Maladaptive Patterns of Behavior

(Psychotic and Non Psychotic Disorders)

 Automatism: repeated purposeless behaviors
•Drumming of Fingers. •Tapping of Foot •Twisting locks or hair
 Waxy Flexibility: maintenance of posture/position over time when it is awkward /
uncomfortable. (schizoprenia).
 Psychomotor Retardation: slow movement, slow speech, posture slumped (depression).
DISTURBANCE IN AFFECT & MOOD
1. Flat: no emotional response
2. Blunt: minimal / slow emotional response
3. Inappropriate: opposite emotions.
4. Restrictive: single emotional response
5. Labile: sudden shift of emotions; rapidly changing
DISTURBANCE IN THOUGHT PROCESS & CONTENT
Thought Process: how client thinks Thought Content: how client says
1. Circumstantiality: excessive unnecessary details before giving an answer
2. Neologism: pathologically coining (if encountered new words ask for meaning)
3. Word Salad: incoherent mixture of words & phrases
4. Flight of Ideas: shifting from one topic to another in a completely unrelated way
(Bipolarity)
5. Looseness of Association: shifting from one topic to another in a somewhat related way
(schizophrenia)
6. Verbigeration: meaningless repetition of words/phrase (no stimuli)
7. Perseveration: persistence response from a previous question (stimuli)
8. Echolalia: pathological repetition of words of others
9. Clang Association: rhyming of words
10. Tangentiality: excessive details but not answering the topic
11. Thought Blocking: stopping abruptly in the middle of a Sentence
12. Thought Broadcasting: delusional belief that others can hear I see one's thoughts
13. Thought Insertion: putting ideas / thoughts in the client's head
14. Thought Withdrawal: client thinks others are taking away his thoughts and he can't
stop it.

Delusion: erroneous fixed false belief

• Grandiose - fame, power, wealth, influence.
• Religious - related to great religious figure/prophet.
• Somatic - "the second Jesus Christ” ; vague, unrealistic beliefs about body
• Nihilistic - believes his organs are non-existent or rotten
• Referential - believes that TV, news, music, newspaper articles, have special meaning to
him
• Persecutory - being watched, ridiculed, harmed / plotted against
• Erotomanic Type - believes an individual (usually famous) is in love with them
• Jealous Type - think that their spouse or lover is unfaithful
Management For Delusions (CAVE):
C-larification of meaning.
A-cknowledge the feelings.
V-oicing doubt
E-ngage in reality-based activities
 DISTURBANCES IN PERCEPTION
 Hallucinations-psychotic (illusion has stimuli)
• Visual (psychedelics): marijuana use
• Tactile (fortification): alcohol withdrawal
• Olfactory (phantosmia): PTSD
• Gustatory (aura of seizure): metallic taste
• Auditory (command): paranoid schizophrenia (most dangerous)
• Illusions - misinterpretation of real external stimuli
( ex. patient sees electric wire and thought it to be snake )
• Depersonalization (contact w/ reality): altered perception of self. Sees self
from afar
• Derealization: altered perception of environment. Hazy, dreamy, unreal
environment.
Management of Hallucinations
Hallucinations must be recognized
Assess the content.
Reality presentation
Divert the attention
Engage in reality-based activities
Reintegrate with the milieu.
Talk back to the VOICES OF VOICE DISMISSAL

DISTURBANCE IN MEMORY
 Amnesia loss of memory.
• Retrograde: memory from before the event
-Reminisce
-Photos, music
• Anterograde: memory from after the event
- Reorient
- Clock, Calendar, notepad
 Confabulation: making stories that are not true to fill the gap between memory loss
Purpose: increase self-esteem
• Seen in dementia
Schizophrenia Spectrum Other Psychotic Disorders
SCHIZOPHRENIA
I month presence of Positive and Negative symptoms.
6 months continuous symptoms

POSITIVE OR HARD SYMPTOMS: increase Dopamine

• Delusions • Ambivalence-contradictory Feelings.
• Hallucinations • Looseness of Association.
• Illusion • Echopraxia
• Paranoia • Bizarre behavior
NEGATIVE OR SOFT SYMPTOMS: brain changes
• Affect Flat • Anosognosia - lacks awareness of
• Apathy disorder
• Avolition - lack of motivation • ADL neglected
• Anhedonia - lack pleasure • Asociality
• Anergia - lacks energy • Alogia - poverty of words/speech
SCHIZOPHRENIA MANAGEMENT
 Antipsychotics - also known as neuroleptics / tranquilizers major
  Indication: schizophrenia and psychotic disorders
 MOA: blocks neurotransmitter dopamine.
Categories:
• First Generation Antipsychotic - also known as Conventional Antipsychotic
Ends in-zine and -dol
- Chlorpromazine - Fluphenazine - Haloperidol
- Pherphenazine - Thioridazine - Droperidol

• Second Generation Antipsychotic (Atypical) - positive and negative S/SX

- also known as: Unconventional Antipsychotic
Ends in -pine and -dore
• Clozapine
• Quetiapine
• Ziprasidone
Antipsychotic Drugs Side Effects
Constipation = increase fluid & fiber
Agranulocytosis = monitor WBC; report signs of infection
Tooth decay = oral care

Dry Mouth = sugarless hard candy o or gum

Orthostatic = hypotension
Galactorrhea = use cotton underwear

Photosensitivity = avoid direct sunlight, SPF 50 lotion

Arrhythmias = immediately report abnormal heart beat
Weight Gain = lesson intake of sugary Food & beverages
Sedation = avoid driving & operating machineries
Antipsychotic Drugs Adverse Effects
1. Extrapyramidal Symptoms
 Dystonia - abnormal muscle rigidity (involuntary)
 Oculogyric Crisis - Akineton
 Opisthotonus – Benadryl
 Torticollis - Congentin
 Akathisia (Most Common) - inability to remain still – Propanolol
 Pseudoparkinsonism – Amantidine
 Shuffling Gait
 Masklike facies
 Unintentional tremor: pill-rolling
Nursing Action: report to physician.
Management: decreased dose/shift.
Prevention: early detection - assess spasm, restless
2. Tardive Dyskinesia – Involuntary; Permanent, irreversible - facial
 Tongue twisting
 Tongue protrusion
 Teeth grinding
 Lip smacking
Nursing action: Notify physician
Medical management: Velbenazine
Prevention: Start lowest dose
3. Agranulocytosis - Most common in clozapine(2nd)
 Malaise
 Leukopenia – decreased mature WBC
Nursing action: notify physician
Prevention: blood monitoring
4. Neuroleptic Malignant Syndrome (NMS) - Most fatal
 High fever 40°C
 Hypertension
 Diaphoresis (Excess sweating)
 Tachycardia
Nursing action: DC drug
Medical management: dantrolene
Prevention: hydration
SCHIZOPHRENIA MANAGEMENT
 Do not confront or argue delusion * Non-judgmental, matter-of-fact
 Maintain reality * Active listening
 Teach positive self-talk,
positive thinking, ignore delusion
OTHER PSYCHOTIC DISORDERS
Brief Psychotic Disorder
Presence of one or more: delusion, hallucination, disorganized speech
catatonic behavior
Duration: 1 day - 1 month
SCHIZOPHRENIFORM DISORDER (IDENTICAL TO SCHIZOPHRENIA)
Presence of two or more: delusion, hallucination, disorganized speech,
catatonic behavior, negative symptoms
Duration: 1 month, less than 6 months
SCHIZOAFFECTIVE DISORDER
Presence of schizophrenic behavior and symptoms of
mood disorder (depression or mania)
Low -Suicidal ideation
High - Euphoria (Excess Happiness)
High - Grandiosity
High - Hyperactivity
Duration at least 2 weeks
MOOD DISORDERS
MAJOR DEPRESSION DISORDER (MDD)
- Sad mood or loss of interest or pleasure
 Hopelessness
 Helplessness
- No manic behavior
- Prevalence women > men
• Endogenous: decreased norepinephrine, serotonin
• Exogenous: loss of loved one, self-depreciation
Diagnostic Criteria
Duration: 2 weeks
• Depressed mood
• Loss of interest or pleasure (anhedonia)
Four or more symptoms
Signs and symptoms (at least 4):
 Depressed mood almost everyday  Significant weight loss or gain
 Interest/pleasure in all or most (children)
activities  Insomnia or hypersomnia every day
  Feelings of worthlessness  Fatigue
 Decreased concentration  Recurrent thoughts of death
 Psychomotor retardation

Levels of Suicidal Behavior

 Suicidal gestures (non-lethal) self-injurious acts
 Suicidal ideations thoughts of suicide
 Suicidal threats) verbal statements
 Suicidal attempt actual implementation
 Completed suicide, warning signs have been missed/ignored
Management
Antidepressant
Indication: MDD, depressed phase of bipolar, psychotic depression
Three categories:
1. Selective Serotonin Reuptake Inhibitor (SSRI)
 First line treatment  Fluoxetine (Prozac)
 Increased serotonin level  Sertraline (Zoloft)
 Effective in 2-3 weeks  Paroxetine (Paxil)
 SSRI Side Effect (BAD SSRI)
Body weight increased
Anxiety
Dizziness
Suicidal thoughts
Serotonin syndrome
Reproductive sexual dysfunction( libido)
Insomnia
2. Tricyclic Antidepressant (TCA)
 Second line treatment
 serotonin and norepinephrine level
 Effective in 4-6 weeks
 Desipramine
 Imipramine
 Amitriptyline
Blurred vision
 Nortriptyline
 Amoxapine Urinary retention
 TCA Side Effect (TCAS)
 Tachycardia Constipation
 Cardiac effects Orthostatic
 Anticholinergics (BUCO PD) hypertension
 Sedation/sexual dysfunction
3. Monoamine oxidase inhibitor Photosensitivity
 Third line treatment
Dry mouth
 Increased all neurotransmitters
 Effective in 2-4 weeks
• Parnate
• Nardil
• Marplan
 Dietary Restriction
- Avoid tyramine rich food hypertensive crisis
 Wine
 Aged cheese (fermented)
 Preserved food (canned)
MAOI Side Effect
 Hypotension (orthostatic)  Hypertensive crisis
 Anticholinergic crisis  Anxiety, agitation, anorexia
Management
 Do not combine antidepressant  Irregular, interval visit
 Monitor blood pressure  Allow verbalizations of feelings
 Caution activities that require alert  Discourage day sleeping to promote
reflexes due to sedation restful sleep at night
 Safe environment: remove sharp  Convey accepting attitude
objects  Observe closely
 Directly ask suicidal intentions
o Near nurse’s station
o One-to-one
o Accompany to CR, meal, med administration

SUICIDE - Intentional killing of self

 Sex male >  Rational thinking loss
 Age. <19 or >45  Separated, divorced, widowed
 Depression  Organized or serious attempt
 Previous attempt  No social support
 Excessive alcohol and drug use

BIPOLAR AND RELATED DISORDERS

Bipolar Disorder
 Manifested by cycles of mania and  Hyperactivity
depression  Neurotransmitter, serotonin,
 Mania-high level of mood norepinephrine
 Inflated self-esteem  Sociocultural factor: upper class
 Grandiosity

SPECTRUM
o Bipolar Disorder Type I
 Manic episodes ; May have depressive episodes
Duration: >1 week
o Bipolar Disorder Type II
 Major depressive episode: 2 weeks
 Hypomanic episodes
• Hypomanic episode: lasts four (4) days

SPECTRUM
 o CYCLOTHYMIA o DYSTHYMIA
 Hypomania (for 1 day )  Mild or moderate depression
 Minor depressed mood (<2 weeks)  No delusion, hallucination, or impaired
 NO impaired functioning communication
 Persists up to 2 years

SIGNS AND SYMPTOMS:

MANIA
 Not influenced by drugs of alcohol
 3 out of 7 symptoms:
o Inflated self-esteem/grandiosity o Psychomotor agitation
o need for sleep o Easy distractibility
o Very talkative (pressured speech) o Impulsivity
o Flight of ideas

Management
 Priority: patient and other safety
 Nutrition high calorie, high protein
- Food on the go, finger food
- Sandwiches, protein bar, French fries, burgers
 Attitude therapy: matter-of-fact approach
 Activities: decelerating, solitary
 Brisk walking, house chores

BIPOLAR AND RELATED DISORDERS

Medical Management: Lithium
 Drug of choice: Lithium carbonate
Onset: weeks

3
Peak hours
Blood test days
 Therapeutic Level: 0.6-1.2 mEq/L
 Laboratory BUN, Creatinine
Medical Management: Lithium Side Effects
1. Polyuria = ✓ urination 2. Polydipsia = thirst
3. Fine Tremors Moderate toxicity: 2.3 mEq/L
Mild toxicity: 1.6-2.0 mEq/L Severe toxicity: 13 mEq/L

ANXIETY - Apprehension / uneasiness Fram danger

Source: mostly unknown /unrecognized
Anxiety ≠stress ; Anxiety ≠fear
• Stress: external pressure = Anxiety is the subjective response to stress
• Fear: cognitive process. = Deemed as threatening stimulus
Neurotransmitters: ↑ Norepinephrine; ↓ GABA
 Anatomical Changes: hippocampus
 Psychoanalytical: id-ego conflict
Remember: Normal anxiety dissipates when stimuli is no longer present
 Mild Anxiety - proactive anxiety
Perceptual Field: ↑perception/senses
✓ Enhanced Learning. ✓Butterflies in the Stomach
✓↑motivation rarely distressful ✓ Hypersensitive to noise
Use of Coping mechanism; Encourage Learning
 Moderate Anxiety
Perceptual Field: ↓ perception
 ↓awareness, alertness, focus  ↑Restlessness, ↑ RR & HR,
 Selective inattention sweating,↑speech, Gl upset
 Discontentment, Focus on self
Uses ego defense mechanism, Allow verbalization
 Severe Anxiety
 Perceptual Field: Focus is one single detail
- No problem solving
- No learning
 Headaches, Nausea, trembling, hyperventilation, diarrhea, chest pain
 Dread, horror, total focus on self. intense desire to relieve anxiety
Allow relief behaviors
 Panic Anxiety - Safety
 Perceptual Field: no focus at all; disturbed perception
 Cannot concentrate at all; Cannot comprehend simple instructions
 Labored breathing, severe trembling, pallor, sleeplessness
 Sense of impending doom, shouting, screaming, running, hallucination, delusion

Generalized Anxiety Disorders

Characterized by:
 Excessive, unrealistic worrying
  Anxiety evident: FIRMD
 Fatigue  Restlessness  Difficulty
 Irritability  Muscle Tension Concentrating
Duration: at least 6 months
Nursing Interventions:
 Stay with the patient- severe panic anxiety
 Speak slowly and calmly
 Use short dimple sentences; brief directions
 Decrease excess stimuli (noise, lighting, people,) - Provide quite environment
DOC: benzodiazepines (anti-anxiety, anxiolytics )

Panic Disorders
Characterized by:
 Unexpected, unpredictable panic attacks
 Intense Fear / terror
 ↑ norepinephrine, & GABA, & serotonin
Signs and Symptoms: TICSS
Trembling I shaking Chest pain Shortness of breath
Impending doom Sweating
Nursing Interventions:
 Panic Control Treatment
✓ Panic invoking exercise; exposure
✓ Teach breath training, cognitive restricting
1. Systematic Desentization
Hierarch of Feared situation • use of muscle relaxation.
2. Implosive Therapy
- Use of anxiety provoking imagery
- Dramatic and Vivid description
3. Exposure Therapy
 Exposure to real stimuli ✓ Brown paper bag
 Flooding  Speak in short, simple sentences.
- Hyperventilation  Allow crying to release tension
✓Slow, deep breathes

Anti-Anxiety
Benzodiazepines – (relaxation, sedating) known as Major Tranquilizers, Anxiolytics
Indication: anxiety & anxiety disorders, panic disorders, phobia
Ends in -pam, -zolam
•Diazepam • Alprazolam • Lorazepam
• Clonazepam • Chlordiazepoxide
(Cibrium)

Benzodiazepines: CNS depressant

 Drowsiness, confusion, lethargy – DO NOT DRIVE/ perform heavy activities
 Do not stop drug immediately: TAPER DOWN
 Avoid alcohol; will further depress CNS

AGORAPHOBIA
Characterized by:
 Fear in situations where escapes might be difficult / help might not be available when panic
symptoms occur
 Fear in the following situations:
- Use of public transportation - Enclosed spaces (theaters,
- Open spaces (parking lots, cinemas)
marketplace) - In a crowd/line
- Outside of home alone

SPECIFIC PHOBIA
Characterized by:
 Fear of specific objects/situations
 Interrupts with ADL
 Fear or anxiety is out of proportion to the phobic stimulus
 Level of anxiety: Panic
HOW DO WE KNOW IF ITS AN INTENSE FEAR OR PHOBIA?

INTENSE FEAR PHOBIA

Does not interrupt with ADL Interrupts ADL
Has no personality disorganization Level 4 anxiety and has personality
disorganization (hysteria, akinesia with
mutism)
COMMON TYPES

Fear of HEIGHT Acrophobia

Fear of SEX Coitophobia
Fear of PAIN Algophobia
Fear of SPIDER Arachnophobia
Fear of CLOSED SPACE Claustrophobia
Fear of BEING ALONE Monophobia
Fear of DISEASE Pathophobia
Fear of DEATH Thanaphobia
Fear of SNAKES Ophidiophobia

Management
 Treatment of Choice: Exposure Therapy
(1. Breathing technique, 2. Muscle relaxation, 3. Cognitive restricting)
 Systemic Desensitization
 Implosive Therapy
 Cognitive Behavior Therapy
 Positive Reframing
 Distraction Techniques
- Splashing cold water, rubber band, shouting

Obsessive Compulsive and Related Disorders

Obsessions
 Intrusive thoughts, recurrent and persistent
- Cannot stop, Cannot control, Cannot forget
 Thoughts are egodystonic → stress and anxiety
Compulsions
 Repetitive behaviors in response to obsession
- Ritual, Relieves anxiety
Diagnostic Criteria:
- Obsession and compulsion - Cause stress to the patient
- More than 1 hour/day - Affects ADLs
Accommodation: when family or friends are involved in compulsive rituals
Scrupulosity: OCD specific for religiosity or morally-intrusive thoughts
Cyberchondria: excessive online searching for health information
Body Dysmorphic Disorder
Formerly dysmorphophobia
 Preoccupation of perceived defect or flaw in physical appearance
Manifestation:
 Ideas of reference – they think others are mocking their body or look
 Excessive mirror checking, grooming, comparing self to others
Hoarding Disorder
Characterized by:
 Difficulty discarding or parting with possessions regardless of its value
 Excessive acquisition
 Treatment: CBT and self-help groups

Trichotillomania
Characterized by:
 Recurrent pulling out of one’s hair that results to hair loss (due to tension)
 Common areas: scalp, eyebrows,eyelashes
 May occur with trichophagia
- Rapunzel Syndrome: masses of hair digested
Excoriation Disorder
- Known as: dermatillomania
Characterized by:
- q Skin picking as means to relieve stress and anxiety
- Use biting, nail cutter, tweezers
- Common area: face, head, cuticles, back
Onychophagia
Characterized by:
- Chronic nail biting as self-soothing behavior
- Complications in nail and oral cavity
- Treatment: SSRI
 DISORDER Distinguishing Feature
OCD Undoing OCD Undoing
Body Dysmorphic Disorder Preoccupation of Body Dysmorphic Disorder Preoccupation of
perceived body defect perceived body defect
Hoarding Disorder Inability to discard Hoarding Disorder Inability to discard
possession possession

Management:
 SSRIs  Don’t immediately stop the ritual
 Behavioral Therapy  Provide time to do rituals, however
 Exposure and Response Prevention attempt to decrease by setting limits
(ERP)
 Structure activities helps divert attention away from obsession
 For handwashing compulsion:
- Tepid water
- Hand cream after washing
- Moisturizing soap > harsh soap

Trauma and Stressor Related-Disorders

POSTTRAUMATIC STRESS DISORDER
Known as: Survivor’s Syndrome (GUILT)
 Reaction to an extreme trauma that cause pervasive distress
Characterized by: FOR ≥ 1 MONTH
 Intrusive symptoms, avoidance of stimuli that reminds of trauma Negative mood assoc. with
trauma
 Hyperarousal
 Hypervigilance
Manifested as:
 Reexperiencing the traumatic event
 High level of anxiety (severe to panic)
 Intense flashbacks and distressing nightmares
 Disassociation: depersonalization, derealization
 Explosive anger, fear, guilt, shame
 Startles easily, sleeps poorly, irritable
 Increased risk of suicide
Management:
 Cognitive Behavioral Therapy  Non-threatening, matter of fact, but
 Exposure therapy friendly approach
 Cognitive processing therapy  Be consistent: keep promises, convey
 Sleep Hygiene acceptance, spend time with client
 Regular bedtime and rising time  Stay with patient during periods of
 Avoid naps flashback and nightmares
 Abstain alcohol or caffeine  Encourage talking about trauma:
 Avoid exercising 3 hrs before bed debriefing is the first step to resolution
 Treatment: SSRI, Antipsychotics, Mood  Support group
Stabilizers  Assess for self-destructive ideas and
 Assign same staff: client is suspicious, behaviors: suicide risk
serves to build trust

Acute Stress Disorder

Exposure to actual or threatened traumatic event:
 Directly experiencing
 Witnessing
 Learning the traumatic event occurred to a close person
Duration: less than 1 month
Treatment: CBT and anxiety management
Other Trauma and Stressor Related-Disorders
Reactive Attachment Disorder
 Inhibited, emotionally withdrawn behavior to accept comfort or affection
 Do not seek or rarely seek and responds to comfort
Disinhibited Social Engagement
 Indiscriminate and excessive attempts to receive comfort and affection
 Willingness to be with strangers

ATTENTION DEFICIT HYPERACTIVE DISORDER

Triad signs: (IHI)
 Inattention (difficulty focusing)
 Hyperactivity (excessive motor activity)
 Impulsivity (hasty actions)
Onset: preschool or school-age
Common in boys
Manifestations:
• Jump and climb on furniture • Cannot listen to directions or complete task
• Run through the house • Cannot play cooperatively
• Cannot tolerate sedentary activities • Low self-esteem
• Excessive noise • Peer rejection
• In-and-out in assigned seat at school

Management - Safety
• Cognitive Behavioral Therapy • Provide breaks as outlet for energy
(Environment structured)
• Reduce environmental stimuli
• Stop unsafe behavior
• Call child’s name for attention
• Close supervision
• Instruction in clear, simple, language
• Schedule daily routine and minimize
• Separate tasks into simple and small steps
changes
Management:
o Safety (Nursing)
o Oxygenation (Medical)
o DOC: Ritalin (Methylphenidate)
• Side effect: insomnia and growth stunt
• Give not later than 4:00 PM or lower the last dose of the day
o Second choice: antidepressant

Personality and Control-Impulse Disorder

Personality Trait: personality that is exhibited in wide range of social and personal context
According to APA:
“An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence
or early adulthood, is stable over time, and leads to distress or impairment”
Groups According to Three (3) Clusters:
Cluster A: odd or eccentric behaviors
 Paranoid Personality Disorder
 Hallmark: suspiciousness and mistrust
 Characteristics: jealous, inability to relax, secretive, hostile
 Defense mechanism: projection
 Critical of others but cannot accept critics about themselves
 Focus of care: paranoia (acceptance, confrontation, reflection)
Nursing Intervention:
- Serious, straight forward approach
- Teach validate ideas before taking action
- Involve client in treatment plan
 Schizoid Personality Disorder
 Hallmark: seclusive, isolated, emotionally-detach
 Characteristics: introverted, distant, loners, cold
 Inability to form close relationships
 Children: solitary activities
 Focus of care: social skills and self-esteem, feelings of pleasure
 Schizotypal Personality Disorder
 Hallmark: magical thinking
 Similar to schizophrenia but less severe
 Perceptual aberrations, referential thinking
 Eccentric behavior, unkempt
 Focus of care: low self esteem, social skills, perceptual disturbance
Cluster B: dramatic, emotional, erratic behavior (BAHN)
 Borderline Personality Disorder
 Characterized by:
- Instability of interpersonal relationship, self image
- Impulsive, destructive, self-mutilation
- Defense mechanism: splitting
- Unmet expectations: shame, self-hate, self-directed anger
 Focus of care: low-self esteem, safety, setting limits, mood stabilizers
 - Safety
- Help cope and control emotion
- Cognitive restructuring
- Mood stabilizers
- Teach social skills

 Antisocial Personality Disorder

 Characterized by:
- Socially irresponsible, exploitative, manipulative
- Deceitful, aggressive, lack of guilt
- They tend to break or not conform to law
- Low self-esteem and difficult temperament:
 Aggression  Hyperactivity
 Inattention  Impulsivity
 Focus of care:
 Limit setting  Self-awareness and self-esteem
 Confrontation  Self-responsibility
 Help problem-solving techniques
 Histrionic Personality Disorder
 Excessive emotionality and attention-seeking behavior
 Characterized by:
- Keeps themselves the center of attention (seduce, flirt)
- Self-dramatization, seeks approval from others
- Projects vain and demanding behavior
 Focus of care: social skills, factual feedback of behavior
 Narcissistic Personality Disorder
 Characterized by:
- Sense of grandiosity, self importance
- Excessive admiration to self
- Lacks empathy
- Fantasizes about success, power, beauty
 Focus of care: matter of fact approach, self-care skills

Cluster C: anxious or fearful behaviors (ADO)

 Avoidant Personality Disorder
 Characterized by:
- F ear of criticism, rejection
- E scapes relationship
- A voids social events because of low self-esteem
- R eluctant to engage in new activities
 Focus of care: increase self-esteem, decrease social isolation, cognitive restructuring,
support
 Dependent Personality Disorder
 Obsessive Compulsive Personality Disorder
 Dependent Personality Disorder (CANT)
 Characterized by:
- C ant make decisions on their own
- A ssumes they are helpless
 -N o self-confidence
-T hey seek constant approval and fears being abandoned
Focus of care: self-esteem, self-reliance and autonomy, problem-solving skills, cognitive
restructuring
 Obsessive Compulsive Personality Disorder
 Characterized by: Egosyntonic
- Focused on every details
- Rigidity and inflexibility
- Excessive devotion to work and productivity
- Extreme perfectionism
 Focus of care: negotiation with others, timely decisions and complete work, cognitive
restructuring

EATING DISORDERS
- Persistent disturbance of eating behavior that results in the altered consumption or
absorption of food, impairs physical health or psychosocial functioning.

Anorexia Nervosa
- Morbid fear of obesity, characterized by:
 Distorted body image
 Refusal to eat
 Preoccupation with food
 Common in Young Women: 12 to 30 years old
 Strict parents that control a woman’s life
Anorexia Nervosa Subtypes:
 Restricting type: past 3 months, no binge eating or purging behavior
 Binge-eating/purging type: past 3 months, with binge-eating or purging behavior
Anorexia Nervosa signs and symptoms:
 Reports “feeling fat” and “not hungry”
 Think and talks about food, prepares great amount of food for family and friends but do
not eat
 Amenorrhea is common
 Extensive exercising

Bulimia Nervosa
 Called binge-and-purge syndrome
 Extreme overeating followed by self induced vomiting and abuse of laxatives
 Common in females
Bulimia Nervosa Signs and Symptoms
 Would eat in a discrete period of time thousands of calories
 No sense of control and purge right after bingeeating
 Weight is predominantly in the normal level
 Eroded teeth due to gastric acid
 Russell sign: injuries in the knuckles

Binge-Eating Disorder
  Same characteristics with bulimia nervosa but NO purging or self-induced vomiting
 Weight – overweight/obesity
EATING DISORDERS Nursing Management:
 Sit with client during meal – at least 30 minutes
 Observe client for at least 1 hour after meals –to prevent vomiting or purging
 Accompany to bathroom if suspected purging
 Strict documentation of intake and output
 Weigh client – SAME TIME, SAME CLOTHES, SAME SCALE
 Therapy: Behavioral (Token Economy)

NEUROCOGNITIVE DISORDERS
DELIRIUM
 Syndrome with disturbances in consciousness and change in cognition:
- Inattention - Sensory disturbance: hallucination,
- Distraction illusion
- Disorientation
 Sudden onset
 Short-period: hours to several days
Common in patients with:
- Post-surgery
- Open heart surgery
- Fractured hips
Risk Factors:
- Drug toxicity or withdrawal - Metabolic disturbances related to
- Older age organ failure
- Dementia
DELIRIUM MANAGEMENT: SAFETY
- Treat underlying cause
- No specific drug
- Sedation can help for self-injurious acts
- Antipsychotic: haloperidol for psychotic symptoms
- Benzodiazepines worsen delirium
- Matter-of-fact approach
- Speak clearly, calmly; brief sentences
- Reduce environmental stimuli:
o Noise
o Color, decors
o People
- Well-lit to avoid illusion
Ensure safety
- Promote patient autonomy in care

DEMENTIA
Marked by progressive cognitive impairment; no LOC changes
Characterized by:
o Aphasia – language dysfunction (receptive, global/mixed, expressive)
o Apraxia – motor dysfunction
o Agnosia – inability to recognize/ name objects
o Disturbance in executive functioning (organize, common sense, planning)
Clinical manifestation:
- Social or occupational functioning or decline
- Memory impairment: early sign (confabulation)
- Difficulty learning
- Echolalia
- Palilalia

STAGES OF DEMENTIA:
Mild:
- Hallmark: forgetfulness
- Difficulty finding words
- Loses objects or belongings
- Social interactions less unejoyable
Moderate:
- Confusion
- Progressive memory loss
- Cannot perform complex task
- End-stage: disorientation, requires assistance
Severe:
- Personality and emotional changes
- Delusional
- Sundowning
- Forgets names of family members
COMMON TYPES OF DEMENTIA:
 Vascular Dementia:
- Vascular lesions in cerebral cortex (TIA) Transient ischemic → decreased blood supply
- Sudden cognitive decline
- Weakness in extremities
- Slurred speech

 Huntington’s Disease:
- Inherited, dominant gene → cerebral atrophy, demyelination, and enlarged ventricles
- Choreiform movement (involuntary, irregular or unpredictable muscle movements)
- Facial contortions
- Tongue twisting, turning, and movement
- Memory loss
- Decreased intellectual functioning
 Alzheimer’s Disease:
- Degenerative and progressive
- Impaired: cognition, emotional, behavioral, functional
 - Confirmatory: autopsy
- Essential Features:
- Aphasia
- Apraxia
- Agnosia
- Disturbance in executive functioning
- Impaired attention, learning, memory, social, perceptual-motor
Risk Factors:
- Familial - Hypertension
- Down syndrome - Hyperlipidemia
- Metabolic syndrome - Hyperglycemia
Alzheimer’s Disease Assessment:
Biologic/Anatomical Changes:
- Amyloid precursor protein
- Beta amyloid plaques
- Neurofibrillary tangles
Physical Function:
 Early changes in abilities to perform ADLs
 Late: incontinence, ataxia, dysphagia
- Bathing
- Dressing
- Toileting
- Feeding
 Hallmark: cognitive disturbance
 Neglecting self-care
 Sleep-wake disturbances
- Daytime sleeping
- Nighttime wakefulness
 Apathy
 Passivity
Memory Loss
- Misplace objects
- Miss appointments
- Forget what they were doing
- Confabulate
Language
- Agnosia/Aphasia (receptive, expressive, global)
- Late: comprehension diminishes, mute and unresponsive
Executive Functioning Impaired
- Problem solving
- Decision making
Psychotic Symptoms:
 - Suspiciousness
- Illusion or misperception
- Delusion
- Hallucinations
- Visual hallucination
- Withdrawal
- Restlessness
- Hyper vocalization to pain
- Disinhibition
Medical Management
- Goal: restore or maintain cognitive function
- Start slow and low in elderly
- Acetylcholinesterase Inhibitors
- DOC: Aricept and Rivastigmine
- Increases acetylcholine level → slows cognitive decline
- Side effects: parasympathetic stimulation
Management
- Do not confront or argue with delusion or hallucination
- Use of pictures for language impairment
- Use of calendar, list, or notebook for memory loss
- Establish a structured and routine environment
- Priority: safety (sundowning)
- Monitor bowel pattern: fluids and fiber prompt
- Therapy: Reminisce

SOMATIC SYMPTOM DISORDER

Somatization
 Transference of mental experience and states into bodily symptoms
 Internalization
 Three Central Features:
- Physical complaints with no organic basis
- Psychological factors and conflict trigger symptoms
- Symptoms not under patient’s control

Somatic Symptom Disorder

- One or more physical symptoms with no organic basis

Conversion Disorder
- Unexplained, sudden sensory or motor deficit
- La Belle Indifference
Pain Disorder
- Primary symptom of pain that is unrelieved by analgesics
Illness Anxiety Disorder
 Formerly: hypochondriasis
 Preoccupation with feat that one has a serious disease or will get a serious disease
Malingering
 Intentional production of false or grossly exaggerated physical or psychological
symptoms
 Motivated by external incentives
- Avoiding work
- Evading criminal prosecution,
- Obtaining financial compensation
Factitious Disorder, imposed on self or Manchausen Syndrome
- Occurs when a person intentionally produces or feigns physical or psychological
symptoms solely to gain attention.

Manchausen Syndrome by Proxy

- Person inflicts illness or injury on someone else to gain the attention of emergency
medical personnel or to be a “hero” for saving the victim.

Management
- Withdraw from focusing on physical symptoms
- Avoid discussing physical symptoms
- Make expectations clear and set patient to participate in activities
- Do not argue
- Focus on feelings, home, work, and relationship
- Introduce coping strategies
- Physical exercise and proper diet