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SUMMARY OF PSYCHIATRIC DISORDERS

ANXIETY DISORDERS

Individuals experience a degree of anxiety that is so high that it interferes with personal, occupational, or social functioning. ANXIETY DISORDERS are the most common
CONCEPT form of psychiatric Disorder in the USA.
OBSESSIVE-
TYPES/ PANIC DISORDER GENERALIZED ANXIETY PHOBIAS COMPULSIVE POST-TRAUMATIC STRESS DIRORDER (PTSD)
SUBTYPES DISORDER (GAD) DISORDER (OCD)
1.The patient experiences recurrent panic 1. More than 6 months of 1. The client fears a 1. The client has intrusive 1. Exposure to a traumatic event causes intense fear,
attacks uncontrollable, excessive, unrealistic specific object or situation thoughts of unrealistic horror, flashbacks, feelings of detachment and
2. Episodes typically last 15-30 minutes worries (inadequacy in interpersonal to an unreasonable level. obsessions and tries to foreboding, restricted affect, and impairment for longer
3. Four or more of the following symptoms relationships, job responsibilities, Phobias include: control these thoughts with than 1 month after the event. Symptoms may last for
are present: finances, health of family members, -SOCIAL PHOBIA compulsive behaviors, years.
-Palpitations, SOB, Choking or Smothering household chores, and lateness for -AGORAPHOBIA which are repetitive – -ACUTE PTSD: Symptoms last less than 3 months-
Sensation, Chest Pain, Nausea, Feelings of appointments) -SPECIFIC PHOBIAS: ritualistic- CHRONIC PTSD: Symptoms last more than 3 months
Depersonalization, Fear of Dying, Chills or 2. GAD causes significant impairment -Fear of specific objects -Clients who engage in SYMPTOMS:
Hot Flashes, Fear of going crazy, Decreased in one or more areas of functioning. (snakes, spiders, constant ritualistic behaviors -Recurrent, intrusive recollection of event
perceptual and cognitive abilities 3. At least 3 of the following symptoms strangers) may have difficulty meeting -Dreams or images
FEATURES 4. Pt may experience Changes in Behavior are present: -Fear of specific self-care needs-If rituals -Reliving through flashbacks, illusions, or hallucinations
and/or Persistent Worries about when the next -Fatigue experiences (flying, being include constant -Irritability, difficulty with concentration, sleep
attack will occur -Restlessness in the dark, riding an handwashing or cleaning, disturbances, avoidance of stimuli associated with
5. May experience Agoraphobia due to fear of -Inability to Concentrate elevator, being in an skin damage and infection trauma, inability to show feelings.
being in places where previous panic attacks -Irritability enclosed space) may occur. (it differs from Acute Stress Disorder in that ASD occurs
occurred. -Muscle Tension after exposure to a traumatic event, causing numbing,
*MAY BE CONFUSED WITH A HEART -Sleep Disturbances detachment and amnesia about the event for NOT MORE
ATTACK 4. Characterized by Remissions and than 4 weeks following the event, with symptoms lasting
*DOES NOT NECESSARILY FOLLOWS AN exacerbations (no acute anxiety attack) from 2 days to 4 weeks)
STRESSFUL, IDENTIFIABLE EVENT
1. Perform a thorough Physical and Neurological examination to help determine if anxiety is primary or is secondary to another psychiatric disorder, a medical condition, or substance use.
2. Assess Risk for Suicide
ASSESSMENT
3. Perform psychosocial assessment (To help client identify the problem to be addressed by counseling (stressful marriage, recent loss, stressful job or school situation)
4. Assess coping mechanisms
5. Use a standardized assessment scale, such as Hamilton Rating Scale for Anxiety.
EXPECTED 1. Client uses coping mechanisms to prevent panic anxiety when stressful situations occur.
OUTCOMES 2. Client verbalizes acceptance of life situations over which he or she has no control
3. The client is able to recognize signs of anxiety and intervene to prevent panic levels
1. Ensure Safety
In General, Interventions for Anxiety disorders attempt to: 2. Stay with the client and provide support (Provide reassurance, use therapeutic communication skills, use
INTERVENTIONS open-ended questions, encourage client to verbalize feelings)
1. Reduce Anxiety 3. Use relaxation breathing techniques as needed
2. Increase Self Esteem 4. Reduce environmental stimuli
3. Increase Reality Testing 5. Encourage physical activity like walking
4. Enhance Coping Mechanisms 6. Administer medications as prescribed (SSRIs, TCAs, MAOIs, Benzodiazepines (anxiolytics), Beta Blockers,
5. Instill Hope Mood stabilizers)
6. Relaxation Therapy 7. Instill hope (but avoid false reassurance)
8. Enhance Self Esteem by encouraging positive statements about self and discussion of past achievements.
9. Postpone teaching until acute anxiety subsides: clients with panic attack or severe anxiety are unable to
concentrate or learn.
10. Teach to limit nicotine and caffeine
11. Promote sleep with comfort measures
PANIC DISORDER: GENERALIZED ANXIETY PHOBIAS OBSESSIVE- POST-TRAUMATIC STRESS DISORDER (PTSD)
DISORDER (GAD) COMPULSIVE
MEDICATIONS DISORDER (OCD) 1. SSRIs
1. SSRIs 2. TCAs
2. Benzodiazepines 1. SSRIs 1. SSRIs 1. SSRIs (Especially 3. Benzodiazepines
*SSRIs are First line 3. TCAs 2. TCAS 2. Benzodiazepine Luvox) 4. SNRIs
for all anxiety 4. MAOIs 3. Buspirone (Buspar) s 2. TCAs (Especially 5. MAOIs
Disorders except 5. Beta Blockers 4. SNRIs 3. Buspirone Anafranil) 6. Beta-Blockers
AAA (see bellow) 6. Depakote (Valproic Acid) 5. Depakote (Valproic Acid) (Buspar) 7. Carbamazepine (Tegretol)
4. Beta Blockers
*Benzodiazepines 5. Gabapentin
shouldn’t be used to (Neurontin) +
treat GAD: this is a + + +
chronic disease and +
benzos should only
-Cognitive-Behavioral
be used for short
Cognitive-Behavioral Cognitive-Behavioral Therapy Behavioral -Family
periods of time, like Therapy Cognitive-Behavioral Therapy -Group Therapy with survivors
in Acute Anxiety *No Benzodiazepines Therapy
Attack (AAA)

Defense mechanisms: Nursing Diagnosis:


-Risk for Suicide (=Risk for self-directed violence) FOR ACUTE ANXIETY ATTACK (AAA)
MISC Phobia: Displacement -Risk for others-directed violence First Line of Treatment: Benzodiazepines (the only time this group is first
Compulsion: Undoing -Risk for injury to self or others
Obsession: Reaction-Formation/ Intellectualization -Anxiety (moderate, severe)
line for anxiety disorders)
PTSD: Isolation/ Repression -Ineffective role performance
-Ineffective coping
-Disturbed thought process
-Disturbed Sleep Pattern
-Self-care deficit
MOOD DISORDERS (AFFECTIVE DISORDERS)

DEPRESSION BIPOLAR DISORDER


TYPES/ • Bipolar disorders are mood disorders with recurrent episodes of depressionand mania. Phases vary depending on
SUBTYPES MAJOR DEPRESSIVE DISORDER DYSTHYMIC DISORDER the type of bipolar disorder.
(MDD) (DD) OR DYSTHYMIA • Bipolar disorders usually emerge in late adolescence/early adulthood, but can be diagnosed in the school-age as
well.
TYPES OF BIPOLAR DISORDERS:
BIPOLAR I: At least 1 episode of Mania alternating w/ Major Depression.
BIPOLAR II: Hypomanic episodes alternating w/ Major Depressive ones.
CYCLOTHYMIA: At least 2 years of alternating episodes of Hypomanic Episodes alternating w/ Minor Depressive
episodes (dysthymia)
BEHAVIORS shown with Bipolar Disorders include:
MANIA: Abnormally elevated mood, also described as expansive or irritable. HYPOMANIA: A less severe episode of
mania that lasts at least 4 days accompanied by 3 or 4 symptoms of mania.
MIXED EPISODE: A manic episode and an episode of major depression experienced by the client simultaneously.
Marked impairment in functioning and may require admission to prevent self-harm or others-directed violence.
RAPID CYCLING: Four or more episodes of acute mania within 1 year

***BIPOLAR DISORDER IS ASSOCIATED WITH THE HIGHEST RATE OF SUICIDE OF ANY PSYCHIATRIC
DISORDERS.
• A single, recurrent, or chronic episode (s) • A milder form of depression that
of depression resulting in a significant usually has an early onset, such as
CONCEPT change in the client’s normal functioning childhood or adolescence
(social, occupational, self-care) (Chronic Depressed Mood) IT
accompanied by at least 5 specific LASTS:
symptoms. • More than 1 year (for Children
• These symptoms must happen almost every and Adolescents)
day, last most of the day, and occur • More than 2 years (For Adults)
continuously for a minimum of 2 years. • Contains at least 3 symptoms of
depression, and may, later in life,
become Major Depressive
Disorder
• Depressed Mood • Depressed Mood
• Insomnia/Hypersomnia • Insomnia/Hypersomnia MANIA HYPOMANIA
• Decreased ability to concentrate • Decreased ability to concentrate
• Anergia (Lack of Energy) • Anergia 1. Severe enough to cause a marked impairment in 1. Associated with an unequivocal change in
• Significant weight loss or gain (of more • Decreased Self Esteem occupational activities, usual social activities, or functioning that is uncharacteristic of the person
than 5% of body weight in 1 month) • Feelings of Hopelessness and relationships. when not symptomatic
• Indecissiveness Despair
• Decreased/Increased Appetite OR 2. The disturbance in mood and the change in
• Increase or Decrease in motor activity functioning are observed by others
• ****Suicidal Ideations **** 2. Necessitates hospitalization to prevent harm to self
Specifiers (Features)
• Anhedonia (Inability to feel pleasure in or others, or there are psychotic features
FEATURES
life) 3. Absence of marked impairment in social or
• Early Onset (before 21 y/o)
Specifiers (Features): 3. Symptoms are not due to direct physiological effects occupational functioning.
• Late Onset (21 years or older) of substance (drug abuse, medication, alcohol) other
• Atypical Features (Appetite medical condition (hyperthyroidism) 4. Hospitalization not indicated
• PSYCHOTIC FEATURES (Hallucinations, changes, weight gain,
Delusions etc) Hypersomnia, extreme sensitivity
• POSTPARTUM ONSET (Begins within 4 to perceived interpersonal 5. Symptoms are not due to direct physiological effects
weeks of childbirth, known as Postpartum rejection) of substance (drug abuse, medication, alcohol) other
Depression) medical condition (hyperthyroidism)
• SEASONAL FEATURES (SEASONAL
AFFECTIVE DISORDER –SAD-)
(Generally occurring in fall or winter, and
remitting in Spring)
• CHRONIC FEATURES (Episode lasts over
2 years)

• History of prior episodes of depression BIOLOGICAL THEORIES:


ETIOLOGY • Family history of depression, especially first degree relatives • Genetic Factors: Strong genetic component
& Risk Factors • History of Suicide attempts and/or family history of suicide • Neurobiological Factors: Neurotransmitters (NE,Dopamine and Serotonin) INCREASED: Mania
• Female Gender DECREASED: Depression
• Age 40 years or younger • Neuroendocrine Factors: Hypothyroidism: Depressed mood and rapid-cycling
• Postpartum period
• Neuroanatomical: Prefrontal cortex (PFC) and Medial Temporal Lobe (MTL) dysregulation
• Medical Illness
SOCIOLOGICAL FINDINGS: More prevalence in the upper socioeconomic classes. Reason unclear; it seems people
• Absence of Support System
with BD achieve higher levels of education and higher occupational status than nonbipolar individuals
• Negative, stressful life events PSYCHOLOGICAL INFLUENCES: There seems to exist an association between high expressed emotions and
• Active alcohol or substance abuse relapse. Abused children tend to reveal BD earlier in life than non abused ones.

MAJOR DEPRESSIVE DISORDER DYSTHYMIC DISORDER MANIA HYPOMANIA


(DD) OR DYSTHYMIA
• Assess Suicide Potential (applies also for Bipolar Disorder) • Labile moods • Talks and jokes incessantly (“life of the party”)
ASSESSMENT Follow Algorithm “SAD PERSONS” (Sex _male- Age –25-44 or more 65-Depressed • Inappropriate and intrusive behavior • Demands constant attention
+ mood, Previous attempt(s), ETOH-alcohol-, Reality testing impaired, Social support (lack), • Profane speech; crude sexual remarks • Treats everyone with familiarity; often crude.
Additional Organized plan, No spouse, Sickness (severe or chronic) • Flight of ideas; may have clan associations (rhyming) • Sexual talk often inappropriate and obscene; proposes to
Symptoms • Assess Risk factors for Depression • Good humor turns into rage and hostility, especially when strangers
Follow the algorithms “SIGECAPS” (Sleep disturbances, Interest –decreased-,Guilt, not getting his way or controls are set. • Flits from topic to topic
Energy -decreased-, Concentration –decreased-, Appetite –decreased/increased-, • Quick shifts in moods, hostile to docility • Full of pep, humor, euphoria and sociability
Psychomotor movements, Suicidal Ideation • Grandiose delusions • Inflated self confidence and enthusiasm. Many plan to
Other areas to assess: • Judgment extremely poor become rich and famous
• Decreased attention span and distractibility • Poor judgment; involved with schemes in which job,
• Affect
• Restless, disorganized and chaotic behavior difficult to financial, o marriage is destroyed.
• Thought processes • High degree of involvement with the rich and famous;
control; frequent outbursts and briefly assaultive when
• Feelings crossed world-wide phone calls
• Guilt • Too busy for sex • Decreased attention span, overactive
• Physical Behavior • No time to eat or sleep. Too distracted and disorganized • Increased sexual appetite,; sexually irresponsible and
• Communication • Severely hyperactive and restless. Can result in indiscreet; illegitimate pregnancies, increased incidence of
exhaustion and death. venereal diseases. Sex used for escape, not for relating.
• Same as Hypomanic with finances, but extreme • Voracious appetite, gobbles food, eats on the run
• May go without sleeping, unaware of fatigue
• Remains Safe • Financially extravagant; buying sprees, gives money and
• Verbalizes hope for the future gifts freely. Goes easily into debt.
EXPECTED • Wears extravagant, often inappropriate clothes and jewelry.
• Identifies precursors of depression
OUTCOMES
• Reports improved mood
• Develops strategies to cope with stress and painful feelings
• Exhibits no evidence of physical injury
• Has not harmed self or others
FOR DEPRESSION:
• Is not longer exhibiting signs of physical agitation
• Safety!! Prevent Suicide!!
• Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status
• Encourage to verbalize feelings • Accepts responsibility for own behaviors
• Assist through grief process • Does not manipulate others for gratification of own needs
• Increase Self Esteem and Reality Testing • Interacts appropriately with others
• Decrease Anxiety
• Confront anger
• Administer medications & assess effects
• Teach coping mechanisms, disease process and medication regimen
• Ensure all basic needs are met
• Approach: caring, supportive, and firm
• Have patient sign “No Suicide Contract”: To take responsibility and make
commitment.
FOR SUICIDE
• Safety in the environment!!
• One-to-one nurse-client relationship
• “No Suicide” contract
• Non-judgmental, accepting attitude
• Encourage verbalization of feelings
• Provide Hope
• Assist in meeting basic needs
• Provide diversional activity
• Ensure safety in the environment
• Decrease Anxiety: use firm, calm approach, use short and concise explanations
• Remain neutral,
INTERVENTIONS
• Give simple step-by-step instructions
• Set limits and tell in concrete terms consequences of inappropriate behavior
• Firmly Redirect violent behavior (use distraction)
• Decrease environmental stimuli
• Structured solitary activities with staff
• High calorie, high protein “finger foods” snacks and drinks. Avoid caffeine.
• Provide frequent rest periods
• Administer and make sure pt takes prescribed medications
• When violent or extreme agitation use antipsychotics and seclusion
• Monitor lithium levels/observe s & s of toxicity
MEDICATIONS/ 1. SSRIs (First Line treatment)
TREATMENT 2. TCAs
MODALITIES 3. MAOIs 1. ANTIPSYCHOTICSs & BENZODIAZEPINES (Initially, used to calm manic symptoms until Lithium
4. ATYPICAL ANTIDEPRESSANTS therapeutic levels and full effects are achieved, in approx. 14 days)
2. MOOD STABILIZERS (Lithium, Anticonvulsives)
PSYCHOLOGICAL TREATMENTS:
• Individual Psychotherapy
• Group Therapy
• Family Therapy
• Cognitive Therapy
ORGANIC TREATMENTS:
• ECT
• PSYCHOPHARMACOLOGY
• ALTERNATIVE OR COMPLEMENTARY THERAPY
Suicide Facts
OTHER 1. Depression is the fourth leading cause of disability in the US. • Most common method: firearm
FACTS 2. Twice as common in women as in men • Most common sex: males
3. Suicides are more common in men than women • Most common occupations: Physicians, dentists, nurses, Social workers
4. It is partially hereditable • Elderly attempt suicide less often, but have higher completion rate (more lethal methods)
• Suicide is more common in people with comorbidities (Major depression, bipolar disorder, schizophrenia,
alcohol and substance abuse, borderline and antisocial personality disorders, panic disorder)

PERSONALITY DISORDERS (PDs)

A personality disorder is an enduring pattern of inner experience and behavior that: 1. Deviates markedly from the expectations of one’s culture 2. Is pervasive, maladaptive and
inflexible, 3. Has an onset in adolescent or early adulthood 4. Is stable over time and 5. Leads to distress or impairment
CONCEPT
ALL PERSONALITY DISORDERS have four common characteristics:
-Inflexibility/maladaptive responses to stress
-Disability in social and professional relationships
-Tendency to provoke interpersonal conflict
-Capacity to cause irritation or distress in others

CLUSTERS CLUSTER A CLUSTER B CLUSTER C


Odd or Excentric Traits Dramatic, Emotional, or Erratic Traits Anxious or Fearful Traits; Insecurity and Inadequacy
PERSONALITY
TYPES PARANOID SCHIZOID SCHIZOTYPAL ANTISOCIAL BORDERLINE HISTRIONIC NARCISSISTIC AVOIDANT DEPENDENT OBSSESIVE-
COMPULSIVE
Characterized by Characterized Characterized Characterized by Characterized by Characterized by Characterized by Characterized by Characterized by Characterized by
Distrust And Emotional by Odd Beliefs, consistent Instability of Emotional Arrogance, Social Inhibition Extreme Perfectionism
Suspiciousness Detachment, leading to Disregard for Affect, identity Attention-Seeking Grandiose Views of and Avoidance of Dependency in a with a focus on
Towards Others, disinterest in close interpersonal Others with and Behavior, in which Self-Importance, the all situations that close Relationship orderliness and
based on the belief relationships, and difficulties, an exploitation and Relationships; the person needs to need for constant require with an urgent control .They
(unsupported by indifference to eccentric repeated unlawful fear of be the center of admiration along interpersonal search to find a become so
evidence) that praise or criticism; appearance, and actions, deceit and abandonment, attention; often with a lack of contact, despite replacement when preoccupied with
FEATURES others want to often magical failure to accept splitting seductive and empathy for others wanting close one relationship details and rules
exploit, harm, or uncooperative. thinking or personal behavior, flirtatious, the that strains most relationships, due ends; the most that they may not
deceive the The person with perceptual responsibility. manipulation, histrionic person is relationships; often to extreme fear of frequently-seen be able to
person. These this disorder does distortions that Previously called and impulsive and sensitive to criticism. rejection; often personality disorder accomplish a
individuals are: not seek out or are not clear Psychopaths or impulsiveness; melodramatic. Underneath the very anxious in in the clinical given task.
-Hypervigilant enjoy close delusions or Sociopaths. There often tries self- Relationships do surface of arrogance, social situations. setting. Individuals Persons with
-Anticipate relationships. hallucinations. is a clear history of mutilation and not last b/c their narcissistics feel Because in their with Dependent PD Obsessive-
hostility These individuals conduct disorder in may be suicidal. partner often feels intense shame and social presentation have difficulty Compulsive PD
-May provoke may be able to childhood, and the Individuals w/ smothered or reacts fear that if they are they appear timid making independent feel genuine
hostile responses function in a individual show no Borderline PD to the insensitivity “bad” they will be and with low self- decisions and are affection for
by initiating a solitary remorse for hurting desperately seek of the histrionic abandoned. They are esteem and poor constantly seeking friends and
“counterattack” occupation. others. They relationships to person. The afraid of their own self-care, they are reassurance. Their family, and don’t
-Demonstrate repeatedly: avoid feelings of individual with mistakes, as well as often mistreated in submissiveness have insight
jealousy, Schizoid PD can -Neglect abandoned, but histrionic PD has the mistakes of groups. If they do makes them about their own
controlling be a precursor to responsibilities often drive no insight into his others. May seek develop vulnerable to difficult behavior
behaviors, and schizophrenia or -Tell lies others away b/c role in breaking up help, feeling that relationships, they abusive creating tension
unwillingness to delusional -Perform of their excessive relationships. In the loved ones do not cling to their relationships. The in their close
forgive. disorder. There is destructive or demands, treatment setting, show enough partners in a have a deeply held relationships, in
**Paranoid people increased illegal acts, without impulsive the person appreciation of their dependent way. conviction of which the person
are difficult to prevalence of the developing any behavior, and demands “the best special qualities. They are seen in personal tries to control
interview b/c they disorder in insight into their frequent use of everything” and Tx for symptoms incompetence that the partner.
are reluctant to families with predictable of splitting. can be very critical of anxiety. they cannot survive
share information schizophrenia or consequences. on their own.
about themselves. schizotypal PD.
1. Minnesota Multiphasic Personality Inventory (MMPI)
ASSESSMENT 2. Full medical history to rule out medical causes
3. Psychosocial history :
• Suicidal, homicidal, or aggressive thoughts.
• Current use of medicines and illegal substances
• History of current or abuse
• Legal history
• Ability to handle money
• Current or past physical, sexual, or emotional abuse
• Risk of harm of self and others
EXPECTED The patient will be able to:
OUTCOMES • Use adaptive coping strategies to deal with conflict
• Accept responsibilities for own actions/behaviors
• Communicates needs appropriately
• Demonstrate self-restrain of compulsive or impulsive behavior
*Usually not admitted for Personality Disorders. For a patient to be eligible for admission to the hospital, must have an AXIS I psychiatric diagnosis, plus the AXIS II Personality Disorder.
*Realistically, behavior probably will not change significantly
CLUSTER A CLUSTER B CLUSTER C
Odd or Excentric Traits Dramatic, Emotional, or Erratic Traits Anxious or Fearful Traits; Insecurity and Inadequacy
• Objective, matter-of-fact approach • Prevent self-harm. No harm contract. • Caring consistent approach
• Avoid being too “nice or friendly” • Set limits on inappropriate or manipulative behaviors • Clear expectations for behavior
• Clear, simple, consistent verbal-non-verbal • Provide clear, consistent boundaries • Expect patient to make decisions
communication • Assist examining consequences of behavior. • Teach assertiveness
INTERVENTIONS
• Give clear straightforward explanations • Consistent approach by staff • Encourage to identify positive attributes
• Warn about changes, side effects etc • Do not rescue or reject • Provide positive feedback for increased
• Help identify feelings • Remain neutral, avoid engaging in power struggles or be coming interactions in social situations
• Assist with problem-solving defensive to patient’s comments • Teach stress management and relaxation
• Gradually involve in group situations but do • Give recognition for goal achievement techniques
not insist. Respect need for social isolation. • Explore feelings AGGRESSIVE BEHAVIOR
• Teach problem solving and role model assertiveness ANGER CONTROL ASSISTANCE!!
• Encourage and model concrete and descriptive communication -Determine appropriate behavioral expectations for
expressions of anger, given pt’s level of cognitive and
• Document behaviors and incidents objectively
physical functioning
• Encourage follow up treatment -Limit access to frustrating situations until pt is able to
express anger in an adaptive manner
-Encourage pt to seek assistance from nursing staff during
periods of increasing tension
-Monitor potential for inappropriate aggression and
intervene before its expression
-Assist pt in identifying source of anger
-Prevent physical harm if anger is directed towards self or
others
-Provide physical outlets for expressions of anger or
tension (e.g. pushing bag, sports, clay, journal writing)
MANIPULATIVE BEHAVIOR
INTERVENTIONS SET LIMITS!!
FOR: -Discuss concerns about behavior with patient
-identify undesirable behavior, and discuss with
patient what is desirable behavior in a give situation IMPULSIVE BEHAVIOR
or setting IMPULSE CONTROL TRAINING!!
-Establish consequences for occurrence or -Assist pt to: Identify problem or situation that requires thoughtful action, and
nonoccurrence of desired behavior in a non punitive courses of possible actions, their costs or benefits
ad easily understood way -Teach pt to cue himself to “stop and think” before acting impulsively
-Refrain from arguing or bargaining with patient -Assist pt to evaluate the outcome of the chosen course or action
about established behavioral expectations and -Provide positive reinforcement for successful outcomes (e.g. praise and
consequences rewards)
-Modify behavioral expectations as needed based on -Provide opportunities for pt to practice problem solving in social and
reasonable changes in patient’s situations interpersonal situations outside the therapeutic environment
PSYCHOBIOLOGICAL INTERVENTIONS: Clients with Personality Disorders usually do not like taking medications unless it calms them down; they are fearful about taking something over which they have no
MEDICATIONS control. They worry if they don’t have an adequate supply, but have difficulty organizing themselves to fill a prescription. Dependent on the chief complaint, psychotropic agents that are geared toward maintaining
cognitive function and relieving symptoms may be used. These include: ANTIDEPRESSANTS, ANXIOLYTICS, ANTIPSYCHOTICS, or a combination of these.

MILIEU THERAPY: When individuals with PDs are in hospital, partial hospitalization, or day treatment settings, Milieu Therapy is a significant part of treatment.
The primary goal of Milieu Therapy is affect management in a group context. Community meetings, coping skills groups, and socializing groups are all helpful for these clients.
MISC CASE MANAGEMENT: CM is beneficial for clients who have PDs and are persistently and severely impaired. In Acute Care Facilities: CM focuses on obtaining pertinent history from current or previous
providers, supporting integration with the family/significant other, and ensuring appropriate referrals to outpatient care.
In long-term outpatient facilities, case management goals include reducing hospitalization by providing resources for crisis services and enhancing the social support system.
SCHIZOPHRENIA

• Schizophrenia is a group of psychotic disorders that affect thinking, behavior, emotions, and the ability to perceive reality.
CONCEPT • The term “Psychosis” refers to the presence of hallucinations, delusions, or disorganized speech or catatonic behavior.
• The typical age at onset is late teens and early twenties, but schizophrenia has occurred in young children and may begin in later adulthood.

TYPES/ PARANOID DISORGANIZED CATATONIC RESIDUAL UNDIFFERENTIATED


SUBTYPES (MIXED TYPE)
• Characterized by • Characterized by withdrawal • Characterized by abnormal motor movements. • Active-phase (positive) symptoms • Client has symptoms for
suspicion toward from society and very • There are two stages: the withdrawn stage and are not longer present (Delusions, schizophrenia, but does not meet
others inappropriate behaviors, such the excited stage. hallucinations, disorganized speech criteria for any of the other types
• Dominant: as poor hygiene, or muttering • WITHDRAWN STAGE: and behaviors) (no one clinical presentation
Hallucinations and constantly to self. o Psychomotor retardation; client may • However, the client has two or dominates (e.g. paranoid,
Delusions (positive • Frequently seen in the homeless appear comatose. more “residual symptoms” (some disorganized, catatonic)
symptoms) population o Waxy Flexibility or stupor negative symptoms) such as: • Any positive or negative
• NO Disorganized • Dominant: Disorganized speech, o Echolalia and/or Echopraxia o Marked social isolation or symptoms may be present (has
FEATURES speech, disorganized disorganized behavior, and o Client often has extreme self-care needs, withdrawal active-phase symptoms (does have
behavior, catatonia or inappropriate affect. such as for tube feeding due to inability o Impaired role function (wage hallucinations, delusions, and
inappropriate affect • Marked regression to eat earner, student, homemaker) bizarre behaviors)
present. (No negative • EXCITED STAGE: o Anergia, Anhedonia, or • Eccentric
• Poor Reality Testing
symptoms) o Peculiar voluntary movement: Unusual Avolition • Psychotic features are extreme:
• Poor social skills
posturing, Stereotyped movements, o Alogia (speech problems) o Fragmented delusions
• Inappropriate emotional
Prominent mannerisms, Prominent o Odd behavior, such as o Vague hallucinations
responses
Grimaces walking in a strange way o Bizarre, disorganized
• Outbursts of laughter
o Excessive purposeless motor activity o Impaired personal hygiene behavior
• Silly behavior o Disorientation, Incoherence
(agitation) o Lack of initiative, interest or
o Self-care needs may predominate energy
o Client may be a danger to self or others o Blunted or inappropriate
affect
Diagnostic criteria: The four “A”s:
1. Affect: Refers to the outward manifestation of a person’s feelings or emotions. In Schizophrenia, clients may display flat, blunted affect.
ASSESSMENT 2. Associative Looseness: Refers to haphazard and confused thinking that is manifested in jumbled and illogical speech and reasoning. The term “looseness of association” is also used
3. Autism: Refers to thinking that is not bound to reality, but reflects the private perceptual world of the individual. Delusions, hallucinations, and neologisms are examples of autistic thinking in
persons with schizophrenia. (Also termed as “response to internal stimuli”)
4. Ambivalence: Refers to simultaneously holding two opposite emotions, attitudes, ideas, or wishes toward the same person, situation, or object.
DISEASE Schizophrenia is characterized by periods of exacerbations and remissions. Has three phases:
PROGRESSION: o ACUTE PHASE: Periods of both positive and Negative symptoms
o MAINTENANCE PHASE: Acute symptoms decrease in severity
o STABILIZATION PHASE: Symptoms in remission
o Alterations in perception: Hallucinations: Sensory perceptions for which no external stimulus exists (auditory, visual,
olfactory, tactile), Personal Boundary Difficulties, Depersonalization, Derealization
CHARACTERISTIC o Alterations in thinking:: Delusions: A false belief held and maintained as true, even with evidence to the contrary, concrete
DIMENSIONS OF POSITIVE SYMPTOMS: thinking, thought broadcasting, thought insertion, thought withdrawal, delusions of being controlled)
SCHIZOPHRENIA o Alterations in speech: Associative looseness (Disorganized Speech), Neologisms, Echolalia, Clang Association, Word
(No single symptom is These are the most easily identified symptoms
Salad.
always present in all
cases) o Alterations in behavior (Bizarre behavior): Extreme motor agitation, stereotyped behaviors, Automatic obedience, waxy
flexibility, stupor, negativism)
NEGATIVE SYMPTOMS (THE FIVE “A”s): o AFFECT: usually Blunted (narrow range of normal expression) or Flat (Facial expression never changes).
o ALOGIA: Poverty of thought or speech; client may sit with a visitor but may only mumble or respond vaguely to
These symptoms are more difficult to treat successfully than positive questions
symptoms o AVOLITION: Lack of motivation in activities and hygiene
o ANHEDONIA: Inability to find pleasure in life; the client is indifferent to things that often make others happy
o ANERGIA: Lack of energy, chronic fatigue
o Disordered thinking
COGNITIVE SYMPTOMS: o Poor problem-solving skills
o Poor decision-making skills
Problems with thinking make it very difficult for the client to live o Inattention; easily distracted (Difficulty concentrating to perform tasks)
independently o Impaired judgment
o Impaired memory
 Long-term memory loss
 Working Memory loss (such as inability to follow directions to find an address)
o Hopelessness
DEPRESSIVE SYMPTOMS: o Suicidal Ideation
ACTIVE PHASE:
-Client safety and medical stabilization STABILIZATION PHASE:
MAINTENANCE PHASE: -Target negative symptoms
EXPECTED -Adherence to medication regimen -Anxiety Control
OUTCOMES -Understanding schizophrenia -Relapse prevention
-Participation of client and family in psycho educational activities
ACUTE PHASE: (Hospitalization, Client Safety, Stabilization Of Symptoms)
1. Administer antipsychotic medication as prescribed MAINTENANCE AND STABILIZATION PHASES:
2. Observe client behavior closely
INTERVENTIONS 3. Set limits on inappropriate behavior -Psychosocial education
4. Increase reality testing when delusional or hallucinating -Relapse prevention skills
5. Do not touch without warning
6. Offer foods that are not easily contaminated
7. Assist with ADLs as needed
8. Supportive counseling
9. Milieu Therapy
10. Family psycho education
TYPICAL (CLASSIC) ANTISYCHOTICS (Treatment of positive symptoms) ATYPICAL ANTIPSYCHOTICS (Treatment of both positive and negative symptoms)
o HALDOL (Haloperidol) o ZYPREXA (Olanzapine)
MEDICATIONS o THORAZINE (Chlorpromazine) o RISPERDAL (Risperidone)
o PROLIXIN (Fluphenazine) o SEROQUEL (Quetiapine)
o SERENTIL (Mesoridazine) o GEODONE (Ziprasidone)
o TRILAFON (Pherphenazine) o CLORAZIL (Clozpine)
o MELLARIL (Thioridazine) o ABILIFY (Aripriprazole)