary role
- Higher incidence (about seven times
more likely to develop the disorder)
among first-degree relatives of person
with bipolar disorder than in the general
population.
- Autosomal-dominant in affected families
- Probably stems in part from
neurotransmitter abnormalities or
imbalances, possibly involving sensitivity
of receptors on nerve cells.
- In predisposed individuals, episodes are
possibly triggered by stressful life events
(serious loss, physical illness, financial
problems)
- Their trigger, for clients it is
possible, because the symptoms
may early come out in the early
childhood or early adolescence
 then it is possible that the thing
that triggers it is a specific
circumstance in their life which
may have caused them to really
get into the darker side of
themselves. It may be a serious
loss, physical illness or financial
problems.
- I remember before I had this
friend that was introduced to me
by a friend cause they were like
highschool friends man and then
for some reason we saw each
other kay she is into business
man and we got into a business
place. So my friend, my colleague
introduced her to me nag chika2
ra siya she is actually very pretty
woman she's already married and
then suddenly wala na sya sa
iyang place of business ni hunong
sya na hibung mi for some reason
and my friend actually told me
that she was diagnosed with even
admitted for bipolar disorder, you
can never tell and then she said
nawagtang sya because of that
and the trigger that her father
died and had some financial
issues
Other possible triggers:
- Use of antidepressants drugs to treat depression
(may cause a switch to mania)
- Sleep deprivation
- Hypothyroidism
Signs and symptoms:
Manic phase
● Expansive, grandiose, or hyperirritable mood
● Increased psychomotor activity, such as agitation,
pacing, or hand wringing
● Excessive social extroversion (social butterfly)
● Rapid speech with frequent topic changes
○ Murag gi gukod mo sturya
● Decreased need for sleep and food
● Impulsivity
● Impaired judgement
Depressive phase
● Low self esteem
● Overwhelming inertia
● Social withdrawal
● Feelings of hopelessness, apathy, or self reproach
● Difficulty concentrating or thinking clearly (without
obvious disorientation or intellectual impairment)
● Psychomotor retardation
○ Slows down or becomes sluggish
● Anhedonia
○ Does not feel pleasure in usually
pleasurable things
● Suicidal ideation
Treatment
Drug of choice for Bipolar
Lithium (eskalith)
● Highly effective in both preventing and relieving
manic episode; curbs accelerated thought
process and hyperactive behavior without
sedating effect of antipsychotic drugs
● May prevent recurrence of depressive episodes,
but ineffective for treatment of acute depression
● Effectively decreases the risk of suicide
● Has narrow margin of safety and small
therapeutic window for efficacy; requires
beginning treatment cautiously with a low dose
(adjusted slowly as needed) because of possible
toxicity
● Requires frequent blood specimens to determine
therapeutic levels, must maintain therapeutic
blood levels for 7 to 10 days before desired
mood stability occurs- at start of therapy,
possible use of antipsychotic drugs for mood
stabilization and symptom relief until desired
effects are achieved
○ For clients in manic episodes for them to
calm them down they may be given a
mood stabilizer which is your lithium, may
also be given antipsychotic drug
especially those with bipolar ones in
which they already show schizoaffective
features
Valproic Acid (depakote)- second line of choice
● May be prescribed for rapid cyclers or for patients
who can not tolerate lithium
● Check for baseline and ongoing liver function
tests, serum ammonia levels and platelets, and
bleeding times
● An antiseizure drug but also acts as a mood
stabilizer
Carbamazepine (tegretol)
 ● May be useful in treating mania, although not ● Ataxia
approved by food and drug administration for ● Tremors
bipolar disorder
● Baseline and periodic lab testing must be done to Nursing Interventions
monitor for suppression of WBC Manic phase:
○ Low WBC high risk for infection ● Provide for the patients dietary needs
○ Give High calorie finger foods
Antidepressants ● Assist the patient with personal hygiene
● Usually prescribed to augment a mood stabilizer ● Involve the patient in activities that require gross
● Occasionally prescribed to treat depressive motor movements, maintain a calm environment,
symptoms and protect him from overstimulation
● Must be used cautiously; may trigger a manic ● Promote rest- suggest short daytime naps
episode ● Provide diversionary activities suited to a short
● They are typically attached to reality except for attention span
those with schizoaffective features but then there
are medication are very tricky so have a constant DATS IS DONE START AT 44:30
check up on psychiatrist cos if gaan
antidepressant it may trigger a manic episode if ● Provide diversionary activities suited to a
not used cautiously short attention span
○ Do not let them engage in chess
Other meds: Lamotrigine (lamictal), olanzapine (zyprexa) games
○ Only short attention span
Guidelines for patients on lithium therapy
● Provide emotional support and set realistic
● Blood levels should be checked 8 to 12 hours
after first dose, two or three times weekly for first goals for behavior
month, then weekly to monthly during ● In a calm, clear, self-confident manner,
maintenance therapy establish limits for the patients
● Instruct patient to maintain fluid intake of 10 to 13 demanding, hyperactive, manipulative
oz glasses (2,500 to 3,000 ml)/ day and acting out behaviors.
● 0.6- 1.2 meq normal for lithium ○ Manipulative: firm and matter of
● Teach patient that lithium can cause sodium fact attitude
depletion ○ Do not be silent
○ Dats y u drink water cos where water ● Avoid reinforcing socially inappropriate or
goes sodium follows and to prevent
suggestive comments and tactfully divert
lithium toxicity
conversations that become intimately
● Inform patient that increasing salt intake may
increase lithium excretion involved with other patients or staff.
● Teach patient and family to watch for evidence of ○ Because they may come out
lithium toxicity sexually preoccupied because
● Advise patient to take lithium with food or after they are presumptuous
meals ● Do not let an opening for the patient to
● Caution patient against driving or operating test or argue with you
dangerous equipment ○ Have locus of control
● Includes listening to requests attentively
Lithium toxicity: S/S and with a neutral attitude, but avoiding
● Abdominal cramps
power struggles if the patient pressures
● Frequent urination
for an immediate answer
● Diarrhea
● Vomiting
○ You have to learn to deal with
● Drowsiness them because they will
● Unsteadiness manipulate you
● Muscle weakness ● Watch for early signs of frustration- when
 the patients anger escalates from verbal
threats to hitting (An object or person)
certain actions may be necessary)
● Alert the healthcare team promptly when
acting-out behavior escalates
● When acting out- incident ends and then
patient is calm and in control, discuss his
feelings with him and offer suggestions to
prevent recurrence
● Collaborate with other staff members to
provide consistent responses to the
clients manipulations or acting out
behaviors
● Anticipate the need for excessive
verbalizations
● Channel clients need for movement in
socially acceptable motor activities.
● Promote safety
● Remind the client on the importance of.
medication compliance and the need for
ongoing laboratory values
○ Because patient is non
compliance to their drugs then
readmitted
● Set limits on clients behavior
● Remind the client to respect distance
between self and others
DEPRESSIVE EPISODE
● Provide the patient’s physical needs; if he’s too
depressed to care for himself, help him with
personal hygiene
○ Facilitate in conducting personal hygienes
● Encourage him to eat to feed him if necessary
○ Feeding is excepted bc some do not eat
● If the patient is constipated , add high fiber foods
to his diet ; offer small, frequent meals and fluids
and encourage physical activity
○ Bc they are depressed and they dont
want to move
● Help the patient sleep by giving back rubs or
warm milk at bedtime
○ Back rubs depende sbc they might
mistake it as something more
● Provide continual positive reinforcement to help
build self-esteem- maintaining a structured
routine, including activities to boost confidence
and promote interaction with others (group
therapy)
○ Engage clients in a group therapy with
same conditions in order for the client tp
feel they are not alone and have support
● Avoid overwhelming the patient
● Take measures to prevent the patient from
self-injury and prevent suicide
○ Ask your client if they have suicidal
thoughts bc when they have the energy
they might complete the task i
○ Process
○ Engage them in no harm contract
■ A type of contract between nurse
and pt wherein pt should not
harm himself
■ If they feel the urge, tell them to
call someone they can talk to so
as nurse give them family
members or your work numbers
■ No harm policy
● Not guarantee they will
not harm their self
● Remove harmful objects (glass, belts, shelves,
rope,bobby pins) from the pts environment
○ Depressed clients are very creative in
measures to kill their self
● Closely observing and strictly supervising
medications
- Ask client to open mouth and lift tongue
up and down and check cheek
- Hoards medication and takes them all at
once
● Suicide precautions
- Be watchful and stay close to the client
even when going to CR
● Remove harmful objects (such as glass, belts,
shelves, rope and bobby pins ) from the
environment
● Always taking suicidal thoughts, gestures or plans
seriously
● Teach patient the importance of continuing bfgfb
Hhded
CYCLOTHYMIC DISORDER
- Short periods of mild depression alternating short
perioids of hypomania
- Jasd
- Between depressive and manic episodes
Common cause: genetics Treatment:
Group therapy
Signs and SYmptoms Short time psychotherapy
● Inability to maintain enthusiasm for new projects Behavioral therapy
● Odd, eccentric or suspicious personality Antidepressants such as SSRIs or TCAs especially for
● Dramatic, erratic or antisocial; patient who exhibit pessimism
Hypomania phase
- Increased productivity Nursing Interventions:
- Grandiosity ● Teach patient about the illness
- Insomnia ● Encourage positive health habits
- Hyperactivity and physical restlessness ● Provide supportive measures such as
- Irritabilit or aggressiveness reassurance, warmth, availability, and acceptance

Depressive phase MAJOR DEPRESSIVE DISORDER

- Insomnia or hypersomnia ●Incidence increases with age
- Lethargy ●Aka. Unipolar major depression
- Suicidal ideation ●Accompanying problems:
- Feelings of inadequacy - Thoughts of death
- Decreased productivity - Loss of mood reactivity
- Social withdraw - Anhedonia : inability to feel pleasure to
things you consider pleasurable
Treatment : - Feelings of guilt , helplessness or
Pharmacological optionS: hopelessness
- Lithium - Poor concentration
Other therapies: - Sleep disturbances
● Individual therapy- - Lethargy
● Couple or family therapy to help patient deal with - Appetite loss or weight gain
relationship problem Causes:
- Porrbible involebemt of serotingn, neuroendocrine
Explore ways to help the patient cope with frequent mood and hypothalamic potuire
changes - Genetic biochemical, physical, psychological and
Encourage vocational opportunities that allow social factors
Encourage patient with artistic - Possibly drugs prescribed for certain medical and
psychiatric conditions such as hypertensives,
DYSTHYMIC DISORDER psychotropics, antiparkinson drugs, opioids, and
- Aka dysthymia nonopioid analgesic steroids
Mild depression at least 2 years
Twice as common in women S/S
More prevalent among poor and unmarried ● Poor coping
● Low self esteem
Causes: ● Feeling down in the dumps
-below normal serotonin levels ● Increase or decreased appetite
Increased vulnerability when ● Sleep
● Constipation or diarrhea
s/s ● Suicidal thoughts
Reduced energy level ● Possible worsening of symptoms in morning
Sleep difficulties ● Clues related to suicidal thoughts a preoccupation
Weight or appetite changes with death or previous suicide attempts.
Persistently sadm anxious or empty mood Treatment
Excessive crying -ECT
Increase feelings of guilt, helplessness, or hopelessness Antidepressant
 1. SSRI
- First line treatment
- Inhibit serotonin reuptake; may inhibit
reuptake of other neurotransmitters
2. TCA’S
- Older class of antidepressant
- Inhibit reuptake of norepinephrine,
serotonin and dopamine
- Cause intolerable adverse effects; not
used first-line , not given with MAOIs and
not used among the elderlies
- Contraindicated : impaired liver and renal
function, MI, DM, Respiratory problems
- Has a lag period of 10-14 days before it
reaches a therapeutic level to alter
symptoms, 6 weeks to take full effect, 1-4
weeks before steady plasma levels are
reached and symptoms begin to decrease
4. MAO inhibitors
- Examples: phenelzine, tranylcypromine
- Increases norepinephrine, serotonin and
dopamine levels by inhibiting MAO
- May have actions that contribute
- Hardly used because ebay cause toxicity
with food substances
- Conservative doses may be combined
with TCA
Pharmacologic options
- TCAs : Amitriptyline , imipramine
,....
- Mao inhibitor:isocarboxazid
- SSRI: Fluoxetine
- - Putting affairs in order
- - Describing a suicide plan
NUrsing Considers:
- Administer SSRIn in the morning with/ot food
- Monitor liver function
- Avoid alcohol
- Monitor serum drug levels of lithium
- Monitor blood pressure every 2 - 4 hours during
initial therapy with MAO inhibitor
- Asses patient taking
- Advice patient taking an SSR to avoid alcohol
- Monitor serum drug levels of lithium
ECT
- Given a series 6-15 times 3 times a week
- Patient is at immediate risk for suicide
- Uses poses of lower risk than other treatments
- Used to treat severe depression
- Its use poses a lower risk than other treatments
Nursing interventions for patients with MDD:
- Provide for patient’s physical needs
- Plan activities for times when patient’s energy
level peaks
- Assume active role in initiating communication
- Assume active role in initiating communication
- Avoid feigned cheerfulness
- Ask pateitnt whether he think about death or
suicide
- Be aware that theres a higher risk of suicide with
lifting of depressed mood
- Know that suicidal thoughts signal immediate
need for consultation and assessment
- For patients taking antidepressants, stress need
for compliance and review adverse reactions
- For patients taking drugs that produce strong
anticholinergic effects, suggest using sugarless
gum or hard candy to relieve dry mouth
- Caution patient taking a sedating antidepressant
to avoid activities that require alertness
- For patient taking a MAO inhibitor,bdaiubfsibf
- Caution patient taking a TCd and SSR to avoid
alcohol beverages or other CNS depressant
-
S/s of suicide potential
- Overwhelming anxiety
- Withdrawal and social isolation
- Saying farewell to friends and family
- Expressive obvious suicidal thoughts
- Sending covert suicide messages
- Hoarding medications
- Talking about death
- Behavior changes
Foods to avoid with MAO:
- Aged cheese
- Avocado
- Bananas
- Beer
- Chocolates
- Coffee
- Fava beans
- Liver
- Raisins
- Cherry
 - Sour cream 2. Hallucinations
- Yoghurt - Without stimulis hear, see or
feel things
3. Disorganized speech
4. Disorganized (catatonic) behavior
5. Negative symptoms (diminished
motivation or emotional expression)
● Other 1 or 2 more can any be of the five
PRE-RECORDED NOTES ● Delusion, hallucination and disorganized
SCHIZOPHRENIA speech has to be one of the symptoms client
● Major disturbances in thought, emotion and will show
behavior ● Functioning in work, relationships, or
● Disorder thinking self-care has declined since onset
- Leads not logically related - Affects different aspects in life to
- Faulty perception and attention consider it as disorder
- Ideas are illogical ● Signs of disorder for at least 6 months; if
- Jibberish or irrational during a prodromal or residual phase,
- Cannot be understood negative symptoms or two or more symptoms
● Lack of emotional expressiveness 1-4 in less severe form
- Inappropriate or flat emotions
- Apathetic Clinical Description of Schizophrenia
● Disturbances in movement or behaviors
Summary of Major Symptom Domain in
- Disheveled appearance Schizophrenia
- Hygienic routine are unattended to
● Disrupt interpersonal relationships, diminish Positive Negative Disorganized
capacity to work or live independently Symptoms Symptoms Symptoms
● Increased rates of suicide and death -Beyond
● Causes distorted and bizarre thoughts which normal
-above normal
affects the perception, movement and -symptom
behavior of an individual additionally
● Not define just a single illness seen on clients
● A SYNDROME- collection of s/s -Normal client
● Lifetime prevalence ~ 1% won’t feel or
● Affects men slightly more often than women see
● Onset typically late adolescence or early Delusions -It is Avolition Disorganized
adulthood an extra Alogia behavior
-men diagnosed at a slightly earlier age additional Anhedonia Disorganized
● Diagnosed more frequently in african manifestation Blunted affect speech
americans associality
- Reflect diagnostic bias Hallucinations

DSM-5 Criteria for Schizophrenia

● Two or more of the following symptoms for at - If the positive symptoms actually composed
least 1 month; one symptom should be either of an additional manifestation which may be
1,2, or 3 : seen in a client with schizophrenia but not in
1. Delusions normal individual, in negative symptoms
- False fix belief these are actually like the manifestations that
 are rather decreased or are rather ina client
but it is decreased or reduced as the word it
connotes “negative” meaning reduced,
decreased manifestation of such normal
activities.
- Lastly, the third major cluster of symptoms-
Disorganized symptoms .
Positive Symptoms: Behavioral Excess and
Distortions
● Delusions
○ Firmly held beliefs
○ Contrary to reality
■ No matter how you tell him or
her that it is not true they
would insist and stick to what
they think is right or wrong
○ Resistant to disconfirming evidence
■ Even if you show them that
what they believe is not true
they will still not conform to it
and stick to what they believe
in
● Types of delusions:
○ Persecutory delusions
■ Most common in
schizophrenia
■ “The CIA planted a listening
device in my head”
■ 65% have these
○ Thought insertion
■ They have that belief that
anyone can just insert their
thoughts, ideas in their thought
○ Thought broadcasting
■ In opposite to thought
insertion, they also believe
that ideas have the capacity of
being broadcasted
■ Clients with schizophrenia
would just example sit here or
stand in a room and he or she
think his thoughts are being
broadcasted among other
people in the room which may
cause her to show signs of
paranoia if not, persecutory
delusions
○ Outside control
■ They have this belief that they
have outside control of things
○ Grandiose delusions
■ they have this grandiose
delusion that they are usually
connected with height, military
connection or if not with the
president or if not with CIA or
anyone who is in authority
○ Ideas of reference
■ They think everything they see
on tv or what they hear on
radio is referring to them
● Hallucinations
○ Sensory experiences in the absence
of sensory stimulation
■ There is no external stimulus
or stimuli here yet they still see
things, hear things, smell
things and so on and so forth.
● Types of hallucinations
○ Auditory
■ 74% gave this symptom
■ Most common hallucination
that occurs in most
schizophrenic patients.
■ Their hallucination would give
them commands either to
harm someone or to kill
someone
■ Called command hallucination
because the voice that they
hear usually tell them to harem
someone
○ Visual
■ They usually see things that
are not there
○ Hearing voices
■ Increased levels of activity in
Broca’s area during
hallucinations
■ Broca’s area is involved in
speech
Negative Symptoms: Behavioral Deficits
- Things that are normally there but reduced in
clients with schizophrenia
● Avolition
○ Lack of interest; apathy
○ There is indifference
○ They do not care, because they are
so caught up in their own world
● Asociality
○ Inability to form close personal
relationships
○ This can be attributed due to their
bizarre thought, perceptions,
emotions, movement and behavior
○ The reason for that is they tend to
hear things and see things that are
not there and a normal individual
would be appalled by that or even be
turned off by that
● Anhendonia
● When clients with Anhendonia do the things
that usually give pleasure to them, they no
longer feel pleasure
○ Inability to experience pleasure
■ Consummatory pleasure
They cannot have that
feeling of satisfaction which
is complete when they do
things which usually gives
them pleasure
■ Anticipatory pleasure
They cannot be excited on
things that usually make
them excited
For us, when we have a
vacation, we like that, so we
anticipate the pleasure
● Blunted affect
○ Exhibits little or no affect in face or
voice
● Alogia
○ Reduction in speech
● Can be grouped into 2 domains:
All the domains for clients with
schizophrenia are affected, which is also
the reason why they are not able to form
interpersonal or meaningful relationships
○ Experience domain
■ Motivation
■ Emotional experience
■ Sociality
○ Expression domain
■ Outward expression of
emotion
■ Vocalization
Disorganized Symptoms
● Disorganized speech (formal thought
disorder)
Their speech don’t make sense, they’re
gibberish. They say things, but then it’s
illogical
○ Incoherence
■ Inability to organize ideas
○ Loose associations (derailment)
■ Rambles, difficulty sticking
to one topic
Tend to be derailed about
certain topics and then jump
to another topic and ramble
on specific topics which are
not necessarily connected
to each other. They would
either use “word salad”
meaning different words
with no connection with
each other and sometimes,
they rhyme. They use words
that rhyme with no
connections to each other.
They have difficulty sticking
to one topic
○ Disorganized behavior
■ Odd or peculiar behavior
● Silliness, agitation,
unusual dress
○ E.g., wearing
several heavy
 coats in hot
weather
Movement Symptoms
● Catatonia
○ Motor abnormalities
○ Repetitive, complex gestures
■ Usually of the fingers or
hands
○ Excitable, wild flailing of limbs
They rock their legs all the time
● Catatonic immobility
○ Maintain unusual poster for long
periods of time
■ E.g., stand on one leg for a
long period of time,
unmoved
● Waxy flexibility
○ Limbs can be manipulated and
posed by another person
For example, if someone will
actually get your arm and then
throw it in the air, it will go back
down, but with waxy flexibility, if
you bring his arm on the air, it will
just stay there on the air, unless
you move it on a different position
Other Psychotic Disorders
● Schizophreniform Disorder
○ Same symptoms as schizophrenia
○ Symptom duration greater than 1
month but less than 6 months
○ Symptoms must include either
hallucinations, delusions, or
disorganized speech
It doesn’t mean that if the client
would show, for example,
hallucinations, delusions or
disorganized speech, it’s right
away categorized or client is right
away diagnosed with
schizophrenia
You have to also, according to
DSM-V, look into how many
months or the duration in which
these specific symptoms would
occur, so if it only lasts for more
than a month, but less than 6
months, it’s not schizophrenia, but
rather, Scizophreniform Disorder,
but it tells us that, maybe for the
next trigger, it may progress to
schizophrenia that’s why all efforts
should be made to try to find out
the triggers, to try to get the client
into therapy and get the client
his/her support system so that it
will not progress
● Brief Psychotic Disorder
○ Symptom duration of 1 day to 1
month
○ Often triggered by extreme stress,
such as bereavement
○ Symptoms must include either
hallucinations, delusions, or
disorganized speech
● Schizoaffective Disorder
○ Symptoms of both schizophrenia
and either a depressive or manic
episode
This specific disorder actually
shows the manifestations or the
features of schizophrenia as
discussed earlier and
manifestations of either a
depressive or manic episode, in
other words, bipolar
○ Symptoms of a major mood
episode are present for a majority
of the duration the illness
● Delusional Disorder
○ Delusions may include:
■ Persecution
■ Jealousy
■ Being followed
■ Erotomania
 ● Loved by a famous
person
■ Somatic delusions
○ No other symptoms of
schizophrenia It only shows
delusion
Table 9.2
Family and Twin Genetic Studies
● This is the summary of major family and
twin studies of the genetics of
schizophrenia.
● You can see, if you have a spouse who’s
schizophrenic, there’s only 1% chance
that you would also get the mental
disorder, if you have grandchildren, that’s
2.84% chance.
● If you have nieces or nephews, you have
2.65% chance.
● If you have children who are diagnosed
with schizophrenia, then 9.35% chance of
also getting the mental disorder or illness.
● If you have siblings with schizophrenia,
it’s 7.30% chance. Dizygotic twins (occurs
when 2 eggs are released at a single
ovulation and are fertilized by 2 different
sperm, these 2 fertilized eggs then
implant independently in the uterus, so in
other words, DZ twins are actually uro?
Fraternal twins) If you have a fraternal
twin who has schizophrenia, then you
have a 12.08% chance of also getting the
mental illness of the disease.
● Another is identical twins, so here, it is
developed when 1 egg is fertilized by a
single sperm, and during the 1st 2 weeks
of conception, the developing embryo
splits into 2. As a result, 2 genetically
identical babies develop, so your identical
or monozygotic who’s diagnosed with
schizophrenia, your chance of getting
schizophrenia is 44.30%
● If you have any of that related to you,
then you have more chances of getting
the disease, but it is not absolute. It did
not even reach 50%, so it is not
absolutely sure that you’ll get the
disease. You can adjust your environment
to reduce your susceptibility to that illness
because schizophrenia, as in any other
diseases, or illnesses, may it be medical
or psychiatric, is both nature (genetically
predisposed) and nurture (environment
and lifestyle)
TABLE 9.3: CHARACTERISTICS OF ADOPTED
OFFSPRING OF MOTHERS WITH
SCHIZOPHRENIA
- So here you have the characteristics of
adopted offsprings of mothers with
Schizophrenia
- If you have both parents with
schizophrenia, you have 27.3% chance
- One parent with schizophrenia, it’s 7.0%
- If you have no parent with schizophrenia,
you still have a 0.86% chance
 - If you have one parent with schizophrenia
and one parent with bipolar disorder, then
you have 15.6% chance
ETIOLOGY OF SCHIZOPHRENIA:
A. GENETIC FACTORS
- Genetically heterogenous
- Not likely that disorder caused by
single gene
- This specific illness or mental
disorder is not likely caused by a
single gene
- Family studies
- Relatives at increased risk
- Negative symptoms have stronger
genetic component
- If you have relatives who have
schizophrenia, then you have a
higher risk
- Twin studies
- 44% risk for MZ twins vs 12% risk
for DZ twins
- Children of non-schizophrenic MZ
twin were more likely to develop
schizophrenia (9.4% vs 1% in
general population)
MONOZYGOTIC = MZ | DIZYGOTIC = DZ
- Adoption studies
- Increased likelihood of developing
psychotic disorders if you’re being
adopted or if you’re adopted by
schizophrenic parents or if with
siblings who have schizophrenia
B. NEUROTRANSMITTERS
- This is actually a chemical imbalance just
like any other mental disorders
- Dopamine Theory
- Disorder due to excess levels of
dopamine
- Drugs that alleviate
symptoms reduce dopamine
activity
- Amphetamines, which
increase dopamine levels,
can induce a psychosis
- Primarily dopamine other
neurotransmitters may also come
into play but the primary reason
why schizophrenia would occur is
because of excess levels of
dopamine so drugs that alleviate
symptoms would reduce dopamine
activity
- Amphetamines is a drug, a CN
stimulant and it increases
dopamine levels and can induce
psychosis
- Theory revised
- Excess numbers of dopamine
receptors or oversensitive
dopamine receptors
- Localized mainly in the mesolimbic
pathway
- Mesolimbic dopamine
abnormalities mainly related
to positive symptoms
- Underactive dopamine activity in
the mesocortical pathway mainly
related to negative symptoms
- This means it showed in the later
part of research that excess
numbers of dopamine receptors or
over-sensitive dopamine receptors
are actually a culprit so it’s not
anymore just the neurotransmitter
rather, it also has something to do
with the receptors; either there’s
excess number of dopamine
receptors which catches more
dopamine causing all your positive
symptoms or if not excess in
numbers, they’re over sensitive
that they usually catch more
dopamine than a normal dopamine
receptor would and which again
 caused the positive symptoms of is involved with speech, memory, abstract
schizophrenia thinking, concentration and personality
- So mesolimbic dopamine - And then if dopamine neurons are
abnormalities mainly related to underactive in prefrontal cortex, it would
positive show negative symptoms of
- And then there’s also underactive schizophrenia
dopamine activity in the - However if, there’s a release of
mesocortical pathway mainly mesolimbic dopamine neurons from
related to negative symptoms inhibitory control, it would show positive
FIGURE 9.2: THE BRAIN AND symptoms of schizophrenia
SCHIZOPHRENIA C. EVALUATION OF DOPAMINE THEORY
- Dopamine theory doesn’t completely
explain disorder
- Antipsychotics block dopamine
rapidly but symptom relief takes
several weeks
- To be effective, antipsychotics
must reduce dopamine activity to
below normal levels
- So dopamine theory doesn’t completely
explain the disorder, antipsychotics block
dopamine rapidly but symptom relief
usually takes several weeks so just like
your antidepressants, it doesn’t really like
- A misolymptic pathway and the take one week after it takes its optimum
amygdala, the cingulate gyrus and the therapeutic effect so there’s really no use
hippocampus are also the one being that you will ask the doctor to change or
affected with your schizophrenia to change his/her prescription; you have
FIGURE 9.3: DOPAMINE THEORY OF to let it stay for two to four weeks
SCHIZOPHRENIA - Other neurotransmitters involved:
- Serotonin
- GABA
- Glutamate
- Medication that targets
show promise in treating
with schizophrenia
D. BRAIN STRUCTURE AND FUNCTION
How does the brain of a client with
Schizophrenia affect that?
● Enlarged ventricles
● Implies loss of brain cells
- So there’s brain injury to the prefrontal ● Correlate with
cortex, which is a part of the brain which
 ○ Poor performance on cognitive
tests
○ Poor premorbid adjustment
○ Poor response to treatment
● Prefrontal Cortex
○ Many behaviors disrupted by
schizophrenia (e.g., speech,
decision making) are governed by
prefrontal cortex (prefrontal cortex
is responsible for many mental
functions of the clients. If it’s
affected due to high levels of
dopamine, then the client’s speech
and decision-making will also be
affected)
○ Individuals with schizophrenia
show impairments
neuropsychological tests
prefrontal cortex (e.g., memory)
○ Individuals with schizophrenia
show low metabolic rates in
prefrontal cortex
■ Failure to show frontal
activity related to negative
symptoms
○ Disrupted communication among
neurons due to loss of dendritic
spines
■ Disconnection Syndrome
- Etiology of schizo: brain structure and
function
- Structural and functional
abnormalities in temporal cortex
- Temporal gyrus
responsible in integrating
the auditory-sensory visual
and lymbic functions aka
polysensory) They will not
be able to connect the dots
between what they see and
hear and they wouldn’t
know the connection and
the significance of it
- Hippocampus - Helps
humans process and
retrieve 2 kinds of memory:
declarative and spatial
memories
- Also where the short term
memories are turned into
long term memories. These
are then stored elsewhere
in the brain that’s why
client’s with schizophrenia
have loss of memory. They
will be able to recall the
long-term memory, but for
the real memories, they will
not be able to store them in
on their short-term, much less
of in their long-term memory
- Declarative
memories - These
are the memories
that are related to
facts and events
(e.g., learning how to
memorize speeches
or lines in a play)
- Spatial relationship
memories - Involve
pathways or routes
like when you travel,
going to a place
where you know the
route and where
- there is less traffic
and so on and so
forth)
- Amygdala
- This is recognized as
a component of the
limbic system.
- It is thought to play
important roles in
 emotion and dysfunction in clients
behavior. processing
- It is best known for - Reduced gray matter and volume
its role in the evident
processing of fear - Disrupted connectivity in the
although this is an brain
oversimplified - Environmental factors
perspective on its - Damage during gestation or
function. birth
- Since the client’s - Obstetrical
amygdala is already complications rates
affected, when the high in pts w/schizo
client is exposed to a - Reduced
fearful stimulus, they supply of
process it less oxygen during
sensitively and in a delivery may
manner in which it result in loss
will not create of cortical
urgency to them. matter
- The amygdala is - Viral damage to fetal brain
actually the one - Presence if parasite,
which causes your toxoplasma gondii,
body to respond in associated with 2.5x
either fight or flight greater risk of
response. developing schizo
- Anterior cingulate - In finnish study,
- This resembles a schizo rates higher
collar form around when mother had flu
the corpus callosum. in second tri, of
- They play a role in a mother
wide variety of -
autonomic functions -
(e.g., regulating -
blood pressure, heart - Developmental factors
rate) as well as - Prefrontal cortex
specific functions matures in
(e.g., error detection, adolescence or early
anticipation of tasks, adulthood
attention, motivation, - Dopamine activity
and modulation of also peaks in
emotional responses) adolesc.
- *if these parts of these brain are - Stress activates HPA
affected so there is a (Hypothalamic
 pituitary adrenal) causes
system which disorder
triggers cortisol - Social selection
secretion theory
- Cortisol - Downward
increases drift in
dopamine act socioeconomi
- If HPA c status
activated, - Research supports
increases social selection
cortisol then - FAMILY FACTORS
increases - Schizophrenicgenic mother
dopamine - Cold, domineering,
- Excessive pruning of conflict-inducing
synaptic connections - No Support for this
- Use of cannabis theory
(marijuana) during - Communication deviance
adol. Associated with - Hostility and poor
increased risk communication
- May explain why symptoms - Poor communication
appear in late adol. But environment which
brain damage occurs early will go to stress
in life - Nonconvulsive at this time

ETIOLOGY OF SCHIZOPHRENIA: Families and

- Psychological stress Relapse
- Reaction to stress
● Family environment impacts relapse
- Indiv. With schizo. And their
- If you dont have a strong support
first degree relatives more
system. For example, you just got out
reactive to stress of the mental facility and come home
- Greater decreases in to a dysfunctional environment, you’ll
positive mood and increase probably just relapse back to that
in negative mood mental state
- More pessimistic ● Expressed emotions (EE)
- See bad things only ○ Hostility, critical moments, emotional
overinvolvement
- Socioeconomic status ● Bidirectional association
- Higher rates of schizo ○ Unusual patient thoughts -> increased
critical comments
among urban poor
○ Increased critical comments ->
- Sociogenic
unusual patient thoughts
hypothesis
- Stress of ETIOLOGY OF SCHIZOPHRENIA:
poverty DEVELOPMENTAL STUDIES
 - Associated with feeling
● Use of retrospective or “follow-back” studies restlessness
- Trying to find out what really is the - Client really wants to move
cause of schizophrenia; triggers, around
emotions - In children: Physical
● Developmental histories of children who later discomfort, agitation, or
developed schizophrenia physical irritability
○ Lower IQ ■ Parkinsonism
○ More often delinquent (boys) and - Pseudoparkinsonism due to
withdrawn (girls) no damage in brain, only drug
● Coding of home movies induced side effect
○ Poorer motor skills - Rigid muscles in limbs
○ More expression of negative emotion - Tremor
- Increased salivation
TREATMENT OF SCHIZOPHRENIA: - Changes in gait
MEDICATIONS - After taking the antipsychotic
● First-generation antipsychotic medications ■ Acute Dystonia
(neuroleptics; 1950s) - 20-40% of people taking 1st
○ Phenothiazines (Thorazine), gen antipsychotics develop
butyrophenones (Haldol), this symptom
thioxanthenes (Navane) - Begins gradually, after a few
■ Reduce agitation, violent days of taking drug
behavior ■ Neuroleptic malignant
■ Block dopamine receptors syndrome
■ Little effect on negative - Rarest and most serious
symptoms - First signs: rigid muscles,
■ NOT DRUG OF CHOICE CUZ drowsiness, confusion
IT TREAT POSITIVE S/S, NO - Can experience seizure
EFFECT ON NEGATIVE S/S - Client’s nervous system
○ Extrapyramidal side effects function may be affected
- Drug induced movement - Symptoms commonly appear
disorders, describes the right away after a few horse of
effects caused by your first taking 1st gen
generation drugs antipsychotics
- Causes a syndrome/collection
of S/S such as: ● Maintenance dosage to prevent relapse
■ Tardive dyskinesia - Needed to prevent relapse
- Involuntary facial movements,
such as tongue twisting, lip TREATMENT OF SCHIZOPHRENIA:
smacking, grimacing, jerky Medications
limb movements/shrugging ● Second-generation antipsychotics
- Late onset of symptoms, at ○ Clozapine (Clozaril) DRUG OF
least 6 months or longer of CHOICE
dosage ■ Impacts serotonin
- Symptoms persists in spite of receptors
treatment ■ This is why they also have
■ Akathesia effect on negative
 symptoms and disorganized
movements
○ Fewer motor side effects
■ Compared to the first
generation, antipsychotics
have fewer motor side effects
○ Less treatment noncompliance
○ Reduces relapse
● Side effects
○ Can impair immune symptom
functioning
■ There may be a need to test
the client’s CBC to check for
WBCs, RBCs, or even the
platelets
○ Seizures, dizziness, fatigue, drooling,
weight gain
● Newer medications may improve cognitive
function:
○ Olanzapine (Zyprexa)
○ Risperidone (Risperdal)
Table 9.4 Summary of Major Schizophrenia Drugs
● First-generation drugs
○ All those drugs can usually cause
extra pyramidal side effects
○ Usually, these drugs are still being
used by the psychiatrists nowadays
○ They pair it with a drug which will treat
the extrapyramidal effect
TREATMENT OF SCHIZOPHRENIA: Medications
● Clinical Antipsychotic Trials of Intervention
Effectiveness (CATIE) study
○ Second-generation drugs were not
more effective than the older,
first-generation drug
○ Second-generation drugs did not
produce fewer unpleasant side effects
○ Nearly three-quarters stopped taking
the medications before study ended
○ Although it addresses the many
symptoms of your first-generation
drugs, you could have thought that
since we have a 2nd generation drug
and stick with it. Since it treats both
the positive and the negative
symptoms plus it has minor side
effects. But then, they cannot take
away these from the market since it is
more effective than the older drug.
● Second-generation antipsychotics have
serious side effects
○ Weight gain, diabetes, pancreatitis
● Disturbing trend for people of color:
○ Not prescribed second-generation
antipsychotics
■ Both the first generation and
the second generation of the
psychotics actually have a
distinct and separate and
independent effect.
■ It has both good and bad side
effects but nevertheless, it
treats schizophrenia.
PSYCHOLOGICAL TREATMENTS
● Patient Outcomes Research Team (PORT)
treatment recommendation:
○ Medication PLUS psychosocial
intervention
○ Since the client here is out of touch of
reality, to treat them, they have to stay
in touch with reality and for it to be
done, they have to be taking their
medications.
● Social skills training
○ Teach skills for managing
interpersonal situations
■ Usually, the clients who are
diagnosed with schizophrenia
when discharged from a
mental facility, they would
have problems integrating with
the society because of the
stigma and the residual
symptoms of schizophrenia.
■ Completing a job application
■ Reading bus schedules
■ Make appointments
○ Involves role-playing and other
practice exercises
● Family therapy to reduce expressed emotion
 ○ Educate family about causes,
symptoms, and signs of relapse
○ For them to find the trigger and there
will be less chances of them to go to a
mental facility for treatment
○ Stress importance of medication
■ Unlike other mental illnesses,
medication for clients with
schizophrenia is the mainstay
therapy plus the psychosocial
intervention.
○ Help family to avoid blaming patient
○ Improve family communication and
problem-solving
○ Encourage expanded support
networks
○ Instill hope
○ We instill hope but we don’t give false
reassurance.
● Cognitive behavioral therapy
○ Recognize and challenge delusional
beliefs
○ Recognize and challenge
expectations associated with negative
symptoms
■ e.g., “Nothing will make me
feel better so why bother?”
■ Scrutinize the statement. Don’t
do power tripping. Don’t argue
with your client. Don’t play
along.
■ What you need to do here is to
present reality.
● Cognitive remediation training or cognitive
enhancement therapy (CET)
○ Improve attention, memory, problem
solving and other cognitive-based
symptoms
● Case management
○ Multidisciplinary team to provide
comprehensive services
○ Because there may be a need for
Occupational Therapy to teach them
basic skills so that they will be able to
integrate smoothly into the
community.
● Residential treatment
○ Vocational rehabilitation
○ Even if they are already discharged
and they are already integrated back
to the community, there will still be
halfway home where they can go for
support.
ALCOHOL DEPENDENCE PRERECORDED
VIDEO
● Substance abuse
○ The repeated use of alcohol or other
psychoactive drugs that leads to
problems
■ Problem here with substance
abuse, even if the client
already knows the bad effects
of the substances he/she is
abusing, he/she still continues
to do that because maybe
he/she has become so
dependent or addicted to it
that he can no longer function
normally without it.
■ Even if they know, it is not that
they do not know the bad
effects, they know but in spite
of it they still continually do it
or take it because they can no
longer function without it.
● Substance Dependence
○ Compulsive, repetitive use of
psychoactive substance resulting in
tolerance to the drug’s effects and
withdrawal symptoms when drug use
is decreased or stopped
■ Conditon where an individual
will continually use a specific
substance which when he/she
abruptly stops it it will cause
him/her to manifest some
withdrawal symptoms which
comes in a lot of
manifestations of discomfort.
■ Here, the person can no
longer function normally
 without this specific substance
and because of that, they have
repetitively using this, this will
cause tolerance of the drug
● Tolerance
○ Decreased response to a drug that
occurs with repeated use
■ Ex: take one bottle of alcohol
but continued use, the alcohol
won't make him feel sleepy
then this would decrease in 2
bottles and more
○ The user who develops a tolerance
must take increasingly higher
amounts to get the desired effect
● Physical dependence
○ Adaptive state that occurs as a
normal physiologic response to
repeated drug exposure
○ Does not necessarily indicate drug
abuse or addiction
■ More on your body can no
longer function if you dont take
this drug
● Coffee does not cause
addiction but causes
physical dependence.
So you cant live
without coffee or you
cant function without
coffee
■ Not drug abuse or addiction
■ Your body has already
adapted to it and you can no
longer function properly unless
you take that specific
substance but again, it doesn’t
indicate drug abuse or
addiction
ADDICTION
- State of chronic or recurrent drug intoxication
in which a person experiences severe
psychological and behavioral dependence on
the drug and tolerance
- This is a state where a client becomes
intoxicated
- If the client no longer takes the specific
substance that causes him/her to be addicted
to, the client will have psychological cravings
and behavioral changes in order to get that
drug
- In here, the client knows that the drug or
substance is no good to him/her but client
would continue taking it because he/she is
addicted to it
WITHDRAWAL
- Uncomfortable syndrome that occurs when
tissue and blood vessels of the abused
substance decrease in a person who has
used that substance heavily over a prolonged
period
- This usually happens when you abruptly stop
taking the substance you used
- Even caffeine has withdrawal syndrome
which causes you to have headache, to be
irritated, agitated and all that so withdrawal
goes for all substances as well
- But let me tell you, caffeine just like your
alcohol and nicotine are substances that are
not prohibited unlike your cocaine, shabu
and methamphetamine, etc
- But those 3 substances that i mentioned
earlier (nicotine, caffeine and alcohol),
although they’re not prohibited however they
can cause physical dependence
Intoxication
- A reversible, substance specific syndrome
caused by ingestion of or exposure to that
substance
- Ex. when you take alcohol too much
to more than what your liver can
metabolize which can affect mental
state
Alcohol dependence
Characteristics:
● Biological adaptation
○ Client used to continuously using
alcohol and she cannot function
without it
● Loss of control
 ○ She knows it can cause detrimental ● Minor complaints
relationships, career yet continues to - Minor complaints on everything
do it - Irritable, hard to please
● Maladaptive consequences ● Poor personal hygiene
○ Losing loved one bc continually go - No longer attend to themselves
home intoxicated, choose hanging because of their preoccupation to
around ppl who also drink, lose job bc alcohol
they go to work intoxicated - Usually tipsy if not drunk
● Untreated injuries
Common causes - Same reason why they have poor
● Possible genetic influences personal hygiene
● Biochemical abnormalities ● Unusually high tolerance for sedatives and
○ Chemical imbalance, disease in mind opioids
● Urge to drink to reduce anxiety - The more that you drink alcohol, the
● Desire to avoid responsibility in family, social higher tolerance to sedatives, opioids
and work relationships - If you will be operated and you will be
● Low self esteem given anesthesia, it may not have the
● Easy access same effect to you compared to other
○ Alcohol at home individuals who do not drink alcohol.
● Group or peer pressure Instead of being anesthetized, you
● Stressful lifestyle can still feel pain
● Nutritional deficiency
Complications ● Secretive behavior
● Cardiopulmonary - You wanna try to hide your hangout
○ High Blood pressure, cardiomyopathy place or people you go to or where
● GI you get drunk
○ Ulcers, alcohols would not eat they ● Denial of problem
would rather drink ● Tendency to blame others and rationalize
● Hepatic problems
○ Hepatitis, liver cirrhosis, liver cancer - Protect their ego that it’s not usually
● Neurologic their problem, they’re drinking
○ Affects px state of mind, alcohol is a because they’re stressed.
good carcinogenic paired with - They will have a hard time growing
smoking (cancer) emotionally because they don't want
● Psychiatric to feel pain
○ Repetitively using can cause - That's why they drink alcohol to feel
neurochemical imbalances, induce numb instead of facing their problems
alcohol psychosis head on.
● Fetal alcohol syndrome
● Hypoglycemia
○ Low blood sugar, not eating prior to Excessive alcohol use
drinking, effect of alcohol in low blood ● Episodes of anesthesia or amnesia during
sugar intoxication
● Leg and foot ulcers - That term you call blackout, it may be
● Prostatitis true for some instances when they are
very intoxicated
Signs of alcohol dependency ● Violent behavior
 ● Needed for daily or episodic alcohol to
function adequately
- When you can say someone is an
alcoholic, can't go a day without
alcohol
● Inability to stop or reduce alcohol intake
● Blood testing revealing elevated BUN,
increased plasma ammonia level, and
decreased serum glucose level
● Liver function studies demonstrating
alcohol-related liver damage

Alcohol Withdrawal Mild Withdrawal

- Trying to wean oneself from alcohol might ● Hand Tremors
cause them to go through certain ● Impaired appetite
manifestations, such as: ● Nausea
● Anorexia, nausea ● Tachycardia
● Anxiety, agitation
● Fever Moderate Withdrawal
● Insomnia ● Visible tremors
● Diaphoresis - sweat a lot ● Obvious motor restlessness and painful
● Tremor anxietyMarked insomnia and nightmares
● Hallucinations ● Anorexia
● Withdrawal delirium ● Vague, transient visual and auditory
hallucinations
If you are an alcohol dependent and you want to ● Pulse 100-120 bpm
wean yourself from alcohol, you wanna ask for help ● Usually elevated BP
so you may be able to cope through with these signs ● Obvious sweating
and symptoms ● Possible seizures

Diagnosing Alcohol Dependence Severe Withdrawal

● Blood alcohol level to indicate intoxication
- Obtained through breathing through a
breathalyzer device
- Blood alcohol concentration (BAC) is
calculated from the concentration of
alcohol in the breath (in USA)
- Blood alcohol intoxication - 0.8%
- If 0.0% = SOBER
- 0.8% = LEGALLY INTOXICATED
- 0.8% - 0.40% = Difficulty walking and
speaking; others may include
confusion, nausea, and drowsiness
- >0.40% BAC = At risk for serious
complication; risk for coma and death
● Urine toxicology to reveal use of other drugs
● Serum electrolyte analysis revealing
electrolyte abnormalities associated with
alcohol use
- Sodium and potassium may be
affected
● Gross, uncontrollable shaking
● Extreme restlessness and agitation; intense
fearfulness
● Total wakefulness
● Vomiting
● Confusion and disorientation
● Visual and occasionally, auditory
hallucinations
● Pulse 120-140 bpm
● Elevated BP
Treatment Options (for clients who wants to cut their
alcohol intake)
● Withdrawal in a monitored, therapeutic
setting (one of the withdrawal is the seizure
so if you’re just at home, it might cause more
complication, you must get medical facility
where you can be attended to).
● Medications that deter alcohol use
● Measures to relieve associated physical
problems
● Psychotherapy-behavior modification, group
therapy, family therapy
● Counseling and ongoing support groups
● Symptomatic treatment
● Antagonist therapy
- Uses the opioid antagonist naltrexone
(ReBia) to reduce alcohol craving and help
prevent an alcoholic from relapsing to heavy
drinking (when it’s combined with counseling)
- Sometimes when you're really dependent to
alcohol, you sometimes get the best of you,
so there should be a mixture of med therapy
and counseling
- The counseling can be a group counseling,
like anonymous or family counseling,
because this can be genetic, cause family
can be an influence
● Aversion therapy: involves the use of a daily
oral dose of disulfiram (Antabuse) to prevent
compulsive drinking
● Counseling and psychotherapy for long-term
rehabilitation
Signs and Symptoms of Disulfiram Reaction
- When client is taking Disulfiram, they have to
be warned that they should not take any
alcohol at all because if they take alcohol
with it, they will experience these reactions:
● Flushing
● Throbbing of neck and head
● Nausea and vomiting
● Headache
● Sweating
● Thirst
● Shortness of breath
● Chest pain, palpitations, tachycardia,
hyperventilation, hypertension, or syncope
● Weakness
● Vertigo
● Blurred vision
● Confusion
Nursing Interventions for a Patient with Alcohol
Dependence
● Warn patient taking disulfiram that even a
small amount of alcohol will induce an
adverse reaction
- It is important that you tell them, due
to it causing a lot of discomfort to the
client and induce the adverse rxns
● Arrange visit with patient’s religious or
spiritual advisor to help provide motivation for
commitment to sobriety
- For client’s inner strength and
motivation, sometimes those around
us are not enough and we need
spiritual advisor
● Recommend that patient join support
groups--Alcoholic Anonymous, NAtional
Association for Children of Alcoholics
- Cause for them to be exposed to
individuals of have the same
problems, who wants to overcome it
and are trying their best not to be
alcoholics anymore
- They will feel that they’re not the only
ones going through with it
- SUPPORT SYSTEM
- Alcoholic anonymous = have steps
wherein they have to follow for them
to be able to graduate
- Train their minds, control impulses
-END <3 perfek