PSYCHIATRIC NURSING

Overview:
A. Psychiatric Nursing B. Main Tool Mental health Primary purpose is to promote mental health Not curable, only to reduce the symptoms : IPR (Interpersonal Relationship) Nurse: self-awareness to

Client, individual, family, environment minimize weakness, maximize strength C. Focus of Psyche :

Human Behavior - Leads to identification of feelings - Responses to the environment, changes are meaningful : Therapeutic use of self acquired thru self-

D. Tool Used By The Nurse awareness E. Levels Of Prevention:

3 Levels Of Prevention: 1.) Primary Promote mental health (Healthy) Remove factors before they can cause illness Ex. Stress reduction Health Teachings/Community Teachings/Community Demographics Support System Accident Prevention 2.) Secondary Lessen the duration of mental illness (ill) Ex. Suicide Prevention Crisis Intervention/ Treatment & Diagnosis Providing Psychotherapy & Milieu Therapy 3.) Tertiary Function to become independent Ex. Rehabilitation Centers/ Al anon Relapse Avoidance F. Stages Of Interaction 1st Stage: Orientation Assessment Establishment of Trust
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2nd Stage: Working Problem Solving

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Tell Patient of Termination Discussion Stage: Termination Set contract Patient is mostly cooperative Evaluation Goodbye Patient is resistant of RN) I. MENTAL HEALTH ----- A state of mind 6 Concepts In Mental Health: 1. Self-Awareness 2. Self-Actualization Self-fulfillment or self-realization 3. Perception Of Reality 4. Autonomous Behavior: Independence, decision-making ability 5. Adaptation : Use of Adaptive Defense Mechanisms Compensation Rationalization Identification Fantasy Substitution Sublimation

3rd Summarize Say Grief-Anger (Focus Pt. violent/suicidal

6. Integrative Capacity - Time to evaluate frustrations - Ability to solve conflicts: *Conflictpresence of 2 goals resolved through

a. Double Approach = 2 + goals b. Double Avoidance = 2 goals c. Approach-Avoidance = (+) & (-) outcome Ex. Developmental Task

II. PERSONALITY DEVELOPMENT: *Our beliefs & thoughts influence our feelings & consequently manifests as behavior. BELIEFS BEHAVIOR Create the
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FEELINGS

Different Inputs/Factors * Per sonare ------- to sound through--- The sum total of traits w/c are unique

III. THEORIES ON PERSONALITY DEVELOPMENT: 1. SIGMUND FREUD - Father of Psychoanalysis

Psychoanalysis Uses the principle of free association (Talk of anything that comes to mind & correlate w/ the behavior) - As the treatment for the unconscious mind - The role of the unconscious w/c has conflicts-----results to maladaptive behaviors (Dr. Karen Horney- detractor of Freuds Penis Envy - ALL BEHAVIOR HAS MEANING Different Theories Of Sigmund Freud: A. 3 STRUCTURE OF THE PERSONALITY

it now

I S

D IMPULSIVE Part WANT TO

Operates on PLEASURE PRINCIPLE Instinctual drive: Eat, urinate, have Avoidance of pain, All I Ex. Babies are all ID: I want it, I want

sex

UPEREGO SHOULD NOT MALL VOICE OF GOD

CONSCIENCE Higher self, ideal ego Tells you what is right or wrong The censoring part, the moral values What makes you a perfectionist, rigid & Ex. I should not eat yet.. Function: 1. Inhibit the ID impulse

righteous

GO XECUTIVE Arbiter

Operates on REALITY PRINCIPLE In touch with reality The self, self-identity

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Develops 6 months Functions: 1. Higher Functions: memory, orientation, decision-maker 2. Integrator of Personality: mediator bet. the Id & Superego between self & environment 3. It will tolerate frustrations 4. Solve conflicts Ex. I can wait for what I want 5. Uses Defense Mechanism---to maintain balance (PRN only) 6. Directs motor skills 7. Evaluate the environment 8. Reduces anxiety *The ability to tolerate frustration based on the balance of the 3 functions: Imbalance -----Maladaptive Behavior 1. ID EGO SUPEREGO ID 2. SUPEREGO

EGO SUPEREGO is Characteristic of: OBSESSIVEANOREXIA PERFECTIONIST,

ID is dominant; needs a superego (conscience) dominant; needs an ID Characteristic of: MANIC COMPULSIVE ANTISOCIAL (Serial-killer) NERVOSA NARCISSISTIC RIGID 3. ID EGO If theres Weakened EGO SUPEREGO

Impaired Reality Perception Characteristic of: SCHIZOPHRENIA

B.

THE THEORY OF LIBIDO LIBIDO - Sexual energy for survival Mans sexual desires & urges Personal-----libidal striving w/c focuses on gratification

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C.

THE THEORY OF DREAMS Resides in the unconscious THE THEORY ON LEVELS OF AWARENESS 3 Levels of Awareness:
> Highest level of Awareness > Contains all experiences that can be > Tip Of The Tongue; Deja Vu > Experiences that partly forgotten & partly remembered > Forgotten > Experiences that cannot be recalled Ex. Dreams, accidents, anxieties & phobias > Where traumatic experiences are stored (Repression) Ex. Birth Trauma (the cause of 1st

D.

recalled voluntarily

CONSCIOUS

PRE-CONSCIOUS (Sub-conscious)

UNCONSCIOUS

anxiety)

*The ID, Ego & Superego -----all resides in the unconscious & operates on different levels of the mind Except the ego when dealing with reality----resides on the ---conscious Repression Unconscious forgetting of an anxietyprovoking event THE PSYCHOSEXUAL THEORY Suppression Conscious forgetting of an anxiety-provoking event (voluntary)

E.

STAGES OF PSYCHOSEXUAL DEVELOPMENT 1. ORAL STAGE 0 18 months

Survival All ID Cry, suck mouth Biting, Thumb sucking & Nail biting-----------------all normal in infancy Dependent, Helpless----------------needs to develop sense of trust, sense of security After 6 months, EGO develops------Development of Self-Concept Maternal Deprivation results if theres no feeding, not given milk/water, not kept warm

Residuals Developed :
Behavior: Overeating Narcissisti c
Stems from being deprived &

3 Maladaptive

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Regressi on
Going to an earlier developme

Fixation
Stopping in a certain5 stage of Developm

Over-talkative Gossiping Chewing gums Smoking & Drinking alcohol

2.

ANAL STAGE

18 months 3 years old -------the 1st to developed

Focus on Elimination -----Bowel

-----Bladder (Bedwetting) Toilet training Temper Tantrums---Normal---Ignore as long as no harm is present: If (+) harm---set limits SUPEREGO is being formed(begins)---------------Mother as the superego Sense of Autonomy Develops------manifested through Negativism (No) Stubbornness

Concerns:

Punishment Cleanliness Habit-training Stage Perfectionist, Rigid, Righteous, Collectors &

Residuals Developed:
Hoarders

Problems: Strict Toilet Training Too much punishment w/ Toilet-training result to a child who is: Good mother Successful Bad mother Clean Organized Obedient Dirty Disorganized Disobedient

SE

SE
Anal Retentive Expulsive (Obsessive-Compulsive) 3. (Antisocial) PHALLIC STAGE 3 years 6 years old

SE
Anal

HALLIC ENIS ARENT RE - SCHOOLER

Focus: Genitals------Penis only Development of Gender Identity

Masculine/Feminine
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Sense of Being

 Sense of Initiative
Genital Exhibitionism/Masturbation Imaginative With a friend Explorative Why Residuals Developed: Sexual Deviation Sibling Rivalry is normal

Development of Complexes----child attachment to opposite sex

Oedipus Complex (boy loves mommy) Electra Complex (girl loves daddy)

Both complexes Identification To parent of the (Role Identification)

resolved thru
Identification (girl imitates mommy) GirlsPenis Envy

same sex

Identification (boy imitates daddy)

4. LATENCY STAGE 6 to 12 years old (School Age) ang libido)

(Log tu tulog

Focus:

School & Peer The Homosexual Stage-----------Identify with the same sex------Best friend Areas on school & social competition--------------form the sense of group success Sense of Industry Fear: School Phobia-------------Separation-Anxiety

R
W

EADING ITING ITHMETIC

Sublimation placing sexual energies (feelings) toward more productive endeavors

Residuals Developed: School Dropout 5. GENITAL STAGE 12 years and above energy) Focus: Genitals Emergence of LUST The Heterosexual Stage Sense of Identity AMBIVALENCE: Child (Gising na ulit ang sexual

G
Adult

ENITAL ISING

Struggle for independence from parents Problems: Conflicts & Frustrations dominates 2. Residuals Developed: Drug Addiction, Promiscuity, Alcoholism ERIK ERICKSON------- Psychosocial Theory Of Development

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 Considered the Social Factors Man as a Social Being Person play different roles & as we play them, we achieve something PSYCHOSOCIAL STAGES OF DEVELOPMENT Freud Stage 0-18 months (Infancy) 18 months 3 years (Toddler) Oral (+) Trust ( Friendly/ Affectionate) (Self-Confidence) Autonomy (SelfDetermination) (Independence) Initiative (Responsible) (Role Identification) Initiate the 1st step Industry (Competition) (Cooperative) Sx of High SelfEsteem (-) Mistrust (Withdrawn/Susp icious) Shame & Doubt (Overtly Compliant) Factor Significa nt Person Mother

Feeding

Anal

Toilet Training No,No My Independe nce Teach The Child

Parents

3 6 years (PreSchooler)

Phalli c

Guilt (Denial, Restrictions) Anger To Self

Family

6-12 years (School)

Laten t

Inferiority (Social Loner) (School Dropout)

School Who Am I based on beliefs, selects & become who you are along w/ your peers Peers (Major factor in the devt of beliefs

Teacher Peer

12 20 years (Adolescen ce)

Genit al

Identity (Self-Actualized) (Self-Direction)

Role Confusion (Identity Crisis)

Opposite Sex

20-25 years (Young Adult) 25-45 years (Middle Adult)

Intimacy (Commitment) Generativity (Productivity) Sharing

Isolation (Relationships/Jo bs on Temporary Basis) Stagnation (Selfish, SelfCentered) No Learning

Love

Husband/ Wife Children

Parenting Sharing beliefs w/

Children Grandchil dren

8

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children 45 & Above (Late Adult) Ego Integrity (Worthiness) (Completeness) Despair (Hopeless, Unworthy) (Fear of Death) Husband/ Wife Best friend

Reflection

Paranoia = Stems from the development of mistrust

Exercise: Newly admitted Patient:----Develop 1st ----Trust ----Develop/teach autonomy since pts. Are dependent with self-care deficit 3. JEAN PIAGET-------Theory Of Cognitive Development Four Stages Of Cognitive Development 1st Stage : Sensorimotor 0- 2 years old Preverbal Recognizing environment by the use of senses (baby can see,perceive,hear) Adapt through the use of reflexes & motor skill Concept of Object Permanence ----even if they cannot see the object, they still believed its existence

2nd Stage

: Pre-Operational 2- 7 years old Egocentric----does not feel what adults feel Animistic Thinking -------cartoons are powerful Imitates other people Pre-Conceptual 2-4 y/o -----Use of language to talk Intuitive Stage 4 -7 y/o-----Unidimentional classification/characteristics (Child can fix toys according to size, color, height--1 at a time only : Concrete Operational 7 12 years old Logical Concept of Cause & Effect : Formal Operation Idealistic Abstract Thinking 12 years old & above

3rd Stage

4th Stage

4.

ABRAHAM MASLOWS

HIERARCHY OF NEEDS > Continuous > Low self- esteem: Give

Improvement of Self Task

SELF-ACTUALIZATION SELF- ESTEEM LOVE & BELONGINGNESS SAFETY & SECURITY

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BASIC PHYSIOLOGICAL NEEDS

5. OTTO RANK------Theory Of Birth Trauma Birth Trauma---------Manifested Through----------Separation Anxiety Birth Trauma --------the 1st cause of Anxiety CARL JUNG------Theory Of Libido 7. 8. Theory Of Libido-------derived from an energy level

6.

ADOLF MEYER--------Psychobiology Theory Concept of the mind & body as one entity ALFRED ADLER------Individual Psychology Unique Man born with a weakness but overcomes it through Compensation Inferiority Vs. Superiority Concept HARRY STACK SULLIVAN-----Theory Of Interpersonal Relationships

9.

Theory of Interpersonal Relationships

Mother & Child developed IPR during infancy------if lacking------anxiety Builder Of Self-Esteem Motivation Stages: 1. Infancy--------------- 0-18 months Mouth 2. Childhood------------18 months- 6 y/o Egocentric/Gender Identity 3. Juvenile----------------6-9 y/o Competitive 4. Pre-Adolescence------ 9-12 y/o Best Friend Depends on group success 5. Early Adolescence--- 12-18 y/o Emergence of Lust Attraction to opposite sex-----bases: physical appearance 6. Late Adolescence------18-22 y/o
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 Development of lasting relationship----based on security 7. Adulthood-----------------22 y/o & above Achievements Focus on emotional & sexual maturity 10. BEHAVIORAL MODELS

A.

IVAN PAVLOV

------------------CLASSICAL CONDITIONING MODEL

All behavior is learned through CLASSICAL CONDITIONING Unconditioned stimulus (food) Conditioned stimulus (bell) B. B.F. SKINNER Unconditioned Response (salivation)

---------------------OPERANT CONDITIONING MODEL

If all behavior is learned, then it can be unlearned Good Behavior Reward Repeated behavior Bad Behavior Punishment Extinguishes behavior / extinction IV. PSYCHOPHARMACOLOGY Positive reinforcement Negative reinforcement

Anatomy:

Frontal Lobe = Personality, Learning, Judgment, Language Occipital Lobe = Vision Temporal Lobe = Hearing, Smell Parietal Lobe = Touch

How do you interact with your environment?

S I M

ENSORY NTEGRATION OTOR

-----1st ------seeing ------2nd------analyze

------3rd------action

Voluntary Movements (SOMATIC)SNS ANS

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Involuntary Movements (AUTONOMIC)

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Brain (Alert) Sympathetic Parasympathetic (Relax) Spinal cord RR Motor Nerves GI

moist mouth

HR

dry mouth
constipation retention

diarrhea

Ach
frequency

GU

Acetylcholine on switch of muscle (transmits message to the muscle)

Acetylcholine

Neuro

Epinephrine/

Synapse
Vasodilatation

Transmitter Norepinephrine Pupils Midriasis Blood Vessel Vasoconstriction BP

Increased

Myotic

Decreased

Muscle Fiber

Anti-Cholinergic/ Anti-Parasympathetic sympathetic Sympathetic Drug Classifications: A- anxiety P- psychotic C-cholinergic D- depressants

Effect is

ANTI

V. DEFENSE MECHANISMS

Mental mechanisms Coping Mechanisms from stress Patterns of adjustment Affects/Interferes with ADL--------harm to self or others Operates on the unconscious level

Processes on the Ego---------to reduce anxiety--------maintain selfesteem Results to > Adaptive/ Maladaptive > Distort reality > Self-deception
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DEFENSE MECHANISMS Displacement Transfer of feelings to less threatening object/person rather than the one who provoked it Unacceptable Ex. Boss shouts at you, you shout to your Failure to acknowledge an unacceptable trait or situation or reality Ex. I am not an alcoholic Returning to an earlier developmental stage (earlier pattern of behavior) Ex. Acting like a child Unconscious forgetting of anxiety provoking concept (Selective forgetting) Illogical reasoning for a socially unacceptable trait (Giving rational reasons) Uses because Most common defense mechanism used Ex. I drink the beer in the ref rather than waste it Doing opposite of the intention (Hypocrites)

subordinate Denial

Regression

Repression Rationalization

Reaction-Formation Undoing

Doing opposite of what you have done (Action & then amends) Ex. Show true feeling then feels guilty after doing it Assuming trait, persona, social & occupational role (Models a certain behavior) Unconsciously imitating another person Attribute to others ones unacceptable trait Mechanism) Ex. Not me but them (Scapegoat

Identification

Projection

Introjection Suppression

Assume anothers trait as your own (Taken into oneself) Ex. Not only you, Me too Conscious forgetting of an anxiety-provoking concept (Voluntary forgetting) Intentional forgetting to an unpleasant experience Ex. I dont want to talk about it Excessive energies put towards more productive endeavors Redirect feelings (anger) to a socially acceptable behavior Replacing a difficult goal with an accessible one Repression. Anger repressed & converted to physical symptoms
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Sublimation

Substitution Conversion

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Ex. numbness & motor paralysis Compensation Solve conflicts by manifesting physical symptoms

Overachieving in one area to cover defective part or weakness To overcome inferiority & excel in other aspect of personality Use of imagination/daydreaming Separating your feelings from the situation Arrest of maturation/Persistence of one stage of development Give meaning to objects Psychological flight from self Ex. Amnesia, Rape or traumatic experiences Unconscious separation of certain parts or functions of personality

Fantasy Isolation Fixation Symbolism Dissociation

Alteration in--------Memory Identity Consciousness To reduce/avoid anxiety Categories: 1. Psychogenic Amnesia------loss of memory 2. Fugue new place 3. Multiple Personality Dissociative identity disorder 2 or more personalities 4. Depersonalization Unreality to oneself With altered sense of self 5. Dissociation not otherwise classified Sleep talking---somniloquism Sleepwalking--somnambulism Amok aggression --New identity in a

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

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VI. CONCEPT OF NEUROSES & PSYCHOSES Neuroses 1. Maladaptive emotional state 2. Reality is present 3. Ego in the conscious 4. Behavior is socially acceptable appropriate Core Symptom: Anxiety Illusion, Delusion Tx: Minor Tranquilizer Ex. Valium, Ativan VII. THERAPEUTIC COMMUNICATION Tx: Psychoses 1. Disturbance of the mind 2. No reality 3. Ego in the unconscious 4. Behavior is Core Symptom: Hallucination, Major Tranquilizer Ex. Thorazine, Haldol

THERAPEUTIC COMMUNICATION TECHNIQUES THERAPEUTIC Offering Self Ill sit with you Ill stay with you Silence (giving patient time to think) Making observations You seem sad Active Listening Nodding, establish eye contact, leaning forward Exploring questions Who, what, where, when, how Broad Opening How are you today? How are things going today? General leads Go on. Im listening. And then what else? Restating Client: Im sad. Nurse: Youre sad? Refocusing We were talking about the exam. NON-THERAPEUTIC

Ignoring patients feelings or emotions Dont worry be happy False Reassurance Everythings going to be fine Ignoring the client

Changing the subject

Asking why? Putting client on the defensive Making value-based judgments Prejudicial, use of adjectives Nice weather today Flattery You are the most beautiful Advising You should do this. In my opinion Commanding client

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

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Focusing Tell me more about this

Arguing with the patient

Clarification What do you mean by plooplank?

Do not impose your opinion

CONCEPTS & DISORDERS VIII. ANXIETY - Vague sense of impending doom - Afraid of the unknown - Present is the anticipation of danger - A feeling of uneasiness---------vague apprehension------uncertainty Different with Fear afraid of what you know - Presence of an external danger A. ASSESSMENT: Level of Anxiety 0 = Ataraxia------absence of anxiety----------uncommon---------present only in clients on shabu/drug addicts
P E R C E P T U A L F I E L D MILD PANIC MODERATE SEVERE

Mild +1

Moderate +2

Severe +3

Panic +4

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Widened Perceptual Field acing ont know what to do uicide Increased motivation RN meds ont know what to say afety Restless irective Enhance learning capacity Selective Inattention Free-floating anxiety Increased Hearing Presence of Physical Sx muscle tension DONT TOUCH client Problem-Solving present Narrowing of attention Respiratory alkalosis* * Good: Client more aware *Breathe into bag * Bad: Contagious Disorganized Level * Normal anxiety r/t everyday tension Terror/Threat USE THERAPEUTIC COMM Apathy Ex. You seem anxious *An emergency Words are usually enough to SNS Activation Manage mild anxiety

NURSING DIAGNOSES:

Ineffective Individual Coping Powerlessness Impaired Skin Integrity

PLANNING/ IMPLEMENTATION: level of anxiety level of environmental stimuli Relaxation techniques (Psychophysiology) EVALUATION: Effective individual coping B. DISORDERS ASSOCIATED WITH ANXIETY 1.) GENERALIZED ANXIETY DISORDER

6 months excessive worrying Restless Concentration difficulty Sleep problems Palpitations Feeling of being at the edge of seat Easy fatigability Patient knows what the problem is

2.) PANIC DISORDER 15-30 minutes escalation of the SNS Sudden: Happens w/o warning With or W/O agoraphobia 2 Types: Agoraphobia Sign of Panic Disorder
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

Fear of open spaces > Outstanding

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Social Phobia -

Fear of public

3.) POST TRAUMATIC STRESS DISORDER (PTSD) Trauma Disasters Rape War Others

Victims (not forever)

Survivors

Flashbacks : > 1 month Nightmares 4.) MALINGERING - Pretending to be sick - No organic basis - Intentional that (Conscious)

*Primary gain the result you get when you manifest certain behavior anxiety (Ex. Escape from Teacher) *Secondary gain = Attention ( Ex. from mother) Physiology: ANXIETY I am sick

Malingering (Pretending)

Somatoform (Unconscious)

5.) SOMATOFORM DISORDERS Unconscious Not pretending but no organic basis SOMATOFORM (unconscious) Affects the 3 system

Psychosomatic Disorders (Real pain/ real Sx, )

Major Sign:
DOCTOR HOPPING Favorite pastime of people suffering

Nervous System CONVERSION La belle difference (Emotional detachment) Loss of Sensory/Motor Fx S &Sx real

HYPOCHONDRIASIS Minor discomfort interpreted as major illness

BODY DYSMORPHIC DISORDER Illusion of structural defects S &Sx not real

NURSING FOCUS: Clients Feelings (anxiety leads to symptoms)

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6.) PSYCHOSOMATIC DISORDERS Psycho physiologic Real illness, real Sx & pain with organic basis

Physiology:

ANXIETY

SNS

PNS

BP Hypertension

Vasoconstrictio n

Bronchoconstrictio n

Cerebral Artery Migraine

Left Gastric Artery

Asthma

Decreased O2 supply----cells die Breakdown of mucosal lining----ulceration Stress ulcer

7.) OBSESSIVE-COMPULSIVE DISORDER (OCD) Physiology: Beliefs/Thoughts reflect into feelings

Factors: If disturbed thoughts Obsession (Persistent Thoughts) (Root of Anxiety)

Anxiety Anxiety

Do something to relieve anxiety Action : Compulsion Persistent Behavior & Action

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

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 anxiety Reasons when compulsion becomes negative: 1. Interferes with ADLs 2. Harms self & others

8.) PHOBIA Irrational fear Etiology: object Intervention: REMOVE stimulus (object of fear) to anxiety (Immediate intervention) Increased stimuli = anxiety Decreased stimuli = anxiety Belief Object will hurt patient Avoidance: Interferes w/ ADL Tx: BEHAVIORAL THERAPY: Systematic Desensitization - gradual exposure to feared object Individual Therapy Hypnosis--------------------Relaxed state Free Association----------Ideas shared to psychoanalyst Catharsis--------------------Free to express feelings Transference---------------Patient feels something for psychoanalyst 5. Counter transference-----Rn feels something for patient EATING DISORDERS ANOREXIA NERVOSA & BULIMIA NERVOSA ANOREXIA Diet, diet, diet Underweight, < 85% of body weight 3 months amenorrhea Failure To Recognize
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

Prior knowledge Experience

Ex. Tire will cause burning Ex. Trauma in past related to feared

Ex.

Feelings Scared

Behavior

1. 2. 3. 4.

IX.

BULIMIA Eating Pattern Weight Menstruation Knowledge Eat, Eatinduce vomiting Normal weight Irregular menstruation Knows the Problem But
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Problem

Ashamed & Embarrassed NURSING CONSIDERATIONS Bulimic induces vomiting & tends to abuse laxatives Assess for: Dental caries Wounded knuckles Vomiting - Risk for metabolic alkalosis

NURSING ALERT Most fatal complication: ARRHYTHMIAS

MANAGEMENT: Priority: DEFICIT Restore fluid & electrolyte balance Anorexic & bulimic clients are at risk for FLUID VOLUME Collaborate with client re: menu through use of CONTRACT to ensure cooperation

Priority: Target weight gain & Monitor eating pattern & weight

Nsg Dx: N.I.

Stay with client for 1 hour after meals to ensure client eats food & does not induce vomiting. Accompany in the toilet Body Image Disturbance

- Establish nutrition pattern - Teach stress management, Journal keeping - Anti-depressant

RELATED DISORDERS: 1. BINGE EATING DISORDER - Recurrent episodes of binge eating - No regular use of appropriate compensatory behaviors 2. NIGHT EATING SYNDROME (NES) - Characterized by morning anorexia - Evening hyperphagia (Consuming 50% of daily calories after last evening meal) - Nightime awakenings (at least once a night) 3. COMORBID PSYCHIATRIC DISORDERS COMMON IN CLIENTS WITH EATING DISORDER X. PERSONALITY DISORDERS Cluster A

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SCHIZOID can stand on his own

Avoids people, Do not care about people & believes he

Detachment from social relationships Avoids activities & group more concerned with things No enjoyment: Limited range of emotional expression in interpersonal settings PARANOID SCHIZOTYPAL Cluster B ANTISOCIAL Suspicious Violent Acute discomfort in relationships Eccentric behavior Breaks the law Usually charming, witty As kids, were usually cruel to animals, steals, lie As Adults, drug addicts-drives fast-unsafe sex-thrill Are slick talkers BORDERLINE Loves to split groups My life is an empty glass Likes to keep spares (-) (+) Afraid of being alone suicidal fill Manipulative friends Self-mutilation Splitting Superficial Relationships
Labile affect (sudden change of mood)

seeker

HISTRIONIC

Attention-Seeking Excited, dramatic Manipulative I love myself Insensitive, Arrogant Self-absorbed Exaggerated Avoid people & groups Fears criticism, Self-esteem Have a talent but no confidence Cant live without you Self-Esteem Poor decision-making skills

NARCISSISTIC

Cluster C AVOIDANT

DEPENDENT

OBSESSIVE-COMPULSIVE Organized Constancy in Environment Perfectionists------Provide time to do rituals OTHER CATEGORIES: PASSIVE-AGGRESSIVE DEPRESSIVE in a variety of context NURSING INTERVENTION TO ALL:
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

Always says yes but resistance is hidden Pattern of depressive cognitions & behaviors Improve Interpersonal Relationships
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Build Trust XI. SCHIZOPHRENIA EGO Disintegration Impaired Reality Perception

Famous example: John Forbes Nash, Jr. THEORIES OF CAUSATION: > Stress Diathesis Model - Stressful living pushes person to escape into fantasy Far better to be king in your fantasy world idea > Genetic Vulnerability - Runs in families; genetic component (biological) > Unknown > Physiological Finding: Dopamine in schizophrenic clients Physiology:

ACH

ON switch

OFF switch

ACH

ACH ACH

Dopamine

D
Parkinso ns

Dopamine

ACH

ACH

Schizophr enia

Antipsychotic agents Dopamine Client manifest Parkinson-like symptoms known as

ACH

Dopamine

D
ACH

Give ANTICHOLINERGICS to treat EPS Except Tardive Dyskinesia

EXTRA PYRAMIDAL SIDE EFFECTS (Voluntary movt of the skeletal muscles) (D & ACH) A kathisia (restlessness, inability to stay still)* Most common A kinesia ( muscle rigidity) D ystonia ----earliest sign (1-5 days) Characteristic Features: Torticullis (wry neck) Oculogyric crisis (fixed stare) Opisthotonus ( arched back) T ardive Dyskinesia (irreversible effects) d/t Adenosine Triphosphate Lip smacking Tongue protrusion Cheek puffing
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Anti-Psychotic & AntiCholinergic Both given to Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM Schizophrenia to balance

N euroleptic Malignant Syndrome or NMS Hyperthermia,

ACH
ANTICHOLINER GICS A kineton A rtane

D
DOPAMINERGI CS Parlodel Larodop a

OTHER SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS: Photosensitivity Teach patient to use sunscreen, wide-brimmed hat when going out Agranulocytosis ( monocytes, lymphatic) Teach client to report SORE THROAT (1st sign of Blood Dyscrasia) Hypersensitive Reactions Ex. Allergy Epinephrine ------Hypotension Endocrine-------------M = Gynecomastia F = Enlargement of breast & libido Arrythmia Blurring of vision, Opacity of the lens, retinitis Pruritus, dermatosis, rashes, eczema, dermatitis & hyperpigmentation A. THE NURSING PROCESS: ASSESSMENT: 4 As
Types Of Affect

FFECT

MBIVALENCE UTISM Self-absorbed, Trapped in own world SSOCIATIVE LOOSENESS Unrelated ideas

1. Appropriate External manifestation (feelings & 2. Inappropriate emotion) 3. Flat (none) 4. Blunt Pull between 2 opposing forces (incomplete)

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

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4 THINGS TO ASSESS IN SCHIZOPHRENIC PATIENTS Assess Nsg Dx Content of Thought Disturbed Thought Processes Hallucinations/ Illusions Disturbed Sensory Perception Suspicious Risk for OtherDirected Violence Present Reality Provide Safety Minimize/ Eliminate risk for otherdirected violence Suicidal Risk for SelfDirected Violence Present Reality Provide Safety Minimize/ Eliminate risk for selfdirected violence

Planning/ Implement ation Evaluation

Present Reality Provide Safety

Present Reality Provide Safety

Improved Thought Processes

Improved Sensory Perception

B. SYMPTOMS S & Sx OF SCHIZOPHRENIA 2 Types POSITIVE Hyperactive Sociable Talkative Restless Queen of the World Flight of ideas (Hallucinattion,Illusion, Delusion) NEGATIVE Hypoactive Withdrawn Quiet Flat Affect Apathy PARANOID Poverty of Uses Projection words
Problems with: Mistrust-------Suspicious

N.I. 1. Develop Trust: C. TYPES OF SCHIZOPHRENIA Orientation 2. One-to-one interaction SCHIZOPHRENIA 3. Short but frequent visits 4. Foods in sealed container DISORGANIZED Meals wrapped CATATONIC Inappropriate affect 5. Consistent Approach Ambivalence (sad but smiles) Waxy Flat affect Scared/Withdrawn/Viol flexibility Disorganized ent No (Rebel) speech/manner Negativism (flight of ideas) N.I. Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM Hebephrenic 1. Keep door open (giggling) 2. Dont touch patient 3. Establish Eye

25

RESIDUAL No more (+) or (-) Sx Social Withdrawal Withdrawn

UNCLASSIFIED or UNDIFFERENTI ATED Mixed classification s Cannot be classified

D. THOUGHT PROCESS DISTURBANCE

FLIGHT OF IDEAS Fragmented thoughts; moving one unconnected topic to another The sun is shining. The mouse is on the mat. Here is the bag. - New topics

Vs.

LOOSE ASSOCIATIONS -Stringing together of unrelated topics with a vague connection I am going home. The home of the brave. The brave little Indian boy.

AMBIVALENCE forces ECHOLALIA ECHOPRAXIA WORD SALAD CLANG ASSOCIATION

Feeling of being pulled between 2 opposing I repeat what you say (Word Repetition) I repeat what you do (Action Repetition)

Just mixing of words, no rhyme Rhyming words

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

26

NEOLOGISM can use CLARIFICATION DELUSIONS

Newly created words-------Fixed, false beliefs

* NURSE

Persecutory The FBI is after me Grandeur I am queen of the world Ideas of Reference They are talking about me. CONCRETE THINKING words & phrases proverb Inability to conceptualize the meaning of * Test by asking client to tell the meaning of a

P
HALLUCINATIONS ILLUSIONS

ilosopo roverb

False sensory perceptions; without stimulus (-) for visual, auditory, tactile Misinterpretations of real external stimuli (+) for stimuli, visual, tactile, auditory Believes that he has magical power

MAGICAL THINKING

MANAGEMENT TECHNIQUE

H A R

ALLUCINATIONS

Auditory hallucinations are common. IMPORTANT: Also ask what the voices are saying because 10% of schizophrenic clients are

CKNOWLEDGMENT I know the voices are real to you

EALITY ORIENTATION----------Present reality But I dont hear them.

IVERSION Lets go to the garden. IRECTIVE

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

27

XII.

ALZHEIMER nomia gnosia phasia praxia Dont know name of object Problem with senses (smell, taste , hear, touch) Cant say it Cant do it

A
away place. anymore

issociative Fugue

Takes a new personality from a far

New Place, New Identity issociative Identity Disorder Multiple Personality issociative Amnesia Dont know who/where I am epersonalization Believe that they are not persons I want to talk about something,

+ Perseveration this is what I want to do."

Mngt: ECT Therapy

XIII. DISORDERS OF THE CHILD 1. AUTISM Trapped in own world/ live in a fantasy world Unresponsive to people Echolalia Poor eye contact Cannot express feelings verbally----root of self-directed violence/self-mutilation Boys > Girls Autistic-savant (gifted) - about 1% of all autistics ASSESSMENT: ABCs

APPEARANCE
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

Flat affect
28

Consistent movement Neat, OC, Wants constancy

BEHAVIOR

Repetitive Ritualistic

COMMUNICATION Echolalia
attention

Incomprehensible/Difficulty communicating * Cant cry for help; usually hurts self to get *Talk slowly to autistic child

Nsg Dx: turned it inward

Impaired Verbal Communication Impaired Social Interaction ------cannot form IPR Self-mutilation ------cannot express anger, Risk for Injury

PLANNING/ IMPLEMENTATION: Use Maslows Hierarchy of Needs Promote constancy & safety EXPRESSIVE THERAPY----uses art, music, literature, poetry Purpose: risk for injury, improved social interaction, able to express feelings EVALUATION: Enhanced Communication Improved Social Interaction Safety

2. ATTENTION DEFICIT & HYPERACTIVITY DISORDER (ADHD) Cannot focus on anything Can progress to Conduct Disorder----to---Antisocial Behavior---Future Criminal ID dominant Residual ADHD Onset: Duration: Settings: ID dominant: Mother & RN will act as SUPEREGO may grow up to be ANTISOCIAL may not be antisocial 7 years old & below 6 months & above Must appear in 2 (home & school)
29

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

ASSESSMENT:

APPEARANCE
BEHAVIOR

Usually dirty

Clumsy Hyperactive Impatient, Easily Distracted Talkative, Blurts out in class

COMMUNICATION
Nx Dx:

Risk for Injury Impaired Social Interaction

PLANNING/ IMPLEMENTATION MILIEU THERAPY

Tructure ----Provide place to study,eat,play,bath Chedule ----Time for everything et limits afety Medical Mgt:
RITALIN

EVALUATION: Minimize risk for injury Glucose Improved social interaction Glucose Safety
Frontal lobe Frontal lobe judgment judgment S/Sx of ADHD Ritalin ( a stimulant)

3. MENTAL RETARDATION

Levels Of Mental Retardation: Profound Normal 20 Severe 35 50 Moderate 70 Mild Borderline 90

IQ 110

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

30

Profound: the Client Severe:

<20

Thinks like an INFANT---Cannot be trained-----Stay with 20-35

Moderate: 35-50 Can be trained. Mental age is 2-7 y/o------------Preoperational Stage Mild: 50-70 Can go to school. Mental age is 7-12 y/o

XIV.

CHILD ABUSE

teeth)

Burns Bruises Bone Fractures (Bungi) Body of Evidence should not be lost ( Dont bathe child, Dont brush BANTAY BATA 163

XV. MOOD DISORDERS A. BIPOLAR 2 poles------ Happy (dominant) & Sad Too self-actualize

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

31

BIPOLAR I MANIC TYPE an episode BIPOLAR II MANIC-DEPRESSIVE TYPE BIPOLAR I USUAL PROFILE: Female Usually 20 years old & above Under stress Obese DRUG OF CHOICE: work ASSESSMENT: Lithium ( for mania)

* Mania is not a Dx but of bipolar disorder

NE ------Takes 2-4 weeks to

Use Maslows Hierarchy of Needs

3 Or More Signs Confirms Disorder:

G F S P E E D
MANAGEMENT:

grandiose, risk activities flight of ideas sleeplessness pressured speech exaggerated SE extraneous stimuli (easily distracted) distractibility

Self -Actualized

Manifested by Defensiveness & Compensation Self Esteem by giving TASK

Compensation: S/Sx: flamboyant, heavy make-up, loud voice Self -esteem Caregiver Role: Train / Safety Impulsive so ensure safety Impaired Social Interaction Lock doors & windows Place in room with low Risk For Injury/ Other-Directed stimulus Violence Not with other manics or Manic clients usually Eat Sleep Hyperactive masturbate because of Sex worrying Finger foods Private room anxiety Tell pt. it is not allowed

What are appropriate tasks? No competition or group games, sports e.g. basketball------------- Anxiety Gross motor skills e.g. watering plants, sweeping the floor to put energies to productive endeavors Avoid activities with fine motor skills e.g. sewing Escort outdoors Punching bag------Displacement B. MANIA
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM 32

Needs a mood stabilizing agents------ LITHIUM & GROUP THERAPY

NE LITHIUM - drug of choice If level is near 2.5- 3 mEq/L Ataxia Mental Confusion

evel : 0.5 1.5 mEq/ dL

Toxicity

ncrease urination

T Kiidneys
Check first before beginning therapy (BUN, Creatinine) Only 90% absorb by iidneys kidneys

remors, fine hand

3 Signs of Lithium ausea, vomiting, diarrhea a ( sodium intake to correct FVD) (Na: 135-145 mEq/L)

H ydration l/day I U

ncrease PUPU

M outh, dry *
* Lithium absorbs water

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

33

C. DEPRESSION Serotonin If unresponsive to drugs------- ECT Therapy THE GRIEF PROCESS Denial Anger Bargaining Depression 2 wks or more is a sign of MAJOR CLINICAL DEPRESSION Acceptance ASSESSMENT 5 4 3 Self Actualization Self esteem

Give Simple TASK

Withdrawn Stay with client

Risk for self-directed violence

eat

sleep hypoactive sex Be sensitive to clients needs

MANAGEMENT OF DEPRESSED PATIENT: 1. Give Antidepressants 2. If Drugs not working----Electroconvulsive Therapy (ECT) Pre-ECT: N A B S Post-ECT: Side-lying position---Lateral
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM 34

npo for 6 hrs. atropine sulfate------dry mouth barbiturates succinycholine Chloride-----To relax muscles

S/E: Headache, Dizziness Temporary Memory loss (distinct Sx) Rn reorient LEAD TO: SUICIDE SUICIDAL CUES Verbal I wont be a problem anymore This is my last day on earth Non Verbal Gives away valuables Sudden change in mood ALONE SUICIDE TRIAD: LOSS OF SPOUSE JOB

Who Will Commit Suicide?

s
A D P

Ex--------Male (more successful) ------Female (hesitant) Ge-------15-24 y/o or above 45 y/o epression atient with previous attempts will try again

E thanol (ETOH) Alcoholics R irrational S lacks social support O rganized plan----greater risk N o family S ickness, Terminal
MANAGEMENT OF SUICIDAL PATIENT:

Suicide Area: Hospital Majority happens on a weekend from 1-3 AM Sunday Weekend----less personnel

D I

irect Question/Approach Do you plan to commit suicide? rregular nterval Visit frequently but should not be predictable
35

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

Most suicides are done in the early morning & ndorsement during endorsement arly AM Close Surveillance

XVI. SUBSTANCE ABUSE

Types of ADDICT:

1. Nervous
Tremors Give DOWNERS

2. Depressed

Sits down on chair Give UPPERS

DOW NERS
Asleep Bradypnea Bradycardia Pupils constrict Hypotension Coma Asleep Weight Gain *Constipation * GU Retention

UPPERS
EUPHORI A
Awake Psychological sense of well-being Tachycardia Tachypnea Pupils dilate Dry mouth Hypertension Seizures Weight loss (Thin) *Diarrhea

Alcohol Barbiturates Opiates Narcotic Marijuana

Morph Code Hero

INE
Coma Bradypnea

Cocaine Hallucinogen Amphetamines

STOP UPPERS Antidote: NARCAN (narcotic antagonists) Alcohol Overdose Morphine Overdose Tremors Fatigue Crash Syndrome

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

36

Depressed Suicide

OVERDOSE vs.

WITHDRAWAL WITHDRAWAL HR BP RR seizures HR BP RR LOC (coma)

OVERDOSE Alcohol HR BP RR LOC (coma) Cocaine HR BP RR seizures Narcan (Naloxone HCl) Narcotics Withdrawal

Sx of WITHDRAWAL: Sx Of OVERDOSE to 2 Types: 1. Know if drug is Upper or Downer 1. Identify if drug is Upper or 2. Downer Check for opposite effect & 2. Check Effect 3. Sx of Withdrawal

Narcotic Antagonist: Drug of choice for Overdose Drug of choice for

Valium (Diazepam) Methadone Detoxification ALCOHOLISM

(for seizures) Drug of choice for Narcotics

Alcohol Abuse - Awake, happy----socializing - A way of escape from problems - D/T peer pressure Etiology: Theory of Intergenerational Transmission (child imitating parents) Physiology:

ALCOHOL BLOCKOUT CONFABULATIO

N
Awake but unaware Inventing stories to increase selfesteem I am not an alcoholic I cant live without you a. Physical tremors, tachycardia,

D
restless

ENIAL EPENDENCE

b. Psychological Carving

CODEPENDECY
tolerated by the body
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

ENABLING or

Significant other tolerates abuser Increased Drinking

37

Tolerance

MANAGEMENT

A
B C

VOIDs ALCOHOL VERSION THERAPY LCOHOLICS ANONYMOUS NTABUSE (Disulfiram)

Ask 1st the time of last alcohol intake before giving Anatabuse: There should be a 12 HOUR INTERVAL NEVER take alcohol with antabuse OR ELSE Nausea & Vomiting

Problems of Alcoholics: 1 VIT. DEFICIENCY(Thiamine) Monitor for: WERNICKES ENCELOPATHY (motor problems) KORSAKOFFS Provide well-lit room to avoid

OMPLICATIONS

SNS stimulation Within 24-72 of withdrawal

D ELIRIUM TREMORS
Tremors, Hallucinations, Illusions

F
THERAPY: 1.

&

ORMICATION AMILY THERAPY

Feeling of bugs crawling under the skin

DETOXIFICATION

- Withdrawal with MD Supervision

Role of the Nurse: Alcohol CHECK belongings for: Mouthwash Elixir (alcohol-based) ASK TIME of last alcohol intake to monitor delirium SELF-HELP vs. GROUP THERAPY Nurse as organizer Nurse as facilitator e.g. Alcoholics

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

38

XII.

P H A R M A M O M E N T S

ANTI-ANXIETY

AGENTS

V L A S T

alium ibrium tivan erax ranxene

M iltown E quanil V
istaril A tarax

I B uspar

nderal

(Used also for Alcohol Withdrawal) VLAST ME VAIB

THE AUTONOMIC NERVOUS SYSTEM

(2 Neurotransmitters) Epinephrine/ Norepinephrine excite the SNS Gamma aminobutyric acid (GABA) (Stops) inhibits SNS

ANTI-ANXIETY AGENTS
ANXIETY E/ NE ANTI CHOLINERGIC Constipation Retention Dry mouth Blurred vision *Effects of GABA: Drowsiness Orthostatic Hypotension *Contraindicati ons No coffee No alcohol Do not drive

GABA

If ABRUPT Withdrawal: Rebound phenomenon Within 1 wk Seizures

ANTI-ANXIETY AGENTS GABA

WITHDRAWAL

Recommended: Gradual Withdrawal Tapered dose

D E P E N D E N C E

RELAXED

To prevent Orthostatic Hypotension: S it D angle S tand gradually

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM 39

All Medications Taken On Full Stomach-------except Anti-Anxiety

ANTI-DEPRESSANTS sendin orpramin ofranil inequan rozac (ssri) A nafranil

A N T S

A ventyl V ivactil E lavil P P axil

Serotonin

Serotonin Give ANTIDEPRESSANTS ------------------taken on full

stomach

Serotonin S afest S ide effects low R I to 4 wks Selective Serotonin Reuptake Inhibitors

Serotonin & NE T wo to 4 wks wo neurotransmitters C A * Higher incidence of side effects Tricyclic

Serotonin, NE & Dopamine M ono A mine O xidase I inhibitors *2-6 wks effect MAO destroys serotonin; MAO will

With MAOIs , AVOID TYRAMINE-RICH FOODS or else HYPERTENSIVE CRISIS Diaphoresis Tyramine rich foods:

A vocado
foods ged cheese B eer foods

F ernented

P ickles reserved

MONOAMINE OXIDASE INHIBITORS ( MAOIs)

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM M

N P

PLAN DIL NATE

Marplan Nardil

40

AR
ANTI-PARKINSON AGENTS CAPABLES

C ogentin A rtane P arlodel

ldedpryl A kineton ymmetrel 2 CLASSIFICATION

B enadryl L
arodopa

E S

ANTICHOLINERGICS ABC A kineton, Artane B enadryl C ogentin

DOPAMINERGICS PLSE P arlodel L arodopa S ymmetrel E ldepryl

ANTI-PSYCHOTICS

rolixin

S tellazine S erentil T horazine T rilafon

SNS Effect-------2-4 wks

C lozaril M ellaril H aldol P

TRANQUILIZERS Produces emotional relaxation/calmness 2 Types Minor Anxiolytics (ANTI-AXIETY) PSYCHOTIC) Valium Anxionil Ativan Tranxene Xanax Serax Librium Equanil
Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

Major Neuroleptics (ANTIThorazine Haldol Serenace Mellaril Trilafon Proloxin Modecate Clozaril
41

Miltown Action: Anxiety CNS Depressant

Risperdal Dopamine Produces EPS

Acts on Limbic system Responsible for alertness S/E: Habit-forming, Produces Drug Tolerance
VLASTMEVAIB ANXIETY E/NE
Anticholinergic S/E Constipation Dry mouth Blurred vision

SSTTCMHP SCHIZOPHREN D
Always ON EPS/E Akathisia Akinesia Dystonia Tardive Dyskinesia NMS Ach

MANIA NE

ANTI-ANXIETY GABA

ANTIPSYCHOTICS D

N ausea
T H

S/E

Drowsy X alcohol X coffee X drive eqpmt Orthostatic Hypotension

gradual

D Anticholinergic Dopaminergic ABC PLSE Constipation retention

I U

N
M

Vomiting Diarrhea a

Diarrhea Frequency

RELAXED

SSRI PPZ

Serotonin only Anticholinergic S/E Constipation Retention Male Erectile Dysfuncion

Serotonin TCA /NE ANTSAVE

ANTI-DEPRESSANTS

all

Health Teaching To All: Drug Compliance

NO to Tyramine or else HYPERTENSIVE CRISIS

MAOIs MNP

Serotonin DEPRESSI

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

42

Table 1. Somatoform Disorder (DSM-IV) Temporal & Other Requireme nts Onset <30 y of age Exclusions By Other Psychiatric Illness Not specified

Somatoform Disorder (DSM-IV) Somatization Disorder

General Description History of many physical complaints; 4 pain sites or functions: 2 nonpain GI, 1 sexual or reproductive, 1 pseudoneurologic

Other Exclusions

Not explained by general medical condition or substance effect

Undifferentia One or more ted physical somatoform complaints disorder Conversion Disorder

Duration >6 Not accounted mo for by another mental disorder Not limited to pain or sexual dysfunction; not exclusively during course of somatization disorder; not better accounted for by other mental disorder

Not explained by medical condition or pathophysiologic mechanism Not intentionally produced or feigned; not explained by other neurologic or medical condition, substance effect, or culturally sanctioned behavior and/or experience

Symptoms Associated affecting voluntary psychologic motor and/or al factors sensory function suggesting neurologic and/or medical condition

Pain Disorder

Pain is predominant focus; severe enough to warrant clinical attention

Psychologic al factors in important role

Not better Not specified accounted for by mood, anxiety, or psychotic disorder; does not meet criteria for dyspareunia Not of delusional intensity; not restricted to circumscribed concern about appearance

Hypochondri asis

Preoccupation Duration >6 Not exclusively with fear of having mo during obsessive or idea that one compulsive has serious disorder (OCD), disease based on generalized misinterpretation anxiety, panic of bodily disorder, major

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

43

symptoms; persistent fear and idea despite medical evaluation and reassurance Body Dysmorphic disorder Preoccupation with imagined defect in appearance or excessive concern about slight physical anomaly Somatoform symptoms Not applicable

depressive episode, separation anxiety, or other somatoform disorder Not better Not specified accounted for by other mental disorder

Somatoform disorder, not otherwise specified

Can be <6 Does not meet mo duration criteria for any other somatoform disorder

Not specified

Note.To qualify for this category of diagnoses, the symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

Ni: jigglypuff,CPE,RN,RM,RPrT,MAN,DNM

44