Personality Disorders: Cluster A & B - Symptoms, Diagnosis, Treatment

MODULE 7: PERSONALITY DISORDERS CLUSTER A: PARANOID - pervasive mistrust and suspiciousness of others CM - interpret others’ actions as potentially harmful - aloof and withdrawn, guarded or hypervigilant - survey the room and its contents, look behind furniture or doors, and generally appear alert to any impending danger - sits near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, can’t show warmth or empathy - labile, quickly changing from quietly suspicious to angry - responses may become sarcastic for no apparent reason DSM V (≥4) - suspects others are exploiting/harming/deceiving - preoccupied with doubts about loyalty/trustworthiness - reluctant to confide - reads hidden demeaning/threatening meanings - bears grudges - perceives attacks on character and reacts angrily - suspicious of partner’s fidelity DEF MECH - Projection NX - approach in a formal, businesslike manner refrain from social chitchat or jokes be on time, keep commitments, and be straightforward involve px in formulating their care plan help validate px ideas before acting TX - - Psychotherapy o supportive therapy o cognitive-behavioral therapy o group therapy Pharmacotherapy o antipsychotics o anxiolytics/antidepressants EX A 40-year-old man refuses to eat hospital meals, insisting “the food is poisoned.” He isolates in his room and demands to see medication packages before taking them.  Nursing Response: Acknowledge his concerns without agreeing (“I understand you feel unsafe. The food is from our hospital kitchen and safe to eat”). Provide sealed foods, if possible, show meds in original packaging, and build trust slowly. CLUSTER A: SCHIZOID - pervasive pattern of detachment from social relationships - restricted range of emotional expression in interpersonal settings CM - constricted affect and little, if any, emotion aloof, indifferent, cold, uncaring, unfeeling report no pleasurable activities rarely experience enjoyment appears passive and disinterested under stress can’t express emotions, particularly anger or aggression can distinguish fantasies from reality has no disordered or delusional thought processes intellectually involved with computers or electronics spend hours solving puzzles or math problems - indecisive and lacks future goals or direction dissociation from or no bodily or sensory pleasures don’t have friends, rarely date or marry, have little or no sex few social skills and do not engage in social conversation DSM V (≥4) - neither desires nor enjoys close relationships, even family - almost always chooses solitary activities - little interest in sexual experiences with others - takes pleasure in a few activities - lacks close friends other than relatives - appears indifferent to praise or criticism - emotional coldness, detachment, or flattened affect DEF MECH - Dissociation - Repression - Isolation - Idealization - Fantasizing NX TX - - EX focus on improved functioning in the community the nurse can make referrals to social services Psychotherapy o individual therapy o social skill training Pharmacotherapy o no specific meds o antidepressants or low-dose antipsychotics A 32-year-old man admitted for pneumonia prefers to stay in his room, doesn’t talk to other patients, and reads books all day. He avoids eye contact, and when praised for recovering, he shrugs and shows no emotion.  Nursing Response: Respect his preference for solitude, ensure his physical needs are met, encourage but don’t force group therapy, and provide neutral, factual feedback about his progress. CLUSTER A: SCHIZOTYPAL - pervasive pattern of social and interpersonal deficits - acute discomfort, reduced capacity for close relationships - cognitive-perceptual distortions and behavioral eccentricities - may develop into schizophrenia, but most do not - precursor to schizophrenia CM - unkempt and disheveled, and their clothes are often illfitting, do not match, and may be stained or dirty - wander and, at times, become preoccupied - speech is coherent, but may be loose, digressive, or vague - use words incorrectly and bizarrely - restricted range of emotions - flat affect, sometimes silly or inappropriate - ideas of reference, magical thinking, odd beliefs preoccupation with parapsychology - great anxiety with unfamiliar people; does not improve with time or repeated exposures; rather, may intensify - have only 1 significant relationship with a 1st degree relative - may remain in their parents’ home - limited capacity for close relationships, even though they may be unhappy being alone DSM V (≥5) - ideas of reference - odd beliefs or magical thinking - unusual perceptual experiences - odd thinking and speech - suspiciousness/paranoid ideation - inappropriate or constricted affect - behavior/appearance is odd or eccentric - lack of close friends - excessive social anxiety, does not diminish with familiarity DEF MECH - Repression - Projection - Displacement - Reaction Formation - Regression NX TX - development of self-care and social skills improved functioning in the community encourages a daily routine for hygiene and grooming prepare a list of people in the community with whom they must have contact (landlord, store clerk, or pharmacist) role-play interactions that px would have with these people may be able to make written requests or use the telephone for business because f2f is uncomfortable social skills training Psychotherapy (preferred) o supportive and structured therapy - o cognitive-behavioral therapy o group therapy Pharmacotherapy o low-dose antipsychotics – for cognitive-perceptual distortions o SSRIs or antidepressants CLUSTER B: ANTISOCIAL - pervasive pattern of disregard and violation of the rights - central characteristics of deceit and manipulation CM - skillful at deceiving others (nx: validate info during assessment) - childhood: enuresis, sleepwalking, and syntonic acts of cruelty, neglectful, harsh, or even abusive parenting - adolescence: lying, truancy, sexual promiscuity, cigarette smoking, substance use, and illegal activities - normal general appearance; engaging and charming - may exhibit mild to moderate anxiety - displays false emotions - cannot empathize with the feelings of others, which enables them to exploit others without guilt - do not consider morals or ethics when making decisions - egocentric - absenteeism, theft, or embezzlement, or they may simply quit out of boredom NX DX - Ineffective Coping - Ineffective Role Performance - Risk for Other-Directed Violence DSM V (≥3) - failure to conform to social norms/laws - deceitfulness (lying, conning others) - impulsivity or failure to plan ahead irritability and aggressiveness (fights, assaults) reckless disregard for the safety of self/others consistent irresponsibility (work, finances) lack of remorse (indifferent or rationalizes) DEF MECH - Denial - Projection - Rationalization - Acting Out - Splitting NX - - TX - form a therapeutic relationship and promote responsible behavior limit setting o state behavioral limit o identify consequences o identify the expected behavior confrontation o manage manipulative behavior o point out problem behavior o help px solve problems and control emotions decreased impulsivity expressing negative emotions e.g. anger or frustration taking a time-out enhance role performance identify barriers to role fulfillment eliminate use of drugs and alcohol no specific drug Mood Stabilizers o lithium and valproate - o control aggression/impulsivity SSRIs – for irritability Antipsychotics – for severe aggression EX A 25-year-old male admitted after a bar fight jokes with staff, flirts with nurses, and convinces another patient to give him cigarettes. He blames police for his arrest, saying, “They’re just out to get me.” He shows no remorse for injuring another man.  Nursing Response: Firmly set limits (“Smoking is not allowed here”), avoid power struggles, keep interactions professional and consistent, and monitor closely for aggression toward staff/patients. CLUSTER B: BORDERLINE - most common - pervasive pattern of unstable interpersonal relationships, self-image, and affect, as well as marked impulsivity - engage in deliberate self-harm or nonsuicidal self-injury CM - disturbed early relationships with their parents - developmental independence was met with punitive responses from parents or threats of withdrawal of parental support and approval - 50% experienced sexual abuse, physical/verbal and parental alcoholism - tend to use transitional objects (teddy bears, pillows, blankets, and dolls) – sense of security - disheveled and may be unable to sit still, or they may display very labile emotions - px in the ER shows threatening suicide or self-harm may seem out of control, whereas in an OPD appear calm - dysphoric, unhappiness, restlessness, and malaise - intense loneliness, boredom, frustration, feeling “empty” - - pervasive depressed affect, it is unstable and erratic feels intense emotions (anger), but doesn’t show it hypersensitive to others’ emotions (easily trigger reactions) minor changes may precipitate a severe emotional crisis major emotional trauma when therapists take vacations excessive fear of abandonment; intolerance of being alone engage in obsessive rumination about almost anything, regardless of the issue’s relative importance report flashbacks of previous abuse or trauma (PTSD) impaired judgment and lack of care and concern for safety, such as gambling, shoplifting, and reckless driving make decisions impulsively based on emotions unstable view of themselves that shifts dramatically 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 suicidal threats, gestures, and attempts are common may also engage in binging and purging, substance abuse, unprotected sex, or reckless behavior like a drunk driver difficulty sleeping NX DX - Risk for Suicide - Risk for Self-Mutilation - Risk for Other-Directed Violence - Ineffective Coping - Social Isolation DSM V (≥5) - frantic efforts to avoid abandonment - unstable, intense relationships (idealization ↔ devaluation) identity disturbance impulsivity in potentially self-damaging areas recurrent suicidal behavior, gestures, or threats affective instability (mood swings) chronic feelings of emptiness inappropriate, intense anger transient, stress-related paranoia or dissociation DEF MECH - Splitting - Dissociations - Projective Identification - Acting Out NX TX - promote px safety, cope and control emotions establish personal boundaries realistic expectations of the relationship making a written schedule of activities making a list of solitary activities to combat boredom teaching social skills, effective comm skills entering therapeutic relationship limit setting confrontation Psychotherapy o dialectical behavior therapy (gold) – teaches emotional regulation, distress intolerance, mindfulness, and interpersonal effectiveness o cognitive behavioral therapy – restructure distorted thinking o schema-focused therapy - Pharmacotherapy o SSRIs – mood instability, depression, anxiety o Mood Stabilizers – impulsivity, aggression  Lamotrigine, Valproate o Antipsychotics – low dose for transient psychosis, anger o Benzodiazepines are avoided EX A 23-year-old woman threatens suicide after her boyfriend breaks up with her. In the ward, she first praises one nurse as “the only one who cares,” then later angrily calls the same nurse “useless” when her request is denied. She cuts her forearm with a plastic utensil during visiting hours.  Nursing Response: Ensure immediate wound care and safety, remove harmful objects, notify the team of suicidal risk, avoid taking sides in splitting behavior, reinforce unit rules consistently, and encourage participation in DBTbased skills groups. CLUSTER B: HISTRIONIC - pervasive pattern of excessive emotion & attention seeking CM - colorful and theatrical speech, full of superlative adjectives, insincere and shallow - emotionally expressive, gregarious, and effusive - will agree with almost anyone to get attention - express strong opinions very 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 - exaggerate the intimacy of relationships - hugging and kissing someone who has just been introduced or sobbing uncontrollably over a minor incident DSM V (≥5) - uncomfortable when not the center of attention - inappropriately sexually seductive or provocative - rapidly shifting and shallow expression of emotions - uses physical appearance to draw attention to self - speech is impressionistic and lacking in detail - theatrical, exaggerated emotional expression - easily influenced by others or circumstances - considers relationships to be more intimate than they are DEF MECH - Repression - Regression - Somatization - Denial - Dissociation NX TX - provide feedback about their social interactions with others, including manner of dress and nonverbal behavior feedback should focus on alternative not criticism teaching social skills and role-playing those in a safe, nonthreatening environment eye contact, engaging in active listening, and respecting personal space quite sensitive to discussing self-esteem and may respond with exaggerated emotions encourage assertiveness by using “I” Psychotherapy - o Psychodynamic Therapy – helps identify unconscious drives for attention o Cognitive-Behavioral Therapy – restructures distorted thinking and teaches healthier selfesteem o Group Therapy (with caution) – helps them see they are not “the only one,” but may try to dominate Pharmacotherapy o Antidepressant o Mood Stabilizers EX A 28-year-old female patient becomes upset when she is not the focus of a group therapy session. She suddenly begins sobbing loudly, saying, “No one cares about me, I might as well die!” Later, she flirts with a male staff member, calling him “handsome” and asking for “special treatment.”  Nursing Response: Acknowledge her feelings calmly but don’t reinforce the dramatics, redirect her back to the group, maintain clear professional boundaries, and encourage her to verbalize her emotions instead of acting them out. CLUSTER B: NARCISSISTIC - pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy CM - arrogant or haughty attitude can’t recognize or empathize express envy and begrudge others’ success tend to disparage, belittle, or discount the feelings of others - preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love they view their problems as the fault of others underlying self-esteem is fragile and vulnerable hypersensitive to criticism; sense of entitlement needs constant attention and admiration expect special treatment; angry if not given they think they are underpaid even though they are not DSM V (≥5) - grandiose sense of self-importance - preoccupation with fantasies of unlimited success, power, beauty, or ideal love - belief they are “special” and unique, only understood by other special/high-status people - requires excessive admiration - sense of entitlement - interpersonally exploitative - lack of empathy - often envious of others or believes others envy them - shows arrogant, haughty behaviors/attitudes DEF MECH - Grandiosity - Projection - Denial - Idealization and Devaluation - Splitting - Rationalization - Externalization of Blame - Fantasy and Escapism - Selective Perception - Emotional Regulation NX - TX - use self-awareness skills to avoid the anger and frustration that these clients’ behavior and attitude can engender nurse must not internalize such criticism or take it personally goal is to gain the cooperation of these clients Psychotherapy Pharmacotherapy o Antidepressant o SSRIs or Mood Stabilizers EX A 35-year-old male patient boasts that he is “smarter than all the doctors here” and demands VIP treatment in the ward. When told that rules apply to everyone, he lashes out at the nurse, saying, “You’re just jealous of me!” Later, he becomes withdrawn and irritable when ignored.  Nursing Response: Set firm but respectful limits, avoid power struggles, encourage him to express feelings without arrogance, and redirect him to constructive coping strategies. CLUSTER C: AVOIDANT - pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation CM - overly inhibited as children often avoid unfamiliar situations and people anxious, may fidget in chairs and make poor eye contact reluctant to ask questions or to make requests sad and anxious, shy, fearful, socially awkward easily devastated by real or perceived criticism - reluctant to do risky (almost anything) wish for closeness, but fear of rejection and humiliation may reject a promotion DSM V (≥4) - avoids interpersonal contact (fear of criticism/rejection) - unwilling to get involved with people unless they are liked - restraint in intimate due to fear of shame/ridicule - preoccupied with being criticized or rejected - inhibited in new social situations (feeling inadequate) - views self as socially inept, unappealing, or inferior - reluctant to take risks or try new activities DEF MECH - Avoidance - Withdrawal - Fantasy NX TX - - support and reassurance explore positive self-aspects, positive responses from others, and possible reasons for self-criticism practice self-affirmations and positive self-talk reframing and decatastrophizing can enhance self-worth teach social skills and help clients to practice them in the safety of the nurse–client relationship Psychotherapy o Cognitive-Behavioral Therapy (CBT) – challenge negative self-beliefs, exposure to social situations gradually o Group Therapy –practices social skills in a safe envi o Supportive Psychotherapy – builds self-esteem Pharmacotherapy o SSRIs or SNRIs – for coexisting anxiety or depression o Anxiolytics (short-term) – for severe social anxiety EX A 27-year-old patient avoids social gatherings and has never dated. She expresses, “I’d love to have friends, but I know people will just laugh at me.” At work, she avoids team projects for fear of criticism.  Nursing Response: Acknowledge her feelings, build a therapeutic alliance without judgment, encourage her to participate in a small support group, and provide CBTbased strategies to challenge negative thoughts CLUSTER C: DEPENDANT - pervasive and excessive need to be taken care of - leads to submissive, clinging behavior, fear of separation - common in the youngest child CM - frequently anxious and may be mildly uncomfortable often pessimistic and self-critical feeling unhappy or depressed unrealistic fears of being left alone to care for themselves tremendous difficulty making decisions seek advice and repeated reassurances can’t initiate projects or complete simple daily tasks independently reluctant to express disagreement for fear of losing the other person’s support or approval DSM V (≥5) - can’t make decisions without advice/reassurance - needs others to assume responsibility - can’t express disagreement due to fear of loss of approval difficulty initiating projects or doing things on own goes to excessive lengths to obtain nurturance/support feels helpless or uncomfortable when alone urgently seeks another relationship when one ends preoccupied with fears of being left to care for oneself DEF MECH - Introjection - Regression - Idealization NX - - TX - - help px to express feelings of grief and loss over the end of a relationship while fostering autonomy and selfreliance identify their strengths and needs reframing and decatastrophizing needs assistance in planning menu, doing the weekly shopping, budgeting money, balancing a checkbook, and paying bills teach problem-solving and decision-making Psychotherapy o Cognitive-Behavioral Therapy (CBT) – build independence, assertiveness o Assertiveness Training – learn to say no, express needs o Psychodynamic Therapy – explore origins of dependency Pharmacotherapy o SSRIs, SNRIs – comorbid depression or anxiety o Anxiolytics (short-term) – for acute anxiety. EX A 32-year-old woman repeatedly asks staff, “Do you think I’m making the right choice?” for every small decision, such as meal selection. When her partner doesn’t visit one day, she becomes panicked and tearful, saying, “I can’t survive without him.”  Nursing Response: Reassure her safety, encourage her to make small decisions independently, avoid making choices for her, and gradually increase her autonomy while providing support. CLUSTER C: OBSESSIVE-COMPULSIVE - pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency - higher incidence in oldest children CM - formal and serious - answer questions with precision and much detail - report feeling the need to be perfect beginning in childhood - expected to be good to win parental approval - can’t show emotions; rigid, stiff, formal, lacks spontaneity - very stubborn and reluctant to relinquish control - preoccupied with orderliness and tries to maintain it - strive for perfection - preoccupied with details, rules, lists, and schedules - absorbed in their own perspective, believe they are right - don’t listen to others due to dismissed what is being said - check and recheck the details - problems with judgment and decision-making - consider and reconsider alternatives - desire for perfection prevents reaching a decision - rules or guidelines cannot be flexible in any instances - prefer written rules for every activity at work have low self-esteem and are always harsh, critical, and judgmental of themselves believes that they “could have done better” regardless of how well the job has been done burdened by extremely high and unattainable standards DSM V (≥4) - preoccupied with details, rules, lists, order, organization - perfectionism that interferes with task completion - excessive devotion to work/productivity, excluding leisure/friends - overconscientious, scrupulous, and inflexible about morality/ethics - unable to discard worn-out/worthless objects - reluctant to delegate unless others submit to their way - miserly spending style toward self/others - rigidity and stubbornness DEF MECH - Intellectualization - Isolation of Affect - Reaction Formation - Undoing - Rationalization NX - help px to view decision-making and completion of projects from a different perspective set a goal of completing the project or making the decision by a specified deadline accept or tolerate less-than-perfect work or decisions made on time may benefit from cognitive restructuring technique TX - - encourage to take risks, such as letting someone else plan a family activity, may improve relationships practicing negotiation with family or friends also may help clients to relinquish some of their need for control Psychotherapy o Cognitive-Behavioral Therapy (CBT) – cognitive restructuring for rigid/dichotomous thinking; behavioral experiments to tolerate imperfection o Schema Therapy / Psychodynamic Therapy – explore early schemas about control, shame, and perfection o Group Therapy / Social Skills Training – can help with interpersonal flexibility (use cautiously) Pharmacotherapy o no meds cures OC o SSRI – reduce perseveration and anxiety EX A nurse notices a patient (50 y/o accountant) stays late organizing charts, rewrites notes repeatedly, misses discharge deadlines, snaps at family for touching items, and insists charts must be organized in a “certain” way.  Nursing response: Validate their attention to detail (“You take pride in accuracy”) → negotiate a time-limited plan for charting (e.g., one extra hour only), teach and schedule brief relaxation breaks, encourage delegating nonessential tasks, praise attempts to be flexible. MODULE 8: SOMATIC ILLNESS DISORDER FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER / CONVERSION DISORDER - presents with neurological symptoms (motor, sensory, or seizure-like) that cannot be fully explained by a neuro dse, medical condition, or substance use CM - weakness or paralysis of a limb abnormal movements (tremors, gait, dystonia) aphonia (inability to produced voiced sound) numbness, loss of touch or pain sensation - blindness, double vision, tunnel vision, deafness convulsion loss of coordination, dysphagia KEY FEATURE: px is calm about the symptoms (“la belle indifférence”) compared to the expected anxiety DSM V (≥) - one or more symptoms of altered motor/sensory function - clinical findings show incompatibility between symptoms and recognized neurological/medical conditions - symptoms cause distress or impairment in functioning - not better explained by another disorder NX - - - Establish therapeutic relationship – validate that symptoms are real to the patient. Avoid confrontation like "It’s all in your head" Ensure safety – prevent injury during seizures, paralysis, or sensory loss episodes Promote independence – encourage ADLs despite symptoms. Avoid reinforcing dependency Reduce anxiety & stress – relaxation techniques, grounding, stress management Encourage expression of feelings – journaling, verbalizing emotions instead of somatization Collaborate with interdisciplinary team – psychotherapy (CBT), physical therapy, sometimes SSRIs or anxiolytics for comorbid anxiety/depression Psychoeducation – explain disorder in a supportive, nonjudgmental way: “The brain is not sending/receiving the right signals, but no damage is found” PAIN DISORDER - primary symptom is pain that is severe enough to cause distress and functional impairment, but cannot be fully explained by a medical condition, substance use, or another mental disorder CM - persistent, severe pain in one or more body areas (e.g., back, head, chest, abdomen, joints) - pain disproportionate to physical findings or inconsistent with medical conditions - pain worsens with stress or emotional conflict - leads to functional impairment (difficulty working, social withdrawal, frequent hospital visits) - high healthcare utilization but repeated negative tests DSM V (≥) - One or more distressing somatic symptoms (pain being predominant) - Excessive thoughts, feelings, or behaviors related to the symptoms (e.g., constant worry, frequent doctor visits) - Symptom persists for >6 months NX - - Acknowledge pain as real – do not dismiss it as “imaginary.” Establish trust – therapeutic relationship to reduce repeated demands for medical tests. Promote coping strategies – relaxation techniques, deep breathing, distraction, guided imagery. Encourage emotional expression – journaling, talking about stress instead of somatization. Limit reinforcement of pain behaviors – do not focus excessively on pain complaints; redirect to functional goals. Collaborate with healthcare team – psychotherapy (especially CBT), stress management programs, physical therapy. - antidepressants (e.g., SSRIs, TCAs) may help with both mood and pain perception. Encourage independence – gradual return to normal activities. ILLNESS ANXIETY DISORDER - excessive preoccupation with having or developing a serious medical illness, despite mild or no somatic symptoms and negative diagnostic findings CM - repeatedly checking body for signs of illness - frequent doctor visits, excessive health research - avoiding hospitals, medical tests, or talking about illness for fear of diagnosis - “doctor said im fine, but what if they missed something?” - Preoccupation is chronic, even if the feared illness change DSM V (≥) - Preoccupation with having or acquiring a serious illness. Somatic symptoms are mild or absent - High level of anxiety about health, easily alarmed by bodily sensations - Excessive health-related behaviors or maladaptive avoidance - Illness preoccupation present for ≥6 months, though feared illness may change - Not better explained by another mental disorder (e.g., GAD, OCD) NX - Establish therapeutic rapport – acknowledge concerns without reinforcing unrealistic beliefs. Limit excessive reassurance – constant reassurance strengthens anxiety. Instead, set structured health visits. - Encourage stress management – relaxation techniques, mindfulness, physical activity. Promote adaptive coping – redirect focus from bodily symptoms to healthy lifestyle changes. Cognitive-behavioral therapy (CBT) – most effective treatment; helps reframe catastrophic thinking. SSRIs or SNRIs if severe anxiety or depression coexists. Support gradual exposure – help patient face healthrelated fears in a controlled manner MUNCHAUSEN SYNDROME DISORDER - a person deliberately fabricates, exaggerates, or induces physical or psychological symptoms in themselves CM - fakes or induces illness in themselves - caregiver fabricates or induces illness in another person to gain attention from medical staff (child-abuse) - injecting themselves with bacteria to cause infection DSM V (≥) - Falsification of symptoms (physical or psychological) or induction of injury/disease. - Patient presents themselves as ill, impaired, or injured. - Deceptive behavior occurs even without obvious external rewards. - Not explained by another mental disorder (e.g., delusion, psychosis). NX - Ensure safety – monitor for self-inflicted injuries. Avoid confrontation – directly accusing patient may lead to anger, denial, or leaving AMA. Use a nonjudgmental, supportive approach – acknowledge distress without reinforcing the false symptoms. - - Set clear boundaries – limit unnecessary medical tests/procedures. Encourage consistent care – coordinate among healthcare providers to avoid duplicate workups. Psychotherapy (esp. CBT) – to address underlying trauma, stress, or personality issues. Family therapy (if by proxy) – report suspected abuse (legal/ethical duty). no direct treatment, but antidepressants or anxiolytics may be used for comorbid conditions. - Bradycardia, hypotension, hypothermia. Electrolyte imbalance → arrhythmias. Restrictive eating or extreme dieting. Excessive exercise. Preoccupation with food, calories, weight. Denial of hunger. Ritualistic eating behaviors (cutting food into tiny pieces, eating very slowly). Social withdrawal, irritability, depression, anxiety. MODULE 9A: EATING DISORDER ANOREXIA NERVOSA - restriction of nutritional intakes 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. DSM V (≥) - Restriction of energy intake → significantly low body weight. - Intense fear of gaining weight or becoming fat, despite being underweight. - Distorted perception of body weight or shape, undue influence of body weight on self-evaluation, or denial of seriousness of low body weight. CM - body weight that is less than the minimum expected weight - preoccupation with food and food-related activities and can have a variety of physical manifestations - still experience hunger but ignore it and also ignore the signs of physical weakness and fatigue - preoccupied with food-related activities such as grocery shopping, collecting recipes or cookbooks, counting calories, creating fat-free meals, and cooking family meals - refusing to eat around others, cutting food into minute pieces, or not allowing the food they eat to touch their lips - Amenorrhea (loss of menstrual cycle). - Lanugo (fine body hair). - Cold intolerance, dry skin, brittle nails. TYPES - Restricting Type o weight loss achieved primarily through dieting, fasting, or excessive exercise. - Binge-eating/Purging Type o involves recurrent binge eating or purging behaviors (e.g., vomiting, laxatives, diuretics, enemas). DEF MECH - Denial → refusing to acknowledge illness despite low weight. - Rationalization → “I’m just eating healthy” or “I don’t feel hungry.” - Introjection → harshly internalizing unrealistic body standards. NX TX - - establish trust avoid power struggles about food supervised meals and snacks gradual weight restoration Psychotherapy o Cognitive Behavioral Therapy – for initial treatment and relapse prevention o Family-Based Therapy for px under 18 years o encourage expression of feelings Pharmacotherapy o Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) can promote weight gain o Olanzapine (Zyprexa) has been used with success because of its antipsychotic effect (on bizarre body image distortions) and associated weight gain. o Fluoxetine (Prozac) prevents relapse in clients whose weight has been partially or completely restored however, close monitoring is needed because weight loss can be a side effect EX A 17-year-old female presents with 15 kg weight loss in 6 months, BMI = 16. She reports “feeling fat” despite visible ribs and lanugo. She avoids eating with family, exercises 2 hours daily, and denies being underweight. Labs show hypokalemia and bradycardia. BULIMIA NERVOSA recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid weight gain, such as purging, fasting, or excessively exercising CM - engages in binge eating secretly - may eat low calorie foods or fast - purging episodes are often precipitated by strong emotions and followed by guilt, remorse, shame, or selfcontempt - may store food in their cars, desks, or secret locations around the house - eating unusually large amount of food - sense of loss of control during binge - secretive eating, often at night - self-induced vomiting - misuse of laxatives, diuretics, or enemas - fasting or excessive exercise - dental erosion from vomiting - parotid gland swelling (chipmunk cheeks) - calluses on fingers from vomiting (Russell’s sign) - irregular menstruation - electrolyte imbalance - preoccupation with food, weight, and dieting - shame and secrecy around eating - anxiety, depression, substance use DEF MECH - Denial → “I can control my eating anytime.” - Undoing → bingeing, then “undoing” with purging/exercise. - Dichotomous thinking → “If I eat one cookie, I’ve ruined everything.” NX TX - - establish trust by avoiding judgment and focus on empathy normalize discussion of eating patterns supervised meals to break binge-purging cycle encourage regular eating scheduling Self-monitoring – identifies behavior patterns then implement techniques to avoid them Psychotherapy o CBT – most effective, changing thoughts about food/body o DBT for emotion regulation o Group or Family Therapy Pharmacotherapy o desipramine (Norpramin) o imipramine (Tofranil) o amitriptyline (Elavil) o nortriptyline (Pamelor) o phenelzine (Nardil) o fluoxetine (Prozac) EX A 20-year-old college student presents with frequent binge eating episodes followed by self-induced vomiting. She reports eating “huge amounts of pizza and ice cream” at night and then exercises excessively the next morning. On exam, she has parotid gland swelling, dental caries, and calluses on her knuckles. Her BMI is 22. She feels “out of control” and ashamed. MODULE 9: SLEEP AND WAKFULNESS DISORDER NARCOLEPSY - CM - a chronic neurological sleep disorder characterized by the brain’s inability to properly regulate the sleep–wake cycle - excessive daytime sleepiness sleep attacks while talking, eating, driving cataplexy (sudden weakness of muscles) remains conscious but cannot move, lasting secs to min sleep paralysis hypnagogic or hypnopompic hallucination (vivid, frightening dreams) frequent awakenings and poor sleep quality at night NX - schedule short naps during the day good sleep hygiene counseling prevent injuries during sleep attacks educate px to avoid driving or operating heavy machines TX - Pharmacotherapy o Stimulants (modanafinil, armodafinil) – fewer side effects than amphetamines o Methylphenidate and Amphetamines o Sodium Oxybate for cataplexy and EDS o Antidepressants – suppress REM sleep, reduce cataplexy INSOMNIA - persistent difficulty with sleep initiation, duration, consolidation, or quality, despite having adequate opportunity for sleep CM TX - - - difficulty falling asleep (sleep-onset insomnia). difficulty staying asleep (sleep-maintenance insomnia). early morning awakening (terminal insomnia). non-restorative sleep fatigue, low energy. poor concentration and memory. irritability, mood disturbances. impaired work or academic performance Psychotherapy o CBT: sleep hygiene education, stimulus control, sleep restriction therapy o Relaxation techniques Lifestyle o avoid caffeine, alcohol, nicotine o maintain regular sleep-wake cycle o exercise during the day not before bed Pharmacotherapy o Benzodiazepines and Non-benzo o Melatonin receptor agonist (Ramelteon) o Antidepressant with sedative effect – trazadone, doxepin HYPERSOMNOLENCE - excessive daytime sleepiness (EDS) despite getting adequate or prolonged sleep CM - excessive daytime sleepiness: persistent and irresistible. - prolonged nighttime sleep (>9 hours), yet px feels unrefresh - difficulty waking up: often experiences sleep inertia (“sleep drunkenness”), with confusion, irritability, and impaired coordination. - unintentional daytime naps that are long and not refreshing. problems with memory, attention, and concentration. interference with work, school, or social life. NX - maintain consistent sleep-wake schedule. avoid alcohol, sedatives, and caffeine close to bedtime. schedule planned naps (short and strategic). promote regular exercise and a healthy diet. TX - Pharmacotherapy o Stimulants (modanafinil, armodafinil) – fewer side effects than amphetamines o Methylphenidate and Amphetamines – promote wakefulness o Antidepressants – if linked with depression MODULE 10: SCHIZOPHRENIA SPECTRUM DISORDER SCHIZOPHRENIA - a syndrome or as a disease process with many different varieties and symptoms CM POSITIVE NEGATIVE - ambivalence - alogia - associative looseness - anhedonia - delusions - apathy - echopraxia - asociality - flight of ideas - blunted affect - hallucinations - catatonia - ideas of reference - flat affect - perseveration - avolition - bizarre behavior - inattention DSM V (≥) - 2 or more symptoms that lasts over 6 months NX TX - - ask about hallucination “Are you hearing voices? What are the voices say?” command hallucination is life threatening “I am not hearing voices but I believe when you said you hear one” decrease stimuli in the environment never whisper to others in the patient’s presence warm the patient before touching them reorient to reality provide distraction for hallucination monitor for suicide ideation Psychotherapy o CBT o Individual Therapy o Social Skills Training o ACT – for persistent and severe that focus high risk in the community and prevents hospitalization Pharmacotherapy o First Gen Antipsychotics  for positive symptoms but high risk of EPS  haloperidol, chlorpromazine o Second Gen Antipsychotics  for positive and negative symptoms, lower EPS, but cause metabolic syndrome  risperidone, olanzapine, quetiapine, clozapine o IM meds for 2 to 4 weeks and PO every day  long-acting injectables for adherence  Fluphenazine  Haloperidol  Risperidone    Paliperidone Olanzapine Aripiprazole SCHIZOPHRENIFORM DISORDER - schizophrenia but at least 1 month but less than 6 months SCHIZOAFFECTIVE DISORDER - combination of psychotic symptoms (hallucinations, delusions, disorganized speech) and mood disorders (MDD or manic) CM - hallucination, delusion, disorganized speech flat affect, social withdrawal sadness, hopelessness, fatigue, anhedonia elevated mood, grandiosity difficulty with memory, attention, decision-making DSM V (≥) - uninterrupted period of illness where there is a major mood episode (manic or depressive) concurrent with schizophrenia symptoms - delusions or hallucinations must be present for ≥2 weeks without mood symptoms at some point during the illness - mood symptoms are present for the majority of the total duration of the illness NX TX - ensure safety medication adherence Psychotherapy o CBT o Family Therapy - o Social Skills Training Pharmacotherapy o Antipsychotics – risperidone, olanzapine, quetiapine o Mood Stabilizer – lithium, valproic acid, carbamazepine o Antidepressant – SSRIs o Combination Therapy BRIEF PSYCHOTIC DISORDER - short-term, sudden onset of psychotic symptoms such as delusions, hallucinations, disorganized speech, or grossly disorganized/catatonic behavior - at least 1 day but less than 1 month DSM V (≥) - Delusions – fixed, false beliefs (e.g., persecution, grandiosity) - Hallucinations – usually auditory ("hearing voices") - Disorganized speech – incoherent, illogical, loose associations - Grossly disorganized or catatonic behavior – agitation, immobility, unusual postures NX TX - ensure safety (suicide/harm risk assessment) maintain calm, structured envi to reduce overstimulation use clear and simple communication monitor medication side effects (eps, sedation) encourage gradual reintegration into social/occupational Psychotherapy o Supportive Psychotherapy o Family Education o Stress Management Techniques - Pharmacotherapy o ACUTE PHASE  Antipsychotics  Benzodiazepines DELUSIONAL DISORDERS - one or more nonbizarre delusions—that is, the focus of the delusion is believable - may be persecutory, erotomanic, grandiose, jealous, or somatic in content - psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre. TYPES - Persecutory o belief of being conspired against, cheated, spied on, or harassed - Erotomanic o belief that another person, usually of higher status, is in love with them - Grandiose o belief of having special talent, insight, power, or a relationship with a deity or famous person - Jealous o belief that their spouse/partner is unfaithful - Somatic o belief of having a physical defect or med condition - Mixed and Unspecified DSM V (≥) - ≥1 delusion lasting at least 1 month - schizophrenia criteria not met (no disorganized speech, negative symptoms) - functioning is not markedly impaired outside of delusion NX TX - - if mood symptoms occur, they are brief compared to the delusional periods not due to a substance, medication, or medical condition establish trusting, non-confrontational relationship do not argue with delusions; instead, focus on patient’s feelings (“that must be very distressing for you”) encourage reality-based activities monitor for risk of violence (persecutory and jealous have high risk) ensure medication adherence Psychotherapy o Supportive Therapy and Family Education o CBT Pharmacotherapy o Antipsychotics o Adjunct – SSRI, mood stabilizer SHARED PSYCHOTIC DISORDER - two people share a similar delusion - the person with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusions, most commonly siblings, parent and child, or husband and wife - the more submissive or suggestible person may rapidly improve if separated from the dominant person NX - Maintain therapeutic alliance with both individuals Avoid reinforcing delusions, but don’t confront aggressively Promote social interaction with others to break isolation Monitor for risk of violence, especially in persecutory TX - - Psychotherapy o Separation o Supportive Therapy o Family Therapy o Psychoeducation Pharmacotherapy o Antipsychotics MODULE 11: MOOD DISORDER BIPOLAR DISORDER - extreme mood swings from episodes of mania to episodes of depression - MANIC: euphoric, grandiose, energetic, and sleepless, poor judgment and rapid thoughts, actions, and speech - DEPRESSED: MDD TYPE TYPE 1 - At least one manic episode (lasting ≥7 days or requiring hospitalization). May also include depressive episodes, but depression is not required for diagnosis. Example: Alternating full mania and depression. TYPE 2 - At least one hypomanic episode (lasting ≥4 days, less severe than mania). At least one major depressive episode (lasting ≥2 weeks). No full-blown mania. Example: "Mood swings," but hypomania is not as disruptive as mania. Cyclothymic - - Numerous hypomanic and depressive symptoms for ≥2 years (≥1 year in children/adolescents) that do not meet full criteria for mania or major depression. "chronic, milder but persistent" form of bipolar DSM V (≥) - 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: o exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments PHASES Manic Episode - - Elevated, expansive, or irritable mood lasting ≥1 week. Symptoms: inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, risky behavior. Can cause marked impairment or require hospitalization. Hypomanic Episode - Similar symptoms to mania but milder. - Lasts ≥4 consecutive days. No marked impairment in functioning. Depressive Episode - Sad mood, loss of interest, fatigue, feelings of guilt/worthlessness, psychomotor changes, sleep/appetite disturbance, suicidal ideation. NX During Mania - Maintain safe environment (risk-taking, impulsivity). Set clear limits and firm boundaries. Use short, clear, direct communication (patients are distractible). Promote rest and sleep (low-stimulation environment). Provide finger foods and fluids (they often don’t sit still for meals). During Depression - Assess for suicidal ideation. Encourage small, achievable goals. Monitor medication adherence (risk of stopping meds when mood improves). Encourage participation in therapeutic activities. Ongoing - Educate on importance of medication adherence (relapse is common if stopped). Teach warning signs of relapse (sleep changes, increased energy, irritability). Support family involvement. TX - Psychotherapy (not useful during acute manic stages) o useful in the mildly depressive or normal portion Pharmacotherapy (lifetime regimen) - Lithium - - stabilize bipolar disorder by reducing the degree and frequency of cycling or eliminating manic episodes competes for salt receptor sites but also affects calcium, potassium, and magnesium ions as well as glucose metabolism peaks in 30 minutes to 4 hours for regular forms and in 4 to 6 hours for the slow-release form crosses the blood–brain barrier and placenta and is distributed in sweat and breast milk can lead to first-trimester developmental abnormalities drink adequate water (approximately 2 L/day) and continue with the usual amount of dietary table salt Anticonvulsant - - used to treat seizure disorders have proved helpful in stabilizing the moods 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 o drug serum levels checked regularly o therapeutic level: 4 to 12 µg/mL Valproic Acid o for simple absence and mixed seizures, migraine prophylaxis, and mania - - - o therapeutic level 50 to 125 µg/mL o baseline and ongoing liver function tests, including serum ammonia levels and platelet and bleeding times Gabapentin (Neurontin), lamotrigine (Lamictal), and topiramate (Topamax) o used as mood stabilizers, but they are used less frequently than valproic acid. Clonazepam (Klonopin) o used in simple absence and minor motor seizures, panic disorder, and bipolar disorder o not used alone to manage bipolar disorder Aripiprazole (Abilify) o dopamine system stabilizer antipsychotic medication used as an adjunct to other moodstabilizing drugs Second Gen Antipsychotic: Ziprasidone (Geodon), lurasidone (Latuda), and quetiapine (Seroquel) o prevent a “switch to mania” MAJOR DEPRESSIVE DISORDER - two 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 and changes in weight, sleep, energy, concentration, decision-making, self-esteem, and goals CM SIGECAPS mnemonic: - Sleep disturbance (insomnia/hypersomnia) Interest diminished (anhedonia) Guilt/worthlessness Energy loss/fatigue Concentration difficulties Appetite changes (weight loss/gain) - Psychomotor changes (agitation/retardation) Suicidal ideation/thoughts of death TX - DSM V (≥) - 5/9 symptoms - depressed mood (hopeless, empty) - anhedonia - weight loss (anorexia) or weight gain - psychomotor retardation o slow speech and response time o decreased movement - insomnia, hypersomnia - fatigue, anergia - feelings of worthlessness, guilt - difficult concentration - suicidal thoughts NX - - assign patient near the nurse’s station and frequent rounds in irregular intervals monitor for medication adherence monitor for suicide risk o calmer or more energetic o sudden, abrupt, rapid change in energy if they want to die o continuous one to one observations o remove harmful objects o supervise meals o reassess changes in suicidal thoughts o GOOD SIGN: clear plans of the future involving personal goals, family and friends o never leave the room - Psychotherapy o Interpersonal Therapy  focuses on difficulties in relationships, such as grief reactions, role disputes, and role transitions  Ex. 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. o Behavior Therapy  increase the frequency of the client’s positively reinforcing interactions with the environment and to decrease negative interactions  may also focus on improving social skills o Cognitive Therapy  focuses on the person’s distorted thinking, which, in turn, influences feelings, behavior, and functional abilities. Pharmacotherapy SSRI o produce few sedating, anticholinergic, and cardiovascular side effects, which make them safer for use in older adults o Fluoxetine (Prozac) produces a slightly higher rate of mild agitation and weight loss but less somnolence o SEROTONIN SYNDROME  occurs when there is an inadequate washout period between taking MAOIs and  - - - SSRIs or when MAOIs are combined with meperidine S/Sx: Change in mental state: confusion and agitation Neuromuscular excitement: muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, and muscle paralysis Autonomic abnormalities: hyperthermia, tachycardia, tachypnea, hypersalivation, and diaphoresis Cyclic o relieve symptoms of hopelessness, helplessness, anhedonia, inappropriate guilt, suicidal ideation, and daily mood variations (cranky in the morning and better in the evening) o have a lag period of 10 to 14 days before reaching a serum level that begins to alter symptoms; take 6 weeks to reach full effect Tricyclic o contraindicated in severe impairment of liver function and in myocardial infarction o cannot be given concurrently with MAOIs o overdosages: confusion, agitation, hallucinations, hyperpyrexia, and increased reflexes Tetracyclic o Amoxapine (Asendin) may cause extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome o create tolerance in 1 to 3 months o increases appetite and causes weight gain and cravings for sweets o Maprotiline (Ludiomil) carries a risk for seizures (especially in heavy drinkers), severe constipation - - - and urinary retention, stomatitis, and other side effects Atypical o used when the client has an inadequate response to or side effects from SSRIs o venlafaxine (Effexor), duloxetine (Cymbalta), bupropion (Wellbutrin), nefazodone (Serzone), and mirtazapine (Remeron) MAOI o used infrequently because of potentially fatal side effects and interactions with numerous drugs o most serious side effect is hypertensive crisis, a life-threatening condition that can result when a client taking MAOIs ingests tyramine-containing foods o S/Sx: occipital headache, hypertension, nausea, vomiting, chills, sweating, restlessness, nuchal rigidity, dilated pupils, fever, and motor agitation o for hypertensive crisis, transient antihypertensive agents, such as phentolamine mesylate, are given to dilate blood vessels and decrease vascular resistance o 2- to 4-week lag period before MAOIs reach therapeutic levels o adequate washout periods of 5 to 6 weeks are recommended Electroconvulsive Therapy o treat depression in select groups, such as clients who do not respond to antidepressants or those who experience intolerable side effects at therapeutic doses o can be used in pregnant women o application of electrodes to the head of the client to deliver an electrical impulse to the brain; this causes a seizure o shock stimulates brain chemistry to correct the chemical imbalance of depression. o a series of 6 to 15 treatments scheduled thrice a week; max benefit at 12 to 15 treatments o PRE: npo after midnight, removes any fingernail polish, and voids just before the procedure, intravenous line is started, o INTRA: short-acting anesthetic, muscle relaxant/paralytic, electrodes are placed on the client’s head: one on either side (bilateral) or both on one side (unilateral), client receives oxygen and is assisted to breathe with an Ambu bag o POST: monitor VS, assess return of gag reflex, mildly confused or briefly disoriented, very tired and often has a headache, short-term memory impairment, client may eat as soon as he or she is hungry and usually sleeps for a period o Unilateral ECT results in less memory loss for the client, but more treatments may be needed to see sustained improvement o Bilateral ECT results in more rapid improvement but with increased short-term memory loss. PHASES OF TREATMENTS Acute Phase - 6 – 8 weeks high suicide risk GOAL: remission of symptoms and restore the function with antidepressant, psychotherapy and ECT Continuation Phase - increase ability to function GOAL: prevent relapse Maintenance Phase - 6 – 12 months GOAL: prevent reoccurrence and we want to return the client to normal function SUICIDE - intentional act of killing oneself - Suicidal ideation means thinking about killing oneself - Active suicidal ideation is when a person thinks about and seeks ways to commit suicide - Passive suicidal ideation is when a person thinks about wanting to die or wishes he or she were dead but has no plans to cause his or her death - Attempted suicide is a suicidal act that either failed or was incomplete - Incomplete suicide attempt, the person did not finish the act because (1) someone recognized the suicide attempt as a cry for help and responded or (2) the person was discovered and rescued CM - history of previous suicide attempts increases risk for suicide - first 2 years after an attempt represent the highest risk period, especially the first 3 months - relative who committed suicide are at increased risk for suicide: the closer the relationship, the greater the risk - increased sunlight in spring is believed to explain why most suicides occur in April - NX - - - - most suicides happen on Monday mornings, when most people return to work people contemplating suicide have ambivalent and conflicting feelings about their desire to die “I keep thinking about taking my entire supply of medications to end it all” (direct) or “I just can’t take it anymore” (indirect) Be authoritative: a client may want to be alone in her room to think privately. This is not allowed while she is at an increased risk for suicide. Provide a safe environment: staff members remove any item they can use to commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with drawstrings. Low lethality: observe every 10 minutes High lethality: one-to-one supervision, no more than 2 to 3 feet away, under constant staff observation with no exceptions Create a support system MODULE 12: TRAUMA AND STRESSOR-RELATED DISORDER DISSOCIATIVE IDENTITY DISORDER - a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory CM - Dissociative amnesia: cannot remember important personal information (usually of a traumatic or stressful nature) o fugue experience where the client suddenly moves to a new geographic location with no memory of past events, and often the assumption of a new identity - Dissociative identity disorder (formerly multiple personality disorder): displays two or more distinct identities or personality states that recurrently take control of their behavior. o accompanied by the inability to recall important personal information. - Depersonalization/derealization disorder: persistent or recurrent feeling of being detached from their mental processes or body (depersonalization) or sensation of being in a dream-like state where the environment seems foggy or unreal (derealization) o client is not psychotic or out of touch with reality - false memory syndrome: has created problems in families when clients made groundless accusations of abuse o fears exist, however, that people abused in childhood will be more reluctant to talk about their abuse history because, once again, no one will believe them NX - When you approach the client, be nonthreatening and professional. assign the same staff members to the client if possible; try to respect the client’s fears and feelings. Gradually - - - TX - - increase the number and variety of staff members interacting with the client Remain nonjudgmental in your interactions Be consistent with the client; convey acceptance of him or her as a person while setting and maintaining limits regarding behaviors Encourage the client to express his or her feelings through talking, writing, crying, or other ways in which the client is comfortable positive feedback for expressing feelings and sharing experiences practice stress management and relaxation techniques, assertiveness or self-defense training, or other skills as appropriate Encourage the client to make realistic plans, integrating his or her traumatic experience Grounding techniques remind the client that he or she is in the present, is an adult, and is safe Psychotherapy o group or individual therapy in the community to address the long-term effects of their experiences o focuses on reassociation, or putting the consciousness back together Pharmacotherapy o medications for anxiety or depression or both if these symptoms are predominant POST-TRAUMATIC STRESS DISORDER - 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 - symptoms occur 3 months or more after the trauma - victims of rape have one of the highest rates of PTSD ACUTE STRESS DISORDER o similar types of symptoms, but lasts at least 3 days or up to 1 month o onset can be delayed for months or even years CM - reexperiencing the trauma through dreams or recurrent and intrusive thoughts - showing emotional numbing (feeling detached from others) - being on guard, irritable, or experiencing hyperarousal - reports losing a sense of connection and control over their life - lead to avoidance behavior, or trying to avoid any places or people or situations that may trigger memories of the trauma - seeks comfort, safety, and security, but can actually become increasingly isolated over time, which can heighten the negative feelings they were trying to avoid TX - Psychotherapy o Counseling or therapy, individually or in groups, for persons with acute stress disorder may prevent progression to PTSD o CBT are the most common and successful o Self-help groups offer support and a safe place to share feelings o Exposure therapy combats the avoidance behavior that occurs with PTSD, helps the client face troubling thoughts and feelings, and regains a measure of control over their thoughts and feelings o relaxation techniques are employed to help the client tolerate and manage the anxiety response - o Prolonged exposure therapy has been particularly effective for both active military personnel and veterans o 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  incorporates exposure therapy as well as the empty-chair technique, in which the participant says whatever he or she needs to say to anyone—alive or dead  similar to techniques used in Gestalt therapy o Cognitive processing therapy has been used successfully with rape survivors with PTSD as well as combat veterans  structured sessions that focus on examining beliefs that are erroneous or interfere with daily life, such as guilt and self-blame, reading aloud a written account of their worst traumatic experience, recognizing generalized thinking, and regaining more balanced and realistic ways of appraising the world and themselves Pharmacotherapy o SSRI and SNRI antidepressants are most effective, followed by SGA, such as risperidone o Benzodiazepines are lacking ADJUSTMENT DISORDER - a reaction to a stressful event that causes problems for the individuals - has more than the expected difficulty coping with or assimilating the event into their life - symptoms develop within a month, lasting no more than 6 months after 6 months, adjustment has been successful or moves to another diagnosis Tx: outpatient counseling or therapy 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 - can be a precursor to PTSD - Tx: cognitive–behavioral therapy (CBT) involving exposure and anxiety management can help prevent the progression to PTSD REACTIVE ATTACHMENT DISORDER (RAD) & DISINHIBITED SOCIAL ENGAGEMENT DISORDER (DSED) - occur before the age of 5 years in response to the trauma of child abuse or neglect, called grossly pathogenic care - shows disturbed, inappropriate social relatedness in most situations - grossly deficient parenting and institutionalization are the two most common situations leading to this disorder - RAD o minimal social and emotional responses to others o lacks a positive affect o may be sad, irritable, or afraid for no apparent reason - DSED o unselective socialization o allowing or tolerating social interaction with caregivers and strangers alike o lack the hesitation in approaching or talking to strangers evident in most children their age 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 - may rubs his genitals against the victim’s thighs and buttocks or fondles her breasts or genitalia with his hands - acts of frottage occur most often between the ages of 15 and 25; frequency declines after that MODULE 13: PSYCHOSEXUAL DISORDER (PARAPHILIA) 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 - person might masturbate while holding or rubbing the object - begins by adolescence and tends to be chronic - Transvestic Fetishism: recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing by a heterosexual male 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 - 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 – blowjob, oral sex of the penis - cunnilingus – oral stimulation of the female genitalia - 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 strangers - many individuals with pedophilia do not experience distress about their fantasies, urges, or behaviors SEXUAL MASOCHISM - recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer - some individuals act on masochistic urges by themselves, others with a partner. SEXUAL SADISM - recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving acts in which the psychological or physical suffering of the victim is sexually arousing to the person - can involve domination (caging the victim or forcing victim to crawl, beg, plead), restraint, spanking, beating, electrical shock, rape, cutting, 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 - usually begins before age 15, is chronic, and may involve masturbation during the voyeuristic behavior MODULE 14: COGNITIVE, SUBSTANCE, AND NONSUBSTANCE DISORDER ALZHEIMER’S DISORDER - a progressive brain disorder that has a gradual onset - causes an increasing decline in functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence - atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain DELIRIUM - syndrome that involves a disturbance of consciousness accompanied by a change in cognition - develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day - Elderly patients are the group most frequently diagnosed with delirium CM - - NX TX - difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations disturbances in the sleep–wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy physical restraints if client is agitated and threatens to dislodge IV tubing give realistic reassurance to clients with confusion avoid lengthy discussion use short simple and allow time for clients to grasp content provide orienting cues: calls them by name and referring to the time of the day or expected activity may be helpful to sit with clients at meals or to frequently offer fluids Assisting clients to the bathroom periodically may be necessary Promoting a balance of rest and sleep Discouraging or limiting daytime napping may improve ability to sleep at night exercise during the day to promote nighttime sleep Psychotherapy Pharmacotherapy o Hypoactive Delirium: does not need o Sedation: prevent inadvertent self-injury o Haloperidol: to decrease agitation and psychotic symptoms and facilitate sleep o Short- or Intermediate Benzo (Lorazepam): for sleep o Long Benzo: AVOIDED, can worsen delirium DEMENTIA - progressive cognitive impairment with no change in the level of consciousness - acetylcholine, dopamine, norepinephrine, and serotonin are decreased in dementia CM - multiple cognitive deficits, initially, memory impairment - Aphasia: deterioration of language function - Apraxia: impaired ability to execute motor functions despite intact motor abilities - Agnosia: inability to recognize or name objects despite intact sensory abilities - Memory impairment is the prominent early sign of dementia - difficulty learning new material and forget previously learned material - recent memory is impaired - in latter, it affects remote memory - may exhibit echolalia (echoing what is heard) or palilalia (repeating words or sounds over and over) MILD - Forgetfulness is the hallmark of beginning difficulty finding words, frequently loses objects, and begins to experience anxiety about these losses - Occupational and social settings are less enjoyable, and the person may avoid them MODERATE - Confusion is apparent, along with progressive memory loss cant perform complex tasks but remains oriented to person and place still recognizes familiar people loses the ability to live independently and requires assistance because of disorientation to time and loss of information such as address and telephone number SEVERE - Personality and emotional changes delusional, wander at night, forget the names of spouse and children, and require assistance in ADLs ETIOLOGY Alzheimer’s Disease - - a progressive brain disorder that has a gradual onset causes an increasing decline in functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain - Vascular Dementia - - - progressive cognitive impairment and extensive neuropsychiatric symptoms and motor symptoms Delusions and visual hallucinations are common symptoms like those of Alzheimer’s disease, but onset is typically abrupt, followed by rapid changes in functioning; a plateau, or leveling-off period; more abrupt changes; another leveling-off period; and so on DX: CT and MRI shows decreased blood supply to the brain Tx: diet, exercise, control of hypertension, or diabetes Frontotemporal Lobar Degeneration (Pick’s Disease) - - degenerative brain disease that particularly affects the frontal and temporal lobes same with Alzheimer's Early signs include personality changes, loss of social skills and inhibitions, emotional blunting, and language abnormalities most commonly 50 to 60 years of age; death occurs in 2 to 5 years Prion Diseases - Lew Body Dementia - Functional impairments may initially be more pronounced HIV caused by a prion (a type of protein) that can trigger normal proteins in the brain to fold abnormally Creutzfeldt–Jakob disease is the most common prion disease affecting humans CNS disorder altered vision, loss of coordination or abnormal movements, and dementia that usually progresses rapidly (a few months) Mad cow disease and kuru - can lead to dementia and other neurologic problems mild sensory impairment to gross memory and cognitive deficits to severe muscle dysfunction Parkinson’s Disease - slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and postural instability cognitive and motor slowing, impaired memory, and impaired executive functioning Huntington’s Disease - - inherited, dominant gene disease that primarily involves cerebral atrophy, demyelination, and enlargement of the brain ventricles Personality changes are the initial psychosocial manifestations, followed by memory loss, decreased intellectual functioning, and other signs of dementia TBI - repeated head injury (e.g., from boxing) may lead to progressive dementia RELATED DISORDER Korsakoff’s Syndrome NX - Long-term use of alcohol that results in dementia previously known as an amnestic disorder since amnesia and confabulation are common - - - - - Provide opportunities for reminiscence or recall of past events Encourage the client to use written cues such as a calendar, lists, or a notebook Minimize environmental changes TX - Establish a usual routine, and alter the routine only when necessary Provide single-step instructions for the client when instructions are needed Provide verbal connections about using implements. For example, “Here is a washcloth to wash your face” reminders of previous events into current interactions such as “Earlier you put some clothes in the washing machine; it’s time to put them in the dryer.” Assist with tasks as needed, but do not “rush” to do things for the client that he or she can still do independently. use a matter-of-fact approach when assuming tasks the client can no longer perform. Do not allow the client to work unsuccessfully at a task for an extended time Supportive touch is effective with many clients AVOID “everyone is supposed to do.” A wide variety of activities have proven beneficial for clients with dementia Reminiscence therapy (thinking about or relating personally significant past experiences) is an effective intervention for clients with dementia Photo albums may be useful in stimulating remote memory not to interrupt clients or to finish their thought Distraction involves shifting the client’s attention and energy to a more neutral topic Time away involves leaving clients for a short period and then returning to them to re-engage in interaction Going along means providing emotional reassurance to clients without correcting their misperception or delusion For degenerative: no cure to reverse - - - - - - replenishment therapy with acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors. Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl, Razadyne, Nivalin) are cholinesterase inhibitors and have shown modest therapeutic effects and temporarily slow the progress of dementia Tacrine (Cognex), a cholinesterase inhibitor, elevates liver enzymes Memantine (Namenda) is an NMDA receptor antagonist that can slow the progression of Alzheimer’s in the moderate or severe stages Namzaric (memantine and donepezil) is a new combination of two other medications, thereby having the actions of both cholinesterase inhibition and NMDA receptor antagonist SSRI for accompanying depression haloperidol (Haldol), olanzapine (Zyprexa), risperidone (Risperdal), and quetiapine (Seroquel), may be used to manage psychotic symptoms of delusions, hallucinations, or paranoia, and other behaviors, such as agitation or aggression Lithium carbonate, carbamazepine (Tegretol), and valproic acid (Depakote) help to stabilize affective lability and to diminish aggressive outbursts Benzodiazepines are used cautiously because they may cause delirium and can worsen - WARNING: ANTIPSYCHOTICS are associated with increased risk of mortality in elderly patient for dementia INTOXICATION – ALCOHOL - alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream - effects are relaxation and loss of inhibitions - slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment - aggressive or display inappropriate sexual behavior - may experience blackout - short period: vomiting, unconsciousness, and respiratory depression - alcohol-induced hypotension leads to cardio shock and death Withdrawal Symptoms - begin 4 to 12 hours after cessation or marked reduction of alcohol intake - coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting - may progress to transient hallucinations, seizures, or delirium - peaks on the second day and is over in about 5 days - may take 1 to 2 weeks NX TX - central nervous system stimulants is contraindicated gastric lavage or dialysis to remove the drug, and support of respiratory and cardiovascular functioning in an intensive care unit - - safe withdrawal by administration of benzodiazepines such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium) to suppress the withdrawal symptoms Clinical Institute Withdrawal Assessment of Alcohol Scale o <8: mild withdrawal o 8 – 15: moderate (mark arousal) o >15: severe INTOXICATION – SEDATIVES, HYPNOTICS, ANXIOLYTICS - central nervous system depressants - benzo and barbiturates are the most frequent - S/Sx: same to alcohol, slurred speech, lack of coordination, unsteady gait, labile mood, impaired attention or memory, and even stupor and coma, for barbiturates – cardiac failure - Tx: gastric lavage, followed by ingestion of activated charcoal and a saline cathartic; dialysis can be used if symptoms are severe - - Withdrawal: opposite of the acute effects of the drug: that is, autonomic hyperactivity o (increased pulse, blood pressure, respirations, and temperature), hand tremor, insomnia, anxiety, nausea, and psychomotor agitation. Seizures and hallucinations occur only rarely in severe benzodiazepine withdrawal Detoxification o Tapering the dose INTOXICATION – STIMULANTS - used by people who wanted to lose weight or to stay awake - cocaine causes intense and immediate feeling of euphoria - causes psychosis - S/Sx: high or euphoric feeling, hyperactivity, hypervigilance, talkativeness, anxiety, grandiosity, hallucinations, stereotypic or repetitive behavior, anger, fighting, and impaired judgment - S/Sx: tachycardia, elevated blood pressure, dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac dysrhythmias, seizure and coma - Tx: chlorpromazine (Thorazine), an antipsychotic, controls hallucinations, lowers blood pressure, and relieves nausea - Withdrawal: few hours to several days after cessation o dysphoria is the primary symptom and is accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation o may experience depressive symptoms, including suicidal ideation, for several days o not treated pharmacologically INTOXICATION – CANNABIS - short-term effects of lowering intraocular pressure - not approved for the treatment of glaucoma - relieving the nausea and vomiting associated with cancer chemotherapy and the anorexia and weight loss of AIDS - two cannabinoids, dronabinol (Marinol) and nabilone (Cesamet), have been approved for treating nausea and vomiting from cancer chemotherapy - S/Sx: high feeling similar to that with alcohol, lowered inhibitions, relaxation, euphoria, and increased appetite - Intoxication: impaired motor coordination, inappropriate laughter, impaired judgment and short-term memory, and distortions of time and perception - S/Sx: increased appetite, include conjunctival injection (bloodshot eyes), dry mouth, hypotension, and tachycardia, delirium - Withdrawal: o muscle aches, sweating, anxiety, and tremors INTOXICATION – OPIOIDS - they desensitize the user to both physiologic and psychologic pain and induce a sense of euphoria and well-being - Intoxication: euphoria then apathy, lethargy, listlessness, impaired judgment, psychomotor retardation or agitation, constricted pupils, drowsiness, slurred speech, and impaired attention and memory - Severe Intoxication: coma, respiratory depression, pupillary constriction, unconsciousness, and death - Antidote: Naloxone every few hours until the opioid level drops to nontoxic - Withdrawal o anxiety, restlessness, aching back and legs, and cravings for more opioids o withdrawal progresses include nausea, vomiting, dysphoria, lacrimation, rhinorrhea, sweating, diarrhea, yawning, fever, and insomnia o Substitution of methadone during detoxification reduces symptoms to no worse than a mild case of flu o anxiety, insomnia, dysphoria, anhedonia, and drug craving may persist for weeks or months INTOXICATION – HALUCCINOGENS - distort the user’s perception of reality and produce symptoms similar to psychosis, including hallucinations (usually visual) and depersonalization - cause increased pulse, blood pressure, and temperature; dilated pupils; and hyperreflexia - mescaline, psilocybin, lysergic acid diethylamide, and “designer drugs” such as Ecstasy - acts as anesthetics too (PCP) - Intoxication o anxiety, depression, paranoid ideation, ideas of reference, fear of losing one’s mind, and potentially dangerous behavior such as jumping out a window in the belief that one can fly o Physio S/Sx: sweating, tachycardia, palpitations, blurred vision, tremors, and lack of coordination o PCP S/Sx: belligerence, aggression, impulsivity, and unpredictable behavior - Tx: supportive, isolation from external stimuli, use of restraint if needed. Meds used to control seizure and blood pressure, cooling devices too - Withdrawal o craves for the drug o produce flashbacks, which are transient recurrences of perceptual disturbances INTOXICATION – INHALANTS - anesthetics, nitrates, and organic solvents that are inhaled - aliphatic and aromatic hydrocarbons found in gasoline, glue, paint thinner, and spray paint - cleaners, correction fluid, spray can propellants, and other compounds containing esters, ketones, and glycols - can cause significant brain damage, peripheral nervous system damage, and liver disease - Intoxication o dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision, stupor, coma o belligerence, aggression, apathy, impaired judgment, and inability to function. Acute toxicity causes anoxia, respiratory depression, vagal stimulation, and dysrhythmias o death from bronchospasm, cardiac arrest, suffocation, or aspiration of the compound or vomitus - Tx: supporting respiratory and cardiac functioning until the substance is removed from the body - Withdrawal o treated symptomatically SUBSTANCE ABUSE - Pharmacotherapy o to permit safe withdrawal o to prevent relapse o for alcohol: vitamin B1 (thiamine) is often prescribed to prevent or to treat Wernicke– Korsakoff syndrome o for nutritional deficiencies: cyanocobalamin (vitamin B12) and folic acid (B9) o for alcohol: benzo anxiolytic agent to suppress abstinence (lorazepam, chlordiazepoxide, diazepam) o Disulfiram (Antabuse) may be prescribed to help deter clients from drinking o Acamprosate (Campral) may be prescribed for clients recovering from alcohol abuse or dependence to help reduce cravings for alcohol and decrease the physical and emotional discomfort that occurs especially in the first few months of recovery (cant take if the patient has renal dse) o Acamprosate (relief cravers) o Naltrexone (reward cravers) o Methadone is used as a substitute for heroin in some maintenance programs o Levomethadyl is a narcotic analgesic whose only purpose is the treatment of opiate dependence o Buprenorphine/naloxone (Suboxone) is a combination drug used for opiate maintenance and to decrease opiate cravings o Naltrexone is also available as a once-monthly injectable marketed as Vivitrol o 4 meds off-label to decrease cocaine craving:  disulfiram  modafinil (Provigil), an antinarcoleptic  propranolol (Inderal), a β-blocker  topiramate (Topamax), an anticonvulsant also used to stabilize moods and treat migraines o Nalmefene is an opioid receptor antagonist combat opioid overdose o Clonidine, (α2-adrenergic) agonist used to treat hypertension for opiate dependence to suppress some effects of withdrawal or abstinence o Ondansetron (Zofran), a 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin in the small intestine, is used as an antiemetic o Quetiapine (Seroquel) was used in one study to control alcohol cravings as well as moderating their psychiatric symptoms GAMBLING DISORDER - problem gambling, spending money one cannot afford to lose, lying about gambling, getting money from others, and an inability to refrain from gambling for any specific time - attempts to quit or cut down result in restless, anxious, and irritable behavior DSM V (≥) Diagnosis requires ≥4 of the following within 12 months: - Needs to gamble with increasing amounts of money (tolerance). Restless/irritable when attempting to cut down (withdrawal). Repeated unsuccessful efforts to stop/control gambling. Preoccupation with gambling. Gambles when feeling distressed. “Chasing losses” (returns another day to win back money). Lies to conceal gambling involvement. Jeopardized significant relationships, job, or education. Relies on others for money due to gambling losses Severity: NX - - Mild: 4–5 criteria Moderate: 6–7 criteria Severe: 8–9 criteria Ensure safety and suicide prevention Encourage patient to express feelings about guilt, shame, and loss “It seems gambling has become difficult to control for you. Can you share more about how it’s affecting your life?” Avoid confrontation—focus on motivating change. TX Psychotherapy - Cognitive Behavioral Therapy (CBT): Identify triggers, restructure thoughts, develop coping skills. Motivational Interviewing: Enhance readiness to change. Group therapy / 12-step programs: Gamblers Anonymous Pharmacotherapy - SSRIs: For comorbid depression/anxiety. Mood stabilizers (lithium, valproate): Helpful if bipolar comorbidity. Opioid antagonists (naltrexone): Reduce craving and urge to gamble. Other - Financial counseling and debt management. Family therapy.

Personality Disorders: Cluster A & B - Symptoms, Diagnosis, Treatment

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