Personality Disorder Ch.

14
ATI- Ch 15
1. According to DSM-IV-TR Personality Disorder is- an enduring pattern of inner experience
& behavior that deviates markedly from the expectations of the individual's culture, is
pervasive & inflexible, has an onset in adolescence or early adulthood, is stable over time, &
leads to distress or impairment.
2. PD Risk Factors (ATI)
1. Individuals who have personality disorders often have comorbid substance use
disorders, and may have a history of nonviolent and violent crimes, including sex
offenses.
2. Psychosocial influences, such as childhood abuse or trauma, and developmental
factors with a direct link to parenting.
3. Biological influences including genetic and biochemical factors
3. PD DSM:
4. Enduring pattern of inner experience & behavior that deviated markedly from the
expectations of the individuals culture. Manifested by:
1. Cognition- ways of perceiving & interpreting self, other people, and events
2. Affectivity
3. Interpersonal fxn
4. Impulse control
5. Enduring pattern is inflexible & pervasive across broad range of personal & social
situations.
6. Enduring pattern leads to clinically sig. distress/impairment in social, occupational, or
other imp. areas of fxning
7. Pattern is stable & of long duration, & its onset can be traced back at least to
adolescence or early adulthood
8. The enduring pattern is not better accounted for as a manifestation/consequence of
another mental disorder
9. Enduring pattern is not due to direct physiologic effects of substance (drug of abuse, a
medication) or a general med condition (head trauma)
4. Personality traits- behaviors and patterns of perceiving, relating to others, & thinking about
environment & oneself that are exhibited in a wide range of social & personal contents
10. Traits are either adaptive or maladaptive
5. Personality Disorder- When person demonstrates inflexible & maladaptive methods of
problem solving & relating to to others that cause difficulty w/ functioning
11. Symptoms are longstanding, enduring, & not responsive to short term
psychotherapy/pharmacologic measures.
5. They intensify during crisis, but maladaptive behavior continues after crisis is
resolved
6. W/ schizotypal PD & Borderline PD they have moderate /poor fxning across
several levels of psychosocial fxn such as marital status, completion of school,
& the ability to maintain employment.
7. Avoidant PD- intermediate fxn impairment
12. Cluster A: Odd, eccentric, difficulty relating to to others, isolate themselves, unable to
socialize comfortably
8. Paranoid
1. S/s:
1. Distrust
2. *Suspicion
3. Anxiety, short temper
4. Lack of tender feelings toward others.
5. Jealousy of spouse or sig. other, often w/out evidence.
2. Interventions:
9. Schizoid:
3. S/S:
13. Emotional detachment
14. Disinterest in close relationships
15. Indifference to praise & criticism
16. Brief psychotic episodes
17. Lack of trust
18. Difficulty expressing anger
19. Lack of desire to socialize, enjoys solitude
20. *Aloof, even cold
4. Interventions:
10. Schizotypal
5. S/S:
25. Incorrect interpretation of external events & belief that all
events refer to self
26. Anxiety in social situations
27. Magical thinking
28. Affect is bland or silly
29. Uncomfortable w/ strangers
30. Peculiar beliefs
6. Interventions:
11. DX For all Cluster A:
7. * Disturbed thought process
8. Ineffective coping
9. Social isolation
10. Anxiety
12. Given Antipsychotics
13. Cluster B: Dramatic, emotional, impulsive . Underlying problem of low or no self-
esteem
13. Antisocial (303)
11. S/S:
34. Irresponsible
35. Failure to honor financial obligations
36. Commit unlawful actions
37. Pattern of violating social norms
38. Disregard for rights of others
39. Witty, charming- Manipulative
40. 75% of inmates (per lecture)
12. Intervention:
41.
14. Borderline
13. S/S:
42. Suicidal ideation
43. Self mutilation
44. Impulsivity: spending money, driving, sex
45. Negative/angry affect
46. Freq. angry outburst
47. Complaints of emptiness
48. Unstable interpersonal relationships
49. * Splitting
50. Difficulty being alone/feeling of abandonment
51. Intense/stormy relationships
15. Histrionic:
14. S/S:
52. Attention seeking, self centered attitude
53. Seductive, flirtatious
54. Dramatic
55. Vague logic, often switching sides
56. Tantrums
57. Complaints of physical illness; somatization (full body)
58. Use of suicidal gestures & threats when feeling abandoned.
16. Narcissistic:
15. S/S:
59. Grandiose sense of self importance
60. Lack of empathy toward others
61. Need for admiration
62. Hypersensitive to evaluation
63. Preoccupation w/ fantasies of success, brilliance, beauty, &
ideal love.
17. SSRIs given
18. DX For All Cluster B:
16. Risk for suicide
17. Risk for other directed violence
18. Risk for self mutilation
19. Risk for self directed violence
20. Disturbed personal identity
21. Ineffective coping
22. Impaired social interaction
23. Complicated grieving
14. Cluster C: Anxious & fearful cluster
19. Avoidant:
24. Fearful of criticism, disapproval, or rejection
25. Avoidance of social interactions
26. Tendency to withhold thoughts & feelings
27. Few friends, but desires social contact
28. Neg. sense of self & low self- esteem
20. Dependent:
29. Inability to make decisions independently
30. Inability to be able to express neg. emotions
31. Difficulty following through on tasks
32. Pattern of dependence
33. Believes they can't fxn w/out help of others
34. Submissiveness & tendency to cling.
21. Obsessive Compulsive
35. Preoccupation with perfection, organization, structure & control
36. Exaggerated orderliness
37. Rigid
38. Inflexible
39. Procrastination
40. Abandonment of projects b/c of dissatisfaction
41. Excessive devotion to work
42. Difficulty relaxing
43. Rule-conscious behavior
44. Self-criticism & inability to forgive own errors
45. Unable to discard anything
46. Rejection of praise
47. Reluctance to spend money
48. Restricted emotionality
22. DX For All Cluster C:
49. Anxiety
50. Impaired social interaction
51. Ineffective coping
52. Chronic low self esteem
Child Disorders (Ch. 17, ATI-):
1. Mental Retardation (393)
1. Mild:
1. Only minimal sensorimotor problems
2. Not identified until later age
3. Develop academic skills up to 6th grade
4. Require some level of supervision, guidance, & assistance
2. Moderate
5. Rarely ever advance academically past 2nd grade level (394)
6. Provide self care hygiene
7. Can travel to familiar areas
8. Problems w/ recognizing & acquiring socially correct interactions w/ peers
9. Generally perform unskilled/semiskilled work
10. Live & fxn in community w/ supervised setting
3. Severe
11. Acquire little if any communicative speech
1. Sometimes learn to use basic communication
12. Live in protected environment w/ in community like a group home or with
family
4. Profound:
13. Usually accompanied by neurologic condition- cerebral palsy, epilepsy, etc
14. Considerable sensorimotor deficits- poor head control, feeding probs, inability
to roll over.
15. Require highly structured setting w/ constant monitoring & assistance
2. Can develop sufficient motor skills, self care skills, & communication
abilities to perform simple tasks w/ this level of care
3. Closely supervised & sheltered setting.
5. Prognosis:
16. Severe-profound have shortened life expectancy r/t medical conditions (self
care, feeding, epilepsy)
2. Autism:
6. Etiology- Undetermined
17. Possible genetic, neuro, metabolic, immunologic, & environmental factors.
18. Multifaceted
19. Excessive food sensitivity, sugar, food additives, vaccines, & allergies do not
cause autism.
7. Epidemiology:
20. 3 to 4 times more common in males
8. S/S:
21. Hyperactivity
22. Short attention span, impulsivity
23. Aggressiveness, self-injurious behaviors
24. Temper tantrums
25. Abnormal eating patterns- limiting intake to few foods or eating non-nutritious
objects
26. Abnormal sleeping patterns- recurrent awakenings w/ rocking
27. Catastrophic Reaction- Unable to tolerate minor changes in environment
4. Ex. A new chair or new seating arrangement at dinner
28. Stereotypic Motor Activities- clapping/flapping of hands, spinning, odd
postures, strange hand movements.
29. Intense preoccupation w/ objects such as buttons/zippers
30. Fascinated w/ movement of fans, revolving objects, opening/closing of doors &
drawers, or turning light switch on/off
31. Attachment to unusual objects- strings, rubber bands
5. Ignore typical items like a blanket of teddy bear.
32. Lack emotional reciprocity & don't participate in social play/games
33. Prefer solitary activities or involve others as objects of their play (using
another kid as a bench)
34. Mood or affective abnormalities
35. Inappropriate responses to danger- showing no fear of danger or excessive
fear of harmless objects
36. High pain threshold
37. Self harm- banging their head or biting themselves
38. Fascination w/ sensory stimulation such as rubbing hard surface
39. Spoken language is absent
40. Those that speak can't begin convo or keep it up.
6. Use repetitive/ stereotypic language
41. Grammar is idiosyncratic, immature, stereotyped, repetitive
42. Not able to understand simple questions, directions, jokes.
43. Some develop excellent long term memories- train schedules, stats, songs, etc
44. Some acquire islands of genius- developmental of exceptional circumscribed
skills
7. Cant count change in a store but can solve complicated mathematical
formulas
9. DSM:
(I) A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one
each from (B) and (C)
(A) qualitative impairment in social interaction, as manifested by at least two of the
following:
1. marked impairments in the use of multiple nonverbal behaviors such as
eye-to-eye gaze, facial expression, body posture, and gestures to regulate
social interaction
2. failure to develop peer relationships appropriate to developmental level
3. a lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people, (e.g., by a lack of showing, bringing, or
pointing out objects of interest to other people)
4. lack of social or emotional reciprocity ( note: in the description, it gives the
following as examples: not actively participating in simple social play or
games, preferring solitary activities, or involving others in activities only as
tools or "mechanical" aids )
(B) qualitative impairments in communication as manifested by at least one of the
following:
1. delay in, or total lack of, the development of spoken language (not
accompanied by an attempt to compensate through alternative modes of
communication such as gesture or mime)
2. in individuals with adequate speech, marked impairment in the ability to
initiate or sustain a conversation with others
3. stereotyped and repetitive use of language or idiosyncratic language
4. lack of varied, spontaneous make-believe play or social imitative play
appropriate to developmental level
(C) restricted repetitive and stereotyped patterns of behavior, interests and activities,
as manifested by at least two of the following:
1. encompassing preoccupation with one or more stereotyped and restricted
patterns of interest that is abnormal either in intensity or focus
2. apparently inflexible adherence to specific, nonfunctional routines or rituals
3. stereotyped and repetitive motor mannerisms (e.g hand or finger flapping
or twisting, or complex whole-body movements)
4. persistent preoccupation with parts of objects
(II) Delays or abnormal functioning in at least one of the following areas, with onset prior to
age 3 years:
(A) social interaction
(B) language as used in social communication
(C) symbolic or imaginative play
(III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative
Disorder
10. Prognosis:
45. Early interventions help pts achieve highest level of fxn
11. Modified Checklist for Autism in Toddlers (M-CHAT)
46. Does child use index finger to point?
47. Respond to his/her name?
48. Take an interest in other children?
49. Bring objects to show you?
50. If you point at a toy across the room, does your child look at it?
51. Does your child imitate you?
12. Therapy:
52. Behavioral:
8. Positive Reinforcement
9. Repetition (24-40 hrs /wk)
53. Diet modification
54. Chelation to remove heavy metals
55. NIH Pilot Study: minocycline to downregulate microglial inflammation.
3. Aspergers Disorder
13. S/S:
56. Similar to autism w/ no effect to language & cognition
57. Behavioral problems, underdeveloped/impaired social interactions, & restricted
repetitive patterns.
58. Follows continuous course, usually lifelong
14. Prognosis: Best if tx started at 24-36 months old.
4. Reactive Attachment Disorder (396)
15. Etiology- Children w/ parental physical and emotional abuse/neglect, or who are
institutionalized, or who are exposed to extreme poverty.
16. S/S:
59. Inhibited:
10. child unable to socially interact at respective developmental level.
60. Disinhibited:
11. Child lacks appropriate boundaries
1. Unable to differentiate between strangers & safe attachment
relationships
2. Ex. child may seek comfort & attention by running up to
strangers in a public place and hug them.
12. Caregivers often bring them to pediatrician reporting of severe
colic/feeding difficulties, failure to gain weight, detached & responsive
behavior, difficulty being comforted, or avoidance of social
interactions.
13. Prognosis- good, they may able to develop health attachments in
stable, nurturing environment
5. Separation Anxiety Disorder (397)
17. Recurrent, excessive distress when away from home or loved ones
6. ADHD (398):
18. Etiology: Unknown
61. Studies suggest possible relation of genetics more than environment
19. S/S
62. Must have behavioral probs before age 7 for dx and seen in at least 2 settings
(home/school).
63. Attention impulsivity
64. Hyperactivity
20. DSM:
A. Persistent pattern of inattention and/or hyperactivity-impulsivity that is more
frequently displayed and is more severe than is typically observed in individuals at
comparable level of development. Individual must meet criteria for either (1) or (2):
(1) Six (or more) of the following symptoms of inattention have persisted for at least
six months to a degree that is maladaptive and inconsistent with developmental level:
65. Inattention
14. Often fails to give close attention to details or makes careless mistakes
in schoolwork, work or other activities
15. often has difficulty sustaining attention in tasks or play activity
16. often does not seem to listen when spoken to directly
17. often does not follow through on instructions and fails to finish
schoolwork, chores or duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
18. often has difficulty organizing tasks and activities
19. often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
20. often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books or tools)
21. is often easily distracted by extraneous stimuli
22. is often forgetful in daily activities
Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for
at least six months to a degree that is maladaptive and inconsistent with
developmental level:
66. Hyperactivity
23. often fidgets with hands or feet or squirms in seat
24. often leaves seat in classroom or in other situations in which remaining
seated is expected
25. often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness)
26. often has difficulty playing or engaging in leisure activities quietly
27. is often on the go or often acts as if driven by a motor
28. often talks excessively
67. Impulsivity
29. often blurts out answers before questions have been completed
30. often has difficulty awaiting turn
31. often interrupts or intrudes on others (e.g., butts into conversations or
games)
21. B. Some hyperactive-impulsive or inattentive symptoms must have been present
before age 7 years.
22. C. Some impairment from the symptoms is present in at least two settings (e.g., at
school [or work] and at home).
23. D. There must be clear evidence of interference with developmentally appropriate
social, academic or occupational functioning.
24. E. The disturbance does not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better
accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder,
Dissociative Disorder, or a Personality Disorder).
25. Code Based on Type:
68. Attention deficit/hyperactivity disorder, combine type:
32. if both A1 & A2 are met preceding 6 months
69. Attention deficit/hyperactivity disorder, predominantly inattentive type:
33. If criterion A1 is met but A2 not met for the preceding 6 months
70. Attention deficit/hyperactivity disorder, predominantly hyperactive-impulsive
type:
34. A2 is met but A1 is not met preceding 6 months.
26. Prognosis:
71. Symptoms of hyperactivity diminish in 50%
7. Oppositional Defiant Disorder:
27. Etiology
72. Occurs more commonly in families where child care disrupted by succession of
different caregivers were harsh, inconsistent, or neglectful child rearing
process occurs
73. Occurs more commonly when serious marital problems occur
28. Epidemiology:
74. More common in males before puberty than the same for females after
puberty
29. S/S- DSM:
A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during
which four (or more) of the following are present:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults' requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is
typically observed in individuals of comparable age and developmental level.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or
occupational functioning.
C. The behaviors do not occur exclusively during the course of Psychotic or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older,
criteria are not met for Antisocial Personality Disorder.
30. Prognosis:
75. Some will progress to conduct disorder where 25% will not meet criteria for
ODD any longer. Onset is typically gradual, occurring over course of
months/years
8. Conduct Disorder (401)
31. Etiology:
76. High risk: Continual parental neglect, rejection, harsh discipline practices,
physical/sexual abuse, institutionalization, & association w/ delinquent peer
group
77. More common when parent has Antisocial PD, alcohol dependence, mood
disorder, schizo, or history of ADHD/conduct disorder.
78. Believed to have genetic predisposition triggered by environment, low stress
tolerance, & ineffective coping.
32. Epidemiology: 4 times more popular in boys.
79. Generally 10-12 yr old boys; 14-16 yr old girls
33. S/S DSM:
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major
age-appropriate societal norms or rules are violated, as manifested by the presence of three
(or more) of the following criteria in the past 12 months, with at least one criterion present in
the past 6 months:
Aggression to people and animals
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat,
brick, broken bottle, knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion,
armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing serious
damage
(9) has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else's house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting,
but without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before age 13
years
(14) has run away from home overnight at least twice while living in parental or
parental surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in social, academic, or
occupational functioning.
C. If the individual is age 18 years or older, criteria are not met forAntisocial Personality
Disorder.
Specify type based on age at onset:
Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior
to age 10 years (new code as of 10/01/96: 312.81)
Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to
age 10 years (new code as of 10/01/96: 312.82)
(new code as of 10/01/96: 312.89 Unspecified Onset)
Specify severity:
Mild: few if any conduct problems in excess of those required to make the diagnosis and
conduct problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between "mild"
and "severe"
Severe: many conduct problems in excess of those required to make the diagnosis or
conduct problems cause considerable harm to others
9. Depression (405)
34. Episodic w/ initial s/s
80. Declining academic fxn
81. Impairment in peer relationships
82. Withdrawal from after school activities
35. S/S:
83. Change in appetite, sleep, energy level, & concentration.
84. Depressed/irritable mood, behavioral probs
85. Low frustration tolerance
86. Anxiety symptoms accompanied w/ somatic symptoms
87. Adolescents:
35. Increased sleep, appetite disturbances, suicidal ideations/attempts,
difficulties fxning in relationships in school and home
36. Etiology: 3 times higher chance w/ 1 depressed parent.
10. Bipolar Disorder:
37. Dx is often missed b/c of overlapping symptoms
38. Atypical symptoms:
88. Markedly labile & irregular
89. Irritable
90. Aggressive, or mixed rather than euphoric
39. Youths dx are more likely to have rapid cycling/mixed episodes w/ greater suicide risk
Week 5
Ch. 10: Anxiety and anxiety disorders
Ch. 11: Somatoform, factitious, & dissociative Disorders
Ch. 25: Psychopharm
Ch. 27: Kee pg 391- 395
ATI: Ch 11, 19
1. Purpose of Anxiety:
1. To warn individual of impending threat, conflict, or danger.
1. AEB: Fleeing threatening situation, controlling dangerous impulse, or freezing/
not acting.
2. Defense Mechanism: Primary method that ego uses to control/manage anxiety.
Defense Mechanism Definition Example
High Adaptive Level
Humor Using humor assists person
with the management of
everyday stressors
Comedian discussing about
his substance abuse &
recovery w/ humorous stories
audience can identify w
Sublimation Channeling maladaptive
thoughts & feelings such as
aggression into socially
Man bullied as a child
becomes a cop. Channels
anger into observing law &
acceptable behaviors protecting others.
Supression Avoiding thinking about
problem areas intentionally
Student nurse focuses all
energy on school assignments
avoiding several problems
happening at home.
Mental Inhibitions:
Compromise Formation
Level

Displacement Transferring feeling/response
toward 1 person onto another
less threatening person or
object.
Mother was angry w/ her
teenage daughter for doing
poorly in school & disobeying
so she goes to the gym &
plays a rigorous game of
racquetball.
Dissociation Alteration in an awake state
during which person feels
detached from his/her
surroundings
Pt describes feeling detached
from his body & looking down
at his body from the corner of
the room
Repression UNintentionally pushing back
disturbing thoughts, desires,
or experiences from the
conscious mind *more intense
than suppression)
When describing sexual
abuse, pt is unable to recall a
lot of her early experiences &
appears to be detached from
them.
Minor Image Distorting
Level

Devaluation Attributing negative qualities
to the self or to others
Pt finds fault in every aspect
of hospitalization experience
Disavowal Level
Denial Unconsciously refusing to
acknowledge some painful
reality or subjective
experience that others
identify
Pt consumes a 6 pack of beer
every day; he does not
identify a problem w/ alcohol
consumption
Projection Attributing negative qualities
to the self or others
Pt is angry at the nurse for
setting limits but accuses
nurse of being angry w/ hi
Major Image Distorting
Level

Splitting of the self image or
of the image of others
Inability to integrate positive
& negative aspects of self or
others to situations. Viewing
everything as all good or all
bad.
Pt views everything as either
black or white.
3. Anxiety Levels
Anxiety
Level Physiologic Cognitive/Perceptual Emotional/Behavi
oral
Mild - VS Normal, minimal muscle
tension, pupils normal
Perceptual field broad,
thoughts random but
controlled
Comfort/safety, relaxed &
calm appearance & voice.
Habitual behaviors
Moderate VS normal/slightly elevated
Uncomfortable or experiences
pleasure (tense/excited)
Alert, perception
narrowed & focused.
Optimum state for
problem solving and
learning.
*Attentive
Energized, feelings of
readiness, voice & facial
expression
interested/concerned
Severe - Fight or flight response,
- VS , diaphoresis , dry
mucous, appetite , pupils
dilated, muscles rigid/tense,
senses affected, hearing &
pain sensation
Prob solving difficult,
selective attention,
distortion of time,
dissociative
tendencies,
detachment
Feels threatened, feels an
overload activity or (may
pace, run away, wring hands,
moan, shake, stutte, become
disorganized/withdrawn)
- Freeze in pxn, Denia,
depressed, complains of
aches/pains, need for space
, Eyes move around room or
gaze is fixed. Some pts close
eyes to shut out environment.
Panic Symptoms from above worsen
than SNS release occurs
- Pale, BP , hypotension, poor
muscle coordination,
pain/hearing sensations
minimal
Perception totally
scattered /closed
- Problem solving &
logical thinking highly
improbable.
Unreality about self,
environment, or
event.
Dissociation often
occurs
Feels helpless, w/ total loss of
control; pt is angry/terrified;
becomes combative/totally
withdrawn, cries, or runs
away
Completely disorganized;
extremely active/inactive
behavior.
4. Anxiety Etiology:
2. Psychodynamic Model
2. 3 Types of Anxiety:
1. Reality- painful emotional experience that results from the perception
of danger in external world such as fear of possibility of a terrorist
attack
2. Moral- Ego experiencing guilt/shame
1. Experiencing guilt for expressing anger at a family member
3. Neurotic- Perception of a threat according to ones instinct
3. Behavior model- anxiety symptoms is a generalization from an earlier traumatic
experience to a benign setting or object.
3. Ex. an awkward child whose parents ridiculed him while he was bowling now
associates embarrassment and shame w/ sports events in indoor facilities &
develops panic attacks.
4. In this, anxiety occurs when individual encounters signal that predicts
a painful/feared event.
4. Systematic Desensitization- applied to simple phobia
5. Therapist exposes deeply relaxed pt to graded hierarchy of phobic
stimuli.
6. Vivo desensitization- redefinition where therapist exposes pt
progressively to more anxiety-provoking situations.
5. Panic S/S (191):
4. Panic anxiety differs from generalized anxiety by sudden onset of distressing physical
symptoms in combination w/ thoughts of dread, impending doom, & death & the fear
of being trapped.
5. Panic Disorder:
5. Following 2 must be met
7. Recent & unexpected panic attacks are present
8. At least 1 of the attacks has been followed for 1 or more months by
2. Persistent concern about having additional attacks
3. Worry about the implications of the attack or its
consequences- losing control, having a heart attack)
Panic Attack DSM:
A panic attack is a period of intense fear or discomfort, developing abruptly and peaking within
10 minutes, and requiring at least four of the following:
Chest pain or discomfort
Chills or hot flushes
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
Fear of losing control
Feeling dizzy, unsteady, lightheaded, or faint
Feeling of choking
Nausea or abdominal distress
Palpitations or tachycardia
Paresthesias
Sensations of shortness of breath or smothering
Sense of impending doom
Sweating
Trembling or shaking
6. Phobias (191)
6. Prominent feature of phobias is that pt has panic attacks in response to particular
situations or has learned to avoid situation that cause panic attacks.
7. Agoraphobia:
6. Individual experiences fear when perceiving he/she is unable to escape from
situations that is restricting, like a moving automobile or from embarrassing
situation when help is not available if there is an unexpected panic attack.
7. Lecture- fear and avoidance of settings where panic attacks have occurred
8. Specific Phobia:
8. The client has a fear of specific objects, such as spiders, snakes, strangers.
9. The client has a fear of specific experiences, such as flying, being in the dark,
riding in an elevator, being in an enclosed space.
9. Social Phobia (AKA Social Anxiety Disorder):
10. ATI: The client has a fear of embarrassment, is unable to perform in front of
others, has a dread of social situations, believes that others are judging him
negatively, and has impaired relationships.
11. Book:
9. Overwhelming fear of being in a social situation or having to interact
w/ many people at once.
10. Children express their fear y crying or exhibiting tantrum-life
behaviors
11. Adults acknowledge fear is excessive or unreasonable.
12. Individuals are unable to work well in a group
13. Group format therapy would not be therapeutic for in-patients.
10. PTSD (192): Exposure to a traumatic event causes intense fear, horror, flashbacks,
feelings of detachment and foreboding, restricted affect, and impairment for longer
than 1 month after the event. Manifestations may last for years.
12. Experience increased arousal after incident:
14. Sleep disturbances
15. Irritability, angry outbursts, difficulty concentrating, hypervigilance,
exaggerated startle response.
13. Eye movement desensitization and reprocessing (EMDR) is a therapy for
clients who have PTSD.
16. EMDR encourages eye focus on a separate stimuli while thinking of or
talking about the traumatic event.
Acute Stress Disorder PTSD
Precipitating Event
In both disorders, the client witnesses or
experiences an actual event that
threatens severe injury or death to the
client or others.
The client responds with fear,
helplessness, or horror to the event.

Onset & Duration
Manifestations often begin immediately following
the traumatic event and persist for at least 3
days.
Duration is 3 days to 1 month.
Manifestations may occur any time following the
traumatic event with potential delays of months
or years. The duration of manifestations last
more
than 1 month.
Re Experience of the event
The client persistently re experienced the event
through:
Distress when reminded of the event
Dreams or images
Reliving through flashbacks
The client persistently reexperiences the event
through:
Recurrent, intrusive recollection of the event
Dreams or images
Reliving through flashbacks, illusions, or
hallucinations
Manifestations
Dissociative manifestations, such as
amnesia of the trauma event, absent
emotional response, decreased
awareness of surroundings,
depersonalization
Indications of severe anxiety, such as
irritability, sleep disturbance
Indications of increased arousal, such as
irritability, difficulty with concentration,
sleep disturbance
Avoidance of stimuli associated with
trauma, such as avoiding people,
inability to show feelings
3 differences between ASD & PTSD (193):
Individual experiences at least 3 symptoms indicating dissociation
The time frame of development & duration of symptoms is shorter
Dissociative symptoms prevent individual from adaptively coping w/ trauma.
7. General Anxiety Disorder:
11. Occurs w/ excessive anxiety & worry that impeded ability to fxn at home, work,
school, or in community.
14. More than 3 months (ATI) BUT lecture says minimum 6 months.
15. TX:
17. Rule out medical disorders: hyperthyroid, substance abuse (caffeine,
cocaine, other stimulants), alcohol withdrawal, arrhythmia
18. Treatment: SSRIs for anxiety and depression, buspirone
(BuSpar

), short-term benzodiazepines while waiting for SSRI to work

(4-6 wks until results are experienced), psychotherapy
19. Venlafaxine (GAD), enderol, xanax, lexapro,
4. Meds help take care of symptoms but not source of anxiety.
20. * Avoid all CNS stimulants- caffeine, smoking, drinking
16. S/s (ati):
21. Restlessness
22. Muscle tension
23. Avoidance of stressful activities or events
24. Increased time and effort required to prepare for stressful activities or
events
25. Procrastination in decision-making
26. Seeks repeated reassurance
8. Obsessive Compulsive Disorder (193...)
14. Pts have insight and want help
15. Tx:
17. SSRIs, often in greater than normal dosages particularly fluvoxamine
(Luvox

)
18. Other serotonin modulators
19. Behavior therapy
20. Desensitization Therapy (ATI 92)
27. Systematic desensitization begins with mastering of relaxation
techniques. Then, a client is exposed to increasing levels of an
anxiety-producing stimulus (either imagined or real) and uses
relaxation to overcome the resulting anxiety.
28. The goal of therapy is that the client is able to tolerate a greater and
greater level of the stimulus until anxiety no longer interferes with
functioning.
29. This form of therapy is especially effective for clients who have
phobias.

9. Anxiety Assessment (lecture)
16. Eating and eliminating patterns
17. Pacing
18. Concentration
19. Talking rapidly? N
20. Refusing attend groups more to aggressive pts that anxious.
21. Role change: problems in work, finances, family, role strain
22. Sadness is to depression as concentration is to anxiety.
23. Culture/values
24. Coping strategies
25. Physical disability/motor dysfunction
26. Mental status, fears, pain
27. Measurable outcomes necessary
28. Rating scales
21. Hamilton Anxiety Scale .. http://psychology-tools.com/hamilton-anxiety-
rating-scale/
22. Yale-Brown Obsessive-Compulsive Scale- Y-BOCS
10. Anxiety Disorders Dx: (196)
29. Anxiety
30. Ineffective coping
31. Interrupted family processes
32. Fatigue
33. Risk-prone health behavior
34. Risk for loneliness
35. Post Trauma syndrome
36. Powerlessness
37. Rape-trauma syndrome
38. Ineffective role performance
39. Impaired memory
40. Chronic low self-esteem
41. Social isolation
42. Spiritual distress
11. Anxiety Disorders Outcomes:
43. GAD
23. Demonstrate sig decrease in physiological, cognitive, behavioral, & emotional
symptoms
24. Demonstrate effective coping skills
25. Exhibit enhanced ability to make decisions & problem solve
26. Discuss med regimen & take medications as prescribed
27. ID when to call therapist for more visits when a crisis occurs
28. Demonstrate use of mindfulness meditation when experiencing symptoms of
heightened anxiety (Box 10-2 196)
44. OCD:
29. Participate actively in learned strategies to manage anxiety & to decrease OC
behaviors
30. Describe increasing sense of control over intrusive thoughts & ritualistic
behaviors
31. Demonstrate ability to cope effectively when thoughts or rituals are
interrupted
32. Identify when to call therapist for more visits when crisis occurs.
45. PTSD:
33. Demonstrate concern for personal safety by beginning to verbalize worries
34. Participate actively in support group
35. Identify support system
36. Acquire & practice strategies for coping w/ anxiety such as breathing
techniques, relaxation techniques.
12. Anxiety Disorders Interventions;
46. Maintain pt safety; 1st priority is to protect pt and environment
47. Recognize pts use of relief behaviors (pacing, wringing of hands) as indicators of
anxiety.
48. Inform pt importance of limiting caffeine, nicotine, & other cns stimulants.
37. Minimizes anxiety physical symptoms- rapid heart rate, jitteriness
49. Teach anxiety reducing techniques:
38. Progressive relaxation techniques
39. Mindfulness meditation (box 10-2)
40. Slow deep breathing exercises
41. Focusing on a single object in the room
42. Listening to soothing music or relaxation tapes
43. Visual imagery or nature related DVDs
44. Exercise
45. Assist w/ gaining control of overwhelming feelings & impulses.
13. Medication Administration for Anxiety:
50. Benzos: Alprazolam (xanax), clonazepam (klonopin), diazepam (valium), lorazepam
(ativan),
46. May cause physical & psychological dependence.
47. Alcohol should be avoided esp in elderly pts
48. Blood dyscrasias- fever, sore throat, bruising, rash, jaundice are rare
49. Herbal Considerations: Kava kava & St. John Wort may potentiate (increase)
action of drug
50. Dietary Consideration: Grapefruit juice may increase blood concentration and
risk of toxicity
51. Do not take w/ MAOIs
51. Clonazepam (Klonopin)
52. Why?
30. Panic disorder with or without agoraphobia.
31. Prophylaxis of:
5. Petit mal,
6. Lennox-Gastaut,
7. Akinetic,
8. Myoclonic seizures.
53. Therapeutic Effect- Decreased manifestations of panic disorder &
prevention of seizures.
54. Action-
32. Produces sedative effects in the CNS, probably by stimulating
inhibitory GABA receptors.
33. Anticonvulsant effects may be due to presynaptic inhibition.
55. Contraindications- Severe hepatic impairment, lower dose for geri pts
56. Implementation/Nursing Considerations-
34. Administer with food to minimize gastric irritation.
35. Tablets may be crushed if patient has difficulty swallowing.
36. Administer largest dose at bedtime to avoid daytime sedation.
37. Taper by 0.25 mg every 3 days to decrease signs and symptoms
of withdrawal. Some patients may require longer taper period
(months).
38. No liquid is needed to take the orally disintegrating tablet.
9. Dont pop it out of the pouch, peel the pack open and
place on tongue w/ dry hands.
57. Safe Dose-
39. PO: (Adults)
10. Panic disorder0.125 mg twice daily; after 3 days
toward target dose of 1 mg/day (some patients may
require up to 4 mg/day).
11. 0.5 mg 3 times daily; may by 0.51 mg q 3 days. Total
daily maintenance dose not to exceed 20 mg.
40. PO: (Children <10 yr or 30 kg): Initial daily dose 0.010.03
mg/kg/day (not to exceed 0.05 mg/kg/day) given in 23 equally
divided doses; by no more than 0.250.5 mg q 3 days until
therapeutic blood levels are reached (not to exceed 0.2
mg/kg/day).
58. Toxic/SE: Therapeutic serum concentrations are 2080 mg/mL.
41. Flumazenil antagonizes clonazepam toxicity or overdose (may
induce seizures in patients with history of seizure disorder or who
are on tricyclic antidepressants).
52. Diazepam (Valium)-
59. whY:
42. Adjunct in the management of:
12. Anxiety Disorder,
13. Athetosis,
14. Anxiety relief prior to cardioversion (injection),
15. Stiffman Syndrome,
16. Preoperative sedation,
17. Conscious sedation (provides light anesthesia and
anterograde amnesia).
43. Treatment of status epilepticus/uncontrolled seizures (injection).
44. Skeletal muscle relaxant.
45. Management of the symptoms of alcohol withdrawal.
60. Therapeutic Effect:
46. Relief of anxiety.
47. Sedation.
48. Amnesia.
49. Skeletal muscle relaxation.
50. Decreased seizure activity.
61. Action:
51. Produces skeletal muscle relaxation by inhibiting spinal
polysynaptic afferent pathways.
52. Depresses the CNS, probably by potentiating GABA, an inhibitory
neurotransmitter.
53. Has anticonvulsant properties due to enhanced presynaptic
inhibition.
62. Contraindications
54. Comatose patients;
55. Myasthenia gravis;
56. Severe pulmonary impairment;
57. Sleep apnea;
58. Severe hepatic dysfunction;
59. Pre-existing CNS depression;
60. Uncontrolled severe pain;
61. Angle-closure glaucoma;
62. Geri- associated with risk of falls ( dose required or consider
short-acting benzodiazepine).
63. Toxic/SE:
63. Flumazenil is an adjunct in the management of toxicity or
overdose
64. SE: dizziness, drowsiness, lethargy, RESPIRATORY DEPRESSION,
hypotension (IV only)
64. Implementation/Nursing Considerations:
65. Patient should be kept on bedrest and observed for at least 3 hr
following parenteral administration.
18. If opioid analgesics are used concurrently with
parenteral diazepam, decrease opioid dose by 1/3 and
titrate dose to effect.
66. Use lowest effective dose. Taper by 2 mg every 3 days to
decrease withdrawal symptoms. Some patients may require
longer taper periods (mos).
67. Assess IV site frequently during administration; diazepam may cause
phlebitis and venous thrombosis.
68. Full therapeutic antianxiety effects occur after 12 wk of therapy.
69. Medication may cause drowsiness, clumsiness, or unsteadiness. Advise
patient to avoid driving or other activities requiring alertness until
response to medication is known. Geri: Advise geriatric patients of
increased risk for CNS effects and potential for falls.
70. Caution patient to avoid taking alcohol or other CNS depressants
concurrently with this medication.
71. PO: Tablets may be crushed and taken with food or water if patient
has difficulty swallowing.
72. IM injections are painful and erratically absorbed. If IM route is used,
inject deeply into deltoid muscle for maximum absorption.
73.
65. Safe Dose:
74. Antianxiety
75. PO: (Adults) 210 mg 24 times daily.
76. IM: IV: (Adults) 210 mg, may repeat in 34 hr as needed.
77. PO: (Children >6 mo): 12.5 mg 34 times daily.
78. IM: IV: (Children >1 mo): 0.040.3 mg/kg/dose q 24 hr to a
maximum of 0.6 mg/kg within an 8 hr period if necessary.
Route Onset Peak Duration
PO 30-60 MIN 1-2 HR Up to 24 hrs
IM w/in 20 min 0.5 - 1.5 hr unknown
IV 1-5 min 15-30 min 15-60 min
Rectal 2-10 min 1-2 hr 4-12 hr
Wk 5 Ch. 11: Somatoform, Factitious, & Dissociative Disorders
1. Types:
1. Somatization disorder
1. DSM:
1. A history of many physical complaints beginning before age 30 years
that occur over a period of several years and result in treatment being
sought or significant impairment of functioning.
2. Each of the following criteria must have been met, with individual
symptoms occurring at any time during the course of the disturbance:
1. 4 pain symptoms: a history of pain related to at least 4
different sites or functions
2. 2 gastrointestinal symptoms: a history of at least 2
gastrointestinal symptoms other than pain
3. 1 sexual symptom: a history of at least 1 sexual or
reproductive symptom other than pain
4. 1 pseudoneurological symptom: a history of at least 1
symptom or deficit suggesting a neurological condition not
limited to pain
3. Either 1 or 2:
4. After appropriate investigation, each of the symptoms cannot be
explained by a known general medical condition or the direct effects of
a substance OR
5. When there is a related general medical condition, the physical
complaints or resulting social or occupational impairment are in excess
of what would be expected from the history, physical examination, or
laboratory findings
6. The symptoms are not intentionally produced or feigned
2. Outcomes (212)
7. Construct exercise program including anxiety reducing techniques
8. Address 2 positive somatic responses that satisfied feeling after
successful exercise- massage therapy
9. Keep journal to document somatic preoccupation & stressors including
intrusive thoughts or concerns.
10. Take prescribed meds
2. Pain disorder:
3. Pain in 1 or more anatomic sites w/ severity that calls for clinical attention and
sig impairment.
3. Conversion disorder:
4. 1 or more symptoms that affect voluntary motor/sensory fxn
5. S/S:
11. Blindness, paralysis, deafness, seizures, anesthesia, or abnormal
motor movements.
6. Defining Characteristics:
12. Psychologic factors identified being r/t onset or exacerbation of
symptom
13. Specific & identifiable conflicts/stressor precede the development of
the conversion symptoms
14. Person demonstrates obvious lack of concern about seriousness of
symptoms.
5. La belle indifference- lack of concern.
4. Hypochondriasis (207)
7. Fears having (or the idea of having) a serious medical problem
8. Misinterpretation of symptoms persist despite medical evaluation
9. Preoccupation with illness d/c criteria show insight
10. Causes significant distress in everyday function
5. Body dysmorphic disorder:
11. A serious long-term disabling condition
12. Preoccupation with an imagined defect in appearance
13. Slight anomaly has an excessive response
14. May avoid social or work leading to social isolation
15. Low self esteem , shame and worthlessness may lead toSuicide.
16. Assessment:
15. Ask pt if they have any worries about his/her body appearance
16. Determine amount of time pt spends thinking about imagined defect.
17. What actions7 does the person take to hide or get rid of deficit-
makeup, baggy clothes, surgery
18. How has the concerns about the deficit affected persons ability to fxn
at school, work, & family
6. Factitious Disorder:
17. Intentionally producing symptoms of a psychological or physical nature for the
purpose of assuming the sick role or gain of attention.
18. Knowledgeable health care workers?
19. Behavior satisfies need for secondary gains
19. Dont want to give them secondary gain
20. Malingering similar to factitious but motivation is external:
20. Getting sick leave from work, Child has stomach ache to miss school.
21. Only need to know factitious not malingering for exam
2. Somatoform Disorder Dx (Lecture but more on 211):
7. Anxiety
8. Ineffective coping
9. Compromised family coping
10. Impaired social interaction
11. Post Trauma syndrome
12. Risk for self-directed/other-directed violence
3. Dissociative Disorders
13. Dissociative amnesia
22. One or more episodes of inability to recall important personal information,
usually of a traumatic or stressful nature
14. Dissociative fugue
23. Sudden, unexpected travel away from home or ones customary place of work,
with an inability to recall ones past
24. * Danger for injury
15. Dissociative identity disorder
25. Demonstrates two or more distinct identities or personality states. Change in
voice and attitude
26. At least two of these personality states recurrently take control of the persons
behavior
27. Outcomes
21. Alert therapist or use hotline when feeling suicidal
22. Respond to his/her name when addressed by member of tx team
23. Identify periods of increasing anxiety
24. Refer to himself in 1st person pronoun form (I think..)
25. Keep written journal to ID stressors
26. Take meds
16. Depersonalization disorder
28. Persistent or recurrent episodes of feelings of detachment or estrangement
from ones self
29. Sensation of being outside of ones own body or mental processes or being an
observer of ones body.
30. * Aware of what is happening, not delusional or hallucinating.
31. S/s:
27. Sensory anesthesia, lack of affective response, sense of lacking control
of ones actions/speech.