Psychiatric Nursing Review

PSYCHIATRIC NURSING

Overview:

A. Psychiatric Nursing

Mental health Primary purpose is to promote mental health Not curable, only to reduce the symptoms

B. Main Tool : IPR (Interpersonal Relationship)

Client, individual, family, environment Nurse: self-awareness to minimize weakness, maximize strength

C. Focus of Psyche : Human Behavior- Leads to identification of feelings- Responses to the environment, changes are meaningful

D. Tool Used By The Nurse : Therapeutic use of self acquired thru self-awareness

E. Levels Of Prevention:

3 Levels Of Prevention:

1.) Primary Promote mental health (Healthy) Remove factors before they can cause illness

Ex. Stress reductionHealth Teachings/Community Teachings/Community DemographicsSupport SystemAccident Prevention

2.) Secondary Lessen the duration of mental illness (ill)

Ex. Suicide PreventionCrisis Intervention/ Treatment & DiagnosisProviding Psychotherapy & Milieu Therapy

3.) Tertiary Function to become independent

Ex. Rehabilitation Centers/ Al anonRelapse Avoidance

F. Stages Of Interaction

1st Stage: OrientationAssessment 2nd Stage: WorkingEstablishment of Trust Problem Solving Tell Patient of Termination Discussion 3rd Stage: Termination Set contract Patient is mostly cooperative SummarizeEvaluation Say Goodbye Patient is resistant Grief-Anger (Focus of RN)

Pt. violent/suicidalI. MENTAL HEALTH ----- A state of mind

6 Concepts In Mental Health:

Created by Niňa E. Tubio 1

1. Self-Awareness

2. Self-Actualization –Self-fulfillment or self-realization

3. Perception Of Reality

4. Autonomous Behavior: – Independence, decision-making ability

5. Adaptation : Use of Adaptive Defense Mechanisms Compensation Rationalization Identification Fantasy Substitution Sublimation

6. Integrative Capacity- Time to evaluate frustrations- Ability to solve conflicts:

*Conflict—presence of 2 goalsresolved through

a. Double Approach = 2 + goalsb. Double Avoidance = 2 goalsc. Approach-Avoidance = (+) & (-) outcome Ex. Developmental Task

II. PERSONALITY DEVELOPMENT:

*Our beliefs & thoughts influence our feelings & consequently manifests as behavior.

BELIEFS FEELINGS BEHAVIOR Create the

Different Inputs/Factors

* Per sonare ------- “to sound through”--- The sum total of traits w/c are unique

III. THEORIES ON PERSONALITY DEVELOPMENT:

1. SIGMUND FREUD - Father of Psychoanalysis

Psychoanalysis – Uses the principle of free association (Talk of anything that comes to mind & correlate w/ the behavior)

- As the treatment for the unconscious mind


- The role of the unconscious w/c has conflicts-----results to maladaptive behaviors(Dr. Karen Horney- detractor of Freud’s’ Penis Envy

- “ALL BEHAVIOR HAS MEANING”

Different Theories Of Sigmund Freud:

A. 3 STRUCTURE OF THE PERSONALITY

D Operates on “PLEASURE PRINCIPLE” IMPULSIVE Part Instinctual drive: “Eat, urinate, have sex”WANT TO Avoidance of pain, All “I”

Ex. Babies are all ID: “I want it, I want it now”

UPEREGO “CONSCIENCE”SHOULD NOT Higher self, ideal ego MALL VOICE OF GOD Tells you what is right or wrong

The censoring part, the moral valuesWhat makes you a perfectionist, rigid & righteous

Ex. I should not eat yet…..Function:

1. Inhibit the ID impulse

Operates on “REALITY PRINCIPLE”GO In touch with realityXECUTIVE The self, self-identityArbiter

Develops 6 monthsFunctions:

1. Higher Functions: memory, orientation, decision-maker

2. Integrator of Personality: mediator bet. the Id & Superegobetween self & environment

3. It will tolerate frustrations4. Solve conflicts

Ex. “I can wait for what I want”

5. Uses Defense Mechanism---to maintain balance (PRN only)

6. Directs motor skills

7. Evaluate the environment

8. Reduces anxiety*The ability to tolerate frustration based on the balance of the 3 functions: Imbalance -----Maladaptive Behavior

1. 2.

EGO EGO

ID is dominant; needs a superego (conscience) SUPEREGO is dominant; needs an IDCharacteristic of: Characteristic of:

MANIC OBSESSIVE-COMPULSIVEANTISOCIAL (Serial-killer) ANOREXIA NERVOSA


IS

E

ID

SUPEREGO

SUPEREGO

ID

NARCISSISTIC PERFECTIONIST, RIGID

3.

EGO

If there’s Weakened EGO Impaired Reality Perception Characteristic of: SCHIZOPHRENIA

B. THE THEORY OF LIBIDO

LIBIDO - Sexual energy for survival Man’s sexual desires & urges Personal-----libidal striving w/c focuses on gratification

C. THE THEORY OF DREAMS Resides in the unconscious

D. THE THEORY ON LEVELS OF AWARENESS

3 Levels of Awareness:> Highest level of Awareness> Contains all experiences that can be recalled voluntarily

> “Tip Of The Tongue”; Deja Vu> Experiences that partly forgotten & partly remembered

> Forgotten> Experiences that cannot be recalled Ex. Dreams, accidents, anxieties & phobias> Where traumatic experiences are stored (Repression)

Ex. Birth Trauma (the cause of 1st anxiety)

*The ID, Ego & Superego -----all resides in the unconscious & operates on different levels of the mindExcept the ego when dealing with reality----resides on the ---conscious

E. THE PSYCHOSEXUAL THEORY

STAGES OF PSYCHOSEXUAL DEVELOPMENT

1. ORAL STAGE 0 – 18 months

“ Survival” All ID Cry, suck mouth Biting, Thumb sucking & Nail biting-----------------all normal in infancy Dependent, Helpless----------------needs to develop sense of trust, sense of security

After 6 months, EGO develops------Development of Self-Concept

Maternal Deprivation results if there’s no feeding, not given milk/water, not kept warm

Residuals Developed : 3 Maladaptive Behavior:


ID SUPEREGO

CONSCIOUS

PRE-CONSCIOUS(Sub-conscious)

UNCONSCIOUS

Repression – Unconscious forgetting of an anxiety-provoking event

Suppression – Conscious forgetting of an anxiety-provoking event (voluntary)

- The only conscious defense mechanism

Successful CleanOrganizedObedient

P

Overeating Over-talkative Gossiping Chewing gums Smoking & Drinking alcohol

2. ANAL STAGE 18 months – 3 years old

Focus on Elimination -----Bowel -------the 1st to developed -----Bladder (Bedwetting) Toilet training Temper Tantrums---Normal---Ignore as long as no harm is present: If (+) harm---set limits SUPEREGO is being formed(begins)---------------Mother as the superego

Sense of Autonomy Develops------manifested through

Negativism (No) Stubbornness

Concerns: PunishmentCleanlinessHabit-training Stage

Residuals Developed: Perfectionist, Rigid, Righteous, Collectors & Hoarders

Problems: Strict Toilet TrainingToo much punishment w/ Toilet-training result to a child who is:

Anal Retentive Anal Expulsive(Obsessive-Compulsive) (Antisocial)

3. PHALLIC STAGE 3 years – 6 years old

HALLIC

ENIS ARENT RE - SCHOOLER

Focus: Genitals------Penis only Development of Gender Identity Sense of Being Masculine/Feminine Sense of Initiative Genital Exhibitionism/Masturbation Imaginative With a friend Explorative “Why” Residuals Developed: Sexual Deviation Sibling Rivalry is normal

Development of Complexes----child attachment to opposite sex

Both complexes resolved thru


NarcissisticStems from being deprived & neglected as a child

Regression Going to an earlier developmental stage

Good mother Bad mother

DirtyDisorganizedDisobedient

SE SE

SE

Oedipus Complex(boy loves mommy)

Identification(boy imitates daddy)

Boys-“Castration fears”

Electra Complex(girl loves daddy)

Identification(girl imitates mommy)

Girls-“Penis Envy”

Fixation Stopping in a certain stage of Development

R

Identification To parent of the same sex(Role Identification)

4. LATENCY STAGE 6 to 12 years old (School Age) (“Log tu” tulog ang libido)

Focus: School & Peer The Homosexual Stage-----------Identify with the same sex------Best friend Areas on school & social competition--------------form the sense of group success Sense of Industry Fear: School Phobia-------------Separation-Anxiety

EADING W ITING

A ITHMETIC

Residuals Developed: School Dropout

5. GENITAL STAGE 12 years and above (Gising na ulit ang sexual energy)

Focus: Genitals Emergence of LUST ENITAL The Heterosexual Stage ISING Sense of Identity AMBIVALENCE: Child Adult

Struggle for independence from parents Problems: Conflicts & Frustrations dominates

Residuals Developed: Drug Addiction, Promiscuity, Alcoholism2. ERIK ERICKSON------- Psychosocial Theory Of Development

Considered the “Social Factors” Man as a Social Being Person play different roles & as we play them, we achieve something

PSYCHOSOCIAL STAGES OF DEVELOPMENT

Stage Freud (+) (-) Factor Significant Person

0-18 months(Infancy)

Oral Trust( Friendly/ Affectionate)

(Self-Confidence)

Mistrust(Withdrawn/Suspicious)

Feeding Mother

18 months – 3 years

(Toddler)

Anal Autonomy (Self-Determination)

(Independence)

Shame & Doubt (Overtly Compliant)

Toilet Training“No,No”

“My”

Parents

3 – 6 years(Pre-Schooler)

Phallic Initiative(Responsible)

(Role Identification)Initiate the 1st step

Guilt(Denial, Restrictions)

Anger To Self

Independence“Teach The

Child”

Family


Sublimation – placing sexual energies (feelings) toward more productive endeavors

G

6-12 years(School)

Latent Industry(Competition) (Cooperative)

“Sx of High Self-Esteem”

Inferiority(Social Loner)

(School Drop-out)

School“Who Am I” based on

beliefs, selects & become who you are along w/ your peers

TeacherPeer

12 – 20 years(Adolescence)

Genital Identity(Self-Actualized)(Self-Direction)

Role Confusion(Identity Crisis)

Peers(Major factor in

the dev’t of beliefs

Opposite Sex

20-25 years(Young Adult)

Intimacy(Commitment)

Isolation(Relationships/Jobs on

Temporary Basis)

Love Husband/WifeChildren

25-45 years(Middle Adult)

Generativity(Productivity)

“Sharing”

Stagnation(Selfish, Self-Centered)

“No Learning”

Parenting“Sharing beliefs w/ children”

ChildrenGrandchildren

45 & Above(Late Adult)

Ego Integrity(Worthiness)

(Completeness)

Despair(Hopeless, Unworthy)

(Fear of Death)

Reflection Husband/WifeBest friend

Paranoia = Stems from the development of mistrust

Exercise: Newly admitted Patient:----Develop 1st ----Trust ----Develop/teach autonomy since pts. Are dependent with self-care deficit

3. JEAN PIAGET-------Theory Of Cognitive Development

Four Stages Of Cognitive Development

1st Stage : Sensorimotor 0- 2 years old Preverbal Recognizing environment by the use of senses (baby can see,perceive,hear)

Adapt through the use of reflexes & motor skill Concept of Object Permanence

----even if they cannot see the object, they still believed its existence

2nd Stage : Pre-Operational 2- 7 years old Egocentric----does not feel what adults feel Animistic Thinking -------cartoons are powerful Imitates other people Pre-Conceptual 2-4 y/o -----Use of language to talk Intuitive Stage 4 -7 y/o-----Unidimentional classification/characteristics

(Child can fix toys according to size, color, height---1 at a time only

3rd Stage : Concrete Operational 7 – 12 years old Logical Concept of Cause & Effect

4th Stage : Formal Operation 12 years old & above Idealistic Abstract Thinking

4. ABRAHAM MASLOW’S HIERARCHY OF NEEDS


> Continuous Improvement of Self> Low self- esteem: Give Task

5. OTTO RANK------Theory Of Birth Trauma Birth Trauma---------Manifested Through----------Separation Anxiety Birth Trauma --------the 1st cause of Anxiety

6. CARL JUNG------Theory Of Libido

Theory Of Libido-------derived from an energy level

7. ADOLF MEYER--------Psychobiology Theory Concept of the mind & body as one entity

8. ALFRED ADLER------Individual Psychology Unique Man born with a weakness but overcomes it through

Compensation Inferiority Vs. Superiority Concept

9. HARRY STACK SULLIVAN-----Theory Of Interpersonal Relationships

Theory of Interpersonal Relationships

Mother & Child developed IPR during infancy------if lacking------anxiety

Builder Of Self-Esteem

MotivationStages:

1. Infancy--------------- 0-18 months Mouth

2. Childhood------------18 months- 6 y/o Egocentric/Gender Identity

3. Juvenile----------------6-9 y/o Competitive

4. Pre-Adolescence------ 9-12 y/o Best Friend Depends on group success

5. Early Adolescence--- 12-18 y/o Emergence of Lust Attraction to opposite sex-----bases: physical appearance

6. Late Adolescence------18-22 y/o Development of lasting relationship----based on security

7. Adulthood-----------------22 y/o & above Achievements


SELF-ACTUALIZATIONSELF- ESTEEM

LOVE & BELONGINGNESSSAFETY & SECURITY

BASIC PHYSIOLOGICAL NEEDS

Focus on emotional & sexual maturity

10. BEHAVIORAL MODELS

A. IVAN PAVLOV ------------------CLASSICAL CONDITIONING MODEL

“All behavior is learned” through CLASSICAL CONDITIONING

Unconditioned stimulus Unconditioned Response(food) (salivation)

Conditioned stimulus (bell)

B. B.F. SKINNER ---------------------OPERANT CONDITIONING MODEL

If all behavior is learned, then it can be unlearned

Good Behavior Reward Positive reinforcement Repeated behavior

Bad Behavior Punishment Negative reinforcement Extinguishes behavior / extinction

IV. PSYCHOPHARMACOLOGY

Anatomy: Frontal Lobe = Personality, Learning, Judgment, LanguageOccipital Lobe = VisionTemporal Lobe = Hearing, SmellParietal Lobe = Touch

How do you interact with your environment?

S ENSORY -----1st ------seeing

I NTEGRATION ------2nd------analyze

M OTOR ------3rd------action

Voluntary Movements Involuntary Movements (SOMATIC)SNS (AUTONOMIC) ANS

Brain (Alert) Sympathetic Parasympathetic (Relax)

Spinal cord ♥ HR ↑ ↓

RR ↑ ↓ Motor Nerves

GI ↓ dry mouth ↑ moist mouth constipation diarrhea

GU ↓ retention ↑ frequency Acetylcholine – “on” switch of muscle(transmits message to the muscle) Neuro Epinephrine/ Acetylcholine


Ach

Transmitter Norepinephrine Synapse Pupils Midriasis Myotic

Blood Vessel Vasoconstriction VasodilatationBP Increased Decreased

Muscle Fiber

Anti-Cholinergic/ Anti-Parasympathetic Effect is sympathetic

Sympathetic Drug Classifications:

A- anxiety P- psychotic

ANTI C-cholinergic D- depressants

V. DEFENSE MECHANISMS

Mental mechanisms Coping Mechanisms from stress Patterns of adjustment Affects/Interferes with ADL--------harm to self or others Operates on the unconscious level

Processes on the Ego---------to reduce anxiety--------maintain self-esteem

Results to

> Adaptive/ Maladaptive> Distort reality> Self-deception

DEFENSE MECHANISMS

Displacement Transfer of feelings to less threatening object/person rather than the one who provoked it

UnacceptableEx. “ Boss shouts at you, you shout to your subordinate”

Denial Failure to acknowledge an unacceptable trait or situation or realityEx. “I am not an alcoholic”

Regression Returning to an earlier developmental stage (earlier pattern of behavior)Ex. Acting like a child

Repression Unconscious forgetting of anxiety provoking concept (Selective forgetting)

Rationalization Illogical reasoning for a socially unacceptable trait (Giving rational reasons) Uses “because” Most common defense mechanism used

Ex. “I drink the beer in the ref rather than waste it”

Reaction-Formation Doing opposite of the intention (Hypocrites)

Undoing Doing opposite of what you have done (Action & then amends)Ex. Show true feeling then feels guilty after doing it

Identification Assuming trait, persona, social & occupational role (Models a certain behavior)


Unconsciously imitating another person

Projection Attribute to others one’s unacceptable trait (Scapegoat Mechanism)Ex. “Not me but them”

Introjection Assume another’s trait as your own (Taken into oneself)Ex. “Not only you, Me too”

Suppression Conscious forgetting of an anxiety-provoking concept (Voluntary forgetting) Intentional forgetting to an unpleasant experienceEx. “I don’t want to talk about it”

Sublimation Excessive energies put towards more productive endeavors Redirect feelings (anger) to a socially acceptable behavior

Substitution Replacing a difficult goal with an accessible oneConversion Repression. Anger repressed & converted to physical symptoms

Ex. numbness & motor paralysis Solve conflicts by manifesting physical symptoms

Compensation Overachieving in one area to cover defective part or weakness To overcome inferiority & excel in other aspect of personality

Fantasy Use of imagination/daydreaming

Isolation Separating your feelings from the situation

Fixation Arrest of maturation/Persistence of one stage of development

Symbolism Give meaning to objects

Dissociation Psychological flight from selfEx. Amnesia, Rape or traumatic experiences Unconscious separation of certain parts or functions of personality

Alteration in--------MemoryIdentityConsciousness

To reduce/avoid anxietyCategories:

1. Psychogenic Amnesia------loss of memory

2. Fugue --New identity in a new place

3. Multiple Personality Dissociative identity disorder 2 or more personalities

4. Depersonalization Unreality to oneself With altered sense of self

5. Dissociation not otherwise classified Sleep talking----somniloquism Sleepwalking---somnambulism Amok aggression

VI. CONCEPT OF NEUROSES & PSYCHOSES


Neuroses Psychoses

1. Maladaptive emotional state 1. Disturbance of the mind2. Reality is present 2. No reality3. Ego in the conscious 3. Ego in the unconscious4. Behavior is socially acceptable 4. Behavior is appropriate

Core Symptom: Anxiety Core Symptom: Hallucination, Illusion, Delusion

Tx: Minor Tranquilizer Tx: Major TranquilizerEx. Valium, Ativan Ex. Thorazine, Haldol

VII. THERAPEUTIC COMMUNICATION

THERAPEUTIC COMMUNICATION TECHNIQUES

THERAPEUTIC NON-THERAPEUTIC

Offering Self“I’ll sit with you”“I’ll stay with you”

Ignoring patient’s feelings or emotions“Don’t worry be happy”

Silence (giving patient time to think)

False Reassurance“Everything’s going to be fine”

Making observations“You seem sad”

Ignoring the client

Active Listening Nodding, establish eye contact, leaning forward

Changing the subject

Exploring questionsWho, what, where, when, how

Asking “why?”Putting client on the defensive

Broad Opening“How are you today?”“How are things going today?”

Making value-based judgmentsPrejudicial, use of adjectives“Nice weather today”

General leads“Go on. I’m listening.”“ And then what else?”

Flattery“You are the most beautiful …”

RestatingClient: “I’m sad.”Nurse: “You’re sad?”

Advising“You should do this.”“In my opinion…”

Refocusing“ We were talking about the exam….” Commanding client

Focusing“Tell me more about this…” Arguing with the patient

Clarification “What do you mean by plooplank?” Do not impose your opinion


P D S

CONCEPTS & DISORDERS

VIII. ANXIETY - Vague sense of impending doom- Afraid of the unknown- Present is the anticipation of danger- A feeling of uneasiness---------vague

apprehension------uncertainty

Different with Fear – afraid of what you know- Presence of an external danger

A. ASSESSMENT:

Level of Anxiety

0 = Ataraxia------absence of anxiety----------uncommon---------present only in clients on shabu/drug addicts

MILD MODERATE SEVERE PANIC

Widened Perceptual Field acing on’t know what to do uicide Increased motivation RN meds on’t know what to say afety Restless irective Enhance learning capacity Selective Inattention Free-floating anxiety Increased Hearing Presence of Physical Sx muscle tension DON’T TOUCH client Problem-Solving present Narrowing of attention Respiratory alkalosis* * Good: Client more aware *Breathe into bag * Bad: Contagious Disorganized Level * Normal anxiety r/t everyday tension Terror/Threat

USE THERAPEUTIC COMM Apathy Ex. “You seem anxious” *An emergency Words are usually enough to SNS Activation Manage mild anxiety

NURSING DIAGNOSES: Ineffective Individual CopingPowerlessnessImpaired Skin Integrity


PERCEPTUAL

FIELD

Mild+1

Moderate+2

Severe+3

Panic+4

PLANNING/ IMPLEMENTATION: ↓ level of anxiety↓ level of environmental stimuli

Relaxation techniques (Psychophysiology)

EVALUATION: Effective individual copingB. DISORDERS ASSOCIATED WITH ANXIETY

1.) GENERALIZED ANXIETY DISORDER

6 months excessive worrying Restless Concentration difficulty Sleep problems Palpitations Feeling of being at the edge of seat Easy fatigability Patient knows what the problem is

2.) PANIC DISORDER

15-30 minutes escalation of the SNS Sudden: Happens w/o warning With or W/O agoraphobia

2 Types:Agoraphobia - Fear of open spaces > Outstanding Sign of Panic DisorderSocial Phobia - Fear of public

3.) POST TRAUMATIC STRESS DISORDER (PTSD)

Trauma Disasters Rape War (not forever) Others

4.) MALINGERING - Pretending to be sick (Conscious) - No organic basis - Intentional

*Primary gain – the result you get when you manifest certain behavior that ↓ anxiety (Ex. Escape from Teacher)

*Secondary gain = ↑ Attention ( Ex. from mother)

Physiology:


Victims Survivors

Flashbacks : > 1 monthNightmares

ANXIETY

“I am sick”

Malingering(Pretending)

Somatoform(Unconscious)

Psychosomatic Disorders(Real pain/ real Sx, ) illness

5.) SOMATOFORM DISORDERS

Unconscious Not pretending but no organic basis Major

Sign:

Affects the 3 system

6.) PSYCHOSOMATIC DISORDERS

Psycho physiologic Real illness, real Sx & pain with organic basis

Physiology:

Decreased O2 supply----cells die

7.) OBSESSIVE-COMPULSIVE DISORDER (OCD)

Physiology:


SOMATOFORM(unconscious)

Nervous SystemCONVERSION

La belle difference(Emotional detachment)

Loss of Sensory/Motor FxS &Sx real

HYPOCHONDRIASISMinor discomfort interpreted

as major illness

BODY DYSMORPHIC DISORDER

Illusion of structural defectsS &Sx not real

DOCTOR HOPPINGFavorite pastime of people suffering from this disorder

↑ ANXIETY

SNS PNS

↑BPHypertension

Vasoconstriction Bronchoconstriction

Cerebral ArteryMigraine

Left Gastric Artery

Breakdown of mucosal lining-----ulceration

Asthma

Stress ulcer

NURSING FOCUS: Client’s Feelings (↓anxiety leads to ↓symptoms)

Beliefs/Thoughts reflect into feelings

Factors: If disturbed thoughts Anxiety

Obsession (Persistent Thoughts) Anxiety (Root of Anxiety)

Do something to relieve anxietyAction : Compulsion

Persistent Behavior & Action

↓ anxiety

Reasons when compulsion becomes negative:1. Interferes with ADLs2. Harms self & others

8.) PHOBIA Irrational fear

Etiology: Prior knowledge Ex. Tire will cause burningExperience Ex. Trauma in past related to feared object

Intervention: REMOVE stimulus (object of fear) to ↓ anxiety (Immediate intervention)

Increased stimuli = ↑ anxietyDecreased stimuli = ↓ anxiety

Ex. Belief Feelings Behavior Object will hurt patient Scared Avoidance: Interferes w/ ADL

Tx:BEHAVIORAL THERAPY:

Systematic Desensitization - gradual exposure to feared object

Individual Therapy

1. Hypnosis--------------------Relaxed state2. Free Association----------Ideas shared to psychoanalyst3. Catharsis--------------------Free to express feelings4. Transference---------------Patient feels something for psychoanalyst5. Counter transference-----Rn feels something for patient

IX. EATING DISORDERS

ANOREXIA NERVOSA & BULIMIA NERVOSA

ANOREXIA BULIMIA


Diet, diet, diet Eating Pattern Eat, Eat…induce vomiting

Underweight, < 85% of body weight Weight Normal weight

3 months amenorrhea Menstruation Irregular menstruation

Failure To Recognize Problem Knowledge Knows the Problem But Ashamed & Embarrassed

MANAGEMENT:

Priority: Restore fluid & electrolyte balance Anorexic & bulimic clients are at risk for FLUID VOLUME DEFICIT

Collaborate with client re: menu through use of CONTRACT to ensure cooperation

Priority: Target weight gain & Monitor eating pattern & weight

Stay with client for 1 hour after meals to ensure client eats food & does not induce vomiting.

Accompany in the toilet

Nsg Dx: Body Image Disturbance

N.I. - Establish nutrition pattern - Teach stress management, Journal keeping

- Anti-depressant

RELATED DISORDERS:

1. BINGE EATING DISORDER - Recurrent episodes of binge eating- No regular use of appropriate compensatory behaviors

2. NIGHT EATING SYNDROME (NES)- Characterized by morning anorexia- Evening hyperphagia (Consuming 50% of daily calories after last evening meal)- Nightime awakenings (at least once a night)

3. COMORBID PSYCHIATRIC DISORDERS COMMON IN CLIENTS WITH EATING DISORDER

X. PERSONALITY DISORDERS

Cluster A

SCHIZOID Avoids people, Do not care about people & believes he can stand on his ownDetachment from social relationships Avoids activities & group more concerned with thingsNo enjoyment: Limited range of emotional expression in interpersonal settings

PARANOID Suspicious


NURSING CONSIDERATIONSBulimic induces vomiting & tends to abuse laxatives

Assess for:Dental caries

Wounded knucklesVomiting - Risk for metabolic alkalosisDiarrhea – risk for metabolic acidosis

NURSING ALERT Most fatal complication: ARRHYTHMIAS

Violent

SCHIZOTYPAL Acute discomfort in relationshipsEccentric behavior

Cluster BANTISOCIAL Breaks the law

Usually charming, wittyAs kids, were usually cruel to animals, steals, lieAs Adults, drug addicts-drives fast-unsafe sex-thrill seekerAre slick talkers

BORDERLINE Loves to split groupsLikes to keep sparesAfraid of being aloneManipulativeSelf-mutilationSuperficial Relationships

HISTRIONIC Attention-SeekingExcited, dramatic Manipulative

NARCISSISTIC “I love myself”Insensitive, ArrogantSelf-absorbedExaggerated

Cluster C

AVOIDANT Avoid people & groupsFears criticism, ↓ Self-esteemHave a talent but no confidence

DEPENDENT “Can’t live without you”↓ Self-EsteemPoor decision-making skills

OBSESSIVE-COMPULSIVE OrganizedConstancy in EnvironmentPerfectionists------Provide time to do rituals

OTHER CATEGORIES:

PASSIVE-AGGRESSIVE Always says “yes” but resistance is hiddenDEPRESSIVE Pattern of depressive cognitions & behaviors in a variety of context

NURSING INTERVENTION TO ALL: Improve Interpersonal RelationshipsBuild Trust

XI. SCHIZOPHRENIA

EGO Disintegration Impaired Reality Perception

Famous example: John Forbes Nash, Jr.

THEORIES OF CAUSATION:> Stress Diathesis Model - Stressful living pushes person to escape into fantasy

“Far better to be king in your fantasy world” idea> Genetic Vulnerability - Runs in families; genetic component (biological)> Unknown> Physiological Finding: ↑Dopamine in schizophrenic clients


“My life is an empty glass”

(+)fill

friends

( - )suicidal

SplittingLabile affect

(sudden change of mood)

Physiology: “ON” switch “OFF” switch

OTHER SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS:

PhotosensitivityTeach patient to use sunscreen, wide-brimmed hat when going out

Agranulocytosis (↑ monocytes, ↑ lymphatic)Teach client to report SORE THROAT (1st sign of Blood Dyscrasia)


↓Dopamine↓ACH

↑Dopamine

ACH D

ACH

D

↑ACH↑ACHD

ACHParkinson’s Schizophrenia

↓Dopamine

D

ACH

Antipsychotic agents → ↓DopamineClient manifest Parkinson-like symptoms known as

EXTRA PYRAMIDAL SIDE EFFECTS (Voluntary mov’t of the skeletal muscles) (↓D & ↑ACH)

A kathisia (restlessness, inability to stay still)* Most common A kinesia ( muscle rigidity) D ystonia ----earliest sign (1-5 days)

Characteristic Features: Torticullis (wry neck) Oculogyric crisis (fixed stare) Opisthotonus ( arched back)

T ardive Dyskinesia (irreversible effects) d/t ↑ Adenosine Triphosphate

Lip smacking Tongue protrusion Cheek puffing

N euroleptic Malignant Syndrome or NMS Hyperthermia, Unstable BP, ↑ CPK, Diaphoresis, Pallor A medical emergency, discontinue drug

Give ANTICHOLINERGICS to treat EPS

Except Tardive Dyskinesia

↑ACH

DACH

ANTICHOLINERGICS A kineton A rtane Benadryl Cogentin

DOPAMINERGICS Parlodel Larodopa Symmetrel Eldepryl

Anti-Psychotic & Anti-Cholinergic Both given to Schizophrenia to

balance the effect

A

Hypersensitive Reactions Ex. Allergy ↓ Epinephrine ------Hypotension Endocrine-------------M = Gynecomastia F = Enlargement of breast & ↑ libido Arrythmia Blurring of vision, Opacity of the lens, retinitis Pruritus, dermatosis, rashes, eczema, dermatitis & hyperpigmentation

A. THE NURSING PROCESS:

ASSESSMENT: 4 A’s

FFECT External manifestation (feelings & emotion) MBIVALENCE Pull between 2 opposing forces UTISM Self-absorbed, Trapped in own world SSOCIATIVE LOOSENESS Unrelated ideas

4 THINGS TO ASSESS IN SCHIZOPHRENIC PATIENTS

Assess Content of Thought Hallucinations/ Illusions Suspicious Suicidal

Nsg Dx Disturbed Thought Processes Disturbed Sensory Perception

Risk for Other-Directed Violence

Risk for Self-Directed Violence

Planning/ Implementation

Present RealityProvide Safety




Evaluation Improved Thought Processes Improved Sensory Perception

Minimize/ Eliminate risk for other-directed violence

Minimize/ Eliminate risk for self-directed violence

B. SYMPTOMS

S & Sx OF SCHIZOPHRENIA 2 Types

C. TYPES OF SCHIZOPHRENIA


Types Of Affect

1. Appropriate2. Inappropriate3. Flat (none)4. Blunt (incomplete)

POSITIVEHyperactive

SociableTalkativeRestless

Queen of the WorldFlight of ideas

(Hallucinattion,Illusion, Delusion)

NEGATIVEHypoactiveWithdrawn

QuietFlat Affect

ApathyPoverty of words

SCHIZOPHRENIA

D. THOUGHT PROCESS DISTURBANCE

Vs.

AMBIVALENCE Feeling of being pulled between 2 opposing forces

ECHOLALIA I repeat what you say (Word Repetition)

ECHOPRAXIA I repeat what you do (Action Repetition)

WORD SALAD Just mixing of words, no rhyme

CLANG ASSOCIATION Rhyming words


FLIGHT OF IDEASFragmented thoughts;

moving one unconnected topic to another

“The sun is shining. The mouse is on the mat. Here is the bag.”

- New topics- No connection

LOOSE ASSOCIATIONS-Stringing together of

unrelated topics with a vague connection

“I am going home. The home of the brave. The brave little Indian boy. Little boy blue…” - Use of same words to different sentence

DISORGANIZED Inappropriate affect

(sad but smiles) Flat affect Disorganized speech/manner (flight of ideas) Hebephrenic (giggling) (+) and (-) symptoms

CATATONIC Ambivalence Waxy flexibility “No” (Rebel) Negativism

PARANOID Uses Projection

Problems with:

Mistrust-------Suspicious

N.I.1. Develop Trust: Orientation2. One-to-one interaction3. Short but frequent visits4. Foods in sealed container Meals wrapped5. Consistent Approach

Scared/Withdrawn/Violent

N.I. 1. Keep door open 2. Don’t touch patient

3. Establish Eye contact4. Maintain 1 arm distance5. Have visibility: stand halfway6. Stay near door not window7. Call for reinforcement 8. Calm & Firm

RESIDUAL No more (+) or (-) Sx Social Withdrawal Withdrawn

UNCLASSIFIED or UNDIFFERENTIATED Mixed

classifications Cannot be

classified anymore

P

DA

NEOLOGISM Newly created words--------* NURSE can use CLARIFICATION

DELUSIONS Fixed, false beliefs

Persecutory “The FBI is after me” Grandeur “I am queen of the world” Ideas of Reference “They are talking about me.”

CONCRETE THINKING Inability to conceptualize the meaning of words & phrases* Test by asking client to tell the meaning of a proverb

ilosopo roverb

HALLUCINATIONS False sensory perceptions; without stimulus(-) for visual, auditory, tactile

ILLUSIONS Misinterpretations of real external stimuli(+) for stimuli, visual, tactile, auditory

MAGICAL THINKING Believes that he has magical power

MANAGEMENT TECHNIQUE

ALLUCINATIONS

CKNOWLEDGMENT“I know the voices are real to you…”

EALITY ORIENTATION----------Present reality“But I don’t hear them.”

IVERSION“Let’s go to the garden.”

IRECTIVE

XII. ALZHEIMER

nomia Don’t know name of objectgnosia Problem with senses (smell, taste , hear, touch)


HAR

Auditory hallucinations are common. IMPORTANT: Also ask what the voices

are saying because 10% of schizophrenic clients are suicidal.

D

phasia Can’t say itpraxia Can’t do it

issociative Fugue Takes a new personality from a far away place. New Place, New Identity

issociative Identity Disorder Multiple Personality issociative Amnesia Don’t know who/where I am epersonalization Believe that they are not persons anymore+ Perseveration “I want to talk about something, this is what I want to do…."

Mngt: ECT Therapy

XIII. DISORDERS OF THE CHILD

1. AUTISM Trapped in own world/ live in a fantasy world

Unresponsive to people Echolalia Poor eye contact Cannot express feelings verbally----root of self-directed violence/self-mutilation Boys > Girls

Autistic-savant (gifted) - about 1% of all autistics

ASSESSMENT: ABC’s

APPEARANCE Flat affectConsistent movementNeat, OC, Wants constancy

BEHAVIOR RepetitiveRitualistic

COMMUNICATION Echolalia Incomprehensible/Difficulty communicating

* Can’t cry for help; usually hurts self to get attention*Talk slowly to autistic child

Nsg Dx: Impaired Verbal Communication


Impaired Social Interaction ------cannot form IPRSelf-mutilation ------cannot express anger, turned it inwardRisk for Injury

PLANNING/ IMPLEMENTATION:

Use Maslow’s Hierarchy of NeedsPromote constancy & safetyEXPRESSIVE THERAPY----uses art, music, literature, poetry

Purpose: ↓ risk for injury, improved social interaction, able to express feelings

EVALUATION: Enhanced CommunicationImproved Social InteractionSafety

2. ATTENTION DEFICIT & HYPERACTIVITY DISORDER (ADHD)

Cannot focus on anything Can progress to Conduct Disorder----to---Antisocial Behavior---Future

Criminal ID dominant: Mother & RN will act as SUPEREGO

ID dominant may grow up to be ANTISOCIALResidual ADHD may not be antisocial

Onset: 7 years old & belowDuration: 6 months & aboveSettings: Must appear in 2 (home & school)

ASSESSMENT:

APPEARANCE Usually dirty

BEHAVIOR ClumsyHyperactive

Impatient, Easily Distracted

COMMUNICATION Talkative, Blurts out in class

Nx Dx: Risk for InjuryImpaired Social Interaction

PLANNING/ IMPLEMENTATION

MILIEU THERAPY


S

B

Tructure ----Provide place to study,eat,play,bathChedule ----Time for everythinget limitsafety

EVALUATION: Minimize risk for injuryImproved social interactionSafety

3. MENTAL RETARDATION

Levels Of Mental Retardation:

Profound Severe Moderate Mild Borderline Normal IQ 20 35 50 70 90 110

Profound: <20 Thinks like an INFANT---Cannot be trained-----Stay with the Client

Severe: 20-35

Moderate: 35-50 Can be trained. Mental age is 2-7 y/o------------Pre-operational Stage

Mild: 50-70 Can go to school. Mental age is 7-12 y/o

XIV. CHILD ABUSE

Burns Bruises Bone Fractures (Bungi) Body of Evidence should not be lost ( Don’t bathe child, Don’t brush teeth) BANTAY BATA 163


Medical Mgt: RITALIN

↓ Glucose ↑ Glucose

↓ Frontal lobe ↑ Frontal lobe

↓ judgment ↑ judgment

S/Sx of ADHD

Ritalin ( a stimulant) Given after meals to prevent loss of appetite Last dose given 6˚ hs Don’t give at bedtime ---- will cause insomnia

Compensation: S/Sx: flamboyant, heavy make-up, loud voice

XV. MOOD DISORDERS

A. BIPOLAR 2 poles------ Happy (dominant) & Sad Too self-actualize

BIPOLAR I MANIC TYPE * Mania is not a Dx but an episode BIPOLAR II MANIC-DEPRESSIVE TYPE of bipolar disorder

BIPOLAR I USUAL PROFILE: Female Usually 20 years old & above Under stress Obese

DRUG OF CHOICE: Lithium ( for mania) ↓ NE ------Takes 2-4 weeks to work

ASSESSMENT: Use Maslow’s Hierarchy of Needs

3 Or More Signs Confirms Disorder:

G grandiose, ↑ risk activities

F flight of ideas

S sleeplessness

P pressured speech

E exaggerated SE

E extraneous stimuli (easily distracted)

D distractibility

MANAGEMENT:


↓ Self -Actualized

Impaired Social Interaction

Risk For Injury/ Other-Directed Violence

↓ Eat ↓ Sleep Hyperactive ↑ Sex

Manifested by Defensiveness & Compensation↑Self Esteem by giving TASK

Caregiver Role: Train / Safety

Impulsive so ensure safetyLock doors & windowsPlace in room with low stimulusNot with other manics or depressives

Manic clients usually masturbate because of worrying

“Tell pt. it is not allowed”

↓ Self -esteem

iidneysK

N ausea, vomiting, diarrheaa ( ↑ sodium intake to correct FVD) (Na: 135-145 mEq/L)

iidneys

Finger foods Private room ↓ anxiety

What are appropriate tasks? No competition or group games, sports e.g. basketball-------------↑ Anxiety Gross motor skills e.g. watering plants, sweeping the floor to put energies to productive endeavors Avoid activities with fine motor skills e.g. sewing Escort outdoors Punching bag------“Displacement”B. MANIA

Needs a mood stabilizing agents------ LITHIUM & GROUP THERAPY

↑ NE

LITHIUM - drug of choice

3 Signs of Lithium Toxicity


L

I

T

H

I

U

M

evel : 0.5 – 1.5 mEq/ dL

ncrease urination

remors, fine hand

ydration 3 l/day

ncrease “PUPU”

outh, dry *

* Lithium absorbs water

Check first before beginning therapy (BUN, Creatinine)

Only 90% absorb by kidneys

If level is near 2.5- 3 mEq/L Ataxia Mental Confusion

C. DEPRESSION ↓ Serotonin If unresponsive to drugs------- ECT Therapy

THE GRIEF PROCESS

Denial Anger Bargaining Depression

2 wks or more is a sign of MAJOR CLINICAL DEPRESSION Acceptance

ASSESSMENT

5

4

3

2

1

MANAGEMENT OF DEPRESSED PATIENT:

1. Give Antidepressants

2. If Drugs not working----Electroconvulsive Therapy (ECT)

Pre-ECT:N npo for 6 hrs.

A atropine sulfate------dry mouth

B barbiturates

S succinycholine Chloride-----To relax muscles

Post-ECT:

Side-lying position---Lateral

S/E: Headache, Dizziness


↓ Self –esteem

Withdrawn

Risk for self-directed violence

↕ eat ↕ sleep hypoactive ↓ sex

Be sensitive to client’s needs

Stay with client

Give Simple TASK

↓ Self –Actualization

s

Temporary Memory loss (distinct Sx) Rn reorient

LEAD TO: SUICIDE

SUICIDAL CUES

ALONESUICIDE TRIAD:

LOSS OF

SPOUSE JOB

Who Will Commit Suicide?

Ex--------Male (more successful) ------Female (hesitant)

A Ge-------15-24 y/o or above 45 y/o

D epression

P atient with previous attempts will try again

E thanol (ETOH) Alcoholics

R irrational

S lacks social support

O rganized plan----greater risk

N o family

S ickness, Terminal

MANAGEMENT OF SUICIDAL PATIENT:

irect Question/Approach“Do you plan to commit suicide?”

rregular nterval

ndorsementarly AM

XVI. SUBSTANCE ABUSE


Verbal“I won’t be a problem anymore”“This is my last day on earth”“I’ll soon be gone.”

Non VerbalGives away valuablesSudden change in mood

D

I

E

Visit frequently but should not be predictable

Most suicides are done in the early morning & during endorsement

Close Surveillance

Suicide Area: Hospital Majority happens on a weekend from 1-3 AM Sunday Weekend----less personnel Early AM----everyone is asleep

INE

Types of ADDICT:

1. Nervous 2. Depressed

Tremors • Sits down on chair Give DOWNERS • Give UPPERS

AsleepBradypnea

BradycardiaPupils constrictHypotensionComaAsleepWeight Gain*Constipation* GU Retention

Morph Code Hero

STOP UPPERS Antidote: NARCAN (narcotic antagonists)

Alcohol Overdose Coma Tremors Fatigue

Morphine Overdose Bradypnea

Crash Syndrome

Depressed

Suicide

OVERDOSE vs. WITHDRAWAL


AlcoholBarbituratesOpiatesNarcoticMarijuana

DOW NERS UPPERS

CocaineHallucinogenAmphetamines

Awake Psychological sense of well-beingTachycardia TachypneaPupils dilateDry mouthHypertensionSeizuresWeight loss (Thin)*Diarrhea

EUPHORIA

Created by Niňa E. Tubio

OVERDOSE WITHDRAWAL

Alcohol↓ HR↓ BP↓ RR

LOC (coma)

↑ HR↑ BP↑ RR

↑seizures

Cocaine↑ HR↑ BP↑ RR

↑seizures

↓ HR↓ BP↓ RR

LOC (coma)

31

Sx Of OVERDOSE to 2 Types:

1. Identify if drug is Upper or Downer2. Check Effect3. Sx of Withdrawal

Sx of WITHDRAWAL:

1. Know if drug is Upper or Downer2. Check for opposite effect & Sx

D ELIRIUM TREMORS Tremors, Hallucinations, Illusions

AB1 VIT. DEFICIENCY(Thiamine)

SNS stimulationWithin 24-72˚ of withdrawal Provide well-lit room to avoid

hallucinations

Narcotic Antagonist: Narcan (Naloxone HCl) Drug of choice for Overdose

Valium (Diazepam) Drug of choice for Narcotics Withdrawal (for seizures)

Methadone Drug of choice for Narcotics Detoxification

ALCOHOLISM

Alcohol Abuse - Awake, happy----socializing- A way of escape from problems- D/T peer pressure

Etiology: Theory of Intergenerational Transmission (child imitating parents)

Physiology:

a. Physical – tremors, tachycardia, restless b. Psychological Carving

Tolerance Increased Drinking tolerated by the body

MANAGEMENT

VOIDs ALCOHOL VERSION THERAPYLCOHOLICS ANONYMOUSNTABUSE (Disulfiram)

Problems of Alcoholics:


ALCOHOL

BLOCKOUT

CONFABULATION

ENIAL EPENDENCE

ENABLING or CODEPENDECY

Awake but unaware

Inventing stories to increase self-esteem

“I am not an alcoholic”“I can’t live without you”

Significant other tolerates abuser

D

Ask 1st the time of last alcohol intake before giving Anatabuse:

There should be a12 – HOUR INTERVAL

NEVER take alcohol with antabuse OR ELSE Nausea &

VomitingHypotension

C OMPLICATIONS

Monitor for:WERNICKE’S ENCELOPATHY

(motor problems)KORSAKOFF’S PSYCHOSIS

(memory problems)

F &

ORMICATION

AMILY THERAPY

THERAPY: 1. DETOXIFICATION - Withdrawal with MD Supervision

Role of the Nurse: Alcohol

CHECK belongings for: Mouthwash

Elixir (alcohol-based)

ASK TIME of last alcohol intake to monitor delirium

XII.

THE AUTONOMIC NERVOUS SYSTEM

(2 Neurotransmitters) Epinephrine/ Norepinephrine excite the SNS


PHARMA

MOMENTS

ANTI-ANXIETY AGENTS

V alium M iltown L ibrium E quanil A tivan V istaril S erax A tarax T ranxene I nderal B uspar

(Used also for Alcohol Withdrawal) “VLAST ME VAIB”

Feeling of “bugs crawling under the skin”

SELF-HELP vs. GROUP THERAPY Nurse as organizer Nurse as facilitator e.g. Alcoholics Anonymous

DEPENDENCE

Gamma aminobutyric acid (GABA) inhibits SNS (Stops)

ANTI-ANXIETY AGENTS GABA

E/ NE

All Medications Taken On Full Stomach-------except Anti-Anxiety

↑ Serotonin ↓ Serotonin

Give

ANTIDEPRESSANTS ------------------taken on full stomach


ANXIETY

RELAXED

ANTI-ANXIETY AGENTS

↑ GABA*Effects of GABA:

DrowsinessOrthostatic

Hypotension

*Contraindications No coffee

No alcoholDo not drive

ANTICHOLINERGIC

ConstipationRetentionDry mouth

Blurred vision WITHDRAWAL

If ABRUPT Withdrawal:Rebound phenomenon

Within 1 wk

Seizures

Recommended:Gradual WithdrawalTapered dose

To prevent Orthostatic Hypotension: S it D angle S tand gradually

↑ Serotonin

S afestS ide effects lowR I to 4 wks

Selective Serotonin Reuptake Inhibitors

“PPZ”

↑ Serotonin & NE

T wo to 4 wks wo neurotransmittersC A * Higher incidence of side effectsTricyclic Antidepressants

“AANTSAVE”

↑ Serotonin, NE & Dopamine

M onoA mineO xidase I inhibitors

*2-6 wks effectMAO destroys

serotonin; ↓MAO will ↑serotonin

ANTI-DEPRESSANTS

A sendin A ventyl N orpramin V ivactil T ofranil E lavil S inequan P rozac (ssri) A nafranil P axil (ssri)

Z oloft (ssri)

MONOAMINE OXIDASE INHIBITORS ( MAOIs) M PLAN Marplan N DIL Nardil P NATE Parnate

ANTI-PSYCHOTICS

S tellazine C lozaril S erentil M ellaril T horazine H aldol T rilafon P rolixin

SNS Effect-------2-4 wks

ANTI-PARKINSON AGENTS “CAPABLES” C ogentin B enadryl A rtane L arodopa P arlodel E ldedpryl A kineton S ymmetrel

AR

With MAOIs , AVOID TYRAMINE-RICH FOODS or else HYPERTENSIVE CRISIS Diaphoresis

2 CLASSIFICATION

ANTICHOLINERGICS DOPAMINERGICS ABC PLSE

A kineton, Artane P arlodel B enadryl L arodopa C ogentin S ymmetrel

E ldepryl


Tyramine rich foods:

A vocado F ernented foods ged cheese P icklesB eer reserved foodsC hocolate S oy sauce

TRANQUILIZERS

Produces emotional relaxation/calmness

2 TypesMinor Major

Anxiolytics (ANTI-AXIETY) Neuroleptics (ANTI- PSYCHOTIC)

Valium ThorazineAnxionil HaldolAtivan SerenaceTranxene MellarilXanax TrilafonSerax ProloxinLibrium ModecateEquanil ClozarilMiltown Risperdal

Action: ↓ Anxiety ↓ Dopamine

CNS Depressant Produces EPS

Acts on Limbic system Responsible for alertnessS/E: Habit-forming, Produces Drug Tolerance


L I T H I U M

Always ONEPS/E

AkathisiaAkinesiaDystoniaTardive

DyskinesiaNMS

Ach

NED

DrowsyX alcoholX coffeeX drive eqpmtOrthostatic Hypotension

Anticholinergic S/E

ConstipationDry mouthBlurred vision

E/NE

RELAXED

ANXIETY

VLASTMEVAIB

↑GABA

MANIASCHIZOPHRENIA

gradual

↓D

S/EN ausea

Vomiting Diarrhea N a ↑

KD

AnticholinergicABC

Constipationretention

DopaminergicPLSE

DiarrheaFrequency

SSTTCMHP

ANTI-DEPRESSANTS

Anticholinergic S/E

ConstipationRetentionMale Erectile Dysfuncion

↑ Serotonin only

↑ Serotonin /NE

SSRIPPZ

TCAANTSAVE

ANTI-PSYCHOTICSANTI-ANXIETY

Health Teaching To All: Drug Compliance

Table 1. Somatoform Disorder (DSM-IV)

Somatoform Disorder(DSM-IV)

General DescriptionTemporal &

Other Requirements

Exclusions By Other Psychiatric Illness Other Exclusions

Somatization Disorder

History of many physical complaints; 4 pain sites or functions: 2 nonpain GI, 1 sexual or reproductive, 1 pseudoneurologic

Onset <30 y of age

Not specified Not explained by general medical condition or substance effect

Undifferentiated somatoform disorder

One or more physical complaints

Duration >6 mo Not accounted for by another mental disorder

Not explained by medical condition or pathophysiologic mechanism

Conversion Disorder

Symptoms affecting voluntary motor and/or sensory function suggesting neurologic and/or medical condition

Associated psychological factors

Not limited to pain or sexual dysfunction; not exclusively during course of somatization disorder; not better accounted for by other mental disorder

Not intentionally produced or feigned; not explained by other neurologic or medical condition, substance effect, or culturally sanctioned behavior and/or experience

Pain Disorder Pain is predominant focus; severe enough to warrant clinical attention

Psychological factors in important role

Not better accounted for by mood, anxiety, or psychotic disorder; does not meet criteria for dyspareunia

Not specified

Hypochondriasis Preoccupation with fear of having or idea that one has serious disease based on misinterpretation of bodily symptoms;

Duration >6 mo Not exclusively during obsessive compulsive disorder (OCD), generalized anxiety, panic disorder, major depressive episode,

Not of delusional intensity; not restricted to circumscribed concern about appearance


DEPRESSION

↑ all

↓SerotoninMAOIsMNP

NO to Tyramineor else

HYPERTENSIVECRISIS

persistent fear and idea despite medical evaluation and reassurance

separation anxiety, or other somatoform disorder

Body Dysmorphic disorder

Preoccupation with imagined defect in appearance or excessive concern about slight physical anomaly

Not applicable Not better accounted for by other mental disorder

Not specified

Somatoform disorder, not otherwise specified

Somatoform symptoms Can be <6 mo duration

Does not meet criteria for any other somatoform disorder

Not specified

Note.—To qualify for this category of diagnoses, the symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning.


Psychiatric Nursing Review

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