PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

ACUTE AND CHRONIC

Queen (maria.giannina on ig)

2. Changes in sleep or psychomotor

activity
MODULE 5
3. Decreased energy
MOOD DISORDERS 4. Feelings of worthlessness or guilt
5. Difficulty of thinking, concentrating or
● Also called affective disorders, are making decisions
pervasive alterations in emotions 6. Recurrent thoughts of death or
that are manifested by depressions, suicidal ideation, plans r attempts.
mania or both.
These symptoms must be present everyday
● They interfere with a person’s life,
for 2 weeks and result in significant distress
plaguing him or her with drastic and
or impair social, occupational or other
long term sadness , agitation or
important areas of functioning. Some people
elation.
also have delusions and hallucinations, the
● Accompanying self-doubt, guilt and
combination is called Psychotic depression.
anger
● Alter life activities, especially those
that involve self esteem, occupation
Bipolar Disorder (most common)
and relationships.
● Mood disorders are the most common Is diagnosed when a person’s mood cycles
psychiatric diagnoses associated with between extremes of mania and depression
suicide. Depression is one of the
most important risk factors for it. MANIA = is a distinct period during which
● Female is higher to attempt suicide, mood
● Male is for complete suicide ● Is abnormally and persistently
● Best time to commit suicide is during elevated, expansive or irritable
endorsement ● This period lasts about 1 week, but it
CATEGORIES may be longer for some individuals
● Don't want to sleep, rest, poor
PRIMARY MOOD DISORDER
hygiene but always on the go
Major depressive disorder ● Sexual prerequisite
● Shopping
A major depressive episode lasts at least 2
● Irritability
weeks during which the person experiences a
depressed mood or loss of pleasure in all At least three of the following symptoms
activities accompanied the manic episode

In addition, 4 of the following symptoms are 1. Inflated self esteem or grandiosity

present: 2. Decreased need for sleep
3. Pressured speech
1. Changes in appetite or weight
4. Flight of ideas

1
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

5. Distractibility People with Bipolar disorder may experience

6. Increased involvement in goal a euthymic or normal mood and affect
directed activity or psychomotor between extreme episodes or they may have
agitation a depressed mood swing after a manic
7. Excessive involvement in pleasure episode before returning to a euthymic mood.
seeking activities with a high potential
for painful consequences
Other disorders classified in the Diagnostic
Some people experience hallucinations and
and Statistical Manual of Mental Disorders,
delusions during manic episode
5th edition, text revision (ADA, 2000). As
HYPOMANIA = is a period of abnormally and mood disorders but with symptoms that are
persistently elevated, expansive or irritable less severe or of shorter duration include:
mood lasting 4 days, including 3 or 4 of the
1. Dysthymic disorder – is characterized
additional symptoms described earlier.
by at least 2 years of depressed
The difference is that hypomanic episodes do mood, for more days than not with
not impair the person’s ability to function and some additional, less severe
there are no psychotic features symptoms that do not meet the
criteria for major depressive episode.
Bi - twi
2. Cyclothymic disorder – is
Polar - two poles characterized by 2 years of numerous
periods of both hypomanic symptoms
that do not meet the criteria for
A MIXED EPISODE bipolar disorder.
3. Substance Induced Mood disorder –
Is diagnosed when the person experiences is characterized by a prominent and
both mania and depression nearly everyday persistent disturbance in mood that is
for at least 1 week. judged to be a direct physiologic
● Are often called rapid cycling consequence of ingested substances
● For the purpose of Medical Diagnosis, such as alcohol, other drugs or toxins.
Bipolar Disorders are described as: Mood disorder due to a general medical
○ BIPOLAR I DISORDER – one condition is characterized by a prominent and
or more manic or mixed persistent disturbance in mood that is said to
episodes usually accompanied be direct physiologic consequence of a
by major depressive episodes medical condition, such as:
○ BIPOLAR II DISORDER – one
or more major depressive a. Degenerative neurologic conditions
episodes accompanied by at b. Cerebrovascular disease
least one hypomanic episode c. Metabolic or endocrine condition
d. Autoimmune disorders

2
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

e. HIV (human immunodeficiency virus) episode, with onset

f. cancers within 4 weeks of
delivery.
Other disorders that involve changes in mood
● Postpartum psychosis
include:
○ Is a psychotic episode,
4. Seasonal Affective Disorder (SAD) developing within 3
- Too much of melatonin, induces sleep, weeks of delivery and
increase the number in dark/night beginning with
time fatigue, sadness,
A. Winter depression or fall emotional lability, poor
onset SAD – people memory and
experience increased sleep, confusion, progressing
appetite, carbohydrates to delusions,
cravings, weight gain, hallucinations, poor
interpersonal conflict, insight and judgment,
irritability and heaviness in the loss of contact with
extremities reality.
B. Spring onset SAD – is less
ETIOLOGY
common, with symptoms of
insomnia, weight loss and The most recent research focuses on the
poor appetite. chemical biologic imbalances as the cause
● Postpartum or maternity blues
- Psychosocial stressors and
○ Are frequent normal
interpersonal events appear to trigger
experiences after
certain physiologic and chemical
delivery.
changes in the brain, which
○ They are characterized
significantly alter the balance of
by labile mood and
neurotransmitters
affect, crying spells,
sadness, insomnia and
anxiety.
● Postpartum or maternity blues BIOLOGIC THEORIES
○ Symptoms begin 1 Genetic theories
day after delivery,
usually peak in 3 to 7 ● Genetic studies implicate the
days and subside transmission of major depression in
rapidly. first degree relatives who are at twice
● postpartum depression the risk for developing depression
○ Meets all criteria for a compared with the general
major depressive population.

3
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

○ First degree relatives of NOREPINEPHRINE

people with bipolar disorder - levels may be deficit in depression
have 3% to 8% risk for and increased in mania.
developing bipolar disorder - This catecholamine energizes the
compared with 1% risk in the body to mobilize during stress and
general population inhibits kindling.
KINDLING
** For all mood disorders, monozygotic
● is the process by which seizure
(identical)twins have a concordance rate
● activity in a specific area of the brain
(both twins having the disorder)2 to 4 times
is initially stimulated by reaching a
higher than that of dizygotic (fraternal) twins.
threshold of the cumulative effects of
● Although heredity is a significant stress, low amounts of electric
factor the concordance rate for impulses or chemicals such as cocaine
monozygotic twins is not 100%, so that sensitize nerve cells and
genetics alone do not account. pathways
● The highly sensitized pathways
respond by no longer needing the
Neurochemical Theories stimulus to induce seizure activity,
which now occurs spontaneously
● Neurochemical influence of ● It is theorized that kindling may
neurotransmitters focus on Serotonin underlie the cycling of mood disorders
and norepinephrine. as well as addiction.
Serotonin Roles in behavior: ● Anticonvulsants inhibit kindling, this
may explain their efficacy in the
1. Mood treatment of bipolar disorders
2. Activity ● Dysregulation of Acetylcholine and
3. Aggressiveness dopamine is also being studied in
4. Irritability relation to mood disorders.
5. Cognition ● Cholinergic drugs alter mood, sleep,
6. Pain neuro endocrine function and the
7. Biorhythms electro encephalo graphic pattern.
8. Neuro endocrine processes (i.e. Therefore acetylcholine seems to be
growth hormone, cortisol and implemented in depression and
prolactin levels are abnormal in mania.
depression) ● The neurotransmitter problem may
** deficit in serotonin, its precursor not be as simple as underproduction
tryptophan or metabolite of serotonin found or depletion through overuse during
in the blood or cerebrospinal fluid occur in stress, changes in the sensitivity as
people with depression. well as the number of receptors are
being evaluated for their roles in

4
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

mood disorders (Tecoh & Smart, able to achieve these ideals

2005) all the time.
NEUROENDOCRINE INFLUENCES ● JACOBSON compared the state of
● Mood disturbances have been depression with a situation in which
documented in people with endocrine the ego is a powerless, helpless child
disorders such as those of the thyroid, victimized by the superego. e,g. a
adrenal, parathyroid and pituitary powerful mother who takes delight in
glands torturing the child.
● Elevated glucocorticoid activity is ● MEYER viewed depression as a
associated with the stress response reaction to a distressing life
and evidence of increased cortisol experience such as an event with
secretion is apparent in about 40% of psychic causality
clients with depression with the ● HORNEY believed that children
highest rates found among older raised by rejecting or unloving parents
clients were prone to feelings of insecurity
● About 5% to 10% of people with and loneliness, making them
depression have thyroid dysfunction susceptible to depression and
● An elevated TSH Thyroid Stimulating helplessness.
hormone, this problem must be ● BECK saw depression as resulting
corrected with thyroid treatment or from specific cognitive distortions in
treatment for the mood disorder is susceptible people
affected adversely. ○ Early experiences shaped
distorted ways of thinking
Psychodynamic Theories about self, the world and
● FREUD looked at the self depreciation future.
of people with depression and
attributed that self reproach to anger
turned inward related to either a real CULTURAL CONSIDERATIONS
or perceived loss
○ Feeling abandoned by this Other behaviors considered age appropriate
loss, people become angry can mask depression, which makes the
while both loving and hating disorder difficult to identify and diagnose in a
the lost object. certain age group
● BIBRING believed that one’s ego (or Children
self) aspired to be ideal and that to be
loved and worthy, one must achieve ● Children with depression often
these high standards appear cranky
○ depression results when in ● They have school phobia,
reality the person was not hyperactivity, learning disorders,

5
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

failing grades and antisocial ● In clients who have acute depression

behaviors. with psychotic features, an
antipsychotic is used in combination
Adolescents
with an antidepressant
● Adolescents with depression may ● Evidence is increasing that
abuse substances, join gangs, engage antidepressants therapy should
in risky behavior, be underachievers or continue for longer than the 3 to 6
drop out of school months originally believed necessary.
Fewer relapses occur in people with
Adults depression who receive 18 to 24
● Manifestations of depression can months of antidepressant therapy. As
include substance abuse, eating a rule, the dosage of antidepressants
disorders, compulsive behaviors such should be tapered before being
as workaholism, gambling and discontinued.
hypochondriasis
Antidepressants
Older adults ● selective serotonin reuptake
● Who are cranky and argumentative inhibitors (SSRIs) - first line, lesser
may actually be depressed. side effect
○ Prozac (antipsychotic mune
Many somatic ailments (physiological dahil matagal maging
ailments)accompany depression. This effective, more compliant to
manifestation varies among cultures and is help regulate dopamine level)
more apparent in cultures that avoid ● Tricyclic Antidepressants (TCA) -
verbalizing emotions. pag ayaw ng SSRIs
● Monoamine oxidase inhibitors
(MAOIs) - pag ayaw paden ng TCA,
TREATMENT AND PROGNOSIS hypertensive crisis effect (least)
○ Increase bp
PSYCHOPHARMACOLOGY
○ Nahihilo
● Major categories of antidepressants ○ Headaches
include cyclic antidepressants, ○ Bawal kumain tyramine rich
monoamine oxidase inhibitors food (overripe fruits, cheese,
(MAOIs), selective serotonin reuptake laman loob, cured meats,
inhibitors (SSRIs), and atypical process foods, ketchup;
antidepressants. The choice of which anything na preserve matamis
antidepressant to use is based on the or maalat, mataas ang
client’s symptoms, age, and physical sodium)
health needs. ● selective norepinephrine reuptake
inhibitor - are medications prescribed

6
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

to manage symptoms of attention the morning and better in the

deficit hyperactivity disorder (ADHD), evening).
such as lack of attention, impulsive ● Other indications include panic
behavior, and hyperactivity disorder, obsessive-compulsive
disorder, and eating disorders. Each
SELECTIVE SEROTONIN INHIBITORS
drug has a different degree of efficacy
SSRIs, the newest category of in blocking the activity of
antidepressants, are effective for most clients. norepinephrine and serotonin or
increasing the sensitivity of
postsynaptic receptor sites. Tricyclic
and heterocyclic antidepressants have
a lag period of 10 to 14 days before
reaching a serum level that begins to
alter symptoms; they take 6 weeks to
reach full effect.
● Tricyclic antidepressants are
contraindicated in severe impairment
of liver function and myocardial
● Their action is specific to serotonin infarction. They cannot be given
reuptake inhibition: these drugs concurrently with MAOIs. Because of
produce few sedating, anticholinergic, their anticholinergic side effects,
and cardiovascular side effects, which tricyclic antidepressants must be used
make them safer for use in older cautiously in clients
adults. Because of their low side ● Who have glaucoma, benign prostatic
effects and relative safety, people hypertrophy, urinary retention or
using SSRIs are more apt to be obstruction, diabetes mellitus,
compliant with the treatment regimen hyperthyroidism, cardiovascular
than clients using more troublesome disease, renal impairment or
medications. respiratory disorders
CYCLIC ANTIDEPRESSANTS ● Overdose of tricyclic antidepressant
● Tricyclics , introduced for the occurs over several days and results
treatment of depression in the in confusion, agitation, hallucinations,
mid-1950s, are the oldest hyperpyrexia, and increased reflexes.
antidepressants, they relieve Seizures, coma and cardiovascular
symptoms of hopelessness, toxicity.
helplessness, anhedonia,
TETRACYCLIC ANTIDERESANTS
inappropriate guilt, suicidal ideation,
and daily mood variations (cranky in ● Amoxapine(Asendin) may cause
extrapyramidal symptoms, tardive

7
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

dyskinesia and neuroleptic malignant ● The most serious side effect is

syndrome. It can create tolerance in 1 hypertensive crisis, a life-threatening
to 3 months. It increases appetite and condition that can result when a client
causes weight gain and cravings for taking MAOIs ingests
sweets. tyramine-containing foods and fluids
● Maprotiline (Ludiomil) carries a risk or other medications
for seizures (especially in heavy ● Symptoms are occipital headache,
drinkers), severe constipation and hypertension, nausea, vomiting, chills,
urinary retention, stomatitis and other sweating, restlessness, nuchal
side effects. rigidity, dilated pupils, fever and
motor agitation. These can lead to
ATYPICAL ANTIDEPRESSANTS
hyperpyrexia, cerebral hemorrhage,
● These are used when the client has and death.
an inadequate response to or side ● For hypertensive crises, transient
effects from SSRIs. Atypical hypertensive agents such as
antidepressants include venlafaxine phentolamine, mesylate, are given to
(Effexor), duloxetine (Cymbalta), dilate blood vessels and decrease
bupropion (Wellbutrin), nefazodone vascular resistance.
(Serzone) and mirtazapine (Remeron).
OTHER TREATMENTS AND
PSYCHOTHERAPY

ELECTROCONVULSIVE THERAPY (ECT)

● Psychiatrists may use ECT to treat

depression in select groups, such as
clients who do not respond to
MONOAMINE OXIDASE INHIBITORS antidepressants or those who
(MAOIs) experience intolerable side effects at
therapeutic doses. Clients who are
● These are used infrequently because actively suicidal may be given ECT if
of potentially fatal side effects and there is concern for their safety while
interactions with numerous drugs, waiting weeks for the full effects of
both prescription and over the counter antidepressant medication.
preparations. ● ECT involves application of electrodes
to the head of the client to deliver an
electrical impulse to the brain; this
causes a seizure. It is believed that the
shock stimulates brain chemistry to
correct the chemical imbalance of
depression.

8
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

PSYCHOTHERAPY

● A combination of psychotherapy and

medications is considered the most
effective treatment for depressive
disorders. The goals of combined
therapy are symptom remission,
psychosocial restoration, prevention
of relapse or recurrence, reduced PROMOTING A THERAPEUTIC
secondary consequences such as RELATIONSHIP
marital discord or occupational ● It is important to have meaningful
● Difficulties and increasing treatment contact with clients who have
compliance. Interpersonal therapy depression and to begin a therapeutic
focuses on difficulties in relationships, relationship regardless of the state of
such as grief reactions, role disputes depression. Some clients are quite
and role transitions. Interpersonal open in describing their feelings of
therapy helps the person to find ways sadness, hopelessness, helplessness
to accomplish this developmental or agitation
task. ● Clients may be unable to sustain a
● Behavior therapy seeks to increase long interaction, so several shorter
the frequency of the client’s positively visits help the nurse to assess status
reinforcing interactions with the and to establish a therapeutic
environment and decrease negative relationship.
interactions. It may also focus on ● Clients with psychomotor retardation
improving social skills. (slow speech, slow movement, slow
● Cognitive therapy focuses on how the thought process) are very
person thinks about the self, others noncommunicative or maybe even
and the future and interprets his mute. The nurse can sit with such
experiences. This model focuses on clients for a few minutes at intervals
the person’s distorted thinking, which, throughout the day.
in turn, influences feelings, behaviors ● The nurse’s presence conveys genuine
and functional abilities interest and caring. It is not necessary
for the nurse to talk to clients the
Example of cognitive distortions entire time; rather silence can convey
that clients are worthwhile even if
they are not interacting.

NURSING INTERVENTIONS FOR

DEPRESSION

9
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

● Provide for the safety of the client and Client: “I don’t feel like myself. I don’t
others. know what to do.”
● Institute suicide precautions if
Nurse: “That must be frightening.”
indicated.
(validating)
● Begin a therapeutic relationship by
spending non demanding time with
the client MANAGING MEDICATIONS
● Promote completion of activities of
daily living by assisting the client only ● The increased activity and improved
as necessary. mood that antidepressants produce
● Establish adequate nutrition and can provide the energy for suicidal
hydration. clients to carry out the act. Thus, the
● Promote sleep and rest. nurse must assess suicidal risk even
● Engage the client in other activities when clients are receiving
● Encourage the client to verbalize and antidepressants. It is also important
describe emotions to ensure that
● Work with the client to manage ● Clients ingest the medication and are
medications and side effects not saving it in attempt to commit
suicide. Clients and family must learn
USING THERAPEUTIC COMMUNICATION how to manage the medication
regimen because clients may need to
● Clients with depression are often
take these medications for months,
overwhelmed by the intensity of their
years, or even a lifetime. Education
emotions. Talking about these
promotes compliance.
feelings can be beneficial. Initially, the
nurse encourages clients to describe PROVIDING CLIENT AND FAMILY
in detail how they are feeling. Sharing TEACHING
the burden with another person can
provide some relief. ● They must understand that
depression is an illness, not a lack of
At these times, the nurse can listen willpower or motivation. Learning
attentively, encourage clients and validate the about the beginning symptoms of
intensity of their experience. For example: relapse may assist clients to seek
treatment early and avoid a lengthy
Nurse: “How are you feeling today?”
recurrence.
(broad opening)
EVALUATION
Client: “I feel so awful, terrible.”
● Evaluation of the plan of care is based
Nurse: “Tell me more. What is that
on achievement of individual client
like for you?” (using a general lead ;
outcomes. It is essential that clients
encouraging description)
feel safe and do not experience

10
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

uncontrollable urges to commit

suicide.

BIPOLAR DISORDER TREATMENT

PSYCHOPHARMACOLOGY

If a client in the acute stage of mania or

depression exhibits psychosis (disordered
thinking as seen with delusions ,
hallucinations, and illusions), an antipsychotic
agent is administered in addition to the *1.2-1.4 mEg/L (therapeutic level)
bipolar medications. Some clients keep taking
both bipolar medications and antipsychotics. Lithium ===== Eskalith

ANTICONVULSANT DRUGS Several

anticonvulsants traditionally used to treat
LITHIUM. Lithium is a salt contained in the seizure disorders have proved helpful in
human body; it is similar to gold, copper, stabilizing the moods of people with bipolar
magnesium, manganese and other trace illness. Clients taking carbamazepine need to
elements. Lithium could also partially or have drug serum levels checked regularly to
completely mute the cycling toward bipolar monitor for toxicity and to determine whether
depression. The response rate in acute mania the drug has reached therapeutic levels,
to lithium therapy is 70% to 80%. which are generally 4 to 12 ug/ml.
Lithium’s action peaks in 30 minutes to 4 Anticonvulsants used as a mood stabilizers
hours for regular forms and in 4 to 6 hours for
the slow-release form. It crosses the
blood-brain barrier and placenta and is
distributed in sweat and breast milk. Lithium
use during pregnancy is not recommended
because it can lead to first-trimester
developmental abnormalities . Onset of
action is 5 to 14 days ; with this lag period ,
antipsychotic or Antidepressant agents are
used carefully in combination with lithium to
reduce symptoms in acutely manic or acutely
depressed clients.

Symptoms and interventions of Lithium EVALUATION

Toxicity

11
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

Evaluation of the treatment of bipolar ● Teach about medication management,

disorder includes but is not limited to the including the need for periodic blood
following: work and management of side effects
● For client taking lithium, tech about
● Safety issues
the need for adequate salt and fluid
● Comparison of mood and affect
intake
between start of treatment and
● Teach the client and family about
present
signs of toxicity and the need to seek
● Adherence to treatment regimen of
medical attention immediately
medication and psychotherapy.
● Educate the client and family about
● Changes in client’s perception of
risk-taking behavior and how to avoid
quality of life.
it.
● Achievement of specific goals of
● Teach about behavioral signs of
treatment including new coping
relapse and how to seek treatment in
methods
early stages.
FOR MANIA
SUICIDE
● Provide for the client's physical safety
and those around. ● Suicide is the intentional act of killing
● Set limits on client’s behavior when oneself. Suicidal thoughts are
needed common in people with mood
● Remind the client to respect distances disorders, especially depression. Each
between self and others. year more than 30,000 suicides are
● Use short, simple sentences to reported in the United States; suicide
communicate attempts are estimated to be 8 to 10
● Clarify the meaning of client’s times higher. In the US, men commit
communication. approximately 78% of suicides, which
● Frequently provide finger foods that is roughly 3x the rate of women,
are high in calories and protein. although women are 4x more Likely
● Promote rest and sleep than men to attempt suicide. Suicide
● Protect the client’s dignity when is the 2nd leading cause of death (after
inappropriate when behavior occurs accidents) among people 15 to 24
● Channel client’s need for movement years of age, and the rate of suicide is
into socially acceptable motor increasing most rapidly in this age
activities group. Clients with psychiatric
CLIENT FAMILY EDUCATION disorders, especially depression,
● Teach about bipolar illness and ways bipolar disorder, schizophrenia,
to manage the disorder substance abuse, posttraumatic stress
disorder and borderline personality
disorder, are at increased risk for

12
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

suicide. Chronic medical illnesses “Specifically, just how are you

associated With increased risk for planning to sleep and not think
suicide include cancer, HIV, diabetes, anymore?”
cerebrovascular accidents, and head
“ By sleep, do you mean die?”
and spinal cord injury. Environmental
factors that increase suicide risk
include isolation, recent loss, lack of
social support, unemployment, critical CLIENT STATEMENT
life events, and family history of “I want it to be all over.”
depression or suicide. Suicidal
ideation means thinking about killing “It will just be the end of the story”
oneself. Active suicidal “ You have been a good friend.
● Ideation is when a person thinks Remember me.”
about and seek ways to commit
suicide. Passive suicidal ideation is NURSE RESPONSES
when a person thinks about wanting
“What is it you specifically want to
to die or wishes he or she was dead
be over?”
his or but has no plans to cause his or
her death. People with active suicidal “Are you planning to end your life?”
ideation are considered more
“how do you plan to end your story?”
potentially lethal. Attempted suicide
is a suicidal act that either failed or “You sound as if you are saying
was incomplete goodbye. Are you?”
WARNINGS OF SUICIDAL INTENT

● Suicide includes ambivalence. Many CLIENT STATEMENT

fatal accidents may be impulsive
suicides. Most people with suicidal “ I can’t stand the pain anymore”
ideation send either direct or indirect NURSE RESPONSES
signals to others about their intent to
harm themselves. “How do you plan to end the pain?”

SUICIDAL IDEATION: CLIENT STATEMENTS “Tell me about the pain.”

AND NURSE RESPONSES

CLIENT STATEMENT
CLIENT STATEMENT
“ I just want to sleep and not think
Non verbal change in behavior from
anymore.”
agitated to calm, anxious or relaxed,
NURSE RESPONSES depressed to smiling, hostile to

13
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

benign from being without direction develop new coping skills that do not
to appearing to be goal directed. involve self harm. Other outcomes
may relate to activities of daily living ,
NURSE RESPONSES
sleep and nourishment needs, and
“You seem different today. What is problems specific to the crisis such as
this about?” stabilization of psychiatric
illness/symptoms.

LETHALITY ASSESSMENT Examples of outcomes for a suicidal person

include the following:
When a client admits to having a “death
wish” or suicidal thoughts, the next step is to - The client will be safe from harming
determine potential lethality. This self or others
assessment involve asking the following - The client will engage in therapeutic
questions: relationship
- The client will establish a no suicide
- Does the client have a plan? If so, contract
what is it? Is the plan specific? - The client will create a list of positive
- Are the means available to carry out attributes
this plan?(for example, if the person
plans to shoot himself, does he have INTERVENTION
access to a gun and ammunition?
● Using an authoritative role
- If the client carries out the plan, is it
● Creating a support system list
likely to be lethal? (for example, a
● Family response
plan to take 10 aspirin is not lethal,
● Nurses’ response
while a plan to take a 2-week supply
● Community-based care
of a tricyclic antidepressant is.
● Elder considerations
- Has the client made preparations for
death, such as giving away prized Depression is common among the elderly and
possessions, writing a suicide note or and is markedly increased when elders are
talking to friends one last time? medically ill. Suicide among persons older
- Where and when does the client than age 65 is doubled compared with
intend to carry out the plan? suicide rates of persons younger than 65.
Elders are treated with ECT more frequently
OUTCOME IDENTIFICATION
than younger persons younger than 65.
- Suicide prevention usually involves
Elders are treated for depression with ECT
treating the underlying disorder, such
more frequently than younger persons.
as mood disorder or psychosis, with
Elderly people have increased intolerance of
psychoactive agents. The overall
side effects of antidepressant medications
goals are first to keep the client safe
and may not be able to tolerate doses high
and later to help him or her to

14
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

enough to effectively treat depression. ECT Personality disorders have been highly
produces a more rapid response than correlated with criminal behavior, alcoholism,
medications. and drug abuse.

● Dopamine - delusion and

POINTS TO CONSIDER WHEN WORKING
hallucination, increase
WITH CLIENTS WITH MOOD DISORDERS
● Norepinephrine and serotonin - high
● Remember that clients with mania
may seem happy, but they are
suffering inside. Biologic Theories
● For clients with mania , delay client ● Personality develops through the
teaching until the acute manic phase interaction of hereditary dispositions
is resolving and environmental influences.
● Schedule specific , short periods with
depressed or agitated clients to Temperament
eliminate unconscious avoidance of
● refers to the biologic processes of
them
sensation, association, and motivation
● Do not try to fix a client’s problem.
that underlie the integration of skills
Use therapeutic techniques to help
and habits based on emotion.
him or her find solutions.
The four temperament traits are harm
MODULE 6 avoidance, novelty seeking, reward
dependence, and persistence. Each of these
PERSONALITY DISORDERS four genetically influenced traits affects a
person’s automatic responses to certain
ETIOLOGY situations. These response patterns are
ingrained by 2 to 3 years of age.
Clients with personality disorders have a
higher death rate, especially as a result of
People with high People with low
suicide; they also have higher rates of
harm avoidance harm avoidance
suicide attempts, accidents, and emergency
department visits, and increased rates of
separation, divorce, and involvement in legal
proceedings regarding child custody.
Incidence is even higher for people in lower
socioeconomic groups and unstable or
disadvantaged populations.

15
PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

■ exhibit fear of ● carefree,

People high in People with low
uncertainty, ● energetic
reward dependence reward dependence
■ social ● outgoing
inhibition, ● optimistic
■ tenderhearted ● practical
■ shyness with ● Low harm
, ● tough-minde
strangers, avoidance
■ sensitive d
■ rapid behaviors
■ sociable ● cold
fatigability, may result in
■ socially ● socially
■ pessimistic unwarranted
dependent. insensitive
worry in optimism and
■ may become ● irresolute
anticipation of unresponsive
overly ● indifferent to
problems. ness to
dependent on being alone
■ High harm potential
approval from ● Social
avoidance harm or
others withdrawal
behaviors may danger
■ readily ● detachment
result in
assume the ● aloofness
maladaptive
ideas or ● disinterest in
inhibition and
wishes of others can
excessive
others without result.
anxiety
regard for
high novelty-seeking person low in their own
temperament novelty seeking beliefs or
temperament desires.

● quick-tempere ● slow-temper Highly persistent People with low

d ed people persistence
● curious ● stoic
● hardworking ● inactive
● easily bored ● reflective
● ambitious ● indolent
● impulsive ● frugal
overachievers ● unstable
● extravagant ● reserved
who respond ● erratic
● disorderly ● orderly
to fatigue or ● tend to give
● prone to ● tolerant of
frustration as up easily
angry monotony;
a personal when
outbursts ● may adhere
challenge frustrated
● fickle in to a routine of
● may persevere and rarely
relationships. activities.
even when a strive for
situation higher
dictates they

16
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

should change accomplishm They cannot set and pursue

or stop ents meaningful goals.

2. Cooperativeness refers to the extent

These four genetically independent to which a person sees him or herself
temperament traits occur in all possible as an integral part of human society.
combinations. Some of the previous
descriptions of high and low levels of traits Highly cooperative people are
correspond closely with the descriptions of described as empathic, tolerant,
the various personality disorders. compassionate, supportive, and
principled.

People with low cooperativeness are

Psychodynamic Theories self-absorbed, intolerant, critical,
unhelpful, revengeful, and
Temperament is largely inherited, however
opportunistic; that is, they look out for
social learning, culture, and random life
themselves without regard for the
events unique to each person influence
rights and feelings of others.
character.
3. Self-transcendence describes the
Character consists of concepts about the self
extent to which a person considers
and the external world. It develops over time
him or herself to be an integral part of
as a person comes into contact with people
the universe.
and situations and confronts challenges.
Self-transcendent people are
Three major character traits have been
spiritual, unpretentious, humble, and
distinguished, Cloninger & Svrakic (2017)
fulfilled. These traits are helpful when
said that when fully developed, these
dealing with suffering, illness, or
character traits define a mature personality.
death.
1. Self-directedness is the extent to
People low in self-transcendence are
which a person is responsible,
practical, self-conscious, materialistic,
reliable, resourceful, goal-oriented,
and controlling. They may have
and self-confident.
difficulty accepting suffering, loss of
Self-directed people are realistic and control, personal and material losses,
effective and can adapt their behavior and death.
to achieve goals.
Character matures in stepwise stages from
People low in self-directedness are infancy through late adulthood. Each stage
blaming, helpless, irresponsible, and has an associated developmental task that
unreliable. the person must perform for mature
personality development. Failure to complete

17
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

a developmental task jeopardizes the A group of disorders characterized by a

person’s ability to achieve future PERVASIVE pattern of behavior and thinking
developmental tasks. that differs markedly from the norms of the
patient’s cultural or ethnic background
Experiences with family, peers, and others
can significantly influence psychosocial It occurs when personality traits -- behavior
development. Social education in the family patterns that reflect how a person perceives
creates an environment that can support or and relates to others and himself – become
oppress specific character development. rigid, maladaptive, and fixed.

Personality develops in response to

inherited dispositions (temperament) and
Diagnosis is made when the person exhibits
environmental influences (character), which
enduring behavioral patterns that deviate
are experiences unique to each person.
from cultural expectations in two or more of
Personality disorders result when the the following areas:
combination of temperament and character
● Ways of perceiving & interpreting self,
development produces maladaptive,
other people, & events
inflexible ways of viewing the self, coping
● Range, intensity, lability, and
with the world, and relating to others
appropriateness of emotional
Clusters of Personality Disorders response
● Interpersonal functioning
Personality disorder is a generalized pattern ● Ability to control impulses or express
of behaviors, thoughts, and emotions that behavior at the appropriate time/place
begins in adolescence, remains stable over
time, and causes stress or psychological
damage.

● affects the person’s cognition,

behavior, and style of interacting with
others.
● have trouble getting along with
others
● may be irritable, demanding, hostile,
fearful, or manipulative
● have inadequate coping mechanisms
and thus have trouble dealing with
everyday stresses

18
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

Personality disorder diagnoses are organized distortions, including psychotic symptoms;

according to clusters around a predominant affective symptoms and mood dysregulation;
type of behavioral pattern. aggression and behavioral dysfunction; and
anxiety.

TREATMENT
Individual and Group Psychotherapy
Several treatment strategies are used with
clients with personality disorders; these ● Therapy helpful to clients with
strategies are based on the disorder’s type personality disorders varies according
and severity or the amount of distress or to the type and severity of symptoms
functional impairment the client experiences. and the particular disorder.

Combinations of medication and group and Inpatient hospitalization is usually indicated

individual therapies are more likely to be when safety is a concern,
effective than is any single treatment. Not all
● for example, when a person with
people with personality disorders seek
BPD has suicidal ideas or engages in
treatment, however, even when significant
self-injury.
others or family members urge them to do so.
● Otherwise, hospitalization is not
useful and may even result in
Psychopharmacology dependence on the hospital and staff.

Pharmacologic treatment of clients with Individual and group psychotherapy

personality disorders focuses on the client’s
● goals for clients with personality
symptoms rather than the particular subtype.
disorders focus on building trust,
The four symptom categories that underlie teaching basic living skills, providing
personality disorders are cognitive-perceptual support, decreasing distressing

19
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

symptoms such as anxiety, and

improving interpersonal relationships
(Cloninger & Svrakic, 2017).

Relaxation or meditation techniques

● can help manage anxiety for clients.

● Improvement in basic living skills
through the relationship with a case
manager or therapist can improve the
functional skills of people with a
schizotypal personality disorder.

Assertiveness training

● groups can assist people to have

more satisfying relationships with
others and to build self-esteem when
that is needed.

Cognitive–behavioral therapy

● has been particularly helpful for From ppt <3

clients with personality disorders.
Personality
Several cognitive restructuring
techniques are used to change the an ingrained, ingrained,enduring pattern of
way the client thinks about him or behaving and relating to self, others, and the
herself and others: environment ;includes
thought stopping perceptions,perceptions,perceptions,
attitudes, attitudes, and emotions .
● in which the client stops negative
thought patterns; ● group of disorders characterized by a
PERVASIVE pattern of behavior and
positive self-talk
thinking that differs markedly from
● designed to change negative the norms of the patient’s cultural or
self-messages; and decatastrophizing. ethnic background
● which teaches the client to view life ● diagnosed when personality traits
events more realistically and not as become inflexible and maladaptive
catastrophes. and significantly interfere with how a
person functions in society or cause
the person emotional distress.

20
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

● Occurs when personality traits - ● reduced occupational functioning,

behavior patterns that reflect how a ranging from compulsive
person perceives and relates to others perfectionism to intentional sabotage
and himself – become rigid,
maladaptive, and fixed.
Categories
● affects the person’s cognition,
personality
behavior, and style of interacting with
Disorders
others.
● have trouble getting along with CLUSTER A Individual whose
others may be irritable, demanding, behavior appear odd
hostile, fearful, or manipulative or eccentric and
● have inadequate coping mechanisms include paranoid,
and thus have trouble dealing with schizoid, and
everyday stresses schizotypal
personality
Diagnosis is made when the person exhibits disorder
enduring behavioral patterns that deviate
from cultural expectations in two or more of CLUSTER B Include people
the following areas: appear dramatic
● Ways of perceiving & interpreting self, emotional or erratic
other people, & events and include
● Range, intensity, lability, and antisocial
appropriateness of emotional borderline
response histrionic and
● Interpersonal functioning narcissistic
● Ability to control impulses or express personality disorder
behavior at the appropriate time/place .
To one degree or another, most people with
personality disorders share the following CLUSTER C Include people who
features: appear anxious or
● disturbances in self image fearful and
● inappropriate range of emotions include avoidant
● Poor impulse control dependent and
● Maladaptive ways of perceiving obsessive
themselves, others and the world compulsive
● Long standing problems in personal personality disorder
relationships, ranging from
dependency to withdrawal

21
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

■ distorts reality
■ magical thinking
■ clairvoyance
● odd thinking
and speech
● reports
feelings of
being different
” or not fitting
in”
CLUSTER A
PARANOID PERSONALITY SCHIZOTYPAL PERSONALITY
● chronic hostility that is projected to ● displays abnormal or highly unusual
others thoughts, perceptions, speech &
● suspicious and distrusting behavior patterns
● argumentative ● emotionally isolated & socially
● hostile aloofness detached
● rigid, critical, and controlling of others ● they possess bizarre characteristics
● grandiosity found in schizophrenia but are NOT
SEVERE enough to be diagnosed as
SCHIZOID PERSONALITY such
● introvert, cold and distant ○ suspicious, paranoia, ideas of
● lacking close friends reference
● prefers solitary activities ○ distorts reality
● aloof and indifferent ○ magical thinking
● restricted expression of emotions ○ Clairvoyance
● inability to form warm, close, and ○ odd thinking and speech
satisfying human relationships ○ reports feelings of being
● displays abnormal or highly unusual different ”or not fitting in”
thoughts, perceptions, speech & CLUSTER B
behavior patterns emotionally
ANTISOCIAL PERSONALITY
isolated & socially detached
● Walang superego
○ they possess bizarre
● They can kill people na wala lang sa
characteristics found in
kanila
schizophrenia but are NOT
● More on male
SEVERE enough to be
● onset before the age of 15
diagnosed as such
● characterized by a pattern of behavior
■ suspicious, paranoia,
that shows callous disregard for the
ideas of reference
rights and feelings of others

22
PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

● Diagnosis of this disorder is not based BORDERLINE PERSONALITY

on the mental status of the person characterized by pervasive instability in
but on the history of longstanding moods, interpersonal relationships, se image
IRRESPONSIBLE, IMPULSIVE, AND and behavior
ANTISOCIAL BEHAVIOR ● more frequent in women
● High Manipulative ● history of abuse
● Often appear witty and intellectual ● uses denial, splitting, projection
but people who fall for their charm ● unclear gender identity:
soon find out that they are extremely A person must possess 5 or more of the
unreliable. following
● When confronted they smooth talk symptoms to be diagnosed with such:
their way out, often RATIONALIZING ● frantic efforts to avoid real or
his Behavior. imagined abandonment
● LACK SUPEREGO ● unstable and intense interpersonal
○ NO shame & guilt relationships that alternate between
○ Impulsive & aggressive idealization and devaluation
○ reckless with the safety of self ● identity disturbance – persistently
& others unstable self image
○ does not learn from mistakes ○ at least 2 types of impulsive
○ no concern for others behavior that are self -
○ failure to accept social norms damaging
○ poor sexual judgment inability ○ Excessive spending,
to form monogamous substance abuse, binge
relationships eating, or engaging in unsafe
○ poor work history, financially activities, including unsafe sex
unstable, history of divorce ● suicidal gestures or threats or se
and separation mutilating behavior
○ a pattern of fighting, stealing, ● Rapidly shifting, unstable moods
criminal record that usually ● chronic feelings of emptiness
begins before the age of 15 & ● difficulty managing anger
continues throughout life ● transient paranoid ideas or
○ Manipulative and narcissistic dissociative symptoms in response to
behavior stress
○ Pit staff against one another
○ superficial charm HISTRIONIC PERSONALITY
○ exploit others for materialistic “Hysterical Personality”
gain or personal gratification ● Characterized by overly dramatic and
○ perceives the world as hostile intensely expressive behavior
● Tolorates frustration poorly ● Their theatrical behaviors and
appearance that easily attracts

23
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

attention is an unconscious ○ believe themselves to be very

expression of their basic wish for important, they expect favors
dependency and protection and become angry or
CHARACTERISTIC : surprised when people do not
● conspicuously seek attention want what they want
● are vain and overly conscious of ○ Justify exploiting others
appearance whose needs or beliefs they
● express exaggerated emotions in consider less important due to
response to minor stimuli their exaggerated sense of se
● sexually seductive and provocative importance
● childish ● due to their grandiose thinking they:
● Superficial, often appear as “false” or ○ Overestimate abilities and
“shallow” underestimates contributions
● bores easily of others
● controlling of partner ○ lacks empathy and sensitivity
● they establish relationships easily but to needs of others
their relationships are often ○ are pr occupied with fantasies
superficial and transient and unlimited success and has
● engage in dissociation to avoid a constant need for attention
feelings and admiration
● exaggerate somatic complaints to ○ occur in high achievers but
support dependency may also occur in persons
● tend to consider recent acquaintances with few achievements
as dear friends
CLUSTER C
NARCISSISTIC PERSONALITY
● have exaggerated sense of superiority AVOIDANT PERSONALITY
and self importance extreme sensitivity to criticisms and potential
● they feel & think that they are above rejection that causes them to avoid social
everything relationships and interaction
● due to their grandiose thinking they CHARACTERISTICS
require constant admiration ● feelings of inadequacy
○ extremely sensitive to ● anger, depression, social phobia
criticism, failure or defeat. ● hypersensitivity – they are devastated
When confronted with a by the slightest criticisms
failure to fulfill their high ● social phobia
opinion of themselves, they
can become enraged or DEPENDENT PERSONALITY
seriously depressed ● lacks self confidence and the ability to
● due to their grandiose thinking they function independently

24
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

● they are intensely INSECURE to

function on their own which causes
them to allow other people to decide
for them and assume responsibility
for major areas in their lives
● believes that others are more capable
than them
● reluctant to assert themselves due to
the fear of offending & their lives
● they often allow the needs of the
people they depend on to supercede
their needs
● they cannot bear to be alone
● must have a CLOSE relationship to
depend on constantly

OBSESSIVE COMPULSIVE PERSONALITY

Characteristics
● perfectionist
● engages in over devotion to work,
reliable but inflexible to change
● they are NOT COMFORTABLE in
situations that are unpredictable, and
that includes relationships
● They have difficulty in forming warm
& close human relationship where
they cannot exert complete control
● It is also difficult for them to express
real, warm and tender emotions

25
 PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

2. Give positive feedback for honesty.

The client may try to act as though he
or she is “sick” or “helpless” or use
other techniques to avoid
responsibility.
3. Identify behaviors that are
unacceptable.
4. Develop specific consequences for the
identified unacceptable behaviors.
5. Avoid any discussion or debate about
why the rules or requirements exist.
State the requirements or rules in a
“matter-of-fact” manner.
6. Inform the client of unacceptable
behaviors and the resulting
consequences in advance of their
occurrence.
7. Communicate and document in the
client’s care plan all behaviors and
consequences in specific terms for all
Cognitive-Behavioral Therapy staff members.
● May be given in INDIVIDUAL or 8. Avoid discussing another staff
GROUP Psychotherapy Session. member’s actions or statements with
● Indicated to change the way the client the client until the other staff member
thinks about self and others. is present.
● Helps clients to view life events more 9. Be consistent and firm with the care
realistically. plan.
10. Avoid trying to coax or convince the
Other Psychotherapeutic Approach client to do the “right thing”.
DIALECTICAL BEHAVIOR THERAPY 11. Point out the client’s responsibility for
● designed for clients with borderline his or her behavior in a
personality disorder. non-judgemental manner
● focuses on distorted thinking and 12. Provide immediate positive feedback
behavior based on the assumption or reward for acceptable behavior.
that poorly regulated emotions. 13. Encourage the client to identify
sources of frustration, how he or she
Nursing Process Applied : Intervention dealt with it previously, and any
1. Encourage the client to identify the unpleasant consequences that
actions that precipitated resulted.
hospitalization.

26
PRNU134 NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ACUTE AND CHRONIC

Queen (maria.giannina on ig)

14. Explore alternative, socially and

legally acceptable methods of dealing
with identified frustrations.
15. Include exploration and information
on job seeking, work attendance, debt
paying, court appearances, and so
forth when working with the client in
anticipation of discharge.

27