PERSONALITY DISORDERS:

Age of diagnosis: Adolescent

Age of Improvement: 40 – 50 years old

Cluster A – ODD / ECCENTRIC / MAD

• Paranoid – suspicious
• Schizoid – social isolation and indifference
• Schizotypal – superstitious, magical thinkers

Cluster B – EMOTIONAL / ERRATIC / BAD

• Borderline – unpredictable mood, clings to relationship
• Antisocial – law breakers, no regard for right or wrong
• Histrionic – attention seekers, dramatic and theatrical
• Narcissistic – self-entitlement, denies weakness and failure

Cluster C – FEARFUL / ANXIOUS / SAD

• Avoidant – avoids responsibilities and social interactions
• Dependent – extreme submissiveness (depends on others for decision making)
• Obsessive compulsive – extreme neatness and perfectionism

Management: Behavioral therapy (Role Playing)

Initial step: Acknowledgement of own behavior
Goal of Management: Client to be able establish meaningful relationships, and find a stable job.

EATING DISORDERS
Psychodynamics: Parental harassment/antagonism/overprotective parents/enmeshment (lack of boundaries)
Sociocultural factor: Developmental pressure
Age group: Adolescent Females

Neurotransmitter: ___ SEROTONIN AND NOREPINEPHRINE

Anorexia Nervosa Bulimia Nervosa

Diagnostic criteria: Diagnostic criteria:
1. Intense fear of gaining weight 1. Recurrent BINGE eating
2. Body weight less than ___ % of the ideal 2. Distress regarding binge eating (GUILT)
3. Food intake restriction 3. Compensatory behaviors (PURGING)
4. Distorted body image
5. Amenorrhea Once a week for _____________

___ loss of appetite

___ refusal to talk about food
___ lack of knowledge about food

___ counting calories

___ compulsive exercising
___ ritualistic food behaviors
___ preoccupation with food related activities

___ RECOGNIZES the problem

Complications: Alopecia, Anemia, Lanugo

BINGE - EATING DISORDER: __________________________

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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NURSING DIAGNOSIS:
- Electrolyte imbalance _____ Body Image Disturbance
- Altered Nutrition _____ Altered Body Image

INTERVENTIONS:
- Plan meals with the client
- Set time limit during meals
- Supervise client after eating
- LIMIT TIME ON SOCIAL MEDIA

PSYCHOTHERAPY: Self-monitoring
- Diary of food intake
- Journal

EVALUATION: Normal BMI (18.5 – 24.9)

MEDICAL TREATMENT: Selective Serotonin Reuptake Inhibitors

ANXIETY
Neurotransmitter: _____ GAMMA AMINO BUTYRIC ACID

Characteristic: Contagious
Initial Nursing Action: Determine own level of anxiety
Priority: SAFETY (Stay with the patient)

Drug of choice: Benzodiazepines Midazo Diaze Burpi

Azapirones Alprazo Clonze Ispapi
Loraze
Nursing education: Avoid ____________

Antidote: Flumazenil (Romazicon)

LEVELS OF ANXIETY
Increased alertness, learning is effective Acknowledgement
Gastrointestinal butterflies Verbalization
MILD

Selective attention, narrowed perception Redirect

Can be redirected Refocus
MODERATE Gastrointestinal upset ORAL anxiolytics

Cannot complete task, cannot solve problem ATTEND TO PHYSICAL

Cannot be redirected SYMPTOMS
Nausea, vomiting, diarrhea IM anxiolytics
SEVERE
Physiologic symptoms (chest pain, tachycardia)

Delusions and Hallucinations Take Control

PANIC Violence and Suicide Restraint if needed

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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GENERALIZED ANXIETY DISORDER
3 or more of the following symptoms for more than ___________.
- Feeling on edge -irritability
- Easily tired - muscle tension
- Poor attention span -difficulty sleeping

ANXIETY RELATED DISORDERS

OBSESSIVE COMPULSIVE DISORDER
Obsession – repetitive thoughts
Compulsion – repetitive actions (RITUALS)

Defense Mechanism: Undoing

Management:
1. Allow the patient to perform the ritual
2. Adjust the schedule of the patient
3. Gradually limit the ritual
4. COGNITIVE BEHAVIORAL Therapy

PHOBIC DISORDER – irrational fear

Social Phobia – fear of interacting with strangers
Agoraphobia – fear of inescapable places
Specific phobias:
Claustrophobia – fear of enclosed spaces
Nosocomephobia – fear of hospitals
Thanatophobia – fear of death

Defense Mechanism: Displacement and avoidance

Management: Flooding – sudden exposure to maximum stimulus
Systematic Desensitization – gradual exposure to the feared object
1st step: Let the client think and talk about the feared object

SOMATOFORM DISORDERS
Physical symptoms Excessive worry
Complex Somatic Symptom Disorder
Illness Anxiety Disorder (Hypochondriasis)
DOCTOR SHOPPING

Functional Neurologic Disorder (Conversion Disorder)

LA BELLE INDIFFERENCE

Factitious Disorder imposed on self (Munchausen syndrome) Intentional induction or

Factitious Disorder imposed on others (Munchausen by proxy) falsification of illness

Primary Gain: Relief of anxiety or guilt

Secondary Gain: Attention

Nursing interventions:
Rule out any possible organic of physiologic cause
Attend to physical complaints
Consistent care giver must be provided
Encourage verbalization of feeling

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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TRAUMA RELATED DISORDERS
POST TRAUMATIC STRESS DISORDER
Cause: Rape, War, Natural calamities
Survivor’s guilt

Manifestations:
More than 6 years old: Hypervigilance, Flashback, Avoidance, Dissociation, Detachment
Less than 6 years old: Repetitive play and re-enactment

Psychotherapy:
• Adaptive closure therapy (empty chair technique)
• BREATHING technique
• Catharsis – releasing repressed emotions thru art and music
• Debriefing – client is asked about their emotional reaction to an incident
• Exposure therapy – confronting trauma associated thoughts rather than avoiding

Medical Management:
Selective Serotonin Reuptake Inhibitors

DEPERSONALIZATION / DEREALIZATION DISORDER

Depersonalization – out of the body experience
Derealization – out of the world experience

Primary Management: Talk Therapy

SUBSTANCE ABUSE DISORDERS:

Abuse – use of a drug that is inconsistent with medical or social norms
Intoxication – substance use that result in maladaptive behavior
Tolerance – need for a higher dose to produce the same effect
Dependence – unsuccessful attempts to stop using the substance
Withdrawal – physical or mental symptoms occurs when a person stops the use of the substance

Contributing factor: Genetics and Family Dynamics

NARCOTICS (downers)
Purpose: to escape reality
Commonly abused narcotics: Codeine, Tramadol, Oxycodone, Morphine, Meperidine, Fentanyl
Worst complication: HIV / Hep B

Signs of Abuse: Hypotension, Bradycardia, Bradypnea, Pupil _______________

Detoxification: _________________________ (Medication Assisted Therapy)

Antidote: ________________________

Early signs of withdrawal: Lacrimation, Diaphoresis, Rhinorrhea, Yawning

Late signs of withdrawal: Vomiting and Diarrhea

BARBITURATE (sedative-hypnotics)
Purpose: to cause sedation
Commonly abused barbiturates: -barbitals (phenobarbital, methohexital, thiopental)
Sign of abuse: same with narcotics
Management for overdose: Activated charcoal
Signs of Withdrawal: Anxiety and Seizure

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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STIMULANT
Purpose: to cause euphoria
Signs of abuse: Hypertension, tachycardia, tachypnea, pupil _____________

Commonly abused stimulants

➢ METHAMPHETAMINE
Sign of abuse: Decreased appetite, insomnia
: stained and rotting teeth
Sign of withdrawal: HALLUCINATIONS

➢ COCAINE
Sign of abuse: Excoriated nostrils, nosebleeds
Sign of withdrawal: BIPOLAR CYCLING

Medical Management: Bromocriptine (Parlodel) – decreases cravings

HALLUCINOGENS
Purpose: to cause hallucinations
Most commonly abused hallucinogens:
Cannabis Sativa (Marijuana) – Blood shot eyes (increased blood flow to eyeballs)
Active ingredient: Tetrahydrocannabinol

Lysergic Acid Diethylamide (LSD) – Synesthesia

Phencyclidine (PCP) – violence
Ecstasy – aggression

ALCOHOLISM
Effects of alcohol: Sedation
Defense mechanism: Denial

AVERSION THERAPY
Purpose: to stop alcoholism / to maintain _________________
Drug used: DISULFIRAM ANTABUSE

DISULFIRAM + ALCOHOL = severe adverse reaction (headache, abdominal pain, vomiting)

Assessment: TIME OF THE LAST INTAKE

Contraindication: Anything with alcohol (Mouthwash, cough suppressants, perfume etc)

ALCOHOL WITHDRAWAL
Stage 1 (6-12 hours): Pain (Abdominal)
Anxiety
Insomnia
Nausea

Stage 2 (12-48 hours):

Stage 3 (48-72 hours): Delirium Tremens (seizures and hallucinations)

Other Managements:
To decrease cravings to alcohol – Acamprosate (Campral)
To block the effect of alcohol – Naloxone / Naltrexone

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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GROUP THERAPY
Note:
No. of participants: 8 - 10
CODEPENDENCY
Stages: Forming, Norming, Storming ENABLING
Formation: Circular formation
Leader: Stable patient Support Groups:
Decision Maker: All members Alcoholic anonymous
Prime Rehabilitator: Patient Al-Anon
Most important element: Motivation Alateen
Tool: Cut, Annoy, Guilt, Eye opener (Cage) Rainbow Recovery

WERNICKE – KORSAKOFF’s SYNDROME

Cause: Alcoholism – causes THIAMINE DEFICIENCY

Wernicke’s Korsakoff’s
Acute Chronic
Short-term Long-term
Reversible Irreversible

Ataxia Confabulation
Confusion Hallucination
Ophthalmoplegia Amnesia

Management: Thiamine-Rich diet

GLOBAL COGNITIVE DISORDER

DELIRIUM DEMENTIA
Cause Impairment of neurons Death of neurons
Onset Sudden Gradual
Example Alcohol withdrawal Alzheimer’s disease
Prognosis Reversible Irreversible
Disorientation Temporary Permanent
MEMORY LOSS Temporary Permanent
Duration Hours to days Lifetime
Level of consciousness
Attention Span

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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BEHAVIORAL MANAGEMENT
WITHDRAWN CLIENT
- Aloof, alone, catatonic (have the tendency to hold their breath)
• Active Friendliness
Activity – Achievable, and non-competitive activities
Accompany – Offering self
Appraise – _____ material rewards

DEPRESSED CLIENT
• Kind Firmness
Silence
Offering Self
Motivate – remind client of time when she or he felt better and was successful

Engage in _________________________________.

SUICIDAL CLIENT
Giving of valuables
Cancelling of appointments
Apologetic
Sudden cheerfulness and increase in energy
Homicidal and suicidal thoughts

Most Common Time: Early morning, Monday, During endorsement

Most Common Method: Hanging
Most Common Place: Home
Gender and age: Males (20-24), Female (15-19)

Civil Status: Single

Important factor to consider: _________________________

DIRECT CONFRONTATION APPROACH

Clarify the client’s statement
Confront the client directly
Consider the plan, method, and lethality (How? When? Where?)
Confiscate dangerous objects
Contract of Safety: “I will not harm myself intentionally or accidentally with the next 24 hours”
Effectiveness: if client calls the attention of the nurse if there is increasing anxiety

Constant Observation _______________

Create a list of support system (SUICIDE / CRISIS HOTLINE)

Counsel the family (suicidal clues)

PARANOID CLIENT
• Passive Friendliness
Develop trust
Involve the client in planning
SEALED CONTAINER (for food and medicine)
Avoid staring, whispering, and giggling
Respect personal space (not less than _______)
Maintain professional tone (use simple, direct, concise words)

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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MANIC / MANIPULATIVE client
Matter-of-fact Approach (SET FIRM LIMITS)
- Point out unaccepted behavior, and inform client of what is expected
(Calm, non-threatening, non-punitive, directive tone of voice)

Room: Private Room

Activity: Non-competitive, Solitary, Gross Motor Activities

Diet: high calorie, finger food

AGGRESSIVE CLIENT (Verbally abusive)

Decrease Stimulation – turn of television, let other clients leave the room
Deescalate – Encourage expression of feelings, promote ASSERTIVE COMMUNICATION
Directive approach – calm, non-threatening

SHOW OF FORCE - Visibility of 4 – 6 staff members

Note: Only 1 RN is allowed to communicate with the patient

ASSAULTIVE CLIENT (Physically violent)

Goal of Management: To strengthen patient’s impulse control

ASSAULT CYCLE
Phase Behavior Intervention
Triggering Non – compliance Acknowledgment; Verbalization
Escalation Verbal aggression TIME OUT (Client’s room, Garden)
Crisis Physical violence SECLUSION or RESTRAINT
Recovery Relaxation Assess for injury
Post crisis depression Reconciliatory actions Discuss alternative behavior

SECLUSION
Room: lockable and observable from the outside
Purpose: RESTORATIVE, NOT PUNITIVE
Goal: to help client regain self-control
Monitoring: one-on-one monitoring on the first hour
Environment: less stimulated environment (no visitors and phone calls allowed)

RESTRAINT
Doctor’s order (Application): _________________
Proper Application:
- 6 to 8 staff members required
- Adequate circulation must be ensured
- Anchor on a stable part of the bed

Doctor’s order (removal): ____________________

Proper Removal:
Temporary – alternately, one at a time, for 10 minutes every 2 hours
Permanent – alternately one at a time

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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NURSE-PATIENT RELATIONSHIP
Most Important Element: ACCEPTANCE
Purpose: To help client develop new and effective coping mechanisms

Professional Relationship
Elements of a contract:
- Time, duration, and venue of sessions
- Termination and criteria for termination
- Nurse’s and patient’s responsibilities
- Participants

Phases of Nurse Patient Relationship (POWT)

PRE – ORIENTATION
Nurse’s Responsibility: Read the patient’s chart Problem: Reluctance of the nurse
Goal: Self – awareness / INTROSPECTION
- Determine preconceptions
- Acknowledge past experiences
- Resolve past conflicts
- Explore own thought and feelings

ORIENTATION
Nurse’s Responsibility: Formulate Nursing Diagnosis Problem: Resistance of the patient
Goal: Establish TRUST / Build RAPPORT
- Mutually set the contract

WORKING
Nurse’s Responsibility: Promote the client’s insight Problem: EMOTIONAL ATTACHMENT
Goal: RN (explore); Patient (verbalize) Transference – Patient to Nurse
Countertransference – Nurse to Patient

Intervention:
▪ Remind the patient about the contract

TERMINATION
Nursing responsibility: Problem: Separation Anxiety
Determine client’s feelings about Prevention: Constantly remind patient about the contract
the end of the relationship Intervention: Encourage verbalization of feelings

Goal: Evaluate effectives of intervention

CRISIS and CRISIS INTERVENTION

CRISIS - When coping mechanism are ineffective that results to disequilibrium.

TYPES OF CRISIS
Situational – caused by unexpected event (Loss of a job / starting a new job, Death of a loved one)
Adventitious / Social – caused by natural catastrophe (earthquake, fire, tornado)
Maturational / Developmental – caused by expected events (menarche, marriage, pregnancy, retirement)

Duration of Crisis: 4 – 6 weeks (self-limiting) Initial assessment: Precipitating event

Goal: To help patient return to pre-crisis level
Focus: Here and Now (GESTALT THERAPY) Factors to consider:
immediate problem, feelings, and solutions Perception
Approach: Directive – promote problem solving, Support system
Supportive – encourage expression of feelings Coping mechanism

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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Freud’s Structural Theory of Personality
ID Pleasure seeker, needs immediate gratification
EGO Balancer – REALITY
SUPEREGO Moral conscience, guilt

EGO DEFENSE MECHANISMS

Denial – failure to admit the reality of a situation Diabetic person eating chocolate candy

Regression – return to early stage of development Man pouts like a 4-year-old if he is not the center of his
girlfriend’s attention

Identification – imitating or emulating others while Nursing student becoming a critical care nurse because
searching for identity this is the specialty of an instructor she admires

Introjection – accepting another person’s attitude beliefs, Person who dislikes guns becomes an avid hunter, just
and values as one’s own (conforms feelings for approval) like a best friend

Projection – unconscious blaming of unacceptable An unfaithful husband suspects his wife of infidelity
inclinations or thoughts on an external object

Displacement – ventilation of intense feelings toward Person who is mad at the boss yells at his or her spouse
persons less threatening

Reaction Formation – Acting the opposite of what one Person who despises the boss tells everyone what a
thinks or feels great boss she is

Undoing – Exhibiting acceptable behavior to make up for Person who cheats on a spouse brings the spouse a
or negate unacceptable behavior bouquet of roses

Suppression – conscious forgetting Student decides not to think about a parent’s illness to
study for a tests

Repression – unconscious forgetting Woman has no memory of the mugging she suffered
yesterday

Dissociation – unconscious forgetting with disintegration DISSOCIATIVE IDENTITY DISORDER

of personality, consciousness, memory, identity, and Formerly known as MULTIPLE PERSONALITY DISORDER
emotion.
DISSOCIATIVE FUGUE (Psychogenic fugue)
different identity in a different environment

Rationalization – Distortion of facts, unjustifiable excuse Man says he beats his wife because she does not listen
to him

Intellectualization – acknowledging the facts but not the Person shows no emotional expression when discussing
emotions serious car accident

Substitution – replacing unattained goals with by one Woman who would like to have her own children opens
that is more attainable a day care center

Compensation – overachieve in another area to Nurse with low self-esteem working double shifts so
compensate for failure that her supervisor will like her

Sublimation – rechanneling of unacceptable impulses to Person who has quit smoking sucks on hard candy when
acceptable once. the urge to smoke arises

Splitting – categorizing people as either good or bad Seeing all people without mustache as all feminine

Prof. Kenneth Arzadon, RN (UK-CBT Passer)

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